The English Crisis:III. The Infirmity of British Medicine
Schwartz, Harry
Harry Schwartz The Infirmity of British Medicine • Editor's Note Since—roughly speaking—the first quarter of the last century, a powerful sense of cultural inferiority has crept into American...
...But when it came time to pay them, the junior doctors discovered that all that wascontemplated was a redistribution among them of the same total funds, with money added to the salaries of some often simply deducted from the salaries of others who had little or no opportunity to work long hours...
...Perhaps some future British Government will have the courage to turn to this solution...
...Medical care in Britain is better in the mid-1970s than it was thirty years ago...
...This is the result of a compromise reached between the consultants and Aneurin Bevan at the very birth of the NHS, a compromise reminiscent of that Stalin reached with Soviet collective farmers in the early 1930s...
...They argue that these physicians take care of most minor and self-limiting physical illnesses and that they provide at least part of the psychological support for those, patients with emotional problems...
...Britain tried to circumvent thisdifficulty by keeping a tight lid on NHS expenditures, especially for fixed capital...
...For varying periods of time, they announced, they would not serve patients in private beds, hoping literally to starve those patients out of the hospitals...
...Those who have access to treatment in the London teaching hospitals and in a rather small number of similar hospitals in other parts of the country probably do get good care, but the great majority of the NHS clients live in areas with inadequate numbers of hospital beds, grossly deficient numbers of medical and surgical specialists, and inadequate and outmoded medical equipment...
...Owen's admission of the "fallacy" on which the NHS was launched: "We were going to finance everything, cure the nation and then spending would drop...
...And in all of Bli' t;D, according to the British Medic:4 Journal, there are fewer than a dozen EMI brain scanners, remarkable machines which have revolutionized the diagnosis of brain disease and brain injuries, while there are over two hundred in the United States (and these are British machines...
...Consider the disillusionment of Dr...
...The consultants' discontent was further sharpened in mid-1975 when it became plain that the Wilson Government planned not only to eliminate private beds from NHS hospitals, but also to make it virtually impossible to build any significant number of private hospitals to replace the NHS private beds...
...Just how poor their training is did not become fully evident—and a matter of public knowledge—until after mid1975...
...Bevan promised that a small number of beds would be reserved in NHS hospitals for private patients and that these would be under the control of the consultants...
...Yet it is clear that the politicians who launched the National Health Service were little concerned about cost...
...Judged by these lights, the British National Health Service is hardly a model for American medical care...
...In 1973, 49 percent of all consultants had part-time contracts and saw private (paying) patients...
...The Jewkeses calculated that per capita hospital construction expenditures were six times as great in the United States between 1950 and 1959 as they were in England and Wales during the first 13 years of the NHS...
...The consultants and their subordinates are all government employees, but the consultants may also engage in private practice, a lucrative privilege many of them use and treasure...
...21, 1975...
...Owen also spoke of great inequalities in the health services available to the people of Britain, and of the existence of "quite severe areas of health deprivation" even in the otherwise favored London metropolitan region...
...they don't know who's going to operate on them, and they realize the chances of getting me are slim...
...But we are now in a position to pronounce some judgments on the National Health Service...
...Dixon indicate, the rhetoric of the 1940s has long been discredited...
...A resolution demanding this abolition was passed at the 1975 annual conference of the British trade union movement...
...The essential question is why every year tens of thousands of British citizens pay fees to consultants (as private patients) when those same consultants are theoretically available free of charge through the NHS...
...In 1974 there were 4,500 pay beds in England and Wales out of a total of about 420,000 beds...
...As the Conservative politician Enoch Powell formulated it, in what has come to be known as Powell's Law, the demand for "free...
...These are ridiculously low figures and they show that the old promises that everyone would have access to the best possible medical care are not being kept...
...Most of the difficulties the NHS experienced in December 1975, however, came from the junior hospital doctors, the consultants' subordinates, rather than the consultants...
...Under these pressures, the Labour Party platform in the last election campaign promised that if returned to power the Wilson Government would eliminate private beds from NHS hospitals...
...When they're to be operated on, I do the operation and I take care of them after the surgery...
...Nor have we raised the question of how first-rate medical care can be given to the people of England and Wales when there are so few specialists...
...23, 1975...
...The costs of health care soon began to provoke serious political conflicts within the Labour Government, e.g., in February 1949 when it became known that 52 million pounds (an enormous sum of money then) would be required in excess of original budget estimates to meet NHS costs...
