NHS Bill 1946

Summary of the proposed new service Command paper no 6761

Presented by the Minister of Health to Parliament by Command of His Majesty March 1946

NATIONAL HEALTH SERVICE BILL

SUMMARY OF THE PROPOSED NEW SERVICE

This paper contains a general description of the proposed health service with which the Bill deals. It is intended only as a factual summary, omitting comment or argument. Moreover, being only a  general summary, it cannot always be in precise terms and it is to the Bill itself, not this paper, that anyone must look for more exact definition of what is proposed.

INTRODUCTORY

1. The Bill provides for the establishment of a comprehensive health service in England and Wales. A further Bill to provide for Scotland will be introduced later.
2. The Bill does not deal in detail with everything involved in the service. It deals with the main structure. Within that structure, further provision will be made by statutory regulations on lines which the Bill lays down and subject always to the control of Parliament.

Scope of the service

3. The Bill provides for the following kinds of health services:-

(i) Hospital and specialist services-i.e. all forms of general and special hospital provision, including mental hospitals, together with sanatoria, maternity accommodation, treatment during convalescence, medical rehabilitation and other institutional treatment. These cover in-patient and out-patient services, the latter including clinics and dispensaries operated as part of any specialist service. The advice and services of specialists of all kinds are also to be made available, where necessary, at Health Centres and in the patient’s home.

(ii) Health Centres and general practitioner services-i.e. general personal health care by doctors and dentists whom the patient chooses. These personal practitioner services are to be available both from new publicly equipped Health Centres and also from the practitioners’ own surgeries.

(iii) Various supplementary services including midwifery, maternity and child welfare, health visiting, home-nursing, a priority dental service for children and expectant and nursing mothers, domestic help where needed on health grounds, vaccination and immunisation against infectious diseases, additional special care and after-care in cases of illness, ambulance services, blood transfusion and laboratory services. (Special school health services are already provided for in the Education Act of I944.)

(iv) The provision of spectacles, dentures and other appliances, together with drugs and medicines at hospitals, Health Centres, clinics, pharmacists’ shops and elsewhere, as may be appropriate.

Availability of the service

4. All the service, or any part of it, is to be available to everyone in England and Wales. The Bill imposes no limitations on availability e.g. limitations based on financial means, age, sex, employment or vocation, area of residence, or insurance qualification.
5. The last is important. If the National Insurance Bill now before Parliament is passed into law, almost everyone will become compulsorily insurable, and after payment of the appropriate contributions will become, entitled to the various cash benefits-including sickness and maternity benefits-for which that Bill provides. A proportion of their contributions will be used to help to finance the health services under the present Bill, but the various health service benefits under the present Bill are not made conditional upon any insurance qualification or the proof of having paid contributions. There are no waiting or qualifying periods.
6. The service is to be available from a date to be declared by Order in Council under the Bill and it is hoped that this will be at the beginning of the year I948.

The service to be free of fees or charges

7. The health service is to be financed partly from the exchequer, partly from local rates, partly from the help (mentioned above) which part of the National Insurance contributions will give. There are to be no fees or charges to the patient, with the following exceptions:-

(i) There will be some charges (to be prescribed later by regulations) for the renewal or repair of spectacles, dentures and other appliances, where this is made necessary through negligence in the care of the articles provided.

(ii) There will be charges (taking into account ability to pay). for the provision of domestic help under the Bill and for certain goods or articles (e.g. supplementary foods, blankets, etc.) which may be provided in connection -with maternity and child welfare or the special care or after-care of the sick.

(iii) It will be open to people if they wish, in certain cases, to pay for additional amenities within the arrangements of the service–e.g. to pay extra for articles or appliances of higher cost than those normally made available, or to pay charges for private rooms in hospitals (which they will nevertheless be able to obtain free where privacy is medically necessary).

General organisation of the service

8. The Bill places a general duty upon the Minister of Health to promote a comprehensive health service for the improvement of the physical and mental health of the people of England and Wales, and for the prevention, diagnosis and treatment of illness. To bring physical and mental health closer together in a single service, it transfers to the Minister the present administrative functions of the Board of Control in regard to mental health (the Board retaining only its quasi-judicial functions connected with the liberty of the subject).
9. The Bill proposes that the Minister shall discharge his general responsibility through three main channels:-

(a) For parts of the service to be organised on a new national or regional basis-i.e. hospital and specialist services, blood transfusion and bacteriological laboratories for the control of epidemics–the Minister is to assume direct responsibility; but he is to entrust the actual administration of the hospital and specialist services to new regional and local bodies established under the Bill. These bodies are to act on his behalf in suitable areas to be prescribed by him, and they are to include people of practical experience and local knowledge and some with professional qualifications. Special provision is made for hospitals which are the centres of medical and dental teaching.

(b) For parts of the service to be organised as a function of local government-i.e. the provision of new Health Centre premises and a variety of local domiciliary and clinic services direct responsibility is put upon the major local authorities, the county and county borough councils. They will stand in their ordinary constitutional relationship with the central Ministry, but their general arrangements for these local services are made subject to the Minister’s approval.

