Fabian Tract no 160
THE final aim of Socialism includes the socialization of the national wealth. But before coming to close quarters with this great problem we have to recognize that a large amount of spade work, of a nature less dazzling, perhaps, than direct Socialist propaganda, but not less necessary, must take the shape of organizing for social purposes those services called the professions, which contain a large proportion of the intellectual and trained members of the community, by whose efforts, even though hitherto only to a small degree secured for public ends, the cause of social reform has been so consistently helped forward. It is certain that long before the democracy is ready to undertake its widest responsibilities the educational profession will have to be organized in its service, and the nationalization of the medical service should be considered a prior step to that of the great routine industries. Working for Socialism along these lines we have the advantage of securing the sympathy and active help of a larger section of the population than any mere industrial propaganda would bring to our aid. The provision of good secondary schools by the County Council, for instance, has begun already to bring home to the poorer middle classes the economy and efficiency of State action. The application of the principles of Socialism to the profession of medicine would be another powerful demonstration of the sanity of our ideals to working and middle classes alike, and would put into the hands of the Socialists the most powerful weapon they could possess. There exists in relation to this branch of Socialist effort an abundance of those forces which make for a radical transformation of structure and function. There is widespread discontent with the present system, both inside and outside the profession; there is a crying need for economic coordination, for collective and individual efficiency; and reforming zeal is likely to be none the less active, because no one will seriously lose by the change, while both the profession and the public welfare will stand to gain.
It may be necessary at the outset to remind the layman that the present system—or want of system—in the medical service is but a temporary phase in its history. There have been three stages in medical progress. First, the mysterious when the practitioner was found in the garb of the medicine man, the druid, and the witch, leading up to the ecclesiastical, which led to a medico-theological sway in Europe throughout the Middle Ages, when the recognized medical work was performed by the monks. The second stage may be described as the commercial or guild system, which developed with the downfall of the monasteries, when the function of the healing art was assumed by the smiths and barbers, as servants of the monks; and later the establishment of apothecaries, surgeons, and physicians, who were organized into guilds, and who sold their services to those who could pay for them. The growth of science combined with the natural repugnance towards selling professional service to the person in need, and the beginnings of a State medical service, have ushered in the third stage, which may be called the professional. At all times there has been a mingling of these main features, but the growing feeling that medical service cannot be appraised in terms of cash: the disability on suing for fees voluntarily accepted by Fellows of the Royal College of Physicians: the suppression of ordinary advertisement: the tacit recognition of only one medical status in the eyes of the law: the gradual rise of a medical civil service: the professional ban placed on the patenting of remedies discovered by the individual: are all signs that the third stage is well upon us. In fact, one of the most distinguished physicians of to-day (Sir R. Douglas Powell) recently declared: “The healing of the sick was never a business. It was in early times attached to religious rites, and more or less sanctified as a divine calling. Hippocrates, St. Luke, Christ himself were examples. The monasteries in the Middle Ages were the great, centres of medical treatment: to each or to most of them, were attached infirmaries. The great hospitals —St. Bartholomew’s, St. Thomas’s, Bethlehem—were priories in the twelfth and thirteenth centuries, and were only secularized at the time of the Reformation. The practical result was that any money equivalent for medical services had from all time been more or less of the nature of an offering, an offering to the gods at one time, an offering to the servants of the gods at another, and still offering, honoraria, voluntary offerings rather than exacted payments.”
The best description of the blending of the commercial with the professional man is given us by Thackeray: “Early in the Regency of George the Magnificent there lived in a small town in the heart of England, called Clavering, a gentleman whose name was Pendennis. There were those alive who remembered having seen his name upon a board, which was surmounted by a gilt pestle and mortar, over the door of a very humble little shop in the city of Bath, whence Mr. Pendennis exercised the profession of apothecary and surgeon, and where he not only attended sick gentlemen in their sick rooms and ladies at the most interesting periods of their lives, but would condescend to sell a brown paper plaster to a farmer’s wife across the counter or to vend tooth brushes, hair powder, and ladies’ perfumery.”
At the time here described, and for many years after, there was connected with medicine competition enough to please the most enthusiastic member of the Manchester School. Many corporate bodies had been granted special rights with regard to the conferring of licences to practise medicine—societies of apothecaries, colleges of surgeons and physicians, and several universities in different parts of the kingdom possessed these powers, and the competition for the licentiates’ fees resulted in an alarming reduction of the standard of qualification. There was no reciprocity between the licensing authorities, and at the same time no effective authority to put down illegality. Hence there were many spurious diplomas arid licences, and numerous quacks both inside and outside the profession, while, at the same time, an ignorant public possessed no means of distinguishing the good from the bad; qualified men were frequently only persons who had “walked the hospitals” for a few months, and had finally bought a diploma from a body that knew well that if not granted it would be easily purchased elsewhere. But competition reigned also among the qualified, arid the effect of this on not very scientific doctors is described by George Eliot in the persons of the practitioners of Milby: “Mr. Pilgrim looked with great tolerance on all shades of religious opinion that did not include a belief in cures by miracle.” “Pratt elegantly referred all diseases to debility, and, with a proper contempt for symptomatic treatment, went to the root of the matter with port wine and bark. Pilgrim was persuaded that the evil principle in the human system was plethora, and he made war against it with cupping, blistering and cathartics.”
