posals were not carried into effect. A National Health Service: The British Sixteen years later similar proposals were made by a Voluntary Hospitals White Paper* Commission established by the Brit• ish Hospitals Association under the THE BRITISH WHITE PAPER on a Na• Health Insurance was enacted in chairmanship of Lord Sankey. tional Health Service was made pub• 1911; shortly after medical benefits lic on February 17. In it the Minister became payable it was recognized One of the most complete official of Health and the Secretary of State that there was a strong case for add• surveys of Scottish health services for Scotland recommend the estab• ing consultant services to the general and health problems ever attempted lishment of a National Health Service practitioner services provided. In was published in 1936 in the Cathcart "which will provide for everyone all 1920, a Consultative Council on Med• report of the Committee on Scottish the medical advice, treatment and ical and Allied Services, appointed by Health Services. Their recommenda• care they may require." The pro• the Minister of Health, with Lord tions assume throughout that the posals are offered at this time for dis• Dawson of Penn as chairman, re• separate medical services must be cussion in Parliament and in the ported and recommended a compre• integrated and that the coordinated country but not as fixed decisions. hensive scheme under which all forms medical service should be based, as "The Government will welcome con• of medical service would be made far as possible, on the family doctor. structive criticism and they hope that available, under suitable conditions, The latest official report on hospital the next stage—the stage of consul• to the population at large. The re• problems—issued by that Committee, tation and public discussion—will en• port recommended the establishment under the chairmanship of Sir Hector able them to submit quickly to Par• of health authorities for local admin• Hetherington—contains detailed liament legislative proposals which istration and contemplated, as does recommendations for setting up five will be largely agreed." the present Paper, the coordination of regional hospital advisory councils in The British Medical Association municipal and voluntary agencies as Scotland, makes various suggestions has given the proposals a "cautious the basis of the scheme. In the same for improved cooperation between welcome" and plans to send a copy of year a similar Consultative Council hospitals, and deals at length with the White Paper, together with an appointed by the Scottish Board of financial arrangements as affecting analysis of it in relation to the prin• Health, under the chairmanship of the future voluntary hospital system. ciples already adopted by the profes• Sir Donald MacAlister, urged that a sion and a questionnaire prepared by complete and adequate medical serv• Throughout the period between the the British Institute of Public Opin• ice should be brought within the two wars, the British Medical Associ• ion, to every doctor, whether civilian reach of every member of the com• ation was active in focusing the mind or in the armed forces, at home or munity; the report made a number of the medical profession on construc• abroad, member or nonmember of the of recommendations designed to en• tive proposals for extending and de• Association. sure that the family doctor (on whom veloping the existing health services. The Prime Minister, speaking to the the organization of the Nation's In 1930 and again in 1938 the Asso• Royal College of Physicians on March health service should be based) ciation issued comprehensive propos• 2, emphasized the desire of the Gov• would be provided with all supple• als for A General Medical Service for ernment for constructive criticism of mentary professional advice and the Nation, and in 1942 the Medical the plan. "We ask your aid. We assistance, and proposed that the Planning Commission, organized by invite your counsel." State insurance medical service the Association, issued a draft Interim should be extended to cover persons Report offering for the consideration of the same economic level as in• of the medical profession far-reach• Background of the Government's sured persons and dependents of in• ing suggestions for improving the Proposals sured persons. medical services of the community.1 The White Paper proposals have In 1921 the Voluntary Hospitals Other organizations making recom• been prepared and are put forward Committee, with Lord Cave as chair• mendations include Medical Planning against a background "of construc• man, recommended an Exchequer Research,2 representing for the most tive thinking and discussion during grant to meet the immediate needs part the younger elements in the pro• the last quarter of a century." These of the hospitals and proposed the fession, the Society of Medical Offi• recommendations for an improved establishment of permanent machin• cers of Health,2 and Political and Eco• health service, summarized in Ap• ery to coordinate the work and fi• nomic Planning (P E P) .1 pendix B of the White Paper, started nances of voluntary hospitals Without attempting to review the only a few years after National throughout the country through a whole field of recommendations, the central Voluntary Hospitals Commis• White Paper declares that, in