377

SPECIAL ARTICLES

ESSENTIALS OF A NATIONAL MEDICAL

SERVICE

ON Feb. 3rd Sir HENRY BRACKENBURY, chairmanof the council of the British Medical Association,addressed a large meeting at Brighton on the Essen-tials of a National Medical Service. The chair wastaken by Dr. J. 0. SUMMERHAYES, and the meetingwas arranged by the local division of the B.M.A.

. Sir Henry laid down four conditions for any nationalmedical service, namely -

(1) The service must offer scope and opportunity for the Iachievement of the three-fold aim of modern medicine :curative, preventive,’and constructive.

(2) Any service of the kind should afford opportunitiesfor clinical and laboratory research.

(3) The service should be based upon the provision of ageneral practitioner for every individual, and the relation-ship between doctor and patient should be, as in privatepractice, primarily, if not solely, between those two, withno one else intervening, and should be a free relationship-free both in the sense that the doctor was not confined tosome limited or prescribed system within which he musttreat his patients, and in the sense that there was free choiceboth of patient by doctor, and, especially, of doctor bypatient.

(4) The service must be a complete one, providing not onlygeneral practitioner service, but consultant and specialistservices, various ancillary services, and necessary hospitalaccommodation.

He went on to say that the medical profession was infavour of providing this national medical service onlyfor those who could not provide what they requiredfor themselves. Its attitude in this matter wasdetermined not by monetary considerations (for it wasconceivable that an agreement might be negotiatedon the widest basis which would be equallyremunerative to the doctors), but it was because oftheir jealousy for the preservation of the fundamentalconditions in the relationship of doctor and patient,which were completely preserved in private practice.As to the method of provision, the profession wouldfavour an extension of the compulsory insurancesystem, partly because experience had shown thatwithin that system it was possible to preserve thefundamental conditions of relationship just mentioned,and also because under that system a certain amountof experience had already been accumulated. He

emphasised the desirability of unification in adminis-tration of the health services of the country, especiallyin bringing together the machinery responsible forpublic health and poor-law administration, and thatresponsible for the insurance medical service. In allthese questions of administration the medical profes-sion should be consulted, represented to some extentupon the authorities concerned, and trusted as

completely as possible in matters of internal profes-sional discipline.Turning to institutional provision, he pointed out

that hospitals were shifting away from the old

voluntary basis to an increasing basis of self-support.It was very necessary, in view of this development,that the services of the medical and surgical staffshould be recognised financially in some form or other,and a hospital staff fund was one of the featuresof the modern hospital conceived of as a piece ofmachinery within the national medical service. In

conclusion, he referred to certain other ideas whichthe profession would like to see carried into effect.One of these was the employment as far as possibleof the members of the local medical profession bylocal authorities in discharging their functions

towards certain classes of individuals or in respect tocertain diseases. Again, practitioners should be

brought into closer relationship with, or be consideredan integral part of, the public health service of thelocality; the services should not be walled off fromone another. The present period during which freshenterprise was held up on the ground of economyconstituted, he said, a breathing-space during whichit was a very good thing to explore certain ideas andto endeavour to obtain harmony and agreement asfar as possible, so that when a scheme was broughtforward it might move to fruition with the widestpossible consent.

THE TSETSE FLY

IN 1925 a Tsetse Fly Committee was set up as a sub- -committee of the Committee of Civil Research (nowabsorbed into the Economic Advisory Council). This

body was charged to prepare a practical scheme ofBritish inquiry and action aimed at controlling thetsetse fly as a carrier of human and animal trypanoso-miasis and at a preventive and curative treatment ofthat disease in man and animals. It has now issuedits report.! A preliminary report published in 1925recommended that research should be centralisedunder a trypanosomiasis committee and assisted byparliamentary and local government grants and bysubscriptions. This proposal did not, however, meetwith the approval of the officers administering thevarious territories, and since 1927 the Tsetse FlyCommittee has itself acted as an advisory committeeon human and animal trypanosomiasis.

It is now established that nagana (trypanosomiasisof animals) is caused by any of three trypanosomes :T. brucei, T. congolense, and T. vivax. Often all threeare found together in one animal, but T. brucei is theimportant agent in horses and dogs, and T. con-

golense and T. vivax in cattle, the former being themore virulent. The course of the disease varies verygreatly, according to the infective agent, to the host,to the conditions, such as rain, food, work, andintercurrent disease. Different strains vary widely

, in virulence. Besides the recognised acute, subacute,I and chronic forms of infection there is a latent ordormant form, characterised by an absence of ansemia

.

and other signs of ill-health. It is common in all the. East African territories ; in Northern Nigeria 20-30j per cent. of cattle show it. Host and parasite haveL attained an equilibrium which may last throughout- life, but is easily upset by a change in conditions ofJ food and work and by exposure to such a disease asrinderpest. This " premunity" may be to local- strains of trypanosome only, and it is more easily

acquired by the young than by the adult. At present,t authorities do not know whether the " immune "1 herds are really immune or whether their resistance. is only to local strains or is a

"

premunity." Some

preliminary cross-breeding work has suggested thatI resistance is transmissible.

g DIAGNOSIS AND TREATMENT IN ANIMALS AND MAN

f Recent work has shown more and more the diffi-II culties of diagnosis. Inoculation of Halarsine andti Antimosan causes an increase in the number ofj. circulating parasites, and may prove useful. Com-e plement fixation and the adhesion phenomenon areY ’" Economic Advisory Council. Tsetse Fly Committee8Report. London: H.M. Stationery Office. 1933. Pp. 27. 6d.