37 In a great ma ments with Betalt. 15 families belongIES have made similar agreemm Under H.R. 470), Ize SOCIA since it would be insurant Spield plans as agent, or m methods are used by med. Armed Forces. Participation on the par more than it is JET TO operate on & benencia as a patient There are about 16,000 practicing surgeons of their specialty boards) practically all of wa pate under the terms of the bill. Qualined doctors who wished to participate in the agreed-upon payments from the insurance system as fied services would so indicate, presumably by registe or pane. They could enter or withdraw at any time sujet to potential patients and to the insurance system. 3. British National Health Service The National Health Service differs in a number of major rem program of hospitalization insurance. The scope of services pre prehensive. The entire population is eligible to use the services, with to the payment of contributions. About 80 percent of the costs are met from general revenues. There is attached a brief summary description of the Natal Bath Somm prepared by the British Ministry of Health. This with regard to the financing of the system and e HR. 4700. The organization of services around her.. doctors" on the other reflects certai Great Britain, but which differ from the Sa ists and consultants in the British Is salaried doctors practicing in a band -doctor who sees patients in his ser family doctor has never provided diagnostic tests, X-rays, and so it hospital: patients are accustomed to the family doctor. This is a featur by U.S. physicians who are a practice available in their ow The cost of the British Na in 1957 than in 1950, the fr health and medical care in this same period. Like the United States. growth in the past 11 7 expenditures under the r country recovered from Like the United States and are making use of are more costly than to validate claims as a cause of riv A P dicines which are umber of surgical Spitals). 400 appliance supd and Wales. ApAfter dispensing, ig offices under the e executive council. in elastic hosiery) >ctor and presented or 10 shillings for her supplier except n dispensing, the 1 harges can be made nd persons who are ne else who satisfies and the Ministry of s or others suffering of accepted war dis They may practice ell as patients under eneral practice takes ive council in whose ister with any parg part in the service the dentist receives ition before seeking ill normal conservardinary denture recreatment which inlentures; provision ed treatment of the and oral surgery. es board consisting >mbers and two lay mitted by dentists, tient's mouth, but treatment if less der half the full replaced because ed to the patient dental treatment m) are not made hers, or mothers in receipt of nae hardship (on ice Board for a stimates board, wns, or metal vishes to have *he hospital s organized be tested acles supopticians medical 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." (There is a separate act for Scotland and also one for Northern Ireland, but the health services in these countries are run on very similar lines to the one in England and Wales.) The Minister of Health is responsible to Parliament for seeing that health services of all kinds of the highest possible quality are available to all who need them. He is advised by the Central Health Services Council (and certain standing advisory committees dealing with special subjects), which he appoints after consultation with the various interested bodies. The National Health Service (Amendment) Act, 1949, received royal assent on December 16, 1949. This act mainly provides for amendments in detail rather than in principle. There are, however, two amendments in principle: The act empowers the Minister, if he so desires, to introduce a charge for prescriptions-a power which was invoked in 1952-and also empowers the Minister, if he so desires, to prescribe charges to be paid for the use of the service by persons ordinarily resident abroad The National Health Service-which is available to every man, woman, and child in the country—is a charge on the national income in the same way as the armed forces and other necessities. Everyone resident in this country is entitled to use any complete part or all of the services and no insurance qualification is necessary. Under the old health insurance scheme, which came to an end on July 4, 1948, only those who paid weekly contributions were entitled to use it and payment had to be made for many months or years before one could claim many of the benefits and there was some things which were not available at all, but which are now available under the National Health Service (for example, hearing aids). Most of the cost of running the National Health Service is paid out of the National Exchequer, that is, from taxes, and about half the expenses of the local health services are met from local rates. Until September 2, 1957, a transfer of about £36,000,000 was made each year from the national insurance fund toward the cost of the National Health Service. As from September 2, 1957, this amount was doubled and was constituted as a separate National Health Service contribution. On July 7, 1958, this contribution was raised again and is now 2s. 4d. a week for a man, of which 1s. 10d. is paid by the employee and 51⁄2d. by the employer. (Women, persons