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The theory and practice of community medicine
Public Health THE
JOURNAL
OF
THE SOCIETY OF COMMUNITY MEDICINE (FORMERLY THE SOCIETY OF MEDICAL OFFICERS OF HEALTH)
Volume 88, Number 6, September 1974 The Theory and Practice of Community Medicine THERE ~S A remarkable dichotomy in community medicine at the present time. Although many people think that community medicine is a natural evolution from hygiene, preventive medicine, and public health, there is still considerable difference of opinion as to whether community medicine is closer to the practice of family medicine, whether community medicine has a greater affinity to the realm of hospital administrators, or whether the community physician will have the prerogative of being its sole practitioner. Even the foundation of the Faculty of Community Medicine of the Royal Colleges of Physicians of the United Kingdom and the change of name of the Society of Medical Officers of Health to that of the Society for Community Medicine does not seem to have resolved the situation. The editorial in the Lancet, "Who's for Community Medicine ?" (16 December, 1972) may make for amusing reading, but the first sentence has many implications. "Nine months ago the board of studies in preventive medicine and public health of London University asked its medical schools what they were doing and what they intended to do in their curricula under the heading 'community medicine'--or any other title which might be in use to cover this many-sided subject." The Todd Committee defined community medicine a s : . . . . . a term currently used with different connotations. In the sense in which we use the term, community medicine is the specialty practised by epidemiologists and by administrators of medical services--e.g, medical officers of local authorities, central health or other government departments, hospital boards or industry--and by the staffs of the corresponding academic departments. It is concerned not with the treatment of individual patients but with the broad questions of health and disease in, for example, particular geographical and occupational sections of the community and in the community at large. It embraces many activities and interests and includes doctors employed in different spheres, partly because the health services have developed in this country under several different authorities. It makes use of a variety of techniques and procedures which are not necessarily exclusive to it. Nevertheless the functions of all doctors working in this field are closely related; there are no intrinsic differences in their requirements for basic training or in the techniques they employ. Over the years a variety of names has been used to describe the traditional and important responsibilities (or certain facets of them) which we include in our concept of community medicine: among familiar terms in use are public health, preventive medicine and social medicine; confusion has arisen because they are often treated as synonymous.
262
PUBLIC HEALTH VOL. 88 NO. 6
It is apparent that this definition has been derived by a system of exclusion, with the result that some people still prefer the name Population Medicine for the practice of medicine e n m a s s e . This immediately raised the query whether community medicine is really the type of medicine as applied to groups of the community. If this were the case, then some people will undoubtedly regard community medicine as medicine practised outside the hospital, while others again would consider that hospital medical care should be within the ambit of community medicine. To confuse the issue even further, the committee dealing with "The Management Arrangements for the Reorganized National Health Service" (1972) gave an indication of its thinking on this subject by defining the role of the specialist in community medicine as "a specialist in community medicine must stimulate the process of integration. He will provide a service to clinicians, acting as an additional link between them, also as a link with the local authority services. He will assist clinicians by providing them with information on needs and advice on the effectiveness of alternative approaches to care." This certainly seems some way from the historical role of either a Medical Officer of Health or a Senior Administrative Medical Officer working in the hospital environment. The Hunter Committee reporting in the same year took a slightly different line, and it certainly highlighted a breakdown in communications between the two committees. As far as the Hunter Committee is concerned, they discussed the role of community medicine in the following terms : - - " T h e concern of community medicine with the general health of the population extends more widely than the direct responsibilities of the new health service authorities. Considering the organization of health care, community medicine specialists must also have regard to the service provided by central and local government agencies and voluntary organizations, and to the need for full cooperation with these bodies." The implications of these comments have been discussed in the professional and national press on numerous occasions, and recent informed comment suggests that the reorganization of the National Health Services is only the first stage in a further reorganization. The Faculty of Community Medicine has shed considerable light on some of the more obscure points, by rationalizing the community medicine concept into the components necessary for the membership examination of the Faculty. The four categories comprise epidemiology, statistics, social sciences in relation to community medicine, and the principles of administration and management. One would have thought and hoped, that would have been the