The real reason why the National Health Service survives

When Aneurin Bevan was asked how he convinced doctors to come on board the National Health Service (NHS) he allegedly replied, “I stuffed their mouths full of gold.” Bevan recognized that to conscript doctors to the largest socialist experiment in health care in the world he had to appeal not so much to their morals, but their pockets.

There is much piety about the NHS. It is the envy of the world, though oddly Saudi oil barons still favor Cleveland Clinic and Texas Heart Institute over quaint little hospitals in rural Scotland. The NHS featured in Britain’s 2012 Olympic parade along with Mr. Bean and the human right activist Shami Chakrabarti — only one of them was there for parody. Brits aren’t ones to posture self-righteously, except when it is about the NHS when the violins come out full mast, and we’re treated to a spectacular display of sanctimony and disingenuity. The NHS is a religion which keeps its prophets happy.

Bevan, an arch-socialist Labour to the bone and founder of the NHS, was no social justice warrior. He recognized that berating doctors into doing the right thing wasn’t going to work, selling them a utopian paradise wouldn’t work either. Remember, this was post-WWII Britain when socialism was in fashion, and sympathies towards the communist Soviet Union was an intellectual fad. Selling the concept of the NHS should have been a cakewalk — most of all to doctors. But Bevan was a pragmatist, not sentimentalist. He knew that he needed more than ethos, logos, and pathos.

In a stroke of genius, Bevan allowed doctors to see private patients in NHS hospitals, a small quirk with considerable consequences. In essence, Bevan legitimized a two-tier system, in which the rich could jump queues, and doctors could serve the rich and the poor, though the rich a little faster and with a more personal touch. The NHS is living embodiment of George Orwell’s famous quip, “Everybody is equal, but some are more equal than others.”

If the NHS isn’t the envy of the world, it should be the intrigue of the world. Its survival wasn’t probabilistic. There are two reasons why the NHS hasn’t imploded — foreign-trained doctors and private medicine. The contribution of the private sector to the longevity of the NHS isn’t immediately apparent. Both tiers support each other. The parallel private track allows doctors in Britain to earn more than their NHS salaries with only a little extra effort. Private insurance in Britain compensates handsomely.

The fact that doctors could multiply their income, through the private sector while working in the NHS arguably reduced the incentive for doctors to form private conglomerates and desert the NHS. To put it more clearly — the private track kept doctors working for the NHS. I know this sounds paradoxical, and I’ll try to explain more.

Further, the private sector allowed the NHS to compensate all doctors the same — e.g., pay the neurosurgeon the same as the psychiatrist. This didn’t bother neurosurgeons because they knew that in the private sector, they’d make up for the egalitarianism. I’m not saying that neurosurgeons deliver more value to society than psychiatrists. But neurosurgery training is more exacting than psychiatry. A system which pays neurosurgeons the same as psychiatrists will have fewer medical students who want to become neurosurgeons than a system which pays neurosurgeons more than psychiatrist. You don’t have to be a health economist to figure this out.

The training in the NHS for hospital doctors, by that I mean those not in general practice and particularly for surgeons, was always long and unpredictable. It wasn’t uncommon for physicians to spend 15 years after medical school before they became a hospital consultant (attending), some spending the last few years as a locum consultant, a pseudo-consultant who has the responsibilities of a consultant but not their share of the private pie. What kept them going wasn’t just that they had no choice, but that there was light at the end of the tunnel — a pot of silver.

Once the private practice picked up, and it often did, doctors multiplied their NHS salaries often by several integers. And they finally bought that four-bedroom detached house in a nice suburb which they’d been eyeing, sent their kids to private (oddly called “public”) schools and holidayed in Algarve and Goa. Given what doctors went through in their training, they never asked for much — just a slight separation from the masses, in both their indulgences and expression of tastes.

A close friend, an NHS orthopedic surgeon, spent a year in Boston in a fellowship. He was seriously considering staying in the U.S. and was on the verge of signing on the dotted line for a faculty position in venerated Boston when a post in a London teaching hospital opened. Choosing between Boston and London was a no-brainer. Raj returned to the U.K. and now has a private practice so successful that wait times to see him privately are longer than NHS wait times for some elective procedures. Last year, his private income exceeded his NHS income by a factor of eight. Yes, he’s minting it, making more than he would ever have made in Boston.

