V. “State of the Union”

V. " S t a t e of tne U n i o n " Chairman: Dr. Wilfrid G. Harding, London Borough of Camden You may ~ o n d e r abottt the title of this afternoon's session---"State of the Union". 1 can assure you that it is not in any way connected with ,.t~e intention e,f the Society to seck the T.U.C.'s recognition, but that h's ralher the suggestion tha~ some people outstanding in our own tield should be raIher introspective about ourseJ',cs and then look without from within. Our tirst speaker is Joan 13awkins whose contributions are invariably well-considered and beautifully produced. I)R. JOAN ST. V. D A W K I N S Medical Officer of lh, alth, Northamp/ott Rural District Comlcit The President of the United States, in his State of the Union message--and this is how i interpret Ibis State o f the Union .... reviews the present situation and indicates future policy, recommending to the nation such measures as would seem expedient. Today this message is shared by three speakers who have been asked broadly to review our own slate of the union in respect of their individual disciplines. My remarks here, therefore, will be limited mainly to the lirst four chapters of the second Green Paper, leaving the wider implications to my fellow speakers. 1 shall discuss primarily the future role o f the present district medical officer o f health and work at local level. Nevertheless while endeavouring to limit my context, it wilt be impossible to forecast without reference to some of the broader issues, that inevitably must influence even this narrower field. There has been, during the last year. formidable prospective legislation introdt~ced with haste due to lack o f political time at the end o f the Parliamentary term, which,has inevitably created a situation of uncertainty if not confusion to those whose destinies will be involved. It is imperative that this period must be as short as possible if the service is to survive. At present recruitment is negligible, there is an exodus of trained personnel, and Warren and Cooper have shown a prcponderance o f older age groups. Other branches of medicine can offer a certain career structure and pecuniary advantage and there is every likelihood that this running down will continue and could prove disastrous. However, it is agreed that reform is essential, and those who practice this discipline have ever shown the adaptability necessary for the vocation Of preventive medicine. It is my belief that the seeds are being sown at the present time for energies and resources to be concentrated once m o r e on prevention. The pendulum which swung away from prevention during t~le heyday o f curative medicine o f the last thirty years, is now steadily moving towards the centre in which prevention and cure will be a continuous process. To quo~'¢ Morris "since the middle 1950"s, the decline in death rate has slowed, most death rates are virtually stuck and at some ages there is a tendency to rise. Presently incurable conditions, violence and ageing are relatively m o r e important. 1~ looks like the close of a chapter and a rougher road ahead. Therefore, betbre any re-organization takes place it is necessary to assess what are the priorities in ill-health prevention and health promotion today, and suggest the means for their solution." My own particular task is then to allocate their job to doctors who are directly concerned in the environmental cor'trol o f health and clescribe how their skills may be used to meet these future needs. After 20 years of sporadic and often random growth, the structure

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of the National Health Service is nox~ under close scrutiny and on the threshold of revision. At present, when public needs, often undefined, and public unlimited demand bear little relationship to each other, it is necessary that needs and resources be matched, and in the process absolute priorities in medicine should be clearly stated and their solution placed in the forefront of medical planning. Our own service is almost entirely preoccupied in mainraining existing services with dwindling staff and as Bryant said in a recent Paper "there is a tendency to continue services long after the needs that called them into being have disappeared.'" Our future ethica! concept of our work must therefore lay emphasis on the priorities. My list of these--not in any specific order--would be: population controi--a primary need, not only in developing countries but here, where 250,000 unwanted children are born annually; cigarette smoking---the major cause of early unnecessary death and the greatest challenge to preventive medicine in history: chronic bronchitis together with rheumatic conditions, the principal cause of absence from work; atherosclerosis and its prevention, with all the implications of the use of leisure, diet, exercise, stress and presymptomatic screening; accidents both in the home and on the roads, and in the latter, affecting predominantly the young, particularly males in the age group 18 to 24; alcoholism; mental health; violence; crime; drug dependence; use of tranquillizers; the increasing needs of the elderly; the survival of the handicapped; the fostering of their independence; pollution of the environment; noise: pre-symptomatic screening; the early detection of diabetes; glaucoma; prevent.ion of arthritis; osteoporosis--a condition often forgotten, and crippling; fluoridation--even this list is incomplete. Other needs exist and new ones wilt emerge. Many of these problems will require the co-ordination of skills including those of social workers, public health inspectors and others, and here one must inevitably question the wisdom of separating health from social and environmental services at such a crucial time. Are the true needs of the community to be sacrificed to political expediency and to placate certain clamant groups? As Professor McKeown said last year at the Royal Society of Health, "surely at some time soon, the commensurate benefit to be obtained from an outlay of expenditure should be assessed against the gain." The concentration of limited resources should be directed towards these priorities and as most of them are environmentally influenced the local community physician will have a major role to play. 1 now return to my narrower field--to the district medical officer o f health. These officers usually hold multiple appointments, are employed by district councils and by county councils in various different aspects. A holder of such multiple appointments may serve councils which vary from as little as 2000 to 60,000. Some small councils, for instance those of ancient boroughs, have a full hierarchy of officials and councillors in one part of an area, while the rural district with its light complement of staffis in ~another. Such duplication of services, devised when the horse was the means of communication, is clearly an anomaly, and because of this, the time of the officer is unnecessarily fragmented and energies are diverted which could be employed productively elsewhere. Reform is needed and has been overlong delayed, However, knowledge of local conditions is extensive and there is a constant contact with all aspects of the community. It is not in the scope of this paper to detail the duties of the district medical officer, but 1 have outlined them in an appendix. In addition to statutory duties this officer may be required to bring medical expertise to numerous community problems, acting as arbiter, referee and advisor. The dual appointment to both district and county, and contact with hospital and general practitioner colleagues, promotes liaison, and frequently in cases of the elderly, problem families, the

