677 a reliable method for the detection of A.B. The reliability if the procedure after vulval cleansing was 90% for all gram-negative strains isolated, and 93% for the E. coli grains. The observed prevalence-rate of significant A.B. was 4.7% for the total female population over 14 years of age. This is comparable with previous studies of adult females in the general population4-6 as is the significant increase with age.’ In 8 women a symptomatic urinary-tract infection deleloped in the period between the first and second urine cultures, therefore these women did not fulfil the requirements for A.B. This observation raises the question whether the interval between first and second urine cultures needs a more precise definition and should ideally be as short as possible so as not to exclude persons with a possible bacteriuria of the transient or symptomatic type from studies on the prevalence and natural history of A.B. In the negative control-group a total acquisition-rate of both symptomatic and asymptomatic bacteriuria of 12 6% was observed. This figure is comparable to the reported incidence of 5% asymptomatic and 6% symptomatic bacteriuria during a one-year follow-up study.8 A definite influence of sexual activity and pregnancy on the prevalence of bacteriuria has been reported as well as a lower prevalence among single women and 10 Our findings nuns as compared to married women.9 are in accordance with this. During pregnancy the incidence of symptomatic A.B. was three times higher compared with non-pregnant women of the same age-group (table in). Furthermore, both in pregnant and non-pregnant women, symptomatic infections developed seven times more frequently in women with pre-existing A.B. This is in accordance with other findings.The higher total incidence of symptomatic infections during pregnancy could therefore be the result of an increased acquisition-rate of A.B. during pregnancy. Our follow-up results suggest that women with A.B. fall into three groups with a different natural history. These groups were defined as transitory A.B., symptomatic A.B., and persistent A.B. Comparison of these groups ’table n) revealed that women with symptomatic A.B. were younger and had lower mean serum urea and creatinine levels and more signs of upper urinary tract involvement than the group of women with persistent A.B. This latter group showed more signs of lower urinary tract involvement. Differentiation into the three groups can be established at its earliest after a follow-up period of six months. At that time most symptomatic episodes have occured and women with transient A.B. have become apparent when their bacteriuria spontaneously disappears. This would mean, that an evaluation of the effect of treatment on persistent A.B. should be initiated after A.B. has been present for at least six months. Otherwise the conclusions about the effect of treatment would be hampered by the apparent heterogeneity within the total group of women with A.B. at screening. It could be calculated that the acquisition-rate exceeded the losses in A.B. caused by the transitory and symptomaticcases (details of calculations may be obtained from H.A.V.), thus explaining the increase in prevalence with K. Results of treatment of persistent A.B. are not yet ailable in sufficient detail for women in the categories defined by us to enable us to reach a definite decision To whether persistent A.B. should be treated or not.
At present we do not advocate a screening programme for A.B. in the open adult female population for the following reasons: (1) screening would have to be repeated too frequently in order to detect all cases with significant A.B.; (2) a simple detection of A.B. without follow-up of at least six months yields only limited information as to the type of A.B. present: (3) persistent A.B. in our study predominantly showed lower urinary-tract involvement as opposed to symptomatic A.B.; (4) treatment of A.B. does not prevent future symptoms of urinarytract infections9 and the natural history of treated and untreated A.B. in young girls runs possibly a similar course.12 During pregnancy these considerations apply less if not at all. The increased risk for symptomatic infections and the higher acquistion-rate in pregnant women justifies screening for A.B. during the period of gestation. Regular antenatal control renders pregnant women readily accessible for repeated urinary examination.
Requests for reprints should be
addressed
to
H.A.V.
