Now for Health 11 Education

Education is the basis upon which to-day advance in all fields of human effort is made; and in a health service it is of fundamental importance. There are, however, two kinds of education concerned, types which have for long been divided from each other though they should be complementary— the education of the public in health and the education of health workers in their particular job. The more the public know about the health service, about the general principles of health and the causes of disease, about the working of the human body, the better they will co-operate with doctors and others to preserve health. The better that health workers are chosen and educated, the more they understand the social factors underlying health, and the more information they have to pass on in simplified form to the lay public the better they will do their job.

We should not overlook that one part of health education will be the training of the people in the value and use of the new service. That proviso has already begun to operate, and a recent analysis of public opinion by accurate methods (as opposed to the unscientific efforts of certain newspapers) has shown how the public is already preparing for “the appointed day.” The British Institute of Public Opinion (Gallup Poll) reported in the News Chronicle of June 17th, 1946, that of the adult population, 65 per cent, said “Yes” to the question, “Have you followed the discussion on the National Health Service?” Those who said yes were then asked if they thought the plans “will or will not result in better health services for the country as a whole,” and less than one in four answered “No.” Excluding the elderly and wealthy, the number who did not think the service would mean an improvement was small indeed.

Health education, talks, film shows, demonstrations of the causes of health and ill-health will be a feature of the health centres. Advice on individual problems will be mainly the duty of the doctor, health visitor, midwife or other health worker concerned with the case. More general advice is likely, however, to be a function of only those officers who have a special aptitude and have had special training in the instruction of the public. The translation of scientific and technical information into terms easily understood by the ordinary citizen is a matter of some difficulty, and most medical men. find it nearly impossible. The selection of the information to be given is also difficult, for too much, especially if it leads to self-medication, would be dangerous.

Self-medication is of course a feature of the present day, and it is variously estimated that the public spends between twenty and thirty million pounds sterling every year on “patent” medicines. Most of that is simply waste and a part of it may even be harmful in itself, apart from the evil economic results of such spending. Methods of direct attack on this system are not included in the present Bill, but by the indirect methods of education and by the provision of a full service without fee there may be a rapid diminution of this trade.

The doctors in the health centres should, of course, be protected by law if they do their duty and tell their patients about proprietary remedies. As it is to-day, no one can criticise or even discuss these so-called cures without running the risk of a libel action which might prove very costly whether won or lost. A scientific method of tackling the problem would, of course, be for the Ministry of Health to set up a committee to report publicly on the price, quality and action of all substances offered as therapeutic remedies.

Attempts have been made in the past to educate the public, especially by the Central Council for Health Education; but one great drawback has been the absence of a place at which a continuous stream of advice, information and propaganda could be maintained. A second problem has been that health workers—doctors in particular— have not been able to give the necessary talks and so on because of the individualistic basis of medicine, their lack of training for the work, and the fact that they were paid for treating disease rather than its prevention or the promotion of health.

All these points are met by the health centre system and by the payment by basic salary. The health centres provide the place, and the basic salary can include payment for this work to those doctors with special ability in this direction. The team at the health centre can all join in and the health visitor, for instance, can assist by individual advice to a much wider circle. The techniques to be employed— poster, stage, screen, radio and television— have all to be worked out, for we have not made a real beginning in this field in Britain.

The education of health workers is still in a chaotic state, chaotic in both senses, unplanned and underdeveloped. As ancillary groups have developed they have acquired methods of training, standards ,of attainment, forms of professional organisation, issue of diplomas, registration of members and relationships with other health workers in the most haphazard and incomplete fashion. Some have attained national recognition, as with the State registration of nurses, but others have still no officially recognised position, although playing an important part in the health service. In some groups we find methods of training, professional machinery, trade union organisation, and diploma-granting in the hands of more than one organisation, leading to many difficulties, especially in regard to conditions of employment, In the U.S.S.R. there is one “all-health-workers” trade union: in this country there are at least twenty organisations catering for health workers, arid being either trade unions or acting as such, A further difficulty is that many ancillary workers have not yet reached a consolidated position in which their duties are clearly defined and their status fixed. The nurse, for example, has changed in position and duties many times in the course of centuries and her position is not yet absolutely fixed. The laboratory worker began as a menial who did purely domestic work, graduated to laboratory assistant, later to become technician and now finishes as F.I.M.L.T., (Fellow of the Institute of Medical Laboratory Technology), an examining and diploma-granting organisation not yet given State recognition. It also, however, negotiates working conditions although the Association of Scientific Workers operates as a trade union for all grades of laboratory personnel.

