The case of Britain

Abstract

What factors influence the determination of physician manpower policy in Britain? To address this question there will be no detailed description of the methods of forecasting physician manpower, the alternative projections that have been made by the Department of Health, the resource assumptions behind the forecasts in the period 19651985 and beyond, the relative earnings of physicians, or a comprehensive review of the defects of forecasting practice. All this material can be found elsewhere [3] copies of which are available from the authors and the arguments are all too familiar (e.g., Refs. 17-20), even though they have not been translated into changes in policy [7,8]. The reasons why policy formation continues to be based on inadequate analysis of the market for physician manpower are related to the power of the profession. Why is it that in Britain the profession’s numbers have been forecast irregularly (e.g., 1944,1957,1968,1978 and 1988) but usually in isolation from the supply and demand for other health care manpower, with little regard to resource constraints, and in ignorance of substitution trends and their cost-effectiveness? The health service in Britain is largely publicly financed (E28 billion), with only a small specialised elective (acute) sector (f 1000 million). The bulk of the finance of the NHS is derived from general taxation (85%), with ‘ear-marked’ national (social) insurance meeting only 11.8% and user charges contributing 3.2% of the total cost. Health care in the NHS is provided in State owned hospitals and the private cold (acute) sector owns only 10000 beds. Given this buying power the managers of the NHS could, but have not, driven down the costs of health care and, in particular, the relative and absolute earnings of doctors. With the average hospital consultant making decisions to treat which result in resource costs of over f 700 000 per year and with GPs spending on average in excess of f55 000 on pharmaceuticals alone, doctors are the gatekeepers to the British health care system, the main determinants of expenditure, and subject to little appraisal.