Fabian occasional paper 6 15p
Somerville Hastings memorial lecture
This paper is based on the third Somerville Hastings memorial lecture delivered at Ruskin College, Oxford in February 1971. The lecture was endowed by the Socialist Medical Association.
This pamphlet, like all publications of the Fabian Society, represents not the collective view of the Society but only the view of the individual who prepared it.
Fabian Society, 11 Dartmouth Street, London SW1
April 1971 SBN 716330067
Last year’s Somerville Hastings lecture was delivered by Professor Richard Titmuss on the subject of the giving of blood by donors to people who were in need, but who were complete strangers. Professor Titmuss analysed the moral and ethical lessons to be drawn from this aspect of human relations and reached two conclusions: that this is an important development in human relationships indicating a high moral development; and that a comparison between the British voluntary transfusion service and others showed it was not only ethically the finest in the world, but that it led in the end to the most efficient, safe and economic service that could be devised.
This tribute to a part of the British National Health Service might serve to introduce to you the man whose life and work this lecture commemorates. Somerville Hastings was exceptional in many ways, but his whole political life illustrates the flow and ebb and flow again of socialist thinking in this country. He formed his views while still a student and around 1910 began to join in discussions into the need for a national health service. In medical politics no group supported the free market idea of society more strongly than the consultants of the London teaching hospitals. Yet Somerville Hastings without concealing for one minute views that were considered, and indeed were, revolutionary, became senior consultant at the Middlesex Hospital and gathered round him others of like mind and like status. Those who are fortunate enough to be chosen to deliver these memorial lectures must endeavour to develop new ideas on the delivery of medical care, accepting his belief that someone has to be thinking ahead for medicine never stands still and we must be ready to make all new developments available to the sick.
We are faced with a strange situation in Britain in regard to health today. There can be no question that to the British a national health service is part of their way of life and that not even a ruthless pro-free market government, such as we now have, would dare to propose to get rid of it. It is fortunate, of course, that it is not a successful profit making organisation and so is unlikely to be offered for sale. When we come to look at the financing of health services all over the world we will see that a modern service can be sustained only by governmental organisation and finance. Besides, we have had some kind of publicly financed and controlled service in this country for so long that the clock would need to be put back more than a century to find a completely free market system to which we could return.
In this century we have instituted national health insurance 60 years ago, municipal hospitals 40 years ago, and public health services growing and developing during the whole period. Yet in spite of the built in nature of the National Health Service the present government is seeking ways in which it can establish what it calls selectivity in health and social security. Selectivity is a disguise for methods of dividing the nation into at least three groups. Those who can pay will get a moderately good service sometimes and in some places; those who can afford or elect to pay insurance will get a slightly inferior service to that and inferior to the service the middle class have today; and the great mass of the people will go on paying for the service, as they do today, by taxation and insurance contributions, but will get something less efficient, less humane and lacking in resources. Part of the argument put forward by Tory speakers is that other countries manage without a national health service on the basic principles of ours and that a country like the USA must have a better service than ours because it spends a higher proportion of its gross national product—a full 2 per cent more—on health than we do.
It is therefore essential that we examine the health services of other countries, see what lessons they have for us and try to assess whether the citizens of these countries get as good or better services than we do. So far as USA spending is concerned, articles and television surveys like the CBS programme, “Don’t get sick in America” have shown that the majority of citizens in the USA either get no service or get some elements of health care at very great expense.
I use the phrase “some elements of health care” deliberately. It is health care, not medical attention we wish to discuss. It is interesting, and an indication of how thought changes, that when Somerville Hastings and his colleagues first formed a medico-political organisation they called it the National Medical Service Association; when the Socialist Medical Association was formed 20 years later, thinking still clung to that word medical even if it became clearly socialist; but within two years the SMA was taking as members all health workers, as it does today, and in its publications it was a national health service that was advocated. If we have not yet achieved a socialist health service it is not because our thinking is wrong, but because those who believe in it have not yet taken the public and the professions with us into thinking of health and not the treatment of disease as our number one priority. It is paradoxical that one can attend many medical meetings without hearing the word health; one cannot speak to groups of ordinary folks without having to answer questions about health, its basis and its preservation. The paradox has some strange repercussions for just because doctors do not do or say enough about health in general and in their daily work, the public does not readily accept the profession’s advice on the dangers of cigarette smoking and so on. The public accepts the medical profession as experts in treatment, but has not yet grown sufficiently accustomed to the profession as guardians and advocates of health to accept its advice to drop its most dangerous addiction. Nevertheless when we examine the international position we must keep this aspect very much in mind.
But since the recognition and treatment of disease is still the main task which the public puts upon the medical and allied professions and since that is what our doctors and most other health workers are trained and paid for, it is the delivery of medical care that must today be our chief concern. A moment’s thought will show that there can be a great variety of ways by which the sick and the doctor come in contact, a great many different possible contracts between them, a vast possible difference in the way in which general practitioner and specialist care might reach the patient and a very large variety of ways in which the health professions can be paid for their services. I am thinking not only of modern techniques for payment by third parties, insurance and the like, but much older yet still persisting barter systems. A recent Harpers Magazine carried the story of a doctor in a rural area of the USA who was telling a reporter of the bad debts he had and how one farmer’s wife had been paying him for her midwifery care for years after her last baby by leaving two dozen eggs at his surgery every week. That was all right, he was reported as saying, so long as the hens were laying, but some weeks they let him down. Exceptional, perhaps, but still a commentary on that affluent society across the Atlantic.
