Published by the Fabian Society

NOTE.This pamphlet, like all publications of the FABIAN SOCIETY, represents not the collec­tive view of the Society but only the view of the individual who prepared it. The responsibility of the Society is limited to approving the publications which it issues as worthy of consideration within the Labour Movement.

Two shillings and sixpence

I. Introduction

Throughout the world the cost of modern hospital care is giving cause for alarm. Efforts are being made everywhere to reduce the length of stay in hospital and to encourage the use of the domiciliary health services. In fact, the patient is often found to do better in the environment of his own home.

During the first decade of the National Health Service our hospital services have been transformed. In spite of old buildings, the shortage of nurses and trained technicians and other difficulties, the standard of hospital care has been vastly improved. Yet no such improvement has taken place in the quality of the domiciliary medical care. The hospital services now receive £57 out of every £100 spent on the National Health Service; the figure was £50 in 1948. The general practitioner service receives £10, as com­pared with £11 in 1948. We are, in fact; spending proportionally less than we were in domiciliary medical care.

This is a short-sighted policy. Unless the family doctor can do his work efficiently the cost of the hospital service will be bound to rise. A well-organised general practitioner service would remove a great deal of work from the hospitals.

The citizen’s first point of contact with the National Health Service is his family doctor. What happens then determines his future as a patient. Will he go to the out-patient department of the local hospital for further investigation? Will he be admitted forthwith for treatment? Will the domiciliary services provided by the Local Health Authority be used—nurses, health visitors, home helps and so on? Will the voluntary health agencies be called in? Or, will he remain under the G.P.’s care? All these questions can be answered only by the family doctor, for he alone is responsible for the continuing care of a patient.

Despite his key position, however, very little attention has been paid to the efficiency of the general practitioner service. Whether the G.P. works in a fine modern building, equipped with the latest diagnostic aids, and is helped by receptionists and nurses, or whether he practises unaided in a lock-up surgery in a back street with nothing more than a stethoscope for equipment, is apparently of little interest to the authorities. Whether he examines his patients with scrupulous care or devotes a few minutes to a cursory appraisal, referring all matters of any complexity to the hospital, is his affair. As long as he attends his surgery for the prescribed number of hours a day, and visits his patients on demand, he is asked no questions.

Yet the sum total of the actions of 20,000 G.P.s is of immense import­ance to the community It has a direct bearing on the efficiency of the whole health service. The purpose of this pamphlet-the first Fabian publication to deal with this subject—is to examine the present general practitioner service in some detail, to take note of its weaknesses and to suggest practical steps for its improvement.

Dr. J. Hunt, Honorary Secretary of the College of General Practi­tioners, defines a general practitioner as follows:

`A doctor in direct touch with patients, who accepts continuing, responsi­bility for providing or arranging their general medical care, which includes the prevention and treatment of any illness or injury affecting the mind or any part of the body.’

The key words here are continuing responsibility and prevention and treatment. In few countries would this definition be valid. Apart from the British Commonwealth and to some extent the U.S.A., no countries have family doctors in the sense in which we use the term. On the continent the patient tends to select his doctor for a particular illness. The wife and children of the family may be sent to a gynecologist- or a. pediatrician. This arrangement has two results. First, doctors, except in the remote country, tend to specialise. Second, few patients and fewer families are looked after by a doctor who knows their background and has a record of their illnesses.

Polyclinic Medicine

In some countries, the patient is attached to a particular clinic rather than to an individual doctor. His symptoms suggest the need to see one or other of the special departments. He finds himself in the hands of one or more specialists, who inevitably see the patient in terms of their own specialities. The argument for the specialised approach to medicine was put forward in a pamphlet issued to visitors to the Russian pavilion of the Brussels World Fair in 1958:

‘Medicine has made big strides in the past few years, and the general practitioner or ” all-round ” doctor is no longer able to satisfy the growing demands of the population. For successful treatment and prevention of disease we now need the specialist who has made a thorough study of a specific branch of medicine. The general practitioner is gradually disappear­ing, to be replaced by rapidly growing forces of specialists in various branches of medicine.’

This approach to medicine is a false one. The living organism is not a machine. For convenience we talk of the various systems of the body—the cardio-vascular, the nervous, the digestive, and so on. But in practice the whole must be considered together. The simple digestive disorder may be the result of a wide number of causes remote from the stomach itself—for instance, a prolonged stay by an unloved mother-in-law.

Specialisation in medicine, as in other sciences, is, of course, inevitable. But the role of the specialist should be that of the expert adviser to the general physician, who alone sees the patient as a whole in all his relation­ships. The general physician is a dying entity in the hospital world but he still exists in the person of the general practitioner.

In England under the National Health Service we are each entitled to the services of a G.P. When ill we visit him and follow his advice about subsequent treatment. He may send us to the local hospital for investiga­tion or to see a specialist, but he retains the overall responsibility for treat­ment, however complex the case. The specialist advises the family doctor, not the patient.

The British Family Doctor

This method has much to commend it. The patient has someone he can depend upon in all his troubles ; the doctor gains an increasing insight into his patient’s needs. Only the very rich tend to neglect the advantages of this excellent arrangement and flit from specialist to specialist. What­ever the changes in National Health Service general practice, we must retain the principle of one patient one doctor and of the doctor’s continuing responsibility. The problem is not to replace this principle by a new one, but to allow it to become more effective. The weakness of the British family doctor idea is that the patient puts all his eggs in one basket. If the doctor is painstaking and reasonably competent (he need not be brilliant), the patient is safe. If he is slack—for example, by failing to take a good history or make a full examination—the results may be unfortunate, for the patient is committed to his care. Equally unfortunate may be the fate of the patient of a naturally conscientious doctor who is so overworked that he has no time to do his job properly.

By vocation and training most G.P.s are humane men and women with a high sense of duty; black sheep are rare. But far too many doctors are forced to lower their clinical standards because they are ill-equipped or short of time to practise good medicine. How often one hears the remark, ‘Oh, my doctor is an excellent fellow, but it’s a waste of my time going to see him. He can never give me more than a few minutes.’

2. Growth of the State Service

To understand the problem of general practice to-day it is not necessary to delve deeply into the past. During most of the nineteenth century the general practitioner was a private entrepreneur selling his skill to anyone who could afford to’ pay him. Many people—perhaps a majority of the population—had no family doctor and attended the out-patient depart­ments of the voluntary hospitals when ill. Towards the end of the century certain trade unions and large employers of labour recognised the need to protect their members and employees and made arrangements with in­dividual doctors and groups of doctors to attend them on a contract basis. These clubs ‘ rapidly increased in number but left untouched many workers and nearly all dependants. Their growth was not a smooth one; both the standards of care and the pay of the doctors were sources of constant dispute.

In 1913 the National Health Insurance Scheme was introduced, and ‘ the panel ‘ or ‘the Lloyd George’ remained a feature of our national life for the next 35 years. It was designed to provide a general practitioner and drug service to the medium and lower paid workers. For those workers earning less than £160 per annum it was compulsory. This limit was raised in 1919 to £250 and in 1942 to £420. Family dependants obtained no benefits. The scheme was administered by approved societies each of which offered its own range of financial benefits.

The Birth of the ‘ Panel’

Despite the active hostility of the British Medical Association, most doctors joined the ‘ panel ‘ scheme and for the first time enjoyed some financial security. The Medical Practitioners’ Union was founded in 1914 largely as a protest at the ineffectual manner in which the profession’s affairs had been handled during the dispute.

The method chosen for paying the family doctor was by ‘capitation’ that is, an annual sum on account of every patient at risk. The doctor received 9s. a head, of which 7s. was for himself and 1s. 6d. for drugs and 6d. for additional drugs as necessary.

