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T H I S D O C U M E N T IS T H E P R O P E R T Y O F H I S B R I T A N N I C MAJESTY*S G O V E R N M E N T
Printed
for the Cabinet.
June 1945.
Copy No.
SECRET.
C P . (45) 13.
kth June, 1945.
CABINET.
NATIONAL H E A L T H SERVICE.
MEMORANDUM BY THE LORD P R E S I D E N T OF THE COUNCIL.
T H E public will expect at the Election to know where the Government stand
on the National Health proposals on which we have given no indication of policy
apart from the White P a p e r of February 1944.
I n order to carry the Labour p a r t of the Coalition, we put into that
White P a p e r certain proposals envisaging that there might be salaried practice
in Health Centres and that doctors practising in the Centres would be in contract
with the local authority as well as with a Central Medical Board., These
proposals proved unpopular with the doctors.
The Minister of Health has, with the late Secretary of State for Scotland,
carried through many months of negotiation with the several professional bodies
concerned.
He has come down against salaried practice in the Health Centres and any
direct contract between the local authorities and general practitioners. This will
give great satisfaction to the medical profession.
Further, in all substantial matters, he has got agreement with the Voluntary
Hospitals and with all local authorities except the London County Council. I n
Scotland, too, a wide measure of agreement has been secured.
I suggest that it would be well to state the Government position now in the
form of the attached short Parliamentary paper submitted by the Minister of
Health and Secretary of State for Scotland.
W.
Office of the Lord President of the
4th June, 1945.
[30005]
Council,
CONFIDENTIAL-PROOF
MINISTRY O F
HEALTH
D E P A R T M E N T OF H E A L T H
FOR
SCOTLAND
PROGRESS W I T H
THE
PROPOSALS FOR A
ATIONAL HEALTH
SERVICE
Presented by tke Minuter of Health and the Secretary of State for Scotland
to Parliament by Com?nand of His Majesty
June 1945
LONDON
HIS M A J E S T V S STATIONERY
NET
Cmd.
OFFICE
C O N T E N T S
I.
INTRODUCTORY
I I . O U T L I N E O F THE R E V I S E D
PROPOSALS—
General objectives a n d principles
Range of the service
...
...
...
...
"...
Central organisation of the service
Local organisation for planning local services as a whole
Area planning bodies
Regional Advisory Councils
The London Area ...
Hospital and specialist services under the plan
Other local authority services
General medical practitioner service ...
Ordinary general medical practice arrangsniBats
Health Centres
"...
Sale and purchase of medical practices
Dental services
Ophthalmic service
Mental health services ...
Other developments
The service in Scotland
General
P R O G R E S S WITH T H E P R O P O S A L S FOR A
N A T I O N A L H E A L T H SERVICE
I
INTRODUCTORY
i. T h e White P a p e r on a National Health Service was published in
February, 1944.
Its p u r p o s e was not to a n n o u n c e a finally settled scheme.
It was intended that the proposed service should be freely examined and dis­
cussed with all concerned before final decisions were t a k e n , a n d t h a t the
Paper itself should serve as a focus for such discussions. It was h o p e d t h a t
draft legislation for establishing the service could then be p r e p a r e d , in the
light of the discussions, for submission to P a r l i a m e n t .
2. In March, 1944, the White P a p e r was debated in b o t h H o u s e s of
Parliament a n d both H o u s e s welcomed the intention, declared in the P a p e r ,
to establish a comprehensive health service.
3. Since then, discussions h a v e t a k e n place between the H e a l t h Ministers
(the Minister of Health a n d the Secretary of State for Scotland) a n d repre­
scntatives of the local g o v e r n m e n t authorities, v o l u n t a r y hospitals, a n d the
medical and dental professions, of nursing, midwifery, a n d p h a r m a c y , a n d
of other organisations a n d bodies concerned in the proposals. I n these dis­
cussions the w a y s a n d m e a n s of establishing a n d m a i n t a i n i n g the new service
have been reviewed, v a r i o u s alternative suggestions h a v e been e x a m i n e d a n d
ideas h a v e been e x c h a n g e d — i n accordance with the intention expressed in
the W h i t e P a p e r .
