The   Cost

It is inevitable that any suggestions for new medical services will sooner or later be assessed according to how much they will cost the country. From one point of view this is no concern of the doctors; in their work of saving life and alleviating suffering they are quite justified in a complete disregard of the cost of medicines and other therapeutic agencies, and one of the greatest defects of the present system is that doctors and patients alike so often have to count the cost. Patients are always afraid of being ill because they assume that if they arc suffering from anything more than the most trivial complaint they will be involved in considerable expense. For this reason they very often delay seeking medical advice until it is too late. Doctors in general practice have also to count the cost of the medicines they use; for their panel patients there are certain restrictions and always the danger that if expensive drugs are prescribed the Panel Committee will call the doctor before them and may fine him for excessive prescribing; in the case of middle-class patients a doctor is well aware that while his patient will be content with his treatment so long as it can be carried out at home without costing too much, he may lose his patient altogether if he advises consultations, operations or treatment at a greater cost than the patient is accustomed to paying. This is particularly the case with con­valescents, for while the favoured few among the wealthy class may benefit from a month or two in Switzerland it is very difficult for the great majority of the population to pay for prolonged holidays even at their nearest seaside resort.

In hospitals the position may be even worse, for while ordinary day to day treatment will not be interfered with, requests for improved apparatus whether for diagnosis or treatment have to go before the hospital finance committee, which will only pass them if the hospital finances have a satisfactory bank balance. Since so many of our voluntary hospitals usually have an overdraft it repeatedly happens that a request for new apparatus is turned down even when the medical staff have agreed unanimously that it is necessary for the welfare of the patients.

One of the features of the medical service of the future will undoubtedly be that these questions of finance will cease to interfere between the sick person and the most efficient forms of medical care. Nevertheless there will be many who would apply the ordinary financial judgment to this question and demand that the health services of the future should cost no more than they do at present. For those who advocate a fully socialized medical service giving the most complete nation-wide service that is possible it is fortunate that the present system is exceedingly wasteful, and that on this account the health service of the future is likely to cost no more than at present, and on the basis of services rendered will cost relatively less.

It is exceedingly difficult to estimate the total cost of pre­war medical services. A very large amount of the money spent on our ordinary municipal and national services is really part of the health bill, for without our great network of water supplies, drainage and sewerage, the toll of ill-health would still be as high as it was before these systems came into existence. Even if every known item that is indirectly connected with the preser­vation of health could be calculated there would still be much that would be beyond the powers of any computation. There is a constant vast amount of suffering among millions of people who suffer from no disease that can be named and yet are far from enjoying normal health. Taking into account only those amounts which are directly concerned with ill-health the P.E.P. report on British health services estimated the total economic burden of ill-health at three hundred million pounds a year.

To this three hundred million pounds we may add one hundred and twenty million pounds for work lost through ill-health and thirty million pounds spent by the British public on patent medicines. It would therefore appear that the treat­ment and maintenance of sick persons, public expenditure on the prevention of ill-health, public environmental services, work lost and patent medicines cost the citizens of Great Britain approximately four hundred and fifty million pounds a year. If for the expenditure of this staggering amount the public obtained a health service that was complete, that really did prevent disease, that restored health in the maximum possible number of cases, provided adequate maintenance during illness, and so on, the money might be well spent, but as we have shown the whole system is one of waste and inefficiency in which only a fraction of what could be done in the prevention of disease is done and in which large numbers of people are not restored to normal because of the absence of certain essential facilities.

We shall concern ourselves here only with that part of this sum which is directly concerned with health and disease, and omit all amounts spent on maintenance and on the environ­mental services. In this field we can produce figures which are fairly accurate, but there are a number of items which must remain a matter of estimation. It will be recalled that the income of the existing medical services comes from a variety of sources, from charity, from fees paid by patients, from con­tributory schemes both for domiciliary and hospital care, by insurance schemes both national and individual, from rates and from taxes. The total income from these sources has been most accurately calculated by Dr. Hilliard and Mr. McNae in an article in Medicine To-day and To-morrow (March 1941) as follows:

Fees to doctors and dentists	45,000,000
Medicines, etc. (not N.H.I.)	20,000,000
Voluntary hospitals	18,000,000
Public Health hospital services	22,000,000
Poor Law hospital services	7,000,000
Mental hospitals	12,000,000
N.H.I, doctors’ fees	10,000,000
N.H.I, medicines, etc.	4,000,000
District nursing, etc.	2,000,000
Total	140,000,000

