What  Kind Of Service Had We?

It is no part of the duty of the politician, the administrator, or even of the dreamer, to suggest wide-spread changes in any of our institutions or services if these are already performing their function in a way which gives the maximum results that can reasonably be expected. We are concerned here, however, with suggesting changes and must, therefore, in the first place, demon­strate that the present arrangements for medical care are neither complete nor satisfactory.

To many people this statement will, unless they examine it in detail, appear extreme. So many people have received such help from their doctors, and so many owe their lives to one or other of our medical agencies that they may not feel that any change is necessary; likewise, so many doctors have found their jobs professionally satisfactory and financially sound that they may not feel any need even for considering the question of medical care; but it is in no way clear that a large proportion either of the doctors or of the public are satisfied by our present medical arrangements, and one could indeed quote many opinions and advance many arguments to show that there is a large measure of dissatisfaction. The amount of self-medication that goes on and the large number of people who turn at some time or another to the unorthodox and quack healer or healing cult, is in some respects (but not all) due to dissatisfaction with the present services; but the dissatisfaction goes deeper than that, and in a survey made by the British Institute of Public Opinion in the summer of 1941 sixty-six per cent of those who were asked said that they were in favour of drastic alterations in the organisation of medicine.

We must therefore consider our present medical services in some detail and see how far the basic principles we have discussed already are fulfilled at present. It will be necessary, however, to devote a separate chapter to the changes that have been brought about by the war, and the present consideration is therefore of the services as they stood in the summer of 1939.

The usual place for beginning a discussion of the medical services is with the general practitioner; it is to him that the sick person first turns, and almost everyone is agreed that, what­ever the structure of a medical service, someone must be pro­vided to carry out the duties at present done by general practitioners for every individual in the country. There does not appear to be a completely accurate record of the number of people who actually practise as general practitioners, but for England, Wales and Scotland the figure is sufficiently near twenty thousand for us to take that as correct. In 1931 the census showed that there were approximately 33,000 registered doctors of every kind, and we may therefore assume that 13,000 were engaged in hospitals as specialists, and in public health departments.

It is worth noting in passing that the distribution of medical personnel is exceedingly variable and follows lines familiar to all who have studied social needs, for those districts likely to have the highest sickness rates, the mining and heavy industry areas, have fewer doctors than residential towns. The doctors in the former districts are over-worked, but they can only earn a living by seeing more patients since the average fee is lower. Medicine To-day and To-morrow (March, 1939) published some interesting figures on this point. Reducing all the figures to the equivalent of a population of 100,000, Blackpool has 84, Northampton 65, St. Helen’s 48 doctors and other similar examples could be given. No calculation is available for the distribution of specialists, but they are mainly concentrated in towns having a medical school and in Harley Street.

When we begin to consider the type of service given by the general practitioner, two outstanding points at once strike us; the first is that, except where a very small group, usually, not more than four, have joined together to constitute one practice, all doctors outside hospitals exist and carry on their work as separate individuals; the second point is that the types of men employed, the types of practice which they build up, the size of fee which they collect, and the attitude they show towards their patients and towards medicine in general is so variable that one is at a loss to generalise, as some people do, as to what is the typical doctor or what constitutes a good or bad practice.

This variability is further shown by the different relation­ships that exist between the general practitioner and his patients. The doctor who takes every type of work that comes his way may see in one consulting hour patients who come to him and ask for charity because they cannot afford to pay; patients who, recognising their inability to pay, come as paupers through the machinery of the Public Assistance Board; panel patients who have paid into the National Health Insurance funds and so do not pay the doctor direct; the dependants of panel patients whose link with the doctor is through the panel, but who have to pay for their own medical attention and usually wish_< to do so at the lowest possible rate; those patients who are above the national health insurance level and who must therefore pay their own fees and are assumed to be able to pay the doctor’s usual fee; and lastly those who are considered to be so far above the N.H.I. maximum that the doctor can charge them more than he gets on the average. It is asking a great deal of any individual to see patients under such varying conditions and expect him to give precisely the same attention, amount of time, and prescriptions to all of them. Of course, the reaction of doctors differs, and there are those who give their panel patients a very good service, but are impatient with their richer clients whom they suspect of making a fuss about nothing, and there is the doctor who tries to propitiate his richer customers in every possible way even at the expense of the time given to the others.

