OUR MEDICAL HERITAGE
Alexandra Artley explains national
affection for the NHS and compares it with the soulless private sector
RECENTLY, as I was crossing Parliament Square, I noticed a crowd of people gathering at the gates of the House of Commons. They seemed attracted there by the presence of two nurses from St Tho- mas's Hospital, Lambeth, carrying Night- ingale lamps beneath their red-lined cloaks. In heavy rain these nurses were standing in vigil for six-hour shifts before they went on duty. It was to remind incoming politicians that St Thomas's has just lost 20 per cent of its beds and that nursing conditions at the hgspital are in- tolerable. Perhaps the vigil was also to remind younger, less thoughtful politicians that should sudden illness strike in Parlia- ment or the roads outside, St Thomas's is traditionally the MPs' hospital. One of the nurses had just returned from Australia where she had earned in a week what she is paid here in a month. But 'here the medicine is gentle. If I can manage to live, I want to stay with the NHS'.
Gentleness, a sense of spirituality and moral values in medicine are at the histor- ical roots of the British hospital tradition. The public has always instinctively felt this about the NHS, but nowadays they know it. The dramatic rise of popular interest in the history of medicine (once a very specialist subject) means we are now aware that the NHS is the direct descendant of those hospitals founded for all by mediaev- al religious orders. St Peter's, York was the first (937), then what is now St Thomas's, Lambeth (1106) and Bart's (1123). Whether they are mediaeval, Baroque, 19th-century red-brick or plate-glass 'mod- ern' in outward appearance, hospitals are our medical abbeys and their atavistic appeal far outweighs the soul-less private sector ('Bupa bungalows').
In other ways historical tradition infuses the NHS. Perhaps nurses uniforms strike such a deep chord because they are directly descended from the clothes worn by mediaeval religious nursing orders. The professional title 'Sister' is another survival and until the 1960s, hospital social workers (essential to the successful discharge of frail people living alone, or of children in social distress) were called almoners.
Public awareness has also been shaped by the rise of another form of history personal testimony or oral history. Here, ordinary people record, sometimes for production companies like the Television History Workshop, their own reminisc- ences of what life was like before the NHS was founded. Elderly people put on record what it was like before 1948 when the poor were often immediately distinguishable by lack of teeth, or by the ceaseless headaches accompanying eye-strain. That was be- cause specs had to be picked up second- hand from street markets (`and you just tried them', said one old woman from Stoke-on-Trent 'until you got a pair you could see a bit better with'.) One such television programme (and play) based on oral history, broadcast on Channel 4 this year, was called Can We Afford The Doctor? In medicine, oral history of this type comes from the elderly. It is most unjust that nowadays 'an increasingly ageing population' is seen as some kind of excuse for underfunding the NHS. These people have paid taxes all their lives in the belief that treatment would be available in their hour of need.
Whether personal testimony has been recorded or not, the lives of most British people are inextricably mixed with the NHS because like all good medicine it is there to take its place in your life when you need it. This is in contrast to the ghastly 'permanent crisis' of American medicine for profit in which the first question people ask on learning you have been ill is not 'are you feeling better' but 'did the insurance cover it'? In contrast to the humanitarian British tradition, the American doctor is ethically compromised as a healer by being a mere cog in someone else's commercial machine. In other words, when the money runs out he may no longer continue treat- ment. Doctors working in the NHS today are increasingly forced to achieve numeric- al targets rather than provide open-ended healing. When politicians boast of 'treating more people than ever before' it means that 'throughput' has been increased by discharging patients before they are really well enough to go.
The American idea of medicine merely for profit is such anathema to the British public (and to the ancient humanitarian tradition of the British medical profession) that hitherto there has been little investiga- tion or interest in the British private sector. Until 1986 very little Was known about the finances of private health care in Britain becuse there was no reliable data-base. But in Marketing Week on 29 May this year, William Fitzhugh, a financial analyst of the independent health market, revealed that overseas-owned 'for profit' hospitals in Britain had actually lost more than £5 million in 1986, largely because of the withdrawal of over-charged Arab patients to West Germany. 'Three or four years ago in the US,' he wrote, 'health care was considered to be a very bullish high-growth industry. It started to look for other markets. The companies decided they wanted to have a London flagship. That's how they got here, developing expensive prestige hospitals. In those days the optim- ists were prOjecting forward to there being 10 or 12 million people with private health insurance. The actual number today is half that. The decline in the overseas patients has exacerbated the situation . . . Central London is now [privately] over-bedded. This will seriously affect profitability though the rest of the country is probably more profitable'. John Randle (until April this year an administrator of the Associa- tion of Independent Hospitals) recently confirmed these findings in The Health Service Journal on 19 November. Allowing for. creative accounting, he decided that `private hospitals are not exactly the glit- tering prizes which many people, including insurers and doctors seem to think . .