very *This summary, prepared in the Divi• sion and local voluntary hospitals general terms, "the principles most sion of Publications and Review, Office of the Executive Director, is based on A Na• committees for county and county frequently recurring in the presenta- tional Health Service (Cmd. 6502, London, borough areas. The Government 1944, 85 pp.) and A National Health Serv• accepted the findings of the Com• 1A brief statement of some of the pro• ice, The White Paper Proposals in Brief posals was carried in the Bulletin, Decem• (London, 1944, 32 pp.), both issued by the mittee to the extent of providing an ber 1942, pp. 11-21. Ministry of Health and the Department of Exchequer grant for the voluntary 2 See the Bulletin, March 1943, pp. 43-48, Health for Scotland. hospitals, but the long-term pro• for a brief summary. tlon of plans for future developments possible help and expert guidance who uses the new service is assured are the following:— from the outset. It was arranged of ready access to whichever of its "(1) that there should be made with them that, for the first stage, branches he or she needs." Partici• available to every individual in the they should appoint small groups of pation in it will not be compulsory community whatever type of medical representatives of their own choice for either medical practitioners or care and treatment he may need; and that these groups should take the public. "(2) that the scheme of services part in general preliminary discus• The White Paper points out that should be a fully integrated scheme sions." much of what is required is already and that in particular a much closer Evolution of the Government's pro• provided in one or another of the linking up between general practi• posals was planned in three stages. existing health services. "The prob• tioner services on the one hand and In the first, a preliminary exchange lem of creating a National Health consultant and hospital services on of ideas would be conducted infor• Service is not that of destroying the other ought to be achieved; and mally and confidentially and without services that are obsolete and bad and "(3) that for certain services, par• commitment on either side, to enable starting afresh, but of building on ticularly the hospital service, larger the Ministers to get a general impres• foundations laid by much hard work areas of local administration are sion of the feeling of these represent• over many years and making better needed than those of any existing atives on some of the main issues in• what is already good." The need for kind of local authorities." volved and to help them to clear the a new attitude toward health care is ground. The second stage would be perhaps the most important point. In October 1941, the White Paper one of public discussion in Parliament "Personal health still tends to be re• continues, the Government an• and elsewhere, when everybody—the garded as something to be treated nounced their intention to ensure, by public generally, for whom the serv• when at fault, or perhaps to be pre• means of a comprehensive hospital ice would be designed, the doctors and served from getting at fault, but sel• service, that appropriate hospital the hospitals and the local authorities dom as something to be positively treatment should be readily available and other organizations which would improved and promoted and made to everyone in need of it. Responsi• be concerned in it or affected by it, full and robust." bility for the enlarged services was to and those men and women (including be placed with the major local au• doctors) who are now engaged in the The services proposed by the Gov• thorities, in close cooperation with armed forces—would be able to dis• ernment at this time are grouped voluntary agencies working In the cuss what was proposed and to voice into three main categories—a general same field; it was expressly recognized their opinions about it. To assist in practitioner service, hospital and that the service would have to em• this the Government would issue a consultant services, and local clinic brace areas larger than those of most White Paper to serve as a focus for and other services. Arrangements of the existing local authorities and detailed discussion. In the third for general medical practice are de• that the full use of the powerful re• stage, the Government would settle scribed as the most important part sources of the voluntary hospitals, as what exact proposals they would sub• of the proposals for a comprehensive well as the coordination of their re• mit in legislative form for the decision program and at the same time the lationships with the local authorities, of Parliament. would be essential. To pave the way, most difficult. "The family doctor is a detailed and expert survey was the first line of defence in the fight started on the Minister of Health's General Nature of the for good health; it is to him that behalf—partly conducted directly by Government's Proposals every citizen using the new service the Ministry and partly organized for will look for advice on his own health the Minister by the Nuffield Provin• The new health service in all its and the health of his family; and it cial Hospitals Trust—of the hospital branches will be free to all, apart is generally through him that access services already available in each area