With all its limitations the ‘ panel ‘ was a great success and laid the foundations on which the National Health Service was subsequently built. Wage earners received not only medical care but sickness benefits. Doctors knew that a proportion of their income (perhaps two-fifths) was assured; private practice provided the rest. They came to accept the scheme and on the whole worked it well. The level of capitation fees was the sole cause of friction.

Nevertheless the ‘ panel ‘ scheme was seen to be a halfway step to a more comprehensive health service. In 1928 the British Medical Association published new proposals under the title of General Medical Services for the Nation, followed in 1933 by a more detailed memorandum Essentials of a National Health Scheme. In June, 1938, the Government took steps to establish an Emergency Medical Service in anticipation of war-time needs. The voluntary and municipal hospitals were brought under regional control; Public Health and Hospital Laboratory Services were established and a Civilian Blood Transfusion Service formed; local committees were set up to organise the general practitioner services in case of war.

What Did the Doctors Want?

The British Medical Association in co-operation with the Royal Colleges and Scottish Corporations set up a ‘Medical Planning Commission’ in August, 1940, with the duty of examining ‘war-time developments and their effects on the Medical Services to the present and future’. The ‘ Draft Interim Report’ was published in May, 1942, and its recommenda­tions for a comprehensive national medical service became the basis of Assumption B of the Beveridge Report. The Government accepted the Beveridge recommendations and in 1944 published as a White Paper A National Health Service Scheme. Among its recommendations was one for ‘grouped practices in Health Centres, the doctors in which would be on a salaried basis’.

In 1944 the British Medical Association issued a questionnaire to all registered medical practitioners to ascertain their opinions of the proposals contained in the White Paper. Doctors were divided on many points. Their views on Health Centres are interesting to note in retrospect. Two-thirds of all doctors who replied were in favour of Health Centres in which both preventive and curative work is done, including e.g. Maternity and Child Welfare, School Medical treatment’ and in which they would be paid either by salary or by a small basic salary plus capitation fees.

The Labour Party took office in July, 1945, and introduced the National Health Service Bill in March, 1946. It became law in November of that year, but the Service was not introduced until nearly two years later. One reason for the delay was the protracted negotiations between the Govern­ment and the doctors’ Negotiating Committee over the conditions of service. After two plebiscites the medical profession agreed to work the new Act. All but a handful of general practitioners accepted compensation for the right they had lost to sell their practices. Although some loose ends remained to be tied up, the new National Health Service was successfully launched on 5th July, 1948.

The First Ten Years

Most general practitioners undoubtedly felt that they had been dragooned into the National Health Service. They remained disgruntled and suspicious of the Government’s ultimate intentions. Private practice, as expected, rapidly declined until only 2 per cent. of the population remained as private patients. Gradually, however, doctors came to accept the new conditions. They appreciated the removal of financial barriers between themselves and their patients. They discovered that the Minister of Health had no intention of interfering with their clinical freedoms. The threat of an oppressive disciplinary machinery was seen to be unfounded. There were continuous arguments over minor details, but on the broad issues, with one exception, there was no basic divergence of view.

The exception was remuneration. Before the Service had been started doctors had adjusted their scale of fees to keep pace with changes in the cost of living. Now they were unable to do so. They depended on the Govern­ment to make the adjustment—called ‘ betterment ‘—and this the Government was reluctant to do. In 1951, however, Mr. Justice Danckwerts was asked to assess the correct rate of betterment for the years 1948 to 1951. This he did. at rates which shocked both the Government and the Opposi­tion. £40 million in back pay was awarded.

Doctors remained satisfied with this award until November, 1956, by which time the cost of living had again soared. A new claim was presented to the Ministry. It was turned down and after threats of mass resignation a Royal Commission was set up to examine the whole problem of medical and dental remuneration within a state service. The Commission has not yet reported.

Causes of Dissatisfaction
Apart from disputes over pay, there has been no major cause of friction between general practitioners and the Ministry of Health. But this does not mean that both sides have been satisfied with the Service as it exists. In 1950 the Central Health Services Council formed a committee under the chairmanship of Sir Henry Cohen (now Lord Cohen of Birkenhead) ‘ to consider and make a report on whether the existing arrangements for engaging in general practice under the National Health Service are such as to enable general medical practitioners to provide the best possible standard of service . . .’ The Report appeared in March, 1953. It con­tained nothing startling and the changes recommended were of a minor character. Nevertheless few people would accept that all is well to-day with general practice. The deficiencies are all too clear. It is their cure which presents the problem.

3. General Practice Today

We must now look at the structure of general practice in closer detail. Plans for the future, if they are to succeed, must be based on present realities. The number and distribution of doctors; their practice organisa­tion and their pay; and the changing content of their work are all important factors to be taken into account.

Approximately 18,000 G.P.s entered the National Health Service in 1948. The number to-day is 22,551 (or 21,703 if only those giving an unrestricted service are included). Since 98 per cent. of the population are registered with doctors, each doctor has on the average 2,250 patients. No principal may have more than 3,500 on his list; with an assistant he is permitted 5,500.

During the last ten years the number of doctors has grown faster than the population, so that the average list has dropped by 250.

Two-thirds of all G.P.s are now in partnership as compared with about half in 1948. This increase probably took place because of the greater ease in working a practice and arranging off-duty times. It does not necessarily imply any fundamental change in the quality of the service.

Another development has been towards group practice in which several doctors (3-6) work together in common premises. They share recep­tionists and secretaries and consult each other on clinical matters. The patients, while remaining the responsibility of an individual doctor, may on occasion be seen by one of the other partners. The number of true group practices (as opposed to partnerships) is not known. It probably does not exceed 200.

Apart from 21,703 principals giving an unrestricted service, there are 1,546 assistants who are employed by principals to help them. Of these 713 are employed by single-handed principals, the remainder by doctors in partnership. The institution of assistantships is justified on the following grounds:

  1. Young doctors straight from hospital are given the opportunity of obtaining experience in general practice before becoming estab­lished as principals.

  2. Principals who wish to take on new partners should have the chance of working with one or more assistants before deciding whether to offer a partnership.

  3. It is difficult to forecast whether a practice will grow sufficiently to support an additional partner. An assistant has, therefore, to be employed until the growth of the practice is assured.

These are sound arguments which justify the employment of assistants for limited periods. Unfortunately, some principals who could perfectly well take on another partner prefer to employ an assistant permanently. There should be no place for permanent assistants within the National Health Service. Recently the regulations have been altered to allow Executive Councils to refuse a principal permission to continue employing an assistant if the circumstances do not justify it. It is too early to assess the effect of this new regulation.

Assistants gain experience, but are not specifically trained. Young doctors from hospital wishing to be taught methods of general practice may receive a year’s training from an experienced principal. The Ministry of Health pays the trainer £885 per annum out of which he finds the trainee’s remuneration. The system works well when the principals take their training duties seriously. About 350 young doctors are trained each year.

Distribution of Doctors

One of the main complaints of the old order of medicine was that doctors tended to congregate where the patients had most money rather than where the medical need was greatest. Official figures are not avail­able for the period immediately preceding the Act, but the distribution of doctors certainly did not conform to the needs of the community. Industrial northern areas of the country had only one doctor to every 4,000 persons while the, richer residential areas of the south had a doctor for every 1,000 patients. One of the main objects of the National Health Service was to correct this maldistribution by offering the incentive of a larger list of patients to the G.P.s who were willing to enter the under-doctored areas.

As more doctors entered the Service the pre-Service average of 2,500 patients per doctor was reduced to 2,273 in England and Wales and 1,980 in Scotland. Whereas five years ago over half the population of England and Wales lived in under-doctored areas, only a fifth do to-day. This process of redistribution is continuing. Within another decade under-doctored areas should have disappeared. One of the main purposes of the Act will have been achieved.

