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Not for Sale
LEADING
THE 1. AN C ET LONDON
14
JANUARY
1961
Not for Sale SINCE the inception of the National Health Service all patients in this country have been paying patients, though comparatively few now pay their doctors individually. Like paying patients in former days, they are entitled not only to medical care but also, with one reservation, to the medical care of their own choice. The single reservation-that their choice must not conflict with our professional freedom-has enabled us, through the generations, both to regulate our own affairs and also to impose on those who seek our help a system of bylaws of our own making. This, we believe, is the only way in which we can safeguard our patients’ rights; and our professional claim has not yet been seriously disputed. But it would cease to be valid if public and profession were to disagree on what these rights are. In a letter to the Press, quoted in Parliament, a family doctor declared that " queue-jumping for hospital beds has become a racket "; and, though we agree with the Under-secretary of State that this is not a matter that can be analysed statistically by lay administrators, it is certainly one to be considered by the profession itself. Do we all, in fact, fully recognise that the National Health Service, besides creating a new framework for medical practice, has changed its contractual basis ? The change has come because those twin pillars of the pre-war system-public charity and voluntary service-have largely been replaced by financial agreements which in turn have made the hospital consultant no longer a dispenser of private gifts but a guardian of public property. One of the services for which he accepts payment today is the administration of hospital beds; and if he is allowed great freedom in allocating them, his
authority rests entirely on the public’s
trust.
In this country fundamental beliefs
are seldom put into words and they are often all the stronger because they lack definition. Before the war the limits of the duty a doctor owed his hospital patients were neither laid down by Parliament nor promulgated by professional committees; yet no doctor and few patients had doubts about them. Similarly, the privileges that could be accorded to those who paid a fee, though undefined, were as easily grasped as the distinction between an act of charity and the fulfilment of a business deal. In this tradition the National Health Service, which recognises two types of paying patient-one public and the other private-gave no instructions about the extra service to which the latter would be entitled; and it could not be expected that the ethics of the new system would at once replace the ethics of the old. Thus it is that the question of free drugs for private patients is still passionately 1. See
Lancet, 1960, ii, 212.
91
ARTICLES
disputed; that we are still burdened with a few absentee consultants whose private practices would wither away if they were conducted on the lines of their outpatient clinics; and that some hospital facilities are still irregularly used for private patients. On the other hand, those who dispute about free drugs do not doubt the sincerity of their opponents; the services of the great majority of consultants make up for the deficiencies of the few; and it can be argued that hospital patients benefit indirectly from the experience and incentive provided by private practice. The truth is that an inarticulate feeling has grown up among doctors that, in a medical scheme defined by law, the regulations must be tempered by common sense; and some of the outward manifestations of this feeling have been in the highest tradition. (We have yet to hear of a surgeon who has cut short an operation, or a physician a ward-round, at the end of his notional half-day; and few would doubt that if hospital staff punctiliously observed the timetable on which their remuneration is based the National Health Service would soon be in difficulties.) Most people have grown accustomed to the idea that a little juggling with the regulations is not only permissible but even perhaps beneficial. The dangers of rigidity are such that in every large human orgariisation there should certainly be a little " give". Even so, however, there surely can be no possible justification for depriving a patient of a hospital bed which he not only needs but which is his by right. To give priority to a patient, not because of clinical urgency but because he has paid a consultation fee, is not an exercise in professional freedom but more nearly an act of conspiracy; and it brings us face to face with the question whether, in an admittedly imperfect organisation, we wish to allow such conspiratorial arrangements to take precedence over public treaties. The cost of supplanting our legal contract with the public by undercover personal liaisons would eventually have to be paid in professional privileges-a currency in which the vast majority of doctors in this country are not prepared to deal. Standards of practice cannot be maintained without professional freedom; and it is in the interest of public as well as doctors that this should not be whittled away. But in the long run our only guarantee that it shall be preserved is public faith in our integrity.
Bretylium
and Guanethidine
THERE is argument as to how " essential " primary hypertension is and this bears on the practical question whether it is ever truly " benign ". But at least there is no doubt that any notable and sustained elevation of the
diastolic blood-pressure will have a dangerous impact on vital organs, and that severe diastolic hypertension and safely as possible. Bretylium tosylate (’ Darenthin ’), introduced in 1959, was found to have the great advantage over the ganglionblockers that its action in therapeutic dosage was limited to adrenergic blockade 11.2 For the first time patients
must
be controlled
as
quickly
"
1. Morrison, S. L., Morris, 2. See ibid. 1959, ii, 27.
J.
N. Lancet,
1960, ii,
829.
