NationalHealth Service in Great Britain
1 Descriptionof the National Health Service
The National Health Service is under the control of the Ministerof Health, who is advised by a central health services council made up of 41persons, 35 of whom are appointed by the Minister himself, selected from thevarious groups dealing with the care of the sick. The NHS is administered bythe civil servants of Whitehall-this is important to remember-and it is dividedinto three sections. The first one is the hospital services, the second is themedical practice services and the third is public health.
The hospital services control all the hospitals in Great Britainwith the exception of a very few denominational hospitals. The whole country isdivided into 14 regions arranged around one or more medical schools andadministered by the regional hospital boards. These regional boards, 25% ofwhose membership are physicians, are responsible for all consultans’ andregistars’ appointments in the hospital. Each hospital in turn is controlled bya hospital management committee. The 36 teaching hospitals are under thecontrol of boards of governors which are independent of the regional hospitalboards. Each hospital must submit in September its budget for the yearcommencing the following March and must return to the Treasury any unspentmoney. This makes planning extremely difficult and complicated and invariablyresults in the complete expenditure of all funds in order to avoid a smallerallocation the following year.
To the second section of the medical practices committee belong tothe general practice of medicine which includes the general practitioner, thedentist, the oculist and the druggist. The section controlled by 163 localexecutive councils, which succeeded the national insurance committees, isresponsible for personal medical services. There are at present in GB about19,000 physicians for a population of 45 millions which is a proportion of onephysician per 2,300 people.
In the third section of the public health service we find thehealth centres, the various clinics for pre-natal care, for school children,for vaccination, for immunization, for tuberculosis and for rehabilitation.
At the present time it should be pointed out that the medicalservices are not entirely free since the patient has to make a weeklycontribution to the national insurance system and has to pay a certain fractionof the cost of the prescriptions, dentures, glasses, trusses and other medicalaccessories. About 95% of the medical profession receive their income throughgovernments cheques. Almost all the hospitals and sanatoria belong to thegovernment and the whole NHS is ultimately controlled by civil servants of theMinistry of Health. It is estimated that about 92-95% of the population inEngland is now under the NHS.
2 Cost ofthe National Health Service
The individual weekly contribution to the national insurancesystem varies between 35 cents for an unemployed person under 18 to $1.25 for aworker whose employer pays half of its amount. Less than 10% of the totalcontributions to the national insurance system or about $100 million went tothe division of the NHS in the years 1950-1951. Since the total cost of the NHSin those years was 1.2 billion dollars, it means that 92% of the total cost ohNHS had to come from the general taxation moneys. This represents about 3.5% ofthe total government revenue, about 22% of the expenses of the nationalinsurance system and about $27.00 per head of population.
One of the cornerstones of the NHS was intended to be the creationof health centres throughout the country. At the present time, because of thelack of money and the enormous cost of the other services, it has only beenpossible to build one or two. Each of these centres which would provide generalmedical, dental and public health services for a population of about 20,000persons under the local health branch of the NHS would cost about $450,000.Such a centre would include six general practitioners, two dentists and one ortwo health officers. On this basis, greater London alone would need about 450such centres.
3 Freeservices and contributory services
The vast majority of NHS services are free at the point of use.
This term, which is commonly used, means that people generally donot pay anything for their doctor visits, nursing services, surgical proceduresor appliances, consumables such as medications and bandages, plasters, medicaltests, and investigations, x-rays, CT or MRI scans etc. Hospital inpatient andoutpatient services are free, both medical and mental health services. This isbecause these services are all pre-paid from taxation.
Because the NHS is not funded by contributory insurance scheme inthe ordinary sense and most patients pay nothing for their treatment there isthus no billing to the treated person nor to any insurer or sickness fund as iscommon in many other countries. This saves hugely on administration costs whichmight otherwise involve complex consumable tracking and usage procedures at thepatient level and concomitant invoicing, reconciliation and bad debtprocessing.
Eligibility for free NHS services is based on having«permanent residence status» (a birthright for some or granted by theHome Office for those who have immigrated). The person must be registered witha general practitioner and have an NHS card and number. This will includeoverseas students with a visa to study at a recognized institution for 6 monthsor more, but not visitors on a tourist visa for example.
Citizens of the EU holding a valid European Health Insurance Cardand persons from certain other countries with which the UK has reciprocalarrangements concerning health care can likewise get emergency treatmentwithout charge.
In England, from 15 January 2007, anyone who is working outsidethe UK as a missionary for an organization with its principal place of businessin the UK is fully exempt from NHS charges for services that would normally beprovided free of charge to those resident in the UK. This is regardless ofwhether they derive a salary or wage from the organization, or receive any typeof funding or assistance from the organisation for the purposes of workingoverseas. This is in recognition of the fact that most missionaries would beunable to afford private health care and those working in developing countriesshould not effectively be penalized for their contribution to development andother work.
