- Email: [email protected]
The public medical service
IiO
PUBLIC HEALTH.
revenue which had fallen off to an alarming extent, is now recovering, and arrears are being rapidly paid off. The fact that every branch is now given a financial interest in the collection of arrears wilt give universal satisfaction. Another ancient grievance was concerned with the mysterious disappearance of the Society's notices and copies of PUBLIC HEALTH in the post, and in order to reduce these to a reasonable minimmn; the revised Register of Members is now well in hand, and any member who has had cause for complaint in this connection should communicate with the Executive Secretary at once. Reference to the reconstruction of the Society of Medical Officers of Health, must include congratulations t o the Society upon the fact that Professor Kenwood has accepted a second term of office as President. The Society will, therefore, have the advantage of his wise leadership dffring the coming year when the new constitution will be on its trial. Professor Kenwood has taken a foremost part in the work involved in drafting the new constitution, and everyone who has shared in that work realises the fact that without his cheerful insistence and persistence, the work would have not been accomplished in the time. Anyone who knows the difficulties which attend such a task will marvel t h a t it has been possibIe to carry through the scheme in less than a year. Professor Kenwood's presidential address to the Society in October last year made it evident that he has ambitious views as to the sphere of influence which may be occupied by the Society. It may be well, however, to remind members that this influential position can only be secured through a greatly increased membership, which in its turn depends upon individual efforts of the present members. We suggest, therefore, that special efforts may be organized by every branch forthwith to aid the President in making the Society completely representative of the Public Health Service. We believe that branches will gladly undertake this crusade and will show their appreciation of the changes which have been carried out at their bidding by securing a great increase in membership.
SHEFFIELD HOSPITAL SUPERINTENDENT.--The salary of Dr. E. H. Williams, Medical Superintendent of the City Hospital, Sheffield, has been increased from £6oo to £8oo per annum, with house, coal, light and laundry free. The telegraphic address of the Society of Medical Officers of Health is now-EPIDAIYROS, WESTCENT, LONDON. I~[embers are requested to make a note of this alteration.
JIJLY,
T H E P U B L I C MEDICAL S E R V I C E . * BY THOMAS GIBSON, M.D.,
Medical Offwer of Health, W~kefield. the m a n y schemes Of social reform A MONG which aIe now engaging the attention of the p u b l i c , there are none of greater importance to the nation, and naturally none of greater interest to medical men, than those which are concerned with the r e e o n : struction of the PuBlic HeMth Administration and the improvement of the PuMic Medical Service. For m a n y years past there has been, both within and without the profession; a growing dissatisfaction with the eonditi0ns under which medical succour and advice have been provided for the public, and during the war dissatisfaction has become more freely expressed and schemes for improvement have been more actively discussed. These schemes are m a n y and varied. Some advocate an extension of the Insurance Act to include dependants" t h a t is, all or practically all persons belonging to the working classes. My own opinion is,. t h a t the Insurance Act, so far as sickness benefits are concerned, is to be u t t e r l y condemned, and to extend it, with all its intricate expensive and useless machinery, is only to make confusion worse confounded. Then there are the schemes for a quasi public medical service, such as the one suggested b y the British 5Iedieal Association, which, a l t h o u g h preferable to t h a t of extending the Insurance Act, would, I am afraid, fail to meet the real needs of the public. Then we come to a salaried whole-time public medical service, run either as a nationai service or under local authorities. Differing as t h e various schemes do, t h e y are all postulated on the admitted need for radical changes , and all agree in the pressing need for increased hospital accommodation, increased laboratory facilities, and b e t t e r facilities for consultation. Many of these schemes also agree in demanding t h a t in any public medical service established in the futur~ there shall be a ele~r line of demarcation drawn between curative a n d preventative medicine, and t h a t the administration o f these two departments shall be k e p t entirely separate, each w i t h its own set of
*A Paper read before the Yorkshire Branch of The Socie2y of Medical Officers of Health, 25th March, 1919.
19! 9.
PUBLIC "HEALTH.
officials, its. own machinery, a n d its own domain of action. Now this proposition is one of extreme importance, one that closely concerns medical officers of health, and one which should receive their serious consideration. For m y own part, I think it is a proposal which should be met with the strongest opposition, inasmuch as it appears to me t o be founded on an utterly wrong conception of the role of medical science, and would prove in practice expensive, wasteful, and inefficient. On the contrary, I believe that no public medical service can be satisfactory and efficient which does not intimately and organically combine the preventative and curative aspects of medicine in one system of administration, both central and local. Theoretically, of course, you can draw a clear line between the two departments, b u t in actual practice any distinction is altogether arbitrary and artificial, and can only be accepted as indicating the extent to which either of these two aspects predominates in the work of any given practitioner. The activities of the sanitary service of the country is, of course, mainly directed towards the prevention of the diseases, and the medical officers attached to that service are primarily employed in directing these activities. But it does not follow that they have no concern with curative work and modern advances in preventative work are more and more recognising the important role of earl?- treatment in the prevention of disease. For many y e a r s p a s t medicM officers of health have been directly Concerned in the treatment of infectious diseases, and in fever hospitals, and during recent years, their clinical domain has rapidly extended s o as to include the treatment of tuberculosis in dispensaries and sanatoria, the treatment of venereal diseases at clinics, the medical inspection and treatment of school children, and of infants and children under school age, and even the medical oversight of women during pregnancy and confinement. In fact, the modern public health department affords an excellent example of .a combined preventative and curative system of medicine actually in being and growing up to serve the needs of the public, and one that can only be regarded as unsatisfactory because of the limitations imposed upon it b y tile existing system of general medicine. On t h e other hand, the general medical practitioner, while mainly concerned with the cure 0f diseases, should also be concerned with
Iii.
its prevention, and it is his misfortune as well as the nation's that the exigencies of general practice and his relationship to the public should limit his sphere of action so m u c h to merely curative work. The opportunities for combating disease that lie to the hand of the general practitioner are incalculable, and I think it may be safely said that no public medical service, which does not reeognise the all-important service which tl~e general practitioner can render to preventative medicine, will ever prove satisfactory or efficient. • That the assistance of the general practitioner is absolutely essential to the carrying on of ordinary measures of prevention of infectious diseases is Mready recognised by the State, and the obligations imposed on the practitioner with regard to the notification of these diseases are being extended rapidly. The number of diseases already on the notification list make no little tax on the memory, but I a m afraid the tendency will be to add to them, and also to extend the scope of notification to other conditions, such as cases of food poisoning and the like. There is no question, I think, b u t that all this information is desirable and indeed essential to an effective public health administration, but at the same time I am doubtful if the State can go on extending its requirements of the general practitioner under p r e s e n t conditions of practice without creating grave dissatisfaction and possibly opposition. Medical practitioners as a whole recognise that they owe a d u t y to the State, b u t there is a growing feeling that they are not being t r e a t e d fairly, and the action of the Government in reducing the notification fee, to m y mind a mean and indefensible action, has helped to greatly intensify this feeling of grievance. I t is also Mr, and I think q u i t e properly, that there must be a limit to the duties which can be imposed b y the State upon medical men working as they do under present conditions, and that this limit, if not already reached, is being closely approached. I t is, I think, pretty obvious that this state of affairs cannot continue, and that either the State will: have to curtail or check its demands, and to make a radical change in its present-day policy, or the position of the general practitioner in relation to the State and the public will have itself to be radically altered. Of the two alternatives the former is not the one that is likely to happen, and it would be pursuing the policy of the ostrich to ignore the possi-
II2
PUBLIC HEALTH.
bilities of the latter. It m a y be taken for granted, I think, that the general practitioner Will more and more be eMled in to assist the efforts of the State to improve the social and physical welfare of the. community, and he will be called upon to concern himself more and more with t h e prevention of disease. One cannot get away from the fact that the position of the general practitioner must of necessity be changed, and fitted in somehow with the new order of things. Now I want you to think of the future practitioner as one concerned as much, nay, even' more, with preventative medicine as with curative, and then to think into what system he can harmoniously be introduced. Not, it Seems to me, into any system which is merely an amplified Insurance Act system, not into any semipublic, semi-private system, b u t only in an outand-out wholeCtime salaried medical service can this ideal be realised. The new wine must be put into new bottles. I must confess I have come somewhat reluctantly to this conclusion, and have looked for other solutions Of the problem, but I can find none that seems likely to work, and in no other can the essentiaI idea of a combined preventative and Curative service be introduced with any prospect of success: It is impossible within the limits of this paper to discuss in detail the arguments for and against such a service. I will just mention some of the advantages as they appear t o me. ADVANTAGES TO THE PUBLIC.
