A National Medical Service

Dr Milson Russen Rhodes, Didsbury Manchester

as placed before the British Medical Association.

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MANCHESTER: Chas. Sever, printer, &c., 40, King Street West.

1912.

Reprinted from the British Medical Journal, April 20th, 1912

Now that it appears evident that the Commissioners will not grant the reasonable demands of the medical profession, and that medical men are casting about for some organized scheme of national medical aid, it is well to call a halt and to look round whether or not either the Government or the medical profession are taking the right direction.

It hardly needs argument to prove that the medical pro­fession exists for the sake of the national health. Why, then, is the national health left in the hands of the lay public under all existing systems, with the incalculable loss of life to young and old such means at the present time—as any general practitioner and hospital physician or surgeon could abun­dantly testify if he wished? For under all existing systems— and this late National Insurance Act is no exception—it is left to the public to call in the doctor, and so often too late. Let me give one instance of the call of a medical man to a fine intelligent boy of six—the old-fashioned Paul Dombey type— delicate of tissue, refined and over-active of mind, and, alas! too intelligent, with a mind and heart too big for the frail little body, and the beautiful and fine spirit shining through the eyes having but a slight hold on this world through the delicate little body; indeed, a child presenting in a word the dreaded tuberculous diathesis so well known to the physician. But the boy has never in all his six years, even from birth when, attended by a midwife under the pernicious system organized ten years ago, come under observation of a medical man.

How the people love such a little lad and his old-fashioned, thoughtful sayings, far in advance of his years! They draw him out and take from his nerve-energy, already constitution­ally deficient. The child contracts measles, and the parents, being poor, see him through it themselves without the aid of a doctor, confine him to a room for the accompanying cold or catarrh, shut up windows and doors—and the tubercle at all times with us havre just the constitution, debilitated system, frail soil and environment they want for their growth, and as the measles is recovered from the tubercle bacilli have firm hold of the vital parts of the body. Thus the doctor is called in too late,—to soothe as well as he can the last days of a child suffering from tuberculous meningitis and peritonitis, and to sign the death certificate, “Acute general tubercu­losis,” which closes the scene.

Why is the cry of the little ones thus dying daily in our midst not heard? Why is this great loss to the nation of life in instances such as these and in hundreds of other ways? Because of the perpetuation of a system intrinsically bad.

From the moment of birth, and even before, until adult life, the growing child should be under medical observation— not merely when it goes to school, but, most important time of all, before that, in the first few years of life, when only a midwife with a three months’ training has seen it under present systems.

The nation has now a splendidly equipped medical pro­fession, and it may be news to some of the public that there is now a standard below which no college or university can go, so that in every medical man turned out nowadays the public has a complete assurance of such efficiency as never existed in the old days.

It is indeed time that there should be one State examina­tion carrying with it the title of “Doctor of Medicine,” and fitting the medical man for any position in the public service, in practice, or hospital, and doing away with the multitude of different degrees, leaving some men, who are handicapped in their youth, handicapped all their lives. Why is not this efficient medical service placed at the service of the public? The way is easy and simple: —

1. Let the medical profession be made a branch of the Civil Service with salaries ranging from £400 to £1,000 per annum.
2. Let every medical man be placed on that service and let the one State examination fit him for that service.
3. Let every householder or lodger already in or coming into a neighbourhood put his name dawn to the medical man of his choice.
4. Let such medical man’s duty be to call on and see such household and note where constitutional tendencies, such as indicated above, exist, and where medical or surgical assistance is needed; and thus his duty will be the prevention of disease and the maintaining the health of his patients.
5. Let such medical man be allowed only a certain number of families, say 300 to 500, and as soon as the number is made up for one doctor, then the neighbourhood must choose one of the others.
6. Let any medical man newly starting be drafted to a place where he is required, in the same way as in Germany—the Apoteker—corresponding to our dispensing chemist, is appointed to a certain vacant place; or he may take up his stand where there is a vacant place.
7. Let there be a central depot for instruments, books, serums, , and even a cottage hospital.

