NOTES FOR DISCUSSION GROUPS ON NATIONAL SERVICE FOR HEALTH
Introductory Note
The Labour Party’s Policy is contained in the official pamphlet, National Service for Health (price 2d). It is set out clearly in chapters with appropriate cross-headings and sub-headings, and is presented in a form that will be found convenient for study and discussion by Local Groups.
The object of these Discussion Notes is to stress main principles, call attention to special points, and provide additional factual matter. They should be taken in conjunction with the pamphlet.
CHAPTER I (Pages 2, 3, 4)
WHAT MEDICAL SERVICES DO WE NEED?
The health of the people is a supreme national concern, and it should be a definite social responsibility. The nation must, therefore, have a Health Policy, and that policy a properly defined and well-understood aim. We have to deal not only with the effects of ill-health; we must also seek to prevent ill-health by a social offensive against its causes.
The aim of the nation’s health policy can be nothing less than the utmost possible fitness of mind and body for all the people.
This aim of Positive Health calls for practical policies of a domestic and international character.
Under the heading Health and Government the Labour Party deals with this important point.
It is recognised by the third of President Roosevelt’s Pour Freedoms—Freedom from Want, giving to every nation “ a healthy peace-time’life for its inhabitants.”
It is also recognised by Article V of the Atlantic Charter, which proclaims the object of “securing for all improved labour standards, economic advancement, and social security.”
United States Vice-President Henry Wallace has called for “freedom from unnecessary worry about sickness and hunger.”
The Beveridge Plan of Social Security is “to make want under any circumstances unnecessary.”
All this is of vital importance because, as Labour points out, “poverty is still the greatest single cause of ill-health.”
Labour calls for a social offensive to lay the social foundations of human security and well-being. But that is not all. We need also the most complete health provision which modern science and national planned organisation can provide: a comprehensive service, by which is meant a service that covers all the people and is capable of meeting all necessary medical requirements.
The Labour Party Policy sets out the essential character of such a service.
It must be Planned as a whole; Preventive as well as curative; Complete, covering all kinds of treatment required; Open to all; Efficient and up to date; Accessible to the public; Preserve confidence between doctor and patient; Equitable for the doctors; and so organised as to enable the medical profession to play its proper part in all the nation’s efforts to promote health.
These principles will be found elaborated on pages 3 and 4 of the pamphlet.
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CHAPTER II (Pages 4-12)
OUR EXISTING MEDICAL SERVICE
This section of the pamphlet is devoted to a compact and comprehensive review of Britain’s Health Record and of the health services available. The following information may provide some useful additional facts.
THE CONDITION OF THE PEOPLE
It is an historical truth to say that the Labour Party has made the problem of the condition of the people a “live” issue in our national political life. It is now generally recognised that questions of work and wages, and the standard of life they give, of housing and home conditions, of the conditions of employment and welfare in places of work, the conditions in which children are born and reared, play, and are educated, and kindred social questions have a direct bearing on health, for good or ill.
We have only to think of maternal and infant mortality, the ill- health of mothers and babies, the toll of infectious diseases, the range of industrial diseases, occupational and civil accidents, the lowering of health due to fatigue or overwork, to under-nourishment, to the worry and strain of keeping and running a home bin inadequate resources, and the hundred-and-one other anxieties and fears that can beset a decent working-class household—of the many forms of sickness, disablement, physical or mental unfitness which threaten healthy life—to realise the need for an efficient, modern and comprehensive health and medical service.
Consider a few facts:—
Cost of Ill-health
Before the war the loss resulting from ill-health, together with the cost of the medical services came to over £300,000,000 a year.
Poverty and Ill health
Recently stress has been laid on the national menace of a falling birth-rate. The explanation of this disturbing trend is partly to be found in poverty, the fear of it, and the consequences of it.
Pneumonia, diphtheria, tuberculosis, measles, whooping cough are the diseases of poverty which ravage child life, especially in the overcrowded slum. Bad housing without space, water supply, room for food storage, cooking facilities and private sanitation essential to good home-making are a source of ill-health. Bad feeding, inadequate sleep, insufficient air and lack of healthy exercise and recreation affect mind and body, and undermine health.
