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National health service
PUBIAC HEALTH, January, 1943
42
N A T I O N A L HEALTH SERVICE REPORT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH
FOREWORD Health is a national asset, and every member of the community should be entitled to the best possible health and its minimum disturbance by disease or any adverse condition. The Society of Medical Officers of Health was established in 1856 for the advancement of public health. The Society has twelve Branches, to which its members are attached on a territorial basis. There are also six Groups of the Society for members interested in special provinces of public health. On September 19th, 1941, the Council of the Society set up a Medical Planning Committee with members appointed by the Council and by the Branches and Groups of the Society. Each Branch and Group was requested to consider how the health of the nation could be best secured and to report to the Medical Planning Committee. The Committee having received and considered these reports, and in addition a number of individual communications from members of the Society, produced the Interim Report of the Society which appeared in PtrBLt¢ HEALTh, September, 1942. This Interim Report was referred to the Branches and Groups and their further observations were duly considered by the Council of the Society at its meeting on November 19th and 20th, 1942. As a result of thesedeliberations by medical officers engaged in administration, public health and clinical work, the Society issues its report on a National Health Service as a contribution by professional men and women with wide experience in planning for health. C Y R I L B A N K S , President, Society of Medical Officers of Health, 1942-48. 1. Many services have been established in this country over a period of years for the medical care and the health of the people. Some of them have been established under Statute while others have been instituted under voluntary auspices. A number are administered by Central Government Departments, many by local authorities--widely different as to character and functions--and others by voluntary bodies. Few of the services are complete and there is no adequate machinery for their co-ordination and harmonious expansion. The war has brought into prominence the lack of system for medical care, and many are the improvisations which have had to be made in connection with the allocation of medical personnel to the Armed Forces, Civil Defence, the Civil Population, and the Emergency Medical Services. The time has arrived when the many questions involved require to be reviewed and an organisation established able to deal adequately and efficiently with the medical care and health needs of the nation. 2. The health of the nation is dependent not only on the medical care of the people but also on such factors as heredity, environment and social and economic circumstances. Chief among the environmental factors which will call for attention in the period of reconstruction after the war are housing, overcrowding, atmospheric pollution and the working conditions of the people. Such circumstances and conditions have always exercised and will continue to exercise a profound influence on the national health; the medical profession must therefore have constantly in mind their bearing on the health of the community, and the considered views of the medical profession should be of great importance in planning for social betterment. The plan which follows provides for the closest association between the medical service and other services in which its guidance would be
useful by placing the administration of all the services under the same local government authorities. The proposals are also conceived so that every branch of the medical profession may play its part and specialists, medical and public health practitioners at hospitals, health centres and in the homes of the people may work together for health. A N e w Health Ministry
8. At the present time several Government Departments have health and medical functions--e.g., the Ministry of Health, the Board of Education, the Ministry of Pensions, the Home Office, the Ministry of Labour, the Ministry of Supply and the Board of Trade (Ministry of War Transport). The medical and health functions of these various departments should all be brought within one Central Government Department with health as its sole function and with a Cabinet Minister as its responsible head. Such a Ministry would be concerned with : (a) Hospital, medical, health and ancillary services, including environmental and personal health services. (b) The acquisition and dissemination of special knowledge and information for the promotion of health. (c) Nutrition, food standards and the purity of foods. (d) International health. (e) The provision of such national health or medical institutions or services as it would be uneconomical or undesirable for the new local authorities to establish. (f) Allied and cognate social services. (g) The encouragement of medical research. These proposals for the establishment of a Ministry with health as its sole function should extend to Scotland as a separate national unit with the Department of Health for Scotland as the central authority and the Secretary of State for Scotland as the responsible Minister. The provisions to be made for Wales should empower the Minister of Health to constitute a Board of Health in Wales through which he would exercise and perform in Wales any of his powers and duties. N e w Local Authorities
4. At the present time local services for medical and health care comprise : - A. Health and medical services established by various local authorities, e.g. : (a) Environmental health services. (b) Maternity, Child Welfare, School Medical, Infectious Diseases, Tuberculosis, and Venereal Diseases Services. (c) Hospitals or institutions for the physically sick, the mentally sick, the mentally defective, the epileptic, or other abnormal conditions. B. General practitioner medical services, including visits to homes and consultations in surgeries, given (a) to some 20,000,000 persons, under the National Health Insurance Acts; (b) to persons who are destitute or in need of public assistance under the Poor Law; (c) to persons making their own arrangements with medical practitioners. C. Health and medical services established by various voluntary associations, e.g. : (a) Child Welfare, Child Guidance, Rheumatism, and other similar services. (b) Hospitals or institutions for the physically sick, the mentally sick, the mentally defective, the epileptic, or other abnormal conditions. The foregoing services are administered locally by one or other, or more than one, of the several types of local authorities, by local insurance committees, or by voluntary associations. These various schemes, however, be they for the cure of disease or its prevention or for the maintenance or improvement of health, do not work within a unified or co-ordinated plan for any area, and few if any of the services are complete,
