The WHAT, WHY and HOW of the National Health Service
ST. BOTOLPH PUBLISHING CO., LTD., 5, Little Britain. London, E.C.1
D. Stark Murray and L. C. J. McNae 1946
INTRODUCTION
By the beginning of 1948 Britain is promised the start of a National Health Service that will be the envy of and model for all other nations.
As a part of the general programme for post-war reconstruction and national advancement it may appear a relatively small part of what has to be done ; yet viewed by itself it is a great undertaking pregnant with remarkable improvements in the health of every citizen.
It will always be the case, however, that this service cannot reach its fullest development unless the people for whom it is designed learn to use it, to avail themselves of all it offers early, frequently, completely ; and to do that they must know what is being guaranteed to them by the National Health Service Bill. We believe, however, that understanding will be greater if they know also why it has been necessary to provide this new service, and how it is proposed to do it.
We have therefore tried to set out simply and straightforwardly the what, why and how of the National Health Service.
D.S.M. L.C.J.M.
Chapter 1 The Past
He was born: he died …. Cynics have suggested that these five words tell the whole story of a man’s life. But between birth and death he was well and he was ill. His life, his pleasure in and enjoyment of it, the part he was able to play in his immediate circle, in his country and in the world at large depended on how well he was and how seldom he was ill. So many accidents may happen, so many defects develop and so many diseases be acquired that a man’s life is apt to be interrupted many times, and sometimes entirely ruined, by these unforeseen events. Health is therefore one of man’s main preoccupations, and the avoidance of ill-health one of the chief desires of every man and woman.
But it is now recognised to be more than an individual problem, for no person is ill or incapacitated without affecting those around him, possibly even endangering the lives of those in contact with him and ultimately damaging the community of which he is a part. His incapacity calls for expenditure in money and services on the part of the community and deprives the State of his producing capacity so long as he is ill. This lost production, estimated for Great Britain to be some £300,000,000 in 1937, makes the health of each individual a concern of the State as much as of the person himself.
Indeed it is now an axiom of most civilised communities—though not of all groups within such communities—that health is the concern of the people, and calls for threefold action—by the individual, by the citizens organised in localities, and by the State as a whole; it is this triple action that we are now to discuss. In the final analysis many of the problems go far beyond national boundaries and all of them are outside the ordinary groupings of our present social system. .Health is indivisible because disease may attack all social groups (not always with the same severity, it is true). The standard of health of our people falls short in many ways of what can be achieved; if it is to be raised “the people themselves,” as the British Medical Association says in A Charter for Health, “must share with the Government the responsibility” for that standard.
The standard of health attained by any country depends on environmental factors many of which do not appear at first sight to be of a medical nature. The need for an adequate diet, for good housing, for well-planned cities, for healthy factories, good clothing, leisure and education have all been stressed over and over again and are neatly summarised in the B.M.A. document already quoted. To these must be added the need for social security generally, for adequate sickness and unemployment allowances so that conditions necessary for health can be maintained, for such auxiliary schemes as industrial accident compensation and children’s allowances, and above all for ample payments for those retired from industry.
These social and environmental factors are common to all present-day States and must be dealt with by political and economic measures. There are, however, other aspects which are more purely medical, and the greatest is the rapid growth of medical science, an increasing exactitude of diagnosis and certainty of treatment, and a tremendous widening of the field of scientific knowledge (up to and including atomic fission) which is used in medicine. All call for a new relationship between medicine and State, between doctor and patient. Above all, they call for liaison between the ever-growing army of people who fight against disease.
The “industry of health,” as T. B. Layton calls it, now employs in this country some 500,000 people directly, and if those manufacturing drugs and apparatus are included, many thousands more. This army of health workers is headed by about 50,000 doctors, and includes nurses, social workers, pharmacists, technicians in laboratories and X-ray departments, dentists (and their mechanics), masseurs, chiropodists and many others.
We can look at the battle they fight in two ways. We can quote figures to show the great fall in the death rate in this country — to about a third of the figure of a hundred years ago; or the increase in the expectation of life, which was 41 years in 1870 and is now 60 years ; and we can claim that we have cause for pride and satisfaction. Or we can analyse the amount of preventable disease, as does A Charter for Health and remind ourselves of 100,000 deaths every year that should not occur or recollect that infantile mortality and death from common children’s ailments is far higher amongst those with low incomes than in the wealthier classes.
| Preventable Disease – deaths annually | |
|---|---|
| Tuberculosis | 25,000 |
| Infectious diseases | 22,000 |
| Acute Rheumatism & Rheumatic Heart Disease | 17,000 |
| Premature Birth, etc. | 10,000 |
| Diarrhoea & Enteritis | 4,000 |
| Respiratory Diseases | 22,000 |
| Total | 100,000 |
And if we take this point of view we shall be angry or hurt that such defeats are still inflicted by disease on the army of health workers. In that case we will know that there is still much to be done to improve and ultimately perfect our health and medical services, and it should lead us to ask some pertinent questions on the present situation of these services.
| Class 1 | Class 2 | Class 3 | Class4 | Class 5 | |
|---|---|---|---|---|---|
| Measles | 25 | 70 | 194 | 246 | 469 |
| Whooping Cough | 28 | 52 | 109 | 140 | 209 |
| Bronchitis and Pneumonia | 128 | 223 | 448 | 607 | 861 |
How does a family get its medical services to-day? Let us say right’ away that for a portion of the population, estimated variously between three and ten per cent, of the total, medical care is obtained by paying whatever fee is asked for it. As for the rest of the people, it is true to say that for none of them is a complete system of health and medical care provided by any organisation.
