2
25 addition give an .atmosphere of individuality to each hospital ; others require personal service, and it would be an unhappy day when that were cast out from our midst. A house committee will not manage its hospital, but it will have a valuable function in advising the management committee and in meeting these indefinable needs of the hospital patient. As chairman of a hospital management committee the first thing I can see is that groups of hospitals which used to go their own way will now be united under a single managing body. This offers an immediate opportunity for the staff, both senior and junior, to get together and inquire what service they can render, not to one unit alone but to the group. It also creates for the first time a real chance for the visiting consultant to become an active member of the staff of the hospital in which he used to pause for an hour or two on his great journey. THE EXECUTIVE COUNCIL First to be established among the many new bodies needed to administer the National Health Service Act, the executive councils suffered at the start because of this priority. They were set up when medical opinion was running strongly against the Act, when every move of the Minister was regarded with suspicion, and when any cooperation offered was likely to be grudging and conditional. Moreover, they had to try to weld into an executive whole elements drawn from five distinct (and potentially antagonistic) sources. Three of the groups were professional, severally representing the doctors, the dentists, and the pharmacists, while the rest were govern- mental-nominees of the local health authority and of the Minister. The Minister’s nominees were mostly survivors of the old insurance committees, often having strong associations with approved societies. It can hardly be said that this pattern gave promise of easy coöpera- tion. Nevertheless in most areas things have worked out better than might have been expected. The local medical committees chose doctors of experience to represent them, and the expert professional advice they have been able to afford on a host of different complicated schemes coming before the council for ratification has done much to promote respect and understanding for the doctor’s point of view. The executive councils have found it necessary to set up financial and other subcommittees. Doctors have been afforded a full share of responsibility in these sub- committees, and have often been chosen as chairmen or deputy chairmen. Particularly in the larger local- authority areas, the need for liaison with such bodies as the hospital management committees-of which there may be twenty or more within the boundaries of the larger counties-has thrown a considerable extra strain upon the already overtaxed time of council members. The doctors have had to accept part of this responsibility, each taking his place on the appropriate local hospital committee. The executive machine must at present run in top gear, if it is to be able to cope with the influx of applica- tions and settle the problems of patients and doctors proposing to participate in the service. Soon this initial work should quieten, and more time and thought can then be spared to face the tasks the future holds. Pre- dominant among these must be the establishment of health centres. By the time this appears on the agenda the doctors in most counties will probably have settled into a relationship with their colleagues on the council that will give them considerable authority in discussion. The doctors are now numerically stronger than in the old insurance committees, and can be drawn from a wider selection of areas. For the first time they meet and confer with the councillors, who in another place are responsible to the people for health provision. The design is one which can, and eventually will, provide great and growing opportunity for professional guidance of, and influence on, the developing pattern of the new service. THE TEACHING HOSPITAL The Act gives the teaching hospitals opportunities which, if used wisely and imaginatively, augur well for the future of medicine in general, and of medical educa- tion in particular. All hospitals will be less susceptible to those financial anxieties which changing economic circumstances bring in their train ; equipment and facilities will be more closely related to demonstrable needs and less dependent on the whims of the generous. But it is especially in the solution of two closely related problems for the teaching hospitals that the new order opens the way. Firstly, in adjusting the internal pattern of its services so that the demands of undergraduate teaching may best be met. In the past few decades the increasing complexity of diagnosis and treatment has been reflected in an increasing compartmentalism ; the teaching hospital has too often become a collection of highly specialised units, and undergraduate training has correspondingly suffered. The future offers opportunities for experiment: for example, in the design of the undergraduate teaching hospital ; the distribution of beds ; the provision of " admission " wards through which most patients will pass before they are directed to the medical, surgical, or specialist services ; the association of model health centres with the work of the hospital ; and a host of other issues. Secondly, teaching hospitals have hitherto remained too often isolated both from each other and from non- teaching hospitals. The inadequate use, for teaching, of the staff and facilities in non-teaching hospitals has been rightly criticised. Clearly all suitable resources in both groups of hospitals should be tapped for both under- graduate and postgraduate teaching. To this end the term " non-teaching " hospital should be abolished, and two desiderata promoted: (1) There must be a large measure of common staffing between both groups of hospitals. Special units will be placed where they are best suited, and the needs of the undergraduate will not be sacrificed to those of the member of a teaching hospital staff who is developing such a unit. (2) There must be set up non-statutory committees, repre- senting three interests-the university medical school, the regional board, and the board of governors-whose prime concerns will be how to ensure this common staffing and how and where can best be provided the clinical requirements of the medical school for its undergraduates and postgraduates. The harmonious working of such a committee, and the personal contacts it would permit, would play a most useful part in breaking down any barriers which might arise between regional and teaching hospitals. Nothing will militate more against the success of the projected hospital service than its inheritance of antagonisms analogous to those which so often existed in the past between teaching and non-teaching hospitals, and between voluntary and municipal hospitals. In a unified hospital system, the regional and teaching hospitals have complementary roles : both will take part in teaching; both will, it is hoped, provide the highest, standards of service. But each will so model itself that it can best fulfil its special purpose for the general good. THE REGIONAL BOARD , Most regional boards have now completed their first task-the grouping of hospitals and the selection of committees of management ready to take over on the appointed day. Much more " domestic " spade-work lies before them. Work of this type is all-important if the hospitals are to be efficiently and economically administered. For the most part such problems are the