Four systems of health care
There are, in fact, four main systems which should be examined. There are few fields of human effort in which we have four different systems available for study and which can so readily be studied in abundant written material or on the spot. The outstanding common feature of all four is that in modern times with advanced but increasingly expensive systems of medical care, no country can adhere to unorganised free enterprise medicine, but must make arrangements both to organise medical care and to pay for it in some communal or governmental way. In any capitalist society with gross inequalities of income the poor can seldom pay for even the simplest form of medical care, if the doctors are to make a living, and the great mass of the people, all except the very rich, can seldom afford to pay for a full primary physician service and even less for hospital and, in particular, surgical care. In a really acquisitive society like the USA the costs can be so high as to defeat even the concept of payment by insurance. No market system has ever been devised that can take care of the prevention of disease and of health education. We have, in fact, no example today of a country in which medical care is not at least in part the affair of government and paid for by governmental means.
There is no field of comparison in which it is more difficult to get correct figures of expenditure than in health services and I do not propose to spend a great deal of time on finance. The subject is, of course, of great importance and of importance in many different ways, as to how much a country spends on health, whether it gets good value for the money it spends, how it collects that money and from whom. To get figures for comparison one has to refer to a learned paper by Brian Abel-Smith, a survey done for WHO, in which he uses 1961 figures—slightly modified here for simplicity. The position has not changed except that the totals and percentages of GNP have risen. In Canada the position is rapidly changing and more is being spent by central government. The UK is now spending about 5 per cent and the USA almost 7 per cent of the GNP. There is no comparable figure for the USSR, but if we take public expenditure as the guide, we spend about 9 per cent on health, the Soviet Union 7.1 per cent.
|
Expenditure on Health Services
|
|||||||
| Country | Total millions | % of GNP | General government % | Compulsory sickness insurance | Other agencies | Recipients | |
| Canada | C$ | 2045 | 5.5 | 18.4 | 29.6 | 15.6 | 36.4 |
| France | fr | 16374 | 4.2 | 15.0 | 67.1 | 7.4 | 10.5 |
| Netherlands | G | 2344 | 4.5 | 20.7 | 42.4 | 4.2 | 32.7 |
| Sweden | Kr | 3683 | 4.9 | 66.3 | 12.2 | – | 21.5 |
| UK | £ | 1.88 | 4.0 | 84.7 | 11.0 | 0.9 | 3.4 |
| USA | $ | 29859 | 5.5 | 22.4 | 1.7 | 28.3 | 47.6 |
The four systems may be described as:
1. The European system, found, with a number of variations, in all the countries of Europe, the variations being almost entirely concerned with the method of payment and the extent to which government has made itself responsible for the care of its citizens.
2. The Soviet system in which health and health care is a constitutional right carried into effect by a chain of governmental agencies and institutions, and paid for, with the curious exception of medicines, from central funds.
3.The USA form of health care is really a non-system and has been so classified even by President Nixon. It is held by many that health, and by corollary, health care is a citizen right under the constitution and the states does, in fact, assume that it is a right when it finds a minority group for whom no provision can be made except by government. In the USA we can, in fact, examine side by side areas and groups served entirely under market conditions and others served entirely by state institutions. The USA has everything from the first complete state organised health insurance scheme, nearly two hundred years old but for a small minority group and groups of citizens for whom no provision is made or is available.
4.The British National Health Service, unique in that it established not only the right of every citizen to health and to health care, but by Act of Parliament placed the responsibility on a Minister to provide the institutions, the staff and the money to provide the same care to every citizen.
The right to health
Behind these four systems and as the basis on which each is built are sets of principles laid down by governments as a guide to the type of service to be developed. The great modern developments in medicine as well as the fact that most of the countries we are to discuss took part in or were ravaged by two world wars, have led to constant revisions of the service as operated and that process is still going on but the principles remain much the same. Practically all countries have declared the citizen’s right to health—it is, after all, part of the United Nations declaration of human rights—but three at least, Eire, Spain and Portugal, have said that governments are not bound to supply health services to all, and Holland says she prefers a balance between governmental services and self help. In practice the governments of all these countries spend considerable amounts on health services, especially on hospitals and all have poor law or welfare systems for those not otherwise provided for by schemes designed, say, for those in employment. Those of us who accept the principles of the NHS naturally look at other countries to see how near they approach that ideal system, a universally available comprehensive service free at the time of use.
Much more difficult to compare is the standard of medical care. This is often done by comparing certain health statistics but so many factors contribute to them that it is very difficult to assess how much is due to health services alone. But even a few such figures reveal that the present position does not seem to be related to affluence and must be affected by the medical arrangements.
