Anaesthesia, 1977, Volume 32, pages 225-227
Editorial
'Government is a contrivance of human wisdom to provide for human wants. Men have a right that these wants should be provided for by this wisdom' EDMUND BURKE (1729-97)
Our politicians have frequently asserted that the British National Health Service (NHS) provided the best standards of health care in the world. Recently an American critic' stated that the service would in his opinion be all but totally unacceptable to any American not depending on welfare for medical services and that British physicians' salaries are derisory, even by reference to those prevailing in other members of the European Economic Community, let alone the United States. As the directives will shortly become effective, enabling free movement of doctors throughout the EEC, comparison with France seems valid. In France, between 1960 and 1970,100,000 beds were built or rebuilt,Zthis is one third of the total number of beds in France. By the end of 1980, 80% of the total number will be built or rebuilt, so they are confident of the future. Full-time doctors working in French hospitals are paid up to E20,OOO per year and in addition full-time doctors may be granted private beds (up to 5% of the ward beds) and private surgery hours (twice a week). In either case they receive fees directly from the patient. These additional fees have been allowed to encourage doctors to accept full-time posts. It is clear that part-time doctors, despite limitations on their hospital salaries, can achieve comparable, or even high incomes-after all, the private sector manages half of all the surgical beds in France. Compare this situation with that in the United Kingdom where vast numbers of hospital beds are facing closure, inflictingincreased suffering on sick patientsY3and where the exclusion of private beds from the NHS, purely to satisfy political dogma, will result in a loss of €40,000,000per annum from an already near bankrupt service. The needs for trained anaesthetists in France were calculated as 5874 in 1972.4 In actual fact the number of doctors trained in anaesthesia (C.E.S.d'Anesth6siologie) will be about 4700 in 1978. Additionally, there appear to be over 2000 anaesthetic trainees, at various stages, in service at any given time. Thus the grand total of anaesthetists at over 6500 is nearly double the number of anaesthetists in the United Kingdom (1608 Consultants at end 1974 plus a slightly larger number of trainees)-which has a similar national population. Clearly the British anaesthetist is by comparison greatly overworked.This confirms the Association's study of manpower which indicated a significant degree of understaffing of anaesthetic departments in the NHS. In Britain the anaesthetist is almost uniquely punished by the loss of pay beds from the NHS for he cannot functionoutsidehospitals-other specialists such as physicians,psychiatrists,dermatologists and even surgeons to an extent-can continue some private practice from their consulting rooms. Furthermore very few anaesthetists are ever able to claim a domiciliary fee-the average consultant in many other clinical specialties may earn over €1000 per annum in this way. Similarly, anaesthetists cannot earn fees for insurance examinations, cremation fees or post-mortem payments, which may bring in as much as f1500 per annum to consultants in some other specialties. Although dental anaesthetic fees are available to anaesthetists, the fees paid are so derisory as to make it uneconomic for anaesthetists to participate.5 225
226
Editorial
It is small wonder then that emigration of anaesthetists is rising to a crescendo-last year two professors from our small national cadre left permanently, more recently 6 British consultants and one senior registrar were among the applicants for a post in Leiden. In the recent past 17 trained anaesthetists from one's own department have emigrated mostly to posts in the U.S.A. and Canada. The written evidence from the Association of Great Britain and Ireland to the Royal Commission on the NHS,5 which has now been examined and amended by the nationwide network of linkmen, puts forward sensible proposals to improve patient care and to improve the working conditions of doctors generally and of anaesthetists in particular. In addition to proposals about funding of the service as a whole, a case is made for the need to make allowance for justifiable identifiable expenses (motor car, telephone, secretarial, study leave, etc.) against income before tax (Schedule D). The public cannot expect doctors to provide %hour cover for their needs without these allowances-here is a special case. If the lack of such recognition leads to a failure to attract doctors to hospital work the public can only blame the system. Any attempt at dilution of standards to fill a numerical lack of anaesthetists is likely to endanger public safety. We have already pointed out the fall in the number of deaths associatedwith anaesthesia in England and Wales from a figure of over 800 per annum in