A State Medical Service

December 1919

This subject has been already discussed editorially in these columns, and we think it is the most important consideration before the medical profession at the present time. Expressions of opinion were invited from the readers of the JOURNAL, but unfortunately the hope for some constructive criticism has been vain. However, the question of a State Medical Service will be fully discussed at the annual meeting at Dunedin in February, and the consensus of opinion in the profession appears to favour the formulating of a scheme which will be acceptable, or objectionable in the least possible degree, to the Medical Association, for it is well recognised that some form of State medical service is inevitable.

In the first place the staff of the Health Department will be increased, and this form of extension of State medical service will meet with the warm approval of the profession. At present it is probable that more money is spent by the State on the health of the beasts of the field than on human beings. State medical service will also increase as regards beasts and children during the period of education. The State is pledged to medical service for mining communities, and also for the Maori race. As regards the treatment of tuberculosis, tuberculosis dispensaries and farm colonies, and probably seed-raising and forestry settlements, and sanitoria will be established, and it is a moot point as to whether the Health Department or the Hospital Boards should staff these institutions. In this connection, the treatment of infectious diseases generally, and in particular the treatment of venereal diseases is likely to require central control, and a staff of medical experts who will probably be State medical officers. The treatment of the insane belongs now almost solely to Government doctors.

There are two new directions in which State medical service will soon extend, the first the establishment of a poor law medical service in the cities, although in this country it must be called by a different name, and the second a medical service in remote and sparsely-populated districts. The first, the poor law service, will relieve ordinary private practitioners of a burden they have carried since the early days of the colony, and we think it will meet with no opposition if reasonable safeguards against abuse are provided. As regards the establishment of a State medical service in remote districts, we know that attractions must be offered to medical men to settle in such districts. We understand that the system of subsidy at present in vogue has broken down. The inducements that can be offered to young doctors taking up this work under the State include a guaranteed salary of not less than say £450, a free house, free means of transport, annual holiday leave and study leave, a generous and elastic system of superannuation, and the prospect of transference and promotion, and the right of resignation at any time. Further than this, the rewards should be commensurate with ability and industry, and stipendiary hospital appointments will be available in most of the areas. It may be arranged that the doctor must furnish a monthly report of the work he has done to the local Hospital Board, and the Hospital Board will collect the fees and mileage fees, and the doctor will be paid in accordance with the grade to which his work entitles him. If the minimum salary is £450, the next grade may be £550, the next £650, the next £850 to £1000. Another method proposed is that for amounts earned above the actual guaranteed salary the Hospital Board should take half and the State medical officer half. Thus if a doctor on the lowest or initial grade earns not £450, but £650, he is paid £550, and the outlay of the Board is recouped £100 so that instead of having to pay £450 agreed upon the Board only has to find £350, and to extend the principle, as regards the Board, the doctor may be self-supporting. It is understood that drugs and dressings will be supplied by the Board. Lodges may agree with Hospital Boards to be charged reduced rates, but mileage rates for Lodges should not be materially reduced to prevent Lodge members from sending a long distance for a doctor for a trivial or unnecessary reason. In the districts referred to, regulations must prevent the State doctor from encroaching upon the practices of private doctors in the surrounding districts. When a district supporting a State doctor grows sufficiently populous to support a second doctor the State medical service should cease in regard to that district.

The present system of contract Lodge practice is most unsatisfactory whereby the doctor underwrites himself the medical insurance of Lodge members, and he may earn 5s. a visit or only 1s. a visit depending upon the amount of use or abuse of his services. A better system would be for the Lodge to pay the doctor a flat rate of 5s., or whatever sum it may be, for each visit or consultation for a Lodge member, the Lodge thus getting a cheap service, and the doctor knowing his exact position financially in respect to the amount of work he performs, and making no bad debts. Under a modified State medical service, such as has been outlined, direct dealing between the servant, the doctor, and the master, the Lodge would be prevented, and the doctor would be directly concerned with the Hospital Boards and the Government.

The profession stands secure because any State medical service will be more or less of a failure unless it has the confidence and support of the profession generally. A State medical service in New Zealand must not be under the control of the Health Department alone, but under a Board such as the Public Health Board or Medical Registration Board on which is represented the Medical Association and the Health Department. We have no doubt that at the present time the Health Department and the private practitioners through their organisation are united in sympathy and cordiality, but this happy relationship could be easily strained if a policy of give and take is not maintained.

We think a modified State medical service is inevitable, and that it can be moulded into a form that is not objectionable to the profession as a whole. If established, we trust that it will be well tested before it is used as the thin edge of a wedge for further cleavage of established customs and institutions. We believe that private practice will never be abolished, and in studying a State medical service we have found that it, like private practice, is very far from perfect, subject to anomalies, and full of pitfalls and difficulties. The Labour Party in New Zealand favours a State medical service, but has not elaborated any definite scheme, and knows little of the intricacies and difficulties involved in attempting to carry its designs into execution.

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