PUBLIC HEALTH, January, 1943 5. The foregoing statement deals primarily with medical services, but any plan for the provision of medical services must include the provision of the necessary auxiliary services --e.g., health visiting, nursing, midwifery, sanitary, pharmaceutical, ambulance, veterinary, etc., services. All of these are required and some are already provided more or less incompletely by local authorities or voluntary agencies or both. A dental service--although not an auxiliary service in the sense of the foregoing--requires also to be provided for health reasons. 6. Having regard to these provisions and the need for their co-ordination and expansion, what is required is that in any local government area there should be a single authority for health purposes. Such an authority would be responsible within its area for the administration of medical, health and allied services, including the environmental and personal health services and be further responsible for the provision of an adequate hospital service for all the inhabitants of its area. Few of the existing local authorkies are sufficiently large to be able to provide complete health services, and new local government areas will have to be devised in which not only population but geographical and other considerations will require to be taken into account. There should be 1so ad hoc health authorities: the extended Health Services should continue to be administered by elected bodies responsible for the other services of local government. Treasury grants should be available for the equalisation of the financial resources of the new local government areas. It is difficult to lay down any hard-and-fast rule as to the sizes of areas having regard to distribution of the population. The enlarged local government areas should, however, be able to provide efficiently and economically all the hospital and health services commonly required. In respect of some rare conditions or occasional occurrences--e.g., brain surgery, smallpox, typhus fever or leprosy--it might be necessary or desirable for the new local authorities to combine, or perhaps for the central health department to act. It would further be the business of the new local authorities to utilise to the best advantage all voluntary organisations in their area dealing with health or medical care. It is appreciated that new local government areas will not be constructed on health considerations alone, but these observations as to the need for such new areas are submitted as the result of knowledge and experienee of hospital and health administration. The New Medicine 7. The future aim of medicine must be not only to cure disease and restore health, but to .prevent disease and to maintain and improve health. It follows therefore that all members of the medical profession must be actively concerned with the environmental and personal factors which retard the achievement of health, and that all hospital and health services must be administered with health as the constant objective. DOMICILIARY SERVICES, CONSULTATIONS, HEALTH CENTRES 8. In the new organisation of medicine it cannot be too strongly emphasised that it will be general practitioners or groups of practitioners who will be in the first lines of defence against the encroachment of disease and for the maintenance and improvement of health. The family should be regarded as the health unit, and practitioners should have the care in health as well as disease of suitable numbers of persons. They would deal with matters with which general practitioners at present deal in respect of patients by way of visits to their homes or consultations at surgeries. They would also participate in maternity and child welfare and school medical work, and have such responsibilities relative to the notifiable infectious diseases, tuberculosis, venereal diseases, and industrial medicine as may be considered desirable or
43 convenient. To enable them to carry out these duties satisfactorily specialist help and all necessary auxiliary services should be available. In order to encompass this work with the greatest benefit to the public and the greatest conservation of time, Health Centres should be established at which and from which doctors would work. These health centres, together with all necessary auxiliary services, would be located, provided, furnished, maintained, and administered by the local authority for the area. As far as possible all health centres provided in populous areas should be fully equipped. In less populous areas a number of smaller health centres with essential services may require to be established round a central health centre completely equipped and staffed. Even in populous areas it may be that for some of the less common forms of treatment, such as o~hoptic treatment, only one of the health centres would be equipped to deal with it. Variations of this kind would have to be made to suit the particular circumstances of the area. 9. The mtcaber of practitioners working in a health centre would vary according to the type of area, and in rural areas, where practitioners may be single-handed, special arrangements would require to be made by the local authority. At the health centre each doctor should be provided with sufficient accommodation, and certain of the consultations with consultants would be held in the doctors' rooms. Special sukes would require to be provided for certain branches of work as might be deemed necessary--e.g., ante-natal work, orthopaedics, ophthalmology, throat, nose and ear conditions, etc. 10. Every doctor would have at his disposal clerical and nursing services and should keep himself well informed through the health visiting and sanitary services of the social and environmental conditions affecting the persons under his care. 11. The consultants of the area would attend at all or such of the health centres as might be convenient at regular times to deal with cases referred to them by the doctors. These consultants would also be available for consultations with doctors in the homes of patients as required. 12. Arrangements would be made with the consultants of the area for conferences and demonstrations at the health centres or hospital at frequent intervals, so that doctors may be well informed of the latest developments in medicine. Provision should be made to enable doctors to undertake research and to have study leave. Opportunities should be given to selected general practitioners to participate in hospital practice and to become consultants. Health centres should be linked up with the teaching hospitals in order that the medical student may get the necessary training to fit him for the improved type of medical practice envisaged. 18. The above picture of a health centre equipped for services of preventive and curative medicine portrays the doctor as the essential element in the organisation with facilities for giving effect to the real purposes of national medicine--namely, to maintain and improve health, to prevent disease, and to treat disease and re-establish health. The doctor in this organisation becomes a real family doctor with full responsibility for the health of the persons under his care. His work would be suitably organised and the doctor provided with all the assistance needed to carry out the work efficiently. Under such conditions the doctor would no longer work alone, but would have the advantage and encouragement of discussion and communion with colleagues with like ideals as to the ends to be achieved. DENTAL SERVICE 14. Provision should be made at the health centres for dentistry. The dental work should be arranged on the same lines as the medical work, with which it should be closely co-ordinated. With the establishment of a dental service at
44
PUBLIC HEALTH, January, 1943
the health centre doctors and dental surgeons and their staffs would be enabled to work in close association with each other. Dental surgeons, in the same way as doctors, would be provided with the necessary staff of nurses and clerks and would have the services of dental mechanics and facilities for X-ray examination, prosthetic and orthodontic work. Hospital beds would also be available for their patients as might be required. HOSPITALS
