How would you guys feel?

[lliam]

How would you guys feel about a, 'National Health Service', the same as we have in the UK?
================================================


We in the UK take the National Health Service for granted now, but it is only 50 years ago that health care was a luxury not everyone could afford. It is difficult today for us to imagine what life must have been like without free* health care and the difference that the arrival of the NHS made to people's lives.

Just before the creation of the NHS, the services available were, as you might expect, the same as after; no new hospitals were built nor hundreds of new doctors employed. What was different was that poor people often went without medical treatment, relying instead on dubious - and sometimes dangerous - home remedies or on the charity of doctors who gave their services free to their poorest patients.


Hospitals charged
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Access to a doctor was free to workers, who were on lower pay, but this didn't necessarily cover their wives or children, nor did it cover other workers or those with a better standard of living. Hospitals charged for services, though sometimes-poorer people would be reimbursed. Even so, it meant paying for the service in the first place - which not everyone could afford.

The need for free health care was widely recognised, but it was impossible to achieve without the support or resources of the state.

Philanthropists and social reformers.
=====================================
Throughout the 19th century, philanthropists and social reformers working alone had tried to provide free medical care for the poor. One such man was William Marsden, a young surgeon, who in 1828 opened a dispensary for advice and medicines. His grandly named London General Institution for the Gratuitous Cure of Malignant Diseases - a simple four-storey house in one of the poorest parts of the city - was conceived as a hospital to which the only passport should be poverty and disease and where treatment was provided free of charge to any destitute or sick person who asked for it.

Royal Free Hospital
=====================
The demand for Marsden's free services was overwhelming. By 1844 his dispensary, now called the Royal Free Hospital, was treating 30,000 patients a year. With consultant medical staff giving their services free of charge and money from legacies, donations, subscriptions and fund-raising events, the Royal Free - now re-housed in larger premises - struggled to fulfil Marsden's vision until 1920 when, on the brink of bankruptcy, it was forced to ask patients to pay whatever they could towards their treatment - just like every other voluntary hospital in the country.

Municipal hospitals.
=====================
As well as the charitable and voluntary hospitals, which tended to deal mainly with serious illnesses, the local authorities of large towns provided municipal hospitals - maternity hospitals, hospitals for infectious diseases like smallpox and tuberculosis, as well as hospitals for the elderly, mentally ill and mentally handicapped.

Mentally ill people.
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Mentally ill and mentally handicapped people were locked away in large forbidding institutions, not always for their own benefit but to save other people from embarrassment. Conditions were often so bad that many patients became worse, not better.

Older people.
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Older people who were no longer able to look after themselves also fared badly. Many ended their lives in the workhouse - a Victorian institution feared by everyone - where paupers did unpaid work in return for food and shelter. Workhouses changed their names to Public Assistance Institutions in 1929, but their character, and the stigma attached to them, remained.

*(Not exactly free, we have to pay a weekly 'National Insurance Stamp' deducted from salary, the deduction increases with the rate of inflation.)

[Serenity]

I generally don't like the government taking over. Maybe I would not mind the government taking taxes if they only take out a fixed percentage from every worker instead of the current tax system. The government always seem to need more and more and more. They should learn to prune their budget like everyone else has to live on a certain salary. Taxes in the states generally run from 15 to 38% for individuals. What percentage of income is taxed in the UK? Other countries seem to make their health programs work but what is the downside to their system?

[lliam]

The National Health Service became reality on 5 July 1948. It was a momentous achievement and everybody wanted the new service to work.

However, food was still rationed, building materials were short, there was a dollar economic crisis and a shortage of fuel. The war had created a housing crisis - alongside post-war re-building of cities, and the designation of overspill areas, the New Towns Act (1946) created major new centres of population and all needed health services.


Administrative difficulties.
============================
The NHS brought hospital services, family practitioner services (doctors, pharmacists, opticians and dentists) and community-based services into one organisation for the first time. But it was not easy. Holding everything together and keeping everyone on board continued to create administrative difficulties for years.

