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What Price the N.H.S.?
201
and nearly half the personal-socialservice costs, is increasing rapidly. The definition of elderly is those aged over 65 years. Were data available for people over 75 they would be even more impressive, because the changes between dependence and independence in the decade of age from 68 to 77 are probably as great, albeit in the opposite direction, as those in the decade 8 to 17. The reorganised N.H.S., with its mechanisms for increased decentralisation of policy-making, planning, and expenditure, will have to grapple with this and the other problems. A key could be the effective consummation of integration, a procedure which is in the hands of the teams of clinical doctors, community physicians, nurses, administrators, and treasurers-teams which have the authority and responsibility to plan and direct the use of funds in the way that seems best suited to the needs of the local community whose care is in their charge. But integration is a problem with which they must grapple at a time when economic growth has been reversed. At first sight the economic stringencies which they must face may seem a disaster, and indeed no Government could have contemplated the preplanned reduction of funds available for the completion of so complex an operation. Yet integration must mean the rationalisation and consolidation of existing services. There could be no greater stimulus to achieve this, and to achieve it quickly, than that of limited funds. The Centre for Social Studies report points out that the largest single component of the health budget, and the one which is least susceptible to change, is the cost of manpower. It is here too that the demands for increase are greatest, not only for higher salaries, but for more personnel. It is therefore here that a searching examination of just whom we need to run the service might reap the greatest rewards. What specialties are strictly necessary-at professional and subprofessional levels? What exactly should a specialist or a general practitioner do ? (As we have already indicated, the past is no sure indicator of what should be done in the future.) What training should each have ? Training of itself is an expensive item, and it tends to have little bearing on future needs of the trainees.! SPITZER and his colleagues5 in Canada, where professional tradition is as strong as ours, have produced good evidence that delegation of the doctor’s daily tasks is by no means as unthinkable as it formerly was. This matter has been explored, too, in The Lancet’s Medical Alliance series. Financial problems are not limited to the finding of more money for the N.H.S., nor, on the basis of national strategy, to devising more efficient methods of spending the money we have. All the evidence suggests that present levels of expenditure are not only
hospital
What Price the N.H.S.? IT is not many decades since doctors’ were almost
impotent to alter the course of disease. With that impotence grew the belief that no expense was too great to save human life. But as the effectiveness of medical practice has developed, so have its costs, and, willy-nilly, prices are being set on life itself. In the United States, where the patient or his family have been held personally responsible for finding the means to pay for medical care, the situation emerges starkly when, for example, young people have to forgo university education so that the life of a parent dying of cancer may be prolonged. In other parts of the world such as Britain, where society has, by the use of public funds, footed the bill, the implications of untrammelled spending by doctors have been less obvious. Indeed,as SCOTThas pointed out, most doctors are themselves unaware of the nature of the financial crisis which has arisen. Thus we face the paradox that, as medicine became more effective, it began to price itself out of the reach of the individual. Now the question arises, what should an economically developed society such as that of Britain, Canada, or the United States be prepared to pay for health services ? Were this not enough, ILLICH2 has outlined a third dimension of the problem. He argues that doctors, blinded by the short-term outcome of techniques at their disposal, burden society with a load of chronic illnesses which brings misery to the sick and healthy alike. Doctors now have the power to lavish on their patients resources larger than those which anyone could call his own-powers which lead whole populations to survive on low levels of personal health ". A thorough and informative analysis of public spending has been published by RUDOLFKLEIN and three colleagues3 from the Centre for Studies in Social Policy. Their essay was stimulated by the cuts in public spending initiated "
in his emergency budget in December, 1973, and is based largely on the official five-year projections made by the Treasury in 1973.4 KLEIN points out that, because the British population is still increasing, given a fixed demand, the funds for health mu’t also be increased if service is to continue to be offered at the existing level. He emphasises that even :hh is not enough because the proportion of elderly who already account for over a third of
by Air BARBER
1. Scott, J. S. J. Irish med. Ass. 1974, 10, 285. 2. illich, I Lancet, 1974, i, 918. 3. Social Policy and Public Expenditure 1974.
