Had the policy of transfer of the duties of Poor Law authorities to the Councils of Counties and County Boroughs recommended in 1909 by the Poor Law Commission been adopted, these last named authorities would already possess a medical service for the poor employing some 4,000 doctors; they would be in possession of the large infirmaries and other medical institutions of the poor law, and given reforms and readjustments of these which are urgently required, and combination of the hospital arrangements of poor-law and public health, would have a greatly improved medical service freed from poor-law shackles and capable of gradual extension as needs and policy indicate. The fusion of these two services with the school medical service would have been an easy further step; and England would by this time have built up a National Medical Service, for the very poor, for all purposes of public health—including poor-law—administration, and for children and their mothers in special circumstances.
Insurance v. Public Health
Political circumstances, into which it is unnecessary to enter, led to the adoption of a course, which medically ran directly athwart the course of needed reform. The National (Health) Insurance Act, 1911, was passed, giving sickness and invalidity benefits to those employed persons below a certain income who could contribute a weekly sum, which was considerably less than half the estimated cost of the benefits to be received; and an additional medical service, further complicating the already existing medical services of the poor law, public health, and educational authorities, was set up.
The establishment of national insurance against sickness and disablement in the United Kingdom exemplifies the contagiousness, under modern conditions of life, of a new course adopted in any country; and Bismarck’s attempt to counteract socialism by insurance has been responsible for international, state and official experimentation in insurance which has not generally been well advised, and which is associated in England with extravagant cost of administration.
Insurance against sickness is a praiseworthy and valuable provision against future contingencies; and on its non-medical side free from drawbacks. Neither on its medical nor on its non-medical side, however, is it an alternative to prevention of disease; and the National Insurance Act in England must be held in the main to have delayed the public health reform which would have been secured had equal effort been devoted to it, and the money lavished on insurance given in the form of central public health grants conditional on the active coöperation of local authorities. True, the English public have been educated to think in regard to sickness in millions when previous provisions for the treatment and prevention of sickness had been thought of in thousands of pounds; and there has been an extension of provision for the institutional treatment of tuberculosis, which probably has been more rapid than would otherwise have been made, in the absence of the alternative grants named above. It should be added that, owing to the natural insistence of insured tuberculous patients on treatment in a sanatorium, and to the desire of Local Insurance Committees and their officers to satisfy insured persons, sanatoria have often been filled with unsuitable patients, sent there regardless of relative social and public health needs. The Maternity Benefit (of a sum of money on the birth of an infant to the wife of an insured person or to an employed woman) similarly is given unconditionally, and should be replaced or supplemented by the provision of service needed at this time (doctor or midwife, nurse, domestic assistance), which would ensure the welfare of both mother and infant.
Apart from other reforms the transfer of medical provision, of provision for tuberculous patients, and for parturient women to public health authorities is urgently needed; and the service should be given according to need irrespective of insurance. The valuable fund for medical research has already been placed under the Privy Council.
The absurdity of regarding insurance as anything beyond a possibly useful handmaiden and auxiliary to Public Health, when strict administrative arrangements are made for this purpose, may be illustrated by the question as to what would have been the result in sanitary progress if Chadwick or Simon had persuaded the government of their day to insure a favoured section of the public against the risk of typhus or smallpox or tuberculosis or even of non-infectious illness?
Under the National Insurance Act medical domiciliary assistance,—but only to the extent which is within the competence of a medical practitioner of average ability,—is provided under contract for one-third of the total population; and evidently this implies an immense abstraction from ordinary private medical practice. There is no provision, hitherto, for consultant and expert facilities when required (except for tuberculosis), for the nursing of patients, or for institutional treatment of any disease, except tuberculosis; and no funds are generally available for these purposes except such as belong to the community at large.
In view of the preceding facts and of other considerations which I have not mentioned, reconstruction of the English Insurance scheme is obviously required. The scheme cannot persist in its present form. The already accomplished amalgamation of the Local Government Board and National Insurance Commission, should make radical changes easier; an equally important step would be the transfer of the medical functions of the Local Insurance Committees to Public Health Authorities. The creation of these independent committees was one of the greatest blunders of the National Insurance Act, which was conceived ill-advisedly, had too short a gestation, and suffered a premature and forced delivery; and we may hope that ere long, it may be replaced entirely, on its medical and hygienic side, by a rapid extension of the medical activities of the public health service which will conduce to the welfare of the whole nation.
It is impossible to justify the continuance of state subsidisation of benefits for a favoured portion of the wage-earning classes, when poorer persons who do not come within the category of employed persons or who fall out of employment, and when clerks and others on limited salaries who are unable to provide adequately for sickness, are left unprovided for.