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Scottish health services
PUBLIC HEALTH real one, for tile Society's journal is, on the one hand, its " ambassador " to outside bodies and on the other, the only medium through which many members who are prevented by circumstances from attendance at meetings can keep in touch with the Society's activities and with developments in the practice of preventive medicine. Moreover, the range of subjects covered by our journal's title becomes yearly more widespread. This is reflected in the multiplicity of items on our Council's agenda and by the far-reaching discussions at Branch and Group meetings. One of our aims in the future conduct of PUBLIC HEALTH will be at least to summarise the majority of papers read at meetings, and another to invite, from those who are best qualified to contribute them, articles reviewing new legislation or recent advances in particular aspects of preventive medicine. For further details of the future policy and control of PUBLICHEALTH, yOU are referred to the Report of the Journal Committee, published on page 27 of this issue. We hope at least that no specialist in the Society's ranks will be justified in complaining that his own subject is consistently neglected by this journal. For this first issue, Prof. W. W. Jameson has written a short " guide " to the new Public Health Act and this contribution should be of value to many members who may have contemplated with some alarm the prospect of having to master a new measure. Finally, an appeal. What Milton wrote of the Englishmen of his time should be equally apposite to our own Society: " There be pens and heads there, sitting by their studious lamps, musing, searching, revolving new notions and ideas . . . others as fast reading, trying all things, assenting to the force of reason and convincement." Let our members put their investigations and their theories on to paper and try their luck with us. The space available in PUBLIC HEALTH is subject to considerations of cost but there will always be room for a contribution which shows originality of thought or research. The Society is essentially dependent on the co-operative efforts of its members, and in the same way PUBLIC HEALTH must rely for its comparative success or failure on the practical support which is forthcoming from its readers. We expect outspoken criticism of the altered " make-up " of this n u m b e r ; we hope that the verdict will be favorable.
Scottish Health Services When the financial crisis occurred in 1931, the cost of local government was one of the subjects inevitably marked down for scrutiny. The Ray Committee, which reported on local expenditure in England and Wales in 1932, recommended quite a number of economies in public health 2
OCTOBER administration and ventured to criticise procedure in the scientific field which it was not appropriately constituted to appreciate. Perhaps for this reason the Ray Report is virtually dead. The corresponding committee for Scotland more wisely admitted its inability to make definite recommendations towards economy but advised instead that a comprehensive inquiry into the health services should be conducted. With this object the Secretary of State for Scotland appointed a Committee on Scottish Iiealth Services in June, 1933, which has now reported after three years of" deliberation. * There have been 88 meetings of the full committee and many meetings of subcommittees; evidence has been heard from 76 b o d i e s and 22 individual witnesses; visits have been made to different parts of the country in order to study the services in operation. Official public health was represented on the Committee by Dr. A. S. M. Macgregor, Medical Officer of Health of Glasgow, by Dr. J. L. Brownlie of the Scottish Health Department (later replaced by Dr. T. Ferguson of that Department) and by Dr. John Jardine, Assistant Secretary to the Scottish Education Department. Other medical members were Dr. Craig, Mrs. Chalmers Watson, Mr. Miles and Prof. E. P. Cathcart, who occupied the chair from April, 1935. The report covers 404 pages. The summary alone runs to 25 pages, and further abbreviation would be impossible. Here it is practicable to touch only on one or two of the issues which it raises. It finds that the public health system of the past has been fully justified by its results, but makes certain recommendations for amendment of existing law, e . g . , as to the prescription of food standards, speeding up action for the removal of nuisances and the control of tipping. It emphasises the need for much more effective education of the public as to health, especially in the purchasing and preparation of foods. It presses for open spaces and facilities for recreation as a part of housing schemes and urges that the housing code for compulsory acquisition of land should be made applicable generally to all environmental services. Interest, however, will be specially concentrated upon its discussion of the medical and allied services which occupies, with relevant questions of finance and administration, about a half of the Report. Stress is 'laid upon the need for a general practitioner service for all members of the class of which most of the adults are entitled to medical benefit under the National Health Insurance Acts. It is pointed out that much of the development of the *Department of Health for Scotland. Report of Col~nittee on Scottish Health Services. Cmd. 5204, H.M.S.O., 6s.
1936
PUBLIC HEALTH
statutory services of local authorities and the pressure on hospital out-patient departments are due to this deficiency, and that the efficiency even of these services is correspondingly impaired. " The statutory provision for general medical attendance should be extended to include dependants of insured .persons and, so far as practicable, others in similar economic circumstances, and all the statutory provisions for general medical attendance should be co-ordinated." " This co-ordinated service should be based, as far as possible, on the family doctor, who should act as health adviser and in liaison between the homes of the people and the statutory health services."
central department should have more say in the appointment of medical officers of health. Obviously, unanimity on such controversial topics could not be expected and the reservations, of which there are many, are perhaps as important as the main body of the Report. Everyone in the public health service must read this publication. Although it refers to Scottish Health Services there is almost nothing in it which has not a bearing on the present and future of public health in England and Wales. Indeed a similar enquiry south of the Border is overdue.