REFERENCES 1. Leigh, D. A., Williams, J. D., J. clin. Path. 1964, 17, 498. 2. Norden, C. W., Kass, E. H. A. Rev. Med. 1968, 19, 431. 3. Kass, E. H., Finland, M. Trans. Ass. Am. Physns, 1956, 69, 56. 4. Miall, W. E., Kass, E. H., Ling, J., Stuart, K. J. Br. med. J. 1962, ii, 497. 5. Freedman, L. R., Phair, J. P., Seki, M., Hamilton, H. B., Nafziger, M. D., Hirata, M. Yale J. Biol. med. 1965, 37, 262. 6. Sussman, M. A., Asscher, A. W., Waters, W. E., Evans, J. A. S., Campbell, H., Evans, K. T., Williams, J. E. Br. med. J. 1969, i, 799. 7. Kass, E. H. in Biology of Pyelonephritis (edited by E. L. Quinn and E. H. Kass); Boston, 1960. 8. Asscher, A. W., Sussman, M. A., Waters, W. E., Evans, J. A. S., Campbell, H., Evans, K. T., Williams, J. E. Br. med. J. 1969, i, 804. 9. Kunin, C. M., McCormack, Regina C. New Engl. J. Med. 1968, 278, 635. 10. Kunin, C. M., ibid. 1970, 282, 1443. 11. Asscher, A. W., Chick, S., Radford, N., Waters, W. E., Sussman, M., Evans, J. A. S., McLanchlan, M. S. F., Williams, J. E. in Urinary Tract Infection (edited by W. Brumfitt and A. W. Asscher); p. 51, London, 1973. 12. Savage, D. C. L., Howie, G., Adler, K., Wilson, M. I. Lancet, 1975, i, 358.
Dear Continuing
Royal
our
Commissioners
collection
have not been seen by the National Health Service.
of items of evidence which Royal Commission on the
MANAGING THE HEALTH SERVICE: THE DOCTOR’S CONTRIBUTION* DOCTORS have a better opportunity than anyone else the resources of the N.H.S. to good effect and thus to improve its management. Changes in the attitudes to use
and
practices of doctors could have far-reaching
conse-
quences.
Prescribing Two factors have reinforced whatever element of indifference to the cost of treatment there may have been in the minds of doctors over the past 27 years. The first is the belief that the principle of a "comprehensive" health service commits Governments to make generally available whatever treatments become fashionable, regardless of cost. The second is the promotional activity of pharmaceutical manufacturers: once the representa*Based
on
an
essay awarded a first prize in the North Western 1976 annual essay competition.
Regional Health Authority’s
678
tive of a drug firm has satisfied a general practitioner that a particular product is prescribable on form E.c. 10 the actual cost of that product becomes for many doctors a matter of passing academic interest. It is a function of central Government to monitor prescribing costs, and to tell general practitioners if their prescribing costs greatly exceed the average. Within the hospitals in Lancaster a
computerised scheme analyses drug costs by ward, by occupied bed, and by case: such information enables clinicians to make comparisons and to probe the reasons for wide variations from the mean. Such systems may be worth extending to other hospitals. If "prescribing" is allowed to mean also the advocacy of complex networks of services, then considerations other than finance must be taken into account. The allocation of buildings, manpower, and money to the development of one service can today be achieved only by withholding these resources from other services. In the words of Alan Williams,’ the true cost of a thing is what you sacrifice in order to get it. Among the makers of these priority decisions, three of the six members of the management teams in the districts and single-district areas are doctors, and at area and at regional level the medical committee has a powerful voice. Doctors must again be encouraged to become ever more costconscious : otherwise they cannot assess the full implications of the options open to them in their "prescribing" role.
