CHAPTER II

Summary and Conclusions

The impressive achievements of the British National Health Service stem from the firm commitment by government to accept responsibility for providing health care of high quality to all citizens without regard to their ability to pay. In 1946, the National Health Services Act was passed and in July, 1948, the NHS was launched amid naive prophecies, both for sucess and for failure. Today, after over 23 years of slow, evolutionary change, it stands as an impressive national achievement and a major source for national pride.

Health care has effectively been removed from the vagaries and inequities of the market place. Faced with the same awesome cost implications of modern advances in medicine and medical technology as other developed nations, this underlying social equity has become an even more prominent hallmark of national achievement than was even imagined by those responsible for the original enabling legislation.

It has recently been estimated that less than 2% of health care is provided outside the NHS. Thus, the NHS plays a central and dominant role in health care delivery and financing. Almost 80% of its funds are derived from general revenues of government. The rest comes from a payroll tax, from local taxes based on real estate and from direct payments by patients for services.

The best in modern medicine is provided to all citizens with virtually no direct payment for important services.

While facile international comparisons of costs are to be avoided, the total cost of health care provision in the United Kingdom is both of interest and relevance to the current national debate on the health crisis in America. In the United Kingdom the total expenditures on health services in 1970 was of the order of 1,800 million pounds. If this figure is multiplied by 10 to convert to U.S. dollars and to correct for the disparity in population size, the $18 billion total fails to reflect differences in wealth and standards of living. However, if this amount is further multiplied by a factor which represents the ratio between the American and the United Kingdom per capita GNP, one arrives at a total of $41 billion, an amount substantially less than the sum of over $70 billion spent on health care in the United States in 1970. These figures strongly suggest that with appropriate reform of the delivery system in the United States a much more equitable distribution of health services of higher quality can be achieved at substantial cost savings.

From the vantage point of an American perspective, another striking lesson to be learned from the National Health Service is the cost saving and the quality improvement which flow from their system of primary care provision. The general practitioner service provides virtually every man, woman, and child in the United Kingdom with

a family physician who is able competently to manage over 95% of the real or imagined ills of his patient. For those who require specialist attention, the general practitioner is able to guide them into the complex maze of modern hospital medicine and into the hands of the appropriate hospital-based specialist. Throughout, the patient has no fear of financial ruin.

This system allows a remarkable degree of freedom. Contrary to misleading myth, patients have free choice of a general practitioner (within reasonable geographic limits), and in turn, the general practitioner can exercise his right to accept or reject an application for a new patient to join his "list".

Each of the 22,000 general practitioners has an average of 2,450 patients. This average is exceeded in the more sparsely doctored areas. but even there the average is seldom significantly more than 3,000 patients. (In 1965, the General Medical Services Committee of the British Medical Association recommended ultimately an average of the order of 2,000 patients per general practitioner as an ideal to aim at.)

As a matter of national policy, the general practitioner service has received special attention from successive governments. The rational organization of health manpower has been buttressed by the general practitioner service. Rightfully, general practitioners are considered the bedrock of the system and access to specialists in the National Health Service can only be gained on referral from a general practitioner.

In contrast, this rational and efficient division of labor between generalists and specialists in the United States is essentially nonexistent. Here the declining number of generalists and the sometimes ludicrous proliferation of specialists has, in many areas of the United States, made general practitioners a dying breed. The func tional maldistribution of medical manpower, together with the absolute shortage of physicians, has had appalling consequences both in terms of cost and quality of health care.

In the United Kingdom, unlike the United States, the specialist is unencumbered with the comparative trivia of minor complaints dealt with more appropriately by the primary care provider. In addition, he is spared much of the task of managing the broader and more com plicated problems of his patients' physical, social and psychologic adjustment, problems for which he is untrained to cope as successfully as is his colleague in general practice. For this reason, the British manage with fewer neurosurgeons serving its population of 50 million than there are at present in the city of San Francisco. Similarly, two pediatricians suffice in Oxford, which had a 1968 population of 110,000, while New Haven, Connecticut, has about 30 pediatricians serving its 1970 population of approximately 134,000. To quote Walter Me Nerney in describing the National Health Service, "Nominal needs. are spared the costly reflexes of the Consultant (specialist)."

Again in contrast to the United States, the public attitude toward the National Health Service in general, and toward their general practitioners in particular, is enthusiastically approving. Nearly everyone can name their general practitioner, which stands in bold contrast to the situation in the United States. Here the number of general practi tioners is rapidly declining and, because of the age distribution of those who remain, the further precipitous decline in their numbers in

the immediate future is inevitable even if there is a heavy infusion of funds and other incentives to encourage recruitment among young medical graduates.

