- Email: [email protected]
NATIONAL OR PERSONAL HEALTH SERVICE ?
96
cardiomyopathy. These particles differ strikingly in range, and appearance from the new agents recently described in cardiac tissue from patients with idiopathic cardiomyopathy by Mr. Braimbridge and his co-workers.3
viral
size,
This work was supported in part by attending staff project 5035 of the Los Angeles County Hospital, which we gratefully
no.
acknowledge. MURRAY B. GARDNER
PETER V. LEE University of Southern California School of Medicine, Los Angeles County Hospital, Los Angeles, California.
JOHN C. NORRIS EDWARD PHILLIPS PETER CAPONEGRO.
NATIONAL OR PERSONAL HEALTH SERVICE ?
SIR,-May I make a final comment on Mr. Inglis’s letter 4 ? We differ on the extent to which the form of payment affects the basis of confidentiality and personal service between doctor and patients. Mr. Inglis asks if I " seriously believe that the ordinary general practitioner would give his patients less efficient service if he were salaried than he does on capitation ". My reply is, yes. My reasons are my experience of salaried doctors in the Armed Services, observation of salaried doctors in the public service, my experience as a patient in the National Health Service and as a fee-payer, my reading of developments in other countries where capitation arld salaries are used, and discussions with people who know these two and other systems in countries in several continents. Mr. Inglis fears financial interest. Unhappily, in the real world disinterest usually means uninterest. The choice is between giving the doctor a financial interest in ridding his patients of disease and relying on the sense of public duty. The former, as Mr. Inglis says, can go to excess; the latter, with exceptions, especially in emergency, is patently ineffective. Let doctors and But we need not prejudge the outcome. patients who want to try a salary, or any other, system be free to do so. And let them be free to abandon it if they do not like it. My central objection to the N.H.S. is that it virtually prevents the mass of doctors and patients from trying alternative methods of financing to see which they prefer. I believe that a payment at the time of receipt of service is essential, even if it is largely reimbursed (or prepaid) by insurance and the remainder (the " patient’s fraction ", as it is called in Australia) is paid by the State in case of need. A doctor who had ten years in the N.H.S. and left it exhausted has written "... if you do not have to pay for something, you tend to undervalue it. I think we need to be reminded that the contents of our little bottle costs E3 or E4 ". And he adds a comment which should make the supporters of the N.H.S. " ponder: In spite of the politicians shouting that we have the best health service in the world, not a single Western country has followed our example ". The case for payment per unit of service is increasingly accepted by politicians of all parties. In the past few weeks charges for State medical care have been advocated by Mr. Douglas Houghton, chairman of the Parliamentary Labour Party, and by two Labour M.P.s, Mr. Desmond Donnelly and Mr. Brian Walden. Mr. Houghton has elaborated his views in a paper, Paying for the Social Services, which will stimulate thinking on the financing of medical care and other welfare services. In it he says,"... we are now getting the worst of both worlds. The Government cannot find the money and the citizen is not allowed to pay it out of his own pocket ". He speaks of a new kind of private patient " who would pay for better service in the N.H.S. If we can contemplate payment for unit of State medical service, the days of universal, free welfare are numbered. "
Institute of Economic Affairs, 66A Eaton Square, London S.W.1.
AKTHUR SELDON.
V., Darracott, S., Chayen, J., Bitensky, L., Poulter, Braimbridge, L. W. ibid. 1967, i, 171. 4. Inglis, B. ibid. 1966, i, 1327. 3.
M.
A GRIM DAY-ROOM SIR,-I have just visited in a geriatric unit a childless widow, nearly 80, who had a cerebral thrombosis a month ago. She made good progress at home, but was unable to rise from bed or chair, or to walk unaided, so she was admitted to hospital for physiotherapy and mobilisation. I found her in a small day-room with nine other patients. From a sitting position (and all except one were unable to stand without help) the only views from the too-high windows were of an iron fire-escape and brick walls. I was told that patients were brought into this room at 8 A.M. and not taken out again, except to the lavatories, until 8.30 P.M. Any little article which they might want with them during the 121/2 hours had to be held in their laps, because there were no lockers or personal tables. Meals were served in this room, when tables were placed down the centre, where visitors sat during visiting periods. So there was no change of scene at meal-times. Seven of the ten patients had obvious degenerative mental changes; one or two, because of flaccid muscles, sprawled precariously. There were no bells to summon help and visitors wandered into other rooms to find nurses. The lady I was visiting is mentally alert, and the plight of the more helpless patients distressed her. The patients’ beds, reasonably well spaced, were on pleasant verandahs overlooking attractive lawns. But it was impossible not to feel depressed in that grim day-room. The care of such patients is a considerable nursing problem, of course. But unfortunately there still seems to be something in the training of nurses which causes many to accept too readily the established arrangements; and something which produces in some nurses blind obedience to the letter rather than to the spirit of doctors’ instructions. Why else did kindhearted nurses seem perfectly content with that awful dayroom and happy because they were fulfilling the doctors’ orders to keep the patients up all day? Burton in Lonsdale, via Carnforth, MARIE A. SIMPSON. Lancashire.
