Joan Sohn-Rethel & John Carrier
Socialist Medical Association 16/04/71
I. Introduction
This pamphlet opens the issue of private medical practice so that the discussions about the future of the National Health Service as a valuable social institution not operating in the competitive market can be placed in a political and not merely a social context. The coexistence of two systems of medical care will inevitably lead to competition for scarce resources, the deciding factor being economic power and the distinction between consumers able and unable to buy. Private medical care thrives within this system and does so most successfully in a period of inadequate public spending.
The aim of the National Health Service was of the highest order. Indeed the N.H.S. Act 1946 declares in Part 1, Section 1, Sub-section i:
“It shall be the duty of the Minister of Health to promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness.”
These words suggest an even distribution of the service, regardless of wealth or class distinction, but in subsection ii. appears the loop-hole to the principle of a free comprehensive service:
The services so provided shall be free of charge except where any provision of this Act expressly provides for the making and recovery of charges.
Thus the seed was set for the existence of a private paying sector. At that time Aneurin Bevan, in order to gain the agreement of the medical profession, felt compelled to sacrifice certain of the basic principles which were originally built into the socialist conception of the health service. He permitted consultants to work only part-time for the N.H.S. and in the remainder of their time they could treat paying patients, sometimes in special pay-beds in N.H.S. hospitals. He allowed general practitioners to remain “private contractors” instead of “salaried servants”, and as a result made almost impossible their organisation in health centres.
In the first enthusiasm for the N.H.S. the serious implications of these concessions were not fully appreciated, but over the years they have snow-balled into a threat to the very structure of the service which set out to meet a common need for society as a whole and not merely for individual needs, dependent upon ability to pay or to persuade. The functions which serve the whole population such as preventive medicine, health education and occupational health services have been sorely neglected in the past, and the present policy of cuts in government expenditure will delay progress even more, whilst encouraging the growth of the private sector.
Condemnation of private practice within the N.H.S. is nothing new. But some of the medical profession, though generally devoted to the care of their patients, have been reluctant to relinquish their most cherished stronghold, the chance to treat the better-off in a privileged manner for extra profit to themselves. They have defended this principle sometimes even by threat of militant action. Thus, even with a Labour Government and Ministers sympathetic to socialist ideas, private practice continued to flourish. The doctors’ threat to emigrate, not always only to better conditions of work, but more often to obtain higher incomes, served as a brake on any radical attempt to change the status quo.
But conditions in medicine and prevention and treatment of disease have not remained the same. Revolutionary changes have occurred as in other spheres of twentieth century life. It may appear more spectacular to witness the space programmes and lunar landings than the medical progress of the century. Indeed, this is so carefully concealed by out-of-date hospital buildings, archaic surgeries and old-fashioned thinking that it is not surprising that the amazing progress is not fully appreciated. And it is not only that this progress has taken place and is rapidly continuing to do so but that it adds a different dimension to medical possibilities, a dimension which makes the old system not merely cumbersome but a positive menace to modern advances.
Present day problems of health care are not unique to this country. The enormous growth of medical and scientific discoveries and the conquest of many of the major killing diseases of fifty years ago, such as tuberculosis, poliomyelitis, diphtheria, all these dramatic changes have occurred in other developed countries as well as in Great Britain. But the eyes of most of the capitalist world have turned to this country as the first which attempted a socialist solution to its medical problems. Critics from abroad have been only too ready to exaggerate and condemn our faults to prove to themselves that out socialist solution will not work. Almont Lindsey, himself an American admirer of our National Health Service, wrote in 1962 “Such an elaborate and daring attack in July 1948 upon an urgent national problem aroused the interest of the world, and numerous laymen and medical experts descended on England for a quick look at this remarkable experiment . . . Dire predictions were voiced about the future of British medicine and the health of the people . . . From the outset the climate of the United States was unfriendly towards this British venture.”
It should not only be the concern of the British people to produce a health service of unparalleled efficiency for themselves, but also to show the world how socialist planning can work even within a capitalist setting. But is it working at present? Is the problem greater than one of cost? Can it be that a cancer is eating into the structure which, if permitted to spread, will destroy the basis itself? These questions make it imperative that an analysis of the situation of private practice within the Health Service is undertaken. This will mean a brief survey of the historical development of the hospitals, professions and institutions; the effect of the system at present and the possibilities for the future.
We shall show that private practice within the N.H.S. means more than special treatment for the few whilst adding cash to the pockets of the doctors. It means a process of part-time consultants giving part-time loyalty to the National Health Service with no incentive to reduce their waiting lists; in fact, the incentive is to maintain them and drive more patients into the private channels. It means that the consultants are actually subsidised by the state in the form both of use of expensive equipment bought with public means, and of the service of fully salaried staff. Without these they could not treat their private patients and so augment their income. It means a mushrooming of insurance schemes which adds more to the pockets of the consultants and places more and more people who can pay at an advantage to those who cannot It means the impossibility of comprehensive planning and the inefficient use of manpower and equipment, always in short supply.
But at the same time, despite a two-tier system with particular advantages regarding waiting times and privacy to some, we shall show that not all the advantages are for those who pay. In fact, the money factor in health matters can produce strange anomalies which result finally in a less good health service all round, with only one beneficiary, the doctor, giving apparently a different service to the “paying patient.”
We believe the doctors, having chosen a profession whose object is to alleviate suffering, are basically eager to help rich and poor alike regardless of status, but that the conditions under which the part-time consultants are permitted to work are incompatible with fair play to all. We have set out to show that this need not be the case and that the time has come to change these conditions, and to build up a health service which can offer the best standard of care to all.
2. The growth of the hospitals
It is not easy to understand the role of the specialist consultants in the British Isles today without understanding the origins and development of the hospitals into their present position. Even after more than twenty years of the National Health Service the inequality in types of hospitals and in medical services throughout the different regions is astonishing. So, too, are the differences in the pay and status of the medical staff of these hospitals. Some are fully salaried servants of the State devoting all their working time to the care of patients within their hospitals. Others receive payment from the State for only part of their services and are permitted to spend as much of their remaining time as they wish caring for “private patients” who pay them for their services. In some hospitals all medical staff are paid for their full-time services whilst in others the full-time consultants work side by side with their part-time colleagues. How did such a complex system come into being? Has it been carefully planned or has it merely evolved in the course of historical events?
The First Hospitals
Hospitals as we understand them today did not exist until the eighteenth century and even then on a very small scale. Around 1700 a public awareness awakened of the necessity to look after the sick and throughout the eighteenth century charitable organisations abounded. Hospitals were built, first in London and later throughout the country, and run entirely from voluntary contributions. Samuel Johnson saw the danger of the voluntary system and in 1758 he wrote: “There is danger lest the blaze of charity which now bears with so much heat and splendour should die away for want of lasting fuel; lest fashion should suddenly withdraw her smile and inconstancy transfer die public attention to something which may appear more eligible because it will be new.” (Idler no 4)But his fears seem to have been unfounded, and by the end of the century the success of the voluntary hospital was assured.
It may appear unkind of us now to see in the voluntary service of that time something other than an altruistic desire to help the needy. The rich were rapidly becoming very rich and the poor, if possible, poorer and their misery increasing. A subscriber to a hospital was in a privileged position, gaining prestige in the eyes of his neighbours, employees and tradesmen. His subscription gained him the right to admit his sick servants and others, and incidentally remove risk of contagion from himself. If he or his kind fell ill they would be cared for at their homes, with all the luxury and skill that money could buy. If he subscribed as much as five guineas annually he could become a vice-president and have his name inscribed with the nobility. So the seeds were set for privilege by payment. In 1828 there is a record of a man who died outside the gates of St. Bartholomew’s Hospital because he had no sponsor to admit him. Poverty was still regarded more as a sin than a misfortune and charity was, for the rich, in the nature of an insurance for their own salvation in the hereafter.
Hospitals in the 19th Century
By the beginning of the nineteenth century, therefore, voluntary hospitals existed in most of the big towns. The smaller towns and sometimes even villages subscribed for the “cottage hospital”. The building of these hospitals occurred very sporadically and was often dictated by a generous donor or an enthusiastic cleric more than by the need of the population. Many of these hospitals continue right to the present day which helps to account for the extraordinary placing of hospitals throughout the country.
The medical staff of the voluntary hospitals were also imbued with the charitable spirit and “gave” their services in an entirely voluntary capacity while they earned their livelihood by treating the rich outside the walls of the institution. The history of the hospital in Winchester, which was the first voluntary hospital outside London, is significant in showing the attitude of the people of the time towards hospitals and the care of the sick. It was opened in 1736 as the result of the efforts of Dr. Alured Clarke, a Doctor of Divinity, and a pioneer of the voluntary hospital movement. He was criticised on the grounds that it would have been better to open a workhouse for the vagrant sick who might even be attracted to the town by the comforts of the Winchester Hospital. He replied that though the workhouse might dispense medicines this was never on the advice of a physician.
At the beginning the voluntary hospitals, supported by local charity and endowments, were served by local doctors. It was only the fact that some were appointed in a voluntary capacity to serve the hospital that a distinction arose between “consultant” and “general practitioner”. It was not until 1800 that the Royal College of Surgeons bestowed Fellowships for higher qualifications and this established the consultant as we now know him.
The voluntary hospitals continued to expand and became centres for research and teaching, and as time went on wealthy patients, seeking the best treatment, came to realise that what had originally been a paupers’ hospital could now offer more in amenities and skill than were available in their own homes or even in nursing homes. So by the beginning of the present century the contrast was fully developed between the sick who, by payment or patronage, could obtain treatment at a voluntary hospital and those who were reduced to the workhouse infirmary.
The voluntary hospitals usually treated short-term sickness only, and the chronic sick among the well-to-do were still often cared for at home. Meanwhile the authorities who had already found the necessity of building their workhouses for the destitute added infirmaries to these buildings. These were indeed for the second class citizen and were specifically built and run in such a way as to discourage any desire for admission. Only the most destitute and sick would enter those dreaded doors.