But apart from whether the general practitioner constantly, and in every case, maintains the attitude he swore to observe at his graduation in medicine to give to all the sick the maximum attention of which he is capable, we must consider whether under modern conditions there is any justification for a service which should be identical being priced at such varying rates. In the ordinary commercial world no manufacturer or shop­keeper could possibly attempt to run a business efficiently if he had to estimate the financial position of every customer before he fixed the price of the goods. Indeed, one can go further and say that such a procedure would be regarded as sharp practice, and a shop which did not price its goods clearly and stick to the fixed price which so many manufacturers advertise would be avoided by the great majority of shoppers.

Doctors themselves recognise the absurdity of the present basis on which their incomes are founded. There are, of course, many ways other than in the collection of fees from patients by which a large number of doctors add to their earnings; there are many part-time medical jobs as factory surgeon, public vaccinator, and so on; and there are many certificates to be signed, and reports to be issued to insurance companies, all of which bring something to make up the gross income of a practice. We mention these only to emphasise the absurdity of the present financial position; even more important is the first point we discussed—that of the isolation of the general practitioner. As we shall show, the key-note of modern medical services is teamwork, and whether the team consists of two or more general practitioners working together or of a general practitioner co-operating with consultants it is recognised that so intricate is the diagnosis of all known diseases, and so com­plicated may be the process of saving life and minimising suffering, that efficient team-work is absolutely essential. Yet there are twenty thousand general practitioners who, so long as they do not break any of the laws that bind them as citizens, do not offend against the Dangerous Drugs Act, and do not allow themselves to be detected in anything which the General Medical Council would regard as immoral, can carry on their practice without any contact, to say nothing of supervision, from any other individual or authority.

These remarks apply almost fully even in the case of doctors who have joined with others in a practice. This arrangement is to a very large extent a financial one, although it has the advan­tage of enabling each of the partners to obtain a little leisure while the others carry on the work. One can, of course, quote many practices in which all the partners not only work in harmony but recognise each other’s special ability or knowledge in a particular direction, but one can quote on the other hand just as many where there is no real co-operation, and sometimes definite antagonism within the partnership.

An even more important aspect of this isolation is that it cuts the general practitioner off from contact with his colleagues who are doing different types of medical work, or who are recognised to have special ability. When a group of medical men work together, as in a hospital, each of the group is constantly stimulated by the example and criticism of the other members. Indeed, so far as raising the standard of the medical profession is concerned the most potent factor is contact between doctors of every type and level of ability. The present system of general practice deprives most of the twenty thousand practitioners of this country of any real share of hospital work, and so denies them the advantages that relationship would bring.

We may note also that the general practitioner comes in contact only with those patients who are themselves conscious that their body is not functioning normally or is actually diseased. The general practitioner therefore has no opportunity for fulfilling the two basic principles of medicine—health protection and disease prevention. These should be the basis of the whole practice of medicine, and on these grounds alone the work of the general practitioner must be so changed that he can play his part in them. Indeed, it undoubtedly will be to the general practitioner of the future that the protection of the individual and the prevention of disease in the individual is handed, while other doctors tackle the wider problems of protecting the mass.
However good the general practitioner may be at the detection of disease, and however successful he may be in treatment, he is also unable to do much about the restoration of health and rehabilitation of the sick and injured. We shall have occasion to discuss this in relation to industrial health, but so far as those members of the community who are not in industry are concerned the method used for restoring full health and of guiding return to full duty should be in the hands of the general practitioner.

The question of health education is one on which there is much division of opinion. Undoubtedly there are among general practitioners many men who are able to impart knowledge and who, from their close contact with patients in their own area, are aware of the problems on which health education is most needed, but in one’s experience there are more general practitioners who dislike having to do anything in the way of health propaganda. While, therefore, health education must be closely linked with the work of the general practitioner, it can probably be best carried out by those with a special aptitude for this work.

 

We may summarise the position of the general practitioner, therefore, by saying that he has to see an almost infinite variety of types of patient who pay him in a great variety of ways while he also obtains part of his income from sources not connected with the individual patient, and he carries out these functions in a state of isolation from criticism and organised assistance, and is prevented from fulfilling many of the functions which a medical service should carry out.

