Volume 2. Number 2. NOVEMBER 1933

The Official Organ of the Socialist Medical Association.

PRICE THREE PENCE

EX-MINISTER OF HEALTH AND THE S.M.A.

IN introducing ourselves we claimed that the justification for placing a new journal before the public was the need for new ideas in health matters. This point is emphasised in a letter we have received from the Right Hon. Arthur Greenwood, M.P. (the ex-Minister of Health). Mr. Greenwood says :-

“I am very glad to hear that the Socialist Medical Association has decided to issue a publication which will be devoted to urging the claims of a publicly-controlled health service. There is no more fundamental problem than that of the health of the people. Experience has shown that prevention is better than cure. It avoids unnecessary human suffering, and it is, in the long run, far more economical.

“The existing public health service has laid the foundations of preventive medicine. It recognises the provision of an adequate and pure water supply, of a proper system of drains and sewers, an effective system of refuse collection and disposal, of the vital importance of proper housing accommodation for the people. It realises, in a word, that a healthy environment is indispensable to the maintenance and improvement of the health of the people. The public health service has therefore become a part of the social organisation of the country.

“Parliament, which created the public health service, has also recognised that there are certain individual human needs, apart from the need for a healthy environment for the community as a whole. And in the interests of public health and well-being, school meals have been provided, school medical inspection and treatment instituted, though on a some­what restricted scale, and a maternity and infant welfare service has been established. Finally, Parliament brought into being a system of National Health Insurance.

“A great part, therefore, of the medical service of the country—preventive and curative—is already under direct public control. But the situation is far from satisfactory. We have to ensure that the whole medical profession works as one in the interests of public health; that the results of research and experience are available for all; and that the necessary institutions and equipment exist to enable doctors and nurses alike to carry out their public duties.

“It is one of the functions of the Socialist Medical Association to mobilise opinion- both in the medical and nursing professions and outside them, in these directions, and I hope its new venture will prove to be a powerful ally in these tasks.”

THE PEOPLE’S HEALTH IN SWEDEN

by SOMERVILLE HASTINGS.

IN Sweden they seem to be solving to some extent the difficult problem of the transition from Capitalism to Socialism—at any rate this is so in regard to health questions, about which alone I am entitled to speak, since the ten days I have recently spent in Sweden were given up almost entirely to an intensive investigation of the medical services of that country. I was not a little surprised to find there a mixture of Socialism and Capitalism working in practice much better than I should have anticipated, the principle apparently at present accepted being that no one shall lack the very best that medical science can give for want of the means to pay for it, but that everyone shall pay at least something, if able to do so.

Sweden has now a Labour Government, but it is a Government without an independent majority. The development of the services which I am about describe has therefore resulted more from the education of the public opinion by the Socialist Party through a number of years than from legislation brought in by the Government now in office.

Doctors are relatively less numerous Sweden than in England. I would not like to say that there are better doctors there, but certainly their period of training is longer, being eight years instead of five, and a much larger proportion of the population is drawn upon in the selection of the doctors. In England, as is well known, there are no maintenance scholarships of sufficient duration to allow the holder to qualify for a medical degree.

In Sweden, on the other hand, there are scholarships from the primary to the secondary schools, and from the secondary schools to the universities, that any child has the opportunity becoming a doctor. Only instead of making these scholarships entirely free, part of the cost of maintenance and education is granted to the student on loan, and has to be paid back gradually after qualification. This is undoubtedly a considerable handicap, but it does at least get rid of the class-bias that we have in England.

In Sweden every district has its own medical officer, who is paid a fixed salary by the State, and everyone living in that district is permitted to take advantage of his services if he cares to do so. I saw little of the practical working of this system, as most of my time was spent in the hospitals, and I have no hesitation in saying that, as far as I could judge, both in organisation and equipment the Swedish hospitals are the best in the world.

The hospitals of Sweden are provided by the State, and are of two sorts —town hospitals and county hospitals. In Stockholm, for instance, there are two principal hospitals, one with a large out-patient department providing service for the town, and a second supplying the requirements of a large area of South-Eastern Sweden.

The Swedish hospitals themselves are models of comfort and efficiency. The wards are small, and usually contain from four to eight beds. There are also side wards containing a single bed to which patients who are likely to disturb their neighbours can be moved. A special feature is the day-rooms with easy chairs, pictures, plants, and flowers, as well as tables for meals; and patients who are able to get up, instead of sitting dolefully at the foot of their beds, spend most of their time in these rooms. The waiting-rooms for out-patients are equally comfortable, and are provided with magazines and periodicals.

