The Future of Medicine 9 Could the Money be Better Spent?

The provision of a medical service is not a very expensive business for a modern State.. It is a source of considerable astonishment even to doctors themselves to learn how small the total income of the medical profession is. If we were, beginning from zero and had to provide, all the buildings and apparatus which are used by the medical profession today, the capital expenditure involved would be very high. As it is, a survey of those hospitals which have been bombed and of those which although undamaged by the war are nevertheless sufficiently inadequate and inefficient to warrant their re­placement, may show that a very large sum will need to be spent at the conclusion of the war in reestablishing our hospital service. Calculations of the possible cost are at the moment quite impossible, but there is no reason to believe that when the job is completed the total addition to the annual upkeep will be so great as to alter materially the existing estimates for the cost of present and proposed medical  services.

There are many ways in which one can approach this, question of the cost of medical care, and doctors might legitimately claim that it is for them to study exactly what is required for the care of their patients, and if the community fails to provide what is considered necessary, the responsi­bility for failure to produce the optimum results in health preservation and in treatment of disease must lie with the community as a whole. Up to the present moment, unfortunately, the medical profession has rarely adopted such an attitude but has been content to struggle along with inefficient apparatus and ill, co-ordinated activities, trusting rather to the ability of the individual doctor than to the proven advantages of organised team-work.

Since, however, affairs are controlled by these questions of cost it will be legitimate to ask whether a better medical service than that which now exists can be provided for the same sum of money— £140,000,000— as we have estimated the cost today to be. That a form of service can be provided for that amount of money can be shown easily; that it would be a better service depends on our view of what would con­stitute a better service.

This consideration cannot be divorced from our general opinion as to the changes which are likely to be made in the structure of British society after the war. It is clear that the final development of the medical service must depend on the form which other activities take and on the type of State organisation which evolves. A consideration of the past century illustrates and confirms this conception. Professor Sigerist, professor of medical history at Johns Hopkins University, Baltimore says of this : “Society has undergone a profound change in the last hundred years. We live in a highly industrialised, highly specialised society. At the same time medical science has been revolutionised, has become highly specialised and highly technical also. Science and technology are the driving forces that transform both society and Medicine. It is obvious, that a new Medicine in a new society calls for new forms of medical service.”

The provision of this new service may be of such fundamental importance that the question of its cost would not be allowed, in a fully organised society, to stand in the way of its institution. So vital is the need for medical services that necessity should be the only measure of how much money is to be spent on it, and that necessity can only be accurately estimated by doctors who are widely experienced in the practice of Medicine and intensely concerned with the health of the community. Today Medicine is cramped for lack of money, for it takes a lot of penny flags to run a hospital. Probably the worst example of parsimony in medical matters is the Government’s contribution to medical research.

Medical research in this country is financed in many ways, but if new discoveries in health are to be made for the benefit of the State as a whole it must surely be one of the State’s duties to provide for research. The truth is that the Government’s payment to the Medical Research Council amounts to only £200,000. Since the war began many a small town has collected larger sums than this in a war weapons week. In ordinary times many firms concerned with the manu­facture and sale of medical products spend much more than this on their research departments. The manufacturers of patent medicines and proprietary remedies may not spend very much on research, though they are often quite ready to take advantage of the discoveries made by others, but they spend very large sums in other ways. An official of one manufacturing concern has declared that when his firm spends less than £1,000,000 on advertising in a year their sales show a decline.  Contrast £1,000,000 spent in advertising products of unproven value with £200,000 for trying to discover the causes of and the cures for disease. The work done by the Medical Research Council’s team on influenza alone was worth many times that amount of money to Medicine and to the State. We ought to remember also that the £200,000 cannot all be spent on original research; for the Medical Research Council has certain control duties— particularly in safeguarding the quality of products under the Therapeutic Substances Act mentioned in an earlier chapter.

Let us assume that we are to be allowed to spend only the same amount as at present on our medical service and see in what ways a better service could be provided. In a recent number, writers in Medicine Today & Tomorrow (March 1941) suggested that the money should be spent as follows :

£ millions
  • Domiciliary service
  • Hospital service
  • Mental hospitals
  • Aids and appliances
  • Additional salaries : Medical   .
  • „          „          Dental
  • „          „           Nurses
  • „          „           Auxiliaries
  • Research
  • Administration (5 per cent)
  • 23
  • 23
  • 12
  • 10
  • 15
  • 7
  • 4
  • 5
  • 7
  • 7

The first thing that impresses us in this estimate is that £7,000,000— thirty-five times the amount spent-by the Government at present, and probably three or four times that spent today on every aspect of medical research—is allowed for. If we add that the authors’ of this estimate believe that the sale of patent medicines would largely be abolished, thus saving some £20,000,000, a first glance certainly suggests that the country could in fact get better value for the money it now spends on fighting disease.

So intricate,, as we have shown, are the medical services that accurate figures for some items are difficult to ascertain This estimate for the future is however, capable of being checked from the writers’ own figures, and there appears no reason to doubt its accuracy. Further, they allow for 75,000 more hospital beds, thousands more nurses, a domiciliary service employing15,000 doctors at higher salaries than their average income today, £10-000,000 for the provision of better medicines and expensive appliances, £5,000,000 to be spent in better wages for larger numbers of medical auxiliaries, and a great improvement in the availability of dental work everywhere, The service that is suggested is a complete one, covering the whole country, every citizen and every medical need, at a total cost identical with that estimated as being spent today but coming from the community as a whole through equitable taxation and without direct payments from patients.

In other words, a far better and unified service than the present tangle can be provided for the same amount of money. It will be shown that the organisation of such a service need not be difficult, and can be sketched in fairly full detail now. Its institution depends on acceptance of the dictum that “the people’s health is essential for the welfare of a nation. If a society is to function successfully it requires healthy members. Besides, health is one of the goods of life to which man has a fight. Wherever this concept prevails the logical consequence is to make all measures for the protection and restoration of health accessible to all free of charge. Medicine like education is then no longer a trade ; it becomes a public function of the State “‘(Sigerist).

The medical profession, however, has a large amount of capital and goodwill invested in medical practice as it exists today, and doctors on being told that patients can be given a better and more complete service without extra cost to the community, are apt to jump to the conclusion that to do this the amount spent on one or other section of the profession must be reduced, and they fear, therefore, that such a service will be achieved at :the expense of their standard of living. This fear is quite groundless, for the better spending of money is achieved through the co-ordination of the services, by the cutting-out of all overlapping, and by the reduction of the waste that arises in unstandardised hospitals, doctors’ sur­geries, and other medical institutions.

So far as the doctors are concerned there does not appear to be a single item in which considerable improvement for the majority of the profession would not be possible. It is true that a very small number – those who have been able, especially in Harley Street practice, to make very high annual incomes— may find themselves restricted to a lower but not necessarily less satisfactory income-level.     It must be remembered that the number of men at the top of the medical profession who have earned incomes running into five figures is very small indeed, and many of those who have earned the highest esteem among their colleagues have not always acquired the biggest financial reward.   It has often been remarked in Harley Street that the consultant whose opinion is most valued among doctors is asked to see so many, of those same doctors’ relatives, from whom naturally he does not accept a fee that if in addition he attends conscientiously those hospitals to which he gives honorary service his busy day may bring him in much less than might be supposed.  In any case the high income of Harley Street, is always related to the very high expenses, for even the shared consulting room of that important street costs a lot to rent, and the net income may not even approach the amount acquired by men in less responsible positions in industry.

This question of the expenses entailed in running a medical practice constitutes a great difficulty in putting forward suggestions as to the salaries which the doctors in a full-time, salaried service might expect. The salary-level does not, of course, indicate the standard of living, which depends on so many factors over which ;the State already has, control, not the least important being income tax. It can, however, be said that if the State devises a domiciliary medical service in which all those present-day expenses for surgeries, secre­tarial assistance, travelling, etc., have no longer to be borne by : the doctor, the total income paid to each doctor may appear to be lower than at present but should provide a better standard of living nevertheless.   It is worth noting, however, in passing that in New Zealand the Government, in formu­lating its free, medical service under its splendid Social Security Act, offered the doctors a total income 5 percent higher than they had previously earned.

Among the other advantages which, from our existing ex­perience of community control of medical services, we can assume would accrue to the. doctors are such things as pen­sions at a reasonably early retiring age, provision for depend­ants, adequate holidays with suitable arrangements for the work to be carried on in their absence, and a certain amount of time off at regular intervals for study leave. The latter has long been the dream of the medical profession in this and most other countries. The principle that a doctor in general practice should have an opportunity for a “refresher” course has already been accepted in this country and a proportion of doctors attend each year at the British Post-Graduate Medical School made possible by the joint action of the Government and London County’ Council. The principle should, however, be extended, to all doctors, and this regular return for instruction by those with wider experience and the most up- to-date information is looked forward to by every section of the medical profession, and will undoubtedly lead to a great improvement in the average standard in medical practice.

Doctors are not the only people concerned with the detailed development of medical services. Dentists, for ex­ample, can claim to told a vitally important place in the struggle for health. There is constant co-operation between the medical and dental professions. On the one hand the dentist frequently requires the services of doctors for the giving of anaesthetics. It is to be regretted that the practi­tioners on whom they call for this service cannot usually claim anything more than a general knowledge of this important specialty, but the fault is one of organisation, and the individual doctors undoubtedly give the best service of which they are capable. On the other hand, the dentist is just as frequently consulted by the doctor who needs to have an opinion as to whether dental disease is playing any part in lowering a patient’s general condition. Closer co-operation on this point is unquestionably required. It must, however, be linked with X-ray facilities, and suggests that the dentist should in fact work in the same buildings as do other special­ists who might be consulted. This implies that dentists will demand and must receive the same conditions as we have put forward for doctors.

The medical profession depends to a very large extent on the work done by nurses in hospitals, in clinics, and in the homes of patients. Perhaps no other profession demonstrates the anomalies that arise in an unplanned profession or indicate the tremendous time-lag that occurs in the struggle between scientific advance and tradition more than does the profession of nursing the sick. Just as Medicine had its first roots among the religious orders and has not yet completely separated itself from the moral and ethical beliefs of some religious faiths, so the first nurses were to a large extent connected with religious bodies, and their profession retains many features of a form of life which in other respects bears no resemblance to that origin. To nurse the sick would in itself be sufficiently hard and difficult without surrounding those who do this work with restrictions and discipline that disappeared from the lives of most young women many years ago when they entered offices and factories.

The overdue improvement in nurses’ conditions is not only a question of improving their financial position, though in spending our £140,000,000 on a complete medical service the claims of nursing for higher remuneration have not been over­ looked. In other respects, too, the nurses’ of the future will undoubtedly claim the same advantages that we have sug­gested for doctors and dentists. There are many problems connected with their training on which they themselves have never been sufficiently vocal, and it is time that they demanded the removal of all those almost feudal stigmata and relics of monastic life which still exist. The greatest improvement in nurses’ .conditions, and one which would have greater effect on the recruitment of adequate numbers of suitable girls, would be the provision of such, conditions as their sisters have in factory and office, including the opportunity to live at home m their own family circle. There is no reason why a hospital should attempt to supervise the moral life of its nurses nor any reason to impute to them less moral habits than the rest of the female population, hut in so far as such imputations are made and such reason, exists the best corrective lies in family life.  Even more important than the changes which one must visualise in hospitals is. the relation of nurses to the domiciliary medical service. However complete the hospital service there will always be sick people to be nursed in their own homes, and today the provision of nurses in these cir­cumstances is either the work of charity or an expensive business. Neither  of these methods meets, the need, which is for a sufficient corps of nurses who, can assist the doctor as readily in the homes, of his patients as they do in hospital.  Such a service can only be supplied on the same principles as we have already laid down, namely, as one of the functions, of the State. Detailed consideration of this problem cannot be given here, but it is linked with the provision of a midwifery service, and must include consideration of the conditions, under which those nurses who undertake this type of work (and therefore remain comparatively isolated) should live.

A catalogue of all the different workers who are directly involved in medical practice would take too long, but the number of recognised auxiliary services is steadily increasing. For each there are individual problems which have yet to be discussed even by  the workers themselves, but the general principles of full-time salaried servants with all the advantages indicated will apply to all who  are directly engaged in the medical service.

The reader may have become impatient, during the last few pages, but this long dissertation on the advantages which the doctors and their many assistants may expect to receive when the State starts spending the money on medical services instead of leaving it in the hands of many different agencies has not led us to overlook the real reason for setting up any medical service, namely, the care of the sick. It would be possible to describe many different forms of medical service in which the primary consideration was the safeguarding, of the income of the doctors. This has indeed been one of the main criticisms of the policy of the British Medical Associa­tion, for one of the changes which it suggested— the extension of the Panel System to include the dependants of insured workers— would have the effect, it is estimated, of almost doubling the income of each doctor from that source. The demand of the sick is, however, for a service in which without introducing any serious disadvantages for the medical and other personnel the care of the individual patient is the first and constant consideration.

The care of the sick should not begin when the patient reaches a point at which his illness can no longer be borne without medical aid. Medical service must aim at recognis­ing disease at the very earliest stage, and must adopt every possible method to maintain health. It follows therefore, that what the sick really need is a chain of medical services which covers the whole of life and which in the case of every attack by disease can guarantee the speediest and most accurate diagnosis, the latest and finest form of treatment, and, when the acute stage is over, restoration to a state of health as close to normal as can be achieved. The chain of services must, therefore include methods of rehabilitation and extensive use of occupational and recreational therapy in a way which has today only been hinted at. Further, every activity of the individual must be covered, including, therefore, Industrial Medicine, and in the same figure of speech every link must be equally well formed and there must be a direct connection from one end of the chain to the other. In more direct language, the citizen has a right to demand that he can call upon the whole of medical science to ensure that those functions of his body which can be tested are normal, that he should be instructed and given every assistance to maintain them in normal conditions, and that once a defect has been recognised by himself or by a doctor he should be able to obtain the opinion of any specialists who may be helpful both indiagnosis and in treatment.

The benefits to the patient of such a service would be many. The financial benefit is not one to stress, for each and every citizen would pay a share of the cost. What must be stressed is that as no question of fee payment would arise between the patient and the doctor or institution; we would be rid of all those doubts and difficulties which beset the great majority of the population faced with the prospect of ill health. This in itself would benefit the sick as would the knowledge that the whole medical profession had combined for the service of the community in health and in sickness in order to improve further the standard of bodily fitness and to increase the expectation of life which medical science has already done so much to raise.