This SMA pamphlet was published in 1975
All health centres established in England and Wales have been approved by the Ministry of Health and later by the Department of Health and Social Security following implementation of Section 21 of the National Health Act 1946.
“It will be the duty of every local health authority to provide, equip and maintain and staff health centres at which facilities will be available for any of the purposes listed. These are:-
- for the provision of general medical services by medical practitioners;
- for the provision of general dental services by dental practitioners;
- for the provision of pharmaceutical services by registered pharmacists;
- for the provision or Organisation of any of the services which the local health authority are required or empowered to provide;
- for the provision of the services of specialists or other services provided for out-patients under Part II of this Act; or
- for the exercise of the powers conferred on the local health authority for the publication of information on matters relating to health or disease and for the delivery of lectures and the display of pictures or cinematograph films in which such questions are dealt with.”
Following the NHS Re-organisation Act 1973, responsibility for promoting health centres has been transferred to Area Health Authorities. In Scotland, the Scottish Central Department has had overall responsibility for all medical services, including executive control.
HEALTH CENTRE – THE NEXT STEP
Part 1. THE CONCEPT OF HEALTH CENTRES
We must have health centres:-
But they must really be concerned with health as much as, and possibly more than with the treatment of disease. It is a commonplace among doctors that if we could apply all our existing knowledge of disease and its treatment universally the world would be a different place. But it should be equally understood that here in Britain we could advance into an age of positive health if only we would carry out the original socialist plan for a National Health Service based on health centres. Once it was theoretical. We now have enough experience to be certain that we have made only a tentative step towards what is needed and we must move forward. In this pamphlet the Socialist Medical Association examines the next step.
Britain is unique in having a health service based on the concept of a primary care physician who, in addition to attending to the illnesses of those who have freely chosen him or her as their general practitioner, directs them to all the specialist services they may need. These primary care doctors have been given the greatest freedom available to any medical men to treat, prescribe and advise their patients without any question of money coming between doctor and patient. But primary care still retains many of the concepts on which it acted before 1948. We need to redefine it and to clarify its relation to the health centres of the future.
Primary health care in its widest sense can mean the personal health services given by doctors, dentists, opticians, pharmacists, physiotherapists, chiropodists, nurses, health visitors, social workers, home helps and many others who should be given the opportunity of working together in the best possible conditions for serving the community. The SMA has long campaigned for this as the ideal. It is now accepted in fact as it was by the 1946 NHS Act. But the public still has to discover, and the medical profession be convinced, as to the type of health centre which will serve the community best. The way must be shown in which the public themselves can increase the demand for them, particularly through the activities of the recently created Community Health Councils. Developments in the treatment of disease, in health education of the public and in the training of health workers are all in a continuous process of change which makes working from health centres a necessity if the service as a whole is to function to its full capacity.
One of the reasons why the building of health centres has not increased to the extent we had hoped appears to be the financial stringency caused by inflation, and the consequent cuts in health funding which we all deplore, especially when they are imposed by a Labour Government. But a close analysis will show that in the long term the service as a whole would be more economically as well as more efficiently run if the work at health centres becomes more fully developed. Instead of cutting the service to the public it might even be possible to extend it to give far greater satisfaction than at present and at the same time improve the conditions of work and the career and training opportunities of the whole of the health team involved.
Hospital versus Home Care
In the past it has been taken for granted that hospitals should supply all treatment and care for those patients unable to receive it in their own homes or in the doctor’s surcery. This has included the care of the mentally sick, the physically disabled and the aged when a stage is reached that home care is no longer considered possible. But to most people the hospitals are more often seen as the places for providing treatments – surgery, radiotherapy, drugs and diagnostic measures by consultants, all of which have been considered difficult to undertake outside the walls of a hospital. This division into two camps, hospitals and home care, has been so completely accepted that new thinking is necessary if we are to accelerate desirable changes.
The working of the NHS since 1948 has made even more sharp than previously the contrast and division between the consultants who man the hospitals and the general practitioners who treat patients in the community. We can only highlight here the most obvious results of this division. The consultants became the most powerful of the medical profession demanding in the loudest voice their requirements in terms of finance from the Minister, it has largely been the part-time consultants practising both NHS and private work who were the most vociferous. Thus, as we all know, the general hospitals and particularly the teaching hospitals received the lions’ share of the money whilst the mental and geriatric services, manned by full-time consultants who seldom had private practice, became the cinderellas of the hospital service. It would, however, be wrong to overlook the advantages which came out of this for the acute hospitals, which benefitted by research into modern techniques and by the opportunity for the medical staff to work as a team within the hospitals, gradually drawing into the team other, non-medical workers.
Meanwhile, the general practitioners stubbornly determined to work as “independent contractors” from their individual surgeries, rejected the chance until recently to co-operate with each other. They refused then, and still continue to refuse, a salaried service We should like to believe the words of the Central Office of Information Reference Pamphlet No. 20 published by HMSO in 1974. “The general practitioner – or family doctor as he is more usually known – plays a key role in the NHS. He has detailed knowledge of his patients and their families, their background and the environment in which they live and work. Through the family doctor service the professional attention of a family doctor of his own choice is made freely available to everyone”. This indeed is what the role of a G.P. should be and we believe that the description could become nearer to the facts if he worked with others in a health centre where the team work of all the health workers could improve the service both for the doctors and the patients. How has the G.P. failed to approach this ideal?
