By David Stark Murray

Undated but probably 1944

Author’s Note

A new national health service will be one of the great social advances made by the present Labour Government. It will follow lines elaborated in many books and pamphlets and familiar to those who have studied the subject. It is, however, of vital importance to the ordinary citizen and it is essential that everyone should understand what is being proposed.

Hence this pamphlet. It is largely new, but free use has been made of my Penguin Special, “The Future of Medicine,” now out of print, from which the diagrams on pages and 19 are taken.

D.S.M.

GOOD HEALTH is the desire of every man and woman and the object of the care given to their children by every mother and father. Many things are needed to give a sure foundation for a healthy life, adequate food, good homes, hygienic environment, freedom from industrial hazards and recreation, but the ordinary citizen— you, Mr. Smith— has a right to demand in addition the best form of medical care that can be devised. The new National Health Service should provide that medical care and it is essential, before it is too late, that every citizen should realise that it is on his incessant demand that the new system has been devised and it is on his vigilance that its maintenance at the highest level will depend.

It is no mere coincidence that all the Mr. Smiths of the world have been making the same demands. Everywhere medical science has outgrown its present method of organisation and everywhere there are new plans to bring the practice of medicine into line with the science of medicine. New discoveries in treatment and prevention arrive so rapidly that the doctors of tomorrow must be given a better opportunity to use them than is possible with the methods of yesterday.

First, Mr. Smith, let us ask what you should expect from your doctor. We must assume, of course, that you are aware of the full potentialities of modern medical practice. Few people really look upon the doctor as a miracle worker although occasions occur when people sigh for a doctor who could produce a miraculous result. To the surgeon, more than any other doctor, the opportunity for the seeming miracle sometimes happens, but for the General Practitioner there are few spectacular affairs.

What the patient needs most, is however, the constant services of an efficient medical practitioner. That does not mean the constant attention of one particular doctor for efficient medical care today can be achieved only by the work of a team of people, not all medical, organised for the purpose of preventing and curing disease. What the patient requires, and has a right to expect, is that the service of the whole team, and all the apparatus and equipment they require, should be available to him or her by one single route. This implies that every citizen must be able, at all times and in all parts of the country, to call upon the services of a team of general practitioners (a team because they must each have leisure but the service must go on), who can obtain at once and without question the assistance of specialists and consultants, of nursing and medical auxiliaries, and admission to hospital when that is needed.

Above all, the patient has a right to demand that these services should be his of right, and that no question of fee or payment should stand between him and the fullest possible service. Life and health are too important to the individual and to the community to allow economic barriers to interfere with their preservation.

Ultimately, what the patient has a right to expect is that while medical science perfects its methods of cure, every means of preventing disease will be sought and every effort made to promote and improve the standard of health of the individual. The education of the people in health matters must be developed so that health becomes their concern individually and collectively.

OUR CHAOTIC SERVICES

Everyone is aware that these demands cannot be met by the present system of medicine. We have an entirely unplanned system which has developed along many different lines. That development has on the one hand been assisted by a feeling of unity among medical men which has made all advances in knowledge the property of the whole of the profession, and at the same time has been hindered by the economic basis of Medicine which has kept doctors isolated from one another in almost every aspect of their work. The founding of the voluntary hospitals on a method which involved the giving of many hours of free work among the sick poor by those doctors who were attached to the hospitals with the consequent necessity of charging the wealthier classes extravagant fees, gave the development of specialisation within the medical profession, a form of organisation which exists in no other. The industrial revolution, bringing with it the need for the provision of large hospitals for those who came under the Poor Law, added further complications to the medical scene. In the end we have a combination of medical agencies which can only be described as chaotic.

We now have in this country three different standards of qualification for a doctor and two totally different and unrelated hospital systems. In these two systems there is a complete lack of uniformity not only as to the size of the hospital buildings and the standards of comfort available in them but also as to the services which they provide and their method of staffing. Among voluntary hospitals, for example, there is a very great difference between the small cottage hospital staffed by general practitioners and the large teaching hospitals with many consultants and full-time staffs in most of the special departments. Public hospitals vary from institutions still bearing all the stigma of the Poor Law—badly built, badly staffed and badly run—to large, new, completely modern hospitals differing from the best voluntary hospitals only in the fact that their staffs are full-time officers. In addition to these general hospitals there are special hospitals and isolation hospitals; there are many special schemes, some of a voluntary nature and some organised by trade unions or workers’ organisations such as the miners’ medical societies, which in some cases have their own hospitals. There are also those services for infant and child welfare and for maternity and post- and ante-natal care operated by local authorities— but not always by the same local authority as provides the hospitals and sanatoria; there is the school medical service, there are many industrial medical services usually privately provided, and on top of all this there are the nursing homes and the private wards of voluntary hospitals serving a similar purpose.