In contrast, collective health provision makes financial sense. Earlier this year, Nicholas Timmins of the Independent calculated that the British man, woman and child gets all-in cover from the NHS for £373 per head per year. Before the implementation of the current White Pap- er, this includes free dental and optical checks, casualty admission should you be scraped from the road, acute illness, hav- ing a baby (for which you cannot insure) and long-term or terminal illness (the health insurer's bates noirs). What do private hospitals offer instead? Because one can only insure against complications in delivery (the need for forceps or a Caesarean) childbirth is a good example of the real cost of private medi- cine. First I rang the American-owned Portland Hospital for Women and Chil- dren in Great Portland Street to ask the horrid question How Much (`what scale of fees would I be looking at') to have a baby there? 'Reservations,' said a voice rather like a restaurant or air-line. 'For a normal delivery and your first 24 hours in hospital, £600, then for every day on top after that, £250'. On-topness seemed to figure quite a lot. 'Then, if you have an epidural, your anaesthetician's fees will be on top, say £200. Then, your consultant's fees will be on top, probably £800-£1,500. Then, there would be a paediatrician to have a look at the baby £70'. `Oh,' I said. 'Well, £50. Say £50.' Altogether, a normal delivery and four days in hospital 'looked like' £3,000. `A Caesarean would, of course, cost more,' continued the woman in Reservations. There you would be looking at £800 for your first 24 hours and £250 per day thereafter. The consultant would also cost more. You would probably be looking at £4,000.'
the next day, I found myself looking at the small coloured AMI brochure. Inside was a soupy vaseline-on-the-lens picture of a model holding a child dressed in yellow (a clever colour which avoids blue-for-a- boy or pink-for-a-girl). Opposite was a picture of a man and woman merrily swigging wine at a table covered with a white linen cloth. Before them were set plates of lamb cutlets wearing frilly paper socks, grilled tomatoes and other veg. It seemed to me absurd that a hospital should feature food on its lead picture (one so rarely goes to a restaurant for an X-ray). Thrust into the far corner of the room was a baby, lying in the usual new-born perspex trolley-cot. Strangely for a newborn it appeared to be raising its arm. Perhaps the hungry AMI baby is born with an inbuilt reflex to ring for room service.
In May this year, Charles Taylor, chief executive of the Cromwell Hospital, Lon- don, explained that private medicine in Britain would have to become increasingly aggressive and innovative in marketing to survive. One of the many objections to medicine for profit is that the marketing required to propel the commercial process can sometimes lead the public into the dangerous area of medical fashion rather than good medicine. At its worst it can be dangerous. One example of this is the cosmetic surgery which cowboy clinics advertise in women's magazines. For cheapness (and higher profits) inexperi- enced junior surgeons are often used. The grotesque results of this consumer medi- cine were recently commented on by Peter Davis, consultant plastic surgeon at St Thomas's Hospital, London. 'I see a dozen patients a year who have had disastrous cosmetic surgery in these clinics and my colleagues see others. I have seen drooping eyes, scars on the forehead, misplaced nipples and appalling scars on the breasts'. The jungle of US consumer medicine, litigation and ethical ugliness lies here.
The patient as aggressive consumer, not only breaks down the gentle trusting rela- tionship between sick person and doctor but in a free market fuels medical inflation by 'defensive medicine'. Here the doctor at needless expense tests or screens the pa- tient far beyond those procedures required for normal diagnosis just in case he is sued. A doctor's fees then rise to cover the cost of his own escalating professional insur- ance and this cost is passed to the patient. Even in respectable private medicine obstetrics is another area vulnerable to medicine-for-profit marketing. In Seven- ties' New York I remember seeing ads in the papers offering Caesarean `to keep those passages honey-moon fresh'. Natural childbirth (or rather a romantic ad-man's view of it) is the latest marketing strategy for some private hospitals. Natural child- birth is something of an ideal, but many mothers whose hopes are raised, later feel failures if they cannot cope with the great severity of pain involved. The romantic view can be seen in the brochure of the Garden Hospital, Hendon, whose American-style presentation is aimed at the young well woman. 'Welcome' it says on page one, where two air-hostess figures swoon over telephones at a curved marble- topped reception desk. Inside, 'Our Maternity Unit' centres on a large photo- graph of a woman (wearing two silver chain bracelets) and a baby, both im- mersed up to the armpits in a foaming Jacuzzi. In marketing terms this is a cleaned-up, cosy version of Leboyer's in- finitely more messy and arduous underwa- ter birthing technique Ca Leboyer-type atmosphere' said the Sunday Times).
Recently, I suspected the influence of this medical marketing on an otherwise intelligent friend. When she first became pregnant she asked about University Col- lege Hospital, where I received the most kind, considerate and professional atten- tion during the birth of our children. There in her own delivery room a mother can choose an 'active' birth (moving around in labour), an epidural (a lower-spinal anaes- thetic) or traditional analgesics. You can lie in a deep conventional bath.
Having looked into the history of UCH, I could have said that here in 1846, the first major operation in Europe was performed under ether and in 1887 Lord Lister introduced antiseptic surgery. Eventually the pregnant friend seemed sold on the Garden Hospital's Leboyer-style brochure. The progress of a first labour cannot be totally predicted and far from natural childbirth she ended up with a Caesarean. That cost £1,750 (£2,500 without insur- ance) and a good deal more 'on top'.
Seven years ago, I lay in the National Hospital, Queen Square being investigated for multiple sclerosis. Stunned by the prospect of serious illness I did not want to be in an isolated 'hotel room' attended by a Garden Hospital-style waiter with a bow tie. I was grateful for the presence of people of all kinds — doctors, nurses, cleaners, porters, technicians, other pa- tients and clergy. Collected together, in a communal way typical of British medicine since the Middle Ages, all these people were examples of kindness, courage and faith. On 5 July next year I will be celebrating the 40th anniversary of the NHS — The Appointed Day, as it was called in 1948. By chance next year The History of the Health Service Vol I by its official historian, Charles Webster will also be published (HMSO, £35). The National Health Service, is he said recently, 'the legal and moral guardian of our medical inheritance'. The Government has a clear mandate to fund it adequately from the Exchequer because our national faith in it is not for sale.