9. The local education authorities provide for the medical inspection of each scholar in elementary day schools several times during the nine years of his compulsory attendance at school. Parents are advised as to treatment needed, in suitable cases are referred to hospitals (payment being made by the education authorities), and for an increasing number of conditions actual treatment is provided at school clinics (teeth, eyes, ringworm, etc.).
The above enumeration, which does not include the recently necessitated activities of the Pensions Department for sailors and soldiers, and those under the National Insurance Act, is not otherwise complete; but it serves to indicate that the state is already committed very deeply to provide for the medical needs of the community. That the work done on behalf of the community, plus the work accomplished by private medical practitioners, is not equal to national needs is obvious to any one considering the vast amount of avoidable disease in our midst. Why is this and what is the remedy? A partial answer is given by English experience. The medical provision made in a large proportion of cases is belated and inadequate; and in perhaps a still larger proportion of cases medical advice is not obtained, or being obtained, is not followed. This applies even more to hygienic than to clinical medical advice.
Destitution and Sickness
It was one of the greatest misfortunes in the history of medicine in England that poor law medicine and public health medicine were not administratively combined when the Local Government Board was formed in 1870, and that the preventive ideals of public health were not allowed to operate in the treatment and supervision of the destitute. Although there has been a fairly steady improvement in the conditions of medical treatment under the poor law, its association with the deterrent general policy of that department of state, as well as its actual defects, culminated in the appointment of a royal commission of inquiry, which in 1909 presented reports recommending the abolition of the local boards of guardians and transference of their duties to the larger public health authorities.
Behind these proposals of the royal commission lay the absolutely sound principle—which many years previously had been recognized by the pioneers of public health—that the treatment and the prevention of disease cannot administratively be separated without injuring the possibilities of success of both. The public health activities preceding the report of the royal commission illustrate this axiom, such as the isolation and treatment of infectious cases, the treatment of tuberculosis, the provision for the care of parturient women and of their infants, and the medical inspection and treatment of school children.
It was an even greater misfortune to the satisfactory progress of public medicine that the report of the royal commission on the poor laws was not followed by legislation on the lines of its recommendations. So much of destitution is associated with sickness, and sickness is the cause of such a preponderant share of the total destitution in our midst, that the continued administrative separation of the two problems of poverty and sickness is inconsistent with a full measure of success.
Had the transfer of the duties of the poor law authorities to the councils of counties and county boroughs been adopted, and ancillary legislation enacted, the public health organization would have at once possessed a medical service for the poor of some 4,000 doctors, in addition to the doctors already engaged in the public health service; it would have had large infirmaries and the other medical institutions of both services; would have been able to make liaison working arrangements with the committees of voluntary hospitals; and there would have been secured a greatly improved medical service, freed from poor-law shackles, which could gradually be extended as needs and policy indicated.
Insurance versus Public Health
Political circumstances led to the adoption of a course which medically ran directly athwart the course of needed reform. The National Insurance Act of 1911 was passed, giving sickness and invalidity benefits to all employed manual workers and to others below an income limit of £160 (recently increased to £250), who could contribute a weekly sum which was considerably less than half of the estimated cost of the benefits to be received; and a new medical service was created, further complicating administratively the already existing medical services of the poor law, public health, and educational authorities, and converting the majority of general practitioners into part-time civil servants.
The case is an illustration of the moral contagiousness under modern conditions of life, of a new course adopted in any country. Bismarck’s attempt to counteract socialism by insurance has been responsible for state and official experimentation in insurance in many countries, which at least in England was not actuarially, financially, or medically sound, and which has involved expenditure in administration entirely incommensurate with the benefits received.