734

ADDITIONAL COSTS ARISING FROM CLINICAL TEACHING

Teaching hospitals are on average more costly to run thanhospitals in which no teaching takes place. Additional servicecosts necessarily incurred as a result of the presence of medicalstudents need to be the subject of special protection withinrevenue allocations. The report sets out methods of identifyingthe sum of money involved, and of ensuring that it is takeninto account in the revenue distribution process to R.H.A.S,A.H.A.S, and Districts. "Service increment for teaching" (SIFT)should be the term used to describe the element within therevenue allocations to cover these additional costs. Researchshould be set in hand on the effects on levels of service provi-sion and costs of (i) "centres of excellence", (ii) centres forclinical teaching, and (iii) centres where other educational andresearch facilities are concentrated.75% of the median excess cost per student of teaching hospi-

tals set against comparable non-teaching hospitals should bethe starting point for calculating the sum to be protected as aSIFT. The basis for assessing and distributing the SIFT shouldremain student numbers, disregarding research students. Pro-jected student numbers for 1980-81 should be the basis for fix-ing the amount of SIFT nationally for the next three years.

ALLOCATION OF CAPITAL

Different criteria and methods are needed for capital distri-bution. The existing stock must be taken into account; and itis important to balance the assessment of the need of a region’spopulation for health-service capital against the extent to

which that need is already met through the existing stock. Thereport proposes a way of combining these elements to arrive atan overall assessment of each R.H.A.’s relative need for capital.The pace at which imbalances can be remedied will be gov-erned by practical considerations. Population should be

weighted for capital purposes in a way similar to that used forrevenue. Capital targets for R.H.A.s should be set by notionallydistributing total existing stock value and new capital moneyavailable for distribution in proportion to weighted popula-tion. Progress towards capital targets should take place as fastas possible, subject to the operation of special transitional ar-rangements in the early years, of a "set minimum" arrange-ment designed to secure a minimum share of available capitalfor all R.H.A.s, and of a "ceiling" arrangement controlling therate of growth to take account of practical considerations, withsafeguards against excessively rapid change.

EFFECTS OF RECOMMENDED CHANGES S

The report identifies the regions in greatest need of a biggershare of the available revenue resources as North Western,Trent, Northern, Yorkshire, and Wessex. To allow faster

growth to these and other regions whose present allocationsare below their resource "targets", the report suggests restrict-ing growth in the five regions whose present revenue alloca-tions are above their "targets". These are the four Thames Re-gions and Oxford. Ultimately the aim is that all regions shouldreceive the share of revenue indicated by their "targets". Butthe report emphasises that a period of transition is requiredduring which authorities can plan for their changed resourceexpectations.

In terms of the percentage swing of each region in relationto its revenue target, the report compares the 1976-77 positionwith 1977-78 with the recommended changes fully applied. A12 ‘7o growth nationally has been assumed for 1977-78. Thelargest swings are seen in the North Western, Trent, Northern,Mersey, North West Thames, and North East Thames regions,while Wessex, South Western, East Anglian, South West

Thames, and South East Thames are affected very much less.The change having the greatest effect is the introduction of

a morbidity factor based upon s.M.R.s affecting North Western,East Anglian, Mersey, and Oxford more than others. The for-mula combines expected bed utilisation and S.M.R.S by condi-

tion and the results are therefore influenced largely by thoseconditions having a high bed usage.

The effect of the new approach to assessing the additionalservice costs arising from clinical teaching is largely to increasethe apparent needs of provincial R.H.A.s by contrast with thoseof the Thames R.H.A.s.

The introductions of a need measure based on capital stockvaluation would restrict for a period the level of capital invest-ment in East Anglian, North West Thames, North East

Thames, South West Thames, Oxford, and Mersey in favourof the remaining R.H.A.S. Unless such an adjustment is made,distribution by reference to weighted population as the sole cri-terion would tend to perpetuate indefinitely the historic differ-ences in the availability and condition of capital stock.

BALANCE BETWEEN CAPITAL AND REVENUE

The working party considers it essential to allow R.H.A.s toseek an augmentation of their future capital allocations at theexpense of their future revenue allocations (and vice versa)over and above the permitted limit of flexibility within theyear. The arrangement proposed would permit much greaterflexibility in strategic planning and give Authorities more roomto manoeuvre while at the same time retaining the tactical free-dom conferred by the existing flexibility limits.

