HEALTH INSURANCE

Manawatu Times, Volume 63, Issue 64, 17 March 1938, Page 2

HEALTH INSURANCE

Medical Profession’s Views BIG CHANGES DESIRABLE “It is the firm conviction of ®e medical profession that the development of the health service should proceed on evolutionary lines, and that it should not be attempted radically to revolutionise the existing system which has grown to meet needs and experience; that a service as complete as possible should first be given to those who cannot provide for themselves, and that as need exists and means are available it should be extended to others requiring it; and that the liberty of the people to choose for themselves, and the individual enterprise of the profession should alike be preserved," said Dr. J. P. S. Jamieson, Nelson, president of the New Zealand branch of the British Medical Association, stating the views of the medical profession about national health insurance at the annual meeting of the branch. In the longer view the promotion of health was a greater object than the treatment of sickness, said Dr. Jamieson. National health insurance, being really a system of indemnification for sickness, did not materially advance the greater object. The profession also considered that it would be wiser, before introducing national health insurance, to review and amend the existing administrative machinery, which had developed in an irregular manner. “The year upon which we are entering is likely to be one of great moment both to the people of New Zealand and to the medical profession on account of changes in the system of medical service which are foreshadowed by the proposed introduction of a measure for national health insurance," said Dr. Jamieson. “From the earliest years of settlement this country has had its own particular difficulties to meet in respect to health matters. In the course of time the steps taken to meet those needs have developed a system which is in some respects unique. That what we have done in the past has been done reasonably well is proved by the comparisons which, may be taken between the general standard of health of the New Zealand people and that of the people of other countries of temperate climate, and also between the efficiency of treatment of disease in this and Other countries. Standard of Health. “In contemplating developments of the health service there are two objectives to be kept before us: First, improvement of the standard of health and fitness of the people; and second, to make necessary treatment as accessible as possible and maintain the efficiency of treatment. The question of national health insurance resolves itself into an assessment of the extent to which it may advance us towards those objectives. On both points we have serious doubts, having regard to the special conditions of this coumry. 1 ‘ What we wish to emphasise is that, in the longer view, the promotion of the health of the people is of a basic importance. The promotion of health is a greater object than the treatment of sickness, though we do not underestimate the latter, just as the promotion of employment is a greater object than the relief of unemployed. National health insurance, being really a system of indemnification for sickness, does not materially advance the greater object. Sir Arthur Newsholme, once principal medical officer of the Local Government Board, says: 'lt is always true that prevention is more important than provision. Insofar, then, as provision for sickness slackens personal or communal efforts for its prevention, or diverts funds which necessarily are limited, from prevention to provision, it is to be strongly deprecated.' “Having regard to our natural advantages and race, New Zealanders fall a great deal short of what could reasonably be expected in physical standard and fitness, although we may compare satisfactorily with less favoured people. We venture to draw attention to certain commonplace matters which we think warrant attention in priority to drastic alteration in the system of curative medicine, and which will do something to advance the major object above referred to. In what follows we wish it expressly understood that we make no indictment of any Government department, public body, or the officers of any of these. We only indicate a condition of affairs. “Housing: The Government has taken keen interest in this question, and the investigations undertaken will have show in actual figures what we are well aware of in a general way from the nature of our work, that apart from the actual shortage of houses, a surprising number of houses are inadequately furnished with the necessary equipment for personal and domestic cleanliness. “We do not know actual numbers, but there is no doubt that a largo number of dwellings are insufficiently supplied with baths, sinks, tubs, and proper sanitary and cooking arrangements, or are defective in light, ventilation, and space. We submit that remedy of those conditions is more pressing than provision of free medicine for all. “Conditions at work; Our experience leads us to observe that in shops, places of business and factories, employers and employees too frequently spend their working lives in quarters which are cramped, with by no means a sufficiency of light and air, and have sanitary arrangements which are primitive and unwholesome, though perhaps complying with minimum requirements. In places of public resort, especially in the country, the latter point is frequently to be noted. We are not satisfied that the sanitation and cleanliness of schools, in which the children spend about a third of their waking lives, is always as efficient as it should be. “Domestic help: A good deal of in different health in women and poor development in children may be ascribed directly to insufficient home assistance. Women carry on duties too heavy for them, and, having too little out-of-doors recreation, become unable to 1 care satisfactorily for their families, "''is is not remediable by. medical

means, but it often results in these being necessary, though the costs involved do not remove the cause. Nutrition Defects.

“Every doctor notices in his daily work a frequency of nutrition defects, especially in children, which is out of keeping with the plenitude of wholesome nourishment this country affords. This will be borne out by the systematic observation of school medical officers. It is but necessary to choose a few of the well-nourished in any group, whether of a school class, territorial cadets or health camp, to see how far short of good standards too large a proportion falls.

“There are admittedly problems of nutrition requiring investigation, but, without waiting for this, there are obvious common causes. As applied to towns, pressure of domestic duties encourages the housewife to use the most quickly and easily prepared foods, with the least use of utensils. This leads to reliance on prepared and preserved articles of diet, lacking in freshness, devitalised by sterilisation, and of lowered nutritive quality from over-refine-ment, but lauded by advertisement. In country districts, children who have done farm work, had a hasty breakfast, travelled to and from school with a pocket lunch, and done more farm work after school, are not in a condition to [ make a healthful evening meal. “Remedy of the conditions causing these things, and education in the value of the natural produce furnished in such abundance and variety by this country, to suit every individual taste and requirement of omnivorous man, will do more for the people than all the dietary systems in vogue or the entire national health insurance formulary of medicaments.