4. T h e content of these discussions could not be m a d e public while the dis­
ciissions proceeded. It was of their purpose a n d n a t u r e t h a t the t a l k s should
be free a n d informal a n d should n o t involve the t a k i n g a n d a n n o u n c i n g of
Government decisions at all stages. It was felt to be m o r e profitable t h a t
there should first be consultations between the two Ministers a n d the various
representative bodies over the whole field and that after t h a t the G o v e r n m e n t
should assess the situation a s a whole, in the light of these consultations, a n d
make k n o w n their conclusions to P a r l i a m e n t in the form of a Bill. T h i s
point, at which draft legislation could h a v e been considered a n d settled, h a d
practically been reached when, in view of t h e imminence of a dissolution, it
became clear t h a t there w a s insufficient time for consideration of t h e detailed
terms of a Bill or for its introduction in the present session.
5. In this situation there was an obvious possibility that m u c h of the
protracted work of the last y e a r m i g h t lead to no early conclusions, in spite
of the energy a n d the goodwill w h i c h all the different representative bodies
had devoted to it in the interests of arriving at a good service. I t might h a v e
been t h a t the discussions would h a v e been interrupted, for several m o n t h s a t
least, without P a r l i a m e n t a n d the public being able in a n y w a y to judge of
their usefulness a n d of the progress so far m a d e .
6. T h e G o v e r n m e n t therefore t h i n k it their d u t y to report to P a r l i a m e n t .
They h a v e reviewed the whole of the ground so far covered a n d h a v e decided,
on as m a n y as possible of the issues involved, w h a t measures t h e y would
be prepared to r e c o m m e n d to P a r l i a m e n t for inclusion in new legislation
when it c a n be introduced. T h e p u r p o s e of this P a p e r is to set o u t the
decisions which they h a v e reached.
7. These decisions do not cover every aspect of the necessary legislation.
There are some points on which the G o v e r n m e n t feel t h a t further considera­
iion is desirable before conclusions are reached. T h e r e will also be m a n y
matters—forming more n a t u r a l l y the subject of detailed s t a t u t o r y regulations
43052
A2
submitted after the general legislative framework has been settled on
which the various representative organisations ought to be further consulted
B u t the conclusions summarised in this P a p e r touch u p o n most of th
issues with which a n y Bill will have to deal, and indicate the way in which
the present G o v e r n m e n t would propose to deal with them.
e
8 . These proposals differ in a n u m b e r of respects from the corresponding
proposals set out in the White P a p e r of 1944. T h e y do not differ in regard
to any of the fundamental objectives of the comprehensive service, or in
regard to the fullness of its range or its universal availability to tnc public;
the)' do not differ in regard to, any of its governing principles or its general
conception. T h e y affect only ways and m e a n s a n d not e n d s . Where they
differ, the changes from the e a r l i c proposals are m a i n l y designed to
strengthen the protection of - individual freedom in using or providing any
p a r t of the service, to eliminate a n y possible excess of standardisation and
to encourage variety a n d individuality in the services p r o v i d e d .
9. The position
in Scotland.—The
proposals which follow refer to the
service in E n g l a n d and Wales. While maintaining the s a m e objectives and
general principles for the service in Scotland, the earlier White P a p e r pro­
posed a somewhat different administrative structure, chiefly as regards local
organisation, to fit the different conditions there. The considered views of
certain of the organisations concerned, with which the special Scottish features
of the proposed service h a v e been discussed, h a v e not yet been made
k n o w n to the Government, a n d in particular the medical profession have
yet to hold their Representative Meeting on the subject.
I n a n y case a
separate Bill for Scotland will b e necessary. A p a r t , however, from certain
points mentioned below ( p a r a .
) the Government do not contemplate
t h a t a n y substantial modifications of the Scottish proposals as contained in
the earlier White P a p e r will be found necessary.
II
OUTLINE OF THE REVISED PROPOSALS
General objectives and
principles
T O . All the main objectives and principles of the earlier White Paper
must, in the G o v e r n m e n t s view, be fully assured, including: —
(i) a comprehensive service, covering all forms of medical and allied
care for all people who wish to take a d v a n t a g e of it, free from a n y financial
deterrents;
(ii) freedom for everybody to use the service or not, and freedom for
every professional m a n or w o m a n to t a k e p a r t in the service or not;
(iii) freedom of choice of doctor, with no question of creating a separate
state medical service distinct from the ordinary practice of medicine;
(iv) complete clinical freedom for doctors a n d other professional people
taking p a r t , with no question of lay supervision of the professional person's
clinical discretion and j u d g m e n t in his patients' interests;
(v) the full partnership of the two great hospital systems of the country,
with participation of the v o l u n t a r y hospitals as a u t o n o m o u s bodies and no
question of them being " taken over " by the State;
(vi) a proper combination of public responsibility for the service and the
participation of the expert in its provision centrally a n d locally.
