PRIORITIES IN MEDICINE

PRIORITIES IN MEDICINEAuthor(s): HENRY MILLERSource: Journal of the Royal Society of Arts, Vol. 121, No. 5199 (FEBRUARY 1973), pp. 157-166Published by: Royal Society for the Encouragement of Arts, Manufactures and CommerceStable URL: http://www.jstor.org/stable/41371030 .

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PRIORITIES IN MEDICINE

I The Peter Le Neve Foster Lecture by I

I HENR Y MILLER , MD , FRCP I

Vice-Chancellor , University of Newcastle upon Ту ne, delivered to the Society on Wednesday 6th December 1972,

with Sir Selwyn Selwyn-Clarke , KBE, С MG, MC, MD, FRCP, in the Chair

The Chairman: In explanation of my occu- pying the Chair this afternoon, and with the kind concurrence of our lecturer and of the Society's Secretary, I am going to open the proceedings in a somewhat unusual way. I am acting as a very unworthy substitute for Lord Rosenheim, who died on 2nd December. Only a few days earlier he had taken me in his car from the Royal College of Physicians to my home, and he then told me how excited he was at the prospect of going to Zambia early in the coming year to examine the first batch of students taking their final examination. Lord Rosenheim became a Fellow of this Society at my suggestion, when he was President of the Royal College of Physicians. As a tribute to the memory of a great man, and a wonderful friend to many people, and one whose death will leave a gap well nigh impossible to fill, I am going to ask you to stand for a moment in silence.

I am sure you will be glad to know that amongst the audience to-day are Mr. and Mrs. Peter Le Neve Foster. This lecture was established in 1938 to commemorate the former

Secretary of the Society of that name, who served from 1853 untü his death in 1879. The family association with the Society goes back to 1 76 1, and the Mr. Le Neve Foster who is with us to-day represents the seventh generation of that family connection.

Dr. Miller, our lecturer, graduated in 1937 at Durham University. In 1940 he became a Member of the Royal College of Physicians. He took a diploma in psychological medicine in 1943 and was elected a Fellow of the Royal College of Physicians ten years later. He has filled a number of hospital posts : in neurology in Newcastle and London, and in pathology at Johns Hopkins University in the USA. He is the joint author of Progress in Clinical Medicine (1961) and has contributed papers on The Aetiology of Multiple Sclerosis , Accident Neuro- sis and many other subjects. He has served with distinction on many important medical committees. Without fear of contradiction I can say that his colleagues would assess him as being particularly well qualified to address us this

I afternoon on 'Priorities in Medicine'. The following lecture was then delivered.

When were the most

I

morphia,

qualified effective

digitalis

in medicine drugs

and available aspirin.

in 1937 I the most effective drugs available were morphia, digitalis and aspirin.

They remain invaluable, but during my year at Johns Hopkins Hospital in 1938 the modern scientific revolution in medicine was initiated by the dramatic discovery that lobar pneumonia could be cured within 48 hours by a new drug - a sulphonamide, M&B 693. The impact of this British announcement on a great American university hospital was startling. The bacteriological departments of

American universities and hospitals had just been combed for microbiologists able to set up units for the manufacture of anti- pneumococcal serum - scientists who had to find new careers after the few months that were occupied in confirming the claim that M&B 693 had in fact transformed pneumonia from an always serious and often fatal illness into a manageable indisposition. Since this time the scientific revolution in medicine has progressed apace. Major developments in chemotherapy continue: from the 1940s

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JOURNAL OF THE ROYAL SOCIETY OF ARTS FEBRUARY 1973

onwards an increasing battery of antibiotics has outpaced the ability of bacteria to develop effective resistance; successful vac- cination against a number of serious virus diseases has been developed, poliomyelitis being the outstanding example; psychotropic drugs have removed many of the terrors of ubiquitous depressive illness and have done something to blunt the impact of schizo- phrenia ; more recently still the development of renal dialysis and organ transplantation has added a new dimension to the treatment of otherwise fatal chronic renal failure. New developments in clinical genetics offer some promise for the prevention of congenital abnormalities. Medicine has changed more in the last thirty-five years than in the previous 350, and there are no signs of any slackening in this process. However, its success has faced administrators with some difficult problems.

TOTAL RESOURCES The National Health Service has proved to be much more expensive than was antici- pated, and its success has not led to the predicted decline in demand. As far as the hospitals are concerned it took over a run-down plant, and since the rate of new hospital building since its inception has unbelievably been slower than under the pre-war system, the service continues to wrestle with the increasing demands of modern medicine under the physical handi- cap of old buildings, often in the wrong places and unsuited to the practice of modern medicine.