under 18, self-employed, and nonemployed persons pay a smaller contribution.) This national health contribution is just over one-seventh of the national insurance contribution (15s. 10d.), for a man, and, for convenience, is collected with the national health insurance contribution in a single combined stamp. It is estimated that in 1958-59 about £95,000,000 will come from National Health Service contributions. It is important to remember that eligibility for treatment, etc, under the National Health Service does not in any way depend on the payment of contributions. Under the National Health Service Act, 1946, the only charges falling on a patient for any of the services were in certain cases for the renewal or repair of glasses or for the replacement of dentures; for domestic help, for bedding or nursing requisites, etc., required at home; and for accommodation and treatment in private wards in hospitals. It was open to anyone, if they wished, in certain cases to pay the extra cost, if not clinically necessary, of more expensive glasses, more expensive dental treatment and more expensive artificial limbs. It was also possible if a person wished for privacy in hospital, and it was not considered medically necessary, for him to have an amenity bed, in which case he paid a fixed charge for this but nothing for the cost of treatment or mainte nance. Owing to the worsening of the general economic situation in 1949-50, the Chancellor of the Exchequer found it necessary to call a halt to the amount which could be supplied from the Exchequer for the National Health Service and decided that the estimate for 1950-51 should be treated as a “ceiling" and total expenditure should not rise above it. Until 1954-55 the "ceiling" for the National Health Service for England, Wales, and Scotland remained at about £400 million, the only exception being the supplementary estimate introduced in 1952 as the result of the additional remuneration to general practitioners resulting from the Danckwerts Award. The net cost to the Exchequer increased each year from 1954-55 to 1957-58, but, due to the increase in the yield after July 7, 1958, from National Health Service contributions, the amount to be borne on the Exchequer is estimated to fall by £13 million in 1958–59. In order to keep within the original "ceiling" and to avoid drastically cutting down the services available, it was found necessary in May 1951, and again in May 1952, to empower the Minister to introduce charges for certain items in the National Health Service. The National Health Service Act, 1951, authorizes the making of charges to meet part of the cost of dentures and glass provided through the Service. These charges operated from May 21, 1951. Patients who cannot afford to pay the charges are able to apply for help to the National Assistance Board. The National Health Service Act, 1952, authorizes the making of charges for medicines and certain appliances supplied to hospital outpatients (medicines and appliances prescribed by a general practitioner are covered by the 1949 act), for dental treatment (excluding examinations) provided under the General Dental Services, and for day nurseries run by local health authorities. As with the 1951 act, people who are unable without hardship to meet the charges may apply to the National Assistance Board and there are also some exceptions from charges made to outpatients and for dental treatment. These charges came into force on June 1, 1952. Except when elastic hosiery was prescribed, the 1s. charge for prescriptions covered all items ordered on one form. By regulations operating from December 1, 1956, this charge was altered to 1s. per item. All the charges plus the small Health Service contribution referred to above, meet rather less than one-fifth of the total cost of the Service, which remains a predominantly "free" service available to all. Details of the main branches in which the Service is broadly divided are as follows: HOSPITAL AND SPECIALIST SERVICES On July 5, 1948, ownership of 2,688 out of 3,040 voluntary and municipal hospitals (including mental hospitals, mental deficiency institutions, convalescent homes, and certain types of clinics), in England and Wales was vested in the Minister of Health. About 250 hospitals remain outside the National Health Service, most of these being hospitals run by religious orders. The hospital service, of which the specialist and consultant facilities form part, includes general and special hospitals; maternity accommodation; tuberculosis sanatoriums; infectious disease hospitals; provision for chronically sick, mental hospitals, and mental deficiency hospitals, accommodation for convalescent hospital treatment and medical rehabilitation, and all forms of specialist treatment, for example, plastic surgery, radiotherapy, orthopedic and ear, nose, and throat treatment, together with the provision of most surgical and medical appliances. In the main, this part of the Service is organized on behalf of the Minister of Health in regions by 14 (15 after April 1, 1959) regional hospital boards. Each hospital region is associated with a university having a teaching hospital or medical school. The board members who serve in their own time and without payment, have a variety of experience gained with all kinds of organizations and official