Whilst we do not want to play down the necessity for the G.P. (and the dentist) to become fully salaried members of the health team it would be futile to make our recommendations for health centres dependent on this change of status. However we believe that all independent contractors within the NHS make full integration and therefore maximum efficiency impossible. Throughout this pamphlet it will be assumed that it is understood that the Socialist Medical Association takes the strongest possible line on this point, and deeply regrets that in the Reorganisation of 1974 the old Executive Councils responsible for G.P. Organisation have changed in little more than name to that of Family Practitioner Committees. We feel that in the past the G.P.’s insistence on remaining “independent contractors” who were paid for each patient on their list and were, therefore, to a certain extent working in competition with each other, has done more than any other factor to isolate them from other members of the health team. Only recently as their payments have increased and allowances have been made for rents, receptionists, secretaries etc. has the status of the G.P. risen. (Now half of the income of the average G.P. comes from allowances and half from capitation fees.) Previously their position was such that even as late as the 1960’s their work was frequently described as a “cottage industry” in which the patient was denied modern facilities and necessary techniques. However, this is not our main complaint about the G.P. service of the present day.
It is, in fact, strangely enough, scientific progress which has changed the doctor-patient relationship. The old “bed-side manner” which was once rightly considered of such great importance, now plays a minor part. With far stronger ammunition than charm and sympathy the doctor doles out prescriptions to patients who have been brainwashed to expect a cure for all ills. There may be many patients who would prefer a chance to talk to their doctors instead of the ready hand-out of pills and medicines, but the present image in the public eye and the reflection in the doctor’s eye all too frequently shows a picture of a demanding public and a prescribing doctor. As a result too many of us become addicts, even in a minor way, to tranquillisers, sleeping- pills and other remedies. The doctor himself may be misled into thinking that some of his patients are making trivial complaints, and as a consequence may miss an urgent and necessary examination; so mistrust and dissatisfaction thrive. We believe it is possible and essential to change this image.
Examination of health services in other countries confirm our view that we must retain the general practitioner as the front line in the personal health service within the community. In many countries nearly all doctors are specialists, and the patient must himself choose a specialist to suit his symptoms – often with disastrous and expensive results. We are fortunate in having the possibilities of a really excellent service, and if during the past years our expectations and those of the doctors have fallen far short of the ideal, we must decide now how we can put right the faults; we must not throw away the possible advantages the N.H.S. has over other schemes.
A centre for health
The type of health centre we envisage is quite literally a “centre for health”, where the team can work together and where the public, not even always the “patient”, should be welcomed and easily able to see the way through the intricacies which have developed in the giving of health care. In this respect the centre must indeed be different in buildings planning and atmosphere from what we have come to expect at the hospital. There, even with the best will in the world, it is hard to prevent the “we” and “they” attitude – “we” being- the doctors and their retinue whose hierarchy is hard to break, though a crack here and there is just discernible; “they” being the patients and their visitors who walk the awesome corridors and wards, seldom expecting to understand what is happening, even to their own bodies, or to be informed in intelligible language.
So, our first demand upon our health centre is an atmosphere of friendship where the public can feel at ease. The services which can be given must depend on many factors and will be described in part two of this pamphlet. They cannot be standardised, since local conditions differ; rural or urban situation; land available; distance from hospitals where laboratory and other services may be available, and so on. However, when services do not exist within the walls of the health centre they must nevertheless be easily attainable and direction to them must be clear and free from red tape. It is the mystique. the difficulties and the frequent waiting times which wear down the public. On the one hand some people may appear to be too demanding; on the other many who may be in real need of attention simply fail to stand up to all the complications. In spite of all the prescriptions, there is probably a mountain of unrelieved suffering-, particularly among the disabled and the elderly.
Before we can consider the type of service which a health centre should offer we must recognise the changes in medical needs since the early days when the service, if it was planned at all, was geared to entirely different conditions. Our rising expectations have followed the enormous scientific progress and medical discoveries one leading to the next – which have increased our life span and almost eliminated the killing diseases of early life. True, these attacks on disease have not always resulted in a return to good health; indeed, they have sometimes, though not always, achieved little more than a continuation of the living process without regard to the quality of life.
We must also take into account in our planning the illnesses which result from our greedy capitalist society which, in the “developed” countries are counterbalancing the improvements science could achieve; such illnesses as those encouraged by profit and advertisements caused by smoking, over-eating, alcohol and drugs; illnesses caused by our modern method of work, occupational hazards, exhaustion, boredom, deafness, pollution, lack of exercise. The list is almost endless and accidents on the road, in the home and at work causing deaths or temporary or permanent disablement must not be forgotten
Great progress has been made in the treatment of mental disease. There is the beginning of a change in attitude towards both the mentally and physically disabled together with more modern and humane methods of caring for the elderly. Many hospital beds are emptied, but this is only beneficial if the necessary community resources are made available. Thus, as we plan for the future, we should be clear about the type of services which the hospital should supply and those which are best carried out within the community.
