The Dystonias.

or referring general practitioner. The problem is that other aspects of the university hospital's work previously funded in a general way out of SIFT would then be left unfunded unless additional resources were found. What structure of funding would help to guarantee the future ofmedical education, research, and development in the NHS? How can we be sure to continue to attract many of the best brains into health care and use them to the full? Can we deny that while university hospitals surely must submit to strict managerial, medical, and educational audit (much of which they have themselves devised) their true success will never be measurable in commercial terms, that medical knowledge and development will be constrained in a market where cost effectiveness is the touchstone? Are we really prepared to see medical education and science jeopardised by the uncertain outcome of a market environment aimed at solving completely different problems? There is no reason to doubt the sincerity and truth of Mr Clarke's statement on 10 July 1989 that "The comprehensive and high quality health service which will be needed to face the demands and challenges of tomorrow's world will depend crucially on the standard of medical education we provide and the range and quality of the nation's medical research programmes. Both are an intrinsic part of our commitment to the NHS" (speech to doctors in London). We believe that the solution is to accept that it is in the national interest to have a small number of institutions whose special task it is to set the highest standards of care, to advance knowledge, and to inspire future doctors to excellence in a rapidly changing world, sending them out to every part of Britain once qualified with these models of care before them; and further, to accept that excellence is costly and must be funded, managed, and assessed in its own right but is at the same time a key componQnt of care in the inner cities. This requires direct funding of the main university teaching hospitals by the Department of Health with a managerial mandate similar to that of the existing special health authorities but with the crucial difference that the undergraduate teaching hospitals continue to serve their locality as well as the country at large. Direct funding will not solve all the problems but it will greatly simplify the administrative process, stabilise the financial base, and allow time, energy, and imagination to be concentrated on the fundamental educational challenge, which has long been submerged in other pressures.