Health Service Problems

By LAIN MACLEOD, M.P.

IT is a pity that discussion of the role of doctors in the National Health Service tends to cerllre on their remuneration. It is true that many doctors—and some of the finest general prac- titioners are included—find it difficult to make art adequate income, particularly in rural and residential areas. There seems to be an extremely strong case for a weighted capitatiori fee which would give greater rewards to those who, owing to the nature of their practice, cannot accumulate a large list. Doctors' pay is a concrete problem on which indignation and publicity can readily

be focused. It is not the real problem. The real problem is one of frustration. The doctors feel that they are becoming increasingly concerned with matters unrelated to the cure of their patients. The relationship between doctor and patient is often more difficult and less intimate. The burden of certification is wearisome.

This frustration is also the real,.point at issue in the hospital strike at the Kingston and Malden Victoria Hospital, where the Regional Hospital Board is being defied. Of course regions have to plan for the whole.of their area. Of course this means that local pride may—and sometimes must—be overborne. The sin of the regions is that they are driving the general practitioner from the hospitals. Fundamentally, the Kingston crisis is a protest against this narrowing of the field. Nor are the specialists and the registrars any happier. There have been few more stupid circulars from Whitehall than the recent one from the Ministry of Health, with its curt forecast of future needs, and its crude hints of opportunities

in the Colonies and the Forces. I am afraid that specialists are discovering now what it means for their numbers and their- pay to be dependent, not on their skill or on the social need, but on the Treasury. The teachers could have told them.

Of course there is much to be said 'on the other side. In spite of the growing waiting-lists at every hospital, the death-rates from most of the killing diseases are moving (often dramatically) down.

The fear of the doctor's bill has disappeared, and that is an excel- lent thing. The ideal of the family consultation is slowly being achieved. But we have a scheme to cure ill-health ; we need a scheme to promote good health. We spend too small a proportion of our resources on medical research. Health centres at the moment can only be a dream. But until group practice comes to help the overworked doctor, we must aim at giving him opportunity through the hospitals and through refresher courses to recreate his skill.

In Parliament, and I think in the country as well, the aspect of the Health Service most discussed is the problem -of tuberculosis.

It is dangerously easy to over-simplify the problem. Tuberculosis is more than a social disease, and its cure is not just a matter of housing. Four hundred men and women, most of them young, die every week from this disease. Certainly the death-rate is now improving, even in Scotland, where the disease two years ago was described as " epidemic," but it remains the field in which we have made least progress. Perhaps we have been too cautious in- our use of B.C.G., perhaps have not dared to face the loss of some less essential part of the Service if we gave full' priority to tuberculosis.

In part the difficulty comes from the dichotomy between the local health authorities and the Regional Hospital Boards. Prevention is the duty of the local health authorities ; cure of the Regional Hospital Boards. An additional complication, of course, is that the general practitioner comes under yet a third body, the Executive Council. Again, after-care should also mean after-cure, but in many cases patients leave sanatoria uncured and have to return to unsuitable homes or lodgings. Night sanatoria for such persons are an urgent necessity, but, on Treasury instructions no doubt, many projects are being turned down. There is a great shortage of staff. The reasons are complq=full employment, fear of infection, remote sanatoria, and, of course, pay. Here again the clamour may be for more pay. I suspect we should offer career rather than financial inducements.

Is there, then, an answer to the problem of-tuberculosis ? I think pere is. In the House of Commons last week I suggested, in a brief Adjournment Debate, that perhaps we should treat the disease as one outside the normal mould of the Regional Boards and the Hospital Management Committees ; that we should, in fact, weld the different bodies into one force to fight tuberculosis. The Parlia- mentary Secretary to-the Ministry of Health replied:

" We have under consideration the question of the adminis- trative organisation of the Health Service in relation to some of these particular problems, both in T.B. and in other special fields. Our minds are by no means closed to any changes that might be necessary in order to secure more effective co- operation between all the agencies concerned."

I regard this as most encouraging news. Some of the " other special fields " in his mind. may have been geriatrics and mental health. This may mean a long step towards humanising the Health Service.

The honeymoon in expenditure which lasted for two years from the start of the Service seems to be over. Certainly the Chancellor of the Exchequer was definite enough in his Budget statement that no more money could be spent. It remains to be seen whether this instruction has been translated into action and whether there will be any Supplementary Estimates this year. In previous yeaTs the gross cost of the scheme has been under estimated by no less than £100,000,000. We must not forget that we are an ageing population and that the demands of sickness will increase. There are claims for increased expenditure, some of which, such as doctors' pay and night sanatoria that I have mentioned in this article, should be met.

It seems urgent that some charges should be imposed. Perhaps these should be on dental appliances and spectacles. Another possible field is that of hospital maintenance. Slowly extravagances are being cleared from the scheme. For example, action has recently been taken to rid the ambulance service of many of its abuses. Obvious waste is not very easy to detect in administration, but the truth is that there is too much administration. Too many people are paid to do work which previously they were glad to do for nothing. Too many people, in short, are minding other people's business. •

Then, too, we must enforce a reasoned and reasonable system of priorities. Tuberculosis is one ± the school dental service is another. Since Korea and rearmament have underlined the Chan- cellor's Budget warning, there are, in fact, two choices open to us. Either we must clamp down on expenditure and freeze the cost of each part of the Service, .or we must re-shuffle expenditure within the total sum. The second choice must surely be ours.

Administrative efficiency and priorities are, then, the key words for the future of the Health Service. They are not, however, the main aim. The Minister should first strive to achieve a happier Service. I wish I fiad any confidence in his ability to do this. Jekyll- Bevan could make a reasonable job of Health administration,. if only Hyde-Bevan could be gagged and forgotten. The Minister at one time or another has insulted almost every professional body in the scheme. Every time the gibes are justified by the claim that the Minister speaks on behalf. of the patients against the vested interests of the_ professional me,n. We need not waste time arguing such nonsense. 'After his own family, no one cares so deeply for the patient's welfare as the man or woman attending him. It has always been so. It always will be so. The first- duty of any future Minister of Health will surely be to seek again—and deserve again —the confidence of all those who serve in our National Health Service.