Control of the Health Services

Socialist Medical Association August 1944 C1. D.5 (Final)

The S.M.A. has already warmly welcomed the main thesis of the White Paper.  It regards as of primary importance the principle that the comprehensive health service should be freely available to all, the conception of the Health Centre and the emphasis on “positive health”. ”

A clear statement of the intention to make the National Health Service of the highest quality and on the machinery where­by this can be done, will lead to the use of the service by such a proportion of the people that most doctors will decide against trying to retain any private practice. The S.M.A. holds that it is not ethical for a doctor in the public service to practice privately as well. Nevertheless, since the success of the new service should cause the people to prefer it to any other form of service, the Association does not consider the question of dual service to be a fundamental problem.  The important points are that the high standard should satisfy the patients and that the administration should be satisfactory to the doctors and other health workers.

The S.M.A.has always advocated that all health workers should be paid on a salaried basis. The B.M.A. has suggested that such a method of remuneration provides no incentive to hardwork and initiative. This appears to put doctors on a much lower ethical level than, for example, salaried midwives, and, indeed, all either salaried officers. Nor can it be contended that under the present system the more painstaking the doctor, the more he “will earn.  There is probably no profession in which merit receives due financial reward,

The quality of the new service, the proportion of doctors willing to enter it on a salaried basis and the avoidance of all the evils prophesied tor the service, will depend to a con­siderable extent on the administrative method adopted.  None of the existing arrangements are entirely satisfactory, and therefore the plan must:

(l) be capable of practical application in the immediate situation

(2) secure the support of the large body of professional opinion which the B.M.A, questionary has shown to be in favour of a health service, available to 100% of the people. and of practice in health centres, but which is still anta­gonistic to present methods of local government.

On this point the S.M.A. declares its firm allegiance to democratic principles, the control of services essential to the people by the people, through their elected, representatives. The form of organisation must, however/ give to each health

Worker the opportunity to make his or her maximum contribution to the service, and freedom must be given to all to express their opinion on any matter connected with the service. Health workers must retain their full rights as citizens and the organisation must encourage the closest contact between health workers and other citizens.

The administrative structure must provide that:

(a) National optimum standards for the service are fixed and health workers are at liberty to make representations if a backward local authority is not maintaining these standards.

(b)    There must be opportunity for direct contact between the local authority and all health workers through their elected representatives.

(c)   Clinical workers must not be subordinate to administrators. It is safe to say that doctors are as much afraid of being “under” the Medical Officers of Health as of control by a lay committee.  This fear will not be allayed by the words of the Minister who, in his speech to the Society of Medical Officers of Health said, in referring to Health Centres, Home Nursing, Dental Services, etc.: “In all these ways there must be immense additions to the scale and importance of the work of Medical Officers of Health.”  In many municipal hospitals there has been much friction because of the power of the Medical Superintendent to interf­ere in the clinical work of other hospital officers, Collective responsibility through staff committees will, of course, make action to prevent this simple.  In general practice, collective responsibility is a new conception which must develop as health centres are established.

(d) There must be a measure of control over the conditions of the service by the health workers actually doing the job.
It is not enough to state that the Local Authority will not interfere with the doctors’ clinical work, for the conditions under which that work is carried out may in itself be an interference.  This is well exemplified in the Out-Patients Departments of hospitals in many of which great crowds of sick are daily herded together in  conditions which make the best work impossible.  The hospital officer who is compelled to look after too many beds is working in con­ditions which interfere with his clinical work.


Remembering that the service which is made attractive to the health workers engaged in it is likely to prove best for the patients, we suggest that the following executive, advisory and professional bodies and activities must be provided for the ad­ministration.

(1) The Ministry of Health must be concerned solely with the health services, assisting through liaison committees in all other matters affecting health and should have charge of the planning of all health services on a national scale.

(2) The Joint Authorities may be accepted provisionally until a new scheme for all-purpose elected local authorities governing wide areas has been devised,  Legislation in these matters must include provision for all health workers to retain their rights as citizens so that they can be elected as members of their employing Council, or of any other constituent of the Joint Authority. Co-option on health service committees must also be continued and the co-option of health workers by the parties represented in any local authority should be encouraged 0

(3) The co-ordination of the work of contiguous authorities will often necessitate the setting up of joint committees or action by the Ministry of Health. In this connection a place may be found for a National Health _Service Advisory Council composed of representatives of each health authority.

