The Doctor
In the Middle Ages medicine, like all learning, was closely linked with the Church, though surgery developed separately. The physician influenced by Renais- sance learning and by Greek literature progressed. In 1518 by the efforts of Linacre the Royal College of Physicians of London was established. The Act of 1522 provided that no person except a graduate of Oxford or Cambridge should practise medicine unless he had been approved by the College, though the ecclesiastical authorities also possessed licensing powers.
The status of the surgeon in the meantime had receded, and they in time combined with the barbers to form the Barber Surgeons Guild, though the practice of the arts of barber and of surgeon remained distinct. But by the eighteenth century neither the Royal College nor the uni- versities were providing the trained doctor. The apothecaries who, originating as a species of grocer, by 1617 had secured a charter for the Society of Apothecaries, filled the gap. Already under the Act of 1542 they had obtained the right to prescribe. By 1722 the Society obtained powers to exercise supervision over the London apothecaries and by 1748 they were authorized to appoint a Board of Examiners.
In the meantime the state of the surgeon had improved. In 1745 t ne association of barbers and surgeons was ended on the formation of two separate companies. The Surgeons’ Company which had been created in turn came to an end in 1796 and the Royal College of Surgeons of London was formed in 1801, becoming in 1843 t ne Royal College of Surgeons of England.
The training and the licensing of the various sections of the medical profession in the eighteenth century was chaotic. There were twenty-one disconnected and uncontrolled cor- porate authorities who could grant a licence to practise, though often enough this licence extended only to a limited territorial area. The training of the medical student was as varied and as unequal as was his title to practise, for there was no authorized curriculum, nor any recognized standard of practice. T h e drive for reform from this chaotic state came mostly from the surgeons and the apothecaries. T h e practice grew for a man to qualify both as apothecary and as surgeon, these being the general practitioners. The Act of 1815 gave the Society of Apothecaries the right to examine not only the London but all apothecaries, and to impose a five- years apprenticeship. The instruction of students at hospitals, which began at the end of the seventeenth century, had developed in the next century when the practice of * walking the hospitals ‘ became part of the training supplementing that of apprenticeship. A system of medical education was evolved, conducted mostly by practitioners at private medical schools, though four London hospitals had arrangements which later developed into the medical schools connected with the larger hospitals. The Society therefore provided the nation with a large body of well-educated practitioners who in time organized themselves into such societies as the National Association of General Practitioners.
In 1832 on these lines the Provincial Medical and Surgical Association was founded at Worcester, later becoming the British Medical Association. These societies demanded the sweeping away of the old licensing authorities and a thorough overhaul of the profession. Bitter agitation followed, and two Parlia- mentary Select Committees were set up to deal with the problem. In 1858 the General Medical Council was created. Intended to be on a temporary basis, the Council gradually established itself and moulded the profession into an organic whole, while it left the older bodies, the licensing authorities, subject to its ruling, to do the work they had previously carried out. Even after the Medical Act, then, the licensing bodies remained, carrying on their work as examining and as teaching bodies. With the growth of the new universities, others have come into being. The General Medical Council exercises a control over the general standard of medical educa- tion through its power of representing to the Privy Council that any licensing authority should have its licence revoked because its teaching or its standards of examination are not sufficiently high.
It was not until the 1886 Medical Act that the professional qualifications demanded a proficiency in the whole of practical medicine as an integrated unit—medicine, surgery, and mid- wifery—bringing to an end the former legal recognition of fragmentary, partial, or subordinate qualification.
Up to the beginning of the present century doctors carried on their profession largely independently of local or of central authority. They were obliged under the Births and Deaths Registration Act of 1874 to sign certificates of the cause of death. They could sign the necessary documents which were the preliminary to the admission of a lunatic to an appropriate institution. It was not until 1889 t n at those living in certain localities were obliged to notify the local authority of certain infectious diseases occurring in their patients ; while not for another ten years did this notification become obligatory throughout the country. Certain industrial diseases became notifiable in 1895, but it was not until 1907 that doctors were obliged to notify births to local authorities, and then only in certain areas, the Notification of Births Act not becoming generally operative throughout the country until its extension in 1915.
A few medical officers had been appointed to the central government in the latter part of the nineteenth century. The first medical officer of health was appointed in 1847. In the next few years such posts became more common, but it was not until 1872 that all over the country the local sanitary authorities appointed their full-time or part-time medical officers of health. Some doctors had become engaged in industrial medicine ; while for many years the guardians had employed, frequently whole-time but more often part- time, local medical practitioners to attend to the sick to whom they owed a duty. An increasing number of medical practi- tioners then was gradually being employed either whole- time or part-time by local authorities or by a central government department.
During the present century the doctor has become much more closely associated with both local and central govern- ment. With the growth of the personal services they were providing, local authorities engaged many whole-time or part-time medical officers on their staffs, including consul- tants. This practice was very much more marked when authorities became responsible for the hospital services, by which time there were in the employ of authorities, in addition to the medical men engaged in administrative duties, many more occupied whole-time or part-time on clinical work.
