MINISTRY OF HEALTH
DEPARTMENT OF HEALTH FOR SCOTLAND
Presented by the Minister of Health and the Secretary of State for Scotland
to Parliament by Command of His Majesty February
1944
LONDON
PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICF
1944 Price 1s. 0d. net
Cmd. 6502
INTRODUCTORY
1.The Present Situation
II.The next Stage; A Comprehensive Service for All.
The method of approach
The scope of a " comprehensive" service
Temporary exceptions to "comprehensiveness"
Mental health
Some misconceptions about the meaning of "comprehensive"
General nature of the Government's proposals
IIII. The General Administrative Structure of the Service.
Central and local responsibility
Central organisation
Central responsibility of the Minister
A Central Health Services Council
Central Medical Board
Local organisation
Service to be based on local government
Need for larger administrative areas for the hospital service
The place of the joint authority outside the hospital service
General.. .
Professional guidance in local organisation
Local Health Service Councils .
Direct professional representation on local authorities
IV.Hospital and Consultant Services.
The part of the voluntary hospital
Preparation of local area plan
Central approval of local area plans
General conditions to be observed by hospitals...
Financial arrangements with voluntary hospitals...
Inspection of hospitals
Provision for consultant services in the local plan
Some principles affecting consultant services
V.General Practitioner Service.
Methods of approach to the problem
The part of central and of local organisation in the service
Grouped general practice
General lines of Health Centre development
Provision of Centres
Terms of service in Health Centres
Separate general practice
Scope of separate practice
Control over entry into new practice
The part of the new joint authority
General
Permitted number of patients
Entry into the public service
Compensation and superannuation
Sale and purchase of public practices
Creation of a Central Medical Board
Supply of drugs and medical appliances
The need for a new attitude in patient and doctor
VI.-Clinic and other Services.
Maternity and child welfare services
School Medical Service
Tuberculosis dispensaries and other infectious disease work
Cancer diagnostic centres
Mental clinics
Venereal diseases
New services likely to develop
Medical research
The part of Medical Officers of Health and others
VII.- The Service in Scotland.
Central administration
Local organisation
Administration of the hospital and consultant service
Administration of the clinic services... ...
Administration of the general practitioner service
Local Medical Services Committees
VIII.-Payment for the Service
IX.-General Summary
APPENDICES.
Appendix A.-The existing health services; general survey of the present situation
and its origins.
Appendix B.-Earlier discussions of improved health services and an outline of
events leading up to the preparation of
this Paper.
Appendix C.-Possible methods of securing local administration over larger areas
than those of present local government.
Appendix D.-Remuneration of general practitioners.
Appendix E.-Finance of the new service
The Government have announced that they intend to establish a comprehensive health service for everybody in this country. They want to ensure that in future every man and woman and child can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available; that their getting these shall not depend on whether they can pay for them, or on any other factor irrelevant to the real need-the real need being to bring the country's full resources to bear upon reducing ill-health and promoting good health in all its citizens.
The idea of a full health and medical service for the whole population is not a completely new one, arising only as part of post-war reconstruction. In the long and continuous process by which this country has been steadily evolving its health services the stage has been reached, in the Government's view, at which the single comprehensive service for all should be regarded as the natural next development. The end of the war will present the opportunity, and plans for post-war reconstruction provide a setting, but the proposal to set up a comprehensive service has to be seen against the past as well as the future and to be recognised as part of a general evolution of improved health services which has been going on in this country for generations. The case for it stands on its own merits, irrespective of the war or of other proposals for post-war reorganisation, although it must form an essential part of any wider proposals for social insurance which may be put into operation. Nor is it a question of a wholly new service, but of one with many roots already well established. The methods of organising it must be closely related to history and to past and present experience.
The decision to establish the new service applies, of course, to Scotland as well as to England and Wales and the present Paper is concerned with both countries. The differing circumstances of Scotland are bound to involve certain differences of method and of organisation, although not of scope or of object. To draw distinctions throughout the Paper in regard to the detailed application of the new proposals in each country would unduly complicate the text. For this reason the principal differences which arise in applying the proposals to Scotland are reviewed all together, in chapter VII. Similarly most of the Paper has, for convenience, to be expressed in terms (e.g. in its references to local authorities) which are not equal1y appropriate to both countries. Subject to the review or the main differences in chapter VII these terms should normally be taken as covering whatever is their counterpart in Scotland. Throughout the Paper references to the Minister should normal1y be construed as references to the Minister of Health in the case of England and Wales and the Secretary of State for Scotland in the case of Scotland.
The purpose of the Paper is to examine the subject generally, to show what is meant by a comprehensive service and how it fits with what has been done in the past or is being done in the present, and so to help people to look at the matter for themselves. The proposals made in the Paper (and summarised at the end) represent what the Government believe to be the best means of bringing the service into effective operation. The Government want these proposals to be freely examined and discussed. They will welcome constructive criticism of them, in the hope that the legislative proposals which they will be submitting to Parliament may follow quickly and may be largely agreed.
The record of this country in its health and medical services is a good one. The resistance of people to the wear and tear of four years of a second world war bears testimony to it. Achievements before the war - in lower mortality rates, in the gradual decline of many of the more serious diseases, in safer motherhood and healthier childhood, and generally in the prospect of a longer and healthier life- all substantiate it. There is no question of having to abandon bad services and to start afresh. Reform in this field is not a matter of making good what is bad, but of making better what is good already.
The present system has its origins deep in the history of the country's social services. Broadly, it is the product of the last hundred years, though some of its elements go much farther back. But most of the impetus has been gathered in the last generation or two, and it was left to the present century to develop most of the personal health services as they are now known.
This historical process, and the health services so far emerging from it, must be looked at in some detail if the present situation is to be understood and if new proposals are to take proper account of it. There is, therefore, appended to this Paper (in Appendix A) a general survey of the medical and health services as they exist now, and of the way in which they came into being. Some features of the present services will also be discussed as they arise in later parts of this Paper, when the different branches of medical care -general, specialist, hospital and others - are considered in more detail. The immediate question is how far the present arrangements are inadequate and what are the reasons for altering or adding to them.
The main reason for change is that the Government believe that, at this stage of social development, the care of personal health should be put on a new footing and be made available to everybody as a publicly sponsored service. Just as people are accustomed to look to public organisation for essential facilities like a clean and safe water supply or good highways, accepting these as things which the community combines to provide for the benefit of the individual without distinction of section or group, so they should now be able to look for proper facilities for the care of their personal health to a publicly organised service available to all who want to use it - a service for which all would be paying as taxpayers and ratepayers and contributors to some national scheme of social insurance.
In spite of the substantial progress of many years and the many good services built up under public authority and by voluntary and private effort, it is still not true to say that everyone can get all the kinds of medical and hospital service which he or she may require. Whether people can do so still depends too much upon circumstance, upon where they happen to live or work, to what group (e.g. of age, or vocation) they happen to belong, or what happens to be the matter with them. Nor is the care of health yet wholly divorced from ability to pay for it, although great progress has already been made in eliminating the financial barrier to obtaining most of the essential services. There is not yet, in short, a comprehensive cover for health provided for all people alike. That is what it is now the Government's intention to provide.
To take one very important example, the first-line care of health for everyone
requires a personal doctor or a family doctor, a general medical practitioner
available for consultation on all problems of health and sickness. At present,
the National Health Insurance scheme makes this provision for a large number
of people; but it does not give it to the wives and the children and the dependants.
For extreme need, the older Poor Law still exists. For some particular groups
there are other facilities. But for something like half the population, the
first-line health service of a personal medical adviser depends on what private
arrangements any particular person can manage to make.
Even if a person has a regular doctor- and this is not now assured to all -
there is no guaranteed link between that doctor and the rest of necessary medical
help. The doctor, both in private practice and in National Health Insurance
practice, has to rely on his own resources to introduce his patient to the right
kinds of special treatment or clinic or hospital -a great responsibility in
these days of specialised medicine and surgery- or the patient has to make his
own way to whatever local authority or other organisation happens to cater for
his particular need.
When a hospital's services are needed, it is far from true that everyone can get all that is required. Here it is not so much a question of people not being eligible to get the services which they need, as a matter of the practical distribution of those services. The hospital and specialist services have grown up without a national or even an area plan. In one area there may be already established a variety of hospitals. Another area, although the need is there, may be sparsely served. One hospital may have a long waiting list and be refusing admission to cases which another hospital not far away could suitably accommodate and treat at once. There is undue pressure in some areas on the hospital out-patient departments - in spite of certain experiments which some of the hospitals have tried (and which should be encouraged) in arranging a system of timed appointments to obviate long waiting. Moreover, even though most people have access to a hospital of some kind, it is not necessarily access to the right hospital. The tendency in the modern development of medicine and surgery is towards specialist centres -for radiotherapy and neurosis, for example- and no one hospital can be equally equipped and developed to suit all needs, or to specialise equally in all subjects. Fracture treatment is a single example. It is now a highly specialised service, coupled with the modern aim of total rehabilitation and re-employment. A fracture may be mended in a local hospital, and all the associations of habit and local interest may foster recourse to the local hospital in such cases. But the plain fact may be that ten or twenty miles away is a highly developed fracture centre, specialising in total rehabilitation of this kind of case, which the local people ought to be able regularly to use in preference to their "own" hospital The difference between the facilities which the two hospitals can offer may determine whether or not the patient ultimately makes a full recovery from the effects of his injury. The time has come when the hospital services have to be thought of, and planned, as a wider whole, and the object has to be that each case should be referred not to one single hospital which happens to be " local" but to whatever hospital concentrates specially on that kind of case and can offer it the most up-to-date technique.
Many services are also rendered by local authorities and others in special
clinics and similar organisations, designed for particular groups of the population
or for particular kinds of ailment or medical care. These are, for the most
part, thoroughly good in themselves, and they are used with advantage by a great
many people in a great many districts. But, owing to the way in which they have
grown up piecemeal at different stages of history and under different statutory
powers, they are usually conducted as quite separate and independent services.
. There is no sufficient link either between these services themselves or between
them and general medical practice and the hospitals.
In short, general medical practice, consultant and specialist opinion, hospital
treatment, clinic services for particular purposes, home nursing, midwifery
and all other branches of health care need to be related to one another and
treated as many aspects of the care of one person's health. That means that
there has to be somewhere a new responsibility to relate them, if a service
for health is to be given in future which will be not only comprehensive and
reliable .but also easy to obtain.
