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THE LANCET

The Royal CommissionIN London last week copies of the newly pub-

lished report of the Royal Commission on theNational Health Service were hard to find. Maybethose available had all been bought up by visitorsfrom other countries anxious to find lessons fortheir own health-care systems in- this impressivesaga of the N.H.S.’s experiences, successes, woes,and prospects. We included in our last issue (p.142) some of the Commission’s conclusions andrecommendations. On later pages this week werecord some first reactions from several quarters.

FINANCING

In keeping with the less than enthusiastic wordsfrom the Government (see p. 212), a common firstresponse has been: that’s all very well; maybe the.H.S. is not as groggy as some of us thought-butwhere is the money to come from if the graver defi-ciencies are to be remedied, not to speak of theexpansions manifestly desirable in many areas?The Commission (rightly in The Lancet’s view)concludes that the great bulk of the N.H.S.’s

money should continue to be raised by taxationrather than by charges or by insurance. Parliamentand people must determine how much the nationcan afford. Perhaps, after all, the people would beprepared to pay more if the tax was separatelyidentified as support for the N.H.S.-a questionwhich has never been put to them. In the interna-

tionalleague table of percentages of gross domesticproduct devoted to health care, the United King-dom is lowly placed. Though many doubts can bepresented about the reliability of such comparisons,few countries are ’as bothered as Britain is becauseit fears it may not be spending enough on health,for cure or for prevention: elsewhere it is often thenormity of the bill which is the prime complaint.In Western Europe and North America, for

:xample, insurance schemes are the customaryinancial base for protection against the costs of1ickness; and they have become increasingly expen-

and open to criticism. Such schemes evolved inTany varieties and packages of voluntary and com-pulsory combinations, in response to local tradi-

needs, and pressures. In concluding that the; K. should not turn back from its momentous de-: on in 1946 to establish an Exchequer-financedi

service, the Commissioners recognised that, thoughthe benefits of introducing the insurance marketplace into the N.H.S. could well be real, the dis-advantages would be serious. Over 60% of presentN.H.S. expenditure is devoted to the care of elderlypeople, children, and the mentally and physicallyhandicapped. The,citizens whose need for medicalcare may be greater than most and who are toopoor to pay substantial premiums suffer under in-surance financing. Government support can sus-tain them with some basic level of care; but if a

range of benefits is offered according to ability topay the richer members of the community derive alarger share of resources than they are reasonablyentitled to. If a choice of insurance and a lavishextension of private practice should emerge, one ofthe objectives of the N.H.S.—equality of entitle-ment to health services-would be utterly lost. TheCommission states: "The introduction of an insur-ance system would incorporate into the N.H.S. anew principle, namely that a different standard ofhealth care under the N.H.S. was available to thosewho chose to pay for it. Some may feel such a

change to be desirable, but at least it should be

clearly recognised for what it is." Another substan-tial flaw (often overlooked) in an insurance-basedservice is the high cost and complexity of its admin-istration, compared with the directness of paymentvia personal and other forms of taxation.

Thus, the Commission’s judgement on the insur-ance argument puts financing back where it began-as a decision to be taken by the Government andits advisers. And no Government, Conservative orLabour, has ever been able to justify to itself anylarge expansion in N.H.S. spending to meet rapidlymounting claims from a populace well aware ofwhat Medicine can or might provide. What, then,of supplementary money for the N.H.S.-from-

charges to patients, from local voluntary funding,from the popular and daringly non-British sugges-tion of a lottery? Charges to N.H.S. patients atpresent produce about £125 million a year (about1.6% of the cost of the N.H.S.): half of this sumcomes from dental charges and about a quartereach from charges for prescriptions (before therecent increase) and ophthalmic services. Amongthe new charges which have been proposed are"hotel" payments for non-medical services in hos-

pitals and charges for visits to hospital accidentand emergency departments and for consultationswith general practitioners. The accumulated in-come from all these items (if continued, raised, oradopted) would be considerable and, the reportmaintains, "would probably lead to a reduction infunds made available from the Exchequer". Inother words, more and higher charges might notbenefit an underfinanced N.H.S., though theywould transfer some of the cost from the taxpayerto the patient. Would they discourage patients from

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using the N.H.S.? The Commissioners are not

attracted by the case for charges as deterrents : ’

"... the patient does not become a major user of N.H.S.resources until he becomes a hospital patient, and he becomesa particularly large user if he is admitted as an in-patient. Ingeneral, to be admitted as an in-patient requires not only thewillingness of the patient himself but also the clinical judge-ment of at least two doctors. It follows that there can be littleabuse of hospital resources by patients, and that if incentivesand disincentives are to have a major effect on the use of hospi-tal resources then they must be offered to doctors and not topatients. This does not apply to visits to G.P.s, but would theextra administrative costs and inconveniences of charges becompensated for by keeping away from G.P.S those whodemand his service frivolously? We doubt it, and we would beuneasy that it could well discourage patients from seeking helpwhen they really need it".Doctors are therefore reminded all too plainly ofthe powerful influence of their decisions on the costof the N.H.S. As for local voluntary fund-raising,the report welcomes any extension of these efforts,though they are unlikely to add significantly toN.H.S. funds; and the more glamorous causes,such as new buildings or expensive equipment, arenot always those for which the need is greatest.Moreover, such enterprises can lead to the commit-tal of N.H.S. revenue more urgently needed else-where. Nor is the Commission keen on a lottery, anunreliable and expensive way of collecting a rela-tively small sum of money for the N.H.S.