(I) Simplicity Of organisation and administration, as compared with the complex machinery of administration inseparable from any system like that of the Insurance Act or indeed of any system in which private and public medical Work are intermixed. (2) Abolition of unnecessary waste of time and labour of the profession secured b y arranging work on the district system. (3) Flexibility of organisation, allowing for example the transfer of medical men from one district to another to meet the abnormal demands of an epidemic. (4) Better attention from doctors who are not overworked and who have better facilities for keeping abreast of advances in' medical science. (5) The advantages of a co-ordinated preventative and curative service. (6) Fuller facilities for securing data as to incidence of sickness and conditions affecting the public health. :
I ~L'¢;
ADVANTAGES TO THE PRACTITIONER.
(I) Facilities for newly-qualified medical men at once taking up professional work, and for graded advance in the service. (2) Regular hours of work, and arrangements as to regulation of night work, and for holiday leave. "(3) Abolition of over work. (4) Opportunities for post-graduate s t u d y at regular intervals. (5) Facilities for consultation and obtaining e v e r y necessary assistance in the discharge of duties. (6) The interest a t t a e h d to the combination of preventative and curative duties. (7) The abolition of the commercial aspects of private practice. (8) Superannuation. I will now turn to some of the commoner objections raised against such a set,nice. I. '" The system does not provide/or a/ree choice o/doctor." This is considered b y many an insuperable objection, and at first sight it does seem a formidable one. But if you look into it more closely, it becomes less formidable, and b y no means so insuperable as many imagine. In the existing SYstem of medical practice the choice of a doctor is b y no means so free as some Would make out. The choice of doctor open to a resident living in a given district is largely limited t o the doctors practising in that district, and these doctors have not been" selected b y the community. The fewer the doctors, the narrower the range of choice, and in many country districts where o n l y one doctor is in practice, there is really no opportunity of exercising choice. And it is a curious and interesting fact that nowhere will you find such unstinted confidence bestowed on a .doctor b y his patmnts than in these country areas, whose medical needs are supplied b y one man, and b y a m a n who has settled in the district without any call from or selection b y the residents. Then think of the thousands in hospitals, sanatoria, and convalescent homes, attending tuberculosis dispensaries, school clinics, child welfare centres, and kindred institutions, and the host of poor law patients, all under the medical care of doctors in whose appointment the patients have not had t h e slightest say. I t is extraordinary what little objection one finds to treatment under these conditions, and it is significant t h a t : the demand for increased institutional treatment in which the patients have for the most part no choice of doctor is
z919.
PUBLIC HEALTH.
becoming : more insistent. Lastly, I think increased facilities for consultation would largely do away with any real difficulties attendant on this question of free choice. 2. "'A whole-time salaried service would be worked by oy~cials, and the work o/oficials is mechanical and per[unctory." It would certainly be worked by officials - - t h a t is, b y medical men paid a salary for doing certain work and not remunerated b y fees :paid b y the individual patients. The term " officials " is sometimes made an opprobrious one, a n d possibly in some cases deservedly so, but, after all, it is a term of no real significance and might b e applied indiscriminately to the Whole army of wage and salary earners. That the work of the salaried medical officers is done less thoroughly or with less regard to the feelings and sentiments of his patients than that of the medical man paid b y a fee, I utterly deny, and I claim that the standard of professional work, viewed from whatever point of view you like, is at least as high among the salaried medical men as it is among the private practitioners. 3. " A whole-time salaried service would eliminate competition." W h a t kind of competition would it eliminate? The only kind of competition that it could eliminate would be the commercial one, which, instead of being something salutary, has for long enough been the curse of the profession, and which even now threatens the extinction of the profession as a profession, and its conversion into a mere trades union. The establishment of whole-time salaried service would promptly do away with many objectionable features which characterise the ,relations of not a few rival practitioners, while it would give free play to the exercise of that "nobler rivalry b y which each one seeks to raise his own standard of professional efficiency, and the service need not be devoid of the more material rewards which appeal to so many of us. 4. " A whole-time salaried service would be poorly paid and would ~nil to attract the best men and women into it." With regard t o t h i s objection, I can only s a y that I believe the community would be found prepared to p a y salaries which at any r a t e would compare favourably with the present average income of general medical practitioners, and certainly would pay salaries sufficiently high to. attract persons of character a M c a p a c i t y into the .profession. The scope for making very large incomes would certainly
xI3
be reduced, b u t I have no fear that the average person would be any "worse off, and superannuation which would certainly be introduced into the service would prove a substantial benefit. T h e general amenities of practice would also be so considerably enhanced--more regular hours of work, less difficulty about holidays, more abundant opportunities for study, and attending professional meetings, etc., that I believe the medical profession would become more attractive to men and women of the right stamp than it is at the present time. I have no time to deal further with objections, and need only say that I have seen none that will stand close investigation, or which could b e regarded as an insuperable objection to the establishment of a whole-time salaried medical service. I wish now to set out in mere outline a scheme for the establishment of a public medical service, combining in itself the preventative and curative aspects of medical
work. (I) T~IE CENTRAL AUTHORITY. This, of course, will be the ~inistry of Health, the Bill for the constitution of which is at present before Parliament. (2) LOCAL AUTHORITY. It has been suggested that the medical and public health services should be directly run by the State, independently of local Control. Such a scheme has its attractions, but I am afraid it would not prove at all a practicable one, and having regard to the needs of the public would not prove so satisfactory as are organised under the auspice s of local authorities. B u t when we t u r n to the existing local authorit i e s - t h e sanitary authorities, we are at once faced with a great difficulty, for it is obvious that a proper service, witl~ the necessary hospitals, laboratorie s , consulting staff, etc., could only be established in areas sufficiently large and populous to maintain the necessary institutions and staff. Outside the ~ County Boroughs and larger urban districts the areas of most Sanitary Authorities would be far too small to properly run the necessary service, and even the smaller county boroughs would not be large enough, while the larger and more populous County Council areas would prove, I am afraid, too large and unwieldy for the purpose. The only remedy, so far as I can see, is for the Government to map out the whqle country into administrative areas :w~M~ are large enough or poputous en0ugh to :maintain an efficient service, b u t not:: too large to make the detailed administration a matter of difli-
Iz4
PUBLIC HEALTIt.
cnlty and to grant to the local Sanitary authorities Of these areas powers similar to those now possessed b y County Boroughs. Apart from t h e s u b j e c t now under consideration, there are many weighty reason why something of this kind should be done, and revolutionary as the suggestion m a y seem, I do believe that it is absolutely essential to the establishment of local government on a really satisfactory basis. At any r a t e , it will be quite impossible to establish a public medical service under local authorities and on proper lines unless the areas of these authorities a r e delimited afresh b y some central authority, having regard only to geographical relationships, population, and facilities for administration. Possibly certain of these new administrative areas might with advantage combine for particular purposes-e.g., for asylum accommodation b u t for practically all other purposes each would be a self-contained unit, responsible only to the Central Authority. In such a scheme there would be no place for County Councils, except perhaps in those smaller counties, where the County Council would itself become the new authority. County Councils have done a splendid public work in the past, and particularly so in connection with the public health, b u t it seems to me that County Councils as such will have to go along with so m a n y of the existing sanitary authorities, and their place t a k e n b y the newer authorities I have suggested. If this is not done, there is going to be an increasing amount of unnecessary and wasteful overlapping in local administration, which in time will prove nothing short of disastrous. This question of adfninistrative areas and local authorities will be probably one of the first problems to be tackled b y the Ministry of Health, and it will be also raised on the question of transferring the powers of Guardians to Local Authorities. To the Public 'Health Committees of the Local Authority should be delegated all matters relating to the public health and the public medical service, and this committee would appoint a medical man of experience as Chief Administrative Officer. A ~[edical Advisory Committee should also be constituted to deal with complaints as to medical treatment, a n d to advise the Public Health Committee thereon. 3. DISTRICT ORGANISATION. We now come to the kernel of the subject, for in the working of the district arrangements depends the success or failure of the whole scheme. It seems to me that the best working
JULY,
arrangements would be to divide the administrative area into small districts, each in charge of a District Medical Officer. The size of these districts would vary according to local circumstances, b u t in a populous compact area a population of, say, 5,000 might b e allotted to a district medical officer, who would be provided with the assistance o f a junior medical officer. In rural districts, with a scattered population, the number alloted t o the Medical officer would have of course to be reduced. The district medical officer would be responsible for attending to the ordinary medical and surgical needs of the people living in his district, and, in fact, would take the place of the present day general practitioner, as well as the place of the poor law district medical officer and the public vaccinator. But he would do a good deal more, and would undertake the duties at present carried out b y medical officers attached to Public Health Departments. He would act as school medical officer for his district, would supervise the work of the Maternity and Child Welfare Centre, as well as the work of the health visitors, nurSes, and midwives i n h i s district. He might also very well take on the duties of factory surgeon. He would also act as a d e p u t y medical officer of health for his district, and would fulfil Sir Arthur Newsholme's ideal condition, in which each medical practitioner becomes a medical officer of health in the range of his own practice, and he would have opportunities for successful preventative work as are not possessed b y a medical officer of health under the existing regime. Suppose, for example, he discovers a case of diphtheria. H e does not simply content himself wittl notifying it to the Central Office, and perhaps arranging for its removal to hospital. He makes it his business to promptly investigate all the circumstances connected with the case, to examine the home contacts, and, if need be, to swab their throats. H e will note the sanitary condition of the dwelling, and he m a y go into the school or into the factory and workshop, or visit the dairy, and in all such ways as m a y be necessary, ferret out all the important facts connected with the case. And he does all this simply as part of his daily duty, and he does it there and then. If he gets a case of food poisoning, he at once makes inquiries, likely to throw light on its causation, and initiates a n y necessary preventative measures. And so on. Going about his district, he is ever on the look out for nuisances
r 919:
P U B L I C HEel L TH.
