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

CHAPTER 11

There appears to have been little cause for complaint on the part of the dentists. Patients were flooding in, and the same scale of fees was applicable as in England. At first the Manx scheme provided that the sum which would be payable for normal treatment under the scale could be contributed as a "grant-in-aid" towards more expensive treatment or dentures selected by the patient, but it was soon realised that this gave the undesirable and erroneous impression that the normal service was in some way inferior, whereas the Terms of Service required that both the materials and workmanship should of first class standard. This provision was therefore discontinued.

A source of discontent on the part of the dentists did arise in respect of the School Dental Service. The Education Authority was concerned that the Service should continue, and the introduction of the NHS raised problems. It felt that its dentists should continue to do regular inspections, as being the most effective method of ensuring dental fitness for all children, but a free service outside the schools would adversely affect the Service's viability as there would be a reduced demand for treatment on its part. They would not have the same ability to try to ensure that work revealed as necessary by an inspection was followed up, and when there were children whose parents were conscientious enough to see that they had treatment under the NHS, the school dentists could then be put in the invidious position of appearing to be checking on their fellow practitioners' workmanship. A further factor, which obviously appealed to the Health Services Board, was that the School Service was considerably more economical. The solution was that from October 1950 it was ruled that children of school age could have free treatment, except in an emergency, only from the School Dental Service, which was to be extended. This move was strenuously opposed by the Dental Association, to the extent that representation was made by counsel on their behalf when the amended regulations were before Tynwald, but the regulations were approved.

An unforeseen outcome of this was that, as practice under the Health Service was proving so lucrative, the Education Authority suffered a continual loss of dental staff, and their Service was prevented from fully meeting its obligations. To counter this, sessions in the schools were offered to NHS dentists, without much success, and eventually the further solution found was a compromise, that children over the age of eleven could have treatment under either the School Dental or National Health Services.

The take-up of the Dental Services, greater even than had been expected, was mirrored in England, and both there and on the Island there was some dismay as to the cost, and the concomitant result that the dentists' remuneration was far higher than had been seen as acceptable. The first step, following England, was that a limiting factor was imposed, by which any treatment given which would increase the gross payment made to a dentist to above £4,800 a year was to be paid for at half the normal fees. This measure, applied from 1st. February 1949, was rescinded from 1st. June 1949, when a schedule of reduced fees became operative. This reduced the expenditure, but not enough, the final attempt being a reduction of the gross remuneration by 10% from May 1950, this and the falling demand for services apparently keeping the situation reasonably under control. The 10% reduction ceased to be applied in May 1955, when the preceding year to 31st. March had shown the lowest number of cases since the commencement of the Service.

The Pharmaceutical Services had always been the field over which the Board had least control. Doctors, and in some cases dentists, were free to prescribe of the preparations available those that they felt would most benefit the patient, the only sanction available being when a doctor was reported for possible over-prescribing, and could be called upon for an explanation of his actions. This reporting was one of the functions of the Prescription Pricing Bureau, in Manchester, whose services the Board had been fortunate to secure, as even from the start the sheer volume, and the expertise needed, made an Island-based operation impossible. Figures for the cost were difficult to produce, as the pricing took some time, and to avoid an unacceptable delay in paying the chemists, a system was devised whereby the chemists received a payment of 90% of the estimated value of the prescriptions for the month, with an adjusting payment later. Due to the heavy workload on the staff the Board had at their disposal, at one time the adjustments were running ten months late, and in one year, in addition to the twelve normal monthly payments, there were sixteen adjustment payments.

As an effort to exercise control nearer home, the Bureau undertook to prepare statistics showing the average cost of each doctor's prescribing against the average as a whole, an exercise which unfortunately contributed to the delay in making payments, but which proved worthwhile as the Board set up a Prescribing Committee, of whose six members four were doctors and one a chemist, who perused the reports, and, being fellow professionals, were in a position to interview any doctor giving cause for concern, and give advice and guidance.

Pharmacies have always been in a midway position, between an establishment providing a service, and a shop. The Board had to devote some time to matters such as the setting up of rota services, and other provisions for dispensing out of normal hours, which led to involvement in mundane matters outside the expected normal scope of the Health Service, such as the Shop Hours Acts, and what a chemist could sell at those times.

