Dr. Dawe:

A CURIOUS DEMAND came one day in London from a patient of mine, a middle-aged factory worker.

He wanted me to prescribe for him 10 pounds of absorbent cotton, which is used in packing open wounds and which could be ordered almost free under Britain's program of nationalized medicine.

"What on earth do you want with all that absorbent cotton?" I asked. "I want to restuff a sofa," he replied.

When I refused to approve this improper request, he angrily threatened to withdraw his whole family of six who were my regular patients.

This attitude of disdain for the British health care program and the doctors who serve under it became widespread soon after the National Health Service was established in Great Britain in 1948.

It is only one-and perhaps the least important of the potential dangers America faces if a system of nationalized medicine is adopted in this country. A compulsory federal health insurance bill now pending in the U. S. Congress is the thin end of the wedge that quite

wishful promises and tranquilizing assurances that were heard in England 13 years ago.

Americans should heed the lesson taught in England, and guard well the high medical standards and freedoms they now possess.

The proposed medical care legislation now at issue in Congress would provide for payment of hospital, nursing home and home health services to aged beneficiaries under the social security system. Providers of the health care would have to agree to meet specific gov. ernment requirements. They would be paid by an increase in the social security taxes levied on employers and employes.

Abraham Ribicoff, Secretary of Health, Education and Welfare, who would administer the proposed law, has been widely quoted as saying that the legislation would not authorize government supervision or control over the practice of medicine, the manner in which medical services are provided or the selection or compensation of those offering the health care services.

However, the bill itself states that

WERNER WOLFF BLACK STAR

hospitals, nursing facilities and home care agencies must meet such conditions of participation as the Secretary of Health, Education and Welfare requires.

The Health Secretary says that doctors would not be included in the program. However, the bill specifically includes pathologists, radiologists, physiatrists and anesthesiologists working in hospitals or serving the hospital's outpatient clinics. The bill also would include interns and residents in teaching hospitals.

It is naïve to suppose that once this legislation became law it would not be extended gradually to cover all medical practice and health care services for the entire U. S. population. It is equally naive to suppose that government financing will be provided without government control and ultimate government operation of medical services. The government would be irresponsible if it spent public funds without adequate controls and supervision.

Innocent-sounding provisions of the medical care measure can prove to be far different in practice. I saw

similar provisions as they were applied under Britain's National Health Service.

For example, the pending medical care legislation limits the drugs and biologicals that will be provided for patients to those included in the U. S. Pharmacopoeia, National Formulary or New and Non-official Remedies.

In Britain the amount and kind of drugs were also restricted for the general practitioner. Only doctors on the staffs of hospitals initially could prescribe new drugs not listed in the British Pharmacopoeia or National Formulary. Governmentlicensed drug houses supplied medicines, which the general practitioners were supposed to prescribe

by their generic name.

How he faced fines

Nearly every week, either the doctor with whom I was in practice or I would be fined because we had prescribed a drug which in our best judgment was needed by a patient but which was not on the government's official list.

Once I was charged for prescrib ing a drug that actually was in the official listing. I pointed this out rather acidly to the bureaucrats who had erred. The charge was remitted, but I never received an explanation or apology.

On another occasion I discovered that Luminal, a brand name for phenobarbital, which was being produced in large quantities by a private firm, was actually less expensive to obtain than the phenobarbital being made in the government's drug houses.

The restrictions on a physician's judgment to prescribe the best medicine for his patient fell particularly heavily on the younger doctor. For instance, the new man in the field might prescribe a new and expensive drug for arthritis, whereas the older physician might order aspirin. Since the government levied a charge on doctors whose prescriptions exceeded a certain percentage of the average cost for the particular area in which they prac

DR. DAWE

ticed, the physician who prescribed the more expensive medicines suffered financially.

It became natural for a doctor to hesitate to prescribe certain drugs when he knew it would cost him money. It was difficult enough to get by on the restrictive compensation the government allowed.

A physician in general practice was paid a fixed fee per patient per year no matter how frequently he saw the patient. To earn a living of about $4,000 a year he had to see approximately 100 patients a day. Medical specialists were attached to hospitals and paid a salary by the government.

I have a friend who has a rural practice in England still. He gets by only because he also has a chicken farm. His income from his chickens is greater than from his practice.

Since medical care theoretically was available to everyone at anytime, we were literally swamped with patients, many of them with trivial complaints or with no ailment at all. I remember one elderly woman who was in and out of the office three or four times a week. This old dear lived alone and mainly wanted someone to talk to.

Free service to all naturally leads to overutilization. Patients and proper medical care suffer.

With the best will and intentions we could not give all the time we should have to our patients. The general practitioner tended to send any cases where diagnosis was difficult or time-consuming to outpatient departments of the hospitals. Less and less minor surgery was done in the doctor's office, since there was no time.

Besides the heavy patient load, the time spent on government paper work was fantastically high. If a man was too ill to work, he had to have a certificate filled out by his physician. For each week he was not on the job, a certificate was necessary, and another certificate had to be completed when he returned to work.

There were certificates for free milk or orange juice for children when this added nourishment was necessary, and complicated forms any time any one was treated who was not on a doctor's list of regular patients. Form-filling and correspondence with the government thus became one of the physician's major functions. He was reduced to the role of part-time clerk.

The lack of time to care for patients meant more of them had to be shunted off to hospitals. Doctors tended to lose touch with their patients when this happened as practically no general practitioners are on hospital staffs. The doctor could visit his patient in the hospital, but he got the uncomfortable feeling that he was in the way, because he had no responsibility for the patient then. The hospital staff was in authority.

