Some Special Services

in modern medicine the team extends far beyond the ordinary doctor. It involves other workers such as dentists, health visitors and nurses, all of which have been mentioned before. There is as yet in this country, however, no very clear recognition of the fact that so closely bound up is the work of everyone in the health field that they should be regarded as constituting one unit. Up to the moment each section has stood quite apart from the others, and doctors, for example, have concerned themselves only to a very minor extent with the working conditions of others connected with the health services. Had this not been the case doctors would undoubtedly have taken up the position that so essential are nurses to modern medicine that the conditions under which they work should be improved out of all recognition. The trouble with medicine is that since it is a developing science it includes many trades which are becoming professions requiring a higher standard of general education and qualification than before and that while these standards are developing there is still much of the old super­stitious basis remaining. Nursing, it will be recalled, was very largely a religious exercise and to many people the nurse is still a person who has answered a call to do work involving tremendous personal sacrifice in order to earn merit for religious purposes. As a result nursing remains a trade in which the financial returns are very poor, the work is arduous, and the atmosphere is one of the greatest imaginable restriction of personal liberty. When doctors as a whole realize that nursing is in reality a profession requiring in its way a training as hard as that of a doctor, and involving very heavy physical work and a high degree of responsi­bility, the conditions of our nurses will be brought into line with modern needs.

The same applies to other parts of the medical profession, particularly in hospitals. Since our voluntary hospitals depend on charity, and our municipal hospitals are controlled as a rule by men whose idea of local government is to spend as little money as possible, our hospitals very often employ for their menial tasks people who because of their unsuitability are prepared to accept very low wages. The way in which sections of the non-medical staff of our institutions may develop into recognized professions is shown by the case of the laboratory technician. When hospital laboratories began to develop the medical men responsible for them found it necessary to employ attendants to do some of the preparatory work, and in particular the cleaning up of glass­ware. These laboratory attendants differed very widely in their educational attainments, but many of them rapidly acquired a sufficient technical knowledge to be able to take over many of the technological procedures which were at first carried out by the doctors. As clinical pathology developed it became clear that by employing laboratory attendants of a better educational standard a very large amount of the routine work could be safely handed over to them, leaving the pathologist free to tackle the important problems. Now we have reached the stage where a hospital laboratory is staffed by one or more clinical pathologists under whose direction and supervision are employed a number of highly-skilled laboratory technicians who often hold university degrees. The menial laboratory attendant has in fact developed into a skilled professional worker without whom no clinical laboratory could function. It still remains, however, for this position to be fully, recognized, and for an adequate national standard of qualification and a recognized rate of remuneration to be fixed for these workers.

Undoubtedly one feature of a socialized service will be the clearer recognition of the part to be played in medicine by the clinical pathologist and the laboratory. Much of the work done in a laboratory for other members of the medical profession is, of course, of a routine nature and provides answers to questions that have been asked by the doctor concerned in the case, and which are so definite in their result that there can be no misinter­pretation. The most important part of the work, however, is that in which the laboratory assists in the diagnosis of a case to which the physicians attending it have been unable to reach a decision by their own methods. In such cases the pathologist must take into account all the facts that have been ascertained about the case by his medical and surgical colleagues and by his interpretation of the laboratory findings in the light of the history and the physical signs assist in giving a name to the disease from which the patient is suffering. There are, of course, many conditions in which the clinical pathologist is able to carry out a test which gives a definite diagnostic answer, but there are still many in which interpretation, judgment and experience play a large part.

From the point of view of our present discussion the implica­tion of this is that the laboratory service must be so organized that the clinical pathologist will be in close contact with every doctor using the laboratory and be able at any time to act as consultant to the rest of the medical personnel of the district. The laboratory must therefore be of such a size that it can handle the whole of the work of a health centre unit, and small enough to enable the medical staff to maintain control over the whole of the work no matter how much delegation of preparation and routine tests to technicians there may be. The standard of laboratory work will continue to advance for many years to come and a socialized medical service will almost certainly lay down a minimum standard of training for laboratory technicians as for doctors themselves. In this way the work of the skilled laboratory technician will attain full professional rank and the relationship between the technician and the doctor be put on a permanent footing.

