the future of the specialty. Demands for more health services appearto be insatiable. The Department of Health and Social. Security (DHSS), in England and ...
Journal of the Royal Society of Medicine Volume 73 January
I& e?31 O
Editorials The future of community medicine It is now almost six years since the reorganization of the National Health Service (NHS). The basic reason for reorganization was to ensure better planned services, and community physicians were seen to be crucial to achieving this. The Faculty of Community Medicine of the Royal Colleges of Physicians was established in 1972. Seven years is a short period after which to review the speciality's position when considered against the development of other medical disciplines. Indeed, no other specialty has ever had to face as many challenges so soon after its founding. Prior to 1974, NHS community physicians were mainly employed as hospital administrative medical officers or medical officers of health (MOsH). These respectively had to reorientate themselves to be also concerned with the health of populations outside hospital (including preventive and environmental aspects) and MOsH, many for the first time, were thrust into the problems associated with hospitals. These changes coincided with world economic depression and national stagnation. In short, community medicine has had a fairly stormy infancy. But during that time the Faculty has laid firm foundations for future development through its specialist training programmes (Warren 1978). Several recent reports have reviewed the work and functions of community physicians and some have suggested far-reaching changes (Royal Commission on the National Health Service 1978 a, b, Cang 1978, Unit for Continuing Education 1978). Most importantly a working party (The Duncan Committee) on the state of community medicine, set up in 1977 jointly by the Faculty and Central Committee for Community Medicine (CCCM), published its report last year (Report of a Joint Working Party 1979). The results of surveys, carried out for the working party, on the work of community physicians (Donaldson & Hall 1979) and the aspirations of those in training (Hagard et al. 1978) have recently become available. It is therefore timely to consider the future of the specialty. Demands for more health services appear to be insatiable. The Department of Health and Social Security (DHSS), in England and Wales, has set national priorities for the development of services (DHSS 1977), is committed to the more equitable distribution of funds (DHSS 1976) and has stated its support for preventive medicine (DHSS/DES 1977). All these have a direct bearing upon the practice of community medicine. Community
0141-0768/80/010001-03/$01.00/0
4
C4
physicians should primarily be concerned with the health of whole populations or groups. They should be 'involved in establishing relative needs for health services. The task of quantifying health requirements must be based upon epidemiological techniques and an extension of this is the establishment of the most cost-effective ways these needs might be met. Another important responsibility is to assist in the implementation of measures known to be effective, whether of a preventive, curative or caring kind. This essentially management function should be concerned with monitoring services and ensuring these change as local circumstances require. It ought not to be confused with administration which is more concerned with maintaining the service machine and is far more bureaucratic in nature. It is self-evident that in order to carry out these complex tasks, community physicians require considerable assistance. This should basically consist of information and planning units, which have the facility to use routine data, and complement these with studies to establish needs, produce costed options for meeting them and monitor the functioning of services. The requirement for this type of intelligence network within health services has been widely recognized (Morris 1969, Knox et al. 1972, White etal. 1977, Barr 1977). While it has been questioned whether better information will necessarily lead to improved planning (British Medical Journal 1978, Lancet 1978), when scarce public resources are at stake it is important to ensure that the implementation of developments and changes are as fully appreciated as possible. It was envisaged at reorganization that there would be well-resourced information units at regional and area level (DHSS 1972a); very few have been established (Crown 1978, McLachlan 1978). In addition, it has become increasingly evident that much of community physicians' time is devoted to administration as opposed to the investigative, interpretive and managerial aspects oftheir role as envisaged by the HunterCommittee (DHSS 1972b). This was to be expected to a certain extent amongst those community physicians involved in 'management' teams, i.e. the Regional Medical Officers (RMOs), Area Medical Officers (AMOs), and District Community Physicians (DCPs). Donaldson & Hall (1979) confirm that AMOs and RMOs devote most of their time to administrative tasks (70%-80Y%) and DCPs about 55%. More disturbing, they show that those community physicians primarily concerned with service planning and information are spending almost half of their time on administration. With © 1980 The Royal Society of Medicine
2
Journal of the Royal Society of Medicine Volume 73 January 1980