We have already made a start, by the domiciliary consultation service, in showing that the hospital specialists and other health workers can give excellent service by devoting some of their attention to work in the homes and health centres within their districts. (The Community Health Councils may find it valuable to enquire why excellent domiciliary services exist in one area and not in another.) No rigid rules should be laid down since local needs and existing facilities vary, but the building up of co-operation between the public arid the medical profession is all important. The whole of the health service must be planned for the needs of the people and the doctors must be expected to advise on the best methods without adopting a dictatorial pose as so often in the past.
Part 2. PLANNING OF A HEALTH CENTRE
The Department of Health arid Social Security has stated that the responsibility for the planning, of health centres shall normally be the function of the Area Health Authorities. Priority for capital financing will be considered on a regional basis by the Regional Health Authorities, and to be approved by the Department. The number of new centres opened each year from 1965 to 1972 was 1: 7: 12: 36: 50: 61: 83: 94 and after re-organisation the demand for the approval of building was so high that a cut back was announced. There are now approximately 500 centres in England and Wales with around 3,000 family doctors – 1 in 7 of all such doctors –.working in them. In Scotland, 48 centres have been commissioned, 150 are in course of development and it is estimated that by the mid 1980’s health centres will cover 80% of Scotland’s population.
Expenditure in terms of grant of loan sanction rose from about £l 1/2 million in 1967/68 to an estimated £12 million in 1974. Further allocations have been forthcoming in 1975, and the increasing demand indicates the popularity of the concept. It is clear, however, that with the severity of the present financial cuts all possible pressure will be needed if the building of health centres is not to dwindle. The concept of health centres as an essential feature of the N.H.S. is not emphasized by the D.H.S.S. and it will certainly be necessary for the public to demonstrate its acceptance of a desire for them if their full use is to materialise.
In March 1974 the Department circularised all Health Authorities and relevant Committees and Councils (Community Health Councils were not yet established) with N.H.S. Reorganisation Circular HRC (74) 21 entitled “Health Centres” describing the technical procedure for planning, building,, financial arrangements and running of a health centre, referring also to the Health Centre Design Guide which sets out the Department’s views on the policy considerations to be taken into account and the procedures to be followed in designing health centres, together with recommendations about the size of the various rooms and their relationship to one another, etc.
It is therefore not the purpose of this pamphlet to attempt to repeat such information. Instead we set out to underline the basic consideration which we as socialists must have in mind, and we are aware that some of our suggestions may fall in line with long term planning whilst others could become immediate objectives. In particular we would emphasize that for the first time the machinery does exist for every one of us to express our demands. The Labour Government has greatly strengthened the functions of the Community Health Councils which came into existence with Sir Keith Joseph’s Tory Reorganisation and were not originally intended to have real power. Whilst not directly democratically elected they are intended to represent the public and fullest use should be made of their influence. Their meetings are open to all and they are permitted to visit and investigate all aspects of the health service and make recommendation to the Area Health Authorities. We have long pleaded for democracy in the service and we must now, as individuals, trade unionists, labour party or co-operative branch members take the fullest advantage of any opportunities which offer themselves to make our rights and demands known and to campaign for them.
A National Comprehensive Health Centre Service
Socialist and Labour party policy for health services in the Community should be positively directed to the long-term institution of such a service comprehensively and nationally, with the eventual phasing out of all the independent contractors, i.e. doctors, dentists, pharmacists and opticians.
The health centre service must provide the total health needs, both preventive and curative, for all those not requiring hospital service. The basic purpose of a centre is to serve its community with the complete spectrum of health care and education, and benefit people by utilising all the advantages of comprehensive health teams.
Medical Service within the centre
The number of general practitioners working in a health centre must vary according to local conditions. There are many rural areas, and even some urban ones where there might of necessity be as few as two, especially if patients are not required to travel too far. Whether the doctors are paid as at present by capitation fee or by salary the patient must be permitted to choose his own doctor, but certain limitations are inevitable. In some sense too rigid adherence to the “own doctor” principal may not be good. For instance it may well be that some of the doctors in a centre develop special skills or have special training, so that it might be of benefit for ante-natal work to be performed by one, geriatric patients be seen by another, and so on. In such cases the interest of the patient may be best met by a degree of internal specialisation and even on occasions by a change of doctor. Much opposition to the concept of health centres at present is based on the false assumption that no choice would be available, but the choice would be no less, and might even possibly be more, than at present.
In some areas and for certain conditions sessions at a health centre can be taken by hospital consultants to the great benefit of patients; enabling consultations to take place, on the spot, between the specialist and health centre doctor. There are also advantages if certain hospital workers, – the children’s nurse and the midwife are the most obvious of many – also do domiciliary and health centre work.
