Public Health The Journal of The Society of Community Medicine (Formerly the Society of Medical Officers of Health) Volume 89
Number 5
July 1975 ~
Community Medicine--Where Now? The re-organized National Health Service is now just over one year old and has already entered into a period of serious crisis. There are those who are even predicting its collapse on account of serious under-financing and there is, of course, the present conflict between the Secretary of State and the medical profession which, although it must be resolved, cannot expect to leave the service unscathed. The under-financing is, however, not something which has recently happened and I am reminded that in the 1960s many senior administrative medical officers were easily able to demonstrate considerable under-capitalization in the hospital service and made representation, in varying degrees of strength, through their boards that unless this financial deficiency was made good there would be a lowering of standards or even a breakdown of parts of the service. One is also reminded of the serious problems of general medical practitioner recruitment staved off by the introduction of the "Doctors' Charter" in 1968 and by other measures. There were the all too familiar adverse comments of committees of enquiry concerning types of long stay hospitals often with public censure of officials without allowing them the opportunity to be legally represented and thereby to introduce evidence of the serious financial and other difficulties with which they had to contend, and the fact that priorities had to be chosen in such a way that certain vital services got urgent improvement to avert breakdown and that this could only be done at the expense of other aspects of the service also requiring attention. It had been thought by some that re-organization would somehow miraculously cure these ills but unless the problems of under-finance and staff recruitment and unless staff training and identification of particular patient needs and assessment of priorities is tackled vigorously and on a national scale it may even serve to exacerbate rather than improve the malaise of the health service. It has been obvious from many publications in recent years that specialists in community medicine must play a vital rble in the context of developing an efficient re-organized health service. The Faculty of Community Medicine has defined its speciality as "that branch of medicine which deals with populations or groups rather than with individual patients. In the context of a national system of medical care, it therefore comprises those doctors who try to measure accurately the needs of the population both sick and well. It requires to bring to this study special knowledge of the principles of epidemiology, of the organization and 177
178
T. A. Ramsay
evaluation of medical care systems, of the medical aspects of the administration of health services and of the techniques of health education and rehabilitation which are comprised within the field of social and preventive medicine. Community medicine thus brings together within the one discipline those who are presently engaged in the practice of public health, in the administration of the health services, whether in hospital, local authority or central government, in relevant research and those responsible for undergraduate and postgraduate education in the university departments of social medicine." The Hunter Committee spells out in some detail the main spheres of activities of these specialists and the recent rounds of new appointments have reflected in varying degrees the job specification along lines which seem to be implementing much of what this committee envisaged. The newly appointed community medicine specialists recruited from public health departments, regional hospital boards, academic departments of social (community) medicine and to some extent from the central health departments are now mostly placed in posts of varying degrees of appropriateness. Many will need specific programmes of additional training to fill gaps in their repertoire of experience and no doubt some will seek to obtain other posts by horizontal movement which they feel more appropriate to their particular skills and previous experience. Coincidental with these developments the Faculty of Community Medicine, which is the child of the three Royal Colleges of Physicians of the United Kingdom has become well established. It has stated its objectives and has published the requirements for membership examination and provided the model of a training programme for the specialty. The initial examinations have taken place and specialists with the membership by examination are becoming available to compete for posts in the re-organized service. A system for inspection of posts has been instituted by the Faculty within the embrace of the J.H.M.T.C. authority. Readers are referred to the appropriate publications by the Faculty for further information. This undoubted progress by the Faculty will have to be matched by activities in the field of recruitment and this in turn demands the provision of sufficient places on comprehensive training programmes. It is also necessary to present a career structure at least as acceptable to medical graduates as that for the other disciplines. In this context the fact that the higher specialist training programme for community medicine comes within the terms of reference of the J.H.M.T.C. ensures that the training requirements and the professional standards of specialists are constantly under examination alongside the other medical disciplines. It is also essential that undergraduates are made aware of the importance of community medicine and of the fact that a career in this specialty can be a rewarding professional endeavour, intellectually, in terms of work satisfaction and also in financial return. It is therefore necessary for those concerned with the specialty to examine how undergraduates and young medical graduates are influenced in choosing their specialties and to see what intervention is required and by whom to secure for community medicine at least its share of each cohort of medical graduates. One already sees advertisements for trainees in the specialty under the auspices of certain of the health authorities who are arranging training programmes involving university departments of community medicine on a consortia basis. The Scottish Council for Postgraduate Medical E~ducation has set up a working party representing all concerned in the training of community medicine in Scotland including the Faculty. This working party should report soon on how future training might be organized in Scotland for the specialty. One must not put aside the serious problem of the fairly large number of doctors in the specialty who for various reasons have so far failed to obtain specialist posts and arrangements are required urgently to offer them suitable training programmes so that as many of these as possible may qualify for specialist appointments.