15. A hospital service should be complete and able to deal with all forms and stages of invalidity. It includes hospitals both for the physically sick and for persons suffering from mental disorder and mental deficiency. There must be coordinated administration of all hospitals within the area of a local authority so that if may be possible not only to determine the functions of individual hospitals but how these hospitals may best be linked up with one another and with the work of health centres and domiciliary practice. The hospital service is in fact a necessary part of the health service. The function of the health services is to detect disease and to develop the hospital on its preventive as well as its curative side. The hospitals' staffs would be concerned to add their contribution to the prevention of disease and the maintenance of health, and their findings could only be suitably assessed and utilised with the hospitals as an integral part of the health service. The health administration would know the incidence of disease, the requirements of the people and their social circumstances, and be able to relate this knowledge to the need for hospital provision and to set up the kind of service which the community requires. It must be regarded as a cardinal principle that hospital services are an integral part of the health services. The duty of providing hospital services should be the function of the new local authorities in co-operation with the voluntary hospitals and, ff necessary, with one another. Any suggestion to create ad hoc hospital authorities for the purpose of administering hospital services would create fresh confusion in a field where integration is essential. 16. With the development of health centres out-patient departments of hospitals would generally be necessary only for emergency cases, consultations, special treatments and for the continued treatment of discharged patients requiring special supervision. 17. Areas would be so arranged that at least one hospital on account of its size and location will come to be regarded as a principal hospital. Sometimes it will be a voluntary and teaching hospital and sometimes a municipal hospital. Municipal hospitals should be included as teaching hospitals, and it should be borne in mind that in any complete hospital system an equally high standard of service will be demanded for all areas. 18. All hospitals, voluntary and local authority, should be available for all members of the community on similar terms and conditions. All facilities for diagnosis and treatment provided by any unit of the hospital service should be available to every patient admitted to any of the hospitals of an area. Provision for continuity in the care of the sick in the acute and chronic stages of illness is essential. An adequate number of beds for convalescent patients of all types is required. Facilities for physical and occupational therapy should be available. A follow-up system should be instituted so as to ensure complete recovery and to afford an opportunity of detecting the earliest signs of relapse or recurrence. A complete domiciliary nursing service co-ordinated with the hospital service should be provided. LABORATORY SERVICE 19. An adequate laboratory service forms an essential part of an efficient medical service and should be conducted so
as to ensure regular personal contact between the staff of the laboratory, the officers engaged in epidemiology and other public health work, the clinical staffs of hospitals and the medical practitioners in the area. RES~CH 20. Research will be able to play an even more important part than heretofore in the progress of medical science. In an organised system of medicine many converging lines of investigation in the field and in the laboratory will suggest themselves and advances in knowledge should be rapid. The new local authorities should encourage research and make adequate provision for the workers and all necessary equipment in this field of medicine. Research should be directed to the elucidation of the causes of disease and to its prevention as well as cure. Investigations directed towards the maintenance and improvement of health must take a high place in the research work of local authorities. Such research work should be .closely linked up with the research department of the central government so that, by full co-operation and co-ordination in this important branch of medicine, the most effective results can be obtained. T o encourage local authorities to make adequate provision for research work, including field research, Government grants should be available. Availability of Services 21. All hospital, medical, health and allied services, including the environmental and personal health services, shOuld be available to every member of the community without charge.
Staffing 22. CentraL--The chief officer of the new central health department should be the chief medical officer of the department responsible for all the work of the department to the Minister of the Crown. The chief medical officer should have such assistance, medical, technical and lay, as may be necessary for the purposes of the department. 28. Local.--In each new local government area there would be a Chief Medical Officer responsible for the administration of hospital, medical, health and allied services, including the environmental and personal health services. There would be associated with him Medical Directors or Medical Superintendents for the various medical services or such combinations of them as might be considered suitable for the area. 24. Advisory Medical Committees.--Central and local advisory medical committees should be appointed by the medical profession and be recognised by the appropriate authority. They should meet regularly with the appropriate chief medical officer for purposes of consultation and advice respecting any matters within his purview. 25. Whole-time Salaried Service.--It has been suggested that the medical personnel of the services herein outlined might be employed: (1) on a capitation basis as under the National Health Insurance system; (2) on a part-time salaried basis ; or (8) on a whole-time salaried basis. Private enterprise cannot provide and maintain complete hospital, medical, health and allied services, and such services conducted on a whole-time salaried basis have the dual advantages of administrative efficiency and the elimination of undesirable competition for patients. Hitherto the doctor has been mainly interested in the illness of his patients, but it is of the first importance that his attention should be directed to the maintenance of health. This means not only a re-orientation of outlook on the part of the individual practitioners but the provision of all services necessary to enable practitioners to study and investigate departures from health in their earliest stages. In these circumstances a
PUBLIC HEALTH, January, 1943 national medical and health service should be established on a whole-time salaried basis with the complete facilities outlined in this report. It should be available to all members of the community who wish to take advantage of it, and should offer to doctors conditions of employment and opportunities for study and advancement likely to attract to the profession the best type of individual and to ensure his continued interest and contentment in his work. The maximum freedom of choice should be given to patients in the selection of their doctors within the organisation provided. 26. Appointments.--All appointments, whether central or local, should be advertised. Appropriate Advisory Committees should be established, and all applications for admission to or transfer or promotion within the services should be referred to the appropriate Advisory Committee. On the occasion of a vacancy the appropriate Advisory Committee would submit the names of suitable applicants for appointment to the appropriate authority. 27. Conditions of Service.--The conditions for all types of medical service should be determined by a suitable national body and there should be adequate machinery for the protection of officers in the discharge of their duties. 28. Superannuation.--All medical posts in the central and local government departments should have an optional retiring age of 60 years with provision for added years so that such medical officers may have full pension. All medical officers should be compulsorily retired at 65 years of age. 29. Compensation for loss of office or practice.--Suitable provision should be made for loss of office or practice.
