Now for Health 9 the Citizen and the Health Centre

It is the patient for whom the National Health Service has been designed, and it is the patient who is going to benefit most from a health centre and regional hospital system. The outstanding advantage of the health centre is that at and through it by a single route under the, control of a family doctor of the patient’s own choice the whole, of modern medical care and scientific knowledge, is available without economic or other restrictions. The Health Service Bill leaves it open as to whether a doctor goes into a health centre or not, but few will elect to remain out. If they do their patients will probably make it clear why they want their family doctor to work at a health centre.

One other person will almost invariably add her considerable powers of persuasion to the doctor to enter a health centre at the earliest moment—the doctor’s wife ! Only those who have tried it know how difficult and many-sided is the life of the young doctor’s wife. She has all the normal duties of wife and mother; but she has all the added worries of a husband whose hours, day and night, are irregular and erratic, of front door bells and surgery bells, of telephones, of staff, domestic and surgery, and very often a house which is neither where she would like it to be nor of the type and size she would prefer. She will gain immensely from not living over the surgery, and in some instances has already expressed herself strongly on the matter. She will want her husband to have all the advantages of the health centre and herself to be free from all the disadvantages of the usual general practitioner’s house. All this Mr. Bevan recognised in the Committee Stage of the Bill with the remark, “The doctor’s wife will be a great help in inducing her husband to use the centre.”

Ultimately the health centre will be an accepted institution to which everyone turns whenever they want advice on matters of health. In the first stage, however, people will have to learn to use the health centre, and by using to influence its development. To the harassed mother with children the advantage will probably be more obvious than to anyone else. She has become accustomed to visiting the “clinic” for ante-natal advice, for post-natal guidance, for attention to the baby, for regular weighings and examinations, for baby food and fruit concentrates ; and later she has gone there for diphtheria immunisation, for dental care and in, some cases has attended for special attention to herself.

But she did not fare so well when she was ill or when the children suffered the frequent upsets of childhood. Then she had to go to “her own doctor,” the nearest, the cheapest, or the one that would come (especially at night time); and she had to consider the expense. What sad tales of maternal heart-burnings could be told on the subject ! Every doctor knows them; but women welfare officers, district nurses, all tell their tales of the difficulties and indecisions of the mother who has a small income and a large family. Those night emergency calls are in fact largely a reflection of this economic barrier to family doctor service, for they are often calls to children who have been ill all day but become serious enough to justify expense only with nightfall.

Then there is the misery of mothers who know their health is “below par” but must keep going for the sake of the family, and who never spend on themselves in any case ; and all the worries of the period of “change of life” when care and attention would help so much but the possibility of the expense of hospital and specialist care makes most women bear the burden without seeking help.

But now the “clinic” becomes the Health Centre, the doctors and nurses who gave such good advice and attention in fields which came under the local authority are joined by the family doctors, and all the difficulties of fees and expenses, all the feeling of not wishing to call the busy doctor unnecessarily, and many other subtle deterrents will disappear. The specialist will still be the great expert at the hospital but he can be seen at no cost at the centre or, if the family doctor says so, at home.

Above all, the general practitioner can at last be the “family” doctor. He will be paid by the same method for looking after all the members of the family, and in most instances all the family will choose the same doctor. If they don’t, and mother may prefer a woman doctor, they will at least be attended by members of the same health centre team, not as has so often been the case in the past, by commercial rivals. He will be in a position to advise the whole family on all matters of health, and he will always be able to guarantee that they can get every item of medical care, treatment, drug and appliance that he orders.

A patient who visits the health centre will, of course, be able to do so at any time in emergency, but normally will make an appoint­ment to see the doctor of his choice at a particular time. He will be expected to keep to the time, for otherwise the system will break down. At the centre he will report to the clerk on duty— no longer creeping into a crowded surgery unwitnessed, unnoticed, and having to remember his own place in the queue. His previous notes will have been looked out and will either be already in the doctor’s room or handed to the patient, according to the system adopted by the doctors at that centre.

The whole centre will be well heated and ventilated, and the patient will go to whichever of the many rooms and places is the waiting room, for his doctor, a pleasant, well-lighted place with comfortable chairs, magazines and flowers— subjects of ribaldry, scepticism or sarcasm in many quarters. But these are things that create the right atmosphere; they have long been the rule in expensive clinics and consulting rooms, and it is one of the duties of all citizens and all health workers in co-operation to achieve that atmosphere in the health centres.

