CENTRES FOR MEDICAL TREATMENT.
[COMMUNICATED.]
THE high cost of living, associated with widespread industrial depression, has had the almost inevitable result on our voluntary hospitals of precipitating the financial crisis which many of them had even in pre-war days with difficulty succeeded in warding off. So difficult has the position become that, in spite of the newly instituted system of payments by the patients, several, of our largest hospitals have recently announced the reduction of their in-patient accommodation by many hundreds of beds— beds for which there is already a far too lengthy waiting list. On the other hand, it is true that in the metropolitan area, and in some of the large industrial towns such as Bradford, there has been considerable development of the municipal hospitals, the old workhouse infirmaries, and that the treatment to be obtained in the best of these institutions is far in advance of what was obtainable there a decade ago, and compares not unfavourably with that given in the voluntary hospitals ; but there are serious objections to this piecemeal handling of a stupendous question intimately concerned with the health and pros- perity of the entire community. At the best, under present circumstances it would seem to result in robbing Peter to pay Paul. Of course no one would suggest that any but the best treatment should be given at the Poor Law infirmaries, but their sphere of activity should be clearly defined, and they should be made an integral part of our hospital system. We have had from the late Minister of Health many protestations of friendship for the voluntary hospitals, but appearances suggest that by means of municipal hospitals, municipal clinics, and modifications of the panel system, the bureaucrats who are in control at the centre desire to present us with a fait accompli in the matter of a State medical service.
Now, whatever view may be held about the advantages or disadvantages of a universal State medical service, it is obvious that in the present condition of financial stringency the country cannot adequately support both the voluntary hospitals and a greatly extended system of municipal hospitals ; yet if other voluntary hospitals are driven to follow the lead of the London and King's College Hospitals, and reduce considerably the number of their beds; the arguments of those who advocate further development and extension of the municipal institutions cannot fail to be greatly strengthened, for it is admitted on all sides that the present in-patient accommodation available is far below present needs.
To overcome the present difficulties various plans have been suggested, such as a State subsidy for the hospitals, but this, in the opinion of many, would involve State control, to which they are strongly adverse. Probably any large subsidy would of necessity mean State control, but it 'has to be remembered that the State already makes grants to hospitals without so far any protest from those who are opposed to a subsidy. However, at the present moment a scheme on the lines suggested by Dr. -Gordon Dill, which has already been adopted and put in practice in Sussex, holds the field. Under this scheme the individual or the head of the family is to be persuaded voluntarily to insure against sickness and to receive in return the assurance of hospital treatment, when necessary, and certain specialist and consultant services at home. Apart from the obvious financial difficulties which will have to be overcome before such a scheme can be successfully developed, it appears to the writer that the mistake that is being made is the almost constant one of considering the various sections of the health services separately. No real advance can be made on those lines. We are all justly proud of our large and vohintary hospitals, not least those of us who have been trained in them, yet the time has surely come when we should consider whether there is not too great a tendency to develop these institutions at the expense of other branches of medical service, more especially that which is in the hands of the general practitioners. Any scheme of the Gordon Dill type must result in stereotyping our views of the importance of the respective branches of the health services, so that before such schemes receive our support it will be well to consider whether by concentrating on the question of financial support of our voluntary hospitals, and seeking to develop them still further, we shall be doing the best for the health of the community.
