SOME OBSERVATIONS ON THE DELIVERY OF HEALTH CARE IN GREAT BRITAIN

EVIDENCE SUBMITTED TO THE COMMITTEE ON WAYS AND MEANS,

SUB-COMMITTEE ON HEALTH

U. S. HOUSE OF REPRESENTATIVES, WASHINGTON, D. C.

FRIDAY 12th SEPTEMBER, 1975.

DR. MAX GAMMON, LONDON, ENGLAND

I would first like to thank you for doing me the honour of inviting me to testify before these hearings and thus to take part in what I believe to be an historic debate.

I am the most junior member of the British Medical Delegation, by quite a long way. I qualified in medicine at University College Hospital in London in 1966 and worked for five years in British NHS Hospitals as a hospital doctor. Four years ago I left the NHS in order to develop a teaching hospital in London, independent of the State. I should point out here that I am using the word "state" throughout this paper to denote the supreme civil power and government vested in a nation as distinct from the more limited territorial usage.

You have already heard from my senior colleagues something of the nature of the conditions within the British state-run service. It was my personal daily experience of those conditions which

Note The presentation by Dr. Gammon delivered to Members of the U. S. Congressional Ways and Means Committee and Members of the Congress of County Medical Societies Inc. at The Tower Hotel, London, 27th June 1975, (P/SM/3) forms the first part of this evidence.

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convinced me that an independent alternative system must be

developed in Great Britain and led me to take my own personally

decisive step.

A few weeks ago in London I was privileged to be invited to speak on the delivery of health care to a delegation of U. S. congressmen and doctors, many of whom are here today. In that presentation I discussed in some detail the empirical evidence of disorder within our National Health Service (NHS), and I have requested that that presentation should be regarded as the first part of my contribution to these hearings.

I would like briefly now to discuss some of the wider general implications for society of a state-run health service with special reference to the British NHS.

I believe that in attempting to assess and draw conclusions from the performance of the NHS since its inception in 1948 it is important to bear in mind that the period under consideration has

been one of unparalleled growth in medical science.

This growth

has transformed medicine throughout the world irrespective of what system of delivery has been employed. It has at the same time placed unparalleled strains on the financing and organization of the medical services of the world and no system is exempt from

the effects of these strains.

In favour of the NHS it can be said that it provides an assurance,

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in theory, that no one in Britain today will be denied essential

medical care by reason of his or her immediate or ultimate inability to pay. However with 500,000 people on waiting lists treatment is likely to be delayed. If "justice delayed is justice denied" then medicine delayed is most assuredly medicine denied and denial is final for those who die on the waiting list. In practice those who can afford to do so avoid the waiting lists by paying doctors and nursing homes for private treatment. These people are in effect paying twice for their treatment, once through taxation and then again in private fees.

It is a significant comment on the NHS that despite the erosion of personal disposable incomes by increasing taxation and despite complete lack of official encouragement the numbers of subscribers to private medical insurance in Great Britain have shown a continuous steady increase since the early nineteen-fifties. The total number of persons insured by U. K. medical provident schemes between 1950 and 1975 shows a 20-fold increase. Even under conditions of extreme financial stringency in 1974 subscription income showed a 25% increase over the preceding year (1) ̧ However in

order to restrict this means of escape legislation is now proposed to control the total volume of private provision for medical care so that it shall not exceed the present level about 2% of total hospital beds. For the vast majority of the population

(doctors and patients) a state-monopoly is to be imposed; the

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ostensible reason is to ensure that the private sector does not operate to the detriment of the NHS. An objective assessment of our nationalized system of health care under conditions of near monopoly during the past 26 years does not provide grounds for confidence in permitting that monopoly to become complete but, barring a miracle, that is what is going to happen.

I am aware that empirical evidence, no matter how overwhelming, can never be conclusive. In particular, protagonists of socialized medicine are likely to argue that given a little more money a satisfactory service can be achieved.

This argument is not however

borne out by examination of the facts of the British experience. Gross expenditure on the NHS has risen steadily from 500m in 1951, (equal to approximately 1,750m in 1973 terms), to 3,000m (3) in 1973. (2) Over that period waiting lists have slowly grown

and even the strongest advocates of socialized medicine could not argue that standards of service and of staff morale have done other than deteriorated.

A most important question to be considered by those embarking on a comprehensive national health care experiment is whether or not the experiment can be discontinued if it proves unsatisfactory. A few weeks ago Enoch Powell, speaking to the delegation of U. S. congressmen and doctors already mentioned, stated that in his opinion the nationalization of the means of delivery of health

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care is an irreversible measure.

After four years unremitting

labour on the development of proposals for a hospital independent of the state in Britain I understand only too well what Mr. Powell means. If in the last analysis I do not agree with Mr. Powell's pessimistic assessment, my own experiences do lead me to concede that de-nationalization of medicine cannot be achieved without

a severe struggle.

The ramifications of a nationalized health service spread widely
and bind tightly within the body politic and economic. The state
comes to be intimately involved in every aspect of life from
before the cradle in genetic counselling, contraception and
abortion, to beyond the grave, with the advent of transplant
surgery. Each aspect of state-directed solicitude has its own
government department and a massive bureaucracy is built up to
manage the service. Moreover after a generation of state-provided
health care it is almost impossible for doctors and patients,
politicians and institutions, to think in terms of any other than
a state system as is reflected in this rather complacent statement
from the Newsam Report on Family Doctors' Service in the NHS,
published in 1959 "Fifty years hence what is happening today

and what may happen tomorrow in the NHS will seem to have been
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inevitable".

Turning briefly to the theoretical basis of the case for delivery