(c) crown copyright Catalogue Reference:cab/66/66/13 Image Reference:0001 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 . LONDON PRINTED AND PUBLISHED BY HIS MAJESTY'S STATIONERY OFFICE To be purchased directly from H.M. S T A T I O N E R Y O F F I C E at the following addresses: York House, Kingsway, London, W.C.2 ; 13a Castle Street, Edinburgh 2 ; 39-41 King Street, Manchester 2; I St. Andrew's Crescent, Cardiff; 80 Chkhester Street, Belfast; or through any bookseller 1945 Price (43052) Wt - : o 5 6/45 D.L. G. d. net