FOOTNOTES:

[9] The Wesley M. Carpenter lecture delivered October 2, 1919, before the New York Academy of Medicine.

[10] Thus Mr. Bishop Harman, an ophthalmic surgeon, and a member of the Council of the British Medical Association, says:

“In my out-patient clinic 60% of the patients are insured persons who attend for treatment that is essential to their industrial efficiency.... A scheme of medical benefit which does not provide for specialist service and for institutional treatment is no scheme, it is poorer in status than the Poor Law provision which does all these things.” (British Medical Journal, Mar. 15, 19).

Dr. R. Sanderson, of Brighton, writing on behalf of medical practitioners, says:

“We are the victims of a half-fledged, inadequate piece of legislation which is founded apparently on the supposition that disease can be dealt with effectually by giving bottles of medicine or liniment to the sick, or that if this fails and the sick get worse, they can be sent to one of the overcrowded voluntary hospitals with which the legislature has nothing whatever to do. Anything more unsatisfactory to the sick, or demoralizing to us as a profession, it is hard to imagine.”

He then proceeds to advocate an urgent need of the profession, viz: the establishment of an adequate number of auxiliary hospitals throughout the country, staffed by teams of general practitioners, to which all practitioners can have access, and to which they can send cases requiring clinical observation of any kind, rest or treatment that cannot be carried out in the sick person’s home. (British Medical Journal, July 19, 19.)

Dr. Howarth, Medical Officer of Health of the City of London, and Dr. B. A. Richmond, Secretary of the London Panel Committee, affirm “the limitation of medical benefit to insured persons alone cannot continue. Another service has been added to the many competing classes of state treatment”; and they bring out the fact that personal contributions of insured persons are swallowed up in supplying the sickness and disablement benefit, and contribute nothing to the cost of the sanatorium benefit, maternity benefit, or medical benefit.

Dr. H. S. Beadles, Secretary of the Stratford & West Ham Panel Committee, says: “The British Medical Association should fearlessly acknowledge that the attendance under the National Insurance Act, which is itself a part-time State service, is an absolute failure and amounts to little more than first aid, carried on at an enormous cost.”

CHAPTER IV
Insurance and Health[11]

So far as a majority of the population are concerned, it is necessary to realize that they are never far removed from the line dividing destitution from adequacy, using the word destitution to mean insufficiency or lack of some provision essential for health and continued welfare.

It may be urged that this is owing in large measure to the improvidence or thriftlessness of the wage-earners who are chiefly concerned; but such a statement fails to appreciate the higher standard of conduct and the greater self-denial which is demanded from weekly wage-earners than from ourselves, if out of their wages provision is to be made for a “rainy day,” without affecting unfavourably the present health of the worker or his family.

The general appreciation of the above considerations has led to the provision of non-contributory old-age pensions in the United Kingdom; and similar sentiments have led in many countries to compensation for accidents at the expense of employers; and to the various national systems of insurance against sickness. With the principle of sickness insurance there can be no quarrel. It is the substitution of coöperative for individual provision, thereby distributing some of the loss and eliminating some of the risk of suffering from illness.

The value of any system of sickness insurance, however, must necessarily be judged by several criteria.

Criteria of Value of Insurance

Is the adopted system one which is equitable in its incidence and economical in its administration; and does it supply maintenance during sickness adequate for the needs of the patient and his family, while at the same time offering no temptation to the patient to continue on the sick funds, when his condition no longer necessitates this?

In the case of the English National Insurance Act, these questions unfortunately cannot be answered completely in the affirmative.

The finance of the Act arranges for the uniform contributions (differing for each sex) from some thirteen million persons, living under most diverse conditions, to furnish equal benefits (differing for each sex) to all insured persons, irrespective of age, locality, or occupations; while at the same time some 23,000 independent insurance societies continue to administer the distribution of money benefits, each with its own segregated experience, some prosperous, others owing to excessive sickness almost bankrupt. There is the remote possibility for each society to pay additional benefits if justified on the quinquennial valuation.

Substantially men and women have been placed on a similar financial basis. The sickness of pregnancy apparently was overlooked; and for this and other reasons the insurance funds for women are financially inadequate for the benefits promised.

On the point of equity, it must be admitted that any system of so-called insurance which, like that of the English Act, excludes a large proportion of the population who, while paying in taxes in aid of the insured, require but do not receive their benefits, is contrary to the principle that any expenditure of Government funds should enure to the whole community in need of the provision in question.