(c) For the personal practitioner services both in the Health Centres and outside–i.e. the family doctor and dentist and the pharmacist-new local executive machinery is created, in the form of local Executive Councils. One half of the members of each of these Councils will consist of people nominated by the major local authorities and by the Minister, and the other half of people nominated by the local professional practitioners concerned. There will normally be an Executive Council for each of the major local authorities’ areas, and they will work within national regulations made by the Minister.

10. By the Minister’s side, to provide him with professional and technical guidance, there is to be set up a Central Health Services Council. This will include people chosen from all the main fields of experience within the service with various standing committees of experts on particular subjects, medical, dental, nursing and others.
11. Each of these branches of the new organisation is described in more detail in the nest of this paper.

HOSPITAL AND SPECIALIST SERVICE

12. This part of the service covers hospital and consultant services of all kinds, including general and special hospitals, maternity accommodation, tuberculosis sanatoria, infectious diseases units, provision for the chronic sick, mental hospitals and mental deficiency institutions, accommodation for convalescent treatment and medical rehabilitation, and all forms of specialised treatment-e.g. orthopaedics, cancer, neuro-surgery, plastic surgery, paediatrics, gynaecology, ophthalmic services, ear, nose and throat treatment, and others.
13. It is made the Minister’s general duty to provide these physical and mental hospital services but he is to entrust their administration to Regional Hospital Boards, together with separate Boards of Governors for the teaching hospitals, in manner to be described later.
14. The existing premises and equipment of voluntary and public hospitals are transferred to the Minister under the Bill, and he is empowered also to acquire by purchase-if necessary—other hospitals and their equipment which may be required for the purposes of the new service. If in any particular case he is satisfied that the transfer of a hospital is not in fact necessary for the new service he can-with that institution’s concurrence–except it from transfer. The general transfer of hospitals includes the present mental hospitals and mental deficiency institutions.
15. The endowments of voluntary teaching hospitals defined in the Bill to mean, broadly, all their property other than buildings and their contents will pass, not to the Minister, but directly to the new Boards of Governors, who are to be free to use them as they think best but are required, so far as practicable, to see that the purposes for which they were previously usable are still observed.

16. The endowments of other voluntary hospitals are to pass to a new Hospital Endowment Fund which the Minister is to set up and administer in the following way. He is first to meet from the Fund, to such extent as may be settled by subsequent regulations, existing debts and liabilities attaching to the voluntary hospitals concerned. He is then to apportion the capital value of the Fund among the several Regional Hospital Boards and, as it were, to earmark to each a portion. The income of each portion will then pass automatically to each Board and it will be free to use it as it wishes, within such general conditions as may be prescribed. Any Board will be able also at any time to draw on its portion of the capital for any purpose which the Minister approves.
17. The Boards – and the Boards of Governors of teaching hospitals – are fully able under the Bill to receive gifts or legacies, and to hold any property on trust, for any purposes connected with the hospital or health services.
18. The detailed arrangements affecting the new Hospital Endowment Fund, its apportionment and administration, are left to be settled by later statutory regulations.

Hospital administration

19. The Minister is to entrust the future administration of all the hospitals (other than teaching hospitals) to Regional Hospital Boards to be set up under the Bill for such hospital service regions of the country as he will prescribe each region being such that its services can conveniently be associated with a university medical school. There will probably be between sixteen and twenty of these regions.
20. Each Board will be composed of people chosen and appointed by the Minister for their individual suitability for the task, but before making the appointments the Minister is to consult any university with a medical school in the region, bodies representative of the medical profession, the local health authorities of the area, and others concerned including, initially, those with experience of the voluntary hospital system. The Boards are to include some members with experience of the mental health services.
21. Each Board is required by the Bill to appoint, in accordance with a scheme approved by the Minister, local Hospital Management Committees, one for each large hospital or related group of hospitals forming a reasonably self-contained hospital service unit. Each of these Management Committees will contain members appointed after consulting the major local authorities in its area, the Executive Councils for the general practitioner services in its area, the senior medical and dental staff of the hospitals concerned, and others, including those with experience in voluntary hospitals.
22. It is to be the duty of the Regional Boards, within the scope of general regulations and such particular directions as the Minister may give, to undertake on his behalf the general administration of the hospital and specialist services in their regions. With the Minister, and in collaboration with the teaching hospitals, each Board will plan, and execute the plan for, a co-ordinated hospital and specialist service for its region.
23. It is to be the duty of the Management Committees to carry out day to-day management of the particular hospitals under their control—within such limits as are to be prescribed by the Minister. They are to be the local managing bodies on the spot, and they will, for example, appoint nursing and other general staff (appointing them as employees of the Regional Boards). They will be able, as required, to set up small house-committees for any individual hospitals within their care.
24. It is the object that the Regional Boards, with their local Management Committees, shall enjoy a high degree of independence and autonomy within their own fields. Their use of existing voluntary hospital endowments has already been described. For the general financing of their hospital services, however, they will look to the Exchequer and they will be given as much financial freedom – by a system of block annual budgets or otherwise – for local initiative and variety of enterprise as general principles of exchequer responsibility make possible.

