Now for Health 8 The Health Centre

A new health service not only requires new machinery for providing the service, it needs a focal point which will epitomise for public and profession alike the change that has been made. There will be a change in the theoretical basis of medicine, the application of social methods and the analysis of social phenomena to be discussed in a later chapter, which will mark a great step forward in the development of medical science. For most people, however, the obvious difference will be the establishment of Health Centres, crystallising the change to a health service and the end of isolation for the family doctor.

A Parliamentary Bill is no place for details, and so we have to fill in from other sources the picture of what Health Centres will be and what functions they will have. Two things are clear at the outset. There has been so much discussion of health centres since they were first proposed over thirty years ago, and so many projects pioneered in various countries, that there is no need for further experimentation; but at the same time the scheme must be sufficiently elastic to enable health centres to fit in with local conditions and needs, and to permit further development and change as experience in their operation dictates.

That elasticity will probably result in three main types of health centres, in all of which the aim will be not only to develop team-work to the greatest possible extent but to strike a correct balance between supplying the highest quality service and making it easy of access to the patient. Thus, while the whole service must be available by a single route, at or through the health centre, there will be some types of attention in which the highest quality can be given by taking the service to the patient and others in which it can best be done by taking the patient to the service.

In rural areas this dictum may involve on the one hand a transport system very different from any “ambulance” service we have known, and on the other the use of mobile units, medical and dental.

There are two problems to be settled in setting up the health centre service—structure and administration. Since elasticity is to be a feature, there is much to be said for not at once building expensive and durable centres ; building restrictions will in any case mean that for a time many temporary arrangements will be made. Plans have already been published, for example by The Lancet, showing how standard medical huts as used by the Ministry of Health can be employed as centres, varied in size according to the needs of the area.

Many, however, will hope to see at the earliest possible moment the ultimate ideal, a Health Centre which is architecturally a focal point of healthful interest, especially as part of the Community Centre of a neighbourhood unit. Indeed, in some districts plans have already been made for building a health centre as a memorial to those who died in war, and this idea is likely to commend itself to many communities who want something better than a stone cross. Nationally we should so organise the building of health centres that the maximum internal standardisation of fittings and equipment is achieved with a great degree of architectural variation. That standardisation would, of course, represent a great saving in building costs, but that is not why it is needed. It is necessary so that doctors moving from centre to centre will know what to expect and what will be provided for their use. The equipment must be the best, and of as wide a range as possible; but that condition satisfied it is a great asset to the doctors in their work to have familiar equipment.

The architectural plan can be varied also to fit in with local conditions. It is possible to build health centres for a similar unit of population on a single-floor span spread over a fairly large area, or on two, three or four floors in congested districts.

The three types of health centre which we have suggested will develop are not basically different—cannot be if they are to merit their name—but differ only in size and in the number of services provided. The largest, which will often perforce be associated with the district general hospital, will provide practically all desirable services, act as consultant unit to smaller centres around it, and be the main organisational point for its area. The smallest will provide little more than a general practitioner service in co-operation with the medical welfare workers, and will be set up in areas with smaller or more scattered units of population.

With these extremes in mind, we can describe the medium-sized health centre, which will be the most numerous, as the “type” of this social innovation. There will still, of course, be variety as to size, but in our view it should comprise from eight to twelve family doctors serving a unit of population between 15,000 and 25,000.

The actual figures will depend on. the number of doctors joining the new service and on their proper distribution ; but we have assumed, purely for purposes of illustration since no official statistics have been issued, that there will be one doctor per 2,500 of the population. Over and above that there will have to be one additional doctor in six, or two in ten, to act as holiday relief, sick leave and emergency assistant, and these will be usually the young men not yet settled in their own practice. The figure will almost certainly be altered from time to time, on the advice of the Central Health Services Council, and may ideally be progressively lowered to something below one doctor per 2,000 persons. Indeed, until the average ratio falls even lower than that there will be small variations in different parts of the country, while since travelling time and other similar factors have to be allowed for in rural areas the ratio there will always be lower than in towns.

The Health Centre, it will be recalled, is to be provided by the local Health Authority, who “will directly administer such of their own local clinic facilities as they may provide in the centres.” The Bill gives the authority no option, as has so often been the case in past legislation, as to whether it builds such health centres or not. It is a duty which must be carried out or the Minister can step in and make the provision himself. The duty is “to provide, equip and maintain to the satisfaction, of the Minister, premises which shall be called ‘Health Centres’.” The facilities to be provided are a formidable list :—

  1. General medical services by medical practitioners;
  2. General dental services by dental practitioners;
  3. Pharmaceutical services by registered pharmacists;
  4. Any of the services which the local health authority is required or empowered to provide ;  and
  5. For the publication of information on questions relating to health or disease, and for the delivering of lectures and the display of pictures or cinematographic films in which such questions are dealt with.

