Proposals For The Organization Of  Medicine

The position reached by our medical services to-day has been very largely unorganized, and there has never been any suggestion of a plan for the whole nation or for the whole country, although in some districts there have been local attempts at providing some form of medical plan. However, it -has been so clearly recognized that the medical service is inadequate in many different ways that there are now on record many proposals to change the medical system of this country.

The idea of insuring the working-class section of the popu­lation against illness originated quite early in the industrial era, and Germany had a system as early as 1883. In this country the first official attempts to provide medical treatment for those who could not afford it was made by the setting up of Poor Law Institutions, to which were attached sick wards and, later, hospitals. This method provided only for the section of the community which were to the medical profession the least profitable, and it did not make any radical change in the medical system. The first real attempt at this was made in 1911 when Mr. Lloyd George introduced, and saw passed into law, the National Health Insurance Act. This was at first resisted by a very large proportion of the doctors of the country, who used against it precisely the same arguments as are being used thirty years later against the conception of a socialized medical service. These objections were briefly that the standard of medical service given would be lowered, that State interference would come between the doctor and his patient, and, even more important, that the payment suggested would mean the lowering of the doctors’ economic position. As soon as the Act became law, however, a great majority of doctors accepted the system at once and, except for a few older men who remained outside it the whole profession was soon engaged in panel practice.

The thirty years that have elapsed have shown that the arguments against National Health Insurance were entirely false; on the economic side it has raised the income level of the average general practitioner far above that of the years prior to 1911, and has enormously enhanced the capital value of medical practice. The position had now been reached that the doctor who has a good list of panel patients can always obtain a higher value for his practice when he tries to sell it. The buying and selling of practices has become a recognized practice into which many non-medical bodies such as banks and insurance companies enter, and an unknown but very high proportion of the practices of this country are in actual fact held by such financial companies and not by the doctors who engage in the practice. In peace time any doctor who had not acquired a bad record could obtain advances for almost any amount for the purchase of a practice, and most doctors spend at least fifteen years of their professional life paying back the money they have borrowed. From the point of view from which we are considering this problem the most important point about this subject is that the sale of practices takes place in the certain knowledge that most patients, and particularly panel patients, can be bought and sold in the open market without raising any objection and without there being any legal bar to this consideration of human beings as chattels of commerce. It is exceptional for there to be much wastage, as an insurance company refers to these patients who change from a practice, i.e. from a particular doctor’s surgery, when the doctor changes through death or the ordinary sale of the practice. In other words some ninety-five per cent of those who have attended at a doctor’s surgery remain bound to that surgery, no matter what change takes place in the doctor consulting there. It is as well to say frankly that this buying and selling of practices is the basis of most doctors’ objection to a change in our medical system, for they fear the loss of the capital value of their practices and the complications that might arise with those to whom the practice is mortgaged.

As to the fear that the N.H.I. would produce a lowering in the standard of medical service, everyone is agreed that this has not been the case. There are still many critics of the panel system, and undoubtedly many grounds for real complaint as to its deficiencies, but on the whole the panel system has led to an improvement in the medical service available to a large section of the community. What if amounts to is that some seventeen millions of the population are able to consult a general practitioner whenever they feel the least bit unwell, without the fear that if anything is found to be wrong they will be involved in paying heavily for their medical service. So far as the quality of the medical service is concerned we must recognize that in the past thirty years there has been a very steady advance in medical knowledge, and the probability is that under any system there would have been an improvement in the service given by general practitioners. N.H.I, has, however, meant that many people have consulted their doctor at an early stage of illness, and where the panel practitioner so consulted has been a man who liked to consider himself a good doctor they have had an early opportunity of treatment. Even those who have become attached to a practitioner who might not be regarded as of very high standard by an outside observer, may have obtained quite good medical advice by the habit which has grown up during the same period among doctors of referring their patients to hospitals for a second opinion.

This has also been a cause of criticism of panel practitioners, many saying that the routine observed by them has been to use a few stock mixtures for the treatment of all their patients, and to refer to hospital those who did not respond to this form of treatment. While this has undoubtedly been true in some cases it does not follow that the patient has been any the worse off, for the advice given by the hospital doctor may have been of a high standard.

This question of referring patients to the consulting physicians and surgeons in the out-patients department of a hospital is one of those unorganized and sub-conscious tendencies with a very important lesson for us; it indicates that the doctors have recognized for themselves that the service as given by the ordinary general practitioner is far from being the best available, and that every such practitioner requires a consultative centre situated near his practice.

