The Socialist Doctor vol 2 no 4

NOVEMBER, 1934

The Official Organ of the Socialist Medical Association.

PRICE THREE PENCE

A STATE HEALTH SERVICE.

ON this page of our last number we raised the question of whether the advent of a Labour London County Council, with the possibility of rapidly developing a municipal medical service through the hospitals of such a local authority, did not necessitate a complete revision of the policy of the Socialist Medical Association. It has always seemed best that the problem should be tackled on a national basis, taking as a foundation, however poor, the present National Health Insurance Scheme. The L.C.C. and the probability of other local bodies being controlled by the Labour Party suggests, as amplified in the article on the following pages by Mr. Somerville Hastings, that a rapid approach to a complete municipal health service may be possible.

This consideration received new force with the publication, in the annual report, of the views of the committee set up last year by the Labour Party. Its work is very far from complete; but, in a preliminary report, it gives the opinion that of the two main possible avenues of development the proper one is through the Local Authority Health Services. This report will do nothing to further the case for a State Health Service, for it shows no comprehension of the whole problem; it suggests abolishing the much over-emphasised vested interests of the medical profession, while retaining, at least in part, those of the approved societies, and as a whole is far from clear as to how much of the present wasteful voluntary system should be allowed to continue.

Nevertheless, it will be valuable if it causes a complete reconsideration of the S.M.A. programme. We think such a revision will lead to a confirmation of most of it, but many details require much fuller working out if the scheme is to be quickly available to progressive legislators and administrators.

MUNICIPAL HOSPITALS: THEIR PRESENT SCOPE AND FUTURE DEVELOPMENT

BY SOMERVILLE HASTINGS, M.S, F.R.CS.

(Part of the President’s address at the Annual General Meeting)

I WONDER how many of the Conservative Members of Parliament who voted in favour of the Local Government Act, 1929, really appreciated what they were doing? Mr. Neville Chamberlain, the author of the Act, did, I am convinced, for several years before I heard him tell one of the voluntary hospitals what their inevitable fate must be.

The Local Government Act, 1929, is the key which, used rightly, will open the door to a complete and unified municipal hospital system. The Act itself is not easy to understand. It is full of uncertainties and anomalies, and a clarifying Act of Parliament is badly needed. What the Act does, in short, is to transfer the powers under the Poor Law from small local Boards of Guardians to the councils of much larger areas, i.e., of counties and county boroughs, and then tells these bodies to sit down and think out how they can best utilise the powers now given them.

As far as the development of hospitals is concerned, no increased powers are given. Section 131 of the Public Health Act, 1875, states that -“any Authority may provide for the use of the inhabitants of their district hospitals or temporary places for the reception of the sick,” and the only subsequent addition to these powers of any account has been the inclusion of pregnant women amongst the sick, so that the provision of maternity hospitals or maternity beds is also possible.

The Local Government Act, 1929, did two very valuable things: It enlarged the area in every case, except that of the county borough—and experience has demonstrated how impossible it is to provide an efficient hospital service unless the area is large—and it set the Local Authorities thinking, which is always a good thing. The results of this thought has led them in one of three directions :—

(1) Many have left their hospitals as Poor Law infirmaries much as they found them.

(2)A few Local Authorities have adopted the course made possible by Section 5 of the Act, and have made a declaration that any assistance which could be provided either by way of Poor Relief, or by virtue to the Public Health Act, 1875, shall be exclusively provided by the latter method.

(3)A much larger number of Local Authorities, including London, have adopted neither of these courses, but have appropriated the Poor Law hospitals, and are now running them as municipal hospitals.

It might appear at first sight that the obvious and right thing for any progressively-minded Local Authority to have done was immediately to have made a declaration and to have said boldly that all treatment provided, both for those in receipt of Public Assistance and others, shall be provided under the Public Health Act, 1875. The main objection to doing so, however, is that, if this course is taken, the Local Authority must be quite certain that it has sufficient accommodation and facilities to fulfil all that can possibly be expected of it; for, once a declaration is made, it would be acting illegally to treat any sick person of any kind in any Poor-Law institution.

On the other hand, if appropriation is decided upon, the commitments are less serious and the advantages, nevertheless, very considerable. In the first place, admissions to hospitals are much simplified and, except in the case of the destitute, are carried out through the medical superintendents. It is a great disaster that, by Clause 16 of the Local Government Act, the cost of maintenance and treatment in any municipal hospital for any disease other than infectious disease has to be recovered from those patients who can afford to pay for it. If the hospital is still under the Poor-Law, this maintenance and treatment is “indoor relief’’ and its cost has to be recovered through the machinery of the Poor-Law; but if the hospital is appropriated, the determination of the sum that should be paid and its collection can be carried out by almoners or in any other way desired.

There is still another advantage. If the hospital is appropriated, and is, therefore, no longer under the Poor Law, consultation with the Ministry of Health concerning details of administration is unnecessary, and much greater freedom is possible to the Local Authorities.

Directly complete severance of the hospitals of a district from the Poor Law is an accomplished fact, either through the making of a declaration or by appropriation, enormous possibilities of development become apparent, especially in urban areas where the population is considerable, and the hospitals not too far apart. In the first place, specialisation becomes possible with all its advantages from the patients’ point of view. At the same time, because of the unification that exists, it is an easy matter to transfer patients from one hospital to another, or obtain the services of any type of specialist that the service provides for any given case.

Another, equally valuable asset is the elasticity that is provided. A severe epidemic of infectious disease breaks out and the isolation hospitals are filled to overflowing. In such a case, a block of wards or even an entire general hospital can be evacuated and used for infectious disease if sufficient alternative accommodation is available. A Local Authority cannot legally refuse the admission of any patient to hospital if his medical necessities demand immediate “hospital treatment. This does not, of course, apply to out-patient treatment.

Whether an out-patient department can be described in the terms of the Public Health Act, 1875, as “a temporary place for the reception of the sick” or not is uncertain. Nevertheless, for many reasons, it is essential that out-patient departments should be developed in connection with our municipal hospitals, and in such departments it will be convenient to have carried out, where geographical conditions make this possible, the tuberculosis, V.D., and maternity and child welfare work of the Local Authority. Here also school clinics can be established as well as clinics for sunlight, dental, and other treatment, and here, as far as circumstances permit, the District Medical Officers under the Poor-Law, who should generally be members of the resident staff of the hospital, can see their patients. In other words, the out-patient departments of municipal hospitals and their branches can be developed into the medical centres of the district.

This same unification, which should prove itself of much value for research purposes, must of necessity be equally advantageous in connection with medical education. For very many years instruction in fevers has been given in the infectious disease hospitals controlled by local authorities, and within the next few months a post-graduate medical school will be opened in connection with one of the L.C.C. municipal hospitals. Everything possible should be done to bring the stimulating and critical influence of students within the walls of municipal hospitals, arid there would appear to be nothing to prevent the development of medical schools in association with municipal hospitals where facilities for teaching exist.

Where municipal hospitals are being developed on the lines just indicated, the confidence of the public in them is steadily increasing, and they are being preferred by many to the voluntary hospitals. The public are beginning to feel that the hospitals belong to them, that they go there by right of citizenship, and not as a charity, and should anything go amiss, have the right of protest through their elected representatives.

The Local Government Act, 1929, came into being because intelligent administrators were impressed by the wastefulness of two systems of treatment, one for Poor-Law patients and the other for the public generally. If the same Act is the means of freeing the public from the equally wasteful system of dual hospital administration it will have proved itself of even greater value.

PROPOSED HEALTH INSURANCE FOR NEW YORK STATE

WE have already seen that America, faced with an enormous amount of sickness as the result of her vast unemployment, is giving serious consideration to various schemes for State assistance to the sick. Most of these schemes are attempts to bolster up the present system of private enterprise in medicine, but more advanced views are held by quite a large proportion of both the medical profession and the public. The “Medical Record” has just printed a long article giving very detailed proposals for a complete public service for the State of New York. (“A Practical Plan of State Health Insurance,” by H. Goldstein. (” Medical Record,” September 5th, I934.)) Taking the present position as a basis, it is calculated that each doctor should have a panel of 500—600 patients, but in addition private practice will be allowed to some extent. This will be limited to a period during the afternoon, and in each locality the doctors will work on a two-shift basis, having consulting hours for one half, 9 a.m.—1 p.m., and for the other half 4—8 p.m.

Emergency work will be done by each seventh doctor in turn from 8—11p.m., and during the night by the ambulance doctor from the hospital. Similarly, every fifteenth doctor will be on duty all Sunday, except from 10—12 a.m., when all will have consulting hours. By this arrangement every man on the panel will have abundant leisure, while there will always be some practitioner on duty.

Specialists, who must have been in practice ten years, and whose ability will be judged by the medical men they will serve, will also be on a panel with somewhat similar arrangements as to duty hours.

The finance of the scheme is by an insurance system to cover all employed with incomes under £600 per annum and others who desire to be in the scheme—and is to be financed by a levy, collected by employers, on gross incomes, 2 per cent, to be deducted weekly. The families of all insured are covered by this levy, and the scheme is purely one of health insurance for medical services only, and not including sick benefits, nursing, drugs, sundries, and hospitalisation. On the present income figures for New York State, it is estimated that this 2 per cent, levy will more than cover the total cost of the service, and the balance will be used at a later date to develop new services.

The medical profession seem likely to benefit, even although the field for private practice will be very limited, because the proposed salaries are fairly generous for the consulting hours involved. Approximately the suggested figures are, for the newly-qualified, £480 per annum, rising by £40 to a maximum of £1,000. Those already in practice will come in at the appropriate figure for their years in practice. Specialists will commence at £1,000, and by annual increments of £100 rise to a maximum of £1,500 per annum. The senior administrative officers will have salaries above this range.

The above summary indicates that the author of the scheme has worked it out in considerable detail, but it is not, of course, a real State medical service. It covers more than a simple insurance scheme, for it includes specialist treatment. It is somewhat analogous to the open choice system suggested by certain writers in this country, but it is implied that the panels will be so regulated that no practitioner will be able to have more than five to six hundred patients on his list. Hospitalisation is not included, although the writer thinks that the fund will accumulate balances sufficient to enable this question to be taken up in a few years.

M. D.

REVIEW: “HEALTH PROTECTION IN U.S.S.R” By N.A. SEMASHKO

(Gollancz, 3/6 net)

A GOOD many books have appeared recently on the Health Services of Russia. These have been written for the most part by people who have paid only a fleeting visit to that country to learn something of what the Soviet Government was doing for the health of its people. Such books give at best the impressions of a particular individual, usually unacquainted with the Russian language, and generally prejudiced either for or against the Communist regime. The book before us is of an entirely different type. It is written by a man who held the high office of the first People’s Commissar of Health for twelve years, and if it has a fault it is because its author knows too much rather than too little of what is taking place in Russia to-day. The book is so stacked with facts and figures that it perhaps fails to leave in the minds of its readers an accurate impressionist picture of feverish activity in health matters; of growing hospitals and medical schools; of developing clinics and health centres; and all that is being done by education and treatment to improve the health of Russia to-day.

Only those who have been to some of the out-of-the-way parts of Russia, and learned something of the standard of life and education of the peasants there, can have any idea of the difficulties of the situation, and the advances that have already been made. Semashko tells us that in 1914 there were no less than 7,277,577 cases of that terrible scourge, typhus fever, in the country of the Czar, and even if, as is possible, typhoid fever is also included in this number, the figure is appalling. The average Russian, outside the towns, had but the vaguest idea of the nature of infectious disease, and no conception at all of the value of cleanliness and sanitation.

The writer tells us that ”prior to the revolution, only 115 towns had anything resembling a water-supply system, and only twelve had sewage systems. At the present time, 366 towns have efficient water-supply systems with good water, and fifty-five cities have sewage systems.”

The book is of necessity but a summary, and sets out briefly how the Soviet Republic is dealing with such questions as recreation, food production, alcoholism, recruitment of the medical profession, as well as the more specialised health services.

THE PROFESSION IN GERMANY

THE German medical profession has had in the past a very high standard of scholarship, and a high degree of specialisation; but it has been very rare for a physician to come into the foreground as spiritual leader or as the true helper of suffering mankind, as defender of the poor and oppressed. One name, Rudolf Virchow, can be mentioned. To him science, the healing art, and culture are endlessly indebted. In the middle of last century he took his place in the first rank in the struggle for freedom of thought, for the rights of the people, and against the beginnings of anti-Semitism. Untroubled by the threats of those in authority, he constantly fought for the down-trodden. He felt strong enough to swim against the stream.

In the last decades, however, the leaders of the medical profession have, as a rule, sided with reaction. In the last war they were willing tools of the militarists. In the need for “sticking it” they helped, against their better knowledge, in deluding the people as to the true position. Their behaviour at this time is, above all, responsible for the breakdown of faith in the profession.

This lack of firm convictions in the profession made the rapid spread of Fascism possible. Few withstood the lies and stupidity or fought against the loss of freedom of thought and the enslavement of a whole people. The leaders of the profession suffered the loss of rights, and were hounded out of their positions by colleagues with whom they were in close personal contact. Sauerbruch, who might have personified the conscience of the nation, only for a moment resisted being forced to dismiss his intimate colleagues and assistants. Protected by his international fame, he could have said something in favour of his shamefully persecuted colleagues, but found it better to serve the Nazi regime and broadcast in support of Hitler.

Another, Dr. Seiler (first Chairman, Association of Physicians of Dusseldorf), became prominent in August of this year when he ordered the disciplined medical profession, in agreement with the Nazi officials, to boycott and ruin financially the Catholic hospital of St. Mary. In this famous hospital more than 50 per cent, of the governors, the staff, and the patients had the courage to vote “No” to Hitler. The voting was supposed to be free and secret, but since it took place an order has been made by Dr. Seiler: “That it is forbidden to send patients to the St. Mary Hospital. Those German physicians who do so in spite of this prohibition, I will publicly expose by leaflet. Heil Hitler! ”

Such is the shameful position of the “leaders” of the present medical profession with whom we do not wish to identify the large number who still stand on the side of culture and Socialism. The time will come when the German nation as a whole will have freed itself from the madness of nationalism. One cannot foretell if these physicians will be able to forgive themselves for the aid and support they have given to this criminal regime. But it is certain, we Socialist physicians can never forgive or forget.