The National Health Insurance Act of 1911 brought most of the general medical practitioners into contractual relation- ship with a central department. In the same way the growth of industrial medicine brought an increasing number of practitioners as factory surgeons into association with another government department. T h e position had so changed then that, so far from the medical practitioner carrying on his work in almost complete independence of local and of central government, he had been brought into the most intimate relationship with the one or the other, in one of two ways or in both—either generally, as were most of his colleagues by the obligation to comply with certain acts, rules, orders, or regulations ; or more specifically by his entering voluntarily into a contractual relationship with either a local authority or a central government department.
At the same time as the medical man was in these ways being brought closer to the work of central and local govern- ment departments, local authorities were gradually extending their activities in the field of clinical medicine, more especially for certain sections of the population and for those suffering from certain diseases or abnormal states. The school health service had expanded until, by the Education Act of 1944, education authorities were obliged to provide free of cost to all children attending maintained schools any medical treat- ment they required, excepting a domiciliary service.
Increasing use was being made of their powers by local authorities to provide extensive services, including the treatment of those suffering from certain conditions, for nursing and for expec- tant mothers, and for children up to the age of five years. Certain local authorities had been obliged to make arrange- ments for the care of those suffering from tuberculosis, venereal disease, mental deficiency or affliction, or blindness. Since 1911 a large proportion of the male adults of the country have obtained their medical services under the arrangements of the Insurance Act; the financial limit of this group was raised, reaching the figure of £420 per annum. When authorities were obliged in addition to provide a general hospital service for their areas, it could only be a matter of time before the introduction of a general medical service.
The Health Service Act provides a comprehensive medical service for all, that is, for all who wish to take advantage of it, though none is compelled to do so. All medical practi- tioners are entitled to participate in the arrangements, though again none is obliged to. There will then for a time at least remain some medical practitioners carrying on an independent practice outside the national arrangements.
The Dentist
Dentistry has only slowly achieved the dignity of a profession. Tooth drawing was for long the function of the barber. In the latter half of the eighteenth century some medical men specialized in dental surgery. By 1800 there were many dental surgeons, and the subject was being taught at Guy’s Hospital. But most of the work was being done by those who were not doctors. This difference in status between those who were and those who were not doctors was probably responsible for the dentists not drawing together to become a professional body. By 1840 certain of their members moved to exclude the untrained man from the right to practise. The 1878 Dental Act achieved a partial success in that it empowered the General Medical Council, the only supervisory body at that time, to keep a register of dentists, and to supervise an examination system for the protection of the title of the dentist and the dental practitioner. But while it enabled the public to distinguish between the trained and the untrained, it did not make practice by the unqualified or unregistered illegal. All those who were in bona fide practice at the date as well as those possessing academic qualifications were admitted to the register. Further action was deferred both because of the undesirability of depriving anyone of his means of livelihood, and because barring practice by the unregistered would have created too great a shortage of practitioners. It was not until the 1921 Act that the practice of dentistry except by duly registered medical or dental practitioners was prohibited. The right of admission to the register was given not only to those holding the diploma of one of the recognized licensing bodies, but to some other well-defined groups.
The 1921 Act set up the Dental Board of the United Kingdom, which, subject to the control of the General Medical Council, is responsible for the discipline of the profession.
The Nurse
Such nursing as existed in this country before the Reformation was carried out under the influence of the religious orders. When these were suppressed in the sixteenth century there was no organization to take their place, so the standard of nursing fell, remaining at that low level until the middle of the nineteenth century. An Institute of Nursing was established in 1840, carrying on its work among the poor. It was, however, through the efforts of Florence Nightingale that nursing was revolutionized and really became a profession. The Nightingale Training School founded in i860 at St. Thomas’s Hospital was followed by others, so that many had been established by the end of the century. A nurse trained at a hospital was entitled to the certificate of her training school.
A society for the state registration of nurses was formed in 1902, but it was not until 1919 that Parliament set up the General Nursing Council for this purpose. There is, apart from the general register, a supplementary register for the inclusion of such as male nurses, mental nurses, fever nurses, children’s nurses, etc., while more recently recognition has been given to the assistant nurse.
Nurses are employed in a variety of ways. Many continue to accept hospital appointments. T h e public health service engages a large number as health visitors, school nurses, tuberculosis visitors, etc. Many are engaged in the prison services or with the armed forces. Increasing numbers are employed as industrial nurses working at the larger factories ; while many, too, work at private nursing homes. Some are engaged on private nursing in the homes of the patient. Most of these nurses join one of the co-operative organizations, contributing part of their earnings to the general fund. Many are engaged as district nurses ; these need to be mid- wives and to have had district experience as well. In some districts this work is undertaken by Queen’s Nurses, who are general trained nurses who have had district experience and are often qualified midwives. District nurses undertake follow-up work and after-care, visiting chronic invalids and the bed-ridden. The nursing associations which employed them were in general organized on a voluntary basis, though recently much of the money came from contributory and provident schemes ; while many local authorities, includ- ing the public assistance authorities, paid for specific services. T h e maintenance of a domiciliary nursing service is now the responsibility of the local health authority.
