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T H I S . D O C U M E N T I S T H E P R O P E R T Y OF H I S BRITANNIC M A J E S T V S G O V E R N M E N T
Printed
for the War Cabinet.
February
S E C R E T .
1944.
Copy No.
W.P. (44) 74.
5th February,
1944.
I
v
V
i
/
WAR CABINET.
PROPOSALS FOR A NATIONAL H E A L T H
SERVICE.
MEMORANDUM BY THE M I N I S T E R OF RECONSTRUCTION, THE M I N I S T E R OF H E A L T H
AND THE SECRETARY OF STATE FOR SCOTLAND.
T H E W a r Cabinet Connnittees concerned with reconstruction have
considered, in a series of meetings lasting over many months, detailed proposals
for the National Health Service which the Government have promised to
establish.
There have been differences of opinion among members of the Committee on
a number of points. T h a t was inevitable in the consideration of a scheme so
extensive and so complex.
The Reconstruction Committee have, however, agreed to recommend the
scheme described in the attached prints :-—
(a) The draft of a W h i t e P a p e r ; and
(b) a memorandum explaining the W h i t e P a p e r proposals more shortly,
which will be issued as a Stationery Office publication.
A t their last meeting the Reconstruction Committee agreed to make certain
amendments in the text of both Papers. Most of these relate to points with which
we need not trouble the W a r Cabinet. Certain questions of principle were also
raised, however; and, with a view to meeting these, the Committee agreed to
recommend the modifications set out in the Appendix to this Memorandum.
W e now submit the scheme for the approval of the W a r Cabinet.
W.
H . U. W .
T. J .
5th February,
1944.
APPENDIX.
(1) I n the Longer paper, on page 30, for lines 5-10 of the second p a r a g r a p h
under the heading " General Lines of H e a l t h Centre Development," substitute:—
" . . . . 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 t h a n
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."
[26872]
In the Shorter paper, on page 7, for the last sentence in the third p a r a g r a p h
under the heading " Grouped Practice and Health Centres," substitute :—
' ' Alternatively, they must be able, if they prefer it, simply to choose
their Centre rather than any particular doctor in it, and then the Centre 's
arrangements must be such as to ensure that they are offered all the proper
advice and treatment there which they may need."
(2) I n the Longer paper, on page 35, and in the Shorter paper, on page 11,
add, at the end of the p a r a g r a p h headed " Entry into the public service," the
following sentence : ­
" 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 t h i s . "
(3) I n the Longer Paper, on page 35, at the end of the first p a r a g r a p h
headed " Sale and Purchase of Public Practices," add at the end :—
" I n 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
p a r a g r a p h s ; and measures to prevent this must be included in the
discussion."
I n the Shorter paper, on page 11, at the end of the p a r a g r a p h headed " Sale and
Purchase of Public Practices," add :—
" . . . . including any measures which may be needed to prevent the
operation of the new public service from itself increasing the capital value
of an individual practice and therefore also the compensation which may
later have to be p a i d . "
A
N A T I O N A L
H E A L T H
Presented
by the Minister
SERVICE
of Health
to Parliament
and the Secretary
by Command
of State for
of His
Scotland
Majesty
1944
LONDON
PRINTED A N D PUBLISHED BY HIS M A J E S T V b STATIONERY OFFICE
To be purchased directly from H.M. STATIONERY OFFICE at the following addresses 1
York House, Kingsway, London, W.C.2 ; 120 George Street, Edinburgh a j
39=4: King Street, Manchester 2 ; 1 St. Andrew'? Crescent, Cardiff;
,
80 Chichester Street, Belfast ;
or through any; bookseller
r
944
Price d. net
Cmd.
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6
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P
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4
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F
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8
CONTENTS. Page
INTRODUCTORY
...
...
...
...
...
...
.-.
I.—The Present Situation.
II.—The next Stage; A Comprehensive Service for All.
The method of approach The scope of a " comprehensive " service... Temporary exceptions t o " comprehensiveness " . . . Mental health... Some misconceptions about the meaning of'' comprehensive "
General n a t u r e of t h e G o v e r n m e n t s proposals ...
...
...
...
-
III.—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 services
The place of the joint authority outside the hospital
services
...
....
...
... . ...
General ...
...
...
...
...
...
Professional guidance in local organisation
Local Health Service Councils
Direct professional representation on local authorities
IV.—Hospital and Consultant Services.
The p a r t of the v o l u n t a r y hospital
...
Preparation of local area plan
...
...
'...
Central approval of local area plans
...
...
General conditions to be observed b y hospitals ... Financial arrangements w i t h 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 t o the problem The p a r t of central and local organisation in t h e service... Grouped general practice
General lines of H e a l t h 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 p a r t of t h e new joint authority ...
General
Permitted n u m b e r of patients...
E n t r y into t h e 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 a t t i t u d e in patient and doctor...
...
VI.—Clinic and other Services.
M a t e r n i t y and child welfare services
School Medical Service
...
...
\..
Tuberculosis dispensaries and other infectious disease work
Cancer diagnostic centres ...
...
Mental cliiiics...
Venereal diseases
...
...
...
New services likely to develop
Medical research
The p a r t of Medical Officers of H e a l t h and others
VII.—The Service in Scotland.
Central administration
...
...
....
Local organisation
Administration of t h e hospital and consultant service
Administration of t h e clinic services ...
Administration of t h e general practitioner service ...
Local Medical Services Committees ...
...
VIII.—Payment for the Service.
IX.—General Summary.
APPENDICES.
Appendix A.—-The existing health services ; s u m m a r y
present situation a n d its origins.
of
the
Appendix B.—Earlier discussions of improved health services and
an outline of events leading u p to t h e preparation of
this Paper.
Appendix C.—Possible methods of securing local administration
over larger areas t h a n those of present local
government.
Appendix D.—Remuneration of general practitioners.
Appendix E.-—Finance of the new service.
INTRODUCTORY.
T h e G o v e r n m e n t h a v e a n n o u n c e d t h a t they intend to establish a com­
prehensive health service for e v e r y b o d y in this c o u n t r y . T h e y w a n t to ensure
that in future every m a n a n d w o m a n a n d child can rely on getting all the
advice arid t r e a t m e n t a n d care which t h e y m a y need in m a t t e r s of personal
health; t h a t w h a t they get shall be the best medical a n d other facilities avail­
able; t h a t their getting these shall not d e p e n d on whether t h e y can p a y for
them, or on a n y other factor irrelevant to the real n e e d - t h e real need being
to bring the c o u n t r y ' s full resources to b e a r u p o n reducing ill-health a n d pro­
moting good health in all its citizens.
A comprehensive health service w a s c o n t e m p l a t e d b y the Beveridge Report
on Social I n s u r a n c e a n d Allied Services. T h a t R e p o r t founded its proposals
for social security on three " Assumptions " . O n e of these Assumptions was
t h a t there w o u l d be a national health service, w h i c h —
' ' will ensure t h a t for every citizen there is available w h a t e v e r medical treat­
ment h e requires, in w h a t e v e r form he requires it, domiciliary o r institutional,
general, specialist or consultant a n d will ensure also the provision of dental,
ophthalmic a n d surgical appliances, nursing a n d midwifery, a n d rehabilita­
tion after a c c i d e n t s . "
It was not the concern of the R e p o r t to say how this should b e d o n e . I t simply
pointed out t h a t it w o u l d need to be d o n e , if t h e m a i n p r o p o s a l s in regard
to social security were to b e able to be p u t into effect.
B u t the comprehensive health service does not, of c o u r s e , derive only
from t h e p r o p o s a l s of the Beveridge R e p o r t . T h e idea of a full health and
medical service for t h e whole p o p u l a t i o n is not a completely n e w one, arising
only as p a r t of post-war reconstruction. I n the long and continuous process
b y which this c o u n t r y has b e e n steadily evolving its h e a l t h services the stage
h a s been r e a c h e d , in the G o v e r n m e n t ' s view, at which the single compre­
hensive service for all should be r e g a r d e d as the n a t u r a l n e x t development.
T h e e n d of t h e w a r will p r e s e n t the o p p o r t u n i t y , a n d p l a n s for post-war recon­
struction p r o v i d e a setting, .but t h e proposal to set u p a comprehensive
service has t o be seen against the p a s t as well as the future a n d t o be recognised
as p a r t of a general evolution of i m p r o v e d health services w h i c h h a s been
going o n in this c o u n t r y for generations. T h e case for it s t a n d s on its own
merits, irrespective of the w a r o r of other proposals for post-war reorganisation.
It is n o t a question of a wholly n e w service, b u t of one w i t h m a n y roots
a l r e a d y well established. T h e m e t h o d s of organising it m u s t b e closely related
to history a n d to p a s t a n d present experience.
T h e decision t o establish t h e new service applies, of course, to Scotland as
well as to E n g l a n d a n d W a l e s a n d the' present P a p e r is concerned with both
countries. T h e differing circumstances of Scotland are b o u n d to involve
certain differences of m e t h o d a n d of organisation, although n o t of scope or
of object. T o d r a w distinctions t h r o u g h o u t the P a p e r in r e g a r d to the detailed
application of t h e n e w proposals in each c o u n t r y would u n d u l y complicate
the t e x t . F o r this reason the principal differences which arise in a p p l y i n g the
proposals t o Scotland a r e reviewed all together, in chapter V I I . Similarly
most of the P a p e r h a s , for convenience, to b e expressed i n t e r m s (e.g. in
its references to local authorities) which are n o t equally a p p r o p r i a t e to both
countries. Subject to the review of the m a i n differences in chapter V I I ,
these t e r m s should n o r m a l l y be t a k e n as covering w h a t e v e r is their counter­
p a r t in Scotland. T h r o u g h o u t the P a p e r the a p p r o p r i a t e Minister will be the
Minister of H e a l t h for E n g l a n d a n d W a l e s a n d for Scotland t h e Secretary of
State, a n d references to the Minister should n o r m a l l y b e so c o n s t r u e d .
The p u r p o s e of the P a p e r is t o e x a m i n e t h e subject generally, to show
what is m e a n t b y a comprehensive service a n d how it fits with w h a t h a s b e e n
done in the past o r is being d o n e in t h e present, a n d so to help people to
look at the m a t t e r for themselves. T h e p r o p o s a l s m a d e in the P a p e r (and
summarised at the end of the P a p e r ) represent what t h e G o v e r n m e n t believe
to b e the b e s t m e a n s of bringing fhe service into effective operation.
The
Government w a n t these proposals t o be freely e x a m i n e d a n d discussed. T h e y
will welcome constructive criticism of t h e m , in the h o p e t h a t the proposals
which they will b e submitting to P a r l i a m e n t m a y follow quickly a n d m a y b e
largely agreed.
I. THE PRESENT SITUATION. T h e record of this c o u n t r y in its h e a l t h a n d medical services is a good
one. T h e resistance of people to the w e a r a n d t e a r of four years of a second
world war bears t e s t i m o n y to it. A c h i e v e m e n t s before the w a r — i n lower
mortality r a t e s , , in the g r a d u a l decline of m a n y of the more serious diseases,
in safer m o t h e r h o o d a n d healthier childhood, a n d generally in t h e prospect
of a longer a n d healthier life—all s u b s t a n t i a t e it. T h e r e is no question of
h a v i n g to a b a n d o n b a d services a n d t o start afresh. Reform in this field
is n o t a m a t t e r of m a k i n g good w h a t is b a d , b u t of m a k i n g better w h a t is
good already.
T h e present system has its origins d e e p in the history of t h e c o u n t r y ' s
social services. B r o a d l y , it is the p r o d u c t of the last h u n d r e d y e a r s , though
some of its elements go m u c h farther b a c k . B u t most of the impetus- has
been gathered in the last generation o r two, a n d it w a s left to the present
c e n t u r y to d e v e l o p most of the personal h e a l t h services as t h e y are now
known.
This historical process, a n d the health services so far emerging from it,
must be looked a t in some detail if the present situation is to b e understood
a n d if new proposals are to t a k e p r o p e r a c c o u n t of it. There is, therefore,
a p p e n d e d to this P a p e r (in A p p e n d i x A) a general s u r v e y of the medical and
health services as t h e y exist now, a n d of t h e w a y in which t h e y c a m e into
being. Some features of the present services will also be discussed as they
arise in later p a r t s of this P a p e r , when the different b r a n c h e s of medical care
—-general, specialist, hospital a n d o t h e r s — a r e considered in m o r e detail. The
i m m e d i a t e question is h o w far the present a r r a n g e m e n t s are i n a d e q u a t e and
w h a t are the reasons for altering or a d d i n g to t h e m .
T h e m a i n reason for c h a n g e is t h a t the G o v e r n m e n t believe t h a t , a t this
stage of social d e v e l o p m e n t , the care of personal h e a l t h should be p u t on a
n e w footing a n d b e m a d e available t o e v e r y b o d y as a publicly sponsored
service. J u s t a s people are accustomed to look to public organisation for
essential facilities like a clean a n d safe w a t e r s u p p l y or good highways,
accepting these a s things which the c o m m u n i t y combines to p r o v i d e for the
benefit of t h e i n d i v i d u a l w i t h o u t distinction of section or g r o u p , so they
should now be a b l e to look for p r o p e r facilities for the care of their personal
health to a publicly organised service available to all w h o w a n t to use it—
a service for which all would b e p a y i n g as t a x p a y e r s a n d r a t e p a y e r s and
c o n t r i b u t o r s to some national scheme of social security.
I n spite of t h e substantial progress of m a n y y e a r s a n d t h e m a n y good
services built u p u n d e r public a u t h o r i t y a n d b y v o l u n t a r y a n d p r i v a t e effort, it
is still not t r u e t o say t h a t everyone can get all the kinds of medical and
hospital service which h e or she m a y r e q u i r e . W h e t h e r people c a n do so
still d e p e n d s t o o m u c h u p o n c i r c u m s t a n c e , u p o n where t h e y h a p p e n to live
or work, t o w h a t g r o u p (e.g. of age, or vocation) t h e y h a p p e n to belong, or
w h a t h a p p e n s to b e the m a t t e r with t h e m . N o r is t h e care of h e a l t h y e t wholly
divorced from ability to p a y for it, a l t h o u g h great progress h a s a l r e a d y been
m a d e in eliminating the financial b a r r i e r to obtaining most of t h e essential
services. T h e r e is not yet, in short, a c o m p r e h e n s i v e cover for health pro­
v i d e d for all people alike. T h a t is w h a t it is now the G o v e r n m e n f s intention
to provide.
T o t a k e one v e r y i m p o r t a n t e x a m p l e , 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 p r o b l e m s of health a n d sickness.
A t present, t h e N a t i o n a l H e a l t h I n s u r a n c e Scheme m a k e s this provision for a
r
lar^e n u m b e r of people; b u t it does not give ft to the wives a n d t h e children
and the d e p e n d a n t s . F o r extreme need, t h e older P o o r L a w still exists.
For some particular groups, there are other facilities. B u t for s o m e t h i n g like
half the population, the first-line health service of a personal m e d i c a l adviser
depends on w h a t p r i v a t e a r r a n g e m e n t s a n y p a r t i c u l a r person can m a n a g e
to m a k e .
Even if a person h a s a regular d o c t o r — a n d this is not n o w assured to all—
there is no g u a r a n t e e d link between t h a t doctor a n d the rest of necessary
medical help. T h e doctor, b o t h in p r i v a t e practice a n d in N a t i o n a l H e a l t h
Insurance practice, has to rely on I r s own resources to i n t r o d u c e his p a t i e n t
to the right k i n d s of special t r e a t m e n t or clinic or hospital—a g r e a t responsi­
bility in these d a y s of specialised medicine a n d s u r g e r y — o r the p a t i e n t h a s to
make his own w a y to w h a t e v e r local a u t h o r i t y or other organisation h a p p e n s
to cater for his p a r t i c u l a r need.
When a h o s p i t a l ' s services are n e e d e d , it is far from t r u e t h a t e v e r y o n e
can get all t h a t is r e q u i r e d . Here it is not so m u c h a question of p e o p l e
not being eligible t o get the services w h i c h t h e y need, a s a m a t t e r of t h e
practical distribution of those services. T h e hospital a n d specialist services
have grown u p without a national or e v e n a n a r e a p l a n . I n o n e a r e a t h e r e
may be a l r e a d y established a variety of h o s p i t a l s . A n o t h e r a r e a , a l t h o u g h
the need is there, m a y b e sparsely served. One hospital m a y h a v e a long
waiting list a n d be refusing admission to cases w h i c h a n o t h e r hospital n o t far
away could suitably a c c o m m o d a t e a n d treat a t once. T h e r e is u n d u e pressure
in some areas on the hospital out-patient departments—-in spite of certain
experiments which s o m e of t h e hospitals h a v e tried (and which should b e
encouraged) in a r r a n g i n g a system of t i m e d a p p o i n t m e n t s to- o b v i a t e long
waiting. Moreover, even though most p e o p l e h a v e access to a h o s p i t a l of
some kind, it is not necessarily access to the r i g h t hospital. T h e t e n d e n c y in
the modern d e v e l o p m e n t of medicine a n d surgery is t o w a r d s specialist c e n t r e s
—for r a d i o t h e r a p y a n d neurosis, for e x a m p l e — a n d n o one h o s p i t a l c a n be
equally e q u i p p e d a n d developed to suit all needs, o r to specialise e q u a l l y in
all subjects.* T h e time has come w h e n t h e hospital services h a v e t o b e
thought of, a n d p l a n n e d , as a wider whole, a n d the object h a s to- b e t h a t e a c h
case should be referred n o t to one single hospital which h a p p e n s . t o b e " local "
but to w h a t e v e r hospital concentrates specially on that k i n d of c a s e a n d c a n
offer it the most u p - t o - d a t e t e c h n i q u e .
Many services a r e also rendered b y local authorities a n d others in special
clinics and similar organisations, designed for p a r t i c u l a r g r o u p s of t h e p o p u l a ­
tion or for p a r t i c u l a r k i n d s of ailment o r m e d i c a l care. T h e s e a r e , for t h e
most part, t h o r o u g h l y good in themselves, a n d t h e y are used w i t h a d v a n t a g e
by a great m a n y people in a great m a n y districts. B u t , o w i n g t o t h e w a y .
in which t h e y h a v e grown u p piecemeal a t different stages of h i s t o r y a n d
under different s t a t u t o r y powers, t h e y a r e u s u a l l y c o n d u c t e d as quite s e p a r a t e
and i n d e p e n d e n t services. T h e r e is n o sufficient link either b e t w e e n t h e s e
services themselves or b e t w e e n t h e m a n d general medical p r a c t i c e a n d the
hospitals.
In short, general medical practice, c o n s u l t a n t a n d specialist opinion,
hospital t r e a t m e n t , clinc services for p a r t i c u l a r purposes, h o m e n u r s i n g ,
* 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 t h a t ten
or twenty miles away is a highly developed fracture centre, specialising in total rehabiti­
tation 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.
midwifery a n d all other b r a n c h e s of health care need to be related to one
a n o t h e r a n d treated a s m a n y aspects of the care of one p e r s o n ' s health. T h a t
m e a n s t h a t there h a s to b e somewhere a new responsibility to relate t h e m ,
if a service for h e a l t h is to be given in future which will b e not only compre­
hensive a n d reliable but also easy to obtain.
Last, b u t not least, personal health still t e n d s to b e r e g a r d e d as something to
be treated when at fault, or p e r h a p s to be preserved from getting at fault, b u t
seldom as s o m e t h i n g to b e positively i m p r o v e d a n d p r o m o t e d a n d m a d e full
a n d robust. Much of p r e s e n t custom a n d h a b i t still centres o n the idea t h a t
the doctor a n d the hospital a n d the clinic are the m e a n s of m e n d i n g ill-health
rather t h a n of increasing good health a n d t h e sense of well-being. While
the health s t a n d a r d s of t h e people h a v e e n o r m o u s l y i m p r o v e d , a n d while
there are gratifying reductions in the ravages of p r e v e n t a b l e disease, the plain
fact r e m a i n s t h a t there a r e m a n y m e n a n d w o m e n a n d children w h o could be
a n d ought t o be enjoying a sense of health a n d p h y s i c a l well-being which they
do not in fact enjoy. T h e r e is m u c h s u b - n o r m a l h e a l t h still, which need not
be, with,a corresponding cost in efficiency a n d personal h a p p i n e s s .
These a r e some of the chief deficiencies in t h e p r e s e n t a r r a n g e m e n t s which,
in the view of t h e G o v e r n m e n t , a c o m p r e h e n s i v e health service should
seek to m a k e good.
II. T H E N E X T STAGE: A COMPREHENSIVE SERVICE FOR ALL. T h e idea of m o v i n g o n to the n e x t stage h a s been developing for some time.
T h e r e is m u c h agreement on w h a t the aim should be, if n o t on the m e t h o d of
achieving it. T h e general idea of a fuller a n d better co-ordinated service has
been s u p p o r t e d in most knowledgeable quarters—professional a n d l a y — b y
official Commissions a n d C o m m i t t e e s , b y interested public or v o l u n t a r y organ­
isations a n d persons, in reports, in articles a n d in b o o k s , before t h e w a r and
d u r i n g it. Some reference to these is included in A p p e n d i x B , w h e r e a sum­
m a r y is also given of t h e p r e l i m i n a r y discussions a n d events which have
preceded the issue of this P a p e r .
The method of approach.
There are two possible w a y s of a p p r o a c h i n g t h e task.
O n e , with all
t h e attraction of simplicity, would b e to disregard the p a s t a n d t h e present
entirely a n d t o invent ad hoc a completely new organisation for all health
requirements.
T h e o t h e r is t o use a n d a b s o r b t h e experience of the past
a n d the present, building it into the wider service. T h e G o v e r n m e n t have
a d o p t e d the latter m e t h o d , as m o r e in accord with n a t i v e preference in this
country.
There is a c e r t a i n d a n g e r in m a k i n g personal h e a l t h the subject of a national
service a t all. I t is t h e d a n g e r of over-organisation, of letting the machine
designed to ensure a b e t t e r service itself stifle t h e c h a n c e s of getting one. Yet
medical resources m u s t b e b e t t e r marshalled for t h e full a n d equal service of
t h e public, a n d this m u s t involve organisation—with public responsibility
b e h i n d it.
I t is feasible t o combine public responsibility a n d a full
service with the essential elements of personal a n d professional freedom for
t h e patient a n d the doctor; a n d t h a t is t h e starting p o i n t of this Paper's
p r o p o s a l s . T h r o u g h o u t , t h e service m u s t b e b a s e d on the personal relation­
ship of p a t i e n t a n d doctor. Organisation is needed t o ensure t h a t the service
is there, t h a t it is there for all, a n d t h a t . i t is a good service; b u t organisation
must b e seen as t h e m e a n s , a n d never for one m o m e n t a s . t h e e n d .
Nor should t h e r e be a n y compulsion into the service, either for the p a t i e n t
or for the doctor. T h e basis m u s t be t h a t the new service will b e t h e r e for
everyone who w a n t s i t - a n d i n d e e d will b e so designed t h a t it c a n be looked
upon as the n o r m a l m e t h o d b y which people get all the a d v i c e a n d help
, h i c h t h e y want; b u t if a n y o n e prefers n o t to use it, or likes to m a k e p r i v a t e
a r r a n g e m e n t s outside the service, h e m u s t b e at liberty to do so. Similarly, if
a n y medical practitioner prefers n o t to t a k e p a r t in the new service a n d t o rely
wholly o n private w o r k outside it, he also m u s t be at liberty to d o s o .
v
The scope of a " comprehensive " service.
T h e proposed service m u s t b e " c o m p r e h e n s i v e " in two senses—first, t h a t
it is available to all people a n d , second, t h a t it covers all necessary forms of
health c a r e . T h e general a i m h a s been stated a t the beginning of this P a p e r .
The service designed to achieve it m u s t cover the whole field of medical
advice a n d attention, a t h o m e , in the consulting room, in the hospital or t h e
sanatorium, or w h e r e v e r else is a p p r o p r i a t e — f r o m t h e p e r s o n a l or family
doctor to the specialists a n d consultants of all k i n d s , from t h e care of m i n o r
ailments to the c a r e of m a j o r diseases a n d disabilities. I t m u s t include
ancillary services of n u r s i n g , of midwifery a n d of t h e other t h i n g s which
ought to go with m e d i c a l care. I t m u s t secure first t h a t e v e r y o n e c a n b e
sure of a general m e d i c a l adviser to c o n s u l t as a n d w h e n t h e need arises, a n d
then t h a t everyone can get a c c e s s — b e y o n d the general medical a d v i s e r — t o
more specialised b r a n c h e s of medicine or s u r g e r y .
T h i s c a n n o t all be p e r ­
fected a t a stroke of t h e p e n , o n an a p p o i n t e d d a y ; b u t n o t h i n g less t h a n
this m u s t b e the object in view, a n d t h e framing of the service from t h e
outset m u s t b e such a s t o m a k e it possible.
Temporary exceptions to " comprehensiveness."
F o r a time s o m e aspects of t h e new service will b e less c o m p l e t e t h a n
could be wished.
A full d e n t a l service for the whole p o p u l a t i o n , for
instance, including r e g u l a r c o n s e r v a t i v e t r e a t m e n t , is u n q u e s t i o n a b l y a
proper a i m in a n y whole h e a l t h service, a n d m u s t b e so regarded. B u t there
are not a t present, a n d will n o t b e for some y e a r s , e n o u g h dentists in
the c o u n t r y to p r o v i d e it. Until the s u p p l y c a n be increased attention will
have to be concentrated on priority n e e d s . These m u s t include the n e e d s of
children a n d y o u n g people a n d of e x p e c t a n t a n d n u r s i n g m o t h e r s . T h e whole
dental problem is a peculiarly difficult one, and a C o m m i t t e e u n d e r the chair­
manship of L o r d T e v i o t h a s been set u p b y the two H e a l t h Ministers to consider
and report o n it.
There m a y be similar (though p e r h a p s less acute) difficulties i n getting a
full service in o p h t h a l m o l o g y . B u t these, like t h e difficulties in dentistry, m u s t
be treated rather as practical p r o b l e m s arising in the o p e r a t i o n of a new
service t h a n as m a t t e r s of d o u b t in p l a n n i n g the service's scope a n d objectives.
Mental health.
(
The inclusion of t h e m e n t a l services also p r e s e n t s s o m e difficulty,
until a full re-statement of the law of l u n a c y a n d m e n t a l deficiency c a n b e
undertaken.
Y e t , despite the difficulty, the m e n t a l health services should
be included. T h e aim m u s t b e to r e d u c e t h e distinctions d r a w n b e t w e e n
mental ill-health a n d physical ill-health, a n d t o accept the principle declared
by the R o y a l C o m m i s s i o n on Mental Disorder t h a t " the t r e a t m e n t of mental
disorder should a p p r o x i m a t e as n e a r l y t o the t r e a t m e n t of p h y s i c a l a i l m e n t s
as is consistent w i t h the special safeguards which a r e i n d i s p e n s a b l e w h e n the
liberty of the s u b j e c t is i n f r i n g e d . "
Some misconceptions about the meaning of " comprehensive."
T h e r e is one c o m m o n misconception a b o u t the m e a n i n g of a
compre­
hensive ''' health service. Such a service emphatically has to c o m p r e h e n d all
kinds of personal h e a l t h t r e a t m e n t a n d medical advice.
B u t t h a t does not
m e a n t h a t there should be no other G o v e r n m e n t or p r i v a t e activity involving
the use of the medical expert, or h a v i n g a n y bearing u p o n health.
There
are m a n y specialised and separate forms of u n d e r t a k i n g — s u c h ^ as the
supervision of industrial c o n d i t i o n s - w h i c h m a y affect health a n d which m a y
require t h e medicai expert as m u c h as t h e y require the engineering or the
legal or a n y other expert, b u t which cannot, simply for t h a t reason, be
regarded as necessarily p a r t of the personal health service.
T h e present system of factory medical inspection a n d the arrangements
m a d e for t h e e m p l o y m e n t b y industry of " works doctors " (described
in A p p e n d i x A) are cases in point.
F r o m the point of view of
industrial organisation, of working conditions in factory, m i n e a n d field,
there is a continuing a n d specialised need for enlisting medical skill in ensuring
a p r o p e r working e n v i r o n m e n t , a p r o p e r allocation of t y p e s of work to the
individual w o r k e r ' s capacity, a p r o p e r s t a n d a r d of working hygiene and
a general protection of the w o r k e r ' s welfare. T h e enlistment of medical help
for these purposes is p a r t of t h e complex m a c h i n e r y of industrial organisation
a n d welfare, a n d it belongs to t h a t sphere m o r e t h a n t o the sphere of the per­
sonal doctor a n d the care of personal health—which centres on the individual
a n d his family a n d his h o m e . W h a t m a t t e r s is t h a t such specialised services,
where they exist, should not i m p a i r the u n i t y of personal health service on
which h e will rely; t h a t , when a question arises of personal medical treatment
or consultation (beyond recognised incidental services of the k i n d described
in A p p e n d i x A ) — p e r h a p s first detected in work-place or factory—this should
be regarded a s a m a t t e r for the personal health service.
A n o t h e r e x a m p l e is t h a t of the school medical service.
Very similar
considerations a p p l y . I t should b e the p a r t of a n y school medical arrange­
m e n t s to refer t h e school child for a n y a n d every form of personal doctoring
to the general health service—the family doctor a n d other resources which
t h a t service will p r o v i d e . B u t t h a t does not m e a n t h a t as a n integral part
of the educational organisation the e d u c a t i o n authorities should not h a v e their
o w n a r r a n g e m e n t s for looking after medical a n d welfare conditions in the
schools, for m a i n t a i n i n g inspection a n d supervision of the child in the school
g r o u p a n d — v e r y usefully—for encouraging p a r e n t a n d child to see that
for personal t r e a t m e n t a n d advice the child resorts, w h e n e v e r necessary, to
the family doctor a n d the full resources of the new h e a l t h service.
T h e p r o p e r continuance of e n v i r o n m e n t a l and p r e v e n t i v e services in school
a n d i n d u s t r y should be coupled increasingly, as time goes on, with the
h a b i t of using for those services doctors w h o are also engaged in, the personal
health s e r v i c e - s o t h a t there is a continuous blending of experience in both
k i n d s of work. W i t h the b u l k of the profession engaged, p a r t - t i m e or whole­
time, in the new service, this process c a n b e m o r e readily accelerated and
arrangements
made
for
proper
post-graduate
training
of
general
practitioners who are going to engage in industrial or o t h e r specialities
a p p r o p r i a t e to general practice.
Similarly, while m a t t e r s like industrial
organisation ,require medical a s well as other experts in the central
d e p a r t m e n t s of G o v e r n m e n t which deal with them, t h e r e is room, for a better
linking of the expert staffs so engaged with the e x p e r t staffs whose time
is wholly o r m a i n l y given t o the personal health a n d t r e a t m e n t services.
T h e r e is also a n o t h e r point o n which it is necessary to be clear. The
s u b j e c t of h e a l t h , in its b r o a d e s t sense, involves not only medical services
but ali those e n v i r o n m e n t a l factors—good housing, sanitation, conditions
in school a n d at w o r k , diet a n d n u t r i t i o n , economic security, a n d so o n — w h i c h
create the conditions of health a n d p r e p a r e t h e ground for it. All these
are f u n d a m e n t a l ; all of t h e m m u s t receive their p r o p e r place in the wider
pattern of G o v e r n m e n t policy a n d of p o s t - w a r reconstruction. B u t t h e y are
not the subject of this p a r t i c u l a r P a p e r , which is concerned exclusively with
the direct services of personal h e a l t h care a n d advice a n d t r e a t m e n t .
No
matter how successful t h e indirect influence of the e n v i r o n m e n t a l services
m a y become in p r o m o t i n g good h e a l t h a n d reducing sickness, there will
remain a need for m e d i c a l a n d n u r s i n g a n d hospital services.
General nature of the Governmenfs proposals
T h e rest of this P a p e r is concerned with t h e G o v e r n m e n f s p r o p o s a l s for
bringing the new comprehensive service into being. First, the a d m i n i s t r a t i v e
structure, central a n d local, will b e considered.
Then each of the m a i n
branches—the hospital a n d c o n s u l t a n t services, the general practitioner service,
and the local clinic a n d other services—will be discussed in some detail. After
that, the special circumstances of the service in Scotland will be reviewed,
and the P a p e r will end with a general s u m m a r y of w h a t is p r o p o s e d .
At this stage, therefore, before the more detailed p a r t of t h e P a p e r begins, it
m a y m a k e s u b s e q u e n t reading easier if t h e b r o a d shape of t h e p r o p o s a l s is
indicated.
It is proposed t h a t t h e new responsibility for providing t h e c o m p r e h e n s i v e
service shall be p u t u p o n a n organisation in which b o t h central a n d local
authority t a k e p a r t , a n d which b o t h centrally a n d locally is a n s w e r a b l e
to the public in the o r d i n a r y democratic m a n n e r . C e n t r a l responsibility
will lie with the Minister, local responsibility will lie w i t h the m a j o r local
government authorities (the county a n d c o u n t y borough councils) operating
for some p u r p o s e s severally over their existing a r e a s a n d for o t h e r p u r p o s e s
jointly over larger a r e a s formed b y c o m b i n a t i o n . Both a t the c e n t r e a n d
locally, special new consultative bodies a r e p r o p o s e d , for e n s u r i n g professional
guidance a n d the enlistment of the e x p e r t view. At the centre, in addition,
a new a n d m a i n l y professional b o d y is to b e created, to p e r f o r m i m p o r t a n t
executive functions in r e g a r d to general medical practice in t h e n e w service.
T h e mew joint authorities, i . e . the c o u n t i e s a n d c o u n t y b o r o u g h s i n
combination, will b e responsible (over suitable areas d e t e r m i n e d b y t h e
Minister after consulting the local interests) for assessing t h e n e e d s of those
areas in all b r a n c h e s of t h e new service a n d for p l a n n i n g generally h o w those
needs should best b e m e t . T h e y will d o this in consultation w i t h the local
professional bodies referred to, a n d t h e y will s u b m i t their p r o p o s e d a r r a n g e ­
ments to the Minister for final settlement in each case.
T h e n , w h e n each a r e a p l a n is settled, the joint a u t h o r i t y will h a v e the d u t y
of securing all the hospital and c o n s u l t a n t services c o v e r e d b y it, b y their
own provisions a n d b y a r r a n g e m e n t s with the v o l u n t a r y hospitals in the a r e a ,
and they will for this p u r p o s e b e responsible in future for the existing local
authority hospitals of all k i n d s . T h e i n d i v i d u a l c o u n t y a n d c o u n t y b o r o u g h
councils m a k i n g u p the joint a u t h o r i t y will usually be responsible for local
clinic and other services within the general framework of t h e p l a n , b u t t h e r e
will be special p r o v i s i o n for the child welfare services—to e n s u r e a close
relation b e t w e e n t h e m a n d child e d u c a t i o n . General medical p r a c t i c e in
the new scheme will b e specially organised, largely a s a n a t i o n a l a n d
centralised service, b u t with p r o p e r links with the local organisation tc
relate it to the hospitals and to other branches of the service a s a whole.
T h e r e will b e certain variations of these proposals for Scotland, to suit the
differing c i r c u m s t a n c e s t h e r e .
T h e whole of the new service will be free of charge to all w h o take
a d v a n t a g e of it (except for certain possible charges in respect of appliances)
and the cost will b e borne p a r t l y from exchequer funds, p a r t l y from local
rates and p a r t l y from the contributions of the public u n d e r a n y scheme of
social insurance which m a y be brought into operation. T h e v o l u n t a r y hospitals
will take their own i m p o r t a n t part in the service as fully a u t o n o m o u s organisa­
tions, under i n d e p e n d e n t m a n a g e m e n t as now, b u t observing certain general
conditions which will b e applied to all hospitals, v o l u n t a r y or m u n i c i p a l alike.
III.
T H E GENERAL ADMINISTRATIVE STRUCTURE OF T H E SERVICE. If people are to h a v e a right to look to a public service for all their medical
needs, it m u s t be s o m e b o d y ' s d u t y to sec t h a t t h e y do not look in v a i n . The
right to the service involves the corresponding d u t y to see t h a t t h e service is
provided.
Some organisation h a s to carry that d u t y , a n d a s the service is
to be publicly p r o v i d e d this involves responsible public a u t h o r i t y in some
form.
CENTRAL
AND LOCAL RESPONSIBILITY.
W i t h the exception of medical benefit u n d e r the National H e a l t h Insurance
scheme the p u b l i c health services of this c o u n t r y h a v e from the outset been
administered b y some form of local g o v e r n m e n t organisation. I n the case
of medical benefit the administrative b o d y — t h e I n s u r a n c e Committee—though
operating over a local area, the c o u n t y or c o u n t y b o r o u g h , is not answer­
able to a local electorate but consists in the m a i n of persons representing
A p p r o v e d Societies which are non-territorial units. A p a r t from this excep­
tion, in a long series of Public H e a l t h Acts a n d similar measures Parliament
has placed t h e p r i m e responsibility for providing the health services—hospitals,
institutions, clinics, domiciliary visiting, a n d o t h e r s — o n local, rather than
central, a u t h o r i t y .
T h i s system recognises t h a t , in intimate a n d . personal
services of this k i n d , local factors such as distribution of p o p u l a t i o n , transport
facilities, t h e n a t u r e of local e m p l o y m e n t a n d vocation (and generally local
tradition a n d habit) h a v e a profound- influence on detailed p l a n n i n g .
T h e absorption of the existing services into a comprehensive service does
not m a t e r i a l l y alter this situation. T o u p r o o t the p r e s e n t system a n d to put
into the h a n d s of some central a u t h o r i t y the direct administration of the new
service, transferring to it every institution a n d every piece of present Organisa­
tion, would run counter to the whole historical development of the health
services; a n d 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 t h e present organisation of local areas and
administrative bodies will be necessary.
F o r reasons discussed later the
organisation of the services of general practitioners will call for a higher degree
of central control t h a n other p a r t s of the service. B u t there is n o case for
departing generally from the principle of local responsibility, coupled with
enough central direction to obtain a coherent a n d consistent national service
CENTRAL ORGANISATION.
Central responsibility must rest with a Minister of the C r o w n , answerable
directly to P a r l i a m e n t a n d t h r o u g h P a r l i a m e n t to the p e o p l e . T h e suggestion
has been m a d e t h a t , while this principle should be accepted, there is a case
for replacing t h e n o r m a l d e p a r t m e n t a l m a c h i n e r y b y some specially con­
stituted corporation or similar b o d y ( p e r h a p s largely m a d e u p of m e m b e r s
of the medical profession) which would, u n d e r the general auspices of a
Minister, direct a n d supervise t h e service. T h e exact relation of this p r o ­
posed b o d y to its Minister has n e v e r been defined, a n d it is h e r e t h a t t h e
crux lies.
If in m a t t e r s b o t h of principle a n d detail decision n o r m a l l y
rested in t h e last resort with the Minister, t h e b o d y would in effect b e a new
d e p a r t m e n t of G o v e r n m e n t — n o less t h a n (say) the N a t i o n a l H e a l t h I n s u r a n c e
Commission, which w a s later replaced b y the Ministry of H e a l t h , or the
present B o a r d of Control or P r i s o n Commission.
If, on the o t h e r h a n d ,
certain decisions were r e m o v e d from the jurisdiction of t h e Minister (and
consequently from direct P a r l i a m e n t a r y control) t h e r e would b e n e e d to define
with the u t m o s t precision w h a t those decisions were. Clearly t h e y could not
include major questions of finance. N o r could any local g o v e r n m e n t authori­
ties responsible for local p l a n n i n g or administration r e a s o n a b l y b e asked to
submit to being over-ruled b y a b o d y not answerable to P a r l i a m e n t .
Nevertheless, the G o v e r n m e n t recognise t h a t the provision of a health ser­
vice involves technical issues of t h e highest i m p o r t a n c e and t h a t in its
administration, b o t h centrally a n d locally, there is r o o m for special devices
to secure t h a t the guidance of the expert is available a n d does n o t go
unheeded. Otherwise the quality of the service is b o u n d t o suffer.
They
also recognise t h a t , in a service which will affect the professional life of almost
every doctor, t h e r e is need within the a d m i n i s t r a t i v e structure for some
largely professional b o d y which can concern itself with t h e professional welfare
of doctors w h o t a k e p a r t in t h e service.
T h e proposals w h i c h follow are
designed to meet this situation.
Central Responsibility of the Minister.
There will b e direct responsibility to P a r l i a m e n t , therefore, resting on
the Minister of H e a l t h a n d the Secretary of State for Scotland, respectively,
as the Ministers of the C r o w n concerned with the health of t h e p e o p l e .
A Central H e a l t h Services Council.
At the side of the Minister, b u t i n d e p e n d e n t of h i m , t h e r e will be created
a special professional a n d e x p e r t body.'
It might be called t h e Central
Health Services Council, a n d it will b e a s t a t u t o r y b o d y .
Its function will be to e x p r e s s the expert view on a n y general technical
aspect of t h e service. T h e r e c a n n o t b e d u a l responsibility for the service a n d
so it will b e consultative a n d a d v i s o r y , a n d n o t e x e c u t i v e . I t will b e entitled
to advise, not only on m a t t e r s referred to it b y the Minister, b u t o n a n y
matters within its p r o v i n c e on which it feels it right t o express its expert
opinion, a n d t h e Minister—quite a p a r t from a n y o t h e r p u b l i c a t i o n of the
Council's views a n d proceedings which h e m a y from time to t i m e m a k e —
will be required to s u b m i t to P a r l i a m e n t a n n u a l l y a report on t h e C o u n c i F s
work d u r i n g t h e y e a r . T h e Minister, in addition to the regular a n d general
consultation which he will obviously w a n t to m a i n t a i n w i t h s u c h a b o d y ,
will refer to it in draft form a n y general regulations w h i c h h e p r o p o s e s t o .
make in t h e n e w service on subjects within its expert field.
The constitution of s u c h a b o d j ' , given s t a t u t o r y recognition a s the m o u t h ­
piece of expert opinion i n ' t h e central a d m i n i s t r a t i o n , will obviously need to be
considered carefully a n d in detail with the professional a n d other organisations
concerned. At this stage only the general k i n d of constitution which m i g h t
suit its p u r p o s e a n d function c a n be suggested.
It will, it is assumed, be primarily medical in its m a k e - u p , because
the main technical aspects of t h e h e a l t h service in all its b r a n c h e s will be
medical.
B u t it will not be wholly medical; it will need to be able to
provide an expert view on m a n y questions—e.g. of hospital administration,
nursing, dentistry, p h a r m a c y a n d auxiliary services—which will involve
other experts t h a n the physician or surgeon. Y e t , to be effective, it must
not be too large a n d u n w i e l d y ; nor could m u c h of its v a r i e d work be regu­
larly done b y the single full Council. T h e Council itself might consist of about
thirty or forty m e m b e r s , representing t h e m a i n medical organisations (specialist
a n d general), the v o l u n t a r y a n d municipal hospitals (with b o t h medical and
lay representation), a n d professions like dentistry, p h a r m a c y a n d n u r s i n g . For
a n y of its special purposes the Council could establish small groups or sub­
committees, on each of which it w o u l d be open to it to i n t r o d u c e additional
experts in the p a r t i c u l a r subject referred—the Council itself, however, retain­
ing a n ultimate single responsibility for all views or advice expressed in its
name.
T h e members will be appointed b y the Minister in consultation with the
professional a n d other organisations concerned, a n d the Council will select
its own c h a i r m a n a n d regulate its own p r o c e d u r e . T h e Minister will be
p r e p a r e d to provide a secretariat, a n d the expenses of the Council will be
met from public funds.
%
Central Medical Board.
There will also be set u p , f o r . c e r t a i n specific p u r p o s e s , a Central Medical
Board.
This will b e in a different cateogry from the Central Health
Services Council, i n a s m u c h as it will perform executive functions in the
d a y - t o - d a y working of the general practitioner service, r a t h e r t h a n voice
opinion on general m a t t e r s of medical policy.
I t is mentioned here only to complete the picture of the central organisa­
tion. I t s duties a n d its constitution will need to be referred to in c h a p t e r V, when
the participation of doctors in the. service a n d the terms and conditions of that
participation are considered.
LOCAL ORGANISATION.
Local organisation is inevitably more c o m p l e x . T h e n e w service has to
include hospitals and institutional services for the sick in general, for mental
cases, for infectious diseases a n d tuberculosis, for m a t e r n i t y a n d for every
general and special hospital subject. I t has to include the m a n y k i n d s of service
usually provided in local clinics, a family doctor service a n d m a n y ancillary
services—nursing, h e a l t h visiting, midwifery a n d others. I t ranges from the
one extreme of highly specialised services, requiring relatively few centres for
the c o u n t r y as a whole, to the o t h e r extreme of services involving a large
n u m b e r of local clinics a n d a r r a n g e m e n t s for care in the individual h o m e .
Suggestions h a v e been m a d e for a completely n e w k i n d of local or
" regional " a u t h o r i t y — s o m e t i m e s p r o p o s e d as a vocational or technical body
(like the special kind of central organisation a l r e a d y m e n t i o n e d ) . I n so far
as those suggestions would conflict with the principle of public responsiblity,
they need not be considered h e r e .
B o t h the principles applied to central
organisation—that of democratic responsibility a n d t h a t of full professional
g u i d a n c e — m u s t be equally applied to local organisation.
Service to be based on local goverment.
T h e present local g o v e r n m e n t system a m p l y embodies t h e former of these
principles—that of democratic responsibility—and the existing local authorities
are already responsible for m a n y kinds of personal health service which will
need to be incorporated in the new a n d wider service in future. It is certainly
no p a r t of the G o v e r n m e n t ' s intention to supersede a n d to waste these good
existing resources, o r needlessly to interfere with t h e well-tested m a c h i n e r y of
local g o v e r n m e n t as it is already k n o w n ; n o r would the record a n d experience
of the existing local authorities in t h e personal h e a l t h services justify such a
course. On the c o n t r a r y the G o v e r n m e n t p r o p o s e to t a k e as the basis of the
local administration of the new service the c o u n t y a n d county b o r o u g h councils.
But there are some requirements of the n e w service which the c o u n t y a n d
county b o r o u g h councils c a n n o t fulfil if t h e y c o n t i n u e to act s e p a r a t e l y , each
for its i n d e p e n d e n t area; a n d changes will be necessary. " I n p a r t i c u l a r , for
the future hospital service, it will b e essential t o obtain larger local areas
than at present, b o t h for p l a n n i n g a n d a d m i n i s t r a t i o n . T h e special n e e d s of
this service c a n be considered first.
Need for larger administrative areas for the hospital service.
Broadly s p e a k i n g the hospital services, so far as they are p u b l i c l y p r o v i d e d
now, are in t h e h a n d s of t h e c o u n t y a n d c o u n t y b o r o u g h councils, w i t h the
exception of isolation hospitals for infectious disease in the counties.
The
areas of counties a n d c o u n t y b o r o u g h s v a r y e n o r m o u s l y — r a n g i n g (without
counting L o n d o n ) from R u t l a n d a n d C a n t e r b u r y , with p o p u l a t i o n s of some
1 8 , 0 0 0 a n d 2 6 , 0 0 0 respectively, to Middlesex a n d B i r m i n g h a m with p o p u l a t i o n s
of o v e r 2 , 0 0 0 , 0 0 0 a n d
1,000,000.
It would b e theoretically possible to p u t u p o n the council of e a c h c o u n t y
and county b o r o u g h t h e d u t y to p r o v i d e , or to a r r a n g e with other agencies for,
the whole r a n g e of hospital services. This would impose responsibility for the
services o n authorities m a n y of w h i c h lack the size a n d resources a n d a d m i n i s ­
trative organisation to p l a n and conduct a n d p a y for the service. W h a t is more
important, it would leave untouched the d e m a r c a t i o n between town a n d country
which is reflected in the system of a d m i n i s t r a t i v e counties a n d c o u n t y b o r o u g h s ,
but which h a s n o m e a n i n g in relation to hospital services. T h e t o w n s largely
serve the c o u n t r y in the m a t t e r of hospitals.
If for p u r p o s e s of hospital
administration they are k e p t a p a r t by continuing the separate c o u n t y a n d
county b o r o u g h basis, the result will be a complicated criss-cross p a t t e r n of
" customer " a r r a n g e m e n t s , since in most areas (particularly those of counties)
it will b e out of the question to secure the whole range of service—or even
the bulk of i t - i n s i d e the area b o u n d a r y . These " c u s t o m e r " a r r a n g e m e n t s
will in t u r n involve complicated a d m i n i s t r a t i v e a r r a n g e m e n t s a n d a mass
of financial a d j u s t m e n t s between different a r e a s . Alternatively, if the provision
of, a complete service within each area were a t t e m p t e d , the resulting system
would r u n counter to the whole conception of a n ordered p a t t e r n of hospital
accommodation a n d could only lead to wasteful competition in hospital building.
T h e need for larger areas h a s long been recognised b y local authorities hi
many b r a n c h e s of hospital a d m i n i s t r a t i o n . T h e m a n y c o m b i n a t i o n s a l r e a d y
in existence m a k e this clear; a n d t h e v e r y existence of these c o m b i n a t i o n s
would in itself give rise to great a d m i n i s t r a t i v e difficulties if it were decided
that the new hospital service as a whole w a s to be in the h a n d s only of the
individual c o u n t y a n d c o u n t y b o r o u g h councils in future.
T h e essential needs of a reorganised hospital service, b a s e d on a new public
duty to p r o v i d e it in all its b r a n c h e s , a r e t h e s e —
(a) T h e organising a r e a needs to cover a p o p u l a t i o n a n d financial resources
sufficient for a n a d e q u a t e service t o be secured on an efficient a n d economical
basis.
(b) T h e area needs to b e n o r m a l l y of a k i n d where t o w n a n d c o u n t r y re­
quirements can b e regarded as b l e n d e d p a r t s of a single p r o b l e m , a n d
catered for accordingly.
, (c) T h e area needs to be so defined as to allow of most of t h e v a r i e d hos­
pital and specialist services being organised within its b o u n d a r i e s (leaving
for inter-area a r r a n g e m e n t only a few specialised services).
I n t h e majority of the a r e a s of existing authorities n o n e of the three condi­
tions w o u l d b e met.
I t is therefore necessary t o decide what the form of a u t h o r i t y for these
larger hospital a r e a s should b e . On this, various alternatives are examined
in A p p e n d i x C to this P a p e r . T h e course most c o n v e n i e n t — a n d indeed, in
t h e G o v e r n m e n t s view, the only course possible a t t h e present time—will be
to create t h e larger area authorities b y combining for this p u r p o s e the existing
c o u n t y a n d c o u n t y borough councils, in joint boards operating over areas
to b e settled b y t h e Minister after consultation with local interests at the outset
of t h e scheme. T h e r e will b e some exceptional cases (the. c o u n t y of London
is the m o s t obvious) where n o combination is necessary at all; in such cases
a n existing authority will fulfil b o t h its own functions a n d those of the new
form of a u t h o r i t y — b u t this will b e unusual. W h e r e the new form of joint
a u t h o r i t y is referred to in the rest of this P a p e r it should be t a k e n as including
a n y individual council which, in such exceptional circumstances m a y b e acting
in the two capacities.
While b o t h p l a n n i n g and administration will usually need t o be based on
larger areas, this does not m e a n t h a t a standard-sized a r e a need b e , or-can
b e , prescribed for the hospital services. Local conditions—distribution of
p o p u l a t i o n , n a t u r a l trends t o various main centres of t r e a t m e n t , geography,
t r a n s p o r t a n d accessibility—must determine the size a n d s h a p e of the
o p t i m u m a r e a . Sometimes simple c o m b i n a t i o n of a c o u n t y with the county
boroughs within its b o u n d a r y (i.e. the geographical county as a unit) will be
sufficient; sometimes, the linking of two or three small counties will b e needed,
sometimes other variations.
Special mention should b e m a d e of the isolation hospitals for infectious
diseases, because in the counties these hospitals are with few exceptions owned
a n d administered b y the minor authorities and not b y the c o u n t y councils, and
therefore a decision to transfer t h e m to the new joint a u t h o r i t y will not only
r e m o v e t h e m from their present owners (as with t h e hospitals of the counties
a n d c o u n t y boroughs) but will p r e v e n t their present owners from retaining
e v e n the p a r t interest in t h e m which membership of the new joint authority
will afford in the case of the counties a n d county b o r o u g h s . (It is, of course,
not practicable to give direct representation on t h e joint authority to these
m i n o r authorities, without a t once duplicating the representation of all local
g o v e r n m e n t electors who h a p p e n to live in a c o u n t y a n d not in a county
borough.)
T h e case for this absolute transfer of the isolation hospitals has
n o t h i n g to do with the p a s t record of the minor authorities, n o r is it in any
w a y a reflection upon the q u a l i t y of the work which t h e y h a v e hitherto done.
T h e whole trend of medical opinion h a s for some time b e e n in favour of treating
these hospitals, not p r i m a r i l y as places for the reception of patients to prevent
the s p r e a d of infection, b u t as hospitals where severe a n d complicated cases
of infectious disease can receive expert t r e a t m e n t a n d n u r s i n g . T h e small
isolation hospital of the p a s t c e n t u r y is not only u n e c o n o m i c in d a y s of rapid
t r a n s p o r t b u t c a n n o t r e a s o n a b l y b e expected to k e e p a b r e a s t of modern
m e t h o d s . One result of the new outlook will be t h e d e v e l o p m e n t , in addition
to the larger isolation hospital serving the densely p o p u l a t e d area, of accom­
m o d a t i o n for infectious diseases in blocks forming p a r t of the general hospitals. .
These considerations all indicate t h a t the infectious disease hospitals must in
future form p a r t of the general hospital system.I t m a y b e , a s time goes on, t h a t for certain specialised hospital functions
t h e r e is room for the development of a few p a r t i c u l a r centres which would
serve national rather t h a n local needs. In this field t h e r e m a y be a,case for
direct provision or a r r a n g e m e n t b y the G o v e r n m e n t centrally.
But such
provision or arrangement would b e special a n d . e x c e p t i o n a l a n d need not be
considered here a s p a r t of t h e n o r m a l organisation of the new service.
n
1
As will b e seen, w h e n the hospital services are fully considered in chapter I V ,
the function of the new joint authorities will be to secure a complete hospital
and consultant service of all k i n d s for each of the new and larger a r e a s — p a r t l y
by their own direct provision and p a r t l y by a r r a n g e m e n t w i t h v o l u n t a r y
hospitals, and all on the basis of a n area hospital p l a n which they will
formulate in consultation with t h e hospitals a n d others c o n c e r n e d , a n d which
will require t h e M i n i s t e r s final settlement a n d a p p r o v a l . T h e existing p o w e r s
and duties of t h e present local authorities in r e g a r d t o hospital services—
including tuberculosis, infectious diseases a n d m e n t a l health—will pass to t h e
joint authorities, together with the existing hospitals a n d other institutions
concerned.
The place of the joint authority outside the hospital service.
