Health Centres

NHS history

This was first published in 1942 as part of Stark Murray’s book  Health for All. It still seems relevant to discussions about how services might be integrated today.

It has already been suggested, in previous pages, that an essential feature for the medical service of the future will be a building and organization known as a “Health Centre”. There are already in various parts of the country Health Centres set up and run by local Authorities. A few of these such as that at Finsbury, are very modern buildings beautifully equipped for their work, which is mainly concerned with such aspects of preventive medicine as maternity and child welfare. The legis­lation under which these health centres were set up is permissive, with the result that only a few of the most enterprising local authorities have attempted to make these places what they really should be — a focal point for all the health activities of a district. Where full advantage has been taken of all the legislation governing the activities of local health authorities, quite a wide range of services can be given. The Bermondsey Borough Council, for example, provides fourteen different types of service, including such special clinics as consultative clinics for rheumatism and. diseases of the heart, and includes a full laboratory service, and a system whereby any practitioner in the borough can send a patient for X-ray examination. In general, treatment is impossible at these centres except in the case of minor ailments of school children. The Acts under which these health centres operate does not permit domiciliary treatment, and any condition dis­covered at them which requires more than can be dealt with on the spot has to be referred to a general practitioner or hospital.

There is therefore in this country very little on which we can base bur conception of the health centre of the future. Nevertheless it is no great departure from orthodox medical practices because it is intended to be a combination of all that is best in the different services which exist at present. It involves a number of problems other than purely medical ones, for while in the first instance existing buildings might be used for this purpose the health centre of the future should constitute such an important feature of communal life as to be worthy of a new architectural design and a very prominent position in post­war town planning.

Whether the health centre is part of a fully socialized medical service, or of a service which is only partly organized, its functions in general terms should be identical with those of a fully socialized service—health preservation, health protection, detection and diagnosis of disease, treatment and cure, health restoration and health education; the scheme must be one which can be adapted to rural areas as well as cities, and it must be sufficiently elastic to meet the ever growing science of medicine.

The health centre must ensure that everyone can get primary medical advice, either in their homes or at a place easily accessible to their homes, and must provide for rapid reference for specialist investigation and treatment. Overlapping must be avoided and it is necessary therefore to divide both the population and the medical personnel into units. These units must be of such a size that they will be economic to run, and will require specialists of every type, so that the service they give will be complete. They must, on the other hand, be sufficiently small to be respon­sive to the needs of every individual whom they serve, and the number of personnel employed must be such that every doctor has an opportunity of knowing and appreciating the work of every colleague employed with him in the unit. The health centre must be closely linked with, or even part of, a large general hospital, the specialist staff of which should provide the consultant staff of the centre. There are many ways in which the size of the best unit can be estimated, but the soundest appears to be to base it on this general hospital. In this country hospitals vary in size from the cottage hospital of twenty beds to the large municipal hospital which may have fifteen hundred beds. The hospital of between eight and twelve hundred beds is generally considered to be most efficient and would certainly require a type of staff which would be able to carry out the work of the health centre. We may therefore take as our basic figure a hospital with a thousand beds, which could be expected to serve a population of one hundred thousand. We have in this country at the moment some districts in which the number of beds available approach this figure, but none which exceed it, and it would appear to be a figure which is likely to be adequate for the population for a long time to come.

In a unit hospital of this type a medical staff of about fifty would be required, allowing a considerable margin of capacity so that holiday and sick leave can be arranged without additional assistance. This staff would have functions in relation to the health centre which we shall discuss shortly. For the domiciliary service a population of one hundred thousand would require about fifty general practitioners, if allow each two thousand on their list.  In the initial stage of such a service this figure could certainly hot be lower in view of the shortage of doctors, but should not be less than thirty-three allowing some three thousand persons to each practitioner. The higher figure of the number of doctors is, however not excessive, and only when that number of doctors is available will regular periodical health examinations and preventive work through the practitioner, be fully possible. The unit suggested would therefore require some eighty to one hundred doctors, a group large enough to comprise nearly every type of specialist, but small enough to develop a co-operative spirit and be practically self-controlled. In a unit like this the constant contact of all medical men within it, which we have already indicated is one of the advantages of such a system, would be a notable feature. It is intended that the home doctors in a unit of this size should work entirely inside it, but within that territorial unit as large an amount of free choice as possible would be arranged. The fundamental aim in the unit would be to provide a complete and constantly available service, but this need not imply rigidity.

