J Enoch Powell 1966
4. Supply and Demand
Medical care under the National Health Service is rendered free to the consumer at the point of consumption— apart, that is, from spectacles and certain dental treatment and appliances. Consequently supply and demand are not kept in balance by price. Since, therefore, resources are limited, both theoretically and in practice at any given time, while demand is unlimited, supply has to be rationed by means other than price. The forms of rationing adopted deliberately or by default, and usually unrecognised— certainly unproclaimed— as such, are among the major irritant ingredients in Medicine and Politics.
Common thought and parlance tend to conceal or deny the fact that demand for all practical purposes is unlimited. The vulgar assumption is that there is a definable amount of medical care ‘needed’, and that if that ‘need’ was met, no more would be demanded. This is absurd. Every advance in medical science creates new needs that did not exist until the means of meeting them came into existence, or at least into the realm of the possible. For every heart-lung machine or artificial kidney in operation there must be many times that number of cases to which the treatment would be applicable. Every time a discovery is made in, for example, the techniques of grafting, the horizon of ‘need’ for medical care is suddenly enlarged.
THE INFINITY OF DEMAND
Then again, there is virtually no limit to the amount of medical care an individual is capable of absorbing. The moment it was established that the cervical smear test enabled incipient or prospective cancer to be diagnosed, this check-up became a ‘need’ of every woman between the relevant ages. But we would all benefit from having our incipient or suspected ailments detected and treated sooner: everyone knows that he suppresses or ignores medical conditions that could be alleviated or removed.
Not only is the range of treatable conditions huge and rapidly growing. There is also a vast range of quality in the treatment of those conditions. Every general practitioner knows that he palliates with pills psychiatric or psychological disorders to which a great amount of skill and care could be justifiably (in a professional sense) devoted. There is hardly a type of condition from the most trivial to the gravest which is not susceptible of alternative treatments under conditions affording a wide range of skill, care, comfort, privacy, efficiency and so on. Anyone who thinks that in treatment for a given condition there is a definite and limited quantum of demand would do well to consider why the oil sheikhs come to London consultants and the private wards of London teaching hospitals.
Finally, there is the multiplier effect of successful medical treatment. Improvement in expectation of survival results in lives that demand further medical care. The lower (medically speaking) the quality of the lives preserved by advancing medical science, the more intense are the demands they continue to make. In short, the appetite for medical treatment vient enmangeant.
The fact that the demand for medical care is potentially unlimited does not distinguish it per se from demand for most of the other good things of human life. In those other cases, however, limits are placed on the fulfilment of demand by the impersonal forces of circumstance. Such limits are not resented, and indeed are rarely even noticed. Where, on the other hand, the state has undertaken to meet a demand, the limitations are seen as the personal decisions of human authority. They are then felt and resented as the arbitrary determination of fellow human beings to limit the supply of the good things of life.
It is noticeable, and significant, that human needs become ‘good things’ in this sense only when, or in proportion as, public responsibility is taken for supplying them. For example, food and clothing, though surely as basically ‘good’ as medical care or education, are not regarded in the same light. Nobody says: ‘Obviously we cannot have too many people stitching away at trousers, or canning away at tomatoes, because there can’t be too great an improvement in clothing or feeding.’ Yet everybody, or almost everybody says, ‘Obviously we can’t have too many nurses or doctors, or too many teachers: we want just as many as we can get, for surely health and education are good things’. One even finds the same requirements falling into both categories, ‘good’ and ‘not good’, according to whether they are publicly or privately provided. Roads are ‘good things’ and you can’t have too much of them; yet cars are not. Rail transport to an out-of-the-way spot is a ‘good thing’; road transport is not.
There is a characteristic of medical care that makes its public provision exceptionally problematic. The demand for it is not only potentially unlimited; it is also by nature not capable of being limited in a precise and intelligible way. This can be made clear by comparison with, for instance, education. The potential demand for education is unlimited, just like the demand for medical care. Nevertheless it is possible to define a specific quantity and quality of education to be provided, by laying down, for instance, the ages between which children are to attend school, the subjects they are to be taught, the size of classes, and the qualifications of the teachers. There will still, of course, be variations in quality, but the size of the need delimited, and the logic of the delimitation, is there for all to see.