Medical Education, Post-Graduate Training and Careers 80. Medical practitioners taking part in the new service should have a preventive outlook in relation to their work. It will take some time to achieve this and to establish the proposition that the prevention of disease and maintenance and improvement of health must occupy at least as important a place in the training of the medical student as the cure of disease. An early beginning can be made by associating existing teaching hospitals with the hospitals, health centres, clinics and public health practice of local authorities, so that the student may obtain during his undergraduate career a wide perspective as to the scope and purpose of medicine. 81. After graduation there should be post-graduate training extending over a minimum period to be subsequently determined. During this period the medical graduate should undertake whole-time salaried medical work at hospitals and health centres so that he may acquire experience in the practice of both preventive and curative medicine. 32. Having obtained this insight into and experience of the various forms of medical practice, the graduate should bear in mind the possibilities for a career in his profession in accordance with the plan for the future of health and medical practice. Careers would in the main be in respect of administrative or clinical or laboratory or research work. Clinical posts should not necessarily be paid on a lower basis than administrative posts. Operation of the Plan 88. In present circumstances the immediate operation of the plan is not practicable. A number of factors govern its growth and consideration must be given to the transitional period pending its complete development. 84. Hospitals.--It is accepted that curative and preventive medicine cannot be separated on any sound principle. It is therefore imperative that the hospitals should be an integral part of the health services which should be considered as a whole so that there need be no unnecessary delay in the inauguration of a complete national health service. The cure of the sick is always an urgent matter, and the hospital policy
45 of the government so far as it has been disclosed may be useful in the transition period. It would appear necessary, however, to emphasise that the greater need for unified measures for the maintenance and improvement of national health must not be lost sight of in connection with any interim hospital policy. 35. Health Centres.--Time will be required to provide health centres and for their medical staffing. Such staffing should be on a whole-time salaried basis. It is realised, however, that such a method of staffing may have to be brought about gradually. It would therefore appear desirable in connection with the erection and organisation of these centres to empower each local authority after consultation with the local medical profession to determine which method or methods of staffing they consider most appropriate for the hospitals, health centres or domiciliary practice in the whole or parts of their area. Such choice would appear to be essential during the ~ransition period having regard to the fact that the establishment of health centres and hospitals will be gradual. 36. The New Medical Practitioner.--It will take time, too, for a new type of medical practitioner to be trained for the care of persons in health as well as disease. Hitherto the education and trainin~ of the medical practitioner have mainly had regard to the cure of disease. Future training must also embrace the study of the prevention of disease and the maintenance of health. Time must accordingly elapse before a sufficient number of such practitioners is available. Nevertheless the change over must be begun and take place pari passu with the establishment of health centres and the development of hospitals. 37. Having regard to the foregoing considerations it would appear that to avoid any unnecessary delay in the ultimate operation of the plan steps should be taken at the earliest possible moment : (1) To establish a new Health Ministry with health as its sole function; (2) to establish new Local Government Areas; and to give powers to the new Local Government Authorities to plan and develop their hospital, medical, health and allied services within their discretion and according to circumstances during the transition period. 38. Having regard to the probable state of medical practice immediately after the war, it is suggested that steps might be taken to ameliorate the post-war situation by empowering major local authorities to set up a whole-time salaried domiciliary service on lines which would ultimately fit into the scheme outlined in this report. A limited number of reprints of the above report are available for medical officers of health on application. For the information of readers the constitution of the Medical Planning Comm]:ttee of the Society is printed on p. 59 of this issue. The Minister of Health, addressing the Congress of the British Medical Students' Association in London on December 18th, said, " The air is full of new ideas and new trends ; and there is one which we must all keep constantly in front of us --preventive medicine and positive health. The age-long function of the physician is to cure and relieve the sick. But it is right that as Minister of Health (not Minister of Disease) I should insist that you have a second duty--to prevent disease and point the way to positive health . . . . In your clinical work you try to make a diagnosis at the earliest possible stage . . . . Carry this a step farther, and you will find yourselves preventing disease before it has shown itself in any way. Perhaps the greatest handicap to the practice of preventive medicine to-day is not that we do not know how to prevent many diseases--which is still unfortunately true--but that the public does not take full advantage of the knowledge we already have."
