Britain's Search for Health: The First Decade of the National Health Service [Reprint 2016 ed.] 9781512816198

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BRITAIN'S SEARCH FOR HEALTH

BRITAIN'S SEARCH FOR HEALTH The First Twelve Years of the National Health

by PAUL F. GEMMILL Professor of Economics, Emeritus University of Pennsylvania

Philadelphia U n i v e r s i t y of Pennsylvania Press

Service

© i960, 1962 by the Trustees of the University of Pennsylvania Published in Great Britain, India, and Pakistan by the Oxford University Press London, Bombay, and Karachi Library of Congress Catalog Card Number: 6 2 - 8 4 0 1

Printed in the United States of America

To My Wife JANE BROWN GEMMILL

PREFACE

T h e British N a t i o n a l H e a l t h Service is a n u n d e r t a k i n g , by a nation of some fifty million people, to p r o v i d e collectively w h a t e v e r h e a l t h care m a y be n e e d e d individually by any or all of the fifty million. Britain's Search for Health is a short account of the first twelve y e a i s of the Service. I n w r i t i n g this book, I h a v e d o n e my best to give t h e g e n e r a l r e a d e r a simple, accurate, objective story of how the H e a l t h Service c a m e into being, w h a t it is like today, a n d how the British people feel a b o u t it.

Very few Americans know anything at all about the National Health Service (NHS). Of the small number of my fellowcountrymen who have written on the subject, some appear to have been more interested in supporting opinions already formed than in letting the facts speak for themselves—with a consequent spread of misinformation and misinterpretation. As Sir James Ross, the distinguished historian of the NHS, wrote several years after the Service had got under way: "There is still current in some quarters in America a picture of the British Service in which it would be difficult for anyone to get a correct knowledge of its main features or a just estimate of its value." In the last five years I h a v e spent m u c h t i m e o n this study, including a great deal of library work in this c o u n t r y a n d a

seven-month "on the spot" survey (wholly independent and unsponsored) in England, Scotland, and Wales. My present 7

8

PREFACE

task, as I see it, is to do a job of accurate reporting, without presuming to make a personal evaluation of the National Health Service; for a sound appraisal, I feel, must come from Britons themselves. It is their system, which they have lived with for more than a decade; and they are fully qualified, as one Englishman has put it, to "balance its good and its bad points." All I can promise the reader is the facts as I see them— facts based on personal observation, on much reading of authoritative sources, and on the things that British doctors, British patients, and other Britons told an American who was trying to learn all he could about their nation-wide system of health provision. Many people have taken part, in one way or another, in the making of this book. A survey that reports the answers given by some hundreds of doctors and patients to a score of questions is clearly in the nature of a co-operative undertaking. And, indeed, I owe my sincere thanks not only to these doctors and patients but, in addition, to the many hospital officers, nurses, local health authorities, members of Parliament, businessmen, journalists, and others who so willingly took the time to give me important, first-hand information about the Service. To Mr. Arthur Blenkinsop, sometime Parliamentary Secretary to the Ministry of Health; Lord Taylor of Harlow (formerly Dr. Stephen Taylor) ; Mr. François Lafitte, long associated with the London Times, and now Professor of Social Policy and Administration in the University of Birmingham; and Sir Hugh Linstead, O.B.E., M.P., I am greatly indebted for reading my manuscript in whole or part, and offering constructive suggestions. Lord Taylor, the author of Good General Practice, Sir James Stirling Ross, author of The National Health Service in Great Britain, and Oxford University Press, who published both books, have kindly allowed me to quote freely from these outstanding works. The extracts used from Her Britannic Majesty's Government publications are reproduced by kind

PREFACE

9

permission of the Controller of Her Britannic Majesty's Stationery Office. I must acknowledge my debt, also, to the publishers of other books, journals, and newspapers from which I have quoted in this volume, in each instance with specific mention of the source. The Ministry of Health has gone far beyond the call of duty in granting me interviews and providing background material, documents, official data, and answers to innumerable questions. Officers of the British Medical Association, the Fellowship for Freedom in Medicine, and the Medical Practitioners' Union have also been generous in giving interviews and in supplying materials which set forth their views on the NHS. Dr. Henry Durant, of Social Surveys (Gallup Poll), Ltd., kindly made available all of the polls his organization has taken on the subject of health provision over a period of nearly twenty years. For all of this help, so cheerfully given, I am deeply grateful. My thanks are due to the Trustees of the University of Pennsylvania for granting me leave of absence from my teaching duties, and thus making possible my survey in the United Kingdom. To my wife, co-worker in the gathering and handling of data, and a most discerning editor of the manuscript, I owe a very special debt of gratitude. P. F. G.

CONTENTS

PAGE PREFACE

7

Chapter 1.

THE

SHAPING

OF T H E

HEALTH

PROGRAM

2.

BRITISH

3.

THREE

4.

PAYING

5.

THE

PATIENTS'

LIKES A N D DISLIKES

95

6.

THE

DOCTORS'

LIKES AND DISLIKES

II4

7.

FURTHER

DOCTORS AT W C R K STUBBORN FOR T H E

BRITISH

HEALTH

15 24

SERVICE

NATIONAL

PROBLEMS

HEALTH

APPRAISALS

OF T H E

SERVICE

NHS

49 63

134

FOOTNOTES

155

INDEX

l6l

BRITAIN'S SEARCH FOR HEALTH

I

THE SHAPING OF THE HEALTH PROGRAM

O n July 5, 1948, everybody in the United K i n g d o m — n o t only British citizens, but alien residents and mere tourists as well—became eligible for free medical care of all kinds, under the British National Health Service. A t the very start of the Service (on the "appointed d a y , " as it was called in the Health Service Act of 1946) I was a tourist in Britain, and went back again in 1956 to make the seven-month study on which this book is largely based. M y purpose in making the study was threefold. I wanted, first of all, to get an accurate, fairly detailed picture of the Health Service in operation. Second, I was eager to inquire into questions that had been raised—in some cases by my fellowAmericans—about the adequacy and efficiency of the Service. Third, and finally, I hoped to hear from the British people themselves how they felt about their National Health Service (NHS) after some years of experience with it. T o foreigners with a limited knowledge of Britain's domestic affairs, the proposal to provide free health service for all must have seemed nothing less than revolutionary. T o Britons in general it was the logical outcome of a project that had been launched thirty-five years earlier, and discussed almost continuously thereafter. In the shaping of this program, the Liberal party, Conservative party, and Labor party all played a part. As the London Times said in 1958, the tenth anniversary '5

I6

BRITAIN'S

SEARCH

FOR

HEALTH

of the start of the N H S , the Service was "conceived by a Liberal [Lord Beveridge, of the 'Beveridge Plan' of social insurance], nurtured by a coalition government under a Conservative [Sir Winston Churchill], and brought to life by a Labor Government [headed by Prime Minister Attlee, later Lord Attlee]." 1 British writers usually date the beginning of the Service from 1 9 1 1 . In that year, David Lloyd-George, then Chancellor of the Exchequer, presented to Parliament and managed to get passed the National Health Insurance Act, the country's first compulsory health insurance measure, which went into effect on J u l y 15, 1912. Contributions to this scheme were compulsory for all manual workers, and for non-manual workers with annual incomes up to £ 1 6 0 * (about $775 in American money at that time), and for their employers.** The average working man was then earning roughly 30 shillings ($7.30) a week, or $380 a year. Membership in this early insurance program entitled workers to sickness, disability, and maternity benefits, in the form of small weekly cash payments; and to free family-doctor service and free medicine as required, but not to specialist or hospital Someone whose name I do not recall has said that footnotes are like "little dogs barking at the text." To give the reader some protection from such canine distraction, I have indicated by numerals, and placed in the back of the book all footnotes that deal solely with sources of materials. The few that remain in the text itself (marked by asterisks) are explanatory notes which, it would seem, can be read most profitably in their immediate context. 1 9 I 9> to * This remuneration level was raised to £ 2 5 0 ($1,215) £ 4 5 0 ($1,800) in 1942. ** M a l e workers were required to pay 6 J pence (13 cents) a week into the insurance f u n d ; women workers, 5 I pence (11 cents); employers, pence for each worker. By 1942, total weekly insurance contributions had risen to 21 pence (then about 42 cents) for men, and 18 pence (36 cents) for women employees. Employers had to pay 21 pence for each man, and 17 pence for each woman worker. T h e health portion of these contributions was 11 cents a week each for male workers and employers, and 10 cents for women employees.

THE

SHAPING

OF

THE

HEALTH

PROGRAM

17

treatment. A married worker's insurance did not cover any of his dependents. A t the start, the Lloyd-George plan applied only to about one-third of the total population. A n insured worker was free to choose his doctor from among the general practitioners who had joined the insurance medical service; and at stated intervals he had the privilege of changing doctors. Under certain circumstances, a doctor could reject an applicant, and could have an undesirable patient removed from his "panel" (or list). T h e doctor-patient relationship, under this plan, did not involve the payment of fees by patients or the keeping of accounts by doctors. T h e doctor's pay came to him from the government in the form of a "capitation f e e " — a fixed amount per year, but payable quarterly, for each patient on his list. This pa/ment was set in 1911 at six shillings (then $1.44) a year, but the amount of the capitation fee was changed from time to time in later years. T h e Lloyd-George insurance plan caught on. By 1920 the Consultative Council of the newly created Ministry of Health announced that there was an "increasing conviction that the best means of maintaining health and curing disease should be made available to all citizens." 2 A R o y a l Commission on National Health Insurance, reporting in 1926, noted that this insurance plan had "long since become an accepted institution in the national life." T h e commission offered suggestions for the further development of the health service, but concluded: " T h e ultimate solution will lie, we think, in the direction of divorcing the medical service entirely from the insurance system and recognising it, along with all other public health activities, as a service to be supplied from the general public funds." In 1930, and again in 1938, the British Medical Association (which in 1911 had opposed the Lloyd-George Bill) urged that health insurance coverage be extended to dependents, and that its benefits be expanded to include specialist, ophthalmic, dental, and full maternity care. " W h a t kind of health service

18

BRITAIN'S

SEARCH

FOR

HEALTH

should be at the disposal of every m e m b e r of the c o m m u n i t y ? " asked the B M A in its 1930 Proposed for a General Medical Service for the Nation.

" T h e answer is simple. Every kind o f service

w h i c h m a y be necessary for the prevention and cure of disease and for the promotion of full mental and physical efficiency." But the association did not favor b r i n g i n g under the plan the upper 10 per cent of the country's income-getters w h o , in its view, were " w i l l i n g or a b l e " to p a y for w h a t e v e r

medical

service they needed. T h e threat of w a r in the late 1930's pointed u p the fact that E n g l a n d had suffered some d a m a g e f r o m b o m b i n g in World W a r I, w h e n air warfare was in its i n f a n c y ; a n d the idea of nation-wide medical care was given fresh impetus by the need to prepare for handling the h e a v y casualties that might result from air raids b y a L u f t w a f f e a r m e d w i t h the most modern weapons of destruction. It was not possible to estimate with any degree of accuracy h o w h e a v y the b o m b i n g w o u l d be, but it was thought that at the worst there might be as m a n y as 800,000 casualties within

the first six weeks, and that this

n u m b e r might be exceeded if an invasion took place. 3 By 1940, w h e n the raids finally c a m e — l u c k i l y both later and lighter than had been e x p e c t e d — a n E m e r g e n c y M e d i c a l Service had been organized, and the government had requisitioned over 1,200 hospitals w i t h a total of some 400,000 beds, more than half of w h i c h were allotted for casualties. 4 War-injured civilians w h o could not be m o v e d to hospitals were to be treated in their homes b y doctors paid by the government on a capitation basis, when the patients themselves were u n a b l e to p a y . Another w a r t i m e milestone in the m a r c h of national health provision was the

Interim

Commission—"perhaps

the

Report of a Medical most

representative

Planning body

ever

established by the medical p r o f e s s i o n " — w h i c h was set up in 1940 b y the B M A in co-operation w i t h other important medical groups. T h e commission's study of " w a r t i m e developments and

THE

SHAPING

OF

THE

HEALTH

PROGRAM

19

their effects on the country's medical services both present and future" led it to outline proposals for a truly comprehensive national health service. M a n y of these proposals proved useful to Sir William (later Lord) Beveridge in carrying out his duties as chairman of a parliamentary committee which was instructed to undertake a survey of the existing national schemes of social insurance and allied services. In his famous " C r a d l e to G r a v e " report, published in 1942, Lord Beveridge stated that the "ideal plan" would be " a health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to i t " 8 — " i n other words," as the British Medical Journal expressed it, " a 100 per cent service for 100 per cent of the population." 8 T h e Beveridge Report was given wide publicity in the press and by the British Broadcasting Corporation; and a countrywide Gallup Poll, taken two weeks after its publication, showed that nineteen in every twenty adults polled had some knowledge of the report. When asked whether they approved the Beveridge proposal that "doctors' and hospital services should be extended, free of charge, to every person," 88 per cent of those interviewed said Yes; 6 per cent, No; and 6 per cent, Undecided.'' Examined with respect to the economic status of the persons polled, it was found that Yes was the answer of 81 per cent of the upper-income group, of 90 per cent of the middle-income group, and 88 per cent of the lower-income group. In 1943, the Churchill Coalition Government accepted the Beveridge Report in principle, and a year later published, and thus made available for public discussion, an 85-page "White Paper" 8 which described a detailed though tentative proposal for " a comprehensive health service for everybody in this country." T o this program, M r . Churchill (later Sir Winston), as Prime Minister, gave support in these words: The discoveries of healing science must be the inheritance of all:

20

BRITAIN'S

SEARCH

FOR

HEALTH

that is clear. Disease must be attacked whether it occurs in the poorest or the richest man or woman, simply on the ground that it is the enemy: and it must be attacked in the same way that the fire brigade will give its full assistance to the humble cottage as it will give it to the most important mansion. . . . Our policy is to create a national health service, in order to secure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available. 9 T h e doctors, however, were less enthusiastic than the Prime Minister and members of Parliament about the health service outlined in the White Paper. In the summer of 1944, a questionnaire sponsored by the British Medical Association was sent to all physicians in Great Britain, asking their views on some forty questions. T h e answers to an overall query showed that 39 per cent of all doctors who replied were favorable to the proposed scheme, 53 per cent were unfavorable, and 8 per cent undecided. An even higher degree of disapproval was found among the general practitioners, only 31 per cent of whom voted "favorable," as against 62 per cent "unfavorable," with the remaining 7 per cent "undecided." M a n y specific features of the government's program were generally acceptable to the doctors, but others were not. And before the modifications that seemed necessary for reaching agreement were acted upon, Labor's victory in the general election of 1945 brought new ministers into the picture, and led to still further consultation and negotiation between the Ministry of Health and the representatives of the medical profession. Somewhat less than a year after the Labor party came into power, the new Minister of Health, Aneurin Bevan, presented to the House of Commons a health plan (the Bevan Act) which differed considerably from the one that had been proposed by the Coalition Government, though its ultimate objective was the same. T h e new act was widely discussed by the public and debated at length by Parliament. But the Opposition members

THE

SHAPING

OF

THE

HEALTH

PROGRAM

21

now found themselves in the difficult position of having to argue against a health bill which, in policy and aims, resembled closely the one they (as members of the Coalition Government) had only recently been stoutly defending. Their heart was not in the fight, their attack was not carried through effectively, and "thus it came about that on this theoretically most radical piece of Labor legislation, there was, in effect, no real opposition at all." 1 0 While the Bevan Act was under consideration in Parliament, a leading medical journal, The Lancet, expressed editorially in measured terms its estimate of the current situation: Seldom has a Bill been presented after so full a canvass of those affected, or so wide an explanation of alternatives; and the outcome is not the doctrinaire Socialist programme that was deemed inevitable. To a profession of individualists, the whole concept of Government control is repugnant. To some it may seem that, whatever the safeguards, such control must mean the triumph of bureaucracy over medicine, and the degeneration of much we hold dear. Nevertheless there is another possibility—the triumph of medicine, in its own field, over bureaucracy. . . . In any medical service the opinion of medical men and women, when adequately expressed, is bound to command attention; and if it cares to apply its energies to continuous improvement of the National Health Service the profession cannot fail to produce something finer than we have yet known. . . . It is easy to be too much afraid. We should ask ourselves whether, with all its risks, the Service contemplated does not give us opportunities. It is a great end—that whatever persons can benefit from medical knowledge or skill shall have it without hindrance. The means now proposed to that end may need modifications, but they certainly do not call for wholesale condemnation or irreconcilable opposition. 11 The Bevan Act was passed by a vote of 261 to 1 1 3 , and became law on November 6, 1946, to go into effect on July 5. 1948. But the future of the Service was still very uncertain.

22

BRITAIN'S

SEARCH

FOR

HEALTH

There remained the task of persuading the doctors to take part in it. T h o u g h the profession was not against a national health service (and, indeed, expressed approval of "the bulk of the present A c t " ) , it was by no means sure in 1946 that the specific plan provided for in the Bevan Act could win acceptance. A poll taken by the British Medical Association in November of that year showed that 55 per cent of the voting doctors were against even having a negotiating committee discuss the matter with the Minister of Health.* Nevertheless further talks took place, and the Minister gave assurances which led to negotiations that stretched out over most of the year 1947. T h e results were most disappointing; and on January 8, 1948, a Special Representative Meeting of the British Medical Association unanimously resolved that "the National Health Service Act in its present form is so grossly at variance with the essential principles of our profession that it should be rejected absolutely by all practitioners." T h e effect of this emphatic denunciation was apparent in the second poll of the doctors, taken on February 18, 1948, in which nearly 90 per cent of the returns expressed disapproval of the National Health Service Act of 1946 " i n its [then] present form." July 5, 1948, the date on which the Service was scheduled to start, was fast approaching. Finally, the Minister gave positive pledges—touching upon such matters as the way the doctors would be paid, the practitioners' freedom of movement, their legal rights, partnerships, and so o n — i n place of his earlier statements, which had seemed to the doctors to be unduly vague. When a third poll was taken, it showed that more than half * It has been suggested by close observers of the scene that the Minister of Health, Mr. Bevan, was "unnecessarily provocative" in his dealings with a profession whose leaders—shocked by the election of a Labor Government in 1945, when they had expected a Conservative victory, and fearful that the Minister might soon insist upon a full-time salaried service (the traditional Labor idea)—"were only too willing to be provoked."

THE

SHAPING

OF

THE

HEALTH

PROGRAM

23

of the doctors were still against entering the Service. However, the British Medical Association decided, at a meeting on M a y 28, 1948, to recommend that its members take part in the Service. "There will be no shortage of good will," declared Dr. Guy Dain, Chairman of the B M A Council, shortly after this decision was announced, and continued: " [ T h e medical profession] will seek to make the new public service the best which is humanly possible under present circumstances. T h e individual citizen will be free to decide whether he will take advantage of the public service in whole or in part. But this does not mean that there will be two qualities of medical service rendered to the public. O n l y the best is good enough for the public service, and we shall do our best to provide i t . " 1 2 By the "appointed d a y , " the great majority of the general practitioners of Great Britain had joined the N H S . T h e actual operation of the British National Health Service — u n d e r the Labor Government from 1948 to 1951, and under the Conservatives ever since—has been marked by frequent arguments over details. But the general principle of the Service — r e a d y access for all to every kind of medical care—has been accepted by all political parties in Britain and by an overwhelming majority of the British people. Emphasizing the orderly and non-revolutionary procedure that was followed in introducing the social services (including the National Health Service) in Britain, the English historianeconomist R . H. T a w n e y comments: "These advances toward the conversion of a class-ridden society into a community in fact, as well as in name, have taken place, it may be noted in passing, with almost melodramatic sedateness. T h e y have been effected without excursions and alarms, after prolonged debate in Parliament and the press, by the pedestrian and unspectacular processes of democratic government." 1 3

2 BRITISH DOCTORS AT WORK

From the very start of the British National Health Service, membership was open to all who wished to join, but doctors and patients alike were free to take it or leave it. A person whose family doctor decided to join could either remain with him under the N H S or change to another doctor—inside or outside the Service—as he preferred. Anyone who did not have a regular physician could become the patient of any N H S doctor who was willing to accept him. A doctor had the choice of remaining exclusively in private practice, of practicing only under the N H S , or (as most doctors decided to do) of joining the N H S while retaining as many private patients as cared to stay with him on the old fee-for-service basis. Under the National Health Service, it has always been easy for a patient to change to a new doctor, or for a doctor to get an objectionable patient off his hands. This right to change at will is clearly set forth in the General Practitioners Handbook for all to see. However, it is a right seldom exercised by the doctors; and severances made by patients are usually those necessitated by a shift in the location of the patient's home or the doctor's office, or by the retirement or death of the doctor. Nearly half of the six hundred British 24

BRITISH

patients*

whom

DOCTORS

I interviewed

AT

WORK

25

had changed doctors since

joining the N H S , but only 15 per cent of those who changed said the reason was dissatisfaction with the doctor. Having joined the Service by signing up with an

NHS

doctor, a patient was entitled to whatever health care he might need, within the capacity of the country to provide it. Probably most important of all was the fact that, as Professor François Lafitte* puts it, "every child, housewife, and old person now had a personal d o c t o r " — a service previously available to lowincome workers under the compulsory National Insurance A c t of 1 9 1 1 , but not to their dependents, and hence out of reach for perhaps half of the total population because they could not afford it. But free access to a general practitioner was only a beginning, for the N H S also provided specialist care, hospitalization (medical and surgical), dental care (including dental plates), ophthalmic care (with spectacles, if needed), and free medicine, however high its price might be. Under his contract with the Executive Council of his area, * In seeking information from N H S patients, I placed questionnaires in the hands of 1 , 5 0 0 prospective participants, personally or by mail, aiming at and obtaining substantial diversity in location, age, sex, occupation, and economic status. Each questionnaire was accompanied by a printed explanation of the purpose of the survey, and by a stamped envelope directed to my American address, making it easy for those solicited to answer or not, as they preferred. T w e n t y questions were asked, and nearly all were answered. Patients were asked to preserve their anonymity by omitting their names. Returns from the 600 participating patients (40 per cent of all who were invited) showed a wide distribution geographically (49 counties) ; occupationally (93 classifications, including skilled and unskilled workers, housewives, bank officers, business executives, salespeople, retired persons, civil servants, professional men, and so on) ; and economically (stretching over ten income brackets running from a " l o w " of " u n d e r £ 2 5 0 " ($700) to a " h i g h " of " o v e r £ 3 , 5 0 0 " ($9,800) a year). There is, of course, no certainty that the answers to my questions express the views of N H S patients in Britain as a whole. * François Lafitte is a British expert on social questions, who was long associated with the London Times. H e is now Professor of Social Policy and Administration in the University of Birmingham.

26

BRITAIN'S

SEARCH

FOR

HEALTH

the N H S family doctor agreed to provide adequate waitingroom and consulting-room facilities; to establish office hours (called "surgery-hours" in Britain) convenient to his patients, and to be on hand at the stated times unless absent on emergency call; to visit in their homes any patients who were too ill to come to his office; to be accessible b y telephone at all times; to provide a substitute general practitioner when he himself was a w a y on nights-off, week-ends, or vacations; to arrange with others (specialists, hospital officers, etc.) for health care which he personally was not trained or otherwise equipped to provide; and so on. " T h e conditions imposed as terms of service are, in fact, equivalent to those of the usual general

practitioner's

practice, and can in no w a y be regarded as unreasonable or onerous," wrote D r . O . L . Peterson, an American physician w h o m a d e a study of the N H S for the Rockefeller Foundation in 1 9 5 1 . 1 4 Today,

a dozen

y e a r s a f t e r the start of the S e r v i c e ,

this

brief o u t l i n e of the rights of patients a n d responsibilities of the doctors

holds g o o d ,

except

for several

financial

obligations

w h i c h h a v e since b e e n p l a c e d u p o n the p a t i e n t s . O n e of these, w h i c h w e n t into effect on J u l y

1, 1 9 6 1 , is a specific c o n t r i b u -

tion p a y a b l e b y e v e r y o n e ( w h e t h e r " e m p l o y e r , "

"employed,"

" s e l f - e m p l o y e d , " or " n o n - e m p l o y e d " ) w h o m a k e s N a t i o n a l I n s u r a n c e p a y m e n t s . T h e a m o u n t of this N H S c o n t r i b u t i o n

is

$ 2 0 . 2 5 a y e a r f o r e a c h a d u l t m a l e e m p l o y e e , a n d slightly less for w o m e n w o r k e r s a n d y o u n g p e o p l e . * T h e other obligations n o w

borne by

patients a r e

financial

the r e l a t i v e l y

c h a r g e s f o r c e r t a i n d e s i g n a t e d services, w h i c h they a r e

small now

* As is noted in Chapter 4, the NHS had from 1948 to 1958 received a subsidy from the National Insurance Fund, in the form of a "transfer" of some £ 3 6 million (about $100 million) a year. This National Insurance subsidy has now been discontinued, and is replaced by the specifically designated NHS contribution, which is expected to provide a revenue twice as great as the amount formerly transferred.

BRITISH

DOCTORS

AT

WORK

27

required to pay—all of which are refundable to anyone who convinces the proper authorities that payment would entail undue hardship. B e g i n n i n g in

1 9 5 2 , a c h a r g e of one shilling ( 1 4 cents)

was

m a d e for each prescription f o r m issued by a doctor. S i n c e 196^ this c h a r g e h a s b e e n t w o s h i l l i n g s f o r each item example, calling

it is n o w six s h i l l i n g s

for cough

syrup,

(84 c e n t s ,

prescribed—for

for a

nose d r o p s , a n d

prescription

tonic—though

the

m e d i c i n e itself, w h a t e v e r it m a y cost t h e g o v e r n m e n t , c o s t s t h e patient

nothing.

(In

t h e six y e a r s f r o m

1952

to 1 9 5 8 ,

some

£ 3 , 2 0 0 , 0 0 0 , or about S9 million, for prescription c h a r g e s r e f u n d e d to n e e d y p e r s o n s . ) a m a x i m u m c h a r g e o f £1

13

was

I n t h e field o f d e n t i s t r y t h e r e is

($2.80) for " c o n s e r v a t i v e " work such

as f i l l i n g s , a n d a b o u t 8 : 4 f o r f u l l d e n t a l p l a t e s . S p e c t a c l e s cost the patient S i . 7 5 f o r e a c h lens, a n d

now

m i n i m u m o f 8 0 cents

f o r a f r a m e o f s t a n d a r d t y p e ; o r , if d e s i r e d , N H S l e n s e s w i l l b e fitted

into

expensive

frames NHS

which

the

patients

already

have.

More

f r a m e s r u n n i n g as h i g h as S 2 . 5 0 , c a n b e h a d

b y a n y o n e w h o is w i l l i n g to p a y t h e a d d i t i o n a l a c t u a l c o s t . M o s t hospital patients are c a r e d for in w a r d s — a n d often in w a r d s that are quite large. H o w e v e r , of the half-million beds in British

hospitals,

"amenity

there

are

about

six

thousand

so-called

b e d s " for patients w h o w a n t privacy a n d are

pre-

p a r e d to p a y a little f o r it. A n a m e n i t y b e d in a s e m i - p r i v a t e room

costs S i 1 . 7 5 a w e e k ;

$23.50.

There

are

in a p r i v a t e

also some

six

room

thousand

the c h a r g e

"pay

beds,"

is for

p a t i e n t s w h o w i s h to m a k e p r i v a t e a r r a n g e m e n t s t o b e t r e a t e d by

specialists

whom

they

personally

have selected.

Each

of

t h e s e p a t i e n t s m u s t p a y t h e f u l l m a i n t e n a n c e costs o f h i s r o o m ( w h i c h m a y a m o u n t to as m u c h as $ 7 0 a w e e k ) a n d p a y a l s o , of course,

whatever

f e e is c h a r g e d

b y the p r i v a t e l y

specialist. H o w e v e r , both a m e n i t y beds and p a y ever they are available

engaged

beds,

when-

(for not all hospitals h a v e t h e m ) ,

are

s u p p l i e d o n a p r i o r i t y basis a n d w i t h o u t c h a r g e to N H S p a t i e n t s

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needing them on strictly medical grounds; but, in fact, pay beds are very little used in this way. Though some four-fifths of the National Health Service doctors also have private patients, the majority of general practitioners interviewed in my survey had fewer than forty each and very few indeed as many as a hundred.* (The London Economist estimates that "some 600 general practitioners, out of some 24,000 in the country as a whole, are able to make a living solely from private patients, quite apart from the much larger number for whom the Health Service provides their bread and butter and private practice their j a m . " ) 1 * Unlike N H S patients, a private patient must pay his doctor for his services, and also pay for whatever medicine he requires; and in these days of so-called miracle drugs the cost of the medicine may easily be higher than the doctor's fee. * M y first-hand information on this and other matters concerning f a m i l y doctor service comes from 1 3 9 general practices which, because m a n y are partnerships, include 3 7 2 general practitioners who are responsible for the medical care of some 850,000 patients. Responsibility for the choice of participants in the survey is entirely m y own. I neither sought nor received assistance in this matter. L a c k i n g facilities for getting a sample of general practitioners that could be called statistically representative, I picked 14 centers of population; and, working out from these centers, I got "returns" from 4 8 English, Scots a n d Welsh cities, towns, and villages—which included industrial, commercial, residential, resort, university, shipping, and other types of communities. I n choosing specific doctors for interviews I used the N H S generalpractice lists found in post offices, selecting from them both one-man practices and partnerships of various sizes, and also practices in different parts of a city or town. I then interviewed the doctors in their surgeries, or, if a personal interview could not be arranged, left a questionnaire together with stamped envelope for its return to my Philadelphia address. T h e average number of patients per doctor in the practices surveyed w a s 2 , 2 8 3 , which happened to be almost identical with the average for Britain as a whole. These doctors were requested to answer 3 1 questions, a n d cooperated most generously. From the procedure used, it follows that the answers to my questions do not necessarily reflect the opinion of N H S general practitioner« in Britain as a whole.

BRITISH

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Why, then, do some Britons engage a physician on a private basis when they could just as readily be the same doctor's patients without cost ? There are at least four possible answers. First, it is probable that some people feel that a degree of prestige attaches to being a private patient. Second, business and professional men, and others with crowded schedules, can save valuable time by not having to wait in the doctor's office; for a private patient can see his doctor by special appointment outside of office hours.* Third, some patients apparently prefer the greater privacy and more leisurely pace of the privatepatient consultation; though it is clearly understood by N H S doctors that, in the quality of actual medical service rendered, there must be no discrimination between private and N H S patients. Fourth, many old-time patients, and especially the more elderly ones, are reluctant to disturb a pleasant doctorpatient relationship of long standing by shifting from private to N H S status and thus reducing the doctor's income. T h e first three of these reasons may be sufficiently strong to provide a moderate degree of support for private practice for some years. T h e fourth is far less promising. As the senior member of a partnership in the Lake District explained to me (somewhat sorrowfully, I thought): ' ' M y partners and I have 5,000 N H S and 800 private patients. If you come to see me ten years from now, we may still have a total of 5,800, or even more. But there won't be many private patients left, for most of those we now have are already over seventy, and a few are in their nineties! A n d the young people are all joining the Health Service." There seems to be general agreement among * " F o r quite a number of [very important] people, the N H S , however excellent it m a y be in m a n y respects, falls short of w h a t they want. N o one, for example, would expect a busy m a n like the Prime Minister, or the L e a d e r of the Opposition in the House of Lords, to queue u p in a doctor's surgery under the N H S . Just how far d o w n the list of V . I . P . ' s this expectation evaporates, no one has d e t e r m i n e d . " (British Medical Journal, N o v e m b e r 29, 1958, P- 1343. editorial.)

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doctors that the generation now growing up will not provide many private patients. Is it true, as has often been charged, that British doctors are overwhelmed by having too many patients to look after? I decided to ask the doctors themselves. Those who took part in my survey have an average of 2 , 2 8 3 patients each. Fifty-three (53) P e r c e n t them have fewer than this average, a n d 47 per cent have more. A very few have maximum lists of 3 , 5 0 0 patients. Most of these doctors have at least two, a n d often three, office hours a day. T h o u g h an office hour is nominally 60 minutes, it sometimes—and in the winter very often—runs to 120 minutes or more; and sandwiched in between these office sessions are visits to the homes of house-bound patients. British general practitioners are also subject to emergency call at any time. T o these busy doctors I put the following question: " W i t h your present list of patients, do you find it reasonably easy, or difficult, or almost impossible to give them what you regard as adequate medical care ?" T h e answers may surprise the reader, as indeed they surprised m e ; for 58 8 per cent said they found it reasonably easy, 37-8 per cent found it difficult, and only 3-4 per cent reported that it was almost impossible for them to do an adequate job. In about two-thirds of these returns, the report "reasonably easy" came from doctors with fewer than the average number of patients, and the answer "difficult" or "almost impossible" from those having more than the average—as one might perhaps expect to be the case. But 13 per cent of the doctors who answered "difficult" or "almost impossible" had fewer t h a n the average, and in two instances even fewer t h a n a thousand patients each; while i8£ per cent of those who had more than the average, and often the maximum or near-maximum, number of patients replied that it was "reasonably easy" to give them adequate medical care.

