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Good for the Constitution
427
LEADING ARTICLES
THE LONDON
LANCET 25
FEBRUARY
1967
Good for the Constitution AT this time of year all sorts and conditions of men and institutions give weighty advice to the Chancellor about his budget for the coming year. By all accounts Mr. CALLAGHAN has an unenviable task for 1966-67; and forebodings about the future of the National Health Service are already grim. Yet it is doubtful whether the N.H.S. as it is now planned is seriously threatened. The economic growth-rate assumed in the National Plan may well not be achieved according to time-table, but there is no evidence that the Chancellor is planning to raid the finances of the centrepiece of British social services. If the fiscal measures taken last year mean anything at alland their results have apparently impressed many experts-it must be assumed that financial cryotherapy will be effective, and that the economic prognosis is good, to the extent that as a nation Britain will grow even richer. Thus, even if there is no room for manoeuvre in 1967-68, it is none too early to put forward the claims of the N.H.S. in later years for an appropriate share of the national wealth. If, as seems likely, the N.H.S. is to be in business for a very long time, its rate of development should be kept under continuous review. This demands a sensible view of priorities. In a Service capable of arousing fierce emotions, there will always be competitive and uncoordinated pressures for improvements. Too often in the past, the frustration caused by official resistance to these pressures has led to impatient proposals for radical and often irrelevant administrative changes being paraded before a bewildered, but largely unconcerned, public. What is needed is a sober review of the real achievements of the N.H.S. and a realistic assessment of its future needs, with due regard for the human and material resources of the society in which we live. Today people are beginning to realise that there is no simple administrative solution. The N.H.S. is not a monolith but a mass of individual services. It consists of a vast number of extremely valuable publicly owned physical assets, which are continuously being worked, according to high traditions, by an army of highly skilled men and women to serve many needs. Its morale is not shallowly rooted, though it can be weakened by neglect and continuous complaints and complaining. Its organisation is too intricate and its functions too complex for it to be described as an experiment which can be written off as a failure of which the apparatus can be easily dismantled. Academic discussion about the possibility of radical change in its organisation and finance ignores the principle on which it is based-the inalienable right of all citizens to medical treatment without barrier of cost.
Unlike the medicine of the market-place it offers free care however long the illness, however expensive the therapy. Nor does the experience of the past twenty years in the United States suggest that the N.H.S.’s areas of particular weaknesses-shortage of manpower, arrangements for vocational training, and continuous postgraduate education, the need for rationalisation of services-will be strengthened by a return to marketplace economics. None of these inconvenient issues is touched on in the latest pamphlet from the Institute of Economic Affairs1 on the reorganisation of medical care. As soon as one delves below the cliches of " freedom of choice " and of " market", and gets down to real intractable problems, no sensible alternatives emerge, such as hard-headed men of economic affairs might be expected to demand. Individual members of the study group responsible for the pamphlet record that they are not " committed to the detail of solutions, which are included not as specific agreed recommendations but as indications of the methods suggested... as possible ways of applying the underlying principles ". In view of the oversimplification of some of the recommendations, which raise questions on such issues as the implications of control, authority, and the philosophy of community as against experience rating for insurance, this may be prudent, but it hardly adds to the value of the pamphlet as a practical guide. The citizen’s basic right of choice is not, of course, supported only by the Institute: nor indeed is it contrary to the ideals of the N.H.S. (The right of access to private practice is embodied in section 5 of the Act.) The real nub of the Institute’s theory is concerned not so much with choice as to find some, so far undefined, alternative to the N.H.S. where the economics of the market-place will ensure not only a more effective service but also higher and more effective expenditure than can be expected from a centrally financed organisation dependent on public funds. Though the Institute sees indications of an increasing demand for private arrangements, it still seems shy of discussing how the background services needed, such as education and research, are likely to be owned, organised, and run (to say nothing of improved) or how private care would get on without the support of N.H.S. laboratories and equipment. Above all, it is totally unconvincing in its thesis that choice will ensure buoyancy and that more money will be spent on health. The plain fact is that, while individual doctors might be able to sell their services profitably-and with the costly and complex scientific procedures and growing specialism of today even this approach is bound to be limited-it is unlikely that there would be a buoyant " market " for institutions and services offering medical care.