Then there is the relationship between the ancillary worker and the doctor. Is the latter always to be in charge of the former? Or are there services and situations in which the ancillary worker should carry out procedures affecting the health of the patient without any medical intervention? An example is the problem to be faced in the new health service of reconciling the relationship between the optician and the ophthalmologist. Some advocate that all seeking advice about their eyes should first be seen by the medical, fully-trained ophthalmologist, who will then refer any case requiring glasses to the refracting optician (and other cases to opticians with other special skills) ; while some believe that the non-medical refractionist is quite capable of seeing all cases, testing their eyes if necessary, and referring them to the ophthalmologist for treatment of conditions other than simple errors of refraction. This is a seeming dilemma on the solution of which largely depends the amount of eye service we can give. The solution lies in the development of the team and the disappearance of such rivalries which arise from economic structures.

Another facet of this inter-relationship is the question of the amount of medical knowledge nurses and technologists should be given to enable them to be of the greatest service. They cannot be given a full medical training, for that would probably prevent them from acquiring their own special skills, some of which take a long time and depend on a wide background of general knowledge. It would obviously be impossible without imposing a great strain on every trainee to give much medical instruction in addition. The amount of this varies in any case considerably. The laboratory worker gains a very detailed knowledge of the causes of disease, while the nurse becomes expert in the course of diseases, but may have little understanding of cause or diagnosis, and so on. The doctor, on the other hand, may know next to nothing about the work of either and yet be a good doctor.

There is a very general feeling that in some ancillary groups, possibly in the case of nurses most of all, there has been in recent years a tendency to expect too much detailed medical knowledge at the expense of special skill in their own work. This makes the qualifying Examination much more formidable than it need be, and is one reason for the high proportion of girls who want to be nurses but never qualify. There is also the difficult question, which applies to doctors also, of who is to set the examination standard and what the qualification is to be. In some cases, it is set within the group; in some others outside the group, and in still others by organisations representing both the workers and the medical profession. A national health service will clearly need national standards for all ancillary workers, and a single national method and portal of entry into the ranks of the health workers.

It may be noted in passing that these national standards will need to be linked with national standards of wages and other conditions; and that upon these will largely depend the numbers of people attracted to and retained within the ranks of health workers. It is very interesting to see in the latest figures published that there is no shortage of recruits to these vital services. In the beginning of 1946 we have recruited, for example, more nurses than ever. The important question is whether or not we shall retain them until qualification, for in the nursing profession more than any other the position has always been that we have recruited more than we needed, but given such conditions that only a small proportion have stayed the course. Up to the present the Ministry of Health has had no power to deal with this problem, but in a national service will be able to effect the necessary changes.

A further point, which is an outcome of those already discussed, is the absence of a common body of knowledge as to the aims of medical science, the methods by which the problems involved can be tackled, and the scientific facts on which we are working. This arises both from the facts already noted about our lack of planning and from the type of textbook available, and the methods of teaching used. These are detailed technical problems which need not be discussed here but must be tackled in the early years of the new service.

When we turn to medical education we find similar problems. The medical profession is not the homogeneous body of popular supposition. Even a cursory glance reveals lack of planning, multiple qualifications, wide variation in training methods, and, some think, failure to alter the curriculum quickly enough to meet the rapid development of medical science. There is an almost unanimous call in the profession, very strongly made by those who have studied the matter closely, for radical change in the whole set-up of medical student training. The unanimity applies to the need and not to the precise type of change, for a vast number of different reforms have been suggested. Two years ago a Government-appointed committee, presided over by Sir William Goodenough, issued a lengthy report on these matters, showing up many of the deficiencies and defects and indicating some of the solutions suggested. Unfortunately, it was not far-seeing enough in view of the present Health Service Bill, and the subject requires further detailed study in the light of the new service.

