WANTED– A SOCIALIST HEALTH SERVICE
An SMA discussion document. Probably 1966
” . . , it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole. We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end”.
SOCIALIST MEDICAL ASSOCIATION 13 Prince of Wales Terrace, London, W.8 (WEStern 7770)
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“.. it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole. We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end”.
The-present administration of the National Health Service is chaotic, fragmented, and unsuited to its further progress.
It arose as an amalgam of compromises with historical leftovers from a century of uneven advance in the provision of medical care.
Its three major divisions are, first, public health through the local authorities, themselves part of an admittedly difficult structure of local government, in need of reform, secondly the personal services of family doctor, dentist, pharmacist and optician, through the executive councils which derive from a “panel”, system of insurance devised in 1911 for a section only of the population (employees); thirdly the hospital service, which is a new structure under the Regional Hospital Boards, but these are entirely undemocratic and based on nominations and (except in Scotland) separate from the powerful teaching hospitals.
This completely unintegrated structure has many critics and few defenders, yet without a clear perspective for a reformed structure little progress is made in campaigning for a change. It is the task of socialists and the working-class movement to work out the necessary, policies, for, as the Socialist Medical Association has always proclaimed, the health of the people is the responsibility of the people themselves.
Apart from the divisions broadly outlined above, there are many other aspects of social policy which profoundly affect medical care. The drug industry is in private hands and the development of new drugs, prescribing habits, costs, and the attitude of the public (for example, in seeking medication for real or imagined ills instead of developing preventive medicine) are all factors influenced by the search of drug firms for profits, and are not necessarily in the public interest. Quality and design in other supply sectors, from dental equipment to hospital beds, are also in private hands.
Broader social problems of behaviour, which a unified health service would have to take account of and actively influence, and for which in the present situation the Ministry of Health cannot deploy any coherent programme, should also be borne in mind. Thus the safety design of vehicles (it is only now that safety belts are compulsory, but general design, speed, drink and driving, psychological attitudes of driving, are other factors which could be mentioned) is of vital concern to orthopaedic surgeons who have to deal with accidents. And, looked at generally, we are still waiting for a coordinated accident service.
Housing has enormous effects on health. There is not only design (e.g., for old people) and questions of priorities, but the effect of slums on health, which is counted socially in broken homes, delinquency, increased illness, even lead-poisoning in children from the crumbling plaster of old houses.
Health and safety in workplaces is the responsibility of management, that is, in private hands, and a diversity of Government departments shares the task of enforcing the legislation on safety, itself inadequate, This entire aspect of health is at present a vacuum so far as the NHS goes.
Finally, despite the growth of studies and research in costing and efficiency, largely in the hospital service, and apart from the basic need for an increased global sum to finance the NHS, where shortages are producing a state of quiet desperation in every sector of the service, the question of priorities remains, and would remain even in a socialist society.
Is it better to have a new cobalt bomb for treating cancer, or a new geriatric ward? Six research teams are seeking funds for questions ranging from study of a rare disorder to the sociology of the reasons for illegitimacy. Who decides? Such decisions should not be made except in the context of an informed and actively concerned public, so that the issues involved are looked at from every point of views for what seems to be only a technical problem of allocating funds is often a profoundly political one. Great glamour may accrue to a new artificial limb system — but the thalidomide disaster was in large part a failure, to insist on proper controls for drug development — an apparently mundane and even “negative” affair,
The Community is responsible
These considerations should serve to show that a new and democratic structure for the NHS must develop from the basic principle of community care, and community health. At present there are as many health services as health workers, for each sees the NHS locally and narrowly as his place of work, as a means of livelihood, and not as the instrument for service to society. Each patient also has his own NHS, which is to serve him (people speak of “my General Practitioner”) and complains when he has to wait, unconcerned with the wider problem of society’s needs and his own duty to help solve it.