Last, but not least, personal health still tends to be regarded as something to be treated when at fault, or perhaps to be preserved from getting at fault, but seldom as something to be positively improved and promoted and made full and robust. Much of present custom and habit still centres on the idea that the doctor and the hospital and the clinic are the means of mending ill-health rather than of increasing good health and the sense of well-being. While the health standards of the people have enormously improved, and while there are gratifying reductions in the ravages of preventable disease, the plain fact remains that there are many men and women and children who could be and ought to be enjoying a sense of health and physical well-being which they do not in fact enjoy. There is much sub-normal health still, which need not be, with a corresponding cost in efficiency and personal happiness.
These are some of the chief deficiencies in the present arrangements which, in the view of the Government, a comprehensive health service should seek to make good.
The idea of moving on to the next stage has been developing for some time. There is much agreement on what the aim should be, if not on the method of achieving it. The general idea of a fuller and better co-ordinated service has been supported in most knowledgeable quarters-professional and lay -by official Commissions and Committees, by interested public or voluntary organisations and persons, in reports, in articles and in books, before the war and during it. Some reference to these is included in Appendix B, where a summary is also given of the preliminary discussions and events which have preceded the issue of this Paper.
There are two possible ways of approaching the task. One, with all the attraction of simplicity, would be to disregard the past and the present entirely and to invent ad hoc a completely new organisation for all health requirements. The other is to use and absorb the experience of the past and the present, building it into the wider service. The Government have adopted the latter method, as more in accord with native preference in this country .
There is a certain danger in making personal health the subject of a national service at all. It is the danger of over-organisation, of letting the machine designed to ensure a better service itself stifle the chances of getting one. Yet medical resources must be better marshalled for the full and equal service of the public, and this must involve organisation-with public responsibility behind it. It is feasible to combine public responsibility and a full service with the essential elements of personal and professional freedom for the patient and the doctor; and that is the starting point .of this Paper's proposals. Throughout, the service must be based an the personal relationship of patient and doctor. Organisation is needed to ensure that the service is there, that it is there for all, and that it is a good service; but organisation must be seen as the means, and never far one moment as the end.
Nor should there be any compulsion into the service, either for the patient or for the doctor. The basis must be that the new service wi1l be there for everyone who wants it- and indeed will be so designed that it can be looked upon as the normal method by which people get all the advice and help which they want; but if anyone prefers not to use it, or likes to make private arrangements outside the service, he must be at liberty to do so. Similarly, if any medical practitioner prefers not to take part in the new service and to rely wholly on private work outside it, he also must be at liberty to do so.
The proposed service must be "comprehensive" in two senses-first, that it is available to all people and, second, that it covers all necessary forms of health care. The general aim has been stated at the beginning of this Paper.
The service designed to achieve it must cover the whole field of medical advice and attention, at home, in the consulting room, in the hospital or the sanatorium, or wherever else is appropriate-from the personal or family doctor to the specialists and consultants of all kinds, from the care of minor ailments to the care of major diseases and disabilities. It must include ancillary services of nursing, of midwifery and of the other things which ought to go with medical care. It must secure first that everyone can be sure of a general medical adviser to consult as and when the need arises, and then that everyone can get access- beyond the general medical adviser- to more specialised branches of medicine or surgery. This cannot all be perfected at a stroke of the pen, on an appointed day; but nothing less than this must be the object in view, and the framing of the service from the outset must be such as to make it possible.
For a time some aspects of the new service will be less complete than could be wished. A full dental service for the whole population, for instance, including regular conservative treatment, is unquestionably a proper aim in any whole health service, and must be so regarded. But there are not at present, and will not be for some years, enough dentists in the country to provide it. Until the supply can be increased, attention will have to be concentrated on priority needs. These must include the needs of children and young people and of expectant and nursing mothers. The whole dental problem is a peculiarly difficult one, and a Committee under the chairmanship of Lord Teviot has been set up by the two Health Ministers to consider and report on it.
There may be similar (though perhaps less acute) difficulties in getting a full service in ophthalmology. But these, like the difficulties in dentistry, must be treated rather as practical problems arising in the operation of a new service than as matters of doubt in planning the service's scope and objectives.
The inclusion of the mental services also presents some difficulty, until a full re-statement of the law of lunacy and mental deficiency can be undertaken. Yet, despite the difficulty, the mental health services should be included. The aim must be to reduce the distinctions drawn between mental ill-health and physical ill-health, and to accept the principle declared by the Royal Commission on Mental Disorder that "the treatment of mental disorder should approximate as nearly to the treatment of physical ailments as is consistent with the special safeguards which are indispensable when the liberty of the subject is infringed."
There is one common misconception about the meaning of a "comprehensive" health service. Such a service emphatically has to comprehend all kinds of personal health treatment and medical advice. But that does not mean that there should be no other Government or private activity involving the use of the medical expert, or having any bearing upon health. There are many specialised and separate forms of undertaking- such as the supervision of industrial conditions- which may affect health and which may require the medical expert as much as they require the engineering or the legal or any other expert, but which cannot, simply for that reason, be regarded as necessarily part of the personal health service.
The present system of factory medical inspection and the arrangements made for the employment by industry of "works doctors" (described in Appendix A) are cases in point. From the point of view of industrial organisation, of working conditions in factory, mine and field, there is a continuing and specialised need for enlisting medical skill in ensuring a proper working environment, a proper allocation of types of work to the individual worker's capacity, a proper standard of working hygiene and a general protection of the worker's welfare. The enlistment of medical help for these purposes is part of the complex machinery of industrial organisation and welfare, and it belongs to that sphere more than to the sphere of the personal doctor and the care of personal health- which centres on the individual and his family and his home. What matters is that such specialised services, where they exist, should not impair the unity of personal health service on which he will rely; that, where there arises- perhaps first detected in work place or factory-a question of personal medical treatment or consultation (beyond recognised incidental services of the kind described in Appendix A) this should be regarded as a matter for the personal health service.
Another example is that of the school medical service. Very similar considerations apply. It should be the part of any school medical arrangements to refer the school child for any and every form of personal doctoring to the general health service- the family doctor and other resources which that service will provide. But that does not mean that as an integral part of the educational organisation the education authorities should not have their own arrangements for looking after medical and welfare conditions in the schools, for maintaining inspection and supervision of the child in the school group, and indeed for providing, until the new health service is fully developed, such forms of treatment as may be needed by the children and may not otherwise be available for them.
The proper continuance of environmental and preventive services in school and industry may well be coupled with the habit of using for those services doctors who are also engaged in the personal health service-so that there is a continuous blending of experience in both kinds of work. With the bulk of the profession engaged, part-time or whole-time, in the new service, this process can be more readily accelerated and arrangements more readily made for proper post-graduate training of general practitioners who are going to engage in industrial or other specialties appropriate to general practice. Similarly, while matters like industrial organisation require medical as well as other experts in the central departments of Government which deal with them, there is room for a better linking of the expert staffs so engaged with the expert staffs whose time is wholly or mainly given to the personal health and treatment services.
There is also another point on which it is necessary to be clear. The subject of health, in its broadest sense, involves not only medical services but all those environmental factors- good housing, sanitation, conditions in school and at work, diet and nutrition, economic security, and so on-which create the conditions of health and prepare the ground for it. All these are fundamental; all of them must receive their proper place in the wider pattern of Government policy and of post-war reconstruction. But they are not the subject of this particular Paper, which is concerned exclusively with the direct services of personal health care and advice and treatment. No matter how successful the indirect influence of the environmental services may become in promoting good health and reducing sickness, there will remain a need for medical and nursing and hospital services.
The rest of this Paper is concerned with the Government's proposals for bringing
the new comprehensive service into being. First, the administrative structure,
central and local, will be considered. Then each of the main branches- the hospital
and consultant services, the general practitioner service, and the local clinic
and other services- will be discussed in some detail. After that, the special
circumstances of the service in Scotland will be reviewed, and the Paper will
end with a general summary of what is proposed.
At this stage, therefore, before the more detailed part of the Paper begins,
it may make subsequent reading easier if the broad shape of the proposals is
indicated.
It is proposed that the new responsibility for providing the comprehensive service shall be put upon an organisation in which both central and local authority take part, and which both centrally and locally is answerable to the public in the ordinary democratic manner. Central responsibility will lie with the Minister, local responsibility will lie with the major local government authorities (the county and county borough councils) operating for some purposes severally over their existing areas and for other purposes jointly over larger areas formed by combination. Both at the centre and locally, special new consultative bodies are proposed, for ensuring professional guidance and the enlistment of the expert view. At the centre, in addition, a new and mainly professional body is to be created, to perform important executive functions in regard to general medical practice in the new service.
The new joint authorities, i.e. the counties and county boroughs in combination, will be responsible (over suitable areas determined by the Minister after consulting the local interests) for assessing the needs of those areas in all branches of the new service and for planning generally how those needs should best be met. They will do this in consultation with the local professional bodies referred to, and they will submit their proposed arrangements to the Minister for final settlement in each case.
Then, when each area plan is settled, the joint authority will have the duty of securing all the hospital and consultant services covered by it, by their own provision and by arrangements with the voluntary hospitals in the area, and they will for this purpose be responsible in future for the existing local authority hospitals of all kinds. The individual county and county borough councils making up the joint authority will usually be responsible for local clinic and other services within the general framework of the plan, but there will be special provision for the child welfare services- to ensure a close relation between them and child education. General medical practice in the new scheme will be specially organised, largely as a national and centralised service, but with proper links with the local organisation to relate it to the hospitals and to other branches of the service as a whole. There will be certain variations of these proposals for Scotland, to suit the differing circumstances there.
The new service will be free to all apart from possible charges where certain appliances are provided. (The payment of disability benefits during sickness- and related questions as to the adjustment of benefit during periods of free maintenance in hospital- are matters which belong to the Government's proposals on social insurance, to be published in a later Paper). The costs of the new health service will be borne partly from central funds, partly from local rates and partly from the contributions of the public under any scheme of social insurance which may be brought into operation.
If people are to have a right to look to a public service for all their medical needs, it must be somebody's duty to see that they do not look in vain. The right to the service involves the corresponding duty to see that the service is provided. Some organisation has to carry that duty, and as the service is to be publicly provided this involves responsible public authority in some form.
