Reprinted from Labour Magasine April, 1931,
By SOMERVILLE HASTINGS, M.S., F .R.C.S., M.P.
Lecture given at the Fabian Summer School August 1930
SICKNESS and ill-health and premature death are a great loss to the community. It has been calculated that the net annual loss from sickness in Great Britain alone, as the result of decreased earning power and cost of treatment is nearly £300,000,000. But this does not take any account of what might be described as the capital value of the lives, the loss of which might have been prevented. We must remember that the maintenance and training of a child is a costly business, and that the child does not commence to be a productive unit until he is at least fourteen years of age. Further, that should death of an individual occur before the time at which, through old age, he ceases to be a producer, the capital sum invested in his maintenance, education, and training is lost. Therefore, it is an economic proposition for the State to take care of the health of its people and to see to it that the best possible is done for them in case of sickness. It is also necessary to remember what a large amount of disease is preventable. In 1927 the death rate of the babies under one year old in the Borough of Paddington varied between 1 in 8 and 1 in 42 in the different wards. We have also to remember how much disease is amenable to treatment and can be greatly relieved or permanently cured if taken early, so that in the public interest it is desirable that everyone should be encouraged to seek competent medical advice at the earliest possible moment. Further, it may be useful to recall that unhealthy people are liable to be a danger to others as well as themselves. It is obvious that if people, unhealthy from any cause, are attacked by infectious disease, they will most probably suffer from this disease more severely than would healthy people, but what is not so obvious is the fact that in many cases when an infectious disease attacks unhealthy people it may take on a more severe form and so spread to people who would not otherwise be affected . We have all heard how plague or some other infectious disease had attacked people in a famine area and there acquired sufficient virulence to spread across a continent.
In this country we deal with health matters in two ways: (1) By private enterprise; and (2) By a co-ordinated co-operative effort; in other words, by Socialism. Those who can afford to buy health get it, just as they buy sugar and tea over the counter in a shop, and those who cannot afford to get it go without. A sufficiency of the right sort of food and decent housing accommodation are to be obtained only by those who have money to pay for them, and for those who have not, ill-health, disease, and premature death are in many cases inevitable. But not only is money often the deciding factor in connection with the prevention of disease, it is also of equal importance in connection with its cure. Few people realise what can be done for the relief and cure of illness by really scientific medical treatment, but it must be obvious to all, so complicated a science has medicine become, that no one practitioner can understand all of it thoroughly and therefore, for efficient diagnosis and treatment not one, but many different doctors are required. The well-to-do, though they are willing to pay for the best that medical science can supply, by no means always get it. They go for advice to their family doctor or general practitioner and he does his utmost to give them the best that he knows. And it is only when his good intentions fail and the patient does not improve that further advice or a specialist is recommended. In other words, the need for a second opinion is only recognised by the failure of the first. But you may ask ought not a practitioner to know from the very first that he is incapable of dealing with the patient’s trouble? It is very difficult for many of us to realise or admit our own deficiencies; moreover, a doctor may easily imagine that he loses caste by sending for a specialist. In any case, however, what right has the public to expect a higher moral code from one sort of tradesman than another, although it must be admitted that in the case of the medical profession, it usually gets it. A baker may know quite well that better bread than he produces can be obtained from another baker round the corner, but who will expect him to tell this to his customers in the present capitalist age?
It may be objected that in most districts there are several doctors to choose from, and if a patient does not get satisfaction from one he can go to another. But this is surely not what is required, and, in future, the team and not the individual must be the unit. In many villages there are half-a-dozen general shops, each of which sells, perhaps, lard, candles, and peppermints amongst other things. If you want some commodity you have an equal chance of getting it at either of these shops or may not get it at all. A wise shopper, therefore, prefers to go to a large multiple store like Selfridge’s where he can be pretty certain of obtaining what he needs. Exactly the same principles must apply in connection with medical treatment.
The large general hospital with its medical school and training institute for nurses has taught the world the value of team work in medicine. Such a hospital is really composed of a large series of departments, many of which, such as those for registration, bacteriology, bio-chemistry, etc., are not even known of by the patients generally. All these departments work together and the patient is passed freely from one to the other according to his needs. There is no competition in the general sense between these departments. . Certainly there is no competition for patients, and if competition exists at all it is in the discovery of new methods of curing disease and skill in applying them.
