Monday, July 02, 2007

The beginnings of the NHS

I have been prompted by a couple of e-mails to say something about the NHS and NICE. Michael Moore’s film Sicko has raised the profile of the NHS in America and recently the election of a Democrat congress and the possibility of a Democrat President have made it more likely than not that something will be done to change the organization of health care for America.

The National Health Service (NHS) was introduced in Britain in 1948 at a time when the country was on its knees following World War Two. Britain (and its empire) was the only country that had fought against Germany for the whole of two world wars and despite having entered the twentieth century as the richest nation on earth, it had become not just impoverished, but also indebted. In 1945 a Socialist government was elected. Perhaps as a necessity almost everything was nationalized: coal, steel, the railways, the docks, much food production, and medicine. The Thatcherite revolution has undone all of that but medicine remains a nationalized industry. Why is that?

Establishing an NHS was not primarily an idea of the socialists. It had started under Lloyd George, the Liberal Party Prime Minister early in the century and multi-party committees operating during WWII produced the Beveridge (a liberal Peer) Report that advocated major changes in how health care was provided. There were already many quasi-insurance schemes that enabled the poor to get access to doctors. Before the NHS most doctors operated a sort of ‘club’ scheme whereby relatively poor people, by paying a small amount a week, could have access to a family doctor when they needed one. There were even schemes where employers operated such systems for the benefit of their employees. The great teaching hospitals were charitable trusts where free treatment was available to the poor, the consultants making no charge for their time, but making up for that by charging a great deal to their rich private patients. Harley Street and Wimpole Street were the sites of many consulting rooms and patients came from all over the country to see the great men. There were private hospitals and private wings in the teaching hospitals.

Elsewhere in the country the hospitals were sometimes also charitable trusts but sometimes owned and run by the municipal authorities. There is no doubt that most doctors were very well paid. They drove the sort of cars that had the stamp of quality. It was usual that a teaching hospital consultant drove a Rolls-Royce. Even a family doctor would drive a Rover. If you read AJ Cronin’s The Citadel you will get a good flavour of how it was.

There was a great deal of resistance from the doctors to the imposition of the NHS. Eventually Aneurin Bevan, the fiery Welsh Health Minister famously ‘stuffed their mouths with gold’. He allowed the consultants to keep their private practice and allowed the family doctors to run their own businesses. This remains to this day; family doctors (known in the UK as General practitioners – GPs) still act on a contractual basis, each partnership having a separate contract to provide health care as a business, and consultants, though salaried, have the right to have a private practice outside their contracted hours.

When the NHS began there was very little that medicine could do. The surgeons could do most, and these comprised most of the consultants. (When the Bournemouth Hospital was taken over by the NHS it was discovered that there was a substantial Trust Fund). The Medical Staff Committee decided what to do with it. It would be split into 8 shares. One share would go to each of the seven surgeons and the remaining share would be split between the anesthesiologists.) Most of the operations that were done then are no longer performed. Most physicians were little different from GPs, but they had the right to admit patients into hospital. They also often doubled up as anesthesiologists. There were no pathologists except in the Teaching Hospitals and doctors had to act as their own radiologists.

At that time TB was the great health problem. In Bournemouth there was a country branch of the Brompton Hospital, the famous London Chest hospital, but even this was about to be replaced by a sanatorium among the pines of the New Forest. Streptomycin meant that it never opened. Until recently you could visit the ruins of the half-constructed hospital.

Even though the health service could provide little beyond now-defunct operations it soon began to run out of money. Patients were able to obtain for free anything remotely health-related – even hot-water bottles to keep out the cold at night. The nation was on its knees. In 1947 Churchill famously criticized the Labor government “…on an island made mainly of coal and surrounded by fish, this government has contrived a shortage of both.” New medicines were coming on line at an alarming rate. The cost of the NHS doubled and then trebled. In order to contain the costs the government introduced a charge for prescriptions. Rationing had begun. This was a resigning issue for Anuerin Bevan.

In fact it quickly became clear that the demand for health care is unlimited but the money available for it has to be limited. Enoch Powell, Tory health minister in the 1960s and a very clear thinker – Professor of Classics in Sydney, Australia at the age of 28 – recognized this and said that rationing is inevitable. All health care is rationed, wherever you are in the world. In America it is rationed by price. Anything is available if you can pay for it. If you can’t then you can’t have it unless you can persuade someone else to pay for it. In Cuba there is no rationing by price, but for many treatments nobody can have them.

Over the past nearly 60 years there have been many reorganizations of the NHS. The biggest pressures have been for equality and efficiency. The drive for equality has meant more and more central control; the drive for efficiency have given us NICE. I have said before that what patients want is not either of these but another ‘E’ – effectiveness.

I shall write some more tomorrow.


Anonymous said...

I find it ironic that the very, very fat Michael Moore is railing against a system that disproportionately provides service to fat people.

Obesity is an obvious risk factor for circulatory disease and cancer, as well as diabetes.

That aside, it is well-known that Americans spend more per capita than any other country does. It also has the best medical system in the world.

As Terry has pointed out, in the 'old days', medical intervention was extremely limited.

That's not true today. The list of acronyms in testing alone is daunting - MRIs, CT scanners, PET scanners, ultrasound machines, EKGs, EEGs, mammography, etc.

None of this is free. And it does not include drugs.

Various schemes abound that can ensure that the poor and those who simply want to play the lottery with their health have access to care, while preserving all that is good in medicine.

If government gets more involved, you can bet it will screw it up.

dreamingspire said...

"When the NHS began there was very little that medicine could do. The surgeons could do most, and these comprised most of the consultants."
And in between were those who just kept people alive, very dedicated. Even then we had immigrants working in the NHS: in 1949/50 my mother was convinced that it was the care of a young German nurse in West Yorks that kept my younger brother alive as the polio epidemic and then pneumonia almost did for him.

Exiled in mainstream said...

I'm not sure that this will change anyone's mind but on the principle that evidence helps debate, here goes...

"it is well-known that Americans spend more per capita than any other country does. It also has the best medical system in the world."

Not true - it probably has the best medics in the world, and the best care is probably the best in the world, but the system is frankly broken and the variations in care unacceptably high.

Between 20-25% of expenditure in the "efficient free market" American health is on bureaucracy compared with less than 10% in the "bureaucratic socialised medicine" in the UK, Canada and Europe. There is one notable exception to this - the VA (i.e. the bureacratic government funded and supplied service - which also by the way has seen by far the greatest increase in quality in the US in the last 15 years). These costs are pretty clearly due to the lack of single payer system (different paperwork for every provider) and gaming in the system between providers and purchases (bill padding by providers, and trying to get out of responsibilities by purchasers). A fee for service payment system encourages this.

The international comparisons of the US system (not the quality of individual medics) that have been undertaken are damning. And I'm not referring to the WHO report of 2000 (?) but the recent Commonwealth Fund comparisons here.

I think the anonymous poster makes the mistake of confusing "doing lots of stuff" with "giving good care". This has been challenged for 20 years through the work of Wennburg at Dartmouth University, and more recently Elliot Fisher
Explicit conclusion:
"Medicare enrollees in higher-spending regions receive more care than those in lower-spending regions but do not have better health outcomes or satisfaction with care"