At 50, British National Health Service in Need of Reconstructive Surgery

It was the early hours of July 5, 1948, and Doris White was rejoicing over the birth of her daughter. But she had an extra reason to celebrate: Thanks to Britain’s brand new free-to-all state health system, her hospital stay would cost her nothing.

“My mother is very fond of telling me how, during her labor, she drove all the nurses mad by asking what the time was,” says her daughter, Susan Sewell. “When it got to midnight, she stopped asking, because she knew that the National Health Service was born and her hospital stay would be free.”

In the 50 years since, the state health service has cared for millions of Britons from cradle to grave, providing most treatment without direct charge.

But as the NHS enters middle age, the question looms: Can an already overloaded system funded almost solely by taxes continue to cater to a population with growing expectations and longer life spans, in a world where expensive new treatments appear almost daily?

With the number of taxpayers steady at about 25 million and the proportion of elderly in the population of 60 million rising, spending and services lag demand. There are now almost 1.2 million patients waiting for non-urgent hospital treatment, such as hip replacements and cataract operations.

Many hospitals and clinics are dilapidated, and the number of available beds has declined from 550,000 in the 1960s to around 200,000 today.

Self-Inflicted Ills

The service has suffered a series of embarrassing failures, such as a scandal at the Royal Bristol Infirmary, where surgeons continued to perform heart operations on babies despite warnings that death rates were unusually high.

On July 14, the government announced it will inject an extra $34 billion into the NHS over the next three years, much of it for new technology and equipment and for new buildings. Some of the money will come from the sale of government assets, but most will be provided by taxpayers.

Health Secretary Frank Dobson pledged to “improve and modernize the NHS to make it fit for the 21st century.”

Rudolf Klein, professor of social policy at Bath University, and some other experts contend the system must be reorganized because it is overcentralized.

The government’s own audits show “many of the NHS’s financial ills are self-inflicted. Resources are often used inefficiently and ineffectively,” Klein said.

Government officials reject the idea of pushing responsibility down to local or regional authorities.

On the plus side, Britons can summon their doctors, free of charge, around the clock for emergency consultations and check out of hospitals without having to settle hefty bills.

Life expectancy is up: A boy born in an NHS hospital today is expected to live an average of 75 years, compared with 66 years for a boy born before 1948.

A Popular Success

The NHS, which dispenses 1.7 million prescriptions a day, has done pioneering work in hip replacements, the use of ultrasound and in-vitro fertilization.

A recent Gallup poll said 89% of Britons consider the service a success. Gallup questioned 1,006 voters by phone June 25-July 1, with a margin of error of 3 percentage points in either direction.

“Yes, the NHS has its problems,” said Julian Le Grand, a professor of social policy at the London School of Economics. “But it is the least worst of all health systems. It costs relatively little, produces a reasonable quality of health care and its health outcomes are not bad.

“Male life expectancy here is higher than in both the United States, which spends 14% of its gross national product on health, and in Germany, which spends 10%,” Le Grand said.

Britain puts 7% of GNP into health care.

Aneurin Bevan, health minister in the post-World War II Labor Party government, launched the state-run service to provide medical treatment “free at the point of delivery.”

In 1948, most British hospitals were overcrowded, inefficient and run-down. Historian Geoffrey Rivett notes, for example, that the legs of beds in the maternity ward at London’s Paddington general hospital stood in tins of oil to stop cockroaches from crawling up.

Many hospitals were run by charities or were grim municipal infirmaries built in former workhouses. More than half of Britain’s people had no medical insurance.

Early in 1948, every home in Britain received a leaflet announcing that, beginning that July 5, the new National Health Service would “provide you with all medical, dental and nursing care.”

“Everyone--rich or poor, man, woman or child--can use it or any part of it,” the leaflet promised.

Bevan bought up broke charity hospitals and won over doctors by offering them decent pay and conditions.

Soon, lines formed at doctor and dentist offices and, in its first nine months, the service spent tens of millions of dollars more than expected. The government assumed it all was due to a backlog--but the lines grew steadily, and the service continued to gobble money.

Since the 1950s, the NHS has charged for dental work. A fee for eye tests was introduced in 1989, although the government said in July that pensioners will now be exempt from this charge. Most patients pay a standard charge of $9.30 for each prescription.

But the fees bring in only 2% of the NHS’s annual budget, which stands at $74 billion.

Despite its cost, the NHS has remained in state hands, surviving even Prime Minister Margaret Thatcher’s relentless privatization drive in the 1980s.

Some experts have suggested that the government encourage more people to take out private health insurance, but Britons remain committed to the NHS. Only 10% of Britons have such insurance, a proportion that has changed little since the mid-1980s. Most who “go private” cite the slowness in NHS treatment.

In an analysis of the NHS’s state of health, John Willman of the private Social Market Foundation suggested patients be required to directly pay some of their medical costs. For instance, $16 for a doctor visit and $80 a day for hospital stays would raise an extra $8 billion a year, he said.

Sweden’s health system gets 10% of its budget this way, Willman said. But Britain’s government has ruled out extra charges.

At a 50th anniversary ceremony, Dobson, the health secretary, said the NHS succeeds because of “the bargain that each of us strikes with one another.”

“While I’m doing well, I’ll pay into the system,” he added. “And I do so in the sure and certain knowledge that if I fall ill, or have an accident, or get old, other people will pay in to help me.”

So Le Grand, the social policy professor, said, “The system will continue to muddle along, funded by taxes--with lots of sound and fury when things go wrong.”