Outside the hospital a n d c o n s u l t a n t services—that is, in t h e k i n d s of service
appropriately given in local clinics a n d similar premises, or b y domiciliary
visiting (like midwifery or h o m e - n u r s i n g ) — t h e c a s e for centralising all
administration in t h e one a u t h o r i t y over t h e larger a r e a is n o t the same, a n d it
is the G o v e r n m e n t s view that there should be as little u p s e t t i n g of the exist­
ing organisation for these services a s is compatible with achieving a unified
health service for all. It will not b e enough, however, s i m p l y to leave all
these separate services exactly as t h e y are now. W h a t is essential is t h a t ,
although still locally conducted "with all t h e a d v a n t a g e s of local knowledge
and enthusiasm, t h e y should b e r e g a r d e d in future as t h e related p a r t s of a
wider whole a n d should fit in with all the other b r a n c h e s of a c o m p r e h e n s i v e
service in their p l a n n i n g a n d their distribution. F o r this p u r p o s e it m u s t
be the single responsibility of some a u t h o r i t y to p l a n the whole, a l t h o u g h
not necessarily to provide the p a r t s , a n d the o b v i o u s a u t h o r i t y to do t h i s —
from the point of view both of its area of operation a n d of its constitution—will
be the n e w joint a u t h o r i t y .
The n e w j o i n t a u t h o r i t y will therefore b e c h a r g e d to e x a m i n e the general
needs of the a r e a from the p o i n t of view of the health service as a w h o l e —
not only in t h e hospital services for w h i c h it will itself b e responsible b u t
also in these m o r e local services.
I t will h a v e the d u t y of p r o d u c i n g ,
in consultation with the local authorities a n d others concerned, a n a r e a
arrangement o r p l a n for a related service of all k i n d s — a n d this will need
the approval of t h e Minister.
- B u t , within the general framework of the
approved p l a n , t h e provision a n d a d m i n i s t r a t i o n of m o s t of the local services—
including some n e w k i n d s of service—will n o r m a l l y rest with the individual
county a n d c o u n t y borough councils, a n d the j o i n t a u t h o r i t y will be con­
cerned o n l y to w a t c h that t h e general area a r r a n g e m e n t p r o v e s to be the
right one w h e n p u t into actual o p e r a t i o n , t h a t in fact it w o r k s out as i n t e n d e d ,
and that a n y subsequent additions to it, or a m e n d m e n t s of it, which seems
to be required are p u t in h a n d a n d submitted to t h e Minister.
i
There are, h o w e v e r , some forms of local clinic service w h i c h — a l t h o u g h p r o ­
vided in s e p a r a t e premises so a s to m a k e their facilities m o r e accessible—are
in essence o u t - p a t i e n t activities of the hospital a n d c o n s u l t a n t services; of
which, in fact, the essential feature needs to b e t r e a t m e n t a n d advice a t the
consultant and specialist level, p r o v i d e d b y the same consultants a n d specialists
as serve the hospitals or s a n a t o r i a a n d are b a s e d on t h e m . O b v i o u s e x a m p l e s
are the tuberculosis dispensaries, m e n t a l clinics and c a n c e r diagnostic centres.
This kind of service m u s t usually b e the responsibility of t h e s a m e a u t h o r i t y
as is responsible for the hospitals a n d consultants over the larger area the
"outpost " s e r v i c e going w i t h t h e p a r e n t service of w h i c h it ought to be
part. T h e y differ in this respect from the other local services which belong
more to the g e n e r a l practitioner s p h e r e — t h e m a t e r n i t y a n d child welfare clinics,
school medical services, clinics for general dental or ophthalmic treatment and
advice, arrangements for midwifery or h o m e nursing or health visiting, and
similar activities.
These certainly need to b e linked with the consultants
a n d the hospitals for difficult cases (as the area plan will provide), b u t they
do n o t ' h a v e to be directly administered with the hospitals, a n d the counties
a n d county boroughs are normally a p p r o p r i a t e areas for their operation.
One case requires special mention.
T h e Local G o v e r n m e n t Act of
1 9 2 9 initiated the policy of securing t h a t local child welfare and education
responsibilities should be brought closer together, a n d t h a t the local education
authority in each area should as often as possible be the welfare authority.
I n the view of the G o v e r n m e n t t h e time has come to c a r r y t h a t policy to
its full conclusion.
T h e destination of the present welfare functions (now
exercised p a r t l y b y c o u n t y and county b o r o u g h councils, p a r t l y b y other local
authorities within the counties) will therefore d e p e n d u p o n the decisions
taken b y P a r l i a m e n t u p o n the educational functions of these various authori­
ties under t h e c u r r e n t E d u c a t i o n Bill.
W h e n the relationship between the
county a n d c o u n t y borough councils and the m i n o r authorities in
regard to education h a s been settled, s o m e t h i n g on b r o a d l y similar lines can
be adopted a s the a r r a n g e m e n t between these authorities in regard to child
welfare. T h i s does not mean, however, t h a t this service will be excluded
from the general area p l a n n i n g of the health services b y the new joint autho­
rity. I t affects only the local operation of the service.
I n dealing with the clinic a n d other local services generally it will not
be wise to prescribe an absolutely h a r d - a n d - f a s t rule to b e applied in all
circumstances. I t m a y b e that in a p a r t i c u l a r county or c o u n t y borough of
exceptionally small a r e a or resources a case for transferring local functions to
the larger joint a u t h o r i t y will be overwhelming, in the interests of a n efficient
service. I n another area, for some p a r t i c u l a r local reason, even somp of the
dispensary o r out-patient functions just described as belonging properly to the
hospital a n d consultant sphere m a y be found more suitable for discharge
b y an individual c o u n t y or c o u n t y b o r o u g h . A rigid a n d universal rule about
the allocation of the various services would preclude a good common-sense
a r r a n g e m e n t on which all were agreed in a p a r t i c u l a r case. F o r reasonable
flexibility, the detailed allocation of services will be left to b e finally settled
as best suits each case, but- observing the general d e m a r c a t i o n described in
the absence of a n y exceptional reason to do otherwise.
This can be achieved in the following w a y . The new joint authority, in
preparing its a r r a n g e m e n t or p l a n for the whole health service of its area and
submitting it to the Minister, will include proposals as to t h e exact allocation
of responsibility for p r o v i d i n g the various local services covered—-he., proposals
as to which services should be p r o v i d e d b y the county a n d county borough
councils severally a n d which in combination through the joint authority itself.
I n all cases the hospital a n d c o n s u l t a n t services will be required to be the
joint a u t h o r i t y ' s responsibility; in all ca'ses the child welfare service will be
required to- lie with the same authorities as carry responsibility for education
under the new E d u c a t i o n Bill; in between these two fixed points the allocation
of clinic a n d other local services can v a r y to suit exceptional needs, but
with the n o r m a l rule as stated a b o v e — t h o s e services which belong essentially to
the consultant sphere, like tuberculosis dispensaries, going to the joint autho­
rity, while those which do not will rest with the several counties and county
boroughs m a k i n g u p t h a t joint a u t h o r i t y . T h e decision, as in other proposals
of the a r e a plan, will rest finally with the Minister in each case.
Special considerations will a p p l y to the " family d o c t o r " or general
practitioner b r a n c h of the new service, which is reviewed in detail in
chapter V . T h e organisation there suggested will be one which is largely j
central a n d national arid only p a r t l y local.
Those m a i n aspects of the
service which affect the individual practitioner—including the t e r m s of his
participation in the service, t h e protection of his professional interests a n d the
"eneral personal relationship of the doctor t o t h e new p u b l i c service—will
be governed b y central a r r a n g e m e n t s applicable t o t h e c o u n t r y as a whole.
On the other h a n d it is not proposed t h a t there shall be a n y question of exclud­
ihg this b r a n c h of the health service from t h e concern of t h e new joint
authorities to p l a n , with t h e Minister, for t h e r e q u i r e m e n t s of their areas,
and the locally p l a n n e d a r r a n g e m e n t of t h e n e w service will in each case
have regard to resources a n d needs i n the sphere of general practice as well
as in hospital a n d other facilities.
Apart from these local functions in the general practitioner service, there
will also be t h e provision a n d m a i n t e n a n c e of special H e a l t h C e n t r e s for
the grouped medical practice of some of the doctors in t h e n e w service, in
areas where it is decided to t r y this form of practice. T h i s , a s a function
not belonging to the hospital a n d c o n s u l t a n t sphere, will b e a p p r o p r i a t e t o the
individual c o u n t y a n d c o u n t y b o r o u g h councils.
General.
An important task, therefore, of t h e new joint authorities will b e to unify
and to co-ordinate t h e service. T h e y will be the i n s t r u m e n t t h r o u g h which,
with the Minister, a rational a n d effective p l a n for all b r a n c h e s of t h e health
service in their respective a r e a s is secured. I t will b e t h e i r responsibility to
see that their proposals provide for all t h a t t h e i n h a b i t a n t s of their areas
will require, to s u b m i t t h e proposals t o t h e Minister as an area p l a n for final
settlement, a n d subsequently to k e e p the p l a n u p to d a t e a s requirements
develop and to bring before t h e Minister a n y necessary c h a n g e s if the p l a n is
found not to b e w o r k i n g o u t in t h e m a n n e r designed. T h e y will n o t t h e m ­
selves provide a n d o p e r a t e all t h e services for which t h e a p p r o v e d area plan
provides; nor is there a n y need for t h e m to d o so.
T h e y will usually
administer themselves only those b r a n c h e s of t h e service w h i c h d e m a n d
direct administration o v e r t h e larger area a s a whole, a n d n o t those which
can suitably be administered (when once a unified plan is settled) on a more
localised basis. In short, t h e existing major local authorities will c o m b i n e to
secure, with t h e Minister, a unified general p l a n of t h e whole service for their
grouped areas; they will t h e n c o m b i n e to c a r r y o u t those p a r t s of this p l a n
which demand a single administration over all their a r e a s together; b u t
they will be charged individually t o carry out those p a r t s which c a n be
separately and locally a d m i n i s t e r e d .
Professional guidance in local organisation.
In order to secure good professional g u i d a n c e in t h e local a d m i n i s t r a t i o n
of the new service a special local professional organisation will be established
to advise and guide a n d , if necessary, to initiate new suggestions.
Local Health Services Councils.
The need to ensure technical g u i d a n c e — b y creating special professional a n d
expert bodies for t h e purpose—offers scope for i n n o v a t i o n in local g o v e r n m e n t
method and justifies i t .
W h a t is w a n t e d is t h a t t h e r e should b e , in
each area, s o m e n e w provision for the organised expression of the views
of the expert a n d for ensuring t h a t the local a d m i n i s t r a t i o n c a n get t h e
fullest a d v a n t a g e from it.
T h e simplest w a y will b e to a p p l y to local
administration the k i n d of consultative m a c h i n e r y suggested for central
administration; i.e. t o h a v e in each case a local expert t e c h n i c a l b o d y , which
might be k n o w n as the Local H e a l t h Services Council.
T h e p u r p o s e of these bodies will b e to provide locally t h e s a m e kind of
m e d i u m for expressing the expert point of view on technical aspects of the
service as has been proposed at the centre. The a p p r o p r i a t e a r e a for each
will be the larger areas of the new joint authorities a l r e a d y discussed. Their
functions will be n o t only to advise on m a t t e r s referred to t h e m b y the joint
authorities or o t h e r local authorities in t h e a r e a , but also to initiate advice on
a n y matters within their expert province on which they t h i n k it right to do' so
a n d , if they wish, to s u b m i t their views a n d advice n o t only t o the joint
a u t h o r i t y or o t h e r local authorities concerned with the m a t t e r s in question,
b u t to the Minister. A p a r t from its o r d i n a r y consultation, the joint authority
will be required to consult t h e m on t h e area plan for the local health service
which it submits to the Minister, and on subsequent material alterations or
additions to t h a t p l a n .
T h e constitution a n d m e m b e r s h i p of these bodies will call for detailed
consideration later. P r o v i d e d that all the professional interests are fairly
represented, there is n o reason w h y t h e p a t t e r n should be precisely uniform
t h r o u g h o u t t h e c o u n t r y and the most convenient course will p r o b a b l y be to
provide for t h e m a t t e r b y w a y of local schemes a p p r o v e d b y the Minister.
Direct professional representation on local authorities.
It is sometimes suggested t h a t the best method of linking the e x p e r t point
of view with t h e direct administration of the service would be to include in
the local administrative authorities themselves, and in their committees, a pro­
portion of professional m e m b e r s a p p o i n t e d for the p u r p o s e b y the appropriate
professional organisations with or without voting powers. Arguments can
be a d d u c e d b o t h for a n d against a s y s t e m of this kind, b u t on balance the
G o v e r n m e n t feel t h a t the risk of i m p a i r i n g the principle of public responsi­
bility—that effective decisions on policy must lie entirely with elected
representatives answerable to the people for the decisions that t h e y t a k e ­
outweighs a n y a d v a n t a g e s likely to accrue.
IV.
HOSPITAL
AND CONSULTANT
SERVICES.
The term " hospital services " is used in this P a p e r to include all forms
of institutional care of every kind of sickness a n d injury. It comprises the whole
range of general and special hospitals, including infectious disease hospitals,
s a n a t o r i a for tuberculosis, a c c o m m o d a t i o n for m a t e r n i t y cases a n d for the
chronic sick, and for rehabilitation; a n d it comprises also t h e usual ancillary
hospital services for pathological examinations, X - r a y , electro-therapy,
a m b u l a n c e s a n d other purposes. O u t - p a t i e n t ho less t h a n in-patient treat­
m e n t is included. It will be the a i m to restore the out-patient work of the
hospitals as m u c h as possible to its p r o p e r field of specialist a n d consultant care,
when the existence of a general " family doctor " for all h a s been secured.
T h e m e n t a l hospitals a n d mental deficiency institutions h a v e also to be
included in the scope of the hospital a n d consultant p a r t of the new service,
u n d e r the care of the new joint authorities. T h e y will p r e s e n t m a n y problems
of their own, calling for some degree of special organisation to fit
t h e m . The present general review does not a t t e m p t to deal with this special
subject, and the discussion which follows is directed mainly to the more
general range of hospital a n d consultant services—although m u c h of it can
obviously be applied to the mental h e a l t h services a s well.
T h e p r e s e n t hospital services are described in A p p e n d i x A. T h e y present
two m a i n p r o b l e m s . T h e first is to b r i n g together over suitable areas the
activities of the v a r i o u s separate a n d independent hospitals, to e n s u r e t h a t
all the different kinds of special a n d general hospital t r e a t m e n t a r e so l i n k e d
that the individual c a n get the best of each. T h e second is to e n a b l e t h e
two quite different hospital systems (the v o l u n t a r y hospitals a n d t h e m u n i c i p a l
hospitals) to join forces in future in a single service.
The proposed joint authority, operating over a large area, has. b e e n
described. I t will be that a u t h o r i t y ' s responsibility, with the Minister, t o
see that a full hospital service of all kinds is available for people in its a r e a .
Rut the authority neither will, nor will need to, p r o v i d e the whole service itself.
The part of the v o l u n t a r y hospital.
The conception of a public authority discharging its d u t y b y c o n t r a c t i n g
with others for the provision of services has long been familiar.
As early
as 1 8 7 5 local authorities were enabled b o t h to p r o v i d e hospitals themselves
and to enter into a g r e e m e n t s with other hospitals for t h e reception of p e o p l e
from their district. L a t e r legislation followed similar lines; in recent Acts
dealing with special services (e.g., the Midwives Act, 1 9 3 6 , the C a n c e r Act,
1039) the use of v o l u n t a r y agencies has been clearly contemplated. T h e r e a r e
already large n u m b e r s of a g r e e m e n t s under which existing local authorities
arrange for a c c o m m o d a t i o n in hospitals, s a n a t o r i a , dispensaries, or clinics,
sometimes belonging to other local authorities a n d sometimes to v o l u n t a r y
agencies.
,J
^The facts of t h e existing a c c o m m o d a t i o n in v o l u n t a r y a n d municipal
hospitals (given in A p p e n d i x A) m a k e it clear t h a t w i t h o u t the collaboration of
the voluntary hospitals it would be m a n y y e a r s before t h e new joint authorities
could build u p a system a d e q u a t e for the needs of the whole p o p u l a t i o n ; so
that, from t h a t point of view alone, the co-operation of the v o l u n t a r y hospitals
is a necessity. B u t the m a t t e r cannot be r e g a r d e d -from that p o i n t of view
alone. The v o l u n t a r y hospital m o v e m e n t not only represents the oldest
established hospital system of the country, b u t it a t t r a c t s the active personal
interest and support of a large n u m b e r of people w h o believe in it a s a social
organisation and w h o wish to see it maintained side b y side with t h e hospitals
which are directly p r o v i d e d out of public funds. I t is n o t merely t h a t t h e best
of the voluntary hospitals h a v e , in a degree so far unsurpassed, developed
specialist a n d general hospital resources which t h e y will be able a t once to
make available, while most of the rest of the v o l u n t a r y hospitals h a v e experi­
ence and a n existing, organisation which it will be obviously sensible to enlist.
It is certainty not the wish of the Government t o d e s t r o y or to diminish a
system which is so well rooted in the good will of its supporters.
Yet the acceptance b y the c o m m u n i t y of responsibility for a service for
all might affect f u n d a m e n t a l l y the position of the v o l u n t a r y hospitals.
A new universal public hospital service m i g h t h a v e the g r a d u a l effect of
undermining the foundations on which the v o l u n t a r y hospitals are based,
if this is not to h a p p e n , a w a y has to be found of combining t h e general
responsibility of the new joint authority for the service with t h e continued
participation in t h a t service of the v o l u n t a r y m o v e m e n t as s u c h ; a w a y ,
in fact, of s e c u r i n g ' a whole service under o n e u l t i m a t e public responsibility
without destroying the independence and traditions to which the v o l u n t a r y
hospitals attach v a l u e . T h e G o v e r n m e n t believe t h a t this can b e done, a n d
in settling the details arising out of the following p r o p o s a l s they will welcome
the help a n d the suggestions of' the v o l u n t a r y hospital representatives in
securing it.
Preparation of local a r e a p l a n .
The joint a u t h o r i t y ' s first task will be to assess in detail the
hospital needs of its area a n d the hospital resources available to its a r e a .
T h i s it will d o in close consultation with the local e x p e r t body,
the Local H e a l t h Services Council. I t is hoped t h a t the hospital surveys,
referred to in A p p e n d i x B a n d now n e a r i n g completion, will b e of valuable
help in this.
T h e a u t h o r i t y ' s next t a s k , again in consultation with the local expert
b o d y a n d with other local interests (including the v o l u n t a r y hospitals con­
cerned) will be to work out a p l a n of hospital a r r a n g e m e n t s for its area,
based o n using, a d a p t i n g a n d , w h e r e necessary, s u p p l e m e n t i n g existing
resources. T h e object of the plan will be to arrive a t "the right quantities,
kinds a n d distribution of hospital facilities for the area; to settle where, how,
a n d b y w h a t hospitals, each necessary b r a n c h of hospital t r e a t m e n t can best be
secured, to produce a b a l a n c e d s c h e m e in which all the necessary specialist
facilities in medicine a n d surgery (including fracture and orthopaedic, gynaeco­
logical, paediatric, o p h t h a l m i c , psychiatric a n d others) a r e p r o v i d e d in due
proportion, together with general a c c o m m o d a t i o n for cases, acute or chronic,
of the ordinary t y p e . T h e plan m u s t ensure t h a t the v a r i o u s special treat­
m e n t s are concentrated in centres c o m p e t e n t a n d c o n v e n i e n t to provide them,
and not dispersed h a p h a z a r d in uneconomic a n d o v e r l a p p i n g units; t h a t proper
linking of services is secured b y relating the work of special a n d general
hospitals; t h a t a r r a n g e m e n t s are at h a n d for the transfer of patients to the
hospitals best suited to their medical needs; and t h a t the skill of t h e consultant
staffs of the various hospitals t a k i n g p a r t c a n be used to the maximum
a d v a n t a g e of the area as a whole.
I t will be the aim of the authority to m a k e its area (which will h a v e been
determined with this in view) as self-sufficient as possible i n hospital and con­
sultant services. - B u t where it is obviously m o r e sensible, as in some of the
rarer services, the p l a n will provide for certain services b y agreed arrange­
m e n t s outside the a r e a .
T h e basis of the p l a n will be t h a t the joint a u t h o r i t y will secure
the necessary service for its area p a r t l y t h r o u g h its own hospitals a n d institu­
tions, p a r t l y through contractual a r r a n g e m e n t s m a d e with v o l u n t a r y hospitals
for t h e performance of agreed services set out in the p l a n , to a minor degree
(where necessary) t h r o u g h a r r a n g e m e n t s with t h e joint authorities of other
areas.
Central approval of local area plans.
T h e plan will then be submitted to the Minister for a p p r o v a l , a n d will have
no validity until so a p p r o v e d . T h e Minister, a b l e to look at t h e country as a
whole and a t the effect of the local p l a n s one u p o n a n o t h e r , will h a v e power to
modify or s u p p l e m e n t the p l a n before giving his a p p r o v a l . H e will consider
all objections or representations m a d e to him b y local organisations (including
the Local H e a l t h Services Council), v o l u n t a r y hospitals o r others.
' T h e p l a n , when a p p r o v e d , will be open to a m e n d m e n t a t a n y time, and the
Minister will be empowered to call on t h e j o i n t a u t h o r i t y to reconsider the
plan a n d s u b m i t fresh proposals. T h e p r o c e d u r e for a m e n d i n g the plan will
be the same as for its original p r e p a r a t i o n and will include all necessary local
consultation.
No v o l u n t a r y hospital will be compelled to p a r t i c i p a t e . Its participation will
rest o n a c o n t r a c t between it and the joint a u t h o r i t y to provide the services
specified in the p l a n . W h e r e it agrees to participate, it will—like each of the
a u t h o r i t y ' s own hospitals—have t o o b s e r v e certain general conditions, just as it
will obtain certain a d v a n t a g e s .
General conditions to be observed by hospitals.
T h e s e conditions will be settled centrally, for the c o u n t r y as a whole, and
t h e y will then b e c o m e the conditions o n which e x c h e q u e r g r a n t will be payable.
In framing the conditions the Minister will seek the advice of the C e n t r a l Health
Services Council; b u t the more i m p o r t a n t conditions will relate to subjects such
as the f o l l o w i n g : —
.
(a) each hospital will be required t o m a i n t a i n the services which under
the terms of the a p p r o v e d hospital p l a n it undertakes to m a i n t a i n , a n d
generally to comply w i t h the terms of the p l a n ;
(b) each hospital will observe certain national r e q u i r e m e n t s such as
the Rushcliffe or Taylor rates a n d conditions for its n u r s i n g staff;
(c) in appointing senior medical a n d surgical staff each hospital will
conform with a n y national a r r a n g e m e n t s which m a y be a d o p t e d for regulat­
mg a p p o i n t m e n t s a n d r e m u n e r a t i o n ;
(d) each hospital will be open to visiting a n d inspection, in respect of
its part in the public service, u n d e r a r r a n g e m e n t s laid d o w n centrally;
(e) in the case of v o l u n t a r y hospitals some conditions to secure reasonable
uniformity in t h e keeping of accounts a n d in the m a t t e r of audit will p r o b ­
ably be necessary so far as they t a k e p a r t in the new service. T h e presenta­
tion of accounts of m u n i c i p a l hospitals is a l r e a d y largely subject to central
direction.
Financial a r r a n g e m e n t s with v o l u n t a r y hospitals.
As already e m p h a s i s e d , it is the a i m of the G o v e r n m e n t to enable the
voluntary hospitals to take their i m p o r t a n t p a r t in the service w i t h o u t loss
of identity or a u t o n o m y . But it is essential to this conception t h a t t h e hospitals
should still look substantially to their o w n financial resources, to p e r s o n a l bene­
factions and the c o n t i n u i n g s u p p o r t of those who believe in the v o l u n t a r y
hospital m o v e m e n t . So long, and so long only, c a n they retain their indi­
viduality. If once the situation were to arise i n . w h i c h the whole cost of the
voluntary h o s p i t a l s ' p a r t in the public service (a service designed for the whole
population) was repaid from public m o n e y , o r indeed in which it w a s recognised
that public funds were to be used to g u a r a n t e e those hospitals' financial security,­
the end of the v o l u n t a r y m o v e m e n t would b e n e a r at h a n d .
On this footing, the financial relation b e t w e e n the j o i n t a u t h o r i t y and
the individual v o l u n t a r y hospital m u s t be t h a t of a n a g r e e m e n t to p a y a
specified sum in return for services r e n d e r e d or to be r e n d e r e d , a n d this
should not be assessed as a total r e i m b u r s e m e n t of costs i n c u r r e d .
Whether
the sum will b e calculated in t e r m s of b e d s or occupied beds, o r otherwise,
is for the m o m e n t immaterial. In o r d e r to a v o i d a large n u m b e r of individual
bargains, and t h e risk of competitive b a r g a i n i n g leading to u n d e s i r a b l e results,
it will b e convenient for s t a n d a r d p a y m e n t s , in respect of different kinds
of hospital service w h i c h involve different levels of expense, to be settled
centrally. These p a y m e n t s will be m a d e b y the joint authorities a n d will
fall on local r a t e s , assisted b y e x c h e q u e r g r a n t .
In addition, b o t h t h e municipal a n d the v o l u n t a r y hospitals will receive
a direct grant from c e n t r a l funds which will include the s h a r e , a t t r i b u t a b l e
to hospital services, of a n y s u m allocated t o w a r d s the cost of t h e c o m p r e h e n s i v e
health service from t h e contributions of the public to a n y scheme of social
insurance. So far as this sum represented contributions b y potential p a t i e n t s of
hospitals it could fairly be said t h a t the G o v e r n m e n t would h a v e collected
money which m i g h t otherwise h a v e b e e n p a i d to the hospitals direct, a n d t h a t
the proposed g r a n t w o u l d t h u s restore t h e balance. T h i s g r a n t could b e
based on the n u m b e r of beds p r o v i d e d b y each, hospital, b u t in the
case of v o l u n t a r y hospitals it would b e feasible, if so desired, to r e g a r d the
aggregate of their share of the p a y m e n t s as a central pool from which p a y m e n t s
to individual hospitals could be varied according to the needs a n d resources
of each.
In either case it will b e the M i n i s t e r s responsibility t o see t h a t the con­
ditions of the g r a n t are fulfilled. If the idea of a variable g r a n t to t h e v o l u n t a r y
hospitals is a d o p t e d , the Minister will be p r e p a r e d to b e guided in questions
of relative need b y some suitable b o d y representing the hospitals, though the
final responsibility a n d decision m u s t r e m a i n with h i m .
Special considerations apply t o ' h o s p i t a l s used-for t h e clinical teaching of
medical s t u d e n t s , a n d the question of the a p p r o p r i a t e form of financial
assistance to these hospitals will need to be reviewed when the report is
available of the C o m m i t t e e on Medical Schools now sitting u n d e r the chairman­
ship of Sir William Goodenough.
Inspection of hospitals.
I n a service of this m a g n i t u d e , in which h u n d r e d s of hospitals under
different a n d i n d e p e n d e n t m a n a g e m e n t s will b e t a k i n g p a r t , the problem
of inspection is a difficult one. A p a r t from special inspection in cases of
difficulties arising or changes in contemplation, routine inspections—at not
too frequent intervals—would serve the double p u r p o s e of bringing to notice­
defects of organisation or m a n a g e m e n t a n d , w h a t is equally important, of
enabling individual hospitals to be k e p t in touch with the latest practice
a n d ideas. T h e foundation of a n y inspectorate m u s t clearly b e a team of
highly qualified medical m e n , b u t the inspectors need not all be persons'
employed whole-time on this work; from m a n y points of view there are
a d v a n t a g e s in e m p l o y i n g o n a p a r t - t i m e basis medical men' or women of dis­
tinction in v a r i o u s b r a n c h e s of professional work or medical administration.
I n addition to doctors, there is scope for experts of v a r i o u s k i n d s for dealing
with an organisation so varied a n d c o m p l e x as a m o d e r n hospital. Hospital
administrators, a c c o u n t a n t s , nurses, engineers, catering and kitchen experts
to mention n o others—should find a p l a c e .
A solution would be the a p p o i n t m e n t b y the Minister of a b o d y of persons
of the t y p e s mentioned, some of whom would b e on a whole-time and others
on a part-time basis. These a p p o i n t m e n t s could b e m a d e with the advice
of the Central H e a l t h Services Council a n d for convenience those appointed
might be grouped in suitable p a n e l s o p e r a t i n g over different areas of the
c o u n t r y . T h e selection of the p a r t - t i m e d o c t o r s could be p a r t l y from those
associated with consultant practice a n d v o l u n t a r y hospitals a n d partly from
those with experience of municipal hospitals, as in t h e case of those who are
already c o n d u c t i n g on the Minister's behalf the s u r v e y of hospital resources
referred t o in A p p e n d i x B . I n cases of i m p o r t a n c e the inspectors could, again
like the hospital s u r v e y o r s , w o r k in p a i r s .
The system of inspection m u s t take account of the fact t h a t the new joint
authorities, no less than the Minister, will h a v e a responsibility for the
hospital service as a whole in their respective a r e a s . T h e arrangements are
intended t o serve the double p u r p o s e . Inspectors' reports on a n y hospital
will be available- both to the Ministry a n d to the joint a u t h o r i t y , and it
will be open t o the latter to ask for a special inspection if it thinks it
desirable. W h e r e in the past c o n t r a c t u a l a r r a n g e m e n t s h a v e been made
between a local a u t h o r i t y and a v o l u n t a r y hospital, special provision has not
u n c o m m o n l y been m a d e for a right of e n t r y for the a u t h o r i t y ' s medical officer.
There would b e n o t h i n g to p r e v e n t similar a r r a n g e m e n t s being locally agreed
u n d e r the system now p r o p o s e d , b u t n o r m a l l y a m o r e general system of the
k i n d described will better serve the p u r p o s e in view.
Provision for consultant services in the local plan.
A m a i n object of the new a r r a n g e m e n t s will b e to ensure all kinds of
consultant and specialist advice and t r e a t m e n t to all who need it. This part
of the service will be best and most n a t u r a l l y based on t h e hospital sendees,
in the wide sense in which these h a v e been defined.
This means t h a t it will become one of t h e duties of the joint authority
to ensure that, t h r o u g h the v a r i o u s hospitals taking p a r t , there will be pro­
vided an a d e q u a t e consultant service available to all general practitioners
in the service. It will d o this, as in other branches of the hospital service,
partly by its own direct a r r a n g e m e n t a n d p a r t l y b y contracting with the
voluntary hospitals. In the latter case it will be for t h e a u t h o r i t y to agree
with a v o l u n t a r y hospital for the provision b y the latter of consultant services
both at the hospital a n d — w h e r e n e c e s s a r y — b y visits to a clinic or health
centre or the p a t i e n t s h o m e . T h e hospital will itself enter i n t o t h e necessary
engagements with t h e consultants a n d specialists concerned. T h e local service
payments to the hospitals, a l r e a d y m e n t i o n e d , can be based on the assump­
tion of a consultant staff p r o p e r l y r e m u n e r a t e d to enable the hospital to
fulfil the tasks which it had u n d e r t a k e n to perform.
Some principles affecting consultant services.
Before p r o p o s i n g in detail the form of a consultant service the Government
are awaiting the report of Sir William G o o d e n o u g h s C o m m i t t e e on Medical
Schools. But it is clear that there are certain general considerations of which
account m u s t be t a k e n in devising the new service.
The need is twofold—more consultants, a n d a better distribution of them.
Apart from distribution, there are not yet enough m e n a n d w o m e n of real
consultant s t a t u s a n d o n e of the a i m s will b e to encourage m o r e doctors of
the right t y p e to enter this a r m of medicine or surgery a n d to provide the
means for their t r a i n i n g . A s to distribution, the need is f o r a more even
spread. T h e m a i n consultant facilities now are inevitably concentrated at
the medical t e a c h i n g centres. T h e consultant service still n e e d s to be organised
with the teaching centre as its focus, b u t the service m u s t b e s p r e a d over a
wider area b y enabling a n d e n c o u r a g i n g consultants t a k i n g p a r t in it to live
and work farther afield. A p a r t from the m a i n effect of greater accessibility
to the public, this will also h a v e a beneficial effect u p o n general medical
practice over larger a r e a s — w h e r e the h a b i t u a l presence and services of con­
sultants will serve as a m e a n s of c o n t i n u o u s p o s t g r a d u a t e e d u c a t i o n .
The consultant t a k i n g p a r t in the service m u s t b e associated with his
particular hospital or hospitals o n a m u c h more regular b a s i s — a n d with
more regular a t t e n d a n c e s a n d d u t i e s — t h a n is often the case n o w , when h e is
regarded as m e r e l y " on c a l l . "
It will often b e desirable t h a t the con­
sultants association should b e with m o r e t h a n one m a j o r hospital, so a s to
enable the s h a r i n g of a c o m m o n consultant staff to b e c o m e an effective link
between hospitals.
T h e c o n s u l t a n t s function will b e n o r m a l l y one of
regular a n d f r e q u e n t visiting of these hospitals, b o t h for i n - p a t i e n t a n d for
out-patient consultation; also of p r o p e r l y arranged visiting of outlying
"general p r a c t i t i o n e r " hospitals, w h i c h need to b e linked with t h e major
hospitals; a n d — f o r certain consultants as circumstances m a y require—of visit ­
ing Health C e n t r e s a n d clinics, a n d , in case of need, t h e p a t i e n t s home, at
the request of the general practitioner.
For this sort of d u t y the p r o p e r a n d regular r e m u n e r a t i o n of consultants,
through the hospitals with which t h e y are associated, will b e c o m e essential.
This remuneration, a n d t h e e n g a g e m e n t s entered into in respect of it, can
be on either a full-time or a p a r t - t i m e basis (and might well include p a r t ­
time engagements with more t h a n one hospital). T h e r e will b e n o need to
make either whole-time or p a r t - t i m e a p p o i n t m e n t a universal rule.
The conditions, including t h e financial t e r m s , o n which c o n s u l t a n t s under­
take work on a whole-time or p a r t - t i m e basis will b e a m a t t e r for t h e authori­
ties of the hospitals, v o l u n t a r y o r m u n i c i p a l , which offer t h e a p p o i n t m e n t s ;
but in order t o avoid a n o m a l i e s as between hospital a n d hospital a n d between
4 area and area some central regulation of scales will be r e q u i r e d .
Some degree of control of the discretion of individual hospital authorities
will be required in a p p o i n t m e n t s to senior clinical posts. U n d e r existing prac­
tice a d a n g e r of " in-breeding " h a s been c o m m o n l y recognised, a n d while
it is i m p o r t a n t t h a t the ultimate responsibility for an a p p o i n t m e n t should
rest u n m i s t a k a b l y with the b o d y of persons c o n d u c t i n g the hospital's affairs,
it will be necessary t o consider a system u n d e r which an e x p e r t advisory
b o d y r e c o m m e n d s a n u m b e r of suitable c a n d i d a t e s from which t h e hospital
a u t h o r i t y m a k e s the final choice. T h e necessary m a c h i n e r y could b e organised
in a variety of w a y s . I t might consist of a n u m b e r of advisory panels,
working o v e r regions b a s e d , b r o a d l y , on the university a n d teaching centres
and representing b o t h the consultant m e m b e r s of t h e profession a n d the
university a n d teaching organisations. One or more representatives of the
a p p o i n t i n g hospital could join the panel dealing with the sifting of candidates
for a p p o i n t m e n t .
V.
GENERAL PRACTITIONER
SERVICE.
T h e a r r a n g e m e n t s for general medical practice in the comprehensive service
— i . e . for ensuring a personal or family d o c t o r for e v e r y b o d y — p r e s e n t the
most difficult p r o b l e m of all. T h i s is p a r t l y because this will b e the front­
line of the service, t h e first source of help o n which the individual will rely
a n d one involving a close personal relation between doctor and patient.
I n addition, although the provision of medical benefit u n d e r N a t i o n a l Health
I n s u r a n c e covers over t w e n t y millions of persons a n d h a s afforded much
experience of the w o r k i n g of a public general practitioner service, the
widening of public responsibility to cover the whole population a n d the need
to fit the general practitioner into a c o m p r e h e n s i v e service will create new
p r o b l e m s a n d will m a k e it necessary to reconsider, without preconception,
the whole of t h e existing a r r a n g e m e n t s .
If the service is to b e free to the people for w h o m it is provided, the
doctors t a k i n g p a r t in it will look to public funds for their remuneration
T h e y m u s t , therefore, b e in some c o n t r a c t u a l relationship with public
a u t h o r i t y , which in t u r n m u s t b e able to a t t a c h such conditions as will
e n s u r e t h a t the services which t h e people get are the services which they
need (and for w h i c h t h e y will be p a y i n g in t a x a t i o n and otherwise) and that
t h e y can get them where and w h e n t h e y need t h e m . T h e State must, there­
fore, t a k e a greater p a r t in future in r e g a r d to general medical practice.
T h e m e t h o d of e m b o d y i n g general medical practice in a national
service m u s t observe two principles.
T h e first, which mainly con­
c e r a s the patient, is t h a t people m u s t b e able to choose for themselves
the doctor from w h o m t h e y wish to seek their medical advice a n d treatment,
a n d to change to a n o t h e r doctor if t h e y so wish. F r e e d o m of choice is not
absolute n o w ; it d e p e n d s on the n u m b e r a n d accessibility of doctors and on
the fact t h a t there is a limit to the load which a n y one doctor can or should
take on. But t h e present degree of freedom m u s t not be generally
diminished, and t h e fact t h a t public organisation ensures the service must
not d e s t r o y the sense of choice a n d personal association which is at the heart
of " family " d o c t o r i n g . T h e second principle, which m a i n l y concerns the
doctor, is that the practice of medicine is a n individual a n d personal art, im­
p a t i e n t of regimentation. W h a t e v e r the organisation, the doctors taking
p a r t m u s t remain free to direct their clinical knowledge a n d personal skill
for the benefit of their p a t i e n t s in the w a y w h i c h t h e y feel to b e best.
Methods of approach to the problem.
One m e t h o d would be t o a b a n d o n entirely t h e present system, on which
National H e a l t h I n s u r a n c e h a s been based, a n d t o substitute for it a system
under which all doctors t a k i n g p a r t would become the direct employees of the
State or of local authorities a n d would be r e m u n e r a t e d b y salary. As a
problem of administration, there would be no insuperable difficulty in organis­
jng a scheme of this kind. B u t this is a highly controversial question, on
which opinions are sharply d i v i d e d .
M a n y experienced a n d skilled
doctors would be unwilling to take p a r t in a service so conceived.
They would hold t h a t it infringed the second of t h e t w o principles just
stated, a n d t h a t if t h e y b e c a m e t h e salaried s e r v a n t s whether of t h e
State o r of local authorities, t h e y would lose their professional freedom
and be fettered in t h e exercise of their individual skill. Other doctors,
with a n equal right t o be h e a r d , would welcome a salaried service, believing
that it would relieve t h e m from business anxieties a n d enable t h e m to d e v o t e
themselves m o r e freely to t h e practice of their profession. L a y opinion is
similarly v a r i e d .
The G o v e r n m e n t h a v e a p p r o a c h e d the question solely from the point of view
of what is needed to m a k e t h e n e w service efficient.
Some of t h e proposals
made in this P a p e r involve forms of medical practice for which present m e t h o d s
of payment a r e i n a p p r o p r i a t e , if n o t u n w o r k a b l e . W h e r e this is so, r e m u n e r a ­
tion b y salary or its e q u i v a l e n t is suggested. A universal c h a n g e to a salaried
system is n o t however, in t h e G o v e r n m e n t s view, necessary to t h e efficiency of
the service. T h e y consider t h a t to m a k e , unnecessarily, so total a n d
abrupt a c h a n g e in the c u s t o m a r y form of general medical practice would
offend against t h e principle—earlier s t a t e d — t h a t the n e w service should be
achieved not b y t e a r i n g u p all established a r r a n g e m e n t s a n d start­
ing afresh b u t b y evolving a n d a d a p t i n g t h e present t o suit the future. T h e y
are averse from i m p o s i n g a total salaried service m e r e l y for the sake of
administrative tidiness.
Another alternative would be to m a i n t a i n the " panel " system of N a t i o n a l
Health I n s u r a n c e as it is n o w k n o w n , while e x t e n d i n g it t o t h e whole p o p u l a ­
tion a n d e x p a n d i n g it t o include consultant a n d specialist services.
This
system h a s h a d , a n d still h a s , its critics, a n d some of t h e criticism is well
founded. Y e t , for m o r e t h a n a generation it h a s p r o v i d e d a better medical
service t h a n w a s previously available to a l a r g e ' section of t h e p o p u l a t i o n
and it has enlisted t h e regular professional services of a great m a j o r i t y of the
doctors of t h e c o u n t r y . T h e r e a r e , however, t w o o v e r r i d i n g reasons w h y it
will not b e possible to m e e t t h e n e w need merely b y extending t h e p a n e l
system in this w a y .
First, there is a t p r e s e n t no effective m e a n s of ensuring a p r o p e r
T o some extent the d e m a n d in a n y area
distribution of doctors.
will, b y affording o p p o r t u n i t y for practice, itself i n d u c e t h e s u p p l y ; b u t
that does n o t work out reliably o r universally.
I t is true even n o w t h a t
the need for doctors in one area m a y be scantily o r u n s u i t a b l y m e t , while
that of a n o t h e r area m a y b e over-supplied.
C e r t a i n l y when t h e m u c h
bigger public responsibility is a s s u m e d of ensuring a personal doctor service
for the whole p o p u l a t i o n there will h a v e to b e m e a n s of securing, t h r o u g h
public organisation, t h a t t h e resources available are so disposed as to
fit the public need.
Second, there is a great deal of a g r e e m e n t in t h e profession a n d
elsewhere that developments in t h e m o d e r n technique of medical practice point
the way to changes which need e n c o u r a g e m e n t a n d e x p e r i m e n t in a n y future
service. T h e recent draft I n t e r i m R e p o r t of t h e Medical P l a n n i n g Commission
(organised b y the British Medical Association) summarises these trends very
well. F o r instance, the R e p o r t s t a t e s : —
" T h e d a y s when a doctor a r m e d o n l y with his stethoscope and his drugs
could offer a fairly complete medical service are gone. H e cannot now be
all-sufficient.
F o r efficient work he must h a v e a t his disposal modern
facilities for diagnosis a n d t r e a t m e n t , and often these c a n n o t be provided
b)' a private individual or installed in a private surgery. H e must also have
easy a n d convenient access to consultant a n d specialist opinion, whether
at hospital or elsewhere, a n d he m u s t h a v e opportunities of real collabora­
tion with consultants. Facilities such a s these are i n a d e q u a t e at t h e present
time. There m u s t also be close collaboration a m o n g s t local general prac­
titioners themselves, for their different interests a n d experience can be of
v a l u e to each other.
Although this need is recognised b y practitioners
collaboration h a s not been developed as it should b e . "
Or, again, in another p a s s a g e —
" At the present t i m e the single-handed practice or p a r t n e r s h i p is usually
conducted from a d o c t o r ' s p r i v a t e residence. Certain r o o m s a r e used for
professional purposes, a n d personal or b o r r o w e d capital is invested in
equipping the practice with a p p a r a t u s a n d in keeping it u p - t o - d a t e ; addi­
tional domestic staff is employed to k e e p the surgery a n d waiting rooms
clean a n d to deal with callers; the secretarial work a n d record keeping are
done b y the doctor himself .or a secretary employed for t h e p u r p o s e ; dis­
pensing, if d o n e at the surgery, is u n d e r t a k e n either b y the doctor or a
dispenser employed b y him. This a r r a n g e m e n t is repeated m a n y times over
in a fairly well-populated d i s t r i c t . "
T h e tendency will be a w a y from t h e idea of the all-sufficient doctor
working alone, a n d t o w a r d s a bigger element of g r o u p e d practice and team­
w o r k — i n which the individual doctor retains his personal link with the
p a t i e n t , b u t has at his side t h e pooled ability of a g r o u p of colleagues as
well as consultant and hospital services behind h i m . T o q u o t e the Medical
P l a n n i n g Commission once m o r e : —
Diverse as are the views of the organization of medical services, there
is general agreement that co-operation a m o n g s t i n d i v i d u a l general practi­
tioners in a locality is essential to efficient practice u n d e r m o d e r n conditions,
t h o u g h views v a r y on the form of t h e co-operation. T h e principle of the
organization of general practice on a g r o u p or co-operative basis is widely
approved."
- T h e G o v e r n m e n t fully agree that " g r o u p e d " practices, to which numerous
p r i v a t e l y a r r a n g e d p a r t n e r s h i p s are a l r e a d y p o i n t i n g the w a y , m u s t have
a high place in t h e p l a n n i n g of the n e w service a n d they are designing the
service with this c o n s t a n t l y in view. Y e t t h e conception of g r o u p e d practices
c a n n o t represent the whole s h a p e of t h e future service. I n the first place,
th,ere h a s not y e t been enough experience of the idea t r a n s l a t e d into fact.
N o t enough has been found out, b y trial a n d error, to d e t e r m i n e the con­
ditions u n d e r which individual doctors can best collaborate o r even the extent
to which in the long r u n the public will prefer the g r o u p s y s t e m . Second,
it is certain t h a t the system could n o t b e a d o p t e d e v e r y w h e r e simultaneously.
T h e c h a n g e , if experience shows t h a t it should b e c o m p l e t e , will take time.
T h e G o v e r n m e n t intend, therefore, t h a t t h e new service shall b e based on a
c o m b i n a t i o n of g r o u p e d practice a n d of separate p r a c t i c e side b3' side. They
propose to place the g r o u p idea in the forefront of their p l a n s in order that
there m a y be a full trial on a large scale of t h e w o r k i n g of a r r a n g e m e n t s of this
k i n d . Grouped practices a r e m o r e likely to be found s u i t a b l e in densely
p o p u l a t e d and highly b u i l t - u p areas a n d it is t h e r e p a r t i c u l a r l y (though not
exclusively) that they should first be tried. It will t h e n b e possible to watch
the development, with the medical profession, a n d to decide in the light of
experience how far a n d , h o w fast a c h a n g e over to the new form of practice
can and should be m a d e .
The part of central and of local organisation in the service.
All doctors in general p r a c t i c e who join in the new relationship with their
patients and rely largely in future o n public funds for their n o r m a l livelihood,
must be treated on a similar footing; t h e t e r m s of their r e m u n e r a t i o n , t h e
general conditions to b e o b s e r v e d ' b y t h e m and. t h e rights to b e enjoyed b y
them must be nationally negotiated and settled.
In the National H e a l t h I n s u r a n c e s c h e m e successive G o v e r n m e n t s h a v e
accepted this principle, on which the medical profession itself h a s laid
much stress.
Although the local I n s u r a n c e C o m m i t t e e s p l a y a v a l u a b l e
and recognised p a r t in the administration of t h e scheme (and particularly
in handling minor m a t t e r s of discipline) the service is in fact highly centralised.
Terms are laid down in g r e a t detail in the Medical Benefit R e g u l a t i o n s , a n d
all major questions h a v e either been m a t t e r s for negotiation between the
Government and representatives of the profession o r - a s in the case of
enquiries involving the r e m o v a l of a doctor from t h e s e r v i c e — h a v e b e e n dealt
with by central tribunals a p p o i n t e d by, a n d a n s w e r a b l e to, the Minister.
The Government are convinced t h a t , b r o a d l y , this system is still t h e right
one and that it would be a mistake to a p p l y to the new general practitioner
service the normal c a n o n s of local g o v e r n m e n t a d m i n i s t r a t i o n . O n t h e other
hand, it is essential t h a t general medical p r a c t i c e in the new h e a l t h service
should not b e divorced from the other b r a n c h e s of t h a t service; t h a t would
perpetuate w h a t is recognised to be the o u t s t a n d i n g defect of the present
system. Therefore w h a t is proposed, in outline, is as follows: —
(i) T h e present p r a c t i c e of settling centrally all m a j o r t e r m s a n d condi­
tions of service, including r e m u n e r a t i o n , will s t a n d . T h e local I n s u r a n c e
Committees will be abolished a n d in future doctors, in so far as; t h e y t a k e
part in the new general practitioner service, will b e in c o n t r a c t u a l relation
with a Central Medical B o a r d , to which t h e y will look for their r e m u n e r a t i o n .
(2) I n general, the other functions of the I n s u r a n c e C o m m i t t e e s
will also fall to the B o a r d , b u t to avoid over-centralisation in detail the
Board will discharge m a n y of t h e m i n o r d a y - t o - d a y functions t h r o u g h a
local committee or similar a g e n c y , on which there will b e included m e m b e r s
of the local a u t h o r i t y in each a r e a .
(3) The new joint a u t h o r i t y will h a v e an i m p o r t a n t p a r t t o p l a y of a
different k i n d . As the general p l a n n i n g a u t h o r i t y for the whole health
service in ' its. area, it will include the needs of general medical p r a c t i c e ,
no less t h a n of other services, in its a r e a p l a n ; it will provide for the
linking of general practitioners (whether in g r o u p e d or sepai-ate practices)
with the hospital a n d c o n s u l t a n t a n d other services in the a r e a .
(4) T h e c o u n t y a n d c o u n t y b o r o u g h councils which m a k e u p t h e joint
authority will n o r m a l l y each h a v e t h e function of p r o v i d i n g a n d m a i n ­
taining such premises (in H e a l t h Centres a n d otherwise) as a r e a p p r o v e d
in the area p l a n .
(5) The doctor himself will, in his c o n t r a c t with t h e B o a r d , be r e q u i r e d
to observe the a r r a n g e m e n t s of the a r e a p l a n a n d will be given all the
necessary information a n d facilities to enable h i m to do t h i s .
These are all m a t t e r s foi further e x p l a n a t i o n . T h e a r r a n g e m e n t a d o p t e d
is, first, to deal with the p a r t i c u l a r points arising on " g r o u p e d " general
practice and on " s e p a r a t e " general practice respectively, a n d t h e n to
deal with features c o m m o n to b o t h k i n d s of practice a n d with the constitution
^ and functions of the p r o p o s e d C e n t r a l Medical B o a r d .
GROUPED GENERAL PRACTICE.
T h e conception of g r o u p e d practice finds its most usual expression i n the
idea, advocated b y t h e Medical P l a n n i n g Commission a n d others, of conduct­
ing practice in specially designed a n d equipped premises where the g r o u p can
collaborate and share up-to-date resources—the idea of the " Health Centre " .
The G o v e r n m e n t agree that it is in this form t h a t t h e a d v a n t a g e s of t h e group
system can b e most fully realised, t h o u g h it will also b e desirable to encourage
the idea of grouped practice without special premises. T h e y intend, there­
fore, to design t h e n e w service so as to give scope t o a full trial of this new
method of organising medical practice, a n d so as t o enable it to b e expanded
and developed a s time goes o n t o t h e m a x i m u m extent which t h e practical
experience of its working is found t o justify.
General fines of Health Centre development.
W h e r e H e a l t h Centres a r e set u p , their t y p e s will need, particularly at
first, t o b e varied. Scope m u s t b e given (with central a n d local professional
Broadly,
guidance) t o experiment a n d t o design c a p a b l e of later a d a p t a t i o n .
the design should p r o v i d e for individual consulting-rooms, for reception and
waiting-rooms, for simple l a b o r a t o r y work, for n u r s i n g a n d secretarial staff,
telephone services and other accessories, a s well as—in v a r y i n g degree according
to circumstances—recovery a n d rest r o o m s , d a r k rooms, facilities for minor
surgery, a n d other ancillaries. T h e object will be t o p r o v i d e the-doctors with
first-class premises a n d e q u i p m e n t a n d assistance a n d so give t h e m the best
facilities for meeting their p a t i e n t s ' needs. T h e doctors will thus b e freed from
the necessity to provide these things a t their own cost. They will j o i n in some­
t h i n g like t h e p a r t n e r s h i p g r o u p s already often p r i v a t e l y formed, a n d there
will b e new scope for t h e y o u n g doctor, fresh from hospital training, to take
his share in t h e Centre a s a n assistant t o t h e practitioners engaged there, and
t h e n , later on, t o b e eligible for full participation.
Limitation of the permitted n u m b e r of p a t i e n t s will a p p l y whether in.the
C e n t r e o r ' o u t s i d e it, a n d , subject to this, t h e o r d i n a r y basis of t h e patienfs
choice of doctor will n o t b e affected. E a c h C e n t r e will need to b e so planned
as to b e regarded b v natipntc; n o t ss q r o m n l e t e b r e a k with present habit but
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a patient will, in e m e r g e n c y , b e able t o g e t i m m e d i a t e attention even though
his o w n doctor does not h a p p e n t o b e available. T h e grouping of practices
will, moreover, m a k e it easier for doctors t o o b t a i n reasonable holidays and
t o attend" refresher courses. T h e internal organisation of t h e Centre so as
to facilitate reasonable absences consistent with t h e d o c t o r ' s responsibilities
to his patients will b e a m a t t e r for t h e doctors a t t h e C e n t r e themselves.
T h e Centres will be p r o v i d e d first in selected a r e a s . Both central and
local organisation, a n d local professional interests represented b y the Local
Health Services Council will all h a v e their p a r t to p l a y in this provision.
Xhe wish of t h e local doctors t o bring their work into the n e w Centres m u s t
obviously b e a big factor in a decision to provide a C e n t r e , b u t in the last
resort t h e decision will rest on t h e r e q u i r e m e n t s of the public interest.
Provision of C e n t r e s .
It will b e essential to associate a n y decision to provide Centres, a n d their
location, with the rest of the a r r a n g e m e n t s of the a p p r o v e d a r e a p l a n . This
will m e a n , in effect, t h a t t h e decision in each case t h a t the H e a l t h
Centre system should be initiated in a particular p a r t or p a r t s Of the a r e a ,
and the consequential decis ions cis to the location a n d size a n d k i n d of
Centres to be provided, will normally s t a r t in t h e area itself where the needs a r e
best k n o w n a n d where t h e general h e a l t h services p l a n is formulated, b u t
will depend in t h e last resort u p o n t h e decision of t h e Minister in the light
of his central policy on the general practitioner service a n d t h e new H e a l t h
I t will b e for t h e joint
Centre e x p e r i m e n t in t h e c o u n t r y as a whole.
authority in t h e first instance, in consultation with the local medical p r o ­
fession, to formulate proposals for a C e n t r e o r Centres as p a r t of the area plan
or, later on, as a n extension or alteration of t h a t p l a n — a n d to submit t h e m
to the Minister.
The actual provision of a C e n t r e will normally be t h e responsibility of t h e
county or c o u n t y b o r o u g h council.' T h i s accords with t h e principle earlier
discussed u n d e r which t h e clinical a n d other services which a r e not essentially
part of t h e c o n s u l t a n t a n d hospital field will b e allocated t o these councils
and not to the joint a u t h o r i t y .
Terms of service in H e a l t h Centres.
The t e r m s a n d conditions of service will b e settled centrally for all doctors
taking p a r t in t h e n e w service, w h e t h e r in group practice or n o t , a n d all doctors
will enter into a contractof service w i t h the central organisation. T h e d o c t o r
practising in a C e n t r e will not b e d e b a r r e d . from p r i v a t e practice outside it, for
those patients w h o do n o t wish to t a k e a d v a n t a g e of the n e w public service,
though t h e r e will be provision to e n s u r e t h a t t h e interests of patients w i t h i n
the new service do n o t suffer in a n y w a y as a result of this.
In certain respects t h e contract of t h e doctor in t h e H e a l t h C e n t r e m u s t
differ from t h a t of one practising outside. , After t h e establishment of a C e n t r e
the a p p o i n t m e n t of a n e w doctor to t h e Centre will b e m a d e jointly b y t h e
Central Medical B o a r d a n d the Council administering t h e C e n t r e a n d similarly
the termination of his e n g a g e m e n t a t the C e n t r e (except where the doctor
himself wished to b r i n g it to a n e n d ) . w i l l rest with these t w o bodies, or if
they failed to agree, w i t h t h e Minister. I t will be p a r t of t h e a r r a n g e m e n t
that the Council provide the doctors in the Centre with t h e necessary premises,
equipment a n d ancillary staff. T h e c o n t r a c t will h a v e to b e a t h r e e - p a r t y
one between t h e doctor, the C e n t r a l Medical B o a r d a n d t h e Council.
