Surgery on Health Service : Reform of Medical Care Stirs Controversy in Britain

The National Health Service, one of the world’s most highly regarded, is in the throes of major reforms that have provoked controversy and opposition.

At its best, the service--which was founded in 1948, as what American conservatives dubbed “socialized medicine,” and which provides virtually free care to 58 million Britons--includes first-rate attention from some of the finest practitioners anywhere.

Take, for example, what it offered Frank Melville, 69, a journalist living in London’s Chelsea District. Experiencing bouts of fever, he went to his local general practitioner, who referred him to nearby Charing Cross Hospital, a major teaching institution.

After extensive tests, the doctors determined that he had a tumor of the colon; he was immediately operated on by top-flight surgeons and spent 10 days in recovery with round-the-clock nursing. Now, as an outpatient, he is examined regularly. Except for nominal expense for outpatient prescriptions, his care has come free of charge.

American tourists who are suddenly taken ill or injured in Britain express amazement at the speed and effectiveness with which they are treated without charge.

“There certainly is no better or more cost-effective health service anywhere else in the world,” says Dr. James Le Fanu, a general practitioner who writes on medical subjects.

Hospital care is free, including administered drugs; patients choose their family doctors, dentists, opticians and pharmacists, if the health-care providers contract with the health service.

(Dental care, except for the poor, carries some costs, but the maximum for extensive work is $400 or so.)

British residents enroll with a general practitioner who provides initial diagnosis and care or refers them to a specialist. Prescriptions for all but costly items are covered for a flat fee of less than $7. (Drugs are free for children, expectant mothers, the poor and the elderly.)

So far, so good.

But there is a downside to the National Health Service. At its worst, patients run into shabby hospitals, impersonal general practitioners and specialists, and, most of all, long delays in getting elective--non-priority--surgery. The waiting in most areas, for example, for hip- or knee-replacement or cataract surgery lasts for more than a year. Britons also experience long waits for outpatient care and for routine appointments with specialists.

Because of the demand for surgeons, they sometimes adopt a peremptory approach to major operations: In a recent, nationally publicized case, doctors in several major hospitals refused to perform heart bypasses for heavy smokers unless they agreed to quit smoking. One such patient consented and was wait-listed for surgery. But while visiting the doctor’s office a week or so before his scheduled operation, he collapsed and died.

Despite the adverse publicity from such cases, the health service, as most reports agree, has been a largely successful institution: It has provided universal access to health care, allocated on the basis of need. It employs skilled, conscientious doctors and gives them considerable autonomy.

The service is also relatively cheap to provide and administer. One estimate suggests that Britain spends only 6% of its gross domestic product for health care, versus double that amount in the United States.

Nevertheless, faced with increasing budget pressures, the government has insisted on reforms to make the tax-supported service--which, like every other national agency must compete vigorously for limited government funding--more cost-effective. (The government, through the Health Department, sets an overall budget for the year for the service--which determines how much money is available to hospitals, community care organizations and doctors.)

In the past, reformers say, there was waste in the health system, partly through its sheer size: With 1 million staffers, the service is Britain’s largest employer and one of the world’s largest organizations.

“Accounting was dreadful,” grumbled one former government official. “Some of these hospitals did not really know how much equipment or even bed linen they had. They just assumed the government would pick up the check.”

Further, critics say, the service was rife with such other problems as: no incentives to limit prescriptions or discretionary care; little choice for patients of doctors or hospitals; hospitals that saved money often finding the sums diverted elsewhere and not to their benefit, and a confusing division in management between doctors and administrators.

Since the Conservatives gained control of the government, the Health Department has come under increased pressure to cut waste in the health service, particularly in its management.

As Sir Roy Griffiths, a supermarket executive who reviewed the service’s administration, put it in 1983: “If Florence Nightingale were carrying her lamp through the corridors of the (health service) she would almost certainly be searching for the people in charge.”

Since then, the government has set up a review board to propose reforms. After three years of study, changes were made in 1991, altering relationships among doctors, hospitals and health service administrators. The reforms, which are continuing, are designed to make the system more competitive, with the hope of improving the cost-effectiveness of patient care.

Under the new system, hospitals have received more independence from health service administrators, allowing the institutions to become independent corporations or “trusts” and to contract out for services--from cleaning to ambulances. General practitioners working with the service also have been encouraged to enter group practices and to select their own hospitals for patients--presumably those offering the best, quickest and most economic care.

While the health service, which still ultimately will pay the bills, will monitor hospitals and practitioner groups for efficiency, the government agency’s own bureaucracy is to be slashed, reducing the number of regional and district health authorities. (Many experts say the bureaucracy could be cut by 20% without harm.)

As for the working relationships between public and private hospitals, they will be tightened under the reforms. About 12% of Britain’s health expenditures occur in the private sector; physicians working for the health service still may treat some private patients.

Private patients--an estimated 6 million of whom are covered by medical insurance--may work with their own doctors. They generally are wealthier individuals who prefer to choose their own doctor and hospital and be assured of a private room--with no waiting. Their insurance pays most bills, although some patients with such coverage opt for a mix of private doctors (say, for surgery) and health service providers (say, for outpatient care).

Of course, no matter how good and efficient the National Health Service may be, because of its huge budget and staff it is bound up in politics. As Aneurin Bevan, a Labor Party member and prime mover for the service, once declared: “When a bedpan is dropped on a hospital floor, its noise should resound in (Parliament).”

Indeed, the reform effort has created public acrimony. When a recent major report recommended after years of study that 10 of the 20 largest inner-London hospitals--most located in areas of dwindling population--be merged or closed, there was a giant fuss from area residents and doctors practicing in the institutions. (The hospitals, many famed but ancient, included St. Bartholomew’s, founded in 1123 to treat the poor.)

Perhaps a more damning criticism of the new reforms is that the competitive style of contracting out services or buying them by hospitals and group practices ties up doctors and administrators with red tape. As the Financial Times put it recently: “The NHS currently resembles a huge conglomerate in which slimmed-down subsidiaries are struggling to reform an unwieldy head office.”

Despite the controversies about the health service, Dr. Brian Mawhinney, a junior health minister, says: “It is all too easy to forget that the purpose of the reforms is not organizational perfection but to improve people’s health. Patients and the public must have a say in health service decision-making. The changes in the last few years have tipped the balance much more in their favor.”

Sean Revit, a young oil company executive who, like almost 90% of Britons, avails himself of free medical care, also had an upbeat assessment of the system, saying: “We’ve got the best health service in the world. You’re not frightened of becoming sick. Look around Europe--and elsewhere--and see what you get. What country can beat it?”

Fleur Melville of The Times’ London Bureau contributed to this report.