and conditions prejudicial to health, and he is in a position either directly or ind{rectly through the Central Office, to institute steps for their removal. He comes to know in time most of the residents in his district, and gains an intimate knowledge of their general physique and social circumstances. As child welfare doctor and school doctor, he has a first-hand knowledge of the infants and children living in his district, both in health and disease, and so is in a position to advise authoritative!y on questions relating to the health and physical well-being of the community. I t is obvious that a man holding the position of a district medical officer has great responsibilities, and to fulfil these responsibilities he should have b e h i n d him a sound t r a i n i n g and a varied experience. In the future I can only imagine a man reaching this position after a medical training definitely designed to fit him for his future work, in which the preventative aspect is duly emphasised, and after holding junior hospital and then junior district appointments. His position must b e d u l y reeognised by the authorities that be. As regards his clinical duties, he should be in an independent position, at least as independent as any medical man can be, and administratively he should have as much independence as is compatible with proper control. As far as possible, I would have him take the place of the family doctor of the past, with the difference that h e is now as much, or even more, concerned with keeping his parishioners well as with curing them when ill, and that he is now remunerated by salary instead of being paid by fees. Each district would be provided with a Central Dispensary, which would serve not: only for the purposes of ordinary out-patient consultation and treatment, but also as School Clinic, Ante-natal Clinic, Child Welfare Centre, and possibly Tuberculosis Dispensary and Venereal Disease Clinic. I am convinced that much of the work now done at Tuberculosis Dispensaries and Venereal Diseases Clinics could be quite as well done at the. Central Dispensary of the district, and by the District Medical Officer himself. Of course, cases requiring special examination for diagnosis or special treatment could be referred to the specialists attached to the hospital. 4- HOSPITALS There is general agreement, I think, t h a t our hospital accommodation is very inadequate for the needs of the people, inadequate in the actual number of beds available, and adeqtmte
z 15
in the facilities by which the existing beds can be made available. I n a reconstructed medical service it is of the utmost importance t h a t adequate hospitM provision should be made for the sick, and that the provision should be promptly available when required. The first thing to be done is to convert the existing r a t e supported institutions. P o o r Law hospitals into Municipal hospitals, and enlarge these institutions as m a y be required. Many of t h e e x i s t i n g P o o r Law hospitals are excellent institutions, of modern construction, and well staffed, and would readily lend themselves to adaptation for present-day needs. As regards voluntary hospitals, no doubt these will in time have to come on the rates, and become co-ordinated into the general hospital provision of the Local Authority, but no doubt the transference will be a gradual one, a n d will depend very much on local circumstances. Attached to the public hospitals would be physicians, surgeons, and specialists in various departments of medicine and surgery, whose services would also be available for consultation with the district medical officers. The lack of facilities for consultation, except in t h e case of those patients who can afford to pay a consultant fee, is a serious defect in the existing system of medical service, but it is a defect which would be easily remedied by the establishment of a public medical service. The need for public rate-supported hospitals is emphasised b y recent development in public health work, and the various special hospitals or wards which local authorities are being urged to establish, e.g., Maternity Hospitals, wards for sick infants and children, hospitals for advanced tuberculosis or non-pulmonary tuberculosis, clinics for venereal diseases, etc., could be most satisfactorily, and most economically fitted in with existing institutions, The tendency to multiply small institutions for speeiM objects is to be deprecated, and if unchecked will run to unnecessary expense and unnecessary labour. Our experience with the recent disastrous outbreaks of influenza also provides another argument for the local hospitals being in the hands of the public health authority. 5. LABORATORIES. I have only a word to say on the questipn of laboratories, which are needed : i ~ = ! : e ~ district, and which shotdd ~be~:!:organisedon broad lines serving n0t: oNy t~e public health, bu~ ~ 0 :the ctinical n e e d s Of the district. The~lab0ra~6~ W0Uid be most conveniently
ii6
PUBLIC HEALTH.
attached to the hospital, and the " c h i e f " of the laboratory should be the pathologist of the hospital and of the _district. i t would be t r e a t y t o the advantage of medical science in general, and not seldom to t h a t of medical jurisprudenc e in particular, i f all post-mo~tem examinations were made by an expert pathologist, and i f t h e medieal man who h a d charge of the ease were Present at the examination, SO that the post-mortem findings could be correlated with the clinical history. S u c h an arrangement could easily be made under a public medical service. CONCLUSION. T h e views which I have put before you in this paper are by no means novel or original, but they are views which at the moment are probably only acceptable, at least in their entirety; to a minority of the medical prof e s s i o n . Outside the profession I cannot gather t h a t : t h e public have as yet any strong Opinion one way or the other, and this is indeed surprising when one sees the great public interest taken in the question of a Ministry of Health, which, important as it is, and i n d e e d necessarily preceding any a t t e m p t to dea! with the medical service of the public, is relatively of far less importance than the question of the medical service itself But when the Ministry of Health gets to work, and begins to tackle, as it must, the problem 0f the medical services of the community, there will be an active and widespread interest awakened; and the public will want to know all the facts, and will demand the very best service the medical profession can offer. I am sanguine enough to believe t h a t the best Service we can give, the best for the community and the best for the profession , will be organised on lines n o t much different from those which I have outlined in this paper. After all, the medical profession exists for the benefit of the community, and not the community for the benefit of the profession, a truism which is sometimes overlooked or even' reversed. Omnia mutantur et nos rnutamur in illis. DISCUSSION. DR. PEARCE thanked Dr. Gibson for his paper, which opened up tremendous scope for discuasion and thought, and he therefore imdted the members to discuss the paper. DR. BULLO~GHconsidered that it won/d be a long time, if ever, before private practice was abolished in this country. Many objections of the
JULY,
general practitioner had been adduced b y Dr. Gibson; but in his opinion the supreme objection was that o f supervision. As regards establishing public laboratories in each area or to every hospital,~thi s would mean that only men of poor pathological and baeterioIogical qualifications would be secured. He advocated concentration of pathol0gical and bacteriological work in a limited number of special laboratories with skilled bacteriologists to do the work, aided by trained assistants. These laboratories should be either at the Universities or work in conjunction with them. As regards a State Medical Service itself, Dr. Bullough classified the Medical Service into (I) Hospital which would include centre, etc. ; (2) CIinic, which would include private surgeries, tuberculosis dispensaries, dental clinics, schoot clinics, venereal clinics, etc. ; and (3) domiciliary visiting. He was of the opinion that the hospitals and clinics would be worked most efficiently b y whole-time and; in some cases, part-time public health officers; but he was strong!y of the opinion that the general publie would not countenance domiciliary visiting by public officers. DR. STANSFIELD was of the opinion that the great majority of the general practitioners were strongly opposed to whole-time services, and he adduced in favour of this opinion the experience of the 'National Health Insurance Act. He also thought that even with an assistant, 5,ooo people would provide an abnormal amount of work for the medical officer in charge of the district. DR. BURMAN said that he had been mtteh interested in the arguments brought forward b y Dr. Gibson, and it might be a good thing for the country when actually put into operation, b u t he certainly hoped that it would not be in his time. He would not want to give up many of his old patients, whose grandfathers had been attended by his grandfather, and he thought this feeling would be reciprocated by the patients. DR. BUCttANsaid that the State Medical Service on the outlines suggested by Dr. Gibson would not work. On paper, the scheme seems very simple, but in his opinion it exclude~t the most important factor, viz., human nature. He thought the public had not yet complete confidence in a municipal medical service, and that they were still of the opinion that the school medical inspector and tuberculosis officer had not quite the same qualifications as their own private doctor. He Said it would be some generations before this opinion was corrected. COLONm, SCAT~rERT¥ said that according to Dr. Gibson's notions, the district medical officer would need to be an expert in every branch of the profession, both in respect to clinical and preventive medicine. He was of t h e opinion t h a t this could not be achieved by the great majority of the general practitioners.