With the exception of medical benefit under the National Health Insurance scheme the public health services of this country have from the outset been administered by some form of local government organisation. In the case of medical benefit the administrative body- the Insurance Committee- though operating over a local area, the county or county borough, is not answerable to a local electorate but consists in the main of persons representing Approved Societies which are non-territorial units. Apart from this exception, in a long series of Public Health Acts and similar measures Parliament has placed the prime responsibility for providing the health services- hospitals, institutions, clinics, domiciliary visiting, and others- on local, rather than central, authority. This system recognises that, in intimate and personal services of this kind, local factors such as distribution of population, transport facilities, the nature of local employment and vocation (and generally local tradition and habit) have a profound influence on detailed planning.
The absorption of the existing services into a comprehensive service does not materially alter this situation. To uproot the present system and to put into the hands of some central authority the direct administration of the new service, transferring to it every institution and every piece of present organisation, would run counter to the whole historical development of the health services; and from a practical point of view a step of this kind would certainly not contribute to the successful and early introduction of the new service. Changes, some of a drastic kind, in the present organisation of local areas and administrative bodies will be necessary. For reasons discussed later the organisation of the services of general practitioners will call for a higher degree of central control than other parts of the service. But there is no case for departing generally from the principle of local responsibility, coupled with enough central direction to obtain a coherent and consistent national service.
Central responsibility must rest with a Minister of the Crown, answerable directly to Parliament and through Parliament to the people. The suggestion has been made that, while this principle should be accepted, there is a case for replacing the normal departmental machinery by some specially constituted corporation or similar body (perhaps largely made up of members of the medical profession) which would, under the general auspices of a Minister, direct and supervise the service The exact relation of this proposed body to its Minister has never been defined, and it is here that the crux lies. If in matters both of principle and detail decision normally rested in the last resort with the Minister, the body would in effect be a new department of Government- no less than (say) the National Health Insurance Commission, which was later replaced by the Ministry of Health, or the present Board of Control or Prison Commission. If, on the other hand, certain decisions were removed from the jurisdiction of the Minister (and consequently from direct Parliamentary control) there would be need to define with the utmost precision what those decisions were. Clearly they could not include major questions of finance. Nor could any local government authorities responsible for local planning or administration reasonably be asked to submit to being over-ruled by a body not answerable to Parliament.
Nevertheless, the Government recognise that the provision of a health service involves technical issues of the highest importance and that in its administration, both centrally and locally, there is room for special devices to secure that the guidance of the expert is available and does not go unheeded. Otherwise the quality of the service is bound to suffer. They also recognise that; in a service which will affect the professional life of almost every doctor, there is need within the administrative structure for some largely professional body which can concern itself with the professional welfare of doctors who take part in the service. The proposals which follow are designed to meet this situation.
There will be direct responsibility to Parliament, therefore, resting on the Minister of Health and the Secretary of State for Scotland, respectively.
At the side of the Minister, but independent of him, there will be created a special professional and expert body It might be called the Central Health Services Council, and it will be a statutory body.
Its function will be to express the expert view on any general technical aspect of the service. There cannot be dual responsibility for the service and so it will be consultative and advisory, and not executive. It will be entitled to advise, not only on matters referred to it by the Minister, but on any matters within its province on which it feels it right to express its expert opinion, and the Minister- quite apart from any other publication of the Council's views and proceedings which he may from time to time make will be required to submit to Parliament annually a report on the Council's work during the year. The Minister, in addition to the regular and general consultation which he will obviously want to maintain with such a body, will refer to it in draft form any general regulations which he proposes to make in the new service on subjects within its expert field.
The constitution of such a body, given statutory recognition as the mouthpiece of expert opinion in the central administration, wil1 obviously new to be considered carefully and in detail with the professional and other organisations concerned. At this stage only the general kind of constitution which might suit its purpose and function can be suggested.
It will, it is assumed, be primarily medical in its make-up, because the main technical aspects of the health service in all its branches will be medical. But it will not be wholly medical; it will need to be able to provide an expert view on many questions- e.g. of hospital administration, nursing, midwifery, dentistry, pharmacy and auxiliary services- which will involve other experts than the physician or surgeon. Yet, to be effective, it must not be too large and unwieldy; nor could much of its varied work be regularly done by the single full Council. The Council itself might consist of about thirty or forty members, representing the main medical organisations (specialist and general), the voluntary and municipal hospitals (with both medical and other representation), medical teaching and professions like dentistry, pharmacy and nursing and midwifery. For any of its special purposes the Council could establish small groups or sub-committees, on each of which it would be possible to introduce additional experts in the particular subject referred- the Council itself, however, retaining an ultimate single responsibility for all views or advice expressed in its name.
The members will be appointed by the Minister in consultation with the professional and other organisations concerned, and the Council will select its own chairman and regulate its own procedure. The Minister will be prepared to provide a secretariat, and the expenses of the Council will be met from public funds.
There will also be set up, for certain specific purposes, a Central Medical Board. This will be in a different category from the Central Health Services Council, inasmuch as it will perform executive functions in the day-to-day working of the general practitioner service, rather than voice opinion on general matters of medical policy.
It is mentioned here only to complete the picture of the central organisation. Its duties and its constitution will need to be referred to in chapter V, when the participation of doctors in the service and the terms and conditions of that participation are considered.
Local organisation is inevitably more complex. The new service has to include
hospitals and institutional services for the sick in general, for mental cases,
for infectious diseases and tuberculosis, for maternity and for every general
and special hospital subject. It has to include the many kinds of service usually
provided in local clinics, a family doctor service and many ancillary services-nursing,
health visiting, midwifery and others. It ranges from the one extreme of highly
specialised services. requiring relatively few centres for the country as a
whole, to the other extreme of services involving a large number of local clinics
and arrangements for care in the individual home.
Suggestions have been made for a completely new kind of local or "regional"
authority- sometimes proposed as a vocational or technical body (like the special
kind of central organisation already mentioned). In so far as those suggestions
would conflict with the principle of public responsibility, they need not be
considered here. Both the principles applied to central organisation-that of
democratic responsibility and that of full professional guidance-must be equally
applied to local organisation.
The present local government system amply embodies the former of these principles -that of democratic responsibility-and the existing local authorities are already responsible for many kinds of personal health service which will :need to be incorporated in the new and wider service in future. It is certainly no part of the Government's intention to supersede and to waste these good existing resources, or needlessly to interfere with the well-tested machinery of local government as it is already known; nor would the record and experience of the existing local authorities in the personal health services justify such a course. On the contrary the Government propose to take as the basis of the local administration of the new service the county and county borough councils. But there are some requirements of the new service which the county and county borough councils cannot fulfil if they continue to act separately, each for its independent area; and changes will be necessary. In particular, for the future hospital service, it will be essential to obtain larger local areas than at present, both for planning and administration. The special needs of this service can be considered first.
Broadly speaking the hospital services, so far as they are publicly provided now, are in the hands of the county and county borough councils, with the exception of isolation hospitals for infectious disease in the counties. The size of counties and county boroughs varies enormously- ranging (without counting London) from Rutland and Canterbury, with populations of some 18,000 and 26,000 respectively, to Middlesex and Birmingham with populations of over 2,000,000 and 1,000,000.
It would be theoretically possible to put upon the council of each county and county borough the duty to provide, or to arrange with other agencies for, the whole range of hospital services. This would impose responsibility for the services on authorities many of which lack the size and resources and administrative organisation to plan and conduct and pay for the service. What is more important, it would leave untouched the demarcation between town and country which is reflected in the system of administrative counties and county boroughs, but which has no meaning in relation to hospital services. The towns largely serve the country in the matter of hospitals. If for purposes of hospital administration they are kept apart by continuing the separate county and county borough basis, the result will be a complicated criss-cross pattern of of "customer" arrangements, since in most areas (particularly those of counties) it will be out of the question to secure the whole range of service- or even the bulk of it- inside the area boundary. These "customer" arrangements will in turn involve complicated administrative arrangements and a mass of financial adjustments between different areas. Alternatively, if the provision of a complete service within each area were attempted, the resulting system would run counter to the whole conception of an ordered pattern of hospital accommodation and could only lead to wasteful competition in hospital building.
The need for larger areas has long been recognised by local authorities in many branches of hospital administration. The many combinations already in existence make this clear; indeed. the very existence of these combinations would in itself give rise to administrative difficulties if it were decided that the new hospital service as a whole was to be in the hands only of the individual county and county borough councils in future.
The essential needs of a reorganised hospital service, based on a new public
duty to provide it in all its branches, are these:
(a) The organising area needs to cover a population and financial resources
sufficient for an adequate service to be secured on an efficient and economical
basis.
(b) The area needs to be normally of a kind where town and country requirements
can be regarded as blended parts of a single problem, and catered for accordingly.
(c) The area needs to be so defined as to allow of most of the varied hospital
and specialist services being organised within its boundaries (leaving for inter-area
arrangement only a few specialised services).
In the majority of the areas of existing authorities none of the three conditions would be met.
It is therefore necessary to decide what the form of authority for these larger hospital areas should be. On this, various alternatives are examined in Appendix C to this Paper. The course most convenient-and indeed, in the Government's view, the only course possible at the present time-will be to create the larger area authorities by combining for this purpose the existing county and county borough councils, in joint boards operating over areas to be settled by the Minister after consultation with local interests at the outset of the scheme. There will be some exceptional cases (the county of London is the most obvious) where no combination is necessary at all; in such cases an existing authority will fulfil both its' own functions and those of the new form of authority-but this will be unusual. Where the new form of joint authority is referred to in the rest of this Paper it should be taken as including any individual council which, in such exceptional circumstances may be acting in the two capacities.
While both planning and administration will usually need to be based on larger areas, this does not mean that a standard-sized area need be, or can be, prescribed for the hospital services. Local conditions- distribution of population, natural trends to various main centres of treatment, geography, transport and accessibility- must determine the size and shape of the optimum area. Sometimes simple combination of a county with the county boroughs within its boundary (ie. the geographical county as a unit) will be sufficient; sometimes the linking of two or three small counties will be needed, sometimes other variations.