But there is one i m p o r t a n t question in regard to the m e t h o d of r e m u n e r a t i o n
of the doctor, w h e n practising in co-operation with a g r o u p of colleagues in
a Health C e n t r e , which does n o t arise in t h e s a m e w a y w h e n h e is in s e p a r a t e
practice outside. T h a t is the m e t h o d of p a y m e n t of the i n d i v i d u a l doctor.
It seems f u n d a m e n t a l that inside a C e n t r e the g r o u p e d doctors should n o t
be in financial competition for p a t i e n t s . All t h e practical a d v a n t a g e s of t h e
Centre—the u s e of n u r s i n g a n d secretarial staff, record-keeping, e q u i p m e n t ,
the availability of y o u n g assistant doctors in p a r t i c u l a r — w i l l b e , u n d e r a
system of a salaried t e a m , at t h e disposal of t h e g r o u p in w h a t e v e r w a y t h e y
liked collectively to a r r a n g e ; it is the whole idea t h a t t h e y should a r r a n g e their
own affairs together in this w a y . B u t if individual r e m u n e r a t i o n is based
on mutual competition for p a t i e n t s , complication will enter i n t o a n y
attempt of t h e g r o u p t o allocate a n d s h a r e these services—for t h e m o r e a n y
GROUPED GENERAL PRACTICE. T h e conception of g r o u p e d practice finds its most usual expression in the
idea, advocated b y the Medical P l a n n i n g Commission and others, of conduct­
ing practice in specially designed a n d e q u i p p e d premises where t h e g r o u p can
collaborate a n d share up-to-date resources—the idea of the " H e a l t h Centre " .
T h e G o v e r n m e n t agree t h a t it is in this form t h a t the a d v a n t a g e s of the group
s y s t e m can be most fully realised, t h o u g h it will also be desirable to encourage
the idea of grouped practice without special premises. T h e y intend, there­
fore, to design the new service so as to give scope to a full trial of this new
m e t h o d of organising medical practice, a n d so as to enable it to be expanded
a n d developed as time goes on to the m a x i m u m extent which the practical
experience of its w o r k i n g is found to justify.
General lines of H e a l t h C e n t r e d e v e l o p m e n t .
W h e r e H e a l t h Centres are set u p , their t y p e s will need, particularly at
first, to be varied. Scope must be given (with central a n d local professional
guidance) to experiment a n d to design capable of later a d a p t a t i o n .
Broadly,
the design should p r o v i d e for individual consulting-rooms, for reception and
waiting-rooms, for simple l a b o r a t o r y w o r k , for nursing a n d secretarial staff,
telephone services and other accessories, as well as—in v a r y i n g degree according
to circumstances—recovery and rest r o o m s , d a r k rooms, facilities for minor
surgery, a n d other ancillaries. T h e object will b e to p r o v i d e t h e doctors with
first-class premises a n d e q u i p m e n t a n d assistance and so give t h e m the best
facilities for meeting their p a t i e n t s ' needs. The doctors will thus be freed from
the necessity to provide these things a t their own cost. T h e y will join in some­
thing like the p a r t n e r s h i p groups a l r e a d y often privately formed, a n d there
will b e new scope for t h e y o u n g doctor, fresh from hospital t r a i n i n g , to take
his share in the C e n t r e as a n assistant to the practitioners engaged there, and
then, later on, to be eligible for full participation.
Limitation of the permitted n u m b e r of p a t i e n t s will a p p l y whether in the
Centre or outside it, a n d , subject to this, the ordinary basis of the patient's
choice of doctor will not be affected. E a c h Centre will need t o be so planned
as to be regarded b y p a t i e n t s not as a complete break with present habit but
l a s a new place at which they can continue to see their own doctor, in better
E q u i p p e d surroundings if they wish to, or can if they prefer seek advice at
the Centre without h a v i n g previously m a d e their choice of a p a r t i c u l a r doctor.
It will be i m p o r t a n t to avoid an a t m o s p h e r e of an impersonal clinic, at which
the doctor's individuality would b e s u b m e r g e d in a n a n o n y m o u s public
service.!
There has often been misconception as to the precise implications of Health
Centre practice. I t h a s been t o o r e a d i l y assumed t h a t a d o c t o r would be
" on d u t y " only for stated periods daily, a n d that, outside those periods,
his patients would a l w a y s b e attended b y some other doctor. T h a t need not
be so. Normally, a doctor will attend his own patients as necessary, either
at the Centre or a t t h e h o m e . H e will h a v e his consulting h o u r s at the
Centre a n d visit his p a t i e n t s as at present. B u t the g r o u p i n g of practices
at a H e a l t h Centre will m a k e possible, n a t u r a l l y , a g r e a t e r fluidity of arrange­
ments; for e x a m p l e , as a r r a n g e m e n t s will b e m a d e for c o n t i n u o u s staffing,
a patient will, in emergency, b e able to get immediate attention even though
his own doctor does n o t h a p p e n to be a v a i l a b l e . T h e g r o u p i n g of practices
will, moreover, m a k e it easier for doctors to obtain reasonable holidays and
to attend" refresher courses. T h e internal organisation of t h e Centre so as
to facilitate reasonable absences consistent with the d o c t o r ' s responsibilities
to his p a t i e n t s will be a m a t t e r for the doctors at the C e n t r e themselves.
T h e Centres will b e provided first in selected a r e a s . B o t h central and
local organisation, and local professional interests represented b y the Local
Health Services Council will all h a v e their p a r t to p l a y in this provision.
The wish of t h e local doctors to b r i n g their work into t h e new Centres m u s t
obviously be a b i g factor in a decision to provide a C e n t r e , b u t in t h e last
resort the decision will rest o n the r e q u i r e m e n t s of the public interest.
Provision of Centres.
It will be essential to associate a n y decision to provide Centres, a n d their
location, with t h e rest of t h e a r r a n g e m e n t s of the a p p r o v e d a r e a p l a n . T h i s '
will mean, in effect, t h a t the decision in each case t h a t the H e a l t h
Centre system should be initiated in a p a r t i c u l a r p a r t or p a r t s of the area,
and the consequential decisions as to t h e location a n d size a n d k i n d of
Centres to be p r o v i d e d , will normally start in the area itself where the needs a r e
best known a n d where the general h e a l t h services p l a n is formulated, b u t
will depend i n t h e last resort u p o n t h e decision of t h e Minister in the light
of his central policy on the general practitioner service a n d t h e new H e a l t h
I t will b e for t h e joint
Centre experiment in t h e c o u n t r y a s a whole.
authority in t h e first instance, in consultation with t h e local medical p r o ­
fession, to formulate p r o p o s a l s for a C e n t r e or Centres as p a r t of the area p l a n
later on, as a n extension or alteration of t h a t p l a n — a n d to submit them
to the Minister.
The actual provision of a Centre will n o r m a l l y b e t h e responsibility of the
county or c o u n t y b o r o u g h council.- This accords with t h e principle earlier
discussed u n d e r which the clinical a n d other services w h i c h a r e not essentially
part of the c o n s u l t a n t a n d hospital field will b e allocated t o these councils
and n o t to t h e joint a u t h o r i t y .
0 I j
Terms of service in Health Centres.
The terms a n d conditions of service will be settled centrally for all doctors
taking p a r t in t h e n e w service, w h e t h e r in g r o u p practice or not, a n d all doctors
will enter into a contractof service with t h e central organisation. T h e d o c t o r
practising in a C e n t r e will n o t b e d e b a r r e d , f r o m p r i v a t e p r a c t i c e outside it, for
those patients who d o not wish to t a k e a d v a n t a g e of the new public service,
though there will be provision to e n s u r e t h a t t h e interests of patients within
the n e w service do n o t suffer in a n y w a y as a result of t h i s .
In certain respects the contract of the doctor in t h e H e a l t h Centre m u s t
differ from t h a t of o n e practising outside. After t h e establishment of a C e n t r e
the a p p o i n t m e n t of a new doctor to the C e n t r e will b e m a d e jointly b y t h e
Central Medical B o a r d a n d the Council administering t h e C e n t r e a n d similarly
the termination of h i s e n g a g e m e n t a t t h e C e n t r e (except w h e r e the d o c t o r ,
himself wished to b r i n g it t o an e n d ) . w i l l rest with these t w o bodies, or if I
they failed to agree, with t h e Minister. I t will b e p a r t of t h e a r r a n g e m e n t
that the Council provide t h e doctors i n t h e Centre with t h e necessary premises,
equipment a n d ancillary staff. T h e contract will h a v e to b e a t h r e e - p a r t y
one between t h e doctor, t h e Central Medical B o a r d a n d t h e Council.
But there is one i m p o r t a n t question in r e g a r d to t h e m e t h o d of r e m u n e r a t i o n
of the doctor, w h e n practising in co-operation with a g r o u p of colleagues in
a Health C e n t r e , which does not arise in t h e s a m e w a y w h e n h e is in s e p a r a t e
practice outside. T h a t is t h e m e t h o d of p a y m e n t of t h e individual doctor.
It seems f u n d a m e n t a l t h a t inside a C e n t r e the g r o u p e d doctors should n o t
be in financial competition for p a t i e n t s . All t h e practical a d v a n t a g e s of t h e
C e n t r e - t h e u s e of n u r s i n g a n d secretarial staff, record-keeping, e q u i p m e n t ,
the availability of yOung assistant doctors in particular—will b e , u n d e r a
system of a salaried t e a m , a t the disposal of t h e group in w h a t e v e r w a y t h e y
liked collectively to a r r a n g e ; it is t h e whole idea t h a t t h e y should a r r a n g e t h e i r
own affairs t o g e t h e r in this w a y . B u t if individual r e m u n e r a t i o n is b a s e d
on mutual c o m p e t i t i o n for patients, complication will enter into a n y
attempt of t h e g r o u p to allocate a n d s h a r e these services—for t h e m o r e any
one individual is able to d r a w on the ancillary helps of the C e n t r e (and
particularly on medical assistants) the more he will gain and his fellows
lose in t h e 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 m u t u a l competition within the Centre. W h e n the salaried or similar
principle is a d o p t e d , the scales will h a v e to be decided in consultation with
the profession itself. In this respect attention is d r a w n to A p p e n d i x D , which
suggests the m e t h o d by which a basis could be arrived at for settling both
salaried r e m u n e r a t i o n a n d the p a y m e n t b y capitation later proposed for
" s e p a r a t e " practice. It m a y also b e possible, if desired b y the doctors them­
selves, to offer remuneration on a salaried basis or on some other basis than
that of capitation fees to doctors engaged in g r o u p practice even where the
practice was not conducted in a H e a l t h Centre.
SEPARATE GENERAL PRACTICE.
I n " separate " practice t h e general framework of t h e National Health
I n s u r a n c e Scheme will be retained b u t there will h a v e to be important
changes from t h e p a s t a n d t h e scheme will h a v e to b e m u c h extended and
a d a p t e d . T h e n a t u r e of these c h a n g e s will b e evident n o t only from the
following p a r a g r a p h s which relate to " separate " practice, b u t also from the
later p a r a g r a p h s dealing with features c o m m o n to b o t h " g r o u p " and
" separate " p r a c t i c e .
Scope of S e p a r a t e Practice.
I n future e v e r y o n e will be entitled, as only " insured " persons are entitled
at present, to receive from t h e doctor chosen b y h i m all the o r d i n a r y range of
general medical practice, either at t h e consulting r o o m or at h i s h o m e , as
the case requires. He will also be entitled, n o r m a l l y t h r o u g h his doctor,
to all t h e n e w r a n g e of consultant a n d specialist a n d h o s p i t a l or clinic services
already considered.
A doctor in separate practice will engage himself to provide ordinary
medical care a n d t r e a t m e n t to all persons a n d families accepted by
him u n d e r t h e n e w a r r a n g e m e n t s . H e will w o r k from h i s own consulting­
r o o m a n d w i t h his own e q u i p m e n t , as he does h o w , b u t h e will b e backed
b y the n e w organised service of consultants, specialists, hospitals a n d clinics,
which h e will be expected to use for his p a t i e n t s in accordance with the
a p p r o v e d area p l a n earlier described. H e will receive his remuneration
for w o r k w i t h i n t h e new service, n o t ' f r o m t h e individual patient, b u t from
public funds; a n d this r e m u n e r a t i o n will b e b a s e d — a s it is now in National
Health I n s u r a n c e — o n a capitation system, d e p e n d i n g o n t h e n u m b e r of
p a t i e n t s whose care h e u n d e r t a k e s . (A settlement on n e w lines of t h e basis
for calculating capitation o r other forms of r e m u n e r a t i o n is suggested in
A p p e n d i x D a l r e a d y referred to.) E v e n in t h e case of separate practice there
will be some circumstances in which it will b e possible to remunerate the
practitioner on a salaried o r similar basis if he so desires. Opportunity for
such a n a r r a n g e m e n t m a y occur, for e x a m p l e , in sparsely populated areas
w h e r e a single doctor is in fact responsible for all t h e work of the area
a n d is not therefore in competition with other doctors in t h e neighbourhood.
But, h o w e v e r r e m u n e r a t e d , t h e doctors in separate practice will remain
entitled to engage in private practice, since it is n o p a r t of t h e intention of the
n e w service t o prevent persons w h o prefer to do so from m a k i n g private
a r r a n g e m e n t s for medical c a r e o r to p r e v e n t doctors from meeting their needs.
C o n t r o l o v e r e n t r y into- n e w practice.
T h e r e will b e h o interference with t h e right of a d o c t o r to go on prac­
tising w h e r e h e is now a n d to t a k e p a r t in t h e public service in that area.
B u t an unrestricted right to a n y doctor to enter a n y n e w practice a n d t h e r e to
claim public r e m u n e r a t i o n , at his own discretion, would m a k e it impossible
to fulfil the new u n d e r t a k i n g t o assure a service for all.
U n d e r the present N a t i o n a l H e a l t h I n s u r a n c e system every qualified doctor
has a right to t a k e u p panel practice where he likes. T h e system enables
the Minister, if satisfied t h a t the service in a n y area is i n a d e q u a t e , to replace
the panel system b y s o m e other form of a r r a n g e m e n t s , a l t h o u g h — w i t h m i n o r
exceptions at the outset, of the scheme—this p o w e r h a s not been i n v o k e d ,
t h e r e h a s never been a n y real m e a n s of securing t h a t the doctors of t h e
country are reasonably distributed. This h a s p e r h a p s hot b e e n a pressing
necessity while the scheme covered less t h a n half t h e population, b u t . it is
well-known t h a t great disparities h a v e existed.
If u n d e r the new scheme the whole p o p u l a t i o n are to be entitled
to a general practitioner service, a m u c h h e a v i e r responsibility will b e
thrown on the G o v e r n m e n t to see t h a t the needs of the whole p o p u l a ­
tion are met.
This implies s o m e . degree of regulation of t h e d i s ­
tribution of medical resources, at least to t h e e x t e n t of securing t h a t a
doctor does not in future t a k e u p practice in t h e p u b l i c service (whether b y
purchasing a practice o r b y " s q u a t t i n g " ) , in a locality which is a l r e a d y
fully or o v e r - m a n n e d . Such control c a n b e left in the p r o f e s s i o n ^ o w n
hands a s far as possible, t h o u g h it m u s t be g u i d e d b y n a t i o n a l policy.
A
suitable m a c h i n e r y will b e to vest it in the C e n t r a l Medical B o a r d , w o r k i n g
under general guidance on policy from the G o v e r n m e n t b u t i n d e p e n d e n t l y
in its individual decisions. A n y practitioner wishing to set u p a n e w — o r
take over a n existing—public service practice in a p a r t i c u l a r area will seek
the consent of the B o a r d . T h e B o a r d will t h e n h a v e regard to t h e n e e d
for doctors in the public service in t h a t area, in relation to the c o u n t r y as a
whole, a n d to the general policy for the time b e i n g affecting t h e d i s t r i b u t i o n
of public medical practice. If it is considered t h a t the a r e a h a s sufficient
or more t h a n sufficient doctors in public p r a c t i c e while other a r e a s n e e d
more doctors, consent will b e refused. Otherwise it will usually b e g i v e n
without question. T h e B o a r d will t h u s be able to help the n e w j o i n t
authorities which, in their general concern w i t h the health services of t h e i r
area, will t u r n to the B o a r d to encourage or discourage a n y further increases
in general practice in t h e area.
The part of t h e new j o i n t a u t h o r i t y .
It will be the d u t y of the new joint a u t h o r i t y to consider t h e n e e d s
of its area in general medical practice, including " s e p a r a t e " practice, no less
than in the other b r a n c h e s of t h e comprehensive service, a n d to i n c l u d e in t h e
area plan for central a p p r o v a l the a r r a n g e m e n t s — i n t e r m s of n u m b e r s a n d
distribution of general practitioners—which it considers to be necessary t o
meet these needs. I n this it will h a v e the a d v a n t a g e of consultation w i t h
the Local Health Services Council. T h e plan will need t h e Minister's a p p r o v a l ,
after hearing a n y conflicting local views. T h e a p p r o v e d p l a n will b e m a d e
known to the Central Medical B o a r d , to b e t a k e n into account in t h e s u b s e ­
quent exercise of their functions in the distribution of public medical p r a c t i c e .
It will also b e the dut)? of the joint a u t h o r i t y to w a t c h t h a t t h e s u p p l y
of all b r a n c h e s of the c o m p r e h e n s i v e service is a d e q u a t e "to the n e e d s of
their area a n d in the m a t t e r of general practice, therefore, to b r i n g to t h e notice
of the Minister a n d the C e n t r a l Medical B o a r d a n y n e e d s which they feel s h o u l d
be more a d e q u a t e l y m e t . T h e y will also b e responsible for e n s u r i n g t h a t
all the other services in their area (hospital, clinic, n u r s i n g , consultant a n d
specialist) are fully k n o w n to t h e general practitioners p a r t i c i p a t i n g
in the new service a n d t h a t t h e latter are e n a b l e d (as their c o n t r a c t will
require them) to use these services fully for t h e i r p a t i e n t s in a c c o r d a n c e w i t h
the approved a r e a p l a n .
It remains to consider certain general questions affecting medical practice,
b o t h " grouped " a n d - " separate " , and to describe more fully the proposals
for a Central Medical Board.
Permitted n u m b e r of patients.
F r o m the outset of medical benefit under N a t i o n a l H e a l t h I n s u r a n c e , provi­
sion has been made for imposing a limit on t h e number of insured persons
for whose t r e a t m e n t a doctor m a y m a k e himself responsible. T h e limit is fixed
b y a local scheme which is subject to the Minister's a p p r o v a l , b u t the regula­
tions themselves provide for certain over-all m a x i m a . An additional n u m b e r
of patients is permitted to a doctor who employs one or m o r e assistants. Under
this system every doctor has a right to u n d e r t a k e as m u c h -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 a n d children u n d e r private
arrangements.
I n the new service also there will h a v e to be prescribed limits to the number
of patients whose care a n y one doctor can properly u n d e r t a k e . B u t the
situation will be substantially altered b y a scheme w h i c h covers the whole
population and which contemplates b o t h grouped a n d separate practice.
I t is not the wish of the G o v e r n m e n t to d e b a r a n y o n e who prefers n o t to avail
himself of the public service from obtaining t r e a t m e n t privately, nor to
prohibit a doctor in the public service from carrying on a n y private practice
but it will b e necessary to ensure t h a t the interests of the p a t i e n t s in the public
service do n o t suffer t h e r e b y .
In fixing the a p p r o p r i a t e limits, in future, allowance will need to be made
for private practice remaining after the new service is i n operation. There
will need to be room for flexibility. A d o c t o r entirely free from outside activity
a n d able to give his whole time to general practitioner w o r k in the n e w service
will need t o be able to work to a higher p e r m i t t e d limit of public patients. A
doctor with an unusually large a m o u n t of p r i v a t e work, o r with appointments
in other b r a n c h e s of the public service, will b e expected to work to a lower
permitted limit. T h e effective w a y to provide reasonable flexibility is t o entrust
the aecision in such cases to a suitable professional organisation—which will
naturally b e the Central Medical Board w o r k i n g through its local committees.
The details of. this are for discussion with the p r o f e s s i o n ^ representatives at a
later stage, b u t the object must be t o see t h a t t h e care of p a t i e n t s u n d e r public
a r r a n g e m e n t s does not suffer in quality or q u a n t i t y b y reason either of private
c o m m i t m e n t s or other public e n g a g e m e n t s . N o r m u s t a n y o n e come to believe
t h a t he can obtain more skilled or more considerate t r e a t m e n t by obtaining it
privately t h a n b y seeking it within the n e w service.
E n t r y into the public service.
There is a strong case for requiring all y o u n g doctors, leaving hospital and
entering individual practice for the first time, to go t h r o u g h a short period of
apprenticeship " as assistants to m o r e experienced practitioners. There is a
particularly strong case for saying t h a t this should b e required b y the State in
medical practice remunerated from public funds. W h e n such a rule is made
the y o u n g assistant doctor will h a v e to b e assured of r e a s o n a b l e conditions and
o p p o r t u n i t y , a n d certainly' must not be a t risk of being precluded from a proper
professional livelihood b y the operation of t h e rule. O n e way will be to
require a suitable period as an assistant except w h e r e the Central Medical
Board dispensed from t h e rule (e.g. to meet cases w h e r e a n assistant post is
not reasonably obtainable). T h e r e will, n o d o u b t , be m a n y opportunities to
105 employ assistants in Health Centres where t h e t e r m s and conditions of
employment can b e ' regulated a n d the Board will be able to help n e w
entrants to find suitable vacancies.
I n the case
of " s e p a r a t e "
practices within t h e public service, t h e . B o a r d m u s t b e . empowered
to' satisfy itself t h r o u g h its local organisation
as to t h e proposed
arrangements
and remuneration
for a n assistant, before
consenting
to his e n g a g e m e n t b y the principal seeking h i m - g e n e r a l guidance o n stan­
dards a n d terms being given c e n t r a l l y t o t h e B o a r d , i n consultation with
the profession. T h e ordinary general practitioner wishing to u n d e r t a k e t h e
care of a larger nurnber of public p a t i e n t s t h a n t h e o r d i n a r y p e r m i t t e d
maximum will then inform the B o a r d , a n d the B o a r d — a f t e r satisfying itself
of the circumstances a s a b o y e ^ - w i l l h e l p a n intending assistant to get t h e p o s t
on the t e r m s a p p r o v e d .
cA
v-.,i-
G
U
8
s
Compensation;
The B o a r d m u s t a l s o b e a b l e t o r e q u i r e
young d o c t o r d u r i n g t h e e a r l y y e a r s
of h i s c a r e e r t o give h i s f u l l time t o
t h e p u b l i c s e r v i c e w h e r e t h e n e e d s of t h e
service require this.
The G o v e r n s
Paper will, in
i n such cases
j i u i e s s i o n DUt m e r e are
the arrangemer,
two classes of case in which a j u s t claim for c o m p e n s a t i o n will clearly arise.
The first is t h a t of a practice i n a n " over-doctored " a r e a , to t h e sale of
which the C e n t r a l Medical B o a r d refuse consent. H e r e t h e out-going doctor
or his representatives will b e p a i d c o m p e n s a t i o n for a n y loss of t h e value
of his practice.
The second case is t h a t of a d o c t o r w h o decides t o give u p his " separate "
public practice a n d to take service in a H e a l t h Centre. I t will b e wholly
incompatible with t h e conception of a H e a l t h Centre t h a t i n d i v i d u a l practices
within the Centre should b e . b o u g h t a n d sold a n d a d o c t o r will therefore,
by entering a Centre, exchange a p r a c t i c e h a v i n g a realisable v a l u e for a
practice which he. will be d e b a r r e d from selling o n retirement.
On the
other h a n d t h e G o v e r n m e n t consider t h a t a n efficient s u p e r a n n u a t i o n system
will be an essential p a r t of t h e H e a l t h Centre organisation. A d o c t o r entering,
a Centre will c o n s e q u e n t l y acquire b o t h s u p e r a n n u a t i o n rights a n d o t h e r
facilities of considerable value. T h e p r o p e r course will b e to strike a fair
balance between w h a t h e is gaining a n d w h a t he is losing a n d to c o m p e n s a t e
him accordingly. .
It would b e m o r e difficult to i n s t i t u t e a s u p e r a n n u a t i o n scheme for doctors
engaged in " separate " practices, b u t t h e G o v e r n m e n t would be glad to
discuss with t h e medical profession t h e possibility of w o r k i n g out a n accept­
able scheme to p r o v i d e for retirement within specified a g e limits and the
granting of s u p e r a n n u a t i o n rights on a c o n t r i b u t o r y basis.
Sale and purchase of public practices.
The G o v e r n m e n t h a v e n o t overlooked t h e case which c a n b e m a d e for t h e
total abolition of t h e sale a n d p u r c h a s e of- publicly r e m u n e r a t e d practices,
t h e abolition would, h o w e v e r , involve g r e a t practical difficulty a n d is n o t
essential to the w o r k i n g of the n e w service which t h e G o v e r n m e n t p r o p o s e .
The Government i n t e n d , h o w e v e r , to discuss t h e whole question with t h e
profession, t o see if some w o r k a b l e a n d satisfactory solution c a n b e r e a c h e d .
The creation of H e a l t h C e n t r e s will, m e a n w h i l e , d o a g r e a t deal to limit
the scope of the p r e s e n t system. T h e C e n t r e s will afford a wide o p p o r t u n i t y to
young doctors t o enter their profession without financial b u r d e n s . T h e y will
also, wherever t h e y a r e set u p , b r i n g into being a n e w f o r m of p r a c t i c e which
C
L
c
a
^
O
!
l)
31032
Bg
v
I n p a r t i c u l a r , i t v/ould o b v i o u s l y be
* Bi
i n c o n g r u o u s t h a t t h e new p u b l i c s e r v i c e
should i t s e l f have t h e e f f e c t of i n c r e a s - ;
i n g t h e c a p i t a l v a l u e of a n i n d i v i d u a l
p r a c t i c e and t h u s i n c r e a s i n g t h e amount
o f c o m p e n s a t i o n w h i c h may h a v e t o b e
provided under the circumstances
described in the preceding paragraphs;
and m e a s u r e s to p r e v e n t t h i s must be
included in the discussion.
if)
It r e m a i n s to consider certain general questions affecting medical practice,
b o t h " grouped " and- " separate " , and to describe more fully the proposals
for a Central Medical Board.
P e r m i t t e d n u m b e r of p a t i e n t s .
F r o m the outset of medical benefit under N a t i o n a l H e a l t h Insurance, provi­
sion has been made for imposing a limit on the number of insured persons
for whose treatment a doctor m a y m a k e himself responsible. The limit is fixed
b y a local scheme which is subject' to the M i n i s t e r s a p p r o v a l , b u t the regula­
lions themselves p r o v i d e for certain over-all m a x i m a . An additional n u m b e r
of patients is permitted to a doctor who employs one or more assistants. U n d e r
this system ever)/ doctor h a s a right to u n d e r t a k e as m u c h private practice as
h e 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 a n d children u n d e r private
arrangements.
In t h e new service also there will have to b e prescribed limits to the n u m b e r
of patients whose c a r e a n y one doctor c a n properly u n d e r t a k e . B u t the
situation will be substantially altered b y a scheme which covers the whole
population and which contemplates both grouped a n d separate practice.
I t is not the wash of t h e G o v e r n m e n t to d e b a r a n y o n e who prefers not to avail
himself of the public service from obtaining t r e a t m e n t privately, nor to
prohibit a doctor in the public service from c a r r y i n g on a n y private practice
b u t it will be necessary to ensure that the interests of the patients in the public
service do not suffer t h e r e b y .
In fixing the a p p r o p r i a t e limits, in future, allowance will need to be made
for p r i v a t e practice r e m a i n i n g after the n e w service is in operation. There
will need to be room for flexibility. A doctor entirely free from outside activity
a n d able to give his whole time to general practitioner work in the new service
will need t o be able to work to a higher p e r m i t t e d limit of public patients. A
doctor with an unusually large a m o u n t of p r i v a t e work, or with appointments
in other branches of the public service, will be expected to work to a lower
p e r m i t t e d limit. T h e effective w a y to provide reasonable flexibility is t o entrust
the decision in such cases to a suitable professional organisation—which will
n a t u r a l l y be the Central Medical Board w o r k i n g t h r o u g h its local committees.
The details of this are for discussion with t h e p r o f e s s i o n ^ representatives at a
later stage, b u t the object m u s t be to see t h a t t h e care of patients u n d e r public
a r r a n g e m e n t s does n o t suffer in quality or q u a n t i t y b y reason either of private
c o m m i t m e n t s or other public engagements. N o r m u s t a n y o n e come to believe
t h a t he can obtain more skilled or more considerate treatment b y obtaining it
privately t h a n b y seeking it within the n e w service.
E n t r y into the public service.
T h e r e is a strong case for requiring all y o u n g doctors, leaving hospital and
entering individual practice for the first time, to go t h r o u g h a short period of
" apprenticeship " as assistants to more experienced practitioners. There is a
particularly strong case for saying that this should be required b y the State in
medical practice r e m u n e r a t e d from public funds. W h e n such a rule is made
the y o u n g assistant doctor will h a v e to b e assured of reasonable conditions and
o p p o r t u n i t y , and certainly m u s t not be at risk of being precluded from a proper
professional livelihood b y the operation of the rule. One w a y will be to
require a suitable period as an assistant except where the Central Medical
B o a r d dispensed from the rule (e.g. to meet cases where a n assistant post is
not reasonably obtainable). There will, n o d o u b t , be m a n y opportunities to
employ assistants in H e a l t h Centres where t h e terms and conditions of
employment can b e regulated and t h e Board will be able to h e l p n e w
entrants to find suitable vacancies.
I n t h e case
of
" separate "
practices within the public service, the . Board must b e . e m p o w e r e d
to' satisfy itself t h r o u g h its local organisation
as to t h e p r o p o s e d
arrangements
and remuneration
for
an
assistant, before
consenting
to his engagement b y t h e principal seeking h i m — g e n e r a l guidance o n s t a n ­
dards and terms b e i n g given centrally to t h e B o a r d , in consultation w i t h
the profession. T h e o r d i n a r y general practitioner wishing to u n d e r t a k e t h e
care of a larger n u m b e r of public p a t i e n t s t h a n t h e o r d i n a r y p e r m i t t e d
m a x i m u m will then inform the B o a r d , a n d t h e B o a r d — a f t e r satisfying itself
of the circumstances as a b o v e - w i l l help a n i n t e n d i n g assistant to get t h e post
Q^SURA. .
'.r . . .
. y C \ \ '\
on the t e r m s a p p r o v e d .
j
Compensation and superannuation.
The Government recognise t h a t the a d o p t i o n of the proposals m a d e in this
Paper will, in certain cases, destroy the v a l u e of existing medical practices.
In such cases c o m p e n s a t i o n will b e p a i d . I t will b e necessary to discuss
the a r r a n g e m e n t s for this in detail with the medical profession b u t t h e r e are
two classes of case in which a j u s t claim for c o m p e n s a t i o n will clearly arise.
The
which
or his
of his
first is t h a t of a p r a c t i c e in an " over-doctored " a r e a , to t h e sale of
the Central Medical B o a r d refuse consent. H e r e t h e out-going doctor
representatives will b e p a i d compensation for any loss of t h e v a l u e
practice.
The second case is t h a t of a doctor w h o decides to give u p his " s e p a r a t e "
public practice and to t a k e service in a Health C e n t r e . I t will b e wholly
incompatible with t h e conception of a H e a l t h C e n t r e t h a t individual practices
within the Centre should b e . b o u g h t a n d sold a n d a doctor will therefore,
by entering a Centre, e x c h a n g e a practice h a v i n g a realisable v a l u e for a
practice which he will be d e b a r r e d from selling on retirement.
On t h e
other h a n d the. G o v e r n m e n t consider t h a t an efficient s u p e r a n n u a t i o n system
will be an essential p a r t of the H e a l t h Centre organisation. A doctor entering
a Centre will c o n s e q u e n t l y a c q u i r e b o t h s u p e r a n n u a t i o n rights a n d o t h e r
facilities of considerable v a l u e . T h e p r o p e r course will b e to strike a fair
balance between w h a t h e is gaining and w h a t he is losing a n d to c o m p e n s a t e
him accordingly.
It would be m o r e difficult to institute a s u p e r a n n u a t i o n scheme for doctors
engaged in " s e p a r a t e " practices, b u t t h e G o v e r n m e n t w o u l d b e glad t o
discuss with t h e medical profession t h e possibility of w o r k i n g o u t a n accept­
able scheme t o p r o v i d e for retirement within specified age limits a n d t h e
granting of s u p e r a n n u a t i o n rights on a c o n t r i b u t o r y basis.
Sale and p u r c h a s e of public p r a c t i c e s .
The G o v e r n m e n t h a v e n o t overlooked t h e case which can be m a d e for the
total abolition of t h e sale a n d p u r c h a s e of p u b l i c l y r e m u n e r a t e d p r a c t i c e s .
The abolition w o u l d , h o w e v e r , involve great p r a c t i c a l difficulty a n d is n o t
essential to the working of t h e new service which the G o v e r n m e n t p r o p o s e .
The G o v e r n m e n t i n t e n d , h o w e v e r , to discuss the whole question with the,
profession, to see if some w o r k a b l e and satisfactory solution can b e reached.(C
The creation of H e a l t h C e n t r e s will, m e a n w h i l e , d o a great deal t o limit
the scope of the present s y s t e m . T h e Centres will afford a wide o p p o r t u n i t y to
young doctors to enter t h e i r profession w i t h o u t financial b u r d e n s . T h e y will
also, wherever they are set u p , bring into being a n e w form of p r a c t i c e which
:
31032
B 2
I n p a r t i c u l a r , i t would o b v i o u s l y be
*S
i n c o n g r u o u s t h a t t h e new p u b l i c s e r v i c e
should i t s e l f have t h e e f f e c t of i n c r e a s ­
i n g t h e c a p i t a l v a l u e of an i n d i v i d u a l
p r a c t i c e and t h u s i n c r e a s i n g t h e amount
o f c o m p e n s a t i o n w h i c h may h a v e t o b e
provided under the circumstances
described in the preceding paragraphs;
and m e a s u r e s to p r e v e n t t h i s must be
included in the discussion.
v
will thereafter b e entirely free from a n y necessity of sale a n d p u r c h a s e . More­
over, the system proposed earlier of requiring y o u n g m e n w h o join the public
service n o r m a l l y to undergo a period of assistantship will go far to avoid
the d a n g e r of a doctor purchasing a practice which h e has not the necessary
experience to h a n d l e successfully.
Creation of a Central Medical Board.
I t is intended to create from the profession itself a special executive body
at the centre, which will u n d e r t a k e some of the administrative work of the
service requiring a specially intimate link with the profession.
As the c o n t r a c t of the doctor will be in a public service, r e m u n e r a t e d from
public funds, the B o a r d will clearly h a v e to be subject to the general direc­
tions of t h e Minister, b u t subject to those general directions it will b e 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 i n " separate " or in g r o u p e d or H e a l t h Centre practice (although
in H e a l t h C e n t r e practice the local authority will be joined in the contract).
I t is not for this P a p e r to suggest all the details of the doctor's contract at
this stage (they will be for discussion with the profession'^ representatives);
b u t t h e y will need to provide—­
(a) for the doctor to give all n o r m a l professional advice a n d services
within his p r o p e r competence to those whose care h e u n d e r t a k e s ;
(6) for him to c o m p l y with t h e a p p r o v e d area p l a n for obtaining consultant
a n d specialist a n d hospital services;
(c) for p r o p e r m a c h i n e r y for the h e a r i n g of complaints b y patients a n d for
the general k i n d of disciplinary a n d appeal procedure a l r e a d y familiar in
National Health Insurance;
(d) for the observance of reasonable conditions, centrally d e t e r m i n e d with
t h e profession, respecting certification a n d other m a t t e r s which must arise
a n y publicly organised service.
T h e existing doctor will enter into the new contract in respect of his existing
practice; the n e w doctor, or doctor entering a new practice, will first obtain
the B o a r d ' s consent (as already suggested) a n d t h e n enter into the necessary
contract in respect of his new p r a c t i c e . T e r m i n a t i o n of the contract will
o r d i n a r i l y be either b y the doctor, a t a n y time after d u e notice, or b y the
B o a r d , u n d e r conditions which will n o d o u b t b e substantially similar to
those n o w obtaining u n d e r N a t i o n a l H e a l t h I n s u r a n c e , with such special
e x t r a provisions as m a y be necessary in the case of H e a l t h Centre practice.
U n d e r these a r r a n g e m e n t s there will be n o need for the continuance of
the p r e s e n t local I n s u r a n c e C o m m i t t e e s of t h e National Health Insurance
scheme, a n d these C o m m i t t e e s will b e abolished. T h e minor day-to-day
functions now exercised b y I n s u r a n c e Committees (so far as these still arise
u n d e r t h e new a n d wider service) can b e h a n d l e d b y a local medical Com­
mittee of the B o a r d in each area, on which local a u t h o r i t y m e m b e r s can be
included.
T h e B o a r d will also watch over the distribution of public medical practice
generally. I n " separate " practice it will d o this t h r o u g h the arrangements
a l r e a d y described, u n d e r w h i c h its consent will b e required before a vacant
public practice is refilled or a new public practice established.
In Health
C e n t r e p r a c t i c e it will be the agency t h r o u g h which a n y additional doctors
r e q u i r e d in future are introduced into a n y p a r t i c u l a r Centre, after suitable
consultation with the doctors a l r e a d y working there, t h r o u g h the local
committees earlier proposed in place of the present I n s u r a n c e C o m m i t t e e s .
It will b e the agency t h r o u g h which y o u n g doctors obtain a p p o i n t m e n t s
as assistants at H e a l t h Centres a n d b y which t h e terms a n d conditions of
assistants in " separate " practice are protected in the w a y a l r e a d y p r o p o s e d
a n d from which any dispensation of t h e requirement of a n initial ' ' a p p r e n ­
ticeship " for n e w doctors will h a v e to be sought.
The B o a r d will also t a k e on m a n y functions o n t h e d o c t o r ' s behalf—e.g.
in a p p r o a c h i n g the a p p r o p r i a t e medical schools a n d hospitals with a view
to t h e a r r a n g e m e n t of p o s t - g r a d u a t e a n d refresher courses for those in general
practice, in acting as the general centre of advice a n d help in the move­
ment of doctors within t h e public service a n d in the various p e r s o n a l
I t will,
problems a n d requests for information which will doubtless arise.
with the Minister, provide the central organisation t o which the n e w joint
authorities will m a k e k n o w n their a r e a ' s needs in general practice, in accord­
ance with t h e a p p r o v e d a r e a p l a n s for the health service as a w h o l e .
T h e B o a r d c a n be a small b o d y , u n d e r a regular c h a i r m a n — a few of its
members being full-time a n d t h e rest p a r t - t i m e .
I t would b e m a i n l y p r o ­
fessional, b u t it will also h a v e l a y m e m b e r s on its strength. I n view of t h e
wide scope of its executive functions a n d h a n d l i n g of public funds its meimber­
ship and organisation will h a v e t o b e finally settled b y the Minister, a l t h o u g h
of course in full consultation with the profession.
Supply of drugs and medical appliances.
T h e existing system u n d e r National H e a l t h I n s u r a n c e , u n d e r which p a n e l s
of chemists are formed in each area on lines closely corresponding to the
panels of doctors, h a s w o r k e d on the whole w i t h success. ' I n detail the
system is n o d o u b t capable of i m p r o v e m e n t , a n d discussion with the appro­
priate p h a r m a c e u t i c a l bodies will be welcomed by the G o v e r n m e n t .
In
particular, it will be necessary t o consider t h e a r r a n g e m e n t s t o b e m a d e in
connection with t h e supply of drugs to p a t i e n t s a t t e n d i n g H e a l t h C e n t r e s .
As regards medical a n d surgical appliances, the existing system entitles
an insured p e r s o n t o the s u p p l y , free of charge, of certain a p p l i a n c e s specified
in the Medical Benefit Regulations if ordered by a doctor. These " pre­
scribed a p p l i a n c e s " a r e , in the m a i n , t h e articles m o s t c o m m o n l y required
in general practice. I n a service which i n c l u d e s treatment of all kinds,
whether in or o u t of hospital, the range of necessary a p p l i a n c e s will have
to b e greatly extended; but, a s w a s indicated i n t h e Beveridge R e p o r t , it
will be a m a t t e r for consideration w h e t h e r in t h e case of t h e m o r e expensive
appliances the patient himself should not be called upon, if his financial
resources permit, to contribute t o w a r d s the cost—either of the appliances
initially ordered, or at least of repairs and r e p l a c e m e n t s .
The point will
be of particular i m p o r t a n c e in connection with the dental and ophthalmic
services.
The need for a new attitude in patient and doctor.
The a i m of t h e service will b e to provide e v e r y person, or better still
every family, with a personal or family practitioner who will be able to
become familiar with the circumstances of those in his c a r e - i n t h e home
and at w o r k .
I t is to b e h o p e d t h a t doctor a n d p a t i e n t will n o t wait
always till the latter falls ill and urgently requires treatment. The doctor
must try, in short, to become t h e general adviser in all matters concerned
with health (no less than with disease) on which a doctor is so well qualified
to advise. This m e a n s a c h a n g e d outlook in much of present medical
practice—a c h a n g e that h a s long been w a n t e d a n d a d v o c a t e d by most doctors
themselves a n d for which t h e y more t h a n a n y o n e have desired the
opportunity.
But such a change cannot be effected overnight.
It will
be helped if a new trend c a n b e given to u n d e r g r a d u a t e medical education
a n d , fortunately, there are p l e n t y of signs t h a t medical schools are begin­
ning to realise t h e i m p o r t a n c e of t h i s .
I t will t a k e time to develop; but
it is worth stating clearly at the outset that, unless this kind of medical
care is ultimately provided for every person and every family, the medical
profession will n o t be giving t h e public the full service which it needs anc
which 'only the medical profession can give. T o provide or to extend a
service w h i c h considers only t h e t r e a t m e n t of the sick is neither in accordance
with the m o d e r n conception. of w h a t a doctor should be trained to d o noi
in keeping with the general desire t h a t the family practitioner should begin
to u n d e r t a k e m a n y of the duties at present performed b y his colleagues
in the p u b l i c h e a l t h service,
VI.
CLINIC AND OTHER SERVICES.
A p a r t from t h e hospital a n d consultant a n d family doctor services, the
comprehensive health service m u s t include a r r a n g e m e n t s for h o m e nursing
a n d midwifery a n d health visiting a n d die v a r i o u s kinds of local clinic and
similar services which h a v e either been provided in t h e p a s t under special
statutory p o w e r s or will h a v e t o be established in t h e future.
W h e n t h e n e w service is established, these local services will not be pro­
vided as entirely separate entities, b u t r a t h e r a s p a r t s of t h e one new general
d u t y to secure a whole provision for health. It will b e t h e d u t y of the new
joint a u t h o r i t y — b y m e a n s of the a r r a n g e m e n t s p r o p o s e d b y it a n d approved
b y the Minister in the general area p l a n — t o ensure t h a t all these different
activities a r e p r o p e r l y related t o e a c h other, to t h e personal or family doctor
service a n d to' t h e hospitals a n d consultants, a n d t h a t t h e y a r e arranged in the
right w a y and in the right places t o meet the a r e a ' s needs. This d o n e , it will
b e the d u t y either of the joint a u t h o r i t y or of the s e p a r a t e c o u n t y a n d county
borough authorities which together constitute it, as t h e case m a y be, to provide
a n d m a i n t a i n t h e various services on the lines of t h e settled area p l a n . The
usual sharing of responsibility in this respect between t h e joint authority and
t h e several counties a n d c o u n t y b o r o u g h s — u n d e r the proposals described
earlier in this Paper—will b e recalled.
W h e n these local services a r e a r r a n g e d a n d r e g a r d e d as p a r t s of the one
p l a n n e d service of the wider area, there will b e r o o m for experiment and
innovation in the w a y they are p r o v i d e d — p a r t i c u l a r l y a s time goes on and
the full service gets into its stride. I t is reasonable t o look forward to the
time w h e n the general medical practitioner, the p e r s o n a l doctor with whom
the individual a n d the family a r e regularly associated, will b e a b l e to be
connected more closely with the services which are performed at special
clinics—e.g. for child welfare, in which there is n o d o u b t t h a t in much of
the general care of the y o u n g child a n d the h a n d l i n g of m a n y of its day-to-day
p r o b l e m s the clinics a n d the family doctor who h a s t h e general medical care
of the child m u s t be e n a b l e d to w o r k in b e t t e r contact for their common
p u r p o s e . To m a k e this possible on a n y substantial scale there will have to
b e m u c h m o r e opportunity t h a n t h e r e is n o w for t h e family doctor to acquire
special experience in the c h i l d r e n ' s w a r d s of h o s p i t a l s a n d in general cMd
welfare subjects a n d the c h a n c e of p o s t - g r a d u a t e t r a i n i n g a n d refresher work
in these a n d other special s u b j e c t s . W h e r e g r o u p e d general practice in Health
Centres is tried there will b e special o p p o r t u n i t y for this k i n d of development.
B u t w h a t e v e r d e v e l o p m e n t s t h e r e m a y b e in t h e clinics or other services
locally p r o v i d e d , or in the m e t h o d of operating t h e m in relation to other
b r a n c h e s of t h e service as a whole, it is clear t h a t the c o m i n g into operation
of the new service will certainly not involve closing d o w n or a b a n d o n i n g
any existing facilities—but m u c h rather increasing and strengthening t h e m
to fit the new a n d wider objects in view. Therefore the effect of the p r o ­
posals in this P a p e r on the m a i n local services of this kind as they are k n o w n
a n d on the position of the local authorities responsible for t h e m — c a n
be summarised.
n
o
w
Maternity and child welfare services.
The a r r a n g e m e n t of lying-in a c c o m m o d a t i o n in hospital or m a t e r n i t y h o m e
indeed all the institutional provision for m a t e r n i t y , both for n o r m a l a n d
for complicated cases—will become simply one p a r t of t h e re-organised
hospital a n d consultant services a n d will b e t h e responsibility of the new
joint a u t h o r i t y . T h e o r d i n a r y functions of the m a t e r n i t y -and child welfare
clinics, however—concerned, a s they are, not primarily with direct medical
treatment b u t more with the convenient local provision of general advice a n d
care in the d a y - t o - d a y bringing-up of y o u n g children a n d in the m o t h e r s '
associated problems—will n o t b e transferred to the new joint a u t h o r i t y b u t
will lie wherever the related functions of child education are m a d e b y
Parliament to lie u n d e r the new E d u c a t i o n Bill.
U n d e r t h e p r o p o s a l s in
that Bill, as they s t a n d n o w , this will m e a n t h a t the c o u n t y a n d c o u n t y
borough councils will be the authorities primarily responsible, b u t t h a t
arrangements will be m a d e in suitable cases for delegating m u c h of the
practical care of the service to some of t h e existing authorities, within the
counties, which have hitherto carried the responsibility a n d which h a v e
accumulated good experience and local interest.
The m a t e r n i t y a n d child welfare clinics, a l t h o u g h provided and m a i n t a i n e d
in this special w a y o v e r the v a r i o u s p a r t s of the joint a u t h o r i t y ' s area to
meet the need for the link with education, will be as much a subject a s a n y
other p a r t of the h e a l t h service for the general p l a n for t h a t area which the
joint a u t h o r i t y will p r e p a r e a n d the Minister finally settle. T h e sufficiency
of the clinics, their distribution, their connection with the necessary specialist
services and the hospitals, a n d the other m a i n a r r a n g e m e n t s concerned, will
all be covered b y the wider a r e a p l a n .
What has been said of t h e clinics applies e q u a l l y to those a r r a n g e m e n t s
for domiciliary mid wives and health visitors which need to b e ancillary to
the clinics' work, a n d responsibility for those will lie with the s a m e
authorities and be similarly affected b y t h e general area p l a n .
School Medical Service.
In this service also t h e p r o p o s a l s need t o b e related to t h e p r o p o s a l s in
the current E d u c a t i o n Bill. T h e conception underlying b o t h the Bill a n d
the present P a p e r is t h a t the education . authorities will retain a s p a r t of
their educational m a c h i n e r y t h e functions of inspection of c h i l d r e n in t h e
school group (the supervision, in fact, of the state of h e a l t h in which t h e
child attends school a n d of t h e effects of school life a n d activities on the
chi!d's health), together with the i m p o r t a n t function of using the influence
of the school a n d the teacher and the whole school relationship with child
and parent to encourage the recourse of t h e child to all desirable medical
treatment.
B u t , as from t h e time w h e n the new health service is able
to take over its comprehensive c a r e of h e a l t h , the child will look for its
treatment to the organisation which that service p r o v i d e s — a n d the education
authority, as such, will give u p responsibility for medical t r e a t m e n t .
Tuberculosis dispensaries and other infectious disease work.
The local tuberculosis dispensaries will in future be r e g a r d e d a s out­
patient centres of the hospital a n d consultant service, and responsibility
for t h e m will n o r m a l l y rest directly with the joint a u t h o r i t y dealing with
the whole of this "aspect of the new service over its wide a r e a . . J u s t as
it will be the aim to enable the m a i n s a n a t o r i u m a n d hospital t r e a t m e n t
of tuberculosis t o be more fully related in future to other specialist aspects,
of the diagnosis a n d care of diseases of the r e s p i r a t o r y tract generally a n d of
orthopaedic conditions, so it will also b e essential to develop the local tuber­
rulosis dispensaries as specialist out-post centres of t h e s a m e service, where
the physician h a s c h a r g e of—and direct access to—hospital a n d sanatorium
beds a n d w h e r e the s a m e consultants cover both i n - p a t i e n t a n d out-patient
activity. T h e physician in c h a r g e needs particularly to concern himself
also with the social a n d h o m e conditions of his p a t i e n t s in tuberculosis,
b u t it is not proposed t h a t such activities as the securing of a p p r o p r i a t e
housing for the tuberculous shall pass with the dispensaries to the new
j o i n t a u t h o r i t y . I n such m a t t e r s the physician in c h a r g e m u s t look to the
local authority n o r m a l l y concerned with these things.
All isolation hospital responsibilities will similarly p a s s u n d e r the pro­
posals earlier e x p l a i n e d , . to the n e w joint a u t h o r i t y as p a r t of. the general
hospital p r o b l e m of its a r e a .
B u t there will r e m a i n a field of day-to­
d a y epidemiological w o r k — m a n y of the measures dealing with the notifica­
tion of the diseases, the local control of the spread of' infection, and
e n v i r o n m e n t a l factors affecting this, which are the subject of s t a t u t o r y powers
u n d e r the P u b l i c H e a l t h Acts a l r e a d y - w h i c h c a n , still b e suitably carried
o u t locally in the different p a r t s of the joint a u t h o r i t y ' s area, a l t h o u g h it
will p r o b a b l y be found t h a t m o s t of these activities should in future be
centred in the county and c o u n t y b o r o u g h councils r a t h e r t h a n distributed
more widely, as t h e y are now, over the districts of the m i n o r authorities.
I n epidemiology in its wider sense there will be some activities which must
be organised on a full national basis, r a t h e r t h a n locally, a n d here the valuable
experience of the E m e r g e n c y P u b l i c H e a l t h L a b o r a t o r i e s will b e a pointer
to future d e v e l o p m e n t .
Cancer diagnostic centres.
Responsibility for the local centres of diagnosis and advice which
c o n t e m p l a t e d when t h e C a n c e r Act of 1 9 3 9 was passed, a n d which
h a d little c h a n c e to develop substantially during the w a r , will pass
the other responsibilities of t h a t Act to t h e new joint authorities as a
of the general hospital a n d c o n s u l t a n t service.
were
have
with
part
Mental clinics.
Local m e n t a l clinics are essentially a n out-patient activity of the hospital and
consultant service—like the tuberculosis d i s p e n s a r i e s — a n d responsibility for
these clinics will therefore belong to t h e n e w joint a u t h o r i t y in its general care
of m e n t a l h e a l t h .
Venereal diseases.
T h e allocation of the present service for venereal diseases, in the h a n d s of
the c o u n t y a n d c o u n t y b o r o u g h c o u n c i l s , . between those authorities and
the new joint a u t h o r i t y in w h i c h t h e y will for s o m e p u r p o s e s b e combined,
presents peculiar difficulty. I n one sense it is essentially a clinic service which
can continue to b e locally organised within t h e framework of the new
a r e a p l a n , a n d which—it is a r g u a b l e — n e e d not b e r e g a r d e d as essentially
p a r t of the wider hospital a n d c o n s u l t a n t field. T h e newly developing u s e ­
started d u r i n g the w a r - o f the help of i n d i v i d u a l general practitioners to
s u p p l e m e n t the w o r k of the clinics lends some p o i n t t o this. On the other
h a n d it is a service r e q u i r i n g a high degree of specialisation in future and it
4i
.
is as a m a t t e r of convenience one w h i c h is usually a t t a c h e d to h o s p i t a l
premises; these are factors which point to associating it directly with the
re-organised hospital service.. I t is something of a " border-line " case,
in fact, a n d will be best left to the settlement of the area plan, in each case
to d e t e r m i n e .
New services likely to develop.
A full h o m e nursing service m u s t b e one of the aims of the new re­
organisation. H o w far it n e e d s to be directly p r o v i d e d b y public a u t h o r i t y ,
or indirectly by public a r r a n g e m e n t s m a d e with other bodies,, or b o t h , will
be m a t t e r s for discussion. I t s object m u s t be t o ensure t h a t all w h o need
nursing attention in their o w n h o m e s will b e able to obtain it without c h a r g e .
Responsibility for securing this will n o r m a l l y b e exercised by t h e individual
county a n d county borough councils within the general a r e a p l a n .
T h e fact t h a t there m u s t be delay in reaching a stage at which general
dental a n d ophthalmic services c a n be p r o v i d e d for all has b e e n referred to
earlier in the P a p e r . Nevertheless, nothing less must b e the object in view
and the best w a y s and m e a n s will need to be discussed in detail w i t h the
dentists a n d doctors a n d others concerned.
F o r some time d e n t a l care,
at least, will h a v e to b e concentrated o n "the p r e s e n t priority classes—-and
particularly on the children a n d adolescents. These a r e m a t t e r s on which,
so far a s dentistry is concerned, t h e views of t h e Teviot Committee, a l r e a d y
referred to, will h a v e a v a l u a b l e bearing a n d m u s t be awaited. B u t it is clear
that o n e of the m a i n calls a t first will be on the clinics and similar services
for the pre-school a n d school child.
T h e new service of the H e a l t h Centre for general medical practice has
already been considered, a n d w h e n it comes into operation it will n o r m a l l y
be the c o u n t y or c o u n t y b o r o u g h council's function to provide a n d m a i n t a i n
the Centres.
Medical research.
A valuable p a r t of t h e medical research carried o n in this c o u n t r y is
conducted in the hospitals, a n d in close association with t h e d a y - t o - d a y
work of the hospitals.
I t h a s been t h e policy of the Medical R e s e a r c h
Council—the body set u p u n d e r R o y a l C h a r t e r a n d u n d e r the auspices of
the Committee of the P r i v y Council for Medical R e s e a r c h to guide a n d stimulate
and co-ordinate research—to encourage this work in the hospitals themselves
and to assist it financially. Generally, it is felt t h a t this is a more fruitftd
method of securing valuable results t h a n t h e alternative m e t h o d of multiplying
special State institutions for the p u r p o s e , a n d it is of first i m p o r t a n c e t h a t
it should continue and develop, b o t h in t h e municipal a n d in t h e voluntary­
hospitals a n d institutions.
