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Health Centres of Tomorrow

I-SCOPE

" IN the last two years there has been such a clamourfrom sectional interests in the field of national healththat we are in danger of forgetting why these proposalsare being brought forward at all." This remark byMr. Aneurin Bevan applies very well to health centres.In controversy on whether, how, where, and by whomthese centres shall be built, we have lost sight of why theyare needed at all.

WHY ARE HEALTH CENTRES WANTED ‘

In 1942 the Medical Planning Commission, after longand.detailed discussion by representatives of all branchesof medical practice, issued an interim report which said :

" The days when a doctor armed only with hisstethoscope and his drugs could offer a fairly completemedical service are gone. He cannot now be all-sufficient. For efficient work he must have at hisdisposal modern facilities for diagnosis and treat-ment, and often these cannot be provided by a privateindividual or installed in a private surgery. He mustalso have easy and convenient access to consultant andspecialist opinion, whether at hospital or elsewhere, andhe must have opportunities of real collaboration withconsultants. There must also be close collaborationamongst local general practitioners themselves, fortheir different interests and experience can be of valueto each other.

" Greater efficiency and economy would be securedand less expense incurred if groups of practitionerswould cooperate to conduct a single centre at whichall of them would see their -own patients and shareequipment and the services of secretarial, domestic,and dispensing staff. The value of the practitionerto his patients would gain immeasurably from hisclose and constant contact with his colleagues....

" A convenient term for the focal point of coöpera-tion is health centre.’ ...

" The health centre must on the one hand preservethe professional independence of the cooperating generalpractitioners, it must on the other hand be capable ofbecoming an organised unit in an integrated medicalservice." c

The main purpose of the centre, as the Medical Plan-ning Commission saw it, is to create better conditions forgeneral practice by allowing the more general use ofmodern methods of diagnosis and treatment, by encourag-ing practitioners to work with one another and withdentists, nurses, and midwives, and by making fulleruse of secretarial and other ancillary staff so as to preventwaste of medical time and effort.

WHAT KIND OF CENTRE ? ‘

Most of this has long been common ground, butopinions differ over the emphasis, and consequentpriority, to be given to the several aims. Of the twomain schools of thought the first holds that what the

general practitioner needs most of all is access to specialdiagnostic methods carried out on his behalf by experts.The other school chiefly seeks better facilities for thepractitioner’s own use ; it wants to increase his usefulnessby sparing him non-medical tasks and by promotingmore cooperation with his fellow practitioners and otherhealth workers.From the arguments of these two different schools we

have different conceptions of the type of health centreneeded*.The first would be an elaborately equipped building

staffed by consultants and technicians and devoted

entirely to the examination of patients already seen else-where by the general practitioner. The kind of workdone at such a centre would mostly resemble that donein a hospital outpatient department : indeed some of theinvestigations demanded would almost certainly involve

keeping the patient under observation overnight or evenfor several days, and thus make it necessary to provideinpatient or hostel accommodation, with nursing andcatering staff.But if the work is to be that of a hospital outpatient

department, why should it not be done at the hospitalrather than at some special new centre ? True, there areareas without hospitals, where a diagnostic, centrestaffed by specialists would be invaluable ; but reallythis is an argument for seeing that every area has ahospital accessible to it. In a genuinely comprehensiveservice there should be no gaps in hospital provision ; andwith modern methods of transport there need be none.

If then the object of the first type of health centre isbest fulfilled by the hospital, we can concentrate ourattention on the second type-the centre in which generalpractitioners undertake all work ordinarily coming withintheir scope, and, where they assist each other, with ampleaid from technicians. But before we come to detailsof the structure, layout, and equipment there are stillone or two matters of general policy to be considered.