But although the hospitals of Sweden are provided, equipped, and financed by the State, they are not free. Everyone can use them who cares to, but a charge of two shillings a day is made, to those who can afford to pay, for board, operations, and all necessary treatment. In most of the hospitals there are also paying wards, and for accommodation in these a charge is made of twelve shillings a day in the case of single-bedded wards and six shillings a day for wards with two or three beds. In such cases a small charge is usually made by the hospital doctor for operative or other treatment. To a Socialist such a scheme as this must of necessity appear somewhat undesirable. I therefore made careful inquiries about it and was surprised to find it working well. One thing I am sure of: the patients in the general wards had no reason to complain of the treatment they were receiving.

What impressed me most of all in the Swedish hospitals were the excellence of the operating theatres and equipment generally, the very latest types of apparatus from all parts of the world being provided. The doctors in the hospitals obviously enjoyed the fullest confidence of their patients, and there was none of that military spirit that one often sees in the hospitals of Germany and other parts of Central Europe. Almost invariably the doctor shook hands with his patient before asking him questions or carrying out any examination or treatment.

Lastly, from the point of view of the advancement of medical science, the State hospitals of Sweden are an undoubted success. The doctors appear to have time to do their work thoroughly, they have every facility for dividing up their work and specialisation, and are assisted in keeping accurate records of their cases, not only by the provision of the necessary secretarial assistance, but also by the State paying travelling and maintenance expenses of patients returning to hospital for inspection. It will be readily appreciated, therefore, that their contributions to medical literature are valuable and extensive.

We are opening our pages to a few selected advertisements, and we hope our readers will give them careful consideration.

A National Maternity Scheme

THOUGH the need for a National Maternity Service is generally admitted and public opinion is ripe for the launching of such a scheme, it is as well before discussing the details to restate the grounds for the belief that this service is necessary.

There is not the reduction in mortality and morbidity in midwifery that has been achieved in other branches of medicine and surgery in the last twenty or thirty years. And yet in certain maternity services in this country and in some foreign countries remarkably good results are obtained over the. course of many years. Careful study of the factors behind these seemingly contradictory conditions have been made by the Departmental Committee on Maternal Mortality and Morbidity, and the results of its findings are instructive.

The careful investigation carried out into the cause of death in more than 5,000 cases showed that no less than 45.9 per cent, revealed a primary avoidable factor. The report not only shows the cause of death, it also points out where the responsibility for that death lies. It groups the sources of error into four classes, and gives the relative degree of blame.

(1) Lack or failure of antenatal care……..15.3%

(2) Error in judgment 19.1 %

(3) Lack of facilities 3. 7 %

(4) Negligence on the part of the patient………………7.7%

The ideal scheme must be capable of eliminating each of the four groups of primary avoidable factors detailed in the report, elastic enough to be modified to meet the geographical and sociological needs of the area, economical in that every penny of public money is used to the fullest and to the best advantage, and secure enough to attract to it workers of the highest standing.

The following scheme is outlined as an attempt to formulate a complete unit.

The maternity service must be a public service—-publicly financed. It must be linked with a general improvement in the standard of living of the people, particularly in relation to the important matters of housing and nutrition. It must be associated with careful educational propaganda not only of the patients and their friends, but also of the medical and nursing professions.

The scheme should be supervised nationally by the Ministry of Health and locally, at the present time, by the sanitary authorities responsible for the maternity and child welfare, though ultimately one must visualise a change in this unit for the complete health unit outlined in “A Socialised Medical Service.”

The Supervising Services.

In urban areas antenatal clinics should be held in easily accessible places. Long journeys must be avoided for the sake of the mother and for the popularity of the clinic. Large clinics also must not be allowed, and waiting an undue time must be prevented.

It is not essential, and it is indeed impracticable that the antenatal clinician should be on call for emergencies; but it is highly important that there should be close co-operation between those responsible for the confinement and the clinic. All abnormalities should be referred at once to hospital or to the doctor booked for the delivery. A case that has booked to go into hospital for the confinement should attend the local clinic for her routine supervision, but should be seen at hospital at the seventh and eighth month, and at term.

The midwives working in the area should have the right to attend the clinics with the cases, and should have access to all the records of their patients. These records should contain, as well as the observations of the pregnancy, details of the home conditions, history of the previous pregnancies, past illness, and general health. Postnatal clinics should be set up in association with the antenatal clinics.