end of the dichotomy, but it was not to be. What then does all this mean? Have hygiene, preventive medicine, and public health become fragmented, or have they all been unified under the banner of community medicine ? This is the question that we need to ask ourselves. If left unresolved, there is no doubt that future developments in community medicine will be stunted. In this respect the Society of Community Medicine has a particularly important role, making its greatest contribution by acting as the unifying scientific body. If Community Medicine is not to be regarded as the same for everyone, and it would be unrealistic to expect it to be everything to everyone, can we analyse community medicine in such a way as to determine precisely what the component parts are ? After all, there are many precedents for this. On the administrative planning side, there were SAMOs and County Medical Officers of Health. In the County Boroughs there were Medical Officers of Health, and then there were the Medical Officers of Health of divisions. Practice
If one hopes to see the future practice of community medicine in action, I think it is quite salutory to compare the management function as prescribed in the management document of 1972, namely that "the community physician as a manager has four main roles, namely
THEORY A N D PRACTICE OF C O M M U N I T Y MEDICINE
263
planning; the development and interpretation of information; the evaluation of service effectiveness; and the coordination of preventive care services and the deployment of clinical doctors in public health," with the interesting comment on "what is management" mentioned in The Lancet in the same year, "management denotes a radical extension of scientific methods of prediction and control to manufacturing and human affairs: planning and coordination from the top in place of the uncertainty of the market; the organization of elements of production into viable systems permitting coordination and economies of scale in place of fragmentation; and decision making through quantitative analysis and computer techniques in place of human subjectivity and idiosyncrasy." Can one reconcile these two views ? And is it too much to expect one person to be able to cope with this perspective of management in the provision of medical care ? Faced with this complex situation, it is worthwhile to look at the aim of undergraduate education in the realm of community medicine, and I envisage this as: to make sure that the student is aware of the continuity of medical care. To enable a student to gain an insight into the biography of health and disease, so that when the student meets and studies patients, the student will see the patients as individuals in the context of the natural history of their illness. At the same time, the principles and practice of preventive medicine are taught, and this is integrated into the framework of an understanding of the function of the health service. At the postgraduate stage, these concepts are elaborated, both in theory and in practice, as outlined by the Faculty of Community Medicine, leading to membership of that body. In the reorganized Health Service, this training should make individuals capable of functioning as regional medical officers, as area medical officers, and as district medical officers. It may be useful to list these main functions (Table 1) so that comparisons can be made. TABLE 1
Management arrangementsfor the reorganized N.H.S. (1972) Regional Medical Officer (a) Coordinate the development of planning guidelines for A.H.A.s on regional policies and priorities for the distribution of medical specialties, (b) Develop priorities for the distribution of medical specialties, (c) Review A.H.A. planning proposals. (d) Coordinate the briefing stage.
Area Medical Officer (a) Advise the team on health care policies, (b) Recommend to the team district planning guidelines. (c) Assist the team to monitor and coordinate the performance of district management.
District Medical Officer (a) Identify opportunities to improve the operational health-care services. (b) Coordinate the work of the health-care planning teams. (c) Coordinate preventive services in the district. (d) Advise his consultant and general practitioner colleagues.
When looked at in this way, the job specification of the Chief Administrative Medical Officer for Scotland makes one pause: JOB SPECIFICATION FOR THE CHIEF ADMINISTRATIVE MEDICAL OFFICER FOR SCOTLAND He will be the chief medical advisor to the Health Board and the general coordinator of health care planning. He will head the team of specialists in community medicine. As a member of the Area Executive Group he will be jointly responsible with the other members for the functions delegated to the area executive group by the Board.
264
PUBLIC HEALTH VOL. 88 NO. 6 In particular he will: (1) Identify the health care needs of the population. (2) Measure the extent to which these needs are being met. (3) Coordinate the development of health care objectives and plans to meet them. (4) Coordinate the preventive health services and the promotion of health education. (5) Develop working relationships between the Board and the Medical Advisory structure. (6) Ensure the discharge of statutory obligations imposed under a wide range of enactments on the Chief Administrative Medical Officer and other medical officers of the Health Board consequent to the National Health Service (Scotland) Act, 1972. (7) Provide medical advice to and liaise with the responsible local authorities in all relevant matters including (a) education services, (b) social work services, (c) communicable disease control, (d) environmental control. (8) Coordinate with the bodies responsible for postgraduate medical education. (9). Where relevant, develop the Board's relationship with Universities.
