Attainment

Utopia cannot be attained in any service except by a great deal of hard work and the most careful consideration of the steps which are necessary. Even under the kind of conditions which are bound to arise at the end of the war, with many thousands of doctors returning to civilian life, with the need for large scale rehousing schemes, to say nothing of the actual building of hospitals, no system that can be devised can be put into operation at once. But there is a danger in attempting any change in the medical service unless it is clearly laid down as the first and most beneficial stage in an orderly development to a fully socialized service. Thus it would be folly to imagine that the making of medical service free to patients without any departure from the position of doctors as isolated practitioners, or a simple extension of N.H.I. without the provision of specialist facilities, or any other single stage which we have discussed would, of itself, be an advance. The scheme as a whole must be accepted, and the principles having been laid down, the order in which the necessary changes shall take place can be decided upon and the tempo of the change regulated to the circumstances. The speed of change need not therefore be so slow that those responsible cannot see the progress that is being made, and there is certainly no reason to suppose that even so great a change as that from an individualistic, incomplete, inefficient and uneconomic uncoordinated system to a service which is complete for every patient and in respect of every branch of medicine need take more than five or, at the most, ten years.

Undoubtedly, when it becomes clear that the State and the majority of the medical profession are prepared for and indeed anxious for this change, compromises designed to retain a place of privilege for some of those earning the highest incomes in the present system of individual medicine will be suggested. It is clear that no system can be suggested which caters for less than the present subscribers to N.H.I., their dependants, and those of similar financial status, that is to say for everyone earning £420 a year or less, and that in the post-war period this is likely to include at least ninety-five per cent of the population. Although it is obviously much simpler and socially necessary to include the remaining five per cent in the scheme there will be some who think that this five per cent should be left as the prey of the higher consultant ranks; it is clear that while this five per cent can certainly be permitted to make whatever arrangements they like about their medical care, neither the State nor the medical profession can be expected to make any separate arrangements for them in a scheme which will cater for ninety-five per cent of the people during one hundred per cent of their lives and over the whole country.

The first steps to be taken will depend very largely on the precise economic and political position at the time the service is inaugurated. If the need for a socialized service has been completely recognized the whole service can be introduced by legislation on a fixed date and the details worked out by the regional authorities who must in this be compelled to initiate the scheme and given a time limit for its completion. Whether the system is so introduced, or is brought in piecemeal, the first necessity is for a rapid survey of the medical needs of the country and the giving of priority in all medical matters to those districts found to have the greatest need. It will probably be necessary in such districts to allow every medical man who wishes to do so to enter the service on terms analogous to those he has managed to make for himself as a private practitioner. Wherever possible, however, and particularly in view of the large number of service doctors who will require special opportunities, new appoint­ments should be thrown open to all applicants. Two stages of development should certainly be taken together immediately the service starts; that of getting into the service the maximum number of general practitioners and specialists on a full-time salaried basis, and the setting up of health centres. There are, already, a number of health centres which can be utilized, but in most areas new buildings or the adaptation of existing build­ings will be required, and the regional authority must therefore be given ample funds so that grants in aid of these centres can be made to the largest possible extent. According to the Govern­ment arrangements at the time of writing, post-war reconstruc­tion of this type will be in the hands of a separate ministry and it is to be hoped that the Ministry of Health will be able to obtain a considerable degree of priority for hospitals and health centres; they certainly cannot be left out of the plan, and there should be an immediate consideration given to the size and type of building best suited for this purpose.

The building of new hospitals will, of course, take some time, but until every health centre unit can be provided with a modern hospital there must be a system of co-ordination of all the available hospital beds and of other special services; a survey of each region will indicate the places where new hospitals are most needed, and where existing services can be allowed to continue to function until a better service can be completed.

The way in which doctors enter the service will be of consider­able importance to the medical profession and requires careful working out if difficulties over the capital value of practices is to be avoided. A clear distinction must be made between money which the doctor himself has invested in a practice and money which he has borrowed but not yet paid back to the insurance company or bank concerned; despite the fact that the buying and selling of practices, with its attitude of regarding the sick as the personal chattels of the doctor concerned, is generally looked upon as immoral, the financial interests concerned will require to be dealt with by compensation or otherwise in accordance with the general practice of the State in these matters.

So far as the actual capital put in by the doctor himself is concerned there are two different possible procedures; on the one hand, compensation for that loss of capital may be paid and the doctor come in at the entering salary of the service and qualify for a pension according to the actual years he remains in practice after the service has been inaugurated; the second and certainly the better way is to disregard the loss of capital and allow every doctor to enter the service at a salary which takes into account the years he has already spent in medical practice and the type of work he has been doing, and to allow some or all of those years to rank in the calculation of his ultimate pension; provided that that pension includes compensation for the widow or other dependants of a man who dies or is incapacitated before he himself has attained pensionable age, this method would appear to be definitely advantageous to the individual doctor as well as being simpler for the organizing authority.

There are certain parts of the medical service of the future which will not involve great changes at the outset because they are themselves in an early stage of development; industrial medicine, for example, has not yet reached the stage at which even those engaged in it have fully realized its possibilities. The separation of mass problems from those of the individual which will be required on the one hand are not incompatible with the close linkage between the industrial medical officer and the home doctor which will be a feature of the health centre system; similarly the maternity services and the mass inspection of school children will develop as the system grows and will fall into their proper place when the health centres are in full operation.

We must not overlook that in a socialized medical service the patient has a very important part to play; no group of medical men and no system of medicine can give an individual optimum health unless the individual is prepared to understand what is meant and to co-operate in its maintenance. The individual citizen can make a socialized medical service a success in every way only if he takes an interest in the election of the right Minister of Health and suitable regional authorities, if he co-operates with the health centre doctors in any case of illness in his family, and if by regular attendance at the health centres he enables a full picture of his own state of health to be built up and kept up to date.

In order that this change in attitude among the potential patients of the health service, but more particularly in order that a new conception of a health service in place of the treatment of disease can become universally recognized, the education of the public in health matters must be intensified and should begin even before the first stages of the State service are initiated. There are many new ideas in health propaganda to be tried out and the medical profession must set itself the task of finding out how much of modern medical knowledge can and should be passed on to the public; the ways in which this is to be done must also be considered, for some people fear that it might be just as easy to inculcate a neurotic attitude towards health as to build up a recognition of man’s true relation with disease.

In this connection the medical profession has a greater problem to solve than any that have so far been tackled; the workings of the human body and the causes of many diseases have been worked out, and with the methods of treatment now available there seems no reason why at a no distant date all diseases that attack man from without should not be conquered, and many of his own defects put right, but the major problem of adapting the environment to man’s needs is still to be solved. In this matter the profession must lead the rest of the community, but before they can do so doctors themselves have much to learn of the social function of medicine. Properly organized, free to express itself, and undistracted by the interference of lay people however democratically elected, the profession should at last recognize and state with no uncertain voice its belief that all systems of curative medicine are valueless if the environment is not adjusted to the needs of the individual man, woman and child. If this implied the granting of dictatorial authority to the organized medical profession over such things as nutrition, housing con­ditions, town planning and industrial conditions, there would be no reason to fear it if the doctors were educated in and enlightened on these questions; implying as it does the closest co-operation between all who are interested in social advance­ment and a medical profession working under conditions satis­factory for itself and the community there is every reason to wish that the combination should occur at the earliest possible moment.