...In December 1974, the NHS had a list of 517,000 people in England alone waiting for what was officially called noncritical surgery...
...Barbara Castle—the Minister for Health and Social Security—and Dr...
...One of the reasons often cited for nationalizing British health care was the need to modernize and expand Britain's antiquated hospital system...
...A year's practical working of the scheme would be needed to discover the cost with real accuracy...
...In addition to enjoying higher income, part-time consultants also gain income tax advantages because they can deduct the costs of earning the extra private fees...
...So what they get when they pay is courtesy, time, my personal expert care, and the convenience of having the problem taken care of quickly...
...These were commendably honest admissions for the socialist head of a socialized medical system...
...I spend time with them in consultation...
...There is some truth to these arguments and many Britons seem to be quite satisfied with this arrangement...
...Supporters of the NHS see the availability of a personal family doctor for most Britons as a great achievement...
...In fact they verge on the stoical as compared with the American patient, and, of tour-at...
...According to the 1974 report of the Department of Health and Social Welfare, there were 95 cardiology consultants, 181 dermatology consultants, 36 infectious disease consultants, 15 nuclear medicine consultants, 134 neurology consultants, 82 neurosurgery consultants, 77 plastic surgery consultants, 180 radiotherapy consultants, and 111 thoracic surgery consultants...
...In 1974 about one-third of all consultants received distinction awards worth from 1,500 pounds (more than half of all awards) to almost 8,000 pounds (to only 112 recipients...
...dlis fact rivkes them, purely from a physician's polar of view the tnes pleasant patients...
...The potential demand for care—including psychiatric care, the effort to develop the full potential of the severely retarded, and the effort to give geriatric patients the benefit of all possible help—can bankrupt any nation which attempts to provide it free of charge...
...The availability of private, paid care for British patients since the beginning of the NHS shows that the alleged goal of equality was abandoned at the outset of the enterprise...
...In a revealing discussion, Bevan's biographer—the present Labour Party cabinet member Michael Foot—reports that the father of the NHS attached little importance to advance estimates of cost...
...But he saw his single private patient for a full half-hour...
...In every society one of the most highly prized rewards for outstanding work, talent, position, and accomplishment is prompt access to superior medical care with all possible amenities...
...Few funds are available, for example, for kidney grafts or dialysis machines, and many patients requiring kidney treatment have nawhere to turn for help...
...Then costs would drop...
...There is a limit even to British patience, and the almost endless demand for "free" services quickly translated into political clamorings for more of them...
...Also they put a value on their convenience and they don't want to wait...
...Surgeons and anesthetists earn most of the private fees...
...By early December 1975, the British Medical Journal was already raising the question of when the standard of clinical knowledge required in the tests might have to be lowered to produce adequate numbers of foreign doctors for NHS hospitals (British Medical Journal, Dec...
...Hospitals are not much better...
...Space limitations prevent us from considering other important aspects of the NHS...
...Many of these people will have to wait years for care they want and need, and horror stories about the effects of such delays abound in the British medical literature...
...Certainly a British GP whose office I visited saw his thirty or so NHS patients very quickly, giving them each one to four minutes as timed on my watch...
...I can arrange for them to be operated on quickly, maybe a few days or one or two weeks after the initial consultation...
...They see each patient for a very few minutes, give him a rushed examination, and prescribe something which they hope will hold him until his problem vanishes...
...The British people, famous for their patience, for their willingness to queue up for buses or for whatever else they had to wait for, could queue up as well for nonemergency medical care...
...More fundamentally, Bevan was the victim of a colossal misconception, implied by Dr...
...Owen conceded that a generation's experience tended to confirm the fears conservative economists had expressed when the NHS was first being debated and fought over...
...In 1974 and 1975 more militant elements of the Labour Party began agitating for the abolition of private practice...
...Patients often complain that where GPs require patients to have appointments, the secretaries are instructed to try to discourage the patient from coming in...
...But in Britain, amidst the shambles of their economy and their political system, many prominent observers now openly acknowledge that the chickens have come home to roost for their health service...
...We have not, for example, even mentioned the very heavy dependence of NHS hospitals on Asian, African, and Caribbean doctors, many of them poorly trained...
