May 2020 marks the centenary of the publication of the Interim Report of the Consultative Council on the Future of Medical and Allied Services, popularly known as the Dawson report after its principal author, Lord Dawson of Penn.[i] The report, commissioned in 1919 by the newly established Ministry of Health, outlined a plan to bring together existing services funded by national health insurance, local authorities, and voluntary bodies in a coherent and comprehensive healthcare system. The final report was never published, being consigned to oblivion by a worsening economy and changed political climate. Though cautiously welcomed by professional leaders, Dawson’s plan was condemned by a hostile press as grandiose and unaffordable.[ii] However, recent NHS policy directives regarding Integrated Care Systems show that the principal task which Dawson’s group had set itself, that of successfully integrating primary, secondary and ‘allied’ health services, is one with which NHS leaders are still grappling today.[iii]
Lord Dawson of Penn, courtesy of the British Medical Association archive
Central to Dawson’s plan, and its most revolutionary idea, was the creation of a network of ‘primary health centres’ (PHCs) in each district in which general practitioners (GPs) could access diagnostic, surgical, and laboratory facilities for their patients and which would also house infant welfare and maternity services, facilities to promote physical health, and space for administration, records, and postgraduate education. GPs and other professionals would see and treat patients at PHCs, referring only complex cases to specialists at secondary care centres (essentially district hospitals) located in large towns, while patients needing the most specialized treatment would be referred to regional teaching hospitals with attached medical schools. This ‘hub and spoke’ model is one to which recent generations of NHS health planners have returned time and again, seemingly unaware of its antecedents.
A firm believer in teamwork, Dawson hoped that collaborative use of PHCs by GPs would encourage group practice and multi-disciplinary working. But the individualistic nature of general practice at that time meant GPs remained wary of his ideas, despite the fact that examples of PHCs already existed in Gloucestershire and in Scotland and many of the facilities they were meant to comprise could be found in GP-run cottage hospitals and Poor Law infirmaries.[iv] Experiments with architect-designed health centres in the 1920s and 1930s failed to elicit a major change in professional or governmental attitudes.[v] In 1948 the NHS brought public, voluntary and local authority hospitals under state control but in its early years the promise of new PHCs remained largely unrealised.[vi] Proprietorial traditions and fear of local government control led to a mushrooming of purpose- built, GP-owned practice premises between the late 1960s and 1990s independently of local authority-owned health centres, for which there was a major building programme in the 1970s.[vii]
Illustration of a Primary Health Centre, from the Dawson Report, courtesy of the BMA archive
Although by the late twentieth century the Dawson report had largely been forgotten, interest in PHCs resurfaced in the early 2000s with a major investment in primary healthcare facilities through the establishment of Local Improvement Finance Trusts (LIFT). These were a form of private finance initiative designed to provide state of the art community health and social care hubs housing GP practices and other services. Unfortunately, LIFT buildings proved more expensive than anticipated and their facilities, intended to promote the transfer of work from secondary to primary care, were often underutilised.[viii] While these were being constructed, the Labour health minister, Lord Ara Darzi, announced the establishment of a number of ‘polyclinics’, bearing a close resemblance to Dawson’s PHC idea. However, the Darzi Centres that were established were either mothballed or repurposed, being condemned as an expensive ‘white elephant’ by professional leaders.[ix]
In the last few years a ‘quiet revolution’ has been taking place in the NHS in England involving attempts to dismantle the financial and institutional barriers between primary, secondary and community care created by the internal market. Its byword, ‘Integration’, echoes Dawson’s overriding goal and the ‘hub and spoke model’ he advocated is now well established. Meanwhile, the pressures of unending demand have forced GPs to collaborate as healthcare providers in locality groups called Primary Care Networks (PCNs). Though guidance on these is not prescriptive, some PCNs have adopted the idea of a community ‘hub’ housing shared diagnostic and treatment facilities much as Dawson had envisaged.[x]
While the full impact of COVID-19 on our struggling health services is still unknown, the abiding necessity for all parts of the NHS to collaborate, communicate and mutually support each other during this crisis underlines the value and relevance of Dawson’s vision of integrated services. It remains to be seen if, in its aftermath, his ‘big idea’ of ubiquitous multi-purpose PHCs will come any closer to being realised.
Chris Locke is a fourth year PhD student in the History Department at the University of Sheffield. His research is focused on the political consciousness of British GPs and their struggle for professional self-determination in the early Twentieth Century.
Cover image: LIFT -built Primary Care Centre, Retford, Nottinghamshire, photographed by the author.
[i] Interim Report of the Consultative Council on the Future of Medical and Allied Services, Cmd 693 HMSO 1920. For an account of the origins and significance of the report see Frank Honigsbaum, The Division in British Medicine (London, 1979) chapters 6-12.
[ii] The British Medical Association’s blueprint for health services reform, A General Medical Service for the Nation (1930) and the report by Political and Economic Planning, The British Health Services (1937) both referenced the Dawson report, and it clearly influenced the Beveridge report, Social Insurance and Allied Services (1942).
[iii] https://www.kingsfund.org.uk/publications/making-sense-integrated-care-systems (last accessed 3 April 2020)
[iv] The report referenced the hub and spoke model of healthcare facilities overseen by Gloucestershire County Council’s Medical Officer of Health, Dr J Middleton Martin. Commentators also noted similarities with Sir James McKenzie’s Primary Care Clinic in St Andrews and Trade Union-run Medical Aid Institutes in South Wales.
[v] Jane Lewis and Barbara Brookes, ‘A Reassessment of the Work of the Peckham Health Centre 1926-1951’, Health and Society vol 61, 2, 1983 pp.307-350; For Finsbury Health Centre see A B Stewart, ‘Health Centres of Today’, The Lancet, 16 March 1946 pp. 392-393.
[vi] For one exception see R H Parry et al, ‘The William Budd Health Centre: the First Year’, British Medical Journal, 15 March 1954 pp.388-392.
[vii] BMA General Practitioners Committee guidance: The Future of GP Practice Premises (Revised 2010)
[viii] Nottinghamshire Local Medical Committee, NHS LIFT in Nottinghamshire (Nottingham,1997)
[ix] Peter Davies, ‘Darzi Centres: an expensive luxury the UK can no longer afford?’, British Medical Journal, 13 November 2010, 341; c6237.
[x] https://www.england.nhs.uk/primary-care/primary-care-networks/ (last accessed 3 April 2020)