Special mention should be made of the isolation hospitals for infectious diseases, because in the counties these hospitals are with few exceptions owned and administered by the minor authorities and not by the county councils, and therefore a decision to transfer them to the new joint authority will not only remove them from their present owners (as with the hospitals of the counties and county boroughs) but will prevent their present owners from retaining even the part interest in them which membership of the new joint authority will afford in the case of the counties and county boroughs. (It is, of course, not practicable to give direct representation on the joint authority to these minor authorities, without at once duplicating the representation of all local government electors who happen to live in a county and not in a county borough.) The case for this absolute transfer of the isolation hospitals has nothing to do with the past record of the minor authorities, nor is it in any way a reflection upon the quality of the work which they have hitherto done. The whole trend of medical opinion has for some time been in favour of treating these hospitals, not primarily as places for the reception of patients to prevent the spread of infection, but as hospitals where severe and complicated cases of infectious disease can receive expert treatment and nursing. The small isolation hospital of the past century is not only uneconomic in days of rapid transport but cannot reasonably be expected to keep abreast of modern methods One result of the new outlook will be the development, in addition to the larger isolation hospital serving the densely populated area, of accommodation for infectious diseases in blocks forming part of the general hospitals. . These considerations all indicate that the infectious disease hospitals must in future form part of the general hospital system.
It may be, as time goes on, that for certain specialised hospital, functions there is room for the development of a few particular centres which would serve national rather than local needs. In this field there may be a case for direct provision or arrangement by the: Government centrally. But such provision or arrangement would be special, and exceptional and need not be considered here as part of the normal organisation of the new service.
As will be seen, when the hospital services are fully considered in chapter IV, the function of the new joint authorities will be to secure a complete hospital and consultant service of all kinds for each of the new and larger areas- partly by their own direct provision and partly by arrangement with voluntary hospitals, and all on the basis of an area hospital plan which they will formulate in consultation with the hospitals and others concerned, and which will require the Minister's final settlement and approval. The existing powers and duties of the present local authorities in regard to hospital services- including tuberculosis, infectious diseases and mental health- will pass to the joint authorities, together with the existing hospitals and other institutions concerned.
Outside the hospital and consultant services- that is, in the kinds. of service appropriately given in local clinics and similar premises, or by domiciliary visiting (like midwifery or home-nursing) -the case for centralising all administration in the one authority over the larger area is not the same, and it is the Government's view that there should be as little upsetting of the existing organisation for these services as is compatible with achieving a unified health service for all. It will not be enough, however, simply to leave all these separate services exactly as they are now. What is essential is that, although still locally conducted with all the advantages of local knowledge and enthusiasm, they should be regarded in future as the related parts of a wider whole and should fit in with all the other branches of a comprehensive service in their planning and their distribution. For this purpose it must be the single responsibility of some authority to plan the whole, although not necessarily to provide the parts, and the obvious authority to do this from the point of view both of its area of operation and of its constitution-will be the new joint authority.
The new joint authority will therefore be charged to examine the general needs of the area from the point of view of the health service as a whole-not only in the hospital services for which it will itself be responsible but also in these more local services It will have the duty of producing, in consultation with the local authorities and others concerned, an area arrangement or plan for a related service of all kinds- and this will need the approval of the Minister. But, within the general framework of the approved plan, the provision and administration of most of the local services including some new kinds of service- will normally rest with the individual county and county borough councils, and the joint authority will be concerned only to watch that the general area arrangement proves to be the right one when put into actual operation, that in fact it works out as intended, and that any subsequent additions to it, or amendments of it, which seems to be required are put in hand and submitted to the Minister.
There are, however, some forms of local clinic service which- although provided
in separate premises so as to make their facilities more accessible -are in
essence out-patient activities of the hospital and consultant services; of which,
in fact, the essential feature needs to be treatment and advice at the consultant
and specialist level, provided by the same consultants and specialists as serve
the hospitals or sanat.oria and are based on them. Obvious examples are the
tuberculosis dispensaries, mental clinics and cancer diagnostic centres.
This kind of service must usually be the responsibility of the same authority
as is responsible for the hospitals and consultants over the larger area- the
" outpost" service going with the parent service of which it ought
to be part. They differ in this respect from the other local services which
belong more to the general practitioner sphere- the maternity and child welfare
clinics, school medical services, clinics for general dental or ophthalmic treatment
and advice, arrangements for midwifery or home nursing or health visiting, and
similar activities. These certainly need to be linked with the consultants and
the hospitals for difficult cases (as the area plan will provide), but they
do not have to be directly administered with the hospitals, and the counties
and county boroughs are normally appropriate areas for their operation.
One case requires special mention. The Local Government Act of 1929 initiated the policy of securing that local child welfare and education responsibilities should be brought closer together, and that the local education authority in each area should as often as possible be the welfare authority. In the view of the Government the time has come to carry that policy to its full conclusion. The destination of the present welfare functions (now exercised partly by county and county borough councils, partly by other local authorities within the counties) will therefore depend upon the decisions taken by Parliament upon the educational functions of these various authorities under the current Education Bill. When the relationship between the county and county borough councils and the minor authorities in regard to education has been settled something on broadly similar lines can be adopted as the arrangement between these authorities in regard to child welfare. This does not mean, however, that this service will be excluded from the general area planning of the health services by the new joint authority. It affects only the local operation of the service.
In dealing with the clinic and other local services generally it will not be wise to prescribe an absolutely hard-and-fast rule to be applied in all circumstances. It may be that in a particular county or county borough of exceptionally small area or resources a case for transferring local functions to the larger joint authority will be overwhelming, in the interests of an efficient service. In another area, for some particular local reason, even some of the dispensary or out-patient functions just described as belonging properly to the hospital and consultant sphere may be found more suitable for discharge by an individual county or county borough. A rigid and universal rule about the allocation of the various services would preclude a good common-sense arrangement on which all were agreed in a particular case. For reasonable flexibility, the detailed allocation of services will be left to be finally settled as best suits each case, but observing the general demarcation described in the absence of any exceptional reason to do otherwise.
This can be achieved in the following way. The new joint authority, in preparing its arrangement or plan for the whole health service of its area and submitting it to the Minister, will include proposals as to the exact allocation of responsibility for providing the various local services covered- i.e., proposals as to which services should be provided by the county and county borough councils severally and which in combination through the joint authority itself In all cases the hospital and consultant services will be required to be the joint authority's responsibility; in all cases the child welfare service will be required to lie with the same authorities as carry responsibility for education under the new Education Bill; in between these two fixed points the allocation of clinic and other local services can vary to suit exceptional needs, but with the normal rule as stated above-those services which belong essentially to the consultant sphere, like tuberculosis dispensaries, going to the joint authority, while those which do not will rest with the several counties and county boroughs making up that joint authority. The decision, as in other proposals of the area plan, will rest finally with the Minister in each case.
Special considerations will apply to the "family doctor" or general practitioner branch of the new service, which is reviewed in detail in chapter V. The organisation there suggested will be one which is largely central and national and only partly local. Those main aspects of the service which affect the individual practitioner-including the terms of his participation in the service, the protection of his professional interests and the general personal relationship of the doctor to the new public service-will be governed by central arrangements applicable to the country as a whole. On the other hand it is not proposed that there shall be any question of excluding this branch of the health service from the concern of the new joint authorities to plan, with the Minister, for the requirements of their areas, and the locally planned arrangement of the new service will in each case have regard to resources and needs in the sphere of general practice as well as in hospital and other facilities.
Apart from these local functions in the general practitioner service, there will also be the provision and maintenance of special Health Centres for the grouped medical practice of some of the doctors in the new service, in areas where it is decided to try this form of practice. This, as a function not belonging to the hospital and consultant sphere, will be appropriate to the individual county and county borough councils.
An important task, therefore, of the new joint authorities will be to unify and to co-ordinate the service. They will be the instrument through which, with the Minister, a rational and effective plan for all branches of the health service in their respective areas is secured. It will be their responsibility to see that their proposals provide for all that the inhabitants of their areas will require, to submit the proposals to the Minister as an area plan for final settlement, and subsequently to keep the plan up to date as requirements develop and to bring before the Minister any necessary changes if the plan is found not to be working out in the manner designed. They will not themselves provide and operate all the services for which the approved area plan provides; nor is there any need for them to do so. They will usually administer themselves only those branches of the service which demand direct administration over the larger area as a whole, and not those which can suitably be administered (when once a unified plan is settled) on a more localised basis. In short, the existing major local authorities will combine to secure, with the Minister, a unified general plan of the whole service for their grouped areas; they will then combine to carry out those parts of this plan which demand a single administration over all their areas together; but they will be charged individually to carry out those parts which can be separately and locally administered.
In order to secure good professional guidance in the local administration of the new service a special local professional organisation will be established to advise and guide and, if necessary, to initiate new suggestions.
The need to ensure technical guidance-by creating special professional and expert bodies for the purpose- offers scope for innovation in local government method and justifies it. What is wanted is that there should be, in each area, some new provision for the organised expression of the views of the expert and for ensuring that the local administration can get the fullest advantage from it. The simplest way will be to apply to local administration the kind of consultative machinery suggested for central administration; ie. to have in each case a local expert technical body, which might be known as the Local Health Services Council.
The purpose of these bodies will be to provide locally the same kind of medium for expressing the expert point of view on technical aspects of the service as has been proposed at the centre. The appropriate area for each will be the larger areas of the new joint authorities already discussed. Their functions will be not only to advise on matters referred to them by the joint authorities or other local authorities in the area, but also to initiate advice on any matters within their expert province on which they think it right to do so and if they wish, to submit their views and advice not only to the joint authority or other local authorities concerned with the matters in question, but to the Minister. Apart from its ordinary consultation, the joint authority will be required to consult them on the area plan for the local health service which it submits to the Minister, and on subsequent material alterations or additions to that plan.
The constitution and membership of these bodies will call for detailed consideration later. Provided that all the professional interests are fairly represented, there is no reason why the pattern should be precisely uniform throughout the country and the most convenient course will probably be to provide for the matter by way of local schemes approved by the Minister.
It is sometimes suggested that the best method of linking the expert point of view with the direct administration of the service would be to include in the local administrative authorities themselves, and in their committees, a proportion of professional members appointed for the purpose by. the appropriate professional organisations, with or without voting powers. Arguments can be adduced both for and against a system of this kind, but on balance the Government feel that the risk of impairing the principle of public responsibility-that effective decisions on policy must lie entirely with elected representatives answerable to the people for the decisions that they take-outweighs any advantages likely to accrue.