A mere list of all the agencies does not indicate the full complexity of medical care. The real complexity arises from the fact that not all these services are available to every patient, that the route to be followed from one to another is not always the same, and that those services which are available to one member of a family may for a variety of reasons be quite outside the reach of another member of the same family. It must be emphasised also that the accident of geographical position may render it possible for a patient to obtain everypossible type of medical service, yet if he moves to another district inside what is after all a relatively small country, he may find nearly all those medical facilities entirely lacking.

Economic barriers

The nature of the complexity and chaos of our medical services may be more clearly seen if we consider how medical care is obtained by individuals.. In the case of that very small proportion of the population which has a high income the matter is relatively simple if they live in London or a large city, or can afford to seek their medical advice at such a centre. For all except the most trivial illnesses the general practitioner will have no hesitation in calling in a consulting physician or surgeon and will be able to arrange at a suitable fee for all specialist examinations.

In the case of those who are described as middle class because their income exceeds a certain unspecified amount the position is less satisfactory. The general practitioner cannot but be aware that while his own charges for even a prolonged illness may be paid, difficulties will arise as soon as the question of consultations and special investigations is brought up. If hospital care is required, the tendency, based to a large extent on snobbery and on ignorance of the conditions prevailing in our hospitals, will probably turn the sick person’s mind to nursing homes or the hospital private wards. Such expense is not to be faced without deep consideration, and it follows that, except in an extreme emergency or conditions where the need for hospital care over-rides all other objections, the general practitioner will be tempted to keep patients of this class in his own care at home for as long as possible, and may delay calling in the necessary consultants until the disease is well advanced.

It is when we come to the lower incomes, which constitute some 90 per cent of the population that the real “mix-up” in Medicine becomes clear. If we take an average family (see diagram on page 5) the extraordinary position is revealed that not only is there no provision for even minimum medical service for the whole family but there is no direct route to all medical services or even to one of them, and where-an approach can be made it may be different for every member of the family. Thus the only person who is guaranteed the services of a general practitioner is the husband—you, Mr. Smith.

Medical Services in 1944

For Mr. Smith, National Health Insurance provides a general practitioner.” Mrs. Smith will have to pay a small fee for calling in a doctor. If she likes the panel doctor and if this doctor charges a fee which she considers low enough, she may call him in and so obtains the first stage of medical care from the same practitioner as her husband; but in a very large proportion of cases the wife actually calls in her own private doctor, a quite different person (for instance, a woman doctor). This is, however, not the only source of medical advice available to Mrs. Smith, for she has been a regular attender, both before and since the birth of her last baby, at the maternity and child welfare clinic provided by her borough cbuncil. If the baby is slightly ill she takes him to the same clinic for advice from the medical officer. In the case of a more serious illness she usually takes the baby along to the out-patient department at the children’s hospital. If she has to call in a doctor for the baby, or for John, her next child, she will most likely call in the doctor she would consult herself.

John, being at school, is seen at regular intervals by the school medical officer, and he has once or twice been sent along specially because his teacher thought he needed attention. The school medical officer has records of John’s health since he went to school and so is in a position to note any change. He is not, as the law stands, able to prescribe any treatment at home, for the school medical service may diagnose, may treat minor ailments at the clinic, but cannot apply treatment in the home of the patient. If John is suddenly taken ill, therefore, he cannot be seen at home by the doctor who has been watching his health at school.

The remaining member of the family, Ruby, has recently left school and started work. Before the war she would have obtained her medical attention in the same way as her mother, but it is now possible for her to have a panel doctor, although she gets no cash benefits while sick. She never has liked her father’s panel doctor and has put her name on the list of the only woman doctor on the panel in her district. But she has not yet needed the services of this doctor because the works at which she is employed provides a medical officer who examines all new entrants before they commence work, and sees them at regular intervals and attends them in the event of accidents or minor illnesses.

Hospital care

If the Smith family is lucky enough to have no serious illnesses these different ways of obtaining the first stage of medical service may have no more serious results than the obvious ones, waste, inefficiency and expenses.But as soon, however, as the need for specialist and hospital treatment comes into the picture the chaos becomes intensified. We will discover that no member of the Smith family has any absolute right to hospital care or specialist services. The direction in which they will go for these additional medical needs will be dictated by whichever general practitioner they have called in, except where the preliminary medical examination has been done at one of the clinics we have mentioned. The general practitioner who decides that a sick member of this family must have another opinion or another form of treatment has at once to decide which of the two hospital systems he will patronise. He has to remember that the voluntary hospital retains the right to accept or refuse any particular patient, but cannot demand payment once it has admitted a sick person to its wards. On the other hand the municipal hospital cannot refuse the admission of anyone who is urgently in need of medical care but it can assess and demand payment for the service rendered.