afflicted. It is at the heart of medical practice that the doctor should be able to distinguish between procedures which are effective and those which are not. In part this . judgment can be based on scientific evidence, but the profession is not sufficiently critical and too much of what is done rests on no more than tradition or fashion. During the past decade, for example, intensive coronary care units and mobile coronary-care ambulances have become fashionable. The case for them rested on studies which showed that patients intensively treated in hospitals fared better than patients given ordinary hospital treatment. But Mather et al. found that 226 patients randomly allocated to home care after what was judged to have been a coronary attack did marginally better than 224 patients randomly allocated to intensive care in hospital. Rose6 analysed hospital fatality ratios, hospital admission-rates, and mortality-rates for coronary heart-disease at ages 45-64 in England and Wales from 1963 to 1971 (i.e., before and during the period in which intensive coronary-care units have sprung up throughout the country): while acknowledging that such statistics constitute a blunt weapon, he pointed out that there had been no change in the death-rate over this period; what had changed was the hospital admission-rate (in other words it had become more fashionable to admit these patients to hospital). An
of activity where more critical appraisal from "efficiency" and the "effectiveness" viewpoints might pay dividends is that of investigative medicine. Carter et al. explained how escalation of demand for ever more numerous tests has made the argument for automation in laboratories irresistible: the increased availability that automation provides has further encouraged clinicians to ask for tests, thus lowering their critical assessment of whether they are really necessary, while the increase in the sheer volume of work in the laboratory has lessened the urge of the pathologist to challenge those who ask for the investigations. area
both the
Efficiency Doctors have a large measure of control over N.H.S. How efficiently are the resources used? There is great variation. In the North Western Region, 1974 data gave averages for entire Areas with variations of the following order: average total attendances pe: new psediatric outpatient, from 3.2 in one Area to 9.0 in another; "throughput" of gynaecological patients per available bed per year, from 35.7 to 54.4; and average duration of stay of geriatric patients, from 44.4 to 136.6 days.2 Quite apart from value for money, the patient’s time is a resource which doctors have tended to discount. Longson and Young3 described the programmed investigation unit at Manchester Royal Infirmary, in which the more economic use of the patient’s time has led to more efficient utilisation of hospital resources. One aspect of "efficiency" which can lead to difficulties within the profession is the matter of delegation. The Director General of the World Health Organisation said:4 "Surely there are immediate opportunities of shifting action downwards at least one step—from teaching hospitals to regional hospitals, from consultants to general practitioners, from general practitioners to nurses, from nurses to mothers"
resources.
Effectiveness "Effectiveness" service alters the
means
the extent to which any health
outcome
of
a
disease
process-for
example, by increasing the expectation of life or by lessening the degree of personal or social disability of those 1. Williams, A. H. Lancet, 1974, ii, 1124. 2. North Western Regional Health Authority. Comparative figures of in-patient and out-patient activities for Areas and Districts in the North Western Region, 1973 and 1974. Manchester, 1975. 3. Longson, D., Young, B. Br. med. J. 1973, iv, 528. 4. Mahler, H. Lancet, 1975, ii, 829.
Over-investigation disease is
may lead to "non-disease". "Non-
and
unhappiness and distress, many out-patient attendances, much unnecessary occupation of hospital beds and much time off work. It causes unnecessary expense to patients and to common
causes
much
the National Health Service. One ignore it."8
cannot
therefore
What about screening for disease? Among the criteria by which to justify a screening programme, the most important are that the disease sought can be identified unequivocally, that the "cases" so found can be treated effectively, and that it is necessary to treat them.9The importance of these criteria is still not always adequately appreciated. Screening programmes have been wamh advocated by doctors, they have attracted voluntary or political support, and they have sometimes been esta lished before convincing evaluation has been carried Mather, H. G., Morgan, D. C., Pearson, N. G., Read, K. L. Q., Shaw. D, B., Steed, G. R., Thorne, M. G., Lawrence, C. J., Riley, I. S. Br med J. 1976, i, 925. 6. Rose, G. Br. J. prev. soc. Med. 1975, 29, 147. 7. Carter, P. M., Davison, A. J., Wickens, I., Zilva, J. F. Hosp. Hlth Serv. Rev. 1975, 71, 346. 8. Hart, F. D. Practitioner, 1973, 211, 193. 9. Wilson, J. M. G., Jungner, G. Pnnciples and Practice of Screening for Dis ease. World Health Organisation, Geneva, 1968. 10. Whitby, L. G. Lancet, 1974, ii, 819. 5.
