Some Difficulties And Objections

it would be quite useless to ignore the fact that quite a number of objections are raised to any scheme for planning the medical services and that there are some inherent difficulties in operating a system of the type discussed. Chief among the difficulties is that of administration and control, both of which are so wide in their bearings that they will be discussed separately. On analysis it becomes clear that many of the points which are raised as difficulties in the scheme are, in reality, objections which are quite often not without prejudice. There is, for example, the objection that in a medical service of this kind the income of the doctors would tend to be lower than at present, and the fear is often expressed that, having obtained the control of all doctors, the State would drive a very hard bargain and offer salaries that would not be commensurate with the work and responsibility involved. This fear has been heightened by the arbitrary action of the Ministry of Health in fixing the salaries for officers in the Emergency Medical Service without consultation with the profession and without much consideration of the incomes which doctors were earning prior to the war. As it is, the full-time salary of the great majority of officers in the E.M.S. is £800 a year plus £100 living allowance if not accommodated at a hospital, and this figure has meant a very considerable reduction in income to quite a large number of those who are in that service. It is true that such a salary may be higher than the income which the doctor might have earned in other ways during wartime, but, apart from all questions as ‘ to what is a suitable salary during a war in which the whole population is concerned, the E.M.S. salary figures certainly have increased the fear that an organized medical service would involve a reduction in the standard of living particularly of general practitioners.

To make the position clear it must be pointed out that the net income of general practitioners taken at an average for the whole country has been estimated to be in the region of £700 a year. It is certainly unlikely that, were the cost of living stationary, any Government would try to pay doctors less than that amount. In view of the changing standard of living under war conditions it is impossible to suggest figures which would be correct at the moment when such a service was introduced. The salaries should, however, be a matter of negotiation between the different interests concerned, and it is certainly no reason why in a socialized medical service the income level of the doctors should, by comparison, suffer any diminution.

Linked to some extent with the question of income is that of free choice of doctor for every patient. It is usually said that free choice is necessary for psychological reasons and because the patient tends to regard the doctor as a friend and guide in matters not connected with health, in addition to his function in relation to disease. It is clear that in a small proportion of cases psychological disturbances of a minor nature can be alleviated as much by the confident manner of the doctor as by any medicine he prescribes; but factors of this type play an ever lessening part in the treatment of disease for which the medical profession has discovered specific remedies. It plays a far greater part in promoting the sale of patent medicines which have little or no effect on the condition for which they may be used, and in so far as it is still a valid reason for sug­gesting that patients might select their own doctor it will rapidly disappear as people are educated in matters of health and become accustomed to a scientific service.

The free choice motive is used by some opponents of a planned medical service as a way in which the financial results of medical practice could be varied as between different practitioners. In other words if patients were allowed to choose, and a large number pick on a particular doctor, he should obtain some additional payment for the number of people who had in this way put their names on his list. This is, of course, a remnant of the gambling spirit which exists in all private enterprise; in this case the doctor gambles with his own personality as a method of attracting patients, and thereby additional fees, and such a device has obviously no place in a modern service. So long as a patient is paying directly for such a service he will, of course, feel some interest in selecting the person who will render the service; if the service is free, however, the patient will be concerned only that it should be the very best service that can be given, that some controlling authority will be responsible for seeing that a minimum degree of efficiency is reached, and under these circumstances the psychological im­portance that is supposed to be attached to the individual doctor at the moment will be transferred to the service as a whole. Future generations accustomed to health centres and to a medical service backed up by every scientific advance, will certainly feel no need for choosing doctors, about whom they know little, from a list which has been vetted by the higher authorities of the service.

The present generations will, however, retain part of this free choice fetish for some time, and there is no reason why arrangements for it should not be made, but none at all why it should be related to financial reward. A mechanism suggested is that with the establishment of Health Centres every citizen will be given the opportunity of registering at the Health Centre of their district and on the list of the doctor for whom they express a preference. Once the maximum number of names had appeared on a doctor’s list he would not be allowed to add further names. To allow an increase over the maximum would be to decrease the general efficiency of the service and make unworkable the time schedules laid down. It is important, however, that patients who have for any reason expressed a dislike for a particular doctor should be permitted to select another, but even these personal antipathies should not be allowed to interfere with the operation of the Emergency Service.

There is, of course, no question of compelling either patients or doctors to enter this service. It will be open to any doctor who thinks he can attract a sufficient number of patients to continue in private practice, but if he does so he will require to make his own arrangements for specialist service, and it is very doubtful if there will be a sufficient number of good con­sultants outside the service to make it easy for any doctor to build up a good practice. The patient who refuses the service cannot, of course, expect to obtain its advantages, and it is not anticipated therefore that any large number of the population would endeavour to make their own medical arrangements, by an expensive and doubtful way, once the very highest possible standard of service is available in every district.

