We have already remarked that medical services in this and indeed most other countries have simply grown up, without any official guidance or underlying plan. The story of their development from the early medicine-man through the guilds of barbers and surgeons in the Middle Ages to the modern complexity of specialists and scientific, techniques makes fascinating reading. Throughout the ages the development of Medicine has on the one hand been assisted by a feeling of unity among medical men which has made all advances in knowledge the property of the whole of the profession, and at the same time has been hindered by the economic basis of Medicine which has kept doctors isolated from one another in almost every aspect of their work. The founding of the voluntary hospitals on a basis which involved the giving of many hours of free work among the sick poor by those doctors who were attached to the hospitals with the consequent necessity of charging the wealthier classes extravagant fees, gave the development of specialisation within the medical profession a form of organisation which exists in no other. The industrial revolution, bringing with it the need for the provision of large hospitals for those who came under the Poor Law, added further complications to the medical scene. In the end we have a combination of medical agencies which can only be described as chaotic.
We now have in this country three different standards of qualification for a doctor and two totally different and unrelated hospital systems. In these two systems there is a complete lack of uniformity not only as to the size of the hospital buildings and the standards of comfort available in them but also as to the services which they provide and their method of staffing. Among voluntary hospitals, for example, there is a very great difference between the small cottage hospital staffed by general practitioners and the large teaching hospital with many consultants and full-time staffs in most of the special departments. Public hospitals vary from institutions still bearing all the stigmata of the Poor Law —badly built, badly staffed, and badly run— to large, new, completely modern hospitals differing from the best voluntary hospitals only in the fact that their staffs are full-time officers. In addition to these general hospitals, there are special hospitals for children which are usually voluntary in character, there are sanatoria run by local authorities and mental hospitals, and isolation hospitals very often operated by joint boards representing a number of districts. There are many special schemes, some of a voluntary nature and some organised by trades unions or workers’ organisations such as the miners’ medical societies, which in some cases have their own hospitals. In addition there are those services for infant and child welfare and for maternity and post- and antenatal care operated by local authorities— but not always by the same local authority as provides the hospitals, and sanatoria; there is the school medical service, there are many industrial medical services usually privately provided, and on top of all this there are the nursing homes, and the private wards of voluntary hospitals serving a similar purpose.
A mere list of all the agencies does not indicate the full complexity of medical care. The real complexity arises from the fact that not all these services are available to every patient, that the route to be followed from one to another is not always the same, and that those services which are available to one member of a family may for a variety of reasons be quite outside the reach of another member of the same family. It must be emphasised also that the accident of geographical position may render it possible for a patient to obtain every possible type of medical service, yet if he moves to another district inside what is after all a relatively small country he may find nearly all those medical facilities entirely lacking.
The nature of the complexity and chaos of our medical services may be more clearly seen if we consider how medical care is obtained by individuals. In the case of that very small proportion of the population which has a high income the matter is relatively simple if they live in London or a large city, or can afford to seek their medical advice at such a centre. For all except the most trivial illnesses the general practitioner will have no hesitation in calling in a consulting physician or surgeon and will be able to arrange at a suitable fee for all specialist examinations. If hospital care be required, the patient will be sent either to an expensive nursing home or to the best room in the private wing of the voluntary hospital to which the consultants who have been called in are attached. When the serious stage of the illness is over and the patient is convalescent the need for abundant fresh air, sunshine and adequate diet will be met by a trip to the seaside or country, or in happier days to the Riviera.
In the case of those who are described as middle class because their gross income exceeds a certain unspecified amount the position is less satisfactory. The general practitioner cannot but be aware that while his own charges for even a prolonged illness may be paid, difficulties will arise as soon as the question of consultations and special investigations is brought up. If hospital care is required, the tendency, based to a large extent on snobbery and on ignorance of the conditions prevailing in our hospitals, will probably turn the sick person’s mind to nursing homes or the hospital private wards. Such expense is not to be faced without deep consideration, and it follows that, except in an extreme emergency or conditions where the need for hospital care overrides other objections, the general practitioner will be tempted to keep his patients of this class in his own care at home for as long as possible, and may delay calling in the necessary consultants until the disease is well advanced.
