The Nationalisation Of Health

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Title:     The Nationalisation Of Health
Author: Havelock Ellis [More Titles by Ellis]

It was inevitable that we should some day have to face the problem of medical reorganisation on a social basis. Along many lines social progress has led to the initiation of movements for the improvement of public health. But they are still incomplete and imperfectly co-ordinated. We have never realised that the great questions of health cannot safely be left to municipal tinkering and the patronage of Bumbledom. The result is chaos and a terrible waste, not only of what we call "hard cash," but also of sensitive flesh and blood. Health, there cannot be the slightest doubt, is a vastly more fundamental and important matter than education, to say nothing of such minor matters as the post office or the telephone system. Yet we have nationalised these before even giving a thought to the Nationalisation of Health.

At the present day medicine is mainly in the hands, as it was two thousand years ago, of the "private practitioner." His mental status has, indeed, changed. To-day he is submitted to a long and arduous training in magnificently equipped institutions; all the laboriously acquired processes and results of modern medicine and hygiene are brought within the student's reach. And when he leaves the hospital, often with the largest and noblest conception of the physician's place in life, what do we do with him? He becomes a "private practitioner," which means, as Duclaux, the late distinguished Director of the Pasteur Institute, put it, that we place him on the level of a retail grocer who must patiently stand behind his counter (without the privilege of advertising himself) until the public are pleased to come and buy advice or drugs which are usually applied for too late to be of much use, and may be thrown away at the buyer's good pleasure, without the possibility of any protest by the seller. It is little wonder that in many cases the doctor's work and aims suffer under such conditions; his nature is subdued to what it works in; he clings convulsively to his counter and its retail methods.

The fact is--and it is a fact that is slowly becoming apparent to all--that the private practice of medicine is out of date. It fails to answer the needs of our time. There are various reasons why this should be the case, but two are fundamental. In the first place, medicine has outgrown the capacity of any individual doctor; the only adequate private practitioner must have a sound general knowledge of medicine with an expert knowledge of a dozen specialties; that is to say, he must give place to a staff of doctors acting co-ordinately, for the present system, or lack of system, by which a patient wanders at random from private practitioner to specialist, from specialist to specialist _ad infinitum_, is altogether mischievous. Moreover, not only is it impossible for the private practitioner to possess the knowledge required to treat his patients adequately: he cannot possess the scientific mechanical equipment nowadays required alike for diagnosis and treatment, and every day becoming more elaborate, more expensive, more difficult to manipulate. It is installed in our great hospitals for the benefit of the poorest patient; it could, perhaps, be set up in a millionaire's palace, but it is hopelessly beyond the private practitioner, though without it his work must remain unsatisfactory and inadequate.[1] In the second place, the whole direction of modern medicine is being changed and to an end away from private practice; our thoughts are not now mainly bent on the cure of disease but on its prevention. Medicine is becoming more and more transformed into hygiene, and in this transformation, though the tasks presented are larger and more systematic, they are also easier and more economical. These two fundamental tendencies of modern medicine--greater complexity of its methods and the predominantly preventive character of its aims--alone suffice to render the position of the private practitioner untenable. He cannot cope with the complexity of modern medicine; he has no authority to enforce its hygiene.

The medical system of the future must be a national system co-ordinating all the conditions of health. At the centre we should expect to find a Minister of Health, and every doctor of the State would give his whole time to his work and be paid by salary which in the case of the higher posts would be equal to that now fixed for the higher legal offices, for the chief doctor in the State ought to be at least as important an official as the Lord Chancellor. Hospitals and infirmaries would be alike nationalised, and, in place of the present antagonism between hospitals and the bulk of the medical profession, every doctor would be in touch with a hospital, thus having behind him a fully equipped and staffed institution for all purposes of diagnosis, consultation, treatment, and research, also serving for a centre of notification, registration, preventive and hygienic measures. In every district the citizen would have a certain amount of choice as regards the medical man to whom he may go for advice, but no one would be allowed to escape the medical supervision and registration of his district, for it is essential that the central Health Authority of every district should know the health conditions of all the inhabitants of the district. Only by some such organised and co-ordinated system as this can the primary conditions of Health, and preventive measures against disease, be genuinely socialised.

These views were put forward by the present writer twenty years ago in a little book on _The Nationalisation of Health_, which, though it met with wide approval, was probably regarded by most people as Utopian. Since then the times have moved, a new generation has sprung up, and ideas which, twenty years ago, were brooded over by isolated thinkers are now seen to be in the direct line of progress; they have become the property of parties and matters of active propaganda. Even before the introduction of State Insurance Professor Benjamin Moore, in his able book, _The Dawn of the Health Age_, anticipating the actual march of events, formulated a State Insurance Scheme which would lead on, as he pointed out, to a genuinely National Medical Service, and later, Dr. Macilwaine, in a little book entitled _Medical Revolution_, again advocated the same changes: the establishment of a Ministry of Health, a medical service on a preventive basis, and the reform of the hospitals which must constitute the nucleus of such a service. It may be said that for medical men no longer engaged in private practice it is easy to view the disappearance of private practice with serenity; but it must be added that it is precisely that disinterested serenity which makes possible also a clear insight into the problems and a wider view of the new horizons of medicine. Thus it is that to-day the dreamers of yesterday are justified.

