Public Health The Journal of The Society of Community Medicine (Formerly the Society o f Medical Officers o f Health) Volwne 90
Number 1
Norember 1975
The Society of Community Medicine: Presidential Address--1975 The Changing Face of Community Medicine When you did me the honour of electing me to the Presidency o f this ancient and learned Society my reaction was that of ~arofound humility, on two counts. First, that it would be difficult for anyone to follow adequately your pfigtPresident, Alastair Nelson, who was also Chairman of the Council over the last three years. His frietidliness, out-going personality and ablhty to enthuse others has made an outstanding contnbut~omt9 the work o f th~s Society. Accordingly, I am delighted that he will be continuing to work f6"~/':t'heSociety and I shall greatly appreciate his advice and support. Over this difficult period the Society has been well served by all its officers but special thanks are due to our Treasurer, Philip Moore, and to our helpful Secretary, Mr N. G. Taylor. The second cause of the "butterflies" in my stomach was the knowledge that the Society has entered upon a critical period in its history, reflecting the growing wind of change which has reached typhoon force throughout the world. A few weeks ago I returned from a holiday in the Middle East where all the countries are in ferment. The Ottoman Empire broke up 50 years ago but the repercussions still continue with riots--civil wars and revolutions and coups. Three governments have been overthrown by force int various parts o f the world in the past two months. It is no wonder that Britain cannot stared completely isolated as a Sea of Tranquility in a violent world. Violence has now been with us for several years in Northern Ireland and has spread to Britain. Perhaps then it is no wonder that the prevailing mood of Britain appears to be one of doubt, gloom and self-criticism. We are not alone in this--for t h e mood and indeed the same criticisms of the health services are extant in Israel as in Britain. What then are the causes of our discontents ? The uncertainties caused by a series o f re-organizations o f the social services and the health service must rank high and these were compounded by galloping inflati0n, a falling standard of living and a check on the pace o f development. •
.
.
.
"?.-:.
.
2
1t. Binysh
Lack of development is n o new phenomenon in the health services and many of you must remember how few health centres and hospitals were built in the 15 years following the N.H.S. inception in 1948. When I entered the community medicine field at that time, medical officers of health were gloomy about the loss o f clinical work in the public health hospitals, fever hospitals and maternity hospitals. The clinical medical officers were doubtful as to their future and required reassurance that there was still need for maternal and child health clinics. Both groups found, as the years went by, that there were new needs and opportunities, so that by 1974 there was an impressive record of achievement in the community health field. Coming back to Britain last m o n t h I had a profound sense of relief to be in a country which was still a democracy--where wrongs could be righted b y a n O m b u d s m a n or by a "question in the House". Perhaps we in this country have become a little blas6 about the wonder o f a universal health service--a service which has raised minimum standards and has provided low cost treatment to all its citizens, and a service which is continued for each patient for as long as it is needed. We who live with the health service seeit "warts and all" so that we begin to rage that the pace o f improvement is not sufficiently great. We are like children who have had a taste of the goodies and cannot bear to have them taken away when the realities o f our e c o n o m i c situation make it necessary. It is a paradox that the more successful One becomes in keeping alive the old and the sick the greater are the demands on medical resources. The medical press frequently quotes the proportion of the gross national product in various countries which is spent on the health service. Britain certainly gets excellent value for money in its health services even though it seems to spend less than many other developed countries. Whether we should be spending more depends on value judgements as to what are the priorities for development--is it more important to " e x p o r t " and earn o u r daily bread, or to build homes or hospitals where our citizens can live in dignity with better chances o f good health ? One of the greatest o f our health problems, particularly in the south, is that of the care of the aged. The number of old people in the population is expected to rise rapidly until the end of this decade. A high proportion o f our hospital beds are taken up by the elderly. Several surveys have shown that a substantial proportion of those in hospitals could better be dealt with in the community in sheltered housing, hostels, homes for the aged and in their own homes with domiciliary supporL King Edward VII said of tuberculosis--"If preventable, why not prevented'?." If~I may p a r a p h r a s e - - " I f misplacement o f the aged is preventable, then why not prevented ?'" This .then will be one of the primary functions o f the c o m m u n i t y physician in the years ahead. The days o f massive spending on hospital building are now at an e n d for many years. The role o f specialist in comnaunitv medicine will be to devise means whereby existing resources are used to best.advantag,~- and ensure that priorities for development are agreed on the basis of fac~ and n o t emotion. The community physician must then be alert as to the failings a n d deficiencies of the service to ensure that the needs o f all groups receive balanced consideration. The community physician must be watchful for advances in other disciplines which can be applied in the health services whether they be in the fields o f computers, communication lasers, or ambulance service.design. The community physk:~an must be alert for new hazards, whether toxic hazards from industry and technology, o r new infections. We cannot neglect the possibility o f the return of the old hazards such as rabies, cholera and poliomyelitis. T h e unexpected is always a possibility, and the likelihood of new dangers ahead was dramatically demonstrated recently by the deaths from Lassa Fever. The moon has
