Posts Tagged ‘D. Stark Murray’

Fee Paying, Patronage and Bankruptcy in Pre-NHS Voluntary Hospitals

May 15, 2016

Future Medicine Pic

Yesterday I put up a piece from D. Stark Murray’s 1941 book, The Future of Medicine, which described how some patients were driven to seek medical help from the hospitals, rather than their own family doctors, because they could not afford the doctor’s fees. Murray also describes the poor state of the hospitals at the time he was writing, before the advent of the NHS. Along with the municipal hospitals were the voluntary hospitals. These were supposed to be supported by private charity, but in fact this was no longer sufficient and by his time most of them had large fundraising departments. They also raised money in other ways, through charging fees and running insurance schemes. This was, however, not sufficient, and many of the small voluntary hospitals were facing closure.

Murray wrote

Today the situation is very different, and in some hospitals almost the only part of the service which is voluntary is the work of the honorary medical staff, and only a small proportion of the income arises from gifts donated in a purely voluntary fashion. How far removed from the ideals of Christian charity are those hospitals which need a large staff of paid workers to run an Appeals Department and devise schemes for collecting money! The flag day still remains the most popular method, but serves more and more to illustrate how unreliable charity has become as a means of maintaining the health of the community. Not only are hospitals staffs kept busy finding money, and incidentally costing a very considerable portion of the money which they thus collect, but few patients obtain and service from a voluntary hospital without paying in some way. The hospital almoner, who in earlier days answered the dictionary definition and bestowed the charity of the hospital on the poor, has become instead a collector of whatever small sums even the poorest can be persuaded to pay for services received. To such an extent have the users of hospitals resented this reversal of the voluntary and charitable principles that there has sprung into being, as we have noted, a very largely supported system of insurance by regular contributions against the need for hospital care.

This is of course a better system than that which was at one time the mainstay of many hospitals, and which still exists to a very large extent – the patronage system by which wealthy subscribers earn the right to nominate so many outpatients and so many in-patients according to the amount of their subscription. the securing of such nomination-the letter, or “line” as it is called in many parts of the country-is essential before the patient can obtain hospital care, but it does not guarantee admission, which is still at the discretion of the medical staff, nor does it free the patient from the attention of the lady almoner. It may be noted that membership of hospital contributory schemes does not automatically secure admission either, but it should be sufficient to cover the patient for all charges coming with the scope of the scheme…

For our purposes it is enough to note that the yearly income of all voluntary hospitals shows a steady increase in the proportion obtained as payments from patients, by contribution schemes, and by other similar methods. We must add that local authorities now have the power to pay voluntary hospitals for services rendered, and to make considerable contributions from the rates. If all these amounts are added together, it is found that in the provinces of England and Wales only 32 per cent of the income is gained by new charitable contributions. It has been admitted that the voluntary hospitals have to maintain a constant struggle to discover new methods of raising money, and are constantly revising their system for recovering some part of the cost of maintenance from the patients.

Despite these efforts the voluntary hospitals find themselves increasingly in danger of bankruptcy. It is no exaggeration to say that a very large proportion of the time spent at meetings of hospital boards is taken up with questions which hinge on the state of the hospital’s finances. This may cause difficulties in the medical treatment of patients, for it is a common experience of all staffs of hospitals that even when the Medical Committee is unanimously in favour of certain provisions of certain procedures they may find it impossible to obtain the sanction of the Finance Committee. There are those who fear that an organised hospital service may restrict the rights of the medical staff, but at least patients should be ensured that whatever is necessary for their health and well-being can and will be provided. The voluntary hospitals themselves have realised that they are no longer able to give a service wholly in keeping with modern ideas. An attempt is therefore being made to “rationalise” the hospitals, not in the sense in which a scientist would use the term but in that familiar to business men and industrialists who reorganise great industries so that their output and financial profit may be increased. The Nuffield Provincial Hospitals Trust, generously financed by Lord Nuffield, is actively engaged in persuading voluntary hospitals that they can no longer exist as isolated units, and is setting up councils and committees to reorganise the voluntary hospitals so as to concentrate their finances, to cut out overlapping hospitals so as to concentrate their finances, and to provide a service which still contain certain features of the present voluntary system.

At the moment it looks as though the Nuffield suggestions for regionally organising the hospital services will lead to the disappearance of some of those voluntary hospitals which are of such a size that they are usually termed “cottage hospitals”. These are usually hospitals so small that they cannot possibly provide a complete hospital service, or can only provide something approaching a complete service by extravagant methods….[C]ottage hospitals usually have no resident medical officer, receive only periodical visits from the consultants of larger hospitals, and are generally staffed by local practitioners. This is of course a complete denial of whole modern conception of the function of a hospital. (pp38-41).

