A Health Service for the Nation

with special reference to preventive services and Health Education

Some suggestions made on behalf  of  the Women  Public Health Officers’  Association

Founded 1896

1. The ultimate object of a National Health Service is to make available to all the possibility of complete physical and mental health,
2. This involves the provision of a healthy environment at home, at school, and at work, adequate and appropriate food, social security, freedom from strain and anxiety, adequate leisure and a wide range of interests.
3. The National Health Service must therefore concern itself with .all these factors, placing the advice of those of its members who are qualified to give it at the disposal of architects, educationists, economists and others responsible for other depart­ments of national life. It should be the responsibility of the Central Government to see that this advice is taken.
4. The National Health Service must provide for the health education of the people, who must learn that, given reasonable conditions, full health is both a possibility and a duty. This teaching is needed by children in school and by men and women, whether at home or at work. It includes the lesson of personal responsibility for obtaining and following medical and dental advice as soon as there is any loss of complete well-being.
5. The provision of this advice and of all forms of treat­ment is essential in any new National Health Service. This advice and treatment should be readily available to all members of the community irrespective of their economic position or of the part of the country in which they live.
6. Several schemes have been formulated for the provision of such medical treatment through a National Health Service, including that of the Planning Commission published by the British Medical Association, and that of the Socialist Medical Association. All these schemes suggest that the services of salaried general practitioners shall be available at “Health Centres” and, if necessary, in patients’ homes, this new service superseding the present National Health Insurance and Poor Law general practitioner services; these schemes also suggest that consultant and hospital services shall be at the disposal of the general practitioner.
7. The members of the Women Public Health Officers’ Association attach very great importance to the retention and extension of existing environmental, preventive and educational health services. They believe that Health Visitors and other women Public Health Officers have contributed greatly to bringing about an improved standard of national health, and especially to the fall in the Infant Mortality rate from 150 to 50 per thousand in the last 50 years.
8. In the early years of this century, the greatest number of infant deaths was caused by “summer diarrhoea,” due to feeding babies with contaminated raw milk. The spectacular reduction in the national Infant Mortality Rate has certainly been very largely due to the successful personal efforts of Health Visitors in teaching and convincing the mothers of the value of breast-feeding and of safe methods of bottle feeding. Such teaching is still necessary.
9. The remarkable diminution in cases of severe rickets is also largely attributable to the teaching and influence of Health Visitors, exercised both in the homes of the mothers and in the Welfare Centres. The weekly or fortnightly weighings at the Centres provide the opportunity for the Health Visitor to see the baby stripped and so to observe any early signs of rickets. Where these are present, the mother is referred immediately to the Centre Medical Officer, who gives detailed instructions with a view to preventing any further development of rickets. This advice will certainly deal with diet, clothing, sunshine and fresh air.  It becomes the Health Visitor’s duty to see that the mother realises the importance of carrying out this advice, and to help her to do     This may well involve helping her, probably through the Housing Department of the local authority, to find and move into another house. The practice, even in narrow back streets, of leaving the baby nearly all day in its pram on the pavement is directly due to the teaching of Health Visitors.
   In former years the practice was to keep the baby in a dark corner near the fire.
10. As the scope of the medical services provided by local authorities has widened, each service has been popularised by the Health Visitors in the homes of the families concerned. The attendance of babies and toddlers at Welfare Centres, ante-natal and post-natal sessions have all in turn been accepted and welcomed. The Annual Report of the Chief Medical Officer of the Ministry of Health for 1938, states that 60% of expectant mothers attended ante-natal clinics. While it is true that the provision of free or cheap milk only through Maternity and Child Welfare Centres—prior to the wartime National Milk Scheme—was an added inducement to some mothers to attend Welfare Centres, this country is unique in having made attend­ance at these Centres genuinely popular among the great majority of the nation’s mothers—a popularity not dependent on the association of such attendance with any insurance or other material benefit.
11. Similarly, for any new preventive services to be pro­vided in a new National Health Service to be fully utilised and appreciated, it will be necessary to popularise them by similar methods,i. e., by inviting people to make use of them and explain­ing how, when and where the sessions are held, by ensuring that a personal welcome is given at the Health Centre and that the medical advice given is understood, and, finally, by visiting in the home to see that the advice is being followed. The recent appeal made to Health Visitors by the Ministry of Health to popularise immunisation against diphtheria illustrates this point.
12. As an Association of women Public Health Officers, we believe therefore that the future  of  the National Health Service should be two-fold :—
    1. Environmental, preventive and educational.
    2. Curative.

We suggest that both these branches should be administered by one Regional Medical Officer of Health.

13. We submit the following suggestions for:—

(a) Conserving our existing Public Health Services, e.g., Maternity and Child Welfare, School Medical and Tuberculosis services,

(b) Making available to all members of the community the services of salaried general practitioners, who, we suggest, should be known as Home Doctors, and

(c) Co-ordinating these services with each other as part of the two branches of the National Health Service of the future.

