The Health and Medical Treatment of the UninsuredAuthor(s): Stewart JohnsonSource: Journal of the Royal Statistical Society, Vol. 76, No. 4 (Mar., 1913), pp. 410-414Published by: Wiley for the Royal Statistical SocietyStable URL: http://www.jstor.org/stable/2340268 .

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410 [Mar.

THE HEALTH AND MEDICAL TREATMENT OF THE UNINSURED.

By STEWART JOHNSON.

So much thought has been concentrated on the health and medical treatment of persons insured under the Act, that the medical treatment and health of such persons as remain uninsured has dropped somewhat out of sight. Nevertheless, the provision of medical attendance and sick pay for the working classes. and the more regularly employed of the poor, will allow the question of the health and medical treatment of the poorest classes, who are frequently confounded with those rather better off, to be envisaged as a separate and distinct problem.

Before considering the main question, it may be well to arrive at some estimate of the numbers of the uninsured. They can be divided into several classes. First, there are those who are in receipt of more than i 6o1. a year, and are not manually employed. These may be mentioned merely to show that they have not been unintentionally omitted. They have their special problems, but this paper is not concerned with them. Next come the dependents of insured persons. These will form a considerable body. They will be eligible for sanatorium benefit on the recommendation of the insurance committees, and their position will be materially improved by reason of the sick pay and medical attendance which the head of the family will receive during those periods of illness in which, in earlier times, he would have been out of work and running up a doctor's bill. Moreover, we may anticipate that the dependents of insured persons will be by degrees drawn within the scope of the Insurance Act, as approved societies gradually accumulate sufficient surplus to enable them to grant medical benefits to dependents, a point which will be attained on an average in some twenty years' time, when the reserve value on lives entering insurance over the age of 16 has been redeemed. In addition, children of school age already receive medical attention from the education authorities, and will probably receive more in the future. The same remark applies to babies and the public health authorities. A third class of uninsured persons will also be eliminated as time goes on-voluntary contributors over the age of 45 who do not care to pay the enhanced premiums which their years entail. In twenty years' time the youngest of these will have passed out of the range of the Act.

There remain those compulsorily insurable who from the irregu- larity of their employment fail to obtain sufficient stamps on their cards to secure any benefits; those eligible for the voluntary section, who will refrain, on account of the smallness of their earnings, from contributing; and those ineligible on account of the nature of their work for either form of insurance. These three classes will amount, according to the actuarial calculations to close upon 2 millions (1,979,000) of which I2 millions (I,639,000) are men and W million (340,000) women.

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1913.] The Health and Medical Treatment of the Uninsured. 411

To these may be added the deposit contributors who are not insured in the full sense of the word, and whose position is to be reconsidered in January 1915. Of these there are computed to be rather over i million (638,ooo men and 244,000 women). Uninsured and deposit contributors together we have just over 2 million persons of both sexes (2,56i,ooo). With their dependents they would probably constitute a class of at least 5 million persons, as nearly as possible Ith of the population of the United Kingdom, about the same proportion which Mr. Charles Booth and Mr. B. S. Rowntree in their investigations in London and York respectively have found to be in extreme poverty in those places.

How are these people provided with medical attendance ? The following is an attempt to answer this question, at least, so

far as Greater London is concerned. In the yeair 1908 I classified approximately one half (13,377)

of the out-patients attending the Hospital for Sick Children, Great Ormond Street, by the scale drawn up by Mr. Rowntree,l and in the twelvemonth, April 1, 1909 to March 31, 1910, approximately one- third (9,85I). The results of these investigations, which were published in the Journal, May, 1911, showed that in the first instance 47 per cent., and in the second, 45 per cent. of the families attending were in what Rowntree calls "primary poverty."

