Assumption B.   Comprehensive Health And Rehabilitation Services

426.   The second of the three assumptions has two sides to it.    It covers a national health service for prevention and for cure of disease and disability by medical treatment ; it covers rehabilitation and fitting for employment by treatment which will be both medical and post-medical.   Administratively, realisation of Assumption B on its two sides involves action both by the depart­ments concerned with health and by the Ministry of Labour and National Service.   Exactly where the line should be drawn between the responsibilities of these Departments cannot, and need not, be settled now.   For the purpose of the present Report, the two sides are combined under one head, avoiding the need to distinguish accurately at this stage between medical and post-medical work.   The case for regarding Assumption B as necessary for a satisfactory system of social security needs little emphasis.   It is a logical corollary to the payment of high benefits in disability that determined efforts should be made by the State to reduce the number of cases for which benefit is needed.   It is a logical corollary to the receipt of high benefits in disability that the individual should recognise the duty to be well and to co-operate in all steps which may lead to diagnosis of disease in early stages when it can be prevented.   Disease and accidents must be paid for in any case, in lessened power of production and in idleness, if not directly by insurance benefits. One of the reasons why it is preferable to pay for disease and accident openly and directly in the form of insurance benefits, rather than indirectly, is that this emphasises the cost and should give a stimulus to prevention.    As to the methods of realising Assumption B, the main problems naturally arise under the first head of medical treatment.   Rehabilitation is a new field of remedial activity with great possibilities, but requiring expenditure of a different order of magnitude from that involved in the medical treatment of the nation.

427. The first part of Assumption B is that a comprehensive1” national health service will ensure that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it, domiciliary or institutional, general, specialist or consultant, and will ensure also the provision of dental, ophthalmic and surgical appliances, nursing and midwifery and rehabilitation after accidents. Whether or not payment towards the cost of the health service is included in the social insurance contribution, the service itself should

(i) be organised, not by the Ministry concerned with social insurance, but by Departments responsible for the health of the people and for positive and preventive as well as curative measures;

(ii) be  provided  where  needed  without  contribution  conditions in  any individual case.

Restoration of a sick person to health is a duty of the State and the sick person, prior to any other consideration. The assumption made here is in accord with the definition of the objects of medical service as proposed in the Draft Interim Report of the Medical Planning Commission of the British Medical Association:

” (a) to provide a system of medical service directed towards the achievement of positive health, of the prevention of disease, and the relief of sickness;

(b) to render available to every individual all necessary medical services, both general and specialist, and both domiciliary and institutional.”

428. Most of the problems of organisation of such a service fall outside the scope of the Report.    It is not necessary to express an opinion on such questions as free choice of doctor, group or individual practice, or the place of voluntary and public hospitals respectively in a national scheme.    It is not necessary to express an opinion on the terms of service and remuneration of doctors of various kinds, of dentists and of nurses, except in so far as these terms may affect the possibility of diminishing and controlling sickness andso may affect the finances of the Social Insurance Fund.    Once it is accepted that the administration of medical treatment shall be lifted out of social insur­ance to become part of a comprehensive health service, the questions that remain for answer in this Report are, in the main, financial.    Shall any part of the cost of treatment, and if so what part, be included in the compulsory insurance contribution?   But, though that question is in itself financial, the answer to it may affect the organisation of the service and may therefore depend in part upon views as to organisation.

429. In dealing with this financial question, it is desirable to consider separately domiciliary treatment, institutional treatment, special services like dental and ophthalmic treatment, and subsidiary services such as supply of medical or surgical appliances, nursing and convalescent homes.

430. Domiciliary treatment is now paid for by persons subject to  health insurance, for themselves by compulsory contributions, for dependants either by a charge for treatment when it is given or more rarely by voluntary contri­bution through associations for public medical service.    There is no obvious reason, apart from a desire to keep the insurance contribution as low as possible, why insured persons should be relieved of this burden wholly, in order that they may bear it as tax-payers.    If importance attaches to preserving the contributory principle for cash benefit, it attaches also to contribution for medical treatment.    There appears to be a case for including part of the cost of domiciliary treatment in  the insurance  contribution.    This means that a proportion of the receipts of the Social Insurance Fund would be paid by the Fund to the health departments as a grant towards the Cost of the medical service.    The administration of this money would rest with the health departments.