|
1961 Health Statistics – Rates per 1000
|
||||
| Infant Mortality | Death Rate | Live Births | % deaths by infection and parasites | |
| Canada | 27.2 | 7.7 | 26.0 | 1.1 |
| Denmark | 21.8 | 9.4 | 16.6 | 0.8 |
| France | 25.3 | 10.8 | 18.3 | 2.6 |
| Netherlands | 17.0 | 7.6 | 21.3 | 0.9 |
| Sweden | 15.8 | 9.8 | 13.9 | 1.0 |
| UK | 22.2 | 12.0 | 17.9 | 1.0 |
| USA | 25.3 | 9.3 | 23.3 | 1.2 |
But what most people are concerned with in discussing the standard of medical care is the standard of the doctors giving the care. Here it must be confessed that the range of that standard in any one country is probably as great as the variation in average standards from one developed country to another. But at least two very distinct factors combine to provide a standard, one the education and training of the doctor, and the other the way in which the medical services are organised. The personality of the doctor will, of course, be modified by these two features but will still be important. So far as training is concerned there is a very close approach to the same standards in clinical medicine, much more variation in the teaching on and the treatment of mental disease and not nearly enough anywhere on community medicine and on health and health education. The greatest gap is in any form of training that would lead to social responsibility. The motivation of medical students is still too much towards personal gain everywhere and this is, of course, greatly influenced by the structure of the health services in any country. If private practice predominates, as in the USA, the motivation of the medical profession will not be towards the care of the poor; if a country wishes to have a universally available service it must train and pay its doctors to play a full part in such a service. Above all, of course, if finance is divorced from treatment as it is in this country, the doctor can look at his patient in a way which is objective but also humane, and quite undisturbed by other considerations. In the USA, for example, there are many situations in which the doctor makes his financial demands on his patient without any reference to the effect it will have on the patient’s economic position. In Norway, on the other hand, a doctor working in a rural area near the Arctic Circle, has to be freed from such financial distraction and has to be a fully integrated member of the community he serves. In Britain the standard of care is still held back by those doctors who adhere to private practice and who have neither freed themselves from the past nor allowed their colleagues, especially GPs less affluent than themselves, to get free from the past and move into a form of salaried service based on health centres where they could raise the quality of care given to all because they would have no divided loyalty.
From the point of view of the patient probably the most important question is how he gets his primary medical care, by whom it is given, and under what circumstances. This will be influenced by the resources available, but even in this regard there is quite a degree of similarity in modern societies.
The number of doctors seems to be reaching some kind of universal normal, except in the USSR, but the variation in nurses and midwives is very difficult to explain and must produce very variable results. Nomenclature is, however, a stumbling block for some countries employ, for example, nursing aids who may in many respects be equivalent to the nurse in other countries. In Holland the pharmacist is paid a capitation fee and does much more truly professional work and much less ordinary shopkeeping. At any rate all these countries, with the exception of USA and Sweden, adhere to the idea of a physician of primary contact and, of course, in both USA and Sweden they still exist even if the profession has tried to organise itself differently, and his future is very much the subject of study and discussion. He cannot remain the general practitioner, single handed, self-sufficient we once knew in Britain. But whatever we call him and however we train him and organise his work he must remain a physician who is the primary diagnostician and the advisor of the citizen on all matters of health and sickness. When we look at some other countries we will see that in so far as they depart from this ideal the delivery of medical care falls below what is needed and in most instances below British standards.
| Resources per 10,000 of Population | |||||
| Doctors | Hospital Beds | Dentists | Nurses & Midwives | Pharmacists | |
| Belgium | 12.5 | 82.0 | – | – | – |
| Canada | 11.7 | 110.0 | 3.0 | 77.4 | 4.1 |
| Denmark | 12.3 | 91.0 | 5.2 | 39.6 | 3.2 |
| France | 11.0 | 133.9 | 3.3 | 20.4 | 4.5 |
| Holland | 11.2 | 75.7 | 2.3 | 12.0 | 1.3 |
| Norway | 12.0 | 106.2 | 7.2 | 32.0 | 3.4 |
| Sweden | 9.9 | 159.1 | 7.0 | 107.8 | 0.1 |
| UK | 11.0 | 105.5 | 2.7 | 31.3 | 5.9 |
| USA | 12.9 | 90.0 | 5.1 | 41.5 | 6.3 |
| USSR | 24.0 | 96.0 | – | 35.0 | – |
The Soviet health system
So we may turn to the services as they exist in other countries. I do not want to dwell too long on the system of the USSR, because it is separate and is likely to remain separate from all the other countries I want to discuss, which are within NATO and, therefore, bound by treaty obligations to approach a common form of medical care or, at least, a system of complete reciprocity—and the EEC countries must do this very soon. The Soviet Union has, of course, a comprehensive system of care available to all. Allowing for the vastness of the country and the variations imposed by geography, climate and history, it has an organisational structure reminiscent of what the SMA has always proposed for this country, a national strategy for health, a regionally planned service with day to day control at district level. It is difficult to take in that one quarter of all the doctors in the world are Russian and that they operate from a chain of interlocked clinics and hospitals covering the whole territory. At village level the clinic may be manned by a feldsher and staff of nurses and midwives. The feldsher has less training than a doctor, and restricted duties, but still has considerable responsibility for primary care and preventive medicine. In urban areas the clinics are polyclinics manned both by general practitioners and specialists who are, however, not equivalent to our consultants, since they have no hospital duties. Polyclinics may be provided for geographic, industrial or age groups, such as for children, so the family gets its medical care in a variety of ways. Without question the USSR citizen is guaranteed a fully comprehensive system of medical care with some highly developed services not known in western societies; for example, the emergency and accident services; and is supported by convalescent and rehabilitation units of size and depth not available in any other country. To the western doctor’s eye, however, the personal and domiciliary services are not so good or so firmly grounded as in Britain, where the GP has a direct personal responsibility for a group of patients; and the separation of polyclinic specialists from hospital beds is certainly a source of weakness and wasteful overlap. On the preventive and educational aspects the Soviet Union spends large sums and employs many doctors and has achieved great successes in a country which not so long ago suffered from every epidemic disease known.