The health centres may, in addition, provide residential accommodation for any officers employed on the staff.

From the patient’s point of view these powers require explanation and further elaboration. Thus the “Centre will, in effect, stand in place of the doctors’ own surgeries,” but the service to be given will be much higher in quality and greater in quantity than that phrase from the White Paper implies. When fully developed the Health Centre should make provision for all or any of the following :—

  1. Visits to general practitioners by those who can attend at the centre ;
  2. Visits by general practitioners to the sick in their homes ;
  3. The work of hospital “casualty” departments ;
  4. The work of “treatment centres ” as provided in the school medical service ;
  5. Consultations with specialists, replacing the present consultative work of out-patient departments of hospitals ;
  6. Consultations, on the request of the family doctor, in the homes of the sick ;
  7. Specialist service, in the home or at the health centre, from laboratory, X-ray and other specialists attached to the hospitals ;
  8. All the work now done at public authority clinics, ante- and post-natal care, infant welfare, child guidance, immunisa­tion, chest clinics, tuberculosis dispensaries, etc.;
  9. Health visitors, social welfare, home helps, home nursing;
  10. Midwives adequate for the area served ;
  11. Dental service ;
  12. Dispensing of pharmaceutical products for those attending the centre or served by it ;
  13. Provision of appliances, deaf-aids, spectacles, etc. ;
  14. A range of special clinics, such as foot clinics, cancer clinics, rheumatism clinics, etc;
  15. Massage, physiotherapy, electrotherapy,  and re-abling services generally.    Possibly some occupational therapy;
  16. Periodic examination for the early detection of disease and the maintenance of health ;
  17. Psychiatric clinics for mental health ; and
  18. Health education and propaganda.

We can generalise sufficiently to say that every unit of 100,000 population requires, in addition to 1,000 hospital beds, all of these services in one or more health centres. The decision as to how many of them and which are to be at each centre within the area must be a matter for local discussion, but as an example we would say that for many types of X-ray and laboratory examination it would be best, both for quality of service and economy to arrange for a large unit at one centre or at the hospital, and to make it easy for the patient to be seen by appointment at that unit. Since the Minister will have the power to pay the expenses of a patient and a companion in travelling from their homes to such a unit there is no economic difficulty; and the local authority can also provide transport through its ambulance service. Always the highest quality must be the aim and a balance struck between that arid the convenience of those using or those working in the service.

Those staffing this great variety of services are to be employed, it is true, by different bodies—local health authorities, executive councils, regional hospital boards—but they are to be brought into the closest contact and given the greatest possibility of co-operating in these health centres. Many problems remain to be solved. Every general practitioner will have the full use of all the services available at or through the health centre—he is in fact the key to and arbiter of all the individual patient requires—but he has still to settle his relationship with those professional colleagues who have in the past been in competition with him, but who are now working in the same service and in the same building with him.

There are already arguments, for example, as to whether every doctor must have his own purely personal consulting room. Some have visualised a number of doctors, being on duty at different times, sharing a consulting room ; but Dr. Stephen Taylor, M.P., told the House of Commons, “We will all agree that the doctor should have his own consulting room at the health centre, with a personal atmosphere about it—and there should be no question about its being his room—where the, patient, can feel completely at home.”

Coupled with this must be adequate dressing room accommodation, and, of course, waiting room facilities must be very different from those the sick have known in the past. There is no difficulty in making appointments, which will obviate “the wretched waiting which we all dislike, both in out-patient department’s and in doctors’ surgeries.” There is no need to provide a waiting room for each doctor for the number waiting at any moment should not be large; equally, the room will be nothing like the “waiting hall ” we have seen hitherto— large, gaunt, bare and cold. For different purposes there should be different sizes and types of waiting rooms, but in all there must be an atmosphere conducive to well-being and comfort.

It cannot be too often stressed that the doctor will not have to make the appointments, attend to filing records, marking up accounts, dispensing medicines and the hundred other duties which waste his professional time to-day. These will be carried out by the staff of the health centre.

So a vastly different atmosphere will be created in the place where people go seeking freedom from ill-health. Justification for outworn jokes about tattered periodicals in dingy waiting-rooms will vanish when health centres get under way, while the clause in the Bill permitting health education in health centres opens up visions of many interesting ways of linking visits to the health centre with instruction in the arts of health and the science of the human body.

To simplify the picture, let us first look at the health centre from the point of view of the family doctor working in it and then as a patient will see it. Both have to be convinced of the advantages of this new conception of medical practice ; moreover the resulting improvement in the doctor’s conditions of work will lead ultimately to the greatest benefits to the patient.