In the United States the whole emphasis now is on area-wide planning in which the main insurancecarriers take a leading part and demand rationalisation of services in accordance with some preconceived notions of adequacy of provision. The Institute’s views would command more respect if it set out more clearly 1. Towards
Square,
Welfare Society. Institute of Economic Affairs London S.W.1) 1967. Pp. 40. 6s.
a
(66a Eaton
428
how it envisages a medical market would work, what controls would be necessary (as they are becoming in America) to ensure quality of medical care under competitive conditions, who would own and run the hospitals, and so on. All these issues are fundamental to any discussion about change. It is not without significance that Mr. ENOCH POWELL, the most notable political advocate of the superiority of the market over a planned economy, has, perhaps regretfully, admitted his lack of confidence in the ability of the market to develop adequate health services.2 clear that no Government, of whatever comoffer a sound basis on which to introduce plexion, revolutionary alternatives to the present organisation of our health services. This makes it all the more important to understand the plans of the present administration for the future of the N.H.S. The part of the National Plan dealing with health was probably based on a little-known study financed by the Treasury and published with a grant from the Department of Economic Affairs.3 The authors reach their estimates as projections of current expenditure and policies, and seem to have little awareness of the inadequacies of much current policy. Even so the capital expenditure shown as desirable for the N.H.S. in 1975 is E160 million (at 1960 prices), which is an annual rate higher than is shown in the National Plan for 1970. There is, of course, no saying that this figure will be allowed to the N.H.S. in 1975, but the study makes it plain that this should be the immediate target for the task in hand, which is to " modernise and replace a big proportion of all the beds in general hospitals and hospitals for mental illness ". As might be expected, the recurrent expenditure forecast as needed in 1975 shows similar trends. Impressive as are these figures besides those that have gone before, they are probably still nowhere near great enough. Is there any sign that they are scientifically based and are the last word in Government policy ? If not, the real question is how to assess and achieve a level of finance that will allow the N.H.S. to develop as a stabilising, sound institution. It
seems
can
Looking at what other countries spend on social services, including health, it is not difficult to make a case for a more expansive, and expensive, Government policy in this country. The total taxes and contributions we pay, compared with members of the European Economic Coxnniunity, do not suggest that as a nation we overburdened that we need starve an essential service.4 Indeed in both West Germany and France, though the incidence between direct and indirect taxation varies, the citizenry would seem to be more heavily taxed than in this country. The relatively small increase necessary to ensure a sound future for the N.H.S. could come from savings on Defence expenditure, which seems inevitably to be the favoured target for more and more cuts as Britain’s role in the world becomes clearer, but there is also a good case for the are so
2. Powell, J. E. Medicine and Politics. London, 1966. 3. Health and Welfare Services in Britain 1975. London, 1966. 4. Hansard: House of Commons. Jan. 19, 1967, col. 121.
