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The 1911 Act was in two parts. One set up an unemployment insurance and labour exchange scheme. The other was the health insurance scheme. William Beveridge who recommended the establishment of a National Health Service thirty years later co-wrote the unemployment insurance scheme but, as he says in his autobiography, he had nothing to do with the health insurance scheme.5,6 Both parts of the 1911 Act owed impetus to Lloyd George's visit to Germany in 1908 where he saw the German insurance system established by Bismarck. In his budget speech in 1909, Lloyd George spoke of 'putting ourselves in this field on a level with Germany; we should not emulate them only in armaments'. The remark echoes through time. The 1911 Act could be seen as preparing for war, the 1948 Act was widely seen as the dessert of victory. The argument about needing to be on a level playing field with Germany is alive and well in 1997. The 1911 National Health Insurance system, however, also owes its origins to the nineteenth century clubs in the UK.
The clubs paid doctors out of weekly contributions made by members. The club managers usually paid the doctors on the basis of an amount per member: capitation. Their aim was generally to get the most services for members at the cheapest cost. A graphic description of general practice in Wales under the club system is given in Cronin's novel: the clubs trying to exploit their doctors and the doctors exploiting their assistants and dispensers.1
The legislation of 1911 introduced the pool and established the fundamental characteristic of the 1948 system, which is that the total size of the 'cake' for paying GPs was fixed by central government but the distribution between GPs was more open to negotiation between government and profession and competition within the profession. Central to understanding how the pool worked (and still works) is the assumption that there are 'average' GPs doing what an average GP does and getting average remuneration. GPs who departed from the norm could find themselves heavily penalized. There was a pool for spending on drugs shared between the doctors and the pharmacists. The East London doctor, Harry Roberts, got into deep trouble with his colleagues for prescribing cod liver oil with malt instead of the cheaper cod liver oil alone. He was fined the best part of a year's income for this.3
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| Book Title: Making Sense of The Red Book | ||