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Medical Opinion and the First Year of National Health Insurance in Britain

Published online by Cambridge University Press:  20 November 2017

Norman R. Eder
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Extract

In late 1912 British domestic social politics were dominated by the noisy dispute between David Lloyd George and the British Medical Association over the details of the national health insurance act. Led by the B.M.A., doctors bitterly opposed the insurance scheme and threatened to boycott panel medical service. The profession's inept political maneuvers and the skillful gamemanship of Lloyd George have been well documented by Bentley Gilbert, as well as Alfred Cox and William Braithwaite, two participants in the controversy. Yet, the story of the medical profession's relationship with the insurance act remains unfinished. Almost nothing is known about what followed the political collapse of the B.M.A. after medical benefit became a reality in January 1913. The post-January period, however, was nearly as tumultuous as 1912, and certainly more important to the efficient working of the insurance act which was for the next thirty-five years to provide health care to Britain's laboring poor. This essay will examine the conditions and politics of medical practice during the initial year of national health insurance in Britain.

Type
Research Article
Information
Albion , Volume 11 , Issue 2 , Summer 1979 , pp. 157 - 171
Copyright
Copyright © North American Conference on British Studies 1979

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References

1 Gilbert, Bentley B.. The Evolution of National Insurance in Britain: The Origins of the Welfare State (London, 1966).Google Scholar Cox, Alfred, Among the Doctors (London, 1950).Google Scholar Braithwaite, William J., Lloyd George's Ambulance Wagon: Being the Memoirs of William J. Braithwaite, 1911-1912, ed. Bunbury, Henry N. (London, 1957)Google Scholar.

2 There is no way of determining how many insured persons had actually registered as panel patients prior to 15 January. Most local insurance committees were not able to publish an accurate list of participating practitioners, and those few that were, often were late in distributing registration forms. Spectator (4 January 1913): 3-6.

3 The Lancet (22 March 1913), p. 855. Throughout 1913 The Lancet published the report of a secret special correspondent who traveled throughout the country in an effort to reveal how the act was working.

4 The National Insurance Yearbook 1913 (London, 1913).

5 The British Medical Journal (25 January 1913), supplement p. 104.

6 The Times (London, 30 January 1913).

7 The British Medical Journal (25 January 1913), supplement p. 197. Later many medical men told two American observers, Douglass W. Orr and Jean Walker Orr, as they were preparing their book. Health Insurance with Medical Care: The British Experience (New York, 1939), that the complaints about excessive paper work were voiced only by an old fashioned disgruntled minority who objected to the state's insistence that adequate records be kept. The evidence, however, strongly suggests that more than a few of Britain's doctors found the keeping of thorough records a new and exasperating experience. In this regard the insurance act must be viewed as a significant modernizing force within the medical profession.

8 The Times (11 July 1913). In some approved societies sick rates were as much as 70% higher than the previous year largely due to a great deal of unsuspected sickness among the insured class, especially among women.

9 The British Medical Journal (15 February 1913), supplement p. 152.

10 Great Britain, Parliamentary Papers (Commons), 1914-16. 30. (Reports, vol. 1). Cd. 7687, “Report of the Departmental Committee on Sickness Benefit Claims Under the National Insurance Act.” The committee was formed to investigate the unexpectedly high sickness rate among the insured and it discovered that the vast majority of claims were legitimate and represented a heretofore unknown quantity of chronic illness among the laboring classes. Excessive sickness, it found, was excessive only in the sense that the government actuaries had greatly underestimated the normal rate of disability due to ill health.

11 The British Medical Journal (1 March 1913), supplement pp. 218-220. The Times (14 July 1913).

12 The Working of the Insurance Act,” The New Statesman (14 March 1914): 11.

13 See R.W. Harris, “National Health Insurance Medical Service in Great Britain.” The Canadian Public Health Journal (February, 1931): 55-69.

14 The Manchester Guardian (28 March 1913).

15 A constantly voiced fear of the profession was that it would be formally split and thus destroyed. Those who held this opinion failed to recognize that the profession had never been a singular unit. It had always been divided sharply along class lines.