Costs.
=====
Financial problems, however, were worse. It was impossible to predict the day-to-day costs of the new service and public expectations rose. Medical science was rapidly gathering pace, hospital beds for tuberculosis were closed, allowing cash to be released for other services.

More mothers were wanting their babies delivered in hospital, cardiac surgery was being applied to rheumatic heart disease, and the first hip replacements were beginning to be performed.

But initial estimates of the cost of the NHS were soon exceeded as newer, more expensive and more frequently used drugs were developed.


Fees.
====
Within three years of its creation, the NHS, which had been conceived as free of direct charges for everyone, was forced to introduce some modest fees. Prescription charges of one shilling (5p), which had been legislated for as early as 1949 but had not been implemented, were introduced in 1952. A flat rate of £1 for ordinary dental treatment was brought in at the same time.

Balancing demands.
=================
Many of the tensions that emerged in the early days of the NHS have challenged its senior management and successive Governments ever since. Today the NHS has a workforce of over one million people and a budget of around £42 billion year - it is a sophisticated and modern organisation with all the advantages of state-of-the-art technology. Yet, the fundamental questions that tested Bevan and his colleagues - how best to organise and manage the service, how to fund it adequately, how to balance the often conflicting demands and expectations of patients, staff and taxpayers, how to ensure finite resources are targeted where they are most needed - continue to challenge the system.

Bevan foresaw this. We shall never have all we need he said. Expectations will always exceed capacity. The service must always be changing, growing and improving - it must always appear inadequate.

Family doctors.
================
The foundation of the new service was the family doctor or general practitioner (GP). Then, as now, the family doctor acted as gate-keeper to the rest of the NHS, referring patients where appropriate to hospitals or specialist treatment and prescribing medicines and drugs.


Dental services consisted of check-ups and all necessary fillings and dentures. There was a school dental service and a special priority service for expectant and nursing mothers and young children that was organised by local authorities. Eye tests were provided by ophthalmic opticians on production of a GP referral note.

Community health.
=================
A major innovation was the community health centres - a special premise with accommodation and equipment supplied from public funds to enable family doctors, dentists and others to work together to provide a range of services on the spot. There were also specialist ear clinics at which patients could get an expert opinion and, if needed, a new hearing aid.

[lliam]

By the second decade, the NHS was beginning to settle down. Treatment was improving as better drugs were introduced. During this decade, the polio vaccine came in, dialysis for chronic renal failure and chemotherapy for certain cancers were developed.

Doctors' pay.
==============
There were, however, problems for both GPs and hospitals despite the development of a measure of trust between the professions and the Government. The Royal Commission on doctor's pay alleviated some of the arguments which had caused problems during the first decade.


Negotiations between the Government and GPs leaders led to a review body award which provided a basis for the development of the modern group practice.

Management.
===========
Better management became a priority. Hospital Activity Analysis was introduced to give clinicians and managers better patient-based information and divisions were created with the aim of grouping medical staff by speciality. Increasingly, though, the structure of the service was being criticised.

Porritt Report.
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In the 1962 Porritt report, the medical profession criticised the separation of the NHS into three parts - hospitals, general practice local health authorities - and called for unification.

Hospital plan.
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While much had already been done to appoint consultants in the major specialities throughout the country, their skills were not matched by the outdated and war-damaged buildings in which they worked. Enoch Powell's Hospital Plan, published in 1962, approved the development of district general hospitals for population areas of about 125,000 and in doing so, laid out a pattern for the future.


The ten year programme put forward was new territory for the NHS and it became clear it had underestimated the cost and time it would take to build new hospitals. But, a start had been made and with the advent of postgraduate education centres, nurses and doctors were given a better future.

Salmon Report.
===============
The Salmon report in 1967, detailed recommendations for developing the senior nursing staff structure and the status of the profession in hospital management. Then, also in 1967, the first report on the organisation of doctors in hospitals (known as the Cogwheel Report) proposed speciality groupings that would arrange clinical and administrative medical work more logically.

