The Price of Free Medicine; C. Brogan

[296 ] than faith in magic, but vast sums are poured out of the public purse for cures of largely imaginary value for diseases which are also largely imaginary. At the same time, nearly half the hospital beds in Brit ain are occupied by mental patients, and many would-be voluntary patients must be refused admission. Condi tions in some of these mental hospitals are deplorable. They are badly understaffed and shockingly over crowded. Yet not one new mental hospital has been opened in Britain since the start of the Health Service, nearly eight years ago. In fact, no hospital of any kind has been built and opened. At a time when both medical advance and thechal lenge to medicine are undergOing great and dramatic changes, British practice is being fossilized in attitudes as out-of.;.date as the hansom cab and the wooden stethoscope. "Nable Experimenf~ That, of course, was not the original purpose of those who framed the Health Act. They offered it as an "ex periment noble in purpose"; and the British people were promised everything, regardless of expense. Not only would their home treatments be provided free of direct charge, but the hospitals would for the first time have ample funds for treatment and research. It was said to be a disgrace to a progressive country that the great voluntary hospitals, some of them of world-wide fame, should be dependent on uncertain charity and sorely [297 ] handicapped in their beneficent work. There would no longer be any need for humiliating appeals, nor restric tions on staffing, building,. or research; and in addition, health centers would be established everywhere to bring all the general practitioners of an area together in happy comradeship, with all the most expensive resources of modern medicine at their immediate command.

That was a fine dream, but the reality proved to be far different. The administrators soon found themselves faced with two inescapable facts. The available supply of trained doctors, nurses, medical scientists, and mem bers of the semiprofessional ancillaries like physiothera pists and orthoepists was not enough to meet all the needs of the grandiose plan. The financing of the plan was even more strictly lim ited. Enthusiasts for nationalized medicine found them selves in competition with the enthusiasts for extended education, state subsidized housing, higher state pensions and benefits, and a dozen other schemes with a strong emotional and vote-catching appeal. There was competi tion not only for funds, but also for materials and for future staff. While hospital wards were shut for lack of nurses, the potential nurses of the future were tempted into teaching to meet the demands of the risen birth rate and the extra compulsory year at school ordained by the socialist government. Building materials and labor that might have been used for temporary hospital and clinic accommodations were used for temporary classrooms.

If no checks had been put on Health Service expendi ture, it would have assumed fantastic proportions. But [298 ] when expenses soon came to more than double the original estimate, it was found necessary even for a socialist government to impose a ceiling and eventually call a halt. A part of the corrective action attracted much atten tion and stirred a good deal of resentment. The patient looking for spectacles or for dental treatment had to pay a proportion of the cost, and for some the proportion was substantial. In addition, all patients were required to pay a shilling for each prescription filled. The pre scription charge failed in its purpose, however. Most of the patients resented having to pay and tried to get as much as possible on one prescription, which doubtless encouraged waste. In any event, the Labor Party, which originally imposed the charges, promises to abolish them when they get back to office"-a measure of the depths to which demagogy can sink.

Dentists in Difficulty But the other thing that was done attracted little notice outside of the medical profession. Dentists were paid by piecework, and the original rates for the various jobs were lavishly set to coax dentists into the scheme. For some time, dentists were in financial clover. But the rates have been slashed three times, reducing dentists to a very modest standard and putting some in grim finan cial difficulty as they must pay surtax on the high earn ings of a previous year out of a current income drasti cally reduced by arbitrary decree. This situation has [299 ] brought a catastrophically reduced enrollment in dental colleges, thus ending most dreams of a dental service that would concentrate on scientific conservation instead of hasty pulling and· patching. The doctors fared better than the dentists. Their re sistance to the scheme had been so strong that they were offered an income equal in purchasing power to the average medical income of 1938. When R. A. Butler became Tory Chancellor of the Exchequer, he was faced with an arbitration award which gave general practi tioners not only an increased annual payment for each patient but also a lump sum of fifty million pounds to make up for past underpayment. Nurses and lay hospital workers were in no mood for cuts in salaries and wages.

