/
S E C R E T
C^P. ( 5 0 )
31.
COPY NO.
11
10TH MARCH, 1 9 5 0
CABINET
NATIONAL HEALTH SERVICE (ENGLAND AND WALES):
CONTROL OF EXPENDITURE
Memorandum b y t h e M i n i s t e r
of
Health
1.
At t h e i r m e e t i n g on 9 t h M a r c h (C. M. ( 5 0 ) 9 t h .
C o n c l u s i o n s , M i n u t e 1 ( 2 ) ) , t h e C a b i n e t I n v i t e d me t o s u b m i t a
memorandum e x p l a i n i n g t h e e x i s t i n g f i n a n c i a l b a s i s o f t h e
N a t i o n a l H e a l t h S e r v i c e and t h e m o d i f i c a t i o n s which would have
t o b e made i f t h e c e n t r a l Government w e r e t o be a b l e t o
e x e r c i s e c l o s e r c o n t r o l o v e r t h e e x p e n d i t u r e i n c u r r e d on t h i s
Service.
T h i s p a p e r d e a l s o n l y w i t h England and W a l e s :
t h e r e h a s b e e n n o t i m e t o c o n s u l t t h e S e c r e t a r y of S t a t e f o r
Scotland.
2.
The N a t i o n a l H e a l t h S e r v i c e f a l l s i n t o t h r e e f a i r l y
d i s t i n c t p a r t s - t h e Hosxoital and S p e c i a l i s t S e r v i c e , t h e
G e n e r a l P r a c t i t i o n e r S e r v i c e s , and t h e L o c a l H e a l t h A u t h o r i t y
Services.
F o r c o n v e n i e n c e , e a c h can be l o o k e d a t s e p a r a t e l y
and t h e n t h e p i c t u r e a s a w h o l e can be s u m m a r i s e d a t t h e end.
H o s p i t a l and S p e c i a l i s t
Service
3.
In e x p e n d i t u r e t h i s i s , as i t must b e , t h e b i g g e s t
of t h e t h r e e p a r t s .
C u r r e n t n e t c o s t i s about £209 m i l l i o n s
( o u t of a t o t a l of a b o u t £ 3 1 8 m i l l i o n s ) .
Estimates for the
c o m i n g y e a r i n d i c a t e some £ 2 3 8 m i l l i o n s ( o u t of a t o t a l o f
£351 m i l l i o n s ) .
4.
The M i n i s t e r i s d i r e c t l y r e s p o n s i b l e by s t a t u t e f o r
this service.
He a d m i n i s t e r s i t t h r o u g h t h e a g e n c y o f R e g i o n a l
H o s p i t a l B o a r d s , v o l u n t a r y and u n p a i d b o d i e s a p p o i n t e d by him
a n d r e s p o n s i b l e f o r t h e w i d e r g e n e r a l a s p e c t s of t h e s e r v i c e
over large a r e a s ;
and t h o s e B o a r d s i n t u r n u s e t h e agency of
l o c a l Management C o m m i t t e e s , v o l u n t a r y and u n p a i d b o d i e s
a p p o i n t e d b y t h e B o a r d s , f o r t h e o r d i n a r y l o c a l r u n n i n g of t h e
hospitals.
Teaching H o s p i t a l s are s e p a r a t e l y run by s p e c i a l
B o a r d s of G o v e r n o r s , v o l u n t a r y a n d u n p a i d b o d i e s a p p o i n t e d b y
t h e M i n i s t e r , b u t w i t h a p r o p o r t i o n of d i r e c t l y n o m i n a t e d
members.
5.
T h i s d e l e g a t i o n of r e s p o n s i b i l i t y t o v o l u n t a r y b o d i e s
was a l w a y s f e a t u r e d , i n P a r l i a m e n t and g e n e r a l l y , a s one of t h e
b a s i c p r i n c i p l e s of t h e s c h e m e , a n d a s t h e p r e v e n t i v e of an
over-bureaucratised service.
The a l t e r n a t i v e w o u l d h a v e b e e n
t o g i v e t h e w h o l e Job t o l o c a l g o v e r n m e n t , w i t h E x c h e q u e r
g r a n t s , b u t the p r e s e n t l o c a l government s t r u c t u r e would have
been q u i t e u n s u i t a b l e ;
i f r a d i c a l r e f o r m of i t i s e v e r u n d e r ­
t a k e n , t h e p o s i t i o n s h o u l d p e r h a p s be c o n s i d e r e d anew.
As i t
i s , c o n t r o l of e x p e n d i t u r e r e s t s on t h e f o l l o w i n g d e v i c e s .
6.
F i r s t , a n d a s t h e m a i n c o n t r o l , l o c a l Management
C o m m i t t e e s have t o f o r m u l a t e a n n u a l e s t i m a t e s , or b u d g e t s , of
t h e i r t o t a l requirements for each y e a r ;
and t h o s e , w i t h t h e
r e q u i r e m e n t s of t h e R e g i o n a l B o a r d s , h a v e s o f a r h a d t o b e p u t
up f o r t h e M i n i s t e r ' s e x a m i n a t i o n a n d a p p r o v a l .
( B o a r d s of
G o v e r n o r s of T e a c h i n g H o s p i t a l s p u t t h e i r s u p s e p a r a t e l y , b u t
similarly.)
I t h a s now become c l e a r , h o w e v e r , t h a t t h e
M i n i s t r y cannot p o s s i b l y s c r u t i n i s e , in enough d e t a i l , t h e
e s t i m a t e s of 377 s e p a r a t e M a n a g e m e n t C o m m i t t e e s ;
a l l t h a t has
b e e n p o s s i b l e h a s b e e n t o make a b r o a d c o m p a r i s o n of o n e
Region w i t h another.
This i s n o t good enough.
Therefore,
i t h a s now b e e n d e c i d e d t h a t i n f u t u r e t h e C o m m i t t e e s ' b u d g e t s
w i l l be d e a l t w i t h in d e t a i l by t h e R e g i o n a l B o a r d s , w h i l e t h e
Minister will deal with regional t o t a l s .
This should secure
a much more e f f e c t i v e e x a m i n a t i o n .
7.
S e c o n d l y , t h e v a l i d i t y of a b u d g e t c a n n o t b e a s s e s s e d
U n l e s s t h e r e i s some m o r e r e l i a b l e g u i d e t o p r o p e r s t a n d a r d s
t h a n h a s b e e n a v a i l a b l e u n d e r t h e i n f i n i t e l y v a r i e d f o r m s of
r e c o r d s and a c c o u n t s i n h e r i t e d b y t h e M i n i s t e r i n a l l t h e
v a r i o u s h o s p i t a l s taken over.
T h i s means b e t t e r " c o s t i n g " .
Too much m a g i c c a n e a s i l y b e a t t r i b u t e d t o d e t a i l e d h o s p i t a l
costing;
in p r a c t i c e , r e a l l y d e t a i l e d c o s t i n g - with, checks
and r e c o r d s of e v e r y m i n u t e t r a n s a c t i o n - i s n o t p r a c t i c a b l e
i n t h e o p e r a t i o n o f a h o s p i t a l , a s i t may be i n a f a c t o r y .