Community medicine--where now ?
179
It is important to examine the relationship of specialists in community medicine to their clinical colleagues. There is no doubt that the delivery of health care to individual patients must remain the responsibility of the various clinicians and if the Merrison Committee's recommendations that every doctor should train to become an accredited specialist are implemented then the time will be reached when every patient is the ultimate responsibility of a specialist. It is clear that the specialist in community medicine must work alongside his clinical colleagues in ensuring that optimum standards of health care are provided and in developing new diagnostic and therapeutic services as the advance of medical science shows them to be necessary. Specialists in community medicine should be able to identify the need for such developments and how resources are being used at present. He should form opinions as to how better use could be made of them, for only by a continuous monitoring and reallocation of resources can the service keep up with the progress of medical science. This poses a serious problem for community medicine specialists. At long last it is being admitted by the central health authorities and by the Secretary of State that there never will be enough resources to satisfy the needs of all aspects of health care. There is still the need to select priorities as there always has been and it would be most unfortunate if specialists in community medicine were expected to accept public censure without the opportunity for defence for what, with hindsight and examination of only one aspect of an alleged deficiency in the service, appears to have been a wrong choice of priorities. In the reorganized National Health Service the hierarchical relationship which undoubtedly existed between many different types of medical administrator has been done away with so as to bring the specialty of community medicine into line with the other medical specialties. Without in any way wishing to take a position on this issue, if one accepts for example that there is no hierarchical relationship between the regional medical officer and the area medical officer, etc., the regional medical officer can hardly be expected to be called to question for the actions of all the specialists in community medicine in the region in which he is situated. I believe that the relationship of these specialists to each other will require further and detailed examination in the light of development and evolution of the reorganized service. Specialists in community medicine will also have a vital role to play in matters concerning the "competence to practice" of their clinical colleagues. It would be presumptious on my part to develop this subject in detail since the matter is at present being examined by an expert committee but I feel bound to state that at the end of the day it will remain difficult to decide whether or when clinical work has fallen below an acceptable standard. Even if "acceptable" can be defined, the precise responsibility of the community medicine specialist at district, area and regional level must be laid down with clear guide lines as to how he is to deal with this very delicate and difficult problem. There can be no doubt that the community medicine specialist must handle this type of thorny situation early and firmly but at all times with understanding and the full backing of his clinical colleagues. The particular skills required by specialists in community medicine have been defined elsewhere but it might be useful to consider how these particular skills can be used by such specialists in assisting clinicians with the treatment of individual patients. I consider that by applying the skills of epidemiology, medical statistics, and medical sociology in joint studies concerning the ill health pattern of populations, particularly when these have such varying geographical and ethnological significance, the causal factors of certain disease might become clearer. Community physicians are concerned with creating action to set up screening programmes, health educational or even therapeutic programmes, since improving the standards of health of the population will naturally also improve the standards of health of individual patients. Selected specialists in community medicine should continue to
180
T. A. Ramsay
practice preventive medicine as we understand it at present and to establish immunization programmes for children, etc. They will also be involved with research into more effective methods of developing immunity in "at risk" populations. It is also necessary to say something of the relationship between community physicians and management. They are, of course, by the very nature of things part of the management structure. They should have received training in management techniques, but they are also medical practitioners, bound by the ethical code of their profession and with continuing loyalties to their fellow practitioners. They can and should be an effective link between the understandable demands of management and the sometimes not so well understood requirements of practising doctors and other health care workers, but unlike mere interpreters they must also be advocates, teachers and innovators. So far nothing has been said about the relationship between specialists in community medicine and the nursing and paramedical professions. It is self-evident that they have avital role in bringing together all the health care professions but this is a vast subject which cannot be covered in this necessarily brief summary. In conclusion the specialty of community medicine is emerging potentially greater after reorganization. There are many teething troubles to overcome, there are some dangers for the developing specialty, more clearly defined relationships have to be established between specialists within the discipline and with their clinical colleagues and with the other health care professions. Training programmes for new entrants, existing specialists and transferred officers will be required, Continuing education is necessary in this discipline as well as in others. In all these matters the Faculty of Community Medicine must, and 1 believe, will play a prominent part. T. A. Ramsay
Announcement
At the general meeting, held on 13 June 1975, Dr H. Binysh, Area Medical Officer, Cornwall and Isles of Scilly Area Health Authority, was elected President of the Society for the 1975-76 Session.
