All Commentary
Saturday, May 1, 1971

Why I Left England

Dr. McNeil came from England several years ago to the private practice of medicine in the United States. His article is reprinted by per­mission from the January, 1971 issue of the magazine, Private Practice.

I am often asked why I left Eng­land and the National Health Serv­ice to come to this country. There is no simple answer like “money,” “opportunity,” “politics,” or “cli­mate,” but if I describe the con­ditions under which I found my­self practicing medicine in Eng­land, the reader may find his own answers.

When I qualified as a physician and surgeon, the NHS had been established for five years and there was virtually no private practice of medicine in England. The prac­tice of medicine in wartime did not offer any relevant basis for comparison with the system I found myself involved in; nor did the practice of medicine before 1939 as, in retrospect, that was another era about which the older practitioners were reluctant to talk. (I naturally suspected the old system of private practice wasn’t good.)

My only knowledge of private practice in the U.S.A. was from a small number of patients and friends who had been there and reported that medical care was very expensive and that one had to establish credit at a hospital before being treated or admitted.

It was not until I had been in my own solo practice in Yonkers, New York, for about two years that I realized the tremendous ad­vantages of the private practice system.

As a student I had always been more inclined toward the surgical disciplines, so my first “house job” was as House Surgeon in a London hospital with two surgical wards, 36 male beds, and 36 fe­male beds. There was also a small­er ward of about 10 beds which was used to isolate clean ortho­pedic cases and serve as a spare ward for overflows of one or the other sex. There was rarely an empty bed and I had the unpleas­ant task of turning down at least two out of three requests by GP’s for emergency admissions. Selec­tive surgery cases had their ad­missions arranged through the waiting lists compiled by OPD clinics.

I later learned what it was like to be a GP trying to have a patient admitted for an emergency condi­tion, telephoning five or six dif­ferent hospitals without success, then, in frustration, sending the patient to the emergency depart­ment of a hospital that had al­ready turned down a request for admission, and hoping for the best. In later years, London had what was called the Emergency Bed Service to which a GP could direct his requests for admission and they would call all the hospitals for him, then force the hospital they considered most able to adapt to an extra admission to take the patient. (This system was fine in theory, but in practice it would often take the EBS six to twelve hours to find a bed, and some patients could not wait that long.)

As the only house surgeon for at least 80 surgical patients, in­cluding some in the pediatric ward, I worked very hard but appreci­ated the technical experience which I crammed into six months. Within two months of qualifying, I was performing laparotomies in the middle of the night, relying entirely on my own diagnostic abilities, relying on the house phy­sician or obstetric house surgeon (also newly qualified) to give the anesthetic, and relying on only one scrub nurse for my surgical assist­ance. (Before 5 P.M. I did have an Indian surgical registrar—a senior resident who was an ex­cellent surgical tutor—to guide me, and the two attending sur­geons did “rounds” every other day and a rushed “round” after their operating sessions.)

Clinic vs. G. P.

What humility I had as a “new boy” receded very quickly with the volume of experience, and I soon found myself agreeing with the other house staff that those doc­tors out there in GP land had minimal medical knowledge and no manners. Fancy an experienced GP sending a patient to the Cas­ualty Department with a scribbled note saying, “Please see and treat,” with no history noted or any attempt at diagnosis; and such bad manners, when I had already told him on the telephone that I didn’t have any empty beds and we had seven extra beds up in the corridors and down the middle of the ward!

Assisting the Chief and the Registrar at the surgical clinic also put me in the position of ad­vising GP’s with decades of ex­perience about the diagnosis and management of their patients. The conceit of youth! At the clin­ics, the Chief would see the least number of patients and those most potentially interesting. The Reg­istrar would share the remainder with the house surgeon. From the patients’ point of view, it was pot luck whether they saw a real sur­geon or me.

(Only a few years later, I found myself as a GP referring cases to the clinic and waiting a few months for a letter from a newly qualified pipsqueak house surgeon telling me that the diagnosis had been considered to be “so and so,” “such and such” had been done, and the patient was referred back to me on “such and such” medi­cation.)

I quite naturally came to the opinion that a newly qualified phy­sician was at the peak of medical knowledge and know-how and there­after it was a steady decline in his knowledge and ability. I took com­fort in the excellence of my medi­cal training but was repeatedly surprised at meeting situations I had not been taught about and finding patients didn’t all respond to treatment as they should. Some­thing seemed wrong with the system.