For the moment the term “Health Centre” is used as if there would be one only in each unit but the number, size and type will be discussed later. In practical terms the work of a Division Health Centre in such a unit would be:

  1. Periodic examination for the maintenance of health and the early detection of disease.
  2. The work of the general practitioner for those patients who can attend at the centre.
  3. The organization of the home visits of the general
  4. The work of hospital “casualty” departments.
  5. The work of consultative Out-Patient Departments, and the provision of consultants in the home.
  6. The work done at present-day health centres, ante- and post-natal care, infant welfare, child guidance, immunization, (Note that “Chest Clinics”, tuberculosis dispensaries, etc. would disappear as such; cases would be seen by the appropriate specialist at the request of the general practitioner.)
  7. Dental service.
  8. Pharmacy for those attending the centre, or served by it.
  9. Special clinics, e.g. Foot Clinics, Cancer Clinics, etc.
  10. Accident and factory service. (Note: this is not the whole industrial medical service which requires other provisions.)
  11. Rehabilitation and occupational therapy.
  12. Health education and propaganda.

It will be seen from this list that such a centre requires like the one-thousand-bed hospital, nearly every type of specialist, X-ray equipment, and a large laboratory. The most efficient way in which these can be provided is to place the whole centre at or in close proximity to, the unit Hospital and to utilise the hospital staff at the centre. Perhaps the simplest example of the way in which it would work is furnished by the laboratory. A division health unit, as described, would require a fairly large laboratory with a staff of at least three doctors and six to eight technicians. It should be so equipped as to be capable of giving a complete laboratory service to the hospital, to the centre, and in the homes of the people. It should be essentially a clinical laboratory and the staff should all have training in clinical medicine so that their assistance to the rest of the profession should be of the highest standard. It should, however, carry out in addition all the routine bacteriological examinations for the general practitioners of the unit, as is now done through — and sometimes by — public health departments. The size and staff of such a laboratory should as far as possible be in excess of these requirements, so that ample opportunities for research and for co-operation with general practitioners and hospital staff should be possible.

The Division Health Centre would therefore in essence provide a suite of consulting rooms for a proportion of the general practitioners of the unit, for consultants who would attend at the same time as those general practitioners who were seeing patients, and at special sessions for types of work not directly concerned with the general practitioner. In most city areas, and in all rural districts it would not be possible to organize the whole of the domiciliary service at the Division Health Centre, and therefore would require to be subsidiary Local Health Centres. These would be placed wherever the population distribution or transport facilities indicated they would be most useful. In an urban area the one hundred thousand population unit would require three or four Local Health Centres, each staffed by eight to twelve general practitioners; the exact division of work between the Divisional and the Local Health Centres would vary slightly in different districts, but generally the first eight items given in the lust above would be carried out at the smaller centres, except that the work of organising the visits of specialists would fall on the Divisional Health Centre.

The population would receive its primary medical attention by registration at one of the health centres of its unit. It would then only be necessary to telephone that centre to make an appointment to see the general practitioner of choice at the centre or to arrange for a doctor to attend at the home.

In these respects the status and duties of the general practitioner would not be altered. The greatest change would be that the work of the general practitioner would be organized from a centre, and while it would be necessary for him to be immediately available when he was on duty, it would be equally unnecessary for him to be even at the end of a telephone during his off-duty hours. This may seem a small point to many people, and even some general practitioners would not admit that they find the necessity of being constantly on duty a greater tie than they are capable of putting up with, but there is for the patient a tremendous advantage in the doctor knowing that when he has finished the work he is doing he will definitely be able to rest, and need not carry out his work in the expectation that when he returns to his surgery urgent calls, which must be attended to at once, will be waiting for him.

There is also a decided advantage both to doctors and patients in having night work done by a staff who are specially on duty for that purpose. The total number of calls in the middle of the night which the ordinary doctor gets, as distinct from those which occur late in the evening, after he has finished his surgery, are relatively small in number, but they are so often calls that create a more than average worry and annoyance that they are definitely detrimental to the doctor’s peace of mind and therefore to the whole of his work. In a health centre service all the night calls would be concentrated on the Division Health Centre, with the result that each general practitioner would be on night duty only for a very few weeks in the year, and these would be placed at suitable intervals. The doctor on emergency duty would also feel the advantage of ready access to specialist opinion or hospital admission, for real emergencies so often mean either one or the other.

