The Director-General
With the development of the National Health Service the Commonwealth must expect to be confronted by annually increasing costs arising from the incentive of the insured subject to secure each year maximum value for his contribution and from the liberality of the medical profession – now relieved of any obligation to consider the patient’s purse – in providing services and therapeutic agents without regard to expense.
As costs increase there may develop a political or financial demand to lower them without impairing the benefits offered. This could be attempted by reducing the fees paid for service – a device which might well disturb amicable relations between the Government and the professions concerned, thereby jeopardizing the quality of the service.
Preferable to this course would be –
(a) to reduce the incidence of disease by systematic application of appropriate preventive measures;
(b) to effect a reduction in the demand for the more costly services minimising hospital admissions by facilitating and encouraging home nursing;
(c) to improve diagnostic and therapeutic measures to expedite cure.
For the application of these measures the Commonwealth must logically look to the States, for traditionally in Australia the prevention of disease is a function of their Public Health Departments. These, however, are constituted in the Chadwick tradition and in general their structure and the powers conferred upon them are designed for applying an out. moded control of infectious disease for imposing certain standards of environmental sanitation and for ordering the conditions under which food may be sold.
Even some or the powers requisite to the thorough and efficient discharge of the limited responsibilities imposed upon them by their Acts have, over the years, been transferred to other technical authorities lacking suitably trained medical staff, for example, milk may have become entirely the responsibility of a Milk Board, meat of the Department of Agriculture, bread of the Department of Industry, water supply may be wholly controlled by a Water Board or Irrigation Commission, drainage relegated to a Sewerage Board, and the standard of dwellings determined by a Housing Commission. The Local Health Authority in its sanitary jurisdiction may even be responsible not to the Health Department but to a Local Government Department. In some States, too, hospital administration is no longer a function of the Health Authority, being vested in a Charities Board or Hospitals Commission upon which the Health Department may have no representation. By this administrative arrangement the Health Authority is denied ready access to information essential to its efficient functioning and deprived of opportunities for intervention to meet special needs.
An active and efficient Health Department may be said to be concerned –
(a) to study the incidence of disease and the causes of morbidity and mortality in the community;
(b) to identify factors which are preventable and to devote itself to removing them;
(c) to initiate and foster research into improved methods of diagnosis and into methods of treatment calculated to shorten the period of illness or avert a fatal outcome, to extend the knowledge of these and to provide facilities for their universal application.
State Health Departments as at present constituted may be said to be so restricted :in their powers by their structure and by their Health Acts that there can be no prospect of them undertaking these tasks in a complete, systematic and co-ordinated programme until and unless they are radically reconstituted. An essential element of this reconstitution must be the integration of the general medical practitioner into both the planning and the executive activities of the Health Authority.
This being so, it would seem that for the moment there is little prospect of the Commonwealth being effectually assisted by the States in any major effort to lower the costs of the National Health Service by reducing the incidence of disease and improving the quality and accessibility of treatment. Indeed the Minister, some months ago, asked State Ministers of Health to study means whereby the co-operation of the medical profession could be enlisted by them in an organized plan for the better study and prevention of disease. Replies so far received, whilst promising co-operation, evade the crucial point – integration of the medical profession into the Public Health Service. No doubt this evasion is to be attributed to the fact that the scope of the Health Acts and the structure of Health Departments in the States provide no ready facility for taking the action suggested whilst, on the contrary, the interests of other Departments would be opposed to such a course in some of its implications.
Accepting for a moment the proposition that the States may be unwilling or unable to undertake the task outlined for the time being, it would still be to the advantage and within the constitutional jurisdiction of the Commonwealth to commence it at once either with the intention of facilitating its eventual assumption by the States or with the firm policy of pursuing it indefinitely as a Commonwealth activity. The National Health Service Act (Section 9(l)(d) and (e)) permits the Governor-General to provide teaching, research and advisory services for the improvement of health or the prevention or disease and anything incidental to such a service. Section 9(2) permits the Minister to disseminate information relating to health and the prevention of’ disease.
It is submitted that the undertaking is one primarily of collecting information and devising more effectual means of collecting information which will serve as a basis for advice and for publicity. A recommended method or approach would be –
(i) Survey of the incidence of disease throughout the Commonwealth. Hitherto information regarding the occurrence of disease has been unobtainable except in relation to certain notifiable conditions which are not uniformly reported in the several States and concerning which no detailed information as to sex, age and distribution is furnished to the Commonwealth. The returns now required to be supplied by insuring organisations under the National Health Service Act make it possible for the first time for this Department to study the incidence of disease generally.
(ii) Assessment, in the light of expert advice, of the possibilities of reduction in the volume of disease by –
(a) correction of the environment;
(b) correction of the diet;
(c) immunisation;
(d) prophylactic therapy;
(e) other means.
(iii) Enquiry into the means of improving clinical and laboratory diagnosis and extending the knowledge of and facilities for these.
(iv) Assessment of the possibility of reducing the cost of treatment by –
(a) improved methods of therapy leading to speedier cure;
(b) informing medical practitioners of these methods;
(c) treatment- in the home instead of admission to hospital.
(v) Study of practicable means of –
(a) restricting the use of expensive therapeutic substances in cases where they are not strictly necessary;
(b) conserving the value of therapeutic substances where this is likely to be marred by misuse;
(c) discouraging the use of therapeutic substances in circumstances under which they are likely to become a danger.
(vi) Education of the public in the fundamentals of prophylaxis.
It is recommended, therefore, that the Commonwealth avow and emphasise its interest in the development of a programme for the detailed study of preventive measures in new fields of medicine.
It is further recommended that the Minister give his authority for the Department, as a first step, to enter into formal and detailed discussions with representatives of the British Medical Association, with State Health Authorities and with other persons, to determine what organisation or machinery acceptable to all parties, can be devised to facilitate the study of disease and its prevention and to apply in Australia the lessons learned from this study.
(C. E. COOK)
15th July, 1954