No similar criteria are available in relation to medical care. On the contrary, the need for any criteria at all is strenuously repudiated in the popular mythology of the National Health Service. This asserts, with maddening idiocy, that the service secures ‘the best of medical care for the poorest when they need it’. Apart from the question-begging ‘when’ and the meaningless ‘need’, the claim implies either that there is no medical care but the best (which is absurd) or that the inferior medical care is enjoyed by the better-off (which is equally absurd, as well as unjust). In order to produce some sort of objective limitation it would be necessary to confine the supply of medical care to those suffering from certain conditions, such as epidemic diseases (as was done at the outset of public medicine), or to certain categories of patient, such as children (as is done with the free supply of certain spectacles and dental appliances).
The National Health Service, then, must and does apply covert rationing devices in order to limit demand to the actual amount of the supply.
CONTROLLING THE SUPPLY
That supply is, in theory, determined by the government from time to time, and in particular from year to year through the parliamentary votes for the National Health Service. The reality is substantially otherwise and much more complex. It differs in the two halves of the service, hospital and non-hospital.
In the hospital service the Minister, on behalf of the state, does in form decide from year to year, or more often, how much money each hospital board shall be permitted to spend. In practice, as the political odium of being seen to reduce expenditure could not be faced, the decision is how much increase, if any, to make on each board’s present rate of expenditure. For similar reasons, expenditure has to be regarded ‘in real terms’, that is, any increase in the money cost of the items of service being currently supplied must be made good.
The Minister can, if he wishes, and dares, achieve appreciable variation in the increases he allows to different boards, but he must be able to justify at least the overall increase politically. Life has been more difficult in this respect since the cult of the gross national product and its growth-rate has been invented and popularised. As medical care is a ‘good thing’, it would be out of the question to be caught arranging for expenditure on the hospital service to grow at a slower rate than the gross national product; and indeed it could plausibly be argued that with increasing affluence the proportion, and not merely the amount, of the national income represented by medical care observably tends to increase.
This is the explanation of the famous 2 1/2 per cent adopted for the annual rate of increase of ‘real terms’ expenditure on the National Health Service generally, and on the hospital service in particular, in the first half of the present decade, 2 1/2 per cent being the average rate of growth of the national product experienced in the recent past. The figures in the National Plan1965 suggest that about the same rate is being projected up to 1970.
The decision of the state thus amounts to the acceptance of a historically determined figure, going back year by year to what was being spent on the hospital services before they were nationalised, with an annual increase that is fairly constant but necessarily arbitrary, superimposed upon it.
In contrast, the Minister has no direct control over expenditure outside the hospitals. Over most of the country the local health executive councils stand ready to enter into contract with general medical practitioners, and to pay (less any charges) for all the treatment that dentists and opticians supply. No upper limit is imposed by the Minister. Likewise, he pays automatically (through the executive councils) for whatever medicines, short of gross and demonstrable abuse, that are prescribed by the medical practitioners for their patients. In this half of the service, therefore, there is properly speaking no budget, but only an estimate of what will get itself spent. The commitment is, in Treasury jargon, ‘open-ended’.
In fact, the Minister does exercise substantial control over the volume of service provided, but he does so indirectly through his power to fix what remuneration the executive councils shall offer to the practitioners in contract with them. If this remuneration were such as to attract into contract with the councils rapidly increasing numbers of practitioners, then indeed the volume of service rendered and consequently the expenditure would go through the roof. In practice, apart from some misjudgements over the remuneration of dentists in the early years of the service, successive Ministers of Health have succeeded in holding remuneration at levels which have resulted in the numbers of practitioners increasing only slowly, if at all. Indeed, in the last three years the number of general medical practitioners in the service has actually begun to fall at a rapidly accelerating pace. (Latest figures in the Review Body’s Seventh Report (Cmnd. 2992), para. 55.) Thus, in reality the state does set the level of supply in the non-hospital part of the service also, and again by admitting arbitrary variations upon a historically determined base. In this instance, however, the variations are not laid down in advance and are not even foreseeable with any precision.
The different organisation, and relationship with the Minister, of the two parts of the service, places the medical profession in a fundamentally different context inside and outside the hospitals. The difference is pivotal to Medicine and Politics in the National Health Service and merits a certain digression at this point.
MEDICAL REMUNERATION
Hospital care being provided in state-owned hospitals by public servants, the medical profession has in the hospitals a career structure which, as in other parts of the public service, affords financial and other recognition of success in climbing it. The structure is not so clearly marked and firmly graduated as in administration or the armed forces. There is nothing like the Jacob’s ladder that reaches up from assistant principal to permanent under-secretary of state, or from second lieutenant to field-marshal. But it is real and substantial and, what matters most, recognised in the profession itself.