Chancellor to look a little further ahead and review other of raising money-perhaps on a local and discretionary basis. The National Health Service is here to stay, and it is all the more a pity that almost everyone concerned with it has an unusual capacity for pessimism-perhaps because the service was conceived by the modesty of charity out of the self-denigration of public service. The time has come to inform the country that we are getting the N.H.S. on the cheap and that we must pay more if we are to make the best of a good thing. Instead of moaning apologetic swan-songs, we must sound unashamed clarion calls. means
Acute
Cholecystitis
FOR several reasons it is tempting to remove the gallbladder in the acute stage of cholecystitis: perforation is avoided; if empyema exists, an abscess is removed; an operation will be necessary sooner or later-so why not sooner, to prevent the patient having to endure an illness and its possible complications for longer than necessary ? Orthodoxy in this country has dictated that a reasonable period should elapse between an acute episode and operation, allowing inflammation to subside and so reducing the hazards of operation in an engorged and oedematous area containing ducts and vessels, where damage can cause considerable disability and be hard to correct. This " reasonable " period is variously interpreted as a few weeks to three months, and the patient is then readmitted for the elective operation. As the advocates of earlier surgery rightly point out, he is often discharged after a first attack to suffer a further acute episode before he is due to return. WALL and WEISS1 studied 642 patients with cholecystitis admitted to hospital in 1945-55. In 468 an operation was performed; gangrene of the gallbladder was found in 38%, perforation in 7%, and empyema in 9%. In 16 patients operated on within forty-eight hours of onset of symptoms, no organisms could be grown from the bile; of 43 cases of three or four days’ duration, positive culture was obtained in 4; but culture was positive in no less than 25 out of 33 patients operated on after six days. Earlier operation carried a lower mortality because perforation was then less common: of 32 patients with perforation, 8 died. WALL and WEISS therefore advocated2 early operation. By contrast, MCCUBBERY and THIEME favoured conservative treatment since, of 345 cases with acute cholecystitis seen between 1952 and 1956, 154 were discharged without operation and without a death; whereas, of the 191 who required operation, only 65 needed urgent or emergency operation, the remaining 126 having an elective cholecystectomy (121) or cholecystostomy (5) without a death. 9 deaths followed the emergency operations (38 cholecystectomy, 27 cholecystostomy) and MCCUBBERY and THIEME were inclined to ascribe this to the older age of the 65 patients. Immediate operation, they felt, might be satisfactory in 1. 2.
Wall, C. A., Weiss, R. M. Archs Surg., Chicago. 1958, 77, 433. McCubbery, D., Thieme, T. Surgery, St. Louis, 1959, 45, 930.
LEADING ARTICLES
THE LONDON
LANCET 25
FEBRUARY
1967
Good for the Constitution AT this time of year all sorts and conditions of men and institutions give weighty advice to the Chancellor about his budget for the coming year. By all accounts Mr. CALLAGHAN has an unenviable task for 1966-67; and forebodings about the future of the National Health Service are already grim. Yet it is doubtful whether the N.H.S. as it is now planned is seriously threatened. The economic growth-rate assumed in the National Plan may well not be achieved according to time-table, but there is no evidence that the Chancellor is planning to raid the finances of the centrepiece of British social services. If the fiscal measures taken last year mean anything at alland their results have apparently impressed many experts-it must be assumed that financial cryotherapy will be effective, and that the economic prognosis is good, to the extent that as a nation Britain will grow even richer. Thus, even if there is no room for manoeuvre in 1967-68, it is none too early to put forward the claims of the N.H.S. in later years for an appropriate share of the national wealth. If, as seems likely, the N.H.S. is to be in business for a very long time, its rate of development should be kept under continuous review. This demands a sensible view of priorities. In a Service capable of arousing fierce emotions, there will always be competitive and uncoordinated pressures for improvements. Too often in the past, the frustration caused by official resistance to these pressures has led to impatient proposals for radical and often irrelevant administrative changes being paraded before a bewildered, but largely unconcerned, public. What is needed is a sober review of the real achievements of the N.H.S. and a realistic assessment of its future needs, with due regard for the human and material resources of the society in which we live. Today people are beginning to realise that there is no simple administrative solution. The N.H.S. is not a monolith but a mass of individual services. It consists of a vast number of extremely valuable publicly owned physical assets, which are continuously being worked, according to high traditions, by an army of highly skilled men and women to serve many needs. Its morale is not shallowly rooted, though it can be weakened by neglect and continuous complaints and complaining. Its organisation is too intricate and its functions too complex for it to be described as an experiment which can be written off as a failure of which the apparatus can be easily dismantled. Academic discussion about the possibility of radical change in its organisation and finance ignores the principle on which it is based-the inalienable right of all citizens to medical treatment without barrier of cost.
