Health Care in England: Not Your Cup of Tea: Part 1

Published December 1, 2001

It is one thing to read the U.S. media’s meager reporting on the critical condition of Britain’s health care system. It is quite another to experience first-hand how those who depend on their government for medical care have been trapped in a failing single-payer health care arrangement.

The single-payer approach, deemed “free health care” by its beneficiaries and proponents, has led to limitless and often irresponsible demands on Britain’s National Health Service (NHS), without providing a funding mechanism anywhere near up to the task.

Ninety percent of Britons must access medical care through the NHS bureaucracy; just 10 percent of the population subscribes to private health insurance and medical care. The NHS encompasses all of the English mainland, Northern Ireland, Scotland, and Wales.

A Little History

Founded in 1948, the NHS was based on Germany’s centralized health care system, and it is not unlike China’s social insurance plan. In recent years, those programs have weakened . . . and Britain’s is not far behind.

The German “sickness insurance” approach has evolved into a two-tiered system. About 75 percent of German residents are covered by compulsory government health insurance: you must have it, and your employer must provide it. A rapidly growing 25 percent are now covered by private health insurance—which is also compulsory.

In April 2001, the Chinese government declared its socialized health care system dead. Hospitals are now encouraged to compete, and consumers are expected to pay. The first $240 of medical expenses are paid from a social insurance fund with individuals paying half the cost of medical care out-of- pocket. A mutual fund, similar to state-run high-risk health insurance pools (HIPs) in the U.S., exists for those with exceptionally high medical expenses.

Germany and China are part of an international trend toward less government interference and greater individual responsibility in health care. While there are dramatic demographic differences between Germany and China, both have embraced the competition and consumer choice that are keystones of free-market health insurance and health care delivery.

NHS now distinguishes itself internationally by recognizing neither competition nor consumer choice. This was made abundantly clear to me this summer, while I spent time in London on a fact-finding trip.

In the final days of this year’s re-election campaign, the title of a June 2 editorial in the London Express declared its unwavering support for NHS and the status quo: “It’s the Principle That Matters, Not Consumer Rights.”

Examining the Bureaucracy

In a sprawling arrangement reminiscent of the failed Clinton national health care scheme, the NHS is a “top-down” approach to the delivery of health care.

The Department of Health has offices in Leeds and London as well as eight regional offices. Its primary function is to develop standards of patient care and enforce rules governing how care is delivered, to ensure the standards are met.

In England and Wales, local NHS Trusts develop proposals requesting funding for the health services they deem needed by their service areas. Those proposals are submitted to the central Health Authorities, who evaluate the requests and fund them. In Scotland various Health Boards carry out the evaluating/funding function, and in Northern Ireland it is the responsibility of the Health and Social Services Boards.

A board of executive and non-executive directors rules over each Health Authority. The chairperson of each authority appoints directors. Each authority is monitored by the regional office which, in turn, is monitored by a regional NHS executive who is monitored by the government.

The NHS Direct office opened in March 1998 and was designed to offer patients 24-hour advice on health care. In practice, NHS Direct acts as a “gate-keeper.” NHS Direct nurses offer advice and reassurance on how patients can take care of themselves at home. For more serious conditions, the nurses advise on what actions to take. If appropriate, the nurse will call for an ambulance.

NHS Trusts, or hospital trusts, are found in most large towns and cities and claim to offer a wide range of health care services through centers and clinics. The trusts also make house calls to patients living in rural communities. Except in the case of emergencies, a referral for hospital admittance can be made only by a general practitioner (GP). Appointments and treatment by the GP are free.

Together, the NHS Trusts employ most of the health care system’s workforce, including doctors, nurses, dentists, pharmacists, and midwives.

Support professionals, including physiotherapists, radiologists, podiatrists, speech and occupational therapists, psychologists, and administrative staff—from receptionists to maintenance workers—are also employed by the NHS.

Signs of Dissatisfaction

As the British media regularly reports, beneficiaries of the NHS all too frequently don’t get timely care; are subjected to queuing for 12 months or more; get better on their own; are sent to other countries for care; are shifted to the private sector for care; or die while on the waiting list to see a doctor or gain access to a hospital.

But of the many indicators pointing to a dysfunctional NHS, the dissatisfaction of medical professionals rises to the surface as possibly the single most serious issue capable of undermining all confidence in the British health care arrangement.

Zosia Kmietowicz wrote in the October 20, 2001 issue of the British Medical Journal, “one in four general practitioners (GPs) in Britain’s National Health Service is seriously considering leaving general practice.”

According to a recent survey conducted by the British Medical Association (BMA), almost half of the GPs interviewed said they plan to retire before the age of 60. The BMA said the findings show the scale of the challenge facing the government as it seeks to recruit and retain doctors and bring down long waiting lists for medical treatment.

Two-thirds of the 42,360 GPs surveyed complained morale in the profession is low or very low. Nearly two-thirds say it is worse now than it was five years ago.