Teaching hospitals

25. Special arrangements are provided for teaching hospitals–that is, hospitals or groups of related hospitals which are designated by the Minister as providing the facilities for undergraduate or post-graduate clinical teaching. These will enable any hospital or group of hospitals to attain “teaching” status whether it is already a teaching hospital at the outset of the scheme or not.
26. The general system of Regional Boards and Management Committees will not cover the teaching hospitals. The Minister is to constitute for each such hospital or group of hospitals its own separate Board of Governors, including members nominated by the university, the Regional Board for the area, and the senior staff of the hospital itself and members appointed after consultation with the major local authorities and other organisations concerned, including the previous governing bodies. The Board of Governors of a teaching hospital will be responsible generally for administering their hospital on the Minister’s behalf.
27. The financial arrangements in regard to existing voluntary endowments of the teaching hospitals -have already been described. For the general financing of their services they will look to the exchequer and again the general object will be to assure them all the financial freedom and autonomy of management which the general conception of a nationally reorganised and nationally financed service makes possible. In this case, in addition, it is intended to keep in the forefront of any arrangements the special position of these hospitals as the centres of clinical teaching and technical experiment and innovation.
28. The fact that special administrative and financial arrangements may be made for teaching hospitals does not mean, however, that these hospitals are not to form an integral part of the hospital service as a whole. They will be joined with the Minister and the Regional Boards in the general planning and arrangement of the hospital services of each Region, and the Regional Boards will be represented on their Boards of Governors.

Medical and dental schools

29. Medical and dental schools are not to be transferred to the Minister or to the Board of Governors of the teaching hospital with which they are associated. No property which is held for the purposes of these schools is to be transferred. The schools will continue to be owned and administered, in London, by their own governing bodies, and elsewhere by the governing bodies of the universities of which they form part; and the Bill. provides for the transfer , of any existing hospital property held for school purposes to these governing bodies.
30. The Bill contains also a special provision relating to medical and dental schools, based on recommendations of the Interdepartmental Committee on Medical Schools (the Goodenough Committee). Any medical or dental school of London University which is not yet a body corporate is required to take; steps within six months of the passing of the Bill to become incorporated.

Hospital staffs

31. The staff of all hospitals in the service will be in the employment of the Regional Boards or Boards of Governors of teaching hospitals, as the case may be. Specialists taking part in the service, whole time or part-time, will be attached to the staff of hospitals. Part-time participation in the service will not debar the specialists from also continuing any private practice outside the service which individual patients may wish them to undertake.
32. Special provision is to be made by regulations affecting the appointment of senior medical and dental staff employed on the staff of hospitals. In these cases the Regional Board or the Board of Governors, as the case may be, is to be required to advertise vacancies and to constitute an expert advisory appointments committee. This committee will draw up a list, from among the applicants, of those suitable by qualification and experience for the vacancy, and the person to be appointed will then be selected from that list by the Board.
33. The Boards will determine the terms of engagement of any staff employed in the hospital service. The Minister, however, is empowered to make regulations governing the qualifications, conditions of service and remuneration of any or all classes of hospital staff–as of the staff engaged in any other part of the health service. Before making regulations he will consult any appropriate organisations representing the staffs concerned, and it will be his intention–wherever appropriate –to use existing, or set up new, negotiating machinery to facilitate those consultations. Existing hospital officers employed on a paid whole-time basis are to be protected, either by being transferred to the new bodies or by compensation if they are not transferred or are re-employed on less favourable terms than before.

“Pay-bed” accommodation

34. Where there are single bedrooms or small wards in hospitals the Minister is empowered to make them available to patients who wish to buy greater privacy by paying the extra cost; but this is to be subject always to the requirements of patients who need such accommodation on medical grounds, and they will be able to have it without payment.
35. In addition, the Minister is empowered to provide separate pay bedrooms or blocks for which people can pay the whole cost privately and in which part-time specialists within the service can treat private patients. This power is subject to the Minister’s deciding, in each hospital, whether it is reasonable to provide such private accommodation having regard to the needs of the general service, and it is also subject to the overriding right of other patients to be admitted to it, without payment, if medical considerations urgently require it. Private patients using the accommodation will pay their own specialists’ fees, but the Bill enables the Minister to prescribe maximum fees which specialists may charge in these circumstances.

