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From International Socialist Review, Vol.22 No.2, Spring 1961, pp.57-61.
Transcription & mark-up by Einde O’Callaghan for ETOL.
FEW domestic issues seem to arouse so much impassioned controversy in America as the question of socialized medicine. When the Forand bill, providing only limited health care for older people under the social security system, was introduced in the last Congress, one newspaper screamed in large print, “This isn’t creeping socialism – it’s galloping socialism!”
The problem of medical costs for people over 65 in the United States is a severe and often tragic one. According to the US Department of Health, Education and Welfare, 77% of the people in this age bracket have chronic ailments while 48% have family incomes of less than $2,000 a year, and only one-quarter are covered by insurance. Still, this modest, inadequate bill, strongly backed by the AFL-CIO, was defeated.
The bill was fought by the US Chamber of Commerce. It urged employers to provide paid health insurance coverage for all retired workers and made no bones about the fact that its move was aimed at heading off a government health plan under the social security system. “Successful private plans will provide the Chamber with the evidence it needs to combat the compulsory approach,” it said.
The strength of the American Medical Association, considered the most powerful medical organization in the world, was pitted against the Forand bill. The AMA asked its members to “fight with all our resources any effort to add medical care to the retirement benefits provided by the social security system.”
The resources of the AMA are enormous. In 1950 alone, this organization waged a million-dollar advertising campaign against what it called “the dangers of socialized medicine and the threatening trend toward state socialism.”
The Yale Law Journal, in an article on the AMA, said that it has “acquired such power over both public and practitioners that it can channel the development of American medicine ... Measures assured of passage have been voted down, buried in committee, or substantially amended upon announcement of AMA disapproval.”
Due in part to the influence of the AMA on the press and in part to the general atmosphere of ignorance and fear of anything termed “socialist,” it is very difficult to get a realistic appraisal in this country of socialized medical plans elsewhere. Nevertheless, there are several countries that have some kind of health scheme available to their people, without having achieved socialism, creeping or galloping. They have accumulated considerable experience in planning health care and have made steady progress toward making life a little healthier, a little happier and a little more civilized than it was before. Apart from the countries in the Soviet bloc, health plans, varying in effectiveness, exist in New Zealand, the Scandinavian countries, Great Britain, and they have the start of one in Canada.
Here we shall deal with socialized medicine in Great Britain, perhaps the most advanced medical system outside the Soviet bloc, whose history began on July 5, 1948, when the National Health Service came into existence.
Before 1948 there were two main types of hospitals: the Voluntary and the Municipal Hospitals. Many of the former originated in institutions founded by monastic orders in the Middle Ages. With the break with the Catholic Church in the middle of the sixteenth century, the monastic orders were dissolved, but in many cases the hospitals carried on, and today some of them still bear the original names, such as St. Thomas’s and St. Bartholemew’s of London (or “Tommy’s” and “Bart’s,” as the medical students irreverently refer to them). The vast majority of the Voluntary Hospitals, however, were founded during the “Age of Philanthropy” in the eighteenth and nineteenth centuries.
As the name implies, the Voluntary hospitals were charitable organizations for sick poor. Local citizens with wealth founded and financed them. The medical staffs were made up of men who gave their services free.
The big drawback was that these hospitals could be set up only in areas where there were people with sufficient money to finance them, and where there was a large enough practice to enable doctors to give a few hours a week for charity work.
Even before the last world war it was obvious that something would have to be done. Fewer people were available to finance these hospitals, and there were fewer private patients to keep the doctors going. Although charges were by then imposed on the patients in accordance with their means, together with sums of money which local authorities gave them, the Voluntary Hospitals were increasingly unable to carry out their functions.
The Municipal Hospitals were started under the system of Poor Law Relief established at the end of the sixteenth century. With the earlier dissolution of the monasteries, the poor lost many of the charity organizations which at least had kept them alive, if only barely so. In the so-called “Golden Age” of English history, when English seamen sailed around the world and the first steps were taken to construct the rich and powerful British Empire, there was, at the same time, such an increase in poverty and misery that some action had to be taken. That action resulted in the Poor Law Relief system that established charity hospitals and workhouses for the poor. The system continued to expand during the next three-and-a-half centuries, until a network of such institutions had spread throughout most urban areas in the country. Conditions in the vast majority of them were absolutely deplorable.