16 The British Medical Journal (7 February 1914), supplement p. 66.

17 Ibid. (3 January 1914), supplement p. 6.

18 Ibid. (7 February 1914), supplement p. 66.

19 D.S. Lees and M.H. Cooper “Payment-Per-Item-of-Service: The Manchester and Salford Experience” Medical Care vol. 2., No. 3 (July-September 1964): 151-156.

20 Section 15 clause 3 of the insurance act stated that “The Committee may contribute, towards the expense of the treatment furnished by any approved institution to an insured person who elects to obtain treatment through it.” The National Health Insurance Yearbook 1913 supplement, p. 49.

21 The British Medical Journal (7 February 1914), supplement, pp. 67-88.

22 Ibid. (1 March 1913), supplement pp. 212-213.

23 Great Britain, Parliamentary Papers (Commons), 1914-17, 72, (Reports, vol. 3.), Cd. 7496,

“Report for 1913-14 on the Administration of National Health Insurance” p. 85. Also see The British Medical Journal (10 May 1913):1014-1015.

24 The New Statesman (11 April 1914): 5-7.

25 The British Medical Journal (11 January 1913), supplement, p. 83.

26 Ibid. (22 March 1913), supplement, pp. 265-266. The “touting” carried on by many institutes angered the medical community as it was seen as a violation of medical ethics.

27 “The Battle of the Clubs,” The Lancet (25 April 1908): 1240-1242.

28 The Lancet (20 December 1913): 1796-1798.

29 The Times, 28 April 1913.

30 The Lancet (29 March 1913):920.

31 The British Medical Journal (5 April 1913), supplement pp. 304-306. The State Sickness Insurance Committee of the B.M.A. was given the power to make monetary grants to doctors who had suffered financial losses as a result of boycotting the panel system.

32 Ibid. (12 July 1913), supplement p. 75.

33 Ibid. (5 April 1913), supplement pp. 304-305.

34 The Manchester Guardian (28 March 1913).

35 The British Medical Journal (1 March 1913), supplement, pp. 209-210. In Aberdeenshire, the local committee established a base rate of 2s. 6d. for each attendance, excluding anesthetics, applicances, mileage fees and minor operations or the setting of broken bones. In contrast, medical men received an average of 1s. 5d. for visiting insured patients, regardless of the patient's illness or of the use of anesthetics and appliances.

36 “Medical Remuneration,” New Statesman (21 February 1914):615-517.

37 The British Medical Journal (29 March 1913), supplement pp. 281-285.

38 The Lancet (10 May 1913):1355-1356.

39 Cox, Among the Doctors, pp. 84-100.

40 The British Medical Journal (25 January 1913), supplement p. 90. Between January and the end of March, the B.M.A. attempted to occupy the neutral ground between panel and nonpanel practitioners. However this would be an untenable stance if the association was to gain a voice in the formation of national health policies. Under the tutelage of Alfred Cox, the council moved slowly to a pro-panel position.

41 Ibid. (5 April 1913), supplement pp. 304-306.

42 The insurance regulations issued in January had established a complicated procedure for paying doctors who attended insured nonresidents. Instead of billing the patient's home insurance committee, the association asked, repeating an earlier request, that a central fund be established to reimburse doctors for providing care to vacationers and migrant workers.

43 London had already established a referee service, and while it had not drastically cut the sick rate, doctors saw that referees could be used as a corps of expert advisors. For this reason, the B.M.A. insisted that the referees must be above political pressure and suggested that any service be national in scope.

44 The Times (24 October 1913). Also see J. Staveley Dick, “The Working of the National Insurance Act,” The British Medical Journal (25 October 1913), supplement pp. 330-332.

45 The British Medical Journal (5 July 1913), supplement pp. 40-42.

46 Ibid. (12 July 1913), supplement p. 70. An actuarial report estimated that this measure would add an additional 240,000 persons to the insurance rolls at a first year cost of £260,900.

47 The Tories actively supported the friendly society claims not out of sympathy with the plight of the societies, but because they saw the amending bill as a political tool that might be used to embarrass the government. The generally conservative B.M.A. therefore was unable to make an appeal to its profession's natural ally.

48 J.E. Moorhouse, “The Insurance Act of 1913 and the New Regulations,” The British Medical Journal (22 November 1913), supplement pp. 453-455.

49 “A State Medical Service,” British Medical Journal (17 January 1914), pp. 158-159.