Medicine and Duty
By the Rt. Hon. WALTER ELLIOT, M.P.
DR. FFRANGCON ROBERTS recently wrote a close and painstaking study of the very problem which has so engaged the attention and the time of Parliament, the problem of the Health Services, their conduct and their cost. His book* has thus become since its publication more and more topical, instead of less. After the recent declarations of Opposition leaders that, when they recover power, they will reverse not only the Conservative legislation but their own, and bring to an end all health-service charges of every kind, Dr. Roberts' work has become in fact indispensable to every serious student of this question.
A problem indeed it is." Sir William Beveridge, after a careful review of the whole field, working with all the knowledge and all the authority of the great Government departments at his command, estimated in 1942 that the cost of a compre- hensive health service for Great Britain would be £170,000,000 a year. Furthermore, he predicted that it would not exceed that sum, since development would be cancelled out by reduc- tion in the need for the service. The cost is now running at some £400,000,000 a yeaf; and, as everyone knows, the bitterest language is being used about any attempts to limit it to that figure. Even allowing for the fall in the value of money since 1942, this figure represents a most formidable previous under- estimate.
There are, indeed, several miscalculations which it is diffi- cult to explain. The Government White Paper of 1944 believed that " it would probably be several years before the net expenditure on the new dental services reached £10,000,000, and on the new ophthalmic services, £1,000,000." In the first year of operation, however, the dental services cost £28,000,000 and the ophthalmic services £20,000,000. Anyone could see that the dental services were going to reach a figure only governed by the endurance of the dentists at the chairside of their patients, and that on an unlimited basis of new dentistry widespread injury to the existing dental services was inevitable. Indeed, the National Government had already pointed out officially that the existing supply of dentists simply would not cover a universal service, and that without some arrangement of priorities a scramble, bringing all sorts of trouble in its wake, was unavoidable. In bringing the service into operation, these points were just ignored. But the difficulty obviously goes much deeper than that. Dr. Ffrangcon Roberts contends that our whole approach to the question of a universal, free health service disregards the outstanding fact that the unparalleled progress which has been made in the last fifty years towards the conquest of disease has resulted in, or at least has been accompanied by, a greater demand for treatment, and a greater inadequacy of supply, than has ever existed in our history. This, he says, may have four possible explanations: (1) that modern diagnosis has * The Cost of Health. Dr. Ffrangcon Roberts. (Turnstile Press. 16s.) revealed more disease; (2) that real ill-health is increasing; (3) that factors other than ill-health are stimulating demand; (4) that the advance of medicine itself is increasing the true incidence of disease. These are fundamental problems. They have, alas, entered very little into the recent discussions in Parliament. In fact, it may be said that in the twenty-three hours' debate in Committee on the first five lines of the Health Services Bill, which.brought about the use of the guillotine to .get the consideration of the Bill concluded at sail, not one of these topics was so much as broached.
We are certainly facing a difficult question of administration. In view of the declaration of the Opposition, already mentioned, that it will, immediately it has the power, reverse the acts of its predecessors, whatever the circumstances—a declaration which has been paralleled in the case of other legislation—it may be that we are in the presence of a problem affecting democratic government itself. All the more reason, therefore, for discussing and working over these questions outside Parliament. The author of this volume starts with definitions. Ill-health is defined as " the failure of body and mind to adapt themselves to the environment, a failure which is the resultant of two factors, the imperfection of human nature and hostility of the environment." Clearly, a service setting-out to connect these two factors, by methods which will not relate the task to the immediate resources either of the individual or of society, will have a formidable endeavour before it.
This leads to Dr. Ffrangcon Roberts' main contention—that the demand for such a connection is really unlimited, that it might, and probably will, involve the absorption of so much of the national resources as actually to impair the general effort for production on which everything depends. In other words, that you may have a hypochondriac nation just as much as a hypochondriac individual, and that, if a hypochondriac does not have a comfortable independent income he will, before very long, perish of inanition. Even if we consider this to be an exaggeration, and hold that the natural instincts of man to be up and about will overcome his equally natural instincts to enjoy, and to indulge in, being coddled, there is a further modern danger which everyone-will admit. The very success of medicine in prolonging life means that a greater and greater proportion of our people will reach the higher age-groups, in which illness, by the very nature of things, will be chronic, and eventually incurable, rather than acute and yielding to treat- ment. An older nation—or a nation of older people—has certain advantages over a younger nation. The smaller pro- portion Of children means more spare time for the grown-ups; the number 'of women at present working in factories, for instance, would be impossible if they had all families of young children to look after. But such a society will develop troubles of its own—and of these the proportion of individuals with the chronic ailments of advancing years will not be the least.
Much of this difficulty arises from the decision to cut off health service almost entirely from both a payment and an insurance basis. If it is considered too great a burden to ask someone demanding treatment to make some personal payment towards its cost, it should not be out of the question to ask for some more adequate collective payment, some contributory scheme. If a rise in demand on the health services were followed by a rise in the insurance payment required to keep the scheme solvent, cause and effect would reveal their connection much more directly than they do at present. Otherwise, the alternative is eventually, and sooner rather than later, the State Medical Service. Its simple sanction is crystallised in the words with which this article is headed. The Medical Officer's. task is not principally to keep the battalion fit._ It is to keep the battalion fit for work. He issues his judgement. There is, in practice, no appeal. A Gloucester private turning up in the lines of the Sherwood Foresters to seek another medical opinion, or to con- tend that his case is not receiving proper treatment, is not listened to with any great attention. In the first place he will be chivvied away. If he persists he will be crimed. That is what lies at the end of the present road for the community as a whole.
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