The society of medical officers of health eleventh annual symposium the unity of medicine—The theory and practice of integration

PubL Hhh, Land. (1972) 86, 325-338

Session IV. T h e Alliance in Community Medicine A Panel Discussion W. G. H A R D I N G M,R.C.P., M.R~C.S.~ D,P.H.

~¢edical Officer of Health, London Borough of Camden C. D. L. LYCETT Md)., B.S.., M.R.C.S.~, L.R.C.P.~, D.P.H.

(~unty Medical Officer of ltealth, Wiltshh'e A. M, NELSON M,I'~.~ Ctt.B,: D.P.H,

Medical Qfficer of Health, London Borough of Richmond Dr Ne/soll t::irst of all, we have been, over the last day and a half, looking at the ~rfity of medicine. Michael Warren gave us a masterly account from the theoretical point of view. Mr. Lee followed this from lhe angle of" the management consultant a n d several speakers have dealt with the practicalities. Dr Harding is President of the Society of Medical Officers of Healttl, Vice-Chairman of the Public Health Committee of the B.M.A. and Vice President of the Faculty of Community Medicine. Dr Lycett.is Chairman of the Public Health Committee of the B.M.A. and I am at present Chairman of the Council of the Society. i would stress that in this afternoon's discussion we speak purely as individuals, but between us we obviously have a reasonable knowledge at" what the three organizations are thinking. Public health, as was men! ioned earlier on, has progressed fi'om a sanitary police approach, then. with the beginning of bacteriology and epidemiology, to the control of the contagions, ne×t to the sludy of the non-infectious diseases, and now to the era of social medicine, the personal health services approach with its study of morbidity and mortality and the delivery of medical care. We have been arguing and debating and shall continue to debate, what are the parameters of community medicine. There is one very small use of a preposition that I personally feel is important; there is medicine 'in" the community, and therefore a physician 'in' the community, our colleague the family doctor; or the physician o f primary contact, whichever you like to call it, and there is medicine 'to' the community, that is the physician to the group, the community physician. Dr Reid made the point v e r y strongly this morning, that the hospital is part of the carom unity. I think there was a time, two or three years back, when some of us were thinking in terms of medicine within the hospital walls, and medicine without the hospital walls, with the latter as community medicine, bu~ that is now disappearing and we are now looking at medicine as a whole. There will continue, ! hope, to be debate as to what is the content of community medicine. Dr Parry put the case for the epidemiologists, both from the infectious and the" noninfectious point of view. You heard Professor Cochrane yesterday mention that he wanted to see the statistical approach. Quite a n u m b e r ' o f people have been skirting round the