This form of consultation is a better link between G.P.’s and the hospital than the present arrangement of a G.P. doing, and being paid extra for doing, a session at a hospital as a clinical assistant. Indeed, the whole question of how much work and what kind of work G.P.’s should do in hospital needs a great deal of fresh and open discussion. Rather than an attempt to be a part-time hospital assistant it is far better that the general practitioner is recognised as a specialist in his own very wide field. As such his status should be the same as that of any other specialist and he must have proper post-graduate training.
There are many procedures at present undertaken at hospital which could be performed at the health centre, sometimes, if desirable, by combined G.P. and hospital consultant staff. It could be of great service to the community and relieve pressure on outpatient clinics. For instance we have in mind follow-up after treatment of diabetes, thyroid diseases, cancer and so on. These changes would require knowledge of local conditions such as laboratory services, but it seems easier to organise sending of specimens to the laboratories than to expect each patient to attend hospital individually. This is the type of change, and very many more could be added, which could make the concept of health centres something different from our previous general practitioner service, and even different from the best of the group practices which have proliferated in recent years.
It should go without saying that the S.M.A. condemns in the strongest terms any provision for private patients to attend health centres. At present the terms of employment of G.P.’s and dentists do not prohibit them from taking fees from patients who are not on their lists. Some doctors do not treat such patients because they dislike the additional work involved. However, there might unfortunately be more doctors who would accept private fees at health centres where the organisation and much of the additional work would fall on other staff (incidentally not paid extra for these services). Quite apart from the ethics, we condemn such practice because the inducement for patients to pay can only be the belief that they will receive better treatment. When payment is presumed to buy extra service, non-payment must, therefore, be presumed to be for worse service. Standards must be raised to satisfy all. But there is no evidence that private practice does provide a better service medically and the false implication involved in the fee is dishonest. Above all a socialist service must be honest.
This is a sphere which should be closely observed by Community Health Councils, and other watchers of the N.H.S. The solution, of course, as for so many ills, is a fully salaried medical service.
Emergency and out of hours service
Although doctors as independent contractors agree to be on call 24 hours a day 7 days a week everyone knows that doctors must have time off and holidays. But there are still some unthinking people who resent the fact that they cannot see the doctor of their choice it all times. Of vital concern to patients is the arrangement for alternative medical care when their doctor is off duty, or for emergency calls when he is engaged elsewhere. Clearly a health centre requires a 24 hour telephone service which can be achieved by adequate administrative staff who must also answer personal callers and know which doctor to alert at all times. Ideally the on-call doctor should be a member of the Centre, and this is possible when the complement of doctors is large enough. Since 1955, starting in London deputising services have evolved which now operate in many large towns and involve 13 separate commercial agencies all run for profit, some of them by the British Medical Association. A report of a Joint Working Party entitled General Medical Services was published by H.M.S.O. in 1973, (price 45p) reviewing in some depths the advantages and disadvantages of such a system, and for those centres considering the matter reference to this report is essential. One of their comments reads “The services are primarily interested in expanding,, in ways which are profitable and fit with their existing business. Such expansion is not necessarily in the form best calculated to benefit the Health Service”.
The doctors which these services supply are often general practitioners themselves, who are in other practices but earn extra for working in this way. Sometimes they are junior hospital doctors (now reasonably paid) but nevertheless earning extra by working in their off duty time. If such a service is necessary (as it probably is for some G.P.’s working in small groups or alone, because they have not yet got a health centre) it should be organised by the N.H.S. itself and not left to private profit concerns. The same report, however, writes of a most successful deputising service at Woodside Health Centre in Glasgow as follows:
“. . . twenty general practitioners group together to provide a highly organised system of out-of-hours health care … The telephone” (at the health centre) ” is permanently manned and the patients are not involved in the delays of a post office diversion system. In the evening the telephone is answered by an experienced registered general nurse who can give advice where it is appropriate. In the event of a visit being required the nurse is able to contact the doctor on duty by radiotelephone. . . . . The patient’s previous notes are readily available to the nurse in the health centre and can be passed on to the doctor on duty. . . . Control of the system is exercised by a sub-committee of the health centre committee of management. The system thus has the advantages of a commercial deputising service in allowing doctors to have adequate time off duty, but control is exercised from within the health centre.”
It seems without question that such a system is ideal for the health centres of the future. When the number of G.P.’s is not sufficient to man all hours and holidays either the health centre or the Area Health Authority can act in place of the commercial agency, engaging additional doctors for the service, instructing them about the health centre customs and about hospital admission etc. and seeing that they know the district well enough to undertake night calls without delay.
Again this service is one which would be greatly simplified by a salaried general practitioner service. It is interesting to observe that when money-making enters into the sphere of medical practice, as it does in the case of doctors earning more for these sessions, private commercial firms soon realise that they, too, can rake in a profit, and of course all this is at the expense of the N.H.S. which means YOU, the tax-payer.
