Working Class Patients and the Medical Establishment

”The National Health Service is the closest thing the English have to a religion,” wrote the former Tory chancellor Nigel Lawson in his memoirs.

Daniel Hannan MEP was torn to pieces politically for daring to say that in his view the service provided was not optimal.  In the book he co-authored book with Douglas Carswell, The Plan: Twelve Months to Renew Britain, they suggest alternative solutions.

In the late summer of 2009, in the run up to the General Election the following year, this sparked David Cameron into a defensive stance, and being the astute politician he is, he sensed the political mood music and declared his “wholehearted commitment” to the NHS.  He suggested that the NHS represented a “simple, practical, common sense, human understanding of a fantastic and precious fact of British life”.  He added “That’s why we are committed to the NHS and the principle of a healthcare system that is free at the point of use, based on need and not the ability to pay.”

It is generally understood that if you wish to be taken seriously in this country, you must never be critical of the NHS. Suggest a reform here and a fine tuning there, but don’t so much as imply that fully taxpayer-funded and state-provided health care might not the best solution for the people. Should you dare go down that line of thinking, you are sure to be dismissed as a wide-eyed loony!

It is assumed that the market for health care is naturally monopolistic as the medical profession can organise at the expense of the consumer, who is ignorant.  Naturally, the State needs to step in and protect the ignorant consumer. This is akin to saying that food producers know more about food (essential for life!) and they will have a tendency to organise at the expense of the consumer, so the State should step in and we can have a National Food Service (God forbid: an 18 month wait for a can of Baked Beans!) and all those starving people that the private sector does not provide for will be fed!  Also private provision will never cover the poor, already sick, and the needy; therefore the State must step in. Historically this has notbeen the case.

David Green in 1985 wrote a magnificent book Working Class Patients and the Medical Establishment: Self-help in Britain from the Mid-nineteenth Century to 1948. He shows that health care provision prior to the 1911 National Insurance Act was spontaneously provided by worker-organized mutual or friendly societies. Indeed, 75% of all provision was via these organizations with the balance paid for by private provision by those who could pay on the nose directly for medical related services; and for the utterly impoverished small minority, the Poor Law provision. Interestingly, these societies were paid for by a flat subscription fee for all. Green shows that only 4.5% of applicants were turned down.

These societies employed doctors, on the whole provided drug dispensing services and sick pay for their members. Doctors were often elected and answerable to the committee of lay people of the society. This democratic control was detested by a vocal minority of doctors as it afforded accountability. They also detested the dominant consumer. Many, though, were happy and content.

The societies, who negotiated individually with doctors, would ensure a good wage for the doctor, but some in the General Medical Council viewed this to be “infamous conduct” — lowering your wage to be affordable to the masses was enough to get you struck off. Ironically the Trade Union thugs and dinosaurs of the 70’s and 80’s would have no doubt approved of this closed shop, restrictive practice which was so much at the expense of the working-class patient. How the original trade unionists, who were so supportive of the friendly societies, would be spinning in their graves.

The great success of the mutual provision of a private welfare state was in effect its own downfall. Lloyd George sought to extend the benefits that the freely chosen mutual provision of the masses had achieved to cover the very poor. Green shows us how during the passage of the bill, the medical profession, which did not like working for the proles and being governed by lay committees, managed to advance arguments that would deliver control of the goods and services provided by the mutual societies, demanded by the patients and the lay committees that ran them, to the medical profession themselves.

It was successfully argued that the pay that the Doctor received on contract to the Society prevented him from providing a full unbiased professional service for the benefit of the patient. It was argued that the practice of certain doctors in competing for the individual subscriptions of members by undercutting other doctors was bad for the provision of medical care. Working-class fraternalism was the BMA’s worst enemy, as competition for patients kept the doctors’ pay at levels that the masses of working-class people could afford.

The commercial insurance companies too had long detested the competition that the Societies had given them and with the BMA, they formed themselves into the Combine and extracted concessions to the Bill.

Green says

The essence of working-class social insurance was democratic self-organization: amendments to the Bill obtained by the BMA and the Combine undermined it. Doctors pay had to be kept within limits that ordinary manual workers could afford: under pressure, the government doubled doctors’ incomes and financed this transfer of wealth from insured workers to the medical profession by means of regressive poll tax, flat-rate National Insurance contributions.

The unhappy outcome of this legislation initially intended to extend to all citizens the benefits of friendly society membership, already freely chosen by the vast majority, was a victory for the political muscle of the Combine and the BMA. They achieved a very considerable transfer of wealth and power from the relatively poor working –class to the professional class.

Post 1911, the doctors were paid out of the state insurance provision and ultimately by the state via the National Health Service, post 1948. Popular, affordable, voluntarily-funded healthcare was crowded out.  We now have inefficient Soviet style provision of health care. Dress it up how you like, but essentially the state is the prime provider of health care. Private provision is sidelined and often only available to the wealthy.  Choice in services is limited. Patient consumer control of the doctor / medical provider is negligible. Until we have consumer control, our service will always be suboptimal.

David Cameron and the Big Society: Could this be a return to mass private affordable consumer controlled democratic provision of medical care?

I have previously written here about my enthusiasm for the Big Society project.

On August the 13th 2010, 12 projects were launched that allowed public sector workers to take control of delivering services.  Could it be possible that we could take control of our local general purpose hospital and local GP services? For this to happen, we would need to get a full tax rebate for all participating members and form a traditional friendly society and extract those services from the state and return them from whence they came, on the whole, to the working-class mutual societies that Green writes so eloquently about.

Would the government be prepared to give a rebate in our tax so we could use the money as our ancestors did, to arrange our own healthcare in a mutual format?  Can we see the lay people of say Welwyn and Hatfield, where I live, rise up and form a mutual for all its members benefit?  That is a truly wonderful thought.  At the moment, our local QE11 hospital where my youngest child was born is facing closure with only the A&E services and one or two other things being left open, and there is much popular support to keep it open.  Do the people want to go this far? If we were given our tax back I am confident most citizens would seek to pay their subscriptions, vote in their doctors, and arrange for the full service that they want on a lowest cost basis. Could consumer control and patient power return to Britain?

How bold are Andrew Lansley and David Cameron?

Readers interested in more from David Green may enjoy his 1993 Civitas paper, Reinventing Civil Society: The Rediscovery of Welfare Without Politics“.

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