But some b r o a d , s i m p l e r a n d more u n i f o r m c o s t i n g s y s t e m i s
c e r t a i n l y wanted.
A w o r k i n g p a r t y of s e l e c t e d h o s p i t a l
o f f i c e r s has Just produced p r o p o s a l s for t h i s ;
t h e ; / seem
p r o m i s i n g and a r e t h e r e f o r e b e i n g a d o p t e d f o r t h e f u t u r e .
In
a d d i t i o n , and f o r t h e l o n g e r t e r m , e x p e r i m e n t c i n more d e t a i l
a r e a b o u t t o b e c a r r i e d , o u t i n s e l e c t e d h o s p i t a l s , on t h e
r e c o m m e n d a t i o n of t h e C e n t r a l H e a l t h S e r v i c e s C o u n c i l .
All
of t h i s w i l l f a c i l i t a t e a b e t t e r a c c u r a c y i n j u d g i n g t h e
v a l i d i t y of b u d g e t s .
8.
Another control l i e s in the r e g u l a t i o n by the Minister
of t h e s c a l e s of r e m u n e r a t i o n of h o s p i t a l s t a f f of a l l k i n d s .
W h i t l e y m a c h i n e r y now e x i s t s f o r n e g o t i a t i o n of t h i s i n a l m o s t
a l l f i e l d s , a n d s c a l e s of p a y a r e t h e r e f o r e p r a c t i c a l l y a l l
g o v e r n e d from t h e c e n t r e and n o t l e f t t o l o c a l d i s c r e t i o n .
Up
t o n o w , h o w e v e r , t h i s g o v e r n s s c a l e s b u t n o t n u m b e r s ** o r
establishments.
This "is a d e f e c t .
To p r e s c r i b e e s t a b l i s h m e n t s
i n g e n e r a l , even f o r p a r t i c u l a r c l a s s e s and k i n d s of h o s p i t a l s ,
i s i m p r a c t i c a b l e ( l o c a l n e e d s a r e a f f e c t e d b y t h e s h a p e of a
b u i l d i n g , s i z e of w a r d s , n u m b e r of s t o r e y s , e t c . ) .
The o n l y
way i s t o s e t t l e an e s t a b l i s h m e n t ad h o c f o r e a c h h o s p i t a l .
T h i s c o u l d b e d o n e b y a s m a l l v i s i t i n g b o d y of e x p e r t s
( p r o b a b l y i n c l u d i n g some f r o m t h e O r g a n i s a t i o n a n d M e t h o d s
D i v i s i o n of t h e T r e a s u r y ) w h i c h c o u l d go t o t h e h o s p i t a l a n d
s e t t l e a general e s t a b l i s h m e n t for i t , a f t e r which t h e h o s p i t a l
w o u l d h o v e t o s e e k a p p r o v a l f o r a n y e x c e s s of t h a t f i x e d e s t a b ­
lishment.
Done a s a c o n t i n u o u s p r o c e s s , s t a r t i n g w i t h t h e
priraa f a c i e worst c a s e s , t h i s could s t e a d i l y extend over the
whole f i e l d .
New and. b e t t e r f o r m s o f s t a f f r e t u r n s , r e s u l t i n g
f r o m t h e w o r k i n g p a r t y of s e l e c t e d h o s p i t a l o f f i c e r s ,
referred
t o i n p a r a g r a p h 7 , w i l l now e n a b l e t h e " o r i m a f a c i e w o r s t c a s e s
t o be p i n - p o i n t e d .
It is proposed, therefore, that t h i s
p r o c e s s of f i x i n g i n d i v i d u a l e s t a b l i s h m e n t s s h o u l d s t a r t a s s o o n
as p o s s i b l e .
9.
Economies can sometimes be e f f e c t e d t h r o u g h t h e c e n t r a l
n e g o t i a t i o n of b u l k - b u y i n g c o n t r a c t s f o r some k i n d s of h o s p i t a l
supplies.
T h i s i s a l r e a d y a p p l i e d t o some o f t h e m o s t e x p e n ­
s i v e i t e m s , s u c h a s X - r a y a p p a r a t u s , a n d t h e m e r i t s of f u r t h e r
e x t e n s i o n s of c e n t r a l s u p p l y a r e b e i n g e x p l o r e d .
"10.
The C e n t r a l H e a l t h S e r v i c e s C o u n c i l h a s a s p e c i a l
committee to consider the a d m i n i s t r a t i v e s t r u c t u r e of"the
h o s p i t a l s e r v i c e , and t h a t c o m m i t t e e ' s r e p o r t i s e x p e c t e d in t h e
near future.
In a d d i t i o n , I have o u s t appointed, a f i n a n c i a l
e x p e r t , S i r C y r i l J o n e s , t o b r i n g a f r e s h mind t o b e a r a n d t o
u n d e r t a k e a p e r s o n a l and i n d e p e n d e n t e x a m i n a t i o n of t h e whole
f i n a n c i a l a d m i n i s t r a t i o n of t h e h e a l t h s e r v i c e .
I have asked
f o r h i s c o n s i d e r e d v i e w s w i t h i n t h e n e x t few m o n t h s .
With
t h e s e two e n q u i r i e s a f o o t a l r e a d y , I s h o u l d d o u b t t h e v a l u e of
i n i t i a t i n g a n y o t h e r s p e c i a l i n v e s t i g a t i o n Toy a n y new c o m m i t t e e
at t h e moment, b u t t h i s ought t o be c o n s i d e r e d a g a i n i f t h e
r e s u l t s of t h e s e p r e s e n t e n q u i r i e s p r o v e u n s a t i s f a c t o r y .
11.
On c a p i t a l e x p e n d i t u r e , o f w h i c h t h e r e i s r e l a t i v e l y
l i t t l e at- t h e m o m e n t , a i l t h e l o c a l b o d i e s e n g a g e d i n h o s p i t a l
a d m i n i s t r a t i o n a l r e a d y have t o g e t M i n i s t e r i a l a p p r o v a l t o any
w o r k of b u i l d i n g : o r c i v i l e n g i n e e r i n g c o s t i n g more t h a n
In a d d i t i o n t h e y h a v e t o s e e k M i n i s t e r i a l a u t h o r i ­
w h i c h i s of a k i n d
s a t i o n f o r a n y c a p i t a l w o r k of o v e r
w h i c h f a l l s - a s m o s t c a p i t a l w o r k s do - u n d e r P a r t I I o f t h e
S i x t h Schedule t o the Defence (General) R e g u l a t i o n s .
£10,000.
£1,000
12.
T h e s e a r e some of t h e m e a s u r e s i n h a n d , o r t o b e
p u t i n h a n d , t o i m p r o v e t h e c o n t r o l of h o s p i t a l e x p e n d i t u r e .
T h e r e a r c , of c o u r s e , m o r e d r a s t i c p o s s i b i l i t i e s .
The
t r a n s f o r m a t i o n o f t h e t r e a s u r e r s o r s e c r e t a r i e s of l o c a l
M a n a g e m e n t C o m m i t t e e s i n t o come k i n d o f " p r o t e c t e d " o f f i c e r s
of t h e M i n i s t r y h a s s o m e t i m e s b e e n s u g g e s t e d .
