A National Service for Health

by SOMERVILLE  HASTINGS, M.S., F.R.G.S., M.P.

Two lectures on a National Service for Health given at an International Vacation Course at Munster University, Germany, July, 1948.

I The Health Of Each Is The Concern Of All

Positive health is much more than the absence of active disease. On it depends both our ability to work and our capacity to enjoy life. Illness results not only in pain and suffering but also in frustration, the result of inability to carry out our plans and intentions. Many estimates have been made of the cost of illness to a nation in terms of decreased production and expenditure on the treatment of the sick, but nearly all these omit the capital value of the individual, that is money expended on his food, clothing, housing, education, etc., before work begins and the consequent loss to the nation if he is cut off before his working life is complete.

That much can be done to improve health is shown by the fact that in Britain the prospect of life for the average citizen has been increased by 19 years since 1871, and that also in Britain the mortality of mothers in childbirth is now only one-third of what it was ten years ago, and the infantile death rate is now but a third of that of fifty years ago.

It has been suggested that since the main cause of illness is poverty with all that it means in lack of food, clothes and shelter and unhealthy conditions of life, it would be better for a nation to expend all its available resources in improving these rather than in the develop­ment of a curative health service. In this connection it is pointed out that while the average age of death in New Zealand is 67 it is approximately 30 in many eastern countries, and that in Britain the death rate from measles and its complications in children is approx­imately nineteen times greater in the poorer classes than in the middle and upper, and that the corresponding figures are—for bronchitis, six times, whooping cough, seven times, and acute rheumatism, twelve times greater.

While there is some substance in this argument it is necessary to point out (i) that the prevention of disease cannot be separated from its cure; (2) that the results of modern curative treatment of cancer by surgery, radiation and other methods, and of infective diseases by sulphonamides and penicillin, to mention two examples only, are too valuable to be neglected; (3) that anyone when faced with illness in himself or his intimate friends will demand treatment and refuse to be put off by a dissertation as to how the trouble might have been prevented.

There are two fundamentally different conceptions regarding health and disease.

The first, the individualistic, suggests that health must be looked upon as a personal matter, of interest mainly if not exclusively to the individual concerned. It is admitted, of course, that good health is a useful thing to have, and if one can acquire the money to provide food and shelter sufficient to keep oneself and family in health one is to be congratulated. But if one cannot one must make the best of it and not complain. In the same way it is suggested that the best treatment in sickness is a great blessing to those who can afford to pay for it, but those who cannot must get along as best they can with something inferior or nothing at all.

The other outlook, the co-operative, suggests that everyone should have an opportunity of living a healthy life and that all possible help and instruction should be given them in doing so. Moreover, the best that medical science has to offer should be at the service of anyone when he is ill, and this independently of whether he can afford to pay for it or not. Those who accept this second outlook do so not only because they believe that it is ethically right but also because they know that it is economically sound, because each one is to a large extent dependent on the rest.

Our health needs are also provided by two separate and distinct methods.

(i) By co-ordinated and co-operative effort organised locally or nationally. Such services are for the most part for the benefit of all who are willing to take advant­age of them, and some, like those for the control of infectious disease, are made compulsory. They were at first mainly preventive in character and still are so to a considerable extent in many countries.

(2) The medical needs of the public are also in part provided by private enterprise through general practi­tioners and specialists who are in private practice, as well, as by certain hospitals. There is neither public responsibility nor public accountability for these services.

Every doctor will agree, I think, that it is mainly the preventive services, organised by co-operative effort either locally or nationally, that have been responsible for the increased expectation of life of the average citizen.

In Britain, by careful supervision of our water supply we have almost completely wiped out those terrible epidemics of cholera and typhoid fever that we had in the past; by instruction in our maternity and child welfare centres, and cleaner streets, we have to a large extent disposed of those attacks of infantile diarrhoea that used to be such a menace to child life; by notifica­tion, isolation and disinfection we have been able to reduce the incidence and mortality of infectious disease.

The history of public health legislation and admin­istration during the last fifty years in Britain is a record of how people who did not believe in nationalised medicine and did not want it have been compelled to discard that private enterprise they so much trusted, to secure efficiency. It was only when each individual householder had been persuaded to give up his own particular well, in his own particular back garden, with the cesspool running into it, and had agreed to the collective provision of a pure water supply and an efficient drainage system, that the health of the people began to improve.