By RUDOLF KLEIN, Jack Barnes, Martin Buxton, and Edward Craven. Centre for Studies in Social Policy (62 Doughty Street, London WC1N 2LS). £1 50. 4. Public Expenditure to 1977-1978. H.M. Stationery Office, 1973.
costs
with
5.
Spitzer, W. O., Kergin, Spitzer, W. O., et al. Lancet, 1974, i, 608.
D. J. Can. med. Ass. J. 1973, 108, 991; New Engl. J. Med. 1974, 290, 251. See
202
but also inequitable. Although, in general, consultation-rates tend to be highest per head among the poorer sections of British society,6 TOWNSEND7 believes this is probably not the case if usage is expressed in terms of the need for medical care. Certainly between the 14 regions the amount spent in 1971-72 on family-practitioner and local-authority services has been shown to bear no relation to the proportion of the population aged 65 and over, nor to the infant-mortality rate, both of which are unquestionably measures of need.8 We must therefore also face the problem of maldistribution of the funds which are already at the disposal of the N.H.S. The argument for redistribution must surely now come from parts of the country which are receiving fewer funds. The new Health Service has, in addition to its multidisciplinary professional teams, another powerful method for helping the people of the country and their doctors to come to terms with local inequalities as well as the more profound conundrums of the economics of life and death. The establishment of the area health authority (A.H.A.), a statutory panel at county and borough level, together with the less formal community health council (c.H.c.) at district level, offers to the citizen, for the first time, an opportunity to shape the clay on the potter’s wheel. Members of the administrative teams, and of the medical profession in general, tend to look upon the c.H.c.s as rods for their backs devised by a series of unsympathetic Governments, and others see them as a battering-ram to breach the walls of medical professionalism.99 Yet the multi-disciplinary district management team (D.M.T.), which in most parts of the country is coming to grips with its work with a will, is pari passu starting to put the role of the doctor on a new footing. In many districts consultant, family doctor, and community physician are working constructively with each other and with their other colleagues on the team. It would be a small step for the D.M.T. to take the initiative and open discussion with the c.H.c. The D.M.T. could seek the views of the consumer about where the money should go, having first considered and presented with the help of the community physician 10 the possible benefits which might accrue from various forms of expenditure. Existing statistics can be used to estimate financial need at the local level 8; and, where the quality of services is low, c.H.c.s could have a powerful voice. National spending on health services has varied little with successive Governments, which have struck a crude balance between public demand and financial exigency. In the coming economic troubles, the fate of the National Health Service may depend on the vocal vigilance of community health councils everywhere.
Renal-artery Stenosis and Renal Failure
unequal
6. General Household Survey, Introductory Report. H.M. Office, 1973. 7. Townsend, P. Lancet, 1974, i, 1179. 8. Noyce, J., Snaith, A. H., Trickey, A. J. ibid. p. 554. 9. Hardie, M. C. Long Range Planning, 1974, 7, 2. 10. Lancet, 1974, ii, 30.
