CS: It’s something people interact with all the time, both in their daily and medical lives and when they think about politics. It is something people pay a lot of attention to. They do care about the NHS, not only because they rely on it for needs and such, but also—people are proud of it, and of Britain—as a sort of sign of social solidarity. Attempts to tinker with it, or change it, only work if people agree that there is a problem that needed solving.

TL: Americans love to say we have the best healthcare system in the world, but when you probe further, you find Americans deeply troubled by the system. It’s organized around private insurance companies and most Americans don’t like them. On the other hand, doctors work in private offices, or for private companies like HMOs, and people generally love their doctors.

The nub of our reforms was to bring more people under the umbrella of private insurance, by mandating that everyone carry insurance and requiring insurers to give coverage to everyone—even those who are very sick and not welcome by insurance companies today.

CS: The biggest difference you notice coming over here is that sense of fear that people have about how to pay for healthcare, and what happens if people get sick. If they lose their job, will they be covered? That’s the greatest thing the NHS does: people don’t have to worry about that. They know they’re going to get treatment, whatever happens. People like to complain about it, but I think fundamentally that is what is most valued about the NHS. Everyone, across the political spectrum really, appreciates that about it. It removes that worry from life.

Reform: British style and American style

TL: Tell us about the recent healthcare reforms in the UK.

CS: The funding mechanism will not change, it’ll all still be taxpayer funded. But what’s changing is how primary care doctors would be given money to spend on their patients. They would be able to buy services, like tests and X-rays, from NHS hospitals and clinics as they do now, but also increasingly from private companies, or charities, or cooperatives.

TL: But the public was upset about the reforms, right?

CS: Most of the substantive criticism of the NHS reforms is not really about privatization, but about the fact they were trying to address the wrong problem. The coalition supporting reform never really presented a problem to the public to which these reforms were the answer. Reform advocates sort of came out of nowhere as far as the average voter was concerned.

In the last election the government promised there would be no more pointless, top-down reorganization of the NHS. Then a few months after the election, a huge top-down reorganization of the NHS appears. As far as the average voter was concerned, here are the Tories, having promised not to reorganize the NHS, suddenly reorganizing the NHS! And that revived all sorts of suspicions from the 80s and 90s, in which the conservatives were seen as the privatizing party and were never really trusted on the NHS.

TL: My understanding of the UK reforms is that it involved the way doctors arranged for services, and it set up these so-called commissioning groups, which, as you say, open up the NHS to more privatized services.

CS: Primary care doctors would be given money to spend on their patients, as we discussed, and they would be able to buy services from NHS hospitals and clinics as they do now but also increasingly from private companies or charities, or cooperatives. The NHS has been moving in that direction for some time, and the government wants to sort of continue that. My own view is that it’s unlikely that the reforms themselves will lead to American-style healthcare. The NHS is still too different. That’s not, I think, what the government aimed to do. But it’s still an open question about how far increasing competition and private sector involvement will build up its own momentum

TL: What’s the problem that should be tackled?