from possible charges for certain ap• will be had to the many other forms in England and Wales. This survey pliances. "Those who prefer to make of medical care which the National is now nearlng its completion. So their own arrangements for medical Service will provide." In determin• also is a similar survey in Scotland. attention must be free to do so. But ing the best form of general medical to all who use the service it must practice, the report says, "The Gov• In February 1943 the Government offer, as and when required, the care ernment fully agree that 'grouped' announced acceptance of Assumption of a family doctor, the skill of a practices, to which numerous pri• B of the Beveridge proposals for a consultant, laboratory services, treat• vately arranged partnerships point comprehensive unified system of ment in hospital, the advice and the way, must be placed in the fore• social insurance and allied services— treatment available in specialised front of their plans for the National that a comprehensive national health clinics (maternity and child welfare Health Service and their proposals service, for all purposes and for all centres, tuberculosis dispensaries and are designed with this in view." Be• people, would be established. "The the like), dental and ophthalmic cause of lack of sufficient experience Health Ministers thereupon ap• treatment, drugs and surgical appli• to determine the best conditions un• proached the medical profession, the ances, midwifery, home nursing and der which individual doctors can best voluntary hospitals and the major all other services essential to health. collaborate or the extent to which local government authorities, from Moreover, all these branches of med• in the long run the public will prefer each of whom they wanted—on a pro• ical care must be so planned and re• the group system, and because the posal of this magnitude—to obtain all lated to one another that everyone system could not be adopted every- where simultaneously, the plan pro• the chairmanship of Sir William "The absorption of the existing poses that the new service shall be Goodenough. "There are not yet services into a comprehensive service based on a combination of grouped enough men and women of real con• does not materially alter this situa• practice and separate practice, side sultant status and one of the aims will tion. To uproot the present system by side. "Grouped practices are more be to encourage more doctors of the and to put into the hands of some likely to be found suitable In densely right type to enter this branch of central authority the direct admin• populated and highly built-up areas medicine or surgery and to provide istration of the new service, transfer• and it is there particularly (though the means for their training. There ring to it every institution and every not exclusively) that they will first is also need for a more even distribu• piece of present organisation, would be started. It will then be possible tion." run counter to the whole historical to watch the development, with the Clinics and other local services— development of the health services; profession, and to decide in the light the third branch of the Government's and from a practical point of view a of experience how far and how fast proposals—"must include arrange• step of this kind would certainly not a change over to this form of practice ments for home nursing, midwifery contribute to the successful and early should be made. and health visiting." The existing or introduction of the new service. "The conception of grouped prac• future local clinics and similar serv• Changes, some of a drastic kind, in tice finds its most usual expression ices for maternity and child welfare the present organisation of local in the idea, advocated by the Medical and other special purposes are also areas and administrative bodies will Planning Commission and others, of to be included. "As time goes on and be necessary . . . But there is no case conducting practice in specially de• the new scheme gets into its stride, for departing generally from the signed and equipped premises where there will be room for experiment and principle of local responsibility, cou• the group can collaborate and share innovations in the way in which these pled with enough central direction to up-to-date resources—the Idea of the various local services are provided. obtain a coherent and consistent na• Health Centre. The Government In particular, there will be opportuni• tional service." agree that in this form the advan• ties for associating the family doctor tages of the group system can be most more closely with the work of special The Government's proposal is that fully realised, though it will also be clinics—e. g., child welfare centres. central responsibility shall rest on the desirable to encourage grouped prac• But, whatever developments there Minister of Health (for England and tice without special premises. They may be in the clinics and other lo• Wales) and the Secretary of State for intend to design the new service so cally provided services, the introduc• Scotland, who are answerable directly as to give full scope to the Health tion of the new service will not mean to Parliament and through Parlia• Centre system." that any existing facilities are aban• ment to the people. "Indeed, no other doned, but rather that they