A FAMILY DOCTOR'S REPORT ON SOCIALIZED MEDICINE

...Entrance to general practice is becoming increasingly difficult...

...and the machinery of a Royal Commission so cumbersome, so unsuitable, and so time wasting, that they reacted instantly and violently...

...On this contention the government resisted suggestions that the dispute should go again to legal arbitration, and without any consultation with the doctors, set up instead a Royal Commission to advise upojp what should be the doctors' tutui^: levels of payment in comparison wftfc people in other professions...

...When used to full advantage these methods can add materially to the length of life and to the comfort and safety of living...

...But all this has changed...

...The newer antibiotics, tranquilizers, and cortisone derivatives, all now freely prescribable, are expensive and widely used...

...I believe they are basically due to the fact that though we have achieved much, we have not been able to do that great deal more that we had hoped and expected by now to have achieved, and we have not been able to do so because we could, or would, not afford to...

...Any such step would certainly be strongly resisted by doctors and patients alike...

...waiting lists are months (sometimes years) long for admission to hospital for non-urgent surgical and gynecological operations...

...Several factors go to account for this steadily increasing cost...

...A. Talbot Rogers, is a general practitioner in Great Britain who served lately as joint chairman with Sir Russell Brain of the Doctors' Negotiating Committee...

...For the family doctor—and I am one—it has been the greatest comfort to know that one could order for any patient the drugs he needed, however expensive, or seek in the hospital advice or investigation, medical treatment, or surgical operation without having first to determine whether the patient could afford these services...

...Although they have not led to any lasting fall in the use of medicines, they have at least contributed something to offset the cost of the drugs...

...A memorandum presented to the Guil-lebaud Committee showed that, expressed in terms of the "gross national product," the current gross cost of the Health Service in its first full year was 3.8 per cent, and the current net cost (after allowing for patients' payments) 3.75 per cent, while four years later the respective proportions had fallen to 3.42 per cent gross and 3.24 per cent net...

...During this last year they have had a rude awakening...

...This claim proved far too great for the Exchequer, and it was refused...

...The Editors THE ADVANCES achieved by medical science in Britain now place in the hands of the doctors techniques of prevention, investigation, and treatment of illness undreamed of fifty years ago...

...During the course of discussions on this issue, meetings of doctors were held up and down the country, and it became obvious at these meetings that deficiencies of finance were not the only, indeed not even the chief, concern of the doctors assembled...

...It is good to feel that no thought of the cost need deter patients from seeking early advice for themselves or their families...

...wages and costs were not changing rapidly...

...In 1954-55 in England and Wales, when the charge was still one shilling per form, this payment yielded $16,800,000, against a total drug bill of $137,200,000...

...Nevertheless the current cost of the health services continues to rise and has increased from around $910,-000,000 in its first full year to a present annual cost of about $1,540,000,00...

...In addition to providing for the care of patients in hospitals, and a consultative outpatient service, the state provided a consultant service in" their own homes for patients unfit to come to a hospital, access to laboratories and to X-rays, to physiotherapy and to radiotherapy, and an ambulance service, all without charge to the patient at the time, all paid for by taxation and by weekly contributions to the National Insurance Fund...

...The service was planned at the time when values in Britain were relatively stable...

...well-trained young men wait impatiently for specialist appointments in a consultant service that does not expand, though the need for its expansion is apparent...

...For it was no single party that decreed this new health service...

...They have come to accept the service as an essential part of their lives, and no politician, however critical of this or that aspect of the service, would ever advocate its abolition or material curtailment...

...It reported that "any charge that there has been widespread extravagance in the National Health Service whether in the spending of money or the use of manpower is not borne out by our evidence...

...This would seem to indicate that the health service has good claim for generous consideration, as soon as budgetary savings can be achieved...

...This committee will not consist of doctors alone, but will include laymen of distinguished ability well able to weigh the evidence that will be set before them and to help both the doctors and the government to make possible still greater achieve ments in the national health service in its second decade...