In 1930 responsibility for these institutions was transferred from the Poor Law Boards of Guardians (groups of charitable men and women who gave time voluntarily) to the County or County Borough Councils (composed of men and women elected by the local inhabitants to run these institutions). They were given permission to turn the workhouses over for use as hospitals and in the next few years most of the wealthier and more progressive councils had done so. These new Municipal Hospitals, which in some cases began to compete with the established Voluntary Hospitals, had full-time, salaried, medical staffs. However, there were many Councils that were neither wealthy nor progressive, and in those areas hospital facilities were sadly lacking.
In addition, of course, there were a number of private hospitals. These were either very expensive, exclusive organizations for the wealthy, or run for the poor by various religious bodies.
In 1943, teams of experts were set up to undertake a complete survey of all the hospitals in the United Kingdom. Much of the subsequent hospital planning has been based on their reports.
As far as the family doctors were concerned, there were in existence a number of different insurance schemes. The largest started in 1912, the National Health Insurance Scheme. It provided general practitioner service for all workers earning less than £250 a year, or approximately $750. This was later raised to £420, or about $1,260 a year. For the payment of additional dues, extra benefits, such as dental and ophthalmic treatment could be received. (The conversion of pounds into dollars is here made for a rough approximation on the basis of $3 for £1. The actual exchange rate fluctuates around $2.85 for £1. – Ed.)
Under this plan, both the employee and his employer paid a contribution. If the employee fell ill or was unemployed, he received sickness or unemployment benefits and free medical care from a general practitioner, together with free medicines. However, this didn’t include any hospitalization that might be needed, nor did it cover the retired old people, the wives of the workers or their children, with the result that only about one-half of the population was insured with the National Health Insurance. The rest had to pay the full doctors’ fees or join either one of the more expensive schemes or one of the numerous sickness clubs under which the people paid the doctor a few pennies a week and received medical treatment when ill without provision for covering the cost of medicine or hospitals.
When the National Health Insurance Scheme started in 1912, it was decided to pay the money to the different health insurance agencies already in existence. Some were cooperative undertakings, some were run by trade unions, and some by insurance companies, so that there arose the anomaly of a national, compulsory insurance scheme being administered through separate, private insurance organizations. The benefits tended to vary. While the sickness benefit remained fixed by law, some of the wealthier organizations gave additional services, dental care, eyeglasses and so on, while the poorer ones gave only the minimum.
In addition to the general practitioners there were also some Public Assistance doctors who looked after the destitute sick. As a general rule, medical help received by this means was not of a high standard.
There were also local health authorities which were responsible for certain aspects of public health These included clinics, midwifery, maternity and child welfare, water supplies, sewage and refuse disposal, control of epidemics and the provision of domestic help for families unable because of illness to look after themselves.
The main difficulty lay in the fact that there were over 400 authorities, many of them too small and too poor to carry out their functions. In addition, there were no home-nursing services available other than midwifery.
In 1942, Sir William Beveridge (now Lord Beveridge), a Liberal member of Parliament, proposed a comprehensive health service which would “ensure that for every citizen there is available whatever medical treatment he requires in whatever form he requires it, domiciliary or institutional, general, specialist or consultant, and will ensure also the provision of dental, ophthalmic and surgical appliances, nursing and midwifery, and rehabilitation after accidents.”
Great interest was stirred by this idea and when General Elections were held in 1945, one of the main planks in the Labor party platform was the formation of just such a comprehensive health service. The Labor party won the elections with a large majority in the House of Commons.
The British Medical Association opposed the Health Service as bitterly as the American Medical Association does here. They held a plebiscite among doctors and the whole idea was voted down – not so much by the doctors in poor urban and rural areas as by the majority of doctors who were centered in the cities and around the hospitals.
