By SOMERVILLE HASTINGS, M.S., F.R.C.S.,

Surgeon and Lecturer, Ear and Throat Department, Middlesex Hospital; Chairman, Hospitals and Medical Services Committee, London County Council.

Reprinted from THE MEDICAL OFFICER, 16th March, 1935.

The Evolution of a State Medical Service

WE have been finding out many things, since the War. One of these is the limitation of usefulness of money and its uncertainty as a medium of exchange. We have learned, to our cost in some cases, how governments and financiers, by inflation and deflation can change the purchasing power of money within wide limits, and because of this countries have even found it expedient to return to the old world system of barter in their dealing with one another.

It is now a long time since the medical profession-by far the most advanced ethically of all professions-decided that monetary considerations should play no part in the professional relationships between its members. The fact that charges are never made and payment never accepted for treatment by one doctor of another, is to my mind one of the finest of the traditions of our profession.

It is unfortunate, however, that in our relationship with the public, we have to accept for the most part the position of the ordinary trader, and little as we may like it, we are compelled to sell our services to the highest bidder. This economic dependence of the doctor on his patient may be bad for both. It may make it difficult for the doctor to tell his patient unpleasant truths or refuse to sign certificates which he is not sure that he ought to sign. On the other hand, it may prevent his services being called for as early as they ought to be, for fear of the expense incurred.

I have been told by several of my colleagues that they get more real satisfaction from the treatment of their panel patients than of any others, because in such cases the medical needs of the patient can and must be the sole consideration, while in the others there is always the possibility that the doctor will be accused of neglecting his patient if his visits are few or of wanting to run up a bill if he attends frequently.

And here I would like to point out in case there should be any possibility of misunderstanding, that in advocating a State medical service, I am not proposing that anyone should give his services for nothing, or for a low scale of remuneration. If the doctor is to give of his best, he must be reasonably certain that as long as he continues to do this, all his legitimate needs will be amply met and he will have no anxiety for the future. A sense of injustice or insecurity is even more inimical to first-class work than economic dependence on one’s patients.

There can be very few who have carefully and. dispassionately considered the matter, who can have any doubt that the development of a socialised medical service in some form or other is inevitable within the relatively near future. Illness is one of the catastrophies of life which cannot. be avoided, and it is the tendency of the. age as far as possible, to insure against such catastrophies. Thus, we have unemployment insurance, National Health insurance, life, fire, burglary, and a host of other insurances as well as burial clubs, hospital savings associations, and many similar organisations, for weekly wage earners. People are also finding out that modern and efficient treatment for disease, involving as if often does a team of doctors, and not merely a, single practitioner, is a complicated and therefore expensive business, the cost of which it is very difficult for the ordinary citizen to meet in case of sudden emergency. We are discovering also that as a rule the larger the organisation the more economically and efficiently it can be run, and so we are willing that the government should do the running for us while each one pays according to his ability, through rates and taxes. We are also finding out that bulk purchase of either goods or services is always cheaper, but not necessarily, I would hasten to add, because the services are less well paid for, but rather because of the waste that is inevitable in competition. Every doctor knows how much better service he would render if his work were organised and he had more efficient clerical and nursing assistance at his disposal.

But why should I labour the point? A State medical service is inevitable. It will be complete, providing everything necessary for preventive and curative treatment, and it will be free and open to all. (For a fuller account; see “A Socialised Medical Service,” published by the Socialist Medical Association, price 2d.)

It must follow, therefore, that it must eventually be staffed by full-time medical officers, for who is going to pay for services that he can get for nothing, unless he has reason to believe that by going to the doctor in his private capacity, he can get better attention. This must necessarily imply that the services given by the doctor in his public capacity are not of the best, which would, of course, be fatal to the success of any publicly organised medical service.

Now I think it is clear that no government that this country is ever likely to have will suddenly and at one fell swoop repeal all these Acts of Parliament that have, anything to do with preventive and curative medicine, and at the same moment suddenly create a fully developed and complete State medical service. Much more likely is it, therefore, that the State medical service of the future will be evolved by modification and development of existing services.