The third point of criticism of the proposed National Health Insurance scheme which we have mentioned was that Govern­ment interference would upset the relationship between the doctor and his patient. This fear was based in 1911 on the same idea as we find expressed by many of the older leaders of the British Medical Association in 1941, that there exists some kind of basic relationship between the sick person and the physician, which on the one hand is based on’ the ability of the patient to recognize the good qualities of this doctor as being better than those of any of his colleagues, and on the other hand that the psychological value of the bedside manner of a doctor chosen in this way is greater than the value of correct diagnosis and application of remedies known to be specific for the disease that is diagnosed. In practice the degree of interference between the patient and the doctor which has been exercised by the Government under the National Health Insurance is negligible. It is true that unnecessary and, in some cases, quite unwarranted restrictions have been placed on the prescription of certain drugs. As a general principle one would say that there should be no restriction whatsoever on the list of recognized drugs which a doctor should be able to prescribe for his patients, no matter whether the financial arrangement between him and that patient is one of direct payment for services rendered or indirect payment by an insurance system.

Unfortunately one is compelled to recognize that the medical profession, consisting as it does of many thousands of men and women chosen haphazardly from Our school and university students is apt to contain a very large number of practitioners who are quite unable to estimate the value of different prepara­tions and totally unable to assess the truth of the claims put forward by manufacturers of therapeutic materials. There are therefore an all too large number of doctors who prescribe remedies of which they have no more knowledge than that possessed by the average lay person as to the composition and effects of a patent medicine. There is therefore a real need for certain restrictions on the prescribing of certain classes of medicines, so long as our present system both of providing a medical service for the working class by an insurance system persists, and so long as the manufacture and sale of medical preparations is entirely uncontrolled. The need for this form of State interference will disappear, as we shall show later, when the pharmaceutical industry becomes an integral part of a socialized medical service.

A brief consideration of these points, together with what has been said in earlier chapters about the mixture of agencies dealing with medical care, makes it readily understood why there should have been proposed during the past twenty years a great variety of schemes for changing the medical services of this country. These are of three types based on a recognition of different defects both in the care of private patients and in the care of insured persons. There are those who have suggested forms of a national medical service for most or all of the popula­tion and for most or for all of the services needed; there are others who regard the outstanding defect of the panel system as its lack of provision for the services of the consultant and other hospital treatment; then there are those who regard the greatest defect as the failure to provide a general practitioner for every citizen.

To meet the latter defect the obvious improvement, and one which has a very large measure of support both with the doctors and with the public, is a simple extension of the panel to take in a much larger proportion of the population. It would be a relatively simple matter to extend National Health Insurance to cover the dependants of all insured persons so that, to take the case of a married man with a wife and family, it would now be possible for the same panel doctor to treat the wife and children as part of his N.H.I, practice instead of as private patients as the matter stands at present. Such an extension of the panel would, it is estimated, cover at least eighty-five per cent of the population so long as the upper income level limit for N.H.I, at £250, remained. This level has, however, been changed since the outbreak of war, and might be still further increased so that all with incomes up to £500 a year would be included. This would bring some ninety-three per cent of the whole population of the British Isles under the one general practitioner service, and if the provision of a general practitioner on such a basis was all that was required for a medical service there would be much to be said for carrying out this change at once.

It would in fact merely perpetuate the weaknesses and deficiencies of the present system; it would leave the doctors still working as isolated individuals, and while if all sources of income are taken into account it would mean that not less than eighty per cent of the income of the general practitioners was derived from what would be practically national resources, there would be no greater control over them and the service which they rendered than there is at present. It would also perpetuate the position of the approved societies whose relation to the provision of medical care is a totally artificial one which all who have studied the question are agreed should be abolished, but the worst defect of all would be that the services of consultants, of radiologists, pathologists and other specialists, and the whole of hospital treatment, would remain outside the service provided by the insurance system.