Thus we see that everywhere the voluntary hospitals which were those of the longest renown and the pride of the towns and neighbourhoods were always staffed by consultants or, in the case of the cottage hospitals, by the general practitioners who gave their services for no pay. However, the honorary appointments to these hospital posts were essential if they were to build up a reputation so that they could develop a remunerative private practice. They therefore had the dual advantage of, in the first place, the status and gratitude which came to them as voluntary workers dispensing their skills and attention to the sick, and secondly of the chance of earning a high income from the rich who flocked to them for treatment. (Later the N.H.S. allowed the consultants to keep this status and adequately paid them for their services. Paradoxically they were to be the greatest beneficiaries.)
Gradually at first, but at an increasing pace in the nineteenth century, the voluntary hospitals replaced the patients’ homes and the private nursing homes as the place of choice for treatment, and wards and rooms were set aside for the treatment of these paying or private patients. With the development of modern scientific medicine “the bedside manner” which had hitherto sufficed in the home gave way to new techniques and equipment and the additional services of all types of ancillary workers who increasingly staffed the hospitals — radiographers, chemists, biologists, pathologists, etc. These new professional workers had little direct access to the patients themselves. They were all fully salaried staff. Only the doctors remained in the position of the paternal benevolent figures with an almost god-like authority and in, their position as teachers of future generations of doctors helped to ensure that the myth was maintained.
Hospitals in the early 20th Century
By the turn of the century the voluntary hospitals were no longer able to cope with the growing demand for treatment. However, it was not until 1929 under the Local Government Act of that year that the workhouse infirmaries were removed from the Board of Guardians and became the responsibility of the Local Authorities. In addition to the workhouse infirmaries, municipal hospitals were built not only for the treatment of the destitute and chronic sick but also for acute cases of all kinds. Many of these municipal hospitals, staffed by full-time salaried doctors, gave excellent service but never gained the reputation of the voluntary hospitals, not only among patients but particularly within the medical profession itself. It was the ambition of many young doctors who aspired to reach specialist status to serve in the voluntary hospitals and to open a private consulting room in the locality, for those appointed to the municipal hospitals as full-time salaried doctors forfeited the right to treat private patients.
The hostility between the voluntary hospitals and the municipal hospitals and workhouse infirmaries was augmented even further by the fact that when patients from the voluntary hospitals became too ill to return home they were frequently candidates for admission to the other hospitals. The impression that only the “good” and “interesting” cases were admitted to the voluntary and teaching hospitals was a very real one.
Mental Hospitals
In this brief survey of the history of hospitals we have not yet mentioned the care of the mentally sick. The first mental hospital, Bethlehem, later known as “Bedlam,” had its origin in the religious orders and remained the only hospital for admission of “lunatics” until 1700. From then onwards the care of these patients, or more often merely their detention, was divided between the voluntary hospitals where very occasionally a few patients were admitted in a separate section of the hospital and the workhouse accommodation provided by the Poor Law.
The accommodation was so inadequate that during the eighteenth century privately owned madhouses were opened. Later in the century a few of the better run madhouses benefitted by medical inspection and management and some even by kindness, but both these improvements are likely to have been rare. Very few of these private madhouses survived the next century. An Act of 1808 recommended that asylums, as they had then come to be called, should be built and controlled by the county justices.
The need for “healthy airy sites” and “a pure water supply” and sufficient land to allow for outdoor occupations, as well as the proximity to the participating parishes dictated the situation of the asylums. However, many counties took no steps to implement this more progressive Act and only in 1845 was the provision of asylums by counties and principal boroughs made compulsory by another Act of Parliament. Then the need was, of course even greater. Many of the mental hospitals in use now were built following this Act.
Until the coming of the National Health Service the care of the mental patient was, with few exceptions, neglected even more than the care of the chronic sick and elderly. The doctors in mental hospitals were full-time salaried staff and their position was usually unenvied by the consultants in the voluntary hospitals. The Mental Treatment Act of 1930 for the first time made it possible for patients to be admitted voluntarily. This led to much greater awareness of bad conditions in mental hospitals and to demands for their improvement.
Hospitals 1939-1948
All these facts made up the picture of British hospitals in 1939 with one additional factor. The voluntary system during the nineteenth century had been able to pay its way mainly because so little equipment was necessary and so many diseases remained untreated. As modern medicine developed the voluntary contributions did not decrease but the expense of treating disease increased enormously Patients who had been previously left to die without treatment now required expensive services and hospital beds. At the beginning of the Second World War the whole system was nearing a state of collapse; too few beds, too few and badly paid nurses, too few ambulances; no planned health organisation. There were enormous waiting lists for in-patients. Out-patients were seen without appointments and waiting rooms were crammed. Conditions would be considered intolerable by present-day standards. Many of the hospitals were already completely outdated. Owing to lack of money few could be modernised and hardly any new ones were built. Charity, insurance clubs, hospital contribution schemes and local authority grants could not support one of the major sectors of the tottering health service of Britain.
At the outbreak of war the voluntary hospitals were very near bankruptcy. Clearly with such an inadequate service the country could not risk the enormous number of expected casualties from bombing and fighting, and a wartime Emergency Medical Service with large financial grants from Exchequer funds was established. At least fifty thousand beds were added to the hospital service and X-Ray and surgical equipment, ambulances and other facilities were enormously augmented. Unknowingly and in the expectation of crisis, the health service had taken a first step towards nationalisation and conditions were ripe for a national health service after the emergency ceased.
3. The general practitioners
At the beginning of this century it was quite impossible for poor people to pay the doctor and Friendly Societies, clubs and Medical Aid Societies were organised either publicly or privately, sometimes even by the doctors themselves. Membership payment averaged under four shillings a year, and entitled the member, but not his family (unless they also paid), to attend the doctor and receive medicine. Fortunately for the doctor prescriptions were not so costly as at present and many of the doctors dispensed their own medicines. Needless to say medical treatment was frequently inadequate, as also was the doctors’ pay, averaging about 10 ½ d per member attendance.
National Health Insurance Act 1911
As far back as 1909 Beatrice and Sidney Webb proposed a salaried medical service run by Local Authorities but the doctors were not interested. Discussions on methods of payment continued until 1911 when, with Lloyd George as Chancellor of the Exchequer, the National Insurance Act was introduced. This Act made provision for “insurance against loss of health and for the prevention and cure of sickness” for all manual workers and for non-manual workers earning no more than £150 a year. Each male worker paid 4d. and his employer 3d. per week and approximately 2d. was added from the State to pay for medical treatment and drugs and cash allowance during sickness and disability. “Ninepence for fourpence” was the telling phrase by which Lloyd George won the support of the workers for the plan.
Although the medical profession accepted the need for change the British Medical Association objected to the financial and administrative arrangements proposed, and organised massive opposition. Mass meetings of doctors took place and finally 27,000 doctors undertook not to accept service under the new scheme except on terms in accordance with the policy of the B.M.A. The doctors’ campaign continued throughout 1911 and 1912 with much violent and emotional language. Eventually most of the doctors’ requests were conceded and the Government raised its original offer of 6/- to 9/- per head per annum. This was still less than the B.M.A.’s demands but many of the doctors began to accept service under the Act and by January 1913 the B.M.A. was forced to release them from their undertaking and the National Insurance Act was put into force.
The doctors contracted with newly formed “insurance committees” (the forerunners of the present Executive Councils) whilst Approved Societies collected the contributions of insured persons and employees and were responsible for payment of cash benefits. The whole system was extremely cumbersome and complicated, due to the compromises necessarily made by Lloyd George to placate the doctors. From 1913 when the new Act was enforced until July 1948 when the National Health Service superseded it there were constant claims for increased payment and alteration of capitation fees.
It is true that the general practitioners were not normally well-paid members of the medical profession and for a reasonable living they were dependant upon private payments from uninsured patients. In districts where the middle class or rich lived the livelihood could be very good indeed. In slum areas it was, in fact, dismal. Since only the employed person was entitled to free medical service and drugs, his dependents, his wife, children and parents, had to pay for each item of service. When one recalls the poverty of the first half of the century it is clear that much of the population had minimal medical attention if any at all. The setting up of the school medical and infant welfare service were successful government attempts to rectify the omissions. These were run by the Local Authorities and the principal medical staff were full-time and salaried, precluded from private practice. And yet there were still large numbers of people quite uncovered by any medical security. It is depressing to remember the plight of many of the population particularly at the time of the slump and mass unemployment. There were cancer patients who had no medical help or drugs during the terminal stages of their illness and, of course, no money to buy even ordinary essential food quite apart from invalid diets. Many of the aged also had no medical care or attention. Needless to say hospitalisation at this time was impossible for the majority of such patients, and as we have seen, the Local Authority hospitals were so overcrowded and understaffed that the phrase “I’d rather die than go there” was commonly heard in all parts of the country. It is to the credit of many general practitioners that they did in fact attend some of the uninsured aged and sick free of charge or for minimal payment, but not all sufferers were so fortunate in their choice of doctor.
General Practice in the N.H.S.
It is against this background that the N.H.S. was planned. It was as clear then at it is today that only a fully salaried service for general practitioners could solve the problem. Thirty years ago the advantages of co-operation in a health centre instead of competition of doctor with doctor was obvious to socialists. But the medical profession and in particular general practitioners are notorious for their stand against changing what they perceive as the basic principles of administering medical care. In 1946 they threatened to withhold their services unless their demands were met and, as a result of their combined opposition, in April 1948, only three months before the Appointed Day, Aneurin Bevan was obliged to amend the Act to exclude a salaried service. The capitation fee, (the payment per patient on the doctor’s list) remained the basis of the general practitioners’ pay under the N.H.S. as it had been under the Act of Lloyd George.