However, under the leadership of Aneuran Bevan, then Minister of Health, the Labor party steered the necessary legislation through parliament and in November 1946 the National Health Service Act became law. As before mentioned, it came into effect on July 5, 1948. It applied only to England and Wales, but very similar laws were passed at the same time for Scotland and Northern Ireland.
The National Health Service is available to every man, woman and child in the country without any qualification. In addition, any visitors to the country from abroad are entitled to use the Service, without charge, should they fall ill while in the country. Any visitors, however, who go to Britain deliberately to get medical treatment, are expected to pay for it.
The Service is regarded as a charge on national income in the same way as education and the armed services. It is recognized that it is as necessary to spend money on healthy bodies and minds as it is to provide education for the people.
Most of the cost of the Service is paid by the National Exchequer – that is, out of taxes. About half of the Local Health Service expenses are met from local property taxes. In addition, contributions are collected from the people.
These contributions have risen slightly since 1948. The cost today is 2s. 4d. (about 30¢) per week for a man, of which 1s. 10½d. (about 25¢) is paid by the employee and 5½d. (about 6¢) by the employer. Women, youth under 18, the self-employed and the non-employed pay somewhat less. However, it is important to remember that eligibility for any necessary treatment does not, in any way, depend upon the payment of contributions. If a person has never paid a contribution in his life, he or she is still entitled to whatever medical care may be required.
Under the National Health Service Act of 1946, the only charges were for the renewal or repair of glasses or dentures if it was considered that they had been lost or broken through carelessness, and for domestic help or nursing requisites needed at home. Any one could, if they wished, pay extra for more expensive eyeglass frames, or gold fillings in teeth, or such extra benefits which were not medically necessary. It was also possible if a patient wanted privacy in a hospital but was not sufficiently ill to need a private room, to pay a fixed sum (not more than 12s., or about $1.80) a day for private accommodation, although nothing was paid for treatment. And, of course, if someone preferred to have private treatment and not come under the Health Service at all, he or she was free to do so.
There was, as expected, and as the British Medical Association had direly warned, a sudden rush to the doctors. This came mostly from women and children excluded from the previous National Health Insurance Scheme who had needed medical help, perhaps for years, but had not been able to afford it.
There were, of course, some people who saw a chance to get something “free” and ran to the doctor’s office for every headache or minor scratch. Malingerers still exist, but on the whole, after the first few months most of those who overdid the visits to doctors realized how unnecessary this was, considering that both the doctor and the Health Service were going to stay. They stopped going unless they genuinely needed help.
In 1951, claiming the scheme was too expensive, Hugh Gaitskell, then Chancellor of the Exchequer in the Labor government, introduced legislation imposing charges on dental treatment. This aroused great controversy within Labor’s ranks and Aneuran Bevan resigned in protest. But the right-wing element won the day, and so set the precedent for future increases in charges.
The following year the Conservatives, who were by then in power, added additional charges to the service. These were increased again in 1956. Today, there are charges for eyeglasses, dental treatment, dentures, day nurseries for children of working mothers (made free in 1948) and for each item on a prescription for hospital out-patients or patients of general practitioners. Any patient unable to meet these charges may apply for help to the National Assistance Board. This, however, to many people has overtones of the hated means test that workers, unemployed and the aged had hoped was gone forever.
Nevertheless, in spite of these charges, the National Health Service remains largely a “free” service available to all.
On July 5, 1948, 2,688 out of the 3,040 existing hospitals came under the National Health Service. These included mental hospitals, convalescent homes and certain types of clinics, as well as straight hospitals. The remaining hospitals outside the Service are run mainly by religious bodies, and there are still a few exclusive private institutions.
The Hospital Service includes specialist and consultant facilities, maternity accomodation, both ante-and post-natal care, child-guidance clinics, tuberculosis sanitoriums, infectious-disease hospitals, psychiatric hospitals, V.D. clinics, convalescent homes, rehabilitation centers, all kinds of specialist treatment such as plastic surgery, blood transfusions, radiotherapy, physiotherapy and occupational therapy, orthopedic and eye, ear, nose and throat treatment, and the provision of surgical and medical appliances such as artificial limbs, etc. Hospital in-patients are not charged for anything unless they choose to go in on a private basis.
