Intended for healthcare professionals

Editor's Choice

Brexit: doctors’ duty is to inform patients

BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l5382 (Published 05 September 2019) Cite this as: BMJ 2019;366:l5382

Greener pastures? Perhaps, but don’t bring along your personal values and expectations

Dear Editors

I am frankly surprised when Prof Dodge (ref 1) suggested with such confidence that Japan had a healthcare system similar to UK’s NHS, and had remained essentially unchanged since introduction post Second World War.

I actually had to double check with Wikipedia to confirm that my recollection is correct and Prof Dodge’s assertion is misleading.

Upon its formal launch in 1948, the NHS is free on point of delivery, supports by a government run national health insurance scheme funded by taxation. There was no private insurance provider involvement in delivery of healthcare within the NHS framework.

In Japan, the 2-tier healthcare system primarily involved employee-individuals subscribing in a compulsory personal healthcare insurance scheme with a nominated private healthcare insurer operating in a highly regulated health insurance market. Payment is often via deduction from salary. Self employed or those ineligible for employer healthcare insurance will need to subscribe to municipal- run National Health insurance scheme which need to be transferred when changing address, as each municipal run the NHI scheme according to local conditions. Premiums are calculated according to income, age etc hence there is some attempt at equity, but there is still expectations of some premium payments out of pocket by individuals. In addition to insurance premiums, there is an additional user-pay costs in the form of copayment as much as 30% of the receipts.

Post-war German healthcare system involved individuals pay out of pocket as premiums in a compulsory personal healthcare insurance scheme with a nominated private healthcare insurer operating in a highly regulated health insurance market. Copayment was introduced also in a user-pays concept as well.

Both systems expects visitors (who stays beyond a minimum duration) to take up healthcare insurance as part of user pays approach.

Both systems have large non-clinical staff contingent, but nothing like the bloated NHS management and administration. Within the clinical workforce, there is still hierarchical framework, in part by seniority and appointments, which some UK clinicians will have difficulty to cope with, even if they can get over the “universal healthcare must be free for all, regardless of eligibility” mindset.

Furthermore, there are some basis for the stereotypical attributes of both German and Japanese people having strong sense of social and personal responsibilities, which significantly changes how healthcare is consumed in these countries unlike UK (or Australia).

They may be greener pastures, but not just because of how the farmers look after the land, but the animals behave differently as well.

Reference
1. https://www.bmj.com/content/366/bmj.l5382/rr-5

Competing interests: No competing interests

13 September 2019
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia