- Email: [email protected]
IDEAS, INSTITUTIONS, AND A DIAGNOSIS
676
However, if it is assumed that early detection does abort the course of this disease, the figures suggest that the running of an efficient screening service in NorthEast Scotland is financially justified. We thank Sister S. McCombie, ward sister, and Mr K. B. Stewart, of the hospital pharmacy, for their help. Details of basic data and calculations may be obtained from J. B. T. Requests for reprintsshould be addressed to J. E. M., Department of Pathology, University Medical Buildings, Foresterhill, Aberdeen AB9 2ZD.
REFERENCES 1.
Magee, C. C., Edwards, J. R., Connies-Laing, P., Richards, M. Report on Costing Cervical Cytology. University College, Cardiff, 1974.
2. Scottish Home and Health Department. Patient Costing Study: Scottish Health Services Studies no. 31. Edinburgh, 1974.
Point of View IDEAS, INSTITUTIONS, AND A DIAGNOSIS N. G. C. HENDRY
Department of Orthopcedics, Royal Infirmary, Aberdeen THE founding purpose of the N.H.S. can be very simply stated. It was that the community as a whole wished to take responsibility for the misfortunes of its members, in so far as these misfortunes came within the medical profession’s power to prevent, alleviate, or cure. By a political decision this concept was given a concrete form; and its embodiment has been the subject of party political decision (the distinction is important) ever since. How has the concept fared ? Doctors started from the unarguable premise that there could not be a health service without them, and proceeded thence to the belief-still relatively unexceptionable-that their own interests and the interests of patients were virtually the same. Now their representatives are dug in behind the dubious proposition that their self-interest is so paramount to the survival of the service that it justifies the inflicting of at least some medical misfortune on some members of the community. The political Parties started with the simple general political decision that the entire national community was the appropriate organisational unit, and the national exchequer the appropriate source of money for a national health service. They have moved from there into positions in which their commitment to maintain the service is put forward as synonymous with a comniitment to the original concept, while in fact the form and extent of the service are left subservient to Party needs. The Government alone carries the responsibility for the political component in the present impasse; no political party, large or small, can escape responsibility for the gradual build-up over the years of cynicism, dismay, and distrust. Is it too facile to see this distrust as the symptom of an unrecognised divergence, not of doctors from Government, but of both from the concept they believe they are serving? Certainly, it is not unrealistic to foresee the possibility of a continuing divergence that might take a generation to close. Is it too naive to suggest that both sides should step back from their confrontation and examine their consciences ? Or are we to continue with public and private disputations as to who is holier than whom ?
In any serious impasse such as the present one, the for a new initiative rests primarily with the more adult of the two participants. Doctors will still hope that this designation can be applied to their representatives. The profession should reaffirm its willingness to serve the community, and add that it accepts that its own selfinterest is less important than the general political will of the people who make up that community. The Government should respond by recognising that neither it nor its predecessors have yet devised political arrangements that satisfactorily embody the general wish for community responsibility for health. It should concede, even if privately, that medicine and Party dogma have in fact been disastrous bed-fellows. Publicly it should announce, and urgently, the setting up of an all-Party inquiry into the means whereby the Health Service can be made subservient to the general, but not to the particular, political will. It should recognise that health needs do not change with changes of Government; and it should not only recognise but also emphasise that Party politicking is an irrelevance in the massive (and largely untouched) field of matching access to the service with the real medical needs of the onus
people. Nothing
is more important at this time-not even the consultants’ contract-than that the rationing of health care should become a respectable subject for discussion, and that the methods should be seen to be based upon objectively determined medically oriented criteria. Since 1948 there has been a rationing system based upon a political concept, modified by the attitude of patients, the temper of receptionists, and a blockage at the far end of the line, at the hospital bed. The entire system-and not least the patients in it or waiting to get in it-is under strain: the effect is the opposite of what the Health Service set out to create, and it is miraculous that so much has in fact been achieved. But if the same means of rationing are to be continued in the stringent days that lie ahead, present discontents, both medical and lay, will be many times multiplied. If, alternatively, an attempt is made to base restrictions on political dogma, whether of the left or the right, the resulting overflow of feeling might well wreck not only the fact but also the concept of a health service. A second and general remit for an all-Party inquiry must therefore be to devise a mechanism whereby widely based medical opinion can, by its interaction with all shades of political opinion, determine the priorities and general direction of the N.H.S. If the Government could respond to a professional initiative by giving some undertaking of this sort, doctors could look for an end to their fears of involvement in a game of political ping-pong: they should then in turn examine the means of keeping professonal self-interest in its proper place, and preventing its impingement on the welfare of patients. If moves of this sort do not regenerate enough good will to permit an interim solution of immediate difficulties, both sides should at least face the fact that their present performance puts their sense of values seriously in question.
" Since I forwarded you the case I considered malignant cholera, I have had an opportunity of witnessing several others here in the Borough ... It was my intention to have made a few observations respecting the cases that have occurred up to this time in this neighbourhood, but must unavoidably postpone it on account of being obliged to make a sudden and unexpected departure for the country." —JAMBS GANE, Lancet, Feb. 25, 1832.