But t h i s would
bo a r a t h e r r e v o l u t i o n a r y c h a n g e i n t h e m a i n p r i n c i p l e s a n d
s p i r i t of t h e o r i g i n a l s c h e m e , a n d i f i t i s e v e r done i t must
e m e r g e n a t u r a l l y f r o m t h e r e c o m m e n d a t i o n s of some i n d e p e n d e n t
b o d y o r comrnitteo and n o t bo d i r e c t l y i n i t i a t e d by t h e c e n t r a l
Government - f o r i t w o u l d provoke a l o t of o u t c r y a b o u t
bureaucracy.
13B e y o n d a l l t h i s , t h e o n l y s u b s t a n t i a l and e f f e c t i v e
r e d u c t i o n i n co;::ts w o u l d l i e i n b a s i c c h a n g e s of t h e s e r v i c e
i t s e l f , s u c h a s t h e r e c o v e r y of p a r t i a l p a y m e n t s f r o m p a t i e n t s
f o r t h e i r " h o t e l " m a i n t e n a n c e i n h o s p i t a l , o r e v e n of p a y m e n t s
t o w a r d s t h e c o s t of more e x p e n s i v e a p p l i a n c e s s u p p l i e d b y t h e
hospitals.
I am s u r e t h a t s u c h c h a n g e s ( w h i c h we h a v e
p r e v i o u s l y c o n s i d e r e d a n d r e j e c t e d ) w o u l d b e open t o h e a v y a n d
l e g i t i m a t e c r i t i c i s m , a n d t h a t we c e r t a i n l y h a v e n o t r e a c h e d
t h e t i m e when t h e y m u s t b e c o n s i d e r e d .
They would a l s o have
t h e consequence t h a t s p e c i a l p r o v i s i o n would have t o be made,
t h r o u g h N a t i o n a l A s s i s t a n c e , t o meet a l l h a r d s h i p c a s e s , and
my c o l l e a g u e s a r e w e l l a w a r e o f t h e i m m e n s e amount of i r r i t a t i o n
a n d g r i e v a n c e w h i c h w o u l d a c c o m p a n y a n y s u c h r e t u r n Co t h e o l d
p r i n c i p l e s of t h e m e a n s t e s t .
14.
Allowing for a l l s e n s i b l e a d m i n i s t r a t i v e measures t o
p r e v e n t w a s t e , t h e p l a i n f a c t i s -chat t h e c o s t o f t h e h o s p i t a l
s e r v i c e not o n l y w i l l , b u t ought t o , i n c r e a s e .
Most of t h e
h o s p i t a l s f a l l f a r s h o r t of a n y p r o p e r s t a n d a r d ;
accommodation
n e e d s t o be i n c r e a s e d , p a r t i c u l a r l y f o r t u b e r c u l o s i s and m e n t a l
h e a l t h - i n d e e d some of t h e m e n t a l h o s p i t a l s a r e v e r y n e a r t o a
p u b l i c s c a n d a l a n d we a r e l u c k y t h a t t h e : / h a v e n o t s o f a r
a t t r a c t e d more l i m e l i g h t a n d - p u b l i c i t y .
Throughout the service
t h e r e a r e p i l i n g u p a r r e a r s of e s s e n t i a l c a p i t a l w o r k .
Also
i t i s i n t h i s f i e l d , p a r t i c u l a r l y , t h a t c o n s t a n t new d e v e l o p ­
ments w i l l always be needed t o keep pace w i t h r e s e a r c h p r o g r e s s
(as,
recently, in p e n i c i l l i n , streptomycin, cortisone, e t c . )
and t o expand e s s e n t i a l s p e c i a l i s t s e r v i c e s , such a s h e a r i n g ­
a i d s or the h o s p i t a l ophthalmic c e r v i c e s .
The p o s i t i o n c a n n o t
b e e v a d e d t h a t a n a t i o n a l l y owned a n d a d m i n i s t e r e d h o s p i t a l
s e r v i c e w i l l always involve a very c o n s i d e r a b l e and expanding
Exchequer outlay.
If t h a t p o s i t i o n cannot, for f i n a n c i a l
r e a s o n s , b e f a c e d , t h e n t h e o n l y a l t e r n a t i v e s ( t o my m i n d
t h o r o u g h l y u n d e s i r a b l e ) a r e e i t h e r t o g i v e up - i n whole or in
p a r t - t h e i d e a of a n a t i o n a l r e s p o n s i b i l i t y f o r t h e h o s p i t a l s
o r e l s e t o i m p o r t i n t o t h e s c h e m e come r e g u l a r s o u r c e o f r e v e n u e
s u c h a s t h e r e c o v e r y of c h a r g o a f r o m t h o s e who u s e i t .
I am
a f r a i d i t i s c l e a r t h a t we c a n n o t h a v e i t b o t h w a y s .
15These, between them, account f o r a t o t a l e x p e n d i t u r e
of a p p r o x i m a t e l y £ 1 3 9 m i l l i o n s i n t h e c u r r e n t y e a r a n d a r e
e s t i m a t e d a t a p p r o x i m a t e l y £138 m i l l i o n s f o r n e x t y e a r .
They
c o v e r t h e g e n e r a l m e d i c a l , p h a r m a c e u t i c a l , d e n t a l and o p t i c a l
services.
16.
T h e i r e x p e n d i t u r e l i e s , almost e n t i r e l y in t h e payment
of t h e d o c t o r s , c h e m i s t s , d e n t i s t s and o p t i c i a n s t a k i n g p a r t i n
t h e m a n d t h e c o o t of d r u g s a n d m a t e r i a l s s u p p l i e d b y t h e m .
The M i n i s t e r i s r e s p o n s i b l e b y s t a t u t e a n d u s e s , f o r l o c a l
a d m i n i s t r a t i o n , t h e a g e n c y of t h e 138 E x e c u t i v e C o u n c i l s .
T h e s e C o u n c i l s h a v e l i t t l e s a y , h o w e v e r , i n t h e k i n d of
expenditure i n c u r r e d , which i s mainly governed by c e n t r a l
r e g u l a t i o n s a b o u t t h e p a y m e n t of t h e v a r i o u s p r a c t i t i o n e r s .
W i t h t h e e x c e p t i o n of t h e d o c t o r s , t h e s i s e of t h e a c t u a l b i l l
i n most of t h e s e s e r v i c e s i s v e r y l a r g e l y d e t e r m i n e d b y t h e .
a m o u n t of t h e p u b l i c demand f o r , and u s e o f , t h e f a c i l i t i e s
provided.
T h e p r o b l e m of c o n t r o l i s , t h e r e f o r e , one of o r g a n ­
i s a t ion t o see t h a t t h e i r use i s r e a s o n a b l e .
17.
The g e n e r a l f e a t u r e of a l l t h e s e s e r v i c e s a t t h e
moment i s t h a t , a f t e r a p e r i o d o f c o m p l e t e u n c e r t a i n t y a s t o
t h e e x t e n t of t h e demand f o r t h e m a n d of b e w i l d e r i n g f l u c t u a ­
t i o n s i n t h a t demand, i n t h e o p e n i n g p h a s e s , t h e r e s e e m s t o b e
g o o d r e a s o n now t o h o p e t h a t t h e l e v e l of demand i s s t e a d y i n g
and t h a t t h e f u t u r e i s r e a s o n a b l y p r e d i c t a b l e .
