799

Economy

THE LANCETLONDON: : SA T Z7RD Y, OCT. 29, 1949

FOR the moment the MINISTER OF HEALTH has

successfully defended the National Health Service

against arbitrary cuts that might have done it muchdamage. But the pressure will continue-first on the

ground that equally good value might be obtainedfor less expenditure, and secondly on the groundthat the country cannot at present afford a goodservice.Are there grounds for thinking that we are not

getting a pint out of the pint pot ? If we are candidwe must surely admit that there are places whereappreciable leaks may be suspected. For example, itseems a fair guess that a business consultant calledin to have a look at the rapid and expensive growthof the hospitals, and their high cost relative to theservices of the general practitioner, would ask whatis the relationship of the two, with reference tomethods of remuneration. On hearing that generalpractitioners are paid capitation fees but are at

liberty to refer their patients to the hospitals for

diagnosis and treatment, he would observe that hereis a point which calls for inquiry. He might remarkthat if no change in the financial arrangements canbe contemplated, at least accurate information shouldbe available as to what is happening, so that the

process can be guided and controlled. Referenceof patients to hospitals rose steeply after 1911, andthe present financial arrangements are likely to

encourage the process to go further ; and this shiftof the centre of gravity towards the expensive hospitaland specialist services is further stimulated by thefact that it is to everyone’s interest to press ontowards expansion. The consultants are naturallyall for more sessions and for more registrars. - Eventhe chief executive officer’s remuneration is steppedup in accordance with the increasing number of bedsin the group for which he is responsible. These and

many other important arrangements have been settledwith the best of intentions-what is medicallydesirable, and what is fair as between employer andemployed-but without any sufficient eye to their

bearing on the growth of the hospital and specialistservices. Exhortations from the MINISTER or fromthe regional boards, or even cuts in the estimates, arepoor substitutes for incentives to economy, and arealmost wholly ineffective. The technical elementsare so easily able to sway the layman, at almost anylevel from hospital management committee to Parlia-ment itself, that unless matters are arranged on asystem of checks and balances within the systemthere can be little hope of controlling the expansionisttendencies.

Secondly, there is the larger question : " can thecountry afford the present rate of expenditure onmedicine and the other social services ? " We are beingwarned by our American friends that the burden

of taxation is throttling our industries and threaten-ing our standard of living. We as a country haveembarked on this programme, financed out of taxa-tion, not because we think that it will pay in terms ofproductivity (though that may incidentally be so) butbecause we think it right to redistribute the nationalincome in this way, and because it has become partof our conception of the social democratic State. Itwas accepted by the electorate in 1945 and is notnow likely to be reversed whichever party wins thenext election. But the revenue side of the budgetis mainly sustained by the income-tax and variousother forms of taxation, a large proportion of whichis levied on industry : and if we have to rely on ourindustries to buy us our bread and meat and cottonfrom across the Atlantic we cannot pile any moreburdens on to them. Therefore, runs the argument,expenditure on the social services, however desirableand right, must be checked. This line of thoughtis now dominant : it will be all that the MINISTEROF HEALTH can do to hold the present line, andfurther advances, on which many hopes had beenset, must be eschewed for an indefinite future. Yetthe fact remains that, strange to say, there are largesections of the population, by no means all of themwith large incomes, who have money to spare forthis and that, for anything from sweet rations andnylons to television sets and holidays abroad-notto speak of an expenditure on tobacco sufficient toprovide the Exchequer with a revenue three timesas great as the whole cost of the hospital services.Is it really true that a country which has money inits pockets for all these things cannot " afford " to

bring its hospitals for the chronic sick up to date ?Is it not perhaps rather the case that we have notyet found the right way of financing the social service,and that the mistake has lain in loading this expendi-ture on to the national budget while the latter remainslargely dependent on taxation of industry for itsresources ? Ought not the cost of the social services tobe considered, not in relation to the total nationalrevenue as computed by the CHANCELLOR OF THEEXCHEQUER for his Budget, but against the far largertotal national income ? Should not means be devisedfor making the necessary cost of a healthy communityas much a first charge on each man’s earnings as is’his expenditure on food and shelter ?

It is easy to write " and means devised " ; but

they would of course imply a revolution in methodsof taxation. It was perhaps of the ultimate necessityof some such change that Sir STAFFORD CRIPPS hada glimpse when he spoke of a special tax to financethe health service. Big changes in our fiscal system,not cuts in the social services, may be the rightanswer to our dilemma. It certainly seems worthreconsidering the possibility of redesigning the patternof taxation so as to reduce the load of the socialservices on industry, and give expression to a truerscale of values, in which health and education cometo the fore and cigarettes and television masts arepushed into the background. We can, one suspects,have a good health service if we want it badlyenough. And if we tell the Americans that we preferto have our health service-and to wear our togastill they are patched and patched again-what isthat to them ?