BRITISH

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31

These answers suggest the great difficulty—if not, indeed, the impossibility—of establishing a standard "workload" for all British general practitioners. What has been done by Parliament is to set the maximum number of patients a doctor may have—originally 4,000, now 3,500—but to permit each practitioner to accept, within that limit, as many patients as he feels able to handle, in fairness both to them and to himself. T h e result is a distribution which has given approximately one-half of the practitioners not more than 2,500 patients each, one-fourth from 2,501 to 3,000, and the other fourth from 3,001 to the maximum of 3,500. It is estimated that, on the average, about a third of the persons listed with a general practitioner will not ask for any service whatever in the course of a year, or perhaps over a longer period. O f the two-thirds who require attention, a few may have to be seen quite often. However, from surveys made of specific general practices, it appears that the number of times a British doctor is called upon for service amounts, on the average, to approximately five a year for each of his listed patients (including those who do not call on him at all). T h e ratio of office consultations to home visits is roughly two to one. Office visits differ greatly in the amount of time consumed, depending upon the needs of the patients; for it may take only a minute to write a work certification or renew a prescription, but perhaps a half-hour or more for the diagnosis of a new case. In like manner, an emergency home visit is likely to require much more time than an en-route call made with the thought of merely cheering-up a bed-fast patient. Available estimates indicate that ten minutes per "item of service" of all kinds is a fair average to employ in attempting to measure a general practitioner's work-load. Figured on this basis, it seems that a British doctor with the maximum number of patients (3,500) spends about fifty-seven hours a week ministering to their medical needs, as compared with about

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thirty-seven hours for a doctor with a list of average size (2,300). It is evident, then, that Health Service doctors are busy men; but that they are busier now than in pre-NHS days is definitely challenged by Professor Richard M . Titmuss of the University of London. Having examined fifteen "pieces of evidence," consisting chiefly of statistical surveys of high character, Professor Titmuss arrives at this conclusion: " T h e widespread belief, especially among the medical profession, that the advent of the National Health Service led to an immense increase in work for general practitioners is thus not borne out by the facts—and particularly the published facts by the [British Medical Association] itself." 1 7 It would be pleasant to report, if only it were true, that each of Britain's general practitioners is neatly fitted out with both the number of patients he wants to have, and the number he is able to serve most effectively. So happy an arrangement doubtless exists in individual instances, but hardly on a very wide scale. T h e right number of patients for a given practitioner would seem to depend upon a combination of such factors as the doctor's age, vitality, state of health, medical skill, ability to plan a j o b and see it through, and the location and territorial extent of the practice in question. Since the size of a general practitioner's income hinges mainly upon the number of patients he has, a money-minded doctor might be expected to want a large panel, and perhaps even one too large for the welfare of his patients. There are, on the other hand, a good many doctors who deliberately stick to panels of moderate size, either because they feel they cannot do full justice to a larger number or because they value leisure more highly than additional income. I recall two practitioners in different parts of London, both of whom appeared to be thoroughly competent doctors, devoted to their profession but well satisfied with small panels. One of these was a m a n about seventy years of age, who met

BRITISH

DOCTORS

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33

his 1,400 patients in a poorly furnished and somewhat shabby "'lock-up" office—one that is accessible only during office hours—in a low-income section of the city. He said that his current income met his needs, that he expected to retire before long anyhow, and did not care to have a longer list of patients. The second was a somewhat younger doctor who practiced in a more prosperous area. He had a panel of about 2,000, employed a receptionist-nurse, and had converted his livingroom into an unusually attractive waiting-room where (he told me with obvious pleasure) his patients loved to wait! He, too, was content with his panel of less-than-average size. " M y practice is very compact," he explained. " I do all my home-visits 011 foot, and have just enough patients to keep me nicely busy." But patients are not always easy to come by, and many practitioners have fewer than they want and some, no doubt, too few to make full use of their professional abilities. This was true of a young doctor in a Shropshire town of fifty thousand, who applied for and was assigned the worn-out practice of an elderly physician, recently deceased. The panel he took over had dwindled to 300; but he built this number up to 700 in the first year of his practice, and confidently predicted he would have three or four times as many "before too long." In the meantime, however, he was getting less professional practice and a smaller income than he could have used to advantage. In a crowded London street not far from Victoria Station, I was told by a discouraged practitioner that it was very hard for a young doctor to build up an independent practice "because of strong competition." After six years he had a total of only 700 patients, and felt strongly that general practitioners should be paid fixed salaries rather than incomes based on the size of their panels. T w o city blocks away was another doctor of about the same age, who had also spent about six years in practice in the same community, but whose steadily growing panel had passed the 2,000 mark. Located between the two

34

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was a partnership of three older practitioners, who collectively had 9,000 patients, the help of a secretary-receptionist and an office-nurse, and a well-equipped, smooth-running organization. T o this lay observer, it seemed clear that these three general practices had different grades of medical service to offer, and that through the operation of consumer-choice an appropriate distribution of the available supply of patients was gradually being worked out. Indeed, it has been claimed for the "capitation" (or per capita) system of paying doctors that it stimulates general practitioners to give their patients the best service they are capable of giving. The assumption is that the unquestioned right of patients to change doctors will be exercised whenever a patient gets the notion that another practitioner is better than the one he already has—and that the fear of losing patients, or the desire to attract additional ones, will supply the economic incentive needed to induce N H S doctors to compete with one another in trying to render the best service. In "underdoctored areas," where patients are so plentiful that every doctor can readily get as many as he wants up to the maximum, the principle is presumably not applicable. But in some communities at least, the general practitioners who reputedly are outstanding in the quality of service they give are also the ones with the largest panels—a fact which suggests that what one British economist has called "poor old competition" may have taken refuge and found a limited field of usefulness in the National Health Service. Before 1948, a British doctor was as free as a British manufacturer or merchant to carry on his vocation wherever he found what seemed to him a promising opportunity. As a result, the N H S inherited a geographical maldistribution of general practitioners which called for prompt action if all sections of the country were to have adequate family-doctor service. In some communities (such as working-class industrial

BRITISH

DOCTORS

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35

areas) there were fewer practitioners than were required to take care of all who, under the N H S , were entitled to free medical treatment. In other places (say, in middle-class residential towns) there were not enough patients to give to all of the already established doctors panels big enough to provide the standards of living to which these practitioners had been accustomed. " T h e r e has never [up to 1944] been any real means of securing that the doctors of the country are reasonably distributed. This has perhaps not been a pressing necessity while the scheme covered less than half the population, but it is wellknown that great disparities have existed," said the Churchill Coalition Government White Paper of 1944. T o remedy this situation, the Central Mcdical Piactices Committee (consisting mainly of doctors) classified every part of the country into one of three broad categories, according to whether the number of doctors in it was already adequate or more than adequate (a "restricted" area); whether the number was inadequate (a "designated" area); or whether, finally, it fell somewhere between these first two categories (an "intermediate" area), with the adequacy or inadequacy of its supply of general practitioners not as yet so definitely determined as in the restricted and designated areas. As an example of the maldistribution of family doctors before World War I I , Dr. R o b e r t Logan of Manchester University cites the fact that Hastings, a famous seaside resort in southeastern England, had one general practitioner to every 1 , 1 7 8 persons, while the ratio in South Shields, an important seaport and holiday resort in northern England, was one to every 4 , 1 0 0 . 1 8 Regulations have been passed for the purpose of reducing the number of doctors in restricted areas, and increasing the number in designated areas. New practices may not be opened in a restricted area unless and until the proper authorities decide that a new practice is desirable. When a practitioner is

36

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lost through retirement or death, a "logical successor" (a partner or assistant already in the practice) may be allowed to take over the list of patients thus made available. On the other hand, the local Executive Council may decide that these patients should be distributed among the practitioners already established in the area, if their panels are still small. (This would not be done by assigning patients to doctors, but by closing out the old practice and letting the patients choose freely from among the practitioners still active in the area.) If the doctor-patient ratio makes it desirable to bring in a new practitioner to take over the vacant practice, the council advertises the vacancy and the Medical Practices Committee assigns the post to the applicant who seems best qualified for the opening. It is not unusual for fifty to a hundred practitioners to apply for an especially attractive vacancy. Since designated areas are those which are underdoctored, applications to start new practices in such areas are granted readily, and indeed almost automatically. In areas which are sparsely populated or for some other reason are unattractive to medical practitioners, and which would provide insufficient income in the ordinary way to insure the maintenance of a satisfactory medical service, Initial Practice Allowances are sometimes made to assist doctors in setting up new singlehanded practices. These allowances are designed to make it highly probable that the practitioner's professional gross income will not be less than £ 1 , 2 5 0 ($3,500) in either his first or second year, and not less than £ 1 , 3 7 5 ($3,850) in his third year. Applications to practice in intermediate areas are "carefully considered" in the light of the conditions existing in a given area at a given time. 19 As the average number of patients per doctor increases in the restricted (overdoctored) areas, and decreases in the designated (underdoctored) areas, the total number of areas within these two classifications falls, and the number of intermediate areas

BRITISH

rises.

DOCTORS

AT

WORK

37

W h e n the doctor-patient ratio in a given restricted or

designated area has i m p r o v e d sufficiently, the area is reclassified

as intermediate.

W h a t e v e r progress has been m a d e in

redistribution shows u p in the shifts that take place in the relative i m p o r t a n c e of these three categories. In

1 9 5 2 , 4-5 per cent of the total population of E n g l a n d

and Wales was living in restricted areas, 5 1 - 3 per cent in designated areas, and 44 2 per cent in intermediate areas. Since c o m p a r a b l e figures for 1958 were, respectively, 5-0, 18 5, and 76 5 per cent, it is a p p a r e n t that the doctor-patient ratio had changed substantially for the better in this six-year period. 2 0 T h e i m p r o v e m e n t becomes even clearer when the underdoctored (designated) areas are c o m p a r e d with the a d e q u a t e l y doctored (intermediate plus restricted) areas. V i e w e d in this w a y , it is evident that the proportion of the population living in underdoctored

(designated) areas fell f r o m 5 1 - 3 per cent

in 1952 to 18-5 per cent in 1 9 5 8 , while the proportion that lived

in a d e q u a t e l y

doctored

(intermediate

and

restricted)

areas rose from 48-7 to 8 1 - 5 per cent of all the people. T h e Ministry of H e a l t h reported that 72 per cent of the people in E n g l a n d a n d Wales as a whole were on doctors' lists which did not exceed 3,000 patients each. 2 1 I f general practitioners c a n be kept f r o m going into overdoctored areas a n d induced to set u p practices in areas that are underdoctored, a substantial degree of equalization m a y be expected to result, in the course of time, to the a d v a n t a g e of both the doctors a n d the people w h o depend upon t h e m for medical service. P r e s u m a b l y , all parts of the country w o u l d in this w a y eventually become " a d e q u a t e l y d o c t o r e d , " unless the total supply of doctors a v a i l a b l e w a s smaller than the n u m b e r required to p r o v i d e proper medical attention for the total population. T h e average n u m b e r of patients per doctor would be roughly the s a m e in all " a r e a s " throughout the country, except in rural communities w h e r e doctors must travel long

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distances to reach their patients, and cannot be expected to serve as large a number as doctors in towns and cities. However, general-practitioner panels within a given area would doubtless continue to vary considerably, since their size would still be determined largely by consumer-choice, and would tend to reflect the patients' estimates of the relative merits of the doctors available in that particular area. Many young British doctors have discovered that it is not an easy matter to break into general practice on their own. However, this difficulty did not originate with the NHS. Before 1948, it was customary for a retiring physician, or the executor of one who had died, to sell the practice to a physician who was looking for an opening as general practitioner. It is quite possible that the necessity of finding funds to pay for a purchasable practice in those days was no less an obstacle to getting into practice than are the NHS "redistribution" regulations faced by the beginning doctor today. The advice usually given to young doctors who are determined to go into single-handed practice is " G o north, not south"—that is, go to areas where more doctors are needed, panels are more easily built up, and the newcomers may count on receiving a warm welcome from the underdoctored communities into which they bring medical service. Indeed, the Ministry of Health keeps reminding young doctors that "the difficulty of entering general practice is far greater in the south than in the north." 2 2 However, setting up a new, singlehanded practice anywhere presents so many problems that doctors are often warned against attempting it. According to the Committee on General Practice, headed by Sir Henry (later Lord) Cohen: " A period of assistantship [with an established practitioner] is normally the best introduction to general practice. For those who intend to remain in general practice it has unequalled educational value, and it is certainly the best means of providing a trial period during which doctors

BRITISH

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get to know one another before forming a partnership." 2 3 Lord T a y l o r (formerly Dr. Stephen Taylor), in his widely read Good General Practice, concurs in this view. After completing an eighteen-month survey, of which his book is a detailed report, he wrote: " I t has been generally agreed by the doctors visited in the survey that the ideal method of entry for the would-be general practitioner is a six- to twelve-month assistantship with a view, followed by a partnership if both sides are happy in their relations." 2 4 ("With a v i e w " means, in this connection, with a view to probable partnership.) Lord T a y l o r found that 70 per cent of the doctors enter general medical practice through "partnership with or without a period as an assistant, including 'logical successor' cases"— so that partnership clearly is "the main road to practice." T h e doctor's business arrangement with his assistant is a matter of agreement between the two; and since the assistant has relatively little bargaining power, he may get the short end of the deal if the principal is inclined to drive a hard bargain. T h e principal collects the capitation fees paid by the government for all patients in the practice (including those served by his assistant), and pays the assistant a salary which may be, and probably usually is, somewhat less than the assistant earns for his principal by the service he renders. As Lord T a y l o r points out, many doctors "treat their assistants fairly and well; but there is always the temptation to do otherwise." 2 5 T h e Cohen Committee reported some evidence of abuse of the doctor-assistant arrangements—that, for example, a principal may employ a series of assistants with a view to partnership, but the partnership never materializes! 2 6 T h e committee concluded, however, that " t h e doctor-assistant relationship is not more open to abuse than are other similar professional arrangements, and that on the whole there are sufficient safeguards." T h e question has been raised whether the profession of medicine, under the National Health Service, remains suffi-

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ciently attractive to insure the training of medical manpower to replace retired and deceased practitioners, and to provide as well whatever additional doctors might be needed to take care of increases in population. T h e problem is how to be sure of having enough but not too much medical manpower. As the Cohen Committee has said, it is "linked with wider questions concerning the rate of entry into the medical profession as a whole, and how much of the national income the Exchequer can afford for its Health S e r v i c e . " 2 7 Insufficient medical manpower would endanger the health of the country. M a n y people feel that the addition of enough practitioners to reduce appreciably the number of patients per doctor would be desirable, on the ground that it would provide more doctor's time per patient. But a reduction in the size of practitioners' panels, unless accompanied by an increase in the capitation fee, would mean smaller incomes for doctors and would not be welcomed by most medical men in Britain. In recent years, new admissions to the medical lists have exceeded the losses suffered through emigration, retirement, and death; and the net increase in the number of doctors has been greater than was required to maintain the doctor-patient ratio. " I f , " was the Cohen Committee's comment in 1954, " t h e rate of entry into general practice continues as at present, there will come a time in the not too distant future when the general medical service may be unable to continue to support this expansion." 2 8 This was also the view of the Willink Committee, which was appointed in 1955 to inquire into the future needs of medical manpower. In November, 1957, this committee recommended that a reduction of 10 percent be made, at "as early a date as is practicable," in the number of applicants admitted to medical schools. 2 9 However, the soundness of this policy has been challenged by such able scholars as Professor Titmuss ind Professor Lafitte.

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T h e N H S general practitioner ordinarily sees his patients in his surgery- or in their own homes. T h e N H S specialist, who is a salaried hospital staff officer, does his work at his hospital unless the patients he examines or treats are too ill to be moved from their homes. British specialists are graded on the basis of their age, training, and experience, and fall into five main classifications: Consultants (the highest grade), Senior Hospital Medical Officers, Senior Registrars, Registrars, and House Officers. An N H S specialist practices in one (or occasionally in more t h a n one) of twenty-two fields of specialization, which run alphabetically from Anaesthetics to Venereology. Responsibility for the appointment of specialists is shared by several boards in each of the hospital regions (fourteen in England and Wales, five in Scotland) into which Britain has been divided to insure that patients in all parts of the country shall have ready access to hospital and specialist service. In the British view, illnesses that can be handled satisfactorily in the patients' homes should be treated there, and not in hospitals. Hospitals are thought of as institutions for taking care of the seriously ill, whose ailments require the use of modern hospital equipment, or perhaps the services of physicians whose long experience as specialists has given t h e m special skill in the diagnosis and treatment of certain diseases. In requesting that a patient be admitted to a hospital, the general practitioner says, in effect, that he is u n a b l e to provide the medical care he feels his patient requires. I n admitting a patient, the hospital authorities accept full responsibility for his care, and they (and not the general practitioner) decide what the course of treatment shall be. If the general practitioner visits a patient d u r i n g his stay in a hospital, it will in all probability be a social and not a professional call. T h e acceptance of responsibility for the patient's welfare is thus linked with full authority for the specialist to follow whatever medical procedure he considers best, without general-practitioner participation. A n d the family

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doctor, having delivered his patient into what he regards as safe hands, is free to give his undivided attention to cases which he feels quite competent to handle himself. " I am much too busy to take on hospital beds," says one general practitioner. "Besides, I don't need them. If I cannot look after a patient at home, it is almost always because they need some special investigation or treatment, calling for an expert." 3 0 Like the general practitioner, the specialist may join the Health Service on either a whole-time or part-time basis. But unlike the practitioner, who receives a fixed annual fee for each of his patients, the specialist is paid a salary (the amount of which depends upon his rank and length of N H S service) for the "half-days" (of, theoretically, 3 J hours each) he works in the course of a week. Eleven half-days (a total of five and a half days) constitute whole-time service; but a doctor may become a part-time specialist, with the proviso that the maximum number of half-days per week for which a part-timer can be paid is nine. Specialists and general practitioners may both add to their incomes by taking on private patients, in addition to carrying on their N H S activities, or by accepting other remunerative appointments which do not interfere with the proper performance of their Health Service duties.* The pre-NHS maldistribution of general practitioners (discussed earlier in the chapter) was paralleled by a maldistribution of specialists, with perhaps an even greater waste of medical skill than resulted from overdoctoring and underdoctoring by the general practitioners. For the concentration of first-rate specialists in the big cities, where they could find enough well-to-do private patients to give them substantial incomes, had led to a severe shortage of such doctors in the small cities, towns, and villages, leaving many communities with few if any really expert specialists and consultants. Lord * Detailed information about pay for both general practitioners and specialists will be found in Chapter 4.

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M o r a n , w h o was President of the R o y a l College of Physicians for a decade, has described the redistribution of consultants and other specialists under the provisions of the National Health Service A c t : Before

the

National

Health

Service

[he

writes],

consultants

congregated in the great centers of population. It was economically difficult or impossible for m a n y consultants to exist outside these centers, because there was no scope for private practice. T h e Service, by p a y i n g consultants for their hospital work, made it possible for them to work outside the big cities. Moreover, the consultant was content to leave L o n d o n for a small and distant town because he knew he would have the same chance of a merit award there as in London. It is not only that the consultants have been redistributed over the country, but that there are m a n y more of them. For example, in the Newcastle R e g i o n there were 164 consultants in 1949. In 1957 there were 409. Moreover, it is not only possible at the present time to consult a specialist in hospital. T h e general practitioner can call a consultant to a patient's house without worrying about the financial implications. In 1956 there were 265,000 domiciliary consultations. 3 1

Dr. Robert L o g a n has also commented on the effectiveness of this redistribution: " T h e regional system of [hospital] organization has produced a distribution of specialist skills superior to any in the world; nowhere outside Britain can provincial areas boast such a range and calibre of specialist services. . . . [This] spread of specialist services makes it possible for [the general practitioner] to have free specialist opinion in slum, cottage, or farm, or obtain direct hospital x-ray or laboratory investigation." 3 1 T h e general practitioner is the doctor upon w h o m nearly all N H S patients first call for help in time of illness, and indeed the only doctor w h o is ever consulted by the great majority of patients. Probably for these reasons, he is often referred to as the keystone (or linchpin, or pivot) of the Service. But when serious illness strikes, the specialist (with his greater skill in a narrower field) becomes the man of the hour. T h e services of

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both general practitioners and specialists, and complete hospital service as well, are essential parts of a comprehensive system of medical provision; and all three of these are available to rich and poor alike, without payment, under the British National Health Service.

Section 21 of the National Health Service Act of 1946 made it the duty of local health authorities to establish, equip, and maintain "premises which shall be called 'health centers,' " and thus to provide under one roof general medical, dental, and pharmaceutical services, as well as specialist and other outpatient services that are the responsibility of the local health authorities under the act. It was intended that there should be one health center to about every 10,000 to 15,000 people, with consulting-rooms for six or eight doctors. T h e centers would house the health clinics of the local authorities, and the outlying clinics of the hospital services. It was expected that they "would develop teamwork, with its cross-fertilization of ideas, and enable doctors to specialize among themselves. T h e y would be convenient for the general public, and would give much relief to overworked doctors and their harassed wives." 3 3 Even before the N H S began operations, it became evident that the development of health centers would be slow. In J a n u a r y , 1948, six months before the actual start of the Service, the local authorities were asked by the Ministry of Health to postpone their plans for health-center construction. T h e reasons given for the delay were the shortage of building materials and the feeling that "the extensive provision of health centers should wait on the experience to be gained from the use of a limited number of experimental centers." 3 4 In the first ten years of the Health Service, only ten centers were established under the provisions of Section 21 of the act, running in cost from £ 4 0 0

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($1,120), for adapting old quarters to health-center needs, to the £178,000 (nearly $500,000) spent by the London County Council in building, furnishing, and equipping the Woodbury Downs "full-scale health center for a population of 20,000 persons" in the Borough of Stoke Newington. Some additional centers have been built "outside the statutory provision of Section 2 1 , " with financial assistance from the Nuffield Trust, the Rockefeller Foundation, the City of Manchester, and other agencies. ss The scarcity of funds for capital investment, which interfered with as rapid construction of hospitals in Britain as could have been used to advantage, has retarded also the growth of health centers and of other kinds of social provision as well. Speaking from the experience of the first five years of the Health Service, Lord Taylor wrote in 1953 that "at present a widespread health-center building program, to cover the country, at a cost of perhaps £7,000 [about $20,000] for every thousand potential patients, could have a much lower social priority than houses, schools, hospitals, or mental-defective institutions." He estimated, however, that a good group-practice building could be constructed at a cost of not more than £ 1 , 0 0 0 or £2,000 [$2,800 to $5,600] per doctor, and suggested that, "now that the local health authorities are thinking in more modest terms, the Ministry of Health should allow them to undertake more experiments." 34 The experiments that took place in the following five or six years included not only the establishment of additional health centers, as noted in the preceding paragraph, but also a very substantial growth in the formation of partnerships and group practices among general practitioners. By J u l y 1, i960, more than two-thirds of the NHS general practitioners were members of partnerships; and of these 13,936 partners, about one-half were in partnerships consisting of three or more doctors each. 37 " T h e essence of simple partnership," says Lord Taylor, "is that

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each practitioner works from his own surgery and keeps his own list of patients. The partners pool their takings and expenses, and divide shares on an agreed basis. They also relieve each other over night-work, at off-duty and holiday times, and in emergencies." 58 According to Lord Taylor, a partnership becomes true group practice when it consists of at least three doctors; when these doctors work from a single building which houses their main surgeries; when they have two or more ancillary helpers (secretaries, nurses, etc.); when they co-operate to give complete coverage for their patients, and adequate off-duty and holiday time for themselves; when they co-operate clinically, seeing each other's patients on request; when each doctor develops some special medical interest within the sphere of general practice; when the doctors own or rent the building from which they practice, and control the way it is used, and also control the composition of the group—that is to say, the entry of new members and the dismissal of existing members; and when financial partnership is practiced. 3 * Any group of general practitioners that can satisfy these requirements of "true group practice" is surely on its way to winning, for both the doctors and their patients, many of the advantages that health centers are said to provide. It is not known accurately how many group practices are in operation, or how well those that exist would measure up to the criteria set up by Lord Taylor. It seems clear, however, that the Ministry of Health is at least temporarily more kindly disposed toward group practice than toward health centers. For in 1953 a Group Practice Loans Fund was created, for making interestfree loans "to doctors working in group practice, to enable them to acquire and/or adapt central surgery premises from which members of the group must practice." 40 The total amount available annually for this purpose is £88,000 (about $250,000). Of the 323 applications that have been considered

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since the fund was set up, 144 have been a p p r o v e d — a b o u t half of them for establishing entirely new central premises. T h e total amount allocated up to December, 1958, was £677,693 (approximately $1,900,000). T h e r e has been some criticism of successive ministers of health for their failure to push vigorously the development of health centers, which were once expected to become an outstanding feature of the N H S . However, the ministry's policy in this matter has seemed to be in line with the views of general practitioners and patients in general, and with those expressed by the Cohen and Guillebaud Committees. T h e future of group practice and health centers is discussed in this paragraph of the Cohen Report: Many of the advantages both to doctors and to patients, which have in the past been urged in favor of health centers, may it is hoped be more easily secured through the evolution of group practices consisting of doctors who have chosen to work together in communal premises which they own themselves. These doctors can design their own premises to suit their own particular requirements and alter them later if experience shows this to be desirable. A member of such a group who fails to work harmoniously with the others can either resign or be induced to retire from the group without the publicity or slur upon his reputation which might attend such a move were he practising in a health center. Moreover, group practice is an easy and natural evolution from partnerships which are already in existence.41 T h e Guillebaud Committee, reporting two years later, tells of a change that took place in the attitude toward health centers " w h i c h was shared by a great many people, including quite a large proportion of the medical profession, before the inception and during the first few years of the National Health Service." In more recent years, however, there has been a marked swing 01 opinion against any wide-scale provision of health centers, and there are many who now doubt the wisdom of expending any large amounts of money for this purpose at least until more experience

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has been gained about the working of the existing centers. Indeed, the great majority of our witnesses have taken the line that health centers must for some time remain in the experimental phase, and that meantime other experiments should be carried out to discover how far group practice, working in close association with maternity and child welfare and school clinics, might be able to provide some at least of the benefits of a health center at a much lower cost. Future developments should then be based on the experience gained from both the health center and group practice experiments 42

3

THREE STUBBORN HEALTH SERVICE PROBLEMS

Some of the views on the National Health Service, which have from time to time been expressed in both Britain and the United States, have stated quite bluntly that the general practitioners in the Service were being greatly overworked— that the Ministry of Health had given them an exceedingly heavy load of "paper w o r k " ; that their patients (because the service was free) kept them busy attending to the most trivial ailments; that, in general, the doctors had so many patients that they could not possibly give them proper care, and so on. What do the doctors themselves have to say about these charges of overwork ? How serious, for example, is the problem of paper work, which includes keeping medical records for each patient; issuing medical certificates of many kinds; and, indeed, handling any or all of the forty-three "forms in general use by doctors," the mere listing of which fills two pages of the General Practitioners Handbook? The fact is that some of these forms are used often, others seldom, and still others almost never. To my question: " D o you find the volume of 'paper work' very burdensome?" only 39 per cent of my doctors said Yes, while the other 61 per cent said No. Some doctors volunteered the information, which was later widely confirmed by others, that the increase in certain kinds of paper work has been largely, if not fully, offset by the almost total disappearance of one especially unpleasant type—billing their private patients 49

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for services rendered. Because some 97 per cent of the British people have joined the N H S , and are no longer on a fee-forservice basis, the irksome task of billing patients has been virtually wiped out. It should be noted that the trend toward general-practitioner partnerships, which has been quite pronounced during the past five or six years, has helped to lessen the burden of paper work. A partnership of two or more doctors is often able to afford secretarial help, and thus is relieved of much of the handling of medical records and other office chores which are performed personally by many of the single-handed practitioners, as the British call them. The latest figures show that on J u l y 1, i960, more than 70 per cent of the British general practitioners were in partnerships. Slightly less than half of the partnerships consist of two members, the rest of three to six or more doctors. T h e partnership form of organization offers general practitioners many advantages over single-handed practice. Depending upon the size of the partnership and the total number of patients it serves, it may not only relieve the general practitioners of most of the drudgery of telephoning, record-keeping, and letter-writing, but make it possible also to employ a parttime or full-time receptionist, and an office nurse who can take care of such things as bandage-changing, inoculations, and immunizations. A highly prized advantage of the partnership form of general practice is the opportunity it affords to organize a " r o t a " system of partnership duties, which insures the members, in their turn, regular nights-off, free week-ends, vacations, and perhaps even an occasional chance to attend refresher courses, and thus keep in touch with recent advances in medical knowledge. (The attendance at such courses has shown a steady increase, year by year; for example, it was nearly 12 per cent greater in i960 than in 1959.) Rota systems often extend far beyond partnerships, and sometimes include all the doctors in a town. Within reasonable

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limits, the more participants a rota system has, the more fully can it perform its function of giving each m e m b e r free time, while at the same time making certain that any of his patients w h o need medical attention w h e n he is off d u t y will be properly cared for. T h e r e is fairly general agreement a m o n g British

general

practitioners that some patients call upon t h e m for service so often as to m a k e nuisances of themselves. ( A m e r i c a n doctors m a y h a v e a similar feeling about their patients, but in the United States the patients p a y each time for the privilege.) T h e specific question I asked the British doctors in this connection w a s : " D o patients often, occasionally, or almost never take u p your time with very minor a i l m e n t s ? " Forty-nine (49) per cent said ofien, 30 per cent, occasionally, 21 per cent, almost never. F r o m these replies, it w o u l d seem that four-fifths o f these doctors feel that part of their time is being spent on patients w h o need little or no medical treatment. H a v i n g duly recorded each doctor's answer, I frequently pursued the matter a litde further, asking " W h a t do

you

consider a very minor a i l m e n t ? " T h e wide variety of reactions to this q u e r y suggests the improbability of being a b l e to arrive at a w o r k a b l e definition w h i c h would enable the l a y m a n to know, unless he was experiencing considerable p a i n , w h e t h e r or not his condition warranted a visit to or f r o m his doctor. Several doctors a r g u e d strongly that it is the doctor's j o b — a n d not his p a t i e n t s ' — t o decide whether there is need for treatment, and that patients should be encouraged to seek medical advice freely. A s one doctor put it: " A patient should see his doctor w h e n e v e r he feels at all below par. I f he doesn't, he will be worried a b o u t his condition. W h a t m a n y patients need most o f all is reassurance." T h o u g h very frequent office visits are regarded w i t h disapproval b y m a n y general practitioners, especially w h e n they turn o u t to be unnecessary in the doctor's j u d g m e n t , they are

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not always r a t e d b y h i m as " u n p r o d u c t i v e l a b o r . "

"Do

you

t h i n k , " I a s k e d m y d o c t o r s , " t h a t requests for m e d i c a l a t t e n t i o n f o r v e r y m i n o r a i l m e n t s lead o f t e n , o c c a s i o n a l l y , or a l m o s t n e v e r to t h e p r e v e n t i o n o f serious a i l m e n t s or to their d e t e c t i o n w h i l e still in t h e i r e a r l y s t a g e s ? " T h e a n s w e r s w e r e : often,

u

per

c e n t ; occasionally, 60 p e r c e n t ; almost never, 29 per c e n t . T h e s e replies a r e p a r t i c u l a r l y

interesting w h e n considered

side

by

side w i t h the a n s w e r s to t h e p r e v i o u s q u e s t i o n . F o r against the g l o o m y c o n c l u s i o n r e a c h e d b y most o f these p r a c t i t i o n e r s , t h a t s o m e o f their t i m e is t a k e n u p b y patients w i t h v e r y

minor

a i l m e n t s , c a n b e set the c o u n t e r v a i l i n g c o n s i d e r a t i o n t h a t r e a d y access to m e d i c a l service s o m e t i m e s l e a d s to the p r e v e n t i o n or e a r l y d e t e c t i o n o f serious a i l m e n t s . T h e n e e d for g e n e r a l p r a c t i t i o n e r s to g i v e e a r l y a t t e n t i o n to even

t h e slightest a i l m e n t s o f their patients,

to t h e end

of

h o l d i n g to a m i n i m u m the s u m total o f serious illnesses, has b e e n stressed b y D r . Peterson, the A m e r i c a n d o c t o r w h o w a s cited in C h a p t e r 2. T h e volume of work confronting the general practitioners, increased as it has been by the National Health Service, is unfortunately the subject of many political and emotional attacks upon the N H S [says Dr. Peterson]. Such criticism presumably rests upon the assumption that medical services for w h i c h no direct fee is paid are often trivial or unnecessary. . . . T h e r e does not appear to be any evidence that abuse, in the sense of actual fraud or really frivolous demands upon the doctor, is a n y t h i n g but rare. T h e charge of " a b u s e " more often appears to mean demand for treatment of minor illnesses w h i c h the C o h e n C o m m i t t e e defined as the sphere o f the general practitioner, or for treatment of emotional problems w h i c h certainly only the doctor can treat. . . . T h e patient's feeling that he needs the help o f the doctor is the only practical method of deciding w h i c h patients are in need of general practitioner services. It is necessary that patients should consult their doctors for minor conditions if preventive medicine or early diagnosis of serious diseases are to be a m o n g the functions of general practitioners. 4 3

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I have quoted this American view at some length because it seems, on the whole, to express quite well the attitude of many British doctors toward the problem of minor ailments. Most of these general practitioners would welcome a solution to the problem, but would be reluctant to adopt measures which might lighten their work-load to the possible detriment of their patients. " I think an increase in the prescription charge by five times would keep away the minor ailments, but of course it might also keep away the more serious ones," says a doctor in the Cotswolds with a practice of average size. "Earache comes to mind. As a result of encouraging people to let us know as each child gets earache, it has been possible to eradicate mastoid infections completely." T h e inability to get immediate treatment in case of illness is understandably a matter of concern to both patients and doctors, though chiefly no doubt to the former. Waiting of any kind is likely to be tedious business, and waiting for medical service is no exception to the general rule. T h o u g h medical attention is not always sought promptly, it is a type of service which, once definitely decided upon, is usually wanted without delay. Waiting in doctors' surgeries and in out-patient departments of hospitals is an old story in Britain, but it increased enormously with the greatly expanded demand that followed the introduction of nation-wide medical provision in 1948; and much has been written and spoken (especially by people unfriendly to the Service) about the interminably long waits to which the Health Service patients are said to be subjected. Some of these waits are indeed long, but some are quite short, as I can testify from personal experience. I think it highly probable that in 1956 I did more waiting to get generalpractitioner attention than any other person in Britain. T h e attention I wanted was interviews with the doctors, who granted them willingly and generously. I discovered that the

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simplest way to meet a doctor was to walk into his waitingroom, unknown and unannounced, and join the patients who, true to the good old British custom of "queuing u p , " were waiting their turn to enter the consulting-room. By waiving my turn and waiting until the last of the bona-fide patients had gone in, I was able to talk to the doctor at once or to arrange for an interview at his convenience; and meanwhile I could note approximately how long each patient had had to wait, and how much time each was given by the doctor. From these "long waits" of mine—often repeated three or four times a day for many weeks—I learned that the time a patient spends in the doctor's waiting-room is long or short, depending upon such things as the hour at which he arrives; the nature of the ailments of the persons who precede him, for this will affect the amount of the doctor's time they take up; and the time of year, for waits are usually much longer in the busy winter season than in the relatively slack summer. Unfortunately, much of this information proved interesting rather than important, for it did not lend itself to useful generalization. The question which I finally asked the patients I interviewed was this: "How often, in the past year or so— usually, occasionally, or almost never—have you had to wait as long as hours in the doctor's surgery before getting attention?" Six (6) per cent replied that they usually had to wait that length of time; 15 per cent said occasionally, 79 per cent,. almost never. By 15 per cent of the persons answering this question, the category "almost never" was rejected and an unqualified "never" substituted, producing the following corrected tally: usually, 6 per cent; occasionally, 15 per cent; almost never, 64 per cent; never, 15 per cent. A very few patients went so far as to reply "certainly never" or "absolutely never." By reaching the doctor's office a little earlier than the announced office hour and hence before many others have arrived, or by getting there just a few minutes ahead of the

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scheduled closing time and thus after most of the patients have come and gone, a person may be able to avoid long waits. However, if the doctor happens to have a lock-up surgery (one that is not open until he himself turns up at the established hour—or, as sometimes happens, even later than that hour), early arrival is scarcely a satisfactory solution of the problem of long waits unless the weather is fine. There are tales of mothers with small children who have had to await outside, in rain or snow, the coming of their general practitioners; and these stories doubtless have some basis in fact. But my personal experience suggests that doctors' surgeries are, in general, open well ahead of the stated time; that they are almost never locked up before the posted closing hour; that all patients who are in the waiting-room at closing time are given whatever treatment they require before they leave; and that admission is rarely denied a late-comer if the doctor is still on the premises. My after-hours interviews with general practitioners were at times interrupted by tardy patients, and with no show of annoyance or even surprise on the part of the doctors. It might seem obvious that the use of an appointment system, which assigned a specific time at which the doctor would see each patient seeking treatment, would greatly reduce the amount of time that is now being wasted in surgery waitingrooms. The fact is that the relatively few general practitioners who have operated successfully under such a system are loud in its praise; that a slightly larger number have tried to introduce the system into their practices, and failed; and that the great majority, perhaps influenced largely by the experience of this second group, have never given it a trial but feel quite certain that it is not for them. "It is remarkable that appointments systems should have developed so little," says Lord Taylor, who endorses them strongly and cites several striking examples of their successful operation. "The cause appears to be almost entirely the firm belief of the GPs that they cannot

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be worked, and that the patients will not co-operate. . . .

