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National Health Service History
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RHB(48)1 is amongst the most important early planning documents in the NHS, issued in January 1948 - in other words before the NHS began.. It is also probably one of the rarest. The author has a copy and has scanned and attempted to correct the errors thrown up by scanning a faded typescript reproduced on poor paper. Not all of it yet appears here, the subsequent sections dealing with individual specialties.
The Ministry reproduced it in 1950 with minor revisions, including more paragraphs, and in normal printed format. Some reflected that time had moved on, and the RHBs were up and running. The title was changed to The Development of Consultant Services, and it sold for ninepence. A number of appendices and maps were added. Reading the guide today, the word "he" for doctors shows how few women were in the profession.
1. In earlier memoranda sent to Regional Hospital Boards an outline has been given of their responsibilities and suggestions have been made as to the steps to be taken in setting up the new administrative framework for the hospital service and in preparing to undertake the immediate tasks which will face the Boards and Management Committees from the appointed day. The object of the present memorandum is different. It has been prepared, in fulfilment of the promise given in paragraph 24. of R.H.B.(47)1) in order to assist the Boards in facing the long-term problems arising in connection with the planning and future development of the specialist services.
2. It is clear that the first care of the Boards must be to ensure the effective maintenance of the present services. This immediate duty will be more satisfactorily discharged if it is seen against the background of the long-term
organisation of the service. The attempt has therefore been made in this memorandum to examine the scope and content of the different specialist services; to consider how they might best be organised on a regional basis, bearing in mind the part to be played by the Teaching Hospital; and to estimate in terms of hospital facilities and medical staff what are the optimum future requirements of a developed service. In short, the aim has been to state objectives and to suggest methods by which over a period of years those objectives may be reached from the starting point of the existing resources in buildings and personnel.
3. Two points in particular should be mentioned. The first is that the memorandum is not put forward in any sense as a series of instructions which Regional Boards must follow. It seeks merely to suggest tentative answers to questions which each Board must necessarily face in considering the planning of the services for their area. The second point is the obvious one that the whole of the proposals made in the memorandum cannot be made effective on the appointed day. Arrangements must clearly be made for the continuance of specialist services from that day, based on the existing hospitals and on the part-time and whole-time specialists then available. Further suggestions will be made to Boards in a later memorandum as to the action needed to make these arrangements.
SPECIALIST SERVICES I.
INTRODUCTION
1. Historical. The planning of specialist services on a regional basis has been advocated in medical circles for many years. It has not hitherto been practicable, however, except in such limited fields as radiotherapy, and then only in a few-regions, where progress is of recent date. The distribution of specialists has been haphazard, determined in large measure by those economic factors upon which depends the existence of private consulting practice. There have been salaried part-time or whole-time specialist posts in general hospitals but they have been relatively few. Furthermore the tuberculosis service and the larger infectious diseases hospitals have been staffed almost entirely by whole-time salaried officers. But In the main specialist practice has been a matter of unpaid hospital responsibilities, coupled with private consultant work which has provided the whole or greater part of the specialist's income. The inevitable consequence has been an uneven distribution of specialists who are too few to meet the needs of the whole population.
2. Increase and Distribution of Specialist Staff. An immediate result of the introduction of the National Health Service will be the remuneration of specialists for all their work within the Service, unless they elect to serve in an honorary capacity. Thus, for the first time, there will be generally available the means of providing additional staff where it is most needed. Regional planning then becomes possible and will be one of the most important functions of the Board. Distribution can be improved by the creation of new salaried posts, part or whole-time, beginning first in those areas where the need is greatest. The deficiency in numbers can be made good only gradually3 because the training of specialists is necessarily long. Regional Boards should ensure, however, that only specialists of a high degree of competence are appointed to posts of responsibility. The mere possession of a special diploma is not the moat important qualification far specialist rank; adequate training and experience are better criteria.