It will also be evident that in a health centre unit laboratory all work relating to the individuals living in the unit will be carried out. In other words, the health centre laboratory should not only carry out the work from the hospital wards, from the health centre and from the homes of the individual patients seen by the domiciliary doctor, but also the bacteriological work at present done by, or for, the Public Health Department. In this way the clinical pathologist and his staff will form a very valuable liaison between the different sections of the profession and be able to pass on information as to possible epidemics and the presence of carriers in the district. It is true that there would remain problems in mass bacteriology which could be better dealt with by the staffs of special epidemiological laboratories. In this country we have fortunately few cases of the most important epidemic diseases such as cholera and typhus, so that the number of these laboratories required is relatively few. They could therefore be associated with the laboratory of the teaching schools so that there would be not more than one for each medical region.

In passing it might be mentioned that even without a full socialized medical service the organization of a laboratory service would appear a relatively simple matter and one likely to be acceptable to the voluntary hospitals. The Nuffield Trust has already indicated to its Divisional Councils that the organi­zation of a laboratory service should be undertaken immediately. There are still many hospitals in the country which have no laboratory facilities and a very large number of districts in which the services of a clinical pathologist are unobtainable. The clinical laboratory of a health centre unit would be almost self-contained, but there are a number of tests which might be   conveniently   centralized   at   special   laboratories.   In   the London County Council system, and to some extent in the Emergency Pathological Service, the work of morbid anatomy is done at central laboratories, and some of the bio-chemistry involving unusual methods, or for which there is not enough demand to justify the provision of the necessary equipment at every laboratory, is carried out at a central chemical laboratory. Such a system can be admirably adapted to the health centre units that have been suggested. Each laboratory could undertake specialised work for the others and there might be a regional laboratory capable of undertaking those investigations which it is thought advisable to centralize. Such a laboratory might also be the distributing agent of goods purchased centrally and probably also the manufacturing centre for certain products. Much of the material used in laboratories can be manufactured very cheaply and easily in large amounts and this system is at present under trial in the London sector laboratories and has indicated that under peace-time conditions an efficient and economical service could be maintained.

In some ways analogous to the provision of the laboratories is the question of pharmacy. The ways in which pharmaceutical products are distributed to our hospitals and to the patients within each hospital vary enormously. In the cottage hospital prescriptions may still be sent to a local chemist who has been given the contract for the supply of all medicines to the hospital; in others a certain stock of drugs and the more commonly used mixtures is kept by the matron who distributes to the wards what has been ordered by the doctors. In the larger hospitals, how­ever, there is usually a full-time dispensing staff, in the case of the voluntary hospitals making their own purchases direct from commercial firms, and in the case of municipal hospitals obtaining their supplies through a central purchasing organization which makes contracts with the manufacturers. Whatever the system, it is recognized that too much of the work done by hospital dispensers falls in the field of unskilled labour, and that there is too little control by hospitals over the quality of the phar­maceutical products with which they are supplied.

In our considerations, however, we have to take into account not only the hospitals but the medicines supplied to domiciliary patients either at the health centres or in their homes. At the moment the supply of medicines to the individual patient not in hospital is carried out either by the doctor himself or by the ordinary retail chemist. It would be feasible, though ill-advised, for the supply of medicines in a socialized medical service to be carried out by the chemists but it is obvious that so far as visits to the doctors at the health centres are concerned it will be both simplest and cheapest to supply the medicines from a pharmacy which serves both the health centre and the hospital.

There should, however, be no half measures in this matter and most pharmacists who take a professional pride in their work would welcome a system which restored pharmacy as a profession of some importance in the medical service and broke its connection with the sale of cosmetics, patent medicines, hot-water bottles and photographic materials. For a variety of reasons it is only the lesser part of the income of the retail chemist’s shop which comes from the sale of preparations which could not be supplied by any ordinary shopkeeper.

