- Email: [email protected]
NON-SENSE AND SENSIBILITY
312
Points of View
of slender
fact
and gross
opinion
of which
they
are
examples. *
NON-SENSE AND SENSIBILITY Recent Criticisms of the National Health Service
*
Meanwhile they are widely said of Jewkes pamphlet
*
quoted. When The Lancet5
"
GORDON MCLACHLAN
SOMEWHAT surprisingly, the operation of the National Health Service has never been the subject of really deep, penetrating study; and the reason for this may be the same as the reason why the service has attracted so much specious abuse. It is a vast and complex organism which is beyond simple analysis by the kind of man-and-boywith-an-abacus type of social research to which we are addicted in this country, yet which offers many easy targets to people with grievances. In the face of this abuse, its general acceptance by the mass of the population sometimes astonishes outsiders, and indeed appears to be one of the wonders of the modern world-evidence no doubt of the creeping paralysis of " socialised medicine "! It is now being said that 1961 was notable for a number of attacks on the basic premises of the National Health Service. Since two were in the form of pamphlets written by "academic economists, 12 these might be expected to be substantial " (in the words of the Times 3) and worthy of some attention. Yet a study of the various criticisms suggests that altogether they are contradictory and add up to very little. Above all, the bases of the conclusions reached are almost always very slender. The essays of the economists show the inadequacy of a wholly economic appraisal of a subject whose form, development, and performance depends in great measure on social, political, and moral forces; and these particular critiques show lack of any deep knowledge and understanding of the development of medical services in Britain. Sadly, the narrowness of their approach might explain the indifferent record of the professional economists in the diagnosis and cure of the recurrent economic crises which are so much a feature of life in the 20th century. But, on the National Health Service, it seems that practically anything which appears in print, goes. It is indeed astonishing these days how avidly every conclusion on social affairs derived from a study labelled as " research " is eagerly reported and commented upon as worthy news, with scarcely a glance at the hypotheses and substance of the argument. As Mr. Malcolm Bradbury4 said recently, the usages of sociological thinking " have spilled over into the general thinking and the public consciousness much as the usages of literature spread in the nineteenth century. Every newspaper reporter and politician and social worker applies its assumptions." Unfortunately, it is questionable whether the public appetite for knowledge is matched by the quality of the fare. Thus many " reports " on issues in the public eye have found themselves in the admittedly thin bibliography of sociology, without being subjected to a scrutiny of the postulates, of the bases of the facts, of the solidity of the arguments. For the present, no doubt, the Jewkes or Lees pamphlets will be added to the literature of criticism of the National Health Service; but sophisticated students in the future seem unlikely to give much consideration to the milange 2.
Jewkes, J., Jewkes, S. The Genesis of the British National Health Service. Oxford, 1961. Lees, D. S. Health through Choice. Hobart paper no. 14. London:
3. 4.
Times, Dec. 27, 1961. Bradbury, M. Punch, Sept. 13,
1.
Institute of Economic Affairs. 1961. 1961.
Because Professor Jewkes occupies the chair of economic organisation in the University of Oxford and was a member of the Royal Commission on the Remuneration of Doctors and Dentists which reported last year, the pamphlet which he and his wife have written on the Health Service will be mistakenly regarded-especially outside this country-as embodying the results of a dispassionate inquiry ",
it drew upon itself a tart retort from the Jewkes. Yet the essential truth of the remark was soon to be borne out. The A.M.A. News, the news-sheet of the American Medical Association, wrote on Sept. 4: "
Oxford University Prof. John Jewkes and his wife, Sylvia, well qualified to judge the benefits and shortcomings of the British National Health Service. Professor Jewkes, whose field is economics, served in Britain’s Royal Commission on Remuneration of Doctors and Dentists, and his wife has collaborated with him on a number of published articles on social affairs. " When they suggest as they do in The Genesis of the British National Health Service, that the system adopted in England 13 years ago may have ’positively hindered the growth of the British Medical Service ’, their observation merits close attention on this side of the Atlantic." are
This seems rather a sweeping comment on a pamphlet of some 20,000 words which the authors describe as " not designed as a full assessment of the National Health Service ". The debate for and against the establishment of a National Health Service is very much a case of fighting the last war now. The plain fact of the matter is that the N.H.S. is no longer an experiment, the apparatus for which can be dismantled at whim, but a complex of highly organised services in operation, covering 50 million people day by day. Professor Jewkes may of course have been writing principally for the world outside Britain; but, if there are questions for the United Kingdom, these must surely be posed within the hypothesis that the National Health Service is the established order. The primary question then becomes: What are the arguments for disturbing the essentials of the present arrangements? This would require a rather more detailed consideration of all the conditioning factors-other than the economicfor the best provision of medical care than Professor Jewkes is apparently prepared to give. It is also worth noting that, whatever quantitative facts Professor and Mrs. Jewkes used, their most widely reported " positive " criticisms such as that given in the A.M.A. News, are not very adequately argued in the pamphlet. They seem to be giving a largely personal judgment which, though valid enough to them, owes more to a personal social and political philosophy than to an examination of the economics of the National Health Service in relation to the present situation in the United Kingdom, or the requirements of the times. Professor Jewkes as social philosopher has not quite the standing of Professor Jewkes as economist. *
*
*
recently, at the beginning of his extraordinary pamphlet, Dr. D. S. Lees2 wrote : "... so far, NHS (as we shall call it) has largely escaped More
5. Lancet, 1961, ii, 190. 6. ibid. 1961, ii, 313.
313 economic analysis. Thirteen years on, it seems time this strange neglect." But later he introduces a more cautious note:
to
repair
"
What follows does not pretend to be a definitive critique of NHS. This lies in the future, with the accumulation of data, more knowledge of foreign medical systems, and a sharpening awareness of the right questions to be asked about the role of health services."
prudent insurance, which suggests that judgment should await better information, and even the construction of fundamental questions, has not deterred him from venturing well beyond his initial, self-imposed limits. Yet it is still difficult to relate his sparse facts directly to his weighty judgments given. Here, once again, the economist is a bit shy on the particular: the social theorist has taken This
control. Nevertheless it is worth looking closely at some of Dr. Lees’ fundamental hypotheses; for it is hard to believe many people conscious of the complexity of the age, and with a sense of balance, will be ready to accept them. The bleak assumptions, with their pre-Keynesian overtones, are more than a little crude, for they could only apply to societies centuries before Keynes was born. " The market", he tells us, " is generally superior to the ballot box as a means of registering consumer preference." Yet later comes his proposal to introduce more (local) ballot boxes-to stimulate competition and therefore the forces of the market ":
over
"
"The control of hospital services should be dispersed by transferring ownership from the central government to local authorities and private institutions."