This state of chaos continued well into the middle of the nineteenth century, but was being undermined mainly by two influences: First, the immense advance of science in relation to medical practice, and second, the movement, led on the one hand by Wakley of the Lancet, and on the other by Sir J. Simon, Medical Officer to the Privy Council, which aimed at the establishment of medicine on a State basis. The two forces making for reform may be described as (1) State interference or control, and (2) State organization.
The first great step towards the co-ordination of the medical profession and its control by the State was taken in 1858 by the passing of the Medical Act of that year, followed in 1876 by the Act admitting women to qualification for the register. This measure of 1858 was carried primarily in the interests of the public, although the profession has reaped its reward also. Its main purpose was to enable persons to distinguish between qualified and unqualified practitioners. Mr. S. H. Walpole, the Home Secretary of the time, and the chief supporter of the Bill, stated expressly that it was not intended to prevent the public from consulting whomsoever it wished —whether qualified or unqualified—and that any advantage that might accrue to the profession was quite secondary to the main object of the Bill, viz., the protection of the public from fraud. Under its provisions was created, as an offshoot of the Privy Council, that body which is becoming daily of greater importance in all matters affecting the relations between the medical profession and the public—the General Medical Council: This is a statutory body including representatives of the profession, but principally charged with its regulation and control for purposes of public protection.
At the present: time it is composed of thirty-four members, five representing the Privy Council, five the profession, and twenty-four the educational bodies. It is not even incumbent upon (although generally the practice of) the educational bodies and the Privy Council to select medical men as representatives. The functions of the General Medical Council are as follows: (1) The keeping of a register to enable “qualified men to be distinguished from unqualified; (2) the controlling of medical education and the raising of its standard by preventing down-grade competition between the educational bodies (with this end in view it carries out a systematic and careful inspection of all medical examinations); (3) to act as a professional court of justice and remove from the register the names of those convicted of crime or of “infamous conduct in a professional respect,” such as “covering,” “canvassing,” the employment of unqualified assistants, etc.; and (4) the drawing up of a pharmacopoeia.
The General Medical Council is the authority which brings the community into touch with the profession, and gives it an enlightened means of control. Its creation is an admission of professional rights, it is true; but much more does it lay down the principle that the medical service exists for the public interest, and should be administered, controlled, and governed with that idea. It is a recognition of medicine as a trade union, and also of the need for adequate control by the community of such a powerful organization. By the creation of the General Medical Council we have laid the foundation for that State organization of the medical service which it will be the work of the future to carry out.
Great as was the advance made by the Act of 1858, strengthened later by the Dentists’ Act of 1878, and the Amending Act of 1886, yet all authorities are agreed that the work of co-ordination and organization has only just commenced. There are too many varying examinations which alike qualify for the register, though their value differs widely. There is great overlapping of educational institutions in single areas such as London. There is scandalous underpayment of professional teachers in connection with medical education. Finally, the relation between the charity-supported hospitals, and the medical schools is not clearly defined, and is far from satisfactory. It is not surprising, then, that amendments of the Acts of 1858 to 1886 are contemplated by Bills now before Parliament, promoted by the British Medical and British Dental, Associations, the former of which aims at (1), the reduction of the personnel of the General Medical Council and an addition to its representative character; (2) the institution of one State examination for entrance to the profession, and (3) the legal prohibition of practice, by any but qualified men; while the Dentists’ Bill aims at prohibition of unqualified practice. It, will thus be seen that from the profession, itself there is a widely voiced demand for further State interference, and for a more uniform system; and it is for the public to see that the general interests of society are at the same time carefully safeguarded. In view of the measures relating to medical matters that are likely to come up for solution during the next few. years, it is well to realize that the probity and efficiency of the medical service is of the utmost importance to all classes. Socialism has had most effective support from scientific members of a profession whose whole tendency is towards reform, whose daily study makes for an equalized conception of human nature, and who are taking an increasing interest in Socialist propaganda. The influence of quackery, with its secret remedies, its advertisement, its ignorant audacity, and its intense commercialism, is essentially anti-social; and the widespread use of patent medicines must be regarded as a form of exploitation of the ignorant and weak, as hateful and injurious as that represented by the individual appropriation of rent and interest. The denunciation of the qualified man is no part of Socialist propaganda. He does not necessarily represent the reforming element in society, nor does he enter his profession for propagandist reasons, but, as a rule, he compares very favourably with his fellow citizens in the matter of humanity, enlightenment and sympathy.
We have glanced at the chief step which the community has taken towards controlling the profession from without; it remains for us to consider to what degree its organization directly as a State service has already been carried out. In order to make this clearer, let us review the present constitution of the whole profession. There are at present (1911) 40,642 registered practitioners, who may be classified as follows:
Few people realize to what a large extent the medical service is already socialized. The Army and Navy and Indian Services account for 3,300 practitioners, excluding a numerous and ever growing Colonial Service. In addition there are the full time public health officers, to the number of about 400 in England and Scotland; the medical staff of the Local Government Board and the Board of Education; the prison surgeons; medical inspectors under the Factory Acts; medical visitors in lunacy; poor law medical officers; the medical staff of the Metropolitan Asylums Board; medical officers of lunatic asylums; and school doctors.
