Money, manpower and the national health service

PUBLIC HEALTH, January, 1953

54 w h e l m a n d even overlook the o t h e r divisions, a n d t h a t the interest of the clinician is m o r e u p o n t h e case r a t h e r t h a n u p o n the cause, u p o n t h e disease r a t h e r t h a n u p o n t h e patient. T h e organisation is certainly b e c o m i n g very c o m p l e x a n d the complications m a k e it v e r y difficult to b r i n g t h e hospital services into line w i t h social medicine, e n v i r o n m e n t a l h e a l t h a n d t h e p r a c t i t i o n e r services. I t is easy to p r o p o u n d the p r o b l e m a n d t h e solution is as yet far f r o m clear, b u t will p r o b a b l y be f o u n d w h e n everyone w o r k i n g in each part of the Service will find out s o m e t h i n g a b o u t a n d appreciate the work t h a t others are d o i n g in o t h e r parts. I t is r i g h t t h a t t h e clinicians s h o u l d k n o w w h a t the authorities are doing in social m e d i c i n e , a n d t h a t M e d i c a l Officers of H e a l t h s h o u l d b e aware of t h e m o v e m e n t s w i t h i n t h e hospital w o r l d ; t h e m o r e we can b r i n g t h e various workers t o g e t h e r the better. It is n o t p u r e l y an a d m i n i s t r a t i v e p r o b l e m , n o r yet a p u r e l y m e d i c a l one, a n d we can still pay h e e d to t h e advice of m e n llke Sir J o h n S i m o n , w h o wrote m a n y years ago of t h e pioneers w h o w e n t forward, " s o m e of t h e m in lines of scientific s t u d y , o t h e r s in lines of political principle, towards a day w h e n statecraft a n d medical knowledge s h o u l d sincerely take counsel t o g e t h e r for t h e h e a l t h of t h e p e o p l e " (Simon, 1890). REFERENCES

BRYANT, A. (t950.) T h e Age of Elegance. London, 347. BURN, J. L9 (1947a.) Recent Advances in Public Health. London, 3. . (1947b.) Ibid. London, 3. DAWSON COMMITTEE. (1920.) Report of Future Provision of Medical and Allied Services. H.M.S.O. 1920. 6. DUNN, C. L. (1952.) T h e Emergency Medical Services. Ibid. London, 14. FRAZER, W. M. (1950a.) History of English Public Health, 114. (1950b.) Ibid., 241. .. (1950c.) Ibid, 307. Hansard. (1941.) Parliamentary Debates. House of Commons. V. 374- Column 1116. JONES, A. T., NIXON, J. A., PXCKEN, R. M. F. (1945.) T h e Hospital Services of South Wales and Monmouthshire, 30. Lancet. (1939.) Special Commission. Lancet, October 28th, 1939, 945. NEWIV~N, Sir G. (1928a.) Annual Report Chief M.O., Min. of Hlth., 95. . (1928b.) Ibid, 73. NEWSHOL~m, Sir ARTHUR. (1936.) T h e Last 30 Years of Public Health. London, 113. NUFFIELD PROVINCIAL HOSPITALS TRUST. (1945.) T h e Hospital Surveys, 4. ROBERTS, FF. (1952.) T h e Cost of Health. London : T u r n stile Press, 179 SIMON, Sir JOHN. (1890.) English Sanitary Institution. London, p. iv. TITMUSS, R. M. (1950a.) Problems of Social Policy. H.M.S.O., 66. (1950b.) Ibid., 66. (1950c.) Ibid., 466. 9 (1950d.) Ibid., 505. VOLUNTARY SERVICE AND THE STATE. (1952a.) London, 28. 9 (1952b.) Ibid., 22-27. WELSH CONSULTATIVE COUNCIL. (1920-21.) Medical and Allied Services in Wales. WINSLOW, C. E. A. (1951.) T h e Cost of Sickness and the Price of Health. W.H.O., Geneva, 10.

Mr. P. Arthur Wells, who has been deputy secretary and secretary-designate since April 1st, 195I, assumed the secretaryship of the Royal Sanitary Institute on January 1st, 1953, in succession to Dr. J. W. Dudley Robinson, who retired on December 3Ist, 1952. Mr. Wells also took office as secretary of the R.S.I. and S~initary Inspectors Examination Joint Board, and as secretary of the National Nursery Examination Board on the same date. He holds the degrees of M.A., M 9 F.C.C.S., F.Inst.P., in science and in public administration, and was pre.viously director o f education to the International Wool Secretariat and general secretary of the Society of Dyers and Colourists.

MONEY, M A N P O W E R A N D THE N A T I O N A L HEALTH SERVICE* By A. ELLIOTT, M.D., D9

County Medical Officer of Health, Kent T h e idea t h a t the welfare of individuals was the c o n c e r n or responsibility of t h e c o m m u n i t y h a d b e e n r e c o g n i s e d for certain g r o u p s of people a n d for certain special c o n d i tions for a very long p e r i o d of o u r history. T h e e x t e n s i o n of responsibility, however, to cover all m e m b e r s of t h e c o m m u n i t y , w h i c h is t h e basis of t h e m o d e r n W e l f a r e State, was first p u t f o r w a r d in a c o m p r e h e n s i v e f o r m i n the Beveridge R e p o r t of N o v e m b e r , 1942. I n t h e c o n d i tions t h a t o b t a i n e d in 1942 the R e p o r t h a d a p r o p a g a n d i s t use a n d value, b o t h at h o m e a n d overseas, w h i c h i n e v i t a b l y m i l i t a t e d against its b e i n g a reliable b l u e p r i n t for t h e future, a n d t h e times could scarcely have b e e n less p r o pitious for a cool a n d r e a s o n e d criticism of t h e f u n d a m e n t a l issues of h u m a n b e h a v i o u r u p o n w h i c h t h e R e p o r t was f o u n d e d . I t is, however, o n t h e basis of t h e R e p o r t p u b lished at a time, as I have said, of great n a t i o n a l stress, t h a t the f o u n d a t i o n s of t h e Welfare State rest, t h a t State h a v i n g b e e n b r o u g h t into legislative life in July, 1948. O u r m a i n c o n c e r n w i t h the Beveridge R e p o r t is in its references to t h e necessity in t h e Welfare State of a c o m p r e h e n s i v e N a t i o n a l H e a l t h Service, a n d it is i n t e r e s t i n g to q u o t e t h e exact w o r d s : " I t is a logical corollary to t h e receipt of h i g h benefits in disability t h a t t h e i n d i v i d u a l s h o u l d recognise t h e d u t y to b e well a n d to c o - o p e r a t e in all steps w h i c h m a y lead to diagnosis of disease in early stages w h e n it c a n b e p r e v e n t e d . " R e v i e w i n g t h e logic of this s t a t e m e n t in light of events, we may, I t h i n k , ask ourselves h o w i t is possible to p r e v e n t disease t h a t h a s already o c c u r r e d ; b u t I t h i n k we were p r o b a b l y b l i n d e d to a critical a n d logical e x a m i n a t i o n of t h e proposals i n t h e R e p o r t b y t h e events of t h e t i m e a n d b y t h e m a g n i f i c e n t p r o s p e c t t h a t was .created b y t h e R e p o r t ' s proposals. T h e financial proposals for t h e creation of a N a t i o n a l H e a l t h Service i n t h e Beveridge R e p o r t are, however, o u r direct c o n c e r n a n d in 1942 for G r e a t Britain it was estim a t e d t h a t t h e gross cost w o u l d b e s of w h i c h s would come from the proposed National I n s u r a n c e f u n d , t h a t is, b y a t r a n s f e r f r o m t h e p a y m e n t s t h a t all wage earners w o u l d make, leaving s to b e paid b y t h e T r e a s u r y f r o m general taxation. I t is, however, n o t e w o r t h y t h a t t h e Beveridge R e p o r t e s t i m a t e d t h a t t h e cost of a N a t i o n a l H e a l t h Service w o u l d r e m a i n m o r e or less c o n s t a n t a n d t h a t t h e figure of s w o u l d still b e t h e cost in 1965. T h e R e p o r t a r g u e d this a s s u m p t i o n o n t h e basis t h a t a c o m p r e h e n s i v e h e a l t h service w o u l d so i m p r o v e the h e a l t h a n d w e l l - b e i n g of t h e n a t i o n t h a t while e x p a n s i o n of faeilities w o u l d o c c u r t h e extent of use w o u l d decline. T h e r o a d to a d m i n i s t r a t i v e hell is p a v e d w i t h a s s u m p t i o n s . O u r first task, therefore, is to look at t h e actual figures a n d see w h e t h e r this a s s u m p t i o n has b e e n b o r n e o u t i n practice 9 L o o k at t h e c h a r t s h o w i n g w h a t in fact h a s happened. The middle column showing the Ministry of H e a l t h estimate was p r e p a r e d w h e n t h e original N a t i o n a l H e a l t h Service Bill was p r e s e n t e d to P a r l i a m e n t in M a r c h , 1946. W e m a y also n o t e t h a t a n additional s a year has got to b e f o u n d u n d e r t h e n e w A w a r d for general practitioners 9 (See G r a p h I.) I w a n t to diverge h e r e for a m o m e n t to e x a m i n e v e r y briefly t h e bases u p o n w h i c h m o d e r n civilisation rests. I n a n y c o m m u n i t y , be it p r i m i t i v e o r m o d e m , m a n c a n o n l y survive if h e is fed, clothed, k e p t w a r m a n d has some p r o tection against his enemies, w h e t h e r t h e y b e i n t e r n a l o r external. I n a p r i m i t i v e c o m m u n i t y the m e e t i n g of t h e s e basic n e e d s takes u p t h e w h o l e or practically t h e w h o l e of t h e energies of t h e people, w h i l s t i n all c o u n t r i e s t h a t lay claim to a civilised way of life t h e s e basic n e e d s h a v e * An address to the County Medical Officers of Health Group (and Association of County M.O.H.s of England and Wales), July 18th, 1952.