bodies. Day-to-day administration of the hospitals is carried out on behalf of the boards by hospital management committees. There are 383 of these and they are usually responsible for a group of related hospitals. Their members also serve voluntarily. This means that there is great scope, as in the past, for local responsibility and local interest. The only hospitals in the Service outside the regional boards' immediate responsibility are the teaching hospitals which have the responsibility for providing facilities for undergraduate and postgraduate medical or dental education and which are administered by boards of governors. There are 26 boards of governors in London and 10 in the Provinces. Nearly all specialists and consultants take part in the Service. They hold hospital appointments and can take up whole-time or part-time service. Those who have part-time appointments can still accept fee-paying patients outside the Service. Certain hospitals have accommodation in small wards or single rooms which, if not required for patients who need privacy for medical reasons, may be made available to patients who desire it as an amenity. Amenity bed charges are fixed under regulations at 6s. to 12s. per day. In such a case, the patient pays nothing for the cost of treatment or the cost of maintenance. In some hospitals a number of pay beds has been placed at the disposal of part-time specialists taking part in the Service for use by private patients who agree to pay full hospital maintennace costs and (usually) private fees to the specialist as well. The fees that may be charged by specialists to patients occupying private pay beds are normally restricted to 75 guineas to cover everything. For exceptionally long or complicated treatment, this limit may be raised to 125 guineas, and special arrangements may be made in a limited portion of pay beds for patient and doctor to agree to fees outside these limits. Arrangements to obtain the service or advice of a hospital specialist are made by the patient's family doctor as in the past. A specialist usually sees a patient at the hospital or clinic at which he works, but arrangements will be made for the specialist to visit a patient at home if he is unable, for medical reasons, to be taken to hospital. No charges are made to National Health Service inpatients (except for amenity beds, see above), but there is a charge of 1s. to outpatients for each item on a prescription form for drugs and medicines (unless administered at the hospital). Exceptions from this charge are made in the case of patients receiving national assistance or their dependents; war pensioners receiving medicines for their accepted disability; and patients attending venereal disease clinics who receive medicines as part of their treatment. Persons who find hardship in paying the charge can apply to the National Assistance Board for repayment which will be met if, on national assistance standards, a person has insufficient means to pay the charge. Hospital outpatients also have to pay fixed charges for elastic hosiery, surgical abdominal supports, surgical footwear (and heeling and soling repairs), and wigs. Repayment can be made as above or assistance obtained before supplying. Exceptions are made in the case of a child under 16 years of age or at full-time attendance at school, to national assistance recipients and their dependants and to war pensioners in respect of their accepted war disabilities. At the end of 1957 there were 80 hospitals providing distribution centers where hearing aids can be supplied free after a recommendation by a specialist. GENERAL MEDICAL AND DENTAL SERVICES, PHARMACEUTICAL SERVICES AND SUPPLEMENTARY OPHTHALMIC SERVICES Family doctor service The family doctor service is organized in accordance with regulations by 138 executive councils whose members serve in a voluntary capacity. These councils also organize the dental, pharmaceutical, and supplementary ophthalmic services for their areas. Executive councils have been set up to cover every county council and county borough area, but in some instances, for more efficient administration, one council covers two areas. Twelve members of each executive council are appointed by local doctors, dentists and pharmacists, eight by the local health authority, and five by the Minister. The council elects its own chairman from among its members. All doctors are entitled to family medical doctor service, and general practitioners (about 22,000) have decided to do so. Taking part does not prevent them from also having private fee-paying patients. The Health Service doctor is paid on a capitation basis, i.e., a fee in respect of each patient whom he accepts on his list. Everyone aged 16 and over can choose his doctor (parents or guardians choose for children under 16) and the doctor is also free to accept a person or not as he chooses. A person may change his doctor if he wishes, either at once if he has changed his address or obtained permission of the doctor on whose list he is, or by informing the local executive council (in which case a delay of about 14 days is usual). When people are away from home they can still use the family doctor service if they ask to be treated as "temporary residents," and, in an emergency, if a person's own doctor is not available, any doctor in the service will give