place to place in the country. We also have a growing number in senior jobs.

I moved on in section 8 to refer to some of the headaches you may meet in a centrally organized service. One becomes inevitably and inextricably tied up with establishments and salary scales. In a rather hidebound bureaucratic system.

I also cited in that part the serious delays which have occurred even in the simple matter of advertising staff vacancies at the time of retirement. Two vacancies at one of my hospitals remain unfilled for 12 years despite the fact there are eligible people available but the jobs have still not been advertised due to bureaucratic delays.

Now, I also moved into section 9 to talk about the so-called contract of the National Health Service hospital doctors and specialists because it was a proposed new contract which was the cause of the recent confrontation with the Secretary of State.

I would say that, whereas doctors in the past very happily exploited themselves they are now rather less keen to be exploited by the NHS. I have emphasized in that section my belief that a satisfactory symbiosis between private and public sectors could have been achieved in our country. I stress, too, that because I work also in the private sector my telephone is always available for any of my young men in my NHS hospitals to call me. The telephone transfer system is in widespread use in Britain at the present time in NHS general practice. A final word on personal responsibility.

It has been truly said that liberty is the luxury of self-discipline but it is equally true that without a reasonable amount of personal liberty it is difficult for folk to recognize the virtues of self-discipline and personal responsibility. When as in the more extreme examples of State welfare people are relieved of decisionmaking and consumer choice it becomes more and more difficult for them to make decisions on their own behalf.

People in general are prepared to strive harder for themselves and their families rather than for some nebulous notion of the general good.

A major task of public policy is to harness this self-interest to the public good. In other words, to promote the spread of truly enlightened self-interest.

It is not simply the recipients of health care, the patients who are damaged by a surfeit of State welfare, but also the doctors, nurses, and ancillary staff.

The old local loyalties to the district hospital and the great teaching center are fast diminishing in Britain. They are diminishing for the simple reason that local team spirit and loyalty to an institution are threatened and often ultimately destroyed, by any system which also tries to impose allegiance to a centralized, bureaucratic, and politically oriented administration.

It is my belief that a sensible mixture of independent and Statefinanced medicine is essential to the health of each. We are unrepentant supporters of a mixed medical economy and utterly reject the concept of State monopoly or near-monopoly in medicine.

In your own country you already have a remarkably variegated setup so far as your hospitals and specialist service are concerned. Thus, Americans may be treated in municipal, veterans, and service

hospitals, as well as in university or private hospitals, or in one of your internationally famous private clinics such as the Mayo, the Cleveland or the Lahey.

It would be impertinent for a mere Briton, and even for one who had a naturalized American father and an American stepmother, to tell your own great country how to arrange its medical affairs. But perhaps one could be so bold as to suggest that you should seek every possible means of promoting the greatest measure of personal responsibility, and of preserving a substantial element of variety and choice for both patient and doctor.

[Dr. Murley submitted the following:]

HOSPITAL AND SPECIALIST CARE IN THE BRITISH NATIONAL HEALTH SERVICE (By Reginald S. Murley, M.S., F.R.C.S., Surgeon to the Royal Northern Hospital, London and St. Albans City Hospital, Herts, Member of Council of the Royal College of Surgeons, President of Fellowship for Freedom in Medicine)

SUMMARY

1. Inheritance of high medical & nursing standards. Lack of Capital Investment in Hospitals.

2. The Economics of Excellence. The importance of pace-setters. Risks of levelling down.

3. Disastrous deterioration in morale. Effects of workload, financial stringency & staff shortages. Confrontation with trades unions and "action groups".

4. Private practice in the Hospitals. The origin of pay-beds. At present 2% of general beds or 1% of all N.H.S. beds. "Phasing out" and proposed control of independent sector. Dangers of Totalitarian State control. The idea of an independent corporation.

5. Financing medical care. The vital importance of variety. Personal responsibility. Consumer choice. Understanding the economic facts of life. Priorities in Medicine & differences between short-term and long-term problems. Ways of helping those who are prepared to help themselves.