55

PUBLIC HEALTH, January, 1953 GRAPH I Cost of National Health Service BEIrER/DGE .Z-ST/MATE 1942

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LOCAL HEALTHAUTHO~/TY HOSPITAl d SPZCIALIST SERVICES

long since b e e n m e t w i t h o u t a b s o r b i n g t h e whole of t h e effort of t h e c o m m u n i t y . T h o s e m e m b e r s of t h e c o m m u n i t y w h o are n o t n e e d e d in t h e struggle for bare existence can be used, a n d i n d e e d are used, for the m a n y o t h e r tasks a n d f u n c t i o n s t h a t go o n a r o u n d us. W e can t h e r e fore c o n c l u d e t h a t if a c o u n t r y o n l y j u s t p r o d u c e s e n o u g h to keep its people fed, clothed a n d w a r m , it c a n n o t b e said to have e n o u g h resources to provide o t h e r t h i n g s s u c h as teachers, nurses, doctors, a n d so on, a n d h e n c e we can see w h y it is t h a t t h e so-called b a c k w a r d c o u n t r i e s h a v e n o social services w o r t h speaking about. Incidentally, you m a y b e i n t e r e s t e d to see h o w m a n y people in various c o u n t r i e s devote t h e i r t i m e to food p r o d u c t i o n , E n g l a n d a n d Wales b e i n g well at t h e b o t t o m , a n d t h a t figure of 6 . 4 % in 1931 is n o w 5 . 4 % in 1950 for G r e a t Britain. (See G r a p h II.) GRAPH IT Percentage of population in various countries engaged in agriculture

CZECHOSLOVAKIA 1950 S WI TZER LAND 1930

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O n e of t h e p r o b l e m s t h a t h a d to be solved in this a n d o t h e r countries was t h e control of e p i d e m i c disease, a n d it is o n e of t h e great t r i u m p h s of p r e v e n t i v e m e d i c i n e t h a t i n t h e 19th c e n t u r y smallpox, cholera a n d t y p h o i d came u n d e r control. I n o t h e r c o m m u n i t i e s the k n o w l e d g e a n d technical application of m e t h o d s to deal w i t h malaria, yellow fever a n d o t h e r tropical disorders has o p e n e d t h e way to an e x t e n s i o n of civilisation a n d t h e utilisation of resources, w i t h a c o n s e q u e n t i a l raising of t h e s t a n d a r d of life, t h a t is to say, life in those places has b e c o m e m o r e t h a n a struggle m e r e l y to satisfy t h e basic n e e d s I h a v e described. M a n is, however, s u r r o u n d e d b y his e n e m i e s a n d t h e history of m e d i c i n e has b e e n , a n d always will be, t h e s t o r y of a struggle for: life b e t w e e n m a n a n d t h o s e enemies. F o r p r e v e n t i v e m e d i c i n e t h e age of r e v o l u t i o n i n t h e c o n q u e s t of m a j o r epidemics is over a n d n e w fields of p r e v e n t i o n of disease t h a t m a y yield similar t r i u m p h s h a v e n o t yet m a n i f e s t e d themselves. W h a t is t h e cost of t h e N a t i o n a l H e a l t h Service ? T h e first p o i n t I m u s t m a k e is t h a t t h e n e t cost f r o m t h e E x c h e q u e r does n o t m e a n t h a t t h o s e figures s h o w n are t h e only costs t h a t h a v e to b e f o u n d because, as you will realise, the m o n e y f r o m the whole service has got to be f o u n d f r o m s o m e w h e r e , b u t t h e figure of s for t h e p r e s e n t year is of great i m p o r t a n c e because t h e ceiling b e y o n d w h i c h t h e T r e a s u r y was n o t p r e p a r e d to

find the m o n e y was first i n t r o d u c e d in 1949 b y Sir Stafford Cripps. W e m u s t therefore realise t h a t the m o n e y to be f o u n d for t h e N a t i o n a l H e a l t h Service, a n d automatically, therefore, t h e resources it can c o m m a n d , has n o w b e e n t h e s u b j e c t of limitation for some years a n d t h a t t h e service, therefore, c a n n o t be r e g a r d e d as c o m p r e h e n s i v e in the sense e n v i s a g e d b y the Beveridge Report, b u t only c o m p r e h e n s i v e in t h e sense t h a t it is p r o v i d e d so far as possible for all w i t h i n a b u d g e t t h a t h a s n o w b e e n limited. T h i s is n o t an address o n economics b u t it is necessary to p o i n t o u t t h a t w h e n we refer to t h e N a t i o n a l H e a l t h Service as costing so m a n y million p o u n d s , we have got to t h i n k w h a t those million p o u n d s r e p r e s e n t t o t h e n a t i o n b y way of resources. I n this p a r t i c u l a r context those costs r e p r e s e n t t h e a b s o r p t i o n of materials a n d m a n p o w e r to t h e extent of the total m o n e y given. T h e basis of h e a l t h is n o t p r i m a r i l y a m a t t e r of m e d i c a l a n d n u r s i n g services b u t is essentially a m a t t e r of a d e q u a t e provision of food, w a r m t h a n d clothing. W e m a y h a v e t h e finest hospital a n d a m b u l a n c e services in t h e w o r l d b u t unless at t h e same t i m e we can m a i n t a i n a s u p p l y of food w h i c h will e n s u r e a reasonable s t a n d a r d of n u t r i t i o n to everyone, we c a n n o t b e a h e a l t h y people. I would r e m i n d you t h a t in G r e a t Britain we can only grow e n o u g h food for h a l f t h e population. T h e o t h e r half of t h e food t h a t we require, e v e n at o u r p r e s e n t levels of c o n s u m p t i o n , has to b e b r o u g h t f r o m overseas a n d it has to b e p a i d for in goods a n d serviceg w h i c h we, as a nation, p r o v i d e to those w h o g r o w a n d s e n d us t h a t food. I believe t h a t to m a n y people m u c h of the p r e s e n t talk a b o u t financial crisis, t h e crisis in t h e balance of p a y m e n t s , dollar a n d gold reserves a n d so o n is n o t fully u n d e r s t o o d , b u t t h e issue seems to b e capable of simple e x p r e s s i o n in t h e p h r a s e t h a t at t h e p r e s e n t stage t h a t half of t h e food s u p p l y we need, t o g e t h e r w i t h raw materials t h a t we m u s t h a v e for o u r industries, is n o t b e i n g p a i d for b y a sufficient p r o d u c t i o n of goods a n d services in this country.. A p o i n t I shall b e discussing later is t h a t t h e n u m b e r of m e n a n d w o m e n in this c o u n t r y w h o c o n s t i t u t e t h e pool f r o m w h i c h we recruit everyone w h o works is fixed. E v e r y m a n a n d w o m a n w h o is r e c r u i t e d f r o m t h a t pool to w o r k in t h e N a t i o n a l H e a l t h Service, or for t h a t m a t t e r a n y o t h e r social service, s u c h as education, has to b e p r o v i d e d w i t h food a n d t h e o t h e r basic necessities of life b y s o m e o n e w h o is e n g a g e d on o r o d u c t i v e work. I t is true, of course, t h a t every p r o d u c e r is a c o n s u m e r , b u t it is o b v i o u s l y the case t h a t n o t every c o n s u m e r is a p r o d u c e r . W e can, of course, say t h a t in m o d e m civilisation t h e services of m a n y people w h o are n o t p r o d u c e r s t h e m s e l v e s are v e r y n e c e s s a r y to t h e p r o p e r f u n c t i o n i n g of the p r o d u c e r s , a s i m p l e illust r a t i o n b e i n g t h e lorry d r i v e r w h o carries food f r o m t h e f a r m s to t h e markets. As I have explained, m o n e y can, as a b r o a d generalisation, be r e g a r d e d as a m e a s u r e of t h e d e m a n d t h a t t h e i n d i v i d u a l or organisation h a v i n g it c a n m a k e o n t h e available resources of the n a t i o n and, b e a r i n g this in m i n d , let u s e x a m i n e briefly h o w t h e cost of t h e NatiOnal H e a l t h Service is m e t . P a r t of the social legislation t h a t came into effect in 1948 was t h e N a t i o n a l I n s u r a n c e Act a n d t h a t p r o v i d e s f o r p a y m e n t s to b e m a d e b y all paid workers (for example, I p a y 5s. ld., m y e m p l o y e r s pay 4s. 4d.) a n d t h e M i n i s t r y of National Insurance administers the tremendous funds that arise as a result of all of us w h o are w o r k i n g m a k i n g paym e n t s of this sort. T h e s e p a y m e n t s are d e v o t e d to a variety of purposes, for example, sickness benefits, m a t e r n i t y benefits, a n d so on, b u t u n f o r t u n a t e l y it is v e r y widely believed t h a t t h e whole of t h e N a t i o n a l I n s u r a n c e c o n t r i b u tion t h a t a n i n d i v i d u a l pays goes t o w a r d s t h e N a t i o n a l H e a l t h Service, a n d this is s u p p o s e d b y some people to justify a c l a i m t h a t h a v i n g p u t so m u c h in, t h e y are e n t i t l e d to d r a w so m u c h o u t in t h e way of medical a n d o t h e r h e a l t h services. I n fact, only a b o u t 10d. of t h e 5s. ld. goes to t h e N a t i o n a l H e a l t h Service a n d we can say that, of t h e total figure of s t h a t has got to b e f o u n d n e x t year for the N a t i o n a l H e a l t h Service, only a b o u t s comes f r o m t h e N a t i o n a l I n s u r a n c e f u n d . T h e r e are, of