1 9 I 9.
PUBLIC
DR. A2CGIyS (Bingley) considered t h a t as a c o m m e n c e m e n t a scheme could b e i n t r o d u c e d b y establishing in e v e r y u r b a n d i s t r i c t a centre or clinic o r h o s p i t a l a t which t h e various forms of t r e a t m e n t could be had. These could b e staffed either b y w h o l e - t i m e m e d i c a l officers or b y general p r a c t i t i o n e r s in r o t a t i o n . DR. SU~r~I~RLANI~ (Cleckheaton) h o p e d t h a t t h e f a m i l y p r a c t i t i o n e r w o u l d n e v e r b e done a w a y w i t h , as h e was convinced t h a t i t was o n l y t h r o u g h ctose i n t i m a t e r e l a t i o n s h i p b e t w e e n p a t i e n t a n d d o c t o r t h a t t h e b e s t results could be obtained.
DR. GIBSON, in reply, expressed his gratification a t t h e discussion w h i c h h a d followed his p a p e r . I n r e p l y t o Dr. Bullough, he said t h a t t h e l a b o r a tories he a d v o c a t e d in each area were i n t e n d e d for o r d i n a r y elinicaI a n d p u b l i c h e a l t h purposes, a n d h e agreed t h a t research w o r k w o u l d b e b e s t c a r r i e d o u t i n special l a b o r a t o r i e s a t t a c h e d t o Medicat Schoots. W i t h r e g a r d t o . D r . Stansfield's o b s e r v a t i o n s on t h e f l a g r a n t defect i n t h e I n s u r a n c e A c t , which allowed a p r a c t i t i o n e r to t a k e on a p a n e l list which i t was hnpossible to do justice to, Dr. Gibson p o i n t e d o u t t h a t t h i s would n o t occur in t h e scheme he h a d suggested. Dr. Gibson qtfite a p p r e c i a t e d t h e difficulties arising o u t of i n d i v i d u a l predilections, b u t he r a t h e r t h o u g h t t h a t h u m a n n a t u r e was n o t such a n u n c h a n g e a b l e q u a n t i t y as was supposed, a n d if t h e p u b l i c reatised, a s he b e l i e v e d i t w o u l d one d a y , t h a t i t w o u l d g e t t h e b e s t service from a scheme like t h a t o u t l i n e d in t h e p a p e r , i t would be quite p r e p a r e d to a c c e p t it. Dr. Gibson agreed t h a t t h e m e t h o d suggested b y Dr. Angus m i g h t p o s s i b l y b e t h e first s t e p t a k e n , b u t he believed i t w o u l d e v e n t u a l l y develop into a m o r e c o m p l e t e scheme. NURSERY
SCHOOLS.
R~GIYLA~rlO~S d a t e d M a r c h 5th, 1919, concerning N u r s e r y Schools, h a v e b e e n issued b y the B o a r d of E d u c a t i o n . I n t h e p r e f a t o r y m e m o r a n d u m accomp a n y i n g these Regulations, t h e question of medical supervision is d e a l t w i t h in a v e r y s a t i s f a c t o r y m a n n e r . T h e m e m o r a n d u m states t h a t a N u r s e r y School should s t a n d in close r e l a t i o n t o t h e School Medical Service. W h e t h e r m a i n t a i n e d b y t h e local E d u c a t i o n A u t h o r i t y o r b y a v o l u n t a r y b o d y , t h e school should be u n d e r t h e supervision of t h e School Medical Officer. I'n t h e case of a v o l u n t a r y nursing school, i t m a y n o t a l w a y s be convenient for t h e School Medical Officer to u n d e r t a k e t h e whole of t h e medical inspection, b u t even in such a case t h e medical p r a c t i t i o n e r e m p l o y e d for this p u r p o s e should b e in t o u c h w i t h t h e School 2vIedical Officer, who should visit t h e school from t i m e t o time. T h e medical p r a c t i t i o n e r selected should p r e f e r a b l y live n e a r t h e school, t o b e r e a d i l y a v a i l a b l e h i case of emergency.
HEALTH.
I I7
DIETARIES
I N SANATORiUI~IS.
A circular h a s been issued b y t h e L o c a l G o v e r n m e n t B o a r d s u b s t i t u t i n g new dietaries for those p r e v i o u s l y lald down a n d giving t h e m a x i m u m w e e k l y a m o u n t s for each male over t e n y e a r s of age residing in a s a n a t o r i u m or in a special w a r d set a p a r t for t h e t r e a t m e n t of tuberculosis. F o r t h e i n f o r m a t i o n of our readers, v/e h a v e h a d t h e s e w e e k l y allowances p r i c e d O u t , w i t h t h e r e s u l t t h a t t h e cost a p p e a r s t o b e a p p r o x i m a t e l y £ I p e r h e a d p e r w e e k for food : - Estimated ~OSt at present .prices. s. d.
Meat (including suet)* ... Fish and poultry ...... Bacon . . . . . . . . . . . . Bread ... ......... Flour . . . . . . . . . . . . Sugar . . . . . . . . . . . . Butter and Margarine ... Lard and edible fatsi . . . . . . Potatoes ......... Vegetables (fresh) ...... Milk . . . . . . . . . . . . Jam, syrup, ete . . . . . . . Cereals . . . . . . . . . . . . Oatmeal ......... Peas, beans, and lentils ' Tea ............ Chesse . . . . . . . . . . . .
56 ozs. 16 ozs. 8 ozs. 64 ozs. 8 ozs. 8 ozs, io ozs. 3 ozs. 80 ozs. 28 ozs. 14 pints 8 ozs. 12 ozs. 8 ozs. 8 ozs. 2 ozs. 4 ozs,
Total Cost per Patient per week
..,
5 2 I o o o
o o o o 5 o o o o o o
io o 2 9 2½ 3½ 9 2 IO 7 3 5½ 6 2 3 4 5
I9 I I~
*The whole or any part of the meat ration may be butcher's meat, tOt which more than 2 ozs. must be lard. O n t h e certificate of t h e Medical Officer of t h e Institution, additional milk up to 7 pints weekly m a y b e allowed in special c i r c u m s t a n c e s i n s t e a d of p a r t of t h e allowance of peas, b e a n s , lentils, p o t a t o e s , a n d bre~d, F e m a l e s o v e r t e n y e a r s of age are e n t i t l e d to four-fifths of t h e a b o v e allowance, while children u n d e r t e n are e n t i t l e d to t h r e e - fifths, b u t in each of t h e s e cases t h e f u l l allowance of 8 ozs. of s u g a r a n d 3 ozs. edible fats w e e k l y is allowed. LONDON COUNTY COUNCIL M.O.H. T h e s a l a r y of Dr. %V. H. H a m e r , Medical Officer of H e a l t h a n d School Medical Officer t o t h e L o n d o n C o u n t y Council, has been increased from f I , 2 5 o a y e a r t o ~2,OO0. SALARY OF VENEREAL DISEAS~ OFFiCI~R.--Dr. J. C. B u c k l e y h a s b e e n a p p o i n t e d V e n e r e a l Disease Officer for t h e C i t y a n d C o u n t y of N o t t i n g h a m , a n d on t h e suggestion of t h e Local G o v e r n m e n t Board, his s a l a r y has been fixed a t fI,OOO a y e a r , w i t h t r a v e l l i n g expenses.