The recent illness of His Majesty the King presented to the world a fine example of what could be done by team work and scientific medicine. Physicians, surgeons, anaesthetists, and specialists in bacteriology, bio-chemistry, X-rays and light treatment were all called in to help in the good work. A dozen different doctors, at least five nurses, and a good many technicians in connection with bacteriology, X-rays and light treatment all made their contribution to the satisfactory result obtained. The King’s illness was in no sense exceptional. There are probably 100, perhaps even 1,000, persons to-day in England suffering exactly as the King did, and needing as complicated treatment if the very best results are to be obtained.
Fortunately, however, in addition to the treatment of disease by private enterprise, there has been in recent years an increasing tendency for the State to provide for the medical needs of the people and mainly because of these practical applications of Socialism to health matters, the expectancy of life for the average man and woman has increased by about twelve years during the last half century. The State has provided services applicable to the needs of all such as: (a) Sanitation, that is to say, the care of drainage, refuse disposal, water supply, and the inspection and supervision of food; (b) By the notification. of infectious diseases to the Medical Officer of Health, and through him to the Ministry of Health, the location of cases of communicable disease becomes known and in many cases a common cause can be discovered and dealt with. Further, isolation of those infected and disinfection of dwellings can be insisted upon as well as the effective treatment of those suffering from infectious diseases; (c) Another very valuable aid in the preservation of health and prevention of disease is health visiting. The Health Visitor, in fact, often becomes the general health adviser to the family; (d) A good deal has been done and much more remains to be done by propaganda towards the formation of public opinion in health matters and habits of health. The almost complete elimination of the objectionable habit of spitting can be cited as an example.
In addition to the above the State has thought fit to deal with an increasing number of special classes of individuals and special diseases. The terrible ravages of consumption has induced the State to provide some minimum of treatment for all those affected. The waste involved in the education of physically defective children has resulted in inspection and treatment in the schools. For similar reasons maternity and child welfare centres have sprung up and venereal disease clinics have been instituted. There has been factory legislation and the panel services have been evolved to provide some forms of medical treatment for insured persons. Altogether, according to the British Medical Journal there are now seventeen “departments, spheres or directions of clinical activity” now dealt with by the State, and there is the continuously increasing demand for further medical provision for special diseases or classes of people. It is pointed out with truth that much of the work of the school medical service is rendered incomplete because there is so little provision for treatment of the pre-school child. Again, the gap of two years between the school leaving age and the commencement of national health insurance is liable to result in neglect of the early recognition and treatment of disease at this important period of life. Special clinics for rheumatism are demanded and a strong case can be put up for special clinics for Orthopaedics and cancer, as well as for many other diseases. And so it comes about that there is a constantly increasing demand for treatment by the State of an ever-increasing number of different diseases and classes of people.
This tendency, useful as it may be in some directions, must be viewed with some anxiety. What we have been doing during the past twenty years or more, is to provide a large number of water-tight compartments for the treatment of special diseases or special types of persons. If the right sort of person with the right sort of disease happens to fall into the right watertight compartment he usually gets efficient treatment. But the difficulty is that there is but little provision to ensure that he necessarily reaches the right compartment or compartments for one person may be suffering from more than one disease. A good example of this danger came under my personal notice some two or three years ago; 83 of the patients of a large County Sanatorium were children, and of these only three showed definite signs of tuberculosis after careful observation lasting for several weeks. Most of the others were classified as “indefinite, for observation,” but 58 per cent. of these children were found to be suffering from septic tonsils and adenoids when they were seen by two nose and throat specialists separately. Unfortunately but little machinery existed to provide for these children the correct treatment, and in some cases this was found to be absolutely impossible. “Tuberculosis” they had been diagnosed and tuberculosis they had to remain to the end of the chapter. The Ministry of Health has provided co-ordination of our various public medical services at the centre. What is required is co-ordination at the periphery as well. What is necessary is that every family in the country should have a general medical practitioner as health adviser and director. It should be his business to do his utmost to preserve health and in case of illness to give treatment as far as is within his power, and to pass his patients on to the care of the proper specialist or special department for diagnosis or treatment as required. No doubt, such is the complexity of medical science, an ever-increasing proportion of treatment will have to be undertaken by specialists and a good deal of it within the walls of hospitals or similar institutions. Nevertheless, the general practitioner must always remain the most important person in the health team. It will ever be his duty to advise on health matters, to diagnose the type of disease and refer his patient to the required specialist or department. Any scheme of medical service that fails to take this into account is of necessity doomed to failure. The State Medical Service of the future must, therefore, be built up with the general practitioner as the keystone of the arch.