These services represent the growing needs of an organized community; most of them are of recent origin, and all are increasing in numbers from year to year. But they do not represent the whole scope of publicly controlled medical work. A large amount of official duty is also done by practitioners who, to the number of 1,423 in Great Britain, add to their own practice the duties of medical officer of health, the 4,000 poor law doctors, the Post Office medical officers, certifying factory surgeons, medical advisers under the Workmen’s Compensation Act. It will not be denied that the combination of public functions with private practice is viewed with a growing distrust, which will end in forcing more and more of the official work into the hands of the whole time man, a change that would be easily accomplished by means of co-operation between different local government areas, and one which would greatly improve the administration, as it should raise the standard of the officials affected. In any case, a large and growing proportion of medical practitioners is already removed from the sphere of competitive practice. This proportion is working as a civil service under such conditions as any Socialist would approve of, nor can it be doubted that the public services compare favorably with any branch of the profession. Their popularity is proved by the great competition there is for such posts as happen to become vacant or are created for fresh necessities. Removed from the petty worries of fee collecting (a kind of tax gathering which is in no way connected with medicine, and which to the average medical man is wholly distasteful), there is ample opportunity for scientific work over and above the routine duties; and that such opportunity is taken advantage of, the records of the Local Government Board and the annual reports of the medical officers of health will clearly prove.
There is taking place at the present moment a movement for the. partial nationalization of the medical profession which, according to many, is likely to surpass all the steps that have hitherto been taken in that direction, viz., the Scheme of Compulsory National Insurance against Sickness and Invalidity. If this bill become law, nearly half the medical work of the nation will henceforth be. paid for in part out of public funds administered for that purpose through the agency of the trade unions, the friendly societies, and the Post Office. This will, no doubt, commence in the form of a vast system of well paid club medical work, but as its scope extends to a wider circle of persons and the State continues to buy control through its increasing contributions, it is likely that an ever increasing number of private practitioners, becoming freed from competitive practice, will find the advantages of regular salaries, with emancipation from the many calls to gratuitous work, amply compensate them for the gamble for success which medical practice has too often been in the past. The organization of a majority of medical men in the different localities again, will bring the possibility of arranging for hours of duty, will obviate the scandal of the twenty-four day for the doctor and make for complete organization with ultimate nationalization.
The Private Practitioner
The bulk of medical men, however, are still private practitioners, either consultants or in general practice, and it remains to analyze the conditions under which their work is carried out so that we may find out to what degree Socialist opinions and social development will modify them. The medical student spends his five or six years, at the hospital or medical school, passes his final examination, registers his name, and, if he chooses to be a consultant—for which money as well as brains will be necessary—he gets a series of hospital appointments and bides his time. If he select general practice he buys or starts such a practice in a chosen locality and waits for work. He has been for years devoting himself to scientific study, too much influenced by the approaching examination, it is true, yet largely disinterested. He now finds himself in a new world: he has to compete for patients with others in the same calling. His work and ways are now appraised by persons who are in no way qualified to discern the best man. The public judge of the qualities they can appreciate, and, needless to say, the prize of practice too often goes to the man whose manner, establishment, social intercourse, religion, amusements, motor-car, etc., most favorably impress his would-be patients. Up to the time of starting, all his work was subject to professional valuation. Now he is thrown on the mercy of public opinion—often the opinion of the very persons whose diseases he is called upon to treat, and from whom he may, or may not, get that mysterious reputation implied in the epithet “clever.”
Whatever competition may do for trade, it has nothing but a thoroughly bad influence on professional work. It often brings rewards to the least worthy; it tends to drive down fees below a level compatible with efficiency, as is shown by the sixpenny and shilling dispensary practices. It tends to crush out that fraternal feeling that should always exist in such a service as medicine; it undermines that co-operation which is of great importance in practice, both to patient and doctor; and it places an educated man at the mercy of each individual member of an unenlightened public, on whose ailments he is made dependent for his living. There is a further blot on the present chaotic condition of the medical profession, namely, the fact that when the student starts in practice—unless he is one of the favored minority who happens to get a hospital appointment—he surely, if slowly, loses touch with the more methodical and scientific side of his profession, and stands in danger of drifting into a routine manner of looking at things, from which even the occasional opportunity of post-graduate lectures and the excellent medical periodicals cannot save him, if his practice is a small one; while if his clientele grows to fairly large proportions, sheer fatigue, emphasized by the continuous nature of his work and the pressure on his time, acts equally effectively.
In the matter of over-work, all branches of the medical and allied professions are worse off than any other calling, and the results are shown in the high mortality among doctors, ranging above all others, except the three somewhat closely related occupations of wine merchants, innkeepers, and cabdrivers. (Mulhall’s “Dictionary of Statistics,” 4th edition, p. 181, and “Vital Statistics”, by Win. Farr, 1885 edition, p. 401) There is no more useless waste of valuable human life and energy than that which competitive commercialism has attached in the form of day and night work to the practice of medicine, and there is just as good a case for legal interference in this matter as in any of those instances in which Acts of Parliament have regulated the hours of labour. The medical men do not like the arrangement; it is injurious to the public interest in that it may lead to individual disaster just as surely as the overemployment of a signalman or engine-driver may lead to a collision, and yet nothing is done because we regard commercialism as inevitable.
