Draft for discussion 4th July 1942
It is proposed to publish as soon as possible a new document,- at one and the same time an answer to the Medical Planning Commission Interim Report, and a statement of the policy of the S.M.A. This summary is intended as a basis for discussion on all points on which the S.M.A. has not declared its policy, or which the M.P.C. report suggests requires further emphasising.
This summary has been divided into sections to facilitate discussion at the meeting on July 4th.
- Health is a national asset and its preservation must therefore be a state responsibility.
- The aim of the health services should be the achievement of optimum health for the whole population, the prevention of disease, relief of injury and sickness, and restoration of health after either.
- The patient must be free from economic barriers between himself and health.
- The public must be encouraged to play an increasing part in the maintenance of health.
- The medical service must be complete; domiciliary, institutional, and specialist. It must also be constantly available, and medical care must be evenly distributed throughout the country.
- There must be a single standard of medical service for all citizens, the highest which medical science can provide.
- The service must consider the needs of the community, of the patient and of the medical personnel-. It must be efficient, involving the minimum of bureaucracy, and give the greatest possible degree of clinical freedom.
- There must be a national plan for the service under central direction, modified to suit local conditions by democratically elected local authorities.
- Any proposals must be practicable in the present political system, and capable of expansion under socialism,,
(In the final document a section will be inserted here, giving factual basis to the criticisms that have been levelled at the present system. This will be followed by a discussion of Sections 47/49 of the M.P.G. report, leading to the conclusion that a partial state service such as they suggested appears to be based on a desire to introduce financial loopholes into an otherwise state organised service.)
Outline of SMA proposals
- 1. Unification. All the health services of the country to be developed on a national plan by a reconstituted Ministry of Health, concerned solely with health services, and which would be responsible for the provision of proper facilities over the whole country.
- Regionalisation. The country to be divided into areas; each to be a new administrative unit of local government. Democratic control to be effected by direct election to the Area Council. To ensure the efficiency or the medical services, such an area should not have a population less than 500,000, and only in exceptional circumstances should it exceed 2,000,000. The working unit in each area would be the Local Health Unit.
- Co-ordination. The health services in each area would be ensured by the control of the Ministry of Health, but administered locally by the Health Committee of the Area Council, which would modify the general plan according to the needs of the area. That committee would include members, usually doctors, co-opted for their experience in health matters. Representatives from all area health committees would form a central health council, advisory to the Ministry of Health. That council would be concerned with the general plan for the medical services, and would not prevent the appointment of medical advisory committees to assist the Ministry of Health in professional and technical questions. The local health units would be under the general control of the Area Health Committee, but largely autonomous through local committees of all health workers.
- Finance. The cost of the medical services to be borne nationally, not locally. The State Health Fund allocated according to the needs of each area, to be administered locally by the area authority.
- Health Centres to be provided in each local health unit and to be responsible for the provision of domiciliary, out-patient,maternity and child welfare, and school medical services, with General Practitioner, consultant, prophylactic, diagnostic and therapeutic facilities. In each unit one health centre would usually be connected with a general hospital, but subsidiary health centres would be placed where the distribution of population, transport facilities, etc. made them most easily available to patients. The needs of the patients on the one hand, and the efficiency with which specialist services can be obtained from the hospital should be the factors taken into consideration when fixing the size of local health units. In general, these should aim at serving a population of about 100,000. The complete service provided by the health centres would be available to the whole population. Those accepting the service would be required to register at the health centre most convenient for them and for non-emergency medical attention and health advice, would be able to choose a doctor from the health centre staff, subject to a restriction on the total number on each doctor’s list. Emergency work,including all night work, would be on a rota basis, and under these circumstances, no choice would be possible. A doctor would be able to refuse a patient, and a patient to refuse the services of a particular doctor in special circumstances.
- Hospitals. All hospitals must be general hospitals of large size, and capable of providing a full consultant service both inside the hospital, at the health centres, and in the homes of the people. All hospitals in the area would be linked to each other, and certain special subjects would be dealt with by centralisation at one hospital. Ideally, there would be a teaching hospital in each area, so that the special knowledge of the teaching staff and the additional facilities for research provided there, would be available to the whole area. The staff of the hospital would be one with the staff of the health centres and the domiciliary service.
- Personnel. All health workers would be employed as whole-time officers of the Area Council, and appointed to the service of the area. A national salary scale and superannuation scheme to be instituted, permitting a transfer of personnel to one area from another; promotion in the service to be based on ability and experience; appointments, advancement , etc. would be under the contrpl of a sub-committee, including representatives of the Universities.
- Special Services. All the special services would require to be co-ordinated and expanded so that facilities are available to every health centre and hospital. In particular, all doctors in the domiciliary service should have easy access to pathological laboratories, X-ray departments, etc., under expert supervision. Accident services, to be responsible for all casualties .(home, road, industrial) to be set up in each area with specialist personnel and facilities.
- Industrial Medical Services.to.be responsible for health working conditions throughout industry, to supervise the health of all workers, and to act in close co-operation with the local Health Centres and hospitals.
- Midwifery Service would be organised from the Health Centres and all personnel engaged would be required to have special training and qualifications in. this branch of medicine, and as a rule would, be full-time workers in the subject.
- Monetary Benefit There should be a national scheme to provide adequate uniform sick benefit, disability pensions and accident compensation for every worker, and his dependents, irrespective of place of work or cause of accident,
- Medical Education. – to be so organised that the best use is made of all material and experience in each area. In a socialised medical service the ultimate aim would be the provision of free medical education with maintenance, to those chosen as most suitable for this training, In the meantime there should be instituted a greatly extended system of scholarships to cover the cost of maintenance where necessary, as well as fees.
- Research to be developed and assisted. by increased grants; to be co-ordinated to eliminate reduplication of work and to provide greater facilities for research for those in clinical practice,
- Health Education The public to be educated in the principles of healthy living by propaganda, especially at health centres and hospitals,
Whether the reform of medical practice takes a long time or not, there is need for very urgent measures which should be taken now, especially as medical man-power is depleted by the needs of the Forces.
These measures must fit into the ultimate scheme and the following are suggested:
- The Ministry of Health should be reconstructed to deal solely with all aspects of civilian medical services, with authority to plan, and powers to enforce the plan.
- All hospitals should be co-ordinated if necessary by ad hoc regional committees.
- All E.M.S. services to be made available for the whole population.
- Health Centres to be started in temporary buildings where necessary as a means of organising the’work of the GP.s remaining in each district.
- Efficiency committees to be set up in all hospitals, in districts where health centres are initiated, with instructions to consider particularly dilution in the medical services.