The term "hospital services" is used in this Paper to include all forms of institutional care of every kind of sickness and injury. It comprises the whole range of general and special hospitals, including infectious disease hospitals, sanatoria for tuberculosis, accommodation for maternity cases and for .the chronic sick, and for rehabilitation; and it comprises also the usual ancillary hospital services for pathological examinations, X-ray, electro-therapy, ambulances and other purposes. Out-patient no less than in-patient treatment is included. It will be the aim to restore the out-patient work of the hospitals as much as possible to its proper field of specialist and consultant care, when the existence of a general "family doctor" for all has been secured.
The mental hospitals and mental deficiency institutions have also to be included in the scope of the hospital and consultant part of the new service, under the care of the new joint authorities. They will present many problems of their own, calling for some degree of special organisation to fit them. The present general review does not attempt to deal with this special subject, and the discussion which follows is directed mainly to the more general range of hospital and consultant services -although much of it can obviously be applied to the mental health services as well.
The present hospital services are described in Appendix A. They present two
main problems. The first is to bring together over suitable areas the activities
of the various separate and independent hospitals, to ensure that all the different
kinds of special and general hospital treatment are so linked that the individual
can get the best of each. The second is to enable the two quite different hospital
systems (the voluntary hospitals and the municipal hospitals) to join forces
in future in a single service.
The proposed joint authority, operating over a large area, has been described.
It will be that authority's responsibility, with the Minister, to see that a
full hospital service of all kinds is available for people in its area. But
the authority neither will, nor will need to, provide the whole service itself.
The conception of a public authority discharging its duty by contracting with others for the provision of services has long been familiar. As early as 1875 local authorities were enabled both to provide hospitals themselves and to enter into agreements with other hospitals for the reception of people from their district. Later legislation followed similar lines; in recent Acts dealing with special services (e.g., the Midwives Act, 1936, the Cancer Act, 1939) the use of voluntary agencies has been clearly contemplated. There are already large numbers of agreements under which existing local authorities arrange for accommodation in hospitals, sanatoria, dispensaries, or clinics, sometimes belonging to other local authorities and sometimes to voluntary agencies.
The facts of the existing accommodation in voluntary and municipal hospitals (given in Appendix A) make it clear that without the collaboration of the voluntary hospitals it would be many years before the new joint authorities could build up a system adequate for the needs of the whole population; so that, from that point of view alone, the co-operation of the voluntary hospitals is a necessity. But the matter cannot be regarded from that point of view alone. The voluntary hospital movement not only represents the oldest established hospital system of the country, but it attracts the active personal interest and support of a large number of people who believe in it as a social organisation and who wish to see it maintained side by side with the hospitals which are directly provided out of public funds. It is not merely that the best of the voluntary hospitals have, in a degree so far unsurpassed, developed specialist and general hospital resources which they will be able at once to make available, while most of the rest of the voluntary hospitals have experience and an existing organisation which it will be obviously sensible to enlist. It is certainly not the wish of the Government to destroy or to diminish a system which is so well rooted in the good will of its supporters.
Yet the acceptance by the community of responsibility for a service for all might affect fundamentally the position of the voluntary hospitals. A new universal public hospital service might have the gradual effect of undermining the foundations on which the voluntary hospitals are based. If this it not to happen, a way has to be found of combining the general responsibility of the new joint authority for the service with the continued participation in that service of the voluntary movement as such; a way, in fact, of securing a whole service under one ultimate public responsibility without destroying the independence and traditions to which the voluntary hospitals attach value. The Government believe that this can be done, and in settling the details arising out of the following proposals they will welcome the help and the suggestions of the voluntary hospital representatives in securing it.
The joint authority's first task will be to assess in detail the hospital needs
of its area and the hospital resources available to its area.
This it will do in close consultation with the local expert body, the Local
Health Services Council. It is hoped that the hospital surveys, referred to
in Appendix B and now nearing completion, will be of valuable help in this.
The authority's next task, in consultation with the local expert body and other local interests (including the voluntary hospitals and, where appropriate, the medical schools) will be to work out a plan of hospital arrangements for its area, based on using, adapting and, where necessary, supplementing existing resources. The object of the plan will be to arrive at the right quantities, kinds and distribution of hospital facilities for the area; to settle where, how, and by what hospitals, each branch of hospital treatment can best be secured; to produce a balanced scheme in which all the necessary specialist facilities in medicine and surgery (including fracture and orthopaedic, gynaecological, paediatric, ophthalmic, psychiatric and others) are provided in due proportion, together with general accommodation for cases, acute or chronic, of the ordinary type. The plan must ensure that the various special treatments are concentrated in centres competent and convenient to provide them, and not dispersed haphazard in uneconomic and overlapping units; that proper linking of services is secured by relating the work of special and general hospitals; that arrangements are at hand for the transfer of patients to the hospitals best suited to their medical needs; and that the skill of the consultant staffs of the various hospitals taking part can be used to the maximum advantage of the area as a whole.
It will be the aim of the authority to make its area (which will have been determined with this in view) as self-sufficient as possible in hospital and consultant services. But where it is obviously more sensible. as in some of the rarer services, the plan will provide for certain services by agreed arrangements outside the area.
The basis of the plan will be that the joint authority will secure the necessary service for its area partly through its own hospitals and institutions, partly through contractual arrangements made with voluntary hospitals for the performance of agreed services set out in the plan, to a minor degree (where necessary) through arrangements with the joint authorities of other areas.
The plan will then be submitted to the Minister for approval, and will have no validity until so approved. The Minister, able to look at the country as a whole and at the effect of the local plans one upon another, will have power to modify or supplement the plan before giving his approval. He will consider all objections or representations made to him by local organisations (including the Local Health Services Council), voluntary hospitals or others.
The plan, when approved, will be open to amendment at any time, and the Minister will be empowered to call on the joint authority to reconsider the plan and submit fresh proposals. The procedure for amending the plan will be the same as for its original preparation and will iinclude all necessary local consultation.
No voluntary hospital will be compelled to participate. Its participation will rest on a contract between it and the joint authority to provide the services specified in the plan. Where it agrees to participate, it will- like each of the authority's own hospitals- have to observe certain general conditions, just as it will obtain certain advantages.
These conditions will be settled centrally, for the country as a whole, and they will then become the conditions on which exchequer grant will be payable.
In framing the conditions the Minister will seek the advice of the Central
Health Services Council; but the more important conditions will relate to subjects
such as the following:
(a) each hospital will be required to maintain the services which under the
approved hospital plan it undertakes to maintain, and generally to comply with
the plan;
(b) each hospital will observe certain national requirements such as the Rushcliffe
or Taylor rates and conditions for its nursing and midwifery staff and the recommendations
of the Hetherington Committee for its domestic staff;
(c) in appointing senior medical and surgical staff each hospital will conform
with any national arrangements adopted for regulating appointments and remuneration;
(d) each hospital will be open to visiting and inspection, in respect of its
part in the public service, under arrangements laid down centrally;
(e) in the voluntary hospitals conditions to secure reasonable uniformity in
accounts and audit will probably be necessary so far as they take part in the
new service. The presentation of accounts of municipal hospitals is already
largely subject to central direction.
As already emphasised, it is the aim of the Government to enable the voluntary hospitals to take their important part in the service without loss of identity or autonomy. But it is essential to this conception that the hospitals should still look substantially to their own financial resources, to personal benefactions and the continuing support of those who believe in the voluntary hospital movement. So long, and so long only, can they retain their individuality. If once the situation were to arise in which the whole cost of the voluntary hospitals' part in the public service (a service designed for the whole population) was repaid from public money, or indeed in which it was recognised that public funds were to be used to guarantee those hospitals' financial security, the end of the voluntary movement would be near at hand.
On this footing, the financial relation between the joint authority and the individual voluntary hospital must be that of an agreement to pay a specified sum in return for services rendered or to be rendered, and this should not be assessed as a total reimbursement of costs incurred. Whether the sum will be calculated in terms of beds or occupied beds, or otherwise, is for the moment immaterial. In order to avoid a large number of individual bargains, and the risk of competitive bargaining leading to undesirable results, it will be convenient for standard payments, in respect of different kinds of hospital service which involve different levels of expense, to be settled centrally. These payments will be made by the joint authorities and will fall on local rates, assisted by exchequer grant.
In addition, both the municipal and the voluntary hospitals will receive a direct grant from central funds which will include the share, attributable to hospital services, of any sum allocated towards the cost of the comprehensive health service from the contributions of the public to any scheme of social insurance. So far as this sum represented contributions by potential patients of hospitals it could fairly be said that the Government would have collected money which might otherwise have been paid to the hospitals direct, and that the proposed grant would thus restore the balance. This grant could be based on the number of beds provided by each hospital, but in the case of voluntary hospitals it would be feasible, if so desired, to regard the aggregate of their share of the payments as a central pool from which payments to individual hospitals could be varied according to the needs and resources of each.
In either case it will be the Minister's responsibility to see that the conditions of the grant are fulfilled. If the idea of a variable grant to the voluntary hospitals is adopted, the Minister will be prepared to be guided in questions of relative need by some suitable body representing the hospitals, though the final responsibility and decision must remain with him.
Particular regard will need to be given, in connection with the area plans, to the position of hospitals used for the clinical teaching of medical students, and the question of financial assistance in respect of teaching work will be reviewed when the report is available of the Committee on Medical Schools now sitting under the chairmanship of Sir William Goodenough.
In a service of this magnitude, in which hundreds of hospitals under different and independent managements will be taking part, the problem of inspection is a difficult one. Apart from special inspection in cases of difficulties arising or changes in contemplation, routine inspections-at not too frequent intervals-would serve the double purpose of bringing to notice defects of organisation or management and, what is equally important, of enabling individual hospitals to be kept in touch with the latest practice and ideas. The foundation of any inspectorate must clearly be a team of highly qualified medical men, but the inspectors need not all be persons employed whole-time on this work; from many points of view there are advantages in employing on a part-time basis medical men or women of distinction in various branches of professional work or medical administration. In addition to doctors, there is scope for experts of various kinds for dealing with an organisation so varied and complex as a modern hospital. Hospital administrators, nurses, catering experts and others should find a place.