Other Hardships of the Competitive System
Slowly the evils of competition are revealing themselves to the profession, but there are certain other hardships which are more obvious. The first of these to be noted is the constant tendency on the part of the public to impose on the physician or surgeon in the matter of gratuitous work. A well-known surgeon (J.F. Fuller FRCS) has said: “The well-to-do philanthropist is so moved by the sight of suffering that he is impelled to ask the doctor to cure it gratis.” Practically all hospital appointments (except those under the control of the State) are unpaid, and although the eclat of a position on the staff of a large city hospital is in some ways its own reward, yet there are endless posts held in connection with small provincial hospitals, orphanages, epileptic colonies, etc., etc., which bring to the holder of them neither the reward of education nor any professional distinction, and which are filled without fee by the long-suffering profession. Then, again, there are countless reports and certificates (some of which, such as the death certificates, are matters of compulsion), which the doctor is asked to sign, and for which he is unpaid; and there are those who, regarding his calling as a noble one, consider that, it would be demeaned by the settlement of their quarterly or half yearly accounts, which for social reasons it is almost impossible for the creditor to recover in the legal manner. No body of men is more imposed upon in these ways, and if ever a doctor asks for his fee in advance, or refuses to get up at night to attend a case without the assurance that it will be forthcoming, he is regarded by the public almost in the light of a criminal.
Hospital Competition (“Abuse”)
There is another factor that tells heavily against the average medical man, especially in the poor and populous localities, that is, hospital competition—or “abuse,” as it is called. The immense increase in free hospital, of assisted dispensary treatment is making this more and more serious. Although some hospitals—notably the London—are trying to carry out a selective process with regard to their patients’, the temptation for statistical and educational reasons is all in the direction of encouraging them to come. It is hard for a democratically minded doctor to refuse hospital treatment to an interesting case whose income is £5 a week, and take under his care an alcoholic dyspeptic whose average wage is £1. The impossibility of any effective selection of patients according to appearance and wages, is apparent to anyone who thinks. If you put up a barrier of appearance, you exclude the tidy and penurious clerk, and include the skilled artizan, whose comfortable circumstances make him careless as to his appearance. If, on the other hand, you erect a maximum wage barrier, then you admit a bachelor with twenty-five shillings a week, and exclude a married man with a family of five who earns thirty shillings. The most superficial observer knows, in fact, that there are thousands of the small shopkeeper or poor professional class who need free hospital treatment just as much as those imaginary persons for whom hospitals are intended, and yet who would be excluded as unfit. That this competition, is really serious is shown by the growth in the number of patients annually treated in the London hospitals: These were, according to Sir H. Burdett:
1895 … … … … 1,753,611 patients.
1902 … … … … 2,098,905 patients
The same authority concludes that, in spite of the fact that each visit to the hospital, with the journey and the waiting, took five to six hours, counting the whole population of London, one out of every two persons gets free medical advice, while thirty years ago the figure was one in every four. The same condition, only less acute, holds good in the provinces, as the following table shows:
- In Portsmouth 1 out of 14 people received free medical relief
- In Cardiff 1 out of 7.1
- In Glasgow 1 out of 5.3
- In Manchester 1 out of 3.5
- In Liverpool 1 out of 3.4
- In Birmingham 1 out of 3.2
- In Brighton 1 out of 3.1
- In Bristol 1 out of 2.9
- In Edinburgh 1 out of 2.8
- In London 1 out of 2.2
- In Newcastle 1 out of 1.9
- In Dublin 1 out of 1.3
This means that the proportion of cases to the population is as stated; but one person may be counted as several cases or may attend several, hospitals in the course of a year.
This question is being further complicated by the fact that working men are becoming collective subscribers to hospitals in urban areas, and it is not unreasonable to suppose that they will fall into the same error as members, of the middle class;, in considering that a donation entitles them to free treatment: Whatever may be said with regard to out-patients, there is no doubt whatever that the inpatients. belong to a large extent to a class above the necessitous poor; and one is not surprised that sick members of the middle and lower middle classes should use all their ingenuity to get admitted to a hospital when they cannot; afford the best treatment at home. Nor is this surprising when it is remembered that modern medical treatment implies the use of expensive apparatus, such as those used for the X Rays, for bacteriological diagnosis, etc., as well as all the necessities of modern aseptic surgery. With the growth of hospitals there is an increasing opportunity of education for those on the staff, making them a more dangerous: competitive class in the eyes of the majority of their colleagues, while at the same time that efficiency is gained, in the treatment of patients who would normally fall to the share of the poorer practitioners.
Hospital competition as a source of discontent is supplemented by that of the optician, who poaches, in the preserves of the ophthalmic surgeon; the chemist; who prescribes as well as dispenses remedies, and even does minor surgery; the herbalist and all kinds of quack healers as well as patent medicine vendors, who make the lives of the less fortunate members of the profession a story of respectable penury: Circulated a few weeks ago among the members of the Marylebone Branch of the British Medical Association was a pamphlet, written by one of the victims of this competition. He says, addressing his more fortunate West End brethren: “We do not ‘hunger and thirst’ after your righteousness; our needs are food, clothing, house rent, and wherewithal to pay our taxes, or for our house, or carriage, or motor, or even a new bicycle. This is our ‘economic’ question, to be worked out on the basis of ‘advice and medicine for sixpence,’ ‘a visit for one shilling,’ ‘a labour for ten shillings.’ We cannot afford Westminster or Charterhouse for our sons, but even we struggling doctors must educate our daughters. In short, it is the old schoolboy heading: ‘Edendum est vivere.’ This is our economic need. Change places with us for one week. Come away from your carriages and motor cars, your butlers and retinues of servants, your houses furnished like palaces. Forget, your shooting lodges and fishing lettings and come to ‘poverty, hunger, and dirt,’ where ‘women’s lives are wearing out’ and the men are weaving their shrouds. Come to the factories and the coal mines. Live sandwiched in between a butcher and a pawnbroker, and feel that they both are more independent than you are.”