It is a long time since enlightened business firms first came to the conclusion that it was to their interest to provide complete medical and dental services free of cost for their workpeople. Equally it is in the interest of the State that every citizen of this country shall be able to obtain the best that medical science has to provide for his particular case directly he needs it. Further, he should also be encouraged to be medically examined at intervals so that disease even before it gives rise to symptoms, may be recognised and dealt with. This service must be free to all; there must be no question of “can we afford it?” In an ordinary working class family when a child becomes ill the question arises whether it is wiser to let some member of the family go without some of the necessities of life or seek medical advice. While the matter is being debated an illness may take a turn for the worse and advice may be sought too late. We provide free medical treatment to convicts, prisoners, lunatics, and sufferers of venereal disease. But if an honest citizen, even though insured under the National Health Insurance Act happens to get an acute attack of appendicitis or falls down and breaks his thigh, he has in most cases to go cap in hand to a voluntary hospital and beg for admission. In 1870, we found that private enterprise had failed to educate a large number of our population, so the State took the matter in hand and proceeded to provide education for the Nation’s children. No one is compelled to send his child to the State school if he can show that the child is receiving a sufficiency of education elsewhere. What the State does is to say that no child shall lack the rudiments of education through the poverty or carelessness of its parents. Necessary as education undoubtedly is, health is even more important. Seeing how lamentably private enterprise has failed in health matters, it is surely time for the State to step in.
What I and those who think with me have in mind is the acceptance of the principle that it is the duty of the State through the local authorities to provide the best that medical science can give for all who need it. The service must be free so that no financial barrier can separate the doctor from his patient. The pivot of the whole scheme must be the family doctor; his business must be to keep the patient well, in addition to treating him when he is ill, and health lectures and instruction in health matters must be encouraged. Further, all patients should be advised to submit themselves to periodical examinations by their doctors even though they are feeling well. Moreover the clinical and preventive sides of medicine must be much more closely associated, and it must be the business of the family doctor to report to the Medical Officer of Health and his department anything connected with the patient’s environment, either at work or in his home, that seems to militate against his health. Of course, the family doctor will not work alone, he must have ample opportunity to meet his colleagues, talk over his work with them, and get their opinions about difficult cases; more important still his patients must have access to consultants and specialists whenever they themselves or their family doctor feels the desirability of this course. All the necessary drugs and special foods and appliances must be at the service of the patient when ordered by his doctor and the necessary hospital accommodation must be provided.