hindsight this might have been predicted, considering the undermanning within community medicine and the almost total absence of support and credible intelligence units. A survey oftrainees carried out by Hagard etal. (1978) showed that the majority of respondents (80%) were attracted to community medicine by the opportunity to practise applied epidemiology, including preventive medicine. It seems likely that low recruitment and high drop-out rates during training are largely due to disillusionment at finding that the greater part of a community physician's work is administrative (Donaldson & Hall 1979). The dilemma in which community medicine is placed is that until more resources are devoted to under-pinning its essential applied epidemiological basis, recruitment is likely to remain at a low level. Yet because there are unfilled posts, and responsibilities are often poorly defined, attention is disproportionately given to immediate administrative tasks, to the detriment of the core matters of planning, information and preventive medicine. This situation is compounded by the uneven age structure of those in substantive posts. Over the next 10 years there must be a considerable reduction in the number of community physicians in career posts and this will be accentuated if low levels of recruitment persist. Of 737 established posts in January 1978 (England and Wales), only 613 were filled (Tate 1978). The vacancies (124) are mainly among those posts which are particularly important if the objectives of the reorganized service are to be approached, i.e. 54 posts out of approximately one hundred in health care planning, information and research. In contrast, there were only 13 out of 320 unfilled posts in the more immediate management - administrative posts of the RMO, AMO and DCP. If present levels of recruitment continue, it is estimated that by 1988 there will be only 430 filled posts (Hagard et al. 1978). It is vital that the tasks of community physicians are reconsidered. This has already been suggested by several groups. A research team from the Centre of Industrial, Economic and Business Research of the University of Warwick has recently reviewed the management of financial resources in the NHS (Royal Commission on the National Health Service 1978b). Among the many recommendations are some concerned with community medicine: '(a) That the tasks originally assigned to community physicians be reviewed and reduced to those which require medically qualified staff so that in the future the staff who will be available can fully discharge their responsibilities. (b) Those tasks which do not require medically qualified staff should be clearly assigned to other staff.' These suggestions are similar to proposals made by others (Galbraith 1976, Royal Commission of the National Health Service 1978a, Shegog 1978).
Rather different proposals are put forward in a document from the Health Services Organisation Research Unit at Brunel University (Cang 1978). Here it is argued that the core functions of community medicine are essentially administrative and that this should be accepted and formalized. It is further suggested that most epidemiological work might be more appropriately identified as research and located in academic departments. I think there would be grave dangers if these last proposals were accepted. Services would tend, to an even greater extent, to be 'planned' in a 'normative' and 'bartering' fashion and not related to varying levels of need. Epidemiology might well become even more peripheral to service developments. What are required are closer links between planning and epidemiology, not less. It is essential that there is a thorough review of the unique medical contribution of community medicine. Agreement is required between the Faculty, Health Authorities and the DHSS on how this might be best used. Once this has been established, careful allocation of the resources to enable community physicians to apply these skills will be required. The discussion document produced by the Duncan Committee is a welcome first step. While there has been much central encouragement to community medicine in the form of words, this has not been followed through by the necessary financial commitment, in the form of well resourced planning and preventive medical units and other support services. The situation, to a certain extent, has been analogous to the appointment of a consultant radiologist without the provision of associated X-ray equipment or surgeons without operating theatres. In all regions committees of community physicians are examining ways in which, given the predicted reduction in numbers, they can best organize themselves. Their main proposals are: more rigorous central control of community medicine posts to guard against geographical disparities; encouragement of structural changes leading to fewer districts; provision of better support services; and flexible use of existing manpower. However, unless there is a preliminary stage of explicitly agreeing which tasks require community medical skills and ruthlessly concentrating on these, there are dangers that the same undue concentration on medical administration will persist. There are other people in the service with responsibility for administration and it is essential that community physicians shed those tasks which can be performed by other non-medical people. If the community physician persists in devoting a large proportion ofhis time to administration, then this will destroy his capacity to carry out the more important applied epidemiological and preventive