Ti~e changingface of communiO, medichze
3
been explored and has proved to be lifeless but there are n o w two space probes on the way to Mars. No doubt astronauts will one day make that journey and we shall then be faced with the possibility of importation of alien organisms. We need a new philosophy to ensure that problems are looked at as a whole and that the medical view-point is not submerged within the complexities o f the N.H.S. The care o f a child or an old person must be seen as a continuing process and dealt with as part o f a family group. This implies a far closer working liaison with the social services to ensure that patients are not admitted to hospital unnecessarily and that when in hospital there is full discussion regarding each patient's future needs and possibilities. It needs implementation of the philosophy that hospital care is just one episode in patient care and that long-stay hospitalization may sometimes be only a confessi6n of failure of the medical and social services. There is little I can say regarding the future o f the child health services at this time. The tripartite system o f care will surely disappear in the future although the present processes of integration are slower than some might have hoped. Perhaps we may also hope that the recommendations o f the Court Committee will envisage a pattern o f development which will link the hospital, community, and family d o c t o r child health services. Every seriously handicapped child needs long-term supervision and the community physician must ensure that each child receives all the potential help available--both in the medical and educational field. There is then still a valuable field o f work here for the clinical medical officers. Many of the clinical medical officers are at present engaged in family planning work and this is also a field where a revolution is in progress with the recent financial arrangement to encourage fafilily planning by hospital doctors and family practitioners. It is unclear as to the eventual role of the clinical medical officers, but there must be proper career opportunities for those who have specialized in this field. It is a little o d d that the Government should be offering financial inducement to extend the contraceptive services at a time when the number of births is rapidly falling, so that a decline in population is now a real possibility. The Society came into being some 100 years ago because of the need for like-minded people to come together to discuss their c o m m o n problems and so help overcome them. That need still exists. The Society has recognized the profound changes of recent years with a changed name, a new constitution, and a new geographical structure. The need for likeminded people to come together has brought into being a number o f associations of community physicians and the Committee of Chairmen of the Society has already had discussions with representatives of some of these bodies. The Society has offered representation on one of its major committees to the Association o f Area Medical Officers. It is inconceivable that the Society should stand aside while community medicine becomes fragmented. Within so small a specialty there must be a unified voice to express the opinions, wishes, hopes and fears of the practitioners of community medicine. Many of the members o f this Society are also members or fellows of the Faculty of C o m m u n i t y Medicine and of the British Medical Association. Both o f these bodies have an assured and important role to play in the future o f community medicine. Our learned Society by virtue of its charitable status has never undertaken negotiations regarding terms and conditions of service of its members and this we leave to the British Medical Association. The Faculty has an essential role in the sphere of medical education and the maintenance of standards of training. The Society has a wide membership embracing dental members and clinical members in addition to community physicians, so that the Society is able to express the view of a wide crosssection o f those in community medicine. We hope to work in close collaboration with each o f these other bodies, so that at m i n i m u m there will be co-ordination o f views.
4
H. Binysh
The strengths of the Society have always been its readiness to adapt to changing needs, its democratic structure and its valuable educational role which is coupled with the opportunities given for social contacts. To each of the members o f the Society I would stress that it is in being to serve their needs. As such it is incumbent on each member to support its activities and to let me know if there should be any apparent failure tO meet these needs. This is not a petrified organization but one which is eager to keep abreast of a rapidly changing world. Our journal, Public Health has had a recent change o f editor and a new look which reflects the work of an active and vigorous body. Again I would ask members to send letters and contributions to the Editor.of the journal, Dr Gordon, so that it may become a lively forum for their ideas. The future, as ever, is uncertain: the problems are difficult--the pace of change seems to become increasingly rapid--yet I am certain that so long as the Society continues to meet the needs o f its members then it will flourish. Together we can ensure that this continues to happen in the future as it has in the past.
