[from "The Birth of a Service", 2008]

CHAPTER 5

The amount and variety of work got through by the Board in these early stages seems incredible considering the almost total lack of resources. Having no premises of its own, meetings were held in the Tynwald Committee Rooms; the best that could be done for the Secretary was to be offered the use of the corner of someone's desk in the offices of the Mental Hospital Board, but there was no chair, so he had to stand! It was a great relief when he was given the use of 72, Buck's Road, the offices of the former Hospitals Contributory Scheme, (popularly known as the "Penny in the Pound"), and was able to take over their staff of a man and two young ladies. As virtually every resident had to be registered for medical services, upwards of 50,000 forms had to be sent out and processed: medical cards issued, with duplicates to the doctors with medical record folders. This monumental task was handled by hiring St. Andrew's Hall, and recruiting teams of boys from the High School who were leaving, or otherwise on holiday.

Tribute should here be paid to the enormous and invaluable help which was so freely given by the English authorities, both at their London headquarters, and, particularly, Liverpool Region, without which the Manx scheme could have fallen at the start. Their ability and cheerful willingness to supply forms, details and advice is a debt which can never be sufficiently acknowledged.

As an example, the chemists were starting to submit prescription forms for payment, and it would have been out of the question that the Island could have set up an economical independent system, finding persons with the knowledge of the preparations, and the expertise to deal with the pricing structure required. Here the Board were very fortunate in being able to secure the services of the Manchester Prescription Pricing Bureau, to whom the scripts could be dispatched on a monthly basis, and payment made accordingly. It might be mentioned here that this facility (now by the Prescription Pricing Authority based in Newcastle) is still in use, having served the Board or the Division well for 60 years, especially as part of the service includes reporting on irregularities, such as over-prescribing.

It appears that the Board were able at last to take over their proper offices at 32, Circular Road, by the beginning of March, 1949, but as if the difficulties purely in administration which could be expected from the lack of preparation were not enough, there were manifold other problems confronting the Board, and some of the questions asked by members in Tynwald were about matters which had been the subject of weighty concern to the Board themselves.

Possibly the most repetitive, although the easiest to answer once the principle was grasped, was the provision and status of private and amenity beds. It was explained that amenity beds were in separate rooms, and had a twofold use, in that they could be allocated to a patient where privacy would be beneficial on medical grounds, in which case there would be no charge to the patient, or, if otherwise not required, a patient who wished for privacy could be accommodated for a relatively low charge, while still receiving free treatment and care under the Service. A private bed, on the other hand, was for use when a patient had elected to pay the full cost of treatment and accommodation: the specialists' fees, and a sum intended to reflect the cost of diagnostic facilities, drugs and dressings, and nursing and hospital administration. Against the charge that these patients had already paid their contributions under the National Health Insurance, it was pointed out that the yield from contributions was only a small proportion of the cost of the Service. However, the Board appreciated the point, and gave an undertaking that charges would always be held to a minimum.

Another, and this was a point which had been raised by the Governor as long before as 1946, when the concept was still being passed around Government Office, was what was to be the situation as regards Temporary Residents, or "the visitors", as they have always been known on the Island. It has to be borne in mind that in those days the Island could expect to play host to upwards of 500,000 holiday-makers in a year, and although the slant of the tourism literature, possibly in competition with the Channel Islands, was on the principle that they were visiting a different country ("Come abroad to the Isle of Man"), it was felt that it would hardly be an inducement once it became common knowledge that they were leaving the umbrella of the United Kingdom N.H.S., and liable to charges if they should fall ill. In any case, probably few of them realised that they were in fact leaving the United Kingdom. The question then, was what was their position under the Act, seeing that the Island's service was to be a mirror of the United Kingdom's, and it was known that there free emergency treatment was to be accorded to visitors, including those from the Isle of Man? Reference was made to the Attorney General, who ruled that in Section 1(1) of the Act, "people of the Isle of Man" could and should be interpreted as including anybody physically present on the Island at the time. That being the case, how was the expenditure, which could be very considerable, to be met, and here the Board displayed an acumen which can only be described as masterly, in that they were able to make an agreement with the English authorities that, in return for looking after the interests of the visitors, Manx patients could be sent, as necessary, for free treatment in English hospitals, or for other treatment not available on the Island, and by extension, this would apply to Scotland and Northern Ireland.

One bone of contention very quickly settled was over the services of opticians. It had originally been intended that opticians should practice from Health Centres, but this had been abandoned when it was appreciated that most also dealt in items, through their shops, other than aids to be provided by the Service. However, there was still a provision that a patient was only to be given a consultation on a referral by his general practitioner. The opticians protested that this was manifestly nonsensical, as there must have already been some valid concern on the part of the patient to have sought attention in the first place! This was agreed to be a reasonable argument, and the regulations were amended accordingly to give direct access.