...Voices were raised to say that 'the time was now ripe for an overhaul of the whole health service with a view to removing existing frustrations, to providing better conditions for practicing good medicine, and better incentives for the best work...

...The general practitioners called a national meeting with a view to agreeing on a plan for their withdrawal from the National Health Service until such time as the government agreed to a satisfactory settlement of their claim or to arbitration...

...This charge has recently been increased to one shilling for each item on the prescription form...

...The exceptions—hospitals that elected to remain outside the state scheme—were a few owned by religious bodies, by the Masons, and, strangely enough, by the trades unions...

...This has gone on rising steadily in spite of all efforts to stem its climb, until, as is seen from the percentages quoted above, each doctor now prescribes drugs costing, every year, almost as much as is paid to him yearly by the nation for his own services to his patients...

...The last adjustments made to their remuneration were those made as the result of an adjudication by a judge of the high courts which brought their payments into line with money values in 1951...

...it added that "the service's record of performance since the appointed day has been one of real achievement...

...and the question of withdrawal from the service was deferred at least until such time as it will be known (it is now hoped in the first half of 1958) how the Commission has reported, and what new arrangement the government will agree to in the light of its advice...

...Just over four years ago an expert and independent committee (the Guille-baud Committee) was set up to survey the cost of the service in its first five years...

...Speaking in 1942, Sir William Beveridge said, "My Report proposes...

...The doctors entered the service of the government in 1948 believing that the recommendations made by the two committees chaired by Sir Will Spens and which had laid down ranges of remuneration suitable for those serving, respectively, in general, and in consultant, practice in a government-organized service of medicine, would continue to assure them the status and a standard of living comparable with theirs before the government became almost their sole employer...

...A general practitioner service was made available to all, and this included medical, dental, and ophthalmic care, and the free provision of all necessary drugs, dentures, spectacles, hearing-aids, and other appliances...

...But they also add to the cost of medical care, and their full and proper use for the community everywhere propounds new problems which different countries solve in different ways...

...Whether such economies are essential is arguable...

...By the time this conference met several weeks later, the chairman of the Royal Commission had given public assurances that persuaded enough of the doctors that their claims and their arguments could be fully presented to the Royal Commission...

...The doctors believe that in principle this procedure is wrong because any charge made at the time of service could act as a deterrent which might delay that early seeking of advice which is counted among the advantages offered by a fully available service...

...Much needed extensions and improvements have had to wait, and raids and restrictions are made, or threatened, upon what have hitherto been accepted as essential parts of the service...

...Relationships with the local government health service charged with responsibility for preventive medicine, for district nursing for domiciliary midwifery, and for child welfare services have been good...

...In Britain, long before 1939, we had come to see that we could rely no longer on charitable endowment for the provision of modern hospitals, nor upon their maintenance at low cost by vocationally inspired and poorly paid staff...

...Against this background it is understandable why the Ministry of Health has had to concern itself less with expanding the service and more with seeking economies...

...The patients have taken full advantage of the facilities available to them, but have not made frivolous or unjustifiable demands upon the health service...

...And we still have no new hospitals, our physicians and surgeons practice modern medicine in antiquated buildings, and obsolescent equipment is difficult to replace...

...The service has been costing more and more each year in spite of all efforts to curb its growing cost...

...The population grows slowly larger, and with it the number of people using the service...

...Now, in an era of continuing inflation, maintenance budgets run so high that little margin remains for capital expenditure, particularly when the capital spent on building new, or expanding old, hospitals brings in its train increased maintenance costs in the years ahead...

...True, these are advances attributable to modern medical science, but we feel our ability to use modern methods early and fully derives in no small measure from our having freely available a comprehensive health service...

...Experience has shown, however, that, in a time of full employment, charges of this small magnitude have been accepted without question by the patient...

...And that was what Parliament set out to provide...