Not only is Raj minting it, he’s minting it knowing that, thanks to the taxpayer, the poor and disenfranchised receive his services for their emergencies free at the point of care. Bevan allowed doctors to be a sort of Robin Hood — who took copiously from the rich so that they could serve the poor.

Private insurance in Britain, held by less than 15 percent of the population, expedites elective care but doesn’t hasten emergency care, which is reasonably rapid in the NHS. This is redistribution with clinical acumen.

I asked Raj what he wanted to do when he grew up. May be run a hospital. Or an insurance company. His reply was curt, “I want to keep drilling.” At a time when many doctors are drawn to administrative and leadership positions, physicians in the NHS with successful private practices aspire to nothing more in their future except medicine and even more medicine.

Raj loves orthopedics, partly because he’s good at it, partly because he’s autonomous and spared interference from mediocre busy-for-nothing bodies, and partly because he’s minting it. He works incredibly hard, is technically competent and does a good job, and has a gift of the gab. He wants to be rewarded. Piety would have lasted four hours with Raj. Money pushes him to eighty hours per week.

The NHS is important for private practice just as private practice is important for the NHS. His NHS patients tell their GPs, “Raj — what a charming surgeon. He fixed my hips.” Raj’s private referrals come from GPs impressed by his work, his succinct summary letters and how quickly he sees their patients. It is a perfect symbiosis. Reputations which lead to private work are derived from quality work done in the NHS. Of course, this is not the only source for private referrals, and some referrals come from shared experiences on golf courses, and memories of the fields of Eton and Harrow. The point is that many paths to private riches run through the NHS. This architectural marvel was Bevan’s genius.

Since the inception of the NHS, the government has tried to limit private practice. When I was a junior doctor in surgery, the government’s limitation on private practice was supported by the president of the Royal College of Surgeons Barry Jackson who suggested that surgeons not see private patients for the first phase of their careers, and see private patients only after seven years of becoming a consultant. Sir Jackson — who was the Queen’s surgeon and was a knight — had a booming private practice of his own. Jackson’s motivations were unclear, though many believed he wanted to keep the nugget, the colloquial term for private practice, for the older codgers.

This created an uproar amongst trainee surgeons, one of whom, Tom, a talented chap aspiring to become a plastic surgeon, a lad who modeled himself on Peter Benton, the surgeon from the TV series “ER,” left surgery and joined a consulting group. I still remember his pithy words when he resolved to leave: “F*ck this bullshit.”

The path to becoming a plastic surgeon was long, though not uniquely long. Typically then in Britain, you entered medical school at 18 and after six years got the MBBS degree, followed by a year of house jobs and three years of basic surgical training. Then, most people went off and did a stint of research for two or three years, not because of intellectual curiosity but to pad their CVs. Everyone else was padding their CV with publications, because there was a bottleneck in competitive specialties. And what started off as a way to distinguish yourself from others, became a default requirement for specialties such as cardiology, urology and plastic surgery.

After research, you’d apply for higher training — which typically took six years, at the end of which you’d become a consultant in a specialty, such as urology or plastic surgery — meaning at 37 if all went well. Many, like me at 29, with ten years of education and training behind us, were still uncertain what we’d be when we grew up. If Jackson’s rule passed, Tom would be 44 before he was allowed a dip in the nugget. That he’d be on a miserable trainee’s salary till he was 37 was acceptable, because he knew that at 38 his salary would increase considerably. But Jackson’s proposal meant that Tom had to defer that four-bedroom house in the outskirts of London till he was 44. This was the last straw on Tom’s morale.

Several people I knew left surgery at the end of basic surgical training and became GPs, in large part because of the impending moratorium on private practice, though few would admit that was their reason. British GPs don’t earn as much as consultant plastic surgeons, once you factor in the private income of the surgeon, but they’re more settled by 30, making considerably more than junior doctors in hospitals who still take the brutal hospital call, some well into their forties.