The great scheme of State Insurance was certainly an important step towards the socialisation of medicine. It came short, indeed, of the complete Nationalisation of Health as an affair of State. But that could not possibly be introduced at one move. Apart even from the difficulty of complete reorganisation, the two great vested interests of private medical practice on the one hand and Friendly Societies on the other would stand in the way. A complicated transitional period is necessary, during which those two interests are conciliated and gradually absorbed. It is this transitional period which State Insurance has inaugurated. To compare small things to great--as we may, for the same laws run all through Nature and Society--this scheme corresponds to the ancient Ptolomaean system of astronomy, with its painfully elaborate epicycles, which preceded and led on to the sublime simplicity of the Copernican system. We need not anticipate that the transitional stage of national insurance will endure as long as the ancient astronomy. Professor Moore estimated that it would lead to a completely national medical service in twenty-five years, and since the introduction of that method he has, too optimistically, reduced the period to ten years. We cannot reach simplicity at a bound; we must first attempt to systematise the recognised and established activities and adjust them harmoniously.

The organised refusal of the medical profession at the outset to carry on, under the conditions offered, the part assigned to it in the great National Insurance scheme opened out prospects not clearly realised by the organisers. No doubt its immediate aspects were unfortunate. It not only threatened to impede the working of a very complex machine, but it dismayed many who were not prepared to see doctors apparently taking up the position of the syndicalists, and arguing that a profession which is essential to the national welfare need not be carried out on national lines, but can be run exclusively by itself in its own interests. Such an attitude, however, usefully served to make clear how necessary it is becoming that the extension of medicine and hygiene in the national life should be accompanied by a corresponding extension in the national government. If we had had a Council of National Health, as well as of National Defence, or a Board of Health as well as a Board of Trade, a Minister of Health with a seat in the Cabinet, any scheme of Insurance would have been framed from the outset in close consultation with the profession which would have the duty of carrying it out. No subsequent friction would have been possible.

Had the Insurance scheme been so framed, it is perhaps doubtful whether it would have been so largely based on the old contract system. Club medical practice has long been in discredit, alike from the point of view of patient and doctor. It furnishes the least satisfactory form of medical relief for the patient, less adequate than that he could obtain either as a private patient or as a hospital patient. The doctor, on his side, though he may find it a very welcome addition to his income, regards Club practice as semi-charitable, and, moreover, a form of charity in which he is often imposed on; he seldom views his club patients with much satisfaction, and unless he is a self-sacrificing enthusiast, it is not to them that his best attention, his best time, his most expensive drugs, are devoted. To perpetuate and enlarge the club system of practice and to glorify it by affixing to it a national seal of approval, was, therefore, a somewhat risky experiment, not wisely to be attempted without careful consultation with those most concerned.

Another point might then also have become clear: the whole tendency of medicine is towards a recognition of the predominance of Hygiene. The modern aim is to prevent disease. The whole national system of medicine is being slowly though steadily built up in recognition of the great fact that the interests of Health come before the interests of Disease. It has been an unfortunate flaw in the magnificent scheme of Insurance that this vital fact was not allowed for, that the old-fashioned notion that treatment rather than prevention is the object of medicine was still perpetuated, and that nothing was done to co-ordinate the Insurance scheme with the existing Health Services.

It seems probable that in a Service of State medical officers the solution may ultimately be found. Such a solution would, indeed, immensely increase the value of the Insurance scheme, and, in the end, confer far greater benefits than at present on the millions of people who would come under its operation. For there can be no doubt the Club system is not only unscientific; it is also undemocratic. It perpetuates what was originally a semi-charitable and second-rate method of treatment of the poorer classes. A State medical officer, devoting his whole time and attention to his State patients, has no occasion to make invidious distinctions between public and private patients.

A further advantage of a State Medical Service is that it will facilitate the inevitable task of nationalising the hospitals, whether charitable or Poor-law. The Insurance Act, as it stands, opens no definite path in this direction. But nowadays, so vast and complicated has medicine become, even the most skilful doctor cannot adequately treat his patient unless he has a great hospital at his back, with a vast army of specialists and research-workers, and a manifold instrumental instalment.

A third, and even more fundamental, advantage of a State Medical Service is that it would help to bring Treatment into touch with Prevention. The private practitioner, as such, inside or outside the Insurance scheme, cannot conveniently go behind his patient's illness. But the State doctor would be entitled to ask: _Why_ has this man broken down? The State's guardianship of the health of its citizens now begins at birth (is tending to be carried back before birth) and covers the school life. If a man falls ill, it is, nowadays, legitimate to inquire where the responsibility lies. It is all very well to patch up the diseased man with drugs or what not. But at best that is a makeshift method. The Consumptive Sanatoriums have aroused enthusiasm, and they also are all very well. But the Charity Organisation Society has shown that only about 50 per cent. of those who pass through such institutions become fit for work. It is not more treatment of disease that we want, it is less need for treatment. And a State Medical Service is the only method by which Medicine can be brought into close touch with Hygiene.

The present attitude of the medical profession sometimes strikes people as narrow, unpatriotic, and merely self-interested. But the Insurance Act has brought a powerful ferment of intellectual activity into the medical profession which in the end will work to finer issues. A significant sign of the times is the establishment of the State Medical Service Association, having for its aim the organisation of the medical profession as a State Service, the nationalisation of hospitals, and the unification of preventive and curative medicine. To many in the medical profession such schemes still seem "Utopian"; they are blind to a process which has been in ever increasing action for more than half a century and which they are themselves taking part in every day.

 

NOTE:

[1] The result sometimes is that the ambitious doctor seeks to become a specialist in at least one subject, and instals a single expensive method of treatment to which he enthusiastically subjects all his patients. This would be comic if it were not sometimes rather tragic.

[The end]
Havelock Ellis's essay: The Nationalisation Of Health

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