England's Public Medicine: The Facts

In the storm of praise and blame which British socialized medicine has blown up on this side of the Atlantic, the findings of independent experts have been all too scarce. For the past twenty-seven years DR. JAMES HOWARD MEANS has been Jackson Professor of Clinical Medicine at the Harvard Medical School and Chief of the Medical Services at the Massachusetts General Hospital. In his repealed visits to Britain he has come to have a close knowledge of British hospitals and clinics, and in 1949 he made his most recent trip of inspection.

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I HOLD no brief either for or against the British National Health Service, but I firmly believe that information about its success or failure will ultimately prove to be of great value to us in our own country. We have problems in this field to solve ourselves. We can be aided by the experience of others.

Americans either hold up the British Health Service as a horrible warning or use it as a talking point in favor of compulsory health insurance for the United States. Neither of these positions can be regarded as objective or realistic. What is needed is less recrimination and more investigation, and the first question to be put is, How is the system serving Britain? On my visit to England and Scotland last year I chatted with many people, both medical and nonmedical, I visited clinics, and I read a variety of British newspapers and journals. Some of the people I talked with were friends of many years’ standing, the value of whose opinions I am sure I know accurately. Others were new, and some were chance acquaintances. Since returning home I have kept up a brisk correspondence on the subject.

I started off with the steward and stewardess aboard ship going over: both are English; both live in Liverpool. The steward was strongly in favor of the Health Service; the stewardess was against it. Both were working people, but one belonged to the Labor Party, the other to the Tory. This even split, it soon became evident, was no accurate indication of how the British people as a whole view the Health Service. There can be no doubt whatever that, with varying degrees of enthusiasm, the vast majority of the people are for it.

The attitude of the doctors, however, is very different. Among them there is undoubtedly much discontent. This runs all the way from trifling dissatisfaction to something approaching actual hostility. A very small number are enthusiastic proponents of the service. Organized medicine in Britain, represented by the British Medical Association, fought certain provisions of the National Health Service Act vigorously, but did not oppose its basic principles in any such uncompromising fashion as the American Medical Association has resisted any and all proposed legislation for a national health program here at home.

In Britain at the present time, the Health Service being a fait accompli, I found it to be practically the unanimous opinion of all with whom I talked, doctor and layman alike, that it is there to stay, regardless of the outcome of February’s general election. The problem is how to improve it to the point where it is, for everyone, fit to live with.

The actual direction which the development of Britain’s National Health Service has taken was conditioned to a considerable degree by the war. When, in 1940, invasion of Britain became imminent and aerial bombardment certain, an integrated emergency medical service (EMS) for the entire realm, to take care of military and civilian wounded and sick, was rapidly set up under the wartime powers of the government. The system devised made use of all hospital and professional services in the United Kingdom. Each individual, each unit, was assigned an area of responsibility — a particular function in relation to the whole. First aid, dispensary service, and hospitalization were systematized and services distributed so as to become universally available. Channels for the evacuation of sick and wounded were established. Though set up hurriedly, the EMS worked with great smoothness and success. Forced upon Britain by the war, it set the pattern for, and accelerated the tempo of, the socialization of medicine.

The main intent of the act which brought the National Health Service into existence on July 5, 1948, is to provide complete medical care for all people, to promote health, and to prevent disease. The training of professional personnel and the conduct of research are both recognized as essential to the success of the plan, and although these are primarily still in the hands of the universities, there is extensive interlocking with the Health Service at the level of the teaching hospitals. In a socialist state it becomes an obligation of government to ensure the production of a sufficient number of optimally trained physicians and surgeons and other professional personnel; also to see that medical knowledge is advanced to the greatest possible extent through research. In our more conservative democracy these functions have been left to a considerable degree to private enterprise. With us, the Federal or the state governments take some, but by no means complete, responsibility for them.