Number 5
July 1975 ~
Community Medicine--Where Now? The re-organized National Health Service is now just over one year old and has already entered into a period of serious crisis. There are those who are even predicting its collapse on account of serious under-financing and there is, of course, the present conflict between the Secretary of State and the medical profession which, although it must be resolved, cannot expect to leave the service unscathed. The under-financing is, however, not something which has recently happened and I am reminded that in the 1960s many senior administrative medical officers were easily able to demonstrate considerable under-capitalization in the hospital service and made representation, in varying degrees of strength, through their boards that unless this financial deficiency was made good there would be a lowering of standards or even a breakdown of parts of the service. One is also reminded of the serious problems of general medical practitioner recruitment staved off by the introduction of the "Doctors' Charter" in 1968 and by other measures. There were the all too familiar adverse comments of committees of enquiry concerning types of long stay hospitals often with public censure of officials without allowing them the opportunity to be legally represented and thereby to introduce evidence of the serious financial and other difficulties with which they had to contend, and the fact that priorities had to be chosen in such a way that certain vital services got urgent improvement to avert breakdown and that this could only be done at the expense of other aspects of the service also requiring attention. It had been thought by some that re-organization would somehow miraculously cure these ills but unless the problems of under-finance and staff recruitment and unless staff training and identification of particular patient needs and assessment of priorities is tackled vigorously and on a national scale it may even serve to exacerbate rather than improve the malaise of the health service. It has been obvious from many publications in recent years that specialists in community medicine must play a vital rble in the context of developing an efficient re-organized health service. The Faculty of Community Medicine has defined its speciality as "that branch of medicine which deals with populations or groups rather than with individual patients. In the context of a national system of medical care, it therefore comprises those doctors who try to measure accurately the needs of the population both sick and well. It requires to bring to this study special knowledge of the principles of epidemiology, of the organization and 177
178
T. A. Ramsay
evaluation of medical care systems, of the medical aspects of the administration of health services and of the techniques of health education and rehabilitation which are comprised within the field of social and preventive medicine. Community medicine thus brings together within the one discipline those who are presently engaged in the practice of public health, in the administration of the health services, whether in hospital, local authority or central government, in relevant research and those responsible for undergraduate and postgraduate education in the university departments of social medicine." The Hunter Committee spells out in some detail the main spheres of activities of these specialists and the recent rounds of new appointments have reflected in varying degrees the job specification along lines which seem to be implementing much of what this committee envisaged. The newly appointed community medicine specialists recruited from public health departments, regional hospital boards, academic departments of social (community) medicine and to some extent from the central health departments are now mostly placed in posts of varying degrees of appropriateness. Many will need specific programmes of additional training to fill gaps in their repertoire of experience and no doubt some will seek to obtain other posts by horizontal movement which they feel more appropriate to their particular skills and previous experience. Coincidental with these developments the Faculty of Community Medicine, which is the child of the three Royal Colleges of Physicians of the United Kingdom has become well established. It has stated its objectives and has published the requirements for membership examination and provided the model of a training programme for the specialty. The initial examinations have taken place and specialists with the membership by examination are becoming available to compete for posts in the re-organized service. A system for inspection of posts has been instituted by the Faculty within the embrace of the J.H.M.T.C. authority. Readers are referred to the appropriate publications by the Faculty for further information. This undoubted progress by the Faculty will have to be matched by activities in the field of recruitment and this in turn demands the provision of sufficient places on comprehensive training programmes. It is also necessary to present a career structure at least as acceptable to medical graduates as that for the other disciplines. In this context the fact that the higher specialist training programme for community medicine comes within the terms of reference of the J.H.M.T.C. ensures that the training requirements and the professional standards of specialists are constantly under examination alongside the other medical disciplines. It is also essential that undergraduates are made aware of the importance of community medicine and of the fact that a career in this specialty can be a rewarding professional endeavour, intellectually, in terms of work satisfaction and also in financial return. It is therefore necessary for those concerned with the specialty to examine how undergraduates and young medical graduates are influenced in choosing their specialties and to see what intervention is required and by whom to secure for community medicine at least its share of each cohort of medical graduates. One already sees advertisements for trainees in the specialty under the auspices of certain of the health authorities who are arranging training programmes involving university departments of community medicine on a consortia basis. The Scottish Council for Postgraduate Medical E~ducation has set up a working party representing all concerned in the training of community medicine in Scotland including the Faculty. This working party should report soon on how future training might be organized in Scotland for the specialty. One must not put aside the serious problem of the fairly large number of doctors in the specialty who for various reasons have so far failed to obtain specialist posts and arrangements are required urgently to offer them suitable training programmes so that as many of these as possible may qualify for specialist appointments.