(By Dr Silva, in “Internationales Aertztliches Bulletin,” September, 1934.)

ARCHITECTURE AND HEALTH

ARCHITECTURE is one part of human activities which is undergoing rapid changes, and many of those changes are closely connected with health. It was therefore appropriate that the London and Home Counties branch of the S.M.A. should have a well-attended meeting on October 10th to hear a lecture on this subject by Mr. G. Samuel, A.R.I.B.A. The speaker gave a very detailed description of the present-day aims of architects, who now regard building from the point of view of fulfilment of social functions. Having described the fundamental needs of modern society in housing—economic, aesthetic, healthy, and well-ventilated and warmed houses—he gave, by lantern slides, many illustrations of how these could be achieved contrasted with examples of out-of-date houses. Many points of medical interest were raised, and, as was emphasised by many who took part in the discussion which followed the lecture, there are still many questions in ventilation and in heating which the medical profession needs to study if the architect is to be assisted to build the best houses.

Similar problems arise in the case of buildings designed for medical purposes, but there are also a large number of important points to be dealt with specially in the case of hospitals. This is a subject which cannot be too much discussed at the present. It is recognised that many hospitals all over the country are hopelessly out of date, and in the L.C.C. area it is hoped we will see some of the really dreadful old hospitals demolished and new buildings erected. One question that will cause controversy is that of the height to which hospitals should be built. If, as many consider, a hospital should have not less than 800 beds with all the special departments needed for such an establishment, it is obvious that if confined to three or four floors it will have to be spread over a very wide area with miles of corridors. There would be many advantages in building upwards, so that, given enough lifts corridors would be reduced to minimum. In this connection the speaker showed some pictures of the proposed “Hospital City of Lille (France),” which deserves close study. The architect (Paul Nelson) has worked out all the details for a complete hospital city, and he believes that it could best be done by building upwards to height of twenty-six floors. His plan for hospital and medical school seems on paper, perfect in every detail, but it is suggested that many patients would have very strong objections to being nursed at such a height above ground.

There are many other problems about which the medical profession will have to make up its mind; there can be no question that the conception of medical science as a preventive as well as curative science will play an important part in shaping contemporary architecture. The architect who gives us airy, bright, quiet, an efficient buildings will be of great service to the campaign for a healthier nation. D. P. H.

JOIN THE S.M.A.

Secretary: Dr. C. W. BROOK, 72, Balkam Park Road, London, S.W.ia.

MOVEMENTS

NO great developments towards a socialised medical service seem to have taken place since our last issue. But the work goes on with considerable vigour. Many of our most active members are very fully occupied by their work on the London County Council, and are concerned, largely, with pushing on the detailed development of hospitals under that body’s control.

Much discussion still goes on over the question of malnutrition, and a joint meeting of various organisations interested in the problem has recently been held. One of the most important papers dealing with an aspect of this subject has appeared in “The Medical Officer,” and gives many figures for the heights and weights of school children in a district near London. The writer, Dr. Victor Freeman, has examined the figures for over nine hundred children. While the averages compared favourably with those of other investigators, he demonstrates that the height-weight ratio is closely related to the incidence of certain physical defects and illnesses. Children who were above the average had the smallest proportion of defects, while those below the average had the highest percentage of defects. As the writer points out, a survey such as he has made for one district should be carried out everywhere, and would give a very accurate picture of the physique of the community as a whole.

A writer in our last number drew attention to the need for a consideration of the milk problem in its various aspects. Since then arrangements have been made to supply school children with milk at a reduced price. As usual, however, the regulations do not appear to cover all children, and in some districts the arrangement is not being carried out. Nevertheless, the present distribution should benefit many children, and it is a start in the right direction.

The Labour Party Conference did not discuss the motion standing in the name of the Socialist Medical Association. It may not have been as important a motion as should be put forward by the S.M.A., but before next year steps must be taken to see that our policy has its proper place on the agenda, and if possible the conference must be made to see that health is of primary importance, and that the S.M.A. is the organisation which can give the Movement an authoritative statement on the subject. It would be easier, if one judges from certain columns in the “Daily Herald,” to get our views put forward if we advocated any—or all—of the non-medical methods of treating disease. The Socialist Movement harbours too large a number of those who, in ignorance of any scientific principles, support the many who pretend to be able to treat disease without any comprehension of how disease is caused. Our emphasis on preventive medicine, which their methods cannot deal with, will prevent them becoming dangerous to a large proportion of the general public, but we must make it clear they can have no place in a State Medical Service.

Onlooker.