The Price of Free Medicine
JUNE 01, 1956 by COLM BROGAN
Mr. Brogan is a British journalist, author, advocate of individualism, and critic of socialism.
Britain’s experiment in socialized medicine should be of interest to those who wonder if the United States ought to try it.
Last year the British National Health Service paid one million pounds ($2,800,000) for bottles and other containers to be used for drugs and medicine. In contrast, the grant for research in mental health was a mere 27 thousand pounds ($75,600).
These figures illustrate the most damaging though least heeded effect of socialized medicine. Floods of money feed the in: satiable appetite for pills, while fundamental medical research is largely neglected. Intelligent doctors are fully aware of this threat to the whole future of British medicine, but the British people generally do not sense the danger. Socialized medicine allows popular demand to dictate the use of available resources through political pressure, the consequence being this gross distortion of the strategy and tactics of medical development.
Not even Mr. Bevan himself denies that the British people are heavily overindulging in nostrums of dubious value. Faith in these nostrums is scarcely more intelligent than faith in magic, but vast sums are poured out of the public purse for cures of largely imaginary value for diseases which are also largely imaginary.
At the same time, nearly half the hospital beds in Britain are occupied by mental patients, and many would-be voluntary patients must be refused admission. Conditions in some of these mental hospitals are deplorable. They are badly understaffed and shockingly overcrowded. Yet not one new mental hospital has been opened in Britain since the start of the Health Service, nearly eight years ago. In fact, no hospital of any kind has been built and opened.
At a time when both medical advance and the challenge to medicine are undergoing great and dramatic changes, British practice is being fossilized in attitudes as out-of-date as the hansom cab and the wooden stethoscope.
That, of course, was not the original purpose of those who framed the Health Act. They offered it as an “experiment noble in purpose”; and the British people were promised everything, regardless of expense. Not only would their home treatments be provided free of direct charge, but the hospitals would for the first time have ample funds for treatment and research. It was said to be a disgrace to a progressive country that the great voluntary hospitals, some of them of worldwide fame, should be dependent on uncertain charity and sorely handicapped in their beneficent work. There would no longer be any need for humiliating appeals, nor restrictions on staffing, building, or research; and in addition, health centers would be established everywhere to bring all the general practitioners of an area together in happy comradeship, with all the most expensive resources of modern medicine at their immediate command.
That was the fine dream, but the reality proved to be far different. The administrators soon found themselves faced with two inescapable facts. The available supply of trained doctors, nurses, medical scientists, and members of the semiprofessional ancillaries like physiotherapists and orthopedists was not enough to meet all the needs of the grandiose plan. The financing of the plan was even more strictly limited. Enthusiasts for nationalized medicine found themselves in competition with the enthusiasts for extended education, state subsidized housing, higher state pensions and benefits, and a dozen other schemes with a strong emotional and vote-catching appeal. There was competition not only for funds, but also for materials and for future staff. While hospital wards were shut for lack of nurses, the potential nurses of the future were tempted into teaching to meet the demands of the risen birth rate and the extra compulsory year at school ordained by the socialist government. Building materials and labor that might have been used for temporary hospital and clinic accommodations were used for temporary classrooms.
If no checks had been put on Health Service expenditure, it would have assumed fantastic proportions. But when expenses soon came to more than double the original estimate, it was found necessary even for a socialist government to impose a ceiling and eventually call a halt.
A part of the corrective action attracted much attention and stirred a good deal of resentment. The patient looking for spectacles or for dental treatment had to pay a proportion of the cost, and for some the proportion was substantial. In addition, all patients were required to pay a shilling for each prescription filled. The prescription charge failed in its purpose, however. Most of the patients resented having to pay and tried to get as much as possible on one prescription, which doubtless encouraged waste. In any event, the Labor Party, which originally imposed the charges, promises to abolish them when they get back to office—a measure of the depths to which demagogy can sink.
But the other thing that was done attracted little notice outside of the medical profession. Dentists were paid by piecework, and the original rates for the various jobs were lavishly set to coax dentists into the scheme. For some time, dentists were in financial clover. But the rates have been slashed three times, reducing dentists to a very modest standard and putting some in grim financial difficulty as they must pay surtax on the high earnings of a previous year out of a current income drastically reduced by arbitrary decree. This situation has brought a catastrophically reduced enrollment in dental colleges, thus ending most dreams of a dental service that would concentrate on scientific conservation instead of hasty pulling and patching.