In the end, therefore, everything comes back tothe Treasury and the taxpayer-which is the wisedecision, though it leaves unresolved the oppressivequestion of "how much?" A medical witness givingevidence to the Commissioners declared "we caneasily spend the whole of the gross national pro-duct". They had no difficulty in believing him,and, disappointingly, make no attempt to estimatewhat extra might be needed to boost a good serviceinto a first-class one. Since the report was written,the new Government’s plans have demonstratedthat the N.H.S. is going to feel the pinch, despiteassurances (from the Prime Minister, among others)that it would be sheltered from the sharper cuts inpublic spending. As protests mount again aboutthreatened hospital closures and other setbacks, thereport can offer little comfort to those afflicted,except perhaps in its passages which advocate moreskilful and provident use of resources and greaterfinancial awareness among decision-makers.

Though the Commission has praise for N.H.S. ad-ministrators (a compliment they receive much toorarely) and pronounces that the N.H.S. gives goodvalue for money, the report’s most telling quotationon finance comes from the body representingregional administrators in England:

"The National Health Service has become accustomed

throughout the 25 years preceding reorganisation to the pros-pect of continual growth in the financial resources availableto it. Though agreeable, the result has been to allow slack

1. See Lancet, July 21, 1979, p. 159.

nanagement, with no incentive to examine obsolete patterns of,pending, or to develop a coherent plan for the future."

ORGANISATION AND MANAGEMENT

Our contributors (p. 208) and our parliamentarycorrespondent (p. 212) have much to say aboutfinancing (Mr SELDON is in splendid voice) andmany other aspects of the report. The Lancet willrefer this week to only one more of the principalthemes-the organisation and management of theN.H.S. They were forecast for another gentle shake-up at the Commission’s hands; and the tips wereaccurate. The proposed Select Committee is to dealwith policy and leave local affairs to be handledlocally. But just how will it exert its control? TheCommissioners are opposed to the transfer of theN.H.S. to local government; and they do not advo-cate (as many have done before them) the creationof a Health Commission as a buffer betweenN.H.S. and Government. They are, however, allfor devolving power from the Secretary of Stateand the D.H.S.S. to regional health authorities inEngland, making the authorities accountable toParliament. But just how? Such devolution hasdrawn criticism on the grounds that it could creategreater unevenness in the N.H.S., especially in

manpower policies, which are only briefly discussedin the report. The report puts an undeniable casefor monitoring the quality of service, though MrsROBINSON (p. 211) finds the recommendations toolily-livered in their application to standards in

general practice. The proposed abolition of family-practitioner committees has met prompt opposi-tion. An effective structure here is particularlyvital, since general-practice costs are unrestrictedexcept by practitioners’ actions. The report favoursa limited list of prescribable drugs. Many will agreethat the labyrinth of advisory committees repre-sents democracy run mad. The expected recom-mendation for slimming the administrative struc-ture is qualified by the assertion that the N.H.S,must get hospital management right: that is muchmore important than creating or destroying tiers.Again, power must come away from the centre andmove towards the periphery. The objectives mustbe: local machinery for decision taking; good hospi-tal management; and all this within the frameworkof a national policy. The Commission believes thatthese aims will best be achieved by dividing theN.H.S. structure into two-planning and deliveryRegional health authorities should be planningbodies; and the second tier, for the delivery of ser,vices, should be constructed, according to localneeds, from the present areas and districts.

REFORM NOT REVOLUTION

When Sir ALEC MERRISON, chairman of the

Commission, declared that its views did not consti

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tute a political report, disbelief was to be heard.How on earth could the Conservative Governmenttake kindly to many of the recommendations whichwere so vigorous an echo of ANEURIN BEVAN? Thereport has been unfairly condemned2 as just thestuff to be expected from a Commission appointedby a Labour Government. Sir ALEC and his col-leagues have ably performed the first comprehen-sive review of the N.H.S. since it began; and,though they admit they have been unable to

emerge with any blinding revelation by which totransform all deficiencies into perfection, their for-mula of "reform not revolution" is unquestionablyright.

Endogenous Pyrogen and FeverTHE association between fever and a variety of

diseases has been recognised since ancient times,and the measurement of body temperature is usedeverywhere as a non-specific indicator of illness.The final common pathway in fever is now thoughtto be a small-molecular-weight protein, endogenouspyrogen (EP), which is produced within the body.Human EP can be assayed in rabbits, and we nowknow something about its production and sub-sequent action.