Unlike the medicine of the market-place it offers free care however long the illness, however expensive the therapy. Nor does the experience of the past twenty years in the United States suggest that the N.H.S.’s areas of particular weaknesses-shortage of manpower, arrangements for vocational training, and continuous postgraduate education, the need for rationalisation of services-will be strengthened by a return to marketplace economics. None of these inconvenient issues is touched on in the latest pamphlet from the Institute of Economic Affairs1 on the reorganisation of medical care. As soon as one delves below the cliches of " freedom of choice " and of " market", and gets down to real intractable problems, no sensible alternatives emerge, such as hard-headed men of economic affairs might be expected to demand. Individual members of the study group responsible for the pamphlet record that they are not " committed to the detail of solutions, which are included not as specific agreed recommendations but as indications of the methods suggested... as possible ways of applying the underlying principles ". In view of the oversimplification of some of the recommendations, which raise questions on such issues as the implications of control, authority, and the philosophy of community as against experience rating for insurance, this may be prudent, but it hardly adds to the value of the pamphlet as a practical guide. The citizen’s basic right of choice is not, of course, supported only by the Institute: nor indeed is it contrary to the ideals of the N.H.S. (The right of access to private practice is embodied in section 5 of the Act.) The real nub of the Institute’s theory is concerned not so much with choice as to find some, so far undefined, alternative to the N.H.S. where the economics of the market-place will ensure not only a more effective service but also higher and more effective expenditure than can be expected from a centrally financed organisation dependent on public funds. Though the Institute sees indications of an increasing demand for private arrangements, it still seems shy of discussing how the background services needed, such as education and research, are likely to be owned, organised, and run (to say nothing of improved) or how private care would get on without the support of N.H.S. laboratories and equipment. Above all, it is totally unconvincing in its thesis that choice will ensure buoyancy and that more money will be spent on health. The plain fact is that, while individual doctors might be able to sell their services profitably-and with the costly and complex scientific procedures and growing specialism of today even this approach is bound to be limited-it is unlikely that there would be a buoyant " market " for institutions and services offering medical care.
In the United States the whole emphasis now is on area-wide planning in which the main insurancecarriers take a leading part and demand rationalisation of services in accordance with some preconceived notions of adequacy of provision. The Institute’s views would command more respect if it set out more clearly 1. Towards
Square,
Welfare Society. Institute of Economic Affairs London S.W.1) 1967. Pp. 40. 6s.
a
(66a Eaton
428
how it envisages a medical market would work, what controls would be necessary (as they are becoming in America) to ensure quality of medical care under competitive conditions, who would own and run the hospitals, and so on. All these issues are fundamental to any discussion about change. It is not without significance that Mr. ENOCH POWELL, the most notable political advocate of the superiority of the market over a planned economy, has, perhaps regretfully, admitted his lack of confidence in the ability of the market to develop adequate health services.2 clear that no Government, of whatever comoffer a sound basis on which to introduce plexion, revolutionary alternatives to the present organisation of our health services. This makes it all the more important to understand the plans of the present administration for the future of the N.H.S. The part of the National Plan dealing with health was probably based on a little-known study financed by the Treasury and published with a grant from the Department of Economic Affairs.3 The authors reach their estimates as projections of current expenditure and policies, and seem to have little awareness of the inadequacies of much current policy. Even so the capital expenditure shown as desirable for the N.H.S. in 1975 is E160 million (at 1960 prices), which is an annual rate higher than is shown in the National Plan for 1970. There is, of course, no saying that this figure will be allowed to the N.H.S. in 1975, but the study makes it plain that this should be the immediate target for the task in hand, which is to " modernise and replace a big proportion of all the beds in general hospitals and hospitals for mental illness ". As might be expected, the recurrent expenditure forecast as needed in 1975 shows similar trends. Impressive as are these figures besides those that have gone before, they are probably still nowhere near great enough. Is there any sign that they are scientifically based and are the last word in Government policy ? If not, the real question is how to assess and achieve a level of finance that will allow the N.H.S. to develop as a stabilising, sound institution. It