Abundant experience here and abroad has shown there is no magic dynamism in free competition; otherwise there would not have been the vast differences in the quality of the
pre-1948 hospital services provided by such neighbouring local authorities as Middlesex on the one hand and Bucks and Herts County Councils on the other. It seems that Dr. Lees is dealing in theoretical speculations without having examined the existing evidence or the working of the arrangements to which he seeks a return. It also seems his knowledge of the present operation of the health services is scant; for the upgrading of the old neglected hospitals, which has been one of the features since 1948, has come from comparisons of local differences and the resultant pressures. Indeed with the record of improvement of hospitals over the past few years, such observations as the following seem to come from viewing the National Health Service in a distorting mirror, from the wrong end of a powerful telescope: "The NHS has a virtual monopoly of medical care and absence of substitutes means that there are no strong external forces making for improvements in quality and efficiency. Within NHS, insistence on a single standard of service for all eliminates the internal forces making for improvement that would be generated by emulation between diverse standards ..." "... the most acute danger of the NHS is that it will prevent the emergence of more effective methods of medical care."
An
the
even more
extraordinary assumption is also made in
statement:
"
Medical care is a personal consumption good, not markedly different from the generality of goods bought by consumers. Therefore if the aim is to maximise consumer satisfaction, medical care should be supplied through the market" (my
italics). How far does this philosophy, taken to its logical end, fit in with the practicalities of our time? Dr. Lees is
clearly an enthusiastic exponent of the absolute freedom of the market, and his claims for the market’s efficiency seem endless: "
Unlike the market, NHS contains no spontaneous forces to redress imbalance. The shortage of dentists was intensified by free services and has been perpetuated by official refusals to expand the capacity of the Dental Schools ..."
working
Does this mean that Dr. Lees would leave to free enterprise the development of universities and of dental and medical schools, so as to redress imbalances ? It does. How ? By " loans "-from whom, or in what way, he does not say; but it is unlikely they will be from other than official sources. It is interesting to muse how far his own university-Keele-or any of the newer foundations in the United Kingdom would have developed through the market " and without " official " help. But above all he is contradictory and purblind to the realities of politics: "
"
care
It is another weakness of NHS that it into the cockpit of politics..."
but
on
the
...
plunges
medical
next
page State finance of all or part of medical fees is quite compatible with this freedom " (of doctors and dentists to settle with their patients)"
as
if any method of State finance
recourse to
can
be used without
politics!
It is difficult to avoid the conclusion that this thesis of the " market’s " efficiency is as nonsensical as the title, Health Through Choice, with its linguistic muddle as to what can be chosen. *
*
*
Because of the size and sprawl of the National Health Service, a valid assessment of its operation is likely to be beyond the resources of all but a multidisciplined comprehensive survey, on a scale hitherto unattempted in Britain. Yet the superficial impression that it is a monolith, and that its apparent defects owe most to its form, has attracted theorists of structure. The speculations of Dr. Seale7 are one of the latest of a long line of rather academic dissertations from would-be reformers. In his Lloyd Roberts lecture,8 the Minister of Health laid to rest the ancient notion of the prescriptive right of any service to a proportion of a theoretical national income. No more can Dr. Seale’s other suggestions stand up to close scrutiny. For the real fact is that his theoretical model at heart does no more than perpetuate what the present arrangements are designed to do. On administration he says: "
The Government will be responsible only for major policy within the service. This includes the size of the health-service tax [that is, Dr. Seale’s new’ method of financing!], the ratio of capital to current expenditure, the range of services to be supplied free of direct charges, and the scale of any charges which patients may be required to pay."
responsibilities are at present exercised by the Government; the only difference is that these proposals involve a redistribution of personal wealth through the substitution of a Health Service tax for general taxation, National Insurance contributions, and the rates-for the peculiar reason that "the individual citizen will then know how much he is paying for the service All these
Dr. Seale goes
on to
say: " The Government will allocate money from the health service fund to the regions. The basic criterion for assessing 7. 8.
Seale, J. R. ibid. p. 476. Powell, J. E. The Lloyd Roberts lecture delivered before the Royal Society of Medicine on Oct. 19, 1961. See Lancet, 1961, ii, 968.
314 distribution will be the population will be the sole criterion."
covered, and eventually it
There may be different ideas about whether " population to be served " should be the main criterion; indeed, because of the fairly obvious differences in morbidity throughout the country, this is very unlikely ever to be the sole criterion for the allocation of resources for health services. The point is, however, that in fact this is exactly the present machinery for financing. Dr. Seale’s outline illustrates the common fault of most non-radical reforms proposed for the Health Service, which is that they do not disturb the power centres in any way, and contribute almost nothing to reducing the real stresses endemic to, " not a monolithic structure, but a web of personal services in which a great deal of individual personal the reformer merely judgment is exercised. Invariably " shell an ", leaving untouched over-simplified peddles the question of the local procedures which cause most of the pother. These have been evolved to meet " political " and practical issues not discussed in the proposed reforms, and will still be as real under any system. Again, later in his paper, in discussing the development of more research and information- on services, Dr. Seale does not in effect propose any change in the present methods or channels used for the collection and dissemination of information. Nor does he seem to appreciate how far thinking has already gone on this subject, which is vast. His emphasis on a small permanent institution for research, based on a university, shows a lack of understanding of the range of operational studies needed for a rational appraisal of what is actually happening. There is already a number of research groups based on universities, looking at some of the many facets of the involved question of health services, but there are not nearly enough of them! "
Dr. Seale is no doubt to be commended for his energy and initiative, but he is propounding an oversimplified solution for a set of very complex problems. To construct a simple casing and compartments into which intricate mechanical and electronic devices can readily be fitted is a suitable undergraduate exercise, but little else; for it still leaves untouched the electronic and computing problems. *
*
*
The other matter on which Dr. Seale has been widely quoted is the current debate on whether or not there is a shortage of doctors. The subject has generated a great deal of heat, but the articles and correspondence about it merely confirm the confusion. Concerning the number of doctors to be trained, the Government based their policy on the findings of the Willink Committee. Since the Willink figures have now been shown to be in error, the Government have changed their plans; but they are still at fault. Above all, the National Health Service has to be arraigned because so many British-trained doctors emigrate; but though there has been much comment there is a curious lack of facts about the rate of emigration over the years, and whether emigration is a result of the National Health Service. That so many bitter things have been said-without real evidence of changes in the rate of emigration, or of a significant change in the net total number of doctors in practice in Great Britain since 1948-is strange to a Scot like myself who was brought up to understand that universities and medical schools do not exist merely to produce graduates for home consumption. Whether there is really a grave shortage of