679
out.A cervical cytology service, for example, has been available in British Columbia for nearly thirty years, but it is still open to question whether the existence of such a service materially affects the death-rate from cervical cancer.
Rationing? These arguments seem to point in the direction of the rationing of secondary health care-in some way or other. Cooper" is not alone in pointing out that all health care is in effect rationed (because available supply falls short of actual and potential demand): he asks vwhether, with a better understanding of need and with a reappraisal of the nature of clinical freedom, unavoidable rationing would not take place more rationally, consistently and efficiently to the mutual benefit of taxpayer and patient." It is the
general practitioner who unlocks the gate to expensive secondary health care by referring his patient to hospital. The unanswered question is whether or not
the monitoring of referral rates should be and would it do any good? *
Cooper, M. Rationing Health Care. London. 1975.
Round the World Israel NAZARETH TODAY
Ideas of Nazareth, induced in Sunday school, as a dusty hamlet of five houses, a carpenter’s shop, and numerous donkeys could not be further from reality. Skyscraper blocks are visible on the horizon for miles during the approach over the Plain of Jezreel; the one-time population of 40 000 Arabs has now been doubled by an influx of immigrant Jews from all corners of the globe who have made Nazareth an industrial town matching the modern State of Israel. Medically, the population of Nazareth and its environs has its super-specialist services provided by a district general hospital in Afula 20 miles away, while general hospital services are supplied by the French, Italian, and English Hospitals; the last is the name given by the locals to the E.M.M.S. Hospital, presumably to the chagrin of the Scottish supporters of the Edinburgh Medical Missionary Society, who run the hospital ’although the staff includes Swiss and Germans as well as representatives of the four Home Countries). General-practitioner services are supplied by the outpatient clinics of the hospitals, by private practitioners, and by the Kupat Holim (General Federation of Labour) Health Centre, which depends for its money on a levy on all trade-union members in the district, in return for which members and :he[r families are entitled to care from the centre. An estimated population of 36 000 is cared for by 11 general practitioners, including 4 paediatricians and 1 obstetrician, and each expects to do only two or three domiciliary visits daily, the bulk of the Aork being in the health centre. The centre is planned around a courtyard with consulting-rooms in pairs separated by a arse’s treatment room. Records are kept in family groupings, bread-winning trade-unionist’s name. Dispensing costs are worrying the administration; an
: the
-rage of 20 prescriptions per patient are dispensed annually ;, the health centre’s dispensary, and it is not unusual for the :’.b-centre staff to find medication dumped in the gutter - je the centre. Hot discussion rages about whether a
*
The management of the N.H.S. would be better if doctors were (a) more cost-conscious; (b) more sensitive to the issue of efficiency in the use of resources under their control; (c) more questioning in the assessment of the effectiveness of what they are doing; and (d) prepared to face the implications of the necessity of sharing on a more sensible basis, the limited resources available to them. The issue of clinical freedom lurks in the background. Unfettered clinical freedom includes freedom to prescribe expensively, to use resources inefficiently, and to maintain ineffective services. It is up to the profession to face these issues-and when better than in the present lean times?-and to determine within itself how far the basic principle of freedom for the individual clinician must be reinterpreted if the profession as a whole is to use for the greatest possible benefit of the greatest possible number of patients the vast, but finite, resources with which the nation has entrusted it. Gateway House, Piccadilly South,
11
*
attempted-
Manchester M60 7LP
WILLIS J. ELWOOD Regional Specialist in Community Medicine, North Western Regional Health Authority
about 6p) should be introduced in an attempt to reduce this waste. Another type of waste is generated by the free-choice-of-doctor system: there is no fixed list as in the British National Health Service, and patients tend to shop around between private sector, health centre doctors, and one or other or all of the hospitals, seeking, it seems, an instant cure or a check on treatment already advised. The record is said to be held by a patient who consulted 15 different doctors in one day for the same complaint; perhaps she was looking for a miracle 2000 years too late.
