The Development of the Health Services reprinted from The Medical Officer 27 February, 1943
By SOMERVILLE HASTINGS, M.S., F.R.C.S., Chairman, Hospitals and Medical Services Committee, London County Council.
The first of a Series of eight Lectures on Social Medicine and Public Health delivered on January 14th, 1943, at Conway Hall, London.
IN a series of eight lectures the Socialist Medical Association is breaking new ground. In the past we have been largely a propaganda organisation, the main object of which has been to advocate a socialised medical service. We are now attempting to give students the facts of social medicine and public health.
In this first lecture I want to try and give a bird’s eye view of the principal health services and some explanation of how and why they came into being. It is, of course, not easy to say exactly where the health services begin and end. The greatest of the preventible causes of ill-health is poverty. Accordingly, any services that tend to lessen poverty or improve the conditions of life of the people, be they in connection with wages, unemployment, pensions, public assistance or any other factors, must in the broadest sense be regarded as health services. They cannot be referred to to-day, though some will be dealt with in subsequent lectures.
Two principal emotions have, I think, been responsible for the development of the health services – pity for suffering and fear of communicable disease. St. Bartholomew’s Hospital, Rochester, was founded in 1078, and St, Bartholomew’s, London, in 1123, both inspired, no doubt, by sympathy for suffering; but on the other hand even before these days, Nineveh, Athens and Rome had drainage systems. To these emotions must be added, especially in more recent years, the outlook which realises the importance of each individual to the nation, and in consequence the duty of the nation to provide as far as may be for every citizen the possibilities of a healthy life.
It was the Industrial Revolution and the crowding together of people under appalling hygienic conditions that enabled cholera to become epidemic between 1832 and 1866, and it was these epidemics that directed the minds of the legislators of those days to the need for the environmental health services, especially those relating to drainage and water supply. Edwin Chadwick, perhaps the greatest pioneer of sanitation of these times was described as “the apostle of efficient drainage and pure water.” The Public Health Act of 1875 and subsequent enactments have given to local authorities many duties and responsibilities in connection with health. These were at first mainly negative or preventive in character. They called for the “abatement of nuisances,” laid down minimum standards for houses and made illegal the sale of impure or injurious food, etc. But very soon it was found that negative action was not enough, that if it wanted things done properly the local authority must do them itself, and powers were accordingly given for drainage, refuse disposal, street cleaning, and the provision of water supply, markets, recreation and burial grounds, and since 1885, for the building of working-class dwellings.
In addition to the provision of these environmental services, local authorities were early called upon to deal with infectious disease. In 1840 vaccination against smallpox was made free and in 1853 this became compulsory for infants under three months, although this was relaxed in 1898 when the parents alleged conscientious belief in the danger of vaccination. Inoculation of children against diphtheria is now carried out without charge by most local authorities. In 1889 the notification of certain infectious diseases was made permissive to local authorities and in 1899 it became compulsory. Local authorities are responsible for seeing that measures are taken to prevent the spread of infection, including the disinfection of premises. In this connection isolation hospitals are provided for those suffering from smallpox, scarlet fever and other infectious disease. The incarceration of patients in these hospitals was first undertaken for the protection of the public, and it may be that treatment was provided largely because of the heavy cost of prolonged residence in hospital. In this way the important principle was demonstrated that prevention and cure cannot be separated, and that prevention of disease involves the treatment of existing disease.
Another service undertaken primarily for the protection of the public is the care of mental disease. For many centuries mentally afflicted persons had been kept under restraint often under conditions of the greatest brutality. At the end of the eighteenth century a movement for more humanitarian methods was started by William Tuke of York, among others, who founded in 1792 his famous “Retreat” . But it was not till 1845 that a board of commissioners on lunacy was set up. Since this time there has been an increasing tendency to regard lunacy as mental disease with the possibility of cure- by appropriate treatment like other diseases. The Mental Treatment Act of 1930 permits the reception of voluntary or temporary patients in institutions without certification as well as their treatment as out-patients.
But in addition to health services the principal object of which is the protection of the public, there have arisen others in which the health of the individual concerned has been the main consideration.