If we pass to the other medical agencies we are met with an even more bewildering position. While it may be true that only fifteen per cent of those who consult the general practitioner require to be sent to other agencies or individuals for diagnosis and treatment, almost every member of the community does, at one time or another, require hospital care; our hospitals, there­fore, constitute a very important part of our medical services, and it is true to say that however spectacular may be the occasional case in a doctor’s practice in which he saves the life of a very sick patient most of the work of dealing with conditions which would otherwise be fatal falls upon hospitals. Were we dealing with a country in which there were no hospitals it would be obvious that there should be only one hospital system, and that all the hospitals in it should be organised on a similar basis, and that the standard of the service given by the very best of them should be the aim of all. In trying to reach that standard it would develop that hospitals should, on the average, be of a certain size, require a certain number of nurses per patient, and a certain staff of doctors, and while one would look for a certain variation to fit in with local conditions of various kinds nevertheless the hospitals of such a service would on the whole be very similar.

We are struck, therefore, at the outset of our consideration of hospitals in this country by the fact that there are two totally different and completely unrelated hospital systems. To say that this is now quite indefensible is no reflection on the historical features of life in Britain which have given rise to these two systems, and is certainly no reflection on the vast number of men and women who have laboured to build up and maintain the voluntary hospitals. The arguments for and against the voluntary hospitals must wait to a later stage, but meantime we must notice the result not only of the division into these two systems but also the effect of capitalism’s recognition during the last century that certain diseases and abnormal conditions were a danger to the community and must therefore be dealt with by the provision of isolation hospitals for infectious diseases and mental institutions for those of unsound mind. Of course, the development of our public hospitals was also due to the recog­nition of the fact that neither the charity system of the voluntary hospitals, nor the amount of free service given by specialists in the voluntary hospitals, could cope with much of the sickness among the poorer classes.

As Prof. H. E. Sigerist summarises it in Socialised Medicine in the Soviet Union (Gollancz), “Charity proved to be an unreliable system for protecting the people’s health since funds are needed most urgently in times of economic depression. Besides, the development of a large industrial proletariat increased the number of indigent sick to such an extent that it soon became impossible to provide medical care for them on the basis of charity. . . . Another factor entered the scene. , The protection of society against epidemics and the sanitation of the environment of man were administrative tasks which could be solved only by the State through its public health agencies. . . . As a result of such developments the systems of protecting the people’s health are in all capitalist countries compromise-systems. Medical service is given to the population by various agencies in various ways . . . state medicine, insurance medicine, charity medicine, and private medicine exist side by side.”

In the hospital sphere the result of this complex development and compromise is that we have over one thousand voluntary hospitals, about one hundred and fifty public hospitals that deal with general cases, over five hundred poor-law hospitals and institutions having sick beds, nearly two hundred institutions for tuberculosis and three hundred for smallpox, while there are over seven hundred hospitals for dealing with infectious diseases gen­erally, and over one hundred providing beds for maternity cases.

These thousands of hospitals do not constitute anything resembling a hospital system. It is even not quite accurate to speak of two different hospital systems for, to quote a recent P.E.P. report, “the thousand and more voluntary hospitals are self-governing institutions jealous of their independent status, only loosely associated with each other; and Britain’s two thousand public hospitals are administered by hundreds of separate local authorities”. The two systems of which we speak are therefore not administrative systems but only systems in the sense of groups of institutions carrying out similar functions by similar methods. There is in the voluntary system an almost endless variation. During September, 1941, many letters appeared in the correspondence columns of the British Medical Journal in answer to one writer’s question as to what are the special virtues of the voluntary hospital system; the letters revealed that from the point of view of doctors the variation in the voluntary hospitals was so wide that almost diametrically-opposed state­ments could be made as to the way in which they were run. The best of our voluntary hospitals undoubtedly give a very good and a very full medical service, and indeed, so far as a few of them are concerned, it is difficult to suggest additional duties and functions which could be conveniently carried out in a hospital and which would be an essential part of a modern medical service.

