I move that the Estimate be referred back for further consideration. I do so because I think this Estimate and the whole position in respect of National Health Insurance in this country reveals a very alarming and very disquieting condition of affairs from the point of view of the insured persons. In this Estimate there is a decrease of £7,000 in respect of benefits paid to insured persons during the year, and the total reduction in benefits for the year will amount to £27,000. It is rather significant, however, that while we are providing for a reduction in benefit to insured persons, and while the National Health Insurance Society, which has been created by legislation passed in this House, is also paying substantially less benefits than previously, the number of insured persons has risen rapidly during the past few years, so that on the one hand you have a rising membership of the National Health Insurance Society and on the other hand you have the society paying less in benefit, and the State making a lesser contribution to benefit than in former years.
I want to ascertain and to examine the causes which are leading up to the apparent saving by the State and by the National Health Insurance Society and, at the same time, to direct attention to a quite different tendency in respect of the administration of National Health Insurance in this country. In 1933, when the Bill to provide for the amalgamation of 65 National Health Insurance societies was passing through this House, the Government claimed that unification would result in a saving on administration, that there would be more efficient administration, and that there would be available for expenditure in the interests of insured persons money which, up to this, it was contended, was being wastefully spent on the separate administration of 65 separate societies. But we find that the opposite is, in fact, the case, and that, far from unification having brought down the cost of administration, the cost of administration has, in fact, substantially increased, although there is less justification now for such high expenditure on administration than there was when there were 65 separate societies functioning in the country.
I want, first of all, to give the House a picture of the National Health Insurance position in 1937, which is the last year for which I can get full details, and the position in 1933. In 1933, the membership of 65 separate societies amounted to 474,000. In 1937, the membership of the single National Health Insurance Society amounted to 583,000. In 1933, 104,000 persons received benefit from the National Health Insurance, from the 65 National Health Insurance societies, whereas, in 1937, although the membership had increased by 109,000 in the intervening four years, only 95,000 persons received benefit from the single National Health Insurance Society. So that you have a very substantial increase in the membership, on the one hand, represented by 109,000, and, on the other hand, you have 9,000 less persons receiving benefit in 1937, as compared with 1933.
I begin to ask myself whether that is due either to an excessive policing of the membership of the society by the administration of the new society, or whether it is due to improved national health. I think the report of the Minister's Department, published in the Press to-day, does not indicate that there has been any considerable improvement in the state of our national health. In many respects there is cause for quite considerable alarm in some of the figures issued. The reports of medical officers of health refute the suggestion that there has been any improvement in the national health. Many of the reports of the county medical officers of health indicate that children, in particular, are suffering from mal-nutrition in consequence of long-continued unemployment. The statistics prepared by boards of health, the reports prepared by county medical officers of health, all indicate that there has been no improvement whatever in national health, such as would justify a belief that the payment of less national health insurance benefits to day is in any way due to the fact that the health and physique of the nation has improved.
If you take the figures of infantile mortality you find that in 1934 there were 63 deaths per 1,000 births, and in 1937 there were 72 deaths per 1,000 births. You find too, that the position in respect of tuberculosis and cancer affords room still for grave concern. The position in that respect is such as to cause grave concern to the nation. Rheumatism has now become a national disease. The statistics available, official statistics, do not indicate that we are entitled to say that the reduction in benefits paid to insured persons is in any way attributable to an improvement in the health of the nation. I think the money saved on benefit has been saved as a result of excessive and unreasonable supervision of persons claiming National Health Insurance benefits.
At one time there were insurance commissioners functioning in this country and I will say for the insurance commissioners that, so far as the insured person was concerned, they were very much better guardians of his interest than the substituted machinery which is in existence to-day. The insurance commissioners always took the view, when a medical referee reported that a man was capable of light work, that it was not merely sufficient to say a man was capable of light work, but it was necessary for the light work to be available. To-day all the decisions given by the Minister or his arbitrator on this subject indicate that once a man is certified to be fit for light work there is an obligation on the man to try to get the light work, and if he cannot get the light work himself, then he loses benefit.