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handicapr~cd, and in dealing with certain environmental problems, these officers acl ~.~s a catalyst betv, cen T t l e many a£encies invo],, cd. The prop~,.<',~ <~t,.,,,~,.,~i,:~ !:,r ch:~nge are s~veeping but some o f then] ~',e can welcome. I lca',c lhc ,aide :~, • ,,~!,' ,'~,,'-- :~,',! ',,. ilhin Ihe narrm~ ,..onre,<~ o f Tll\ ~,\~" discipline,

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st;tied that there ',','ill be a corps o1 ::dm,~ ~ . ~ wd;~ai - ,!~ . : :. ..' [hi' a r c ; l~oard and the local authority. One hopes ltmt tht: chief c-ommt~nily physiciar, ,~iti be pr/mns i m e r p a r e s wilh his other communily physician colleagues serving the population of the Area Health Board which would generally embrace two district general hospitals areas, and have approximately half a million population. While the function in detail of these community physicians is as yet undefined, Morris, McGregor, EIliotl, Gooding, Reid and Ewell, Warm and others have all endeavoured to poslulate possible roles, while kycett has prepared a slaff structure l\)r the first Green Paper xvhich could be suitably moditied. However, l envisage thai medical staff" will be employed both at area and at dis;tic-; level. Those at area level will be concerned ,,,,'ilia the organization o f all branches o f the heahh services and with the fulfillment of some of the presenl local authority personal services. My concern today is with what I shall call, purely for this paper, tile local or district community physician. He will serx.e the population area of the district hospital which should be approximately 200,000-.300,000. This physician will serve the district committee which at present is defined as having little executive Fower and will act only as a sounding board for local needs. To be effective it may require delegation both o f financial and executive funclion. Those duties which a medical officer of health has today will still have to be carried out whatever the superimposed legislation, and the officer 1 envisage is one who will fulfill this function literally, not directing his reconunendations through statistics received behind closed doors in remote offices o f an Area Health Board, but from local knowledge acquired directly at source, To quote Elliot; "'Traditionally and as o f right the medical ofl]cer has roamed freely in many spheres, largely to the advantage o f all concerned", Morris sees him as "'teacher, watchdog, and t rouble-maker. " The Area Health Board will direct its administrati've staff, but tile local c o m m u n i t y physician would be responsible to the district committee as he is today to the district council. He will provide the annual report; make a close scrutiny of statistics which would include new morbidity reporting and would indicate development of epidemiological studies of infectious and non-infectious disease. He would evaluate and p r o m o t e research and introduce local remedies. These could relate to morb~idity statistics such as heart attacks in middle age" cancer; accidents and other conditions including industrial diseases and causes of absence from work. He could make surveys on living conditions and habits, keep registers of the severely disabled and housebound, problem families and others who might require specific environmeo.tal needs such as sheltered housing, recreational facilities, pre-school provision and day-care. This close scrutiny.of statistics could be aided by computer intelligence and record linkage and could result in the keeping of registers of other populations at risk and could assist in programming population control, care o f the elderly, the handicapped and the mentally ill. There would be t[ree passage of this information to Area level for further executive action as necessary. To quote Morris again "'after twenty years o f the National Health Service, one o f the sadder disappointments is the poverty at local level of its learning resources."

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if communicable disease control is under' the local authority, the responsibility must, and withoul equivocation, remain with the community phy, sician, who alone has the necessary training and knowledge. Ill this function 1he statutory responsibility must be clear. Notitication of disease by doctor to doctor must continue. The long, amicable, and mutually respected relationship between tile public health inspeclorate and the medical oflicer o f health should remain and if they are separated--I am still doubtful if this is the solution.~ the good,viii which has operated mus~ be maintained. Lines of communication should be free and the informal passing of information on all matters relating to health should continue. At present there is a trend tbr larger departments in local authorities, and public health inspectors may find they are responsible to a director. One must hope that should administrative change occur, their relationship to the community physician is clearly defined. Should the public health inspector find himself under the overall administration of another chief medical officer, where, in time of need, would his priorilies lie? The personalities o f the medical officer and his local authority colleague could be in conflict to the detriment o f the community. The need for a statutory link in this field may prove necessary. The local unitary authorities will inevitably require to divisionalize their services, in these divisions the local physician may be required to fulfill the occupational heahh requirements of the authority as they do at present. The medical advice which will be necessary to the social service department will, 1 envisage, come from area level, and ! am therefore not making any reference to the fulfillment of these Ikmctions. However, as at presen.t, the environmental officer will be required to give his advice on the sanitary control of all the institutions and schools which are under the control of the local authority in his area. In respect of port health, those authorities with sea and air responsibilities will continue to require expert medical supervision. in concentrating the limited resources of the Health Service, the local community physician will also have a major part to play in health education. His intimate contact with all the agencies of the community, particularly voluntary organizations, places him in an ideal situation in this respect. In the role of tertiary prevention, particularly with the prevention of handicap in the elderly, there is a vital role to play, and 1 do not envisage that the social services department will fdnction in respect of prevention of these handicaps; this Will be our job. In respect of all other legislation the local physician will act as advisor and there are many facets of environmental conditions which will continue to present problems. Increasing population, crowding, traffic congestion, pollution of air, land and sea, factory farming, pesticides, the increasing siarvival of the elderly and the handicapped, will all create problems in the environment. Though a recent leader in the B.M.J. stated, "the hospitals are the powerhouse o f medicine, and all doctors are cradled in them and return to them to be refreshed", it is in the community that the genesis of disease'ties and it is here that the pi-imary field worker in preventive medicirie must practice and remain dontinually vigilant. In allocating duties I have specified one local community physician to serve the district committee. Circumstances, local needs and developments may require more at this level. [ envisage that the majority of those employed will be employed locally. However, a certain proportion would be eligible for posts at area and particularly" at regional level, where as Reid and his colleagues have stated, they would by means of statistical and computer information evaluate health programmes and ensure that prioritie~s are assessed by the correct application of epidemiotogical information. The prompt organization of training programmes and the early application of medical officers of local health authorities to the planning of re-organization for this-future is imperative now, particularly in relation to

