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Special Articles

AMERICAN HEALTH SERVICES

The President’s New Proposals" The dramatic results of new medicines and new

methods-opening the way to a fuller and more usefullife-are too often beyond the reach of those who needthem most", said President Kennedy in a message to theUnited States Congress urging acceptance of a new healthprogramme. Announced in Washington on Feb. 9, thesix-point programme calls for a new health-insurancescheme for the elderly, besides Government aid to com-munity health services, child health, reablement, andmedical education.

THE OLD

Perhaps the most controversial proposals are those forinsurance for old people. Pointing out that the annualincome of people over 65 is half that of their youngerneighbours, while their annual medical bill is twice as

big, and that for one-tenth of aged couples hospital billsabsorb over 700 dollars a year-more than a third of theirincome-the message proposes a health-insurance pro-gramme covering such bills under the existing Social

Security scheme. The programme would pay for in-

patient hospital services for a single spell of up to 90 daysof hospital care (less 10 dollars a day for the first 9 days),for 180 days’ " nursing-home " care immediately afterdischarge from hospital, and for community nursing and" home health services " for a limited time. The cost of

hospital outpatient diagnostic services (in excess of 20dollars) would also be covered. The benefits would beavailable to all persons (now numbering over fourteenmillion) aged over 65 and eligible for Social Security orrailroad retirement benefits. The scheme would befinanced by a small increase in the Social Security con-tributions. The message emphasises that every personcould choose his own doctor and hospital, and that thescheme would not directly affect any service performedor fee charged by any doctor; and the practice of doctors sand the provision of hospital services would not be

supervised.Complementary proposals, designed to encourage home

and outpatient care rather than admission to hospital, callfor Federal grants to States for the construction of

nursing-homes and for improving nursing-home and

home-nursing services. Legislation is proposed to enablethe Public Health Service to create a bureau of communityhealth. Emphasising that 6000 million dollars a year ofthe nation’s resources is spent on hospitals, the messagecalls for research and planning in the best and mosteconomical use of " these costly structures ", and callsfor more grants for such research and for the constructionof experimental and demonstration hospitals.

OTHER PROPOSALS

Turning to medical education, the President’s messagesays that, in the next 10 years, capacity of medical schoolswill have to be increased by 50% (and of dental schoolsby 100%) merely to maintain the same ratio of doctorsto population. But the ratio should be increased, becausethe United States has medical responsibilities in otherlands, whereas it is at present importing rather than

exporting physicians; moreover the number of applicantsat medical schools has been falling. This fall is attributed

in part to the high cost of medical education. Accordinglythe message makes four proposals: (1) planning grants tobe made to colleges to plan expansion and improvementof medical education; (2) matching grants to be made tohelp expand medical schools under a 10-year programme;(3) Federal scholarships to be given to talented medicaland dental students in need of financial help (in amountsequal to 1500 dollars for a quarter of the newly enteringstudents); and (4) a grant to be made to each school of1000 dollars for each Federal scholarship, since the costsof schools far exceed the tuition fees. Similar formula.tions for nursing are being considered.

Since 1950, the United States has fallen from sixth totenth place in the world’s nations in saving infant lives,and a new National Institute of Child Health and HumanDevelopment is proposed; and appropriations for theprogrammes of the children’s bureau would be increased.Finally, the message calls for an increase in matchinggrants for vocational reablement; and in matching grantsfor research construction and Federal payments for bothdirect and indirect costs of medical research projects.

DIFFERENCES OF OPINION

The health-insurance proposals are vigorously opposedby the American Medical Association and by many con-servative members of Congress; in fact, a Bill with similarprovisions, introduced by Mr. Kennedy when he was asenator, was defeated last year. A substitute law (theKerr-Mills Bill) was enacted expanding Federal grants toStates, to provide funds for old people unable to paymedical expenses. Eventually supported by the AmericanMedical Association, this Bill would increase payment ofFederal funds to the States for nearly two and a halfmillion citizens over 65 on old-age assistance, andauthorise additional sums to provide full or partial carefor about ten million who might need help in paying theirmedical bills. But to get such assistance, the elderly haveto qualify by a means test-in effect, they have to take apauper’s oath. Many of the States have not yet even takenone step to put the Kerr-Mills Bill into effect, eitherbecause they lack the funds to match the proposedFederal grants or because they have thought that it mightbe superseded; and if tlie new proposals are adopted it isuncertain whether that law will remain on the statute-

books.

Financing of the insurance scheme through SocialSecurity, the President says, will spread the cost of thehealth services in old age through the working years, "ina manner consistent with the dignity of the individual")it will " meet the needs of those millions who have nowish to receive care at the taxpayers’ expense, but arenevertheless staggered by the drain on their savings-orthose of their children—caused by an extended hospitalstay ". Opponents hold, on one hand, that the schemewill open the door to socialised medicine, and willunwarrantably increase the Social Security burden onworkers and employers (especially since rises are alreadyprojected for 1963 and 1966); and, on the other hand, thatthree million persons not covered by Social Security willbe left out in the cold. There has, so far, been less dis.cussion of the project-in some ways more revolutionaryin the American context-for Government concern overthe most economical use of hospital resources.