The variety of efforts being made at this time to reduce the disadvantages of the three part structure showed the growing acknowledgement of the complexity of the NHS and the importance of change in order to meet future needs.

[BigJon]

How are the limited resources metered and distributed? Who decides, and is there a clearly defined appeal process?

BigJon

[barfle]

I'm pretty much of the opinion that if you want a program to become bloated, inefficient, expensive, and difficult to use, have the Federal Government take it over.

Maybe Brits don't have quite the problem with bureaucrats we do, but I doubt it.

[lliam]

In 1968, clinical and organisational optimism prevailed in the NHS, but the mood progressively receded until, by 1977, various factors had combined to bring the third decade to an unpromising close.

Medical progress.
==================
This said, medical progress continued, with advances including the increasingly wide application of endoscopy and the advent of CAT (Computerised Axial Timography) scanning as the service's investigative armoury was extended.


Transplants.
=============
Transplant surgery was becoming increasingly successful, and genetic engineering slowly began to influence medicine. Intensive care units were now widely available and new drugs appeared, including for example non-steroidal anti-inflammatory treatments.

Kidney dialysis was introduced and surgery established a place in the care of coronary heart disease.

On the downside, new infections, such as Lassa Fever emerged, and changes in abortion law led to new pressures on gynaecological services.

GP's charter.
============
In general practice, the GP's charter was encouraging the formation of primary health care teams, new group practice premises and a rapid increase in the number of health centres.


New hospitals.
==============
As the result of the Government's Hospital Plan, new hospitals were providing more people with a better and more local service. The organisation of hospital nursing services was changed by the Salmon Report and nurse education by Briggs, while the advent of information technology saw the first steps in health service computerisation and clinical budgeting.

From 1968 to 1974 debate continued on the crucial question of how the NHS should best be organised. Key issues included local government reorganisation and the desire to improve the co-ordination of health and social services by matching the boundaries of health and local authorities.

Resources planning.
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What was also needed was a planning system to distribute resources more fairly and to improve management. Two plans fell by the wayside; the third was implemented in 1974, but not until the Government that devised it had been replaced in a General Election.

The new system soon earned criticism as too complex and managerially driven. Within two years, a Royal Commission on the NHS had been appointed to look into the problem areas.

Just as strategic planning, long-range forecasts and reallocation were introduced, inflation reached 26 per cent and wage restraint came in. Industrial action hit the NHS while consultants too were alienated by proposals to reduce private practice within the service.

[lliam]

The decade 1978 - 1987 was characterised by the growing acknowledgement that clear financial bounds existed within which the NHS operated. It simply could no longer do everything that had become medically possible.


The NHS had become a victim of its own success. New technology was being introduced and more people were being treated in more complex ways. This led to both rising expectations of the health service and an increasingly elderly population with all its attendant health needs.

Advances.
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Advances spanned all fields of NHS activity: primary health care was improving, although less so in the inner cities. Genetic engineering was yielding its first drug successes and magnetic resonance imaging was introduced.

On the surgical side, the decade saw the advent of minimal access techniques, while the number of operations for fractured neck of femur and osteoarthritis of the hip was reaching almost epidemic proportions.

Increasing numbers of heart and liver transplants were being performed and surgical treatment for heart disease was becoming more common by the day.

General management.
====================
Beginning in 1978 with what was dubbed by the newspapers as the winter of discontent, the service's financial problems were worsened by the oil crisis.

NHS management tried to improve efficiency and there were attempts to set priorities in 1979, to restructure the NHS again in 1982 and to introduce a tier of general management between 1983 and 1985.

The 1979 change of government brought little immediate change in health service policy, as attempts to equalise the allocation of resources between different parts of the country continued.

