The British Nationalized Health Service; G. Winder

THE BRITISH NATIONALIZED HEAL TH SERVICE THE LATE Lord Horder, who was one of Great Britain's most distinguished surgeons, speaking prior to the time Britain's medical system was taken over by the state, said, "It is universally acknowledged that our health services are the best in the world." It is probable that a good many other countries will have made the same claim so we shall not press the point except to say that in 1948, when a socialist government established the British National Health Service, it took over a medical system well up to the standards of the time. Yet that government seems to have been quite certain that once in the control of the state this system would improve. Many socialist Members of Parliament claimed that the country had, in fact, no medical organization, for they could not conceive of such a thing without a central authority to guide it. The central control which they established would, they believed, not only secure a Mr. Winder, formerly a Solicitor of the Supreme Court of New Zealand, is now farming in England. He has written widely on law, agriculture, and economics.

155 156 GEORGE WINDER more efficient medical service but would also ensure a cheaper one. The expected cost of the new National Health Service had been carefully worked out before hand by the famous economist, now Lord Beveridge, who arrived at an estimate of £170 million a year. This was less than the £180 million which all medical services were believed to have cost the people in private expendi ture before the war. Moreover, it was claimed that this figure should not have changed much by 1965; the im provement in general health which the nationalized serv ices would bring about should prevent any increased costs. Britain's National Health Service has now functioned for fourteen years so let us see to what extent the high hopes for it have been fulfilled. The Esthnate Was Low The first and most obvious fact is the gross error in the forecast of costs that was made by Lord Beveridge.

In its first year the nationalized service cost not £170 million but £377 million. The figure has risen year by year; in 1960 it cost £820 million of which only £23 mil lion was for capital expenditure. The British Cost of Living index shows that most prices were multiplied by three between 1938 and 1960. Medical costs, however, are more than four and a half times what they were. This, as we shall see later, has been due, not to any increased remuneration going to doctors, but chiefly to increased hospital expenses.

THE-BRITISH NATIONALIZED HEALTH SERVICE 157 Below are the published costs of three famous hospi tals, in 1938 when they were charitable trusts, and in 1960 when they were state institutions. Average weekly Hospital Number of beds cost per patient 1938 1960 1938 1960 Guys Charing Cross Royal Portsmouth 690 293 250 630 286 205 £6/ 3/ 8 £4/10/ 1 £2/ 9/11 £36/10/11 £36/14/11 £23/ 8/10 These show a rise of costs from six to nine times-far above any increase which can be accounted for by infla tion. These figures are typical of an increase which has taken place in all of Britain's hospitals. Administrative costs, included in the above figures, have risen from eleven to eighteen times although hospitals no longer have to collect funds from many sources as they did under the old system. The rising costs of drugs and pharmaceutical prepara tions have also been of concern to the government. In 1950 these were £37 million and in 1960, £89 million. In 1951, in an effort to prevent waste, the government im posed a charge of one shilling on each prescription. This was increased to two shillings in 1961.

Both these charges were hotly resented by the social ists as being departures from their principle of free medi cine. As a socialist Member of Parliament once expressed it, "If the Tories laid their sacrilegious hands on the Health Service, which the Opposition regarded as the 158 GEORGE WINDER very temple of the nation's social security system, the Labour Party would fight it with the same determination which they had brought to fighting the Rent Act." Such tirades, however, had no effect on the conservative gov ernment in its determination to enforce these minor charges, even though they have not stopped the rise in total cost of drugs and pharmaceutical preparations. Better Service? That all British medical services cost so much more in real terms than they did before they were nationalized might be tolerable if the services the people receive had correspondingly increased. But, who can value that inti mate association which should exist between the patient and his doctor? Under the old system of free enterprise the doctor was an authoritative master, a trusted friend, and at the same time a servant of his patient who must pay his fee. Under the system now practiced in Great Britain, much of this excellent relationship is undoubt edly retained; nevertheless, it is interrupted by an in visible stranger in the form of a higher medical author ity peering over the doctor's shoulder with power to criticize his work and inflict a fine upon him if he is too experimental in his treatment or prescribes too many ex pensive drugs. The doctor is no longer the servant of the patient but of the National Health Service.