The institutional part of the Service is organized into 15 regions, each associated with a university having a teaching hospital or medical school. The daily administration of the hospitals is carried out by Hospital Management Committees. The members of both the Regional Boards and the Hospital Management Committees serve voluntarily, the aim being to stimulate local interest and responsibility.
Nearly all the specialists and consultants take part in the service, either on a full or part-time basis. Those who participate only part-time can accept fee-paying private patients outside the Service. In order to see a specialist within the system, it is necessary to get a referral from the family doctor. The specialist usually sees patients at the hospital, but will visit the patient at home if he is too ill to go out.
Since 1952, hospital out-patients have to pay 1s. (about 15¢) for each item on a prescription for drugs and medicines (unless administered at the hospital), and there are charges for elastic hosiery, surgical abdominal supports, surgical footwear and wigs. Exceptions to these charges are made for patients receiving National Assistance and their dependents, war pensioners receiving medicine for war disabilities and patients being treated for venereal disease. Children under 16, or older ones who are still attending school fulltime, are exempted from charges on surgical appliances.
By the end of 1959, there were 76 distribution centers providing free hearing aids, an item which, before 1948, was not covered by any of the insurance schemes. Batteries and maintenance are also free.
The family doctor, dental, pharmaceutical and ophthalmic services are administered on the local level by executive councils whose members serve voluntarily. Twelve members of each council are elected by local doctors, dentists and pharmacists; eight are appointed by the local health authority and five by the Minister of Health.
Nearly all the general practitioners in the country take part in the Service. This does not prevent them from having private, fee-paying patients as well if they wish. They are paid according to the number of patients they accept on their list, or panel, as it is called. They receive 18s. (about $2.70) per patient per year and they are limited to a maximum of 3,500 patients for a single-handed practitioner. If the doctor wishes to take on more patients, he can only do so if he takes in a partner or assistant. The average yearly income for doctors today is £2,426 (about $7,275); but it is important to remember that these figures mean more in England where the average national income is about $30.00 a week.
In addition, the doctor receives 12s. (about $1.80) for every patient between 501 and 1,500 on his panel. Also, interest-free loans are provided for doctors wishing to improve their waiting rooms and other facilities.
All doctors who joined the Service in July 1948 were free to continue practicing where they were. However, any doctor wishing to join since then must receive permission from the Medical Practices Committee, consisting of nine members, seven of whom are doctors, six of them in actual practice. The Committee may only refuse a qualified doctor if the number of applications exceeds the number of vacancies in a given area. The Committee surveys the country’s medical needs and classifies each area as “restricted” (no additional doctors needed), “intermediate” (additional doctors may soon be needed) and “designated” (more doctors required).
Everyone is free to choose his or her own doctor and the doctor is free to accept or reject a prospective patient. A patient may change doctors at any time, either because he or she is dissatisfied or has moved. In an emergency, any doctor will give treatment, whether or not the patient is on his panel; and if someone falls ill while away from home, he will receive treatment where he is. The doctor receives additional fees under the Health Service for treating these extra patients.
Dentists are free to have private patients as well as patients under the Health Service. Patients do not have to register with a particular dentist, but may go to anyone who is willing to accept them. The dentist is paid for the treatment given each patient. Since 1952, there has been a charge on dental treatment. The original examination is still free, but there is a maximum charge of £1 (about $3.00) for any treatment required. If dentures are needed, the patient pays something like half the cost – up to a maximum of £4 5s. (about $12.75). Free dental care is provided for children under 21, expectant mothers, or women who have had a child during the preceding twelve months.
Free sight testing is available to all. However, since 1951, if eyeglasses are required, the patient pays 10s. (about $1.50) for each lens and the full cost of the frames. Children’s glasses, however, are free in standard frames. If treatment or surgery is required, it is referred to the Hospital Eye Service and comes under the free Hospital Service. The optician is paid for individual treatment given.
As stated earlier, there is a charge of 1s. (about 15¢) on each item on a prescription. Most of the pharmacists are now under the Health Service, and they take turns to ensure that a pharmacy is open in each area in the evenings, on Sundays and on holidays. A patient has to pay the full cost of the drugs or medicines only if he has chosen to go to a doctor on a private basis.
