Co-ordination of a National Medical Service Socialist Medical Assn

“THE MEDICAL OFFICER,’ AUGUST 23rd and 30th, 1941

In the planning of a complete national medical service the first essential would appear to be to ensure that there is effective co-ordination of its many constituent branches. When approaching the problem, I am certain it is better to start from the periphery and work to the centre because it is an undeniable fact that the vast bulk of illness for which medical attention is required is definitely of a minor nature. Quite recently in my own practice I collected data which showed that of all the patients I saw over a fixed period, less than 15 per cent, had to be referred to or were attending hospitals and clinics, and of these only a small number required admission to hospital or attendance at a hospital out-patient department for minor specialist investigation and treatment. It is therefore necessary to elaborate a system whereby everybody can get primary medical advice either in their homes or in the vast majority of cases at a place easily accessible to their homes, and then, if necessary, they can expeditiously be referred for investigation and treatment at special institutions. In this respect the method adopted in the organisation of education constitutes an admirable basis for the proper co-ordination of our health services. Thus primary schools are conveniently situated for everybody (and incidentally are free), while higher and more specialised education requiring more elaborate equipment is more centrally organised. A point worth noting in this connection is that children going to secondary schools ate, when the occasion demands, provided with free or cheap travelling facilities. It is strange that no apparent effort has been made to enable poor people requiring, frequent attendances at hospital out-patient departments, which may involve long and expensive journeys, to be provided with free or cheap passes on public conveyances.

Co-ordination of a National Medical Service

When considering in some detail a suggested method of organising a complete co-ordinated and unified medical service due allowance must be made for the wide variation in the distribution of the population.

I.—organisation in urban areas

A.—The Local Clinic

Local clinics should be so situated that in a thickly populated district each clinic would provide a service for all inhabitants residing within a, radius (of say one mile) from the clinic. The structure of the local clinic and its equipment need not be elaborate, and, in view of the work that is to be undertaken, it would probably be most economical and practical to attach it to an existing primary school. A single-storey building of a standard design and of a semi-permanent construction such as that used by many education authorities would probably, be the most useful type of building for the clinic., The advantage of erecting the clinic building on, or adjacent to, a school site would be:—

The obviation of the difficulty of acquisition of the necessary land;
Economy in maintenance, since the education and health authorities could jointly arrange for care taking and cleaning;
Standardisation of construction ;
Situation at a place already well-known to the inhabitants;
Improvement in facilities for the prevention and treatment of disease among the child population, for frequent routine inspections could be undertaken by the medical staff;
A convenient centre for local health propaganda.

If a plan such as this were to be adopted, there could be close cooperation between the Ministries of Health and Education in any future building developments with resulting convenience and economy.

If an existing building suitable for adaption was available it would, of course, be unnecessary to adhere rigidly to the plan I have outlined. However, the idea of using a site adjacent to a school would appear to be desirable in future new housing estate developments or in large scale plans of post-war reconstruction.

It might be argued that many existing school play-grounds are already insufficient in size to allow for the erection of additional buildings but it should be appreciated that progressive educationists hold the view that in the future the recreational facilities for all schoolchildren must not be restricted to asphalt playgrounds but that proper playing fields must be provided. The effect of this would be to release in many instances a sufficiency of space to erect a clinic building.

The following services could be provided or centred at the local clinic:—

The Domiciliary Medical Service.
A section of the Dental Service.
The Pharmacy Service.
Sections of the Infant Welfare and Maternity Service and of the School Medical Service.
The District Nursing Service.
The Local Social Welfare Service.
Certain special services.

These may be elaborated in some detail.

1. The Domiciliary Medical Service.

I am not attempting here to forecast the exact form in which the Domiciliary Service of the future will take, although I personally have always been in favour of a full-time salaried General Practitioner Service, but in any case it would be vastly preferable for each general practitioner in the district served by the clinic to have a consulting room and waiting room at the clinic. Here, all the patients’ records could be kept and each practitioner would have the considerable advantage of being provided with clerical and nursing assistance. One general practitioner should always be on duty for dealing with emergencies and for night calls and the work of a practitioner absent through illness, etc., could quickly and easily be transferred to a deputy. Residence at the. clinic by the doctors responsible for urgent or night calls would not be necessary, provided that they were always easily accessible. As far as possible, one of the doctors attached to the clinic should be a woman who would be able to undertake the preliminary investigation of gynaecological disorders.

2. Part of the Dental Service.

In the preparation of any complete scheme special consideration will have to be devoted to the dental care of the whole population and it is necessary to elaborate a scheme whereby all persons shall be entitled’ to the service of a dentist. At the local clinic there should be dental officers (I use the term dental officer to avoid any discrimination between dental surgeons and registered dentists) and routine operative and. prosthetic treatment could be undertaken. Such an arrangement would be very economical because the same surgeries could be used for children in the mornings and for adults in the afternoons and evenings and nursing and clerical staff would always be available. The fact that the dental treatment would be carried out at or near school premises would’ provide for much more adequate inspection and treatment of the teeth of school-children and would facilitate more frequent and speedier treatment for adults.