1

Many cells (polymorphonuclear leucocytes,blood monocytes, peritoneal and alveolar macro-phages, and the phagocytic cells. of the reticulo-endothelial system in liver, spleen, and lymph-nodes) produce endogenous pyrogen after theyhave been activated by phagocytosis, viruses, bac-teria, endotoxins from gram-negative bacteria,pyrogenic steroids, or indirectly by antigen-anti-body complexes.2 The EP produced is then releasedinto the circulation. The temperature-regulatingcentre in the preoptic hypothalamus is sensitive toEP,3 and body temperature rises, through an in-crease in heat conservation and production. Themechanism is not yet known, but may involvemetabolites of arachidonic acid.4

Naturally occurring fever is characterised byvasoconstriction, shivering, malaise, headache,nausea, and polymyalgia, although these featuresdo not necessarily coincide. It arises in many dif-ferent types of illness, such as infections, neoplastic

diseases, incompatible blood-transfusions, and

allergies. The pattern of fever is of little value in

Daily Telegraph, July 19.iRawlmsMD, Cranston WI. Clinical Studies in the pathogenesis of fever. In:

Thephamacology ofthermoregulation. San Francisco. 1972: 264-77.2Atkins E, Bodel PT. Role of leucocytes in fever. In: Wolstenholme G, Birch

J eds Pyrogens and Fever. Ciba Found Symp. London: Churchill Living-stone. 1971: 81-97.

Cooper KE, Cranston WI, Honour AJ. Observations on the site and modeof action of pyrogens in the rabbit brain. J Physiol 1967; 191: 325-37.

Cranston WI, Central mechanisms offever, FedProc 1979; 38: 45-47.

the diagnosis of illness, except in the case of estab-lished malaria. The tertian and quartan fevers ofmalaria are clearly associated with recurrent eventsin the life-cycle of the parasite, each episode offever following the rupture of infected erythro-cytes. A pyrogen has been found in peripheralblood taken during the rising phase of malarialfever, no pyrogen being seen during the afebrilephased Circulating EP has not been detected inother diseases, perhaps because the concentration istoo low to be detected in a blood-sample of reason-able size. Nor could circulating EP be demon-strated in blood from febrile volunteers infusedwith EP. EP has, however, been found in inflam-matory pleural and peritoneal effusions,6 and alsoin aspirates from joints with non-bacterial inflam-mations.’

Phagocytosis may be largely responsible forfevers in septicaemia and infection of deep tissues,blood-transfusion reactions, and immune hsemo-lytic anæmias.8 Chemotactic factors, either micro-bial or produced by tissue injury, induce inflamma-tion and may activate cells to produce EP, resultingin inflammation fevers and those associated withacute gout and pancreatitis.8 Unexplained fever iscommonly traced to malignant diseases such asrenal carcinoma.9,10 These fevers may disappearwhen the tumour is removed or suppressed andoften reappear when the malignancy recurs. Cellsfrom human Hodgkin’s- and renal tumours, andhistiocytic, myelomonocytic, and lymphomatousneoplasms, can release EP spontaneously in vitro,9so it may be that a local lesion is synthesising andreleasing EP in vivo, and thus producing fever.

Although EP seems to be involved in many clini-cal fevers, this substance is not vital to the produc-tion of a raised body temperature. Hypothalamiclesions and cerebral haemorrhages may have a di-rect effect on thermoregulation; other conditionsdirectly affect the thermoregulatory effectors

(thyrotoxicosis, malignant hyperthermia), or thecentral nervous system (antidepressant poisoning).The value of fever in infective conditions is not

yet proven, but it seems unlikely that this universalresponse of homoeotherms would have persisted ifit did not confer some advantage. In experimentswith fish, reptiles, and mammalsll fever was corre-lated with survival, and there is some evidence that

5. Cranston WI. Temperature regulation. Br Med J 1966, ii: 69-75.6. Snell ES. Pyrogenic properties of human pathological fluids. Clin Sci 1962;

23: 141-50.7. Bodel PT, Hollingsworth JW. Pyrogen release from human synovial exudate

cells. Br J Exp Path 1968; 49: 11-19.8. Atkins E, Bodel PT. Clinical fever: its history, manifestations and patho-

genesis. Fed Proc 1979; 38: 57-63.9. Bodel PT. Generalised perturbations in host physiology caused by localised

tumors. Tumors and fever. Ann NY Acad Sci 1974; 230: 6-13.10. Cranston WI, Luff RH, Owen D, Rawlins MD. Studies on the pathogenesis

of fever in renal carcinoma. Clin Sci Mol Med 1973; 45: 459-67.11. Kluger MJ. The adaptive value of fever. In: Fever, its biology, evolution and

function. Princeton University Press. (In press).