charge (of
United States A GOOD POLL RESULT
Amidst all the bad news for the medical profession, the barrage of criticism from all sides, and the recent strikes, a Gallup poll provides comfort with its report that the medical profession is still highly regarded by the public. 55% of those questioned thought that the medical profession stood first, very high, or high in its honesty and ethical standards. Engineers, college teachers, and journalists were all so approved by 33% or more. Lawyers and building contractors were ranked next. Business executives, Senators, and Congressmen ranked next in the approval of the citizens; and bottom were labour union leaders and advertising executives. It is evident that, despite all criticisms and attacks, a wide section of the population has a high regard for their physicians, and a pretty poor opinion of their politicians, union leaders, and businessmen. The survey is held to indicate an anti-business and anti-Congress attitude because of the scandals in these areas of life. If so, the warning to the medical profession may be that it had better put its house in order while it holds the public esteem. In New York State alone, where a quarter of all Medicaid funds spent nationally are paid out, there have been a series of violations in which a number of physicians have been disqualified, suspended, or forced to make restitution for overcharging, for unnecessary charging, or for making fraudulent claims. The public expects that the law will play its part in bringing offenders to book; but if the profession is to retain its public stature, it too had better do something about it.
At present we do not advocate a screening programme for A.B. in the open adult female population for the following reasons: (1) screening would have to be repeated too frequently in order to detect all cases with significant A.B.; (2) a simple detection of A.B. without follow-up of at least six months yields only limited information as to the type of A.B. present: (3) persistent A.B. in our study predominantly showed lower urinary-tract involvement as opposed to symptomatic A.B.; (4) treatment of A.B. does not prevent future symptoms of urinarytract infections9 and the natural history of treated and untreated A.B. in young girls runs possibly a similar course.12 During pregnancy these considerations apply less if not at all. The increased risk for symptomatic infections and the higher acquistion-rate in pregnant women justifies screening for A.B. during the period of gestation. Regular antenatal control renders pregnant women readily accessible for repeated urinary examination.
Requests for reprints should be
addressed
to
H.A.V.
REFERENCES 1. Leigh, D. A., Williams, J. D., J. clin. Path. 1964, 17, 498. 2. Norden, C. W., Kass, E. H. A. Rev. Med. 1968, 19, 431. 3. Kass, E. H., Finland, M. Trans. Ass. Am. Physns, 1956, 69, 56. 4. Miall, W. E., Kass, E. H., Ling, J., Stuart, K. J. Br. med. J. 1962, ii, 497. 5. Freedman, L. R., Phair, J. P., Seki, M., Hamilton, H. B., Nafziger, M. D., Hirata, M. Yale J. Biol. med. 1965, 37, 262. 6. Sussman, M. A., Asscher, A. W., Waters, W. E., Evans, J. A. S., Campbell, H., Evans, K. T., Williams, J. E. Br. med. J. 1969, i, 799. 7. Kass, E. H. in Biology of Pyelonephritis (edited by E. L. Quinn and E. H. Kass); Boston, 1960. 8. Asscher, A. W., Sussman, M. A., Waters, W. E., Evans, J. A. S., Campbell, H., Evans, K. T., Williams, J. E. Br. med. J. 1969, i, 804. 9. Kunin, C. M., McCormack, Regina C. New Engl. J. Med. 1968, 278, 635. 10. Kunin, C. M., ibid. 1970, 282, 1443. 11. Asscher, A. W., Chick, S., Radford, N., Waters, W. E., Sussman, M., Evans, J. A. S., McLanchlan, M. S. F., Williams, J. E. in Urinary Tract Infection (edited by W. Brumfitt and A. W. Asscher); p. 51, London, 1973. 12. Savage, D. C. L., Howie, G., Adler, K., Wilson, M. I. Lancet, 1975, i, 358.