326

PUBLIC HEAL TH :VOL. 8;3 NO. 6

concept o f medical soc:,e!ogy. I Ibr one have always hem ~.l~evie,: th.a{ medk-me i:, a .-ocb~ science in its own right: no1. everybody accepts this poh-a o~ view. bui rea~y .tb.cre i., a c<,~.,-:e for medical soc.io!og~' wh.id! brings itll,t,,'; ~-in *he finality of commut~{~3 medk:ine. There is ~.he wkole concept of vulnerabiliay, the probDms of the de',ce,.ion of ',;u~.,>u, diseases and disorders and the various diseases o f society {>elf and th::: therapy,: ;.b,a, goe, with it. There is management., the in--fkshion-qhe m-~-c!igion, if yogi. iike. |s i, msr;?.~?.c,?:c~,~ by objectives, is it m a n a g e m e n t by resources? AI~ ! say i< this. z.hat t:,x t h e h deed.. ,.c s.i-a~i k n o w them', and therefore 1 approach this probabl3: ai~h a little bit of na.:i~ e c;.tr~n? ca u tio r" The Society is a scientific and educationaT; bod~,._ I am not gei~g to, N..~re .You bv rc~,~,~, ~ ";5'. out w h a t are the aims and objects o f the Society, It c,.~mains rt~~ only ~hc mcd~c¢,! o~icc~, o f health, as the Presiden'~ in his Presidential Addre>s sta{cd k~st Octobvt. bul "'the e t i : c r < . a very important group indeed. In the current issue ,..,f P~h/i,.. I:h".:,/d~ 11-wrc iq a. ~or-, k~-,cful and valuable contribt~tion---qhe Society of Medic~.~l Of!icer:; of }-~eatth. ~f Pa.~*, t":c>cr.:.', and Future.' It is by the General Purposes Commi~lee and Cotmcii, bin, h x~:.> x~'-i{~c~ mainly by Dr. E d g a r o f N o r t h a m p t o n and ,he Society owes him .,. cc~rl.-;iderab!e dcb{ I'm~ having so written it that it i~ well wortiz reading. I 'aotdd sugges~ :.o >,.~,.t ~i>:~ v,c -,v.mi Io interest others as welI in problems of the community. There are specialists in obstetrics, who are interested in. social ob~,;i.etric>, I},cre iltd tiW paediatricians w h o are interested in social paediatric>o thvse who are imcre~cd ir~ ~hc mentally handicapped and the mentally ilt and those u h o are intcrebted it~ ~I.,e cldcri~. These are the sort of specialties that have a commtmit} imcrc.,t. !'~'~e Society imxc beth pioneers in training and in education, the School t~ealti.~ Service Gro,,.p, and the MatcrIfi,~'~ and Child Health G r o u p in. parlicular have done a t r e m e n d m ~ :m.-.~m~t c,f in->c~vicctraining. The Society itself, has been a pioneer m the field of developmental paediatric-, ;.:,d the six-week course is very well supported indeed. The teaching group had a,~ (> er-su~,:-,,:cibcd c.ourse last year on applied epidemiology and ~he Menta! Health G r o u p ha.,, a!bo bccrt bu':y. The C o u n t y Borough G r o u p has pioneered some vet'., valuable cou,:ses a~d .
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community iq'.,y~ician. M.any of us have seen the Factiftv;s memotandum fi'om its l~dL;cation C o r n m i t i e e . !t is v e r y d e s i r a b l e d~.-lt such ~.iews s!~ould be form~.ihlted a n d t h a t t h e y s h o t l l d bc e x p r e s s e d , but wi~h re.<;pect to t h e a t i i h o r s , t h e y a r e a b o u t p e r s o n a ! views, d r y b o n e s w h i c h ca.,.mot be c l o t h e d w i t h flesh a n d live, u n l e s s t h e y a r e a c c e p t e d and put i n t o ell'oct, n o t o n l y by us, b m t:~y o u r c o l l e a g u e s in o t h e r branches of medici~m; e v e n in o t h e r p r o f e s s i o n s , a ~ d certai,aly t h e G o v e r m n e n t . T h i s brir,.gs m e :,.t o n c e 1:o w h a t h a s c o m e to b e c a l l e d m e d i c a l p o l i t i c s , a n d w h i l e o t h e r orga.,tiza~.io,~s, ii~c[udiqg oF course the Society, play an important part in m e d i c a l politics. t h e B . M . A . is, w i t h r e s p e c t I;o M r J e n k i ~ s a n d o t h e r s , t h e o n l y o r g a n i z a t i o n o n a l a r g e scale

representing all kinds of doctors. This is a f~mdamcntal point ab(mt the :g.~ .l.,-t. a~?d the need which it: lilts, which is not adequately filled otherwise. The Association can ti~erefore tm.dertake the kinds of cons'.Atations that ate needed, both to resolve and detine tlte attitude of the prof'ession to various que~ions, arid to consult with the Governmenl and other bodies and, one ~:.ould add, to deal with questions of pay. There is no clear boundmT in my opinion, between professional and medico-political questions. Y o n cannot separate medical politics from the professional considerations ,
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330