It is when we come to the lower incomes, which constitute some 85 per cent of the population and under war-time conditions of increased income tax would probably cover over 90 per cent that the real mix up in Medicine becomes clear. If we take an average family (see diagram), the extraordinary position is revealed that not only is there no provision for even minimum medical service for the whole family but there is no direct route to all medical services or even to one of them, and where an approach can be made it may be different for every member of the family. Thus the only person who is guaranteed the services of a general practitioner is the husband— let us call him Mr. Smith. (Since the war medical benefit, without the other benefits of National Health Insurance, has been extended to include adolescents in employment who are under the usual N.H.I, age of sixteen.) Mr. Smith may, however, have been unemployed for so long as to have ceased to be eligible for the panel, and his only source of medical attention will then be the parish medical officer. We may assume, however, that Mr. Smith is in employment. Therefore if his wife becomes ill she is in a position to pay a small fee for calling in a doctor. If she likes the panel doctor and if this doctor charges a fee which she considers low enough, she may call him in and so obtains the first stage of medical care from the same practitioner as her husband, but in a very large proportion of cases the wife actually calls in her own private doctor, a quite different person (for instance, a woman doctor). This is, however, not the only source of medical advice available to Mrs. Smith, for she has been a regular attender, both before and since the birth of her last baby, at the maternity and child welfare clinic provided by her borough council. If the baby is slightly ill she takes him to the same clinic for advice from the medical officer. In the case of a more serious illness she usually takes the baby along to the out-patient department at the children’s hospital. If she has to call in a doctor for the baby, or for John, her next child, she will most likely call in the doctor she would consult herself, though again this may be the same doctor as attends her husband.
John, being at school, is seen at regular intervals by the school medical officer, and he has once or twice been sent along specially because his teacher thought that he needed special attention. The school medical officer has records of John’s health since he went to school and so is in a position to note any change. He is not, as the law stands, able to prescribe any treatment at home, for the school medical service may diagnose, may treat minor ailments at the clinic, but cannot apply treatment in the home of the patient. If John is suddenly taken ill, therefore, he cannot be seen at home by the doctor who has been watching his health at school.
The remaining member of the family, Ruby, has recently left school and started work. Before the war she would have obtained her medical attention in the same way as her mother, but it is now possible for her to have a panel doctor although she gets no cash benefits while sick. She never has liked her father’s panel doctor and has put her name on the list of the only woman doctor on the panel in her district. But she has not yet needed the services of this doctor because the works at which she is employed provides a medical officer who examines all new entrants before they commence work, and sees them at regular intervals and attends them in the event of accidents or minor illnesses.
If the Smith family are lucky enough to have no very serious illnesses these different ways of obtaining the first stage of medical service may have no more serious results than the obvious ones, waste, inefficiency, and expense. But as soon, however, as the need for specialist and hospital treatment comes into the picture the chaos becomes intensified. We will discover that no member of the Smith family has any absolute right to hospital care or specialist services. The direction in which they will go for these additional medical needs will be dictated by whichever general practitioner they have called in, except where the preliminary medical examination has been done at one of the clinics we have mentioned. The general practitioner who decides that a sick member of this family must have another opinion or another form of treatment ;has at once to decide which of the two hospital systems he will patronise. He has to remember that the voluntary hospital retains the right to accept or refuse any particular patient, but cannot demand payment once it has admitted a sick person to its wards. On the other hand the municipal hospital cannot refuse the admission of anyone who is urgently in need of medical care but it can assess and demand payment for the service rendered. The portal of entry to each of the systems is different, and in the case of the voluntary hospital many considerations other than purely medical ones must be, taken into account. Thus the urgent surgical case or one which is of great medical interest and rarity will be more readily received than one of a common arid uninteresting kind while a really chronic condition may lead to an absolute refusal on the plea that no bed is available. If the Smith family can afford to pay for one consultation it may be worthwhile asking a member of the staff of the voluntary hospital to see the case, and he may then not only give his opinion and advice but be able to arrange for immediate admission to his hospital under his own care. Whatever the doctor decides, it is highly probable that both in view of the difficulties and of the fact that more than one general practitioner is likely to be attending to the family, one member of the Smith family goes to a voluntary hospital and another goes to the municipal hospital. The children will of course go to the children’s hospital, although there is in fact no reason why the general hospital should not have its own children’s department.
