Take a health check, Tony

Until last month I had never visited the United States. Like many left-wing people I had a rather jaundiced view of that country based on a dislike of their foreign policy and apparent disregard of the environment. But I had never been there, and must confess I did not know much about what life in America was like.

I had an opportunity to go, and visited Chicago, Springfield (the state capital of Illinois) and New York.

Various things struck me. America is very tidy. They do not seem to drop litter the way we do, despite the fact that they invented the takeaway. They are much more overt about their patriotism. The Stars and Stripes are everywhere. I saw one very moving front garden full of flags, one for every serviceman killed in Iraq, I was told. Americans support the President, which is not the same as liking George W.

I suppose we all believe the images given to us by Hollywood. In fact, I heard far less bad language than in England, and sexual images are not thrust at you they way they are here. The press is rather staid and, by our standards dull, but it has none of the excesses of our tabloids.

Despite the awful nature of some of the television, there are also extremely worthy programmes where politicians drone away, seemingly, all day. I put one on when I wanted to go to sleep in the hotel.

Individually, Americans are much more direct than we are, but also extremely hospitable, helpful and kind.

But being a political animal I wanted to find out a bit more about how their domestic political system works. I managed to speak to some politicians and visited Chicago City Hall and the Chicago Housing Authority. Again the impressions we have are wrong. The big difference between America and Great Britain is how health is managed. In Britain the majority of the system is publicly owned, in America it is private.

So if you take health out and then look at the different public sectors you will find that the American sector is probably as big as, if not bigger than, it is in Britain. Everywhere you go the mayor or governor, depending where you are, will remind you of his or her largesse.

I stopped at a lay-by in Illinois to find a large sign telling me that this facility had been provided by the governor, and presumably I should remember that at the next election. In England there would be a council sign telling you not to drop litter. Americans do not apologise for their public sector, as some of our politicians seem to. They are proud of it.

That does not mean everything in the garden is rosy. Public housing in America was, until recently, a mess as a prominent official told me. It was for those on benefit, and in a bad state. There was also considerable corruption in public works departments. But efforts are now being made to turn this round.

Political attitudes are different. There is no ideological belief that public housing should be abolished. I was told that there is little demand to buy it, so that is not a political issue. Instead, both sides recognise it is necessary to have it and get on with solving the problem.

I was told that the Republican administration was actually more helpful than the Democrats had been. Ninety per cent of the funding for regeneration comes from the Federal Government. But it does not interfere with the local authorities or threaten them as is the case in England. The city council is trusted to get on with it. The Constitution requires this.

True, the Federal Government will interfere if things really are bad, but there is an attitude that it is better for it to be done locally.

In England local authorities are very restricted in what they can do, and subject to constant inspection and target setting. Central government does not seem to have much confidence in them.

I was impressed by the "can do" attitude of the housing department. Bad housing was being demolished, and new schemes being built which mixed public and private provision. This was encouraging private developers to move back into the city centre. It seemed to be working, although the housing authority admitted they still had some "bad estates".

There was also a very different attitude towards tenants. Those who behaved, or could prove they had a steady income, got first shot at the good housing. We had a discussion about "tipping points" - how many difficult tenants there could be in an area without pulling it down. The problems with the public works department had been solved by privatising it. I am not sure whether I agree with everything that is being done, but what impressed me was the attitude that they were going to get on with it and solve the problem.

There are very efficient commuter train services in both Chicago and New York, although I was told this is not the case in all American cities. When I was there it was announced that the Federal Government was to pay for improvements to the line out to the suburbs. My American friend told me that no-one would imagine that this should be done privately, by PFI or some such device. The current efforts to rebuild the London Underground with private companies and all the resulting chaos and missed targets would simply not happen in America.

The big difference, of course, is health. The majority of provision is private, including charitable and religious bodies, although about 30 per cent is provided through state hospitals. A new one has just been built in Cook County Illinois. Payment is mainly private, usually through some sort of insurance scheme. But there is a federal scheme called Medicare which pays hospital bills for senior citizens, and Medicaid which pays for the poor. The Bush administration has just introduced a scheme to pay for prescriptions for senior citizens.

Thus paying for health care is partly provided by the Federal Government in America, and there is pressure to increase this. The Governor of Illinois is currently campaigning to introduce a scheme whereby the State Government pays for the health care of children.

America is a richer country than we are, and it spends about 14 per cent of its gross national product on health care, compared with about eight per cent in the UK. Any rich individual can spend what they like on health care in America, so there are many unnecessary operations and dubious treatments. Because the system requires treatment to be available when the insurance companies need it there is also some slack in the system.

And, of course, the providers must make a profit. Americans worry about the increasing cost. In the British system costs are much more tightly controlled, and the Americans regard it as a system of state rationing, but most other countries think we spend our money more efficiently, and probably more fairly.

A major car components firm, Delphi, is currently going into bankruptcy, and who will pick up the tab for the workers' healthcare, previously paid by the company, is a matter of public concern. Thus there is a desire amongst some people for the state to pay for all healthcare insurance as it already does for senior citizens.

This is popular amongst what Americans call "hard working families" or "the middle class". They do not qualify for means-tested assistance and find paying health insurance hard. Thus there is a big constituency in America which would like the state to pay for health care.

Most countries now try to separate who plans a service from who provides it. This can lead to better accountability and better planning. We now have this "purchaser/provider" split in health and local government, although most services still remain publicly owned. Public ownership of provision would certainly reduce costs in the American system, and I think there are a substantial number of Americans who would welcome this. The problem is that it is extremely difficult and expensive to buy out the existing vested interests.

So my conclusion from my American visit is that the Americans are good at running public services, and have far more confidence in doing it than we do. There is much that we could learn from them about housing and transport, and in trusting local government to run itself.

Where they probably envy us is our state controlled health service where we are much more able to control costs and direct resources than they are.

And there is a warning too. It is very easy to sell off public assets, but it is very difficult to buy them back. So please, Mr Blair, pause and think about the virtues of a publicly owned health service before you privatise large chunks of it.

* David Taylor-Gooby is councillor for Howletch on Easington District Council.