New Views on the Health Service



by D. Stark Murray

There are many rumours and suggestions as to the intentions of the new Minister of Health, and it will be as well for the Council of the SMA to consider these and make some preliminary decisions as to the attitude to be adopted should the rumours prove to have some substance. In this memorandum no attempt has been made to differentiate between rumours, the author’s own views and official information which he and others on the Council have been given, but it will be as well to treat the whole matter as confidential.

The Minister of Health in the Labour Government is faced not only with the difficulties inherent in dealing with the vested interest of the medical profession, the voluntary hospitals and the local authorities, but also with those created by Mr. Willink’s discussions with the BMA. Owing to these it can no longer be claimed that the White Paper is the accepted view of the Government or any section of Parliament; and it may very well be that a Minister, anxious to make progress as we know Mr. Aneurin Bevan to be, will ask the Cabinet to agree to a new set of proposals cutting right through the previous discussions and the difficulties. We shall then have to decide whether or not the basic principles for which we have always stood are being sacrificed or whether the new proposals fulfill them and above all, whether they give a possibility of introducing the new service at the earliest possible date.

It has always been clear that the technical and professional foundations of the service, completeness, universal availability, freedom from economic barriers, team-work, collective responsibility, prevention of disease and health promotion, could all be attained by a variety of administrative methods of which the SMA favoured Regional elected authorities administering a national plan and employing whole time salaried officers in Health Centres and large Hospitals, (which involved the ultimate disappearance of the voluntary hospitals). Our conception of collective responsibility meant that while the decisions on policy must be made by the Ministry and by the Regional authorities, every member of the staff must have a say in the running of the service without yielding to the BMA clamour for control by doctors.

It is worth while noting that similar problems are arising in other fields and some attention should be paid to the tri-partite arrangements suggested for industry whether nationalised or capitalist, and the method used in the Education Act of nominated Divisional Executives. Both introduce new methods that may be of significance.

The suggestions now being discussed are, very briefly, as follows.

Administrative structure;

The Ministry will take full responsibility for the new service. It will plan, lay down standards and see they are carried out; it will delegate certain executive, powers to Regional Health Boards (which will continue in existence until such time as a revision of Local Government has been carried out), who will be nominated by local authorities, the Minister, and, possibly, the health workers. (Note Bevan has already spoken of his desire for industrial democracy in the health industry and by the term he means representation in the day-to-day control by all workers). He has also recognised that it would mean a strong Planning body at the centre.

A single Hospital Service:

It is recognised that some 80 per cent of the income of Voluntary hospitals and 60 per cent of the income of Municipal hospitals will come direct from the Government. Since the spending of public money mean public responsibility, the correct body to take that responsibility is the Ministry of Health; the same argument applies to both types of hospital; and we can never get a complete new hospital service unless we have one integrated service based on a definite number of beds per unit of population and unless every hospital accepts its quota of service to that unit. The hospitals must therefore be the responsibility of the Ministry, the administration delegated to the regional boards, and a large measure of control given to the staffs, including some spending power.

A complete integrated service.

One difficulty the White Paper could not overcome was the blending of the Industrial, School and “M. and C.W.” services with the personal health service and the hospitals. There is an obvious difficulty in placing the industrial health service under any existing local authority whose duties in relation to industry are very limited. A new method of dealing with the service as a whole would enable the Industrial and other services to be brought in at the same time and built up as part of the national service.

Health Centres and the doctor’s income.

The actual income to be paid to doctors will be, more or less, fixed by the report of the Spens committee which is expected shortly; and which is expected to be more than generous. Health Centres must be provided with the greatest rapidity and it is clearly worth while sacrificing some pre-conceived ideas in order to get doctors anxious to get into health centres. Differential incomes within the Health Centres by a method that commends itself to the BMA is one possible way of attracting the doctors; but the SMA will not easily abandon its belief that competition within the HC or competition between HCs. (except on the technical or intellectual level) will be wrong. But the Spens Committee will almost certainly present a formula for varying incomes taking into account various factors of which the number of patients will be one. We know that basic salary plus capitation fees will meet the demand of the majority of the profession and while the arguments against it are strong, it has its attraction, especially if it enables the greater reforms to go through more easily. What will probably be suggested is that the financial responsibility of the Ministry should be limited by a global payment paid to each HC according to the number of patients it is allocated; that all doctors should be given security by a high basic salary; that the maximum income obtained by capitations should be strictly limited. Thus within the HC competition would be small; and elasticity can be given so that other methods of payment, including whole-time salary can be tried.

Private Practice is another great difficulty unless one visualises it as-having no place at all; but it is seriously suggested that a limited form may be permitted to all practitioners in this way: that no one will be allowed to see private patients from the area served by his or her HC; but that all may see and accept private fees from patients outside their HC area.

Buying and selling: an announcement may have been made before November 4th that this is no longer permitted.

We may anticipate that before Spring 1946 we shall have a Bill fixing the form and date of commencement of the new service. We can assume that it will provide a complete free service for every citizen, a single hospital service, no buying or selling of national practices, an “ad hoc’ regional administration, a form of industrial democracy which will give doctors a considerable say and all health workers some say in the running of the service, and an over-riding control by the Ministry of Health.

Will the BMA accept the view that these are the essentials and back a scheme which (a) removes the power from directly elected authorities (even if powerful 1nterests like the LCC or MCC have to be fought); (b) permits basic salary plus capitation fee as the chief, method of payment; (c) allows very limited private practice to all practitioners?

Tthis document was clearly produced and distributed in haste and there has been no attempt to correct it.