A great deal has been written about the desirability of free choice of doctor. There can be no doubt that a patient’s progress is accelerated if he can trust his doctor and feel sure that the very best is being done for him. It is possible, however, to trust an institution or team as much as an individual, as is shown by the readiness of patients to submit to operations in certain hospitals, although they do not know even so much as the name of any one member of the staff. It would, however, be as easy to provide free choice of doctor under a State system as under the present, at any rate, in urban areas. In practice, in country districts where the number of doctors is necessarily limited, it is only the doctor’s widow who has any real free choice, for it is she who sells the practice to the new doctor. The medical requirements of urban areas would be most satisfactorily dealt with by dividing them into units of, say, approximately 30,000 population, in placing ten doctors in charge of the medical needs as far as a general practitioner service is concerned. Each doctor would then have medical charge of 3,000 individuals. The panel of the most popular doctor would, of course, become the most rapidly filled, but there would still be work for the others for there will always be people who do not select their doctor until an illness overtakes them. One objection to the present system is the inadequacy of the equipment and the inconvenient waiting accommodation of so many doctor’s surgeries. Under the State scheme the doctors of a unit would have their consulting rooms in one or more centres where nurses would be in attendance, and the necessary medicines and appliances provided. This would have many advantages, not the least being that the doctors would be in closer touch with one another and so able to discuss their cases and pool their medical experience. There are two essentials for the success of such a service. Firstly, it must be free and open to all. There must be no incomes limit; the millionaire must be encouraged to take advantage of the service as well as the pauper, for experience shows that any service confined only to a less-well-to-do class has a great tendency to become inferior in quality. The other essential of necessity follows from this. The service must be staffed by full-time doctors. If all patients can obtain a doctor’s services without payment during some part of the day, while they have to pay for the same services at another period, it seems certain that they will all consult the doctor during his free hours unless, of course, they have reason to suppose that they are obtaining better treatment when the services are not obtained gratuitously. Such conditions are obviously not to be permitted, for it is clear that the State doctor must do his very best for his patient under all circumstances. Clearly, therefore, the State service must be a full-time one and free to all who care to take advantage of it.
A complete service run by full-time doctors without the element of competition entering in to spoil the efficiency of their work has been in being at Swindon for several years. The employees of the Great Western Railway with their dependents numbering some 45,000 souls, have formed themselves into the Swindon Medical Fund Society. Each member pays a certain sum per week, and in the employ of this Society there are some twelve doctors, five dentists, and ten nurses, all giving their whole time to the care of the health of those they serve. Ten of the doctors act as general practitioners while two of them act in a specialist capacity, and there are also other part-time specialists. Each medical officer is in charge of patients in a certain district and should his patient desire a second opinion, the services of one of the consultants is brought in. In addition to this each of the doctors attends the central dispensary on one or more days a week, and any member who desires it can see him there. The Swindon unit is, of course, a relatively small one and not really large enough for the development of a complete service, but as far as it goes, the scheme works admirably.
There are two recent occurrences which are calculated to assist the development of a State Medical Service and make it even more inevitable than it otherwise would be. First of all there is the Local Government Act of 1929. This Act makes it possible for what were previously the Poor Law Infirmaries to be developed into first class Municipal Hospitals. It is true that Clause 16 of this Act compels Local Authorities to recover the cost of treatment from those patients who are able to pay for it, but this Clause can readily be repealed, and, in any case, the fact that it is now possible for local authorities to develop hospitals, admission to which all residents of the district can claim as a right, is a great step forward. Although the Act has been in operation for less than a year, considerable developments have already taken place and the inauguration of a medical school in at least one of these Municipal hospitals has now been decided upon. It will be easy for local authorities to develop their Municipal hospitals as the medical centres of their district and associate with them much of the maternity and child welfare, tuberculosis and venereal disease work. Some local authorities have already appointed full-time medical officers to undertake the district medical work under the Poor Law, and have arranged that these officers shall reside in the Municipal Hospitals, have their consulting rooms \within them, and carry out all their medical work in close association therewith.
The second fact of importance is that the medical profession itself appears to be much less opposed to a State Medical Service than was the case some few years ago. The British Medical Association has recently brought forward proposals for a General Medical Service for the Nation. Another body, the Medical Practitioners’ Union, has also developed a somewhat similar scheme. The B.M.A. proposals do not at present visualise either a free or complete service. The extension of the present panel service to dependents of the insured is proposed, and it is suggested that the scheme should be financed mainly by payments from those receiving its benefits. The scheme provides a general practitioner services for about 88 per cent. of the population and a specialist service is to be included with it. The impossibility of large classes of the population, such as farm labourers with families, paying further weekly levies without depriving themselves and their children of the necessities of life, must be obvious. Of some importance also, is the difficulty of collecting from large classes, e.g., hawkers, costermongers, gypsies, small shopkeepers, etc., who are not in the ordinary sense employed persons, the necessary contributions. These persons are said to number from two million to four million and should certainly be included in a scheme, for their economic position is no better than that of the skilled artisan class. Nevertheless, the fact that bodies representing such a large proportion of the medical profession are prepared to consider some form of Public Medical Service is not without significance.