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district medical ott]cers. Whe,~ districts become vacant, amalgamation should take place and dutie~ be re-oricntaled wilhin Ihe present structu.e. This would help to ensure transfer withoul rcdunda~lcy, An elticient service must provide the framework which will fulfill the primary objective of dealing wi/h these problems as \veil as an administrative structure to create the smooth operation of a complicatcd and diverse heahh and sickness service. The unification o f the three major disciplines o f medicirvc is indeed the first step to this solution and is welcomed, When the hislory of the tirst 20 years of the National Health Service is related, it is ironic that flaough the public health was one o f the reasons for its original formation, when in 194S local go',ernment retained control o f the preventive services, it failed, because of rigid adherence to old formulae, to perccixe the great potential o f the inheritance. Perhaps the liberation from this smmture may prove to be the renaissance o f the preventive ideal.

Appemlix The District Medical Otticer of Health

Appohttmettt I. A Medical Officer of Health is appointed tinder the provisions of the Local Government Act 1933 (sections 103 and 106-t 13). 2. The Public Heahh O[-[icer Regulations t9.59 describe the qualifications, mode o f appointment. tenure of office, power of enliy and duties o f Medical Officers of Health including, those appointed to ports. The appointment may not be for a limited time and must be approved by the Secretary of State in the case of counties, urban, borough, and rural districts and ~.be majority of county boroughs. He m a y not be dismissed from office without the consent of the Secretary of Slate. 3. A person appointed as a Med-it,.z., Otficer o f Health must be a fully qualified medical practilioner who holds a registereo diploma in public health or its equivalent (if he is appointed to a district o f more than 50,000 population), 4. He must not engage in private practice, Aczs relatiug to em'iromnental health PrhwO~al /tots relating [o control
Reluting Io em'ironmemal heahh Public Health Act 1936 and 1961 National Assistance Act t948 (Section 47) (and as amended 1951) F o o d and Drugs Act 1955 Clean Air Act 1956, 1968 Housing Acts 1957-1969 Noise Abatement Act 1960 Factories Act t961 Offices Shops and Railway Premises Act 1963 Health Services and Public Health Act 1968

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Duties under the various acts

1. Provision e)l'am~u~H r(7)ort (Regulations 5 (31 and 15 (5) Public Health Officers Regulations 1959) As soon as practicable after December 31 st each year the Medical Officer of Health must prepare an annual report for his Council and send copies to the Secretary of State or other Ministries. He must deal ~itla sanitary circumstances, administration and vital statistics, as well as an5' other public heahh matters which he may consider desirable to report. 2. Preventirm and control o f ilt.fecliottx disease (a) Notification (1) Health Services and Public Health Act 1968 Section 48 (1) places the responsibility for notification of infectious disease to the Medical Officer o f Heahh on the doctor who is attending the patient. (t l ) A weekly return is required to be sent to the Registrar General and to the County Medical Officer of He~,.lth of alI infectious diseases notified to him. A quarterly return of these diseases is also required. (b) Control 1. Prevention Section 26 of the National Health Service Act 1946 require every Local Health Authority to make arrangements for vaccination and immunization of persons against infectious diseases including smallpox and diphtheria. 2. Colin'o[ Public Health Act 1936 Sections 48 and 170 Public Health Act 1961 Sections 38-42 Public Health (Infectious Diseases) Regulations 1968 These acts confer powers on Medical Officers of Health relating to vaccination and immunization of contacts, medical examinations o f persons suspected of carrying infection liable to cause a notiliable disease, power to discontinue employment and removal of persons suffering from infectious diseases to hospital, and other measures to prevent spread of infections. 3. Duties relating to houshtg l-lousing Act 1957 The Medical Officer of Health being satisfied that a house or houses are unfit for human ha~bitation and is not capable of being .rendered fit at reasonable expense, may represent such houses for demolition, closure or he may declare a clearance or Improvement Area. Sections 16, 17, 28, 42-52, 157. He also has duties to alleviate overcrowding, (Section 76-86) or deal with houses in multiple occupation (Housing Act 1961 section 12-23). 4. Food and Drugs Food and Drugs Act 1955 Medical Officers of Health and Public Health Inspectors are deemed authorized officers for all purposes under this Act (~ection 86 (2)). The Food and Drugs Act relates to the composition and labelling of food and drugs, food unfit for human consumption, hygiene in connection with the sale of food, sampling

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(chemical, biological, bacterological~, registration o f premises and of food poisoning. Many facets of food hygiene are coxered by Regulations such as: The Imported Food Regulations: Meat Inspection and Slaughterhouse Regulations; M ilk Regulalions; Food Hygiene General Regulations. They are also concerned with diseases o f animals as far as they affect human health. Public Health Act 1936

