J Enoch Powell 1966
7. Alternatives
The phenomena of Medicine and Politics explored in the foregoing pages result automatically and necessarily from the nationalisation of medical care and its provision gratis at the point of consumption. A great part of my argument has been to show that these phenomena are implicit in such an organisation and are not the accidental or incidental results of blemishes which can be ‘reformed’ away while leaving the system as such intact. If those phenomena are judged unacceptable, the rejoinder must be Hamlet’s: ‘Oh, reform it altogether’.
This conclusion appears so hard and uncompromising that it is only human nature to try to dodge it. There is little enough public enthusiasm detectable for denationalising the nationalised industries, where charges to the consumer do at least provide some link, some means of comparison, with activities organised on a different principle. Nationalised medical care is virtually insulated from external comparisons by its universality and its free provision to the consumer. The very contemplation of denationalising it is enough to daunt the stoutest political heart. Periodically the ‘deficiencies’ of the National Health Service, or the agitation of a profession employed in it, attract passing attention; but the vulgar conclusion that ‘the Government ought to be prepared to pay more’ is sufficient to provide a rationalisation until the fuss subsides again.
Some communal provision of medical care is anyhow as general as it is immemorial. Such provision, for instance, for the mentally handicapped or disordered, or for the victims of violent disaster, is manifestly indispensable on any view. Without entering into the difficult philosophic question, whether the charitable motives of persons acting voluntarily, as individuals or groups, can be transferred to the state using its powers of compulsion, the general public interest in seeing that medical care is provided for the members of society in a great range of situations is not open to dispute and has been long and widely recognised. In many such situations it is equally obvious that a convenient way to achieve this is by direct provision, by the community itself maintaining for example— to use old-fashioned terminology— fever hospitals or lunatic asylums. The general public interest here merges insensibly into the notion of the necessities of life being guaranteed at a minimum standard by society to all its members. As medical care by its nature may be a necessity of life no less than food or shelter, the medical needs of the individual are to that extent a necessary subject of public concern; and the step from public concern to public provision is an easy one. The National Health Service is therefore widely felt to have done no more than to have generalised and rationalised forms of public provision which are indispensable. So it appears paradoxical, not to say reactionary, to call nationalisation itself into question in this context.
This accounts for the curious fact that the principal ‘reforms’ of the National Health Service which have been propounded simply evade the central issue.
SUBSIDISED PRIVATE CARE
The most popular proposals, not perhaps unnaturally, have been for the provision of a public subvention to medical care outside the National Health Service and in addition to it. One example is the suggestion that if private beds in hospitals were less dear, more patients would then be treated privately. But the most celebrated case in point is the strange story of the ‘drugs for private patients’ episode, which is perhaps worth telling again. The idea that a person who seeks (as everyone is intended to be free to seek) medical attention under private arrangements and chooses not to resort to the National Health Service, should have part of the cost of that attention, namely, the medicine, paid for by the state, had never occurred, so far as is recorded, to anyone on any side during the long discussions, in and out of Parliament, which preceded the inception of the service in 1948. Then, in the autumn of 1949 the notion occurred to some of those drafting the Conservative Party’s pre-election policy statement, The Right Road for Britain, as something new and attractive to put into it. Almost at that very moment the Labour government, in what is now seen as one among many in the series of financial crises characterising the last twenty years, decided to introduce, as an economy measure, the principle of charges for prescriptions and other items. Not being anxious to propose a subsidy for private treatment while supporting a charge for public treatment, the Party leadership tried to delete the proposal. But it was too late. The policy document was already in print; and though the proposal never reappeared in any official publication— not, for instance, in any election manifesto from 1950 onwards— it stuck to successive Conservative governments and Ministers of Health like a flypaper, until the spring of 1961, when, to the accompaniment of the then newly increased 2/- prescription charge, the Council of the National Union of Conservative and Unionist Associations threw it out.