In February, 1955, the Government set up a committee (under the chairmanship of the former Minister of Health, Sir Henry Willink) to assess the future medical man-power of the country. It came to the conclusion that there were likely to be enough doctors to meet all expected needs and that the intake of medical students might be reduced by a tenth in 1961. This conclusion was reached, as far as general practice was con­cerned, on the assumption that the present doctor-patient ratio was a reasonable one—a short-sighted view—for it assumes not only that the standard of service offered by the present-day G.P. is adequate, but that the public is not entitled to look to an improvement in the future. Patients have become accustomed to waiting long periods before seeing their doctors and have often had to be satisfied with a few minutes of his time. There is no reason to assume that they will continue to accept such standards. Indeed, one may reasonably look forward to the time when the average doctor will have a list of 1,500 patients and when the maximum permitted list will be 2,500. As in every other field of human activity, standards of service will be expected to rise. To fulfil these expectations, more doctors will be needed and the money will have to be found to pay them;

The G.P.’s Work

The G.P. is a private entrepreneur who contracts with the Local Executive Council to provide a complete clinical service to all the patients on his list (and to any other patient in an emergency). He must render `all proper and necessary treatment’ and if he considers that the patient needs hospital treatment he must ‘ take all the necessary steps to enable him to receive such treatment’; he must also `give his patients such advice or assistance as he may consider appropriate to enable them to take advan­tage of the Local Health Authority services and maternity services’.

It is clear from these quotations from the G.P.’s terms of service that the immediate examination and treatment of his patients do not exhaust his obligations. He must also be in frequent telephonic and written com­munication with a number of other health agencies. To assess the volume of his work solely in terms of the number of consultations and visits rendered, gives a somewhat inadequate measurement of his real commit­ments. Nevertheless it is the only assessment that can be made, for the additional tasks he has to perform are not susceptible to detailed analysis.

A rough-and-ready method of measuring work load is to group all visits to the patient’s house under one heading and all attendances at the surgery for any purpose under another. Each item will have a different work content—one patient requires a repeat prescription, another a full clinical examination—but the differences will average out.

Many estimates of the number of items of service provided have been made by different observers and by analyses of individual practices. Large variations clearly exist between areas and between practices with different illness rates. Each age group, too, makes its own demands on the G.P.’s time. Nevertheless the national average is known to be approximately 5-6 items of service per year per patient at risk. This does not mean, of course, that each of us sees his doctor five times a year. Some see him twenty times, others hardly ever.

Assuming that each person attends the doctor’s surgery, on the average, four times a year and receives a visit from him twice a year, we can examine the work load for doctors with different sized practices. The full-list practitioner with a 3,500 list will give 21,000 items of service a year and the average practitioner with a 2,200 list, 13,200 items.

The work load is likely to be 25 per cent. heavier in the winter and 25 per cent. lighter in the summer. Eliminating work on Sundays and Bank Holidays we obtain the following figures, as shown in Table 1:

Table 1: Daily Work Load of Practitioners

Surgery attendances Visits
No of Patients 1500 2200 35000 1500 2200 3500
Summer 14 21 33 8 11 16
Average 18 28 44 10 14 22
Winter 22 35 55 13 17 28

To examine the meaning of these figures in terms of time occupied, we must assume the length of the working day. On the assumption that each doctor spends four hours daily in his surgery and four hours visiting patients, the time available for each item of service is as follows (Table 2):

Table 2: TIME OCCUPIED BY ITEMS OF SERVICE

(In minutes)

Surgery attendances Visits
No of Patients 1500 2200 35000 1500 2200 3500
Summer 17.2 11.4 7.3 30 21.8 15
Average 13.3 8.6 5.5 24 17.2 10.9
Winter 10.9 6.9 4.4 18.5 14.2 11.7

These calculations give only a very rough guide to the doctor’s com­mitments. Practices vary widely in type and morbidity.

It might appear that a patient could not expect to receive much of his doctor’s time. But the reality is far worse, for we have assumed that every moment of the doctor’s eight-hour day is devoted to seeing his patient. In fact he has much else to do. Here are some of the items for which no time has been allowed:

  1. Writing letters to hospitals and clinics.

  2. Keeping medical records.

  3. Telephoning about admissions, ambulances, etc.

  4. Consultations by telephone with specialists (which are increas­ingly common).

  5. Clinical investigations undertaken.

  6. Travelling time to visit patients.

Quite apart from the care of National Health Service patients many doctors have other medical commitments, such as private medical practice, insur­ance examinations, industrial medical work and so on. The more time that is given to these outside activities the less is available for the care of National Health Service patients.

No wonder some patients are heard to say, ‘ My doctor is too busy . .’

The G.P. is required to diagnose and treat illness and to refer his patients elsewhere when he cannot carry out these tasks himself. He is left considerable latitude to interpret the scope of his duties. Some doctors with the time, inclination and equipment may carry out many diagnostic tests; others refer any case which requires more than elementary examina­tion procedures to the hospital. The same applies to treatment. The content of general practice is therefore extremely variable not only as between adjacent practices but as between town and country. The proximity of hospital and the quality of the service offered in it influence the scope of a practitioner’s work. No two doctors see their tasks in exactly the same light.

The capitation method of payment does not encourage doctors to do work which is not strictly necessary, for their pay remains the same regard­less of the work they do. Financial considerations are not, of course, the only or indeed main ones. Nevertheless they provide a powerful motive to a doctor to reduce his work to a minimum.

There is much to be said for finding some financial method of encourag­ing G.P.s to undertake all the possible tasks for which they are trained.

The Changing Face of Medicine

The family doctor of fifty or more years ago held a special position of esteem in the eyes of his patients. The respect for his powers was com­pounded of a recognition of his wide knowledge and experience and of a certain sense of awe. This attitude could not last nor should we wish for its return. As mechanistic values were increasingly accepted in our society so too did the patient’s view of his doctor change. No longer were the wise words and the bottle of ‘doctor’s medicine’ the panacea they had once been. The patient living in a world of machines began to see his own body in mechanical terms. The family doctor’s job was to discover which part of the machine was at fault and by surgery or medicine to put it right. If he failed, then there were the super-mechanics at the hospital who would find the answers.

This mechanistic view of medicine has been strengthened in recent years by the great rapidity of pharmacological and surgical advance. Whole areas of disease have disappeared or been rendered innocuous. Simultaneously there is a growing awareness of other disease processes which give hope of no easy mechanical solutions. The stress disorders, the

psychoneuroses and the degenerative diseases are now seen to be related to the patient’s environment in its widest sense. To diagnose these con­ditions, to treat and to cure, demands a correct assessment of the environ­mental factors and, more difficult, an ability to control them.

It is thus of great importance that the G.P. should be equipped and organised to use his first-hand knowledge of the patient’s background, job and family relationships to full advantage. Without training and personal interest in this type of medicine he will fail to deal with the problems presented to him—or even to appreciate their nature. But even with the proper education and desire to succeed he still must fail unless he has the time to devote to each case and the necessary help from the appropriate social agencies. Few doctors to-day would claim to have both or indeed either. The average practitioner is hamstrung by lack of time and by the multiplicity of his tasks. He does his best to cope with his patient’s problems—often a magnificent best—but few doctors would claim that they are capable of giving each patient the attention he needs.

The patient no longer needs a father figure who will dispense placebos and wise advice, but an expert and intelligent friend through whom he may come to understand his own troubles.

This new role is not an easy one for the family doctor. It demands an ability to listen to and to understand problems as the patient sees them— and a willingness to treat patients as equals. The medical schools and text­books have not prepared him for this role and he learns it only after years of experience in practice, or, perhaps, not at all.

