1947

The range of remuneration of specialists in the National Health Service can be decided only when certain principles as to their mode of employment and relation to other workers in the service have been accepted.  The income earned by some specialists in the past is no guide and new standards must be set up.

One of the most important features of the new National Health Service is that specialists and consultants are to be available to every citizen according to their needs either at home, in health centres, in hospitals or any special institution set up under the Service.  In order that the highest quality and the necessary quantity of specialist care may be available to every citizen new methods of organisation of their work must be adopted. Above all every measure must be taken to avoid wastage of their time. Practically every one of the hospital surveys has commented on the fact that the present organisation of specialist practice, under which posts are held at widely separated voluntary and municipal hospitals and in addition private cases are seen over a wide area, leads to an enormous waste of time in every consultant’s life.  Waste of time means lower quality and lower quantity of service.  The consultant attached to voluntary hospitals has, of course, always included domiciliary visits in his practice and there is no administrative difficulty in organising the work of consultants so that these domiciliary visits are continued.  The fact that County Councils have not usually in the past permitted or arranged for their whole-time hospital officers to act as consultants in the homes of the people must not be regarded as an indication that there is any inherent difficulty in making the necessary arrangements.

The Socialist Medical Association believes that in the organi­sation of our hospital services within a region four important points must be observed. The first is that every general hospital should take charge of its quota of the general sickness of the unit of popu­lation it serves, A second is that in addition to that general function, most hospitals over a certain size should probably have a special function in addition.  The third is that the specialists of the hospital service should be available at the request of the family doctors in the area for consultations both in the home and at health centres so that there is continuity of consultant care.  In other words, it should be possible for the general consultant who has seen a case outside, to take it straight to his hospital ward and continue the treatment he has prescribed, and for the specialist to maintain his contact with any case to which he has been called.  The fourth point is that the details must be settled locally, taking into account the staffs of the hospital available and the local conditions.

There does not seem to be a matter of principle with regard to which specialist does the domiciliary visits.  In most special subjects it should be the senior who goes out to see the cases which the family doctor has found difficult.  The case of urgent or dangerous disease which the general practitioner recognises and knows must be treated in hospital, does not usually require the visit of a consul­tant.  It is the difficult and doubtful case which has caused the family doctor to seek special advice which calls for the consultant with the highest possible qualification and widest experience. Normally therefore, in the home it should be the senior who goes to see the case. It is, however, probable that where a session for con­sultation is being conducted at the health centre that the junior members of the consultant staff would be most suitable for this particular work. The cases seen under these circumstances would usually be those requiring more investigation than the family doctor could give, and provide special training in examination, but many of them would be relatively simple to the junior consultant.  Cases which he selected as being of particular interest or difficulty could still be seen by the senior in hospital or by special appointment at the health centre.

It is clear that the basis of employment and the method and range of remuneration of consultants and specialists could follow many different patterns. The Socialist Medical Association believes that the ideal is that all consultants and Specialists should be whole-time salaried officers of the Regional Hospital Boards although in some instances they may serve a number of hospitals of quite large size and they may occasionally, be dealing with special conditions of such relative rarity.as to be employed even by two neighbouring Regional Hospital Boards. The S.M.A. presses the need for a whole-time basis because it has long been the opinion of the Association that only in this way can the highest quality of service be given. The quantity of service will depend on how the work is organised but the quality depends on the elimination of competition for fees be­tween consultants and for the establishment of an undivided loyalty to the unit of population which the specialist serves.  We believe that for the consultant, physician and surgeon and clinical patho­logist, the type of population unit we have always advocated, namely 100,000, will provide ample work if hospital, health centre and home are combined as the field of the consultant’s activities.  There must, however, be elasticity for some of the other specialists may have to draw upon a larger unit of population to maintain their efficiency as well as to find full employment.

Not only will the elimination of competition for fees avoid jealousies between seniors of equal rank but it will avoid difficul­ties between seniors and assistants.  Suggestions that juniorsshould be whole-time and seniors part-time are made by those who think that in that way the senior would earn the highest possible income but this would inevitably lead to lack of co-operation within the team.  If a higher rate of remuneration is necessary it should be fixed by the committee and not left to the chance of competition.

Allowances for the expenses of those engaged in this work must also be generous. The consultant today expects to run a reasonably good car, to have the telephone at his home and to employ perhaps secretarial and other assistants.   Insofar as these are necessary for consultations with family doctors within the area which he serves the consultant must have these provided or allowances be made for them, We believe that lump sum allowances cutting out the necessity of keeping records of visits, telephone calls etc., lead to a more efficient service than any other method.

As to the relationship between the income of the consultant and other health workers, the full time method in itself means a reduction of the range of remuneration of all grades.  Two points are of parti­cular importance. In the first place it is essential that the senior consultants should not be in a position financially inferior, to that of any administrative officer in the service.  In the second, there is not, in our opinion any need for a great difference in income between the consultant of the future and the family doctor.  The consultant must be a member of a team with the others and the admini­stration and financial, structure must encourage the spirit of the team.

In addition, we would suggest that any scheme of grading specialists must leave wide open the portal of entry so that general practitioners, from whose ranks many believe all physician consultants and most of our specialists should mainly come, can move from one part of the service to another.  Higher qualifications may be used as a guide to the payment of those within the service, but their absence must not be regarded as a bar to entry.

We would also stress the importance of free movement within the service of those who have been accepted as suitably qualified by diploma and experience to hold consultant rank.  Constant exchange of views between different hospitals and between hospital and family doctor are essential and while senior consultants, should be relatively stable in their appointments, juniors should move from one part of the service to another without difficulty.

We would stress also that most of the professional and research workers in a region, will be whole-time salaried officers and the relationship between them and their clinical colleagues will be much closer if they are all employed by the same method.   In addition all the arrangements for holidays, refresher course and sickness locums, attendance at scientific meetings and other professional activities, are rendered much easier if the staffs concerned are on a whole-time basis, and the contract of service makes provision for all these activities.   Satisfactory superannuation arrangements are also facilitated by this method.

Taking all these factors into consideration we would suggest that the range for consultants should not exceed a maximum of £3,000 per annum net, should normally have a celling of £2,500 and that the esta­blished consultant, serving a 1,000 bed unit as is envisaged by Regional Hospital Boards should range from £1,500 -£2,250 plus the necessary allowance already mentioned.  If we interpret the earlier Spens Committee reports correctly then figures would be a little higher than the corresponding groups in general practice and more than sufficient to attract all the recruits necessary for our consultant services.

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