The provision of 10 shillings a week for incapacity lasting 26 weeks (7s. 6d for women), followed by 5s. a week disablement benefit, although inadequate provision for family maintenance during sickness undoubtedly is helpful. It is mischievous when in consequence of this provision, the patient is tempted to remain at home under unsatisfactory domiciliary treatment, instead of receiving the shorter and more successful institutional treatment, which should have been given.

As to economy of administration, I can speak only with reserve; but it requires little imagination to appreciate that the numerous migrations of wage-earners imply great difficulties in book-keeping as well as in securing insurance medical attendance, and that a very high percentage of the total insurance funds is swallowed up in elaborate and meticulous account keeping.

The point as to malingering can best be considered in connection with a discussion of the

Medical Benefit

This consists of such medical treatment, at home or at the office of the panel doctor,[12] as “can consistently with the best interests of the patient be properly undertaken by a practitioner of ordinary professional competence and skill.”

The Act itself promised “adequate medical attendance and treatment,” but under regulations this has been limited, so that in practice it means chiefly the treatment only of minor ailments. Thus (a) there is no provision for hospital treatment of patients needing this, except the Sanatorium provision for tuberculosis; (b) with the same exception, there is no provision for expert services. A patient requiring operative treatment for fractures, for an amputation, or an operation for appendicitis, or needing treatment for some affection of the eyes, or nose, or throat, or ears, or the intravenous treatment of syphilis is excluded from medical benefit. So likewise are dental requirements. (c) There is no provision for pathological diagnosis, except such as is common to the entire population, and no X-ray diagnosis, except possibly for tuberculosis. (d) There is no provision for nursing assistance.

In view of the unequal distribution and insufficient provision of hospitals for the general population, of their inaccessibility to large masses of patients, and of the insufficiency of the present provision for the scientific aid to treatment which modern medicine demands for insured and non-insured alike, it is evident that the provision for medical treatment under the Act is unsatisfactory and inadequate, and that it conduces to prolonged illness, which treatment provided on more satisfactory lines would avoid.

To state adequately the defects of the medical provisions of the Insurance Act a long address would be required. They are, however, generally well known, and their existence and seriousness is admitted by all. (See also page [90].)

It is necessary, however, to say more on the

General Practitioner Treatment

provided under the Act. Every insured person is allowed to choose his own doctor within a given distance. In practice very few patients change their doctor at a fixed time each year as they are allowed to do; and a considerable proportion of insured persons do not trouble to choose a doctor at all. The free choice of doctors is rather a sentimental than a real demand. The panel doctor is paid an annual capitation fee, and hitherto no limit has been placed on the number who may place themselves on his roll. The domiciliary treatment given by some doctors is entirely satisfactory within the limits stated above. Commonly, however, it is as unsatisfactory as the “club practice” which preceded it, and against which the British Medical Association inveighed. It involves a continuance of the mischievous ideal of medical practice of the past, a conception still held by a large portion of the public to its own detriment, that a hasty inquiry, a perfunctory examination, and a bottle of medicine, represent the best that scientific medicine can offer a patient. Had there been organized a chain of medical services for all needing it, including consultations and expert assistance when needed, every patient having the right to call for these when dissatisfied with his panel doctor, including also hospital provision and nursing as required, what a different story could now be told!

It is probable that some at least of these additional services will be added gradually; but it must be noted that the present payments of the insured will not suffice to pay for them; and that if they are to be provided,—as they will probably need to be,—out of public funds, the general public are in equity entitled to these services even though they are not insured.

If these complete services were provided, the medical treatment now provided largely at the expense of the community could be made a means for advancing the public health. This it can not at present claim to be. For nothing is more certain than that the prompt and adequate treatment of disease curtails its duration, diminishes its severity, and prevents its spread to others.

But even such a service would not fulfil its complete possibilities for good unless it were joined to a system of hygienic supervision of each insured person and of each insured person’s family, this system being organically linked up with the wider public health work of the larger Public Health Authorities.

The chief justification of a national system of insurance against sickness is that it shall be an active auxiliary in the prevention of disease. At present it is doubtful whether any national system of sickness insurance has been so. It has only been so, to the extent to which the medical treatment of the masses of the population has been improved by it; and no such improvement can be claimed for British insurance. The wider possibilities of prevention of illness and elevation of the general standard of health, by making each medical practitioner a family adviser on health more than a practitioner in medicine, have not been realised or even brought within sight.

Evils of the Present Medical Benefit

The inadequacy and unscientific character of the medical treatment given to insured persons are associated with a large amount of lax certification of illness, which is injurious to the character of doctor and patient, besides being unfair to the insurance funds. Those interested in this point should read paragraphs 118, 119, 120, 121, 123, 125 of the Report of the Departmental Committee on Sickness Benefit Claims (Official Report Cd 7687).