There are, in the hospital service, four normal grades below that of consultant: house officer, senior house officer, registrar, and senior registrar, and in each of these there is a more or less formalised scale of increments. Service in these grades might cover ten or more years of the hospital doctor’s career after qualification. In addition, there is a new grade of medical assistant, with its own incremental scale, providing either an alternative or a bridge to consultancy.
As consultant, the hospital doctor has before him again an incremental scale extending over a decade, and what is more, a system of distinction awards. Over one-third of all consultants hold a distinction award. At the top level an award can virtually double the maximum remuneration, while even the bottom grade of award, which one consultant in five holds, is worth £750 a year. Thus, without considering further details or other forms of hospital appointment, it is clear that the hospital doctor can look forward to the state rewarding his efforts and his relative success, both by visible status and by money.
What is just as important, the medical public servant in the state hospital service is not debarred by law or, usually, by circumstances from practising as an entrepreneur outside the hospital service. More than half the consultants are employed by the state on a part-time basis, and paid at rates per session that are based on the whole-time salary scale, and can amount to as much as nine-elevenths of the whole-time scale. Part-time consultants seek the rest of their income in private practice.
The fees that can be charged for the care and treatment of private patients in state hospitals are fixed by a maximum scale which, despite repeated solicitation, the politicians did not find it expedient to raise from the early years of the service until the beginning of 1966, when it was announced that, most commendably, this illogical limitation is to be removed. In any case, there has never been any restriction, other than what the customer can and will pay, upon what can be obtained from private consultation and from the treatment of patients elsewhere than in state hospitals.
THE SITUATION OF THE GENERAL PRACTITIONER
Outside the hospital service the situation of the medical practitioner is wholly different. In form, he is a private contractor. For a sum of so much per patient he contracts with the local health executive council to give whatever medical advice and care, other than hospital care, the patient may require. Like any other contractor he provides, broadly speaking, such fixed and working capital and such subordinate staff as is necessary; and the performance of the contract is policed by a ‘disciplinary’ procedure through the executive council and the Minister, without, however, interfering with any common law rights the patient may have. Somewhat inconsistently, the family doctor in contract with the service has a contributory superannuation scheme. On superannuation he also receives the value of his practice as assessed when the state health service came into effect; but he cannot sell the goodwill attaching to his National Health Service list of patients, or indeed to any private patients whom he may have, either.
The capitation-fee is flat-rate, except for a certain weighting for and against small and large lists respectively, and a certain local inducement in favour of ‘under-doctored’ areas. Whether the practitioner is good, bad (up to the point of incurring a disciplinary stoppage), or indifferent, he gets the same remuneration for the same list. Inside general practice he can increase his earnings only by increasing the length of his list. When the number of patients per doctor is stationary or, as at present, tending to rise, he is not primarily dependent upon ability or reputation to enable him to do this, though undeniably, even in the areas with the highest average number of patients per doctor, this has some influence.
In such competition as there may be for length of lists, the doctor’s willingness to prescribe a placebo, or the drug recommended by the patient, or to complete the desired certificate, may be as effective as skilled and conscientious care.
The situation of the family doctor, therefore, combines private enterprise and state service without the characteristic advantages of either. The doctor cannot build up a practice and a reputation that enables him to reap the reward of his efforts either in income or in satisfaction. Paradoxically, the better he does his work, the worse off he is. The money he spends on improving his premises, providing himself with modern equipment, paying for efficient reception or clerical and other administrative staff, will not increase his earnings by one penny. On the contrary, the cost will come out of an income that would have been undiminished if he had spent on none of these things. If he restricts his list to the number of patients he can treat properly and conscientiously, and devotes to consultation the amount of time and care he considers to be required, he cannot recoup himself, as under the old combination of private enterprise with rough-and-ready charity, by ‘soaking the rich’. He will merely end up with a lower income than his less able or scrupulous fellows, with the added chagrin of knowing that the money he forgoes will be redistributed among them. The essence of the private enterprise system, competition for gain, has been gouged out of family doctoring, while leaving the empty shell.