PUBLIC HEALTH VOL. 86 NO. 6

N o w finally, what is t h e relationship to be with the Society? I hope one thing should be quite cIear; there should be no confusion-of function. The Faculty basically is a setter of educational standards, a watch-dog, a pioneer in the promotion o f c o m m u n i t y medicine into the future. I see the role of the Society in part as that of a deliverer o f educational g o o d s - - d o not let us underrate the educational function o f the Society to which the Chairman has already referred---and then, jointly with the B.M.A. a representative of the profession. The Faculty will not and can not strive to be either. There are then separate functions. But there is, o f course, as c a n be seen here today, a great degree o f cross-representation as there will always be in a democratic body, which the Faculty is or will be f'rom now on. This gives a means of expression o f the wish of the majority, and the majority of the Faculty are in fact ~nembers of the Society. l |hink the members o f the Society who Jbrmed the provisional board and then the Board itself have been wise, not to worry about majorities. The Society could have collared by majority, eight-tenths o f the board membership. It was quite deliberate that we held back. because we knew that others must be made to feel that they are equal partners and their particular c o n t r i b u t i o n ~ a n d I particularly refer here to our academic colleagues---had to be held out to be esteemed and valued right fi'om the start. It is up to you from now on to see to it that it performs and operates and represents you in the way which you think fit.

Dr Nelson This, as I have said, the last session of the Symposium, is very m u c h an intbrmal thmily affair and the organizers felt that you should have an opportunity tO discuss and debate freely this interrelationship between the professional organizations involved. Dr S. J. McClatchey M. O.H. Windsor Could I start off with the concern that a number of us feel for the financing o f the Society in the future, whether we are going to get the support from all those who have become m e m b e r s o f the Faculty. Apart from that, a concern that I have tbund is that in so many courses that we have run, quite well attended courses, over-subsCribed so often, we find that only perhaps 50 ~/o who attended are members of the Society. 111 other words there.are a vast number of o u r colleagues, largely those in the clinical field, w h o m we help with our educational facilities, and on w h o m we will be dependent in the future for subscriptions. We find already tltat perhaps half o f our professional colleagues have j o i n e d the Faculty. [ h o p e I a m wrong, but I a m pessimistic as to whether all our clinical colleagues who can join the Faculty are also going to remain members of the Society, while so m a n y members who are working in the field are not yet members of the Society. HOW we can encourage them to become m e m b e r s I do not know, but it is the financial aspect that I am concerned about. Dr Nelson As the Society's Treasurer up until 30th September, I would say that its finances are to m y m i n d fairly healthy, although we still have t o exercise a considerable prudence, and there has been, over the last few years, considerable emphasis in the financing from the educational side, s o l t h a t w e c a n get a balance between income from our educational courses, our investments, and the subscriptions.