The remuneration of general practitioners has remained a subject for discussion and bitter disagreement throughout the whole life of the N.H.S.; a discussion which proceeded from the Spens Report in 1946 to the Royal Commission on Doctors’ and Dentists’ Remuneration which reported in February 1950, to the Dankworth Adjudication in 1952; all changed the method of calculation of the general practitioners’ pay but not the basic method of payment, so that a salaried service was excluded.
History has shown that their refusal to become a salaried profession ultimately reduced their status as compared with the hospital doctors. In order to maintain their “independence as individual contractors” many general practitioners have worked in primitive conditions, often in a small room in their own home, conditions which justly earned their service in the 1950’s the title of “the cottage industry.”
Importance of General Practice
But the method of medical care in this country demands that the role of the general practitioner shall be maintained. We accept him as the doctor who should provide primary care to the patient in his surgery or at home and who should refer patients to hospital or consultants as the need arises. Studies of medical practices in other countries highlight the advantages of our system. But it can only remain the best method of medical care if conditions permit it to develop and expand with advancing knowledge. The present training of medical students emphasizes the use of laboratories and modern equipment in the investigation and treatment of patients, yet these are at present denied to the average general practitioner.
It is not the place here to describe work as it can be undertaken in health centres, but it is of interest to record that the Medical Planning Commission of the B.M.A. as far back as 1943 and thus before the N.H.S. described a centre for six to twelve practitioners in words which can hardly be bettered today. They advocated that general practitioners should have responsibility for preventive educational and curative work with a direct link with hospital specialist services both domicilary and institutional, and would embrace antenatal, postnatal, infant welfare and school medical services. The stumbling block was, of course the remuneration of the doctors. All such planning demands a fully salaried service without which it is bound to fail. The element of competitive rivalry is incompatible with health care, and where it exists it must reduce efficiency and frequently precludes the advance of progress. When modern and expensive methods are available the use of these scarce resources is often minimised owing to the terms of employment of the most expensive members of the team, the doctors.
With a salaried service and exclusive ion of private practice in the N.H.S. the role of the general practitioners working as a team in a health centre should be as highly specialised as the hospital consultants and their opportunity for advancement as attractive. The rivalry which has bedevilled the possibility of co-operation in the past and the inferiority which has been attached to general practice in the eyes, not only of the public, but of the medical profession itself would cease if the status of the full-time general practitioner in the health centre could assume its proper level.
4. The dentists
The position of dentistry is quite different from other medical services. Both before and after the N.H.S. the patient did not register with a particular dentist but was, and still is, able to approach any practising dentist and ask for treatment; the dentist likewise is free to accept him or refuse to do so. The patient may move from one dentist to another. A dentist who has previously treated a patient is not obliged to continue to treat him.
The growth of dentistry is of comparatively recent origin. Only as late as 1921 was a register of qualified dentists started. After that date no new unqualified dentist could set up practice, but many who were already practicing without qualifications were allowed to register. Prior to the N.H.S. dentistry was an unpopular profession with generally poor remuneration. In 1946 the Spens Report showed that over a quarter of the dentists at the highest earning ages of 35 to 55 earned less than £450 per annum and only 10% over £1600— even at that time a very low income for a profession. There were very few dentists in rural areas, and large parts of the country were without or seriously short of dentists. The demands of the working class usually consisted only of requests for extractions and sometimes for dentures. The state of teeth throughout the country was appalling. A dental survey at three Royal Ordnance Factories in 1942 revealed only 1% of the workers to be dentally fit. Of those under the age of 45, 34% had both upper and lower dentures, many imperfectly fitted, and over three quarters of all workers needed dental treatment. In 1946 a survey in Wolverhampton showed that one third of old men and women had inadequate teeth and one tenth were without any teeth whatever.
Dentists set up their practices privately and charged such fees as they thought fit. In middle class districts their standing and incomes were reasonable. In the existence of dire need, the promise working class areas, if they existed at all, their income was pitiful. Only a few of the Approved Societies included dentistry in their benefits and even then usually paid only part of the costs. Applications for acceptance of payments often had to be made prior to the start of the treatment.
The only free dental treatment by fully salaried dentists paid by the State was at the Infant Welfare Centres for expectant mothers and mothers of children up to the age of five and their infants, and in school clinics for children up to school leaving age. Even here shortage of dentists often prevented adequate treatment and even when dentistry was available it consisted too often of extractions. Statistics showed that for every hundred mothers treated 316 teeth were extracted and only 36 filled. Even with children there were twice as many extractions as fillings.
Dentistry in the N.H.S.
No wonder that by the Appointed Day, of free treatment, and the education of the public on the importance to health of good teeth ensured a positive bombardment of the existing dentists. The dentists themselves were divided into various organisations of which the British Dental Association was the strongest and finally the only one. Like the British Medical Association it led the way in reaction and advised its members not to serve in the new N.H.S. scheme. But, like the doctors, the dentists were soon aware of the advantages to themselves and served against the advice of their Association.
In the N.H.S. the dentists continued to be self-employed (except for those paid salaries by the local authorities and hospitals). They, like the doctors, registered with the Local Executive Councils. They were free, however, and still are, to take private patients. Unlike the doctors they are not paid for each patient on a list, indeed they have no lists. They are paid for each item of treatment at recognised rates, which have undergone changes throughout the years.
At the beginning of the N.H.S. the Spens Report had recommended a rate to be paid by the State calculated upon items of service, which they believed would average about £1920 per annum for a dentist working full-time on N.H.S. patients. But they had not calculated the public need for dental care nor the dentists’ ability to work longer hours and organise their practices better when so much money was to be earned. Soon many dentists were reported to be earning enormous sums of money, frequently exaggerated by newspaper reports. However, by January 1949 the Minister announced that the Government would retain one half of the gross earnings of any dentist above £400 per month. The pay by the state of the self-employed dentists was so good that the priority services for mothers and children suffered by the exodus of salaried dentists to the more lucrative roles. Dentists trying to supply the enormous backlog of dentures neglected the more conservative treatments. The public were even accused of demanding dentures unnecessarily. The improvement in health with better dental treatment is difficult to assess, but of interest was a dramatic drop in the incidence of cancer of the mouth from the 1950’s onwards.
Throughout the history of the health service dentistry has undergone many changes. First an enormous improvement in dental training and a great increase in students and dentists; second repeated changes in payment for items of service with attempts to encourage conservation of teeth by higher payment, and charges to N.H.S. patients towards treatment and dentures.
Private Practice in Dentistry
As with medicine, the mixture of private practice and N.H.S. practice has proved increasingly detrimental to the N.H.S. patient, with a growing tendency to the development of a two-tier system. If a dentist does not wish to undertake one of the less profitable treatments on the N.H.S. he can tell the patient that he cannot do so except by treating him as a private patient; in fact, he can give the impression that the N.H.S. will not pay for such and such a form of treatment or that they will only pay for an inferior method of doing it. He can suggest that under the N.H.S. the patient will wait longer for dentures or that the dentures will not be such good ones. Although many dentists do give excellent service to both paying patients and to N.H.S. patients, the confidence of the public is undermined and the impression is extending that N.H.S. treatment is inferior. Many people feel compelled to pay for treatment even when it is against their inclinations or when they can ill afford it; others must pay because they can find no dentist to treat them as N.H.S, patients.
The whole principle of the N.H.S. is at stake, more obviously in dentistry than in medicine. In this case the dentist is absolutely free to dictate to his patient what he will or will not do. If he wishes to charge his patient more for an item of treatment than the N.H.S. standard rate the patient has no redress. The patient is usually quite unable to tell whether information given to him is correct and he is obliged for his own or his family’s sake to accept the dentist’s suggestions. The shortage of dentists in some areas makes the situation worse. The increased dental charges by the Tory Government will intensify these mal-practices but now the dentists as well as the patients will suffer. The British Dental Association states “if the government is not forced to change its mind dental treatment in this country will step 20 to 30 years backwards . . . poor people simply will not be able to afford expensive work—they will choose drastic but cheaper solutions” (Guardian 31.10.70) Dentists are particularly concerned for the age groups 18 – 25 who, like all adults, will be expected to pay so much that they are likely to neglect their teeth at a time when conservation is most essential.
A planned salaried dental service where dentists at no expense to them; it should is essential for an adequate health service. Once again health centres are the solution to the problem where the dentists would serve side by side with the doctors with every chance of advancement, and with easy access to hospitals for patients requiring special forms of treatment. There is no room in a National Health Service for private contractors who make their own rules, whilst at the same time accepting state payment at their own convenience. The state is responsible for the training of dentists at no expense to them; it should also be responsible for the output of the dentists, so that a one-tier service — the best — is available for all.
5. The ophthalmic service
Prior to the N.H.S. the ophthalmic service consisted of three professional groups. The largest, the ophthalmic opticians, who tested sight, prescribed glasses and supplied them; the dispensing opticians who only supplied spectacles; and the smallest group, the ophthalmic medical practitioners, who were medically qualified and usually worked within the hospitals. The opticians learned their trade by apprenticeship, usually in retail shop premises. Not until 1958, when a Central Optical Council was set up, were standards of training and qualifications specified and a register of trained opticians started. Until the Appointed Day only mothers and children were allowed free eye-tests and spectacles, and all other people either had to pay for tests and spectacles or occasionally obtained a grant towards these from their Approved Society.
In 1948 the N.H.S. arranged with the Executive Councils to set up Ophthalmic Service Committees consisting of about sixteen members, seven of whom were of the ophthalmic profession, to supervise arrangements for testing sight and supplying glasses. Any practicing optician could enter the scheme and all but a negligible number made contracts with the Executive Councils. At that time no charge to the public was made. The Whitley Council negotiated fees to be paid to the optician (at first 25/-per pair of spectacles, 18/- for a sight test if glasses were not required, and 16/- if they were; the rates have frequently changed over the years). For the first test a general practitioner had to refer the patient to an optician on the assumption that a medical examination would detect any serious defects, but frequently the referral became routine. After the first spectacles were supplied the patient could go directly to the optician for further tests.
