An Appraisal of the American and British Health-Care Systems

AN APPRAISAL OF THE AMERICAN AND BRITISH HEALTH-CARE SYSTEMS CHARLES L. HUDSON, M.D.* Introduction A speech by Dr. Paul Beeson at the annual meeting of the Association of American Medical Colleges published in thefournal ofMedical Education [1] reprinted in the Archives ofInternal Medicine [2] was the stimulus for this paper which is intended not as a rebuttal so much as a commentary . While his title is positive, "Some Good Features of the British National Health Service," and seemingly noncontroversial, comparison with our medical-care system comes through the text in such a way as to suggest that our system needs changing. But for what purpose? My plan first is to underline briefly some differences in the British and American systems and also to note similarities in the systems where we can be commendatory or, as in abuse of laboratory examination, we can agree to point with alarm. To reduce this discussion to manageable proportions I have focused on the major concerns about medical care in both countries—price and volume of expenditures, quality of care, and distribution—in an attempt to measure the potential of either system to make a significant impact for change or improvement. I agree with Dr. Beeson and would emphasize that in principle and in many details the British system would not be successfully applicable to the United States. Regardless ofthat opinion, any modification is worthy of consideration if indeed there are major defects in our system which modification could correct. Comparison of Medical Plans A National Health Insurance plan (NHI) in the United States became a strong possibility, if not a foregone conclusion, a few years ago when the American Medical Association (AMA) joined the ranks of numerous *Senior consultant in medicine emeritus, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44106. Clinical associate professor of medicine, Case Western Reserve University School of Medicine, Cleveland. 238 I Charles L. Hudson · American and British Health-Care Systems others with a NHI plan of its own, Medicredit. It is not my purpose in this article to compare and criticize various insurance plans, but rather to review some national concerns to be considered by any national medical system, first as they might be found operating in Britain, and then as they are related to our own medical practice in the United States. It is fortuitous that the British National Health Service (NHS) has just been changed [3,4]. Examination of the circumstances that led to a decision to alter the NHS may forewarn us of examples where a national health system may be faulty and can provide us with valuable insights for our future use and benefit. Perhaps I should first apologize for my temerity in attempting this article at all. I have no volumes of data—what I did have direct from the British Ministry of Health [personal communication] was largely "off the record" and is now 7 years old—except, of course, for Dr. Beeson's data, which are quite general but adequate for our purposes,judging by what I have read. I have had many unusual opportunities to make contact with persons knowledgeable in the social, economic, and political fields of medicine both in this country and abroad, and I would like to believe that I have demonstrated an ability and inclination to bejudicious about information that comes to my attention. Any other qualification will have to wait. It should not be necessary to point out that in size and homogeneity the United States and Britain are quite dissimilar. Dr. Beeson surmises that some of the features of the NHS would not be applicable to us in the United States, and I agree. Not the least of these is the attitude of physicians regarding organization and control of their practices. The British had a NHS of sorts for the underprivileged for many years before 1948, the year the NHS was initiated, and except for the outbreak of World War II probably would have extended it to all citizens earlier than they did. Even so, one of my acquaintances at the Health Ministry said it would not have been established even in 1 948 were it not for the fact that "the purse strings...