Health care in the USA
There can be no greater contrast than that between the health position in the USA and the USSR. Yet, paradoxically, the USA is spending every year more and more on health and medical services paid for and often organised by state and para-governmental agencies. The medical profession and the firm believers in free enterprise continue to advocate and organise for a system in which every doctor acts on his own, for himself, and at the highest possible fee he can extract. In practice, however, something over 40 per cent of all Americans get all their medical care through central and state government services and 60 per cent get some at least of the service they get in that way. Of those who still think they get their medical service from private enterprise doctors almost all have a large part of their medical care paid for by third parties, insurers; and even in this field the premium is often paid in whole or part by yet another party, the employer or the trade union, or both together. Some of the insurers, the Blue Cross schemes for hospital services, are united in one nationwide scheme which is almost parastatel in operation. The question now being asked in the USA is whether either the individual or the nation is getting value for the money they spend; and those who depend on insurance find it disturbing that for each insurance dollar the insured gets only about 30 cents of his total expenditure. It is certainly a fair question to ask if the USA gets value for what it spends. In 1961-62, the comparative figures were that the usa spent $161—and today this is certainly over $200—while Canada spent $107, France $70, Holland $54 and the uk $57 per capita. In 1964-65 the USA spent $9,949.3 millions on public health services of one kind and another, $28,492 millions on private medicine, including $8,150 millions for insurance and $16,680 for direct payments. Even more interesting is the $11,754 millions spent on health benefits organised by industry or by trade unions or by both as part of a wage settlement. To my mind this is not “private enterprise” medicine and if you add this heading and that for public medicine together, private enterprise is getting less than half the money spent and giving in return a great deal less than half the medical care in the country. America is waking up to this anomaly and the pressure is now on to develop some form of national health insurance or even national health service. Bodies so diverse as the United Automobile Workers and the Physicians Forum have issued schemes for a style of service clearly like that of Britain. This year the USA will spend more than $45 billion on health and direct payments will be around $17,000 million only of that amount, so the arguments for private practice are growing thin except for that part of the medical profession which gets the whole of its income in that way. Already the number of doctors in hospitals and clinics who are paid by salary is a great majority of the profession.
Now in such a situation we can be certain that there will be a vast number of attempts, by patients and by doctors, separately or together, to experiment in new ways of providing care. One of the biggest problems created by market systems in medicine is that doctors practice in those fields and those areas which are most lucrative and this leads, first of all, to the diminution of the importance of the physician of primary care and the narrowing of specialisation so as to enhance the importance of the man who “knows more and more about less and less” so long as that pushes the fees upwards. But even worse is that not only does the family doctor disappear but the medical profession hives off the less lucrative parts of diagnosis and treatment. In the medical field this results in the admission of personnel with minimal training as “medical aids”, and in other fields the optician becomes the diagnostician, the chiropodist does amputation of toes and the osteopath becomes officially recognised and indeed ceases to be a spine manipulator and becomes in places the primary care physician and promptly puts up his fees.
On the other side of the balance sheet the USA has some of the finest experiments in socialised medicine in which team work replaces the individual, prepayment replaces fees for service, schemes of prevention and health education operate and a return to something like family doctoring becomes possible. In these schemes there is often patient participation in control and the trade unions may pay for the care given to their members. Trade unions, like the United Automobile Workers, the Garment Workers and the Clerks (shopkeeping assistants) own clinics and hospitals and provide free at the time of use services. Government agencies such as the Office of Economic Opportunity, have set up clinics initially for the poor now often operating as community care centres. Community care is now very much the vogue in the USA and many areas have now set up regional hospital planning bodies. In all such matters, as yet, Government makes an indirect approach. Hospitals can get money for all sorts of schemes from central government and at one time there was little control, but now money for new hospitals, facilities and services is paid only for items which fit into the regional plan and so avoid wastage and overlap.
We are so accustomed to thinking of the USAas an affluent society and accepting cliches about it being the land of opportunity for all, that we forget it is the modern industrial society with the greatest number of unemployed, that it has millions below the poverty line and many more millions who are medically “indigent”, that is to say, just rich enough to live but too poor to pay medical fees, that there are many minority groups, the Red Indians and Eskimos, the new Puerto Rico immigrants, the men returning from the Vietnam war or who have served in the armed forces at one time or another, the Mexican agricultural workers, the Appalachian miners, the aged, some 70 millions in all who get their medical care from state agencies. Medicare and Medicaid have made a vast difference to the senior citizens, but are both expensive and incomplete schemes. The veterans of the armed forces get medical care from 164 hospitals and 93 out patient clinics which in 1964-65 cost the government $1,139 millions. The truth is that although the USA has decided that “every citizen has a right to receive the services made possible by modern science,” Professor Jerome Pollack of Harvard Medical School has said, “it does not follow that the care delivered is necessarily the best”. He added that in a country that has some of the finest medical schools, hospitals and practitioners in the world, “care is exemplary in the instance, not in its organisation”. He has constantly attacked attempts to pay for medical care by government subsidy or insurance methods because “these are concerned only with the rising price of medical care and not with standards. The mass purchase of care almost entirely without specifications is virtually without precedent in governmental action”. It is also true that America is short of home trained health workers and exists only by drawing doctors and others from countries far less developed than itself. It has been said that it would take 15 new medical schools to supply the doctors that now come in from the Philippines, Korea, India, and other countries —our contribution of 60 or so means little in an intake of over 3,500 a year. The final truth one draws from the American scene is that in a ruthless capitalist society the rich may be able to buy good service, the middle class may be able, at some risk to their living standards, to get good care and the poor will get it only if they are lucky enough to be medically indigent in a place where the doctors still have some belief in the Hippocratic oath, as many do. To the observer, if 40 per cent of a nation are badly provided, a second 40 per cent precariously served by a variety of agencies and 20 per cent depend entirely on their purchasing power in an unorganised market, the average of medical care must fall far below modern standards. We now have President Nixon accepting the almost universal criticism of American medicine in a demand that Congress pass legislation “for improving American health care and making it available more fairly to more people, a programme to ensure that no American family will be prevented from obtaining basic medical care by inability to pay”. That word basic is indicative of the deficiencies he sees in his nation’s health care. President Nixon prepares to tackle many of the problems that I have discussed today: “A major increase in and redistribution of aid to medical schools to greatly increase the number of doctors … to improve the delivery of health services . . . more medical care resources in areas that have not been adequately served … to encourage better preventive services”.