Postgraduate Education

Since the content of medicine is rapidly changing and the family doctor works in comparative isolation, far from the centres of learning and scientific advance, his need for periodic ‘refreshment’ is great. Town doctors are sometimes attached to nearby hospitals as clinical assistants and are thus enabled to keep their knowledge reasonably up to date. The majority of urban and rural doctors are not so fortunate and must rely on occasional visits to a hospital for their post-graduate education.

Refresher courses for G.P.s are organised by the British Postgraduate Medical Federation in London and by similar bodies elsewhere. They are held in many hospitals and their number is increasing. In 1957 there were 110 courses attended by 1,763 practitioners. One out of every twelve G.P.s, therefore, had some post-graduate education in that year—not a high pro­portion, but far higher than it was a few years ago.

The total cost to the state of these arrangements (including subsistence allowances and locum tenens’ expenses) was under £16,000 or less than £1 a year per practising doctor.

It must not be thought that the refresher course is the only method of post-graduate education. Indeed many doctors consider these courses a waste of time. As long as a G.P. retains his natural curiosity (and a little surplus mental energy) he will find ways of acquiring new knowledge. Read­ing the medical journals, lively discussions with his colleagues and attendance at local medical society meetings can all provide mental stimulation. The College of General Practitioners, founded in 1952, has done a sterling job in raising practice standards wherever it can. Unfortunately, only 3,000 G.P.s are members of the College, and they are amongst the most con­scientious practitioners and therefore least in need of help.

The Medical World, organ of the Medical Practitioners’ Union, has also played its part. Each year a conference of G.P.s is held to discuss their special problems. This journal is also producing a series of discussion films on problems of general practice.

4. Surgery or Health Centre?

Traditionally the family doctor’s surgery has been a part of his home. On entering practice he has either taken over a retiring doctor’s house or bought another, converting the ground floor into waiting room and surgery accommodation. Frequently the practice outgrows the house and the doctor must then seek to adapt the house or find a new one nearby.

Despite the general movement towards partnership and experiments in group practice and health centre practice, four out of every five doctors still practise from their own homes. This traditional arrangement has some features to commend it. From the doctor’s point of view it is cheaper and reduces his travelling time; the patients who are conservative in their habits attach themselves not only to him but to his home—so much so that 90 per cent. will continue to attend the house even when a succession of doctors have occupied it. They seem to like the arrangement; they know what to expect; the fittings may be old fashioned, the lighting bad and the seats hard, but the atmosphere is casual and friendly and they are not reminded of the hospital, an institution they associate with serious illness or death.

These are real advantages based on deep human feelings and must not be underrated.

Nevertheless there are strong reasons against a doctor practising from his home. Let us summarise them.

  1. Not only the doctor but his wife and family are constantly involved in practice affairs.

  2. Few houses are suitable for the conduct of good medical practice. Even if suitable in the early stage of a practice, they cease to be as the practice grows. Secretaries and receptionists may be needed but there is no accommodation for them. The choice of a house is determined by availability and by its proximity to a potential list of patients. It is rare to find the right house at the right place at the right moment.
  3. By attaching his practice to his house a doctor often predetermines how he should practise medicine. The size of the unit is fixed and does not allow for the introduction of partners or ancillary staff.
  4. The longer a doctor practises from his home the more difficult it is for him to move. Patients become accustomed to visiting a particular house and are loath to go elsewhere.

It may be thought inappropriate that the practice of a scientific profes­sion should be conducted in residential premises. The patient compares what he seems in a modern general hospital with the background of his family doctor. The latter’s status is imperceptibly undermined by such comparisons.

For better or worse, however, four out of five doctors continue to practise from their own houses. The remainder practise elsewhere. Prac­tice arrangements for these vary widely.

Lock-up Surgeries

In many towns there may be found converted shops which serve as doctors’ surgeries. These usually consist of a front waiting room and a back office serving as a consulting room. They are normally open only during surgery hours. Sometimes a caretaker is employed to take messages; otherwise messages are left. These lock-up surgeries are seldom satisfactory; the available space is inadequate and does not permit the employ­ment of ancillary staff. Nevertheless, many doctors have to use them, for no other accommodation is available in the district.

In some instances partnerships (rarely individual doctors) erect buildings for the sole purpose of conducting their practices. This is an excel­lent arrangement but is apt to be costly. The cost apart, before any decisions can be taken, all the partners in a practice must agree to trans­ferring their practices to central premises. There is a real danger, too, of losing patients when they are required to travel great distances to visit the centre. A fund was established in 1953 (with the doctors’ money) to encourage group practice of this kind. So far less than 100 practices five years have been thus subsidised.

Not all group practices are recent creations. Some have been estab­lished for many years, mostly in small country towns—and they often provide a very high standard of service.

Health Centres

Section 21 of the National Health Service Act (1946) reads in part, ‘It shall be the duty of every local health authority to provide, equip, and maintain to the satisfaction of the Ministry premises, which shall be called “Health Centres ” . . .’ These centres were to house G.P.s, dentists, chemists and the local authority clinics and to provide for visiting con­sultants from the hospitals. It was clearly envisaged that gradually all general practice would be conducted from health centres, and that a broad area of co-operation would be established. All three branches of the Service would work together; public money would finance the erection and main­tenance of the health centres; receptionist, clerical staff, nurses and part-time pathological technicians would be made available; preventive and curative medicine would go hand in hand. This was the pattern foreseen in the 1945 White Paper and by most sociologists.

The actual number of health centres built in ten years is ten. There are a few other centres which are converted dispensaries. All told they serve less than 100,000 patients and employ fewer than 100 doctors. More important, perhaps, they have made little or no impact on the organisation of general practice. Viewed solely in terms of their achievements to date, health centres must be said to have failed.

Nevertheless the failure of existing health centres is not final. The concept of the health centre is still valid. There was undoubtedly a lack of foresight by those who planned the Service. They did not appreciate the difficulty of establishing islands of co-operation in a sea of competitive practice.

Pros and Cons

Those who press the Government to build more health centres should realise the very real obstacles that must be overcome if this new form of practice is to succeed.

Here are some of the difficulties :

  1. When a Health Centre is built in an already populated area all the patients are already on the list of doctors established in the area. Either some of these doctors must be persuaded to move their practices to the Centre or new doctors must be brought in. In no instances have established doctors been willing to close their exist­ing surgeries on entering the Centre, because they have feared (justifiably) that many patients will not follow them. To practise half in and half out of the Centre and in competition with the other G.Ps in the Centre is the negation of the Health Centre idea. Yet that is what has happened. If it were decided to staff the Health Centre with other doctors from outside the area, they would have no patients to start with: those patients who registered at the Centre would come from the lists of established doctors who would have good grounds for complaint.

  2. The essence of the Health Centre idea is that competition should be eliminated. The G.P.s entering the Centre should want to work together as a group. This is difficult, if not impossible, to achieve while they remain in competition outside the Centre.

  3. The original intention was for the G.P.s in the Centre to man the Local Authority Maternity and Child Welfare and other clinics held in the Centre. In some Centres this has been done. In most, however, the clinics are still run by the Local Authority doctors, a practice which is justified on the grounds either that the G.Ps have not the time or the specialised knowledge to conduct the clinics or that other doctors would not like their patients to be seen by a doctor with whom they are in competition.

  4. The cost of the large Health Centres (Woodberry Down or Sight Hill) is so great that no G.P. could afford to pay an economic rent. To cover the cost of accommodation and the ancillary services provided, a rent of £1,000 to £1,500 p.a. would be required from each doctor. In practice a much smaller sum is charged by the local authorities.

  5. The Local Health Authority owns and runs the Health Centre. In theory and practice the G.P.s are free from all control. Yet the doctors still tend to fear they may lose their independence if they enter the Health Centres.

