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From International Socialist Review, Vol.24 No.3, Summer 1963, pp.88-90.
Transcribed & marked up by Einde O’Callaghan for ETOL.
FOR YEARS the American public has been barraged by propaganda from the American Medical Association in its fight against any form of “socialized medicine” – their estimation of the various Medicare plans to help alleviate the problems of falling real income and accelerating chronic ailments facing more than 18 million Americans living on social security, state pension, or welfare. The AMA has told us, over and over again, that Medicare represents direct government intervention into the free enterprise rights of the medical profession; that the doctors will lose all their clinical freedom, their intitative; that research will come to an abrupt end. They say that the doctor-patient relationship will be destroyed.
We have been told that most old people are in good health, that those sick already receive adequate care, that most of them have hospitalization insurance. We have been told these things so repititiously that some people are beginning to believe the big lie. Personally, I think “they protesteth too much,” especially when they use as a horrible example, what has happened to the quality of medicine, the doctor-patient relationships, the research capabilities and the success of the British Medical profession during the last fourteen years under the National Health Service.
In 1952, a professor of history from the University of Virginia, Almont Lindsey, went to England to find out what National Health Service was all about. He spent six months traveling around England and Wales, interviewing doctors, patients, government officials, hospital managements and personnel. He came back so impressed that he spent the next eight years reading everything he could lay his hands on – Ministry of Health reports, many commission reports (the Parliament sets up commissions on everything), papers from the British Medical Journal, reports from the multitudinous boards and commissions at local government levels. Last year he published his findings in a 562 page book, Socialized Medicine in England and Wales.
Dr. Lindsey’s book is a gold mine of information, with every one of its 562 outsized pages crammed with facts and figures, interestingly put together. Unfortunately, it is not a book which will appeal to the general public, although anyone interested in this particular phase of social welfare should read and study the book. Those who should give it the most attention however, the leadership of the AMA, will either ignore it entirely or find it leaves a very bad taste in their collective mouths.
I venture to guess that the AMA is still smarting under the impact of the March 31, National Broadcasting Co. White Paper telecast, British Socialized Medicine, wherein one prominent British physician, Dr. Hugh Clegg, editor of the British Medical Association Journal, called his American colleagues to task for “misrepresentations” thus: “... we are tired of being misrepresented. And undoubtedly the National Health Service of Britain has been misrepresented in the US ... We think it is about time they (the AMA) stopped.”
Dr. Clegg’s statement is all the more impressive since he and his parent organization fought against the National Health Service with the same methods, the same words, the same arguments that the AMA is using today against Medicare!
THE history of that fight, the issues, the compromises which finally settled it, are far too complicated to cover in this article. Suffice it to say the main issue was financial – the method of compensation for doctors registering under NHS, and the size of their capitalization fees.
The National Health Service inherited all of the ills inherent in the old private medical practice system. The general health of the vast majority of the population was bad. Employed workers had been covered by National Insurance since 1912, but not their wives, children and other dependents. A sick insured worker had the care of a doctor and free medicine, but none of the ancillary necessities were provided – X-ray, hospitalization, surgery, etc. Low wages and recurring unemployment made even care by a doctor and free medicine a doubtful blessing for the average worker. One former Insurance Panel doctor told Dr. Lindsey, “If my treatment recommendations included such necessities as eggs, milk, meat, how was the patient to carry out my orders?”
Tuberculosis was rampant. In 1948 the death rate was 48,000. In 1960 it had dropped to 4,500.
The mortality rate for infants under five, and for mothers in childbirth was one of the highest in the world. Today it is among the lowest, second only to Holland.
Doctors, dentists and nurses were in very short supply, poorly distributed. Medical and nursing school enrolment was dropping year by year. Badly needed potential replacements in the profession were discouraged by the low income levels of most general practitioners, and the costly method of either buying an established practice or facing the hardships of starting from scratch to establish one’s own. Today, with an assured income right from the start, with an adequate pension guaranteed on retirement, and the chance to really practice medicine without economic chaos, young people are crowding the medical and nursing schools.
