HEALTH SERVICE

Evening Post, Volume CXXIII, Issue 46, 24 February 1937, Page 8

HEALTH SERVICE

EXISTING FAULTS

POSITION ANALYSED

DR. STOUT'S ADDRESS

A reorganisation of the central and local administration of health services in the community, so as to set up a highly efficient Board of Health with full administrative control of all activities in the country, was urged upon the Government by Dr. T. D. M. Stout, president of the New Zealand branch of the British Medical Association, in his presidential address. Dr. Stout dealt at some length with the difficulties and deficiencies of the existing medical service in New Zea.land, and suggested a number of lines along which it could be improved. He also suggested that' the ■"■:' Government, in introducing :■ its 'health . insurance scheme, should arrange for the community hospital- system, and should make provision for medical' research on an'adequate'scale.

In discussing the way in' which medical practice in New Zealand was not producing a : service that was requisite to the community, Dr. Stout said that there were two main difficulties. First there were unfortunately a large number of citizens who could afford to pay for efficient medical treatment, especially treatment as supplied by a general practitioner, in their homes. The public hospitals did supply hospital treatment for, the ; greater number of these patients, but there was a;lack of: efficient co-operation in the service. "I am pleased to say," he continued,1 "that the profession, especially during the depression, have endeavoured, largely at their own expense, to supply a medical service for their fellow-citizens who have had the misfortune to be unable to finance their own treatment. These citizens have also not had the benefit. of efficient consultants, specialists, nursing, and other auxiliary services. "Secondly, there are members of the community who are able to make adequate provision for ordinary sickness or temporary incapacity, but are unable to make provision for serious and 'prolonged incapacity, especially where hospitalisation is necessary. In most countries their necessities are provided for by the provision of what is termed intermediate beds attached to the' public hospitals, or else in a separate institution where reasonablypriced accommodation is supplied, and where moderate medical fees are charged, "Thirdly, there is the anomaly associated with industrial and motor-car accidents, where as a rule no adequate provision is made for the hospital care of these cases, and, up till recently, no provision whatever for medical attendance. The accident cases are usually admitted at once to a public hospital where part, if not the whole, of the expense may be thrown on the State and treatment carried out by a medical staff that may be acting in an honorary capacity. This is surely an anomaly that should be rectified, first by adequate cover under the insurance policy for both . hospital and medical attention, and provision of a system, whereby the patient may be attended,- if desired, by their medicalpractitioner and pay for his services, "Fourthly, there is no adequate provision for medical research. TWO CONDITIONS. "I do not think that any of our difficulties are due to any deficiency in the supply of medical practitioners. I have pointed out already that there are more practitioners in proportion to the population than anywhere else in the world. There are two conditions, however, where deficiencies do arise: (a) House surgeons in the public hospitals. The marked variation in the numbers of students, qualifying in medicine which' arises through the fluctuating conditions of supply and demand Qften gives rise to an insufficient"■.■"supply-' of recently^qualified nienVto fill these,positions. This,need, however;. causes no.great difficulty, as in all the; larger centres there is an ample supply, of.;young'1, practitioners able and willing to render their services, and use has been; made of them with' very ; satisfactory; results' in our own city, lit may mean a little move finance, ;-bui it< need cause no lack of efficiency, (b). The other /difficulty is in regard-to the practices in scattered and often poor, districts of the country, where" the surroundings '"and rewards are unattractive to medical men. If subsidies; are' provided by the ;Gbverriment it would go a long way to clear up this difficulty. SOLUTION OF PROBLEMS. "I have considered the conditions of medical practice and its difficulties, I will now proceed to consider what may be possible solutions of our problems. In this consideration may I urge the profession to- do all. it,can to help the rest of the community, and. especially. the general and local' government bodies, to elucidate and to solve our common difficulties. It often appears to me that the aid. of .the. profession as; not sought in health,matters when. it should be, and also thafthe profession is very shy and retiring in offering its advice. It should be very easy for our advice to be both sought and given. Nobody who is, not a member of the profession can possibly understand the disaster' that 'would' ensue if a firm grip is not kept on all that makes our profession honourable. And yet \ve as a profession and as an association often feel that we. are distrusted by the-people, our finest ideals suspected, and ourselves treated as a race apart. ; : "What then are the improvements one can suggest? .. "First'and.foremost I would suggest a medical service for those of our fellow-citizens who are unable to make provision for their medical treatment. The service should be a complete, ope with a;general, practitioner service as the .basis, and' incorporated with that consultant .and specialist and hospital service, as well as nursing, massage, and Qtheriauxiliary/services.- It is possible for manyHo make .partial provision by ..means of; a national health insurance ■ scheme, but .there will be many, and, these the/most. needful of help, who will not b>able : .to make any provision, and for' whbni..: the/ community will have to pay. their insurance premium either in full or in.part. "(2). The provision of . intermediate hospital beds, for those unable to pay private hospital. fees and yet willing and able to pay for their hospital and medical attention. Arrangements could be made with the profession for the charging of'moderate'fees-to these patients.: I. submit that this, system could readily be grafted on to our public hospitals, or, by subsidy, the establishment of private intermediate hospitals encouraged, if a satisfactory co-ordinated hospital administration were provided. "(3) The provision of community hospitals to enable all classes wishing, to do so, to obtain treatment at our general hospitals, by paying for their accommodation, and by arranging for their medical treatment by the practitioner of their choice. This provision is especially desirable in the treatment o.£ such cases as cancer, where special