If in practice, this is what is expected of community medicine, then there is no doubt that some compromise will be necessary in the relationship of the theory and the practice of community medicine. All the training programmes for community physicians are in the melting pot at the moment, and while innumerable opinions have been expressed about what the community physician is expected to do, the community physician's present and future function should be the subject of intensive study and analysis. We have to recognize that many existing health care methods will have to be modified, new methods will be introduced, and obsolete methods, or methods which are no longer applicable, abandoned in the new Health Service. This implies that the community physician will have to be trained, not only to fulfill the job specification, but also to be prepared for a very fluid and rapidly changing situation. One or two examples will illustrate this. It is estimated that a reliable, but rudimentary, information service will take ten years to become functional: if this is the case, then for the next decade the community physicians will have to work with the existing information service, but thereafter will be able to adapt their planning and administrative function to quite a different framework. The interrelationship between the public and the Service is another problem. The more enlightened the public, the more they are likely to cooperate with the health services. This, in the climate of Health Education, means that both the needs and demands made on the health services will certainly change. When providing services, the results of a major capital expenditure like the building of a hospital may take ten years from the drawing board to the opening ceremony. This focuses on the need for adaptability and flexibility in the provision of medical care, which will be the prime concern of the Community Physician. We therefore need to pose the following questions: (1) If we emphasize the theoretical concepts of community medicine, will we be preparing the future community physician for a very rapidly changing role ? (2) Would it be better to train some of our community physicians for a changed Health Service, while others are expected to cope with the transitional stages 9. The time has come when we have to realize that travelling hopefully is not enough. The new Health Service has arrived. There will be many opportunities for experiments in the practice of community medicine, but it would seem opportune to highlight the fact that we have to arrange a marriage between theory and practice. Although the concept of community medicine is slowly evolving and becoming more unified, the practice of
THEORY AND PRACTICE OF COMMUNITY MEDICINE
265
community medicine will, even if only in an interim period, remain fragmented. The needs of the community require attention during the transitional phase, so that the practice of community medicine should have priority now, before the "ideal" concepts can be integrated into future practice, perhaps in the 1980s. Kurt Sehwarz
The Society of Medical Officers of Health and CIBA Foundation With the change in title and emphasis of the Society of Medical Officers of Health, which has become the Society of Community Medicine, the teaching group of the Society decided to disperse and so discontinue the annual meeting which it had held at the Foundation since 1963. In agenerous gesture of appreciation, the Teaching Group presented to the Foundation a first edition copy of La Charitd sur les Champs de Bataille by Henri Dunant, containing a report of an informal conference in 1863 which preceded the formal creation of the International Red Cross in the following year. The book contains a plate which is believed to be the first to depict the Red Cross emblem.
JOURNAL
OF
THE SOCIETY OF COMMUNITY MEDICINE (FORMERLY THE SOCIETY OF MEDICAL OFFICERS OF HEALTH)
Volume 88, Number 6, September 1974 The Theory and Practice of Community Medicine THERE ~S A remarkable dichotomy in community medicine at the present time. Although many people think that community medicine is a natural evolution from hygiene, preventive medicine, and public health, there is still considerable difference of opinion as to whether community medicine is closer to the practice of family medicine, whether community medicine has a greater affinity to the realm of hospital administrators, or whether the community physician will have the prerogative of being its sole practitioner. Even the foundation of the Faculty of Community Medicine of the Royal Colleges of Physicians of the United Kingdom and the change of name of the Society of Medical Officers of Health to that of the Society for Community Medicine does not seem to have resolved the situation. The editorial in the Lancet, "Who's for Community Medicine ?" (16 December, 1972) may make for amusing reading, but the first sentence has many implications. "Nine months ago the board of studies in preventive medicine and public health of London University asked its medical schools what they were doing and what they intended to do in their curricula under the heading 'community medicine'--or any other title which might be in use to cover this many-sided subject." The Todd Committee defined community medicine a s : . . . . . a term currently used with different connotations. In the sense in which we use the term, community medicine is the specialty practised by epidemiologists and by administrators of medical services--e.g, medical officers of local authorities, central health or other government departments, hospital boards or industry--and by the staffs of the corresponding academic departments. It is concerned not with the treatment of individual patients but with the broad questions of health and disease in, for example, particular geographical and occupational sections of the community and in the community at large. It embraces many activities and interests and includes doctors employed in different spheres, partly because the health services have developed in this country under several different authorities. It makes use of a variety of techniques and procedures which are not necessarily exclusive to it. Nevertheless the functions of all doctors working in this field are closely related; there are no intrinsic differences in their requirements for basic training or in the techniques they employ. Over the years a variety of names has been used to describe the traditional and important responsibilities (or certain facets of them) which we include in our concept of community medicine: among familiar terms in use are public health, preventive medicine and social medicine; confusion has arisen because they are often treated as synonymous.