The European system
So we may turn to the European system which in the past 50 years has been developing and trying out many devices for doing just what President Nixon thinks the USA should now start, ensuring that “no family will be prevented from obtaining basic medical care by inability to pay”. Most European countries have, in fact, gone beyond that many years ago and have made an approach to the British ideal of providing a comprehensive system, not just basic medical care, to all or most citizens irrespective of ability or inability to pay.
The European position can be simply stated as one of accepting that the community has a responsibility for health care and some 80 per cent of the population receive all or a very high proportion of their health care through an official programme. Some of the schemes are derived from voluntary insurance systems started in the nineteenth century, but most of these covered only a part of the people leaving some dependent on charity or poor law hospitals. When the first compulsory insurance schemes were brought in the poor were left out as being already provided for and the rich still made their own arrangements. But the insurance cover varied and most schemes required the sick to make a primary payment to the doctor and then claim back the fees from the insurance funds, getting usually about 80 per cent, but often less. The health cover is usually part of a general system of social security; and both the amount of money collected directly from the insured and the way in which benefits are paid, vary so much as to make accurate figures difficult to get; and most estimates quoted fail to distinguish between money collected by taxation and money deducted from wages, and often confuse social security payments and spending on health. Most insurance premiums and benefits are graduated according to income.
The European countries long ago struck the problem now worrying the USA— the rising cost of hospital care; and in most countries the insurance funds could not meet the increasing burdens and so the state had to subsidise or provide the hospital service. Hospitals are owned and run by local, provincial and central government but also by religious and other voluntary bodies. In all of them the patient can be presented with a bill which he can then send to his insurance fund and may receive all or part of it in return. This applies to private practice as well and in many continental hospitals the specialists have a whole time contract within which is permitted limited private practice. Whatever they charge the insurance funds pay only according to a standard negotiated list of fees, so that the patient sometimes finds he has to meet quite a large sum personally.
In most European countries there is a physician of primary care, but there is great variation in his duties. In Holland he is called “the house doctor” and is today usually a member of the College of General Practitioners. In Norway his duties are dictated by geography for working in a mountainous country he has to be more than a general practitioner doing also the duties of the medical officer of health for his area and acting as Chairman of the local health service committee.
The Scandinavian countries, including Finland, have drawn very close together on health matters and have a joint council which meets regularly to consider mutual problems. There are only small variations, but Sweden has become somewhat Americanised and patients there tend to go direct to specialists—as the sick fund will pay they see only advantages in doing so. In all these countries the declared aim is to provide high quality care for the whole population. Dr Karl Evang, the Chief Medical Officer of Norway, has said that “Norway is not a country where the medical profession generally performs low quality work” and in fact his country’s services fully confirm his often expressed opinion that the standard of medical care is highest “where prepaid medical systems have been fully developed”. In Denmark the modern system stems directly from an earlier voluntary service, the difference, one writer says, being that “voluntary has become universal for 96.7 per cent of the people are today actively insured against sickness”. The whole system is, in fact, centrally controlled and the medical profession has co-operated fully in developing the present service.
There are curious divisions among Danish citizens which fix the amount they pay. People are usually active members of a sick fund, ‘but if not the law requires them to be “associates”; and citizens are classified as a or b members, according to their income. The dividing line is fixed annually, but results in 87 per cent of a members. The b members pay higher premiums and do not necessarily receive the full range of benefits given to a members, being required to pay for some items of service. But as incomes change citizens move from a to b and back again and so every effort is made to minimise the differences in service as much as possible.
The health service in Denmark depends on general practitioners and to make this clear an a patient who goes direct to a specialist is given no monetary assistance by the sick fund. If a b patient goes direct he must pay the specialist but can claim back a proportion of the fee from the sick fund. However, hospital care is free to all, the sick funds paying only a token amount to the hospital for any member admitted. Maternity care in hospital is free to all. Drugs are partly paid by the sickness funds, but they must be on the official list of about 850: only three quarters of the cost is refunded. We have noted that the quality of primary care depends to a large extent on the services available both to the primary care doctor and the consultant and in Denmark laboratories and X-ray are available all over the country. The laboratory in Copenhagen is of particular interest, for it was set up by the doctors themselves long before there was any other laboratory available ; but in the rest of the country the service is obtained through the district hospitals.