The recognition of social responsibility as the keynote for administration would also need to take account of the extent to which the priorities of the NHS are distorted by the class structure and inequalities of wealth in society. For this reason alone, participation by the Labour Movement is vital,
A few examples of this distortion will help to show the changed emphasis required.
Thus the private sector in medicine should be clearly separated from the NHS. Private beds in NHS hospitals divert scarce resources, corrupt the attitudes of the medical profession, and serve as a method of queue-jumping, Through the maintenance of part-time consultant appointments the loyalties of specialists are divided between private and public work, and even within MS hospitals this helps to scatter their energies between different hospitals. All this is to the detriment of the working class, and to the planning of comprehensive services and the elimination of waiting lists (that this can be done has been shown notably by the Oxford RHB).
Even in the use of hospital beds it was shown by Cartwright (“Human Relations and Hospital Care”) that higher income groups had a favoured admission rate and use of hospital facilities because of ease of communication with doctors, and their superior “know-how” on getting attention.
The NHS has decreased the disproportion in resources going to well-to-do areas, which in pre-1948 days left many industrial areas devoid of whole departments and specialities in medical care, but prestige teaching hospital projects are still favoured, and the disproportion is by no means overcome.
Similar examples of the better use by middle and upper class sections of such facilities as family planning, ante-natal clinics, the new cervical screening test, and general practitioners, are well known.
In the perinatal mortality survey it was clearly shown that the use of medical facilities was in inverse relation to the need for them, the sections of the population with the highest perinatal mortality making least use of proper ante-natal care, being attended later in pregnancy, and being booked less often for hospital confinement.
These defects can only be overcome by planned health education, involving participation in running the NHS by much wider sections of the population.
Now for some examples of an integrated approach in medical care.
First, family doctors. Here, despite the changes of the “Charter” which abolish the “pool” system of payment and attempt to relate payment more accurately to work done and expenses incurred in running a practice, general practice remains fragmented.
Under the ten-year local authority plan, ten times as many health centres will be operative in 1974 as in 1964, but this is still only ten per cent of general practice. GPs remain out off from community care (mental health, social work, school health, occupational medicine, health education). It will be very difficult to apply new computerised systems of epidemiology, diagnostic aid and information retrieval without standardised and organised, family doctor units. GPs remain cut off from hospitals too. Many are still denied X-ray and pathology facilities and certainly under-use them. Most have no access to physiotherapy. Only a third attend refresher courses, and the organisation of post-graduate, medical education (apart from the College of GPs which is in any case a private body) is largely out of their hands. Separation from hospitals has aided the neglect of general practice by teaching hospitals.
New screening programmes, health checks and pre-symptomatic diagnosis are all fields eminently suited to general practice at present being developed outside it with difficulties therefore in co-ordination, in dealing with treatment for cases discovered, and in evaluating results.
It is easy to see how a unified administration could bring these threads together and raise the status of general practice, but this demands health centres as a pre-condition.
A second example is the reports of the Select Committee on Maternal Deaths. Each death associated with pregnancy is analysed for avoidable factors, and in nearly half the cases these are found. This is related to the confusion of three different authorities responsible for the care of the expectant mother. For instance toxaemia, if diagnosed as soon as it develops, as the monthly (and later fortnightly or weekly) readings of blood pressure are designed to do, can be treated. Failure to attend for check-up may result in dangerous delay in treatment and this is in fact a major reason why toxaemia still heads the list of causes of maternal deaths.
Division of responsibility for maternity care leads to wrong bookings (e.g. for home instead of hospital confinement) and has delayed the extension of the scheme for discharging women 48 hours after confinement — for there is no unified midwives’ organisation for after-care. Auxiliary midwives resent having care of the woman only after labour, and hospital midwives the extra pressure of an increased hospital delivery rate.
Again in geriatric, care, it is of the utmost importance that appropriate action be taken immediately, before irreversible changes occur. Thus an old lady may fall and, although there is no fracture, take to her bed through pain and shock. If she is not to be bedridden, welfare services, perhaps new housing, or a local authority home, a short term admission to hospital for rehabilitation, possibly psychiatric advice, may all be required. Each is differently administered, and can only co-operate or assess priorities on an ad. Hoc basis. No one has responsibility for seeing that something is done, least of all the GP who is supposed to be in command.