The service given by these hospitals comprises both out­patient and in-patient diagnosis and treatment facilities. In-patient treatment is normally only possible, except in the case of street accidents, on the recommendation of a general practitioner or a member of the hospital staff; out-patient advice may be available to any member of the general public who cares to attend, but in recent years many hospitals restrict even their out-patient service to those who have been recom­mended by their general practitioner. The correct procedure, except in the case of emergencies, is, therefore, that the general practitioner sends the case to the hospital in order to obtain a second opinion, to have investigations carried out in the hospital laboratories or other departments, and to have treat­ment given which is impossible in the home of the patient.

The staffing of such a hospital is usually by a combination of honorary and paid personnel; the whole of the nursing staff and most of the junior medical officers are paid on a full-time basis; the radiologist, pathologist, and a number of other specialists are very often paid either on a full-time or on a part-time basis; the senior physicians and surgeons are, however, unpaid and their service remains almost the only part of the service given to the patients which is not paid for in a direct fashion. The possession of an honorary title to a large and important voluntary hospital is, however, regarded by its possessor as the best method of payment for the work which he does; it is by his possession of his honorary position that he is able to build up his private practice, and it is through the knowledge and experience gained in attending the many who cannot afford to obtain their medical services in any other way that he is able to charge large fees to the few whose incomes take them outside the ordinary hospital level.

There is indeed on the part of the personnel of the voluntary hospitals no true voluntary work in the sense of charity done for no personal gain, and there are in fact an ever growing number of voluntary hospitals who find it necessary to pay some fee to an increasing number of members of their staffs. From the point of view of the patient the voluntary nature of his relations with the hospital have also disappeared, for while he may not be compelled, and legally cannot be compelled, to pay the whole cost of his maintenance and treatment, the efficiency of the almoner’s department of most hospitals leads to a very high proportion of patients making definite payments to the hospital. In recent years a noteworthy departure from the charitable basis of hospitals has been the setting up of contri­butory schemes which, on an insurance basis, produce quite large sums of money for many hospitals. On the administrative side there is no pretence that Britain’s voluntary hospitals are run by the voluntary charity of the rich or the carefree, for well-paid staffs are employed to work out new ideas for collecting money and for running ventures such as garden parties, dances, etc., on which a profit can be made.

We have, therefore, even in the best voluntary hospital a very large and continuous amount of work aimed at perpetuating the appearance that these are charitable institutions open freely for the treatment of the sick poor.

The voluntary hospitals are in fact not freely available even to the sick, and certainly not to the poor. There are a large number of restrictions, some open and some that have never been formulated, but which are nevertheless real, by which a selection only of cases is admitted to these hospitals, and in the case of our larger hospitals in which the teaching of medical students is done this selection is quite definite and quite strict; its aim in such a case is to admit to the wards of the hospitals only those cases which will be of the greatest value for teaching purposes, and the only departure from this is the admission of cases in which, for some reason, or another, a member of the staff is particularly interested.

The poorest of our voluntary hospitals give, however, a totally different type of service. We have a very large number of small voluntary hospitals most of which are of comparatively modern date, and the staffing arrangements of these are often so poor that they constitute a danger rather than a source of benefit to the community. The type of hospital one has in mind is the small cottage hospital staffed by the general practitioners of the neighbourhood with no doctor in residence and no consulting staff. When the general practitioner staff is restricted so that only a portion of the doctors in a district are connected with the hospital, the position is even worse than when every member of the medical profession has a right of entry; in such a case the cottage hospital becomes little more than a nursing home to which some of the doctors can send some of their patients for nursing attention; if surgery is done in such a hospital it is either restricted in nature because the more difficult and more unusual cases must be sent to a larger hospital, or it is restricted in quality because none of the general practitioners who carry it out ever get enough practice to become really good surgeons: there is in such a hospital usually no provision for out-patient consultations; so that a district with one of these small voluntary hospitals may be deluded into believing that it has a full medical service when in fact it is being deprived of most of the advantages that come from a good hospital system.

Some of our voluntary hospitals have a history that goes back for centuries. All public hospitals on the other hand are of relatively recent date and it is really only since 1929 that real development has been possible; in that year the Local Govern­ment Act made it possible for a local authority, whose poor law institutions had lost their original function of catering only for the infirm poor and were being compelled to carry out a great deal of work similar to that done by the voluntary hospitals, to convert them into municipal hospitals and to remove from them the stigma of the poor law.

