How Britain’s National Health Service works
A Canadian reporter, newly arrived with his young family, takes a hard look at the system that Britons no longer call “socialized medicine”
LESLIE F. HANNON
MACLEAN’S OVERSEAS EDITOR
FOR A DOZEN YEARS now the British have had what most Canadians would call “socialized medicine.” Millions literally don’t know what it is to worry about doctors’ or hospital bills. Their National Health Service gives them everything medical or dental that you could name, free at the time of purchase, or at ridiculously cheap rates.
But is that the whole story? Is the scheme truly the godsend and boon its advocates expected? Is it an intrusive bureaucratic bumble, lowering medical standards, as many North American doctors argue? Can a British doctor adequately care for 3,500 patients, as he must if he has the maximum permitted “list”? Does a patient have any choice of doctor — or a doctor a choice of patient? What happens in the hospital, and to the man who doesn’t know what’s wrong but is simply feeling lousy? And how does the country afford all this when, for instance, a prescription for the most expensive antibiotic costs the buyer, on the spot, just thirteen cents?
I arrived here with my wife and four small children two months ago and we’ve had some medical service since then. I’ve also spent the last four weeks putting these questions to just about everyone I’ve met. I deliberately sought out known opponents of the NHS, and just as deliberately called at the Ministry of Health to get the official line. I called on doctors in the British Medical Association’s granite tower, in rural
Essex, in grimy Manchester, in fashionable Mayfair.
The answer can be summed up with deceptive ease: It works fine. There is no possibility of any government’s throwing the scheme out, nor would the British doctors as a body kill the service, even if they could.
The NHS has faults — everybody here cheerfully admits that. Some of the faults are being tackled, others are pigeonholed. A few of them would be present even if the NHS had remained only a dream. The biggest fault I could see is that the method of payment to the doctor by the state is an open encouragement to the lazy or cynical doctor to make a good living with the minimum of work. As a matter of fact, the less time he spends with each patient, the more patients he can carry and the more money he collects. Yet fifty years of study by sincere and dedicated men has failed to produce a satisfactory alternative payment system. Another flaw is that, currently, a general practitioner may follow a case every inch of the way, up to the hospital door — but no farther. Through that door, the patient passes out of his control and becomes simply “next case” to a salaried specialist. Yet another fault is that new hospital construction in Britain is lagging far behind need.
But, balancing the faults, the NHS has brought Britain some great and even revolutionary advances. The development of the voluntary group practice is outstanding among them.
The Caversham Centre, in teeming Kentish Town, seems an unlikely place for a revolution. Its spruce-up paint job doesn’t conceal its origins as the end unit of a row of ugly four-story houses considered respectably middle-class when Victoria reigned. Thousands of other houses in London’s northern suburbs, taken over by working - class families since World War I, look exactly the same. Nevertheless, Caversham offers Canada — and the rest of the world — a striking example of the tremendous changes taking place in the practice of modern medicine.
In this inconvenient made-over building, four general practitioners work in harmonious partnership. They have quelled their competitive instincts, forsworn private practice and committed themselves to an ideal. Each doctor has his own list of patients under the National Health Service and the per-head fees he collects for them from the state go into the partnership funds. They all share and pay for the building, the services of a staff nurse, laboratory technician, receptionist, secretary and part-time accountant. Each day during surgery (consulting) hours, two doctors are on duty and, if a patient has no appointment, he can take his seat in the waiting room. Either doctor will see any temporary resident, or visitor, or accident victim. For vacations, weekends and night calls, the four doctors take each other’s appointments and any district emergency calls on a rota system. Over morning coffee they discuss their current cases and weigh new techniques and entertain a constant stream of visitors.
The Caversham group practice is not unique. Throughout the country today, half the GPs are working in partnerships of two, three, four and more. But group practices similar to the Caversham model number at most 200 and few are as well integrated and solidly established as is Caversham.
The ideal most of them are striving to attain is the dream of the comprehensive community free health centre, incorporating all medical and public-health services outside hospital, as pictured in the National Health Service Bill introduced in
1946 by Aneurin Bevan, then Minister of Health.