The shortage of nurses so marked to-day is no new thing. In 1930 The Lancet set up a Commission to inquire into the shortage of candidates, trained and untrained, for nursing the sick in the general and special hospitals throughout the country, and to offer suggestions for making the service more attractive to women suitable for this necessary work. In 1937 the Ministry of Health set up an Interdepartmental Committee under Lord Athlone to inquire into the recruit- ment, training, registration, and terms and conditions of service of nurses. To-day the conditions have been much improved throughout the country, being now controlled by the awards of the Rushcliffe Committee, which deals with such matters as salary, off-duty time, holidays, etc. Never- theless this marked improvement in their conditions has done little to reduce the shortage, which probably is as great to-day as ever before, a shortage partly due to the increased demand for nurses which followed on the extension of the hospital services under the 1929 Local Government Act. It is this shortage which has led to the official recognition of the ‘ assistant nurse.
The Midwife
Up to the eighteenth century midwifery was undertaken in England as elsewhere almost entirely by women who had no training or qualifications for the work. A number of medical practitioners specialized in this branch, but the omission of the 1858 Medical Act to include mid- wifery as one of the subjects of the qualifying examination for medical degrees was not rectified until 1886. In the meantime a number of women’s organizations pressed for the recognition and training of midwives. This led to the passing in 1902 of the Midwives Act which created the pro- fession of midwifery and established the supervisory body, the Central Midwives Board. Those in active practice were admitted to the roll as bona fide midwives, but since that date the right of admission has been restricted to those who have passed a qualifying examination which they can sit for only after having received an approved course of training.
Even during this century, however, the practice of mid- wifery was far from satisfactory. Fees were low, so mid- wives were obliged, in order to earn an adequate income, to attend to too many cases. On the other hand, many pin- money midwives were not attending sufficient patients to maintain their skill. Again, parts of the country, particularly rural areas, were very meagrely supplied with midwives. The Midwives Act of 1936 was designed to remove these shortcomings. This imposed a duty on certain local authori- ties to see that there were in their areas sufficient midwives to attend on those women being confined in their own homes. To ensure this an authority might engage the midwives direct, or contract with some such body as a district nursing association.
Compensation was offered to those surrendering their certificates within three years. There were to be sufficient midwives so that each would be required to attend a limited number of cases only, leaving her sufficient time for her nursings, her ante-natal super- vision, etc The Act, by improving the conditions of service, which, like those of the nurses, are now governed by the awards of the RushclifTe Committee, has made the midwifery profession more attractive. Should the result be a sufficient increase in the number of those entering the profession, it will be possible to extend the length of the period of training and to improve the standard of entrant. It should then be possible for midwives to do much more than they are per- mitted to do to-day in dealing with certain abnormal states, so that in time they could be looked on as the natural attendants of the woman in normal labour.
Today there is a marked shortage of practising midwives. Although the roll contains the names of some 60,000, only about one-quarter are in actual practice.
The Pharmacist
The Pharmaceutical Society was created in 1841 primarily to protect the professional interests of the pharmacists against the attempts of the apothecaries to prevent them dispensing. By the Acts of 1852 and 1868, however, this body was being used by the State to secure to the public definite standards of service. Only persons on the Register of the Society may call themselves * pharma- ceutical chemists ‘ or * chemists and druggists ‘. The School of Pharmacists founded by the Society became in time the College of Pharmacy for the University of London. Degrees can now be obtained at some provincial universities. T h e Society is the statutory examining body, and determines the qualifications for admission to the register.
Since 1868 registered pharmacists have enjoyed special privileges in connexion with the sale of poisons, and, under the National Health Insurance Act all medicines could be dispensed only under the direct supervision of a registered pharmacist.
The Society has the duty of enforcing the law relating to pharmacy and poisons. Up to 1933 it was responsible for amending the poisons list. This duty has now been imposed on the Poisons Board, a body consisting of representatives of the Home Office, of medical organizations, and of members of the Society.
The Society by its statutory committee has the power of removal from the register and of restoration. It cannot properly watch over certain specific trading interests of the profession, so these functions are carried out by the National Pharmaceutical Union, which is the body which negotiates with the Minister of Health about the chemists’ terms of service.
Medical Auxiliaries
There are many others in trades or professions who provide treatment. Some of these do not deal with patients directly but only under the supervision of the patient’s medical attendant ; others deal with them directly. Some have formed professional organizations which control the standards of professional qualification and the conduct of their members.
In 1936 the British Medical Association formed the Board of Registration of Medical Auxiliaries, the object being to establish a national register of auxiliaries of approved quali- fications. Those on the register operate only under the direction of a registered medical practitioner. Included in the first register were the names of members of the Chartered Society of Massage and Medical Gymnastics (now the Chartered Society of Physiotherapy), the Society of Radiographers, the Association of Dispensing Opticians, and Biophysical Assistants. The register now contains the names of Chartered Physiotherapists, Biophysical Assistants, Radio- graphers, Dispensing Opticians, Chiropodists, Orthoptists, Speech Therapists, and Dietitians.
E.W Caryl Thomas, 1948
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