Those who are not «ordinarily resident» who do not fallinto the above category (including British citizens who may have paid NationalInsurance contributions in the past) are liable to charges for services.
There are some other categories of people who are exempt from theresidence requirements such as specific government workers and those in thearmed forces stationed overseas.Prescriptioncharges
As of April 2009[update] the prescription charge for medicines was£7.20(which contrasts with Scotland at £4.00 and Wales and NorthernIreland where they are free). People over sixty, children under sixteen (orunder nineteen if in full time education), patients with certain medicalconditions, and those with low incomes, are exempt from paying. Those whorequire repeated prescriptions may purchase a single-charge pre-paymentcertificate which allows unlimited prescriptions during its period of validity.The charge is the same regardless of the actual cost of the medicine, buthigher charges apply to medical appliances. For more details of prescriptioncharges, see Prescription drugs.
The high and rising costs of some medicines, especially some typesof cancer treatment, means that prescriptions can present a heavy burden to thePCTs, whose limited budgets include responsibility for the difference betweenmedicine costs and the fixed prescription charge. This has led to disputeswhether some expensive drugs (e.g. Herceptin) should be prescribed by the NHS.
The good points of the NHS
a) The main part of medicalresearch in England depends on the Medical Research Council which is agovernment body, free of political influence. The characteristics of medicalresearch in England are that the greatest part of the funds available come fromone central body which is the MRC, that most of the work done under its grantsis of good to superior quality and there is a minimum of useless duplication.
b) Medical care costs very littleto the individual and there is no question that the public is satisfied.
c) The previously full timephysicians in the hospitals receive a better income than before and are giventhe importance they deserve. Many of them are happy about the change.
d) The out-patient departmentsare given greater importance and better organization.
e) The most competent sectionof the medical profession, professors, consultants, and top research workersare given more importance than formerly in the advisory committees, in theorganization and the development of the service.
f) It appears that that theBritish doctors have a reasonable income and are much happier in comparisonwith the rest of English society.
Weak points of the NHS
a) One of the most importantfailures of the NHS lies in its artificial administrative division into thethree branches of the hospital services, general medical services, and publichealth, without any integration at any level. There is very little relationshipbetween the consultant in the hospitals, the general practitioner and thepublic health officer. This often leads to misunderstanding and mutualignorance. In the end it is the patient who suffers in this artificial no man’sland between the three divisions.
b) Animal experimentation isunder the control of the civil servants of the Home Office, who sometimes haslittle or no knowledge of hospital problems, medical care or of medicalresearch. Any experimentation involving the use of animal requires a writtenapplication to the Home Office. Permission is usually given without difficultybut still there are exceptions.
c) The private charitable andthe voluntary welfare associations have been chocked and replaced by the cold,slow and impersonal machinery of the various government bodies.
d) Since the actual number ofyoung physicians prepared for consultants’ posts is too great there is strongcompetition for these, as well as competition between consultants for thespecial awards, with all the unwelcome features attendant on these struggles.
e) Because of the number ofcertificates required and the impersonal character of hospital care,professional secrecy and discretion are in many instances things of the past.
f) Surgeons are paid byoperating sessions and receive the same payment whether they do oneappendectomy per operating session or four gastrectomies.
g) In the care of the aged,tuberculous patients, the chronically sick, the infirm and the patients withinfected tonsils the situation is so bad that there is a waiting period ofnon-urgent cases of 6 months to 2 years before admission to the hospital andduring that time the patient becomes a burden on the general practitioner.
In summary, the main weaknesses of the NHS consist of:
1) The lack of unity betweenthe three divisions of general practice, public health, hospital services andconsultants;
2) The excessive demands forservices of the general practitioners which render them unable to give thenecessary time to cases which deserve close attention;
3) The isolation of the generalpractitioners from hospitals, the long waiting list in all hospitals fornon-urgent cases, and the lack of facilities for the aged and chronically sickpatients.
References
1) National Health Service Act,1946, 9&10 Geo.6 Ch.81, H.M. Stat Off-
Amendment-1949,12,13,14,Geo.6 Ch.81
Amendment-1951,14,15,Geo.6 Ch.31
2) Beveridge Report on “SocialInsurance and Allied Services”, H.M. Stat. Off.,1942, Cmd 6404
3) Green,F.H.K.:Science,116:99, 1952
4) Peterson, O.L.: “A study ofthe National Health Service of Great Britain”,1951