If

appointments systems b e c a m e general, it would be a big step forward in the organization of medical practice." 4 4 A n o t h e r possible explanation of the doctors' lack of interest in a p p o i n t m e n t systems is the feeling of m a n y general practitioners that w a i t i n g in surgeries does not, after all, constitute a real hardship for their patients. Whether this conclusion is warranted or not depends, a m o n g other things, upon whether the waiting-room is sufficiently large and adequately furnished to a c c o m m o d a t e all patients without any having to stand; whether the lighting, temperature, and ventilation are satisf a c t o r y ; and of course w h e t h e r it is kept neat and clean. A few of the waiting-rooms I visited could properly be described as genuinely attractive; a few again were bare and forbidding enough to m a k e an hour seem at least twice as long. T h e great majority were quite adequate for a wait of moderate length; and the waiting patients gave little evidence of impatience at their not getting speedy entry to the practitioner's consulting-room. T h e doctors' attitude t o w a r d surgery-waiting is indicated by their answers to m y specific question: " D o y o u regard the problems of 'long waits' as a really serious problem at the present t i m e ? " T w e n t y - f i v e (25) per cent of the general practitioners interviewed said Yes; 75 per cent, JVo. N H S patients w h o seek medical attention are expected to report in person to their doctors during surgery hours, if they are well e n o u g h to do so; b u t it is the doctor's responsibility to visit in their homes " a n y of their patients whose condition so requires,"

as the

General Practitioners Handbook points

out.

T h o u g h the ratio of surgery-attendances to home-visits varies greatly a m o n g doctors, L o r d T a y l o r suggests that " a n efficient and conscientious doctor will probably have an A : V [surgeryattendance to h o m e visit] ratio of 3 : 1 or less"; and adds that any doctor w i t h a higher

figure

than three attendances at

surgery to one visit in the h o m e "should ask himself candidly

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whether he is exercising too great a pressure on the patient to attend at the surgery." 4 5 M y own survey did not inquire into the relative frequency of surgery and home services, but asked the patients the following question about long waits in connection with home visits: " I f you have ever required an urgent home visit, did your doctor usually, occasionally, or almost never arrive within two hours of being c a l l e d ? " Eighty-nine (89) per cent replied usually, 7 per cent, occasionally; 4 per cent, almost never. (Five per cent of the 89 per cent, who are reported above as having answered " u s u a l l y , " in fact reworded their replies to read that their doctors always arrived within two hours of being called.) Though about 60 per cent of the total annual expenditure for the National Health Service consists of hospital and specialist costs, there has always been, and continues to be, a shortage of hospital service, both in-patient and out-patient, and a long list of applicants waiting for appointments. For despite the almost revolutionary improvements that were made in British hospital plant and staff during and after World War I I , the unprecedented demand for hospital service which accompanied the adoption of the Health Service in 1948 was one that was bound to outstrip supply for years to come. T h e latest published figures show that 011 December 3 1 , i960, there were in Britain 466,000 persons on hospital waiting lists. However, waiting-list figures show a decrease from a 1950 peak of 5 3 1 , 0 0 0 to the i960 total of 466,000—a slow but fairly steady decline. Some 4,136,000 persons received inpatient treatment and were discharged from N H S hospitals in i 9 6 0 — a n increase of 136,000 over the previous year. About 74,000 received day-patient treatment. Hospital out-patients in all departments and clinics numbered 12,768,000 in i960. On the average, they attended clinics somewhat oftener than

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three time during the year, with a total of almost 42 million clinic "attendances" by out-patients in 1960." T h e data available on out-patient and in-patient waiting (though official, and doubdess better than no figures at all) must not be taken too seriously. T h e national totals, published by the Ministry of Health, are arrived at by adding up the local waiting-lists, which are subject to error for a variety of reasons. Professor Lafitte has given the matter much attention, drawing upon studies of waiting lists for particular towns, and has come to the conclusion that far fewer people are waiting for hospital service than the numbers on the waiting lists suggest. For example, some persons, after their names were listed (1) have gone into another hospital; or (2) no longer wish, or need, hospital care; or (3) have moved elsewhere; or (4) in some instances have died. There is also a certain amount of deliberate duplicate listing, with the same patient getting his name on the lists of two hospitals. Some patients are listed who do not really need hospital care at all, and who when their turn comes are unlikely to be admitted. For these and other reasons, the official figures make the hospital-waiting situation look worse than it actually is. O n the other hand, as Professor Lafitte points out, there are doubtless some patients who should be (but are not) in hospitals, and who nevertheless remain unlisted. " T h i s applies especially to chronically ill and elderly patients, whose nursing at home sometimes (though not always) causes an intolerable burden on relations or landladies." T h e national list for such patients is surprisingly small, probably (Professor Lafitte suggests) because both the general practitioners and the families of these persons have given up hope of ever getting them into hospitals. An N H S general practitioner who is not completely satisfied with his own diagnosis or treatment of a patient's illness has the definite obligation to see that the patient gets whatever further

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professional care is needed. He may turn him over to a specialist whose experience with the suspected ailment, or whose facilities for diagnosing it, are superior to his own. The procedure usually followed in getting specialist diagnosis or treatment is for the general practitioner to refer his patient to a hospital as an outpatient, perhaps indicating specifically "Dr. So-and-So's clinic." If the patient is too ill to go to the hospital, the specialist will visit him in his own home. As a result of the specialist's examination, the patient may be given home, out-patient, or in-patient hospital treatment by the specialist himself, or he may be returned to the care of his family doctor. When a general practitioner decides to refer his patient to a hospital out-patient department, he may find that the earliest appointment that can be made is days or even weeks in the future—unless the case appears to be an urgent one. And when the patient reports to the hospital at the appointed time, he may have to wait a while before reaching the doctor who is to examine him. I asked the patients who took part in my survey how often they had waited more than two hours as out-patients before seeing the doctor with whom they had an appointment. Thirteen (13) per cent answered that their wait was usually longer than two hours; 25 per cent said occasionally, 62 per cent, almost never. Many out-patient departments have, in the past, required all the patients scheduled for a given clinic to report at the very start of the clinic, with a consequent waste of time for those whose examinations came toward the end of the session. It is now fairly common practice to give each out-patient an individual appointment, or to call patients in groups of two or three at short intervals. Reporting great improvement in the matter of out-patient waits, the Minister of Health stated in 1956 that in the vast majority of hospitals the average waiting time (that is, from the time of the appointment to the time when seen by the doctor) did not then exceed thirty minutes,

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and was frequently less.* The general practitioner has authority to arrange a home visit by a specialist for any patient who, in his opinion, requires such service but whose condition makes inadvisable a trip to the hospital for an examination. Among the people on hospital in-patient waiting lists are many kinds of illnesses, and many degrees of urgency. Here again, faced with a shortage of hospital facilities, the British medical authorities follow the principle of "first things first," and try to insure that patients whose lives might be endangered by a delay in treatment are cared for ahead of those whose ailments are of a less serious nature. Theoretically, every Health Service patient is entided to the best that British medical skill can provide, and as promptly as possible; but the speed with which the service is rendered is likely to vary with the nature of the case. If what is indicated is nothing more pressing than an operation for hernia or a tonsillectomy, a patient may be in for a moderately—or, as it will probably appear to him, immoderately—long siege of waiting before he is asked to report to the hospital for the required surgery. On the other hand, internal bleeding and certain types of abdominal pains are viewed with great respect, and receive first priority. The testimony of practitioners seems to indicate that, in general, they can get hospital service for their patients when it * " T h o u g h waiting for the doctor can be a worry, it is possible to make too much of it," says the British Medical Journal editorially in its issue of October 1 1 , 1958. " T h a t it should be a cause of complaint among patients is natural^-travellers complain about delay on the railways, litigants about delay in the courts, and babies about delay in getting the next feed. As is well known in hospitals, these are often as much problems of human personality as of administrative machinery, and in the great majority of hospitals a proper concern for the patients' welfare is never allowed to become obscured on the one hand by forgetfulness, or on the other by over-zealous supervision. A n d has it escaped the investigators' notice that for many people the regular visit to the out-patient department is the equivalent of going to a club for a good gossip?"

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6l

is clearly important to do so. "When you refer patients to hospital for examination or bed-occupancy, do you have difficulty getting them admitted promptly ?" I asked my doctors. Seventy-three and one half (73 J) per cent said No. The other 26^ per cent said Yes, frequently adding "unless very urgent," and explaining that their greatest difficulty was gaining admission for chronic invalids and for the aged, who are likely to be long-term inmates once they get in. In i960, for example, the average duration of hospital stay of the chronic sick was 149 days. In the early days of the National Health Service, some credence was given to the rumor that the N H S hospitals were so largely filled with malingerers as to crowd out people who were sorely in need of hospital care. One American who wrote several magazine articles on the N H S informed his readers that it was "virtually impossible for hospital managements to sift out the malingerers and those who exaggerate their illnesses and demand care as a government right." In support of this statement he told the story of an old lady, " a cheerful soul" named Granny, who in February, 1949, died of pneumonia because a bed could not be found for her in the crowded London hospitals. He added that "in the first year of the [NHSJ program, in the London area alone, more than 5,000 emergency patients, most of whom were elderly folk like Granny, could not find beds," and proceeded to the conclusion: "There are no nationwise statistics of such failures, but proportionately the total would be 30,000 per year." 4 7 However convincing this type of argument may have seemed at that time, it would appear to have little validity today. T w o of the questions which I put to general practitioners in my survey brought answers that should be reassuring to "Grannies" now living under the National Health Service. The notion that "patients who genuinely require hospital treatment are often kept out of hospital beds because the beds are occupied by

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persons with minor ailments" found support from only 2 J per cent of the doctors questioned. Twenty (20) per cent said this occurs occasionally. According to 77 per cent of the respondents, it almost never happens. The improbability of seriously ill persons being crowded out of hospitals by the unduly long stays of those with trivial ailments is noted by the Guillebaud Committee: " I t is, after all, the [hospital] doctor in charge of the case who decides when a patient shall be admitted or discharged; and, with the continuing pressure on hospital beds, the patient is unlikely to remain in hospital any longer than is necessary either for his treatment or for making alternative arrangements for his accommodation." 48 To the short but particularly important question, "Would it be correct to say that 'an emergency case can always get into hospital promptly' ?" the answer from 98 per cent of the doctors was an unqualified Yes. It seems clear that if anyone in Britain is going without adequate medical provision under the National Health Service, it is not the seriously ill. After reading a preliminary report of the views of British doctors and patients I had interviewed, Mr. Arthur Blenkinsop (who was Parliamentary Secretary to the Ministry of Health during the 1948-51 Labor party regime) commented: "Above all, you are right to emphasize [as you do, by giving exact figures on the doctors' and patients' answers to your specific questions] the almost unanimous opinion about the high standard of care of urgent and important cases, while there is much more division of opinion about the treatment, and the waiting for treatment, of relatively minor complaints."

4 PAYING FOR THE NATIONAL HEALTH SERVICE

The National Health Service was large-scale even at the start, and is somewhat larger today. The population of England, Scotland, and Wales is about fifty million, of whom some 97 per cent have joined the NHS as patients. An estimated 98 per cent of both the 23,000 doctors in general practice and the 7,800 consultant-specialists, and about the same percentage of all persons in general dental practice, have joined on either a full-time or part-time basis. Most of the oculists, and practically all dispensing opticians and druggists (or "chemists," as they are called in Britain), are in the Service. In the NHS, too, are Britain's 36 teaching hospitals, and 2,681 non-teaching hospitals (all but about 300 of the country's total), with some 507,000 beds. On hospital staffs are 153,000 full-time and 41,000 part-time nurses; outside the hospitals arc 10,000 home nurses. There are in addition, of course, many thousands of other workers—administrative, clerical, professional, technical, and so on, full-time or part-time, some paid and some voluntary—whose services are used by the NHS. The total number of men and women employed in the Service was recently estimated at more than a half-million, of whom about four-fifths are full-time workers. A n undertaking of such size is bound to be costly, and the N H S turned out to be unexpectedly so. In 1949-50, the total 63

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cost of the Service was about £ 4 4 0 million ( $ 1 , 2 3 2 million); by 1956-57 the figure was £ 6 5 9 million ( $ 1 , 8 4 5 million). In J u l y , 1958 it was estimated that total N H S expenditures might reach £ 7 4 0 million ($2,072 million) by 1959-60. 4 8 T h e actual gross cost for that year was £ 7 2 6 million ($2,033 million). These substantial increases were due in part to the advancing age of the population and the increasing use being made of the Service. But they were also largely attributable to the costliness of present-day drugs and hospital care, which is related to the steady rise that took place in the general price level and added at least 25 per cent to the money cost of consumer goods in Britain since 1949. Another way to figure the cost of the N H S (and the one used by the British Institute of Economic and Social Research) is to calculate the proportion of the gross national product that is required to carry on the Service year by year. Figured on this basis, N H S costs have been remarkably stable over the years. In 1949-50, the first full year of the National Health Service, Britain spent a little less than 4 per cent of her gross national product on the N H S . Since then, the proportion of national product used for the Service has varied slightly year by year, but has not exceeded the percentage used in 1949-50. T h e pounds-sterling comparison of N H S costs in 1949-50 and 1959-60, made in the last paragraph, will be regarded by some as evidence that these costs have been skyrocketing—for a 65 per cent rise in ten years is undeniably a big increase. T h e present statement—that the Health Service has not, in any year, taken more than 4 per cent of the gross national product (and in 1959-60 took only 3-2 per cent)—is far less startling, but would seem to give a clearer picture of the degree to which the N H S may properly be regarded as a real cost to the country. Expressed in pounds that have not been corrected for changes in the general price level, N H S costs give the appearance of having increased enormously; expressed as a percentage of the gross national product, they are notable for their stability.

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Dr. Brian Abel-Smith (joint author, with Professor Titmuss, of The Cost of the National Health Service in England and Wales, which provided the basic statistical material for the Guillebaud Report) noted in 1956 that up to that time "the share of the community's resources used in the Service" had been declining. In 1958, his appraisal of the situation was essentially the same: "Instead of the widespread development of health services, envisaged in 1945 to fill the gaps of pre-war and wartime neglect [he wrote], the proportion of the national income spent on the Health Service has been allowed to fall since the Service began. This has been the general trend. With this year's cuts on the hospital service, the cost of the Health Service as a whole may well be the lowest proportion of the national income sincc 194.3." 5 0 However, the government tends to think in terms of pounds rather than percentages, and has been much concerned over the rise in the money-cost of health provision, even though the proportion of the country's real resources used to operate the Health Service has changed but litde. The Service is paid for chiefly from public funds; that is, with money obtained through national and local taxation. In 1 9 5 9 - 6 0 , the latest year for w h i c h detailed figures arc a v a i l a b l e , about 7 6 } per cent of the necessary funds came from national and local taxes; 4 J per cent from payments by patients using the several kinds of services (dental, ophthalmic, etc.) for which specific charges are made; 4 J per cent consisted of superannuation contributions withheld from N H S salaries—which, combined with somewhat larger contributions from the government, make up a fund from which pensions are paid to individual contributors when they retire; and r 3 J per cent consisted of the first National Health Scrvice contributions which (having been increased in 1961) are now required of all employees, employers, and self-employed persons. (The National Insurance Fund is made up of compulsory contributions—insurance premiums—from "in general,

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everyone between school-leaving age and pension a g e " ; and from it are paid, as needed by the insured persons, unemployment, sickness, maternity, and certain other types of benefits.) A good many Britons fail to distinguish between the National Health Service, to which (up to J u l y 7, 1958) no specific payments were made except for the few special health services mentioned above, and National Insurance, to which all employees and employers make weekly contributions. In an effort to make this distinction clear, the government has repeatedly published statements similar to one issued by the Ministry of Pensions and National Insurance, which follows : T h e N a t i o n a l H e a l t h Service is often confused w i t h the N a t i o n a l Insurance scheme, and its medical, hospital, dental a n d other services are often believed to be all paid for out of national insurance contributions. T h i s is not so. T h e N a t i o n a l Health Service is a completely separate scheme [ a n d ] its services are available to everyone in G r e a t Britain whether or not they are paying national insurance contributions. T e n p e n c e [ 1 1 f cents] out of the combined [weekly] national insurance contribution . . . for a n employed m a n a n d his e m p l o y e r is allocated to the N a t i o n a l H e a l t h Service. T h e remaining 1 1 shillings, 1 1 pence [ $ 1 . 6 6 ] goes into the National Insurance F u n d a n d the Industrial Injuries F u n d to p a y for the cash benefits a n d pensions. 6 1

This transfer from National Insurance to the N H S had at the start taken care of only about 7 per cent of the total cost ol the Health Service. But a substantial number of the people who have been using the N H S have not realized that nearly all of its cost has been met from tax revenues, and only a small portion from their insurance payments. Relatively few adult male workers, whose National Insurance payments for some years amounted to the British equivalent of about $49 a year for each worker, have seemed to understand that almost $46, or 94 per cent, of this money went toward providing unemployment, industrial injury, retirement, sickness (part pay), and other benefits which they receive in times of income-reducing

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misfortune, and had nothing at all to do with paying for the National Health Service; and that only §3.00, or approximately 6 per cent, of their National Insurance payment was spent for N H S purposes. O f course, the worker, if he wished, could properly have regarded this annual S3.00 transfer to the Health Service as a specific charge made upon him for "health insurance"—and without confusion, provided he kept firmly in mind the fact that, apart from the N H S share of whatever he might be paying in national and local taxes, this transfer from the National Insurance Fund was his only payment for the comprehensive health coverage with which he and his non-employed dependents were provided. Indeed, the government decided in 1957 that users of the Health Service might well be asked, as individuals, to pay a larger part of the costs of the Service than this small National Insurance transfer, in so far as they were able to do so. On the ground that it was "not unreasonable for people to contribute a little when they are well in order to be looked after when ill," Parliament passed the National Health Service (Contributions) Acts of 1957 and 1958, which not only increased employees' and employers' contributions, but established a separate National Health contribution. Though the N H S contribution is now distinctly a Health Service payment, it is, as a matter of convenience, collected with the National Insurance contribution in one combined " s t a m p . " Since J u l y 1, 1 9 6 1 , the combined total National Insurance and N H S contributions for an adult male employee and his employer have been 19 shillings, 2 pence ($2.68) a week, with the employee paying 10 shillings, 9 pence ( $ 1 . 5 0 ) and the employer 8 shillings, 5 pence ( $ 1 . 1 8 ) . Of this total, the National Health Service receives approximately 49 cents a week—39 cents from the employee, and 10 cents from the employer. T h e adult male employee's specific contribution

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to the N H S is now ¿ 7 / 4 / 1 0 ($20.25) a n d the employer's £ 1 l I 7 l 3 ( S 5 2 0 ) a year. (The contributions for women workers and young people are somewhat smaller.) The $20.25 collected for N H S use is a trifle more than 26 per cent of the adult male worker's present total payments of S77 a year to the combined National Insurance and National Health Service contributions. It is the government's hope that the revenue derived from these increased payments will make it unnecessary for Parliament and local authorities to appropriate annually more public funds than have been allotted to the N H S in recent years.

T h e costs of the N H S are unequally, though not necessarily inequitably, distributed among its three administrative branches. In 1957-58—and the figures for 1958-59 and 1959-60 are very largely the same—approximately 63 per cent of the total was spent on the Hospital and Specialist Services, 28 per cent on the Family Practitioner Services (including general medicine, pharmaceutical, dental, and eye services), and 9 per cent on Local Authority Services (child health, maternity, ambulance, health education, domestic, and other services). From 1949-50, up to and including 1957-58, the money outlays for all three of these administrative divisions increased as the total costs of the Health Service increased; but while the proportion of the total expenditure that is used for Hospital and Specialist Services rose from 56 to 63 per cent over this nineyear period, the proportion going into Family Practitioner Services fell from 36 to 28 per cent, and that spent on Local Authority Services fluctuated only within exceedingly narrow limits, and was 9 per cent in 1957-58 as against 8 per cent in I 949~"5°The possibility that N H S costs might conceivably be reduced without, at the same time, lowering the quantity or quality of

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the services rendered has not been overlooked. Overuse or misuse of the services of a public health program is obviously waste. Dr. Eveline M. Burns of Columbia University, in a recent work dealing with "problems peculiar to public medical services," states that excessively high expenditures are likely to be found in pharmaceuticals, in overuse or careless use of medical appliances, and in the use of hospital facilities where no real need for in-patient care exists. " I n part," says Dr. Burns, "the problem [of overuse] is attributable to the demands of the consumers of medical care, a commodity on which people in general seem to spend less of their own incomes than is socially desirable, but which they will use in great quantities if they get it free." 5 2 Whether or not there has been substantial waste in the use of health facilities in Britain, measures have been taken to reduce the demand upon the Service for unnecessary drugs, dental service, spectacles, and hospital treatment. The steady rise in the number and average cost of prescriptions up to 1951 led (as was noted in Chapter 2) to the imposition of a one-shilling charge for each prescription issued. This charge was increased, in 1961, to two shillings for every item of a prescription; and the total payments by patients of such charges amounted in 1959-60 to £ 1 1 , 0 0 0 , 0 0 0 (S30J million).* The original purpose of the prescription charge was not to get additional revenue, but rather to discourage patients (by putting them to a slight expense) from urging their doctors to write prescriptions that were not actually needed. T o the same end, all general practitioners have from time to time been admonished to exercise great care in the quantity of drugs they prescribe; and some have been fined for indulging in overprescribing that has greatly exceeded the average prescription costs of other doctors with patient lists of similar size in the same area. But doctors are not always praised for practicing * T h e figures are for E n g l a n d a n d W a l e s .

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e c o n o m y in prescribing. A Wiltshire physician told me a b o u t a patient of his w h o insisted on h a v i n g a h u n d r e d tablets of a certain kind, but was given only the twenty-five he actually needed. T h e patient c o m p l a i n e d to his m e m b e r of P a r l i a m e n t , w h o c o m p l a i n e d to the Ministry of H e a l t h , w h i c h wrote the doctor saying that they appreciated his desire to k e e p d o w n the cost of medicines, but that he must be careful " n o t to cause his patient h a r d s h i p . " Despite measures that h a v e been taken to discourage overprescribing, the n u m b e r of prescriptions filled by druggists in E n g l a n d and Wales in i960 was over 2 1 8 m i l l i o n — a

drop,

however, of 10 million from 1 9 5 6 which had a larger total than any

previous

NHS

y e a r , exceeding

even

1951

which

was

m a r k e d by an epidemic of influenza. T h e total cost of prescriptions dispensed in E n g l a n d a n d Wales in i 9 6 0 ( £ 7 5 - 8 million, or $ 2 1 2 million), a n d the a v e r a g e cost per prescription (7s. 3d., or about

$1.00),

were both higher

than

ever

before.

(Sir

H u g h Linstead, M . P . , S e c r e t a r y of the P h a r m a c e u t i c a l Society of G r e a t Britain, observes that the c o m p a r a b l e cost per a v e r a g e prescription is about $ 2 . 0 0 in C a n a d a and $ 2 . 8 0 in the U n i t e d States.) 5 3 T h e high a n d rising costs of prescriptions are said to be d u e mainly to the use of new and expensive drugs (particularly antibiotics), a n d also, to a lesser degree, to the increased quantity of drugs prescribed. It should be added that w a r n i n g s against overprescribing are a l w a y s a c c o m p a n i e d by a r e m i n d e r that the patient is entitled to, a n d must be given, the kind a n d quantity of medicine the doctor decides is indicated, regardless of expense—for emphasis is put upon the a v o i d a n c e of waste in prescribing, a n d not u p o n the reduction of m o n e y costs at the risk of endangering a patient's health. T h e e x t r a o r d i n a r y popularity of the dental and o p h t h a l m i c services, in the early years of the N H S , g a v e rise to t w o widely different views. T h e first ran to the effect that m a n y people w h o previously needed but could not a f f o r d such treatment

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w e r e at last a b l e to get it because it was free, a n d that the e n o r m o u s d e m a n d w a s m e r e l y a reflection o f the extent o f the need. C o u n t e r i n g this opinion was the a r g u m e n t that the flood o f requests for such things as dentures and spectacles h a d c o m e not so m u c h f r o m real need for these a p p l i a n c e s as f r o m the fact that t h e y c o u l d b e h a d w i t h o u t p a y m e n t . T h i s second v i e w a p p e a r e d to some persons to be confirmed b y the substantial r e d u c t i o n in the d e m a n d for these specific services, f o l l o w i n g the imposition o f t h e relatively small d e n t a l a n d o p h t h a l m i c c h a r g e s described in C h a p t e r 2 ; for this r e d u c t i o n seemed to some observers to support the idea that m a n y people had been using the services o n l y because they were free. H o w e v e r , the report o f the G u i l l e b a u d C o m m i t t e e , the most comprehensive

study

of

NHS

costs

that

has

been

made,

demonstrates t h a t the total cost of dental services h a d a l r e a d y passed its p e a k a n d was a c t u a l l y falling before the charges to patients w e r e i n t r o d u c e d ; a n d that " t h e cost to p u b l i c funds of s u p p l y i n g dentures declined f r o m a peak o f a b o u t £ 3 4 million [$95 million] in 1 9 4 9 - 5 0 to a b o u t £ 8 million [$22£ million] in 1 9 5 3 - 5 4 . " T h e r e p o r t continues w i t h this further e x p l a n a t i o n : A t the beginning of the Service, it looks as though the high costs were attributable to an accumulation of demand from persons with unsatisfactory dentures and persons requiring dentures. After this back-log of demand had been largely dealt with, a decline set in as a rising proportion of needs were met. T h e subsequent introduction of charges probably contributed to some extent, however, to a further fall in the gross cost by inducing persons either to defer obtaining dentures or to continue with unsatisfactory sets longer than they would have done had replacement been free. 54 T h e costs to the g o v e r n m e n t o f all N H S d e n t a l services (and not m e r e l y

the cost o f dentures, m e n t i o n e d

above)

totaled

a p p r o x i m a t e l y £ 4 2 - 6 million ( $ 1 1 9 million) for E n g l a n d a n d W a l e s in 1950. T h e n they declined over a period o f years, r e a c h i n g their lowest point in 1954, w h e n they w e r e a little

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less than £ 2 1 - 5 million (56o million); but by i960 they had risen to almost £ 3 2 5 million ($91 million). The N H S patients' appeals for ophthalmic services followed much the same course as their requests for dentistry, according to the Guillebaud Report: All the evidence we have examined suggests the following interpretation of the trend in demands on the ophthalmic service. At the start of the Service there were substantial demands from persons who had not previously had their sight tested and from persons who were overdue for a re-test. By 1951 these demands had been substantially met and the service was dealing more and more with normal new needs, re-testing and replacement. The introduction of charges in 1951 and their extension in 1952 caused some postponement of sight tests and some diversion of the demand for spectacles to the private sector. In 1953-54 the service expanded slightly, partly in response to the demands which had been postponed when charges were introduced and partly because the abnormally large issues at the start were beginning to need replacement.54 Government expenditures for supplementary ophthalmic services (which consist chiefly of eye-testing and the provision of spectacles) dropped, for England and Wales, from £ 2 1 - 7 million ($61 million) in 1950 to £6 million ($17 million) in 1953, and then rose to £ 1 0 million (about $28 million) in i960. Though the cost to public funds of both ophthalmic and dental services has been moving upward from the low levels reached in 1953 and 1954, respectively, in neither case has it come anywhere near the total expenditure for such services in the peak year, 1950. In i960, N H S patients made individual payments totaling about £ 5 2 million ( $ 1 5 million) for ophthalmic, and ¿9-2 million (slightly more than $25 7 million) for dental services. N H S charges of the types described above have been both championed and opposed. It is claimed for them, first, that they deter some patients from using unnecessarily (and hence

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wastefully) services w h i c h w o u l d be d e m a n d e d if they were entirely free; and that these charges thus reduce somewhat the costs of the Health Service. Second is the fact that the substantial sum collected in these part-payments of the cost of prescriptions, dentures, and spectacles forms a w e l c o m e a d d i tion to the national and local tax revenues that are n e e d e d in meeting the total costs of the N H S . T h e r e is, on the other h a n d , a widespread feeling that health services of all kinds should be encouraged,

not

discouraged;

and

that

the

imposition

of

charges m a y prove too effective a deterrent, and cause some patients to forgo required health care. W h e n the Ministry of H e a l t h in 1956 raised the one-shilling charge for each prescription to one shilling for each item of a prescription, The Lancet c o m m e n t e d editorially that alternative v/ays of getting revenue m i g h t better h a v e been chosen, that a higher

prescription

c h a r g e would bear most heavily upon persons with dependents, and that it might interfere with some people's getting

the

medical care they need. 5 4 T h e Guillebaud C o m m i t t e e reported in its study of N H S costs that the prescription c h a r g e (then only a shilling) did not a p p e a r to "hinder the proper use of the Service by at least the great majority of its potential users"; but stated that the dental treatment charge was " i n fact impeding a n u m b e r o f people from making use of the general dental service," and that the c h a r g e for spectacles was "likely to constitute a barrier to a proportion of the people w h o need to m a k e use of the service." T h e committee did not recommend immediate abolition of a n y of these charges, but suggested that " w h e n additional resources b e c o m e a v a i l a b l e " it w o u l d be appropriate to adjust d o w n w a r d both the dental-treatment charge and the c h a r g e for spectacles. 6 7 A n d it concluded that " n o convincing case has been m a d e out for the imposition of n e w charges." 5 8 It seems probable that the charges now in effect will be continued for some time to come. W h e n Her Majesty's L o y a l

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Opposition urges the government in power to abolish all N H S charges " a s a matter of principle," it speaks as a party which would not immediately have the unwelcome responsibility of finding new funds to replace the revenue—estimated officially at some £ 2 8 million ($78^ million) for the fiscal year 1958-59 —that would be lost if the Health Service were made "completely free." (Because the abolition of N H S charges would doubtless cause an increase in the use of some of the health services, and thus raise N H S expenditures while lowering its revenues, Professor Lafitte "guesses" that the resultant total net increase in cost to public funds might run somewhere around £ 3 0 million [$84 million].) Conservative members of Parliament have asserted, and some L a b o r members have privately admitted, that a change in government would not promptly be followed by the disappearance of prescription, dental, ophthalmic, and the few other N H S charges. But the members of all parties give the impression that they would gladly vote to wipe out these charges if the economy were sufficiently prosperous to warrant their abolition. Great Britain, with an annual national income of about £ 4 2 5 ($1200) per capita (or about 40 per cent of the per capita income of the United States), finds it necessary to make her public funds go as far as possible. T o quote the Guillebaud Committee, which was acutely aware of the limitations placed upon the N H S by the shortage of funds: We do not believe that the country will be in a position to provide a fully comprehensive health service, which is adequate for all desirable needs, in the foreseeable future. The Government's problem is how to make the best use of the available funds and to decide which are the most urgent priorities to be met as and when more resources become available. The question of the priority to be given to the reduction of [NHS] charges must, therefore, depend on the relative importance attached to other outstanding needs in the Health Service as a whole, as well as on the financial resources at the disposal of the Government for all purposes.6*

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It has often been suggested that economies might be effected, or at the very least increases in expenses might be slowed d o w n somewhat, in that most costly of the three m a j o r branches of the N H S — t h e Hospital and Specialist Services. F r o m 1950 to 1956, for e x a m p l e , the a n n u a l hospital-specialist expenditures rose about 43 per cent in current money prices, but only a b o u t 11 per cent w h e n expressed in pounds of constant purchasing p o w e r ; so that the rise in money cost was largely attributable to price-level increases. H o w e v e r , a substantial part of the added cost was caused b y an increase in the size of hospital staffs, and b y the purchase of additional goods necessitated b y the expanded d e m a n d for services. It is not possible to j u d g e accurately h o w the gain in " p r o d u c t " (in the form of additional medical care) c o m p a r e d w i t h the loss to the country o f the re2l resources used u p in producing this added health s e r v i c e — resources w h i c h would otherwise h a v e been available for other productive purposes. But it m a y be noted that during the period in which real hospital costs rose 11 per cent there was a 27 per cent increase in the annual n u m b e r of in-patients, and 11 per cent in the n u m b e r of (consultative clinic) out-patients receiving hospital and specialist care. Despite the benefits that have been reaped in the f o r m o f additional health provision, the cost of hospital and specialist s e r v i c e — a n d , in particular, in-patient service—is sufficiently high to c o m m a n d attention and causc concern about possible future increases. T h e data for N H S hospitals in E n g l a n d and Wales, for the y e a r ended M a r c h 31, i960 showed that the average cost of maintaining hospitals handling w e e k ; in maternity

"acutc"

an

in-patient

in

cases was £25/16/7

non-teaching ($7 2 -3°)

a

hospitals, £27/3/5 (S76.08); in mental-

illness hospitals, £7/12/8 ( S 2 1 . 3 5 ) ; and in tubuerculosis and chest hospitals, £20/3/3 ($56.50). In-patients costs arc especially high in teaching hospitals. In the " a c u t e " teaching hospitals, the average weekly expenditure per patient, from A p r i l

1,

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1959 to March 3 1 , i960, was £36/9/7 (S102.15) in London, and £30/4/11 ($84.70) in the provinces. 60 Weekly costs such as these, for each of the 4 1 million inpatients who may use N H S hospitals in the course of a year, make up a formidable total. The cost per individual is not so bad in the case of people with ear, nose, and throat trouble (the most transient of hospital in-patients), who on the average stay in hospital only about a week. But for such patients as the chronic sick and those suffering from chest ailments, whose lengths of stay in non-teaching hospitals average 20 and 10 weeks, respectively, an individual case may cost the Health Service several hundred pounds, the equivalent of a thousand or more dollars.* There is good reason, then, for the Ministry of Health and the hospital authorities' seeking to make a more intensive use of hospital beds, whenever it is possible to do so without harm to the patients. This may be done by increasing the rate of "bed turnover" (shortening the stay of individual patients where that can be done without prejudicing the patient's recovery), and by reducing to a minimum the "turnover interval" (shortening the empty gap between successive patients' occupancy of the same bed). That such measures can be applied effectively is shown by the fact that, though the numbers of available and occupied hospital beds were raised by only 6 per cent between 1950 and 1956, the number of patients treated (as was noted above) rose about 27 per cent. 41 A question often raised, in discussing the problem of keeping * "The patient who stays in hospital a day longer than necessary uses the hospital as a hotel.. . . The phase of acute illness in medical and surgical diseases is now generally short. A period follows of varying length during which there could be no better place in which to recover than at home under the supervision of the family practitioner, provided the necessary facilities exist and the patient and relatives desire it." (Dr. J . A. Stallworthy, Director, Area Department of Obstetrics and Gynaecology, United Oxford Hospitals, in The Lancet, January 9, i960, p. 104.)