The dental service for the public and, indeed, for the dentist themselves is in a more perilous state than the medical service. Dental patients do not even have the security of knowing they can obtain N.H.S. treatment by registering with a dentist No registration is necessary but any dentist can legally refuse to give N.H.S. treatment. At present it is understandable that they do so since the payment offered for certain treatments by the N.H.S. is too small to cope with the rising costs of materials, technicians and other dental ancillary workers. The Socialist Medical Association has already published a pamphlet “The Future of Dentistry” price 10p, which considers the subject in depth. It concludes “the long term solution which the S.M.A. can give with no hesitation is as clear as when is was stated before the N.H.S. Act. The full dental team’s place is in the health centre, in exactly the same way as the medical team. According to the population which the centre is planned to serve there will need to be so many dental chairs and dentists. The whole dental team will be paid by the State and their uses will be organised by the dentist, in the same way that any hospital consultant can call on the team of workers he requires to carry out his treatment plan. The dental health educators will be incorporated into the health centre preventive medicine team, where they will have facilities for visual aids, lecture room, special children’s department and so on. The dental hygienists, also State employed will be at the service of the dentists and of course of the school dental service which will also be incorporated in the health centre. For the aged and infirm the health centre staff will arrange appropriate appointments and transport.”
It is not necessary to add more to this summary except to say that in the immediate future this is an area which will cost the N.H.S. more than it spends at present. This is because it has so far entirely failed to fill the need for supplying dental treatment to the public, and has left private enterprise free to flourish. It has been estimated that dental education and early dental treatment and preventive measures and fluoridation of the drinking water supplies could in the future, cut down enormously on the need for dental treatment in later life. Moreover the cost, even now, may not perhaps be as great as feared since far better use can be made of the work of dental auxiliaries who can relieve the dentists of a considerable amount of their work and free them for more specialised procedures.
It must not be forgotten, however, that there are already some dentists who work on a salaried basis. The dental clinics of the school dental service and the local health authority clinics for the priority classes of mothers and young children are now incorporated under the Area Health Authority with the rest of their services and employ about 1,800 salaried dentists. or around 11% of all dentists. Salary scales compare badly with those for salaried medical colleagues, and it is not surprising that the services are most inadequately staffed with dentists, dental technicians and dental hygienists. Integrated health teams at health centres must include the dental team to carry out the entire field of dental work, in close co-operation with the medical side, and utilising the educational, nursing, administrative and clerical staff of the centre. The shortage of dental personnel makes it more necessary that those engaged should work in the most favourable circumstances and to optimum effect. Given the right conditions and remuneration, the present salaried dentists could constitute the nucleus for establishing a comprehensive salaried dental team in an integrated health centre service.
The nursing services must be clearly seen as a highly specialised service for the patient, complementary to the G.P. service and not subservient to it. Both services have particular skills and expertise which must be recognised and utilised fully. For example, health visitors, unlike the general practitioner or the other nursing services, undertake an essentially preventative service which can probably be greatly expanded through health centre practice. The way in which the medical and nursing professions co-operate can not only increase efficiency but add to the interest of both professions and should be a matter for discussion and review by the management committee of a centre. The public, however must not be made to feel that such co-operation is merely hiving off work from a busy or reluctant doctor; nor must this, in fact, be the case. Many patients may, on occasion, prefer the probably more relaxed and sometimes more intimate discussion that a health visitor or nurse is prepared to have with them.
There are of course many nursing duties based on the health centre, but there is possibly no sphere where the inter-relation between hospital and primary health services can be more clearly demonstrated than in the work of the nursing profession. In certain areas the same duties might be performed in hospital out-patient or emergency departments, in the health centre or in the home, and decisions are likely to evolve slowly, in the course of experience and considering local conditions. The goal must be the maximum good for the patient and the best use of the highly qualified nurse, always in short supply. Part-time married or retired nurses and health visitors may find more congenial work in a local health centre and of course the use of the auxiliary nurse must not be forgotten. As we have indicated in our section on training, the health centre could well be a most valuable base for part of the training of nurses.
There is no reason why the local authorities responsible for social work should not wish to utilise a health centre when it proves to be a useful base for their activities. Certainly easy contact between social workers and the other professions is desirable, and the possibility of one or more social workers with head-quarters on the premises must be considered. Services such as home helps and the Organisation of meals-on-wheels come to mind.
Preventive, Personal and School Health Services
The preventive health services have produced tremendous improvements in community health in the past half-century. Infant mortality rates have been halved and quartered, and killing infectious diseases such as diphtheria and poliomyelitis have been virtually wiped out. But there is still far too much preventable ill health and subnormal health.
These services were the responsibility of the local Health and Education Authorities, who employed for this work either whole or part-time salaried doctors and dentists, or engaged them on a sessional basis. A health centre must include at least some of these services locally, so that clinical work in a centre may be done by doctors and dentists employed directly by the Area Health Authority and working under the same roof as doctors and dentists engaged as independent contractors. The setting up of fully coordinated and integrated health teams is certainly not facilitated by different and sometimes conflicting conditions of employment.