Demand i s
p r o b a b l y s t e a d y i n g a t r a t h e r t o o h i g h a l e v e l , and c a r e f u l
a d m i n i s t r a t i o n - w i t h t h e v a r i o u s measures, about t o be
m e n t i o n e d - s h o u l d s e r v e t o l o w e r i t t o some e x t e n t .
But t h e
p e r i o d of u n e x p e c t e d " p e a k s " i s , I h o p e , c o m i n g t o an e n d .
General
Medical
Practitioners
18.
General medical services
£ 4 1 , 7 4 5 , 0 0 0 and w i l l p r o b a b l y c o s t
a t p r e s e n t c o s t some
some £ 4 2 , 7 3 4 , 0 0 0 n e x t
year.
19.
This s e r v i c e p r o b a b l y w a r r a n t s no s u b s t a n t i a l a l t e r a ­
t i o n a t t h e moment.
A d e q u a t e c o n t r o l of t h e b u l k of t h e
e x p e n d i t u r e i s s e c u r e d by t h e system under which the d o c t o r s
u n d e r t a k e a c o l l e c t i v e r e s p o n s i b i l i t y i n r e t u r n f o r a fixed,
" p o o l " of r e m u n e r a t i o n , w h i c h i s t h e n d i s t r i b u t e d among t h e m -­
t h e s h a r e of e a c h b r o a d l y d e p e n d i n g on t h e s i z e of h i s l i s t of
patients.
Whether the " p o o l " i s adequate i s a m a t t e r f o r
p e r i o d i c argument with t h e d o c t o r s ;
b u t , as long as i t i s
f i x e d , i t a u t o m a t i c a l l y g o v e r n s m o s t of t h e a n n u a l b i l l .
20.
T h e r e i s p r o b a b l y some s c o p e f o r e c o n o m y - n o t e a s y
t o a c h i e v e - i n t h e r e d u c t i o n of - u n n e c e s s a r y c e r t i f i c a t i o n o f
incapacity, e n t i t l i n g p a t i e n t s t o sickness cash benefit.
Any
s a v i n g w o u l d b e r e f l e c t e d i n t h e V o t e of t h e M i n i s t r y of
N o t i o n a l I n s u r a n c e , n o t t h a t of t h e H e a l t h S e r v i c e .
There is
no s i n g l e s o l u t i o n t o l a x c e r t i f i c a t i o n , which must be a
t e n d e n c y i n any scheme w h e r e b y p o p u l a r i t y w i t h p a t i e n t s
i n c r e a s e s l i s t s and t h e r e f o r e incomes.
The a v a i l a b l e c h e c k s
can be i n t e n s i f i e d however:
t h e y a r e ( a ) an i n c r e a s e i n t h e
n u m b e r of d o u b t f u l c a s e s r e f e r r e d b y t h e M i n i s t r y of N a t i o n a l
I n s u r a n c e t o t h e m e d i c a l o f f i c e r s of t h e M i n i s t r y of H e a l t h f o r
checking;
( b ) an I n c r e a s e i n t h e c o n t a c t s o f t h e s e m e d i c a l
o f f i c e r s w i t h d o c t o r s i n a r e a s w h e r e a b s e n t e e i s m seems t o
justify special enquiry.
S t e p s on b o t h t h e s e l i n e s a r e
already being taken.
The C h e m i s t s
and
Prescriptions
21.
The c o s t o f t h i s s e r v i c e i s now a b o u t £ 3 1 , 7 0 0 , 0 0 0
and h a s b e e n e s t i m a t e d a t ' £ 2 8 , 2 2 8 , 0 0 0 f o r n e x t y e a r .
It
c o v e r s s o m e t h i n g l i k e 2 o 2 m i l l i o n p r e s c r i p t i o n s a y e a r , an
a v e r a g e o f a b o u t 5 p e r h e a d of t h e p o p u l a t i o n .
Here t h e r e
o u g h t t o b e s c o p e f o r s a v i n g , i f ways a n d means can b e f o u n d .
W h i l e f l a g r a n t a b u s e may be t h e e x c e p t i o n , i t i s o b v i o u s t h a t
t h e r e i s more p r e s c r i b i n g t h a n can be r e a l l y n e c e s s a r y .
22.
The f i r s t a p p r o a c h i s t o t r y t o check e x p e n d i t u r e
from t h e p r e s c r i b i n g end.
h n y f u l l s c r u t i n y of a l l p r e s c r i p ­
t i o n s , b e f o r e payment, can be r u l e d out as u t t e r l y i m p r a c t i c ­
a b l e , a n d up t o now, c h e c k i n g h a s b e e n m a i n l y b y s n a p s a m p l e s
only.
T h i s i s now b e i n g s u p p l e m e n t e d .
First, a special
i n v e s t i g a t i n g u n i t i s b e i n g e s t a b l i s h e d , t o p i c k up m o r e of t h e
bad c a s e s ;
s e c o n d l y , e f f o r t s a r e b e i n g made t o i n c r e a s e t h e
n u m b e r of d i s c i p l i n a r y p r o c e e d i n g s a n d t h e p u b l i c i t y g i v e n t o
them.
23.
Within the Central Health Services Council other
steps are being taken.
A sub-committee, under t h e chairman­
s h i p of S i r H e n r y C o h e n , i s t r y i n g t o c l a s s i f y d r u g s a n d
m e d i c i n e s i n t o some b r o a d s y s t e m o f " w h i t e l i s t s " of t h o s e
w h i c h c a n a l w a y s bo f r e e l y p r e s c r i b e d , a n d o t h e r l i s t s of t h o s e
f o r -which s p e c i a l j u s t i f i c a t i o n may h a v e t o be s h o w n .
In
t h e o r y t h e r e s h o u l d be g r e a t o p p o r t u n i t i e s , i n c u t t i n g o u t
u n n e c e s s a r y e x p e n s e i n " p r o p r i e t a r y p r e p a r a t i o n s " , f o r many of
w h i c h t h e r e may bo a c h e a p e r a n d e q u a l l y e f f e c t i v e a l t e r n a t i v e .
T h e s u b j e c t i s c o m p l i c a t e d b y t h e p r e j u d i c e of d o c t o r s a g a i n s t
a n y i n t e r v e n t i o n i n t h e i r c l i n i c a l j u d g m e n t of t h e i r p a t i e n t s '
needs;
b u t i t i s c l e a r t h a t no e f f o r t o u g h t t o b e s p a r e d t o
g e t from t h i s p r o f e s s i o n a l c o m m i t t e e t h e utmost p o s s i b l e
b a c k i n g on w h i c h t o b a s e m o r e r e s t r i c t i v e r e g u l a t i o n s .
21+.
The s e c o n d a p p r o a c h i s t o t r y t o c u t c o s t s a t t h e
d i s p e n s i n g end.