The portal of entry to each of the systems is different, and in the case of the voluntary hospital many considerations other than purely medical ones must be taken into account. Thus, the urgent surgical case or one which is of great medical interest and rarity will be more readily received than one of a common and uninteresting kind, while a really chronic condition may lead to an absolute refusal on the plea that no bed is available. If the Smith family can afford to pay for one consultation it may be worthwhile asking a member of the staff of the voluntary hospital to see the case, and he may then not only give his opinion and advice but be able to arrange for immediate admission to his hospital under his own care. Whatever the doctor decides it is highly probable that both in view of the difficulties and of the fact that more than one general practitioner is likely to be attending to the family, one member of the Smith family goes to a voluntary hospital and another goes to the municipal hospital. The children will, of course, go to the children’s hospital if there is one.

Special departments lacking

But many of the illnesses which the Smith family meet do not require admission to hospital but need the services of the consultants attached to the hospital or of the laboratory and X-ray methods of diagnosis. For these they are to a large extent dependent on the out-patient departments of the voluntary hospitals. The position is made more difficult by the fact that the general practitioner may wish a simple laboratory test to confirm his diagnosis but may not be able to obtain this without sending the patient through the outpatient department because the hospital insists that these investigations can only be carried out at the request of the hospital’s own staff.

In many districts the question of laboratory facilities is complicated by the fact that even quite large hospitals do not run their own laboratory but send their work out to commercial laboratories where for a fee per specimen all kinds of examinations may be made. On top of this there is usually an arrangement whereby investigation of cases suspected of being infectious can be done at the expense of the local authority. The reader must not, however, imagine that all such investigations will of necessity be done at the one laboratory, for each Council makes a contract with a commercial or hospital laboratory for the work it wants done while examinations for suspected cases of venereal disease can be sent only to laboratories which are recognised as suitable for that purpose. In the most complicated districts it is possible for the pathological work relating to a family such as the Smiths to be carried out by five different laboratories. We must remember that clinical pathology is only of value where there is active co-operation between the general practitioner or other doctor and the pathologist, who can in many instances offei exceedingly valuable suggestions when he sees the patient personally.

In the case of X-ray examinations this need for personal consultation by the radiologist—that is to say, the qualified expert—is essential except perhaps in the most simple fracture cases, Where the procedure of “screening” a patient (the direct examination of the body under the X-rays as distinct from the taking of a photograph) is carried out, the radiologist does see every case. In this specialty, as with pathology, a much closer relation between the specialist and general practitioner is urgently required.

In both these specialties too, what is lacking is that they should be available to the Smith family in their own home. There are some occasions when the patient is too ill to move and the doctor would like very much to have an X-ray taken in the home, and there are a very large number of cases where examinations of the blood by the clinical pathologist would be of the greatest assistance. Medicine certainly can do more when it is able to use all these facilities, but the general practitioner must remain an incomplete servant of science and of his patients so long as he has to do without them. The practice of sending patients to out-patient departments is one that is universally condemned and causes more annoyance to the sick than any feature of British Medicine. The long waiting-time, the failure of honorary medical and surgical staff to attend at the proper time, the visits to the almoner’s department and the queue at the dispensary have all been depicted and ridiculed over and over again.

Better convalescence

Despite all these difficulties, inconveniences and incongruities the Smith family do recover from their illnesses and have many times had to thank the medical profession for great assistance in defeating disease. Having got over the serious stage of an illness, it is important that before going back to work or back to school they should have a period of recuperation. Everyone is aware that a change of scene and a short period in the open air combined with gentle exercise that tones up the system may make a very big difference in the ultimate health of a patient who has been seriously ill. For the Smith family the simplest way in which this valuable item of health restoration could be provided would be by a visit to a convalescent home. Yet convalescent homes are to a large extent divorced from the hospital system. The Smith family wilt be very fortunate if they have subscribed to any fund which arranges for convalescence or if they are members of a cooperative society or trade union which provide for their members this facility, for the fees at such homes, according to P.E.P., vary from “what the patient can pay to what the management thinks it right to ask.”

Complex as this description and the diagram which accompanies it are, a complete survey of all the medical agencies reveals still further intricacies. In particular, one would be astonished and sometimes amazed to discover how great is the variety of organisations and associations, religious, political, racial, academic and fraternal, which concern themselves with medical matters. One would discover hospitals set up for highly-specialised functions which they no longer carry out, and if one waded through all the complex legacies and endowments made for special purposes which have now no validity in medical science one would be astonished not that chaos remains in the medical services of the country but that there should have been such technical developments as we have seen and that we should have reached any degree of organisation whatsoever.

