HOW THE POOR DIE

Government's plans for health will help the most vulnerable not a jot

IN Britain a married couple pays £560 a year over 48 years in state medical insur- ance (in the form of various taxes) of which £100 a year is set aside for paying the general practitioner. As people usually consult their GP about twice a year over a lifetime of 71 years each consultation costs the patient approximately £16.50.

But the average time of each consulta- tion — usually five minutes, or £198 per hour — does not seem to be very good value for money, either to the patient or to the doctor, especially the latter who re- ceives about f24 of the £198. Certainly it compares unfavourably with the type of patient care most Europeans receive and for which they pay much less, even if they have to pay their doctors directly. Mr John Moore's proposals for general practice published last week as a White Paper are meant to be a step in that direction.

There is talk of more competition be- tween doctors, of encouraging private practice and of making it easier to change your doctor. Unfortunately he has been hoodwinked by crafty officials in the DHSS. While some improvements such as payment for better cancer screening are being offered, bureaucratic control of the GP service is to be tightened, the present system of negative reward — paying doc- tors more the less they see their patients is to be continued, and the customer distanced even more from a real choice of medical care by making doctors an even scarcer commodity. Although 2,000 doc- tors remain out of work those in work will be allowed even more patients on their lists.

DHSS officials are realists. Despite all the grand talk about Primary Health Care, they believe the GP's main purpose is to ration expensive technology — buying off the natives with the beads and mirrors of cheap antibiotics, tranquilisers or, lately, fast-food psychotherapy. To maintain such a divorce of the customer from the product just needs a lot of administrators and planners. Already the call has gone out for more.

When the NHS was set up in 1949 the planners were worried. How on earth could you cope with a limitless demand for something which was free? It was as if in modern terms the Government was asked to set up a free supermarket service throughout the country paid for by indirect taxes. Critics feared that the greedy, the strong and the socially assured would strip the shelves leaving the poor, the crippled and the old to pick up the crumbs. This is what has happened, but in 1949 those who forecast it were dismissed as elitists or cranks.

But the planners knew they had to keep the costs down by creating some form of rationing. It was, after all, the era of ration-books and shortages. Accordingly the general practitioner would be paid a yearly fixed sum for each patient he had on his books regardless of whether he saw him once, twice, 20 times or never. In 1949 the Government fixed the average number of patients per doctor at 2,500, about 40 consultations a day; now he looks after 2,000, about 30 consultations per day. The modesty of this fall in the consultation rate does not, however, reflect a continuing shortage in the supply of doctors. Since 1949 the number graduating each year has doubled. What it does reflect is a govern- ment regulation that prevents new doctors moving into an area where there are fewer than 1,750 patients per doctor. If list sizes are to be increased, as in the new propos- als, it is difficult to see how this can be changed.

This is of course an incentive to practice the hurried medicine that patients fre- quently complain about. Yet the majority of doctors are dissatisfied at having to see so many people each day and irked by a strange, almost Confucian, method of pay- ment that tries to establish an uneasy seesaw between the doctor's professional conscience and his pocket book, And while it never consciously influences them the financial reality remains that every time a doctor sees a patient in his office, the running of which he has to pay for, he loses money, while a home visit wipes out his fee for two years. Under Mr Moore's propos- als this unsatisfactory basis for a contract is not going to change. But perhaps the worst effect of 'free' medicine on a doctor is that it means `free' patients. Doctors don't know if their patients come to them be- cause of the service they offer or because there is little alternative.

Which patients benefit? Generally the wealthy, the educated and the crafty. Who suffer? The poor.

Mr Patel, who was 40 and had been a postman for the past 20 years, was woken one morning about two by terrible indiges- tion. He lay there for an hour hoping it would go away but it got worse and he began to vomit. This woke his wife who when she saw his grey, sweating face got up to call the doctor. Normally Mr Patel would have forbidden her to waste such an important man's time but now he felt so ill he could only make the feeblest of pro- tests. Mrs Patel knew that if she could talk to her doctor she would know what to do. He was an Indian, a good man who took a lot of trouble over his patients. But ten years of night calls have taken their toll and now he relies on the deputising service after 10 p.m. He would like a partner but, as with the rest of inner London, the area has been closed to further recruitment of doctors by the government planners. But when she dialled the doctor's number all she got was a recording in English, a language of which she only understood about one word in 20. She wondered about calling the hospital but she would never make herself understood over the phone. Depressed and worried she made her husband a cup of tea which he instantly brought up. She tried to settle him down for the few remaining hours of the night. In the morning she would telephone and speak to the doctor himself. The next morning, immediately he heard what had happened, the doctor came and, after making an examination, told Mrs Patel that her husband had had a heart attack and would have to go to hospital. An ambulance would come for him very quickly. But when it arrived she realised that she could not go with him. She could not speak English and, having rarely ven- tured beyond the high street shops, would not be able to find her way back. Instead from behind a curtain in her bedroom window she watched its blue lights flashing up the high street. After they vanished she could still hear its siren and then that too was swallowed in the noise of the city. In the evening Cousin Patel came to tell her that the hospital had telephoned him. They were very sorry but her husband had died.