People are beginning to enquire everywhere why this same collective provision of services that has been so successful in the prevention of disease should not be applied more and more completely for its cure as well. Why, in other words, the nation or the local authorities should not be made responsible for the organisation of the necessary services tor diagnosis and treatment.

There are many reasons why it is dangerous to leave the treatment of disease to the tender mercies of private enterprise, with the doctor financially dependent on his patient. When people buy food and clothing or any of the ordinary things sold in shops, they soon discover the quality of the product purchased. But when they purchase the services of a doctor in sickness they are unable to fully estimate the quality of the services rendered. They can, of course, say if the doctor is kind and attentive, but they can have no conception whether the treatment they are receiving is up-to-date and efficient.

The quality of most of the goods that are bought and sold is mainly the concern of the purchaser, but the quality of the medical treatment received by the in­dividual in time of sickness is the concern of everyone, because the real strength of a nation depends most of all on the health and capacity of its citizens in both mind and body. In all civilised countries it has been agreed that it is undesirable in the national interest to permit any child to grow up without education, and in consequence nearly everywhere a national system of education has been developed which in most cases is provided either free or at slight cost to the parents of the child. But important as education must be, health is even more essential. In the national interest, therefore, there must be no financial barrier to prevent an individual from seeking medical advice directly he feels the need for it, for in health matters perhaps more than in any other, to quote a well-known English proverb, “a stitch in time saves nine.”

There is some evidence to show that unhealthy people are liable to be a danger to others as well as themselves. It is obvious that if people, unhealthy from any cause, are attacked by infectious disease, they will most probably suffer from this disease more severely than would healthy people, but what is not so obvious is the fact that in many cases when an infectious disease attacks unhealthy people it may apparently take on a more severe form and so spread to people who would not otherwise be affected.. We have all heard how plague or other infectious disease had attacked people in a famine area and there acquired sufficient virulence to spread across a continent.

It is the concern of the doctor in private practice to treat only declared disease when its symptoms are sufficiently severe to cause inconvenience or interfere with working capacity. It is not his business to prevent disease or keep his patients well, and until recently he has been able to acquire but little training in this direction as a medical student. The doctor in private practice is not concerned with seeking out the causes of disease and trying to remove them, nor is he always in close touch with the preventive services of the area in which he works.

If we accept the principle that it is the duty of the nation to prevent disease, it is not difficult to show that the development of a complete national health service to provide curative as well as preventive treatment is the only logical way to fulfil this duty.

Many years ago it became evident that many cases of infectious disease could not be satisfactorily treated at home, and fever hospitals were provided. When these hospitals were first started in Britain they were regarded mainly as a variety of prison, in which people who were a danger to the public could be shut up until they became harmless, and it was in the first instance largely because of the heavy cost of long detention that treatment was provided so that the sufferers from infectious diseases might safely return to their ordinary duties in the shortest possible time. What our forefathers discovered as the result of experience was that one could not possibly separate prevention and treatment, that by treatment one actually helped prevention.

Now the great discovery of the close association between prevention and treatment, first made in con­nection with the infectious diseases, has had to be applied with modifications to many other conditions. To assist in the prevention of venereal disease clinics have been opened where treatment is given by experi­enced surgeons. To prevent consumption many countries have adopted much the same method, and it is true to say that the principal preventive measures that are carried out are the early recognition and treatment of disease.

If free treatment is provided for consumption, venereal disease, diphtheria and smallpox in the public interest, why should not the same apply to treatment for cancer, rheumatism, and other diseases which cause as much suffering and national loss. Rheumatism in its various forms probably produces even more invalidity than cancer, and heart disease has a higher mortality rate than either. Surely public provision should be made for the treatment of these diseases.

The tendency to add the public provision for treatment to that for prevention of disease, once started, is bound logically to continue and extend and to be applied to an ever-increasing number of diseased conditions. But this piece-meal provision for the treatment of disease, valuable as it has been in the past, has its own peculiar dangers. We have been so busy with treatment that we have forgotten that something is necessary before treatment is commenced, for a diseased condition must be diagnosed before it can be intelligently treated. It is essential, therefore, to bring in the general practitioner, who is first consulted in illness and whose business it is .to recognise the nature of the diseased condition if the best is to be done for the sufferer.

If it is true to say that to prevent we must treat, it is equally true that to treat efficiently we must treat early.  However good a service for treatment may be, however specialised the methods adopted, unless it is concerned with the earliest recognition of disease the result will be imperfect. A National Health Service must, therefore, include a sufficient number of capable general practitioners whose duty must always be to diagnose disease in its earliest forms as well as to refer it for specialised treatment when this is necessary.

