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again, only to accept another course and so on. These are only a few examples of the Swedish large-scale unemployment coverup.
Let's not make ourselves any illusions about NHI. Taxes will increase, inflation will worsen, and an army of bureaucrats will tell doctors and hospitals how to work and patients where to go. If doctors are made employees of the government, the much-needed doctorpatient relationship goes down the drain here as in Sweden.
My solution: Government will not be able to do anything to reduce the overall costs for health care as little in this country as elsewhere in the world. Why not then enjoin upon the major involved parties, AMA, AHA and others—to jointly work out a formula for comprehensive medical services for all citizens and have a workable oranization within 10 years acceptable to the Bureau of Health Planning and Resources Development. I am thinking of a system with criteria-linked sliding scale fees down to a "zero" fee where the "cuts” would be tax deductible on par with charitable contributions. A mandatory participation by every doctor, dentist, et cetera of up to 15 percent of the number of patients could do more with less pain than any giant Federal plan. The plan could be made abuse-safe with minimal control.
Eugene J. Rubel is the 34-year-old director of the Bureau of Health Planning and Resources Development. He states that the reason for Government intervention now in private medicine is dollars. He states that everyone should have easy access to health care, the main problem thus being costs and maldistribution.
He, for one, has to be rudely awakened. He should be told that this country has the lowest hospital bedding and shortest hospital stays of any comparable country. I can foresee a lot of overinflated bureaucratic planning superstructures investigating, recommending, regulating, and intervening to absolutely no avail, simply because hospitals are working on a near-optimal level, and so are doctors.
I wish that certain other prestigious professions could claim that. Here we have a big organization like AMA, who fears Federal intrusion more than anything else, mostly because of the Federal track record here and abroad. Given an ultimatum whether to cooperate or be reduced to neutralized spectators, they would hardly have a choice. This organization has a central management, a regional statewide organization and local organizations and, above all, a deep understanding of the subject in question.
A physician is a pretty formidable character to tackle. His training has taught him to be an authority. He does not stand in awe of anyone and he is much more likely to give orders than to take them.
My solution, shocking as it may seem and highly unconventional as such, but a truly American one: AMA and HEW—Unite your forces. Work together instead of fighting each other. We have in America an excellent health care for most of the people. Let's invite to the medical common those who today stand outside.
Mr. ROSTENKOWSKI. Thank you, Dr. Lofstead.
STATEMENT OF REGINALD S. MURLEY, M.D. Dr. MURLEY. Mr. Chairman, gentlemen, for a mere Cornishman like myself, whose forbearers stayed in that rugged western part of the old country instead of setting sail with the pilgrim fathers, it is a great
privilege to have this opportunity of giving evidence before a congressional committee. I thank you most sincerely for having invited me to talk on hospital and specialist care in the British National Health Service.
When some of your Congressmen were recently in Britain I was asked at rather short notice whether I could show a few people around one of my NHS hospitals. Unfortunately I was already irretrievably booked up; but, I must confess that my initial reaction was: “Why, with all the present problems which beset the NHS, should I spend time in trying to put the Americans right?” However, I hasten to reassure you that this was no more than an initial reaction. Enlightened self-interest quickly convinced me that, just as in former centuries America had provided a welcome escape route from religious and political oppression so, in the 20th century, might it now offer a necessary lifeline for those determined to escape the extremes of socialism.
But, I have more positive reasons for wanting to help your country. In 1962 I contributed to a book on "Financing Medical Care" in which we compared and contrasted systems of governmentally supported medicine in the United Kingdom, Australia, and five European countries. The editor of that work was Helmut Shoeck, then professor of economics at Emory University, Atlanta. Second, during World War II, I had the pleasure of collaborating with American units abroad; and since the war I have enjoyed the warmest bonds of friendship with many medical colleagues in the United States. Last, and not least important, my father became a naturalized American and I had an American stepmother. These are all compelling reasons why I have always felt the strongest bonds of kinship with your country.
I am now 59 years of age. Since the inception of the NHS I have been a "maximum part-time consultant surgeon.” That is to say, I work officially nine-elevenths of my time in the NHS and the remainder of my week in private (independent) practice.
My thesis is that the highest standards of service in medicine are best achieved in a mixed medical economy, and that a State monopoly, or State near-monopoly, must ultimately prove nothing short of a disaster. I believe that the best interests of the patient, and of medicine, are more likely to be fulfilled where there is a sensible combination of personal expenditure by the individual, plus genuine independent insurance. In many countries people have come to accept that an element of governmental (tax-financed) subvention is needed. That governmental element is felt to be especially important for the reckless and the indigent and, as many Britons tend to believe, to cover the cost of long-term and truly catastrophic illness.
However, logic compels one to admit that, when it is said that something is too expensive for anyone but “the State” to foot the bill, this is simply admitting that the product of the sum of our individual skills and effort is more economically and wisely spent by bureaucrats than by we ourselves. Bureaucratically organized medicine may be better able to meet the catastrophes of life, but that proposition is neither self-evident nor apparently supported by experience.