5. General p,~blic health if the duty of the Medical Officer of Health to promote the health of the community by provisions for removal o f rats, abatemems of nuisances, safe water supply~ satisfactory sewerage disposal, refuse collection, cemeteries, removal of offensive trades etc., Under the Clean Air Act, air pollution must be prevented. The medical officer has power to enter premises under Section 143 (4), 241 (4), 243 (31, 255 (21 and 267 (similar powers are provided under other Acts). 6. Eff/brcement responsibigties The Factories Act and lhe Office, Shops and Raihvay Premises Act, deal with the health, safety and welfare o f employees. The Medical Officer of Health of every district council is required to report annually on the administration of the Factory Act. Power o f entry is given to the Medical Officer of Health under Sections 37 and 128 of the Factories Act. 7. Port health Port heallh authorities are empowered to appoint medical officers with the following duties: (a) lo examine any person suffering or suspected to be suffering fi'om infectious disease; (b) to detain any person he is authorized to examine; (c) cause such persons clothing to be disinfected; (d) to prohibit such persons from living in a vessel; (e) to require the Master to canLv out such steps as are necessary. It is the duty of the Port Medical Officer to inspect any vessel which has come from a port or sea board on the infected list at or upon notification of the Master of the ship of the occurrence o f an infectious disease. The duties o f tlae Port Health Authority include the prevention of importation o f infectious disease, carrying out the provisions o f the International Sanitary Conventions to the supervision of the hygiene o f the crew and passenger accommodation on ships and inspection o f imported food intended for human consumption to ensure its soundness and freedom fi'om disease. 8. National Assistance Act 1948 (Section 47 A m e n d m e n t 195I) For the purpose of securing necessary care and attention persons may be removed to suitable premises in circumstances: (a) where they are suffering from grave chronic illness, or being aged and infirm (etc.) and are not receiving proper care. Under the Amendment (1951) a simplified form o f procedure may be used for removal for a shorter period. The duties of a Medical Officer o f Health are described in a M e m o r a n d u m issued by the Ministry of Health:

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"The chief h~unction o f the Medical OMcer o f Health is to safe~mrd the health o f the area for which he acts by such mean.s as are at his disposal, and to advise his Authority how kno~'ledge of Public Health and preventive medicine can be made available and tttilized for the benefit of the community. He should endeavour to acquire an accurate knowledge o f the influences, social and environmental and industrial, which may operate prejudicially to health in the area, and of tile agen'cies, official or unofficial, whose help can be evoked in amelioration of such influences. While he has special duties for the prevention of infectious diseases, all morbid conditions contributing to a high sickness rate or mortality in the area from these or ~ther causes should be studied with a view to their prevention or conlrol. The Medical Officer o f Health should be prepared to advise on all matters concerning the Public Health Services undertaken by the Council, and generally on questions affecting the health o f the district or county, including Public Health considerations involved in the preparation of local legislation, in lhe adoption o f stzitutory provisions and in the framing and subsequent working o f bye-laws and regulations. He will also be called upon to take executive action where required to do in the administration o f the Statutes and Orders noted . . . . and to certify for the guidance o f the Council or o f the justices as to any matter in respect ofwhich the certificate of the Medical Officer of Health or o f a medical practitioner is required as the basis or in aid o f sanitary action". Chairman: Thank you Dr. Dawkins for this so beautifully thought out and delivered paper. 1 hope that in the discussion we will, among other things, touch on this hierarchical idea which was slipped into the second Green Paper by virtue of the term Chief C o m m u n i t y Physician. Dr James Galloway, sometimes, 1 think somewhat unfairly, has been described as the "'enfant,terrible" of public health. The truth of the matter is that he speaks out because he thinks it is the only way in which h e ' c a n d r a w attention to matters which otherwise go by default. He is no longer a medical officer of health. He is now the Birmingham Regional Hospital Board's advisor, on geriatrics, psychiatry and mental subnorn~ality. DR. J, F. G A L L O W A Y M.D., CH.B., M.R.C.S., L.R.C.P., D.P.H., D.P.M.

Former Medical Officer of Health, Woh'erhampton It would be ungracious o f me to be here this afternoon without thanking you for inviting me. Everybody will-have forgotten, but I.have not, that when the,first Symposium was held in February 1962, I had the honour--which I still greatly c h e r i s h - - o f being the first medical officer o f health to give a paper, and I look back on that with great pleasure. It seems perhaps right that as this is probably the last time I address you as a community, I should also be doing it in a Symposium. I still t a k e p a r t in discussions. I a m frequently being invited to give talks on the problems o f retirement, which I do with a certain a m o u n t o f feeling. 1 have so far refused to have a vested interest in the disposal o f the dead. However, it does keep one in touch with thing~ and I am better off than one o f m y former colleagues, who retired since I did, who thought that trisomy occurred in private between three conseniing adults. In this country the function o f the government includes the abolition o f want, idleness, disease, ignorance and squalor. This is no new nostrum, but the inevitable consequence o f the larger sympathy of men with men that became a force in England in the early eighteenth cen.tvry, when a new solieit~ade was developing among our people, coupled with a realization o f the hard and cruel struggles of tl~e poor. The National Health Service Act m a r k e d the