4
R a n g e of the service
I I . T h e new service m u s t be designed to secure:—
(a) a family doctor of the p a t i e n t ' s own choice, working usually from
his own surgery as n o w — b u t with a full experiment conducted in the
opening y e a r s in the varied possibilities of publicly e q u i p p e d H e a l t h
Centres;
( 6 ) all kinds of hospital a n d s a n a t o r i u m services, including medical re­
habilitation, a n d all k i n d s of specialist a n d " second-opinion " services
organised in a n d from the hospitals;
(c) priority dental services for e x p e c t a n t a n d nursing mothers, y o u n g
children a n d schoolchildren; also a general dental service which, while not
able to g u a r a n t e e t h a t d u r i n g the present shortage of dentists, t r e a t m e n t will
be available in every instance, would offer all necessary t r e a t m e n t to all who
can a r r a n g e with a dentist taking p a r t in t h e service to provide it;
(d) a service for the c a r e of the eyes a n d provision of spectacles;
(e) m a t e r n i t y a n d child welfare, midwifery a n d home-nursing services;
and home-helps in case of need t h r o u g h sickness;
-(/) all necessary drugs, medicines a n d appliances, a n d a m b u l a n c e s a n d
hospital t r a n s p o r t services;
(g) a public h e a l t h l a b o r a t o r y service a n d a blood transfusion service
organised on a national basis;
(h) the greater fusion, in future, of responsibility for the m e n t a l a n d the
physical health services in a single a d m i n i s t r a t i v e organisation centrally
a n d locally.
Central organisation of the service
12. As the earlier W h i t e P a p e r emphasised, the central organisation of
the service will be based upon the central responsibility to P a r l i a m e n t a n d
the people, in the n o r m a l constitutional m a n n e r , of the Minister of H e a l t h .
The present responsibilities of the B o a r d of Control for mental health,
under the L u n a c y Acts a n d Mental Deficiency Acts will be transferred to
the Minister of H e a l t h , with the exception of functions specially concerned
with the liberty of t h e subject in respect of the detention of persons of
unsound mind a n d m e n t a l defectives; for these the B o a r d will be continued.
13. A new a n d s t a t u t o r y organisation will b e set u p at the centre, to advise
the Minister.
This will consist of a C e n t r a l Health Services Council—
representing in a single b o d y all the m a i n expert fields, medicine a n d sur­
gery, dentistry, nursing, midwifery, p h a r m a c y , a n d v o l u n t a r y hospital a n d
local g o v e r n m e n t experience—and also of various separate S t a n d i n g Advisory
Committees associated with the Council, b u t with direct access to the Minister
as well a s to the Council.
14. These separate A d v i s o ^ / C o m m i t t e e s will include a general medical
advisory committee, a hospitals advisory committee, a n o t h e r on dentistry,
one on nursing, one on mental health a n d one on p h a r m a c y . All the p r o ­
ceedings and reports of these Committees will automatically b e m a d e k n o w n
to the C e n t r a l Council a s well as to t h e Minister, a n d the Central Council
will be able to pick u p a n y subject on which it thinks t h a t its wider general
point of view should b e expressed, and advise the Minister on it.
15. The m e m b e r s of the Central Council a n d the S t a n d i n g A d v i s o r y C o m ­
mittees will b e a p p o i n t e d b y the Minister only after full consultation with the
professional a n d other organisations c o n c e r n e d ; there will also b e some ex
officio m e m b e r s . T h e Council and the C o m m i t t e e s will be able to advise
at all times, of their own initiative, and will not be restricted to questions
referred to t h e m b y the Minister. T h e Minister will publish a n a n n u a l report
of the work of the Council and Committees, prepared by the Council itself
except in so far as there m a y be some reason of the public interest for not
doing so. The Council a n d Committees will appoint their own Chairmen
a n d arrange their own p r o c e d u r e ; they will h a v e joint secretariats—i.e. one
secretary appointed by themselves and one supplied by the Minister.
16. Generally, the object will be to bring to the responsible Ministers side
a strong a n d thoroughly representative grouping of the best expert opinion
in all fields of health service policy, and to give that opinion full opportunity
of expressing itself to him.