The total resource available to medicine is usually measured in terms of the gross national product (GNP), of which the NHS at present absorbs something like 5 J per cent. Successive Health Ministers fight shy of international comparisons, but there can be no doubt that this proportion is rising steadily in every developed country. The figure of 10 per cent is likely to be reached well before the end of the present century, and has already been approached in more than one developed country where medicine enjoys a higher priority than in Britain.

In the matter of allocation of total resources for medicine the physician has the right of any citizen to press the claims of his particular interest, but exerts little influence on the outcome. The medical profession has, however, one further social duty; to indicate the magnitude of need and the nature of

deficiencies if the declared national goal of a comprehensive and effective health service is to be achieved and maintained. Accurate ascertainment of need has been made in few sectors of medicine, but to give one simple example, the provision of effective rehabilitation for head injury in Britain would require about 8,000 places in head injury rehabilitation centres. In fact such provision is negligible.

ALLOCATIONS AND PRIORITIES The medical profession can contribute more to issues of priority than to deliberations on total allotment. Unfortunately information as to cost-effectiveness and cost-benefit in medicine is scanty, and many figures quoted are useless as standards of comparison because of lack of uniformity even in such simple matters as to whether or not they take the capital cost of buildings employed into consideration. However, a course of treatment can be costed more effectively than its benefit can be measured. Such studies should be undertaken, but with their limita- tions clearly in mind. There is a natural tendency to rely on easily ascertainable parameters such as length of stay in hospital and duration of absence from work. Pain and suffering or the ultimate qualitative results of medical or surgical treatment lend themselves less easily to quantification. However, there can be little doubt that the Health Depart- ment would gain from the establishment of pilot departments of Medical Economics directed by experienced physicians in a few selected medical schools.

One thing is perfectly clear: under any conceivable system demand will outstrip available resources. Where this is a case of testing new methods of treatment it is reasonable that carefully designed and controlled trials should be limited to a few selected centres. However, once a routine such as dialysis and transplantation for chronic kidney disease has been firmly established as life-saving, the profession and public are not unexpectedly impatient so long as it can be offered to only a minority of victims of such a disease. The implications of such issues - in relation to personnel even more than to finance - cannot be taken lightly. Meanwhile a French economist has calculated that to furnish dialysis for all those at present waiting for it in his country would equal the costs of the whole of the rest of the French health services.

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PERSONNEL To the writer the most remarkable fact about the NHS is that twenty-three years after its inception his own hospital region relies on medical graduates from India and Pakistan for no less than 75 per cent of its junior hospital staff, that figures of this order have been accepted with astonishing complacency by a long succession of health ministers, and that even to-day the steps being taken to remedy the situation are too little, too late, and unlikely to have any measurable impact for ten years at the very earliest. The United States is in a similar position, relying as it does on graduates from North Korea and Puerto Rico. The difference is, however, that the United States makes no pretence to furnish a comprehensive health service. After two decades of operation and planning, on the other hand, our Health Department accepts no responsibility whatever for ensuring the provision of doctors to staff the NHS. Responsibility for medical education lies firmly on the doorstep of the Department of Education and Science, and its agency the the University Grants Committee gives a distinct impression of regarding medical education as an unruly and expensive burden in unfair competition with more respectable academic pursuits. The provision of medical education in state academies in Eastern Europe has disadvantages, but it means that there really is somebody - in this case the Health Minister - responsible for matching need and supply in the provision of professional services.

NURSING For reasons that are probably at least as much sociological as financial, the shortage of nurses is a world-wide problem in the developed countries. Britain usually tends to repeat the mistakes of the United States - fifteen years later and in a halfhearted man- ner. There is a grave danger that exactly this will happen in the field of nursing. In many American hospitals the ward is run by a professional manageress controlling a team of relatively untrained staff. The manageress is probably a 'graduate nurse' with little practical experience and virtually no direct patient contact. The results are deplorable. The British system has depended on recruit- ment of a now shrinking group of educated and intelligent young women, for whom there are now many other occupational opportunities, and on giving them professional autonomy and responsibility within a

medical team. Unfortunately the Salmon Report erodes the professional responsibility of the individual ward, theatre or casualty sister and replaces it by a hierarchy more appropriate to the Civil Service. It also anticipates the subsequent Briggs report in insisting on the full-time nursing teacher, whose dissociation from the daily practice of a changing and increasingly technological discipline can be guaranteed to ensure that what she teaches is already out of date.