THE UNITY OF MEDICINE

331

Dr S..L McClatcher May I just add a little appeal? I can remember wheJl I first became a m e m b e r of the Society, it was due to lhe influence of my then Medical Officer of Health and I was wondering if lhe new chiefs could work in the same way on their staff'. Dr A. II!. Macara Univcrsio' of Bristol There is a serious question to which t would like to move if 1 may. We have been discussing the need for education and we have been doing this in relation to education of undergraduates, at post-graduate and at the continuing stages. What is not cleat to me is really exactly who is to do what, by way of advising and stimulating and encouragi1~g innovation and implementation of the necessary changes in education at all those levels in our specialty. To take undergraduate education first of all, we rely upon the General Medical Council to recommend in general terms what the content of the undergraduate curriculum should ..be. We have never had---and when 1 say " w e " 1 mean those of us in this discipline--a representative as such on the General Medical Council and therefore we might feel that we have had less influence in encouraging undergraduate medical schools to develop in the way in which they should have done in relation to the various elements ofpublic health and social medicine wlaich we now call community medicine. It's probably extraordinary that we have survived as we have in the absence of such representation. In the post-graduate field we have had the G.M.C. laying down, or proposing, recommendations because we have had our own committee or sub-committee and we have been fortunate in recent years in having Sir John Brotherston safeguarding our interests there. In the continuing education tield we have had the Society developing the function about which you have spoken. What is to happen from now on? Who exactly is going to collect ideas, to promote them, to sell them, and to try to encourage their implementation at each of these three consecutive levels, undergraduale, post-grad uate, continuing ? We have not yet had an opportunity to m a k e mature study of the document fl'om the Education: Committee of the infant Faculty, but from a quick glance through this one gets the impression that the Faculty will look after the recommendations on immediate postgraduate training and it may be that we can happily leave that to the Faculty. That still does not answer the question as to who is going to recommend and implement what is required at undergraduate and post-graduate level. Is this to be a function of the Society of Community Medicine as the successor to the Society o f Medical Officers of Health, and if so, how do we ensure that there is liaison between it and the new Faculty of Community Medicine which is responsible for ensuring that medical schools provide what is required in the immediate post-graduate educational field ? Or are some o f m y premises inaccurate, sir? Dr NeZron I would take it fl'om what Dr. Harding was saying and following on what Dr Macara is saying, that this is part o f evolution. If the Faculty spell s out the educational prescription, then I a,m sure it is in partnership between the Society and the Faculty that it will be dispensed. O f course one must also remember the academic units and the means of post-graduate education and so forth. The immediate off-the-cuff discussion and evolution o f the undergraduate ! would leave to D r Macara. I would accept guidance from him as to how to bring it in on the undergraduate field, because he probably knows m o r e about this t h a n m a n y of us in this room.

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Dr Macara I am concerned about how we mean to ~et our views across to the Deans not or~b' of the Bristol School but o f the other schools as well. H o w do we p r o m o t e what we/'eel to be the necessary content of undergraduate education? Do we do this through the Faculty o f Conununity Medicine, or is this going to concentrate primarily or exclusively on a postgraduate stage, or is this to be a functio~a of the successor to the present Society? Dr Harding We in the Faculty had to concentrate on utility first, let us thce it, and utility is to prepare for vocational registration. This perhaps is why we ma~~at present give undue prominence to our views on post-graduate qualification because n.o doubt, we as a Faculty will be expected to advise the General Medical Council about standards o f post-graduate registration if this is decided upon generally throughout medicir~e, as we would of course assume that in the formulation o f such policies, even if the Faculty were not to ask for advice it would be fi:eely lbrlhcoming if not from the Society then from various acade-mic bodies which Dr. Macara knows very m u c h better than I do. In the same way, the Royal Colleges, on their own and through their joint mechanism are advising on undergraduate medical educatioJ1 and I have not the slightest doubt that the Faculty must do this. You do not start rearing a child when he is a late adolescent. The most deplorable things might have happened by then, a n d so whilst this has been pushed into the background at the moment, 1 do see the Faculty also as the academic body to advise the G.M.C. and to advise academic bodies in general on undergraduate education. Again no doubt it will seek advice and whether it does or does not. advice will be forthcoming. In continuing education 1 see the role o f the Society as of far greater importance than that o f the Faculty. We have taken, as it were, reserve powers to found lecturerships or whatever m a y be appropriate. This is really s o that if in five years time we wanted to ask Dr. Macara to give a lecture in Bristol, a n d . t o p a y him live guineas, we might not be ruled out of order by the Charity Commissioners and so have to pay it ourselves. Doubtless the market price by that time will be well over five guineas. In that field the Faculty does not at present envisage this as one o f its main centres o f activity. Dr Macara This is very helpful and what I hoped to hear. ]n fact this shows that there is a co~tinuing function of fills Society in the continuing education field which is in facL o f co'urse, in terms o f total quantity, perhaps the greatest, because o f the need for continuing professional courses o f various kinds. Dr L~,cett I only want to m a k e the point that I hope that a feed-in from other branches o f the profession will be thought o f in connection with the education o f the community physician, and o f course in connection with student education as well as post-graduate education. 1 would even like to think that the feed-in to these other branches of medical education would come f r o m c o m m u n i t y medicine, and I w o n d e r how this is provided for? The B.M.A. m a y have a part to play in it. but probably there are other academic bodies which m a y have a greater one.