A NATIONAL HEALTH SERVICE

If we are to establish a system of health care, if we are to provide a single route to the whole medical service, jf the people are to play a part in its development and running, we must plan the service as a single integrated whole. Fundamental changes must be made if chaos it to give place to order.

In no country has the development of Medicine been a conscious and planned procedure; new knowledge has been grafted on to old and ancient methods and anachronistic procedures have remained side by side with scientific advances which have been as rapid in this field as in any other. Hospital buildings, designed to last a hundred and more years, have tended to influence the retention of a system of staff appointments and methods of working that have vanished from every other profession. Charity has become inextricably mixed with systems of collecting money from even the poorest, and doctors have surrounded themselves with an ethical code which prevents them dealing as they should with the evils of both orthodox and unorthodox methods of healing.

This ethical code has developed because the profession has felt that Medicine should not be governed by the ordinary rules of business, and that so necessary is the work of the physician to mankind as a whole that his service should not be bound by financial considerations. The young doctor is therefore supposed to dedicate himself to humanity and to dare all and do all in that service. Yet he soon finds himself “up against” many types of economic and social difficulty. The ethical code has long lost its altruistic nature and in a large measure ” consists of regulations for enforcing what might be called fair business practice.” The ethical guardians of the profession can do little more, as Sigerist says, than try to avoid “the worst abuses of competitive business by forbidding advertising, splitting of fees, taking patients away from a colleague, making money from patients, avoiding competition through contract practice, etc.”

Perfect relationship

It is only when Medicine ceases to be a trade or business and doctors can regard their patients without any consideration of fees, either their own or those of specialists or charges in hospitals, that these modern additions to the basic altruistic code of Medicine become clearly superfluous and without meaning. When all questions of fees have been banished the perfect relationship between patient and doctor can be established.There can then be only one standard of medical attention, only one class of patient, and the whole of medical science can be used for his benefit.

Since Medicine involves so many specialists, so much intricate and costly machinery, since it needs the co-operation of so many different professions and the correlation of disease prevention with the greater national questions of environment and nutrition, it cannot be effective unless it is available completely to all. Its basis then becomes scientific and as disease loses its ” magical implications ” it can be considered —as it is in fact—” a biological process that has to be faced openly and to be treated scientifically.”

This development cannot, however, take place while, as Sigerist puts it, ” the fight against disease is not led by one general staff but by a multitude of staffs among which there is often little or no co-operation.” It is clear that a complete medical service available to every citizen at all ages and all times must be led and controlled by a central organisation, a Ministry of Health. That we have such a body is due, not as it should be to the recognition of past Governments that a health service is needed, but to the accumulation of those ” unprofitable cases ” which the State had to step in and handle since no existing medical organisation could or would do so.

Ministry of health

The Ministry of Health must, therefore, be not only reorganised but given a completely new orientation to the question of health. It must be the inspiration and guiding force of the new medical service; it must visualise disease prevention as no British Minister of Health has ever had the chance to do; it must lay down the principles on which the service is to stand; it must see that the equipment, machinery, buildings and personnel are available wherever needed. It will have to move far beyond its present narrow orbit and become the mainspring of all movements to improve the environmental conditions of the country.

A service controlled by the Ministry of Health must obviously be a national one, and the term brings to mind all those bogies of bureaucracy and red tape which have in the past led doctors to fear the intervention of the State in medical matters. We shall make it clear that in matters affecting the individual patient no one has any right, or will be given the right, to interfere between the doctor and his patient. The “Whitehall bureaucrat” has no part in a modern medical service beyond those indicated—relating it to other services and guaranteeing that a minimum service will reach every person in the country.

That a State medical service can be so constructed as to avoid the evils of “muddling bureaucrats” appears impossible to many of the older members of the medical profession who are far from moderate in their criticism of our civil servants, of whom, in this connection, the late Sir Henry Brackenbury, of the B.M.A., once wrote : “The qualities required of the Civil Service are in many respects the antithesis of those needed in the actual practice of Medicine.” He went on to say, “The indifferent physician may well find his best interests served by a bureaucratic system with office hours and a pension.” This attitude is as unfair as that which classifies all doctors as “money-grabbers,” or stigmatises the panel practitioner as interested only in the financial side of that system because some doctors make the double standard of treatment to which patients are liable too obvious.

