Presented to the Labour Party Conference 1934
A STATE HEALTH SERVICE
A Sub-Committee appointed by the National Executive Committee has had under consideration recent Annual Conference resolutions relating to a State Medical Service, and has prepared the following Preliminary Report.
Because of the complicated nature of the subject, and in particular the difficult relationship of National Health Insurance, the Approved Societies, the Medical Profession, and the local Public Medical Services, it has been thought desirable to seek the general views of Conference on the proposed lines of policy, before asking the Sub-Committee to proceed to further detail.
PRIMARY CONSIDERATIONS
At the present time, medical care is provided in four main forms—the private practitioner, the voluntary hospitals and other voluntary services, National Health Insurance, and the various Local Authority services, including the Poor Law.
Assuming, for the purpose of this preliminary Report, that the aim should be a State Health Service, the first question to be decided is whether such a Service should be built (a) on National Health Insurance (by its extension to dependants, etc.), or (b) on the Local Authority Health Services.
It is suggested that the proper course is the latter.
NATIONAL HEALTH INSURANCE
If this be accepted, it is difficult to maintain a separate panel system for insured persons, while at the same time uninsured persons and all dependants are provided for by the Local Authorities. Moreover there are very grave deficiencies in the panel system, as regards both the type and standard of medical care provided and the existence of vested property interests in panels as such.
A primary practical requirement, therefore, would be take medical to benefits away from Health Insurance altogether and to confine the Insurance Scheme to cash benefits only.
If Health Insurance were confined to cash benefits, the following changes would have to be considered’ :—
- Insurance contributions to be wholly devoted to cash benefits and their administration.
- Rates of benefit as far as possible to correspond to the rates of Unemployment Insurance benefit at the time, but maternity cash benefit to continue to be paid.
- Benefits to be at national standard rates, which would involve the complete pooling of contributions and of Approved Society funds.
- Compulsory insurance to include manual workers as at present, without income limit, and for non-manual workers the maximum limit to be raised from £250 to, say, £500; any uninsured worker within the £500 limit to be eligible to join voluntarily at the ordinary combined rate of employer’s and employee’s contribution.
On any such terms, Health Insurance would become a cash benefit scheme only, the Approved Societies being the agents for paying out standard rates of benefit and receiving appropriate administrative expenses for the work.
Unfortunately, for financial reasons, it would not appear possible to forego contributions; and if this be so, the raising of the income-limit for compulsory insurance is long overdue.
UNIFIED MEDICAL SERVICE
The ultimate aim of a unified and comprehensive Public Medical Service would be to provide, through the County and County Borough Councils, free domiciliary and medical care to the population as a whole, in the same Way as Primary Education is now provided free. For financial and other reasons this can only be achieved by stages.
There are three prerequisites to any substantial development of the Public Health Service
- The consolidation in each area, under non-Poor Law control. of all existing Local Authority Medical Services should be carried out as soon as possible.
- The delegation of Local Authority health functions to voluntary agencies should rapidly be brought to an end. Efforts should be made to take over voluntary hospitals and other institutions by agreement; and no financial assistance should be given to voluntary agencies or institutions without an appreciable measure of public control. Otherwise the attitude of the Local Authorities should be one of neutrality. The valuable services rendered by voluntary institutions are not unappreciated, but the provision of a fundamental service such as medical care should not be left to private charity.
- The removal of medical benefits from Health Insurance necessitates from the outset the provision, by the Public Health Service, of an equally good service for insured persons—and it should be something very much better.
Bearing these requirements in mind, it is suggested that the first main stage of a developing Public Health Service might be the provision of free domiciliary and institutional medical care to all insured persons, all uninsured persons of similar income, and all dependants of either category. Uninsured persons over the insurance income limit and their dependents might continue to make their own arrangements for non institutional treatment, but be entitled to institutional treatment on payment of reasonable charges according to means. In certain cases where free treatment is now available irrespective of means, the practice might be continued.
It is not suggested, however, that even this first stage can be achieved right away. The comparatively early provision of free non-institutional treatment is possible, provided the existing Local Authority services are built up as they ought to be and appropriately extended; but much of this preparatory development has yet to be done. Even more has to be done before institutional facilities are adequate.
We are anxious to see the Public Health Service evolving round a system of clinics, particularly in the towns. These would be in effect well-equipped surgeries where the patient would receive the best examination, diagnosis and treatment—without the interminable of waiting so typical of the average hospital out-patients’ department.
This does not mean that the clinic should replace domiciliary medical attendance, but that it should be the centre round which such attendance and the other facilities of the Public Health Service should evolve.
THE MEDICAL PROFESSION
The panel system has created vested interests, in that panel practices are bought and sold and a de facto transferable property right exists. It is highly undesirable that this should be extended to the Public Health Service, which should not for a moment tolerate a policy of selling appointments to the highest bidder. As soon as possible, therefore, the panel, as such, might be transformed into non-saleable appointments in the public service; and in fairness it would be desirable to give an equivalent advantage to the doctors concerned, whether by way of a public appointment or direct compensation, or partly one and partly the other. ” Additional ” insurance medical benefits might similarly be absorbed into the public service. Insurance Committees and the existing medical referee machinery would come to an end.
At the outset of the scheme, most of the new, domiciliary and institutional appointments might be apportioned among existing local doctors, mainly on a part-time basis, in a way roughly corresponding to their loss of panel and other patients as a result, of the scheme. This appears to be a practicable and fair method and the least likely to cause friction, and would avoid heavy compensation claims. The part time appointments would not be transferable or saleable by the holders; and as the existing doctors went out of practice, for whatever reason the aim would be to amalgamate part-time appointments into full-time public appointments.