In this connection there are three possible directions of extension, each of which merits some consideration:

I. By development of the present panel service and extension to dependants of the insured, or the public generally.

II. By development of the present local government services and especially by the provision of domiciliary treatment in connection with them.

Ill. By the development of a general whole-time free domiciliary service apart from the panel.

Before considering each of these different lines of development in detail, it may be useful to recall two or three points of principle which must be kept in mind in planning, especially the early stages of the transition between the present state of chaos and an ordered public medical-service. In the first place the State has already undertaken to provide preventive and curative treatment for certain afflictions under certain conditions, and considerable public resentment would be felt if any worsening, even though temporary in character, took place in connection with existing services. The public has learned to appreciate and depend on the maternity and child welfare, school medical, tuberculosis, and other services. The 14,000,000 insured persons realise that while as ratepayers and taxpayers they are helping to pay for the health services of the nation generally, they are as insured contributors in a very special position, as they are also paying a considerable proportion of the cost of medical benefit and they might easily resent any restriction or supposed restriction, of the services now provided for them, unless, of course, some definite compensatory advantages were offered.

The position of the panel practitioner also merits consideration. In some cases he has built up from nothing a large panel practice, while in others he has purchased the practice often for a very considerable sum of money. In either case, however, he is now possessed of transferable property which can be bought and sold. In any scheme for absorption of National Health Insurance in a State medical service, these facts cannot be ignored. There is also the position of the doctor, with or without a panel, who practises in a working-class district, and whose patients are mainly the wives and children of the insured, and other less-well-to-do members of the community, the greater number of whom would unquestionably take advantage of a free State medical service. The position of these doctors will also need careful consideration.

I. It will be remembered that the Minority Report of the Royal Commission on National Health Insurance recommended that medical benefit should be extended to the dependants of the insured. The British Medical Association has accordingly suggested the extension of the present panel system, so as to provide a general practitioner service for about 80 per cent. of the population. It has been pointed out, however, that there are, with dependants, some three or four million persons who are no better off than those insured, and yet who are not, and can never be, insured persons. Such are costers and small shopkeepers, cobblers, gipsies, agricultural smallholders, etc., and it would be practically impossible to collect insurance subscriptions from these. Moreover, the necessary increase in insurance contributions, if dependants were included, would so reduce the income of many of the less-well-paid workers that definite hardship would result. The Medical, Practitioners’ Union, recognising these facts, suggests that a general practitioner service should be provided free to all those with incomes below a certain fixed level together with their dependants. That each individual should select the practitioner of his choice, and that the State should foot the bill, by paying an annual capitation fee to the practitioner for every individual who selects him as his doctor.

Now, in my opinion, in the interest of democratic government and public health it would be impossible even to contemplate either of these alternatives, which would only extend and increase all the evils of the present panel system. It would result in appointments paid for largely, according to the British Medical Association scheme, or entirely, according to that of the Medical Practitioners Union, by the State, being freely bought and sold. It would result in any practitioner within certain wide limits, whatever his record or qualifications, who could curry favour with a section of the populace being guaranteed a living at the expense of the State. After all, it is very difficult for the public to estimate correctly the relative value of the services rendered to them and impossible in most cases for them to distinguish between the efficient and the inefficient doctor. Moreover, by maintaining the complete separation between the doctors who prevent and those who treat disease, it would accentuate one of the greatest evils of our present regime.

II. It is not generally realised what very wide powers are given to local authorities by the Maternity and Child Welfare Act. The usefulness of the Act is, however, much diminished by the following facts; (1) that most of its clauses are permissive instead of compulsory, (2) that a good deal of the work can be farmed out to voluntary agencies, and (3) that the Local Government areas are in many cases too small. In-patient hospital treatment can be provided for all persons under the Local Government Act, 1929, and also, subject to the consent of the Ministry of Health, for children under 5 who are not on a school roll, and for expectant, parturient, and nursing mothers under the Maternity and Child Welfare Act. In practice, domiciliary nursing is also often provided for children, but a general service of domiciliary medical treatment is prohibited. If the county councils and county borough councils were made the administrative authorities, and all that is permissive under the Act made compulsory, an excellent service could be developed, providing everything essential for expectant and nursing mothers and children under school age, except domiciliary treatment, and a further amendment of the Maternity and Child Welfare Act could make it incumbent on the local authorities to provide a complete domiciliary service for the treatment of mothers and children when , unable to attend at the centres.

