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about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to 'strafe' the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity otherwise it would lengthen but of a backlog which, once 'cleared off', ought P. 40

not to be allowed to recur. "1

-

"Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca tamen usque recurret: though you drive Nature out with a pitchfork, she will still find her way back." P. 40 "...when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. thing, 'urgent' and even 'critical' are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the 'urgent' cases, seen or treated at once, and the 'non-urgent' cases on the waiting list case may be, not on the waiting list at all. The latter are squeezed down or

For one

or,

as the

by the former. To point to the fact no 'urgent' case goes untreated as

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evidence that supply and demand can be brought into balance without rationing is

like arguing in a famine that because nobody dies of starvation, there need have been no rationing system."

P. 41

"The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service."

P. 41 "There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting." P. 43

"The result is to impart a unique rigidity and centralization to the conduct of the activities of something approaching half a million persons in a vast variety of institutions throughout the country. The effects are felt both in the relationship between the state and the professions and in the form the development P. 44

of the service takes."

"In the professions it promotes the sense of being subordinate, in a professional capacity, to lay control and decision. In the last resort, all final decision is lay, whether the decision be that of an individual to undergo an operation or of Parliament to institute a national health service. The principle is not limited to medicine but is universal: the professional is the servant, albeit specially endowed and equipped, while the layman (albeit often called the 'client') is the consumer who commands the service and decides whether he will take the advice or no. In all government the last word is of necessity lay, that is, non-expert:..." P. 44

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"The idea therefore that the professional could ever be 'on top', like that of a state health service controlled by the doctors, is a chimera."

P. 45

"...the amount of private medical care, by volume or value, is between one and two per cent of the value or volume of medical care in the National P. 70

Health Service."

"Thus a voucher scheme resolves itself merely into a method of increasing state expenditure upon medical care." P. 72