medically qualified persons in this country is not yet clear, and information of real value cannot readily be obtained. The debate, however, poses questions which, because they relate to standards of practice and the real multiprofessional requirements of medical care, go much deeper than is evident from the comment or correspondence on the subject till now. From the available data, it is often deduced that, were it not for the non-British university graduates, especially in the hospital service, things would be parlous. It is also undeniable that these graduates are coming to this country to continue their training and education, and there must be some attraction here. If such training and education needs the discipline of actual work to be effective, so long as the training posts in British hospitals are attractive and the standards of practice are recognised to be high, this large group of practitioners is a factor which always must be reckoned in the count and distribution of the medical force. Here again the emphasis of criticism is wrong at this time. The urgent problem is not that there is a shortage which must be remedied immediately, but rather that the arrangements for the training-in-service of hospital doctors is unsatisfactory. The real criticism which can be levelled at the hospital authorities is that they have not yet fully organised themselves, in association with universities, to make the best use of this medical influx and to ensure its continuance by providing these doctors with the facilities they need for postgraduate
experience. At the higher level of hospital staffing the evidence of a shortage of consultants is doubtful; but it may be relevant to point out that, should a crisis develop, a simple administrative decision could correct it until a long-term solution is found. At the moment, all consultants must resign at the age of 65. It would not be an exaggeration to say that many resent this and would certainly be prepared to carry on for a longer period if, say, the retiring age were raised to
67. *
*
*
The other whips and scorpions applied to the National Health Service in 1961 were those which appeared in more popular journals (pace the serious " Sundays "); and, if they set out gravely to discuss the major issues, they fell sadly short of target. One 11 was almost exclusively a horror story of the " plight of British hospitals ", and its level of contribution towards solving the current complex logistical problems of the planning of services and construction of hospital buildings may be judged by one of its climactic conclusions, in the words of an " eminent architect ": " If only people would let us get on with the job without endless delays, we could." .
The Observer’s five-article probe 10 suffered from an oversimplification of complex issues, and therefore from a distortion of perspective. If the author’s objective was to survey the Service, he set out, of course, to do the impossible. But it was interesting to note that, while criticising the way in which it was developing, the articles reiterated his faith in the ideal of a National Health Service. *
Looking there is
no
9. 10.
*
*
at the result of the 1961 bowl of brickbats, clear pattern of marks on the target, and it is
Sunday Times, Nov. 12 and 19, 1961. Observer, Nov. 5, 12, 19, and 26, and Dec. 3, 1961.
315
distinguish from them a sensible positive alternative proposal to the present arrangements. Even Dr. Lees shied away from the construction of a blueprint for an alternative service, although he did indicate lines of approach to reform. It is a pity, however, that he did not, in his preliminary reconnaissance, look at published studies of foreign systems approximating to an application of the principles he formulates. In particular there is a revealing report of an ambitious study commissioned by the Department of Health of New York, and published just over a year ago by the School of Public Health and Administrative Medicine of Columbia University, on the eight Blue Cross Plans serving New York residents.ll Perhaps the land of free enterprise might have been expected to turn towards a freer operation of the " market " mechanism, but this is not so. The Columbia group recommend that a Hospital Review and Planning Commission should be established at State level with, among others, the following functions:
impossible
to
(c) establish a basic State-wide system of fact-gathering about the utilisation of hospitals, nursing homes and related services... (f) serve as an official advisory body to the State Department of Insurance with respect to requests for subscriber rate increases by pre-payment plans; (g) serve as an official advisory body to the State Department of Welfare, etc., with respect to licensing of new construction, approval of renovation or expansion of services or facilities. Such construction should not be licensed, approved or financed unless recommended by the appropriate Regional Council (my italics).
Also, Regional Hospital Review and Planning Councils should be established in such geographical areas as are recommended by the Hospital Review and Planning Commission. These councils should have the following functions:
(a) collect statistics on hospital organisation services and use, such as admission, length of stay, credentials of medical staffs, tissue committee reports, outpatient visits, etc.... (d) certify to the Hospital Review and Planning Commission that specific proposals for hospital construction or renovation, expansion of bed capacity and/or services meet the criteria of a Regional master plan. As noted above, no construction or expansion should be licensed or financed without such approval
(my italics). Later
"
proposed that: Blue Cross return to its original principle of paying only accredited hospitals " (i.e., hospitals with basic minimum standards of facilities). on
it is
It thus seems that the mechanism of the " market " and the free operation of competition and insurance cover is not good enough to produce a satisfactory system in the State of New York. Above all, the implication that there is need to rationalise development (i.e., the regulation of the market ") should not escape notice; for the report recommends that certain planning functions (which, it will be seen, are somewhat similar to those exercised by regional hospital boards in the United Kingdom) should be centralised and subject to regulation. "
This report
was the result of a large-scale study, and is data on the working of the plans and services as the Jewkes and Lees dissertations are short of real information. Yet the important deduction to be drawn from this documented, evidence should not be that the relatively unregulated " American " arrangements are bad
as full of basic
11.
Payment for Hospital Care in New York State: a report on the eight Blue Cross Plans serving New York residents. School of Public Health and Administrative Medicine, Columbia University.
in need of ultraradical structural reform because they fail to meet all the needs. It is too often forgotten that the arrangements for social services such as health almost universally mirror the pattern of organisation of the general social and fiscal system of the country concerned. In societies of roughly similar cultures and moral attitudes, there are, however, certain common basic hypotheses in the application of such arrangementsclinical freedom; respect for the individual; the personal nature of the association between doctor and patient. In the same way, despite differences in administrative organisations, the basic, urgent problems are broadly similar: how to ensure uniformly high standards of care over the whole population; how best to ensure that the needs of all citizens are met; how to ensure a rightful share of national resources; how to make the best use of such resources to meet rising demand. Many of the charges continually being laid at the door of the National Health Service could equally be made against what pass for freer systems. and
are
.
