WELFARE STATE

Medicine

The collapse of the NHS

John Linklater

Most of us would agree that the National Health Service is falling short of its expected ideal: its foundation on the premise that nobody resident in the United Kingdom should ever lack the best medical care because of poverty. This being accepted, the Labour Government then organised a vast and costly bureaucracy to bring the medical profession under Government control, making headlines of the fact that because we were all contributing willy-nilly, we now at last all had an equal right of free access to our doctor, as if in some way the mere act of re-organisation could in itself increase the total quantity of medical care available to the population at large.

Now, more than a quarter of a century later, notwithstanding the fact that most doctors have worked hard and long to make the system work, and notwithstanding that the graduates of the British medical schools are among the best trained in the world, the daily press carries an increasing and perfectly justified number of reports of abuse and catast rophe and the public is becoming increasingly aware that the national health service is being strained to breaking point.

No government has yet had the guts to face its electorate and admit that the system of totally free medical consultation is simply not working out in practice.

The cost.to the National Health Service continues to rise while the pay of the doctors becomes relatively smaller year by year and, in order to stop the National Health Service from collapsing entirely, the Government has been forced to throw open the doors to a large number of newly qualified immigrant doctors whose standards of skill and training fall short of the traditionally high standards required by medical schools in the United Kingdom, and who are often scarcely able to com municate with their patients. Instead of collapsing, the Service continues to function at a generally low. standard.

Examples are legion. A man of forty-five recently died of an abdominal emergency because the nurse who attended him during the night did not fully understand the instructions for measuring his fluid balance. A forty-two-year-old woman with a coronary thrombosis was discharged from hospital with a diagnosis of gallstones because the doctors looking after her did not have the time to carry out the blood test which would have clinched the diagnosis and because the nursing staff did not have the time to take routine blood pressure readings. Two cases of septic wounds were treated in one of our surgeries in one afternoon after being sewn up by a hospital Casualty Officer without first being probed and cleaned, apparently because he did not properly understand that one had been caused by a garden fork and the other patient had impaled herself deeply on a rusty nail. An elderly lady who went into hospital for routine abdominal surgery then suffered a stroke because the doctor looking after her in the ward failed to read the introductory letter which explained that she was a sufferer from intractable hypertension Another patient at a psychiatric hospital was being persuaded to undergo electric shock treatment which, if she had accepted it, would probably have killed her because she was suffering from acute bronchopneumonia as well as her depression; the immigrant doctor did not understand what she had told him and he har not had the time to examine her. doubt be aware of examples of his own.

We may well ask ourselves, therefore, what has gone wrong with the system and why it is that, with such high ideals and indisputable devotion to duty, doctors are as a whole unable to offer a better service.

Part of the answer is to be found in the very structure of the National Health Service itself. It was designed by fools, to be operated by saints, without making allowance for human failings and for the human characteristic that, having paid for a service, we feel justified in trying to get something back from it for ourselves. The number of consultations at home or in surgery increased year by year, and the general practitioners' working burden soon became intolerable. General practitioners were therefore forced to submit cases to hospital through sheer lack of time to deal properly with problems well within their competence and skill.

Thus the hospitals became overcrowded and new hospitals were built and these became overcrowded in their turn. In hospital today, therefore, where there would previously be a small queue of panel patients waiting for a brief ten minute consultation with a senior specialist, nearly all patients wait, sometimes for several hours, for a five minute consultation, often with a doctor who does not speak their language nor they his.

The Government has been giving the problem considerable thought and has published Green Papers and interim reports and in August of this year published a White Paper in an effort to come to grips with it. There is now a Bill before Parliament.

The government solution, in a nutshell, is to reorganise the bureaucratic superstructure and to tidy up the administrative control of the medical profession. It imagines that the Service will function properly as soon as it looks tidy on paper.