Although intended to provide medical care for all people (even aliens temporarily in the country) the Health Service is not compulsory; any person or any doctor can remain out of it. Doctors may serve under it and also engage in private practice, if they can find any. Medical care in Britain today is on a basis analogous to that of primary and high school education with us. All are entitled to it without direct payment but are not compelled to take it. As we may send our children to private schools, so Britons may go to private practitioners of medicine if they wish, and can afford, to do so. But as we pay for education in this country through taxes, whether we send our children to private or public schools, so do British citizens pay for the Health Service through taxes1 whether they use it or not. Harley Street in London and its equivalents in provincial cities seem as full of doctors’ offices as ever, and a considerable volume of private practice is going on in them. However, the doctors with whom I talked were convinced that it would slowly diminish until it might reach the vanishing point.

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FINAL responsibility for the administration of the entire Health Service rests with the Minister of Health, a cabinet officer appointed by the Prime Minister and therefore likely, as with us, to be replaced with each change in the government. The present Minister of Health, Aneurrin Bevan—one of Winston Churchill’s pet antipathies — while by no means the originator of the concept of a unified national health service, was nonetheless to a considerable extent the architect of the present act. Of it in 1946 he said, “We have just passed through Parliament the greatest single health measure of our history. We are facing, at this moment, the monumental task of putting it into operation. We are trying to secure that in future the medical and health resources of the country are available to everybody in a rational and organized way, irrespective of personal means. But the availability of the health services is not our only object; we are also aiming at their improvement and expansion. This will not be achieved in a moment; it will require a great deal of hard work, and it will require the intelligent coöperation of the public.”

He might have added “and of the medical profession,” but he didn’t, and there, I gather, lies a considerable portion of the rub. The majority of doctors with whom I talked had the feeling that Bevan had consulted the profession inadequately in drawing up his plans. This has embittered them rather extensively. It is not health acts in general to which they are opposed, but this particular one, which they think was set up in a bungling manner.

From the Minister of Health extend three main ramifications of administrative responsibility — namely, those of hospitals, general practice, and local health authority. The classification of hospitals and doctors under the act needs elucidation. Hospitals in Britain, as with us, prior to the inauguration of the National Health Service, fell into three major categories: voluntary hospitals, municipal hospitals, and private or commercial hospitals — generally called “nursing homes.” The so-called voluntary hospitals, such as Guy’s or Saint Bartholomew’s in London, are the equivalent of our privately endowed charity hospitals, such as the Massachusetts General Hospital in Boston, the Presbyterian in New York, or the Barnes Hospital in St. Louis. The voluntary hospitals are the ancient hospitals of Britain; originally run by the Church, they later became secular charitable enterprises. It is in them for the most part that medical education has been conducted.

For the administration of the government-owned hospitals, England and Wales have been divided into fourteen hospital regions, each based on a university medical school. In Scotland, which has an independent but similar national health service, there are six regions. The administrative control of the Scottish system lies in the Secretary of State for Scotland. Each region has a regional hospital board appointed by the Minister to govern hospital affairs.

On July 5, 1948, the ownership of all voluntary and municipal hospitals was transferred to the Minister of Health. The nursing homes were left out, I have no doubt with the expectation that they will gradually wither on the vine.

It must be remembered that at the end of the war the voluntary hospitals were close to bankruptcy. Something had to be done about them, and done fast. The hospitals and the doctors at the head of them were swept along in the process of socialization then taking place in Britain.

The doctors of Britain under the Health Act are classified into four categories: (1) general practitioners, (2) a large and diverse group of hospital doctors, consultants, and specialists, (3) full-time clinical teachers, and (4) medical officers of health and their associates in the local health authorities.

In the promotion of health and the attack upon disease, the general practitioners are the front-line troops. Each general practitioner has a list of persons in his area who have joined the Health Service, who have chosen him to be their doctor. Such a practitioner is paid by the government so much a head per year for every name on his panel. He is allowed to take up to 4000 persons. In our country this number would usually be considered excessive. To them he must render complete general practitioner service. The patients under this system are entitled to free medicine, which they can get on the doctor’s prescription only.