There have been a number of experimental health centres built and maintained by universities and trust funds. Notable among these are Darbishire House in Manchester, the five health centres in Harlow in Essex, erected by the Nuffield Foundation, and the teaching centre in Edinburgh, which was financed by Edinburgh University. These experiments have been an undoubted success. Since they were privately financed, it was possible to make unofficial arrangements with the doctors concerned. In the case of Darbishire House, for instance, the doctors entering the ‘centre’ were required to limit the size of their lists and to be willing to teach students as a part of their duties. In Harlow, also, certain stipulations are made as to the terms under which the doctors are allowed to practise in the centres. Since private bodies are providing the finance, they can to some extent dictate the terms under which doctors will enter these ‘centres’. This the Local Authorities cannot do.

Future Policy

It is clear from the facts set out above that experiments in group practice and in health centres development have been concerned with a very small proportion of G.P.s. Our experience to date is insufficient to make any considered judgment on the future of health centres. Neither the Labour Government of 1945-1951 nor the Tory Government which has followed it have found it possible to authorise the Local Health Authori­ties to spend money on building many experimental health centres so that more experience could be gained. And yet that is what must be done if a real trial is to be given to an idea which a few years ago commanded wide support.

It is to be hoped that the next Labour Government will set aside enough money for these experiments to be made. Before this is done, however, there are certain questions which will have to be asked and answered, for it is useless to repeat in any new venture the mistakes of the past. Here are some of the questions;

  1. Do patients like attending health centres?

  2. What is their optimum size?

  3. Can competition for patients in health centres be eliminated?

  4. Does the health centre serve a useful purpose if the doctors main­tain their practices outside and if the Local Authority services provided in the centre are manned by Local Authority doctors?

  5. Would efficient general practice with ancillary help available in health centres result in—

  1. more patients being returned to work more quickly?

  2. less use of costly hospital out-patient facilities?

  3. an overall financial saving to the country?

On informed answers to these questions will depend the whole develop­ment of the general practitioner services. Without this knowledge plans must be based on dogmatic assertions or prejudices.

Group Practice

While experiments continue with health centres other ways must be found of improving standards of general practice. Group practice offers many but not all the advantages of health centre practice. From the doctor’s point of view group practice is the more attractive. First, it is based on a voluntary association of members with a common agreed aim. Second, it enables the group to select their point of practice, to plan the layout of the building to their own requirements and to choose their own secretaries and receptionists. Third, the doctors own and control their practice and cannot be interfered with. Fourth, they can nominate their own successors.

Against these advantages must be placed the drawback that the group practice is not linked to the preventive and clinic services of the local authority. Some of the more go-ahead authorities, however, are willing to attach health visitors and district nurses to suitable group practices. In these cases the group practice provides nearly all the benefits of health centre practice without any of the disadvantages.

5. The Doctor’s Pay

THE medical profession is often thought of as a vocation rather than a means of livelihood. It is of course a mixture of both. It comes as a disagreeable surprise to many laymen to read of monetary disputes between doctors and their employers. Medical men and women are sup­posed to be above such things. Yet they, like other professional folk, are striving to maintain a certain standard of life, which will enable them to take holidays and to educate their children privately if they want to. Perhaps they should not be concerned with these mundane matters, but they undoubtedly are. It is not simply a question of keeping up with the Jones’s. They feel that their status in the community and their ability to influence their patients are measured to some extent by their mode of life.

Before the National Health Service was established doctors derived nearly two-thirds of their income from private practice. In times of infla­tion, therefore, they could raise their fees so as to avoid any worsening of their lot. Now that all but a fraction of their income comes from the State no such method of adjustment is possible.

When the negotiations between the medical profession and the Govern­ment took place after the war it was agreed by both sides that more information was needed about the existing earning levels of the profession. Two committees were set up under the chairmanship of Sir Will Spens­ – one for G.P.s and the other for consultants—to discover what doctors had earned and to recommend what they should earn in a state service. Here we are concerned only with the G.P. report. The average pre-war G.P. was found to have earned £938 p.a. net (i.e. after practice expenses were deducted, but before tax Was paid). The Committee considered that this figure should be increased to £1,111 p.a. in terms of pre-war values of money. It was left to others to assess any changes in the value of money. The Spens Committee also found that the distribution of money between doctors had been very uneven before the war and recommended that the numbers of doctors in each earning group should be substantially altered. No method was suggested for effecting these changes.

No Basic Salary

When the negotiations were eventually begun it became clear that the medical profession would discuss no method of payment except by capita­tion fees. Mr. Bevan, the Minister of Health, sought to give each G.P. a basic salary of £300 p.a., but this suggestion was hotly resisted. Eventually it was agreed that these payments should be restricted to new entrants to practice and others with small lists.

The level of the capitation fee was also in dispute. A provisional arrangement was accepted by which a central pool was created with enough money to pay the average G.P. £1,111 p.a. plus 20 per cent. `betterment’ (an adjustment for the cost-of-living change) and all his legitimate practice expenses. The adjustment of 20 per cent. was arbitrary and did not satisfy the doctors. After several years wrangling the Government agreed to refer the dispute to adjudication by Mr. Justice Danckwerts. To the consternation of Parliament, he fixed the correct level of `betterment’ at 85 per cent. for 1948 and 1949 and at 100 per cent. for 1950 and 1951. The Central Pool was accordingly adjusted to give the `average’ doctor £2,222 per annum.

For four years the doctors put in no further claim, although the value of money had by 1956 depreciated by a further 24 per cent. When a claim was eventually lodged it received a chilly reception from the Government. No hope was offered of any adjustment. The B.M.A., through the agency of its ghost organisation, the British Medical Guild, started to plan a with­drawal from the National Health Service. The whole future of the Service seemed, for a time, in jeopardy. Then came the appointment of a Royal Commission to enquire into the remuneration of all doctors and dentists working for the State. Simultaneously an arbitrary interim award of 5 per cent. was made pending the findings of the Commission. Although the profession was now thoroughly upset it accepted the position and agreed to wait for the report. Since the Commission’s task was likely to be a long one a further award of 4 per cent. was made in December, 1958.

The ‘average G.P.’ now receives £2,426 p.a. (i.e £2,222 plus 5 per cent. plus 4 per cent), plus his legitimate practice expenses. His remuneration is made up of capitation payments and a number of other payments from different sources—e.g. maternity fees, sight-testing, local authority payments and private practice. Approximately 76 per cent. of the average doctor’s income is derived from capitation fees and 24 per cent. from other sources of income.

The Pool System

The pool system is one which has certain advantages for the Exchequer. By multiplying the number of practitioners by an agreed average sum of money and adding the total for expenses it knows the State’s total commit­ment of the year. There are, however, drawbacks.

The Central Pool System discourages any alteration in individual fees for items of service. If the Ministry wished to encourage G.P.s to take on work in the hospitals, it might well decide to raise the level of the existing fees so as to attract them to this type of work. But any additional money found for this purpose would be immediately deducted from the Central Pool and would result in lower capitation payments for all doctors. Recently G.P.s were asked to undertake a great volume of additional work in inoculating children against poliomyelitis. All the fees they received for this work (5s. each from the local authority for notifying a completed inoculation) were promptly deducted from the Central Pool. It is as if the overtime earnings of certain workers in a factory were deducted from the earnings of the rest of the workers. The present Central Pool system may suit the Exchequer, but it is difficult to understand how it can work in the public interest.

Repayment of Expenses

All the payments made to G.P.s contain an expense element. But how is this arrived at? Each year every doctor has to declare his earnings and his expenses to the income tax authorities so that they can compute his net taxable income. By agreement between the profession, the Ministry of Health and the Exchequer, the total of expenses for all G.P.s is made known, which enables the Ministry to calculate the average expense ratio. This ratio works out at approximately one-third of a G.P.’s gross earnings—which means, in effect, that out of every £3 he earns, £1 is for expenses and £2 for net payment.