In addition, there exist Local Health Authorities, mainly concerned with providing care for patients in their own homes. For some of these services, such as domestic help, there are charges in accordance with the patient’s means. But, on the whole, most of the services such as midwifery, home nursing, etc., are provided free.
One area in which there has been great improvement is in mental health work. Mental and physical health have been brought closer together to the extent that most hospitals now have mental wards attached. In fact, 44% of the hospital beds are today reserved for mental patients. All treatment is available free.
Broadmoor Institute for insane criminals is now regarded less as a prison and more as a treatment center. Since 1948, it has been run under the Minister of Health instead of the Home Secretary who is responsible for the prison system.
While there are many improvements that still can be made, the National Health Service has brought tremendous help to the British people. Today, no one says, “What if I should fall ill? How could we manage?” It is bad enough to be ill, without having the additional worry that your family is mortgaging its future to pay doctors’ and hospital bills. That worry has now been lifted, and patients are able to receive full care without their recovery being hampered by anxiety over the cost of treatment.
Perhaps the greatest advantage is the growth of preventive medicine. When people feel a pain, they no longer have to put off seeking help until it’s too late. Regular physical check-ups, even before symptoms appear, are no longer the privilege of the rich. In this way many lives are saved and much suffering is prevented.
Furthermore, since doctors are assured of their income, they tend to go out to the poor urban and rural districts where an extreme shortage of doctors used to exist. Today some excellent work is being done in small country hospitals that previously had only second-rate medical staffs and few facilities.
Many attempts have been made to whittle away the original gains made by the British working people. Today the Conservative government is engaged in trying to force through legislation designed to increase the charges still more. If they are successful, and with their present large majority in the House of Commons there is every reason to believe they will be, the weekly contributions will be raised by 1s. (about 15¢); prescriptions will be doubled to 2s. (about 30¢) per item; the cost of dentures will rise to a maximum of £5 (about $15.00); private hospital beds for patients receiving medical treatment under the National Health Service will cost twice as much as before; and welfare foods for children such as orange juice, cod liver oil and vitamin pills, previously free or only nominal in cost, will now carry a substantial charge.
The Labor party is fighting these increases and parliament is engaging in many late-night sittings while the question is hotly disputed. As leader of the Labor party, Hugh Gaitskell is complaining loudly and bitterly that the Conservatives are gradually beginning to move away from the conception of a Welfare State. “Naturally,” he says, “we are strongly opposed to these moves.” Naturally – but it was Gaitskell himself who imposed the first charges.
In spite of these increases the National Health Service has become so much a part of British life, that it would not be possible for anyone to suggest abolishing it now. The British people have accepted it and would not tolerate its removal, and many members of the medical profession would now support them.
An indication of the opposition that might be expected is shown in the demand from a branch of the National Union of Mineworkers for a 24-hour general strike in protest against the latest charges, together with a call for the nationalization of the drug and medical supply industry and a cut in the arms program.
At the same time, the London Local Medical Committee, which represents about 2,500 general practitioners, consultants, medical officers of health and private practitioners in the County of London, passed a resolution with only one dissenting vote, against the increased prescription charges. Part of their resolution states:
That the committee opposes charges on prescriptions on principle, since they create a financial barrier between the patient and the treatment he or she requires; That the committee supports colleagues who do their own dispensing in their objections to the collection of these taxes for the Government.
Even the Conservatives recognize that to attempt to abolish the Service would create a situation with which they would be unable to deal. It was a Conservative Minister of Health who stated:
“The National Health Service, which started on July 5, 1948, is an agreed Service from the point of view of politics. All three of the major political parties have accepted it and played their part in its planning, and it is therefore wrong to refer to it as ‘Socialized Medicine’ as though it were a feature of one party only. All three parties are committed to it, and it is not expected that a change of government would make any serious difference to the scheme as a whole, although details might be altered.”
It will be a great day for the American people when a spokesman from, say the Republican party, can say the same thing about a similar medical plan in this country.
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