TI:tE UNI-[Y O F M E D I C I N E

333

Dr ltardin,,, O f cotlrse, the Central Council for Post-graduate Medical Education is a body which combines the various interests and disciplines in mulli-diseiplinary discussions and I think the B.M.A. is ofiicially represented on that body. Dr Macara The corn.reunify medicine discipline will be represented, will it ~ot, on tile Central Council through the Vaculty? Will there not be a representative of the Faculty o f C o m m u n i t y Medicine on the Central Council I\~r Post-graduate Medical Education ? Dr' Ita;dil1.e At least by lhe I:acu(ty. l)r 13. G. Gret'on-t~"ats'o~z Cozmtv Medical O[/icer o[" Hea/th, Cke.vh#'e 1 only wanted to ask a couple of questions, ttas any thought been given to having any consultations with fellow associations like the Association of Industrial Medical Officers, and lhe Sociely of Social Medicine. with regard In a sort of federation and working in association wilh them in the fulure? Also what about the future of Commzlltit.l' MeeEcine and tile journal Puhlic ttealth; have we thought a!:~,ut widening their horizons in any way'? 19r ;Vc]);otl

Thanks l\w the two suggestions you made, Dr Grelton-Watson, I have noted lhem. l do llOt w a l l t to prgiudge Dr Anderson's Working Party and what he is going to suggest to ihe Society. I am r~ot sure whether Miss Lewis--the new Editor of Cmmmmitv Medicine wishes Io make an), poin~ or not, I would not have though! so at lhis stage, but yotl have heard the cmmnent from Dr Gretton-Watson. And for Public IIealth weJl I do know that this again is part o f our consideration which will be actively pursued in relation to the journal. Whether Dr Kershaw wants to say anything at this particular point in time or not 1 don't know.

Dr J, D, Kershaw Editor, "Public Health" Since you suggest that 1 might comment, as regards the journal we are trying to cast our net even wider and we are meeting the problems now of exactly how wide we can cast tile net, how m a n y disciplines and h o w many interests we can possibly comprehend in a journal which is being published only half a dozen times a year. Certainly I w o u l d agree from the point of view of the Editorial Board that the more widely we can think and the more disciplines in the whole community medicine field we can interest, the better fl~r all parties.

Dr J. Stuart Hor, er Medical Officer o f Health, London Borougk of HillhNdon I am not sure whether this is the stage to introduce a revolutionary note. ! must admit 1 am a little bit concerned by the impression that Dr. Harding has conveyed in nay mind about

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the Faculty. We have been assured that the Society is going to retain its present role. I am now left in some doubt as to precisely whe~'e the Faculty is going. The revolutionary nole I wanted to put t\~,rward was to say that most o f us find it difficult, I think, to get involved very actively in m o r e than perhaps two or three professional organizations and it would seem that we have them :represented in front of us today. Certainly to judge by the lneetings in the L o n d o n area that I have attended khat would certainly seem to be the case. The problem as 1 see in the future is going to be the one o f bringing various professional disciplines together, professional disciplines concerned in their own particular areas, but coming together in a professional relationship, perhaps as a District Management Team and I would have thought wanting opportunities therefore to come in at other stages. 1 am particularly concerned about the nurses. It seems to me that the health visitors, about w h o m we heard anxiety this morning, and c o n u m m i t y nurses generally, are not in a particularly encouraging position in the paper that we have seen from Mr. Lee. I am just wondering how these magnificent new directors of nursing services that we have all got are going to relish becoming principal nursing officers of c o m m u n i t y services, which seems to be the rote which is envisaged for them. So the revolutionary note I w~mt to put is perhaps, should not the Society be looking not nlainly in terms any m o r e of its medical educative function but rather in terms of bringing other professional discil~fines in? Certainly tttc dentists are in already; what o f the nurses, dare I suggest the social workers?