GENERAL PRACTICE Britain is the only major country where the system of general practice plus specialist referral remains the basis of medical care. Recently transfused by a considerable increase in remuneration, it has so far defied the prophets of gloom who have pointed out the virtual impossibility of being a competent general practitioner in an era of speciali- zation and have questioned the professional and financial viability of a two-tier system of medical care. However, both the DHSS and the BMA are committed to this system, and it may be that Britain will maintain it against all odds. So far as scattered populations are concerned there is of course no alternative, though the populations of such areas must have access to more sophisticated medical attention by means of good communications and transport. Amongst the younger practitioners in Britain there is considerable enthusiasm for group practice in purpose- built premises with some degree of speciali- zation within the group. This would certainly be preferable to the condition that obtains in some of our largest cities to-day, where the Australian or Nigerian postgraduate who is deputizing for the commuting GP by way of an emergency call service must often take major decisions without access to the patient's records. However, it is still a far cry from the traditional family doctor who furnished a continually available personal service, in collaboration with a small group of trusted consultants. In this matter I find myself swimming against the tide. I mistrust the generalist trying for part of his time to be a partly-trained specialist, and in the long term I would regard it as more realistic for all clinicians to be specialists, but with a training and background in general medicine in the widest sense that will equip them to partici- pate in the provision of primary medical care to the community which they serve. To most traditional British practitioners such an arrangement would be anathema, and

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the example of the United States would be quoted as an indication that the patient is quite unfitted to choose his own specialist. In my view the problems of American medicine are related more to the financial conditions of practice than to the question of choice of specialist. The fear carefully nurtured by generations of practitioners that the specialist's clinical vision is constricted is not usually well-founded, and the patient with a complaint of short sight who wanders by accident into the clinic of a rectal surgeon is more likely to end up with a pair of spectacles than with an operation for piles.

HOSPITALS The high priority accorded by the Health Ministry to the hospital service since its inception has been evident in the lion's share of finance it has enjoyed, and indeed the coverage of Britain by a network of hospital services providing competent specialist hospital care to the whole community is a remarkable achievement. It has been made possible only by fairly generous financing of the hospital boards, which has permitted a steady expansion of both general and specialized hospital services. Unfortunately the plant that was taken over at the inception of the health service was hopelessly run- down, and capital expenditure on new hospital building has been very inadequate. The average age of our hospitals is about seventy years, and many are much older and inconveniently sited. On Teesside, for instance, there are no less than twenty-three hospitals, which might have been specifically arranged to ensure that their medical staff spend more time travelling between them than working in them. At the present rate of building the replacement of this ramshackle system will take half a century, by which time what is built now will be outdated. The problem is made more acute since shortage of capital is aggravated by what seems to be the interminable delay between planning and execution which characterizes British hospital building but which experience in other countries shows is not inevitable. However, capital cost is the major factor, and since the capital cost of a primary school place at present is £296, that of a bed in an old people's home £4,000 and in a district general hospital more than £10,000, the relative frequency of new schools as compared with new hospitals is perhaps not entirely unexpected.

The hospital service at present faces some special difficulties, of which one is the move from institutional to community care for the mentally subnormal and mentally ill, before adequate community services have been provided by often reluctant local authorities. Another is continuing controversy on optimal hospital size. The Secretary of State is undoubtedly right in sustaining the rôle of the better cottage hospitals as places where illness requiring no more than nursing or terminal care can be dealt with by staff recruited locally on a part-time basis. There are also other parts of the country where a general hospital of 200 to 500 beds, coping with general work and passing more com- plicated cases up the line to a larger centre is the only practical method of meeting the needs of a peripheral community. However, the original concept that between 600 and 1,000 beds was adequate for a major district general hospital may have met the needs of 1939 but is now hopelessly outdated. This is the problem that concerns the major conurbations, and if the advances of modern medicine are really to be made available to the general population specialized units must be able to furnish a 24-hour service, which means for each a staff of four specialized teams and a unit of 120 beds if they are to be economically employed. Furthermore the arrangement originally envisaged whereby one general hospital would have a major neurosurgical unit, another a major thoracic unit, and another an orthopaedic unit on a realistic scale has been made nonsense by the increasing toll of traffic accidents, the victim of which may well require the services of all three. In other words the major specialist units must be on the same campus, close at hand and integrated with the massive services that characterize the modern general hospital. A major regional centre of this kind could hardly operate effectively with less than 2,000 beds.