No one could object to the present method of distributing expenses were all G.P.s to spend a third of their incomes on their practices. In fact, the percentage varies enormously. Some spend as much as 60 per cent., others only 20 per cent. Yet each receives 33.4 per cent.

The results are unfortunate, to say the least. Doctors Smith and Jones, two single-handed practitioners, earn £3,000 p.a. apiece. Each is assumed to have spent £1,000 on practice expenses and to have therefore a net income before taxation of £2,000 p.a. The facts are very different. Dr. Smith employs a secretary and part-time nurse and spends money on his waiting-room furniture and decorations. His actual expenses amount to £1,500 and he is, therefore, left with £1,500 net income. Dr. Jones, on the other hand, has always practised from a small lock-up surgery in a poor part of the town. He has no one to help him and spends little or nothing on decoration. His real expenses are £600 p.a., so his taxable income is £2,400 per annum.

If the Government had set out to deter the G.P. from improving his standards of general practice, they could scarcely have devised a more effective system. The lazy and complacent are encouraged; the con­scientious lose on every count.

How Should G.P.s be Paid?

The method by which any group of workers is paid determines to a large extent the type of service they give. One need not be a rigid Marxist to recognise that the relationship between G.P.s and the public must be influenced by the way in which the state pays them. If our aim is to mould the development of the family doctor service into a more useful pattern, we must be sure that the method of payment encourages that development and does not hinder it.

There are only three methods of payment which need be considerd in relation to general practitioners, and all have been tried in one country or another. These are payment by fee for service, payment by salary or by sessional fee, and payment on a capitation basis. It is worth while considering each of these methods to see their relative advantages and disadvantages.

The Fee for Service Basis

This is the method of payment found in most countries which provide a health service under a compulsory insurance system. Many continental countries operate it, and it is even found in a special form in the Communist state of East Germany. Both New Zealand and Australia have adopted this system.

The theoretical advantage of the fee for service system is that it encourages the doctor to look after the patient fully ; the more visits he pays the greater is his reward. Since in most of the countries mentioned the patient still has to pay some part of the cost of treatment, the doctor cannot easily impose too great a financial burden on his patients by render­ing too many items of service. In this country, however, the health service is free at the time of use and a fee per service basis of payment would give a tremendous inducement to the doctor to over-treat. He would tend inevitably to reduce the number of patients he cared for and increase the number of items of service he save, The cost to the state could be astronomic. Moreover, each doctor would have to maintain an accurate record of all the services he rendered, and an army of clerks would have to check and price several hundred million items of service given each year.

There would be another consequence which many would think un­desirable. The patient would presumably have the right to visit any doctor on any occasion, as he may in other countries using the system. This would mean that the patient was no longer under the continuous care of one general practitioner.

For all these reasons this method of payment can be dismissed as quite unsuitable for the Health Service in this country.

A Salaried Service?

Most Socialists have pinned their faith on the salaried method of pay­ment. They argue that many doctors in the hospital and local authority services are already paid on a salaried basis and that G.P.s should also be paid in this way. A salaried service would certainly eliminate com­petition between doctors and provide the basis for close clinical co-operation between colleagues working together. Since many of the evils of the present system are recognised to result from the competitive aspect of the capita­tion system, a salaried service would appear to offer an easy and acceptable solution.

General practitioners, however, would certainly reject any such proposal. It is very doubtful whether more than 5 per cent. would welcome it. Year after year the doctors attending the Annual Representative Meet­ing of the B.M.A. pass resolutions reiterating their hostility to a salaried service. So great is this hostility that Mr. Bevan when Minister of Health was forced to agree to an amendment to the 1946 Act to render illegal the introduction of a salaried service in any form. It would be difficult for any government, however determined, to introduce a salaried service at the present time.

Leaving aside the profession’s antipathy to being paid by salary, there are obstacles of a different kind to be surmounted. G.P.s are now private entrepreneurs, financing themselves, organising their own work, choosing their own partners and deciding the limits of their own commitments. One may decide to have 1,000 patients only and to spend most of his time doing industrial medical work; another may look after 3,500 patients and do little else. How would it be possible to pay them all by salary in these circumstances? Only by varying the salary according to the size of list, which is what the capitation method now does. To introduce a salaried service all general practitioners would first have to be accommodated in premises provided by the state or by the local authority. The day may come when practitioners will all be housed in such premises, but it is a long way off.

There are other practical objections to introducing a salaried service. The opposition from the patient might become as vocal as is the practi­tioner’s at present. In publicly-owned premises each doctor would presumably be required to attend approximately the same number of patients. The bad or unpopular doctor who at present fails to attract many patients to his list would have to look after as many patients as the good doctor. Indeed it is difficult to see how the patient would retain any freedom of choice. If doctors were paid by salary, they would undoubtedly ask to work for a limited time each day, as do other workers. They would presumably be employed on some type of shift system and would not be available to follow up their own patients when they were off duty. Some doctors might welcome such a change but many would prefer to retain the continuing responsibility for those under their care and the patients themselves might well object to a succession of doctors visiting them during an illness.

The main burden of complaint against a capitation system is that it encourages undesirable competition for patients and gives no incentive to the doctor to attend his patients frequently. There is no doubt that un­limited competition between doctors should be discouraged. This can, however, be done without abolishing the system itself. Providing the maximum list allowed to a doctor is not too far removed from the average, competition is limited. The average list, as we have seen, is now 2,200 and the maximum permitted list 3,500. In a few years’ time the average list may well be no more than 2,000 per doctor, and then it may be possible to reduce the maximum permitted figure list to a figure not too far above this. As the distribution of doctors throughout the country becomes more uniform the variations from the average will become less. The competitive element of the capitation system will gradually decline. The profession will find itself paid by what is virtually a salary without any of the evil consequences it fears.

The Capitation System

The capitation system is a very flexible method of payment. Already during the last ten years it has been substantially modified so as to bring about a more equitable distribution of money. There is a special loading for all patients on a doctor’s list between 501 and 1,500, which helps the doctor with the smaller list. There are other possible variations of the capitation system which could be envisaged. For instance, the remunera­tion of doctors could be separated from the payment of expenses. This would enable the Government to repay expenses on a more realistic basis and encourage doctors to spend money on improving their practice premises. One could also provide a sliding scale of capitation payments designed to discourage doctors from taking too many persons on to their lists. Special payments could be made for the care of children and of elderly persons ; more money per head might well be paid in areas of high morbidity. Doctors with higher degrees or with special skills could be specially rewarded as could those who maintained high standards of practice organisation. These are some variations which could be considered. Not enough thought has been given to the possibility of moulding the capitation system to the needs of a comprehensive National Health Service. We inherited the system from the past and have done little to adjust it to present-day needs.

6. Training the Family Doctor

Medical students are taught by consultants and senior registrars in the teaching hospitals. Many of these teachers have spent all their working lives within the walls of a hospital. They have specialised in their own particular subjects. They rarely have any close contact with general practitioners, medical officers of health, or, indeed, with doctors and other health workers interested in environmental or social medicine. In the modern hospital there is, for economic reasons, an increasing tendency to aim at a high turnover rate of beds. The average length of stay has been continuously reduced. The aim is, therefore, to cure the patient and to return him to his home in the shortest possible time. Even with the help of hospital almoners there is little opportunity for making exhaustive enquiries into the patient’s home background and working conditions, factors which are ever-present in the minds of the general practitioners. The medical student tends to get a distorted view of medicine. He sees many acute cases where a rapid cure may be effected, but few of the chronic disabling diseases which are so common outside the hospital. When for the first time in general practice he is faced with the chronic bronchitic or psychoneurotic he is often at a loss as to how to handle the case. The problem of the family doctor is so often not to cure—for that is not always possible—but to teach the patient to live with his disabilities.