It is difficult to give a clear picture of such a new conception as the health centre, so let us look at it from the point of view of the patients wishing to receive medical attention because they believe themselves to be ill, and also from the point of view of the average working day of the doctor. We will assume that the patient has been registered at the health centre for some time and has attended there for a periodic examination, which has indicated that he is suffering from no detectable defects, and when that patient feels ill—say from an acute infection—he immedi­ately turns to the health centre. If so ill that he cannot, or feels it would be inadvisable, to leave his home he sends a message by telephone or otherwise to the health centre asking for his doctor to visit him. Unless the message indicates that the condition is urgent, or the doctor nominated is off duty for any reason, the visit would be placed on the doctor’s list by the clerical staff of the centre, and carried out on the doctor’s round as at present. If the doctor is off duty, or the condition appears sufficiently acute to warrant it, the doctor who is on emergency duty, or one of the other doctors at the centre for whom the visit will be convenient and immediately possible, will attend. Whichever doctor attends can obtain from the centre the record, of the patient’s previous health. Having seen the patient the doctor has only to communicate to the centre what additional assistance, opinions, treatment, he wants and it will be arranged without further difficulty or delay. If he has decided that the patient must go to hospital the ambulance will be sent and arrangements for admission made.

In speaking of the doctor requesting additional assistance, we have in mind such things as the services of a nurse in the home, the provision of a home help or arrangements for taking care of children where it is the mother of the family who is ill. This provision of home helps and home nursing and other auxiliary services will be of great importance in the health service of the future, and is discussed in detail in a later chapter.

There is another important point which must be discussed, for it has its bearing not only on the patients’ attitude towards their health but on the way the doctor’s work will be arranged, and in fact on the way in which the whole health centre system will operate, but has important bearings in addition on our attitude towards social security in general. This question is that of the present inability of those who are unwell, but still able to work getting their medical attention at any other time than in the evening. It is quite probable that most of the defects in the panel system which have given rise to criticism arise from the fact that patients who were insured in pre-war days were those whose incomes were under £5 a week, and who therefore were bound to continue at work as long as possible, even although they were aware that they were far from fit. For this reason most panel patients actively employed have had to see their doctor after working hours, that is to say in the evening. This has meant that the busy panel practitioner, having spent his day climbing up and down stairs to see cases sufficiently ill to tax his medical skill and his sympathy, is faced with an evening surgery begin­ning about six in the evening and stretching on over an indefinite number of hours. It is not exceptional, in a purely working class area, for an evening surgery to last until nine or even ten o’clock. The patients seen during those hours have to be dealt with in the quickest possible way, otherwise the surgery would stretch out till midnight, and all that even the best practitioner can hope to do is to pick out those cases which are really ill, and arrange either to see them in their homes in slightly more leisurely conditions, or to send them to the out-patient department of a hospital for another opinion. Every doctor knows that correct diagnosis should be a process of careful consideration and assess­ment of the signs and symptoms that are discovered; the crowded surgery encourages the practice of spot diagnosis which, while it may sometimes be brilliantly successful, is very often no more than guess-work. It is true that those cases in which the first rapid diagnosis is incorrect may return the more quickly to the doctor’s surgery, when the diagnosis may be revised or further steps taken to elucidate the trouble.

This problem can only be dealt with in one of two ways; either surgeries must be held in the factories so that men can seek advice without stopping work for more than half an hour, or it must be a recognized practice to allow time without loss of wages for those who wish to consult a doctor. In our opinion with a system of health centres built where most required by the population the second procedure is the better, and the doctor’s certificate after examination would be the proof that the patient’s wish for time off was justified. This minor point in social security represents an attitude without which neither a socialized service nor any other form of social security will be successful. It enters into the question, for example, of whether married women should continue in industry, and whether if they become pregnant they should have holidays with pay before and after birth of the baby, and is in fact part of the recognition that health is one of the rights of man and that the State and industry must make it easy for health to be maintained.

Health centre arrangements must therefore be based on the expectation that men and women will be able to attend at the health centre during daylight, and that we need not arrange for general practitioners to be seeing ambulatory patients at the health centres at such widely spaced hours as 9 a.m. and 9 p.m. The precise number of hours which each doctor will have to work is a matter that has not been discussed, but it should in ordinary circumstances not be greater than that of workers in industry, and if he is to have time to see something of the work of his colleagues in other departments, to keep in touch with patients who have gone into hospital, to attend scientific meetings, and so on, the ordinary doctor should probably not spend longer than six or seven hours per day in actual consultations.