Infant mortality has shown a remarkable decline in this country during the past fifty years. Yet Mr. Richard M. Titmuss (Birth, Poverty and Wealth, Hamish Hamilton, 1943, 7s. 6d.) concludes that between the census years of 1911 and 1931 a 50 per cent, reduction of the national average infant death rate was accompanied by a widening of the difference between the economically favoured and the economically handicapped.
He states:
“The fact that for 11 infants of the economically favoured groups who die from preventable causes 90 children of the poor die from similar causes summarises, as a matter of life or death’, the power of environment and economics.’
Dr. Spence, Medical Officer of Health for Newcastle, in a comparison between a group of children from one to five years of age from the city’s poorest streets and a group of similar age from families of the professional class, found the following facts: —
One hundred and twenty-four children of the professional class had had:—Pneumonia 2; pleurisy 1; chronic and recurrent cough 2; measles 6.
One hundred and twenty-five children from the poorest city streets had had;—Pneumonia 17; chronic or recurring bronchitis 32; measles 46; recurrent chronic diarrhoea 6; abscesses, septic skin infections and otitis media frequent.
It has been rightly said that “Battles are only the most sensational form of human wastage. Year by year, poverty and disease pursue their unremitting campaign against the most defenceless; year by year an army of little soldiers fight and fall almost before they have lived, or limp on enfeebled in body and warped in mind.”
This wastage of Britain’s human capital calls for action inspired by an offensive social spirit.
In “Our Towns—-A Close-up” (Oxford University Press 1943, 5s) a study made during 1939-42, a conversation overheard in a bus is reported. As the vehicle passed down the main street of a prosperous seaside’ town, a group of poverty-striken children was seen standing on the curb. “They don’t look much, do they?” said one housewife,to another. “Well, anyhow,” replied her companion, “that’s what England always falls back on!”
Overcrowding
The density of population for England is the highest among the Western countries. It bears a population of 766 persons per square mile. Belgium comes second with 702, Great Britain third with 518, and the United States, with the largest population and the greatest territory, lowest with 36.
Richard AT. Titmuss in his Poverty and Population (Macmillan, 1938, 10s. 6d) showed that Durham and Northumberland have, as compared with all other regions in England—
- A very low income level, particularly in Durham, where it appears to be the lowest of any county.
- The highest overcrowding rate.
- The highest death rate and infantile mortality rate.
- The highest death rate for children up to four years of age,
- with a particularly heavy excess of death from respiratory diseases.
- The highest death rate for children from 5-14 years, with a heavy excess of death from diphtheria and tuberculosis.
- The highest maternal mortality rate, more than double that of Greater London.
This dark picture shows the interlinking of poverty and overcrowding on the one hand and ill-health on the other. Underfeeding
Sir John Orr has stated that the diet of, roughly, half the population—the poorer half—is not up to the standard required for health, and the diet of the poorest 5,000,000 is so bad that it is deficient in nearly every respect. This 5,000,000 contains 25 per cent, of the children of the country.
Maternity and Child Welfare
About 600,000 babies are born every year.
Over 30,000 of them die before they are one year old.
About 2,000 mothers die in child-birth every year.
The health of thousands more is seriously injured by causes arising out of child-birth. Expert opinion holds that by far the greater part of the damage and ill-health which follows child-birth could be prevented.
The Pre-School Child
There is a dangerous gap in the medical care of children. The pre-school child, from two to five years, does not come under any health service, except where there are nursery schools.
The result is that the School Medical Service—which at its best is very incomplete—has a heavy task in the first years of children’s school life in dealing with the aftermath of neglected conditions in the pre-school years.
Industrial Diseases and Accidents
Mr. Will Lawther, President of the Mineworkers’ Federation, stated at the recent Annual Conference that “in death and suffering the miners pay a price higher than that in any other industry, and the lists of those crippled and injured grow.”
According to the Minister of Fuel and Power, in any one week there are 60,000 miners who do not work through sickness or injury, and the number of accidents reported each year involving absence for three days or more is between 160,000 and 160,000. This high rate of occupational injury or sickness accounts for 7 per cent of absenteeism out of the total of 11 per cent.