Does the patient have any choice of physician? Yes, to a certain extent. So far as possible he is allowed to choose among the doctors in his area, but obviously in any area ultimately the total number of patients must be assigned among the available doctors in some reasonable proportion. The doctor is not obliged to receive any patient on his panel that he doesn’t want, nor is the patient compelled to remain with a doctor he does not like. No troublesome obstacles are placed in the way of patients wishing to change doctors. General practitioners also are allowed to take on as private patients any persons not enrolled on their panels and charge them fees for service.

When the general practitioner encounters something he cannot handle, he transfers the patient via a hospital to one of the doctors of the class which I have numbered 2. This class includes the great group of practitioners who under the previous regime were on the staffs of voluntary or municipal hospitals. They made their living in whole or in part in private practice, chiefly of a specialist or consulting character — they were the Harley Street type of doctor. Under the National Health Service they function much as before, but they are paid by the government for everything they do for the service. They are based on hospitals and see their public patients as arranged by the hospital administration. This duty may be in ward or dispensary (outpatient department); or when necessary, arrangements can be made through the hospital for the consultant to see a patient with a general practitioner in the patient’s home, and this type of domiciliary service is proving very helpful for a class of society to which it was not formerly available.

Payment of the consultant-specialist class of doctors is not on a panel system, it is on a time basis. The word “session” has been employed as the unit of work for doctors of this class. A “session" is half a day’s work once a week per year. It may consist of any kind of professional work which this type of doctor is called upon to do — consulting, operating, or teaching.

Doctors are free to choose how many sessions they will serve, up to a total of eleven, and for each they receive a flat rate per annum. A doctor taking nine and a half sessions or more is considered to have an adequate wage without the necessity of supplementing it with private practice. There are a few doctors who have stayed out of the Health Service altogether and still succeed in making a living on the old private practice basis, but they are excluded from all the nationalized hospitals — which is, from the point of view of keeping educated, a great handicap. There are a larger number who fall between these extremes, and carry on some public and some private practice.

A very significant item in the over-all administration plan of the Health Service is that those hospitals which have been designated as teaching hospitals have been put in a special category. In England and Wales they are not directly under the regional hospital boards (in Scotland they are), but instead have their own boards of governors, which are appointed by joint action of the university concerned, the hospital staff, and the regional board.

This arrangement is to be interpreted as a consciousness on the part of the drafters of the plan of the fundamental necessity of preserving a measure of academic freedom in medical education, and of protecting it against any kind of political influence. My observations would indicate that this objective so far has been attained. It is through the teaching hospitals that the universities and the National Health Service find themselves engaged in a joint enterprise. The universities beyond this are not related to the Minister of Health. They as yet have not been nationalized.

Research is done chiefly in the university medical schools and the teaching hospitals as with us, although the Health Act gives every regional hospital board and every hospital management committee the power to initiate research and through a separate amenity fund to spend money on research.

It is interesting, however, that the most important research organization in the country, the Medical Research Council, is not under the Minister of Health at all. It is administered through the Privy Council, a separate department of the government. The Medical Research Council was set up in this way during the First World War, and was not changed when the Health Service came into being after the Second.

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THE Health Service is working — that much is fact —but how well? Fairly well, but far from perfectly would be my judgment. Its success or lack of success, for want of an adequate frame of reference or control, cannot be measured quantitatively. One can only attempt to find out whether the British people are getting good, bad, or indifferent medical care under the National Health Service, or whether post-war Britons are getting as good service out of their medical system as pre-war Britons did out of theirs. One cannot expect to discover whether, as things are now in Britain, the service provided under the National Health Act is better or worse than that which might be provided under some other type of system.