Other centralized services

36. The Minister is made directly responsible for the provision of two other services, both of them developed from services which have grown up during the war.
37. The first is a bacteriological service for the control of the spread of infectious diseases, including, in particular, the provision of laboratories. These will be operated – at least in the first instance – by the Medical Research Council on the Minister’s behalf and their services can be made available to medical men and others who wish to make use of them.
38. The second is a blood transfusion service for the collection of blood from volunteer donors, the provision of “blood banks” and blood products at hospitals and of mobile transfusion teams which will be on call for hospitals not possessing facilities of their own and for specialists and general practitioners.
39. The Minister is also expressly empowered by the Bill to conduct research, and to give financial help to voluntary agencies conducting research, into any question relating to the prevention, diagnosis or treatment of illness or mental defectiveness. Boards of Governors of teaching hospitals and Regional Boards are also empowered to conduct research.

GENERAL PRACTITIONER SERVICES

40. This part of the service covers the personal health services provided by general medical practitioners and dentists and the supply of drugs, medicines and appliances.
41. To arrange these services locally new bodies – to be called Executive Councils –are to be established in the area of each county and county borough. As already explained, each Council is to be so composed that one half of its members are professional – appointed by the local doctors, dentists and chemists through their own representative committees in the area – while the other half of the members are to be appointed partly by the local county or county borough council (one third of the Executive Council) and partly by the Minister (one sixth). The Chairman will be appointed by the Minister. Single Executive Councils may sometimes be established for the areas of two or more local authorities.

Health Centres

42. A main feature of the personal practitioner services is to be the development of Health Centres. The object is that the Health Centre system, based on premises technically equipped and staffed at public cost, shall afford facilities both for the general medical and dental services (described immediately below) and also for many of the special clinic services of the local health authorities (described later), and sometimes also for out-post clinics of the hospital and specialist services (already described). Beside forming a base for these services – e. g. providing doctors with equipped and staffed consulting rooms in which to see their patients-the Centres will also be able to serve as bases for various activities in health education.
43. The Bill makes it the duty of the county and county borough councils to provide, equip, staff and maintain the new Health Centres to the satisfaction of the Minister. The local authorities will directly administer such of their own local clinic facilities as they may provide in the Centres. Doctors and dentists, however, who use the new Centres while participating in the general personal practitioner service will be in contract only with the new Executive Councils, and it will be for those Councils t-o arrange with the local authorities for the use of the Centres’ facilities by those doctors and dentists. In the case, for instance, of doctors in the general practitioner service the Centres will, in effect, stand in place of the doctors’ own surgeries and the doctors’ responsibilities to their patients on their personal lists – e.g., in visiting their patients’ homes and in general responsibility for their patients art all times-are not affected by whether a doctor practises from a Health Centre or not.

Family doctor service

44. All doctors are to be entitled to take part in the new arrangements in the areas where they are already practising when the scheme begins. Taking part will not debar them from also continuing to make private arrangements for treating such people as still wish to be treated outside the service instead of taking advantage of the new arrangements, provided that such persons are not on their lists as public patients or on the lists of their partners in a Health Centre. People will be free to choose their own doctor (including their present doctor) subject to the doctor’s consenting and being in a position to undertake their care.
45. All doctors taking part in this part of the new service will be in contract with the Executive Council for the area in which they practise. The Executive Council will be required to draw up and publish lists of all general practitioners who wish to participate. People will then choose their doctor and each doctor will have his own list of the people whom he has agreed to attend. There will be machinery for allocating among the doctors concerned such people as wish to take advantage of the service but have not chosen a doctor for themselves or have been refused by the doctor chosen by them. The relationship of the doctor with any person on his list – i.e., his functions under this part of the service – will then be similar to the ordinary relationship of doctor to patient as it is now known, except that the doctor’s remuneration will come from public funds and not directly from the patient.
46. The Bill itself does not determine the detailed terms and conditions for doctors joining in the service or the doctors’ remuneration. These are left to be settled by regulations and the necessary regulations will be made in consultation with the doctors’ professional representatives. It is, however, the intention that remuneration should take the form of a combination of fixed part-salary and of capitation fees, the latter varying with the number of persons whose care is undertaken by each doctor and being so graduated as to diminish in scale as the total number of patients rises. Variations of the fixed part-salary will be possible so as to take account of different circumstances and experience and the differing conditions of practice in particular areas. It is intended also to institute, under powers contained in the Bill, a contributory superannuation scheme for doctors taking part in the new arrangements.
47. Actual rates of remuneration for doctors can be determined, in consultation with the profession, only after the report has been received of the Spens Committee – a special committee set up, by agreement with the profession’s representatives and under the chairmanship of Sir Will Spens, with a membership half medical and half non-medical, to make an independent report on the appropriate range of remuneration for doctors taking part in a publicly organised service of this kind.
48. When the necessary regulations affecting terms of service and remuneration have been settled it will be for the Executive Councils to contract with the doctors on the lines thus prescribed.