Since the NHS began its pioneering life in July 1948, not a single complete health centre of the kind that was projected has gone into operation. A few approach the goal — places like Woodberry Down in London, Sighthill in Edinburgh, Darbishire House in Manchester — but in each case certain services have remained in the hands of other local bodies, and special arrangements have been made to suit local personalities and local conditions. The three main stumbling blocks are, first, the unwillingness of most doctors to accept a straight salary from the state; second, a shortage of government funds for the capital outlay for the centres (across the country, they’d cost many millions of pounds) and, third, a natural reluctance among civil servants already administering certain health services to give up or change their jobs.
As things stand now, it’s generally accepted that the dream is on ice, and will remain there for at least a decade. Into the vacuum, then, has come the group-practice plan. And, as it grows from a sincere desire among young GPs to give the public the best possible family-doctor service and because it is not marred by the regimentation implied by the acceptance of wages, it is perhaps superior to the original dream. And, quite unheralded, it offers a revolutionary conception to other nations nervously approaching the brink of national health services. No doctor, however brilliant or dedicated, can offer single - handed the comprehensive care available from the groups.
My four children were all due for polio booster shots and, in our status as temporary residents, I took them along to the Caversham Centre. It seemed as good a way as any to open a personal acquaintanceship with the NHS.
The most common criticism in North America of the British service is that the doctor-patient relationship has deteriorated. Most of the lay visitors to the group-practice centres subtly turn their questions toward that quarter. Because the doctors get a capitation fee for all patients on their lists (it totals a little over six cents a week per patient) irrespective of whether an individual patient has cancer or a cold in the nose, irrespective of whether he calls once in five years or five times a week, do the doctors fall into an assemblyline technique? Do they scribble off a drug prescription every five minutes during the normal two hours of “surgery”? If complications appear even faintly possible, do doctors simply send the patient off to hospital where he becomes the responsibility of the consultant (specialist) branch of the NHS?
Since photographer Bert Hardy was present, the arrival of the Hannons at Caversham couldn’t be called typical. However, the centre’s staff had no prior warning of our arrival and an average Saturday morning crowd was in the waiting room. A group of small children played with blocks and puzzles; a young mother sat with a listless baby on her lap; a collarless elderly man stared with tired eyes out into the garden at the rear; a youth with ducktail haircut flicked over the sport pages of a day-old paper.
The receptionist, flustered by the arrival of the photographer, fluttered the patients’ registration cards and was relieved when Dr. Hugh Faulkner, the darkly handsome senior partner, led us up the narrow stairs into his surgery. Many a Canadian doctor would call the room dingy, but it brightened as Faulkner explained his instruments to the children. His easy manner won their confidence in a few seconds. Once, to oblige a friend, he demonstrated his CONTINUED ON PAGE 44
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Of course it isn’t really free — the estimated cost to the nation for 1959-60 is $2,300 million
bedside manner in soothing a migraine for tempestuous Sophia Loren.
While I filled out four temporary-resident cards, he took the children into the lab where the centre’s state-registered nurse, Marion Weiss, does the injections — and a lot of minor surgery. The hypodermic needle was of the ultra-modern spring-and-return type and the vaccine was injected before the children felt the needle sting. The few routine tears that followed were stifled by gloriously messy black lollipops. The whole small experience was quite unlike the regular calls the children had paid to their Canadian pediatrician — a brilliant young man as chilly and dignified as he was well qualified, in his efficient chrome-and-plastic office. He would have frowned on that black candy.
Some of the central facts about the NHS need to be stated: It is of course not free — the estimated cost for 195960 is £819 million ($2,300 million). This will be met by a direct contribution (for instance, men 18 and over pay 2/4d — 33 cents — a week, of which 5!/2d is paid by the employer) that will bring in £110 million; in small part by charges payable for drugs and for such things as elastic stockings and dentures, and in great part by the transfer of £563 million from general taxation revenues. In total, the cost of the NHS works out to roughly £16 ($45) a year for each man, woman and child in Great Britain. This means that Britain is spending about 3!/2 percent of her gross national income on health — about the sum she spends on education. That much said, it should be emphasized that full medical care under the NHS is the unqualified right of every Briton whether he has paid a penny or not.