the 1930s to about 100 in the late 1960ss-this was surely due to the emergence of the properly trained anaesthetist following the initiative of the Association. Others' have c o h e d this trend; Wylie* has pointed out the disastrous morbidity which may result from the unskilled administration of an anaesthetic. The Association will surely need to watch these statistics to safeguard the public welfare during the current deplorable attenuation of resources accompanied by the loss of skilled anaesthetists. A final disincentive is the current attitude to the medical profession. Over 20 years ago Sir Harold Himsworthppointed out the obligation on the part of the professional man to use his best endeavours to meet the particular need of his society and in return obligation on the part of society to accord to the professional man such status, authority and privilege as shall be required for him to dischargehis obligations. Ferris, writing in the Observer recently,l0 said that he 'heard a very senior official at the Department talk enthusiastically of how consultants in the not too distant future would find themselves downgraded; it was said with relish'. The current spate of doctor-bashing must cease if serious damage is not to be done to standards of patient care-this would not be due to any perverse reaction on the part of doctors. The brightest and ablest young men and women from the schools and universities will be deterred from entering the profession, practising doctors may be forced to limit effective treatment when it incurs even a well-calculated risk, and lastly advances in medical science will be inhibited. Already there are signs that British medical standards-where capable of meawrementhave fallen well behind those of other advanced countries-one can cite perinatal and infant mortality or pacemakerll and transplantation figures to prove this. In order to retrieve the situation conciliatory and constructiveattitudes on the part of ministers are indicated rather than the present spirit of antagonism and constraint. If the service fails, members of the Association must explain to the public at large where the responsibility lies-it is not with the doctors. C. F. SCURR
References 1. SCHWARTZ, H. (1976) An American looks at the National Health Service. World Medfcfne,l2,21 (April). 2. AUROUSSEAU, P. (1976) The National Health Service and the European Economic Community. Kings Fund Project Paper, 10, 16. 3. LEADWOARTICLB(1976) London Health Service cuts. Plan for free cash for pooror regions. Times, 27 November. J. (1976) Les besoins et la formation d'amstkiologio on France. Cahiers d'Anesthdsfologie,24, 4. MONTAGNE, 463. 5 . ASSOUATION OF ANAESTHETBTSOF GREAT BRITAINAND IR~LAND (1977) Evidence to tho Royal Commission on the National Health Service. 6. SCURR,C.F. (1971) Evolution and revolution in anaesthetic training. Frederic Hewitt lecturo. Anna& of the Royal College of Surgeons of England, 48, 274. 7. EDrrom (1976) Anaesthesfa,p. 13. OfTice of Health Economics, London.
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8. WYLE, W.D. (1975) There but for the grace of God. Joseph Clover lecture. Annals of the Royal College of Surgeons of England, 56, 171. 9. HIMSWORTH, H. (1953) Change and permanence in education for medicine. Lancet, ii, 789. 10. FERRIS,P. (1976) Doctors a suitable case for treatment. Observer Magazine, 31 October, p. 22. 1I. SOWTON, E. (1976). Use of cardiac pacemakers in Britain. Brirish Medical Journal, iv, 1182.
...
Editorial notices Anaesthesia-Ten issues in 1977 This year Anaesthesia will appear every month with the exception of August and December. News and Notices sections Full News and Notices sections will be published in the first issue of each quarter. Copy dates for these issues will be: 4 April for the July number; 4 July for October; 3 October for January 1978. Supplementary News and Notices sections will be published in other issues but they will contain only material which
requires urgent publication before the next full News and Notices section. Other issues in 1977 will be thinner than those of 1976 because of the new format but they will contain the same amount of scientific material.
The use of Syst6me International (SI)units Authors will still be permitted to use either the SI system or the old metric notation throughout 1977 but they will be expected to be consistent in each manuscript. Blood pressure will continue to be expressed as mmHg. Imperial measurements will not be used even in parenthesis, except in exceptional circumstances (e.g. historical articles). Conuersion tables were published in each issue in 1976. They were repeated in the January 1977 number but will not be published again this year. Binding Anaesthesia Kemp Hall Bindery will undertake to bind all volumes from 1973 onward. Details will be found under Association News in News and Notices sections. The Index and Title Page for 1976 (volume 31) appeared as an integral part of the November 1976 issue as all title pages and indices have done since 1973.
