Re-organisation of medical services

1941

PUBLIC HEALTH

from a simple erythema to a deep necrosis. T h e " gas " burn, however, has two special characters: that the necrotic process tends to spread during the first few days, and that the exudation is remarkably profuse. Treatment varies according to the area affected. In the " open " areas such as the trunk and the larger limb surfaces early application of amyl salicylate has given good results by reducing exudation, relieving discomfort, and limiting the extension of the burn. The undiluted liquid is applied on gauze and the dressing is changed once or twice daily according to the amount of exudate. After some days, if progress is slow, the amyl salicylate may be replaced by one of the milder coagulants such as the triple dye. In " closed " areas, such as the perineum, the use of amyl salicylate is not practicable ; the most satisfactory treatment is irrigation with saline or eusol. The hip-bath is very comforting as it relieves the oedema and extreme irritation. For lesions of the face raw cod-liver oil gives satisfactory results. Amyl salicylate is not suitable as its vapour is injurious to the eyes. Blisters caused by mustard gas should be evacuated, but it is not necessary to remove the epithelium. General nursing is of great importance : the patient should be protected as far as possible from irritation from clothing, and the use of full-size bed cage and modem methods of slinging is recommended. It is too early to indicate whether the use of sulphonamide preparations will be of benefit, but their effects will no doubt be reported if gas casualties occur. Cautious local application of sulphanilamide powder should have some influence in the prevention of sepsis, but the blood picture, especially the number of white cells, must be watched. It need hardly be added that a constant watch should be kept for the onset of albuminuria.

systemic effects which this gas produces render it a potentially dangerous weapon for a surprise attack. Liquid lewisite produces an immediate stinging sensation on the skin, and its rapid penetration renders the usual remedies of little avail after the first few minutes. After penetrating the skin lewisite forms a reservoir capable of distributing poison throughout the system. In the eye the liquid causes immediate pain and spasm, with profuse lachrymation. An acute conj unctivitis follows in a few minutes, with oedema of the lids, intra-ocular pain, and photophobia. In a matter of hours there may be irreparable damage to the cornea. The vapour of lewisite is fortunately much less violent in its action, but the damage is rapid and preventive treatment must be begun at once. Water is the most accessible preventive and no time should be lost in washing the eyes and any skin affected. When the patient reaches hospital the injury is fully established. For the eyes warm normal saline followed by liquid paraffin are probably the best remedies, and good experimental results have been obtained with albucid. On the skin the immediate application of plenty of hot water is the best preventive. When the injury is developed, application of hydrogen peroxide (20 vols.) to the affected skin relieves the local condition and hinders the absorption of the poison. The skin is first washed, and then the hydrogen peroxide is applied on a gauze compress. This is effective from a half to one hour after injury.

RESPIRATORY LESIONS Severe laryngitis occurred in, a third of the cases, but • ulceration of the vocal cords was reported in only 1"4 per cent. The lower tract was involved in 25 per cent. of the cases, varying from bronchitis to a rapidly fatal pneumonia. In the pneumonic cases the principal complications were acute bronchiectasis, abscess formation, empyema, and pneumothorax. These were the result of focal necrosis of the bronchiolar walls and of surrounding areas of pulmonary tissue. Good nursing is all-important. Frequent cleansing of the mouth and nose is essential, and the patient must be encouraged to effort in bringing up sputum. Oxygen was tried for a time, but abandoned because it caused great discomfort to the patient without any compensating advantage.

Before the war great concern was being expressed both among doctors and among the general public at the inadequacy of our medical services. Built up piecemeal, as they have been, they inevitably leave big gaps and, on the other hand, result in occasional overlapping. The rising standard of public welfare has resulted in the institution of new forms of public medical service, so that it is now true that the greater part of medical practice is public ; as much of it is on a part-time basis there is not yet a majority of the profession on a full-time salaried basis. Owing to the necessity for progress general practitioners have for the most part abandoned the old complaint against the " encroachments " of the public services ; as a matter of fact the most considerable recent " encroachments" have arisen, not from extensions of the public services, but from the Hospitals Savings Association and changes in hospital practice which have been necessitated by economic conditions.

Lewisite Little is known of the mass action of lewisite on human beings, but if the people are so trained that they carry their respirators there should be no danger of catastrophic results from its use as a weapon of war. It differs from mustard gas in several respects. In the first place it has an immediate, powerfully vesicant action and is therefore less insidious than mustard. In the second place it is less stable than mustard, and is readily hydrolysed by hot water and by alkalis. On the other hand its rapid penetrative action and the grave

R E - O R G A N I S A T I O N OF M E D I C A L SERVICES* By VYNNE BORLAND, B.SC., M.B., CH.B., D.P.H.,

Medical Offtcer of Health, Bethnal Green.

