In 1919 Sir Bertrand Dawson was commissioned by the new Ministry of Health to chair a council to advise on the systematised provision of health services. The report in 1920 proposed the linkage of hospitals into a single system. The report suggested that the organisation of medicine had become insufficient and was failing to bring the advance of medical knowledge adequately within the reach of the people: ‘The insufficiency of organisation has become more apparent with the growth of knowledge, and with the increasing conviction that the best means of maintaining health and curing disease should be made available to all citizens.’
The report outlined the structure that the NHS would take nearly 30 years later and illustrated that the system would need to change to cope with technological and medical advances.
Dawson noted that previously a condition such as appendicitis might be treated with drugs in a patient’s home, but advances meant that patients were treated by operations which required different levels of resources and infrastructure.
Dawson recommended that preventative and curative medicine should be aligned and be brought together by general practitioners. The report outlined the following service model:
Doctors’ surgery: doctors would be accessible to their patients, attending them at home or in their surgeries.
Primary health centres: domiciliary services of a district would be based on a primary health centre encompassing curative and preventative medicine conducted by general practitioners. Domiciliary care included health visiting, pharmacy, community doctors and nurses. Primary health centres would refer complex cases to secondary health centres. The centres might include operating rooms, radiography rooms, a public mortuary and a dispensary, but it was not expected that all centres would include the full range of facilities.
Secondary health centres: secondary health centres would be staffed by consultants and specialists and would be based in towns. The secondary health centres would be aligned with a teaching hospital within a medical school. In some areas the secondary health centre and the teaching hospital might be merged. The centre would be equipped to deal with general medical and surgical services, specialist services such as obstetrics, dermatology and orthopaedics, laboratories and services such as pharmacy and hydrotherapy. Cases referred for consultation or treatment would attend outpatient clinics or would occupy inpatient beds.
With regard to hospital provision, the report suggested that in those areas with modern and well-equipped poor law hospitals, these institutions should be transferred to the health authority. The report proposed that consultants should be part-time officers, allowing them to continue private practice.
Supplementary services: supplementary services serving a wide area would comprise provision for patients suffering from mental illness, diseases such as tuberculosis, epilepsy and certain infectious diseases.
The committee was split on whether or not treatment at the health centres should be free. There was concern that free treatment would place a heavy burden on public funds. It was thought that preventative services should be publicly provided. The report recommended that standard charges should be made in the public wards and that the cost should be met by some type of insurance.
The report suggested that the voluntary hospitals had fallen on ‘evil days’ due to increases in the prices of commodities and wages as well as advancing technology. Some hospitals’ endowments were not sufficient to meet the increased expenditure and were finding it difficult to remain financially sustainable. The committee suggested that their proposals would place the voluntary hospitals on a more stable footing as they would be an essential part of the scheme and would receive grants: ‘Capital expenditure in a hospital differs from capital expenditure in business, in that when a business house grows, it grows in earning capacity, but when a hospital grows, it grows in spending capacity. And therefore almost without exception every hospital in the country is facing increasing difficulty in carrying on its work.’