262
PUBLIC HEALTH VOL. 88 NO. 6
It is apparent that this definition has been derived by a system of exclusion, with the result that some people still prefer the name Population Medicine for the practice of medicine e n m a s s e . This immediately raised the query whether community medicine is really the type of medicine as applied to groups of the community. If this were the case, then some people will undoubtedly regard community medicine as medicine practised outside the hospital, while others again would consider that hospital medical care should be within the ambit of community medicine. To confuse the issue even further, the committee dealing with "The Management Arrangements for the Reorganized National Health Service" (1972) gave an indication of its thinking on this subject by defining the role of the specialist in community medicine as "a specialist in community medicine must stimulate the process of integration. He will provide a service to clinicians, acting as an additional link between them, also as a link with the local authority services. He will assist clinicians by providing them with information on needs and advice on the effectiveness of alternative approaches to care." This certainly seems some way from the historical role of either a Medical Officer of Health or a Senior Administrative Medical Officer working in the hospital environment. The Hunter Committee reporting in the same year took a slightly different line, and it certainly highlighted a breakdown in communications between the two committees. As far as the Hunter Committee is concerned, they discussed the role of community medicine in the following terms : - - " T h e concern of community medicine with the general health of the population extends more widely than the direct responsibilities of the new health service authorities. Considering the organization of health care, community medicine specialists must also have regard to the service provided by central and local government agencies and voluntary organizations, and to the need for full cooperation with these bodies." The implications of these comments have been discussed in the professional and national press on numerous occasions, and recent informed comment suggests that the reorganization of the National Health Services is only the first stage in a further reorganization. The Faculty of Community Medicine has shed considerable light on some of the more obscure points, by rationalizing the community medicine concept into the components necessary for the membership examination of the Faculty. The four categories comprise epidemiology, statistics, social sciences in relation to community medicine, and the principles of administration and management. One would have thought and hoped, that would have been the end of the dichotomy, but it was not to be. What then does all this mean? Have hygiene, preventive medicine, and public health become fragmented, or have they all been unified under the banner of community medicine ? This is the question that we need to ask ourselves. If left unresolved, there is no doubt that future developments in community medicine will be stunted. In this respect the Society of Community Medicine has a particularly important role, making its greatest contribution by acting as the unifying scientific body. If Community Medicine is not to be regarded as the same for everyone, and it would be unrealistic to expect it to be everything to everyone, can we analyse community medicine in such a way as to determine precisely what the component parts are ? After all, there are many precedents for this. On the administrative planning side, there were SAMOs and County Medical Officers of Health. In the County Boroughs there were Medical Officers of Health, and then there were the Medical Officers of Health of divisions. Practice
If one hopes to see the future practice of community medicine in action, I think it is quite salutory to compare the management function as prescribed in the management document of 1972, namely that "the community physician as a manager has four main roles, namely
THEORY A N D PRACTICE OF C O M M U N I T Y MEDICINE
263
planning; the development and interpretation of information; the evaluation of service effectiveness; and the coordination of preventive care services and the deployment of clinical doctors in public health," with the interesting comment on "what is management" mentioned in The Lancet in the same year, "management denotes a radical extension of scientific methods of prediction and control to manufacturing and human affairs: planning and coordination from the top in place of the uncertainty of the market; the organization of elements of production into viable systems permitting coordination and economies of scale in place of fragmentation; and decision making through quantitative analysis and computer techniques in place of human subjectivity and idiosyncrasy." Can one reconcile these two views ? And is it too much to expect one person to be able to cope with this perspective of management in the provision of medical care ? Faced with this complex situation, it is worthwhile to look at the aim of undergraduate education in the realm of community medicine, and I envisage this as: to make sure that the student is aware of the continuity of medical care. To enable a student to gain an insight into the biography of health and disease, so that when the student meets and studies patients, the student will see the patients as individuals in the context of the natural history of their illness. At the same time, the principles and practice of preventive medicine are taught, and this is integrated into the framework of an understanding of the function of the health service. At the postgraduate stage, these concepts are elaborated, both in theory and in practice, as outlined by the Faculty of Community Medicine, leading to membership of that body. In the reorganized Health Service, this training should make individuals capable of functioning as regional medical officers, as area medical officers, and as district medical officers. It may be useful to list these main functions (Table 1) so that comparisons can be made. TABLE 1
Management arrangementsfor the reorganized N.H.S. (1972) Regional Medical Officer (a) Coordinate the development of planning guidelines for A.H.A.s on regional policies and priorities for the distribution of medical specialties, (b) Develop priorities for the distribution of medical specialties, (c) Review A.H.A. planning proposals. (d) Coordinate the briefing stage.