In Denmark one meets many consultants who are whole time salaried members of a hospital service which dates from 1900, “in which there is no question of money between patient and doctor”, and they are so proud of their position that they actually regard specialists who take money from the sick as of lower professional and ethical status. This may indeed be true when we remember that there are no out patient departments as we know them, but the university hospitals supply polyclinics for consultation purposes and these university consultants are usually whole time officers. All have an appointment system and in a city are linked to a central bureau so that patients can be allocated where they can get the speediest appointment. The standard of hospital care is very high and in some fields, especially clinical biochemistry, Danish research has been outstanding. There are weaknesses in the general practitioner service because men still work single handed, but this is changing and Denmark has a clear aim to give “a decent life for all members of the community”, and health is part of that decent life.
France and Belgium
There is not time to discuss all European countries in detail, but some of the differences in health care provision must be noted. A handbook on health services issued by the French Government says, “The French system is very varied: it is characterised by the juxta-position of many conceptions, bringing into play all possible solutions. It is much more diversified than the organisation of the British National Health Insurance”. The British observer certainly finds French diversification exceedingly difficult to follow. France has, in fact, been much more concerned with the question of paying for services than with organising them and has had a national system of social insurance since 1930, although it is only in the last ten years that agricultural and other groups have come into it. There was, and still is, for those not covered by the insurance system, a social aid scheme: and health is very much a part of the whole social security system. It is operated by regional offices and nearly 90 per cent of the population is now covered through salary graduated premiums. The insurance system is of the refund type, but while the patient is free to choose his own doctor, chemist and so on, he is refunded only 80 per cent of a fee laid down in a tariff agreement: if the professional charges are more than that fee then the refund represents less than 80 per cent. Doctors are expected to signify that they accept and adhere to the tariff, but in many areas only half the doctors do so. General practice is still very individualistic and the doctor has no fixed list of patients, so he often does other work as well. There is a chain of over 700 dispensaries for maternity and child welfare ; and social insurance funds can be used in many different fields including preventive work. Hospitals are very mixed in ownership, the State, the universities, local authorities, private and religious bodies and all get their income from insurance fund payments. Today, in order to avoid overlap, all new hospitals, indeed all capital expenditure, has to be approved by the Ministry of Health and it is proposed to grade all hospitals within a regional framework. There is a definite feeling in France that hospital specialists should have a whole time contract, but up to 8 per cent of beds may be available for private cases. The cost of a stay in hospital is in theory met by the patient, but he refers his bill to the insurance fund.
France has two additional well developed services, ambulance and other mobile units for dealing with accidents, burns and other emergencies; and there is a highly developed occupational health service which looks after industrial hazards, compensation and the provision of factory doctors. They give a very full service in factory and in agriculture, and at the end of 1966 there were over 2,000 doctors (10 per cent women) full time, and 2,500 part time, in the industrial service. We have remarked that the doctors in Norway and Denmark had always been very co-operative in developing new services; in France the profession has neither been co-operative nor constructive, being less concerned with the quality of service than with preserving what it calls the “liberal” concept of the medical profession. The services supporting general practice have been very poor, but it is now proposed to build up a chain of polyclinics with laboratories and X-ray departments.
France’s nearest neighbour among the NATO countries is Belgium, and both the professional attitudes and the type of service are very similar to those in France. The service is the usual basic European pattern, a combination of governmental control, governmental provision, patients who pay part of the cost, social insurance which pays both public and private purveyors of medical care. Sickness insurance was put on a national basis in 1945 and gave the worker free choice of hospital, for which the insurance fund would pay, from a mixture of public, private and religious institutions. It also gave the Ministry of Health power to approve each hospital. The Ministry had no powers to reorganise hospitals, but by withholding approval and by giving improvement grants it gradually changed the hospitals of Belgium. In 1954 the State took over the legal ownership of all hospitals but left the day to day running in the hands of the previous owners. Only 40 per cent are in the hands of municipalities, but all hospitals must now fit into the national plan for the fulfilment of which capital is provided from both government and insurance funds. Belgian family doctoring is quite well supported by laboratories and other services, many of which are in privately owned hospitals run for profit which arises from the fees paid by the insurance funds. The profession is still fighting the State, and has taken militant action, two years ago, in an effort to maintain a purely individualistic type of practice, but hospitals are becoming more and more run by whole time specialists with very limited private practice. The internal political and sectarian struggle in Belgium makes rapid advance very difficult.
The Netherlands and West Germany
Over the border in Holland health care was to a considerable extent paid for by voluntary insurance funds until the German occupation, when a compulsory system of social insurance and medical care was introduced. Although compulsory the scheme is not universal. All below a fixed income must join and constitute about 70 per cent of citizens. Another 10-15 per cent join one of the sick funds and the rest carry private insurance either as their whole cover or as an addition to membership of such a fund. There are 115 sick funds, but they are tightly controlled by a Central Sick Fund Council which collects the premiums from employer and employees and adds in a grant from government to cover those unable to pay the normal premium—the aged, for example, cannot be refused by a sick fund and pay a half or a quarter of the normal amount. One thing is important; the sick funds control the quality of what their members get, a legacy of the fact that many of the funds were started by the medical profession itself or by industry which employed the doctors. The house doctors are paid by capitation fee and so patients have to register with the doctor of their choice, who can have up to 3,000 patients, but is paid a higher fee for the first 2,000. The quality of care is watched by “controlling doctors”, who are expected to check on wastage and abuse. Drugs are free only if on the official list or if permitted by the controlling doctors. The “house doctor” refers his cases to specialists who have been recognised by an official registration committee and the sick funds do not pay the specialist if the patient goes to him directly and not through the GP. The College of General Practitioners is very active and is now advocating the setting up of some form of group practice.