Dear Continuing
Royal
our
Commissioners
collection
have not been seen by the National Health Service.
of items of evidence which Royal Commission on the
MANAGING THE HEALTH SERVICE: THE DOCTOR’S CONTRIBUTION* DOCTORS have a better opportunity than anyone else the resources of the N.H.S. to good effect and thus to improve its management. Changes in the attitudes to use
and
practices of doctors could have far-reaching
conse-
quences.
Prescribing Two factors have reinforced whatever element of indifference to the cost of treatment there may have been in the minds of doctors over the past 27 years. The first is the belief that the principle of a "comprehensive" health service commits Governments to make generally available whatever treatments become fashionable, regardless of cost. The second is the promotional activity of pharmaceutical manufacturers: once the representa*Based
on
an
essay awarded a first prize in the North Western 1976 annual essay competition.
Regional Health Authority’s
678
tive of a drug firm has satisfied a general practitioner that a particular product is prescribable on form E.c. 10 the actual cost of that product becomes for many doctors a matter of passing academic interest. It is a function of central Government to monitor prescribing costs, and to tell general practitioners if their prescribing costs greatly exceed the average. Within the hospitals in Lancaster a
computerised scheme analyses drug costs by ward, by occupied bed, and by case: such information enables clinicians to make comparisons and to probe the reasons for wide variations from the mean. Such systems may be worth extending to other hospitals. If "prescribing" is allowed to mean also the advocacy of complex networks of services, then considerations other than finance must be taken into account. The allocation of buildings, manpower, and money to the development of one service can today be achieved only by withholding these resources from other services. In the words of Alan Williams,’ the true cost of a thing is what you sacrifice in order to get it. Among the makers of these priority decisions, three of the six members of the management teams in the districts and single-district areas are doctors, and at area and at regional level the medical committee has a powerful voice. Doctors must again be encouraged to become ever more costconscious : otherwise they cannot assess the full implications of the options open to them in their "prescribing" role.
afflicted. It is at the heart of medical practice that the doctor should be able to distinguish between procedures which are effective and those which are not. In part this . judgment can be based on scientific evidence, but the profession is not sufficiently critical and too much of what is done rests on no more than tradition or fashion. During the past decade, for example, intensive coronary care units and mobile coronary-care ambulances have become fashionable. The case for them rested on studies which showed that patients intensively treated in hospitals fared better than patients given ordinary hospital treatment. But Mather et al. found that 226 patients randomly allocated to home care after what was judged to have been a coronary attack did marginally better than 224 patients randomly allocated to intensive care in hospital. Rose6 analysed hospital fatality ratios, hospital admission-rates, and mortality-rates for coronary heart-disease at ages 45-64 in England and Wales from 1963 to 1971 (i.e., before and during the period in which intensive coronary-care units have sprung up throughout the country): while acknowledging that such statistics constitute a blunt weapon, he pointed out that there had been no change in the death-rate over this period; what had changed was the hospital admission-rate (in other words it had become more fashionable to admit these patients to hospital). An
of activity where more critical appraisal from "efficiency" and the "effectiveness" viewpoints might pay dividends is that of investigative medicine. Carter et al. explained how escalation of demand for ever more numerous tests has made the argument for automation in laboratories irresistible: the increased availability that automation provides has further encouraged clinicians to ask for tests, thus lowering their critical assessment of whether they are really necessary, while the increase in the sheer volume of work in the laboratory has lessened the urge of the pathologist to challenge those who ask for the investigations. area
both the
Efficiency Doctors have a large measure of control over N.H.S. How efficiently are the resources used? There is great variation. In the North Western Region, 1974 data gave averages for entire Areas with variations of the following order: average total attendances pe: new psediatric outpatient, from 3.2 in one Area to 9.0 in another; "throughput" of gynaecological patients per available bed per year, from 35.7 to 54.4; and average duration of stay of geriatric patients, from 44.4 to 136.6 days.2 Quite apart from value for money, the patient’s time is a resource which doctors have tended to discount. Longson and Young3 described the programmed investigation unit at Manchester Royal Infirmary, in which the more economic use of the patient’s time has led to more efficient utilisation of hospital resources. One aspect of "efficiency" which can lead to difficulties within the profession is the matter of delegation. The Director General of the World Health Organisation said:4 "Surely there are immediate opportunities of shifting action downwards at least one step—from teaching hospitals to regional hospitals, from consultants to general practitioners, from general practitioners to nurses, from nurses to mothers"
resources.