We may therefore visualize the day of the health centre general practitioner as beginning with a session of appoint­ments at the health centre. These patients have either recognized for themselves that their condition is not acute, or are going to see the doctor for a follow-up of some previous complaint. They have therefore made, appointments in advance at the health centre, and can therefore estimate how long they are likely to be there on this occasion. Since the amount of time spent on different cases varies, these appointments may not be accurate to the minute, but the health centre staff and the doctor con­cerned will not be doing their job if more than three patients are waiting at one time or anyone is waiting more than thirty minutes. Large as the health centre may be therefore, and many as may be the doctors consulting there, there is no suggestion that a health centre would in any way represent the out-patient department of our voluntary hospitals where hundreds of patients wait for many hours to see members of the honorary staff. They will not even represent the present day surgery of a busy doctor where, crowded into a sitting-room of a small suburban house or perched on a bench round the wall of an out-of-date shop in a narrow street, patients now wait nightly for their panel service.

Having completed his session of consultations at the centre, the doctor will carry out his home visits which, because they do not go over the boundaries of the unit in which he is working, and because they consist only of those patients who are suffering from illnesses which have not required an emergency call, will neither be so enormous as at present, nor so time wasting as are many of the visits done at present. At any time a doctor may return to the centre for further consultations which have been made at special times to suit his, the patients’ or a consultant’s time-table. The health centre, however, will not be idle even if there are no general practitioners seeing patients, for there are many specialized clinics to be held, and there will be visits from consultants to see lists of patients who have been referred by the general practitioners. In the case of the Division Health Centre, of course, many of the consultations will take place at the same time as the first visit to the general practitioner, for at the busiest hours it will, of course, be possible to have certain consultants on duty.

We have so far spoken almost exclusively of urban areas, and with the present population distributions in Great Britain a very large proportion of the health centres would be in towns with a population big enough to make one health unit. There are one hundred and forty towns in England and Wales with populations of over fifty thousand. Some of these are so large that they would have to be divided up. London presents, as always, special problems, but they can all be solved by local variations of the plan. The scheme is, however, equally applicable to rural districts, although in those with a very scattered popula­tion the local health centre might have a very small medical staff. There are very few districts, however, in which there would be any reason for having less than three doctors, and when we add the health visitors, district nurses, midwifery and ambulance services, even the smallest health centre is something infinitely superior to the surgery of the isolated practitioner.

On the whole, however, there are few places in this country where it would not be possible to place the Divisional Health Unit Hospital and Health Centre in a town or section of a town, so that with the population of the country which normally tended to look to that town for its services it would have a population that would justify the setting up of a full consultant service such as we have described. It would, however, be import­ant to recognize that it is often easier for an organized service to get to the patient, than for the patient to get to the centre. The staffing arrangements would therefore require to take this into consideration and mobile units would certainly require to be developed. It is of interest to note that in November, 1941, Australia was making arrangements for sending X-ray caravans to the most outlying and sparsely populated parts of that continent. One of the most important needs in the rural areas would be an ambulance service freely at the disposal of everyone who needed it, so that there would be no tendency to regard the health centres as hospital units. It might be necessary to have a rest home or small isolation unit in a local health centre; with efficient ambulance arrangements cases should be taken to hospital with sufficient speed to avoid any danger that might arise from delay. The ambulance service in these areas would, of course, require to be centralized. The London County Council Ambulance Service is in many ways a model that could be copied elsewhere.

In addition to the organization of the work of the general practitioners, and of providing for them the services of specialists, the health centres would have other important functions to perform. Most important perhaps would be in relation to industrial health, a subject which is only now beginning to be taken seriously. The health of workers in industry depends to a very large extent on the conditions under which they are employed. We have spoken already about the need for perfect nutrition, and the obvious corollary of an adequate standard of living, but even when a perfect nutritional basis has been achieved the actual conditions inside factories may have profound effects on health. There has been a considerable amount of legislation aimed at ensuring good factory conditions, and we have a number of factory inspectors whose duties are to see that these legal provisions are carried out. It will still be necessary, even with an organized medical service, to have a system of factory inspection which must not only aim at seeing that the minimum requirements of the law are fulfilled but is constantly on the look out for new dangers and for the better prevention of those that have been recognized. There have been in modern times a number of cases where new industrial processes have come into existence, without adequate check, and have resulted in injury or death to a number of workers, before the hazard was fully recognized.