Little Prospect for Advancement as a Surgeon

As previously mentioned, I was surgically inclined and considered I would eventually become a sur­geon. A look at the prospects of surgical colleagues who were five or six years ahead of me in the race made me realize I might as well forget it. I knew many who had spent over five years in the specialty only to quit and go into general practice because the chances of becoming an attending surgeon (known as a Consultant) were so slim. A hospital of over 200 beds would only have one or two surgeons of consultant status and often the same surgeons would cover other hospitals as well. The only vacancies for consultantship occurred when a surgeon died or retired at the age of 65.

The situation in 1956 was that for every vacancy there would be about 70 applications for the post, each applicant having had con­siderable experience in surgery, holding an FRCS and many also having a Masters Degree in Sur­gery. Many of the vacancies would be in localities one wouldn’t rationally choose as a place to live and bring up a family.

(I have heard that the situation has altered over the last few years and the competition for the posts is not as frustrating. This is because so many of the trained surgeons have emigrated. For many years, over 500 doctors were leaving the United Kingdom each year. Last year approximately 400 left.)

After my first surgical job, I became the house physician in the lovely Wiltshire market town of Salisbury near to Stone Henge. I enjoyed the experience and the six days off I received in the six months. One of the doctors in the hospital had just returned from a residency in the U.S.A., and from him I caught a glimmer that there were other ways to practice hos­pital medicine—and combine it with general practice.

However, my roots were in England and in its system, and one year of experience was not enough to say it didn’t suit me. I entered general practice in a working-class suburb of London in close proximity to where I had been the house surgeon. It did not take me long to question the attitudes and infallibility of the hospital-based doctors when I was wearing the GP’s shoes. If I visited my pa­tients who had been admitted to hospital on my old wards, I found I was less than welcome. Other GP’s informed me that I would be considered to be interfering if I did visit them.

To supplement my income and get my foot in the door of a hos­pital, I obtained a post as clinical assistant in the OPD of the Royal National Throat, Nose, and Ear Hospital in London. There, at least, I was able to order some follow-up studies and see some X-rays.

One of my duties in the ENT clinic was to help re-evaluate those children on the waiting list to have their tonsils removed, to see if they should be moved up the list or onto the list with less priority. Some had been on the list six years! (At the time I left, the theoretical waiting time on the day the child’s name went on the list was 10 years. This reckon­ing was with the assumption there would be no modification of pri­orities, no child would leave the area, and no tonsils would recover without surgery.)

Make the Patient Wait

An ex-minister of health, The right honorable J. Enoch Powell, admitted in his book, Medicine and Politics, that the only effective method for putting a brake on the unlimited demand for medical services was making patients wait for services. Many elective surgical procedures such as chole­cystectomy and herniorrhaphy have a waiting list for admission. One to two years is not an un­common time to wait for these procedures. The “novel” method of using “payment for services” —be it only a small price—has been little used as a brake on unlimited demand for services.

Some years ago, when prescrip­tion costs were soaring and the NHS was under a greater financial strain than usual, a token charge of approximately 25 cents was placed on each prescription in­stead of the medication being “free.” During the six months following the initiation of this charge, the number of prescrip­tions decreased by almost 30 per cent. With an election in the of­fing, the government in power at the time interpreted this decrease as meaning that 30 per cent of the patients receiving a prescription from a doctor could not afford 25 cents (the cost of one-third of a packet of cigarettes)! The charge was then discontinued.

Much Hard Work Often Wholly Unnecessary

To return to the subject of my year in general practice, I was already used to working hard and long so the volume of patients seen in the office and on house calls didn’t bother me too much until I realized that at least one-quarter of the patients needn’t have come to see me at all on the occasion on which they did. The patient load fluctuated too closely with the midweek soccer games being played at home and with the pre-holiday seasons.

Certificates for sickness absence (after the fact) were always tricky and frequent. If I hinted that I suspected some hanky-panky, the patient usually stuck to the story that he had come to my office but there were too many patients waiting and he felt too sick to sit there and wait. I usu­ally handled the situation by giv­ing the patient the certificate and saying, “Of course, I’m sure YOU were sick but some people use my certificates improperly and they may get me into lots of trouble.”

