Printed for Today and Tomorrow Publications probably 1960

Step by step the ground is being prepared for a vital breach in the National Health Service. It is a breach which must be resisted, resisted because it is an attempt to create a privileged position for a few.

The issue is whether the private patients of general practitioners shall be enabled to receive their drugs free on the health service.

Agreement has been reached between the Ministry of Health and the Private Practice Committee of the British Medical Association on the administrative procedures which would be a prerequisite, but although there is thus agreement between the Government and a section of the doctors this change in the service cannot occur without the passage of amending legislation. The matter, therefore, will have to be brought before Parliament.

The Socialist Medical Association believes that this measure is a grave threat to the National Health Service, and is therefore the concern of the whole people and not only of interest to the 5% or fewer who now have private doctors.

The Gillebaud Committee, which at the request of the Conservative Government investigated the National Health Service, pointed out in discussing the relationship between doctor and patient that this had greatly improved, and it attributed this change to the removal of the financial barrier. With the advent of the service it was for the first time possible to offer to the whole population the benefit of recent medical advances without favour and without feat that the patient could not afford them.

For the vast majority of family doctors the National Health Service is the main source of their livelihood, though some undertake a little private practice. Well over 95% of the population are on their National Health lists.

But doctors who go into the hospital service enter it either as whole-time specialists, working entirely in the service, or as part-timers, that is, they agree to give a stipulated time to the service but retain the right to unrestricted private practice. Although nursing homes have largely disappeared, much private consulting work at these specialists’ own premises and work in the private wards of public hospitals is an important part of the part-time specialist’s income.

And it is within the hospital service that experience of private practice has been gained. There it is clearly understood that patients using pay-beds will meet the full cost. This ensures them privacy and priority of treatment.

The principle is that pay-beds are outside the National Health Service and therefore cost it nothing. It would be quite a different matter if consultants were to accept private fees to enable their patients to get priority within the National Health Service. This would be very properly condemned as being harmful to the service.

At present there is such a financial and professional bias against those specialists who are working whole-time in the service that there is an increasing change-over to part-time status—and a corresponding drive to expand facilities for private patients in the hospitals.

If private patients received their drugs free on a State prescription the national character of the service would be further weakened. Although the negotiations for this change have been carried out on behalf of medical practitioners, there has not been any widespread public demand for it. The S.M.A. is confident, despite the earlier approval of the Representative Body of the B.M.A. to it, that there is a growing awareness among doctors of its implications, and that if a new approach were made the vast majority would not be in favour.

Its advocates argue that in supplying free drugs to private patients we are merely righting a wrong, that it is an injustice to deprive anyone of the right to free drugs since all contribute to the National Health Service by insurance contributions, rates and taxes, and should there­fore be entitled to any or all of the benefits provided.

Should we counter these arguments by objecting that it will encourage more private practice, the further argument is advanced that that, in itself, is desirable since it would relieve the burden on the National Health Service!

For the doctor the incentive would be financial. At present doctors do not encourage their patients to become private patients because they are aware that this would involve the patient in having to pay for drugs. If this obstacle disappears doctors would stand to gain directly for every patient they could induce to transfer to private status.

They would, however, be gaining at the expense of their colleagues, since fees received from private patients are deducted from the common pool from which all general practitioners are paid.

Doctors who have reached the maximum number of patients allowed on National Health lists would be able to increase their commitments further by taking on additional private patients.

A patient paying a private fee will expect to get preferential treatment with regard to waiting time and visits to his home. He may also expect to get more sympathy regarding the prescribing of expensive drugs.

Although the quality of. medical treatment would not be different, there would be a tendency to accord certain privileges to private patients which could only be granted at the expense of the non-paying patients, since the doctor’s total available time is circumscribed.

The belief would thus be encouraged that by paying a fee, better medical services could be obtained. The demand for expensive drugs, which is more likely to arise from fee-paying patients, would be difficult to resist since refusal would involve the danger of an immediate loss of fees to the doctor.

One recalls that in March, 1950, Dr. Charles Hill said in the House of Commons: “One of the causes of the increased cost of the pharmaceutical services was the pressure of the middle-classes for the proprietary medicines to which they were accustomed”.

Thus, far from relieving the burden on the National Health Service, the probability is that the drug bill would show an enormous increase.

In the hospital service the pay-beds are held to be outside the health service, and those who use them have to pay the full cost. Similarly in the medical service those who elect to be private patients must be held to be outside the health service and to pay the full cost of treatment and drugs.

There is an analogy in the education services. We have a national system and a totally separate private system of so-called “public” schools. To argue that private patients should have free drugs is tantamount to urging that as parents who send children to private schools are thereby helping to reduce the national cost of education, free books, equipment, school uniform and playing fields should therefore be provided by the State in those schools.

Since the inception of the National Health Service there has been a determined effort by a small minority to extend the privileges of a few at the expense of the majority.

Nobody dares to attack the Health Service directly, but changes have occurred which are advantageous to private work, and tend to take place within the service and at the expense of it.

But changes which could help forward a fuller implementation of the Act—closer co-operation among general practitioners leading to group practice in health centres, the merging of the former voluntary hospitals and local authority hospitals into a national system with equal pro­fessional status and standards of service, and the abolition of every type of privilege within the service—are being blocked by measures which exacerbate the present divisions within the service and create interests which will resist further change.

If the proposed changes go through we shall be left with a facade masquerading as a National Health Service, behind which there will in fact be two services—one, a State service for those who cannot afford to buy the best, and another, where the best will be partly paid for by the private patient and partly subsidised by the State.

Drugs for private patients from State funds means not justice for a minority but injustice for the majority of patients and doctors alike.

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