GENERAL AND SPECIAL WORK

Firstly, what duties should in fact come within thescope of the practitioners who will work in the centre ? ‘Obviously all ordinary methods of examination andtreatment now undertaken in the doctor’s private consult-ing-rooms would be included. So also would minorsurgical techniques which do not necessitate inpatientnursing. At almost every centre, moreover, there willbe one or more practitioners particularly interested inone of the specialties, who could be of considerable helpto their colleagues, especially if they could enlarge theirknowledge by special courses or experience. Provisionshould therefore be made in the centre for carrying outthe simpler techniques of (for example) dermatology,ophthalmology, and otorhinolaryngology.What about radiology and pathology Is it better to

put radiographic and pathological equipment in the healthcentre, for the use of the practitioner himself (assistedby appropriate technicians), or to put it in the localhospital under full specialist supervision ?Where a centre accommodates six or more general

practitioners there seems to be a strong case for givingit a pathological laboratory with a full-time technician.Such a laboratory could undertake all’routine bio-chemical, many haematological, and some bacteriologicalexaminations. It would need to be linked with themain district laboratory, both for the performance ofinvestigations which it could not undertake and forregular supervision by the hospital pathologist, whowould have to be responsible for the work of all thehealth-centre laboratories in his charge. To such a

laboratory the practitioner would himself take specimensor (better still) patients ; and whether or not he madehis own investigations he would generally get earlyinformation. The difficulty, the delay, and the expenseof obtaining laboratory help have often prevented or,postponed proper investigation of the patient, and havedepressed the practitioner-esp’ecially the younger manfresh from hospital, where he has been accustomed tosuch aids. Undoubtedly a very wide undiscloseddemand would be revealed wherever a service of thistype was established in a health centre, and there needbe little fear that a full-time technician would not soon be

fully occupied. Laboratory technicians are of course

not nearly numerous enough for the establishment oflaboratories on this wide scale ; but, as it will probablybe several years before the health centres can be builtin any number, there is time to recruit and train moreof these people if the need to do so is recognised now.The case of radiology is rather different, and there

are good arguments both for and against having radio-graphic equipment in the health centre. Those who

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think it undesirable say that X-ray examination requirescomplicated and expensive apparatus, which has to bereplaced regularly because it is always obsolescent.Its most efficient use demands the services of expertsboth for taking and for interpreting X-ray pictures.If every health centre were to be given radiographicapparatus, this would have to be comparatively cheap,and would be infrequently renewed or replaced. Thetendency would be to use it for tasks beyond its propercapacity, and to entrust difficult radiographic problemsto general practitioners who could not justly claim thenecessary training and experience. All this would beuneconomical if it meant that the expensive apparatusand skilled ancillary staff of the larger radiologicaldepartments were not to be used to the full. And itwould be unnecessary if every health centre were linked,as it should be, with a nearby hospital to which thepractitioner had easy access, and from which he wouldreceive the fullest possible assistance from an expertteam working with the best equipment.Those who favour wide provision of radiological

facilities argue, on the other hand, that times are changingand that we are planning for a future in which we canhave standardised and simplified apparatus which willnot be costly and which will serve its purpose for manyyears. We are planning, too, for a generation of doctorswho are being brought up to regard radiography as

necessary for accurate diagnosis and for any exactestimate of progress and prognosis-who are beingtaught themselves to interpret X-ray films and are

encouraged to be present whenever their patients areexamined under the X-ray screen. The health centrewill be properly equipped only if it enables them to usethe knowledge acquired in their training.But if, in due course, it proves both desirable and

possible to have X-ray apparatus at all centres, this mustnot be used in isolation : the health centre must be linkedwith the district hospital in such a way that the radiologistthere can keep an eye on the work done at the centreby the practitioners and their radiographer. The radio-

logist should indeed have regular and frequent meetingswith the centre staff so as to be able to offer his expertadvice and aid on any radiological problem which mayarise, and all examinations outside the scope of the centreand its staff should be referred to the parent hospital.Such is probably the ideal arrangement for the future ;

but until there is suitable apparatus, and enough radio-graphers, the doctors at health centres will have to relyon the hospitals for most of the radiography required.Access to this and other hospital specialist services mustbe made as simple as possible, or we shall miss most ofthe improvement of general practice which healthcentres are meant to promote.