PUBLIC HEALTH.
revenue which had fallen off to an alarming extent, is now recovering, and arrears are being rapidly paid off. The fact that every branch is now given a financial interest in the collection of arrears wilt give universal satisfaction. Another ancient grievance was concerned with the mysterious disappearance of the Society's notices and copies of PUBLIC HEALTH in the post, and in order to reduce these to a reasonable minimmn; the revised Register of Members is now well in hand, and any member who has had cause for complaint in this connection should communicate with the Executive Secretary at once. Reference to the reconstruction of the Society of Medical Officers of Health, must include congratulations t o the Society upon the fact that Professor Kenwood has accepted a second term of office as President. The Society will, therefore, have the advantage of his wise leadership dffring the coming year when the new constitution will be on its trial. Professor Kenwood has taken a foremost part in the work involved in drafting the new constitution, and everyone who has shared in that work realises the fact that without his cheerful insistence and persistence, the work would have not been accomplished in the time. Anyone who knows the difficulties which attend such a task will marvel t h a t it has been possibIe to carry through the scheme in less than a year. Professor Kenwood's presidential address to the Society in October last year made it evident that he has ambitious views as to the sphere of influence which may be occupied by the Society. It may be well, however, to remind members that this influential position can only be secured through a greatly increased membership, which in its turn depends upon individual efforts of the present members. We suggest, therefore, that special efforts may be organized by every branch forthwith to aid the President in making the Society completely representative of the Public Health Service. We believe that branches will gladly undertake this crusade and will show their appreciation of the changes which have been carried out at their bidding by securing a great increase in membership.
SHEFFIELD HOSPITAL SUPERINTENDENT.--The salary of Dr. E. H. Williams, Medical Superintendent of the City Hospital, Sheffield, has been increased from £6oo to £8oo per annum, with house, coal, light and laundry free. The telegraphic address of the Society of Medical Officers of Health is now-EPIDAIYROS, WESTCENT, LONDON. I~[embers are requested to make a note of this alteration.
JIJLY,
T H E P U B L I C MEDICAL S E R V I C E . * BY THOMAS GIBSON, M.D.,
Medical Offwer of Health, W~kefield. the m a n y schemes Of social reform A MONG which aIe now engaging the attention of the p u b l i c , there are none of greater importance to the nation, and naturally none of greater interest to medical men, than those which are concerned with the r e e o n : struction of the PuBlic HeMth Administration and the improvement of the PuMic Medical Service. For m a n y years past there has been, both within and without the profession; a growing dissatisfaction with the eonditi0ns under which medical succour and advice have been provided for the public, and during the war dissatisfaction has become more freely expressed and schemes for improvement have been more actively discussed. These schemes are m a n y and varied. Some advocate an extension of the Insurance Act to include dependants" t h a t is, all or practically all persons belonging to the working classes. My own opinion is,. t h a t the Insurance Act, so far as sickness benefits are concerned, is to be u t t e r l y condemned, and to extend it, with all its intricate expensive and useless machinery, is only to make confusion worse confounded. Then there are the schemes for a quasi public medical service, such as the one suggested b y the British 5Iedieal Association, which, a l t h o u g h preferable to t h a t of extending the Insurance Act, would, I am afraid, fail to meet the real needs of the public. Then we come to a salaried whole-time public medical service, run either as a nationai service or under local authorities. Differing as t h e various schemes do, t h e y are all postulated on the admitted need for radical changes , and all agree in the pressing need for increased hospital accommodation, increased laboratory facilities, and b e t t e r facilities for consultation. Many of these schemes also agree in demanding t h a t in any public medical service established in the futur~ there shall be a ele~r line of demarcation drawn between curative a n d preventative medicine, and t h a t the administration o f these two departments shall be k e p t entirely separate, each w i t h its own set of
*A Paper read before the Yorkshire Branch of The Socie2y of Medical Officers of Health, 25th March, 1919.
19! 9.
PUBLIC "HEALTH.
officials, its. own machinery, a n d its own domain of action. Now this proposition is one of extreme importance, one that closely concerns medical officers of health, and one which should receive their serious consideration. For m y own part, I think it is a proposal which should be met with the strongest opposition, inasmuch as it appears to me t o be founded on an utterly wrong conception of the role of medical science, and would prove in practice expensive, wasteful, and inefficient. On the contrary, I believe that no public medical service can be satisfactory and efficient which does not intimately and organically combine the preventative and curative aspects of medicine in one system of administration, both central and local. Theoretically, of course, you can draw a clear line between the two departments, b u t in actual practice any distinction is altogether arbitrary and artificial, and can only be accepted as indicating the extent to which either of these two aspects predominates in the work of any given practitioner. The activities of the sanitary service of the country is, of course, mainly directed towards the prevention of the diseases, and the medical officers attached to that service are primarily employed in directing these activities. But it does not follow that they have no concern with curative work and modern advances in preventative work are more and more recognising the important role of earl?- treatment in the prevention of disease. For many y e a r s p a s t medicM officers of health have been directly Concerned in the treatment of infectious diseases, and in fever hospitals, and during recent years, their clinical domain has rapidly extended s o as to include the treatment of tuberculosis in dispensaries and sanatoria, the treatment of venereal diseases at clinics, the medical inspection and treatment of school children, and of infants and children under school age, and even the medical oversight of women during pregnancy and confinement. In fact, the modern public health department affords an excellent example of .a combined preventative and curative system of medicine actually in being and growing up to serve the needs of the public, and one that can only be regarded as unsatisfactory because of the limitations imposed upon it b y tile existing system of general medicine. On t h e other hand, the general medical practitioner, while mainly concerned with the cure 0f diseases, should also be concerned with
Iii.
its prevention, and it is his misfortune as well as the nation's that the exigencies of general practice and his relationship to the public should limit his sphere of action so m u c h to merely curative work. The opportunities for combating disease that lie to the hand of the general practitioner are incalculable, and I think it may be safely said that no public medical service, which does not reeognise the all-important service which tl~e general practitioner can render to preventative medicine, will ever prove satisfactory or efficient. • That the assistance of the general practitioner is absolutely essential to the carrying on of ordinary measures of prevention of infectious diseases is Mready recognised by the State, and the obligations imposed on the practitioner with regard to the notification of these diseases are being extended rapidly. The number of diseases already on the notification list make no little tax on the memory, but I a m afraid the tendency will be to add to them, and also to extend the scope of notification to other conditions, such as cases of food poisoning and the like. There is no question, I think, b u t that all this information is desirable and indeed essential to an effective public health administration, but at the same time I am doubtful if the State can go on extending its requirements of the general practitioner under p r e s e n t conditions of practice without creating grave dissatisfaction and possibly opposition. Medical practitioners as a whole recognise that they owe a d u t y to the State, b u t there is a growing feeling that they are not being t r e a t e d fairly, and the action of the Government in reducing the notification fee, to m y mind a mean and indefensible action, has helped to greatly intensify this feeling of grievance. I t is also Mr, and I think q u i t e properly, that there must be a limit to the duties which can be imposed b y the State upon medical men working as they do under present conditions, and that this limit, if not already reached, is being closely approached. I t is, I think, pretty obvious that this state of affairs cannot continue, and that either the State will: have to curtail or check its demands, and to make a radical change in its present-day policy, or the position of the general practitioner in relation to the State and the public will have itself to be radically altered. Of the two alternatives the former is not the one that is likely to happen, and it would be pursuing the policy of the ostrich to ignore the possi-
II2
PUBLIC HEALTH.
bilities of the latter. It m a y be taken for granted, I think, that the general practitioner Will more and more be eMled in to assist the efforts of the State to improve the social and physical welfare of the. community, and he will be called upon to concern himself more and more with t h e prevention of disease. One cannot get away from the fact that the position of the general practitioner must of necessity be changed, and fitted in somehow with the new order of things. Now I want you to think of the future practitioner as one concerned as much, nay, even' more, with preventative medicine as with curative, and then to think into what system he can harmoniously be introduced. Not, it Seems to me, into any system which is merely an amplified Insurance Act system, not into any semipublic, semi-private system, b u t only in an outand-out wholeCtime salaried medical service can this ideal be realised. The new wine must be put into new bottles. I must confess I have come somewhat reluctantly to this conclusion, and have looked for other solutions Of the problem, but I can find none that seems likely to work, and in no other can the essentiaI idea of a combined preventative and Curative service be introduced with any prospect of success: It is impossible within the limits of this paper to discuss in detail the arguments for and against such a service. I will just mention some of the advantages as they appear t o me. ADVANTAGES TO THE PUBLIC.
