Government Medicine: You Want the Good News or the Bad News First?
If only we had a national health plan, they always say, we could control rising medical costs, curtail unnecessary tests and surgery and medication, and guarantee that no person will lie sick or dying for lack of money. What they don't ever say is that nationalizing medical care means that all doctors and other health care providers become government employees; that it means setting up a bureaucracy to dispense examinations, medications, surgery, and so on. This may seem like a minor price to pay for all the stated advantages of government provision of health services. People who are not convinced otherwise by the example of the federal bureaucracy that is closest to them—the US Post Office—ought to look at the British experience with socialized health care.
The National Health Service Act was passed by Britain's Labour-dominated Parliament in 1946. Two years later, Minister of Health Aneurin Bevan's dream, the National Health Service, came into being.
I recently visited England with a group of doctors and members of Congress. The purpose of the trip, sponsored by Private Practice magazine, was to give us a first-hand view of the workings of socialized medicine.
FREE LUNCH COSTS Paradoxically, although the NHS budget has increased dramatically, Britain still spends on medical care a smaller proportion of its gross national product than almost any other Western nation. (The latest available data show that in 1976 Britons were spending 5.6 percent of that country's GNP on medical care, while US residents were spending 8.5 percent and West Germans 9.7 percent.) Politicians can always find more politically interesting uses for the taxpayers' money. As socialist politician Richard Crossman admitted: "People are prepared to subscribe more in a contribution for their own personal or family security than they ever would be willing to pay in taxation."
Thus, because every cent spent on medical care must come from taxes, too little is spent. And too much—too much, that is, because such a large percentage of the Health Service budget goes for administration, which benefits patients not at all. In fact, it harms them, by bureaucratizing the delivery of care.
In the Health Service, there are five layers of almost impenetrable bureaucracy: the Department of Health and Social Services, the Regional Health Authorities, the Area Health Authorities, the District Management Teams, and the Sectors (Hospitals). Stories are rife concerning the effects of all this administration on the health care being administered.
• In Newcastle, young doctors making applications for residencies have their candidacies considered by 14 separate committees. In Truro, the local bureaucrats spent $150,000 on "reorganization" but refused to allocate $40,000 for the operating rooms desperately needed by the city's major hospital.
• The dean of a medical school in northern England adds up all the committee meetings he is supposed to attend and finds they would take all of his time, leaving none for work.
• One London hospital finds 25 percent of its outpatient records missing, thanks to administrative mix-ups.
• A clinical professor at a great London teaching hospital says that the simplest hiring decisions take a year.
TERMINAL WAITING Bureaucratic, rationed medicine can have more dangerous effects than administrative muddle, however. Mike Wallace, in a laudatory report on the NHS on the TV program 60 Minutes, told of a woman who needed open-heart surgery and got it immediately, with no expense but bus fare from home. He missed the more typical story of the woman from Wales whose case was described in a report by Sir Alan Marre, the NHS ombudsman: After a long wait she was called into the hospital for open-heart surgery on January 20. On January 30, one day before she was to be operated on, the surgery was cancelled and she was discharged because of crowding on the surgical schedule. Four and a half months later she was readmitted but was again discharged four days later. She was to enter the hospital again on June 27 but on June 26 she was notified by telephone that her operation was cancelled. She died two days later.
The NHS ombudsman also reported on a man needing surgery as a result of an automobile accident. Even though his pain prevented him from working, he had to wait more than 11 months.
A general practitioner referred a woman patient to the hospital for a biopsy of a lump in her breast. It was eight weeks before the hospital got around to it, and afterwards she was discharged while still groggy from the anesthesia. When she returned to have the stitches removed, the biopsy results were "not available." Some days later her doctor was notified that the lump was malignant. He then referred her back to the hospital for surgery, but she was informed that they could give her no firm date for admission.
An elderly woman needed a hip replacement. She was told that she could be admitted in nine months to a year. Two years later she was still thirty-second on the list. Another older lady was placed on the waiting list for hip replacement. One year after her admission had been classified as "urgent," she was still waiting.
An orthopedic surgeon at St. Mary's Hospital, Paddington, told me that any elderly person needing a hip replacement will probably die before getting to the top of the list. In London, he said, it takes an average of nine months to get an appointment with an orthopedist. In other specialties it is not much better, with waiting lists for hospital admission ranging from one to two weeks for acute cases, to two to three years for hernias and other non-life-threatening problems.
Dr. Christian Loehry, chairman of the medical staff at Royal Victoria Hospital, said that crowding has led to patients' dying at home before they can be admitted, patients' dying in the emergency rooms after waiting hours for a bed, cancer patients' waiting up to six weeks for treatment while their tumors spread, the smuggling of emergency cases into the beds of patients being operated on (leaving no room for the patients who successfully return from surgery).
MAD AS HELL One of Britain's leading orthopedic surgeons, Dr. John Cozens-Hardy, called a meeting of his patients, or would-be patients. He felt they were entitled to know why they had to spend years "imprisoned by constant pain." At the present rate, he told them, it would take 36 years to clear the 127 people on his waiting list. The delay was caused by a chronic shortage of beds, operating rooms, and trained medical staff. And the reason for the delay, he said, was political.
"I'm paid to help these people," he told a newspaper before the meeting, "but I am denied the opportunity. When this ever-worsening situation goes on, year after year, one reaches the point where one either resigns, commits suicide, or screams. I have decided to scream."