Stationery
EXPERIMENTAL renal-artery constriction in animals, well as causing hypertension, can result in fibrinoid necrosis (the vascular lesion of malignant hypertension) with a distribution similar to that in hypertensive man. An important finding in animals is, however, that the kidney with the constricted artery is spared. 1,2In the rat with a unilateral renal-artery clip and both kidneys remaining in situ, fibrinoid necrosis was found in the untouched kidney, but it was absent, or much less severe, in the kidney distal to the stenosis.3,4 These observations suggested that hypertension per se might be responsible for the intra renal vascular lesions, while the clipped kidney, not being exposed to high arterial pressures, was spared.5 Renal biopsies in patients with unilateral renal-artery stenosis confirmed a considerably greater incidence of intrarenal vascular lesions in the contralateral exposed kidney than in the kidney distal to the stenosis.6 WILSON and BYROM 4 had earlier developed the concept that the histological abnormalities induced in the untouched kidney might be responsible for perpetuating hypertension when a unilateral clip was removed, and this notion was further elaborated by FLOYER.7 STAMEY8 extended these ideas into the clinical sphere, showing that, in patients with unilateral renal-artery stenosis, corrective arterial surgery was likely to give a poor result if the non-stenotic kidney had distinctly reduced renal plasma-flow, since such reduction presumably indicated irreversible hypertensive vascular damage. as
,
Three patients have been described in whom surgical correction of unilateral renal-artery stenosis was alone insufficient to relieve hypertension, and in whom subsequent excision of the contralateral kidney, which in all three showed extensive arteriolar lesions, was performed. In the first two instances,9,lo blood-pressure remained raised after relief of the stenosis, and divided studies showed gross functional impairment on the contralateral side. Hypertension was relieved after removal of the damaged contralateral kidney. The relationship was less clear in the third case,l1 since the contralateral kidney was thought to have sustained such obvious hypertensive vascular damage that it was excised during the repair operation. In this instance also, the hypertension was relieved. Two reports in these pages have underlined 1. Goldblatt, H.J. exp. med. 1938, 67, 809. 2. Wilson, C., Pickering G. W. Clin. Sci. 1938, 3, 809. 3. Wilson, C., Byrom, F. B. Lancet, 1939, i, 136. 4. Wilson, C., Byrom, F. B. Q. Jl Med. 1941, 10, 65. 5. Pickering, G. W. High Blood Pressure; p. 148. London, 1968. 6. Brown, J. J., Owen, K., Peart, W. S., Robertson, J. I. S., Sutton, D. Br. med. J. 1960, ii, 327. 7. Floyer, M. A. Clin. Sci. 1951, 10, 405. 8. Stamey, T. A. in Antihypertensive Therapy (edited by F. Gross); p. 555. Berlin, 1966. 9. Thal, A. P., Grage, T. B., Vernier, R. L. Circulation, 1963, 27, 36. 10. Miller, H. C., Phillips, C. E. Surgery Gynec. Obstet. 1968, 127, 1274. 11. McAllister, R. G., Michelakis, A. M., Oates, J. A., Foster, J. M. J. Am. med. Ass. 1972, 221, 865.
and nearly half the personal-socialservice costs, is increasing rapidly. The definition of elderly is those aged over 65 years. Were data available for people over 75 they would be even more impressive, because the changes between dependence and independence in the decade of age from 68 to 77 are probably as great, albeit in the opposite direction, as those in the decade 8 to 17. The reorganised N.H.S., with its mechanisms for increased decentralisation of policy-making, planning, and expenditure, will have to grapple with this and the other problems. A key could be the effective consummation of integration, a procedure which is in the hands of the teams of clinical doctors, community physicians, nurses, administrators, and treasurers-teams which have the authority and responsibility to plan and direct the use of funds in the way that seems best suited to the needs of the local community whose care is in their charge. But integration is a problem with which they must grapple at a time when economic growth has been reversed. At first sight the economic stringencies which they must face may seem a disaster, and indeed no Government could have contemplated the preplanned reduction of funds available for the completion of so complex an operation. Yet integration must mean the rationalisation and consolidation of existing services. There could be no greater stimulus to achieve this, and to achieve it quickly, than that of limited funds. The Centre for Social Studies report points out that the largest single component of the health budget, and the one which is least susceptible to change, is the cost of manpower. It is here too that the demands for increase are greatest, not only for higher salaries, but for more personnel. It is therefore here that a searching examination of just whom we need to run the service might reap the greatest rewards. What specialties are strictly necessary-at professional and subprofessional levels? What exactly should a specialist or a general practitioner do ? (As we have already indicated, the past is no sure indicator of what should be done in the future.) What training should each have ? Training of itself is an expensive item, and it tends to have little bearing on future needs of the trainees.! SPITZER and his colleagues5 in Canada, where professional tradition is as strong as ours, have produced good evidence that delegation of the doctor’s daily tasks is by no means as unthinkable as it formerly was. This matter has been explored, too, in The Lancet’s Medical Alliance series. Financial problems are not limited to the finding of more money for the N.H.S., nor, on the basis of national strategy, to devising more efficient methods of spending the money we have. All the evidence suggests that present levels of expenditure are not only