I recall meeting an old medical school friend for a drink. He was a gastroenterology registrar, only three years from becoming a consultant gastroenterologist with access to the endoscopic nugget. He had a particularly brutal night on general medical call and seemed unusually miserable. To raise his morale, I asked, with unsubtle admiration, what kept him going. He replied, with characteristic self-deprecation, “I’m a mug.” Shortly afterward, he left gastroenterology and became a GP. He has never stopped being happy since. Not everyone braved it out for the nugget.

Tom is now making more money than he ever would have as a plastic surgeon, but he still misses surgery. Good riddance, you might say. We got rid of a doctor who was motivated by money, not patients. And many hold this hopelessly naïve ideal, that physicians should not be influenced by money, whatsoever, in their professional choices. Some even contend that if physicians are underpaid, the profession will be enriched by the nobility and by knight-errant physicians.

That money is the only thing which matters for physicians is patently absurd, and a tad offensive. But to believe that money doesn’t matter at all is disingenuous and naïve. The truth is that some minimum matters, and though everyone’s floor is slightly different, it is not wildly different. Tom did not want a seven-figure salary, but could not abide a salary which was barely touching six figures, particularly after all the years he had sacrificed. He did not want to fly first class, but was tired of looking for the cheapest vacation package deal. He worked neither despite the money nor because of it.

Not all hospital specialists have opportunities for private practice, and the ones which don’t, yet which exact long training, predictably, face a shortage of physicians. Intensive care is a notable example. There’s an emerging shortage of intensivists in Britain in general, and London, in particular, and London because the house prices are off the roof. It’s not good for patients if a city prices consultant intensivists out of the housing market. Many intensive care trainees are looking to the antipodes, where the salary is higher, weather better, and there are fewer clipboard-carrying bureaucrats. Aussies have an excellent work ethic, and when they’re not working, many are surfing or diving, leaving little time for whining.

Moses pleaded with the Pharaoh to raise the living conditions of the workers if he wanted more work to be done in the scorching Egyptian heat. The solution to the shortage of intensivists in the NHS is simple and obvious and carries the risk of actually working — which is to double the consultant salaries. This is not an unusual strategy and raising wages even when supply exceeded demand was a strategy used by Percival Perry, and later by his employer, Henry Ford, to attract and retain loyal workers. It is well recognized in the private sector that to keep workers happy and productive you need to raise their wages, not threaten them with outsourcing or artificial intelligence — a concept known as “efficiency wages.” Those who believe that flooding the market with doctors, so that the dog-eat-dog competition lowers their wages and raises their quality, a win-win, classic economics teaching, are deluded. Supply side economics doesn’t work in medicine.

The tussle between the government and doctors in the NHS is often about money. The government wants to pay doctors as little as possible but wants doctors to work as hard as they can. The government wants from doctors the highest bang for the buck — i.e., efficiency. Efficiency was made health policy by the market-driven Baroness Thatcher who, allegedly, after reading Hayek’s “Road to Serfdom,” had a bright idea — internal competition. It was never clear what exactly the doctors were competing for, and why they’d run faster than others on the hamster wheel. Thatcher once said that the South African government needed both carrots and sticks to encourage them to abolish Apartheid. With doctors, Thatcher, and her clones were all stick, no carrot. Naturally, the doctors showed her and her clones the middle finger.

A few years ago, the Tories proposed a reduction in pensions, still generous by public sector standards, for doctors. Unsurprisingly, this wasn’t terribly well received by doctors. In the Lancet, several doctors voiced concerns about the reduction in pensions. The specific concern was that the reduced pension was a small step to the privatization of the NHS. You may think that this self-serving logic is stretching irony a bit, even by British standards. But the truth is even more ironic. The government yearns for privatization of the NHS precisely because they believe that only corporations can bring doctors down a notch. The government’s efforts to de-professionalize doctors is fiscal at its root, fiscal in its intent, a means to thrift, with thrift being the end. To put it rather bluntly — it’s about money.

British doctors, even those who don’t double dip in the two-tiered system which gives them a decent wage without the moral turpitudes of the market, know they have it good with the NHS. Money isn’t unimportant for doctors, even in the socialist NHS. This was Bevan’s intuition. This was Bevan’s genius, which Sir Barry Jackson — whose proposed moratorium on private practice was mercifully never enforced — singularly missed.

Saurabh Jha is a radiologist and can be reached on Twitter @RogueRad.  This article originally appeared in the Health Care Blog.

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