(I) Simplicity Of organisation and administration, as compared with the complex machinery of administration inseparable from any system like that of the Insurance Act or indeed of any system in which private and public medical Work are intermixed. (2) Abolition of unnecessary waste of time and labour of the profession secured b y arranging work on the district system. (3) Flexibility of organisation, allowing for example the transfer of medical men from one district to another to meet the abnormal demands of an epidemic. (4) Better attention from doctors who are not overworked and who have better facilities for keeping abreast of advances in' medical science. (5) The advantages of a co-ordinated preventative and curative service. (6) Fuller facilities for securing data as to incidence of sickness and conditions affecting the public health. :
I ~L'¢;
ADVANTAGES TO THE PRACTITIONER.
(I) Facilities for newly-qualified medical men at once taking up professional work, and for graded advance in the service. (2) Regular hours of work, and arrangements as to regulation of night work, and for holiday leave. "(3) Abolition of over work. (4) Opportunities for post-graduate s t u d y at regular intervals. (5) Facilities for consultation and obtaining e v e r y necessary assistance in the discharge of duties. (6) The interest a t t a e h d to the combination of preventative and curative duties. (7) The abolition of the commercial aspects of private practice. (8) Superannuation. I will now turn to some of the commoner objections raised against such a set,nice. I. '" The system does not provide/or a/ree choice o/doctor." This is considered b y many an insuperable objection, and at first sight it does seem a formidable one. But if you look into it more closely, it becomes less formidable, and b y no means so insuperable as many imagine. In the existing SYstem of medical practice the choice of a doctor is b y no means so free as some Would make out. The choice of doctor open to a resident living in a given district is largely limited t o the doctors practising in that district, and these doctors have not been" selected b y the community. The fewer the doctors, the narrower the range of choice, and in many country districts where o n l y one doctor is in practice, there is really no opportunity of exercising choice. And it is a curious and interesting fact that nowhere will you find such unstinted confidence bestowed on a .doctor b y his patmnts than in these country areas, whose medical needs are supplied b y one man, and b y a m a n who has settled in the district without any call from or selection b y the residents. Then think of the thousands in hospitals, sanatoria, and convalescent homes, attending tuberculosis dispensaries, school clinics, child welfare centres, and kindred institutions, and the host of poor law patients, all under the medical care of doctors in whose appointment the patients have not had t h e slightest say. I t is extraordinary what little objection one finds to treatment under these conditions, and it is significant t h a t : the demand for increased institutional treatment in which the patients have for the most part no choice of doctor is
z919.
PUBLIC HEALTH.
becoming : more insistent. Lastly, I think increased facilities for consultation would largely do away with any real difficulties attendant on this question of free choice. 2. "'A whole-time salaried service would be worked by oy~cials, and the work o/oficials is mechanical and per[unctory." It would certainly be worked by officials - - t h a t is, b y medical men paid a salary for doing certain work and not remunerated b y fees :paid b y the individual patients. The term " officials " is sometimes made an opprobrious one, a n d possibly in some cases deservedly so, but, after all, it is a term of no real significance and might b e applied indiscriminately to the Whole army of wage and salary earners. That the work of the salaried medical officers is done less thoroughly or with less regard to the feelings and sentiments of his patients than that of the medical man paid b y a fee, I utterly deny, and I claim that the standard of professional work, viewed from whatever point of view you like, is at least as high among the salaried medical men as it is among the private practitioners. 3. " A whole-time salaried service would eliminate competition." W h a t kind of competition would it eliminate? The only kind of competition that it could eliminate would be the commercial one, which, instead of being something salutary, has for long enough been the curse of the profession, and which even now threatens the extinction of the profession as a profession, and its conversion into a mere trades union. The establishment of whole-time salaried service would promptly do away with many objectionable features which characterise the ,relations of not a few rival practitioners, while it would give free play to the exercise of that "nobler rivalry b y which each one seeks to raise his own standard of professional efficiency, and the service need not be devoid of the more material rewards which appeal to so many of us. 4. " A whole-time salaried service would be poorly paid and would ~nil to attract the best men and women into it." With regard t o t h i s objection, I can only s a y that I believe the community would be found prepared to p a y salaries which at any r a t e would compare favourably with the present average income of general medical practitioners, and certainly would pay salaries sufficiently high to. attract persons of character a M c a p a c i t y into the .profession. The scope for making very large incomes would certainly
xI3
be reduced, b u t I have no fear that the average person would be any "worse off, and superannuation which would certainly be introduced into the service would prove a substantial benefit. T h e general amenities of practice would also be so considerably enhanced--more regular hours of work, less difficulty about holidays, more abundant opportunities for study, and attending professional meetings, etc., that I believe the medical profession would become more attractive to men and women of the right stamp than it is at the present time. I have no time to deal further with objections, and need only say that I have seen none that will stand close investigation, or which could b e regarded as an insuperable objection to the establishment of a whole-time salaried medical service. I wish now to set out in mere outline a scheme for the establishment of a public medical service, combining in itself the preventative and curative aspects of medical
work. (I) T~IE CENTRAL AUTHORITY. This, of course, will be the ~inistry of Health, the Bill for the constitution of which is at present before Parliament. (2) LOCAL AUTHORITY. It has been suggested that the medical and public health services should be directly run by the State, independently of local Control. Such a scheme has its attractions, but I am afraid it would not prove at all a practicable one, and having regard to the needs of the public would not prove so satisfactory as are organised under the auspice s of local authorities. B u t when we t u r n to the existing local authorit i e s - t h e sanitary authorities, we are at once faced with a great difficulty, for it is obvious that a proper service, witl~ the necessary hospitals, laboratorie s , consulting staff, etc., could only be established in areas sufficiently large and populous to maintain the necessary institutions and staff. Outside the ~ County Boroughs and larger urban districts the areas of most Sanitary Authorities would be far too small to properly run the necessary service, and even the smaller county boroughs would not be large enough, while the larger and more populous County Council areas would prove, I am afraid, too large and unwieldy for the purpose. The only remedy, so far as I can see, is for the Government to map out the whqle country into administrative areas :w~M~ are large enough or poputous en0ugh to :maintain an efficient service, b u t not:: too large to make the detailed administration a matter of difli-
Iz4
PUBLIC HEALTIt.
cnlty and to grant to the local Sanitary authorities Of these areas powers similar to those now possessed b y County Boroughs. Apart from t h e s u b j e c t now under consideration, there are many weighty reason why something of this kind should be done, and revolutionary as the suggestion m a y seem, I do believe that it is absolutely essential to the establishment of local government on a really satisfactory basis. At any r a t e , it will be quite impossible to establish a public medical service under local authorities and on proper lines unless the areas of these authorities a r e delimited afresh b y some central authority, having regard only to geographical relationships, population, and facilities for administration. Possibly certain of these new administrative areas might with advantage combine for particular purposes-e.g., for asylum accommodation b u t for practically all other purposes each would be a self-contained unit, responsible only to the Central Authority. In such a scheme there would be no place for County Councils, except perhaps in those smaller counties, where the County Council would itself become the new authority. County Councils have done a splendid public work in the past, and particularly so in connection with the public health, b u t it seems to me that County Councils as such will have to go along with so m a n y of the existing sanitary authorities, and their place t a k e n b y the newer authorities I have suggested. If this is not done, there is going to be an increasing amount of unnecessary and wasteful overlapping in local administration, which in time will prove nothing short of disastrous. This question of adfninistrative areas and local authorities will be probably one of the first problems to be tackled b y the Ministry of Health, and it will be also raised on the question of transferring the powers of Guardians to Local Authorities. To the Public 'Health Committees of the Local Authority should be delegated all matters relating to the public health and the public medical service, and this committee would appoint a medical man of experience as Chief Administrative Officer. A ~[edical Advisory Committee should also be constituted to deal with complaints as to medical treatment, a n d to advise the Public Health Committee thereon. 3. DISTRICT ORGANISATION. We now come to the kernel of the subject, for in the working of the district arrangements depends the success or failure of the whole scheme. It seems to me that the best working
JULY,
arrangements would be to divide the administrative area into small districts, each in charge of a District Medical Officer. The size of these districts would vary according to local circumstances, b u t in a populous compact area a population of, say, 5,000 might b e allotted to a district medical officer, who would be provided with the assistance o f a junior medical officer. In rural districts, with a scattered population, the number alloted t o the Medical officer would have of course to be reduced. The district medical officer would be responsible for attending to the ordinary medical and surgical needs of the people living in his district, and, in fact, would take the place of the present day general practitioner, as well as the place of the poor law district medical officer and the public vaccinator. But he would do a good deal more, and would undertake the duties at present carried out b y medical officers attached to Public Health Departments. He would act as school medical officer for his district, would supervise the work of the Maternity and Child Welfare Centre, as well as the work of the health visitors, nurSes, and midwives i n h i s district. He might also very well take on the duties of factory surgeon. He would also act as a d e p u t y medical officer of health for his district, and would fulfil Sir Arthur Newsholme's ideal condition, in which each medical practitioner becomes a medical officer of health in the range of his own practice, and he would have opportunities for successful preventative work as are not possessed b y a medical officer of health under the existing regime. Suppose, for example, he discovers a case of diphtheria. H e does not simply content himself wittl notifying it to the Central Office, and perhaps arranging for its removal to hospital. He makes it his business to promptly investigate all the circumstances connected with the case, to examine the home contacts, and, if need be, to swab their throats. H e will note the sanitary condition of the dwelling, and he m a y go into the school or into the factory and workshop, or visit the dairy, and in all such ways as m a y be necessary, ferret out all the important facts connected with the case. And he does all this simply as part of his daily duty, and he does it there and then. If he gets a case of food poisoning, he at once makes inquiries, likely to throw light on its causation, and initiates a n y necessary preventative measures. And so on. Going about his district, he is ever on the look out for nuisances
r 919:
P U B L I C HEel L TH.