Apply that to the case of a man who is a docker or an agricultural labourer. In what phase of agriculture can you get light work? With so many agricultural labourers idle, any farmer seeking a man will obviously seek one who is able-bodied and capable of doing all kinds of work; he would have no use for a man who was not capable of doing all kinds of work and his circumstances would not enable him to take pity on a man capable only of light work. When you tell an agricultural labourer that he is capable of light work and he should get light work, what you are doing is you are offering to that man an excuse for depriving him of benefit in circumstances in which he was previously entitled to and received benefit. To tell a docker that he is fit for light work when everybody knows his occupation requires the possession of herculean strength, is merely to give him an excuse for depriving him of National Health Insurance benefit.
Those of us who have experience of the National Health Insurance Society's operations know well that the plea of light work is being utilised by district medical referees, by the society, by the arbitrator and by the Minister or his Department as an excuse for depriving persons of benefit which they would have got if the insurance commissioners were still functioning and exercising the same benevolent interest as they formerly did in respect of insured persons. I think the administration of the society in respect of light work is very unsatisfactory, and that the insured person is paying substantially in hardship and suffering and in want of money for the reduction of benefits recorded here in this Estimate and for the saving in benefits which the National Health Insurance Society now records.
As I said earlier, we were told in 1933 that a part from the actual financial structure of the 65 separate societies, that the amalgamation of them all and the creation of one society would confer substantial benefits on insured persons generally and that there would be a considerable saving in administration. What is the position? In 1933 we had 65 societies with separate offices, separate staffs, separate administration and with all the other kinds of duplication that inevitably goes hand-in-hand with a multiplicity of offices and societies. In 1933 the expenditure in the administration of the 65 societies was £162,000. In 1936, with one society, the expenditure was £186,000, so that as between 1933 and 1936 it cost £24,000 more to administer one society than it did to administer 65 societies in 1933. It is true that, for 1937, the expenditure on the Unified Society fell to £155,000, but even £155,000 expended on one society, particularly having regard to the expenditure in other years, is something which, I think, ought to be investigated in the light of the circumstances presented to us by the Minister in 1933.
One might understand if this increased expenditure was due to the payment of decent scales of salary to the employees of the society. I do not pretend to speak with any detailed accuracy on the salaries paid to the clerical staffs in the headquarters office of the society although I do not think that they are anything that can be described as princely or generous in any degree, but I do know of the salaries which are paid to the agents of the society throughout the country. While the society can apparently say that these are only part-time agencies, the fact remains that, from the point of view of ensuring compliance with the Act and from the point of view of efficient operation of the Act the agent of the society throughout the country is a very pivotal man and he renders excellent service to the society. The scale of wages paid to these men is simply intolerable. No private employer would dare to offer salaries of the amount these agents are now forced to accept. The rates of wages are very inadequate, notwithstanding the responsible nature of the agent's work. The agent is a man whose activities enable the society to run smoothly and satisfactorily. He has custody of a fair sum of negotiable securities and it is desirable that the agent of the National Health Insurance Society should be adequately paid, or reasonably remunerated for the responsible work which he performs on behalf of the society.
The expenditure, therefore, in so far as it is due to decent rates of wages, or salaries per head of the staff employed, is not explainable, but the Minister may be able to throw some light on how it comes about that 65 societies could be administered in 1933 for £162,000, while it cost £186,000 to administer the one society in 1936. The expenditure in 1937 on one society was almost the same as on 65 societies in 1933. Similarly, if we turn to administration, so far as the Department is concerned, we find and equally puzzling position. Departmentally, the expenditure on National Health Insurance has increased between 1933 and 1937, although, bear in mind, between those years there has been a very substantial reduction in the amout of benefit paid to insured persons. In 1933 the Departmental expenditure in respect of National Health Insurance was £268,000 and in 1937 £280,000. While the Departmental expenditure was going up, the administration of the National Health Society was such that the amount of benefit paid to insured persons was going down. In 1933, £318,000 was paid in benefit to insured persons. In 1937 the amount so paid was £264,000—a very substantial reduction in benefit to insured persons, while the cost of the society's administration and of the Departmental administration was rising. This year there will be a reduction of a further £27,000 in respect of the benefit paid to insured persons. The position up to date is that in 1939, £81,000 less than in 1933 is being paid to insured persons, notwithstanding the fact that in that period the membership of the society has increased by 120,000.