There is no compulsion, and little regimentation. Everyone 16 and-over can choose his own doctor; a doctor can decline a patient. A patient can phone ahead for an appointment and get it; he can call the doctor to his home if necessary. A patient can call in a doctor who practises entirely outside the NHS or he can become the private patient of a doctor who practises both within and without the service. Machinery is available for patients to register complaints against doctors with the Ministry of Health (complaints average one mild one a day, one serious one a week; if a complaint is found to be justifiable, action is taken by the British Medical Association's disciplinary bodies). Doctors practise in complete clinical and professional freedom, but cannot buy or sell their practices and can establish themselves in an area only after consultation with the governing authority.
Seeking a more exact answer to the controversy over doctor-patient relationships, I went into the clanging heart of industrial Lancashire. A couple of miles from the grimy centre of Manchester stands the prosaic clump of buildings known as Darbishire House. Once it housed elderly and impecunious gentlewomen under the will of a local philanthropist. It’s a long time, though, since gentlewomen lived around Upper Brook
Street. It’s a crowded laboring and artisan area now. where the average income is below the national industrial average of forty dollars a week. In 1954, with help from the Rockefeller Foundation and the Nuffield Trust, the University of Manchester opened Darbishire House as a health centre close to the NHS dream and with special provision for introducing undergraduate GPs to a new concept of their life’s work.
As at London’s Caversham Centre, four doctors make Darbishire the sole centre of their practice. They are paid tutorial fees by the university, allowing them to cut down their lists to 2,750 patients (from a theoretical individual maximum of 3,500). All the university's medical undergraduates spend two weeks of their final year at Darbishire, sitting
in on a resident GP’s consultations, accompanying him on his house calls and participating in the bull sessions each morning over the pale mud that the English call coffee.
The sparkplug of Darbishire House is Dr. Robert Logan, a highly charged and highly qualified medical scholar whose official title is Reader in Social and Preventive Medicine at the University of Manchester. Logan, half-Australian and half-Scottish, has a burning zeal that is as infectious as it is wearying. His many published papers reveal a conception of the job of a GP that, right or wrong, is a generation ahead of the general thinking in corresponding quarters in North America. When I questioned him about possible deterioration in the doctor-patient relationship, he pushed an impatient hand through his blond hair and said: "Heavens, you're asking me to put my thinking back at least five years.” Logan has spent a total of two years in Canada, and many months in the U. S. He was approached to superintend and integrate GP participation in the British Columbia provincial health scheme hut refused. He won’t say why, but he does say that "Vancouver is just another Inverness."
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The inference to be taken is that the prevailing attitude, in both B. C. government and medical circles, is approximately medieval. Logan and Darbishire House attract many official visitors from Canada and the U. S. He tells them all, and firmly believes, that the North Americans’ fear of a deterioration of the doctor-patient relationship under a health service like Britain’s is rather like fretting about the passing of sail. “Surely,” he says, “it’s obvious that the role of the family doctor has changed dramatically since the war — whether there's a health service or not. No one man can pretend to keep up with all the tremendous advances in knowledge. Even assessing the values of every 'drug of the month' in the Reader’s Digest is beyond the GP who has perhaps three thousand patients.”
Logan is foremost a teacher: "The GP is, or should be, the integrator of the health service — a specialist in family health care. To the patient, the hospitalconsultant and local-authority services are largely peripheral: they exist to support the general practitioner to provide comprehensive medical care."
Finding himself astride his academic hobbyhorse, Logan leaps off nimbly: “But you Americans are fretting about what happens when a patient comes in and says, ‘Doc, I feel lousy.’ Right?” Well, at Darbishire they don’t even wait for that. For instance every patient aged 60 or over who is on the centre’s lists is called in for a general checkup each year, whether he asks for it or not. Dr. H. W. Ashworth, one of Darbishire’s GPs, last year completed a voluntary five-month study of all his patients in the 45-54 age group. He found seventy patients with symptoms not previously recognized — ten of them of serious significance.
One of the most portentous changes taking place in British medicine occurs long before a fledgling doctor writes his first prescription, in the university medical school, in fieldwork sessions at such centres as Darbishire House, the undergraduate is being taught that the aura of mystery that once surrounded the profession has vanished. The doctor, once a figure of awe, can no longer get "half his pay” in quiet enjoyment of the automatic deference his profession commanded only twenty years ago. An educated public has seen the lay scientist move into medical research with the same success
achieved in, say, the atomic field. The wonder drugs, the antibiotics that conquer or control a dozen once-dreaded diseases, have in the main been developed by men to whom the Oath of Hippocrates is nothing but.an interesting bit of historical rigmarole. So the doctor tends to be viewed more and more as a technician who must simply decide which shot or pill or mechanical repair to order.