Journal of the Royal Society of Medicine Volume 73 January 1980
3
functions w%hich only he can perform. One group of community physicians which must increasingly be brought into the service are those in the academic departments of community or social and preventive medicine. It is salutory to note that over half of trainee respondents to a survey thought that the relationship between academic and service departments of community medicine was poor or very poor (Hagard et al. 1978). If research and teaching carried out in these academic departments is to be relevant to the service, then academics must be more directly involved in the service in a way similar to that usually found in other academic medical departments. More jobs should be joint or jointly funded between health authorities and universities. While the exact future of community medicine is uncertain, the potentially important contribution of applied epidemiology to the delivery of medical care and the promotion of effective preventive measures are likely to be increasingly recognized. If community medicine is to rise to these challenges it needs to define clearly its unique medical role as opposed to its administrative contribution and to make this role recognizable. Those administrative tasks which can be carried out by non-medical people must be shed. Godfrey J A Walker Specialist in Community Medicine City and East London Area Health Authority (Teaching)
McLachlan G (1978) By Guess or by What? Information Without Design in the NHS. Oxford University Press, Oxford Morris J N (1969) Lancet ii, 811-816 Report of a Joint Working Party (1979) The State of Community Medicine. British Medical Association/Faculty of Community Medicine Royal Commision on the National Health Service (1978a) The Working of the National Health Service, Research Paper No. 1. HMSO, London; pars. 5.12-5.13 Royal Commission on the National Health Service (1978b) Management of Financial Resources in the National Health Service, Research Paper No. 2. HMSO, London; pars. B8.7-B8. 10 Shegog R F A (1978) In: By Guess or by What? Information Without Design in the NHS. Ed. G McLachlan. Oxford University Press, Oxford; pp 111-125 Tate R M (1978) Community Medicine - Manpower. In: Report of conference on Education, Training and Manpower (abridged). Faculty of Community Medicine; pp 28-31 Warren M D (1978) In: Recent Advances in Community Medicine. Ed. A E Bennett Churchill Livingstone, Edinburgh; pp 245-260 Unit for Continuing Education (1978) What Do Community Physicians Do? Department of Community Medicine, University of Manchester White K L, Anderson D O, Kalimo E, Kleczkowski B M, Purola T & Vunimanovic C (1977) Health Services, Concepts and Information for National Planning and Management. Public Health Papers No. 67. WHO, Geneva
References
The assumption is widely made that any woman can provide milk to fit the needs of her baby for at least the first six months of his life. However, it is now known that in developing countries the milk output of women generally fails to increase in step with the baby's growth so that many infants have outstripped their energy supply by the age of 3 months. Maintenance or improvement of supply is related to more frequent suckling rather than larger amounts at longer intervals (Whitehead et al. 1978). The performance of well nourished and highly motivated women in Cambridge is only a little better over the first 3 months, and after 6 months there is a conspicuous fall off in yield (A Paul & R
Barr A (1977) The Hospital and Health Services Review 73, 387-390 British Medical Journal(1978) ii, 652 Cang S (1978) Doctors and the NHS. Health Services Organisation Research Unit, Brunel University, Uxbridge Crown J (1978) Health Trends 10, 35-36 Department of Health and Social Security (1972a) Management Arrangements for the Reorganised National Health Service. HMSO, London; pars. 3.33-3.35 Department of Health and Social Security (1972b) Report of the Working Party on Medical Administrators. HMSO, London Department of Health and Social Secnrity (1976) Sharing Resources for Health in England. Report of the Resource Allocation Working Party. HMSO, London Department of Health and Social Security (1977) Priorities in the Health and Social Services: The Way Forward. HMSO, London Department of Health ad Social SeclutyfDepartment of Edocatho and Science (1977) Prevention and Health. Cmnd 7047. HMSO, London Domaidson R J and Hall D J (1979) Community Medicine 1, 52-68 Galbraith N S (1976) British Medical Journal ii, 805-806 Hagard S, Tiplady P and Alderiade R (1978) Survey of Trainees in Community Medicine. In: Report of conference on Education, Training and Manpower (abridged). Faculty of Community Medicine; pp 32-36 Knox E G, Morris J N and Holland W W (1972) Lancet ii, 696-700 Lancet
(1978) ii, 720
0141-0768/80/010003-02/$01.00/0
Aspects of breast feeding'
G Whitehead, unpublished). In the UK there is now talk of National Dried Milk as if it were a poison, but perhaps it should be remembered that the post-war generation was very largely reared on it and was the healthiest Britain has yet seen. Now breast feeding is advocated, if possible exclusively for at least some weeks, with the strongest scientific reasons, but inadequate lactation must be anticipated. Obviously this will show as a baby who is failing to thrive - but not all 1 Based on Presidential Meeting of Section of Paediatrics, 24 November 1978. Accepted 9 May 1979
©) 1980 The Royal Society of Medicine