The London County Council has in this matter been an out-standing example and during the period 1930-39 the poor law hospitals of London have been transformed, and as the buildings and staffing arrangements have improved so larger numbers of people have come to use these hospitals until one can safely say that they have almost overcome the prejudice that every class , felt against them. Other local authorities have also changed their hospitals from poor law to public health and now give a hospital service which, at least so far as in-patient work is con­cerned, rivals that of our largest voluntary hospitals.

In the voluntary hospitals the medical staff usually consists of honorary physicians and surgeons who visit the wards at intervals to see their own patients; lower in rank, but not directly subordinate to them, there may be assistant honorary physicians and surgeons on whom may fall much of the out-patient work; the resident staff of the hospital consists of newly qualified doctors who serve under the honorary staff and are responsible to them for seeing that the treatment they have prescribed is carried out, and in the larger hospitals one or more resident officers of higher standing who may act in emergency if the senior member of the staff is not available.

In the municipal hospitals the system up until recent years was to appoint assistant medical officers, all of whom were resident and each of whom had the sole responsibility for certain wards or a certain number of beds. In the larger municipal hospitals there were usually senior assistant medical officers who also had their own quota of beds to look after but were at the same time available as consultants to the juniors and usually carried out the more important surgical operations; in addition con­sultants in those specialities in which there was not enough work to justify having a resident full-time officer were appointed, and usually paid according to the number of attendances they made. The staffing arrangements for municipal hospitals are at present in a fluid state as the redistribution of medical personnel because of the war has enabled experiments to be made.

The fact that we have no real hospital system at present is emphasized by a consideration of the position of hospitals for special diseases; those hospitals, for example, that deal with mental disorders are set quite apart from all other hospitals, are differently controlled and have different methods of staffing; hospitals for infectious diseases are, in almost all cases, run by local authorities but not by the same local authorities as run the municipal hospitals, and very often by special committees set up by a number of town or borough councils in co-operation for that purpose; institutions for the care of the tuberculous are also separate; and in addition there are quite a large number of hospitals for the treatment of men in the armed forces.

We are endeavouring to stress the complexity and haphazard nature of our present medical service, and a very clear view of this can be obtained by studying the diagram in which the arrangement of our medical services is depicted from the angle of the sources from which the finance of these services is derived. It will be seen that the money which the ordinary citizen pays for his medical service goes in a great many different directions, into taxes, into rates, into voluntary hospital funds, into provident insurance funds, into trades unions and other societies, and that each of these collecting agencies in its turn distributes the money to an equally bewildering collection of medical agencies. This is made more bewildering by the fact that most of the agencies collecting the money pay it out for a variety of medical services. A place has also been found in this diagram to indicate the money that is spent on patent medicines and unorthodox medical treatment. The financial implications of all this will be discussed later, but the diagram illustrates that even on paper our medical services are broken up like the pieces of a jigsaw which may or may not be complete; it is when these are translated into the buildings with all the beds and parapher­nalia of a modern hospital, and when all the different personnel required to run them are considered that one discovers that there are very many parts of the jigsaw that are not only missing but have never even been considered necessary in the past, and that one discovers further that this jigsaw is in more than one dimension, and that parts which are present in one part of the country are missing in another.

We have stated, however, that this subject must always be looked at from the point of view of the patient, and a second diagram gives an indication of the complex way in which the ordinary British family has, at this moment, to set about getting its medical services. In theory it is possible to agree with the British Medical Association’s idea that the fundamental need is to provide a general practitioner for every individual, but this diagram demonstrates that the service we have at this moment provides no direct route between the individuals of a family and a complete medical service, and makes very little provision for those important functions of medicine—the preservation of health and the restoration of a function after illness.

At the end of 1939 our hospitals and medical services generally were put to a new test, the impact of war. In the past, when wars were almost entirely a matter of small armies fighting against each other and each provided with its own medical service, the medical system of Great Britain remained almost entirely unaffected by any international conflict. The present war, however, has given rise to a totally different situation, and in preparing for war it was realized that with the possibilities of enormous numbers of civilian casualties and of air-raids on most of our large cities that the medical service of the whole country must in some way be prepared for the shock. The system as we have outlined it is as it existed up to September 1939, but in the years that have since passed changes have taken place which must be considered for the light they throw both on the past and on the future.