Performance indicators.
======================
But as time passed, the tension between increasing demand and finite resources prompted experiments in clinical budgeting and a desire for better health service information. Performance indicators were introduced, and the level of acute hospital services likely to be available in London in the future was examined by the London Health Planning Consortium.

Audit.
=======
Closer examination of what the professionals were doing followed international concern about rising costs. People began to discuss audit of, for example, the results of anaesthesia and surgery.


Community health.
=================
Clinical advances placed increasing demands on nursing and medical staff, and each profession looked at its education and organisation. One option for the NHS was to move care from a hospital to a community setting. Community nursing was examined and the Government established a review of general practice and primary health care.

Yet by 1987 health authorities throughout the country were in debt, waiting lists were growing and hospital wards were being closed - despite evidence of higher spending, steady increases in staff numbers and the treatment of more patients.

Neither the public nor the health care professions were satisfied and the service was increasingly subjected to scrutiny in the media.

[lliam]

Internal market.
==================
The NHS experienced the most significant cultural shift since its inception with the introduction of the so-called internal market, outlined in the 1989 White Paper, Working for Patients, and which passed into law as the NHS and Community Care Act 1990.

The internal market was the Conservative Government's attempt to address problems, such as growing waiting lists, which had arisen in the 1980s as a result of NHS resources being constrained while demand rose inexorably.

Before the 1990 Act a monolithic bureaucracy ran all aspects of the NHS. After the establishment of the internal market, 'purchasers' (health authorities and some family doctors) were given budgets to buy health care from 'providers' (acute hospitals, organisations providing care for the mentally ill, people with learning disabilities and the elderly, and ambulance services).


To become a 'provider' in the internal market, health organisations became NHS trusts, independent organisations with their own managements, competing with each other.

NHS trusts.
===========
The first wave of 57 NHS Trusts came into being in 1991. By 1995, all health care was provided by NHS trusts. Over the same period, many family doctors were also given their own budgets with which to buy health care from NHS trusts in a scheme called GP fund holding. Not all GPs joined this scheme and their budgets were still controlled by health authorities, which bought health care 'in bulk' from NHS trusts.

GP fund holders.
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Patients of GP fund holders were often able to obtain treatment more quickly than patients of non-fund holders. This led to accusations of the NHS operating a two tier system, contrary to the founding principles of the NHS of fair and equal access for all to health care.


The New NHS: Modern, Dependable
Observers credit the internal market with improving cost consciousness in the NHS, but at a price: that the competition it encouraged between 'providers' saw unnecessary duplication of services.

The election of a new Government in May 1997 brought a new approach to the NHS. Pledging itself to abolition of the internal market, the new Government set out an approach which aimed to build on what had worked previously, but discarding what had failed.

A new white paper issued by the Department of Health, "The New NHS. Modern. Dependable.", put forward a "third way" of running the service - based on partnership and driven by performance. The paper set out an approach which promised to "go with the grain" of efforts by NHS staff to overcome obstacles within the internal market, building on the moves which had already taken place in the NHS to move away from outright competition to a more collaborative approach.

Six principles.
===============
The white paper described this approach as "a new model for a new century", based on six key principles:

to renew the NHS as a genuinely national service, offering fair access to consistently high quality, prompt and accessible services right across the country;
but second, to make the delivery of healthcare against these new national standards a matter of local responsibility, with local doctors and nurses in the driving seat in shaping services;
third, to get the NHS to work in partnership, breaking down organisational barriers and forging stronger links with local authorities;
fourth, to drive efficiency through a more rigorous approach to performance, cutting bureaucracy to maximise every pound spent in the NHS for the care of patients;
fifth, to shift the focus onto quality of care so that excellence would be guaranteed to all patients, with quality the driving force for decision-making at every level of the service;
and sixth, to rebuild public confidence in the NHS as a public service, accountable to patients, open to the public and shaped by their views.
As the NHS entered its 50th year, a new era had begun.

