The National Insurance Act was passed, placing one-third of the total population (all employed manual workers and other employed workers with an income below £160, since increased to £250) under an obligation to pay 4d weekly (women 3d), 3d being contributed for each person by the employer and 2d by the State. In return each worker receives a money payment weekly during disability from illness, attendance by a doctor, sanatorium treatment for tuberculosis, and a maternity benefit on the birth of a child to his wife (30 shillings), or, if the wife also is industrially employed, an additional 30 shillings. The medical benefit is limited to such domiciliary attendance as a medical practitioner of average ability can furnish. It continues the old popular conception of private medical practice, and allows the public to remain obsessed with the notion that satisfactory medical care consists in a “visit and a bottle.” No provision is made for pathological aids to diagnosis, beyond what is already provided by public health authorities. No nurses are available for serious cases; the insured person is not entitled to surgical operations, when needed, except of the simplest character. With few exceptions, no appliances are provided; the treatment of special diseases of the eye, ear, nose and teeth is commonly excluded. No hospital provision whatever, except for tuberculosis, is made.
The contract system of medical practice has been accompanied by a serious amount of lax certification of sickness. The sanatorium benefit is unnecessary, as soon as the duty of public authorities to provide treatment for tuberculosis is declared obligatory. It is already very largely provided. The maternity benefit is entirely unconditional; there is no guarantee that it is devoted to the welfare of the mother and infant. It needs to be supplemented or replaced by the arrangements for providing nurses, doctors, midwives, and domestic assistance which are in process of development by public health authorities. In short, there is no justification for providing medical services, preponderantly at the expense of the state (contributions by employers are a form of taxation), which are limited to a favored portion of the total population, and which do not benefit all in need of these services.
Provision for Sickness
The principle of monetary insurance against sickness and disability is thoroughly sound. It forms a praiseworthy and valuable provision against future contingencies. Insurance, however, is not synonymous with prevention as is too often suggested. In England insurance has been an actual impediment to public health work, though it might have gradually become a useful auxiliary to it if otherwise organized, and especially if the creation of independent insurance committees representing interests to a preponderant extent had been avoided. But any medical service needed for purposes of insurance should not form part of the insurance system. Medical aid is needed for a large section of the population who are unable to afford deductions from their wages, or who have no wages. It is needed for wives and children as much as for the industrially employed head of the household; and it is needed for many others who are excluded from the scope of the National Insurance Act. Only when the medical is separated from the insurance service, and when the medical practitioner, as far as practicable, is made independent of the patient who desires too facile a sick-certificate, will good medical work and sound sickness insurance be secured.
General Summary
The preceding review of the history of public health in England is necessarily fragmentary. It does not include, for instance, a discussion of the relationship of the medical profession to public health authorities. On this I content myself with repeating my oft stated opinion that until every medical practitioner is trained to investigate each case of illness from a preventive as well as from what is often rather a pharmaceutical than a really curative standpoint, until a communal system of consultant and hospital services independent of any insurance system is made available for all needing it, and until every medical practitioner is related by financial and official ties to this communal system, full control over disease,—to the extent of our present available medical knowledge,—will not be secured.
The communal system will include not only the provision of domiciliary nurses for all needing them, but also a greatly increased staff of public health nurses engaged in educational supervision in connection with the work of the communal services and of each individual practitioner. Such a system will repay the community manifold in improved health and in a higher standard of happiness and well being.
If objection is taken to such wide sweeping proposals, let me remind you that free communal services of sanitation and education are already provided; and that the care of personal health is of equal importance with these. All will agree that a large proportion of the population cannot afford to pay individually for medical attendance and nursing under present conditions, still less for the consultant and hospital services which advances in medical service have rendered indispensable. There is always present in our midst a large mass of illness which might have been avoided or curtailed, had there been an organized system of state medicine.
Lest there should be alarm as to the possible consequences of the coöperative provision on such a scale of this primary need of humanity, let me also remind you that coöperative medical aid differs from financial aid in an essential particular. It does not create a demand for further aid, but is always engaged in diminishing this demand. Dependency on financial assistance is liable to continue indefinitely; much wants more. This result of medical aid is almost inconceivable. The Reverend Doctor Chalmers, of Glasgow, said early in the last century: “Ostensible provision for the relief of poverty creates more poverty. An ostensible provision for the relief of disease does not create more disease.”
Doctor Chalmers was opposed to the giving of any domiciliary assistance from rates or taxes, and he organized his parish so that every needy person was adequately helped out of charitable funds. But he advocated extended hospital and other medical assistance for the poor; and until this is done, apart altogether from any system of insurance, and as a complete measure on the lines of our educational system, we cannot say that all that is practicable has been done to secure the physical well being of our fellow citizens.