Final details in each centre will have to be settled by the doctors working there, since they are not to be employed by anyone ; but imagine that they have come together and in spite of the inevitable rivalry due to the retention of capitation fees have agreed to work together, or, in the words of the White Paper, “have entered into a partnership arrangement whereby their joint remuneration within the service is pooled and then divided among them on some agreed basis of apportionment.” They will then arrange their own rota of duties, making it possible for doctors to be like other workers, as the B.M.A. has asked, completely off duty when they are supposed to be, instead of hanging on the end of a telephone line or listening for the surgery bell, as is so often the case to-day   The work of all practitioners in a centre would then be organised so that the service would always be immediately available through at least one doctor being on duty there. With the knowledge the doctor would have his definite periods off-duty for refreshment and recreation, there would be an immediate advantage to the patient, for the doctor would not be working with the disturbing thought of interruptions and emergency calls always at the back of his mind.

This  would  apply  particularly  to  night  duty, which must be organised not because it takes up so much of a doctor’s time, but because it is so irregular and therefore a source of worry and annoyance which is detrimental to the doctor’s peace of mind and to his efficiency. In a fully co-ordinated health centre service it might even be possible to concentrate all night calls on one of the centres of a district, but in any case the organisation should mean that each general practitioner is on night duty for only a very few weeks in any year, and that his spells of such duty would be suitably spaced.   It is a point to be settled by the doctors in any health centre as to whether everyone takes his share or whether only the younger men do this work.  The doctors will also have to decide whether and under what circumstances a doctor who is not on duty is nevertheless to be called to a particular case or even to special types of cases.    The doctor who is on emergency duty will naturally be able to call on all the hospital specialists who are likewise on call, so that real emergencies should be speedily and efficiently handled.

Another question the doctors have to settle, in collaboration and, we hope, the closest consultation with their patients, is the time at which ” surgeries ”  are to be held at health centres.    The present times have only tradition to commend them, but to change them, especially the evening surgery, must mean a change in the attitude of employers to the health of their workers.    It should be made easy for a worker who is unwell or wants medical advice to get it without losing his wages or incurring the wrath of the “boss.”    The workers themselves would resent a system which made their heaviest hours of work 9-10 a.m. and 6-8 p.m., and there is no good reason why doctors at health centres, or at least some of them, should not try out other hours.  At the health centre built in conjunction with the Community Centre, where a mother can do her shopping after leaving baby at the creche, there is no reason why a doctor, having done an early round of visits, should not have a surgery later in the forenoon.  It is very important also that the doctors’ times should enable him to visit his colleagues in hospitals for consultations over cases he has sent in, and that he should be able to attend frequent scientific meetings.    No  one suggests that a doctor’s day can or should be so tightly organised that he works to a whistle, but he deserves as much as any worker to have. a much shorter working week, and under this Bill he will be able, to, arrange this with his colleagues.    Of his working week he should spend not more than six or seven hours a day in the actual examination of patients.

At the health centre the doctor will,  in   sharp  contradistinction to to-day, have only his actual care of the individual to preoccupy him. He will not, for example, be permitted (except in special circumstances) to   do  his  own  dispensing.    The  Bill  places  the  responsibility for dispensing   upon   properly-trained   pharmacists,   and   declares  that except as may be provided by regulations, no arrangement shall be made with a medical practitioner under which he is required or agrees to  provide pharmaceutical  services  to  any person  to  whom he  is rendering   general   medical   services.”    An   exception   would  be   in scattered rural areas.

He will have help from nurses in handling patients, and with dressing-room accommodation attached to his consulting room—and even if desired, a separate ” examination ” room—he will be able, without waste of time, to carry out full physical examinations. Then he will have help in preparing, and even in issuing, certificates, he will have secretarial assistance in making, keeping, filing and looking up the health records of every patient. Continuity of medical records, a complete summary of the illnesses and hazards suffered by every individual, is a prime necessity in an efficient health service.

There are many misconceptions —and not a few intentional mis-statements —on this question of health records. In order to frighten people and put them against health centres it is suggested that because confidential clerks will file those records, privacy and secrecy is going to be lost. A moment’s reflection shows this to be nonsense, for the records will be dictated by the doctor who will record what is important in the way of symptoms, special tests, diagnosis, treatment, but not of intimacies confided by the patients. When people learn how much such records mean in saving time, trouble and life when a patient passes into the hands of another doctor—which is inevitable in the course of even the most uneventful lives—they will realise that it is more important to have accurate information than to be afraid that more than one person will handle their records.

This is, of course, the normal method of Harley Street and of all hospitals, and the patients in those places where notes are kept by trained staff have no objection. The important point is that the staff doing this work will be specially trained and will know that they are doing work of a highly confidential nature ; just like bank officials and many other officers.

One more point in the doctor’s favour is that when working in a health centre he will be saved much time and trouble by the ease with which he will be able to obtain second opinions and specialised tests, and by the fact that he can order all kinds of physio-therapy at his own centre or at one in his area. He will achieve more rapid and more accurate diagnosis, upon which the most efficacious treatment depends. Altogether he will find his life much more satisfying in a professional sense.