Even more than the now quiescent squabble over rates of remuneration, the changing status of the doctor is at the root of what problems exist in the NHS. A young doctor, in one of the committee rooms of the huge stone headquarters of the British Medical Association, recently stated in all seriousness: "The main trouble with medicine in Britain today is that no one stands up when the doctor comes into the room." Robert Logan summed up the change most vividly for me. “Remember the days not so long ago when the doctor came to the house for father’s pneumonia? Dad was obviously deathly sick. The house was in semi-darkness, the kids hushed and scared, the neighbors gathering at the gate with strained faces. The doctor’s black car outside was probably the only one in the street. Inside, he alone was calm and purposeful. When the crisis came, the doctor was at his patient’s bedside in a personal fight against the spectre of death. In the morning, the fever had broken, sunlight came back into the house, the doctor had won his battle and the housewife, with thankful tears in her eyes, kissed his hands. Easy for the doctor to appear almost godlike. But today? Everybody who can read a newspaper knows that a handful of pills and a few days in bed working out the football pools will probably do the trick.”
Acceptance of the change in status is, although grudgingly in some quarters, practically universal, and the best of the younger medical brains have been working for ten years now not to fight against the tide but to block out a modern, practical and considerably improved professional life for the family doctor.
Dr. Bruce Cardew. the brilliant general secretary of the Medical Practitioners’ Union (established in 1914). says, “As mechanistic values were increasingly accepted in society, so patients began to see their own bodies in mechanical terms. The family doctor’s job was to discover which part of the machine was
faulty and by surgery or medicine put it right. If he failed, then there were the super-mechanics at the hospital who would find the answers. The patient no longer needs a father figure who will dispense placebos and wise advice. He needs an expert and intelligent friend through whom he may come to understand his own troubles. The new role is not an easy one for the family doctor. It demands an ability to listen to and to understand problems as the patient sees them—and a willingness to treat patients as equals."
The term "socialized medicine” annoys the Ministry of Health, the British Medical Association, and individual doctors almost equally. In discussing the NHS with at least a hundred people from all classes. I never heard the term used. It puzzles Britons that in Canada and the United States ignorance of the NHS is so widespread that opponents of state medicine are still able to suggest the British scheme is in some way politically oriented. "Do you speak of socialized education, socialized police forces, socialized atomic-power stations?” one Englishman asked. No one political party in Britain seriously claims individual credit for the present NHS: all parties have played a part in its evolution, are committed to it. and accept it wholeheartedly. Although some sections of the BMA once darkly talked of a strike, it was mainly over money, not principle.
Although the present comprehensive health service has been in operation only twelve years, Britain has in fact had a national health service for forty-seven years — the historic panel system. In 1913. David Lloyd George, then Chancellor of the Exchequer, gathered up the various private group plans started by trade unions and large employers of labor over the previous twenty-five years and introduced the National Health Insurance Scheme. This provided a GP and drug service to mediumand lowerpaid workers. Their dependents were not covered. The BMA was actively hostile to that scheme, almost as the Canadian and American Medical Associations are hostile today, nearly fifty years later, to the incipient national schemes in North America. The British doctors as individuals, however, accepted the panel scheme in 1913 and made it work satisfactorily. For the first time, all doctors had a measure of financial security.
By 1928 the BMA itself was working toward a fully comprehensive health scheme, and in 1933 published , a study called Essentials of a National Health Service. The obvious approach of war in 1938 brought the country's scattered health services into tighter unity in the Emergency Medical Service. During the war, continuous research, often on BMA initiative, resulted in recommendations for a comprehensive national medical service. These in turn were incorporated in the Beveridge Report, which was accepted by Winston Churchill's coalition government of the day. Labor came to power in 1945 under Clement Attlee and, the next year, introduced the National Health Service Bill. I'wo more years passed before the service was inaugurated. It has been both modified and expanded by the successive Conservative governments of Churchill, Eden and Macmillan.