3. The Pharmacy Service.

All prescriptions issued by the staff of the local clinic as well as those ordered for patients referred elsewhere for consultation would be dispensed at the local clinic pharmacy. This would prove to be of great convenience to the patients who would not have to go elsewhere to get their prescriptions dispensed. The fact that the pharmacy would be at the local clinic would also prove to be very economical because the pharmacist would be able, by personal consultation with the medical staff, to prevent immediately any excessive prescribing and the need for the N.H.I, pricing bureau would be obviated. The pharmacist (or senior pharmacist) would also act as clinic manager and -as such would be responsible for the procuring and maintenance ‘of all the equipment at the clinic. This should be a very effective arrangement in view of the business training of pharmacists.

4. Sections of the Ante-Natal. Infant Welfare and School Medical Service.

At the local clinic, the first routine examination of expectant mothers would be undertaken and normal cases would continue to attend. Cases requiring special, investigation and treatment would be referred elsewhere. Similarly, the infant welfare centre should be situated at the local clinic and routine medical and dental inspections of children attending the primary schools would be carried out— if possible at monthly intervals.

5. Special Services.

It is my experience that a large number of people who are not incapacitated from working are put to considerable inconvenience and lose many hours from work when they are referred to a hospital for special advice for affections of the eyes or skin or for minor gynaecological disorders. It would, therefore, be very desirable for a visiting dermatologist and oculist to attend at the local clinic for regular evening sessions. Eye refractions could be undertaken there instead of at separate national ophthalmic treatment board centres. It would also be useful to organise at the district clinic sessions for diseases of women, when preliminary investigations could be carried out, either by a woman practitioner on the fixed staff of the clinic or by a visiting gynaecologist. A massage and remedial exercise department would also prove to be a valuable addition to the activities of the clinic, especially for children. Special sessions could be organised at the local clinic for diphtheria immunisation, etc.

It would be valuable for each local clinic to contain a small laboratory for certain limited routine investigations{e.g. of blood and urine) which would be continuously required by members of the medical staff of the clinic. This work could be adequately performed by a visiting technician attached to the district clinic.

6. The District Nursing Service.

The local clinic would be the centre for the local District Nursing Service. The nursing staff attached to the clinic would not only visit patients in their homes, but would also do the dressings, etc., at the clinic and would give any necessary assistance to the medical and dental, staff.

7. Social Welfare Service.

My own criticism of the present hospital almoner service is that the almoners working in their offices at the hospital are far removed from the homes of the patients they interview and therefore they cannot obtain first-hand information about the home conditions, etc. This is a service which requires some decentralisation and there should be almoners and social workers at the local clinics as well as at the hospitals. The effect of this would mean that they would be in close and constant touch with the people they have to advise and. they would be able to work in close co-operation with the doctors and district nurses attached to the clinic. Members of the local tuberculosis care committee would have their headquarters at the local clinic. Health visitors should be attached, to the local clinics as well as to the district clinics.

Personnel

(a) Fixed Staff.

The fixed staff would include general practitioners, dentists, pharmacists, district and school nurses, almoner(s), health visitors, and social welfare officers. The number would vary according to the population served by the clinics. Residence by the staff at the clinic would not appear to be essential, but a competent person must always be on duty at the clinic to receive and send messages. A doctor and a nurse on the staff of the clinic should always be on call.

(b) Visiting Staff.

The visiting staff would be attached to the district clinic (see below) and would attend the local clinic for regular sessions according to requirements.

B The District Clinic

This would provide for an area in which a number of local clinics (say about ten) are situated and should be housed in a building which is easily accessible to all local clinics in the area. The district clinic would provide the following services:—