will be arrangement is possible, having re• To implement a fully organized increased and strengthened to meet gard to the magnitude of the scheme system of hospitals—termed "the the wider objects in view." and the large sums of public money keystone of the National Health that will be involved." But while the Service"—two main problems must Costs of the comprehensive health service will be under general Ministe• be solved. The first concerns the services—estimated at £148 million a rial control, only one part of it—the cooperation and working relation• year—"will be borne partly from cen• general practitioner service—will be ships between the voluntary hospi• tral funds, partly from local rates and in the main centrally administered. tals, the oldest established hospital partly from the contributions of the For the other services, local adminis• system, and the steadily developing public under any scheme of social in• tration is postulated under the major system of local public hospitals. "The surance which may be brought into local government authorities—the Government's proposals are based on operation." Questions of the dis• local county and county borough the fullest cooperation between the ability benefits payable during sick• councils—operating for some purposes two hospital systems in one common ness at home or during periods of severally over their existing areas and service." The second problem is to free maintenance in hospital are for other purposes jointly over larger determine the areas most suitable for termed matters for the Government's areas formed by combination; these hospital organization, and bring the later proposals on social insurance, are the "new joint authorities" re• various separate and independent to be published in a later Paper. ferred to in the report, who will have hospitals together in a working plan Responsibility for providing the the duty of securing all the hospital for each area. comprehensive service "shall be put and consultant services covered by the Tied in closely with the hospital upon an organisation in which both area, either through their own pro• services should be consultant serv• central and local authority take part, vision or through arrangements with ices, the report declares. Lack of and which both centrally and locally the voluntary hospitals in the area, such services in the present National is answerable to the public in the or• and responsibility in the future for Health Insurance is "perhaps the dinary democratic manner . . . With the existing local authority hospitals most marked gap in the range of the exception of medical benefit un• of all kinds. The individual county health services provided." The form der the National Health Insurance and county borough councils making the new consultant services should scheme the public health services of up the joint authority will usually be take is not outlined in detail, however, this country have from the outset responsible for local clinic and other pending the report of the Committee been administered by some form of services within the general framework on Medical Schools now sitting under local government organisation . . . of the plan. Both at the center and locally, part in the new service and it is con• guidance on technical aspects of special new consultative bodies are sequently with the Board that the the Health Service. There will proposed, to ensure development and individual doctor will be in contact, be a similar body in Scotland, (b)Localoperatio n in close association with whether he is engaged In separate (i) professional and experLocalt opinion . At practice or responsibilityin group o r Health Centre will be the side of the Minister, but independ• practice." Practice in health centers, based on the county and county ent of him, the Government would set however, raises a problem, since "it borough councils, which are the up by statute a Central Health Serv• would be difficult to place on local au• major local government authori• ices Council, to consist possibly of 30 thorities the duty of providing, main• ties now. They will administer or 40 members representing the main taining and staffing the Centres and the new service partly in their medical organizations, the voluntary give them no voice in the employment present separate capacities over and publicly owned hospitals (with of the doctors who work there." It their present areas, partly—as both medical and other representa• is proposed, therefore, that a doctor the needs of the service require— tion), medical teaching, and profes• employed in a health center will be by combined action in Joint boards sions like dentistry, pharmacy, nursover• appointed by the Board and the localargerl areas. (ii) ing, and midwifery. ThArease Counci l will authority jointlysuitable, with his terms of for hospital be appointed by the Minister in con• service centrally negotiated and organisation will be designated sultation with the appropriate pro• settled; his service in the center would by the Minister after consultation with fessional bodies, and will select its own be terminatelocald onl y by the Joint de• interests. (iii) chairman and regulate Theits own pro• cision of thcountye Boar d and the local and county cedure. Expenses of the Council will authority, or, if they fail to agree, by borough councils in each area will