It is clearly false to suggest that a man only does work that he is paid for doing and that he is vitally interested only when he is going to get in return something more than other men get. In the case of doctors there is no evidence that those in salaried positions do less than those in private practice, for all doctors are fortunate in doing work which is ever varied and ever valuable, providing incentives greater than any financial motive.

Regional planning

The medical service of the future, however, will necessitate, in addition to the Ministry of Health, two further administrative stages—one related to the universally accepted view that in Medicine (as in most other activities, defence, transport, electricity and water supply) the controlling authority of the future must cover a wider area than any existing local authority, for we must free ourselves from centuries-old boundaries which bear no relation to the changes wrought by the growth of industry; the other intensely democratic, responsive to the needs and wishes of every individual citizen, and directly concerned with the medical service of its own neighbourhood.

The first of these forms of organisation is generally spoken of as “regionalisation” and is accepted by all medical organisation as one of the lines of future development. This would necessitate the establishment of Regional Health Boards. It would involve dividing the country into a number of Regions which will get rid of those local government boundaries which pay no regard to natural social and economic groupings and so inevitably create problems. This is not a question of increasing the area of population to be controlled by the new regional authority, for it is conceivable that investigation would show that in this or that area the necessary co-ordination could only be obtained by changes which would lead to a diminution of the population falling within a particular region. In general, however, it would lead to a wider region than any now in existence and this should bring about greater efficiency and economy, for all organisations which have studied the question believe that a great deal of readjustment and co-ordination can be effected without additional expense.

The method of election of these regional authorities must be settled for the whole country and for all public services, as most of the latter will also benefit from this form of control— one which will lead to carefully thought-out plans for wide areas instead of improvisations in many small districts. It will be the work of these committees to consider the national plan as prepared by the Ministry of Health and to relate the service to the needs of every citizen and group in their areas. It will be for them to see that the service does, in fact, exist in a form that makes it accessible to all; it will be for the doctors in the smaller units to inspire the system with the spirit of service which will make it a living thing.

Among the problems which.the Regional Health Boards will consider is the number and distribution of hospitals in its area. There will, of course, be active co-operation between the areas so that overlapping is avoided at the new boundaries, but the latter should be fixed so that, in fact, overlapping is almost impossible. The whole question of hospitals bristles with debatable points which we have not space to discuss; and since it involves the co-operation of architects and town-planning experts it cannot be finally settled until the principles of town-planning have been agreed upon. If, as medical men would suggest, our towns are restricted in size, if houses are planned in relation to industry and transport, if they give maximum light and air and look out on growing trees and grass, there will be no difficulty in placing hospitals in suitable sites within the town. Our conception is that all hospitals should be placed in the closest proximity to the patients whom they will serve, but so long as we are faced with unwieldy, unplanned cities such as London, we may have to modify that. We may perhaps want to put some hospitals in the open country; that should not be necessary provided convalescing facilities are adequate, but it emphasises the need for relating our hospital provision to other developments.

Better hospitals

Hospitals have in the past been built as too-permanent structures. Whether we can devise new methods of hospital building which will enable us to embody all scientific departments and yet be elastic enough to meet those new demands which are today as little guessed as were our needs in the era before operating theatres and laboratories is a problem which has not yet even attracted attention. Whether we should build upwards for light and air and convenience of transport, or outwards—as at present—getting light and air at the expense of long corridors, time-consuming distances, and expensive heating and lighting systems is one of the questions yet to be debated. Another is how we can serve invalid food on a large and economic scale. Such questions as these will be dealt with by the Regional authority, which will also see that the funds available are evenly distributed.

But it is only when we come down to the smaller administrative unit, which we may call the local Health Unit, that the form of our medical service as it affects the individual citizen and the individual doctor becomes clear. This should be a unit of a size and form dictated by local conditions and constituted for the purpose of preserving health. In each of the large regions already visualised there will be as many local units as the population requires, and each unit will, with certain highly specialised exceptions, provide a complete service for the preservation of health and the treatment of disease. From what has been said in earlier chapters it will be seen that it must be based on the provision of a general practitioner doctor for every individual, that that doctor must be a member of a group of doctors providing all specialists, and that the service must be centred on a large hospital at which provision has been made for all the institutional needs of the community.

We must, therefore, have a clear idea of the size of the unit, and in some respects this depends on the hospital, and constitutes indeed one of the problems which the regional authority will have to debate. Hospitals vary in size from the tiny cottage hospital of some twenty beds or less to huge mental hospitals of 2,000 beds. General hospitals with full medical and surgical facilities vary from some 300 to 1,500 beds; in some, out-patients form the greater part of the work done.