*
*
*
such criticisms as are reviewed here, one wonders whether the Service to which they refer would be recognised by most of those working in, or associated with, the N.H.S. The latter is certainly not a " monolithic " structure, but is made up of a number of services and units-some excellent, some good, some obviously open to improvement. Much of the improvement called for reflects past shortcomings which will eventually be met, whether there is a national system or not. Much of it can only come from official prompting and financing through a nationalised system. On the other hand, a very great deal of the quality rating and room for improvement in the units and services making up any system depends on the human factor, which in turn depends on morale. It is therefore well occasionally to look at the basic platitudes concerning the National Health Service which we too often forget. No large enterprise consisting of a sprawl of institutions depending on people of all kinds of professions, trades, skills, and above all, character, is ever likely to be perfect down to the last detail. Whatever the arguments before 1946, a national health service is probably very suitable for the present shape and mores of British society; and as far as the development of institutions and services is concerned, the present scheme, for all its faults, is broadly appropriate to the level and distribution of wealth over the nation. It is very unlikely that this social and economic pattern will be altered considerably in the foreseeable future. Any assertion that the National Health Service is responsible for hindering research and for holding back real improvements in practice in the United Kingdom cannot survive close examination; because, in the event, it is the compulsion felt by individuals which produces the kind of results described in the articles on research and the practice of medicine in the medical journals week in and week out. If these articles are indeed evidence, it can be added to the solid achievements of the health system since 1948. These achievements, though real enough, often go unsung because they are generally accepted as the normal pattern of life. Because the health services are nationalised, the pressures for reform likely to be most heeded in the near and intermediate future-because they will tend in the best British tradition to be pragmatic-will almost certainly be those for rationalisation of organisation. The
Looking
at
316
important thing will be to keep under constant vigilance any tendency towards undue bureaucratic encroachment on those basic principles which should apply to health services, no matter what the framework in which -they function. Principal among these are that a health service should consist of a combination of personal services, and that whatever the system, formal or loose, it should enshrine such a combination and enable the good practice of medicine
flourish. the Minister has, also in his to
Recently Lloyd Roberts lecture, expounded a theory embodying an appeal to use resources " more wisely, more cunningly, more effectively." Many will, no doubt, construe this as a devilish warning hatched up in Great George Street. However, it is possible to recognise in it a sensible call for a cool and close look at how and why we are doing things now. It is above all important that standards of hospitals and services should be adequately high and that such standards should be universal. It is no more immoral or impossible for a nationalised system of hospitals to be efficient than it is for an unregulated system of private unlinked institutions. In the present state of affairs it is neither sufficient for the medical profession to be ostrich-like on matters of administration, nor to sigh à la recherche du temps perdu, which never was. It therefore behoves them to be as well informed as possible on the real issues as well as on the basis and marginal nature of much of the criticisms now being made and the alternatives offered. If among the basic platitudes there is also-as there must surely always be-the right and choice of private practice, is one of the prime honours not satisfied ? Do the mass of individual doctors really wish to involve themselves in a free, undignified scramble for existence, under the control of an economic " market ", with the prizes made up of an accumulation of private bargains with patients ? Stripped of the persiflage, this is the real alternative gate of choice at which the medical profession seems to be standing now, if the efficiency of the-" economic "-market, or any related theory is elevated to a creed and basis of an alternative to the National Health Service. To go through this gate might, however, mean the final rejection of the special ethic surrounding medicine, and the acceptance of an equation with other professional groups. It is true there seems to be disquiet; but frustration is not the monopoly of the medical profession or parts of it. The equivalents of the dissatisfied senior registrars, and consultants without a satisfactory degree of merit award, are to be found in all professions and enterprises. The I.C.I., for all its reported efficiency, has doubtless its quota of discontents under training, or on the career ladder, no less than the National Health Service; but an important difference is that, while there may be freedom to discuss and to publish damning criticisms of the crass" in ness of both enterprises, the forces of the " market jobs in the commercial and industrial world are a little restrictive on those critics seeking alternative outlets. The fact is, we are bemused and slightly embarrassed by meaningless terms such as " socialised medicine "; but the paradox is that there is possibly more absolute clinical freedom in 1962 in the National Health Service than under more competitive conditions. What price Tissue Committees for all hospitals in the United Kingdom ? The * is more a sign of the times anger of Dr. James Porter than the result of a nationalised service. Yet the field of health services is rich in one particular *
A cousin of the
original A.Y.M.
asset which can and should be exploited for the common good. This is the moral atmosphere that can be generated in a service devoted to the relief of suffering. It is no exaggeration to say that the morale of the health services, whether publicly or privately organised, depends largely on the moral and intellectual leadership exercised by the medical profession, not only in the personal relationships that each doctor has with his patients but also in the sum total of doctors’ attitudes towards, and understanding of, the real problems of administering and developing social services on a 20th-century scale. In the case of the National Health Service those problems arise only in
minor part from defects in the administrative structure. They become acute because of shortfalls in morale, in intellectual discipline, in education, in understanding, and in social behaviour. It is to failure in these qualities we owe most of the crises of our times, and the effects are only too apparent both in the health services and in the flurried debates on them. Part of this is perhaps due to insufficient information on which to judge the operation of the services-and there is a case for more and better data. But much of it is due to a lack of appreciation of the real issues. In formulating questions about what can be done about the National Health Service, in listening to thundering denunciations, and in looking at abracadabra solutions, this should soberly be borne in mind.