C h e m i s t s a r e p a i d t h e c o s t of t h e d r u g s p r e ­
s c r l b e d , p l u s a d i s p e n s i n g f e e f o r e a c h p r e s c r i p t i o n and p l u s
"on-cost" allowances for t h e i r business overheads.
This
s h o u l d n o t i n c r e a s e i n e x a c t p r o p o r t i o n t o t h e g r e a t n u m b e r of
p r e s c r i p t i o n s now b e i n g d i s p e n s e d .
A case i s , t h e r e f o r e , to
be p u t t o t h e W h i t l e y C o u n c i l f o r a r e d u c t i o n in t h e a l l o w a n c e .
25.
The c o s t of d r u g s h a s t o be a p p r o a c h e d a t t h e s u p p l y
end.
N u m e r o u s m i n o r a d j u s t m e n t s a r e a l r e a d y g o i n g on t o
r e d u c e w a s t e , s u c h a s t h e b e t t e r s u i t i n g of t h e s i a e of
m a n u f a c t u r e r s ' p a c k e t s t o t h e n o r m a l n e e d s of t h e s e r v i c e ;
t h e u s e of r e a s o n a b l e b u l k p r e s c r i b i n g i n c a s e s , such as
s c h o o l s or o t h e r i n s t i t u t i o n s , where t h e r e i s a c o n v e n i e n t l y
grouped need;
t h e p o s s i b i l i t i e s of s t o c k i n g d o c t o r s ' s u r g e r i e s
w i t h , some of t h e m a t e r i a l s m o r e o f t e n r e q u i r e d i n s m a l l a m o u n t s
( t o save p r e s c r i b i n g s e p a r a t e packages f o r each p a t i e n t ) .
26.
When t h i s s e r v i c e w a s l a s t c o n s i d e r e d i t w a s d e c i d e d ­
and a n n o u n c e d - t h a t a c h a r g e n o t e x c e e d i n g 1 / - w o u l d be
r e c o v e r e d from t h e p a t i e n t f o r e a c h p r e s c r i p t i o n .
Powers were
o b t a i n e d in t h e amending B i l l ,
B u t , a s s o o n a s m e t h o d s of
g i v i n g e f f e c t t o t h i s were c o n s i d e r e d in d e t a i l , i t became
m a n i f e s t t h a t i t was f a r more c o m p l i c a t e d t h a n was a t f i r s t
t h o u g h t , b e c a u s e i t w o u l d a t once i n v o l v e e l a b o r a t e m a c h i n e r y
f o r t h e e x e m p t i o n o f w h o l e c l a s s e s of p a t i e n t ( s u c h a s
p e n s i o n e r s ) a n d b e c a u s e , when a l l t h e f a c t o r s w e r e t a k e n i n t o
a c c o u n t , t h e e s t i m a t e d s a v i n g w o u l d b e r e d u c e d f r o m some £10
m i l l i o n s t o some £ 5 - 6 m i l l i o n s .
M o r e o v e r , i n my own v i e w ,
i t would be i n d e f e n s i b l e t o i n t r o d u c e t h e p r i n c i p l e of c h a r g e s
f o r b e n e f i t s i n t o a " f r e e " h e a l t h s e r v i c e i n t h i s one l i m i t e d
b r a n c h , of t h e s e r v i c e a l o n e .
If t h e p r i n c i p l e of c h a r g e s were
t o b e a c c e p t e d . , w h i c h I. am s u r e w o u l d b e - p o l i t i c a l l y u n w i s e , i t
s h o u l d on m e r i t s a p p l y t o o t h e r b r a n c h e s of t h e s e r v i c e a t l e a s t
a s much a s t o t h i s , a n d t h e r e w o u l d b e n o p o s s i b l e j u s t i f i c a t i o n
f o r u p s e t t i n g t h e w h o l e main p r i n c i p l e of a c o m p r e h e n s i v e
"free ' service for t h i s r e l a t i v e l y p a l t r y saving.
Moreover,
i n t h i s p a r t i c u l a r f i e l d , I am s u r e t h a t we s h o u l d d o b e t t e r t o
r e l y u p o n t h e m e t h o d of c o n t r o l l i n g p r e s c r i b i n g m e n t i o n e d i n
p a r a g r a p h 23 t h a n t o a d o p t t h i s b a s i c c h a n g e i n t h e s e r v i c e .
J t h e r e f o r e s u g g e s t t h a t " w e s h o u l d a t l e a s t d e f e r a c t i o n on
this decision for the present.
1
General
dental
service
27.
T h e c o s t o f t h i s s e r v i c e i s now a b o u t £ 2 + 3 m i l l i o n s a
y e a r , a n d i s e s t i m a t e d a t £ki'S
millions for next year.
The
d e n t i s t i s p a i d on t h e b a s i s o f a s c a l e of f e e s f o r e a c h k i n d
o f i t e m of s e r v i c e c a r r i e d o u t - e x t r a c t i o n s , d e n t u r e s , f i l l i n g s
and t h e l i k e .
He s u b m i t s h i s c l a i m , f o r t h e w o r k h e c o n s i d e r s
n e c e s s a r y , t o a Dental E s t i m a t e s Board for approval - a f t e r t h e
e v e n t i n m o s t c a s e s , b e f o r e i t i n t h o s e c a s e s w h e r e some p r i o r
c h e c k i s n e e d e d b e f o r e he i s a l l o w e d t o b e g i n .
If t h e Board
doubt t h e n e c e s s i t y i n any c a s e , t h e y r e f e r i t t o t h e D e p a r t ­
m e n t ' s d e n t a l o f f i c e r s , who i n v e s t i g a t e a n d a d v i s e w h e t h e r t h e
work i s n e c e s s a r y .
When t h e y a p p r o v e t h e w o r k , t h e d e n t i s t i s
paid.
28.
T h u s , c o n t r o l of t h e v a l i d i t y of e x p e n d i t u r e h e r e
d e p e n d s on t h e e f f i c i e n t w o r k o f t h e D e n t a l E s t i m a t e s B o a r d .
Here t h e r e has been a d i f f i c u l t y .
A l t h o u g h m o s t of t h e g e n e r a l
s o r t i n g o u t of c l a i m s i s d o n e , a n d c a n . b e d o n e , b y a l a y
c l e r i c a l s t a f f , t h e p i n - p o i n t i n g of d o u b t f u l c a s e s must r e s t
u p o n p r o f e s s i o n a l d e n t a l a d v i s e r s - t o whom a l l p r i m a f a c i e
c a s e s of d o u b t s h o u l d b e r e f e r r e d .
T h e B o a r d n e e d some 12 o r
16 d e n t a l a d v i s e r s f o r t h i s w o r k , b a c k e d b y an e f f e c t i v e t e a m
of D e p a r t m e n t a l d e n t a l o f f i c e r s .
They have a t p r e s e n t o n l y 3 ,
while t h e Department's d e n t a l s t a f f i s a l s o under s t r e n g t h .
T h e r e a s o n i s t h a t t h e a u t h o r i s e d s c a l e s of p a y f o r t h e s e
o f f i c e r s not only w i l l not a t t r a c t r e c r u i t s but a c t u a l l y leads
t o a p r o g r e s s i v e l o s s of e x i s t i n g o f f i c e r s .
