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Annotations

LIBERTY, EQUALITY, AND HEALTHOVER the years opposition to health legislation has been

steadily weakening and falling back on untenable posit.ions.Its deepest ditch has always been that health measurescurtail the freedom of the individual. In an interestingreview of the organisation of medical care during the pastfifty years Prof. R. M. Titmuss 1 suggests that even thisis based on a misconception. The summits of healthlegislation in these years were of course the Acts of 1911and 1946, and in his view both of them only substitutedone form of collectivism for another and each offered

increasing freedom to a growing circle of doctors and

patients.The development of scientific medicine since the

beginning of the century, accelerated by two world warsand what Professor Titmuss describes as the scientific

discovery of malnutrition in the 1930s, made the

reorganisation of medical care inevitable. Advances,which were swift and seldom simple, ranged from newfundamental concepts such as the new ideas of Freud to

complicated techniques of the laboratory and operating-theatre, and to potent new drugs. Their complexity madespecialism a necessity. Their cost raised problems ofdistribution that were thrown into sharp relief by newstatistical and social methods which showed the inequalitiesof health among different groups of the population.Emphasis began to shift from the environment to theindividual patient, from the public-health officer to thegeneral practitioner, though general practice at the timewas in a sorry way. Professor Titmuss estimated that inthe days before the panel only 10-20% of the populationwere able to afford to have a private doctor for the wholefamily. For the rest of the population there was clubpractice for the breadwinners. The women, children, andold people had to make do with the outpatient depart-ments of the voluntary hospitals, the poor-law institutions,and the sixpenny doctors. One unhappy result of thissporadic medical care was people’s reliance on the " secretremedies " which turned many of them into " permanentmedicine swallowers ", a national habit which, as we knowto our cost, still persists.

Contract practice, in Professor Titmuss’ view, was alsoone of the chief reasons for the doctors’ distrust of layadministrators which was shown in their negotiationswith the Government in 1911 and in 1946. Indeed the

present structure of the National Health Service, hesuggests, owes more to the opinion of doctors than topolitical and public opinion. As he assesses the situation,in 1945 many of the consultants, foreseeing the comingbankruptcy of the voluntary hospitals, the threat of

greater local-government control, and the probable harmfuleffects for doctors as well as patients of the rise in theprivate costs of health, shrewdly led the profession intothe National Health Service. However that may be, theAct of 1946 extended health enfranchisement to womenand children and the middle classes. Professor Titmussconsiders that the service would perhaps not have been socomprehensive but for the nation’s post-war mood forjustice and equality of opportunity. But it was also, inhis view, a renewal of the argument for the freedom ofdoctor and patient. To see it solely as a collectivist

1. A lecture on health, in a series on Law and Opinion in England in theTwentieth Century, given at the London School of Economics onApril 29. The series will be published later under the general editorshipof Prof. Morris Ginsberg.

device for the benefit of the working-classes is too simple,and he believes that the middle classes have benefitedeven more, and the doctors most of all.

1. See Lancet, 1952 ,ii ,1122.

GOING TO HOSPITAL WITH MOTHER

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THE children of this country are ill less often than everbefore in our history. But for the many who still fall

seriously ill what is the best type of care to provide?Wider recognition of the emotional sufferings of littlechildren separated from their mothers has led thoughtfuldoctors and nurses to promote various reforms. Elective

operations can be postponed until a stay in hospital is aless disturbing experience for the child-that is, until heis over the age of 5 or 6. Daily or unlimited visiting isbecoming much more common in children’s wards.Mothers are now sometimes admitted with their youngchildren; and, finally, more illnesses are being treated inthe home.The first film made by Mr. James Robertson, of the

Tavistock Clinic, A Twa-J.lear-old Goes to Hospital,lhelped to draw notice to the need for these improvements.This moving picture of a young child’s suffering in

hospital caused a painful emotional struggle in manypeople, who had to recognise that their conscientiousefforts to help had caused avoidable suffering. When Mr.Robertson’s second film, Goiug to Hospital with Mother,was shown to a Press audience a few days ago it was

preceded by excerpts from his first film, and the juxta-position emphasised convincingly the contrast betweenthe emotional states of two young children admitted to

hospital for the same operation. For the second film is ofa mother and child entering the children’s ward ofAmersham General Hospital, where nearly half the under-5-year-olds are accompanied by their mothers. Makingallowance for differences in temperament, there can be nodoubt whatsoever that the little child who had her motherwith her overcame a more serious physical reaction to theoperation with far less emotional disturbance than thechild whose mother could spend only a short time withher each day. Even the most sceptical audience couldhardly fail to be impressed by this second film, which istechnically of a high order and well constructed to conveyits message.

But bringing mother into hospital with the child is notenough in itself. The film makes clear that a big changeof attitude is called for-particularly in the nursing staff.In a ward where mothers and children are admitted

together those in charge must be able to appreciate themother’s anxiety and to help her with it. Not only hasthe mother an ill child to worry about, she has had toleave her husband and possibly other children to fend forthemselves. She may also have conscious or unconsciousanxieties herself about hospitals, and medical or surgicalprocedures. This maternal anxiety can, and does incertain cases, communicate itself to the child or othermothers. But, provided the mother can be given under-standing support, there is no doubt that the child willbenefit greatly from her presence and comfort at a difficulttime. The mother will, at the same time, gain confidencein her relationship with her child, through encouragementto help him when he is ill and needs her most.The ward-sister who can find satisfaction in helping

mothers to help their children is unfortunately still toorare, though if more doctors were far-seeing enough togive the lead hidden reserves would surely be uncovered.But a wholesale change in the attitude to childhood illness