Special
Articles
MASSIVE NIACIN TREATMENT IN SCHIZOPHRENIA Review of
a
Nine-year Study
H. OSMOND M.R.C.S., D.P.M. LATE MEDICAL
SUPERINTENDENT, SASKATCHEWAN HOSPITAL, WEYBURN, SASKATCHEWAN
A. HOFFER
M.D., Ph.D. DIRECTOR OF PSYCHIATRIC RESEARCH, PSYCHIATRIC SERVICES LOCATED at UNIVERSITY HOSPITAL, SASKATOON
BRANCH,
OUR interest in niacin began at the end of 1951 when exploring ideas developed with Dr. John Smythies (Osmond and Smythies 1952). We thought that schizophrenia might be caused by a disorder of adrenaline metabolism in which the body produced a substance with psychological effects like those of mescaline or d-lysergic acid diethylamide. These ideas have since been called the adrenaline metabolite theory of schizophrenia, and the adrenochrome hypothesis is a special example of that
theory. From time to time we asked ourselves what, supposing the right track, would be an ideal treatment for schizophrenia. If our adrenaline metabolite idea was correct, then anything which reduced adrenaline production should help. We decided to try niacin because it might compete for methyl groups and so prevent more noradrenaline being methylated to adrenaline. The introduction of a new treatment depends on a few cases responding favourably at the start. We had such luck with half a dozen cases early in 1952, the most dramatic being that of a boy of 17 admitted in February with acute schizophrenia: A few days earlier he had become excited, overactive, silly, we were on
Points of View
of slender
fact
and gross
opinion
of which
they
are
examples. *
NON-SENSE AND SENSIBILITY Recent Criticisms of the National Health Service
*
Meanwhile they are widely said of Jewkes pamphlet
*
quoted. When The Lancet5
"
GORDON MCLACHLAN
SOMEWHAT surprisingly, the operation of the National Health Service has never been the subject of really deep, penetrating study; and the reason for this may be the same as the reason why the service has attracted so much specious abuse. It is a vast and complex organism which is beyond simple analysis by the kind of man-and-boywith-an-abacus type of social research to which we are addicted in this country, yet which offers many easy targets to people with grievances. In the face of this abuse, its general acceptance by the mass of the population sometimes astonishes outsiders, and indeed appears to be one of the wonders of the modern world-evidence no doubt of the creeping paralysis of " socialised medicine "! It is now being said that 1961 was notable for a number of attacks on the basic premises of the National Health Service. Since two were in the form of pamphlets written by "academic economists, 12 these might be expected to be substantial " (in the words of the Times 3) and worthy of some attention. Yet a study of the various criticisms suggests that altogether they are contradictory and add up to very little. Above all, the bases of the conclusions reached are almost always very slender. The essays of the economists show the inadequacy of a wholly economic appraisal of a subject whose form, development, and performance depends in great measure on social, political, and moral forces; and these particular critiques show lack of any deep knowledge and understanding of the development of medical services in Britain. Sadly, the narrowness of their approach might explain the indifferent record of the professional economists in the diagnosis and cure of the recurrent economic crises which are so much a feature of life in the 20th century. But, on the National Health Service, it seems that practically anything which appears in print, goes. It is indeed astonishing these days how avidly every conclusion on social affairs derived from a study labelled as " research " is eagerly reported and commented upon as worthy news, with scarcely a glance at the hypotheses and substance of the argument. As Mr. Malcolm Bradbury4 said recently, the usages of sociological thinking " have spilled over into the general thinking and the public consciousness much as the usages of literature spread in the nineteenth century. Every newspaper reporter and politician and social worker applies its assumptions." Unfortunately, it is questionable whether the public appetite for knowledge is matched by the quality of the fare. Thus many " reports " on issues in the public eye have found themselves in the admittedly thin bibliography of sociology, without being subjected to a scrutiny of the postulates, of the bases of the facts, of the solidity of the arguments. For the present, no doubt, the Jewkes or Lees pamphlets will be added to the literature of criticism of the National Health Service; but sophisticated students in the future seem unlikely to give much consideration to the milange 2.
Jewkes, J., Jewkes, S. The Genesis of the British National Health Service. Oxford, 1961. Lees, D. S. Health through Choice. Hobart paper no. 14. London:
3. 4.
Times, Dec. 27, 1961. Bradbury, M. Punch, Sept. 13,
1.
Institute of Economic Affairs. 1961. 1961.
Because Professor Jewkes occupies the chair of economic organisation in the University of Oxford and was a member of the Royal Commission on the Remuneration of Doctors and Dentists which reported last year, the pamphlet which he and his wife have written on the Health Service will be mistakenly regarded-especially outside this country-as embodying the results of a dispassionate inquiry ",
it drew upon itself a tart retort from the Jewkes. Yet the essential truth of the remark was soon to be borne out. The A.M.A. News, the news-sheet of the American Medical Association, wrote on Sept. 4: "
Oxford University Prof. John Jewkes and his wife, Sylvia, well qualified to judge the benefits and shortcomings of the British National Health Service. Professor Jewkes, whose field is economics, served in Britain’s Royal Commission on Remuneration of Doctors and Dentists, and his wife has collaborated with him on a number of published articles on social affairs. " When they suggest as they do in The Genesis of the British National Health Service, that the system adopted in England 13 years ago may have ’positively hindered the growth of the British Medical Service ’, their observation merits close attention on this side of the Atlantic." are
This seems rather a sweeping comment on a pamphlet of some 20,000 words which the authors describe as " not designed as a full assessment of the National Health Service ". The debate for and against the establishment of a National Health Service is very much a case of fighting the last war now. The plain fact of the matter is that the N.H.S. is no longer an experiment, the apparatus for which can be dismantled at whim, but a complex of highly organised services in operation, covering 50 million people day by day. Professor Jewkes may of course have been writing principally for the world outside Britain; but, if there are questions for the United Kingdom, these must surely be posed within the hypothesis that the National Health Service is the established order. The primary question then becomes: What are the arguments for disturbing the essentials of the present arrangements? This would require a rather more detailed consideration of all the conditioning factors-other than the economicfor the best provision of medical care than Professor Jewkes is apparently prepared to give. It is also worth noting that, whatever quantitative facts Professor and Mrs. Jewkes used, their most widely reported " positive " criticisms such as that given in the A.M.A. News, are not very adequately argued in the pamphlet. They seem to be giving a largely personal judgment which, though valid enough to them, owes more to a personal social and political philosophy than to an examination of the economics of the National Health Service in relation to the present situation in the United Kingdom, or the requirements of the times. Professor Jewkes as social philosopher has not quite the standing of Professor Jewkes as economist. *
*
*
recently, at the beginning of his extraordinary pamphlet, Dr. D. S. Lees2 wrote : "... so far, NHS (as we shall call it) has largely escaped More
5. Lancet, 1961, ii, 190. 6. ibid. 1961, ii, 313.
313 economic analysis. Thirteen years on, it seems time this strange neglect." But later he introduces a more cautious note:
to
repair
"
What follows does not pretend to be a definitive critique of NHS. This lies in the future, with the accumulation of data, more knowledge of foreign medical systems, and a sharpening awareness of the right questions to be asked about the role of health services."
prudent insurance, which suggests that judgment should await better information, and even the construction of fundamental questions, has not deterred him from venturing well beyond his initial, self-imposed limits. Yet it is still difficult to relate his sparse facts directly to his weighty judgments given. Here, once again, the economist is a bit shy on the particular: the social theorist has taken This
control. Nevertheless it is worth looking closely at some of Dr. Lees’ fundamental hypotheses; for it is hard to believe many people conscious of the complexity of the age, and with a sense of balance, will be ready to accept them. The bleak assumptions, with their pre-Keynesian overtones, are more than a little crude, for they could only apply to societies centuries before Keynes was born. " The market", he tells us, " is generally superior to the ballot box as a means of registering consumer preference." Yet later comes his proposal to introduce more (local) ballot boxes-to stimulate competition and therefore the forces of the market ":
over
"
"The control of hospital services should be dispersed by transferring ownership from the central government to local authorities and private institutions."