Inflation steadily increased the bill for all hospital sup plies and also for the drugs and pills doled out so lav ishly through the doctors' offices. The End of Medical Progress Thus, the National Health Service budget was strained to the breaking point. And the cuts fell on the unprotected sector of health expenditure, though this was the sector which alone could keep Britain abreast of the civilized world in medical advance. The grandiose schemes of expansion were almost all dropped, and the great teach ing and research hospitals suddenly found themselves more pinched than they had ever been before. One hos pital, which had almost completed an ambitious and modem laboratory, had to tum the key in the lock for a [300 ] considerable time because they lacked funds for the microscopes needed if the .laboratory were to serve its purpose. This is only one example of a deleterious process.

Public demand and demagogic compliance have di verted available funds away from the fruitful and im perative lines of medical advance in order to supply that kind of medicine which satisfies the credulous patient. The mass of the public were well enough pleased. Hypo chondriacs and people with nothing much to do could still crowd a harassed doctor's office at no immediate cost to themselves and call for a pill or a bottle which they might have seen advertised. Many doctors have told me that since the enactment of the Health Act a growing number of patients come to the office and say they want this drug or that, not waiting for the doctor's examina tion and verdict, but making their own selection as they might choose sweets in a confectioner's shop. There is the case of a woman whose baby was suffer ing diaper rash. She got a doctor's prescription for no fewer than ten bottles of an expensive new medicament.

The rash finally was cured when the woman was told to keep her baby dry and to apply a simple ointment. The ointment which did the trick cost fourpence (about 5 cents); the ten bottles which did no good cost thirty pounds ($84). This is one example of waste, but it could be multiplied indefinitely. The Ministry of Health has tried to deter doctors from easily prescribing expensive proprietary drugs when much cheaper equivalents are available, but the doctors [301 ] resent any dictation and the patients are even more resentful. For a long time it has been the ambition of conscien tious practitioners to wean their patients away from this pathetic faith in bottles and pills; but the Health Service has undone all such effort, and fundamental medical research is the chief sufferer. The brilliant triumphs of modern medicine have nearly all been won in the laboratory, not at the patienfs bed side or in the doctor~s office. The weight of medical investment should be in that direction, but in Britain it is being swung in what is strictly the reactionary and obsolete way.

Diseased Minds As for mental illness which is the greatest and most disturbing challenge to Western civilization, the treat ment and the cure of this menace is only in its infancy. Patient research and investigation covering the whole of social life are necessary, and equally necessary is a huge expenditure to provide the material means of effective treatment here and now. But there are British mental hospitals where the patients' beds are so crowded that it is impossible even to put a locker between them. It is impossible to get anything like enough native-trained nurses, men and women, for any kind of hospital; but at the same time, many experienced and highly qualified nurses are employed in "welfare" work where their skill and knowledge are thrown away. [302 ] I have no space to deal with the wastefully expensive tests and treatments to safeguard the doctors against legal action by litigious patients, whose court action is likely to be paid for by the same State that pays for the hospitals.

I believe that the contemporary and scientific concep tion of medicine cannot flourish fully and firmly where medicine has been socialized. The great medical advance will continue, but there is nothing in prevailing British conditions to .encourage the hope that British medicine will play in the future as remarkable and as leading a part in that advance as it has played in the past. This pessimism is not purely personal. It is shared by nearly every doctor I know who is alive to what is going on in international medicine, while stagnation of method is forced upon himseH. [303 ] FREE-MARKET FARMING AN ECONOMIST of national reputation once told me: "The trouble with agriculture is that it is a decadent business." This came as something of a shock to one who had been raised on a good Illinois farm, attended an agricultural college, operated a farm for a time, and who had dedi cated his life to teaching and research in the field of agriculture. Isn't food the first essential to life? Haven't people, through the ages, given up almost everything else rather than go hungry? Then how could the production of food be a decadent occupation?