These arrangements were meant at first to be only temporary. It was planned that the ophthalmic service would become part of the developing hospital programme. However, the service initially proved so satisfactory from both the patients’ and the opticians’ standpoint that no change was suggested. The opticians all retained their freedom to work for the N.H.S. as well as continuing private work. They had negotiated for good payment for health service work on the grounds that free spectacles for all would greatly reduce their private earnings. As with the dental service, neither the profession nor the N.H.S. had any previous idea of the enormous demands from the public and, again, exaggerated stories of abuse were reported.
In 1951, partly in order to check these so-called abuses and more importantly to curtail the expense of the service, a charge of 10/- for lenses and the cost of the frame was imposed. Even before this charge the worst of the backlog had been almost satisfied and the demand had started to decrease. With the charges the decrease was much more rapid. In 1951 a social survey showed that 80% of people of age 45 – 65 used glasses and 90% of those older than 65. Nevertheless the opticians believed that the charges prevented many from applying for tests although the tests themselves were free to the public. By 1953 demand had again started to increase and has continued to do so despite increased charges.
Throughout, the opticians have benefitted greatly from the N.H.S. work combined with private practice. For they, like the dentists, were making the best of two worlds. The N.H.S. supplied a choice of forty frames (those in small demand were later discontinued), However, the sale of private frames with N.H.S. lenses was permitted and greatly increased the profit to the opticians. Good salesmanship and fashion trends lave placed the optician in the frontline of the market economy. Some have failed to display the best lines of N.H.S. frames and the profit from private frames has been large.
The imposition of charges has prevented many of the lower income groups applying for spectacles. For the most needy a refund of charges can be made but it has been found that the means test acts as a deterrent where it is most intended to help. The numbers of those needing spectacles who are deterred by charges cannot be estimated. There are probably many in the lower income group not eligible for exemptions but who still find the charges a serious drain on their small incomes. The removal of charges and the full-time employment of both dispensing and ophthalmic opticians to undertake only N.H.S. work is the only solution. Those who prefer private work should remain outside the Service. The public who want to pursue the fashion trend or to possess multiple spectacles can market outside the N.H.S. The chance of a career structure and superannuation which opticians do not at present enjoy should be offered to them and their places of work should be within the health centre and the hospital.
6. The pharmaceutical service
The subject of private practice within the pharmaceutical industry is of extreme complexity. Although we consider it outside the province of this study to discuss in any depth the nationalisation of the drug industry it must be remembered that the cost of drugs represents a large part of the N.H.S. expenditure. In 1950 10.5% of the total N.H.S. expenditure was for the purchase of drugs and this represented a greater sum than the total cost of the general practitioner service. The number of drugs and their uses constantly increases and it would be folly to underestimate their enormous value in the fight against disease. Every year more discoveries in this field make possible treatment and health for those hitherto doomed to suffering or death, and the use of countless hospital beds is avoided. So a large expenditure is to be expected, but what a poor solution it is to tax the sick themselves! Meanwhile there is no attempt whatever to curtail the profits of the drug industry here or to reduce the import of drugs from other countries. Nationalisation and rationalisation could save more than the prescription charges and avoid, not only the tax on the sick, but the risk of preventing them seeking medical advice because of their fear of the cost or of the dread of the means test.
Drugs were free to all on prescription at the beginning of the Health Service. When in 1952 charges were introduced it proved indeed the thin end of the wedge and the abandoning of the socialist principle that the sick should not pay, but that the service should be free at the time of need. At first the charge was for only 1/- for each prescription, then 1/- for each item on the prescription. In 1961 this was increased to 2/- per item, in 1967 to 2/6d, and in the 1970 “mini-budget” to 4/- with a possibility of a charge to come according to the expense of the drug.
But another aspect is that of the employment of the pharmacists themselves. In 1948, as with the doctors, dentists and opticians, pharmacists who wished to partake in N.H.S. work (and this included the great proportion of the 14,300 pharmacists then practicing) registered with the Executive Council. They dispensed doctors’ prescriptions and sent them in to the Executive Council who priced the drugs and paid the pharmacists. When prescription charges were imposed the Executive Council deducted the charges collected by the chemist. The National Pharmaceutical Union through the Whitley Council negotiated the payments.
It is as clear for the pharmaceutical service as elsewhere in the N.H.S. that enormous increases in efficiency and economy could have been made had the pharmacists working for the Health Service been fully salaried and therefore confined their work to Health Service requirements. The phenomenal amount of work which goes to pricing prescriptions and paying the pharmacists; (each item must be sent to the Executive Council and the pharmacist paid proportionally) the additional expense caused by each pharmacist buying appliances and ingredients; the vast amount of overhead expenses and the prevention of bulk buying in the best markets even in an unnationalised industry; these are obvious fields of extravagance. In 1968/69 there were 1515 persons employed full-time pricing prescriptions alone.
It is, of course, the doctor who prescribes the drug and with his plea for freedom of action he supplies the drug of his choice, whereas there is frequently an equivalent drug of the same composition at a cheaper price. Within the hospital service where the pharmacist is salaried and on the spot he can consult on such points with medical staff (although we must admit that this consultation does not always succeed). Working in retail premises in the chemist shop there is no such opportunity for consultation with the general practitioner. The medical profession is open to enormous pressure of the drug firms’ advertisements. Indeed these meet with such success that the drug firms can offer larger salaries and perks than the N.H.S. pays at present to the hospital pharmacists, many of whom are enticed from the hospitals to act as agents for selling the drugs.
In no other branch of the N.H.S. is there a greater opportunity and more to gain financially than a rational solution to the pharmaceutical industry and service where the market at present plays havoc with economic planning. The Tory plans for prescription charges places an increasing burden on the sick. If the scheme for charges proportionate to the cost of the drug is enforced, doctors will find themselves unable to prescribe the drug of their choice but the one suitable to their patients’ pockets. A tangible class division in medical care will appear.
7. The insurance schemes
Since private health insurance schemes, and the British United Providence Association in particular, are playing an increasing part in health service usage and discussions it is necessary to look into their growth and purpose in some detail. The cost of medical care has risen astronomically and the types of ill health which remained untreated in the early part of the century and cost nothing, are now amenable to active and expensive treatment. It is therefore obvious that only a very small number of people could afford private treatment out of income or investments. Without insurance schemes private practice would have become the prerogative of these upper income groups. It might have played the part which public schools play in education — an affront to socialist justice; a means of diverting many of the best teachers (or in medicine the best doctors and nurses) from the public sector, but not radically detracting from education generally (or in medicine from health care generally). This analogy is imperfect. For private medicine of today is absolutely dependent on the most expensive equipment and on the support of non-medical workers who man the hospitals and are not available in nursing homes, so that most private medicine must be undertaken in the N.H.S. hospitals. If similar care could be given in nursing homes the costs would also rise astronomically and no insurance scheme could pay its way. In America where the private market is the major method of allocating medical care, either the premium is prohibitive or the insurance does not cover the full cost of treatment, or it excludes high-risk groups.
The significant fact is that private health insurance, which is now rapidly increasing, has not initially been due to the demand of the consumer. It has been the method used by doctors anxious to maintain private practice for financial gain, as a means of supplying them with a continuing flow of paying clients. It has sometimes been necessary to remind the medical profession that there are limits to the sums which can be paid them. In 1964 the chairman of BUPA talking to the medical profession said, ”If private practice is to survive fees and charges must be kept to a minimum. The position of the private patient is too precarious for fancy fees.” However, this minimum up to 1966 was as much as £125 for a major operation which could be paid to one surgeon, and afterwards all limits were removed and the surgeon can now ask whatever he wishes; in London often £500 for a single operation. The growth in insurance is used to convince the public of the advantages of private care and at the same time these advantages must appear to exist even when, in fact, they are hard to find. In the next chapter we shall enlarge on this point, but here emphasize only that insurance schemes, with their separation of certain patients for different attention, not only produce dissatisfaction and a class structure in medical care but they must be made to continue to produce dissatisfaction. Surgeons would rise in horror if the suggestion were made that they operate less efficiently on their non-paying patients; physicians would be equally concerned at any idea that their patients are less likely to regain health because of inadequate attention in the public wards. It is much easier for both to blame the government for not spending enough money to prevent waiting lists even though they would be the last to want them abolished. They know waiting lists are the main concerns of the uninsured public and the starting point for the desire to insure for private treatment. They may also know that better organisation within the hospitals could rapidly diminish or even abolish waiting lists altogether, but they are in the key position to prevent such reorganisation, and in the nicest possible way will act as a brake on any radical change in the system. With justification they could add to the lists more patients for admission and no lay person could question whether investigation and treatment might be undertaken as efficiently in out-patient department or health centres, instead of in a hospital bed. At present the bed situation renders it unlikely to require such action but to those who think that more beds would be the solution to all these ills we would emphasize this point, for we believe that within the existing system the consultants who benefit by waiting lists would see to it that more beds would make no difference to private practice, and waiting lists would continue.
The development of Insurance schemes
Before the existence of the N.H.S. insurance existed by two different methods. The contributory associations which provided free hospital care for low income groups, and the provident societies which only developed in the 1930’s and met partial costs of hospital care for the middle and upper classes. In 1946 a joint meeting of representatives of both contributory and provident societies planned for the future. The function of the contributory schemes as paying for hospital care for its members would no longer exist after the Appointed Day and many of these societies in fact went out of existence; others turned to providing sickness benefits to their members. The provident societies, however, concentrated on insuring members against the cost of private nursing home and hospital care. Many provident societies decided to amalgamate and in 1947 BUPA was formed as a result. The only other large provident societies which now remain are the London Association of Hospital Services and the Western Provident Association. By 1964 BUPA had approximately 510,000 subscribers with over £6 million annual income, the London Association 81,000 members with £1,13 million, and the Western 25,000 members with £265,000 income. During this time the premium for insurance had increased rapidly due as we have shown to the rapid increase in the cost of hospital care.