The Committee comes down definitely on the side of the panel system with remuneration by capitation fee, which it tentatively suggests should be at the rate of 6s. per dependant. It envisages some replacement of whole-time service in maternity, child welfare and school health by this general practitioner service, and returns more than once to the need of reform in medical education to make the general practitioner a fit adviser of the people in the preservation of health. His functions are to include attendance on all pregnant and parturient women on his panel as part of a new Maternity Service with or without whole-time. salaried midwives. Administration of the scheme should be in the hands of the larger local authorities, insurance committees being abolished. Additional contributions of 3d. per week per male and ld. per week per female insured person, with State subvention but no contributions by employers, are estimated to be required to finance the scheme. The appropriate sums are to be paid to the local authorities out of insurance funds, these authorities to provide amounts sufficient, for the medical care of the indigent non-insured through the same panel system. Each authority would be required to appoint a general practitioner service sub-committee containing representatives of insured persons and the medical profession. Recommendations are also made for tightening up the supervision of insurance medical practice and for assisting and advising its participants. The Committee recognises that even the larger authorities of Scotland are, in many cases, too small for efficient management of such an extended service and especially of the scheme of regional hospitals propounded in 1926 by the Hospital Services (Scotland) Committee, adopted by the Scottish Department of Health and again endorsed by this Committee. Their view, however, is that areas of local government will have to be considered for other services as well as public health and that, for the present, combination of authorities enforced by a strengthened central department is the best practicable alternative. They also urge that the
Maternity and Child Welfare It is characteristic of Dr. M'Gonigle's work and outlook that he should have chosen " Our Future " as the title of his Presidential address to the Maternity and Child Welfare Group. Readers will note that the r61e of prophet is disclaimed at the outset but read on and learn that whatever else the future may be it will not be dull. Those who know most of the achievements and difficulties of maternity and child welfare work will most readily accept this concept of the future as a fight for perfection and will have least difficulty in giving form and substance to those enemies referred to under the discreet abstractions of dogma and prejudice. For those who have maternity and child welfare at heart the future will not be otiose. It may fairly be said of this work that it blazed the trail of public health thinking, across the threshold and into the home. As is very well known, Dr. M'Gonigle has carried this trail into the larder and has there started asking awkward questions about the housekeeping money. These questions are fundamental. It is not a coincidence, but evidence of the interest that has been awakened in this subject, that three other papers read before the Maternity and Child Welfare Group and printed or summarised in this issue deal with various aspects of the question of nutrition. Lady Williams adduces important experimental evidence and careful argument in support of the view that there is a prima facie case for believing that high puerperal death rates in certain areas are mainly due to malnutrition. The conclusion towards which Lady Williams' work is leading is one which would, if firmly established, exercise a profound influence upon steps being taken to reduce maternal mortality, and for this reason it is necessary to emphasise that her paper is confined almost entirely to a record of experimetats carried out in certain areas hard hit by industrial depression and that no claim is made to a cast iron proof of her thesis. This caveat, however, is equally a warning against ;3
Scottish Health Services When the financial crisis occurred in 1931, the cost of local government was one of the subjects inevitably marked down for scrutiny. The Ray Committee, which reported on local expenditure in England and Wales in 1932, recommended quite a number of economies in public health 2
OCTOBER administration and ventured to criticise procedure in the scientific field which it was not appropriately constituted to appreciate. Perhaps for this reason the Ray Report is virtually dead. The corresponding committee for Scotland more wisely admitted its inability to make definite recommendations towards economy but advised instead that a comprehensive inquiry into the health services should be conducted. With this object the Secretary of State for Scotland appointed a Committee on Scottish Iiealth Services in June, 1933, which has now reported after three years of" deliberation. * There have been 88 meetings of the full committee and many meetings of subcommittees; evidence has been heard from 76 b o d i e s and 22 individual witnesses; visits have been made to different parts of the country in order to study the services in operation. Official public health was represented on the Committee by Dr. A. S. M. Macgregor, Medical Officer of Health of Glasgow, by Dr. J. L. Brownlie of the Scottish Health Department (later replaced by Dr. T. Ferguson of that Department) and by Dr. John Jardine, Assistant Secretary to the Scottish Education Department. Other medical members were Dr. Craig, Mrs. Chalmers Watson, Mr. Miles and Prof. E. P. Cathcart, who occupied the chair from April, 1935. The report covers 404 pages. The summary alone runs to 25 pages, and further abbreviation would be impossible. Here it is practicable to touch only on one or two of the issues which it raises. It finds that the public health system of the past has been fully justified by its results, but makes certain recommendations for amendment of existing law, e . g . , as to the prescription of food standards, speeding up action for the removal of nuisances and the control of tipping. It emphasises the need for much more effective education of the public as to health, especially in the purchasing and preparation of foods. It presses for open spaces and facilities for recreation as a part of housing schemes and urges that the housing code for compulsory acquisition of land should be made applicable generally to all environmental services. Interest, however, will be specially concentrated upon its discussion of the medical and allied services which occupies, with relevant questions of finance and administration, about a half of the Report. Stress is 'laid upon the need for a general practitioner service for all members of the class of which most of the adults are entitled to medical benefit under the National Health Insurance Acts. It is pointed out that much of the development of the *Department of Health for Scotland. Report of Col~nittee on Scottish Health Services. Cmd. 5204, H.M.S.O., 6s.