PUBLIC HEALTH, January, 1953

56 course, t h e various p a y m e n t s t h a t are made, for example, for private beds, local a u t h o r i t y p a y m e n t s , civil defence, a n d so on, t h a t r e d u c e t h e gross cost of the service f r o m s to j u s t u n d e r s t h a t h a s to b e m e t f r o m general taxation. N o w general t a x a t i o n s i m p l y m e a n s taxes t h a t are levied for t h e general u p k e e p o f t h e n a t i o n ' s essential services, s u c h as the Navy, t h e A r m y , t h e Civil Service, a n d so on, a n d they, of course, affect every individual. W h y is it t h a t t h e cost of t h e N a t i o n a l H e a l t h Service is so widely different f r o m t h e estimates of 1942 a n d 1946 ? W h e n we c o n s i d e r t h e p r e s e n t figure of s we have to r e m e m b e r t h a t t h a t does n o t adequately reflect t h e cost of w h a t w o u l d be a t r u l y c o m p r e h e n s i v e service because if we h a d t h a t t h e cost w o u l d certainly b e far greater. Since 1949 t h e G o v e r n m e n t s of the day have limited the cost to be m e t f r o m general taxation to a b o u t s as r e p r e s e n t i n g t h e m a x i m u m t h a t we can devote to the service f r o m o u r resources of m a n p o w e r a n d materials. F i r s t of all, of course, we m u s t r e m e m b e r t h a t t h e r e has b e e n a d e p r e c i a t i o n in t h e value of m o n e y , t h a t is, a p o u n d n o w b u y s less in t h e w a y of resources t h a n it did in 1946 a n d 1942. (See G r a p h IIT.) GRAPH II1 Cost of National Health Service in Great Britain V~uE

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T h a t , however, is n o t t h e whole of t h e story a n d we get c o m p l a i n t s of extravagance in a d m i n i s t r a t i o n , i n t h e s u p p l y o f wigs a n d corsets a n d the provision of medical services to foreigners w h o m a y h a v e suffered severe s t o m a c h injuries f r o m E n g l i s h cooking. T h e r e m a y be extravagance in a d m i n i s t r a t i o n ; it m a y cost s to p r o v i d e wigs a n d c o r s e t s ; it m a y cost a little to p r o v i d e foreigners w i t h m e d i c a l care, b u t none o f t h o s e t h i n g s is really r e s p o n s i b l e for t h e wide miscalculations as to cost. A favourite a r g u m e n t is t h a t t h e cost o f t h e service shows t h e e x t e n t of t h e n e e d t h a t existed before t h e A c t came into force a n d t h e corollary to this a r g u m e n t , therefore, m u s t b e t h a t in s o m e way or o t h e r c o n t i n u e d e x p a n s i o n of t h e N a t i o n a l H e a l t h Service m u s t n o t b e p r e v e n t e d as " o t h e r w i s e the n e e d t h a t has b e e n disclosed is n o t b e i n g m e t in a c o m p r e h e n s i v e fashion. T h e difficulty a b o u t a n objective a s s e s s m e n t of this type o f a r g u m e n t is to d e t e r m i n e w h a t true n e e d is in a m e d i c a l sense a n d w h e t h e r it is i m p e r a t i v e t h a t every n e e d t h a t a n i n d i v i d u a l h a s in respect of h e a l t h services m u s t , at all t i m e s a n d at all costs, be met by the community. W e m u s t also ask. ourselves w h e t h e r , in o u r o w n opinions, t h e e n o r m o u s increase in t h e co~t of t h e service has b e e n t r u l y reflected b y a p r o p o r t i o n a t e increase in t h e n u m b e r of doctors, n u r s e s a n d h o s p i t a l b e d s t h a t b e c o m e available as c o m p a r e d w i t h p r e 1948 days, a n d I t h i n k t h e a n s w e r to t h a t is t h a t t h e p r o p o r tionate increases in these facilities are well b e l o w t h e general increases in cost. I believe t h a t t h e true e x p l a n a t i o n of t h e cost a n d e x p a n sion of t h e N a t i o n a l H e a l t h Service is to b e m e t i n t h e m o s t cogent a r g u m e n t s p u t f o r w a r d b y D r . F f r a n g c o n R o b e r t s i n his b o o k " T h e Cost of H e a l t h . " H e p o i n t s o u t t h a t t h e Beveridge Report, in dealing w i t h a c o m p r e h e n s i v e h e a l t h service, was b a s e d u p o n a fallacy i n believing

t h a t a c o m p r e h e n s i v e h e a l t h service could m a k e t h e p o p u lation healthy a n d keep it so. It is a f u n d a m e n t a l fact t h a t h u m a n life s u r v i v e d for at least a million years w i t h o u t a n y form of organised medical services, b u t t o - d a y we are, of course, n o t c o n c e r n e d with survival of life i n t h a t relatively p r i m i t i v e form. W e are c o n c e r n e d far m o r e w i t h securing a n d m a i n t a i n i n g in every i n d i v i d u a l t h e h i g h e s t possible s t a n d a r d of health. D r . Roberts, however, p o i n t s o u t t h a t the d e m a n d s w h i c h a c o m p r e h e n s i v e N a t i o n a l H e a l t h Service can m a k e in m o n e y a n d m a n p o w e r a r e illimitable because m e d i c i n e is n o w closely i n t e g r a t e d w i t h science a n d science has n o k n o w n b o u n d a r i e s n o r is it likely, w i t h i n a n y f u t u r e t h a t we c a n foresee, to h a v e explored every possible field o p e n to it. As you all know, we only s t a n d at the gateway o f t h e field of a t o m i c physics. T h e r e are vast fields of research into the f u t u r e a n t i b i o t i c s ; c h e m i c o - t h e r a p y is still developing. All t h e s e fields are, however, ones t h a t call for very great d i v e r s i o n of m o n e y a n d m a n p o w e r for t h e i r fullest exploitation a n d I t h i n k we m u s t , w i t h reluctance, accept t h e fact t h a t t h e limitations w h i c h are i m p o s e d b y t h e v e r y n a t u r e of h u m a n social organisation in t h e p r e s e n t stage of n a t i o n a l a n d i n t e r n a t i o n a l o r g a n i s a t i o n m u s t slow d o w n a n d r e s t r i c t the fullest application i n practice of t h e a d v a n c e s of m e d i c i n e , n o w so closely allied to scientific enterprise. I t h i n k it essential t o an u n d e r s t a n d i n g of t h e N a t i o n a l H e a l t h Service in t h e m o d e r n Welfare State to look back at w h a t was t h e position before 1948. T h e n a t i o n a l i n s u r a n c e s y s t e m created b y M r . L l o y d G e o r g e i n 1911 p r o v i d e d t h a t s o m e 9 0 % of t h e w a g e e a r n i n g p o p u l a t i o n , b u t n o t t h e i r wives a n d c h i l d r e n , p a i d a weekly c o n t r i b u t i o n to i n s u r a n c e f u n d s , t h e i r e m p l o y e r s p a i d a s o m e w h a t similar c o n t r i b u t i o n a n d t h e S t a t e c o n t r i b u t e d a small a m o u n t t o w a r d s t h e cost of a d m i n i s t r a t i o n . O r i g i n ally, in 1911, t h e s e c o n t r i b u t i o n s w e r e o n l y c o m p u l s o r y for wage e a r n e r s e a r n i n g b e l o w s a year ; t h e n t h e limit was raised to s a year i n 1919, a n d later to s a n d t h a t covered some 9 0 % of t h e wage earners. I n r e t u r n for his weekly p a y m e n t s , t h e i n s u r e d w o r k e r was e n t i t l e d to general p r a c t i t i o n e r services, t o g e t h e r w i t h m o n e y p a y m e n t s w h e n h e was ill. T h e s c h e m e was, however, a n i n s u r a n c e o n e i n t h e t r u e sense of t h e t e r m , t h a t is, t h e total a m o u n t of m o n e y t h a t was collected f r o m t h e worker, his e m p l o y e r a n d t h e State was t h e total a m o u n t o f m o n e y to p r o v i d e doctors, m e d i c i n e s a n d m o n e y p a y m e n t s w h e n h e was sick. S o m e o f the A p p r o v e d Societies, t h r o u g h w h i c h t h e s c h e m e was a d m i n i s t e r e d , h a d a little m o r e m o n e y t h a n o t h e r s a n d were able to give additional benefits, for example, d e n t u r e s , glasses a n d convalescent care, a n d this t h e y could do because the a m o u n t of m o n e y p r o d u c e d f r o m t h e t h r e e c o n t r i b u t o r s was m o r e t h a n was n e c e s s a r y to p r o v i d e doctors, m e d i c i n e s a n d sickness p a y m e n t s . T h a t was a n i n s u r a n c e scheme, a n d to p a r a p h r a s e a p o p u l a r phrase, t h e sky was n o t the limit in u s i n g it, t h e l i m i t as to w h a t could b e d r a w n o u t b e i n g fixed b y w h a t was b e i n g p a i d in. O n t h e hospital side, local authorities p r o v i d e d services for w h i c h people h a d to pay a c c o r d i n g to t h e i r m e a n s . O n t h e v o l u n t a r y h o s p i t a l side similar a r r a n g e m e n t s applied, except t h a t t h o s e hospital authorities h a d n o legal p o w e r to recover d e b t s a n d were f r e q u e n t l y r u n n i n g i n s u r a n c e schemes w h e r e b y , for t h e p a y m e n t of a few p e n c e a week, a c o n t r i b u t o r a n d his family were e n s u r e d hospital t r e a t m e n t w h e n t h e y n e e d e d it. I n passing, I w o u l d say t w o t h i n g s : t h e first is t h a t I v e r y m u c h d o u b t w h e t h e r , before 1948, anyone w e n t w i t h o u t hospital t r e a t m e n t because t h e y could n o t afford it ; a n d secondly, the a m o u n t t h a t m e m b e r s of t h e c o m m u n i t y were p r e p a r e d to pay in t h e f o r m o f i n s u r a n c e s c h e m e s for s e c u r i n g hospital care was e x t r e m e l y small w h e n c o m p a r e d w i t h t h e a m o u n t t h e y w e r e p r e p a r e d to pay for football pools, d r i n k i n g a n d b e t t i n g . T h e r e is a lesson to b e learned f r o m this second p o i n t a n d it is t h a t w h e n a n i n d i v i d u a l was c o n f r o n t e d w i t h a choice as to h o w h e was to s p e n d his m o n e y , h e d i d not, in t h e years before 1948, a p p e a r to value very h i g h l y t h e h e a l t h service. A p a r t , therefore, f r o m t h e N a t i o n a l H e a l t h I n s u r ance s y s t e m w h e r e b y t h e r e was a legal s a n c t i o n o n e m p l o y e d