It is distressing to hear and read the attempts of B.M.A. spokesmen, but especially the Secretary of that organisation, Dr. Charles Hill, who as the Radio Doctor exhorts us all to look after our health, to decry the health centre as a place “full of chromium plating and platinum blondes.” Chromium plating there will be—if it is necessary for the efficiency of the centre, the standard of hygiene, or the comfort of the patient. The creation of an atmosphere conducive to health is one that might have commended itself to the Radio Doctor instead of stimulating him to cheap and scarcely comprehensible sneers.

The patient will be seen by the doctor in his own consulting room, to which will be attached one or more dressing rooms. The doctor will have time for full examinations, and the patient of the future will learn to expect more than a perfunctory questioning, a “spot” diagnosis and a bottle of medicine. When the family doctor decides that other things are needed — X-ray, blood tests, consultant opinion — the health centre’s appointments staff will make all the arrangements, including transport.

The visit over, the patient collects his medicines, if any, from the pharmacy section (or if he prefers, takes the prescription to his own chemist), but finds other things of interest in the Centre. In the lecture hall there is a show of short health films or a talk by one of the local doctors, or maybe an exhibition of health interest. Should there be nothing of that kind at the Centre at the moment, the Community Centre, of which the health centre is part, will probably have something of interest, instruction or amusement to offer. In short, a visit to the doctor will no longer be something of an ordeal but a procedure as normal as going shopping.

But it will be the emergency calls that will bo the greatest test of the Centre. The system adopted to deal with these will doubtless vary from place to place, since it will be a matter for local arrangement, but the guiding principle must be that no call goes unanswered, that all the medical care called for is supplied at once, and the family doctor of choice kept informed of any change in regard to his patients while he was off duty. Records of all emergencies must be complete and the emergency doctor must always consult at a suitable time the doctor,if it is not himself, who normally takes care of that particular patient.

There are many other services the family will get from the health centres. The Health Bill clearly indicates that at some date dentistry will be mainly carried out at health centres although for the moment much of it will continue to be done at dentists’ own surgeries. Dentistry is one of the services which can most easily be carried out at health centres, and the association of a number of dentists with a well-staffed dental laboratory and the assistance of dental technicians and hygienists would enable much better work to be done. It may be some time before a full dental service for all can be provided, but in the House of Commons debate, Mrs. F. Corbet, M.P. for North-West Camberwell, made a very strong plea for supplying the service now by using the skill of dental technicians of one kind and another so as to give the dentist the maximum of assistance and thus enable all to have the complete service.

The Eye Service is envisaged in the Bill as a specialist service provided through the hospitals except at the start, when, as “supplementary ” methods, other optical workers may be employed. This question needs further discussion, and a study of the position may show that the health centre is the ideal place for sight-testing, and that by a judicious combination of medically-trained ophthalmologists and non-medical opticians we can do most of what is needed.

Then there is the question of Foot Clinics under the care of qualified chiropodists, for foot defects are exceedingly common under urban conditions. In existing health centres like those at Finsbury and Bermondseywhere such clinics have been available to the general population for years, the number of people visiting them is surprisingly large. Bermondsey had a population of 95,000 in 1938; at a small fee 14,500 patients consulted the foot clinic at the borough health centre in that year.

One big problem that is not discussed to any extent in literature on this subject is the provision for physical medicine, physiotherapy, massage, electrotherapy, medical gymnastics and rehabilitation generally. Increasingly, these methods are being used, and in the hands of experts cut down enormously the time required by a patient for a return to normal activity after an accident or illness. They are essential in every hospital in future, but they may in part be a feature of every health centre.

Midwifery, home nursing, home helps, health visiting, are all parts of the service to be provided by the local health authority through the health centre. To some extent all exist already, but the new service must witness a big advance in the personnel employed in these services, and they must develop in close touch with the family doctor service. The social aspects of disease are now seen to be of the utmost importance, and the collaboration of all these ancillary workers with the general practitioners must produce big social developments.

There are many details still to be worked out, but, as will be seen, the broad outline of the Health Centre is clear. It needs only a spirit of real co-operation to be breathed into it, by those who work it and those who use it, and general practice in Britain will be carried forward in a sweeping advance