1.5 BBB; Bismarck Beats Beveridge – now a permanente feature
The Netherlands example seems to be driving home the big, final nail in the coffin of Beveridge healthcare systems, and the lesson is clear: Remove politicians and other amateurs from operative decision-making in what might well be the most complex industry on the face of the Earth: Healthcare! Beveridge systems seem to be operational with good results only in small population countries such as Iceland, Denmark and Norway.
1.5.1 So what are the characteristics of the two system types?
All public healthcare systems share one problem: Which technical solution should be used to funnel typically 8 – 11 % of national income into healthcare services?
Bismarck healthcare systems: Systems based on social insurance, where there is a multitude of insurance organisations, Krankenkassen etc, who are organisationally independent of healthcare providers.
Beveridge systems: Systems where financing and provision are handled within one organisational system, i.e. financing bodies and providers are wholly or partially within one organisation, such as the NHS of the UK, counties of Nordic states etc.
For more than half a century, particularly since the formation of the British NHS, the largest Beveridge-type system in Europe, there has been intense debating over the relative merits of the two types of system.
Already in the EHCI 2005, the first 12-state pilot attempt, it was observed that “In general, countries which have a long tradition of plurality in healthcare financing and provision, i.e. with a consumer choice between different insurance providers, who in turn do not discriminate between providers who are private for-profit, non-profit or public, show common features not only in the waiting list situation …”
Looking at the results of the EHCI 2006 – 2015, it is very hard to avoid noticing that the top consists of dedicated Bismarck countries, with the small-population and therefore more easily managed Beveridge systems of the Nordic countries squeezing in. Large Beveridge systems seem to have difficulties at attaining really excellent levels of customer value. The largest Beveridge countries, the U.K., Spain and Italy, keep clinging together in the middle of the Index. There could be (at least) two different explanations for this:
1. Managing a corporation or organisation with 100 000+ employees calls for considerable management skills, which are usually very handsomely rewarded. Managing an organisation such as the English NHS, with close to 1. million staff, who also make management life difficult by having a professional agenda, which does not necessarily coincide with that of management/administration, would require absolutely world class management. It is doubtful whether public organisations offer the compensation and other incentives required to recruit those managers.
2. In Beveridge organisations, responsible both for financing and provision of healthcare, there would seem to be a risk that the loyalty of politicians and other top decision makers could shift from being primarily to the customer/patient. Primary loyalty could shift in favour of the organisation these decision makers, with justifiable pride, have been building over decades, with justifiable pride, have been building over decades (or possibly to aspects such as the job-creation potential of such organisations in politicians’ home towns).