The district medical service, under the Poor Law, provides medical treatment for “poor persons” who are not of necessity destitute in the financial sense, but unable otherwise to obtain the necessary medical care. In Elizabethan times each parish was responsible for its own poor. Then in 1834 the Poor Law Amendment Act set up unions of parishes with elected Guardians of the Poor. The Local Government Act of 1939 still further extended the unit of administration to the largest of local government authorities, the county and county borough. Here the tendency for the formation of larger and larger areas of administration of the health services is demonstrated.
The long hours worked under appalling conditions by children of tender age was responsible for the commencement of factory legislation, the first two Acts of which in 1802 and 1833 were concerned only with cotton mills. Certifying factory surgeons were appointed by the Act of 1844. It is the business of these officers to examine medically those under 16 who become employed in a factory and to recognise and. investigate causes of industrial disease. Since the war an order has decreed that every factory of any size shall have appointed to it a medical officer, whole or part-time, whose duty if shall be to supervise the health and welfare of all employed in it.
The difficulty of those in receipt of weekly wages to pay directly for medical treatment when they are ill had long been recognised, and to provide for this medical clubs and friendly societies had been in existence before the passing of the National Health Insurance Act in 1911.But instead of creating a comprehensive public medical service through the agency of the local authorities, as at first seemed likely, the vested interests of the friendly societies and the medical profession secured the introduction of a complicated, wasteful and imperfect scheme. From the health point of view the main defects of National Health Insurance are that it has no connection with the preventive and environmental services; and that it is incomplete, providing only the medical attention that any practitioner is able to give and no specialist or hospital treatment whatever. It is true that some of the “approved societies,” who administer the cash benefits, use part of their funds for the provision of dental, ophthalmic and other services, but these are often unavailable to those who need them most.
There are two kinds of hospital in the country, municipal and voluntary. Before the war the thousand odd voluntary hospitals provided about 85,000 beds, and the municipal hospitals about three times this number. The voluntary hospitals have a long and distinguished record of public service. Most of the early hospitals were. monastic institutions. Thus, the first general hospital in England, St. Peter’s, York, was founded by King Athelstan, and the cathedral canons. Lanfranc, Archbishop of Canterbury, instituted another hospital in York St. John’s in 1084. When Henry VIII suppressed the monasteries, St. Bartholomew’s and St. Thomas’s hospitals, London, lost their income and their work practically ceased. As Henry could not allow this to happen, he was compelled (with the city corporation) to make financial provision for these hospitals and for the first time hospitals became ” rate-aided”.
For many centuries the voluntary hospitals were responsible for the sole institutional provision for the sick poor who were retained within their walls until they were (in the words of a bequest to one of them), “relieved by art or released by death.” But the very success of the voluntary hospitals in due course proved their undoing, as more and more people became willing to take advantage of the services they rendered. The first result of this was that the voluntary hospitals also were compelled to select their cases, referring those requiring less active or more prolonged treatment to the Poor Law. These patients were received, in some cases, in the sick wards of general mixed workhouses, and in others in specially built Poor Law infirmaries. But even so, the difficulties of the voluntary hospitals were not solved. While generous benefactors have been and still are ready to give money for the extension of voluntary hospitals or foundation of fresh ones, they are much less willing to subscribe large sums for their ordinary upkeep and maintenance. Many new methods for raising money were accordingly adopted: patients payments, contributory schemes, contributions by local authorities, or payments by them for work done. But in spite of all these and many other sources of income the voluntary hospitals have found it impossible to provide accommodation for all acute cases urgently needing hospital care, and an increasing number of such cases, especially in the towns, have been compelled to seek accommodation in the Poor Law infirmaries. To this new demand, the Poor Law guardians responded nobly in many cases, and even before the passing of the Local Government Act (1929), many of these infirmaries had been transformed into well equipped general hospitals and as a result an increasing number of persons were only too ready to take advantage of the treatment provided in them, albeit that by doing so they became technically what till recently were called “paupers” and are now designated “poor persons.”
In 1929 there was placed on the statute book a Local Government Act which is having a profound effect on the development of the hospital services. By abolishing the Boards of Guardians it brought all the existing municipal hospitals (fever, tuberculosis, etc.) and all Poor Law infirmaries under the charge of county or county borough’ councils. It also invited these same councils to remove their infirmaries completely from the Poor Law and run them as public health general hospitals. Many of the more progressive local authorities at once took advantage of the new power which has great administrative advantages, as it gives much greater freedom and elasticity by permitting the use of all the publicly controlled hospitals of a county or county borough as a single unit.