PUBLIC HEALTH, January, 1953 persons earning under s a year to m a k e a c o n t r i b u t i o n t o w a r d s t h e i r m e d i c a l care, the position before 1948 was that, in general, t h e a m o u n t of medical care t h a t an i n d i vidual chose to have was his o w n c o n c e r n a n d unless h e could p r o v e his n e e d u n d e r the P o o r Law, h e accepted financial responsibility for it. Since 1948, however, this responsibility of t h e individual has b e e n almost entirely abolished so far as freewill p a y m e n t s are c o n c e r n e d . I say almost entirely because, as y o u know, t h e N a t i o n a l H e a l t h Service n e v e r has b e e n entirely free because c e r t a i n parts of the local a u t h o r i t y service have h a d to b e paid for b y those w h o h a d t h e m e a n s to d o so, for example, t h e d o m e s t i c help a n d recuperative or holiday h o m e care u n d e r Section 28, a n d increasingly P a r t I V services are n o w t h e subject Of charges. I t seems to m e t h a t for at least two years past t h e N a t i o n a l H e a l t h Service has, in fact, b e e n in the position that, in t h e o p i n i o n of two G o v e r n m e n t s of opposite political faiths, it has, in its d e m a n d s o n national resources a n d m o n e y materials, r e a c h e d t h e level t h a t c a n n o t b e exceeded for the p r e s e n t ; raising t h a t level of e x p e n d i t u r e of m o n e y w o u l d b e g i n to a b s o r b resources t h a t are n e e d e d in o t h e r directions, for example, to s u p p l y us w i t h a n a d e q u a t e a m o u n t of food, coal to keep us w a r m a n d t h e m a n y o t h e r services such as e d u c a t i o n t h a t h a v e s t r o n g claims to a p r o p e r share of n a t i o n a l resources. I t seems, therefore, t h a t we can s u m u p w h a t we have already c o n s i d e r e d b y saying t h a t t h e N a t i o n a l H e a l t h Service n o w faces a crisis in m o n e y expressed i n t e r m s of resources of m a n p o w e r a n d materials a n d it w o u l d a p p e a r a reasonable a s s u m p t i o n to say t h a t this crisis has arisen because two t h i n g s were n o t foreseen. T h e first t h i n g t h a t w a s n o t foreseen was t h e t r e m e n d o u s e x p a n s i o n t h a t could take place in a h e a l t h service because of t h e w e l d i n g t o g e t h e r of m e d i c i n e a n d science, a n d t h e s e c o n d t h i n g t h a t was n o t foreseen was h o w t h a t . e x p a n s i o n w o u l d b e utilised once t h e m a i n b u r d e n o f p r o v i d i n g m e d i c a l care was t r a n s f e r r e d f r o m each i n d i vidual to the c o m m u n i t y as a whole. N o w we cannot, a n d i n d e e d m u s t not, fail to recognise t h a t since 1948 the N a t i o n a l H e a l t h Service h a s p r o v i d e d a m u c h b e t t e r d i s t r i b u t i o n of available resources for t h e diagnosis a n d t r e a t m e n t of illness, particularly in t h e h o s p i t a l field. W e m u s t recognise t h a t t h e unified n a t u r e o f t h e organisation of t h e N a t i o n a l H e a l t h Service u n d e r t h e M i n i s t r y of H e a l t h has b r o u g h t a b o u t a far b e t t e r d e p l o y m e n t of available resources ; yet we are b o u n d to recognise certain a w k w a r d facts a b o u t the deficiencies of t h e service a n d ask ourselves w h e t h e r t h e gap b e t w e e n n e e d a n d t h e provision is stationary, increasing or decreasing. T h e M i n i s t r y of H e a l t h tells us we are 29,000 n u r s e s s h o r t a n d in t h e a n n u a l r e p o r t for t h e year e n d e d M a r c h , 1950, t h e M i n i s t r y goes o n to p o i n t o u t t h e large n u m b e r of b e d s t h a t are e m p t y b y r e a s o n of this shortage. I do n o t n e e d to tell you a b o u t t h e p r o b l e m s created b y t h e shortage o f staffed beds in sanatoria, m e n t a l hospitals, m e n t a l deficiency colonies a n d e v e n t h e general h o s p i t a l s - - t h e s e are k n o w n . T h e question, however, w h i c h we m u s t ask ourselves is, are we s h o r t of 29,000 n u r s e s because of G o v e r n m e n t a l decisions to impose, to use t h e f a s h i o n a b l e t e r m , a ceiling o n e x p e n d i t u r e , or is it because t h e resources in t e r m s o f m a n p o w e r a n d materials are n o t t h e r e ? T o p u t it a n o t h e r way, w h a t w o u l d h a p p e n i f t h e G o v e r n m e n t s u d d e n l y decided to s p e n d a n o t h e r s on the health service ? W o u l d we t h e n get o u r nurses, n e w hospital buildings, a n d so o n ? M y view is t h a t if we d i d h a v e another s w e still could n o t p r o v i d e a t r u l y c o m p r e h e n s i v e service to satisfy everyone because t h e alliance of m e d i c i n e a n d science would, I believe, foster d e v e l o p m e n t faster t h a n t h e rate of d e v e l o p m e n t of resources to m e e t n e w needs. I t seems to m e t h a t as a c o m m u n i t y we h a v e n o t yet r e a c h e d the stage w h e r e we are p r e p a r e d to recognise a n d accept t h e fact t h a t t h e State is o n l y t h e i n d i vidual writ large a n d h e n c e t h e resources of t h e State are n o greater t h a n t h e resources t h a t c a n b e c o n t r i b u t e d b y all i n d i v i d u a l s w i t h i n t h e State. T h e r e is still t h e l i n g e r i n g belief t h a t s o m e w h e r e a n d in some fashion t h e r e is a h i d d e n

57 reservoir of m o n e y , resources a n d p o w e r that, b y some P a r l i a m e n t a r y feat of legislation, can b e t a p p e d to p r o v i d e us w i t h e v e r y t h i n g t h a t we w a n t to have. T w o n e w c o n s i d e r a t i o n s n o w arise o n m a n p o w e r . T h e first is w h a t is t h e availability of w o m e n for the m i d w i f e r y a n d n u r s i n g profession n o w a n d in the next 10 years, a n d t h e second is w h a t t y p e of p o p u l a t i o n h a v e we got in G r e a t B r i t a i n a n d w h a t will be the d e m a n d s of t h a t p o p u l a t i o n o n t h e social services, i n c l u d i n g t h e N a t i o n a l H e a l t h Service ? F i r s t of all we m u s t recognise the fact t h a t food is an essential to h e a l t h a n d t h a t half of o u r p r e s e n t p o p u l a tion has to b e fed b y food g r o w n b y s o m e o n e overseas. W e m u s t , therefore, r e m e m b e r that, in r e g a r d to t h e d e m a n d s m a d e for pairs of h a n d s in a n y social service, t h e first essential is t h a t these pairs of h a n d s c a n be s p a r e d f r o m t h e p r i m a r y j o b of p r o d u c i n g e i t h e r food for half of us or p r o d u c i n g s o m e t h i n g else t h a t can be e x c h a n g e d for foreign food to feed t h e o t h e r half. W i t h o u t t h a t basic fact b o r n e firmly in m i n d , we c a n n o t arrive at a t r u e u n d e r s t a n d i n g of w h a t t h e f u t u r e task is in regard to t h e o r g a n i s a t i o n of t h e social services. H o w e v e r , to r e t u r n to the question of w h a t sort of p o p u lation we have. T h e first p o i n t I m u s t make is t h a t we have a p o p u l a t i o n in w h i c h t h e average age is steadily rising. (See G r a p h IV.) GRAPH IV T h e average age of the population, England and Wales AVERAGE AGE IN YEARS

