Financing the health service

Vernon Coleman

Paradoxically, although most of the problems in the National Health Service would respond favourably to money, we do not need to spend more money on the health service in order to solve most of its prob lems. The paradox is not difficult to explain: the health service is not financially anaemic but the circulation is inequitable, some areas are too richly supplied while other areas are starved.

It is this unfair distribution of resources, rather than any massive shortage of finance, • which has led to the debility of the health

service and the anger and frustration of those doctors actively involved in the care

• of the sick.

Doctors have not lightly made the threat to strike. Last week's decision to hold a one-day strike if their pay demands gre rejected was not made after a short conference in Glasgow attended by a few medical men — it is the result of years of frustration experienced by all members of the medical profession. And it is not only the size of the cheque they receive every month or quarter that worries doctors.

: General practitioners find themselves apologising more and more frequently for the shortcomings of the service' they can provide. The family doctor has to try to explain why it takes nine months to Obtain an appointment with a specialist and why it takes another two years to get an essential operation performed. It is the family doctor who has to watch his elderly, patients struggling to survive with only a minimum Of help from the health service, knowing that accommodation for the elderly in hospitals and homes is severely limited.

' Hospital specialists find themselves using basic equipment that is out of date and in poor repair. They find themselves working in buildings that were erected half a century 'ago and intended to provide only temporary accommodation. And while doctors must put up with these shortcomings they see health service money being poured away in great quantities. They see millions spent on administrative centres which do little or nothing to improve the quality of care offered by the health service; they see millions spent on providing the community with more and more social workers and they See patients in hospital provided with free meals and hotel facilities. Waste in these areas has been well documented.

Most infuriating of all, however, is the fact that those doctors working in provincial hospitals and in general practice see many millions of pounds being spent on highpowered medical research. I am not referring here simply to research done in expensively equipped laboratories, and unlikely

to produce any useful information for many decades, but also to the research done in major teaching hospitals.

Britain, like any other country down on its luck, can provide only a limited amount of money for medical care. 'However difficult it may be to accept the fact, priorities have to be selected. We cannot afford to pay for transplant operations, dialysis machinery, computerised axial tomography of the head and test-tube babies while at the same time, in other parts of the country, patients are dying while they wait for simple, routine tests and treatment which cannot be done because there is not enough money.

In the area where I practise medicine, for example, it can take several weeks to obtain an urgent barium meal investigation of the stomach simply because the equipment is not available to cope with the demand and because, even if the equipment were available, doctors would not be available to use it. On the other hand, it is possible to arrange for patients to undergo open heart surgery of a fairly experimental nature.

Besides a shortage of diagnostic facilities there is an extraordinary disregard for preventive medicine as a. specialty. We spend very little money on trying to protect people from their own bad habits, although doctors largely agree that by doing just this we could greatly improve the health of' the community.

Money is spent on medical research for several reasons, of course. Patients, prospective patients and doctors all have a feeling that, if money is spent on research, miracle cures may turn up. Doctors share a traditional although factually invalid belief that a greater understanding of disease processes will lead to an increased ability to cope with them. And the patients who are the guinea pigs for researchers are real people who can be photographed and interviewed. Spending money on diagnostic and preventive medicine is less exciting and the people who do not get lung cancer or have a heart attack cannot be identified although, of course, they are just as real.

In short the situation in Britain is not unlike that in many developing African countries where citizens in the major cities have access to a great deal of modern equipment while people in the provinces are still dying of infectious diseases contracted from impure water supplies.

As a result of this unfair distribution of resources many practising doctors, well away from the establishment, are unhappy and angry. Their own financial predicament is deteriorating rapidly and as a result their patience is running out. You 'can keep 'a doctor poor if you ensure that his working

conditions are good, and you can help doctors forget bad conditions by paying them well, but you cannot keep doctors happy for ever if their working conditions are poor and their own financial state unsatisfactory.

The doctors' fall in income has meant that newly qualified doctors have to buy smaller houses than their professional ancestors, drive smaller cars and send their children to state schools. The medical profession has followed the decline of the clergy and the teaching profession. The reduction in income and the division between health service practitioners and private practitioners has reduced the independent status of most doctors and weakened their bargaining position.

The inevitable result of this has been the loss of many young doctors. Already a new type of brain drain has appeared; the flow of anaesthetists, radiologists and pathologists to European countries where language barriers do not matter and where rewards for technical skills are considerable, has left Britain dangerously short of doctors in these specialties. And so doctors, who have many times in the past flexed their muscles and made threatening noises, are on the attack again. This time I have a feeling that the dog may bite as well as bark, There will endoubtedly be a fierce fight. Mr Ennals, who is less emotional and therefore probably more dangerous than Mrs Castle, seems to believe that doctors should take their place in the 'health team' alongside porters and kitchen workers. He simply does not understand that although nurses, administrators and others in the health service are important the doctors are essential. They are the brain which keeps the health service alive. Labour Party policy seems to find the prospect of the doctor leading a health team unbearable. But if doctors lose this fight then the future for the health service is a bleak one. The most intelligent and skilled doctors will continue to drift away and the doctors left will have even less authority.

But if doctors succeed with their pay claim, it could mark the beginning of a new era; medical practitioners in the provinces may at least realise that they have some authority in the health service. Certainly their influence is needed. The politicians have proved conclusively that they have no idea how to run the health service. Politicians will always be swayed by the strongest breezes when it comes to allocating resources and the strongest breezes do not always turn out to be blowing in the right directions. The public still finds it difficult to accept the fact that there have to be priorities in medical care; they want everyone to be treated regardless of cost. The establishment figures in the medical profession have too much interest in the status of British medicine in the world. To them the collection of information is often more important than the use of information.

It is the medical profession as a whole which should make the decisions about how national health service resources are to be divided. If doctors can win their current battle with the Government over pay (and it may well need a mass resignation) then they will perhaps acquire the confidence to take hold of the health service, for if this ailing monster is to survive it needs a considerable amount of attention. Basic needs must be identified and given priority. And to satisfy those basic needs, and solve many of the major problems in the health service, will need not more money but a better distribution of the money already available.