The study exposes the current working conditions under the NHS:

  • Most GPs have between 1,500 and 2,500 patients, and more than one-quarter manage between 2,000 and 3,000 patients.
  • Ninety-three percent say they want to treat a smaller number of patients.
  • Ninety-three percent say they want longer consultations with patients.
  • One in five complain work-related stress is excessive and unmanageable.
  • More than half say the extent to which work impinges on their quality of life is unacceptable.
  • More than 80 percent feel the government’s plans for improving the NHS are unrealistic and cannot be achieved in the given 10-year time frame.

In May 2001, a ballot of all GPs indicated 86 percent of those who voted would be prepared to consider resigning from their current contract if a better contract and negotiating rights cannot be secured by April 2002.

Waiting for the Next Crisis

According to Anthony Brown, health editor of The Observer, “Britain’s hospitals are facing a winter crisis similar to that of two years ago, when the NHS came close to collapse.”

In the winter of 1999-2000, the NHS almost ground to a halt because of an influenza epidemic. Almost all non-emergency operations were cancelled, and at one point the country was left with just two intensive-care beds, with patients shuttled hundreds of miles in search of somewhere to stay.

The crisis shook the public’s faith in the NHS and forced Prime Minister Tony Blair to launch a national plan to save it. A similar crisis was avoided last year because the flu season was unusually mild.

Doctors are convinced the NHS is heading for a similar crisis this year. Jonathan Fielden, clinical director of emergency services at Royal Berkshire & Battle Hospital, said, “This year we are more concerned—hospitals are already in perpetual crisis, even during the summer, and there are reports the Sydney flu might hit us. I think it likely the crisis will be as bad as two years ago.”

According to reports I read while in London, intensive-care beds in the country should be running at less than 85 percent occupancy . . . but most hospitals I contacted were running at over 90 percent occupancy. In November, an Audit Commission report showed emergency room (ER) capabilities were deteriorating rapidly.

Dr. Peter Hawker, chairman of the British Medical Association’s Central Consultant’s Committee, warned, “We are running flat out already; there is no spare capacity. Even if we have just an averagely bad winter, we will be in for trouble. There will be a lot of patients having their operations cancelled.”

Paying for the Bureaucracy

The British approach is to say all health care should be equal, so there is no difference between the standard of care enjoyed by the rich and the poor. The NHS emphasizes equality first, consumer rights last.

This approach, repeatedly defended by successive English governments, is hardly free. The burden on the public—measured by heavy income taxes, insurance premiums, and stress—is significant.

Steve Whitlam, Knowledge Systems Manager for the London Regional Office of the NHS, explained to me there is no such thing as NHS Insurance. “United Kingdom employees and employers pay National Health insurance contributions which help fund the NHS as well as providing other social welfare benefits.” This socialized entitlement system includes Incapacity Benefits (like long-term care and disability insurance,) Jobseeker’s Allowance, Maternity Allowance, Retirement Pension, Widowed Mothers Allowance, Widows Payment, and Widows Pension.

Whitlam further explained 13 percent of NHS funding comes from National Insurance contributions; the remainder comes from general taxation and some patient charges for eye tests and dental care.

National Insurance contributions are 10 percent of the employee’s gross earnings, starting at £87 per week ($124), to an upper weekly limit of £575 ($820). The employer contributes 11.9 percent of the employee’s gross.

An income tax is also levied on earnings over a personal allowance of £4,535 per year ($6,467). Income over this amount is taxed at 10 percent for the first £1,800 ($2,681). The next £29,400 ($41,927) is taxed at 22 percent. For those earning more than £29,400 over the personal allowance, the tax is 40 percent.

Health Care Utopia?

In its publications and on its Web site (, NHS touts its coverage as being “equal in a manner of uniformity across the country and a uniformity between rich and poor, comprehensive, of the highest standard, and free at the time of use.”

As I have come to understand the NHS, these are grand overstatements of the program’s success, part of a politically incorrect problem: If you criticize the NHS, you will come under attack for being against “the best.” In England, being against “the best” is like making a slur against the Queen.

I’ll risk being improper: The facts do not support “the best” claim. The NHS achieves only one of its stated goals, being largely free of direct payments, co-pays, and deductibles. It is this single-mindedness to avoid charges that makes it impossible for the system to achieve its remaining goals.

At the heart of single-payer health care in general, and the NHS in particular, is a belief that health care is a right, and government has the responsibility to provide it. This belief, more than any other factor, makes reform British health care a daunting task vulnerable to political posturing and social unrest.

According to Eammon Butler, director of the highly regarded Adam Smith Institute, “the Prime Minister wants to see more NHS cases going to private hospitals, but private providers will be very wary of investing in that, if they think that ministers might subsequently change their minds and leave private hospitals bankrupt, ready for picking by the state. The only solution is to go beyond this: to allow the public to choose service providers for themselves, not to have politicians directing public budgets on their behalf.”

Next month: British policy experts propose greater freedom of choice in health care.

For more information . . .

The text of Zosia Kmietowicz’s article in the October 20, 2001 issue of the British Medical Journal, “Quarter of GPs want to quit, BMA survey shows,” is available on the Internet at

Anthony Browne, health reporter for The Observer can be reached by email at [email protected]