The only inaccuracy of this picture is the exaggerated idea of financial success, which, according to the writer, Marylebone offers to its professional population, If we are to, believe writers such as the late Sir James Paget and others, we are forced to the conclusion, in the words of a well known surgeon, (Dr. J.F.Fuller) that “in London the position of the young consultant is tragic in the extreme.”
“The Battle of the Clubs.”
There is one other evil resulting from the present circumstances of the medical man that must be noted, because it has caused a very great outcry in the profession, —namely, the sweating of doctors by the working classes organized as friendly societies and burial clubs. Such organizations represent the attempts of the people to obtain collective medical service at a small weekly rate per member. This has represented a new form of collective bargaining. On the one hand a single medical, man, and on the other an organized, readymade clientele. Under these circumstances, the individual professional man has been powerless to escape overwork and gross underpayment. Tempted by a fixed nucleus of salary, or the threat of seeing a stranger called in to do his work, the unfortunate individual has been driven to accept the most unfavorable terms, and has been at the same time subject to that kind of treatment which the aggrieved always receive at the hands of the aggressor.
Two shillings to five shillings per member per annum is a common sum for the doctor to receive, the average fee for each attendance working out at 10.60d.; in the case of one club a fee of 10d. per member per year was received by the club doctor. Attempts have been made by the doctors to combine against this kind of thing, but, for obvious reasons, with only partial success. When local men have combined successfully a man from a neighboring town has been imported, and in some instances, where this has failed, a substitute has been tempted away from the remoter parts of Ireland. This sweating of medical men and the way they are treated by clubs (trade union and otherwise) is similar, except that it is worse, to blacklegging in industrial trades, and shows that the working classes have still, a good deal to learn in the matter of meting out fair conditions to their employees.
Of course, remedies for the above-mentioned grievances are being constantly suggested by those who see the evil, or feel the pinch, but most of them are based upon the idea that the present order is from everlasting to everlasting, and often the treatment suggested is of the most, futile and symptomatic kind. The suggestion, for instance, of cutting down hospital attendance, as well as those other remedies mentioned already in connection with “hospital abuse,” display a great ignorance of human nature, as well as a total incapacity to realize the grievances bound up with the general problem in the matter of medical attendance. It need only be said that for thirty years the cry of “hospital abuse” has been heard, and has been accompanied by a steady rise in the number seeking relief from hospitals. Co-operation between the general practitioner and the hospital has been suggested, with equal lack of insight into the problem. Combination among the profession is, from its very economic conditions, only partially possible, and, indeed, under present circumstances, anything like a thorough combination would be a public danger. Other palliatives might be named, but it is well before looking for a remedy, to bear in mind that any solution of the problem, to be satisfactory, must take into consideration the case of the public as well as the profession, and briefly to consider the hardships which result to the lay community from the present individualism in medicine.
It will be seen at once that the most serious hardships resulting from the present system of medical service fall upon the middle classes. The small tradesman, for instance, when he happens to visit the local hospital, sees a finely equipped machinery for the cure of disease, staffed by the most able and scientific members of the profession offered freely for the treatment of the poor, to which category he knows secretly that he belongs, but dares not acknowledge it for prudential reasons. He sees hospitals endowed and adapted for every purpose of treatment, with polished teak, floors, glazed tile walls, ample cubic space and ventilation, perfect operating theatres, well kept instruments, with a highly skilled and specialized staff’ of physicians, surgeons, ophthalmic surgeons, gynaecologists, dental surgeons, nurses, dispensers and, attendants, all ready and willing to receive the first member of the submerged fifth who happens to contract disease or meet with accident. He knows, too, that paupers in the large cities, and—to a greater degree than was the case formerly —throughout the provinces, are getting a care which is almost as good. While he has to call in his medical man, and to be treated (if seriously ill) in a room above his shop, which is, in no way suitable for prolonged treatment, and where wall-paper, carpet, curtains, want of proper ventilation, all make for a prolongation of his misery. If an operation be required he must have the man on the spot to perform it, or pay a large fee to get a specialist from a neighboring city who knows that everything is against the patient whose only operating theatre is his own bedroom, or whose operating table is the one on which dinner is usually served! If the patient happens to be the bread-winner, he finds the procuring of efficient medical treatment, which implies each year, in place of physic, a growing need for skilled nursing and costly therapeutic appliances, a very costly affair, and that, too, at a time when he can least afford the money. If his illness becomes more serious, even though he cannot afford it, his family spend their last twenty pounds to call in one of the consultants who attended his general servant when she was in the hospital of the neighboring town. He knows, too, that in the matter of the best medical treatment the very rich, who can afford the expensive nursing home and the many appliances necessary for restoring health to the diseased, share these advantages with the poor, and he is apt to ask himself why he should not have his share of the good things. But with all the disadvantages mentioned above, there is another from which the poor patient is often delivered-—he alone does not employ his medical man and hence his treatment is likely to be unbiassed by those little concessions to a client which this relationship of employer and employed so often calls forth. If the poor man is alcoholic, is suffering from the need for occupation, is inclined to excesses of any kind, he is told so more plainly by his hospital doctor than is the average patient in private practice. A further advantage of the hospital patient whether “out” or “in,” consists in the fact that he is treated at a sort of medical exchange, where there is co-operation between a staff numbering among them specialists of all kinds. I have seen two leading London surgeons consulting with two physicians of equal eminence over a poor old woman in a hospital ward. This kind of professional co-operation contrasts singularly with private practice on a competitive basis which always tends to shut the profession into water-tight compartments, and puts beyond the reach of all but the hospital patient that free, unbiassed and many-sided consultation which in serious illness is of so much importance. Only a complete re-organization of the profession will put proper specialist treatment within the reach of the middle-class man, and make his chance of recovery as good as that of the pauper in the State-managed hospital.