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O u r p o p u l a t i o n has g r o w n f r o m 18,000,000 in 1851 in E n g l a n d a n d Wales to nearly 44,000,000 in 1951. T h e rate of increase is, of course, b e g i n n i n g to flatten out, a n d G r a p h V shows w h y t h a t is so. Y o u see t h e b i r t h - r a t e and t h e d e a t h - r a t e s h o w n over t h e past 100 years and, very briefly, w h e n t h o s e two rates come together, as t h e y nearly did in 1940, t h a t m u s t result in a static population. GRAPH V Birth and death rates, England and W'ales, 1851-1951 PER I000 POPlTLATION

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58 GRAPH VI Infant mortality rates, England and Wales J50 ~

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G r a p h V I shows t h e i n f a n t m o r t a l i t y rate over t h e past 100 years a n d you will see h o w that has b e e n reduced. E v e r y child is, of course, a potential citizen a n d wage e a r n e r of t h e f u t u r e a n d it is obvious t h a t a series of events w h i c h resulted in s u c h a s h a r p drop f r o m 1901 o n w a r d s c a n n o t result in giving us a large n u m b e r of additional c h i l d r e n in t h e f u t u r e because the rate is n o w e x t r e m e l y low at 26 deaths u n d e r t h e age o f o n e for each t h o u s a n d live b i r t h s and, in spite of e v e r y t h i n g we m a y do, it is n e v e r likely t h a t we shall get to t h e state of n e v e r losing a single child u n d e r one. E a c h c h i l d u p to t h e age of 15 at least is a d e p e n d a n t , t h a t is, a p e r s o n w h o requires to have his or h e r n e e d s m e t w i t h o u t directly c o n t r i b u t i n g h i m s e l f or h e r self t o w a r d s t h e resources of t h e c o u n t r y ; yet b e a r i n g in m i n d t h a t t h e n a t i o n is i m m o r t a l , e v e n a l t h o u g h t h e i n d i viduals w h o compose it are mortal, it is to t h i s g r o u p of d e p e n d a n t s t h a t we look to carry o n in t h e f u t u r e a n d indeed, to p u t it o n a selfish basis, to m a k e provision for u s in o u r old age. I m a k e this p o i n t because, in o u r p l a n n i n g t o - d a y it o u g h t to b e a d u t y u p o n us to see to it t h a t we d o n o t e x p e n d too m a n y of o u r resources for i m m e d i a t e needs, but, as a direct expression of n a t i o n a l policy, use some of those resources to b u i l d u p for the n e x t generation. I come now, however, to G r a p h V I I w h i c h , I think, is of t h e greatest i m p o r t a n c e a n d w h i c h shows t h e age d i s t r i b u tion in E n g l a n d a n d Wales of t h r e e m a i n g r o u p s of people. GRAPH VII Age distribution,England and Wales o~l" OFIO0

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t h e r e were 67 o u t of every 100 people w h o were workers ; 22 out of every 100 were u n d e r 15, b u t 11 were over 65. N o w the significant feature a b o u t t h a t series is t h a t it is o u t of t h e l e f t - h a n d g r o u p t h a t the workers of t h e f u t u r e are to come, a n d it is o u t of t h e age g r o u p of the workers t h a t the old will come. N o t h i n g t h a t we can do c a n a l t e r t h a t figure of c h i l d r e n a n d t h e r e is n o i m m e d i a t e sign t h a t in t h e n e x t 10 years t h e n u m b e r of c h i l d r e n to b e b o r n is likely to be very r n u e h different f r o m t h e n u m b e r of c h i l d r e n b o r n in t h e past 10 years. I will n o t take you u p to 1990, b u t let us look briefly at t h e figures for 1970. T h e r e t h e n u m b e r o f people over 65 has risen to 14 in each 100 a n d t h e n u m b e r of c h i l d r e n has d r o p p e d to 20 in each 100. W h a t are t h e p r o s p e c t s facing t h e N a t i o n a l H e a l t h Service in regard to t h e availability o f workers to it ? I n t h i s c o u n t r y t h e M i n i s t r y o f L a b o u r tell us t h e r e are s o m e 22,000,000 people working, w h i c h is 2,000,000 m o r e t h a n in 1939. O f this increase in n u m b e r s , j u s t over h a l f - - i n fact 1,075,000--are w o m e n a n d t h a t m e a n s t h a t 2 0 % m o r e w o m e n are e m p l o y e d t h r o u g h o u t t h e c o u n t r y in i n d u s t r y , t h e professions a n d various services t h a n t h e r e were before t h e war. N o w o u t of that 2 0 % increase, or j u s t o v e r 1,000,000, the professions have a b s o r b e d 160,000 w o m e n , m a i n l y in the e d u c a t i o n a l a n d h e a l t h services. T h e interesting t h i n g is t h a t of t h e s e 160,000 increase in t h e n u m b e r o f w o m e n e m p l o y e d in t h e professions, n u r s i n g a n d m i d w i f e r y have taken 5 0 % , t h a t is, 80,000. J u s t reflect o n t h a t figure for a m o m e n t because it m e a n s this : t h a t before t h e w a r t h e r e were 160,000 w o m e n e m p l o y e d in n u r s i n g a n d m i d wifery a n d n o w t h e r e are 240,000. Whilst, t h e r e f o r e , t h e r e has b e e n a 2 0 % increase in t h e n u m b e r of w o m e n e m p l o y e d since 1939, in t h e field of n u r s i n g a n d m i d w i f e r y t h e increase has b e e n 5 0 % a n d it can, I t h i n k , be a r g u e d t h a t t h e h e a l t h services have h a d far m o r e t h a n t h e i r f a i r share. N o w I m e n t i o n e d j u s t n o w t h a t t h e r e is a s h o r t a g e of 29,000 n u r s e s a n d we m u s t ask ourselves w h a t w o u l d b e t h e effect o n t h e c o u n t r y ' s e c o n o m y if those vacancies were filled. I a m no p r o p h e t o n e c o n o m i c events, b u t I t h i n k we m u s t take t h e view t h a t w h e n t o - d a y t h e u r g e n t n e e d is for m o r e pairs o f h a n d s to p r o d u c e m o r e goods f o r sale abroad, it is unrealistic to c l a i m t h a t w h a t e v e r h a p p e n s elsewhere t h e h e a l t h services m u s t c o n t i n u e to claim greater n u m b e r s o f those w h o are available for work. G r a p h V I I I shows t h e n u m b e r of girls b e t w e e n t h e ages o f 15 a n d 19 a n d t h e t r e n d for t h e future. GRAPH V I I I N u m b e r of women (age-groups 15-19) per 1,000 female population, England and Wales

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80

ESTIMATED 19TO

I []

I

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F o r t h e sake of convenience, this age d i s t r i b u t i o n is w o r k e d o u t over 100 p e o p l e - - t h o s e u n d e r 15 w h o are d e p e n d a n t s - - t h o s e b e t w e e n 15 a n d 65 w h o m a y b e r e g a r d e d as the pool f r o m w h i c h we d r a w t h e b u l k of o u r wage e a r n e r s - - a n d those over 65 w h o we w o u l d like to r e g a r d as b e i n g n o longer called u p o n to work a n d who, as you well know, in m a n y cases r e q u i r e care a n d attention. As a generalisation, we can say t h a t it is t h e d u t y of those b e t w e e n 15 a n d 65 to work a n d look after t h e o t h e r two groups, t h a t is, those u n d e r 15 a n d those over 65. L o o k at t h e position in 1901. T h e r e were t h e n 63 people o u t of every 100 w h o were w h a t we can call workers a n d t h e r e were 37 who, b r o a d l y speaking, were d e p e n d a n t s . In 1950

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65

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60 5F Ys

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193,7 /~/2

1947 I952 -

1957 1962 1967 -

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1972 I97Z

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I n G r a p h V, g i v i n g t h e b i r t h - r a t e s of t h e nation, o n e of the m o s t significant features is the s h a r p d r o p t h a t took place b e t w e e n 1920 a n d 1930 a n d the slower d r o p t h a t took place b e t w e e n 1930 a n d 1940. O b v i o u s l y a d r o p in t h e b i r t h - r a t e m e a n s that, as fewer babies are b o r n , 20 years later t h e r e will be fewer adults available for work. T h a t d r o p in t h e b i r t h rate for some 20 years before t h e w a r m e a n s that, in t h e n e x t 10 years, t h e n u m b e r of w o m e n b e t w e e n 18 a n d 30 w h o will b e available for e m p l o y m e n t will decrease b y nearly 485,000. T o p u t it a n o t h e r way, we are faced w i t h

PUBI.IC HEALTH, January, 1953 the position that until 1957, w h e n we get some relief f r o m the higher b i r t h - r a t e f r o m 1945 onwards, t h e r e will be 100,000 f e w e r girls r e a c h i n g the age of 18 each year t h a n t h e r e were in 1939. As you know, at the m o m e n t the c o u n t r y ' s schools are having to take in increased n u m b e r s of c h i l d r e n w h o have n o w reached the age of five, these n u m b e r s having increased as a result o f the b i r t h - r a t e in p o s t - w a r years. W e d e m a n d smaller classes, w h i c h m e a n s m o r e teachers, and at the same t i m e nullify our efforts to recruit those teachers b y e m p h a s i s i n g the n e e d for r e c r u i t m e n t into nursing. T h e s e figures s h o w us quite plainly that for t h e next 7 to 10 years, as c o m p a r e d with the past 20 years or so, there is g o i n g to be a serious shortage of y o u n g people and that will be particularly marked in the case o f women.