ASSESSING Rh-SENSITISATION RISK SIR,-Undoubtedly the hypothesis set up for testing by Taylorand described in your columns2 is important for learning more of the Rh-group involvement in development of erythroblastosis. However, acceptance of this work as proof that sensitisation takes place in an Rh-negative girl born to an Rh-positive mother does not follow easily from a careful reading of Taylor’s presentation. Many aspects of her study are open to question. From the total of 236 original families only 157 are included in the analysis, the remainder being removed for reasons both good and bad prognostically for the grandchildren. But these exclusions contain 50% of the families with Rh-negative grandmothers, whereas only 11 % of those with Rh-positive grandmothers are left out. It is more likely that these figures should be nearly equal, though the large difference is not
mentioned. The two groups of mothers compared are selected differently. The first group comprised all families in the area with a child thought to have erythroblastosis, whereas the second was a non-random sample of unaffected families with Rh-negative mothers-namely, those referred to one prenatal Rh-testing service. Thus the manipulations involving the transfer of families from the first group to the second are not legitimate when used in Taylor’s way. You quote Taylor’s statement: " of children with Rh-positive grandmothers, 78-65% had erythroblastosis, whereas 60-29% of children with Rh-negative grandmothers were affected, an increase of 18% ". Since the size of the second group is arbitrary, the percentages calculated, and wrongly referred to as 1. Taylor, J. F. 2. Lancet, 1967,
i,
New Engl. 1205.
J. Med. 1967, 276,
547.
cardiomyopathy. These particles differ strikingly in range, and appearance from the new agents recently described in cardiac tissue from patients with idiopathic cardiomyopathy by Mr. Braimbridge and his co-workers.3
viral
size,
This work was supported in part by attending staff project 5035 of the Los Angeles County Hospital, which we gratefully
no.
acknowledge. MURRAY B. GARDNER
PETER V. LEE University of Southern California School of Medicine, Los Angeles County Hospital, Los Angeles, California.
JOHN C. NORRIS EDWARD PHILLIPS PETER CAPONEGRO.
NATIONAL OR PERSONAL HEALTH SERVICE ?
SIR,-May I make a final comment on Mr. Inglis’s letter 4 ? We differ on the extent to which the form of payment affects the basis of confidentiality and personal service between doctor and patients. Mr. Inglis asks if I " seriously believe that the ordinary general practitioner would give his patients less efficient service if he were salaried than he does on capitation ". My reply is, yes. My reasons are my experience of salaried doctors in the Armed Services, observation of salaried doctors in the public service, my experience as a patient in the National Health Service and as a fee-payer, my reading of developments in other countries where capitation arld salaries are used, and discussions with people who know these two and other systems in countries in several continents. Mr. Inglis fears financial interest. Unhappily, in the real world disinterest usually means uninterest. The choice is between giving the doctor a financial interest in ridding his patients of disease and relying on the sense of public duty. The former, as Mr. Inglis says, can go to excess; the latter, with exceptions, especially in emergency, is patently ineffective. Let doctors and But we need not prejudge the outcome. patients who want to try a salary, or any other, system be free to do so. And let them be free to abandon it if they do not like it. My central objection to the N.H.S. is that it virtually prevents the mass of doctors and patients from trying alternative methods of financing to see which they prefer. I believe that a payment at the time of receipt of service is essential, even if it is largely reimbursed (or prepaid) by insurance and the remainder (the " patient’s fraction ", as it is called in Australia) is paid by the State in case of need. A doctor who had ten years in the N.H.S. and left it exhausted has written "... if you do not have to pay for something, you tend to undervalue it. I think we need to be reminded that the contents of our little bottle costs E3 or E4 ". And he adds a comment which should make the supporters of the N.H.S. " ponder: In spite of the politicians shouting that we have the best health service in the world, not a single Western country has followed our example ". The case for payment per unit of service is increasingly accepted by politicians of all parties. In the past few weeks charges for State medical care have been advocated by Mr. Douglas Houghton, chairman of the Parliamentary Labour Party, and by two Labour M.P.s, Mr. Desmond Donnelly and Mr. Brian Walden. Mr. Houghton has elaborated his views in a paper, Paying for the Social Services, which will stimulate thinking on the financing of medical care and other welfare services. In it he says,"... we are now getting the worst of both worlds. The Government cannot find the money and the citizen is not allowed to pay it out of his own pocket ". He speaks of a new kind of private patient " who would pay for better service in the N.H.S. If we can contemplate payment for unit of State medical service, the days of universal, free welfare are numbered. "
Institute of Economic Affairs, 66A Eaton Square, London S.W.1.