At first, the dispensing was largely of the long-established remedies, relatively cheap to produce, but this was the start of the era of the new drugs, with the emergence of evermore sophisticated, and consequently more expensive preparations, leading to further disquiet. When Aureomycin started to make an impression in 1953, for example, the reaction to its cost was that it was decided that it should only be supplied through the dispensary at Noble's Hospital, and the Board asked the Prescribing Committee to draw up a list of other expensive antibiotics which might also be supplied only through the Hospital. What had really shaken the members was to learn that ACTH (Corticotrophin), then in use as an alternative to corticosteroids in conditions such as Crohn's disease or rheumatoid arthritis, and of which two grams per month was being supplied to Noble's by the English authorities, was costing a few shillings less than £43 a gram. Despite the fact that this further restriction on dispensing had been the suggestion of the Committee in the first place, no positive action appears to have been taken; possibly there was some reluctance to proceed, as no similar measure applied in England. The Committee reversed its view, and suggested in January 1955 that all antibiotics should be generally prescribable, but it was not until October of that year that the Board agreed.

The charge for prescriptions of 6d. per form, from November 1950, which had led to the "chemists' strike", previously noted, was increased in April 1953 to 1/- (5p.) per form, in line with England, and charges for elastic hosiery were introduced.

Compared to the foregoing, the introduction and conduct of the Supplementary Ophthalmic Services appears to have gone remarkably smoothly. The Board's agreement that referrals for ophthalmic services did not, after all, have to come from the patient's general practitioner, and the introduction of charges, have already been commented on. The records of those early days are mainly concerned with straightforward matters: the opticians' remuneration remained the same as in England, and where alterations to the scheme had been introduced which made it differ from England, to effect economies, these had the full agreement and co-operation of the opticians. For some years, the charges for spectacles brought in from August 1952 remained constant, at 10/- (50p.) a lens, and the whole cost of a Health Service approved frame. The patient paid any additional cost for special requirements. Sight tests were free, as were spectacles for children, again with a contribution for alternative choices. Artificial eyes also came within the Board's ambit.

The records show the Board's involvement in those days mainly as making decisions as to the exemption from charges in certain specific cases, and the allowability or otherwise of the supply of various types of visual aids, some of which are at the least intriguing, such as the disallowing of "reversible" frames, and spectacles either supplied, or requested, for visits to the cinema.

Meanwhile, over a period from June 1951, various sections of the Board had moved into its new Head Office at 3,Harris Terrace, Douglas, the final move being the first Board Meeting there in January, 1954, where they were to remain until 1975, and of which many of the staff must have retained happy memories, as being one of the most pleasant of Government offices in which to work, with its garden, flowering almond tree, and rear views over the grounds of what was then the House of Industry, now the Ellan Vannin Home. The building had been conveyed to the Board for a nominal consideration by the Board of Social Services, as successors to the Board of Guardians of the Poor of Douglas, complete with the stone-breakers' yard next door, in which able-bodied supplicants had been obliged to work for their allowance, and the beautiful stained-glass windows in the porch (framed and still carefully preserved at Jane Crookall House), bearing the coat of arms of the Guardians, and their motto, "Lesh Cooney Jee" ("With the Help of God", but more often rendered by the unfortunate clients as "God help us!"). Also treasured was the bullet hole in the window behind the Secretary's desk, believed to have been the legacy of a dissatisfied applicant.

An indication of how the Board was still grappling with the duties thrust upon them is that one of the first alterations to the new offices was a small extension, with sound-proofing materials on the walls, to house the hearing-aid department, little larger than a broom cupboard. The service was provided, not by a technician, but by one of the clerks who had been sent on a short course, and the memories of him are of his mainly being seen with a soldering iron, or finding some space to store the batteries. Long before the days of transistors, the aids were of course valve-operated, needing high-tension batteries, and consequently very bulky and prone to damage.

The functions of the Board had not all gone to Harris Terrace, however. The Secretary was still heavily engaged in keeping track of developments in England, and drafting either new or amended regulations. Even so relatively minor a matter as the introduction of the new acrylic fillings necessitated amendments to the Dental Regulations. It was thought that if he was too close to the day to day running of the Service, there would be too many calls on his time, and that he should continue to be accommodated in Circular Road in comparative isolation. The question then arose of the delay that would be occasioned should he be required at Harris Terrace, but the solution was simple: the Board bought him a motor-scooter.

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