3. Estimation of Numbers of Specialists. Subsequent sections of this memorandum will deal with individual specialties in detail and some attempt is made to forecast probable requirements in specialist services for a population of a given size. Such estimates must be largely speculative, as there is not yet sufficient information on which to base even approximately accurate estimates. But a plan of development, however tentative, is needed now, and it is the object of this memorandum to provide material which may be useful to Regional Boards in formulating their ideas. The realisation of those ideas may not be achieved for several years, since buildings on the scale required will not exist for some time yet, and the necessary specialists cannot be mass produced. It is imperative to avoid the mistake of expanding specialist staffs toe rapidly by recruiting men and women with inadequate training and experience,
4. Estimates of numbers of specialists given in subsequent sections are in the main, in terms of whole or half-time service at one hospital centre, but the proportion of the individual specialist's time given to the hospital service which may include domiciliary work) will vary. Some specialists may wish to engage whole—time in the service; others may engage in private practice for part of their time. Specialists employed part-time in one hospital centre may give part—time service in another associated centre.
5. Background of General Plan. The planning of the specialist services is one of the primary duties of the Regional Hospital Boards, but it is a task which must clearly be carried out in close collaboration with the Teaching Hospitals. Each of the 14 Regional Boards will normally provide a complete range of specialist medical service within its region. There is no wish to standardise specialist services throughout the country and each region will be able to plan these services in the way best suited to the local organisations and local needs; indeed experiment and variation between regions are essential to future development. There are, however, general principles which will be applicable in all regions and it is probable that broadly similar plans will emerge in each. The present memorandum has been prepared to give Regional Boards a general background which may be useful in the preparation of local plans. It is not intended to prescribe a pattern which must be followed or which can immediately be adopted in full, but merely to offer suggestions as to the broad lines along which development might be guided.
7. Staffing of General Hospitals by Specialists. A common feature of the published reports of the Surveys of Hospital Services, undertaken during the war by the Minister and the Nuffield Trust, was the recommendation that the clinical responsibility for hospital patients, other than, those in general practitioner or cottage hospitals, should rest with specialists. It is necessary, therefore, to provide not only a sufficient number but a sufficient range of specialists. It is not enough to provide a general surgeon at a Hospital Centre and expect him to accept responsibility for all types of surgical cases. Ophthalmic surgery and the surgery of the ear, nose and throat, to take two obvious examples, each require the services of a surgeon who
practices his specialty exclusively.
In addition there are types of specialisation which may be developed within general medicine or general surgery and which are rarely an exclusive interest; the two examples given, however, and that of dermatology in the province of medicine do not "belong to this category.
8. The Distribution of Specialist Services. Throughout this memorandum the term Hospital Centre is used to describe a group of hospitals which together provide for a natural aggregation of population, all the normal specialist services. Whether the hospitals are all in the same town, or one or more of them situated outside it, they may be regarded as having a functional union and may share in a common staff. This does not exclude the possibility that there may be more than one Management Committee in the Hospital Centre. For the treatment of pulmonary tuberculosis, long-stay orthopaedic cases and mental diseases it may be necessary to provide in—patient accommodation at some distance from the main hospital group. General practitioner hospitals included in the group should be visited regularly by specialists for consultations.
9. The term Regional Centre is used to describe the Hospital Centre at the headquarters of the region and includes the Teaching Hospital, although the latter is outside the administration of the Regional Hospital Board, Here will be provided both the range of specialist services which must be available in every Hospital Centre, and in addition those exceptional services which require the collection of cases from a large population in order to make full use of a team of experts who have made those subjects their particular interest. The four principal examples of these are Plastic Surgery, Neurosurgery, Thoracic Surgery and Radiotherapy.
10. It may happen in other fields of work, however, that certain types of case will be referred by specialists to individual colleagues, anywhere in the region, who have acquired a special skill or who have specialised apparatus. For instance, there may be some form of operative treatment for a rare disease which may be developed by one man, working at the Regional Centre or some other hospital centre, to whom these rare cases will be referred from the region as a whole. This sort of association grows up voluntarily and requires no special planning.
11. The Integration of Hospital Services. The main problem of the Regional Board will be to integrate the specialist services of the Regional Centre and the Hospital Centres. In theory there are two possible ways of doing this:
(a) In the first, responsibility for the care of patients in the hospitals throughout the region would be in the hands of a large staff of senior specialists resident in or near the Regional Centre, assisted by specialists of lesser experience working under their direction in the outlying Hospital Centres, None of the Regions, however, is so small that specialists living at the Regional Centre could effectively assume responsibility for the care of all patients in the hospitals of the region. Any attempt to operate such a plan would involve for the senior specialists an expenditure of time in travelling which could not be justified. Furthermore to diminish the responsibility of the staffs of outlying Hospital Centres in this way and to this extent would not be in the interest either of the staffs themselves or of the public of the area which they served.
(b) The second method therefore appears to be the only practical one. According to this plan, the services of a complete range of specialists (except for the four regional services already mentioned) "would be available a1 each Hospital Centre and they would be fully responsible for the hospital treatment of its population. In the smaller Hospital Centres their services would be shared with other centres. Under such conditions, linkage between the Regional and Hospital Centres would "be maintained by recognising all the specialists throughout the Region as members of one team. Members of the staffs of Hospital Centres should, be given, the opportunity to take temporary duty in hospitals at the Regional Centre, and some grades of specialist in the Regional Centre, should similarly have opportunities of doing temporary duty in a Hospital Centre.
12. Specialist Associations. Regular personal contacts between specialists working at the Regional Centre (including the staff of the teaching Hospital) and those working at the peripheral Hospital Centres should be encouraged and facilitated. With this object in view, professional associations in the various specialties should be fostered on a regional basis so that meetings can be arranged at regular intervals for discussion or clinical demonstrations, sometimes at one centre, sometimes at another, probably most commonly at the Regional Centre. It is desirable that the Heads of Departments of the Teaching Hospital and other specialists of the highest standing at the Regional Centre should visit the outlying centres from time to time, to give opportunities for consultation and exchange of ideas -with the specialists working there. It is by this free professional association rather than by formal inspection and supervision that the university centre will both diffuse its own influence and receive outside stimulus.
13. Association through Post-graduate Training. Arrangements for post-graduate education trill provide an additional link between Regional and Hospital Centres. Newly qualified practitioners will, no doubt, get much of their early experience in resident posts at those hospitals with which their Teaching Hospital is associated, For the training of specialists it is anticipated that a series of graded appointments in the hospitals throughout the region will be organised with the cooperation of the Department of Postgraduate Studies of the Medical School, To meet the needs of general practitioners, arrangements for revision courses and clinical assistantships will be made by the University in Hospital Centres approved for this purpose.
14. Registrars. Although this memorandum is not directly concerned with the training of specialists, practitioners in the later stages of their post-graduate training are important members of the staffs of hospitals. Various designations such as registrar, first or second assistant resident medical or surgical officer or clinical assistant are used for the posts held by such men. In this memorandum the term "registrar" is used where it is desired to suggest the employment of officers senior to the house physician or house surgeon grade and considered to be passing through a probationary period of training in a specialty. Some practitioners may start on such a course and, after a period of a year or two turn to training in some other specialist field or to general practice. Others will continue, acquire post-graduate qualifications and ultimately, after a full period of training, emerge as specialists suitable for more senior appointment on hospital staffs. It is not possible to estimate the numbers in either group and as a result estimates of the numbers of registrars given in later sections include both these groups.
15. Specialist Advisers. This memorandum is only a general guide for the assistance of Boards in the development of their specialist services. It will often prove difficult, even impossible to apply the general recommendations given here to particular cases. In these problems as well as in many others the Boards will need advice from experienced specialists in different branches of medicine and surgery. The Boards will therefore probably consider it necessary to appoint a number of part-time consultant advisers from among senior specialists in their Regions to assist in dealing with the problems of individual specialties. Such a course was followed by the Ministry of Health in the Emergency Medical Services and proved a sound policy.
No reference is made in subsequent sections to medical records and the provision of a statistical service for hospitals. Regional Boards may find it necessary to improve the records departments of hospitals, and to increase staff and accommodation in many of theirs. Certain Universities already have Departments of Medical Statistics and may be able to assist Regional Boards.
