Public health and insurance: American addresses

by Sir Arthur Newsholme

The separation of the medical work of Education Authorities from public health medical work was contrary to the first principles of sound administration; although it is possible that, owing to the inertia in some public health circles, this separation at first favored rapid advance in school hygiene; just as the early development of public health apart from poor-law administration was probably more rapid than could have been expected from centrally ridden local authorities, concerned chiefly in keeping down the poor rates.

The Ad Hoc Vice

But in both instances there was an offence against the first principles of good administration, which require that when a special function is to be undertaken it shall be undertaken by one governing body for the whole community needing the service, and not for different sections of the community by several governing bodies. Medical treatment is needed for school children and for the poor generally. Why separate this into two administrations? Hospitals are required for paupers with tuberculosis, and for non-paupers with tuberculosis. Why have two authorities for this work? The separate existence of Education and Poor-Law Authorities qûa medical attendance on those children needing it erred, not only in this fundamental respect, but also because neither of these authorities had the preventive facilities and powers possessed by Public Health Authorities, who were also partially engaged in the treatment of disease.

The inveterate tendency in the past has been to create a new authority when any new work was inaugurated, this authority then fulfilling all purposes for a special portion of the community and thus necessarily duplicating the staffs of other departments of local or central government. The crowning instance of this recurring instance of legislative myopia is seen in the case of the National Insurance Act, under which has been provided an imperfect and unsatisfactory domiciliary medical service for one-third of the entire population of Great Britain, when by combining and extending the medical forces of existing departments of the state, a satisfactory service for all needing it would have been secured. The axiom that “the object of community service is to do away with group competitions and bring in its place group coöperation or team work” (Goodnow), is especially applicable to all public health and medical work; and the spirit of this axiom is infringed by the existence of separate, sometimes competing, occasionally conflicting, services under separate local and central control.

Principles of Local Government

The preceding considerations bear on the perennial problem of efficient government, local and central. There are three functions to be performed in government, legislation, determination of administrative policy and extent of work, and the actual executive work. In England, legislation is in the hands of Parliament and is usually national in scope. Large cities, however, not infrequently obtain special legislative power to meet local needs; and by this means have succeeded in advancing local efficiency above the average standard. Local authorities, furthermore, have the power to make regulations and by-laws for special purposes, subject to the approval of the Central Authority.

In settling the details of local administration, the elected representatives of the public are supreme. They meet in Council, and action is taken on a majority vote. The councils of counties and cities, and even of smaller municipal boroughs divide themselves into committees, each consisting of about a dozen members, elected by vote of the whole Council. The chairman or mayor of the Council has no special power, except that he may give a casting vote.

The chief defect in local sanitary administration in England is the continued existence of a large number of small and relatively inefficient local authorities. The larger authorities, as a rule, do their work well, and politics enter but little into elections. Official posts are not vacated with changing councils. These councils are approximating to the ideal of a complete local Parliament dealing with all governmental concerns, and to the further ideal that each unit of government should be large enough to minimize the influence of local interested motives, and to undertake each department of municipal work on a considerable scale. The local Parliament has committees concerned with police, finance, public health, education; and when the urgently needed poor-law reforms are made, and when the Education Committee hands over its medical work to the Public Health Committee, the ideal will become a fact.

Power is already given to coopt on to some of these committees a few persons who are not members of the Council, from among men or women having special knowledge of the Committee’s work; and the exercise of this power has been found to be useful.

But in each committee it is the direct representatives of the public who decide points of policy and settle the main outlines of administration. There is growing up a tendency to appoint local advisory committees, consisting of special groups representing professional or trade interests. Thus a medical committee may be consulted on medical proposals, and so on. This is still in the experimental stage. It will probably prove permanently useful, as voicing the occupational aspect of any proposed work of the municipality; but it will need to be kept to its strictly consultative limitations, and the responsibility of the Council as representing the combined wisdom or unwisdom of the entire community must be maintained.