In particular, the hospital may demur at an admission which would “block” a bed for acute illness if the patient may not be able to return home, whilst the local authority may feel unable to cope with a “frail” person, or simply administer its waiting list on a different set of priorities. These difficulties are of course exacerbated by an overall shortage of money and places, but this is not the only question. Parochial boundaries, narrowness of outlook, and accountability to different authorities and different paymasters are very important in causing delay. The different pockets used to pay different sections of the NHS is well brought out in the strictures on GPs to cut prescribing costs.
A major cause for the rise in drug costs is the use of new expensive remedies which may in fact keep patients out of hospital, e.g., in treating old people with heart failure or bronchitis, and so save hospital costs of £40 or more a week. But this saving of course is from another source.
Similarly, in the provision of medical care for new towns, planners have great difficulty in getting the various parts of the NHS together, and “Moreover, even if they do agree, the money necessary for the buildings and their maintenance and running costs is still difficult to obtain. Often it can be found only by persuading the various interests to contribute roughly in proportion to the use they would make of the services” (British Medical Journal, October 30. 1965)
From Ambulances to Medical Education
These examples can be multiplied to cover every aspect of medical care, whether in provision of ambulances (see the 1964 Confederation of Health Service Employees’ resolution to the Trades Union Congress calling for a unified national health service), in standardisation of records (it took four years for a committee, which reported in 1965, to recommend standard records — for hospitals only — to be implemented by 1968), in psychiatric care, follow-up and after-care, the provision of community services such as rehabilitation, hostels, day-centres, social centres, social workers, regular medical supervision. All demand integration of in-patient (and here the separation of mental hospitals from the general hospitals is long outmoded), local authority and general practitioner. Only where local initiative has overcome inertia has anything been done to make a reality of comprehensive psychiatric care.
Finally, the whole structure of medical education (as detailed in the SMA evidence to the Royal Commission) should be recast, so that education serves, the needs and uses all the resources of the NHS. The teaching of all health workers would similarly be brought within the orbit of the NHS. The special colleges would no longer grant degrees or determine career structures. Students must be involved in planning and operating the courses. All hospitals, not just the present unrepresentative teaching hospitals, must be used, along with- greater emphasis on psychiatry, general practice, preventive, occupational and community medicine.
Undoubtedly the fragmentation of the health service is exacerbated by, and a potent cause of, disunity within the medical profession. The various fields of work, wherein it is possible to function only collectively, appear to individual doctors as antagonistic.
Many aspects of medical care can only be dealt with if this disunity is consciously overcome, for institutions in society embody social values and attitudes which can be changed only by an open struggle against these institutions. Thus the emotional element in illness, and the presentation of stress as illness (so-called psychomatic disease) demand a coherent response from doctors, an acceptance of collective responsibility. At present it is far too easy to pass the buck, to refer the patient, to fob him off with drugs alone, to submit to pressures by the patient to play doctors off against each other. Patients also fail to accept their commitment, fail to keep appointments, change doctors without good ground or go from one hospital to another, fail to carry out treatment, use money to get their own way.
Similarly, problems of casualty and emergency work, night and weekend services, over-prescribing and self-prescribing, chronic diseases with social implications, drug addiction, problem families, the continued care of patients with any complaint referred to hospital and thus removed from the GP’s sphere — all these problems demand a unified medical profession. This disunity is expressed in quite separate pay structures and careers, which itself engenders suspicion and jealousy. The basis of employment for doctors in the NHS must be a unified, salaried, wholetime service, as the SMA has always believed, and this single career structure would cover GPs, hospital doctors, teaching, public health, research, industrial medicine, and administration, and would involve increments for responsibility and special factors. Without this, doctors will never be able to accept the status of member of a health team and a trade union approach to the working of the NHS, for temptations to a special “contractual” (professional) attitude will inevitably lead to hierarchical values and a predilection to private practice.