I have had opportunities occasionally to observe the work in the great British hospitals over a period extending back to 1913, and what I saw this past summer gives me the impression that there has been no important change, certainly no deterioration in the quality of care provided. At no time in Britain, in the United States, or in any other country has the practice of medicine been as uniformly good as the medical knowledge of the time would permit it to be. There is always abundant room for improvement. To those tub thumpers of organized medicine in the United States who rant about our having the best medical service in the world, I would say, “Possibly, but how many people get it?” Not many, I am sure. In both countries either now or in the past, there is, or has been, good, bad, and chiefly indifferent medicine. To evaluate a national medical system we need to know the over-all standard of medical practice provided under it. I am unable to assert that the general standard is higher in Britain under the National Health Act than it was before that went into effect; but, on the other hand, I have encountered no convincing evidence that it is lower, and certainly more people get it.

There are many “bugs” to be got out of the Health Service — after all, it has been going for only nineteen months. Doubtless in time they will be got out, and the service will improve accordingly. Right now an amending bill is on its way through Parliament which will correct a number of the faults already found in the act. One of the most crying needs is to improve the lot of the general practitioner. He is today unquestionably overworked, underpaid, and insufficiently related to hospitals. But these abuses are correctable. One of the sorest points is that dentists are making about double what the general practitioners of medicine are. This is partly due to the fact that dentists are paid by the job, whereas general practitioners of medicine are paid on a capitation basis.

Abuse by patients of their privilege to see the doctor is another difficulty. Since it costs them nothing, they go, it is claimed, oftener than is necessary. There is reason to believe that this situation will be rectified. A token fee for each visit might be imposed, sufficient to put on a slight brake without vitiating significantly the principle of free care. Recently a charge of one shilling, not for visits to the doctor but for prescriptions written by him, has been imposed. Whether this will serve a useful purpose is not yet clearly discernible.

A great clamor has been made about free eyeglasses, free dentures, and even, in certain cases, free wigs, provided by the Health Service. Certainly there has been a colossal demand for these props to health. But is that fact a just criticism of the Health Service? All it would seem to mean, when viewed dispassionately, is that under the previous system there were great numbers of people who needed these prosthetic appliances and could not afford to get them. The stories of abuses of these privileges I am convinced are exaggerations, and I am assured that steps are being taken to eliminate such abuse as does exist.

One of the important elements of the program is the development throughout the country of local health centers. These will be primarily to implement and facilitate the work of general practitioners. They will even provide them in many instances with office space.

The difficulty is that the health centers have not yet really got going. The London County Council’s first large health center, I am told on good authority, will be in full operation in 1950, and three or four others in 1951. But for the most part the health centers are still largely in the blueprint stage.

The two most serious criticisms of this system that I encountered were that it is costing more than the country can afford, and that it is undermining the incentive to doctors to do good work.

Certainly the Health Service is costing much more than was anticipated. Whether it is more than the country can afford is a question inextricably bound up with that of the whole economy of Britain.

I am a physician, not an economist, and cannot possibly throw any light on it.

The undermining of incentive to excel would be a serious defect. It is difficult to determine to what extent, if any, it actually prevails. One English prophet of doom, Lord Horder, who talked to American doctors at Atlantic City last June, can see nothing but deterioration ahead for British medicine under government control, but I did not find such a totally pessimistic view to be, by any means, universal among British doctors. It should be remembered that, hardly anything but opinion is available at present. Only experience will answer the question, and nineteen months’ experience with the Health Service is not enough time by which to judge it accurately.

My feeling is that Britain is trying a momentous experiment in the nationalization of medicine. Since we too have great problems before us in our own country regarding the promotion of health and the provision of good medical care to all who need it in the community, it behooves us to watch closely and objectively the progress and outcome of Britain’s project. Our observations will deepen our insight and may lead us to make wiser decisions concerning our own problems, which admittedly are different in many ways from those of Britain. We should be grateful to Britain for making this venture.

  1. A small fraction of the expense of I lie Health Service is met through payroll deductions in the case of employed persons, and from compulsory contributions by employers.