treatment and advice whether the person seeking it is on his list or not. All doctors who joined the service by July 5, 1948, were free to continue practising where they were. Since July 5, any doctor wishing to take up a National Health Service practice must first get the consent of the medical practices committee, consisting of a chairman (who is a medical practitioner) and eight other members, six of whom are medical practitioners-at least five still in actual practice. The committee is only able to refuse an application if the number of doctors in the family doctor service in the area is already considered to be sufficient or the number of applicants exceeds the number of vacancies. Patients are treated either in the doctor's surgery or, when necessary, at home. Doctors may prescribe for their patients all drugs and medicines which are medically necessary for their treatment and also a certain number of surgical appliances (the more elaborate being provided through the hospitals). Pharmaceutical services There are about 13,250 pharmacies, 160 drugstores, and 2,400 appliance suppliers taking part in the pharmaceutical services in England and Wales. Approximately 207 million prescriptions were dispensed in 1957. After dispensing, the chemist sends the prescription forms to one of the pricing offices under the control of a central joint committee. Payment is made by the executive council. There is a charge of 1 shilling for each item (other than elastic hosiery) ordered on a prescription form made out by the family doctor and presented for dispensing. The charge for elastic hosiery is 5 shillings or 10 shillings for each article. The charges are paid to the pharmacist or other supplier except that in the country areas, where the doctor does his own dispensing, the 1 shilling charges are paid to the doctor. Repayment of the charges can be made in certain cases: The National Assistance Board will refund persons who are receiving national assistance, or their dependents, or anyone else who satisfies the board that payment of the charges will cause hardship; and the Ministry of Pensions and National Insurance will refund war pensioners or others suffering from war injury where the prescription is needed because of accepted war disabilities. Dental services Dentists are free to take part in the service if they wish. They may practice in any area they choose and may have private patients as well as patients under the service. The great majority of dentists available for general practice takes part in the service. Dentists are responsible to the executive council in whose areas they provide services. Patients do not have to register with any particular dentist, but are free to go to any dentist who is taking part in the service and is willing to accept them. Instead of a capitation fee, the dentist receives payment for items of treatment for individual patients. There is no need for the patient to obtain a recommendation before seeking dental treatment. The dentist is able to carry out at once all normal conservative treatment (e.g., fillings), emergency treatment and ordinary denture repairs. He needs to get prior approval before undertaking treatment which involves the removal of teeth necessitating replacement by dentures; provision of dentures; orthodontic treatment; extensive and prolonged treatment of the gums; gold fillings, inlays, crowns and special appliances and oral surgery. Prior approval of this kind is given by the dental estimates board consisting of a dental chairman and vice chairman, five other dental members and two lay members. The board also authorizes claims for payment submitted by dentists, actual payments being made by the executive councils. No charge is made for the clinical examination of a patient's mouth, but there is a charge of £1 for treatment, or the full cost of any treatment if less than £1. For dentures a patient has to pay something under half the full cost, but where a denture supplied under the service has to be replaced because of loss or damage, the whole or part of the cost may be charged to the patient if he is found not to have taken reasonable care. Charges for dental treatment (other than the supply or relining of dentures or additions to them) are not made in the case of anyone under 21 years of age, or expectant mothers, or mothers who have had a child during the preceding 12 months. Persons in receipt of national assistance and others for whom the charge would involve hardship (on national assistance standards) may apply to the National Assistance Board for a special grant. A dentist may, with the approval of the dental estimates board, charge his patient a prescribed sum for gold fillings, inlays, crowns, or metal dentures where these are not clinically necessary, but the patient wishes to have them. Supplementary ophthalmic services In addition to the eye services available at clinics as part of the hospital and specialist services, there are supplementary ophthalmic services organized by the executive councils. On the advice of the family doctor in the first instance, sight can be tested by ophthalmic medical practitioners or ophthalmic opticians and spectacles supplied if necessary. Nearly all ophthalmic opticians and dispending opticians take part in the service (more than 7,000) and most of the ophthalmic medical |