When the patient was released, his doctor got a brief letter from the hospital saying what had been done, but this break in medical care continuity is hardly the best kind of treatment for the patient. Rarely, too, did the patient have any choice over who would treat him in the hospital.

The Secretary of Health, Education and Welfare and the politicians

66 British

British business

men found that

absenteeism in plants

and companies
nearly doubled

the first year the

National Health Service

was in effect.99

who support the medical care bill before Congress say that it provides free choice of either hospital or doctor.

Under the National Health Service, patients not only had no choice of hospitals, they were fortunate to get accommodations at all in the jam-packed institutions.

I remember an elderly patient who fractured her hip. I spent more than three hours on the telephone before I could locate a bed for her, and it was in a hospital on the other side of London.

I remember, too, a 24-year-old woman who had a sudden cerebral attack. I believed it was neurologi

cal in nature, but I knew she needed a specialist for proper diagnosis. After four hours on the phone, I finally was able to get her into a hospital. A brain cyst was discovered. The young woman lived, but the wait had not helped her.

I remember, too, a man of about 60 who had a heart attack and was in a state of some shock. Two hours of phoning finally found hospital space for this emergency case. A central phone service finally was established which relieved this problem to some extent. But private or semiprivate rooms were almost unheard of. In some hospitals the crowded wards even had beds down the middle aisles.

Unless surgery was of emergency nature, up to a two-year wait was customary. I had several child patients with chronic tonsilitis who were on the waiting list for operations the whole year I was in practice in London.

A major reason why the hospitals were so overcrowded was the heavy load of elderly patients, the very age group that the health care measure now before Congress would cover. Since hospitalization was free, many of the aged in Britain were shuttled off to the hospitals rather than being cared for at home by their families.

I appreciate that the aim of the aged health care legislation is to help a group of citizens who frequently incur heavy medical expenses. However, as a psychiatrist, I am convinced that the elderly person should not be encouraged in dependency. He should not be made to feel that he is a pitied ward of the state, a worn-out object of charity. Let us not destroy the self-reliant spirit. The older patient must have an incentive to keep living, to continue to be useful.

Existing legislation, enacted by Congress only last year, provides a program of care for needy aged who cannot afford the costs. But to encourage all the aged to give up their independence and become debit members of society, to receive doles regardless of need, could be a destructive influence on the older population.

Though health care of the elderly is often more expensive than that of younger persons, the British found that their attempts to improve the health services for the minority downgraded the services for the majority. There are even indications that the health of the over-all population was not greatly improved by the Service as such.

One might expect that, with health care available to anyone re

gardless of cost, the country would be healthier. However, British businessmen found that absenteeism in plants and companies nearly doubled the first year the Health Service was in effect.

The dissatisfaction with the National Health Service has been strikingly shown in the sharp rise in voluntary health insurance plans in Britain. When the Health Service first was established, private health insurance fell off drastically. But now those who can afford it buy private heath insurance because of the better treatment and benefits it assures, though the insured must also carry the heavy taxes that pay for the nationalized health plan.

The poor British taxpayer has been milked dry. The Health Service now costs more than five times the original estimate. One of the main reasons is that there are two or three government clerks for each doctor. On that basis, if the U. S. adopts a government operated health system, the federal government would have to hire nearly two million more clerks.

When the British Health Service began, the staff of the hospital where I was an intern seemed to double overnight. The signs of bureaucracy-excessive paperwork, overhead and impersonal treatment -were immediately apparent.

Hospitals apply to the government for block grants for operating expenses. If a hospital has any money left over when it has completed a fiscal year, the next year's grant is reduced by this amount. Naturally, this system encourages

wasteful practices and penalizes economical hospital administrators.

I have seen hospital money spent for television sets, new carpeting and other purposes of a nonmedical nature just to use up remaining funds in a budget.

Patients and pharmacists were not guiltless either. Some patients had arrangements with their pharmacists whereby they would bring in a prescription for government paid medicine and use it instead to pay for cosmetics of an equivalent value. The waste and red tape might be worth the price if they assured the best medical practice and health care. However, bureaucratic administration brought outrageous governmental interference that discouraged and handicapped medical men. For example, these two incidents involved my brother-in-law. He, too, is a physician refugee of the National Health Service and is now practicing in New Mexico.

One New Year's Eve, my brotherin-law received a message to make three house calls. There was no indication of an emergency nature. But by the time he reached the third house, the patient had already been sent to a hospital by another physician.

A complaint was brought against my brother-in-law and he was taken before a government Health Service tribunal that acted as prosecutor, judge and jury. A doctor under this situation is not even allowed representation. Though he pointed out that he had no way of knowing the patient was in an emergency condition, he was fined 50 pounds.

On appeal, the decision was overturned and justice was done, but it had cost him untold anxiety and loss of prestige, through the bad publicity of this star chamber procedure. He was not even able to sue for malicious abuse or on other grounds.

On another occasion, government inspectors who periodically check doctor's offices as to the condition of furnishings and even decor, demanded to see the living quarters of my brother-in-law which were in the same building.

I came to the United States because I sought the opportunity to practice medicine in a way that I thought best for both doctor and patient-without regimentation, restrictions and interference. I want only two people in the medical relationship myself and my patient. There should be no impersonal governmental third party.

In this country I have found freedom of action and professional choice. Now I feel I am practicing in the best existing system in the world. It is not perfect. But we are striving to make it better. And the best medical care can be given only in the system where a doctor is not a government clerk but an individual with professional dignity and freedom. END

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Copyright, 1961 Nation's Business