The school health service, now also the responsibility of the Area Health Authority, is usually closely associated with the other preventive health services, in respect of accommodation, facilities, equipment, and medical, dental and nursing staff. All such services dealing mainly with a healthy population have their specialised aspects requiring post-graduate training and experience for doctors, dentists and nurses, but they must also be linked to the other parts of the health service, and the health centre is the place where this can best be done. In the preventive field, in particular, there is much educational and advisory work, and the health visitor and other nursing staff have a major role in the health team. The health centre must also be the main base for domiciliary work of the health visitor, midwife, home and school nurse.
Health education has always been an integral part of the preventive health service with specific expenditure powers for this purpose. Mass campaigns for the improvement of infant and child health, protection against infectious diseases by inoculation; family planning; the health risks of cigarette smoking; drugs and excessive alcohol and so on are entirely dependent upon the cooperation of the health members of the public. Health education, at the personal level, is a major part of the work of the health visitor as a family health advisor, and of the community physician and in larger authorities a whole-time health education officer. As the focus for all local health services, the health centre is the ideal base for personal health education. In the planning of the centre, generous space must be given for this work, which includes such practical services as classes for pregnant women, breathing exercise sessions for asthmatics, British Red Cross and St. John’s First Aid Training courses and so on. With facilities for audiovisual aids the health centre can be the principle means of producing well informed and soundly based public opinion in matters of health.
Health Service Information and Public Relations
There is much unnecessary suffering and inconvenience because people do not utilise services available for them on account of ignorance, timidity and inadequate publicity for services. The elderly, the underpaid, the social problem group, in fact those whose need for advice and help is greatest are least likely to know to whom or where to turn. The health centre is the most appropriate body to undertake the dissemination of all aspects of health service information and be linked with an enquiry bureau as a recognised aspect of centre work. This bureau could also deal with health service complaints it would certainly be receiving them at the grass roots level and everything which increases the channels of communication directly between the services and the people should be carefully considered.
A health centre information and public relations office should form some liaison with the Community Health Council.
There is probably no service which patients at a health centre would more appreciate than a pharmacy on the premises The search for the chemist’s shop, open when needed, distances to travel, waiting for prescriptions, are inconveniences recently highlighted. This is a sphere, too, where the N.H.S. might look for saving of expenditure. A trained pharmacist could give advice to the doctors, as he does already in hospitals, on the prices of drugs performing the same functions. The immense expenditure now necessary in pricing prescriptions for payment to individual chemists could be reduced. There will of course be difficulties facing any radical change and the S.M.A. is at present preparing a pamphlet on the whole subject of pharmaceutical services.
Now that family planning advice is a recognised function of the general practitioner there is no difficulty in incorporating it into health centre services, together with abortion referrals. Care must be taken to see that really good counselling advice is available since a hurried consultation will not make up for the care which the family planning services have previously supplied. This is an area where it is possible that some flexibility may be necessary in accepting patients from other districts, since the reluctance of young girls to attend for advice at the same centres as the rest of their family is understandable and must be dealt with sympathetically
Area Health Authorities now have responsibility for the Ambulance Service. A transport service at the specific disposal of the health centre could be most useful in bringing to the centre the disabled and others who would benefit by attending the centre but for whom public transport is either unavailable or impracticable. The additional services which might be included in a really comprehensive centre make health centre transport more essential.
Other Professional Services
There are many services which would greatly benefit the community if based at health centres, but which we shall not expect to find everywhere, partly because of the variety of local conditions and requirements, but mainly because of shortage of trained staff. The present shortages, however, require that those who are trained must be used to maximum advantage, and various methods of employing them must be considered. They could, for instance, work both in hospitals and health centres, or on rota systems at several health centres. Many could visit patients in their homes if time permits. Planners of health care must bear in mind that good domiciliary services can keep many patients out of hospital and allow many more long-stay patients to be discharged, as well as early discharge after treatment and surgery if home conditions permit. Cost analysis must take account of these possibilities, which will, at the same time, meet with the approval of the vast majority of patients.
We shall mention a few of the professions which could benefit the community if included in health centre services. No doubt there are many more.
Physiotherapists now based in hospital out-patient departments could probably spare some of their staff and even possibly some of their equipment to work in health centres. Some of them might also work part of their time in the community where they could achieve great success in rehabilitation of the elderly, post-accident and post-operative patients, and other work,. for example, treatment of bronchitics which might prevent many hospital admissions. In some areas they already work at day centres so that care must be taken not to duplicate.
Psychiatric work may be undertaken from the health centre.
Ophthalmic services could have sessions at health centres.
Chiropodists, unfortunately at present in very short supply, can do more than many other workers to relieve discomfort in the elderly, and a home service run from health centres seems almost essential.
Speech therapists can be of enormous help particularly with children and victims of strokes, but again there are too few for all the calls made upon them.
Audiometry and hearing aid services. The school health services should attend to the needs of children in this respect, but advice and help are particularly needed for the elderly and this is another service which could probably be combined with hospital facilities.