There is almost universal testimony of the belief (of representatives of friendly societies) that medical certificates are granted recklessly (par. 119).

Doctors ... feel a difficulty in refusing certificates owing to the possible effect upon their practice.... If a doctor falls out with his patient he loses the entire family (par. 120).

These statements ... are representative of an enormous volume of dissatisfaction with the action of the medical profession.

The Committee state:

We are of opinion that in many cases doctors have given certificates for sickness benefit in circumstances in which these certificates were not justified.

From the standpoint of the conscientious practitioner the present position is profoundly unsatisfactory. He has no official access to arrangements for consultative and expert advice, he has no hospital beds, no skilled nurses. For the patient the position is anomalous and leaves him with but a fragment of what he could reasonably expect under the terms of the Act.

Of the other medical benefit, i.e., the Sanatorium benefit and of the Maternity benefit, I can say only a few words here. The former gives the insured patient little more than in the more enlightened sanitary districts is being provided, independently of insurance, by Public Health Authorities. It would have been practicable to make it obligatory on all Public Health Authorities to provide adequate treatment for all consumptive patients. They are already authorized to do this under Public Health Acts, and the duty could have been, and can still be made, obligatory by regulation. And in that case the connection of the Sanatorium Benefit with the National (Health) Insurance Act would happily cease, and one great obstacle to a really national organization against tuberculosis would disappear.

The Maternity Benefit provides a money payment for each insured woman and for the wife of each insured man on the birth of a child. The money payment is made through the Insurance Societies unconditionally, instead of being made a means of securing that the birth takes place under circumstances favourable to mother and infant. During recent years public health authorities (aided by grants from the Government of one half of the total approved local expenditure) have been making medical and nursing provision for the care of women in pregnancy, in parturition, and during the nursing period, on a rapidly increasing scale, the grants including not only skilled assistance but also domestic aid (home helps) in suitable cases. There can be no question that increased provision in these directions will have a more generally beneficial influence than money payments, and should at least supplement the latter.

To sum up, if the national English system of insurance is to continue, it ought in my view to be shorn of its medical functions and to be limited to money payments during sickness, in return for the weekly contribution made by employees and employers. If it be thought inadvisable to limit the State’s contribution, as in Germany, to what is spent in administration, then in equity the present system of insurance cannot continue to be limited to those now participating in it.

I hold strongly that the State should embark on a much larger scale than at present on

The State Treatment of Disease

The great and fundamental mistake made in the initiation of the English Insurance Act was that in effect it ignored the entire history of the relation of preventive and curative medicine to the State. This history cannot be detailed now: but, briefly, for long years the destitute had been entitled to domiciliary and institutional treatment at the public expense. This medical aid was given by Poor Law Authorities, and their method of doing this work had rendered the benefaction commonly unacceptable. Then Public Health Authorities on a steadily increasing scale found it necessary to treat disease in order the more effectively to prevent it. And so fevers and smallpox, and chronic infective diseases like tuberculosis and syphilis came under treatment, practically for all comers, at the public expense. As already mentioned the fundamental importance of maternity and childhood has also been realised, and the State is now taking an increasing share in ensuring health at these periods of life. And while Public Health Authorities were increasing their activities, Education Authorities began to subject school children to medical inspection, and to treat them for the detected defects, the treatment of which they could not otherwise secure. And so, not to make this sketch too complex, three great central government departments or sub-departments and three sets of local authorities were engaged in medically treating the people at the public expense. This sketch does not include the smaller (nevertheless enormous) amount of treatment of disease by voluntary hospitals. It is safe to state that at any one time one-half of the total treatment of disease is being carried out at the public expense. If the domiciliary treatment of insured persons is worthy to come into the same category as the skilled services mentioned above, the proportion of disease already treated at the public expense greatly exceeds 50 per cent. (Note.—Less than four-ninths of the cost of medical treatment of insured persons comes from the contributions of the insured.)

The complexity of local authorities concerned in the treatment of disease was wilfully increased under the National (Health) Insurance Act; and, contrary to the advice of public health workers and of the Royal Commission on the Poor Laws a golden opportunity for securing the merging of poor law into public health work and for initiating a unified system of State Medicine for all who need it was lost.

Poverty to a preponderant extent is due to sickness. Two statements have recently been made by the Medical Society of the State of New York, viz., that “evidence is against the fact that any considerable amount of impoverishment is caused by illness,” and that they can find no “available evidence that ... in the main, medical attendance in this State is grossly deficient in quantity or grossly defective in quality.” (Monthly Labor Review, January, 1920, p. 256.)

