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One problem for the onlooker is whose figures are beingused to estimate these costs. The Minister for SocialSecurity announced recently that Victcria’s lack of co-operation had cost the State$25 million next year. Thisimplies hospital costs of about$50 million. The counter

by the Victorian Minister of Health was that it cost theState$75 million a year just to care for pensioners inhospital-an unlikely figure.As far as doctors are concerned, the medical rebate side

of Medibank, replacing over 100 separate benefit societieswith one paying agency, need not alter the way they earntheir incomes. There is no compulsion to bulk bill andaccept a discount. Presumably this is because such com-pulsion would be civil conscription and so illegal. Afterall, the High Court held in 1949 that the requirement to usea Government-provided prescription form to prescribedrugs provided free under the Pharmaceutical Benefits Actwas civil conscription and so invalid.The hospital side of Medibank does mean a change in

the way that a senior hospital doctor earns his living. Atthe moment, most surgeons and physicians are unpaid,anxsthetists are usually paid a sessional fee, while patho-logists and radiologists in hospitals are usually full-timers,as are many specialised physicians. The bulk of the incomeof the first three groups comes from their private practice,on a fee-for-service basis. Naturally enough, proceduraldoctors, surgeons and anaesthetists, think that their privatepractices will shrink rapidly in the face of a free hospitalservice and that the three sessional payments for their presenthonorary work will not make up the loss. So the AustralianMedical Association is asking the State Governments forfee-for-service contracts for hospital staff. As this wouldcost much more than sessional payments, it is unlikely to beaccepted.The really important negotiations will be with the State

Governments on the conditions of sessional contracts. At

present, the sessional man gets annual leave, but not thesick leave, study leave, long-service leave, and superannua-tion that the full-timer gets. This sort of sessional contractwithout security was at the bottom of the Canberra Hospitalcrisis last year.l Of course, employing full-fimers, who arenot paid for out-of-hours duties, is cheaper than paying forsessions worked. But in Victoria, the Resident MedicalOfficers Wages Board has put the pay of a senior registrar,who does out-of-hours work, above that of a juniorspecialist, who, if he is full-time, usually does not workafter hours. So perhaps overtime payments for full-timerscould eventuate if the problem of overtime arises. InAustralia there is a long tradition of wage rates being set byarbitration, and the various Governments are as muchbound by the decisions of the courts and boards as are anyother employers.

Change is inevitable: even the A.M.A. has decided tomodify its absolute opposition to Medibank and nowadvises doctors not to try to sabotage the rebate side ofMedibank-which sabotage could be achieved by refusingto itemise bills until they had been paid. This would makeit impossible for the patient to ask the Medibank computerto pay the rebate directly to the doctor. In Melbourne,with its high proportion of private-hospital acute beds,there will be plenty of scope for queue-jumping; andprivate practice is confidently forecast to continue.

I have had time to write this because today there is astrike by the hospital employees union which has closedall except the emergency operating-theatres. So thisunemployed anaesthetist has tried to make good use of awintry day.

United States

NURSES AND PHYSICIAN’S ASSISTANTS

Unlike their counterparts in Britain, nurses in the U.S.are not only well paid but also have a fair amount of politicalsway. For the past twenty years or so, the American1. Lancet, 1974, i, 859.

Nursing Association (A.N.A.) has campaigned vigorouslyfor what it chooses to refer to as " professional status ".The A.N.A. is recommending that in future all nursesshould be enrolled in a degree programme, and that the3-year nursing schools be phased out. But the organisationhas not yet realised that, although the graduate nurse witha bachelor’s degree knows about enough English literatureto allow her to scrape through 0 levels, she is almostcompletely devoid of practical nursing experience-a situa-tion that has to be remedied after she has graduated.The A.N.A. campaign has been partly successful, at

least as far as status is concerned; however, with successhave come unanticipated problems. As the professionalstatus of the nurse has increased, so has her reluctance tocarry out what many regard as the essential part of the careof sick persons. Bedpans and temperature-taking becomethe province of the licensed practical nurse or the nurse’saide. The measurement of blood-pressure, the giving ofinjections, catheterisation, and even the changing of atracheostomy tube are procedures which are now oftendelegated to ancillary helpers. The modern professionalnurse is so highly trained that all she wants to do is to sitlooking at an oscilloscope in a coronary-care unit. Herreluctance to carry out what most persons regard as herduties has exasperated the medical profession. As a result,Dr Eugene Stead of Duke University and others havebrought into existence the " physician’s assistant ", or

P.A. This new addition to the health cadre is beginning tocome into his own, and many universities and colleges areoffering 4-year degree courses for P.A.S. The product ofsuch a programme is often very useful, and in some waysresembles the well-trained senior nursing orderly whoused to be so common in the R.A.M.C. Most States are

insisting that the P.A. has to be licensed, but this is not

acting as a deterrent, and indeed is giving him status thathe might not otherwise have. In many instances P.A.s havetaken over tasks that were formerly the province of thenurse, and, needless to say, the nurses intensely resent suchintrusions. The A.N.A.’s obsession with status and itsrefusal to face facts have brought into existence a rivalgroup of health workers who seriously threaten the nursingprofession. But the advent of P.A.S may well take the U.S.back to a pre-Flexner situation with two classes of physician-namely, those from first-class accredited schools andthose from third-class diploma mills. Meanwhile, thestandard of nursing care has deteriorated.

In England Now

Surgeons fascinate me. As a young man I spent manyhours in their midst, when I might have been better em-ployed. They puzzled me then, and they still puzzle me.They look so intelligent, and when they gaze up at youwith those sad soulful eyes you could almost believe theyunderstood every word you said. They are clean in theirhabits but, it must be admitted, too often they showirresolution and infirmity of purpose. You must havenoticed that when they set out to give their little pawsa good scrubbing, they begin with such zest, and then-just when they are making headway-they give it up as abad job and wander off and do something entirely different.This vacillation is most marked in thoracic surgeons, forwhom I have swung on many a scapula. Their favouritetrick, as you know, is Sawing a Woman in Half; but I’venever known one get further than halfway across beforepacking it in.Which reminds me: in fairness to readers I would like

to take this opportunity to correct a grievous error whichhas been perpetuated from one textbook to the next.Believe me, the aorta is not red, neither is the other thingblue. They are both an indeterminate pink, and so ispvprvtnina f1<: vn11 rnrnt- "’("rn"1."1.