6. Waiting lists. Illogical to speak of these on a "National" basis. Some interesting statistics. The "black spots" and the reasons for them. A surgical and geriatric problem. Socialist shibboleths about "queue-jumping". Some facts about queues. Disraeli and statistics.

7. Migration. Britons out & foreigners in. Changing pattern. Registration of foreign doctors. The senior "brain drain".

8. Establishments & salary scales. The incubus of bureaucracy and centralised control. Where does the "buck" stop?

9. Contracts for Consultants. Confrontation in relation to "open" and "closed" contracts. So-called "part-timers" and their work pattern. More a preferred way of life than a means of earning more money. Vital importance of private sector in preserving freedom for patient and doctor.

10. Family doctor and specialist. The traditional British pattern. The built-in incentives, checks and balances.

11. Organisation in hospitals. The "firm" system. Delegation to juniors and training. The consultant's ethical obligation of continued responsibility. No personal guarantee about surgical operation.

12. Liberty the luxury of self-discipline. The "general good" and the individual. The dangers of womb-to-tomb welfare. The vital importance of variety and choice in hospital and specialist services.

STATEMENT

The National Health Service in Britain is basically a method of financing Medicine largely from Governmental sources rather than a new system of medical care. Much of its early strength lay in the high standards of medical and nursing care which it inherited from the past. The first few years of the N.H.S. also resulted in a substantial increase in specialist staff in many peripheral hospitals outside the main teaching centres: That is one of the main points on

the credit side of the N.H.S. But, on the debit side, it must also be emphasised that capital investment in hospitals was totally inadequate.

The planned expenditure on hospital building in 1961-2, thirteen years after the inception of the N.H.S., was, in terms of 1939 values, less than was spent on our hospitals prior to World War II! In other words, Britain was spending more on hospital building (through voluntary and municipal hospital funding) in the "bad old days" than was found from Treasury sources under the new scheme. Indeed, the first completely new hospital to be built under the N.H.S. was not finished until fifteen years after the introduction of the N.H.S., and that was just eight years after I had learnt in 1955 that some fourteen new hospitals had been built in New York City alone since the end of the War.

I am not one of those who assumes that fancy new hospital buildings are synonymous with the highest standards of medical care. But the record of the N.H.S. in respect of new capital works has been disastrous. There has been a disposition to build a few pretentious and very expensive large hospitals when, faced with shortage of funds, it would often have been much better to improve X-Ray departments and other diagnostic facilities, and to build new operation rooms to permit more rapid through-put of patients.

In the rest of this paper I shall try to draw attention to the more important problems which face the hospital and specialist service at the present time. There are so many medical, social, ethnic and economic differences between conditions in the United States and Britain that one must be as careful in comparing medical care in the two countries as in predicting the possible effects of Socialised Medicine in the U.S.A. But, there are a number of broad particulars in which a knowledge of conditions in Britain may help those in the U.S.A. to assess both the hazards and potentialities of greater Governmental intervention in Medicine in your own country.

THE ECONOMICS OF EXCELLENCE

I feel bound to emphasise first of all what I have elsewhere described as "the economics of excellence". The highest standards in any society are achieved by those of surpassing excellence, the pace-setters, and whether we speak of medicine, education or industry it is essential that we should promote conditions in which the best can exist and can manifestly be recognised as such.

After 27 years of N.H.S. many of us have become increasingly depressed by a manifest levelling-down of standards-a tendency towards what some have described as State subsidised mediocrity. To handicap the best performers, whilst appropriate to horse-racing, is hardly the best way of encouraging the highest standards in Medicine.

MORALE IN THE HOSPITAL SERVICE

Our hospital service has faced increasing problems due to financial stringency, over-centralised control and, more recently, excessive preoccupation with administrative reorganisation. One committe after another has reported on almost every aspect of hospital work: few of their recommendations have had much relevance to the practical realities of hospital life, and the impementation of many of their suggestions has caused growing frustration and confusion. It is almost universal experience that there has been a disastrous deterioration in morale during the last year or so. Never have staff in our large teaching hospitals been so dispirited. Never has it been so difficult to fill certain senior staff and other medical vacancies in such hospitals, and never have we had so many senior men resigning in order to seek greener pastures elsewhere.