Community medicine--where now ?
179
It is important to examine the relationship of specialists in community medicine to their clinical colleagues. There is no doubt that the delivery of health care to individual patients must remain the responsibility of the various clinicians and if the Merrison Committee's recommendations that every doctor should train to become an accredited specialist are implemented then the time will be reached when every patient is the ultimate responsibility of a specialist. It is clear that the specialist in community medicine must work alongside his clinical colleagues in ensuring that optimum standards of health care are provided and in developing new diagnostic and therapeutic services as the advance of medical science shows them to be necessary. Specialists in community medicine should be able to identify the need for such developments and how resources are being used at present. He should form opinions as to how better use could be made of them, for only by a continuous monitoring and reallocation of resources can the service keep up with the progress of medical science. This poses a serious problem for community medicine specialists. At long last it is being admitted by the central health authorities and by the Secretary of State that there never will be enough resources to satisfy the needs of all aspects of health care. There is still the need to select priorities as there always has been and it would be most unfortunate if specialists in community medicine were expected to accept public censure without the opportunity for defence for what, with hindsight and examination of only one aspect of an alleged deficiency in the service, appears to have been a wrong choice of priorities. In the reorganized National Health Service the hierarchical relationship which undoubtedly existed between many different types of medical administrator has been done away with so as to bring the specialty of community medicine into line with the other medical specialties. Without in any way wishing to take a position on this issue, if one accepts for example that there is no hierarchical relationship between the regional medical officer and the area medical officer, etc., the regional medical officer can hardly be expected to be called to question for the actions of all the specialists in community medicine in the region in which he is situated. I believe that the relationship of these specialists to each other will require further and detailed examination in the light of development and evolution of the reorganized service. Specialists in community medicine will also have a vital role to play in matters concerning the "competence to practice" of their clinical colleagues. It would be presumptious on my part to develop this subject in detail since the matter is at present being examined by an expert committee but I feel bound to state that at the end of the day it will remain difficult to decide whether or when clinical work has fallen below an acceptable standard. Even if "acceptable" can be defined, the precise responsibility of the community medicine specialist at district, area and regional level must be laid down with clear guide lines as to how he is to deal with this very delicate and difficult problem. There can be no doubt that the community medicine specialist must handle this type of thorny situation early and firmly but at all times with understanding and the full backing of his clinical colleagues. The particular skills required by specialists in community medicine have been defined elsewhere but it might be useful to consider how these particular skills can be used by such specialists in assisting clinicians with the treatment of individual patients. I consider that by applying the skills of epidemiology, medical statistics, and medical sociology in joint studies concerning the ill health pattern of populations, particularly when these have such varying geographical and ethnological significance, the causal factors of certain disease might become clearer. Community physicians are concerned with creating action to set up screening programmes, health educational or even therapeutic programmes, since improving the standards of health of the population will naturally also improve the standards of health of individual patients. Selected specialists in community medicine should continue to
180
T. A. Ramsay
practice preventive medicine as we understand it at present and to establish immunization programmes for children, etc. They will also be involved with research into more effective methods of developing immunity in "at risk" populations. It is also necessary to say something of the relationship between community physicians and management. They are, of course, by the very nature of things part of the management structure. They should have received training in management techniques, but they are also medical practitioners, bound by the ethical code of their profession and with continuing loyalties to their fellow practitioners. They can and should be an effective link between the understandable demands of management and the sometimes not so well understood requirements of practising doctors and other health care workers, but unlike mere interpreters they must also be advocates, teachers and innovators. So far nothing has been said about the relationship between specialists in community medicine and the nursing and paramedical professions. It is self-evident that they have avital role in bringing together all the health care professions but this is a vast subject which cannot be covered in this necessarily brief summary. In conclusion the specialty of community medicine is emerging potentially greater after reorganization. There are many teething troubles to overcome, there are some dangers for the developing specialty, more clearly defined relationships have to be established between specialists within the discipline and with their clinical colleagues and with the other health care professions. Training programmes for new entrants, existing specialists and transferred officers will be required, Continuing education is necessary in this discipline as well as in others. In all these matters the Faculty of Community Medicine must, and 1 believe, will play a prominent part. T. A. Ramsay
Announcement
At the general meeting, held on 13 June 1975, Dr H. Binysh, Area Medical Officer, Cornwall and Isles of Scilly Area Health Authority, was elected President of the Society for the 1975-76 Session.