I t does not a p p e a r to require a n y new express
authority, a n d the powers of local authorities u n d e r statute a n d of v o l u n t a r y
hospitals u n d e r charters or trust deeds or other i n s t r u m e n t s seem t o be a l r e a d y
sufficient.
The Part of Medical Officers of Health and others.
W h a t e v e r changes there m a y be in t h e scope of the health services locally
provided a n d in the local organisation for providing t h e m , it is clear t h a t
there will be an even m o r e i m p o r t a n t p a r t in the future t h a n t h e r e h a s been
in the p a s t for social medicine a n d the medical organisation of public h e a l t h .
The new service will m a k e g r e a t calls u p o n all those medical m e n and w o m e n
already engaged in the work of local h e a l t h authorities, and u p o n all those
who assist in the ancillary services now; j u s t as it will give n e w scope a n d
better o p p o r t u n i t y not only t o those a l r e a d y engaged b u t to n e w c o m e r s to
this b r a n c h of professional life.
THE SERVICE IN SCOTLAND.
W h a t has a l r e a d y been said with r e g a r d to the present state of the health
a n d medical services, the chief deficiencies in the existing a r r a n g e m e n t s , a n d
the general shape of a comprehensive service which would m a k e good these
deficiencies applies equally to Scotland as to E n g l a n d a n d W a l e s .
T h e general administrative structure of the service in the t w o countries,
however, c a n n o t for various reasons be the s a m e . T h e d e v e l o p m e n t of the
health services h a s not been entirely uniform u p to the present time; here and
there differences occur in the scope a n d organisation of corresponding services;
a n d each c o u n t r y h a s services for which there is n o c o u n t e r p a r t in the other.
T h e most i m p o r t a n t of these differences are described in A p p e n d i x A. The
reason w h y t h e new service, a l t h o u g h the same in scope a n d objects in both
countries, c a n n o t be organised o n entirely similar lines is t h a t account must
be t a k e n of certain differences of g e o g r a p h y a n d local g o v e r n m e n t structure
in Scotland, a s c o m p a r e d with E n g l a n d a n d W a l e s . F o r e x a m p l e a b o u t 8 0
p e r cent, of S c o t l a n d ' s population is concentrated in a b o u t 1 7 p e r cent, of the
total area of t h e c o u n t r y , across its industrial " w a i s t . " Outside the industrial
belt are large a n d for the most p a r t sparsely p o p u l a t e d a r e a s . Of the 5 5
existing health authorities in Scotland only 1 0 h a v e p o p u l a t i o n s of more than
1 0 0 , 0 0 0 a n d 3 2 h a v e a p o p u l a t i o n u n d e r 5 0 , 0 0 0 . Against this, the population
of E n g l a n d a n d W a l e s is on the whole m u c h m o r e u r b a n i s e d a n d the local
g o v e r n m e n t units a r e larger with correspondingly greater resources.
CENTRAL ADMINISTRATION.
There will b e n o substantial difference in the cenLral m a c h i n e r y to be set
up in Scotland as compared with E n g l a n d and W a l e s .
T h e Secretary of State, as t h e Minister of the C r o w n concerned with the
health of the people of Scotland, will b e directly responsible to Parliament
for the a d m i n i s t r a t i o n of the new service and will exercise his functions
through the D e p a r t m e n t of H e a l t h for Scotland.
A Central H e a l t h Services Council for Scotland will b e set u p b y statute with
the same kind of constitution, powers a n d functions as the corresponding
Council in E n g l a n d and W a l e s .
It will consist of representatives of the
medical, d e n t a l , p h a r m a c e u t i c a l and n u r s i n g professions a n d of the voluntary
a n d municipal hospital authorities in Scotland, a p p o i n t e d b y the Secretary of
State after consultation with the organisations represented, a n d the Council
will select its own c h a i r m a n .
It will advise the Secretary of State o n any
technical aspect of the service, either in response to a request for advice from
the Secretary of S t a t e or on its own initiative, and the Secretary of State will be
required to s u b m i t to P a r l i a m e n t a n n u a l l y a report on the CounciTs work
during each y e a r .
Similarly, S c o t l a n d will h a v e a separate C e n t r a l Medical B o a r d to act
on behalf of the Secretary of State in the d a y - t o - d a y administration of the
general p r a c t i t i o n e r service. T h i s B o a r d will perform the same functions
as the corresponding English
organisation described, in c h a p t e r IV,
a n d like t h a t organisation it will be created m a i n l y from the medical pro
fession itself. T h e r e will clearly h a v e to be the closest liaison between the
two B o a r d s to secure uniform a d m i n i s t r a t i o n of the general practitioner
service in the two countries, a n d special a r r a n g e m e n t s will h a v e to be made,
b y a c o m m o n list of doctors a n d in other w a y s , to deal with the movement
of doctors from one c o u n t r y t o t h e o t h e r .
LOCAL ORGANISATION.
It is in the local organisation of the service t h a t t h e a r r a n g e m e n t s proposed
for E n g l a n d a n d Wales m u s t b e modified to suit the special circumstances
prevailing in Scotland. I n E n g l a n d a n d W a l e s it is proposed to define a r e a s
of suitable size a n d resources for the direct administration of the
hospital a n d consultant b r a n c h e s of the service a n d for the local p l a n n i n g
of the service a s a whole, a n d to secure suitable authorities to c a r r y
out these tasks by the combination of existing authorities in the
area.
To do this in quite the same w a y in Scotland would usually
be out of the question since t h e areas w h i c h would h a v e to be defined
for the p u r p o s e would be so big as to b e quite unwieldy a n d indeed
destructive of local g o v e r n m e n t a d m i n i s t r a t i o n . T h e point can p r o b a b l y best
be illustrated in relation to the hospital service. Successive Committees o n
hospital p r o b l e m s h a v e emphasised the need for p l a n n i n g a n d co-ordinating
the hospital service in Scotland over wider a r e a s , a n d for this p u r p o s e h a v e
recommended the selection of t h e four n a t u r a l hospital regions based on t h e
Cities of Glasgow, E d i n b u r g h , A b e r d e e n and D u n d e e , where the key hospitals
as well as the medical schools are to b e f o u n d , with a fifth based for geo­
"raphical reasons on I n v e r n e s s . While areas of this size are necessary for
the p l a n n i n g a n d co-ordination- of a comprehensive hospital service, they a r e
clearly too large for local g o v e r n m e n t p u r p o s e s .
T h i s means t h a t c o ­
ordination of the hospital service and responsibility for its actual provision
have in Scotland to be s e p a r a t e d in a w a y which does n o t a p p l y to E n g l a n d
and W a l e s .
As will b e seen, these special requirements in the hospital service m u s t to
some extent affect the local organisation of t h e o t h e r b r a n c h e s of the n e w
service as a whole, a n d in particular it is p r o p o s e d t h a t the scope of t h e
duties of the new J o i n t Hospital B o a r d s in Scotland shall not extend b e y o n d
the hospital and auxiliary services.
Administration of the hospital a n d consultant service.
It is intended to adopt the r e c o m m e n d a t i o n s m a d e b y various C o m m i t t e e s ,
including t h e C o m m i t t e e on Scottish H e a l t h Services a n d the H e t h e r i n g t o n
Committee, t h a t a R e g i o n a l H o s p i t a l s A d v i s o r y Council should b e set u p
in each of the five hospital regions referred t o . T h e Council will consist
of members n o m i n a t e d in equal n u m b e r s b y (i) t h e new J o i n t Hospitals B o a r d s
of combined local authorities in the region, a n d (ii) the v o l u n t a r y hospitals,
with an i n d e p e n d e n t c h a i r m a n to be appointed b y the Secretary of S t a t e . I n
addition, it c a n include a small n u m b e r of representatives of the medical a n d
medical-educational interests of t h e region.
The functions of the Councils will be consultative a n d advisory. T h e y will
advise the S e c r e t a r y of State on t h e m e a s u r e s necessary to secure the co-ordina­
tion of hospital p l a n n i n g within t h e region.
A further i m p o r t a n t function which the C o u n c i l s will perform will b e
to advise the Secretary of State on the co-ordination of the consultant
service between the hospitals a n d other services, a n d t h e y might, t h r o u g h
sub-committees, also advise hospital authorities on t h e filling of vacancies in
consultant a n d senior hospital a p p o i n t m e n t s .
Next, it is proposed to set u p J o i n t Hospitals B o a r d s formed by such c o m b i n a ­
tions of neighbouring m a j o r health authorities as are found necessary to ensure
that an a d e q u a t e hospital a n d consultant service is p r o v i d e d for each c o m b i n e d
area. I n o n e or two a r e a s w h e r e circumstances are suitable, and w h e r e the
population is large enough a n d t h e resources a d e q u a t e to s u p p o r t a satisfactory
hospital service, the m a j o r health authority will continue to be the hospital
authority without c o m b i n a t i o n w i t h a n y other local a u t h o r i t y .
T h e J o i n t Hospitals B o a r d will be c o m p o s e d entirely of representatives
from t h e c o u n t y councils a n d t h e town councils of large b u r g h s in the area
concerned. T h e y will t a k e over the whole ownership a n d responsibility for
t h e hospitals of their constituent authorities, will be charged w i t h the statu­
t o r y d u t y ' of securing a p r o p e r hospital service for their a r e a — b y their own
provision a n d by a r r a n g e m e n t s with other J o i n t Hospitals B o a r d s or v o l u n t a r y
h o s p i t a l s — a n d will, in fact, b e , so far a s executive responsibility for the
hospital service is concerned, the c o u n t e r p a r t of t h e new joint a u t h o r i t y in
E n g l a n d a n d Wales.
T h e J o i n t Hospitals B o a r d will h a v e t h e d u t y of p r e p a r i n g a scheme for
t h e hospital services of their area, after consultation with the v o l u n t a r y hos­
pitals. T h e y will be encouraged also to consult the Regional H o s p i t a l s Ad­
visory Council at this stage to secure the fullest measure of a g r e e m e n t between
t h e area p l a n a n d the wider regional a r r a n g e m e n t s proposed b y the Council.
T h e J o i n t Hospitals B o a r d will then s u b m i t their scheme t o t h e Secretary
of State who will consult t h e Regional H o s p i t a l s Advisory Council to obtain
their final views before deciding to a p p r o v e or a m e n d the scheme.
A s will b e seen, these J o i n t Hospitals B o a r d s will also b e c h a r g e d with
responsibility for the administration of certain clinic services, such a s the
tuberculosis dispensaries, which c a n be r e g a r d e d as essentially a p a r t - o f the
hospital service.
Administration of the clinic services.
T h e a r r a n g e m e n t s p r o p o s e d for the clinic services in E n g l a n d a n d W a l e s will
b e modified in their application to Scotland. T h i s is necessary because, unlike
the n e w joint authorities to be set u p in E n g l a n d and Wales, the J o i n t Hospitals
B o a r d s in Scotland will not h a v e p l a n n i n g functions outside the hospital service.
I n these circumstances the following a r r a n g e m e n t s will a p p l y .
Responsibility for the administration of the school health service with its
n u m e r o u s clinics will r e m a i n with the education authorities, n a m e l y , the
c o u n t y councils a n d t h e t o w n councils of E d i n b u r g h , Glasgow, A b e r d e e n and
D u n d e e , b u t these authorities will be expected to use the t r e a t m e n t services
p r o v i d e d u n d e r the new scheme.
N o r m a l l y the o r d i n a r y local clinics such as those for the maternity
a n d child welfare service, including a n t e n a t a l clinics, for the v e n e r e a l disease
service a n d for scabies will r e m a i n with t h e existing major h e a l t h authorities,
n a m e l y , the c o u n t y councils a n d the t o w n councils of the large b u r g h s which
correspond in Scotland to the c o u n t y a n d c o u n t y b o r o u g h councils in England
a n d Wales. These authorities will n o r m a l l y retain responsibility for the mid­
wifery a n d health visitor services. On t h e other h a n d , there are c e r t a i n clinic
services which are m o r e nearly allied to the hospital service t h a n to a clinic
service. T h e m o s t n o t a b l e e x a m p l e s of this category are the tuberculosis
dispensaries a n d c a n c e r clinics. T h e a d m i n i s t r a t i o n of these " out-post "
clinics will b e entrusted to the n e w J o i n t Hospitals B o a r d s a s b e i n g ancillary
to their m a i n function of hospital a d m i n i s t r a t i o n .
N o further c h a n g e of general scope will b e u n d e r t a k e n w i t h r e g a r d to the
clinic service. As r e c o m m e n d e d b y t h e C o m m i t t e e o n Scottish H e a l t h Ser­
vices, however, it is proposed to strengthen the powers of the Secretary of
State to require local health authorities, after a public local i n q u i r y has been
held, to c o m b i n e for a n y p u r p o s e w h e r e this is p r o v e d necessary for the
efficiency of the n e w health service as a w h o l e . I n this w a y it will b e possible
to leave essentially local clinic services with t h e major h e a l t h authorities while
securing a n a d e q u a t e safeguard that, should t h e need arise in the public
interest for a c o m b i n a t i o n of local authorities in a n y a r e a for a n y specific
p u r p o s e , effective m a c h i n e r y will be available for t h e p u r p o s e .
The responsibility for a n y new clinic services will be d e t e r m i n e d b y their
particular f u n c t i o n : if t h e y are p u r e l y local services t h e y will b e entrusted
to t h e existing major h e a l t h authorities, while if t h e y a r e allied to t h e hospital
service they will p r o b a b l y be entrusted to t h e J o i n t H o s p i t a l s B o a r d s .
Administration of the general practitioner service.
There will b e a difference between t h e two countries so far a s the p r o ­
vision, e q u i p m e n t a n d m a i n t e n a n c e of H e a l t h C e n t r e s a r e concerned. I n
E n g l a n d a n d W a l e s this responsibility will rest n o r m a l l y with t h e c o u n t y or
county b o r o u g h councils.
I n Scotland, however, t h e smaller size of the
problem a n d t h e g e o g r a p h y a n d distribution of p o p u l a t i o n suggest t h a t t h e
whole c o u n t r y c a n m o r e conveniently b e regarded as one a r e a for this
purpose, a n d the Centres—where t h e y a r e decided u p o n — c a n b e p r o v i d e d
by the D e p a r t m e n t of H e a l t h itself, a t least in t h e initial a n d e x p e r i m e n t a l
years. H a v i n g in view the n a t u r e of t h e local organisation of t h e health
service generally, w h i c h is p r o p o s e d for Scotland, it seems desirable t h a t
the provision, e q u i p m e n t a n d m a i n t e n a n c e of H e a l t h C e n t r e s should be
administered centrally in t h e general practitioner service. T h e Secretary of
State will b e e m p o w e r e d , however, t o delegate a n y of his functions with
regard to t h e p r o v i s i o n of Health C e n t r e s t o a local a u t h o r i t y ' w h e r e he thinks
this to b e desirable.
Local Medical Services Committees.
The local o r g a n i s a t i o n already described will secure effective liaison between
the hospital a n d c o n s u l t a n t services o n t h e one h a n d a n d t h e local a u t h o r i t y
clinic services on t h e other. T h e r e r e m a i n s t h e g e n e r a l p r a c t i t i o n e r service.
For the p u r p o s e of linking t h a t service with all t h e other p a r t s of t h e new
service a s a whole, t h e r e will be set u p , over the s a m e a r e a s a s those of the
Joint H o s p i t a l s B o a r d s , n e w advisory bodies to b e k n o w n a s L o c a l Medical
Services C o m m i t t e e s .
These will b e to some extent similar t o the L o c a l H e a l t h Services Councils
proposed for E n g l a n d a n d W a l e s , b u t with differences of function a n d of
organisation t o suit t h e different local a r r a n g e m e n t s in t h e t w o countries.
They will b e p r i m a r i l y advisory bodies, b u t because of t h e vital role w h i c h
they will p l a y in l i n k i n g u p t h e v a r i o u s b r a n c h e s of t h e health service in their
areas t h e y will need to include n o t o n l y professional b u t local a u t h o r i t y
representatives.
The Local Medical Services C o m m i t t e e s will consist of representatives of all
the local h e a l t h authorities in the a r e a , of the local m e d i c a l , d e n t a l , p h a r m a ­
ceutical a n d n u r s i n g professions, a n d of other interests closely concerned
with t h e h e a l t h services. T h e C o m m i t t e e s will be able t o a p p o i n t such sub­
committees, professional or general, a s t h e y find desirable.
The p r i m a r y function of these C o m m i t t e e s a n d of their professional s u b ­
committees will b e t o advise t h e S e c r e t a r y of S t a t e o n a n y questions affect­
ing the lo,cal a d m i n i s t r a t i o n of the general practitioner service a n d its relation­
ship to the other h e a l t h services. As, for reasons given, t h e J o i n t H o s p i t a l s
Boards will b e c o n c e r n e d with h o s p i t a l a n d c o n s u l t a n t services o n l y a n d n o t
with the h e a l t h services a s a whole, t h e Secretary of S t a t e will look t o these
Committees—so far as the general practitioner service is c o n c e r n e d — f o r
information a n d a d v i c e o n t h e sufficiency a n d distribution of d o c t o r s in a n y
area, t h e n e e d for H e a l t h Centres, a n d o t h e r relevant m a t t e r s .
The C o m m i t t e e s will also p r o v i d e a suitable m e a n s of liaison b e t w e e n
the general p r a c t i t i o n e r service a n d t h e local clinic a n d h o s p i t a l a n d con­
sultant services being carried on in their areas b y t h e local authorities a n d t h e
Joint H o s p i t a l s Boards. For example, they will be able to advise the
Secretary of State on methods of effecting the closer liaison between the
family doctor, t h e child welfare clinics a n d the hospital, as forecasted b y the
Orr R e p o r t on Infantile Mortality. T h e y will be t h e r e t o advise all those
authorities as needed, a n d will b e able also to send representatives to sit
with the larger Regional Hospitals Councils to assist—with their right of
directly expressing their views to the Secretary of S t a t e a t a n y time—-in
m a k i n g the liaison complete.
I n addition, a s the new general practitioner service will no longer require the
local I n s u r a n c e Committees which h a v e operated u n d e r t h e N a t i o n a l H e a l t h
I n s u r a n c e scheme in the p a s t , n o d o u b t such of the functions of these bodies
as d o not need in future to be centrally u n d e r t a k e n m i g h t be usefully entrusted
to t h e Local Medical Services C o m m i t t e e . B u t these are m a t t e r s for later
consideration.
VIII.
PAYMENT FOR THE SERVICE.
T h e cost of the comprehensive health service will m a i n l y fall u p o n central
and local public funds. The ways in which it might be shared between the
exchequer a n d the local rates, a n d other financial aspects of t h e service
generally, are considered in the F i n a n c i a l M e m o r a n d u m a p p e n d e d (Appendix
E).
So far a s t h e individual m e m b e r s of the public a r e concerned, they will
be a b l e in future to obtain all necessary medical advice a n d t r e a t m e n t of every
k i n d entirely without charge except for the cost of certain appliances. They
will, in fact, b e p a y i n g for their medical c a r e in a n e w w a y , not b y private
contract a n d fee b u t p a r t l y by a n insurance c o n t r i b u t i o n u n d e r w h a t e v e r social
insurance scheme is in operation and p a r t l y b y the o r d i n a r y processes of
central a n d local t a x a t i o n .
H o s p i t a l s t a k i n g p a r t in the scheme will, as a l r e a d y e x p l a i n e d , receive
from central funds p a y m e n t s which will include their s h a r e of the money
representing the social insurance contributions of the p u b l i c , so far as this is
attributable to hospital services in the scheme. This s h a r e c a n b e m a d e payable
on a bed-unit basis, according to the n u m b e r of beds p u t into the new service
b y each hospital in accordance with each a p p r o v e d area p l a n — e x c e p t that
the share of the v o l u n t a r y hospitals can, if they wish, be pooled a n d redistributed
in the m a n n e r earlier m e n t i o n e d .
The v o l u n t a r y hospitals will receive in addition t h e fixed service p a y m e n t s
from the n e w joint a u t h o r i t y a l r e a d y discussed, in respect of all services which
t h e y contract to r e n d e r to the scheme. F o r the rest, t h e y will meet the costs
of their p a r t i c i p a t i o n in t h e new service out of their n o r m a l resources, includ­
ing charitable subscriptions a n d donations, o n which their v o l u n t a r y status
d e p e n d s . T h e position of the teaching hospitals will be specially considered
after t h e C o m m i t t e e on Medical Schools has r e p o r t e d .
T h e joint authorities will receive directly from central funds the
bed-unit p a y m e n t s which wiU include their share of t h e social insurance contri­
butions a t t r i b u t a b l e to hospital services.
Otherwise the liability to meet
their expenses in the service—including their s e r v i c e - p a y m e n t s to the
v o l u n t a r y hospitals t a k i n g part—will be m e t p a r t l y out of r a t e resources
a n d p a r t l y o u t of central funds. F o r their r a t e revenues t h e joint authorities
will d e p e n d u p o n p r e c e p t upon the counties a n d c o u n t y b o r o u g h s which are
included in each joint a r e a . T h e c o u n t y a n d c o u n t y b o r o u g h councils, both
in meeting these precepts and in meeting their own expenses in t h e service,
will receive e x c h e q u e r a i d .
i
IX.
GENERAL
SUMMARY.
It m a y b e convenient, a t this p o i n t , to s u m m a r i s e the p r o p o s a l s of this
Paper i n o u t l i n e : —
i. Objects in view.
(i) To e n s u r e t h a t e v e r y b o d y in the c o u n t r y — i r r e s p e c t i v e of m e a n s , age,
sex, or occupation—shall h a v e e q u a l o p p o r t u n i t y to benefit from the best
and most u p - t o - d a t e medical a n d allied services a v a i l a b l e .
(2) To p r o v i d e , therefore, for all w h o w a n t it, a c o m p r e h e n s i v e service
covering every b r a n c h of medical a n d allied activity, from t h e c a r e of
minor ailments to m a j o r medicine a n d s u r g e r y ; t o include the c a r e 01
mental as well as physical health, a n d all specialist services, e g . for tubercu­
losis, cancer, infectious diseases, m a t e r n i t y , fracture a n d o r t h o p a e d i c treat­
ment, a n d others; to include all n o r m a l general services, e.g. the family doctor
and t h e n u r s e , the care of the t e e t h a n d of the eyes, t h e d a y - t o - d a y care of
the child; a n d to include all necessary drugs a n d medicines a n d a wide range
of appliances.
( 3 ) To divorce the care of h e a l t h from questions of personal m e a n s or
other factors irrelevant to it; to p r o v i d e the service free of charge ( a p a r t from
certain possible charges in respect of appliances) a n d to e n c o u r a g e a new
attitude to h e a l t h — t h e easier obtaining of advice early, the p r o m o t i o n of good
health r a t h e r t h a n only the t r e a t m e n t of b a d .
2 . General principles to be observed. ­
(1) F r e e d o m for people to use or n o t to use these facilities at their own
wish; n o compulsion into t h e new service, either for p a t i e n t or for d o c t o r ; n o
interference with the m a k i n g of p r i v a t e a r r a n g e m e n t s at p r i v a t e cost, if
a n y o n e still prefers to do so.
( 2 ) F r e e d o m for people to choose their own m e d i c a l advisers u n d e r the
new a r r a n g e m e n t s as m u c h as t h e y do now; a n d t o continue with their
present advisers, if t h e y wish, w h e n the latter t a k e p a r t in the new a r r a n g e ­
rnenfs..
( 3 ) F r e e d o m for the doctor to p u r s u e his professional m e t h o d s i n his
own i n d i v i d u a l w a y , a n d n o t to be subject to outside clinical interference.
( 4 ) T h e personal doctor-patient relationship to b e preserved, a n d the
whole service founded on t h e " family doctor " idea.
( 5 ) T h e s e principles to b e c o m b i n e d with the degree a n d k i n d of public
organisation n e e d e d to see that the service is p r o p e r l y p r o v i d e d — e . g . to
ensure better distribution of resources a n d to give s c o p e - t o new m e t h o d s ,
such a s g r o u p practice in H e a l t h C e n t r e s .
3. General method of organising the service.
( 1 ) T h e m a x i m u m use of good existing facilities a n d experience; n o un­
necessary uprooting of established services, b u t t h e welding together of
what is t h e r e a l r e a d y , a d a p t i n g it a n d adding t o it a n d i n c o r p o r a t i n g it in
the larger organisation.
( 2 ) T h e basis to be the c r e a t i o n of a n e w p u b l i c responsibility; to m a k e it
in future s o m e b o d y ' s clear d u t y to,see t h a t all m e d i c a l facilities are available
to all people; the placing of this d u t y on a n o r g a n i s a t i o n a n s w e r a b l e to t h e
public in the democratic w a y , while enjo3'ing the fullest e x p e r t a n d pro­
fessional g u i d a n c e .
( 3 ) Some t e m p o r a r y limitations of t h e full service inevitable—e.g. in
dentistry (owing to insufficient dentists), in o p h t h a l m o l o g y a n d perhaps else­
where; b u t t h e design to be comprehensive from t h e outset, a n d t o be ful­
filled as fast as resources a n d m a n - p o w e r allow.
(4) The first s t e p t o be t h e m a k i n g of positive p l a n s for each area of the
country, determining w h a t is needed for all people in that area; this to be
followed by m e a s u r e s to ensure t h a t w h a t is needed is t h e n secured.
( 5 ) A c o m b i n a t i o n , for all this, of central a n d local responsibility, to
ensure t h a t b o t h general national r e q u i r e m e n t s a n d v a r y i n g local require­
ments are e q u a l l y m e t .
4. The administrative organisation; central and local.
( 1 ) Central.
(i) C e n t r a l responsibility to P a r l i a m e n t a n d t h e people to he with the
Minister.
(ii) A t t h e side of the Minister, to b e a new c e n t r a l a n d statutory
organisation for voicing professional views on technical aspects of the
service generally; t o be k n o w n a s t h e Central H e a l t h Services Council; to
represent general a n d specialist medical practice, hospital organisation and
other professional interests; to b e a p p o i n t e d b y t h e Minister in consultation
with those interests, a n d to choose its own c h a i r m a n ; to be consultative and
not executive; t o advise the Minister not only on questions referred t o it by
the Minister b u t also on its own initiative; t h e Minister to report annually
to P a r l i a m e n t on t h e work of t h e Council.
(iii) A special executive b o d y to b e also set u p , c o m p o s e d in the main
of m e m b e r s of t h e medical profession; to b e k n o w n a s t h e C e n t r a l Medical
B o a r d , a n d to act u n d e r the general direction of t h e Minister; to be
the " employer " b o d y v/ith w h o m t h e general practitioner enters into con­
tract in the new service, a n d to concern itself with t h e distribution a n d welfare
of practitioners a n d assistants.
( 2 ) Local.
(i) Local organisation to be b a s e d on t h e c o u n t y a n d c o u n t y borough
councils, operating in their n o r m a l local g o v e r n m e n t a r e a s where possible,
but combining a s joint authorities over larger a r e a s w h e r e necessary.
(ii) Areas of suitable size a n d resources for the o p e r a t i o n of a full hospital
service of all k i n d s , to be designated by t h e Minister after consultation with
local interests.
(iii) F o r each of these new hospital a r e a s a joint a u t h o r i t y t o be con­
stituted, being a combination of t h e existing c o u n t y a n d c o u n t y borough
councils in the a r e a ; in t h e few cases where t h e a r e a m a y coincide with
an existing c o u n t y a r e a , t h e a u t h o r i t y to b e t h e c o u n t y council of t h a t area.
(iv) T h e n e w joint a u t h o r i t y also to b e charged with p r e p a r i n g an area
plan for t h e h e a l t h service a s a whole, n o t only t h e hospital service, in
m a n n e r described below.
(v) Existing c o u n t y a n d c o u n t y b o r o u g h councils, while combining for
these duties of t h e new joint a u t h o r i t y , to b e responsible severally for local
clinic a n d domiciliary services n o t belonging t o the hospital a n d consultant
sphere within t h e general area p l a n ; t h e responsibility for child welfare to
be assigned b r o a d l y on t h e s a m e lines a s responsibility for child education.
General medical practice to be the subject of special organisation, partly
local, p a r t l y c e n t r a l .
(vi) I n e a c h joint a u t h o r i t y area, t o b e a local c o n s u l t a t i v e body
for voicing professional g u i d a n c e o n technical a s p e c t s of t h e service; to be
known as t h e Local H e a l t h Services Council; t o serve a similar p u r p o s e
locally to t h e central professional b o d y a l r e a d y described; to advise b o t h
the joint a u t h o r i t y a n d t h e county a n d county b o r o u g h councils, a n d t o b e
free to express advice a n d views to t h e Minister.
5 . The planning of the local services.
( 1 ) E a c h joint a u t h o r i t y , i n consultation with t h e local. professional
body referred t o a n d with others locally concerned, to p r e p a r e a n " a r e a
plan " for securing the c o m p r e h e n s i v e health service for its a r e a ; t h e p l a n
to b e b a s e d on an assessment of t h e needs of t h e a r e a in all b r a n c h e s of
the service, to propose h o w each of those needs should b e m e t , a n d to be
submitted t o the Minister.
(2) T h e Minister to consider each a r e a plan, a n d a n y representations m a d e
to h i m by the local professional b o d y or others affected, a n d to a p p r o v e
the pla"n w i t h or without modification; t h e p l a n , a s a p p r o v e d , to be t h e
operative p l a n for t h a t a r e a ; to b e t h e d u t y of all concerned to provide a n d
maintain t h e i r services within t h e general framework of t h e p l a n ; t h e p l a n
to be modified or replaced from time to time, according t o r e q u i r e m e n t s , b y
the s a m e p r o c e d u r e .
6. Provision of the various parts of the service under the plan.
(1) Hospital and Consultant Services,
(i) T o b e the d u t y of t h e joint authorities themselves to secure a c o m ­
piete hospital a n d c o n s u l t a n t service for their a r e a — i n c l u d i n g s a n a t o r i a , isola­
tion, m e n t a l h e a l t h services, a n d a m b u l a n c e a n d ancillary services—in
accordance with the a p p r o v e d a r e a p l a n .
(ii) T h e joint authorities to d o t h i s b o t h b y direct provision a n d b y
contractual a r r a n g e m e n t s with v o l u n t a r y ' hospitals (or with o t h e r j o i n t
authorities) as t h e a p p r o v e d area p l a n m a y indicate.
(iii) Powers of present local authorities, in respect of these services, to
pass to the joint authority, with all existing hospitals a n d similar institutions.
(iv) T h e v o l u n t a r y hospital system t o continue side b y side w i t h t h e
publicly p r o v i d e d h o s p i t a l s ; v o l u n t a r y hospitals, to p a r t i c i p a t e , if willing t o
do so, as a u t o n o m o u s a n d c o n t r a c t i n g agencies; if so, to observe t h e
approved a r e a p l a n a n d t o p e r f o r m t h e services for which they c o n t r a c t
under t h a t p l a n , a n d to receive v a r i o u s service p a y m e n t s .
(y) All hospitals, m u n i c i p a l o r v o l u n t a r y , t a k i n g p a r t in t h e service to
observe certain national conditions (e.g. as t o r e m u n e r a t i o n of nurses,
appointment of consultants); these conditions being centrally prescribed.
(vi) Special provision t o be m a d e for inspection of t h e hospital service,
through selected expert personnel (some part-time) w o r k i n g in p a n e l s over
different p a r t s of t h e c o u n t r y .
(vii) C o n s u l t a n t services to b e m a d e available to all, at t h e h o s p i t a l s ,
local centres or clinics, o r in t h e h o m e , as r e q u i r e d ; to be based on t h e
hospital service, a n d a r r a n g e d b y t h e joint a u t h o r i t y , either directly or
by c o n t r a c t with v o l u n t a r y hospitals u n d e r t h e a p p r o v e d a r e a p l a n .
(viii) Measures for i m p r o v i n g t h e distribution of consultants, dealing
with m e t h o d s of a p p o i n t m e n t ' a n d r e m u n e r a t i o n , a n d relating this t o
other b r a n c h e s of t h e n e w service generally, t o be considered after t h e
report of t h e " G o o d e n o u g h C o m m i t t e e " b u t general direction of changes
to b e : —
(a) C o n s u l t a n t s t a k i n g p a r t to be r e m u n e r a t e d i n future (usually
b y p a r t - t i m e o r . whole-time salary) b y t h e p a r t i c u l a r hospital or h o s ­
pitals w i t h which they are associated u n d e r the area p l a n ; s t a n d a r d s
So
of r e m u n e r a t i o n to be centrally settled i n consultation with the
profession.
(b) N e w a r r a n g e m e n t s for securing p r o p e r s t a n d a r d s for consultant
a p p o i n t m e n t s in the service, possibly t h r o u g h a professional organisa­
. t i o n set u p to advise all hospitals m a k i n g a p p o i n t m e n t s of senior staff.
( 2 ) General medical practice.
(i) T h e Minister, with the new Central Medical B o a r d , to undertake
nationally the m a i n a r r a n g e m e n t s for a general practitioner service for the
country, t h r o u g h which a n y o n e who wishes to do so c a n associate himself
with a " family doctor " of his own choice a n d obtain the advice and
t r e a t m e n t of t h a t doctor at h o m e or a t his present consulting r o o m or at
a specially provided a n d e q u i p p e d consulting room in a H e a l t h Centre,
as t h e case m a y be.
(ii) These central a n d national a r r a n g e m e n t s t o cover terms of service,
r e m u n e r a t i o n of doctors from public funds, and other general aspects of
organisation, and the individual doctor to b e in contract with the Central
Medical B o a r d .
(iii) T h e joint a u t h o r i t y in each a r e a to h a v e t h e d u t y of: —
(a) including in their area p l a n an assessment of the needs of their
a r e a in general medical practice;
(b) keeping these needs u n d e r review a n d bringing to the notice
0 1 the Minister a n d the Central Medical B o a r d a n y general features
or requirements of the general practitioner situation in the area which
they consider to need a t t e n t i o n ;
(c) ensuring t h a t general medical practitioners t a k i n g p a r t in the
service in the area are a c q u a i n t e d w i t h hospital a n d consultant and
other services available u n d e r the. area p l a n , a n d t h a t t h e y are able
(as, u n d e r their terms of service, they w o u l d be required) t o use those
services for their patients.
(iv) T h e c o u n t y a n d county borough councils to b e responsible for pro­
viding, e q u i p p i n g a n d maintaining such H e a l t h Centres for the conduct of
general medical practice in the new service as m a y be a p p r o v e d from time,
to time b y t h e Minister in respect of a n y p a r t of their a r e a a n d in such
cases to be joined in t h e doctor's contract with the Central Medical Board.
(v) F u t u r e development to ,ir elude both new methods of " grouped "
medical practice in H e a l t h Centres (and, where suitable, outside them)
a n d familiar m e t h o d s of " s e p a r a t e " practice; each being developed
as experience proves best in each a r e a . A high place in the scheme to be
given to a full a n d careful trial of the H e a l t h Centre m e t h o d .
(vi) E x i s t i n g practitioners t o be able to p a r t i c i p a t e in the new service in
their p r e s e n t areas of practice, a n d where t h e y d o so from their own
consulting r o o m s to be n o r m a l l y r e m u n e r a t e d on a capitation basis
(though other m e t h o d s to be considered in certain cases if desired by the
practitioners themselves).
W h e r e they p a r t i c i p a t e in g r o u p practice in
H e a l t h Centres, remuneration to b e b y salary or similar alternative.
(vii) Practice in the public service not to d e b a r a doctor from private
practice for such patients as m a y still request this.
(viii) A p p r o p r i a t e limits to b e fixed to t h e n u m b e r of p e r s o n s whose care
a p a r t i c u l a r doctor can u n d e r t a k e , t a k i n g into due account t h e extent of
p r i v a t e medical practice a n d the calls m a d e upon a d o c t o r ' s time by other
public a p p o i n t m e n t s ; higher limits where assistants are engaged; more
regulation of the conditions of the e m p l o y m e n t of assistants i n the service,
and a r e q u i r e m e n t t h a t newly qualified d o c t o r s shall n o r m a l l y serve a
period as assislants before practising on their o w n in the new service.
(ix) New practitioners wishing to p a r t i c i p a t e in t h e service, a n d exist­
ing practitioners wishing to d o so in new a r e a s or new practices, to be
required to obtain the c o n s e n t ' o f the professional Central Medical B o a r d —
to check the need for a d d i t i o n a l public p r a c t i c e in the area, a n d to ensure
a reasonable -distribution of resources inside the public service.
(x) C o m p e n s a t i o n for loss of selling value of practices to b e p a y a b l e
where a doctor transfers his public practice into a H e a l t h C e n t r e , or where
a public practice falling v a c a n t is not allowed to b e refilled b y t h e Central
Medical Board.
(xi) S u p e r a n n u a t i o n to b e p r o v i d e d for doctors practising at H e a l t h
Centres a n d , if p r a c t i c a b l e , for other d o c t o r s p a r t i c i p a t i n g in t h e service
in " separate " p r a c t i c e .
(xii) T h e question of t h e sale a n d p u r c h a s e of public m e d i c a l practices
in future to be discussed m o r e fully with the profession.
(3) Clinic and other local services.
(i) T o be the d u t y of t h e joint a u t h o r i t y t o deal in its a r e a p l a n with
all necessary clinic and other local services (e.g. child welfare, ante-natal
and post-natal clinics, h o m e - n u r s i n g , health visiting, midwifery a n d others),
and to p r o v i d e for the co-ordination of these services with t h e other services
in the p l a n .
(ii) Administration of these local clinic a n d non-hospital services,
however, to be n o r m a l l y the responsibility of the i n d i v i d u a l c o u n t y
and county borough councils which collectively m a k e u p the joint
authority: the a d m i n i s t r a t i o n t o b e in accord with t h e general provisions
of the a r e a p l a n .
(iii) T h e exact allocation of responsibility between the joint a u t h o r i t y
and the individual county a n d county b o r o u g h councils t o be settled in
each case b y the Minister in d e t e r m i n i n g t h e a r e a p l a n ; b u t n o r m a l l y o n
the principle t h a t services belonging to the h o s p i t a l a n d c o n s u l t a n t sphere
fall to the joint a u t h o r i t y , while other local a n d clinic services fall to t h e
individual councils.
(iv) Child welfare duties always to fall to the a u t h o r i t y responsible for
child education u n d e r the n e w E d u c a t i o n Bill, b u t t o b e as m u c h t h e
subject of t h e " a r e a p l a n " as a n y other b r a n c h of t h e service.
(v) New forms of service, e.g. for general dentistry a n d for general
care of the eyes, t o be considered with the professional a n d other interests
concerned as soon as circumstances allow. I n t h e case of d e n t i s t r y , the
report of the T e v i o t C o m m i t t e e to be first a w a i t e d . ­
7. The service in Scotland.
(1) The scope a n d objects of t h e service to b e t h e s a m e in Scotland as in
England a n d W a l e s , a n d t h e foregoing p r o p o s a l s to a p p l y generally t o both
countries—but subject to t h e differences below.
(2) Certain differences in detailed application in Scotland, d u e to special
circumstances a n d g e o g r a p h y a n d existing local g o v e r n m e n t s t r u c t u r e t h e r e ;
differences mainly affecting t h e a r r a n g e m e n t of responsibility, central and
local, for p l a n n i n g a n d c a r r y i n g out the service.
(3) Central responsibility to. rest with the S e c r e t a r y of S t a t e , a s the Minister
of the Crown responsible t o P a r l i a m e n t for t h e h e a l t h of the people of Scotland.
A Central H e a l t h Services Council a n d a C e n t r a l Medical B o a r d to b e set u p ,
as in England a n d W a l e s .
(4) Local organisation to differ from that in E n g l a n d a n d W a l e s a n d to be
on the following lines: —
(a) Regional Hospitals A d v i s o r y Councils to b e set u p for each of five
big regions; to consist of e q u a l representation of the new local authority
J o i n t Hospital B o a r d s (below) a n d of voluntary hospitals; also representa­
tion of the Local Medical Services Committee (below) a n d of medical and
medical-education interests; i n d e p e n d a n t c h a i r m a n to b e appointed by
Secretary of State.
Councils to be advisory to Secretary of State on the co-ordination of
the hospital a n d c o n s u l t a n t services in each region.
(b) J o i n t Hospitals B o a r d s to be formed b y c o m b i n a t i o n s of neighbour­
ing local authorities (county councils and town councils of large burghs),
to ensure a n adequate hospital a n d consultant service in their areas;
these to t a k e over all responsibility for the hospital services of the con­
stituent authorities (including services like the tuberculosis dispensaries,
which essentially belong to t h e hospital a n d c o n s u l t a n t field) and also
to a r r a n g e with v o l u n t a r y hospitals.
T h e s e J o i n t B o a r d s to p r e p a r e a scheme for t h e hospital service of their
areas, to s u b m i t this to the Secretary of S t a t e , w h o will consult the
Regional Hospitals Advisory Council before deciding to approve or
amend--it.
(c) E d u c a t i o n authorities ( c o u n t y councils a n d t o w n councils of four
cities) to retain responsibility for school health service a n d clinics; existing
health authorities (county councils and town councils of large burghs) to
retain responsibility for t h e o r d i n a r y local clinic a n d similar services; the
necessary co-ordination t o b e secured (i) t h r o u g h their membership of
the J o i n t Hospitals B o a r d s a n d (ii) t h r o u g h t h e Local Medical Services
C o m m i t t e e (below).
P o w e r s of Secretary of S t a t e to b e strengthened to require local authori­
ties to combine for a n y p u r p o s e p r o v e d necessary, after public local
e n q u i r y , for the efficiency of the new service a s a whole.
(d) L o c a l Medical Services Committees to b e set u p over the same areas
as the J o i n t Hospitals B o a r d s ; to be advisory bodies; to include repre­
sentation of all the local health authorities a n d of local medical, dental,
p h a r m a c e u t i c a l a n d n u r s i n g professions a n d other interests; free to
a p p o i n t smaller sub-committees a n d groups, a s found desirable.
T h e s e C o m m i t t e e s to a d v i s e t h e Secretary of State on local administra­
tion of the general practitioner service; also to p r o v i d e liaison between
t h e different b r a n c h e s of t h e service.
- ( 5 ) C e n t r a l provision of H e a l t h Centres more suitable in Scotland owing
to the smaller size of the p r o b l e m a n d the special c i r c u m s t a n c e s of geography
a n d distribution of population-—with a power to the Secretary of State to
delegate his functions in this respect to a local a u t h o r i t y , where found desirable.
8. Financial.
(i) All advice and t r e a t m e n t u n d e r the n e w service, general and
specialist, in t h e h o m e , t h e consulting room o r clinic or hospital, to be
free of c h a r g e to the p a t i e n t (except for certain possible charges in regard to
appliances).
(ii) Cost of the service to be m e t from both central a n d local public
funds. T h e s e a r r a n g e m e n t s , a s affecting the v a r i o u s local authorities and
the v o l u n t a r y hospitals, a r e fully considered in a special financial memo­
randum appended,
A P P E N D I X A.
THE EXISTING HEALTH SERVICES.
GENERAL S U R V E Y O F T H E P R E S E N T S I T U A T I O N AND ITS O R I G I N S .
ENGLAND AND W A L E S .
Before the nineteenth century there was little regular intervention by
public authority in the personal health of the people, which was left to rest in
the main on private arrangements and on various forms of charity and voluntary
organisation for relief. The early nineteenth century brought the beginning of
full-scale attempts to protect and relieve the destitute (and as a corollary to tend
the destitute sick) and also a quickening of interest in the welfare of t h e younger
generation, particularly in the supervision of child labour in industry. As the
century went on, more attention began to be given to the environmental con­
ditions of health, to sanitary services, drainage, water supply, street cleaning and
the whole make-up of public hygiene, and to the idea of local government
responsibility in matters of public health—while measures for t h e prevention of
the major infectious diseases, including notification and isolation, became more
and more the subject of public regulation and concern. I t was not, however,
until the present century t h a t the public provision.of direct services for personal
health began to get into its real stride, and began t o evolve the wide variety of
services which are now familiar—like the services for maternity a n d child welfare,
midwifery, tuberculosis, the health of the school, child, the National Health
Insurance scheme, venereal diseases, and the provision of general hospitals by
public authority for others t h a n the destitute sick.
In general terms, the result is a complicated patch-work pattern of health
resources, a mass of particular and individual services evolved a t intervals over
a century or more—but particularly during the last t h i r t y or forty years—and for
the most p a r t coming into being one by one t o meet particular problems, t o pro­
vide for particular diseases or particular aspects of health or particular sections of
the community. Each, as it emerged, was shaped b y t h e conditions of its time,
by the limited purposes for which it was designed, and perhaps b y the fashions of
administrative and political t h o u g h t current when it was designed. Most of these
services, though progressively expanded and adapted as the years have gone on,
are still broadly running on the lines laid down for them at t h e s t a r t and are
administered largely, or partly, as separate and independent entities. The patch­
work, however, contains some very good pieces—well established a n d by now
rich in experience.
It is worth looking at these principal pieces in more detail—to make a survey
of how the ordinary man and woman and child can a t present get t h e various
medical services which t h e y need.
General Medical Care.
To the individual the natural first-line resource in all matters of personal health
is the general practitioner—the personal medical adviser, the " family doctor."
With - one i m p o r t a n t exception (and a few minor ones) the relationship of
the ordinary member of the publft t o the general medical practitioner has
been, and is now, a matter of private arrangement. He makes his own choice
of doctor, from among those who happen to be accessible to him, seeks his
advice and attention when he wishes to, and pays- whatever private fees the
doctor is accustomed to charge him. The relationship is a purely personal one
between doctor and patient, a n d no form of public organisation is involved in it.
The general medical practitioner, for his part, pursues his profession privately and
individually. H e decides for himself where he wishes to practise, he usually
obtains the " good-will " of an existing practice b y purchase from another practi­
tioner, and he practises in t h e open competitive market.
He may choose to
combine with other practitioners in a voluntary partnership—and there is an
increasing tendency to do so in recent years—but t h a t is an individual decision
and a matter of business agreement. The traditional basis of general medical
practice, in fact, is one of free and private buying and selling in which the State
does not intervene-—apart from t h e provisions of the Medical Acts with regard
to qualification and registration and professional conduct.
The earliest exception to this rule was t h e provision of a general practitioner­
service under the poor law. An organisation designed for the " destitute sick,"
a n d including a domiciliary service, was gradually built up throughout t h e nine­
teenth century and still gives valuable aid to those in difficulty. Although gener­
ally officered by part-time (or occasionally whole-time) District Medical Officers,
it has in recent years been converted in some areas into a service of the " panel "
type, in which all doctors practising in the locality can take a share. Apart from
this limited service,-arrangements for general practitioner treatment were, up to
1912, either of a purely private kind or were organised by Friendly Societies,
medical clubs and similar organisations.
The National Health Insurance service, instituted, in t h a t year, formed
p a r t of the provision made by the National Health Insurance Act
for the protection of the bulk of the working population against loss
of health and for the prevention and cure of sickness. Broadly speaking,
its " medical b e n e f i t " extends to the whole insured population (some
21,000,000 people) representing for the most part those employed under contracts
of service whose income is less than £420 a year. These select from t h e local
panel of doctors their personal medical attendant, who can be consulted as and
when the need arises, without fee, and from whom they can obtain such advice
and t r e a t m e n t (including visits at their homes) as are within t h e ordinary scope
of t h e general practitioner.
Similarly, they can obtain drugs which the
doctor considers requisite and a limited class of surgical and medical appliances.
Provision is also made for the issue of medical certificates free of charge. Any
doctor who so wishes has the right to take p a r t in the service. The range of
medical benefit provided by the scheme does not normally cover consultants or
hospital services, although certain facilities for obtaining specialist advice and
diagnostic services in difficult cases are afforded. The scheme is designed
in fact, for a limited object, which is to enable the great bulk of the employed
population to get advice and treatment and necessary medical certificates from
doctors of their own choice, without the deterrent of fees. This object has, on
t h e whole, been fulfilled.
Apart from the National Health Insurance scheme and the poor law, there is no
public provision for general medical attention on any considerable scale. There
are various special services for children and other limited groups, as will be seen.
Also some adult members of the public are entitled to general advice and treat­
ment under schemes for particular vocational groups (such as Post Office
employees or the Police) some carried on by Government departments,
others by local authorities, and others b y large industrial concerns.
Some
members of the public—particularly in parts of the London area—obtain
advice and t r e a t m e n t from the out-patient departments of hospitals and from
dispensaries of various types without going first t o a general practitioner. Others
d o so through co-operative arrangements made in societies or clubs—an example
of which can be seen in the " Public Medical Services " set u p in some areas,
largely for the dependants of insured persons, on the initiative of t h e medical
profession itself. A war-time development of a somewhat similar kind has been
t h e arrangement made by t h e Government, through the Local Medical W a r Com­
mittees of the profession, for the medica? attendance of evacuated school­
children.
Hospital and Consultant Services.
For those who require hospital treatment, as in-patients or as out-patients, or
who require specialist advice beyond the ordinary scope of t h e general medical
practitioner, a wide range of hospital services is available.
The individual
m a y , of course, choose t o enter a private nursing home and to engage the services
of a specialist t o attend him there—just as he may, for consultation, make purely
private arrangements with t h e specialist a t his home or at t h e specialists con­
suiting room.
In such cases the whole matter is one of personal arrange
m e n t a t private cost, in which no intervention of a publicly organised service
arises—although the State intervenes to a limited extent to secure reasonable
standards by t h e registration and inspection of nursing homes. Similarly, the
individual may arrange t o enter a private room or ward set aside in a voluntary
hospital for those who want to make their own arrangements a t their own
expense.
Apart from any such private arrangements as these, the public
look to the ordinary hospital services b o t h for hospital t r e a t m e n t and for
specialist medical advice, usually arranging for either or both through their general
medical practitioner in the first instance.
There are two distinct systems of hospital provision in this country, running
side by side—the voluntary hospitals and the public or municipal hospitals.
They have quite separate origins and histories, and are quite differently organised
and financed. In earlier years the two systems had little working contact with
each other and each went its own way with its own kind of service to the public.
In recent years there h a s been an increasing tendency for t h e t w o systems to get
closer together, t o realise their common aims in the service of the public
and the value of a greater degree of organised partnership in improving that
service together. B u t in all questions of hospital provision and of future hospital
reorganisation it has t o be clearly k e p t in mind that there are these two quite
distinct systems a t the moment, and t h a t both are strongly rooted and established,
with their own traditions and experience. The way this has come about, and the
extent t o which each contributes in making up the present total service, are not
always clearly k e p t in mind—and are worth summarising.
Until recent years t h e main burden of providing hospital t r e a t m e n t for acute
medical and surgical conditions (though not so much for infectious diseases or
mental ills) was carried by the voluntary hospitals, and rested in fact upon
voluntary philanthropy rather than on publicly organised provision. The volun­
tary hospital is, in essence, an independent charitable organisation, deriving its
money from the voluntary subscriptions or donations or endowments of benevolent
individuals or associations; it is administered by its own governing body or trustees
and provides its own service to the public in its own way, subject to the conditions
laid down by its constitution. In origin/ a few of them can trace their existence
back to mediaeval ecclesiastical foundations, b u t . the great majority have come
into being during the last two hundred years. There are, at the present day,
more than a thousand voluntary hospitals in England and Wales, a n d they vary
enormously in t y p e a n d size and function. Some of t h e m are large and power­
ful general hospitals of the kind familiar in London and certain of t h e big cities,
with distinguished specialists and consultants available, with first-class modern
equipment and t r e a t m e n t facilities, sometimes associated with well-known medi­
cal schools, and drawing their patients from areas wide afield—as leading institu­
tions in the medical world. Others are highly specialised hospitals, concentrating
on particular kinds of diseases and conditions (such as eye conditions, or ear,
nose and throat complaints, or diseases of the nervous system.
The
rest cover a wide and varying range of size and function, with varying degrees
of specialist and other facilities, including a large number of small " cottage "
hospitals served in the main by the local general practitioners and really function­
ing as local nursing homes for the mutual convenience of doctor and patient.
Something of the diversity of size and scope of the voluntary hospitals is
evidenced by the fact t h a t , of rather more t h a n 900 hospitals in England and
Wales of which particulars were available before the war and which provided
about 7 7 , 0 0 0 beds, there were about 2 3 0 specialised hospitals dealing mainly with
particular diseases, a n d the general all-purpose hospitals numbered about 700.
Of these 700 only some 75 were hospitals of more than 200 beds (and about 25 of
these were teaching hospitals); some 115 of the rest provided between 100 and
200 beds each; over 5 0 0 had less t h a n 100 beds, and more t h a n half of these had
less than 30 beds.
The other arm of t h e present hospital services—the hospitals provided directly
by public authority o u t of public funds—had its first roots partly in the early
public measures for protecting the sick poor, in the first half of the last century,
and partly (a little later in t h a t century) in measures which were t a k e n t o combat
the spread of epidemic infectious diseases. F r o m these two strains there gradually
emerged, in recent years, the wider conception of providing through local govern­
ment machinery and o u t of public funds a general hospital service—no longer
related only t o t h e sick poor or to infectious diseases, but catering for the ordinary
public and their ordinary hospital needs.
F r o m the time of the earliest poor-houses it was usual to provide some sort of
public accommodation for the destitute sick. Out of the first horrors of the
mixed workhouse there began to emerge the notion of the separate and special
sick ward, endorsed by the Poor Law Commissioners and adopted more and more
by the early Boards of Guardians; from this the wholly separate infirmary or
poor law hospital developed—catering still in the main for t h e chronic and incirr­
able or senile cases. Standards improved, the poor law flavour diminished, and
the interpretation of t h e " destitute " sick became elastic; t h e field of treatment
grew and the poor law idea as a whole became outworn as the expanding public
health services began t o oust it. This long process of over a century culminated
at last, in 1930, in the final acceptance of t h e principle t h a t general hospital
provision was a proper activity of t h e major local health authorities,
rather than of the poor law machinery.
Since 1930 it h a s been the accepted function (though not the statutory duty)
of t h e major local authorities—the county and county borough councils—to enter
the field of general hospital provision for the ordinary hospital case, side by side
with the voluntary hospitals already engaged in t h a t field. Many of the earlier
poor law hospitals h a v e been taken right out of the poor law sphere and converted
to this new and wider function, and new hospitals have been built. Some of
the older poor law hospitals still form p a r t of the poor law service (which has
itself also passed into the hands of the county and county borough councils),
b u t many even of these have lost their earlier poor law atmosphere. The result
of all this new activity is t h a t , just before the war, there were in England and
Wales-—quite apart from special hospitals for such conditions as maternity,
tuberculosis, or infectious diseases—nearly 70,000 beds in 140 general hospitals
maintained by the local health authorities under public health powers, and
1 nearly 60,000 more in 400 hospitals and institutions still administered under the
poor law. This great pool of 130,000 beds represents a varied service, at every
stage of development from the sick wards of an institution for the aged or chronic
sick to the most modern and' up-to-date of hospitals with every kind of special
department and equipment and highly skilled staff.
I t has for some time been recognised t h a t all these varying and independently
provided hospital facilities, both in t h e voluntary system . and in that
of the public authorities, need jx. great deal more co-ordinating, and some
supplementing, so as to ensure a right distribution of hospital accommodation
according to local need—-and so as to secure t h a t all the types of specialised
and general work which the different hospitals are best qualified t o perform are
arranged in some better related scheme; in a word, to make the hospitals com­
plementary to each other in a combined. and balanced service.
