So You Like Social Security?: You Will Love National Health Insurance!

SO YOU LIKE SOCIAL SECURITY? YOU WILL LOVE NATIONAL HEALTH INSURANCE! LINDA L. HUGHEY* As a product of late sixties social activism, I arrived in Edinburgh to rotate as a senior medical student with a strong bias in favor of a socialized national health care system. But I found that the workings of the British National Health Service (NHS) depend on an underlying economic, social, and philosophic base which differs in key ways from the American system. The hospital system, the health care consumer, and the physicians from consultant level through student level as well as the paraprofessional backup vary fundamentally between Great Britain and the United States. As the United States moves inevitably in the direction of a national health care plan, we can certainly learn much from the British model, but we must also realize that any system of health care must be suited to the unique character of the people it serves. The System Great Britain has some 70,000 physicians, 50,000 ofwhom are general practitioners (GPs) or primary care physicians. The GPs carry an average load of 2,500 patients and are essentially paid "by the head" for the patients on their lists; there is, however, a complex system ofdiminishing returns for increasing the number of patients beyond a certain level. Access to tertiary care centers is mediated by the GPs. For example, GPs near Edinburgh can refer patients to the "consultants" in an academic referral center such as the Royal Infirmary or Western General Hospital (WGH), where I spent 2 months as a student rotating through general medicine, cardiology, and obstetrics. The tertiary care centers are staffed by "housemen" (interns), "registrars" (residents), and medical students. Nurses in the tertiary care centers are more or less government employees; some government nurses also operate in paraprofessional *Resident, Department of Obstetrics and Gynecology, Chicago Lying-in Hospital, 5841 Maryland Avenue, Chicago 60637. This essay was submitted to the second Perspectives Writing Award for Authors under 35 contest.© 1979 by The University of Chicago. 0031-5982/79/2204-0100$01.00 Perspectives in Biology and Medicine ¦ Summer 1979 | 587 roles as "home visitors," often working in conjunction with the GPs to provide ongoing patient care. In contrast to the jigsaw composite forming the American medical system, the NHS functions in theory as a unit. This unitary design has the following effects: (1) greater standardization of tests and results, (2) less duplication oftests and equipment, (3) smoother transfer of patients and records between facilities, and (4) improved patient follow-up. As an illustration ofthese points, at the University ofChicago where I attended medical school, referral patients arrived from a variety of medical centers , often after having received extensive laboratory workups. In some cases this facilitated our own workup, but frequently when we were unsure of the laboratory methods or standards used in another institution or a private office, we had to start essentially from scratch, often duplicating expensive tests. Many patients lacked an identifiable source of primary care to which we could return them for follow-up care. In contrast, the referrals at WGH came with only minimal workups by their GPs. The more sophisticated diagnostic equipment simply does not exist outside the tertiary care centers. Furthermore, the GP in the United Kingdom reaps no financial gain from an extensive evaluation of a patient whom he will refer to a consultant anyway. The NHS system lessens these problems of duplication and also permits some economies of scale. Of course, the typical inefficiencies of a large government-run bureaucracy offset some of these advantages. Charts still vanish, and laboratory tests must be repeated when results are lost or seem improbable, but the overall effect of the unified NHS system is to reduce the duplication and to improve upon the lack of follow-up often found in the American "system" (or lack thereof). The Consumer The NHS offers mixed blessings to the consumer. The boon of "free" medical care is that it frees the families and patients of the devastating financial burden of disease.1 For the American family with inadequate third-party health care payments, the agony of worry about financing medical care compounds the grief of having a sick...