Dr. Clif Cleaveland, Commentary

Upon arriving in England in 1958, I was unexpectedly introduced to the United Kingdom’s National Health Service (NHS). A serious gastrointestinal infection landed me in the Western Fever Hospital in London for a 10-day stay.

The scholarship program under which I would study medicine provided care for me under the NHS. I received kind, expert and timely care in a modern facility. In Oxford over the next three years I benefited from similar care from my general practitioner. Classmates who became physicians grumble about inefficiencies and low pay under the NHS but remain staunch supporters.

Before World War II, England had a poor, disconnected health- care system. Wartime brought regional organization of hospital services. Post-war, a new Labor government proposed in 1946 a comprehensive, tax-supported system of health care that would be free at the point of service.

Two years later, after overcoming strong opposition from many physicians, the NHS began operation. Ninety percent of physicians and most dentists and nurses are employed by the NHS, making it the world’s third-largest employer behind the Chinese army and Indian railways. Seventy-five percent of hospital beds are in NHS-owned facilities.

The NHS was undercapitalized during its early decades. Even after major increases in the health budget during the administration of Prime Minister Tony Blair, England spends less than 8 percent of its gross domestic product on health care services.

Centralized, governmental control characterized the NHS. Stories abounded of long waiting lists for elective, and sometimes urgent, surgeries. Providers and patients felt powerless to alter a paternalistic system.

In the early 1990s, the Conservative Party government introduced a policy of “internal market” competition that allowed some hospitals and groups of general practitioners to administer their own budgets and enact service contracts with each other. Change gathered momentum.

When the Labor Party assumed power in 1997, it pledged to shift the NHS to a mixed, consumer-oriented system. Health care funding was increased dramatically. Providers, including general practitioners, dentists, and pharmacists within a given geographical area were placed in Primary Care Trusts, each with an average patient base of 100,000. The trusts now control 75 percent of NHS expenditures. Each Trust manages its own budget and commissions health care from specialists and hospitals on behalf of its patients. Efforts were made to raise the quality of service, which varied widely among regions of the country. A National Center for Clinical Excellence was established to evaluate new therapies and to formulate nationwide standards for care.

Trusts are graded on the basis of performance goals, such as waiting time, patient satisfaction, and managerial efficiency. High performance leads to increased autonomy. Low performers face governmental take-over. Trusts are allowed to contract with private providers for elective procedures and services. General practitioners, who remain the cornerstone of the system, now have the option of forming polyclinics which can offer a broader range of service.

The NHS has embarked upon a 10-year plan to create an electronic data base for all health care records in hopes of making the health care system more efficient and less costly.

As in past years, patients and physicians may opt out of the NHS. Ten percent of patients chose to buy private health insurance. Complex problems persist. Annual per capita spending for cancer therapy varies widely among regions of the country. Although waiting lists for such procedures as hip replacement and coronary bypass have been dramatically reduced, long waits remain a challenge in some regions. Mental health services need improvement. Dental care, which is managed in a separate branch of the NHS, is stressed by a shortage of providers.

The British media regularly highlight individual cases where the system seems to have failed. Yet the commitment to the system is unwavering for the great majority. General practitioners are generally pleased by higher pay and more autonomy. Care that is free at the point of service remains a cornerstone. The NHS continues a gradual evolution.

Each health system that I have reviewed — Canada, Germany, France, and England — arose in response to unique national traditions and political forces.

Each confronts rising costs as populations age. New technologies with very expensive price-tags strain budgets. While offering varying solutions to these problems, the major political parties in each of the four countries seem committed to the concept of universal health care coverage for their citizens

In two weeks, I shall examine the health platforms of Republican and Democratic Parties.

E-mail Clif Cleaveland at cleaveland1000@comcast.net.

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