The importance of this change in the doctor's status is difficult to measure. The old traditions are still a pow erful force with every honest doctor, but there can be no THE BRITISH NATIONALIZED HEALTH SERVICE 159 doubt that the former relationship between the doctor and his patient is slowly being undermined; and this tendency will increase as control passes to a younger generation of medical men who have never known the old ways. There is little doubt that if the matter were put to a vote the British people after 14 years of experience would still endorse the nationalized system. But this by no means indicates that they are getting better medical services than before; it merely means that they mistakenly be lieve such services are now costing them nothing. To the man who is ill, the fact that he can call on a doctor and pay no fee seems to be such an obvious boon that he usually is oblivious to the price he is in fact pay ing. Thirteen per cent of the cost of the National Health Service is paid in National Insurance Contributions, 4 per cent in minor charges, and the rest in general tax ation. This supposedly free medical service costs an av erage of over a pound per week per family. One would have to be very ill to pay more than this in direct fees.

It is this lack of association between services rendered and payments made which induces the British voter to turn a blind eye to the defects of his National Health Service. The Function of Price As everyone knows, the strength of a demand for any service very largely depends upon its price. When the state took over Britain's medical services and announced 160 GEORGE WINDER that in the future they were to be free, there was an in stant and unprecedented increase in the demand for them. Under free enterprise whenever there is a great increase in the demand for any service, there is almost always a consequent increase in its supply. Does the same principle apply to socialized medicine? At first glance, yes. In 1952 there were 27,879 doctors employed by the National Health Service either in hospitals or as general medical practitioners. The number had increased by 1960 to 32,223. The greater increase took place in the hospitals where the number of salaried doctors rose from 9,650 in 1950 to 12,300 in 1960, that is, by 27 per cent. During the same period, however, the number of staffed hospi tal beds increased only 4~ per cent, from 453,000 to 473,000. This can be contrasted with a 33 per cent in crease between 1929 and 1938 under the competitive system. In 1935 there were more hospital beds in Britain per thousand inhabitants than there are today, yet one of the chief charges made by the socialists against the competitive system was that it had· insufficient hospital beds. The small increase in the number of beds, together with the fact that there were 466,000 people on the wait ing list for such beds in 1960, certainly suggests that the National Health Service has failed to meet the increased demand that the absence of medical fees has made upon it. This great shortage of beds has caused the authori ties to institute a system of priorities. Acute cases can al ways be found a bed, but those requiring operations for such complaints as hernia, varicose veins, and the like may have to wait up to a year and longer.

THE BRITISH NATIONALIZED HEALTH SERVICE 161 Hospital Shortage Perhaps the chief reason for this failure of the Na tional Health Service is that since its inception the build ing of hospitals has almost ceased. Only one hospital was built in thirteen years. Many socialist doctors before na tionalization believed that when the government took over, all financial worries would disappear. With unlim ited funds, the government would hasten to build all the hospitals required. In practice the position has been exactly the opposite. The government has been far more cautious in its capital expenditure than the most con servative of private concerns. Overwhelmed by the un expected and ever-increasing cost of its Health Service, it has tried to keep down expenditure by checking ex pansion. Mr. D. S. Lees, a Senior Lecturer in Economics, in an excellent booklet, "Health Through Choice," has pointed out that this failure to spend money on, new hospitals has been an outstanding feature of the British National Health Service. Whereas before the war the yearly ex penditure for capital purposes was about 20 per cent of current health expenditure, since nationalization it has been only about 5 per cent. Many medical men be lieve that nationalization has actually retarded the de velopment of Britain's medical services and that the British people are receiving a far poorer service than they would have received if the prewar system had been allowed to continue its development.

In "The Genesis of the British National Health Serv162 GEORGE WINDER ice" written by the well-known economist John Jewkes and his wife, the authors support the above conclusion, pointing out that in 1939 Great Britain was more amply supplied with hospital beds in proportion to population than the United States, but that since the war this ad vantage has disappeared. "It is difficult to escape the con clusion that in the United States the quantity of medical services available for each person is larger and is tend ing to increase more rapidly than in Great Britain." They also make comparisons with the medical services of Switzerland which for the most part are still under the competitive system. The Swiss have more doctors and many more hospital beds per 1,000 of population. Between 1948 and 1959, money spent on hospital build ing per head of population was four times as great in Switzerland as in comparatively wealthy Great Britain.