Not a formal problem
This long introduction serves to show that the structure of the NHS is not formal. On the contrary, the entire range of relations between society and individuals, and society and health, is involved. The question of control in the NHS is not the right to have representatives, but collective control, the development of collective methods of work, of collective structures to elect representatives with right of recall, with full reports of decisions, and a constant and informed debate on the issues in medical care. And as responsibility for the patient remains with the individual health worker, the democratic structure of the NHS must retain local initiative, down to health centre and hospital ward.
The NHS should be based on Regional Health Authorities. In the reform of local authority structures at present under consideration it is obvious that questions of scale, planning, finance and staffing all point to the necessity for large Authorities of the size of the Greater London Council or at least the larger RHB areas. It is not necessary to enter the discussion as to the form of Regional Government that may be adopted. There seems little point in creating them as miniature parliaments. From our standpoint, a Regional Health Authority could be set up without a Regional Government at all, and indeed such a government could be a co-ordinated structure derived from the autonomously functioning parts responsible for health, education, transport, housing, etc., rather than the other way round.
The local authorities, as first tier of this two-tier structure, would presumably retain much more their present irregularity of size and area, but based on historical and geographical reality, and thus a sense of local identity. Elections from these smaller authorities (corresponding to boroughs, etc.) in proportion to population would provide one section of members for the RHA.
The health workers would elect further members, and here new organs would be required for the elections. All employees of the NHS would form the electoral body, based on workplace and on area. The prototype for this exists in the Joint Consultative Committees which are set up under Whitley Council machinery to provide for consultation between management and staff on conditions and running of the hospital. Very few meet regularly, or have any effect, since they have no statutory powers. We suggest that they should have powers to form management, along with the present managerial section (hospital secretary, representatives of the community, as in the hospital management committees) and that they should elect members to the Regional Health Authority.
This covers roughly the interests of the public and the worker, but two further sections need representation. First, the trade unions and Labour Movement should have a number of members they elect. It is not enough to appoint a Socialist Chairman to have a Socialist Regional Health Authority. Working-class values, which alone can express the experiences which called the National Health Service into being, must be present. Secondly, there are many voluntary bodies which represent patients with specific problems (St. John’s Ambulance, spastics, diabetics, alcoholics, AIMS, Mother and Child Care Hospitals, Patients’ Association, National Cervical Cancer Prevention Campaign, ate.). These also should elect members.
There is also the question of ultimate responsibility, through the Minister of Health, to the public for a national service (or at any rate to the Treasury). Here one or two members might still be nominated, but only for, say, three years, to represent this. The Chairman, however, should be elected by the Regional Health Authority committee itself.
How it will work
The Regional Health Authority, then, will act
- as agent for the Minister;
- the planning authority;
- the employing authority.
It will plan resources and priorities, have a budget extending over, say, five years, use bulk buying (and develop direct ownership of supplies and ancillaries, direct building, etc.). It will plan research both clinical and operational, develop record-keeping and statistical methods, and regional facilities for rehabilitation, convalescence, special clinical departments and centres, alcoholic, drug addiction and other psychiatric units, accident services, blood transfusion, and so on. It will be responsible for medical education and post-graduate education through regional centres.
As an employer, the Regional Health Authority would be responsible for career structures, for paying for further education and qualifications, guaranteeing security of employment, stability of administration and development of training for all grades of staff, including administrative. There has to be a balance between a stable structure and the need to ensure flexibility and mobility of staff, providing variety of experience and new ideas and people between regions.
Area Health Boards
At the day to day level, under the Regional Health Authority, actual medical care would be carried out by Area Health Boards, made up with as little dislocation as possible of existing organizations from local medical committees, local health authorities and hospital management committees, but with the perspective of transforming this, as health centres develop, and as the joint consultative committees get under way. The final aim is a system of self-management, involving all the workers in the health industry, at this day to day level. So in a health centre the doctors? dentists, pharmacist, nurses, clerical staff, etc., would all meet from time to time to determine the policy and consider all matters affecting that centre, and also elect representatives to the Area Health Board co-ordinating the health centres, hospital and remaining local authority services, within the local community.