Editorial
'Government is a contrivance of human wisdom to provide for human wants. Men have a right that these wants should be provided for by this wisdom' EDMUND BURKE (1729-97)
Our politicians have frequently asserted that the British National Health Service (NHS) provided the best standards of health care in the world. Recently an American critic' stated that the service would in his opinion be all but totally unacceptable to any American not depending on welfare for medical services and that British physicians' salaries are derisory, even by reference to those prevailing in other members of the European Economic Community, let alone the United States. As the directives will shortly become effective, enabling free movement of doctors throughout the EEC, comparison with France seems valid. In France, between 1960 and 1970,100,000 beds were built or rebuilt,Zthis is one third of the total number of beds in France. By the end of 1980, 80% of the total number will be built or rebuilt, so they are confident of the future. Full-time doctors working in French hospitals are paid up to E20,OOO per year and in addition full-time doctors may be granted private beds (up to 5% of the ward beds) and private surgery hours (twice a week). In either case they receive fees directly from the patient. These additional fees have been allowed to encourage doctors to accept full-time posts. It is clear that part-time doctors, despite limitations on their hospital salaries, can achieve comparable, or even high incomes-after all, the private sector manages half of all the surgical beds in France. Compare this situation with that in the United Kingdom where vast numbers of hospital beds are facing closure, inflictingincreased suffering on sick patientsY3and where the exclusion of private beds from the NHS, purely to satisfy political dogma, will result in a loss of €40,000,000per annum from an already near bankrupt service. The needs for trained anaesthetists in France were calculated as 5874 in 1972.4 In actual fact the number of doctors trained in anaesthesia (C.E.S.d'Anesth6siologie) will be about 4700 in 1978. Additionally, there appear to be over 2000 anaesthetic trainees, at various stages, in service at any given time. Thus the grand total of anaesthetists at over 6500 is nearly double the number of anaesthetists in the United Kingdom (1608 Consultants at end 1974 plus a slightly larger number of trainees)-which has a similar national population. Clearly the British anaesthetist is by comparison greatly overworked.This confirms the Association's study of manpower which indicated a significant degree of understaffing of anaesthetic departments in the NHS. In Britain the anaesthetist is almost uniquely punished by the loss of pay beds from the NHS for he cannot functionoutsidehospitals-other specialists such as physicians,psychiatrists,dermatologists and even surgeons to an extent-can continue some private practice from their consulting rooms. Furthermore very few anaesthetists are ever able to claim a domiciliary fee-the average consultant in many other clinical specialties may earn over €1000 per annum in this way. Similarly, anaesthetists cannot earn fees for insurance examinations, cremation fees or post-mortem payments, which may bring in as much as f1500 per annum to consultants in some other specialties. Although dental anaesthetic fees are available to anaesthetists, the fees paid are so derisory as to make it uneconomic for anaesthetists to participate.5 225
226
Editorial
It is small wonder then that emigration of anaesthetists is rising to a crescendo-last year two professors from our small national cadre left permanently, more recently 6 British consultants and one senior registrar were among the applicants for a post in Leiden. In the recent past 17 trained anaesthetists from one's own department have emigrated mostly to posts in the U.S.A. and Canada. The written evidence from the Association of Great Britain and Ireland to the Royal Commission on the NHS,5 which has now been examined and amended by the nationwide network of linkmen, puts forward sensible proposals to improve patient care and to improve the working conditions of doctors generally and of anaesthetists in particular. In addition to proposals about funding of the service as a whole, a case is made for the need to make allowance for justifiable identifiable expenses (motor car, telephone, secretarial, study leave, etc.) against income before tax (Schedule D). The public cannot expect doctors to provide %hour cover for their needs without these allowances-here is a special case. If the lack of such recognition leads to a failure to attract doctors to hospital work the public can only blame the system. Any attempt at dilution of standards to fill a numerical lack of anaesthetists is likely to endanger public safety. We have already pointed out the fall in the number of deaths associatedwith anaesthesia in England and Wales from a figure of over 800 per annum in the 1930s to about 100 