The Domiciliary Service.

The ideal place for a mother to bear her child is in her own home, provided that home is sanitary, suitably equipped, free from infectious disease, and in touch with emergency assistance in case the unexpected happens.

Midwives should be responsible for normal cases. They should be on a whole-time basis, working in a team within the area prescribed. They should be directly responsible to the Medical Officer of Health. Their training, conditions of service, and accommodation should be on a better scale than at present obtains.

Home helps should be provided for all patients who need them whether the mother is delivered at hospital or at home.

There should be a panel of medical practitioners in the area—later the home doctor of the socialised medical service—who are capable and willing to serve on call. This panel should be made by the Medical Officer of Health, and the doctors should be responsible to him. They should serve on a rota in a similar way to the present staffing of cottage hospitals. A panel of anaesthetists should also be made.

Each area should have obstetrical specialists appointed in sufficient number to assure immediate aid should a call come. These should be associated with the local hospital.

The Hospital Service.

All cases of diagnosed abnormality, all cases of previous difficulty, all those showing concurrent disease should be confined in hospital. Patients whose home conditions are not up to standard, and those who have members of the household suffering from some grave disease should have their confinement in hospital. Primigravida and those desiring to enter hospital should be accommodated, if possible. The general hospitalisation of maternity work would, however, be both undesirable and costly.

The maternity unit should be part of a general hospital and not greater than fifty to sixty beds. The unit should be made up of small wards, six to eight beds in size for normal cases. Single-bedded observation wards should be available, and labour wards should always be single-bedded, and away from the lying-in wards.

All infected cases should be in isolation hospitals quite apart from the general hospital and its maternity unit.

The hospitals should have consultative antenatal clinics, at which should be seen the cases booked to come into hospital for their special examinations as detailed above.

Esther Rickards.

THE AUTUMN CONFERENCE

AS previously announced, an autumn conference of the S.M.A. will be held on Sunday, November 19th, to discuss “A National Maternity Service.” The meeting will be held at 12, Park-crescent, W.I, and will commence at 10 a.m. Dr. Esther Rickards’ proposals for a maternity service will be before the meeting. It is hoped to give a fixed amount of time to each section of her scheme, so that at the conclusion the executive should be in a position to prepare a scheme likely to be acceptable to the whole association.

-AND A REVEL

On the Saturday evening preceding the conference, November i8th, at 8 p.m., the association will meet in what has been called “A Revel,” to be held at 170, Regent-street, W .1 Tickets, 5s. 6d. each, provide for dancing, buffet, and cabaret. We hope to see all members, associates, and friends really revelling in the entertainment provided by Dr. Summerskill and her committee.

HOSPITALISATION AS THE BASIS OF A MATERNITY SERVICE.

FOR the past twenty years the maternal mortality rate has remained more or less stationary in England. During the last year there has been some change and the maternal mortality in England and Wales has risen. This is a disgrace to a country which claims credit for its health services. In my view the time has come when money should be spent freely on some scheme which would reduce very considerably the maternal mortality.

Any comprehensive maternity scheme must begin with some form of notification of pregnancy. In view of the opposition that this will probably arouse in the older mothers, the time of notification might be fixed at five months pregnancy.

The Departmental Committee on Maternal Mortality has emphasised the need for the best possible conditions or every confinement. I would lay down the following as essentials:-

(1) Sufficient room and ventilation, with a plentiful hot water supply and a state of ” surgical ” cleanliness.

(2) “Specialist” nurses and doctors, who could work without being hurried.

(3) Complete freedom from work and mental strain for the mother during the puerperium.

These conditions are impossible in he homes of working-class mothers, for whom I regard confinement in hospital as essential. We know the all too familiar picture if a confinement in a poor home. The family is herded in one room, children are present, hot water is scarce, and he patient, lying on newspapers, is the victim of the friendly, but dangerous, ministrations of the neighbours.

The schemes for a maternity service already proposed, including that of the British Medical Association, are grossly inadequate. There is mention in them of a greater supervision of cases, better tuition of doctors and nurses and the provision of a service of obstetricians. Yet in spite of these benefits, the children of the workers can. still be born under the appalling conditions referred to, if the mother cares to stay in her own home.