be met from public funds. The Coun• the Minister. combine to form a joint authority cil will be consultative and advisory, to administer the hospital, con• not an executive body. It will be en• Official Summary of the Proposed sultant and allied services; in the titled to advise not only on matters Services few cases where the area coin• referred to it by the Minister but on cides with an existing county area "any matters within its province on The Government's official abridged the authority will be the county councilwhic h it thinks it right to express anof version of the White Paper includethats area. (iv) expert opinion:At" Comparable locathe l the following sidesummar y (pp. 28-32of ) each new health services councils are proposed reproduced here verbatim. joint authority there will be a 1. for eacScopeh are a of every joinoft authority. the new Service consultative body—professional (a) A National Health Service will and expert—to be called the Local Health Organization of the general prac• be establishedServices. This service will Council. (v) titioner services is seenEach by the Gov• be availabljointe to every citizen in authority will England, ernment as demandinScotlandg a hig h degree and Wales. also prepare—in consultation (b) of centralizeThere d administrationwill , becausbe e nothing to pre• with the Local Health Services of the nature of the services involved vent those who prefer to make Council—and submit for the Min• and the freedom of choice offered both private arrangements for medical ister's approval an "area plan" the patient and the doctor for coming attention from doing so. But, for securing a comprehensive into or remaining outside the system. for all who wish to use the service Health Service of all kinds in its area. "As the doctors will be remunerated it will provide a complete range (vi) from public funds, the MinisteCounty r him• of personaland healt h care—general county bor• self must be ultimately responsible and specialist, at home, in the ough councils combining for these hospital for the central administration,and " elsewhere. duties of the new joint authority (c) MuchThe of the actual serviceadministrativ e willde• be free, apart will also severally be responsible tails, however, are to be the respon• from possible charges for certain for the local clinic and other sibility of a Central Medical Board, appliances. (Questions of dis• services in accordance with the which, like the Central Health Serv• ability benefits will be dealt with area plan. Responsibility for ices Council, will be predominantly in later proposals on social in• child welfare will be specially as• surance.) professional, although it will differ signed in whatever way child edu• 2. from the CounciStructurel in that It will havof e the Service cation is assigned under the cur• (a)Central executive powers. The proposal is rent Education Bill. (i) that the Board shalCentrall b e a small body, responsibility to under a regular chairman; a few of its Parliament and the people will 3. Hospital and consultant Services members will serve full time and the lie with the Minister of Health (a) It will be the duty of the Joint rest part time. "Since the Minister and the Secretary of State for authorities themselves to secure Scotland. will be responsible for its policy, the a complete hospital and con• (ii) BoardAt mus t be appointethe d by himside, bu t of the Minister sultant service for their area— all appointments to it will be made in there will be a professional and including sanatoria, isolation, close consultation with the profes• expert advisory body to be called mental health services, and am• sion." the Central Health Services bulance and ancillary services in Council. The Council will be a accordance with the approved "The Board will in each case be the statutory body and its function area plan. 'employer' of the doctors who take will be to provide professional (b) The joint authorities will do this both by direct provision and practice under the present Na• equivalent could be arranged if by contractual arrangements tional Health Insurance scheme, the doctors concerned so de• but with voluntarwithy hospital s (or with important changes. sired. Rates of remuneration (c) otheGroupedr join t authoritiespractice) as the will be con• will be discussed with the medi• approved area plan may indicate. ducted normally, though not ex• cal profession. (c) The powers of present local clusively, in specially equipped (g) It is not proposed to prohibit authorities in respect of these and publicly provided Health doctors in public practice from services and the ownership of Centres. In England and Wales, engaging also in private practice their hospitals will pass to the the Centres will be provided and for any patients who still want joint authority. maintained by county and county this. Where a doctor under• (d) Voluntary hospitals will par• borough councils—in Scotland, takes private in addition to pub• ticipate, if willing to do so, as by the Secretary of State with lic practice, the number of pa• autonomous and contracting power to delegate to a local tients he is permitted to take agencies; if so, they will observe authority. under the National Service—and the approved area plan, and cer• (d) General practice in the Na• consequently his remuneration— tain national conditions apply• tional