GET THE HEALTH CENTRES GOING NOW
(Socialist Medical Association 1951)
The National Health Service will fail—no matter how much money is spent on it—if Health Centres are not provided. Health Centres are the only 'possible means of providing conditions in which the health personnel, combining as a team, can give the highest standard of satisfying work, and the only way of providing a focal point for the health and healthful activities of a community.
Two problems must be clarified at once if progress is to be made in any measurable period of time. These are to settle the functions of Health Centres; and to decide how many new buildings can be built and how many old ones adapted to fulfil those functions at the earliest date. The need is greatest in overcrowded industrial areas, the opportunity most evident in New Towns and communities being built.
No matter what the, seeming financial and political difficulties, Health Centres must. be provided; the whole position requires new thought and urgent action.
What a Centre will Provide
If a Health Centre is to play its part in providing all that is implied by "a comprehensive national Health Service available to every citizen," its service should include or provide for the following:
1. Periodic examination for the maintenance of health and the early detection of disease.
2. A family doctor service organised from the centre. Patients who are able, will visit their family doctor in the Centre; those who need home visits will arrange through the Health Centre for their family doctor to call. An appointment system, records, clerical and telephone assistance will be necessary for this purpose.
3. A 24-hour emergency service.
4. The work done at present-day health centres and clinics, ante-and post-natal care, infant welfare, child guidance, immunisation, welfare officer, home nursing, etc.
5. A complete general dental service.
6. A general ophthalmic service.
7. A pharmaceutical service for N.H.S. patients and internal 'supplies.
8. Health education and propaganda, and research.
9. Special clinics, e.g., foot clinic or others which experience shows to be necessary.
10. The organisation of factory health and accident services.
11. Rehabilitation and physiotherapy during convalescence.
12. Consultant services.
As medical science develops new functions may be added, and the administration of health centres must be elastic to allow this to happen. (An example which may call for early realisation is that part of compulsory post-graduation/pre-registration training of a young doctor may be in a Health Centre. The education of other health workers, particularly those with specific social duties, may also be completed by a period of health centre work).
The staff of a Health Centre does not, of course, consist of doctors only. Equally important are the other health workers, some of whom have almost separate functions, but all of whom should be in contact with the family doctor. The team must be more than a theoretical ideal; it must be a real working partnership in which all play a part.
Fixing a Standard
In translating this ideal into practical terms, a second factor must be taken into consideration. It is essential to have a standard as to what is an adequate service and to consider the number of staff which will constitute a suitable team.
Of equal importance is the size of the unit of population which will suitably employ that team without waste of man-power and without over-working any member of the team.
Furthermore, having set a minimum standard, local initiative and enthusiasm must be allowed scope to plan for the varying local needs of rural, urban and city populations.
For this reason the S.M.A. has made detailed plans for Health Centres, and suggests that where large scale organisation would best be met by unifying the health services regionally, small scale organisation would best be provided by operational units or divisions of about 100,000 people.
Such a unit of population requires approximately1,000 hospital beds, and the Association believes that an efficient hospital service can be built up from the hospital groups now in operation if they are completely integrated and constitute general hospitals serving primarily a single unit of population.
An operational unit of this size requires a complete Health Centre service. A group of Health Centres would be necessary, one of which might be designated as the Divisional Health Centre and carry out all the functions outlined above. At least four to five other Health Centres would be needed inside the operational unit and would provide as a rule the first eight items on the above list.
Such a scheme must, however, be very elastic if it is to meet widely varying conditions in different parts of the country. Four to five centres per 100,000 of the population, visualises an upward limit of 20,000-25,000 potential patients at each centre. A lower limit must also be postulated if efficiency is to be obtained, and this must be linked to the question of the ideal team of health workers.
Better than a Surgery
The Association has always insisted that the team to be built up should not only be a team of general practitioners but also one which includes all types of qualified medical personnel, plus all the ancillary services. If this is carried out, then even in a health centre serving so sparsely populated a district that at the moment only one or two doctors succeed in making a satisfactory income, the linkage with the other health personnel would produce something better than the surgery of the isolated practitioner.