Local organisation for planning local services as a single whole
Area Planning Bodies
17. T h e comprehensive service needs to be p l a n n e d over suitably wide areas,
with a p r o p e r degree of expert and professional participation in the making,
a n d keeping u p to date, of the p l a n . If this is secured in the m a n n e r pro­
posed in t h e next p a r a g r a p h there is not, in the G o v e r n m e n t s view, any
need in E n g l a n d and W a l e s for a n y large scale transfer to new executive joint
boards of the hospital functions of the major elected local authorities, as
was c o n t e m p l a t e d in the earlier White P a p e r . It was always recognised
that the b a l a n c e of a d v a n t a g e in this transfer was open to question, except
in Scotland where the relatively small population of the average local health
a u t h o r i t y ' s a r e a t u r n e d the scale decisively.
18. It is now proposed that there should be areas determined for the
rational p l a n n i n g of the h e a l t h service as a whole, and that these should be
similar to the " J o i n t A u t h o r i t y " areas of the White P a p e r ; i.e. there should
be about 30 or 35 of t h e m for the whole country, with a population of
a n y t h i n g from half a million to about two millions in each. F o r each of these
areas, there will be established a new H e a l t h Services Council, charged with
the s t a t u t o r y d u t y of p r e p a r i n g a health services plan for the whole area
a n d of submitting it to the Minister for final confirmation—the confirmed plan
becoming t h e b i n d i n g scheme which all concerned must observe, and being
constantly revised a n d k e p t up to date.
19. These Health Sendees Councils will consist, in a proportion of about
3 : 2, of the representatives of the major local authorities (counties and
c o u n t y boroughs) of the area on the one h a n d , a n d of representatives of the
v o l u n t a r y hospitals, the medical profession, dentistry, nursing a n d midwifery
on t h e other. E a c h will p r o b a b l y be a b o d y of something like 30 members,
with 18 local authority and 12 other representatives and a chairman appointed
b y the Minister.
20. In view of the special considerations affecting the hospital and specialist
services p a r t of the area plan, a special Hospital Services Group will be estab­
lished for each of the new planning areas, which will p r e p a r e this p a r t of the
plan a n d provide it for incorporation in the general plan b y the Health Services
Council. If the latter b o d y modifies the p l a n , a n d there is a n y resulting dis­
agreement, the Minister will decide the issue. These Hospital Services Groups
will consist of equal n u m b e r s of v o l u n t a r y hospitals and local authority
m e m b e r s , together with representatives of specialist and general medical
practice. T h e y will need to h a v e special committees on the p l a n n i n g of the
mental services.
R e g i o n a l Advisory Councils
21. There is, in the G o v e r n m e n t s view, a good case for bringing into the
p l a n n i n g a n d a r r a n g e m e n t of the service the voice of those qualified to look
at the subject—particularly the more highly specialised sendees which need
to be correlated over larger fields—from the point of view of even wider
,
.
42
areas or regions, based upon the n a t u r a l spheres of influence of universities with
medical teaching schools. It is proposed, therefore, that for each of the
ten or so spheres of influence of the university medical teaching centres,
there shall be sot u p a small, highly expert advisory body, to be
known as the Regional Advisory Council.
These Councils will consist
of, say, 15 m e m b e r s , including m e m b e r s representing the universities
with schools of medicine, specialist medical practice, and v o l u n t a r y hospital
and local government experts. Their functions will be to assist the a r e a
planning bodies throughout in the m a k i n g of their plans, providing the neces­
sary correlating advice over the wider regions; to h a v e the o p p o r t u n i t y also
of advising the Minister finally on the plans as submitted to him; to establish
machinery for advising on the a p p o i n t m e n t of specialists b y all hospitals in
the region, and to undertake such other expert functions (such as surveys of
hospital resources in their region) as the Minister might call upon them at
any time to perform.
The Condon area
22. F o r the special circumstances of the London area, some of the details
of this p l a n n i n g machinery m a y need to be. a d a p t e d ; this is for further con­
sideration. B u t the general principles of combined p l a n n i n g , the participation
of the experts of various kinds, and the influence of wider regional considera­
tions, would all apply in some suitable form.
Hospital and Specialist Services under the plan.
23. T h e area plan described will settle, as the earlier W h i t e P a p e r pro­
posed, the general lay-out of the various hospital a n d specialist resources
of the area, the best use to be m a d e of existing resources a n d the new p r o ­
vision needing to be m a d e to m a k e u p deficiencies.
Both the v o l u n t a r y
hospitals and the local authorities will h a v e joined in a r r a n g i n g this p l a n .
It will then be for both to c a r r y out their allotted parts in it.