The Regional Health Authority would nominate a number of specialist advisory committees to deal with various technical aspects. Thus a cervical screening campaign might need a gynaecologist, pathologist, medical officer of health, general practitioner, social-workers, etc. Or in occupational health, medical, managerial (of factories), trade unions, safety engineers, inspectors and so on (i.e,, a full Occupational Health Service as part of the. National Health Service). We must emphasise here the vital role of workers and statutory safety delegates.
A parallel discussion on the provision of welfare services is at present going on, with the usual paraphernalia of Royal Commissions. Again, the important and central issue is the integration of the at-present fragmented social services and, perhaps even more important, though not clearly stated, the question of direction. There are arguments about whether a new welfare service should be part of or separate from the National Health Service, whether doctors or social workers should be in charge, how large the departments should be, and so on. A further consideration, which the SMA Social Workers’ Group has been at pains to point out, is the trend towards using the social services to cover up deficiencies in the existing system and to compensate for poverty, instead of using the skills for which they were trained.
In our view, it is essential to have a co-ordinated, efficient, unified welfare department, which would correlate the work of different social workers so that duplication is avoided; provide a satisfactory career structure and enable those in-need to go straight to a single centre for help instead of being harried from pillar to post. Moreover many problems are multiple: a family may need educational, child care, probation, financial and housing help, etc., for different members of the family or at different stages of a crisis. The very varied services for psychiatry (after care, child guidance, special schools, mental subnormality, day centres and hostels, sheltered workshops, etc.) or for old people (laundries, meals on wheels, libraries, health visitors, day centres and clubs, health clinics, etc.) similarly range widely.
A unified social work department could function locally, alongside the health centres which combine family doctor and local health authority work, both under the Regional Health Authority. They could share a management service section dealing with finance, development programmes, staffing, registers (and specific registers for groups at risk). The social work units would be directed by professionally qualified people, and combine all fields of social work, but be able to work with health workers through direct contact in health centres where needed. Again the formal structure is less important than the principle of enabling the people working in a field to make decisions about work and to do so as parts of a comprehensive health and welfare programme for the community.
A socialist perspective
The problems of providing medical care in our society are complex, and it is easy to try to 1ook at them one by one, to devise ten-year plans for hospitals, new looks for general practice, or encourage research on an empirical basis.
This is a terribly wasteful and irrational way of using medical resources for, as society grows in complexity, the inter-relatedness of all its parts, its dependence on social production and social values, becomes ever more apparent. Moreover, without a clear perspective and a sense of participation in whatever decisions and orders of priorities are made, disillusionment and cynicism become prevalent, and health workers become aware that all too often lack of resources and poor organization make heroic efforts seem a waste of time.
This is why it is essential to struggle, not merely for particular advances in particular fields, but for a socialist advance in the National Health Service as a whole. We believe that democratic Regional Health Authorities can provide the basis for this advance and that no half measures will serve, and we call upon the Labour Movement to join us in campaigning for this end.
SUGGESTED FURTHER READING
SOCIALIST CHARTER FOR HEALTH — a comment on the BMA “doctors’ charter”, and a general survey and analysis designed to set the stream of socialist thought for many years (l/- post free printed)
THE CASE FOR HEALTH CENTRES — the brilliant and widely-quoted summary of the socialist case for the reorganization of general practice from health centres (l/- printed)
A SOCIALIST VIEW OF SOCIAL WORK — Socialist social workers consider the history and present position of social work in Britain, and suggest ways in which existing services can be extended and improved (1/6 post free printed)
POVERTY AND OLD PEOPLE — Drs Janet Posner and Geoffrey Richman present a discussion document and a programme for action (9d. mimeographed)