This defect is recognized by all who advocate the extension of the panel system, and they therefore argue that payment for these services should be provided under the terms of the payments made to the National Health Insurance funds. This again would be a relatively simple matter, although there might be considerable objection by the poorer paid sections of the com­munity to the relatively high payments which might have to be made weekly for such a service. It is not generally recognized that the insured person pays what in ordinary insurance terms would be considered a very high premium for a very low financial risk. If the insured person had to pay for his dependants and for specialist services on a calculation similar to that at present made, he would in fact be paying a premium for an amount of cover which most insurance brokers would look upon as a very poor scheme indeed. That consideration, however, we could put aside, for once more the worst defect would be the failure to organize the additional services that Were thus to be provided. No one who has advocated this system, and least of all the British Medical Association who put it forward in considerable detail in their booklet, A General Practitioner Service for the Nation, has suggested that all the hospitals and consultants attached thereto should pass into the control of some authority responsible to the electorate. It is a defect of this and of all other schemes short of a socialized medical service that they suggest forms of medical care which, in their development would require sub­sidies and support from local authorities and the Government, without at the same time recognizing that such support would also involve control.

It was the recognition of this defect in our system of medical care that led to the setting up of the hospitals savings funds and other similar schemes for the insurance of workers and the lower middle class against the cost of hospital treatment; that this need is widely understood by the man in the street is shown by the very large numbers of people who have contributed to these funds, despite the fact that the insurance cover they give is not complete, does not cover a long enough period, and is not particularly generous to the hospitals who accept the scheme.

It is also the recognition of these defects which has led to the setting up of the Nuffield Provincial Hospitals Trust. There can be no question Lord Nuffield has been activated by an intense desire to see a better hospital service for all classes of the population who cannot afford, or who are not provided with, a full hospital service, and in some parts of the country his bene­factions have led to a considerable improvement in the available medical services. Nevertheless one is compelled to recognize the setting up of the Nuffield Hospitals Trust, whatever the motive, as an attempt to prevent the State from recognizing its function in relation to health. On the one hand a spokesman of the Trust has indicated that their desire is the provision for the whole population of a complete chain of medical services/ but on the other hand the method is really a form of rationali­zation of the voluntary hospitals, conceived in much the same was as a modern industrialist would rationalize any other industry.

Other schemes have been put forward which deal exclusively with the hospitals. Of these the most recent and most interesting was a plan for British Hospitals published in 1939 by The Lancet. This scheme was based on the Emergency Hospitals Service and accepted the form of regionalization which is the basis of that service, and aimed at maintaining the voluntary system in combination with the de-centralization of consultant personnel which is a feature of the service. In order to administer the hospitals as a co-ordinated group, it was proposed that there should be set up a National Hospital Corporation controlled by a Board of Governors of whom at least one third should be doctors. This Corporation, like the B.B.C., would be appointed on a charter which could be reviewed by Parliament every five years. It would take over all voluntary municipal and emergency hospitals, all endowments, investments and so on, and would receive in addition a Government grant. Current expenditure would largely be met by patients’ contributions, provident schemes, or compulsory hospital insurance. So far as the general practitioner is concerned The Lancet plan merely suggested an extension of the panel to all wives and dependants, and that all those should be referred for other services to the regional organized hospitals and to the consultants attached to them.

It is perhaps worth while noting that twenty years ago schemes were being proposed for organizing the medical services which involved a co-ordination of the hospitals under an ad hoc committee, very similar to that proposed by The Lancet scheme. The consultative council on medical services set up by the Ministry of Health in 1919 issued an interim report in 1920 which might have made very big changes in our medical services had it been put into action. That committee recommended that while the domiciliary medical services should remain in the hands of general practitioners, consultative services should be provided by a system of primary and secondary health centres. The primary health centres are rather loosely defined in the report, and no indication is given as to their size, but the general idea is of a small hospital including medical, surgical and maternity beds under the control of the general practitioners of the district. There would be certain arrangements for laboratory and other diagnostic facilities, and an ambulance service was be provided. In addition, visiting consultants and specialists would pay regular and emergency visits. These consultants were to come from the secondary health centres, which were to have special facilities for expensive forms of treatment and more elaborate diagnosis. An effort was to be made to relate each secondary health centre to a teaching hospital to which cases of unusual difficulty or interest could be referred. Changes that have taken place in the last twenty years make such a scheme quite impossible, but the method of administration which found most favour was by an independent health authority of whom three-fifths should be elected by popular vote and two-fifths should be appointed for their special knowledge of medicine and would usually be doctors from the Medical Advisory Committee. To some extent such a scheme has been attempted in Gloucestershire where, at the instigation of a former Medical Officer of Health, a special Medical Services Committee controls all the hospitals, public and voluntary. The county is divided into four regions in which there are twenty-eight out-stations where almost every class of treatment is carried out. The work is done by general practitioners who are paid on a sessional basis and keep in close contact with consultants from the larger hospitals. The scheme is, however, only available to a section of the population, mainly those who are covered by some statutory arrangement.

