A scheme for a state medical service Labour Party May 1942

Confidential Labour Party R.D.R. 99/May, 1942

Public Health Sub-Committee

Provision for health in this country is sadly deficient. Most doctors have nothing to do with the maintenance of health or prevention of disease. They are for the most part concerned only with the treatment of declared disease and then only when it is severe enough to interfere with the work or comfort of those who can afford to pay for attention, either directly, or through some insurance system. Moreover there is very little co-ordination between the many different agencies for the prevention and cure of disease, and most doctors work as isolated units and not as members of a team.

The first duty of a state Medical Service is therefore to bring together into Health Centres and Hospitals all the doctors and personal health services of a district. The constant contact of all medical men would have the greatest imaginable influence in improving the standard of medical practise. The doctor working alone in private or panel practice may very easily get an entirely erroneous idea of his own ability and importance. This idea is emphasised by the attitude of his patients who may respect him, or feel that they must not offend him; it is easy for the doctor working alone to regard himself as well-nigh infallible. On the other hand most doctors like to meet colleagues and talk “shop”. If a doctor has plenty of opportunities for meeting and talking with his colleagues at a Health Centre or Hospital, he will soon discover that there is something of value to be discovered from every one of them and will appreciate the importance and value of team work.

A State Medical Service must ensure that 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 must provide for rapid reference for specialist investigation and treatment. In order that over1apping may be avoided it is necessary to divide the population and the doctors into units. The unit should be of such a size that it will be economic, will require specialists of every type so that the service will be complete; yet must be sufficiently small to be responsive to the needs of every citizen and allow of every doctor knowing and appreciating the work of every colleague in the unit. The most economical size of population unit is about 100,000 since this requires a hospital of 1,000 beds.

In an urban area with the 100,000 population unit which we are discussing probably 3 or 4 Local Health Centres, (as these subsidiary centres would be known), would be required. Each would therefore, serve a population of about 25,000 and be staffed by 8 to 12 general practitioners and closely linked for other purposes to the Divisional Health Centre. In this last, which would normally be situated at, or in close association with the hospital, specialists would see cases referred to them and special clinics for X rays, Rehabilitation, Occupational Therapy etc, would be situated.

In rural areas, the Local Health Centres would be arranged so as to cater for a town or section of a town with the country around it. Thus even in the relatively scattered districts as large a unit of population as possible would be aimed at and even if in exceedingly scattered districts the Local Health Centre was little more than the equivalent of the doctor’s surgery something far better would be achieved by the association of a11 the ancillary services at the same place.

From the Local Health Centre all the patients would obtain the services of their general practitioner (who would work on a rota basis with fixed hours and regular leisure) and through him full specialist service at or through the Divisional Health Centre and hospital. The surgeons, physicians, obstetricians, etc. of the hospital would be available in the home as consultants.

The Local Health Centre would have the additional but vital functions of organising midwives, health. visitors, social welfare workers, home nursing services and home helps. The importance of this side of an organised medical service cannot be over-stressed. Nor should it be overlooked that many different types of personnel are involved. The midwives form a team with the Obstetrical Officers and while much of their work may be in the homes of the mothers they must be in close and constant contact with the maternity section of the hospital. The health visitors should be available both at the Health Centre and in the home and form a vital part of the education in health preservation and disease prevention which will be a prominent feature of the medical services of the future. They should form the strongest link between the family and the medical staff of the Health Centres and should assume the protection of the health of the infant as their primary and vital function.

The home helps must not be thought of only in connection with maternity for they must function in homes where for any cause either the mother has been removed to hospita1 or is unable to attend to her house and family without aid. The nurses of the Home Nursing Service need not necessarily be separated from those of the hospital and centre although in practice they would not function in more than one sphere at a given time.

Trained social welfare workers are vital to any medical service but of the greatest possible importance so long as environmental conditions remain important factors in the production of disease. Such workers should be able to contribute to the solution of all environmental problems disadvantageous to health.

The Health Centres would also house the clerical staff whose work would include the keeping of complete health records of the people and making them available to all doctors in the unit and to all other units to which a patient might move. The records of examinations made, say, in the school medical inspection service would pass on and be available to all doctors who might see the patient at the Centres or’ in the home. Invaluable also would be the records of the clerical staff for following-up cases particularly after they had been treated in hospital. This continuity of record would be one of the most important features of such a health service and of almost inestimable value to the medical staffs concerned.

It may next be of value to briefly summarise the type of State Medical Service envisioned by the committee and then to describe briefly the legislative and administrative steps necessary to secure it.

Ultimate Structure

A. PRINCIPLES

Prevention and cure of disease and maintenance of optimum health.