II. TEACHING HOSPITALS
16. Hospitals designated under the National Health Service Act as Teaching Hospitals have been given a separate identity and status. Their Boards of Governors are required
17. Undergraduate Education. No medical school attempts to instruct its undergraduates in the diagnosis and treatment of the whole range of diseased conditions and their varieties. The aims of undergraduate instruction in this country have been well described by the Planning Committee on Medical Education of the Royal College of Physicians, as follows "The first object in the undergraduate course should be the teaching of method, method for elucidating the facts concerning disease, method for welding these facts into an understanding and judgment of the question at issue, method for testing the validity of this judgment; for method is a more lasting acquisition than is fact, and without method a man is lost when he meets an unfamiliar situation, as he is ultimately bound to meet it, away from his teacher's guidance. The second object should be the teaching of principle, that is to say the student should be led to understand those phenomena which recur so frequently in disease that they may be said to be of fundamental importance. The two objects should be brought before the students in such a way as to show him that the scientific method can be used in clinical study - that there is such a thing as clinical science.
18. In view of its special functions the Teaching Hospital may not be able to undertake all varieties of treatment and special investigation. It will inevitably share obligations under these headings with the hospitals of the Regional Board. The number of beds for which its Board of Governors assumes responsibility will be mainly determined by considering the optimum number which will enable it to perform its teaching and research functions efficiently.
19. There will be some selection of the cases admitted to a Teaching Hospital so that suitable cases may be available for undergraduate and advanced education and for the needs of research. This selection wi11 be principally effected in the outpatient clinics, but members of the staff of the teaching Hospital who hold appointments in other hospitals will be able to assist in this matter and it will also be served by general collaboration between the staffs of the hospitals of the region. This collaboration is particularly important in relation to clinical research; it should extend over the whole hospital system of the region and may even cross regional boundaries.
20. It is not possible for the Teaching Hospital alone to provide all the clinical material required for undergraduate and postgraduate teaching. In particular arrangements mil have to be made by the University or Medical School with the Regional Board for the use of facilities for instruction in tuberculosis^ infectious disease and mental disease. In addition it will often be necessary to make similar arrangements for instruction of students in other subjects. There should be no difficulty in making such arrangements, given the cordial relations which should exist between the two boards.
21. Postgraduate Education. The organisation of postgraduate education is primarily the responsibility of the University with which a Teaching Hospital is associated. For the effective administration of the policies adopted by the University there must, however, be the closest co-operation not only between the University and the Teaching Hospital but beween both these and the Regional Board and Hospital Management Committees.
22. Postgraduate education may at present be divided into four categories:-
(a) Graded appointments for the training of specialists.
(b) Courses of instruction for intending specialists from this country and abroad
(c) Advanced revision for established specialists.
(d) Regular teaching sessions and periodic refresher courses for general practitioners
23. The training of specialists will be effected by the provision of suitably graded posts in the departments of the University, the Teaching Hospital and hospitals of the Regional Board.
24. Facilities for the second and third category of postgraduate education may be net (a) in special departments in Teaching or
25. The former method will be that usually followed in the provinces, but in
26. Refresher courses for general practitioners should be provided in those hospitals under the Regional Board which have been approved for this purpose by the University. Constant contact between general practitioners and hospitals will, of course, be encouraged.
III. GENERAL MEDICINE
27. Even the smallest Hospital Centre will need at least one general physician living locally. This is necessary in order to ensure continuity of supervision and the economical use of hospital beds, and also to deal with medical emergencies. In these small Hospital Centres the specialties, other than general medicine, general surgery and obstetrics and anaesthetics may be covered by visiting specialists from neighbouring larger centres.
28. To avoid isolation in his specialty, every specialist working at one of the smaller centres should also be actively associated with a larger centre. A member of the hospital staff in the larger centre should be available to take over
29. The general physician will be expected in future to give an increasing amount of time to the care of the chronic sick as part of his normal duties. Admission to wards for the chronic sick should always be by way of the wards or hospitals for acute cases, and it is to be expected that facilities for the rehabilitation of the chronic sick will be better and more general than they now are; the work will be largely supervised by the general physician.