Abundant experience here and abroad has shown there is no magic dynamism in free competition; otherwise there would not have been the vast differences in the quality of the
pre-1948 hospital services provided by such neighbouring local authorities as Middlesex on the one hand and Bucks and Herts County Councils on the other. It seems that Dr. Lees is dealing in theoretical speculations without having examined the existing evidence or the working of the arrangements to which he seeks a return. It also seems his knowledge of the present operation of the health services is scant; for the upgrading of the old neglected hospitals, which has been one of the features since 1948, has come from comparisons of local differences and the resultant pressures. Indeed with the record of improvement of hospitals over the past few years, such observations as the following seem to come from viewing the National Health Service in a distorting mirror, from the wrong end of a powerful telescope: "The NHS has a virtual monopoly of medical care and absence of substitutes means that there are no strong external forces making for improvements in quality and efficiency. Within NHS, insistence on a single standard of service for all eliminates the internal forces making for improvement that would be generated by emulation between diverse standards ..." "... the most acute danger of the NHS is that it will prevent the emergence of more effective methods of medical care."
An
the
even more
extraordinary assumption is also made in
statement:
"
Medical care is a personal consumption good, not markedly different from the generality of goods bought by consumers. Therefore if the aim is to maximise consumer satisfaction, medical care should be supplied through the market" (my
italics). How far does this philosophy, taken to its logical end, fit in with the practicalities of our time? Dr. Lees is
clearly an enthusiastic exponent of the absolute freedom of the market, and his claims for the market’s efficiency seem endless: "
Unlike the market, NHS contains no spontaneous forces to redress imbalance. The shortage of dentists was intensified by free services and has been perpetuated by official refusals to expand the capacity of the Dental Schools ..."
working
Does this mean that Dr. Lees would leave to free enterprise the development of universities and of dental and medical schools, so as to redress imbalances ? It does. How ? By " loans "-from whom, or in what way, he does not say; but it is unlikely they will be from other than official sources. It is interesting to muse how far his own university-Keele-or any of the newer foundations in the United Kingdom would have developed through the market " and without " official " help. But above all he is contradictory and purblind to the realities of politics: "
"
care
It is another weakness of NHS that it into the cockpit of politics..."
but
on
the
...
plunges
medical
next
page State finance of all or part of medical fees is quite compatible with this freedom " (of doctors and dentists to settle with their patients)"
as
if any method of State finance
recourse to
can
be used without
politics!
It is difficult to avoid the conclusion that this thesis of the " market’s " efficiency is as nonsensical as the title, Health Through Choice, with its linguistic muddle as to what can be chosen. *
*
*
Because of the size and sprawl of the National Health Service, a valid assessment of its operation is likely to be beyond the resources of all but a multidisciplined comprehensive survey, on a scale hitherto unattempted in Britain. Yet the superficial impression that it is a monolith, and that its apparent defects owe most to its form, has attracted theorists of structure. The speculations of Dr. Seale7 are one of the latest of a long line of rather academic dissertations from would-be reformers. In his Lloyd Roberts lecture,8 the Minister of Health laid to rest the ancient notion of the prescriptive right of any service to a proportion of a theoretical national income. No more can Dr. Seale’s other suggestions stand up to close scrutiny. For the real fact is that his theoretical model at heart does no more than perpetuate what the present arrangements are designed to do. On administration he says: "
The Government will be responsible only for major policy within the service. This includes the size of the health-service tax [that is, Dr. Seale’s new’ method of financing!], the ratio of capital to current expenditure, the range of services to be supplied free of direct charges, and the scale of any charges which patients may be required to pay."
responsibilities are at present exercised by the Government; the only difference is that these proposals involve a redistribution of personal wealth through the substitution of a Health Service tax for general taxation, National Insurance contributions, and the rates-for the peculiar reason that "the individual citizen will then know how much he is paying for the service All these
Dr. Seale goes
on to
say: " The Government will allocate money from the health service fund to the regions. The basic criterion for assessing 7. 8.
Seale, J. R. ibid. p. 476. Powell, J. E. The Lloyd Roberts lecture delivered before the Royal Society of Medicine on Oct. 19, 1961. See Lancet, 1961, ii, 968.
314 distribution will be the population will be the sole criterion."
covered, and eventually it
There may be different ideas about whether " population to be served " should be the main criterion; indeed, because of the fairly obvious differences in morbidity throughout the country, this is very unlikely ever to be the sole criterion for the allocation of resources for health services. The point is, however, that in fact this is exactly the present machinery for financing. Dr. Seale’s outline illustrates the common fault of most non-radical reforms proposed for the Health Service, which is that they do not disturb the power centres in any way, and contribute almost nothing to reducing the real stresses endemic to, " not a monolithic structure, but a web of personal services in which a great deal of individual personal the reformer merely judgment is exercised. Invariably " shell an ", leaving untouched over-simplified peddles the question of the local procedures which cause most of the pother. These have been evolved to meet " political " and practical issues not discussed in the proposed reforms, and will still be as real under any system. Again, later in his paper, in discussing the development of more research and information- on services, Dr. Seale does not in effect propose any change in the present methods or channels used for the collection and dissemination of information. Nor does he seem to appreciate how far thinking has already gone on this subject, which is vast. His emphasis on a small permanent institution for research, based on a university, shows a lack of understanding of the range of operational studies needed for a rational appraisal of what is actually happening. There is already a number of research groups based on universities, looking at some of the many facets of the involved question of health services, but there are not nearly enough of them! "
Dr. Seale is no doubt to be commended for his energy and initiative, but he is propounding an oversimplified solution for a set of very complex problems. To construct a simple casing and compartments into which intricate mechanical and electronic devices can readily be fitted is a suitable undergraduate exercise, but little else; for it still leaves untouched the electronic and computing problems. *
*
*
The other matter on which Dr. Seale has been widely quoted is the current debate on whether or not there is a shortage of doctors. The subject has generated a great deal of heat, but the articles and correspondence about it merely confirm the confusion. Concerning the number of doctors to be trained, the Government based their policy on the findings of the Willink Committee. Since the Willink figures have now been shown to be in error, the Government have changed their plans; but they are still at fault. Above all, the National Health Service has to be arraigned because so many British-trained doctors emigrate; but though there has been much comment there is a curious lack of facts about the rate of emigration over the years, and whether emigration is a result of the National Health Service. That so many bitter things have been said-without real evidence of changes in the rate of emigration, or of a significant change in the net total number of doctors in practice in Great Britain since 1948-is strange to a Scot like myself who was brought up to understand that universities and medical schools do not exist merely to produce graduates for home consumption. Whether there is really a grave shortage of
