The variety of services necessary for a really comprehensive health service and the number of specialists in medical practice which must be provided are formidable. Medicine has developed on two different lines, one the splitting tip of medical knowledge and skill into smaller components, and the other the supplementation of the efforts of medical men by ever-increasing numbers of workers in fields outside medicine, workers often without direct training in medicine. Chemists, physicists, mechanics, electricians all carry out medical work, acquiring medical knowledge in the actual pursuit of research or treatment as distinct from academic training.
The term “specialist” is used for those medical men who have narrowed their field of medical skill so as to achieve a higher technical standard in it than is possible to those who try to cover the whole subject. But it must not be thought that because we adhere to that definition we do not realise that in the ever-growing army of health workers there are many who are specialists in their own field. Their training is different and they often work under the guidance or control of doctors and so are spoken of as “ancillary,” but they are vital to the service.
With the great mass of ancillary workers and the service they provide the present Bill does not deal. Since they are. nearly all already engaged as full-time salaried officers in hospital or clinic there is no need to mention them ; their duties continue and the new forms of organisation do not alter them in. any marked degree. What may be altered is their terms and conditions of service, and it is foreshadowed that these will be the subject of national regulation and that most of them will be improved. There are, of course, in the Bill clauses to safeguard pension and other rights of those who on the new service beginning to operate are transferred to new employers. Many of the ancillary services will be the responsibility of the local health authority and be organised through the Health Centres.
One of the main purposes of the Bill is to ensure that adequate numbers of medical specialists will be at the service of the people everywhere. It will be mainly the duty of the Regional Hospital Boards to provide “consultant services of all kinds and all forms of specialised treatment—e.g., orthopaedics, cancer, neuro-surgery, ophthalmic services, ear, nose and throat treatment, and others.” That “and others” covers some of the most important, for it includes laboratory and X-ray services, which are probably not mentioned because they are so universally regarded as essential.
The Bill says that the Minister has to arrange for all these specialists to be available “where necessary, at Health Centres and in the patient’s home.” The specialists are to be attached to the hospitals under the Regional Boards, but some will be on the staffs of teaching hospitals under their Boards of Governors. Specialists may, of course, be employed by both these controlling bodies, for it is laid down that specialists may hold whole-time or part-time appointments. The normal procedure will be for the service of the specialist to be sought by the family doctor. According to the size of a health centre and the amount of work done, specialists will either visit the health centre or patients will be sent to hospital to see the specialist. The question of the specialist visiting the patient in the home will be settled by the family doctor and specialist in consultation. The Regional Hospital Boards will seek to spread specialists-more evenly over the country, but will also concentrate those with rare skill or very special knowledge at main centres of population within the region, the patient being transported to the specialist best able to deal with his case. The service has in. this matter a double aim, to diffuse new and generally applicable knowledge as widely as possible and to concentrate highly specialised skill at focal points where it can be used to the greatest advantage of the greatest number.
There can be no doubt as to the need for these provisions. Specialists at present “are grouped in particular areas and are not as readily available to the people generally as is needed,” as Mr. Key, the Parliamentary Secretary to the Minister of Health, told the House of Commons. The Hospital Surveys declared that ” serious as the bed shortage is, there is an even more serious shortage of medical staff, most obvious in the Consultant-Specialist class….Consultant staffs could be at least doubled.” One of the reasons for this shortage is that under the present system ” it is doubtful whether there is a living for any more specialists.” The faults in the system apply to both voluntary and municipal hospitals, and “it is at least certain that…. existing terms of appointment …… could not support the number required to raise the service of the hospitals and consultation clinics to the level of quality desirable and to increase the volume of that service to the extent anticipated.”
Another great fault with the present specialist services is the habit of consultants accepting “appointments on the staff of a large number of small hospitals, sometimes many miles distant with a consequent waste of time and energy in travelling and an inadequate service.”
A third fault, especially in cottage hospitals, and a great danger to patients and doctors—to the lives of the patients and the professional quality of the doctors—is ” the tendency for the general practitioner gradually to drift into surgery as an offshoot from his general practice.” Nothing rouses more antagonism in the minds of G.P.s attached to small hospitals than the insistence of all students of the problem on the very terrible faults of the cottage hospital system. The Domesday Book, from which we have already quoted, has a remark which must spell the doom of this system—such hospitals “sometimes issue what amount to ‘ bogus prospectuses ‘—lists of visiting consultants which lead one to believe that they all undertake regular work” at the hospital when in fact their visits are infrequent and some never attend at all.