One very important aspect of health care in the Netherlands is the strong support given to the family doctor. Laboratory services may be organised by a sick fund or by the hospitals which are paid on an item of service basis. Every doctor can have the services of district nurses, midwives and medical aids, especially for maternity cases. These are supplied to the patient actually, by virtue of her membership of one of three cross organisations, Roman Catholic, Protestant and non-denominational. This religious involvement is seen also in the hospitals more than half of which are denominational. The hospitals get most of their income from the sick funds, but the State owns the university hospitals and has built some magnificent modern ones. The people of Holland are very aware of the need for health and the citizen is expected to know about and take his part in this comprehensive service.
This lecture should perhaps have started with West Germany, where sick fund insurance systems had their beginning between 1880 and 1890. Today compulsory schemes cover all wage earners and salaried workers below a certain level. Other groups may join and today about 90 per cent of the population are covered. The sick funds are supervised by provincial governments which, in fact, have to subsidise the funds as they are never solvent. Because of the provincial control the service given varies considerably. The delivery of primary medical care is in the hands of general practitioners who must have three years training and experience before being acceptable to the sick funds. Each sick fund builds up its panel of doctors—we changed the meaning of the word when we started health insurance here in 1911 —and the patient has free choice of both GPs and specialists from the list. Fees paid by the sick fund are not paid directly to the doctor, but go into a fund controlled by a committee of doctors, who pay out the individual doctor. This is a complex system which the GPs claim does not provide a high enough average reward so most doctors also take private fee paying patients. In spite of the long history of health insurance, and in spite of the fact that the sick funds will pay for laboratory or other examinations, Germany has not developed a system of assistance for diagnostic work such as we have in this country. GPs are, in many places, now combining to provide their own diagnostic centres which also undertake physiotherapy and other forms of treatment. The GP can, of course, send his patient to one of the whole time chiefs of staff, who keep a tight grip on what private practice there is, at one of the 80 university hospitals. All hospital care is free to members of the sick funds, which largely maintain both public and private institutions. The sick funds employ medical officers to check on abuse, especially on long stays in hospital. Altogether the German service gives the impression of a very rigid system not changing very rapidly and not necessarily giving the highest quality of service. And, in contrast to France and Holland, this highly industrialised nation has no occupational health service.
Since we have raised the question in the title of this address as to Who gets the best delivery of health care, we need not spend much time looking at other European countries where the system is still only partly developed and where poverty is still a great hindrance in the field of health. Italy follows the European pattern but it is only recently that it has reduced the number of small sick funds to a few centrally controlled by the State. Membership of these is compulsory for employed persons and other special groups and the premiums, of which the employer pays much the larger part, are graduated according to income. The position is complicated by an entirely separate system, including hospitals, for industrial injuries. There are, in fact, two chains of health facilities. The National Institute for Sickness Insurance (INAM) provides 900 centres and vary from large urban polyclinics down to village dispensaries, where both GPs and specialists attend, and are paid by a variety of methods. The other chain of facilities are owned by the National Institute for Insurance Against Industrial Accidents (INAIL). The hospitals owned by this service are among the best in the country: the other fund makes use not only of its own hospitals, but of private and religious ones are well. Italy is now reviewing its whole hospital service and has been studying the British system with a view to organising a unified system on a regional and local basis.
Turkey, Greece, Spain and Portugal all have health schemes too complicated to describe in detail. The dictatorships all agree that health is essential, but spend very little on health services. Spain has some of the best prestige hospitals to be seen anywhere. Turkey has the most advanced ideas on how to develop a socialised system. Already more than one third of Turkey is covered by a chain of public hospitals and “socialised health units” which are village health centres linked to small, but modern, hospitals in the nearest town and staffed by salaried doctors. Turkey has a system of social insurance which pays for both general practitioner care and hospitalisation for those in employment, but the bulk of the population is too poor even to pay premiums and so the service is for most people free. Turkey is full of experimental ideas which may become exciting as the national wealth increases.
Summary
This lecture began with reference to the way in which Somerville Hastings was always able to take a long look forward at possible health service developments and so was usually well ahead of his contemporaries. A memorial lecture to him would be meaningless if it did not look forward both theoretically and in practical terms. I have tried to give a picture of the health services in many countries and might have added Canada, India and Eire, in all of which I spent time visiting hospitals and talking to people. Many points emerge from it all, but two or three are of major importance. None of the countries I have visited are satisfied with their health services as they exist: but none is static. All are changing, but the rate of change varies very much. In all countries doctors and politicians discuss the same questions, the education of the doctor and the definition of his work, the position of those who assist him and should be members of a team committed to the health of their community; the amount of money to be spent on health in relation to the per capita income of the country; the participation of health workers in control of the service; the way in which we can provide for democratic control; and how far we can go in preventing disease and how much we can improve the health of the individual. In all the discussions one service is, if not the yardstick, at least the focal point, the British NHS. Many ask if the Soviet health system should not be the source of ideas, but most people find it too rigid in structure and too rooted in slogans— and, in any case, few know enough about it. It is not only because our service is universal and aims to be comprehensive and, above all, because we have broken completely with direct payments and insurance and sick funds—except for the rich—but because the standard of British medical care is admired everywhere. The points that impress others are that everyone can have a primary care physician of his or her own choice and that he can refer all cases to highly trained consultants without question of cost and can prescribe from an unrestricted list of drugs. Our research and innovative reputation is recognised everywhere. The medical textbooks of every country are dotted with British names both in diagnosis and treatment. Going about other countries one has to preserve his objectivity in a continuous atmosphere of praise for what Britain past and present has contributed to medicine.
