A State  Or A Socialized Medical Service?

The reference to bureaucracy at the conclusion of the previous chapter brings us to one of the chief reasons why some medical men have opposed the planning of our medical services. When these ideas were first discussed the advocates of change spoke of the need for setting up a State Medical Service, and to these three words all that the defects that have arisen in different departments in which the State has endeavoured to organize part of our national existence have become attached. The defects of the Civil Service attempt to try to graft State Institutions, which should mean organization for the country as a whole, on to an economic system which is based on private enterprise and the individual, have given rise to difficulties which make it easy to throw doubt on the possible efficiency of a Government-controlled service. These defects include the multi­plicity of forms that have to be filled in before anything can be done, the need for sending to a central department innumerable statistical returns, the long delays in obtaining decisions on even minor points, and the impossibility of the man working at the periphery having any influence on the machine at the centre, and the constant possibility of office chiefs, who are out of touch with practical work, interfering between the patient and the doctor.

Other disadvantages of a State service are also mentioned, such as the fear that men who are engaged in full-time employ­ment will be less efficient in their duties and less anxious about the welfare of their patients. This is, of course, a fear which has no basis whatever, for more than eighty per cent of our popula­tion, including the whole of the army, navy and air force, cabinet ministers and members of parliament, all our school teachers and most factory managers and people in responsible positions, are to-day working on a basis of a salary or wage for full-time service. There is in fact no reason to suggest that those doctors in our municipal services who are already full-time salaried officers give any less good a service to their patients than any other section of the profession, and there are many who believe that on the average the service they give is better. Even if there were some truth in this fear, it can easily be removed by inserting in the scheme for medical service safeguards against those who would take advantage of their full-time position. These safeguards would, of course, be automatic in a State medical service operating in a country in which industry, agriculture and all other services had ‘been fully socialized, and the point we would like to discuss here briefly is whether there is any possi­bility of building up a medical service which would in effect be a socialized medical service, and therefore free from all the defects which attach to a State medical service, even while capitalism continues as it does at the present moment.

It is generally agreed that the complete socialization of any section of our national life is impossible unless everything in the State is socialized at the same time. It might be possible to increase the efficiency of the State, perhaps to, raise the standard of living of the workers, by changes in certain sections of our national activity, but the friction that would arise from time to time between the two opposing systems within one State would prevent even radical changes from having their full beneficial effect.

Nevertheless there are very strong reasons for thinking that a large measure of socialization may be possible in the case of medicine. It is the type of service which can be separated from the rest of the nation’s activities, and even if a completely planned system does not develop in the near future it is evident that there will be much experimentation towards that goal.

There are three main reasons why this may be so. In the first place the State has already been compelled to concern itself with health problems. The expansion of industry during the last century, and the tremendous increase in the population of the country during the same period, produced a working class of which very large numbers had so low a standard of living that they could not be treated medically by private enterprise because they simply could not afford to pay the fees. They tended therefore to be neglected and lived outside the ordinary medical arrangements, and the State – had to make itself responsible. The second reason was the steady realization of the importance of health in relation to the production of goods. At the early stages of the industrial revolution capitalism was content to use the workers in a prodigal fashion as early ages had used slaves, considering that all that mattered was the production of goods and that the loss of life and the amount of ill-health caused by the conditions did not matter. Slowly, however, the idea spread that if the health of the workers was neglected there would soon be none to do the work that was required. This began first of all with the demand that little children should no longer be permitted to work.in factories under a certain age, or to work in the conditions then prevalent at any age. Having freed the children to some extent, and as a result of experiments carried out by more humane indus­trialists, it became clear that to neglect to keep the workers alive was a case of “killing the goose that laid the golden eggs”. A third point which speeded up the provision of some kind of medical service was the realization that epidemic diseases are no respecters of social classes, and that if the workers were kept in conditions in which they were prone to disease the same conditions might spread to the upper class.

To-day these three points have even greater force than before. Under war conditions the State has found it increasingly neces­sary to take over work which does not -yield a high profit in ordinary conditions. Under war conditions also it is more than ever essential to prevent the spread of epidemic disease and to protect the health of the nation as a whole. There is a very close link between health and morale, and the experience of the last war and some aspects of the present conflict make it clear that a nation which is receiving adequate nourishment, which believes that every man and woman is getting his or her share of the available supplies, and of which the standard of health is maintained at the highest level, is best able to stand up to modern warfare with its bombing raids on civilian citizens. Health also is of primary importance in the production of war materials, and it has already been pointed out that a very large proportion of absenteeism from munition factories is due to increasing ill-health and the fear of a breakdown. The position in this country is not free from dangers, and the large increase in tuberculosis, especially among young women in industry, draws our attention very sharply to the need of a health policy which will prevent such dangers from arising.

These very strong reasons for maintaining our health standard and for making any changes in the medical services which will assist in that maintenance, are backed up also by the historical fact that Governments are constantly forced to make conces­sions to popular demand; and one of the points on which they British public has shown its opinion (by the figures of a Gallup survey published in the summer of 1941), is that we can no) longer tolerate a double hospital system and an unorganized)] medical service in time of war. The public have been forced to this realization by two main factors, which are entirely un­connected with any propaganda in favour of a socialized medical service. One is the fact that our Russian allies have put up such a stern resistance to the Germans, and that credit for this has been given by statesmen of both countries to the magnificent morale of the Russian people based on the knowledge that their health service is so planned that it can stand up even to the shock of war. The second point is a clear statement of our own Government that our medical services could not be expected to stand up to the shock of modern war and the institution of the Emergency Medical Services to co-ordinate the work of hospitals and to provide a casualty service. Although the criti­cisms of these services have been mainly technical in nature, they have not been overlooked by the lay public who agree that such an organization was necessary but regret that it should have been so inefficiently and so incompletely carried out.

But there is, in any case, a possibility that medicine may be chosen for one of those experiments in social advance with which the British constitution abounds, because it affects the general question of private enterprise to such a small extent. The Government, wishing to carry out experiments in socializa­tion without a national mandate for setting up a socialized state, would hesitate to attack financial groups controlling our greater industries and utilizing large amounts of capital. The medical profession, however, consists of some fifty-thousand individuals who exist in such isolation that completely united effort against a Government threat would probably be impossible. In addition, the medical profession has a considerable degree of altruism, although not so much as sentimental writers would like us to believe, and maybe the more easily persuaded to allow itself to be experimented with in this way. In any event the amount of capital involved, the way in which it is spread over individuals, banks and insurance companies, makes it much easier to handle either by compensation or expropriation than the capital of modern combines. Indeed almost any government would find it a simpler matter to tackle the medical profession than to interfere with those concerns which manufacture and distribute drugs and chemicals, or even with the manufacturers of patent medicines. The capital and the political influence of these bodies has in the past proven much more formidable than those of the medical profession.

If we regard the essential feature of a socialized service as the freeing of it from financial barriers between doctor and patient, that feature could certainly be achieved, as in the case of education, without disturbing the present system. If we regard the essential feature as the provision of a hospital service, the present Government is already committed to that as a first step in post-war reconstruction. If we regard the essential feature as the prevention of disease, our Ministry of Health and all who speak on medical matters or for medical bodies are agreed, that prevention must be made the keynote to post-war medical services. The position is therefore ripe for great changes, and it is essential that all the possible forms of change should be explored and that both the principles of a socialized medical service and the details of the way in which these can best be carried out should be considered at once.