To sum up then, there is no rational stopping place between the first incursion of a nation into preventive medicine and a fully developed National Health Service. If we want to prevent we must treat as well, and if we want to treat intelligently and efficiently we must make provision for correct diagnosis and for the recognition of disease at its earliest beginning.

II What Sort Of Health Service Do We Want?

In my first lecture I endeavoured to show that some form of National Health Service was essential in the public interest. But what kind of service should it be? It may be useful to endeavour to answer this by postulating a series of further questions.

i. Should the service be curative as well as preventive? For many centuries the preventive and curative services, as far as they have been organised at all, have been running in two parallel but entirely separate streams. Rome, Nineveh and Athens had drainage systems, and the cholera epidemics of the middle of the last century compelled many cities to provide both sewerage and a pure water supply. But hospitals for the treatment of the sick have existed in Britain and other countries for about 900 years. It is however only during the present century that the inseparability of prevention and cure has begun to be generally recognised. It is essential if the best results are to be obtained that the dividing line between these two should be broken down and that every doctor should be closely associated with the preventive services, and that his duty should be, not only to treat declared disease, but also to en­deavour to discover how it may be prevented both in the individual affected and in others like situated. He should give instruction to those for whose welfare he is responsible, both individually and collectively, in the care of health and encourage them, when time permits, to come for medical examination periodically.

2. Should the whole or any part of the health service be paid for by Insurance?

In Britain, Belgium, Sweden, Norway, Austria, Switzerland and Poland, part of the cost of the prevention  and cure of disease is borne by insurance payments, but in France and Holland the whole of the cost of treatment is paid by insured persons. In France, Belgium and Sweden, part only of the “fees paid by insured persons to their family doctors is reimbursed to them. This is particularly undesirable as even part payment of the cost of treatment may act as a deterrent and prevent the seeking of advice at the earliest possible moment. There can be no special .objection to using some part of insurance payments for the provision of curative treatment provided that no one is excluded. This has, been secured so far only in Britain and Sweden in which countries preventive and curative health services are being made available to everyone in the land.

1. If any part of the cost is borne by insurance, should this be compulsory?

Conditions vary greatly in different countries. In Norway for instance, three-quarters of the population are covered by insurance, about half compulsorily and a quarter voluntarily. Germany, France, Belgium and Holland restrict medical benefit to certain occupational and income groups. In Denmark, all must be active or passive members of a sick club. In Britain, all under 65, except children, married women, and those undergoing full-time education, have to pay insurance, some of which goes towards the cost of the National Health Service. In nearly all countries, with the exception of England and Sweden, health insurance is not all-embracing. Some provision has, therefore, to be made for the residuum who are unable to afford doctor’s fees. This may be made the responsibility of the local authority or commune, as in Italy and Denmark, etc., or the local authority may step in only when charitable organisations fail.

Any system that divides the nation into two classes as regards the treatment of ill-health is most undesirable as it is liable to result in two standards of service, one tor the better-off and the other for the poor. In illness only the best is good enough and that in the interest of both the individual and the nation. When Sultan el Mansur Gilavun opened his great hospital in Cairo in 1283, he said: “I have founded this institution for the King and the servant, for the private and the emir (general), for the rich and the poor, for the free man and for the slave, for women as well as for men.”

1. To what extent should Voluntary Services be made use of?

In Britain sickness insurance started in a voluntary way with the sick clubs. In 1911 it became compulsory for wage earners, and the larger of the sick clubs became “approved societies.” In 1948 compulsory insurance was extended to all and taken from the “approved societies” to be administered nationally. But in most other countries, e.g. Holland, Denmark, Belgium, Germany, France, etc., health insurance is still effected through the agency of friendly societies. Once the need for a universal health service is admitted it is difficult to see what essential function friendly societies can perform. In Belgium and Holland a good deal of health work is carried out by voluntary societies with a religious or political bias, and in Britain until recently nearly one-third of the beds available were provided by “voluntary” hospitals supported by voluntary con­tributions, endowments, and contributions from patients and local authorities. There is a good deal to be said for the local interest and pride inherent in such a system, but such advantages are in no way inconsistent with those of a unified system in which the quality of the services everywhere is assured.

j. Should the service be complete, providing everything’ necessary for the prevention and cure of disease?