431. But one consequence of this suggestion has to be noted.    The Report proposes a compulsory social insurance scheme without income limits.    Its contributing Classes I, II and IV, though they pay different contributions according to the cash benefits for which they insure, are not income classes; each contains rich and poor.    Any contribution for medical treatment must apply to all these classes, to every one in each of them, and must cover their dependants in Class III (Housewives) and Class V (Children).    If a contri­bution  for  medical  treatment  is  included  in  the  insurance   contribution, contributions will cover not ninety per cent, of the population (the present insured persons and their dependants), as is assumed in the Draft Interim Report issued by the Medical Planning Commission, but one hundred per cent, of the population.    This will not, of itself, put an end to private practice. Those who have the desire and the means will be able to pay separately for private treatment, if the medical service is organised to provide that, as they may pay now for private schooling, though the public education system is available for all.   But no one will be compelled to pay separately.   The possible scope of private general practice will be so restricted that it may not appear worth while to preserve it.    If, therefore, it is desired to preserve a. substantial scope for private practice and to restrict the right to service without a charge on treatment to persons below a certain income limit, it will not be possible to include a payment for medical service in an insurance contribution which all are required to pay irrespective of income.

432.    Institutional treatment is not included in the present health insurance contribution except to a small extent as an additional benefit. It is obtainable by any citizen in a public hospital subject to recovery of the cost, that is to say to payment according to his means, or free if he has no means.    It is obtainable in a private hospital, as a rule either in virtue of previous voluntary contribution through a hospital contributory scheme or on payment according to means as agreed with the   hospital almoner.    The growth of hospital contributory schemes in the years’ just before this war has been remarkable.    They are stated to cover now more than 10,000,000 wage earners and they produce more than £6,500,000 a year for the voluntary hospitals;   the cost of collecting this money is put at about six per cent.; in London and some other parts of the country contribution to a Hospital Saving Association qualifies the contributor for free treatment either in a voluntary hospital or in a public hospital as may best suit his case.   The Ministry of Labour Family Budgets in 1937-38 showed an average payment to hospital saving associations of 3Jd. a week in every industrial household and 3d. a week in every agricultural household.    British people are clearly ready and able to pay contributions for institutional treatment.   Should a payment for this purpose be included in the compulsory insurance contribution, and be passed on as a grant from the Social Insurance Fund to the health departments towards the maintenance of the institutions?   The answer to this financial question, like the answer to the similar question as to domiciliary treatment, involves problems of organisation as well as finance.   If a payment for institutional treatment is included in the compulsory insurance contribution, there will be little or nothing left for which people can be asked to contribute voluntarily, and an important financial resource of the voluntary hospitals will come to an end.    It will then be for the health departments to use the grant that they will receive from the Social Insurance Fund in whatever way best fits their hospital policy.    If it is not included, people of limited means will have the choice, as at present, of contributing voluntarily beforehand or of paying at the time of treatment, according to means.

433.   The main considerations   relevant   to the choice between these alternatives are:

(i) The importance of securing that suitable hospital treatment is available for every citizen and that recourse to it, at the earliest moment when it becomes desirable, is not delayed by any financial considerations. From this point of view, previous contribution is the ideal, better even than free service supported by the tax-payer. People will take what they have already paid for without delay when they need it, and they pay for it more directly as contributors than as tax-payers. But it can be argued that, under the present system, people do not in practice ‘delay taking hospital treatment when they need it ; their general practitioner will advise going to hospital, as soon as it becomes necessary, and if they are not voluntary contributors they will be asked to pay only according to their means. It is possible that the main practical reasons which now delay recourse to hospital after it has become desirable are not difficulties about paying for the treatment, but either (a) deficiency of accommodation or (b) unwillingness or inability to give up work or household duties in order to be treated. A suggestion for meeting the last-named difficulty is made in para. 344.

(ii) Hospital policy, particularly in relation to the place of voluntary hospitals, the terms of service and pay of their staffs, and the desirability or the reverse of allowing arrangements whereby individuals, whether through membership of a voluntary association or by special payment, can get choice of specialists or hospitals or special treatment in them.

(iii)Financial policy, and particularly the question of the optimum size of the insurance contribution and of the Security Budget in relation to the ordinary budget.

434. A minor question in the relations of the social insurance scheme and the finance of hospitals is whether persons in receipt of disability benefit, on entering an institution, should be required to make any payment towards the cost of their board as “hotel expenses.”    With the small benefits provided by national health insurance hitherto, this question could hardly be raised. But, if the social insurance scheme is to provide benefits in future designed to cover the food and fuel requirements of the insured person and his dependants, it may appear reasonable that, while such a person is getting his food and fuel in a hospital and not in his home, the money provided for that purpose should be directed to the hospital.   The point is not perhaps of great import­ance to the finance of institutional treatment; a sum of (say) 10/- a week is the most that could fairly be regarded as saved in the home by the temporary absence of the insured person in hospital.    But if it appears equitable to make such a charge, it may be expedient to make it, if only in order to avoid making it appear profitable to the patient to stay in the hospital when he could go home.