The reforms suggested aim at providing a wider educational back­ground for medical students, cutting down much of the detailed knowledge taught, and introducing new subjects, such as social medicine previously neglected, and many new methods for rapid teaching.

The total length of the curriculum cannot be made shorter, but there could be established a single standard of graduation and of higher qualification. One proposal will have repercussions on the national health service, and can only be a success when such a service is in being. This is the suggestion that graduation should not, as now, imply licence to practise, but should be followed by a year spent in practical training— six months in a hospital and six in general practice at a health centre.

This and other reforms are vnot tackled by the Health Service Bill. They will involve new legislation and a new economic basis for medical students. If the period before licence to practise is granted is to be lengthened, and especially if part of the time is to be occupied by purely professional work, there must be payment for at least that part of the time. But in addition, the longer the course the more necessary will be the payment of maintenance grants to students during their whole time as students. Ultimately that will mean the payment of maintenance to all students and the granting of free medical education to all suitable candidates of both sexes.

It is estimated that at least ninety per cent— and probably more— are drawn from the ten per cent, of the population in the highest income group. This is an unnecessary and artificial distinction which every year rejects on purely financial grounds large numbers of potentially good doctors, and the new service can use them all. It also permits existing schools to exercise restrictive methods of selection, including, the cynics say, prowess on the rugby football field, one result of which is the virtual exclusion of women students, especially in the London area. This will be changed in 1947, when all medical schools must take a quota of women, but there should be complete equality in this matter. A case has been made out against women because of losses after qualification through marriage, but the record of women doctors in this country and others is sufficiently high to justify the establishment of sex equality in the schools.

The present Health Service Bill does open up the possibility of educating more students than we do to-day. The teaching hospitals come into the national service with all other hospitals, though they will be controlled by separate Boards of Governors, and the Minister has been granted powers to constitute any other hospital, or group of hospitals, a “teaching school.” He will undoubtedly need to do so if the ideal of the regions is to be achieved by having a medical school in each. It will also be necessary if we are to educate more medical and dental students than we do to-day. The deficiency in doctors is not so great as some critics of the Bill suggest, but we can with advantage increase the number of doctors in active practice by from six thousand to eight thousand. If we use all our educational facilities we can do so rapidly.

There remains the vital subject of re-education, and on this the Minister of Health told the Committee of the House of Commons that he intended it to be an important feature of the service, and “refresher courses” would be provided for all health workers. The Bill gives him power to make arrangements for these and to pay expenses to anyone attending them. It is not claimed that such post-graduate courses can of themselves keep every doctor up to the highest standard, but they can play a big part in preventing stagnation and in spreading accurate information on new methods of diagnosis and treatment.

There is a pretence in some quarters to see in this provision the danger of an attempt to make treatment of disease stereotyped by the issue of restrictive instructions. No power is given in the Bill to any of the administrative agencies to do this, and in any case all the doctors do not come within the ambit of a single administrative body, so that would be difficult even if attempted. There is clearly a great need for the dissemination of accurate information and informed advice on all new therapeutic methods, drugs and appliances, which might be undertaken by the Ministry of Health, the Medical Research Council, or any other body. This should be a feature of the new service, but must not be used or regarded as in any way restricting or ordering the individual doctor.

Allied to this is the question of a central or regional supplies system, through which by bulk purchase great savings can be effected, and through which— as wartime experience with penicillin demonstrated— new preparations could be equally distributed. This point was omitted from the Bill, but was strongly advocated in the House of Commons ; it has now been included by an amendment in Committee.

That such a supplies department is needed is a reflection of the amount of medicaments ordered by doctors and used by the public. The blame for the ” bottle of medicine ” habit must be fairly evenly divided between the doctors and the public, and it is likely to continue for some time. One of the objects of both lay education in health and of student education in medicine must be to lessen the faith of the sick in anything but remedies with a specific and proven value, and to train the doctors, not only in their use but in the social techniques which will enable them to inaugurate a new era in which the consumption of medicine decreases and the level of health rises to higher and better standards.