Waiting lists in Swiss hospitals are literally unknown. True, the British government at last has been stung into activity by constant criticism and this year com menced a program to spend £50 million building hospi tals over. the next five years. Whether this expenditure will eliminate the long waiting lists for hospital beds remains to be seen. These waiting lists have angered the socialists who seem to have forgotten that they are responsible for the introduction of the nationalized hospital. In their pub licity at the General Election in 1959 they stated, "Nearly half a million people are waiting for hospital beds; too many doctors' surgeries are still grim and gloomy; too many hospitals are still out-of-date and makeshift; the THE BRITISH NATIONALIZED HEALTH SERVICE 165 m.ental hospitals are overcrowded and dilapidated and, in spite of gallant efforts by those in charge, are quite unsuitable for modern psychiatric care; the committees and staff of the Service have been frustrated by endless administrative delays, and inevitably enthusiasm has been diminished. "

No Evidence of Progress As for the hopeful claim made by Lord Beveridge that the Health Service would improve the health of the peo ple, there is no evidence whatever of this. Infant mor tality rates have improved, but so have they in many other countries with entirely different medical systems. Tuberculosis, pneumonia, and diphtheria have dimin ished, but the same is true elsewhere. Chronic diseases, cancer, and neurosis have increased. It was claimed that the expenditure on the National Health Service was a form of national investment which would increase wealth by reducing the amount of days lost to industry through sickness; but figures for ab sence from work on account of illness have in no way diminished. In summation, the British National Health Service has failed to meet the increased demands made upon it, and even after the change in the value of money is allowed for, medical attention costs the British people a great deal more than before the war. Moreover, in those ma terial factors which lend themselves to measurement, Britain's medical services have expanded far more slowly 164 GEORGE WINDER than they did in the 30 years before nationalization. They also have expanded more slowly than in the United States and Switzerland where medical treatment has re mained, for the most part, on a free enterprise basis. If the British people still believe in their state-owned Na tional Health Service, it is not because of its virtues but solely because of the illusion that it costs them nothing.

What the Poor Had To Lose It may be argued that at least the poor have benefited by not having to pay the doctor's fees. Even this is doubtful. Prior to nationalization, the great amount of charitable hospital service, which then existed, looked after them. Today, the poor must share with others the crowded surgeries which are the result of "free medicine." It could be argued, of course, that these crowded sur geries and hospitals are evidence of the crying need for a free medical service which must have existed before nationalization but was concealed by the inability of the poor to pay the doctor's fees. But the crowded surgeries are not due so much to really sick people asking for treatment they could not previously afford as to the de sire of many people to have free treatment for the slight est cold or illness. Before nationalization, a really sick person was sure of treatment whatever his financial means. Now, with the many claims on the doctors' serv ices, a sick person may fail to get the attention his ill ness requires.

If we look upon the National Health Service as a form THE BRITISH NATIONALIZED HEALTH SERVICE 165 of charity, it is worth considering whether the British people really need it. Whereas in 1960 health services cost them £820 million, their beer and spirits cost £1,001 million and their tobacco £1,140 million. It is sometimes claimed that the chief beneficiaries of the nationalized system are the middle classes who, prior to the National Health Service, had to pay their doctor's fees. It is difficult to see their gain, however. The taxes they pay for medical services they may not receive aver age well over a pound a week per family. The middle classes do, in fact, pay for medical care, the only real difference being that now they are deprived of some of that personal responsibility which was once the basis of their character. Only about 5 per cent of the people now employ those doctors who have kept out of the National Health Serv ice. They pay twice over, for they must also pay in taxation their share of costs for the nationalized service.

An Ambiguous Position In considering the doctor himself under Britain's Na tional Health Service, the word "nationalized" may seem a bit out of order. The position of the general practi tioner, for instance, is an ambiguous one. He may still have his own private patients if he can get them; but the doctor who originally believed he could get the best of both worlds by having both paying and state patients soon found that the vast majority of them preferred to register under the state system, thus retaining his services 166 GEORGE WINDER at no apparent cost to themselves. The result is that all but a few British doctors now depend on the National Health Service for a living. Some six hundred doctors remained outside the scheme from the beginning and are allowed to carryon under the old competitive system. Lately, these independent practitioners have grown in number, probably due to the growth in private health insurance. In 1948 some 100,000 people subscribed to private health policies; in 1960 more than 1,000,000. According to Dr. John Hunt, secretary of the College of General Practitioners, one quarter of British doctors have insured their families for private hospital treatment.