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hospital costs within reasonable bounds, is whether a good many patients who now go to hospitals for treatment could not be properly cared for in their own homes. Hospital care may be required on either medical or "social" grounds. There are ailments which clearly call for the physical equipment and round-the-clock professional skills that are likely to be found only in hospitals, and which cannot therefore be handled satisfactorily in a private home. And there are homes which, because of overcrowding, lack of sanitation, domestic dirtiness, or other bad environmental conditions, are unfit places for the treatment of any sickness, and certainly for a serious illness. Lord Taylor describes homes of this kind which can be found in various parts of Britain—in north and south London, "and indeed in most great towns where large houses have gone downhill and been sub-divided without proper internal conversion." In such an area an obvious smell is detected on entering perhaps one home in three [says Lord Taylor], Such homes consist of one or two rooms. Cooking is usually done on a gas-ring on a table on the landing, or on a n open coal fire. There is usually one or at most two lavatories for the three to eight families in the house, and sometimes only a sink in the basement, from the tap of which all must draw their water. T h e bathroom, theoretically available for all, is out of order. T h e wonder of it is not that one-third of such homes smell, but that two-thirds do not." 6 2

A specific (though exceptionally bad) home, in a northern seaport, is described by Lord Taylor: T h e house was Georgian; at one time it had been a fine home. Now a panel was missing from the front door and no effort had been made to replace it. T h e door of the ground-floor-back was opened, after three minutes' hammering, by a n indescribably filthy woman who had obviously just got out of bed and slipped on a frock. . . . T h e room was of fine proportions. Traces of elegant plastering remained. Elsewhere the plaster was off down to the bricks. There was a fitted kitchen sink with draining-board, but it looked as

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though it was never used. Everywhere there was the usual collection of filthy domestic litter, unwashed cups, a drying load, margarine still in its paper, unemptied chamber pots, a broken chair or so, and the usual pile of rags.88 People whose living conditions are so wretched as to m a k e effective h o m e treatment impossible m a y be sent to hospitals, not because they are suffering from serious ailments but to speed recoveries w h i c h might otherwise be hopelessly d r a w n out. A n d patients w h o require considerable attention in the course o f a d a y m a y have to be moved to hospitals—even t h o u g h they are not seriously i l l — b e c a u s e they live alone and h a v e no one to w a i t on them. Moreover, some patients belong to households consisting of workers whose j o b s keep them a w a y f r o m h o m e all d a y ; and some have families to whose members, even if they are at home during the d a y , the doctors m a y not care to entrust the duty of giving medicines or performing other sick-room chores. T h e local health authorities are responsible for providing various

"home

services"

(among

which

is home

nursing)

" c o m p a r a b l e w i t h the kind of help w h i c h is available to doctors in hospitals." T h e General Practitioners Handbook reminds the N H S practitioners that " b y making proper use of these services it m a y often b e possible to avoid h a v i n g to send a patient to hospital."" H o m e nurses (or, as they are often called, district nurses) serve m a n y patients a d a y , and can seldom on the average spend m o r e t h a n t w o 20-minute periods each day with a given patient. H o w e v e r , this m a y in some instances be sufficient attention to enable a doctor, with the nurse's help, to make a " h o m e c a s e " of w h a t would otherwise be a hospital case; or to m a k e possible the earlier discharge of a patient from a hospital. Sir J a m e s Ross cites the saving to a C a m b r i d g e hospital of 3 J days for each of 170 patients, w h o were able to be transferred to their homes in a d v a n c e of the normal date of discharge,

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through the home care given by district nurses, health visitors, and voluntary workers. 65 " A marked relief to the pressure on hospital beds will come by the treatment of patients at home, on an increased scale, wherever home conditions permit," says Sir James.* 6 The shortage of hospital accommodation, and the high cost of hospital care as compared with treatment at home, make it important for doctors to refer patients to hospitals only for medical reasons or because of adverse social conditions. 67 Stressing the necessity of having the National Health Service operate in the most efficient and economical way possible, the Guillebaud Committee says: It is desirable that, whenever practicable, patients should be treated in their own homes by the general practitioner and the local health services, instead of being admitted to hospital where the running costs are so high; and when a patient is admitted to hospital, he should be discharged at the earliest possible date, any necessary follow-up treatment being provided either in the hospital out-patient department, or at home by the general practitioner and the home health service.48 The average cost of handling maternity cases in N H S nonteaching hospitals is £27/3/5 ($76.08) a week, and the average length of stay is ten days. Home confinements cost only a fraction as much, and are in conformity with the British tradition that maternity is not an illness. " H a v i n g a baby implies something more than the act of parturition on the part of the mother," said Dr. Hugh Paul of the Birmingham (England) Regional Hospital Board, in addressing members of the American Public Health Association at their 1956 convention in Cleveland. " T h e birth of a baby in the home is a landmark in the family history, and there is considerable psychological value in the intimate association of the mother with her family. A hospital birth has much of the flavor of a pathological sickly upset." 69

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Despite gentle prodding by the health authorities, recommending that general practitioners encourage expectant mothers to have their babies at home, and the £ 4 ($11.20) National Insurance bonus that is paid the mother for each home confinement (in addition to the regular National Insurance maternity grant of £ 1 0 ) , about two-thirds of all British births take place in hospitals. In a recent year, hospital maternity cases included about four-fifths of the country's first confinements, and one-half of the second, third, and fourth; for British hospitals are used more extensively for first confinements, when complications might be expected, than for later ones. Home deliveries are usually handled by well-trained midwives, who "probably have more experience taking care of infants and mothers than do physicians, whose interests range through all kinds of sicknesses," according to Dr. Paul, who was quoted in the preceding paragraph. 70 However, home patients may have both midwife and doctor, if they wish; obstetricians and hospital beds are available, if needed; and "obstetric flying squads" (vehicles equipped to give transfusions and other emergency treatments) are on call. It seems clear, as was reported by the Cohen Committee on General Practice, 71 that " a great many confinements take place in hospitals, not on medical but on social grounds"*—not because the N H S obstetrical home service is inadequate, but because the home conditions are often quite unsatisfactory. There can be no doubt that unsatisfactory home conditions are responsible, also, for the use of hospital space and specialist service by many persons who are suffering from acute or chronic illnesses, some of which—pneumonia, for example— * It is reported that in areas where maternity beds are plentiful (as in London) a good many mothers have hospital confinements, not on medical or social grounds but simply because they prefer it that way, and because the terms " m e d i c a l " and "social" are sufficiently elastic to enable the applicants to make the necessary arrangements for hospital admission.

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yield readily to family-doctor treatment in favorable home surroundings. T o provide such surroundings for all may seem like an almost hopeless undertaking, but hospitalization on social grounds may eventually be lessened by the construction, in great quantity, of blocks of modern, subsidized flats such as have already sprung up in London and elsewhere in Britain in large numbers. N o t only is there determination to wipe out industrial and all other slums [wrote Professor C . Fraser Brockington, of the University of Manchester, in 1956], but [there is] also a truer appreciation of w h a t the home should be. . . . It is only in the past fifty years that internal

plumbing,

sanitary

convenience,

and

bathrooms

have

come to be considered a general need. . . . W e h a v e also come at last to appreciate that overcrowding is more d a m a g i n g to health, comfort, and enjoyment than is the insanitary state of the dwelling itself. . . . T h e present-day drive for new housing, if continued, should be enough to overcome the present shortage, of which shared dwellings are the most obvious sign, in a relatively short period of time, and it can then be applied to the elimination of the slum itself. . . . But now that the ideal of one family, one dwelling, is at least within our grasp, we should turn our attention, w i t h o u t delay, to quality. 7 2

It is said that overworked general practitioners, seeking to lighten their own labors, have sometimes sent to hospitals patients whose transfer from home could not be justified on either medical or social grounds, except by a most charitable interpretation of these terms. And it is not hard to find doctors who have been urged to hospitalize patients whose cases, on both medical and social grounds, were entirely suitable for home treatment, simply because their families wanted to be freed from the extra work such care would entail. It seems reasonable to suppose that, in a health service which includes thousands of practitioners and millions of potential patients, there must be a considerable number whose sense of social responsibility is less fully developed than their individual self-

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interest. On the other hand, there are both doctors and patients who deplore waste in health provision, and are doing their best to reduce it. The general practitioners' right to prescribe whatever drugs they think necessary, and to decide (in large degree) whether their patients shall have hospital or home treatment, places N H S doctors in a particularly strong position for effecting economies in these two especially costly fields of N H S expenditure. But however earnestly everyone interested in the Health Service may strive for economy and efficiency, the problem of financing the N H S is pretty certain to be a continuing and perhaps an increasingly troublesome one. T h e growth of medical knowledge adds continually to the number and expense of treatments and, by prolonging life, also increases the incidence of slow-killing diseases [says the Guillebaud Committee Report], N o one can predict whether the speeding of therapy and the improvement of health will ultimately offset this expense. T h e r e is at present no evidence that it will; indeed, current trends seem to be all the other w a y . T h e r e is every reason to hope that the development of the National Health Service will increase the years of healthy life per head of the population, but there is no reason at present to suppose that demands on the Service as a whole will be reduced thereby so as to stabilize (still less to reduce) its total cost in terms of finance and the absorption of real resources. 73

Under the National Health Service, the doctors are paid by the government, and not by their patients on a fee-for-service basis such as is found in the United States. The British general practitioner has a "panel" (or list) of patients, who have chosen him as their personal or family doctor. His chief source of income is a fixed payment of so much a year—called a "capitation" fee—which he receives for (but not from) each of his listed patients. So far as income is concerned, all patients are of equal

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importance to the doctor whether he sees them often or seldom, or indeed whether he sees them at all. The general practitioner is not paid for the medical service he actually renders his patients, but for the service he stands ready to render if and when it is needed and called for. T h e N H S specialists (or "consultants") are salaried hospital officials, and, like all doctors and dentists who work in hospitals, are paid annual salaries. T h e general dental practitioners to whose offices patients ordinarily go for dental treatment, are paid on an established piece-work basis. When I started my survey of the Health Service, I found that the British doctors had for several years been seeking, but not getting, a substantial increase in their pay. In 1956, however, they seemed rather more hopeful than usual about their prospects. " W e ' r e pretty sure to get something this time" was the view expressed by scores of general practitioners whom I interviewed personally in my survey. Though their negotiating committee sought a 24 per cent increase, it was currently rumored that the Ministry of Health would offer somewhat less and the doctors would promptly accept. But the ministry came out with a flat refusal, on the ground that "in the present circumstances it would not be right to give consideration to a claim for a general increase in medical remuneration." , s T h e "present circumstances" were the inflationary pressures that were threatening the country. T h e question of remuneration for medical men is one on which there are differences of opinion even among the doctors themselves. About 60 per cent of those who discussed this question with me said the standard of living that most general practitioners could buy with the money income they were then receiving from professional services was almost certainly lower than it would have been if the N H S had not been adopted. O n the other hand, 39 per cent reported that in their view the Health Service had provided them personally with a higher

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living standard than they would probably be enjoying in its absence. A very few expressed opposition to any current increase in pay, arguing that doctors should join with or even lead the rest of the country in fighting inflation. By and large, however, British doctors did want more pay, not only because they could make good use of the money but because they felt that the much-quoted "Spens Reports" promised them money incomes which would keep pace with changes in the cost of living. In 1959, the NHS general practitioners with 2,300 patients each (the average for the country as a whole), but with no income except capitation fees, were in the highest 3 2 per cent of British income-getters. Those with 3,500 patients were in the highest i-8 per cent, as were also all fulltime consultants of at least three years' standing. Though these figures might seem to indicate that family doctors as a class were doing relatively well, the fact remains that they had had no really significant boost in pay since 1953. "Doctors are united in considering that the Government, by its apparent repudiation of the Spens Report, has broken faith with the profession," according to the British Medical Journal. The Danckwerts Award, a substantial pay adjustment effective as of April, 1953, was cited by the doctors' representatives as an acknowledgment of this "escalator" obligation. And the 24 per cent increase asked for in 1956, but not ruled upon until i960, was the doctors' estimate of the further adjustment needed at that time to make good the Spens promises, and to enable the doctors to keep up with "comparable professional groups" whose incomes had risen considerably since 1950. The London Times, surveying the situation editorially at some length, cited statistics which suggested that medical incomes were not below those of comparable professional groups, and that the doctors themselves were "the real Joneses of the professions," and not an underpaid group seeking to keep up with the members of financially luckier professions. It then

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raised the question whether the escalator pledge based on the Spens Reports—which, it said, "should never have been given in so unconditional a form and with so little regard for its implications"—was still valid. Finally, the editorial urged upon the negotiating committee and the government the necessity of agreeing on "some more practical and durable method of reviewing remuneration from time to time." It was all very confusing, and especially so to foreigners who may not have followed closely the lively give-and-take that has marked negotiations between the Ministry of Health and the medical profession in the past dozen years. Americans, reading in the daily press in 1957 that the British Medical Association was making plans for a "selective withdrawal" from the Service in October of that year, might have supposed that the very survival of the National Health Service was in danger. However, in that year the government set up a royal commission to study the whole situation, and in 1957, 1958, and 1959 granted several relatively small interim pay increases to hospital doctors and dentists, and to general practitioners; the British Medical Association voted " t o defer indefinitely a decision on a plan for the progressive withdrawal of general practitioners from the N H S " ; 7 5 and it was left to the royal commission to recommend to Parliament a solution of the problem of adequate pay, as soon as it had completed its study. Predictions are always risky, but it was a fairly safe guess that withdrawal from the Service was not in the cards. Among the reasons for regarding a concerted (or even "selective") withdrawal by the doctors as unlikely were the unpopularity in Britain of anything that resembles a general strike, the difficulty of practicing medicine outside the Service, the possibility of endangering the doctors' claims to valuable annuity rights and other highly prized benefits which are payable at retirement or death, and the widespread antagonism that withdrawal would arouse among the British people, with whom the Health Service

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is e x c e e d i n g l y p o p u l a r , a n d w h o (as The Lancet h a s p o i n t e d o u t ) " d o not readily understand

h o w doctors justify a n

' w a g e c l a i m ' f o r a n additional £10

average

[$28] a w e e k , w h i c h is m o r e

t h a n m a n y o f [the British workers] earn a l t o g e t h e r . " B u t n o d o u b t the s t r o n g e s t o f all d e t e r r e n t s to

withdrawal

w o u l d be the doctors' d e v o t i o n to their calling. British d o c t o r s m a y h a v e b e e n o v e r w o r k e d a n d u n d e r p a i d , as t h e i r r e p r e s e n t a tives c l a i m e d ; b u t t h e y b e l i e v e in t h e i m p o r t a n c e o f t h e i r j o b a n d state with pride a n d a high degree o f accord that under the N H S t h e m e d i c a l n e e d s o f t h e c o u n t r y as a w h o l e a r e better

met

than

ever before. T h e

dispute over

pay

being

was

at

t i m e s s h a r p a n d e v e n b i t t e r , b u t n o t so e x p l o s i v e as t o s h a t t e r , or severely shake the great m e d i c a l tradition that the patients' n e e d s a l w a y s c o m e first. " W h a t e v e r is d e c i d e d , " c o n c l u d e d t h e British

Medical

Ministry

of

Journal

Health,

i n o n e o f its s p i r i t e d b o u t s w i t h "the

public

may

be

assured—if

the such

a s s u r a n c e is r e a l l y n e c e s s a r y — t h a t t h e s i c k a n d t h e s u f f e r i n g w i l l b e c a r e d f o r as t h e y h a v e a l w a y s b e e n . "

T h e r o y a l commission that w a s a p p o i n t e d to i n q u i r e into the p a y o f N H S d o c t o r s a n d d e n t i s t s p u b l i s h e d its Report* j u s t in t i m e to p e r m i t

the i n c l u s i o n , in the

first

edition of

Britain's

Search for Health,

of the following s u m m a r y of the commission's

r e c o m m e n d a t i o n s to P a r l i a m e n t : T h e commission found that the current earnings of doctors a n d d e n t i s t s w e r e t o o l o w i n M a r c h , 1 9 5 7 , w h e n it s t a r t e d its three-year study. Since that date the earnings in other fessions, in i n d u s t r y , a n d i n c o m m e r c e a t levels

pro-

comparable

* Royal Commission on Doctors' and Dentists' Remuneration, 1957-1960, Report. London, Her Majesty's Stationery Office, Cmd. 939, February, i960. All page citations in the remainder of the present chapter are references to this royal commission Report.

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w i t h those of the doctors and dentists have "increased by rather more than those of doctors generally and of dentists employed in the hospital service, [but] by rather less than those of general dental practitioners." (p. 151.) T h e r e have never been enough dentists [in general practice] to ensure p r o m p t treatment within the National Health Service of all patients, on the basis of a free or very heavily subsidized service. For this reason general dental practitioners have worked longer hours than were envisaged by the Spens Committee, and have not only earned more than was intended but have earned more than general medical practitioners—in sharp contrast to the position in all other countries of w h i c h we have knowledge, (p. 4.) T h e r e has been a complete absence of any effective machinery to see that dentists earned w h a t had been intended; a s a result they have earned more. (p. 3.)

T h e commission decided that this situation did not require any i m m e d i a t e changes in the current rates paid general dental practitioners, whose remuneration is calculated on a fee-forservice basis; that these dentists should earn an average of £2,500 a y e a r

(equal to a b o u t $9,350 in U . S .

purchasing

power), provided they worked between 2,050 and 2,200 hours a y e a r ; and that a study group "should as soon as possible fix rates w h i c h will produce this result." (p. 156.) T h e official estimates of the average annual net income, from all sources, o f N H S

general practitioners have in the

past

included estimated private-practice earnings and the government's contribution to the doctors' superannuation f u n d . T h e royal commission recommends the omission of these two major items in future calculations, and a few additional changes which, if applied to the data for 1956 (the base year of the commission's study), w o u l d make that year's average net income £ 1 , 9 7 5 ($5,530). It recommends that for i960, 1961, and 1962, this 1956 figure be raised b y £ 4 5 0 to a total of £ 2 , 4 2 5 , an increase of a b o u t 23 per cent. ( O f course, the a m o u n t actually

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received by a doctor would depend chiefly, in the future as in the past, on the size of his panel, and might be considerably above or below this average.) It should be noted that the royal commission's estimate of £2,425 for i960 is by no means the same thing as the £2,425 official estimate of the average net income for 1959, which was the average net income from all sources. If the commission's recommendation were adopted, the £2,425 average net income would constitute "take-home pay," over and above whatever income the "average doctor" might get from private practice and other sources outside the NHS, and in addition also to the government's superannuation contribution of 9 J per cent. Part of the £450 increase of i960 over 1956 consists of several interim pay increases that were made while the study was in progress. The commission recommended the payment of £20 million ($56 million) to doctors and dentists as extra pay covering the period of the study. It has also suggested consideration of a scheme of general-practitioner distinction awards, which would distribute additional annual payments of £500 ($1,400) or more to a limited number of doctors in recognition of their distinguished general practice, (p. 155.) If the recommendations of the royal commission are adopted, the incomes of doctors and dentists in hospitals will be raised substantially, with a spread from £7,900 a year for the highestpaid consultants to £ 6 7 5 for newly appointed house officers. (These incomes would be equivalent, respectively, to $29,500 and $2,520 in American purchasing power.) A full-time consultant appointed to a post at age thirty-four would receive a basic salary of £2,550 ($7,140) in his first year, and a decade later would be getting £3,900 ($10,920) a year. The commission has also recommended more and larger distinction awards for consultants—a total of 2,800 grants, ranging from A-Plus awards of £4,000 ($11,200) each to C awards of £750 ($2,100).

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When added to the consultants' maximum basic salaries, these distinction awards (expressed in terms of American purchasing power) would be equivalent to 100 total incomes of $29,500 each; 300 of $25,750; 800 of $21 ,ooo; and 1,600 of $17,350. (pp. 102, 103-) The commission emphasizes the fact that young doctors in particular have been underpaid: " T o d a y many young science graduates start earning salaries in the early twenties, and in many professions earnings are quite substantial well before age thirty. In the light of this, the total earnings of doctors up to age thirty are too low, and we are recommending substantial increases for junior hospital appointments and for trainee assistants." (p. 6.) Examples of these proposed increases are (1) junior hospital medical officers, raised from £ 8 5 0 ($2,380) to £ 1 , 2 5 0 ($3,500) for the first year, an increase of 47 per cent; and (2) trainee assistants, from £ 7 7 5 ($2,170) to £ 1 , 1 5 0 ($3,220), a 48 per cent increase. "Our recommendations will make doctors' total earnings in these early years more nearly comparable with those of science graduates in industry, or with some of the learned professions where earnings in salaried employment customarily start at an earlier age than do those of doctors," says the commission hopefully. The royal commission does "not think that [the Spens] reports should continue to govern the remuneration of the professions." Instead, it urges the appointment of a Standing Review Body of eminent persons experienced in various fields of national life, to keep medical and dental remuneration under review and to make recommendations to the Prime Minister. This, says the commission, is the only means of achieving "the settlement of remuneration without public dispute." " T h e main task of this Body will be the exercise of the faculty of good judgment, and it must be composed of individuals whose standing and reputation will command the confidence of the

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professions, the Government, and the public. It must be regarded as a better j u d g e than either the Government or the representatives of the professions as to what the levels and spread of medical and dental remuneration should b e . " (p. 4.) T h e commission suggests that the Review Body should make recommendations on its own initiative, or when requested by the government or by the professions through the government; that three factors which would always be relevant in considering remuneration would be "changes in the cost of living, the movement of earnings in other professions, and the quality and quantity of recruitment in all professions"; that the Review Body should normally propose adjustments at relatively infrequent intervals, and that these adjustments would be expected to keep the position stable for some time. (pp. 147, 157-) " I t is inherent in these proposals that the Review Body will be advisory only, and that the Government would be free to reject its recommendations," says the commission. So, also, are the proposals of the royal commission advisory only; for as the Report itself notes, "the Government cannot abrogate its functions and responsibility for ultimate decisions." Consequently, final decisions on remuneration for N H S doctors and dentists must await further negotiations, which will doubtless deal extensively with materials found in the voluminous Report of the royal commission.

T h e recommendations of the royal commission (outlined above) were accepted by the government and by both the medical and dental professions, and went into effect early in i960, marking, as the Minister of Health said, " a new phase in the relations between the Government and the two professions."

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T h e incomes received in 1961 by N H S general practitioners and consultants may now be examined briefly. Since remuneration for the family doctor comes chiefly in the form of capitation fees, whether a general practitioner gets much or little income depends primarily on the number of patients he has. If he has 2,300 patients, which is approximately the average number per doctor for the country as a whole, he will get 19 shillings, 6 pence (S2.73) a year for each of the first 400; this amount plus an additional 14 shillings (a total of $4.69) a year for each of the next 1,200 patients; and then back to 19 shillings, 6 pence each for the remainder. This comes to a gross income of £ 3 , 0 8 2 from capitation fees, an amount equivalent to $8,630 in American money at the current rate of exchange. A doctor with a panel of the m a x i m u m size allowed, 3,500 patients, receives £ 4 , 2 5 2 ( $ 1 1 , 9 0 5 ) in capitation fees. After subtracting office expenses, transportation charges, and other necessary costs of running his practice (which amount to about one-third of the gross income, and are deductible for income-tax purposes), the average-panel doctor will have left from his capitation fees a net income (before taxes) of £ 2 , 0 5 5 ( $ 5 , 7 5 5 ) , and the full-panel practitioner approximately £ 2 , 8 3 5 ($7,940). (Because consumer prices are lower in Britain than in the United States, the dollar incomes given here must be raised by one-third if they are to reflect British purchasing power accurately. For example, an English practitioner with a net income of £2,835—$7>94°> a t the current rate of exchange—can buy with this amount of British money a standard of living comparable to that purchasable with about $ 1 0 , 5 9 0 in the United States.) T h e capitation payment of doctors has found favor among the general practitioners of Britain, and won high praise from L o r d T a y l o r , who explains several of its advantages: The capitation payment is a great social invention. It avoids the possible abuses of fee-for-service or salary; the one invites the doctor

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to do too m u c h , and the other too litde. It enables the State to pay the doctor for looking after his patients, without thereby giving the State the upper hand. In the last analysis, under the capitation system, it is the patients w h o decide whether or not a doctor shall be paid, and how much. T h a t most patients tend to take the doctors as they come does not destroy this safeguard. In a rough-and-ready w a y , the capitation fee relates earnings to work done. So the doctor w h o wishes to limit or reduce his work can do so with a good conscience b y limiting or reducing his list, for his income will vary proportionally. 7 4

T h e r e are, to be sure, w a y s to supplement the basic capitation income.

Within the National H e a l t h Service, a doctor

receive s u p p l e m e n t a r y

may

p a y for the emergency treatment of

patients not on his own list, for the treatment of temporary residents o r visitors, for services as anesthetist, for maternity services, for v a c c i n a t i o n a n d i m m u n i z a t i o n , and for a dozen other specified kinds of service. N H S doctors m a y also accept p a i d a p p o i n t m e n t s outside the Service, as insurance-company examiners, as part-time physicians for industrial concerns, and in various other private capacities. M o r e o v e r , in so far as it will not interfere with giving proper service to their N H S patients, general practitioners are permitted to take on as m a n y private patients as they wish, or are able to get. H o w e v e r , about 98 per cent of the British people h a v e j o i n e d the National H e a l t h Service, and private patients are scarce a n d getting scarcer all the t i m e ; so that income from this source, except for a very f e w doctors, is meager and steadily shrinking. M y survey showed that four-fifths of the doctors questioned were getting at least 90 per cent of their income from

N H S practice, and t h a t this p a y was made u p over-

w h e l m i n g l y of capitation fees. T h e official 1961 estimate of the average annual net income of general

practitioners, received from

NHS

sources only, was

£ 2 , 4 2 5 ($6,790), w h i c h , because of the lower consumer prices in Britain, w o u l d U n i t e d States.

be roughly

equivalent

to $9,050 in

the

PAYING

FOR

THE

NATIONAL

HEALTH

SERVICE

93

Full-time doctors on the staffs of British hospitals differ widely in both rank and pay, ranging all the w a y from the top-level "consultants," some with incomcs running as high as £ 7 , 9 0 0 a year, down to newly qualified "house officers" with the modest stipend of £ 6 7 5 , which would command in Britain approximately as much goods as could be bought in America for $29,500 and $2,520, respectively. Within the consultant group itself arc substantial differences in pay. T h e starting pay of a full-time consultant may be as low as £ 2 , 5 5 0 ( $ 7 , 1 4 0 ) a year, but it increases steadily and automatically until the maximum basic salary of £ 3 , 9 0 0 ( $ 1 0 , 9 2 0 , at the present rate of exchange) has been reached. Beyond that point, four grades of distinction awards are available, making it possible to give recognition to special merit by paying maximum total salaries of ¿ 4 , 6 5 0 ( $ 1 3 , 0 2 0 ) , £ 5 , 6 5 0 ( $ 1 5 , 8 2 0 ) , £ 6 , 9 0 0 ( $ 1 9 , 3 2 0 ) , and £ 7 , 9 0 0 ( $ 2 2 , 1 2 0 ) , respectively to 1,600, 800, 300, and 100 consultants. Raising these dollar figures by one-third to make allowance for Britain's lower consumer prices, we find that 2,800 N H S consultants get salaries equivalent to American incomes of about $ 1 7 , 3 5 0 , $ 2 1 , 0 0 0 , $ 2 5 , 7 5 0 , or even $29,500. Consultants may be full-time or part-time, and the latter are free to acccpt private patients. A m o n g the consultant who were receiving distinction awards in England and Wales in i960, 495 w e r e specialists in general medicine, 462 in general surgery, 1 9 5 in obstetrics and gynecology, 1 7 5 in pathology, and 100 each in pediatrics and radiology.