In this necessarily brief sketch or outline of a new system of a National Medical Service the advantages are: —

1. Prevention of disease rather than the cure of disease already well established, as in all existing systems, including the National Insurance Act. The question of medical assistance is not left to the lay mind, but is in the hands of the expert—the medical man. Hence great saving of life and suffering.
2. The interests of the public and the medical profession are identical under this system, for it will be to the interest of the medical man to keep his patients well, and he will therefore not be under the ban of benefiting by his patients’ ills.
3. The regular salary, like that of a clergyman, will do away with the keeping of a multitude of petty accounts, with all the loss of time, energy, and opportunity such entails, not to speak of the vexation of spirit and the soul-destroying work the obtain­ing of such means to a sensitive nature, sapping the vital energies, which should be given rather to fitting  himself mentally and physically for his arduous day and night duties, and yet which terrible loss to himself, and thus to the public, is the usual lot of the general practitioner.
4. The advantage to the public will be that the great cost of administration of this medical branch of Civil Service will be practically nothing compared with that under the present Insur­ance Act.
5. The present gross inequalities of justice to public and profession alike will be remedied and adjusted.

(a) The public: A father of a family has to bear all the expenses of the new generation and to support largely the doctors.

(6) The profession: The general practitioners who do the greatest good in protecting the public by treating and notifying disease among the slums of our great towns are often the worst paid, and yet there can be no doubt that the wealthy and middle class owe their freedom from diseases such as typhoid, scarlatina, diphtheria, etc., to the notifications of diseases by these poor medical men. Such doctors protect the clothes, the food, milk, water, etc., of the public, and are the real medical officers of health, though overworked and underpaid for their great services.

Indeed, the wealthy and middle class do not realize they owe the medical men anything unless they are actually taken ill. This is the great fallacy—interdependent on one another as we are nowadays—of our present system.  The fact is, the neighbourhood owes something to every medical man engaged in finding out, notifying,   and combating disease in its borders. There is a subtle realization of this point, with the result—under the present system—such classes do all they can to avoid the doctor, going to chemists, quacks, hospitals, and even calling in midwives, rather than availing themselves of the services of the medical men in the district.  When really ill they feel caught, knowing that now they have to pay for the health of the neighbourhood. Thus, the doctor’s life under this old out-of-date system is a very unhappy one; he is wanted, but on sufferance only—”Sufferance is the badge of all our tribe.” The householder wishes the doctor to be always ready for him, but does not wish to pay for it.

By suitable taxation the above inequalities to public and profession could be adjusted rightly, and then, instead of having, perhaps, to pay £50 or £60 one year (for example, for operation), the cost would be spread evenly over all the years.

In every way this Civil Service system of national medical aid I have but been able to barely outline would be the most rational way of meeting the great problem of the national health.

DETAILED OUTLINE OF SCHEME

Reprinted from the British Medical Journal, May 4th, 1912

1. The medical  profession  to  be  made  a  branch  of  the Civil Service, with salaries ranging from £400 to £1,000 per annum.

1. The Medical Register to be the qualification for service.
2. The present location of medical men to be accepted for such service.
3.  Their present patients to be their special charge up to a number to be considered as enabling them adequately to prevent illness and to attend to such when it occurs.
4. The calculation of the salaries at first to be on the basis of the actual income—that is, income exclusive of ex­penses to be publicly borne as under—of the average of the last three years of each medical man.
5. Future salaries to be calculated on an average of all the incomes in each neighbourhood, and the salaries gradu­ally approximated throughout the country; a fresh graduate would not expect as much as a more experienced man, and is to accept a position as under (f).
6. Every fresh graduate to be placed at first as assistant or junior partner with an older man in the neighbourhood, and finally drafted to a vacancy occurring through death or retirement, etc., he having the choice of vacancies which occur.
7. The cost of this National Medical Service to be met by a graduated income tax extending to the poorest worker— either deducted from wages or salaries or by the same machinery as at present—collected by a demand note.
8. Consultants and specialists are to be paid on a recognized scale for their hospital services and by a special modified tariff of fees for consultations, operations, etc., ovrtside the hospitals and local cottage hospitals. (See 7 below.)