In 1959 BUPA introduced an insurance plan for general practitioner care but as this did not include the cost of drugs and the GP’s were generally not anxious to complicate their N.H.S. work with private practice which made serious inroads on their free time, this aspect of insurance has not been extended. In 1964 the B.M.A. were trying to persuade BUPA to include drugs in their schemes and the words of their chairman of the Private Practices Commission are significant. “The courage and dedication to the public interest of BUPA in embarking on this scheme despite all purely actuarial considerations to the contrary deserve reward and may yet mark a turning point in the affairs in British Medicine.” By 1965, however, only 19,500 registrations (or less than 4% of BUPA’S total subscribers) had paid the extra premium for private general practitioner coverage, and provision of drugs has not been included in the BUPA benefits.
The premiums of these insurance schemes are too complicated to give in detail here, varying as they do for the age of the contributor on joining the scheme and the inclusion and number of his family; the type of coverage and whether this is complete for all hospital costs or only partial coverage is made, etc. An example is one type of insurance for a married couple and children under 18 to pay £43.16.0 per annum for coverage up to £54 per week with an annual maximum of £728. The fact that by 1965 BUPA had a reserve fund of over £2,5 million proves that the schemes are stable and their power impressive.
A few years ago a trust was set up for the building of nursing homes to supplement the paybeds allocated to hospitals. These have received much publicity from press, radio and television usually combined with deprecatory remarks or pictures of the hospitals. Long queues in hospitals ‘where patients become merely a number” are contrasted with pictures of matron herself escorting the favoured patient to his private room in the nursing home. At best these homes may indeed be useful for simple procedures not requiring the complicated and sophisticated techniques of modern medicine but giving the veneer and glamour of a five-star hotel. At worst they are a danger to the private patient who has no backing of instant blood transfusion and other resources taken for granted in the modern hospital. In any case they are expensive in manpower of doctors and nurses whose time would better be spent in the hospital serving a larger number of patients with support of junior and other hospital staff. In fact a frequent procedure is to transfer patients who require more sophisticated treatment from nursing home to hospital, or sometimes even to transfer equipment and staff from hospital to nursing home to assist in these procedures without which the “privileged” nursing home patient would suffer. The private patient or BUPA do not pay extra for these privileges.
Extension of Insurance schemes
The greatest harm for efficiency of the N.H.S. which comes from these provident schemes is, however, a recently expanding practice which we view with the gravest concern. This is the increasing popularity of the BUPA scheme for group insurance with private firms who offer this as “perks and bribes” to their employees, and themselves obtain tax relief for the expense. This is a departure which divides workers themselves into a health class structure, and does more to perpetuate the idea that private practice has something to offer. Up till now the number of private patients has been relatively small but group insurance can produce different dimensions. Danger to the N.H.S. from insurance schemes lies in the possibilities which may arise from the Common Market. On Dec. 10th, 1970 the Association Internationale de la Mutualite (AIM) to which BUPA is affiliated, met in Brussels to consider arrangements for the EEC between European health insurance funds and a delegation from BUPA attended.
Private insurance schemes become the focus of wrong conclusions and adverse criticisms against the N.H.S. On October 2nd, 1965. the medical correspondent in the Financial Times concluded an article: “The Minister’s antagonism to private practice can only be interpreted as an admission that all is not well with the N.H.S. BUPA and the Provident Societies become a platform for the critics of the Welfare State.”
Even in America opinion is increasing in favour of a comprehensive health service which opposes any form of insurance to finance it. A body of many prominent medical men in USA known as “The Physicians Forum” state that the present method of payment for personal health services precludes adequate health care for the people of the United States and supports two classes of medical care. They ask for a mandated trust fund to be financed by a progressive income tax surcharge for health to be collected nationally for distribution to regional health authorities on a pro capita basis. “The insurance route has reached a dead end in Medicare,” they say.
To sum up we cannot do better than to quote Richard Crossman who produces facts and comments on BUPA in his Fabian Pamphlet “Paying for the Social Services” and who should know better than he the facts and comments to make? He writes on p. 19:
“In the last year for which we have figures 650,000 people were registered as members of BUPA. And if we add all the private insurance schemes together, about 800,000 people were registered. The income of BUPA was £11.2 million in that year and they paid out £9.6 million in benefit. The income of all these private insurance schemes was £14 million and they paid out £12 million. So quite a large number of people visited consultants privately or went into hospital as a private patient and had the insurer pay the bill. The number of beds associated with BUPA is 440 in 14 different nursing homes. A reliable source reckons that 60% of these patients used private beds under the N.H.S.
The unplanned growth of these private insurance schemes is a disturbing element within the Health Service. The blunt truth is that anyone who pays for private insurance expects to buy an advantage for himself; if he doesn’t he won’t pay. These schemes are growing because they enable their members to choose a time for an operation and to choose a consultant by name and guarantee that he will himself look after the patient. BUPA buys a name and buys time, or to put it plainly, facilitates queue jumping. I have heard it said that it would solve the financial problems of the Health Service if we got 4 million people into these schemes even at the cost of tax concessions to them. The answer to this claim is twofold. In the first place judged in terms of scarce skill and scarce resources BUPA solves nothing. In the second place judged in terms of social values it introduced two standards within the Health Service, a top level and a second level. Encouraging these schemes might be mildly convenient for a Chancellor concerned to limit the total public expenditure. But the economy would be achieved at a heavy cost. They cannot provide an alternative to paying for the Service out of taxation — without undermining the principle of the free Health Service.
We shall show in the next chapters that the insurance schemes (apart from queue jumping,) fail to buy better treatment than that given to N.H.S. patients.
8. The effects of private practice within N.H.S. hospitals
We have shown how the existence of private practice within the N.H.S. is historically conditioned. We have seen how the hospital consultants may be paid by salary either for their full-time service to N.H.S, patients or for part of their services only. The part-time consultant may treat paying patients in private beds within or outside N.H.S. hospitals. Both types of consultants are paid by the State, in addition to their salary, for visits to patients in their own homes at the request of the general practitioner. This domiciliary service ensures that all citizens are covered by free specialist advice within and outside the hospitals so that, theoretically, there should be no necessity to pay for these services.
But in our presentday society we have been used to paying for extras when we can afford them. We feel that if we have a large car we do no harm to those with a small car, nor indeed to those without a car at all. We know that paying for education produces a privileged class and therefore as socialists we condemn private education. But we must be prepared to analyse afresh into what category private practice within the N.H.S. falls. We would suggest that the most serious damage lies in the belief that there are two kinds of health service, the best for those who pay or join a private insurance scheme, and the second-best for N.H.S. patients. We use the word belief because in most respects there is no empirical justification for the basis of this idea, but it is increasing rapidly to the detriment of the peace of mind of many patients who feel “condemned” to a poor service since they cannot or do not pay for it. It is a belief damaging to the N.H.S. because it is undermining its reputation.
In most hospitals, however, the medical facilities for the non-paying patients are of the highest order. The private hospital patient is usually treated in small wards or one or two-bedded rooms which are used by all part-time consultants for their patients. The sisters and nurses in these wards are not geared exclusively to the methods of one or two particular consultants or specialists as in the public wards. Treatments today, particularly after difficult operations, are so complex that the nursing and other staff are as important to the successful outcome as is the medical staff itself. So it is possible that the service in the public ward is at least as good, if not sometimes better, than that given to patients in private wards.
In another respect, however, the N.H.S. patient scores over the paying patient. A patient in hospital for treatment of one condition may present problems requiring advice in regard to a different field of medicine. It is with the greatest ease that a patient in the public ward may have one or many consultations with other specialists. A patient undergoing an operation may need the opinion of a heart specialist before an anaesthetic is given; another may be diabetic or rheumatic and there are many other examples for which additional advice should be sought. One specialist may simply prefer to consult another in his own sphere before proceeding with treatment, or a surgeon may prefer to operate together with another consultant surgeon. All these and other forms of teamwork are common practice within the hospitals today. It is quite impossible to imagine that for a patient in a private ward there is the same ease of consultation. He will be under the care of one particular specialist who is bound to consider whether he is justified in asking the patient to pay for additional advice, particularly in cases where this is not essential but only desirable.
It is true that the private patient usually sees the consultant of his choice more frequently than the N.H.S. patient, but it is doubtful whether he has as much attention from the valuable help of registrars and house officers who are in constant touch with the public wards. On discharge from hospital the N.H.S. patient usually attends the out-patient department, but the private patient must pay for each private visit to the consultant’s rooms, and there he will not have easy access to all other facilities, x-rays, blood examinations, physiotherapy, etc. which are used so much in hospital follow-up procedures. So again we would say that the non-paying patient might score on his “more privileged” brethren. So on what grounds is the belief growing that there is an advantage in being a private patient? When visiting was restricted the private patient could be visited every day; now all patients are visited daily. When food was notoriously bad, the private patient fared better; now standards have improved all round. Special amenities used to be available for private patients only. Now many hospitals have portable telephones, mobile shops, dayrooms with television and radio, dining rooms for ambulant patients, single rooms or small wards for those who medically require them. In fact special privileges at one time accorded for payment are becoming increasingly available for all.
Jumping the Queue
Thus we find that the advantages for a private patient rest on two aspects, privacy and jumping the queue both for consultation and hospital beds. So long as private practice exists the N.H.S. patient will fail to obtain the privacy he needs and the waiting lists will never be eliminated because such improvements would deprive the part-time consultant of most of his private patients. Not only does the N.H.S. patient himself feel resentment at this two tier system but very many members of hospital staff are also becoming increasingly aware of the unfair methods employed. There is a vast amount of feeling, frequently unexpressed, among many professional and technical workers who must spend their own time and hospital resources on services to patients who have opted out of the N.H.S. They are aware of the sometimes enormous monetary awards which go only to the consultants although they are entirely dependant upon the skills of so many ancillary workers. Many of these workers are acknowledged to be among the most inadequately paid employees of the N.H.S. and include among others radiographers, physicists, pharmacists, laboratory technicians and, of course, the nurses. Not least of those who suffer from the system are the registrars and junior hospital doctors who must work longer hours and take increased responsibilities since the consultants spend only part of their time on hospital duties.