Dr Nelson Dr H o r n e r has been, as he usually is controversial, but 1 think this has got to be said. and this idea must be put forward, and I am grateful to him for having said it. Yott may gill violently disagree with it, but that does not matter, it has been put forward.

Dr H. E. Mah" Medical Officer of Health, Borough qf Gillingham It is a family failing to write minority reports. I have been on the Worl
Dr Dunlop DepuO' Medical Qfficer of Health, Hull. I in some ways agree too with Dr. Mair, I feel the Society must change and change radically, because the writing, is on the wall for the Society now that the Faculty has been formed.

T H E UNIT5;' O F MED1Ct NE

335

The faculty has got the strongest ca,n'ot to attract membership in that eventually ever? ~,ne who is in conummity medicine will more or less have to be a menlber with the magic letters M.F.C.M. or F.F.C.M. after his name. The time is approaching when membership of the Faculty.. the B.M.A.. and the Society, together wi~h the G.M.C.'s regislration fce and subscription to a Medical Protection Society, will cost a total of about £100 a year. Membership of the Facully, registration and the subscription for protection will be essential; the only optio:l will lie between lhe B.M.A. and the Society and I would not like to guess which will win.

Dr J. R. Prestot: Meclieal Officer cf Health, Borough of Sutton CotdfieM I have been a member of the Working Party of the Society which has beea mentioned a nd it is interesting to hear this discussion because it is almost a reflection of the discussion thai took place over a number o1~"meetings in the Working Party. We are all very conscious of the diffictdties which the Societ~0will obviously run imo unless it broadens its base. The question really is whether we go outside the medical profession, whether we go oulside community work you might say, in regard to membership, and there are various schools of thought t can assure you that the Working Party has given a great deal of attention to this. The Working Party was very concerned about the question of cost, because we did in fact have in mind the subscription to the Society, and the p~ssibility of" alterations in it. A lot of money is obviously going to be paid out by members of the Society, th.c B.M.A. and so on, for services which might have a great deal in common. I think the Working Party had very much in mind what the Society could Offer at regional level, or at area level. In some areas meetings are very poorly attended, As a Working Party, we have to put t\~rward suggestions which might sthnulate attendances at meetings. We must give something at local level, or at Ieast at regional level, and there is no doubt that if we could do so, we might retain and expafM our membership. If we brought in other disciplines, either medical, or community medicine, or perhaps even at lay levels, or social work levels, there would be a change in character which might attract memberskip. I think changes have to come, and certainly the Working Party hope that the General Purposes Committee wilI give very carefld consideration to their thoughts. I trust that they witl also release the t e x ( o f the Working Party's thoughts to the Society as a whole, so that they can consider it as well.

Dr HardO~g The problem I think, vis-a-vis the Horner/Mair programme, is that the nurses very strongly emerge at present as a separate force and do not want to be associated functionwise with different: branches of the profession. Certainly the social workers, in their whole Seebohm philosophy and their generic training, and the generis deployment wh_ich some of us must find most awkward to deal with in terras of providing a service, in this philosophy are unlikely to branch out and come in with us. I think our first rate opportunity must be to bring in other parts of con~munity medicine which are at present either not represented at all such as the central Civil Servants and the hospital services and, dare I say it, our academic colleagues. I am a little pessimistic over this wonderful vista of all com~ected with the community in one way or the other forming one professional society, regardless of protbssional status. I wish it were possible--~I do not think it is,