and conditions prejudicial to health, and he is in a position either directly or ind{rectly through the Central Office, to institute steps for their removal. He comes to know in time most of the residents in his district, and gains an intimate knowledge of their general physique and social circumstances. As child welfare doctor and school doctor, he has a first-hand knowledge of the infants and children living in his district, both in health and disease, and so is in a position to advise authoritative!y on questions relating to the health and physical well-being of the community. I t is obvious that a man holding the position of a district medical officer has great responsibilities, and to fulfil these responsibilities he should have b e h i n d him a sound t r a i n i n g and a varied experience. In the future I can only imagine a man reaching this position after a medical training definitely designed to fit him for his future work, in which the preventative aspect is duly emphasised, and after holding junior hospital and then junior district appointments. His position must b e d u l y reeognised by the authorities that be. As regards his clinical duties, he should be in an independent position, at least as independent as any medical man can be, and administratively he should have as much independence as is compatible with proper control. As far as possible, I would have him take the place of the family doctor of the past, with the difference that h e is now as much, or even more, concerned with keeping his parishioners well as with curing them when ill, and that he is now remunerated by salary instead of being paid by fees. Each district would be provided with a Central Dispensary, which would serve not: only for the purposes of ordinary out-patient consultation and treatment, but also as School Clinic, Ante-natal Clinic, Child Welfare Centre, and possibly Tuberculosis Dispensary and Venereal Disease Clinic. I am convinced that much of the work now done at Tuberculosis Dispensaries and Venereal Diseases Clinics could be quite as well done at the. Central Dispensary of the district, and by the District Medical Officer himself. Of course, cases requiring special examination for diagnosis or special treatment could be referred to the specialists attached to the hospital. 4- HOSPITALS There is general agreement, I think, t h a t our hospital accommodation is very inadequate for the needs of the people, inadequate in the actual number of beds available, and adeqtmte
z 15
in the facilities by which the existing beds can be made available. I n a reconstructed medical service it is of the utmost importance t h a t adequate hospitM provision should be made for the sick, and that the provision should be promptly available when required. The first thing to be done is to convert the existing r a t e supported institutions. P o o r Law hospitals into Municipal hospitals, and enlarge these institutions as m a y be required. Many of t h e e x i s t i n g P o o r Law hospitals are excellent institutions, of modern construction, and well staffed, and would readily lend themselves to adaptation for present-day needs. As regards voluntary hospitals, no doubt these will in time have to come on the rates, and become co-ordinated into the general hospital provision of the Local Authority, but no doubt the transference will be a gradual one, a n d will depend very much on local circumstances. Attached to the public hospitals would be physicians, surgeons, and specialists in various departments of medicine and surgery, whose services would also be available for consultation with the district medical officers. The lack of facilities for consultation, except in t h e case of those patients who can afford to pay a consultant fee, is a serious defect in the existing system of medical service, but it is a defect which would be easily remedied by the establishment of a public medical service. The need for public rate-supported hospitals is emphasised b y recent development in public health work, and the various special hospitals or wards which local authorities are being urged to establish, e.g., Maternity Hospitals, wards for sick infants and children, hospitals for advanced tuberculosis or non-pulmonary tuberculosis, clinics for venereal diseases, etc., could be most satisfactorily, and most economically fitted in with existing institutions, The tendency to multiply small institutions for speeiM objects is to be deprecated, and if unchecked will run to unnecessary expense and unnecessary labour. Our experience with the recent disastrous outbreaks of influenza also provides another argument for the local hospitals being in the hands of the public health authority. 5. LABORATORIES. I have only a word to say on the questipn of laboratories, which are needed : i ~ = ! : e ~ district, and which shotdd ~be~:!:organisedon broad lines serving n0t: oNy t~e public health, bu~ ~ 0 :the ctinical n e e d s Of the district. The~lab0ra~6~ W0Uid be most conveniently
ii6
PUBLIC HEALTH.
attached to the hospital, and the " c h i e f " of the laboratory should be the pathologist of the hospital and of the _district. i t would be t r e a t y t o the advantage of medical science in general, and not seldom to t h a t of medical jurisprudenc e in particular, i f all post-mo~tem examinations were made by an expert pathologist, and i f t h e medieal man who h a d charge of the ease were Present at the examination, SO that the post-mortem findings could be correlated with the clinical history. S u c h an arrangement could easily be made under a public medical service. CONCLUSION. T h e views which I have put before you in this paper are by no means novel or original, but they are views which at the moment are probably only acceptable, at least in their entirety; to a minority of the medical prof e s s i o n . Outside the profession I cannot gather t h a t : t h e public have as yet any strong Opinion one way or the other, and this is indeed surprising when one sees the great public interest taken in the question of a Ministry of Health, which, important as it is, and i n d e e d necessarily preceding any a t t e m p t to dea! with the medical service of the public, is relatively of far less importance than the question of the medical service itself But when the Ministry of Health gets to work, and begins to tackle, as it must, the problem 0f the medical services of the community, there will be an active and widespread interest awakened; and the public will want to know all the facts, and will demand the very best service the medical profession can offer. I am sanguine enough to believe t h a t the best Service we can give, the best for the community and the best for the profession , will be organised on lines n o t much different from those which I have outlined in this paper. After all, the medical profession exists for the benefit of the community, and not the community for the benefit of the profession, a truism which is sometimes overlooked or even' reversed. Omnia mutantur et nos rnutamur in illis. DISCUSSION. DR. PEARCE thanked Dr. Gibson for his paper, which opened up tremendous scope for discuasion and thought, and he therefore imdted the members to discuss the paper. DR. BULLO~GHconsidered that it won/d be a long time, if ever, before private practice was abolished in this country. Many objections of the
JULY,
general practitioner had been adduced b y Dr. Gibson; but in his opinion the supreme objection was that o f supervision. As regards establishing public laboratories in each area or to every hospital,~thi s would mean that only men of poor pathological and baeterioIogical qualifications would be secured. He advocated concentration of pathol0gical and bacteriological work in a limited number of special laboratories with skilled bacteriologists to do the work, aided by trained assistants. These laboratories should be either at the Universities or work in conjunction with them. As regards a State Medical Service itself, Dr. Bullough classified the Medical Service into (I) Hospital which would include centre, etc. ; (2) CIinic, which would include private surgeries, tuberculosis dispensaries, dental clinics, schoot clinics, venereal clinics, etc. ; and (3) domiciliary visiting. He was of the opinion that the hospitals and clinics would be worked most efficiently b y whole-time and; in some cases, part-time public health officers; but he was strong!y of the opinion that the general publie would not countenance domiciliary visiting by public officers. DR. STANSFIELD was of the opinion that the great majority of the general practitioners were strongly opposed to whole-time services, and he adduced in favour of this opinion the experience of the 'National Health Insurance Act. He also thought that even with an assistant, 5,ooo people would provide an abnormal amount of work for the medical officer in charge of the district. DR. BURMAN said that he had been mtteh interested in the arguments brought forward b y Dr. Gibson, and it might be a good thing for the country when actually put into operation, b u t he certainly hoped that it would not be in his time. He would not want to give up many of his old patients, whose grandfathers had been attended by his grandfather, and he thought this feeling would be reciprocated by the patients. DR. BUCttANsaid that the State Medical Service on the outlines suggested by Dr. Gibson would not work. On paper, the scheme seems very simple, but in his opinion it exclude~t the most important factor, viz., human nature. He thought the public had not yet complete confidence in a municipal medical service, and that they were still of the opinion that the school medical inspector and tuberculosis officer had not quite the same qualifications as their own private doctor. He Said it would be some generations before this opinion was corrected. COLONm, SCAT~rERT¥ said that according to Dr. Gibson's notions, the district medical officer would need to be an expert in every branch of the profession, both in respect to clinical and preventive medicine. He was of t h e opinion t h a t this could not be achieved by the great majority of the general practitioners.