seems
can
Looking at what other countries spend on social services, including health, it is not difficult to make a case for a more expansive, and expensive, Government policy in this country. The total taxes and contributions we pay, compared with members of the European Economic Coxnniunity, do not suggest that as a nation we overburdened that we need starve an essential service.4 Indeed in both West Germany and France, though the incidence between direct and indirect taxation varies, the citizenry would seem to be more heavily taxed than in this country. The relatively small increase necessary to ensure a sound future for the N.H.S. could come from savings on Defence expenditure, which seems inevitably to be the favoured target for more and more cuts as Britain’s role in the world becomes clearer, but there is also a good case for the are so
2. Powell, J. E. Medicine and Politics. London, 1966. 3. Health and Welfare Services in Britain 1975. London, 1966. 4. Hansard: House of Commons. Jan. 19, 1967, col. 121.
Chancellor to look a little further ahead and review other of raising money-perhaps on a local and discretionary basis. The National Health Service is here to stay, and it is all the more a pity that almost everyone concerned with it has an unusual capacity for pessimism-perhaps because the service was conceived by the modesty of charity out of the self-denigration of public service. The time has come to inform the country that we are getting the N.H.S. on the cheap and that we must pay more if we are to make the best of a good thing. Instead of moaning apologetic swan-songs, we must sound unashamed clarion calls. means
Acute
Cholecystitis
FOR several reasons it is tempting to remove the gallbladder in the acute stage of cholecystitis: perforation is avoided; if empyema exists, an abscess is removed; an operation will be necessary sooner or later-so why not sooner, to prevent the patient having to endure an illness and its possible complications for longer than necessary ? Orthodoxy in this country has dictated that a reasonable period should elapse between an acute episode and operation, allowing inflammation to subside and so reducing the hazards of operation in an engorged and oedematous area containing ducts and vessels, where damage can cause considerable disability and be hard to correct. This " reasonable " period is variously interpreted as a few weeks to three months, and the patient is then readmitted for the elective operation. As the advocates of earlier surgery rightly point out, he is often discharged after a first attack to suffer a further acute episode before he is due to return. WALL and WEISS1 studied 642 patients with cholecystitis admitted to hospital in 1945-55. In 468 an operation was performed; gangrene of the gallbladder was found in 38%, perforation in 7%, and empyema in 9%. In 16 patients operated on within forty-eight hours of onset of symptoms, no organisms could be grown from the bile; of 43 cases of three or four days’ duration, positive culture was obtained in 4; but culture was positive in no less than 25 out of 33 patients operated on after six days. Earlier operation carried a lower mortality because perforation was then less common: of 32 patients with perforation, 8 died. WALL and WEISS therefore advocated2 early operation. By contrast, MCCUBBERY and THIEME favoured conservative treatment since, of 345 cases with acute cholecystitis seen between 1952 and 1956, 154 were discharged without operation and without a death; whereas, of the 191 who required operation, only 65 needed urgent or emergency operation, the remaining 126 having an elective cholecystectomy (121) or cholecystostomy (5) without a death. 9 deaths followed the emergency operations (38 cholecystectomy, 27 cholecystostomy) and MCCUBBERY and THIEME were inclined to ascribe this to the older age of the 65 patients. Immediate operation, they felt, might be satisfactory in 1. 2.
Wall, C. A., Weiss, R. M. Archs Surg., Chicago. 1958, 77, 433. McCubbery, D., Thieme, T. Surgery, St. Louis, 1959, 45, 930.