On the other hand, the family doctor in the National Health Service is denied the characteristic advantages of a state employee. He has neither assured security nor a career structure nor the rewards of promotion and eminence to look forward to, as a compensation for the lack of commercial opportunity. He cannot demand that his employer shall either provide the tools for the job or take the consequences in the quality of performance. Unlike the part-time consultants, most practitioners have little opportunity to earn fees at market rates from private patients. It is true that there is no restriction on their treating patients privately, provided those patients are not also on their own National Health Service list; but the total income of National Health Service family doctors from private patients is believed to be very small. There is an extraordinary dearth of statistical information on the subject: neither the Ministry nor, one suspects, the medical profession wants to know the precise answer. But it is certainly true to say that outside London and a few large cities and watering places, the volume of private practice altogether, let alone private practice carried on by National Health Service doctors, is quite unimportant. For most it is so trivial that many decline to accept private patients at all, on the ground that the accounting, billing and other separate arrangements would cost more than they were worth.
RELATIONSHIP WITH PATIENTS
The ambiguous half-way house position of the general practitioner affects his relationship with patients in a way that the relationship of hospital doctors is not affected. The hospital doctor is a king in his castle. Traditionally, the hospital patient has been lucky and glad to be looked after, whether in outpatients, casualty or in-patients. The historical origins of the hospitals are either charity, religious or secular, or the poor law authorities. These origins are still detectable in the attitude of hospital staffs to their patients: anyone who questions this can verify it for himself unless he is exceptionally fortunate, by simply taking a seat for an hour or two on the benches in an out-patient or reception department. The patient and the patient’s relatives are face to face not with the doctor as an individual but with the panoply of an institution, physical, corporate and social. All the romance, wonder and terror of modern medical science is associated with the hospital and its deep recesses: the hospital has prestige and inspires awe. For good measure, the hospital patient is often for one reason or another helpless. This is something quite different from the position of the patient of the general practitioner, whom he knows to be contractually obliged to give all necessary care and attention gratis on demand. The natural human tendency to value things at what they cost is not here subject to any inhibition. The general practitioner is therefore deprived of that basis of equality and mutual respect that exists between those who buy and sell in a market: it is private enterprise, but without the supplier-customer relationship.
The cash nexus between supplier and customer is not indispensable. Where the supplier is a charitable institution or a public authority the cash nexus is superfluous or worse: we do not need it with the constable who directs us or the priest who absolves us. Where it is necessary is with the private supplier, individual or corporate, and that is why its removal from the relationship between general practitioner and patient has affected that relationship adversely and undermined the satisfactions of the family doctor. It is a common error to suppose that a cash relationship is inconsistent with mutual respect between professional and client, or is synonymous with selfishness or irresponsibility. A glance at any of the non-nationalised professions proves the contrary. The question is rather whether a tolerable and satisfactory relationship between general practitioner and patient can exist when there is no cash nexus.
The disappearance of the cash nexus from general practice also helps to explain the deterioration in the relationship between general practice and the hospital service, which has been so persistent and bitter a subject of medical complaint ever since the National Health Service began. It is true that the development of medicine has tended everywhere to transfer the centre of gravity of medicine from outside to inside the hospitals, and that the pendulum has probably further to swing yet before it begins to return. It is also true that in Britain the separate administrative structure already described does partly explain the estrangement between general practice and the hospitals. But these causes alone would not have made general practice and hospital doctoring turn their backs on one another in the way they did at the beginning and still to a large extent do. After twenty years of effort to bridge the administrative divide, the general practitioner remains with a resentment against the hospital service. It is this resentment that gives passion and intensity to the medical profession’s defence of the most indefensible ‘cottage hospitals’ against their being replaced in a modern hospital pattern. The general practitioner regards them as his last toehold in the hospital world, which is being destroyed in a malign conspiracy to get him out altogether and finally. In them, at least, he ‘has some beds’.
I remember how strange it used to seem to me that ministerial circulars should be required in the 1960s to inculcate into hospital doctors and administrators— I suspect, with little practical effect in the event— the desirability and methods of maintaining the most elementary and even courteous communications with the family doctors and their patients. Alas, they do not need to do so. The old partnership between the family doctors and the consultants, between general practice and the hospitals, was to some extent a financial partnership: the one needed the other; certainly the consultant needed the goodwill and the recommendation of the general practitioner. There was a cash nexus, which the semi-nationalisation of private practice and the nationalisation of the hospitals destroyed.