medically qualified persons in this country is not yet clear, and information of real value cannot readily be obtained. The debate, however, poses questions which, because they relate to standards of practice and the real multiprofessional requirements of medical care, go much deeper than is evident from the comment or correspondence on the subject till now. From the available data, it is often deduced that, were it not for the non-British university graduates, especially in the hospital service, things would be parlous. It is also undeniable that these graduates are coming to this country to continue their training and education, and there must be some attraction here. If such training and education needs the discipline of actual work to be effective, so long as the training posts in British hospitals are attractive and the standards of practice are recognised to be high, this large group of practitioners is a factor which always must be reckoned in the count and distribution of the medical force. Here again the emphasis of criticism is wrong at this time. The urgent problem is not that there is a shortage which must be remedied immediately, but rather that the arrangements for the training-in-service of hospital doctors is unsatisfactory. The real criticism which can be levelled at the hospital authorities is that they have not yet fully organised themselves, in association with universities, to make the best use of this medical influx and to ensure its continuance by providing these doctors with the facilities they need for postgraduate
experience. At the higher level of hospital staffing the evidence of a shortage of consultants is doubtful; but it may be relevant to point out that, should a crisis develop, a simple administrative decision could correct it until a long-term solution is found. At the moment, all consultants must resign at the age of 65. It would not be an exaggeration to say that many resent this and would certainly be prepared to carry on for a longer period if, say, the retiring age were raised to
67. *
*
*
The other whips and scorpions applied to the National Health Service in 1961 were those which appeared in more popular journals (pace the serious " Sundays "); and, if they set out gravely to discuss the major issues, they fell sadly short of target. One 11 was almost exclusively a horror story of the " plight of British hospitals ", and its level of contribution towards solving the current complex logistical problems of the planning of services and construction of hospital buildings may be judged by one of its climactic conclusions, in the words of an " eminent architect ": " If only people would let us get on with the job without endless delays, we could." .
The Observer’s five-article probe 10 suffered from an oversimplification of complex issues, and therefore from a distortion of perspective. If the author’s objective was to survey the Service, he set out, of course, to do the impossible. But it was interesting to note that, while criticising the way in which it was developing, the articles reiterated his faith in the ideal of a National Health Service. *
Looking there is
no
9. 10.
*
*
at the result of the 1961 bowl of brickbats, clear pattern of marks on the target, and it is
Sunday Times, Nov. 12 and 19, 1961. Observer, Nov. 5, 12, 19, and 26, and Dec. 3, 1961.
315
distinguish from them a sensible positive alternative proposal to the present arrangements. Even Dr. Lees shied away from the construction of a blueprint for an alternative service, although he did indicate lines of approach to reform. It is a pity, however, that he did not, in his preliminary reconnaissance, look at published studies of foreign systems approximating to an application of the principles he formulates. In particular there is a revealing report of an ambitious study commissioned by the Department of Health of New York, and published just over a year ago by the School of Public Health and Administrative Medicine of Columbia University, on the eight Blue Cross Plans serving New York residents.ll Perhaps the land of free enterprise might have been expected to turn towards a freer operation of the " market " mechanism, but this is not so. The Columbia group recommend that a Hospital Review and Planning Commission should be established at State level with, among others, the following functions:
impossible
to
(c) establish a basic State-wide system of fact-gathering about the utilisation of hospitals, nursing homes and related services... (f) serve as an official advisory body to the State Department of Insurance with respect to requests for subscriber rate increases by pre-payment plans; (g) serve as an official advisory body to the State Department of Welfare, etc., with respect to licensing of new construction, approval of renovation or expansion of services or facilities. Such construction should not be licensed, approved or financed unless recommended by the appropriate Regional Council (my italics).
Also, Regional Hospital Review and Planning Councils should be established in such geographical areas as are recommended by the Hospital Review and Planning Commission. These councils should have the following functions:
(a) collect statistics on hospital organisation services and use, such as admission, length of stay, credentials of medical staffs, tissue committee reports, outpatient visits, etc.... (d) certify to the Hospital Review and Planning Commission that specific proposals for hospital construction or renovation, expansion of bed capacity and/or services meet the criteria of a Regional master plan. As noted above, no construction or expansion should be licensed or financed without such approval
(my italics). Later
"
proposed that: Blue Cross return to its original principle of paying only accredited hospitals " (i.e., hospitals with basic minimum standards of facilities). on
it is
It thus seems that the mechanism of the " market " and the free operation of competition and insurance cover is not good enough to produce a satisfactory system in the State of New York. Above all, the implication that there is need to rationalise development (i.e., the regulation of the market ") should not escape notice; for the report recommends that certain planning functions (which, it will be seen, are somewhat similar to those exercised by regional hospital boards in the United Kingdom) should be centralised and subject to regulation. "
This report
was the result of a large-scale study, and is data on the working of the plans and services as the Jewkes and Lees dissertations are short of real information. Yet the important deduction to be drawn from this documented, evidence should not be that the relatively unregulated " American " arrangements are bad
as full of basic
11.
Payment for Hospital Care in New York State: a report on the eight Blue Cross Plans serving New York residents. School of Public Health and Administrative Medicine, Columbia University.
in need of ultraradical structural reform because they fail to meet all the needs. It is too often forgotten that the arrangements for social services such as health almost universally mirror the pattern of organisation of the general social and fiscal system of the country concerned. In societies of roughly similar cultures and moral attitudes, there are, however, certain common basic hypotheses in the application of such arrangementsclinical freedom; respect for the individual; the personal nature of the association between doctor and patient. In the same way, despite differences in administrative organisations, the basic, urgent problems are broadly similar: how to ensure uniformly high standards of care over the whole population; how best to ensure that the needs of all citizens are met; how to ensure a rightful share of national resources; how to make the best use of such resources to meet rising demand. Many of the charges continually being laid at the door of the National Health Service could equally be made against what pass for freer systems. and
are
.