One can, and did, do better. Having invited myself and been remarkably well received, in some four hundred hospitals and clinics in many countries I invited myself to a number of British Medical Schools and many hospitals in the NHS. They were subjected to the same inspection and inquisition as in other countries, the laboratories and supporting services were looked at as well as that example of social responsibility already mentioned, the blood transfusion service. I found no reason to doubt the quality of medical care given to the citizens of Britain. It compares with the best anywhere. But what is even more important is that our average is an average for the whole nation—not just the 60, 70, 80 or 90 per cent covered by schemes dn other countries; and not complicated by sick funds, claims for repayment, arguments with doctors about the cost of every item of service, which are such a feature of the European systems. Those who are taking part in the debate on entering the Common Market, should remember that none of the six have a system for the delivery of medical care that compares ; nor is the social wage, except, perhaps, for family allowances in France, as valuable as it is here. Above all the basis of the family doctor comes out top in all discussions on how to see that the ordinary man and women gets a wide range of medical advice as and when it is needed.
Even more important, however, are the other changes Somerville Hastings pioneered and the SMA has advocated and developed—the building of health centres as the place of work for the community care health workers led by a salaried primary care physician, our GP, the family doctor with his work enhanced in two ways, by his greatly increased training in social problems and by the wider range of assistance from auxiliary workers on the one hand and specialists of every type on the other; and all coupled with a health centre based occupational health service for industry, agriculture and that neglected worker, the housewife. In such a place of work the leader of the diagnostic team would also be the leader and inspirer of prevention and of health education. In my view the British people get as good value for their health service spending as any other people do and far better than most. All countries have high spots and we have ours. But what we should be best pleased with is the even spread throughout the nation of medical care of high standard at low or no cost to the individual. My favourite description of the NHS is that of an American, Professor Almont Lindsey. Written in 1962 it is as true today as then. “As a growing evolutionary programme it will be reappraised from time to time. With its origins deeply embedded in the past, the service is giving good performance in spite of blemishes. In the light of past accomplishments and future goals, the NHS cannot very well be excluded from any list of notable achievements of the twentieth century. So much has it become a part of the British way of life, it is difficult for the average Englishman to imagine what it would be like without those services which have contributed so much to his physical and mental well being”.
But the Englishman—or I would prefer the Briton—has today to face a challenge both in terms of practical service and in that belief in something which it took years to establish, the concept of a universally available service, free at the time of use, from forces of reaction which will attempt to lower it in quality and quantity and in the eyes of the world. Is it to be another part of the cost of entry into the Common Market that we have to accept lower standards of health care: or as part of our subservience to the United States of Richard Nixon that we have to resort to differing standards of health care, for the rich who can afford to pay high insurance premiums, for the middle class who cannot afford but can be compelled to pay some form of expensive insurance, and a low standard for all who are gainfully employed and for the children and the aged. What is now proposed for dentistry is your guide line to what may happen. Just at the moment, when our dental services were beginning to get on top of our dental problems the whole structure is to be destroyed to save money to pay tax relief to our rich and Concordes for the wealthy. In so far as our service has a lead over others it cannot be maintained without more money being spent, health centres built as rapidly as possible, industrial health protected and new vistas of health opened up for all. The principles Somerville Hastings laid down and the Labour Party persuaded the country to accept are the only principles that can give the people of Britain a real chance of health and the rest of the world an example which even if it cannot be copied ever where else can still show to the world that socialist ideals can be put into practice and can be made to work even in hostile capitalist society.
Bibliography
Almont Lindsey, Socialised Medicine, Chapel Hill, 1962.
Evang, Murray and Lear, Medical care and family security, Prentice Hall, 1962.
K. Evang, Health service, society and medicine, I960
Brian Abel-Smith, Cost of medical care, World Health Organisation, 1967.
Health services in Western Europe, Office of Health Economics, 1963.
John Fry, Medicine in three countries, Medical and Technical Publications, 1970.
Booklets on their health services are also published at regular intervals, so giving the latest statistics, by the governments of most of the countries discussed in this paper.
Fabian Society
The Fabian Society exists to further socialist education and research. It is affiliated to the Labour Party, both nationally and locally, and embraces all shades of Socialist opinion within its ranks—left, right and centre.
Since 1884 the Fabian Society has enrolled thoughtful socialists who are prepared to discuss the essential questions of democratic socialism and relate them to practical plans for building socialism in a changing world.
Beyond this the Society has no collective policy. It puts forward no resolutions of a political character, but it is not an organisation of armchair socialists. Its members are active in their Labour Parties, Trade Unions and Co-operatives. They are representative of the labour movement, practical people concerned to study and discuss problems that matter.
The Society is organised nationally and locally. The national Society, directed by an elected Executive Committee, publishes pamphlets, and holds schools and conferences of many kinds. Local Societies—there are a hundred of them—are self governing and are lively centres of discussion and also undertake research.
Enquiries about membership should be sent to the General Secretary, Fabian Society, 11 Dartmouth Street, London, SW1; telephone 01-930 3077.