Postoperative diabetes insipidus.

Abstract

most aspects of sociopolitical organisation other countries provide a vast range of models from which to choose. Looking around the Western world, we see three broad systems. Firstly, in the Scandinavian model a society pays high taxes (marginal rates of income tax at 70% or more) and uses those taxes to finance a health system that makes small charges or no charges to patients. In the Scandinavian countries all patients from all social classes are treated in the same hospitals; the standard of care is high; and the health indices such as infant mortality reflect this. Secondly, in the Franco-German model a society pays lower taxes, has wider differences in income between the rich and the poor, and state expenditure on health is low (less than 20% of the total). Medical expenses are funded by insurance schemes (monitored and regulated by the state) to which all workers and their employers contribute on a sliding scale based on a percentage of earnings. And the state pays the premiums of the unemployed, the long term sick, etc, so that-as in Scandinavia-the whole population has equal access to a single system of medical care. Standards of care are high (at times extravagant); the health professions are well paid; and again health indices such as infant mortality are better than or equal to those in Britain.9 The third model is at its most dramatic in the United States, where taxes are low, state expenditure on health care is low, but the healthinsurance schemes are independent of the state. The result is that growing numbers of the poor and unemployed are not insured and insurance does not cover even the middle classes against all possible contingencies. 10 Serious, chronic illness can still bankrupt a family in the richest country in the world. And health indices show wide contrasts across social classes and between ethnic groups. The first two systems are, we believe, equally acceptable to patients and the health professions; the insurance based model is more expensive to operate (because of the bureaucracy needed to collect premiums and make payments) but both provide cover for all types of illness for the whole population. Our anxiety is that Britain may be slipping towards the third, least satisfactory model as seen in the United States. If the British want to keep their NHS unchanged but adequately financed-the choice preferred by the BMA-they will have to pay higher taxes to sustain it. There is some evidence from opinion polls that the electorate would be willing to do this-but little evidence that the government is willing to go down this road. Yet the harsh fact remains: we can't expect to finance a Scandinavian model of health (or for that matter education") on rates of taxation seen in Germany or Switzerland. If we want a low tax economy and civilised standards of health care I believe that we must have an insurance based health system. Otherwise the sums don't add up. That is the choice that the government should be facing. TONY SMITH Deputy Editor, BMJ I Smith T. New year message. BrAMedJ7 1988;296: 1-2. 2 Applebv J. Dissecting the NHS bonanza. BrMedj 1988;297:1284-5. 3 National Association of Health Authorities. Making ends meet. he financial position oJ districl health authorities.