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so the University Grants Committee now disposing of vast sums of money came more and more under political pressure. It is now less and less free from government and has, in consequence, been more and more restrictive in what it allows to the universities.

In addition to these indirect political pressures, those pressures applied through allocation of money, direct political factors do inevitably intrude on any State-run service. The dispute that has been going on in Britain over the past 2 years about so-called “pay beds” in NHS hospitals is purely political, nothing but. These beds are being phased out by the present government for one reason and one reason on which is political agitation by certain manual workers, unions, and the desire of the Labour Government to be on agreeable terms with the labor unions.

The medical desirability or undesirability of pay beds has been virtually unconsidered in the dispute.

Now, if private medicine is allowed to continue alongside a national health service, it will not be subject to some of the influences I have suggested are entailed in any State-run service. It will, therefore, maintain higher standards of medical care, or will develop higher standards than will be maintained in the State sector. And the contrast becomes increasingly embarrassing. They are not necessarily differences in quality of treatment, but in the care that surrounds the actual treatment.

Now, as the contrast becomes more evident and more embarrassing, inevitably the political attacks come on the private sector. That is what we are seeing now in Britain. The private sector starts to be accused of draining resources away from the National Health Service. That is the excuse always used for attacking it. It isn't true, but it is inevitably the reaction.

The danger always exists, I think, and becomes cumulatively increasingly hard to resist as the National Health Service develops, that the doctors', however many, safeguards are built into the system, become servants of the State.

I have heard it said at the expense of their pateints, they are careful not to offend their political masters. Even if they succeed in resisting this tendency or try to resist this tendency or some try to resist this tendency, they can do so only by becoming politicized themselves because they can only fight political attacks on a political level, and the senior members of the profession, the representatives of the profession, find themselves increasingly engaged not in medical but rather political arguments.

The British system is not, as we know, by any means the only form of socialized medicine. Some of the disadvantages have been avoided in other countries. But the major and deadly disadvantage is unavoidable—the incursion of politics into what should be personal and medical decisions.

[The prepared statement follows:]

STATEMENT OF ANTHONY LEJEUNE, MIDDLESEX, ENGLAND I shall present the following argument:

(1) Nobody would deny that there is something very wrong with Britain's National Health Service. As Dr. Walpole Lewin, the Chairman of the Council of the British Medical Association said recently : “What other business would budget £148 million for the Health Service in 1948, spending more than £3000 million a generation later, and still be nowhere near getting a comprehensive service?"

Despite this huge budget, the Health Service is chronically short of money. Many of its hospitals are squalid with age. The doctors and nurses are underpaid. Some casualty departments have been closed for lack of staff. The number of doctors seeking to emigrate from Britain continues to increase, and now constitutes a significant proportion of the entire medical workforce. The Health Service survives at all only because there is an inflow of doctors from India and Pakistan, but these are of varying quality.

The number of patients who take out private medical insurance, in order to pay for private-rather than Health Service-treatment when they are sick, also continues to increase. They include more than 10,000 doctors, nearly a third of all the doctors in Britain,

Health Service patients may have to wait up to four years for non-urgent operations. Official figures show that 37 per cent wait more than a year, and nearly 20 per cent more than two years.

(2) The question arises : are these defects in some way peculiar to Britain, or are they inherent in any scheme of socialised medicine?

They are, I believe, certainly inherent in any scheme of this kind, which purports to offer all medical services completely free at the time of use. Demand for medical services did not, as the founders of the NHS expected, diminish. On the contrary it has increased indefinitely. Demand at nil cost is unlimited: but the available supply of medical services cannot be unlimited.

Because people believe that they have already paid-through taxation and weekly National Insurance stamps—for the Health Service they feel entitled, if not actually obliged, to get as much as they can from it. Their attitude towards the doctor also changes.

Since this demand cannot be fully met, some form of rationing has to be introduced. Delays, long waiting lists, perfunctory consultations, lack of choice, are a form of rationing. Certain very scarce facilities, such as single rooms, bedside telephones, and the attention of senior doctors for relatively minor ailments, inevitably (though this is usually denied) go first to politically important people: and this tendency must increase, in Britain no less than in the Soviet Union, if private facilities become unavailable.

(3) Under this system of socialised medicine not only is the demand artificially increased but the supply is artificially diminished. A lower proportion of the Gross National Product (5.4 percent, compared with 7.8 per cent) is spent on medical care in Britain than in the United States—because people are not deciding for themselves how much of their own resources they want to spend on their own and their families' health.

