Public health and insurance: American addresses

by Sir Arthur Newsholme

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.)