In Britain, overutilization caused by the zero price not only packs the waiting lists (some 750,000 people are on them by the government's own statistics); it also makes hospital stays longer. The average British patient will spend 11 days in the hospital for an uncomplicated hernia. Some hospitals average 21 days. For an uncomplicated cholecystectomy, the average is 10 days, with some hospitals averaging over 15. In nongovernment hospitals in the United States, the average stay for both operations is 5 to 6 days.
Just as doctors can't choose their patients, patients cannot choose their doctors. "When the patient eventually arrives in hospital for surgical treatment," said orthopedic surgeon Anthony Partridge, "he must sign a consent form before the operation can take place which states: 'No assurance has been given to me that the operation will be performed by any particular practitioner.' But the discerning patient wants to make sure that he has the surgeon of his choice.…The patient is scared stiff of being operated on by some doctor in training. Even the politicians who want to get rid of private practice for the rest of us use it themselves when it is a question of a knife going into them."
Anthony Wedgewood Benn, the ex-viscount who leads the Marxist wing of the Labour party, has demanded the abolition of private medicine. But when Benn's small son required surgery, he was admitted secretly under Mrs. Benn's maiden name as a private patient. "This is in itself a terrible indictment," said British physician Ralph Haris. "It is a corroding force whereby politics is made into a sham. People who recommend the Health Service for everyone else—'It's the finest in the world'—avoid it when their health, or their family's, is at stake."
DANGER LEVEL In many hospitals, over half of the doctors are Asian-trained. If difficult surgery is to be performed, the patient will probably have an English surgeon the equal of any in the world. For more routine surgery, he may get a doctor trained in Bangladesh.
Britain has such a high proportion of foreign physicians because of the "brain drain," which works two ways. British doctors emigrate to the United States, and England is a big attraction over Sri Lanka. And the process is accelerating. A resident at London's Charing Cross Hospital told me that out of the 25 doctors he qualified with, 10 have already left, with more on the way.
But the quality of the doctors immigrating to Britain is much lower than those leaving. Just recently the government started giving tests to foreign physicians wishing to join the NHS. Of the first two groups, 60 and 62 percent failed the tests in language and clinical skills.
"Half of the hospitals in the country should be closed," one NHS employee told me. But even at the better ones, food is atrocious and ancillary services are almost impossible to get outside normal working hours. Doctors told us they could usually get pathology and radiology services between 9:00 and 5:00, five days a week, but sometimes not even then. At night and on weekends, it was out of the question.
A young hospital doctor summed up his feelings for us: "The thing that disturbs me and I think disturbs most of us is that we can all see a steady deterioration in the standard of service we're offering the patient. And that standard has now reached the danger level. Patients are suffering considerably due to this, and some are dying. We are simply not able to provide the care necessary."
Staff shortages at the Royal Northern Hospital in Holloway have led to hospital orderlies routinely administering anesthesia in the operating rooms. The Camden and Islington Area Health Authority has ruled this a safe and proper procedure.
Medical care in the United Kingdom would be far worse, however, were it not for the dedicated English doctors I met. Ill-paid and overworked, they still work miracles for their patients. Dr. James Appleyard, pediatric consultant at Canterbury Hospital, works the normal specialist's week of 65-100 hours, even though his contract calls for only 30 some hours. For two years he devoted his spare time to raising private money, especially hard to get in overtaxed Britain, to built a pediatric intensive care unit that the government refused to provide.
But morale is deteriorating drastically. I didn't find one doctor who isn't bitter toward the NHS as salaries fall farther and farther behind inflation and standards of patient care fall just as quickly. As more and more doctors leave in disgust, the NHS can be expected to provide even shoddier care.
General practitioners are paid the equivalent in pounds of about $5 per patient per year. They usually have over 3,000 patients on their lists, to whom they must give unlimited service. "It is quite easy to manage 3,000 patients," said Dr. Anthony Partridge, "acting as a sort of clearing house. But it is quite impossible to doctor them, to listen to them and to reassure them, as we were taught to do as students.…The doctor is paid on quantity, not quality."
A proper first examination should take about 45 minutes, but in the NHS four minutes is the more usual pattern. Unlucky patients do not get even that but are given a prescription following a telephone conversation with the receptionist.
IF THEY ONLY KNEW "We mourn," Sir Keith Joseph said, "for the advantages of a payment to doctors. Our doctors get no benefit from being popular. Our doctors get no benefit from being successful with patients. Our doctors get no benefit from courtesy to patients. The less time they spend on each patient, the better off they are. We are kicking against human nature in what we've done. The best of our doctors provide devoted service, but against the interests of themselves and their families."
Despite all this, the NHS continues to be politically popular. The British don't think about the kind of medical care they could enjoy if only they were able to spend the money themselves that their government spends for them. "The public," said Sir Keith, "regards the Health Service as being paid for by some invisible source of money and therefore is not realistic about either cost or the service that is to be expected."
As my bus headed away from London toward the airport, I asked the airline's representative, an attractive young woman but for her facial scars, what she thought of NHS.
"It's a good system," she said. "We get all our medical care free, you know. No worry about expense."
"No complaints at all?"
"It is rather slow. I had to wait eight years for an appointment with a plastic surgeon about my face. When I saw him, he said I'd have to wait a year for treatment. But it is free."
Copyright © 1980 by The Intellectual Activist, Inc.
Llewellyn Rockwell is the former editor of Private Practice and is currently an administrative aide to Congressman Ron Paul. This article is excerpted by permission from The Intellectual Activist (175 5th Ave., New York, NY 10010).