5 THE PATIENTS' LIKES A N D DISLIKES

O n e cannot spend seven months talking with British doctors and patients without discovering their great interest in the National Health Service, and their willingness to discuss the subject with foreigners. Indeed, they seemed to welcome the chance to tell an American inquirer about their individual experiences with the N H S ; and in a few instances my informants volunteered the information—not, it should be said, in response to leading questions—that the Health Service was something that "you in the States" certainly ought (or, according to some, ought not) to have. I n addition to questions calling for very specific answers, I asked my doctors and patients a very general o n e — " W h a t changes, if any, do you think should be m a d e in the N H S ? " — which brought forth a great variety of suggestions. O n the basis of this information, supplemented by impressions gained in conversations with journalists, clergymen, politicians, teachers, and others with fairly broad social contacts, and through gleanings from the printed word, I shall discuss briefly, in this chapter and the next, some of the things about the National Health Service that are liked, and some that are disliked, by the doctors who provide medical treatment and the patients who receive it. This admittedly inadequate sketch of patient and doctor reactions to certain aspects of the Service may as well begin with things which the patients do not find to their liking. 94

THE

PATIENTS*

LIKES

AND

DISLIKES

95

SOME THINGS THE PATIENTS DISLIKE

Long Waits. I n general, N H S patients, like patients everywhere, dislike waiting. Waiting in doctors' surgeries, though protested mildly, is usually taken pretty m u c h in stride in Britain; a n d I have sometimes " w a i t e d " with patients who filled the waitingroom, and overflowed into the hall and even outside the building, without my hearing any worse complaint t h a n w h a t sounded like good-natured sallies. I have witnessed, too, genuine anger aroused by the non-arrival of a doctor until some little time after his scheduled office-hour; a n d the speedy subsidence of that anger once it became known that the delay was caused by an emergency call. It would seem that N H S patients resent long waits in surgeries when they are unnecessary, b u t will bear them with reasonable cheerfulness if they are unavoidable despite the doctor's best efforts. T h e long waits to which hospital out-patients have sometimes been subjected in the past were thoroughly disliked and severely criticized, not only because they wasted the patients' time b u t because the waste was unnecessary, as has been proved by the recent adoption of workable appointment schemes which have brought out-patient waits within sensible limits. About a fifth of the patients in my survey have listed, a m o n g the changes they thought should be m a d e in the Health Service, a reduction in the length of N H S waits in doctors' surgeries and in out-patient and in-patient departments of hospitals. With very few exceptions, those who regarded long waits in surgeries as sufficiently serious to deserve special mention placed the blame not on the doctors but on the size of their panels. " M o r e doctors, smaller panels, but no decrease in p a y " was the remedy most often prescribed by these patients. Efficient a p p o i n t m e n t systems were recommended as the proper antidote for u n d u l y long out-patient waits. T o speed up admissions to in-patient departments, the changes proposed were more

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hospitals, more beds, more specialists, and more nurses. There was almost no complaint expressed about long waits in connection with in-patient admissions of " u r g e n t " cases—presumably because N H S patients (like the majority of the doctors I interviewed) had concluded that urgent or emergency cases can ordinarily get into hospitals promptly. I n some instances, patients specifically stated that more hospitals and hospital services were needed so that even non-urgent hospital cases would no longer have to wait weeks or months to get the treatment they required. I have before me the official record of a patient who was advised, on J u l y 26, 1 9 5 1 , to have a minor operation on a bent and stiff little finger. He was put on the waiting-list, to be notified when it was found possible to admit him to the hospital. O n August 12, 1955, he received word to report to the hospital for the operation. Surprised and no longer interested, he replied to the hospital official: " I n the four years that have passed, the finger has got no worse and I have got used to its being bent, and would prefer not to have the operation n o w . " Being in a slightly sarcastic mood, he added: " M a y I congratulate you on the efficiency of your Records system. Y o u certainly do catch up on the patients if they live long e n o u g h ! " I need scarcely say that this is not a typical case. As this patient explained to me, he could probably have had the operation fairly promptly if he had followed up the initial examination with one or more requests for action. This same patient, it may be mentioned, got much prompter attention when he was found to have tuberculosis. H e was admitted to a hospital within twenty-four hours and held there a week for observation and tests. By agreement between the patient, his family, and the hospital authorities, he was then transferred to his home and thereafter treated as a home patient with N H S home nursing. H e made a complete recovery, but still attends a small hospital clinic regularly for check-ups. He rates as

THE

PATIENTS'

LIKES

AND

DISLIKES

97

"excellent" the Health Service care he received throughout this serious illness, and regards the episode of the bent little finger as an amusing and unusual instance of N H S pedestrianism. Hurried Surgery Consultations. If the time spent by a patient in his doctor's waiting-room seems long and drawn out, the minutes he is given in the consulting-room may strike him as most frugally dispensed; and he may even wonder whether the personal attention he is getting is as much as his case really deserves. The feeling that surgery consultations are unduly hurried does not appear to be widespread, but it is specifically cited by a few as a sufficient reason for increasing the number of general practitioners; and it is probable that among others who advocate fewer patients per doctor are some who have in mind that smaller panels might bring to patients the double benefit of less time spent in the waiting-room and more in the consulting-room. It is easier to accept the idea that some of Britain's 23,000 general practitioners rush through their surgery sessions with excessive speed, than to know when a reasonable speed limit has been passed. Doctors and patients alike testify that a minute or two is time enough for signing a work certificate or renewing a prescription (and many of the patients' surgery demands are as simple as that); but a thorough examination may take as long as an hour or more. The amount of time required depends, as a matter of course, upon the nature of the patient's ailment, and whether the doctor is a fast or slow worker—for in medicine, as in other callings, one worker may accomplish twice as much as another in a given time. It seems reasonable to suppose that the doctor is in a better position than anyone else (even the patient) to decide how much time to spend on each of the hundreds of persons who depend upon him for medical care. At any rate, the Ministry of Health has placed on him the responsibility for making the decision. It is reported to me by British doctors that they undertake

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seriously to give every patient as much time and attention as he needs, and feel that on the whole they come pretty close to doing just that. T o the question, " H o w many minutes does your doctor usually spend on you in a surgery visit?" the answers of patients taking part in my survey ran all the way from two to thirty, with approximately half of the estimates—for they were no more than that, since few patients were able to give exact figures—ranging from two minutes upwards. T h o u g h the patients were not asked to evaluate the adequacy of the time allotted them, a good many chose to answer not with figures but with such comments as "always sufficient," "never h u r r i e d , " "ample," "as long as needed," "doctor very thorough," "enough," and so on. It may be doubted that these judgments are any sounder than the appraisals of persons who allegedly have been given insufficient time in surgery consultations; but, on the other hand, there is no reason to suppose that they are any less sound. T h e heavy work-load of Health Service doctors demands strict economy in the use of their time. T h e more leisurely pace of pre-NHS days gave the doctor time for an occasional pause for a friendly chat in the consulting-room, or a cup of tea on a home-visit. This pleasant side of medical practice is hampered today by the necessity of "getting on with the j o b , " if all who need the doctor's care are to have it. " T h e sociability has gone out of medicine," says a practitioner with m a n y years of experience. " W e are giving our patients honest medical service, but we haven't time any more for the trimmings." T w o final comments m a y be m a d e about the patients' reputed dislike of the shortness of surgery consultations. T h e first is the fact that this criticism so often takes the form of hearsay evidence; for among the patients who report this particular shortcoming are a considerable number who state emphatically that their own doctors give them all the time they need! T h e second point is that no patient need remain with a

THE

PATIENTS'

LIKES

AND

DISLIKES

99

doctor who gives him too little attention, provided he can locate a less hurried one, for he is free to change doctors whenever his current one proves unsatisfactory. Sponging by Foreigners. From the very start, the British National Health Service has willingly ministered without charge to tourists, businessmen, and other bona-fide visitors who required medical attention. Such persons are not, in the official British view, sponging on the N H S in accepting doctor or hospital care without paying for it. As I was told by a friendly Londoner: " T h e minute you set one foot on British soil, you are under the National Health Service if you want to be." Foreigners who live in Britain may make full use of the National Health Service just as British citizens do. All residents, whether citizens or foreigners, who become ill while away from their homes (say, while on holiday or business trips), and visitors from abroad who fall sick in Britain, are entitled, as "temporary residents," to call upon local N H S physicians for medical care, which they receive without charge. (However, the government pays the attending doctors a modest extra fee for the services thus rendered.) There is, of course, such a thing as carrying the good>neighbor policy too far, as the British government discovered shortly after the beginning of the N H S ; for it is reported that, at that time, the N H S became a not-too-willing host to a good many nationals of other countries, who decided to come to Britain for free operations and other serious (and expensive) types of medical care. T o guard against such abuse, Parliament in 1949 passed an amendment to the National Health Service Act of 1946, giving the Minister of Health the power, among other things, " t o recover the cost of treatment in the case of persons not ordinarily resident in Great Britain for medical or hospital service which they may have received."' 6 There is every evidence that this law has not been enforced

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except in clear cases of abuse, or attempted abuse. It is true that immigration officials have been instructed to refuse landing permission to aliens coming to Britain temporarily to get free treatment, but the inspection is not very strict. For example, in answering a question asked him in the House of Commons a few years ago, the Minister of Health said: " I f the officials saw a lady pushing a pram, and it would appear the pram was empty and might soon be filled, they would refuse that particular lady permission to land!" 7 7 However, the effort to prevent abuse of the N H S "does not mean that a visitor from overseas is no longer welcome to free treatment, as an act of hospitality, for illness or accident overtaking him during his stay." 7 8 T h e word that comes from those who are best qualified to speak with authority is that sponging on the Health Service by foreigners is now very limited in quantity, and of trifling importance. T h e large-scale invasion by foreigners intent on getting free medical treatment in Britain was successfully repulsed. Aliens who now apply for N H S service are likely to be "within the l a w " ; and a good many Britons appear to get not a little satisfaction from the fact that their country extends the unusual hospitality of free medical care to its legitimate visitors. W e have quite a number of American families on our list [writes a practitioner in a small town near O x f o r d ] . Most are dependents of Service people. It m a y be a pointer to the possible American attitude toward a health service that these people, to a man, sign on within days of arriving here. A l l seem highly satisfied with the system, and make full use of it. A specific incident comes to mind: A 3 J pound b a b y was born to an American service wife here under m y care. T h i s b a b y was at once taken over by the prematureb a b y unit of the Oxford hospitals; it remained in hospital for some five months and did well. This cost this family nothing; you can imagine their feelings.

A foreigner may get treatment from a Health

Service

THE

PATIENTS'

LIKES

AND

DISLIKES

101

practitioner either as an N H S " g u e s t " or a private patient. I f he elects the latter status, the fee the doctor suggests is likely to be "whatever you would be paying at home." If the patient is from America, this will probably be considerably more than the customary British private fee; but for visitors from certain other countries the charge would doubtless be less than the fee ordinarily paid by the British doctor's regular private patients. One hears relatively few complaints from British patients about the free medical provision that is available for foreigners, but the few who announce their dislike of it tend to express themselves in no uncertain terms. It may be that they do not know that this one-time serious problem is now considered a very minor one by those who are fully acquainted with the facts or perhaps their sense of fairness is outraged by the knowledge that the British people are being taxed to make it possible for bona-fide foreign visitors (some of whom are exceedingly well-to-do) to be free of medical expenses during the time they spend in England, Scotland, and Wales. At any rate, 3 ! per cent of the patients in my survey, in reporting changes they felt should be made in the National Health Service, said that foreigners should not have free service except in cases of emergency, or unless they had lived in Britain for a considerable time, or unless their own countries (as is true of Norway and Sweden) reciprocate with Britain in an exchange of health provision. Prescription, Dental, and Ophthalmic Charges. T h e huge domestic demand for the free medical service that became available to all Britons in 1948 caused so heavy a drain upon the country's resources that the government felt compelled to make limited charges for certain specified services, as has already been noted. * " I t is estimated that the use of the Service by overseas visitors costs only a b o u t £ 1 7 0 , 0 0 0 ($475,000) annually, [and that] the administrative costs of recovery would exceed the amount r e c o v e r e d . " (Manchester Guardian Weekly, August 14, 1 9 5 8 , p. 5.)

102

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W h e n doctors and

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patients use the term

"charges,"

they

ordinarily have in mind the three types of part-payments that were described briefly in Chapter 2 — 2 8 cents for each item of every prescription issued by a general practitioner; up to but not beyond $2.80 for fillings or other " c o n s e r v a t i v e " dentistry (however extensive the j o b m a y be), with a m a x i m u m

of

$14.00 for full dental plates, upper and l o w e r ; and a total of about $4.25 for ordinary spectacles, including two lenses and frame. ( T h e charges for amenity beds and pay beds have been in effect ever since the beginning of the Health Service, and are viewed as payments for privacy rather than for medical care. These special beds are not regarded by the N H S as an essential part of adequate medical treatment except in rare instances, and they are then available without charge. T h e y are used b y relatively few patients; and the patients taking part in my survey expressed no objection whatsoever to the existence of these beds or the rates that are being charged for their use.) But there is some evidence that the prescription, dental, and ophthalmic charges are disliked b y patients. It is safe to say that practically all patients w h o make any use of their general practitioners have at some time paid a prescription charge. O f those w h o took part in my survey 79 per cent reported that they had used N H S dental service at least once, and 73 per cent had been supplied with one or more pairs of spectacles. Nine (9) per cent of these patients, in naming Health Service changes they would like to see brought about, chose to mention (with nothing in the question to remind them of " c h a r g e s " ) the abolition or reduction of N H S charges. T h e i r reasons for objecting to these charges were seldom given, though there was some expression of fear that

the

charges might prevent persons in the low-income groups from getting needed treatment. However, at a time w h e n the charge was still only 14 cents for each prescription, a mere 1-2 per cent

THE

PATIENTS'

LIKES

AND

DISLIKES

IC>3

of the patients replied that the one-shilling prescription charge had caused them to see their doctors less often than they would have seen them if no charge had been in effect; but 3-2 per cent said the N H S charges for dental or eye service had prevented, or at least delayed, their having such work done. (The general practitioners w h o m I interviewed, who admittedly had no exact data on which to base their estimates, put the probable deterrent effect of N H S charges at a higher figure than the patients. When I asked how frequently they thought these charges interfered with patients' getting treatment they required, 10 per cent of the doctors said often, 42 per ccnt occasionally, and 48 per cent almost never, in the case of dentistry; and 1 per cent replied often, 30 per cent occasionally, and 69 per cent almost neuer, in the ca^e of getting spectacles. As for the prescription charge, which was at that time only 14 cents, 98 per cent of the general practitioners felt that it almost never, and the other 2 per cent that it only occasionally, kept patients from seeing their doctors whenever necessary.) Asked whether they would recommend any changes in the prescription, dental, and ophthalmic charges, 5 per cent of my doctors said the rates should be reduced; 45 per cent, that they should be continued as at present; 30 per cent, that they should be increased; and 20 per cent, that charges should be extended to include other (unspecified) types of service. Seventy-five (75) per cent of these doctors felt that amenity-bed and pay-bed accommodation in hospitals should continue to be provided; 25 per cent, that they should not. Of those who voted for the continuance of these beds, 3 1 per cent said the charges should be reduced, 66 per cent thought the present rates satisfactory, and 3 per cent suggested that the charges for these special hospital quarters should be increased. T h e introduction of prescription, dental, and ophthalmic charges into a system of health provision which had previously been completely free was a great disappointment to many

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Britons for w h o m one of the chief features of the N H S was its f r e e d o m from fee-for-service payments.

Not m a n y

were

as

outspoken as M r . M a r q u a n d , L a b o r member of Parliament, m e m b e r of the O p p o s i t i o n , and formerly Ministei of Health w h o declared in 1952: " W h e n w e are returned to power w e shall take steps . . . to b r i n g all these charges . . . to an e n d . " 7 9 T h e recommendations of general practitioners, reported in the preceding p a r a g r a p h , d o not suggest a n y strong opposition to these charges; and t h o u g h patients in general w o u l d doubtless be pleased to h a v e these part-payments abolished, there has been no aggressive m o v e m e n t toward that end. For some r e a s o n — p r o b a b l y because they h a v e recognized the need for e c o n o m y in the spending of public funds, and know that N H S charges are refundable in cases of demonstrable hardship—the

British

people

seem

to

have

accepted

the

" c h a r g e s " situation and learned to live with it. Says Sir James Ross on this point: " T h e s e charges are not an infringement of the national policy in the form in w h i c h it was first a p p r o v e d : the Beveridge R e p o r t

specifically mentioned

t h e m as pos-

sible." 8 0 A n d again, opposing any reduction in the quality of N H S services: " W e h a v e either to make charges for some services or lower our standards. . . . T h e essential elements of health provision should be free of any charge. W h e r e good reasons apply, w e c a n single out less essential services for part p a y m e n t . T h i s is subject to help in necessary cases from the N a t i o n a l Assistance B o a r d , on a reasonable means test (not the test of destitution), so that the good principle of 'no barrier' may apply."81

SOME THINGS T H E PATIENTS LIKE

Wide Scope of NHS

Provision.

B a l a n c e d against the

dislikes

discussed a b o v e are m a n y things w h i c h the patients like very m u c h indeed. O n e of the most obvious and widely expressed of

THE

PATIENTS'

LIKES

AND

DISLIKES

IO5

these likes is the comprehensiveness of the Service and its nation-wide coverage. U p to the time the N H S began operations, about one-half of the British people—the employees who were either manual workers or who had annual incomes not exceeding £ 4 2 0 (then about $1,600)—came under the compulsory Health Insurance scheme. These people were entitled to family-doctor service and free drugs; but their insurance coverage did not include specialist or hospital care, nor did it extend to their wives, children, and other dependents. 82 The other half of the population—including the self-employed who, though many of them were quite poor, did not come under the compulsory health insurance plan—were expected in pre-war days to buy for themselves, as private patients, whatever medical treatment they needed, in so far as they were able to do so. However, a Poor L a w general-practitioner service, built up through the nineteenth century for the "destitute sick," was available for uninsured persons who could not pay for the medical attention they required. 83 There were also municipal hospitals, which were required to charge their patients what they "could reasonably a f f o r d " to pay for the treatment they got; and "voluntary" hospitals as well (supported chiefly by subscriptions, contributions, and endowments), which also followed the practice of collecting from patients in accordance with their ability to pay. Some seven million persons of limited means sought protection against the heavy costs which a stay in hospital would entail, by taking out membership in one of the numerous hospital contributory schemes that were available upon payment of a small weekly subscription. 84 The situation was one in which many members of the lowincome groups got medical attention only as a matter of charity, if indeed they got it at all. And before the start of the N H S (if I am correctly informed), it was the mothers who, in families which had little to live on, were the least likely members

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to get needed medical care. I f the father of the f a m i l y took sick, he at least got general-practitioner care by virtue of his compulsory health insurance. When one of the children became ill, the mother could sometimes manage to scrimp on household expenses and save enough to pay the minimum fee of a halfcrown (then 50 cents) which a visit to the doctor would cost. But when she herself was ailing, she would often simply grin and bear it, and leave it to nature to provide a remedy. It is scarcely surprising, then, that the universal coverage of the National Health Service—which makes it possible for everyone in the country (including, as a matter of course, every housewife and every child) to have a personal doctor—rates high among the N H S "likes" of many British wives and mothers, and of husbands and fathers as well. Equally popular among the patients is the comprehensiveness of the Health Service. T h e present attitude is strikingly similar to the view expressed by the British public in 1942, when asked whether doctors' and hospital services should be extended, free of charge, to every person. This proposal, as was noted in Chapter 1 , was "heartily endorsed, with 88 per cent of the public welcoming the idea, 6 per cent expressing disapproval, and a further 6 per cent undecided." 8 5 T h e Churchill Coalition Government's idea of a comprehensive health service was presented in its White Paper in 1944, in these words: The proposed service must be "comprehensive" in two senses— first, that it is available to all people and, second, that it covers all necessary forms of health care. [It] must cover the whole field of medical advice and attention, at home, in the consulting room, in the hospital or the sanatorium, or wherever else is appropriate— from the personal and family doctor to the specialists and consultants of all kinds, from the care of minor ailments to the care of major diseases and disabilities. It must include ancillary services of nursing, of midwifery and of the other things which ought to go with medical care. It must secure first that everyone can be sure of a general medical adviser to

THE

PATIENTS'

LIKES AND

DISLIKES

IO7

consult as and when the need arises, and then that everyone can get access—beyond the general medical adviser—to more specialized branches of medicine or surgery. This cannot all be perfected at the stroke of the pen, or on an appointed d a y ; but nothing less than this must be the object in view, and the framing of the service from the outset must be such as to make it possible. 84

Though published a decade and a half ago, this description sounds very much like the British National Health Service that is in operation in i960. There can be no doubt, I feel, that much of its popularity is attributable to the fact that the Service is available to everybody who chooses to use it, and that it provides care for all types of illness, within the capacity of the country to supply it. " E v e r y day about two million people are making use of the Servict in one way or another," stated the Minister of Health recently. "There is hardly a home in the land that does not rely upon it in time of crisis." 87 Medical Care of High Quality. "Health is a purchasable commodity, of which a community can possess, within limits, as much or as little as it cares to pay for," says Mr. Tawney; and continues: " I t can turn its resources in one direction, and fifty thousand of its members will live who would otherwise have died; it can turn them in another and fifty thousand will die who would otherwise have lived. Though no individual, by taking thought, can add a cubit to his stature, a nation by doing so can add an inch to the height of some groups of children and a pound to their weight." 8 8 If Mr. Tawney is right in his contention that health is purchasable, it would seem to follow that, in a country where medical care is supplied on a private-enterprise, fee-for-service, basis, the health of a family will depend very largely upon the family's economic status. A pre-NHS article in The Lancet lent support to this view, pointing out that in 1946 infant mortality in Britain was more than twice as high among the children of laborers and semiskilled workers as among the children of

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professional men; and that mortality from measles was nearly ten times as high. " I n almost every form of ill health the same pattern occurs; and though infant mortality in all classes has progressively fallen, the time-lag always remains between the higher and lower socio-economic groups: the laborer's baby in 1931 had as good a chance for survival as the professional man's baby in 1 9 1 1 — o r should one say 'no better chance'?" 8 8 But if health is a purchasable commodity, it is one that is becoming increasingly expensive as time goes by. Sir Lionel Whitby, speaking in 1948 as President of the British Medical Association, said that the cost of an illness was beyond the purse of the average person. 90 And according to Professor Lafitte, "the twentieth-century scientific and 'industrial' revolution in medicine, while greatly enhancing the potential efficacy of medical care, requires so high a rate of investment in medical facilities as to put the cost of medical care increasingly beyond the slowly changing spending-propensity of the private consumer." 9 1 However, relatively few Britons are at present "private consumers" of medical care; and M r . T a w n e y is doubtless justified in observing that because of the National Health Service an individual born today into a British working family "will not, as often hitherto, be deprived of means of the treatment in illness required by him or his dependents." 9 2 Health Service patients rate highly the fact that they can rely upon getting the health care they require, regardless of its nature; and perhaps more highly still the assurance (to quote the White Paper of 1944) "that what they get shall be the best medical and other facilities available." Professor Lafitte suggests that the social services (including medical provision) that came out of the "Beveridge revolution" did not aim at "minimum provision at all . . . but something nearer to an o p t i m u m — a standard of service that few could hope or wish to better by making private arrangements." 9 3

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PATIENTS'

LIKES

AND

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Though the goal of optimum service is yet to be reached, there is evidence that a great many patients regard the health service they are now getting as extraordinarily good. " M y case was dealt with by the then foremost specialist in the country"; " N o millionaire could have had better service"; and " M y wife's specialist was known all over Europe for his very great skill" were among the laudatory comments that were let drop by patients in the course of my interviews. A statement by a doctor in the Lake District—"It's great to be able to prescribe whatever medicine the patient needs, regardless of cost, and to get him into the hands of the best specialists"—is, I believe, a fair reflection of general-practitioner opinion from the many doctors who take pride in the quality of service they are now giving their patients. Clearly, one of the "likes" of N H S patients is the fact that medical care of high quality, formerly available only to the well-to-do, is now readily accessible to those in even the lowest income groups. Avoidance of Catastrophic Medical Costs. Doubtless any major illness, and in particular any which involves treatment and great suffering over a long period of time, might properly be called "catastrophic sickness," but in the United States at least the term is most commonly used in an economic sense, as relating to an illness the costs of which have played havoc with the family budget, " 'Catastrophe,' as used with reference to costs of personal health services has always been nebulously defined as 'an awful lot,' depending on family income," says the Health Information Foundation of New York City, in its comprehensive, nationwide study of medical costs covering twelve consecutive months in 1952-53. The foundation does not suggest a more exact definition; but the full meaning of the term "catastrophic sickness" is doubtless understood by many of the 500,000 American families which (in the twelve-month period covered by the foundation's survey) paid out for health services amounts

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equaling or exceeding 100 per cent of their annual family incomes, and even by the additional 500,000 families whose payments of this kind either equaled or exceeded one-half of their incomes. 94 T h e National Health Service has taken from the British people the fear of catastrophic sicknesses which might wreck a family's financial program, and has thus removed many a heavy load of economic worry. T h e knowledge that a siege of illness need not entail the spending of past savings, or the mortgaging of future earnings, is a source of relief to countless N H S patients. T h e timeworn remark, " I can't afford to be sick," spoken sometimes humorously and again seriously, is not heard in Britain today, so far as my experience goes. But I have either read or listened to many personal accounts of critical but successful batdes with sickness, which (I was told) would once have cost a small fortune but today, under what many Britons call "the jolly old health scheme," cost the patients nothing. About half of the patients who took part in my survey reported that their households had experienced what their general practitioners had pronounced serious illnesses. By no means all would qualify as catastrophic sicknesses, but many would almost surely have caused economic hardship in the absence of N H S medical care. Here are a few samples: Patient No. 36. A 25-year-old clothing-worker, with ankylotic spondylitis, who spent 14 months in hospital. Patient No. 190. A 58-year-old Lancashire clerk, suffering from both bronchitis and asthma. "During the past 6 years I have been admitted to hospital seven times, each time as an urgent case. My stays there varied from 2 weeks to 7 months. My last hospital visit was two years ago, but I am at the moment under specialist care." Patient No. 202. A textile worker in the north of England, whose case of tuberculosis required 17 months of hospitalization "and the latest drugs." Patient No. 225. An electrician, 50 years of age, in the English Midlands, who had a fractured skull, and spent 6 weeks in hospital,

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followed by 3 years of convalescence. "During my 3-year illness I was sent to the seashore twice, for a month each time." Patient No. 241. A woman clothing-worker's sister, who was hospitalized 18 months for treatment of a tubercular spine. Patient No. 490. The senile aunt of an Ayrshire, Scotland public entertainer. The aunt had NHS home nursing, followed by 6 years in a nursing home. Under a fee-for-service system of medical care, the cost of health provision as extensive as that outlined above would probably, though not necessarily, seem quite formidable to persons whose gross annual incomes fell within the £ 2 5 1 - ^ 5 0 0 ($700-$ 1,4.00) bracket, as did the incomes in the cases that have been cited. N o patient was asked to express an opinion on this point, but some did it anyhow. Following are several of their comments: Patient No. 19. The wife of a Cambridge schoolmaster developed cancer of the breast. "Secondaries occurred. She received nearly 5 years of specialized treatment, including months of hospital care, years of deep X-ray treatment and hormone injections, which could have been valued at several thousand pounds." Patient No. 107. The very young daughter of a merchant in the south of England spent 4 months in hospital, suffering from hydronephrosis. " T h e service given to my child—-and specialist care, even to the extent of moving her to London for almost-unheard-of operations—would have ruined me were it not for the N H S . " Patient No. 193. The aged mother of a 53-year-old female textile worker had been ill from diabetes and heart trouble for many years. " T h e doctor, specialist, and district nurses have all taken great care of her. I am single, and the only wage-earner. I would be a very poor person today but for the N H S . " Patient No. 473. A London civil servant, aged 48, was required by rheumatic fever to spend 13 weeks in hospital. He also attended rheumatism clinics for treatment during recent years. " I f I had been faced with the costs, this would have been beyond my means." Patient No. 601. A small-scale London druggist, who was held in hospital for 1 o weeks following a lung operation, and later 4 weeks more for treatment of an abscess. He estimated that, all told, this

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treatment (including the extensive use of "miracle drugs") would have cost at least £ i ,000; and ended his statement with the sentence, " T h e Health Service is a godsend." Confidence that, however prolonged an illness may turn out to be, the cost of the best treatment available can no longer bring economic catastrophe to the individuals or families concerned is a source of great satisfaction to those who depend upon the National Health Service for medical care. " I n Britain you don't pay [for medical care], no matter who you are or how complicated your problem is or how long you have to stay in the hospital," writes an American newspaper correspondent stationed in England. "Anyone who has a heart attack or appendicitis or an automobile accident can walk (or be carried) into any hospital and receive complete care free. . . . A medical tragedy can no longer become a financial disaster. In Britain the shadow of medical bills has been removed from family life forever." 9 5 Health Care as a Right, not as Charity. " A t the present time," says M r Tawney, "there is no nation which does not treat as a public obligation some services which its neighbors continue to leave to the unaided efforts of the individuals requiring them, and resign to private charity others which elsewhere are regarded as a social function." 9 8 T h e N H S is an outstanding, large-scale example of the acceptance of such a "public obligation," for it is a system in which (as a government pamphlet made clear in 1949) "the wealth or poverty of an individual becomes irrelevant to health care, as it should be. Bills are paid collectively instead of individually. T h e clubbingtogether of all citizens to meet the cost of medical care provides free service for any citizen at the moment he needs it." 9 7 T h e N H S marshals and utilizes the resources of the whole people to provide an essential service for the whole people. T h e Service is not only available for all who wish to use it, but is being used by an overwhelming majority of Britons, rich

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and poor alike. Its goal is to supply, in so far as this is possible, a single grade o f medical c a r e — t h e best the country can afford. It offers no "second-class service for impliedly

second-class

citizens," 9 8 and subjects no one to the humiliation and haphazardness that often marred the pauper or charitable services which, over the years, had developed from the Victorian Poor L a w . It operates on the basis that collective expenditure makes possible c o m m u n a l provision for a generally shared social need; and that all members of the community are entitled to this provision (and can accept it with no loss of self-respect) because of their c o m m o n c i t i z e n s h i p . " In

1944, the

Churchill

Coalition

Government

found

it

desirable to explain that its proposed health scheme was one that had no taint of charity, but was analogous to other types of social provision w h i c h people did not hesitate to use: "Just as people are accustomed to look to public organization for essential facilities like a clean and safe water supply, accepting these as things w h i c h the c o m m u n i t y combines to provide for the benefit of the individual without distinction of section or group, so they should now be able to look for proper facilities for the care of their personal health to a publicly organized service available to all w h o w a n t to use i t . " 1 0 0 T h e British are a proud and sensitive people. T h e y have a horror o f anything that smacks of means tests or Poor L a w charity. Professor Lafitte cites an example from the days of the Great Depression: " N o fewer than a million aged pensioners w h o h a d quietly refused to ask for poor relief flocked to the Assistance Board in 1940, and qualified for help, w h e n relief was offered t h e m outside the Poor L a w under the new name of 'supplementary pensions.' " 1 0 1 A feature of the National Health Service that appeals to the patients strongly is the fact that the medical care they get comes to them as a right and not as charity.