(4)Expert and Professional _Advice_ The Ministry of Health and the Joint Authorities must have the advice of the medical and technical staffs they employ and of experts of recognised standing. Three points are apt to be overlooked in discussions on this matter;

a. The greater the number of doctors employed in the national health service, the less possible will it become to appoint what might be termed an “independent” committee.

b. When every Joint Authority employs large numbers of highly qualified specialists, advice must no longer be sought exclusively from the Medical Officer of Health, but directly from the specialists concerned.

c. The desire for advisory committees is an expression of the desire of the doctor and of other health workers to be quite free from lay control in their day to day work. In our opinion, this can best be secured, by the setting up of staff committees on which would fall the collect­ive responsibility for the running of a hospital or health centre, within the framework of the Authority’s policy.  In our view the main staff committee should include representatives of all grades of workers within the service, but sub-committees of separate types of staff should be set up as required.  The establishment of such committees must be made a statutory right,

The need for advice at the Centre and locally being somewhat different, we suggest the following:

(5) A Central Health Services Council composed of experts, mainly, but not exclusively medical, chosen because they may be counted on to render the best scientific advice available in the country, and for their ability to work in committee.  Such experts cannot be chosen by an electoral method and this Council should be appointed by the Minister of Health from nominations made by professions! and other bodies.

Although appointed by the Minister, the Central Health Services Council must have the right to publish its own reports to initiate discussion on any matter connected with the service.

(6) Local Health Services Council. The L. H. S.C. will have no executive authority but will have enormous influence in securing a good health service, provided that the Regional or Local Authority must confer with it on all matters affecting the health service. It must have the right; (a) to initiate discussion with the L.A. on any matter that it thinks fit; (b) to publish e quarterly report; and (c) where its advice is not accepted by the L.A. to report to the Central (vide supra) Health Services Council, which will, if it thinks fit, take up the matter with the Minister. Any health worker shall have the right to bring to the notice of a member of the L.H.S.C. any matter which he thinks deserves the attention of the Council; it will be the duty of the Council to encourage health workers to submit their ideas for the improvement of those aspects of the health service with which they are individually concerned, thus encouraging initiative. Consideration should be given to the possibility of sending to the L.H.S.C the Agenda of the Public Health Committee of the Joint Authority.

The Council is to be regarded as an organ, not for collective action in regard to conditions of service, but for giving to every health worker an individual responsibility for promoting a good health service. The giving of partisan advice by such a Council will be avoided by publication and public dis­cussion of its views; and by a composition which ensures that all groups of health workers are represented.  Election will secure neither the representative character nor the selection of those best fitted to give advice and the L.H.S.C. should therefore be appointed by the Joint Authority from nominations received from professional and other organisations.

(7) The Local Health Services Council should take as one of its first problems the elaboration of the best method by which hospital, and health centre, staff committees can carry out their duties and the avoidance of the much-discussed domination of the Medical Officer of Health and the Medical Superintendent. The views of the S.M.A. on these matters have already been published.

(8)     Provision must also be made for trade union activity among health workers and the terms and conditions of em­ployment of all grades of workers must be negotiated centrally. Whitley Council machinery will only be possible when health workers are organised and all local authorities bound to encourage such organisation.

(9) The political activity of health workers individually and collectively must be safeguarded and permitted within the service.

(10) The public must also have the opportunity of influencing and contributing to the development of hospitals and Health Centres.  Ideally this should be a spontaneous development arising from a need and from the public’s educated desire for health, rather than through a statutory body which might have restrictive powers.  What is required is the awakening of a social conscious­ness among the people so that, directly or through their trade unions, co-operative societies, religious and other organisations, committees should be set up to contact the professional staff. It is, however, generally agreed that there must be a statutory com­mittee for hospitals composed of those members of the Joint Authority elected for the area served by the hospital.

Prepared by the Socialist Medical Association, 59, New Oxford Street, London, W.C.1.