...Alas, today England's social democratic institutions appear to be terminally ill and before ours fall into a similar condition, we at The Alternative decided to publish a book on the "Crisis of Social Democracy in England" with especial concern for the lessons that decline holds for England's prodigal son...
...But the legal responsibilities of both full-time and part-time consultants to their NHS patients are identical and total...
...This penny-pinching in capital investment has had many unfortunate consequences for the quality of health care, one being insufficient medical equipment...
...These were the conditions under which preventive medicine, new hospitals and medical schools, occupational health services and medical research were likely to give way to a free supply of drugs, of doctors' services and of hospital care...
...The real test of the National Health Set-vice is twofold, at least if we are to measure it by the promises made originally...
...One rock is the conflict over "equality...
...In that same interview Dr...
...Forgotten was the heady talk about everybody having all the latest medical aid he or she might need when he or she needed it...
...Second, has the NHS made available the best of modern medicine to the sick in Britain...
...The differences between British and American health care go beyond mere spending differences, however...
...In discussing British GPs, we are talking about roughly 26,000 doctors ministering to several tens of millions of patients, about a quality of medicine which varies from the excellent, personalized, compassionate, and technically superb to uncaring travesties of health care, sometimes delivered by a foreigner whose English is none too good and who dislikes his patients as much as they dislike him...
...It is interesting that the con-sultant and his underlings are known as a "firm" and that the consultant is supreme in his medical empire, secure in his job for life, and accountable to almost no one...
...6, 1975...
...What follows is the third essay in this series...
...The charges would save the government an estimated 23 million pounds, and Bevan's chief opponent, Hugh Gaitskell, reasoned that this money would be better spent on old age pensions than on free glasses and dentures...
...Critics, however, dismiss the general practitioners as quacks who quickly lose their original professional skills and become mere hand-holders and tranquilizer prescribers because they never see any serious illness...
...In such a complex situation, excessive generalization is unwise...
...A more realistic note has crept intoAmerican discussion of the subject in recent months, as graphic front-page headlines—"BRITAIN'S HEALTH SERVICE TO UNDERGO INVESTIGATION" ; "BRITISH HOSPITALS HIT BY SLOWDOWN OF YOUNG DOCTORS"—have begun to dispel the illusions of idyllic British health care...
...When they come to me they know I'm the top expert and I'm giving them the benefit of my knowledge and experience...
...But from the government's point of view this has the useful result of keeping tensions and jealousies high among consultants...
...But in Britain the main question, as test after test produced calamitously high failufe rates, was how long the NHS could continue to be even minimally staffed if two-thirds or more of arriving third-world doctors were found ineligible for hospital posts...
...First we were going to finance everything, cure the nation and then spending would drop...
...David Owen, the Labour minister in day-to-day charge of the NHS, as expressed in a recent interview with the London Sunday Times (Oct...
...his reply was: "A high incidence of unemployment...
...Mao Tse-tung gets far better medical care than a Hunan peasant, just as Leonid Brezhnev gets better care than a Ukrainian factory worker...
...that perhaps next year defense expenditures would be smaller, or investment needed for other purposes would be less, or the national income would rise sharply...
...Some come from the ranks of the more than two million British citizens who belong to private health insurance plans that pay fees for private consultations and also pay for the cost of NHS private beds in hospitals...
...medical care quickly outruns any possible provision for it...
...Moreover a system of distinction awards was set up as bonuses to be paid to consultants on the basis of merit, as judged by a committee whose deliberations are kept secret...
...The NHS began in 1948, but its working plans were devised during World War II, when all Britons shared a common fate and a common danger...
...The GP is obliged to pay house calls whenever they are sufficiently urgent, and to be available to his patients every hour of the day and night and every day of the year...
...Or consider these recent criticisms by Bernard Dixon, editor of the British magazine, the New Scientist: "The plight of Britain's Health Service conflicts desperately with the avowedly utopian ideals of its founders...
...their ability to enter a hospital and to be operated on quickly and conveniently rather than waiting in line months or years...
...and by the hope that easier times were coming...
...Dixon added: "Not only is there an acute shortage of resources, but the expertise and facilities that are available are all too often dispensed via a conveyor-belt system which can at times be positively inhuman" (New Scientist, Aug...
...But the worst aspect of the system is the doctors' huge burden of work, especially in "designated areas": the GPs have so many patients that they must practice a mechanical and minimal kind of medicine...