The practitioner consenting to serve in a really difficult part of the country of which there are, fortunately, only a small number, e.g., some parts of Wales, the Borders and Highlands of Scotland, should not be left in isolation. Therefore, in surveying any given region for the allocation of operational units, every effort should be made to avoid health centres in which fewer than three doctors can be employed.
Since long travelling distances use up a very large proportion of a country doctor's time, fewer patients should be attached to such a health centre; the smallest unit of population to be provided for under such circumstances should be about 5,000. It may. well be that the scattered communities of the few remote areas would be better provided for by mobile units.
Local health centres should, therefore, serve units of population ranging from 5,000 to 25,000, and efforts should always be made to divide the country so that the larger number is the more common.
It is vital to the conception of health centres that all family doctors should be paid on a whole-time salaried basis, as are so many specialists today. In fixing salaries, the general practitioners must not be placed in a position of inferiority but should be able to reach a salary that will compare, work for work, with that of the consultant; and a system of optimum salaries should be arrived at so that the job to be done, and not the mere number of heads on a list, settles the income.
This clearly does not mean equality of incomes, for there will be many variations to account for age, experience and responsibility.
Within a system of collective responsibility for the health of the community there may still be quite a wide range of income. The present ceiling of 4,000 patients per doctor's list is generally accepted as being far too high. The average for the country as a whole is about 2,200.
For purposes of calculation and in order to allow for small variations, it may be assumed that the average per doctor in a local health centre of maximum size would be 2,500 with a ceiling of 3,000. There would then be in a unit such as this ten doctors, but one or two trainee assistants might be added so that, while the responsibility would rest with the ten permanent doctors, the relief for holidays, study leave and sickness would be easy.
The Association believes that it is incorrect to levy a charge of rent for premises on doctors working on a salaried basis in the Health Centre.
Staffing the Centres
The National Health Service will be judged largely by the quality of the general practitioner service provided, and this is dependent on the development of first-rate Health Centres. The optimal requirements for personnel and accommodation may need to be modified to meet existing difficulties, but here is a staff list based on a 20,000 unit population for 24 hours a day seven days a week service:
General Medical Practitioners 10
(This appears the maximum number possible at the moment, but 6—7 would be desirable).
Trained Dental Attendants 4-12
Dental Technicians 3
Ophthalmic Opticians (as part of the National Ophthalmic services) 2
This is worked out on the basis of fifty per cent. of all confinements being delivered at home, and would be covered by a midwife doing 70 confinements per annum. Health Visitors 5
This figure is an approximate one based on the numbers at present utilised for maternity and child welfare service.
Social Workers 3
Social workers are at present mainly almoners in hospital, and it will be some time before there are many available for Health Centre work.
However, with the Health Centre taking on a good deal of hospital out-patient routine, it is possible that a number of almoners at present in hospital may be used in Health Centres. The social worker will concentrate mainly on the social problems of the family, whereas the health visitor's work will be mainly in advice for preventive measures.
Nurses—Domiciliary and Health Centre 10
(Including 1 Superintendent Nurse). This figure of 10 is an approximation, and only experience will dictate the actual number required.
(a) Domiciliary nurses could decant off a number of nurses now employed for the present type of out-patient hospital work, which will be taken over by the Health Centre,
(b) If adequate transport was provided for the nurses, more of their time could be spent in actually attending to patients instead of walking long distances each day.
Chiropodists (as part of a National Chiropodial Service) 2
These will be supplied from the Group Laboratory where considered necessary.
It is accepted that the dental X-rays would be done by the dentists themselves, but provision should be made for X-rays for medical work.
Administration Officer 1
Registry Staff 3
Canteen Staff 3
Home Helps, as available and required
Extracts from "Get the Health Centres Going Now" Socialist Medical Association (now Socialist Health Association) article published in the Autumn 1951 edition of Medicine Today & Tomorrow. "The only political medical journal published in Britian