Health Education. Rehabilitation

1. A complete service, including the provision of surgical appliances, dentures, spectacles, etc. convalescence; home helps, (not only for maternity Cases) midwives, health visitors, welfare workers (to assist in the solution of environmental problems) as well as medical and nursing staffs .

2. Free to all. It is important that no question of ability to pay should deter people from early attendance at the Centres. NO insurance basis, flat rate or payment by assessment would be as satisfactory as a Free Service. In education there is already a precedent for having a vital service free.

3. Open to all. No upper income limit. This should not be a service for the poor but for the entire nation, aimed positively at the improvement and maintenance of the health of the nation.

4. Whole-time doctors, salaried with fixed hours of service.

5. Research facilities to be available for all medical staff.

6. Industrial Hygiene. All doctors must be concerned in securing healthy conditions of work in factories, shops, and offices. They must have authority to ensure that a11 their reasonable requests are carried out.

B. OPERATIONAL UNIT

1. A unit of 100,000 population would be convenient in urban areas (perhaps less in rural areas). All doctors in such an area would be in close personal touch and used to working together.

2. 600 to 1,200 bed hospital near traffic centre of the area.

3. Division Health Centre for specialist consultations in close association with the hospital.

4. Local Health Centres from which a total of about 50 Home Doctors should work in groups of 3 (in scattered areas) to 12.

C. DOMICILIARY AND HEALTH GENTRE SERVICE

1. The services of Home Doctors should be available for every member of every family. These doctors’ duties should be to eliminate individual causes of ill health, and to encourage the maintenance of good health.

2. Patients unable to travel would be seen in their own homes. Those able to do so should attend by appointment at the Health Centres where the records would be kept and the other health services located.

3.Each Home Doctor would be responsible for the health of not more than 2,000 persons, but those doctors undertaking special work should have fewer persons on their list. Elasticity is essential.

1. Some choice of doctor is desirable, Or at any rate the possibility of change of doctor without difficulty if dissatisfied.

2. Specialists from the Divisional Health Centres should be available for consultation with the Home Doctors in the patients homes when necessary .

D. HOSPITAL SERVICE

1. The desirable unit is the General Hospital of 600 to 1,200 beds. Special hospitals should be eliminated except for infectious cases and certain types of mental disease. These general hospitals should be associated in groups so that only one out of three or four would admit, say, skin or eye cases and perhaps only one hospital in each region would undertake rare specialities like plastic and cranial surgery. There would thus be specialised units in selected genera1 hospitals.

2. The staff of all hospitals should be available for consultation in the Health Centres and in the patients homes.

3. Home Doctors should be encouraged to take an interest in the progress of patients admitted to hospitals. At present the general practitioner is unable to follow the case histories of patients admitted to hospital. There should be facilities for close co-operation between referring and admitting doctors, both in the interest of the patient’s post hospital treatment and of the doctor’ s knowledge and experience.

E ADMINISTRATION

1. The service should be administered by a new, popularly elected local government body administering the local government service of a relatively large region

2. Each regional Authority should form a Health committee, with sub-Committees:-

(a) Hospitals

(b) Home Medical Service, including Health Centres.

(c)Special Service, e.g. school, maternity and child welfare, tuberculosis, etc.

( d) Medical Training, etc.

1. There should preferably be a Medical School in each region.

2. Environmental services bearing on health might be the responsibility of the subsidiary health authorities of the region but the regional health committee should have some voice in water supply, refuse disposal, sewage and large scale housing.

In endeavouring to enumerate the administrative and legislative steps necessary for the development of the State Medical Service, it may be useful to describe

(a) Hospital Development,

(b) The evolution of a Domicillary Health Service.

A) HOSPITAL DEVELOPMENT

As soon as war was declared the Government put into operation its Emergency Medical Service scheme. The Government undertook partial control of all hospitals of any size and determined how many beds in each should be reserved for what are known as E.M.S. cases, viz. civilian war casualties, patients transferred from other hospitals on Government or E.M.S. orders, and certain other categories, e.g. service patients, A.R.P. personnel, etc.

At first sight it would appear that the simplest way to develop our hospitals after the war would be by taking advantage of the existing E.M.S. system and abolishing the present absurd distinction between E.M.S. and non-E.M.S. cases so that everyone needing hospital treatment would have the right, as far as accommodation permitted to admission into any E.M.S. hospital, that is to say, to any hospital, voluntary or municipal. This proposal is attractive because some grouping of hospitals has already taken place and the country has been divided into a dozen large areas for administrative purposes in the E.M.S. system. The continuance of the E.M.S. scheme after the war, has, however, many serious disadvantages:-

The scheme is completely undemocratic. The public has no local or Parliamentary Control except through the vote of the Ministry of Health on one day per year in Parliament. There is no idea of planning about it. Public money is shared out regardless of the control or the efficiency of hospitals. During the last ten years many Local Authorities have developed at great cost to themselves first class municipal hospitals. Both they and the Voluntary Hospitals would most strongly resent the Government taking control for all time.