Factory inspection, however well carried out, is not enough and the industrial medical service must include examination at regular intervals of all workers at their place of employment, so that observations may be made over a period of the effect of factory conditions on large numbers of people. This study of the mass will have important repercussions in the improvement of factory conditions generally. Where, however, individuals are found to be suffering from disease, or complain that they are ill, they should be seen at the health centre, so that the whole of the diagnostic machinery available there is at their disposal. The industrial medical officer must therefore be in close contact with the general practitioners at the health centre, and must be able to indicate to them whether the condition from which a particular patient is suffering is related to industrial conditions or not. He must also be able to consult with the specialists of the service, so that if they suspect that the condition is due to, or has been aggravated by, the type of employment, steps can be taken to trace the danger in the factory.

Even more important, however, is the close relationship between the industrial medical officer and the other doctors of the health service, when an injured or sick person is about to return to work. The general practitioner is to-day the only person concerned with certifying that a man, who has not worked for some time, is again fit for employment, and unless he is either a particularly knowledgeable person, or is sufficiently interested to make his own enquiries, he knows nothing about the type of work which the patient will require to do. He may therefore certify a man as fit to work who, while able to lead a sedentary life, cannot possibly tackle the work he was doing before his injury or illness, or, on the other hand, he may keep a man too long from his work and thus give rise to psychological difficulties. It should be a part of our medical services to see that every person who has suffered disease or injury causing incapacity for more-than a few days has a proper course of rehabilitation under the combined observation of his home doctor and his factory doctor. It may, of course, happen that in areas where the amount of industry is not great those general practitioners at the health centre who have a particular interest in industrial conditions will act in both capacities, but in our large factories there should undoubtedly be full-time medical officers. When the sick or injured patient has had a period of convalescence, he should be given further training, either by exercises or light work, which will prepare him directly for his ordinary employ­ment, and he should not be forced to attempt a full day’s work until the doctors are satisfied that he is fit. The whole subject of the provision of these rehabilitation centres is one that must engage the attention of the medical profession for some time to come. Those centres already in operation, especially in the Army, have produced astonishing results.

Another service which must be organized at the health centres is that of dentistry. At the moment dentistry is carried out on similar lines to medicine, that is to say, by individual dentists each of whom runs his individual surgery in a private house, but there is one difference, namely, that there is little or no domiciliary treatment. It follows therefore that dentistry can be very easily organized on the basis of the health centres, and there should be both at the Division Health Centre and the Local Health Centre ample accommodation for a complete dental service. On examination it may be found necessary to provide dental centres in addition to the smaller health centres, for the number of dentists at present engaged in the country suggests that if the number required were concentrated at one place it would constitute an unwieldy building and service. We must, however, look to a particular line of the development in dentistry which will alter the amount of space required and the number of hours worked, to a considerable extent. It is suggested that in a health centre there would be a separate laboratory, staffed by highly-skilled technicians who would carry out all the work of making dentures and other appliances and so save much of the time spent by qualified dentists who would concentrate on the work of preserving teeth and repair­ing decay. The conditions of employment of dentists would, of course, follow similar lines to those of the medical staff, and each health unit would probably employ one or more dentists holding medical degrees as well as dental qualifications who would act as consultants both to the other dentists and to the medical men. Here again it must be emphasized that dentistry cannot be isolated from the rest of medicine, as it is to such a large extent to-day. The condition of the teeth is largely a reflection of the general condition, and may also have a profound effect on health, and the dental service must therefore be on the closest possible terms of co-operation with the medical profession. Up to the present that has not been possible, but in a health centre it would be the recognized position.

Another function of the health centre is that of organizing the ancillary medical services, and the staffs of midwives, health visitors, social welfare workers, home nurses and home helps. Physiotherapy is playing an increasingly important part in the restoration of health, and with the development of the rehabili­tation units quite large numbers of personnel trained in massage and remedial exercises would be required. These would be located at the health centres and hospitals, and the services could also be made available in the homes of the patients. They would, of course, be full-time, officers, and their services would be available on the recommendation both of the general practitioner and of the consultant.

The other services are of such importance that each of them would require much more detailed consideration than we can give them in the space available. Many different types of per­sonnel, chiefly women, are involved. The function of the midwives is clear enough, but their organization depends on the type of maternity service which we envisage. For the moment it is enough to say that they form a team with the obstetrical officers, and while much of their work may be in the homes of the mothers, they must be in close and constant contact with the maternity section of the hospital.