Working Days Lost Through Illness
The loss of working time output and wages due to sickness, disease and accident in industry continues a serious problem both in terms of wealth to the nation and of personal well-being and happiness for the workers and their families.
The latest calculation made (1933) on working time lost through these causes showed that amongst workers covered by National Health Insurance there were 29,000,000 weeks lost. This was equal to the loss of a whole year’s work of 558,000 persons.
Scope of National Health Insurance
The present system of National Health Insurance is far from being fully national. It covers only the gainfully employed with an income up to £420 a year.
All dependants are excluded.
Out of a population of about 46,000,000 for England, Scotland and Wales, only half are entitled to the benefits of National Health Insurance. Even for the insured the Service is incomplete: it does not provide specialists or hospital treatment.
The other half of the nation is left to make its own arrangements for medical service.
Health Progress
Now let us look at the brighter side of the picture. As the Labour Party pamphlet shows in the section under Britain’s Health Record, “since the beginning of this century the health of Britain as a whole has been substantially improved.”
There has been a general advance in medical science and it has been speeded up during the war years,
Our knowledge of nutrition has been considerably extended by the special investigations made by experts such as Sir John Orr, Mr. Seebohm Rowntree, and many others.
Our Medical Services have been developed and brought within the reach of a substantial portion of our people through National Health Insurance, our Social Services in general have been strengthened and expanded.
Industrial health and safety measures have been increased and welfare services developed,
The issue of free or cheap milk to school children and the provision of meals are making their quota of contribution to better health.
School medical services provide for dental, and other inspections and treatment, and greater attention is given to cleanliness and physical culture in the schools.
We have steadily improved housing, sanitary and ventilation conditions, and are providing other amenities which affect health.
Our industrial health service has been developing on better lines. The modern standard for most well-run factories and works is to have their own works doctor, with first-aid assistants, and a first-aid centre, and a welfare supervisor with a welfare centre. This makes possible a steady oversight regarding the conditions in which the workers carry on their work, hygiene, ventilation, the administration of protective legislation and factory laws relating to dangerous machinery, industrial diseases, women workers and young persons in industry.
This service needs to be expanded and integrated into our national Health Services.
Greater attention is being paid to what are called the Rehabilitation services. Impetus has been given as a result of the war. There is a growing recognition of the need to restore as fully as possible both service and industrial casualties. Before the war it was estimated that out of every 100 patients treated for fracture in the ordinary way, 37 were left permanently incapacitated, whereas when such patients were treated in properly organised clinics only one out of 100 was left in this condition.
Chapter II then proceeds to deal in some detail with our present medical service. It finds it “ill-planned” and “far from adequate for the needs of the nation as a whole.” It shows that we are not working to a coherent plan; that -control, direction and functions are spread; and that unification and co-ordination are long overdue.
This is now generally recognised. It is not without interest, however, to recall that the Labour Party, (The Labour Movement and Preventive and Curative Medical Service, 1922 ) over twenty years ago, urged that entire reorganisation of the whole mechanism of both public and private medical services, is urgently necessary in order that the greatest possible use may be made of medical science, not merely for the treatment and prevention of disease, but for the inauguration of those systems of living, working and enjoying leisure which experience and scientific research show to be capable of producing the greatest happiness for all.” The remedy it called for was “a Public Medical ‘Service.” ‘It was a service that “must be free and open to all.”
Chapter II of the present pamphlet points out, among other things—
- That there is need for more control at the centre vested in the Ministry of Health.
- That the family doctor’s position is unsatisfactory, and more “teamwork” is needed, and that doctors should have an economic security which the present system cannot give.
- That the hospital system is an unplanned medley of public and voluntary institutions without any unified control and with many financial difficulties. (The Labour Party put forward a scheme (The Labour Movement and the Hospital Crisis, 1922) 21 years ago for the reorganisation of our Hospitals and allied institutions as a foundation for a complete hospital system.)
- That certain important services, such as the provision of care for mothers before, during and after child-birth, and the School Medical Service, are in special need of expansion.
We can be sure that some form of National Service for Health is on the way. The trend of opinion and demand is now strong enough to secure it.