Two arguments for the proposal were advanced. One was that the principle of the National Health Service was free access ‘to any part of it’ at the patient’s choice. Therefore, as the pharmaceutical service was a ‘part’ of the National Health Service, the private patient ought to have a right to free medicine if he took his prescription to a chemist. This is a fallacy. The pharmaceutical service is not a ‘part’ of the service in the same sense as the hospital, general medical, dental and ophthalmic services. The medicine is integral to the treatment given by the general practitioner at his discretion. The chemist is not treating the patient but complying with the doctor’s order. The cost of the medicine is in no different case from the cost of any other element of the general practitioner’s treatment. The point may be illustrated by contrasting what happens when, for instance, the private patient of a general practitioner goes to get hospital treatment in the National Health Service— albeit for the same complaint for which his private doctor has been treating him. It is then the hospital doctor, not the general practitioner, who decides what treatment the patient shall receive, and indeed whether he shall receive any at all.
The second argument for free or cheap medicine outside the National Health Service was that those who resort to private treatment are relieving the service of the cost of their treatment, and that, if more resorted to private care because it was cheapened, that relief would be further increased. This idea rests on a fundamental misconception. At a very rough estimate— there is no means of making a precise one— the amount of private medical care, by volume or value, is between one and two per cent of the value or volume of medical care in the National Health Service. Therefore if twice, or four times, or six times, as many people as now were to resort to private treatment for the whole of their medical requirements, the National Health Service would still employ as much staff and spend as much capital; for no one can suppose that an increase of even ten per cent in the volume or quality of the care given in the service would be regarded as excessive and treated as a signal for reducing expenditure upon it. The result would simply be an improvement (or a slower deterioration) in the quality of the National Health Service, purchased at the net additional cost of the subvention to private treatment. The result would be to spend that much more state money on medical care.
True, if a massive transfer of patients to private care took place, the National Health Service would no doubt begin to reduce the total of care provided instead of simply increasing the quality and the quantity per patient. Even so, as the cost of medicine is considerably more than half the cost of medical care outside hospital, that reduction would have to proceed very far indeed before there could be any net relief. Conversely, the diminution or even disappearance of existing private medical care would reduce the quality of the National Health Service to only a negligible extent— namely, about one or two per cent.
In short, the proposal amounts to introducing a subvention for private medical care in addition to, and not in substitution for, nationalised medical care.
CONTRACTING-OUT
The fallacy about relieving the National Health Service applies to the second group of reforms which have been canvassed, in the shape of various methods of contracting-out. These run into other contradictions in addition.
The simplest form of this approach is the proposition that a person might be excused the National Health Service Contribution in return for renouncing care under the National Health Service. This will not bear examination. In the first place, the yield of the contribution represents only about 13 per cent of the cost of the service and (since the abolition of the prescription charge) only two-thirds of the cost even of the general medical and pharmaceutical services. At most, therefore, it would be possible to identify a substantially increased contribution with the general medical and pharmaceutical services, and apply contracting out only to general practice. Even this, however, would have the effect of excluding the ‘good risks’, the adults in earlier life, who might be able to do with what medical care they could buy or insure for at the cost of £13 (i.e., 50 per cent more than the present adult male contribution). In consequence the equivalent contribution for those remaining covered would have to be still higher. Again, the effect, unless contracting-out were on a massive scale, would only be to improve the volume and standard of the general medical service at an additional cost to the general taxpayer equivalent to the amount of the lost contributions.
In any case, the identification of the contribution with a part of the National Health Service is essentially artificial. It is correctly viewed only as one form of taxation from which, along with all the others, the National Health Service, indistinguishably from all other expenditure of the central government, is financed. Contracting-out therefore encounters the same objection in relation to this as to any other public service: if a person is excused direct taxation for non-use of the service, why not a fortiori corporations, which by their nature cannot use it, or indirect taxpayers, who are unidentifiable? It is the same difficulty as, in the case of education, with the companies, the spinsters, the elderly, etc., who have no children to educate. There is no intellectually satisfactory escape from the fact that as long as the decision stands to make a service or benefit available at the public charge, no group of taxpayers can contract out of their implied share of the burden. One might as well suggest that those who undertake not to resort to national assistance should be allowed to contract out of their share of the cost of providing for it.