If reasonable
i n c r e a s e s i n t h e a u t h o r i s e d s c a l e s w e r e a d o p t e d now, t h e s a v i n g
t o t h e E x c h e q u e r i n t e r r a s of q u e r i e d c l a i m s a n d r e s u l t i n g c u t s
i n c l a i m s ' - w o u l d , on a l l t h e e v i d e n c e , a m p l y o u t w e i g h t h e s l i g h t
e x t r a c o s t in s a l a r i e s .
T h i s i s now b e f o r e t h e T r e a s u r y f o r
a p p r o v a l , a n d t h e u r g e n c y of a l l o w i n g t h e s e i n c r e a s e s c a n n o t b e
ove r - e m p h a s i s e d .
29.
T h e r e i s a l s o a good c a s e f o r i n c r e a s i n g t h e number
of D e n t a l S e r v i c e s C o m m i t t e e s , which e x i s t t o i n v e s t i g a t e
c o m p l a i n t s f o r d i s c i p l i n a r y a c t i o n a g a j . n e t d e n t i s t s who a b u s e
T h e b e s t p r e v e n t i v e of a b u s e i s p r o m p t d i s c i p l i n a r y
t h e scheme.
This i s already under
a c t i o n , and p u b l i c i t y t o t h a t a c t i o n .
discussion with the profession itself.
30.
An i n v e s t i g a t i o n i s a l s o i n p r o g r e s s i n t o t h e p r e s e n t
wholesale charges f o r dental m a t e r i a l s , under the M i n i s t r y ' s
S u p p l i e s D i v i s i o n , and t h e q u e s t i o n of a l l d e n t a l m a t e r i a l s ,
a p p a r a t u s , and. e q u i p m e n t i s now b e f o r e t h e M o n o p o l i e s a n d
R e s t r i c t i v e P r a c t i c e s Commission.
31.
T h e r e h a s a l r e a d y b e e n one s u b s t a n t i a l c u t i n t h e
d e n t i s t s ' remuneration.
A recent -enquiry by a special
C o m m i t t e e , t h e "Penman C o m m i t t e e " , now y i e l d s f u r t h e r e v i d e n c e
f o r p r e s s i n g a r e d u c t i o n of a n y t h i n g u p t o 6% i n t h e p r e s e n t
f e e s , v/hile another proposed i n v e s t i g a t i o n i n t o the average
p r o p o r t i o n t o be allowed f o r p r a c t i c e expenses in paying t h e
d e n t i s t s may j u s t i f y some f u r t h e r c u t i n t h e p r e s e n t a r r a n g e ­
ments.
B o t h of t h e s e o p p o r t u n i t i e s a r e a l r e a d y b e i n g f u l l y
explored.
-6­
32.
Beyond t h i s , t h e r e seem t o be no o t h e r l i k e l y f i e l d s
f o r s a v i n g s i n t h i s p a r t of t h e scheme u n l e s s m o r e d r a s t i c
c h a n g e s - i n v o l v i n g t h e i m p o s i t i o n of p a r t i a l c h a r g e s f o r t h e
s e r v i c e t o p a t i e n t s - a r e t o be adopted.
T h e s e a r e open t o
t h e s t r o n g o b j e c t i o n s a l r e a d y m e n t i o n e d i n p a r a g r a p h 1 2 , and
I s h o u l d d e p r e c a t e a n y s u c h b a s i c a l t e r a t i o n of t h e w h o l e
p r i n c i p l e o f t h e h e a l t h s e r v i c e on t h e e v i d e n c e o f t h e s e e a r l y ,
a n d u n r e l i a b l e , e x p e r i e n c e s of i t s w o r k i n g .
33.
A l o n g e r t e r m m e a s u r e f o r r e l i e f of t h e c o s t of t h e
d e n t a l s e r v i c e l i e s i n more i n t e n s i v e r e s e a r c h i n t o t h e
p r e v e n t i o n o f d e n t a l c a r i e s , b y new m e t h o d s o f u s i n g f l u o r i d e s
a n d t h e f l u o r i n a t i o n of w a t e r s u p p l i e s .
This is being pursued
b o t h by e x p e r i m e n t i n t h i s c o u n t r y and by e n q u i r i e s a b r o a d .
O p t i c i a n s and
spectacles
34.
This i s
Service, intended
t o a h o s p i t a l and
i s a l i t t l e under
£25 k
millions for
:
35.
tibn
cost
w h a t i s known a s t h e S u p p l e m e n t a r y O p h t h a l m i c
u l t i m a t e l y ( a l o n g t i m e h e n c e ) t o g i v e way
s p e c i a l i s t eye s e r v i c e .
I t s present cost
£23 m i l l i o n s a y e a r and i s e s t i m a t e d a t a b o u t
next year.
1
5 5
There are t h r e e elements in t h e opt in c ions
remunera­
- f e e s f o r s i g h t - t e s t i n g , f e e s f o r d i s p e n s i n g , and t h e
of t h e m a t e r i a l s ( s p e c t a c l e f r a m e s a n d l e n s e s / s u p p l i e d .
36.
Sight t e s t i n g f e e s have a l r e a d y been cut once,
on t h e w h o l e t h e r e i s p r o b a b l y n o t much c a s e f o r s e e k i n g
justify further reduction.
and
to
37*
D i s p e n s i n g f e e s do o f f e r something l i k e t h e " o v e r ­
h e a d s " - p o i n t w h i c h a r i s e s w i t h t h e c h e m i s t s - 1 . e . , t h e r e may
be a c a s e f o r e s t a b l i s h i n g t h a t o v e r h e a d s s h o u l d n o t i n c r e a s e
i n a u t o m a t i c - p r o p o r t i o n t o t h e n u m b e r of d i s p e n s i n g s u n d e r t a k e n . .
T h i s i s u n d e r i n v e s t i g a t i o n how.
36.
C o s t of m a t e r i a l s i s s o m e t h i n g t o b e w a t c h e d , b u t
l i t t l e c h a n c e of a d r o p c a n be f o r e s e e n y e t , u n l e s s t h e f u t u r e
o v e r t a k i n g of demand by o u t p u t ( e s t i m a t e d t o o c c u r a b o u t m i d ­
s u m m e r , 1 9 5 0 ) p r o d u c e s a m o r e f a v o u r a b l e f i e l d fore c o m p e t i t i v e
c u t t i n g b y manuf a c t u r e r s .
39E x p e r i e n c e h a s shown t h a t more c a n p r o b a b l y b e d o n e
t o f o l l o w u p s u s p e c t e d c a s e s of u n n e c e s s a r y p r e s c r i b i n g , w i t h
more d i s c i p l i n a r y a c t i o n a g a i n s t t h e o p t i c i a n , and t h e r e c o u l d
be b e t t e r m a c h i n e r y f o r d i s c o v e r i n g and c h e c k i n g t h e o b t a i n i n g
of d u p l i c a t e s i g h t t e s t s , d u p l i c a t e s p e c t a c l e s and u n n e c e s s a r y
free repairs.
This w i l l be undertaken t o whatever extent
proves practicable.
4-0.