Morale has also been seriously affected in the peripheral (regional) hospitals. This has been aggravated by growing financial stringency, increasing workload and staff shortages. So alarming has been the all round loss of morale that the Presidents of our Royal Colleges and Faculties (bodies essentially concerned with training and standards of service) recently took the unprecedented step of making a joint approach to the Secretary of State for Health and Social Services. These leaders of the profession, gravely disturbed by the threat to standards of service to the public, have twice called on the Secretary of State during the last six months to express their concern.1

The President of the Royal College of Surgeons of England, Sir Rodney Smith, has given me permission to append a copy of his May, 1975 newsletter addressed to all fellows.

PRIVATE PRACTICE AND THE HOSPITAL SERVICE

Prior to World War II a number of our major hospitals established special wings for private patients. This occurred chiefly in the undergraduate and postgraduate teaching hospitals with the object of ensuring 1. that paying patients could be provided with at least as good standards of medical care as those in the general (charity) wards, and 2. that medical staff could become more geographically whole-time and thus save from needless waste of time and effort in travelling between hospitals.

After inception of the N.H.S. small numbers of additional private beds were provided in many general hospitals around the country, but the total has never exceeded 1% of all hospital beds (or 2% of beds if mental hospitals are excluded).

It is the declared intention of the present Labour Government to "phase out" (abolish) these pay beds in the course of the next year or so. This is meeting with very great opposition from the medical profession. Doctors feel that the private and public sectors are complementary to one another, and that such separation is likely to be far more damaging to the public than the private sector. Moreover, public opinion polls during the last few years have shown that, even amongst those members of the public who would rarely think of private care for themselves, there is a strong disposition to preserve private practice both within and outside the N.H.S.

The Secretary of State is also seeking powers to exercise much greater control over the independent hospitals. If this intention is implemented then every hospital in the country, whether private or N.H.S., will be subjected to political and bureaucratic control.

The present state of affairs in Britain illustrates the consequences of establishing a State near-monopoly in Medicine. At the inception of the N.H.S. many of us advocated the establishment of a National Health Corporation, comparable to our British Broadcasting Corporation (B.B.C.) or the University Grants Committee (U.G.C.), two bodies which then enjoyed considerable independence despite reliance on Government funds. Though the B.B.C. remains a good example of what has been achieved in Britain by this method, it is, of course, not operating on anything like the same scale as the N.H.S. or the Universities. Moreover, experience in the U.G.C. during the last 25 years has not been too encouraging: as Government funding of the universities has been greatly increased so, inevitably, has there been increasingly detailed control and intervention by the State. A National Health Corporation would only enjoy some measure of independence if it secured funds from independent private as well as State sources.

FINANCING MEDICAL CARE

From what has been said above it will be apparent that opportunity for variety, for experiment and for healthy competition, is more likely to be promoted where financial support comes from a number of sources. Moreover, it is desirable that the individual patient should be able to exercise some measure of direct financial responsibility and consumer choice. And it has been our experience that doctors who work in the private as well as the State sector generally develop a more lively appreciation of the economic facts of life. This is especially well shown in the more economic use of hospital beds, and of expensive investigational facilities, as well as a clearer appreciation of the cost of drugs and other treatments. Those of us who work both in the private and public sectors are keenly aware of the valuable "feedback" in both directions which occurs because we are exposed to these two disciplines.

An outstanding fault of N.H.S. is that in its concept of "free-at-the-time" it tends to give as much priority to the trivial as the catastrophic. In the F.F.M. we feel that, especially in the care of less severe and short-term illness, it is desirable that the patient should carry a greater measure of personal and direct financial responsibility. But, in the care of catastrophic and long-term illness there is much to be said in favour of heavy subvention by the State. It is, of course, commonplace for people to say that long-term and catastrophic illness is far too expensive to be insured against by the individual. This we would accept though one is bound to point out that the resources of "the State" are simply those monies made available by individual citizens through various methods of taxation. In Britain there is growing support for the idea of health and educational) vouchers as a useful method of providing more consumer choice and personal responsibility. Financial help could also be provided by tax relief on medical expenses and private insurance (not allowed in the U.K.) and by other forms of tax relief related to tax coding.

