Doctors and the House
Ferdinand Mount
They are still a heartwarming sight, those brewers' drays with their fat-rumped dray horses and sleek high-hatted drivers. Even though you know they are kept on only as a non-commercial commercial and the beer inside is the same insipid ersatz stuff that they carry in the tanker lorries, your heart cannot help lifting as you come upon one becalmed in the roar of traffic. Just so, there is still a certain magnificence about the sight of a Royal Commission rumbling into view after taking years to travel a mental journey of five minutes. From the first, the whole business is nobly caparisoned and attended with due pomp: `To our trusty and well beloved . . Greeting, whereas we have deemed it expedient that a Commission should forthwith issue., . now know ye that we, reposing great trust and confidence in your knowledge and ability, do by these presents authorise and appoint you. . .' Then there is the Unveiling of the Terms of Reference. Later comes the First Resignation. Then the First Leak. And finally the Report, with as often a Minority Report — a final imperial pint of wind and piss.
In the case of the Royal Commission on the National Health Service under Sir Alec Merrison, we have reached the First Leak Stage; according to the Observer, the commission's report later this month will urge the government to scrap prescription charges and carry on phasing out pay beds. Such robust language would be untypical. One does not become Right Trusty and Well-Beloved by talking like that. No, one suggests, one feels bound to recommend, with the greatest respect that, on the whole, taking one thing with another, the yield of prescription charges does not justify the cost of collecting them. And one feels drawn to the conclusion that, on the available evidence, pay beds represent a diversion of scarce resources which cannot be justified within the context of a National Health Service. And in view of the relatively insignificant contribution made by charges to the patient, there would appear to be no alternative but to continue financing the NHS out of general taxation. That's how you add a bar to your KBE.
Such a leak is the signal for all defenders of the status quo to rush in and declare that for the government to make any change at all in advance of the carefully weighed recommendations to be expected from `Merrison' would be rash, undemocratic and a threat to the integrity of Britain's health service which is the Envy of the World. The ineffable Mr David Ennals, the retired Labour spokesman, ran true to form. And so did his successor, Jeff Rooker, formerly one of the Left's most effective scolds.
In dealing with Royal Commissions Lenin's Who-Whom technique, as so often, comes in handy. This commission was set up by Harold Wilson four years ago to head off mounting criticism of the Health Service. The chairman, Sir Alec Merrison, vicechancellor of Bristol University, has been sitting on assorted committees of inquiry into the medical profession ever since 1972 — in short, a real medical quango man. He was assisted by four members of regional health authorities, three professors of medicine, two GPs, the TUC's welfare officer, a director of social services, a man from the Health Education Council and a legal assessor to the General Medicine and Dental Councils who had to resign when he became the Health Ombudsman — in short, a trenchful of vested interests. Not one of them had any incentive to recommend radical changes in the NHS's financing methods or in anything else. Nor indeed would it have been easy for them to stand back from the habits of a lifetime and suggest experiments which might make them unpopular with their colleagues.
There was also on the Commission, it is true, the now statutory woman journalist to represent the outside customer's view. But, alas, the woman was only Miss Ann Clywd of the Guardian and now Labour Member of the European Parliament for Wales Mid and West — scarcely the sort to suggest laying a finger on Nye's immortal heritage. And there was one health economist, Professor Alan Williams of York. But he resigned because he was dissatisfied with the 'working method' of the Royal Commission.
What may now be forgotten is that the doctors themselves years ago drew up a new financial structure for the NHS. The last time the Service appeared to be running out of cash, in 1967, 17,000 GPs handed in their notice and the British Medical Association set up a panel of ten doctors and two laymen under Dr Ivor Jones. This committee tumbled to the extraordinary fact that Britain is almost the only Western country whose Health Service relies so overwhelmingly on general taxation. Almost everywhere else, there is a much more even balance between taxation, insurance schemes and charges to the patient — and, as a result, people are prepared to spend more of their incomes on health, hospitals are spick and span, and doctors don't emigrate. The Ivor Jones report produced a modest compromise plan — which was shelved by the BMA because, by the time it reported in 1970, the doctors had extracted a tolerable pay increase. The defenders of the status quo argue that charges are not worth collecting because you have to allow for so many exemptions — children, pensioners, the chronic sick, people on the dole. But amazingly enough, the justification cleperkds on the level of the charges; at 20p a bottle, you are scarcely covering the cost of the paperwork; the £200 million a year now raised is indeed a drop in the ocean of a total budget of £8,000 million. But suppose the charge per prescription was raised to £1 — which would still be less than the average actual cost of £1.50 — then you would be raising real money, and only from those who could afford to pay, as the exemptions would still apply.
Ah, but people wouldn't stand for it, we are told, which is another way of saying that any change would be 'politically impossible'. Have not opinion surveys shown time and again that the NHS is the most popular of British institutions? The indefatigable Mr Arthur Seldon, of the Institute of Economic Affairs, argues in his two memorable pamphlets Charge (Temple Smith, £3.50) and Overruled on Welfare (with Ralph Harris, IEA £3.00) that this is only because no price is put on this loyalty.
When people were asked in an IEA survey whether they were prepared to pay more in taxes for the NHS, only 37 per cent said Yes and 60 per cent said No. When people were asked subtler questions in a series of surveys over the past 16 years, such as whether they would welcome a system of vouchers which would cover a proportion of their health bills and which they could 'top up' from their own resources, a growing number said they would.
There is a suppressed demand for free choice in medicine as there is in education, flowing both from greater prosperity and from the growing perception of the inadequacies of state-funded and state-controlled services. This does not conflict at all with the universally held conviction that everyone, however poor, must have access to the best treatment without financial strain, which is what we all admire about the Health Service. As long as the public can be assured that nobody would be left unprotected, there is a greater appetite for reform than imagined by those who continue to spout the cliches of the Fifties.
Merrison, no, the Royal Commission — we must resist the authenticating glibness of the shorthand — is sure to point to the terrible gaps in health care in the United States. But all public services in the United States are notoriously incompetent — the Post Office makes ours look brilliant. I guess the Royal Commission will be less eager to look at West Germany and Benelux, where comprehensive insurance systems have been working smoothly and equitably for years. The supposed practical impossibility dissolves as quickly under inspection as the supposed political impossibility. And anyone who thinks differently should go out and try to get a hernia or varicose vein repaired on the Health this side of November.
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