The supply of pharmaceutical products in a fully socialized medical service would therefore be carried out by the pharmacy of the health centre. A fairly large staff would be required and it is hoped that in thus freeing the general practitioner from the work involved in his present personal dispensing less use will be made in future of stock mixtures and proprietary prepara­tions and work demanding a higher degree of professional skill be placed on the pharmacists.

Just as the laboratories would be linked with more highly specialized  centres  related  to the  teaching  hospitals,  so  the pharmacies would also be linked with a department in which unusual or experimental preparations were made and by which the   distribution   of materials  purchased   centrally  would   be undertaken. This whole question is, however, bound up with that of the control of the manufacture and issue of pharmaceutical products and much depends on the extent to which the State in the post-war period will be compelled to maintain its control or even to take over the process of manufacturing chemical products. On theoretical grounds the whole procedure of manu­facturing pharmaceutical substances should be under the control of the medical service and directed by a joint body of doctors and skilled pharmacists. It is only in some such way that the purity  and  potency  of all  drugs  supplied  to  hospitals  and individual  patients  should   be  guaranteed.   We have in this country many extremely reliable firms of manufacturers, and the quality of the drugs produced is very often of the highest possible standard; on the other hand, however, there is the usual attempt by the finance committees both-of voluntary hospitals and of local authorities to do their purchasing by acceptance of the lowest tender irrespective of the quality of the goods supplied. Any doctor who dares to look at his hospital pharmacy with a critical eye will find products purchased in this way of which, however much their low price may have attracted the committee, the quality is such that results in treatment are bound to be less than can be obtained with the highest quality materials.

The matter goes even deeper, for we cannot consider phar­maceutical products without taking into account the existence in Great Britain of a very large trade in patent medicines, nor can we ignore the tendency of doctors to accept and prescribe proprietary remedies about which their only source of information has been literature supplied by the manufacturer. Both these facts fall into the same class, for they indicate a readiness to accept untrue or exaggerated statements made by a manufacturer, and the results on the one hand are not only serious financially but may be of the greatest importance to health, and on the other hand indicate a lack of responsibility on the part of those doctors who use proprietary remedies which reflects very strongly on their medical education.

So far as patent medicines supplied to the public are concerned, medical and legislative opinion has long been almost unanimous that some method of prohibiting their sale must be devised. However, the vested interests involved are so powerful that up to the present every attempt even at a partial control of the trade has been prevented. It is still possible in this country for any individual to place on the market a completely worthless prepara­tion and to push its sales by quite untrue and exaggerated claims and to make these sales through almost innumerable trade channels so long as he does not claim to have discovered a cure for five or six specified diseases. In fact, while individuals do offer such remedies to the public, the manufacture of a very large number of them is in the hands of a very small number of firms. There is no definite information as to the total amount spent by the public on these so-called remedies, but estimates place it as high as thirty million pounds per year. This amount of self-medication is at the least a waste of public money for something which is of doubtful value, at the worst a waste of money on products which lead to delay in application of the proper remedies and can be demonstrated in the practice of every doctor to lead to prolonged misery and often death which could have been avoided by earlier medical attention.

The use by the medical profession of proprietary products which have not been efficiently tested, or have been tested and proven to be valueless, or having been devised for one condition are recommended and used for other conditions in which they are of no value, is inevitable where there is no official control over the number and quality of products which are offered to the profession. It is impossible to go into these questions here but what the profession requires is some central organization which has the statutory duty to assess the value of every proprietary preparation offered to the profession and to issue reports to every doctor as to whether he should or should not use them as recom­mended. This is no revolutionary proposal, for in America there is a Council of Pharmacy which has these duties and powers. One of the greatest failures of the British Medical Association has been that it has not attempted to obtain official sanction for such a body, nor set up an unofficial professional committee for this purpose. In 1908 it did make an attempt by publishing analyses and estimates of costs to show up the racket behind patent medicines, but has seemingly been afraid to take any such action in recent years.