THE REGIONAL BOARD

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addition give an .atmosphere of individuality to eachhospital ; others require personal service, and it wouldbe an unhappy day when that were cast out from ourmidst. A house committee will not manage its hospital,but it will have a valuable function in advising themanagement committee and in meeting these indefinableneeds of the hospital patient.As chairman of a hospital management committee the

first thing I can see is that groups of hospitals which usedto go their own way will now be united under a singlemanaging body. This offers an immediate opportunityfor the staff, both senior and junior, to get together andinquire what service they can render, not to one unitalone but to the group. It also creates for the first timea real chance for the visiting consultant to become anactive member of the staff of the hospital in which heused to pause for an hour or two on his great journey.

THE EXECUTIVE COUNCIL

First to be established among the many new bodiesneeded to administer the National Health Service Act,the executive councils suffered at the start because of this

priority. They were set up when medical opinion wasrunning strongly against the Act, when every move ofthe Minister was regarded with suspicion, and when anycooperation offered was likely to be grudging andconditional. Moreover, they had to try to weld into anexecutive whole elements drawn from five distinct (and

potentially antagonistic) sources. Three of the groupswere professional, severally representing the doctors, thedentists, and the pharmacists, while the rest were govern-mental-nominees of the local health authority and ofthe Minister. The Minister’s nominees were mostlysurvivors of the old insurance committees, often havingstrong associations with approved societies. It can hardlybe said that this pattern gave promise of easy coöpera-tion. Nevertheless in most areas things have worked outbetter than might have been expected. The local medicalcommittees chose doctors of experience to represent them,and the expert professional advice they have been ableto afford on a host of different complicated schemescoming before the council for ratification has done muchto promote respect and understanding for the doctor’spoint of view.The executive councils have found it necessary to set

up financial and other subcommittees. Doctors havebeen afforded a full share of responsibility in these sub-committees, and have often been chosen as chairmenor deputy chairmen. Particularly in the larger local-

authority areas, the need for liaison with such bodies asthe hospital management committees-of which theremay be twenty or more within the boundaries of thelarger counties-has thrown a considerable extra strainupon the already overtaxed time of council members.The doctors have had to accept part of this responsibility,each taking his place on the appropriate local hospitalcommittee.

- The executive machine must at present run in topgear, if it is to be able to cope with the influx of applica-tions and settle the problems of patients and doctorsproposing to participate in the service. Soon this initialwork should quieten, and more time and thought canthen be spared to face the tasks the future holds. Pre-dominant among these must be the establishment ofhealth centres. By the time this appears on the agendathe doctors in most counties will probably have settledinto a relationship with their colleagues on the councilthat will give them considerable authority in discussion.The doctors are now numerically stronger than in

the old insurance committees, and can be drawn from awider selection of areas. For the first time they meetand confer with the councillors, who in another placeare responsible to the people for health provision. The

design is one which can, and eventually will, provide

great and growing opportunity for professional guidanceof, and influence on, the developing pattern of the newservice.

THE TEACHING HOSPITAL

The Act gives the teaching hospitals opportunitieswhich, if used wisely and imaginatively, augur well forthe future of medicine in general, and of medical educa-tion in particular. All hospitals will be less susceptibleto those financial anxieties which changing economiccircumstances bring in their train ; equipment andfacilities will be more closely related to demonstrableneeds and less dependent on the whims of the generous.But it is especially in the solution of two closely relatedproblems for the teaching hospitals that the new orderopens the way.