There is one further disadvantage from the present system of practice which accrues to the middle-class public: namely, the fact that the power of life and death, the decision as to serious operation, or critical treatment, is too much confined to the judgment of the one—or at most two—medical men which the members of that class can afford to call in. It is high time that the public should appoint in its own interest Inspectors of Surgery, whose duty it would be to give an independent opinion, whenever possible, in cases of serious operations, both as to their advisability for the patient, and as to the competence of the surgeons to carry them out.
It is clear that a co-ordinated State service of medicine, in its widest aspect, is the only solution that offers itself to the student of sociology as in any way satisfactory, whether from the standpoint of the doctor or the patient. The sociologist has come to realize that that ideal will not be attained by any short cut; much public education will be required, both of Socialists and non-Socialists; certain departments of professional work will have to grow and others atrophy before the change will be complete. The important thing is to realize the phenomena of transition so that we may effect the change along the line of least resistance.
In this connection it should be our aim to increase the efficiency of the public departments, of medicine. We know that the 1,800 local sanitary authorities of England and Wales, together with the county councils, have among them about 1,500 medical officers of health, and that out of these only 350 (including those of London, the county councils, and county boroughs) are salaried “full-timers,” whilst about 400 are private practitioners to whom the health authority pays a stipend of from £3 to £30 per annum. Further, in Scotland the 313 local authorities have among them about 120 medical officers of health, of whom 40 devote all their time to their duties, whilst about 80 are engaged in private practice and receive salaries varying from £2 2s. to £200. All reformers should work for the appointment of one whole-time medical officer of health at least for each county Council. The larger cities and towns have appointed medical officers, and it is a public duty to see that their tenure of office is secure, and that they have ample qualified assistance. Large numbers of small boroughs and urban districts have at present only part-time officers, and these are paid salaries ridiculously inadequate. The policy here should be the appointment as opportunity offers of whole-time men, and the pooling of small urban and rural districts so as to make the work important enough and the salaries sufficient for a whole-time public health officer. Preventive medicine is bound to take a more important place in the future, as faith in cures is dwindling, and even the costly sanatoria for consumption are now regarded as doubtful palliatives which restore the consumptive to apparent health, only that he may die more quickly when he returns to his unhealthy occupation or ill-ventilated cottage. The individual demand for curative advice and medicine is likely to be largely replaced by a collective demand for information as to how to suppress or improve the callings and home conditions that kill and maim. Thus the centre of gravity of medicine will leave the curative and tend more, towards the side of preventive medicine. It is around the public health service that all the other branches of medicine will tend to group themselves, and this department has been steadily undergoing a change of function since its establishment by the Act of 1875. For twenty-five years it mainly dealt with the environment of the individual—refuse disposal, drainage, disinfection of houses, ventilation, air space, food adulteration, and kindred matters; recently the change has been in the direction of personal hygiene. The idea that accumulations of refuse can be injurious is supplemented by the conviction that verminous persons may similarly be destructive of social welfare. The public health officer now enters a realm which may be called that of preventive treatment. He draws up placards on the dangers of alcohol, the social risks of the spitting habit; he issues cards of advice for poor mothers as well as pamphlets to consumptives; he is entrusted with the supervision of midwives, whose disinfection may be enforced by him under certain circumstances; he administers the “Cleansing of Persons Act,’- and may prescribe a bath for a verminous person; he is commencing the inspection of school children, and has to arrange not only for advice to teachers and parents, but prescribes ointment and other media of treatment; he organizes a staff of health visitors to superintend the newly born, and is not infrequently head of an infants’ milk depot. It will thus be seen that the medical officer of health is beginning to widen his boundaries, that prevention, in short, needs to be supplemented by a personal attention that is curative as well; in other words, the line of distinction between prevention and cure is tending to disappear.