In recent years there have been signs that the essential dilemma of general practice in the National Health Service, that of being neither private enterprise nor state service, has been identified as the root cause of the malaise of the profession outside the hospitals, and of the doctors ‘voting with their feet’ in the form of the increasing net outflow of British doctors abroad during the 1960s. In theory, at least, the dilemma has to be resolved by moving towards one system or the other.
A SALARIED SERVICE
The proposals that emerged in October 1965 from discussions between the Health Departments and the representatives of the medical profession constitute a distinct move towards the pole of a salaried service. In the first place, the Government agreed in principle to payment by salary where the premises and practice expenses were provided by the public. Secondly, the Review Body (the Kindersley Committee) worked out in financial terms a system, accepted by the profession in June 1966, which represents a considerable modification of the principle of the capitation fee. The principal innovations are a basic allowance of so much per practice, scaled up or down in various circumstances; and the reimbursement of the rent and rates of surgeries, of the greater part of the cost of ancillary help, and of help in illness.
It can be agreed that these changes do reduce the actual penalty laid upon the good family doctor by going far to provide him at the public expense with ‘the tools for the job’ instead of these having to come out of his gross income, and by somewhat reducing the relative importance of the number of patients. They do not and cannot tackle the major problem, namely that good and bad service (in similar circumstances) are remunerated at one and the same price. A capitation fee can no more distinguish between good and bad service than a fee per item of service, which governments have consistently rejected. The disincentive can only be removed by either a variable price, which implies some sort of market for medical care, or alternatively, a salary and promotion structure. Unless somehow, sometime, general practice is to be taken right outside the framework of a service rendered free at the point of consumption, it is tempting to predict that it will end by being a salaried employment. The decline of the single-handed practice and rise of the group practice make a salaried system easier to envisage.
METHODS OF RATIONING
The preceding pages have been devoted to examining how the medical profession is affected by the system that has been adopted for the purchase by the state of a certain quantity of medical care outside the hospitals. That quantity, as already explained, is indirectly fixed by the remuneration the state offers, which determines in the longer run the number and quality of those contracting to provide that care.
Thus, outside as well as inside the hospitals the figure on the supply side of the equation is fixed at any particular time by those complex forces that determine the state’s decisions on expenditure. With this figure demand has to be brought into balance. Virtually unlimited as it is by nature, and unrationed by price, it has nevertheless to be squeezed down somehow so as to equal the supply. In brutal simplicity, it has to be rationed; and to understand the methods of rationing is also essential for understanding Medicine and Politics. The task is not made easier by the political convention that the existence of any rationing at all must be strenuously denied. The public are encouraged to believe that rationing in medical care was banished by the National Health Service, and that the very idea of rationing being applied to medical care is immoral and repugnant. Consequently when they, and the medical profession too, come face to face in practice with the various forms of rationing to which the National Health Service must resort, the usual result is bewilderment, frustration and irritation.
The worst kind of rationing is that which is unacknowledged; for it is the essence of a good rationing system to be intelligible and consciously accepted. This is not possible where its very existence has to be repudiated.
In the hospital service probably the most pervasive, certainly the most palpable, form of rationing is the waiting list. The waiting list is a complex phenomenon in itself. One component can be likened to a reserve of working materials: if the hospital resources are to be continuously used, there must be a waiting list. The simplest case is that of a consultant available (let us suppose) during a two-hour session. If there were no queue in the outpatient waiting-room, there might be gaps between one consultation and another when the consultant would not be productive— not, at least, in that sense. So it is always arranged that there shall be plenty of people waiting when the great man arrives, so that there is no danger of the expensive mill even momentarily lacking grist. Similarly, if the capital and resources represented by operating theatres and their staffs are to be intensively used, there must be, so to speak, a cistern from which a steady flow of cases can be maintained.
This element of the waiting list is only incidentally a rationing device, though even here time is serving as a commutation for money: a consultant in private practice can accept the discontinuity of work implicit in a good appointments system, because his patients are in effect buying his waiting time as well as his consultation time or, putting it another way, the patient finds his own time worth more to him than the consultant’s.