POPULATION SCREENING Outside the medical profession there is a widely held view that the national health service is an ťill-health' service unduly concerned with disease, and that more resources should be directed to the diagnosis of pathological processes before they have caused symptoms. The conspicuous success of population screening for pulmonary tuberculosis in the late 1940s is often rightly quoted as an outstanding example of the success of this approach. However, certain

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special circumstances applied here which are not invariably present ; mass miniature radiography was cheap and highly reliable, while the chemotherapeutic treatment of pulmonary tuberculosis had just become truly effective. The same cannot be said of many fields in which committed enthusiasts regard population screening as already an appropriate priority for health service expenditure. There is, for example, no entirely convincing evidence that the early diagnosis of pre-diabetic abnormalities in the blood sugar curve or of early hyperten- sion justifies treatment that will improve the patient's prognosis, and the same applies even to cytological methods for the early diagnosis of cervical cancer. On the whole the balance of evidence favours the view that the last of these serves a useful purpose, and the combination of this fact with public pressure has led the Department of Health to institute the procedure on a fairly wide- spread scale. However, like most such methods it was introduced by enthusiasts convinced of its value from the start, and became established as a standard technique before it had been subjected to the prospec- tive study that alone can furnish definitive evidence. This is unfortunately a common feature of innovations of this kind. Those who undertake them are enthusiastic rather than critical, and their methods have become established and accepted before rigorous testing. One other disadvantage of population-screening tests - unless they concern a single well-defined parameter such as the chest X-ray - is that they yield a considerable number of equivocal results and that the cost of unravelling them outweighs that of the original investigation. Most experienced clinicians doubt the reliability of pre- symptomatic diagnosis and would sooner see money invested in educating the patient to recognize significant early symptoms of serious disease and seek medical attention as soon as possible. This does not mean of course that those exposed to particular stress or training for particular duties should not be routinely examined, nor that screening processes should not be used for specially vulnerable cases - not well-nourished business executives, but those for example who have already lost one breast from cancer.

NEGLECTED AREAS In conclusion I would like to draw attention to four neglected areas of the health service

which deserve much higher priority than has been traditionally accorded to them.

The first of these is the accident service. After a quarter of a century of professional agitation steps are now being taken to improve this situation, which is critical because of the steady increase in traffic injuries, because many of its victims are young and active people with their working life in front of them, and because they represent a particularly rewarding field of treatment. The essential point here is that a 24-hour accident service under expert supervision must be dispensed from a limited group of large centres. The uproar that occurs when a local accident service is with- drawn or a small local hospital closed is misplaced. No such department can be truly efficient and some can be seriously dangerous. The metropolis presents special problems, but with regard to the regions there is every reason to believe that the essential problem has been grasped and that within ten years we should have a fully integrated accident service.

Although mental subnormality has aroused public concern, it seizes the imagination less readily than many other branches of medicine, and is a problem of considerable magnitude. The possibility of obtaining financial resources for a general up-grading of facilities to civilized standards is remote. Two things, however, could be done. First, pilot schemes should be organized using various combined methods of care, supervision and training in selected areas, with continuing evaluation, to furnish a rational basis for an ultimate national scheme. The second useful step would be the establishment of three or four well-equipped units for research into various aspects of mental subnormality - especially its epidemiology and causation - in selected medical schools in the hope that they could make a serious contribution to prevention in the future.

The third area of concern is that of chronic disease and geriatrics. The two problems are separate. In considerable part chronic disease is a by-product of the partially successful modern treatment of illnesses which would previously have proved fatal, and these patients tend to become the responsibility neither of the hospital nor of the general practitioner. The specialist who treated the original illness is poorly organized to furnish long-term continuing care, while the practitioner faces different problems in the home situation. Historically our great

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general hospitals have always fought shy of responsibility for chronic disease, and this has led both to a hiatus in medical education and an impoverishment in the clinical experience of their staffs. It is only when every major general hospital has its chronic wards, manned by its own staff, that the situation can be adequately dealt with - as it is in a few European centres.