Despite its faults, the hospital and specialist service under the NHS in the United Kingdom has, until relatively recently, appeared to have the potentiality of achieving a reasonable and progressive sym
biosis between tax-financed and independent sectors. But that potentiality has largely been nullified by the growing politicization of British medicine in the last decade. Governments of the left have mounted a progressive attack on the independent sector which governments of the right have failed to neutralize or counterattack. The overall effect can be likened to the slow tightening of a ratchet with but occasional and ill-sustained effort to release the pawl mechanism.
Sadly, therefore, our NHS has been subjected to the viler winds of political change. This has been further aggravated by our own variety of militant trades unionism, and by the sometimes disastrous effects of so-called "action groups," motivated by small minorities. Thus, we have seen the steady breakdown of law and order, and of morale, in an organization which was until a few years ago a notable oasis of peace and loyal service in a growingly disturbed society.
In the remainder of the 15 minutes which you have allocated for this oral presentation I shall highlight the main points in my paper which was sent to Washington last week and circulated to members of your committee.
In the first part of that paper I stress the fact that the National Health Service inherited both standards and a system from the preNHS days. What was introduced in 1948 was essentially a new method of financing medical care largely from taxation.
I have gone on to emphasize the extraordinary small amount of capital development in the earlier years referred to by Mr. Gammon.
We did not complete a single new hospital in Britain in the first 13 years of the health service and the record since then is abysmal.
I go on to stress in section two what I call the economics of excellence. I think it matters not so much who has the best, but only that the best should exist and that it should be manifestly recognizable as such.
Pacesetters are essential in any society, and State subsidized mediocrity is a real danger. You are lucky, sir, for in this country you have many pacesetters in existence.
In section 3 I refer to morale in the hospital service which has taken a fearful knock in the last few years. The powers that be have become obsessed with ideas on management, accountability, and organization, all doubtless in theory very worthy things but only too often of astonishing irrelevance to the day-to-day problems of prividing service to the sick patient.
Morale has been shattered in both our regional and our central teaching hospitals. But it is in the latter, the teaching hospitals, that we have seen some of the most disturbing evidence of this trend in the past few years.
Witness the difficulties I have referred to in my paper in filling jobs, in well-known hospitals, St. Bartholomew's in London, one of our most venerable and oldest institutions, has been unable to fill for 21 years an orthopedic surgeon vacancy and had only one applicant for an anesthetic appointment.
Five members of the teaching staff from Newcastle emigrated in the last year. Emmigration has already been referred to by Dr. Gammon, and I would only stress the changing pattern, it is not only the younger men but established men—a more serious loss to our community-who are now leaving.
Our present Secretary of State plans to abolish private patient facilities in the NHS for our own natives, but to preserve such facilities for foreign patients.
Our own natives therefore would not be permitted to have private treatment in their hospitals but foreigners could. I must add, of course, sir, that the whole object is that the State and not the doctors should collect the fees. It is tantamount to saying, "We totally disagree with the practice of prostitution but so long as the tarts don't collect the money, and he government does, that is okay."
Now, doctors of all backgrounds at the present time, part time and whole time in the NHS academics employed by universities, and junior men, are all with few exceptions totally opposed to the policy which the present Government is pursuing and you will see a massive confrontation before very long.
The Secretary of State, as you have heard, also wants to control the independent sector on the experience basis of assuring fair shares for all.
You have heard about the very small number of beds that are available for private patients in our service at the moment, actually 1 percent of all beds or 2 percent of general beds.
It is significant-in connection with efficiency already referred to by Dr. Lofstead—the turnover of beds in the private health service is more rapid than in the general beds.
My section 5 on financing medical care is the key to many of the problems of whether or not the State should intervene.
Variety will only come where opportunity is allowed for different systems to operate side by side. A good rule, I think, for both independent insurance and any form of State aid, should it be introduced, is to regard these as a springboard rather than a featherbed.
Speaking for myself, I can only say that my keen appreciation of the economic facts of life is due to my being in private practice as well as working in the NHS.
In the early years of the service many specialists found that a basic salary by session such as I was paid, plus private practice, was an admirable combination for practicing surgery.
I stress in this section, too, the fundamental weaknesses of the NHS in rarely having its priorities right. Free service, though theoretically admirable for catastrophic illness and long-term care, is a stupid way of financing day-to-day care of the short-term and sometimes less serious condition.
Now, the waiting list problem has been dealt with already, that was in section 6 and I don't intend to enlarge on it.
You have heard both the British and the Swedish testimony on this subject which seems to be very similar although I had not anticipated this in advance of this meeting.
I go on to refer once again to migration, some of the figures have been given to you by Dr. Gammon. We have lost the output of at least three or four of our medical schools every year by emigration overseas. Immigration too has changed its pattern. No longer so predominantly those from the old commonwealth but in the most recent examination of the General Medical Council in Britain, doctors applied from 26 countries in the Middle East, Near East and Far East.
We have increased numbers of foreign dotcors not only in junior doctor posts where 60 percent are from overseas, though it varies from
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 11/2 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