Margaret Thatcher also wanted to introduce greater private enterprise into the NHS, and believed also that it should also get some funding through private charity. And the Tories have gone further, and are now privatising the NHS piecemeal. The current Health Secretary, Jeremy Hunt, has even written a book in which he demands the health service’s abolition.

This shows that, contrary to what the free marketeers of the Tories and Blairite New Labour claim, charity and insurance contributions alone are not sufficient to maintain hospitals. Even under this private system, the Nuffield Trust was considering closing some down. The same is pretty much true of the modern American system. Before the introduction of Obamacare, 20 per cent of Americans could not afford medical insurance, and even with the introduction of this system, insurance contributions can be crippling. Moreover, American private enterprise is hardly cost efficient. In some hospitals, up to 40% of expenditure can be on marketing, administration and maintaining legal departments against malpractice suits. And medical fees amount to something like 1/3 of all American bankruptcy cases.

For the sake of the health of the people of this great nation, we cannot let the Tories privatise the NHS. We must stop them. Now.

Advertisements

1940’s Book on Medicine Before the NHS

May 14, 2016

Future Medicine Pic

I found this book, The Future of Medicine by D. Stark Murray (Harmondsworth: Penguin 1942) in one of the second hand bookshops in Cheltenham. Its writer was a medical doctor and science writer, and the book was published when the National Government was discussing the establishment of something like the modern NHS with the Beveridge Report. The book is basically a description of the terrible state of health care as it was in the early 1940s, and the possible reforms which would create a better healthcare system.

Amongst the problems it discusses are the fees charged by contemporary doctors, and the inability of the poor to afford them. These could be so costly that some patients were going to the hospitals for cheaper treatment instead.

Whatever relations the doctor has established between himself and his patients, and generally with the public in the area in which he lives and works, the greatest barrier to perfect human relations is that sooner or later the question of fees will arise. Medicine remains a service that is sold by the doctor and much be purchased by the patient, since the doctor operates in a competitive system. To earn his living and to pay the cost of his practice he is bound to make a charge every time his services are utilised. For the patient this is great drawback, which in some cases amounts to an insurmountable difficulty, for the more ill he is the more medical care he will require and, theoretically at least, the more he will be called upon to pay. where sickness means complete loss of income, the illness becomes not merely something that jeopardises his life but part of that nightmare which is the lot of those whose economic stability is balanced precariously. (Pp.28-9)

Doctors also use their right to vary their fees as a way of getting rid of individuals or sections of their practice which they do not consider remunerative or otherwise attractive. “Night fees” fall into this category, and the doctor who has grown tired of going out in the middle of the night and who has a practice which is paying him a good income, may see the end of all but most urgent night calls by charging a sufficiently high additional fee for this service. (p. 29).

On occasions the difficulty is a totally different one. The patient is able to pay the doctor’s ordinary fee for a short illness but unable to face the kind of bill that would mount up if daily visits proved necessary over a long period. In other cases the patient may be able to pay the doctor’s maximum charge but unable to face bills for extras, food delicacies, expensive drugs, nursing assistance, and so on.

This very significant figure shows to what extent the patient has doubted the efficiency and quality of the service obtainable by the panel and private fee systems, leading him to look for something better at hospitals which have acquire a reputation for sound medical work. Whether these people went to the outpatient department through the agency of their own doctor or did so on their own initiative, the significant point is that they are exchanging the personal service of the isolated general practitioner for the organised and therefore possibly more efficient but strictly impersonal services of the doctors attached to the hospital…

Nevertheless it is significant that so many turn to the hospitals for a service they cannot obtain otherwise. This need not be regarded, as in some medical quarters, as a blow at the medical profession as a whole, nor accepted with complacency by those who control the hospitals as proof their perfection; but rather as an indication of the patients’ demand for something more than they get today. That demand is not for a “friend of the family” with a bedside manner, but for a service or chain of services in which the general practitioner and the hospital should be mutually dependent links. (P. 26).

This was the state of healthcare in Britain before the establishment of the NHS, and it’s still the state healthcare in America, where 20 per cent of the population could not afford private medical insurance until the introduction of Obamacare. Medicine is immensely profitable, which is why the Tories under Jeremy Hunt, the Health Secretary, are doing their level best to privatise the NHS. They must be stopped.

Capitalist Healthcare