Sir William. Beveridge in his Report has called for “comprehensive health and rehabilitation services that will provide that for every citizen there is available whatever medical treatment he requires, in whatever form he requires it, domiciliary or institutional, general, specialist, or consultant, and will ensure also the provision of dental, ophthalmic or surgical appliances, nursing, midwifery, and rehabilitation after accident.”
“Restoration of a sick person to health,” he declares, “ is a duty of the State and the sick person, prior to any other consideration.”
The objects of Medical Service have been defined by the Interim Report of the Planning Committee of the British Medical Association as—
(a) to provide a system of’ medical service directed towards the achievement of positive health, the prevention of disease, and the relief of sickness.
(b) to render available to every individual all necessary medical services, both general and specialist, and both domiciliary and institutional.
Lord Dawson, in a recent statement, said: –
“For 25 years or more the idea has been spreading that the practice of medicine, should be occupied not only with those disabled by sickness or accident, but also, if not primarily, with the building up of health, and that for this extended purpose our medical Services have become too haphazard and inco-ordinate in their arrangement.”
CHAPTER III (Pages 12, Id, 14)
WHY A STATE MEDICAL SERVICE IS NECESSARY
We have asserted that some form of National Health Service will be forthcoming and will be outlined in the promised Government White Paper’.
But we have still to discuss: How best can an efficient, sensibly planned and open-to-all Service be provided?
The Labour Party has faced up to that problem. Its conclusion is that effective action lies through the present Service being developed into a State Medical Service as part of a comprehensive Service for Health.
Chapter III sets out its examination of the problem and the reasons which prompt its conclusion.
Though a good deal pf medical opinion has been organised against a State Service, it is far from being unanimous. The following expressions are typical of a substantial and growing opinion which is in favour of a State Scheme.
Dr. Somerville Hastings has urged that “a new conception demands a new method of application. The health services must be unified, organised and co-ordinated if they are to be effective. The work is too great and too important to be entrusted to anything less than the whole nation.”
Dr. E. H. M. Milligan, of Glossop, has stated that “necessary changes would involve all sections of medicine—medical research, preventive medicine, curative medicine, and rehabilitation, and also our family and industrial life. Everything must be integrated, locally as well as nationally.”
The Report of the Society of Medical Officers of Health declares: —
“Private enterprise cannot provide and maintain complete hospital, medical, health and allied services, and such services conducted on a whole-time salaried basis have the dual advantages of administrative efficiency, and the elimination of undesirable competition for patients. Hitherto the doctor has been mainly interested in the illness of his patients, but it is of first importance that his attention should be directed to the maintenance of health.” (February 2, 1943.)
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CHAPTER IV (Pages 14-22)
A STATE MEDICAL SERVICE
Having satisfied itself that a State Medical Service is what is needed, the Labour Party has worked out a scheme to get it. The Plan shows how the Service should be organised, what services it should render, and how the cost can be met.
A study of Chapter IV will make clear the principles upon which the Plan is based.
Briefly summarised, it provides for a Central Health Authority to plan the best use of the nation’s medical resources, and with power to see that the plan is carried out.
- Regional authorities for more detailed planning and administration.
- Within each Region a series of Divisional Hospitals, associated with Divisional Health Centres.
- Within each Division, four or more Local Health Centres, each linked with the Divisional Health Centre, and each served by from eight to twelve general practitioners in urban areas but fewer in rural.
- The general practitioner or home doctor must retain his position as the first line of the nation’s health defences.
- The medical profession should be organised as a national, full- time, salaried, pensionable service.
- Free medical service for all school children.
- Complete National Maternity Service.
- Ante-natal Clinics, as part of Local Health Centres, to provide ante-natal supervision of all expectant mothers, and, when necessary, treatment.
- Industrial Health Service, to be co-ordinated with the National Health Service as a whole. More factory Medical Inspectors and. Industrial Medical Officers. A large development of their work and scope. The work of the Industrial Medical Officers to be fitted in with that of the Inspectors, so as to provide a complete service of health, safety and welfare by a team, comprising the Factory Inspector, arid the doctor, industrial nurse, welfare workers, and the workers themselves.
OPPOSITION TO STATE SERVICE
It will be useful to consider some of the objections which are being raised by members of the medical profession.
There is a great volume of professional and non-professional opinion in favour of a State Medical Service, but there is also a very vocal volume against it.
