“The prevention of disease was overlooked when modern industrial civilisation began; and the promotion of health is only now being brought forward as the true aim of medical science. Promotion of health must be a co-operative effort between health workers and citizens ; insofar as prevention of disease has been attempted it has fallen upon those who represent the people through their local authorities. By various enactments health powers and duties have been given to locally-elected bodies and some real advances in the prevention of disease have been made.
These advances have, however, been irregular because much of the health legislation has been “permissive,” and the degree to which it has been carried out has varied enormously ; moreover, the functions have been divided among the authorities so that co-ordination hag never been very good. The local government machine has been used for many services which have an indirect influence on health— sanitation, drainage, water supply, street cleaning, and so on, as well as for the prevention of infectious diseases, including isolation and notification ; and in recent years maternity and child welfare, midwifery, health of the school child and other services have been developed.
The new Bill proposes to “unify these services in the existing major local authorities—the county and county borough councils— and provides for the formation of joint boards wherever, exceptionally, this may be found desirable.” The services to be unified in this way make quite a formidable list, and the new local health authority must indicate to the Minister how they propose to carry out their duties and must obtain approval for their general scheme. In making these proposals due regard must be taken of any arrangements by the Regional Hospital Board and by the Executive Council for hospital .and for general practitioner services respectively, and of any voluntary organisation which is working in the health field in the health .authority’s area.
It will be noticed that the major local authorities are losing their function as providers of hospital beds but they are being given even bigger tasks. One of the biggest is “to make arrangements for the care of expectant and nursing mothers and of children under five years.” Such arrangements must include ante-natal clinics for the care of all expectant mothers, post-natal clinics, and every kind of care which the infant and child require. In addition there must also be a priority scheme for dental care for young children and pregnant and nursing mothers.
The health authorities are also made the bodies responsible for a complete midwifery service for mothers who are confined at home. The midwives’ service is expected to be expanded, and the local authority may use any existing voluntary organisation or employ the midwives direct. As at present, the midwives will have the right to call in “a suitably qualified doctor in case of need,” but attendance at the confinement is not to be made the general duty of the home doctor (who will of course be expected to give general health care to any woman patient before and after confinement).
There is a division between the domiciliary midwifery service and that given to women who are confined in hospital or maternity homes. There they will be in the charge of the hospital obstetricians and gynaecologists, but it will be the duty of the Minister to see that there is no gap between them. “Continuity between one and the other,” Mr. Bevan has said, “is maintained by the user. If there are difficulties in connection with birth, the gynecologist at the hospital centre can look after them…………. the mother will be properly examined and if difficulties are anticipated she can have her child in hospital.” The local health authority is required to establish the necessary relationship between its domiciliary midwifery service and the specialists employed at hospitals by Regional Hospital Boards.
Major local authorities have had in the past important functions in mental health and lunacy services, most of which are now transferred to the Regional Hospital Boards. There are, however, certain types of mental care which are given at home, and the health authority will therefore be responsible “for all the ordinary local community care, that is to say, the ascertainment of mental defectives and their supervision when they are living in the community.”
One very important field of preventive medicine is active intervention to prevent a particular disease by vaccination or immunisation. Compulsory vaccination was introduced in 1853, but since 1898 it has been possible for a parent to withdraw a child, from the application of the compulsory clause. At present only one-third of children are vaccinated, and the Coalition White Paper said “It is probable that the time has come to amend the law.” The Bill accepts the suggestion then made “to substitute for compulsory vaccination a system of free vaccination for all through the family doctor, the clinic services or otherwise.”
It is by these methods that immunisation against diphtheria has been carried out, and by good publicity a very high proportion of parents have responded and have had their children immunised. The service for this, for smallpox vaccination, and any other method will now be provided by the local health authority, who will supply the materials free and may pay appropriate fees to the doctors who carry out the work.
An increasingly important part of preventive medicine is the service of health visitors who attend at the home to give advice where sickness is concerned and to assist in prevention. The local health authority is required to provide a full health visitor service backed up by -home nursing and home helps. The wartime development of domestic help in the home because of sickness, absence of mother in hospital, or because the mother has just had another baby is to be made a permanent feature of the health service. A charge may be made for this service, but it can be extended free ” wherever it is needed on grounds of ill-health, maternity, age, or the welfare of children.”
Ambulances are a very necessary part of a medical service, and the Bill suggests that they may be provided in two ways. Every hospital may have its own vehicles for purposes within the hospital service. The main ambulance and transport service should, however, be provided by the local health authority, but with no boundary restrictions on the use of such ambulances.
Finally, the local health authority is given a new power, which the Minister may make a duty, to arrange not only for the prevention of disease but for the care and after-care of the sick. This is a very wide provision, some parts of which may be free and some subject to a charge—to cover special foods, blankets, extra comforts, convalescence and special accommodation. If, existing voluntary organisations are used the authority may make appropriate grants to them.
The chief reasons for these changes are the need to overcome the lack of co-ordination in existing local services, to permit of expansion, and to widen the whole sphere. By making the major authorities, or combinations of them, the only health authority, co-ordination over a reasonably large area will be attained, and services which to-day are ha the hands of many varied authorities will come under unified control.
Expansion of the services has been difficult because so many authorities handling a part of the preventive services are small and . cannot afford the machinery for making a really efficient service. The sphere cannot be widened unless the authority is made fully responsible and the permissive nature of legislation is removed.
There are many who would have welcomed an even greater expansion, a direct relationship between the family doctors and the preventive work of the local authorities. There will be a relationship, because one of the new duties of the health authority is the provision of Health Centres. “The Health Centre itself will be provided by the public health authority, and facilities will be made available there to the general practitioner.” At many health centres the clinics and preventive work will be carried out, and a closer relationship than is possible to-day will therefore be forged between the officers doing that type of work and the home doctors.
That co-ordination will be assisted by the fact that the Executive Councils will have at least one-third of their members drawn from the local authorities, and will meet on their committees the doctors, dentists and pharmacists of the area.
There can also be some delegation of the work to be done by the local health authority to smaller bodies. The school health service will continue as laid down in the Education Act, 1944, and an authority may delegate child welfare to “district executives” similar to those in the Education Act.
The machinery by which the local health authority is to carry out its duties is a Health Committee. All matters dealt with in this Bill are to be referred to these Health Committees which may be authorised, as may sub-committees appointed for special purposes, to act in matters of urgency for the health authority.
Full powers to co-opt as members of the Health Committee and its sub-committees non-elected persons with special knowledge and experience are given to the health authority; but always the elected members of the county council or county borough council must have a majority. This permits the skill and knowledge of those who have already shown their ability in this field to be at the service of the Health Committee without submitting themselves for election as members of the council as a whole.
Thus the major local authorities will become the custodians, armed with very full powers, of preventive medicine. The Health Committees to be established under this Bill will play a very important part indeed in raising the standard of health of the ordinary citizen.