24. A v o l u n t a r y hospital t h u s agreeing to play its p a r t in the scheme will
play that p a r t under its own m a n a g e m e n t a n d with full a u t o n o m y a s a
voluntary institution. It will b e , as it were, in the position of a n indepen­
dent contractor, providing agreed services in accordance with the arrange­
ments of the plan which the v o l u n t a r y hospitals, as well as the local
authorities, will have shared in m a k i n g .
25. A v o l u n t a r y hospital will receive from public funds two kinds of ser­
vice p a y m e n t s , central and local, for the services which it will h a v e agreed
to render u n d e r the local p l a n : —
(a) T h e central p a y m e n t s will be m a d e b y the E x c h e q u e r , a n d will b e at
rates settled with the v o l u n t a r y hospitals' representatives in respect of each
of the main types or classes of services rendered. If it proves desirable to
arrange for some element of grouping of a n y p a r t of the total m o n e y s so
due, a n d their redistribution a m o n g individual hospitals on some basis
taking more account of individual needs, the G o v e r n m e n t will be p r e p a r e d
to consider this.
(b) T h e local service p a y m e n t s will also be at rates settled centrally, in
consultation with the voluntary hospitals' representatives a n d those of
the local authorities. T h e y will be received b y the v o l u n t a r y hospitals,
not from individual local authorities, but from a single new " clearing
house " serving each p l a n n i n g a r e a . This clearing house will be p r o ­
vided so as to enable b o t h v o l u n t a r y hospitals a n d municipal hospitals
taking patients from other local a u t h o r i t y areas all to d r a w their a p p r o ­
priate service p a y m e n t from one source, while all local authorities can
simply p a y into that source a flat rate p a y m e n t for every patient from their
area going into any hospital other than their own hospitals—no matter
to what hospital, voluntary or municipal the patient goes.
26. In fixing the a p p r o p r i a t e scales for central and local service payments
in consultation with the v o l u n t a r y hospitals, the desirability of m a k i n g clear
their continuing v o l u n t a r y status and their continuing link with the voluri­
tary good-will of the public will be kept fully in m i n d . This will b e relevant
in determining the proportion of their resources for which they will look to
public funds, and it is therefore a vital m a t t e r to them a n d to the volun­
t a r y contributor)' and savings associations which have been so valuable
link between the hospitals and the public in the past. The G o v e r n m e n t does
not want to determine it finally at this stage, until it has been discussed with
t h e m in further detail.
There will also need to be p r o p e r provision for
enabling the v o l u n t a r y hospitals to obtain necessary capital assistance in
c a r r y i n g out new u n d e r t a k i n g s which they m a y h a v e agreed to c a r r y out in
accordance with the n e w area p l a n s .
a
27. As already indicated, there will be n o general transfer of the munici­
p a l hospitals to new J o i n t Authorities, a n d the d u t y to provide municipal
hospital services of all kinds in accordance with the area plans will fall in
future u p o n the c o u n t y and c o u n t y b o r o u g h councils.
T h e expenditure
of these Local Authorities on the hospital services as on all other local
health services for which the) are responsible, will be the subject of appro­
priate exchequer assistance to be determined in consultation with their
representatives.
28. The general objects and scope of the hospital a n d specialist services will
b e the same as those in the original W h i t e P a p e r , and need not be set out again
here. T h e principal changes in the proposed ways a n d m e a n s lie in (a) the
complete re-arrangement of the earlier proposals for '' J o i n t Authorities "
a n d area p l a n n i n g , already referred to, (b) the direct participation of the
v o l u n t a r y hospitals a n d professional experts in the m a k i n g of the area plans
and in the new regional advisory m a c h i n e r y already described, (c) t h e modified
system of p a y m e n t s for s e n ices rendered, just outlined, (d) the amplification
of the central advisory resources at the Minister's side, mentioned earlier in
this P a p e r .
Other local authority services
29. In the new organisation the new general d u t y to secure all kinds of
hospital and specialist services will, as was a l w a y s intended, a b s o r b in a
larger whole m a n y of the present s e p a r a t e services which really belong to
t h a t sphere—e.g. tuberculosis, isolation hospitals for infectious diseases, in­
stitutional maternity, cancer; and the poor law medical institutions will cease
to exist as such.
30. B u t , outside the new range of the hospital a n d specialist services, there
will be certain local a u t h o r i t y services (e.g the provision of m a t e r n i t y and
child welfare clinics) which will still require special s t a t u t o r y provision in
the new legislation. There will also be some new functions (e.g. t h e provision
of a home-nursing service a n d of home-helps in illness) which will need to be
added. All of these local a u t h o r i t y services will b e joined in future in the
h a n d s of the county a n d c o u n t y borough councils, as the earlier W h i t e Paper
proposed, except for the delegation of child welfare a r r a n g e m e n t s where child
education is already delegated.