Unfortunately, we cannot change immediately the environment and the economic conditions of expectant mothers, but we can at least ameliorate their lot at the time of the confinement by giving them hospital accommodation. Uncomplicated cases should be dealt with in small local hospitals. Each hospital might hold thirty patients, and be under the supervision of one matron. The size of the district would determine the number of these hospitals.

Complicated cases should be sent to a large hospital preferably attached to a general or teaching hospital.

It is desirable that the small local hospitals should be staffed by young, keen doctors with special obstetrical experience, who should be encouraged by post-graduate training to keep up-to date. The ante-natal clinic should be conducted by the medical officer of the local hospital, the patients having a fortnightly examination after the thirtieth week.

The staffing of these small local hospitals in large industrial areas presents very little difficulty, as probably one medical officer could have charge of more than one hospital. In the rural areas where the work would hardly be sufficient for one medical officer, it might be necessary to co-opt a local practitioner with special experience of midwifery on to the staff.

The complicated cases would be dealt with by the obstetricians attached to the large central hospital; these doctors would be paid by the session, but those in charge of the local hospital would have full-time appointments.

One of the two chief objections raised is the expense. The patient must stay in hospital for two weeks, and the cost per week would be in the neighbourhood of £5. A sliding scale of charges could be adopted according to the family income; the rest to be subsidised by the State.

The second objection comes from, or is supposed to come from, the medical profession. The authorities feel that at all costs medicine must be safe­guarded, and to remove midwifery from the sphere of the general practitioner would be disastrous to him financially.

This is a fallacy. The income derived by general practitioners from confinements is not commensurate with the responsibility and work entailed. Most doctors would welcome with relief the removal of midwifery from their practices.

The time has come when we must recognise only one interest—one that has long been ignored—the interest of the expectant mother.

Edith Summerskill.

MEMBERS WANTED

Membership (fee ids. 6d) of the Socialist Medical Association is open to all medical men who are Socialists; associate membership (fee 5s.) is open to all Socialists who are members or students of professions allied to medicine. Information and application forms from Dr. C. W. Brook, 72, Balham Park-road, London, S.W.I2.

” The Socialist Doctor ” is published quarterly, price 3d. Copies may be obtained from the secretary at the above address, or the Editor, 74, Brim Hill, London, N.2.

MOVEMENTS

MUCH of the work of the S.M.A. is carried out by the Executive, and since our last issue the chief movement towards a State Medical Service has arisen in connection with the activities of the E.C. Much time has been spent on the question of working out details of various aspects of a State service, and two committees have been formed to prepare reports. The first committee is to collect information on the present cost of medical care in this country, and to prepare an estimate of how much a complete State service is likely to cost. A second committee is to consider what problems of general and industrial disease will require a detailed policy to be worked out in advance of the establishment of a Socialist service. To begin with, this committee will collect data on nutrition and prepare a report on the present nutritional state of the working class, and on the type and cost of a really satisfactory diet.

This matter is of increasing importance, and a complete survey of the present condition of the working class is badly needed. We hope to deal with it in a future issue. Meanwhile, it is to be hoped that the resolution passed at the Labour Party Conference at Hastings will bear some results. It will be recalled that the S.M.A. resolution called on the Government to institute an inquiry into the diet necessary for health and to take steps to ensure that an adequate diet was available to every member of the community.

At the Labour Party Conference a statement was made that the resolution passed at the last conference calling on the party to prepare its scheme for a socialised medical service had not been forgotten, but was being actively considered. At the conference, also, the opposition of the S.M.A. to a resolution supporting “Naturopaths” resulted in its being unanimously rejected. Mr. Somerville Hastings showed the weakness of this motion by pointing out that if a boilermaker is to be permitted to treat disease, doctors would be equally justified in repairing boilers.

The E.C. has also been considering the question of the so-called “London Medical Service” and the next meeting of the London and Home Counties branch will probably be given over to a discussion of this scheme. The “Daily Herald” gave this scheme something of a boost, implying that it would solve the medical problems of the working class. Mr. Hastings and Dr. Brook at once replied to this, and although only a part of their letter was printed, it was enough to show that this scheme really leaves the problem untouched.

The Executive has also had considerable correspondence from victims of the Nazi terrorism in Germany. The London and Home Counties branch on October 11th, had an opportunity to meet one or two refugees and to hear a paper by one of them. This was a stimulating description of the public health services of Germany as they existed before the Hitler regime. Space does not allow even a summary of this address, but we hope to return to it in a future issue. The meeting was very grateful to the German comrade who gave the address.

D. S. M.

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