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Dr Lvcett I ~ o n d e r if we mighl actually lose membership of doctors if we did ~his? No one has asked whether doclors now in the Society would want to stay i~ il if il became a social worker, nursing etc. body. I would like at this point to p r o p m m d my heresy which I do p r e p o u n d fi'om time ~o time al meetings when these sort of questions come up. First of course, I would agree with those present in wanting to see the Society cont}nue successhHly as the Society. I think all of us nave long-slanding loyalties to the Society must feel this bul there is o f course lhc possibility o f amalgamation with other medical bodies, or another medical body. I said earlier that the B.M,A, and the Society were both considerh~g their constitutions, M~ich has probably never happened before at the same time and probably never will again, t do not k n o w what the constilutional future of the B.M,A, is going lc be, because the reporl of Sir Pau! Chambers has not yet been made available. I do not think it is impossible, for instance, that there will still be romn t\~r a u t o n o m o u s commitlees i~ the B,M.A, As ~ou know, the C.C.H.M.S. and the G.M.S. committee are now auto~lolltous, although {he Public ttealth Committee is not, and have certain scope within the Association which x~e have not got. It might strengthen both the B.M.A, Public Health side, and xsl~al is represented by the Society if in fact they were one. I am saying this in a purely personal capacity.

Dr Elizabeth White, University of Bristol Can I just point out that one way Dr. Harding will not gel academics imo the Socict5 o f Medical Officers o f Health is by uniting them with the B.M.A. I do not really want t~ bring up political issues in this, but there are some academics belonging to ~hc Society ~I" Medical Ofticers Of Health at present; Dr. Macara and myself are ~wo of them frorn Bristc, I. Some academics equally no longer belong ~o the B.M.A. for various reasons and I think this is one way of making sure you have no, or very few. academics in the Society of Medical Officers of Health.

Dr Lycett I would like to saY to that, that of course many academics do belong to the B.M.A. I do not k n o w what the statistics are of the academ.ic membership of the B.M.A.. bu~ they mus! be high and the B.M.A. does concern itself with academic questions. I think lhis is a poin~ that ought to be ventilated. I ana very much struck in going a b o u t flae country, as well as in my own branch and my own part o f the country to tind that as regards public health doctors, as now understood, the same people are the local branch of the Society, and the regional public ihealth doctors under a B.M.A. hat. ln m a n y cases they have meetings, at times on/the same day, and they sometimes even get the nteeting confused but it does ~_ot seem to .matter very much, I think we are some way along this path already.

Dr Hadden Very briefly, M r Chahanan, I have been a devotee o f the Society for many years, so I hope that I say will not be misunderstood, I hope Dr LycetCs suggestion will be very seriously considered. One wants to see the good things of the Society remaining, and perhaps lhe good things are the backing we get from being part of the medical profession. Perhaps, now we have ore" Faculty, we could come m u c h closer to the B.M,A. In saying that I am a devotee o f the Society I concede that m y relationship with the B.M.A. is fairly cool, but this does not prevent me from supporting Dr Lycett.

T i l t ; I.:NITY 0 1 Mi t'dCl,'xl:

3V"

l).," Ld'cc~t One of the sad things m my view ab, ml lhe B.M.A.~ role is the rckui~c decline ,q' !he dixisions, lhe grass r ~ t s of the B.M.A. It ought Io be possible. ~ilhin lhc B..M \ . ~,: ,,.,c~ everbody together m ordinary divishmal organizatim~. Anx COl?slituliona[ challgc l~llt!,l in\'ol~c h~oking.. ~1I Itov,' w e ca.~l ~.~'el. all bra.',-tches o f t h e pr~q'ession tc,gelhcr in the iicM. t h e cof?tribution made from the public health side in Ihi> way could be d~uhlx ilnptwlant {~, Its at t h e p r e s e , ! t time.