Distribution of medical practices

49. To help in dealing with the needs of under-doctored areas it is intended, as already indicated, to adjust the scales of remuneration of doctors so as to provide additional inducement to practise in less attractive areas. In addition, a new body to be called the Medical Practices Committee, mainly professional in composition, is to be appointed under the Bill to regulate in future the succession to old, or the opening of new, practices within the service.
50. To begin with, an appointed day will be fixed and all doctors then in practice will have the right to have their names included on the lists drawn up by the Executive Councils for the areas in which their existing practices are. After the appointed day any doctor who wishes either to join the public service for the first time or, if he is already in it, t-o go and practise in a new area will need to obtain the consent of the Medical Practices Committee. He will normally ask to have his name included in the list of the Executive Council for the area of his choice and that Council will inform the Committee. The Committee may give consent either unconditionally or subject to a condition as to the general part of an Executive Council’s area in which he practises. They will not be able to withhold consent on any ground except that there are already enough doctors practising in the public service in the area in question. If, when a practice becomes vacant in a particular area, there is more than one applicant for taking it over, the Committee will decide to which doctor the necessary consent is to be given. A doctor whose application to practise in a particular area is refused, or granted only subject to conditions, is given the right to appeal to the Minister.
51. Regulations governing all these arrangements will, among other things, require Executive Councils to report from time to time to the Medical Practices Committee on the number of doctors required to meet the needs of their arms and on the existence of vacant practices on their lists. Sale and purchase of practices and compensation
52. The above control of succession to, or opening of, practices will apply to all practices, which are wholly or partly within the service. It will, there- fore, make the sale of the goodwill of such practices inappropriate, and the Bill provides for the prohibition of the sale of such practices in future and for compensation to existing practitioners in respect of the consequent loss of selling values.
53. Doctors who join in the public service at the outset will be entitled to compensation in respect of loss incurred through being unable thereafter to sell their practices. In addition, any doctor who dies or retires from practice between the passing of the Act and the appointed day, and whose practice has not been sold in the meantime, will quality for compensation. If he is compensated, his practice will be regarded as having come within the service at the appointed day.
54. The total amount of compensation to be made available to the profession under the Bill is a sum of £66 millions for England and Wales and Scotland, and the appropriate proportion of this is authorised to be paid in England and Wales under the present Bill. Provision is made for the total sum to be reduced if the number of practitioners taking part in the service falls substantially short of the expected total.
55. Regulations will govern the detailed method of apportioning the global sum among the doctors entitled to compensation and the manner and times at which it is to be paid. It is intended that the settling of the apportionment of compensation among the individual doctors shall be left in the main to the profession itself and the Minister will accept any reasonable proposals within the total sum. Normally compensation is to be payable on the retirement or death of a doctor, though payment at an earlier date will be arranged where hardship (e.g. through outstanding debts) would otherwise arise. In the meantime interest on the compensation due is to be paid each year to the doctor at the rate of 2% per cent. per annum.

Doctors and the Health Centres

56. As and where the new Health Centres are developed existing doctors in the area will be able, if they wish, to use the consulting rooms and other facilities so provided in place of their present surgeries, so tar as they are participating in the new service. Their doing so will not affect the general arrangements already described.
57. Any group of doctors joining in practice from a Health Centre, however, will be encouraged – wherever possible – to enter into a partnership arrangement whereby their joint remuneration within the service is pooled and then divided among them on some agreed basis of apportionment.

Supply of drugs, medicines and appliances

58. Those who use the general practitioner service will be entitled to the supply, free of charge, of necessary drugs, medicines and appliances. A charge will be made if appliances have to be prematurely repaired or replaced as a result of carelessness, and if the patient chooses to be supplied with more expensive appliances than those normally supplied he will be expected to meet the additional cost involved.
59. Every properly qualified pharmacist who wishes to join in the new service will have the right to do so. The Executive Council in each area is to draw up and publish a list of pharmacists who join in the service, and patients will be able to obtain their supplies on the prescription of their doctor either from the shops or other premises Off a pharmacist or from any Health Centre where dispensing services are provided, as the patient chooses. Drugs, medicines and appliances required for hospital purposes will be supplied as part of the hospital service.
60. Regulations, made in consultation with the professional organisations concerned, will govern the detailed terms and conditions, and rates of remuneration, on which pharmacists participate in the new arrangements.