But many of the illnesses which the Smith family meet do not require admission to hospital but need the services of the consultants attached to the hospital or of the laboratory and X-ray methods of diagnosis. For these they are to a large extent dependent on the out-patient departments of the voluntary hospitals. There are, of course, some municipal hospitals which have an out-patient department and have the other facilities mentioned, but in the main these are obtainable only at the larger voluntary hospitals.
The position is rendered difficult by the fact that the general practitioner may wish a simple laboratory test, to confirm his diagnosis but may not be able to obtain this without sending the patient through the out-patient department because the hospital insists that these investigations can only be carried out at the request of the hospital’s own staff.
In many districts the question of laboratory facilities is complicated by the fact that even quite large hospitals do not run their own laboratory but send their work out to the commercial laboratories where for a fee per specimen all kinds of examinations may be made. On top of this there is usually an arrangement whereby investigation of cases suspected of being infectious can be done at the expense of the local authority. The reader must not, however, imagine that all such investigations will of necessity, be done at the one laboratory, for each Council makes a contract with a commercial or hospital laboratory for the work it wants done while examinations for suspected cases of venereal disease can be sent only to laboratories which are recognised as suitable for that purpose. In the most complicated of districts it is possible for the pathological work, relating to a family such as the Smiths to be carried out by five different laboratories. We must not assume that laboratory diagnosis consists only of sending specimens to a laboratory which issues results in a mechanical fashion. Clinical pathology is only of value where there is active co-operation between the general practitioner or other doctor and the pathologist who can in many instances offer exceedingly valuable suggestions when he sees the patient personally.
In the case of X-ray examinations this need for personal consultation by the radiologist— that is to say, the qualified expert— is essential except perhaps in the most simple fracture cases. Where the procedure of screening a patient (the direct examination of the body under the X-rays as distinct from the taking of a photograph) is carried out, the radiologist does see every case. In this specialty as with pathology, a much closer relation between the specialists and the general practitioner is urgently required.
In both these specialties, too, what is lacking is that they should be available to the Smith family in their own home. There are some occasions when the patient is too ill to move and the doctor would like very much to have an X-ray taken in the home, and there are a very large number of cases where examinations of the blood by the clinical pathologist would be of the greatest assistance. Medicine certainly can do more when it is able to use all these facilities, but the general practitioner must remain an incomplete servant of science and of his patients so long as he has to do without them.
It is not only for these special investigations that the Smith family are sent to the out-patient department. The correct use of these departments when they are staffed by consultants of recognised standing in the profession is as centres at which the general practitioner can obtain a higher opinion on those cases in which the diagnosis is not clear. Under ideal conditions a general practitioner would be able to send a patient for whom he wished the opinion of a specialist to see a man whose work he knew and whose opinion he valued, and would be able to arrange a definite appointment for that consultation. He would be able if he so wished to go with the patient and to discuss the case with the consultant. That is, in fact, what many general practitioners do in the case of patients who can afford to pay the full fees for a consultation. But all the doctor can do for the Smith family is to give them a note addressed to the out-patient physician and to send them to the hospital on the day on which that physician attends and at a time so fixed that they arrive at least one hour before there is even the slightest possibility of the consultants attending. During that period, and for as much longer as circumstances compel the patient to remain at the hospital, he must sit in a large and usually draughty out-patient hall surrounded by large numbers of other invalids, subjected to many possible types of infection and listening to harrowing stories of other people’s illnesses. P.E.P. goes so far as to say that “sometimes the provision of waiting-room accommodation in the voluntary hospitals is very inadequate, and crowded waiting-rooms spread infection besides being obnoxious to those who use them. Sometimes also the treatment is perfunctory and even inconsiderate,”
The worst feature of all is that the honorary staff of the out-patients may find it impossible because of the time taken up by their private practice to attend their out-patient session with any great punctuality, and junior officers often see a considerable number of patients. If the honorary is at all popular with his colleagues, he may have so many patients referred to him that he cannot give to the examination even a fraction of the time which he would insist was essential for the examination of a private patient.