Occupational Health services. Whilst such services are at present available in some large factories, although not as part of the N.H.S., there is a great need for such a service for small factories, offices, shops etc. This is a very wide subject and has been dealt with in depth by the S.M.A. in their pamphlet “The Development of an Occupational Health Service”. Until such a service becomes mandatory it cannot be included within the present planned health centres, but it is a possibility to be considered for inclusion in the future, and should encourage the planning of health centres for future expansion wherever this possibility exists.
The Non-professional Staff
The smooth running of a health centre depends as much on many other workers as it does upon the professional staff. The secretaries, receptionists, cleaners, porters, maintenance workers, telephonists and others must be given a dignified place in the kind of health centre we envisage, where hierarchy shall not be allowed to develop. The management committee must include elected representatives of all staff as well as those of the public – who are the patients. Particularly here we shall mention the role of the receptionists, which has recently come in for increasing criticism. The idea has arisen, sometimes with justification, that receptionists act as a barrier between patients and doctors; that they abuse their power by enquiring into the nature of the patients’ diseases to decide whether an urgent appointment is needed. As with all such criticisms the many helpful and efficient receptionists do not make news and are seldom heard of; but training and instruction of new personnel is necessary. An appointment system must be used which allows time daily for urgent cases – and urgent should be on the patients’ assessment (it may be necessary to explain that his “own doctor-” is not immediately available). The main attributes for a successful receptionist are kindness and tact, assisted by enough telephone lines to avoid annoyance and easy access to clearly written appointment lists, – and enough receptionists to cope with the work.
The running of a health centre may be improved in many ways if groups of patients attending for particular purposes are seen at special sessions by appointment — for example, maternity and baby clinics, diabetics, obesity patients and many different types of follow-up procedures. In this way not only are the day to day appointments relieved, but doctors, nurses, pathology services and others are geared for the particular tasks expected. Care must be taken to note which patients fail to attend such clinics, so that when necessary further appointments can be given or transport arranged or home visits undertaken. It has been the lack of such measures in the past that has encouraged hospitals to continue follow-up clinics which in many cases could as well be run by general practitioners, to the greater convenience of patients.
In a similar way we feel that all patients registered with health centre doctors should be examined on reaching pensionable age, and at regular intervals afterwards, so that many illnesses which develop in old age can be detected at an early stage and reference to the various professions we have mentioned could be made in time. This can be done even before all the professions are housed within the centre itself. Such procedures can well result in an ultimate saving of financial and medical resources, as well as alleviating much unnecessary suffering
As at hospital, a central record must be kept and made easily available to all health centre professional staff – at the same time preserving the recognised code of confidentiality. Special departments will need to keep personal records for their own use (for example physiotherapists, psychiatrists, social workers etc.) but the fact that patients have been referred to these workers must be recorded on the central record. We hope that the day will soon be past when the small size inadequate envelopes which the old Executive Councils issued for general practitioners’ records are in use. These discourage any doctor from laying out the record in a meaningful way, and summaries of hospital attendance, though clearly typed, have to be folded into a small size. When patients are referred to hospitals the secretaries from the health centres must send, at the doctors’ dictation, summaries helpful to the hospital consultants, and likewise on discharge complete summaries of investigations, diagnoses and treatment are sent to the health centre. Thus both places hold adequate records of individual patients.
It is to be hoped that a certain number of well-run health centres throughout the country which have access to university computers and medical statisticians will prepare programmes with their help which could produce eventually a new type of medical knowledge. It is only by the most careful recording at general practitioner level that the natural history of certain diseases can be traced. By the time patients reach hospitals which have such statistical arrangements at their disposal it is often too late to obtain all the early data.
There has been a recent upsurge of volunteers in a society which is rapidly becoming more conscious and eager to serve one another. A health centre situated within a community should be a focal place for the organisation of such a service. In hospitals, paid organisers are often considered essential but it is likely that in a well-staffed health centre they will not be necessary. Volunteer services can be of enormous value to professional members of the team, who must frequently be aware that their burden could be lightened by visits from neighbours within the community who could fill a recognised need impossible for them to undertaken. Volunteer services can, indeed, serve a two-way benefit; both for those who require attention and for those volunteers undertaking the work. It is not only the housebound in our society who are lonely. The consequences of isolation fall upon many including, not least, housewives with young families, widows, retired or redundant workers.
The type of services are many; shopping, visiting, car-outings but above all friendship, not always from similar age groups. The elderly welcome the society of younger members of the community, and their experience and knowledge can benefit the “volunteers” – it is good not always to be on the receiving side but also to be among the givers themselves. The possibility of “paid volunteers” should also be born in mind. A small payment may make it possible for a pensioner to help by cooking, regular supervision of the housebound and other services which could keep a patient within the community.
Management of a Health Centre and Patient Participation
There are many possibilities of the ways in which the management of a health centre can be undertaken, and we have indicated in this pamphlet that medical hierarchy must be avoided, and participation by patients as well as staff should be made possible. Dr Alistair Wilson, a S.M.A. general practitioner from South Wales has written a helpful account of local experience, which we quote with his permission.