The statutory duties of Local Authorities as regards hospitals are indefinite and ill-defined, but it is generally held that while they may provide hospital accommodation in general hospitals for all and sundry they are only compelled to provide it for those who are technically “poor persons”. (As defined in the 1936 Local Government Act).

After the war, then, it should be the first task of the Government to charge the Local Authorities with the duty of providing efficient and complete hospital service for all who need it and are willing to use it.

In the time of financial stringency that must follow the war with many hospitals destroyed and the need for hospital beds for both service and civilian sick and wounded perhaps greater than ever before, it cannot be reasonable to expect the Government to ignore the existence of voluntary hospitals that before the war provided nearly one-third of the available beds in the country. However, if the Government were to take over the voluntary hospitals, its action would be described as confiscation only justifiable if all other privately owned property were also confiscated. In view of the damage to both voluntary and municipal hospitals, there will be need for a pooling of all available hospital provision. The Government cannot afford to wait till the voluntary hospitals, faced by financial ruin, come cap in hand to ask to be taken over.

Therefore, the Government must make the best bargain possible with the voluntary hospitals; it must insist on them conforming to a plan that is based on combination of areas, submitting to increasing control by the Local Authorities, and to unification of conditions of service and staff to those of the Local Authorities’ hospitals. Also, voluntary hospita1s must agree to admit patients solely on the basis of medical and surgical needs. They could then receive financial assistance in respect of those cases referred to them by Local Authorities, who should insist on control proportionate to services received by the patients thus referred.

This is in principle the scheme put before Parliament by Mr. Ernest Brown on October 9th, 1941. There is nothing in his statement inconsistent with that described above, and it is for our representatives in Parliament to see to it that nothing less is accepted. This is the scheme that will, it seems certain, be applied in London, and if something less democratic is accepted elsewhere it will be because the majority of the public representatives there do not believe in Municipal control of hospitals and prefer the voluntary system.

Proposal for the development of a Unified publicly- controlled hospital service.

1. The duty must be laid on the appropriate Local Authorities (and enforced) of securing a comprehensive hospital service (as the Minister of Health suggests in his statement) .

2. Pressure must be made on all hospitals to come into and conform to a plan and undertake only that type of work that is accorded to them in the plan. The plan must of course be fluid and kept constantly up to date. A system of Government inspection, public report, and licensing of hospitals would make this easier. Inefficient hospitals should be refused a licence to continue functioning.

3.In so far as this involves some payment being made by Local Authorities to voluntary hospitals for the treatment of cases referred to them by Local Authorities, proportiona1 representation and control must accompany the payment.

1. As soon as the country has recovered from the stringency consequent upon the war all the hospital treatment provided by or through the Local Authorities should be made entirely free.

In this case almost all persons going into voluntary hospitals would do so via the Local Authority, which will mean that the voluntary hospitals come to all intents and purposes completely under control of the Loca1 Authority and the conditions of service and staff having become assimilated we have at last a truly unified hospita1 system.

1. Meanwhile it will have been found that for the development of an efficient plan a large hospital area will have proved itself essential, and, to attain efficiency, existing Local Authorities will have been compelled to pool their resources and unite together into regions.

(B) THE EVOLUTION OF A DOMICILIARY HEALTH SERVICE

The following suggestions are for a series of steps which should lead towards the ultimate development of a Complete Domiciliary Medical Service.

1.The formation of specialist consultation clinics by Local Authorities should be made compulsory.

For about 15 million insured persons a General Practitioner service is provided and “poor persons” are able to obtain assistance of the same kind from District Medical Officers under the Poor Law. But neither of these services makes any attempt to provide more than is within the competence of the average General Practitioner and there is no uniform provision whatever for the advice of specialists. The families of insured persons and other people of moderate means, although able perhaps to meet the fees of a general practitioner, find themselves in serious difficulty when the help of a specialist is required. In many urban areas the blow is softened by the out-patient departments of general hospitals, municipal or voluntary, in which specialist advice and treatment is obtainable but only, of course, by those who are well enough to attend at hospital. Moreover, a few municipalities have provided at clinics advice or treatment for which there is an obvious need but for which hospitals rarely make provision. Thus there may be dental and foot clinics; light treatment, electro-therapy, diathermy massage and X-rays must be made available. There may also be clinics for rheumatism, heart disease, and diseases of women. It is not clear whether this provision by progressive Authorities is really within the law or winked at by the Ministry of Health. In any case, however these special municipal clinics are few in number and confined almost exclusively to urban areas.