In much the same way by making the health clauses of the Education Act, 1921, compulsory, and removing the bar to the provision of domiciliary treatment, a first-class service for children under 14 could be organised, and it would not be difficult to extend the facilities thus provided up to the age of entry into Health Insurance at 16. At the same time a long overdue reform could be carried out by transferring the medical care of these children from the education to the public health committees of the local authorities.

If at the same time dental and specialist services were provided for insured persons and the public generally, preferably in connection with the municipal hospitals, the health needs of children up to school leaving age (or even entry into insurance) expectant and nursing mothers, and insured persons would have been provided for. A not very large number of people would remain, i.e., old people, uninsured men and women, and those in receipt of public assistance.. A general practitioner service would have to be provided for these, who would also make use of the specialist and dental services already mentioned.

A medical service run on very much these lines was in actual practice in parts of Russia when I visited that country in 1931, and was apparently working well. The main objection to such a service seems to be that under certain circumstances as many as four different doctors might be visiting the same household at one time. Moreover, no one doctor would be made responsible for the health of a family and serve as ” guide, counsellor, and friend” to it. These difficulties might, however, be considerably reduced by the appointment of one doctor in an area as domiciliary medical officer in connection with both maternity and child welfare, and the treatment of school children.

III. It seems probable that the municipal hospitals will have a very big part to play in the evolution of the State medical service of the future, and one of the first administrative changes should be the amendment of the Local Government Act, 1929, making it compulsory for the public health committees of county councils and county borough councils to take over the Poor Law infirmaries and run them as municipal hospitals. The next step should be, I think, the transference of all the health activities in a county or county borough, including the school medical service and the medical section of National Health insurance to the supervision of the public health committee of that area, as recommended in the Majority Report of the Royal Commission on National Health insurance; local authorities might also be encouraged to centralise in Health centres in each locality as far as is convenient, their various medical activities, e.g. maternity and child welfare, school clinics, tuberculosis dispensaries, Poor Law medical service, etc., where possible in association with their municipal hospitals. In these health centres, out-patient departments should be opened for dental and specialist treatment.

Already in some localities such out-patient departments exist and are doing good work. Section 131 of the Public Health Act, 1875, permits of the formation of “places for the reception of the sick,” but does not define these in detail. The specialist out-patient departments should be consultative in nature and the patient should be referred back to his own doctor (panel or otherwise) for treatment whenever possible. An amendment of the existing laws would be necessary to permit of the calling out to the patients’ home of specialists at the expense of the local authority (as is already permitted by law in maternity cases) by panel and other practitioners. It is probable that the improved facilities for specialist treatment suggested above would be held by most National Health insurance patients to amply compensate for any decrease of responsibility involved in the transfer of the control of medical benefit to the public health committees.

The next steps should be (without interfering in any way with National Health insurance) the provision of a free service of “home” doctors for uninsured patients, and at first it might be convenient to permit only those below a certain income limit to take advantage of it. The “home” doctors would be general practitioners who would see their patients at the health centres and also visit them in their homes. The appointments might be part-time, with the proviso that all new appointments after five years in urban areas would be full time. In appointing” home” doctors preference should be given to those doctors who would lose a good deal of their practice in consequence of the provision of a free service; indeed it would have to be so, for only by the employment of such practitioners could the necessary personnel be obtained. The “home” doctor would also attend public assistance patients.

As soon as the service of “home” doctors was firmly established, it might be useful to amend the National Health Insurance Act so that all new entrants to insurance would make use of the “home” doctor service, and at the same time have their cash benefit (still administered through the Approved Societies) increased by the saving thus effected. Similar facilities should be made available at any time during the next five years to those already insured. Panel doctors could then be offered part-time appointments, determined by the extent to which their panel patients decided to transfer to the “home” doctor service.

Printers: Sir JOSEPH CAUSTON & SONS, LTD., 9 Eastcheap, London, E.C.3

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