2. Every medical man to be placed on that Service, and the one State examination to fit him for that Service. This applies to: —

1. General practitioners, and
2. Consultants and specialists; but these must have special experience of general or hospital practice respectively.

3. Every householder or lodger already in or coming into a neighbourhood is to put his name down to a medical man of his choice.

1. This is subject, for the sake of efficiency, to the limitation under 5, but as patients die or leave the neighbourhood or change their medical man, the next on the list who desired a particular doctor is to be eligible—subject to that particular doctor’s consent.
2. It is to be perfectly in order for a patient who desires the opinion of a particular doctor to ask his own medical attendant to meet such in consultation.
3. Similarly a consultant or specialist may be required, and such would be arranged for at a particular and modified tariff—less than now—as under this National Medical Service Scheme such are to receive a fixed amount from Government for their hospital services. The modified fee to be paid by the patient would prevent undue or unnecessary calling in of a consultant or specialist.
4. If  the  patient  is  unable  to  afford  even  such  moderate tariff he is to be sent to the hospital as now, or provided for at the local cottage hospital by  Government at an extra tax, as described under 7 below.

4. The medical man’s duty is to call on and see such household—to note where constitutional tendencies exist, and prevent disease; and where actually such exists lie is to give or advise medical or surgical assistance.

1. The doctor is to call at regular intervals on his patients—or where necessary—and to watch their health, especially in the case of infants, children, and child-bearing women, and in special trades; for example, workers in lead, glass, weaving sheds, etc.
2. When he finds constitutional weakness he is to advise and to prescribe suitable remedies or removal to a different locality, to a sanatorium, to a seaside home, to the hill country, or abroad, freedom from sedentary or school life, or whatever  the requirements  of the  particular consti­tutional ailment demands, and thus prevent disease.
3. Where medical or surgical aid is required he will note: —

1. Whether he can efficiently give it.
2. Whether the case is one for special treatment, medical or surgical.
3. Whether a sanatorium or elsewhere as above is required.
4. Whether special advice must be sought either if patient is poor at the hospital or if able to afford by consultation with consultant or specialist according to a modified tariff above referred to.
5. Whether operation or special treatment is required to be provided and paid for as’ indicated above at hospital, local cottage hospital or home at no extra cost to the patient, at extra Government tax, or at a modified tariff respectively.

d.The doctor’s duty will be. to give prescriptions only, all medicine being supplied by the chemists under Government contract.

e.As in Germany, the medical man will provide only a cabinet of emergency drugs and applications, etc.

5. The medical man to be allowed only a certain number of families, say 300 to 500, and as soon as the number is made up for one doctor, then the neighbourhood must choose one of the others.

1. By this National Service, while the medical man is saved the great loss of time in book-keeping and collecting accounts, he is also protected from undue number of calls by not having too many patients on his list who may call on him.
2. Further, his own prevention of disease by looking after his patients will prevent undue amount of illness, and the more efficiently he prevents disease the less will be his duties in curing it.
3. Having a junior, a new graduate, with him, the public and he are also protected if he should be ill, require change, or be at another patient’s in an emergency, etc.

6. Every medical man newly starting to be drafted to a vacancy, or he may elect in which vacancy he will take service.

1. Thus, when a graduate has passed his time at practical experience in general practice with an established general practitioner, he will have the choice of vacancies open at the time in various parts of the country.
2. If he elects to become a consultant or specialist instead of a general practitioner, he will spend his time as now under consultants or specialists at one of the hospitals.

7. A central depot is to be instituted in every locality and thus save individual expense to medical men.

1. Here instruments are to be provided by Government, a proper attendant being provided to see such are kept in order, sterilized, and ready for use by any medical man in the National Medical Service in the neighbourhood. Thus is a great saving in the cost of instruments effected.
2. Here also are kept serums,  testing apparatus, and a laboratory, instead of in each individual house.
3. Apparatus for light and electrical treatment, etc.
4. A library of books and periodicals.
5. A board room for medical meetings.
6. Several wards and an operating room where people of the poor middle class —never yet provided for—can be attended at a moderate tariff or by extra income-tax, surgeons and specialists, as stated above, not requiring the great fees of the present day, as they will receive under this National Medical Service proper remuneration for their hospital work.