With the over-seventy-fives as the most rapidly growing section of the population, the problem of geriatrics is larger and more alarming, though it is different in nature. There are really two aspects of modern geriatric medicine: the treatment of often curable acute disease in the elderly (which is intrinsically part of internal medicine) and the rehabilitation of the elderly sick. Although conditions in this country are far from ideal we have no reason to reproach ourselves unduly about our geriatric services. However, the division of responsibility between the regional hospital boards and the local authorities - that is, between health and social services - has allowed many city and county councils to save their ratepayers' money by furnishing inadequate community services at the cost of a great deal of un- necessary and expensive hospitalization. One hopes that implementation of the Seebohm Report will improve this situation. There are few signs of this as yet, and some local authorities still seem to believe that it is an improper use of ratepayers' money to shore up a nationally funded health service.

Finally, a few words about dental health, which is probably the most neglected area of all. Eighty per cent of our five-year-olds already have some decayed teeth; half our population has lost all its natural teeth by middle-age; our dentists extract 10,000,000

decayed teeth every year and carry out nearly 30,000,000 fillings; a quarter of our young people need dentures by the time they are twenty; 80 per cent of any random sample of the population has unhealthy gums. We have half the dentists recommended by Lord Teviot's Committee of twenty-five years ago, and less than half of those furnished to-day by Sweden per 100,000 head of population. The NHS makes no provision for preventive dentistry, and is essentially a repair service with a scale of charges that puts a premium on inferior work. The present fee for full dentures under the NHS is £16.50 while the charge for a similar service under the West German social insurance system is about £120. Ironically the German dental technician receives more than twice as much as the total fee of the British dentist and his technician combined for the same service.

Melodramatic statements about the break- down of the national health service have often been made without foundation, but there can be no doubt that the dental service has in practice broken down as an effective arrangement for furnishing comprehensive care - and that the steps at present under way to increase the output of dental surgeons and to furnish them with facilities for work of an adequate standard are derisory.

By comparison with arterial reconstruc- tion, organ transplantation and the treatment of unusual cancers, these subjects make uninteresting reading and poor television. However, they draw attention to the fact that while cure of some diseases is relatively easy the main task of medicine in the future is going to be the administration of continuing care, a more expensive, less glamorous, and much more important function.

DISCUSSION

Dame Elizabeth Ackroyd, dbe: Could I ask Dr. Miller a question about education of the public as a priority in medicine ? He mentioned it only in the context of the public being educated in how to get help and advice; that goes without question. But I would have thought education in dental care was particularly relevant. The public could do a lot more about looking after their teeth, and much more needs to be done to prevent them being persuaded to ruin their teeth. Television advertising of sweets to children should be modified or abolished.

The Lecturer: I should prefer to be able to give everybody pills so that they can enjoy

their vices ! Cigarette smoking, I think, is suicidal, but I wonder whether the warning advertisements really had any effect. The tobacco companies' profits don't suggest that they have been enormously successful. Not liking sweets myself, I should acquiesce in advertising against them, but I have a feeling that an appreciable section of the younger population wouldn't pay any attention.

But I take your main point - and I think it is true - that we have not paid enough attention to health education. For a number of reasons: one reason is that it easily slides over into hypochondriasis. Another is that there is not a tremendous lot that you can tell people not to

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do. (The first piece of clinical research I did concerned dental care, and I must say I was rather relieyed to find that children who did not brush their teeth had teeth just as good as those who did!) Another reason is that it very easily falls into the hands of enthusiasts, who claim that you must run five times round a field each morning or drink hot or cold water last thing before retiring. Much of the advice that passes for health education is misleading.

I am a believer in treatment rather than prevention. There aren't very many things we can easily prevent that we aren't already preventing. We are preventing cholera by having a cleaner water supply, preventing smallpox by being vaccinated, polio by being vaccinated. We are not preventing alcoholism, diabetes, arteriosclerosis or multiple sclerosis, or brain tumours, because we don't know how to prevent them.

Dr. W. E. Thompson: On the question of accident service, what does Dr. Miller think about the prospect of staffing casualty departments with better qualified people? I should like his views on the way in which it could be organized. Secondly, the neglected area of the chronic young sick. I have an impression that before 1948 there were more beds available for chronically sick young people than there are now. I have a feeling that, as regards intake and care, multiple sclerosis cases are treated now by private bodies almost entirely. Has he any views on what it might cost or how it could be organized to ensure that these people got a bigger share of National Health Service care ?

The Lecturer: I perhaps didn't criticize the profession sufficiently for its neglect of accident services. There can be no doubt that one of the reasons for the poor development of accident services has been the attitude of the medical profession. In any big hospital the casualty department tends to be nobody's baby. No real career structure has been built up within the accident service. And even where you have a good surgeon in charge of it and spending quite a lot of time there, he often looks on it as a step to some more respectable branch of surgery.