It is objected that this suggests that both the profession and the public will be regimented into contracting into a service even when they feel that it does not give them all that they want. There is certainly a danger in any uniformly applied service that regimentation on fascist lines might creep in, and methods of avoiding this are discussed with the question of the administrative control of the health service. It raises, however, the question of the unorthodox in medical practice. There is a certain small proportion of the population who for a variety of reasons reject the scientific knowledge on which modern medicine is based and turn to cults and individuals claiming to treat disease by methods very different from those used by the medical profession. What, these people ask, will be the attitude of the State once it has inaugurated a socialized medical system? How will men fare who have an idea which is opposed to orthodox theory, and will they be allowed to test their ideas?

To a large extent this problem comes under the heading of health education, because those people who accept the tenets of any of the healing cults of to-day are usually quite ignorant of the cause of disease and of the scientific methods used in medicine. If the whole population receive knowledge of and are constantly reminded of the true basis of health and of the scientifically ascertained causes of disease, and if, the health service that is given them proves its efficiency both in its care of the individual and in the amount of improvement in the health of the nation which it produces, the unorthodox will almost entirely disappear.

One of the things which would certainly disappear is the sale of patent medicines, but in this matter the State would, probably require to interfere very definitely. The sale of alleged remedies direct to the public has increased enormously in recent years, but the position is still the same as it was in 1914 when a Select Committee of the House of Commons reported that so potentially harmful was the sale of such remedies, and to such extent was the public defrauded financially, that legislation should be introduced to control and if possible abolish the sale of all such preparations. Since then the manufacturers of these preparations have so developed their method of appeal to the fear of disease which most modern men and women feel, that the sale of proprietary preparations has become one of the greatest vested interests, and one which it is particularly difficult to combat. The public does not realize to what extent the manufacture and distribution of this class of preparation has passed into the hands of a very few men, and does not understand that the sale is dependent almost entirely on the enormous sums spent on newspaper advertising. It has been estimated that it is this form of advertising which provides the profits made by newspapers, and certainly if the companies reduced the millions they spend, their sales would drop below the point at which substantial profits could be made. Without this barrage of cleverly worded appeals and stories the public would certainly not allow itself to spend as it does some thirty million pounds a year on preparations which may have some little therapeutic action on the body but which, even if they have, are wrongly applied since the diagnosis of the disease they are expected to alleviate is made by the patient himself.  The ques­tion of patent medicines is further bound up with that of the supply of pharmaceutical products in general, which is discussed later.

In so far, however, as medical men in the service would constantly be having new ideas on the cause and treatment of disease there is no question that the advent of a socialized medical service would give the new idea a much greater possi­bility of coming to fruition than at present. The keynote of the medical service would be the prevention of disease, but the method of attaining the greatest possible efficiency in this direc­tion would be by the use of research. Every doctor in the service would be expected and given every opportunity of putting his ideas to the test, not in a haphazard way or in a few isolated cases, but by scientific methods and by co-operation with other doctors in a position to assess the value of the methods under test.

It is a mistake, to some extent, constantly to use the word “research” in this connection. There is, of course, a necessity for elaborate research into the fundamental problems both of disease and of the functioning of the healthy body, and there are many subjects both in physiology and pathology which are far from settled. However, this research by workers who confine the whole of their attention to scientific problems is essential, and much of this work can only be done in institutes specially set aside for the purpose. Since fundamental discoveries will affect the whole of mankind such research departments could, and at some future date probably will, be run internationally, but even at the moment there is considerable co-operation between research institutions in different countries and between individual workers.

The elaboration of new methods of treatment also requires a type of work which can only be done in special scientific departments, but since the test of all therapeutic agents is their application to the ordinary patient in their normal environment a close relationship between the research chemist, serologist or other investigator and the physician is essential. Under present day conditions that co-operation is very often a matter of personal arrangement between the institute and the hospital or general practitioner. For example, there is practically no direct relation­ship between the National Institute for Medical Research run by the Medical Research Council and our hospital services.

With a unified medical service there will be no gap between research and practice and the problems of one department could very quickly be referred to the other, and not only would more rapid results be obtained but new methods of investigation would be devised. There would also be an opportunity for every doctor in the service to play his part in investigations of the cause of disease, but more often of the treatment and of the course of particular illnesses. In Britain today it is exceptional for a general practitioner, however gifted or however much he has the urge to do research, to be able to leave general practice and take up scientific work. As a member of a socialized medical service any doctor in any department, who either had the urge or showed unquestioned ability in such matters, would easily obtain the chance to change over.