This central depot will thus be in the nature of—

1. A cottage hospital,
2. A centre of scientific work in the locality,
3. A nursing home,
4. A board room for doctors,
5. A medical library,

the doctors in the neighbourhood constituting the committee.

Paper read before the Manchester south division of the British Medical Association, on May 3rd, 1912, at which meeting the scheme for a National Medical Service was passed by a majority.

Published in the Manchester Guardian of May 20th, 1912, and in the Lancet of May 25th, 1912.

it is now evident that the medical profession realises that it must consider a constructive policy, and not merely—that which has been its duty since the introduction of the National Insurance Act—a destructive policy. No doubt we in the medical profession all realise now that the old order is changing, giving place to new, and that—

New occasions teach new duties,

Time makes ancient good uncouth,

We must upward now and onward,

If we’d keep abreast of truth.

And truth tells us that we not only cannot go on as previously, but that the old system, or want of system, has become a worn-out garment, however fresh and good and desirable it was at first and in our fathers’ times.

In a pamphlet sent to me by Dr. Rentoul, of Liverpool, he states: —” People are asking—Can doctors cease their clamorous protests, and tell us definitely what they will and will not accept? They ask, “Why are doctors so disastrously cut up by petty jealousies that they cannot combine to form a constructive force, when even scavengers and dock labourers can combine?” They ask, “How is it that doctors find that it pays them to profess to give so much ‘ medical charity ‘ for nothing, when every other class of men and women are asking for higher pay?” They say, business men have had to slam their office doors in the face of doctors canvassing for non-paid hospital jobs; that doctors accept Poor-law and club jobs at a few shillings or pounds a year; while others give ‘efficient’ medical treatment for a few coppers. The public ask, “What is wrong with doctors that they accept lower fees than the lowest of street lads, and how is it that both the House of Lords and Commons have passed an Insurance Act which offers a doctor about fourpence a night visit and per­haps a two to six miles tramp?” They ask, “How is it that so many doctors try to secure patients by every method except the real one of merit—as through politics, social intrigue, by being Churchgoing busybodies, by Masonry, golf, and so on?”

What Dr. Rentoul states here is true, for has not every tradesman put up his prices along with the increase in the cost of living, whereas we—as in my practice—continue charging the same fees as forty years ago.

Realising thus that we have to consider the changes of the times we live in, and that we must march forward undaunted by such, we must set about constructive work. If we do not like the present Insurance Act, and refuse to consider con­structive work, it will be done for us.

Fortunately for us, the Commissioners are allowed by the regulations large powers—so that it is possible for them to consider a constructive policy of the medical profession— extending such at first to those who come under the present Insurance Act, and later, when by trial such has been found efficient—no doubt by an Amending Act such will be further extended to the whole nation. However, as Tennyson says, “Science moves but slowly, slowly, creeping on from point to point,” and this, alas, is too true with regard to the appli­cation of real scientific reforms in the matter of the national health.

Still we must not be discouraged. What we require to combine us in the profession is the rallying cry of a construc­tive policy. What we require to gain the sympathy and ear of the public, and which we appear to have lost, is some constructive scheme, which will, indeed, indicate we have really at heart the good of the national health, for which we as a body exist. What we require is a broad outlook on the problem before us, and to inaugurate freely of our own accord a service for the public we serve, which shall be in the true sense of those words a National Medical Service.

Such a National Service should embody the following seven principles:— [See above]

A National Medical Service thus outlined here would have great advantages considered both from (a) the ethical stand­point and (b) the scientific standpoint.