Round the World

Indonesia

SOCIAL PAEDIATRICS

THE 2nd Asian Congress of Paediatrics, held in August inJakarta, was the largest-ever gathering of pmdiatricians whoseprimary concern is children in developing countries. Thoseattending came from some of the most densely peopled areasin the world, out some countries, such as Iraq, Pakistan, andSri Lanka, were represented by only one member, reflec6ngperhaps their Government’s belief in the irrelevance of suchcongresses. They may well have been mistaken. This congresswas unlike many others in that 30% of the titles of papers indi-cated that the research must have been undertaken outside thehospital or laboratory and within the community. The contentof social paediatrics was high; and paediatricians in this part ofthe world are increasingly concerned with measures to preventthe damage inflicted by too closely spaced births on the physi-cal and intellectual development of children.The congress saw the founding of an Asian Pacific paediatric

gastroenterology group. The successful methods of oral rehyd-ration which have been developed and widely adopted in oneor two countries in south-east Asia need extension by closecooperation between universities and governments, as in In-donesia ; and this group is looking for corresponding membersoutside the region*.A colleague who had not visited Indonesia for ten years

remarked on the impressive changes in the centre of Jakarta.But these changes are perhaps more apparent than real,Within three miles of the hotel it was possible to find an areawhere there was a clinic with no scales to weigh the children,where the water cost the equivalent of lOp for a 2-gallon can,after it had been pushed a mile in a hand cart, and by 11o’clock a family with small children had ’not had their firstmeal. The many adults with one blind eye are a reminder of

past vitamin-A deficiency in this area; and, during a brief visit.we saw a child of 2 years with one eye destroyed. In Kenya,Sauter’ identified the interaction of measles and vitamin-A

4*Those interested should write to the Secretary, Dr Soenoto, MedI-

cal School, University of Indonesia, Jalan Salemba 6, Djakarta, In-donesia.1. Sauter, J. J. M. Xerophthalmia and Measles in Kenya. Groningen, 1976.

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deficiency as the single largest and preventable cause of blind-ness. Although ptEdiatricians report that measles in Indonesiais mild, if the blindness is in any way related to measles andvitamin-A deficiency, the use of oral vitamin-A for every childwith measles could be a major step towards the prevention ofxerophthalmia.

United States

THE STRIKES END

The strikes in New York City against the municipal hospi-tals have ended, but the situation that provoked them has notreally altered. The basic problem is money to pay the staff, andthis applies equally to the private and the public sectors, bothof which have been hit by strikes within a month of each other.The latest strike ended when the employees, to save loss ofjobs, agreed to forgo incremental increases in cost-of-living andother future benefits. The root of the trouble is the soaring in-crease in expenditure and costs following the adoption ofMedicare and Medicaid programmes, which led to the intro-duction of ever-more costly care and equipment, increasedcosts incurred by employing more highly trained technicians,and, filtering down, increased pay for the so-long underpaidancillary hospital staff. The bulk of the revenue of the hospi-tals now comes from governmental sources, which is a fine

thing when revenue is buoyant, but not so good in hard times,when the Government just cuts back on payments, in effectpushing the hospitals into bankruptcy. To cut costs the hospi-tals have no real options but to cut their wage and salary bills,their major expenditure, and to push as much back on the pa-tient by higher premiums, co-insurance, and reduced coverageof services, as possible. Even this, it seems, is not going to helpfor long. Future plans include trying to get the budgetsbalanced by still more staff cuts, which will probably producemore strikes. It seems certain that things will get worse, andthat only the federalisation of the system of health care canprevent the crisis.This is by no means the only field in which the great rise

in health costs is causing concern. In many walks of life, anindividual’s emoluments include considerable, usually non-taxed, so-called fringe benefits, and one of these is often a largecontribution by the employer to the health insurance of the in-dividual and his family. These costs have risen monstrously.For instance, the costs to the automobile manufacturers ofemployee health insurance is said now to exceed what they payfor the steel to make their motor-cars. Quite naturallyemployers want to reduce these costs. The unions agree, butonly if a national health plan, which they have long advocated,is introduced. There are plentiful seeds of conflict here.