Dental service 

61. The arrangements for dental services will be on rather a different basis from the family doctor service. Priority will be given to expectant mothers and young people. This is to be done through the local health authority’s maternity and child welfare service (which the Bill expressly provides is to include dental care) and through the school health services under the Education Act, 1944. Outside the priority arrangements there will be a general dental service made available, but there will not at first be any guarantee that all people will be able to obtain full dental care without waiting. Any dentist who wishes to participate in the general dental service will have the right to do so, and the Executive Council in each area will draw up and publish a list of those who undertake to participate in the service.
62. The object will be to develop general dental services in the Health Centres, or corresponding Dental Centres, as much and as quickly as possible. In the Centres it is intended that dentists shall be able to participate either whole-time or part-time and shall be remunerated by appropriate salaries for the amount of time which they give to the new service. Outside the Centres it will be open to anyone to arrange with any dentist in his own surgery who agrees to undertake his or her dental care. The dentist will normally be able to start treatment without further reference and subsequently to submit a claim for payment from public funds. For certain forms of treatment, however, the dentist will submit an estimate of what is required to a new professional body established by the Bill-the Dental Estimates Board. The Board will have branch offices In different parts of the country whose function it will be to approve dentists’ estimates for treatment to be given or appliances to be supplied. Payment will be made to the dentist by the Executive Council in accordance with a prescribed scale of fees or, in some cases, on special estimates determined by the Dental Estimates Board.
63. The detailed terms and conditions, and rates of remuneration, on which dentists will participate in the service are not settled in the Bill itself, but – as with the doctors – are to be the subject of subsequent regulations made in consultation with the profession’s representatives. The general range of remuneration is to be settled in the light of the findings of a committee established (by agreement with the profession) on lines similar to the Spens Committee on doctors’ remuneration. Dentists taking part in the general dental service will not be debarred from treating under private arrangements anyone who does not wish to take advantage of the service.
64. When the appropriate regulations affecting remuneration and general conditions of participation in the service have been settled, it will be for the Executive Council to contract with the dentists on the lines so prescribed.

Eye services

65. The object is to secure that the care of the eyes, with sight-testing and the supply of spectacles, is carried out-as rapidly as resources special ophthalmic departments and clinics forming part of the hospital and specialist service. These clinics will be in the charge of specialist medical ophthalmologists, and in them the qualified sight-testing opticians will also play their proper professional part. Spectacles will be obtainable either at the clinics themselves or at the premises of dispensing opticians taking part in the service.
66. While this full eye clinic system is developing, however, a supplementary eye service is to be arranged by the Executive Councils in each area. Their arrangements are to be made with suitably qualified general medical practitioners, sight-testing opticians and dispensing opticians who undertake the supply of spectacles. The whole of the arrangements are to be entrusted by each Executive Council to a special committee—an Ophthalmic Services Committee-which will draw up and publish lists of the medical practitioners and opticians who have the necessary qualifications and who wish to participate in the service, on the same lines as the lists of doctors and dentists. The patient will then have freedom of choice among the doctors and opticians on the lists.
67. As in the rest of the general practitioner services, the terms and conditions and rates of remuneration of those participating in the supplementary eye service, arranged by the special Committee of the Executive Council above, will be the subject of later regulations.
68. People will be entitled both to sight-testing and to the supply of spectacles, free of charge, either at the specialist ophthalmic clinics or through the supplementary scheme just described. The Bill provides, however, that as soon as the Minister is satisfied that adequate ophthalmic services are being provided in any area through the specialist clinic services -he may wind up the supplementary service in that area.

Miscellaneous

69. A special Tribunal is to be set up to investigate cases where it is claimed – either by the Executive Councils or otherwise – that the continued inclusion of any doctor, chemist, dentist or optician in the lists drawn up by the Executive Councils would be prejudicial to the efficiency of the service. The Tribunal will have a legal chairman appointed by the Lord Chancellor and will in each case include a member of the same profession as the person whose case is being investigated and one other the latter two being appointed by the Minister. Where it is satisfied that the representations are justified, the Executive Council will be directed to remove from the list the name of the doctor, dentist, chemist or optician, who is given the right to appeal to the Minister. W-here the Tribunal so decides a similar direction can be applied to all lists in all areas, with the same right of appeal.
70. Provision is also made that Wll16I’6 any doctor, dentist, chemist or optician has already been disqualified from participation in the present National Health Insurance service, and the disqualification has not been removed, he shall not have the right to participate in the new service.

71. Where the Minister is satisfied, after inquiry, that the services provided by doctors, dentists, or chemists in any particular area are not adequate he is empowered to take such steps as he considers necessary to secure an adequate service.
72. The Minister is empowered to arrange with universities and medical and dental schools for the provision of “refresher” courses for doctors and dentists in the service, to con-tribute towards the cost of these courses and to pay the expenses of doctors and dentists attending them.

LOCAL GOVERNMENT SERVICES

73. This part of the health service comprises the local and domiciliary services which are appropriate to local government, rather than to central government or to any specially devised machinery. The Bill unifies these services in the existing major local authorities-the county and county borough councils-and provides for the formation of joint boards wherever, exceptionally, this may be found desirable.
74. For most of these services, the Bill requires the local health authorities (as they are to the called) to indicate to the Minister the way in which they intend to carry out their responsibilities, and it requires the Minister’s general approval. Their proposals, so indicated, are to be made known also to the Regional Boards and Boards of Governors -for the hospital service, to the Executive Councils for the general practitioner services, and to any voluntary organisation which to the local authority’s knowledge is working in the same field in their area.
75. The purpose of this last requirement is to ensure that these local arrangements are fitted appropriately to the hospital and specialist services for which the Minister is more directly responsible and to the general practitioner services which will be operated within his general regulations and control. This inter-relation between the different arms of the health service is reinforced by the provision (already mentioned) for the local health authorities to nominate one-third of the members of the Executive Councils for the general practitioner services and to be consulted by the Minister in the appointment of Regional Boards, Management Committees and Boards of Governors in the hospital and specialist services.
76. It will also be reinforced. in the ordinary process of administration by the personal contacts of the local Medical Officers of Health and the principal medical and other officers of the other bodies, and -by various practical devices such as the establishment of local co-ordinating committees of medical and other officers and by the use, wherever feasible, of common employment by different bodies of the same part-time medical or other staff.
77. The various functions comprised in the local government part of the health service are summarised below.

