The Future Of The Health Services

After five years of experience of the N.H.S. we are becoming increasingly convinced of the need for closer integration of the preventive and curative aspects of medicine.  This need for co-operation and integration should affect training for the service as well as the actual service itself.

Though the public has benefited to a great extent from the service it has often involved considerable inconvenience to patients because of its organisational failures, and the public is often more aware of the benefits obtained by administrators,doctors and other health workers that the benefits obtained by the sick patient.  The bad conditions still often found in doctors surgeries, hospital out-patient departments,  the difficulties met with by patients in need of dental or other emergency treatment and the long waiting lists stand out among other difficulties.

One of the basic facts to be taken into account when making plans for the future is that every patient must be seen as a whole person in his environment, and that includes his home as well as his work.   Undergraduate as well as postgraduate teaching in the past has been confined to patients in hospital, separate from their environment.  Preventive medicine, the study of minor ailments and industrial diseases have been almost completely ignored.  The isolation of the teaching hospitals from any local community has aggravated this problem.

At present about 5% of the national income is being spent by the Ministry of Health.  We must convince the people that a larger amount must be spent and we should concentrate our attention on the periphery, that is, the service to the person and the family at home and at work.   Power must be less concentrated at the centre. The people at the periphery must feel that it is their service.  There must be coordination at district, regional and ministerial levels.

The key to this development lies in enlightened general practitioner activity which must be integrated with all other health and social welfare organisation.   This can only be done by creating a new organisation; a local health authority.  What should this local health authority be based on?  A population of 250,000 is probably the absolute maximum; perhaps the optimum, would be a 100,000 to 150,000 inhabitants.  Many local authorities are thus too large for such an authority.   Similarly local executive councils are not suitable, but it appears that many management committee areas are convenient and in some of these there is already excellent liaison between the hospital service and the general practitioners.

Eventually only a reform of local government can bring about an ideal solution to this problem. A local health authority of this size would also be an ideal one to administer the health centres which for such an area would, have to comprise one or two comprehensive ones and six to ten smaller ones.  We must educate the profession and the public to understand the need for these health centres without which an integration of the Health Service such as we envisage would be quite impossible.   On the preventive and occupational aspect this size of local health authority would also be convenient.   While we are working for this development to take place much can be done to prepare for it. Local committees can be formed to co-ordinate the work of the different authorities.

We must examine the scope and structure of such a local health service more closely and consider the personnel it would employ. In doing so we would have to consider the training of this personnel for its special task.

At present we have, often uncoordinated:-

  1. The General Practitioner and other services under the Executive Council.
  2. The Local M.O.H. and his staff.
  3. The Welfare Authority including the Children’s Officer.
  4. The Hospital Service
  5. The Tuberculosis Service.
  6. The Mental Health Service.
  7. The   Factory Health Service

The main task of a local health authority would be to co-ordinate all these services.  It would help this task tremendously if many of the health workers in these different branches had part of their training in common, so that they better understood each other’s work.   This applies mainly to the social workers, such as almoners, psychiatric social workers, , welfare officers, children’s officers, health visitors, duly authorised officers, rehabilitation officers and perhaps   also the district school, clinic and factory nurses who could share one year of their course of training as a course in social case work.

A unified administration could co-ordinate their work and see to the more reasonable distribution of these workers. At present for instance some hospitals are well staffed with almoners who often see every patient admitted or seen in the out-patient department, while in other hospitals there are no almoners. Trained social workers can then concentrate on what is their real function, that is to help, people, who have social and personal difficulties for which they need skilled assistance.   Untrained social workers can both waste time and do damage.  Under this same unified administration should also be the sanitary officers, factory inspectors and home helps.

The person administering this social service would have to be specially trained, a medical man with a broad training in sociology is required who would work under the all purpose local health authority.

In this new context the general practitioner’s work will gradually take on a new aspect. It will give him a chance of increasing specialisation for it is now no longer possible for one man to master all aspects of preventive and curative medicine. His contact with the preventive service and the hospitals would be improved and he could concentrate more on the effective scope of his work for which he will have to be specially trained, not only in hospital but also in health centres and in the field.