The general practitioners employed by the National Health Service are paid, not according to the amount of work they do or the number of patients they attend, but according to the number they can persuade to register on their panel for medical services if they should be required. For every patient on his panel, a doctor re ceives a fee, whether he attends such patient or not. Therefore, the majority of general practitioners aim to get as many registered patients as possible. A doctor is expected to accept on his panel everyone who applies. But he naturally does his best to avoid potential patients who might require his services too often, such as old peo ple and chronic invalids. A general practitioner is allowed to have up to 3,500 registered patients, yet doctors claim that about 1,500 is aU they can properly attend. More than half of Britain's general practitioners have more than 2,500 patients THE BRITISH NATIONALIZED HEALTH SERVICE 167 while 29 per cent have more than 3,000. For each pa tient on his panel, a doctor now receives 19/6 ($2.73) a year-occasionally more, to induce a doctor to go into unpopular areas or to a country area where the panel must necessarily be small. There are also allowances for "good behavior" such as attending refresher courses. Out of his capitation fee the doctor must pay the costs of his surgery and the wages of his receptionist or nurse. The fee is the same for the doctor who employs capable as sistants and uses the most modern equipment as for the doctor who gets along with the aid of a stethoscope and an overworked wife. The result is that the doctor who accepts only as many patients as he can conscien tiously handle will hawe a very inadequate income. For more income, a doctor must have a large panel of pa tients, which will mean a crowded surgery, hurried in terviews, and often a snap diagnosis. The system places a premium on bad and hasty service. Moreover, because the patient has nothing to pay, he tends to visit his overworked doctor as often as possible. As one doctor has put it, "The patient seeks the doctor to g,atify his every whim; the doctor tries everything in his power to avoid the patient."

Under such conditions, it is not surprising when a doc tor develops a feeling of guilt and resigns the service, explaining as one did recently, "The horror of this sys tem is that many excellent doctors are trapped by it, but I have hated myself for it and now I am out of it." Many of the patients also are unhappy. Knowing the reluctance of the doctor to visit them, the more consid168 GEORGE WINDER erate do their best to visit his surgery, though they should have remained in bed. Knowing also that their visit brings the doctor no financial return, some are con stantly apologetic. "I'm sorry to trouble you, Doctor," is a phrase constantly on their lips. Others, of course, ag gressively insist on their rights and expect the doctor to do anything they demand, such as writing a prescription for some patent medicine they have seen advertised so they can have it at the expense of the National Health Service. Young doctors sometimes are suspected of pre scribing too generously in order to attract new patients to their panels. Many doctors believe their surgeries are looked upon as social centers by women patients.

Passing the Buck There is a minimum service which the doctor feels compelled to perform, but only the more conscientious will go beyond this. Most, if they can possibly do so, send their more troublesome jobs to the hospitals, thus add ing to the already excessive demands upon those institu tions. Simple operations, formerly taken in stride, are now handled this way, as are such time-consuming jobs as a check-up to find out the patient's general state of health. The District Medical Executive Councils do not seem to resent this passing of responsibility to the crowded hospitals. They even encourage it by forbidding the general practitioner to do a number of jobs which were formerly within his province. In most areas, he is not allowed to do X-rays or blood tests or perform reguTHE BRITISH NATIONALIZED HEALTH SERVICE 169 larly on women patients the cancer-warning Papanicolous test. One of the most constant complaints of the general practitioner is the great amount of paperwork required by the authorities. The majority of British doctors may still have the skills and loyalties inherited from the past, but under the National Health Service, they have every reason to forget them and to take as little responsibility as possible. Whatever service they may render their pa tient will not in any way affect their capitation fee.

Since nationalization, the people have developed a habit of suing their doctor in the Law Courts for negli gence. Although such actions existed in the past, they have now become much more common. This again makes the general practitioner reluctant to do more than the minimum required of him. After all, there is a limit to the responsibility one can undertake for 19 shillings and 6 pence. Moreover, medical colleagues on the salaried hospital staff are in no such invidious position, for the government is responsible for their mistakes. This has caused some doctors to suggest that the general medical practitioner would be better off as a salaried official than he is under the present system, in which he has all the disadvantages but none of the advantages of indepen dence. It is worth noting that this British system of socialized medicine with its capitation payments was adopted in Australia in 1946 by a socialist government. In 1952 a conservative government abolished it, replacing it by in surance against illness through private companies. AI170 GEORGE WINDER though the government did not entirely desert the medi cal field, it restored the old and well-tried relationship beween doctor and patient. This government, inciden tally, is still in power.

