Doctors and patients in an era of national health insurance and private practice, 1913-1938.

Abstract

I nterwar service industries in Britain have received surprisingly little attention despite providing over half the output, and employing nearly half the workforce.2 Medicine was one of the leading service industries, yet the growth in demand for medical services, and the rising incomes of the members of the medical profession in the interwar period have also had little scrutiny. The extension of a service economy was an important feature of the interwar years-as it has been again recently-and the role played by the medical services was a significant element in this development. The fact that its growth occurred through an unusual combination of state subsidy and private demand gives it added interest. This paper looks first at the changing incomes of all members of the medical profession, before analysing the incomes, expenditure and incentives of the publicly remunerated 'panel doctors'. These are placed in the wider context of overall professional earnings to assess the relative economic importance of the national health insurance scheme for medical practitioners. We turn then to the rising demand for medical services by the interwar patient and the implications this had for the general practitioner's income. Finally, there is an evaluation of the quality of treatment given by the interwar doctor, which emphasizes the disincentives to good medical care that were inherent in the national insurance scheme. The panel system was based on the state health insurance scheme that was introduced by the National Insurance Act of i9 Ii, and came into effect in I9I3. The system was gradually increased to cover a greater proportion of the working population. Initially, the act included those aged between i6 and 70 employed in manual labour or in non-manual jobs with an income less than ?i6o per year. In I920 this limit was raised to ?250; in I928 the upper age limit was reduced to 65; and in I937 the lower limit was also altered since juveniles under i6, but in employment, were added to the panel. This meant that in Great Britain I3.7 million were insured by I9I4 and I9.2 million by I936; a rise from 47 to 54 per cent of the adult population. However, not all the insured population were enrolled on doctors'