One can admire the optimism, while denying the accuracy of the first statement: of the second statement, as it refers to the State of New York, I can say nothing, except that a statement identical with the one denied above would be literally true for England. In 1907 I wrote, “the coexistent but uncoördinated systems of treatment of disease have failed lamentably to provide what the health of the community requires—means for ensuring effectively the early recognition and proper treatment of all disease” (British Medical Journal, Sept. 14, ’07). That remains broadly true, and no remedy will suffice which does not ensure for every member of the community in essential particulars as good treatment as the most favored now possess.

The socialization of medicine has gone too far, its beneficent effects are becoming too well appreciated, to render it possible, even were it not undesirable and mischievous, to hinder its further extension. We have travelled more than half the road towards the goal of general provision of skilled medical assistance by coöperative means, i.e., out of the communal purse. If this is desirable for elementary general education, it is even more important when the aim is the restoration and the maintenance of the highest attainable level of health for each member of the community, who is willing to share in the offered benefits. If we include the third of the total population who now receive in Great Britain the unsatisfactory medical benefit under the National (Health) Insurance Act, and remember the rapidly increasing scope of voluntary and official institutional treatment of disease, hesitation in accepting the inevitable should be replaced by a determination to guide future developments and to render them efficient and economical. What is good for the public is good also for the members of the medical profession.

If asked to advise on the steps which it is advisable to take in regard to Sickness Insurance in a community which has not adopted a scheme, I should emphasise the prior necessity for the State to secure a completely satisfactory system of public medical care before engaging in the more difficult task of providing monetary payments in sickness. It is well to bear in mind that medical attendance is a form of communal assistance the demand for which does not tend to increase with the supply; whereas monetary benefits have always shown this trend, as demonstrated by the experience of both Friendly Societies and charitable agencies. As satisfactory administration of monetary benefits during sickness depends on securing medical certification which is above suspicion, it is fundamentally important that under any method of public medical attendance the certification (for incapacity to work) should be completely independent of any coexistent system of sickness insurance.

A completely efficient public medical service, if preventive as well as curative, will diminish greatly the monetary calls on sickness insurance and lower its expense. Let me briefly enumerate the conditions which such a medical service must fulfil:

1. It must possess facilities for consultations with physicians and surgeons having special knowledge, equalling in efficiency those possessed by the well-to-do.

2. All modern pathological and physical aids to diagnosis and treatment must be available.

3. Hospital treatment must be secured for all whose illness cannot be satisfactorily treated at home.

4. In the ordinary treatment of patients by medical practitioners there must be provision for team work, as for instance at local dispensaries, so that a patient may, where this is desirable be conveniently examined by several doctors. (Group medicine.)

5. Skilled nursing must be obtainable for patients needing to be treated at home, though the extent to which this is required will be greatly reduced by increased use of hospital beds.

6. In every district the patient might have the choice between several doctors; but unnecessary change of doctors should be discouraged. Subject to general regulations, however, he should be entitled to demand a consultation when not satisfied as to his treatment.

7. The doctor chosen by the head of the family should be held responsible for supervising the health of the whole family; and should be required at least once in three months to arrange to see each member of it, to ascertain any existing disease, or any habits, manner of life or work tending to cause disease, and to make a concise statement to the medical officer of health or health commissioner embodying his recommendations as to any public health action which may be needed.

8. The scheme at first might be limited to one section of the population, but there is no reason why ultimately it should not embrace all willing to join it.

9. The remuneration of doctors engaging in this public work should be adequate at once to attract junior members of the profession. The remuneration should not be on a capitation basis, but by salary, modified according to the success achieved. The scheme would enable doctors to have ample leisure and holidays and to take part in post-graduate courses. Every inducement should be given to physicians to undertake along with their family work special work in connection with one of the following activities:

10. Medical schemes on the above general lines can only be completely satisfactory to the extent to which every physician taking part in them becomes imbued with an appreciation of the almost unlimited preventive possibilities opened up by the opportunity to treat disease, and by the realization likewise that an essential part of his family work should consist in detecting the beginnings of disease and in detecting and securing the removal of domestic, dietetic, housing, industrial or other factors liable to cause disease.

If these ideals can be even partially realised, we shall have approached the time when every practising physician will become a hygienist, and when any sickness insurance still demanded or required will be on a scale much lower than is necessary at the present time. In short, compulsory sickness insurance under present conditions is a measure of relief. It has almost as little prevention involved in it, as has insurance against the risk of fire. Relief must be given, by insurance or otherwise. How much preferable, however, it would be to precede it by a far-reaching scheme of effective preventive and curative work, or at the least to place it in a strictly subsidiary position to such a scheme in actual operation!