The supply of voluntary and charitable donations also to a great extent dries up; this has been a major cause of delay in the renewal of Britain's hospitals. Much money is unnecessarily consumed by the administrative superstructure, and much time—including doctors' time-spent on bureaucracy.

Most important of all, the politicians, who—in any system of socialised medicine are the ultimate paymasters, have to allocate money fro the public purse, on which there are innumerable rival demands. Pressed from all sides, they will never allocate to medicine as much money as, from an objective point of view, might be desirable. To save money they will impose restrictions on what doctors, dentists and hospital administrators are allowed to do. Doctors in Britain have, so far, largely retained their freedom to prescribe, but some items, deaf-aids, spectacles, cosmetic dentistry-have been kept at a shoddy utilitarian level.

(4) It has been suggested that, in order to minimise the political element in the allocation of resources, money should be channelled through some relatively independent body, similar to the University Grants Committee. But the analogy is only too relevant. As spending on universities increased, the University Grants Co! mittee came under more and more political pressure, and has been more and restrictive in what it allows.

(5) In addition to these indirect political pressures, direct political factors inevitably intrude on any state-run service. "Paybeds” in National Health Service hospitals are being phased out purely because of political agitation by certain manual-workers' unions.

If private medicine is allowed to continue beside a National Health Service, the contrast in standards is apt to become embarrassing. This in turn leads to political attacks on the private sector, which will be accused of draining resources away from the Health Service. Just such an attack is beginning in Britain now.

(6) The danger always exists, and is increasingly hard to resist as the Health Service develops, that doctors will become servants of the State, careful-sometimes at the expense of their patients—not to offend their political masters. Even if they resist this tendency, they can do so only by becoming politicised themselves.

(7) The British system is not, of course, the only form of socialized medicine. Some of the disadvantages have been avoided in other countries. But the major and deadly disadvantage is unavoidable—the incursion of politics into what should be personal and medical decisions.

Mr. ROSTENKOWSKI. Dr. Lofstead.


Dr. LOFSTEAD. Mr. Chairman, members of the subcommittee, I am 36 years old, a practitioner in Sweden. I left my country last year and brought my family here not only because I disliked the way medicine was brought about, the working conditions, but also the general atmosphere in Sweden. I would not, for instance, like my children to go to the public schools in Sweden.

Unmet health care needs in this society are reflections of an unequal distribution of wealth. The so-called health care crisis is by no means a health care crisis. More people have access today to better care than ever before in history. If we could do today with the diagnostic and treatment sophistication levels of the 1960's and freeze it there, the politicians in all probability would have to look somewhere else for a crisis to intervene in with the prospects of higher voter gratitude.

To make people share all their medical expenditures is by necessity setting a precedent for sharing the costs for any other expenditures. This has been the trend in Sweden for a long time. Let's look at the mechanisms and the results:

1. Have the Swedes solved their health care crisis?

On Monday, August 4, 1975, 1 month ago, a Swedish hospital chief physician wrote the following in a major Swedish paper: “Every system, of course, has its advantages and its disadvantages. Without questioning Swedish health care in many areas still being first class, one must still acknowledge that the situation in some respects is disturbing and that the overall view is less favorable than it was 10 years ago. Despite enormous cost increases, the patient waiting lines are growing everywhere. The extended care crisis has become chronic and the situation for the old and the sick today is, without presumptuous words, a disgrace for our society."

My comment is: Instead of hedging against soaring health care costs, the Swedish Government takeover caused a skyrocketing cost. The maldistribution problem and any other imaginable parameter of the so-called "crisis” is still there together with an array of new problems, created by the system itself.

2. Did not the Swedes "demand” a socialization ?

Maybe some union pressure groups, which have been the true political force in recent years, but the public—No. Allow me to quote Irvin H. Page, M.D., in an editorial in Modern Medicine, June 6 1975:

We should immediately dispose of the myth that the public understands and demands certain bills or any bill at all.

My comment is: The Swedish Social Democratic Party has been able to stay in power by a systematic lollypop approach by selecting carefully certain groups of voters, promising a free lollypop for every




one. Any party could stay in power indefinitely. It is a simple bargaining process. Paying for doctors and hospital bills was one of those big lollypops, I suppose.

I am not trying to be cynical. It is rather quite obvious as we look at it.

3. Isn't there a better utilization of hospital beds in a well-controlled system like Sweden's?

No. There are 7.4 beds per 1,000 population in the United States and these are said to be too many. The number of beds in Sweden is 18, the highest in the world, and empty beds are virtually unheard of. The average length of stay in hospital is 7.9 days in the United States compared to 11.9 days in Sweden.