hospital
What Price the N.H.S.? IT is not many decades since doctors’ were almost
impotent to alter the course of disease. With that impotence grew the belief that no expense was too great to save human life. But as the effectiveness of medical practice has developed, so have its costs, and, willy-nilly, prices are being set on life itself. In the United States, where the patient or his family have been held personally responsible for finding the means to pay for medical care, the situation emerges starkly when, for example, young people have to forgo university education so that the life of a parent dying of cancer may be prolonged. In other parts of the world such as Britain, where society has, by the use of public funds, footed the bill, the implications of untrammelled spending by doctors have been less obvious. Indeed,as SCOTThas pointed out, most doctors are themselves unaware of the nature of the financial crisis which has arisen. Thus we face the paradox that, as medicine became more effective, it began to price itself out of the reach of the individual. Now the question arises, what should an economically developed society such as that of Britain, Canada, or the United States be prepared to pay for health services ? Were this not enough, ILLICH2 has outlined a third dimension of the problem. He argues that doctors, blinded by the short-term outcome of techniques at their disposal, burden society with a load of chronic illnesses which brings misery to the sick and healthy alike. Doctors now have the power to lavish on their patients resources larger than those which anyone could call his own-powers which lead whole populations to survive on low levels of personal health ". A thorough and informative analysis of public spending has been published by RUDOLFKLEIN and three colleagues3 from the Centre for Studies in Social Policy. Their essay was stimulated by the cuts in public spending initiated "
in his emergency budget in December, 1973, and is based largely on the official five-year projections made by the Treasury in 1973.4 KLEIN points out that, because the British population is still increasing, given a fixed demand, the funds for health mu’t also be increased if service is to continue to be offered at the existing level. He emphasises that even :hh is not enough because the proportion of elderly who already account for over a third of
by Air BARBER
1. Scott, J. S. J. Irish med. Ass. 1974, 10, 285. 2. illich, I Lancet, 1974, i, 918. 3. Social Policy and Public Expenditure 1974.
By RUDOLF KLEIN, Jack Barnes, Martin Buxton, and Edward Craven. Centre for Studies in Social Policy (62 Doughty Street, London WC1N 2LS). £1 50. 4. Public Expenditure to 1977-1978. H.M. Stationery Office, 1973.
costs
with
5.
Spitzer, W. O., Kergin, Spitzer, W. O., et al. Lancet, 1974, i, 608.
D. J. Can. med. Ass. J. 1973, 108, 991; New Engl. J. Med. 1974, 290, 251. See
202
but also inequitable. Although, in general, consultation-rates tend to be highest per head among the poorer sections of British society,6 TOWNSEND7 believes this is probably not the case if usage is expressed in terms of the need for medical care. Certainly between the 14 regions the amount spent in 1971-72 on family-practitioner and local-authority services has been shown to bear no relation to the proportion of the population aged 65 and over, nor to the infant-mortality rate, both of which are unquestionably measures of need.8 We must therefore also face the problem of maldistribution of the funds which are already at the disposal of the N.H.S. The argument for redistribution must surely now come from parts of the country which are receiving fewer funds. The new Health Service has, in addition to its multidisciplinary professional teams, another powerful method for helping the people of the country and their doctors to come to terms with local inequalities as well as the more profound conundrums of the economics of life and death. The establishment of the area health authority (A.H.A.), a statutory panel at county and borough level, together with the less formal community health council (c.H.c.) at district level, offers to the citizen, for the first time, an opportunity to shape the clay on the potter’s wheel. Members of the administrative teams, and of the medical profession in general, tend to look upon the c.H.c.s as rods for their backs devised by a series of unsympathetic Governments, and others see them as a battering-ram to breach the walls of medical professionalism.99 Yet the multi-disciplinary district management team (D.M.T.), which in most parts of the country is coming to grips with its work with a will, is pari passu starting to put the role of the doctor on a new footing. In many districts consultant, family doctor, and community physician are working constructively with each other and with their other colleagues on the team. It would be a small step for the D.M.T. to take the initiative and open discussion with the c.H.c. The D.M.T. could seek the views of the consumer about where the money should go, having first considered and presented with the help of the community physician 10 the possible benefits which might accrue from various forms of expenditure. Existing statistics can be used to estimate financial need at the local level 8; and, where the quality of services is low, c.H.c.s could have a powerful voice. National spending on health services has varied little with successive Governments, which have struck a crude balance between public demand and financial exigency. In the coming economic troubles, the fate of the National Health Service may depend on the vocal vigilance of community health councils everywhere.