Below a certain size no hospital could find employment for a full staff; above it administration becomes difficult, duplication of departments may be necessary, and it is almost impossible to maintain that spirit among the staff which leads to harmony and real team-work. To put it dogmatically, all considerations point to a hospital of 600 to 1,000 beds as being the largest likely to be suitable, and the higher figure may prove adequate for the ideal unit of population,namely,100,000 people.

The hospital of the Local Health Unit would sweep away the invidious selection system of the large voluntary teaching hospitals and the remnants of the administrative methods and defects of the Poor Law stillinherent in the municipal hospitals. There would be an open door not only to the cases of interest from a technical point of view, the “interesting and stimulating” surgical cases, and those admitted because the consultant wishes to propitiate his clients, the general practitioners, but to those equally ill but less interesting and chronic patients who are now diverted to the municipal and Poor Law hospitals. Both patients and doctors would benefit from the wider variety; and hospital finance and administration would be less difficult.

It will at once be clear that this is an almost ideal unit for the type of service we have discussed, responsive to the needs of the patients, easily controlled, easily infused with a spirit of social responsibility, and small enough for every man and woman on the staff to be aware of the standard expected and of the class of work put into their departments by every colleague. In such a unit it would be impossible for that fear of the “maintainers of tradition”—red tape; slack and unprofessional work—ever to raise its head. The contact of colleagues, the sense of his importance to the community and the awareness of how much his efficiency means to that community would raise every doctor to a standard of proficiency attained only by the best today.

The greatest change we have to suggest in the hospital is in the out-patient department. Of the three main functions of these departments at present it is generally agreed that two should not be performed by hospitals at all, as they can be provided better in other ways. “Casualty” work, which should be confined, but rarely is, to dealing with slight and sudden injuries, and the giving of advice to those who come direct to the hospital for diagnosis and treatment are functions which, in fact, should be carried out by the general practitioner and would be but for economic difficulties and lack of equipment and facilities. The doctor’s consulting-room is no place for minor surgery, and in any case the doctor is too seldom available just when the casualty occurs. The third function of the out-patient departments, and in the opinion of many the only true function, is to provide a service of consultants to whom other doctors can send cases.

THE HEALTH CENTRE

The Health Centre will be the keynote of the health service of the future. No exact prototype exists, but we have the guidance of many experiments which range from the Peck-ham Pioneer Health Centre over the “streamlined” clinics of Kaiser’s Californian shipyards and the rural centres of Porto Rico to the polyclinics of the U.S.S.R. It is at and through the Health Centre that Mr. Smith and his family will obtain a complete health service by a single route.

The health life of the community will be based on the Health Centre. For the Smith family there will be only one route to a complete medical service, through the general practitioner service of the Health Centre, but by that route all specialist and consultant services will be available in the home and at the Centre. Admission to hospital will also be through the Centre, and from both Centre and hospital there will be certain access to convalescent homes arranged on modern lines. There will be no re-duplication of services; the same laboratory, for example, will serve the community at all stages. The Smith family will then know exactly where to turn for every medical need and will have no fear of accepting the offer of specialist help for they, as taxpayers, will have paid already for the whole service.

To begin with, they will turn to the Health Centre for advice on all matters of health preservation, and this advice they will get individually or as part of the community, health exhibitions, film shows and talks being a constant feature of the Centre. They will also attend for periodic examinations, in the course of which early disease changes may be found long before they are severe enough to produce symptoms.

In the case of illness the general practitioner will be seen at or summoned from the Health Centre. He will set in motion the machinery for diagnosis, treatment and convalescence. Those services which Mrs. Smith and the baby already enjoy at a clinic will still be available, and any service Mr. Smith and the younger members of the family as they leave school need in connection with their industrial employment will be obtainable at or in relation to the Health Centre.

The Health Centre would not only provide the base for the domiciliary service but would combine the functions of the doctor’s surgery and the hospital out-patient department. Those who pretend to understand what is suggested for the medical service of tomorrow always sneer at “clinic” medicine. They fail to see how helpful the Health Centre would be both to the sick and to the doctor. The doctor seeing a case at the Health Centre would have at his service in the same building or in the related hospital every specialist whose assistance he might want. Instead of cudgelling his brains as to where he could send Mrs. Smith for a second opinion, a blood count or an X-ray with a view to admission to hospital, he would only have to step across the corridor to an esteemed colleague who would arrange the necessary tests and give his opinion without interminable delay, and without Mrs. Smith having to come up over and over again and sit in that draughty waiting-hall. If she did have to come back again she would come at a time when she would know she would be seen to the minute, and if she had to wait for hours while tests were being done she would find comfortable and soothing surroundings in which to wait. If she had to bring the baby she would find the creche, in the same building, an excellent place to leave him for a few hours. And if she had to go into hospital it would be arranged there and then without any difficulty about a bed and without any heart-burnings about the cost; she could leave the baby in the day nursery; and her own doctor would have the right to visit her and see how she was progressing.