31. All of this will be b r o a d l y as the earlier White P a p e r contemplated,
and there is no material new point to record under this h e a d i n g . All of these
local authority services will, of course, become the subject of the new area
p l a n n i n g system, and in future all will rest upon a clear d u t y to provide a lull
service, and not merely u p o n a power to do so.
-
32. T h e local authorities should, it is felt, each b e required to establish in
future a new all-purpose health committee (comparable to their statutory
education committees). In the G o v e r n m e n t s view, these health committees
ought in future to include a proportion of doctors and persons of special
experience in the health services.
The committees will h a v e various sub­
committees, including one on mental health.
General medical practitioner service
33. A r r a n g e m e n t s for assuring a personal or family doctor's care for all
will, as the earlier White P a p e r stressed, be the first-line provision of t h e now
service. But there will be some changes in the means proposed in the earlier
Paper for securing this.
34. In the main, this p a r t of the new service will be organised on lines
already familiar u n d e r the present National H e a l t h I n s u r a n c e system, with
the great difference that it will in future be backed b y all the specialist
and hospital services and home-nursing a n d other facilities provided under
the new area schemes—and, of course, t h a t it will in future be equally avail­
able to all people. At the same time, there will b e conducted a carefully
worked out experiment, on a substantial scale, in new developments of
the " Health Centre " type to which the earlier White P a p e r referred.
Ordinary general medical practice arrangements
35. U n d e r the revised a r r a n g e m e n t s there will be no need in E n g l a n d and
Wales (in the G o v e r n m e n t ' s view, which they u n d e r s t a n d the medical pro­
fession to share) for the creation of the Central Medical B o a r d proposed
in the earlier W h i t e P a p e r .
General practitioners will look in future, for
their contract and remuneration, to a new local C o m m i t t e e t a k i n g the place
of—and b r o a d l y similar to—the present local I n s u r a n c e C o m m i t t e e .
This
Committee will in each area consist, as to one-half, of representatives of the
public (two-thirds of these being n o m i n a t e d b y the c o u n t y or c o u n t y borough
council, a n d one third by the Minister) a n d , as to the other half, of profes­
sional representatives of the doctors, dentists and chemists taking p a r t in
the service.
There will be local professional committees for the doctors,
dentists a n d chemists, which will stand in broadly the same relationship
to the new local Committee as the Medical a n d P a n e l and P h a r m a c e u t i c a l
Committes s t a n d now in relation to the present I n s u r a n c e Committees; and
there will continue to be various special sub-committees, a s now, to deal
with complaints a n d disciplinary m a t t e r s .
36. General t e r m s of service and remuneration will be settled b y central
consultation with the professions concerned, as they are now, and will be
broadly based on the same methods of p a y m e n t (as distinct from a m o u n t s
of p a y m e n t ) as n o w . T h e settlement of the a m o u n t s of doctors' remuneration
will be reached in the light of the report of the special C o m m i t t e e recently set
up u n d e r Sir Will Spens, by agreement with the profession, to advise afresh
on the proper s t a n d a r d s a n d range of remuneration in general medical
practice.
3 7 . After careful consideration the G o v e r n m e n t d o not believe t h a t any­
substantial a d v a n t a g e would h e gained b y the earlier proposals to try to
improve the distribution of general medical practice by requiring practitioners
to obtain official consent to starting or t a k i n g over a practice, or b y requiring
full time practice from y o u n g doctors in certain areas. T h e y do not feel
that these restrictions upon the present freedom of choice b y professional
men a n d w o m e n — a n d their potential patients—would be justified b y any
results which would in fact be likely to accrue. T h e y believe t h a t the same
objectives can be better achieved by devising some suitable system of more
attractive terms for work in less attractive areas, a n d they propose to explore
this further.
There is already a power in the National Health Insurance
Acts for the Minister to supersede the ordinary a r r a n g e m e n t s in any p .
ticular area, and to substitute other a r r a n g e m e n t s , if he is satisfied that a
proper service is not being provided in that area; this power will be retained,
a n d applied to the new and wider service.
a r
Health Centres
38. D u r i n g the opening y e a r s of the scheme, a controlled experiment will
be conducted with various types of publicly provided a n d equipped health
centre, including health centres for the conduct of general practice by doctors
willing to transfer their practices, or to open new practices in them.
