Are there lessons from abroad for the NHS?
Authors: D Allen
Journal: BMJ (1984)

The National Health Service is constantly under attack for alleged wastefulness and poor efficiency. At the same time the service is being changed and reorganised. Whether the NHS is as bad as sometimes portrayed and whether it is better or worse than the ways in which other countries pro vice medical care is hard to judge because reliable measures of health care are notoriously hard to establish. Certainly, much of the criticism is ill founded because people do not understand the service and how it differs from other systems. All advanced industrialised countries share similar and serious problems in providing medical care: what is interesting is how different countries have attempted to cope with these. Are there lessons for the NHS in how other countries provide their medical services ? One of the distinctive characteristics of the NHS is the separation between primary and secondary care. This originated in the 19th century, was institutionalised by Lloyd George in 1911, was reinforced when the NHS was launched in 1948, and has had a lasting effect on medical care in Britain. The administrative and financial arrangements for general practice established by the 1911 National Health Insurance Act have preserved general practice in Britain while in most other countries it has declined. Now some countries such as Sweden and the United States are trying to re-establish their primary care and are looking to Britain with its well developed primary care system. Most illnesses (as measured by patient contacts) are dealt with by general practitioners, and relatively few patients pass through this filter and become inpatients in Britain, resulting in a low inpatient rate compared with other similar countries. The ad? mission rate to general hospitals in England and Wales in 1974 was just over half that in the United States and Sweden and three quarters that in West Germany.1 This has kept costs down and helped to make medical care in Britain relatively cheap. In 1977?the latest year for which international figures are available?Britain spent about 5-2% of its gross national product on medical care compared with 8-8% in the United States, 9-2% in West Germany, and 9-8% in Sweden.1 Equity in the provision of health care,  access to the service, and improved effectiveness in providing care were and have remained the guiding principles of the NHS. Unfortunately, these objectives often prove mutually conflicting, which helps to explain many of the difficulties of and complaints about the NHS. In Britain state medical care covers primary and secondary care as well as community services, with local authori? ties providing personal social services. In the United States health insurance cover concentrates on hospital care and physician services, and the development of other services has been largely neglected. Care in the United Kingdom is (almost)  at the time of consumption. The principles of the 1946 NHS Act was to divorce the health care need from personal means. Need is measured not by capacity to pay as in many other systems but by health care professionals such as general practitioners. This open ended system meant that governments so n found that the NHS cost much more than was expected, and in 1951 the then Labour government sought to reduce costs by introducing charges to cover items such as prescriptions, dental care, glasses, etc. Even today, after they have been sharply increased in the past four years, charges cover only about 4% of total NHS costs. Medical care is also free at the time of consumption in other countries?for instance, to those in America who are covered by Medicare or who are veterans. For most Germans who are covered by social insurance funds medical care is almost free, though there are small charges for inpatient care. Medical care is nearly  to most of the French, who pay for it when they receive it but can then reclaim most of the charge (75% for doctors' and dentists' fees) from the government's social insurance scheme. Most French people insure to cover the cost not covered by social insurance. The difference is that medical care in Britain is not only comprehensive but is also available  to all residents ; there is no question about qualify? ing. Indeed, the NHS was the first health service in Western society to offer  comprehensive care to the entire population, though visitors are now expected to pay.