My comment is: Before the "total control” legislation of 1970, there was little utilization control but public and hospital and doctors restraint. Now there is a lot of redtape, but one cost rubric rose from $1 billion in mid-sixties to $2.77 billion in 1972, and neither the public nor the bureaucrats know how to spell "restraint.” Parasites don't want the death of their host, so the bureaucrats proliferate according to Parkinson's law and happily propose new and extended health services.

1. Do differences in vital statistics reflect differences in the quality of health care in Sweden and the United States?

In the quiet backwaters of northern Europe the Swedes are exposed to a very small number of diseases compared to the 211 million American citizens, gathered from all corners of the world. I am thinking of sickle cell anemia and high blood pressure, diseases which are prematurely killing particularly black people in this country; tuberculosis in Indians and other prone groups and an array of infections, not seen in Sweden. Not to mention overnutrition, drug abuse, killing by weapons both in war and peace; only in Detroit are killed more people than in Great Britain, Australia and Sweden together annually.

5. Don't the uniform and egalitarian Swedish hospitals create an atmosphere with relaxed attitudes, where employees can give more tender, loving care to everyone?

The answer is frustrating: Sweden has a depersonalized, factory style, assembly line care, unchallenged by all other nations—with the possible exception of New York City's hospitals, as I have been told.

A Swedish ward nurse is not supposed to spill her precious time "gossiping” with patients. The nurses unions have in vain protested about these working conditions. Of course, no other categories are supposed to talk to the patients either. TV's may be found at the end of the hall where patients least in need of it may gather in the evening.

Comment: The Swedes are often found boasting over their living standard, which including all coverages, benefits, and pensions would challenge even that of the United States. I for one disagree. Living standard has to be something more than only being kept alive. In that respect, the United States of America is unchallenged by Sweden and probably otherwise, too.

6. Is there nothing the United States could learn from Sweden?

Maybe. I am thinking of the regional planning to avoid wasteful duplication of expensive services and the Swedes' more realistic ap

proach to pregnancy and delivery. Routinely only three visits to a Medical Doctor are made before delivery and if no complications are anticipated midwives will take care of the delivery. But these things seem to me already implemented in the recent law, National Health Planning and Resources Development Act.

Between 80 and 90 percent of this country's population has economic coverage for the world's most sophisticated health care, highest standard of living, standard of education, and so forth. The fact that the services seem prohibitively expensive for some groups of citizens does not warrant the term “crisis.” This term is minted on the presumption that costs are too high and unreasonable. That is simply not so.

What the public and some pressure groups fail to understand is the fact that the cost of pushing up life expectancy 1 year for a whole nation today may be tenfold what it once cost to lift it up from 65 to 70 years, but the demands for continuing improvements are there.

It is said that the Swedes in choosing between an annual trip to their beloved Spanish Island of Mallorca and good health care probably would choose both. This has been the situation the last few decades and possibly because of an unusually favorable economic development, which of course is entirely within the private sector.

The reasons for legislating a national health insurance in this country are exactly the same as we know from the government takeovers in Great Britain, Sweden and, lately, Australia. The experience from these and other government-run health care systems could be put on blueprint: Confiscatory income taxes, flourishing bureaucracy, inefficiency, widespread abuses, and skyrocketing inflation plus serious economic burdens on industry.

What do these countries have in common? One thing for sure: Socialist governments, sensitive to labor pressure. Personally, I cannot remember any one union in Europe showing any degree of restraint.

Economists predict the "worse recession for 1978 with a doubledigit inflation returning in 1977. Government has directed fiscal and monetary policies exclusively at stimulating consumption while retarding investment. The prediction is, with present economic policies, an unemployment rate of staggering 12 percent by 1979. We must ask ourselves what we are doing if to this we add increased taxes and increased spending by an imaginary "free" health care.

If this country embarks on the route toward free health care, we know for sure that we are inviting and getting worsening inflation, maybe stagnation, unemployment, and a bureaucratic health industry, paralyzed by suffocating rules and regulations.

Ignoring the warnings for government spending for every true or imaginary crisis the Swedish Government found severe unemployment tendencies. Unemployment programs had to be started, but not by stimulating the economy. That is not to their liking and less palatable for the politicians, who want to please their voters and the unions. Retirement age was cut down in steps from 67 to 60 years, thus removing people from the market. Mandatory schooling was expanded, thus delaying people from entering the market.

Schools and universities were suddenly open for next to everyone. Unemployed were offered courses in welding, lumbering, carpeting, et cetera, and these too then were "off" the unemployment list, but the courses did not lead anywhere so the men were back to the agencies

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