Renal-artery Stenosis and Renal Failure
unequal
6. General Household Survey, Introductory Report. H.M. Office, 1973. 7. Townsend, P. Lancet, 1974, i, 1179. 8. Noyce, J., Snaith, A. H., Trickey, A. J. ibid. p. 554. 9. Hardie, M. C. Long Range Planning, 1974, 7, 2. 10. Lancet, 1974, ii, 30.
Stationery
EXPERIMENTAL renal-artery constriction in animals, well as causing hypertension, can result in fibrinoid necrosis (the vascular lesion of malignant hypertension) with a distribution similar to that in hypertensive man. An important finding in animals is, however, that the kidney with the constricted artery is spared. 1,2In the rat with a unilateral renal-artery clip and both kidneys remaining in situ, fibrinoid necrosis was found in the untouched kidney, but it was absent, or much less severe, in the kidney distal to the stenosis.3,4 These observations suggested that hypertension per se might be responsible for the intra renal vascular lesions, while the clipped kidney, not being exposed to high arterial pressures, was spared.5 Renal biopsies in patients with unilateral renal-artery stenosis confirmed a considerably greater incidence of intrarenal vascular lesions in the contralateral exposed kidney than in the kidney distal to the stenosis.6 WILSON and BYROM 4 had earlier developed the concept that the histological abnormalities induced in the untouched kidney might be responsible for perpetuating hypertension when a unilateral clip was removed, and this notion was further elaborated by FLOYER.7 STAMEY8 extended these ideas into the clinical sphere, showing that, in patients with unilateral renal-artery stenosis, corrective arterial surgery was likely to give a poor result if the non-stenotic kidney had distinctly reduced renal plasma-flow, since such reduction presumably indicated irreversible hypertensive vascular damage. as
,
Three patients have been described in whom surgical correction of unilateral renal-artery stenosis was alone insufficient to relieve hypertension, and in whom subsequent excision of the contralateral kidney, which in all three showed extensive arteriolar lesions, was performed. In the first two instances,9,lo blood-pressure remained raised after relief of the stenosis, and divided studies showed gross functional impairment on the contralateral side. Hypertension was relieved after removal of the damaged contralateral kidney. The relationship was less clear in the third case,l1 since the contralateral kidney was thought to have sustained such obvious hypertensive vascular damage that it was excised during the repair operation. In this instance also, the hypertension was relieved. Two reports in these pages have underlined 1. Goldblatt, H.J. exp. med. 1938, 67, 809. 2. Wilson, C., Pickering G. W. Clin. Sci. 1938, 3, 809. 3. Wilson, C., Byrom, F. B. Lancet, 1939, i, 136. 4. Wilson, C., Byrom, F. B. Q. Jl Med. 1941, 10, 65. 5. Pickering, G. W. High Blood Pressure; p. 148. London, 1968. 6. Brown, J. J., Owen, K., Peart, W. S., Robertson, J. I. S., Sutton, D. Br. med. J. 1960, ii, 327. 7. Floyer, M. A. Clin. Sci. 1951, 10, 405. 8. Stamey, T. A. in Antihypertensive Therapy (edited by F. Gross); p. 555. Berlin, 1966. 9. Thal, A. P., Grage, T. B., Vernier, R. L. Circulation, 1963, 27, 36. 10. Miller, H. C., Phillips, C. E. Surgery Gynec. Obstet. 1968, 127, 1274. 11. McAllister, R. G., Michelakis, A. M., Oates, J. A., Foster, J. M. J. Am. med. Ass. 1972, 221, 865.