6 THE DOCTORS' LIKES AND DISLIKES

This chapter and the previous one do not, of course, comprise anything like a complete picture of patients' and doctors' likes and dislikes with respect to the National Health Service, but discuss only the likes and dislikes which were mentioned most often or most emphatically by those who took part in my survey. It seems fair to say that, on the whole, the gains brought to patients by the N H S were more obvious than those enjoyed by the doctors. T h e Service offered comprehensive health coverage to all who elected to accept it, without interference of any kind with a patient's way of making a living, and without affecting the size of his income. With the general practitioners it was quite a different matter. For, the Ministry of Health (by authority of Parliament) set up rules and regulations which not only reduced the incomes of some doctors, but limited the right (previously enjoyed) to set up practices in certain areas, and abolished completely the right to sell practices, which had been freely exercised in the past by general practitioners when retiring from active practice or moving to new locations. Though the doctors have received, through the Service, some much appreciated benefits which will be described later irrthe chapter, they have had to adjust themselves to altered and sometimes irksome conditions, to an extent quite outside the experience of NHS patients. 114

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SOME THINGS T H E DOCTORS DISLIKE

The Inability to Move Readily from Area to Area. Dr. Eveline Burns has made it clear that a health service such as the N H S is by no means the same thing as a national indemnity health insurance scheme. Since in Britain the coverage of the Service is universal and embraces all kinds of health service, this has meant in fact that the government, through the Ministry of Health, has to assure that adequate personnel and facilities are available everywhere. . . . This is perhaps the feature of a national health service that distinguishes it most sharply from an indemnity health insurance system, however wide the scope and coverage of the latter. In the typical health insurance plan all the government does, in effect, is to remove the economic barrier to access to whatever medical services of the defined types may be available. If the patient cannot find a hospital in his community . . . if certain necessary specialists are not available . . . if there are too few doctors in his community, or if the general level of professional practice is low, [these shortcomings] are no responsibility of the government. Under a public medical service [such as Britain's], however, all these become matters for which government has accepted responsibility and for which it is held accountable. 1 0 2 The Churchill Coalition White Paper of 1944 recognized that the general practitioners of Britain were not satisfactorily distributed

throughout the country, and warned that

"an

unrestricted right to any doctor to enter any new practice and there to claim public remuneration, at his own discretion, would make it impossible to fulfill the new undertaking [set forth in the White Paper] to assure a service to all. . . . This implies some degree of regulation of the distribution of medical resources, at least to the extent of securing that a doctor does not in future take up a practice in the public service (whether by purchasing a practice or by 'squatting'), in a locality which is already fully or over-manned." 1 0 3 When the National Health Service A c t of 1946 was enacted, it included one section

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prohibiting the sale of medical practices, and another (described in Chapter 2) which charged the Executive Councils and the Medical Practices Committee with the responsibility of redistributing general practitioners, by denying doctors permission to enter into practice in areas where the supply of general medical service was already adequate. 104 This restriction on the mobility of general practitioners has doubtless caused inconvenience and even some hardship. One hears, for example, of the elderly doctor who has practiced for some decades in the rigorous north and would like to spend his remaining years of professional work in one of the southern counties of England, but is not permitted to make the transfer. There is, of course, nothing to prevent his moving if he is willing to withdraw from the N H S and accept private patients only. But this would not likely be feasible, for he would almost certainly have few patients and hence an insufficient income. T h e latest official report on the problem of bringing about a redistribution of general practitioners is to the effect that, from the patients' point of view, "there has been a steady and satisfactory improvement." 1 0 5 It is only fair to say that relatively few of my general practitioners expressed specific dislike of restrictions upon the doctors' freedom of movement and location; but those who mentioned it usually did so with considerable heat. There was seldom evidence that the person protesting against enforced immobility would actually have moved to another area if the way had been open. Indeed, I got at times the impression that the remonstrance was impersonal, and was in effect a cry of outrage at the loss of a long-possessed right which might never have been exercised in any case, but which nevertheless was to be surrendered only under protest. Lord Taylor holds that "the right to carry on one's occupation in the place of one's own choosing is a freedom which can never be absolute, for choice must be related to public need

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and availability of work. But given availability of work, it is wrong to try to push or pull the individual away from the place of his own choice." 1 0 6 He then states the principles which he feels should govern the entry of a doctor into general practice: The first requirement is to meet the needs of the community, expressed here in terms of an absolute or relative shortage of doctors. The second is a maximum of freedom of choice for the intending practitioner. The closing of areas to new entrants can be fully justified as a means of pushing doctors towards places where they are urgently wanted. It can be partially justified as a way of protecting established doctors who are providing a satisfactory service to their patients. But if doctors are to retain the true substance of freedom, negative direction must be kept to a minimum. 107 With the plan for the redistribution of general practitioners working well at present, and steadily becoming more effective, but (according to the Minister of Health) "still room for further improvement," the barrier against the entry of new doctors into the currently restricted areas is unlikely to be lowered for some time to come. Hence, the inability to move readily from area to area must remain, for the immediate future at least, one of the things about the N H S that a number of the general practitioners dislike. Prohibition of the Sale of Medical Practices. " W h e r e the name of any medical practitioner is . . . entered on the list of medical practitioners undertaking to provide general medical services, it shall be unlawful subsequently to sell the goodwill, or any part of the goodwill, of the medical practice of that medical practitioner," reads (in part) Section 35 of the National Health Service Act of 1946. This regulation was strongly protested by the doctors of Britain, among whom the sale and purchase of medical practices had become a firmly established custom. M a n y doctors, at the beginning of their professional careers, had paid substantial sums for the practices of retired or deceased physicians, and

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fully expected to be allowed to sell them again when they were ready to give them up. It was generally recognized that the abolition, without compensation, of the sale of practices would work great hardship upon large numbers of practitioners. " M a n y of these doctors look forward to the value of their practices for their retirement," said Aneurin Bevan, who was Minister of Health when the N H S Act was passed. " M a n y of them have had to borrow money to buy practices, and therefore it would, I think, be inhuman and certainly most unjust, if no compensation were paid for the value of the practices destroyed." 1 0 8 T o avoid such injustice, Parliament set up a "global sum" of £66 million (equivalent at that time to about $264 million in American money), based upon British Medical Association figures and actuarial estimates, from which to indemnify the doctors for losses incurred by the abolition of the right to sell their practices. Doctors entitled to share in the distribution of this fund were those who joined the Services before February, 1950, and who submitted their claims for compensation not later than February 28, 1951. O n that date, the total sum was apportioned among "the doctors whose claims had been admitted, in the proportion that the annual value of a doctor's practice bore to the aggregate annual values of all doctors entitled to participate." 1 0 9 The amount thus allotted to each doctor is normally held until his retirement or death, in the meantime drawing interest at the rate of 2 | per cent a year. Though the Ministry of Health was reported to have felt that "these compensation provisions were most liberal," 1 1 0 not all of the doctors agree. A considerable number of the older ones believe, rightly or wrongly, that the sale of their practices (if permitted) would bring them a larger return than they will get in the form of N H S compensation for the loss of the right to sell, and they consequently regret that the change has taken place. Some young doctors, who are finding it hard to build up

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a practice but could afford and would be glad to buy a readymade one, understandably dislike the prohibition of the sale and purchase of practices. But only the most optimistic of the dissenters—and there are very few of these optimists to be found—actually think that the right to buy and sell practices will ever be restored. By the many, this one-time live issue is now definitely regarded as finished business! The Alleged Inadequacy of Doctors' Pay. Enough was said in Chapter 4 about the pay of Health Service doctors to indicate that they—in common with other employed persons, in Britain and elsewhere, whose incomes have failed to keep pace with increases in the cost of living—are in general quite unhappy about this trying situation, and have not hesitated to say so. Some of these practitioners report that their standard o f living has been lower than it was before 1948, and is lower (they feel, but of course cannot prove) than it would be today if the N H S had not been adopted. Others say that their present financial status is probably better than it would be in the absence of the Health Service, but that the amount of work they do has increased out of all proportion to the rise in their standard of living. O n one point—that the government has not lived up to its promise in the payment of general practitioners— there seems to be almost complete agreement. T h e doctors are quite sure that the government agreed, on the basis of the Spens Committee Reports, that the remuneration of general practitioners would be adjusted, from time to time, with "direct regard" to changes in the value of money and to increases in other professions. " I n our judgment," the Spens Committee had said, "it is only if corresponding changes are made in the income of general practitioners that the recruitment and status of their profession will be maintained as against these professions." 1 1 1 It seems probable that the remuneration of general practi-

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doners on the "escalator" principle, as was recommended by the Spens Committee, might place a painfully heavy burden upon the Exchequer; that the required payment, if payment should prove possible, would add somewhat to the danger of runaway inflation; and that the governmental guarantee of medical practitioners against the loss of purchasing power in times of rising prices would inevitably be regarded as discriminatory by other groups in society which were not similarly protected. The i960 Report of the royal commission (outlined in Chapter 4), and the government's acceptance of the recommendations of higher pay and a Standing Review Body, have done much to reassure the doctors that their financial interests will be protected. As of 1961, the once vexatious problem of doctor's pay is not a live issue, though it may of course become troublesome again in the future. Payment for Drugs Used by Private Patients. It was noted in Chapter 2 that anyone who elects to be a private rather than an N H S patient must not only pay for his doctor's services, but for whatever medicine he may require as well. The case against free medicine for private patients, says a well-informed British physician, is that "it would encourage many people to opt out of being N H S patients of their general practitioners, and might therefore encourage discrimination among the practitioners in favor of their private (fee-paying) patients. In my view, this argument is sound. The 'free prescription' for the private patient would damage the general level of service for the public as a whole." This doctor mentioned, also, that the widely representative Cohen Committee on General Practice had voted against recommending that private patients be allowed to obtain medicines under the NHS—that is, without charge. However, the fact remains that many general practitioners are opposed to requiring private patients to pay for medicines

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while N H S patients do not. T h a t people who deliberately choose to stay outside the Health Service should have to pay their privately engaged physicians—even though they have contributed (as they must) to the Health Service fund, and could claim all the medical care that the N H S is able to provide—has seemed entirely reasonable to the N H S doctors. But that private patients should be required to pay for medicines that are supplied free (except for the prescription charge) to N H S patients is widely regarded (even by practitioners who themselves have few if any private patients) as discrimination— and a violation of a 1948 understanding that "the individual citizen [would] be free to decide whether he will take advantage of the public service in whole or p a r t . " 1 1 2 T h e British Medical Association has long supported the view that people who prefer to engage and pay their doctors by private arrangement should have the privilege of using the National Health Service for all their medical needs—and, indeed, they now have that privilege except in the case of free medicine. But the ministry's answer has been that physician and treatment are one, and that "public funds cannot rightly bear the cost of medicines which are ordered by doctors in a purely private c a p a c i t y . " 1 1 3 For the eighth time in nine years, the B M A reaffirmed its stand on free drugs for private patients, at its 1958 Annual Representative Meeting, by passing a motion that "all patients, private or otherwise, should be entitled to drugs under the National Health S e r v i c e . " 1 1 4 T h e doctors' dislike of the situation is based in part on the conviction that the ministry's position is inconsistent, unreasonable, and unfair to the relatively small group of people who find the thought of medical care under the National Health Service distasteful. But some doctors are concerned, too, about the ultimate consequences on private practice of the ruling that private patients must pay for their medicines. M a y it not bring about the gradual but complete extinction of

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private medical practice in Britain? Indeed, m a y it not be a device that was designed for that very purpose? Questions such as these have been m u c h discussed during the past decade. T o the Fellowship for Freedom in Medicine, an organization of some 3,000 doctors w h i c h has been battling for the preservation of private practice ever since the start of the N H S , the answer is clear e n o u g h : " P r i v a t e practice is the sole bulwark against a state monopoly in medicine. T h e Ministry would seemingly be quite content, in the interests of tidy administration, to see private practice d i e . " 1 1 5 T h e statement continues: Why was Mr. Bevan [the first Minister of Health under the NHS] so obdurate on the question of drugs for private patients ? He gave the answer himself: " I f we made the concessions asked for, that 4 per cent [of patients who are not on N H S lists] would grow very rapidly indeed, and before long this would prove the biggest piece of sabotage of the Health Service which could possibly have been conceived." By this he could only have meant that large numbers of patients would, if they could possibly afford it, pay for their doctoring, with the result that his dream of a 100 per cent statesalaried Service would not be realized. 116 Whether the Fellowship's explanation of the purpose of charging private patients for medicines is correct, or whether (as is claimed by others) the charges are necessitated for reasons related to the administration and supervision of the pharmaceutical services, it is hard to escape the conclusion that these charges constitute a real threat to the survival of private general practice. T h e cost of drugs has been mounting steadily, the average cost per N H S prescription is more than twice as high as it was when the Service began, and the trend is still definitely upward. Antibiotics, and other modern drugs w h i c h are now in common use, are so expensive that the cost of a patient's medicine is perhaps more likely, than the size of his doctor's fee, to cause him to shift from a private-patient relationship to a costless Health Service status.

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Only the quite well-to-do and the bitter-enders among the patients are likely to hold out against so obvious an economic disadvantage. The probable effects, on private practice, of a long-term denial of free medicine to private patients are readily predictable; the Ministry of Health shows no signs of weakening on this issue. And so the outlook is not bright for those who believe, with the Fellowship for Freedom in Medicine, that "private practice is the only means of providing a yardstick by which to measure the quality of a State Service, [that] it establishes a standard of worth for the doctor and protects him from exploitation by the State, [and that] it guards the public against the lowered and impersonal standards of treatment towards which a State Service inevitably tends." 1 1 7 When asked whether private patients should be given all required medicines and drugs free, on the same basis as N H S patients, 75 per cent of the general practitioners whom I interviewed said Yes\ 25 per cent, No. The comments these doctors made in this connection seldom went beyond the statement that charging private patients for necessary drugs seemed definitely unfair both to the patient who had to pay the bill, and to the doctor who might lose his patient to the N H S becausc of the heavy cost of the privately bought medicine. There were only a few direct references to the possibility that the continued existence of private practice might be at stake. The most common argument was to the effect that private patients should have free medicine "because everyone pays the National Insurance contributions and supports the Service through taxation." SOME T H I N G S T H E DOCTORS L I K E

Freedom from Financial Dealings with Patients. N H S general practitioners, when asked about the burden of paper work that the Service has imposed upon them, give one the impression that a good deal of their time is consumed in performing such

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duties as keeping records, issuing certificates, and making appointments (often by letter) for consultants to see patients who need special tests or treatment. But a surprisingly large number mention, in this connection, that by way of compensation for having to handle an extra load of paper work of these kinds, they have been relieved of the necessity (always bothersome and sometimes embarrassing) of billing their patients and making collections, which are a part of private medical practice. It seems clear that the clerical j o b of making out bills and mailing them is not, for a good many doctors, the most trying part of the process of getting paid (under private practice) for medical services that have been rendered. How much to charge the patient, when practicing under a fee-for-service system, may be a much more difficult matter, according to general practitioners I have interviewed. Charging what the traffic will bear may be all very well when the patients are known to be wealthy or even moderately well-to-do; but unless I have been grossly misinformed, many a British doctor, in pre-NHS days, worried a good deal over whether what seemed to him a perfectly fair, or even an unduly low, charge might not cause hardship in specific cases. Medical charges, like income taxes in most civilized countries, have traditionally been based on the principle of ability to pay. Kindhearted doctors have often wondered whether certain families in the low-income groups could in fact "afford" to pay anything at all. In any event, the N H S doctors are very happy to be relieved of the responsibility of making such decisions, and many of them express pleasure that the relationship between physician and patients is no longer a commercial one. T h e y are pleased, of course, that the physical chore of sending out bills is a thing of the past. They are delighted to be completely rid of the problem of bad debts, which no longer exists because N H S practitioners are paid by their respective Executive Councils, from funds provided by the Exchequer. " I t is pleasant to have no bad

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debts, and not to have to charge people fees w h i c h you know they can very ill a f f o r d , " I was told b y a doctor in Oxfordshire w h o was expressing for himself and his partners a sentiment w h i c h I heard

repeatedly

in

my

discussions with

general

practitioners. T h e doctors like, too, the financial stability that comes from h a v i n g four equal quarterly payments of income in the course of a year. T h e general practitioner's profession is a highly seasonal one, with financially fat months in the first and last quarters of the year, w h e n the doctors are busiest, and

finan-

cially lean ones during the second and third quarters.

The

result, under a private, fee-for-service medical system, is considerable unevenness in income throughout the year. But the N H S practitioner can estimate fairly accurately w h a t his total income for the year will b e ; he knows he can count on receiving one-fourth of this a m o u n t every three months; and this certainly is a n aid in planning an orderly family budget. The NHS Superannuation Scheme. T h e sale of medical practices, w h i c h was c o m m o n in Britain before 1948, has been described as " o n e of the more serious obstacles to entering the profession and one of the most lucrative sources of gain at the end of a profitable career. [As Professor Lafitte pointed out], 'It was the doctor's substitute for a pension,' but as such was uncertain in a m o u n t — b e i n g high for some, and inadequate for o t h e r s — a n d laid a burden on the i n c o m i n g doctor w h i c h was frequently prohibitively

high for y o u n g

doctors

not in possession

of

independent m e a n s . " 1 1 8 W h e n the sale of practices was abolished in

1948,

general practitioner w h o j o i n e d the Health Service

every became

entitled to compensation (payable u p o n death or retirement) for the loss of the estimated " g o o d w i l l " value of his practice as of that year. A n d with the a b a n d o n m e n t of the right to sell practices, this time-honored "doctor's substitute for a pension" g a v e w a y (so far as future old-age provision was concerned) to

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the present Superannuation Scheme, which may properly be included among the "likes" of British doctors. The scheme is compulsory, and applies to general practitioners, full-time and part-time specialists, dental practitioners, and many other N H S employees. T h e doctor contributes 6 per cent of his annual net income to the superannuation fund, and the government contributes 8 per cent of the same amount.* T h e "normal" pensionable age (at which contributions cease, and after which service is no longer reckonable) is 65. But a general practitioner may retire, on pension, at age 60 after ten years of service. And at age 60, he may apply, if he wishes, to have the pensionable age extended to any age up to 70, and (if such permission is granted) continue to pay and reckon service to that year. The chief benefits paid under the Superannuation Scheme are life annuities and lump-sum retiring allowances, but there are also injury pensions, death gratuities, and widows' pensions. In general, the amount of a given benefit depends upon the " s u p e r a n n u a t e remuneration" (or total net income) that the insured has earned in the National Health Service. Broadly speaking, a doctor's pension amounts to 1 £ per cent of his total net N H S remuneration during the last forty-five years of reckonable service, or the whole of such service if it is less than forty-five years. His lump-sum retiring allowance is calculated as per cent of his total net remuneration as described above, if he is unmarried, or 1 £ per cent if married (as will be explained presently). The Ministry of Health gives a hypothetical example of the pension and retiring-allowance benefits to which a family doctor who "entered the Scheme on the 5th J u l y , 1948, aged 35, and continued as a general practitioner" would be entitled. Assuming that he remained in general practice for twenty-five * T h e government's contribution was increased to 9 J per cent in i960.

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years, and earned a total superannuable remuneration of £ 3 5 , 2 5 0 (approximately $98,700) in that time, he would (if unmarried) get a life income of £ 5 2 8 15s. od. ($1,480) a year (i.e., £ 3 5 , 2 5 0 X per cent), and a retiring allowance of £ 1 , 5 8 6 5s. od. ($4,440) in a single payment (i.e., £ 3 5 , 2 5 0 X 4* per cent). If married, however, his retiring allowance would be only one-third as great ($1,480), as was noted in the preceding paragraph; but upon his death, his widow would receive a life pension one-third as large as her late husband's, or about $490 a year. T o pursue the case a little further: If this doctor remained in active practice five years longer (extending his period of service to a total of thirty years) at the same average rate of net income, his pension at retirement age of 65 would be $ 1 , 7 7 5 year; his retiring allowance would be $5,325 if single, $ 1 , 7 7 5 married; and his widow's pension would be $590 a year. A further five years of service at the same average rate of net income, with retirement at age 70 (after thirty-five years of active practice), would insure this doctor $2,070 a year in pension benefits, and a lump-sum retiring allowance of $ 6 , 2 1 0 , if single. If married, he would get only $2,070 as a retiring allowance; but if his wife survived him, she would rcccivc a life pension of $690 a year. Restated briefly, the 1 £ per cent pension provision of the Superannuation Scheme guarantees a Health Service general practitioner, upon retirement, an annual income of 3 7 J , 45, or 52 £ per cent of the average annual net NHS income he received during his professional career, depending upon whether he has had 25, 30, or 35 years, respectively, of "reckonable service." T h e 4^ per cent retiring-allowance provision of the scheme assures him, upon retirement, a single lump-sum payment amounting (if he is unmarried) to 4^ per cent of the total net N H S income he earned during his years of reckonable service. If married, his retiring allowance is only one-third as much,

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b u t upon his death his w i d o w receives a modest pension for life. T h e superannuation benefits enjoyed by consultants and other specialists are calculated on essentially the same basis as those of general practitioners. T h e government's contribution to the fund f r o m w h i c h benefits are paid is, of course, a feature o f the Superannuation Scheme w h i c h appeals strongly to the doctors. Reduction in the Number of Night Calls. N o one can talk at length with British general practitioners without hearing that they are working harder than before the start of the H e a l t h Service. A m o n g the relatively few respects in w h i c h labors h a v e been lightened, probably none is more

their highly

appreciated than the reduction that has taken place in the n u m b e r of calls they h a v e to make upon patients in their homes at night. However burdensome a doctor m a y consider general practice to b e — e i t h e r as a whole, or in one or more of its parts — u n d e r the N H S , he c a n scarcely have overlooked the startling decline, during the past ten years, in night calls in general and out-of-bed calls in particular. T h i s decline has brought welcome relief to hard-worked practitioners, and stands high a m o n g the things in the N H S that are liked b y the doctors. T h e general practitioners w h o m I interviewed found it hard to answer with exactness m y question, " W h a t percentage of the visits y o u m a k e to your patients'homes are night c a l l s ? " Since few had kept written records on this point, to which they could refer, I asked for and got estimates w h i c h should perhaps be regarded

as merely

"enlightened

guesses" but

nevertheless

showed clearly that there is substantial agreement that the onetime serious problem of night calls has ceased to be really troublesome. Seventeen and one-half (17^) per cent of those w h o answered said only that they now have " f e w " or " v e r y f e w " night calls. O n e doctor reported " 2 night calls in the past 6 w e e k s " ; another, " 6 in a y e a r " ; a third, "practically n o n e " ; a fourth,

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a "negligible" number, and so on. Of practitioners who were willing to talk in percentages, many estimated that possibly one-half of i per cent of their total home visits are now night calls; many others put the figure at i per cent; and 54-2 per cent of all the doctors who answered gave estimates of 3 per cent or lower—indicating their feeling that not more than three in a hundred of their home visits to patients are made at night. (It is possible that a good many of the answers " f e w " and " v e r y f e w , " cited above, if they could be converted into percentages, would also come within the 3-per-cent-or-lower category; but on this point nothing can be said with assurance.) A total of only 2-4 per cent of the estimates made by my doctors fell into the highest three categories of answers, which included ratios ranging all the way from 1 1 night calls in a hundred home visits, to 25 in a hundred. Between these estimates of low and high ratios are approximately 26 per cent of all the answers, with ratio estimates extending from 4 night calls per hundred home visits, to 10 such calls per hundred. Despite the absence of exact figures, there seems to be no question at all that night calls have been greatly reduced under the National Health Service. Contributing to this reduction, according to the general practitioners themselves, are several factors. Chief among these is the conversion of many night calls into daytime or early-evening calls, after the introduction of the N H S had made it possible to have these home visits without charge. This explanation runs to the effect that the cost of p r e - N H S home visits led many people to delay calling the doctor until it seemed absolutely necessary to do so. If a child had a cold, sore throat, or earache, the optimistic parents would mark time, hoping that he would improve as the day wore on and a doctor bill (which, perhaps, they could ill afford) would be saved. But when the early optimism turned out to be unwarranted and the patient got worse instead of better, and when concern over the child's condition forbade

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further delay—in a word, when the "panic hour" had struck— then finally, though it might mean financial hardship, the doctor would be called. And the night call would often come so late as to be an out-of-bed call. From all accounts, the National Health Service changed all that, or at least changed it in very large measure. Since the doctor's visit no longer means a doctor-bill, a child's mother is likely now to telephone the doctor as soon as the trouble develops, asking him to drop in to see the patient while on his daily round of calls. As a consequence, the child gets earlier treatment, the family is saved much worry, and a hard-worked general practitioner is spared a night call. It is sometimes asked whether, since an NHS patient has the "right" to call his doctor out at night, there is not grave danger that he will abuse that right. Doubtless there are abuses of this kind, but they seem to be relatively few. Some doctors report that patients who did not hesitate to require night visits from their doctor under the former fee-for-service system—apparently on the basis that "he's getting paid for it, isn't he?"—now show some reluctance to call him out at night, since they know that under the NHS the night trip means extra work and interrupted rest for the doctor without any extra income. "People tend to be considerate and to ask for day visits, now that they are available without cost," says a doctor with a large practice in the Lake District; and this view has wide acceptance among general practitioners. It is an almost universal experience that patients are now extremely considerate about making night calls [says Lord Taylor]. The exceptions are a few of the younger folk, particularly those just setting up homes of their own and those just out of the Forces. Some of them are simply inexperienced in running a home and a family; but some still have to learn that the N H S can only work on a basis of mutual consideration between patient and doctor. They talk of their rights, forgetting that rights always carry with them obligations. 118

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I3I

T h e stork, in timing his visits, is no respecter of persons, not even of such important persons as his colleagues in childbirth, the general practitioners. As Lord Taylor points out: " T h e number of night calls depends largely on whether the doctor does or does not do midwifery. Inevitably a large proportion of midwifery cases begin at night; so the doctor who attends to his midwifery personally must expect to have his share of disturbed nights." 1 2 0 But even here the Health Service has brought some relief to the general practitioners. For the N H S made hospitals more readily available for confinement cases; and the great increase in the number of women who now choose to have their babies in hospitals instead of at h o m e — a much larger proportion than the Ministry of Health considers really necessary!— has helped to reduce somewhat the number of nocturnal visits required of the doctors who engage in this branch of medical practice. Furthering the good work of reducing night calls for general practitioners is the rota system, mentioned in Chapter 2, "an ingenious device by which the general practitioner is able to give his patients a twenty-four-hour, three-hundred-and-sixtyfive-day service, while enjoying reasonable time off d u t y . " 1 2 1 When a doctor collaborates in a rota group of such size that each member is on night duty—that is, subject to night call from any patient of any of the co-operating practitioners—only one night a week, and has all other nights free, his chances of getting insufficient rest by reason of night calls are materially lessened. Medical Service without Economic Barrier. T h e essence of a profession, wrote M r . Tawney nearly forty years ago, "is that, though men enter it for the sake of livelihood, the measure of their success is the service which they perform, not the gain which they amass. They may, as in the case of a successful doctor, grow rich; but the meaning of their profession, both for themselves and for the public, is not that they make money but

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that they make health, or safety, or knowledge, or good government, or good l a w . " 1 2 2 T h e doctors of Britain are not unmindful of the importance, to themselves and their families, of a high standard of living. But unless this observer is badly mistaken, the thing they like best about the National Health Service is the opportunity it gives them to provide more fully than ever before the medical care needed by the people of Britain. T h e doctors are happy that they can now prescribe the best medicines (regardless of their cost) for even the poorest patient, knowing that a lack of funds will not prevent the prescription from being filled. This was not always the case under the private-enterprise medical system of a dozen years ago. I have talked with physicians who, in pre-NHS days, sometimes felt compelled to prescribe the poorer of two possible remedies, simply because they were sure that the better one, which was quite expensive, would never be purchased by the patient. Unsolicited comments from N H S general practitioners indicate their satisfaction in being able to get the most effective medicines into the hands of their patients. One such comment, from a 9,700-patient partnership in Devonshire, says: " I t is gratifying to order treatment, knowing that the patient can obtain it and not be worried about the cost." Another, from a large general practice in Lancashire: " A t first my partners and I were against the Service. Now we approve of it. Any treatment, however expensive, is open to everyone, no matter how poor." Another source of gratification to doctors who are anxious to provide the best possible medical service is their ability, under the N H S , to visit their patients—or have their patients visit them—as often as they (the doctors) consider necessary. In the days of fee-for-service practice, a doctor who thought a followup home or surgery visit desirable might nevertheless hesitate to suggest it because it would mean an extra fee for him and extra cost to his patient. By dissolving the commercial link that

THE

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formerly existed between doctor and patient, the N H S

133

has

obviated any embarrassment w h i c h this relationship m a y h a v e caused in the past, and has thus made it easy for the physician to continue his treatment of a patient for as long a period as he thinks desirable. R e p o r t has it that the removal of this obstacle to seeing the j o b through to the end is m u c h appreciated b y doctors w h o (like the doctors and other professional m e n cited by M r . T a w n e v ) measure their success very largely in terms of the service they render. Finally, the N H S general practitioners take satisfaction in the f a c t — t o w h i c h I shall refer again in the next c h a p t e r — t h a t British medical provision has made m u c h progress since 1948. In a few instances, a personal c o m m e n t

accompanied

the

answer to m / specific question, as in the case o f the L o n d o n doctor with two partners and some 8,000 patients, w h o s a i d : " I entered medical practice twenty-three years ago. Before the W a r , m y practice was wholly p r i v a t e ; and I feel quite sure that I can do better service to the c o m m u n i t y under the N H S than I could before the W a r . " For the most part, however, the doctors interpreted m y question (as I had intended) to refer to the country as a whole, and reported o v e r w h e l m i n g l y t h o u g h not u n a n i m o u s l y — a n d obviously with professional pride—-that the medical needs of the country are n o w being better met than before the adoption of the National H e a l t h Service.

7

FURTHER BRITISH APPRAISALS OF THE NHS

The British people have always welcomed foreigners who wanted to study their National Health Service, though they have sometimes been rather puzzled by the results. In his scholarly history of the N H S , Sir J a m e s Ross comments on reports about the Service that have been published in the United States. " T h e y vary according to their outlook," he says. " S o m e of them are traveller's tales in which we in Great Britain find it hard to recognize our own Health Service." But he has high praise for the work of those who have studied the Service "in its own British conditions without regard to American problems and interests. In these reports we get valid appreciation and disinterested critical comment on the Service." 1 2 3 It should not be hard for Sir J a m e s and his fellow-countrymen to recognize their National Health Service in this brief account of mine, which indeed aims at reporting the Service as the British themselves see it. The facts I have already given are well known to most Britons and to a small number of Americans. T h e opinions I present in this concluding chapter are those of British doctors, patients, and others who, in answer to my specific questions or in statements they have made in print, have explained how they feel about the Service after some years of experience with it. When asked whether they considered the National Health «34

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I35

Service better or worse than the medical care they had before 1948, or about the same, 37 per cent of the patients in my survey said better, 13 per cent worse, and 50 per cent about the same. Since almost exactly half of the patients interviewed did not change doctors after joining the N H S , it is scarcely surprising that 50 per cent reported that they were getting about the same kind of medical care as before. Among those who pronounced the N H S service " b e t t e r " must have been a considerable number who had previously been unable to afford comprehensive health provision. T h e 13 per cent who felt the service had deteriorated would doubtless include, among others, some fairly well-to-do persons who, under the N H S , could not get the immediate, leisurely attention to which they had been accustomed. It might also include some people with low incomes, for, as The Economist has pointed out: " T h e cost [of the Scrvice] has had to be counted and kept in check, with the result that some demands, some needs, have not been met. This spreading of limited resources over the whole population has also meant that some people may be worse off than they were under the old system, which gave a certain priority to the under-privileged." 1 2 1 T o a related but somewhat different question—whether they were now getting satisfactory service of the several kinds provided by the N H S — 9 1 per cent of the patients interviewed said Yes, and 9 per cent No. Answers to the question discussed in the previous paragraph showed that 87 per cent of the patients in my survey regarded the N H S as either about the same as, or better than, the pre-1948 health service, but expressed no opinion as to the actual adequacy of the current provision. T h e replies to the present question are somewhat more significant, since they show that 91 per cent are satisfied with the kind of service the N H S is giving. " I t is," says The Economist, " a matter of statistics that the Service immediately proved popular and has become increasingly s o . " 1 2 5 It seems fair to

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assume that this popularity is based upon a widespread feeling that the N H S is providing satisfactory health care. As was noted in Chapter 4, the Ministry of Health, because of the high cost of hospital care and the shortage of hospital accommodation, encourages N H S patients to be treated in their own homes whenever the nature of the illness, and the housing and other environmental conditions, make home treatment feasible. The "home services" that are supplied by the N H S in this connection—midwife, home visitor, district nurse, and domestic help—have proved very popular. (Under the Domiciliary Specialist Service, as has already been mentioned, a specialist will call at the home of a patient if the latter is too ill to be moved, or if a decision has to be taken whether a hospital bed should be made available or not.) Slightly more than one-half of the patients in my survey had used one or more of these services, and 98 per cent of the users pronounced them "quite satisfactory." Reports from the Ministry of Health show a growing use of home nurses and home help in the past dozen years. The number of home nurses increased from 8,325 in 1949 to 10,322 in i960; the number of patients attended was 857,000 in 1949 and 897,619 in i960; and in i960 home nurses made more than 23 million visits, of which about 62 per cent were to patients of 65 or over. At the end of 1948 there were 11,338 home helps (persons who take over the housework); on December 3 1 , i960, there were 49,000 such helpers (mainly part-time) who had provided domestic aid for 312,000 cases during that year. 1 2 8 The N H S home services are free, with the exception of home help. The local authorities are required to provide domestic help for households where such help is necessary because of the presence of any person who is ill, the confinement of an expectant mother, or disability owing to old age. But for this kind of help the patients are expected to pay the local authorities whatever they can afford. In many cases this is only a small

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p a r t o f the a c t u a l cost, a n d in s o m e instances n o t h i n g at all. H o w w e l l the seriously ill are c a r e d for is a m a t t e r o f s p e c i a l c o n c e r n to patients a n d their families. T h i s fact led m e to ask the f o l l o w i n g q u e s t i o n : " H a v e y o u or a m e m b e r o f y o u r h o u s e h o l d e v e r h a d , u n d e r N H S , w h a t the doctor c l e a r l y r e g a r d e d as a serious i l l n e s s ? " O n e - h a l f o f t h e answers w e r e Yes; a n d the ailments n a m e d were p n e u m o n i a , coronary thrombosis, nervous b r e a k d o w n , c a n c e r , d i a b e t e s , s c i a t i c a , p e r f o r a t e d gastric u l c e r , r h e u m a t i c fever, peritonitis, spondylitis, f r a c t u r e o f the skull, and

a host o f others. A

good

m a n y o f these p a t i e n t s

were

t r e a t e d at h o m e , o t h e r s w e r e in hospitals f r o m a f e w d a y s to a y e a r or m o r e . T h e l e n g t h o f t i m e r e q u i r e d to get the h o s p i t a l or specialist c a r c t h a t w a s n e e d e d b y these patients w a s m i n u t e s or h o u r s , d e p e n d i n g u s u a l l y o n the n a t u r e o f the illness. H o w e v e r , t h e a n s w e r s r e c e i v e d o n this p o i n t q u i t e d e f i n i t e l y c o n f i r m e d t h e d o c t o r s ' t e s t i m o n y t h a t a n e m e r g e n c y case c a n a l m o s t a l w a y s g e t into a hospital p r o m p t l y .

A

v e r y f e w o f these

patients

suggested (in the s p a c e p r o v i d e d for c o m m e n t s ) t h a t t h e r e h a d b e e n u n d u e d e l a y in g e t t i n g i n t o hospitals, a n d o n e c h a r g e d t h a t the f a i l u r e o f a specialist to d i a g n o s e a case o f Disease,

which

delayed

t h e r e q u i r e d o p e r a t i o n b y some t w e l v e

larger n u m b e r

was

later

reported

discovered

by

Meniere's

another

a bit boastfully that

specialist, months.

they

were

A in

h o s p i t a l w a r d s , or e v e n in h o s p i t a l beds, w i t h i n a n h o u r or so a f t e r the g e n e r a l p r a c t i t i o n e r d e c i d e d that t h a t w a s w h e r e t h e y should

be.