In one sense the Children's Hospital, Great Ormond Street, is a fair sample of the London hospitals, and in another not. First it is almost in the centre of London, and draws its patients from all quarters of London and the outer ring. Secondly, the members of its honorary staff are attached to some dozen or more general and special hospitals in various parts of London, and are all agreed that the patients treated at Great Ormond Street are certainly not poorer than those they see elsewhere. On the other hand, the hospital has the disadvantage for sampling purposes of being a children's hospital. The families on which the statistics are based are all families with children, and children are a cause of primary poverty. Earnings that will support a single man or woman in comparative comfort are frequently insufficient to maintain a family. Had similar figures been collected and tabuilated at a London general hospital, where a proportion of the patients are bachelors and spinsters, it would possibly have been found that a

1 The same cost of living has been taken for this purpose as that used by Rowntree, in York, in 1899. As a matter of fact the cost in London and in 1909 is each iS. more. No attempt has been made to allow for these differences of cost, and they provide a margin of 28. in every case, to compensate for any possible error on account of under statement of income by the parents of patients.

(The standard of diet used by Rowntree for his calculations was that of Atwater, which requires 125 grammes of proteid a day for a man doing moderate muscular work. Had the standard of Chittenden been adopted instead, which requires only 63 grammes of proteid daily, the cost of living for a family of five, father, mother and three children, would have been reduced by about 5s. a week. On the other hand, it clearly appears from the budgets kept by working class families that 5s a week is none too much margin to allow for the difference between the ideal and the performance.)

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412 The Health and Medical Treatment of the Uninsured. [Mar.

smaller percentage of the patients were below the line of primary poverty, probably if the conditions at York are a guide, 12 per cent. less, about 33 per cent. of the total out-patients. These figures receive some confirmation from the inquiries of Miss Roberts on behalf of the Poor Law Commission, who reported that some 38 per cent. of the out-patients of St. Thomas', St. Mary's and the Royal Free Hospitals belonged to the same class that received medical treatment at the Poor Law dispensaries. We take it then that between two-fifths and two-sixths of the patients who attend the voluntary hospitals in London will belong to the uninsured and deposit contributor class.2

But this class do not rely exclusively on the voluntary hospital for their medical attendance. They also furnish patients to the Poor Law doctors, and to private practitioners. Miss Roberts, in the report already mentioned, found that i i per cent. of the out- patients attending these general hospitals had also paid visits to Poor Law dispensaries with half a year of treatment.

In the twelvemonth March to March, 1911-12, 5-5 per cent. of medical and of surgical casualties, and 2 per cent. of the out-patients at St. Thomas' Hospital, were referred to the Guardians of the Poor; at St. Mary's Hospital, in 1911, 2-5 per cent., and at the Royal Free i 6 per cent. were dealt with similarly. At the London Hospital in the same year 7-58 per cent. were referred to the Poor Law for assistance, sanatorium, convalescent or medical treatment. At the Children's Hospital, Great Ormond Street, ollt of 2,977 out-patients interviewed by the almoner, 2-5 per cent. were referred to the Poor Law. These figures all fall short of the i i per cent. of Miss Roberts, but a patient might quite legitimately attend a Poor Law doctor first and a voluntary hospital afterwards for some complaint which required special treatment without being referred back to the Poor Law authorities.

These percentages have reference, of course, to out-patients of all degrees of poverty, and not to those only that are below Rowntree's linle. If we assume the latter to be one-third of the total out-patients, then all the percentages would be multiplied by three, and the ii per cent. of Miss Roberts would become 33 per cent.

As regards the proportion that attend private practitioners, it was found at Great Ormond Street that in 1909 26 per cent., and in 1909-10 25 per cent. of the patients below Rowntree's line of primary poverty had visited doctors immediately before coming to the hospital. (Amongst these were not included those who had been sent with a card or a note by a doctor, nor those who had paid only one visit in an emergency. The average fee paid was is., and the average number of visits that had been paid was four, most often at intervals of two days.) The conclusion, then, that we may form, is that the

2 It nmay be somewhat rash to prophesy on a subject which experience will soon determine; but although it is uncertain whether all those below Rowntree's line will fail to become members of assured societies, it is quite certain that if they do become members they will only be able to pay their weekly contributions by curtailing the diet of themselves and their families.

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1913.] T7he Health and Medical Treatment of the Uninsured. 413

persons that in future will be the uninsured have, in times past, depended to a large extent on the voluntary hospitals, but that one- third of them have also been dependent on the Poor Law Service and one-fourth, to some extent, have availed themselves of private medical attendance.