There is no need again to repeat that almost every item in this list can be criticized from the point of view of being wasteful and inefficient; as previous chapters have indicated there are as many serious gaps in the service as there are overlappings. The health service of the future must be larger in every way, both in personnel employed and in facilities available, yet there appears to be no question that for the same expenditure of money a better average service for the whole country could be provided by co-ordination and reorganization.To quote from the same article, “For this sum of over three pounds per head of the population the public has the services of about forty thousand doctors, fourteen thousand dentists, thirty thousand nurses and seven thousand medical auxiliaries to attend them at home, in surgeries and clinics and at hospital. It has also the use of eighty-eight thousand beds in voluntary hospitals, eighty thousand in local authority general hospitals, fifty-four thousand in poor law hospitals, sixty-two thousand in special hospitals, and one hundred and fifty thousand in mental hospitals. Assisted by twenty-four thousand pharmacists the public consumes countless million bottles of medicine as well as more .specific medicaments.”

One reason for this would be the enormous savings that would be possible. The fees paid to individual doctors have to cover the cost of forty thousand individual surgeries with a like number of private houses, private motor cars, telephones, etc., and a very large number of pharmacists, secretaries and other personal assistants to the doctor. These surgeries vary enormously, and while many of them are sufficiently roomy and well equipped for the doctors using them to do first class work, it requires only the most superficial investigation of surgery conditions in working class and slum areas to realize that the surgery accommodation for which the patient pays is extremely poor. The slum surgery in a back street in a building which should long since have been pulled down, without much in the way of diagnostic apparatus, with very little privacy and with no clerical assistance, makes first-class work impos­sible. Nevertheless these surgeries have to be paid for and a very large proportion of the total income of doctors is spent in this way. As in every sphere, the replacement of these in­efficient, ill-equipped, isolated units by the organized services of the health centre would enable many million pounds to be saved.

Equally uneconomic is the present dispensing of medicines. Whether this is done at the doctor’s surgery or by the retail pharmacists, the medicines supplied to the patients have to be purchased from wholesale distributors, who are rarely the primary manufacturers, in small quantities involving large packing and transport costs. In a system of regionally co­ordinated health centres medicines would be purchased in bulk or produced by a branch of the health service itself and distributed in the most economical fashion direct to the hospitals and clinics. The dispensers at these places would have none of the overheads to pay which at present swallow up a large proportion of the income of the chemist’s shop. In a similar way the unification and in particular the building up of a hospital system in which all the units were of the most economical size, between eight hundred and a thousand beds, would result in very considerable economies. Without going into the matter in any detail it will be obvious that the existence of a large number of small units each endeavouring to run a complete service on its own must be very wasteful. The economies that would be effected by having a single hospital system, using materials that were largely standardized and purchased centrally, would be so great that a twenty-five per cent increase in the total number of hospital beds available would come within the financial possibilities of the service.

Turning to the doctors themselves we have to face the general question of the salaries to be paid to doctors in a socialized medical service. In this matter one would prefer to give no definite figures, for it is obvious that the income of the doctors in common with other sections of the community will depend on the general financial position of the country after the war. What must be made clear is that the salary position in a socialized medical service need not involve any diminution in the standard of living of the average doctor. In any case there is one very great difficulty in putting forward a satisfactory figure, namely, that the conditions of service would be so totally different that the figures are actually not comparable.

As we have outlined the service the economic position of the doctor would be totally different. Having qualified he would not be faced either with a long period of unproductive work if he wished to become a consultant, or with the necessity for borrowing money if he wished to go into general practice. He would begin to earn money as soon as he was qualified. This raises a number of interesting points which, while they do not entirely apply to the question of cost of the medical services, must be mentioned.

The first is that one fault of present-day practice is that because of the long period of study, and the number of years after qualification which are necessary before a moderately good standard of living is attained, doctors on the average marry later in life than most other sections of the community. This has very important economic and social repercussions and it is clear that the guarantee of security given by a socialized service would enable marriage to take place earlier.

Even more important from the standpoint of professional skill is the opportunity that would be given for immediate contact by the newly qualified-doctor with his life work. There is a tendency among certain schools of medical thought to insist that before any newly qualified person is permitted to go into general practice, or to begin to specialize, he must have done a period as house surgeon and house physician in a hospital. This has, of course, never been possible, for the total number of entrants into medicine has exceeded the number of posts available. So far as general practice is concerned it is no preparation for the work which will take up the rest of the doctor’s life, and in many of our smaller hospitals it is no prepara­tion for any of the specialities except, perhaps, surgery.

