Steve Royston

Healthcare in Saudi, the US and UK: Who does it Right?

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Hats off to Dr Abdullah Rabeeah, the Saudi surgeon who, as the Arab News reports, led the successful operation to separate a pair of conjoined twins in Riyadh a couple of days ago. Dr Rabeeah is a rare animal. Although he is a specialist in separating twins – he carried out his first such operation in 1990 – he has an important day job. He is the country’s Minister of Health.

Outside of the financial arena, it is not common for governments anywhere to appoint Ministers who know much about their briefs, at least when they start the job. In my country, the UK, I can’t remember the last time a minister inherited the Health portfolio. Andrew Lansley, the minister recently moved from the job in David Campbell’s recent cabinet reshuffle, tried to establish his credibility on the basis that he suffered a stroke in his thirties, and was treated by the UK’s National Health Service.

You can look at things both ways when ministers inherit portfolios about which they know nothing.

They could succumb to the “Yes Minister Syndrome” and end up being wound around the little fingers of civil servants who have been at the department for donkey’s years, so presumably know their business. The source of the comedy in Yes Minister was a naïve politician being taken for a ride by a wily advisor dedicated to nothing more than the preservation of a comfortable status quo.

Or they could bring the ideological principles of the government of the day and apply them aggressively at their new department, riding roughshod over the sage advice of the non-political mandarins whose job it is to implement policy.

Both approaches can produce good and bad outcomes. Staying with the status quo can lead to continuity and stability, yet it can also deliver stagnation and ossified thinking. Forcing through radical measures against advice can be a game changer, transforming the social landscape and the career of the politician responsible. On the other hand it can demotivate civil servants, lead to half-hearted implementation or unsatisfactory political compromise, and result in a situation worse than that which it was designed to cure.

The UK’s National Health Service is a case in point. For the past thirty years successive governments have tinkered with it. They have introduced one structural change after another – fragmentation, market-style competition between hospitals and regions designed to give patients a choice of service. Strenuous efforts to reduce waiting lists for operations. Agencies to evaluate and approve the purchase of new drugs. Post-code lotteries – some services and drugs available in one area and not in another. A massive growth in management overheads. An obsession with statistics and league tables. Too many doctors, not enough nurses. Incompetence in some areas, excellence in others. Helplines, walk-in centres. MRSI in hospitals. Failed IT projects. Reduced hours and higher pay for general practitioners. Fuzzy boundaries between private and public health. Confusion, uncertainty.

In the end, does the UK have a better health service? In some respects, yes – better equipment, better training, a number of world-class hospitals, an awareness that the patient is a customer – that the NHS and its staff is not doing the public a favour. In other respects, no. Staff demoralised by constant change. An outsourcing culture that makes blaming the contractor an easy escape for responsibility. Decentralisation of authority that has left some local NHS Trusts in permanent deficit. Hot spots of sub-standard care. A young generation of nurses trained to practice but not to care. Massive reliance on foreign staff. Still a long way away from Margaret Thatcher’s vision of decentralised islands of service competing to provide excellence to satisfied customers at a cost affordable to the state.

Also a far cry from the ill-informed characterisation of the service by US politicians of a Republican hue as “socialised medicine”.

Speak about the NHS to an otherwise perfectly rational person from across the pond, and the eyes glaze over. Socialised medicine is the new communism – by wide consent un-American and unacceptable.

They ask why they should subsidise the less healthy with their tax dollars. Look at the UK system, they say  – bloated, inefficient and wasteful – despite being unable to provide any evidence to that effect and having never sampled the goods themselves.

Yes, I know it’s complicated, and we non-Americans wouldn’t understand the deep aversion that Americans have for socialised anything. That freedom for many of our cousins means freedom to make their own choices, to spend their hard-earned dollars as they think fit, and to live their lives untrammelled by the burden and control of a centralised state. Therein lies the ancient tension between federal and state government, and the roots of the American Civil War, in which, lest we forget, the federal government won the argument.

And you can have some sympathy with the libertarian view given that the US has massive federal bureaucracy – some would say bloated, inefficient and wasteful – and is one of the most heavily regulated nations on the planet. So why impose more bureaucracy on the suffering citizens, when the federal government and its various agencies is already the largest employer in the nation? And why throw all those diligent insurance company workers out of a job to create a UK-style behemoth?

Well, you don’t create behemoths out of nothing. They tend to evolve. And the US has built a private heath behemoth of its own sitting on top of the bureaucracy that underpins the country’s safety net systems, Medicare and Medicaid. So you could say that they’re even more bloated than we are. Which is perhaps why it cost my business partner in North Carolina in excess of $60,000 for a hip replacement – five times the typical cost of such an operation from a UK private provider, and up to twenty times the cost of a like-for-like procedure in India.