The employment of part-time consultants is an expensive and inadequate use of the most costly manpower in the National Health Service.
9. Private practice and hospital waiting lists
There are at present two kind of hospital waiting lists, both equally harmful to the patient. There is the waiting time for the first appointment to see a consultant which varies greatly from town to town, from hospital to hospital, and within each hospital from one speciality to another, surgery, medicine, gynaecology, etc. and from one consultant to another. A conscientious general practitioner will make sure that an “urgent case” will be seen immediately or admitted direct to the wards without preliminary outpatient attendance. There is no consultant who would refuse to see an additional patient when cancer is suspected; there is no hospital which would not admit an acute appendicitis or a case of pneumonia at the general practitioner’s request. But there are a vast number of complaints which may not be as obviously urgent as these. To the general public the idea of a hospital attendance is at least a worrying thought which increases with the waiting time. To avoid this mental stress and inconvenience more and more patients are paying for a private consultation at the consulting rooms to prevent the outpatient waiting time. There are many, of course, who cannot afford this and they must still wait.
The second type of waiting list is for hospital admission and again the length of these lists varies in the same way between different hospitals and consultants The full-time consultant can admit patients to a hospital bed immediately for cases of medical urgency or with varying times of waiting if he must put them “on a list.” In both cases no question of money enters into the arrangements. The part-time consultant who sees some National Health Service patients and some private patients can deal with his non-paying patients in exactly the same way as the full-time consultant. The patient who pays for consultation can either be admitted to a nursing home outside the N.H.S. or to a pay-bed in hospital if such beds are available, for which he or the insurance association can pay, or he can be admitted to a free hospital bed. Indeed the danger to the N.H.S. lies in the fact that there is nothing to prevent the consultant, after being paid for the consultation, admitting his patient to an ordinary non-pay bed. If the consultant states that admission is urgent, as indeed it frequently is, the patient may be in hospital more quickly than others on the waiting list whose cases may be equally urgent and who may already have waited a long time for admission. They will certainly have to wait longer if the patient who has paid the consultant has jumped the queue.
Is there a fair solution?
Within the present system it is well-nigh impossible to suggest a “fair” solution. One could not deny the right of admission to a cancer patient who has perhaps paid a hard-earned six guineas to expedite admission, and who could not possibly afford to pay for a private bed or a surgeon’s fee. As we have said a cancer patient would be admitted urgently regardless of payment. But there are many other diseases which might be said to require “urgent” treatment, and the word “urgent” can be differently interpreted by different people and in varying conditions. Every illness and disability is urgent for the patient himself. But it is the consultant’s estimate of urgency which allows the paying patient to jump the queue, so that non-paying patients wait even longer. No one has the right nor the knowledge to question the consultant’s decision. Even though the number of these cases may be small the harm to the reputation of the N.H.S. is great and does much to create the impression that payment is essential for good service. It is quite clear that without the waiting lists the person who would lose would be the part-time consultant, for the necessity to pay would be removed for a large proportion of patients if the waiting time no longer existed.
The demand for privacy is another factor which appears to justify private practice. But in newly built hospitals or many of the old hospitals where new or improved outpatient departments have been built there is in fact every facility for consultation in separate rooms, and it is only when this is no longer considered a special privilege requiring payment that it will be accorded to all as the necessity arises. (There are a few people who object to the presence of medical students but they have the right to request their exclusion whether they pay or not.)
If a study were made of the customs actually in use by consultants when examining hospital patients it would be found that most patients already receive all respect and consideration. The belief that this accrues only as a result of payment is an unjustified slight to the medical profession generally but one which many bear with equanimity since it results in such an increase to their private practices. It is, however, a belief which is particularly unfair to the full-time consultants, who have nothing to gain by private practice.
10. The financial effects of private practice
Many contradictory statements are made about the effects of private practice in the National Health Service. One that we should seriously consider is that private practice actually saves the State a great deal of money. Statistics of the extent of private practice generally are very hard to come by because the nature of private practice is confusing and so frequently interconnected with N.H.S. practice. Just as a general practitioner or part-time consultant can treat both N.H.S. and private patients so also can a patient transfer from the private to the public sector and vice versa. He can attend his general practitioner privately and see the consultant either privately or at hospital or he can be admitted either as a private or a non-paying patient. If he cannot afford to continue payment when in hospital he can transfer to the public sector and this fact prevents many bad debts which the part-time consultants at one time had to face. This system may prove attractive to those who can pay, but it is too often forgotten that it is at the expense of those who cannot.
With these variations it is extremely difficult to assess the amount of private practice in the N.H.S. and consequently either the saving or cost to the Exchequer. We have seen that there are no accurate records of the number of general practitioners who accept private patients and in the same way only estimates can be made of the number and costs of patients treated outside N.H.S. hospitals. At the beginning of the N.H.S. 6647 beds were allocated to private practice out of a total of 453,000 beds. In 1963 out of the higher total of 472.000 beds the private ones had been reduced to 5657. In 1968 the total was 464,902 and the private beds 4453. The numbers are small enough to suggest that the State is unlikely to save much money from the payments received. The money paid for private hospital beds, either by the patient or from insurance, does not help the hospital service. It goes direct to the Treasury to lower taxation. Against any saving to the State must be weighed the considerable additional expense of maintaining private facilities, and the cost of employing part-time consultants when the service of full-time staff would lead to a far greater efficiency in use of expensive equipment. Moreover the bed occupancy in the private sector is seldom over 60% and the waiting lists in the public sector suggest that this wastage cannot be economical. Yet bed occupancy must inevitably be lower in the private sector for without empty beds the main purpose of avoiding waiting lists could not be fulfilled. The Conservative utterances on the continuance of the private sector sometimes speak more clearly than our own of the effects of the system. Mr. Angus Maud, conservative M.P. for Stratford-on-Avon, wrote in the Birmingham Post on December 6th, 1969 in criticism of Mr. Richard Crossman’s Fabian tract “Paying for the Health Service:”
“Private medicine is important, something to be fought for and defended, for much the same reason as pension schemes and independent schools are important”‘. . . They enable you to tell just how good — or how bad —- the publicly provided services are in terms of efficiency and progress. The lack of this yardstick would be very dangerous indeed … If we were to abolish private practice we should be condemning ourselves permanently to a second-class service for all. Standards would deteriorate everywhere.”
We maintain that the contrary would be the case. If all patients used the public services the N.H.S. facilities would be of higher standard for all.
Private practice maintains and augments the enormous inequalities of pay to health service employees. The rise given to consultants in 1970, though less than they demanded, was in itself more than the weekly take-home pay of the porters and domestics. The amount the part-timer may earn from private practice is limitless and unknown except, perhaps, to the income tax officials. The method of distribution of distinction awards to chosen members of all the specialities in the medical profession is a secret more closely guarded than those of M.I.5. The highest award reaches £6,330 in addition to salary and other earnings and once the award is made it is continued annually. The earnings of the medical profession are such that in order to attract doctors to the university professorial chairs the medical professors are paid at a higher rate than all other university professors. It is true that for their salary they treat patients in addition to teaching medicine, but the fact nevertheless indicates the standard of income of the medical profession.
A former excuse for high salaries used to be the long years of medical training at the student’s own expense. This, of course, is no longer true. As in all other State controlled training the student receives a grant throughout and the State pays all costs of training and demands no service whatever from him when he is fully qualified.
It is clear that in a future health service where private practice and part-time employment of consultants is eliminated the negotiation of new salary scales for all doctors would be necessary. These should not only allow for a suitably high ceiling to members of the medical profession, with career structures and superannuation attractive enough to appeal to them, but also additional payments could be attached to appointments requiring particular technical skills or special administrative ability. To those who express fear of wholesale emigration of doctors we would recall that it is young doctors who emigrate, not those in well-established positions. The promise of a good future and modern working conditions will attract the dedicated and clearer-minded doctors who are even now increasingly coming from our medical schools. The abolition of further merit awards, which are unsavoury to all but the recipients, would allow a wide margin of cash for fairer distribution all round. Needless to say, a similar revision of salaries and wages should be negotiated for other health workers to attract more and better personnel into the employment of one of the largest industries of the country.
II. The problems of future demands
Is it possible that these difficulties will eventually be overcome without any radical change in the system? Will the resources of the Health Service ever catch up with public demand? Will the doctors be able to devote time and privacy when needed and can beds be available for all so that the necessity for payment, from the patients’ point of view, will no longer exist?
We believe that the demand for health measures, for the foreseeable future, is inexhaustible. This stems from many different reasons. The health service has never in its history been able to cope satisfactorily with the treatment of the whole population. There have always been vast numbers so grossly neglected as to become the cause of public scandal. The highlight at the moment is the plight of the mentally sick; that of the elderly is only just behind. The percentage of the old to the whole population is in an ever increasing ratio. In 1969 there were 8.5 million people of pensionable age, actually double the number of that age group of 1931. An estimate for 1975 is 9.2 million. Even in a healthy population old people will always require more from the health service than younger age groups.
Technological progress in medicine, while saving lie in dramatic ways, extends equally dramatically the need for expensive health measures. Kidney dialysis is one example; costly in itself, it saves lives which require constant expensive attention. A second example is the surgeons’ skill which saves annually hundreds of spina-bifida babies from death in infancy for a life often doubly incontinent and possibly mentally and physically handicapped; a constant drain on the nation’s health and welfare resources.