I should like if the Minister would give some indication as to what is causing the position whereby the Departmental and society expenditure on administration is rising. While the membership is rising, and has risen by 120,000 persons in the last five years, the amount paid in benefit has fallen by £81,000 in that period. Everybody seems to be able to get more money but the insured persons. When we look at what the doctors have got for certification during the period, we see that the payment to doctors in 1933 was £41,000, and in 1937 it was £51,000. Benefit between those years fell by £54,000, so that the doctors got £10,000 more in 1937 than in 1933 for certifying for payments of £54,000 less in 1937 than they did in 1933. The less we pay to the insured person the more we pay to the doctors and the more we spend on administration departmentally and from a society point of view. Everybody, as I have said, can get more money but the people who need it most.
Then we come to the question of the administration generally of National Health Insurance benefit in this country. An examination which I have made of the figures of expenditure on administration shows a very serious position. My examination indicates that it is costing 5/10 to administer every £1 paid in National Health Insurance benefit. If you make a similar comparison in respect of widows' and orphans' pensions, you find that it costs 3/- to administer £1 of benefit. If you look at the unemployment insurance and unemployment assistance, you find that it costs 2/8 to administer £1 of benefit, so that while it is costing 2/8 to administer £1 of unemployment assistance benefit, it is costing over 100 per cent. more to administer £1 of National Health Insurance benefit.
I do not think any Minister or any Department can pretend to be satisfied with the extravagance which these figures reveal. The insured person can hardly be expected calmly to tolerate a condition of affairs whereby well over 25 per cent. of the fund created for his benefit is being spent on administration and he is apparently finding it harder than ever to get the benefits to which he is statutorily entitled. It seems to me nothing short of an outrage, nothing short of a classic example of waste, that we should be spending 5/10 to administer £1 of National Health Insurance benefit, while it takes only 2/8 to administer £1 of unemployment assistance benefit or unemployment insurance benefit. That is a state of affairs which ought to give the Minister cause for grave concern and certainly is a matter which ought to be inquired into with a view to cheapening the administration and bringing it substantially down from its present inflated level.
When originally conceived, the National Health Insurance scheme was regarded by many social reformers as something which was going to pave the way for a correction of the former attitude of the State in remaining indifferent to the standard of public health or to the hardships and miseries which sick people suffered, particularly in the industrial world. The purpose of National Health Insurance, as originally declared, was to prevent sickness and to cure disease. That was a very laudable objective and in England some effort has been made to keep the primary purpose in view. Efforts have been made there to provide sickness benefit in other than cash form. On the continent, of course, schemes of social insurance and for dealing with the health of the people are very much in advance of anything we know here.
If you were to take the position in Great Britain and in a dozen progressive countries in Europe you would find that our National Health Insurance scheme was merely an institution that gave a person a few shillings a week, and told him to get better as best he could; whereas in Great Britain and in progressive countries on the Continent the whole conception of National Health Insurance is on a much higher plane than it is in this country. We are doing nothing in the way of preventing sickness; we are doing nothing in the way of curing disease. What happens is that an insured person when he gets sick gets a certificate from a medical officer, who gives it to him after a most perfunctory examination and wishes him luck with the society. He makes application to the society and gets 15/- a week benefit. His wages may be £3, £3 10s., or £4 Let us say it is £3 per week. That man, who finds that £3 per week is necessary to sustain his family when he is in good health, submits his certificate to the society and in return gets 25 per cent. of his salary to keep his family and to meet the same expenses, although he himself probably needs the expenditure of more money than when he was in good health in order to cure his illness.
That is the position into which we have allowed National Health Insurance to drift. Its primary object was to prevent sickness and to cure disease. Our translation of that high concept into practice is to give a man 15/- a week and tell him to get better as quickly as he can and any way he can. No effort is made to treat a person under the scheme and no effort is made to advise him. All he may do is to call on the medical officer and get a certificate and wait until the 15/- comes to him. The State is not concerned under the scheme with curing the man. The dispensary medical officer may take him in hands and he may send him to hospital, but that is not part of the scheme envisaged when National Health Insurance was introduced. The State remains passively indifferent as to whether the man gets well or passes away. The concern of the society is to ensure that he does not draw too much benefit and does not stay too long on the books. If he does, the kind of person they send to have a look at him is the district medical referee, who will look at him occasionally and put him through the hoops. If he gives a certificate that the man is fit for light work, the man must try to find work, and if he fails, he loses his benefit. The very lofty purpose of our National Health Insurance legislation has descended to a very low level indeed. The wider purpose of the legislation has been completely forgotten. We are carrying on to-day simply, one might say, as a dole-paying institution, giving a man a few shillings a week, telling him to get better as well as he can. We are doing that at a cost which baffles any attempt to understand. It is costing 100 per cent. more than the administration of the unemployment assistance scheme to administer National Health Insurance. I should like to know whether the Minister has any plans for dealing with that position; whether he has any intention of expanding our legislation to deal with these grave defects in the scheme.