However, relations with the doctors did not go so smoothly, not so much on a personal basis, but because of the continuing dispute in England between the doctors and the then Minister of Health over their Terms and Conditions, which was prolonged and increasingly bitter, and which had obvious implications for the Island. Although the doctors on the Island had been resistive to the scheme, being seen as losing their independence, they had reluctantly agreed as having no real choice, but the point which they had repeatedly stressed was that it was to be conditional on parity with their English counterparts. So, as the row rumbled on, hard-fought agreements were reached, which, when to be applied here, led to further negotiations because, as has been previously mentioned, in some respects the Island's situation sometimes did not lend itself easily to adoption without some modification.

An unfortunate dispute arose with the Advisory Council, who had been charged in the first instance with drawing up a scheme for the provision of Specialist Services: that is, as the term implies, doctors specialising in the diagnosis and treatment of specific fields of medicine, who would be based in the hospitals, but employed by the Board. The scheme, or any variation of it, had to have the approval of the Governor, which had been given, but the issue was raised in Tynwald by one of the Deemsters who queried the number of 28 as seeming excessive: 9 full-time, 12 part-time, and 7 visiting from England. The Board's Chairman explained that as there were already 25 specialists acting in the hospitals at the time the Service started, there were only to be 3 new appointments. Furthermore, it had to be appreciated that some were general practitioners with as little as one session of four hours a week, and a visiting specialist might only be making a visit once every three months. This did not satisfy some members, who voiced the opinion that as the Advisory Council was mainly composed of doctors, their advice could be suspect as being biased in favour of their fellows, a suggestion, despite the Chairman's spirited denial on their behalf, to which the Advisory Council took grave exception. Of greater consequence was the question raised by a member, who served on the Advisory Council as a layman, as to how a memorandum, which the Council would have considered to be confidential, had come into the public domain, as evidenced by the fact that the Deemster had been in a position to query their recommendations. To this the Chairman replied that he had felt that in his position he should feel entitled to take advice where he thought fit, and had in this case in view of the Deemster's past involvement and interest in setting up the Service. This the Council did not find satisfactory.

It might be pertinent at this point to digress a little on the relationship between the Board and the committees. At first, due to the paucity of the staffing, and the fact that as the staff expanded with the increases in work-load, recruitment was almost always of temporary staff, known as Unestablished Officers, because of the Civil Service's reluctance to allow increases in the permanent establishment. The Board's Secretary had perforce to assume the duties of Secretary to all the committees as they were formed, including the Advisory Council. As the Council was intended to be an almost independent body, this could place him in a difficult position, having knowledge to which the Board was not privy. Later this position was rectified, the Board's Secretary functioning as secretary to only one committee, the others being served by senior members of the staff, and the Council's Secretary regarded in that capacity as having loyalty only to the Council. It also appears that in those days the Board were given copies of the various committees' minutes. By the 70's the Board received no minutes, except those (obviously) of their own meetings, and those of the Hospital Committees, and were only informed of any other proceedings of which it was felt they should be aware, and then usually informally.

Relations with the Management Committees of the voluntary hospitals, and particularly that of Noble's, were not always of the best, there being, understandably, some resentment at being overseen by and responsible to politicians, when they could look back at what they could quite rightly regard as having done an admirable job on their own, and not entirely assuaged by the expansion of their services necessitating the injection of much-needed funding. It was in many ways an unsatisfactory half-and-half situation, and in retrospect there is a widespread opinion that it would have been better had the 1948 Act made a clean sweep of "nationalisation", as it has been termed, rather than their eventualtotal assimilation in 1963. As it was, the Board, and therefore the Board's Secretary, had no real function in the running of the Hospitals, so that when he had to visit a hospital, to discuss finances, or to see one of the specialists, who was a Board employee, he has said he felt more like a visitor, there on sufferance.

In the meantime, the Board were struggling to maintain a unified service against the aspirations of the Local Government Board, which had not relinquished its ambitions for expansion into the Health Services field, and in 1949 made an spirited attempt to take over various functions, including the care of mothers and young children, notification of births, the nursing of infectious disease cases outside hospitals, the publication of health information, and the provision of ambulances. The basis was that the Medical Officer of Health, who would be concerned with these functions, was an officer of the Local Government Board, but the attempt foundered when the Health Services Board pointed out that the Local Government Board had already given an undertaking that there should be full liaison between the Boards, and access to his services when required!

Any comments, errors or omissions gratefully received The Editor HTML Transcription © F.Coakley , 2008