The complexity of local authorities concerned in the treatment of disease was wilfully increased under the National (Health) Insurance Act; and, contrary to the advice of public health workers and of the Royal Commission on the Poor Laws a golden opportunity for securing the merging of poor law into public health work and for initiating a unified system of State Medicine for all who need it was lost.
Poverty to a preponderant extent is due to sickness. Two statements have recently been made by the Medical Society of the State of New York, viz., that “evidence is against the fact that any considerable amount of impoverishment is caused by illness,” and that they can find no “available evidence that ... in the main, medical attendance in this State is grossly deficient in quantity or grossly defective in quality.” (Monthly Labor Review, January, 1920, p. 256.)
One can admire the optimism, while denying the accuracy of the first statement: of the second statement, as it refers to the State of New York, I can say nothing, except that a statement identical with the one denied above would be literally true for England. In 1907 I wrote, “the coexistent but uncoördinated systems of treatment of disease have failed lamentably to provide what the health of the community requires—means for ensuring effectively the early recognition and proper treatment of all disease” (British Medical Journal, Sept. 14, ’07). That remains broadly true, and no remedy will suffice which does not ensure for every member of the community in essential particulars as good treatment as the most favored now possess.
The socialization of medicine has gone too far, its beneficent effects are becoming too well appreciated, to render it possible, even were it not undesirable and mischievous, to hinder its further extension. We have travelled more than half the road towards the goal of general provision of skilled medical assistance by coöperative means, i.e., out of the communal purse. If this is desirable for elementary general education, it is even more important when the aim is the restoration and the maintenance of the highest attainable level of health for each member of the community, who is willing to share in the offered benefits. If we include the third of the total population who now receive in Great Britain the unsatisfactory medical benefit under the National (Health) Insurance Act, and remember the rapidly increasing scope of voluntary and official institutional treatment of disease, hesitation in accepting the inevitable should be replaced by a determination to guide future developments and to render them efficient and economical. What is good for the public is good also for the members of the medical profession.
If asked to advise on the steps which it is advisable to take in regard to Sickness Insurance in a community which has not adopted a scheme, I should emphasise the prior necessity for the State to secure a completely satisfactory system of public medical care before engaging in the more difficult task of providing monetary payments in sickness. It is well to bear in mind that medical attendance is a form of communal assistance the demand for which does not tend to increase with the supply; whereas monetary benefits have always shown this trend, as demonstrated by the experience of both Friendly Societies and charitable agencies. As satisfactory administration of monetary benefits during sickness depends on securing medical certification which is above suspicion, it is fundamentally important that under any method of public medical attendance the certification (for incapacity to work) should be completely independent of any coexistent system of sickness insurance.
A completely efficient public medical service, if preventive as well as curative, will diminish greatly the monetary calls on sickness insurance and lower its expense. Let me briefly enumerate the conditions which such a medical service must fulfil:
1. It must possess facilities for consultations with physicians and surgeons having special knowledge, equalling in efficiency those possessed by the well-to-do.
2. All modern pathological and physical aids to diagnosis and treatment must be available.
3. Hospital treatment must be secured for all whose illness cannot be satisfactorily treated at home.
4. In the ordinary treatment of patients by medical practitioners there must be provision for team work, as for instance at local dispensaries, so that a patient may, where this is desirable be conveniently examined by several doctors. (Group medicine.)