The State Medical Service Scheme

Paper read before the Bournemouth Division of the British Medical Association on Wednesday 2 October 1912 by J. E. Esslemont MB

The Organisation of the profession is the question of the day for Medical men, and assuredly it is a question on which doctors differ! Some advocate a State Medical Service in which the bulk of the profession will become a branch of the Civil Service. Others resent State interference and advise a Public Medical Service organised by the profession itself ; while still others resent interference by either the State or the profession, and wish to preserve their practice as purely private as possible.

For dealing with the ailments of well-to-do individuals who can easily afford to pay reasonable fees, private practice is quite appropriate, and I see no reason why it should not continue, if preferred, side by side with an organised public service. In the case of the middle classes, however, the need for something to supplement private practice begins to appear. Under the present system the small professional or business man is apt to delay seeking medical advice, in order to save expense, and the fees charged for surgical operations, bacteriological examinations, vaccine therapy, X-ray treatment, or even for prolonged ordinary attendance, are such as he cannot meet without serious impoverishment. For dealing with disease among the poorer classes, with epidemic diseases, and national plagues like tuberculosis, private practice, whether on the payment-per-consultation or on the club-contract system, has shown itself hopelessly inadequate, even when liberally assisted by voluntary charity. Disease on the large scale has to be met by treatment on the large scale, and at present the urgent necessity for the organization of the medical and allied professions, and of the institutions through which their work is carried on, is apparent to all. The question is: What form of organisation will provide the best service – best both in the interests of the general public and of the profession itself ?

I am one of those who advocate a State Medical Service, and I shall endeavor to explain, briefly, how, in our opinion, the medical service of the country might be improved by closer affiliation with the Government, and, what is also important, how the Government might be improved by closer affiliation with the medical profession.

1. – Take first the important subject of research, which is the basis of all scientific medical work. Present day provision for research work in this country is shockingly inadequate, depending chiefly on the capricious support of private beneficence. Few men, however able and willing, can afford to spend much time in unremunerative work, and research work cannot be immediately remunerative. It is work done not for individuals, but for the community, and therefore ought to be paid for by the community. If we are not to fill hopelessly behind other nations in the march of progress, the State must wake up to its responsibilities in this matter. Why is Germany making such vast strides in science and industry? Largely because of State-aided research. Why is the list of preventable diseases so short and that of unpreventable diseases so long? Simply for want of research. Not only is too little research done, but much that is done in a small way by independent practitioners is lost to the world, because of the want of any central organisation for collecting, classifying and elaborating the observations of scattered workers. Here then, is one important department where there is all to gain and nothing to lose by an alliance of the profession with the State.

2-Take next the subject of preventive treatment. “Prevention is better than cure,” and a medical service worthy of the name must devote the best of its energies to removing the causes of disease-social and environmental well as personal causes. This means dealing with bad housing, bad drainage, tainted milk, unhealthy trades, segregation of infectious cases, and the like. Only a service with the power of the State behind it can be equal to such requirements. The present Public Health Service deals to some extent with these matters, but it is a feeble instrument for such a gigantic task, and requires to be greatly strengthened and developed. As fast as research transfers illness from the list of “unpreventible” to that of “preventible” diseases, so fast must an efficient Public Health Service insist on the transference from the list of “preventable” to that of “prevented” diseases, and demand that Government shall find the money and take the means that are necessary. How far are we at present from this ideal? It is no exaggeration to say that hundreds of thousands of lives are lost annually in Great Britain through preventible illness. Tuberculosis alone costs us 75,000 lives every year. We know where the infection comes from and how it is spread. We know that every year thousands of children are infected by tuberculous milk. We know that thousands of advanced cases of tuberculosis are veritable germ-factories, disseminating infection broadcast among their neighbours. Yet the profession, in its present unorganized condition, is so impotent in relation to the state that Parliament is allowed to go on year after year discussing non-vital questions of purely party politics, while this wicked waste of life goes on unheeded and unchecked.

3. -This brings me to what is probably the most important proposal connected with a State Medical Service – the establishment of a State Board of Health. This board would be to the medical profession what the Admiralty is to the navy and the Army Council to the Army – a great central organizing and representative authority. It would have a council composed mainly of leading members of the medical profession, and a President of Cabinet Rank. . It would be both an advisory and an administrative body.

In the first place it would advise the Government in all matters of legislation affecting the public health, or the medical and allied professions. Had such a board been in existence, a measure like the Insurance Act could never have been rushed through without adequate consultation with the medical profession. On the contrary, the Board of Health would have been responsible for its medical sections and in closest touch with every stage of its development. This Board of Health would receive reports from its Research and Preventive Departments and devise new legislative measures based on these reports. It would thus be like a permanent Parliamentary Commission – always “on the spot” to investigate and make recommendations to Government on matters of public health. As a great State Department, however, it would have far more authority than a commission, and would, when necessary, demand the expenditure of millions for public health, with the same assurance as the Admiralty asks for Dreadnoughts.

It would take too much time to describe in full the administrative functions of the Board. It would institute a single State examination for admission to the medical profession. It would supervise and control the work of all branches of the medical, dental, nursing, and pharmaceutical professions. It would control the Public Health and Schools Medical Services, the administration of all hospitals, asylums, nursing homes, sanitoria, and other medical institutions, and promote research, both individual and collective. These functions are at present discharged (some of them most inadequately) by a bewildering jumble of more or less independent boards, councils, commissions and associations which would have to be superseded, modified or incorporated with the new scheme according to circumstance

The Board, with its subordinate committees and staff would be like the nervous system of the profession, organising and correlating the whole and giving, it new efficiency and status. I venture to think that when, through the Board of Health, the medical profession comes to exert an influence in the affairs of State commensurate with that which the legal profession and the Church, the Army and the Navy exert now, the change will be fraught with good, not only for the profession, but for the public; and considerations of health, heredity, and the improvement of the race, which have been too long neglected by statesmen, will last receive serious attention.

