240

organised the proper distribution of simple low vision aids,let alone found a way of identifying all those who might needthem, so, in the present economic climate, the booklet’sproposals will be seen as no more than pipe-dreams. TheDisabled Living Foundation (see p. 265) has to some extentimproved matters by providing for health workers morereadily accessible infomation about the aids available.Too little attention is paid to the poor mobility of people

who are old as well as visually disabled, and to their problemsin gaining access to centralised help. Even if goodrehabilitation and assessment units became widely availableit is not hard to guess who would use them most and towardswhom continued research into ever more elaborate visual aidswould be directed. And there is a greater incongruity, though-a pardonable one, since the report is concerned chiefly withEurope: all technological advance, as well as fundamentalresearch, takes us further and further away from the millionsof blind and visually disabled people in developing countrieswhose lives are lived in economic misery.

THE MARKET APPROACHTHE principle of an all-embracing national health service is

unsound because it precludes the free play of new ideas; theN.H.S. has "lived on its noble aims for too long" and shouldgive way to "market forces". So runs the rallying call for acollection of essays on the N.H.S., mystifyingly entitled TheLitmus Papers, which was published last November by theCentre for Policy Studies and edited by Mr Arthur Seldon,co-director of the Institute of Economic Affairs. He is

opposed to any form of centrally organised, taxation-fundedhealth service on the grounds that it prevents the

development of "spontaneous, organic, local, voluntary andsensitive medical services". His contributors-mainlydoctors and academics, including two American economistsand an Australian-follow eagerly where he leads. Thevirtues of private general practice are extolled by severalgeneral practitioners, one of whom, Dr Patrick Wood,explains that "private practice is the natural relationship ofdoctor to patient", and that the "fee is a bond, not a barrier".Dr John Jewkes and Dr Sylvia Jewkes go further and declarethat a "free-for-all comprehensive health service lowers thestandards of public morality. It generates hypocrisy andcynicism." .

The arguments in favour of private-medicine rehearsed inThe Litmus Papers are for the most part familiar, though theybecome more bothersome at a time when the country has aGovernment which lends to them too receptive an ear. We aretold, for instance, that demand for health services willcontinue to outstrip supply unless patients have to paydirectly for them; that doctors and dentists need a directfinancial incentive to give of their best (many authors favouritem-of-service payments); that people are prepared to paymore individually for health services than they are willing tosee spent on the N.H.S. through taxation; that charges are theonly way to bring home the true cost and value of medicalcare. Mr Seldon has allowed his authors to wander at willwithin the confines of his philosophy, so theories are airedand corners defended, but no coherent picture emerges ofwhat the alternatives to the N.H.S. are. Mr George Buntonmakes an impassioned plea for the teaching hospitals to berestored to their former autonomy and shielded from currentfinancial pressures. Dr Anne Grüneberg and Dr ReubenGruneberg take a hearty swipe at community physicians, and

1 The Litmus Papers: A National Health Dis-Service. Edited by Arthur Seldon.November, 1980. Centre for Policy Studies, 8 Wilfred Street, London SW1. £5.55.

June Lait takes another at social workers. Large claims aremade for the power of the market to rectify existing defects inmedical services-from medical manpower distribution (theGrunebergs) to overprescribing of medicines (Dr DuncanReekie and Dr Ruth Reekie, who believe that the cost ofdrugs in the N.H.S. is too low, encouraging doctors to writeprescriptions as the quickest form of care, while discouragingpatients from self-treatment of minor ailments). DigbyAnderson calls on health educators to revise their "statist

assumptions and think about how they might adaptthemselves to an expanding private sector".

In their eagerness and, it sometimes seems, haste to exposethe failings of the N.H.S., the authors tend to sidestep themain issues. There is little detail about how private medicinecould be financed and organised to provide the range ofservices that would allow it to take over from or run in

competition with the N.H.S. Indeed, some authors like MrJohn Cozens-Hardy, believe that it does not "matter wherethe money comes from as long as it comes". He at least, seeingthat the present Government appears to want two healthservices, is alarmed at what will happen to those patients whocannot cross the widening gap between the worse and thebetter service. Andrew Moncreiff, however, declares that"lack of purchasing power is not a problem in the supply ofhealth care and has nothing to tell us about the relative meritsof different systems of health care delivery." He thus boldlydisposes of any idea that the main point of the N.H.S. is that itremoves lack of purchasing power as a barrier to health care.Moncreifl’s essay is an attempt to demonstrate that completeand comprehensive private health insurance cover for a largeand actuarially typical section of the population could beachieved for a per-caput figure well under half that spent bythe N.H.S. His comparison is based on current N.H.S.

expenditure and private health insurance premiums, withnotional adjustments which are supposed to take account ofservices not provided in the private sector. Even on thisrough-and-ready level, however, the comparison is far fromcomplete-for instance, he omits any mention of chronic sick,mentally ill, and handicapped patients.

Moncreiffis not the only author to lose sight of some of theawkward detail in painting a broad and glowing view ofprivate medicine. What Arthur Seldon describes in one of hisessays as an agreement between employers and theelectricians’ union (EETPU) to take 40 000 workers "out ofthe NHS into private practice" was in fact a contract forthree-yearly screening with immediate treatment whereindicated. Moreover, it is by no means as certain as heassumes that large sections of trade-union membership areready to follow suit, particularly since EETPU delegatesvoted in May to end this agreement in the interests of

protecting the N.H.S. and solidarity with its workers. Severalauthors do in fact acknowledge that the N.H.S. would have toremain in some form to provide essential services- such aspublic health and preventive medicine, accident and

emergency provision, long-term care, medical research andeducation-which the private sector could not take on. Eventhe much-vaunted benefits of direct payment are largelyirrelevant, since most people would, it seems, be payingthrough health insurance. We are told that the advent of aGovernment prepared to consider radical change in thehealth service was an impetus for these essays. Doubtless theywill be gratefully received by some as evidence of a growingtrend to the market in health care. But it is hard to believe thatThe Litmus Papers will persuade any reader that all would bewell if only the N.H.S. were to give way to market forces.