What, then, is the present condition ? At the hospital, especially the large teaching hospitals, the patient of the ore-time poorer class can receive every form of modern treatment, while for the diagnosis of his condition every modern appliance is available. The only but by no means negligible disadvantage he will suffer is the hospital doctor's ignorance of his, the patient's, home conditions, an ignorance which the most capable almoner can only partly enlighten. The rich patient can avail himself of all the same advantages of diagnosis and treatment, only in his case diagnosis, which may entail visits to the houses of several specialists, will probably consume more time. But one of the large middle class of very moderate means, what does he usually receive ? Advice and a bottle of medicine ! Most excellent advice, and most excellent medicine I Massage, electricity, baths, exercises, diet, any one or all may be recommended to the sufferer, but how to obtain them with the resources of a shallow purse is not, indeed cannot, be explained. And this diffi- culty is not confined to the middle classes. The manual worker, who cannot spare from his working day the large amount of time attendance at a hospital necessitates, finds himself in similar plight ; and again, under the National Insurance Scheme, the State has stereotyped his treatment into advice and a bottle of medicine. According to modern ideas, these two classes of patients are not being efficiently treated, their diseases are not arrested at that stage, when it is most easy to do this, when the patient can in many cases be efficiently treated with a modicum of interference with work. The result is increasing ill- health, till finally in-patient treatment offers the only hope of amelioration, seldom of cure. Is it cause for surprise that so many hospital beds are required ? Is not the ever-increasing demand for such beds the necessary result of fostering the hospitals, developing their capacities for treatment at the expense of the general practitioner, and at the expense of the large non-hospital classes of patients 1 Is not this the consequence of restricting the opportunities of carrying out thorough and efficient medical and surgical treatment to the members of the hospital staffs numbering not more than 10 per cent. of the medical profession and withholding similar opportunities from the 90 per cent. engaged in general practice, on whom the community mainly depends for the maintenance of its health ? No sensible person would desire to impair the efficiency of our hospitals, but surely it is reasonable to inquire whether by centring our attention on the hospitals we are acting in the best interests of the national health. In the report of its Consultative Council of Medical and Allied Services published by the Ministry of Health last year the above point of view finds expression in the sug- gested primary centres to be staffed by general practi- tioners. The scheme outlined by the Council has been severely criticized as being too grandiose, unworkable, financially impossible, most of the critics seeming to be under the impression that the scheme in its entirety was to be put in practice at once, whereas the Chairman of the Council, Lord Dawson of Penn, has stated that the scheme simply embodies an ideal towards which we should strive, and suggests that twenty or more years may be needed to get it fully established. Financially, such a scheme is quite beyond our present national resources, and the needs of our hospitals are pressing and must receive instant attention, but this assistance must not be given in such a way as to render impossible the proper development of other branches of medical service, above all not in such a manner as will impede the development of the general practitioner. The hospital question will only be satisfactorily settled by reducing the pressing need for in-patient treatment by providing more satisfactory treatment for the early stages of disease.
Fortunately, a beginning can be made without any excessive outlay. Throughout the country centres have been established by the British Red Cross Society for the treatment of injured and sink demobilized soldiers. So beneficial have been their activities that many of these centres find that very shortly they will not have sufficient ex-Service patients to keep them going, and it is proposed that by the end of the year many of them shall be closed. Such a policy seems to be fundamentally wrong. Much valuable equipment has been installed, much experience in treatment has been gained ; surely it would be better to open these centres to the civil population, and, as op- portunity offers, to extend their activities, associating the practitioners of the neighbourhood in their working, and endeavouring to make them self-supporting by charging moderate fees. The fact that they could continue to give treatment in the evenings as at present would in itself commend the centres to those who are unable to receive treatment in the daytime. Such a moderate scheme would not affect adversely the financial position of the general practitioner, or the masseur or masseuse ; it would merely increase the efficiency of the general practitioner by giving him opportunities of person- ally supervising the various forms of treatment, massage, electricity, remedial exercises, baths, to mention but a few, and allow him to estimate for himself their value in the cure or amelioration of disease, while those engaged in administer- ing massage would have the longed-for opportunity of popu- larizing their particular form of treatment. As for the general public, in course of time really efficient treatment would replace the system of " advice and a bottle of [In Surrey Red Cross Curative Posts have been treating civilians, and especially children, during the past three years. Not many weeks after the Armistice the Spectator expressed a strong hope that the Red Cross should take as its revised motto : " In pace ut in bello—In peace as in war." The results in Surrey in the case of infant paralysis have been most encouraging, and lend support to "D.'s " sound and persuasive plea.—ED. Spectator.]
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