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end of a century of hcallh Iegislalion in this tradiliom and no other country has such a comprehensive service availab!e lo everyone. It is not the final goal, but only a milestone on the cvcr tk, r~ard march of social progress. When a service that has such a sound ethical bash, is a larger for criticism from consumers, and there is constant agitation by' lhe medi~zal profession it employs, there must be ~eaknesses in it. The public are increfisingly aware o f shortcomings in general praclice, delay m securing hospital consuhation and admission. llladcquale pr,~vision for the aged and ',he subnormal, and deliciencies in lhe provision o f home help,~, home nursing, and hostel accommodation. Those inside the service realize the weaknesses in their own tield but are less inclined to discuss lhclYJ publicly. General praclitioncrs know how impossible it is to persuade new entrants 1o seltle in the industrial areas where the need is greatest and where they have to rely increasingl.v on doctors Irained abroad, who may not be in harmony with the ethos of the comn;uni~v m which they ~ork. They know the limitations of working in unsuitable premise~ ~ il hout ancillary stall'. The h,~ypilal service is a~vare of the dissatisfaction of the junior doctors who relish neither the a.nlotlnl of ~ork expecled o f them, nor lhe rale for the job, nor their career prospecls in a hierarchical w~rld of muted demarcation disputes and restrictive practices. Those in cerlair~ specialities, parlicularly psychialry and geriatrics, fee[ frustrated whe~l they survey the ii~adequnc 5 o f their esscntial resources, while seeing other specialities benefit from sUl~shlIltial inveslnlcl'~t of capital. Thnsc ,aorking wi~h the R)cal authorily health service are m~certain o f their future, ~vorricd by' separation from their professional colleagues, and conscious of the pressures c3n them to supporl general pra'ctice to the detriment o f their own well-organized services. I)elicieucies arisine primarily i)om a demand that is not being met are attributed by the medical profession almost entirely to lack of money. This has led i~ the profession developing an unwh{desome vestcd interest in denigrating the service. In the absence of unlimited subventions, tt'~ev advocate alternative sources of finance that do not withstand inspection. Subsidized private care would require subventions in addition to, and not in substitution lk~r, those required for nationalized care. Contracting out would raise the contributions o f 0~ose remaining in. and a system o f charges is in effect a supplementary tax. There is a method o|" lackling deficiencies a!tributed to shortage of money that has not been suggested by eilher the profession nor Ihe Deparlment o f Health and Social Security, although it has been used by the lhrifty housewife from time immemorial---it consists of getting value for money, and if necessary, shopping around. Observation of the National Heahh Service since its inception reveals some of the factors inimical to getting value for money. The first is that it is outside effective public control, because 50 million people who pay for it have no one authorized to act on their behalf. The local councillor has no authority to influence the actions of the Regional Hospital Boards. Hospital Management Committees, or Executive Councils, while the local M.P. can only approach the Department of Health a n d Social Security thai. has delegated its powers Io these elusive bodies. The service is insulated from Ihe public because no one person in a thousand is likely to be able to identify those who are responsible for it. The consequence o f this absence o f public accountability is that the policies o f these bodies are intluenced by their professional members, who largely are medical and drawn from the higher echelons of the service, and who, as part-timers, are not wholly committed to it. The B . M J . speaking for the profession, declared that elficiency and democratic representalion are anli-palhelic, thai the developments of the medical services will be seriously impaired if the influence of the medical professim~ on the course of events is in any way weakened, and that the Health Service should be run by doctors, and not by laymen.

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Those viexvs, with their refreshing conciseness, and pleasing l'reedom from ambiguity, offer little hope or scope for the remaining 99"8", o f the populalion, and are illustrative o f the importance of establishing a neu form of internal goverl3ment in this country at local level. Absence o f public accountabiliLv promotes public apathy, for it accentuates our disbelief in the practicability of change. If this apathy is to be exorcized we must secure wider participation in political processes, restore faith in the possibility o f change, spread responsibility: demand public accountability and so provide a direct line of commtmicalion lbr conveying to the purveyors of the service the comments, criticisms, and wishes o f the consumers. The second factor inimical to getting value for money arose initially because our legislators of 25 years ago ignored the major problem of constructing sound administrative foundations and relied on a variety of expedients on which to base the Health Service. No one now denies that the three separately organized groups o f acli\ities directed specitically to the prevention and treatment of ill-health, would benefit from a c o m m o n authority to make decisions on objectives and on the allocation o f resources. But mere union o f the services is not enough and what is required is i n l e g r a l i o n - 4 h e formation of one service which requires, #tter alia, a medical profession seeking fervently to make the Nalional Health Service a success, devoid of groups seeking sectional advantages and prepared 1o be represented in all negotiations and on all occasions by a single body that speaks for all members of the professions, in all branches, and at all times. The third factor inimical to getting value for money is the isolation of the National Health Service. The health o f the community depends, in order o f importance, on nutrition.~ environmental conditions, the prevention of particular diseases, and the treatment of' established diseases. The causes of much illness are outside the control of the National Health Service. The consequences of illness make demands that the Health Se}vice is not designed to meet. Provision for the handicapped child, the mentally disordered adult, and the ever-increasing number of old people, is derived from m a n y separate sources and the decision on how best to meet the demands o f an individual can be decided economically. effectively and dispassionately only if the alternatives are seen to be financed out o f a common purse. The services should be the responsibility of an all-purpose authority. What do the proposed changes do to promote or retard the achievetnent of the trinity required to make our services as effective as possible ? In considering public accountability the district committees, without money, without statutory authority, and x~ith half their members drawn from the Area Health AtHhority, can be, 1 think, forgotten. These inbred committees are unlikely to exercise on the Area Health Authority either a critical or a stimulating function. The ninety Area Health Authorities are to have appointed chain~qen, and one third of their membership will be in receipt o f money paid o/it of ftjnds provided by the Secretary o f State, while another third are to be appointed by him. Only one-third of the members will be appointed by local authorities, and presu'mably they will be there to express their individ~aal opinions and not to promote policies formulated by those authorities. Area Health Authorities will raise no money but will rely on allocations from the Secretary of State who must be satisfied that the money is spel~t to the best advantage and, further, promises effective control to achieve this. Regional health councils, heavily weighted with professional members paid out of funds from the Secretary o f State, will not supervise Area Health Authorities, but will advise the Secretary of State who intends to concern himself increasingly with the work of Area Health Authorities. Individual members of the Area Health Authorities obviously will be no more accountable to the man in the street than are members o f the bodies responsible for transport, gas, electricity, and police: and like them they will be secure in their anonymity:

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Not only has publicaccountability been discarded but the Secretary of State intends to exercise considerable central control. Integration is in no better shape. The intention to have a unified administration of local hospital, practitioner, domiciliary nursing and allied services by all-embracing committees of the Area Health Authority will be difficult to achieve, for it requires an integrated medical profession. This requirement already has been discarded by the Secretary of State who has allowed general practice to be excluded fi'om the union, and to retain its special statutory committee. In addition the B.M.A..--which always has a difficulty for every solution--is demanding that regional heallh councils should no longer be advisory, but should have strengthened executive powers and be given responsibility for hospital planning, finance, and deployment of medical staltJng above the most junior grades. There has been no suggestion /'or including the indus|rial health service, or tile most depressed of all services, the prison medical service. The social services of the local authorities will have been severed from the National Heahh Service. Tile opportunity has been rejected also of establishing, through all-purpose authorities, machinery for considering coherently the many factors governing the health o f the community so as to allocate resources in the most effective way. The Town Hall is rejected and in the absence of elected regional authorities, the community must depend on the Elephant and Castle,and its selected instruments. The disadvantages of centralization of power outweigh its advantages, for it carries with it a central swarming point for pressure groups who by one successful piece of persuasion can exercise their will in places where their views are flatly rejected. The Green Paper's immutable decision to make the boundary of the Area Health Authorities co-terminous with those of local authorities, shows that some residual foresight was being exercised by removing one barrier to future changes, but this decision is unacceptable to the B.M.A. it will be instructive to see its fate if negotiations continued, for if it remains immutable it will present the medical and other professions in the National Health Service with a yardstick with which to compare the virtues of local control and those of central control to which the policies of the medical protkssion's representatives are leading them. To the relatively impartial and relatively informed observer, certain things are obvious. The trinity of public accountability, integration and all-purpose authorities needed to get value for money are little favoured. If some compromise is reached between the government and the B . M . A . that lies on the B.M.A.'s side of the Green Paper, the exercise of the last two years will be hardly worth the trouble, apart from demonstrating that it is imperative to try again on a different basis. if some sort of recognizable Area Health Authori.ties do materialize they will need medical administrators, m o s t of whom can come only from local governme~lt. They will need to have had training in modern techniques of management and be proud of it. There will be little room lbr clinicians manque who one used to encounter in local government administration, disliking their environment and looking longingly to the world they had left. All medical officers of health and senior members of their staffs should insist on attending a course of at least three months duration of full-time training in management. The basic need, not only for the Health Service, but for other national services, gas, electricity, transport, planning, and police, is a new pattern of government at local level, and until this is achieved the choice will continue to be between inadequate locat~government and inflexible central control. This is clear to all who give it their attention, and we must hope that there are enough men of good wilt in public life to defeat those interested in maintaining the present inadequate system. This paper was published separa(ely in The Lancet in July 1970.

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Chairman: Professor Wofinden, the last member o f the triad, is one o f the hardest workers for, and supporters of, the Society. He is both a Professor in the university, and a Medical Officer o f Health. I thought that his was a sort of dying race, since modern vested interests appear to be passionately against this sort of thing, and i was delighted when the other day someone from a London teaching hospital advocated the combination o f the post o f Medical Officer o f Health and Chairholder in Public Health, and added "'after all, look how well it works in Bristol".

P R O F E S S O R R. C. W O F I N D E N

Medical Officer of Health and Social Services, Bristol Professor h~ Public Health, University off Bristol What 1 would like to do, Mr. Chairman, is to introduce h a l f a dozen or so talking points, rather practical, perhaps a little bit relating to my own parish, if only to act as pegs for the members o f the audience to hang their contributions to the subsequent discussion. ! wholeheartedlyagree with much if not all of what has been said already by Dr. Dawkins and Dr. Galloway. Dr. Galloway seems to think even at this late stage something might be done to get an all-purpose health authority which is of a local government character with elected representatives. I doubt whether there is a single person in this room who would 11oi wholeheartedly agree with him, but I also doubt whether there are many people in this room w h o think that it has the least chance o f c o m i n g to fruition ; 1 hope you will not accuse me of being defeatist by saying that--! think we have got to be realists. So ! suggest that we look at the practicalities faced as we are at this time with the S e e b o h m Report, and the Local Authorities Social Services Act which is to be implemented next April, the Green Paper about to be translated into a White Paper. and so forth. H o w a m 1 looking at this at the moment in my own parish ? What am I doing now with regard to the things that might happen in the next one year, two years, or five years? ! do believe that we have to fight very hard as a public health profession--those o f us who are medical officers of health--to become the medical advisors to the new social w o r k departments. The Society pressed for this to be written in almost as a statutory requirement in the Social Services Bill. We failed, and I think it might repay us t o a s k ourselves why we failed. It might also repay us to ask ourselves why it is that we as a profession, public health doctors, are so unpopular with so many people, not least in central government circles. We have a pretty shrewd idea of why this is vis-a-vis social workers, but these are not the only people who do not love us. I suspect that one o f the reasons is that we are among the few people left w h o are in the public eye and who have authority, with a capital " A " , backed by Statute, for in these days this is the last thing that so ma0y people want. So far as the Health Service is concerned, and so far as .the medical profession is concerned, we have reached a state--which I j o i n with Dr, Galloway in d e p l o r i n g - - o f over-democratization. In fact so democratic is the Health Service nowadays that the hospital side can get little done because so many people have to be consulted. In contrast to a local authority, where there is one medical advisor to a committee which can get oll with the job, and that one medical adviser has power and authority to take action. This is the very thing, I suggest, which puts us in a bad light with so many o f our colleagues in the rest of the profession, many of w h o m detest us because we are in this very position of authority. This must be taken seriously, particularly b y those members of the S o c i e t y who are members of the Hunter Committee which is considering the whole question o f the future o f the medical administrator~, When its report comes out, and particularly if it couples

