FUTURE OF MEDICAL SERVICES

56 can most efficiently be carried out fromhealth centres, where eight or ten doctors work together." Whether " by almost universally " you mean that almost everyFUTURE OF MEDICAL SERVICES body, both doctors and laymen, agrees or only that SIR,—I believe the proposals you outline would produce almost all doctors agree is not clear, but neither you nor a medical service acceptable to many doctors and at the anyone can know because neither the medical profession nor the populace has expressed or been asked to express The following seem same time democratic and efficient. its opinion.. It is certain from letters in the journals that to me to be weak points in the proposals as they stand. a number of doctors do not agree and have taken pains 1. Constitution of the provincial health councils.—The to say so. But even if this opinion had been generally selection of the members to sit on the provincial councils should be made from the periphery and not by or from the expressed it would still be, scientifically speaking, of small value because direct evidence on which to base it centre. Just as each voluntary hospital possesses a board of management to keep the hospital in touch with public needs does not exist. The " health centre " in this country exists scarcely at all except in the roughest kind of sketch and alive to public criticism, so also every health centre (or The evidence we have on which to form an on paper. in cities groups of centres) should possess a community health council, whose functions should be to act as liaison between opinion is our experience of working in the casualty the public and the medical practitioners in the health centres, departments of hospitals where general practice of a kind is carried on by a number of medical officers in as well as between the health committees of the city and touch with each other, our experience of practice in our boards of hospitals, convalescent homes, &c. From the personnel of these community councils, the public representa- own consulting-rooms or surgeries,, and our experience, from within or from without, of the work done in existtives on the regional health councils should be selected. thought that the only conMembership of the community health councils could be ing clinics. I shouldanhave unbiased mind is that each of clusion possible to decided either by community election, or better by selection these brands of practice has its own familiar and inherent from and by those organisations working in the community merits and defects, and that of the clinical and personal who take an active interest in health matters—e.g., industry, labour (hospital contributory societies), religious bodies, problems brought dailyby patients to their doctors schools, friendly societies, &c., youth councils, welfare societies, some could be best tackled in a clinic and by a team; scarcely, if at all, except by the doctor working cooperative guilds). A good deal of latitude ought to be left, others as a fully responsible unit in his own consulting-room. to the community concerned to select its representatives in its own way. Any of us can make guesses at the probable character of health centre practice, but guesses they must remain 2. I question whether inspectors are necessary. To call until a reasonable number of these centres have been them investigators does not alter my objection. If this kind built, equipped, staffed and run for several years. Only of work needs to be done, it should be done either by members then shall we know whether it is easy, or even possible, of the regular administrative staff or by selected medical to find for each of them a team of eight or ten doctors practitioners. able to work harmoniously and efficiently together; 3. Health centres.-It is hopeless to attempt to plan a single type of health centre. Three or four main types will be whether the daily throng of patients seeking medicines, required. Each community should choose the type that. medical consolation and certificates can ’be prevented from turning the overworked doctor into a mere sorting seems most suited to its needs and be given freedom to develop officer ; whether the conflicting concepts of team work its own service in its own way (subject of course to overriding and individual responsibility can somehow be harcontrol from the regional council and Ministry of Health). The monised ; whether the patient can have a choice of four main types must be for (a) a city, (b) a large town, (c) a doctor or have a doctor of his own despite fixed hours, small-town plus rural area, and (d) rural areas. In my view (d) will differ comparatively little in plan from the service at days off and no competition within the team ; whether present operating in rural areas, while (a) will be more nearly the patient whom only the direst extremity can induce to visit a hospital will go willingly to a clinic if it is called like that outlined in your article. a health centre—these and the many other problems 4. Free choice and freedom to change.-Patients should certainly be free to change not only from one doctor to another which look so formidable to many of us can be put to the test and solved, if they are soluble, only by a direct within the centre, but also from one health centre to anotherexperiment conducted on an adequate scale and for a subject to the usual safeguards. sufficient length of time. 5. You do not stress the point that much of the work to be If, Sir, a new method of treating disseminated sclerosis done in the health centres is not being done anywhere at present. The extension of medicine into the varied fields of had been proclaimed from some eminent quarter, and its immediate and universal adoption were being pressed hygiene must be pressed forward from the outset. on the profession, I am certain that you would demand 6. From the purely medical or professional angle, the sucthe most weighty, unequivocal and well-sifted evidence cess or failure of the whole plan depends on two factors-the ability of doctors to work together harmoniously, and some before giving it the support of an unsigned special safeguards to encourage every doctor to pull his weight in the article. Is it too much to ask that the same scientific standards should be observed when a new methodof group. Two things would greatly increase the chances of good team work being done. First, no doctor must be or feel tied practising medicine is being pressed on us for general and irreversible adoption ? to any particular team. Real freedom to change must be LINDSEY W. BATTEN. London, N.W. preserved ; many partnerships split on this rock. Secondly, increases in salary should not be automatic. They should be RESEARCH OVERLOOKED IN PLANNING subject to the expressly stated satisfaction of the other memSIR,—I have read with benefit and interest the interim bers of the team with the work done. If any member of a report on Medical Planning Research in your issue of firm was informed that his increment in salary was to be 21. As a full-time professional research-worker opposed by the group on the grounds of slackness or indifferent Nov. I would like to offer a few comments on an aspect of work he would be faced by a choice between getting a move medical planning which appears to have been completely on and moving elsewhere. This power to oppose the salary overlooked-namely, medical research itself. advance of members of the group could be made subject to As I see it, the basic state of medical and surgical fact the that it make its use existed would rarely safeguards : rests on active medical and surgical research. progress be members a New of team should chosennecessary. At the present time such new developments as occur at least in the final selection-by the team itself. in Britain and the Empire come from various sourcesIt would be a fatal error not to draw child welfare, universities, medical schools, the Medical Research school medicine and youth welfare into the work of the Council, commercial houses and the Dominion and health centre. If this is not done, good-bye to familyColonial medical services. To my mind (probably now and as-a-unit doctoring. Antenatal, maternity postnatal the sun or eaten by the flies) medical research by warped work ought to be done in or from the. health centre, even seems uncorrelated, badly organised and insufficiently if it is done by whole-time specialists. productive. I am quite sure the men are there. The HOWARD E. COLLIER. Worcester. trouble is difficult to track down, but I offer the following SIR,—One sentence at least in your special article of observations :June 26 must not go unchallenged. You say : " It is (a) The universities feel that teaching is their main function almost universally agreed that urban general practice on earth-and quite rightly so.

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