Concerning “A National Health Service”

The White Paper issued in February 1944 dilates on proposals for a National Health Service. This is the result of discussions with various bodies including the British Medical Association (which may be termed the doctors’ trade union), the Royal Colleges, Voluntary and Municipal Hospital representatives. In the words of the report:-

The Government . . . want to ensure that in future every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them, or on any other factor irrelevant to the real need—the real need being to bring the country’s full resources to bear upon reducing ill-health and promoting good health in all its citizens.

As Socialists we are not impressed by this show of good-will; we give due regard to the capitalist need for healthy workers, and to the date of publication—viz., during a period of something very like war weariness, when accounts of Jap atrocities are needed to pep up morale.

We will digress for a moment to examine the state of medicine at this time in relation to the working class.

Ideas regarding a State medical service for all, not just for insured workers as prevails at the present time, are by no means new, but in their previous forms they have met with opposition from both the British and American Medical Associations. In their organ, the British Medical Journal, the BMA have expressed fear that the present “free” choice of doctor will cease. That freedom of the present choice will be apparent to most workers, but should any retain illusions, they may be quickly dispelled. A worker may not choose a Harley Street specialist, but most have a general practitioner engaged in panel practice, unless he is prepared to spend his meagre earnings on doctor’s fees. The doctor chosen is usually the nearest, in order to save time. Frequently nothing is known of his or her qualifications, letters after the name conveying no more than would hieroglyphics. When the choice is made, unless the worker is extremely ill, he attends an overcrowded surgery, perhaps being allowed five minutes of the doctor’s time. He may, however, not get this, for it has long been the custom for doctors with large panel practices to employ assistants—e.g., newly qualified doctors. The assistant sees the panel patients whilst the doctor attends his fee-paying patients. (This practice is in abeyance during war time, due to the calling up of young doctors, so the poor panel patient gets less time than ever.)

In these days of specialisation, the general practitioner cannot completely attend to all his patients’ requirements. Equipment and the services of dispensers and secretaries are costly. The White Paper recognises this fact and proposes Health Centres in which a group of doctors could practise with staff and equipment provided. The private patients also suffer under the present system. Their own doctor may administer palliatives inserted of sending them to the appropriate specialist for radical treatment.

The BMA have also feared they may find their members working in the guise of civil servants subject to control, which they state would stifle initiative and responsibility towards those sacred trusts, their patients. The American counterpart went so far as to remove from membership any doctor taking part in salaried practice, until prevented from so doing by an order of the Supreme Court in 1942.

Much of the opposition to a National Health Service arises from the inability of doctors to regard themselves as members of the working class. They are, in their own opinion, a class apart, members of the highest profession, rendering selfless service to mankind. No doubt many start with the highest ideals, but few keep them. This is not intended to portray doctors as battening ghoulishly on the lay public, but like all others, they are caught in the cleft stick of capitalism. The doctor is an expensive product; he must keep up certain appearances, and bring up his children in like manner. To be successful he cannot escape the sordid struggle for life under capitalism. He must sell his labour power in order to live, as does his meanest panel patient. These facts are not readily appreciated by the BMA, who, however, by their resistance to salaried schemes, have compelled the doctor to sell in the open market.

Nevertheless, the views of the BMA have not been wholly representative of opinion here or in America. In a leading article, The Lancet (January 22nd, 1944), anticipating the proposals in the White Paper, commented on the advantages to the patient of Cupertino between local authorities, hospitals and the doctor, now inadequate, and states that hitherto most attention has been paid to the convenience of the doctors concerned. Unpopularity of central control may be the reason for this outburst. “Enough of this bureaucratic planning; give me my own show and let me get on with it”. The article continues: “The answer to him has already been given. ‘The needs of the sick are endlessly variable; the resources of medicine are multifarious; and only a large adaptable, sensitive, smooth running organisation will fit one to the other in the largest number of cases.'”

Similarly the attitude in the USA, where there is no National Health Insurance, is changing. Reviewing Kaiser Wakes the Doctors, by Paul De Kruif, New York (a work demonstrating the success of shipbuilder Kaiser’s medical scheme for workers in the mushroom ship yards of the Pacific coast, employing 60 salaried doctors), The Lancet of February 19th, l944, quotes De Kruif’s confession. Hitherto, he had “remained content with official medical explanations that this prepaid medicine was unethical; 100,000 doctors could not be wrong.” It now appears that they could. At the present state of development it is uneconomic for the doctors to sell their labour power in the open market, as the worker cannot afford to buy it, and his health suffers in consequence. The needs of war-time industry here and in the States require workers to receive expert medical attention in every sphere, in order to return to work rapidly and make the wheels of capitalism spin. Note the recent accent on “rehabilitation”. In times of slump the breakdown of a few workers is immaterial when others can be drawn from the reserve army of the unemployed. The present arrangements, in which the general practitioner works alone, are not conducive to the production of efficient, healthy workers. “Accident proneness” is inevitable in sub-healthy states. Also the fact that the worker’s wife has no panel doctor has come to be realised as an anomaly overdue for remedy. As she must be a fee-paying patient, she often fails to seek necessary advice, and comes to accept ill-health as part of her life.

The widespread influence of the BMA compelled the Government to accept its offices in the recent discussions. The White Paper is throughout a sop to the BMA, reiterating again and again that “the patient should choose his own doctor”. The suggested arrangements for the entire population to be covered by insurance has the advantage of simplicity, but not so the arrangement of general practitioners. The Health Centres proposed will be used by a group of doctors who will see their patients there instead of at their surgeries. A salary or equivalent will be paid to them but—and what a large “but” it is—the doctor may still have private fee-paying patients. The report states, however, that no one must be given “reason to believe that he can obtain more skilled treatment by obtaining it privately than by seeking it within the new source”.

Socialists may suppress a smile at so naive a hope. What reason is there to suppose that a doctor now giving greater attention to his private patients than his panel will not continue to do so under the new scheme? It is not hard to visualise a doctor seeing his erstwhile panel patients at the Health Centre, receiving his salary for so doing, and then rushing off to see his private patients. True, the better equipment provided at the Health Centre may even be an inducement to persons of means to attend, so that private practice declines and the doctor ceases to sell his labour power in the open market, but what then?

Will the doctor’s salaried position enable him to see his true place in society? Time will show, but under neither this proposed scheme nor any other will the worker get the requisite attention. Under any scheme in capitalist society expenditure is resisted at every step, as has been the case with housing for the workers (not their masters), sanitation, education and the like. Even the Beverage scheme for health insurance requires that large scale unemployment shall not obtain; such statements serve to demonstrate the hollowness of capitalistic schemes, for it is powerless to prevent unemployment, which is inherent in its constitution. Only under Socialism, where the wages system will no longer exist, and where the workers will enjoy the fruits of their labour under ideal conditions without exploitation, can doctors truly serve their fellow-workers, and a real health service for all be established.

(June 1944)