1936
PUBLIC HEALTH
statutory services of local authorities and the pressure on hospital out-patient departments are due to this deficiency, and that the efficiency even of these services is correspondingly impaired. " The statutory provision for general medical attendance should be extended to include dependants of insured .persons and, so far as practicable, others in similar economic circumstances, and all the statutory provisions for general medical attendance should be co-ordinated." " This co-ordinated service should be based, as far as possible, on the family doctor, who should act as health adviser and in liaison between the homes of the people and the statutory health services."
central department should have more say in the appointment of medical officers of health. Obviously, unanimity on such controversial topics could not be expected and the reservations, of which there are many, are perhaps as important as the main body of the Report. Everyone in the public health service must read this publication. Although it refers to Scottish Health Services there is almost nothing in it which has not a bearing on the present and future of public health in England and Wales. Indeed a similar enquiry south of the Border is overdue.
The Committee comes down definitely on the side of the panel system with remuneration by capitation fee, which it tentatively suggests should be at the rate of 6s. per dependant. It envisages some replacement of whole-time service in maternity, child welfare and school health by this general practitioner service, and returns more than once to the need of reform in medical education to make the general practitioner a fit adviser of the people in the preservation of health. His functions are to include attendance on all pregnant and parturient women on his panel as part of a new Maternity Service with or without whole-time. salaried midwives. Administration of the scheme should be in the hands of the larger local authorities, insurance committees being abolished. Additional contributions of 3d. per week per male and ld. per week per female insured person, with State subvention but no contributions by employers, are estimated to be required to finance the scheme. The appropriate sums are to be paid to the local authorities out of insurance funds, these authorities to provide amounts sufficient, for the medical care of the indigent non-insured through the same panel system. Each authority would be required to appoint a general practitioner service sub-committee containing representatives of insured persons and the medical profession. Recommendations are also made for tightening up the supervision of insurance medical practice and for assisting and advising its participants. The Committee recognises that even the larger authorities of Scotland are, in many cases, too small for efficient management of such an extended service and especially of the scheme of regional hospitals propounded in 1926 by the Hospital Services (Scotland) Committee, adopted by the Scottish Department of Health and again endorsed by this Committee. Their view, however, is that areas of local government will have to be considered for other services as well as public health and that, for the present, combination of authorities enforced by a strengthened central department is the best practicable alternative. They also urge that the
Maternity and Child Welfare It is characteristic of Dr. M'Gonigle's work and outlook that he should have chosen " Our Future " as the title of his Presidential address to the Maternity and Child Welfare Group. Readers will note that the r61e of prophet is disclaimed at the outset but read on and learn that whatever else the future may be it will not be dull. Those who know most of the achievements and difficulties of maternity and child welfare work will most readily accept this concept of the future as a fight for perfection and will have least difficulty in giving form and substance to those enemies referred to under the discreet abstractions of dogma and prejudice. For those who have maternity and child welfare at heart the future will not be otiose. It may fairly be said of this work that it blazed the trail of public health thinking, across the threshold and into the home. As is very well known, Dr. M'Gonigle has carried this trail into the larder and has there started asking awkward questions about the housekeeping money. These questions are fundamental. It is not a coincidence, but evidence of the interest that has been awakened in this subject, that three other papers read before the Maternity and Child Welfare Group and printed or summarised in this issue deal with various aspects of the question of nutrition. Lady Williams adduces important experimental evidence and careful argument in support of the view that there is a prima facie case for believing that high puerperal death rates in certain areas are mainly due to malnutrition. The conclusion towards which Lady Williams' work is leading is one which would, if firmly established, exercise a profound influence upon steps being taken to reduce maternal mortality, and for this reason it is necessary to emphasise that her paper is confined almost entirely to a record of experimetats carried out in certain areas hard hit by industrial depression and that no claim is made to a cast iron proof of her thesis. This caveat, however, is equally a warning against ;3