It has already been announced that the British Medical Association, by 200 votes to 10, opposes the setting up of a “whole-time salaried State Medical Service.” It is quite clear that the B.M.A., while supporting Health Service development, is determined to resist the creation of a State Medical Service at the expense of private practice. It should be borne in mind, however, that the decision mentioned has been taken at a time when a large number of the younger doctors are serving with the Forces, and it seems clear that they have had little opportunity of expressing their views.
The British Medical Association urges the extension of National Health Insurance to include the dependants of the present insured population, thus bringing about 90 per cent, of the nation within the scope of the Scheme.
Of the remaining 10 per cent, it has been said: “This substantial fraction of 4 ½ millions of the community would become the happy hunting-ground of those practitioners fortunate enough not to practise in industrial areas.’
Dr. S. Lipetz, of Edinburgh, has quoted extracts from the Press at the time the National Health Insurance Scheme was being introduced in 1911. He has pointed out that they are very reminiscent of many letters, inspired and otherwise, which are to-day appearing in the medical and lay press. Here are some of them:
- The result must inevitably be absolute ruin to a great number, probably the majority, of general practitioner throughout, the country.
- The Scheme may perhaps end in reducing doctors to so many machines for attending democracy at so much a head.
- We stand at the parting of the ways—independence and self-respect on the one hand, and servitude on the other.
- It is a long step on the downward path towards Socialism. It will tend to destroy individual effort and increase the spirit of dependency which is ever found in degenerate races.
How ill-founded these fears proved to be is now recognised by the Council of the British Medical Association, which is to-day prepared to extend the National Health Insurance Act to embrace 90 per cent, of the population, Yet similar objections are being advanced to-day against the proposed State Medical Service.
Let us consider some of the specific objections which are being raised by members of the medical profession and on which we make brief comments: —
(a) The biggest danger of reorganisation of our Health Services would be the disappearance of the private family doctor. Until the State Medical Service can provide the equivalent of the private doctor, the service will only be used by those who cannot afford private doctors.
Comment: The aim of a State, Medical Service is to make the interest of the patient the first consideration. The objection above is concerned to ensure the retention of private practice side by side with public service. This means a dual system of public and private enterprise in Health Services. Ninety per cent of the people are to be covered by a State scheme, but the remaining 10 per cent, are to be left as a private preserve for the private doctor because they can afford to pay for special attention. What is good enough for the many is, apparently, not good enough for the few. The purpose of the Labour Party’s Policy is to build an efficient State Service of doctors who are economically secure and working on a full-time basis to provide the best medical care and attention for all the people.
(b) When people are highly individualist, State medicine like State education could never be more than a makeshift.
Comment: This is an example of prejudice and muddled thinking. No citizen in his right mind would seek to abolish our State system of education. On the contrary, all enlightened minds demand its extension and completion; a national system of education, free and open to all, irrespective of the means of parents. The same fundamental principles of collective effort underlie a State Medical Service.
(c) Every medical man would become a salaried State officer. There would be no buying or selling of practices.
Comment: In a State Service the doctor would be a full-time salaried public servant just as a teacher is a full-time salaried public servant in the State educational system. In other words, he would have security from financial worry and from over-work which at present assail so many doctors. The second part of the complaint underlines the commercial outlook and vested interest inseparable from the private medical service. The buying and selling of “private” or “panel” practices is an evil feature of the present system. The patients are the human element which gives the practice its goodwill value, but they are never consulted about its sale. They just go with the practice to the new doctor.
(d) The only defect of the present system is that the doctor who has a panel-large enough to keep him in comfort and to enable him to educate his children to his own standard is chronically overworked.
Comment: This, unfortunately, is not the only defect; but it is an important one. If, in order to make a decent living in present circumstances, a doctor must have a large panel by which he is “chronically overworked,” it is obvious that he cannot give efficient service to all his patients, and that, therefore, some of them must suffer. In a State Medical Service a doctor would not have to attend more patients than he could properly and effectively deal with, and the present economic pressure to overtax himself would be removed because he would have security of salary and pension. Thus both doctors and patients would mutually benefit.