Beyond t h i s , as w i t h t h e d e n t i s t s and t h e c h e m i s t s ,
t h e o n l y s u b s t a n t i a l c u t i n t h e p r e s e n t c o s t of t h i s s e r v i c e
w o u l d l i e i n i m p o s i n g u p o n t h e p a t i e n t some p a r t - p a y m e n t
t o w a r d s t h e c o s t o f t h e s p e c t a c l e s w h i c h he o b t a i n s .
This is
o p e n t o t h e g e n e r a l , a n d i n my v i e w o v e r w h e l m i n g , o b j e c t i o n
t o a b a s i c a l t e r a t i o n i n t h e m a i n p r i n c i p l e s of t h e
t h i s s t a g e of o u r r a t h e r u n r e l i a b l e e x p e r i e n c e .
Local Health Authority
Services
l+L
The c h i e f r e m a i n i n g pieces o f - t h e - H e a l t h S e r v i c e a r e
t h o s e i n t h e h a n d s of t h e L o c a l H e a l t h A u t h o r i t i e s - m a t e r n i t y
find c h i l d : w e l f a r e , home n u r s i n g a n d m i d w i f e r y , home d o m e s t i c
h e l p s i n s i c k n e s s , a m b u l a n c e s , v a c c i n a t i o n and i m m u n i s a t i o n ,
a f t e r - c a r e , t h e p r o v i s i o n of b u i l d i n g s f o r h e a l t h c e n t r e s .
T h e s e a r e trie o n l y p i e c e s w h i c h a r e n o t a t o t a l E x c h e q u e r
c h a r g e , a l t h o u g h t h e E x c h e q u e r m e e t s 50'/o of t h e i r c o s t i n
*c
Opticians
are
referred, to
thro
^opticM^
tafcej a s ^ r e
d i s p e h s i n g o r p r o v f s i on o f " o p e c t a
1
b
grant. Their total is not, relatively, very large - some
£30 millions a year - and on the whole the need is more for
further development than for retrenchment. There is no
obvious field for economy, or for drastic administrative
changes.
1+2.
There i s probably room for more effort to check
unnecessary use of the free ambulance services. This is in
hand up to a point, hospital authorities being asked to
scrutinise more c r i t i c a l l y the way calls for ambulances and
hospital cars are now often being exploited. There may be
opportunity to do something more here. Also, there may be
room for increasing charges made for the use of day nurseries
(charges at present are confined to food and articles supplied)
But this kind of modification is t r i v i a l in relation to the
major costs of the Health Service generally.
1+3.
Domiciliary nursing services, especially midwifery,
are relatively cheaper than their corresponding institutional
services. Whether there i s room for greater emphasis on, and
development of, domiciliary confinements and their related
services needs considering with appropriate professional
advice.
kk*
Broadly, however, these services seem to l i e in a
field in which any drastic reorganisation would certainly not
be justified on present merits.
The General picture
is the general picture. The biggest item
hiof expenditure
Thi inthen,
the health service l i e s in the hospital and
specialist service. Here, the inevitable and proper conse­
rjuence of making the service a national responsibility i s that
we must face a substantial and increasing charge on the
Exchequer. It has to be emphasised that at present the increases
in cost in running the hospital service are matched in the
experience of other comparable countries and are certainly not
attributable merely to the fact of the Rational Health Service
in t!iis country. The future burden of administration l i e s , in
this part of the service, in ensuring that development, year by
year, does not extravagantly exceed what i s proper and inevitable.
It is certainly not true that the cost of the hospital service
i s uncontrolled. It would have been, and i s , perfectly easy to
cut this service's expenditure at any time, to any level, but
only if the resulting situation i s also accepted - that people
needing treatment must be turned away, beds closed and the
service curtailed. Unless that situation i s to be accepted, the
graph of hospital expenditure must tend to be a rising one; the
job of administration is to see that the rate of i t s climb is
reasonable against the background of the national situation as
a v/hole.
1+6.
The next biggest item i s in the general medical,
pharmaceutical, dental and optical services. Here the problem
so far has been different in kind. It has been mainly one of
unpredictable demand by the public. It seems, on our present
information, to be levelling out now so that we know better
where we stand for the future. . It looks as though we now can
be fairly confident of the rate at which these services w i l l
run. There i s good hope of reducing that rate.
1+7.
The local health authority services arc a relatively
minor part of the scheme. Apart from any possible future
development of Health Centres, they seem to be already levelled
out and to present no major problems of control.
- o ­
2+8.
On t h i s p i c t u r e , t h e s e n s i b l e c o u r s e s e e m s t o b e t o
c o n c e n t r a t e on t h e k i n d s of a d m i n i s t r a t i v e c o n t r o l w h i c h h a v e
been d e s c r i b e d .
To s l a s h t h e h e a l t h s e r v i c e now b y c u r t a i l i n g
b e n e f i t o r b y i m p o r t i n g t h e p r i n c i p l e of" c h a r g e s t o p a t i e n t s
c o u l d / . s c a r c e l y b e j u s t i f i e d a t t h i s v e r y e a r l y s t a g e of t h e
e v o l u t i o n of t h e s e r v i c e - b e a r i n g i n m i n d b o t h t h e e v i d e n c e ­
that the abuses n a t u r a l to the public s f i r s t enthusiasm for
getting a l l the benefits available are already levelling out,
a n d a l s o t h e v i t a l p s y c h o l o g i c a l e f f e c t ( n o t o n l y a t home b u t
i n a l m o s t a l l c o u n t r i e s o v e r s e a s ) of t h e a d m i s s i o n of f a i l u r e
w h i c h s e r i o u s - a m e n d m e n t of t h e scheme a t t h i s s t a g e w o u l d
imply.
N o r w o u l d t h i s k i n d of c u t t i n g c o n s t i t u t e a n y t r u e
e c o n o m y , b u t o n l y a t r a n s f e r of p a r t of t h e b u r d e n b a c k f r o m
the public to the private purse.
I f t h e c o u r s e of t h e . s e r v i c e
can b e h e l d s t e a d y a t t h i s s t a g e , t h e r e seems e v e r y c h a n c e t h a t
t h e r e w i l l b e much c a l m e r w a t e r a h e a d , and an a m b i t i o u s s o c i a l
a d v e n t u r e w i l l b e f o u n d t o have been amply j u s t i f i e d .
It is,
in s h o r t , too e a r l y to. p a n i c ;
n o r i s t h e r e any good c a u s e t o
do s o .
!
49*
T h e r e i s n o d o u b t t h a t t h e a t m o s p h e r e of o p i n i o n
about t h e h e a l t h s e r v i c e has been u n f o r t u n a t e l y c h a r g e d by t h e
f a c t t h a t i t h a d - . u n a v o i d a b l y - i n i t s o p e n i n g s t a g e s t o show
three sharp Increases in i t s estimated c o s t s .
A s we k n o w ,
t h i s was due t o t h e a l m o s t c o m p l e t e i m p o s s i b i l i t y of m e a s u r i n g
in a d v a n c e t h e b e h a v i o u r p a t t e r n of t h e p u b l i c i n u s i n g i t .