in the late 1960ss-this was surely due to the emergence of the properly trained anaesthetist following the initiative of the Association. Others' have c o h e d this trend; Wylie* has pointed out the disastrous morbidity which may result from the unskilled administration of an anaesthetic. The Association will surely need to watch these statistics to safeguard the public welfare during the current deplorable attenuation of resources accompanied by the loss of skilled anaesthetists. A final disincentive is the current attitude to the medical profession. Over 20 years ago Sir Harold Himsworthppointed out the obligation on the part of the professional man to use his best endeavours to meet the particular need of his society and in return obligation on the part of society to accord to the professional man such status, authority and privilege as shall be required for him to dischargehis obligations. Ferris, writing in the Observer recently,l0 said that he 'heard a very senior official at the Department talk enthusiastically of how consultants in the not too distant future would find themselves downgraded; it was said with relish'. The current spate of doctor-bashing must cease if serious damage is not to be done to standards of patient care-this would not be due to any perverse reaction on the part of doctors. The brightest and ablest young men and women from the schools and universities will be deterred from entering the profession, practising doctors may be forced to limit effective treatment when it incurs even a well-calculated risk, and lastly advances in medical science will be inhibited. Already there are signs that British medical standards-where capable of meawrementhave fallen well behind those of other advanced countries-one can cite perinatal and infant mortality or pacemakerll and transplantation figures to prove this. In order to retrieve the situation conciliatory and constructiveattitudes on the part of ministers are indicated rather than the present spirit of antagonism and constraint. If the service fails, members of the Association must explain to the public at large where the responsibility lies-it is not with the doctors. C. F. SCURR
References 1. SCHWARTZ, H. (1976) An American looks at the National Health Service. World Medfcfne,l2,21 (April). 2. AUROUSSEAU, P. (1976) The National Health Service and the European Economic Community. Kings Fund Project Paper, 10, 16. 3. LEADWOARTICLB(1976) London Health Service cuts. Plan for free cash for pooror regions. Times, 27 November. J. (1976) Les besoins et la formation d'amstkiologio on France. Cahiers d'Anesthdsfologie,24, 4. MONTAGNE, 463. 5 . ASSOUATION OF ANAESTHETBTSOF GREAT BRITAINAND IR~LAND (1977) Evidence to tho Royal Commission on the National Health Service. 6. SCURR,C.F. (1971) Evolution and revolution in anaesthetic training. Frederic Hewitt lecturo. Anna& of the Royal College of Surgeons of England, 48, 274. 7. EDrrom (1976) Anaesthesfa,p. 13. OfTice of Health Economics, London.
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8. WYLE, W.D. (1975) There but for the grace of God. Joseph Clover lecture. Annals of the Royal College of Surgeons of England, 56, 171. 9. HIMSWORTH, H. (1953) Change and permanence in education for medicine. Lancet, ii, 789. 10. FERRIS,P. (1976) Doctors a suitable case for treatment. Observer Magazine, 31 October, p. 22. 1I. SOWTON, E. (1976). Use of cardiac pacemakers in Britain. Brirish Medical Journal, iv, 1182.
...
Editorial notices Anaesthesia-Ten issues in 1977 This year Anaesthesia will appear every month with the exception of August and December. News and Notices sections Full News and Notices sections will be published in the first issue of each quarter. Copy dates for these issues will be: 4 April for the July number; 4 July for October; 3 October for January 1978. Supplementary News and Notices sections will be published in other issues but they will contain only material which
requires urgent publication before the next full News and Notices section. Other issues in 1977 will be thinner than those of 1976 because of the new format but they will contain the same amount of scientific material.
The use of Syst6me International (SI)units Authors will still be permitted to use either the SI system or the old metric notation throughout 1977 but they will be expected to be consistent in each manuscript. Blood pressure will continue to be expressed as mmHg. Imperial measurements will not be used even in parenthesis, except in exceptional circumstances (e.g. historical articles). Conuersion tables were published in each issue in 1976. They were repeated in the January 1977 number but will not be published again this year. Binding Anaesthesia Kemp Hall Bindery will undertake to bind all volumes from 1973 onward. Details will be found under Association News in News and Notices sections. The Index and Title Page for 1976 (volume 31) appeared as an integral part of the November 1976 issue as all title pages and indices have done since 1973.