With regard to the first (a), the ethical standpoint, the members of the medical profession would be saved from the stigma of such degrading expediencies to increase their incomes as are pointed out by Dr. Rentoul in the passage from his pamphlet I have quoted above. The public are not blind in these days, and are well aware why advertising by such means is done, and thus the profession is degraded in its eyes. It is sad to have to confess that members of the profession have to descend to such degrading expediencies to meet the increased cost of living—much sadder to realise it is done everywhere as a matter of course—and it behoves us, therefore, to remove this stigma that rests upon us.

For whatever we have to suffer—as some think and are mortally afraid of—by State control, such honourable service for the State will be nothing like the degradation of such society or social control as indicated above—or of Friendly Society control under the Chancellor’s Insurance Act. Thus from the ethical standpoint one great advantage of a National Medical Service as outlined above, will be the release from all base and degrading advertising expediencies, from flunkyism, and all that is mean and unmanly, and the retention of the manhood and independence of the medical profession.

Considered from (b), the scientific standpoint, there can be no two questions with regard to the value of this National Medical Service, for under such our profession would stand in the first place for the “prevention” of disease, and not as now merely for the curing or alleviating of disease, so well established as to be patent even to the lay mind, to which now the calling in of the doctor is left.

How early in our student days are we taught that the duties of a doctor are three-fold—first, preventive; second, curative; third, palliative or the alleviation of suffering; and we have not been in practice a year before we realise that the first duty of all, namely, prevention, is practically out of our power, except in a very narrow interpretation of such. Again, there is the grave temptation where such “preventive means” properly advised, necessitates the loss of a large slice of our income. The wealthy or respectable patient ordered to leave the neighbourhood, as one absolutely unfit for his con­stitution, is a case in point. Who of us has not suffered in such ways? Let us face these facts and remedy the faults of our present system or want of system by inaugurating and combining together for such a constructive policy as indicated above in this scheme of a National Medical Service.

I have been told that thousands of over-worked and under­paid general practitioners would welcome such a scheme.

Dr. Rentoul, in the pamphlet I have quoted from, states: “In 1889 I proposed the formation of a Public Medical Service. The doctors refused it, because they thought it would affect their money interests. But had they accepted it, we would not now be like mendicants with bended knee, waiting for charity rates of pay to be offered to us by politicians.”

How much medical opinion has changed since then I hope will be shown by the fact that at this meeting of the Man­chester South Division of the British Medical Association the above outline scheme of a National Medical Service will be passed by a majority. Manchester has always been in the vanguard of progress, and I would strongly urge, in the fine words of the poet Longfellow, that we in our beloved pro­fession should—

In the world’s broad field of battle,

In the bivouac of life,

Be not like dumb driven cattle!

But be heroes in the strife!

Trust no Future, howe’er pleasant!

Let the dead Past bury its dead!

Act—act in the living present!

Heart within, and God o’erhead!

Let us then be up and doing,

With a heart for any fate;

Still achieving, still pursuing,

Learn to labour and to wait.

Appreciative  comments  on  the  scheme  of a National Medical Service above outlined.

(1)  National Insurance Advisory Committee.  A Medical Member, appointed by the Commissioners, writes: —

“I am very much obliged for the pamphlet you have sent, much of which I am in agreement with. The Insurance Act, I think, will do a great deal to start the ideas which you write about. Many of your ideas are what 1 have had ever since I started practice.” May 13th, 1912.

(2)  Extract from Daily Dispatch, May 18th, 1912: —

” The Advisory Committee to the Insurance Commission were yesterday occupied with the discussion of the methods by which doctors should be remunerated under the Act. The general opinion seemed in favour of. the capitation system and against the system of payment per attendance; but a third method, that of a State medical service, found some support by reason of the fact that it would obviate many adminstrative difficulties.”

(3)  A Division Chairman of British Medical Association writes: —

“I fully believe that some such scheme will eventually become existent.” April 28th, 1912.

(4)  A prominent Official of the National Medical Union writes: —

“Personally I am in favour of a National Medical Service on the lines of the Civil Service or the Army Medical Service, and I have held the opinion for many years that the adoption of some such scheme is the only logical method of dealing with the problem of the national health.” May 2nd, 1912,

(5)  A Professor of the Manchester University writes: —

“Very many thanks for your interesting letters. They deal with a question so large and important that it can hardly be covered in all its details in the space given to it; but no doubt the underlying idea is excellent, and I think it is extremely probable that at some future date something of this sort may be gradually worked out.” June 24th, 1912.