*
*
*
such criticisms as are reviewed here, one wonders whether the Service to which they refer would be recognised by most of those working in, or associated with, the N.H.S. The latter is certainly not a " monolithic " structure, but is made up of a number of services and units-some excellent, some good, some obviously open to improvement. Much of the improvement called for reflects past shortcomings which will eventually be met, whether there is a national system or not. Much of it can only come from official prompting and financing through a nationalised system. On the other hand, a very great deal of the quality rating and room for improvement in the units and services making up any system depends on the human factor, which in turn depends on morale. It is therefore well occasionally to look at the basic platitudes concerning the National Health Service which we too often forget. No large enterprise consisting of a sprawl of institutions depending on people of all kinds of professions, trades, skills, and above all, character, is ever likely to be perfect down to the last detail. Whatever the arguments before 1946, a national health service is probably very suitable for the present shape and mores of British society; and as far as the development of institutions and services is concerned, the present scheme, for all its faults, is broadly appropriate to the level and distribution of wealth over the nation. It is very unlikely that this social and economic pattern will be altered considerably in the foreseeable future. Any assertion that the National Health Service is responsible for hindering research and for holding back real improvements in practice in the United Kingdom cannot survive close examination; because, in the event, it is the compulsion felt by individuals which produces the kind of results described in the articles on research and the practice of medicine in the medical journals week in and week out. If these articles are indeed evidence, it can be added to the solid achievements of the health system since 1948. These achievements, though real enough, often go unsung because they are generally accepted as the normal pattern of life. Because the health services are nationalised, the pressures for reform likely to be most heeded in the near and intermediate future-because they will tend in the best British tradition to be pragmatic-will almost certainly be those for rationalisation of organisation. The
Looking
at
316
important thing will be to keep under constant vigilance any tendency towards undue bureaucratic encroachment on those basic principles which should apply to health services, no matter what the framework in which -they function. Principal among these are that a health service should consist of a combination of personal services, and that whatever the system, formal or loose, it should enshrine such a combination and enable the good practice of medicine
flourish. the Minister has, also in his to
Recently Lloyd Roberts lecture, expounded a theory embodying an appeal to use resources " more wisely, more cunningly, more effectively." Many will, no doubt, construe this as a devilish warning hatched up in Great George Street. However, it is possible to recognise in it a sensible call for a cool and close look at how and why we are doing things now. It is above all important that standards of hospitals and services should be adequately high and that such standards should be universal. It is no more immoral or impossible for a nationalised system of hospitals to be efficient than it is for an unregulated system of private unlinked institutions. In the present state of affairs it is neither sufficient for the medical profession to be ostrich-like on matters of administration, nor to sigh à la recherche du temps perdu, which never was. It therefore behoves them to be as well informed as possible on the real issues as well as on the basis and marginal nature of much of the criticisms now being made and the alternatives offered. If among the basic platitudes there is also-as there must surely always be-the right and choice of private practice, is one of the prime honours not satisfied ? Do the mass of individual doctors really wish to involve themselves in a free, undignified scramble for existence, under the control of an economic " market ", with the prizes made up of an accumulation of private bargains with patients ? Stripped of the persiflage, this is the real alternative gate of choice at which the medical profession seems to be standing now, if the efficiency of the-" economic "-market, or any related theory is elevated to a creed and basis of an alternative to the National Health Service. To go through this gate might, however, mean the final rejection of the special ethic surrounding medicine, and the acceptance of an equation with other professional groups. It is true there seems to be disquiet; but frustration is not the monopoly of the medical profession or parts of it. The equivalents of the dissatisfied senior registrars, and consultants without a satisfactory degree of merit award, are to be found in all professions and enterprises. The I.C.I., for all its reported efficiency, has doubtless its quota of discontents under training, or on the career ladder, no less than the National Health Service; but an important difference is that, while there may be freedom to discuss and to publish damning criticisms of the crass" in ness of both enterprises, the forces of the " market jobs in the commercial and industrial world are a little restrictive on those critics seeking alternative outlets. The fact is, we are bemused and slightly embarrassed by meaningless terms such as " socialised medicine "; but the paradox is that there is possibly more absolute clinical freedom in 1962 in the National Health Service than under more competitive conditions. What price Tissue Committees for all hospitals in the United Kingdom ? The * is more a sign of the times anger of Dr. James Porter than the result of a nationalised service. Yet the field of health services is rich in one particular *
A cousin of the
original A.Y.M.
asset which can and should be exploited for the common good. This is the moral atmosphere that can be generated in a service devoted to the relief of suffering. It is no exaggeration to say that the morale of the health services, whether publicly or privately organised, depends largely on the moral and intellectual leadership exercised by the medical profession, not only in the personal relationships that each doctor has with his patients but also in the sum total of doctors’ attitudes towards, and understanding of, the real problems of administering and developing social services on a 20th-century scale. In the case of the National Health Service those problems arise only in
minor part from defects in the administrative structure. They become acute because of shortfalls in morale, in intellectual discipline, in education, in understanding, and in social behaviour. It is to failure in these qualities we owe most of the crises of our times, and the effects are only too apparent both in the health services and in the flurried debates on them. Part of this is perhaps due to insufficient information on which to judge the operation of the services-and there is a case for more and better data. But much of it is due to a lack of appreciation of the real issues. In formulating questions about what can be done about the National Health Service, in listening to thundering denunciations, and in looking at abracadabra solutions, this should soberly be borne in mind.
Special
Articles
MASSIVE NIACIN TREATMENT IN SCHIZOPHRENIA Review of
a
Nine-year Study
H. OSMOND M.R.C.S., D.P.M. LATE MEDICAL
SUPERINTENDENT, SASKATCHEWAN HOSPITAL, WEYBURN, SASKATCHEWAN
A. HOFFER
M.D., Ph.D. DIRECTOR OF PSYCHIATRIC RESEARCH, PSYCHIATRIC SERVICES LOCATED at UNIVERSITY HOSPITAL, SASKATOON
BRANCH,
OUR interest in niacin began at the end of 1951 when exploring ideas developed with Dr. John Smythies (Osmond and Smythies 1952). We thought that schizophrenia might be caused by a disorder of adrenaline metabolism in which the body produced a substance with psychological effects like those of mescaline or d-lysergic acid diethylamide. These ideas have since been called the adrenaline metabolite theory of schizophrenia, and the adrenochrome hypothesis is a special example of that
theory. From time to time we asked ourselves what, supposing the right track, would be an ideal treatment for schizophrenia. If our adrenaline metabolite idea was correct, then anything which reduced adrenaline production should help. We decided to try niacin because it might compete for methyl groups and so prevent more noradrenaline being methylated to adrenaline. The introduction of a new treatment depends on a few cases responding favourably at the start. We had such luck with half a dozen cases early in 1952, the most dramatic being that of a boy of 17 admitted in February with acute schizophrenia: A few days earlier he had become excited, overactive, silly, we were on