THE hospital situation was critical. Many areas had no hospital at all. Old Poor Law hospitals which did exist were ancient castle-like monstrosities, few under 100 years old. The high-ceilinged, narrow-windowed rooms were impossible to heat. The drafty halls and tunnels through which the sick had to be moved were a danger in themselves. Operating rooms were ill lighted, ill equipped. Private and voluntary hospitals which were nationalized were operating under such low medical and sanitary standards that many of them had to be closed and completely renovated. During the war, Hitler’s Luftwaffe destroyed many hospitals, along with homes, factories, mills and cathedrals.
It was not until 1958 that the Ministry of Health finally began a hospital building program.
In 1948, on the Appointed Day, July 5, when the National Health Service began its operation, these were but a few of the ills inherited from the old private medical practice.
Another problem the new Service faced was the sudden rush of the English working people to their doctors. Women and children who had always gone without medical care because it could not be fitted into their low income budgets almost swamped the Service in its first days. People who had been buying their reading glasses in the dime stores stood in long lines outside the op-thalmic clinics. A sick population went to the doctor.
DURING the past fourteen years in which it has been possible for the people to get the care they need to cure and prevent illness, what has happened to the general health in the “Tight Little Island”?
Health standards have risen greatly, with contagious and nutritional deficiency diseases on the road to being conquered. Tuberculosis is no longer the main killer, and a vaccine to prevent it has been perfected. Infant mortality and childbed deaths of mothers is low. Radiology teams tour the provinces in mobile units and have dug out thousands of cases of incipient TB and cancer. People who never dreamed of going to the doctor with minor ailments – which so often prove to be major – now see the doctor in time. If they need more than a prescription or a rest in bed, they are referred to a consultant in an outpatient clinic or a hospital.
Britain is beginning to conquer the horrible dental condition of most of its people. Conservation work, not just yanking out teeth, is the practice much more frequently than in the past. A vast educational program, pointing out the relationship between good dietary habits and dental health, is being carried on by the Ministry of Health, the various local government boards and the trade unions.
Two factors keep the dental progress slow – the still acute shortage of dentists and the fee which must be paid by the patient. This charge for a full course of treatment seems almost ridiculous to Americans, but $2.80 to a British worker is exactly 10 percent of his weekly wage, so it is an important reason why even today you see many British workers with few if any teeth or badly fitted dentures.
ONE of the greatest accomplishments of the Service is the lifting of the fear of overpowering medical bills. A member of Parliament commented on this on the 10th anniversary of the Service. He had just returned from Canada and the United States where he found “... that fear a very real thing ... And that is something, thank heavens, which we have eliminated here, once and for all.”
Another “profit” resulting from the improved health of the nation can be counted in money – for the bosses. Statistics prepared by the Information Division of the British Treasury in 1959 revealed that during the first decade of NHS, production had risen by one-third and exports had increased two-fold over the pre-war period.
The care and treatment of mentally ill persons has undergone a revolution. All laws governing “lunacy” and forceful commitment of mentally ill or deficient people have been repealed. They are now treated as sick persons whose malady can respond to treatment or realistic rehabilitation. Only the criminally insane and persons so deranged that they are dangerous to themselves and the public are restrained. A deranged patient who becomes non-belligerent after treatment is returned to the general hospital population for further care.
Mentally ill patients now sign themselves in and out of mental, general, day hospitals (where the patient undergoes treatment during the day but lives at home), and outpatient clinics. They receive psychiatric, electro-convulsant, and modified insulin shock treatments and tranquilizing drugs. When the patient is sufficiently recovered to return to the world from which he retreated, he does it by easy stages. Special hostels, managed by trained psychiatric personnel, help him make the big step. During his medical treatment he is also given occupational therapy – not weaving pot holders or baskets, but actual work in a small factory under controlled conditions, to fit him for a trade commensurate with his mental and physical health. When he does go home, he generally faces a sympathetic neighborhood. An educational program to teach everyone that mental illness is not a disgrace but a treatable malady has done much to remove the “disgrace” of this very real illness.
The changes in care and treatment of the aged is a subject large enough for a separate article.
In February 1948, just a few short months before the “appointed day,” the BMA conducted a postal poll among its members. Ninety percent of those responding voted against entering the Service. In 1958, another poll showed that two-thirds of those voting in the previous referendum now supported the Service.