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~ith medical adminib-tration the l~nctions of the community physician, ! think it is absolutely vital that it should offer a role which is fully acceptable to the rest o f our colleagues in the medical profession. We have got the precedent of the medical superintendent, tile last man on the hospital side ~.ho had an,', authority. The Royal Colleges were determined to destroy him. and he ha~ virtually been destroyed in e~ery hospital now: there are very, ~erv few remaining. We h a \ e seen strong opposition put up against the idea o f resurrecting the medical administrator inside the hospital. We have seen the lengths that are gone to by the p o a e r s thal be, ~ith the Cogwheel Report. to democratize the process, so t+hat power is not given or put into the hands of any one person. Facing this, we must be at pains to avoid giving the impression that ,,~e are trying to get ourselves put into the position of being dictatt~rs; this. ! am sure. would be fatal to any future satisfactory development of the role either of cnmmunity physician, or of a medical administrator. Having said that. I still feel thai in those areas where no final decision has yet been made about ad~crti.,ing for social u'ork director, one should try t o get written into the conditions of ser,,icc that arrangements for the employment and deployment o f medical staff, or medical ad~ ice, in the social w o r k service, will be made through the n~tedicai olticer of health, written in bef~re even the person comes for interview as part o f the understood position in regard to the conditions o f sere, ice. I am. quite certain we are going to find in some areas that we are going to get social ,aork directors who will be extremely resistant to this and who will light it, to the detriment of the social work service, o f the remaining public health ser~:ice and, perhaps more importantly, of the client himsell: The second thing I would plead tbr is thi,,:. Many of us are developing health centres. 1 think perhaps some of us have made mistakes in that they are probably rather too small, and that we are going to ha~,e to try to make them a good deal bigger. At this stage let us see to it that in present centres if possible, but certainly in future centres, there is a base, and quite a sizeable base, for social work staff" to come in. I f w e do not, I think we are going to get quite a lot o f schism going on between the social work service and the health service, much of which may be detrimental to patients. 1 wish it were practicable for health eentres or buildings to be put in which health centre practice could go on, which were big enough to house not only the medical services for the community, but also all the social w o r k service, but this is clearly going to be impossible, having regard to the large number of social workers there arc to employ as well as other workers. But sooner or later, whether we get resistant directors of social work or not, the service is going to realize that it must w o r k very closely with the medical profession in spite of this new split which the government is going to cause between the two professions. 1 think one of the reasons why we have got this separation of social w o r k f r o m public health w o r k and from medicine, is because we have not yet convinced m a n y of our colleagues in medicine of the importance o f the social aspects of medicine. As long ago as 1944 we had the G o o d e n o u g h Committee advocating social medicine in the curriculum for medical undergraduates, we had John Ryle appointed to the first Chair o f social medicine, we had other social medicine chairs erected in different parts o f the country, but our colleagues I think, in social medicine, in medical schools, have been too late to develop concepts of social medicine in general practice on a sufficiently big scale, so that they have not given support to the public health profession at this m o m e n t of crisis, when social work has been hived off. Things might have been otherwise if we had had better training. What we have got to see to in the future in regard to medical undergraduate training, is that we get better training of the medical undergraduate in all aspects of community medicine or social medicine. Any of us who have the opportunity to m o u l d curriculae in medical schools or teach medical students, have a clear duty in this matter. 1 a m very glad

