By Somerville Hastings, M.S. LOND., F.R.C.S.

CHAIRMAN OF THE HOSPITALS AND MEDICAL SERVICES COMMITTEE, LONDON COUNTY COUNCIL

Reprinted from THE LANCET; Feb. 24, 1940, p. 375.

SOME form of state medical service appears to be inevitable in this country fairly soon, and the best way out of the present chaos, due to the outbreak of the war, is by the democratic control of hospitals, medical services, and the profession. The service should be complete- i.e., it should provide not only general practitioners but also specialists, hospitals, convalescent homes, pathologists, dentists, and efficient nursing in hospital and at home. It should aim at prevention as well as cure, and the preventive and curative services should be much more closely associated than they are now. Further, the service would have to be truly democratic and controlled by local authorities and not by a central government from Whitehall. It would certainly be wise for the smaller counties and county boroughs to unite so that the administrated area could be large. There must be elasticity, however, and opportunity to apply different methods to meet special needs. Moreover, advantage must be taken of the assistance and advice of all with medical knowledge and experience in the area. So far most people will agree, but the method of transition is a matter of contention.

It seems clear that the hospital needs of the future will be supplied by the large general hospital, and that the specialists of this hospital will see cases referred to them by general practitioners in the outpatient departments of that hospital and its branches, and that these same specialists will see patients in their homes at the request of the general practitioners. What is not one little bit clear, however, is how we are to pass from the present mixture of panel and private practice to a properly organised general-practitioner service. No doubt, at any rate at first, only those with incomes below £250 will be entitled to the service; but these will constitute about 80 per cent. of the population. Whether the service is to be provided entirely free or paid for in part by insurance need not trouble us at the moment.

The British Medical Association’s scheme for providing a general-practitioner service for the whole of the less well-to-do members of the community is hardly worthy of serious consideration, and it is only just to the association as a whole to add that at the last annual meeting in August, 1939, a resolution asking for the consideration of drastic modifications in the scheme was accepted. Much as he would wish otherwise, the doctor under the panel tends to become little more than a tradesman, whose main responsibility is to please his customers, and whose practice and remuneration depend almost entirely on how he succeeds in this and not infrequently on his willingness to sign insurance and incapacity certificates exactly as desired by his patients.

The immediate effect of the extension or the panel proposed by the B.M.A. would be to double the commercial value of every panel practice, or, in other words, immediately to put about £1000 to £2000 in enhanced capital value into the pocket of every panel practitioner. Panel practices are freely bought and sold and fetch good prices. Indeed, many doctors are compelled to buy a panel practice-often with borrowed money-to make a living. Anyone, therefore, with a minimal qualification and the necessary capital, or who can borrow it from a money-lender, can acquire a panel practice and, provided he has a suave and pleasant manner, can retain or even increase it, because the public mostly cannot appraise the true value of the medical services received. To extend the panel to the dependants of the insured, so that the principal medical service for 80 per cent of the population (paid for to a considerable extent by the state) is provided by appointments sold to the highest bidder, must surely be absolutely impossible in a democratic country. If this is granted, as indeed it must be, some other method of transition from the present mixture of panel and private practice to a salaried general practitioner service must be found.

Suggested Scheme From Panel to Public Service

What is to be aimed at eventually is a full-time salaried general-practitioner service, each member of which should be responsible for the health of a certain number of persons, say 2000 in country districts and 2500 in towns. The salary would depend to some extent on length of time in service -i.e., seniority and might reach a maximum at 50, but there would of necessity be some supervisory posts. There would also be a pension at retiring age, or before if the practitioner is certified unfit. In such a service elasticity is essential if it is to attract the best men. It should be possible for members to become clinical assistants in the special departments (including medicine and surgery) at the hospital and, after the necessary training and experience, heads of such departments. They might also undertake part-time work in hospitals and school clinics, reducing the number of patients on their list accordingly.