The

great

majority were

content

to g i v e

their

e s t i m a t e s o f the t i m e - l a p s e w i t h o u t c o m m e n t . W h a t I e s p e c i a l l y w a n t e d to k n o w a b o u t these p a t i e n t s w h o h a d b e e n seriously ill w a s h o w t h e y themselves a p p r a i s e d t h e c a r e t h e y r e c e i v e d — w h e t h e r t h e y t h o u g h t it e x c e l l e n t , g o o d , f a i r , or p o o r . S e v e n t y - s i x (76) per c e n t r e p o r t e d t h a t t h e y h a d h a d excellent c a r e ; 18-9 per c e n t said good; 2-9 per cent, fair;

and

2-2 p e r c e n t poor. I n g e n e r a l , these patients w e r e l o u d i n t h e i r

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praise of the hospitals, specialists, and nurses—and of the general practitioners as well, in the cases that were treated at home. Few N H S patients get a chance to express their gratitude in print. But the journalist who, under the pen-name "Taper," writes a weekly "Westminster Commentary" for The Spectator, and w h o (as his readers well know) is not addicted to flattery, was moved by a siege in hospital to pay the following "tribute to the human, as opposed to the institutional and mechanical, side of the proceedings:" Apart from the continuous sense of wonder at the care and study, not to mention expense, devoted to the fairly unimportant—to anybody but me, that is—business of finding out what was wrong with me and then curing it, it was difficult to be anything less than awestruck by the patience, consideration, deftness and sense of vocation displayed by every member of the staff with whom I came into contact. In particular, a new Shaftsbury would be needed to do justice to the national—indeed international—scandal of the hours worked by, and the wages paid to, nurses of an almost incredibly high standard of efficiency and gentleness. With my hand on my no longer palpitating heart, I can say that these girls were a credit to their profession and to our society. . . . At any rate, it is largely due to their efforts that I will be back on my beat in Parliament next week and every week thereafter. 1 2 7 T h e N e w York columnist Robert C. Ruark has given, in the Herald Tribune, a picture of the N H S as viewed at close range by a visitor to England: When I keeled over [in a London street], they had an ambulance on the scene in a matter of minutes, and I woke up in a ward with a whole flock of doctors and nurses making clucking sounds. Despite the fact that I a m a foreigner, I hit the free list like everybody else, including such expensive luxuries as electro-cardiograms, simple surgery, special nursing, X-rays, bed, board and doctors—even that involved business of hooking up a bunch of cathodes to my skull. . . . As far as I could determine, the doctors made their special rounds to special patients, with as much interest .and time consump-

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tion as if they were getting a whacking big fee for their trouble. T h e nurses worked harder than any specials I ever saw, and bullied the patients as hard as at home. There was no feeling of "working for the state"—no consciousness of charity at work. . . . I saw some [private] specialists later, and of course there were fees, and I felt at home again. But man, I tell you it is a wonderful thing to be able to get into a hospital in a hurry, without producing a bank statement . . . and to walk out again without leaving one eye in escrow. Another American newspaperman, D o n Cook, chief of the London bureau of the New York Herald Tribune, has been observing the British National Health Service for several years as a foreign resident. In an article in Harpers Magazine he described the prompt, expert, and costless N H S treatment he got w h e n he suffered a chipped elbow in a fall. " O n the whole," he says, "the care I received free could not have been simpler or better." T h e following quotation gives Mr. Cook's report on the general attitude of the British people toward the N H S , and his o w n appraisal of the Service: T h e National Health Service has, in fact, become a source of genuine national pride—like the Royal Navy or the Monarchy. Britons know that there may be more spectacular examples of medical skill or research or treatment in the United States or elsewhere. But in their country more of the population get better medical care than in any other major country on earth. Their pride is far from uncritical. But as the second decade of the Health Service begins, the emphasis is entirely on " H o w can we make it b e t t e r ? " Strikingly, the system itself, the structure, is almost universally judged to be sound. . . . T h e National Health Service, as it is working in Britain today, affords a m a x i m u m of individual freedom to both doctors and patients. Most of the settled families of the country are signed up with the same doctor they had in the old days—only now he is paid by the state and they have no more doctor's bills. T h e middle class needed the Health Service the most, and the middle class has profited the most. An American cannot live in Britain today and see the Health Service at work without coming to a simple realiza-

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tion: what has been done here by democratic processes in a free society is a great step forward and an object lesson for democracy throughout the world. 1 2 8 T h e patients in my survey w h o commented on the treatment they got w h e n seriously ill are not doctors but laymen, and their competence to pass j u d g m e n t on the quality of the surgical or general medical care they received m a y on that account be challenged. But there can be no doubt that an overwhelming m a j o r i t y were themselves convinced that they had been well looked after, as is shown by their 95 per cent vote of either " e x c e l l e n t " or " g o o d , " and also b y the enthusiastic expressions of appreciation which m a n y took the trouble to append to their answers. T h e r e is also the possibility that such high praise as was given the Service by these patients might be expressions of gratitude from people w h o could not in the past afford good medical treatment, and might therefore be favorably impressed even by treatment of mediocre grade. However, a comparison of these replies and the incomes of the patients giving them suggests that economic status had little if any influence on the nature of the answers.

W h a t may be regarded as an interim "progress r e p o r t " on the National Health Service, written by D r . H u g h C l e g g (then, as n o w , editor of the British Medical Journal), was published in 1952, four years after the start of the N H S , in the New England Journal of Medicine: In spite of all the difficulties, the N H S is working more smoothly than many thought it would [wrote Dr. Clegg]. T h e health of the people seems to be better than it was. More students than ever are clamoring to enter the medical schools, and hundreds are being turned away each year from each school. Research is being carried

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on vigorously, and the output, and standard, of published work is higher than it was before the w a r ; at least that is my impression as a medical editor. British doctors are in good heart. T h e y are putting a great deal of work and thought into ideas for improving the Service. 1 2 8 A n o t h e r four years later, in 1 9 5 6 , w h e n (in the course of my on-the-spot study) I was seeking a professional opinion on the quality of current medical care in Britain, I asked the general practitioners: " U n d e r the N a t i o n a l H e a l t h Service, are the medical needs of the country as a whole being better met, less well met, or cared for 'about the same' as before N H S ? " T h e answers w e r e : Better met, 87 per cent; less well met, 3 per cent; about the same, 10 per cent. T h e reply " b e t t e r m e t " was at times reinforced by such expressions as " v e r y much b e t t e r , " " d e f i n i t e l y , " " u n q u e s t i o n a b l y , " " e n o r m o u s l y b e t t e r , " a n d so on. T h e improvement that h a d taken place, as explained by a good m a n y of these practitioners, was both quantitative and qualitative. Quantitatively, the N H S h a d practically doubled the n u m b e r of people w h o could get medical care w h e n it was needed. Qualitatively, the development of n e w drugs, equipment, and professional skills h a d m a d e the previous eight or ten years an outstanding period in the annals of medical a d v a n c e . T h e s e doctors did not suggest that the H e a l t h Service was • responsible for the revolutionary improvements in

medical

techniques that h a d occurred since 1948. But they d i d c l a i m that these i m p r o v e d methods of modern medicine w e r e brought within reach of the whole people only because the

NHS

entitled everyone in Britain to comprehensive medical provision. T h i s , in their view, w a s the great contribution of the H e a l t h Service t o w a r d meeting more adequately than in the past the medical needs of the country as a whole. T h e inability of a large percentage of people to p a y their o w n

medical

expenses w a s emphasized by m a n y doctors, especially by those w h o were practicing in areas where the a v e r a g e income of

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a d u l t m a l e w o r k e r s d i d n o t u s u a l l y e x c e e d £ 1 0 ($28) a w e e k . T y p i c a l c o m m e n t s o n this p o i n t r u n a b o u t as f o l l o w s : O u r patients [in a large industrial city] are chiefly working-class people, many of w h o m w o u l d not be able to pay personally for present-day medical care. A t least 40 per cent of my patients could not pay for the medical service they are now getting free. T h e patients in our practice have incomes w h i c h run from £ 6 to £ 7 [average $18.20] a week for single people to £10 or £12 [average $30.80] for married couples. A great m a n y could not afford to pay for the service the N H S gives them free—especially they could not afford the high-priced medicines. A successful y o u n g d o c t o r w i t h a b o u t 2,000 c o m m e n t is not cited as t y p i c a l — n a m e d

patients—whose

h i m s e l f as a p e r s o n

w h o , " w i t h a fair i n c o m e , " c o u l d n o t a f f o r d to p a y

medical

bills o f the k i n d w h i c h , if a serious illness befell h i m ,

would

p r o b a b l y be charged in the absence of the National

Health

Service. T h e o p i n i o n expressed b y t h e d o c t o r s I i n t e r v i e w e d in 1 9 5 6 — t h a t t h e m e d i c a l n e e d s o f B r i t a i n as a w h o l e w e r e t h e n b e i n g b e t t e r m e e t t h a n e v e r b e f o r e — w a s r e p e a t e d in essence in 1958, t h e t e n t h a n n i v e r s a r y o f t h e b e g i n n i n g o f the S e r v i c e , in s p e c i a l articles a n d editorials a p p e a r i n g in m e d i c a l a n d l a y j o u r n a l s , a n d in the d a i l y press. D r . H . G u y D a i n , w h o w a s C h a i r m a n o f t h e C o u n c i l o f the British M e d i c a l A s s o c i a t i o n i n 1948 w h e n the N a t i o n a l H e a l t h S e r v i c e w e n t i n t o e f f e c t , stated t e n y e a r s later t h a t " f r o m the p o i n t o f v i e w o f the ' c o n s u m e r ' — t h a t is, e v e r y i n h a b i t a n t o f the c o u n t r y , w h e t h e r Britisher or v i s i t o r — [the S e r v i c e ] has b e e n a n e n o r m o u s b e n e f i t a n d s u c c e s s " ; a n d continued: In no other country, whether Welfare State or not, is it possible to have, on requirement, all the professional services that m a y be

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needed for the treatment of all kinds of illness or accident without fee or charge; consequently without any hesitation to call for help on account of the possible cost. A n y Britisher who has had the misfortune to be taken ill while abroad, or on holiday in most countries overseas, will have discovered how costly medical care has become in these progressive days, with all their modern discoveries and developments. Accordingly, for the patients the Service has been a boon, and the knowledge that it is there and available has been a great comfort even at the time when you have no need for it yourself. The absence of any financial barrier between doctor and patient must make the doctor-patient relationship easier and more satisfactory. 1 3 0 Dr. Robert Logan, member of the medical s t a f f o f Manchester University, and leading spirit in the experimental group practice at Darbishire House Health Center in Manchester, finds both weakness and strength in the N H S . Writing in the J u l y , 1958, number of Medical World131 (with Gordon Forsyth, also of Manchester University, collaborating), Dr. L o g a n pointed out that, because small and peripheral hospitals, formerly staffed with local general practitioners, have been taken over by specialists, " a gulf has developed between the practitioner in the home and the specialist in the hospital, with a disruption in the continuity of c a r e " ; and that (because the general practitioner is not able to witness at first hand the new techniques in investigation and treatment) "there is a real risk that the doctor, after his hospital training, may lose touch with recent advances and become out of d a t e . " Another and "fundamental weakness of the present system is its built-in incentives," according to Dr. Logan. " F o r the general practitioner the incentive is not to raise his quality but to keep his list at its maximum. Inevitably this leads to his acting as a collecting agent, passing patients on to the hospitals. T h e system of payment b y session encourages the consultant to keep his out-patients' department busy and his beds fully occupied. Duration of stay in British hospitals is the longest in the world:

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there is no stimulus for the patient or the doctor to achieve a quicker t u r n o v e r . " O n the brighter side of the N H S picture, D r . L o g a n lists (as w a s noted in C h a p t e r 2) " a distribution of specialist skills superior to a n y in the w o r l d , " " t h e application [in all branches of the Service] of the fine principle that treatment shall b e determined by medical need a n d not b y the ability to pay f o r i t , " a decline in rivalry and a spontaneous g r o w t h in cooperation a m o n g general practitioners; and the development in Britain of a f a m i l y medical practice that " h a s become the least c o m m e r c i a l a n d the least competitive in the free w o r l d . " B u t he warns the f a m i l y doctors that the c h a n g i n g a g e structure of the population and the development of n e w drugs

and

techniques h a v e increased the need for p r o m p t and sound diagnosis—for " t o d a y early diagnosis c a n prolong life, and the responsibility

for this rests with the general

practitioner."

H e n c e , the necessity for the practitioner " t o m a k e a serious effort to raise his standards of practice a n d r a n g e of investigat i o n . " " L e t us a c c e p t , " he urges in conclusion, " t h e reality of the changes in medicine a n d in western society w h i c h — m u c h more than the N H S — h a v e affected us as doctors. L e t us look f o r w a r d to new w a y s of achieving comprehensive medical c a r e . " D r . Miles H o w a r d , in his weekly " D o c t o r ' s J o u r n a l " in The Spectator, says that " w i t h goodwill on both sides [the Ministry of H e a l t h a n d the medical profession] and a sense of the future, this country could h a v e the finest health service in the w o r l d . " A s for the present, he asks: " N o w , after a d e c a d e of 'nationalized' medicine, h o w do w e stand ? " a n d gives this answer: T h e sharpest critics of the N H S have got to admit that the Service provided for the ordinary citizen is better than it has ever been. T h e man who earns his living has been relieved of the fear that grave illness in one of his family may eat into his savings. H e knows that he, and his dependents, can have a consultant opinion,

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and any treatment they may need, in hospital or out-patient clinic, not as a charity, but as a public service to which they have contributed by tax payments. T h e N H S is one compartment of the 'quiet revolution' that has unfolded since the end of the war. 1 8 2 In expressing his opinion, Dr. Brian Abel-Smith, an authority on the costs of the N H S , neither wastes nor minces words. " T h e r e can be no doubt that the patient has had m u c h better care since the H e a l t h Service. T h e r e is abundant evidence of this," he writes in the New Statesman.133 " F o r our p a r t , " says The Lancet in a leading article, " w e think the National Health Service one of the biggest improvements in the life of the country since the war. T h a n k s to very hard and intelligent work b y a great m a n y people, professional and lay, it has done m u c h to better the conditions of medical care, especially in hospital, and it has been an immense comfort to the p u b l i c . " 1 3 4 The Economist, w h i c h has not hesitated to criticize the N H S w h e n it has thought criticism called for, finds that the Service has accomplished m u c h in its ten years of existence: It can fairly be said that, as a whole, general practice within the Health Service is nearer to the standards of private practice than the pre-1948 practice was. This has enormously improved the service to the former working-class panel-patient. . . . Although exceptions abound, the hospitals have gone a long way towards such things as an appointment system for out-patients, and even the provision of an evening meal to the patients in the wards. Looking back to the out-patient queues of the old voluntary hospital and to the general wards of the [pre-NHS] municipal hospital, anyone will be convinced that big improvements have been secured. . . . " N o t just a glorified poor law, but a full health service for all the people"—such was Lord Attlee's conception of the Service when it was still in the blueprint stage. T h e Labor Party can fairly be proud both of the aim and the extent to which it has been achieved. 136 Words in praise of the N H S must not be interpreted as proof of full and complete approval of the Service and all its works.

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In f a c t , readers in G r e a t Britain are in little d a n g e r of m a k i n g such a n i n t e r p r e t a t i o n ; for f e w British writers profess to b e entirely satisfied w i t h the Service, a n d most tend to t e m p e r their c o m m e n d a t i o n w i t h constructive criticism. A case in p o i n t is the editorial in the 24-page " N H S

Supplement"

to

the

L o n d o n Times (July 7, 1958) w h i c h introduced a score or m o r e special articles o n various b r a n c h e s o f the N H S , p r e p a r e d b y people w h o h a v e been in close t o u c h w i t h its o p e r a t i o n . As judged by the health of the nation since its introduction, the [National Health] Service has been an unqualified success [says this editorial]. T h e maternal mortality rate and the infant mortality r a t e — t w o of the most sensitive indices of public health—have reached record low levels. Tuberculosis—once the major scourge of the nation—is rapidly coming under control. Pneumonia has lost many of its dread attributes, and surgeons now successfully perform operations which a decade ago were still looked upon as well-nigh impossible. . . . T h e credit for these advances, however, can be attributed only partly to the National Health Service. T h e y would have come about in any case. W h a t the Health Service has done is to ensure that the discoveries of the research laboratories and institutes of the world are made freely available to every citizen of these Islands to an extent that was not possible under the pre-1948 system based on the tripod of the " p a n e l " scheme, the voluntary hospitals, and local authority services. . . . T h e National Health Service can justly claim to be a national institution. Inevitably—and rightly—it has been criticized in detail, but the concept as such has not been seriously challenged. Mistakes have been made, but an impartial review of the past ten years indicates that the nation has good reason to be proud of its Health Service. 1 3 6 The Times then raises the question, as yet unsettled, o f h o w m u c h the c o u n t r y c a n a f f o r d to spend on its H e a l t h S e r v i c e — w h e t h e r the present e x p e n d i t u r e o f a b o u t 3-3 per cent of the gross national p r o d u c t is a reasonable a m o u n t , in v i e w of the funds required for e d u c a t i o n , housing, defense, a n d other public

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needs. It a r g u e s that private practice (of both consultants a n d general practitioners) is indispensable to the m a i n t e n a n c e o f h i g h s t a n d a r d s in the field o f public practice ( N H S ) , a n d must not be a l l o w e d to disappear. It asks for " t h e restitution of the general p r a c t i t i o n e r to his rightful place as the family doctor [by p a y i n g h i m ] in a c c o r d a n c e w i t h the q u a l i t y rather than the q u a n t i t y o f his w o r k , " so that (with a smaller list o f patients) he c a n h a v e m o r e time to d e a l w i t h each o f t h e m himself, and not h a v e to refer so m a n y

to hospitals. It insists that

"an

efficient g e n e r a l practitioner service is the crux of the w h o l e p r o b l e m o f e v o l v i n g a N a t i o n a l H e a l t h Service that will red o u n d to the benefit a n d credit o f the c o u n t r y , " a n d is essential to

"an

efficient

consultant

and

hospital

service."137

This

m i n g l i n g o f praise a n d counsel, in writing o n the N H S , is f o u n d not only in The Times, Journal

but also in the British

( w h i c h issued an " N H S

Medical

Special Supplement,"

with

articles b y eight contributors, on J u l y 5, 1958), The Lancet, The Economist, a n d other w e l l - k n o w n British publications.

W h e t h e r the best possible use is b e i n g m a d e o f the limited f u n d s that are a v a i l a b l e for H e a l t h

Service

expenditures—

w h e t h e r , for e x a m p l e , the proportions o f the total n o w b e i n g spent for hospitals, general practice, a n d p h a r m a c e u t i c a l s are the

right

proportions—has

been

the

subject

of

prolonged

discussion. Most of the hospitals, general or special, have at least parts of their buildings dating back to the last century, and many of them were in use for hospital purposes over a century and a half ago [says Dr. G. E. Godber, Deputy Chief Medical Officer of the Ministry of Health], Bad old buildings do not make good work impossible; but they make it m u c h more difficult and extravagant of time at all levels, and they greatly complicate technical problems such as the preserva-

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tion of asepsis in surgery, so that breakdowns must sometimes occur however careful staffs may be. A hospital so designed that every m e m b e r of the staff walks even only a dozen steps unnecessarily in every hour imposes material extra work on the people w h o work in it, a n d most of our hospitals d e m a n d m u c h m o r e t h a n that. . . , 1 S 8 T h e necessity of using antiquated and often inconvenient hospital buildings has, on the whole, been met courageously and good-naturedly. Though complaints about outdated hospital plant and equipment are common enough, they are often accompanied by assurances that hospital staffs in unsatisfactory surroundings are bearing up well, and managing to do a good job under adverse circumstances. In his article in the N H S Special Supplement of the British Medical Journal, Sir Harry Piatt (President of the Royal College of Surgeons from 1954 to 1957) refers to the criticism that "not enough money is made available (a) to rehabilitate obsolescent institutions; (b) to build new hospitals; and (c) to provide an ever-expanding income which will allow our leading hospitals to plan and experiment and so keep abreast of the advancing front of medical science." I n the early days of the National Health Service [Sir H a r r y continues], we h a d all hoped that the patching-up of obsolescent structures would be a temporary affair, a n d that the epidemic of new hospital construction which has swept the N o r t h American continent, Scandinavia, Switzerland, a n d more recently France a n d G e r m a n y , would spread to Great Britain. This has not happened, a n d we have b e e n compelled to contemplate another long period of practicing twentieth-century medicine in nineteenth-century structures. N o n e the less it is twentieth-century medicine, a n d , despite our physical a n d financial handicaps, British medicine so far retains a position of leadership. But [warns Sir H a r r y ] a sense of frustration prolonged indefinitely must in the end h a n d i c a p progress by limiting the freedom to experiment, which is the life blood of medical science. 13 *

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Dr. Dain, who was quoted earlier in the present chapter, regrets that the lack of funds prevents the replacement of old hospitals by new ones, but takes comfort in the nation-wide coverage and the comprehensiveness of the service provided:

With medical and surgical progress [he says], new methods and materials continually evolve and costs increase, but there is never the proper money to staff the hospitals, and still less the capital necessary to build new ones. It is humiliating to see the up-to-date new hospitals being built in many other countries, less well off materially than Great Britain, and to reflect that we have not been able to afford new buildings for nearly ten years. At the same time, no other country has felt able to pay for complete access to all drugs, or free-at-the-time access to all professional services. 140 Though relatively little new building of hospitals has been possible under the N H S , there has been a considerable amount of rehabilitation and modernization which, in a good many eases, has vastly improved the internal structure and effective usefulness of the old hospitals, while leaving the often drab exteriors virtually unchanged.

Before the National Health Service [writes Lord Moran], there were a number of first-rate hospitals, but there were many others of the type of the Public Assistance Institution, which Dickens might have described in one of his reforming moods. After the Service was established the Ministry aimed at one standard only, and this has been largely achieved. The redistribution of consultants has made the up-grading of hospitals possible. For example, the Barnet General Hospital used to be a workhouse infirmary; St. Ann's, Tottenham, began in a disused hospital which had been used for infectious diseases; St. Mary's, Colchester, was originally a Public Assistance Institution. All three are now first-class hospitals treating acute cases. And this has been happening all over the country. 141 Funds available for capital investment in hospitals will doubtless continue to be limited for a good many years, but if improvement in the situation is slow it is also steady. T h e appropriation for hospital development in England and million ($50.4 million) in 1 9 5 7 - 5 8 , £22

Wales was

£18

million ( $ 6 1 . 6 million)

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in 1959-60, and is expected to be £31 million ($86-8 million) in 1961-62 if the Minister of Health's recommendation is approved by Parliament. In this day and age, few people are likely to question the need for high-grade hospital service in a system of health provision. • But there are many people in Britain who are convinced that general practice should form the keystone of the health structure, and hospital and specialist service should be called upon only in times of special need. T h e y would have the general practitioners paid adequate incomes without being burdened with panels anywhere near the present maximum, so that they would have time to give each ailment a thorough diagnosis, and time also to keep abreast of current medical developments. T h e doctors would expect, and be expected, to look after their patients in the great majority of their illnesses; and to treat them in their surgeries or in the patients' own homes, except when cases unquestionably belonged in hospitals or when home conditions were clearly unsuitable. This shift in emphasis from hospital to family-doctor service would of course require an increase in the expenditure for general practice. Where would the money come from? From unused funds left over from the hospital budget is the usual answer, and the one given by The Times'. " I f the family doctor were able to fulfil his true function, there would be a commensurate financial gain in a reduction in the number of patients referred to hospital. Not only would this reduce the cost of the hospital service—the most expensive item in the whole Service; it would also reduce the need for capital expenditure on new hospitals." 1 4 2 If economies could be effected through more careful prescribing of drugs, as the Ministry of Health and many individuals consider possible, these savings might also be available for financing the family doctor in the fulfilment of his "true function." But warnings have been sounded that cutting the

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expenditure for drugs might turn out to be false e c o n o m y — that the use of costly drugs m a y save h e a v y hospital costs: The steadily rising cost of the drug bill can be plainly seen, but the consequent savings are much more difficult to discern [says Mr. T. H. Manners Kerfoot, whose post as President of the Association of British Pharmaceutical Industry may make it somewhat difficult to view the situation with complete detachment]. M a n y [of these savings] are quite intangible; others, though they cannot unfortunately be accurately estimated, are more obvious. For example, it costs not less than £ 3 ($8.40) a day to maintain a patient in hospital, an average stay costs not less than £ 3 0 ($84). If the expenditure of an additional 30 shillings ($4.20) on drugs will get a patient out of hospital a day sooner, or if an extra £ 5 ( $ 1 4 ) worth will keep him out of hospital, the direct saving is considerable. T o this must be added the saving in sickness benefits. 143

T h e question of how best to divide the available funds a m o n g the several branches of the Service is only one of m a n y N H S problems that await solution, which in some instances m a y be a long time coming. H o w e v e r , it seems clear that, though there will continue to be arguments over many of the details of operation, the general principle of a National Health Service is now firmly established. Dr. H u g h C l e g g , in his review of the situation in 1 9 5 2 , felt warranted in reporting: " T h e N a t i o n a l Health Service has come to stay. T h e r e can be no doubt of that. T h e mass of the people like it. A l l political parties support i t . " 1 4 4 T w o questions asked in J u n e , 1 9 5 6 , in a nation-wide poll taken by Social Surveys (the G a l l u p Poll) indicated that the mass of the people still liked it, and that the f a m i l y doctors were also in f a v o r of it. T h e first of these questions, directed to general practitioners, read: " S u p p o s e y o u had a chance to go b a c k and vote on whether the N H S should be started or not. H o w w o u l d y o u

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v o t e — i n favor of starting it, or against starting i t ? " answers w e r e : In favor,

67 per cent; against, 31

per

The cent;

undecided, 2 per cent. T h e second Social Surveys question was for the patients: " A s far as y o u personally are concerned, how would

you

rate

NHS—favorably

or

unfavorably?"

The

answers: Favorably, 89 per c e n t ; unfavorably, 4 per c e n t ; undecided, 7 per cent. T h e 1956 G a l l u p Poll did not ask the consultants to give their opinion of the National Health Service, but L o r d M o r a n , undertaking to speak for t h e m in 1958, wrote as follows: " I f the consultants were asked at the present m o m e n t whether they desired to go back to the days of the old voluntary hospitals, where all the work was carried out without remuneration, I believe the overwhelming majority would prefer the conditions of today. If I a m right in this, then the consultants accept the nationalization of hospitals." 1 4 6 T o the doctors w h o took part in m y 1956 survey, I put the following question about the permanence of the Service: " D o you regard the N H S , or something of substantially the same nature, as a permanent British institution—that is, is it here to stay ?" Ninety-eight and one-half (98^) per cent said Yes; 1 \ per cent said No. W h e n this question was asked of M e m b e r s of Parliament (Conservative and L a b o r ) , of journalists, of university professors, of businessmen, and others outside the field of medicine, the answer w a s again almost unanimously Yes. The

general agreement

among

Britons that the

Health

Service is destined for long life arises in part out of its present popularity, but also from the conditions w h i c h brought it into existence and w h i c h show n o signs of ending in the near future. Lord M o r a n relates having heard Lord W a v e r l e y say that " i f the L a b o r Party had not launched the Service, the Conservatives would have done so w h e n they took office." All three political parties were committed to provide a health service for the country [continues Lord Moran]. It was, in short,

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politically inevitable. Moreover, it was unavoidable on account of finance. The hospitals were, broadly speaking, bankrupt; they could not have carried on without large Government grants. The profession had the choice between a service set up by the Ministry of Health without any help or advice from doctors, and one shaped and moulded by their own hands. They chose the latter; they could do no other. 148 If it was politically and financially inevitable that the National Health Service should be adopted in the first place, it would seem equally inevitable that it will endure so long as Britain remains a democracy and the service rendered by the N H S is satisfactory to the electorate. T h e Service is not only holding its own, so far as quantity and quality of service are concerned, but has been making measurable progress in the face of a shortage of funds. " T h e N H S is still growing and developing," says Dr. Miles Howard. " O n its tenth birthday, a fair judgment of the N H S is that its 'organism' has great potential capacities, not yet entirely realized, but at any rate it is on the move, and that is the main thing." 1 4 7 I found in Britain no tendency to claim for the National Health Service anything approaching perfection. I do not recall talking with anyone who did not mention the need for more dentists and nurses, more general practitioners with smaller lists of patients, more adequate health provision for the aged and the mentally ill, more capital investment in hospitals, more pay for doctors and nurses, more emphasis on preventive health measures, better integration of all parts of the Service, or some other shortcoming that I was told must one day be taken care of. " I f hopes are seldom realized in full, neither are fears [said The Lancet editorially in January, 1958]. At the beginning of a year which will see the tenth birthday of the National Health Service, we can take comfort from its continuing state of flux. Instead of settling in a solid mould, as was predicted, it remains malleable enough to be adapted to new circumstances and new

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ideas of what the public needs. Already some remarkable changes are beginning." 1 4 8 On the whole, the British attitude toward the National Health Service seems to be one of'cautious optimism, as is indicated by an observation from an administrative officer of a London hospital. " W e know only too well the many problems we must solve," he said, "but we know also that we have something worth-while, and we shall never stop trying to make the Service better until we have won through." I bring this brief account of the N H S to a close by quoting from the preface to a study of the Service, made in 1950-51 by Dr. O. L. Peterson, of the Division of Medicine and Public Health, of the Rockefeller Foundation. I should like to have written these lines myself, for they seem to me to express admirably the attitude which Americans might properly and profitably take toward Great Britain's experiment in providing medical care for all her people. Here is the way Dr. Peterson puts it: It scarcely need be emphasized that the N a t i o n a l H e a l t h S e r v i c e is a characteristic British institution created for and a d a p t e d to British society. U n l i k e so m a n y things p r o d u c e d in G r e a t Britain n o w , it is not for export. T h e social b a c k g r o u n d w h i c h has given rise to the N a t i o n a l H e a l t h S e r v i c e is so different f r o m ours, that w e in the U n i t e d States will h a v e to w o r k out our o w n solution to the problems of medical care. W e w o u l d be v e r y foolish indeed if w e did not profit f r o m the good points, as well as from the mistakes, of the N a t i o n a l H e a l t h S e r v i c e . 1 4 9

FOOTNOTES

CHAPTER

I

1. Quoted in The New York Times, March 28, 1959. 2. The National Health Service in Great Britain, by Sir James S. Ross. London, Oxford University Press, 1952, p. 50. 3. Problems of Social Policy, by Richard M. Titmuss. London, His Majesty's Stationery Office, 1950, p. 187. 4. Ibid., p. 185. 5. Social Insurance and Allied Services, by Sir William Beveridge. New York, The Macmillan Company, American Edition, 1942, p. 162. 6. British Medical Journal, December 12, 1942, p. 700. 7. The Beveridge Report and the Public, a leaflet. London, British Institute of Public Opinion (Gallup Poll), no date. 8. A National Health Service (White Paper). London, His Majesty's Stationery Office, Cmd. 6502 (1944). g. Quoted in Ross, op. cit., p. 4. 10. Crisis in Britain, by Robert A. Brady. Berkeley, California, University of C a l i f o r n i a Press, 1 9 5 0 , p. 370.

1 1 . The Lancet, London, March 23, 1946, pp. 423, 424. 12. Ross, op. cit., p. 126. 13. Equality, by R . H. Tawney. London, George Allen & Unwin, Ltd., 4th Ed., 1952, pp. 252, 253.

CHAPTER

2

14. A Study of the National Health Service of Great Britain, by O. L. Peterson, M.D. New York, The Rockefeller Foundation, 1951, p. 49. 15. The Lancet, March 29, 1958, p. 698. 16. The Economist, London, J u n e 22, 1958, p. 1163. 17. Essays on " The Welfare State," by Richard M. Titmuss. London, George Allen & Unwin, Ltd., 1958, p. 210. 18. Medical World, July, 1958. p. 10. «55

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FOR

HEALTH

19. Good General Practice, by Lord Taylor (formerly Dr. Stephen T a y l o r ) . London, Oxford University Press, 1954, p. 25. ao. Report of the Ministry of Health for the Year Ended 3 ist December, 1958. London, Her Majesty's Stationery Office, C m d . 806 (1959), p. 315. 21. Ibid., p. 318. 22. Report of the Ministry of Health for the Tear Ended 31 st December, 1954. London, Her Majesty's Stationery Office, C m d . 9566 (1955), p. 55. 23. Report of the Committee on General Practice within the National Health Service (The " C o h e n Report"). London, Her Majesty's Stationery Office, 1954, p. 25. 24. Taylor, op. cit., p. 26. 25. Ibid., p. 23. 26. Cohen Report, p. 25. 27. Ibid., p. 29. 28. Ibid., pp. 29, 30. 29. Report of the Ministry of Health for the Tear Ended 3 ist December, 1957. London, Her Majesty's Stationery Office, C m d . 495 (1958), p. 70. 30. Taylor, op. cit., p. 339. 31. British Medical Journal, " N . H . S . Supplement," J u l y 5, 1958, pp. 3, 4. 32. Medical World, July, 1958, pp. 9, 10. 33. Ross, op. cit., pp. 118, 119. 34. Health Services in Britain. New York, British Information Services, rev. ed., 1954, p. 26. 35. Cmd. 806, op. cit., pp. 187-89. 36. Taylor, op. cit., pp. 119, 120. 37. Report of the Ministry of Health for the Tear Ended 31 st December, i960. London, Her Majesty's Stationery Office, C m d . 1418 (1961), p. 213. 38. Taylor, op. cit., p. 93. 39. Ibid., pp. 94, 95. 40. Cmd. 806, op. cit., pp. 99, 100. 41. Cohen Report, p. 21. 42. Report of the Committee of Enquiry Into the Cost of the National Health Service (The "Guillebaud Report"). London, H e r Majesty's Stationery Office, Cmd. 9663, p. 207. CHAPTER

43. 44. 45. 46. 47.

3

Peterson, op. cit., p. 61. Taylor, op. cit., pp. 185-88. Ibid., p. 465. Cmd. 1418, op. cit., pp. 176, 182. " G r a n n y Is G o n e , " by Harold E. Stassen, February, 1950. 48. Guillebaud Report, p. 137.

The Reader's

Digest,

FOOTNOTES CHAPTER

157

4

49. The Times (London), " N . H . S . Supplement," July 7, 1958, p. v. 50. The New Statesman, July 12, 1958, p. 38. 51. Everybody's Guide to National Insurance, a pamphlet. London, Her Majesty's Stationery Office, 1955, p. 32. 52. Social Security and Public Polity, by Eveline M . Burns, Ph.D. New York, McGraw-Hill Book Company, 1956, pp. 144, 145. 53. The Times (London), " N . H . S . Supplement," p. xviii. 54. Guillebaud Report, p. 25. 55. Ibid., pp. 27, 28. 56. The Lancet, November 3, 1956, p. 929. 57. Guillebaud Report, pp. 190-95. 58. Ibid., p. i g i . 59. Ibid., pp. 190, 191. 60. Cmd. 1418, op. cit., p. 205. 61. Report of the Ministry of Health for the Tear Ended 31 st December, 1956. London, Her Majesty's Stationery Office, Cmd. 293 (1957), p. 7. 62. Taylor, op. cit., p. 427. 63. Ibid., pp. 433, 434. 64. Handbook for General Medical Practitioners. London, Her Majesty's Stationery Office, 1955, p. 33. 65. Ross, op. cit., p. 367. 66. Ibid., p. 187. 67. Ibid., p. 186. 68. Guillebaud Report, p. 174. 69. The New York Times, November 16, 1956. 70. Ibid. 71. Cohen Report, p. 32. 72. A Short History of Public Health, by C. Fräser Brockington, M . D . London, J. & A . Churchill, Ltd., 1956, pp. 96, 97, 102, 103. 73. Guillebaud Report, p. 50. 74. Taylor, op. cit., pp. 29, 30. 75. The New York Times, M a y 2, 1957.