Health Service will be in will be adjusted. ing to all hospitals in the new the main organised centrally (h) Young doctors entering indi• service alike; they will perform under the responsible Health vidual practice in the public the services for which they con• Ministers. All the main terms service for the first time will nor• tract under the plan, and receive and conditions of the doctor's mally be required to serve for a various service payments from participation will be centrally period as assistants to more ex• both central and local funds. settled, and much of the day-to• perienced practitioners, and the (e) Special provision will be made day administration will be the Board will be able to require for inspection of the hospital function of Central Medical them to give full time to the service through centrally selected Boards—one for England and service if necessary, expert personnel. Wales and one for Scotland— (j) Compensation will be paid to (f) Consultant services will be largely professional in composi• any doctor who loses the value of made available to all, at the hos• tion, and acting under the gen• his practice—e. g., by entering a pitals, local centres, or clinics, eral direction of the Health Health Centre or because he is or in the home, as required; they Ministers. prohibited from transferring the will be based on the hospital (e) The main duties of each practice to another doctor on the service, and arranged by the Board will be:— ground that there are too many joint authority, either directly or (i) To act as the "employer" doctors in the area. by contract with voluntary hos• of the doctors engaged in the Superannuation schemes will pitals under the approved area public service. Thus, the Board be provided for doctors in Health plan. will be the body with whom every Centres and the possibility of (g) Measures for improving the doctor will enter into contract. providing them in other forms distribution of consultants, deal• In the case of practice in Health of practice will be discussed with ing with methods of appointment Centres in England and Wales, the profession, and the practica• and remuneration, and relating however, there will be a three- bility of abolishing the sale and the consultant service to other party contract between the purchase of public practices will branches of the new service gen• Board, the local authority and the be similarly discussed. erally, will be considered after doctor. (k) Arrangements for the supply the report of the Goodenough (ii) To ensure a proper dis• of drugs and medical appliances Committee. tribution of doctors throughout will be considered and discussed 4. General Medical Practice the country. For this purpose with the appropriate bodies. (a) Everyone will be free, under the Board will have power to pre• 5. Clinics and other services the new Health Service, to choose vent the taking over of an exist• (a) It will be the duty of the joint a doctor—the freedom of choice ing public practice or the setting authority to include in its area being limited, as now, only by up of a new public practice in plan provision for all necessary the number of doctors available an area which is already "over- clinics and other local services and the amount of work which doctored." (e. g., child welfare, home nurs• each doctor can properly under• (f) It is not proposed that there ing, health visiting, midwifery take. should be a universal salaried and others), and to provide for (b) Medical practice in the new system for doctors in the new the co-ordination of these serv• service will be a combination of service. Doctors engaged in ices with the other services in the grouped and separate practice. Health Centres will be remuner• plan. Grouped practice means prac• ated by salary or the equivalent; (b) County and county borough tice by a group of doctors work• doctors in separate practice nor• councils will normally provide ing in cooperation. mally by capitation fee. In some most of these local services. The Separate practice means prac• cases—e. g., grouped practice not exact allocation of responsibility tice by a doctor working on his based on a Health Centre—re• between the Joint authority and own account—broadly similar to muneration by salary or the the individual county and county borough councils will be finally The powers of the Secretary of Paper within a few hours of its publi• settled in each case in the ap• State will be strengthened to en• cation. proved area plan; but the princi• able him to require major local (2) In any case, it is the duty of ple will be that services belong• authorities to combine for any the British Medical Association, be• ing to the hospital and consult• purpose proved necessary after fore expressing a view on behalf of ant sphere will fall to the joint local enquiry. the whole profession, to ascertain that authority while other local and (iv) Education authorities view. The procedure to be followed clinic services will fall to the (county councils and town coun• in ascertaining that view will include individual councils. cils of four cities) will retain re• in the next few weeks sending to every (c) Child welfare duties will al• sponsibility for the school health doctor, member or non-member, ways fall to the authority re• service and clinics, until the civilian or Service doctor, at home or sponsible