Now – or Never

SMA 104


33, Murray Rd. Northwood, Mddx.

To all Medical Members of the S.M.A.

It is Now – or Never. The next three months are vital to the ideas for which we stand. The White Paper of the Minister of Health will be published in mid-September and will show to what extent the twelve years of work of the S.M.A. has directed the medical service of the future, and to what extent we still have to push our ideas. One thing we certainly have to do: to convince as large a number of doctors as possible, especially in the B.M.A., that a socialised health service will give them all they want and the country all it needs.

Letters by S.M.A. members on BMA General Principles

The British Medical Association appears to have decided to oppose the White Paper even before they know what its proposals are going to be. The division of opinion within the Council of the B.M.A. is so marked that their propaganda on the subject is likely to be very muddled and sometimes self-contradictory. There is, therefore, a very good opportunity for effective propaganda by speaking at B.M.A. branch meetings, by letters to the B.M.J. and by letters to local newspapers whenever they mention the subject.

The Council of the B.M.A. and the Representative Committee which has been meeting the Minister of Health appear to accept as fixed policy the vote given by the B.M.A. Annual Representative Meeting against a salaried medical service, but regard the votes of the same A.R.M. that the service should be for 100% of the population, and based on group practice, as not binding. The line they propose to take is that Assumption B of the Beveridge Report should be satisfied with an extension of National Health Insurance but they will use very varied and specious arguments against the whole scheme..

The chief of these are:

1. That it is no use inaugurating a socialised medical service until we have a complete socialist state. They do not say it in that way but their General Principle No. l is as near a statement of socialist policy as one could expect for it says that the health of the people depends primarily on the social and environmental conditions under which they live and work, etc. It does not say that the medical profession must be so organised that it can insist that the nutritional standards, educational facilities and facilities for exercise and leisure which are essential to health must be made a prominent feature of our national life.

2. Great play will be made against the theoretical “state” which is threatening to interfere between the doctor and his patient. General Principle 3 says that State must not invade the personal freedom of the citizen and doctor; General Principle 4 says the State must be responsible for the provision of medical services but must not assume control of the doctors and General Principle 6 says “It is not in the public interest that the State should invade the Doctor/Patient relationship” and General Principle 5 that free choice should be preserved as a basic principle.. These arguments are all familiar political arguments against any form of planning or organisation. They can be answered in a great variety of ways but the best answer in the medical field is that the service should be a socialised service in which all health workers and the public co-operate for the aim of preserving the health of the nation and in which the administrative structure is such that, while the Community retains the control that goes with responsibility and has its methods of ensuring the efficiency of the service, nevertheless the doctor has free control over the treatment of the individual patient and that both the doctor and the patient have the right to change when they find themselves unsuited.

3. General Principle No.8 implies that every citizen shall have the right to utilise and pay a fee for the services of any doctor privately, even although that doctor is already under contract to the national service. This is a “principle” which most people will regard as completely unprincipled. It might lead to a black market in medical attention beside which war-time black markets would be white in comparison. It is essential that a doctor employed by the national health service shall be available to those people for whose health he is responsible and shall not be at the beck and call of any small section of the Community who are prepared to pay him extra. Competition for patients either inside or outside the service would wreck the “team” spirit which is so essential.

4. The B.M.A. have indicated certain changes in national and local administration which they would like to see and go on to say. “These administrative changes should be regarded as foundation changes to be completed before other changes are initiated.” This is largely true, but the Minister is almost certain to suggest a form of ad hoc regional committee to enable the health services, to be organised while we await changes in local government which may take some years to bring in. In any case, the changes suggested by the B.M.A. are not so very drastic as to prevent the inauguration of a national health service and this argument is clearly brought in in the hope that it gives them an air of being progressive and at the same time will embarrass the Government.

5. The B.M.A. also imagine that they will embarrass the Government by introducing the argument “that all branches of medical practice should be regarded as a single service”. This is, of course, S.M.A. policy and the B.M.A. have only introduced it because the Minister of Health was at first inclined to leave out some parts of the service such as Mental Hospitals until a later date.

6. General Principle 4 states “It is not in the public interest that the state should convert the medical profession into a salaried branch of central or local government service”. The die-hards of the Medical Planning Commission were determined that that form of words should be used although by implication it condemns all medical men who work on a salaried basis, although the Planning Commission in its draft interim report did in fact propose that all specialists should be paid on a salaried basis and that general practitioners should have a basic salary plus a capitation fee. It is best answered by linking it up with the B.M.A. argument about the Doctor/Patient relationship and by stressing that it is only in salaried service in which there are no economic barriers that the perfect relationship between doctor and patient can exist.

7. Although these general principles for a national medical service available (but not provided) for the whole population are laid down, the B.M.A. hopes that such a service will not be started and, therefore, goes on to propose an extension of National Health Insurance. The objections to this have been summarised in the draft interim report of the Medical Planning Commission and in the recent pamphlet by Sir Arthur MacNalty. Briefly they are, that such an extension would still divide the population into those below and above the N.H.I income level and would, therefore, lead to two levels of medical attention; would perpetuate and emphasise the buying and selling of practices; would make impossible the provision of a single health service and would make any organisation of the work of general practitioners almost impossible; would necessitate the continuance of approved societies which have been universally condemned (e.g. B.M.A. at A.R.M. 1942).

8. Lastly, there is by implication in the B.M.A. statement the argument that the Government should not commit itself to a solution of this problem without agreement with the whole profession. This argument cannot be better answered than it was in a leader of the Manchester Guardian which said – “Such claims (and the implicit assumption that the Government must “negotiate” an agreed scheme with a professional body empowered to veto anything it does not like) are frankly inadmissible. But it is of fundamental importance that, as the B.M.J. put it a year ago ‘the last word in the management of a service and financed by them should rest with their chosen representatives’ “.

The “general principles” referred to are expected to be published in the B.M.J. on August 7th. or 14th.

I have made these points as an aid to ready and immediate action by every member of the S.M.A. Every letter to the B.M.J.or a newspaper, and every attendance at a B.M.A. meeting to make these points is vital work.

D. Stark Murray Vice President

June 1944