Some Problems Apart from the problems of domiciliary practice, the reduction in the charitable income of the voluntary hospitals has created an increasingly acute problem. This, and the need for the co-ordination of the hospital services, has led to much useful work by the Nuffield Hospital Trust and other bodies, though they have not * Paper read before the Metropolitan Branch of the Society of Medical Officers of Health, 33

PUBLIC HEALTH yet reached any adequate solution of the problems raised. These problems may be stated briefly as follows : 1. The inadequacy of the National Health Insurance scheme in its failure to provide consultant, hospital, and ~luxiliary services such as dentistry, nursing, massage, etc. 2. The large part of the population, including professional and other non-manual workers, who cannot afford adequate medical service on the present fee-paying basis. 3. The separation of general and consultant practice from the public health side of medicine. 4. The decline in the charitable income of the voluntary hospitals rendering inevitable public subsidies and control. 5. General discontent with present lack of organisation among medical services and failure effectively to use modern scientific knowledge and facilities for the promotion of health. Medical officers of health by the duties* laid upon them are intimately concerned in the solutions offered to these problems. It is obvious, however, that the latter are bound up with other social and political issues which the upheaval of the war has brought into prominence, such as the low standard of living of large sections of the population, the need for physical reconstruction of many of our towns and the town-planning and housing problems that arise therefrom, and the need for reconsidering the units and functions of local government. While these matters raise questions of policy with which it is neither necessary nor expedient for medical officers of health to deal, it is important that both the Government and the public health service should recognise the extent to which they affect the health of the community and therefrom the work of public health administrators. Dealing specifically with the problem of creating a national health service imbued with the positive outlook of the modern public health service, the subject may be divided into the following parts : (1) domiciliary service ; (2) consultant and hospital service; (8) areas and methods of administration.

Domiciliary Service Before the war it had been generally recognised that a considerable modification of the National Health Insurance scheme was urgently necessary in order to render it more adequate as a health service and to extend its provisions to a much larger part of the population. Owing to the changes which have taken place since the war, particularly the uncertain position of medical practice, the lowered incomes of a large section of the middle class and the imperative needs of efficient national organisation to face the tasks of reconstruction, the problem to be solved has assumed much greater dimensions. It seems most improbable that it can be satisfactorily dealt with by any mere extension of the 1911 insurance scheme. Sir Arthur Newsholme, in several contributions to this problem before the war, foreshadowed the possibility of a state medical service, and there are substantially increased reasons for thinking that this has now become both a practical and a desirable way of meeting the situation. As he points out in The Ministry of Health, a considerable part of the medical * Ministry of Health Memorandum on Duties of Medical Officers of Health (1925)--Section A (General Duties), pp. 4-6.

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NOVEMBER profession is already engaged on public duties although most of them are on a part-time basis. He furthermore points out in Medicine and the State : " In private medical work the practice of paying in accordance with number of consultations and visits is a handicap to satisfactory medical care,whether hygienic or clinical. The same consideration makes it difficult to resort to specialists in doubtful and complicated cases, except where provisions to this end are made by voluntary hospitals and public authorities. The general practitioner frequently undertakes far too much work in a limited time to be able to do it well. For the above reasons modifications of private medical practice are needed for all except the rich." These conclusions, reached in 1982, would undoubtedly be stated in more emphatic terms to-day. FORM OF THE SERVICE It is nearly as important to decide the form of a state medical service as the principle. The growth of " the firm " in medical practice is a recognition of the value of the team. What the public health service has brought more prominently to notice is the facility for efficient service provided by suitable premises, equipment, and auxiliary staff. It is in the combination of these two ideas--a team of full-time doctors working from a public health centre--that the most satisfactory form of state medical service is likely to be found in all urban areas. For rural districts a different form of service would be provided. It is assumed that each health centre would be equipped with all necessary diagnostic and simple treatment facilities and would be staffed with nursing and clerical assistants. Other auxiliary services such as dentistry, massage, and hydro- and electrotherapeutics could be provided either at the general health centre or at special centres, according to the circumstances of the district as regards distribution of population, etc. In accordance with the common practice of the public service the doctors and other personnel would be paid on a full-time salaried basis commensurate with their qualifications and previous experience, would enjoy regular hours of work (evening and week-end duty by rota), holidays, and superannuation. The doctors in the health service would have the right to obtain for their patients any consultant advice or specialist treatment that might be required. The local units of the State Medical Service would be co-ordinated with existing branches of public health, such as maternity and child welfare, tuberculosis, venereal disease, mental disease, etc. ; these would be regarded as specialist services which in turn could arrange with the general practitioners concerned for any necessary domiciliary observation and treatment. To assist the medical officer of health for the area in the organisation of the domiciliary service there would be assistant medical officers of wide experience in general practice.