THE 1. AN C ET LONDON
14
JANUARY
1961
Not for Sale SINCE the inception of the National Health Service all patients in this country have been paying patients, though comparatively few now pay their doctors individually. Like paying patients in former days, they are entitled not only to medical care but also, with one reservation, to the medical care of their own choice. The single reservation-that their choice must not conflict with our professional freedom-has enabled us, through the generations, both to regulate our own affairs and also to impose on those who seek our help a system of bylaws of our own making. This, we believe, is the only way in which we can safeguard our patients’ rights; and our professional claim has not yet been seriously disputed. But it would cease to be valid if public and profession were to disagree on what these rights are. In a letter to the Press, quoted in Parliament, a family doctor declared that " queue-jumping for hospital beds has become a racket "; and, though we agree with the Under-secretary of State that this is not a matter that can be analysed statistically by lay administrators, it is certainly one to be considered by the profession itself. Do we all, in fact, fully recognise that the National Health Service, besides creating a new framework for medical practice, has changed its contractual basis ? The change has come because those twin pillars of the pre-war system-public charity and voluntary service-have largely been replaced by financial agreements which in turn have made the hospital consultant no longer a dispenser of private gifts but a guardian of public property. One of the services for which he accepts payment today is the administration of hospital beds; and if he is allowed great freedom in allocating them, his
authority rests entirely on the public’s
trust.
In this country fundamental beliefs
are seldom put into words and they are often all the stronger because they lack definition. Before the war the limits of the duty a doctor owed his hospital patients were neither laid down by Parliament nor promulgated by professional committees; yet no doctor and few patients had doubts about them. Similarly, the privileges that could be accorded to those who paid a fee, though undefined, were as easily grasped as the distinction between an act of charity and the fulfilment of a business deal. In this tradition the National Health Service, which recognises two types of paying patient-one public and the other private-gave no instructions about the extra service to which the latter would be entitled; and it could not be expected that the ethics of the new system would at once replace the ethics of the old. Thus it is that the question of free drugs for private patients is still passionately 1. See
Lancet, 1960, ii, 212.
91
ARTICLES
disputed; that we are still burdened with a few absentee consultants whose private practices would wither away if they were conducted on the lines of their outpatient clinics; and that some hospital facilities are still irregularly used for private patients. On the other hand, those who dispute about free drugs do not doubt the sincerity of their opponents; the services of the great majority of consultants make up for the deficiencies of the few; and it can be argued that hospital patients benefit indirectly from the experience and incentive provided by private practice. The truth is that an inarticulate feeling has grown up among doctors that, in a medical scheme defined by law, the regulations must be tempered by common sense; and some of the outward manifestations of this feeling have been in the highest tradition. (We have yet to hear of a surgeon who has cut short an operation, or a physician a ward-round, at the end of his notional half-day; and few would doubt that if hospital staff punctiliously observed the timetable on which their remuneration is based the National Health Service would soon be in difficulties.) Most people have grown accustomed to the idea that a little juggling with the regulations is not only permissible but even perhaps beneficial. The dangers of rigidity are such that in every large human orgariisation there should certainly be a little " give". Even so, however, there surely can be no possible justification for depriving a patient of a hospital bed which he not only needs but which is his by right. To give priority to a patient, not because of clinical urgency but because he has paid a consultation fee, is not an exercise in professional freedom but more nearly an act of conspiracy; and it brings us face to face with the question whether, in an admittedly imperfect organisation, we wish to allow such conspiratorial arrangements to take precedence over public treaties. The cost of supplanting our legal contract with the public by undercover personal liaisons would eventually have to be paid in professional privileges-a currency in which the vast majority of doctors in this country are not prepared to deal. Standards of practice cannot be maintained without professional freedom; and it is in the interest of public as well as doctors that this should not be whittled away. But in the long run our only guarantee that it shall be preserved is public faith in our integrity.
Bretylium
and Guanethidine
THERE is argument as to how " essential " primary hypertension is and this bears on the practical question whether it is ever truly " benign ". But at least there is no doubt that any notable and sustained elevation of the
diastolic blood-pressure will have a dangerous impact on vital organs, and that severe diastolic hypertension and safely as possible. Bretylium tosylate (’ Darenthin ’), introduced in 1959, was found to have the great advantage over the ganglionblockers that its action in therapeutic dosage was limited to adrenergic blockade 11.2 For the first time patients
must
be controlled
as
quickly
"
1. Morrison, S. L., Morris, 2. See ibid. 1959, ii, 27.
J.
N. Lancet,
1960, ii,
829.