Authoritarian Attitudes

The hospital environment is not helpful in developing the right attitude towards patients. People complain, sometimes with justification, that their family doctors are too authoritative—too didactic in manner. Yet this is to be expected, for the medical student absorbs over his years of training the attitude of his teachers. The teaching hospital is still a hierarchy with the consultant medical staff at the top. When students qualify and go into general practice they tend to assume the manners and attitudes of their teachers. Faced in general practice with unfamiliar problems, they may adopt an even more didactic manner—to cover a sense of inadequacy.

It is not easy to see how the training of medical students can easily be adapted to prepare them for work in general practice. As long as the teachers remain isolated from contact with the patient in the environment of his own home, they cannot communicate the right attitude to their students. A period in general practice would undoubtedly broaden the outlook for specialists. If all hospital doctors on completing the post as registrar and while waiting to become senior registrars were required to spend six months in general practice there would be a great gain. Mean­while there are fortunately a growing number of consultants who appreciate the importance of teaching the value of psychological and social as well as physical medicine. Some teaching hospitals are already sending their students out to spend a period, with general practitioners in the neighbour­hood. In Edinburgh there is a general practice teaching unit attached to the University, and in Manchester medical students spend a period in Darbishire House, the group practice financed by the University. These facilities should be extended so that every medical student acquires some knowledge of general practice before he qualifies.

Special Training

The need to orientate the student’s training to deal with cases he will meet in general practice is recognised, at least in principle. What is still not recognised are the particular non-clinical aspects of his work.

The new entrant to general practice is expected to be able to run a complicated business enterprise; to understand the complex organisation of the National Health Service with its regulations, disciplinary machinery and terms of service; to be aware of all the facilities provided by the local health authorities and voluntary agencies; to know the comparative prices of all drugs he might be called on to prescribe while in practice.

Yet he is taught none of these things. He has to pick them up as he goes along—a long and haphazard method of acquiring knowledge which is essential to the practice of good medicine today.

Every qualified doctor who intends to enter general practice should attend a course (a month would not be too long) where he would be given the opportunity to learn the principles of good practice organisation within the National Health Service. It would be time well spent.

7. Looking Ahead

If detailed consideration has been given to the present structure of the general practitioner service, it is because future plans, to be realistic, must take this structure into account. One sometimes hears the view expressed that the present organisation of general practice is so unsatis­factory that nothing could salvage it. Unsatisfactory or not, it is all we have to work on. We are not living in a revolution where ruthless theoretical solutions can be imposed. Even if they could be, the results would be disastrous, for the whole essence of good general practice is active and willing co-operation between doctors for a common end—the good of the patient.

Nevertheless, most people would agree that substantial modifications of existing organisation are needed if G.P.s are to fulfil their proper role in society to-day. Of necessity these can be brought about only gradually. Gradually, but unfortunately not inexorably. Left to itself general practice would not improve. It would tend rather, to ‘gel’ in its present unsatis­factory state. We shall see no marked changes until initiative is shown by those responsible for the Service. The Ministry of Health must first appreciate the need for change and then plan accordingly. It must not be deterred by the difficulties it is bound to encounter. Once a long-term programme is agreed upon with the medical profession it should be carried out by stages—dare one suggest in a series of five-year plans?

Before making plans, however, one must know clearly where one wishes to go. Luckily there is a large measure of agreement over objectives. These can be baldly stated as follows:

  1. The G.P. should have more time to devote to each patient and to prevention as well as cure.

  2. He should be housed in suitable premises.

  3. He should not be required to do work which could be done as well by less highly trained workers.

  4. He should be able to carry out diagnostic procedures himself or get them done quickly nearby.

  5. G.P.s should increasingly work together in groups.

  6. They should have a close working relationship with hospital doctors.

  7. They should work closely with nurses, health visitors and other employees of the Local Authority health and welfare services.

  8. They should be encouraged to undertake work which is not strictly ‘ general practice ‘, e.g. industrial medicine, school health clinics, etc.

  9. They should be stimulated to undertake medical and sociological research work.

  10. Medical schools should prepare students more effectively for general practice with special stress being’ placed on psychological and social medicine.

Omitted from this list of objectives are rather more contentious matters; for example, the future of the domiciliary maternity services and the place of the G.P. in the hospital.

Planning for a Purpose

To achieve all the objectives listed above will be a long and difficult task. If, however, when planning administrative changes they are kept in mind, progress will gradually be made. But it will not happen automatic­ally. Doctors have now become accustomed to certain working conditions and will not readily change their habits.

This raises the question: Who is to do the planning? Clearly, the Ministry of Health. But who in the Ministry? To administer the general medical services, which cost the country over £70m. a year, there is available approximately one-quarter of the time of an Under-Secretary, half of the time of an Assistant Secretary, and the whole time of a Principal Secretary. These overworked men are hard put to it to keep up with day-to-day tasks. They cannot possibly find, the time to plan the future. The Exchequer, which ultimately controls the Ministry’s establishment, is responsible for this under-staffing which makes intelligent planning near impossible. No private firm would tolerate such a state of affairs. A Labour Chancellor should in the interests of true economy make provision not only for more senior staff but for an adequate statistical department with electronic computers.

If the Ministry of Health wishes to encourage more G.P.s to work together in groups, to restrict their lists, to employ receptionists and nurses and to co-operate with the hospitals and local authorities, powerful induce­ments will have to be provided. The Ministry must recognise that the pattern of general practice can be changed only at grave initial inconveni­ence to established doctors.

The Group Practice Loans Committee, which offers interest-free loans to doctors wishing to centralise their practice premises, has received rela­tively few applications for money. Why is this? Probably because the attraction of an interest-free loan is more than offset by the new financial commitments that must be assumed in running a group practice.

Opposition to the provision of financial inducements may come not only from the Treasury but from the doctors themselves. Being in com­petition with their colleagues, they may look with suspicion on any proposal to provide special favours to a minority . This is an understandable yet mistaken viewpoint. In the long run the whole profession will gain by creating circumstances for better work to be done, even if at first it is only some doctors who benefit directly.

Each objective listed cannot be achieved by isolated actions designed for a specific purpose. The future of the development of the family doctor service may best be considered under certain broad headings—time, pay, premises and relationships.

Reducing the Pressure

Every doctor would agree that he needs more time to examine and investigate his patients, to listen to their worries, and to put them in effec­tive touch with the agencies that could help them. Every doctor would agree that he needs more time to read and keep up to date with medical developments; more time to consult with his colleagues; more time for relaxation. Time is the essence of good general practice and few doctors have enough of it.

There are two ways of finding more time for the family doctor; the first is to reduce the number of patients he has to care for and the second is to ensure that he does not have to do work of a non-medical character.

The maximum list at present allowed to a single-handed practitioner is 3,500. This figure should be reduced over a period of about three years to 3,000. Later it should be further reduced to 2,750. These reductions should not lead to a reduction of doctors’ incomes. The Royal Commission now sitting will, it is hoped, recommend a reduction in the maximum permitted lists. Such a reduction would cost the country money. That is inevitable, but the public must realise that it has to pay for higher standards of general practice. They cannot be bought cheaply.

It must not be thought, however, that the doctor with the large list necessarily gives a poor service nor the doctor with a small list a good one. All the State can do is to organise affairs in such a way that family doctors are made capable of giving a good service to their patients. Methods other than controlling the size of lists will have to be found for raising clinical standards,

Doctors must not only have less patients on their lists; they must spend their time looking after them—not in doing secretarial and nursing work. No business executive would write his own letters. Yet very many family doctors have to do so because they cannot afford to employ secretaries. This may mystify the public, who are told that G.P.s get all their expenses reimbursed. But as has been explained, the present method of repaying expenses does not encourage the individual doctor to spend money on his practice. If he takes a secretary at £500 p.a. the Central Pool is increased by that sum, but his personal share of this is only 6d.