But persons such as those under consideration need something more than medical attendance.

In the better off classes, medical advice having remedied the illness, the patient may be trusted to remain in his normal state of health. Where the " very poor," such as the uninsured will be, are concerned the normal mode of life is itself a further cause of illness.

The financial sittuation of the uninsured will render it an impos- sibility to them to carry out the instructions of the medical man, since one must consider as implied in the instructions of every medical attendant the provision of adequate food, warmth and shelter. It is little exaggeration to say that so far as these unfor- tunate people are concerned all recent progress in medical science has been in vain. On the other hand it must ilot be forgotten that there are other forms of charity besides medical. In fact many hospitals, the Children's Hospital, Great Ormond Street, amongst them, have almoners, whose express business it is to secure help for the patients, help other than medical, by co- operation with appropriate charities, in order that the medicine and medical advice given at the hospital may not be wasted. The assistance given in this way is without question most valuable. But its value is limited. It is of great use in helping a patient and his family through some crisis of sickness and misfortune, but for families whose existence is one continual crisis, the additional assistance is as likely to be lost as the medical. Such after-care as was given would in this instance have to be prolonged for the rest of the patient's life. The following figures will give some idea of the magnitude of the help required.

Out of the 9,851 families classified in 1909-10 at the Children's Hospital, Great Ormond Street, 4,445 or 45 per cent. were in primary poverty. To provide these families with the minimum necessaries of life, to raise them above Rowntree's line of primary poverty, would require an addition of 1,07 71. a week to their present wages. 9,851 was less tharn a third of the out-patients treated during the period, so that the figure I,0771. ought to be multiplied by three at least to show the deficit in the incomes of the families of all patients, making 3,23il. The entire Out-Patient's Department cost in 1909 3,4741. Hence we arrive at the result: that it would cost almost as much veekly, as is spent yearly, on the medical treatment of the out-patients of Great Ormond Street, to place them in a position to profit thoroughly by the attention they receive. (Or if we multiply 3,23iI. by 52 we find that the yearly deficit in earnings amounts to no less than i68,o0I21., or sufficient money to maintain the entire Hospital, In-Patient and Out-Patient Departments together, including both ordinary, extraordinary and capital expen- diture for five and a half years.)

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414 The Health and Medical Treatment of the Uninsured. [Mar.

Great Ormond Street Hospital is not an exception, or at least, it is only an exception in that its treatment is rather more costly than and its patients not quite so poor as at the majority of the London hospitals. It is obvious that it would be impossible even if it were desirable, for an almoner to obtain this amount of pecuniary help or its equivalent. Even if the amount 3,4741. were halved or quartered, the task would be as impossible, and the attempt almost equally undesirable.

At this stage it might perhaps be asked whether families in such a condition of want are not fitter objects for the assistance of the Poor Law than of a voluntary charity ? Nevertheless, the answer cannot be yes. Although the majority of the class probably at some time or other during their career receive help from the Poor Law, yet their condition at the time of coming to the hospital was not so desperate, save in a few instances, that they could have expected to have obtained relief on application to the Guardians. Although in nearly two-thirds of the cases (64 per cent.) the head of the family was either irregularly or not fully employed, yet only 8 per cent. were actually out of work, and, except where such was the case, few Boards could be expected to help. Moreover, out-relief given on a scale to make good the deficiency in earnings would surpass even the subsidies to wages granted by the Guardians previous to 1832. The class, though in want, are not, to use Mr. Booth's contrasted terms, in distress. Although pauper matrix, the strata in which paupers are secreted, they are not themselves yet paupers. The Poor Law for the time being can do no more for them than voluntary charity. The more money that is expended on the class, short of a sum sufficient to raise the greater part of the class to a higher social plane, is so much more money thrown away.

The conclusion that is forced upon us is that whereas medical attendance upon the insured class may do much to prevent such poverty as has been caused in the past by sickness, little can be accomplished by medical treatment to prevent sickness among the uninsured until they are first raised out of poverty. The remedy for ill-health among the very poor is not medical but social and economic.

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