With the establishment of health centres it would become possible to give every individual medical graduate a period of contact with general practice at the health centres, with easy access to hospital wards and frequent visits to the homes of the sick, which would be a splendid preparation for all fields of medicine. Indeed, it would probably be laid down that no person could begin to practice until he had undergone this additional apprenticeship period after qualification; the apprenticeship being not to an individual doctor but to the team working at the health centre.

That apprenticeship would be only one of the many advantages which have to be taken into account in discussing the salary of the doctor. Of more direct economic importance is the fact that he would have no surgery expenses, would be provided with the services of secretaries, pharmacists and all the other personnel of the health centre, and that holiday locums, study leave and vacations would be provided. In addition there would be increased possibilities for specialization and of changing, with or without promotion, from one district to another. Remun­eration would be graduated and advances would be on a basis both of length of service and of merit. Taking pre-war standards and remembering that we are speaking of net incomes all grades of the service might begin at £500 a year, rising to £1,200, for most grades and £1,500 for some. There would be less distinction in the remuneration of general practitioners and consultants and professors at the teaching hospital than at present. The specialist who at the moment is expected to maintain ex­pensive rooms in a certain district, to drive a large car, and to employ one or more secretaries, would have none of these expenses, and correspondingly would require a net income comparable with that of his general practitioner colleagues. As we have already suggested there are grounds for hoping that they would be as much specialists in their line as is the surgeon in his.

Keeping in mind the fact already mentioned, that the average income of doctors is not so high as the public thinks, and also that we have to include as salaries in our estimate sums which are at present spent in other ways, we must allow in our figures some fifteen million pounds more for doctors than are included in the ordinary hospital and domiciliary services.

When we turn to dentists, nurses and other medical auxiliaries the salaries already paid are much too low and we are therefore faced with a need for an all-round increase. Much of this increase will be included in the cost of the hospital service but, as the table given below indicates, at least sixteen million pounds more a year will be spent in this way. The total cost of the services estimated in this way work out as follows:

• Domiciliary service                                23,000,000
• Hospital service                                      50,000,000
• Mental Hospitals                                     12,000,000
• Aids and Appliances                                10,000,000
  Additional Salaries:
  • Medical               15,000,000
  • Dental                 7,000,000
  • Nurses                4,000,000
  • Auxiliaries           5,000,000
• Research                                             7,000,000
• Administration 5 per cent               7,000,000

Total   £140,000,000

These straightforward estimates produce exactly the same figure as that given for the present medical care in this country but on a scale not only larger but very much better in every way. They allow for a full domiciliary service including visits from specialists and consultants in the home; they provide a chain of laboratories and X-ray departments which would be available to every citizen; they allow a twenty-five per cent increase in hospital beds, and a raising of the efficiency of any remaining poor-law hospitals to a general high level.

In this estimate no provision has been made for the expendi­ture that would be necessary on new health centres and hospitals. Under ordinary conditions the capital involved in this would be considerable although the total amount to be paid annually as interest and in repayment of capital would not be excessive. It has, however, been omitted because of the building position which will arise at the end of the war. It has been stated that in the London area less than five per cent of all hospitals have escaped air-raid damage, and some hospitals have been very severely hit. It appears likely therefore that a part of post­war reconstruction will involve the re-building of many hospitals and this will be an excellent opportunity to make provision for the national service on a suitable basis.

For those, however, who would like to think of something to offset these charges we would again mention the thirty million pounds which the public pay for patent and proprietary medi­cines. If by the provision of a free health service and by the education of the public to make full use of that service and by other legislative means the sale of patent medicines can be abolished, that thirty million pounds a year will go a long way to pay for any new building.

Another item which has been mentioned in this connection is that paid, chiefly by the working class, as an insurance against burial expenses. We are discussing here the setting up of new health services, but however perfect they may be death is inevitable. In any system of social security therefore provision for funeral expenses would be as naturally included as payment of maintenance while sick or injured. The public still requires much education in the need for simplicity in the interment of the dead, and partly from that reason and partly from the increase in the number of cremations that now take place, a very considerable fall in the amount spent on funerals can be antici­pated. As it is, however, the public spend an amount estimated at about eighty million pounds in insuring against these expenses, and in taking over this business the State could show an economy in the expenditure of the nation as a whole amounting to some fifty million pounds.

If we add to these large sums the incalculable benefit to men and women of positive health obtained through a socialized medical service there is no reason to think that, even calculated with the most exact financial rectitude, a socialized health service will cost much more than the present unorganized system. In terms of human suffering, time and strength wasted, and loss to the national revenue through sickness the money spent on an organized and advancing medical service will always be returned to the community many times over.