But even the sufferings of the insured person do not end there. In 1933, on the coming into operation of the Unified Society, certain additional benefits were being paid by certain societies. I agree that the position of all of them did not allow of their paying these additional benefits, but at least some of them were able to pay these additional benefits owing to the fact that they had good economic units for the purpose of insurance. Some of these societies, in addition to the cash benefits, paid dental benefits, provided hospital treatment, optical treatment, and surgical treatment, and some of them paid much more than the statutory benefit of 15/- per week to insured persons. I know of one society in fact that paid 19/- per week instead of the statutory 15/-. In the case of that particular society, which then went into the unified scheme, its members have lost dental benefit, hospital benefit, optical benefit, surgical treatment, convalescent home treatment, tuberculosis treatment, and the benefit is down from 19/- to 15/-.
I can understand that if you have a scramble for members for the purposes of National Health Insurance that some society because of the avocations of a particular class of members, will be able to get good economic units, and that some other societies will have to take the units which are not so good economically for insurance purposes, and that inevitably you will have inequalities of that kind resulting in the position that one class of member will be able to get benefits substantially higher than another class of member who pays precisely the same rate of contribution. I do not attach so much importance, therefore, to the dissimilarity in the benefits paid by one society as compared with another, but I do say that after six years of unification we ought to see some attempt by the Unified Society to level up the position. Instead of that, there has been a process of levelling down. Everybody has been pushed back to the statutory limit of benefit. There has been no improvement whatever for anybody. Although the good units made sacrifices, the units which are not so good for insurance purposes have got no extra benefits. I can understand a position whereby individual societies would give big benefits and there would be then a steep curve down to the general level of the statutory benefits. What has happened is that the curve has gone off and there has been no rise whatever in what was formerly the statutory level of benefits for the other members. The whole process which has gone on in the past six years has been one of levelling down and doing nothing whatever to improve the benefits in respect of the insured members generally.
The reason for this levelling down, and the plea which has been made as to the society's inability to provide additional benefit, has been that the insurance fund is not in a solvent actuarial position to provide additional benefit. Some expert said that the fund is insolvent. I do not know whether it is insolvent or not. I do not know whether the Minister knows the basis of valuation of the insurance fund, or understands the basis of its valuation. It has baffled many people who tried to take an interest in the matter to ascertain the basis of valuation. I think I am right in saying that the British people had the same basis of valuation as here, but they have since revised their valuation and found a new type of valuation. Apparently, that has not in any way caused a very serious dislocation of National Health Insurance legislation or benefits in England. What is the position of this fund, which is supposed to be insolvent? My inquiries into the matter show that the credit balance in the fund in 1937 was £4,000,000. My calculation was that that was increasing at the rate of £250,000 a year. The Minister, in fact, has put the rate of increase higher in the statement he read this morning, because, I think, he said that during the past year it increased by £289,000, so that this insolvent fund, consisting in 1937 of £4,000,000, has probably assets to-day to the extent of £4,500,000. Many undertakings in this country, commercial and industrial, would regard themselves in a very good position if they had assets to the extent of £4,500,000 and saw no likelihood, at the present rate of benefit, of having to draw on them, when they ascertained, from the current year's trading, that, in fact, that fund was increasing from £250,000 to £290,000 a year.
I should like if the Minister could tell us whether it is intended to revise the basis of valuation, and whether it is intended to release some of the accumulated assets for the benefit of insured persons. I know that the actuarial theory will be, bearing in mind the ages of members, and the expectation of life, that you have to budget for the possibility of what will be done for the last man left in the society. That always seems to be so remote, and so far removed from more pressing problems, that we can allow provision of that kind to become almost a fetish, if we allow ourselves to develop a state of mind where we proceed to do on the 1st of January something which was due to be done on the 31st of the following December. Whether that philosophy will be accepted or not is another matter.