The figures and tables and graphs that chart the past and present of the NHS would bailie anyone but a mathematician. But the most recent tabulation, in the 346-page report of the Royal Commission on Doctors’ and Dentists' Remuneration, at least reveals to the layman that, by British standards, the doctors are doing very well indeed under
the NHS. This report, the culmination of the latest series of wrangles between the doctors and the government over money, has been cheerfully accepted by both sides and its recommendations go into effect some time late this fall. It shows that the NHS doctors as a group swamp all other professional men in earning power at the age of 50 — the theoretical peak. Consultants — that is, specialists working through the hospitals — top the graph with an average £3,400 at 50; general practitioners average £2,400. In the other professions, lawyers average
£2,200 at 50; professors, £1,900; engineers, £ 1,400; architects, £ 1,250. The Manchester Guardian slyly contrasted the quiet reception the report received from the profession with the emotional dispute over pay that led to the appointment of the commission three years earlier.
Most of the disputes that remain between the doctors and their employer (to use another term not favored by the profession) lie in the field of providing the public with an even better health service. Progressive GPs want the maxi-
mum list of patients per doctor eventually cut to 2,500 from the current 3,500, without loss of income, to enable them to spend more time with each patient— or rather, more time with cases that might repay more reflective study — and to give them more opportunity to keep up with the constantly changing medical scene. The national list average is currently only 2,270, though of course this figure represents the United Kingdom as a whole, and includes such diverse regions as Birmingham and the Outer Hebrides.
The critical observer soon becomes aware, however, that, with money problems settled for the time being, the doctors as a profession could be pushing much harder for major improvements in the service. They could, for instance, be hammering the government for more funds to build hospitals. Only one general hospital has been opened in Britain since the war, although several hospitals have added wings. The government pleads poverty at a time when general prosperity is the first and major impression the overseas visitor receives in Britain. Huge buildings, some of them government offices, are rising all over London, and even 10 Downing Street is getting a £500,000 facelift. The Macmillan government is spending only £30 million a year on hospital construction; the Labor party is committed (if elected) to spending £50 million a year; and the Medical Practitioners’ Union (an affiliate of the Trades Union Congress) is pressing for £75 million a year. Even a brief tour of Britain’s crowded, antiquated hospitals should convince anyone that only an all-out building drive would bring the accommodation up to modern standards.
What does the man in the street think about the NHS? For several weeks I raised this question relentlessly with waitresses, real-estate men, barmen, whitecollar workers, bus conductors, housewives, farmers, taxi drivers, shop clerks, retired army officers and one busy baron who writes chamber music on the side. The answers were overwhelmingly favorable: “Ay, they’re doin’ a grand job for us folk,” said a middle-aged porter while rolling a cigarette on Manchester’s Victoria Station. His wife died eighteen months ago after a long illness, and his married daughter had had a difficult time with her first child. It would be tedious to print all the variations on this theme. Two criticisms were voiced several times, usually as riders to general approval of the scheme. The first, and more frequent, was that the doctors were too busy to give all the time that the patient felt his case required. To anyone who said this, I put a further question: “Do you think you would have been better looked after in the long run if you’d been paying the doctor’s bill straight from your pocket?” Most said “no” after reflection, but many of them still seemed to feel they had at times been hurried through a most important occasion. A taxi driver in Maidenhead, thirty years of age, was vehement about his preference for the private-pay system. Yet, since he was a working-class boy of eighteen when the NHS began, it’s unlikely he’d had any personal experience of paying his own doctor.
In my haphazard poll, I found only two people who shunned the NHS. In the country as a whole 97 percent of the population are registered with the service. Six hundred doctors have stayed outside the scheme (in the NHS, at last official count: 23,080 GPs, 7,633 specialists, and nearly all dentists and chemists).
One holdout was the editor and owner of a prosperous trade journal. Sitting over a lager in the dining car of the Comet express from the Midlands, he wagged a gentle finger at me: “When I’m sick, I want my doctor to come at once and to devote his whole mind to my illness. If I go into hospital, I want to be sure that the best man in the business wields the knife. And I’m prepared to pay for it.” My other holdout was a London clubman: “I wouldn’t be found dead at the panel doctor's, old chap."
