One Voice: National Health
In Britain, the 1942 Beveridge Report on social security had included a recommendation for a national health service which gained almost universal support, including from the BMA. A national health service had already been set up in New Zealand.
In Australia, World War II had become a powerful pressure point for change. Doctors were needed for services to the armed forces; those left behind were overworked. The divide between city and country and between regions constituted a challenge to the quality and quantity of medical and hospital services that breathed life into ideas for more coordinated, if not national, health services. Despite the peacemaking work of the Federal Committee, differences over contract practice still irritated relations in various areas between doctors and the friendly societies. Neither Government nor Opposition was satisfied with the state of the legislation governing national health insurance. Even the first Menzies Government was considering systemic change: Commonwealth Health Minister Frederick Stewart had asked the National Health and Medical Research Council (NHMRC) in May 1941 to report on the most effective way towards “the preservation and protection of the health of the people of Australia”. The Government’s reason for asking the NHMRC to produce the report was that it considered it the only organisation at the federal level that represented a wide enough range of medical interests. Thus, it ignored both the range of medical interests represented by the Federal Council and the BMA’s position that the NHMRC should be a purely research and not a policymaking institution.
Federal Council had accepted the creation of the NHMRC with some qualms in the first place. In 1926, the Bruce-Page Government had established a Federal Health Council, which Sir Earle Page, a BMA member and a Minister in the Government, said would help develop a national health policy. The BMA asked to be represented on the Council; the request was ignored. In 1935, when the Lyons Government proposed a Medical Research Council, the BMA insisted that it should confine itself to research matters and not get involved in medico-politics. It also argued that it should not comprise just bureaucrats, except perhaps Dr Cumpston. Dr Page appeared to support the BMA position on this but the Government finally nominated for the NHMRC two officials from the Commonwealth (including Dr Cumpston as chair) and six from the States - but only one representative of the BMA, though some other officials than Dr Cumpston were BMA members. The NHMRC also replaced the Federal Health Council. Federal Council accepted all this with reluctance, and nominated Dr John Newman-Morris, former President of the Victorian branch of the BMA and therefore a person of some weight, as the association’s representative on the NHMRC.
Reform was in the air: the NHMRC inquiry would have serious ramifications for medical professionals and their organisation.
Its report was published in July, only two months after it had begun its work and only days before the Menzies Government gave way to the Curtin Government. It disagreed strongly with the insurance legislation, especially the capitation method of payments, which it said would be unacceptable to any professions or trades. It criticised fee-for-service in private practice as impractical. Instead, it offered a “tentative” discussion paper (Outline of a Possible Scheme for a Salaried Medical Service) that canvassed the idea of salaried doctors providing uniform hospital and medical services in a system of regional health districts, with health centres to service major populated areas. The Commonwealth Department of Health would administer the scheme, which suggested that control of the scheme would be exercised by the Commonwealth, though the paper did not deal with any constitutional complications arising from that. The scheme would be paid for out of taxation. Finally, the paper recommended that the idea receive “critical and dispassionate examination in consultation with the medical profession”.
The NHMRC would have given the paper unanimous approval but for the dissent of one member: Dr Newman-Morris of the BMA, who was unable formally to support any changes to the health system that had not been approved by Federal Council.
The NHMRC report did not seem to go anywhere at first, but it amplified ideas about health policy that were well-known to be already circulating among politicians who had decided that post-WWII arrangements would include a radically new health and hospital system.
So the Federal Council responded immediately to the NHMRC report by issuing far-reaching (if not radical) proposals of its own for a health system; radical at the time because they challenged the current verities. A “proper administrative organisation” was needed to bring together and incorporate all aspects of medical practice into any system of social reform, it said. Private practice and private hospitals should be retained in the district-based health system envisaged by the NHMRC. But the BMA went further. Health was or should be one of a range of social issues, it said. Existing social conditions now meant that “the care of personal health is a social duty and not an individual responsibility”. Medical practice had developed areas of specialised work that had resulted in a complex of uncoordinated activities, all acting for individual health care and all becoming increasingly divorced from the principle that should govern prevention of disease.
There was no great outbreak of public debate or controversy following publication of either the NHMRC discussion or the Federal Council’s response. There was a world war going on, after all. But the Government had now been offered – perhaps even confronted by – an alternative health policy, seriously different from present arrangements and very probably unanticipated in any current government thinking. Whatever the reason, it very quickly headed off any discussion by appointing a Joint Commonwealth Parliamentary Committee on Social Security, with equal representation by the Government and Opposition, which would bring forward recommendations to improve social conditions generally, not just health.
The Committee, though it was set up by the Menzies Government, was retained by the successor Curtin Government. Between 1943 and 1946 it produced not one but nine separate reports, though only the last four concerned health. This constant drip-feed of reports produced widely varied aspects of policy for a national health system for everybody involved to consider. They included proposals for a Ministry of Social Services that would be responsible for medical and health services as well as social services generally. A universal health service should be established, with salaried doctors staffing hospitals. The service would be funded either out of taxation or via a compulsory insurance scheme. A Commonwealth Health Commission, with BMA representation, would implement and run the scheme. The Committee acknowledged that there were constitutional complications with these proposals but it thought that they could be overcome through Commonwealth-State cooperation. Not all these ideas touched ground, but they and others were coming thick and fast.