radio therapautic treatment is necessary, and where the expense of providing the equipment renders multiplicity of plants in the community undesirable and, senseless.,... .' ■'■-. :

, ■ "(4) Hospital staffing should be arranged through a central medical committee working in conjunction'-with a local advisory medical committee, and iii.the case ,of the metropolitan hospitals with the medical school authorities. There should be proper' organisation of, and security of tenure for, the staffs. •■■■'■■ ■:-■ ' "(5) Setting up of an institution for research and provision for clinical research in all the'main hospitals. A CENTRAL AUTHORITY. "I feel, however, that, it is in administration that the greatest improvements can be made," continued Dr. Stout. "There-is every reason why all health activities should be co-ordinated and controlled by a central - health authority,: and of. all health activities hospitals are' essentially those most in need of co-ordinated control. The medical part of the administration should be controlled by medical men' of the highest qualifications and ex-1 perience, and they should be given unfettered authority to develop 'the service from the point of view of efficiency in scientific medicine. In Sweden, a Board of Health is in existence with a personnel of medical men. appointed for life and answerable to the King alone, this bestowing a status comparable to the Judges of the: Supreme Court in this Dominion. They should have the benefit of the assistance of an advisory medical committee, appointed by the profession, to which could be delegated certain specific duties such as those at present carried out by the Medical Council, that is, the registration and discipline of medical practitioners, as well as those of advising concerning the staffing of hospitals and recommending concerning appointments-to the medical staffs. : This central committee would naturally act in , conjunction with local advisory medical committees, and, in the case of teaching hospitals,, in conjunction- with the. Medical School; In/the development of a national health insurance' scheme, and "the inevitable'; and:/difficult i problems involving ■ consultants,' and ■ specialists, and their relation to general practitioners, such a central medical committee, having the confidence of the profession at large, is essential to the smooth and efficient working of the scheme.

"As regards local administration of tlie health services, if efficiency and proper co-ordination are to be attained, this should be carried out by a branch of. the central administration, and no multiplicity of •■administrative > bodies be permitted, and no parochialism al-; lowed to arise. The local areas should be strictly limited.in number and con- | form to geographical considerations. In each local* area local advisory committees, composed of citizens ' as far as possible with special experience and qualifications, representing the local bodies, and sections of the community involved in the service, should be set up. Their functions should, be largely advisory in' nature, and'.:especially aimed at stimulating health, activities, and disseminating knowledge of preventive, medicine .throughout the community.; Local medical aommittees woyld act in conjunction with the ser-^ vice and be1 complementary-to the central medical committee. The hospitals in each ; district would be an important part; of the health, service- and part and parcel of it, and; not '.'a. separate -entity. .* ■. -~ .'■■■' *■" .;•::,:, ■..■_>;'■ ■. .'..''. .' A BOARD OF HEALTH. ■ "In. conclusion,:. I; would;'urge ; the Government'^ arid-"the country to' take the opportunity; afforded" by ;the introduction' .of a national, health insurance scheme .to bring about a reorganisation of the central and local administration of health services in the community, so as to set up a highly efficient board of health with full administrative control of all activities in the country. Also, to set up a central medical committee to advise the board, and particularly to deal with the question of staff appointments, and the interrelations of medical practitioners; to j ensure that the. closed system of hospital staffing is abolished in all the larger hospitals; to arrange for the community hospital system, certainly as regards certain types of patients, and to institute ox subsidise intermediate beds in all hospital districts; to make, adequate provision for medical research, both clinical and laboratory,

■.;■: "I would also urge that in. introduce ing a national health insurance scheme an * evolutionary process be adopted; and the scheme introduced gradually, with the provision of': a complete and/ efficient service for those most need-' ful of it; finally, to leave as undisturbed as possible the general private practice of,-the^ profession,..which has' been : developed' so well to meet; the needs of our special, community^ and has resulted in a profession i which will well: compare- with .the^be.st -'in :anyi ipart' of the world." "'' -"":'"/ •■■-. >