14. We attach great importance to keeping clear this dual function of the new National Health Service, both from the administrative and psychological point of view. We believe that it is important that the public shall grow increasingly “health conscious,” looking to the Health Centre and to Health Visitors to teach them how to keep well, rather than assuming that ill-health is normal and frequent medical treatment necessary.
15. We believe that this country is unique in having genuinely popularised its health teaching services, especially in the homes of the people, and we believe that any attempt to merge this branch of the National Health Service with the curative branch would be a retrograde step. We suggest complete co­operation without loss of identity.
16. We suggest that each of these branches of the National Health Service shall have its central focal point and that each shall work through local Centres.
17. We believe that the focal centre of the Environmental, Preventive and Health Education service should be the Regional Health Office, in which administrative action affecting other branches of the public service, g., housing, can be taken and vital statistics compiled, as at present.
18. We suggest that the focal centre of the Curative Services shall be the Regional General Hospital. (Hospitals for certain kinds of mental and infectious illness will also be required.)
19. We recommend that there shall be two kinds of Health Centres:—
    1. local health centres, regarded primarily as Centres for preventive and educational health work, with facili­ties for medical and dental examination, diagnosis and. treatment for which elaborate equipment is not required.
    2. divisional clinics or treatment centres, largely replacing the present Out-Patient Departments of hospitals and School Treatment Centres (other than minor ailment centres) under the direct supervision of the Consultant Staff of the Regional Hospital and with the Regional Hospital as its focal point. Each of these Divisional Treatment Centres should co-operate closely with a number of Local Health Centres in its vicinity.

LOCAL HEALTH CENTRES.

20. Two-fold function. In addition to providing accom­modation for the work of the existing Maternity and Child Welfare Centres, and for dental and medical inspections of school children, accommodation should be provided in the Local Health Centres for salaried Home Doctors (replacing the present insur­ance and Poor Law practitioners) to see their patients in the doctors’ rooms. We suggest that this part of the Local Health Centres should not be more elaborately equipped than are the surgeries of the present-day general practitioners. Patients re­quiring X Ray examinations or laboratory tests should be referred to the Divisional Clinic or Treatment Centre.
21. In the Health Centre all the personal health records of every person in the district served by the Centre should be kept, and should be available to the   medical staff of the Divisional Treatment Centre or Regional Hospital.  Health Centres would be administered by the Regional Health Depart­ment and not by the Regional Hospital. We suggest that the Home Doctors using the Health Centre should not be responsible for its general working nor that one of them should become its Medical Superintendent, as is suggested in the draft interim report of the Planning Commission published by the British Medical Association, 1942. A senior Health Visitor should be responsible to the “Regional Medical Officer for the cleanliness and good order of each Health Centre and for the co-ordination of all ancillary services desired by the Medical Staff.
22. As Health Centres should be primarily centres for health education as well as for the Home Doctors’ service and, as the National Health Service develops, for periodical medical and dental examination of the whole community, we suggest that they should be much more numerous than the Divisional Treatment Centres which will serve that minority of the population needing medical treatment outside the range of the Maternity and Child Welfare Service and beyond  the  competence of the general practitioner or Home Doctor.
23. We suggest that a local Health Centre should be not more than two miles—in densely populated districts it should be less—from every town or village home in England. No child can be compelled to walk more than two miles to school: it is the duty of the Local Education Authority to see that a school is available within that distance. Similarly, we believe that it should be the duty of the Regional Health Authority to provide enough Health Centres to be easily accessible to all the inhabitants  of all towns and villages.
24.  Where satisfactory buildings for Maternity and Child Welfare and/or School Medical Services already exist, we suggest that these should become Local Health Centres, additional accommodation being provided where neces­sary for the Home Doctors and for the clerical and other staff needed for the extended services based on the Health Centre. In some cases, existing doctors’ rooms in Maternity and Child Welfare Centres could be available for use at times convenient to the Home Doctors and their patients.
25. Where a new Health Centre is required, we suggest that this should not, as a rule, be under the same roof as a Divisional Treatment Centre, but may well form part of a larger building provided for some other form of social service,e g., a school, Day Nursery, a. Community Centre, or a Citizens’ Advice Bureau. Some of our members have been impressed with the practical advantages accruing from this arrangement in the organisation of local health and social services in Toronto and New York.
26. Even in small villages, we believe that two rooms with a separate entrance, added to the school buildings (and many village schools are ripe for re-building) would provide an adequate Health Centre, the various health services, including that of the Home Doctor, being found there in rotation; for certain forms of Medical and Dental Treatment a mobile unit may be useful. In no circumstances should a doctor’s private surgery be designated a Health Centre. In rural areas, the staff of Health Visitors should be numerous enough to enable a Health Visitor to make a weekly visit to each village Health Centre.

STAFFING OF HEALTH CENTRES.