There is one very good reason for this, of course. It is extremely arduous, the hours are irregular, there is a lot of night duty, and for an ageing surgeon it is obviously not a very attractive prospect. It is also not a suitable place for a very junior doctor. In a big accident centre you need four consultants with training in traumatic surgery, orthopaedics and a certain amount of plastic work, because if you are going to give a twenty-four hour service you need three shifts, and one extra consultant who can be on holiday or away; and you also need a considerable number at registrar level, doctors in their late twenties and early thirties, with a certain amount of experience who can take a

good deal of the load. If the size of the unit is adequate and it is physically well organized, it should be easy to get staff. We looked into this in Newcastle and took the step of appointing a Professor of Orthopaedic and Traumatic Sur- gery, and I think this has already had an effect on the respectability of the discipline, and in attracting disciples. This has got to be made a really attractive field in surgery.

The young chronic sick are a big problem in one sense, and yet a small problem numerically. There are two diseases in particular which require chronic institutional care for the sufferer, multiple sclerosis and rheumatoid arthritis. These account for more than three-quarters of all the victims. The trouble is that the small size of the problem in one way makes it more difficult to deal with. The private bodies that you men- tion have on the whole tended to deal with this by establishing special institutions in the country. This means that the patients are a long way away from their homes and friends. It would be better to have a few beds for the young chronic sick in every general hospital so that they can stay within the community in which they live. The worst of all things is to put them in with the geriatric cases, which is what tends to happen in practice. But I know our region is doing its best to make sure that each general hospital has a proper ward of half a dozen beds for the young chronic sick where they can be with a not too disparate age group.

Dr. William Lees, cbe, td, qhp, frcog (Principal Medical Officer, Department of Health and Social Security): I should like to ask Dr. Miller to elaborate on the medical aspects of accident and emergency work, particularly that relating to drug poisoning, and secondly to enquire about the rôle of genetic studies in the prevention of mental subnormality and congenital abnormality.

The Lecturer: There is no doubt that medical accidents have become an increasing load, and of course drug poisoning is the com- monest single cause of admission at the moment. Fortunately the mortality is now relatively low. At one time everybody who got severe barbiturate poisoning used to be very ill, and many died. Now it is quite exceptional for a patient to die from barbiturate poisoning. In most units, the medical emergencies, if they are recognized as such, tend to be treated separately from the straightforward trauma because they involve a different set of problems - of biochemical and pharmacological control. One interesting aspect is that suicide by aspirin poisoning is much easier to-day than by barbiturate poisoning, because you don't need a prescription for aspirin.

It is easy to preach about drugs and their frightful results, but where would we be without them?

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The other point about genetics I have not dealt with to-day because it comprises a number of extremely difficult problems. The symptomatic control of genetically determined diseases like juvenile diabetes, for instance, implies a steady increase in the pool of unfavourable genes in the population. It is unthinkable not to treat the juvenile diabetic, but it does mean of course that there will be a steady increase in the amount of diabetes in the population. The geneticists seem to me singularly light-hearted about this by comparison with the clinicians, their line being that the time scale is so long that it is going to take twenty generations to double the number of cases. There are a number of other diseases of a fairly nasty kind where you can control the individual progress of the disease by surgery. In polyposis of the colon, you have a whole lot of little growths in the colon, and these have a distinct tendency to become malignant in middle life. You can remove the colon and the patient will have a normal expectation, but of course his descendants will carry the gene. Whereas there is a fair chance that if the disease were left to itself, these families would die out.

Not enough is known about mental subnormality for me to answer your question. The problem falls into two distinct groups. One is severe mental subnormality, where you are quite often dealing with identifiable abnormalities, either structural or biochemical. These represent a relatively small proportion. The much bigger problem is mild subnormality, which is responsible for a great deal of petty crime, delinquency, school maladjustment and this sort of thing. Until we know more about this condition we can't tell whether it merely represents the lower end of a normal curve of variability, or whether it represents the summation of things that hap- pened to the mother during pregnancy or whether it represents multifactorial inheritance. A great deal of research is required into this. Only recently was it discovered that drugs had anything to do with the development of the foetus. There is increasing evidence that in- fluenza during pregnancy may have an effect at a certain stage on the developing foetus, and therefore what we really need is an enormous amount of new clinical data which can really only be obtained by an exhaustive survey of pregnancies. There are a few straightforward mechanical things, like looking at the amniotic fluid by sticking a needle into the uterus and looking for abnormal cells or enzymes, but this applies only to a small number of very gross cases of abnormality. But I think that of all fields mental subnormality deserves investment and research and I am sure that if we can get the right people to do it we could get the investment.