A solution would be the appointment by the Minister of a body of persons of
the types mentioned, some of whom would be on a whole-time and others on a part-time
basis. These appointments could be made with the advice of the Central Health
Services Council and for convenience those appointed might be grouped in suitable
panels operating over different areas of the country. The selection of the part-time
doctors could be partly from those associated with consultant practice and voluntary
hospitals and partly from those with experience of municipal hospitals, as in
the case of those who are already conducting on the Minister's behalf the survey
of hospital resources referred to in Appendix B. In cases of importance the
inspectors could, again like the hospital surveyors, work in pairs.
The system of inspection must take account of the fact that the new joint authorities,
no less than the Minister, will have a responsibility for the hospital service
as a whole in their respective areas. The arrangements are intended to serve
the double purpose. Inspectors' reports on any hospital will be available both
to the Ministry and to the joint authority, and it will be open to the latter
to ask for a special inspection if it thinks it desirable. Where in the past
contractual arrangements have been made between a local authority and a voluntary
hospital, special provision has not uncommonly been made for a right of entry
for the authority's medical officer. There would be nothing to prevent similar
arrangements being locally agreed under the system now proposed. but normally
a more general system of the kind described will better serve the purpose in
view.
A main object of the new arrangements will be to ensure all kinds of consultant
and specialist advice and treatment to all who need it. This part of the service
will be best and most naturally based on the hospital services. in the wide
sense in which these have been defined.
This means that it will become one of the duties of the joint authority to ensure
that, through the various hospitals taking part, there will be provided an adequate
consultant service available to all general practitioners in the service. It
will do this, as in other branches of the hospital service, partly by its own
direct arrangement and partly by contracting with the voluntary hospitals. In
the latter case it will be for the authority to agree with a voluntary hospital
for the provision by the latter of consultant services both at the hospital
and- where necessary- by visits to a clinic or Health Centre or the patient's
home. The hospital will itself enter into the necessary engagements with the
consultants and specialists concerned. The local service payments to the hospitals,
already mentioned, can be based on the assumption of a consultant staff properly
remunerated to enable the hospital to fulfil the tasks which it has undertaken
to perform.
Before proposing in detail the form of a consultant service the Government are awaiting the report of Sir William Goodenough's Committee on Medical Schools. But it is clear that there are certain general considerations of which account must be taken in devising the new service.
The need is twofold - more consultants, and a better distribution of them. Apart from distribution, there are not yet enough men and women of real consultant status and one of the aims will be to encourage more doctors of the right type to enter this branch of medicine or surgery and to provide the means for their training. As to distribution, the need is for a more even spread. The main consultant facilities now are inevitably concentrated at the medical teaching centres. The consultant service still needs to be organised with the teaching centre as its focus, but the service must be spread over a wider area by enabling and encouraging consultants taking part in it to live and work farther afield. Apart from the main effect of greater accessibility to the public, this will also have a beneficial effect upon general medical practice over larger areas-where the habitual presence and services of consultants will serve as a means of continuous postgraduate education.
The consultant taking part in the service must be associated with his particular hospital or hospitals on a much more regular basis -and with more regular attendances and duties - than is often the case now, when he is regarded as merely "on call." It will often be desirable that the consultant's association should be with more than one major hospital, so as to enable the sharing of a common consultant staff to become an effective link between hospitals. The consultant's function will be normally one of regular and frequent visiting of these hospitals, both for in-patient and for out-patient consultation; also of properly arranged visiting of outlying "general practitioner" hospitals, which need to be linked with the major hospitals; and - for certain consultants as circumstances may require -of visiting Health Centres and clinics, and, in case of need, the patient's home, at the request of the general practitioner.
For this sort of duty the proper and regular remuneration of consultants, through the hospitals with which they are associated, will become essential. This remuneration, and the engagements entered into in respect of it, can be on either a full-time or a part-time basis (and might well include part-time engagements with more than one hospital). There will be no need to make either whole-time or part-time appointment a universal rule.
The conditions, including the financial terms, on which consultants undertake work on a whole-time or part- time basis will be a matter for arrangement by the hospitals, voluntary or municipal, which offer the appointments; but in order to avoid anomalies as between hospital and hospital and between area and area some central regulation of scales will be required.
Some degree of control of the discretion of individual hospital authorities will be required in appointments to senior clinical posts. Under existing practice a danger of "in-breeding" has been commonly recognised, and while it is important that the ultimate responsibility for an appointment should rest unmistakably with the body of persons conducting the hospital's affairs, it will be necessary to consider a system under which an expert advisory body recommends a number of suitable candidates from which the hospital authority makes the final choice. The necessary machinery could be organised in a variety of ways. It might consist of a number of advisory panels, working over regions based, broadly, on the medical teaching centres and representing both the consultant members of the profession and the medical teaching organisations. One or more representatives of the appointing hospital could join the panel dealing with the sifting of candidates for appointment.
The arrangements for general medical practice in the comprehensive service - ie. for ensuring a personal or family doctor for everybody - present the most difficult problem of all. This is partly because this will be the frontline of the service, the first source of help on which the individual will rely and one involving a close personal relation between doctor and patient. In addition, although the provision of medical benefit under National Health Insurance covers over twenty millions of persons and has afforded much experience of the working of a public general practitioner service, the widening of public responsibility to cover the whole population and the need to fit the general practitioner into a comprehensive service will create new problems and will make it necessary to reconsider, without preconception, the whole of the existing arrangements.
If the service is to be free to the people for whom it is provided, the doctors taking part in it will look to public funds for their remuneration. They must, therefore, be in some contractual relationship with public authority, which in turn must be able to attach such conditions as will ensure that the services which the people get are the services which they need (and for which they will be paying in taxation and otherwise) and that they can get them where and when they need them. The State must, therefore, take a greater part in future in regard to general medical practice.
The method of embodying general medical practice in a national service must observe two principles. The first, which mainly concerns the patient, is that people must be able to choose for themselves the doctor from whom they wish to seek their medical advice and treatment, and to change to another doctor if they so wish. Freedom of choice is not absolute now; it depends on the number and accessibility of doctors and on the fact that there is a limit to the load which anyone doctor can or should take on. But the present degree of freedom must not be generally diminished, and the fact that public organisation ensures the service must not destroy the sense of choice and personal association which is at the heart of "family" doctoring. The second principle, which mainly concerns the doctor, is that the practice of medicine is an individual and personal art, impatient of regimentation. Whatever the organisation, the doctors taking part must remain free to direct their clinical knowledge and personal skill for the benefit of their patients in the way which they feel to be best.
One method would be to abandon entirely the present system, on which National Health Insurance has been based, and to substitute for it a system under which all doctors taking part would become the direct employees of the State or of local authorities and would be remunerated by salary. As a problem of administration, there would be no insuperable difficulty in organising a scheme of this kind. But this is a highly controversial question, on which opinions are sharply divided. Many experienced and skilled doctors would be unwilling to take part in a service so conceived. They would hold that it infringed the second of the two principles just stated, and that if they became the salaried servants whether of the State or of local authorities, they would lose their professional freedom and be fettered in the exercise of their individual skill. Other doctors, with an equal right to be heard, would welcome a salaried service, believing that it would relieve them from business anxieties and enable them to devote themselves more freely to the practice of their profession. Lay opinion is similarly varied.
The Government have approached the question solely from the point of view of what is needed to make the new service efficient. Some of the proposals made in this Paper involve forms of medical practice for which present methods of payment are inappropriate, if not unworkable. Where this is so, remuneration by salary or its equivalent is suggested. A universal change to a salaried system is not however, in the Government's view, necessary to the efficiency of the service. They consider that to make, unnecessarily, so total and abrupt a change in the customary form of general medical practice would offend against the principle- earlier stated- that the new service should be achieved not by tearing up all established arrangements and starting afresh but by evolving and adapting the present to suit the future. They are averse from imposing a total salaried service merely for the sake of administrative tidiness.
Another alternative would be to maintain the "panel" system of National Health Insurance as it is now known, while extending it to the whole population and expanding it to include consultant and specialist services. This system has had, and still has, its critics, and some of the criticism is well founded. Yet, for more than a generation it has provided a better medical service than was previously available to a large section of the population and it has enlisted the regular professional services of a great majority of the doctors of the country. There are, however, two overriding reasons why it will not be possible to meet the new need merely by extending the panel system in this way.
First, there is at present no effective means of ensuring a proper distribution of doctors. To some extent the demand in any area will, by affording opportunity for practice, itself induce the supply; but that does not work out reliably or universally. It is true even now that the need for doctors in one area may be scantily or unsuitably met, while that of another area may be over-supplied. Certainly when the much bigger public responsibility is assumed of ensuring a personal doctor service for the whole population there will have to be means of securing, through public organisation, that the resources available are so disposed as to fit the public need.
Second, there is a great deal of agreement in the profession and elsewhere
that developments in the modern technique of medical practice point the way
to changes which need encouragement and experiment in any future service. The
recent draft Interim Report of the Medical Planning Commission (organised by
the British Medical Association) summarises these trends very well. For instance,
the Report states:
" The days when a doctor armed only with his stethoscope and his drugs
could offer a fairly complete medical service are gone. He cannot now be all-sufficient.
For efficient work he must have at his disposal modern facilities for diagnosis
and treatment, and often these cannot be provided by a private individual or
installed in a private surgery. He must also have easy and convenient access
to consultant and specialist opinion, whether at hospital or elsewhere, and
he must have opportunities of real collaboration with consultants. Facilities
such as these are inadequate at the present time. There must also be close collaboration
amongst local general practitioners themselves, for their different interests
and experience can be of value to each other. Although this need is recognised
by practitioners collaboration has not been developed as it should be."
Or, again, in another passage
"At the present time the single-handed practice or partnership is usually conducted from a doctor's private residence. Certain rooms are used for professional purposes, and personal or borrowed capital is invested in equipping the practice with apparatus and in keeping it up-to-date; additional domestic staff is employed to keep the surgery and waiting rooms clean and to deal with callers; the secretarial work and record keeping are done by the doctor himself or a secretary employed for the purpose; dispensing, if done at the surgery, is undertaken either by the doctor or a dispenser employed by him. This arrangement is repeated many times over in a fairly well-populated district."