Most doctors trained in this country pass between thirty and forty examinations in Chemistry, Biochemistry, Pharmacology, Physiology, Anatomy, Surgery, Midwifery, Neurophysiology and other subjects and, in doing so, work a 100-hour week for many years on scarcely enough money to satisfy their basic needs for food and clothing, books and beer. It is a fair assumption that they could not stay the course without at least some degree of right-minded motivation.

But ask any doctor in general practice today how much of his time is spent doing the job for which he has been so, methodically trained. About half of his working week is spent in listening to tales of family woe, marital stress situations and with other problems still further removed from medicine; filling in forms, administering his practice, making claims and writing letters to the Executive Council and, of course, in dealing with those frivolous and trivial complaints when the patient only consults the doctor because the service is free and it is the doctor's duty to be available. Perhaps the worst abuse comes from the patient who, for one reason or another, feels that he needs a few days off work and so presents a diffuse malaise which has Ito be investigated with just as much tare as an acute and serious illness.

Doctors try to educate their patients in order to reduce the work load but, unfortunately, this education cuts both ways and we are now faced with the phenomenon of an increasing number of conscientious people who really ought to seek medical attention for the early stage of some grave disease but fail to do so out of misplaced consideration for the doctor. So that whereas before the National Health Service a few patients probably could not afford to consult a doctor for a postmenopausal bleed and. thus died later of a preventable carcinoma of the uterus, a different section of the population today will die needlessly and avoidably because the system as a whole is overcrowded.

The general practitioner is a selfemployed contractor responsible first of all to the patients on his list and then to the National Health Service, for giving his patients the best possible up-to-date medical care within his ability. He is paid according to the number of patients and his income has very little to do with the amount of work that he does. Indeed, if he buys expensive diagnostic equipment he does so out of his own pocket and if he spends a great deal of time and trouble on his very sick patients, then he does so knowing that his own expenses will be increased thereby. He therefore has a direct inducement to pass his work load on to the hospitals. The more he works, the less he earns and, in a world where he will anyway take home barely 50 per cent more than the driver of a fast long distance railway train, this is a disillusioning thought.

General practitioners are all trained, for example, in basic surgery and most of us enjoy doing it rather than writing prescriptions. Most of us are well skilled and experienced in the art. It is wrong" in principle that we should be faced with the alternative of spending £1 or £2 out of our own pocket for sutures and dressings and instruments, instead of sending the patient to hospital where the nation will foot the bill to have a sebaceous cyst removed at a cost to the taxpayer of about £8 mostly for overhead charges, with perhaps an additional £5 for the ambulance. Can we wonder, under such a crazy system, that the Out-patients and Casualty departments have become so overcrowded?

Again, when a patient presents himself at his doctor's surgery with some obscure, probably serious, and not readily diagno sable complaint, it is the doctor's instinct to take a detailed history, make a thorough physical examination, send blood samples and specimens for analysis and have the appropriate x-rays done. When the results are available, if he still cannot make a diagnosis, he is trained to write a thoughtful report of his facts and findings and send these to an appropriate specialist for further consideration; all of which costs the general practitioner time and money and it is much cheaper and easier to pass the buck to the hospital with a short note to the effect that "this man has a somewhat sinister bellyache. Please see and advise."

Similarly, when a patient has to go into hospital as an emergency admission, it is the general practitioner who has access to his records, to his background and to the facts and figures which will assist in subsequent treatment. It is up to him therefore to sit down and write his first appraisal with due care. How can he do this if he still has three or four more home calls to do before his first meal of the day? The fact that one or two of these calls will be for tonsillitis or influenza and only made because the patient needs his National Health Certificate, is quite irrelevant. If the doctor fails to call, the patient will feel aggrieved and the doctor will then have much explaining to do to his Executive Council.