Consultant and Hospital Service In order to ensure that the services of consultants may be readily available as part of a national health service, it is necessary for a large number, if not all of them, to be engaged on a salaried basis. Whether such consulta.

1941 tions should take place at the patient's home, the local health centre, or at the hospital to which the consultant may be attached, would depend upon the nature and circumstances of the case, but in any event it is to be noted that the inclusion of all concerned--doctor, consultant, hospital staff--in one national service must considerably facilitate the making and carrying out of such arrangements. It has already been indicated that the tuberculosis and other specialist services already established as part of the public health service will continue so to act. Gynaecology would, of course, be closely associated with maternity and child welfare. The Nuffield Hospital Trust has already done much useful work in supplementing the efforts of other bodies to keep the voluntary hospitals going and to co-ordinate them with the public hospitals in the same area. It must be frankly recognised, however, that the attempt to replace by subsidies and insurance subscriptions the falling charitable income of the voluntary hospitals, and thus perpetuating the artificial distinction between them and the far more numerous publicly owned hospitals paid for out of rates and taxes, is a futile policy. Inevitably if we are to get the best results from existing resources we must have a unified hospital service. It is essential that the decision on this point should be reached soon in order that the post-war reconstruction of hospitals and their replanning, which will be necessary on a large scale, may not be delayed by doubts as to finance or control. The question is largely one of adding further general and special hospitals to the majority which already exist under public ownership and control. It must be remembered that the hospital control branch of public health has acquired valuable experience in this field of administration as a result of the considerable expansion which followed the Local Government Act 1929.

Local Administnttion The war has directed urgent attention to some weaknesses in the present areas and methods of local administration which were under consideration long before the war. Like almost everything else British, local government areas are the product of historical tradition and, as such, lacking in formal logic. They are certainly inapplicable to many large-scale functions, such as hospitals, transport, and town-planning. This irrationality of area applies with special force to the Metropolitan Boroughs and the contiguous boroughs and urban districts which make up Greater London, with the added complexity of allocating functions between the county councils and the local authorities. The extent of the problem is not even limited to that of area and function, because war conditions have emphasised what was previously insufficiently recognised--the need for greater co-ordination of policy between neighbouring authorities in large areas of the country, and for some more satisfactory adjustment of financial relations between local revenues and national exchequer grants. Regional organisation had been mooted long before the war and for other purposes, but war necessities have compelled its adoption for many aspects of civil defence. It does not need much prescience to suppose that regional organisation of some kind is likely to enter into any national health service.

PUBLIC HEALTH GREATER LONDON Leaving on one side the general problem as it affects the country at large, it may be simpler to consider it in relation to Greater London. It may be taken for granted that the present London County area will not survive any revision of London government. The only question will be whether the new area shall be that generally described as Greater London (roughly corresponding to the Metropolkan Police District), or whether it should be extended to include more if not all of the Home Counties. Within whatever the regional area may be, it is similarly probable that changes will be required in the local areas, which now range in size and character from Holborn to Wandsworth. In the provinces k has been found convenient to link small urban district councils together to make a more suitable administrative area. This course might advantageously be taken in London to bring about some greater degree of similarity of size and population between the Metropolitan Boroughs, a task facilitated by the wholesale shifting of population and destruction of property resulting from the war. If we may contemplate a Greater London region with about sixty or seventy local authorities in the area (say some twenty of them in the present London County area) and a regional authority (constituted in what manner does not concern this argument), we may consider the type of health organisation that might be appropriate. The regional authority would have its medical staff, presumably in large part transferred from the London County Council and probably some from the other county councils bordering on London, under the general direction of the Regional Medical Officer of Health. REGIONAL AND LOCAL DIVISIONS The relative functions of the regional and local health authorities should in broad principle be based on the distinction between residential and domiciliary care. The local authority should have the general supervision of the health centres and their personnel, the maternity and child welfare and school medical services, tuberculosis dispensaries, sanitary and food inspection, etc. The regional authority would control the hospitals and consultant service and housing. A considerable measure of government control and guidance, both in general policy and in practical administration, will be inevitable, particularly in the early years of the inauguration of such a big development of public medical service. Whether in this control and guidance the regional organisation of the Ministry of Health will be employed may depend on the extent to which the principle of regionalism is carried in the reconstruction of local government. If in fact there is a regional medical officer of health responsible to the regional authority (possibly a kind of federal body made up of representatives of the local authorities in the area), there does not appear to be much point in a duplicate regional organisation of the Ministry of Health. The chain of direction and guidance would proceed directly from the Chief Medical Officer of the Ministry through the regional medical officer of health to the local medical officer of health. In any event it is of particular importance that the medical personnel, both in the regional

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PUBLIC HEALTH offices and in the central department, should possess such qualifications and experience as may enable them efficiently to fulfil these functions. It is especially necessary that this control should be infused with the public health outlook and informed as to the practical difficulties of local administration; the closest liaison at every point in the service is equally essential.