Mr. Peter Bruce (BBC Television): Re- turning to priorities in medicine, one of the economic problems surely is that services throughout the country are of different standards

and the waiting lists are of different lengths. Whilst an operating theatre team may save one patient by doing a heart valve operation, taking four to five hours and requiring huge staff com- mitments and a lot of money, they might have been able to do seven hernias or half a dozen piles operations or many of the other common operations which would alleviate the condition of larger numbers of people. When sorting out the priorities in medicine are we sorting out the priorities of need of patients ? Who should do this ?

The Lecturer: I agree. The real triumphs of medicine and surgery very often concern the management of inconvenient and disabling rather than very dramatic major diseases. Of course, the number of institutions which furnish facilities for highly technical work is very much less than that of those where general surgery and general medicine are carried on. There are twelve teaching hospitals within a few miles of this building - a crazy situation. That is just one of the remarkable things that happens in London. It is not as bad as Sydney, which has several teaching hospitals, none of them I think with more than 300 beds, and seven neurosurgical teams, none of them on duty most of the time. But if you try to limit highly sophisticated operations you stop all sorts of progress in treatment.

In any case, heart valve operations these days are routine compared to the situation thirty years ago. It is also easy to exaggerate the amount of resources devoted to the bizarre - things like cardiac transplantations, which seem (thank God) to have died a natural death, at any rate for the moment. As a Vice-Chancellor I am always being asked to draw up long-range plans for the future of the university. I don't think this is how institutions work. They tend to work by improvisation, and if you draw up long-range plans some curious event occurs that renders them no longer relevant. I am a pessi- mist about this ; but still, I agree with what you say and I think those in surgery should take much more seriously the surgery of convenience, things like hernias and varicose veins, and see how they can most economically be handled. But don't think you can persuade cardiac surgeons to spend all their time doing varicose veins !

Mr. Bruce: I wasn't suggesting that. I was asking who should make the decisions ? The doctors, the Board, the Ministry ?

The Lecturer: You want a decision of principle, really ?

Mr. Bruce: Well, I would like a discussion on principle. One person may sway a committee and get his extensions and his staff just because he is a good committee man.

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The Lecturer: Perhaps because he is a good surgeon also ? But I think this is true, and that institutions bear the stamp of the people who work in them. But I think this is inevitable. In a highly technical and developing profession there has to be a fair amount of leeway. I am not sure that the board of governors (except in the last resort), certainly not the regional board and certainly not the city council (or even the Consumers' Association) is the best body for making decisions. The man on the spot has to make the decision. This is the essence of professional responsibility. It is a bit like deciding whether you are going to resuscitate somebody or not. The Swedes tried having committees to weigh up patients' moral worth and their relative degrees of turpitude, and to decide whether or not to resuscitate. On the whole it is better left to the doctor. I am really trying to evade the issue.

Mr. Bruce: You are!

Mr. Christopher Sykes (BBC Tele- vision): Dr. Miller said that resources were essentially limited, but demand is potentially unlimited. Will there come a time when we can't, as it were, have everything? We can't at the same time spend four times as much money on care of the mentally ill and provide kidney dialysis to every one who needs it. Is this a situation which will come about, and if so, what criteria will be used, and by whom, to decide which things to spend money on ?

The Lecturer: The situation you describe has already come about to the extent that less than io per cent of those who can benefit from dialysis and transplantation can get it, and the decision as to who gets it really depends on a whole host of factors which again in the last resort are interpreted by the doctor on the scene. First, it depends on where you live; secondly, on whether you are intelligent enough to work the machine yourself ; thirdly, on whether you can accommodate a home dialyser ; fourthly, whether your tissue group is one which can be very easily available. Dialysis happens to illustrate the situation, but in fact there is no part of medicine where resources are really adequate to needs. I don't mean that people can't get enough penicillin, but that in fields like psychotherapy it would be quite impossible to furnish the amount which could potentially be consumed. Since I don't believe in it, this doesn't worry me. But if you really did believe in it, you could put up a strong case for every street having its resident psychoanalyst.