...Once, when a British Medical Association leader asked him, "What, Mr...
...The doctor who wants to maximize his income thus has an incentive to get the largest possible list of subscribers —some doctors have well over three thousand patients—and to do as little as possible for each in order to save time and be able to serve the largest number of people...
...Of all the factors involved in these disappointments, cost has undoubtedly been one of the most important...
...18 The Alternative: An American Spectator April 1976 Don't you think that's worth paying for...
...Whether through greater courtesy, longer and more careful examinations, a more sympathetic reception, or—most likely—some combination of these considerations, private patients are convinced they get better care when they pay their general practitioner...
...Some private patients pay out of their own pockets...
...Similarly, British consultants are allowed to accept a 9/ 11 contract, a legal fiction that gives them only nine-elevenths of a full-time consultant's salary while allowing them to see private patients and accept fees...
...By inference, these results provided shocking information about the competence of foreign doctors who had been permitted for many years to work in hospitals without being tested...
...Many of them worked over one hundred hours a week, and it was their willingness to do so that had made the NHS possible since 1948...
...RET There was a time not so long ago when would-be reformers of the American medical system enthusiastically pointed to Britain's National Health Service as an example to be emulated in this country...
...Similarly, the Government pays bonuses to doctors willing to settle in "designated areas" where there is judged to be a shortage of GPs...
...General practitioners—who are considered independent contractors, notgovernment employees—also enjoy these tax advantages...
...There is no full equality in access to medical care anywhere, nor can there be so long as human societies must depend upon differential rewards to provide incentives...
...The argument was, as always, about priorities...
...The worst consequence, however, is the interminable waiting, caused by the shortages of hospital beds and doctors and surgeons...
...For most of us, it is only when we join a year-long hospital waiting list, or have to take an injured child to a hospital casualty department on Sunday afternoon, that we realize just how threadbare and starved financially the service really is...
...she dies at home shortly thereafter...
...Eighty percent or more of all consultant ophthalmologists, general surgeons, otolaryngologists, orthopedic surgeons, and obstetricians and gynecologists see private patients...
...The answer here is obviously no, a negative reply which the present British Labour Government accepts as much as its opponents do...
...Harry Schwartz The Infirmity of British Medicine • Editor's Note Since—roughly speaking—the first quarter of the last century, a powerful sense of cultural inferiority has crept into American realms of influence...
...native...
...In his 1952 political autobiography, In Place of Fear, Bevan stated his misconception clearly: "When the Service started and the demands for spectacles, dental attention and drugs rocketed upwards the pessimists said: 'We told you so...' "Ordinary men and women were aware of what was happening...
...The conflicts on this issue have only begun, but there can be no doubt that they will be fierce indeed when the Draconian naLure of the alternatives is fully realized...
...Has it achieved equality of medical care for all in Britain regardless of who they are or where they live...
...The consultant and his staff also give outpatient consultations for patients referred by GPs...
...Until then, continued deterioration of morale among key NHS staff and worsening provision of physical facilities for treating the sick seem unavoidable...
...Owen were planning...
...The memorandum outlined a scheme for relocating all general practitioners into government-operated health centers and then prohibiting the GPs from seeing private patients in these centers...
...In 1974, Britain spent about $7 billion on the NHS, while Americans, with somewhat less than four times- Britain's population, spent well over $100 billion on health-care-related activities...
...Suffice it to recall that Aneurin Bevan, who piloted National Health Service legislation through Parliament and then supervised initial organization and operation of the NHS, referred in one parliamentary debate to his conviction "that we ought to take pride in the fact that despite our financial and economic anxieties, we are still able to do the most civilized thing in the world—put the welfare of the sick in front of every other consideration...
...As the quotations from Dr...
...An eminent British surgeon who was then Regius Professor of Surgery at Oxford explained to me some years ago why so many persons resorted to private medicine even though "free" government medicine was available to them: "They value their health and their lives...
...In Britain, where income taxes are very high, these tax advantages are even more appealing than in the United States...
...And the problem, the Jewkeses observed, was not simply a capital shortage: "The excuse usually given, that Britain was short of capital after the war is not convincing...
...Nevertheless the utopian Labour Party dream of "equality" has already gravely injured the National Health Service and may yet cripple it even more...
...Nevertheless it was clear that morale among physicians in the NHS was extremely low and newspaper accounts referred freely and often to the "breakdown" or the "collapse" of the NHS...