Medical Service Based on a Health Centre

A new attitude to health

The Health Centre would be a busy place. It would have one great advantage not yet mentioned. To it would come every citizen while well and so they would become familiar with the place and its wonders while free from the worry of ill-health. They would learn, for the health education and health preservation activities of the community would be centred there, to turn to the Health Centre whenever they felt the slightest thing wrong. The presence of the healthy undergoing the same type of test and examination as the sick in the same building and by the same doctors would alter the whole attitude of the community towards disease and give the doc tors a balanced view of the normal and the abnormal at present impossible.

The doctors, too, would look to the Health Centre as the hub of all their activities. Here their hours of leisure would be arranged and guaranteed; here they would do their turn of night duty; here they would see in operation that new conception of Medicine, a complete chain of medical services always available to all, but a chain in which no link was’overstrained. Here they would find colleagues able to advise, criticise and correct, and here they would gain that wider knowledge and experience which is the never-ending search of every doctor throughout his career.

Part of the staff of the Health Centre would be home visitors who would help the doctor to build up a picture of the . social background to every case he saw. To them would fall the duty of seeing that the home of the sick person—breadwinner or wife—did not deteriorate while they were in hospital. Through them would be provided that home help which would ease so much of the struggle to avoid prolonged illness which leads too many to delay treatment until it is too late. This home help, though, would not in a fully integrated medical service be so urgent as at present, for there would be adequate provision of day nurseries and nursery schools so that care would always be taken of small children.

A record system

As we see the Health Centre will focus all the health activities of the population it serves. It will co-ordinate the domiciliary work of the doctors, arrange consultations and act as the report and record centre for the whole unit. The clerical staff would deal with all requests for visits and complete, up to date records of the health and illnesses of every patient would be kept.

How important this keeping of records is will be recognised by anyone who has been ill and who has tried to answer the doctor’s questions about previous illnesses. It is an essential part of diagnosis to take a careful history of the patient, and many medical men have fallen into errors by neglecting routine inquiries about the health of the patient and his family. Apart from those familial, hereditary and congenital diseases in which the history is of obvious importance there are many conditions in which a knowledge of previous illnesses will immediately clear up the position.

Those who desire to perpetuate the present lack of planned Medicine claim that the ordinary family doctor acquires a full knowledge of his patients and so can judge each illness in the light of previous ill-health. This is false unless one visualises a small community in which neither patients nor doctors change much over a long period of years, and even then any break in the continuity would mean the complete loss of all knowledge of the patient’s previous health standard.

True continuity is possible only when a complete record of the normal health of the individual, his general development and nourishment, his blood condition, and his freedom from detectable defects can be placed alongside the history of any new disease, and the results of examinations and tests compared. With the best will in the world no ordinary doctor can, under present conditions, keep full notes of every patient; and few patients who change their district and their doctor are able to convey anything like a complete picture of their own health standard. Doctors working at a Health Centre would not only have adequate time for full investigations of all complaints but every person would be encouraged to attend for periodic examinations, so that a continuous record of every citizen would gradually be built up and would be available wherever the patient attended for medical advice. How much time would be saved in this way it is impossible to calculate, but years of hospital experience and contact with large numbers of general practitioners suggest that it would save many hours in every doctor’s time and much re-duplication of laboratory and other tests. To a patient, to give a very common example, the taking of any sample of blood is a blood test and the result a hidden mystery; to the doctor an accurate record of all blood tests taken and of the results might be of inestimable value.

The keeping of such records necessitates the employment of large staffs specially trained for this work. It has been objected that the examination and inquiries of a doctor are secret and confidential and that the intervention of lay staff would be a breach of professional etiquette. This, like so many other arguments, is but an apology for those doctors who are incapable of keeping an accurate record or cannot afford a secretary; in Harley Street it is an essential that a consultant should employ a secretary, who makes and keeps the fullest possible notes. This atmosphere of the confessional which some of our more primitive medicine men would like to see preserved, is a relic of the days when disease was regarded as a punishment for sin, when the spite of God or the machinery of the Devil seemed the only possible explanation for sudden illness caused, as we now know, by invisible germs.