The answer is to do the best you can with the resources which are available. There never will be enough, because demand will increase through technological developments. If a kind Fairy came along and informed the Ministry of Health that it could have all the money it required to meet needs to-day, tomorrow some

awkward fellow would invent a new technique which would demand further resources, further evaluation and especially further personnel. One of our main failures has been the failure to train enough doctors of our own to man the service.

The Chairman: Arising out of this question of resources, we were cheered by Dr. Miller telling us that $| per cent of the gross national product was now being devoted to health services. A little over four years ago, when we were spending 4.6 per cent on health and welfare and 6.8 per cent on so-called defence, I wrote to the then Prime Minister criticizing the lower priority of health and welfare. In The Times to-day we are told that defence only absorbs 4^ to 5 per cent, and the medical and welfare side is now 1 per cent in advance instead of nearly 2 per cent in arrears. That is a cheerful thought.

On the question of the inadequate numbers of personnel, you are all familiar with the fact that we had a disastrous committee called the Willink Committee, which recommended cur- tailment of the admission of medical students by 10 per cent. Several years ago the medical press kindly published a letter of mine in which I said that we needed ten additional medical schools as the minimum. I suggested sites where these could be built in connection with existing or projected universities. I think I am right in saying that no more than four, or at the most five, of those ten have in fact been established. In order to overcome the difficulties that Dr. Miller has told us of, we still need far more medical schools. After all, it would be very reasonable for both India and Pakistan to retain their doctors and refuse to advance them the money to come to this country. That may well happen in due course. Then as regards nursing personnel, this is a matter I feel very keenly about. I think our lecturer was a little unfair to the sister tutor grade. One of my jobs when I was at the Ministry some years ago was to visit all the teaching hospitals and a great many of the regional board hospitals, and I must say that in many instances I found that the sister tutor worked in very close co-operation with the ward sister and with the health visitors and local authorities.

I was delighted to hear Dr. Miller support, in a qualified way, a population screening. He mentioned the value of both cervical cytology and screening for the prevention of breast cancer. As you know, fairly recently they have discovered a method of finding out whether a woman has breast cancer by a mammo-graph, which is a very simple apparatus for determining the heat produced by the increased vascularity of very early malignant growths.

I, myself, think that, despite their depleted numbers, a great many dental surgeons have, in fact, done a very good job of work. After all, we were told by Dr. Miller that they had filled

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far more teeth than they had pulled! In my experience, quite a number of school dental officers do a lot of the propaganda referred to by Dame Elizabeth Ackroyd in opening this debate.

On the subject of the size of hospitals, I wonder whether Dr. Miller has recently visited Sweden. I was appalled by some of their colossal 2,000 bed hospitals, where you needed a pair of roller skates to take you from one part of the building to the other. In my day at the Ministry we used to advocate that hospitals should have not more than six to eight hundred beds. Since then, there has been a move in the direction Dr. Miller indicated, because the district general hospitals, those which deal with the acute cases, are going to be designed to have between 800 and 1,300 beds, and community hospitals, which will be dealing with 35 per cent of chronic sick and non-acute cases will have 660 to 880 beds. My own feeling is that if a hospital has 2,000 beds it becomes an institution rather than a hospital, and it is very difficult to operate it really satisfactorily.

I started as a GP, and gave it up in 1919. Since then I have been a consultant, a medical administrator, and various other things, but I still feel that the GP does a valuable service in sifting out those who need specialist care. He is essential. Dr. Miller himself indicated that in certain rural areas, especially those with

cottage hospitals, general practitioners could still deal with a lot of the minor cases. I believe I am correct in saying that the vast majority of people who are sick in the United Kingdom are dealt with by general practitioners, and that only a relatively small proportion of them have even- tually to be seen by specialists and admitted to hospitals. The GP is the front-line officer, doing essential first aid, apart from his service as a counsellor and friend to the family.

Another point Dr. Miller made was the desirability of group practice. I can tell him that in the London Executive Committee area there are a great many single-doctor practices which have to use the deputizing services which Dr. Miller deplored. The deputies haven't access to the patients' notes, they don't know anything about previous treatment, and they are suddenly called out at 12 o'clock at night to make decisions.

I shall be getting into trouble unless I termi- nate the meeting. In doing so I should like you to join with me in expressing our very warm thanks to Dr. Miller for all the trouble he has taken in compiling a very thought-provoking paper. I can promise him that quite a number of the 10,000 people who will be reading it in the Journal in due course will be writing to him!

The meeting concluded with the usual expres- sions of thanks.

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PRIORITIES IN MEDICINE