Diseases of “advanced” countries
In the “advanced” countries where diseases of infection and starvation have been virtually eliminated, the result of progress and plenty have added an enormous and expanding bill to health programmes. Diseases from smoking, over-eating, alcohol, drugs, lack of exercise, air pollution, accidents from mechanisation on the roads and in factories add up to a formidable proportion of the health budget, and, although mostly preventable, we have seen that no progress has been made in reducing them or their cost to the nation. On the contrary, more “casualties” from our mode of civilisation are constantly added to the list.
We have only just started to pay lip-service to preventive medicine which would include a comprehensive occupational health service as well as a great advance in education and family care from birth to death. It is predictable, however, that this too would create unforeseen demands for treatment. It is to be hoped that the result would be a healthier and happier nation but one must bear in mind the possibility that it might also produce a higher proportion of people requiring permanent care. The service the nation is prepared to supply will undoubtedly produce its own demand. We cannot imagine a time when the health service and its employees reach saturation so that the demand can always be met.
Cost of health and welfare
The actual cost of health and welfare doubled from £830 million in 1959 to £1770 million in 1969, which in real cost excluding inflation of money values was a rise of 23% (Richard Crossman Fabian pamphlet) and the demand appears little nearer to being met. It is not our purpose here to discuss how we should pay for the service, but it would be wise to consider whether we make the best of the resources we are prepared to use.
It is not only the provision of money which is a problem in an ever-expanding health service for a growing population. It is probable that shortage of trained man-power will hold back the necessary growth of the service for many years to come. Planning must of necessity be not only economical financially but particularly must use all personnel to the best advantage. Again we quote Richard Crossman:
“In a highly developed industrial nation the dynamic of research and experiment will irrevocably commit more and more of the nation’s resources to services and activities which cannot be financed by private enterprise or sustained by private demand . . . But if the process of expansion cannot be halted, it must certainly be planned.”
And it is in the process of modern planning that the existence of the private sector within the N.H.S. serves like a spanner in the works.
12. A planned health service
In this chapter we describe the health service which could be planned for the future. Obviously it must here be no more than an outline which, however, will demonstrate our contention that private practice has no place in a comprehensive, universal service. The future scheme must revolutionise procedures for health and welfare as radically as the N.H.S. supplanted the previously chaotic state of medicine, but must, nevertheless, build on the successful aspects of the present day. Planners must take into account, and endeavour to avoid, the mistakes and failures of the past, but though we recognise mistakes we contest the wholesale condemnation of the service frequently heard today. We believe that much of the criticism is intended to encourage people to pay privately. This, in a vicious circle, perpetuates the criticism and discontent, not only among the users of the free service, but also by some who feel obliged to pay or insure. The present Conservative Government’s plans for charges will not only add to this trend, but will be expensive and difficult to implement and will be a drain on personnel already in such short supply.
Financing of the service:
An adequate health service, even run economically, will demand increased expenditure. We condemn all charges, which either permit privilege or fall upon those least able to pay, and in any case, at a time when payment is most difficult. We believe that increased expenditure must be met from taxation and that the majority of the population would vote to spend a higher percentage of taxation on health and welfare if they knew that by so doing the service would be universal and of high quality. This is the only way of paying for the service to spread the cost according to wealth.
Unification of administration:
The complete unification of all existing and future services under one administrative structure is an essential prerequisite of future planning. The frustration and wastage caused by the tripartite system dividing hospitals, general practitioners, and local authority services needs no further emphasis here. The poverty or policy of some local authorities has impaired services in areas where they are most needed. Both financially and administratively the service must be unified and distributed according to population and needs. This does not imply a bureaucratic system, indeed far greater democracy than at present must be an essential feature of future planning. Although the equal distribution of services throughout the country is too big and demanding a task to leave to the fate of the existing local authorities, this does not mean that local participation need be denied.
The area required for a large district hospital (which we shall shortly describe) is a useful size in which to set up a special body to administer hospital, health and welfare services. This could be democratically elected at three yearly intervals with participation of the workers in the health service by co-option of their elected representatives. Thus this lower tier of the administrative body of the service would be fully democratic both from within and without the service. Direct participation would add a new interest in this type of local service.
Above these district committees the country should be divided into regional planning bodies, perhaps about thirty in all, consisting of representatives of the lower tier district committees, nominees from the Department of Health and Social Security (responsible for the spending of State money), universities, major trade unions, and other appropriate organisations. Such a structure would ensure the possibility of a national strategy for health financed by the State and enunciated by a central authority, but planned regionally with the local people and health workers controlling the day to day running of their service.
Statistics and planning:
This structure demands a method of planning for hospitals, health and welfare services hitherto not applied on any great scale. Only in very recent years have hospital statistics become accurate enough to allow acceptance of certain premises for future planning. Pilot computer schemes are rapidly adding to our knowledge. Population figures are known and trends are calculable. Mechanisation of certain procedures have been in use for long enough to estimate whether they are efficient and economic and therefore should be universal. Other services may not only be efficient but may add a different dimension to health care and preventive measures; for example,, mechanised laboratory testing may reveal symptomless disease, and may point to the value of periodic health checks on the whole population at certain ages, or may describe the type of population at risk for more detailed surveys.
In short, a new era in health care is developing under our own eyes though concealed at present by immediate inadequacies. We must be prepared to make use of this knowledge, which when pooled by a central authority would already be considerable, and we must rapidly amass further knowledge so that our planning can be accurate as well as amenable to change. Already minimum adequate requirements according to population could be estimated throughout the country.
It is known how many acute surgical cases in a given population according to age will be likely to require hospital admission annually; how many non-acute surgical admissions there will be; how long on average these patients will require intensive care, followed by care requiring reduced medical and nursing attention; convalescent or hostel care before final discharge home. It can be calculated what would be the likely requirements of the aged and chronic sick so that distribution between hospitals, hostels, welfare institutions and home can be estimated, and similarly for psychiatric and mentally sub normal patients. Money could, no doubt, be saved by discharging patients from hospitals if home facilities could be improved, but further research is needed to discover which patients really would be better at home or whether an intolerable burden would be placed on relatives, friends and community services, Information is already available to estimate maternity hospital requirements.
Demands can also be estimated for specialist treatment of all types; for instance, the size of population which can make full use of the vast teams of workers and expensive equipment essential in a modern radiotherapy unit; in a neurosurgical centre; or in a gynaecological, urological or psychiatric department. These facts are known already, yet in the country today some of the teams are underemployed either for lack of patients or beds. Sometimes the teams are not complete or not fully equipped so that treatment of choice is not always available. More often (and particularly north of the Midlands) both manpower and equipment are in such short supply that patients are not treated according to best known standards or even not treated at all.
These are mere fragments to illustrate the possibilities of future planning. Even between 1949 and 1968 the average duration of stay in acute beds had fallen from 21 days to 11.6 days in spite of the extension of advanced surgery. The number of inpatients treated per bed per year rose by 36%. Better use of hospital resources had thus already resulted in economic saving and greatly increased efficiency, but this is only a beginning of what could be done by planning in the future.
District General Hospitals
We have suggested that the democratically elected lower tier of the health service should cover the area required for a large district hospital. Although ideally this should cover a population of at least 200,000, there must be great flexibility owing to the present or prospective siting of hospitals with space suitable for upgrading, and owing to the varying density of population throughout the country. The thirty regional planning bodies would be responsible for seeing that such specialities requiring a greater population are suitably spaced among the district hospitals. Thus in one region there might be up to fifteen district hospitals, one containing a radio-therapy unit, another a neurosurgical and another a plastic surgical unit, but all containing the major services of general medicine, surgery, psychiatry, geriatrics and obstetrics. More than one but not all the district hospitals could contain other specialities such as paediatrics, accident units, orthopaedic, and thoracic units. No isolated hospital should consist of one only of these specialities, for each is dependent upon others for providing adequate care for each individual patient (for example, a patient undergoing radiotherapy also requires the advice and attention of surgeons and physicians). It can be seen that in order to provide minimum adequate care for every individual patient the size of each hospital must have a lower economic limit. For we have not mentioned the multiple departments required by all specialities; laboratories, blood banks, physiotherapy social work, chiropody, dentistry, occupational therapy, record libraries, organisers for voluntary workers. Without these, and many more, no modern hospital is complete but the size of the hospital (or hospital complex) must justify the cost of such departments so that they can be adequately staffed and fully used.
To those who feel that large institutions are impersonal and who agitate for the continuation of their local or even cottage hospitals we would emphasize that if they value the best in their health service they must be prepared to forego the cosiness of the small hospital. We would also point out that however big or small the building may be, it is the attention and manner of the nurse or doctor at the bedside or in the consulting room which is all-important. If this has not been good enough in the past it is due to bad training, selection or shortage of staff and not to size of buildings. Another objection may be the difficulty of travelling from home to hospital. But we submit that it would be easier to organise travelling facilities than to bring adequate treatment nearer home. Full use of health centres which we shall shortly describe will save much travelling to hospitals. The building of new hospitals need not be as expensive as some recently completed which seem to rival each other in magnificence, whilst others remain in the slum-like squalor of the past century. Use should be made of “best-buy” hospital planning with its consequent financial saving. The smaller hospitals in existence need not be scrapped; there are multiple uses to which they could be assigned, such as “half-way hospitals”, welfare homes or hostels for geriatric or psychiatric patients not requiring hospitals attention but still unable to live at home, sheltered workshops, health centres, or, in the right areas, convalescent homes.
There are many additional advantages of the large district hospitals apart from the most efficient and economical means of giving the best treatment to the greatest number of patients. Well known are the difficulties of recruiting nursing staff for the less popular specialities such as psychiatric and geriatric care. When these are within the general hospital, nursing duties will be shared and separate recruitment will not be necessary. Also communal amenities can make the recruitment of all staff easier. Day nurseries for staff babies, canteens, banking and housing facilities, shops, entertainments; these are examples of numerous developments which can engage the attention of the elected district committees. Many of the present problems which clog the work of house committees and regional boards would find their solution in rational planning leaving room for local participation, in these and numerous other possibilities.