...The GP in turn complains that many patients plague him unnecessarily, and he feels it is bitterly unfair that he is always expected to be available to them...
...The demand does not "even out...
...At that time, newly arrived doctors were first given qualifying tests in medical knowledge and in ability to communicate in English...
...The patient who is cured today lives to get sick tomorrow, and the older he gets the more likely he is to become the victim of a serious, disabling ailment requiring long and expensive treatment...
...Much was made of the private patients' "queue jumping," i.e...
...Nor did Bevan foresee the rapid progress of medical technology which provided new means of curing the sick and easing or eliminating disability, but often—as in the case of kidney transplants and open heart surgery—at very high cost...
...Stalin moderated the peasants' objections to collectivization by allowing them to have their own small garden plots on which they could keep some livestock and grow produce to sell at high prices in free markets...
...Two more portions of this historic compromise must be mentioned...
...Britain does not today "put the welfare of the sick in front of every other consideration," nor has Churchill's talk of "equal opportunities to benefit from the best and most up-to-date medical and allied services available" been realized...
...They knew from their own experience that a considerable proportion of the initial expenditure, especially on dentistry and spectacles, was the result of past neglect...
...Now we know that Bevan was wrong...
...The Government has sought to distribute GPs more evenly among patients by discouraging and even prohibiting young doctors from settling in "restricted areas" where authorities have decided there are enough or too many doctors...
...As mentioned earlier, most British GPs have only the most primitive equipment and facilities...
...And they have to wait months or longer for the operation...
...And while American medicine is often extravagant and wasteful, extravagance certainly does not account for the approximately fourfold difference in per capita medical spending between the United States and Britain...
...In the 28 years of the NHS, there has been some progress toward a more equal distribution of GPs throughout the country, but a recent study indicates that much more progress is needed (see The fact is that, by American standards, the NHS is a meager and spartan medical system many of whose economies would be regarded as inhuman brutality if applied to Americans...
...The patient pays nothing out of pocket for this access, and the GP is compensated by the government under a complicated formula whose main ingredient is a capitation payment, so much annually per patient on his list...
...The Alternative: An American Spectator April 1976 15 Prime Minister Winston Churchill, absorbed in his wartime task of rallying the British people to ever greater exertions and sacrifices, was doubtless glad to have a glittering prize to offer his people for the postwar period...
...With the wisdom of hindsight we can see that the NHS is foundering on two rocks which could have been anticipated even in 1948...
...Now we recognize that no country, even if they are [sic] prepared to pay the taxes, can supply everything...
...The rtttuiting .c...
...On the other hand less than twenty percent of all consultants in geriatrics, pathology, and mental retardation do so...
...The second part of the NHS is the hospital service, which generally consists of a series of personal empires, of lordly consultants who are specialists in different fields and who have lower-ranked doctors—many of them in their thirties and even some in their forties—serving under them...
...Owen and Mr...
...Bevan, is your long term prospect and hope for members of the profession...
...These junior doctors had been promised overtime pay for work in excess of 40 hours a week...
...And the British people, we were informed, were so satisfied with the NHS that no British politician of any party would ever dare tamper with it...
...One hospital actually had 20 unconscious patients on its admissions wait-list, and "sent a trained health visitor round to assess the priority of these cases presumably to see who was the most unconscious" (British Medical Journal, June 21, 1975...
...British general practitioners rarely have any medical instruments except for stethoscopes and blood pressure cuffs;they must send their patients to hospitals even for chest x-rays and simple blood tests...
...An open-heart operation is twice postponed for a Welsh woman, because there is no bed for her in the intensive care unit...
...Moreover, it is argued, since access to a doctor is available without charge, patients' serious ills can be caught early when they are more likely to be curable...
...They laid emphasis on those medical items which constituted pressing day-to-day demand, yielded their results quickly and with some certainty, made something of a public splash and conformed with the Britain's leaders soon learned that the only way to cope with the overwhelming demand for 'free" medical services was to impose a ceiling on total NHS expenditure...
...The Wilson Government denied that it planned to eliminate all private practice, but many consultants suspected that this was precisely what Prime Minister Wilson, Mrs...
...And Bevan's resignation signified that even his Labour colleagues were not prepared to give the NHS the overriding top priority he had told the nation it would get...