Another objection to a socialized medical service is that there would be constant interference between the patient and the doctor by lay administrators. It has already been made clear that this is, on the contrary, one of the features of certain parts of our present medical service which a socialized service would eliminate. While lay people, as taxpayers would have a right to control the financial and general administrative arrangements of the service, the purely medical side would be left entirely to the doctors.  So far as general practitioners are concerned they have not suffered very much from lay interference, and there is no reason why the fact that they operate from a health centre should produce any change in this situation. The duties of those members of the health centre staff who arrange appointments and keep records would no more interfere between the doctor and his patient than does the secretary or dispenser already employed by a large proportion of the profession.

Hospital administration is another matter, and here new methods of control will certainly require to be worked out. The dependence of the voluntary hospitals on charity has almost invariably meant that their control has been in the hands of a lay committee under the chairmanship of one of the recognized benefactors of the hospital, or of someone who may by a legacy become such a benefactor. The scramble among voluntary hospitals to get on to their committees the most wealthy men and women of their district corresponds to the endeavour among limited liability companies to have a peer on their board of directors. Such lay committees have sometimes built up hospitals that are beautifully equipped and amply staffed, and have often given the medical staff a very free hand, but there are others which despite the financial stability of the committee as individuals have always had such a large overdraft that finance, and not the needs of the patients or the opinion of the medical staff, has been the controlling factor. Where, in addition to the lay committee, there has been appointed a lay administrator as secretary or superintendent there has often been gross inter­ference between the doctors and their patients.

In the case of the municipal hospitals the course of develop­ment has been different, but has often resulted in similar types of persons to those just mentioned obtaining control over muni­cipal hospital committees. These hospitals developed and some still remain poor law institutions, and in the first instance Boards of Guardians were usually selected from among those of recognized wealth, position or conservative views, in the community they served. Despite the changes that have taken place in recent years there are still large numbers of hospital committees which are composed of or meet under the chair­manship of someone of that type—someone who still regards these hospitals as a palliative for the worst dangers of disease among the wasteful section of the community who are always poor. The failure of such men to recognize that every citizen has a right to expect an efficient hospital service has prevented them from seeing that their duty has changed from that of preventing the spending of poor law funds to that of seeing that the hospitals are raised to the highest possible standard. The latter point has, however, been recognized by most of the medical men working in these hospitals and has therefore led to constant friction between lay committees and medical staffs.

But neither form of lay interference will be a feature of the medical service of the future. There will be in its place co­operation between lay people as potential patients and those whose services they know they will require. This co-operation can only be fully attained when the, people as a whole have been taught that they too have a duty in the matter of health, the duty to attend to themselves and the recognition that they are as much a part of the team that prevents disease as are the doctors.

A further point which may be of some practical importance is made by those who visualize a socialized medical service being introduced by some political party to which the doctors as a whole are opposed. In such a case, it is said, the doctors would refuse to work in the service and it would therefore be a complete failure. At no time was this ever a serious danger, for there always has been a large number of doctors in favour of such a service, and a very much larger number who would not have troubled to oppose it; in addition there would always be a large number of doctors who, whatever theoretical objections they might have, would accept such a service if the conditions offered to themselves as employees were as good or better than those of present day practice. To-day, however, the position is unquestionably that the great majority of doctors are prepared to accept or are actually demanding such a service as is here described. There can be no fear that, although a certain number of the older j men might still stand outside it, the majority of doctors would be prepared to operate a service of the type described.

There remains one objection to the health centre service which has already been mentioned. This is the statement that, however such a service would operate in a large town, it could not be applied in the country. There have undoubtedly been types of health centre service described which would not be operable in sparsely populated districts, but it is claimed that the size of unit described in these pages can easily be adapted to every part of Britain. The experience of the Highlands and Islands Scheme supports this view, and examples from even more sparsely populated districts of Russia indicate that even there something very much better than anything existing at the present day can be provided. In New Zealand Dr. Douglas Robb, of Auckland, has actually analysed parts of that dominion from this point of view, and worked out the number of doctors and other personnel, and the size of hospital that would be required in an area with twenty thousand of a population spread over a distance of sixty to seventy miles; from his experience of that country he sees no reason why the health centre service should not operate to the advantage of the doctor and of the patient. In conclusion we may say therefore that the difficulties and objections which are raised against this type of service have very little weight when examined in detail. They certainly do not outweigh the great advantages to be obtained, although in one or two instances they indicate a point on which those responsible for the development of the service must concentrate some attention if the best is to be achieved.