A t present the hospital facilities t o which any particular individual can get
access, when in need, depend to a large extent on what kind of hospitals happen
t o be available in his area, on his ability—if the right hospital is not a t h a n d ­
to go perhaps a long way afield and arrange for admission t o one elsewhere,
and on the extent to which his local doctor has been able b y his own initiative to
maintain personal contact with hospitals and consultants. It is not a t present
the duty of any public authority, central or local, to ensure t h a t all the right
kinds of hospital facilities are available and reasonably accessible to him or
t h a t every general practitioner is readily able to obtain every kind of hospital or
consultant service which h e is likely to need for his patients. T h e exercise by
the major local authorities of their power to provide hospitals a n d the activities
of voluntary hospitals do between them often have the result t h a t the right
hospital is where it is wanted and do usually have the result t h a t hospital provi­
sion of some kind is available in every area. B u t these present powers and.
activities do not extend to any duty to review all branches of t h e local hospital
service and t o see t h a t t h e y are so adjusted to each other—and if necessary so
supplemented—that the- total service available corresponds, both in kind and in
quality, with the likely demands upon it. The anomalies of large waiting lists in
one hospital and suitable beds empty at another, and of two hospitals in the same
area running duplicated specialist centres which could be better concentrated in
one more highly equipped and staffed centre for the area, are largely the result
of a situation in which hospital services are m a n y people's business but nobody's
full responsibility.
When admitted t o hospital in t h e ordinary way, t h e patient is usually expected
to pay what h e can reasonably afford towards t h e cost of his treatment a n d
accommodation there. Local authorities are required t o make these charges
(except in t h e case of infectious disease, where they have a discretion) a n d
voluntary hospitals usually follow t h e same practice. Very often the patient
compounds for this liability by joining one of t h e m a n y contributory schemes,
associated with voluntary hospitals, in which he pays a small sum weekly and in
return is paid for b y t h e scheme's fund when he is in hospital. Those schemes
may apply only to a particular hospital or group of hospitals—-on which he must
then depend entirely or go elsewhere and pay what he can afford—or they m a y
(and this is t h e growing tendency in t h e more up-to-date schemes) entitle him t o
be relieved of payment in any hospital, whether voluntary or belonging to a
public authority, in a wide variety of hospitals.
On many of the existing hospitals t h e war-time Emergency Hospital Scheme
Seeking t o use (and where
of the Government has had a considerable effect.
necessary to improve) t h e services of t h e hospitals for various war-time purposes,
this emergency service h a s temporarily entered the field, adding new buildings
and extensions to the number of about 50,000 beds; up-grading surgical a n d
X-ray and other medical facilities; relating t h e hospitals one t o another for
the interchange of patients according to their special needs; developing specialised
treatment centres for fractures and rehabilitation, brain surgery, chest
disorders, neurosis and other purposes; and providing inter-hospital transport,
country-branches and recovery a n d convalescent homes. I t is a war-time
organisation which would not suit t h e requirements of peace; b u t it will, in its
. passing, have left improved r e s o u r c e s - e v e n entirely new hospitals where none
existed before—and above all experience of what it means t o translate a collection
of individual hospitals into something of a related hospital, system.
Rehabilitation.
What has come t o be known as ' ' rehabilitation '' is more a process or a method
B u t its requirements, in modern
than a separate organisation or service.
technique, h a v e ca.used it to be so often specially and separately considered in
recent years that it justifies special mention in this review.
So far as it belongs to the sphere of t h e health services (it is partly a health
problem, p a r t l y an industrial and vocational one) i t rests on t h e principle that
the actual mending or curing of an injury or disease is often n o t sufficient unless
it is accompanied b y a process of completely restoring t h e whole of the patient's
previous capacities—or doing so as completely as possible; i.e. restoring t h e whole
of muscle tone, of full function, of general health a n d strength, as well as cure
of what was wrong. It involves various processes srtpplementary t o ordinary
treatment, such as massage, exercise, electro-therapy a n d occupational therapy,
and therefore it may often involve special accommodation a n d apparatus and
staff. Thus, while in principle it h a s been accepted in good surgery and medicine
for a long time, it has still n o t become as- much p a r t and parcel of hospital
and medical practice as many think it ought t o be, and i t is legitimate criticism
of the existing services that they a r e n o t yet organised on t h e whole (although
there are brilliant exceptions in particular areas a n d institutions) t o give the
scope t h a t ought in future to be given to t h e rehabilitation aspect of hospital
and medical treatment.
Considerable experiment has been conducted—and considerable result achieved
- i n this direction by developments in particular hospitals and centres under
the Emergency Hospital Scheme. An important review of the whole subject was
published recently in a report of an Interdepartmental Committee on t h e R e ­
habilitation a n d Resettlement of Disabled Persons, a n d this report recommended
greatly increased attention to t h e rehabilitation principle in a n y future arrange­
ments of the hospital and health services. The subject is n o t one for a n y
detailed review here, b u t it has t o be mentioned if only t o note what h a s
hitherto been a deficiency in existing services and t o keep in mind t h e necessity
for developing it in any reorganisation.
Infectious Diseases and Isolation Hospitals.
Apart from sanitary a n d other improvements, public action in relation to
infectious diseases was first taken in the Vaccination Act of 1840, providing public
facilities for vaccination against smallpox.
In r853 provision was made for
penalties against parents for failure to have their children vaccinated, and a
series of enactments on the vaccination question followed right up to the present
century. Since 1898 it has been possible for a parent or guardian who believes
that vaccination would prejudice a child's health to withdraw the child from
the application of the Acts.
At the present time only one-third of the
children born each year arc vaccinated. It is probable t h a t the time has
come to amend the law, a n d to substitute for compulsory vaccination a system
of free vaccination for all through the family doctor, the clinic services, or
otherwise. This is the method adopted during the present war in organising
the immunisation of children against diphtheria. Supplies of the necessary toxoid
have been provided free, and immunisation has been performed normally without
charge to parents, wdiile every method of publicity has been used to encourage
them to take advantage of the facilities provided. By t h e end of 1942 about
half the child population under 15 had been immunised.
Infectious diseases are the subject of a special service of treatment in
isolation hospitals, which is provided by the councils of the boroughs and
urban and rural districts, b u t not usually the county councils. This separately
organised service was one of the earliest of t h e local government medical services to
take shape—as far back as 1866. Before t h a t , some of the charitable institutions
had provided specially for fever or smallpox patients, and t h e invasions of Asiatic
cholera which began in 1831 had reinforced the arguments of the Poor Law Com­
missioners t h a t there should be more regular provision made for infectious diseases;
but only temporary measures had been taken during epidemics under orders made
by the Privy Council. The first real powers to provide public isolation hospitals
began with the Sanitary Act of 1866, and from t h e n on the local authorities of the
sanitary districts—which became in time t h e county borough, borough and urban
and rural district councils—began to develop, severally or in combination, the
system of t h e separate treatment of infectious diseases in isolation hospitals which
exists to-day. In London a special Metropolitan Asylums Board was created in
1867 for t h e central provision of asylums for certain of t h e sick poor, and it
became in time the general provider of infectious diseases hospitals for the
metropolis, until its services were finally transferred "to the London County
Council in 1930. Outside London, in spite of the general tendency t o attach
public hospital provision t o county councils and county borough councils, the
county councils were not, prior t o 1929, brought very directly into the infectious
diseases service, though they were given certain powers b y the Isolation
Hospitals Acts, 1893 and 1901, which have since been repealed. In 1929, by
the Local Government Act, they were given the function of drawing u p a local
scheme for adequate isolation accommodation in each county, in consultation
with t h e county district authorities.
The carrying out of t h e schemes has
normally remained a function of the latter authorities, though occasionally a
county council has undertaken the provision for the whole or p a r t of a county.
In 1889 the sanitary authorities were authorised to make certain infectious
diseases notifiable in their respective districts, if they^so desired; before that
notification applied only in a few areas where special powers had been conferred.
Ten /years later t h e notification principle was made universal throughout England
and Wales for these diseases. Other diseases, such as tuberculosis, have since
been made notifiable by general regulation of the Minister. Local authorities can
also, with the Ministers approval, make local additions t o the list.
The present situation is t h a t there are some 1,500 local authorities with powers
to provide for t h e hospital t r e a t m e n t of infectious diseases (including smallpox)
in their areas. They do not all make separate and independent provision, and
the obvious good sense of pooling resources so as t o plan a more useful and
economical service for larger areas has resulted in many of them combining
into formal Joint Boards or less formal joint committees for the purpose. About
800 of t h e m h a v e so combined, into about 160 Joint Boards—apart from the
other less formal combinations referred to—so t h a t the principle of planning
over more suitably sized areas already exists t o a considerable extent in this
service.
Altogether there were, just before t h e war, something like 38,000 beds in
isolation hospitals provided under t h e infectious diseases and smallpox service,
and they were to be found in some 8 1 0 separate hospitals, about 6 3 0 of which
contained less than 50 beds.. The hospitals t h u s tend to be small (although there
are well-known exceptions) a n d they vary considerably in quality. Some of the
provision is very good of its kind, much of it reasonably satisfactory; b u t in
general the small and separate hospital for infectious diseases is unecono­
mical, viewed as a medical and nursing organisation; and for most infectious
diseases it is to be regarded as less satisfactory—in future planning from the
medical point of view—than either t h e provision of larger units or of separate
blocks inside the bigger organisation of the general hospitals.
Admission to infectious diseases hospitals is in m a n y areas quite free of charge
for any of the inhabitants of the a r e a - a s distinct from the ordinary practice
of recovery of costs according t o ability t o pay, which applies in the general
hospital services.
Tuberculosis.
Public measures for the care of the tuberculous are organised under a
separate machinery, and in m a n y cases by different authorities from those con­
cerned with general infectious diseases. Before 1912 there existed some 5,000
or 6,000 tuberculosis beds in sanatoria or hospitals, mostly administered by
voluntary organisations or private individuals, and mostly quite small.
The
areater part of them had been established within the previous ten years or so.
A few local authorities had . provided sanatoria themselves, and some were
treating tuberculosis cases in smallpox hospitals or infectious diseases hospitals
when accommodation was available. There were also about 50 tuberculosis
dispensaries in existence. From 1912 onwards public intervention in the treatment
of tuberculosis began t o quicken and in t h a t year all forms of the disease were
made for the first time notifiable. Local authorities were encouraged b y ex­
chequer grants to make better provision for t h e t r e a t m e n t of tuberculous persons
in-their areas, and sanatorium benefit under the National Health Insurance
scheme was designed to secure t h a t insured persons, if they were found to be
suffering from the disease, should get the advantages of sanatorium and other
treatment whether or n o t t h e y could afford t o pay for it.
The strain of the 1914-18 war was reflected in an increased incidence in the
disease and there was a heavy demand for accommodation, in particular for men
discharged from the Forces. This Jed to increased exchequer assistance which
resulted in further provision of sanatoria a n d other accommodation. I n 1921,
Parliament imposed a general duty on the county and county borough councils
to make arrangements for the treatment of tuberculosis, this legislation being
later incorporated in t h e Public Health A c t of 1936. From these beginnings
there has emerged a strong and still developing special service dealing
with all aspects of the diagnosis and t r e a t m e n t of t h e disease and
providing a considerable a m o u n t of supplementary help and after-care to
those suffering from it. The county and county borough councils fulfil their
duties partly by their own direct provision of dispensaries, sanatoria a n d other
institutions, partly by arrangements which they make with v o l u n t a r y and
other agencies. At the outbreak of the present war there were some 28,000
regular beds in tuberculosis institutions, with many more available in approved
institutions for use when required. About 4 0 0 sanatoria were provided by. the
local authorities directly, and some 2 7 0 by other agencies. These sanatoria are
not usually very large, only about 30 having more t h a n 200 beds.
Apart from actual diagnosis and t r e a t m e n t , the service provides—in a degree
varying from area to area, and partly through voluntary Care Committees or
similar organisations—a variety of supplementary services dealing with additional
comforts, extra nourishment and clothes, training for employment, help in
obtaining suitable housing, dental care, and other m a t t e r s . Valuable pioneer work
in rehabilitation and resettlement of the tuberculous has been done by a small
number of voluntary organisations, eminently in two well-known village settlements
and tuberculosis colonies. Local authorities have made full use of these facilities,
just as for suitable types of case they h a v e linked up with the training and
settlement resources of the Ministry of Labour and National Service. Increasing
interest has recently -been taken in t h e rehabilitation of the tuberculous patient
(although hampered at t h e moment b y the restricted conditions of war), and
also in new aids to early detection and diagnosis afforded b y mass miniature radio­
graphy. Another recent advance has been the scheme for the p a y m e n t of allow­
ances to patients under observation or treatment, in order to encourage early re­
course t o t r e a t m e n t where financial responsibilities might otherwise b e an obstacle
tending to delay it.
F o r the exercise of their duties a few local authorities have corn­
bined with each other in seven Joint Boards. Some of these Boards
have taken
over all
the
tuberculosis
services
of
their constituent
authorities; some only undertake t h e joint management of particular institutions.
A unique experiment in large-scale combination has been in operation in Wales
for the last 30 years, in t h e King Edward VII Welsh National Memorial Associa­
tion. This was established in 1910, as p a r t of a national campaign against
tuberculosis in Wales, a n d its special constitution (under a Charter of Incorpora­
tion) provides for the representation of all the county and county borough
councils in Wales, and also includes co-opted members, members nominated by the
Minister of Health and others. I t provides dispensaries and visiting stations
a n d some 2,000 beds in its own sanatoria a n d hospitals, and also- arranges for
accommodation through other agencies.
The tuberculosis service—even after allowing for the indirect effects of
improved housing and food and environmental conditions generally-—-has very
tangible results to its credit over the last twenty years, reflected in improvements
in the rate of mortality from t h e disease. I t tends t o be administered as a
separate entity, perhaps not enough related to t h e diagnosis and treatment of
other chest and respiratory conditions or to the work of the general hospitals,
because it has come into being as a separately organised service with one
particular objective.
Venereal Diseases. .
A special service for t h e early diagnosis and treatment of venereal diseases has,
since 1916, been the responsibility of the county and county borough councils.
I t provides some 200 out-patient clinics and centres (usually b y arrangement
with local hospitals, sometimes independently) for free and confidential diagnosis
and t r e a t m e n t for all, irrespective of place of residence or circum­
stances. Hospital b e d s and hostels are usually available for in-patient
t r e a t m e n t if required. -During the war the service has been supplemented by
arrangements made, particularly in rural areas, under which suitably qualified
general practitioners give free t r e a t m e n t in their own consulting rooms. Doctors
in general practice are always a t liberty—and are encouraged—to use the labora­
t o r y and other resources of t h e service free of charge and t o consult the expert
medical officers of the service on any case under treatment.
Cancer.
Just before the present war t h e Cancer Act of 1939 put upon the county and
county borough councils a new special d u t y , to see t h a t facilities for the
diagnosis and t r e a t m e n t of cancer were available to meet the needs of their areas.
T h e Act contemplated a new and comprehensive service for detecting and
treating the disease, based on a local scheme which would utilise existing resources
(in voluntary hospitals and elsewhere) and would supplement them, as necessary,
with new diagnostic centres and with additional t r e a t m e n t facilities. I t was
expected t h a t , in m a n y cases, it would b e necessary for county and county
borough councils to combine in order to operate an effective scheme.over a "wider
area, and provision for such combination was included in t h e Act. The whole
service would be backed by arrangements for access to a centralised" supply
of radium organised b y the National Radium Trust and Radium Commission.
The outbreak of war immediately after the Act was passed, however, prevented
the new service from materialising—except for a few interim schemes which
have been started in some areas: Some special war-time arrangements, designed
to relieve some of t h e cancer centres in certain large towns, have been made
through the Emergency Hospital Scheme, b u t these do not properly form part
of t h e present review.
Mental Health Services.
Provision for the caxe and treatment of persons suffering from mental disorder
is made by local authorities under t h e L u n a c y and Mental T r e a t m e n t A c t s ,
1890 to 1930. The local authorities concerned are the councils of counties and
county boroughs, and of 15 non-county boroughs. Many of t h e functions are
obligatory, particularly as regards provision for certified patients. T h e powers
conferred on local authorities in regard to provision for voluntary patients and
out-patient diagnosis and t r e a t m e n t are permissive; but this p a r t of t h e service
has in fact developed rapidly since the passing of the Mental T r e a t m e n t A c t oi
1930. In 1941. 35 per cent, of t h e admissions t o public m e n t a l hospitals were
voluntary patients! Local authorities are required by these Acts t o exercise ­
all their powers and duties through Visiting Committees which have powers in
regard to staff and finance t h a t give them a certain measure of independence.
This arrangement is a survival of an Act of 1845. Three county councils—London,
Middlesex and Surrey—have by local Act modified this arrangement so as to
bring the committee dealing with this service into line with the position normally
occupied by statutory committees of local authorities.
In this service combination between authorities is a common feature. There
are three Joint Boards established under local Acts. These provide for t h e
combination of the county council with t h e county boroughs in the county in
Lancashire, the West Riding of Yorkshire and Staffordshire. Joint action h a s
been taken under t h e provision of the L u n a c y Act by a large n u m b e r of
counties and - county boroughs for the provision and maintenance of a mental
hospital to serve the combined area. Of 101 public mental hospitals (accommodat­
ing some 130,000 patients) 4 2 are managed b y a Joint Board or b y a combination
of two or more local authorities. The provision of a public mental hospital
must clearly be entrusted to a n authority covering a considerable area. T h e
average number of beds required per 10,000 of population is a b o u t 3 2 . T h e
optimum size of a public mental hospital is between 1,000 and 1,200 b e d s , and
it has been found t h a t when the number of beds in such an institution is below
500 it tends to become uneconomical i n ' m a n a g e m e n t .
Under t h e Lunacy and Mental T r e a t m e n t Acts a considerable n u m b e r of
patients are treated in private institutions. S o m e 2,500 are in registered hospitals
(i.e. private institutions supported partly by voluntary contributions or charitable
bequests) and rather more in licensed houses, i.e., private profit-making establish­
ments, licensed u n d e r , the Lunacy Act. There are about 12,500 persons of
unsound mind in the public assistance institutions and public health hospitals.
Provision for t h e care of mental defectives is made u n d e r t h e Mental
Deficiency Acts, 1913 to 1938. The local authorities concerned are t h e c o u n t y
and county borough councils. F o r the execution of the Acts these councils are
required t o appoint a committee for the care of defectives, some m e m b e r s of
which may be co-opted.
Certain of t h e functions are obligatory while
others are permissive.
T h e local authorities are required to make arrange­
ments to ascertain w h a t persons within t h e i r areas are defective a n d subject t o
be dealt with under t h e Mental Deficiency Acts. The service covers provision
for institutional care for patients who need i t and community care for defectives
who are placed under guardianship or supervision: There are some 37,000 mental
defectives' in certified institutions, and "about 5,000 under guardianship and
37,000 under s t a t u t o r y supervision. Some 9,500. are in public assistance institutions
approved for the reception of mental defectives.
Institutional provision under t h e Act generally is considered t o b e inadequate.
The operation of t h e principal A c t of 1 9 1 3 w a s checked a t its i n c e p t i o n b y
the outbreak of the last- war, and further developments are essential if an
adequate service is to be provided. Here again joint action is fairly common, 13
out of a total of 61 certified institutions being carried on by Joint Boards or
Joint Committees. Some of the largest certified institutions have been provided
by organisations other t h a n local authorities; a n d there are a number of small
certified houses and approved homes which are privately owned.
The central supervision of t h e mental health services is exercised b y t h e Board
of Control, which was reorganised under t h e provisions of t h e Mental T r e a t m e n t
A.ct, 1930. The members of t h e Board a r e appointed by t h e Crown, on t h e
recommendation Of t h e Minister of H e a l t h , with the exception of t h e legal
member, who is appointed on the recommendation of the Lord Chancellor. The
Minister appoints the Chairman, and the a p p o i n t m e n t of the staff of the Board
is also subject to his approval. He is responsible for the presentation of the
Board's estimate in Parliament, and anwers questions in the House of Commons
relating to the mental health services. He is consulted, and his directions are
taken b y the Board, on all questions of major policy.
The Board exercises
independently of the Minister certain quasi-judicial functions conferred on them
by statute in relation to the discharge of individual patients.
Maternity and Child Welfare.
The health of the expectant or nursing mother and of the child under five who
is not attending school is the subject of a specially organised maternity and child
welfare service. This service is mainly a development of the present century,
and particularly of the years between the t w o great wars. There were beginnings
in the latter part of the nineteenth century, when concern about the high infant
death rate led t o the start of a health visiting service of women workers
(volunteers at first, then professional and qualified visitors) who advised mothers
on infant welfare in their homes; it led also t o the establishment of special depots
or centres, where the mothers could attend for advice, and for milk and other
special necessities. This work was made easier, and t h e way for a more organised
service was paved, by making the notification of births compulsory—-a process
which began in 1907 and was extended in 1915. The real foundation of the present
service was, however, t h e Maternity and Child Welfare Act of 1918.
The service is provided b y local welfare authorities, which m a y be county
councils or county borough councils or minor authorities according t o circum­
stances which need not be elaborated here. The actual result is t h a t outside
London there are nearly 4 0 0 separate local welfare authorities, of which 60 are
county councils, 83 county borough councils, 162 borough councils, 63 urban
district councils, and 10 rural district councils. I n London the Common Council
of the City and the 28 metropolitan borough councils are the welfare authorities.
The service is not a d u t y of these authorities, b u t a power—although in practice
all of t h e m provide it, in varying degree. I t is concerned t o provide medical and
general advice and attention (but not treatment, except for a few minor ailments)
to the young child and its mother, before the child's birth and afterwards until
it is five years old or until i t attends school. The service includes t h e provision
of ante-nataj and post-natal clinics and welfare centres, where attendance is for
the most part free and advice and minor t r e a t m e n t are given, the supply of milk
and special foods, and the visiting and advice of health visitors a t t h e home.
The close connection between this service and t h e school medical service, which
is referred to below, has always been recognised a n d under the Local Govern­
ment Act, 1929, the Minister has power, on representations made b y a council
which is the education authority, to transfer the welfare functions t o t h a t council.
When t h e two services are in the hands of t h e same body t h e y are usually linked
closely with each other.
For her actual confinement the expectant mother m a y be helped by the welfare
authority—through their own provision or through arrangements made by them
with other a g e n c i e s - t o get admission to a bed in a maternity home or hospital.
She m a y , alternatively, be confined in accommodation provided as part of the
general hospital services. Or again she m a y , and commonly does, h a v e her con­
finement at home, and in this case there is a separately established midwifery
service which has grown u p under the Midwives Acts 1902-1936 in t h e hands of
local supervising authorities. These—for historical reasons—may or may not be
the same as the welfare authorities; there are in fact 188 of t h e m and they include
62 county councils, 83 county borough councils, 39 borough councils and 4 urban
district councils. Their original duties (which explain their title) were to supervise
the practice of independent midwives in accordance with t h e professional rules of
the Central Midwives Board; but since 1936 they have been charged t o see that an
adequate service of domiciliary midwives is available in their area for those who
need it, and they do this either by arrangement with voluntary organisations or
b y themselves directly engaging and employing midwives.
Of some 16,000
midwives in practice, nearly 2,700 are directly employed b y the local authorities
as domiciliary midwives a n d over 5,200 are in t h e employment of voluntary
bodies, usually county or district nursing associations. Many midwives, particu­
larly in country areas, combine midwifery work with home, nursing a n d health
visiting.
Nothwithstanding the complication of t h e system, the quality of the maternity
and child welfare a n d midwifery services is in general high, although t h e y vary
in scope considerably from area to area. Results, reflected in lower maternal and
infant mortality, have been striking and well reward the growing efforts of the
service in its relatively short development between the two wars. The commonest
ground of criticism is t h a t it is divided u p among too many separate agencies
and kept too much apart from the related, fields of the family doctor and the
hospital and specialist services.
Home Nursing.
Home nursing forms a most important branch of the health services, and one
which is almost entirely the concern of voluntary organisations. Local authorities
have limited powers to employ nurses for nursing at home patients
suffering from infectious diseases, or expectant or nursing mothers or children
under five suffering from various conditions, b u t they have no general power to
provide a home nursing service and the number of nurses employed directly
by them is very small. Within the limits of their responsibilities local authorities
lave, however, used extensively the services of the voluntary organisations
providing home nurses, and they have also assisted them financially under
powers, originally derived from the poor law, enabling them to make sub­
scriptions and donations to these bodies.
The home nursing service is for the most part provided through district
nursing associations, the majority of which are affiliated directly or through the
appropriate County Nursing Association to t h e Queen's Institute of District
Nursing and are under the supervision of the Institute. The district nurse is a
familiar and welcome figure, particularly in country areas. In co-operation with
the doctor she visits, the patient's homes, tends the chronic sick and t h e injured,
and acts as adviser and educator in health matters. In many districts she acts
also as midwife and health visitor b y arrangement with the local authority. In
all some 8,000 district nurses are a t work over t h e whole of England a n d Wales.
The income of t h e associations is derived from subscriptions and donations,
payments made b y patients directly or through a contributory scheme, and
grants from local authorities.. The proportion received from public funds has
increased in recent years, and especially since t h e Midwives Act 1936 placed on
supervising authorities t h e duty of providing a domiciliary midwifery service.
This duty is frequently discharged by the district nursing associations in return
for a grant from t h e authority.
There is little doubt t h a t , with some development, and with closer co-ordina­
tion with other branches of the health services, home nursing could play an
even greater and more useful part. The need here is for extending and strengthen­
ing a service which has fully proved its value, and for linking it intimately with
general medical practice and with hospital treatment.
The health of the school child.
For the school child, over the age of five, or from the time of his first attending
school, there has gradually developed during the present century a special school
medical service.
Towards the end of the nineteenth century certain special
provision was made for the care of blind, deaf, defective and epileptic children;
but the origin of the school medical service may be traced directly t o the
Report of the Interdepartmental Committee on Physical Deterioration which
was issued a few years after the South African War. As a result of this Report
ihe Education (Administrative Provisions) Act was passed in 1907 setting u p a
regular system of medical inspection a n d empowering authorities t o provide
certain types of t r e a t m e n t . From then onwards, a system of increasing medical
inspection and care of the health of the school child has been steadily built up.
It is now based mainly on the provisions of the Education Act of r92i and is one
of the subjects falling within the scope of the Education Bill n o w before
Parliament.
T h e operations of t h e present school m e d i c a l service are b r o a d l y of three kinds.
First, it provides for the regular m e d i c a l inspection of all children in public
elementary schools, in secondary schools, a n d in certain other schools.
Second,
it provides for t h e m e d i c a l treatment, as well as inspection, of children in public
elementary s c h o o l s — b u t in regard to other schools there is n o obligation (only a
power) to provide t r e a t m e n t .
Third, it e n a b l e s t h e e d u c a t i o n a l s y s t e m , with
its regular c o n t a c t w i t h parent and child, to influence b o t h in principles of
h e a l t h y child life, a n d t o assist and g u i d e t h e m in securing t h a t t h e child resorts
to t h e kinds of m e d i c a l t r e a t m e n t or care t h a t it m a y need. T h e first and last of
these functions are e s s e n t i a l l y aspects of t h e educational s y s t e m , as s u c h , and
it is t h e s e c o n d — p e r s o n a l medical t r e a t m e n t — t h a t is of m o s t interest for the
purpose of t h e present review.
R e s p o n s i b i l i t y for arranging this m e d i c a l t r e a t m e n t rests w i t h t h e local educa­
tion authorities.
There are at t h e m o m e n t , for e l e m e n t a r y e d u c a t i o n , 315 f
t h e s e , and t h e y include counties and c o u n t y boroughs a n d certain non-county
boroughs and urban districts; for higher e d u c a t i o n , there are 146 of t h e s e , all
counties and c o u n t y b o r o u g h s . T h e present provision m a d e b y local education
authorities for medical t r e a t m e n t varies c o n s i d e r a b l y — i n s o m e areas dealing only
w i t h t h e t r e a t m e n t of t e e t h , eyes, ears, n o s e a n d throat, and m i n o r ailments;
in others e x t e n d i n g t o s u c h matters a s o r t h o p a e d i c t r e a t m e n t a n d certain pro­
vision for r h e u m a t i c c a s e s and for m a l a d j u s t e d children.
T h e authorities are
required t o recover t h e c o s t of t r e a t m e n t from t h e parents, unless t h e y are satis­
fied that, this w o u l d n o t be reasonable.
S o m e of t h e t r e a t m e n t activities are
c o n d u c t e d in t h e schools t h e m s e l v e s , s o m e a t clinics, provided for t h e purpose by
the local e d u c a t i o n authorities, s o m e b y arrangements m a d e b e t w e e n these
authorities and hospitals or other i n d e p e n d e n t agencies.
0
T h e local e d u c a t i o n authorities' organisation for t h e s e p u r p o s e s includes
school medical officers, w h o l e time o r part t i m e , t h e chief of w h o m is in nearly
all cases also t h e m e d i c a l officer of h e a l t h of t h e local a u t h o r i t y concerned and
c o m b i n e s his s c h o o l f u n c t i o n s with h i s general public health d u t i e s ; i t also includes
school nurses, w h o are a b l e to" d o m u c h of t h e f o l l o w - u p work in direct
c o n t a c t w i t h t h e h o m e and t h e p a r e n t s (and w h o m a y c o m b i n e their duties with
those of a h e a l t h visitor) and s c h o o l d e n t i s t s a n d other t e c h n i c a l officers. A
valuable a c t i v i t y of t h e education a u t h o r i t i e s , side b y side w i t h this medical
work, is t h e p r o v i s i o n of g o o d school m e a l s and extra n o u r i s h m e n t .
This has
been greatly' e x p a n d e d since the b e g i n n i n g of t h e present war, is n o longer
limited (as it w a s in earlier days) t o children w h o s e p a r e n t s are necessitous or
w h o c a n n o t readily g e t t o their h o m e s at m i d - d a y , a n d will remain a n important
feature in t h e proposed educational reorganisation.
T h e central supervision of t h e s c h o o l medical service rests w i t h t h e Board
of E d u c a t i o n , under p o w e r s delegated b y t h e Ministry of H e a l t h , a n d a close
association of its work w i t h general p u b l i c h e a l t h policy is assured b y t h e two
D e p a r t m e n t s e n j o y i n g t h e services of a single Chief Medical Officer, and by
regular a r r a n g e m e n t s m a d e through h i m for t h e co-ordination of t h e medical
work a t t h e centre in b o t h fields.
Dental Services.
T h e e x i s t i n g p u b l i c l y organised d e n t a l s e r v i c e s . a r e of several k i n d s , a n d apply
to v a r i o u s classes or groups of the' p o p u l a t i o n .
T h r o u g h t h e N a t i o n a l H e a l t h I n s u r a n c e s c h e m e m a n y — b u t n o t all—of the
21,000,000 persons insured under t h e s c h e m e can get w h a t is known
as " dental benefit ".
I n fact,
nearly two-thirds
of
them,
or some
30 per cent, of t h e p o p u l a t i o n , are p r o b a b l y eligible for t h i s benefit, which
first began t o be p r o v i d e d in 1921. It d o e s n o t t a k e t h e form of direct public
provision of dental t r e a t m e n t , b u t of a m o n e y p a y m e n t of t h e w h o l e or a part
of t h e a p p r o v e d cost of t r e a t m e n t . ' T h e i n d i v i d u a l o b t a i n s t r e a t m e n t for himself
from a n y d e n t i s t w h o is willing t o t r e a t h i m , under certain c o n d i t i o n s and at
certain scales of fees w h i c h are c e n t r a l l y regulated b y t h e s c h e m e .
Most
dentists in p r i v a t e p r a c t i c e are willing t o a c c e p t t h e " d e n t a l benefit " patient
in this w a y , a l t h o u g h there is n o o b l i g a t i o n t o d o so a n d n o " panel " system
comparable t o t h a t o n t h e m e d i c a l side of t h e Insurance S c h e m e .
Whether
" dental benefit " is o b t a i n a b l e b y a n y insured p e r s o n , d e p e n d s u p o n t h e a b i l i t y
of t h e A p p r o v e d S o c i e t y (or branch) t o w h i c h h e b e l o n g s t o m a k e p a y m e n t s for
this benefit o u t of its surplus funds. A l t h o u g h p r o b a b l y a b o u t 13,000,000 p e o p l e
are eligible for t h i s benefit, it is n o t e w o r t h y t h a t o n l y s o m e six o r s e v e n p e r c e n t ,
of t h e m a c t u a l l y c l a i m it in a n y g i v e n year.
Under t h e m a t e r n i t y a n d child welfare service m o s t of t h e local welfare
authorities a r r a n g e - i n v a r y i n g degree—for d e n t a l t r e a t m e n t for e x p e c t a n t a n d
nursing m o t h e r s a n d , where necessary, for children u n d e r five. T h e m a j o r i t y d o
this b y p r o v i d i n g a service directly, at t h e i r o w n welfare clinics (or at s c h o o l
clinics dealing w i t h older children), others b y arranging for a service t h r o u g h
private dentists o r a t hospital. T h e scope of t h e service g i v e n varies f r o m area
to area a n d includes t h e p r o v i s i o n of dentures in t h e m a j o r i t y of cases.
No
charge is u s u a l l y m a d e for fillings or e x t r a c t i o n s , b u t for dentures m o s t of t h e
authorities recover w h a t t h e m o t h e r can r e a s o n a b l y afford. T h i s service d a t e s
back t o t h e M a t e r n i t y and Child W e l f a r e A c t of r g i 8 , t h o u g h i t s m a i n d e v e l o p ­
ment is m o r e recent.
D e n t a l t r e a t m e n t is also p r o v i d e d as p a r t of t h e a r r a n g e m e n t s for t h e t r e a t ­
ment of t u b e r c u l o s i s , b y t h e c o u n t y and c o u n t y b o r o u g h councils d e a l i n g w i t h
t h a t disease. H e r e t h e m a i n o b j e c t is t o deal w i t h c a s e s w h e r e t h e s t a t e of t h e
teeth p r e v e n t s t h e p a t i e n t f r o m g e t t i n g t h e full b e n e f i t of t u b e r c u l o s i s t r e a t m e n t
(e.g. b y interfering w i t h proper n o u r i s h m e n t ) and, a l t h o u g h this l i m i t a t i o n is n o t
too strictly o b s e r v e d , t h e a r r a n g e m e n t s are n o n e t h e less o n l y an ancillary a c t i v i t y
of t h e m a i n tuberculosis service.
T h e a r r a n g e m e n t s v a r y locally, being s o m e ­
times p r o v i d e d d i r e c t l y at t h e s a n a t o r i a t h e m s e l v e s , s o m e t i m e s a t other c e n t r e s
by t h e d e n t i s t s e m p l o y e d for t h e m a t e r n i t y a n d o t h e r s e r v i c e s described, s o m e t i m e s
by arrangement w i t h p r i v a t e d e n t i s t s .
In t h e s c h o o l s t h e school m e d i c a l services of t h e local e d u c a t i o n a u t h o r i t i e s
provide d e n t a l i n s p e c t i o n a n d t r e a t m e n t , i n v a r y i n g degree. School dental officers
and dental a t t e n d a n t s and other staff are a p p o i n t e d d i r e c t l y b y t h e a u t h o r i t i e s ,
the work is d o n e a t the. schools or in clinics, or b y a r r a n g e m e n t a t other p r e m i s e s .
There is n o s t a t u t o r y restriction o n t h e scope or n a t u r e of t h e t r e a t m e n t
which can b e g i v e n — a l t h o u g h i t will be r e m e m b e r e d t h a t t h e school m e d i c a l
treatment s e r v i c e is a t present a d u t y of t h e a u t h o r i t i e s o n l y in t h e c a s e of
elementary s c h o o l s , a n d a d i s c r e t i o n a r y p o w e r in o t h e r c a s e s . I n a c t u a l f a c t , t h e
dental service p r o v i d e d ( a l t h o u g h e v e r y local e d u c a t i o n a u t h o r i t y h a s a d e n t a l
scheme of s o m e kind) varies w i t h i n w i d e l i m i t s , and a s a w h o l e i t c a n n o t y e t b e
said (in t h e v i e w of t h e B o a r d of E d u c a t i o n ) t o represent a n y t h i n g like a fully
adequate service for t h e s c h o o l child.
Apart from t h e s e p u b l i c l y organised services t h e i n d i v i d u a l citizen m u s t d e p e n d ,
for his dental care, o n his o w n p r i v a t e arrangements. H e m a y h a v e access e i t h e r
to special d e n t a l h o s p i t a l s (where t h e s e e x i s t ) , or t o s o m e of t h e general h o s p i t a l s
where he will n o r m a l l y be a s k e d t o p a y w h a t he can r e a s o n a b l y afford, or h e m a y .
use certain facilities w h i c h s o m e b u s i n e s s h o u s e s or industrial organisations p r o v i d e
for their o w n e m p l o y e e s , or s o m e charitable or v o l u n t a r y o r g a n i s a t i o n affording
facilities in h i s n e i g h b o u r h o o d . O t h e r w i s e h e u s u a l l y s e e k s t r e a t m e n t p r i v a t e l y
from a d e n t a l practitioner in t h e o r d i n a r y w a y ; or if h e is in serious financial n e e d
and requires urgent t r e a t m e n t he m a y seek t h e a s s i s t a n c e of t h e poor law, w h i c h
in most areas will arrange for essential t r e a t m e n t in t h e last resort.
Ophthalmic Services.
The p o s i t i o n in regard to t h e p u b l i c provision of o p h t h a l m i c services is v e r y
like t h a t in regard t o d e n t a l s e r v i c e s . " O p h t h a l m i c benefit " under t h e N a t i o n a l
Health Insurance s c h e m e is t h e principal m e t h o d of o b t a i n i n g o p h t h a l m i c a d v i c e
and t r e a t m e n t a n d s p e c t a c l e s , and a b o u t half t h e insured g r o u p s , or s o m e 25 per
cent, of t h e p o p u l a t i o n , are eligible ,for benefit.
T h e r e are t w o w a y s in w h i c h
spectacles a r e o b t a i n e d — e i t h e r t h r o u g h a m e d i c a l p r a c t i t i o n e r w i t h special experi­
ence of o p h t h a l m i c w o r k w h o n o r m a l l y g i v e s a p r e s c r i p t i o n for a n y n e c e s s a r y
spectacles t o be m a d e b y a d i s p e n s i n g o p t i c i a n , or t h r o u g h a s i g h t - t e s t i n g o p t i c i a n .
The A p p r o v e d S o c i e t y (or branch) w h i c h p r o v i d e s o p h t h a l m i c benefit is required
to pay the c o s t of o p h t h a l m i c t r e a t m e n t up t o a m a x i m u m a m o u n t , t h e cost of a n
authorised o p h t h a l m i c e x a m i n a t i o n , a n d t h e w h o l e or p a r t of t h e c o s t of s p e c t a c l e s
if they are n e e d e d .
bb
T h e n e x t m o s t i m p o r t a n t c h a n n e l of t r e a t m e n t is t h a t o p e n to schoolchildren
t h r o u g h t h e school m e d i c a l service, w h e r e t h e arrangements are a g a i n a n a l o g o u s
t o t h o s e m a d e for d e n t a l t r e a t m e n t .
A p a r t from this service, o n l y partial and
irregular p u b l i c facilities are a v a i l a b l e , for e x a m p l e t h r o u g h t h e o u t - p a t i e n t
d e p a r t m e n t s of s o m e special and general h o s p i t a l s o r in t h e l a s t resort t h r o u g h the
poor l a w . Otherwise t h e citizen m u s t rely o n w h a t p r i v a t e a r r a n g e m e n t s he is
able t o m a k e w i t h a m e d i c a l practitioner or optician.
I n d u s t r i a l Medical Services.
In a d d i t i o n t o t h e services so far described there are various m e d i c a l activities
a s s o c i a t e d specially w i t h i n d u s t r y and e m p l o y m e n t , w h i c h need t o b e mentioned
i n t h i s general picture a l t h o u g h t h e y are not primarily c o n c e r n e d w i t h the
p e r s o n a l m e d i c a l a d v i c e a n d t r e a t m e n t of t h e i n d i v i d u a l b u t m u c h m o r e with
general welfare and t h e e n v i r o n m e n t a l c o n d i t i o n s of his work.
A l t h o u g h they
can all be referred t o l o o s e l y as " industrial medical services " , t h e y vary
c o n s i d e r a b l y in kind.
F i r s t , t h e F a c t o r y A c t s p r o v i d e for a r r a n g e m e n t s for f a c t o r y i n s p e c t i o n which
are n o w t h e responsibilits; of t h e Ministry of L a b o u r and N a t i o n a l Service (having
b e e n transferred t o t h a t D e p a r t m e n t from t h e H o m e Office in 1940) a n d which
i n c l u d e m e d i c a l as well as o t h e r I n s p e c t o r s . T h e h i s t o r y of t h e direct intervention
b y t h e S t a t e in industrial welfare a n d working conditions is a l o n g one, and
m o s t of i t is not relevant for t h e present p u r p o s e . Sufficient t o s a y t h a t it has
i t s origin, well over a c e n t u r y ago, in t h e a p p o i n t m e n t after 1802 of factory
" Visitors " b y t h e J u s t i c e s of t h e P e a c e ( m a i n l y to enforce t h e legal require­
m e n t s affecting t h e e m p l o y m e n t of j u v e n i l e labour) and t h a t this arrangement
w a s superseded b y t h e first G o v e r n m e n t i n s p e c t o r a t e of factories after t h e Factory
A c t of 1833, from w h i c h t h e line of succession of t h e p r e s e n t s y s t e m can be more
or less directly traced. T h e first a p p o i n t m e n t of a medical inspector w a s n o t made
u n t i l a b o u t t h e end of t h e 19th c e n t u r y ; b u t t h e m e d i c a l side of t h e factory
i n s p e c t o r a t e h a s since d e v e l o p e d i n t o an i m p o r t a n t and w e l l - k n o w n a r m of the
service, a n d n o w occupies t h e w h o l e - t i m e services of m o r e t h a n a d o z e n medical
inspectors. In a d d i t i o n , h o w e v e r , t h e I n s p e c t o r a t e h a s , for o v e r 100 years, been
assisted b y p a r t - t i m e d o c t o r s (formerly called Certifying S u r g e o n s , n o w Examining
Surgeons, a n d n o w n u m b e r i n g a b o u t 1,700) w h o s e duties i n c l u d e d t h e investigation,
o n behalf of t h e D e p a r t m e n t , of c a s e s of a c c i d e n t and i n d u s t r i a l disease as well
as i n v e s t i g a t i n g t h e p h y s i c a l suitability of juveniles for f a c t o r y employment
and periodically e x a m i n i n g workers e m p l o y e d i n v a r i o u s u n h e a l t h y processes—
in c o n n e c t i o n w i t h p r e v e n t i v e measures (including, w h e r e f o u n d necessary, the
suspension of i n d i v i d u a l s from t h e particular k i n d of work). T h e i r investigation
of a c c i d e n t s (but n o t of c a s e s of disease, poisoning, gassing, and o t h e r special
cases) w a s dropped in 1916, b u t t h e other s i d e s of their work h a v e b e e n developing.
T h i s organisation is n o t designed t o p r o v i d e personal m e d i c a l t r e a t m e n t and
a d v i c e t o t h e individual worker; i t is designed a s an integral p a r t of t h e highly
t e c h n i c a l m a c h i n e r y for p r o m o t i n g , f u n d a m e n t a l l y t h r o u g h t h e e m p l o y e r , safety,
h e a l t h a n d welfare in factories a n d o t h e r premises w i t h i n t h e s c o p e of the
Inspectorate.
N e x t , industrial concerns o f t e n a p p o i n t works m e d i c a l officers, full-time or
p a r t - t i m e , w h o are i n a r a t h e r different p o s i t i o n . A n i n t e r m e d i a t e k i n d of case
is w h e r e t h e firm a r r a n g e for t h e E x a m i n i n g Surgeon t o carry o u t additional
functions a t t h e w o r k s , b e y o n d those f o r w h i c h t h e y are l e g a l l y required to
e m p l o y h i m , so t h a t h e is s u b s t a n t i a l l y a p a r t - t i m e w o r k s d o c t o r . These
" w o r k s d o c t o r s " are e n g a g e d m a i n l y t o k e e p an e x p e r t e y e o n t h e medical
aspects of t h e f a c t o r y ' s w o r k a n d h y g i e n e , on t h e effects of e n v i r o n m e n t upon
t h e h e a l t h of t h e workers, on t h e w i s e a d j u s t m e n t of t y p e s of w o r k t o t h e workers'
c a p a c i t y , on a r r a n g e m e n t s for dealirig w i t h a c c i d e n t s a n d emergencies, and
g e n e r a l l y for t h e g i v i n g of proper m e d i c a l a d v i c e t o t h e f a c t o r y management.
Before t h e war, a r r a n g e m e n t s of t h i s k i n d were often e n c o u r a g e d b y t h e Factory
I n s p e c t o r a t e , a n d t h e F a c t o r i e s A c t of 1937 g a v e wider p o w e r s t o t h e Home
S e c r e t a r y t o order e m p l o y e r s t o m a k e a r r a n g e m e n t s for m e d i c a l suoervision in
t h e i r factories. F u r t h e r , in 1940, t h e M i n i s t e r of L a b o u r a n d N a t i o n a l Service
m a d e a n Order, u n d e r E m e r g e n c y P o w e r s , requiring m u n i t i o n s a n d other firms
t o a p p o i n t works d o c t o r s if directed to do so.
F o r m a l directions under the
Order have n o t b e e n f o u n d necessary; b u t , since it w a s m a d e , m a n y more, firms
have in fact a p p o i n t e d w h o l e - t i m e or part-time works doctors, s o that "there are
now some 175 w h o l e - t i m e doctors of t h i s kind and a b o u t 700 exercising s u b s t a n t i a l
medical supervision in t h e factories o n a regular p a r t - t i m e basis. T h e " w o r k s
doctors " d o n o t , a n y more t h a n t h e F a c t o r y I n s p e c t o r a t e , e x i s t primarily a s a
personal m e d i c a l service; b u t i n c o n n e c t i o n w i t h t h e i r f u n c t i o n s of a d v i s i n g
the m a n a g e m e n t a n d "dealing with p r e v e n t i v e and first-aid measures in t h e f a c t o r y
they often p r o v i d e , incidentally a n d as a m a t t e r of c o m m o n - s e n s e u t i l i t y , a
certain a m o u n t of useful personal m e d i c a l a d v i c e t o t h e factory e m p l o y e e s o n t h e
gpQ-t—perhaps particularly in w a r - t i m e w i t h i t s r e d u c e d
o p p o r t u n i t i e s for
ordinary medical c o n s u l t a t i o n o u t s i d e working hours a n d i t s greater n e e d for
uninterrupted a t t e n d a n c e a t a p l a c e of work.
T h e Ministry of S u p p l y , in its c a p a c i t y of f a c t o r y e m p l o y e r , h a s o n similar
principles d e v e l o p e d a m e d i c a l service i n c o n n e c t i o n w i t h its R o y a l Ordnance F a c ­
tories. This service, as m i g h t b e e x p e c t e d in a large industrial u n d e r t a k i n g , i n c l u d e s
a central o r g a n i s a t i o n c o n c e r n e d w i t h t h e general p r o b l e m s of t h e particular classes
of factory u n d e r consideration, i n w h i c h m e d i c a l a n d o t h e r t e c h n i c a l e x p e r t s p l a y
their part, c o m b i n e d w i t h a service of works doctors w h o look after c o n d i t i o n s
at t h e individual works in c o n j u n c t i o n w i t h other experts there, a n d . w h o
incidentally, a s in o t h e r cases, g i v e a certain a m o u n t of personal m e d i c a l a d v i c e .
Similarly, b u t on a smaller scale,, t h e A i r Ministry a n d A d m i r a l t y m a k e arrange­
ments for m e d i c a l services a t their c i v i l i a n industrial e s t a b l i s h m e n t s .
F o r the m i n i n g i n d u s t r y , t h e Ministry of F u e l a n d P o w e r h a s f o u n d i t
increasingly desirable t o enlist t h e m e d i c a l e x p e r t i n its n a t i o n a l o r g a n i s a t i o n
dealing with w o r k i n g c o n d i t i o n s a n d welfare in t h e industry, a n d i t also e n c o u r a g e s
greater use in t h e m i n e s t h e m s e l v e s of m e d i c a l a d v i c e on t h e " w o r k s d o c t o r "
principle.
T h e s e a c t i v i t i e s also i n v o l v e some entry into t h e field of personal
medical care, b u t t h e y d o ' n o t s e t o u t t o provide a n y full s e p a r a t e m e d i c a l
service. T h e miner, like other industrial workers, is w i t h i n t h e s c o p e of t h e
National H e a l t h i n s u r a n c e s c h e m e a n d has recourse t o h o s p i t a l a n d o t h e r
services o n t h e b a s i s already described.
T h e Miners W e l f a r e C o m m i s s i o n h a s
also been a c t i v e i n m i n i n g areas, i n assisting in t h e p r o v i s i o n of a d d i t i o n a l
facilities (such as X - r a y installations or p h y s i o - t h e r a p y centres a t h o s p i t a l s ) .
Generally, i n t h e s e a n d other industrial m e d i c a l services, t h e picture i s n o t
one of personal d o c t o r i n g a n d i n d i v i d u a l h e a l t h a d v i c e organised i n v o c a t i o n a l
groups. I t is n o t a q u e s t i o n of s e p a r a t e l y organised m e d i c a l t r e a t m e n t services
for classes of industrial workers as d i s t i n c t from t h e rest of t h e p o p u l a t i o n . W i t h
lew e x c e p t i o n s (like t h e a r r a n g e m e n t s for t h e police a n d for certain P o s t Office
workers, referred t o under t h e p a r a g r a p h s on general m e d i c a l a t t e n t i o n a b o v e )
the main h e a l t h a n d t r e a t m e n t services, already s u m m a r i s e d i n t h i s p a p e r
(National H e a l t h I n s u r a n c e , t h e local a u t h o r i t y services, t h e " h o s p i t a l s , a n d s o
on) a p p l y in t h e m a i n t o t h e p e o p l e or t o sections of t h e p e o p l e irrespective
of their particular form of v o c a t i o n or e m p l o y m e n t — f o r t h e m o s t p a r t e q u a l l y
to t h e worker in t h e field or in t h e m i n e or i n t h e f a c t o r y or elsewhere. T h e
" industrial " m e d i c a l services are primarily concerned w i t h e n l i s t i n g the" m e d i c a l
expert in t h e supervision of general industrial welfare a n d organisation.
They
are n o t a direct personal t r e a t m e n t service, t h o u g h t o t h e e x t e n t indicated t h e y
are sometimes concerned i n c i d e n t a l l y w i t h personal a d v i c e or l i m i t e d trea.tment.
General.
This, t h e n , i s a b r o a d outline of t h e p i c t u r e of t h e h e a l t h a n d m e d i c a l sendees-—
the main picture, b u t n o t b y a n y m e a n s t h e w h o l e picture. A full r e v i e w w o u l d
have t o detail t h e m u l t i t u d e of v o l u n t a r y and private a n d s e m i - p u b l i c efforts of
a host of a s s o c i a t i o n s , t r u s t s , societies, clinics, i n s t i t u t i o n s a n d other organisa­
tions and groups, w h i c h h a v e s p r u n g from p r i v a t e initiative o r from p u b l i c
charity over a long period of y e a r s . I t w o u l d h a v e t o a n a l y s e t h e m a n y l o c a l
variations of b o t h s t a t u t o r y a n d n o n - s t a t u t o r y services, t h e m a n y different
kinds of e x p e r i m e n t in grouping a n d c o m b i n a t i o n of services l o c a l l y , t h e a t t e m p t s
made both r e c e n t l y a n d earlier, i n different quarters, t o r e l a t e s e p a r a t e services
more closely t o e a c h o t h e r and t o " rationalise " t h e p a t t e r n here a n d t h e r e .
There is n o r o o m t o deal w i t h all t h i s . T h e general p i c t u r e g i v e n i s p e r h a p s
enough t o reveal t h e essential features of t h e present s i t u a t i o n .
T H E P R E S E N T H E A L T H S E R V I C E S IN S C O T L A N D .
Genera].
T h e h e a l t h services i n Scotland h a d t h e s a m e origin a n d t h e i r d e v e l o p m e n t has
followed m u c h t h e s a m e course as t h e health services i n E n g l a n d a n d Wales.
There h a s been t h e s a m e e v o l u t i o n from t h e measures t a k e n b y public authorities
at t h e beginning of last century t o relieve t h e destitute sick, followed later in the
c e n t u r y b y t h e d e v e l o p m e n t of t h e e n v i r o n m e n t a l public h e a l t h services and the
t r e a t m e n t of infectious diseases, t o t h e e x p a n s i o n of t h e personal h e a l t h services
in t h e present c e n t u r y . There h a s b e e n t h e s a m e h a p h a z a r d g r o w t h of these
services through t h e years, l e a v i n g m u c h t h e s a m e gaps t o b e filled a n d t h e same
k i n d of problems t o b e solved. T h i s being so, a description of t h e history and
t h e present state of t h e health services i n S c o t l a n d w o u l d i n e v i t a b l y repeat much
B u t t h e d e v e l o p m e n t .of the
of w h a t h a s a l r e a d y b e e n said i n t h i s A p p e n d i x .
services in t h e t w o countries h a s n o t b e e n uniform. S o m e of t h e S c o t t i s h services
differ i n t h e i r s c o p e a n d organisation from t h e corresponding services in England
a n d W a l e s ; others, such as t h e H i g h l a n d s a n d Islands Medical S e r v i c e , have no
E n g l i s h counterpart at all. T h e following paragraphs draw a t t e n t i o n t o t h e most
i m p o r t a n t of t h e s e differences.
Local Authorities.
T h e Local G o v e r n m e n t (Scotland) A c t , 1929, s u b s t a n t i a l l y reduced t h e number
of local authorities concerned w i t h t h e h e a l t h of t h e people. T h e h e a l t h services
(excluding for t h i s purpose t h e e n v i r o n m e n t a l services—general s a n i t a t i o n , water
s u p p l y , drainage a n d housing) are n o w administered b y t h e 55 " major health
a u t h o r i t i e s , " n a m e l y , t h e c o u n t y councils, of w h i c h there are 31, a n d the town
councils of large b u r g h s , of w h i c h t h e r e are 24. A large b u r g h is one nominally
w i t h a population of o v e r 20,000. T h e school h e a l t h service, h o w e v e r , i s adminis­
tered o n l y b y t h e c o u n t y councils a n d t h e t o w n councils of t h e four Cities (Edin­
b u r g h , Glasgow, A b e r d e e n and D u n d e e ) , w h i c h are e d u c a t i o n authorities.
Hospital and Consultant Services.
I n broad outline, t h e d e v e l o p m e n t of t h e h o s p i t a l services i n S c o t l a n d h a s been
similar t o t h a t i n E n g l a n d a n d W a l e s . T h e t w o hospital s y s t e m s — v o l u n t a r y and
local a u t h o r i t y — h a v e g r o w n u p side b y side i n m u c h t h e s a m e w a y in both
countries. B u t t h e v o l u n t a r y hospitals in S c o t l a n d still provide m u c h the
bigger part of t h e institutional service for t h e t r e a t m e n t of a c u t e medical and
surgical c o n d i t i o n s .