The family doctor, the consultant, the specialist, the hospital, the other therapeutic and rehabilitation services, should be available to everyone, and the normal procedure—-the ideal method from the medical point of view—should be through the family doctor. But up till now it has been no-one’s duty to see that even the family doctor is available; and that he is available in such numbers as to have time to give to every sick person ; arid that he has the equipment and technical assistance to do the job properly.
The other services either do not exist or are badly distributed or are years behind the times; for, as The Domesday Book of the Hospital Services (1946) says, although “hospitals are an essential service it is curious but characteristic that in Britain this essential service, Topsy-like, ‘ just grow’d’ ; and this . . . explains the unevenness and deficiencies and . . . the inadequacy of the numbers of available consultants.” Not only are they deficient in numbers and lacking in co-ordination but exceedingly wasteful of the best talent in the profession.
And no one is satisfied. Sixty million visit the doctor at least once a year; and while the individual doctor may be held in high esteem, the profession and the service is widely criticised. Long waiting for short interviews, hours wasted in out-patient departments of hospitals, superficial treatment without accurate diagnosis backed up by laboratory and other tests, slow spread of new knowledge and discoveries, practitioners working in isolation with no opportunity for team-work, these and many other criticisms are the burden of every independent report during the last twenty-five years.
They warrant a great effort to provide a complete service for everyone, and they call for support for every plan that will provide the social foundations for health. “The electorate, through its representatives in Parliament,” as the B.M.A. has declared, “can demand in all spheres of the national life the adoption of a policy based on the promotion of human welfare.”
The National Health Service Bill is the coping-stone of the Government’s four-tiered structure of social security, the fourth of the great measures which, with its predecessors, National Insurance, Industrial Injuries Insurance, and Family Allowances, show that the Government has answered that call.
Chapter 2 The Health Bill
Crystallising thirty years of discussion, the National Health Service Bill, put before the House of Commons by Mr Aneurin Bevan, the Labour Minister of Health, declares that “it shall be the duty of the Minister to promote … a comprehensive health service designed to secure improvement in the physical and mental health of the people . . . and the prevention, diagnosis and treatment of illness . . . and that the service so provided shall be free of charge” In these phrases the Bill embodies many new principles, for never ‘before has a comprehensive service been provided for all citizens without cost at the time of use, and by a single method.
These principles are elaborated in the explanatory White Paper (Cmd. 6761) which fills out the dry language of the Parliamentary Bill. “All the service, or any part of it, is to be available to everyone.” The Bill imposes no limitations, no waiting or qualifying periods, no need for proof of having paid contributions, no discussion of age, sex, or employment. What a contrast with the present position! This was epitomised in an earlier White Paper (Cmd. 6502), which in 1944 declared that whether a citizen got a health service or not depended “too much upon circumstances, upon where they happen to live or work, to what group (e.g., age or vocation) they happen to belong or what happens to be the matter with them.”
The mere fashioning of a service is only part of the problem. Sir William Beveridge, in writing his famous report on social security, was particularly influenced by the existence of economic barriers which delayed recourse to medical care. “The care of health,” the 1944 White Paper summed up, “is not yet wholly divorced from ability to pay for it,” with the natural corollary that “there is not yet a comprehensive cover for health provision, for all people alike.”
Medically this is a matter of the most vital importance. Unless the highest quality of service is provided for all alike there will be two standards of medical care, one for the rich and one for the poor, and inevitably neither will be the highest possible. Ideally the service should be so organised that no financial question of any kind enters into a doctor’s relationship with his patients so that his mind is free to use his skill and knowledge to the full in the service of the sick.
This ideal, as we shall see, is not completely carried out in the present Bill. It does, however, approach very nearly to it, for the Bill and the White Paper remove all question of fees in normal circumstances, and the only charges that may be made are intended to cover possibilities of waste and the provision of unessential “frills.” Apart from that, any citizen whether paying national insurance or not is to receive the full benefit of this comprehensive system of health care.
The three sections into which the Government scheme is divided cover every requirement. All involve great changes in existing institutions but none destroys good qualities or essential provisions, with which we are familiar. The division into three, in the Government view, is an attempt to overcome certain organisational difficulties but there is one big unifying force, the fact that all parts of the service are available to and will be used by the same patient. There are administrative divisions, but no barriers to the movement of the citizen, sick or well, from one part of the service to another.