But leaving comparisons aside, let’s step back for a moment and consider what most countries consider to be the pillars of civilised society. Would they not include health alongside defence, law and order, education and financial protection for the poorest and weakest members of society?

The US does not allow its taxpayers to opt in or out of the nation’s nuclear deterrent, or to choose not to pay for its wars in Afghanistan and Iraq. And although the private security industry is thriving, I haven’t heard any Americans calling for the option of not being protected from mugging and armed robbery. Nor does there seem to be any appetite for abolishing the public school system or the multitude of state universities. So why would the nation not have the same concern for the health of its citizens, and reckon that it’s OK for an unhealthy underclass to remain mired in a cycle of ill-health, poverty and chronic unemployment? For will not a person who receives decent healthcare have a better chance of leading a productive life?

Yet half or more of US voters are likely to opt for a candidate whose church espouses the doctrine of the survival of the fittest, and seems to have little sympathy for the underdog, except for those who struggle to pull themselves up by their own bootstraps.

Going back to Saudi Arabia, I do not know Dr Rabeeah personally, but I do have a little experience of  Saudi healthcare both professionally and as a patient. The Kingdom’s system, if you can call it that, is definitely a work in progress. Many private hospitals, some good, some less good. Public hospitals that will treat anybody without charge. Specialist hospitals such as the King Faisal in Riyadh that boast the cream of Saudi and expatriate consultants. Semi-public hospitals created by large institutions of the state – the National Guard, for example, the Armed Forces and Saudi Aramco, the national oil company.

All private sector employees in the Kingdom – Saudi or foreign, are obliged to take out health insurance to a minimum level. The more senior the employees, the more extensive their coverage – dependent on employers being willing to pay higher premiums. The health sector is one of the few in the country where women work freely alongside men, subject to the usual dress and social norms. Medicine is one of the most prestigious professions in Saudi Arabia, yet it has taken generations to reach the point at which female Saudi nurses are not subjected to social stigma for their profession, especially among the more conservative elements in society, many of whom regard them as women of loose morals.

Dr Rabeeah has to contend with many challenges. Raising the standards of the private sector. Shocking levels of lifestyle diseases like type 2 diabetes. Genetic conditions such as sickle-cell anaemia. The consequences of generations of consanguineous marriages – cousins marrying cousins. Growing recognition of psychiatric illness – until recently a social taboo. High demands on accident and emergency services as a result of inconsistently applied health and safety regulations, and of the Kingdom’s frightening road safety record. The reluctance of doctors to work outside the country’s main centres of population – Riyadh, Jeddah and the Eastern conurbations that have grown up around the oil and gas industry. And finally, the demographic bubble – a rapidly growing population, resulting in a high demand for paediatric care.

But in one respect he is fortunate. Saudi Arabia has abundant resources to throw at these problems, unlike the US and the UK, where health services are competing for funds in what looks to be a long-term period of financial restraint.

Saudi doctors are held in the highest esteem, both by their patients and in society generally. So on the surface it makes sense to put a medic in charge of the country’s health ministry. But a minister must have more skills than knowledge and expertise in the department’s primary business. Ability to manage a budget, for example. Political skills – in Saudi Arabia particularly, the ability to negotiate through the minefield of conflicting views of society held by the religious conservatives and the western-educated progressives. And most of all, the ability to lead and inspire.

Dr Rabeeah’s track record of leading large multi-disciplinary teams in what is one of the most complex of surgical procedures – twin separation – speaks well of his ability to lead and organise.

If Saudi Arabia is able to find a minister with genuine knowledge and insight into his country’s health challenges from within its population of 22 million, is it beyond of the world’s most populous and technically advanced nations to entrust a medical professional with oversight of their citizens’ health?

At least there would be a chance that among those who treat healthcare as a political football, there might be somebody who knows what they are talking about with a say in the circles where the decisions are made. Easier in the US and Saudi Arabia, where ministers are appointed rather than elected. Not so easy in the UK, where ministers are appointed from a pool of elected members of parliament, of which a tiny fraction have a medical background.

Where would I prefer to receive my healthcare? If I was wealthy, any of the three countries. If I was poor, I would choose the UK without hesitation.

But even a cursory glance at three very different systems suggests that each can learn from the other. And the good Dr Rabeeah, when he finally moves on from his arduous duties in Saudi Arabia, will deserve to be listened to by health authorities well beyond his native country, including the UK and the USA.

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