Before t h e w a r t h e r e were s o m e 220 v o l u n t a r y hospitals
w i t h a t o t a l of over 14,000 b e d s .
O n t h e o t h e r h a n d , local authorities have
entered t h e " general " hospital field o n l y i n recent years a n d s o f a r h a v e provided
o n l y s o m e 5,500 b e d s in nine local a u t h o r i t y general h o s p i t a l s . W i t h one small
T h e r e are still about
e x c e p t i o n , these h o s p i t a l s are found i n t h e four Cities.
1,700 b e d s in public assistance i n s t i t u t i o n s a c c o m m o d a t i n g t h e " chronic s i c k "
c o m i n g w i t h i n t h e scope of t h e poor l a w .
T h e tradition of t h e S c o t t i s h v o l u n t a r y hospitals is t o afford free treatment.
There h a s been v e r y litle d e v e l o p m e n t of t h e p a y - b e d s y s t e m ; a n d it is not
c u s t o m a r y t o a s k t h e p a t i e n t in ordinary wards t o m a k e a payment
t o w a r d s t h e cost of h i s t r e a t m e n t . W h i l e there are organised s c h e m e s in offices,
factories a n d w o r k p l a c e s , for collecting subscriptions for h o s p i t a l s , little has
b e e n done t o organise v o l u n t a r y c o n t r i b u t o r y s c h e m e s of t h e t y p e found in
E n g l a n d and W a l e s .
L o c a l a u t h o r i t i e s w h i c h h a v e p r o v i d e d hospitals for the
general sick apart from t h e poor l a w are obliged b y s t a t u t e t o charge a reasonable
s u m t o w a r d s t h e c o s t of t h e p a t i e n t ' s t r e a t m e n t . B u t there is n o p o w e r t o charge
for t h e hospital t r e a t m e n t of i n f e c t i o u s disease. (Further reference is m a d e below
t o infectious diseases hospitals a n d sanatoria.)
B e t w e e n t h e w a r s , t h e re-organisation of t h e S c o t t i s h h o s p i t a l services was
w i d e l y discussed a n d a n u m b e r of i m p o r t a n t c o m m i t t e e s reported on t h e subject.
Considerable support h a s b e e n g i v e n t o t h e v i e w t h a t S c o t l a n d b o t h requires and
l e n d s itself t o a regional c o - o r d i n a t e d h o s p i t a l service c o m p r e h e n d i n g both the
v o l u n t a r y and local a u t h o r i t y h o s p i t a l s .
T h i s v i e w t a k e s a c c o u n t mainly of
t h e f a c t t h a t t h e c o u n t r y ' s k e y h o s p i t a l s as well as t h e m e d i c a l schools are all to
b e found i n t h e four Cities of E d i n b u r g h , G l a s g o w , A b e r d e e n a n d D u n d e e , a n d that
these centres are natural focal p o i n t s for a regional organisation. T h e c o n c e p t i o n
of four hospital regions based on t h e s e Cities, w i t h a fifth based for g e o g r a p h i c a l
reasons on Inverness, h a s t h u s b e c o m e t h e c o m m o n c u r r e n c y of all discussions
on Scottish h o s p i t a l p o l i c y . T h e r e c e n t l y published report of t h e H e t h e r i n g t o n
Committee n o t o n l y re-affirms t h i s c o n c e p t i o n b u t m a k e s definite proposals for
setting up R e g i o n a l H o s p i t a l Councils w i t h primarily a d v i s o r y f u n c t i o n s .
Scotland h a s for long suffered' from a n a c u t e shortage of h o s p i t a l a c c o m m o d a ­
tion and t h e w a i t i n g list problem h a s b e e n serious. T h i s gives special i m p o r t a n c e
to the fact t h a t t h e E m e r g e n c y H o s p i t a l Service, organised originally for t h e
treatment of air-raid casualties, h a s a d d e d s o m e 15,000 n e w b e d s t o t h e c o u n t r y ' s
total hospital p r o v i s i o n . Of these, 8,000 are in a n n e x e s a t e x i s t i n g h o s p i t a l s , a n d
7,000 are in s e v e n c o m p l e t e l y n e w h o s p i t a l s . W h i l e t h e s e b e d s are in b u i l d i n g s
of emergency c o n s t r u c t i o n and while t h e i r n u m b e r will b e m a t e r i a l l y r e d u c e d t o
conform t o p e a c e - t i m e standards of b e d - s p a c i n g and t h e like, t h e y will f o r m a
welcome a d d i t i o n t o t h e post-war h o s p i t a l service. T h e a n n e x e s are a d m i n i s t e r e d
by the h o s p i t a l authorities responsible for t h e parent h o s p i t a l s t o w h i c h t h e y are
attached: t h e s e v e n n e w hospitals are d i r e c t l y a d m i n i s t e r e d b y t h e D e p a r t m e n t of
Health for S c o t l a n d .
F o r t u n a t e l y , little call h a s h a d t o b e m a d e so far o n t h e e m e r g e n c y h o s p i t a l
organisation for t h e t r e a t m e n t of air-raid casualties a n d b e d s h a v e therefore b e e n
For
free, within t h e l i m i t s of t h e a v a i l a b l e nursing staff, for o t h e r purposes.
example, e m e r g e n c y b e d s h a v e b e e n u s e d t o great p u b l i c a d v a n t a g e in r e l i e v i n g
the w a i t i n g lists of t h e v o l u n t a r y h o s p i t a l s : u p to t h e e n d of 1943, s o m e 2 4 , 0 0 0
patients h a d b e e n a d m i t t e d for t r e a t m e n t from these l i s t s .
The e x i s t e n c e of staffed beds in t h e e m e r g e n c y h o s p i t a l s under t h e D e p a r t m e n t s
direct control w i t h full c o n s u l t a n t a n d d i a g n o s t i c facilities available has a l s o
facilitated a n interesting and successful e x p e r i m e n t in p r e v e n t i v e m e d i c i n e , in­
volving t h e close co-operation of t h e f a m i l y doctor, c o n s u l t a n t and h o s p i t a l
services. T h i s w a s originally k n o w n a s t h e C l y d e B a s i n E x p e r i m e n t w h i c h h a d
its origin i n reports r e c e i v e d f r o m v a r i o u s sources t o w a r d s t h e e n d of 1941
suggesting t h a t w a r strain, long h o u r s , a n d t h e b l a c k - o u t were affecting t h e h e a l t h
of the w o r k i n g p o p u l a t i o n in S c o t l a n d , i n c l u d i n g t h a t of y o u n g w o m e n w h o h a d
entered i n d u s t r y for t h e first t i m e . A t t h e s a m e t i m e i t was b e c o m i n g clear t h a t
the m a n - p o w e r n e e d s of t h e n a t i o n required t h e o r g a n i s a t i o n of t h e c i v i l i a n
medical services o n lines w h i c h w o u l d secure t h a t early a n d correct diagnosis a n d
treatment were a v a i l a b l e for a n y c o n d i t i o n w h i c h t h r e a t e n e d t o i m p a i r t h e
working c a p a c i t y of w a r workers or to l e a v e a war a f t e r m a t h of chronic i n v a l i d i s m .
Accordingly, early in 1942, t h e S e c r e t a r y of S t a t e l a u n c h e d t h e e x p e r i m e n t for t h e
benefit of y o u n g industrial workers b e t w e e n 18 and 25 years of a g e , i n t h e W e s t
of Scotland. F a m i l y d o c t o r s in t h e area were asked t o refer t o t h e D e p a r t m e n t s
Regional Medical Officer p a t i e n t s i n a d e b i l i t a t e d s t a t e or s h o w i n g s y m p t o m s sug­
gesting t h e n e e d for e x p e r t diagnosis. T h e e x p e r i m e n t w a s successful from t h e
start and b y t h e e n d of t h e year i t w a s e x t e n d e d t o c o v e r w a r workers of all a g e s
in the w h o l e of t h e industrial b e l t .
I t is n o w k n o w n as t h e S u p p l e m e n t a r y
Medical Service S c h e m e . U n d e r t h e s c h e m e , t h e R e g i o n a l M e d i c a l Officer, e i t h e r
himself or w i t h t h e aid of c o n s u l t a n t s , m a k e s a t h o r o u g h e x a m i n a t i o n of e v e r y
case referred t o h i m ; a full range of c o n s u l t a n t s is a v a i l a b l e for t h e p u r p o s e .
Where necessary, t h e R e g i o n a l Medical Officer arranges for t h e p a t i e n f s a d m i s s i o n
to hospital for o b s e r v a t i o n and full clinical i n v e s t i g a t i o n or t o a c o n v a l e s c e n t
hospital if rest or " b u i l d i n g u p " is n e e d e d . W h e r e o n m e d i c a l g r o u n d s a c h a n g e
of work s e e m s desirable t h e R e g i o n a l Medical Officer c o n s u l t s t h e M i n i s t r y of
Labour a n d N a t i o n a l Service. A full r e p o r t is furnished t o t h e f a m i l y d o c t o r i n
every case for h i s future g u i d a n c e a n d , in selected cases, f o l l o w - u p work i s
undertaken.
Up to t h e end of 1943, s o m e 6,300 p a t i e n t s h a d b e e n referred t o t h e R e g i o n a l
Medical Officers for e x a m i n a t i o n . T h e s c h e m e has s h o w n w h a t can b e d o n e i n
bringing t h e f a m i l y d o c t o r into close a n d effective c o n t a c t w i t h t h e c o n s u l t a n t s
and t h e h o s p i t a l s — c o n t a c t s w h i c h h a v e e v o k e d t h e w a r m e s t a p p r e c i a t i o n f r o m
doctors and p a t i e n t s alike.
Infectious D i s e a s e s H o s p i t a l s .
As in E n g l a n d a n d W a l e s , i t w a s n o t until t h e m i d d l e of t h e rrhieteerith
century t h a t organised steps w e r e first t a k e n t o deal w i t h i n f e c t i o u s d i s e a s e s .
G l a s g o w ' s first m u n i c i p a l fever hospital was o p e n e d in 1865. T w o y e a r s later the
Public, H e a l t h (Scotland) A c t , 1867, e m p o w e r e d local authorities for t h e first time
t o m a k e provision for t h e prevention and m i t i g a t i o n of epidemic, e n d e m i c or
c o n t a g i o u s diseases.
T h e s e powers included one t o provide hospitals for the
sick generally h u t b y t h e P u b l i c H e a l t h (Scotland) A c t , 1897, t h i s power was
l i m i t e d ' t o t h e provision of hospitals for t h o s e suffering from infectious diseases.
T h i s Act of 1897, w h i c h is still t h e principal P u b l i c H e a l t h s t a t u t e applicable
t o S c o t l a n d , is t h e basis of t h e present s y s t e m of public h e a l t h administration.
I t m a d e compulsorily notifiable t h r o u g h o u t S c o t l a n d t h e diseases w h i c h previously
h a d been notifiable o n l y in t h e areas of local authorities w h i c h h a d a d o p t e d the
Infectious Disease (Notification) A c t , 1889, and it g a v e powers t o t h e Central
D e p a r t m e n t t o require t h e notification of other diseases. T h r o u g h t h e years t h e
list of notifiable diseases h a s been considerably e x t e n d e d .
M a n y local authoritis c o m b i n e d t o discharge their duties under t h e A c t of
1897 w i t h regard t o t h e t r e a t m e n t of infectious diseases. T h e Local Government
(Scotland) A c t , 1929, in reducing t h e n u m b e r of local authorities responsible for
t h i s s e i v i c e to 55, c o n s e q u e n t i a l l y reduced t h e n u m b e r of hospital combinations.
There are now 12 joint b o a r d s providing infectious diseases hospitals on behalf of
23 of t h e authorities.. I n all, there are 109 infectious diseases h o s p i t a l s with
a b o u t 7,600 beds, e x c l u d i n g beds for the t r e a t m e n t of tuberculosis.
Sixty-six
of t h e hospitals h a v e less t h a n 50 beds. T h e institutional t r e a t m e n t of infectious
diseases in Scotland is entirely free.
Tuberculosis.
R e s p o n s i b i l i t y for t h e t r e a t m e n t of tubercu'io.-i.s in Scotkujd is included in the
general responsibility for treating infectious diseases laid b y t h e public health
s t a t u t e s on the .55 m a j o r h e a l t h authorities. There is n o separate statutory
provision dealing w i t h tuberculosis us in E n g l a n d a n d W a l e s a n d in particular
t h e r e i s no specific p o w e r t o provide for t h e after-care of persons w h o have
suffered from t u b e r c u l o s i s .
T h e m a i n features of the tuberculosis s c h e m e s derive from t h e efforts of the
l a t e Sir R o b e r t P h i l i p w h o 111 1887 laid in E d i n b u r g h the f o u n d a t i o n of an anti­
tuberculosis organisation based on t h e association of t h e dispensary, t h e sana­
t o r i u m and t h e farm c o l o n y . T h e higher t e c h n i q u e s in t h e t r e a t m e n t of tuber­
culosis h a v e been greatly d e v e l o p e d since these early d a y s , b u t t h e b a s i c principles
of this pioneering effort still h o l d g o o d .
L o c a l authorities were at first slow t o follow Sir R o b e r t P h i l i p ' s lead. One or
t w o of t h e m in 1904 e x p e r i m e n t e d w i t h t h e isolation of p u l m o n a r y tuberculosis
i n spare wards of infectious diseases hospitals, b u t it w a s n o t u n t i l 1906 that
substantial progress b e g a n t o be m a d e . In t h a t year t h e L o c a l G o v e r n m e n t Board
for Scotland (at t h a t t i m e t h e central D e p a r t m e n t ) m a d e p u l m o n a r y tuberculosis
compulsorily notifiable a n d e x t e n d e d t o this disease t h e s t a t u t o r y obligation which
already rested on local authorities to deal w i t h certain o t h e r infectious diseases.
Before t h e war, t h e r e were about 5,300 tuberculosis beds in S c o t l a n d , of which
a b o u t 4,700 were in local a u t h o r i t y i n s t i t u t i o n s . A l t h o u g h s o m e of these beds
were converted t o o t h e r uses w h e n w a r broke out, alternative arrangements, in­
eluding t h e provision of b e d s in the D e p a r t m e n t ' s e m e r g e n c y hospitals, have
resulted in a n e t increase i n t h e available bed a c c o m m o d a t i o n .
T h e incidence of tuberculosis is relatively higher in S c o t l a n d t h a n in England and
Wcdes, and it h a s t e n d e d t o increase in w a r - t i m e . There are e m p t y b e d s available
for tuberculosis p a t i e n t s w h i c h c a n n o t b e used for lack of n u r s e s . This has
produced a l e n g t h e n i n g waiting list of sufferers requiring institutional treatment,
o n e of t h e distressing features of the present state of t h e public h e a l t h .
Venereal Disease.
There are a b o u t 5 0 o u t - p a t i e n t clinics a n d centres in S c o t l a n d for t h e treatment
of venereal disease. S o m e are in v o l u n t a r y hospitals b u t m a n y h a v e been-specially
provided.
Mental Health Services.
Provision for t h e care and t r e a t m e n t of persons suffering from m e n t a l disorder
i s m a d e b y lecal authorities under t h e L u n a c y l(Scotland) A c t s , 1857 t o 1919.
n
While t h e s e A c t s m a k e s o m e p r o v i s i o n for v o l u n t a r y p a t i e n t s , n o specific p o w e r s
h a v e b e e n conferred o n local a u t h o r i t i e s with regard e i t h e r t o v o l u n t a r y p a t i e n t s
or t o o u t - p a t i e n t diagnosis a n d t r e a t m e n t .
There is i n d e e d n o counterpart i n
Scotland t o t h e English M e n t a l T r e a t m e n t A c t of 1930. N e v e r t h e l e s s , t h i s p a r t
I n 1942, 14.2 p e r c e n t ,
of t h e service h a s developed s t e a d i l y i n recent y e a r s .
of t h e a d m i s s i o n s t o m e n t a l h o s p i t a l s p r o v i d e d b y local a u t h o r i t i e s were v o l u n t a r y
patients.
There a r e 23 local a u t h o r i t y m e n t a l h o s p i t a l s i n S c o t l a n d , of w h i c h 13 serve
combinations of t w o or more a u t h o r i t i e s . T h e 23 h o s p i t a l s h a d 12,800 p a t i e n t s o n
1st J a n u a r y , 1943. F o u r single a u t h o r i t i e s a n d t w o c o m b i n a t i o n s h a v e no m e n t a l
hospitals of t h e i r o w n b u t d e p e n d o n c o n t r a c t s m a d e w i t h t h e R o y a l M e n t a l
Hospitals (or A s y l u m s ) .
There a r e s e v e n R o y a l (or Chartered) Mental A s y l u m s w h i c h originated u n d e r
e n d o w m e n t s c h e m e s a n d are t h e o l d e s t of t h e e x i s t i n g i n s t i t u t i o n s for t h e i n s a n e
in S c o t l a n d . O n 1st J a n u a r y , 1943, t h e y h a d 5,300 p a t i e n t s .
P r o v i s i o n for t h e care of m e n t a l d e f e c t i v e s is m a d e u n d e r t h e M e n t a l Deficiency
(Scotland) A c t s , 1913 a n d 1940. A s i n E n g l a n d , t h e w a r of 1914-18 c h e c k e d
d e v e l o p m e n t s under t h e 1913 A c t , a n d i n s t i t u t i o n a l p r o v i s i o n is still very in­
a d e q u a t e . O n 1st J a n u a r y , 1943, t h e r e were 3,900 m e n t a l d e f e c t i v e s i n certified
institutions a n d 1,750 under g u a r d i a n s h i p .
F i v e o f t h e 13 i n s t i t u t i o n s a r e
managed b y j o i n t b o a r d s or j o i n t c o m m i t t e e s . O n e of t h e largest of the institu­
tions a n d t w o s m a l l o n e s h a v e b e e n p r o v i d e d b y o r g a n i s a t i o n s other than local
authorities.
Central supervision of t h e l u n a c y a n d m e n t a l deficiency s e r v i c e s is the respon­
sibility o f t h e General B o a r d of Control for S c o t l a n d , ' t h e m e m b e r s of which are
appointed b y t h e Crown on t h e r e c o m m e n d a t i o n of t h e S e c r e t a r y of State.
T h e C o m m i t t e e o n S c o t t i s h H e a l t h Services p o i n t e d o u t t h e n e e d for the
revision . a n d c o n s o l i d a t i o n of t h e S c o t t i s h l u n a c y a n d m e n t a l deficiency laws,
and this p r o b l e m is. n o w b e i n g considered b3*- a C o m m i t t e e a p p o i n t e d for the
purpose u n d e r t h e c h a i r m a n s h i p of L o r d Russell.
T h e former - C o m m i t t e e also
emphasised t h a t t h e o u t s t a n d i n g n e e d of t h e m e n t a l h e a l t h service was for a
co-ordinated m o v e m e n t t o d e a l w i t h early m e n t a l a n d n e r v o u s disorders. I t is
in this field t h a t t h e service h a s b e e n chiefly l a c k i n g .
Maternity and Child Welfare.
T h e local organisation of t h e m a t e r n i t y a n d child welfare service is the respon­
sibility of t h e 5 5 major h e a l t h a u t h o r i t i e s . T h e r e is n o c o u n t e r p a r t in Scotland
to t h e minor a u t h o r i t i e s of E n g l a n d a n d W a l e s .
Local a u t h o r i t i e s h a d n o s t a t u t o r y p o w e r s t o u n d e r t a k e child welfare work
till 1915, w h e n t h e y were e m p o w e r e d b y t h e N o t i f i c a t i o n of B i r t h s (Extension)
Act t o a t t e n d t o t h e h e a l t h of e x p e c t a n t a n d n u r s i n g m o t h e r s a n d of c h i l d r e n
under five y e a r s of a g e . A t t h e e n d o f 1919 s c h e m e s for this purpose were in
operation in areas comprising 55 p e r c e n t , of t h e p o p u l a t i o n : t e n y e a r s later the
percentage h a d risen t o 94: a n d s i n c e t h e p a s s i n g of the L o c a l G o v e r n m e n t
(Scotland) A c t , 1929, t h e r e m a i n i n g 6 p e r c e n t , of the p o p u l a t i o n has been
covered.
The s c o p e of t h e service is b r o a d l y similar i n t h e t w o c o u n t r i e s , resting as it does
on the e m p l o y m e n t of d o c t o r s , m i d w i v e s , h e a l t h v i s i t o r s a n d specialists, and o n
the a p p a r a t u s of clinics, centres, nurseries, m a t e r n i t y h o s p i t a l s a n d h o m e s . B u t
there is o n e n o t e w o r t h y difference. T h e M a t e r n i t y S e r v i c e s (Scotland) A c t , 1937,
created a domiciliary m a t e r n i t y service w h i c h differs f r o m t h a t in E n g l a n d a n d
Wales i n t h a t , while the E n g l i s h service i s b a s e d o n t h e m i d w i f e a l o n e , t h e S c o t t i s h
service i s b a s e d on t h e d o c t o r - m i d w i f e c o m b i n a t i o n . T h a t i s t o s a y , under t h e A c t
of 1937 i t is n o w a d u t y o n e v e r y local a u t h o r i t y i n S c o t l a n d t o m a k e a v a i l a b l e to
all w o m e n , w h o are t o b e confined a t h o m e a n d w h o a p p l y for the service, the
joint care t h r o u g h o u t p r e g n a n c y , l a b o u r a n d t h e p u e r p e r i u m of a doctor and of
a certified midwife, w i t h t h e a d v i c e a n d h e l p , s o far a s i t i s p r a c t i c a b l e to provide
it, of a n e x p e r t obstetrician a t a n y t i m e if t h e d o c t o r t h i n k s this necessary.
There are s o m e 1,400 p r a c t i s i n g m i d w i v e s i n S c o t l a n d , including 90 whole-time
employees of local authorities.
31033
E
W h i l e t h e maternal a n d infant m o r t a l i t y rates h a v e shown a b i g i m p r o v e m e n t
o v e r t h e years, t h e p o s i t i o n in S c o t l a n d is still m u c h less favourable t h a n t h a t in
England and Wales.
The recently p u b l i s h e d R e p o r t of t h e Orf C o m m i t t e e
e x a m i n e s t h e p r o b l e m of infant m o r t a l i t y i n Scotland and, a m o n g other things,
calls a t t e n t i o n t o t h e p o o r liaison b e t w e e n t h e hospitals, t h e family doctor and
t h e child welfare s e r v i c e .
H o m e Nursing.
T h e Queen's I n s t i t u t e of D i s t r i c t N u r s i n g h a v e 1,050 nurses operating i n Scot­
l a n d . T h e D i s t r i c t N u r s e p l a y s a n i m p o r t a n t p a r t in m a n y areas a s h e a l t h visitor
a n d tuberculosis nurse under t h e local a u t h o r i t y s c h e m e s . S h e h a s a special im­
porcance i n the s p a r s e l y populated rural areas where clinic services are remote or
n o n - e x i s t e n t . U n d e r t h e Maternity Services (Scotland) A c t , 1937, m a n y of the
authorities are d e p e n d e n t o n t h e D i s t r i c t N u r s e s for their m i d w i f e services. In
respect of these v a r i o u s s t a t u t o r y services, t h e D i s t r i c t Nursing A s s o c i a t i o n s are
subsidised b y t h e local authorities c o n c e r n e d .
T h e H e a l t h of t h e S c h o o l Child.
T h e first step t a k e n in this field w a s t h e a p p o i n t m e n t i n 1902 of t h e R o y a l
C o m m i s s i o n on P h y s i c a l Training (Scotland) to inquire into t h e p h y s i c a l condition
of school children. T h e Commission f o u n d t h a t data on t h e subject hardly
e x i s t e d , b u t t h a t a r m y recruiting returns s h o w e d a d i s q u i e t i n g p r o p o r t i o n of unfit
applicants for m i l i t a r y service. After a m e d i c a l e x a m i n a t i o n of 1,200 children
i n A b e r d e e n a n d E d i n b u r g h , t h e C o m m i s s i o n r e c o m m e n d e d t h a t s c h o o l boards
s h o u l d undertake t h e m e d i c a l i n s p e c t i o n of s c h o o l children a n d record t h e results.
T h i s finding w a s e m p h a s i s e d b y t h e I n t e r d e p a r t m e n t a l C o m m i t t e e o n Physical
Deterioration in 1904.
F o u r years later t h e E d u c a t i o n (Scotland) A c t , 1908,
p r o v i d e d for t h e m e d i c a l e x a m i n a t i o n and supervision of all school children, and
a u t h o r i s e d school boards t o e m p l o y doctors and nurses for t h e p u r p o s e .
This w a s followed b y the passing of t h e E d u c a t i o n (Scotland) A c t , 1913, which
e m p o w e r e d s c h o o l boards t o provide for t h e medical t r e a t m e n t of children of
n e c e s s i t o u s p a r e n t s . More recently, t h e E d u c a t i o n (Scotland) A c t , 1942, in effect
places a d u t y o n e d u c a t i o n a u t h o r i t i e s to arrange for t h e medical t r e a t m e n t of
a n y s c h o o l child w h o is unable, for t h e lack of t r e a t m e n t , t o t a k e full advantage
of t h e e d u c a t i o n p r o v i d e d .
A s already' i n d i c a t e d , the local a u t h o r i t i e s for school h e a l t h a d m i n i s t r a t i o n axe
t h e 31 c o u n t y c o u n c i l s and t h e t o w n councils of the four cities of Glasgow. Edin­
burgh, D u n d e e and Aberdeen, w h i c h c o n s t i t u t e t h e 35 e d u c a t i o n authorities of
Scotland. Central responsibility rests "With t h e Secretary of S t a t e w h o exercises
h i s functions t h r o u g h t h e D e p a r t m e n t of H e a l t h for S c o t l a n d .
T h e H i g h l a n d a n d I s l a n d s (Medical Service) S c h e m e .
T h e H i g h l a n d s a n d Islands area i s t h e o n l y p a r t of S c o t l a n d — a n d for that
m a t t e r t h e o n l y part of t h e U n i t e d K i n g d o m — i n w h i c h a n a t t e m p t h a s been made
t o organise a c o m p l e t e m e d i c a l service available t o all classes. T h e keystone oi
this structure is the H i g h l a n d s a n d I s l a n d s Medical Service, a unique effort in
co-operation b e t w e e n t h e S t a t e and d o c t o r s in p r i v a t e general practice, which has
revolutionised m e d i c a l provision in t h e area. A S u b - C o m m i t t e e of t h e Scottish
H e a l t h S e r v i c e s C o m m i t t e e , reporting in 1936 o n t h e s u i t a b i l i t y of t h e Service to
the peculiar c o n d i t i o n s of t h e H i g h l a n d s a n d I s l a n d s , suggested t h a t i t m i g h t even
provide a m o d e l on w h i c h t o build t h e future m e d i c a l service in Scotland as a
whole. N o w t h a t t h e t i m e is c o m e t o consider t h i s larger issue t h e Highlands and
Islands Medical Service is of special interest a n d worth e x a m i n i n g .
T h e Medical S e r v i c e w a s s e t u p f o l l o w i n g t h e i n v e s t i g a t i o n of t h e D e w a r Com­
mittee w h o reported i n 1912 t h a t o n a c c o u n t of t h e sparseness of t h e population in
s o m e districts, its irregular distribution in others, t h e configuration of t h e country
and t h e climatic c o n d i t i o n s , m e d i c a l a t t e n d a n c e w a s u n c e r t a i n for t h e people,
e x c e p t i o n a l l y o n e r o u s or e v e n hazardous for t h e doctor a n d generally inadequate.
T h e C o m m i t t e e also reported t h a t t h e straitened c i r c u m s t a n c e s of t h e people pre­
cluded t h e a d e q u a t e p a y m e n t of d o c t o r s b y fees alone.
T h e result was the
passing of t h e H i g h l a n d s and I s l a n d s (Medical Service) G r a n t A c t , 1913, which
constituted t h e H i g h l a n d s and I s l a n d s Medical Service F u n d , a n n u a l l y replenished
b y P a r l i a m e n t , for the- p u r p o s e . of providing a n d i m p r o v i n g m e a n s for the pre­
vention, t r e a t m e n t a n d alleviation of illness a n d suffering in t h e area. T h e Fund.
administered b y t h e D e p a r t m e n t of H e a l t h for S c o t l a n d .
1 S
The area covered b y t h e operations of the Medical Service comprises t h e seven
counties of Argyll, Caithness, I n v e r n e s s (excluding t h e burgh of I n v e r n e s s ) , Ross
and Cromarty, S u t h e r l a n d , Orkney a n d Zetland, a n d t h e H i g h l a n d District of
Perthshire. T h i s area covers more t h a n half t h e l a n d surface "of Scotland but
contains less t h a n one-fifteenth of t h e total p o p u l a t i o n .
A single v i s i t in t h e H i g h l a n d s a n d Islands m a y i n v o l v e a d o c t o r i n a journey
of m a n y miles l a s t i n g s o m e hours. F e e s w h i c h w o u l d a d e q u a t e l y r e c o m p e n s e the
doctor in t h e s e circumstances w o u l d be b e y o n d t h e m e a n s of all b u t a f e w of the
population. T h e basis of t h e Medical Service, therefore, is t h a t i t s h o u l d provide
medical attendance t o beneficiaries a t uniform fees irrespective o f t h e d i s t a n c e
which t h e d o c t o r m a y h a v e t o travel. This is secured b y p a y i n g grants to the
doctor to c o m p e n s a t e h i m for h i s travelling a n d h i s t i m e , in return for which
he undertakes t o a t t e n d t o h i s p a t i e n t s a t modified fees. T h i s modified fee system
applies to t h e families a n d d e p e n d a n t s of insured persons, uninsured persons of
the crofter a n d cottar classes, a n d others i n like c i r c u m s t a n c e s w h o could not
otherwise p a y for their m e d i c a l a t t e n d a n c e . T h e s e a r r a n g e m e n t s h a v e led to an
enormous increase in t h e n u m b e r of visits p a i d t o beneficiaries. W h e r e the grant
payable on t h e basis of m i l e a g e travelled w o u l d n o t p r o v i d e t h e d o c t o r with an
adequate i n c o m e , t h e p a y m e n t s o u t of t h e F u n d are calculated w i t h reference t o
the n e t i n c o m e of t h e practice s o a s t o p r o v i d e t h e d o c t o r w i t h a reasonable
living. This applies in 23 o u t of a t o t a l of 153 subsidised practices. The doctor's
income is, of course, n o t derived w h o l l y from t h e F u n d . B u t w h a t i s received
from t h i s source is u s u a l l y a substantial s u p p l e m e n t t o his other sources of income
N a t i o n a l H e a l t h I n s u r a n c e c a p i t a t i o n fees, p a y m e n t s f r o m t h e C o u n t y C o u n c i l
for public a p p o i n t m e n t s , a n d fees from p r i v a t e p a t i e n t s .
The Medical Service is p r o v i d e d i n c o n s u l t a t i o n w i t h t h e C o u n t y Councils in the
area, b u t t h e c o n t r a c t t a k e s t h e form of a n a g r e e m e n t entered i n t o d i r e c t l y b e t w e e n
the doctor a n d t h e D e p a r t m e n t . O n "a v a c a n c y arising i n a single-doctor area
the C o u n t y Council advertises for a local m e d i c a l officer t o u n d e r t a k e public
assistance, school i n s p e c t i o n a n d tuberculosis work.
T h e D e p a r t m e n t then con­
sider w h e t h e r t h e y are prepared t o enter i n t o a n a g r e e m e n t for Medical Service
work w i t h t h e doctor w h o m t h e C o u n t y Council propose t o a p p o i n t . I n areas with
more t h a n o n e doctor, t h e n e w doctor m a y receive n o p u b l i c a p p o i n t m e n t and
the D e p a r t m e n t conclude their a g r e e m e n t w i t h h i m i n d e p e n d e n t l y o f t h e County
Council. I t is a condition of each a g r e e m e n t t h a t t h e d o c t o r uses a car for the
purposes of his practice.The D e p a r t m e n t d o n o t exercise a n y detailed control over t h e doctor's services:
there i s no interference w h a t e v e r w i t h h i s professional p r a c t i c e . Medical officers
011 t h e D e p a r t m e n t ' s staff v i s i t doctors in t h e area periodically t o smooth out
difficulties a n d t o k e e p t h e D e p a r t m e n t generally in c o n t a c t w i t h t h e administra­
tion a n d d e v e l o p m e n t of t h e Service.
T h i s m e t h o d of c e n t r a l administra­
tion, free from restrictive c o n d i t i o n s a n d a n y t h i n g r e s e m b l i n g v e x a t i o u s control,
has proved a n o u t s t a n d i n g s u c c e s s : i t h a s satisfied t h e D e p a r t m e n f s reasonable
requirements a n d is a c c e p t a b l e t o t h e doctors.
Special arrangements are m a d e t o provide t h e d o c t o r s w i t h holiday reliefs and
with o p p o r t u n t i e s for post-graduate s t u d y . T h e F u n d also assists in the building
of doctors' h o u s e s a n d i n t h e i m p r o v e m e n t of e x i s t i n g h o u s e s .
But t h e t e s t of the Medical S e r v i c e is primarily n o t w h a t i t d o e s for the doctor
- a n d i t does m u c h for h i m — b u t w h a t i t does for t h e p a t i e n t . The answer here
is clear. T h e " quite i n a d e q u a t e " general m e d i c a l service, described by the
Dewar C o m m i t t e e i n 1912, is a t h i n g of t h e p a s t a n d i n e v e r y district in the
Highlands a n d I s l a n d s t h e services of a d o c t o r are a v a i l a b l e o n r e a s o n a b l e terms.
And t h e doctors w h i c h t h e Medical Service a t t r a c t s are generally of a better type
than s o m e t h a t were t o b e f o u n d in t h e area before.
A similar i m p r o v e m e n t h a s b e e n effected i n t h e nursing service. This was
lamentably deficient before 1912, partly b e c a u s e of t h e difficulties of travel in the
area, and partly b e c a u s e v o l u n t a r y effort did h o t suffice to maintain an adequate
31032
E a
service. Liberal grants are therefore m a d e o u t of t h e F u n d to district nursing
associations t o w a r d s t h e cost of e m p l o y i n g district nurses, a n d providing them
w i t h houses a n d m o t o r cars a n d cycles. There are n o w o v e r 200 nurses at work
t h r o u g h o u t t h e area, nearly double the n u m b e r w o r k i n g in 1914. A l m o s t all are
fully trained n u r s e s , a n d all are certified m i d w i v e s .
.
T h e r e h a v e b e e n d e v e l o p m e n t s b e y o n d t h e p r i m a r y essentials,' m e d i c a l and
nursing. T h e R o y a l Infirmary, Inverness, h a s been largely rebuilt (the work
being assisted b y substantial grants from t h e F u n d ) ; a n d i t n o w occupies a pre­
e m i n e n t place i n t h e h o s p i t a l resources of t h e area.
T h e L e w i s H o s p i t a l at
S t o r n o w a y h a s likewise benefited a n d , w i t h i t s latest e x t e n s i o n s , is a b l e td^ provide
a c o m p r e h e n s i v e service w h i c h o b v i a t e s t h e transfer of m a n y p a t i e n t s t o mainland
hospitals. A r r a n g e m e n t s h a v e b e e n m a d e w i t h other h o s p i t a l s for t h e employ­
m e n t of full-time qualified surgeons. T h u s grants are p a i d t o w a r d s t h e salaries
of surgeons a t t a c h e d t o hospitals a t Lerwick, K i r k w a l l , Golspie, F o r t W i l h a m ,
Additional subsidised services include a m e d i c a l consultant
Wick and Thurso.
at I n v e r n e s s , a d e n t a l service for t h e people of S k y e a n d part of t h e Outer Isles, a
massage service for Caithness and S u t h e r l a n d , a special service for t h e treatment
of tuberculosis in Zetland, L e w i s a n d S o u t h LTist, w h e r e t h e incidence of this
disease is h i g h , a n d a n ambulance service. T h e air a m b u l a n c e h a s n o w become
a familiar feature of t h e service: p a t i e n t s , in urgent n e e d of t r e a t m e n t , are flown
t o t h e G l a s g o w Infirmaries from i s l a n d s l y i n g off t h e w e s t c o a s t .
T h e a m o u n t of g r a n t s paid o u t of t h e Highlands a n d I s l a n d s (Medical Service)
F u n d for t h e v a r i o u s services during t h e y e a r ended 31st March, 1943, w a s just
under ^100,000.
A P P E N D I X B.
EARLIER DISCUSSIONS OF IMPROVED H E A L T H SERVICES A N D A N OUTLINE
OF EVENTS LEADING U P TO T H E PREPARATION OF THIS PAPER.
I t w a s recognised v e r y shortly after t h e i n c e p t i o n of m e d i c a l benefit under the
N a t i o n a l H e a l t h Insurance S c h e m e i n 1913 t h a t there w a s a strong case for
s u p p l e m e n t i n g t h e general practitioner service with a c o n s u l t a n t service. Prepara­
t i o n s for t h i s were a d v a n c e d a t t h e outbreak of t h e 1914-18 w a r . T h e war p u t an
e n d t o further progress in t h e m a t t e r , b u t towards i t s end a series of discussions
t o o k place b e t w e e n t h e N a t i o n a l H e a l t h Insurance C o m m i s s i o n e r s a n d leading
m e m b e r s of t h e m e d i c a l profession o n t h e general s u b j e c t of t h e extension of
h e a l t h services.
S h o r t l y after t h e establishment of t h e Ministry of H e a l t h in 1919, a Consultative
Council o n M e d i c a l a n d Allied S e r v i c e s w a s a p p o i n t e d b y t h e Minister under the
c h a i r m a n s h i p of L o r d D a w s o n of Perm. This b o d y w a s i n v i t e d t o consider'and
report on s c h e m e s " requisite for t h e s y s t e m a t i s e d p r o v i s i o n of such forms of
m e d i c a l a n d allied services a s should, in t h e opinion of t h e Council, be available
for t h e i n h a b i t a n t s of a g i v e n area
S p a c e d o e s n o t permit describing i n detail t h e r e c o m m e n d a t i o n s m a d e in the
v a l u a b l e report of t h i s b o d y w h i c h w a s published i n 1920, b u t t h e general con­
c e p t i o n w h i c h its a u t h o r s h a d in m i n d w a s t h a t of a c o m p r e h e n s i v e s c h e m e under
w h i c h all f o r m s of medical service w o u l d b e m a d e a v a i l a b l e , under suitable con­
ditions, t o t h e p o p u l a t i o n a t large. T h e report r e c o m m e n d e d t h e establishment
of H e a l t h A u t h o r i t i e s for local administration a n d i t c o n t e m p l a t e d , as does the
p r e s e n t Papjer, t h e co-ordination of m u n i c i p a l a n d v o l u n t a r y agencies as the
basis of t h e s c h e m e . I t is w o r t h n o t i n g t h a t t h e Council justified their recom­
m e n d a t i o n s " b e c a u s e the organisation of medicine h a s b e c o m e insufficient and
b e c a u s e i t fails t o bring t h e a d v a n t a g e s of medical k n o w l e d g e a d e q u a t e l y within
reach of t h e people " .
I n t h e s a m e y e a r (1920) a C o n s u l t a t i v e ' Council o n Medical a n d Allied Services
a p p o i n t e d b y t h e Scottish B o a r d of H e a l t h under t h e c h a i r m a n s h i p of Sir Donald
MacAlister reported o n a s o m e w h a t similar remit.
T h e i r report urged that " a
c o m p l e t e a n d a d e q u a t e m e d i c a l service s h o u l d b e b r o u g h t w i t h i n t h e reach of
e v e r y m e m b e r of t h e c o m m u n i t y . "
T h e y m a d e a n u m b e r of recommendations
designed t o ensure t h a t t h e f a m i l y doctor (on w h o m t h e organisation of the
n a t i o n ' s h e a l t h service should b e based) w o u l d be p r o v i d e d w i t h all supplementary
professional advice a n d assistance, a n d t h e y p r o p o s e d t h a t t h e S t a t e insurance
medical service should b e e x t e n d e d t o cover p e r s o n s of t h e s a m e e c o n o m i c l e v e l
as insured persons a n d d e p e n d a n t s of insured persons.
These and their other
proposals p r o v i d e d a basis for m u c h of t h e l a t e r discussion o n t h e r e q u i r e m e n t s
of a national h e a l t h s e r v i c e .
I n 1921 t h e r e w a s i s s u e d t h e report of t h e V o l u n t a r y H o s p i t a l s C o m m i t t e e
under the C h a i r m a n s h i p of Lord Cave, w h i c h h a d b e e n s e t up b y t h e Minister of
H e a l t h t o consider t h e financial p o s i t i o n of t h e v o l u n t a r y h o s p i t a l s . In, a d d i t i o n
to r e c o m m e n d i n g an e x c h e q u e r grant t o m e e t t h e i m m e d i a t e n e e d s of t h e
hospitals, t h e C o m m i t t e e proposed t h e e s t a b l i s h m e n t of p e r m a n e n t m a c h i n e r y
to co-ordinate t h e work a n d t h e finances of v o l u n t a r y h o s p i t a l s t h r o u g h o u t t h e
country. T h i s m a c h i n e r y w a s t o consist of a central V o l u n t a r y H o s p i t a l s C o m ­
mission a n d of local V o l u n t a r y H o s p i t a l s C o m m i t t e e s for c o u n t y a n d c o u n t y
borough areas. T h e report of t h e C o m m i t t e e t o u c h e d o n m a n y of t h e p r o b l e m s
with which this P a p e r is c o n c e r n e d , t h o u g h i t s s c o p e was l i m i t e d t o r e c o m m e n d a ­
tions affecting v o l u n t a r y h o s p i t a l s . T h e G o v e r n m e n t a c c e p t e d t h e findings of
the C o m m i t t e e to t h e e x t e n t of p r o v i d i n g a n e x c h e q u e r grant for t h e v o l u n t a r y
hospitals of £500,000 ( n o t £1,000,000 as t h e C o m m i t t e e h a d s u g g e s t e d ) , b u t t h e
long-term proposals of t h e C o m m i t t e e for t h e e s t a b l i s h m e n t of c o - o r d i n a t i n g
machinery were n o t carried i n t o effect.
S i x t e e n y e a r s later t h e p o s i t i o n of t h e v o l u n t a r y hospitals w a s again r e v i e w e d
by a b o d y established under t h e c h a i r m a n s h i p of L o r d S a n k e y b y t h e B r i t i s h
Hospitals A s s o c i a t i o n , a n d k n o w n a s t h e V o l u n t a r y H o s p i t a l s C o m m i s s i o n . T h e
report of t h i s b o d y , like t h a t of i t s predecessor, p r o p o s e d t h e e s t a b l i s h m e n t of
central a n d local bodies w i t h co-ordinating f u n c t i o n s a n d r e c o m m e n d e d a s y s t e m
of e x c h e q u e r grants i n a i d of t h e v o l u n t a r y h o s p i t a l s .
I n 1936 t h e report of t h e C o m m i t t e e o n S c o t t i s h H e a l t h S e r v i c e s — ( t h e C a t h c a r t
Report)—was p u b l i s h e d . T h e C o m m i t t e e r e v i e w e d t h e w h o l e of S c o t l a n d ' s h e a l t h
services, personal a n d e n v i r o n m e n t a l , a n d m a d e m a n y i m p o r t a n t r e c o m m e n d a ­
tions within a national h e a l t h p o l i c y for p r o m o t i n g t h e " fitness " of t h e p e o p l e .
The r e c o m m e n d a t i o n s of t h e report a s s u m e t h r o u g h o u t t h a t t h e s e p a r a t e m e d i c a l
services m u s t b e i n t e g r a t e d a n d t h a t a co-ordinated medical s e r v i c e s h o u l d b e
based, as far a s possible, o n t h e f a m i l y doctor. T h e report is t o o c o m p r e h e n s i v e
in scope t o lend itself t o brief q u o t a t i o n , b u t it i s o n e of t h e m o s t c o m p l e t e
official s u r v e y s of t h e c o u n t r y ' s h e a l t h services a n d h e a l t h problems y e t a t t e m p t e d .
The r e c o m m e n d a t i o n s of t h e C o m m i t t e e h a v e a l r e a d y formed t h e basis of legis­
lation in particular fields.
T h e l a t e s t official report on h o s p i t a l p r o b l e m s is t h a t recently issued b y t h e
Committee w h i c h , u n d e r t h e c h a i r m a n s h i p of Sir H e c t o r H e t h e r i n g t o n , w a s
appointed b y t h e Secretary of S t a t e t o a d v i s e o n v a r i o u s post-war h o s p i t a l prob­
lems in S c o t l a n d . T h i s report c o n t a i n s detailed r e c o m m e n d a t i o n s for t h e s e t t i n g
up of five R e g i o n a l H o s p i t a l A d v i s o r y Councils i n S c o t l a n d .
I t also makes
various s u g g e s t i o n s for i m p r o v e d co-operation b e t w e e n h o s p i t a l s a n d deals a t
length w i t h financial a r r a n g e m e n t s a s affecting t h e future v o l u n t a r y h o s p i t a l
system.
Other helpful c o n t r i b u t i o n s t o t h e s t u d y of h o s p i t a l p r o b l e m s h a v e b e e n m a d e
from t i m e t o t i m e b y m a n y other b o d i e s , i n c l u d i n g t h e British H o s p i t a l s A s s o c i a ­
tion, t h e K i n g E d w a r d ' s H o s p i t a l F u n d for L o n d o n , t h e C o n t r i b u t o r y S c h e m e s
Association a n d m o s t r e c e n t l y t h e Nuffield P r o v i n c i a l H o s p i t a l s T r u s t w h i c h h a s
combined t h e o r y w i t h p r a c t i c e in i t s w e l l - k n o w n enterprises i n p a v i n g t h e w a y
for greater local co-ordination i n t h e hospital s e r v i c e s .
Throughout t h e period b e t w e e n t h e t w o w a r s , t h e B r i t i s h Medical A s s o c i a t i o n
have been a c t i v e in f o c u s s i n g t h e m i n d of t h e m e d i c a l profession u p o n c o n s t r u c t i v e
proposals for t h e e x t e n s i o n a n d d e v e l o p m e n t of t h e e x i s t i n g h e a l t h services. I n
1030, a n d a g a i n in 1938, t h e y p u b l i s h e d , as s u p p l e m e n t s t o t h e B r i t i s h Medical
lournal, c o m p r e h e n s i v e . proposals for " A General Medical Service for t h e
Nation " , a n d i n 1942 t h e Medical P l a n n i n g C o m m i s s i o n organised b y t h e A s s o c i a ­
tion issued a draft I n t e r i m R e p o r t w h i c h offered for t h e consideration of t h e
profession far-reaching s u g g e s t i o n s for t h e i m p r o v e m e n t of t h e m e d i c a l services
of t h e c o m m u n i t y .
S a l i e n t p a s s a g e s from t h i s i m p o r t a n t d o c u m e n t are q u o t e d
in t h e b o d y of t h i s P a p e r . Other p u b l i c a t i o n s in this field of w h i c h mention
s h o u l d b e m a d e are a report issued b y a professional group k n o w n as Medical
P l a n n i n g Research a n d representing for t h e m o s t part t h e y o u n g e r elements in
t h e profession, a proposal for a N a t i o n a l H e a l t h Service b y t h e Society of
Medical -Officers of H e a l t h a n d a v a l u a b l e and m a i n l y factual report published
b y Political a n d E c o n o m i c P l a n n i n g ( P . E . P . ) in 1937. T h e s e publications, and
m a n y others t o o numerous t o b e m e n t i o n e d , h a v e been s u p p l e m e n t e d b y copious
discussion in t h e c o l u m n s of t h e professional a n d t h e l a y press.
I t is n o t possible, w i t h i n t h e limits of this d o c u m e n t , t o r e v i e w all this field
of political and professional literature, b u t it m a y b e said in v e r y general terms
t h a t t h e principles m o s t frequently recurring in t h e presentation of plans for
future d e v e l o p m e n t s are t h e following: —
(1) t h a t there should b e m a d e a v a i l a b l e t o e v e r y individual in t h e c o m m u n i t y
w h a t e v e r t y p e of medical care and t r e a t m e n t he m a y need;
(2) t h a t t h e s c h e m e of services should be a fully integrated s c h e m e and that
in particular a m u c h closer linking u p b e t w e e n general practitioner services on
t h e o n e h a n d a n d consultant and hospital services o n t h e o t h e r o u g h t t o be
achieved; and
(3) t h a t for certain services, particularly t h e hospital service, larger areas of
local a d m i n i s t r a t i o n are needed t h a n those of a n y e x i s t i n g k i n d of local
authorities.
I t is against t h i s background of constructive t h i n k i n g a n d discussion during the
last quarter of a c e n t u r y t h a t t h e proposals in t h e present P a p e r h a v e been
prepared and are p u t forward.
T h e G o v e r n m e n t a n n o u n c e d — i n October, 1941—their i n t e n t i o n t o ensure, by
m e a n s of a c o m p r e h e n s i v e hospital service, t h a t appropriate h o s p i t a l treatment
should in future b e readily available t o everyone in need of it. T h e declared
basis for this w a s t o b e a n e w d u t y upon major local authorities, in close co-opera­
tion w i t h v o l u n t a r y agencies working in t h e s a m e field, t o see t h a t a full hospital
service, of every necessary kind, w a s m a d e universally a v a i l a b l e ; i t w a s expressly
recognised t h a t t h i s w o u l d m e a n designing t h e service o v e r a r e a s larger t h a n those
of m o s t of t h e existing local authorities and t h a t t h e full u s e of t h e powerful
resources of t h e v o l u n t a r y hospitals, w h i l e p u t t i n g their relations w i t h t h e local
authorities on a more regular footing, w o u l d b e of t h e essence of t h e scheme. To
p a v e t h e w a y a detailed a n d e x p e r t s u r v e y was started o n t h e Minister of Health'?
behalf—partly conducted directly b y t h e Ministry and p a r t l y organised for the
Minister b y t h e NufBeld Provincial H o s p i t a l s T r u s t — o f t h e hospital services
already available in each area in E n g l a n d and W a l e s .
T h i s s u r v e y is now
nearing its c o m p l e t i o n .
So also is a similar s u r v e y in S c o t l a n d , instituted
by t h e Secretary of S t a t e .
1
T h e n , more recently, t h e report of S i r W i l l i a m B e v e r i d g e h a v i n g t a k e n as one
of t h e bases of its proposals t h e assumption t h a t a c o m p r e h e n s i v e national health
service, for all purposes a n d for all p e o p l e , w o u l d b e e s t a b l i s h e d , t h e Government
a n n o u n c e d in F e b r u a r y , rg43, t h a t t h e y also a c c e p t e d this a s s u m p t i o n .
T h e H e a l t h Ministers thereupon a p p r o a c h e d t h e medical profession, the volun­
tary hospitals and t h e major local g o v e r n m e n t authorities, from each of whom
t h e y w a n t e d — o n a proposal of t h i s m a g n i t u d e - t o obtain all possible help and
expert guidance from t h e o u t s e t . I t w a s arranged w i t h t h e m t h a t , for the first
stage, t h e y should a p p o i n t small g r o u p s of representatives of their o w n choice
and t h a t these groups should take part in general preliminary discussions.
T h e p r o g r a m m e w a s t h a t there w o u l d need t o b e three s t a g e s in t h e evolution
of t h e G o v e r n m e n t s proposals.
T h e r e would b e a first stage, in w h i c h a preliminary e x c h a n g e of ideas would
be c o n d u c t e d informally a n d confidentially and w i t h o u t c o m m i t m e n t on either
s i d e — t o enable t h e Ministers t o g e t a general impression of t h e feeling of these
representatives o n s o m e of t h e main issues i n v o l v e d a n d t o h e l p t h e m t o clear the
ground.
T h i s second stage would b e one of public discussion in P a r l i a m e n t and else­
where.
I t w o u l d b e t h e stage a t w h i c h e v e r y b o d y — t h e p u b l i c generally, for
whom the service w o u l d b e d e s i g n e d , t h e doctors a n d t h e hospitals a n d t h e
local authorities a n d other organisations w h i c h w o u l d be concerned in i t or
affected b y it, a n d t h o s e m e n a n d w o m e n (including doctors) w h o are n o w
engaged in t h e A r m e d F o r c e s — w o u l d b e a b l e t o discuss w h a t w a s proposed and
to voice their o p i n i o n s a b o u t it. T o assist i n t h i s t h e G o v e r n m e n t w o u l d issue a
White P a p e r w h i c h w o u l d serve a s a focus for detailed discussion.
The third s t a g e w o u l d t h e n b e one in w h i c h t h e G o v e r n m e n t w o u l d settle
what e x a c t p r o p o s a l s t h e y w o u l d s u b m i t i n legislative form for t h e decision of
Parliament.
For t h e first s t a g e t h e representative groups were duly formed.
In E n g l a n d
and Wales, for t h e medical profession t h e B r i t i s h Medical Association, in collabora­
tion with t h e R o y a l Colleges, b r o u g h t t o g e t h e r a representative group of m e d i c a l
men and w o m e n .
F o r t h e v o l u n t a r y h o s p i t a l s r e p r e s e n t a t i v e s of the B r i t i s h
Hospitals A s s o c i a t i o n a n d t h e K i n g E d w a r d ' s H o s p i t a l F u n d for L o n d o n , w i t h
representatives of t h e Nuffield P r o v i n c i a l H o s p i t a l s T r u s t joining as observers,
together formed a g r o u p . F o r t h e m a j o r local g o v e r n m e n t a u t h o r i t i e s the C o u n t y
Councils A s s o c i a t i o n , t h e A s s o c i a t i o n of Municipal Corporations and t h e L o n d o n
County Council c o m b i n e d t o f o r m t h e third group.
Separate a r r a n g e m e n t s were m a d e b y t h e Secretary of S t a t e for S c o t l a n d for
discussions w i t h r e p r e s e n t a t i v e s of t h e m e d i c a l profession in S c o t l a n d , the S c o t t i s h
local a u t h o r i t y a s s o c i a t i o n s a n d t h e S c o t t i s h B r a n c h of t h e B r i t i s h H o s p i t a l s
Association. T h e s e separate discussions t o o k a c c o u n t of S c o t t i s h experience a n d
of geographical, a d m i n i s t r a t i v e a n d o t h e r differences.
Discussions t o o k place w i t h e a c h group o n t h o s e a s p e c t s of a c o m p r e h e n s i v e
service w h i c h m o s t a f f e c t e d . 4 h e m .
F o r t h e purpose of discussion t h e Ministers
offered to e a c h g r o u p — i n m e m o r a n d a a n d o r a l l y — a series of s u g g e s t i o n s a n d
ideas for t h e m t o consider. T h e y m a d e it clear t h r o u g h o u t t h a t t h e y w e l c o m e d
criticism and a l t e r n a t i v e s u g g e s t i o n s a n d w e r e n o t a t a n y s t a g e confronting a n y
of the groups w i t h a p r e d e t e r m i n e d s c h e m e .
T h e y received suggestions from
t h e groups o n m a n y of t h e s u b j e c t s i n v o l v e d , a n d discussion from t h e o u t s e t w a s
on the frankest basis.
I n e v i t a b l y there w a s d i v e r g e n c e of opinion on s o m e of
the issues i n v o l v e d , w h i c h each g r o u p a p p r o a c h e d from a different b a c k g r o u n d of
experience a n d opinion, b u t t h e discussions were useful as a preliminary s o u n d i n g
of the e x p e r t v i e w .