H. Binysh
Number 1
Norember 1975
The Society of Community Medicine: Presidential Address--1975 The Changing Face of Community Medicine When you did me the honour of electing me to the Presidency o f this ancient and learned Society my reaction was that of ~arofound humility, on two counts. First, that it would be difficult for anyone to follow adequately your pfigtPresident, Alastair Nelson, who was also Chairman of the Council over the last three years. His frietidliness, out-going personality and ablhty to enthuse others has made an outstanding contnbut~omt9 the work o f th~s Society. Accordingly, I am delighted that he will be continuing to work f6"~/':t'heSociety and I shall greatly appreciate his advice and support. Over this difficult period the Society has been well served by all its officers but special thanks are due to our Treasurer, Philip Moore, and to our helpful Secretary, Mr N. G. Taylor. The second cause of the "butterflies" in my stomach was the knowledge that the Society has entered upon a critical period in its history, reflecting the growing wind of change which has reached typhoon force throughout the world. A few weeks ago I returned from a holiday in the Middle East where all the countries are in ferment. The Ottoman Empire broke up 50 years ago but the repercussions still continue with riots--civil wars and revolutions and coups. Three governments have been overthrown by force int various parts o f the world in the past two months. It is no wonder that Britain cannot stared completely isolated as a Sea of Tranquility in a violent world. Violence has now been with us for several years in Northern Ireland and has spread to Britain. Perhaps then it is no wonder that the prevailing mood of Britain appears to be one of doubt, gloom and self-criticism. We are not alone in this--for t h e mood and indeed the same criticisms of the health services are extant in Israel as in Britain. What then are the causes of our discontents ? The uncertainties caused by a series o f re-organizations o f the social services and the health service must rank high and these were compounded by galloping inflati0n, a falling standard of living and a check on the pace o f development. •
.
.
.
"?.-:.
.
2
1t. Binysh
Lack of development is n o new phenomenon in the health services and many of you must remember how few health centres and hospitals were built in the 15 years following the N.H.S. inception in 1948. When I entered the community medicine field at that time, medical officers of health were gloomy about the loss o f clinical work in the public health hospitals, fever hospitals and maternity hospitals. The clinical medical officers were doubtful as to their future and required reassurance that there was still need for maternal and child health clinics. Both groups found, as the years went by, that there were new needs and opportunities, so that by 1974 there was an impressive record of achievement in the community health field. Coming back to Britain last m o n t h I had a profound sense of relief to be in a country which was still a democracy--where wrongs could be righted b y a n O m b u d s m a n or by a "question in the House". Perhaps we in this country have become a little blas6 about the wonder o f a universal health service--a service which has raised minimum standards and has provided low cost treatment to all its citizens, and a service which is continued for each patient for as long as it is needed. We who live with the health service seeit "warts and all" so that we begin to rage that the pace o f improvement is not sufficiently great. We are like children who have had a taste of the goodies and cannot bear to have them taken away when the realities o f our e c o n o m i c situation make it necessary. It is a paradox that the more successful One becomes in keeping alive the old and the sick the greater are the demands on medical resources. The medical press frequently quotes the proportion of the gross national product in various countries which is spent on the health service. Britain certainly gets excellent value for money in its health services even though it seems to spend less than many other developed countries. Whether we should be spending more depends on value judgements as to what are the priorities for development--is it more important to " e x p o r t " and earn o u r daily bread, or to build homes or hospitals where our citizens can live in dignity with better chances o f good health ? One of the greatest o f our health problems, particularly in the south, is that of the care of the aged. The number of old people in the population is expected to rise rapidly until the end of this decade. A high proportion o f our hospital beds are taken up by the elderly. Several surveys have shown that a substantial proportion of those in hospitals could better be dealt with in the community in sheltered housing, hostels, homes for the aged and in their own homes with domiciliary supporL King Edward VII said of tuberculosis--"If preventable, why not prevented'?." If~I may p a r a p h r a s e - - " I f misplacement o f the aged is preventable, then why not prevented ?'" This .then will be one of the primary functions o f the c o m m u n i t y physician in the years ahead. The days o f massive spending on hospital building are now at an e n d for many years. The role o f specialist in comnaunitv medicine will be to devise means whereby existing resources are used to best.advantag,~- and ensure that priorities for development are agreed on the basis of fac~ and n o t emotion. The community physician must then be alert as to the failings a n d deficiencies of the service to ensure that the needs o f all groups receive balanced consideration. The community physician must be watchful for advances in other disciplines which can be applied in the health services whether they be in the fields o f computers, communication lasers, or ambulance service.design. The community physk:~an must be alert for new hazards, whether toxic hazards from industry and technology, o r new infections. We cannot neglect the possibility o f the return of the old hazards such as rabies, cholera and poliomyelitis. T h e unexpected is always a possibility, and the likelihood of new dangers ahead was dramatically demonstrated recently by the deaths from Lassa Fever. The moon has