Firstly, in adjusting the internal pattern of its servicesso that the demands of undergraduate teaching may bestbe met. In the past few decades the increasing complexityof diagnosis and treatment has been reflected in an

increasing compartmentalism ; the teaching hospital hastoo often become a collection of highly specialised units,and undergraduate training has correspondingly suffered.The future offers opportunities for experiment: for

example, in the design of the undergraduate teachinghospital ; the distribution of beds ; the provision of" admission " wards through which most patients willpass before they are directed to the medical, surgical, orspecialist services ; the association of model healthcentres with the work of the hospital ; and a host ofother issues.

Secondly, teaching hospitals have hitherto remainedtoo often isolated both from each other and from non-teaching hospitals. The inadequate use, for teaching, ofthe staff and facilities in non-teaching hospitals has beenrightly criticised. Clearly all suitable resources in bothgroups of hospitals should be tapped for both under-graduate and postgraduate teaching. To this end theterm " non-teaching " hospital should be abolished, andtwo desiderata promoted:

(1) There must be a large measure of common staffingbetween both groups of hospitals. Special units will be placedwhere they are best suited, and the needs of the undergraduatewill not be sacrificed to those of the member of a teachinghospital staff who is developing such a unit.

(2) There must be set up non-statutory committees, repre-senting three interests-the university medical school, theregional board, and the board of governors-whose primeconcerns will be how to ensure this common staffing and howand where can best be provided the clinical requirements ofthe medical school for its undergraduates and postgraduates.The harmonious working of such a committee, and thepersonal contacts it would permit, would play a mostuseful part in breaking down any barriers which mightarise between regional and teaching hospitals. Nothingwill militate more against the success of the projectedhospital service than its inheritance of antagonismsanalogous to those which so often existed in the pastbetween teaching and non-teaching hospitals, andbetween voluntary and municipal hospitals.

In a unified hospital system, the regional and teachinghospitals have complementary roles : both will take partin teaching; both will, it is hoped, provide the highest,standards of service. But each will so model itself thatit can best fulfil its special purpose for the general good.

THE REGIONAL BOARD

, Most regional boards have now completed their first

task-the grouping of hospitals and the selection ofcommittees of management ready to take over on theappointed day. Much more " domestic " spade-worklies before them. Work of this type is all-important ifthe hospitals are to be efficiently and economicallyadministered. For the most part such problems are the

26

natural concern of the lay members of boards. To themedical members, however, more fascinating problemsloom ahead, and it is clear that the Act has conferred uponus as a profession great responsibilities for the exerciseof imagination and leadership. These responsibilitiesare ours alone, and we must not fail to rise to the occasion.Regionalisation, in essence, is the diffusion throughout aregion of a complete specialist service based on the

hospitals, and the integration of all fields of specialistpractice in a coherent whole. We are primarily concernedwith the standards of the science and practice of medicine.Such regionalisation cannot be achieved by any so-calledbureaucratic plan involving regimentation and directionof the members of a specialist corps within a region ; nor,as I see it, does the Act suggest or even encourage suchnotions. One master there must be in the final analysis-the Treasury-which implements the ideas of thenation on the amount to be spent on the hospital services.To this disciplinary check we must all bow. But regionalboards, boards of governors of teaching hospitals, andcommittees of management all contain large quotas ofmedical members ; and advisory medical committees,both in hospitals and outside hospitals, will soon be setup. As a profession we are in a more powerful positionthan ever before. If we grasp the opportunities presentedto us the hospital services of the future will bear the

imprint of the ideas and standards of our free andlearned profession. July 5 in the hospital world in thiscountry is not the Loss of Independence Day, but, asPresident Woodrow Wilson long ago said of July 4," This is Interdependence Day."

.

THE LOCAL MEDICAL COMMITTEE

So that the transition from National Health Insuranceto the National Health Service should be smooth, theMinister of Health said some months ago that he wouldrecognise the existing local medical and panel committeesas

" local medical committees " for the purposes of thenew Act. As election to these committees was suspendedduring the war, many have been preparing themselvesfor their new duties by fresh elections and sometimes byrevision of their constitution.