Waiting lists, however, normally exceed the minimum related to full employment of the medical resources. They are then directly rationing in their effect. For example, they ration demand for the more able, experienced or celebrated advice and treatment compared with the less: the waiting lists of consultants in the same department of a hospital can differ greatly in length. It is sometimes said that consultants regard a long waiting list as a status symbol and preserve it with the same care and pride as an Indian would a string of scalps. Certainly, consultants are very possessive about their waiting lists. But the taunt is as uncomprehending as it is uncharitable. There has to be some differential rationing for different qualities of an article, and if not price, then, for example, time: better surgeon, longer wait, and vice versa. No wonder consultants, family doctors and patients too resist equalisation of waiting lists, which would mean that rationing by time would have to be replaced by some even less rational or intelligible form of rationing, such as rotation or the initial/letter of the surname.
Generally, the waiting list can be viewed as a kind of iceberg: the significant part is that below the surface— the patients who are not on the list at all, either because they are not accepted on the grounds that the list is too long already or because they take a look at the queue and go away. Naturally, no one knows how many these are. Indeed, the very question is rather absurd, as it implies some natural, inherent limitation of demand. But the part of the iceberg above the water is doing its work, directly as well as indirectly, by attrition as well as by deterrence.
It might be thought macabre to observe that if people are on a waiting list long enough, they will die— usually from some cause other than that for which they joined the queue. Short of dying, however, they frequently get bored or better, and vanish. Here again, time on the ‘waiting list is a commutation not only for money— measurable by the cost of private treatment with less or no delay— but also for the other good things of life. It is an interesting phenomenon of the waiting lists for in-patient treatment that at the holiday season and around Christmas time it may be necessary to go quite far down a lengthy waiting list to get patients willing to accept the long-awaited treatment in sufficient numbers to keep even the temporarily reduced hospital resources fully employed.
I cannot but reflect sardonically on the effort I myself expended, as Minister of Health, in trying to ‘get the waiting lists down’. It is an activity about as hopeful as filling a sieve, although this is not to deny that some of the measures applied and pressures exerted might conceivably have had some useful side-effect in improving, in a slight degree, the direction of effort. There were the circulars enjoining such devices as the use of mental hospital beds and theatres, or of military hospitals. There were the stiff cross-examinations of staffs and hospital authorities in the endeavour to discover what contumacy might explain their continued non-compliance with the official exhortations. There were the special operations to ‘strafe’ the waiting lists, urged on the fallacious ground that a stationary waiting list is not evidence of deficient capacity— otherwise it would lengthen —but of a backlog which, once ‘cleared off’, ought not to be allowed to recur.
Alas, the waiting list that melted under an assault of this kind was back again to normal before long. There were always special, local and temporary explanations that could be cited, such as a sudden coincidence of staff off duty through leave, sickness or change of post. But all too evidently the causes at work were general and deep-seated. There was a mean around which the figures fluctuated, but that was all. Naturam expellas furca, tamen usque recurret: though you drive Nature out with a pitchfork, she will still find her way back.
In a medical service free at the point of consumption the waiting lists, like the poor in the Gospel, ‘are always with us’. If at any moment of time they do not exist, they have to be re-invented, or rather they reproduce themselves effortlessly and automatically. Ministers come and Ministers go: the hospital service spends a rising fraction, or it spends a falling fraction, of the national income; but the ‘waiting list at 31st December’ in the Ministry of Health’s annual reports still stays the same, a reliably stable feature in an otherwise changing scene. On New Year’s Eve 1959 it was 442,519; on New Year’s Eve 1960 it was 475,643; I962, 474,353; 1963, 470,297; 1964, 475,863; 1965, (oh dear!) 498,972. And what had it been, pray, on New Year’s Eve 1951, back in those early, primitive days of the National Health Service? Why, 496,131.
At the same time, Ministers of Health are broadly truthful when they say that for cases diagnosed as urgent or critical the waiting list, practically speaking, does not exist. This is far from disproving the function and necessity of the waiting list as a rationing device. For one thing, ‘urgent’ and even ‘critical’ are not objective magnitudes; on the contrary, they are assessments that have already taken the volume of supply into account. In any case, there is no clear-cut dividing line between the ‘urgent’ cases, seen or treated at once, and the ‘non-urgent’ cases on the waiting list— or, as the case may be, not on the waiting list at all. The latter are squeezed down— or off— by the former. To point to the fact that no ‘urgent’ case goes untreated as evidence that supply and demand can be brought into balance without rationing is like arguing in a famine that because nobody dies of starvation, there need have been no rationing system.