The municipal hospitals also lack enough consultants of highest rank, and in the past they have usually been confined to their own hospital, not available in the homes of the people and rarely meeting their colleagues from other hospitals in consultation or discussion. It is also wrong that in these hospitals the highest salary and most responsibility should go to the medical superintendent “thus driving clinicians of good standing into administrative posts as the only avenue of promotion.”
The mal-distribution of specialists is largely an economic problem, for men of high skill usually demand only that they should have a reasonable but secure monetary reward so long as they have the opportunity, assistance and equipment to serve the sick to the maximum of their powers. It is no wish of such men that there should be areas in which no recognised specialists practise. Some of the Hospital Surveys have revealed astonishing gaps which affect every social class in these areas.
The new Health Bill does not lay down standards either for distribution or recognition of specialists, but these will be indicated to the Hospital Boards who will be required to employ a sufficient number of all kinds of specialists within their region and to arrange .their work economically so that everyone will be able to get the highest quality of care. Special provisions have been indicated as to .the way in which specialists’ appointments are to be made so as to ensure that the words “specialist and consultant” have more meaning than they sometimes have had in the past.
Each Regional Board and Board of Governors is required to -advertise vacancies and ” to institute an expert advisory appointments -committee.” It will be this committee which will “draw up & list, from among the applicants, of those suitable by qualification and experience for the vacancy,” although it will be the Board which finally makes the choice.
One point on which the Minister has insisted in the Bill, although the Labour Party has in the past opposed it, is designed to ensure that at the outset most existing specialists come into the service, namely, the concession that consultants can be in the service yet continue to see patients privately in national hospitals for extra fees. The part-time consultant can of course see, treat and charge anyone outside the service. The concession to which we refer is that the Minister may ” provide separate pay-bed rooms or blocks for which people can pay the whole cost privately and in which part-time specialists within the service can treat private patients.” The patient in such a case will pay his own fee to the specialist but the Minister can fix a maximum charge beyond which no one is allowed to go—as is the case in many ” pay-wings ” in voluntary hospitals to-day.
This concession is, of course, subject to two overriding considerations. In the final plan the Minister has to decide for every hospital whether it is” reasonable to provide such private accommodation. In a region which has only a very small proportion of the beds it needs—one area surveyed has only one-third of its requirements— the Minister will almost certainly be advised by the Regional Board that it would not be “reasonable ” to set aside beds for those who could afford to pay extravagantly.
The second overriding consideration is that such private accommodation as is provided can only be used for private cases when there are no public patients requiring the beds. This is a most important point and one the public must watch; for to have any person on a waiting list for a bed while those who could afford to pay extra could obtain bed, nurses and doctors would be to wreck the whole scheme. The life and health of the public patient, that is, of the general mass, some 95 per cent, of the people who cannot afford to be snobbish, and have no wish to be pampered, cannot be risked because of the financial standing of the remaining few.
The question of how much specialists are to be paid is one on. which up to the moment there is complete silence from all quarters.. There are many schools of thought as to the relative income that a G.P. and a specialist should receive ; and in the transitional stage a differentiation may be made which would not be justifiable or necessary in a fully socialised service. It costs more to-day to become a specialist than to become a family doctor, and even although the ultimate income is higher the delay in reaching peak earnings is considerable.
The Minister can of course, “make regulations governing the qualifications, conditions of service and remuneration” of specialists as of all health workers. Such regulations can, naturally, be made only after consultations with any appropriate organisations representing the staffs concerned. In deciding on the remuneration of specialists the Minister will have to reconcile the salaries paid to-day by municipal hospitals— usually not the highest —with the incomes that are sometimes earned in Harley Street. He could, of course,, refer to the Minority Report in the Spens Report, where Sir Ernest Fass suggests that the general practitioners might be paid a scale similar to that of Middlesex County Council for whole-time hospital officers including those of specialist rank. There is much to be said for a single scale to cover all doctors in the national service, and the. figures of Sir Ernest Fass are therefore worth quoting :—
| Net Earnings | Percentage of Profession |
|---|---|
| £500 – £700 – 3 years then to £1200 | 50 |
| £1200 – £1800 | 30 |
| £180 0- £2200 | 12.5 |
| £2200 – £2500 | 5 |
| £2500 – £3000 | 2.5 |
In some way a decision has to be reached as to the value of the specialist to the community and the relation that should exist between his income and those of other health workers. It will be found that so long as “basic salary” or other device gives a satisfactory income at an early date and the service yields a career satisfying professional standards, then there will be no demand for very high and disproportionate incomes.