The
centres will be provided, equipped and m a i n t a i n e d by t h e local county or
county borough councils, as the earlier White P a p e r proposed, but the doctors
taking p a r t in t h e m will remain—like the doctors in s e p a r a t e practice—under
contract only with the new C o m i r u u e e which takes the place of the Insurance
Committee, a n d will not need to join in a special t h r e e - p a r t y contract as was
earlier proposed. T h e local a u t h o r i t y will arrange with t h a t Committee, and
not with the individual doctors, for the use of the premises by doctors for
the p u r p o s e s of the new service. T h i s will facilitate ease of m o v e m e n t in and
out of separate and health centre practice, by eliminating a n y differences of
contractual status between the doctors inside or outside t h e centres.
39. Doctors in the health centres should, it is t h o u g h t , be r e m u n e r a t e d by
the C o m m i t t e e as a g r o u p p a r t n e r s h i p — t h e aggregate capitation fees due to
t h e m u n d e r the ordinary system being pooled a n d redistributed a m o n g them­
selves u n d e r a partnership a g r e e m e n t . Competition for patients within the
group, or for the us-" of the facilities in the centre, will t h u s be avoided.
40. T h e health centre experiment must be on a wide enough scale to yield
reliable information as to the a d v a n t a g e s a n d p o p u l a r i t y of the system, and
further developments will depend on the results obtained. T h e Minister in
controlling the experiment will h a v e the help of the advisory machinery
a l r e a d y described.
Sale and purchase of medical practices
41. As already a n n o u n c e d on behalf of the coalition G o v e r n m e n t ^ there
will be no abolition or restriction in the first few y e a r s of the present pro­
fessional custom of the sale and p u r c h a s e of goodwill. As soon as the results
of the operation of the new service—and the effects^for instance, upon practice
values of the health centre system—can be better ascertained, there will be
a full enquiry into the merits a n d possibilities of altering the system—with
proper compensation on the lines of the recent p r o n o u n c e m e n t on the subject
in P a r l i a m e n t .
Dental services
42. A priority dental service for m o t h e r s and y o u n g children will rest upon
a new d u t y p u t u p o n local authorities, in place of their present power, as
part of their m a t e r n i t y a n d child welfare functions. Similar provision has
a l r e a d y been m a d e for schoolchildren in the E d u c a t i o n Act of last y e a r .
43. In addition to this, the G o v e r n m e n t believe that a general dental service
can be organised in accordance with the principles of the Teviot Committee's
report, under which a n y person able to arrange with a dentist for dental care
within die new scheme can Be enabled to get all necessary care without fees or
charges, although no g u a r a n t e e can be given of the i m m e d i a t e availability
of dental care in all cases owing to the acute shortage of professional personnel.
Such a service will b e an extension of the earlier W h i t e P a p e r proposals, and
* By the Minister of Health, in] a reply to a Question in t h e H o u s e of Commons on
3rd May, 1944.
it needs further exploration with the dental profession. Discussions in this
field have had to start later than in other fields, and are correspondingly less
far advanced, owing to the need to await the report of the Teviot Committee
before they could begin.
44. T h e merits a n d a d v a n t a g e s of dental health centres, or dental depart­
rrients in health centres, will be ascertained b y controlled experiments on
similar lines to the medical health centres.
Ophthalmic service
45. The G o v e r n m e n t believe that a full service for the care of the eyes,
available for all who want to use it, should be organised as p a r t of the health
service from the outset, although in the earlier White P a p e r some doubt was
expressed as to whether this was yet practicable. Discussions of the best
methods b y which, a n d the stages through which, s u c h a service can best
be achieved are in progress.
Mental health services
46. A r r a n g e m e n t s need to b e m a d e for a closer association of the mental a n d
physical health services. At the centre the mental health functions of the
present B o a r d of Control will, subject to the exceptions already mentioned in
regard to restraints upon the liberty of the subject, be merged in the Ministry
of Health- Locally the mental health services will b e as m u c h p a r t of t h e
comprehensive area planning as a n y other p a r t of the new service, the exist­
ing executive duties of providing the services becoming a direct function of the
county and- county b o r o u g h councils, as p a r t of their wider hospital a n d
clinic duties. E a c h a u t h o r i t y ' s new health committee will have a special
statutory sub-committee on mental health. Visiting Committees under the
Lunacy Act will be abolished, and any r e m a i n i n g links of the mental health
services with the Poor Law will be severed. A full restatement of the law
of lunacy a n d mental deficiency will be u n d e r t a k e n later, as soon as conditions
permit.