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to say in our own parish we have now succeeded with the most recent curriculum in that we are going to have as long as three months with the medical students in our department, during which time they will be taught community medicine, public health, social medicine, call it what you will, a demonstration of what goes on in the community from a health and a sickness point o f view, and all the factors leading up to sickness which haxe an influence ~on the management o f sickness and so on. One suspects that graduates in the future will benefit very considerably in their outlook from a preventive medicine point of view, as compared with their colleagues o f ten o r twep, ty years ago, and it will help us very much more in that integration o f the service which Dr. Galloway was pleading for a few moments a g o - - w e must have an intergrated profession before we can have an integrated structure. F r o m the point o f view of post-graduate training, we are going to have to go on modifying our existing D.P.H. courses. We have modified ours fairly recently and we may have to modify it still more in the light of events, but one suggestion which 1 should like you to give some thought to is this--those of you who are responsible for D.P.H. courses or contribute to teaching D.P.H. courses--that we must give the students something more in regard to clinical medicine. Atwyn Smith, who is developing a sort o f fifth arm o f his two-year D.P.H. course of advances in medicine, a unit course so to speak, has a very good idea, and this is going to be increasingly necessary in the future in an integrated service in which community physicians are going to play an important key role. They must understand very much more about recent developments in clinical medicine if they are going to be responsible for the organization and administration of curative services as well as preventive services. Perhaps this is where some o f us in the r ~ e n t past have missed out in not being close enough to clinical medicine, particularly at the top o f our hierarchies. Another very clear need in the near future is going to be the inservice training o f the middle tiers of staff in the present public health service~ with a view to getling them employed in an integrated service, and it is up to every one of us, as medi~'at officers ol" health, to look at our staff and ask ourselves which we must send away for training and what kind o f training. Indeed this applies not only to the middle tier staffs who may become the future medical administrators or deputy medical administrators, but staff at all levels. Some o f you will k n o w that the London School o f Hygiene and Tropical Medicine is hoping to launch, in the not too distant future, some kind of really high-powered training courses in medical administration and perhaps in epidemiology, for staff in post who are going to need in-service training and re-orientation with a view to working in an integrated service. I doubt whether the School is going to be able to do this for the whole country; other university centres may have to do likewise, but it m a y repay the Society also if the Government are going to lend support to the idea o f an integrated service and a c o m m u n i t y physician, for them to give financial aid, specially arranged aid if need be, to local authorities to get staff trained. If after all there is an integrated service as envisaged in tt~e Green Paper M a r k II, it is going to be a very, very closely centralized service, and I am afraid that 'the doctors employed in it are going to be very much the Establishment's doctors. If so, it's u p to those at the centre to pay for' such training, because if the local authorities think that they are going to lose health services, we may be having a thin time money-wise for the next few years until such time as there is an integrated service. I think the Society set a very good example with its six-week course in developmental paediatrics, 1 think the three-weeks course for ascertainment of E.S.N. children is very good also, but the time is coming when we r e a l l y o u g h t ~ t o press the Colleges to revise once again the Diploma in Child Health course, turning it into a course in social pae~tiatrics, taking in both developmental paediatrics and the ascertainment material, and covering an academic year. This will be invahmble for many o f our present medical officers in

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departments, with a view to their employment in an integrated service as social paediatricians who. whether we like it or not, or rathcr whether the hospital physicians like it or not, are going to be needed in such service, because there just are not enough paediatricians to do this, and the paediatricians that we have are by no means all socially oriented. If we as M.Os.H. can look at problems in this kind of way and work towards these ends we shall be having plenty to do. even though we are going to be losing many of our social services as from April next year. There is much else for us to do and some o f it has been very well dealt with by Dr. Elliott in his first class exposition on the community physician, published by the C o u n t y Councils Association. Even if we have to wait a long time between the implementation o f Seebohm next April and the advent of an integrated health service which may be five, six or even more years away, we can do much to mould an integrated service even short o f one that is statutority provided. General Discussion--Final Session Inevitably the discussion was greatly concerned with the pending integration--or ref r a g m e n t a t i o n - - o f health and social services. There were wistful glances toward the ideal o f complete unification o f all services under a single local executive body. It was not to be expected that this could be regarded as a practical proposition at the present day but fears were expressed that the proposals for the near future might postpone rather than accelerate the implementation of the ideal. It was candidly admitted that the first reaction of those working in the various disciplines might naturally be to ask "what is there in it for m e ? " or at least " h o w can I relain a reasonable part o f what 1 at present enjoy?" Dr. Dawkins's paper was taken as a salutary reminder that the " G r e e n Paper" type o f re-organization of health services, to which the government of the day seemed to be committed and to which any near-future government might also feel committed, could too easily separate the personal services from the environmental services. The danger lay not wterely in the leaving o f the public health inspectors with the local authorities while the medical olticers went to the heahh boards, but in the losing of the wider functions o f the M.O.H. as a general adviser on the health aspects of, all the services provided by local authorities. T h a t there should be at "district" level a doctor specifically charged with looking at all the health aspects of living and able t.o keep them in perspective was vitally important. The imperative need for a statutory link between the community physician and the local authority was stressed, with the comment that this must be provided at "'working level" as well as at higher levels o f administration. In this context, attention was also called to the risk that if there were a substantial time-lag between the re-organization o f the N.H.S. and the reform o f local government, contact between the fairly large health boards and the smaller existing local authorities might become so tenuous that it would be hard to restore it. There were misgivings about the place of even the personal health services in the new structure. Already it appeared that the first Green Paper's ideas had been modified to the point at which general practitioner services would be the concern o f a new sort o f Executive Council rather than o f the Health Board as such; would the hospital doctors also prefer to maintain a kind o f separation defacto within a unity de jure? What kind of rapprochement mig,L~t be attempted in the period before re-organization-why should the g r o u n d not be prepared by bringing the M.O.H. and some o f the clinical public health doctors into the develo~ping "'Cogwheel" structures ?

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As regards relationships between the departments of social services and the health departments (and, in time, the Health Boards) there was more pessimism than optimism. For quite understandable reasons, there xvas a probability that Directors of Social' Services and their staffs might tend to be shy of making advances to the health department and, also, that co-operative overtures from the health side might be misunderstood. Experience had shown that goodwill between individuals could bridge administrative gulfs and in time that goodwill could be built up; the manner of the implementation o f the Seebohm Report, however, had hardly been such as to provide positive incentives to goodwill. It has been said that a main function of such conferences as this is less to seek final solutions than to try to answer present questions in such a way as to clear the ground for the asking o f newer and more apposite ones. It is clear that in this sense the Symposium was a conspicuous success and that not only the individuals who x~'ere present but the general cause of medical understanding must have gained substantially.