4-We must next glance briefly at the position of the ordinary practitioner in the State Medical Service (leaving out of account those whose clientele is among the wealthy, and whose position, as we have seen, would be unaffected). At present the work of the practitioner forms by far the greater portion of the total work done by the profession. It obvious to all, however, that his field is being steadily encroached upon by the public health officer, the schools medical officer, the hospital, the sanatorium, and one public institution after another, and that in the near future such encroachments will be far greater than at present. What is the practitioner to do in face of this situation? Is he to move with the times and join the State Service, or to “make a stand” against State interference and “die hard”?

Experience has amply shewn that the poorer classes, even with the utmost assistance of voluntary charity, are unable to provide for their own adequate treatment. People are coming to see, moreover, not only that it is the duty of the State, but that it will pay the State to look after the health of the poor-that preventable disease costs the country in hard cash many times what it would cost to keep the people healthy. Through the Insurance Act, the State has definitely accepted responsibility for the health of the working classes. It has already collected millions of money to enable it to discharge that responsibility. That being so, it does not require a very astute prophet to perceive that it will have to come to some working arrangement with the profession through which alone it can carry out its promises.

I see no reason why practitioners should not welcome the advent of the State on the field of general practice, provided satisfactory financial arrangements are arrived at. It seems to me that under a State Service the practitioner’s status will be improved in many ways-by greater security of income, freedom from the worry of assessing and collecting fees, better conditions of work and better chances of promotion. Methods of payments and rates of remuneration are matters for arrangement which do not greatly affect the principle of State Service. Practitioners would probably take some part in collective research, medical inspection, and preventive work, as well as ordinary practice, one of the primary objects of the State Service being, to unite preventive with curative medicine, and I see no reason why they should not be paid partly by salary and partly by capitation fees according to the number of their clients, with extras for night work, etc. Free choice of doctor, as far as practicable, is proposed. Pensions on retirement after a certain number of years’ work, or in the case of permanent disablement, are a feature to which some people object in theory, but to which, I fancy, there would be few conscientious objectors in practice! Another proposed feature which would be welcome to many, is an arrangement similar to that which obtains in he Army Medical Corps, by which, after a certain number of years’ service, an officer is entitled, if he chooses, to put in a course of postgraduate study on full pay. All things considered, I think the general practitioner is likely to be amply compensated for any disadvantages he may incur in joining the service.

5-As regards Hospitals and similar institutions, it is probable that their number would be greatly increased and that a much larger number of medical men than at present would be required for institutional posts. It is proposed that all work done in Hospitals should be remunerated at a reasonable rate. A large number of men would thus be enabled to acquire the special skill and experience that only hospital work can give. All Hospitals would, in course of time, be brought into the National Scheme and used for consultative, operative, and therapeutic work at the request of and in conjunction with the patient’s own doctor.

Either in connection with or separately from the Hospitals, it has been proposed to establish in each district or town a Central Medical Dep6t, with Pathologist and Laboratories, a Surgical Instrument Department in charge of a proper attendant who would see that all instruments were kept in order, sterilised and ready for use by any members of the local medical service, a Drug and Dispensing Department, Board Room for Doctors, a Medical Library, Headquarters for District Nurses, etc.

6-A final word as regards promotion in the Service. The whole scheme is as yet in its infancy, and I do not know that any definite arrangements have been proposed as regards methods of promotion, but to my mind this is one of the most important problems to be solved, and one on the wise solution of which the success of the whole scheme largely depends. I consider that in most services too much consideration is given to seniority and social status and too little to keenness and ability, the result being that enterprise and originality are discouraged, and the service attracts the wrong class of men. The curse of every profession is the number of men in it who have taken to it, or whose parents have pushed them into it, not because of their innate fitness for the work or inclination towards it, but to make a living! These are the men who become “slackers,” and a system of promotion that gives undue consideration to seniority or family connections is bound to encourage them. Under such a system they are just as sure of promotion when the time comes as the man who is putting both energy and skill into his work, so why should they worry ? Let us give ripeness of experience and inherited talent their full due, but let us have no round men in square holes, or feeble men in powerful positions. Let fitness for the work be our one criterion in promotion and let the best man win, no matter what his age or his origin. Men who have no real aptitude for the work will then be effectively deterred from entering the profession, knowing that unless they do good work they will get no promotion, while the right sort of men, those who love their work and excel in it, will be correspondingly attracted and encouraged.

I have endeavoured to give you, gentlemen, a rough sketch of the main features of a suggested National Health Service. My object in doing so is not to propose a cut and dried scheme for your acceptance, but rather to shew the need for and the possibility of some adequate scheme. Looking at the matter from the broad National point of view, I think is impossible to feel satisfied with the way in which we are tinkering with disease at present. Even the far-reaching proposals of the Insurance Act and of the Association’s Public Medical Service Scheme make no reference to the fundamental matters of research, preventive measures, or hospital administration. I hope that this great Association, which now for the first time seems to have awakened to a sense of its powers and responsibilities, will not rest content with any scheme which provides merely for medical attendance and medicine, but will bend its energies to the worthier task of devising a plan of Organisation which shall cover the whole field of medical work and deal with the problem of the Nation’s Health in a scientific and statesmanlike fashion.

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