The strengthening of the departments will be supplemented in another direction by the co-ordination of those State medical services which at present overlap and frequently are in conflict with one another. Take, for instance, the poor law medical service, which costs £5,000,000 a year and has a staff of 4,000 medical officers. With its restriction to persons proved to be destitute, its tardy application of treatment, with consequent waste of life and health to the nation, its failure to reach a large amount of illness even amongst the destitute themselves, its unconditioned grants of so-called medical relief, which inculcate no healthy habit in the recipients, it is clear that this service must be co-ordinated with public health administration. For it is the business of the latter service to seek out illness, to treat at the earliest possible moment, to remove injurious conditions; to apply specialized treatment, and, above all, to educate the public, with the end of preventing disease at its source. The mere “relief” of the individual must give way to a method of dealing with disease based upon wider social aims. The recommendations in favor of a unified medical service so ably put forward by the Minority of the Poor Law Commissioners, and supported by the responsible medical heads, of the great departments concerned, viz., the Local Government Boards of England and Wales, Scotland, and Ireland, and the Board of Education, mark one great step forward in the direction of a State medical service based on public health principles. In such a unified medical service, organized in suitable districts, the existing medical officers of health, hospital superintendents, school doctors, district medical officers, workhouse and dispensary doctors, medical superintendents of poor law infirmaries, would find their appropriate places under the administrative control of a county medical officer chosen for his experience and knowledge in this direction.
There are many public appointments which, to the advantage of the community, might be filled by medical men. As governors of prisons, for instance, they would generally be more suitable than military men, and their training adapts them for such posts as inspectors of factories. When it is said that the profession is overcrowded—a statement which is only true of urban areas—it is forgotten that there is abundant medical work waiting to be done before the community has utilized the energy that is at present being wasted.
The Ultimate Solution
However perfect may be the system of preventive medicine, it will always seem unfair to the average man that the only persons to get the very best treatment of a curative kind, should be the pauper, the lunatic, the criminal, and the millionaire. A growing sense of social justice will demand that the best medical service be placed within the reach of all and that implies a very high degree of excellence on the part of the qualified medical man, with an equal facility on the part of the patient for obtaining the most scientific appliances. Now the only way to put them within the reach of the many is to organize the medical service from the ambulance bearer to the consulting surgeon; and to keep that organization vital it must, in the case of the curative arts at least, be built around a public hospital. Every medical man must be connected with his hospital to the end of his career, i.e., his opportunities for scientific study must be constant. The Army and Navy are recognizing this need in the facilities offered to their officers for intermittent hospital study; and it is one of the fundamental reasons for nationalizing medicine. The maintenance of all hospitals out of Imperial and Local funds, and their management by the community, will be the first step towards educational efficiency in the profession. Under the provisions of the Public Health Act of 1875 ratepayers may provide themselves with hospitals of any kind. They are already supporting fever hospitals, asylums, sanatoria for tuberculous patients, and inebriates’ homes. With these institutions in their hands there are no arguments, left to oppose the abolition of all so-called charity in connection with the treatment of disease. Socialist finance will certainly reduce the number of millionaire donors, but it will regard the charge for hospital accommodation as a most necessary form of national insurance against sickness to impose on the people. If the cost of treatment is heavy at the outset this will only demonstrate more clearly the relative economy of prevention. The change, from charitable to publicly controlled hospitals will at once place medicine on a collectivist basis. The staffs will have to be paid just as the Metropolitan Asylums Board now pays its officers, and the, right of free treatment will determine the ultimate connection of all doctors with the hospitals of their respective districts. The extravagant charges of cruelty and wanton experimentation brought against hospital treatment and so often shown to be groundless on investigation, are, where true, due to the lack of public control and the social status of the patient. Both of these wrongs are characteristic of all present social institutions, and it is our duty to remedy them. By this, or some similar method of organization, we should not only remedy those evils of private practice which have already been referred to, but also obviate the hopeless waste of time involved in the waiting for a practice. The working hours of the profession could be regulated, and all its members kept in touch with scientific progress. Skill and capacity could then he made the criteria of success and promotion, while a certain freedom of choice with regard to their medical attendants would at the same time be left to the members of the public.
In a community where the health of the citizens was regarded as of equal importance with its trade statistics, the creation of a Ministry of Health would not long be delayed. This department of the Central Government would be assisted and advised by the General Medical Council, just as the Secretary for War is advised by the Army Council. The Minister of Health would be responsible to Parliament for the following departments: registration of births, diseases, and deaths; meteorology; coroners’ returns; central, and local sanitary and other medical work; adulteration reports; factory supervision and reports; veterinary supervision; prison and police inspection; the oversight: of all public sanitary works. In short, what is needed is a co-ordination of, the health functions, of the Local Government Board and a separation of those of its present activities which are alien to these. With regard to local administration, each county borough or other large and populous district would have its health office, with a principal medical officer of health, having under him the various branches of preventive medicine, such as sanitary inspectors, health visitors, and school inspectors, and the organized hospitals and departments for medicine, surgery, midwifery, ophthalmology, dermatology, dentistry, etc. Each department would have its senior medical officer, with a staff under him. There would be a visiting staff to see patients at their homes, an out-patient department connected with the public hospital for the treatment of minor ailments and accidents, a hospital with wards for the treatment of serious illness, divided according to the class of disease to be treated. Under the same administration should be placed the special hospitals for the insane, the inebriate, the persons suffering from infectious disease, epileptics, etc. These hospitals would continue their work as at present, but with a further degree of cooperation. The social and scientific value of co-ordination between all departments of medicine cannot be overstated, but the prevailing idea underlying all should be prevention. Every opportunity would be given for consultation between the members of the staffs throughout the whole service. At the large central hospitals students would be taught their profession and when qualified to treat disease, would be drafted to those places in need of help.