There are about sixteen million insured workers, nearly all of whom are on the panel of some doctor. These have about fifteen million dependants. When these last require the services or a general practitioner they usually get it, if they get it at all, from the panel doctor of the father or breadwinner of the family. It is suggested that an offer should be made to every panel practitioner that, if on the appointed day he becomes a member of the new home-doctor service, all his existing panel patients and their dependants should be placed on his list, and that he should be paid a salary which is a fraction of the salary of a whole-time doctor in the home service of the same age, the numerator of which fraction is his list of panel and dependant patients and the denominator 2500 in town and 2000 in country, expressed by the following formula:

Salary = (panel and dependant patients)/2500 (2000 in Country) *Salary of whole-time doctor of same age

He would also receive on retirement through age or ill health a like proportion of the pension of a fulltime doctor in the home service of the same age as himself, although he might only have been a member of the service for a few months. Should any of the patients for whom the state accepts responsibility become tired of their doctor, they could transfer to the list of any other doctor in the home service who has a vacancy. Some of the more senior and much respected members of the home-doctor service would have waiting-lists, but so have some panel practitioners today. Vacancies on the lists of the home doctors would be filled by persons who desire him as their doctor or by others who express no preference; but the number on each list on the appointed day would not be exceeded. As existing practitioners die or retire their lists, so far as the public service is concerned, would be amalgamated and taken over by full-time doctors. Experience of the sale of practices indicates that about 90 per cent. of these potential patients would accept transfer. The remainder could be added to the list of the doctor they prefer, so far as vacancies permit. It would be as simple to register for medical advice as for bacon and butter.

Certain special classes of potential patients need further consideration. Many people, such as hawkers, cobblers, smallholders, and small shopkeepers, earn less than £250 a year, but are not insured. With dependants they are said to number about four million. They would be asked to register, indicating the doctor of their choice. If he agreed, their names would swell his list of home-service patients. If he refused, they would be added to that of some other part-time or full-time doctor in which vacancies occurred. District medical officers, who are responsible for the care of public assistance cases, are” senior poor-law officers” and can only be dismissed for some serious neglect of duty. On their death or retirement their patients would be transferred to the home-doctor service.

All the necessary facilities must be provided to assist the doctors in the home service to do the very best for their patients. Pathological, specialist, nursing, and other services must be available, and it must be easy to obtain a second opinion. Machinery must also be provided for the investigation of complaints.

ITS ADVANTAGES

What is the essential difference between appointing part-time home doctors and extending the panel to the dependants of the insured? The difference is clearly fundamental. The part-time home doctor, although he may be selected by his patients, will not be appointed by them. He will be appointed by the local authority. When he dies or retires, no one doctor will have a greater claim to his appointment than any other. The post will be advertised, and the best man who applies will be appointed. In other words, the appointment will be no more saleable than any other civil-service appointment. The important question for the medical profession is whether this scheme would be fair to those who have invested a large sum of money in the purchase of their practices and are trusting that the sum obtainable by their sale later on will provide for their old age. Others have been compelled to borrow money to buy a practice. This they are trying to pay off year by year, and they are hoping that, when the time for retirement comes, the debt will have been repaid and their practice will still be saleable. How will these doctors view the proposed change?

First, there are many advantages that are bound to appeal to the harassed and overworked general practitioner. He will probably live longer to enjoy his retirement, for he will have regular holidays and the certainty of a fixed and secure income if he does his work well. He will also have the satisfaction of being able to do better medical work; for it will be easy to obtain the assistance of his colleagues in all branches of the profession; he will be able to follow up his cases in hospital; and he will have study leave, opportunities of research, and the satisfaction of helping to prevent. disease besides patching up the fallen.

The advantages from the financial standpoint are no less real. Most general practitioners are concerned with patients who may be divided from the financial standpoint into three classes: (1) the relatively well to-do- i.e., those above the panel income limit of National Health Insurance (£250 a year); (2) panel patients; and (3) dependants of those on the panel and persons of a like financial class. Those with an income of more than £250 call for no comment, because they will not be affected, and the value of the practice, so far as they are concerned, will not be influenced in any way. As regards the panel patients, it may be conceded that security of income and absence of any risk through the action of a less scrupulous neighbour who would sign any certificate presented to him will go some way to compensate for the saleable value of the panel part of the practice. Most important, however, is the question of pension. .As has already been stated, this will depend not on length of time in the service but on age and will give absolute security both for old age and retirement due to ill-health, a security much more certain and assured than that obtainable by investment or by purchase of an annuity after the sale of a practice. It is generally agreed that the commercial value of that section of a practice that results from the dependants of the insured is not great, for the very good reason that these patients are as a rule only able to pay small fees and in not a few cases no fees at all. Under the scheme adumbrated, for the first time, reasonable fees and a pension would be received on behalf of these people. In this direction, therefore, the practitioner would greatly benefit.

The Lancet Office, 7, Adam Street, Adelphi, London, W.C.2.

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