42
N A T I O N A L HEALTH SERVICE REPORT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH
FOREWORD Health is a national asset, and every member of the community should be entitled to the best possible health and its minimum disturbance by disease or any adverse condition. The Society of Medical Officers of Health was established in 1856 for the advancement of public health. The Society has twelve Branches, to which its members are attached on a territorial basis. There are also six Groups of the Society for members interested in special provinces of public health. On September 19th, 1941, the Council of the Society set up a Medical Planning Committee with members appointed by the Council and by the Branches and Groups of the Society. Each Branch and Group was requested to consider how the health of the nation could be best secured and to report to the Medical Planning Committee. The Committee having received and considered these reports, and in addition a number of individual communications from members of the Society, produced the Interim Report of the Society which appeared in PtrBLt¢ HEALTh, September, 1942. This Interim Report was referred to the Branches and Groups and their further observations were duly considered by the Council of the Society at its meeting on November 19th and 20th, 1942. As a result of thesedeliberations by medical officers engaged in administration, public health and clinical work, the Society issues its report on a National Health Service as a contribution by professional men and women with wide experience in planning for health. C Y R I L B A N K S , President, Society of Medical Officers of Health, 1942-48. 1. Many services have been established in this country over a period of years for the medical care and the health of the people. Some of them have been established under Statute while others have been instituted under voluntary auspices. A number are administered by Central Government Departments, many by local authorities--widely different as to character and functions--and others by voluntary bodies. Few of the services are complete and there is no adequate machinery for their co-ordination and harmonious expansion. The war has brought into prominence the lack of system for medical care, and many are the improvisations which have had to be made in connection with the allocation of medical personnel to the Armed Forces, Civil Defence, the Civil Population, and the Emergency Medical Services. The time has arrived when the many questions involved require to be reviewed and an organisation established able to deal adequately and efficiently with the medical care and health needs of the nation. 2. The health of the nation is dependent not only on the medical care of the people but also on such factors as heredity, environment and social and economic circumstances. Chief among the environmental factors which will call for attention in the period of reconstruction after the war are housing, overcrowding, atmospheric pollution and the working conditions of the people. Such circumstances and conditions have always exercised and will continue to exercise a profound influence on the national health; the medical profession must therefore have constantly in mind their bearing on the health of the community, and the considered views of the medical profession should be of great importance in planning for social betterment. The plan which follows provides for the closest association between the medical service and other services in which its guidance would be
useful by placing the administration of all the services under the same local government authorities. The proposals are also conceived so that every branch of the medical profession may play its part and specialists, medical and public health practitioners at hospitals, health centres and in the homes of the people may work together for health. A N e w Health Ministry
8. At the present time several Government Departments have health and medical functions--e.g., the Ministry of Health, the Board of Education, the Ministry of Pensions, the Home Office, the Ministry of Labour, the Ministry of Supply and the Board of Trade (Ministry of War Transport). The medical and health functions of these various departments should all be brought within one Central Government Department with health as its sole function and with a Cabinet Minister as its responsible head. Such a Ministry would be concerned with : (a) Hospital, medical, health and ancillary services, including environmental and personal health services. (b) The acquisition and dissemination of special knowledge and information for the promotion of health. (c) Nutrition, food standards and the purity of foods. (d) International health. (e) The provision of such national health or medical institutions or services as it would be uneconomical or undesirable for the new local authorities to establish. (f) Allied and cognate social services. (g) The encouragement of medical research. These proposals for the establishment of a Ministry with health as its sole function should extend to Scotland as a separate national unit with the Department of Health for Scotland as the central authority and the Secretary of State for Scotland as the responsible Minister. The provisions to be made for Wales should empower the Minister of Health to constitute a Board of Health in Wales through which he would exercise and perform in Wales any of his powers and duties. N e w Local Authorities
4. At the present time local services for medical and health care comprise : - A. Health and medical services established by various local authorities, e.g. : (a) Environmental health services. (b) Maternity, Child Welfare, School Medical, Infectious Diseases, Tuberculosis, and Venereal Diseases Services. (c) Hospitals or institutions for the physically sick, the mentally sick, the mentally defective, the epileptic, or other abnormal conditions. B. General practitioner medical services, including visits to homes and consultations in surgeries, given (a) to some 20,000,000 persons, under the National Health Insurance Acts; (b) to persons who are destitute or in need of public assistance under the Poor Law; (c) to persons making their own arrangements with medical practitioners. C. Health and medical services established by various voluntary associations, e.g. : (a) Child Welfare, Child Guidance, Rheumatism, and other similar services. (b) Hospitals or institutions for the physically sick, the mentally sick, the mentally defective, the epileptic, or other abnormal conditions. The foregoing services are administered locally by one or other, or more than one, of the several types of local authorities, by local insurance committees, or by voluntary associations. These various schemes, however, be they for the cure of disease or its prevention or for the maintenance or improvement of health, do not work within a unified or co-ordinated plan for any area, and few if any of the services are complete,