Area Medical Officer (a) Advise the team on health care policies, (b) Recommend to the team district planning guidelines. (c) Assist the team to monitor and coordinate the performance of district management.
District Medical Officer (a) Identify opportunities to improve the operational health-care services. (b) Coordinate the work of the health-care planning teams. (c) Coordinate preventive services in the district. (d) Advise his consultant and general practitioner colleagues.
When looked at in this way, the job specification of the Chief Administrative Medical Officer for Scotland makes one pause: JOB SPECIFICATION FOR THE CHIEF ADMINISTRATIVE MEDICAL OFFICER FOR SCOTLAND He will be the chief medical advisor to the Health Board and the general coordinator of health care planning. He will head the team of specialists in community medicine. As a member of the Area Executive Group he will be jointly responsible with the other members for the functions delegated to the area executive group by the Board.
264
PUBLIC HEALTH VOL. 88 NO. 6 In particular he will: (1) Identify the health care needs of the population. (2) Measure the extent to which these needs are being met. (3) Coordinate the development of health care objectives and plans to meet them. (4) Coordinate the preventive health services and the promotion of health education. (5) Develop working relationships between the Board and the Medical Advisory structure. (6) Ensure the discharge of statutory obligations imposed under a wide range of enactments on the Chief Administrative Medical Officer and other medical officers of the Health Board consequent to the National Health Service (Scotland) Act, 1972. (7) Provide medical advice to and liaise with the responsible local authorities in all relevant matters including (a) education services, (b) social work services, (c) communicable disease control, (d) environmental control. (8) Coordinate with the bodies responsible for postgraduate medical education. (9). Where relevant, develop the Board's relationship with Universities.
If in practice, this is what is expected of community medicine, then there is no doubt that some compromise will be necessary in the relationship of the theory and the practice of community medicine. All the training programmes for community physicians are in the melting pot at the moment, and while innumerable opinions have been expressed about what the community physician is expected to do, the community physician's present and future function should be the subject of intensive study and analysis. We have to recognize that many existing health care methods will have to be modified, new methods will be introduced, and obsolete methods, or methods which are no longer applicable, abandoned in the new Health Service. This implies that the community physician will have to be trained, not only to fulfill the job specification, but also to be prepared for a very fluid and rapidly changing situation. One or two examples will illustrate this. It is estimated that a reliable, but rudimentary, information service will take ten years to become functional: if this is the case, then for the next decade the community physicians will have to work with the existing information service, but thereafter will be able to adapt their planning and administrative function to quite a different framework. The interrelationship between the public and the Service is another problem. The more enlightened the public, the more they are likely to cooperate with the health services. This, in the climate of Health Education, means that both the needs and demands made on the health services will certainly change. When providing services, the results of a major capital expenditure like the building of a hospital may take ten years from the drawing board to the opening ceremony. This focuses on the need for adaptability and flexibility in the provision of medical care, which will be the prime concern of the Community Physician. We therefore need to pose the following questions: (1) If we emphasize the theoretical concepts of community medicine, will we be preparing the future community physician for a very rapidly changing role ? (2) Would it be better to train some of our community physicians for a changed Health Service, while others are expected to cope with the transitional stages 9. The time has come when we have to realize that travelling hopefully is not enough. The new Health Service has arrived. There will be many opportunities for experiments in the practice of community medicine, but it would seem opportune to highlight the fact that we have to arrange a marriage between theory and practice. Although the concept of community medicine is slowly evolving and becoming more unified, the practice of
THEORY AND PRACTICE OF COMMUNITY MEDICINE
265
community medicine will, even if only in an interim period, remain fragmented. The needs of the community require attention during the transitional phase, so that the practice of community medicine should have priority now, before the "ideal" concepts can be integrated into future practice, perhaps in the 1980s. Kurt Sehwarz
The Society of Medical Officers of Health and CIBA Foundation With the change in title and emphasis of the Society of Medical Officers of Health, which has become the Society of Community Medicine, the teaching group of the Society decided to disperse and so discontinue the annual meeting which it had held at the Foundation since 1963. In agenerous gesture of appreciation, the Teaching Group presented to the Foundation a first edition copy of La Charitd sur les Champs de Bataille by Henri Dunant, containing a report of an informal conference in 1863 which preceded the formal creation of the International Red Cross in the following year. The book contains a plate which is believed to be the first to depict the Red Cross emblem.