1. Public Health. While due allowance must be made for the re-organisation of the existing public health services, the district clinic should be the centre for all activities which are now under the control of the public health department of a borough council. The clinic would house the local public health staff (sanitary inspectors, health visitors and public analyst, etc.).
The District Industrial Medical Service. The district would be the headquarters for all the doctors, nurses and inspectors of all factories and workshops in the area.
The Tuberculosis Dispensary Service (or chest clinic).
The Venereal Diseases Service.
Rheumatism Clinic.
Psychiatric Clinic. This would be a ” follow-up centre ” for all cases that had been under investigation and treatment at the central clinic ,(see below) or at a central hospital.
Part of the School Medical Service. School children would be referred from the local clinic when more special but routine treatment was required, e.g., for minor diseases of the ear, nose or throat. Beds would be reserved at the clinic for minor operations.
The Centre for Minor Surgery. There are a large number of persons who are referred to hospitals for minor surgical treatment who require a short period, of in-patient treatment. These cases occupy beds which are required for more serious cases. These minor surgical cases could, be very adequately dealt with at a district clinic and wards could be provided at the clinic for this purpose.
The Headquarters of the Local Midwifery Service. This would constitute the “control centre” for the district midwives and for the obstetricians and anaesthetists required in domiciliary midwifery. There would also be an ante-natal clinic consultant centre for cases referred from the local clinic. There are a large number of persons attending the ante-natal clinic in whom a minor abnormality is found. At the present time these persons have to travel long distances to hospitals and the institution of consultant centres at a district clinic would obviate much inconvenience. In the event of a further opinion being required they could then be sent to the central clinic for further investigation and advice.
The Dental Centre. This centre would be for special work which could not be undertaken by a local clinic. It would also contain the dental laboratory for the making of dentures, etc., required by the dental officers working at the local clinics in the area. A dental surgeon should always be on call to deal with any emergencies.
Pathological Laboratory. In this laboratory only routine investigations would be carried out. Specimens would be collected from the local clinics each day.
Electro-Therapeutic Department. Cases could be treated at the district clinic where the services of the more highly equipped department at the central clinic were not required. The centre would be under the direct supervision of the chief of the department at the central clinic.
The District Ambulance Control Centre. Arrangements would be made through the control centre for persons to be taken to and from the local clinics to the district and central clinics in those areas where public vehicles were not easily accessible.
The District Welfare Centre for the Physically Afflicted (the blind, deaf, etc.).
The Control Centre of the General Practitioners and other services in the district. This centre would make provision for the sending of reliefs as and when they might be required at the local clinics.
The Medical aand Dental Referees Centre. At this centre work would be carried out similar to that now performed by the regional medical officers and regional dental officers. Medical officers at the centre would also act as referees as to fitness for work, suitability for certain employment, or when a grant was contemplated through public funds for extra nourishment, etc. The dental officers at the centre would inspect the mouths of those persons for whom extensive treatment was recommended by the dental staff at the local clinics and they would also, when necessary, carry out inspection after treatment as recommended had been completed.
Stores. For drugs and equipment required by the district and local clinics.

C The Central Clinic (or Polyclinic)

The central clinic would make provision for a population of an area corresponding to (say) ten district clinics. It would constitute the ” major consultative clinic” and would be the centre of teaching and research. To it would be attached a medical school and it would control and staff a requisite number of general, special and convalescent hospitals. The procedure for reference to the central clinic would be that the patients could be sent direct either from the local or district clinics. These patients would be seen, as far as possible, by appointments which would be booked in advance by telephone (it is interesting to note that this procedure has recently been adopted by the Woolwich Memorial Hospital). Whenever necessary free travelling vouchers to and from the central and district clinics would be issued.

D Regional Headquarters

Complete re-organisation of the Local Government Service has been recently foreshadowed and there should be created a single regional authority responsible for the whole of local government throughout Greater London. If this plan was adopted, undoubtedly there would be similar measures of re-organisation throughout the country. In this event, one regional authority might well have under its control as many as 2,000 local clinics, in addition to a large number of hospitals, etc.

The supplies for all these institutions would be arranged at the regional headquarters.

E The National Headquarters (Ministry of Health)

Serious consideration should be given to the medical staffing at the Ministry. In my view, there is at the present time insufficient cooperation between the medical staff at the Ministry and the medical officers of health of the local authorities. I believe that a satisfactory solution could be provided by the appointment of a Central Medical Board with executive powers, consisting of the chief medical officer and the principal medical officer of each region. Perfect co-operation between the Ministry and the regional authorities would thus be ensured and the ” optimum ” standard achieved.

II organisation in rural areas

Owing to the wide variations in the density of populations, the functions of the local and district clinics would have to be considerably modified and re-arranged. The aim should be to have a modified district clinic in every small town and large village and this clinic would combine work carried out in the local and district clinics in the urban areas. The fixed staff would be a small one and its size would vary with the population of the district. In a small town the fixed staff would consist of general practitioners, dentist(s), pharmacist, district nurses and midwives, social welfare officer, sanitary inspector, health visitor(s) and laboratory technician. The remainder of the work would be carried out by a visiting staff, including a tuberculosis consultant, a pathologist, oculist, masseuse and school medical inspection staff. Equipment other than that used by the fixed staff and the pathologist could be portable.

In the rural areas an efficient service of light ambulances capable of taking either stretcher or sitting-up cases, would be essential and in: addition there should be mobile X-ray units. By this means it would be possible to provide a first-class service at all times in the most sparsely populated districts.