The health visitors must be available both at the health centre and in the home, and form a vital link in the education in health preservation and disease prevention which will be a prominent feature of the health services of the future. At the moment they carry out very important functions where local authorities have set up clinics for maternity and child welfare, and their full duties will probably develop as the service as a whole progresses. They should, however, always form the strongest link between the family and the medical staff of the health centres, and should assume the protection of the health of the infant as a primary and vital function.

Trained social welfare workers have a purpose which relates very closely to that of the health visitors, and until we have achieved greatly improved environmental conditions they will be of very great importance to the medical services. No medical case history can be complete unless it includes a survey of the economic, home and factory conditions of the sick person, and this should be provided by the social welfare worker. In this way they should be able to contribute to the eradication of all factors in the environment that are disadvantageous to health.

In a health unit which is fully developed the health centre will have the important task of supplying home helps. At the present day assistance can be provided in the home in maternity cases, but home helps are needed when, for any cause, the mother has been removed to hospital or is unable to attend to her house and family without aid. The importance of this service must be felt by everyone who has ever experienced the tragedy of a working-class house when the mother of a family of young children is suddenly removed. It is not only that the house cannot properly be looked after, but it is extremely diffi­cult to make any arrangements for the children and for the comfort of the breadwinner. Wide social changes are necessary before this problem can be fully solved, for it indicates the need for creches for the babies, for day nurseries for the slightly older children, for complete nursery accommodation for all children, and of communal feeding for children and adults. When these are part of the system no difficulty arises except for the actual housework, and this can easily be arranged. In this country, however, having none of these provisions we must, until they  are provided, visualize the provision of home helps who can undertake all the duties which the mother normally carries out; discussion of this point seems to raise in the minds of many the idea of the worst type of charwoman, but the home help of the future will be a woman with a profession comparable with that of the other sections of the services provided by the health centres for assisting in the fight against disease.

The health centre will also arrange for a home nursing service. If, however, a general hospital is provided for every hundred thousand of the population, and admission is freely and easily obtained and transport is provided, the amount of nursing which is done at home should not be great, and the total number of nurses engaged in this service may therefore not be very large. The nurses of this home service need not necessarily be separated from those of the hospital and the centre, although in practice they would not function in more than one sphere at a given time. The conditions under which they would work would, of course, be improved far beyond present-day standards as a result of the better organization and of the fact that they were members of a profession with opportunities for promotion, and with definite and uniform conditions as to length of service, pensions and so on.

Lastly, the health centre would be the repository of the health records of the population it served. In some respects this will be one of the greatest advances which a socialized medical service can give to medicine. Every medical student is taught at the very beginning of his course in clinical medicine that the most important part of his examination is very often the taking of the history of the case. No patient is admitted to hospital until a full story, not only of the illness for which admission is sought, but of all previous illnesses, is noted by the officer making the admission. Our consulting physicians and surgeons all em­phasize the importance of the patient’s history by making similar notes for every case they see, even when they have already been” provided by the patient’s own doctor. In acute disease the way in which the symptoms develop, the order in which they appear, whether there was a rash or not, may indicate the diagnosis without any other examination; in chronic disease a history more carefully detailed than most lay people can ever give would probably enable an experienced physician to make a diagnosis without further examination.

Under our present system a patient who goes from one district to another, who changes his doctor for any reason, who is sent to see a new consultant, either makes these changes without being able to give exact information as to what has gone before, or puts the new doctor to the trouble of trying to find it out from the old, or, as is most common, gives a story which is incorrect in many details. A continuous accurate record of an individual’s medical history is therefore of tremendous im­portance and it can only be obtained, kept up to date and summarised by the employment of a clerical staff specially trained for this purpose. This staff would form a very important part of the health centre. It would be their duty to see that records made in one department (e.g. by the school or industrial medical officer) were available to any other doctor who had to examine the patient. The clerical staff would also be able to assist in following up cases particularly after they had been treated in hospital. It is difficult to assess how much time that would save the average general practitioner, but certainly much of the irritation of present-day practice in regard to the filling up of forms and certificates would disappear. In a free health centre service the doctors would in fact have practically no forms or certificates of any kind to fill, although they would have a certain number of previously prepared certificates to sign for their own patients.

These are, in brief, the lines on which the health centre would operate, but there are many details which must be further considered, and there are certain objections which must be shown to be invalid before such a system will be generally accepted. There appears, however, to be little doubt that it is on some such method that the medical service of this country will one day be organized, and it is set forth here in the belief that it will lead to a service which will be better in every way for patient and doctor alike.