1 9 I 9.
PUBLIC
DR. A2CGIyS (Bingley) considered t h a t as a c o m m e n c e m e n t a scheme could b e i n t r o d u c e d b y establishing in e v e r y u r b a n d i s t r i c t a centre or clinic o r h o s p i t a l a t which t h e various forms of t r e a t m e n t could be had. These could b e staffed either b y w h o l e - t i m e m e d i c a l officers or b y general p r a c t i t i o n e r s in r o t a t i o n . DR. SU~r~I~RLANI~ (Cleckheaton) h o p e d t h a t t h e f a m i l y p r a c t i t i o n e r w o u l d n e v e r b e done a w a y w i t h , as h e was convinced t h a t i t was o n l y t h r o u g h ctose i n t i m a t e r e l a t i o n s h i p b e t w e e n p a t i e n t a n d d o c t o r t h a t t h e b e s t results could be obtained.
DR. GIBSON, in reply, expressed his gratification a t t h e discussion w h i c h h a d followed his p a p e r . I n r e p l y t o Dr. Bullough, he said t h a t t h e l a b o r a tories he a d v o c a t e d in each area were i n t e n d e d for o r d i n a r y elinicaI a n d p u b l i c h e a l t h purposes, a n d h e agreed t h a t research w o r k w o u l d b e b e s t c a r r i e d o u t i n special l a b o r a t o r i e s a t t a c h e d t o Medicat Schoots. W i t h r e g a r d t o . D r . Stansfield's o b s e r v a t i o n s on t h e f l a g r a n t defect i n t h e I n s u r a n c e A c t , which allowed a p r a c t i t i o n e r to t a k e on a p a n e l list which i t was hnpossible to do justice to, Dr. Gibson p o i n t e d o u t t h a t t h i s would n o t occur in t h e scheme he h a d suggested. Dr. Gibson qtfite a p p r e c i a t e d t h e difficulties arising o u t of i n d i v i d u a l predilections, b u t he r a t h e r t h o u g h t t h a t h u m a n n a t u r e was n o t such a n u n c h a n g e a b l e q u a n t i t y as was supposed, a n d if t h e p u b l i c reatised, a s he b e l i e v e d i t w o u l d one d a y , t h a t i t w o u l d g e t t h e b e s t service from a scheme like t h a t o u t l i n e d in t h e p a p e r , i t would be quite p r e p a r e d to a c c e p t it. Dr. Gibson agreed t h a t t h e m e t h o d suggested b y Dr. Angus m i g h t p o s s i b l y b e t h e first s t e p t a k e n , b u t he believed i t w o u l d e v e n t u a l l y develop into a m o r e c o m p l e t e scheme. NURSERY
SCHOOLS.
R~GIYLA~rlO~S d a t e d M a r c h 5th, 1919, concerning N u r s e r y Schools, h a v e b e e n issued b y the B o a r d of E d u c a t i o n . I n t h e p r e f a t o r y m e m o r a n d u m accomp a n y i n g these Regulations, t h e question of medical supervision is d e a l t w i t h in a v e r y s a t i s f a c t o r y m a n n e r . T h e m e m o r a n d u m states t h a t a N u r s e r y School should s t a n d in close r e l a t i o n t o t h e School Medical Service. W h e t h e r m a i n t a i n e d b y t h e local E d u c a t i o n A u t h o r i t y o r b y a v o l u n t a r y b o d y , t h e school should be u n d e r t h e supervision of t h e School Medical Officer. I'n t h e case of a v o l u n t a r y nursing school, i t m a y n o t a l w a y s be convenient for t h e School Medical Officer to u n d e r t a k e t h e whole of t h e medical inspection, b u t even in such a case t h e medical p r a c t i t i o n e r e m p l o y e d for this p u r p o s e should b e in t o u c h w i t h t h e School 2vIedical Officer, who should visit t h e school from t i m e t o time. T h e medical p r a c t i t i o n e r selected should p r e f e r a b l y live n e a r t h e school, t o b e r e a d i l y a v a i l a b l e h i case of emergency.
HEALTH.
I I7
DIETARIES
I N SANATORiUI~IS.
A circular h a s been issued b y t h e L o c a l G o v e r n m e n t B o a r d s u b s t i t u t i n g new dietaries for those p r e v i o u s l y lald down a n d giving t h e m a x i m u m w e e k l y a m o u n t s for each male over t e n y e a r s of age residing in a s a n a t o r i u m or in a special w a r d set a p a r t for t h e t r e a t m e n t of tuberculosis. F o r t h e i n f o r m a t i o n of our readers, v/e h a v e h a d t h e s e w e e k l y allowances p r i c e d O u t , w i t h t h e r e s u l t t h a t t h e cost a p p e a r s t o b e a p p r o x i m a t e l y £ I p e r h e a d p e r w e e k for food : - Estimated ~OSt at present .prices. s. d.
Meat (including suet)* ... Fish and poultry ...... Bacon . . . . . . . . . . . . Bread ... ......... Flour . . . . . . . . . . . . Sugar . . . . . . . . . . . . Butter and Margarine ... Lard and edible fatsi . . . . . . Potatoes ......... Vegetables (fresh) ...... Milk . . . . . . . . . . . . Jam, syrup, ete . . . . . . . Cereals . . . . . . . . . . . . Oatmeal ......... Peas, beans, and lentils ' Tea ............ Chesse . . . . . . . . . . . .
56 ozs. 16 ozs. 8 ozs. 64 ozs. 8 ozs. 8 ozs, io ozs. 3 ozs. 80 ozs. 28 ozs. 14 pints 8 ozs. 12 ozs. 8 ozs. 8 ozs. 2 ozs. 4 ozs,
Total Cost per Patient per week
..,
5 2 I o o o
o o o o 5 o o o o o o
io o 2 9 2½ 3½ 9 2 IO 7 3 5½ 6 2 3 4 5
I9 I I~
*The whole or any part of the meat ration may be butcher's meat, tOt which more than 2 ozs. must be lard. O n t h e certificate of t h e Medical Officer of t h e Institution, additional milk up to 7 pints weekly m a y b e allowed in special c i r c u m s t a n c e s i n s t e a d of p a r t of t h e allowance of peas, b e a n s , lentils, p o t a t o e s , a n d bre~d, F e m a l e s o v e r t e n y e a r s of age are e n t i t l e d to four-fifths of t h e a b o v e allowance, while children u n d e r t e n are e n t i t l e d to t h r e e - fifths, b u t in each of t h e s e cases t h e f u l l allowance of 8 ozs. of s u g a r a n d 3 ozs. edible fats w e e k l y is allowed. LONDON COUNTY COUNCIL M.O.H. T h e s a l a r y of Dr. %V. H. H a m e r , Medical Officer of H e a l t h a n d School Medical Officer t o t h e L o n d o n C o u n t y Council, has been increased from f I , 2 5 o a y e a r t o ~2,OO0. SALARY OF VENEREAL DISEAS~ OFFiCI~R.--Dr. J. C. B u c k l e y h a s b e e n a p p o i n t e d V e n e r e a l Disease Officer for t h e C i t y a n d C o u n t y of N o t t i n g h a m , a n d on t h e suggestion of t h e Local G o v e r n m e n t Board, his s a l a r y has been fixed a t fI,OOO a y e a r , w i t h t r a v e l l i n g expenses.