Third Party Medicine In the past the doctor was responsible only to his pa tient and to public opinion. Now he has a higher au thority which he must conciliate. He may be told, for ex ample, by his District Medical Executive Council that he is giving his patient too many drugs of an expensive kind and that his drug bill which the state has to meet is above the average for his district. If these excessive costs are continued, he may be required to pay a propor tion of the bill himself. Here is a paradoxical instruction to doctors from a recent memorandum by the Minis try of Health: "Without prejudice to the doctor's rights to prescribe whatever he thinks necessary in any individual case, a doctor may be called upon to justify the cost of his prescription." Another memorandum, evidently try ing to overcome the natural reluctance of the panel doc tor to visit the patient, gives full instruction as to when such visits should be made.

Another cross the general practitioner must bear is that a patient may inform the District Medical Execu tive Council that his doctor is not giving him the full service to which he feels entitled. Occasionally the pub lic is regaled in the press with a list of fines inflicted on doctors who have committed such offenses as failing, to THE BRITISH NATIONALIZED HEALTH SERVICE 171 answer night calls. In 1960, disciplinary action was taken agains t doctors in 410 cases. But what most troubles the general medical practi tioner is that his fixed fee, multiplied by more patients than he can adequately serve, leaves him with a far lower real income than most doctors enjoyed before the war. Doctors Are Leaving In 1951, after an inquiry on the remuneration of doc tors, the capitation rate and the salaries of hospital doc tors were raised to compensate for inflation. Since then, rates have risen only slightly, but prices generally are up a third, causing a decline in the real income of doctors.

Naturally, doctors are dissatisfied. Older members of the profession seldom can do anything about it, but the younger members are showing their disapproval by sim ply leaving the country. John R. Seale, M.D., M.R.C.P., has shown the extent of this exodus in a booklet pub lished by The Fellowship for Freedom in Medicine. Al though doctors have always emigrated from Great Brit ain, they are leaving now at a rate higher than ever be fore. Between 1956 and 1960, of doctors trained in Brit ish medical schools, 1,070 have emigrated to Canada, 1,100 to Australia, 190 to New Zealand, and 750 to the U. S. In the twelve months of 1960 more doctors trained in England and Ireland emigrated to the U. S. than in the whole period from 1930 to 1939. Canadian statistics show that British doctors are entering Canada at a rate 172 GEORGE WINDER five times as great as that for· British immigrants in gen eral. Last year, one-third of the medical students who qualified in Great Britain left the country.

Moreover, knowledge of the disadvantages under which British doctors are now serving has penetrated to the rising generation. Although the number of students at British universities has doubled since the war, the number studying medicine has actually decreased since the introduction of the National Health Service. There were 14,200 medical students at British universities in 1950 compared with 12,700 in 1958. The resulting vacuum in the British Health Service has to be filled with doctors from the Commonwealth and by foreigners. Before the war, some 200 Commonwealth doctors a year registered in Great Britain, chiefly from Canada, Aus tralia, and New Zealand. In 1960 the number was 1,400, mostly from India and Pakistan. The number of foreign doctors registering before the war with the British Medi cal Council was under a dozen a year. In 1960 it was 1,701 and last year over 2,OOO-from such places as Syria, Spain, Greece, Peru, Turkey, Japan, and Yugoslavia.

Some of these are well-trained but, as Dr. Seale points out, others are from medical schools of which the Brit ish authorities can have very little knowledge. Nearly half of all junior posts are now held by doctors from overseas. A report issued by the Nuffield Provincial Trust showed that in many casualty departments the provision of medically qualified supervision had broken down and that able nursing sisters were making the· diagnosis and THE BRITISH NATIONALIZED HEALTH SERVICE 173 carrying out the treatment. A doctor was usually avail able, but often he spoke no language in which he could be understood. Recently the General Hospital at Weston super-Mare advertised for a Senior House Officer in Sur gery. It received applications from one Briton, one Aus tralian, one Portugese, one Greek, one Japanese, three Anglo-Indians, three Egyptians, five Pakistanis, and forty three Indians.

Young British doctors who have some memory and regard for older medical traditions seem to be expressing their opinion of their National Health Service in that manner sometimes described as "voting with their feet." British nurses are infected by the same spirit. There is a general dissatisfaction with their rates of pay and, for the first time in British his tory, there has been talk of a nurses' strike. Fortunately, the high ideals of the profes sion have prevailed. It takes some time to undermine a good medical system and particularly to destroy the long-established traditions of trust between doctor and patient which the older British doctors remember. Never theless, the British National Health Service is doing both. Perhaps the greatest tragedy is that the generation of Britons now growing to manhood may unquestionably accept the National Health Service, for they never will have known anything better.