T w o grave factors therefore arise. T h e first is t h a t t h e field o f r e c r u i t m e n t for all f o r m s of w o m e n labour will be smaller t h a n it has b e e n in the past and will not begin to i m p r o v e for a n o t h e r eight years and even t h e n the i m p r o v e m e n t is n o t going to be marked. T h e second i m p o r t a n t grave factor is t h a t t h e increase that has taken place in the n u m b e r of nurses and midwives since 1939 m u s t , of necessity, be slowed u p very considerably simply because the w o m e n are not there to be recruited. W e cannot, o f course, neglect the fact that, taking a very wide view of our responsibilities in the field of health, w e have to recognise that t h e r e is likely to be a f u r t h e r increase in the d e m a n d s for w o m e n , a n d m e n for that matter, to work in t h e field of p r o d u c t i o n if the nation is to increase its exports to obtain a d e q u a t e food to maintain a reasonable s t a n d a r d of life. I believe it to be true that the National H e a l t h Service faces a crisis in w o m a n p o w e r in that it cannot n o w discharge all its c o m m i t m e n t s and that position is b o u n d to deteriorate over the n e x t few years simply because t h e r e were n o t enough girl babies b o r n in t h e years before the war. It is also, I think, of i m p o r t a n c e to recognise the fact that we have n o t only got to t h i n k about p r e s e n t n e e d s b u t also the future n e e d s of the nation and bear in m i n d that the p r i m a r y f u n c t i o n of w o m e n , in a biological sense, is the p r o d u c t i o n of babies to carry on the future o f the race. H o w far will the b i r t h - r a t e be affected by the e v e r - g r o w i n g d e m a n d s for w o m e n in industry, professions and o t h e r services ? A n o t h e r i m p o r t a n t consideration that, although outside the strict a m b i t of the National H e a l t h Service, nevertheless has a bearing u p o n the n u m b e r o f people that can be e m p l o y e d in it, is the increasing work that has to be m e t in the care of old people. I have s h o w n you a chart giving the increase in the average age o f the population and we m u s t recognise that, o n an average, people to-day are living longer. O n e h u n d r e d years ago there was only one person over 65 for every 13 o f the w o r k i n g population. T o - d a y there is one p e r s o n over 65 for every six of the w o r k i n g population a n d by 1977 the figure will be one in four. C o m p a r e that in 1861 there were 1,000,000 people over 65 and the fact that t h e r e will be 6,000,000 of at least that age by 1977. As you know, the G o v e r n m e n t is at p r e s e n t considering w h a t can be d o n e to keep old people in e m p l o y m e n t , and I t h i n k w e m u s t anticipate a raising of retirem e n t ages, but, even so, the n u m b e r s of old people w h o will require s o m e f o r m of care a n d looking after by the y o u n g e r m e m b e r s of the c o m m u n i t y m u s t inevitably rise and these services, therefore, are going to c o m p e t e for the recruits. I can therefore s u m u p the s e c o n d part of w h a t I have said by saying t h a t the National H e a l t h Service faces a crisis in the s u p p l y of w o m a n p o w e r . W h i l e it is true that t h e r e is no such p e r s o n as an average m a n or a m a n in the street, can we arrive at any conclusion a b o u t w h a t the bulk of the population w h o are not e m p l o y e d in the National H e a l t h Service, b u t w h o s t a n d to benefit f r o m its operation, really t h i n k about these two p r o b l e m s ? I w o u l d hazard a guess that the ordinary individual has little knowledge of the m a n p o w e r position and I w o u l d believe it to be true to say that the

59 p r i m a r y and overriding consideration with w h i c h m o s t citizens regard the National H e a l t h Service is that w h e n they .or t h o s e nearest to t h e m n e e d medical, dental or o t h e r health services, t h e y expect t h e m quite naturally to be free and t h e y w a n t to see that the availability of t h o s e services is free of direct charge. N o one in t h e i r senses could reasonably expect that citizens at large, having b e e n p r o m i s e d a free and c o m p r e h e n s i v e National H e a l t h Service, are going to pay for the service out o f their o w n pockets simply to transfer the b u r d e n f r o m the c o m m u n i t y to t h e m as individuals. T h e only appeal t h a t can be m a d e in p r e s e n t c i r c u m s t a n c e s is to every individual's intelligence to use the service sparingly and only w h e n it is urgently necessary, since the converse o f this p r o p o s i t i o n is that if the service is used by everyone at all times and irrespective of w h e t h e r it is really necessary, t h e n the d e m a n d s m a d e in t e r m s of m a n p o w e r and resources are totally inadequate for that service to cover t h e n e e d s that t h e n arise. Yet can any of us, w h e n faced w i t h ill-health or the fear of ill-health in ourselves or those nearest to us, m a i n tain a p u r e l y objective view as to the responsibilities that devolve on us in using a State service ; indeed, we can go f a r t h e r and say that there is a direct e n c o u r a g e m e n t in the free basis of the National H e a l t h Service to all individuals to seek its aid and services at the earliest possible date in o r d e r that t h e y m a y b e restored to full health, and h e n c e to useful m e m b e r s of t h e c o m m u n i t y . We must, I think, accept the fact t h a t expansion in any h u m a n activity, w h e t h e r it be in the welfare services, State industry, private industry, or even in our o w n personal activities, cannot be achieved automatically and m u s t be g o v e r n e d in direct p r o p o r t i o n to the a m o u n t of materials and m a n p o w e r that can be p u t into t h a t activity. T h e State, in the National H e a l t h Service, can only provide the service according to the resources t h a t can b e m a d e available and at p r e s e n t we are getting near t h e end of available resources in m a n p o w e r . It is a m a t t e r for c o m m e n t here that a l t h o u g h we claim to live u n d e r a p l a n n e d organisation, we have s t o p p e d short at p l a n n i n g w h a t p r o p o r t i o n of our m a n p o w e r w e can devote to the various e n t e r p r i s e s that are u n d e r t a k e n in our state of civilisation. E v e r y b o d y knows that w e are short of nurses, dentists, coat m i n e r s , agricultural workers and so on, yet each of these shortages is c o n s i d e r e d as a separate matter. T h e p r e s e n t organisation that exists to deal w i t h conditions of service in various f o r m s of e m p l o y m e n t rests on the basis that a shortage in any particular field m u s t be o v e r c o m e b y an i m p r o v e m e n t in pay and conditions : yet since there is no great reservoir of m a n p o w e r that remains u n t a p p e d , i m p r o v e m e n t in one field can only result in deficiencies elsewhere. When those deficiencies elsewhere b e c o m e apparent, t h e y are again c o n s i d e r e d in isolation and wages are i m p r o v e d to effect increased recruiting, and so we go on. Surely the time has arrived w h e n t h e r e should be a critical e x a m i n a tion of the National H e a l t h Service to d e t e r m i n e w h a t part of the national resources can be s p e n t on it a n d what, in future years, should be its available resources in m a n and w o m a n p o w e r . D o not forget t h a t nurses are n o t the only w o m e n w o r k i n g in the National H e a l t h Service and reflect u p o n the t r e m e n d o u s increases t h a t have taken place in the n u m b e r o f medical auxiliaries. Is it not possible even n o w to r e c o n s i d e r h o w best w e can p r o v i d e a National H e a l t h Service t h a t will m e e t all essential d e m a n d s and yet d e t e r m i n e w h a t p r o p o r t i o n of the w o m e n in the population, and for that m a t t e r a considerable n u m b e r of m e n too, can p r o p e r l y be spared f r o m all the o t h e r tasks of our civilisation to work in that service ? I f we look at w h a t has been h a p p e n i n g in the National H e a l t h Service over the last f o u r years we see t h a t two successive G o v e r n m e n t s have i m p o s e d charges for certain parts of it. T h e L a b o u r G o v e r n m e n t i n t r o d u c e d charges for d e n t u r e s and glasses and t h e p r e s e n t G o v e r n m e n t has i n t r o d u c e d charges for certain people for dental t r e a t m e n t and the charge of is. for prescriptions. W h a t precisely is the significance of these acts ? It seems to m e it is a tacit acceptance of the fact that some part of responsibility for