...We ought to regard it as part of the national minimum for every citizen that he should be as well as science applied to the prevention and cure of disease can make him...

...a comprehensive medical service covering every kind of treatment at home and in hospital—dental, ophthalmic, general, specialist, consultant, nursing services, everything—• covering that without charge at the time of treatment...

...but the spirit of the times was such that all measures that Beveridge had proposed as being necessary to free Britain of the future from the giant evils of Want, Disease, Ignorance, Squalor, and Idleness had to be enacted without delay...

...Take as an example the drug bill...

...Not so well as its protagonists in 1948 had hoped, but not so badly as its critics then and now would have you believe...

...So, in July 1948, the government took over almost all the existing hospitals, and became the employer of their staff...

...The difficulty of drawing up such a restricted list, the need for including in it so many of the expensive modern drugs, and the disappointing experience of countries that have used such a list, have so far deterred the government from pursuing this policy...

...But it was not until after the publication, during the war years, of the Beveridge Report that the provision of a fully comprehensive national health service became the policy of Parliament...

...The general practitioner has, and jealously guards, the right to prescribe for his patient whatever medicines he himself thinks needful and proper, subject only to his willingness to justify his prescribing to his fellow general practitioners, should any question be raised of undue and persistent extravagance...

...The first, "Health Insurance for All," by Senator James E. Murray, arguing the need for national health insurance for America, appeared in the June issue...

...The real value of the doctor's income is falling...

...The terms of reference of this Royal Commission seemed to the doctors restricted, and so drawn up as to prejudge the issue...

...Though the actual cost of the service to the nation keeps rising, the proportion of the total national income spent on the National Health service is slowly falling...

...These views have impelled the British Medical Association to set up its own committee of inquiry to review the progress of the health service, and to make recommendations to the government for its future improvement...

...The author of the article below, Dr...

...and this trend continues...

...They account for more than 56 per cent of the total cost of the service, as against 11 per cent spent on general medical services, 10 per cent on drugs prescribed by medical practitioners, nine per cent on preventive medicine, six per cent on dentistry, and two and one-half per cent on ophthalmic services...

...The Act was passed and the service begun under the Labor Government that took office in 1945, but the plan used was little different from that devised by the coalition government with a Conservative Prime Minister and a Conservative Minister of Health...

...How has it worked out...

...What has been done is to introduce token charges payable by the patient for his prescriptions...

...Suggestions have been made from time to time that the list of drugs prescribable should be curtailed to those that would officially be regarded as essential...

...When in 1956 (the government itself having meanwhile made no move to augment the falling value of their remuneration), the doctors prepared a claim for a long overdue adjustment, they found that an increase of 24 per cent would be needed to restore their incomes to their value of five years earlier...

...We have inadequate hospital accommodation for the elderly and for mental illness...

...At the same time the government denied that the Spens Reports had any continuing force or that it guaranteed regular adjustment of remuneration in an inflationary period...

...Another field of recent controversy has concerned the doctors' own remuneration...

...Why, then, are there criticisms, and what are they...

...In consequence, frustrations have developed for doctors and patients alike...

...Ever-rising prices of food, drugs, heating, repairs and renovations, and the enhanced cost of providing the services of that multiplicity of staff needed in hospitals today, have made the hospitals and specialist services by far the most expensive item on the yearly budget of the Ministry of Health...

...Doubts were expressed of the wisdom of attempting so much at one time...

...The Ministry hopes, and there is reason to believe their hopes will be justified, that the new charge per item, besides increasing the total payments collected, will also lead to economies in the numbers of medicines used...

...Infant mortality has fallen steeply, our children are growing up fit and well, and beds now lie vacant in pediatric and infectious disease hospitals, while waiting lists for hospitals treating tuberculosis have disappeared...

...When first introduced in 1952 these were at the rate of one shilling (about fourteen cents) for each prescription form (which could, and often did, contain several different items...