30 It is difficult to give any accurate estimate of the number of general physicians required to maintain a satisfactory specialist service. Much will depend on the extent to which general medicine may become partially sub-divided. General medicine should not ordinarily embrace paediatrics or dermatology; some general physicians may elect to give part of their time to paediatrics, but there should, nevertheless be a paediatrician visiting each Hospital Centre. General physicians mil, however., almost certainly need to undertake some neurological and cardiological work. The group of muscular and articular disorders included under the general heading of rheumatism causes a large amount of ill-health and loss of working time. In some regions active measures are already being token in the investigation of this group of diseases special diagnostic and research centres with out-patient facilities and beds at general hospitals in the Regional Centres and beds for long-stay cases in associated hospitals have been established. The subject calls for special attention from physicians and specialists in orthopaedic surgery and physical medicine and it may well become the special, though rarely the exclusive interest of a physician. Some of the large spa hospitals may provide useful accommodation for long-stay cases, provided they are closely linked with the work of general hospitals...
31. For a population, of 100,000 - 120,000 in an area served by one Hospital Centre, it is probable that some 250 medical beds mil be required, apart from those for the chronic sick, tuberculosis and infectious diseases. Estimates of the number of physicians needed for such a centre can only be approximate. Account mil have to be taken, inter alia, of the respective amounts of hospital and domiciliary work to be done, of whether the physicians are employed wholly within the service or on a part—time basis, and of the various gradations in seniority among the physicians. Bearing these conditions in mind, it is suggested tentatively that the medical staff of a centre with a group of 250 medical beds and beds for chronic sick might be —
If any of the physicians devote the whole of their time to duties at this centre the numbers will necessarily require modification,
32. It is undesirable that general medicine should be so rigidly sub-divided that all the cardiological or neurological work becomes concentrated in the hands of specialists engaged only in these subjects. The general physician should be kept in contact with men working in these fields and, of course, with colleagues in general medicine from other centres and, particularly the university centre. Associations of physicians on a regional basis to include those working in the specialties should be encouraged. Neurologists, cardiologists and other specialists of this kind at the Regional Centre (or at major Hospital Centres which are virtually the equivalent of a Regional Centre), should be available for consultation by their colleagues at the periphery.
IV. GENERAL SURGERY
33. As in general medicine, so in general surgery, it is essential that every Hospital Centre should have a locally resident specialist. Since the acute emergency requiring immediate active intervention is commoner in surgery than in medicine, it is desirable that there should be at least two surgeons resident in each centre, although in the smallest centres one or both men may spend part of their time working elsewhere. As in all the other specialties, it is of the utmost importance that a man should be kept in touch with the work of colleagues; the comments made above about the desirability of professional associations of physicians apply with equal force to surgery.
34. General surgery tends more and more to be broken up into special branches. It should, for instance, no longer embrace gynaecology, even in the smallest Hospital Centres. There may be occasions when a gynaecological emergency is dealt with by a general surgeon, as for instance when the initial diagnosis is uncertain, but apart from this, gynaecology should be regarded as a distinct specialty. Similarly, orthopaedic and traumatic surgery constitute a specialty for which separate provision should be made in each Hospital Centre and this provision should include arrangements for dealing with emergencies.
35 In some branches of surgery specialism goes further than in others; for instance, in genito-urinary surgery there is much more marked tendency to separation than in gastroenterology. The time is hardly ripe for separating genitourinary work entirely, except perhaps at Regional Centers. It seems more likely that, as in the case of medicine, each hospital Centre will be served by a team of general surgeons, each of whom may develop a special interest. Thus, the surgeon who acquires particular skill in the operative treatment of diseases of the stomach may still continue to undertake other abdominal surgery. In the large centres there may be more than one surgeon specialising in each of the branches mentioned.
36. Neurosurgery, Plastic Surgery and Thoracic Surgery are much more sharply defined as specialties. It may be necessary for the general surgeon occasionally to deal with a neurosurgical emergency or some very urgent thoracic condition, but the majority of these cases will be handled, in future, by surgeons giving all their time to the specialty.
37.