How valid are these criticisms of the NHS? What about the assembly line? At
Darbishire House, the GPs handle a daily average of thirty patients each during their two two-hour “surgery” stints — that is, a new patient every eight minutes. They also average eight house calls a day. Telephone calls average thirteen a day in office hours. What about the GP as a simple signpost to the hospital? The four Darbishire GPs vary in their referral rates to hospital outpatient clinics from 145 referrals per 1,000 patients to 72. Their hospital inpatient rates vary from 63 per 1,000 patients to 47. What happens at the hospitals? In most cases, a patient referred to hospital is examined by the staff doctor on duty and, if surgery is necessary, operated on by the surgeon specialist in the appropriate category who is on duty that day. Many National Health Service GPs, though, fully aware of hospital duty rosters, can arrange for their patient to be operated on by a certain admired surgeon simply b\ admitting the patient to hospital on the right day. All emergency (or “hot”) surgery is naturally performed immediately, whether the patient is a normal NHS referral or the titled patient of Harley Street’s most famous private consultant. An NHS patient needing “cold” surgery — say the repair of an old rupture — might have to wait months for a hospital bed; the private patient is likely to be admitted at his pleasure, since most participating hospitals retain a small number of beds for private patients.
“A new sense of vocation”
For a Canadian reporter, conditioned by articles in the Canadian and U. S. daily press about seething troubles in Britain’s health scheme, the most frustrating task is trying to root out these troubles and get them down on paper. Even the Fellowship for Freedom in Medicine — the watchdog group set up in 1948 by the royal physician Lord Horder — has no burning quarrel with the NHS today.
More than three years ago, Dr. J. Leslie MacCallum, a leading Fellowship member, told an American audience: "A new sense of vocation in the profession has grown up which may replace the sense of vocation which we feared, or many of us feared, was being lost or stultified by a government-run medical scheme ... I find that the family doctor can call on so many different services that his power to help his patient is infinitely increased.” The forty-one-yearold MacCallum, who practises in a twoman partnership in London’s cosmopolitan Bloomsbury, believes today that not one percent of British doctors would turn the clock back to the days when medicine was free of all state subsidies. He would prefer the GP to retain control of his patient after the patient’s admission to hospital rather than passing him completely into the hands of the hospital specialist — a plea often made by GPs who are otherwise wholehearted in their support of the NHS. He feels that doctors have lost “an abstract something” simply through their association with the state scheme — but not necessarily anything that results in worse care for their patients. The Fellowship’s earlier fears that bureaucrats would stick their noses into the doctor’s surgery — Lord Horder liked to refer to the “triumph of the machine” — have been allayed over the years.
MacCallum's location in Bloomsbury brings him, each summer, a constant stream of tourists, many of whom are delighted at the prospect of getting old ills cured for free. He cannot (and would not) refuse treatment under the NHS to anyone who falls sick or is injured, but
he bleeds internally at the thought of the British taxpayer's being mulcted by comparatively well-to-do visitors. Australians and Americans are the worst offenders, he finds. One Australian, in England for three weeks this summer, cheekily demanded a medical checkup, a set of dentures and a pair of spectacles. (Under the NHS, false teeth and glasses are supplied at less than half cost.) MacCallum sought a ruling from the Ministry of Health and was told that a temporary resident did not qualify for the treatment sought. Visitors are expected
to pay as private patients. They may be expected to pay, but thousands don't. The act is almost impossible to police — if a Canadian tourist complains of a sudden bellyache and is found to have a veteran ulcer, it's a lot easier, probably a lot cheaper, and certainly more humane to fix the thing up than to argue the matter.
Among the many changes made in the British way of life by “free” medicine can be added a new luxury — the Harley Street indulgence. It works this way. A registered NHS patient, perhaps in his
middle years, finds himself wondering if his NHS doctor is really up on the latest medical discoveries. Finally, on his own initiative, he gets an appointment for a checkup with one of London’s eminent and expensive private specialists. Pamela Clarkson, wife of a newspaper editor, gave herself this treat recently. She bought a hat for the occasion. I asked if she learned anything that her NHS doctor hadn't told her.
“Not a damn thing," she said. “And it cost £20. But I enjoyed it thoroughly.” ★