A Complete Service There are, of course, big financial considerations involved in any such national health service. Whether, however, such service should be paid for wholly out of rates and taxes as a civic right like education, or be partly so paid for and partly on some contributory basis, is a matter of general policy with which medical officers of health as such are not concerned. What is of practical moment is that the service should be a complete one and should be open to all who wish to benefit by it, irrespective of income or social class. No truly national and adequate health service can be built on any other basis. T h e potentialities of such a service can hardly be over-estimated. Not only would the curative capacity of medicine be greatly increased, but the closer contact of general practice with the positive outlook of the public health service should lead to a substantial prevention of disease. T h e opportunity for periodical medical overhauls for persons of all ages should be of great value in the early detection of morbid conditions, a factor of immense significance in the future treatment of such diseases as tuberculosis, rheumatism, and cancer. At present, a doctor, whether in the public service or in private practice, confronted by the medical needs of the patient before him has to pause to consider whether the most suitable form of treatment is really available, either because of the income of the patient or because such facilities do not exist in the town, neither charity nor public enterprise having provided them ; and there is no comprehensive health organisation to see that they are there. Incidental advantages such as increased facilities for medical education and research, availability of morbidity statistics planned on a scale hitherto impossible, would add to the tremendous addition to scientific knowledge and human weIfare which a national health service might bring with it.

Transition Scheme T h e great change in our medical outlook and organisation outlined above will obviously require some years to complete. This must occur when many other big tasks of reconstruction are being undertaken. At the same time we must face the fact that there are immediate problems of medical needs and medical man power which cannot and ought not to await the full inauguration of a national health service. It is essential that the main lines of the latter should be laid down now so that any temporary measures adopted may not conflict with, but may if possible, contribute to the final scheme, but there are some steps of an urgent character which should be carried out now. T h e shortage of medical man power which is being so acutely felt arises not only because the actual medical needs of the population have increased as a result of the war, but also because medical needs are in various 36

NOVEMBER categories and the personnel is organised in separate compartments. Having regard, however, to the common expression which sums up the character of totalitarian war " We are all in it together," there does not appear to be sufficient justification for the maintenance of many of these distinctions of medical services, particularly in the light of possible invasion. It is suggested, therefore, that it is very desirable that forthwith all doctors remaining in civilian private practice be invited to enrol as full-time public medical officers willing to join a war emergency national medical service. This would at once make possible a pooling of medical personnel for all necessary services, whether general practice, clinics, hospitals, first-aid posts, rest centres, shelters, or medical examination of recruits. There seems no reason why in areas where the R.A.M.C. and other medical services attached to the armed forces are not fully occupied they might not be drawn upon for civilian needs. T h e institution of the emergency service, with its guarantee of a minimum income, would greatly increase the mobility of doctors now compelled by financial circumstances to hold on to a much diminished private practice. It must be remembered that the abnormal conditions created by the war are likely to extend well into the period of peace and reconstruction, and therefore some rudiments of a national medical service appear to be urgently necessary, to meet both present needs and those of the transition period until a more permanent and comprehensive national health organisation can be created.

DISCUSSION ON DR. BORLAND'S PAPER Dr. Fenton thought that the fears entertained b y some general practitioners in regard to the conditions under which they would work in a State medical service were unwarranted. He pointed out that in a State service medical practitioners would get definite holiday periods, periodical opportunities for leaving their practices to undertake postgraduate study, and regular promotion based on merit. There would still be plenty of room for those who did not wish to enter the State medical service, for there would be many members of the public who would not avail themselves of it, just as there are to-day many who do not send their children to take advantage of the free State education provided in the elementary schools. He also agreed that there would have to be some revision of boundaries for local government administration in the Greater London area. With regard to the most efficient size for the local unit of administration, he felt there would be great difficulty in getting agreement on a basis of rateable value or acreage, and called attention to a report by Sir Harry Haward, late Controller of the London County Council, published in 1909, which indicated that a population of 250,000 provided a unit of administration which was more economical than a lower population or a higher population ; indeed, a population of a quarter of a million proved to be the optimum from the financial point of view. Dr. H. Stanley Banks disagreed with the view that the health and hospital authority should also be the local authority for the area. T o w n and County Councils, no matter how juch enlarged or combined, were not the bodies to which the whole future of British medicine should be entrusted. Their constitution and procedure were ill-adapted for this task. T h e y were too rigidly governed by Acts and By-laws designed for quite