0 n the other hand, Marxina Lenin- mount, unemployed teacher, is not a woman to let her rights go by default. Both she and her husband are lifelong socialists and passionately committed to the idea of free health care. Marxina frequently brings her children to the surgery for minor complaints and is adamant the doctor should do a house call if the children come down with colds or coughs. This has caused friction between her and the practice as this year alone she has had six visits. Sometimes the children are too ill to come to the surgery but often, the doctors suspect, her husband wants the car to visit friends so she can't get down, or she feels she doesn't want to wait.

Marxina has another problem. A martyr to over-eating since her daughter was born six months ago she has not been able to reduce her weight. As she is on benefit (her husband has not worked for two years) she asked the doctor for a certificate to say that her inability to lose weight was due to illness. With it she would be able to apply to the DHSS for an allowance to purchase a complete set of new clothes. Her doctor was rude about it to her, but her husband soon came and put him right. If he refused he would be in breach of the terms of his contract with the Family Practitioner Committee. Six weeks later Marxina and her husband flew to Florida for a three-week vacation. Her doctor often wonders if she bought the clothes out there or here.

Although the area is poor, there are some early signs of gentrification for, like most ghettoes, its poor will eventually move on to fail elsewhere. The wealthy middle classes who are replacing them and are far quicker off the mark in claiming their rights under the NHS. Not even the smallest bottle of panadol syrup to which her son Henry is entitled escapes Mrs Fearfully Rich. Her banker husband is much the same. He has had his piles, his hernia and his skin blemishes all fixed well ahead of time on the NHS. He knows three of the surgeons at the local hospital excep- tionally well, and Fearfully Rich is a man whose whole demeanour leaves the doctor in no doubt what would happen if he tried to thwart his expectations.

Late on Friday evening an elderly man called Smith and his wife present them- selves at the surgery. They are the clean poor, the last remnants of their faded coats ironed almost out of existence. Mrs Smith's white knuckles grip a plastic handbag from which the cardboard stiffener protrudes at one corner. They are both about to receive the benefit of 40 years of paying national insurance contributions. It seems that Mrs Smith went to casualty two months ago at St Burke's because she had a pain in her stomach. After being .seen by a young doctor, she was X-rayed, weighed and had her blood taken before being sent home to await a further appointment. Somehow it didn't arrive. Her family doctor, despite the 30 patients waiting outside, wrote for a fresh one, but that letter too vanished in the huge bureaucracy of St Burke's.

One night, feeling really ill, Mrs Smith, accompanied by her husband,. presented herself once again at casualty. A reception- ist heard her story and explained that a doctor could see her but there would be a long wait. It might be better, she sug- gested, if Mrs Smith saw her own doctor in the morning. Besides, her out-patient appointment was bound to come through soon. Depressed, but being of a class that has always relied on authority, Mrs Smith thought she would try and manage for another few hours and when the morning came she found the pain was less. She decided then that there was no sense in bothering her doctor who was a busy man, and anyhow the long waits at the surgery were just too much for her. The appoint- ment never came, making Mrs Smith secretly hope that it couldn't be that bad or 'If this is your husband I'd forgo the eye-test if I were you.' they would have sent for her before. Besides, the pain, although sometimes awful, would often leave her alone for days. Now three months later, the diagno- sis, widely disseminated cancer, is on her face, and her husband seeing the doctor's expression, begins to sob quietly.

Socialists like to boast that the Health Service is free at the point of demand. It isn't. No money changes hands, but as with everything else in Britain, the coin the patients offer is welded out of an intangible mixture of social class, accent, clothing or political clout. Some coins are worth a great deal more than others. This results in many patients, notably the poor, being deprived of the choice a fee-paying system offers. Instead they become victims of a machine that enshrines rather than elimin- ates differences in social class. Patients on the continent have always recognised this danger and insist on paying their doctors directly. (They later recover the money from either compulsory private or state insurance schemes.) There are no restric- tions on the number of doctors who can practise and patients may go to any doctor he or she wishes. This choice, combined with the direct contract between patient and doctor, puts immediate pressure on those GPs who, in taking on too many patients, are unable to offer an adequate service.

Levellers will complain that those most in need, the very poor, will not be able to pay. But, for this contingency, most Euro- pean states run either a system of exemp- tion certificates or make the doctor's re- ceipt for his consultation fee redeemable — less a small percentage, to prevent abuse — at the post office or social security office. This leaves the poor with the same consumer choice as those who pay out of their own pockets.

Here in Britain it is a measure of how debilitating protected payment is that many doctors express fear at the thought of being exposed to the free market. They feel, quite wrongly, that they may not be up to the mark, or that others will poach their patients. This fear is reflected in the attitudes of many of their representative bodies who never lose an opportunity to tell the public that our 'free' medical care is the envy of the world. It isn't; many European's regard the National Health Service as something you take air- ambulance insurance out against if you visit England.

We have a weakness for totemising our failures, and on this particular pole are carved all the vices that the English love. Mess or muddling through, resistance to change, unease at efficiency and that peculiar English desire to give way to the more socially assured and articulate who will manipulate the system to their advan- tage. As long as doctors are paid per year per head, this system cannot change. Mrs Thatcher must, for all our health's sake, take an axe to it.