Effectiveness "Effectiveness" service alters the
means
the extent to which any health
outcome
of
a
disease
process-for
example, by increasing the expectation of life or by lessening the degree of personal or social disability of those 1. Williams, A. H. Lancet, 1974, ii, 1124. 2. North Western Regional Health Authority. Comparative figures of in-patient and out-patient activities for Areas and Districts in the North Western Region, 1973 and 1974. Manchester, 1975. 3. Longson, D., Young, B. Br. med. J. 1973, iv, 528. 4. Mahler, H. Lancet, 1975, ii, 829.
Over-investigation disease is
may lead to "non-disease". "Non-
and
unhappiness and distress, many out-patient attendances, much unnecessary occupation of hospital beds and much time off work. It causes unnecessary expense to patients and to common
causes
much
the National Health Service. One ignore it."8
cannot
therefore
What about screening for disease? Among the criteria by which to justify a screening programme, the most important are that the disease sought can be identified unequivocally, that the "cases" so found can be treated effectively, and that it is necessary to treat them.9The importance of these criteria is still not always adequately appreciated. Screening programmes have been wamh advocated by doctors, they have attracted voluntary or political support, and they have sometimes been esta lished before convincing evaluation has been carried Mather, H. G., Morgan, D. C., Pearson, N. G., Read, K. L. Q., Shaw. D, B., Steed, G. R., Thorne, M. G., Lawrence, C. J., Riley, I. S. Br med J. 1976, i, 925. 6. Rose, G. Br. J. prev. soc. Med. 1975, 29, 147. 7. Carter, P. M., Davison, A. J., Wickens, I., Zilva, J. F. Hosp. Hlth Serv. Rev. 1975, 71, 346. 8. Hart, F. D. Practitioner, 1973, 211, 193. 9. Wilson, J. M. G., Jungner, G. Pnnciples and Practice of Screening for Dis ease. World Health Organisation, Geneva, 1968. 10. Whitby, L. G. Lancet, 1974, ii, 819. 5.
679
out.A cervical cytology service, for example, has been available in British Columbia for nearly thirty years, but it is still open to question whether the existence of such a service materially affects the death-rate from cervical cancer.
Rationing? These arguments seem to point in the direction of the rationing of secondary health care-in some way or other. Cooper" is not alone in pointing out that all health care is in effect rationed (because available supply falls short of actual and potential demand): he asks vwhether, with a better understanding of need and with a reappraisal of the nature of clinical freedom, unavoidable rationing would not take place more rationally, consistently and efficiently to the mutual benefit of taxpayer and patient." It is the
general practitioner who unlocks the gate to expensive secondary health care by referring his patient to hospital. The unanswered question is whether or not
the monitoring of referral rates should be and would it do any good? *
Cooper, M. Rationing Health Care. London. 1975.