WORK FOR THE LOCAL AUTHORITY

Among the special activities which certainly couldand should be undertaken at the health centre are ante-natal and postnatal examinations and child welfare.And these bring us to the question of the relation betweenthe general practitioner, working in the centre, and thepublic-health authorities.The white-paper on the National Health Service Bill

sets out the position thus :" The Bill makes it the duty of the county and

county borough councils to provide, equip, staff, andmaintain the new health centres to the satisfaction ofthe Minister. The local authorities will directly admini-ster such of their own local clinic facilities as they mayprovide in the centres. Doctors and dentists, however,who use the new centres while participating in thegeneral personal practitioner service will be in contractonly with the new Executive Councils, and it will befor those Councils to arrange with the local authoritiesfor the use of the centres’ facilities by those doctorsand dentists."

The local-authority services which we may expectto be partly or wholly provided at or from the healthcentre include " antenatal clinics for the care of expectantmothers, postnatal and child clinics, the provision ofsuch things as cod-liver oil, fruit juices, and other dietarysupplements, and in particular a priority dental servicefor expectant and nursing mothers and young children."In addition, the Education Act, 1944, requires the localauthority to provide a service both of medical inspectionand of treatment for all children attending State-providedor State-aided schools ; and while the function of inspec-tion will still be performed most conveniently at theschools, the health centre seems a far more appropriateplace for treatment. The local authority has also toarrange a domiciliary midwifery service, and servicesof health visiting and home nursing ; and though in acompact area such as a county borough it may be possibleto conduct all nursing services from a central healthdepartment in the municipal administrative offices, themore widely spread responsibilities of the county M.o.H.will often oblige him to depute the day-to-day super-vision of these services to divisional officers, who maywell find that the health centres are their most suitableheadquarters.

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It will often be necessary, therefore, to establish inthe health centres some form of condominium betweenthe general practitioners and the local-authority doctors.

HEALTH

The work of the centre should thus associate the tech-niques of curative medicine and preventive medicine, and wemay hope that practitioners will increasingly look on thelatter as part of their affair. But both cure and preven-tion are concerned with disease, and an organisationdesigned solely to promote them would scarcely, beentitled to the name of health centre. A health centre

ought also to serve the third and newer branch whichone might call functional medicine, the purpose of whichis to help people to make the best use of their capacities-to have life more abundantly. ,

, " Positive health " is a state of well-being above the

average, while " negative health " is a state of ill-beingbelow the average. The medical profession has hithertohad to give most of its attention to the negative depar-tures from ordinary health which we call disease ; butas curative and preventive medicine grow more successfuldoctors should have more chance to practise functionalmedicine-the promotion of positive health. Thoughthe technique of this branch is in its infancy, it is obviousat least that the health centre is a convenient base forwhat is called health education, applied both toindividuals and to groups. Lectures, films, classes, anddemonstrations are among the means by which thiswork can be done, and if there is no more suitable meeting-point for them the public might be invited to the healthcentre for instruction.The most attractive place for it would of course be a

community centre with some of the characteristics ofPeckham, including swimming-bath, gymnasium, restau-rant, and equipment for amateur entertainment andhobbies. In some towns it might indeed be possiblequite soon to bring the medical work and these socialactivities under a single roof ; but for a long time tocome this will be exceptional. Meanwhile, however, theideal of a true health centre should be kept always inmind, so that our emphasis is increasingly placed on

positive health. This is not so much a matter of planningand building as of mental attitude-particularly theattitude of the practitioner.The term " health centre," like the term " National

Health Service," represents an aspiration rather than animmediate probability; though it is none the worsefor that. It raises problems of medical education towhich we shall return in our concluding article.