This inconvenient and time-consuming method of obtaining a second opinion is not one which the Smith family obtains free, for every visit to the out-patient department must be preceded by a talk with the lady almoner, who, however she may endeavour to assist those who are really in need, extracts a very considerable sum of money in small payments. It is unfortunate that the almoners are so largely concerned with this extraction of cash from these patients because their work would be of immensely greater value if it included something of that checking-up on home conditions which we have already discussed, and if the “follow up” of patients was more efficient. The general practitioner and the consultant have no direct relationship to each other, no effort is made to see that both have in front of them the complete medical history of their patients, and it is very rare for the honorary physician or surgeon to make any attempt to keep in touch with the patients he sees unless they are of unusual medical interest.
Despite all these difficulties, inconveniences, and incongruities the Smith family do recover from their illnesses and have many times had to thank the medical profession for great assistance in defeating disease. Having got over the serious stage of an illness, it is important that before going back to work or back to school they should have a period for recuperation. Everyone is aware that a change of scene and a short period in the open air combined with gentle, exercise that tones up the system may make a very big difference in the ultimate health of a patient who has been seriously ill. For the Smith family the simplest way in which this valuable item of health restoration could be provided would be by a visit to a convalescent home. Yet convalescent homes are to a large extent divorced from the hospital system. A small number of voluntary hospitals and local authorities do run their own convalescent homes, but more than three-quarters of these in existence are financed by private philanthropic efforts. Of these many provide only congenial surroundings and are devoid of any real medical care or of those adjuvants, such as massage, and occupational and recreational therapy, which are so important at this period. The Smith family will, however, be very fortunate if they have subscribed to any fund which arranges for convalescence or if they are members of a co-operative society or trades union which provide for their members this facility, for the fees at such homes, according to P.E.P., vary from “what the patient can pay to what the management thinks it right to ask.” In recent years local authorities have begun to establish their own convalescent homes, and under the Local Government Act they may do so on a scale with which no other medical agency can compete. The shortage of beds in convalescent homes is, however, still very great, and the Smith family will be very lucky if any of them and particularly the children, receive this valuable aid to health.
Complex as this description and the diagram which accompanies it are, a complete survey of all the medical agencies reveals still further intricacies. In particular, one would be astonished and sometimes amazed to discover how great is the variety of such organisations and associations, religious, political, racial, academic, and fraternal, which concern themselves with medical matters. One would discover hospitals set up for highly-specialised functions which they no longer carry out, and if one further waded through all the complex legacies and endowments made for special purposes which have now no validity in medical science one would be astonished not that chaos remains in the medical services of the country but that there should have been such technical development as we have seen and that we should have reached any degree of organisation whatsoever.
It is only fair to say that the medical profession has not been unconscious of this complexity in our medical arrangements. All the organisations inside the profession have discussed and put before the public their views as to the future. The Socialist Medical Association of Great Britain, for example, has long advocated a completely socialised medical service, and has lately been joined by the Medical Practitioners Union in emphasising that the war situation has made the need for changes in Medicine very urgent. The British Medical Association also has had a policy on this question, but during 1940 felt the pressure of events to such an extent that it has set up a Medical Planning Commission “to study war-time developments and their effects on the country’s medical services, both present and future.”
The appointment of this Commission caused a correspondence in the medical press which lasted for months and indicated a very general realisation inside the profession that the isolated practitioner of the past, surrounded by the many agencies we have discussed in this chapter, must at no distant date give place to some new type of organisation, and that it is time the; medical profession itself seriously considered the position: and put forward its own, suggestions.
The first meeting of this Commission, in May 1941 revealed a strong feeling that, as the Chairman, Mr. H. S. Souttar, put it, ”every individual should have at his service, whatever his economic status all necessary medical resources. It is suggested that the report of the Commission may not be ready until late 1942, but Mr. Souttar gave his opinion that this would not be too long to spend on “problems that are complex and difficult, but upon the solution of which would largely depend the health of the nation.”