Health rationing is a question that the British, Russians and other peoples all over the world have to consider. In Britain the NHS has set up an independent National Institute for Clinical Excellence, known as NICE. Its job is to provide national guidance on promoting good health and on preventing and treating ill-health. That sounds uncontroversial, but in fact an important part of the work of the Institute is to deal directly with the problem of rationing. For example, a new but expensive drug becomes available to improve the condition of people suffering from Parkinson's Disease. It works - but it works only at certain stages of the disease and it can only alleviate the symptoms. It is very expensive. Is it worth prescribing the drug? NICE takes advice from medical people, academics and research institutes from all over the world and also consults specialists in medical ethics. Eventually they come to a conclusion. Let us suppose that they decide the benefits outweigh the costs. Yes, NHS doctors can prescribe the drug. That is fine, but everyone knows that the corollary is that there is less money for other treatments. On the other hand, suppose that NICE decides that the costs outweigh the benefits. Victims of Parkinson's Disease cannot be prescribed the drug within the NHS. Is this fair? The point about NICE is that because it is independent it does not make decisions about how money is to be allotted; it does not make policy; it simply decides in its highly qualified committees which drugs are worth the money. At present NICE is more-or-less the only such institute in the world, but other countries are looking very carefully at how it works. It may help to solve world problems of rationing.
Ah, Russian friends say to me - the problem is simple; you go out and buy the drug privately and then bring it to your doctor who can show you how to use it. In fact, since the drug can only be brought on prescription, at least in this country, it is not so easy to obtain it, unless you go to a special private clinic where you have to pay for everything. If however you somehow get hold of the drug and tell your doctor that you want to include it in your treatment, the doctor is in a real dilemma. The whole point of the NHS is that everyone is treated alike, regardless of ability to pay. Now a rich person is saying, 'I can pay for special drugs and I want you to treat me with them'. At present the view is that such people cannot be treated if they are using non-NHS drugs although everyone knows that this cannot always work in practice. The NHS has a duty to care for all people including those who may buy drugs privately; how can it do that and be absolutely fair?
A difference in health service culture between Britain and Russia would not have been so noticeable in my childhood. At that time British hospital doctors were treated like gods; and senior nurses were expected to show their power. Patients were told very clearly (and sometimes crossly) what they must do and what they must not do. Everyone waited for the godlike words of the doctor. He (it was usually 'he' then) announced what should be done in incomprehensible terms, and moved on to the next patient in the next bed. Those attitudes are part of a distant culture. For decades doctors and nurses have been encouraged to be human; to explain and discuss the problem with the patient; to make sure that patient as far as possible is reassured and has been allowed to express his or her doubts and worries. Not all doctors and nurses like this friendly democratic approach, but most accept it, and the majority of our doctors and nurses are genuinely warm with patients. They will often be amazingly controlled and calm even with drunken violent patients who turn up at the Accident and Emergency Department on Saturday nights.
The doctors and nurses whom I have observed in Russia also seem to be friendly and helpful to their patients but Russians tell me that many of them still take the attitude: 'We know what is best, you ignorant person - and your own feelings are irrelevant.' It took us decades to change the medical culture in this country, for experienced professionals do not change their habits overnight. Probably this comparison between health service cultures will soon be out-of-date.
Chapter 7. Mass Media: The Value and Perils of Freedom
In this chapter I discuss newspapers, television, radio and the internet as sources of news, comment and up-to-date information. All these media also offer entertainment, stories, documentary material, jokes, pictures and so forth, just as Russian TV and newspapers do; but the comparisons I want to make are essentially about news and problems of editorial freedom, bias and impartiality.
The British have always by international standards been great newspaper readers; even today, when readership is declining fast as people turn to the internet, around half the adult British population read a national newspaper at least three times a week. Being a small, densely populated country, we were able to print and distribute papers nationwide on a daily basis at a time when larger countries such as the United States depended on local papers with some national content in them. Also we developed a passion for newspapers when the majority of British people were literate and were living in a semi-democratic country before the invention of radio, TV and the internet. Newspapers were how we found out about the world.
Here is a list of our current national daily newspapers: The Guardian: The Daily Telegraph; The Independent; The Times; The Financial Times (these five are 'serious' papers mostly read by professionals and other educated people); The Sun; The Daily Express; The Mirror; The Daily Mail; The Daily Star (these are popular 'tabloid' papers, and it could be argued that The Daily Star does not have and does not intend to have any serious news in its pages). Other national daily papers include The Scotsman, published for Scottish readers. National Sunday newspapers are mostly associated with one of the dailies. (They use the same printing machines, and tend to share their political and ideological views.)
When compared with Russian newspapers, these newspapers are thicker, with many pages of news, of opinion, reviews, arguments, sports reports and features (on celebrities, gardening, film, fashion, etc). The Sunday papers have special supplements on money, travel, sport, cultural reviews, domestic life and other subjects which can attract advertising. Subscribers and casual readers pay part of the cost of our newspapers, but advertising is crucial and advertisers require a wide readership, preferably of specialised groups.
Our newspapers sometimes come close to 'general interest' magazines, but despite their efforts to attract more readers, experts believe that one or two national papers are likely to collapse soon because of competition from online news websites. All these papers have their own websites, some of which are popular with more readers than the papers themselves; but few papers dare to charge internet readers for access. At the time of writing only the Financial Times makes online readers pay a subscription in order to receive up-to-date financial news. Other sites are free. The Guardian website, <www.guardian.co.uk> has a well-organised and highly informative site which has proved particularly popular across the world. Whether the site has helped with newspaper sales is not clear.
Some of these national newspapers are owned by news tycoons (whom you would call oligarchs). For example, The Times and The Sun are both owned by Rupert Murdoch, an Australian-American who likes to direct the way his newspapers approach a particular story. Some are owned by rich families who do not often interfere with editorial decisions - for example, the Daily Mail, mostly owned by the Rothermere family. Others - notably The Independent and The Guardian - are owned by non-profit-making trusts. In both cases the trusts were established to promote a particular approach to our society: The Independent is centre-liberal but open-minded about individual issues, The Guardian is centre-left but often critical of the current Labour government. Since each paper is owned by a trust, any profits go back to improving the paper, not to enrich an owner. This seems to many people to be the best way to establish a newspaper since even if owners do not interfere directly in news content, they are bound to be influenced by schemes which would improve their profits.