[barfle]

OT, when it comes to posts, you're the champ. My puny second place is a pale shadow of your magnificence in that arena. And you probably sing better than I do, too.

But when it comes to posting words, Lliam has you humbled.

[piqaboo]

barfle,
LOL!!!!

[OperaTenor]

Originally posted by barfle:
OT, when it comes to posts, you're the champ. My puny second place is a pale shadow of your magnificence in that arena. And you probably sing better than I do, too.

But when it comes to posting words, Lliam has you humbled.

As many would say on this board, quantity does not infer quality.

As for a singing comparison, may we someday get to find out.

As for Lliam's verbosity, since we have a PostWhore and a ThreadWhore, perhaps we should now confer the title of "WordWhore"?

[barfle]

As for a singing comparison, may we someday get to find out.

Are you sure you want to?

Is this thread properly hijacked yet?

[lliam]

Originally posted by OperaTenor:

Originally posted by barfle:
[b] OT, when it comes to posts, you're the champ. My puny second place is a pale shadow of your magnificence in that arena. And you probably sing better than I do, too.

But when it comes to posting words, Lliam has you humbled.

As many would say on this board, quantity does not infer quality.

As for a singing comparison, may we someday get to find out.

As for Lliam's verbosity, since we have a PostWhore and a ThreadWhore, perhaps we should now confer the title of "WordWhore"?

[/b]

I like it OT.

[OperaTenor]

Oh yeah, I really want to. It'll be fun.

As for getting back OT(on track, that's m' name), as much as I agree that our bloated, festering bureaucracy will waste resources in the administration of a national health system, I feel it would amount to less than the profits made by the insurance companies in our current racke...uh, I mean, system.

The real question remains: Do we, as Americans, feel that equal acess to quality health care is a right, or a priveledge?

[barfle]

Originally posted by OperaTenor:
[b] The real question remains: Do we, as Americans, feel that equal acess to quality health care is a right, or a priveledge?

[/b]

Of course access to quality anything is a privelige. How could it be anything else?

If the government were supplying automobiles to the general public, would we all have a right to a Maserati?

Health care is a funny industry. It's very difficult to let someone die or even suffer because they can't afford health care. But health care is also very expensive. It's difficult and expensive to get an education in medicine, and even then you run the risk of a career ending lawsuit if you make a human mistake. The equipment used in medical procedures is also quite expensive and it's not getting any cheaper.

So why do people feel they deserve this expensive process at no cost to them? I really don't know, except that they feel they can't afford it and they need it, so let the deepest pockets they can find pay for it, with the justification that it's more affordable for a government than it is for a sick person.

But is it honest? I haven't been sick for over 30 years, and even then it was just tonsilitis. So why should I pay the bills of someone who is doing as well as I am financially? For that matter, why should I be forced to pay anyone's medical bills beyond my own family's?

I have made it a point to have adequate means to pay for virtually any concievable scenario, and the inconcievable ones don't leave any responsibilities behind. I donate a reasonable amount to charities to help people who cannot help themselves. I realize I'm fortunate enough to be able to make those choices, but I have almost always worked with people who were equally able to fend for themselves. Why should I be taxed to pay for their bills that they could readily pay on their own?

And is it wise? One well-understood principle of economics is the law of supply and demand. When demand goes up against a constant supply, so do prices. But in this case, the consumer would not be directly affected by the prices. Demand could increase without limit, and the consumer would have no idea of the impact of his or her ongoing feeding at the public trough of free medical care. Divorcing the cost from the consumer is simply foolishness, and having a government middleman in the mix simply serves to isolate the consequences from the actions.

And is it really equal? What level of medical care is proper for a public program to fund? Since I've been an adult, I've had a few medical procedures done to me. I've had a dental implant (at my own expense - the insurance considered it "experimental" but it's the best thing to happen to that tooth since it grew in) and surgery to remove fat deposits from my eyelids that were distorting the lenses. Both of those were voluntary, but both resulted in a considerable improvement in my comfort and well-being. Should anyone besides me have been responsible for the payment, though? How about removing a mole? How about a boob job or liposuction? How about in-vitro fertilization or a abortions? At what point between prosthesis and reconstructive surgery do you draw the line?