III administration and control

The fact that a central authority would be in direct control of the whole service would mean that an optimum standardisation would be achieved. The central authority would act as a spur and not as a halter; but although there would be central control and supervision it is essential that there should be a considerable degree of local autonomy and those employed in the service should have a definite responsibility in its direction and management, as they would have first-hand knowledge of the various problems that had to be faced from day to day. The principal officer of a local clinic should be a senior general practitioner. In charge of a district clinic should be a medical officer specially experienced in public health work (corresponding in status to a medical officer of health of an existing large borough). The direction of the central clinic should be in the hands of one who is essentially a teacher and clinician.

The regional authority should have at the head of its health service a person of essentially proved administrative ability with a complete knowledge and understanding of all the activities of the service. It must be emphasised that the health service is only one of the social services and that its government must be on the same basis as that of the other services.

At the local clinics and in each department of the district and central clinics there should be regular meetings of the staff to discuss the work that is being carried out, to raise any necessary criticisms and to make representations for improvements. Statutory staff committees should be established; these should appoint direct representatives to the controlling authority in the same manner as in the existing National Health Insurance scheme where the panel and pharmaceutical committees are statutory bodies with special duties and have their representatives on the insurance committees. These staff committees would be elected by those employed in the service and all branches would have their representatives. Manual workers would, of course, be separately represented on joint industrial councils through their trade unions. It would be the duty of these committees to examine any recommendations made at the staff meetings mentioned above.

There must be no “bottle-neck” of administrative officialdom as there is unfortunately at present in the public health departments of many of the large local authorities. To obviate this, the supervision of the special services should be placed in the hands of the chief specialists at the central clinics. Thus the chief dental surgeon at a central clinic would be responsible for the direction of all the dental services at the local and district clinics attached to a central clinic. He, with his senior colleagues at the central clinic, would consider and make recommendations on appointments when applications were made for employment as dental officers. The same procedure would be applied to all the special departments. The fact that a clinician would be the director of each special service would ensure much greater efficiency than the present practice generally adopted by local authorities of putting an administrative officer with limited or out-of-date clinical experience in charge of important special services, e.g., maternity and child welfare, school, medical and tuberculosis services. The adoption of this scheme would undoubtedly lead to tremendous developments in the scope of preventive (medicine. At the present time, general practitioners are able to do very little in the way of preventing disease, yet, because of the fact that they are constantly in the homes of their patients they are closely acquainted with individual social conditions, etc., and have a more, intimate knowledge of the lives of the people than any other person can hope to acquire. Under this scheme, the general practitioner would be working at a local clinic under the supervision and guidance of the director of the district clinic (the district medical officer of health). In the event of epidemics, the general practitioner would be able to keep the M.O.H. fully advised, while the latter through close personal contact with the general practitioner would be able to keep the general practitioners in his district adequately acquainted with any new method of diagnoses, prevention and treatment. Furthermore, the general practitioner could keep the social welfare officer fully informed as to unsatisfactory home conditions, etc., so that the latter could take the necessary remedial steps.

I have indicated that the local industrial medical service should be centred at the district clinic. The chief of this department could constantly be in touch with the general practitioners and local welfare, officers.

There is, under this scheme, considerable scope for improving medical education. While the greater part of the clinical training of a student would be at the central clinic and its attached hospitals, a considerable amount of the instruction could be arranged at the district clinics, e.g., in venereal disease, industrial medicine, part of the midwifery and in minor surgery.

Finally, I should like to indicate how the work of a general practitioner can be satisfactorily dovetailed into a complete and unified medical service. It has never been easy to formulate a scheme which would provide for satisfactory promotion for the general practitioner. Under this scheme senior posts would be available to general practitioners in the service and these would carry salaries. The director of a local clinic or the referees at a district clinic would be a senior general practitioner and furthermore, general practitioners who have acquired special qualifications and experience and had proved ability could assist in the work of the special services. In fact, I would go further and insist that every practitioner after qualification who intended to specialise should for a certain period work at a local clinic. Medical practitioners entering the service should be allocated a good deal of ‘routine work at the district and local clinics before specialising or undertaking the considerable responsibilities of a home doctor. Such routine work could include the medical inspection of school children, immunisation, dental anaesthetics, minor surgery and deputising for the doctors attached to the local clinics, such as for emergency and night’ visits.

The obvious advantage of this scheme is that it would mean the unification of all the existing local authority health services as well as a number’ of other activities now under independent and voluntary administration and control. The main criticism may be that in certain sections it is- too brief and sketchy. This has been intentional on my part because I have carefully not elaborated suggested activities of the central clinics, hospitals, public health and industrial medical services, because of my lack of adequate personal knowledge of their scope. I have merely attempted to put forward a few suggestions, which might be examined in conjunction with the many excellent schemes that have been prepared by others. My observations have been based on many years’ experience in general practice and a decade of membership of a local authority.

The Co-ordination of a National Medical Service