Not having any X-ray facilities in the office, less than meager lab equipment, and little or no time for work-up tests, any patient seen who needed those tests had to be referred to the hospital clin­ics. A very few simple tests could be referred directly to the hospital lab (mainly those concerned with the diagnosis and treatment of TB) but anything approaching a blood chemistry, an EKG, or an X-ray could not be ordered by the GP directly, so the patient had to be referred to the appropriate clinic for those doctors running the clinic to decide on the tests and order them.

The result of this angle of the system, plus the difficulty of ob­taining a hospital bed for acute conditions such as myocardial in­farction, pneumonia, and stroke (especially stroke), meant that a GP treated many of these condi­tions in the patient’s home with­out any of the ancilliary diagnos­tic aids which would be routine in a hospital. I recognized the satis­faction of “curing” a condition with minimal help of diagnostic equipment and lab tests but there was always that sneaking suspi­cion at the back of my mind that the patient may not have had the condition I thought I had cured. Without this confirming knowl­edge, there was no testing of one’s diagnostic and therapeutic ability and so improving one’s effective­ness as a physician. With my pres­ent knowledge of cardiac ar­rhythmias which can be prevented or ameliorated by information only to be gained from ancilliary equipment, I shudder at the risks the patients ran under my care.

Toward the end of my year in general practice it became clear to me that if I remained a GP under the NHS, I would be practicing medicine at an unsatis­factory level both from the point of view of my own lack of oppor­tunities to improve my abilities, and from the point of view of my patients, as there seemed few ways of improving the quality of medi­cal care being given. The urge to see the practice of medicine on the other side of the Atlantic in­creased so that when the sub-dean of my medical school asked me if I would be interested in a surgical residency in New York, I was on the boat in less than a month.

A Second Look

After a year in New York which opened my eyes to the tremendous opportunities here and the ad­vantages of private practice, I returned to England for a time to clear up personal matters and to see if I had been mistaken about the NHS. I spent a year as Cas­ualty Surgeon in a North Devon hospital in a charming small town from which part of the English fleet sailed to meet the Spanish Armada. My pay ($45 a week) was three times as much as when I was a house surgeon and I was given a nicely furnished apart­ment, but the bureaucratic administration of the hospital was irksome and wasteful.

The GP’s in the area had de­cided advantages over those in the metropolis and other big cities, insofar as they held appointments as surgeons, internists, and anes­thetists on the hospital staff. How­ever, as these men retired or died, their posts were filled with full-time specialists so the future as regards becoming an attending surgeon or a GP with hospital privileges was the same as else­where in the country.

Although the hospital was small (less than 200 beds) there was a veritable army of administrative assistants. Before nationalization, there had been a maintenance employee who looked after the heating system, lighting, and me­chanical appliances, with occasion­al help from outside private firms. At the time I was there, they had a chief plumber, electrician, heat­ing engineer, and other special­ists, all under a chief maintenance officer, all complete with offices, desks, and secretaries, and in­ventory clerk. The hospital sec­retary also had a secretary. A few miles away was the governing hos­pital of the area, with a large administrative staff to pass on or­ders to the hospitals in the group; and, of course, they were passing on orders from the Ministry of Health in London.

The town badly needed a new hospital with a modern building, and the chance of one being built was nil. Since the inception of the NHS in 1948, only three new hospitals have been completed in the whole country. I would be sur­prised if there were any counties in the U.S.A. that have not had at least one new hospital since 1948. Within two years of returning to this country, I was in private practice and on the staff of three hospitals, and enjoying the im­mense amount of post-graduate education available in those hos­pitals. My office was equipped in a manner that would have been only a dream in England. The advantages of having a lab, X-ray equipment, physiotherapy equip­ment, an EKG machine, and an examining table that was designed to allow proper posturing of the patient, were great luxuries to me. They allowed me to offer serv­ices to my patients that to obtain under the NHS, they would have had to shuffle from clinic to clinic and hospital to hospital, hardly ever knowing who the doctor was who examined them.

I have been here permanently for 13 years now and I often won­der what sort of a physician I would be now if I had remained in England. A few years ago, my old medical school sent a list of all the old students. Reading down the list and noting their present addresses, I counted that more than half of those that graduated in my class had left England or the practice of medicine. Others must have thought as I did.