27. (a) medical. We believe that the specialised medical staff should be common to both branches of the new National Health Service, and that the Home Doctors working at the Health Centres should refer their patients for further advice and treatment either to the Divisional Treatment Centre or to the Regional Hospital. We strongly deprecate the suggestion made in the Draft Interim Report of the Planning Commission that Home Doctors, i.e., general practitioners working in the Health Centres, should assume responsibility for ante-natal, post-natal, and infant welfare sessions. We believe that these services require a greater   degree of specialised knowledge and experience than can reasonably be expected of many general practitioners and we believe that the success and popularity of these existing services is largely due to the confidence which the mothers have in the specialised medical staff now normally in charge of these services.

(b) health visitors. Health visitors should continue to perform their present duties. In the future, the work of Health Visitors may well include the   duties in the school and homes of school children now performed by School Nurses. They should also administer the Home Helps service. They should work in and from the Health Centres, in numbers varying with the population served by the Centre. In each Centre it should be possible for an individual Health Visitor to see mothers in privacy.

(c) municipal midwives would use the Health Centres for interviewing their patients and would attend ante-natal sessions when practicable.

(d) clerical staff. This should be adequate to deal with the Health Records and Health Centre correspondence concerning all persons living in the district served by the Health Centre.

(e)sanitary Inspectors   In large  towns it might economise travelling time and encourage co-operation if an office for the District Sanitary or Housing Inspector, whether man or woman, was provided in some or all of the Health Centres.

DIVISIONAL TREATMENT CENTRES.

28. Buildings. We suggest that, as these should be equipped to deal with patients referred for more elaborate tests or treatment than are available in the local Health Centre, they will be more costly to build and equip, but will also be much less numerous than the local Health Centres.

STAFFING OF DIVISIONAL TREATMENT CENTRES.

29. Staff, (a) medical. We suggest that Divisional Treatment Centres should be staffed and administered from the Regional Hospital, of which they may be regarded as localised out-patient departments. Patients should be normally seen by appointment, the personal health record being forwarded from the local Health Centre of the district in which the patient lives.

(b) Nursing.  A trained nursing staff should be attached to each Divisional Treatment Centre, some of whom might undertake district nursing, perhaps alternating between Treat­ment Centre and District work. In any case, a staff of District Nurses for bedside nursing will be needed, and should be appointed   directly   by   the   Regional   Health Authority.  They should also be available at the request of a Home Doctor to nurse any of the patients attending at a local Health Centre co-operating with the Divisional Treatment Centre.  In no circumstances should Health Visitors undertake bedside nursing.

(c)Clerical staff. The clerical staff should be adequate to deal with all records and correspondence.

(d) We  suggest that an Almoner or trained Social Worker should work at each Divisional Treatment Centre, especially in connection with the social problems arising in the families of tubercular patients and others receiving rehabilitation treatment.

30. The Women Public Health Officers’ Association offers these suggestions as the contribution of a body of women whose lives are already devoted to the cause of Public Health, believing that the health of a nation can be immensely improved by the inauguration of a complete Health Service for the Nation. Its members believe that this service should be both preventive and curative, and that, while making new curative services .available to all, preventive and educational services will be best secured by building on the well-laid foundations of the existing Public Health Services.

31. We suggest therefore that the Health Services available at Local Health Centres and Divisional Treatment Centres respectively might be:-

LOCAL HEALTH CENTRE:

1. Home doctors’ service.
2. Ante-natal and post­ natal sessions.
3. Periodical medical and dental  examinations of infants and toddlers.
4. Medical and dental inspection of school children. .
   We suggest that classes or groups of school children should attend the Health Centre for examina­tion, thus avoiding both the unsatisfactory conditions for examinations in schools, and the disturbance of more than one We believe that school medical inspections should take place annually and dental inspections every six months.
5. Other periodical medic­al and dental  examinations, including those in connection with industrial employment.
6. Classes in parentcraft.  These would be facilitated if the Health Centre were in the same building as a Domestic Subjects and/or Manual Train­ing Centre.
7. Physical training for all ages and both sexes.
8. Formal health teaching.
9. Psychological and child guidance clinics. We believe that patients will attend Health Centres more readily than a Treatment Centre or Hospital.

DIVISIONAL TREATMENT CENTRE.

1. Consultants’ sessions.
2. Physiotherapy
3. X ray examination, in­cluding radiography.
4. laboratory services.
5. tuberculosis dispens­ary service for T.B. patients. We suggest that the periodical examination of contacts should be undertaken at the local Health Centre or, in exceptional cases, their own homes.
6. Rehabilitation and occupational therapy.
7. Dispensary for drugs, also supplying Home Doctors at Local Health Centres.

27th March, 1943.

PUBLISHED BY THE WOMEN PUBLIC HEALTH OFFICERS’ ASSOCIATION, 5 VICTORIA STREET, LONDON, S.W.1, AND PRINTED BY FARMER   &,  SONS, LTD., 295 EDGWARE ROAD, LONDON, W.2,