The tendency will be away from the idea of the all-sufficient doctor working
alone, and towards a bigger element of grouped practice and teamwork-in which
the individual doctor retains his personal link with the patient, but has at
his side the pooled ability of a group of colleagues as well as consultant and
hospital services behind him. To quote the Medical Planning Commission once
more:
"Diverse as are the views of the organization of medical services, there
is general agreement that co-operation amongst individual general practitioners
in a locality is essential to efficient practice under modern conditions, though
views vary on the form of the co-operation. The principle of the organization
of general practice on a group or co-operative basis is widely approved."
The Government fully agree that "grouped" practices, to which numerous privately arranged partnerships are already pointing the way, must have a high place in the planning of the new service and they are designing the service with this constantly in view. Yet the conception of grouped practices cannot represent the whole shape of the future service. In the first place, there has not yet been enough experience of the idea translated into fact. Not enough has been found out, by trial and error, to determine the conditions under which individual doctors can best collaborate or even the extent to which in the long run the public will prefer the group system. Second, it is certain that the system could not be adopted everywhere simultaneously. The change, if experience shows that it should be complete, will take time.
The Government intend, therefore, that the new service shall be based on a combination of grouped practice and of separate practice side by side. They propose to place the group idea in the forefront of their plans in order that there may be a full trial on a large scale of the working of arrangements of this kind. Grouped practices are more likely to be found suitable in densely populated and highly built-up areas and it is there particularly (though not exclusively) that they should first be tried. It will then be possible to watch the development, with the medical profession, and to decide in the light of experience how far and how fast a change over to the new form of practice can and should be made.
All doctors in general practice who join in the new relationship with their patients, and rely largely in future on public funds for their normal livelihood, must be treated on a similar footing; the terms of their remuneration, the general conditions to be observed by them and the rights to be enjoyed by them must be nationally negotiated and settled.
In the National Health Insurance scheme successive Governments have accepted this principle, on which the medical profession itself has laid much stress. Although the local Insurance Committees play a valuable and recognised part in the administration of the scheme (and particularly in handling minor matters of discipline) the service is in fact highly centralised. Terms are laid down in great detail in the Medical Benefit Regulations, and all major questions have either been matters for negotiation between the Government and representatives of the profession or- as in the case of enquiries involving the removal of a doctor from the service- have been dealt with by central tribunals appointed by, and answerable to, the Minister.
The Government are convinced that, broadly, this system is still the right one and that it would be a mistake to apply to the new general practitioner service the normal canons of local government administration. On the other hand, it is essential that general medical practice in the new health service should not be divorced from the other branches of that service; that would perpetuate what is recognised to be the outstanding defect of the present system. Therefore what is proposed, in outline. is as follows:
(1) The present practice of settling centrally all major terms and conditions
of service, including remuneration, will stand. The local Insurance Committees
will be abolished and in future doctors, in so far as they take part in the
new general practitioner service, will be in contractual relation with a Central
Medical Board, to which they will look for their remuneration.
(2) In general, the other functions of the Insurance Committees will also fall
to the Board, but to avoid over-centralisation in detail the Board will discharge
many of the minor day-te-day functions through a local committee or similar
agency, on which there will be included members of the local authority in each
area.
(3) The new joint authority will have an important part to play of a different
kind. As the general planning authority for the whole health service in its
area, it will include the needs of general medical practice, no less than of
other services, in its area plan; it will provide for the linking of general
practitioners (whether in grouped or separate practices) with the hospital and
consultant and other services in the area.
(4) The county and county borough councils which make up the joint authority
will normally each have the function of providing and maintaining such premises
(in Health Centres and otherwise) as are approved in the area plan.
(5) The doctor himself will, in his contract with the Board, be required to
observe the arrangements of the area plan and will be given all the necessary
information and facilities to enable him to do this.
These are all matters for further explanation. The arrangement adopted is, first,
to deal with the particular points arising on "grouped" general practice
and on "separate" general practice respectively, and then to deal
with features common to both kinds of practice and with the constitution and
functions of the proposed Central Medical Board.
The conception of grouped practice finds its most usual expression in the idea, advocated by the Medical Planning Commission and others, of conducting practice in specially designed and equipped premises where the group can collaborate and share up-to-date resources-the idea of the " Health Centre". The Government agree that it is in this form that the advantages of the group system can be most fully realised, though it will also be desirable to encourage the idea of grouped practice without special premises. They intend, therefore, to design the new service so as to give scope to a full trial of this new method of organising medical practice, and so as to enable it to be expanded and developed as time goes on to the maximum extent which the practical experience of its working is found to justify.
Where Health Centres are set up, their types will need, particularly at first, to be varied. Scope must be given (with central and local professional guidance) to experiment and to design capable of later adaptation. Broadly, the design should provide for individual consulting-rooms, for reception and waiting-rooms, for simple laboratory work, for nursing and secretarial staff, telephone services and other accessories, as well as -in varying degree according to circumstances -recovery and rest rooms, dark rooms, facilities for minor surgery, and other ancillaries. The object will be to provide the doctors with first-class premises and equipment and assistance and so give them the best facilities for meeting their patients' needs. The doctors will thus be freed from the necessity to provide these things at their own cost. They will join in something like the partnership groups already often privately formed, and there will be new scope for the young doctor, fresh from hospital training, to take his share in the Centre as an assistant to the practitioners engaged there, and then, later on, to be eligible for full participation.
Limitation of the permitted number of patients will apply whether in the Centre or outside it, and the ordinary basis of the patient's choice of doctor will not be affected. Each Centre will need to be so planned as to be regarded by patients not as a complete break with present habit but as a new place at which they can, if they wish, continue to see their own doctor when he has joined the Centre, or can choose the doctor in the Centre whom they want to attend them. Alternatively, they must be able, if they prefer it, simply to select a Health Centre as such, rather than choose a particular doctor at the Centre; and then arrangements will be made by the Centre to ensure that they obtain all the proper advice and treatment which they need.
There has often been misconception as to the precise implications of Health Centre practice. It has been assumed that a doctor would be "on duty" only for stated periods and that, outside those periods, his patients would always be attended by some other doctor. That need not be so. Normally, a doctor will attend his own patients as necessary, either at the Centre or at the home. He will have his consulting hours and visit his patients as at present. But the grouping of practices at a Centre will make possible a greater fluidity of arrangements; for example, as arrangements will be made for continuous staffing, a patient will, in emergency, get immediate attention even though his own doctor does not happen to be available. The grouping of practices will, moreover, make it easier for doctors to obtain reasonable holidays and to attend refresher courses. The internal organisation of the Centre so as to facilitate reasonable absences consistent with the doctor's responsibilities will be a matter for the doctors themselves.
The Centres will be provided first in selected areas. Both central and local organisation, and local professional interests represented by the Local Health Services Council, will all have their part to play in this provision. The wish of the local doctors to bring their work into the new Centres must obviously be a big factor in a decision to provide a Centre, but in the last resort the decision will rest on the requirements of the public interest.
It will be essential to associate any decision to provide Centres, and their location, with the rest of the arrangements of the approved area plan. This will mean, in effect, that the decision in each case that the Health Centre. system should be -initiated in a particular part or parts of the area, and the consequential decisions as to the location and size and kind of Centres to be provided, will normally start in the area itself where the needs are best known and where the general health services plan is formulated, but will depend in the last resort upon the decision of the Minister in the light of his central policy on the general practitioner service and the new Health Centre experiment in the country as a whole. It will be for thee joint authority in the first instance, in consultation with the local medical profession, to formulate proposals for a Centre or Centres as part of the area plan - or, later on, as an extension or alteration of that plan-and to submit them to the Minister.
The actual provision of a Centre will normally be the responsibility of the county or county borough council. This accords with the principle earlier discussed under which the clinic and other services which are not essentially part of the consultant and hospital field will be allocated to these councils and not to the joint authority.
The terms and conditions of service will be settled centrally for all doctors taking part in the new service, whether in group practice or not, and all doctors will enter into a contract of service with the central organisation. The doctor practising in a Centre will not be debarred from private practice outside it, for those patients who do not wish to take advantage of the new public service, though there will be provision to ensure that the interests of patients within the new service do not suffer in any way as a result of this.
In certain respects the contract of the doctor in the Health Centre must differ from that of one practising outside. After the establishment of a Centre the appointment of a new doctor to the Centre will be made jointly by the Central Medical Board and the council administering the Centre, and similarly the termination of his engagement at the Centre (except where the doctor himself wishes to bring it to an end) will rest with these two bodies, or if they fail to agree, with the Minister. It will be part of the arrangement that the council provide the doctors in the Centre with tile necessary premises, equipment and ancillary staff. The contract will have to be a three-party one between the doctor, the Central Medical Board and the council.
But there is one important question in regard to the method of remuneration of the doctor, when practising in co-operation with a group of colleagues in a Health Centre, which does not arise in the same way when he is in separate practice outside. That is the method of payment of the individual doctor.
It seems fundamental that inside a Centre the grouped doctors should not be in financial competition for patients. All the practical advantages of the Centre- the use of nursing and secretarial staff, record-keeping, equipment, the availability of young assistant doctors in particular- will be, under a system of a salaried team, at the disposal of the group in whatever way they like collectively to arrange; it is the whole idea that they should arrange their own affairs together in this way. But if individual remuneration is based on mutual competition for patients, complication will enter into any attempt of the group to allocate and share these services- for the more any one individual is able to draw on the ancillary helps of the Centre (and particularly on medical assistants) the more he will gain and his fellows lose in the contest for patient lists.
There is therefore a strong case for basing future practice in a Health Centre on a salaried remuneration or on some similar alternative which will not involve mutual competition within the Centre. When the salaried or similar principle is adopted, the scales will have to be decided in consultation with the profession itself. In this respect attention is drawn to Appendix D, which suggests the method by which a basis could be arrived at for settling both salaried remuneration and the payment by capitation later proposed for " separate" practice. It may also be possible, if desired by the doctors themselves, to offer remuneration on a salaried basis or on some other basis than that of capitation fees to doctors engaged in group practice even where the practice is not conducted in a Health Centre.
In "separate" practice the general framework of the National Health Insurance scheme will be retained but there will have to be important changes from the past and the scheme will have to be much extended and adapted. The nature of these changes will be evident not only from the following paragraphs which relate to "separate" practice, but also from the later paragraphs dealing with features common to both" group" and " separate" practice.