Of the approximately 2 billion pounds spent on National Health and Welfare Services in 1970, the general practitioner services absorbed only about 8% of this total. Hospitals accounted for approximately 60% of expenditure, public health and welfare required approximately 15%, drugs about 10%, dental care about 5% and central administration 0.6%.

The cost of the National Health Service is even more worthy of analysis by Americans when one considers the efficiency of the British system in utilizing resources. While the NHS can be justly praised for its underlying equity and for the generally high standard of quality of care provided, on this issue of efficiency it must receive a comparatively poor rating. The basis for this critical judgment is well documented in the "Digest of Health Statistics for England and Wales— 1970" prepared by the Department of Health and Social Security. In 1968, the last year for which figures are currently available, the throughput (cases per available bed) in acute general hospitals ranged from a high of 30.1 in the Oxford region to a low of 20.0 in the Liverpool area. This disparity is reflected in the average length of stay in such acute general hospital beds, varying from 9.4 days in the Oxford region to 14 days in Liverpool.

While the average length of stay in British hospitals has been steadily declining, the fact that such wide discrepancies still exist in a comparatively homogeneous and densely populated country suggests that management of available resources has been less than efficient.

Careful analysis of how the general practitioner spends his time reveals appalling inefficiency. While the trend is toward group practice, with appropriate ancillary staff, nearly half the general practitioners are in solo practice, wasting much of their time providing trivial certificates. (The "certification" load in general practice has its roots in history, Lloyd George's National Health Insurance Act of 1911 set the pattern in this regard, as indeed it did for the capitation payment of general practitioners.)

To quote a high official in the Department of Health and Social Security:

Indeed, we don't pretend to be very efficient. In this matter of efficiency, though we are probably the best of a very bad lot.

The many problems of general practice are broadly appreciated in the United Kingdom by those at the top of the administrative pyramid. Vigorous steps are being taken to improve the status, circumstances, and efficiency of general practice. Sir George Godber, Chief Medical Officer in the Department of Health and Social Security, has

said:

I am not saying that our brand of general practice is right for everyone, only that we can with our system improve it greatly and provide what we want to have.

We do not want to turn general practice into a faint carbon copy of specialist practice. The progress of specialization in hospitals will continue and the personal physician will soon be the only doctor with a truly comprehensive and continuing view of his patient's health. . . . If there is to be a General Physician in the future and surely the patient needs some medical guide through the scientific maze then a general practitioner properly prepared for the role and helped to

by one doctor, but primary use of the skills he needs at the moment, under the guidance of a practitioner who knows when to involve others. The ultimate object is not the organization of medicine for the doctors' sake but better patient

care.

Another great achievement of the NHS has been its very positive impact in improving the geographic distribution of high quality specialist services. These tended to be concentrated in the London area, in Edinburgh, and a few other centers of medical excellence. The National Health Service has effected a radical change in the direction of a more rational and equitable distribution throughout the country. Here the power of central decision making has been used to good effect.

Even more impressive to the Subcommittee than the very consider able and general sense of national pride evoked by mention of the NHS in Britain is the attitude of British doctors toward the Health Service. Contrary to myths which have been so freely circulated in the United States for factional advantage and self-interest, British doctors were found to be largely supportive of the NHS and proud of both the equity of the system and the quality of care they provide within it. Through their democratically organized British Medical Association, which represents all factions and special interests among British doctors, they have a continuing and generally amicable consultative working relationship with government. In this system, as in any other comprehensive system of health services, such cooperation from the medical profession is essential not only in insuring that the system works, but also in providing the necessary pressure for respon siveness to change and informed direction to progressive reform.

At the same time the doctors are obviously cognizant of their de pendence on the government for funds and their relationship with government has not always been entirely happy. In the mid 1960's, for example, there was a brief interlude when many general practitioners were almost in open revolt over remuneration and other condi tions of service. At one point, 17,000 had submitted their resignations from the NHS to their representatives in the BMA to be used as a bargaining chip with government. By adroit negotiation the crisis was averted and government moved a long way in the direction of meeting the demands of the general practitioners. This example of open hostil ity between government and the medical profession is the sort of exception that proves the rule. Generally, the profession bears a cooperative and supportive attitude toward government. This attitude was expressed to the Subcommittee not only by leading representatives of the medical profession in the BMA but by many members of the rank and file whose opinions were assiduously sought. It is also noteworthy that the leadership of the Junior Hospital Doctors Association, the only significant splinter group which is seeking to obtain sep arate negotiating rights for junior hospital doctors (interns and residents), were generally supportive of the underlying principles of the NHS. In spite of the many real and serious grievances which these young specialists-in-training expressed regarding their conditions of service and career prospects, none expressed a desire to return to a free market system of health care provision. While alarmed by the annual emigration rate among British doctors, they themselves vehemently support the underlying equity of the system in treating patients. They themselves don't want to emigrate. They want to stay and make the system work.