(6)  A Professor of the Liverpool University writes: —

“Very many thanks for your valuable pamphlets, all of which I have read with the greatest pleasure. I have recognized your valuable work towards our common cause and ideals.

”There was much good news in your letter, especially the vote of the South Manchester Division. We must get united and push along a vigorous propaganda together.” June 26th, 1912.

(7) A Ramsgate Medical Man writes: —

“I am with you all the way in your advocacy of a National Medical Service. Last June Mr. W. T. Stead published some remarks of mine on that topic in his Review of Reviews. I have been urging the wisdom of the same thing on Dr. Addison, M.P., and the Chancellor of the Exchequer. I am sure that if Lloyd George could feel that the time is opportune he would gladly follow your hint. That Exchequer balance may be in reserve for this purpose—one never can tell.

“I wish the feeling of the profession could be got. My own notion is that there are thousands of us who would welcome this solution of our present muddle. It is the only logical solution.

“What Lancashire says to-day the B.M.A.  may say to-morrow!” April 20th, 1912.

(8) Extract from Daly Dispatch of June 28th, 1912: —

WAY OUT OF DIFFICULTIES

A good deal of new support is being given to the movement for the establishment of a National Medical Service, and it is possible that the idea may be adopted ultimately by the Govern­ment, in some form or another, as a way out of the present difficulties.

A movement has been initiated for the establishment of a body for the promotion of such a service at the British Medical Association meeting in Liverpool in July.

Writing to the Daily Dispatch on the same subject, Dr. Ferdinand Rees, Wigan, says: —

As one who, for the last ten years, has been agitating in favour of the conversion of the medical profession into a State Medical Service, I am naturally delighted with the growing popularity of the idea, both among the profession and the public. Some doctors are hoping that the Insurance Act may be the first step in the direction of conversion. Perhaps I should not say the first step, since already we have an Army Service, Naval Service, and whole time Medical Officers of Health.

Charity and commercialism are the bane of the pro­fession. The charitable basis militates against the efficiency of our hospitals, and lowers the self-respect of our citizens. Commercialism means quackery, touting, and ill-will among the doctors.

Why should medical men be tied to their work for the whole 24 hours? Do book-keeping, and County Court litiga­tion, help to surround the physician with a scientific, philo­sophical atmosphere? I maintain that if the doctors were organised to prevent disease, and not to flourish on it, half the present invalidity could be abolished.

A properly organised State medical service would be immensely more efficient, and more economical than the present competitive, commercial lack of system.

Dr. Milson Rhodes’s scheme in connection with the Insurance Act is the best I have yet come across; and it arranges for each medical officer attending a certain number of families.

Your article says: ‘There seems to be an invisible barrier between them and their club doctors, which is difficult to explain or define.’ The thing is perfectly easy of explanation. It is a contract job, arranged under a competitive, commercial system.

Another disadvantage will be the removal of the incentive to rise in the profession.’ Here you can hardly be serious. In a State medical service the salaries would pro­bably vary from £250 per annum for the assistant to £1,000 or more for the chief medical officers. But what about the love of the work, and the desire to become distinguished and honoured amongst fellow-practitioners, and by the com­munity?'”

Proposed formation of an association for promoting  the establishment of a National Medical Service

As this pamphlet has been published in view of the present crisis, and to help forward the proposed movement to bring up the question of a National Medical Service at the Liverpool Meeting of the British Medical Association, and to form an Association for promoting a National Medical Service, doctors and others in favour of this new movement for a National Medical Service are invited to communicate at once with Dr. Milson Russen Rhodes, Didsbury, Man­chester, from whom also a supply of these pamphlets may be obtained. Single or more pamphlets may also be obtained from Messrs. J. E. Cornish, Ltd., St. Ann’s Square, Manchester.

July, 1912.