It is obviously in the interest of all those covered by sickness (benefit) insurance that the health service should be as complete and efficient as possible, so that the calls on the insurance funds may be few and of short duration. Moreover, valuable as the family doctor must always be, the hospital that deals with serious cases, both acute and chronic, and those requiring operation is equally necessary. But in addition, nurses in the home, as well as health visitors and midwives, the provision of ambulances, and dental, ophthalmic and other specialist treatment, and convalescent homes are all necessary parts of a complete service. Instruction in the laws of health and periodical medical examina­tion should also be encouraged.

1.   Should the doctor be employed whole or part-time?
   There can be only one answer.  It is admitted that the public may demand the right to consult another practitioner for payment when they are dissatisfied with the opinion of the doctor and specialist provided by the national service but this can be readily secured if some doctors continue in practice outside the scheme. But to permit a doctor under contract of service, whether paid by part-time salary or by capitation, also to under­take private practice is to ask for trouble. If two cases of equal urgency present themselves and if he knows that for one he will be paid in any case, while for the other remuneration depends on immediate attention, a doctor, being human, will generally deal with the latter first. This must imply two standards of service which should be impossible under a national scheme. Moreover, if a patient has the right to see a doctor without payment during certain hours of the day, it is difficult to see why he should decide to visit this doctor at some other time and pay for it, unless, of course, he has reason to expect that he will receive better treatment by so doing. This again must imply two standards.

7.    Should the doctor if part-time be paid by sessions worked, capitation, or items of service?

Britain, Denmark and Holland pay their general practitioners by capitation, but in Britain the addition of a small basic salary as well is under consideration. France, Belgium, Norway and, Sweden use the fee for service basis. Specialists are generally paid by fee for service, but in Britain some specialists are full-time and some are paid per session. Some of the objections to payment per session have already been dealt with-Capitation has its advantages in that the doctor is able to provide exactly the type of service that in his opinion each case needs without this being criticised by any supervisory authority for too much attention. But the competition and struggle for patients that is inevitable in capitation must make co-operation and team work difficult, and this is especially the case where doctors are working together from health centres. Moreover, where the ratio of doctors to population is relatively high, it must mean much waste of time for a doctor settling in a district while he builds up a practice, and some unpleasantness if this entails the enticement of patients from other doctors. Payment by item of service is probably the most expensive and least satis­factory of all as it is certain to involve disputes with the authority that pays as to whether all the services rendered were really necessary.

The German system is unsatisfactory and complex. When the insured person or his dependent is ill a demand for treatment is obtained from the office of the friendly society. This is taken to a doctor in the public service who accepts it and with it an undertaking to treat the individual for all afflictions for the next three months. The sum paid to the doctor for this depends on the incidence of sickness in the previous year and varies within fairly wide limits. .The doctor has a vested interest in ill-health and the complaint that the Germans make that too many trivial cases are seen by doctors is easily explained by a desire of patients to repay their doctors for past kindnesses.

1.     Choice of family doctor, is the rule almost everywhere.
   Where payment is made by capitation there is usually a limit to those accepted. What is of real importance is that there should be facilities for rapid change if doctor and patient find that they are temperamentally unsuited to one another and either desires this. It is not always recognised that choice of doctor is just as easy under a full-time service as under any other. Under such a service there must, of course, be a limit to the number of potential patients accepted. Thus the very popular doctor might have a waiting list and the new comer to a district have to put up with a substitute for a time. But this is exactly what happens under capitation to-day.

9.            How should the health services be organised?
Health being to a large extent a personal matter, there are many advantages in local administration. On the other hand it is essential that in a National Health Service standards should be maintained and no area allowed to fall below what is reasonable. This implies some centralised control as well. The tendency in hospital development is for more and more specialisation, and this means the bringing together of many hospitals into a single administrative unit for planning purposes, with perhaps considerable sub-division for administra­tion. The ideal would, therefore, seem to be a central planning unit with a population of about two to four million, divided up into a series of administrative units of 100,000 to 300,000 people, each of these units being administered by popularly elected representatives and each, therefore, responsible to an electorate. But if the scheme is financed entirely from the centre there may be insufficient urge to economy in administration at the periphery. It is preferable, therefore, that some of the finances of the scheme should be provided locally through a local rate or tax.

It is of importance that all the workers in a health service should be able to take their share in the administration and development of the service in which they work. This can best be achieved by means of advisory committees representative of all grades with direct access to the elected bodies in charge, and also by some direct representation of those employed with full powers on these bodies.