The doctors fared better than the dentists. Their resistance to the scheme had been so strong that they were offered an income equal in purchasing power to the average medical income of 1938. When R. A. Butler became Tory Chancellor of the Exchequer, he was faced with an arbitration award which gave general practitioners not only an increased annual payment for each patient but also a lump sum of fifty million pounds to make up for past underpayment. Nurses and lay hospital workers were in no mood for cuts in salaries and wages. Inflation steadily increased the bill for all hospital supplies and also for the drugs and pills doled out so lavishly through the doctors’ offices.
Thus, the National Health Service budget was strained to the breaking point. And the cuts fell on the unprotected sector of health expenditure, though this was the sector which alone could keep Britain abreast of the civilized world in medical advance. The grandiose schemes of expansion were almost all dropped, and the great teaching and research hospitals suddenly found themselves more pinched than they had ever been before. One hospital, which had almost completed an ambitious and modern laboratory, had to turn the key in the lock for a considerable time because they lacked funds for the microscopes needed if the laboratory were to serve its purpose.
This is only one example of a deleterious process. Public demand and demagogic compliance have diverted available funds away from the fruitful and imperative lines of medical advance in order to supply that kind of medicine which satisfies the credulous patient. The mass of the public were well enough pleased. Hypochondriacs and people with nothing much to do could still crowd a harassed doctor’s office at no immediate cost to themselves and call for a pill or a bottle which they might have seen advertised. Many doctors have told me that since the enactment of the Health Act a growing number of patients come to the office and say they want this drug or that, not waiting for the doctor’s examination and verdict, but making their own selection as they might choose sweets in a confectioner’s shop.
There is the case of a woman whose baby was suffering diaper rash. She got a doctor’s prescription for no fewer than ten bottles of an expensive new medicament. The rash finally was cured when the woman was told to keep her baby dry and to apply a simple ointment. The ointment which did the trick cost fourpence (about 5 cents); the ten bottles which did no good cost thirty pounds ($84). This is one example of waste, but it could be multiplied indefinitely.
The Ministry of Health has tried to deter doctors from easily prescribing expensive proprietary drugs when much cheaper equivalents are available, but the doctors resent any dictation and the patients are even more resentful.
For a long time it has been the ambition of conscientious practitioners to wean their patients away from this pathetic faith in bottles and pills; but the Health Service has undone all such effort, and fundamental medical research is the chief sufferer.
The brilliant triumphs of modern medicine have nearly all been won in the laboratory, not at the patient’s bedside or in the doctor’s office. The weight of medical investment should be in that direction, but in Britain it is being swung in what is strictly the reactionary and obsolete way.
As for mental illness which is the greatest and most disturbing challenge to Western civilization, the treatment and the cure of this menace is only in its infancy. Patient research and investigation covering the whole of social life are necessary, and equally necessary is a huge expenditure to provide the material means of effective treatment here and now. But there are British mental hospitals where the patients’ beds are so crowded that it is impossible even to put a locker between them. It is impossible to get anything like enough native-trained nurses, men and women, for any kind of hospital; but at the same time, many experienced and highly qualified nurses are employed in “welfare” work where their skill and knowledge are thrown away.
I have no space to deal with the wastefully expensive tests and treatments to safeguard the doctors against legal action by litigious patients, whose court action is likely to be paid for by the same State that pays for the hospitals.
I believe that the contemporary and scientific conception of medicine cannot flourish fully and firmly where medicine has been socialized. The great medical advance will continue, but there is nothing in prevailing British conditions to encourage the hope that British medicine will play in the future as remarkable and as leading a part in that advance as it has played in the past. This pessimism is not purely personal. It is shared by nearly every doctor I know who is alive to what is going on in international medicine, while stagnation of method is forced upon himself. 
Folly and Presumption
The statesman, who should attempt to direct private people in what manner they ought to employ their capitals, would not only load himself with a most unnecessary attention, but assume an authority which could safely be trusted, not only to no single person, but to no council or senate whatever, and which nowhere be so dangerous as in the hands of a man who had folly and presumption enough to fancy himself fit to exercise it.
Adam Smith, The Wealth of Nations