“When in August 1973 the local Health Centre was opened it was considered that the patients (10,000) should be encouraged to become involved in running their general practitioner services. It was decided that this could best be done by calling a general meeting, open to all patients from which a patients’ committee would be elected and also to have lectures on the theme “Look after your Health”. At the first general meeting a committee of 8 patients was set up. At the second general meeting this was increased to 13. The chairman is a retired teacher, the secretary a young industrial worker. One of the members is also a member of the local Community Health Council.
The Patients’ Committee now meets, (with the practice health team, doctors, nurses etc.) every 5 or 6 weeks – in future the liaison social worker, it is hoped, will also attend. Initially the Committee discussed immediate difficulties, the doctors’ weekend rota arrangements, the surgery appointments system, parking facilities, redecoration, the provision of picture rails, the Health Education programme.
Now, however, we have worked out how to provide a new facility, a limited screening service for the over 60’s, to whom letters, signed by the senior doctor and the secretary of the patients’ committee, are being sent soon after their 60th birthdays.
At a recent meeting the main matters discussed were, the waiting time for Barium Meal X-rays, the Open University training of doctors, the James White Abortion Act Amendment, the Health Education Programme for the next session, Euthanasia.
The Patients’ Committee approached the C.H.C. concerning the waiting list for Barium Meal X-rays. The C.H.C. wrote to the local office of the Area Heath Authority and in view of their reply the Patients’ Committee reconsidered the matter and decided what they thought should be done. One of the doctors and a member of the Patients’ Committee will visit the C.H.C. office shortly to present what is considered to be a reasonable solution to this problem. Patients should be encouraged to attend the Patients’ Committee meeting to give opinions, advice or complaints. There should also be more frequent general meetings for the same purpose. What is envisaged is co-operation between the health centre staff and the patients, rather than confrontation, the aim being to involve as many patients as possible and to utilise the unique and varied experience of as many of the 10,000 patients as possible to assist the practice team of 15 to provide a better service.
Our local patients’ committee is an example of grass roots democracy in an N.H.S. which is, more and more, being controlled at all levels, by appointed, not elected, bodies. Our relations with the C.H.C. are excellent; the C.H.C. Secretary has already spoken to one open meeting of the patients. Is there any good reason why this cannot also happen at every other health centres?”
Staff Training and Careers
We have indicated that health centres throughout the country could make a radical difference to both career prospects and training facilities not only for doctors but for other health workers. Dr Julian Tudor Hart, himself a member of the S.M.A., wrote in the Lancet of Nov. 16th, 1974 an article regarding proposals for assisted entry to medical schools for health workers as mature students, which suggests new and exciting prospects. We would refer any reader seriously investigating these possibilities to ask him for a reprint. He makes clear that the shortage of doctors throughout the country is not, as many people believe, due to shortage of suitable applicants. He pleads, however, for the selection of students with more socially informed motivation and writes as follows:
“The total manpower of the N.H.S. is composed of about 64,000 doctors and dentists, and 878,000 other workers. Because of the very low level of wages for all health workers other than doctors throughout the post-war period, compared with workers in private industry, nearly all of them are highly selected for vocational commitment. After 3 years in the N.H.S. most of them will have discovered that doctors belong to the same species as themselves, and perform no function that cannot be learned, and perhaps learnt better, by mature people with experience of how medical science is translated into patient care in real situations; those willing and able to take the fuller responsibility of a qualification in medicine will have begun to work out some of their own ideas on how this transformation might be made more effective. If 20″% of the annual intake of medical students (about 700 people a year) were reserved for N.H.S. health workers of 3 or more years’ standing in any capacity we could begin to tap this valuable reserve.”
We very strongly agree with these words, If health centres become, as we believe they will, well-known features of a local community, the health professions will not appear so far removed from the life of ordinary people and it should be possible to tap the resources of the more caring members of society. Part of the training of health workers an d doctors should take place in health centres where home visiting and contact with the public could help to break down the hierarchy and class bias which pervades so much of medical work. We trust that the Open University will soon include medical training in its orbit, and that the health centre will then play an important role in providing practical work for students.
This pamphlet has done little more than outline the possibilities of health centres for primary care in the community. Much has been left unsaid – indeed a book could be written to include all we should like to say. But we hope that it has served a purpose if only to stimulate a demand for a new concept of health care and to set in motion other ideas not mentioned here. We invite Socialist Medical Association members and other readers with experience of health centres to write to us for publication in a future pamphlet or for inclusion in the S.M.A. News Letter.
N.H.S. Re-organisation Circular H RC (74) 21
Health Centre Design Guide D.H.S.S. Central Office of Information Reference Pamphlet No. 20.
The Development of an Occupational Health Service (S.M.A. publication) 25p
Dr Julian Tudor Hart – Lancet November 16th, 1974. Reprint from him at Glyncorrwg Health Centre, Glamorgan, SA13 3BL.
Private Practice OUT of the N.H.S. (S.M.A. publication) 20p.
The Future of Dentistry. (S.M.A. Publication) 5p.
Community Health Councils; an Opportunity. (S.M.A. publication) 10p.
General Medical Services, 1973 H.M.S.O. Report of Joint Working Party.