60 a n i n d i v i d u a l ' s u s e of t h e h e a l t h service is n o t to be b o r n e b y t h e n a t i o n as a w h o l e b u t b y t h a t i n d i v i d u a l h i m s e l f . I n o t h e r w o r d s , s p e a k i n g broadly, if a n i n d i v i d u a l w a n t s d e n t u r e s , dental t r e a t m e n t , glasses o r m e d i c i n e , it is g o i n g to be his r e s p o n s i b i l i t y to p a y s o m e p a r t of t h e cost a n d n o t , as w a s t h e case w h e n t h e A c t was i n t r o d u c e d in 1948, h a v i n g t h e w h o l e o f t h e cost t r a n s f e r r e d to t h e c o m m u n i t y as a whole. I h a v e s p o k e n at l e n g t h a b o u t t h e t w o crises t h a t face t h e N a t i o n a l H e a l t h S e r v i c e - - t h e s u p p l y o f staff to it a n d t h e call it m a k e s u p o n r e s o u r c e s ; yet w e m u s t r e c o g n i s e t h a t e v e n in spite o f t h e e c o n o m i c difficulties of t h e time, t h e e s s e n t i a l s of t h e service, t h a t is, t h e p r o v i s i o n of w h a t is e s s e n t i a l l y m e d i c a l care, still r e m a i n free of direct cost. N o o n e c a n p r o p h e s y w h e t h e r f u t u r e G o v e r n m e n t s will f i n d it n e c e s s a r y to t r a n s f e r still m o r e of t h e b u r d e n of p r o v i d i n g t h e c o s t a w a y f r o m t h e c o m m u n i t y as a w h o l e to e a c h i n d i v i d u a l as a n d w h e n t h a t i n d i v i d u a l ' s n e e d s arise. I believe t h a t it is inevitable t h a t in f u t u r e a choice h a s g o t to be m a d e o f w h a t f o r m s o f t r e a t m e n t are g o i n g to be f a r too e x p e n s i v e f o r a n y i n d i v i d u a l to p r o v i d e b y h i m s e l f a n d m u s t be p r o v i d e d b y t h e State, a n d w h a t f o r m s of c a r e c a n be p r o v i d e d b y t h e i n d i v i d u a l in t h a t n o t h i n g e s s e n t i a l to his h e a l t h is b e i n g w i t h h e l d f r o m h i m if h e is n o t p r e p a r e d to m a k e a financial sacrifice h i m s e l f . I can, h o w e v e r , b u t h o p e t h a t a little m o r e d i s c r i m i n a t i o n will be u s e d t h a n at p r e s e n t b e c a u s e w h i l e it m a y be a r g u e d t h a t if s o m e o n e r e q u i r e s a d e n t u r e or d e n t a l t r e a t m e n t a n d will g o w i t h o u t r a t h e r t h a n pay, we o u g h t , I t h i n k , to look m o r e s e r i o u s l y at t h e i s s u e as to w h e t h e r c e r t a i n d r u g s t h a t m a y be r e g a r d e d as l i v e - s a v i n g o u g h t really to b e t h e s u b j e c t o f c h a r g e . By all m e a n s m a k e c h a r g e s for m e d i c i n e s a n d d r u g s , s u c h as a s p i r i n a n d c o u g h m i x t u r e s , t h a t a r e n o t a b s o l u t e l y vital to t h e i n d i v i d u a l ' s recovery, b u t is it a g o o d t h i n g to m a k e c h a r g e s f o r t h i n g s like penicillin a n d i n s u l i n t h a t are o f s u c h p r o v e d efficacy t h a t t h e y are p r o p e r l y r e g a r d e d as essential. O p i n i o n s m u s t vary, b u t m y c o n c l u s i o n is t h a t t h e root c a u s e s of t h e difficulties u n d e r w h i c h t h e N a t i o n a l H e a l t h Service is l a b o u r i n g h a v e n o t y e t b e e n fully a c c e p t e d a n d t h a t t h e policy of c h a r g e s w h i c h h a s b e e n i n t r o d u c e d , while n o d o u b t essential i n t h e p r e s e n t stage o f o u r n a t i o n a l e c o n o m y , c o u l d h a v e b e e n a p p l i e d in a different f o r m . I t is a n u n e n v i a b l e t a s k to s u r v e y t h e v a s t r a n g e o f h e a l t h services t h a t are p r o v i d e d u n d e r t h e A c t a n d to d e t e r m i n e how, w i t h i n t h e limits of n a t i o n a l r e s o u r c e s a n d m a n p o w e r , we c a n c o n c e n t r a t e u p o n t h o s e w h i c h are e s s e n t i a l a n d h e n c e can p r o p e r l y be r e g a r d e d a s a p r o p e r b u r d e n o n t h e c o m m u n i t y , a n d those w h i c h a r e less essential a n d c a n be left to t h e i n d i v i d u a l ' s choice as to w h e t h e r h e p a y s for t h e m or not. Y e t I believe s o m e s u c h choice is n e c e s s a r y , since I h a v e t h e g r a v e s t d o u b t s as to w h e t h e r it is p o s s i b l e in p r e s e n t c i r c u m s t a n c e s so to e d u c a t e t h e w h o l e of t h e c o m m u n i t y t h a t t h e y will u s e t h e h e a l t h service w i t h s u c h a d i s c r e t i o n as to be able to limit t h e i r d e m a n d s to s u c h a level t h a t o n c e again w e c a n r e t u r n to t h e p r i n c i p l e o f a n e n t i r e l y free, a n d at t h e s a m e t i m e e n t i r e l y c o m p r e h e n s i v e , service. DISCUSSION Dr. Elliott, in introducing his paper, remarked that for the past six m o n t h s increasing economic pressure on the local authorities had caused t h e m seriously to consider the limitation of their staffs. His own investigations in this connection had brought s o m e striking facts to light, ;'n particular relating to the availability of women for work in the social services. He had accordingly prepared the paper he was presenting some m o n t h s previously and had subsequently modified it on perusal of Dr. Ffrangcon Roberts' book, " T h e Cost of Health." T h e facts given in his paper regarding manpower and money were from ~fficial sources, but the deductions were his own and he welcomed the opportunity of putting t h e m before his colleagues. T h e P r e s i d e n t (Dr. C. M i l l l k e n S m i t h ) , commenting u p o n the paper which had been given, said that one factor which struck h i m was that when assessing the need for any particular g r o u p of officers, it was always the people who were financially concerned who stated the n u m b e r required, i.e., in the case of speech therapists, educational psychologists, etc., this was assessed according to their own Associations. He had always felt the need

PUBI.IC H E A L T H , January, 1953 for some independent body to decide the n u m b e r of workers available from a central pool, which would avoid the situation visualised by Dr. Elliott. Dr. G. R a m a g e congratulated Dr. Elliott on his excellent paper. W i t h regard to one point, he thought that if the rate of production in industry could be increased, more people would be available to m a n the social services. O n the point of shortage of nurses, a statement had recently been made in the Birmingham Hospital Region that the rate of recruitment was satisfactory. It was the rate of loss of nurses which was causing trouble. A striking feature was that the mental institutions had a higher rate of recruitment. Dr. A. A. L i s n e y thought that m e m b e r s themselves could do something to help in the direction of manpower. T h e introduction of Hollerith machines by the Dorset county council had helped considerably to reduce the staff engaged on statistical work. W i t h regard to the " m i d d l e " section of the population whose work supported the two extremes, was it not a fallacious argument to say that that section was diminishing, and therefore the problem was becoming more serious ? Were there not such things as labour-saving devices which would make an increasing saving in manpower ? T h e r e was an indication that at some time in the future our power stations would be driven atomically and we might be able to avoid having to dig for coal. Dr. E.C. H u d d y was glad that reference had been made to laboursaving devices. He considered the diagram showing the proportion of the population engaged in agriculture was incomplete, because our country was the most mechanised in the world. Dr. Elliott had referred to life as a " fight " - - h e thought that we should rather try to adapt a n d co-operate. He would not consider that food, warmth and clothing were the only basic needs of a civilisation. He thought it a mistake to make the supply of penicillin, insulin, etc., dependent on a charge. A diabetic should not have to pay to keep alive. T h e present difficulties of the Health Service were due to nothing more than the process of adaptation of resources to means. We, of all people, should be able to envisage the effects of prevention. Surely we could see that in the next h u n d r e d years the incidence of disease should be r e d u c e d - - i f not, the Health Services were already redundant. I n his view, in 10 to 15 years' time, tuberculosis would be a very different problem from what it was now. Dr. W. E. T h o m a s said that Dr. Lisney had referred to the need to review establishments. While Dr. Elliott took a m u c h broader view, we m u s t look at the problem from the point of view of our own departments. T h e r e seemed to be too m u c h use of female labour in a clerical capacity in the hospitals and he thought this aspect needed rather critical review. O n the question of his own n u r s i n g establishments, he was often faced with demands for in,teased st~ff, particularly for h o m e nursing work, and he always satisfied himself that these increases were really essential. T h e midwifery service was continually under review. Dr. J. A. F r a s e r said that Dr. Elliott had given a masterly s u m m a r y of the situation. He reminded m e m b e r s that Beveridge had envisaged an hotel charge for people going into hospital. H e had recently been dealing with two aspects of the Health Service problem. In the first place he had been able to persuade the North Riding Executive Council to ask the Ministry to replace the costly supplementary Eye Service with a Hospital Service ; the replacement of glasses was particularly expensive for Education Authorities w h e n a dispensing fee had to be paid for each repair. He had also suggested that in place of the is. charge per prescription, only " official " preparations should be ordered on Forms E.C.10. T h i s would cut out proprietary preparations but allow the life-saving drugs to be prescribed without cost to the patient. On the question of economy in staff, he mentioned the excessive cost of the Children's Department. I n his Riding they had had, before 1948, a carefully-worked-out scheme, under which every child was regularly visited at very little cost by health visitors and education staff, but now there was in being a separate service which cost nearly s a year for visits of inspection alone. Dr. J. L. D u n l o p thought Dr. Elliott's views could usefully be conveyed to the C.C.A. and similar bodies, because he saw no prospect of officers trying to limit social services to the bare essentials so long as committees continued to be impressed by the m a n who did things in the " grand m a n n e r " and so long as committees gave little credit to the officer who, by thought and careful planning, was able to maintain an adequate service without frills and at a modest cost. Dr. T. R u d d o c k - W e s t supported Dr. Fraser on the question of Children's Committees. T h e Children's D e p a r t m e n t was one that could be r u n by the local health authority with greater benefit and tess cost to the community. T h e same remarks applied to all welfare work and probably the institutions as well.

