Column

The battle for the health centre

With all the talk of a primary care led NHS, it is easy to take the existence of the health centre for granted. But it was not always so, explains Charles Webster

In the last issue, healthmatters correctly pointed out that attempts to create a primary care-led health service date back to the Dawson report of 1920. That report launched the idea of a comprehensive health service organised hierarchically, with primary health centres as the front-line contact with the local community. Dawson’s health centres were conceived as a way of reviving the fortunes of general practitioners, already fearing redundancy as a result of the incursions of hospital medicine.

The Dawson report was shelved, but the idea of the health centre survived and gained popularity during the 1930s, largely owing to advocacy by the Socialist Medical Association (SMA). SMA thinking on health centres was much influenced by the polyclinics of the USSR and western Europe. Via this channel, the health centre entered Labour Party policy. It became an omnibus conception, and the many different health service buildings designated as health centres during the interwar period represented rival and indeed incompatible approaches to healthcare.

The best known was Peckham Health Centre, internationally famous for its architecture and its concentration on preventive and promotive medicine. At the opposite end of the spectrum was an equally famous piece of architecture, Finsbury Health Centre, which was merely used for housing the clinics of the Medical Officer of Health.

Despite confusion about its concept, the health centre lost none of its appeal to the medical avant garde. Progressive thinking about healthcare, or new aspirations about the attainment of ‘positive health’, largely revolved around the idea of health centres, a trend which culminated during World War II, which was, of course, the planning stage for the future National Health Service. This strong impetus was indicated by the degree to which the health centre dominated the Medical Planning Commission report of 1942. But this was the nearest the medical profession ever came to adopting the health centre as its official policy. Health service planners mistakenly took the report as a sign that the profession would welcome employment in health centres under the new health service. This expectation was soon disappointed. By 1944, the medical profession was firmly against developing health centres on more than an experimental basis, largely due to fears about the threat they posed to their status as independent contractors. By 1945, the health centre had come to epitomise medical fears about socialised medicine.

But the new Labour government’s White Paper in 1946 said health centres would be a main feature of the new health service: the ‘object is that the health centre system should afford facilities for the general medical and dental services and also for many of the special clinic services of the local health authorities, and sometimes also for outpost clinics of the hospitals and specialist services. The centres will also serve as bases for the various activities in health education’. Bevan was forced to retreat from this position; abandoning health centres was among the many concessions offered to the medical profession to buy their compliance.

Distrust of health centres was extremely slow to wane. Even more liberal expressions of opinion stemming from the profession, such as the Porritt report (1962) and Gillie report (1963), as well as the Medical Practitioners Union’s Our Blueprint for the Future (1963), kept to the line that health centres deserved no more than experimental trials. A more positive attitude towards health centres was evident for about a decade following the Doctors’ Charter of 1965. But this proved to be an intermission, and the health centre of this period was an extremely limited concept compared with the ambitious schemes characteristic of the decade pre-1945.

Abandoning health centres was arguably the biggest policy shift made by Bevan. Was it disadvantageous to the new health service? A case against health centres can certainly be made, but on the whole it seems likely that progressive changes within healthcare would have been facilitated more effectively with health centres than without them. The absence of health centres arguably increased dependence on hospital services and inhibited the development of community and primary care. Health centres were the only means by which the disparate elements within the new health service could be brought into meaningful co-operation. They were also potentially important to the egalitarian aims of the NHS, because they were intended primarily for areas of population relocation. New towns and housing estates often possessed fine new schools, but the absence of health centres meant that healthcare usually possessed no institutional focus for its development and no visual symbol of its importance in the life of these deprived communities. For all these reasons, we should not be too eager to disparage the post-war Labour government’s aspiration for a health service comprising a system of health centres as one of its dominant features.