Pay and Expenses

To encourage the employment of secretaries, receptionists, and in the larger practices nurses, the system of payment should be so altered that doctors who pay for such ancillary help should be reimbursed and those who do not should at least not be rewarded. The present method of repaying a doctor’s expenses puts a premium on bad organisation. This must be ended. The G.P. should be paid separately for the work he does and for the expenses he incurs. A method (with adequate supervision) must be devised for encouraging doctors to spend wisely on their practice organisation. This, too, will cost the state money. But it will be money well spent, for the family doctor will be given more time to devote to his patients and have less need to rely on assistance from his hospital colleagues.

One would like to consider in detail a practical system for the repay­ment of practice expenses which did not encourage unnecessary or extrava­gant spending by the doctor. Unfortunately this is a complex and difficult subject which cannot be dealt with here. Several schemes have been put before the Royal Commission for its consideration.

For reasons already given no fundamental change in the method of remunerating general practitioners is required. Nevertheless, the present capitation system could be modified with advantage in a number of direc­tions. Competition between doctors should be reduced to a minimum. This can be done only gradually. As the wide discrepancies in practice lists diminish and the number of doctors in partnership and group practice who pool their pay increases, so will the competition decline. The greatest single factor, however, in reducing competition will be the provision of an adequate income for the middle list practitioner. A doctor with 2,000 patients should not need to strive to increase his list as he does at present. The Royal Commission will, we hope, plan their recommenda­tions with these points in mind.

Premises

A general practitioner can practise good medicine from bad premises, but his task is difficult. He will almost certainly do better in modern well-designed accommodation.

At present the standard of surgery buildings in this important branch of the National Health Service is determined solely by the G.P.s themselves. They have to find the capital and hence cannot be ordered into new accommodation. True, the local Executive Councils may condemn premises .as unsuitable, but in practice this means little, for doctors cannot be .forced into new premises where none exist. Three years ago. Local Medical Committees (acting on behalf of the L.E.C.) agreed to inspect all surgery premises. In some areas the inspection was thorough and action was taken to improve the worst conditions found; in others the inspection was cursory; in yet others the Local Medical Committee refused to inspect. At best the inspection led to some redecoration and renovations.

Many doctors would welcome the opportunity of transferring their practices to central premises where ancillary help was available, provided they could choose their own colleagues with whom to work, remain clinically and administratively independent, and pay a rent that was not too high. There are at present two ways in which doctors may come together in groups. Firstly, they may build central premises, using their own capital or money advanced by the Group Practice Loans Committee. Not only must each doctor agree to raise the capital (and repay it over a number of years) but each must be willing to face higher running costs. Very few of these private centres have been built.

Secondly, doctors may enter a Health Centre if one is being built. Vacancies are advertised and applicants cannot choose their colleagues. Doctors appointed compete with each other and continue to practise from their own houses as well as in the Centre. Health Centres are, in fact, used as branch surgeries.

To fulfil their proper function Health Centres should provide the basis of group practice and the right to man the Local Authority Clinics. This cannot be done under existing regulations, which could not be easily altered so as to produce the needed result.

A New Capital Fund

One must therefore turn to some other mechanism for encouraging doctors to work together in groups. At present the sole inducement is provided by the £100,000 p.a. set aside from the doctors’ own money for this purpose. The doctors who make use of this fund benefit only in ‘so far as they save interest charges. On a £5,000 loan a group of four doctors now save, say, £300 p.a. in interest. Since this sum is chargeable against practice expenses and thus not subject to income tax the net gain amounts to £188 or £47 per doctor—a small inducement to alter his existing way of life.

To make any real impact on practice organisation the Government must provide a marked incentive to change. A new fund should be set up and at least £1m. p.a. paid into it each year. Its sole purpose would be to encourage better practice organisation. The Trustees of the fund would be empowered to build group practice centres or to acquire existing buildings suitable for conversion. They would own the premises and let them at economic rents to doctors willing to work as a group. The State would accumulate capital assets and the doctors concerned would be relieved of the necessity of finding the capital. As a quid pro quo the doctors should accept certain obligations. They should agree to man the Local Authority clinics which could be built (perhaps at a later date) adjacent to the centres; to train students and inexperienced qualified doctors; to have health visitors, district nurses and social workers based on the centre.

The Trustees would also be empowered to help individual practitioners to improve their premises in areas where group practices were not feasible. Interest-free loans would be made to these practitioners to be repaid over, say, twenty years.

To provide some check that the fund was being used to the best advantage applications would first be submitted to Local Executive Councils. If approved the practitioners concerned would be visited by two doctors appointed by the Trustees who would investigate the local circumstances before granting final support.

What Could be Achieved?

A well-designed group practice centre for four doctors would cost approximately £8,000, or £2,000 per doctor. Five hundred doctors a year could be, accommodated for £1m. In one decade a quarter of all G.P.s could be rehoused in up-to-date premises. If the application rate were slower and the yearly allotment of money not fully used, the Trustees would be empowered to spend the surplus in any way which would encour­age higher standards of general practice.

The rehousing of general practitioners is not an end in itself. Good group practice accommodation leads directly to higher medical standards; less competition between doctors; the possibility of working closely with the local health and welfare authorities; more comfort and better attention for the patient—end because of all these, to a reduced load on the hospital service.

SUMMARY AND CONCLUSIONS

General practice in the National Health Service has been neglected. Less thought and planning has been devoted to it than to any other branch of the Service. The Ministry of Health has failed to appreciate the immense contribution which this branch of medicine could make to the health of the community. If general practitioners had fewer patients to look after, were better housed, better organised and in closer touch with other health and welfare agencies, patients could expect to receive more attention, the hospital would be relieved of much work and there would be less sickness benefit paid out of the National Insurance funds.

The case for improving standards of general practice is very strong, but the task is not easy. The G.P. is a private entrepreneur, responsible for providing a range of services to the patients on his list. He chooses his own premises and equipment and decides for himself what ancillary help he can afford. Hence the variation of practice standards. The problem is to find methods of raising standards generally without interfering unduly with the clinical and organisational rights of the individual doctor.

No dramatic solutions are possible. Ways should be found of persuad­ing and inducing doctors to do the right things themselves. The system of payment must be altered so as to provide financial incentives for better practice—not deterrents as at present. If doctors themselves cannot readily finance practice improvements the State should undertake the task.

The problem, however, is not a financial one only. The present train­ing of medical students does not fit them for general practice. The medical curriculum should be altered so as to give a sound training in environ­mental, social and psychological medicine.

Little progress will be made towards better general practice until the Ministry of Health is willing, in conjunction with the medical profession and the medical schools, to plan for the future. Long-term objectives should be agreed. Their attainment might be left to a working party.

Unless positive action is taken to halt the decline in the status of the general practitioner, there is a grave danger that the family doctor as we know and value him may disappear.

Doctors are mostly busy people with little time to spare for active politics. This is why membership of the FABIAN SOCIETY is so attractive to them. It combines a minimum obligation to participate (although a welcome if you do) with the maximum opportunity to be associated with research of first-rate importance. The Secretary of the FABIAN SOCIETY, 11, Dartmouth Street, London, S.W.1 (Whitehall 3077) would be delighted to tell you how you can join.

Incidentally, have you seen Kenneth Robinson’s Fabian pamphlet Policy for Mental Health (1s. 8d., including postage)?

  • Printed in London by Devonport Press Ltd. (T.U.) W.12

Dr. H. Bruce Cardew was General Secretary of the  Medical Practitioners Union

 

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