Ti~e changingface of communiO, medichze
3
been explored and has proved to be lifeless but there are n o w two space probes on the way to Mars. No doubt astronauts will one day make that journey and we shall then be faced with the possibility of importation of alien organisms. We need a new philosophy to ensure that problems are looked at as a whole and that the medical view-point is not submerged within the complexities o f the N.H.S. The care o f a child or an old person must be seen as a continuing process and dealt with as part o f a family group. This implies a far closer working liaison with the social services to ensure that patients are not admitted to hospital unnecessarily and that when in hospital there is full discussion regarding each patient's future needs and possibilities. It needs implementation of the philosophy that hospital care is just one episode in patient care and that long-stay hospitalization may sometimes be only a confessi6n of failure of the medical and social services. There is little I can say regarding the future o f the child health services at this time. The tripartite system o f care will surely disappear in the future although the present processes of integration are slower than some might have hoped. Perhaps we may also hope that the recommendations o f the Court Committee will envisage a pattern o f development which will link the hospital, community, and family d o c t o r child health services. Every seriously handicapped child needs long-term supervision and the community physician must ensure that each child receives all the potential help available--both in the medical and educational field. There is then still a valuable field o f work here for the clinical medical officers. Many of the clinical medical officers are at present engaged in family planning work and this is also a field where a revolution is in progress with the recent financial arrangement to encourage fafilily planning by hospital doctors and family practitioners. It is unclear as to the eventual role of the clinical medical officers, but there must be proper career opportunities for those who have specialized in this field. It is a little o d d that the Government should be offering financial inducement to extend the contraceptive services at a time when the number of births is rapidly falling, so that a decline in population is now a real possibility. The Society came into being some 100 years ago because of the need for like-minded people to come together to discuss their c o m m o n problems and so help overcome them. That need still exists. The Society has recognized the profound changes of recent years with a changed name, a new constitution, and a new geographical structure. The need for likeminded people to come together has brought into being a number o f associations of community physicians and the Committee of Chairmen of the Society has already had discussions with representatives of some of these bodies. The Society has offered representation on one of its major committees to the Association o f Area Medical Officers. It is inconceivable that the Society should stand aside while community medicine becomes fragmented. Within so small a specialty there must be a unified voice to express the opinions, wishes, hopes and fears of the practitioners of community medicine. Many of the members o f this Society are also members or fellows of the Faculty of C o m m u n i t y Medicine and of the British Medical Association. Both o f these bodies have an assured and important role to play in the future o f community medicine. Our learned Society by virtue of its charitable status has never undertaken negotiations regarding terms and conditions of service of its members and this we leave to the British Medical Association. The Faculty has an essential role in the sphere of medical education and the maintenance of standards of training. The Society has a wide membership embracing dental members and clinical members in addition to community physicians, so that the Society is able to express the view of a wide crosssection o f those in community medicine. We hope to work in close collaboration with each o f these other bodies, so that at m i n i m u m there will be co-ordination o f views.
4
H. Binysh
The strengths of the Society have always been its readiness to adapt to changing needs, its democratic structure and its valuable educational role which is coupled with the opportunities given for social contacts. To each of the members o f the Society I would stress that it is in being to serve their needs. As such it is incumbent on each member to support its activities and to let me know if there should be any apparent failure tO meet these needs. This is not a petrified organization but one which is eager to keep abreast of a rapidly changing world. Our journal, Public Health has had a recent change o f editor and a new look which reflects the work of an active and vigorous body. Again I would ask members to send letters and contributions to the Editor.of the journal, Dr Gordon, so that it may become a lively forum for their ideas. The future, as ever, is uncertain: the problems are difficult--the pace of change seems to become increasingly rapid--yet I am certain that so long as the Society continues to meet the needs o f its members then it will flourish. Together we can ensure that this continues to happen in the future as it has in the past.
H. Binysh