In the country districts the local voluntary hospital may have out-patient departments for medicine, surgery and diseases of the skin, eye, etc., but a patient is rarely seen in these unless he brings a note from his local doctor and this, is only granted when the doctor has sufficient knowledge and experience to realise that the patient’s condition is beyond his capacity. Moreover, the “specialists” in many local Voluntary hospitals are G.P.’ s who happen to take an interest in some special branch of the healing art.

Local Authorities should be obliged to secure the provision of free specialist services, the specialist reporting his recommendations to the patient’s own doctor. Liberal grants in-aid should be provided for this service. In some areas it will be permissible to employ specialists on a sessional basis but already some Local Authorities have found it convenient and economical to employ full-time specialists who divide their time between the clinics and one or more of the municipal hospitals.

This service need not await the provision of new buildings.

2. Consultations in the Home

The law should be amended to permit of the calling out of these specialists to the patient’s home by the local doctor at the expense of the Local Authorities as is already permitted by law in maternity cases.

3. Tuberculosis must be dealt with by the specialists

The existing tuberculosis service should be extended and strengthened and there should be every facility for early diagnosis and for the examination of contacts. The scheme should, however, be linked with a nation-wide provision of ample accommodation in sanatoria and T.B. colonies, and financial arrangements should make prolonged treatment readily acceptable to all in need of it.

4. Development of Health Centres should be encouraged

The Government should offer to pay to Local Authorities a high percentage of the capital cost of all approved schemes. Only those plans should be approved which would be capable of extension. Work should then be put in hand as and when building could be undertaken.

5. Compulsory Maternity and Child Welfare Provisions

The Maternity and Child Welfare Act, 1918 gave apparently unlimited powers to the Local Authority to safeguard the health of mothers and babies, and the Public Health Act, 1936, Section 204 widens these powers by referring to “care of expectant and nursing mothers and children under five” instead of “health” of those persons, apparently with the idea of encouraging general care of all, and not merely sick persons ..

This section is permissive, and the degree to which it is used by Local Authorities varies enormously, but it can be said that no Local Authority is doing as much as is permitted for the care of mothers and babies, while many are doing very little. The section should be amended so as to be compulsory. There should also be a compulsory annual medical inspection of all children under five.

6. Free and improved School Medical Service

All treatment in the School Medical Service should be free. For any condition in a school child with which the private doctor does not deal, the child should be immediately sent by the school authorities to Local Authority clinics or Hospitals for free attention as necessary.

There should be at least four medical inspections of school children during school life, with annual dental and ophthalmic inspections. School children should be weighed and measured twice annually. They should be specially inspected not only when they have definite symptoms, but when they fail to make normal physical or mental progress. When treatment is recommended as the result of a school inspection, there should be a system of “contracting out” for parents instead of the present system of “contracting in”.

7. Local Authorities should be required to undertake intensive health education and propaganda

Existing facilities for health teaching both in Health Centres and in the homes should be extended.

8. GENERAL PRACTITIONER SERVICE

Turning now to the equally necessary GP Service it would of course be administratively easy to provide this by extending the National Health Insurance panel to the dependants of the insured and to those of like economic status or if preferred to the whole community.

The immediate effect of the extension of the panel under present conditions, would be to double the commercial value of every panel practice, for panel practices are freely bought and sold, and fetch good prices. Indeed, a great many doctors are compelled to buy a panel practice – often with borrowed money – if they want to make a living. Anyone, therefore, with a minimum qualification who possesses the necessary capital or is able to borrow it from a moneylender, can acquire a panel practice, and, provided he has a suave and pleasant manner, can retain or even increase it, for the public is, for the most part, quite unable to appraise the value of the medical services received.

A medical service provided by the community and paid for to a large extent out of public funds, ought to be controlled and directed by public representatives. A doctor in such a service must have a responsibility to the nation and must understand it. He must be something more than a tradesman whose sole duty it is to please his customers, and whose practice and remuneration depend almost entirely on the way in which he succeeds in this.

There is further reason for a whole-time salaried service. It seems clear that the doctors of the future will do most of their work from Health Centres in close association with Health Visitors, Nurses, and other full-time officers. It would be extremely difficult to dovetail the work of these with that of a doctor who may have a relatively small and scattered panel ad whose chief interest is his private practice.

It is the opinion of the Committee that there will be an imperative demand for the inauguration of a full-time salaried and pensionable medical service directly after the war. In so far as security of tenure and superannuation rights are not considered adequate, the question of further compensation may have to be examined.