General practitioners are allowed a maximum of 3,500 patients – patients who are chosen by mutual consent. For each person on his list, the doctor receives an annual fee, special payment for maternity cases, and travel expenses for house calls. Doctors with large lists, in areas where there is a scarcity of physicians, get “loading fees.” Young doctors who are just starting get cash allotments to help them get established and to take up the slack until their lists are large enough to support them. They also get “loading fees” on lists of from 500 to 1,500 patients.
GENERAL practitioners who hold their “surgery” (office) hours in industrial areas away from their homes get what amounts to portal to portal pay.
Consultants (specialists) work in the hospitals and outpatient clinics on a yearly salary, generally only part-time. They are also available for house calls when requested by a general practitioner, and get extra payments for this. In addition they can earn cash “merit awards” to bolster their income.
Hospital personnel from interns through several grades are salaried.
Through the years the compensation to doctors has been increased three times. Today the medical profession is in the top tenth income group for all professions.
The lifting of the financial barriers between the doctor and his patient has greatly improved the relationship between them. The doctor no longer has to hesitate to prescribe expensive drugs, make as many house calls as he thinks necessary, or refer his patient to an outpatient clinic or hospital for consultant service. Today he can treat the patient, not his pocketbook!
On the NBC White Paper telecast, one prominent consultant put it this way:
“It was an awful worry ... At least I always felt it when I was in consultant service (private) to know how much to charge people and to be worrying whether they could afford things. If I go the rounds in American hospitals and we’re terribly interested in a patient and we discuss this patient afterwards and somebody says ‘well, can she afford it?’ you know this doesn’t occur to us in England any longer and I think it is a good thing.”
The fact that the general health standards in Britain have risen so greatly, that intensive research into new drugs and vaccines is a continuing part of the service, that 90 percent of the population are satisfied with their care speaks for itself. There is still much to do but the fact is the National Health Service is pointing the way for the rest of what Kennedy euphemistically calls the “Free World.” Real socialized – not just nationalized – medicine is already an accomplished fact in the Soviet bloc, and is beginning right now in Cuba.
The cost of the service is high but it is actually less of the gross national product than in this country – 4 percent in Britain, 4.5 percent in the US. The main part of the bill (75 percent) is picked up by the General Exchequer from general tax funds. About 12 percent of the total is covered by regular weekly payments into the National Insurance fund from NHS deductions of approximately 38 cents from each employed male worker, and 9 cents from his employer. Women workers and apprentices pay a lower rate. Self-employed persons pay their insurance by buying NHS stamps at the post-office. Another 13 percent is collected from the two shilling (28 cents) charge for each prescription item, the $2.80 for initial dental fees, and the payments for eyeglasses.
Drugs are the largest expense item in the budget. The drug industry profits greatly from NHS, despite the fact that it provides drugs to registered pharmacies at “wholesale plus.” The “plus” is sufficient to earn a tidy profit for one of the richest industries in the country. The drug industry has not been nationalized.
THERE are still many “bugs” in the Service. More hospitals are needed to alleviate the unnecessary suffering caused by long waits for beds. More preventive medicine should be practiced. Doctors’ lists should be equalized downward to allow more time per patient, and the drug industry should be nationalized to cut drastically the total cost of the Service to the whole people. But a capitalist, or a capitalist-oriented Labor government, seldom nationalizes a profitable industry – just those who have to be rescued from bankruptcy, like coal and transportation in Britain and the New York subway system and the Chicago Rapid Transit (sic!) systems here!
In evaluating what has already taken place under a nationalized health service in a capitalist nation, it is important to keep in mind that a great majority of the population, except for the very young, carry with them all the scars of undernourishment, lack of medical care, and all the other impediments which are the heritage of a working class which has been the main commodity used up by British colonialism in building an empire upon which the sun never used to set!
It is almost an irony that the Tory Conservative Party, in power now since 1952, has not dared to touch the National Health Service. Several attempts have been made by this government to abolish the Service, to add new fees for patients and cut out various services, but they have been quickly beaten back by an aroused public – including the medical profession.
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