Teaching Hospitals
The separation of teaching hospitals with their own boards of governors should be discontinued. If they are suitably sited, they should take their place (as in Scotland now) as district general hospitals. University representation on regional planning boards would help the spreading of teaching among district hospitals and health centres and widen the horizon of the students. An enormous saving could be made both financially and in man-power by the desegregation of teaching hospitals, some of these, particularly in London, are over-equipped and over-staffed, so that their concern is to find patients to treat in certain specialities (for example radiotherapy) whereas the North is particularly starved of man-power and equipment in the same specialities, and patients there remain untreated, or receive only an inferior choice of treatment.
Patients from abroad
The reputation of the N.H.S. is such that visitors from abroad come to this country specially for treatment as paying patients. The elimination of private practice should not close the doors to these visitors, nor should they be condemned to treatment outside the health service, which as we have seen cannot reach the standard of state medicine in a modern society. If the Minister feels that beds are sufficient to allow for their treatment, arrangements could be made for direct payment (at fixed and agreed scales) to the State to defray the cost of treatment. No additional payment to medical or other health workers should be made. Providing that facilities and staff are available this could be an excellent way of showing the merits of the health service to visitors from abroad, and a means of earning currency.
General Practitioners
We have already indicated the necessity to retain the services of the general practitioner. From the medical standpoint there is no doubt that his task is not only of supreme importance but also requires at least as much skill as that of the hospital consultant. Probably 95% of each individual’s contact with doctors throughout his life is with the general practitioner who must not only diagnose, treat, and re-assure but must call upon specialist advice at the right time. It should be his task to maintain his patient in good health as well as to treat ill health. The idea often expressed that the patient usually goes to his doctor for a bottle of medicine is injurious both to the patient and the doctor’s reputation. But in order to undertake the work demanded, and for which he is trained, the doctor must have the tools of his job and co-operation of other health workers.
A group of doctors working together may decide to divide their work in various ways. They could, for instance, each look after the whole of a family registered with them, or they could divide horizontally, so to speak, into age groups, one devoting himself to paediatrics, another to gynaecology, another to geriatrics, and so on. It does not matter to the planning of the health service which method is used. The possibility of consulting one with another, as is the practice in hospitals would be beneficial to both patients and doctors. With proper organisation, appointments without undue delay, home visiting as medically required, and twenty-four hour rota service, there would be no place for private general practice. Salary scales would be negotiated with advantages for special skills as already suggested.
Health Centres
The ideal place for the teamwork of general practitioners and other health workers is now acknowledged to be the health centre. Already in many parts of the country such centres are built or under construction, (in Devonshire twenty-five are already in use). As in the case of the district hospitals the size and siting of health centres must depend upon many factors, particularly upon suitable space and existing buildings as well as density of population. Ideally in built-up areas a health centre adjoining the district hospital would save duplication of many services like X-Ray, physiotherapy, pharmacy, laboratory, all of which are best organised on a large scale. In areas; where this is impossible the health centre could itself provide certain diagnostic and treatment services and in addition hospital consultants could hold sessions at die health centres for seeing newly referred patients and maintaining follow-up after hospital admissions. The general practitioners would thus establish the closest contact with consultants, without, themselves, actually working in hospital.
An important aspect of work at health centres should be that of keeping personal and statistically useful records. The new health centre planned at Thamesmead will be linked for this purpose to the Essex University computer. This health centre is designed for eighteen doctors, twelve or more dentists, ophthalmic services, etc, and the environment is so planned as to give a personal atmosphere as well as the advantages of a comprehensive system. According to Sir George Godber, DHSS chief medical officer, it is “an example in specially favourable circumstances of the sort of thing we would have to do for the development of the whole country’s health service; district by district.”
Community services
We envisage in the future the health centre spreading itself to cover other services. For example, the work of the D. E. P’s. Disability Rehabilitation Officers is so closely linked with medical care that their association could only benefit doctors and patients. The members of the community receiving supplementary benefits are frequently those needing extra medical help and social welfare services. Therefore a combination of these offices within the health centre complex could be advantageous. The opportunities are endless for embracing a service which will enable society to care for its members in a comprehensive way with regard to the physical and psychiatric weaknesses which are so often the cause for dependence on social support. Day-hospitals, residential nurseries, sheltered workshops, probation services could be attached to or near health centres.
Family Planning
If a long-term financial saving were sought by any Chancellor of the Exchequer he could hardly find a more cumulative one than an immediate national scheme for family planning. At present where such planning is offered at all it mainly supplies a middle-class need which must be paid for. For universal use, widest facilities should be based on the health centre including, if necessary, domicilary services. The saving in abortions and in care for unwanted births from infants to adults, frequently including remand homes and prisons, cannot be estimated.
Occupational health service
The impossibility of setting up a comprehensive occupational health service at present is simply dictated by lack of medical manpower. But with the building of health centres and the existence of a salaried medical service occupational health measures could be integrated and expanded as manpower becomes available. The necessity for the service is evident if one considers that in 1969, against 23 million days lost from strikes, there were 329 million days lost through accidents and illness. Financially the service could become rewarding; in terms of human suffering it is essential.
Preventive medicine and education
Throughout this paper we have shown that measures for preventive medicine have been incompatible with private practice. Planning is particularly essential to all such measures. In the past the efforts of full-time salaried workers have been responsible for virtually wiping out infectious diseases and improving beyond recognition the health of mothers and children. The same intensive campaign must be undertaken and planned centrally to educate and maintain health and detect and treat disease. Such measures will include education campaigns (such as addictions and smoking), improvements of the environment and, we believe, regular health surveys at ages suggested by statistics. We believe that all health measures can be co-ordinated between hospitals and health centres with full-time salaried personnel.
Immediate Needs
Whilst demanding the abolition of all charges, and of all private practice within the National Health Service, the Socialist Medical Association realises that under the present Tory Government such a demand will fall on deaf ears. However on grounds of economy an immediate measure could be taken to reduce the increasing evils of private practice. All new medical appointments to the N.H.S. should be advertised for full-time doctors only so that no new aspirants for private practice would be added. Anomalies on tax relief between full-time and part-time staff should be removed.
Tax relief for group insurance with BUPA should be discontinued. Far greater scrutiny of unfair practices regarding jumping the queues and illegal use of N.H.S. equipment should be made. The Merit Award system must be ended; differentials should be based on duties and skills and should be open, not secret.
In short the whole policy of Private Practice and its effect on the National Health Service must be brought into the open, and reviewed at all levels.
13. Conclusion
It is hoped that this short paper has shown that a free, comprehensive, universal N.H.S. must be regarded as a major social arrangement in our society that guarantees equality in the treatment of ill health and the prevention of disease. We have shown that due to certain historical factors the organisation of health services in our society has been connected with two major themes: the private market place, representative of the worst elements of laisser faire capitalism, and the humanitarian efforts of religiously inspired philanthropists. Both these historically determined forces behind the provision of medical care lost their effectiveness due to two other equally important factors. One was the crisis of capitalism in the 1930’s culminating in the Second World War, and the other was the increasing commitment of socialists to a planned health service. The Socialist Medical Association saw clearly that a national health service was a necessity for British society if economic opportunity and equalisation of life chances was to be achieved. Therefore within the concept of a national health service there was contained a two-pronged critique of the old industrial anarchy of capitalism. One such critique involved the inception of a national health service to be viewed as a socialist method of organising medical care which would prove superior to the old methods of hit-and-miss administration. The second critique saw the national health service as symbolising the fruition of socialist theory and thinking since the earliest days of British socialism.
In this way, then, the private market as a method of organising medical care was made redundant by the passage of the N.H.S. Act. Its continued existence is anomalous, inefficient and finally symbolic of inequality and class division. The whole trend has been away from individual sponsorship of medical goods and services which in any case rely on the national effort to produce. Historical experience shows that modern Western societies are increasingly recognising that the State is the only collectivity capable of bringing rationality to the organisation and distribution of vital goods and services to the population. Not even the most ardent free-marketeer would argue now for the return of the major public utilities such as water, gas and electricity to the private sphere.
The same argument would follow for medical care. The decisive advantages of a nationally organised health service are that it guarantees that medical care is certain and can be available at all times for all contingencies without the imposition of non-medical criteria confusing the equation of need and demand. To impose economic assessments of the individual between his demand for medical care and his need for such care is to impose medically irrelevant criteria.
Only the State can guarantee standardisation of services. Research programmes, computerised bed allocation and geographical distribution of medical manpower and facilities are all dependent on long-term planning in the public interest. This involves large sums of money which require the economies of scale to justify and make efficient. The private market is unable and unwilling to finance independent research in medical advance and certainly does not intend to train its own medical personnel. Economies of scale does not mean faceless bureaucracy and blind administration. It does mean exploiting the large scale production of medical goods, the large-scale organisation of medical administration and the imposition of cost efficiency programmes and finally the standardisation at the optimum level of medical care in our society.
Our main case against the private provision of medical care in the end boils down to a question of political morality.
Given that our consumer oriented society is under continual strain through the aspirations of the population rising to higher and higher expectation we maintain that a corresponding rise in the medical care aspirations of the population is inevitable. This means that greater rather than less resources must be devoted to medical care, and our argument shows that only a nationally administered system of distribution can guarantee this allocation. Moreover, if we are still not a socialist society in our economic affairs, then it is vital that the socialist part of our society remains intact. The National Health Service symbolizes socialist thinking against non-socialist thinking. The existence of a private market in medical care, no matter what its size and scope, is a threat to the socialised, humanised and equalising institution of the N.H.S.
The greatest danger to our society’s health comes, to paraphrase J. K. Galbraith, from the private affluence of some producing and encouraging the public squalor of the many.
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Samuel Mencher, Private Practice in Britain Occ. papers on Soc. Admin. No. 24, 1967
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R. H. S. Crossman, Paying for the Social Services, Fabian Tract 399.
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