The present W h i t e P a p e r does n o t purport t o s u m up t h e discussions w h i c h
have t a k e n p l a c e , or t o reflect a n y a g r e e m e n t or represent a n y v i e w s r e a c h e d
in these discussions. T h a t w o u l d be i n c o n s i s t e n t w i t h t h e terms o n w h i c h t h e
discussion w e r e u n d e r t a k e n .
APPENDIX C.
POSSIBLE METHODS OF SECURING LOCAL ADMINISTRATION OVER LARGER
AREAS THAN THOSE OF PRESENT LOCAL GOVERNMENT.
On t h e a s s u m p t i o n t h a t for certain a s p e c t s of t h e h e a l t h service, particularly
the hospital s e r v i c e , there is n e e d for larger areas of local administration t h a n
exist for t h e s e purposes n o w , and t h a t t h e b o d y responsible for t h e a d m i n i s t r a t i o n
must be r e p r e s e n t a t i v e of and a n s w e r a b l e t o t h e electors of t h e area, t h e r e are,
broadly speaking, three possible c o u r s e s : —­
( i ) t o e s t a b l i s h a directly e l e c t e d b o d y for t h e sole purpose of administer­
ing t h e s e p a r t s of t h e h e a l t h service;
(2) t o e s t a b l i s h a directly e l e c t e d b o d y for t h e p u r p o s e of a d m i n i s t e r i n g a
group of s e r v i c e s including t h e s e p a r t s of t h e h e a l t h service;
(3) t o secure joint action b y t h e c o u n c i l s of t h e e x i s t i n g c o u n t i e s and c o u n t y
boroughs w h i c h m a k e u p t h e p r o p o s e d area of a d m i n i s t r a t i o n .
T h e creation of a directly e l e c t e d local a u t h o r i t y for s o m e particular p u r p o s e
would run c o u n t e r to m o d e r n d e v e l o p m e n t s in local g o v e r n m e n t , which h a v e
been towards replacing t h e s y s t e m of special a u t h o r i t i e s for t h e a d m i n i s t r a t i o n of
particular services (such as B o a r d s of Guardians a n d S c h o o l Boards) b y t h e
system of a u t h o r i t i e s c o v e r i n g a w i d e range of f u n c t i o n s . B u t , a p a r t from t h a t
ye t h e process of electing a one-purpose authority operating over a fairly large area
is not likely t o arouse sufficient public interest t o a t t r a c t an adequate proportion
of local voters t o t h e poll. Moreover, t h e s y s t e m — i f generalised o v e r all the
social services locally a d m i n i s t e r e d — w o u l d create an impossible c o m p l e x i t y of
separate authorities for separate local administrative functions, each requiring
separate local election, each operating over a different area, and each requiring
s e p a r a t e a r r a n g e m e n t s for r a t i n g or precepting in order t o o b t a i n its local revenue.
A n a l t e r n a t i v e s u g g e s t i o n , of establishing n e w local authorities o v e r wider
areas for a s u b s t a n t i a l g r o u p of local services, h a s been canvassed i n recent
years. F o r instance, a proposal for comprising i n a single local administrative
area t h e c o u n t y of N o r t h u m b e r l a n d , part of t h e c o u n t y of D u r h a m , a n d four
c o u n t y boroughs l y i n g on either side of t h e T y n e , w a s m a d e in t h e Majority
R e p o r t of t h e R o y a l C o m m i s s i o n on Local G o v e r n m e n t in t h e T y n e s i d e Area
(1937) a n d i t w a s r e c o m m e n d e d t h a t six of t h e m a j o r local g o v e r n m e n t services
— P u b l i c H e a l t h (Medical a n d Allied Services), E d u c a t i o n , P u b l i c Assistance,
Police, Fire B r i g a d e s , a n d H i g h w a y s — s h o u l d be a d m i n i s t e r e d b y a b o d y with
jurisdiction over t h e w h o l e of t h i s area. P r o p o s a l s of a similar kind h a v e been
m a d e i n various quarters since t h e outbreak of t h e present war.
A n a u t h o r i t y performing so m a n y i m p o r t a n t f u n c t i o n s w o u l d n e e d t o be
directly elected. B u t its e s t a b l i s h m e n t would i n v o l v e a major alteration of the
structure of local g o v e r n m e n t . I t would deprive c o u n t y councils of practically
all t h e i r chief functions—if, i n d e e d , t h e few minor functions left could b e held t o
justify their c o n t i n u e d e x i s t e n c e a t all; and it w o u l d s o denude c o u n t y borough
c o u n c i l s of t h e i r p o w e r s as t o l e a v e t h e m w i t h functions i n some respects less than
t h o s e of t h e " m i n o r a u t h o r i t i e s " of t o - d a y . R e c e n t p u b l i c a t i o n s of t h e various
local g o v e r n m e n t a s s o c i a t i o n s a n d other b o d i e s h a v e s h o w n t h a t there i s a wide
d i v e r g e n c e of v i e w as t o t h e future pattern of local g o v e r n m e n t . I t is clear that
t h i s m u s t b e t h e s u b j e c t of a c o m p r e h e n s i v e inquiry, w h i c h could n o t b e insti­
t u t e d under present c o n d i t i o n s or completed in a s h o r t t i m e . S e t t l e m e n t of the
m a c h i n e r y of t h e n e w h e a l t h service c a n n o t a w a i t t h e conclusions of such an
i n q u i r y a n d t h e passing of a n y consequent legislation.
T h e o n l y practical c o u r s e — p e n d i n g a general r e v i e w of local g o v e r n m e n t — i s to
u s e t h e present m a c h i n e r y a n d t h e existing facilities for securing s u c h com­
b i n a t i o n s of a u t h o r i t i e s as m a y b e necessary. T h i s m e a n s t h e application (and
p o s s i b l y s o m e a d a p t a t i o n ) of t h e well-established practice of securing larger
administrative units b y joint action.
T h e a d v a n t a g e s a n d d i s a d v a n t a g e s of a d m i n i s t e r i n g particular services by
c o m b i n a t i o n s of local authorities organised a s joint b o a r d s h a v e often b e e n argued.
T h e m e m b e r s of t h e T y n e s i d e Commission, referred t o a b o v e , differed on the
p o i n t , t h e m a j o r i t y regarding t h e joint board s y s t e m a s " u n d e m o c r a t i c ", the
s i g n a t o r y of t h e m i n o r i t y report t a k i n g t h e o p p o s i t e v i e w a n d r e c o m m e n d i n g the
e x t e n s i o n of t h e s y s t e m a s going a considerable w a y t o m e e t t h e problems with
w h i c h t h a t area w a s f a c e d .
T h e general c o n v e n i e n c e of arrangements which
m a k e it possible t o h a v e a n area of administration e x a c t l y appropriate t o any
particular service, a n d t o s e t u p a n a u t h o r i t y for t h a t area, chosen b y persons
w h o are t h e m s e l v e s direct representatives of t h e local electorate, c a n n o t be
d e n i e d . B u t it is true t h a t t h e system, if c o m p l e t e l y generalised, w o u l d leave
t h e c o n s t i t u e n t local a u t h o r i t i e s w h o choose t h e m e m b e r s of t h e boards with
little t o d o b e y o n d n o m i n a t i n g t h o s e members, i n s t e a d of administering services
themselves.
O t h e r objections are o f t e n a d v a n c e d . I t is said t h a t j o i n t boards t e n d t o attract
t h e m o r e elderly a n d less effective members of t h e c o n s t i t u e n t councils, and that
their efficiency is t h e r e b y d i m i n i s h e d . T h i s is a m a t t e r of impression. I t may
be t h a t , e v e n if i t is true, i t is d u e n o t t o t h e n a t u r e of joint boards b u t t o the
s u b j e c t m a t t e r s w i t h w h i c h t h e y h a p p e n t o d e a l . A joint board administering
(say) a n infectious diseases hospital or a sewage disposal s y s t e m — a l t h o u g h its
a c t i v i t i e s m a y b e n o t less essential t o t h e public w e l f a r e — m a y well attract less
interest t h a n w o u l d b e t a k e n i n housing or e d u c a t i o n , t w o subjects w h i c h excite­
t h e k e e n e s t interest a m o n g local administrators. I n a n y case, t h i s particular
w e a k n e s s of t h e j o i n t b o a r d . s y s t e m , if it exists, i s one for w h i c h t h e r e m e d y lies
in t h e h a n d s of local a u t h o r i t i e s t h e m s e l v e s .
Another c o m m o n criticism is t h a t t h e powerful w e a p o n of p r e c e p t i n g o n
constituent authorities for funds w e a k e n s ,a joint b o a r d ' s s e n s e of financial
responsibility; or—to p u t it a n o t h e r w a y — t h a t t h e m e m b e r s of a joint board,
being indirectly elected and therefore a t t w o r e m o v e s from t h e r a t e p a y e r s , h a v e
not t h e same need t o justify policy t o their supporters a s t h e m e m b e r s of a
directly elected a u t h o r i t y . T h e r e m a y be s o m e t h i n g in t h i s , b u t it i s a p o i n t
which could b e m e t , e.g., b y requiring t h e joint a u t h o r i t y t o s u b m i t t o i t s
constituent councils (at intervals of, s a y , o n e or t w o or t h r e e years) e s t i m a t e s
of their proposed expenditure, for t h e a p p r o v a l of a l l — o r of a specific m a j o r i t y —
of those councils.
S o m e m e a n s of r e m o v i n g d e a d l o c k s ( p r o b a b l y b y w a y of
arbitral p o w e r s v e s t e d i n t h e appropriate Minister) w o u l d be n e e d e d , unless a
majority decision were t o be b i n d i n g . This d e v i c e , c o u p l e d w i t h a more regular
habit a m o n g t h e c o n s t i t u e n t councils of e x a m i n i n g , and if n e c e s s a r y debating, t h e
annual and other reports of t h e joint board, w o u l d g o a l o n g w a y t o preserve
a proper relation of t h e board t o its c o n s t i t u e n t councils a n d t h e electors.
I t is also said t h a t t h e j o i n t board s y s t e m is b a d in t h a t it separates t h e
services entrusted to it from t h e rest of the m a i n m a c h i n e r y of l o c a l g o v e r n m e n t .
So far as t h e h e a l t h service is concerned, t h e answer is t h e practical o n e — t h a t
the n e e d t o s e t t l e areas of proper size and resources for certain aspects of t h e
service is urgent, a n d t h a t (temporarily at least) t h e j o i n t b o a r d s e e m s to b e t h e
only practicable m e a n s of doing t h i s . There n e e d b e n o q u e s t i o n of ruling o u t
any wider d e v e l o p m e n t of local g o v e r n m e n t w h i c h m a y later e m e r g e , a s the need
for new services and e x t e n s i o n s of existing services reveals itself. B u t t h a t is a
matter of long-term policy, for w h i c h t h e e s t a b l i s h m e n t of a c o m p r e h e n s i v e
health service c a n n o t b e d e l a y e d .
APPENDIX
D.
REMUNERATION OF GENERAL
PRACTITIONERS.
The N a t i o n a l Insurance A c t of 1911 did n o t itself l a y d o w n a n y m e t h o d b y
which t h e d o c t o r s t a k i n g part i n t h e service were t o be r e m u n e r a t e d , nor did it fix
the a m o u n t of t h e remuneration. T h e former h a s from t h e o u t s e t b e e n prescribed
by regulation, t h e latter n e g o t i a t e d b e t w e e n t h e G o v e r n m e n t a n d the profession
or on s o m e occasions d e t e r m i n e d b y arbitration.
F o r t h e former, t h e Medical
Benefit R e g u l a t i o n s h a v e from t h e start envisaged t w o s y s t e m s — o n e b y w a y of a
capitation fee for each person for w h o m t h e d o c t o r h a d a c c e p t e d responsibility,
and t h e other b y w a y of fees for services a c t u a l l y rendered. P r o v i s i o n is m a d e
for combinations and v a r i a n t s of these t w o s y s t e m s , b u t w i t h certain minor e x c e p ­
tions t h e capitation fee q u i c k l y b e c a m e universal, chiefly o w i n g t o t h e difficulty
of checking over-attendance u n d e r t h e other s y s t e m .
So l o n g as p a y m e n t s for insurance work r e m a i n e d a part o n l y — a n d in m a n y
cases n o t t h e major part—of a d o c t o r i s professional i n c o m e , i t w a s difficult t o find
any rational criterion o n w h i c h t o arrive a t a n appropriate c a p i t a t i o n fee other
than b y reference t o previous fees—i.e., b y t h e l i m i t e d m e t h o d of d e c i d i n g w h e t h e r
any events occurring since t h e previous fee w a s fixed were s u c h a s t o justify i t s
further alteration. I t is well k n o w n t h a t t h e original s u m fixed in 1912 h a d
regard t o t h e practice of F r i e n d l y Societies and Medical Clubs, a n d t h a t all
subsequent s u m s h a v e been b u i l t u p from t h a t basis. B u t it m u s t b e e x p e c t e d
that in future t h e b u l k of general practitioners will l o o k t o t h e n e w service for
the whole, or s u b s t a n t i a l l y t h e w h o l e , of t h e i r professional earnings.
Hence,
whatever m e t h o d s of p a y m e n t are a d o p t e d — w h e t h e r b y c a p i t a t i o n fees, b y salary,
or in s o m e o t h e r w a y — t h e s u b s t a n t i a l q u e s t i o n a t issue m u s t b e seen in a n e w
light. I t m u s t be s e e n as t h e q u e s t i o n of w h a t is on ordinary professional
standards a reasonable and proper r e m u n e r a t i o n for t h e w h o l e - t i m e services
of a general practitioner w o r k i n g in a p u b l i c service. W h e t h e r t h i s s h o u l d
be worked o u t in terms of gross or n e t earnings, w h e t h e r s u p e r a n n u a t i o n rights
are t o be a s s u m e d a n d t a k e n into a c c o u n t , w h a t a d j u s t m e n t s are t o b e
made for p a r t - t i m e w o r k , are m a t t e r s of c o m p a r a t i v e detail. W h e n once t h e
main figures h a v e been satisfactorily settled, n o t o n l y r e m u n e r a t i o n b y capitation
fee but remuneration under t h e salaried or part-salaried s y s t e m s c o u l d be easily
determined.
As t h e "White P a p e r m a k e s clear, t h e G o v e r n m e n t d o n o t c o n t e m p l a t e the
introduction of a universal salaried s y s t e m , b u t t h e y propose t h a t doctors taking
part in t h e p u b l i c service should b e remunerated on a basis of salaries or the
e q u i v a l e n t in a n y part o t t h e service in w h i c h this form of p a y m e n t is necessary
t o efficiency.
T h e y c o n t e m p l a t e also t h a t it m a y be possible in certain other
cases t o offer remuneration b y salary where the individual doctors concerned
would prefer such a n a r r a n g e m e n t . I n a n y e v e n t , w h e t h e r p a y m e n t is on a
salaried o r part-salaried s y s t e m or on a basis of c a p i t a t i o n fees, t w o principles
will h a v e to b e observed in t h e a r r a n g e m e n t s m a d e .
First, t h e doctors taking
part in t h e s c h e m e m u s t be assured of an a d e q u a t e a n d appropriate income.
Second, t h e a i m m u s t b e t o a c h i e v e a s y s t e m flexible e n o u g h t o allow for proper
variations attributable t o extra qualifications and extra energy a n d interest, as
well as representing the reasonable a n d normal e x p e c t a t i o n s of general practice
at all its s t a g e s .
T h e G o v e r n m e n t fully recognise t h e i m p o r t a n c e , and t h e u r g e n c y from a pro­
fessional p o i n t of v i e w , of r e a c h i n g an understanding o n t h e s e crucial matters,
and t h e y will b e ready t o discuss t h e m in detail w i t h t h e p r o f e s s i o n ^ representa
tives.
APPENDIX E.
FINANCE
O F THE
ENGLAND
AND
NEW
SERVICE.
WALES.
F i n a n c i a l q u e s t i o n s were i n c l u d e d in the discussions held w i t h t h e interested
bodies before t h e p r e s e n t W h i t e P a p e r w a s issued, and are referred t o in various
places in the P a p e r .
This A p p e n d i x sets o u t t h e general lines o n w h i c h the
G o v e r n m e n t t h i n k t h a t a reasonable financial basis could be found for the scheme
outlined in t h e Paper, and c o v e r s t h e suggested financial responsibility of the
m a i n agencies i n v o l v e d . This basis is s u g g e s t e d as b e i n g appropriate t o t h e early
years of the s c h e m e .
W h e n o n c e t h e service is well e s t a b l i s h e d some, simpler
basis u n r e l a t e d t o t h e e x p e n d i t u r e of individual authorities m a y b e considered.
F u r t h e r i t will be appreciated t h a t a n y e s t i m a t e s of cost m a d e at t h e m o m e n t can
o n l y b e conjectural, a n d it will n o t b e possible t o m a k e b e t t e r e s t i m a t e s until
t h e n e w s c h e m e is nearing i t s final s h a p e , and t h e necessary discussions and
n e g o t i a t i o n s w i t h t h e interested p a r t i e s h a v e m a d e progress.
Responsibilities of Local Authorities.
T h e s c h e m e o u t l i n e d in t h e W h i t e P a p e r c o n t e m p l a t e s t h a t a n e w joint
a u t h o r i t y will b e responsible for t h e h o s p i t a l and c o n s u l t a n t services. T h e new
a u t h o r i t y will also h a v e t h e d u t y of preparing and s u b m i t t i n g t o t h e Minister a
plan for the w h o l e h e a l t h service of i t s area and i t is p r o p o s e d t h a t t h i s plan,
taking a l l t h e local c i r c u m s t a n c e s i n t o a c c o u n t , s h o u l d d e t e r m i n e precisely how
responsibility for t h e remaining services s h o u l d b e a l l o c a t e d .
I t is proposed,
h o w e v e r , t h a t child welfare responsibilities s h o u l d a l w a y s b e entrusted to the
a u t h o r i t y w h i c h is also the local e d u c a t i o n a u t h o r i t y , t h e precise arrangements
t o be m a d e b e i n g g o v e r n e d b y t h e p r o v i s i o n s of t h e current E d u c a t i o n Bill as
finally a p p r o v e d b y P a r l i a m e n t .
T h e i n t e n t i o n a s regards other local services
is t h a t t h o s e w h i c h are essentially c o n s u l t a n t services a n d t h u s closely linked
with h o s p i t a l administration s h o u l d b e the responsibility of t h e n e w joint autho­
rities, a n d t h o s e w h i c h b e l o n g more t o t h e sphere of general h e a l t h care should
be t h e responsibility of c o u n t y a n d c o u n t y b o r o u g h councils.
T h e principal n e w h e a l t h services w h i c h will h a v e t o be set u p if t h e White
Paper s c h e m e is a d o p t e d are h o m e nursing, t h e provision of H e a l t h Centres and
n e w d e n t a l a n d o p h t h a l m i c services. I n t h e case of t h e s e n e w services, as in the
case of e x i s t i n g services, there will b e need for flexibility a n d it is contemplated
t h a t t h e final allocation of responsibility will b e a m a t t e r for t h e area plan.
It is a s s u m e d , h o w e v e r , t h a t ordinarily responsibility for t h e provision of Health
Centres and for t h e h o m e nursing service will be assigned t o c o u n t y and county
borough councils. B u t no a s s u m p t i o n can be m a d e regarding t h e other two
services. T h e shape of t h e n e w d e n t a l and o p h t h a l m i c s e r v i c e s c a n n o t be foreseen
until t h e report of t h e T e v i o t C o m m i t t e e o n t h e former h a s b e e n received and
discussions on b o t h h a v e t a k e n place w i t h t h e interests concerned. I t is conse­
quently impossible t o s a y a t t h i s stage w h e t h e r t h e w h o l e or a part of t h e s e
two services will be administered b y local authorities or, if so, w h i c h authorities
should be m a d e responsible for t h e m .
For t h e purpose of framing a n e s t i m a t e of t h e c o s t of t h e n e w h e a l t h service
as a whole h o w e v e r , it is i m m a t e r i a l t o k n o w precisely h o w responsibility for
different p a r t s of t h e service will b e allocated a m o n g t h e v a r i o u s local a u t h o r i t i e s
or t o a central organisation. T h e h y p o t h e s i s o n w h i c h t h e figures g i v e n b e l o w
are based m u s t n o t therefore be read t o i m p l y t h a t d e c i s i o n s h a v e b e e n t a k e n o n
any questions of allocation of responsibility w h i c h are left open in t h e W h i t e
Paper. T h e h y p o t h e s i s selected as convenient for presenting t h e figures is t h a t
the n e w joint authorities will be responsible for t h e h o s p i t a l a n d c o n s u l t a n t service,
tuberculosis dispensaries a n d m e n t a l clinics, a n d t h e c o u n t y a n d c o u n t y b o r o u g h
councils will be responsible for t h e provision of H e a l t h Centres a n d for t h e other
existing local services, for t h e n e w h o m e nursing services a n d , if t h e n e w dental
and o p h t h a l m i c services a r e , in fact, entrusted w h o l l y t o local authorities, for
these t w o services a s well.
The New Joint Authority.
The s c h e m e outlined i n t h e W h i t e P a p e r c o n t e m p l a t e s t h a t t h e n e w joint
authority will take over all h o s p i t a l s a t present p r o v i d e d b y rate-payers, in­
cluding infectious diseases h o s p i t a l s a n d m e n t a l h o s p i t a l s * a n d will m a k e arrange­
ments w i t h v o l u n t a r y h o s p i t a l s for t h e t r e a t m e n t of p a t i e n t s .
T h e y will also
take over a n y tuberculosis dispensaries a n d m e n t a l clinics. S u i t a b l e financial
adjustments will be m a d e b e t w e e n t h e j o i n t a u t h o r i t y a n d t h e l o c a l a u t h o r i t i e s
in respect of capital assets a n d liabilities t a k e n o v e r . A n e w service for w h i c h t h e
joint authorities will be responsible is t h e p r o v i s i o n of c o n s u l t a n t s (based o n
hospitals). I n addition, t h e y will n e e d a d m i n i s t r a t i v e a n d technical staff in t h e
exercise of their d u t y of c o - o r d i n a t i n g all t h e h e a l t h a c t i v i t i e s of their area.
The t o t a l annual e x p e n d i t u r e of all t h e n e w joint authorities will b e v e r y
considerable. F o r e x a m p l e , in 1938-39 t h e c o s t t o t h e e x i s t i n g local a u t h o r i t i e s
of t h e services to b e transferred was: —
£ millions.
Mental H o s p i t a l s
12.3
Infectious D i s e a s e s H o s p i t a l s . . .
...
...
...
...
....
4.2
Other H o s p i t a l s and I n s t i t u t i o n s
...
...
...
...
. . . 14.fi
Tuberculosis Services
...
...
...
...
...
...
...
4.6
35-7
There w a s n o direct e x c h e q u e r grant in aid of this e x p e n d i t u r e , b u t there w a s
indirect assistance t o t h e r a t e - p a y e r s through t h e o p e r a t i o n of t h e b l o c k grant
to local authorities under t h e L o c a l G o v e r n m e n t A c t , 1929.
After t h e w a r t h e 1938-39 Cost will b e c o n s i d e r a b l y increased. There will b e
some e x p a n s i o n of a c c o m m o d a t i o n a n d services p r o v i d e d (e.g.. for cancer), prices
in general will b e higher, a n d nurses' salaries h a v e b e e n increased s u b s t a n t i a l l y .
In addition t h e joint a u t h o r i t y will b e p u t t o e x p e n s e i n c o n n e c t i o n w i t h t h e
arrangements t o b e m a d e w i t h v o l u n t a r y h o s p i t a l s , a n d in p r o v i d i n g for t h e
consultant service based o n their o w n a n d on t h e v o l u n t a r y h o s p i t a l s . I n t h e s e
circumstances t h e cost t o t h e j o i n t ' authorities of t h e s e services i n t h e y e a r s
immediately after t h e war a n d of their general a d m i n i s t r a t i v e costs m a y a p p r o a c h
/70 millions.
As regards t h e existing services, a l t h o u g h t h e r e is n o direct e x c h e q u e r grant
at present ( e x c e p t for c a n c e r t r e a t m e n t , on w h i c h o n l y a small a m o u n t w a s
spent before or during t h e w a r b y local authorities), t h e G o v e r n m e n t t h i n k t h a t
there s h o u l d be a grant b a s e d on t h e n u m b e r of h o s p i t a l b e d s p r o v i d e d u n d e r t h e
scheme. T h i s grant would b e s u b s t a n t i a l and w o u l d h e l p t o m e e t t h e c o s t of
* The term mental hospital is used in this appendix to include also mental deficiency
institutions.
providing t h e c o n s u l t a n t service b a s e d on hospitals. T h e g r a n t for cancer
t r e a t m e n t w o u l d be discontinued, a s w o u l d t h e t e m p o r a r y w a r - t i m e grant in
respect of increases i n t h e salaries of nurses, m i d w i v e s , e t c . I n t h e case of the
other n e w services t h e y propose a 50 per cent, grant.
F o r t h e purposes of t h i s A p p e n d i x t h e grant per b e d h a s b e e n t a k e n as £100
per a n n u m in t h e case of all h o s p i t a l s other t h a n m e n t a l h o s p i t a l s a n d infectious
disease hospitals a n d £35 per a n n u m in t h e case of m e n t a l a n d infectious disease
h o s p i t a l s . A l o w e r grant in t h e c a s e of b e d s in t h e s e l a t t e r h o s p i t a l s is justified
not o n l y on t h e ground of c o m p a r a t i v e c o s t of t r e a t m e n t a n d m a i n t e n a n c e , b u t
because t h e n e w s c h e m e b r o a d l y d o e s n o t impose a n y a d d i t i o n a l duties on local
authorities in respect of t r e a t m e n t . T h e n u m b e r of m e n t a l h o s p i t a l beds h a s been
t a k e n as 170,000, of infectious disease h o s p i t a l s as 40,000 a n d of other municipal
hospital beds a s 210,000.
O n t h e a b o v e a s s u m p t i o n s , t h e n e w joint a u t h o r i t i e s w o u l d spend about
£70 millions a y e a r . T h e y would r e c e i v e direct e x c h e q u e r g r a n t s of £6 millions
in respect of m e n t a l hospitals, £1.4 . millions in respect of infectious disease
hospitals a n d £21 millions in respect of other hospitals, a t o t a l of £28.4 millions.
T h e balance of c o s t ^ - o n these a s s u m p t i o n s £41.6 m i l l i o n s — w o u l d be raised b y
means of p r e c e p t o n t h e c o n s t i t u e n t c o u n t i e s a n d c o u n t y b o r o u g h s in t h e area
of t h e joint a u t h o r i t y , w h o w o u l d l e v y a rate for i t . T h e rate-payers would
accordingly h a v e t o find t h i s £41.6 millions as a g a i n s t t h e £35.7 millions they
had t o find i n 1938-39. T h e G o v e r n m e n t propose t h a t t h i s increased rate demand
should b e m i t i g a t e d b y a n e x c h e q u e r grant, as e x p l a i n e d in t h e paragraphs
which follow d e a l i n g w i t h c o u n t i e s a n d c o u n t y b o r o u g h s .
Counties a n d C o u n t y B o r o u g h s .
A s already indicated, t h i s financial m e m o r a n d u m is b a s e d o n t h e hypothesis
t h a t c o u n t y a n d c o u n t y b o r o u g h c o u n c i l s will r e m a i n responsible for clinic
services other t h a n tuberculosis dispensaries and m e n t a l clinics, t h e major ones
being m a t e r n i t y a n d child welfare a n d venereal disease, a n d will continue t o be
t h e responsible a u t h o r i t y under t h e M i d w i v e s A c t . I n a d d i t i o n , it is assumed
t h a t t h e y will provide a n d m a i n t a i n H e a l t h Centres a n d will administer the
h o m e nursing service.
T a k i n g figures of cost for 1938-39, t h e t o t a l e x p e n d i t u r e o n t h e services
proposed t o b e transferred t o t h e n e w j o i n t a u t h o r i t y w a s £35.7 millions and
t h a t o n t h e r e m a i n i n g services w a s £4.6 millions. I n c l u d e d in this latter figure
w a s t h e b a l a n c e of expenditure u n d e r t h e M i d w i v e s A c t , after t a k i n g account
of a grant of £.6 million.
T h e cost of t h e s e services will be greater after t h e w a r , o w i n g t o increased
prices g e n e r a l l y , t o t h e cessation of fees charged for t h e a t t e n d a n c e of midwives
a n d t h e increased salaries of m i d w i v e s a n d t o a n y n e c e s s a r y e x p a n s i o n s .
It is
proposed t h a t there should c o n t i n u e t o b e a 50 p e r c e n t , g r a n t t o w a r d s the
cost of t h e m i d w i v e s service, a n d w i t h t h e increased c o s t t h e grant m a y well
a m o u n t t o £1.5 million a year.
In t h e e a r l y y e a r s after t h e w a r £1 million p e r a n n u m m a y b e spent on
h o m e nursing, t h o u g h it i s difficult t o forecast t h e cost of t h i s service.
The
G o v e r n m e n t c o n t e m p l a t e a 50 p e r c e n t , grant.
T h e cost of t h e provision a n d m a i n t e n a n c e of H e a l t h Centres is difficult to
forecast a t t h e m o m e n t .
E x c l u d i n g t h e r e m u n e r a t i o n of d o c t o r s in t h e Centres
t h e running costs (loan charges, h e a t i n g , staff, e t c . ) of t h e Centres established
during t h e first y e a r or t w o w o u l d probably n o t e x c e e d £i million a year.
T h e G o v e r n m e n t propose a 50 p e r c e n t , grant for t h i s n e w service.
I t will t a k e s o m e t i m e t o establish t h e n e w d e n t a l a n d o p h t h a l m i c services, and
it will p r o b a b l y b e several y e a r s before t h e n e t e x p e n d i t u r e - on- t h e services
reaches £10 m i l l i o n s on t h e former a n d £1 million o n t h e l a t t e r . T h e Government
propose a 50 per cent, g r a n t t o w a r d s t h e s e new services if responsibility for them
is placed o n c o u n t i e s a n d c o u n t y borough councils.
:
T a k i n g t h e s e figures, t h e t o t a l direct e x p e n d i t u r e of c o u n t i e s a n d county
b o r o u g h s o n h e a l t h services m i g h t a m o u n t to a b o u t £22 millions', t o w a r d s which
there would b e a direct e x c h e q u e r g r a n t of £8 m i l l i o n s .
(Indirect assistance
of course, also given b y t h e Block G r a n t under the Local G o v e r n m e n t A c t ,
3
2
i9 9-)
The t o t a l a m o u n t s falling o n t h e rate-payers w o u l d b e £41.6 millions under
precept from t h e j o i n t authorities a n d £14 millions direct e x p e n d i t u r e , a t o t a l
of £55millions. T h i s c o m p a r e s w i t h t h e figure for t h e s e services i n 1938-39
of / 4 - 3 millions.
T h e G o v e r n m e n t w o u l d propose that a n y increased rate
demand of t h i s sort s h o u l d b e mitigated- b y a n e x c h e q u e r grant a m o u n t i n g in
total to a b o u t 50 per cent, of t h e increase in a n y y e a r over the d e m a n d in some
axed year t a k e n a s s t a n d a r d . If 1938-39 were t h e s t a n d a r d year-, then on the
figures g i v e n t h e grant i n a i d of rates w o u l d b e a b o u t £7.6 millions. T h e grant
would be paid to each c o u n t y or county borough as a proportion of its increased
rate-burden, t h e proportion b e i n g higher for poor areas than for rich, on general
block grant principles.
6
0
Voluntary Hospitals.
Before t h e w a r there were no e x c h e q u e r g r a n t s t o v o l u n t a r y h o s p i t a l s in
respect of their e x p e n d i t u r e o n t h e t r e a t m e n t a n d m a i n t e n a n c e of p a t i e n t s . Their
income w a s derived a s t o a b o u t half from p a y m e n t s b y p a t i e n t s , either direct or
through c o n t r i b u t o r y s c h e m e s , and as t o t h e rest m a i n l y from v o l u n t a r y gifts
and legacies a n d i n c o m e from i n v e s t m e n t s .
D u r i n g t h e w a r t h e y h a v e received
payments from t h e e x c h e q u e r for work done i n c o n n e c t i o n w i t h t h e E m e r g e n c y
Hospital S c h e m e a n d are a t present receiving a n e x c h e q u e r g r a n t t o w a r d s t h e
cost of increased nurses' salaries based on 50 per cent, of the additional cost
they incur on that head.
The: W h i t e Paper explains, the part which if is suggested that the v o l u n t a r y
hospitals s h o u l d play iu. t h e new health scheme. Each voluntary hospital which
makes arrangements with the new joint authority for the maintenance and
treatment of patients under the, general conditions of the scheme will have part
of the cost, paid to them, b y t h e authority.
This may take the form of a
standard s u m per occupied bed per week, varying only with the type of hospital
concerned. ...
I11 addition, i n connection with the
provision of consultants agreed sums
arrangements of the joint authority for the
may be contributed in aid of salaries, etc.
The war-time g r a n t in respect of increases in salaries of nurses, m i d w i v e s , e t c . ,
will cease, b u t t h e G o v e r n m e n t propose a n e w g r a n t in respect of e a c h b e d i n a
voluntary h o s p i t a l w h i c h , u n d e r arrangements m a d e w i t h t h e joint a u t h o r i t y , is
used or k e p t a v a i l a b l e for p a t i e n t s i n t h e s c h e m e . O u t s i d e t h e a r r a n g e m e n t s of t h e
scheme, a v o l u n t a r y hospital will, of course, b e free t o provide such " p r i v a t e
pay-beds " a s i t t h i n k s fit. A s s u m i n g t h a t this g r a n t will b e t h e s a m e a s w a s
taken for b e d s i n municipal h o s p i t a l s , i . e . , £100 p e r a n n u m , a n d t h a t t h e t o t a l
number of b e d s i n c l u d e d in arrangements w i t h j o i n t authorities m a y p o s s i b l y
This
amount t o 100,000, t h e e x c h e q u e r g r a n t would a m o u n t t o £10 millions.
sum, t o g e t h e r w i t h t h e p a y m e n t s b y j o i n t a u t h o r i t i e s t o w a r d s t h e c o s t of m a i n ­
tenance a n d t r e a t m e n t of p a t i e n t s , w o u l d n o t c o v e r t h e w h o l e c o s t t o t h e
voluntary h o s p i t a l s , w h i c h w o u l d still b e d e p e n d e n t o n v o l u n t a r y resources for a
substantial part of t h e i n c o m e necessary t o b a l a n c e their e x p e n d i t u r e .
The General P r a c t i t i o n e r S e r v i c e .
'
.
I t is clearly n o t possible a t present t o "give a n y b u t t h e roughest e s t i m a t e s of
the p r o b a b l e c o s t of t h e general practitioner service u n d e r t h e n e w s c h e m e . I n
1938, in respect of 17,800,000 insured persons u n d e r t h e N a t i o n a l H e a l t h Insur­
ance s c h e m e , 17,164-general practitioners a s a w h o l e received £8.4 millions, w h i l e
w a s p a i d t o c h e m i s t s for fees a n d drugs i n d i s ­
in the' s a m e y e a r £2.4-millions
pensing prescriptions.
!
'
For t h e purposes o f t h i s A p p e n d i x i t i s a s s u m e d t h a t t h e c o s t of t h e e x t e n d e d
service w o u l d a m o u n t to: £36 millions a y e a r for doctors a n d c h e m i s t s t o g e t h e r .
No a c c o u n t is t a k e n of t h e c o s t of a n y s u p e r a n n u a t i o n s c h e m e w h i c h m a y b e
introduced or of the cost of c o m p e n s a t i o n in those cases where it is applicable.
Total
A n n u a l Cost of the Scheme.
O n t h e basis of t h e rough e s t i m a t e s g i v e n in t h e preceding paragraphs the
following table s h o w s t h e t o t a l a n n u a l c o s t of t h e s c h e m e t o public f u n d s and
t h e proportions in w h i c h t h a t cost m i g h t be borne b y t h e r a t e p a y e r s and by
central funds.
Cost met from Central Funds.
Service.
Service .
(a) b y
direct
grants or
payments.
All services
grants in
aid of
rates or
precepts.
im.
Total
cost from
central
funds.
Cost
Cos t
fallin
fallingg o n
raterate ­
payers.
payers .
Totel
Tote l
cos t t o
cost
public
publi c
funds.
funds .
£m.
£m.
£m.
28-4
28 -4
41 -6
70
10
10
£m.
Expenditure of new joint
authority
Exchequer grant to voluntary
hospitals
...
...
...
Expenditure of county and
county borough councils ...
Fees to general practitioners
and payments to chemists...
(b) b y
8
'
30
76-4
7-6
15-6
10
6-4
30
7-6
84-0
22
30
48 -o
132 -0
H o w far the central f u n d s will c o n s i s t of, or b e a s s i s t e d b y , s u m s of money
s e t aside o u t of c o n t r i b u t i o n s u n d e r a social insurance s c h e m e will fall to be
considered later.
T h e B e v e r i d g e R e p o r t p r o p o s e d t h a t a s u m of ^40 millions
p e r a n n u m should b e available for t h e n e w healthTservices. Of t h i s £35-7 millions
w o u l d be t h e share appropriate t o E n g l a n d and W a l e s , a n d if t h i s assistance is
a s s u m e d t h e proportions in w h i c h t h e t o t a l c o s t of t h e n e w service w o u l d fall on
t h e social insurance s c h e m e , t h e t a x p a y e r a n d t h e r a t e p a y e r w o u l d be, on the
foregoing e s t i m a t e s a n d ignoring t h e effect of t h e block grant u n d e r t h e Local
G o v e r n m e n t Act, 1929 : —
Social Insurance Scheme £35 -7 millions, or about 27
per cent.
Taxpayer
48-3
,,
36-6
Ratepayer
48
,,
36-4
,,
£132. -o
A g a i n ignoring t h e effect of t h e block grant, t h e . c o r r e s p o n d i n g t a b l e for the
i n c o m p l e t e services of 1938-39 w o u l d b e a p p r o x i m a t e l y : —
Contribution under N . H . I . Acts 11 -2 or about 20 per cent.
Taxpayer
3 -o
,,
6
,,
Ratepayer
40-3
,, ,, 74
54 -5
F I N A N C E I N SCOTLAND.
., ,
A s explained i n t h e W h i t e P a p e r , certain differences are n e c e s s a r y in the
a d m i n i s t r a t i v e a r r a n g e m e n t s a n d reoganisation of t h e n e w h e a l t h service in
S c o t l a n d , as c o m p a r e d w i t h E n g l a n d a n d W a l e s . W i t h o n e m a t e r i a l exception,
h o w e v e r , t h e financial a r r a n g e m e n t s will be o n b r o a d l y similar lines in the two
countries. T h a t e x c e p t i o n concerns t h e p r o v i s i o n , e q u i p m e n t and maintenance
of H e a l t h Centres, w h i c h in E n g l a n d a n d W a l e s is l i k e l y t o b e a local responsi­
b i l i t y and in S c o t l a n d t h e responsibility of t h e central a u t h o r i t y . T h i s being so,
t h e w h o l e cost of establishing t h e s e Centres in S c o t l a n d will b e m e t from the
e x c h e q u e r , and t h e precise a d j u s t m e n t s t o b e m a d e in t h e g r a n t s p a y a b l e to local
authorities under t h e n e w s c h e m e t o t a k e a c c o u n t of t h i s difference will be a
m a t t e r for discussion w i t h these a u t h o r i t i e s .
On the b a s i s of t h e best information available t o t h e D e p a r t m e n t of H e a l t h
lor Scotland, t h e following table g i v e s a rough e s t i m a t e of t h e t o t a l annual
cost of the s c h e m e in S c o t l a n d and its a p p r o x i m a t e a l l o c a t i o n b e t w e e n t h e rate­
pavers and central f u n d s .
Cost m e t from Central Funds.
(a) b y
(b) b y
direct
grants or
payments.
grants in
aid of
rates or
precepts.
£m.
£m.
Service
Service..
Expenditure of new Joint
Hospital Boards
Exchequer grant to voluntary­
hospitals
Expenditure of county and
iarge burgh councils
Fees to general practitioners
and payments to chemists...
Health Centres
All services
Total
cost from
central
funds.
£m.
3-4
3-4
I -6
I -6
I -o
I -o
2
-O
Cost
Cos t
falling
fallin g o n
rate
rate-­
payers.
payers .
£m.
4-6
Total
Tota l
cost
cos t t o
public
publi c ­funds.
funds .
£m.
8-o
l
-8
-6
2-8
3-2
3*2
3-2
-2
-2
'2
9-4
I
'0
jo *4
5-4
15-8
If it is a s s u m e d t h a t S c o t l a n d ' s s h a r e of a n y s u m set a s i d e o u t of contributions
under a social insurance s c h e m e be ^ 4 - 3 millions (corresponding t o t h e figure of
£35 - 7 millions for E n g l a n d and W a l e s ) t h e t o t a l cost of t h e n e w service w o u l d fall
on the social insurance s c h e m e , t h e t a x p a y e r and t h e r a t e p a y e r in t h e following
proportions: —
Social Insurance Scheme £4 -3 millions or about 27 per cent.
Taxpayer
£6-1
"
39
Ratepayer
£5-4
34
£15-8
,,
As the e x p e n d i t u r e borne o n the rates in 1938-39 was r o u g h l y £"4-4 millions, t h e
net additional c o n t r i b u t i o n from t h e rates w o u l d be £1 m i l l i o n .
(3103a) Wt. 35x8-3798 13. ISO, 4*. IJ0+3O. 104 */44 D.L. G. 37a
MINISTRY
OF
HEALTH
DEPARTMENT
OF
FOR S C O T L A N D
AND
HEALTH
ational
tee
T H E
WHITE
PROPOSALS
PAPER
IN
BRIEF
NOTE:
This is an official abridged version of the Governments proposals
It is issued for the
in their White Paper on a National Health Service.
convenience both of those who will have a putt to play in the new service
and of the larger number of men and women who, without needing to concern
themselves with all the details of the proposals, want to know what the shape
of the new service is likely to be and how it will affect them.
LONDON:
HIS
MAJESTVS
P R I C
E
STATIONERY
OFFICE:
T H R E E P E N C E
CONTENTS
IRITHODCCTOBY
I. SCOPE OF A NATIONAL, BEALTH SERVICE
What the new service must
offer
..
..
..
N e e d for a new attitude . .
o
oo
II. GENERAL MEDICAL, PRACTICE
Principles of a general practi. tioner service
..
Developments
in
medical
practice
..
..
Grouped practice and Health
Centres
..
..
Separate practice
..
A Central Medical Board . .
Remuneration and terms of
service of doctors
III. oo
oo
oo
oo
oo
oo
HOSPITALS
Deficiencies in the present
system
..
T h e unit of aclministration . .
An area hospital plan
Voluntary hospitals
oo
oo
oo
oo
IV. CONSULTANTS
A consultant service based on
hospitals
..
..
..
oo
Deficiencies in the existing
services
..
..
..
Closing the gaps
..
..
Private practice
Entry
into the publi
service
Compensation and
super
annuation
Sale and purchase of publ
practices
Supply of drugs and medical
appliances . .
Mental hospitals
Hospitals
for
infectious
diseases
Inspection of hospitals
o
oo
00
oo
00
00
00
00
00
Some
principles
affecting
consultant services
CLINICS AND OTHER LOCAL SERVICES
Services required
Increasing importance of work
in clinics
Maternity and child welfare
services
School Medical Service
Tuberculosis dispensaries and
other infectious disease work
oo
oo
oo
VI. ADMINISTRATION
Central organisation . .
Central
Health
Services
Council
..
..
..
Local organisation . .
..
oo
oo
oo
Cancer centres
oo
Venereal diseases
00 N e w services :—
Home nursing
Dental
and
ophthalmic
services
00
Health Centres
00 Preparation of local area plan oo
Local
Health
Services
Councils
..
..
. . oo
VII. THE SERVICE I!V SCOTLAND
Certain differences essential
Regional Hospitals Advisory
Councils
..
..
..
Joint Hospitals Boards
..
oo
oo
oo
Clinics and other services .. oo
Local Medical Services Com­
mittees
..
..
.. oo
VIII. FINANCE
Cost to public funds
State grants
oo
oo
IX. SUMMARY OF PROPOSALS Cost to taxpayer and ratepayer oo
Finance in Scotland
.. oo
3
IVOTE :
The proposals of the Government are set out more fully, with the reasons for them,
in the White Paper" of which this present paper is an abridged version. Every effort has
been made to avoid discrepancies of terms or substance between this and the main White
Paper. Ify however, any uncertainty arises, it is to the main White Paper that the reader
must look for explanation.
* (Grid. 6502. Price Is. od.)
INTRODUCTORY
The Government have announced that they intend to establish a
National Health Service, which will provide for everyone, without
charge, all the medical advice, treatment and care they may require.
This new service represents the natural next development in the
long and continuous growth of this country's health services.
Although it forms part of the wider theme of post-war reconstruction,
it has to be seen in the light of the past as well as the future and it
stands on its own merits as part of a steady historical process of
improving health and the opportunity for health among the people.
Such a service was recommended in the Beveridge Report; the
Beveridge Report summed up its purpose quite shortly as a service
which will ensure for every citizen whatever medical treatment he
requires in whatever form he requires it, at home or in hospital, general,
specialist or consultant, and will ensure also the provision of dental,
ophthalmic and surgical appliances, nursing and midwifery, and
rehabilitation after accidents. That is what the Government propose.
For reasons of geography and local government structure there are
certain differences, principally in matters of administration, in the
arrangements proposed for Scotland.
These differences are explained
in a s e c t i o n on the Service in Scodand and elsewhere in the text;
where n o difference is mentioned it should be understood that the
proposals for England and Wales apply equally to Scotland with the
necessary adaptations.
In considering the form which the new National Health Service
take, the Government have had the help of informal discussions
(in no way binding on those who took part in them) with representatives
of the major Local Authorities, the Medical Profession, the Voluntary
Hospitals and others.
They now put forward definite proposals for
discussion in Parliament and in the country, but they do not at this
stage put the proposals forward as fixed decisions.
Indeed, they
have promised that those concerned, professionally and otherwise,
shall be fully consulted before final decisions are taken. The Govern­
ment will welcome constructive criticism and they hope that the next
stage o f consultation and public discussion will enable them to submit
quickly t o Parliament legislative proposals w hich will be largely agreed
should
SCOPE O F A N A T I O N A L H E A L T H SERVICE
What the new service must OFFER
The new service is designed to provide, for everyone who wishes
to use it, a full range of personal health care. No-one, of course, will
be compelled to use it. Those who prefer and are able to make their
own arrangements for medical attention must be free to do so, and
the scheme must have sufficient flexibility to permit this. But to all
who use the service it must offer, as and when required, the care
of a family doctor, the expert skill of a consultant, laboratory
services, treatment in hospital, the advice and treatment available in
specialised clinics (maternity and child welfare centres, tuberculosis
dispensaries and the like), dental and ophthalmic treatment, drugs ard
surgical appliances, home nursing and all other services essential to
health. Moreover, all these branches of medical care must be so
planned and related to one another that everyone who uses the new
service is assured of ready access to whichever of its branches he or
she needs.
Deficiencies i n the existing services
A very great deal of what is required is already provided in one or
other of the existing health services. The problem of creating a
National Health. Service is not that of destroying services that are
obsolete and bad and starting afresh, but of building on foundations
laid by much hard work over many years and making better what is
already good.
Yet there are many gaps and deficiencies in the existing health
services and much expansion and reorganisation are necessary to weld
them into a comprehensive National Service. Despite the progress
made it would be far from true to say that everyone can get all the
kinds of medical service which he requires. Nor is the care of health
yet wholly divorced from ability to pay for it. To take one very
important example, the first of all requirements is a personal or family
doctor, a general practitioner available for consultation on all problems
of health or sickness. At present the National Health Insurance
scheme makes this provision for a large number of people, but not
for wives or children or dependants—and it does not normally afford
the consultant and specialist services which the general practitioner
needs behind him. 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 private arrangements.
So, too, in the hospital services, despite the well-known achieve­
ments of the voluntary hospital movement, and more recently of the
publicly-provided hospitals of the local authorities, it is not yet true
to say that everyone can be sure of the right hospital and specialist
facilities which he needs, when he needs them.
Again, many existing services are provided-and excellently
provided—by local authorities. But these services have grown up
piecemeal to meet different needs at different times, and so they are
usually conducted as separate and independent services. There is
no sufficient link either between these services themselves or between
diem and general medical practice and the hospitals.
Need for a new attitude
Perhaps the most important point of all is the need for a new
attitude towards health care. 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 sometlving 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
enjoying a sense of health and physical efficiency 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.
Closing the gaps
The Government^ proposals for closing the gaps in the existing
services and building a comprehensive National Service are described
in the paragraphs which follow. For convenience, they are divided
into four main sections dealing with General Medical Practice,
Hospitals, Consultants, and Clinics and other Services. Short sections
are added on Administration, on the Service in Scotland, and on
Finance. Some of the proposals (e.g., a full dental or ophthalmic
service) will take time to develop; the full national service cannot be
built in a day. But the important thing is to make sure that the design
is sound. Some of the proposals are controversial—that is inevitable.
The Government hope, however, that their proposals, modified
where modifications can be shown to be improvements, will win the
approval of all those who will look to the new scheme for the promotion
of their health, and the goodwill of those on whose willing service its
success will depend.
II
GENERAL MEDICAL PRACTICE
Principles of a General Practitioner Service
The arrangements for general medical practice are the most important
part of the proposals for a National Health Service. The family doctor
is the first line of defence in the fight for good health ; it is to him drat
every citizen using the new service will look for advice on his own
health and the health of his family; and it is generally through him
that access will be had to the many other forms of medical care which
the National Service will provide. If there is to be that high degree
of confidence between doctor and patient on which the success of the
new scheme will depend, two principles must be observed.
First, everyone must be free to choose the doctor whom he consults.
Absolute freedom of choice is, of course, impracticable and does not
exist now; the number of doctors in any one neighbourhood is
necessarily limited. But there must be freedom to choose from among
the doctors available.
Second, there must be no such regimentation in the scheme as will
prevent a doctor from exercising his professional skill in whatever
way he believes to be in the best interests of his patient. Yet, if the
State is to provide a universal service of family doctors^ there must
be some degree of State intervention. In particular, the distribution
of doctors must be sufficiently controlled to ensure that there is
everywhere an adequate service. The Government believe that their
proposals preserve the right degree of balance in this.
Developments in medical practice
Another important point is the need to give free range to modern
ideas as to the best form of general medical practice. To this problem
much thought has been given in recent years, particularly by the
profession itself. The idea of grouped practice—of individual doctors
collaborating with each other in teams in which " many heads are
better than one "—has received great prominence in professional and
other discussions of late. The draft Interim Report of the Medical
Planning Commission (organised by the British Medical Association)
summarises the problem as follows :—
" Diverse as are the views on 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 point the way, must be
placed in the forefront of their plans for the National Health Service and
their proposals are designed with this in view. But 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 the extent to which in the long run
the public will prefer the group system. Secondly, it is certain that
the system could not be adopted everywhere simultaneously. The
change, even if experience shows that it should be complete, will
take time.
The Government propose, therefore, that the new service shall
be based on a combination of grouped practice and of separate practice,
side by side. Grouped practices are more likely to be found suitable
in densely populated and highly built-up areas and it is there particularly
1
(though not exclusively) that they will first be started. 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 this new form of practice should be made.
Grouped practice and Health Centres
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 to
design the new service so as to give full scope to the Health Centre system.
The design of a Health Centre will provide for individual consulting­
rooms, for reception and waiting-rooms, for simple laboratory work,
for nursing and f ecretarial staff, telephone services and other accessories,
as well as—in varying degree according to circumstances—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 and saving their own time.
The provision of Health Centres will not affect the patient's freedom
to employ the doctor of his choice :. he will be equally free to choose
his doctor, whether the doctor serves in a Health Centre, in grouped
practice cutside the Health Centre or in separate practice. Nor will
the fact that a doctor is practising in a Health Centre mean that he ­
will not visit his patient at home, when this is required, just as he
does now. 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
a t
plaC
wVli/^h 1-Viorr ^ — - . ' f tKmr imcli tn
thp-ir nwn d o c t o r
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-
ALTERNATIVELY,
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^
P A R T I C U L A R DOCTOR I N I T
AND T H E N T H E C E N T R E S A R R A N G E M E N T S M U S T
B E Sr U C H A S T O E N S U R E T H A T T H E Y A R E
!
M A I I
and
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A
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E
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ADVICE^AND TREAT­
MENT T H E R E W H I C H T H E Y MAY N E E D .
approved oy tne Minister. The wisn, or me louai uuciuia t u U l m 6
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.
In Scotland, where the scale of the problem is smaller, the provision
and maintenance of Health Centres will be a central responsibility
exercised by the Secretary of State, who will have power to delegate
his functions in this respect to a local authority where, after an initial
experimental period, this is shown to be desirable.
die National Service will provide. If there is to b e that high degree
of confidence between doctor and patient on which the success of the
new scheme will depend, t w o principles m u s t be observed.
First, everyone m u s t be free to choose the doctor w h o m he consults.
Absolute freedom of choice i s , of course, impracticable a n d dees not
exist n o w ; the n u m b e r of doctors in any one neighbourhood is
necessarily limited. But there m u s t be freedom to choose from among
t h e doctors available.
Second, there m u s t be n o such regimentation in the scheme as will
prevent a doctor from exercising his professional skill in whatever
way h e believes to be in the best interests of his patient. Yet, if the
State is to provide a universal service of family doctors^ there must
b e some degree of State intervention. In particular, t h e distribution
of doctors m u s t be sufficiently controlled to e n s u r e t h a t there is
everywhere a n adequate service. T h e G o v e r n m e n t believe that their
proposals preserve the right degree of balance in this.
Developments in medical practice
Another important point is t h e need to give free range t o modern
ideas as to the best form of general medical practice. T o this problem
m u c h thought has been given i n recent years, particularly by the
profession itself. T h e idea of grouped practice—of individual doctors
collaborating with each other i n teams in which " m a n y heads are
better than one " — h a s received great prominence in professional and
other discussions of late. T h e draft Interim R e p o r t of the Medical
Planning Commission (organised by the British Medical Association)
summarises the problem as follows :—
" Diverse as are the views on the organization of medical services,
there is general agreement t h a t co-operation a m o n g s t individual
general practitioners in a locality is essential to efficient practice
u n d e r m o d e r n conditions, t h o u g h views vary on the form of the
co-operation. T h e principle of the organization of general practice
o n a group or co-operative basis is widely a p p r o v e d . "
T h e Government fully agree t h a t " g r o u p e d " practices, to which
n u m e r o u s privately arranged partnerships point t h e way, must be
placed in the forefront of their plans for the National H e a l t h Service and
their proposals are designed with this in view. But the conception
of grouped practices cannot represent the whole shape of the future
service. I n the first place, there has not yet been e n o u g h experience
of t h e idea translated into fact. N o t enough h a s been found out, by
trial and error, to determine the conditions u n d e r which individual
doctors can best collaborate or the extent to w h i c h in t h e long run
the public will prefer the g r o u p system. Secondly, it is certain that
the system could n o t be adopted everywhere simultaneously. The
change, even if experience shows that it should b e complete, will
take time.
T h e Government p r o p o s e , therefore, that the new service shall
be based o n a combination of g r o u p e d practice a n d of separate practice,
side by side. G r o u p e d practices are more likely to b e found suitable
in densely populated and highly b u i l t - u p areas a n d it is there particularly
(though not exclusively) that they will first be started. 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 this new form of practice should be made.
Grouped practice and Health Centres
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 to
design the new service so as to give full scope to the Health Centre system.