The same difficulties, in a severer form, confront the idea of any sort of voucher scheme, whereby the individual could opt to be provided with a voucher for a given value expendable on medical care and deemed to represent his (and presumably his dependants’) share of the current cost of the National Health Service. This he could, at need, use to pay, or insure, for any care he (or they) wanted, and would of course be free to add to its value from his own resources. If he (or they) used the National Health Service at all, he would be required to pay in full for whatever he used.
Difficult though such a system is to envisage when applied to school education (where the demand is at least exerted uniformly by definable groups of consumers) it becomes almost inconceivable when applied to the demand for medical care, which varies so widely from one person and period of life to another over the whole population. The service in its present form is in effect a universal scheme of mutual insurance. Unless therefore massive numbers opt for vouchers and insure themselves, a premium equal to the cost per head of the service will be insufficient to insure any but the ‘best risks’ against the whole range of medical contingencies; and the same logic applies, mutatis mutandis, to a voucher scheme for certain specified types of medical care only. Thus a voucher scheme resolves itself merely into a method of increasing state expenditure upon medical care.
A SYSTEM OF CHARGES
The opposite approach to subsidising private medical care is to reduce, so to speak, the subsidy to public medical care.
Reference has been made already to the principle of charges levied at the point of consumption. These have been applied in a minimal form to prescriptions, in a standard form to dental treatment, and as a proportion of cost to dental and optical appliances. Flat-rate or variable charges for consultation and for stay in hospital have also been proposed. Such charges may, as has been shown already,1 have an effect as rationing devices; but they cannot operate as true prices in helping to form and control the quality or content of the medical care demanded and provided. Rather do they represent a minor tax, or toll, which slightly reduces the call of a given service on general taxation, and may thus somewhat increase the total resources applied to it, because the budgetary pressures which go to determine the respective shares of the public services in national resources tend to be applied to the net cost falling on the Exchequer (in this case, the cost of the service net of charges) rather than to the gross cost.
THE FORMS OF INERTIA
A nationalised institution for the provision of medical care will not alter piecemeal and insensibly into a decentralised system on a different basis. Change of the principle could only take place at all if there were a widespread conviction, based on the concrete evidence of experience, of the superiority of an alternative. Even then, the political and other forms of inertia built into a statutory institution of this kind are almost impossible to overestimate. The only practical question, therefore, at this stage and for a long time to come, is from what directions such a conviction might eventually arise. Mere dissatisfaction with the service, which is indeed endemic and inherent in the system, does not in itself contribute to that conviction. What is necessary is a visible alternative.
The nationalisation of medical care does not formally exclude competition; but any competition takes place across the barrier of the difference in cost between virtually nil and a market price, and is confronted by the embodiment in the nationalised service of virtually all the pre-existing hospitals. So far the growth of private medical insurance, which has been striking in money terms, does not appear to have been accompanied by any appreciable net increase in the volume of medical care rendered outside the National Health Service. There is at any rate no evidence of this as yet; and until such evidence is available, it must be assumed that the effect has mainly been to transfer the financing of a given volume of private medical care from other channels (such as direct payment out of income or saving) to those of insurance.
The practical question is whether the number of people who value the advantages of medical care outside the National Health Service sufficiently to accept the differential will ever grow to be substantial. The prospect would obviously be increased if that differential were reduced either by a great enlargement and extension of the system of charges, or by a further restriction of total expenditure on the National Health Service in real terms, or by both at once. There is no obvious likelihood of either happening in the near future. That does not alter the fact that a change in the relationship of Medicine and Politics will be heralded when, and only when, the number of family doctors and the volume of consultation and hospital treatment tendered outside the National Health Service shows a marked and continuing rise.
It may be said that this is a chicken-and-egg conundrum, an argument in a circle. So it is. It is the circle in which Medicine and Politics are imprisoned by the National Health Service.