The British Plan for Health

An old man walked into a drug store in Harvard Square, clutching a pair of broken spectacles. Ignoring the line at the counter, he held up the spectacles and said to the assistant, "I want something that will mend these, stick them back together."

"We don't have anything," she replied, "You need to buy a new pail."

"I've got to find something. Otherwise I can't read." The girl turned to me, the next customer in line. But the old man would not leave. He just stood there holding his glasses. "What am I going to do? I can't possibly afford new glasses and all those visits to the optician...How am I ever going to read?" he asked plaintively. The waiting customers looked away, embarrassed by this pathetic outburst.

I was quite amazed. In Britain, such a scene is virtually inconceivable. When you are raised in a system where health care is something to be taken entirely for granted it is hard to grasp that anyone, like this old man, need ever worry about having to pay for such services. Indeed a well-known British correspondent, trying to bring home this contrast, recently wrote an article that began: "If I could be rich, beautiful, young, but above all healthy, there is nowhere that I would rather live than New York...." This expresses a sentiment shared by many Europeans.

Yet it appears that things are changing in the United States. The ever-rising price of health care here, and the problems of a system without cost controls and with uneven access to care, might at last be forcing a systematic reconsideration of the whole issue of health insurance. Sen. Edward M. Kennedy '54 (D-Mass.) has made plans for a national health insurance scheme one of his major priorities. He is urging reforms in response to what he sees as the "current non-system of health care." He believes there is a growing crisis in the area of health, requiring far-reaching changes.

This feeling is spreading, to some extent, among politicians, lobbying groups and the public. In North Dakota, for example, a question appeared on the ballot earlier this month, calling for total controls on health care costs. Another instance is the recent Senate vote favoring hospital cost containment -- which passed contrary to earlier expectations, and in the face of opposition from the American Medical Association and hospital lobbies.

Still, however, there remain major obstacles to the introduction of a national health insurance scheme. Vested interests spend much energy opposing such proposals -- but possibly more serious is the fact that large areas of public opinion tend to have vague notions about the grave disadvantages of what is generally referred to as "socialized medicine."

The commonest reaction among Americans to any mention of the British National Health Service (NHS) is that, together with the rest of the welfare state, it is responsible for Britain's post-war economic decline. Yet beyond this criticism, many Americans have little conception of what comprehensive national health services like those in Britain consist of, and cling to the conviction that socialized medicine is a bad thing. This tends to mean that they are willing to put up with a system that is costly, uneven, and in which the majority of the population are not even fully covered by health insurance. Consequently, ill-health is something to be feared here, even more than in most other developed countries.

My position is not one of claiming that the British NHS is a perfect institution. It suffers indeed both from problems and limitations. Yet aside from these. I believe that comprehensive health care can work successfully and, moreover, serves as a cornerstone in the more caring society which the welfare state was intended to create. At the risk of lapsing into platitudes, one can say that health is something where there is little justification for the provision of different standards of service for those with different bank balances.

Surely all citizens deserve the very best that the nation is able to provide. At the risk of simplifying things, it was this principle which was supposedly the overriding concern of the creators of the NHS... "that the physician should do his work without reference to the social, financial or racial position of the patient and that the necessary medical attention, preventive or curative, should be given without any question of fees arising."

A second important underlying premise is the notion that individuals have a right to expect certain services from government. In America, to depend too much on government is seen as a weakness and an inhibitor of freedom. At the simplest level, the logical development of this attitude ensures the freedom to starve or to die of ill-health, through inability to pay the doctor's bills. There is certainly a relationship between the values of a society and the form of its healthcare delivery system. Perhaps Europeans have less cultural and ideological inhibitions in allocating certain tasks to the state. As a result of this, the programs which emerge are not seen as demeaning, but are there for all to use. There is not the cultural fear that social services will subvert deeply-held values and pave the way toward totalitarianism.

The development of such values did not come overnight. During the 1945 election campaign, Winston Churchill threatened that the proposed Socialist reforms were the first step toward the concentration camp! He seriously misjudged the wishes of the country. There was a more radical mood, created largely by the war, and this, in addition to the obvious failings of the previous system, meant that the introduction of the welfare state found widespread acceptance. The Labour minister of health, Nye Bevan, was initially faced with opposition by 90 per cent of the British Medical Association. They even attempted to strike, but eventually this opposition disappeared due to a series of compromises. This included the continuation of a small private sector, which shares a great many NHS facilities, and supposedly maintains the notion of free choice.

Since 1948, when the NHS was first set up, there have been various changes in the system. One of the most significant was the introduction of a small charge for prescriptions including spectacles and dentures, which prompted Bevan and Harold Wilson to resign in 1951. Their gesture was largely symbolic, because the charges in question were comparatively small and anyway did not apply to the old, young, poor or unemployed.

The Health Service was reorganized in the early 70's and one new development was the addition of Community Health Councils, which are supposed to provide consumer "feedback." Other changes involved the introduction of free contraceptive services and National Health abortions.

Yet overall there have been no fundamental alterations. The return to power of the Conservatives in 1951 did not result in the dismantling of the NHS, just as later Republican administrations did not undo the reforms of the New Deal in the U.S.

Attributing Britain's post-war economic difficulties to the introduction of NHS is too simple. We need to examine some of the far deeper structural problems concerned with questions such as the level of industrial investment in order to explain her declining economic fortunes, and that would take an article in itself. Furthermore, countries such as Germany have comprehensive health insurance, and are by no means in a weak state economically.

The vast proportion of the British public has been satisfied with the NHS. Polls conducted earlier this year showed that 85 per cent agreed that it provided a good service. In 1948 doctors' waiting rooms overflowed with people who had not seen a doctor in years. In particular there were many uninsured patients who had accumulated debts which they could not pay off. Since then there has been a substantial rise in the overall standard of health. One example is the infant mortality rate, which was virtually halved during the first three years of the NHS.

The U.S. many spend far more than any other nation on health care, but in some respects its standard of health is surprisingly low. According to World Health Organization statistics, it ranks 15th among the developed nations for infant mortality and 17th in life expectancy for males. Yet the AMA claims that the present system provides "the best medical care in the world."

Kennedy's proposals present a serious attempt to answer some of these difficulties, partly be redistributing resources to provede a better service to all. His scheme is based largely on the existing Canadian system rather than the European models. Yet much of the underlying philosophy is similar. In practice the U.S. would have 30 years of European experience to learn from. On the basis of this they could probably make a national health insurance scheme work better and avoid some of the problems encountered by the NHS. It needs only sufficient political will for these measures to be introduced. Kennedy is confident that this is bound to come; if not in the next session of Congress, then in the next one. In the meantime, high costs and uneven services will continue. And the old man in the drugstore might not get his new glasses.

Suzanne Franks, a graduate of Oxford University, is studying at Harvard on a Kennedy Fellowship.

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