for child education medical treatment part of the abroad, (1) a copy of the White Paper, under the new Education Bill. school service can be absorbed in (2) an analysis of it in relation to the (d) New forms of service, e. g., for the wider health service. Existing principles already adopted by the pro• general dentistry and care of the major health authorities (county fession, and (3) a questionnaire pre• pared by an independent expert body, eyes, will be considered with the councils and town councils of the British Institute of Public Opinion. professional and other interests large burghs) will normally re• In addition, and pending the result concerned, In the case of den• tain responsibility for the ordi• of that questionnaire, the White tistry the report of the Teviot nary local clinic and similar serv• Paper will be considered centrally in Committee is awaited. ices; the necessary co-ordina• all the Committees of the Association, 6. Organisation in Scotland tion will be secured through their and locally at meetings of the profes• (a) The scope and objects of the membership of the joint hospi• sion. This procedure will take time, service will be the same in Scot• tal boards and through the Local but so important are the issues in• land as in England and Wales, Medical Services Committees volved that it must in no way be side• but subject to certain differences (below). tracked. What is said now must due to special circumstances and (v) Local Medical Services inevitably be first reactions of respon• the geography and existing local Committees—advisory bodies sible people, rather than the con• government structure in Scot• consisting of professional and lo• sidered view of the Association. land. cal authority representatives— (3) But this can be said:— (b) The local organisation in will be set up over the same areas (a) With the Government's ob• Scotland will differ from that in as the Joint Hospitals Boards. jects, to make available to every• England and Wales and will be The Committees will advise the body in the country who needs it, on the following lines:— Secretary of State on local ad• irrespective of age, sex or occupa• (i) Regional Hospitals Advis• ministration of the general prac• tion, an equal opportunity to take ory Councils will be set up for titioner service and will provide advantage of a comprehensive each of five big regions. The liaison between the different health service, the medical profes• Councils will be advisory to the branches of the service. sion is in the fullest sympathy. It Secretary of State on the co-or• 7. Finance will play its full part in achieving dination of the hospital and con• It is estimated that the cost of the this object. sultant services in each region. new National Health Service will be (b) The Government lays down (ii) Joint Hospitals Boards about £148,000,000 a year compared certain principles. They include will be formed by combination of with about £61,000,000 spent from freedom for people to use or not to neighbouring major local au• public funds on the present health use the service, and freedom for thorities (county councils and services. The cost will be met from doctors to work inside the service, town councils of large burghs) both central and local public funds. outside the service, or both. They within the regions to ensure an The arrangements as affecting the include freedom for the doctor to adequate hospital service in their various local authorities and the vol• undertake his professional work areas. The Boards will take over untary hospitals are fully considered without interference, the preserva• all responsibility for the hospital in the White Paper and more briefly tion of the doctor-patient relation• services of the constituent au• in this paper. ship, and the family doctor concep• thorities (including services like tion. These principles the medical the tuberculosis dispensaries, profession unreservedly accepts, which essentially belong to the British Medical Association and it will use its influence in sub• hospital and consultant field) and Comment sequent negotiations to maintain will also arrange with voluntary On February 18, the day after the them. hospitals. White Paper was released, the Brit• (c) The profession welcomes the (iii) The joint boards will pre• ish Medical Association issued the general policy of building on exist• pare a scheme for the hospital following statement, quoted here ver• ing foundations, of welding to• service in their areas and submit batim:3 gether what is already there, this to the Secretary of State, (1) Clearly it is too early to give adapting and adding to it, until a who will consult the Regional a considered judgment on the White comprehensive service is achieved, Hospitals Advisory Council before however long that may take. deciding to approve or amend it. 3 Mimeographed release. (d) Within this framework of entrants to the profession condi• know it today, would seem to have objects and principles, much re• tions which encourage the develop• no place in the new order of things. mains to be worked out. There are ment of a whole time state salaried (k) Views on the appointment many points to be clarified, as for service. and distribution of consultants—a example— (g) The local administration very important question — must (1) the experimental charac• conforms to the existing