Many of the duties so far undertaken are not new ;they had their parallel under National Health Insurance.It was no novelty to older members of the committeeto be asked to scrutinise, amend, and approve schemesfor allocation, distribution, and mileage ; nor did theyfind it hard to accept membership of such familiar bodiesas the medical service committee (dealing with com-plaints’against doctors) and the allocation committee

(dealing with patients unable themselves to secure

acceptance on any doctor’s list), or even of the executivecouncil itself. For though the council offers the localmedical committee a larger part to play, it remains theold insurance committee writ large. What are new arethe opportunities now being provided for linking theactivities of the local medical committees with those ofbodies such as the statutory health committees of thelocal health authority, the hospital management com-mittees, and the regional committees for consultants andspecialists. In some local medical committees, also,reciprocal cooption of representatives from such fieldsas obstetrics, ophthalmology, and preventive medicineis being discussed. Through these new links the localmedical committees are finding new means of integratingthe different parts of the growing service, and particularlyof ensuring that at no level shall the needs of the generalpractitioner be unknown, nor his advice unsought.

If the load is to be spread and the work well done, suchdiverse calls as these demand that in many areas thereshould be larger committees, meeting more frequentlythan has usually been necessary in the past. On the wholethe extra work is being readily undertaken. In my own

committee, -meetings are well attended : each new

scheme or fresh regulation is critically examined ; the

many nominees required for service, with other bodiesare forthcoming in more than adequate number ; and

altogether there is good reason to hope that,. even thoughthe infant service does not escape all teething troubles,these inevitable maladies will at least be detected andcorrected without either undue delay or disaster.

THE MEDICAL OFFICER OF HEALTH

doubts remain, but the fundamental question is answered.It has been a necessary phase, which has secured to theprofession its essential freedoms. Now the tumult andthe shouting dies and the hum of preparation gains inintensity. What are the opportunities as they presentthemselves to the eyes of a medical officer of health ’?His gaze may at the moment be somewhat myopic-nosection of the profession indeed has been more drasticallyreoriented-and focused on his departing gloriesrather than on the future; but his work, one hundredyears of struggle towards the greatest good of the greatestnumber, both needs and develops the philosophic mind,and he has the consolation of seeing the preventive ideanow dominating the whole of British medicine. He hasthe still greater consolation of an important place in oneof the three great branches of the new service. Herehe can be of real value in fostering the team-work whichshould be the keynote.

Cooperation, not competition. Not at any rate compe-tition for the most patients and the biggest income, butrather for the best standard of service, whether in

consulting-room, health centre, or hospital. And coöpera-tion in placing knowledge and technical resources at thedisposal of any patient who needs them. This is thegreatest of the many opportunities the Act presents.Nothing less must be the goal of those who join. Thosewho stay out will miss something. They may be lesspressed ; the amount of time they can give to individualpatients -may be greater ; but the stage on which theyperform will be smaller. Attending to the medical needsof 40 million people is a big and worth-while job. Itwill mean pressure on those providing the service, it willcertainly involve frustrations and vexations, but it willgive satisfaction-not least the satisfaction of workingin teams.The profession can mould the service. On every piece

of administrative machinery it is well represented andon some it is dominant. Committee work can be boring,but it is indispensable and the profession’s opportunityis as great as its responsibility. Traditions must bemade, and policy guided by the accumulated skill andwisdom of the profession. Its committee men must doa good job.The profession must also examine its r6le in health

education. Much of what now passes under that name

only produces disease consciousness. That in turn meansfear. It is surprising how large a part fears play inmodern life. We have it that the right kind is the begin-ning of wisdom, and the doctor can perhaps discouragesome of the others. The effort, one imagines, will have toconcentrate more on the individual than on the mass,but there will be scope for it in the new service. Evenwithin the profession itself there are some of these fearsand bogies that we might well start to exorcise.The nation has recently lived triumphantly through its

finest hour. We are all a bit tired and the road to thenew service will be uphill at the beginning ; but the vistaat the top will match the vision at the foot. Pioneeringhas never been easy, but the profession now has itschance. Grumbling in traditional style, it is also gettingready to get on with the job. The shades of Simon, Budd,Farr, Hunter, Lister, Osler, Macewen, Robert Jones,Dawson, and others of the elect must be watching withinterest. And so must that of Chadwick.