PUBLIC HEALTH, January, 1943 5. The foregoing statement deals primarily with medical services, but any plan for the provision of medical services must include the provision of the necessary auxiliary services --e.g., health visiting, nursing, midwifery, sanitary, pharmaceutical, ambulance, veterinary, etc., services. All of these are required and some are already provided more or less incompletely by local authorities or voluntary agencies or both. A dental service--although not an auxiliary service in the sense of the foregoing--requires also to be provided for health reasons. 6. Having regard to these provisions and the need for their co-ordination and expansion, what is required is that in any local government area there should be a single authority for health purposes. Such an authority would be responsible within its area for the administration of medical, health and allied services, including the environmental and personal health services and be further responsible for the provision of an adequate hospital service for all the inhabitants of its area. Few of the existing local authorkies are sufficiently large to be able to provide complete health services, and new local government areas will have to be devised in which not only population but geographical and other considerations will require to be taken into account. There should be 1so ad hoc health authorities: the extended Health Services should continue to be administered by elected bodies responsible for the other services of local government. Treasury grants should be available for the equalisation of the financial resources of the new local government areas. It is difficult to lay down any hard-and-fast rule as to the sizes of areas having regard to distribution of the population. The enlarged local government areas should, however, be able to provide efficiently and economically all the hospital and health services commonly required. In respect of some rare conditions or occasional occurrences--e.g., brain surgery, smallpox, typhus fever or leprosy--it might be necessary or desirable for the new local authorities to combine, or perhaps for the central health department to act. It would further be the business of the new local authorities to utilise to the best advantage all voluntary organisations in their area dealing with health or medical care. It is appreciated that new local government areas will not be constructed on health considerations alone, but these observations as to the need for such new areas are submitted as the result of knowledge and experienee of hospital and health administration. The New Medicine 7. The future aim of medicine must be not only to cure disease and restore health, but to .prevent disease and to maintain and improve health. It follows therefore that all members of the medical profession must be actively concerned with the environmental and personal factors which retard the achievement of health, and that all hospital and health services must be administered with health as the constant objective. DOMICILIARY SERVICES, CONSULTATIONS, HEALTH CENTRES 8. In the new organisation of medicine it cannot be too strongly emphasised that it will be general practitioners or groups of practitioners who will be in the first lines of defence against the encroachment of disease and for the maintenance and improvement of health. The family should be regarded as the health unit, and practitioners should have the care in health as well as disease of suitable numbers of persons. They would deal with matters with which general practitioners at present deal in respect of patients by way of visits to their homes or consultations at surgeries. They would also participate in maternity and child welfare and school medical work, and have such responsibilities relative to the notifiable infectious diseases, tuberculosis, venereal diseases, and industrial medicine as may be considered desirable or
43 convenient. To enable them to carry out these duties satisfactorily specialist help and all necessary auxiliary services should be available. In order to encompass this work with the greatest benefit to the public and the greatest conservation of time, Health Centres should be established at which and from which doctors would work. These health centres, together with all necessary auxiliary services, would be located, provided, furnished, maintained, and administered by the local authority for the area. As far as possible all health centres provided in populous areas should be fully equipped. In less populous areas a number of smaller health centres with essential services may require to be established round a central health centre completely equipped and staffed. Even in populous areas it may be that for some of the less common forms of treatment, such as o~hoptic treatment, only one of the health centres would be equipped to deal with it. Variations of this kind would have to be made to suit the particular circumstances of the area. 9. The mtcaber of practitioners working in a health centre would vary according to the type of area, and in rural areas, where practitioners may be single-handed, special arrangements would require to be made by the local authority. At the health centre each doctor should be provided with sufficient accommodation, and certain of the consultations with consultants would be held in the doctors' rooms. Special sukes would require to be provided for certain branches of work as might be deemed necessary--e.g., ante-natal work, orthopaedics, ophthalmology, throat, nose and ear conditions, etc. 10. Every doctor would have at his disposal clerical and nursing services and should keep himself well informed through the health visiting and sanitary services of the social and environmental conditions affecting the persons under his care. 11. The consultants of the area would attend at all or such of the health centres as might be convenient at regular times to deal with cases referred to them by the doctors. These consultants would also be available for consultations with doctors in the homes of patients as required. 12. Arrangements would be made with the consultants of the area for conferences and demonstrations at the health centres or hospital at frequent intervals, so that doctors may be well informed of the latest developments in medicine. Provision should be made to enable doctors to undertake research and to have study leave. Opportunities should be given to selected general practitioners to participate in hospital practice and to become consultants. Health centres should be linked up with the teaching hospitals in order that the medical student may get the necessary training to fit him for the improved type of medical practice envisaged. 18. The above picture of a health centre equipped for services of preventive and curative medicine portrays the doctor as the essential element in the organisation with facilities for giving effect to the real purposes of national medicine--namely, to maintain and improve health, to prevent disease, and to treat disease and re-establish health. The doctor in this organisation becomes a real family doctor with full responsibility for the health of the persons under his care. His work would be suitably organised and the doctor provided with all the assistance needed to carry out the work efficiently. Under such conditions the doctor would no longer work alone, but would have the advantage and encouragement of discussion and communion with colleagues with like ideals as to the ends to be achieved. DENTAL SERVICE 14. Provision should be made at the health centres for dentistry. The dental work should be arranged on the same lines as the medical work, with which it should be closely co-ordinated. With the establishment of a dental service at
44
PUBLIC HEALTH, January, 1943
the health centre doctors and dental surgeons and their staffs would be enabled to work in close association with each other. Dental surgeons, in the same way as doctors, would be provided with the necessary staff of nurses and clerks and would have the services of dental mechanics and facilities for X-ray examination, prosthetic and orthodontic work. Hospital beds would also be available for their patients as might be required. HOSPITALS
