Doctor's Orders

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Germany is further along the reform path on which France is now gingerly embarking. After a scorching debate that enlivened leftist opposition to the Social Democratic–Green coalition of Chancellor Gerhard Schröder, the government launched its reform in January. Its controversial centerpiece: a €10 Praxisgebühr, or quarterly fee every patient must pay on the first doctor's visit during that three-month period. The fee was widely attacked by doctors and patients alike as awkward and onerous. But along with costlier fees for unreferred visits to specialists, a larger patient share of drug costs and a stop to reimbursements for eyeglasses and dental prostheses, it has helped the country round the corner. Health Minister Ulla Schmidt announced this summer that for the first time in 10 years, Germany's public-health system was no longer in the red. The number of doctor visits was down 10% for the first quarter compared to the same period in 2003, as were working days lost to sick leave.

Britain may be a magnet for private surgeons, but for British patients it's no promised land. A relative paucity of practicing physicians — 2.1 per 1,000 people in 2002 as opposed to 3.3 in Germany and France — means long waiting periods. But things used to be much worse. Since Prime Minister Tony Blair took office in 1997, the National Health Service's (NHS) budget has doubled

	Our goal is to get France to realize how undervalued our profession is — PHILIPPE CUQ, head of Surgeons of France

after decades of chronic underinvestment and the longest waiting lists for operations have been reduced. The Labour government has been loath, however, to question the basic structure of the NHS — to the detriment of British patients who can't afford private care, says Dr. Maurice Slevin, an oncologist and member of the U.K. organization Doctors for Reform. "Here patients have no power," he says. "We want to move away from a Soviet-style, monolithic, nationalized industry that provides very poor value for money." Slevin says the number of managers in the NHS has grown three times faster than medical staff.

French anesthesiologist Françoise Iossifidis has seen both sides of the equation, having worked in Britain for 17 years, the last four at University Hospital Lewisham in southeast London. She acknowledges that change has come slowly in Britain, in contrast to the more flexible French system. But she thinks the Continent and Britain are already learning from each other. As British investment increases, NHS doctors are adopting the more patient-centered approach of her home country; France, she says, can learn to reduce costs by empowering nurses and requiring more general-practitioner referrals before patients see specialists. Practical measures like that will help, but they won't be enough to offset all the spiraling costs. Governments may yet need a stronger prescription.