Round the World Israel NAZARETH TODAY
Ideas of Nazareth, induced in Sunday school, as a dusty hamlet of five houses, a carpenter’s shop, and numerous donkeys could not be further from reality. Skyscraper blocks are visible on the horizon for miles during the approach over the Plain of Jezreel; the one-time population of 40 000 Arabs has now been doubled by an influx of immigrant Jews from all corners of the globe who have made Nazareth an industrial town matching the modern State of Israel. Medically, the population of Nazareth and its environs has its super-specialist services provided by a district general hospital in Afula 20 miles away, while general hospital services are supplied by the French, Italian, and English Hospitals; the last is the name given by the locals to the E.M.M.S. Hospital, presumably to the chagrin of the Scottish supporters of the Edinburgh Medical Missionary Society, who run the hospital ’although the staff includes Swiss and Germans as well as representatives of the four Home Countries). General-practitioner services are supplied by the outpatient clinics of the hospitals, by private practitioners, and by the Kupat Holim (General Federation of Labour) Health Centre, which depends for its money on a levy on all trade-union members in the district, in return for which members and :he[r families are entitled to care from the centre. An estimated population of 36 000 is cared for by 11 general practitioners, including 4 paediatricians and 1 obstetrician, and each expects to do only two or three domiciliary visits daily, the bulk of the Aork being in the health centre. The centre is planned around a courtyard with consulting-rooms in pairs separated by a arse’s treatment room. Records are kept in family groupings, bread-winning trade-unionist’s name. Dispensing costs are worrying the administration; an
: the
-rage of 20 prescriptions per patient are dispensed annually ;, the health centre’s dispensary, and it is not unusual for the :’.b-centre staff to find medication dumped in the gutter - je the centre. Hot discussion rages about whether a
*
The management of the N.H.S. would be better if doctors were (a) more cost-conscious; (b) more sensitive to the issue of efficiency in the use of resources under their control; (c) more questioning in the assessment of the effectiveness of what they are doing; and (d) prepared to face the implications of the necessity of sharing on a more sensible basis, the limited resources available to them. The issue of clinical freedom lurks in the background. Unfettered clinical freedom includes freedom to prescribe expensively, to use resources inefficiently, and to maintain ineffective services. It is up to the profession to face these issues-and when better than in the present lean times?-and to determine within itself how far the basic principle of freedom for the individual clinician must be reinterpreted if the profession as a whole is to use for the greatest possible benefit of the greatest possible number of patients the vast, but finite, resources with which the nation has entrusted it. Gateway House, Piccadilly South,
11
*
attempted-
Manchester M60 7LP
WILLIS J. ELWOOD Regional Specialist in Community Medicine, North Western Regional Health Authority
about 6p) should be introduced in an attempt to reduce this waste. Another type of waste is generated by the free-choice-of-doctor system: there is no fixed list as in the British National Health Service, and patients tend to shop around between private sector, health centre doctors, and one or other or all of the hospitals, seeking, it seems, an instant cure or a check on treatment already advised. The record is said to be held by a patient who consulted 15 different doctors in one day for the same complaint; perhaps she was looking for a miracle 2000 years too late.
charge (of
United States A GOOD POLL RESULT
Amidst all the bad news for the medical profession, the barrage of criticism from all sides, and the recent strikes, a Gallup poll provides comfort with its report that the medical profession is still highly regarded by the public. 55% of those questioned thought that the medical profession stood first, very high, or high in its honesty and ethical standards. Engineers, college teachers, and journalists were all so approved by 33% or more. Lawyers and building contractors were ranked next. Business executives, Senators, and Congressmen ranked next in the approval of the citizens; and bottom were labour union leaders and advertising executives. It is evident that, despite all criticisms and attacks, a wide section of the population has a high regard for their physicians, and a pretty poor opinion of their politicians, union leaders, and businessmen. The survey is held to indicate an anti-business and anti-Congress attitude because of the scandals in these areas of life. If so, the warning to the medical profession may be that it had better put its house in order while it holds the public esteem. In New York State alone, where a quarter of all Medicaid funds spent nationally are paid out, there have been a series of violations in which a number of physicians have been disqualified, suspended, or forced to make restitution for overcharging, for unnecessary charging, or for making fraudulent claims. The public expects that the law will play its part in bringing offenders to book; but if the profession is to retain its public stature, it too had better do something about it.