REVERSE DISCRIMINATION

In 1971 the U.S. Supreme Court refused to hear the case inwhich a law student charged that he had been discriminatedagainst because he had been refused admission to the lawschool of his choice, when others from various minority groupswith lower test scores had been admitted. By the time the mat-ter came before the Supreme Court, the student had qualifiedvia another institution, and so the issue could be ducked. ThisIS a pity, because it is still an area both of controversy and un-certainty how far an institution of higher learning can orshould discriminate against fully eligible persons seekingadmission to courses, in favour of less well qualified applicantswho represent minority groups whose up-grading in society isan agreed objective. The courts are soon going to get a freshchance to decide the matter when the case comes before themof a White medical student who charges that a medical schoolwas biased in that 16% of places were reserved for minoritygroups.Few people would deny that there is a need for physicians

from the minority groups. Less than 2% of the nation’s phys-aans are Black, and it seems that in the immediate future theap; far from narrowing, will actually widen, for there is aJrop in the number of Black freshmen medical students this

year-when desperate shortages and maldistribution of phys-icians are becoming more and more obvious. To make mattersworse, there are claims (often hotly denied) that academicstandards have fallen because of the admission of inadequatelyprepared students from minority groups.

There lies behind all this the question of how far universitiesshould be expected to undertake social engineering of this sortwithout very clear directives from those who hold the purse-strings. If this country wishes to make such social adjustmentsthen it should lay down the rules rather than leave it to chanceand circumstances amongst the administrators of institutions.The only guidelines that have been laid down so far are nega-tive ones-that there should be no discrimination-and theseare of no help to administrators, who can see themselves beingopen to legal hazards whatever they do. It is to be hoped,therefore, that the case about to be heard will result in a rulingthat will make the situation clear.

MEDICAID FRAUDS

It has long been foretold that immense opportunities forfraud would be afforded by the Medicaid programmes, whichprovide, under State and local control, for medical care for thepoor, using joint federal and State moneys. Now, thanks toSenator Moss and his aides, and a Senate subcommittee,grossly fraudulent practices on an immense scale have beenrevealed. The Senator and various helpers, poorly clad buthaving previously been given a clean bill of health by theirphysicians, have obtained Medicaid cards and sought medicalattention in some of the Medicaid mills. Clinical examinationswere scant and cursory, for the operators of these clinics donot like actually to touch their patients; stethoscopes wereapplied to the clothed chest, sphygmomanometers to the’clothed arm. X-rays and laboratory tests were ordered on alavish scale, bleedings for such tests were universal, and someill was always diagnosed and drugs ordered-patients beingsteered, quite illegally, to particular pharmacies with a tie-into the medical men concerned. Patients were batted back andforth from specialist to specialist, and it was said that some-times the only way of escape from such ping-ponging was torun out of the clinic.The costs of this must be astronomical, even if the actual

totals and percentages may be disputed. New York City’s sharealone would be sufficient to bring it out of debt and allow it ’tto save many thousands of jobs. The rewards to certain indi-viduals have also been astronomical. Payments of more than$300 000 have been made to quite a few physicians, and evenif this is shared out or used to pay assistants’ salaries, it is stillan enormous sum, and the quality of the staff employed, thenon-professionals too, seems often to be quite deplorable.

Excuses are being made. Physicians stress the inordinatelylong hours they put in, and those providing ancillary servicesin radiology and pathology say they are only doing what theyare asked by colleagues to do. One chilling statement made isthat if Senator Moss had gone to some opulent private diag-nostic clinic he would have been handled in the same way,but that he, rather than the Government, would have had topay for the privilege.The reason why all this misuse of resources has been

allowed to happen is quite clear: inadequate checking and con-trols. New York City has not even spent what it was allocatedon checking. Moreover, such bureaucracy as there was was sodilatory, cumbersome, and inefficient, that the better medicalpractitioners refused to treat Medicaid patients, or preferred totreat without billing. City and State governments are guilty,so is the bureaucracy, so are, directly, many medical men andother health providers, but so is the medical profession at largein this country, and all its professional associations. Theyhave not been slow to point out the defects in health-care sys-tems in other countries; they have condemned "socialist"medicine as compared with the free-enterprise system. Theleaders of the medical profession have for too long toleratedthese abuses, and must now get down to disciplining theirerrant members.

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