In each locality the district health office would keep records of disease and of the means employed for its prevention or cure. Such a register of sickness would enable the student for the first time to find out the extent of the incidence of disease, both qualitatively and quantitatively, and the effect of the methods of treatment employed over the largest possible area.
The cost of the State medical service should fall in part on the national Exchequer; and partly on local taxation, in order to encourage efficiency in prevention. The economy of organization, the greatly lessened cost of illness due to the increase in sanitary control, the immense amount saved in the reduced number of working days lost through illness—computed at the present time at £7,500,000 per annum—would make the health tax seem light, and it would be regarded as a profitable form of insurance. The doctor’s bill comes now at the worst time, especially when the head of the family has been ill; then the small tax in time of health would save many an illness from its most painful side. It is true that the efficient treatment of disease would cost more than the present inefficient methods—in the case of the lower middle class, for instance, the provision of skilled nursing assistance, drugs, dressings, and suitable food would be a fresh charge on the community —but it should not be any part of Socialist policy to lessen the expenditure on preventing disease. If all the broken-down members of society, all its mentally defective persons, all those suffering from debility, incipient phthisis, alcoholism, or heart disease were to be properly taken in hand by the comparatively small residue of moderately healthy persons, it would begin to dawn upon us that these evils are largely due to the waste and folly of present-day commercialism. It is voluntary neglect and blindness that makes things as they are tolerable, and compulsory charges for treatment levied socially would effectively counteract neglect,, and would open the eyes of the most blind. From the point of view of the public, it has been argued that the ample and free provision of medical assistance, would, mean an unnecessary demand for drugs and treatment on the part of an increasing number, of people. “The poor,” wrote Sir William Gull, “have an idea that disease comes from Providence, and that it must be cured by drugs. Now, if there is any idea that ought to be rooted put it is this”; and the practice of modern medicine is becoming more and more a matter of advice as to methods of living and general regimen. In a word it is becoming educational, and fulfilling the words of Sir John Simon: “In proportion as medicine has become a science, it has ceased to be the mystery of a caste.” The enormous consumption of drugged sweets and patent medicines of all kinds is but a reflection of the impotence of the genuine practitioner to cure disease, whose cause is of daily recurrence, and which a change of environment or habit can alone effectually remedy. The patient seeks advice which the doctor dare not give—it is too Utopian—he receives a drug which fails, and in despair turns to those patient remedies which are advertised to cure all ailments, until finally he falls a victim to some parasitic industry or insanitary home condition.
A New Army Organization
The work of co-ordinating and organizing the medical service is perhaps the most important piece of Army reorganization which awaits the statesman of the twentieth century; for disease is an enemy with which we are daily at war, whose victims number annually five hundred thousand in dead alone, while the wounded are ten times as. numerous. Something has been done by organization; yet while the nation seems so indifferent to the story told by the death rates of adults and infants, and only deigns to register a few of the ailments that affect its members, but little can be expected. It is the duty of the Socialist to teach people to think, not only imperially, but in communities, and also, perhaps, to feel in communities as well. Our forty thousand doctors need the guiding hand of a statesman who will do for the health of the people what War Ministers desire to do for its external security.
The falseness of the conception of Socialism as a disintegrating force, and as a dividing up of wealth or material advantages, will be again demonstrated by its application of the problems of public health and medicine. From the provision of surgery to that of sewers its tendency is towards a unification and an amalgamation of interests, and wherever this has taken place it has brought, immense social benefit in its train. The water supply, when co-ordinated and municipalized, was no longer the, source of disease and death that it was in the days of individual enterprise, and the provision of an organized body of medical officers of health has already accomplished a steady reduction in the death-rates, as well as in the incidence of disease, —to mention only two instances.
Medicine and Statecraft
The individual practitioners of the country, acting against that class interest which a commercial age has bound up with the misfortune of their fellows, have done much to improve the lot of the people; but when the medical man has been at the same time something of a statesman, the results of his work have been enormous. The work of Sir G. Baker and many others in the eighteenth century was followed by that of Chadwick, Southwood Smith, and Sir J. Simon in the nineteenth. The secret of their success was the fact that they realized that sickness was a burden on the rates which had to be prevented, and they diagnosed a diseased condition of society which lay beneath the individual suffering they saw around them. They realized that there was a social pathology very analogous to that of the individual organism, that health was a national asset, and that the poverty of masses of the population was but a symptom of a disease—a circulatory disease—that might end in social destruction. While the marriage between medicine and statecraft opens up immense possibilities for the development of the race both physically and morally, it is none the less important, now that the work of the statesman is becoming more and more that of the organizer of economic social conditions, that he too, should be imbued with the same spirit that characterizes the physician or surgeon. He will have to apply or administer remedies distasteful to the sufferer; to perform operations upon a living society, such as the removal of vested interests and social abuses, which have become closely bound to the life of the people; and in doing this it will be well for him to avoid unnecessary pain, using to this end such anaesthetics as compensation and the time limit in his operations for nationalizing health. But the statesman as physician will also realize where and in what degree society is undeveloped, and he will constantly aim at the building up of industries and professions into orderly and organized service. The complete socialization of medical practice will at once raise it from the commercial level to which the modern world has brought it to the height of a profession whose powers for usefulness will be fuller and wider than ever before, so making it one of the greatest forces in the emancipation of humanity from the horrors of modern competitive industrialism.