The design of a Health Centre will 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—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 and saving their own time.
The provision of Health Centres will not affect the patienfs freedom
to employ the doctor of his choice :, he will be equally free to choose
his doctor, whether the doctor serves in a Health Centre, in grouped
practice outside the Health Centre or in separate practice. Nor will
the fact that a doctor is practising in a Health Centre mean that he ­
will not visit his patient at home, when this is required, just as he
does now. 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 continue, ifJhey wish, to see their own doctor
in better equipped surroundings. [Tx will be important to avoid an
atmosphere of an impersonal clinic,"at" which the doctor's individuality
would be submerged in an anonymous public service.]
In England and Wales the Centres will normallyTfe provided and
maintained by county and county borough councils. The provision
and distribution of Centres will be in accordance with a general plan
for the operation in the area of the National Health Service as a whole.
How this plan will be prepared is described later,' but it will be drawn
up in consultation with representatives of the medical profession and
approved by the Minister. 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.
In Scotland, where the scale of the problem is smaller, the provision
and maintenance of Health Centres will be a central responsibility
exercised by the Secretary of State, who will have power to delegate
his functions in this respect to a local authority where, after an initial
experimental period, this is shown to be desirable.
U^A-v-dyv^..^
(A;
Separate practice
In this form of practice the general framework of the National
Health Insurance scheme will (with important changes from the past)
be retained. 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, laboratories and clinics of which he will be
enabled and expected to make full use for his patients.
There will be no interference with the right of a doctor to go on
practising where he is now and at the same time to take part in the
new public service in that area. But for the purpose of securing a
proper distribution of doctors some regulation of new entrants into
any practice will be necessary.
A Central Medical Board
The Government contemplate that the general practitioner service
will, in the main, be centrally organised and that the terms and
conditions of service of the doctors taking part in the new scheme
will be centrally arranged. As the doctors will be remunerated from
public funds, the Minister himself must be ultimately responsible
for the central administration. The Minister will, however, appoint
a Central Medical Board which, acting under his general direction,
will be responsible for much of the administration of the practitioner
service. The Secretary of State will appoint a separate Central
Medical Board for Scotland. The Board will in each case be the
" employer " of the doctors who take part in the new service and
it is consequently with the Board that the individual doctor will be
in contract, whether he is engaged in separate practice or in group
or Health Centre practice.
In the case of practice in Health Centres it would be impossible to
place on local authorities the duty of providing, maintaining and
staffing the Centres and give them no voice in the employment of the
doctors who will v/ork there. In this case, therefore, it is proposed
that there should be a three-party contract between the Board, the
local authority and the doctor. This will mean that a doctor employed
in a Health Centre will be appointed by the Board and the local
authority jointly, with his terms of service centrally negotiated and
settled, and will be liable to have his service in the Centre terminated
only by the joint decision of the Board and the local authority (or, if
they fail to agree, by the Minister). This arrangement will not be
required in Scotland, except where responsibility for mamtairiing
Health Centres is delegated by the Secretary of State to a local
authority.
The Board will also watch over the general distribution of public
medical practice. In separate practice it will be the Board to whom
application for consent must be made before a vacant public practice
is refilled or a new public practice established-a consent which
would be withheld only if there were already enough or too many
s.
doctors in the area. I n Health Centre practice it will be the agency
through which, when vacancies occur, new doctors are introduced
into a Centre.
T h e Board will b e a small body, u n d e r a regular chairman—a few
of its m e m b e r s being full-time and the rest part-time. Whilst it will
be mainly professional, lay m e m b e r s will also be included. Since
the Minister will b e responsible for its policy, the Board m u s t b e
appointed by h i m , b u t all appointments t o it will b e m a d e in close
consultation w i t h the profession.
T h e local Insurance Committees of the National H e a l t h Insurance
scheme will b e abolished, and their day-to-day functions will b e
handled in each area by a local Committee of the Board on w h i c h
local authority m e m b e r s will be included.
R e m u n e r a t i o n a n d t e r m s of s e r v i c e o f d o c t o r s
The remuneration and terms of service of doctors taking p a r t in
the scheme are matters for discussion with the medical profession.
The Government fully recognise the importance a n d urgency of
reaching a n u n d e r s t a n d i n g u p o n them a n d they think it right t o p u t
forward their general proposals on the subject.
Remuneration.
As a m e r e p r o b l e m of administration there would
be no insuperable difficulty in devising a system u n d e r which all
doctors engaged in public practice would be remunerated by salary.
But this is a highly controversial question, o n w h i c h opinions are
sharply divided.
M a n y experienced a n d skilled doctors would be
unwilling to take p a r t in a service so conceived. T h e y would hold
that if they became the salaried servants—whether of the State or of
local authorities—they would lose their professional freedom a n d b e
fettered in the exercise of their individual skill. O t h e r doctors,
with an equal right to b e h e a r d , would welcome a salaried service,
believing that it would relieve t h e m from business anxieties a n d
enable t h e m to devote themselves m o r e freely to the practice of their
profession. L a y opinion is similarly varied. T h e G o v e r n m e n t have
approached the question solely from the point of view of what is
needed to make the new service efficient. While they do n o t believe
that a universal change to a salaried system is necessary to t h e efficient
development of the service, and do n o t therefore propose this course,
they consider t h a t there will b e parts of the new serviee to which
different considerations will apply. I t seems to the G o v e r n m e n t t o
be fundamental that in H e a l t h Centre practice the g r o u p e d doctors
working together in a Centre should n o t be in competition for patients
and that in this form of practice remuneration o n a capitation system
would be inappropriate. T h e y therefore propose t h a t doctors p r a c ­
tising in H e a l t h Centres shall b e remunerated b y salaries or on some
basis other t h a n t h a t of capitation fees, and they will b e ready t o
discuss with t h e medical profession the precise system t h a t should
be adopted a n d the salary scales that would b e appropriate.
It would also be possible, if desired b y the doctors themselves, to
offer remuneration by salary or on some similar - basis to doctors
engaged in group practice, even where the practice was not conducted
in a Health Centre and, perhaps, in certain circumstances, to doctors
engaged in separate practice. Normally, the remuneration of a
doctor in separate practice 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—the maximum number of
patients whose care any one doctor ought to undertake being, of
course, suitably regulated.
But, whatever methods of payment are adopted—capitation fee,
salary or other—the substantial issue will be to decide what is, on
ordinary professional standards, a reasonable and proper remuneration
for the whole-time services of a general practitioner working in a
public service. When that has been satisfactorily settled, remuneration
under any system can be easily determined—any other issues arisirg
in the process being matters of comparative detail.
Terms of Service. It is not necessary at this stage to suggest the
details of the contract into which a doctor who wishes to undertake
public practice will enter with the Central Medical Board. But the
contract will obviously need to provide :—
(i) for the doctor to give all normal professional advice and services
within his proper competence to those whose care he under­
takes;
(2) for him to comply with the approved local arrangements for
obtaining consultant and specialist and hospital services;
(3) 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 Insu rsnce,
(4) for the observance of reasonable conditions, centrally determined
with the profession, respecting certification and other matters
which must arise in any publicly organised service.
Private practice
It is hoped that most doctors in general practice will take part in
the new service and, therefore, it is not proposed to prohibit doctors
who enter the service from also treating in their private practices
any patients who do not desire to take advantage of the new public
arrangements. It will be necessary in such cases to ensure that the
interests of the patients in the public service do not suffer thereby
and this will be done by reducing, as may be required, the number
of persons a doctor is permitted to have on his list under the new
scheme, and so reducing the remuneration he will receive from public
funds. The position of the doctor paid by salary in a Health Centre
presents greater difficulty but, as many doctors will bring most of
their present practices with them to the public Health Centres, it
will be necessary, during the experimental period at all events, to
observe here the same sort of latitude as in the case of separate practice.
In any event the volume of private practice will diminish greatly
under the new scheme; the essential point is that no person must
be made to believe that he can obtain more skilled or considerate
36
treatment by paying privately for it than he can within the terms of
the public service.
Entry i n t o t h e p u b l i c s e r v i c e
There is a strong case for requiring all young doctors, when they
leave hospital and begin to practise in the public service for the first
time, to go through a short period of apprenticeship as assistants to
more experienced practitioners. The Government propose that this
shall be the rule in future, though the Central Medical Board will
- ^The^Board must a l s o be a b l e t o r e q u i r e
t h e young d o c t o r d u r i n g t h e e a r l y y e a r s
Coi o f h i s c a r e e r t o g i v e h i s f u l l t i m e t o T
t h e p u b l i c s e r v i c e where t h e needs of t h e case
service require this.
*-vf^
whe
not
part
The first is that of a public practice in an " over-doctored " area,
to the sale of which the Central Medical Board-refuse consent. Here the
out-going doctor or his representatives will be compensated for any
loss of value.
The second case is that of a doctor who decides to give up his
" separate " public practice and to take service in a Health Centre.
It would be wholly incompatible with the conception of 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 retirement. O n the other hand, the Government consider
that an efficient superannuation system will be an essential part of
the Health Centre organisation. A doctor entering a Centre will
consequently acquire both superannuation rights and other facilities
of considerable value.
The proper course will be to strike a fair
balance between what he gains and what he loses and to compensate
him accordingly.
It would be more difficult to institute a superannuation scheme for
doctors engaged in separate practice, but the Government propose
to consider whether an acceptable scheme can be devised to provide
for retirement within specified age limits and the granting of super­
annuation rights on a contributory basis.
Sale a n d p u r c h a s e o f p u b l i c
practices
The Government have not overlooked the case which can be made
for aboUshing 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 which the Government
propose. The Government intend, however, to discuss the whole
matter further with the profession. ( 3 ^ - * J 6 t - V ^ . ^ * ^ )
w
Supply o f d r u g s a n d m e d i c a l
appliances
The question of the supply of drugs will need to be discussed with the appropriate pharmaceutical bodies. In particular it will be necessary 11
v
t2
i n c l u d i n g a n y m e a s u r e s w h i c h may b e
needed t o p r e v e n t t h e o p e r a t i o n of t h e
new p u b l i c s e r v i c e f r o m i t s e l f
increasing
t h e c a p i t a l v a l u e of a n i n d i v i d u a l
p r a c t i c e and t h e r e f o r e a l s o t h e compen­
s a t i o n w h i c h may l a t e r h a v e t o b e p a i d .
engaged in group practice, even where the practice was not conducted
in a Health Centre and, perhaps, in certain circumstances, to doctors
engaged in separate practice. Normally, the remuneration of a
doctor in separate practice 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—the maximum number of
patients whose care any one doctor ought to undertake being, of
course, suitably regulated.
But, whatever methods of payment are adopted—capitation fee,
salary or other—the substantial issue will be to decide what is, on
ordinary professional standards, a reasonable and proper remuneration
for the whole-time services of a general practitioner working in a
public service. When that has been satisfactorily settled, remuneration
under any system can be easily determined—any other issues arisirg
in the process being matters of comparative detail.
Terms of Service. It is not necessary at this stage to suggest the
details of the contract into which a doctor who wishes to undertake
public practice will enter with the Central Medical Board. But the
contract will obviously need to provide :—
(i) for the doctor to give all normal professional advice and services
within his proper competence to those whose care he under­
takes;
(2) for him to comply with the approved local arrangements for
obtaining consultant and specialist and hospital services;
(3) 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;
(4) for the observance of reasonable conditions, centrally determined
with the profession, respecting certification and other matters
which must arise in any publicly organised service.
Private practice
It is hoped that most doctors in general practice will take part in
the new service and, therefore, it is not proposed to prohibit doctors
who enter the service from also treating in their private practices
any patients who do not desire to take advantage of the new public
arrangements. It will be necessary in such cases to ensure that the
interests of the patients in the public service do not suffer thereby
and this will be done by reducing, as may be required, the number
of persons a doctor is permitted to have on his list under the new
scheme, and so reducing the remuneration he will receive from public
funds. The position of the doctor paid by salary in a Health Centre
presents greater difficulty but, as many doctors will bring most of
their present practices with them to the public Health Centres, it
will be necessary, during the experimental period at all events, to
observe here the same sort of latitude as in the case of separate practice.
In any event the volume of private practice will diminish greatly
under the new scheme; the essential point is that no person must
be made to believe that he can obtain more skilled or considerate
treatment by paying privately for it than he can within the terms of
the public service.
Entry i n t o t h e p u b l i c s e r v i c e
There is a strong case for requiring all young doctors, when they
leave hospital and begin to practise in the public service for the first
time, to go through a short period of apprenticeship as assistants to
more experienced practitioners. The Government propose that this
shall be the rule in future, though the Central Medical Board will
be empowered to grant exemptions-e.g., where an assistants post is
'V"
not reasonably obtainable. ( L c ^ d / g W X J C v ^ C ^ .
V
Compensation and
superannuation
The adoption of the proposals made in this Paper would, in certain
cases, destroy the selling value of existing medical practices, and
where this is so compensation will be paid. Two classes of case, in
particular, are likely to arise.
The first is that of a public practice in an " over-doctored " area,
to the sale of which the Central Medical Board.refuse consent. Here the
out-going doctor or his representatives will be compensated for any
loss of value.
The second case is that of a doctor who decides to give up his
" separate " public practice and to take service in a Health Centre.
It would be wholly incompatible with the conception of 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 retirement. On the other hand, the Government consider
that an efficient superannuation system will be an essential part of
the Health Centre organisation. A doctor entering a Centre will
consequently acquire both superannuation rights and other facilities
of considerable value. The proper course will be to strike a fair
balance between what he gains and what he loses and to compensate
him accordingly.
It would be more difficult to institute a superannuation scheme for
doctors engaged in separate practice, but the Government propose
to consider whether an acceptable scheme can be devised to provide
for retirement within specified age limits and the granting of super­
annuation rights on a contributory basis.
Sale a n d p u r c h a s e o f p u b l i c p r a c t i c e s
The Government have not overlooked the case which can be made
for abohshing 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 which the Government
propose. The Government intend, however, to discuss the whole
u
matter further with the profession^ ('^^-^&M,.Jr^X% )
/
Supply of drugs a n d m e d i c a l
/
appliances The question of the supply of drugs will need to be discussed with the appropriate pharmaceutical bodies. In particular it will be necessary 11
i n c l u d i n g a n y m e a s u r e s w h i c h may b e
needed t o p r e v e n t t h e o p e r a t i o n of t h e
new p u b l i c s e r v i c e f r o m i t s e l f i n c r e a s i n g
t h e c a p i t a l v a l u e of a n i n d i v i d u a l
p r a c t i c e and t h e r e f o r e a l s o t h e compen­
s a t i o n w h i c h may l a t e r h a v e t o b e p a i d .
to consider the arrangements to be made for the supply of drugs to
patients attending Health Centres.
As regards medical and surgical appliances, the existing system
entitles an insured person to the supply, free of charge, of certain
appliances specified in the Medical Benefit Regulations if ordered by a
doctor. These " prescribed appliances " are, in the main, the articles
most commonly required in general practice. In a service which
includes treatment of all kinds, whether in or out of hospital, the range
of necessary appliances will have to be greatly extended; but, as was
indicated in the Beveridge Report, it will be a matter for consideration
whether the patient himself should not be called upon, if his financial
resources permit, to contribute towards the cost of the more expensive
appliances—or at least of repairs and replacements. This point will
be of particular importance in connection with the dental and
ophthalmic services.
Ill
HOSPITALS
Deficiencies in the present system
A fully organised system of hospitals will be the keystone of the
National Health Service. The new hospital service must be complete
and ready of access. It must include general and special hospitals,
infectious disease hospitals, sanatoria for tuberculosis, accommodation
for maternity cases, for the chronic sick and for rehabilitation. Ancillary
hospital services must also be provided—for pathological examination,
X-ray, electro-therapy, ambulances, and other purposes.
The high standard which many of the leading hospitals have
attained needs no recommendation. They have shown the way in
the development of hospital technique. But there are weaknesses in
the present system and, to remedy these, two main problems have to
be solved. The first is to determine the areas most suitable for
hospital organisation, and bring together in a working plan for each
area the various separate and independent hospitals. The second is
to enable the two main hospital systems to work closely together in
future for a common purpose.
The voluntary hospital movement is well known in this country,
not only as the oldest established hospital system here, but also as a
movement which attracts the interest and support of many people
who believe in it as a social organisation and wish to see it maintained.
Its co-operation is essential to the success of the new service, side by
side with the other steadily developing system of the publicly provided
hospitals of the local authorities. The Governments proposals are
based on the fullest co-operation of this kind between the two hospital
systems in one common service.
At present hospitals are not linked as they should be with one
another and with other health services, and their distribution is uneven.
They have grown up without a national or even an area plan. In one
12
area there may be already established a variety of good hospitals.
Another area, although the need is there, is 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 radio-therapy 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. The time has come
when the hospital services have to be planned as a wider whole, with
the object of securing that each case shall be referred, not necessarily
to the particular hospital which happens to be " local," but to whatever
hospital can offer the most up-to-date technique for that kind of case.
To achieve this object and to remedy the present lack of coherence,
there is need of a single authority which has the duty to secure in the
area for which it is responsible a complete hospital service.
The unit of administration
At present, hospital services which are publicly provided are mainly
in the hands of county and county borough councils. The Government
have no desire to disturb unnecessarily the present form of local
government organisation or to interfere without cause in the work of
these major local authorities. Indeed, it is their intention to base
the local organisation of the new Health Service generally on these
major authorities, operating over their own areas where possible and
combining in larger joint areas only where necessary.
But it is abundantly clear that, with a few exceptions, counties and
county boroughs are not large enough to serve as the area on which a
unified hospital service could be based. For the purpose an area must
fulfil three conditions :—
(a) Its population and financial resources must be sufficient to make
possible an adequate, efficient and economical service.
(b) It should normally include both urban and rural areas so that
the needs of town and country can be properly balanced.
(c) It should be such that most of the varied hospital and specialist
services can be organised within its boundaries in a self-sufficient
scheme (leaving for inter-area arrangement only certain specialised
services).
In the great majority of the counties and county boroughs these
three conditions would not be met.
The Government therefore propose that responsibility for the new
hospital service shall be entrusted to new joint authorities, which will
be formed by combining for the 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 combination will be
unnecessary. The powers and duties of the present hospital authorities
will be transferred to the new joint authorities, who will take over
the ownership and management of ail publicly owned hospitals.
A n area hospital
plan
The first task of each new joint authority will be to assess the
hospital needs of its area and the available hospital resources, and to
work out a plan of hospital arrangements for the area, based on using,
adapting and where necessary supplementing the existing resources.
All this will be done in consultation with local professional opinion
and other local interests, including the voluntary hospitals. The plan
will then be submitted to the Minister for approval and will have no
vahdity until so approved.
The approved plan will define the parts to be played by the various
hospitals, both the hospitals of the joint authority and the voluntary
hospitals. Voluntary hospitals will not be compelled to participate
in the plan but the Government trust that they will not hesitate to
do so since their collaboration will be of great importance to the
success of the new hospital service. Indeed, without this collaboration
it would be many years before the new joint authorities could build
up a system adequate for the needs of the whole population.
Voluntary
hospitals
Some voluntary hospitals may fear that participation in the national
service would lead in the course of time to a change in their status,
and thus injure or even destroy the voluntary movement. That is
neither the wish nor the intention of the Government.
Where a voluntary hospital agrees to participate in the new service,
its participation will rest on a contract with the joint authority under
which the hospital will undertake to provide the services specified in
the area plan, and to abide by conditions applying to all hospitals and
settled centrally for the country as a whole. A voluntary hospital
accepting these arrangements will receive certain service payments
from the joint authority—these service payments being in accord
with centrally determined scales, and being less in amount than the
total cost of the service rendered (for if the voluntary system is to be
maintained, the voluntary hospital will still rely in large measure on
its own resources on personal benefaction and the continuing support
of all who believe in the voluntary hospital movement). It will also
receive from central funds certain payments in respect of its help in
the scheme—payments which can, if the hospitals wish, be pooled in
one fund from which the actual distribution to each hospital can take
account of its particular needs. There will be no question of any
interference in the management of voluntary hospitals, of the sur­
render by them of their independence and autonomy, or of any change
in their status.
The Government will discuss their proposals in detail with repre­
1"]
1
sentatives of the voluntary hospitals and they trust that it will be- ­
possible—without infringing the principles on which they believe the
National Health Service should be founded—to avoid any risk of
injury to the voluntary movement, and to ensure the cordial
collaboration of the voluntary hospitals in the new service.
Mental
Hospitals
The inclusion of the mental hospitals in the National Health Service
presents some difficulty until a full restatement of the law o f lunacy
and mental deficiency can be undertaken. Yet, despite the difficulties,
the mental health services should be taken over by the new joint
authority. This will be in accord with 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.
Hospitals for infectious
disease
In the counties isolation hospitals for infectious diseases are with
few exceptions owned and administered by the minor authorities and
not by the county councils, and their transfer to the new joint authority
will mean that their present owners will give up ownership without
retaining even the part interest which membership of the new joint
authority will afford in the case of hospitals belonging to county and
county borough councils.
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.
Inspection o f
Hospitals
Apart from special inspections to enquire into difficulties that have
arisen or changes that are in contemplation, routine inspections at
not too frequent intervals will 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
is
need not all be p e r s o n s employed whole-time on this work ; there are
advantages in employing o n a p a r t - t i m e basis medical m e n or women
distinguished in various branches of professional work or medical
administration. I n addition to doctors, there is scope for experts of
various kinds for dealing with an organisation so varied a n d complex
as a m o d e r n hospital. Hospital administrators, accountants, nurses,
engineers, catering and kitchen experts—to mention no others—should
find a place.
A solution would b e the appointment b y the Minister of a b o d y of
p e r s o n s of the types mentioned, some on a whole-time a n d others on
a part-time basis, grouped in suitable panels operating over different
areas of t h e country. T h e part-time doctors would be selected partly
from those associated with consultant practice and voluntary hospitals
a n d partly from t h o s e with experience of municipal hospitals.
IV
CONSULTANTS
A
Consultant Service based on
Hospitals
Perhaps the m o s t m a r k e d gap in t h e range of health services provided
u n d e r the present N a t i o n a l Health I n s u r a n c e scheme is the lack of
a consultant service. But it is not only a m o n g persons i n s u r e d under
t h e scheme that the need for such a service is felt, a n d a properly
organised consultant service which will be fair to t h e consultants
themselves and will ensure that everyone can obtain, whenever he
needs it and w i t h o u t charge, the skilled advice of a specialist must
have an i m p o r t a n t place in the new National Health Service.
T h e G o v e r n m e n t consider t h a t a service of consultants can be
best and m o s t naturally based o n the hospital services.
T h i s means t h a t it will become one of t h e duties of the joint authority
to see t h a t , t h r o u g h the various hospitals taking p a r t , there will be
provided a n adequate consultant service which will e n s u r e that the
co-operation of consultants a n d specialists is fully available to all
general practitioners in the service. I t will do t h i s , as in other,
branches of the hospital service, partly b y its own direct arrangement
a n d partly by contracting with the voluntary hospitals—the arrange­
m e n t s m a d e forming p a r t of the local plan. T h e authority will
arrange for the voluntary hospital t o provide consultant services both
a t the hospital and, where necessary, b y visits to a clinic or Health
Centre or the p a t i e n t ' s home. T h e hospital will itself enter into the
necessary engagements with the consultants a n d specialists concerned.
T h e local service payments t o t h e hospitals, already mentioned, will
b e based o n t h e assumption of a consultant staff properly remunerated
t o enable the hospital to fulfil t h e tasks which it h a d undertaken
t o perform.
S o m e principles affecting consultant services
Before suggesting in detail t h e form of a consultant service the
Government are awaiting the report of the Committee on Medical
Schools now sitting under the chairmanship of Sir William Goodenough.
Meanwhile some general considerations of which account will be
taken in devising the new service can be mentioned.
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.
There is also need for a more even distribution. The main con­
sultant facilities are now 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 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 continuing 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 he should be associated with more than one major
hospital, so that the sharing of a common consultant staff may become
an effective link between hospitals. His normal function will be the
regular and frequent visiting of these hospitals, both for in-patient and
for out-patient consultation; also the visiting of outlying " general
practitioner" hospitals, which need to be linked with the major
hospitals; also, for certain consultants as circumstances may require,
the visiting of Health Centres and clinics, and, in case of need, at
the request of the general practitioner, of patients in their homes.
For this sort of duty the proper and regular remuneration of con­
sultants, 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).
The terms and conditions for these consultants will be a matter
for the authorities of 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 remuneration will be required.
There will also be need for some control over the discretion of
individual hospital authorities in making appointments to senior
clinical posts.
Under existing practice there is a danger of " in­
breeding " ; and, while the ultimate responsibility for an appoint­
ment should rest unmistakably with the body of persons conducting
the hospitaPs affairs, there is much to be said for a system under
which an expert advisory body would recommend a number of suitable
candidates from which the hospital authority would make the final
choice.
V
CLINICS AND OTHER LOCAL SERVICES
Services
required
The National Health Service must include arrangements for home
nursing, midwifery and health visiting; it must also include the
local clinics and similar services which are now provided for maternity
and child welfare and other special purposes, or which may have to
be provided in the future. In England and Wales, the joint authority
will have the duty of including all these local services in their general
plan for the area and ensuring that they are properly related to each
other and to the other parts of the National Service and are arranged
in the right way and in the right place to meet the area's needs. The
plan, as approved by the Minister, will finally determine in each
area which of the services are to be provided and maintained by the
county and county borough councils and which by the joint authority.
Different arrangements will be necessary in Scodand, but the general
principle in both countries will be that all the local services which
belong to the sphere of general health care will rest with the major
local authority, while those which belong to the hospital and consultant
sphere will rest with the new joint authority.
Increasing importance of work in
clinics
As time goes on and the new scheme gets into its stride, there will
be room for experiment and innovations in the way in which these
various local services are provided. In particular, there will be
opportunities for associating the family doctor more closely with the
work of special clinics—e.g., child welfare centres. But, whatever
developments there may be in the clinics and other locally provided
services, the introduction of the new service will not mean that any
existing facilities are abandoned, but rather that they will be increased
and strengthened to meet the wider objects in view.
The way in which the Governments proposals, based on these
principles, will affect the various services is described below.
Maternity a n d child welfare
services
The arrangement of lying-in accommodation in hospital or maternity
home (indeed ail the institutional provision for maternity, both for
normal and for complicated cases) will become part of the reorganised
hospital and consultant services and will be the responsibility of the
new joint authority. The ordinary functions of the maternity and
child welfare clinics, however—concerned, as they are, not primarily
with direct medical treatment but more with giving advice on the
bringing-up of young children and the problems of motherhood­
will notbe transferred to the new joint authority, but will lie wherever
the related functions of child education are made by Parliament to
lie under the new Education Bill. Under the present proposals in that
Bill, this will mean that the county and comity borough councils will
be the authorities primarily responsible, but that arrangements will
be made in suitable cases for the delegation of much of the practical
care of the service to existing authorities, within the counties, which
have hitherto carried the responsibility and have accumulated good
experience and local interest.
In Scotland there will be no change in the present arrangements
for maternity and child welfare centres which are already being
administered by the major local authorities there, the county councils
and the town councils of the large burghs.
School Medical Service
For this service also the Governmenfs proposals are related to the
proposals in the Education Bill. It is contemplated that the education
authorities will retain as part of their educational machinery the
functions of inspection of children in the school group (the supervision,
in fact, of the state of health in which the child attends school and
of the effects of school life and activities on the child's health), together
with the important function of using the influence of the school to
ensure that the child receives any medical treatment he requires.
But, as from the time when the new Health Service is able to take over
its comprehensive care of health, the child will look for treatment
to that service.
Tuberculosis dispensaries and other infectious disease work
The local tuberculosis dispensaries will in future be regarded as
out-patient centres of the hospital and consultant services, and
responsibility for them will normally rest directly with the new joint
authority dealing with the whole of this aspect of the new service over
its wider area.
Similarly, isolation hospital responsibilities will pass to the new
joint authority as part of the general hospital problem of its area.
But many of the measures dealing with the notification of diseases
and the local control of the spread of infection, which are already the
subject of statutory powers under the Public Health Acts, can still
be suitably carried out locally in the different parts of the joint
authority's area, although most of these activities will probably in
future have to be centred in the county and county borough councils
rather than distributed more widely, as they are now,' among the
minor authorities.
Cancer centres
Responsibility for the local centres of diagnosis and advice which
were contemplated when the Cancer Act of 1939 was passed, but have
had little chance to develop substantially during the war, will pass
with the other responsibilities of that Act to the new joint authorities
as a part of t h e general hospital and consultant service.
Venereal diseases
T h e service for venereal diseases is at present in t h e hands of the
county a n d county b o r o u g h councils, and its allocation between
those authorities and the new joint authority presents difficulty. I
one sense it is essentially a clinic service which could continue to be
locally organised within the framework of the new general area plan
a n d need n o t be regarded as part of the wider hospital and consultant
field. T h e newly developing use—started during t h e war—of the
help of individual general practitioners to supplement the work of
the chnics lends some point to t h i s . O n the other h a n d , it is a service
requiring a high degree of specialisation and it is a m a t t e r of con­
venience one which is usually attached to hospital p r e m i s e s ; these
are factors which point to associating it with t h e reorganised hospital
service. I t is something of a " border-line " case, a n d will be best
left to be determined in the settlement of the area p l a n in each case.
n
New Services
Home nursing.
A full h o m e n u r s i n g service m u s t be one of the
aims of the new service. H o w far it needs t o be directly provided
by public authority, or indirectly by arrangements m a d e with other
bodies, or b o t h , will b e matters for discussion. Its object m u s t be to
ensure t h a t t h o s e who need n u r s i n g attention in t h e i r homes will be
able to obtain it without charge t h r o u g h the new service.
It is contemplated t h a t the task of securing this will b e entrusted
t o county a n d county borough councils.
Dental and ophthalmic services. A full dental service for the whole
population, including regular conservative treatment, m u s t unques­
tionably form p a r t of the new National Health Service. But there
are not at present, and will n o t be for some years to come, enough
dentists in t h e country to provide it. U n t i l the supply can b e increased
attention will have t o be concentrated on priority needs. T h e s e must
include the needs of children and young people, of expectant and
nursing m o t h e r s , and it is these needs which m u s t first b e met. The
whole dental problem is a peculiarly difficult one, a n d a Committee
u n d e r the c h a i r m a n s h i p of L o r d Teviot has been set u p by the two
Health M i n i s t e r s t o consider and report on it.
T h e r e m a y be similar (though perhaps less acute) difficulties in
getting a full service in ophthalmology. But these, like the difficulties
in dentistry, m u s t b e treated rather as practical p r o b l e m s arising in
the operation o f a new service t h a n as matters of d o u b t in planning
its scope a n d objectives.
Health Centres.
T h e arrangements for the local provision of
Health Centres have been already mentioned as the responsibility
normally of t h e county and county b o r o u g h councils.
ADMINISTRATION
Central
Organisation
T h e m a i n lines o n w h i c h the G o v e r n m e n t p r o p o s e t h a t the new
National Health Service shall be organised will have become clear
from the arrangements already described for the various p a r t s of the
service. But the form of organisation contemplated may b e easier
to understand if it is s u m m a r i s e d here as a whole. M o r e o v e r , t h e r e
are i m p o r t a n t p r o p o s a l s affecting the administration o f the new
service which have n o t yet been mentioned.
It is proposed that central responsibility for t h e N a t i o n a l Service
shall rest o n the two H e a l t h M i n i s t e r s . Indeed, n o other a r r a n g e m e n t
is possible, having regard t o the magnitude of the scheme and the
large sums of public money t h a t will b e involved.
While the service will t h u s be u n d e r general Ministerial control,
only one p a r t of it (the new general practictioner service) will be
in the m a i n centrally administered, a n d for m o s t parts of the new
service the principle already adopted in t h e majority of t h e health
services in the p a s t — t h e principle of local responsibility, with co­
ordination at the centre—will be similarly adopted in the future.
In
the general practitioner service, however, m u c h of the day-to-day
administration will be carried out, u n d e r t h e general directions of
the Health M i n i s t e r s , b y t h e two Central Medical Boards already
described.
Central H e a l t h S e r v i c e s
Council
Although it is o n t h e H e a l t h M i n i s t e r s t h a t responsibility to
Parliament for the new H e a l t h Service m u s t rest, t h e G o v e r n m e n t
attach great importance to ensuring t h a t t h e service is shaped a n d
operated in close association with professional and expert opinion.
The provision of a health service involves technical issues of the
highest importance, a n d in its administration, b o t h centrally ar.d
locally, the guidance of the expert m u s t b e available and m u s t n o t
go unheeded. O t h e r w i s e the quality of the service is b o u n d t o suffer.
The Government propose, therefore, that t h e r e shall be set u p by
statute at t h e side of t h e Minister a special professional a n d expert
body, to be called t h e Central Health Services Council. "Its function
will be to express the expert view on technical aspects of t h e H e a l t h
Service. T h e Council will differ from the Central Medical Board
in that it will b e a consultative and advisory body, a n d not—as the
Board will be—an executive body responsible u n d e r the M i n i s t e r s
direction for a defined p a r t of the administration of t h e n e w Service.
The Council will b e entitled to advise, not only on m a t t e r s referred
to it by the Minister, b u t on any matters within its province on which
it thinks it right to express a n expert opinion. A d u t y will be placed
on the Minister—apart from any other publication o f the CounciFs
advice or views which h e m a y make from time to t i m e — t o s u b m i t
annually to Parliament a report on the CounciPs work d u r i n g the year.
T h e constitution of the Council will be considered in detail with
the professional and other organisations concerned.
It must be
primarily medical in its m a k e - u p — t h o u g h n o t wholly so, because it­
will be required to express views on m a n y questions, e.g., of hospital
administration, dentistry, nursing and pharmacy, which will involve
. experts other t h a n the surgeon or physician. It is contemplated that
it might consist of some thirty or forty m e m b e r s , representing the
main medical organisations, the voluntary and publicly owned
hospitals (with b o t h medical and lay representation) and professions
like dentistry, pharmacy and nursing. T h e Council will be appointed
b y the Minister in consultation with the appropriate professional
bodies, and it will select its own chairman and regulate its own
procedure. T h e Minister will b e prepared to provide the secretariat
a n d t h e expenses of the Council will b e m e t from public funds.
A similar b u t separate body will b e set u p for Scotiand by the
Secretary of State.
Local
Organisation
In framing their proposals for the local organisation of the new
Health Service, the Government have been anxious to interfere as
little as possible with the shape of representative local government.
T h e y have set o u t to base the new service as far as possible on the
existing major local authorities, the county and county borough
councils. But t h e requirements of the service will usually demand,
for certain p u r p o s e s , larger areas of operation or planning than the
present counties and county boroughs can usually p r o v i d e ; for
these purposes therefore it will be necessary for the counties and
county boroughs to act in combination as joint authorities established
over appropriate areas by the Minister, rather t h a n in their separate
capacities over their present areas. T h u s , for reasons stated earlier,
it is essential t o its efficiency that t h e new hospital service shall be
based, with a few exceptions, on areas larger than counties and county
boroughs, and it is on this ground that the Government have proposed
the establishment of joint authorities to administer t h a t service—a
proposal which still maintains for t h e county and county borough
councils an interest in hospital administration inasmuch as they will
be t h e constituent bodies of the new combined authority.
It is clear, for reasons also given already, that the joint authority
responsible for the hospital service m u s t also be responsible for the
consultant service and such clinic and other local services as need
to b e organised in close association with the hospitals.
Preparation of local area
plan
O n e further and important duty will be placed on t h e new joint
authorities—that of preparing a rational and effective plan for all
branches of t h e Health Service in their area.
T h e preparation of this plan has been referred to already in the
description of the arrangements for t h e hospital a n d other individual
services. But the intention is that the plan shall cover, not merely
the particular services which the joint authority will itself administer,
but the whole range of services of which the National Health Service
will be composed. Unless provision is made for the interlocking
of the various parts of the service it cannot possess the coherence
and unity of purpose which are essential features of the Governments
proposals.
The preparation of a comprehensive plan of this kind is a function
appropriate to the joint authority and not to its constituent members.
The plan will be submitted to the Minister for approval, and when
approved it will determine how the needs of the area in terms of
general practice, hospitals, consultants, clinics and all other necessary
services are to be met and will define, subject to the principles laid
down, the responsibilities of the various authorities.
The plan will be open to amendment at any time by the same
procedure. Both in its preparation and in its amendment the authority
will fully consult local professional and expert opinion, through the
medium of a Local Health Services Council.
Local Health Services Councils
Expert guidance is no less needed locally than it is at the centre.
To meet the local need the Government propose that there shall be
established, for the area of every joint authority, a Local Health
Services Council. These Councils will be the local counterparts of
the Central Health Services Council. Their constitution will call
for more detailed consideration later but, provided that all the
professional interests are fairly represented, there is no reason why
the pattern should be precisely imiform everywhere—and the matter
might be dealt with by local schemes approved by the Minister. The
Councils will be able to advise, not only on matters referred to them
by the joint authority 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. They will be free, if they wish, to submit
their views and advice not only to the joint authority or, on matters
affecting other local authorities in the area, to those authorities, but also
to the Minister. The joint authority will be required to consult the
Council on the area plan for the health service before it is submitted
to the^Minister, and on any subsequent material alterations or additions
to the plan.
VII
THE SERVICE IN SCOTLAND
Certain differences essential
The scope and purpose of the National Health Service will be the
same in Scotland as it is in England and Wales, but the administrative
structure of the service in the two countries cannot be identical.
J
Account must b e taken of certain differences of geography and local
government organisation in Scotland. For example, about 8 0 p e r cent,
of Scodand's population is concentrated in about 1 7 per cent, of the
total area of t h e country, across its industrial " waist." Outside the
industrial belt are large, and for t h e m o s t p a r t sparsely populated
areas. O f t h e 55 existing health authorities in Scotland only 1 0 have
populations of m o r e t h a n 1 0 0 , 0 0 0 , a n d 3 2 have a population of under
5 0 , 0 0 0 . Against this, t h e population of England and Wales is on the
whole m u c h m o r e urbanised and t h e local g o v e r n m e n t units are larger
with correspondingly greater resources.
T h e r e will b e n o substantial difference i n t h e central machinery
to b e set u p i n Scotland as compared with England and Wales, but
the arrangements proposed for t h e local organisation of t h e service
will n e e d to be modified to suit the special circumstances of Scotland.
Regional Hospitals Advisory Councils
I n England and Wales t h e n e w joint authorities will have t h e dual
function of administering t h e hospital and allied services and of planning
the health service as a whole. T o make a similar arrangement i n Scotland
would usually b e out of t h e question, since t h e areas would b e too
big a n d unwieldy to serve as administrative units. T h e point can best
be illustrated i n relation to t h e hospital service. Successive Committees
on hospital problems have emphasised t h e n e e d for planning and
co-ordinating t h e hospital service in Scotland over wider areas, and
for this purpose have r e c o m m e n d e d t h e selection of t h e four natural
regions based on t h e Cities of Glasgow, E d i n b u r g h , A b e r d e e n and
D u n d e e , w h e r e t h e key hospitals as well as t h e medical schools are to
be found, with a fifth based for geographical reasons on Inverness.
Although areas of this size are necessary for the planning and co­
ordination of a comprehensive hospital service, they are clearly too
large t o serve as administrative u n i t s . T h i s m e a n s that co-ordination
of the hospital service a n d responsibility for its actual provision have
in Scotland to be separated in a way which does n o t apply to England
and Wales.
Accordingly the G o v e r n m e n t p r o p o s e to a d o p t t h e recommendations
made by various Committees, including the Committee o n Scottish
Health Services and t h e H e t h e r i n g t o n C o m m i t t e e , that a Regional
Hospitals Advisory Council should be set u p i n each of t h e five regions
referred to. T h e Council will consist of m e m b e r s nominated in equal
n u m b e r s by t h e Joint Hospitals Boards of t h e c o m b i n e d local
authorities in the region, described i n the n e x t paragraph, and by the
voluntary hospitals, and an i n d e p e n d e n t chairman will b e appointed
by t h e Secretary of State. In addition, it m i g h t include a small number
of representatives of the medical and medical-educational interests of
t h e region.
T h e functions of the Councils will b e consultative and advisory.
T h e y will advise the Secretary of State o n t h e measures necessary to
secure t h e co-ordination of t h e hospital and consultant services
within t h e region.
Joint H o s p i t a l s
Boards
T h e actual administration of the hospital and consultant services
will be entrusted to Joint Hospitals Boards to be set up for smaller
areas within the regions. The Boards will be composed entirely of
representatives from the county councils and the town councils of large
burghs in the area concerned. They will take over the whole ownership
and responsibility for the hospitals of their constituent authorities,
will be charged with the statutory duty of securing a proper hospital
service for their area-by their own provision and by arrangements
with other Joint Hospitals Boards or voluntary hospitals—and will
in fact be, so far as executive responsibility for the hospital service
is concerned, the counterparts of the new joint authorities in England
and Wales.
The Joint Hospitals Boards will have the duty of preparing a scheme
for the hospital services of their area, after consultation with t h e
voluntary hospitals. They will be encouraged also to consult the
Regional Hospitals Advisory Council at this stage to secure the fullest
measure of agreement between the area plan and the wider regional
arrangements proposed by the Council. The Joint Hospitals Board will
then submit their scheme to the Secretary of State, who will consult
the Regional Hospitals Advisory Council to obtain their final views
before deciding to approve or amend the scheme.
Clinics a n d o t h e r
Services
The arrangements proposed for the planning and administration
of the clinic services in England and Wales will also require some
modification in their application to Scotland. The same general
principle will be observed—namely, that the services more nearly
allied to the hospital service will be made the responsibility of the
new Joint Boards. Tuberculosis dispensaries and cancer clinics are
the most notable examples. As the Joint Hospitals Boards will have
no planning functions outside the hospital and consultant sphere,
it is proposed to leave the remainder of the clinic services where
they now are, in the hands of the major health authorities, and to
give power to the Secretary of State to require these authorities
(after a public local inquiry) to combine for any purpose where this
is proved necessary for the efficiency of the new health service as a
whole.
Local M e d i c a l S e r v i c e s
Committees
The only remaining differences between the proposals for England
and Wales and those for Scotland relate to the general practitioner
service ; they are two.
The first proposal—that in Scotland Health Centres will be provided
aiU maintained by the Secretary of State—and the reasons for it have
already been explained (page 8).
The second is that, in lieu of the Local Health Services Councils
to be set up in England and Wales there will be created in Scotland,
for every Joint Board area, a Local Medical Services Committee.
The Committees will be to some extent similar to the Councils, but
they will have a wider function. It will be their duty both to advise
the Secretary of State on the development of the general practitioner
service—the need for Health Centres, for example—and to act as a
means of liaison between the general practitioner service and the
other parts of the health service.
With these wider functions in view it is proposed that the Local
Medical Services Committees shall consist of representatives of all
the major local authorities in the area, of the local medical, dental,
pharmaceutical and nursing professions, and of other interests closely
concerned with the health services.
VIII
FINANCE
Cost to public funds
It is not possible within the limits of a short paper to explain in
detail how the new Health Service will be financed; for that, reference
must be made to the White Paper itself. But the present paper
would not be complete if it did not give some indication of the scale
of expenditure involved and of how it will be met.
It is estimated that in England and Wales the total annual cost of
the National Health Service to public funds will be not less than
£132 millions, as compared with about £55 millions from public funds
spent on the present health services.
Of this sum of £132 millions about £70 millions will be spent by
the new joint authorities on the hospital, consultant and other services
which they will provide and maintain themselves, including payments
made to voluntary hospitals for their services under the area plan.
About £22 millions will be spent by county and county borough
councils on the services for which they are to be directly responsible.
The State will itself spend directly about £30 millions on the new
general practitioner service—including payments to chemists.
(The remaining £10 millions is the part of the expenditure of
voluntary hospitals which will be met by a direct grant from the
State.)
State grants
Apart from its own direct expenditure on the general practitioner
service, the State will give grants to local authorities and to voluntary
hospitals. The arrangements proposed are as follows :—
(1) A hospital grant of £100 a bed (£35 in mental hospitals and
infectious disease hospitals, because of their lower comparative
costs and because the scheme broadly does not impose any
additional duties on local authorities for treatment in these cases)
will be paid to joint authorities in aid of the hospital and consultant
service. A similar grant will be paid to voluntary hospitals (the
£10 millions referred to above.)
(2) Every new service, other t h a n the hospital and consultant
service, will be assisted b y a 50 per cent, grant which will be
paid t o the authority responsible for the service.
(3) W h e n the above grants have been paid the joint authorities
will meet t h e remainder of their expenditure by precept u p o n
their constituent county a n d county borough councils. T h e s e
councils will meet the precept a n d their expenditure on their own
services by a rate charge, but t h e charge will be mitigated by
an additional Exchequer grant a m o u n t i n g to 50 per cent, of the
increase in the total cost of the health services in any year over
the cost in a selected standard year. T h e grant will be adjusted
to give m o r e help to p o o r areas a n d less to rich.
Cost t o t a x p a y e r a n d
ratepayer
How far t h e central funds will consist of, or be assisted by, sums
of money set aside out of contributions under a social insurance
scheme will be considered later. T h e Beveridge R e p o r t proposed
that an a n n u a l s u m of about £40 millions should be available from this
source for t h e new health services. O f this, nearly £36 millions would
be the share appropriate t o England a n d Wales, and if this assistance
is assumed t h e approximate p r o p o r t i o n s in which the total cost of the
new service will fall on t h e social insurance scheme, t h e taxpayer and
the ratepayer will be (ignoring t h e effect of the block grant u n d e r the
Local G o v e r n m e n t Act, 1929), as follows :—
Social Insurance Scheme . .
..
£36
millions.
Taxpayer
£48
,,
Ratepayer
..
..
..
..
£48
,,
£132
Finance i n S c o t l a n d
It is estimated on the same basis t h a t the total cost t o public funds
of the scheme in Scotland will be nearly £16 millions o f which about
£$\ millions will be spent b y t h e State on t h e practitioner service
and health centres, about £8.0 millions by t h e new joint boards,
about £3 millions by the C o u n t y and large b u r g h Councils and about
£i\ millions will be paid direct t o voluntary hospitals.
If it is a s s u m e d that Scotland's share of any appropriation from
the Social Security F u n d will b e about £4% millions (corresponding to
the figure of nearly £36 millions for England a n d Wales) the total cost
of the new service will fall on t h e Social Security Scheme, the taxpayer
and the ratepayer in approximately t h e following p r o p o r t i o n s :— j£4-3 millions Social I n s u r a n c e Scheme . .
..
Taxpayer
..
..
..
..
£6.1
,,
Ratepayer
£5.4
£15-8
SUMMARY OF PROPOSALS
Scope of ike new
Service.
(a) A National Health Service will be established. This National
Service will be available to every citizen in England, Scodand
and Wales.
(b) There will be nothing in the new service to prevent those who
prefer to make their own private arrangements for medical attention
from doing so. But, for all who wish to.use the service it will
provide, without charge, a complete range of personal health
care—general and specialist, at home, in the hospital and elsewhere.
Structure of the
(a) Central.
Service.
(i) Central responsibility to Parliament and the people will
he with the Minister of Health and the Secretary of State for
Scotland.
(ii) At the side of the Minister there will be a professional and
expert advisory body to be called the Central Health Services
Council. The Council will be a statutory body and its function
will be to provide professional guidance on technical aspects of
the Health Service. There will be a similar body in Scotland.
(b) Local.
(i) Local responsibility will be based on the county and
county borough councils, which are the major local government
authorities now. They will administer the new service partly in
their present separate capacities over their present areas, partly­
as the needs of the service require—by combined action in joint
boards over larger areas.
(ii) Areas suitable in size and resources for hospital organisation
will be designated by the Minister after consultation with local
interests.
(iii) The county and county borough councils in each area will
combine to form a joint authority to administer the hospital,
consultant and allied services ; in the few cases where the area
coincides with an existing county area the authority will be the
county council of that area.
(iv) At the side of each new joint authority there will be a
consultative body—professional and expert—to be called the
Local Health Services Council.
(v) Each joint authority will also prepare—in consultation with
the Local Health Services Council—and submit for the Ministers
approval an " area plan " for securing a comprehensive Health
Service of all kinds in its area.
(vi) County and county borough councils combining for these
duties of the new joint authority will also severally be responsible
for the local clinic and other services in accordance with the
area plan. Responsibility for child welfare will be specially
assigned in whatever way child education is assigned under the
current Education Bill.
Hospital and consultant
Services.
(a) It will be the duty of the joint authorities themselves to secure
a complete hospital and consultant service for their area—including
sanatoria, isolation, mental health services, and ambulance and
ancillary services in accordance with the approved area plan.
(b) The joint authorities will do this both by direct provision and
by contractual arrangements with voluntary hospitals (or with
other joint authorities) as the approved area plan may indicate.
(c) The powers of present local authorities in respect of these
services and the ownership of their hospitals will pass to the
joint authority.
(d) Voluntary hospitals will participate, if willing to do so, as
autonomous and contracting agencies ; if so, they will observe
the approved area plan, and certain national conditions applying
to all hospitals in the new service alike; they will perform the
services for which they contract under the plan, and receive various
service payments from both central and local funds.
(e) Special provision will be made for inspection of the hospital
service through centrally selected expert personnel.
(f) Consultant services will be made available to all, at the hospitals,
local centres, or clinics, or in the home, as required; they will
b; based on the hospital service, and arranged by the joint
authority, either directly or by contract with voluntary hospitals
under the approved area plan.
(g) Measures for improving the distribution of consultants, dealing
with methods of appointment and remuneration, and relating
the consultant service to other branches of the new service
generally, will be considered after the report of the " Goodenough
Committee."
4. General Medical
Practice.
(a) Everyone will be free, under the new Health Service, to choose
a doctor—the freedom of choice being limited, as now, only by
the number of doctors available and the amount of work which
each doctor can properly undertake.
(b) Medical practice in the new service will be a combination of
grouped and separate practice.
Grouped practice means practice by a group of doctors working
in co-operation.
Separate practice means practice b y a doctor working on his
own account—broadly similar to practice u n d e r the present
National H e a l t h Insurance scheme, b u t with important changes.
(c) Grouped practice will be conducted normally, though not
exclusively, in specially equipped and publicly provided Health
Centres. I n England and Wales, t h e Centres will b e provided
and maintained b y county a n d county borough councils—in
Scotland, by the Secretary of State with power to delegate to a
local authority.
(d) General practice in the N a t i o n a l Health Service will be in
the m a i n organised centrally u n d e r the responsible Health
Ministers. All the m a i n t e r m s a n d conditions of the doctor's
participation will be centrally settled, and m u c h of the day-to-day
administration will be the function of Central Medical Boards
—one for England a n d Wales a n d one for Scotland—largely
professional in composition, a n d acting u n d e r the general direction
of the H e a l t h Ministers.
(e) T h e m a i n duties of each B o a r d will be :—
(i) to act as the " employer " of the doctors engaged in the
public service. T h u s , the Board will b e the b o d y with whom
every doctor will enter into contract. I n the case of practice in
Health Centres in England a n d Wales, however, there will be a
three-party contract between t h e Board, the local authority and
the doctor.
(ii) T o ensure a proper distribution of doctors throughout
the country. F o r this p u r p o s e the Board will have power to
prevent the taking over of a n existing public practice or the
setting u p of a new public practice in an area which is already
"over-doctored."
(f) It is n o t proposed that there should be a universal salaried system
for doctors in the new service. Doctors engaged in Health Centres
will b e remunerated by salary or the equivalent ; doctors in
separate practice normally by capitation fee. In some c a s e s ­
e.g. g r o u p e d practice not based on a Health Centre—remuneration
by salary or the equivalent could be arranged if the doctors
concerned so desired. Rates of remuneration will be discussed
with t h e medical profession.
(g) It is n o t proposed to prohibit doctors in public practice from
engaging also in private practice for any patients w h o still want
this. W h e r e a doctor undertakes private in addition to public
practice, the n u m b e r of patients h e is permitted to take under the
National Service—and consequently his remuneration—will be
adjusted.
(h) Young doctors entering individual practice in the public service
for the first time will normally be required to serve for a period
as assistants to more experienced practitioners.
(j) Compensation will be paid to any doctor who loses the value
of his practice—e.g. by entering a Health Centre or because he is
prohibited from transferring the practice to another doctor on
the ground that there are too many doctors in the area.
Superannuation schemes will be provided for doctors in Health
Centres and the possibility of providing them in other forms of
practice will be discussed with the profession, and the practicability
of abolishing the sale and purchase of public practices will be
similarly discussed.
(k) Arrangements for the supply of drugs and medical appliances
will be considered and discussed with the appropriate bodies.
5,
Clinics and other
services.
(a) It will be the duty of the joint authority to include in its area
plan provision for all necessary clinics and other local services
(e.g., child welfare, home nursing, health visiting, midwifery
and others), and to provide for the co-ordination of these services
with the other services in the plan.
(b) County and county borough councils will normally provide
most of these local services. The exact allocation of responsibility
between the joint authority and the individual county and county
borough councils will be finally settled in each case in the
approved area plan; but the principle will be that services be­
longing to the hospital and consultant sphere will fall to the
joint authority while other local and clinic services will fall to
the individual councils.
(c) Child welfare duties will always fall to the authority responsible
for child education under the new Education Bill.
(d) New forms of service, e.g., for general dentistry and care of the
eyes, will be considered with the professional and other interests
concerned. In the case of dentistry the report of the Teviot
Committee is awaited.
6. Organisation in
Scotland.
(a) The scope and objects of the service will be the same in Scotland
as in England and Wales, but subject to certain differences due to
special circumstances and the geography and existing local
government structure in Scotland.
(b) The local organisation in Scotland will differ from that in
England and Wales and will be on the following lines :—
(i) Regional Hospitals Advisory Councils will be set up for
each of five big regions. The Councils will be advisory to the
Secretary of State on the co-ordination of the hospital and con­
sultant services in each region.
(ii) Joint Hospitals Boards will be formed by combination of
neighbouring major local authorities (county councils and town
councils of large burghs) within the regions to ensure an adequate
hospital service in their areas. The Boards will take over all
responsibility for the hospital services of the constituent authorities
(including services like the tuberculosis dispensaries, which
essentially belong to the hospital and consultant field) and will
also arrange with voluntary hospitals.
(iii) The joint boards will prepare a scheme for the hospital
service in their areas and submit this to the Secretary of State,
who will consult the Regional Hospital Council before deciding
to approve or amend it. The powers of the Secretary of State
will be strengthened to enable him to require major local authorities
to combine for any purpose proved necessary after local enquiry.
(iv) Education authorities (county councils and town councils
of four cities) will retain responsibility for the school health
service and clinics, until the medical treatment part of the school
service can be absorbed in the wider health service. Existing
major health authorities (county councils and town councils of
large burghs) will normally retain responsibility for the ordinary
local clinic and similar services ; the necessary co-ordination
will be secured through their membership of the joint hospital
boards and through the Local Medical Services Committee
(below).
(v) Local Medical Services Committees—advisory bodies
consisting of professional and local authority representatives­
will be set up over the same areas as the Joint Hospitals Boards.
The Committees will advise the Secretary of State on local
administration of the general practitioner service and will provide
liaison between the different branches of the Service.
7.
Finance.
It is estimated that the cost of the new National Health Service will
be. about £ 1 4 8 , 0 0 0 , 0 0 0 a year compared with about £55,000,000
spent from public funds on the present health services. The cost will
be met from both central and local public funds. The arrangements
as affecting the various local authorities and the voluntary hospitals are
fully considered in the White Paper and more briefly in this paper.
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