In future everyone will be entitled, as only "insured" persons are entitled at present, to receive from the doctor chosen by him all the ordinary range of general medical practice, either at the consulting room or at his home, as the case requires. He will also be entitled, normally through his doctor, to all the new range of consultant and specialist and hospital or clinic services already considered.
A doctor in separate practice will engage himself to provide ordinary medical care and treatment to all persons and families accepted by him under the new arrangements. He will work from his own consulting room and with his own equipment, as he does now, but he will be backed by the new organised service of consultants, specialists, hospitals and clinics, which he will be expected to use for his patients in accordance with the approved area plan earlier described. He will receive his remuneration for work within the new service, not from the individual patient, but from public funds; and this remuneration will be based- as it is now in National Health Insurance- on a capitation system, depending on the number of patients whose care he undertakes. (A settlement on new lines of the basis for calculating capitation or other forms of remuneration is suggested in Appendix D already referred to.) Even in the case of separate practice there will be some circumstances in which it will be possible to remunerate the practitioner on a salaried or similar basis if he so desires. Opportunity for such an arrangement may occur, for example, in sparsely populated areas where a single doctor is in fact responsible for all the work of the area and is not therefore in competition with other doctors in the neighbourhood. But, however remunerated, the doctors in separate practice will remain entitled to engage in private practice, since it is no part of the intention of the new service to prevent persons who prefer to do so from making private arrangements for medical care or to prevent doctors from meeting their needs.
There will be no interference with the right of a doctor to go on practising where he is now and to take part in the public service in that area. But an unrestricted right to any doctor to enter any new practice and there to claim public remuneration, at his own discretion, would make it impossible to fulfil the new undertaking to assure a service far all.
Under the present National Health Insurance system every qualified doctor has a right to take up panel practice where he likes. The system enables the Minister, if satisfied that the service in any area is inadequate, to replace the panel system by same other form of arrangements, although- with minor exceptions at the outset of the scheme -this power has not been invoked. There has never been any real means of securing that the doctors of the country are reasonably distributed. This has perhaps not been a pressing necessity while the scheme covered less than half the population, but it is well-known that great disparities have existed.
If under the new scheme the whole population are to be entitled to a general practitioner service, a much heavier responsibility will be thrown on the Government to see that the needs of the whole population are met. This implies some degree of regulation of the distribution of medical resources, at least to the extent of securing that a doctor does not in future take up practice in the public service (whether by purchasing a practice or by "squatting"), in a locality which is already fully or over-manned. Such control can be left in the profession's own hands as far as possible, though it must be guided by national policy. A suitable machinery will be to vest it in the Central Medical Board, working under general guidance an policy from the Government but independently in its individual decisions. Any practitioner wishing to set up a new- or take over an existing public service practice in a particular area will seek the consent of the Board. The Board will then have regard to the need for doctors in the public service in that area, in relation to the country as a whole, and to the general policy for the time being affecting the distribution of public medical practice. If it is considered that the area has sufficient or more than sufficient doctors in public practice while other areas need more doctors, consent will be refused. Otherwise it will usually be given without question. The Board will thus be able to help the new joint authorities which, in their general concern with the health services of their area, will turn to the Board to encourage or discourage any further increases in general practice in the area.
It will be the duty of the new joint authority to consider the needs of its area in general medical practice, including "separate" practice, no less than in the other branches of the comprehensive service, and to include in the area plan for central approval the arrangements-I n terms of numbers and distribution of general practitioners -which it considers to be necessary to meet these needs. In this it will have the advantage of consultation with the Local Health Services Council. The plan will need the Minister's approval, after hearing any conflicting local views. The approved plan will be made known to the Central Medical Board, to be taken into account in the subsequent exercise of their functions in the distribution of public medical practice.
It will also be the duty of the joint authority to watch that the supply of
all branches of the comprehensive service is adequate to the needs of their
area and in the matter of general practice, therefore, to bring to the notice
of the Minister and the Central Medical Board any needs which they feel should
be more adequately met. They will also be responsible for ensuring that all
the other services in their area (hospital, clinic, nursing, consultant and
specialist) are fully known to the general practitioners participating in the
new service and that the latter are enabled (as their contract will require
them) to use these services fully for their patients in accordance with the
approved area plan.
It remains to consider certain general questions affecting medical practice, both" grouped" and" separate", and to describe more fully the proposals for a Central Medical Board.
From the outset of medical benefit under National Health Insurance, provision has been made for imposing a limit on the number of insured persons for whose treatment a doctor may make himself responsible. The limit is fixed by a local scheme which is subject to the Minister's approval, but the regulations themselves provide for certain over-all maxima. An additional number of patients is permitted to a doctor who employs one or more assistants. Under this system every doctor has a right to undertake as much private practice as he desires and is able to secure, and it is usual for the doctor of an insured head of a family to look after the uninsured wife and children under private arrangements.
In the new service also there will have to be prescribed limits to the number of patients whose care anyone doctor can properly undertake. But the situation will be substantially altered by a scheme which covers the whole population and which contemplates both grouped and separate practice. It is not the wish of the Government to debar anyone who prefers not to avail himself of the public service from obtaining treatment privately, nor to prohibit a doctor in the public service from carrying on any private practice, but it will be necessary to ensure that the interests of the patients in the public service do not suffer thereby.
In fixing the appropriate limits, in future, allowance will need to be made for private practice remaining after the new service is in operation. There will need to be room for flexibility. A doctor entirely free from outside activity and able to give his whole time to general practitioner work in the new service will need to be able to work to a higher permitted limit of public patients. A doctor with an unusually large amount of private work, or with appointments in other branches of the public service, will be expected to work to a lower permitted limit. The effective way to provide reasonable flexibility is to entrust the decision in such cases to a suitable professional organisation- which will naturally be the Central Medical Board working through its local committees. The details of this are for discussion with the profession's representatives at a later stage, but the object must be to see that the care of patients under public arrangements does not suffer in quality or quantity by reason either of private commitments or other public engagements. Nor must anyone have reason to believe that he can obtain more skilled treatment by obtaining it privately than by seeking it within the new service.
There is a strong case for requiring all young doctors, leaving hospital and entering individual practice for the first time, to go through a short period of " apprenticeship" as assistants to more experienced practitioners. There is a particularly strong case for saying that this should be required by the State in medical practice remunerated from public funds. When such a rule is made the young assistant doctor will have to be assured of reasonable conditions and opportunity, and certainly must not be at risk of being precluded from a proper professional livelihood by the operation of the rule. One way will be to require a suitable period as an assistant except where the Central Medical Board dispenses from the rule (e.g. to meet cases where an assistant post is not reasonably obtainable). There will, no doubt, be many opportunities to employ assistants in Health Centres where terms and conditions can be regulated and the Board can help new entrants to find vacancies. In "separate" practices, the Board must be empowered to satisfy itself as to the proposed arrangements and remuneration for an assistant, before consenting to his engagement by the principal seeking him-guidance on standards being given centrally in consultation with the profession. The general practitioner wishing to undertake a larger number of public patients than the ordinary maximum will inform the Board, and the Board- after satisfying itself as above- will help an intending assistant to get the post on the terms approved. The Board must also be able to require the young doctor during the early years of his career to give his full-time to the public service where the needs of the service require this.
The Government recognise that the adoption of the proposals in this Paper will,
in certain cases, destroy the value of existing practices. In such cases compensation
will be paid. It will be necessary to discuss this in detail with the profession
but there are two classes of case in which a just claim for compensation will
clearly arise.
The first is that of a practice in an "over-doctored" area, to the
sale of which the Board refuses consent. Here the out-going doctor or his representatives
will be paid compensation.
The second is that of a doctor who gives up his "separate" public practice and takes service in a Health Centre. It will be incompatible with the conception of a Health Centre that individual practices within the Centre should be bought and sold and a doctor will therefore, by entering a Centre, exchange a practice having a realisable value for a practice which he will be debarred from selling. On the other hand an efficient superannuation system will be an essential part of the Health Centre organisation. A doctor entering a Centre will acquire superannuation rights and other facilities of considerable value. The proper course will be to strike a fair balance between what he is gaining and losing and to compensate him accordingly.
It would be more difficult to institute superannuation for doctors in "separate" practices, but the Government will discuss with the profession the possibility of an acceptable scheme to provide for retirement within specified age limits and for superannuation on a contributory basis.
The Government have not overlooked the case which can be made far the total abolition of the sale and purchase of publicly remunerated practices. The abolition would, however, involve great practical difficulty and is not essential to the working of the new service now proposed. The Government intend, however, to discuss the whole question with the profession, to see if some workable and satisfactory solution can be reached. In particular, it would obviously be incongruous that the new public service should itself have the effect of increasing the capital value of an individual practice and thus increasing the amount of compensation which may have to be provided under the circumstances described in the preceding paragraphs; and measures to prevent this, must be included in the discussion.
The creation of Health Centres will, meanwhile, do a great deal to limit the scope of the present system. The Centres will afford a wide opportunity to young doctors to enter their profession without financial burdens. They will also, wherever they are set up, bring into being a new form of practice which will thereafter be entirely free from any necessity of sale and purchase. Moreover, the system proposed earlier of requiring young men who join the public service normally to undergo a period as assistants will go far to avoid the danger of a doctor purchasing a practice which he has not the necessary experience to handle successfully.
It is intended to create from the profession itself a special executive body
at the centre, which will undertake some of the administrative work of the service
requiring a specially intimate link with the profession.
As the contract of the doctor will be in a public service, remunerated from
public funds, the Board will dearly have to be subject to the general directions
of the Minister, but subject to those general directions it will be the organisation
with which the doctor will deal as the "employer" element in the service-
i.e., the organisation with which he will be in contract, whether engaged in
"separate" or in grouped or Health Centre practice (although in Health
Centre practice the local authority will be joined in the contract).
It is not for this Paper to suggest all the details of the doctor's contract
at this stage (they will be for discussion with the profession's representatives);
but they will need to provide
(a) for the doctor to give all normal professional advice and services within
his proper competence to those whose care he undertakes;
(b) for him to comply with the approved area plan for obtaining consultant and
specialist and hospital services;
(c) for proper machinery for the hearing of complaints by patients and for the
general kind of disciplinary and appeal procedure already familiar in National
Health Insurance;
(d) for the observance of reasonable conditions, centrally determined with the
profession, respecting