pattern of await clarification and details. ter of Health Centres, the pro• local authorities, except for the They are vague in the White Paper. fessional arrangements therein; creation of new joint bodies for the (1) In regard to general medical (2) the relationship of in• administration of hospital and practice, the profession will urge dividual family doctors to hos• allied services over wider areas, and that no rigid form of Health Cen• pitals; for planning health services gen• tre organisation should be created, (3) the mode of appointing erally over wide areas. The con• unless and until widespread experi• and distributing consultants; ception of wide areas has the sup• ment has been undertaken. To (4) the compensation for loss port of the profession. The pro• criticise a uniform construction of capital value of general fession will no doubt press for a and distribution of Health Centres practices; proper place for expert advice is not to criticise the idea. But (5) the machinery by which coupled with responsibility within Health Centres must not be thought the public will intimate its desire the proposed new bodies. to represent the Heaven-sent solu• to avail itself of the service in (h) These local government tion of the problem of medical or• whole or in part; proposals must be regarded only as ganisation. Where grouping of (6) . the future of voluntary a temporary expedient until the practices is undertaken it should hospitals and contributory larger question of local government be done freely, and not under com• schemes, and areas and functions generally is pulsion from above. (7) not least important—the tackled. There will still be more (4) To sum up, the White Paper functions of the proposed Central than one local authority, as there provides a framework within which Medical Board. will be more than one central au• we believe it to be possible to evolve Those and other points will need thority, dealing with health issues. a good comprehensive medical serv• to be clarified and details worked (i) In the plans for hospital ice, though its worth to the public out. Indeed, the success of the services there is much detail to be and its acceptability to the profes• scheme will largely depend on such worked out. For example, as at sion will depend on the clarification details. present proposed, the hospital au• and on negotiation on many impor• (e) The Government has not thority, consisting only of elected tant points. If the principles with accepted the proposal for a corpo• persons, will own the local author• which it opens are the principles rate body, preferring to adhere to ity hospitals, and so have an espe• which permeate the stages to come, the method of the Minister and De• cial pride in them, but may exercise we are hopeful that the profession's partment, without concentrating a measure of control, under cen• full co-operation will be achieved. health functions in one department. tral guidance, of voluntary hospi• Our immediate reaction is one of cau• On this point there will be mis• tals, with whom they enter into tious welcome. givings. The success of central contracts. Unless great care is machinery will depend largely on taken, there will be a danger that The Prime Minister's Statement the extent to which and the method voluntary hospitals will lose the in• Addressing the Royal College of by which medical advice is utilized. itiative and independent spirit Physicians on March 2, the Prime A comprehensive personal health which have been the mainspring Minister urged that it muster its service should not in the public in• of their public service. They may strength behind the Government's terest be administered in the tra• suffer a control financial and other, health proposals, because, he said, ditional departmental manner. which, by its rigidity will endanger "disease must be attacked whether it (f) Heavy responsibilities are their future work. occurs in the poorest or richest man allocated to a Central Medical (j) The general effect of the or woman simply on the ground that Board, a wholly or mainly Civil government's proposals is to leave it is the enemy." The whole destiny Service structure. The profession the voluntary hospitals with a mar• of Britain depends on the health of sympathizes with the Government's gin of money themselves to find but its people after the war and the Na• desire to secure an equitable dis• at the same time to take away a tion's power to recover from the pun• tribution of doctors. But in the main source of finding that money, ishment of war. "The plan we have public interest individual doctors namely, the contributory scheme. put forward is a very large-scale plan must be protected from unwar• What is suggested is not what the and in ordinary times would rivet and ranted or unnecessary interference Minister has promised—a real dominate the attention of the whole with the type and place of their partnership on equal terms—but an country," Mr. Churchill said. "It is practice. No attempt must be arrangement involving the sub• not a rigid or arbitrary plan. We made to regiment the medical pro• servience of voluntary to local au• welcome constructive criticism. We fession of the future by the insid• thority hospitals. claim the loyal and active aid of the ious process of imposing on new The contributory scheme, as we whole medical profession."