We o r e now g e t t i n g o v e r t h a t s t a g e , a n d t h e p r o c e s s of
e s t i m a t i n g can become more and more r e l i a b l e a s our e x p e r i e n c e
grows.
50.
If t h e g e n e r a l d e c i s i o n s about the s e r v i c e are t o be
a s I h a v e s u g g e s t e d i n t h i s p a p e r , I c a n i n s t r u c t my D e p a r t - - ­
merit a c c o r d i n g l y a n d we c a n c o n c e n t r a t e now on a l l t h e d e t a i l e d
m e a s u r e s which, I have d e s c r i b e d - w i t h any o t h e r s w h i c h , from
d a y t o d a y , p r e s e n t t h e m s e l v e s i n t h e o r d i n a r y c o u r s e of
ad n u n i s t r a t i o n .
51.
F o r c o n v e n i e n c e , t h e k i n d s of d e t a i l e d a d m i n i s t r a t i v e
m e a s u r e a l r e a d y b e i n g a d o p t e d o r p r o p o s e d t o be a d o p t e d I n
t h i s p a p e r can be s u m m a r i s e d as f o l l o w s : ­
(1)
Hospital
Service.
(a)
More d e t a i l e d e x a m i n a t i o n of l o c a l M a n a g e m e n t
Committee b u d g e t s by Regional h o a r d s , the
B e a r d s ' t o t a l b u d g e t s then b e i n g examined by t h e
Minister (already arranged.).
(b)
Better hospital costing, enabling
a p p a r e n t e x t r a v a g a n c e t o be more e a s i l y d e t e c t e d
i n t h e e x a m i n a t i o n of b u d g e t s ( a l r e a d y u n d e r w a y ) .
(c)
R e g u l a t i o n of h o s p i t a l s t a f f e s t a b l i s h m e n t s b y
ad h o c e n q u i r y a t e a c h i n d i v i d u a l h o s p i t a l , s u b ­
sequent increases requiring special approval.
(d)
E x t e n s i o n , as t h e f a c t s a r e found t o j u s t i f y i t ,
of c e n t r a l n e g o t i a t i o n of b u l k - b u y i n g c o n t r a c t s
f o r h o s p i t a l * s upp l i e s .
(e)
C o n s i d e r a t i o n of t h e r e p o r t of t h e c o m m i t t e e on
h o s p i t a l a d m i n i s t r a t i o n of t h e C e n t r a l H e a l t h .
Services Council (expected shortly).
(f)
P r o s e c u t i o n of a s p e c i a l e n q u i r y i n t o t h e f i n a n c e
of t h e h e a l t h s e r v i c e ( i n c l u d i n g h o s p i t a l s ) b y
Sir C y r i l Jones ( r e c e n t l y appointed for t h a t
purpose).
;
2
( )
(g)
C o n t i n u e d c o n t r o l of
hospitals. ­
(h)
A f u r t h e r s p e c i a l e n q u i r y b y a new c o m m i t t e e on
hospital service administration, if the facts
are found t o w a r r a n t i t .
General P r a c t i t ionery
(i)
(iv)
Services.
More a c t i o n , w i t h t h e M i n i s t r y of N a t i o n a l
Insurance, to avert unnecessary certification
for sickness benefit, with special a t t e n t i o n to
a r e a s of a p p a r e n t l y u n d u e a b s e n t e e i s m ( a l r e a d y
under way).
Chemists.
(a)
S p e c i a l i n v e s t i g a t i o n t o p i c k up b a d c a s e s of
o v e r - p r e s c r i b i n g b y d o c t o r s , w i t h more d i s c i p l i n ­
a r y p r o c e e d i n g s and p u b l i c i t y f o r them ( a l r e a d y
under way).
(b)
C l a s s i f i c a t i o n of d r u g s , w i t h t h e b a c k i n g o f a
p r o f e s s i o n a l committee, for "white l i s t " f o r
p r e s c r i b i n g , w i t h o t h e r s on l i s t s f o r p r e s c r i b ­
i n g o n l y u n d e r r i s k of h a v i n g t o show j u s t i f i c a ­
t i o n - p a r t i c u l a r l y i n t h e c a s e of " p r o p r i e t a r i e s '
w h e r e a" c h e a p e r a l t e r n a t i v e e x i s t s ( a w a i t i n g
r e p o r t of t h e p r o f e s s i o n a l c o m m i t t e e ) .
(c)
Cuts in t h e amounts p a y a b l e f o r " o n e c o s t "
overheads for chemists (case being p r e p a r e d
Whit l e y C o u n c i l ) .
(d)
(iii)
by
Doctors.
(a)
(ii)
capital expenditure
for
Various d e t a i l e d measures t o reduce cost of
d r u g s a t t h e s u p p l y end ( a l r e a d y p r o c e e d i n g ) .
Dentists.
(a)
Better pay for dental advisers for the Dental
E s t i m a t e s B o a r d and f o r d e n t a l o f f i c e r s of t h e
Department t o f a c i l i t a t e r e c r u i t m e n t and t h e r e ­
f o r e e n a b l e m o r e " q u e r i e d " c a s e s of d e n t i s t s '
c l a i m s t o be i n v e s t i g a t e d ( b e f o r e T r e a s u r y n o w ) .
(b)
I n c r e a s e i n number of d i s c i p l i n a r y c o m m i t t e e s f o r
h a n d l i n g c o m p l a i n t s of a b u s e b y d e n t i s t s ( a l r e a d y
under d i s c u s s i o n with the p r o f e s s i o n ) .
(c)
More i n v e s t i g a t i o n of w h o l e s a l e c h a r g e s
d e n t a l m a t e r i a l s ( a l r e a d y under way).
(d)
Move f o r a r e d u c t i o n i n d e n t a l f e e s , i n t h e l i g h t
of t h e Penman C o m m i t t e e r e p o r t , a n d a l s o an
i n v e s t i g a t i o n of t h e " p r a c t i c e e x p e n s e s " e l e m e n t
in d e n t i s t s ' pay ( a l r e a d y under way).
Optical
(a)
for
service.
Investigation into present rates paid for
"overheads" in the o p t i c i a n s ' remuneration
( u n d e r r e v i e w now).
(3)
(b)
W a t c h on t h e c o s t of s u p p l y m a t e r i a l s ,
e s p e c i a l l y when s u p p l y b e g i n s t o o v e r t a k e
demand.
(c)
More a c t i o n t o f o l l o w u p s u s p e c t e d e x c e s s i v e
p r e s c r i b i n g , and f o r c h e c k i n g abuse by
d u p l i c a t e e y e t e s t s a n d s u p p l y of s p e c t a c l e s .
Local Health A u t h o r i t y
Services.
(a)
F u r t h e r e f f o r t t o reduce u n n e c e s s a r y use
the free ambulance s e r v i c e .
(b)
I n v e s t i g a t i o n a s t o t h e d e s i r a b i l i t y of
i n c r e a s i n g t h e d e v e l o p m e n t of d o r n i c i l a r y
n u r s i n g and midwifery s e r v i c e s , in r e l i e f
t h e demand on h o s p i t a l s .
A. B.
M i n i s t r y of H e a l t h ,
S. W. 1 ,
10TH MARCH, 1 9 5 0 .
of
of