The National Health Service. Ever since 1945 the state has recognised it has a fundamental responsibility to en­sure that nobody should be without the basic necessities of life as a

Ever since 1945 the state has recognised it has a fundamental responsibility to en­sure that nobody should be without the basic necessities of life as a result of poverty, unemployment, old age or sickness. In or­der to fulfil this responsibility the state cre­ated health and welfare services which have been the core of the welfare state. The sys­tem has grown over the years, funded mainly by tax, but also through National Insur­ance contributions, compulsory payments made by all earners and their employers. These contributions guarantee a small pen­sion on retirement (normally at the age of sixty-five for men, sixty for women), a pe­riod of income support after becoming un­employed, and a pension if unable to work because of sickness.

The National Health Service (NHS) was established in 1948 to provide free medical treatment both in hospital and outside. Its fundamental principle from the beginning was the idea of equitable access for all, re­gardless of wealth.

Broadly speaking the system rests on in­dividual registration with a family doctor, known as a general practitioner, or GP. Today most GPs operate within a group practice of three or four GPs. People may register with any GP they choose, as long as the GP is willing to register them. A GP with a full register might refuse extra pa­tients. Beyond the grouppractice lies the whole arrangement of hospitals and com­munity health services, for example health visitors who monitor the health of vulnera­ble categories of people, such as those with newborn babies, or the old and infirm.

Except in the case of an emergency, it is normally the GP who refers a patient to hospital for more specialist care or for an operation. It is also usually the GP who alerts the health visitor to the need to keep a closer eye on a particular patient. On av­erage each GP has about 2 000 people on his or her register. Many or those on the register will hardly ever visit the GP. Oth­ers, the old, the very young, the infirm and the depressed, may be regular callers at the doctors surgery. On a normal day a GP might see about 35 patients in surgery, and make perhaps up to ten home visits to those who feel too ill to attend surgery. The strength of the system lies in a good work­ing knowledge of the families and individu­als in the catchment area, their housing, lifestyle and employment conditions. Good GPs build up an intimate knowledge of their 'parish', and take into account not merely the specific complaint of a patient but also the patient's general conditions of life.

The NHS is the responsibility of the Sec­retary of State for Health. England is di­vided into 14 Regional Health Authorities, usually based upon a university medical school. Each regional authority is subdi­vided into between 10 and 15 districts, each based on a large hospital, but also covering other hospitals.

The entire system is free, with the exception of prescribed drugs, dental treatment and spectacles, for which there are standard charges, except for old age pensioners and children under 16 and some other categories for whom some of these items are free. Anyone entering hospital for surgery will receive all their treatment while in hospital, including drugs, free of charge. Over 80 per cent of the costs of the NHS are funded out of the income tax system. The balance is paid for out of National Insurance contributions and from the prescription charges mentioned above.

On the whole the system has worked extremely well. It has been the envy of many countries with less satisfactory systems. Foreign health economists tend to admire the NHS for its family doctor system; its tight cost control; its treatment for all, re­gardless of the ability to pay; a tax-based funding relating the service to income rather than to need; finally, they admire ifs rela­tive efficiency — a characteristic that would probably surprise the patients in most Brit­ish hospital waiting rooms. Such foreign experts also criticise the lack of consumer choice, and believe that British doctors should delegate more tasks to nurses, and nurses more tasks to orderlies.

The cost of providing the service has al­ways been enormous. By the late 1980s, the health budget reached one fifth of all pub­lic spending.

It was clear that these services were becoming increasingly costly and bureau­cratic. The government decided to under­take major reforms, to use less money and to use it with more discrimination. Re­forming the welfare system, however, has proved more complex than expected. The system still suffers from serious problems, and some critics would argue that new problems have arisen from the attempts at reform.