CHAPTER

76. 77. 78. 79. 80.

5

Ross, op. cit., p. 135. The Times (London), March 16, 1956. Health Services in Britain, p. 13. Ross, op. cit., p. 383. Ibid., p. 372.

158 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94.

95. 96. 97. 98. 99. 100. 101.

BRITAIN'S

SEARCH

HEALTH

Ross, p p . 385, 386. Guillebaud R e p o r t , p. 156. Ibid., p. 157. Ibid., pp. 63, 64. The Beveridge Report and the Public. L o n d o n , T h e British Institute of Public O p i n i o n (Gallup Poll), 1942. C m d . 6502, op. cit., 1955 printing, p. 9. Report of the Ministry of Health for the Tear Ended 31 st December, 1955. L o n d o n , H e r Majesty's Stationery Office, C m d . 9857 (1956), p. vi. T a w n e y , op. cit., p. 150. The Lancet, M a y 4, 1946, p. 655. Ross, op. cit., p. 16. François Lafitte in The New Outline of Modern Knowledge, A l a n PryceJones, Editor. L o n d o n , Victor Gollancz, Ltd., 1956, p. 578. T a w n e y , op. cit., p. 250. Pryce-Jones, op. cit., p. 574. National Family Survey of Medical Costs and Voluntary Health Insurance (Preliminary R e p o r t ) . New York, H e a l t h I n f o r m a t i o n F o u n d a t i o n , >954. PP- 28, 30. D o n Cook, Harper's Magazine, M a y , 1959, p p . 34, 37. T a w n e y , op. cit., p. 133. The National Health Service, a g o v e r n m e n t p a m p h l e t , 1949. François Lafitte, in Pryce-Jones, op. cit., p. 574. Ibid., p. 574. Q u o t e d in ibid., p. 566. Ibid., p p . 572, 573.

CHAPTER

102. 103. 104. 105. 106. 107. 108. 109. 110. 111.

FOR

6

Burns, op. cit., p. 134. C m d . 6502, op. cit., p. 33. National Health Service Act, 1946, Sections 34, 35. C m d . 293, op. cit., p. 53. Taylor, op. cit., p. 23. Ibid., p. 24. Hansard, Vol. 422, col. 54. Handbook for General Medical Practitioners, p. 56, p a r a . 260. Brady, op. cit., p. 385. Report of the Inter-Departmental Committee on Remuneration of General Practitioners (The "Spens R e p o r t " ) . London, H e r Majesty's Stationery Office, C m d . 6810 (1946), p. 4. 112. See statement by Dr. G u y Dain, C h a i r m a n of the British Medical Association Council, q u o t e d in C h a p t e r 1, p. 23.

FOOTNOTES

159

i 13. Ross, op. cit., p. 243. 1 1 4 . British Medical Journal, Supplement, J u l y 19, 1958, pp. 46, 47. 1 1 5 . FFM Broadsheet No. 7. London, T h e Fellowship for Freedom in Medicine, Ltd., 1956, p. 1. 1 16. Ibid., p. 2. 1 1 7 . Are You a Member of the F.F.M.? (a leaflet). London, T h e Fellowship for Freedom in Medicine, Ltd., 1956. 1 18. Brady, op. cit., p. 384. 1 19. Taylor, op. cit., p. i g i . 120. Ibid., p. 192. 1 2 1 . Ibid., p. 123. 122. The Acquisitive Society, by R . H. Tawney. New York, Harcourt, Brace & Company, 1 9 2 1 , p. 94.

CHAPTER

123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 136. 137. 138. 139. 140. 141. 142. 143. 144. 145. 146. 147. 148. 149.

7

Ross, op. cit., pp. 377, 378. The Economist, J u n e 28, 1958, p. 1164. Ibid., p. 1 1 6 3 . Cmd. 1418, op. cit., p. 105. The Spectator, November 2 1 , 1958, p. 670. Harper's Magazine, M a y , 1959, pp. 33, 37. New England Journal of Medicine, September 18, 1952, p. 439. British Medical Journal, " N . H . S . Supplement," p. 1. Medical World, J u l y , 1958, pp. 9 - 1 3 . The Spectator, J u l y 19, 1958, pp. 88, 8g. New Statesman, J u l y 12, 1958, p. 27. The Lancet, J u l y 5, 1958, p. 27. The Economist, J u n e 28, 1958, p. 1 1 6 4 . The Times (London), " N . H . S . Supplement," p. ii. Ibid. The Lancet, J u l y 5, 1958, p. 4. British Medical Journal, " N . H . S . Supplement," p. 5. Ibid., p. 3. Ibid., p. 4. The Times (London), " N . H . S . Supplement," p. ii. Ibid., p. vi. New England Journal of Medicine, September 18, 1952, p. 439. British Medical Journal, " N . H . S . Supplement," p. 3. Ibid., p. 3. The Spectator, J u l y 18, 1958, p. 88. The Lancet, J a n u a r y 4, 1958, p. 34. Peterson, op. cit., p. ii.

INDEX Abel-Smith, Dr. Brian, The Cost of the National Health Service in England and Wales, 65 appraisal of NHS, 145 declining cost of NHS in 1958, 65 Abuse of free medical serv ice, 69 by foreigners, 100 total NHS cost of use by foreigners 101 f.n. Acquisitive Society, The (Tawney), 195. See also Tawney, R. H. Appointments systems, 55, 56 doctors' attitudes toward, 55, 56 Lord Taylor on, 55 Appraisals (American) of NHS by Don Cook, 1 1 2 , 139, 140 by Dr. O. L. Peterson, 26, 52, 154 by R . C. Ruark, 138, 139 Appraisals (British) of NHS, 134-45 adequacy of current provision, '35. ' 4 ' by a British journalist, 138 by British general practitioners, 141, 142 by Dr. Brian Abel-Smith, 145 by Dr. Hugh Clegg (1952), 140, 141 by Dr. H. Guy Dain, 142, 143 149 by Dr. G. E. Godber, 147, 148 by Dr. Miles Howard, 144, 145, 153 by Dr. Robert Logan, 143, 144 by Lord Moran, 149, 152 by Sir Harry Piatt, 148 by The Economist (London), 135, 145

by The Lancet (London), 145, 153, 154 by The Times (London), 146, 147 comparison with pre-NHS service, '34. ' 3 5 on care of the seriously ill, 137 on permanence of NHS, 152 on quality of "home services',' 134. 135 Are You a Member of the FFM? (pamphlet of Fellowship for Freedom in Medicine), 123 Assistantship, as an entrée to general practice, 39 Lord Cohen on, 38 Lord Taylor on, 39 nature of this business arrangement, 39 possible abuse of assistantship arrangement, 39 Attlee, Lord, 16 Bad debts, N H S doctors freedom from, ¡24, 125 Bevan, Aneurin, 20 on free medicine for private patients, 122 on sale of medical practices, 1 1 8 Bevan Act, see National Health Service Act of 1946 Beveridge, Lord, 16 The Beveridge Report and the Public (Gallup Poll), 19, 106, .55 Social Insurance and Allied Services ("Cradle to Grave" Report), 19. 155

INDEX

Beveridge, Lord—cont. "Beveridge revolution," 108 Beveridge Report and the Public, The (Gallup Poll), 19, 106, 155 Blenkinsop, Arthur, on high standard of medical care in urgent cases, 62 Brady, R . A., Crisis in Britain, 21, ' 18, 155 British Medical Association, Proposal for a General Medical Service for the Nation (1930), 18 advocacy of extended health insurance in 1930 and 1938, 17, 18 early opposition to compulsory health insurance, 17 alleged repudiation of Spens Report by government, 84 free drugs for private patients, 121 on NHS and VIPs, 29 f.n. on out-patient waits, 60 f.n. polls on national health provision, 20 promise of continued health care in event of strike, 86 British Medical Journal, 19, 3 1 , 1 2 1 , ' 4 ° ' '43. '47. >48, >49 Brockington, Prof. C. Fraser, A Short History of Public Health, 157 evils of overcrowded housing, 81 Burns, Dr. Eveline M., Social Security and Public Policy, 157 NHS vs. indemnity health insurance, 1 1 5 on overuse of free medical services, 69 Capitation fee, as incentive render best service, 34 defined, 34 described, with examples, 91 Lord Taylor on, 91, 92

to

popularity among N H S doctors, 9 ' . 92 Catastrophic medical costs, 109-12 examples of, 1 1 0 - 1 2 meaning of, log Charges paid by N H S patients dental, 27 disliked by patients, 1 0 1 - 4 NHS "contribution," 26 ophthalmic (spectacles), 27 possible deterrent effect of, 103 prescription, 27 Sir James Ross on, 104 Churchill, Sir Winston, and health program, 16 advocacy of comprehensive health care for all, 19, 20 See also White Paper of Churchill Coalition Government Clegg, Dr. Hugh, appraisal of N H S (1952), 140, 141 Cohen, Lord, see Cohen Report Cohen Report, 156 on abuse of doctor-assistant arrangement, 39 on advantages of group practice, 47 on free medicine for private patients, 120 on future needs of medical manpower, 40 on health centers vs. group practice, 47 on hospital care needed on "social grounds," 80 Comprehensiveness of N H S provision, 104—7 nationwide coverage, 104-6 provision of care of all kinds, 106, 107 WTiite paper (1944) description of proposed care, 106, 107 Conservative Party, and NHS, 15, 16

INDEX Cook, Don, an American of N H S ,

112,139,

Cost o f the N H S , The

Cost

of

Service

Development of N H S ,

National

England

as

Health

and

Wales

Report

proportion

of

gross

national

p r o d u c t , 64, 65 cost of m a t e r n i t y cases, 79 of

cost

chiefly

among

from

ad-

tax

reve-

improbability of stabilizing

NHS

nues, 65

15-23

of

the

health

program "Dislikes"

of doctors,

see

Doctors'

o f p a t i e n t s , see

Patients'

"dislikes" "Dislikes"

of

doctors,

method of collecting N H S

"con-

see

distribution of doctors; tribution of doctors

D o c t o r s p a r t i c i p a t i n g in the a u t h o r ' s s u r v e y , 28 f.n. 115-123

inadequacy

pay, 119,

of

doctors'

120

c h a r g e for d r u g s used b y

tribution," 67, 68 reducing

hospital

MalRedis-

D i s t r i c t n u r s e s , see H o m e n u r s e s

alleged

in m o n e y t e r m s , 6 4

of

Shaping

Doctors' "dislikes,"

t o t a l costs, 8 2

possibility

also

Distribution

ministrative b r a n c h e s , 68 financed

See

"dislikes"

c o s t to p a t i e n t s , 2 6 , 2 7 , 6 6 - 6 8 distribution

cost of, 71

72

( G u i l l e b a u d R e p o r t ) , see G u i l l e baud

Dental service of N H S ,

140

63-93

the

in

appraisal

163

patients,

private

120-123

inability to shift f r o m a r e a to area,

costs, 7 5 - 8 2 p u b l i c cost o f d e n t a l services,

71

115-17

p u b l i c cost o f h o s p i t a l cases, 75, 76

limitations imposed by N H S ,

public

prohibition

cost

of

ophthalmic

ser-

v i c e s , 71

practices,

p u b l i c cost o f p r e s c r i p t i o n s , 6 g Cost

of the National England

and

Health Wales,

Service 1 he

also

Abel-Smith,

muss, Prof. R . Crisis in Britain

sale

in

(Abel-

freedom

of

114

medical

117-19

Doctors' "likes,"

Smith and Titmuss) See

of

123-33

from

financial

with patients,

dealings

123-25

medical service without economic Brian;

Tit-

M.

barrier, reduction

(Brady), 21, 118,

155

calls,

131-33 in

number

of

night

128-31

s u p e r a n n u a t i o n benefits,

125-28

D o c t o r s ' responsibilities u n d e r N H S , Dain, Dr. H. G u y , appraisal of N H S , 142, 143,

149

need for n e w hospitals, promise

of

health

149

service

"in

w h o l e or part',' 121 23 D a t a on N H S , 63

rights

compensation

promise of high-grade health care, D a n c k w e r t s A w a r d , 87

26 Doctors'

under for

NHS surrender

of

r i g h t to sell p r a c t i c e , 1 1 7 - 1 g freedom

to a c c e p t

or reject

any

undesirable

pa-

p a t i e n t , 24 right

to dismiss

tients, 24 superannuation benefits,

125-28

164

INDEX

Doctors' workload, see Workload of N H S general practitioners Drugs for private patients, charge for, 1 2 0 - 2 3 See also Payment for private patients' drugs Economist, The (London), appraisal of N H S , 145 on N H S priority to the underprivileged, 1 3 5 on number of N H S and private GPs, 28 on popularity of N H S , 1 3 5 Emergency Medical Service, in World W a r I I , 18 Equality (Tawney), see T a w n e y , R . H. Essays on "The Welfare State" (Titmuss), see Titmuss, Prof. R . M . Everybody's Guide to National Insurance (Government pamphlet), 66, 157 FFM

Broadsheet No. 7 (Fellowship for Freedom in Medicine), 122 Fellowship for Freedom in Medicine, Are You a Member of the FFM?, 123 FFM Broadsheet No. 7, 122 on free medicine for private patients, 122 on importance of private practice, 122, 123 Foreigners' use of N H S , 99-1 or abuse of, 99 example of, 100 reciprocated by Norway and Sweden, 101 total cost of, 101 f.n. Freedom from financial dealings between doctor and patient, 123-25 absence of bad debts, 124, 1 2 5

freedom from billing patients and making collections, 124 regularity of N H S income payments, 125 relief from deciding on amount to charge patient, 124 Gallup polls, on Beveridge " C r a d l e to G r a v e " Report (1942), 19 on doctors' attitude toward N H S (1956), 1 5 ' : 152 on patients' rating of N H S (1956), 152 General practice, difficulty of getting into, 38 Lord Cohen on, 38, 39 Lord Taylor on, 39 General practitioners, as "keystone" of N H S , 43 average number of patients per doctor, 31 number in N H S , 63 rights and responsibilities of, 24-26 workload of, 30-32 General Practitioners Handbook, 24, 29, 56, 78 Godber, Dr. G . E., appraisal of N H S , 147, 148 Good General Practice (Taylor), see Taylor, Lord Group practice, 45-48 Cohen Report on, 47 cost of group-practice buildings, 45 Group Practice Loans Fund, 46, 47 Guillebaud Report on, 47, 48 Lord Taylor on, 45, 46 "true group practice," outlined, 46 Guillebaud, C . W., Report of the Committee of Enquiry into the Cost of the National Health Service, 156 See also Guillebaud Report

INDEX G u i l l e b a u d R e p o r t , on charges as barrier to needed medical care, 73 on cost of dental services, 7 1 , 72 on cost of ophthalmic services, 72, 73 on early discharges f r o m hospital, 78, 79 on g r o u p practice, 48 on health centers, 47, 48 on improbability of stabilizing N H S total costs, 82 on making best use of a v a i l a b l e funds, 74 on making best use of hospital beds, 62 on scope of p r e - N H S health care, 105 Handbook for General Medical Practitioners, 78, 1 1 8 , 1 5 7 Health care as a right, 1 1 2 - 1 3 R . H . T a w n e y on, 1 1 2 Health centers, 4 4 - 4 8 cost of, 44, 45 experimental centers, 4 5 - 4 8 g r o u p practice as alternative, 45, 46 G u i l l e b a u d R e p o r t on, 47, 48 lack of funds for, 4 5 L o r d T a y l o r on, 45 slow development of, 44, 4 5 W o o d b u r y Downs Center, 4 5 Health Information F o u n d a t i o n of N e w Y o r k C i t y , on catastrophic illness, 109, 1 1 0 Health Services in Britain (British Information Services), 44, 100, 156 Herald-Tribune, N e w Y o r k , 1 3 8 , 1 3 9 History of N H S , 1 5 - 2 3 See also S h a p i n g of the health program H o m e help, 1 3 6 , 1 3 7

H o m e nurses, a n d reduction in n u m b e r of hospital cases, 78 increase in n u m b e r of, 1 3 6 " H o m e services," nature of, 1 3 6 resulting in fewer hospital cases, 78 H o m e vs. hospital treatment, 41 H o m e visits, 5 7 , 59 reduction in n u m b e r of night calls, 128-31 Hospitals, admission on m e d i c a l or " s o c i a l " grounds, 7 7 - 8 0 as institutions for the seriously ill, 41 high cost of hospital o p e r a t i o n , 75-S2 hospital vs. h o m e treatment, 41 little general-practitioner participation in, 4 1 , 42 m a n n e d b y specialists in Britain, 4 1 , 42 use of hospital " a s a h o t e l , " 76 f.n. H o w a r d , D r . Miles, a p p r a i s a l of N H S , 142, 143, 153 Inability of doctors to change location at will, 1 1 5 - 1 7 L o r d T a y l o r on closing of some areas to new entrants, 1 1 6 , 1 1 7 necessity of redistributing m e d i c a l manpower, 1 1 6 , 1 1 7 See also M a l d i s t r i b u t i o n of doctors ; R e d i s t r i b u t i o n of doctors Incomes of N H S doctors, see P a y of N H S doctors Inevitability of a N a t i o n a l H e a l t h Service, 1 5 2 , 1 5 3 Lord M o r a n on, 152, 1 5 3 Initial Practices A l l o w a n c e s , 36 as aid in redistribution of doctors, 36 Labor Party, and N H S , 15, 16

i66

INDEX

Lafitte, Prof. François, on accuracy of waiting-lists, 58 on aim of the "Beveridge revolution," 108 on British horror of Poor L a w charity, 1 1 3 on collective expenditure for communal provision, 1 1 3 on high quality of health care aimed at, 108 on N H S superannuation scheme, •25 on a personal doctor for everyone, 25 on possible consequences of abolishing N H S charges, 74 on purchasability of health, 108 Lancet, The (London), appraisal of N H S , 145, 1 5 3 , 154 on doctors' 1956 wage claim, 84 on increased charge for prescriptions, 73 on purchasability of health, 107, 108 on refunds of prescription charges, 27 on thoroughness of debate on Bevan Act, 21 on use of hospitals " a s a hotel." 76 f.n. Liberal Party, and N H S , 15, 16 " L i k e s " of doctors, see Doctors' "likes" " L i k e s " of patients, see Patients' "likes" Linstead, Sir Hugh, on cost of prescriptions in Britain, Canada, and U . S . , 70 Lloyd-George, David, champion of early National Health Insurance Act, 16 Lloyd-George Act ( 1 9 1 1 ) , 16, 17 Logan, Dr. Robert, appraisal of N H S , 143, 144

on

former maldistribution of general practitioners, 35 on redistribution of specialists, 43 " L o n g waits," 53-62 avoiding long waits, 54, 55 Arthur Blenkinsop on, 62 causes of, 54, 55 a four-year wait, 96 Guillebaud Report on, 62 hospital in-patient waits, 57, 58, 60-62 hospital out-patient waits, 57-61 in doctors' offices, 53, 54 in home visits, 57 Prof. Lafitte on, 58 malingering as possible cause of, 6 1 , 62 patients' reactions to, 9 5 - 1 0 4 priorities in hospital admissions, 60-62 seriousness of, 56 some data on, 54, 57, 58 Maldistribution of doctors, examples of, 35. 43 general practitioners, 34, 35 remedy for maldistribution, 37, 38, 43 specialists, 42, 43 See also Redistribution of doctors Manchester Guardian Weekly, on cost of N H S care given foreigners, 101 f.n. Manpower, medical, see Medical manpower Medical care of high quality, 107-09 Prof. Lafitte on, 108 promise that patients shall get the best care, 108 Medical manpower, adequacy of, 39, 4 ° Cohen Report on, 40 current excess of medical students, 40

INDEX Willink Committee on, 40 Medical service without economic barrier, 1 3 1 - 3 3 ability to prescribe best medicines, 132 ability to visit patients as often as needed, 132 R . H. T a w n e y on "essence of a profession," 1 3 1 , 132 Medical World, 43, 143 Merit awards, examples of. 88, 93 proposed in i960 by R o y a l C o m mission, 88, 89 " M i n o r ailments," 5 1 - 5 3 and prevention of serious illness, 52 difficulty in defining, 51 P r . O. L. Peterson on, 52 waste of doctors' time, 5 1 , 52 Moran, Lord, on consultants' accepance ofhospital nationalization, >52 on inadequate funds for hospitals, '49 inevitability of a national health service, 1 5 2 , 1 5 3 on redistribution of specialists, 43, 149 on upgrading of hospitals, 149 on

National Family Survey of Medical Costs and Voluntary Health Insurance ( U S A ) , 109, 1 1 0 , 158 National Health Insurance Acts, premiums and benefits in 1 9 1 1 , 16, 17 premiums and benefits in 1942, 16 f.n. National Health Service, A (Churchill Coalition " W h i t e P a p e r " ) , set " W h i t e P a p e r " of Churchill Coalition Government (1944) National Health Service, The (Government pamphlet, 1949), 1 1 2

167

National Health Service Act of 1946 (Bevan Act), accepted by B M A and doctors, 23 nationwide discussion of, 21 opposition to, by doctors, 22, 23 passage of, 2 1 National Health Service in Great Britain, The (Ross), 1 5 5 See also Ross, Sir J a m e s Stirling National Insurance Fund, distinguished from N H S , 66 New England Journal of Medicine, 140, 141 New Outline of Modern Knowledge, The (Pryce-Jones, E d . ) , 108, 1 1 3 , >58 New Statesman, 50, 1 4 5 New York Times, The, 16. 79. 80. 84 Night calls, 1 2 8 - 3 1 confinement cases, 1 3 1 explanation of reduction in, 129, 130 Lord T a y l o r on, 1 3 0 , 1 3 1 present extent of, 128, 129 reduction in number of, 128 Obstetric flying squads, 80 Ophthalmic services of N H S , cost of, 72 Overdoctored areas, 3 4 - 3 8 Overworking of N H S doctors, see Workload of N H S general practitioners " P a p e r w o r k , " burdensomeness of, 49- 5 ° reductions in, 49, 50 Partnerships in N H S , advantages of, 46, 5 ° and group practice, 4 5 - 4 7 and " r o t a " systems, 50, 5 1 increase of, 45 L o r d T a y l o r on, 4 5 , 46

INDEX Partnership» in N H S — c o n t . n u m b e r of, in N H S , 45 size of, 50 Patients, n u m b e r on doctors' lists, 31-34 participants in the a u t h o r ' s surv e y , 25 f.n. some individual NHS cases, 110-112 Patients' " d i s l i k e s , " 9 5 - 1 0 4 hurried surgery consultations, 97 long waits, 5 3 - 6 2 , 9 5 - 1 0 4 prescription, d e n t a l , a n d o p h t h a l mic charges, 1 0 1 - 0 4 s p o n g i n g by foreigners, g g - 1 0 1 Patients' " l i k e s , " 1 0 4 - 1 3 a v o i d a n c e of catastrophic m e d i c a l costs, 1 0 9 - 1 2 health care as a right, not as charity, 112, 1 1 3 m e d i c a l care of h i g h q u a l i t y , 107-09 w i d e scope of N H S provision, 104-07 Patients' responsibilities u n d e r N H S , dental c h a r g e , 27 p a y m e n t for a m e n i t y or p a y beds (if w a n t e d ) , 27, 28 p a y m e n t of N H S " c o n t r i b u t i o n , " 26 prescription c h a r g e , 27 spectacles c h a r g e , 27 to c o m e to doctor's office for treatment unless i n c a p a c i t a t e d , 26 Patients' rights u n d e r N H S , a " p e r sonal d o c t o r , " 25 free c h o i c e of doctor, 24 ready access to specialist, hospital, d e n t a l , a n d o p h t h a l m i c care, a n d free m e d i c i n e , 25 right to c h a n g e doctors, 24 P a u l , D r . H u g h , on desirability of childbirth at h o m e , 79, 80

Pay for N H S doctors, 8 2 - 9 3 Royal Commission on Doctors' and Dentists' Remuneration, /957-60, Report, 89-93 a v e r a g e G P i n c o m e ( 1 9 6 1 ) , 92 d e m a n d s for p a y increases, 8 3 - 8 6 e x a m p l e s of specialists' incomes, 85 merit a w a r d s o f consultants, 88 of g e n e r a l practitioners, 91 Spens R e p o r t . 84 s u p p l e m e n t a r y income, 92 See also C a p i t a t i o n fee; M e r i t awards P a y i n g for the N H S , 6 3 - 9 3 P a y m e n t for private patients' drugs, 120-123 as a threat to p r i v a t e practice, 122 A n e u r i n B e v a n o n , 122 B M A on, 121 C o h e n R e p o r t on, 120 Fellowship for F r e e d o m in M e d i cine on, 122 N H S doctors on, 123 Pensions for N H S doctors, see S u p e r annuation scheme P e r t n a n e n c e of N H S , 152 Peterson, D r . O . L . , A Study of the National Health Service of Great Britain, 155 on British doctors' terms o f service, 26 on i m p o r t a n c e of early diagnosis, 52 on N H S doctors' w o r k l o a d , 52 usefulness to U . S . of N H S experience, 154 Piatt, Sir H a r r y , appraisal of N H S , 148 Prescriptions, a v e r a g e cost to g o v e r n m e n t ( ' 9 5 8 ) , 70 c h a r g e for, 27 total cost to g o v e r n m e n t (1958), 69, 7 °

INDEX Private patients of British doctors, 8-30 p a y m e n t s required of private patients, 28 reasons for r e m a i n i n g on " p r i v a t e " basis, 29, 30 Problems of Social Policy (Titmuss,) ' 8 , 155 See also Titmuss, Prof. R . M . Prohibition of sale of m e d i c a l practices, 1 1 7 - 1 9 A n e u r i n B e v a n on, 1 18 indemnification for losses incurred 118, 119 Proposal for a Central Medical Service for the Nation ( B M A , 1930), 18 Purchasability of health, 107-09 Prof. Lafitte on, 108 R . H . T a w n e y on, 107, 108 Sir Lionel W h i t b y on, 108 The Lancet on, 107, 108 Reader's Digest, The,

156

Redistribution of doctors, 34-39, 42, 43 evils of maldistribution, 34, 35 general practitioners, 37 method of redistribution, 3 5 - 3 8 need for redistribution, 34, 35 results of, 37, 43 specialists, 43 Refresher courses for doctors, 50 increased a t t e n d a n c e at, 50 Report of the Committee on General Practice within the National Health Service, see C o h e n R e p o r t Report of the Inter-Departmental Committee on Remuneration of General Practitioners (Spens R e p o r t ) , 84, 119, 120 Report of Ministry of Health (for various years), 37, 40, 45, 46, 58, 76, 106, 107, 1 1 5 , 116, 136 Ross, Sir J a m e s Stirling, The Na-

tional

Health

Britain,

Service

in

Great

155

on A m e r i c a n reports of the N H S , •34 on charges for prescriptions, etc., 104 on health centers, 44 on shortening hospital stays, 78, 79 " R o t a " systems, benefits of, 50 L o r d T a y l o r on, 131 Royal Commission on Doctors' arui Dentists' Remuneration, 1957-60, Report, 8 6 - 9 0 r e c o m m e n d a t i o n s of the C o m mission, 8 7 - 9 0 Royal C o m m i s s i o n on National H e a l t h Insurance (1926), 17 R u ? r k , R C . , an A m e r i c a n appraisal of N H S , 138, 139 Shaping

of

the

health

program,

>5-23 a c c e p t a n c e of A c t of 1946 by B M A , 23 A n e u r i n B e v a n a n d , 20-22 B e v e r i d g e " C r a d l e to Grave" R e p o r t , 19 B M A polls on national health provision, 20 C h u r c h i l l publication of " W h i t e P a p e r " on health service (1944), ' 9 . 35 creation of Ministry of H e a l t h , 17 d e m o c r a t i c procedure used by Britain in a d o p t i n g social services, 23 effects of W o r l d W a r I on, 18 E m e r g e n c y M e d i c a l Service, in W o r l d W a r I I , 18 G a l l u p Poll on Beveridge R e p o r t (1942), 19 L l o y d - G e o r g e a n d , 16, 17 L o r d A t t l e e a n d , 16 L o r d B e v e r i d g e a n d , 16

170

INDEX

S h a p i n g of t h e h e a l t h p r o g r a m m e cont. M e d i c a l P l a n n i n g Commission of 1940, 18, 19 m u l t i - p a r t y n a t u r e of the p r o g r a m , 15. 16 N a t i o n a l H e a l t h I n s u r a n c e Act of 1911, 16, 17 N a t i o n a l H e a l t h Service A c t of 1946 (Bevan Act), 2 0 - 2 3 n a t i o n w i d e discussion of Act of 1946, 2 0 - 2 3 opposition by doctors to A c t of 1946, 22, 23 R o y a l Commission on N a t i o n a l H e a l t h I n s u r a n c e (1926), 17 Sir W i n s t o n C h u r c h i l l a n d , 16, 19, 20 Short History of Public Health, A (Brockington), 81, 157 "Social g r o u n d , " basis of m a n y hospital admissions, 7 6 - 8 1 examples of, 77, 78, 81 relieved by subsidized housing, 81 Social Insurance and Allied Services (Beveridge), 155 See also Beveridge, L o r d Social Security and Public Policy (Burns), 52, 115 See also Burns, D r . Eveline M . Specialists, as salaried hospital staff officers, 41 Domiciliary Specialist Service, 41, 43. 136 effective redistribution of, 4 3 f o r m e r m a l d i s t r i b u t i o n of, 42, 43 full-time a n d p a r t - t i m e , 42 general availability of, 43 n u m b e r in N H S , 63 Spectator, The, 138, 144, 145, 153 Spens R e p o r t , 84, 85, 119, 120 S p o n g i n g by foreigners, 9 9 - 1 0 1 early a b u s e of N H S by outsiders, 99

estimated cost to g o v e r n m e n t of service to visitors, 101 f.n. examples of legitimate use of N H S by foreigners, 100 free N H S c a r e for b o n a fide visitors, 99, 100 1949 amendment prohibiting abuse, 99 Stallworthy, D r . J . A., on u n d u l y long hospital stays, 76 f.n. Stassen, H a r o l d E., 47, 156 Study of the National Health Servire oj Great Britain, A (Peterson), 155 See also Peterson, D r . O . L. S u p e r a n n u a t i o n scheme, 125-28 described, 126 e x a m p l e of, 126-28 in lieu of right to sell practices, '25 Prof. Lafitte o n , 125 Surgery consultations, h u r r i e d , 97 length of, 9 7 - 9 9 " T a p e r , " a p p r a i s a l of N H S , 138 T a w n e y , R . H . , Equality, 155 The Acquisitive Society, 159 o n Britain's d e m o c r a t i c a d o p t i o n of social services, 23 on the essence of a profession, 131-33 on public obligation vs. p r i v a t e charity, 112 on p u r c h a s a b i l i t y of health, 107, 108 T a y l o r , Lord (formerly D r . S t e p h e n T a y l o r ) , Good General Practice, .56 on a d v a n t a g e s of c a p i t a t i o n p a y m e n t , 9 ' - 92 on a p p o i n t m e n t systems, 55, 56 on assistantship as e n t r é e to general practice, 39 on closing of areas to new p r a c titioners, 116, 117

INDEX on cost of group-practice

build-

ln

g s , 45 on ratio of home visits to surgery attendances, 56, 57 on reduction in night calls, 1 3 0 , '3' on " s o c i a l " conditions requiring hospitalization, 7 7 , 78 Times, The ( L o n d o n ) , appraisal of X H S . 146, 1 4 7 on doctors' d e m a n d for p a y increase. 84, 85 on emphasizing family-doctor service, 150 on multi-party nature of N H S , 1 5 , 16 on X H S abuse by foreigners, 100 Titmuss. Prof. P . M . , Essays "n "Th». Welfare State," 3 2 , 1 5 5 Problems nf Social Policy, 18, 1 5 5 The Cost of the .\ational Health Service m England and Wales, 65 011 alleged increase in workload of X H S doctors, 32 on Britain's preparation for World W a r I I casualties, 18 Undoctorecl areas, 34 38 W a i t i n g for medical "Long waits"

service,

see

Waiting-rooms, a d e q u a c y of, 56 W h i t b y , Sir Lionel, on high cost of illness, 108 " W h i t e P a p e r " of Churchill Coalition G o v e r n m e n t ( 1 9 4 4 ) , a health plan based on " c o m m u nal provision for individual use," 1 1 3 need for redistribution of doctors, 35 prevention of new C P s invading localities " a l r e a d y fully or overmanned," 1 1 5 proposal to create " a comprehensive health service for everybody in this c o u n t r y , " 19, 20 to provide " t h e best medical and o'.he r facilities ava'lable," 106-08 Willink Committee, on medical m a n p o w e r needs, 40 Workload of N H S general practitioners, doctors' ability to render adequate medical care, 3 ° . 31 examples

of

specific

practices,

32-34 hours worked weekly by doctors, 31,32 n u m b e r of patients per doctor, 3 1 Prof. Titmuss on alleged increase in workload of N H S doctors, 32