PUBLIC H E A L T H , January, 1953 D r . G. W. H. T o w n s e n d t h o u g h t it was easy to criticise others b u t here we should be critical of ourselves and ask w h a t contribution we could make towards providing the best possible service. T h e r e were fields of social work in which some t h o u g h t should be exercised. F o r instance, it was m o r e important to have T.B. workers than school visitors. I n view of shortages of staff, it was necessary to plan carefully h o w to use the workers to the best possible advantage. D r . G. F. B r a m l e y refused to be depressed by Dr. Elliott's remark that we were becoming an older nation and invalidism would increase. If our health services were any good at all the future m a n of 60 would be a better m a n than his grandfather was. Serious diseases like cholera and typhoid were conquered in the 19th century w i t h o u t the knowledge of preventive medicine we possessed to-day, and this preventive work m u s t go on. D r . G. E. G o d b e r agreed that the work of prevention was not finished yet. H e asked m e m b e r s to consider what the cost of the Health Service m i g h t have been if diphtheria prevention had not been discovered. H e t h o u g h t we were j u s t on the point of being able to c o n q u e r tuberculosis. T h e n u m b e r of deaths this year was likely to fall below 10,000 and the n u m b e r f r o m the great towns was u n d e r 100 weekly for the first time. A l t h o u g h the incidence, as s h o w n by notification, only gave a slight fall, it was not k n o w n h o w far these figures m i r r o r e d the true situation. It was k n o w n that waiting lists were going d o w n and he believed that in five years" time we should be facing an actual drop in tuberculosis cases. I n ten years' time we could have tuberculosis completely u n d e r control and that would m e a n that the greater part of 26,000 beds would be released together with great n u m b e r s of doctors and nurses. Dr. G o d b e r pointed out that the curative services could not be separated f r o m the preventive services and he t h o u g h t the curative services needed some impartial critic at their elbow to see that they were properly used along with the preventive services. T h e Hospital Service could be improved a great d e a l - - i t could be m a d e m u c h m o r e efficient and c o n s u m e considerably less m a n power. T h e r e were striking degrees of variation in the use of hospital beds by different h o s p i t a l s - - i n one, for instance, the n u m b e r of patients going t h r o u g h a bed in one year was 29, while in another case it was only eight. F u r t h e r m o r e , no selfrespecting American hospital would o w n to an average stay by a patient of m o r e t h a n 10 to 11 days, b u t very few English hospitals could claim such a short stay, and at least three teaching hospitals in L o n d o n had an average of 20 days. T h a t was where resources were being wasted and he was sure the hospitals could be managed with fewer beds and fewer personnel. Efforts were also being wasted in trying to operate old and inefficiently equipped hospitals. It was not merely inconvenient b u t also uneconomical to carry patients up and d o w n stairs w h e n a lift could be p u t in. One of the larger teaching hospitals had only t w o lifts and apparatus had to be duplicated on one or two floors becaus~e patients could not be easily m o v e d u p or down. H e was sure r u n n i n g costs could be cut by a little capital expenditure now. He t h o u g h t the next 10 years m u s t be devoted to trying to make the Health Service work m o r e efficiently. Dr. G o d b e r sympathised with the cry for fewer statistics, b u t could he counter with a request for m o r e accurate ones ? It was purposeless to collect for central use compendia of figures to p u t before officials just to save t h e m the trouble of reading the report of the Medical Officer of Health. I n r e t u r n for agreeing to ask for fewer statistics, he would ask to have reports sent in earlier. O n the question of life-saving drugs Dr. G o d b e r said that several countries had official lists of drugs, b u t there were obvious dangers in this method. Australia and D e n m a r k were two of these countries, b u t they found it necessary to review the list frequently. It was very difficult to keep it stable, as m a n y different things could be described a s " life-saving." The Australian list included a large n u m b e r of proprietary drugs. T h e Ministry had considered the idea very carefully b u t t h o u g h t it w o u l d do more damage than it was worth. T h e cost incurred by the diabetic for insulin was not very great, and if he was destitute there were m e a n s to help him. D r . L i s n e y said he t h o u g h t it seemed logical that the welfare services, including Part I I I accommodation, should be r u n by the health department, thus saving manpower. Also, as an e~xample, the situation arose where lay staff dealing with the admission of cases to Part I H accommodation were not in a position to discuss the case with a general practitioner recomm e n d i n g admission if this appeared unsuitable on medical grounds. I n a recent circular f r o m the Ministry on handicapped persons, which was fundamentally a medical problem, it was stated that a sufficient n u m b e r of welfare officers would be approved. As he had pointed out to his committee, the health visitor could do this work w i t h o u t t h e m appointing further specialised staff.

61 D r . Elliott, replying to some of the points raised, said that in his opinion the situation could not be m e t by unilateral action by local authorities and, even if they .took part in some wider measure of planning, the answer, so far as they were concerned, did not lie in the absorption of other departments. T h e President had made the position clear, there needed to be some authority that could lay d o w n the p r o p o r t i o n of m a n and w o m a n p o w e r that the social services could utilise and each social service ought then to consider h o w best to employ the share that it could have n o w and in the future. T h e average age of the population was rising and with the increasing n u m b e r of older people invalidism was b o u n d to increase. Anyone w h o studied the absorption of resources and m a n p o w e r in the geriatric Units could anticipate the d e m a n d s that m u s t inevitably arise in the next few years and could reflect on the figures given in his address. T h e n u m b e r of w o m e n available for work was going to decline because of the low birth-rate in the past. As to the points made about econorrfies in the hospital services he was sceptical as to their value. He foresaw that the rate of saving in resources and w o m a n p o w e r , in, for example, the field of tuberculosis, would be slower than the demand for utilising such facilities in other expanding parts of the hospital services. It seemed to h i m that there had to be a wider realisation of the peril in which we stood and hence the limitation in the a m o u n t of m a n p o w e r that the social services could have f r o m the national pool. He said that it had never been possible to p u t the clock back and specialisation was here to stay, since m o d e r n civilisation could only be carried on by an extreme subdivision of specialised labour. H e was not so optimistic as to s u p p o s e that our particular f o r m of civilised organisation could last for ever, b u t he did think that the decline need not be so rapid. Past civilisations had been o v e r t h r o w n t h r o u g h the neglect of one or m o r e of the basic criteria he had described, usually an u n d u e preoccupation with the raising of internal standards of living at the expense of protection against external enemies. It seemed that at present we were living u n d e r conditions paral!el to those of a siege war, b u t the vital factors governing production, m a n p o w e r and resources were not organised to m e e t these conditions. I n conclusion, the President remarked that the Association did not often have the opportunity of listening to papers which were characterised by a broad philosophical basis, b u t he was sure that m e m b e r s were really grateful to Dr. Elliott for his address. H i s p a p e r was the result of a critical study of the situation. Dr. Elliott was a realist and it was realism that was required to tackle the p r o b l e m s of the Health Service as it existed to-day. He thanked Dr. Elliott very warmly.

CORRESPONDENCE CIRCULAR 28/52

To tile Editor of PUBLIC HEALTH SIR,--Dr. Belam and Dr. Booth, writing in your November issue, appear to assume that all passengers arriving on an aircraft are necessarily to be dealt with as contacts if one of t h e m later becomes ill. If infectious disease occurs on an aircraft, rile passengers should be dealt with as contacts by the airport health control. If, as has usually been the case, the disease develops after arrival in this country, it is unlikely that the other passengers will be contacts. If riley should be, they will probably be better protected against smallpox t h a n most of our po.pulation. T h e r e is no record of major infectious disease occurring a m o n g aircraft passengers in this country as a result of a case occurring in one of their n u m b e r . I have on m a n y occasions while working in an airport health control doubted the value of obtaining the address to which passengers proceed. Also m a n y give accommodation addresses and m a n y of these fail to return the reply cards issued. A traveller who would ignore a B.B.C. or Press notice would hardly bother to return a reply card. Experience has shown that air travel m a y introduce smallpox. Abolition of the personal declaration should have little effect on the degree of risk involved, which can only be completely abolished by strict quarantine, a procedure difficult to justify. As long as smallpox is endemic in some countries, the greatest weakness seems to be the small proportion of people vaccinated in this country. T h i s m a y be altered by panic such as that to which Dr. Booth refers, b u r there was little sign of this when B.B.C. and Press notices were recently put out in accordance with Circular 28/52. Health Department, Yours faithfully, Civic Centre, W . P . CARGILL, Southampton. Deputy Medical Officer of. Health. November 29th, 1952.