However, if it is assumed that early detection does abort the course of this disease, the figures suggest that the running of an efficient screening service in NorthEast Scotland is financially justified. We thank Sister S. McCombie, ward sister, and Mr K. B. Stewart, of the hospital pharmacy, for their help. Details of basic data and calculations may be obtained from J. B. T. Requests for reprintsshould be addressed to J. E. M., Department of Pathology, University Medical Buildings, Foresterhill, Aberdeen AB9 2ZD.
REFERENCES 1.
Magee, C. C., Edwards, J. R., Connies-Laing, P., Richards, M. Report on Costing Cervical Cytology. University College, Cardiff, 1974.
2. Scottish Home and Health Department. Patient Costing Study: Scottish Health Services Studies no. 31. Edinburgh, 1974.
Point of View IDEAS, INSTITUTIONS, AND A DIAGNOSIS N. G. C. HENDRY
Department of Orthopcedics, Royal Infirmary, Aberdeen THE founding purpose of the N.H.S. can be very simply stated. It was that the community as a whole wished to take responsibility for the misfortunes of its members, in so far as these misfortunes came within the medical profession’s power to prevent, alleviate, or cure. By a political decision this concept was given a concrete form; and its embodiment has been the subject of party political decision (the distinction is important) ever since. How has the concept fared ? Doctors started from the unarguable premise that there could not be a health service without them, and proceeded thence to the belief-still relatively unexceptionable-that their own interests and the interests of patients were virtually the same. Now their representatives are dug in behind the dubious proposition that their self-interest is so paramount to the survival of the service that it justifies the inflicting of at least some medical misfortune on some members of the community. The political Parties started with the simple general political decision that the entire national community was the appropriate organisational unit, and the national exchequer the appropriate source of money for a national health service. They have moved from there into positions in which their commitment to maintain the service is put forward as synonymous with a comniitment to the original concept, while in fact the form and extent of the service are left subservient to Party needs. The Government alone carries the responsibility for the political component in the present impasse; no political party, large or small, can escape responsibility for the gradual build-up over the years of cynicism, dismay, and distrust. Is it too facile to see this distrust as the symptom of an unrecognised divergence, not of doctors from Government, but of both from the concept they believe they are serving? Certainly, it is not unrealistic to foresee the possibility of a continuing divergence that might take a generation to close. Is it too naive to suggest that both sides should step back from their confrontation and examine their consciences ? Or are we to continue with public and private disputations as to who is holier than whom ?
In any serious impasse such as the present one, the for a new initiative rests primarily with the more adult of the two participants. Doctors will still hope that this designation can be applied to their representatives. The profession should reaffirm its willingness to serve the community, and add that it accepts that its own selfinterest is less important than the general political will of the people who make up that community. The Government should respond by recognising that neither it nor its predecessors have yet devised political arrangements that satisfactorily embody the general wish for community responsibility for health. It should concede, even if privately, that medicine and Party dogma have in fact been disastrous bed-fellows. Publicly it should announce, and urgently, the setting up of an all-Party inquiry into the means whereby the Health Service can be made subservient to the general, but not to the particular, political will. It should recognise that health needs do not change with changes of Government; and it should not only recognise but also emphasise that Party politicking is an irrelevance in the massive (and largely untouched) field of matching access to the service with the real medical needs of the onus
people. Nothing
is more important at this time-not even the consultants’ contract-than that the rationing of health care should become a respectable subject for discussion, and that the methods should be seen to be based upon objectively determined medically oriented criteria. Since 1948 there has been a rationing system based upon a political concept, modified by the attitude of patients, the temper of receptionists, and a blockage at the far end of the line, at the hospital bed. The entire system-and not least the patients in it or waiting to get in it-is under strain: the effect is the opposite of what the Health Service set out to create, and it is miraculous that so much has in fact been achieved. But if the same means of rationing are to be continued in the stringent days that lie ahead, present discontents, both medical and lay, will be many times multiplied. If, alternatively, an attempt is made to base restrictions on political dogma, whether of the left or the right, the resulting overflow of feeling might well wreck not only the fact but also the concept of a health service. A second and general remit for an all-Party inquiry must therefore be to devise a mechanism whereby widely based medical opinion can, by its interaction with all shades of political opinion, determine the priorities and general direction of the N.H.S. If the Government could respond to a professional initiative by giving some undertaking of this sort, doctors could look for an end to their fears of involvement in a game of political ping-pong: they should then in turn examine the means of keeping professonal self-interest in its proper place, and preventing its impingement on the welfare of patients. If moves of this sort do not regenerate enough good will to permit an interim solution of immediate difficulties, both sides should at least face the fact that their present performance puts their sense of values seriously in question.
" Since I forwarded you the case I considered malignant cholera, I have had an opportunity of witnessing several others here in the Borough ... It was my intention to have made a few observations respecting the cases that have occurred up to this time in this neighbourhood, but must unavoidably postpone it on account of being obliged to make a sudden and unexpected departure for the country." —JAMBS GANE, Lancet, Feb. 25, 1832.