The obvious deficiencies in the B.M.A. proposals, and most of the other schemes put forward, led the annual representative meeting of the B.M.A. to pass a resolution in July 1939 calling for an examination of plans more analogous to a State medical service than anything they had previously considered. The chief suggestion put forward was the Walker plan, in which its author, Dr. E. R. C. Walker, attempted to provide a service which would bring the general practitioner under regional control but leave him a considerable margin of freedom and of variation in remuneration. Those who supported this scheme did so because they believed that the extension of the panel would merely continue the unsatisfactory features associated with a per capita method of remuneration. Chief among these are ” a tendency to favour unfair and unmedical methods of acquiring practices, and the premium put on commercial rather than medical ability involved in the sale, purchase and management of panel practices”. The scheme accepted the idea that sooner or later the State would assume full responsibility for the medical services of the country. This would involve control of the scheme by the Ministry of Health, but the regional sections of the country were to be administered by specially set up committees, and on medical matters the doctors were to be given full authority. The total number of patients which each doctor could have on his list would be limited, but the proportion of those paid for by the State and those paying private fees might vary. The general practitioner would therefore in fact be a part-time employee of the State; consultants would also be salaried officers, mainly full-time, but sometimes part-time, and their services would be available to all patients through their general practitioner. The scheme did not, however, visualize the setting up of health centres, nor did it work out in detail the relationship between the practitioner and the hospital.

It should be noted that among general practitioners there has been an increasing tendency to consider the idea of group practice. As everyone is aware, it is quite a common thing to-day for a number of general practitioners to combine in a partnership. For the most part, as we have already noted, such partnerships are in reality a financial arrangement only, and there is very little attempt to convert the partnership into a team of doctors, each of whom would be specially skilled in one or another part of medicine. It would be quite feasible for a group of six or eight general practitioners to include in their number one who had a special qualification in surgery, another who took charge of maternity work, a third who acted as consultant in diseases of the eye, and others who took a particular interest in other special branches. Such a team, especially in a country district or in a small town which did not possess hospital facilities, could do very good work. It will be recalled that this was the idea with which A. J. Cronin concluded his novel The Citadel, and was his suggestion for getting rid of the evils in present-day practice at which his book was aimed.

Group ‘practice of this type has been tried out particularly in America. Its great weakness is that if the team is to be effective it must be chosen by someone who is competent to judge the capabilities of the other members of the team and who can choose them without reference to the amount of capital which they can bring into the practice. This brings us back again to the same difficulty, that so long as medical practice is unorganized it is impossible to provide such teams, and the facilities they would require, for every part of the country and for every patient; some form of organization is required, and in America group practice is now largely controlled by those forms of co-operative medical society which we have mentioned earlier. The control of such a group is, however, almost entirely in the hands of the patients who are financially responsible for the system, and for that and other reasons it has not found much support in this country. From time to time individuals, notably Dr. Lyburn, have advocated the setting up of a chain of clinics, at which technical assistance in the form of X-ray apparatus and laboratory facilities would be available to all the general practitioners of a district, with the idea that such provisions would enable the general practitioner to make more rapid and more accurate diagnosis. The provision of such facilities cannot, however, replace the experience of the consultant physician and other specialists, and in any case such a chain of clinics could only be provided by an official body, and involves the setting up of a service as distinct from providing additional facilities for isolated practitioners.

The major fault of all these suggestions, and others which we have not quoted, is that they deal either with a part of medical service only, or attempt to safeguard and preserve some part of our existing services without consideration of our medical needs as a whole. So long as the part proposed for preservation is that medical practice should remain a matter for private enterprise, that medical practices should be bought and sold to the highest bidder in the open market, that our hospitals should be of all kinds of different sorts and sizes and that a large proportion of them should obtain much of their current income by begging and by selling flags, so long as the desires of the general practitioner and not the needs of the State and of the individual citizen are the primary considerations, a complete scheme taking full advantage of modern scientific knowledge and method is impossible. Once it has been conceded that health is the inalienable right of man, and that it is a function of the State to protect that right just as it is to provide for other necessities of life, it becomes possible to consider a new theoretical basis of medical service, and to build on that a practical scheme which will be easily operated, free from the defects of a Fascist bureau­cracy and of individual enterprise, and capable of guaranteeing to all citizens at all ages the greatest possible degree of freedom from disease.