1.A Free Health Service
2.A Communal Responsibility
3.State Funding of the NHS
4.The NHS is not a Welfare State
5.Triumphant Collective Action
6.The Cautious Medical Profession
7.Pay Beds in the NHS
8.The Equipment of a Civilized Society
When I was engaged in formulating the main principles of the British Health Service, I had to give careful study to various proposals for financing it, and as this aspect of the scheme is a matter of anxious discussion in many other parts of the world, it may be useful if I set down the main considerations that guided my choice.In the first place, what was to be its financial relationship with national insurance; should the health service be on an insurance basis?
I decided against this.
It had always seemed to me that a personal contributory basis was peculiarly inappropriate to a national health service. There is, for example, the question of the qualifying period. That is to say, so many contributions for this benefit, and so many more for additional benefits, until enough contributions are eventually paid to qualify the contributor for the full range of benefits.In the case of health treatment this would give rise to endless anomalies, quite apart from the administrative jungle which would be created. This is already the case in countries where people insure privately for operations as distinct from hospital or vice versa.
Whatever may be said for it in private insurance, it would be out of place in a national scheme. Imagine a patient lying in hospital after an operation and ruefully reflecting that if the operation had been delayed another month he would have qualified for the operation benefit. Limited benefits for limited contributions ignore the overriding consideration that the full range of health machinery must be there in any case, independent of the patient's right of free access to it.
Where a patient claimed he could not afford treatment, an investigation would have to be made into his means, with all the personal humiliation and vexation involved. This scarcely provides the relaxed mental condition needed for a quick and full recovery.Of course there is always the right to refuse treatment to a person who cannot afford it. You can always "pass by on the other side." That may be sound economics. It could not be worse morals.
Some American friends tried hard to persuade me that one way out of the alleged dilemma of providing free health treatment for people able to afford to pay for it, would be to fix an income limit below which treatment would be free while those above must pay. This makes the worst of all worlds. It stilt involves proof, with disadvantages I have already described. In addition it is exposed to lying and cheating and all sorts of insidious nepotism. And these are the least of its shortcomings.
The really objectionable feature is the creation of a two-standard health service, one below and one above the salt. It is merely the old British Poor Law system over again. Even il the service given is the same in both categories there will always be the suspicion in the mind of the patient that it is not so, and this again is not a healthy mental state.
The essence of a satisfactory health service is that the rich and and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.Two ways of trying to meet the high cost of sickness are the group insurance, and the attachment of medical benefits to the terms of employment.
Group insurance is merely another way of bringing the advantages of collective action to the service of the individual. All the insurance company does is to asses the degree of risk in any particular field, work out the premium required from a given number of individuals to cover it, add administrative costs and dividends, and then sell the result to the public. They are purveyors of the law of averages. They convert economic continuity, which is a by-product of communal life, into a commodity, and it is then bought and sold like any other commodity.
What is really bought and sold is the group, for the elaborate actuarial tables worked out by the insurance company are nothing more than a description of the patterns of behavior of that collectivity which is the subject of assessment for the time being. To this the company adds nothing but its own profits. This profit is therefore wholly gratuitous because it does not derive from the creation of anything. Group insurance is the most expensive, the least scientific, and clumsiest way of mobilizing collective security for the individual good.
In many countries the law implicitly recognizes this because the insurance company is required to invest some, if not all, its income in trustees stock, national bonds and debentures. In other words, the company must invest in those properties which bear the strongest imprint of continuous communal action. The nearer the investment approaches to those forms of property which are most characteristic of competitive capitalism, the less the element of collective security, and therefore the less desirable from the point of view of insurance.
There never can be a clearer case of the private exploitation of a product publicly produced.
Where medical benefits are attached to employment as a term of the contract the situation is somewhat different. Here is an instance where the workers, as occupational groups, succeed in accomplishing what they have failed to do or not tried to do as enfranchised citizens. It has the one advantage that the employer in such a case will be less eager to lobby against legislation for a national health scheme. He may be inclined to support national proposals because these will make others share part of his burden.
As a political tactic, therefore, occupational medical benefits have something to be said for them; and the workers enjoy some protection in the meantime while the national scheme is being held up.But they are no substitute for a national scheme. An industrial basis is too narrow for the wide range of medical needs which should be met, both for the worker and for his family. The incidence of sickness varies from industry to industry and so do the rates of economic obsolescence and unemployment.
We had experience of this in Britain where certain of the Approved Societies under the old National Health Insurance recruited a disproportionate number of members from industries with a high degree of sickness and accident rate, and affected by serious industrial depression.The result was that these Approved Societies were compelled to curtail benefits to their members, while other societies with a different industrial composition were able to distribute the full benefits. That situation consequently helped the strong and hurt the weak.
There are two final objections to the methods I have been describing.
They create a chaos of little or big projects, all aiming at the same end: assisting the individual in time of sickness. A whole network of strong points emerge, each with a vested interest in preventing a rational national scheme from being created. Thus to the property lobby is added the lobby of those who stand to lose under the national project. In the end they may have to be bought out at great cost in time, effort and money.
The second objection is even more serious. These schemes all have for their aim the consumption of the apparatus of health. But they leave the creation of that apparatus without plan and central direction. In place of a rational relationship between all its parts, there arises a patch-quilt of local paternalisms.
My experience have taught me that there is no worse enemy to the intelligent planning of a national health service, especially on the hospital side. Warm gushes of self-indulgent emotion are an unreliable source of driving power in the field of health organization. The benefactor tends also to become a petty tyrant, not only willing his cash, but sending his instructions along with it.
The other alternative is a flat rate compulsory contribution for all, covering the full range of health treatment, or a limited part of it. There is no advantage whatever in this. It is merely a form of poll tax with all its disagreeable features. It collects the same from the rich and the poor, and this is manifestly unjust. On no showing can it be called insurance.
One thing the community cannot do is insure against itself. What it can and must do is to set aside an agreed proportion of the national revenues for the creation and maintenance of the service it has pledged itself to provide. This is not so much insurance as a prudent policy of capital investment. There is a further objection to a universal contribution, and that is its wholly unnecessary administrative cost-unless it is proposed to have graduated contributions for graduated benefits, and I have already pointed out the objections to that.
Why should all have contribution cards if all are assumed to be insured? This merely leads to a colossal record office, employing scores of thousands of clerks solemnly restating in the most expensive manner what the law will already have said; namely, that all citizens are in the scheme.The means of collecting the revenues for the health service are already in the possession of most modern states, and that is the normal system of taxation.This was the course which commended itself to me and it is the basis of the finance of the British Health Service. Its revenues are provided by the Exchequer in the same way as other forms of public expenditure.
(Excerpts from Bevan, A. 1952. “A Free Health Service”. In “In Place of Fear”: 77-97)
Page Updated: 27 May, 2017Tweet