" Over 6 % of our national income ", said the President," is being spent from public and private funds for healthservices. Yet there are major deficiencies in the qualityand distribution of these services ... The measures I have

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recommended ... constitute a necessary foundation onwhich to build."

Rough sailing is foreseen for the Kennedy plan at thissession of Congress, but most observers do not think thatthe Social Security insurance scheme for the elderly canbe blocked very long. They predict that, even if it is notadopted in full at this session, more and more of it will bepassed in succeeding sessions.

ADMISSION OF PATIENTS TO HOSPITAL

THE Joint Consultants Committee has discussed withthe Ministry of Health arrangements for the admission topublic hospital beds of patients previously seen in privateconsultation.The committee has advised the Ministry of Health that

the preparation and management of waiting-lists for publichospital beds is wholly the responsibility of the con-sultants concerned and that, in so far as registrars,house-officers, or other subordinate medical officers assistin this, the overall responsibility remains with theconsultant.The committee agrees that, in view of this responsibility,

care should be exercised by each consultant to ensure notonly that urgent and semi-urgent cases receive their

proper degree of priority, but also that non-urgent caseswhether first seen at a private consultation, a domiciliaryconsultation, or in an outpatient department are admittedin an appropriate and fair sequence.

It has been said that from time to time non-urgentcases seen in private consultation are admitted to publicbeds sooner than they should be, having been givenunjustifiable priority. Whether or not this has in fact

happened the Joint Consultants Committee is not in aposition to say, but the committee fully agrees thatconsultants should take steps to ensure that it never doesoccur and advises all consultants to this effect.

OPTION OF WHOLE-TIME OR PART-TIME

APPOINTMENTS

THE Joint Consultants Committee has again discussedwith the Ministry of Health the agreement reached anumber of years ago that hospital boards should, at thetime of making a whole-time consultant appointment,normally offer the option of whole-time or maximumpart-time. The option was agreed on the understandingthat consultants so appointed would be " prepared todevote substantially the whole of their time to hospitalwork and to give it priority on all occasions ". By hospitalwork is meant, of course, all duties that arise from a con-sultant’s contract. It is important that the right to exercisethis option continues and the joint committee remindsconsultants of their obligation under it. A hospital boardhas a right to advertise for a whole-time post without theoption, but the board should have adequate reasons for sodoing. To state that it requires the whole of a consul-tant’s time is not adequate. Under the agreement it canexpect as much from him on a maximum part-timecontract as on a whole-time contract.

This is a valuable privilege for consultant applicantsand, to safeguard its continuance, the Joint ConsultantsCommittee reminds consultants of its terms and theirobligation under it.The same obligations apply to a whole-time consultant

who applies in due course to become maximum part-time.

Before Our Time

FRANCIS ADAMS

1796-1861

ON Feb. 26, on the centenary of his death, we salutethe memory of Francis Adams, a great Scottish countrydoctor who was at the same time our finest medicalclassical scholar-Doctissimus Britannorum-and a keenobserver of natural history. He lived and worked andstudied in the village of Banchory and its lovely surround-ing district in the valley of the River Dee about 18 milesfrom Aberdeen.

His translation of The Genuine Works of Hippocrateshas been probably the most widely read of his works, buthis masterpiece was

certainly The SevenBooks of Paulusaegineta with its finenotes and commen-

taries that give us sucha wide and clear pic-ture of the medicine of

antiquity. It was called" the finest venture in

pure historical medicalresearch in the Englishlanguage " by the lateProf. Charles Singer,who was one of his

great admirers and whodescribed the interest-

ing life and work andaccomplishments ofAdams in a delightfulessay in his book onNew Worlds and Old.In 1844-45 Dr.

Adams was presidentof the Aberdeen Medico-Chirurgical Society, and a

hundred years later in 1945 I had occasion, as the society’ssecretary, to look for a portrait of him to put on the menucard of our society’s annual dinner. In our universitylibrary I came across a reprint on an article on " FrancisAdams of Banchory " by the late Prof. Lewis J. Moormanof Oklahoma, U.S.A., another of Adams’ admirers, whohad himself been a " buggy doctor " in the country beforehe became a hospital physician in Oklahoma City. Thepicture in the reprint turned out to be one of Dr. JohnBrown, as Dr. Moorman himself, and also the late Dr.David Rorie, pointed out to me in the weeks followingour dinner.

THE BUST

In his article Dr. Moorman mentioned that a bust ofAdams was presented to the University of Aberdeen byhis second son, Prof. Andrew Leith Adams, F.R.S., of

Cork, who incidentally was the discoverer of the dwarffossil elephants of Malta. Mrs. Ella Hill Burton Rodger,I also remembered, had described " the strong featuresand sagacious expression " of the face on the bust in herbook Aberdeen Doctors. So I set off on a quest for the bust.

It was nowhere to be found either in King’s College orMarischal College, the two colleges of our university, andnobody had seen or heard of it. It had been placed in thesenatus room at King’s College, but this room had been givenup as a senate meeting-place many years before.