Other Developments
47. It is proposed t h a t there shall be established a public health p a t h o ­
iogical laboratory- service, organised centralty and on a national basis b y
the Minister, in the first instance through the agency of the Medical Research
Council. Its object will be, without superseding the present l a b o r a t o r y work
of local authorities, to provide them and others with a free bacteriological
service for the control of infectious diseases, and to perpetuate the a d v a n t a g e s
of a nationally organised epidemiological s e n d e e which the war experience
of the E m e r g e n c y L a b o r a t o r y Sen-ice has so well demonstrated.
Similarly,
arrangements will be m a d e on a national scale to continue the a d v a n t a g e s
of the blood transfusion service which, u n d e r the E m e r g e n c y Hospital
Scheme, h a s been vigorously developed d u r i n g the war. Ambulance and h o s ­
jjiial t r a n s p o r t services will fall to be locally- arranged within each of
the new health p l a n n i n g areas, and the responsibility for securing t h e m — b y
direct provision a n d b y contract with v o l u n t a r y agencies—will fall upon the
major local authorities in each case.
The s e n ice in Scotland
48. T h e chief developments of the Scottish proposals, as contained in the
earlier W h i t e P a p e r , will be as follows: —
(a) T h e central advisory machinery will be elaborated, with S t a n d i n g
Advisory Committees in addition to the Scottish Central Health Services
Council o n the lines described in p a r a g r a p h .
of this P a p e r .
(b) The regional Hospitals Advisory Councils (designed for a different
purpose from that of the Regional Advisory Councils in England and
Wales a n d composed of equal numbers of local authority and voluntary
hospitals representatives) take part at a n earlier stage than was originally
proposed in the planning of hospital and allied services. T h e y will draw
u p a provisional general plan for the region to guide the J o i n t Hospitals
B o a r d s (i.e. combinations of local authorities) in framing their a r e a schemes
for these services.
(c) Local service p a y m e n t s to v o l u n t a r y hospitals will be m a d e through
clearing-houses on lines described in p a r a g r a p h
of this P a p e r , operating
in Scotland on a regional basis. These clearing-houses will also handle ser­
vice p a y m e n t s between J o i n t Hospitals B o a r d s . T h e net expenses of the
J o i n t Hospitals B o a r d s will be raised by requisitions from their constituent
authorities, who will in turn h e grant-aided ori all their health services
expenditure.
(a) T h e changes proposed in p a r a g r a p h
of this P a p e r in regard to
the general medical practioner service will be a d o p t e d in Scotland, although
there m a y be found to b e a continuing need for the Scottish Central Medical
B o a r d proposed in the earlier White P a p e r .
(e) T h e Local Medical Services Committees of the earlier White Paper,
covering the same areas as the J o i n t Hospitals B o a r d s , will b e composed
of equal numbers of lay representatives n o m i n a t e d b y the local authorities
and of professional representatives nominated b y the medical and allied
professions in the area, together with a few additional m e m b e r s , lay or pro­
fessional, appointed b y the Secretary of State. In addition to the advisory
functions proposed in the earlier White P a p e r , this Committee will in each
case also act as the successor to the present I n s u r a n c e Committees, and for
this purpose there wall be associated professional committees and appro­
priate services sub-committees on the lines described in p a r a g r a p h ' of
this P a p e r .
General
49. All the necessary m a i n organisation of the new service should, in
t h e G o v e r n m e n t s view, be provided for in a Bill as early as possible in the
new session. Meanwhile, discussions can continue with representatives of the
doctors, dentists, hospitals, local authorities, nurses and others o n the many
o t h e r questions which need to be settled. M a n y of these questions will
necessarily involve complicated a n d detailed a r r a n g e m e n t s a n d will, there­
fore, h a v e to be the subject of subsequent s t a t u t o r y regulations, subject to
review by P a r l i a m e n t .
50.. T h e outline given in this P a p e r is not intended to be a n exhaustive
s u r v e y of the way in which the new service will be organised. I t is intended
mainly to d r a w attention, in a s u m m a r y form, to certain proposals involving
a d j u s t m e n t of the earlier White P a p e r proposals, a n d to give a general
indication of the G o v e r n m e n t s conclusions on the issues which h a v e been
discussed with the various professional a n d other organisations over the
p a s t y e a r . It does not take the place of the main White P a p e r of 1944,
b u t s u p p l e m e n t s it a n d brings it up to d a t e .
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1945
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