Health Means Test ?
By SIR RONALD DAVISON
SINCE 1948 we in Great Britain have had a National Health Scheme which offers us free medical treatment, both the comprehensive variety in the surgery or the home and the specialised services of many kinds in the half-million hospital-beds taken over by the State. But now after four years the scheme is-Mill far from settled down or even working satis- factorily.. Neither the doctors nor the patients are feeling sure of it. The only person who has quite made up his mind is the Chancellor of the Exchequer, who doesn't like it because he has to find at least £450,000,000 a year for it. That is far more money than his predecessors in 1948-51 estimated for—more in fact, than he can afford in these post-war years. So he is calling for economies; whereas the operators of the scheme, on the other hand, are proving that the real need is for a lot more money to make the N.H.S. work even adequately. There is no end to it except economic ruin.
This is disappointing. Those of my friends who had always had a hand in social planning were pleased enough with the Beveridge Report (1943) which put on the stage successfully the so-called National Insurance Scheme for All and Every- thing." This cautious contributory plan looked like being very useful against post-war unemployment, sickness, old age and destitution in all its forms. All this was a very different proposition from granting various important new services like the Health Service free to all, without regard to income; but that is the modern fashion, and that is what our recent legis- lators, who implemented the schemes of 1943, have done.
The result is that today National Insurance is going strong, paying its benefits and making a handsome annual profit from its tripartite contributory income, whereas long faces were already drawn in 1951 at the bills coming in for the free services like the National Health, Children's Allowances and free food subsidies for all. These are all looking very shaky today, and the worst of it is that they are imparting their weakness to free elementary education up to fifteen. We obviously cannot afford them all. I venture to assert that neither the Webbs, who are dead, nor W.H.B. (Lord Beveridge), nor the Family Welfare Association (ex C.O.S.), both of whom are very much alive, would have made such a•hopeless mess of this British legisla- tion for the Welfare State. They would never have abandoned all measurement of money and means in the pockets of those who lodged claims for this or that social service; certainly not for a complete National Health Service. The legislators of , our Welfare State were clearly the wrong people to handle the job. It was not for lack of advice; they lost their heads. We straitly warned there that free bottles of medicine for all and free hospitals would spell both moral and financial bankruptcy. You could put a crude ceiling to your free schemes and say " Nobody over £500 a year to come in," as they do on the Continent; or you could establish a great national health service, but not a free one, and charge according to means with relief according to need. You should certainly charge £2 or £3 per week for bed and board in hospitals and nursing-homes. At what stage the new National Poor Law should be called in to do its proper job of assessing the need for partial or total remission of costs is an important detail. I think it should do the whole job. You would get a more fair and uniform standard of public charity applied over the whole country, and the National Assistance Board today is underworked. However, the hot-headed Governments of 1945-51 decided to take the plunge into a free offer, and now we see the con- sequences. The doctors are overworked in their surgeries, especially if they have 4,000 or 5,000 free patients enrolled on their lists. They cannot distinguish between the genuine and the spurious halves of their waiting-room; so all alike are submitted to long waits. The doctor gives them personal attention for an average time of two minutes per head (which is quite a lot), and then sends them home with an order for a free bottle of medicine to keep them quiet. But the cost to the taxpayer of all these surgeries and the half-million hospital-beds is rapidly growing beyond all bounds. It began to frighten even the recent Labour Ministers, when they wanted the money for other purposes. No realistic estimates had been made beforehand, and in 1950 the " spectacles " department cost twenty times the original figure. Teeth were in a similar case.
At present the grand total is piling up to about £450 million per annum, but this is not the limit yet. We need a much larger number of doctors and dentists and hospital-beds to meet the full demands of morbidity, and they will all cost more money. Nor do the advances of medical science bring much hope; in this century they have, on the whole, resulted in much increased expenditure. It does not pay the modern State to save human life.
These astronomical budgets from the National Health Service, not to mention the rest of the Welfare budget, must very soon frighten the nation into some action. We have taken on more than we can afford in this post-war world. So far the only Government reactions have been the imposition of a few small standard levies, 'which the Minister of Health hopes may save £20 million in a full year. That is not much out of an estimated total of £500 million for 1953. He will have to pluck up his courage again, and attack the excessive staffs and administrative costs of our half-million hospital- beds. And why should he not charge in-patients as much as they can afford for their bed and board in hospitals ? The fact is that we have allowed ourselves to make a bugbear of the Means Test. We cannot forget the impact of the old local Poor Law system with its Relieving Officers upon the unem- ployed in the 1930s. We shudder at the thought of any assessment of needs, which is, after all, not such a barbarous invention and, anyhow, is indispensable at some junctures of a taxpayer's life. Today it is a very mild affair, and many people find it quite a pleasure to be means-tested by the officers of the National Assistance Board.
Thus we could safely restore all the free medical services to a cost basis; i.e., the patient pays for his treatment if he can and if he says he cannot the -N.A.B. officer is called in. That would be a sensible course, and would eliminate this unwholesome dichotomy growing up between a doctor's private practice and his panel lists. Or we can, of course, adopt a somewhat different system which will save Chancellors of the Exchequer a lot of money. We can turn for salvation, as they do in Russia, to a business-like Compulsory Medical Service and do the job thoroughly. We shall find at last that prevention is much cheaper than cure, and our doctors wilr be enjoined to keep us all, not only free from infection, but fit for productive work. Truly, we can have a free public health service, but it will have to be a compulsory and preventive one.
Can our democracy be trusted to settle this pressing matter ?
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