...is has evolved over the veats into a service that would in my ,tp]Mon lac all but totally unacceptable to tny American not depending on welfata for medical services.'' ' Let us turn now to a somewhat more detailed look at the National Health Servi ice, which is really two medical systems, linked but for all practical purposes separate...
...Then there was the period when everybody thought the public could have whatever they needed on the health service—it was just a question of governmental will...
...if he goes away on vacation, he is responsible for finding (and paying) a locum to replace him...
...The Alternative: An American Spectator April 1976 17 British Medical Journal, June 7, 1975...
...12, 1975): "The health service was launched on a fallacy...
...Again the answer is mainly negative...
...In 1971-72 the average part-time consultant earned 8,354 pounds, of which 2,755 pounds came from private practice, while the average full-time consultant earned 7,077 pounds (see Rudolf Klein, in New Society, Oct...
...The fact is that, by American standards, the NHS is a meager and spartan medical system many of whose economies would be regarded as inhuman brutality if applied to Americans...
...But the same progress has taken place in all Western countries, and British medical care would be much better today than in the 1940s even if the NHS had never been formed...
...the point is that other demands for public investment were rated high above that for the National Health Service: The reason seems to have been that successive Chancellors of the Exchequer, trying to keep down total expenditure on the Service by fixing a ceiling, threw the brunt of the saving upon those items where the consequences in the short period would be least noticeable and least likely to arouse protest...
...The Wilson government, of course, promptly denied it had any such intentions...
...12, 1942, this was to be "a 100 per cent service for 100 per cent of the population...
...But now even this is inadequate and the Wilson Government proclaims openly that it will have to adopt an even more stringent system of priorities...
...Given such verbiage from the leader of Britain's Conservative Party, there is no need to present the rosy vistas opened up by Labour politicians...
...When a patient becomes seriously ill and must enter a hospital, he normally loses contact with his GP and is transferred to the care of one of these consultants and his staff of junior doctors...
...Bevan believed that a large amount of sickness in Britain resulted from insufficient medical care...
...This sense of inferiority (combined with shared customs) allowed Europe, specifically England, a powerful influence over American life...
...This difference is so overwhelming that it reduces to insignificance the purely statistical cautions against such a comparison, for example the difference in definitions of health care in the two countries...
...The "progressive" ways of the English have been pointed to throughout this century by Americans intent on conducing America along the English path, and so successful have these `Progressive" Americans been that today most of our government expenditures go toward the support of institutions very similar to the social democratic institutions of England...
...But on the National Health they have to take whatever junior person they get assigned...
...A British family signs up with a local general practitioner, and then, theoretically, its members can see him as often as they want...
...There seems much good sense in the judgment expressed by Dr...
...A 66-year-old man suffers a stroke but is denied admission to the nearest hospital because no one over 65 is supposed to be treated there...
...It was becoming clear that the needs of the NHS were in direct competition with the defense budget, old age pensions, government investment in housing, and all the other multifarious demands on the limited resources of the British government...
...Already in the first months of the NHS operations Bevan had to make several public appeals against abuse of the service, for as Michael Foot has written, "...the demand was exceeding anything he had dreamt of...
...Conversely they tended to neglect those items where spending would bring only slowly-maturing results, where economy would not he quickly noticed and therefore would tte less likely to arouse public opposition...
...Governments followed the line of least resistance...
...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...
...One system consists of family doctors who practice solo or in small groups...
...In 1974 unionized maintenance workers, nurses, and other non-physicians attempted to wipe out private practice in some hospitals...
...Man does not live by bread alone, however, and the British Government has had to accept and cope with the fact that many doctors want to live in the most pleasant parts of the country—for example, in London or its suburbs—even if that means accepting the economic penalty of a smaller income from a shorter list...
...These conflicts came to a head in the spring of 1951, when Bevan resigned from...
...For the background against which to judge these and other current expressions of dissatisfaction, we must go back to the origins of the National Health Service and trace, even if only briefly, its development over the past three decades...
...The result of this system of awards is that some consultants get very high incomes, for those who get the very highest awards are also likely to have the most lucrative private practices...
...He added to the rhetoric: "The discoveries of healing science must be the inheritance of all: that is clear...
...And Britain is much richer now than it was in 1945 and 1948 so it has more doctors, both general practitioners and specialists, than it had when the NHS started...