It is clear that in a socialized health service all pharmaceutical products would be controlled as to quality and that unequivocal reports as to potency would be issued to the service as a whole. One reason why the isolated general practitioner sometimes uses products without knowing their real value is that the conditions of general practice give him no opportunity for assessing the value of the materials he prescribes. It is only in the wards of the hospital where conditions are uniform, and where a large number of cases of the same disease are probably under observation at the one moment, that the efficiency of new lines of treatment can be assessed. Many general practitioners have been aware of this and have asked that some method should be devised to enable the family doctor to maintain a closer contact with hospital work and particularly with the work of the senior members of the staff of the hospital.

There is another reason why general practitioners want the right of entry into hospitals, namely the feeling that as they lose touch with the patient who goes into hospital so they lose the financial claim that they have on a sick person. A patient nursed at home and visited every day means, except in the case of a panel patient, additional fees. A patient nursed in hospital may mean not only the loss of fees during that illness but a tendency for the patient to turn to the hospital rather than the practitioner for future medical care. This latter reason would, of course, disappear in the case of salaried family doctors, but it would still remain necessary to keep the family doctor closely in contact with his hospital colleagues. No system that has been suggested would do this so easily as the health centre at which the family doctors and the hospital staff would be working together and so able to compare notes about every case and arrange for consultations at the bedside inside the hospital as easily as in the patient’s home. There appears no reason for suggesting schemes for clinical assistantships, or for arrangements whereby the general practitioner would go into the wards as semi-skilled assistants to the hospital staff. In a socialized service the hospital staff would be recognized as experts in their own field, and the family doctor would be accepted as the expert in his field as primary diagnostician and health adviser.

A related question to this is that of the maternity service and the school medical service. There are many who have seen in the tendency for the care of school children and of all maternity work to pass into the hands of full-time officers of local authorities an encroachment on the work of the general practitioner. To put it bluntly, this encroachment has been mainly a financial one, for on mature consideration most general practitioners agree that so long as they are placed in a position of economic security they have no particular desire to do midwifery with its night calls and its worries, and still less to engage in the rather boring work of examining hundreds of children.

So far as maternity is concerned it must be laid down that no one should be allowed to engage in this part of medical practice who is not an expert in the subject. It is quite clear that the definition of “expert” must be wide enough to cover those men who work among scattered populations where the greater part of their work is that of a general practitioner, but where they are not only the only medical personnel available for mid­wifery but actually do acquire a considerable experience in it. In urban districts, however, the present-day position is that an ever increasing proportion of all births takes place in hospital, and it seems likely that except in those cases where the household conditions are exceptionally favourable the largest proportion of all births will take place in the maternity section of the health unit hospital. Under these circumstances we shall have a con­tinuity of maternal care which is an absolute necessity if the maternal and neo-natal death rates are to be reduced to the absolute minimum. This continuity of treatment should begin with ante-natal examinations at the health centre, in the early stages by the general practitioner and in the later stages by the obstetrician of the hospital. The birth would then take place in the hospital under the care of that obstetrician who would also be responsible for the post-natal care of the mother. When that period was passed the care of the mother and child would again return to the family doctor. At no stage, however, would the family doctor be out of contact or in ignorance as to what was happening to his patient. Through the records of the health centre, and by notification, he would be kept informed of the progress of the case so that when he resumed full care of the mother and child he would have all the information as to what had happened made available for him.

In so far as births still take place in the home the highly skilled midwives of the local service would operate. It will be realized that only those cases of women who had already had one or more children, and in whom the obstetrician could discover nothing likely to interfere at childbirth, would be permitted to have their babies at home. All first babies, and all cases in which an abnormality had been discovered, would automatically go into hospital, if in spite of these precautions the midwife required assistance she would send for an obstetrical specialist on duty at the hospital. She would also have the option, if she considered the condition sufficiently serious, of taking the case by ambulance direct to the hospital. There would thus be no intermediary between the midwife’s realization of need for help and the arrival of the obstetrical specialist as there is to-day. The midwife who to-day wishes assistance is expected to call in the general practitioner of the patient’s choice, and if he is one of those who, like the practitioners of a London borough of which the figures are available, saw on the average less than two maternity cases in a year, and therefore had not the experience to deal with the matter, there would be considerable delay before the case reached hospital or before the specialist could reach it.