Maternity and child welfare and midwifery

78. The Bill makes it the duty of every local health authority to make arrangements for the c-are of expectant and nursing mothers and of children under five years of age who are not attending school and who are therefore not covered by the school health service. Their arrangements will include ante-natal clinics for the care of expectant mothers, post-natal and child clinics, the provision of such things as cod-liver oil, fruit juices and other dietary supplements and, in particular, a priority dental service for expectant and nursing mothers and young children.
79. The Bill transfers these functions from such of the present “minor” authorities-the non-county boroughs and the district councils-as are at present exercising them. But, for co-ordination with the school health services, provision is made for delegating child welfare to “district executives” in the same way–and with the same rights for the minor authorities-as is done for the school health service under the Education Act, 1944.
80. The same authorities-county and county borough councils-are also made the supervising authorities for the purposes of the existing Midwives Acts; that is to say, they are made responsible for a complete midwifery service for mothers who are confined at home. The midwives are to be employed either by the local health authority itself or by voluntary organisations with whom the authority comes to an appropriate arrangement. Attendance at the confinement is not to be made the general duty of the doctor within the general medical practitioner service, but the midwife will have the usual right and duty to call in a suitably qualified doctor in case of need. The general practitioner’s services will nevertheless be available to the ordinary extent of general advice and health care to a woman before and after confinement as at any other time.
81. Mothers who for any reason have their confinements in a hospital or maternity home will be in the care of the hospital and specialist service. It will also be the object of that service to provide locally for all specialist obstetric or gynaecological care which may be needed in relation to the ordinary domiciliary service of the local authority. The requirement of Ministerial approval to the local authority’s arrangements will link together the two aspects of the maternity service – domiciliary and institutional.

Health visiting and home nursing

82. It is made the duty of the local health authority to provide for a full health visitor service for all in their area who are sick, or expectant mothers, or those with the care of young children. This widens the present conception of health visiting (as concerned with mothers and children) into a more general service of advice to households where there is sickness or where help of a preventive character may be needed.
83. It is also made the duty of the local health authority to provide a home nursing service for those who – for good reason – need nursing in their own homes.
84. In both of these activities the local authority can, if it likes and if the Minister approves, make all or part of its provision by arrangement with voluntary organisations to act on its behalf.

Local mental health services

85. The main mental treatment and mental deficiency services are to be part of the new hospital and specialist arrangements under the Bill. Local health authorities, however, are given responsibility for all the ordinary local community care in the mental health service-that is to say, the ascertainment of mental defectives and their supervision when they are living in the community. This part of the service covers also the initial proceedings for placing under care those who require treatment under the Lunacy and Mental Treatment Acts.

Vaccination and immunisation

86. Compulsory vaccination is to be abolished by the Bill, but it is to ‘be the duty of the local health authority to provide free vaccination and diphtheria immunisation for anyone who desires them. This service the authority will provide by making arrangements with doctors who are taking part in the general practitioner service-paying appropriate fees to those who undertake it. The vaccines, sera or other preparations required may be supplied without charge by the Minister to local health authorities and doctors and the service may, if circumstances demand, be extended to cover vaccination and immunisation against other diseases beside smallpox and diphtheria.

Ambulance service

87. Apart from vehicles which may need to be provided as part of the hospital service, the provision of the main ambulances and hospital transport required for the health service becomes the duty of the local health authorities, either directly or by arrangement with voluntary organisations. In future the local health authority’s ambulances may – and must, if necessary — operate outside their own area.

Care and after-care of the sick

88. Local health authorities are given a new power, and duty where the Minister so requires, to make approved arrangements for the purpose of the prevention of illness and the care and after-care of the sick. This can include such things as the provision of special foods, blankets, extra comforts and special accommodation for invalids and convalescents and the making of grants to voluntary organisations doing work of this kind (but it expressly does not include cash allowances to individuals or families, which is the function of National Insurance). A charge may be made in appropriate cases.

Domestic help

89. Under the existing law local authorities are empowered to provide home helps as; part of their maternity and child welfare functions and, during the war, this power has been extended by temporary enactments to enable them to provide domestic help in a wider range of circumstances. The Bill makes this power permanent and extends it to cover the provision of domestic help, subject to the Minister’s approval, to any household in which it is needed on grounds of ill-health, maternity, age or the welfare of children. The local health authority will be allowed to make appropriate charge for this service.

Health Centres

90. The duty of the local health authorities to provide and maintain, general Health Centres, both for their own activities and for the general practitioner services, has already been described.