WAITING LISTS AND "QUEUE-JUMPING"

The notorious so-caled "National" waiting list has received a good deal of publicity. Socialists tend to seize every opportunity of saying that this is due to the existence of a mere 2% of private beds in the general hospital service. In fact, some of the biggest waiting lists exist in the areas where there are few or no private beds within or outside the N.H.S., and some of the shortest waiting lists exist in those areas (e.g. London) where there are the most private beds. Additionally, at one time when the total number of pay beds was increased the national waiting list became smaller; and, when private beds were slightly decreased the waiting list increased.

To talk of a "National waiting list" of half a million patients is just about as illogical as to say that, on any working day, there are 50,000 people on the underground railway escalators in London. The majority of those on the escalators reach the top in a calculated period of time and so it is with many of those on the "waiting list". Indeed, it is customary to record patients as "waiting" for admission when they are listed for treatment on a firm date entirely suited to their personal convenience. However, it is undeniable that, in some parts of Britain, there are patients who may have to wait many months or even several years before being admitted for a non-urgent operation. In most such places these long delays are due to shortage of staff, of accommodation and of operation room facilities.

Some of the statistics are of considerable interest. In 1949 there were said to be 498.000 patients on the "national" waiting list, during which year 2,937,000 in-patients were admitted. In 1971 the waiting list had increased to 578,000 but 6,207,000 patients (that is, more than twice as many) were admitted. Between 1963 and 1971 the waiting list increased by 57,000, but there were 22.000 fewer general hospital beds in which 1,009,000 more patients were then being admitted annually.

It will be seen, therefore, that to talk of a National list is to confuse the issue. The waiting list is essentially a surgical phenomenon which arises from the need to arrange admission and operation programmes on a reasonably orderly schedule. The generally immediate admission of all emergencies, and the prompt admission of cancer cases, is normal everywhere excepting for those few "black spots" where resources just happen to be inadequate. Waiting lists for the general physician are virtually non-existent because most admissions on the medical side are of acute diseases and emergencies ( stroke, heart attack, bleeding ulcer, etc.). There are, however, substantial waiting lists for geriatric cases in some areas: these are often due to the fact that families sometimes tend to feel that it is much cheaper (and much less troublesome) to get old "grannie" dumped in a "free" hospital bed than to have all the trouble of caring for her at home— so much for the effects of the "Welfare State"!

The undeniable thing about waiting lists is that, year by year, the medical and nursing staff have managed to deal with a steadily increasing number of inpatients despite shrinking facilities.

And now this question of "queue-jumping" by private patients, a subject much beloved by Socialist opponents of the private sector. Such allegations, though often made, are rarely substantiated but it would be a miracle if such queuejumping did not occasionally occur as, for example, by a patient seeking a private consultation in the hope of securing quicker admission to a general hospital bed. But, the private patient is in an entirely separate queue for one of those 2% of all general hospital beds which are officially allocated to them. In many instances, and this is especially true of emergency and urgent cases, the private patient may have to wait longer for a bed. Indeed, he will often be compelled to go into a general bed due to strict limitation on the number of private ones. In this way he does inevitably (and justifiably) jump into a general rather than a private bed.

But "queue-jumping" for social and medical reasons is common: a housewife may have admission accelerated to fit in with her domestic arrangements for care of her children, etc., and the medical priority of a case may change after a firm booking for later admission. Above all, there are notable examples of true "queue-jumping" by politicians and Government officials, sometimes of the most blatant kind into a "free" side room off a general ward. The nurses and doctors look on this practice with a mixture of cynicism and amusement; recognising the frailties of human nature, whilst deploring the hypocrisy and double-standards of such folk when they fulminate about those who are prepared to pay the market-price for privacy and personal care.