15. A hospital service should be complete and able to deal with all forms and stages of invalidity. It includes hospitals both for the physically sick and for persons suffering from mental disorder and mental deficiency. There must be coordinated administration of all hospitals within the area of a local authority so that if may be possible not only to determine the functions of individual hospitals but how these hospitals may best be linked up with one another and with the work of health centres and domiciliary practice. The hospital service is in fact a necessary part of the health service. The function of the health services is to detect disease and to develop the hospital on its preventive as well as its curative side. The hospitals' staffs would be concerned to add their contribution to the prevention of disease and the maintenance of health, and their findings could only be suitably assessed and utilised with the hospitals as an integral part of the health service. The health administration would know the incidence of disease, the requirements of the people and their social circumstances, and be able to relate this knowledge to the need for hospital provision and to set up the kind of service which the community requires. It must be regarded as a cardinal principle that hospital services are an integral part of the health services. The duty of providing hospital services should be the function of the new local authorities in co-operation with the voluntary hospitals and, ff necessary, with one another. Any suggestion to create ad hoc hospital authorities for the purpose of administering hospital services would create fresh confusion in a field where integration is essential. 16. With the development of health centres out-patient departments of hospitals would generally be necessary only for emergency cases, consultations, special treatments and for the continued treatment of discharged patients requiring special supervision. 17. Areas would be so arranged that at least one hospital on account of its size and location will come to be regarded as a principal hospital. Sometimes it will be a voluntary and teaching hospital and sometimes a municipal hospital. Municipal hospitals should be included as teaching hospitals, and it should be borne in mind that in any complete hospital system an equally high standard of service will be demanded for all areas. 18. All hospitals, voluntary and local authority, should be available for all members of the community on similar terms and conditions. All facilities for diagnosis and treatment provided by any unit of the hospital service should be available to every patient admitted to any of the hospitals of an area. Provision for continuity in the care of the sick in the acute and chronic stages of illness is essential. An adequate number of beds for convalescent patients of all types is required. Facilities for physical and occupational therapy should be available. A follow-up system should be instituted so as to ensure complete recovery and to afford an opportunity of detecting the earliest signs of relapse or recurrence. A complete domiciliary nursing service co-ordinated with the hospital service should be provided. LABORATORY SERVICE 19. An adequate laboratory service forms an essential part of an efficient medical service and should be conducted so
as to ensure regular personal contact between the staff of the laboratory, the officers engaged in epidemiology and other public health work, the clinical staffs of hospitals and the medical practitioners in the area. RES~CH 20. Research will be able to play an even more important part than heretofore in the progress of medical science. In an organised system of medicine many converging lines of investigation in the field and in the laboratory will suggest themselves and advances in knowledge should be rapid. The new local authorities should encourage research and make adequate provision for the workers and all necessary equipment in this field of medicine. Research should be directed to the elucidation of the causes of disease and to its prevention as well as cure. Investigations directed towards the maintenance and improvement of health must take a high place in the research work of local authorities. Such research work should be .closely linked up with the research department of the central government so that, by full co-operation and co-ordination in this important branch of medicine, the most effective results can be obtained. T o encourage local authorities to make adequate provision for research work, including field research, Government grants should be available. Availability of Services 21. All hospital, medical, health and allied services, including the environmental and personal health services, shOuld be available to every member of the community without charge.
Staffing 22. CentraL--The chief officer of the new central health department should be the chief medical officer of the department responsible for all the work of the department to the Minister of the Crown. The chief medical officer should have such assistance, medical, technical and lay, as may be necessary for the purposes of the department. 28. Local.--In each new local government area there would be a Chief Medical Officer responsible for the administration of hospital, medical, health and allied services, including the environmental and personal health services. There would be associated with him Medical Directors or Medical Superintendents for the various medical services or such combinations of them as might be considered suitable for the area. 24. Advisory Medical Committees.--Central and local advisory medical committees should be appointed by the medical profession and be recognised by the appropriate authority. They should meet regularly with the appropriate chief medical officer for purposes of consultation and advice respecting any matters within his purview. 25. Whole-time Salaried Service.--It has been suggested that the medical personnel of the services herein outlined might be employed: (1) on a capitation basis as under the National Health Insurance system; (2) on a part-time salaried basis ; or (8) on a whole-time salaried basis. Private enterprise cannot provide and maintain complete hospital, medical, health and allied services, and such services conducted on a whole-time salaried basis have the dual advantages of administrative efficiency and the elimination of undesirable competition for patients. Hitherto the doctor has been mainly interested in the illness of his patients, but it is of the first importance that his attention should be directed to the maintenance of health. This means not only a re-orientation of outlook on the part of the individual practitioners but the provision of all services necessary to enable practitioners to study and investigate departures from health in their earliest stages. In these circumstances a
PUBLIC HEALTH, January, 1943 national medical and health service should be established on a whole-time salaried basis with the complete facilities outlined in this report. It should be available to all members of the community who wish to take advantage of it, and should offer to doctors conditions of employment and opportunities for study and advancement likely to attract to the profession the best type of individual and to ensure his continued interest and contentment in his work. The maximum freedom of choice should be given to patients in the selection of their doctors within the organisation provided. 26. Appointments.--All appointments, whether central or local, should be advertised. Appropriate Advisory Committees should be established, and all applications for admission to or transfer or promotion within the services should be referred to the appropriate Advisory Committee. On the occasion of a vacancy the appropriate Advisory Committee would submit the names of suitable applicants for appointment to the appropriate authority. 27. Conditions of Service.--The conditions for all types of medical service should be determined by a suitable national body and there should be adequate machinery for the protection of officers in the discharge of their duties. 28. Superannuation.--All medical posts in the central and local government departments should have an optional retiring age of 60 years with provision for added years so that such medical officers may have full pension. All medical officers should be compulsorily retired at 65 years of age. 29. Compensation for loss of office or practice.--Suitable provision should be made for loss of office or practice.