AKTHUR SELDON.
V., Darracott, S., Chayen, J., Bitensky, L., Poulter, Braimbridge, L. W. ibid. 1967, i, 171. 4. Inglis, B. ibid. 1966, i, 1327. 3.
M.
A GRIM DAY-ROOM SIR,-I have just visited in a geriatric unit a childless widow, nearly 80, who had a cerebral thrombosis a month ago. She made good progress at home, but was unable to rise from bed or chair, or to walk unaided, so she was admitted to hospital for physiotherapy and mobilisation. I found her in a small day-room with nine other patients. From a sitting position (and all except one were unable to stand without help) the only views from the too-high windows were of an iron fire-escape and brick walls. I was told that patients were brought into this room at 8 A.M. and not taken out again, except to the lavatories, until 8.30 P.M. Any little article which they might want with them during the 121/2 hours had to be held in their laps, because there were no lockers or personal tables. Meals were served in this room, when tables were placed down the centre, where visitors sat during visiting periods. So there was no change of scene at meal-times. Seven of the ten patients had obvious degenerative mental changes; one or two, because of flaccid muscles, sprawled precariously. There were no bells to summon help and visitors wandered into other rooms to find nurses. The lady I was visiting is mentally alert, and the plight of the more helpless patients distressed her. The patients’ beds, reasonably well spaced, were on pleasant verandahs overlooking attractive lawns. But it was impossible not to feel depressed in that grim day-room. The care of such patients is a considerable nursing problem, of course. But unfortunately there still seems to be something in the training of nurses which causes many to accept too readily the established arrangements; and something which produces in some nurses blind obedience to the letter rather than to the spirit of doctors’ instructions. Why else did kindhearted nurses seem perfectly content with that awful dayroom and happy because they were fulfilling the doctors’ orders to keep the patients up all day? Burton in Lonsdale, via Carnforth, MARIE A. SIMPSON. Lancashire.
ASSESSING Rh-SENSITISATION RISK SIR,-Undoubtedly the hypothesis set up for testing by Taylorand described in your columns2 is important for learning more of the Rh-group involvement in development of erythroblastosis. However, acceptance of this work as proof that sensitisation takes place in an Rh-negative girl born to an Rh-positive mother does not follow easily from a careful reading of Taylor’s presentation. Many aspects of her study are open to question. From the total of 236 original families only 157 are included in the analysis, the remainder being removed for reasons both good and bad prognostically for the grandchildren. But these exclusions contain 50% of the families with Rh-negative grandmothers, whereas only 11 % of those with Rh-positive grandmothers are left out. It is more likely that these figures should be nearly equal, though the large difference is not
mentioned. The two groups of mothers compared are selected differently. The first group comprised all families in the area with a child thought to have erythroblastosis, whereas the second was a non-random sample of unaffected families with Rh-negative mothers-namely, those referred to one prenatal Rh-testing service. Thus the manipulations involving the transfer of families from the first group to the second are not legitimate when used in Taylor’s way. You quote Taylor’s statement: " of children with Rh-positive grandmothers, 78-65% had erythroblastosis, whereas 60-29% of children with Rh-negative grandmothers were affected, an increase of 18% ". Since the size of the second group is arbitrary, the percentages calculated, and wrongly referred to as 1. Taylor, J. F. 2. Lancet, 1967,
i,
New Engl. 1205.
J. Med. 1967, 276,
547.