Health committees

91. Local health authorities will, in the future, be required to appoint statutory health committees (comparable in many ways to their statutory Education Committees) and to refer to them all matters relating to the discharge of their functions under the Bill. The health committees may be authorised to exercise functions on behalf of their parent authorities and there is discretion to appoint by co-option expert members who are not members of the authority itself.

GENERAL ADMINISTRATIVE AND FINANCIAL PROVISIONS

Central Health Services Council

92. In paragraph 10 the setting up of new technical advisory machinery by the Minister’s side has been mentioned. In more detail, the arrangements are these. To advise him generally on the administration of the health service the Minister is to have beside him a Central Health Services Council. The members are to be doctors, dentists, nurses and other professional people concerned with the different parts of the service, together with people having experience of hospital management, of local government and of mental health services-all of them appointed by the Minister their individual capacities, but after consultation with the appropriate representative organizations. The Presidents or Chairmen of six of the principal medical bodies in the country are also to serve on the Council, ex officio.
93. The new Central Council will be free to advise the Minister of its own initiative on any expert aspect of the services, as well as on matters expressly referred to it by him. It will report annually to the Minister, who will lay the report before Parliament – with his own comments, if he wishes – unless he is satisfied that it would be contrary to the public interest to publish the report or any part of it.
94. The Minister is empowered also to constitute various Standing Advisory Committees on different technical aspects of the new service. These Committees are not specified in the Bill. They will in fact deal with medical aspects of the service, mental health, dentistry, nursing, pharmacy, and any other matters justifying special advisory machinery. They will deal with questions referred to them either by the Minister or by the Central Council and will have direct access to the Minister as well as to the Council.

Default powers of Minister

95. The Minister is given default powers against local health authorities and any of the bodies constituted by the Bill–the various hospital bodies, Executive Councils and others–if they are not carrying out their functions satisfactorily. He can make an order directing them to do whatever may be necessary and then, if still not satisfied, he may take over their functions, permanently or temporarily, himself.

Position of officers

96. Regulations made by the Minister ma lay down the qualifications and conditions of service of any or all of the officers and employees of all bodies (including voluntary organizations) concerned with providing services under the Bill. In regulating -conditions of service or remuneration, it will be his object – as already stated – to use appropriate machinery of discussion and negotiation with representatives of those affected.
97. The Minister is empowered to establish contributory superannuation arrangements for the staffs of hospitals (including the specialist services), Executive Councils, the bacteriological and blood transfusion services, and doctors and dentists in the general practitioner services. The employees or local health authorities will be entitled to the benefits of the existing local government superannuation scheme, which can be modified by regulations under the Bill for staff in the health services in order to secure the maximum of interchangeability with other parts of the general service. The employees of local voluntary organizations can be brought within local superannuation schemes. The general object will be to make arrangements such as will secure freedom of movement between the central and local services, and within these services, and also between services provided under the Bill and other health services.
98. Protection is given to existing officers of voluntary hospitals, Insurance Committees and local authorities‘ whose functions are transferred or extinguished by the Bill, by providing for their transfer and re-employment by the appropriate authority under the new service or for their compensation if they were previously employed whole-time and suffer loss as a result of the change-over.

Miscellaneous

99. The Bill contains also a number of miscellaneous provisions relating to such matters as the transfer of the property of local authorities and Insurance Committees, the holding of inquiries, the procedure for making regulations and orders and the repeal or adaptation of the existing law to fit the new conditions.

FINANCE

100. The new service is to be financed mainly from the exchequer, assisted by a payment of some £32 millions transferred from the National Insurance Fund, and partly from local rates with the help of exchequer grant.
101. The exchequer will bear the cost of the hospital, specialist and other centrally organized services, the cost of the family practitioner services, the cost of the local health authority services, together with the cost of central administration. The rates will bear half of the cost of the local health authority services previously described.
102. The expenditure of local health authorities on their services – including any payments which they make to voluntary organizations for services on their behalf – is to rank for exchequer grant, calculated in accordance with regulations to be made under the Bill. The grant is to be on a “weighted” 50 per cent. basis, with no local health authority receiving more than three-quarters or less than three-eighths of their expenditure.
103. The transfer of the cost of the local authority hospital services from the ratepayers to the taxpayers (together with other changes which are in contemplation outside the scope of this Bill) must profoundly affect the present financial relations between the exchequer and local authorities. The primary financial effect of the transfer of hospital services from local authorities will be to benefit the richer areas appreciably more, generally speaking, than the poorer areas. Radical changes will be necessary in the general scheme of exchequer grants in aid of local authorities, therefore, to secure that over-all the policy of the Government of concentrating those grants as far as possible where the need is greatest is further developed. The whole of this question is at present under consideration by the Government with a view to the introduction of a reformed scheme by the time the new health service comes into actual operation.
104. The financial memorandum attached to the Bill itself gives details of the general financial background of the new proposals.