A DOUBLE STANDARD
In the last resort the waiting list, or the queue in the general practitioner’s surgery, is one aspect of rationing by quality. In the days of the reform of the poor law and abolition of outdoor relief for the able-bodied, this used to be known as the principle of ‘lesser eligibility’. What are called the ‘deficiencies’ of the National Health Service— the large number of patients per general practitioner, the age and quality of many of the hospital buildings, and so on —are not deficiencies in the literal sense of the word, that the service falls short to a measurable extent of an objectively definable standard. They are those consequences of the quantity and quality of medical care being purchased by the state that help to equate the demand with the supply. The supply of medical care of all kinds through the National Health Service is rationed by forcing the potential consumer to choose between accepting the quality and quantity offered or declining the care offered. If he declines the care offered, he can either renounce or defer treatment altogether or he can endeavour to purchase it outside the National Health Service.
This is why it is absurd to declaim against a ‘double standard’ of medical care, inside and outside the National Health Service respectively. The standard inside is that which balances demand with the amount supplied by the state; the standard outside is that at which the supply and demand for medical care balance in the market, given the existence of the National Health Service. The standard in question is not necessarily one of purely medical treatment, if indeed the purely medical aspect of care can be divorced from the others. For example, it may well be that a patient acutely ill or gravely injured may be treated as skilfully, efficiently and safely in a National Health Service hospital as in an expensive private hospital or ‘nursing home— often, I would guess, more so. But the paradox is capable of rational explanation. The ancillary aspects of medical care— amenity, privacy, attention in convalescence, a degree of freedom, choice and individual self-assertion—may be valued no less than the essentials that affect life and limb. Indeed, they are sometimes valued more highly, surprising though that may seem. There can also be an element of pride, prejudice, snobbery— call it what you will— that values the identical article more highly when it is purchased than when it is received gratis.
The principle of lesser eligibility has always been applied, cannot help being applied in some form, wherever provision is gratis. It was applied before the National Health Service started in the voluntary and municipal (ex-poor law) hospitals and, indeed, from the beginning of time wherever medical care was rendered free at the point of consumption. Since eligibility is a form of rationing, we naturally find that it, like the waiting list, is also used to establish an order of priority. This is the reason why, for instance, the geriatric and long-stay mental hospital wards are, and have always been, the most ineligible in the service. The priority accorded to the demands of acute illness requires that rationing be applied more severely to the chronic.
Two instructive contrasts outside the National Health Service will illustrate the rationing function which lesser eligibility performs in it. One is the striking contrast between the two forms of old people’s accommodation: the workhouse and the new-style old people’s home. The former was designed to meet a legally unrestricted duty to admit; the latter corresponds to a discretionary and highly discriminating right to admit or not to admit. Consequently the poor law institution had to ration by ineligibility, and still in practice does if it continues to exist, while the new-style home explores ever-rising standards of amenity and care under the shelter of a rationing system of a different kind. Similarly, the paradox of the relatively high standard of the subsidised local authority house, although it is subsidised, is explained by the fact that the demand is tailored to the supply by the discretionary waiting-list itself, and consequently the supply can be rendered in a relatively eligible form.
Parkinson’s Law
The fact that the necessity for these covert forms of rationing springs from the very nature of the National Health Service and not from any particular level of supply attained in it is borne out by ‘Parkinson’s law of hospital beds’, which asserts that the number of patients always tends to equality with the number of beds available for them to lie in. Thus, the ratio of hospital confinements to total births ranged in 1965 from as low as 53.8 per cent in East Anglia to 78.4 per cent in Wales—the national average was 69.8 per cent. Yet the pressure on maternity accommodation was at least as high in the latter part of the country as in the former. Again, the number of hospital beds for acute disease in the North-West of England is almost twice as great as in the South-East: in 1961 there were 3 per thousand population in East Anglia against 5.6 in the Liverpool region. Yet the pressure of demand, as evidenced, for example, by length of waiting lists, shows no comparable variation. There is, as has been said above, no reason to suppose that an increase in the quantity or quality of care provided by the National Health Service would reduce the need for rationing. On the contrary, every increase in eligibility must involve an intensification of the other forms of rationing, such as waiting.
It is unfortunate that the nature and the value of rationing by waiting and by ineligibility in the National Health Service are not recognised, at least by the professions. For these are the features that make it possible to avoid invidious discrimination in administering the service and, at the same time, secure a certain rational allocation of priorities. Instead, these features are treated as evidences of ‘inadequacy’ and as blemishes that it lies within the power of politicians to remove, given the insight and the will.