...Dermot B. O'Brien, an Irish physician from Dublin Medical School who has worked in both the United States and Britain, and who wrote in the New England Journal of Medicine (May 8, 1975): "...the British people—whether as a result of different life philosophy or generally lower level of affluence—have a much lower level of expectation from medical intervention in general...
...As the British economists John and Sylvia Jewkes pointed out over twelve years ago in their excellent book Value for Money in Medicine: "What happened under these conditions was what was likely to happen...
...Here, for example, are the numbers of consultants in somekey specialties available to the almost fifty million people of England and Wales at the end of 1974...
...Full-time consultants, who receive only salaries, do not...
...But as it turned out, a bias against capital investment was built into the structure of the National Health Service, so that doctors continue to treat patients in nineteenth-century hospitals, and the number of hospital beds per capita has actually declined...
...the Labour Government after his cabinet colleagues decided to establish charges for eyeglasses and false teeth...
...And if that meant shortages and people being forced to wait for months or even years, so be it...
...This must come down to the decision that some shall be helped at the cost of others being permitted to die before they need to...
...In effect, Dr...
...When the first rush was over, the demand would even out...
...Mr...
...Suffice it to note that GPs have successfully retained their right to see private patients, who pay directly for consultations, unlike NHS patients...
...Most fundamentally he did not understand that if patients need not pay directly for medical care, they will resort to it for the trivial indisposition as well as for the serious illness, and there is no end to the demands of those an American physician has called "the worried well...
...To the consultants, of course, this looked like unilateral renunciation of the historic compromise by which Bevan had bought the consultants' agreement to participate in the NHS in 1948...
...What was worse, the political and economic pressures on the NHS led to budgetary decisions by both Labour and Conservative Governments which, over the long run, only aggravated the shortages and deficiencies of British medical care...
...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...
...Of the hundreds tested in the first six months these examinations were given, only about one-third passed...
...The junior doctors retaliated in many hospitals by closing down emergency rooms after 5:00 p.m., but in many such institutions consultants—despite their own grievances—went on duty to make some emergency medical service possible...
...Yet the myth persists—the myth that the NHS not only can but does offer a high and unvarying level of medical care to all members of the community...
...We shall be publishing this book with Doubleday later this year, and the essays within it are appearing in the Public Interest, Encounter, and other magazines as well as The Alter...
...He called Newham, a town near London, "an appallingly deprived area...
...In the Beveridge Report of 1942 an "ideal plan" was proposed, "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 it...
...16 The Alternative: An American Spectator April 1976 doctrine of equality...
...Obviously patients would pay neither general practitioners nor consultants if they did not believe that they were getting better medical care than they would have received as nonpaying NHS patients...
...All this helped provoke the consultants' slowdown in late 1975...
...In 1949 there were some 43 million people in England and Wales, and an average of 397,600 occupied NHS hospital beds...
...In Britain as in all other countries the sick now have the important advantages gained from progress in medical science since the mid-1940s...
...Those suspicions were heightened when a government memorandum was "leaked" to the medical press...
...That fallacy has been exposed...
...Simultaneously, however, the majority of British consultants do not get any bonuses and many of them are convinced that they have been unfairly denied extra compensation...
...In 1974, there were about 49 million people but only 420,942 available hospital beds...
...Britain had proved, we were told, that a socialized medical system could work, and work well...
...It did not take long, in any case, for the ogre of cost to make its appearance...
...Such estimates were bound to be guesswork, and Bevan said: "The true provision for a free health service must depend on the behavior of the public, and the only way to discover it must be to permit the public to behave...
...However anxious a Government might be to take a longer view, its resolve was likely to be weakened by the pressure of immediate demands...
...Instead there was the hardheaded realization that resources could nut be used if they were not available...
...As the British Medical journalcommented on Dec...
...A rational solution would be to end the effort to realize a completely socialized and "free" medical service and to permit the introduction of a much larger private sector to help share the cost...
...The Alternative: An American Spectator April 1976 19 The second rock is the fact that the successes of past, present, and future medical research all tend to make medical care more expensive, and will probably continue to do so...
...In fact, Britain's political leaders—both Labour and Conservative—soon learned that the only way to cope with the overwhelming demand for "free" medical services was to impose a ceiling on total NHS expenditure...
...Under the NHS, he reasoned, the sick would get well as soon as they were properly treated...
Vol. 9 • April 1976 • No. 7