As soon as war was declared in 1939 the Government put into operation its emergency medical service scheme which had been conceived before the war, but not worked out in complete detail. By it the Government undertook partial control of almost all hospitals, both municipal and voluntary, and determined how many beds should be reserved in each for what are called E.M.S. cases: civilian war casualties, patients transferred from other hospitals on government or E.M.S. orders, service patients, A.R.P. personnel, and other special categories. Beds reserved for E.M.S. cases are paid for by the Government both when occupied and unoccupied, the rate being of course higher in the former case. Instruction was also given as to what beds should be “frozen,” i.e. temporarily closed because of the danger of air attack.
The E.M.S. hospital scheme has brought some order into our chaotic hospital system. The area of administration is large and a certain amount of specialisation has developed, for units for cranial surgery and other specialties have been formed. One great disadvantage is lack of unity of control for the Ministry of Health, E.M.S. officers and the original owners of the hospital not infrequently pull in opposite directions.
An important statement was made by the Ministry of Health on 9th October, 1941, with regard to the Government’s post-war hospital policy. A comprehensive hospital service is to make treatment readily available to all in need of it. The duty of providing this is to be placed on the county and county borough councils in co-operation with the voluntary hospitals, but to avoid wasteful overlapping the area of service will be substantially larger than that of existing local authorities. Moreover, the Government. will assist in meeting the extra cost of the service. Schemes on these lines are already in preparation for London and some other regions.
There remains for consideration certain health services provided for special diseases or special classes of individuals. These arose for the most part as the result of popular clamour. The need was obvious and it was met in the simplest way without thought for the future or of the relationship to other existing services. They might almost be described as “panic legislative services.”
Early in the present century it was repeatedly stated that the physical condition of many of the children in the elementary schools was so deplorable that they could not profit by the education provided. The Government decided that it must put this to the test, and in 1907 made the medical inspection of children attending the elementary schools compulsory. The treatment of the defects thus found, at first optional, was made compulsory in 1913.
Again, the unnecessarily high infantile and maternal mortality induced Parliament to pass the Maternity and Child Welfare Act of 1918. This Act permitted local authorities to set up schemes for the provision of antenatal centres for the supervision of expectant mothers and infant welfare centres for young children. The Midwives Act, 1936, goes a step further, and makes it incumbent on local authorities to secure the provision of an efficient service of domiciliary midwives in their area of administration.
It was the heavy sickness rate as well as the heavy death-rate due to tuberculosis that was responsible for the appointment of a committee under the chairmanship of Lord Astor to make proposals for combating this disease in 1912. As the result of the report of this committee it became the duty of the larger local authorities to formulate schemes for the prevention and treatment of tuberculosis.
The loss of man-power due to venereal disease during the last war turned the attention of the nation to the need for greater facilities for effective treatment. Accordingly in 1917 local authorities were empowered to provide or arrange for the provision of clinics at which free treatment could be obtained under confidential conditions.
In the same way the high mortality from cancer, and the difficulty in obtaining early and efficient treatment, especially by radiation, induced the Government in 1939 to pass the Cancer Act which places an obligation on county and county borough councils in consultation with voluntary agencies to prepare a scheme for treatment. Owing to war conditions this Act is in abeyance.
From a study of the development of the health services, certain general conclusions may be drawn.
1. There has been a tendency to entrust the health services to larger and larger units of local government.
2. A multiplicity of service has been developed each acting for the most part as an independent unit, with, in most cases, but little co-ordination with other units.
3. The inseparability of prevention and cure has been demonstrated. The principal object of a. health service must ever be to prevent disease. But it has been shown in connection with infectious fevers, tuberculosis, V.D. and other conditions, that an essential step in prevention is the treatment of existing disease, and accordingly an ever increasing number of services for dealing with an ever increasing number of’ conditions have been developed. What our legislators seem to have forgotten is that for efficient treatment early, and correct diagnosis is an essential preliminary, and that no scheme that does not include the general practitioner who generally first sees the afflicted person, can be complete. Put into other words we may say that there can be no reasonable stopping place between the first interference by the State. in health matters and a complete State medical service.