To reorientate the training of general practitioners the undergraduate teaching schools should serve as district hospitals, taking a complete cross section of the sick of the local population, both acute and chronic.   It is wrong that the major teaching hospitals are situated in the centre of big cities and select their cases.  Health centres should also be associated with these hospitals so that students can have part of their training in them. If the teaching hospitals are also linked with the local health authority the student would get an insight into the working of the health service in the country.   There will have to be a reorganisation of the pre-clinical and clinical syllabus to provide a more balanced education.   Preventive medicine must become a part of the training and more time should be spent on the problem of the elderly sick.

If doctors are to spend a good deal of their time on the preventive aspect then it is more essential than ever that they should be working on a salaried basis.  Preventive work takes up much time and cannot be related to a fixed number of patients. Practitioners lists will of course have to be cut down, even 3,500 is far too many. If the number is no more than 2,500 then the general practitioner will also have time to do school medical officers’ work as well as maternity and child welfare work from health centres.

Even before we have health centres G.Ps. should start forming Group Practices as much as possible.  Specialisation within the group should be encouraged. Full equipment of surgeries should be ensured and pathological and radiological facilities provided for these groups.  Entry into practice will be facilitated by a salaried service and prolonged assistantships should be forbidden.The hospital can play its part in preparing the doctor for this work by making registrars posts a gateway to consultant and general practitioner work, especially if the registrar has the chance of working in a health centre attached to his teaching hospital.  The other way round many a general practitioner who has specialised may wish to enter hospital practice, starting as a. G.P. clinical assistant.  The path to consultant status should be broadened in this way and any great disparity in status between consultant and practitioner diminished.

The hospital service will continue to need planning on a population basis larger than that of the local health authority already outlined, as there are many specialities which cannot be developed in a restricted locality.  However the hospital should serve the community in close cooperation with all other health and welfare provisions.  Until health, centres are provided and the desired modifications of local authority are made the district hospital with its management committee might serve as the focal point of health workers in the area.   So many problems demand immediate and increasing co-operation that meetings of those concerned are desirable. The hospitals need to discharge patients at the earliest moment.  This necessitates a close association of hospital doctor, practitioner, district nurse and social welfare administration.  This cannot be fruitful unless each understands the problems of the other and personal contact is essential. The team work of the hospital should extend to the district.  The dependence of the local community on its hospital should be reflected in the service of the people to it, for in future we should like to have much more recruitment of nursing and other staff from amongst those who we serve.  Conditions within the nursing profession have improved and they should remain good enough to attract intelligent local girls and any prejudice to local recruitment should be discouraged.  Every opportunity should be taken to interest the local population and practitioners in the hospital.

Local interest and support for hospitals varies greatly in different localities and an increasing number of bodies of organised supporters known as “The Friends of X Hospital” or by a similar title have now developed. In general short-stay hospitals the members may be ex-patients, their relatives or any local citizen who has become interested in the hospital.  With Friends of Sanatoria, children’s long-stay e.g. orthopaedic hospitals, and particularly mental and mental deficiency hospitals the majority of members are relatives of the patients, as they have the maximum interest in and incentive to improve the particular hospital.

Formation of these organisations is an indication of local interest and concern in the hospital and it is the development in the public of identification with its local hospital that can be our greatest safeguard when “economies” are directed to the lowering of hospital standards.

Organisations of hospital friends can learn about the standard of care and the needs of their hospital; and their most useful function is to make known the need to focus attention on it and to stimulate those responsible to meet it.  Additional functions would be the visiting of patients who have no relatives; reading to blind or otherwise incapacitated patients and similar activities. They can also help in recruiting campaigns for nurses and other staff.

The collection of funds for extra amenities should be a very minor function. The danger of such Organisations is that they may be used by people who are not representative and apparently represent no opinion but their own, and that they will be made an excuse for not providing amenities which the National Health Service should provide.

On the other hand, if truly representative of the population the hospital serves they can make a valuable recruiting ground for members of Hospital Management Committees and Regional Boards.

The deficiencies of hospital provision have been accentuated by the lack of any new hospital building since 1938.  If present methods of capital allocation persist this state of affairs will continue. We are patching up slum hospitals and are falling behind most nations in new building. Our conscience has become numbed about the needs of our ill people. The position is especially bad in the case of mental hospitals and mentally deficient institutions.  In tuberculosis also the situation is still serious in many parts of the country.  The waiting period for operations in the case of many women’s disorders and simple surgical procedures like tonsillectomies, operations for hernia or varicose veins is often months, if not years.  Co-ordination between some large and smaller hospitals has increased the service given but this must be extended. Too many vested interests frequently hold up planning and local prejudice perpetuates inefficiency. It is the function of regional boards so to plan existing resources that full use is made of all beds.