Dr I:~ Stara'g, t'rm{'/pa[ ~'~toO'teal (?[)Tccr. I_,~md, m f~,r,~u.:,h of B~'.vk' v tn l'act we ah'eadv have n precedent o~'mixing the prolessi,ms. The Mc~ttat Ile~ttt} (ir,,~p has, l'nm~ the xer\' inception, had psychiall'isls h', its gn,up, and as you can sec ~e haxc survived, even wilh psvch{atrisls, in our em'°u[~Dr ..4. I~'. Mc!.u*osh, Xorlh Ridi:JA' .'.?f Yorkxhi:'~:* C,~imlv Cmtnci/ The growlh of posl-graduale cemrcs has had a ~e:y great effect m,t ,)niy ,m tLN't.A. meetings, ~hich have tended to become more social, but it seems to have had an cll~'ci l,,o orL meciings [ I} [ ] tl~e Society 1 noticed lhal some e l the regional meelings ' : Inecn ponrly attended, excepl the ntost recent ~me h~ my area when the Presiden[ came to ~i,dl us and tell us abol,i the 1-:acuity. when we had an absolutely fi.~ll house. It may he diitJcuIl *~ persuade people to iind the belier parl o[" £100 and belong to the S,~ciet.~ as well. and I feel that it is qtlile likely that there will be eventually a popular demand f~r regional edtwal[onM activhies p,:om~ted and sponsored by the Faculty rather than the Societ\.'. •

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t?.!" .4. Gatherer, ,~h'dk'al Officer el" Itcatt& CotmLv B,:~roue,h ~ / Readit~,k, ICs very dRticult for us really to participate in the discussion, because those of us ~h,~ have not been involved with Sir Paul Chambers and lhose of tls ~tot on the Working Parl;' of tl~e Society are really in the periphery asking t\~r inl\-,rmalion as soon as possihh:. Is there already in existence a small informal mechanism ~¥hereby l]~e three grm.ips repotseined at the front at th.e m.oment will be keeping in touch in ll~e immediate l'tttttre, during what is going to be a very important time tk~r all of us. so that at least the Society, tile B. M..,~.... and the Faculty know ~ h a t each other's evolving thoughls are, and secondly it is possible f,~r some altempt to be made at brief detinitions of some of the terms ,~hich are already being bandied around so much. We now have a Faculty o f C o m m u n i t y Medicine; are ~se 1o u~e the phrase " c o m m u n i t y physician", or to abandon that and use °'specialist m conlmunitx reed ici he". Dr Nelso, Terminology m a y well be a very appropriale debating poinl at some other meeting ~,f the Society or some other group, and I think it is a very good and a very wise thing that \~c should start to get down to wh.at is lhc coJrm'.,unily physician, or specialisl in c,m~munity ~nedicine. 1 w o u l d like to thank Dr Harding and Dr L vceu f~r coming in and at ~he lasI, on the last quarter, talking to you. Also I have been referring right through today to nay associates t~ lhe organizers, a~d t must thank them, Dr Sandy Macara, arid Dr. David Rowlands. This is tile last time. unfortunately, that Dr Rowlands will be associa.ied with the Symposium. because he has h:ft

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PUBL1C HEALTH VOL. 86 NO. 6

the Reading Health I)epartment to be in the Student Health Service at Reading University; we are indeed very grateful to him over the years during which he has been closely associated with the Symposium. D r Stuart H o m e r has now joined ~:he Corml~ittee and I am sure you will be seeing and heating m o r e o f him in tile Annual Symposium.

Dr ltarding I said in the first session that D r Nelson was not only the Chairman o f the Society, but that as a little side issue he was running a Symposium. In fact he has done m o r e than 1bat. This is the latest of a whole series of successful sy~nposia. They have always been successful in content and lhis time it was particularly successful also in audience. We are very grateful to him, and if, as I suspect, this is his last Symposium for the time being, he has done a tremendous job for us. I am afraid 1 said I was only going to talk for half an hour, and I see I appear lo have talked tk~r about fifty minules. I a m sorry about that, but that is roughly what is in the hypothesis that is now being tested, and I would be very interested--if it hasn't been at too high a level of abstraction to stimulate good questions--to answei~ any questions in the discussion about it.