Sir Keith Joseph has, perhaps rightly, complained in public that general practitioners issue certificates too readily and that the number of working days lost to the nation is therefore far too great. But the GP is in a cleft stick when confronted with, say, a pain which may or may not be due to the prolapse of an intervertebral disc, and he has to make a careful and time-consuming examination before finally stating his opinion that the man is none the less fit for work; if he does make such a pronouncement, he will inevitably lose that man and his relatives and friends from his list of patients, with an immediate reduction in his own salary. General practitioners are not saints any more than the rest of the population It would lead to a better standard of medicine altogether if medical examinations for certification purposes were handled not by the general practitioner at all but only by a Regional Medical Officer who had nothing to lose by making a frank disinterested diagnosis. Under the present system the patient can penalise the doctor, but the doctor has no redress against the patient for wasting his time.

There is not the slightest reason why initial medical certification should not be carried out by the social services, or any other responsible body such as the clergy. Any case of doubt could be referred directly to an impartial disinterested Regional Medical Officer and not to the general practitioner. Nor is there any reason in this day and age why consultations should not be paid for in cash on each occasion. The sort of fee I have in mind is 50p for one consultation, £1 for a house call on a weekday in the morning, £2 in the afternoon, and £3 at night or during the weekends. If the doctor himself considered a follow-up to be necessary, then no further charge would be levied so that the chronic sick and hypertensives or diabetics would not be penalised. Such a fee would be paid by young and old and pregnant alike and offset by an increase in child allowance, pension and maternity grant. In cases of true hardship, consultation fees could be recovered subsequently through the social services and in cases of acute medical emergency the doctor might have the discretion to remit payment. The implementation of these two reforms would dramatically lower the work load on the general practitioner and, if the general practitioner were then to receive in ducement, or at the very least com pensation, for actual medical and surgical work done, we would very rapidly benefit from an improvement in the service as a whole. In adidtion, much of the costly hospital rebuilding programme would prove to be unnecessary.

A different line of approach to remedy the ills of the National Health Service has already been tried by the direct inducement of general practice partnerships to form groups and operate from Health Centres instead of from their traditional personal surgeries. The idea is in many ways a sound one because eight to ten doctors in a group can more easily afford to build and maintain attractive, wellheated premises and can also keep in touch more efficiently with health visitors, district nurses and other para-medical workers—but the Health Centre does not even begin to solve the problem discussed here. Indeed, there is already some evidence to show that it exacerbates it. For what happens is that patients rather like the reassuring atmosphere of efficiency in Health Centres and, although they complain that they can no longer always obtain a consultation with 'their own' doctor, they nonetheless attend rather more often than before.

In any case, the suggestions that are made here for improving the standard of medical care are all equally applicable to Health Centre and traditional general practices alike. I do not imagine that they would be a panacea for all the ills of the National Health Service but I am convinced that if the patient had to pay a fee for each consultation and if certification for Social Security purposes could be removed from the general practitioner's shoulders then he would have time to concentrate on serious medicine, surgery and obstetrics and so in turn, allow the specialist consultants more time to do their job properly. A small financial contribution towards the cost of the Health Service would, act as a natural deterrent against abuse, and the high skill and training of the medical profession would be re-deployed to the advantage of the community as a whole.

The principle of a National Health Service is basically sound but the built-in abuses are grinding this one to a halt. Let us forget party politics and individual prejudice and act now to give ourselves the best of all possible Health Services, where the general practitioner can practice the medicine for which he is trained, assisted by a team of nurses and social workers to deal with his marginal problems without having to pay large sums for their salary out of his own. Let us reward him unequivocally for good medicine and hard work instead of penalising him financially whenever he shows enthusiasm by unravelling a difficult diagnosis or performing a minor operation.

It is a ridiculous waste of national resources to train a man so that he may safely take a blood sample from the jugular vein of a new-born infant and then force him to spend most of his working day in dealing with problems that require no skill at all, of which many are not even medical, meanwhile importing less well trained doctors from overseas on the pretext that there are not enough doctors in this country.

John Linhlater,MBE, is an ex-Army officer who became a doctor. He is in general practice. His wife, Barbara Maclean, is also a practising doctor.