We should study carefully the future of administration within this expanding service.  Undergraduate training has tended to produce a desire for professional freedom but it has neglected the need for co-ordinated activity.  Team work throughout is indispensable and some co-ordination of our efforts must be evolved.  Doctors should take their part in joint consultations with other health workers in all spheres of activity.

Present methods of administration have taken the hospitals from the political field. Little pressure is exerted in Parliament on their behalf.  Regional Boards as selected are dominated by Chairmen who regard themselves as agents of the Minister. The status of the Minister of Health in relation to other Ministries is very low. When economy is in the air the health service is very vulnerable and it is essential that there should be a method of financing capital works other than from annual central allocation.  We certainly cannot wait for the completion of the national housing and rearmament programme before adding to our hospitals.

The consultant staffing of our hospitals is still based on the uncoordinated activities of individual small all purpose hospitals which existed before the service.  Too many consultants-spend too much time travelling.  It is not unusual to find one management committee group served by five or six consultants in one specialty and they not having more than thirty beds in the various hospitals. The consequent inefficiency is obvious.  Often even serious emergencies are dealt with by comparatively junior registrars.While a considerable private practice persists and hospitals are staffed on a part-time basis it is often difficult for regional boards to discover the true consultant needs of a locality, for consultants often discourage increased competition.  An effective yardstick for consultant service should be evolved and this will entail further appointments, for few areas of the country can be said to have full provisions yet.  Whole-time appointments should extend throughout our hospitals.

More highly specialised units should be established in regional hospitals for the increase of these in undergraduate schools has almost prevented the student from getting a correct perspective of medicine.

The Junior Staffing of many of our hospitals is presenting great difficulty; this is in part due to the claims of the armed forces whose demands we hope will be temporary.   It is due in part to the fact that hospital experience brings no increased reward or status in general practice.  In fact the more post graduate hospital experience an applicant has had the less eligible is he often for an appointment by a local medical committee. This situation will continue until financial competition ceases to exercise such a strong influence and until the practitioners cease to assert an ability to cover the whole realm of preventive and curative medicine.  Another reason for the difficulty of junior staffing in hospitals is the division between teaching and non-teaching hospitals.  The young doctor who wants to specialise finds that he can only do so with any prospects of attaining consultant rank if he remains in his teaching hospital.

The pre-registration house appointments will give some experience to all young practitioners but such experience should be extended to general practice as soon as conditions permit, for we cannot neglect training and experience in this field in which so many will spend the rest of their professional lives.

Ambulance provision should be an integral part of hospital administration. The present divorce from its main user leads to wasteful lack of appreciation by all concerned.

An Occupational Health Service integrated with a preventive and curative one can be seen to be so essential in mining and other heavy industries that it should soon be extended to the whole of industry.   The method of supplying these services from Health Centres will call for experiment and it may be that some centres can operate in factories where these are served by a local community.  Health centres too cannot be provided without a considerable capital outlay and this must be considered with the need for a capital expansion in the hospital service. We cannot hope to equip our nation for the effective increase of output if we allow our health service to remain in a state of poor development which was sufficient a century ago.

If preventive medicine is to be encouraged practitioners and specialists will need many more convalescent and rest homes than are at present available.  Much organic disease and mental ill-health is resulting from strain both at home and at work.  This could be alleviated by preventive rest breaks.  These should be available for people of all ages. At present it is almost impossible to get adolescents or aged people away.  Teachers in school and university, health visitors, factory nurses and others should be encouraged to refer all who appear to be in need of such a change to their own practitioners for assessment.   Routine medical examination extending throughout life should be the aim when there are sufficient doctors and premises to supply it.  Health education also needs more imaginative handling than it receives at present.  A special study of it could be introduced into the medical curriculum. At the moment too much of it is left to ill considered articles in the press and too little has official and scientific backing.  The application of science to medicine and an increasing social awareness amongst its practitioners are resulting in revolutionary changes in treatment. Similarly great changes could be brought about in prevention. An efficient organisation of the health service can ensure our population reaping ever increasing benefits at the same time the health worker will have a more satisfying life freed from many daily frustrations.