[Serenity]

Sometimes, my health care providers (doctor or dentist, etc.) charge more than the "customary charge" the insurance company has figured out they should charge. In my benefits statement there will be a note that the provider has agreed to the lesser charge and I do not get billed for the difference. What's up with that? Is there a big "fluff factor" in the charges to see if you pay up? OT & Piq, just wait for the Overdue bills to roll in 6 months after the delivery for charges not covered by insurance or for items that you thought you already paid (like TV in the delivery room).

[Nicole Marie]

The US health care system is such a scam. I just found out my health insurance is changing. Co-pays are up and everything is changing with it. Example, the plan I'm on now, if I have to go to the ER, my deductable is now between $12,000 to $18,000! Uh, no thanks. Luckly Beethoven is a great company and with co-pays going up to $30 from $10, my company will pay me back $10, so really I'm paying $20. Thanks boss.

But due to the ER issue I now have to switch to a cheaper plan and I mean cheaper by it's less coverage, fewer doctors to pick from and more red tape. sigh

In related news, 6 nursing homes in CT just shut down due to a budget issue with Medicare/Medicaid. They could not cover their operating costs with thier Medicare/Aid patients and had to close down. Our health care system is messed up, we need something else.

Thankfully since I'm married to a guy from Portugal, I am covered by Portugal for health care. They have free health care for all. So (God forbid) if I get really sick, I'm moving. It's sad I'm covered by another country and my own country can't figure out a fair plan for all.

[OperaTenor]

Hmmm, I pay the same sewage and trash bill as my neighbor, and he has seven kids. I don't think I should have to pay the same amount as he, since they obviously utilize the services more than I do(more sewage, higher volume of trash). Perhaps we should be individually responsible for taking care of our trash and sewage....

If you were in need of critical, life-saving surgery and couldn't afford it, would you not feel some sense of entitlement to it? Or would you tell yourself, "That's the breaks, guess it's time to check out."?

There are simple methods to prohibit abuse of a nationalized system and keep it from being a free-for-all(no pun intended) on the user end. Establishment of a system of diving the electivity of treatment would be one of the methods. It would certainly not be perfect(after all, the feds woulds be involved), but I'm also certain it would be a double-digit percentage less costly than our present system to the end user.

The question of whether it's a right or priveledge is really a matter for a majority to decide. We will never see that because monied influence holds sway over our elected officials. The best democracy money can buy.

I've had plenty of personal experience with the scam the providers and insurance companies play regarding billing. Just this side of criminal, IMO.

<small>[ 06-29-2004, 06:25 PM: Message edited by: OperaTenor ]</small>

[Selma in Sandy Eggo]

I have a HMO; THIS IS GAMBLING!

They take my money, and they bet that we will stay healthy enough that they won't have to pay it all out.

I pay my money and if they lose the bet they have to cover my expenses.

The problems (as in OT's case) arise when the HMO (in essence) welshes on the bet.

Our copays are now $10 for a doctor visit, $10 for a generic prescription drug, $20 for a preferred name brand prescription drug, $30 for a non-preferred prescription drug. Copays apply to each refill. Hospitalization copay is $100 per admission. Emergency room copay is $100 per visit, waived if admitted (in which the hospitalization copay is charged). What do you bet that the "copays" actually cover the real, uninflated cost of the services and prescriptions?

All this for (between the premiums I pay and what my employer pays) just under six grand a year! What a deal! I also get to pay Medicare taxes.

I have noted that my HMO's stock value has not suffered from the current "health-care crisis". They seem to be making a profit. Go figure. Why do you suppose that the health care industry is so opposed to universal health coverage?

<small>[ 06-29-2004, 06:36 PM: Message edited by: Selma in San Diego ]</small>