We cannot leave the question of maternity services without observing that in the post-war period serious consideration will have to be given to the position of the pregnant women in industry. Just as there was after the last war a great increase in the number of women who wanted to continue in some kind of paid employment, so it is likely that so long as post-war recon­struction requires the employment of large numbers of people women will want to take their place in industry and there will therefore need to be a definite statutory arrangement for periods of rest from employment before and after childbirth. The example of the Soviet Union in this matter is one which can well be copied.

The school medical service has not been an encroachment on general practice for it has been concerned in the past with a totally different aspect of health from that which has concerned the family doctor and has provided no treatment of diseases.

The care of the school child of the future will have two aspects, each of which will involve different parts of the medical personnel of the health unit. On the one hand there is the care of the individual child which belongs to the medical service as a whole and must be continuous both in time and space and which will mainly fall upon the general practitioner of the health centre. In so far as he is unable to deal with problems arising in any of his individual child patients he will be assisted by the paedia­trician in charge of the children’s ward of the hospital. He will also, of course, have the assistance of those other specialists who are provided for the service as a whole.

The second aspect of the care of the child is, however, outside the scope and powers of the general practitioner. This aspect is the assessment of those factors in the health of the child which affect or are affected by his relationship with other children and with their environment. These mass problems provide important statistical information for the health officers concerned with the nutrition of school children or with educational problems such as the number of hours to be spent at bookwork and the number to be given over to organized play. For the purposes of these mass investigations only those examinations of the children which will give the desired information can be carried out, and they must be carried out at regular intervals without any relation­ship to the health of the individual child, and they should be done by men and women whose primary medical interest is in the care of children. Thus such investigations do not take into account the many childish illnesses for which the general practitioner would be consulted. They can best be done by the staff of the children’s department at the hospital. Under present day conditions school medical inspection is carried out by whole time officers who do very little other clinical work and who, unless of exceptional quality, neither give their best attention to the job in hand nor are stimulated to better medical work in other fields. School medical inspection carried out by men and women who were devoting their whole lives to the care of children, and who had the variety of work involved in looking at large numbers of children at regular intervals, and of dealing with the intricate problems of the individual child in hospital, would not only bring a new spirit to the routine inspections, but by their contact with healthy children would be inspired to greater efforts for the sick children under their care in hospital.

Space prevents us from dealing with another intricate and vital problem, that of industrial medicine. The principles just suggested for the school medical service apply, however, to industrial medicine, for the worker in industry presents both a personal and a mass problem for medicine. As an individual he is, of course, catered for by the health centre; in the mass his factory environ­ment should be in the hands of a medical specialist with wide powers over industrial conditions; but there must be a link between the general practitioner and the factory, for not only may many of the conditions for which the general practitioner treats a workman be due to his factory environment but rehabilitation after sickness or injury can only be carried out by men closely connected with the factory. In areas where there are heavy industries there is also a need for hospital beds where fractures can be treated by men of wide experience of this type of injury. There should therefore be in each health unit hospital a department in which industrial injuries are treated by salaried officers of special experience in these conditions. It would then be to these men that the investigations of mass problems, e.g. the incidence of tuberculosis, would be delegated and it would be to them that the general practitioner would turn for advice on rehabilitation and other matters related to industry.

There are other specialist services to which similar principles apply and of which, therefore, nothing more need be said. In general, however, the consideration we have given to these problems indicates that the unit of one hundred thousand people obtaining the whole of their medical service from a thousand-bed hospital and related health centres fulfils all the require­ments of a modern medical service. It is clear that through them a service which is complete can be provided at every stage of the life of the individual and at every part of the country, that the problems of the individual and of the mass can be dealt with effectively, and it is suggested that in such a scheme the quality of the medical service given by every individual doctor would be subject to a constant improvement which in unity with the advance of medical science .would lead to an almost incalculable improvement in the average standard of health.