A NATIONAL HEALTH SERVICE ?
By SIR ARNOLD WILSON, M.P.
TjAST month saw the publication of Sir Arthur Newsholme's latest book The Last Thirty Years in Public Health (Allen and Unwin. 15s.) and The Seventeenth Annual Report of the Ministry of Health— for 1935. Sir. Arthur Newsholme is master of his material. and uses it to the best possible advantage : he has cast his net very widely ; he touches many themes. and adorns all, for like all great doctors he is a humanist first and last.
It is not without significance that throughout Holy Writ there is no word of anything but praise for physicians except that famous passage in the three Gospels where it is mentioned that a woman " had suffered many things of many physicians, and had spent all that she had, and was nothing bettered, but rather grew worse " (Mark v. 25). Of the other great professions, the priestly and legal, there is no lack of criticism though, in the thirty-eighth chapter of Ecelesiasticus, the writer sets forth the limitations of doctors in terms which ring true two thousand years later. Sir Arthur. like the writer of the book of the son of Sirach, stresses repeatedly the need for an educational system which, vitalised by Christianity, will serve to strengthen the character of every individual. Unless. this can be achieved, there can be no progress.
Sir. Arthur Newsholme has .been to Soviet Russia ; he praises without stint much that he saw there, but reverts uncompromisingly to the conviction that little can come of a system not based upon allegiance to the First as well as the SeCond of Our Lord's Great Com- mandments. But he is satisfied that the desire for personal gain is not a primary motive, not sucha stimulus e3sential for physiCians and surgeons any more than for soldiers and sailors, civil servants or judges, clergy or (dare I add?) Members of Parliament, whose watchword, like that of the new Germany, is " common welfare before self-interest "—Gemeinnutz vor Eigennutz. He is equally convinced that communal efforts to mitigate the struggle for a livelihood will not lead to " moral para- sitism." Symbiosis, to his scientific mind, is as much a social reality and a biological necessity as evolution.
He stresses afresh the lack, in this country, of a unified medical- service, such as exists in the more advanced countries' in Europe, the value of which. is indicated by the fact that sickness and mortality is less, and the expectation of life therefore greater amongst every section Of the population in Germany than in this country. This has long been the case and may not unreasonably be ascribed, at least in part, to the existence in that country of a really comprehensive public health service, such as exists in several other countries, including Japan.
Mr. Lloyd George's Health Insurance Bill of 1911 was a great forward step, though it was at the :time, as - eve sometimes forget, as iiiipopulai with the 'Left Wing in Parliament as with the extreme Right. Because it was not preceded by reform ol' local govern- ment, of which we had an instalment from Mr. Neville Chamberlain in 1929, it has not given us anything like full value for the vast expenditure involved, for all concerned therewith la bour under peculiar disadvan- tages. The administration of Health Insurance is at its best when it is regional. In this country, on the contrary, it is in the hands of 4.400 independently • administered approved societies and branches. over- lapping everywhere. so that there may be living in a single street members of fifty or inure different approved societies. These members will all be paying contribu- tions at standard rates, but what they get in return may vary so widely as to leave a feeling of resentment against the decisions of a bureaucracy which has long ceased to be " friendly." Five persons out of six will be entitled to dental benefit, provided they are contri- butors of three years' standing : in other words, when their wages are lowest, and the preventive value of dental treatment greatest, they arc ineligible. This is the reason why bad teeth are the main cause of rejection of recruits for the Fighting Forces. Three out of four Will be entitled to ophthalmic benefit and to conva- lescent home treatment, but only one in ten to hospital benefit, and one in thirty to convalescent allowances. The total amount allocated to dental treatment for the past three years is about as much as that paid to chemists for drugs--about t2 million, which is less than 10 per cent. of the total expended on benefits. What middle-class family in normal health expects to pay doctors ten times as much as dentists ?
These figures, taken from the Report of the Ministry of Health for 1934, which was published, even later than usual, at the end of October, give point to Sir Arthur Newsholme's considered comments on the wastefulness of the system. It is in no real sense " national " ; those who need most care are, in general, least entitled to it, e.g., those long unemployed and those living in areas where sickness is relatively greatest. over a long period and where, as the Registrar-General's return shows, expectation of life is relatively shorter.
The curative aspect of the Health Insurance system is, as he points out, at present divorced from the pre- ventive functions of Public Health. The absence of reliable statistics of sickness on a regional basis militates against effective action, and those who most need pro- tection, viz., adolescents, women not gainfully employed, and,. for the most part,. the insured workers' dependants, are not within the scope of the scheme.
Continued unemployment in sonic areas and an influx of workers in others have been a severe strain upon the systeni, and those who work it. The whole machine should be overhauled ; the approved societies should be reorganised upon a regional basis, - or absorbed into a genuinely national service.
One point not dealt with by Sir Arthur Newsholme is the fundamental question whether the system can or should be run on insurance lines with an actuarial basis. Should financial reserves be laid up, in good times and in bad, or should we lay down what we consider to be the best service we can afford for a period of, let us say, seven years, and levy such contributions as we estimate to he requisite to supply such services, leaving the Treasury to pocket any surplus, or make good any deficit ?
In most commercial insurance schemes the insured person is the real safeguard against the contingency covered. Motorists are anxious to avoid accidents, workmen to avoid the physical pain and financial loss inseparable from any mishap which entitles them to compensation. But these inhibitions scarcely operate in the domain of medical, dental or maternity benefit or in the case of tuberculosis or other special treatments.
The other outstanding point to which no allusion is made in the book under review, or in its predecessors, is the vital difference between the British and nearly all other Health Insurance schemes in force in civilised countries. Except in Great Britain and America, almost all these schemes include " death benefit " as an automatic and logical culmination of the system.
Our schemes, so far as they have yet been developed, provide for maternity benefit when life begins ; they will, before long, cover the insured person's life from the cradle to the grave. But no provision is made here by the national schemes for the greatest expense of all— that of sepulture, upon which the survivors must spend a sum which is seldom less than £20 and may be as much as the household earns in two or three months.
• Our pensions cease on the day of death. ha most parts of Europe a final payment of as much as 20 weeks allowance is made, in order to ensure that the veteran, whom it was the concern of the State to keep in decent conditions during his life, shall not create a burden on his relatives, if he has any, or suffer the crowning indignity of a pauper funeral. Similar provisions exist in relation to persons insured under national health schemes in most countries, including Japan.
Not until this " benefit " is added to others can we regard our system as being either modern or well adapted to the needs of those for whom it is provided.
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