(e) Successful doctors worked very long hours, and, on the basis of the economic law of supply and demand, were able to command higher fees, and were able to give free advice to the hospitals and clinics.
Comment: It is wrong that the health of the people should be governed by the arbitrary law of supply and demand, providing high incomes to some doctors and inadequate incomes to others; that both classes of doctors should be overworked, and that “free” advice to the poor should depend in part on the humanity of the successful doctor and in part on the high fees which he is able to charge well-to-do private patients;
(f) Hospitals are for those who cannot afford nursing homes, and clinics are for those who cannot afford private doctors.
Comment: Hospitals and clinics for the poor; nursing homes and private doctors for the well-to-do. That is precisely what a State Medical Service is designed to end, so as to ensure that all patients are treated purely from the health standpoint and regardless of whether they happen to be rich or poor.
(g) The free choice of doctors should be preserved.
Comment: Under a State Medical Service in which doctors are attached to Health Centres and are assured of an adequate salary for full-time, service, as much free choice of doctors will be possible as under the existing service. The idea that the public have effective free choice to-day is largely illusory for urban patients, and almost wholly so for rural patients. The buying and selling of private and panel practices without the patients having any voice in it is one proof of this. With team work at Health Centres, to which would be attached eight or ten doctors in urban districts and fewer in rural districts, and from which the duties of the family doctor and other health workers would be organised, it should be possible to give a greater measure of satisfaction (a) to the doctors in the exercise of their medical skill, and (b) to the patients in the provision of proper medical care.
(h) The so-called “free choice” of doctors should be accompanied by a method of remuneration related to the amount of work done or to the number of persons for whom medical responsibility is accepted.
Comment: If this were permitted it would defeat one of the central purposes of the State Medical Service. It would leave doctors free to compete for panel patients, since their remuneration would be based on the amount of work done or the number of patients on their panels. This point has been dealt with in (d) above. It would perpetuate some of the worst defects of the present system; it would continue vested interest in panel practices and provide a means for increasing their saleable value, thereby encouraging the commercial element which is a bad feature of our present medical service.
(i) Every member of the community should be free to consult a doctor of his choice, either officially or privately, and private consulting practice should continue as at present for those who wish to be treated in private accommodation.
Comment: This is a plain demand for what has been described above as a “dual system.” It means that the selected few, because they can pay for it, are to have privileged attention. It means that for health we are to perpetuate the “two nations” division—the broad masses to use the public service, while the 10 per cent are to have what is presumably regarded as a superior service. The principle of “the best for the patient” will be attained only when it is provided by a service in which the best resources of medical science and of the medical profession are brought into full play in a community service which excludes any form of social distinction, regards every citizen as having an equal right to good health, and does not allow that right to be circumscribed in any way by ” means ” capacity.
CAN WE AFFORD A STATE MEDICAL SERVICE?
On pages 23 and 24 the Labour Party pamphlet deals with the important question of whether we can afford the Service which it proposes.
This financial aspect is dealt with both as regards methods and costs in a simple and convincing way. This section of the pamphlet should be closely studied. Here it is sufficient to give a brief summary of the proposals.
The Labour Party proposes that the necessary cost of the scheme should be drawn partly from national taxation expended directly by the Ministry of Health; partly from national taxation, allocated by the Ministry to Regional Authorities in the form of percentage grants and partly from rates payable to the Regional Authorities.
The pre-war cost of the existing Medical Service (excluding cash benefits) was in the neighbourhood of £150,000,000.
A carefully worked out estimate for providing a comprehensive service for the treatment of sickness (excluding cash benefits), is given in the Beveridge Report at £170,000,000.
The Report proposes that this cost should he defrayed out of public funds, subject to a grant-in-aid of £40,000,000 from the Social Insurance Fund.
After the war we shall, in any case, be spending something like £170,000,000 a year on the existing services, with all their admitted deficiencies. For about the same money the Labour Party and Sir William Beveridge agree, we could have a comprehensive service, economically planned, efficiently organised, and open to all.
We can afford a National Service of Health on the lines proposed by the Labour Party. We can have such a Service if the citizens of our land want it sufficiently. For they have the power to get it.
Labour’s Task is to Educate the Public in Support of
NATIONAL SERVICE OF HEALTH
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