“It is naturally in the earlier stages of life that such measures produce the best results. The growth of prematernity supervision, Plunket Society work, and school medical inspection are all a recognition of this. But all those are tending to develop into organisations divorced from the ordinary practice of medicine. In this connection we think that those types of prophylaxis would bd made more effective by closer co-operaton both among themselves and with the members of the profession who are working among the people and are necessarily most conversant with home conditions and family histories. National Blemishes. “Certain conditions of disease, not unknown elsewhere, are met with so frequently in New Zealand as to constitute national blemishes. The treatment of these adds materially to the costs of medical care in this country. We hold strongly that a wiser policy is to stimulate research for the elimination of those conditions. To provide more treatment which does not eliminate them merely adds to the cost. Examples of what we refer to are dental caries, goitre, the prevalence of adenoids and tonsillar disease, the frequency of cardiac diseases in young people, minor degrees of malnutrition, and infantile paralysis. The first of these furnishes a good instance of what wo mean. “If dental benefit were included under national health insurance, the provision made would naturally be free extractions, standard fillings, and standard dentures. But extractions, fillings, and dentures provided ad iufinitum and in perpetuity would not enable the whole population to produce a single better tooth. ‘ ‘This country, for a number of reasons, is now eminently suited for many branches of medical research. It is gratifying that a suggestion made by this association last July for the setting up of a Council of Medical Research has already been adopted, and that this council has set several investigations afoot. A Cumbrous Structure. “In regard to matters of aflministration, the view we take is that national health insurance is a system invented over fifty years ago to meet difficulties iu other countries which, to a large extent, have been overcome iu New Zealand by following lines and methods of our own. The health insurance system involves a complicated administration of its own; and if we superimpose upon our health administration this borrowed system, a cumbrous structure will result. “We consider that it would be wiser before introducing national health insurance to review and amend the existing administrative machinery which has developed in an irregular manner during the rapid changes of a century’s growth and settlement. “An important point is that present health responsibilities are scattered among so many departments arid unrelated bodies. “There are also too few health districts and too many hospital districts. In a better planned system these would coincide, hospital districts being niado largo enough to enable all local health interests to be related to the department through the district health officer. Administrative System. “There is need of a system of better co-ordination of hospitals throughout the country in order that the functions of hospitals in different areas may be more clearly resognised and provided for inconstruction and otherwise, and patients be more readily assigned to the institutions most suited for the particular treatment required. For example, the four metropolitan hospitals have to serve functions to specialism and medical education which go far beyond the limits and service of their particular hospital districts, and they require special consideration accordingly. And the functions of provincial base and subsidiary hospitals require to be bettor related, as long ago advocated by Dr. Valintinc. There is also need-' for review of the method of training and appointment of administrative officers and professional staffs. We are aware of the great difficulties surrounding such reform, but as the administration of an insurance system, if and when adopted, must fit into the general health administration, -we think it a necessary prelude to any further addition to our system if complication, or even confusion, is to be avoided. “The perplexing question of population and its changing age-constitution is probably that which, in the minds of statesmen, transcends all other in im

portance. There are various factors to be thought of in connection with national health insurance. Having reached a point when it appears doubtful whether we shall maintain our numbers long by reproduction, it becomes a question how far the State should commit itself to a system requiring heavy taxation. Again, the proportion of the population living in the declining period of life is steadily increasing. In 1876 only 6 per cent, of the populaton was over 50. By 1927 that proportion had risen to 17 per cent.; last census returns will have shown a still higher figure. Also, the age at which earning begins, tends to be delayed by the increasing period of education required, so that the burden on people in the productive and reproductive period of life becomes heavier and. heavier. One may question, therefore, whether it is possible that additional taxation for national health insurance will assist the country in the prob** lem of population. The Basic Element. “We regard the family doctor as tha basic element of a country's health service. He is the medical man who is in closest contract with the people, and who knows most fully their medical histories and needs. It is through him that additional and special forms of treatment should be arranged. ‘ ‘He acquires a kind of knowledge which is not open to any polyclinic or hospital, and which makes him frequently the person referred to iu all sorts of domestic difficulties, which may even not be technically medical. There are some who think he is doomed to extinction but so long as the family remains the basis of our social system the family doctor cannot die—the people will not let him. Nor need they; for he is not costly. He costs much less than the 'essential ' luxuries. “Nevertheless, there are some, both in town and country, and the greutes the distance the greater the difficulty, who cannot afford a family doctor. The first function of any schema should be to make that service available to those who, from their own resources, cannot obtain it. But to provide through a national health insure ance system a family doctor for thos* who can command that service foe themselves will not result in any benefit to the health of the nation. “Year by year, advances iu knowledge and improvement in medical training increase the responsibilities and extend the work of the family doctor. At the same time, diagnostic methods become more technical and special subjects become more highly developed, so that is more and more difficult for hi to be self-sufficient. To at* tempt to be so is unfair to his patients, and the wise family doctor refers in creasingly to laboratories, specialists, and hospitals, because those are essential for efficient diagnosis and treatment. He cannot remain a good doctot unless he has access to those and maintains contact with them, as they involve his patients’ interests. He cannot discharge his duty to his patients without these aids; but they cannot replace his service. The two should work together in the patients' interests. “Laboratories, specialist services and hospitals are necessarily the costly items of medical treatment, which, therefore, cause people the greater difficulty in meeting their medical needs. This is true, even for those who are in relatively good circumstances. This is the second function which could be served by a national health insurance scheme. There is sufficient evidence to indicate that a national system to defray the cost of diagnostic, special and hospital services for a large proportion of the population would be a workable proposition. These two functions together present the merit of making a complete service available to all, while preserving a free relationship between the people and the profession. ’'