These three parts are the General Practitioner Service, the system of Hospital and Specialist care, and the supplementary and clinic services already provided mainly by the local authorities. In addition spectacles, dentures, aids for the deaf and other appliances are all to be provided through whichever section of the service is appropriate.
What does this mean to the ordinary citizen? Will he or she be better off in the quantity and quality of the service received as well as in the freedom from economic barriers? The promised service should be greater in quantity and can be better in quality than anything we know to-day.
General practitioners will continue to visit the sick in their homes as at present and may continue to use their own surgeries for those able to go to them ; but the bulk of doctors will transfer their practice to publicly-owned Health Centres. The Health Centres will be the focal point of the family doctor service of the future. They represent great gains to the patient in a variety of ways, but chiefly through the improvement in the conditions under which the home doctor works, improvements which indirectly mean better service for the sick. The assistance which the G.P. will get in the Health Centre represents as much to him as the Health Centre will in other ways to the sick.
It is the hospital and specialist provisions that present the biggest gains to patient and family doctor alike. Hitherto there has been no absolute right to the highest consultant and specialist service and no direct route to a bed in an adequately-staffed and equipped hospital. The service is to cover every field, ” general and special hospital provision, including mental hospitals, together with sanatoria, maternity accommodation, treatment during convalescence, medical rehabilitation and other institutional treatment.”
The home doctor is to be backed up by all kinds of out-patient and in-patient services. The specialists and consultants whose primary job is inside the hospital are to be available at Health Centres, in clinics or other institutions used for specialist services, and whenever necessary in the home of the patient. The precise provisions for specialist care are to be planned to fit each specific area, but the intention is to see that a complete system is rapidly developed.
For the patient, a wider range of services is to be provided through the larger local authorities. At present, different types of local government agency, town, borough, county, have duties and powers in the health field. Most of these powers have been permissive, so that the service provided varies widely. The new Bill amalgamates all of them, making them compulsory, and gives them to the County or County Borough Councils.
They will build, staff and equip the Health Centres and associate with them such existing services as the midwifery, maternity and child welfare clinics. They will be responsible for health visiting, home helps, home nursing on a new and better scale, and it is by these forms of assistance that the lot of the sick will be made much easier than ever before. How all this will be done is discussed in later chapters.
The Bill contains many other provisions, of which we must note here the decision to provide a dental and ophthalmic service as soon as personnel are available, and if necessary to make certain priorities as to who will get these services until they are fully staffed. The war-time blood transfusion service is to be a permanent and very necessary feature of the hospital service, and the system of special bacteriological laboratories for control of infectious diseases which was called into being by the demands of war is to be retained.
Vaccination is no longer to be compulsory, but both vaccination against smallpox and , newer methods of immunisation against other diseases are to be freely available to all who wish to protect themselves and their children. Since prevention of disease rather than cure is to be the aim of the service the Minister of Health is given, wide powers to promote any method that will achieve that aim. Among other things is the power to encourage, to start and to further all forms of research into the cause and cure of disease.
As we have mentioned, one of the deficiencies of our present system is the time lag between a new discovery and its universal application. The new service is therefore expected to make arrangements for refresher courses for doctors, and the Minister has the power to pay the cost of these and the expenses of the doctors who attend them. No rule is laid down as to how often such courses should be taken, but the power to provide them is one of the points built into the service with the object of improving its quality.
One other departure which the Bill brings about which may, if the medical profession uses it wisely, greatly improve the quality of the service is the setting up of a Central Health Services Council, “to advise the Minister upon such general matters relating to the services provided as they think fit and upon any questions referred to them by the Minister.” The members of this Council “are to be doctors, dentists, nurses and other professional people concerned with the different parts of the service,” or having experience in existing services. This Central Health Services Council may be strengthened by ‘Standing Advisory Committees on various special subjects, and these committees may act either at the request of the Central Council or of the Minister, so that fairly rapid decisions may be reached.
The National Health Service Bill, we may summarise, endeavours to provide a complete service of all kinds of medical advice, treatment and assistance by a single route, through a family doctor “whom the patient chooses,” and a single hospital service. To carry this out different administrative bodies, which we discuss in detail later, are given the duties of providing parts of the service.
But if they don’t? The Minister is invested with a wide general power to act against any local authority or any of the bodies constituted by the Bill which fails to carry out its duties. He can make orders directing them to do whatever is necessary and for which Parliament has given sanction; and if they still fail to provide essential .services or fall below the numbers of health workers or the standards of care laid down “he may take over their functions permanently or temporarily himself.”
So this National Health Service cannot fail because any of its constituent administrative authorities neglect to carry out the duties laid upon them. Permissive legislation has in the past too often meant neglect ; this service is, however, one guaranteed to every citizen through the social security system, and the Government cannot permit any part of it to fall below what is promised. It is, moreover, one that must appeal to all men and women who care for their own and the nation’s health, and this valuable but drastic power given to the Minister is unlikely ever to be used.