Medical Education, Post-Graduate Training and Careers 80. Medical practitioners taking part in the new service should have a preventive outlook in relation to their work. It will take some time to achieve this and to establish the proposition that the prevention of disease and maintenance and improvement of health must occupy at least as important a place in the training of the medical student as the cure of disease. An early beginning can be made by associating existing teaching hospitals with the hospitals, health centres, clinics and public health practice of local authorities, so that the student may obtain during his undergraduate career a wide perspective as to the scope and purpose of medicine. 81. After graduation there should be post-graduate training extending over a minimum period to be subsequently determined. During this period the medical graduate should undertake whole-time salaried medical work at hospitals and health centres so that he may acquire experience in the practice of both preventive and curative medicine. 32. Having obtained this insight into and experience of the various forms of medical practice, the graduate should bear in mind the possibilities for a career in his profession in accordance with the plan for the future of health and medical practice. Careers would in the main be in respect of administrative or clinical or laboratory or research work. Clinical posts should not necessarily be paid on a lower basis than administrative posts. Operation of the Plan 88. In present circumstances the immediate operation of the plan is not practicable. A number of factors govern its growth and consideration must be given to the transitional period pending its complete development. 84. Hospitals.--It is accepted that curative and preventive medicine cannot be separated on any sound principle. It is therefore imperative that the hospitals should be an integral part of the health services which should be considered as a whole so that there need be no unnecessary delay in the inauguration of a complete national health service. The cure of the sick is always an urgent matter, and the hospital policy
45 of the government so far as it has been disclosed may be useful in the transition period. It would appear necessary, however, to emphasise that the greater need for unified measures for the maintenance and improvement of national health must not be lost sight of in connection with any interim hospital policy. 35. Health Centres.--Time will be required to provide health centres and for their medical staffing. Such staffing should be on a whole-time salaried basis. It is realised, however, that such a method of staffing may have to be brought about gradually. It would therefore appear desirable in connection with the erection and organisation of these centres to empower each local authority after consultation with the local medical profession to determine which method or methods of staffing they consider most appropriate for the hospitals, health centres or domiciliary practice in the whole or parts of their area. Such choice would appear to be essential during the ~ransition period having regard to the fact that the establishment of health centres and hospitals will be gradual. 36. The New Medical Practitioner.--It will take time, too, for a new type of medical practitioner to be trained for the care of persons in health as well as disease. Hitherto the education and trainin~ of the medical practitioner have mainly had regard to the cure of disease. Future training must also embrace the study of the prevention of disease and the maintenance of health. Time must accordingly elapse before a sufficient number of such practitioners is available. Nevertheless the change over must be begun and take place pari passu with the establishment of health centres and the development of hospitals. 37. Having regard to the foregoing considerations it would appear that to avoid any unnecessary delay in the ultimate operation of the plan steps should be taken at the earliest possible moment : (1) To establish a new Health Ministry with health as its sole function; (2) to establish new Local Government Areas; and to give powers to the new Local Government Authorities to plan and develop their hospital, medical, health and allied services within their discretion and according to circumstances during the transition period. 38. Having regard to the probable state of medical practice immediately after the war, it is suggested that steps might be taken to ameliorate the post-war situation by empowering major local authorities to set up a whole-time salaried domiciliary service on lines which would ultimately fit into the scheme outlined in this report. A limited number of reprints of the above report are available for medical officers of health on application. For the information of readers the constitution of the Medical Planning Comm]:ttee of the Society is printed on p. 59 of this issue. The Minister of Health, addressing the Congress of the British Medical Students' Association in London on December 18th, said, " The air is full of new ideas and new trends ; and there is one which we must all keep constantly in front of us --preventive medicine and positive health. The age-long function of the physician is to cure and relieve the sick. But it is right that as Minister of Health (not Minister of Disease) I should insist that you have a second duty--to prevent disease and point the way to positive health . . . . In your clinical work you try to make a diagnosis at the earliest possible stage . . . . Carry this a step farther, and you will find yourselves preventing disease before it has shown itself in any way. Perhaps the greatest handicap to the practice of preventive medicine to-day is not that we do not know how to prevent many diseases--which is still unfortunately true--but that the public does not take full advantage of the knowledge we already have."