The implications of such a service will have become apparent to the reader. In the first instance all doctors employed in the service must be salaried officers, with all the advantages that implies. Given an education in the social background of disease they will be able to apply themselves vigorously to the prevention as well as the cure of disease, and to appIy themselves without ever having to consider the financial position of their patients. The total cost of the service will be such that the State will accept the burden as its own and the service will be freely available to the whole community. This will not prevent any who are so possessed of anachronistic anti-social habits as to wish to make their own arrangements to “contract out” of the service if they can find a doctor to attend them; nor will it prevent a doctor from setting up in practice if, without any of the advantages the rest of the profession would enjoy at the Health Centre and hospital, he thought he could attract enough patients to earn a living.

Service always available

The service would also be available at all times. This appears to some to be a revolutionary conception which would undermine the morale of the people, for it is thought to be an inherent instinct of the British people to make abnormal demands on anything they know is free and available at all times. That this is a habit of any race is probably quite untrue, but there is evidence from many places that in the case of the medical service it is quite without foundation. The greatest fear of the doctor is that he should be called out unnecessarily and especially at night. There is evidence that when people know they can always see the doctor at the Health Centre the number of urgent visits drops at once; and in any case no doctor working at a properly organised centre is ever likely to be over-worked or to take anything but a pride in the number of calls made on him during his rota of duty.

At the moment not only is the individual doctor often brought out unnecessarily, but the medical profession as a whole has calls made upon it which no other profession or trade would tolerate. It is every doctor’s fate to return from a round of visits to find new calls waiting for him in the streets he has just left; and more wasteful still, for a number of doctors to be visiting in the same street at the same time.

The answer to the second point—unnecessary night calls— is two-fold. As with day visits the greatest cause of calls on the doctor after dark is the economic difficulty of the patient who bears pain, temperature and other disability moderately well during the day but is apt to be panic-stricken when darkness falls or when the temperature rises in the evening. This outweighs the cost involved and the doctor is hurriedly sent for, particularly when the patient is a child; and every doctor can tell of being called at midnight to see one with a sore throat whose parents, well aware of the times sore-throats have cleared up without medical intervention, have not suspected diphtheria until the child got worse in the evening and have felt that whatever the cost they must get advice. Remove this economic barrier and doctors will only be called out at night by the real emergency.

The second answer is that while the service will be continuously available the individual doctor will not be, as at present, continuously on call. Doctors who have so often told men to rest and avoid over-work are almost the only workers who are expected to be on call for the whole twenty-four hours. In the Local Health Unit night work will be done on a rota system’and each general practitioner will be on duty at intervals which, according to the needs of the system and the presence or absence of particular epidemics may be as infrequent as one week in every ten. It is true that he may occasionally miss seeing an emergency in a family in which he feels a special interest, but he will not be—as he would today were another doctor called in his absence—unaware of it, for the health record of the patient will be available to him and if he likes he can see the case in hospital or discuss it with the colleague who happened to be on duty.

We have spoken of the need for working out the details of the new Regional organisations of the post-war Britain and in particular of the Regional Health Boards. By some it is suggested that the Regional Boards should deal with hospitals only, leaving many smaller parts of the service to the county and county borough councils. Such a compromise may, of course, be necessary until local government is reformed as a whole. This would probably involve a separate administrative machine for general practice which, however necessary in transition, could be only a temporary measure.

Another organisation is needed at the periphery of the service, in the Local Health Unit, in hospitals and Health centres. In the latter we must have a form of ” industrial democracy” which gives to all health workers a definite share in the day-to-daly running of the service. Staff committees, sectional and total, must be a recognised part of the system and must have clearly defined degrees of collective responsibility, including spending power. With these must be linked lay representatives whose primary function is to represent the patients rather than to represent the committees of the regional authority. Clarification of these matters may not be completely possible until the service is further developed, but a start should be made in developing such methods even before the service itself is in being.

This National Health Service is more than an advance in the social arrangements of Britain, for it will provide a model on which all the new health services of the world will be based. Health will become the most carefully guarded, as it is the most valuable, asset of mankind.

Important Pamphlets

  • The Labour Party’s Plan 2d.
  • A SOCIALISED HEALTH SERVICE S.M.A. Policy 6d.
  • A SOCIALISED DENTAL SERVICE S.M.A. Policy 3d.
  • THE SOCIAL SERVICES The immediate problem and the way forward 6d.
  • MILK : The need for Pasteurisation 4d.
  • NEW WEAPONS AGAINST TUBERCULOSIS Mass radiography and financial allowances 3d.
  • HEALTH AND SAFETY COMMITTEES IN INDUSTRY Their origin, growth and development 6d.
  • NURSING: The Post-War Plan 6d.
  • MOTHER & CHILD The Maternity and Child Welfare Services 3d.

Any of the above can be obtained from

TODAY TOMORROW PUBLICATIONS, LTD.,

35, Long acre, London, W.C.2

 

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