In estimating the number of surgeons required same factors rust be taken into
account in determing the appropriate establishment as were considered in the
case of physicians. Although in
surgery- fewer domiciliary consultations my be necessary, this may be
more than. balance the claims of urgent operative work.
38. Bearing these
conditions in mind, it is suggested. tentatively that to serve a population of
100,000-120,000 ,-% group of 180 surgical beds should be provided and that these
will require the services of:
3 general surgeons of senior grade (half-time)
3 general surgeons of junior grade (half-time)
Not less than 3 surgical registrars (whole-time)
If any of the surgeons give the whole of their time to work at this centre,
adjustment will
be needed.
39. It will be
appreciated that the chronic sick., though requiring surgical attention on
occasion, do not need the same amount of supervision by surgeons as by
physicians.
V. OBSTETRICS and GYNAECOLOGY
40. These two allied
subjects constitute one specialty, although, rarely, a specialist may
concentrate on one or the other side. As the service develops, gynaecology will
cease to be undertaken by general surgeons.
41 Midwifery alone, on
the other hand, is not a service restricted to specialists. It is contemplated
that a domiciliary service will be provided under Parts III and IV of the
National Health Service Act by midwives and general practitioners with
experience in midwifery. In addition Local Health
Authorities will continue to provide ante-natal and post natal clinics.
Institutional midwifery will be the responsibility of the hospital and specialist service,
which will need also to provide specialist aid for domiciliary emergencies,
consultative ante-natal and post-natal clinics (normally at the hospitals), and
beds for abnormal cases.
42 It is clear from the
foregoing that co-ordination of the three branches of the Suggestions on this
matter will be made to Regional Boards in a separate memorandum.
43 the number of maternity beds
theoretically required for a given population varies with the birth rate, but
for some years to come all the beds which can be made available and staffed will
be necessary. It is probable that, in present conditions of housing and
availability of domestic staff, the great majority
of women would elect to be confined away from home.
Certainly the aim should be institutional provision for at least three quarters
of the births. A population of 100,000 would, therefore, require 60 to 75
lying-in beds, (as the birth rate ranges between 16 and 20), and about 30
ante-natal beds.
44 The main maternity units
should be at general
45. It is
estimated that one gynaecological bed is
46.
The Hospital Centre with 100,000 population would, therefore, require a
total of some 90 maternity beds, including ante-natal beds, and 30
gynaecological beds including those for abortions.
The staff required for such a group would be 2 half-time or one
whole-time obstetrician and gynaecologist and 1 registrar - whole-time - with
other senior and junior resident medical staff.
47.
Both the gynaecological and obstetric work should be closely associated
with other specialist services. The paediatrician should be in charge of the
babies in the nurseries of maternity units.
Physicians should supervise the treatment of certain cases, e.g. patients
with heart disease in ante-natal wards.
Pathological and biochemical services, including facilities for endocrine
investigation, must be available. The gynaecological out-patient service should
include the provision of Infertility Clinics.
VI.
PAEDIATRICS
48.
Paediatrics is, briefly, medicine applied to the maintenance of health
and the treatment of disease in children. For this purpose children may include
persons up to the age of fourteen.
49.
Fully
staffed paediatric departments, distinct from those of general medicine, should
be provided in every Regional Centre, usually associated with a University
Institute of Child Health. A
paediatric department should also be established in every larger Hospital
Centre, not as a subsidiary to that of the Regional Centre, but as an
independent special department, responsible for the care of all children's
medical wards in the area. There
will also be centres
which are
too small to provide sufficient work for a locally resident paediatrician and in
these a service should be provided by a visiting paediatrician, even though
there may be available general physicians with a special interest in paediatric
work.
50. It is of the utmost
importance that hospitals or wards for infectious diseases should be closely
associated with paediatric departments, since so many of the patients
51. It is also important that pediatricians working in hospitals should be associated with the preventive clinic services for children which are maintained by the Local Education and Health Authorities. This is especially desirable at the university teaching centre. Suggests for co-ordination with Local Health Authority Services will be made by the Regional Hospital Boards separately.
The remains of this document have not as yet been scanned