435. Dental and ophthalmic treatment and appliances are now over­whelmingly the most popular of the additional treatment benefits under national health insurance.    That is to say, they are being paid for in part by compulsory contributions and for the rest mainly by a charge when treatment is given.   There is a general demand that these services should become statu­tory benefits available to all under health insurance.   There appears to be ground for regarding a development of preservative dental treatment as a measure of major importance for improving the health of the nation.    This measure involves, first, a change of popular habit from aversion to visiting the dentist till pain compels into readiness to visit and be inspected periodically; it involves, simultaneously with creation by these means of a demand for a larger dental service, the taking of steps to organise a larger supply of the service.    That the insurance title to free dental service should become as universal as that to free medical service is not open to serious doubt.   The only substantial distinction which it seems right to make is in the supply of appliances.   To ensure careful use, it is reasonable that part of the cost of renewals of dentures should be borne by the person using them.   This might possibly be extended to the original supply.   The same holds true of optical appliances.

436. Surgical appliances, convalescent homes and nursing are less widely provided as additional benefits, but are essential to a comprehensive health service.     Decision as to making these subsidiary services contributory or non-contributory for the individual depends on the line taken in regard to the major problems of domiciliary and institutional treatment.    It is reasonable that insured persons should contribute something for such services, as they have shown themselves able and willing to do in the past; in regard to appliances of all kinds, the terms of supply and renewal must be such as to give an incentive to careful use. But it would be anomalous to   require compulsory contributions for special and subsidiary purposes, if the main ser­vices were non-contributory.

437. This review of some of the problems involved in establishing a comprehensive medical service makes clear that no final detailed proposals, even as to the financial basis of this service, can be submitted in this Report. It suggests the need for a further immediate investigation, in which the finance and the  organisation of medical services can be  considered   together,  in consultation with the professions concerned and with the public and voluntary organisations which have established hospitals and other institutions.   From the standpoint of social security, a health service providing full preventive and curative treatment of every kind to every citizen without exceptions, without remuneration limit and without an economic barrier at any point to delay recourse to it, is the ideal plan.   It is proposed accordingly that, in the con­tributions suggested as part of the Plan for Social Security, there shall be included a payment in virtue of which every citizen will be able to obtain whatever treatment his case requires, at home or in an institution, medical, dental or subsidiary, without a treatment charge.    It is proposed that the sums derived from these payments shall be transferred to the Department or Departments concerned with the organisation of the health service to meet part—it can only be part—of the total cost.    But these proposals are pro­visional only subject to review, in the light of the further enquiry suggested, in which organisation and finance can be dealt with together.    The primary interest of the Ministry of Social Security is not in the details of the national health service or in its financial arrangements. It is in finding a health service which will diminish disease by prevention and cure, and will ensure the careful certification needed to control payment of benefit at the rates proposed in this Report.

438 Assumption B covers not only medical treatment in all its forms, but also post-medical rehabilitation. In regard to the latter, as in regard to-the former, it would be inappropriate here to discuss details of organisation. During the preparation of this Report, the practical problems of rehabilitation have been under consideration by the Departments concerned and it is hoped that practical measures will follow. Rehabilitation is a continuous process by which disabled persons should be transferred from the state of being incapable under full medical care to the state of being producers and earners. This process requires close co-operation between the health departments and the department concerned with employment, that is to say, the Ministry of Labour and National Service. Whether this co-operation can be secured best by the setting up of an executive organ representative of both sides or by allocation of specific duties to each department, is a problem of departmental organisation on which it would be inappropriate here to express an opinion. It is sufficient to put forward three general propositions:—

(a) that rehabilitation must be continued from the medical through the post-medical stage till the maximum of earning capacity is restored and that a service for this purpose should be available for all disabled persons who can proiit by it irrespective of the cause of their disability.

(b)    That cash allowances to persons receiving rehabilitation service should be the same as training benefit, including removal and lodging allowances where required.

(c)     That the contributions paid by insured persons should, as in the case of medical treatment, qualify them for rehabilitation service without further payment.

439.    It will be consistent with the proposals made here to include part of the cost of post-medical rehabilitation of men injured in scheduled hazardous industries in the industrial levy of these industries, that is to say, to add a contribution towards the cost of this service to the amount of the levy (see paras. 279 (iii) and 360).

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