Medicine Today and Tomorrow June 1940
Problems of the Post War Practitioner
The manning of the National Health Insurance service is going to be a difficult problem after the war. There are two aspects of the problem— both having their roots in financial stringency; one is the definite possibility of a shortage of entrants to the medical profession; the other, the almost certain drastic forcing down of the monetary return from practice.
While it is true that the goodwill value of practices has slumped since the war began, there may be a terrific post-war boom unless an entirely different system is put into operation. There will be hundreds of doctors who after demobilisation will desire to enter general practice, but their prospects will be quite hopeless unless they have adequate capital. The majority will not have the cash or be able to secure the necessary financial backing either to purchase a practice or a share in a partnership, or to get through the often long period of waiting if they desire to establish a new practice. Furthermore, there will be little private practice because nobody will have any money to pay doctors bills.
Even assistantships may be at a premium, and as there is no fixed scale of salaries for assistants similar to the Askwith scale for medical officers of health the earnings of assistants may be forced to unprecedented low levels.
Equally serious for the future will be the student shortage. A period of intense retrenchment in the social services is a very definite possibility. Scholarships and educational grants may be reduced, and it is likely to become increasingly difficult for boys and girls from working-class homes to enter the medical profession. But that is not all; the profession is today largely recruited from the middle classes, but so great will be the post-war impoverishment that even this source of supply of future doctors may completely dry up.
More insistent than ever must be the demand that ability and not financial resources shall be the essential basis of entry to the profession and methods must be devised for ensuring that a sufficient number of recruits shall always be maintained. In my view a simple solution would be the establishment of a trust fund by the General Medical Council from which grants would be made.
The fund would be inaugurated by (1) a Government grant, (2) a gift by a philanthropist, and (3) requiring every practitioner on the Register to pay an annual licence fee. Dentists have to, so do solicitors, auctioneers, and valuers. The Dental Board, out of its income from licences, makes very large grants towards the education of students, and that is the reason why a considerable number of dental students, often very much poorer than medical students, is able to complete a course of study which is more expensive, I believe, than that contained in the medical curriculum. If every registered medical practitioner were obliged to pay an annual fee of £5 a sum of over a quarter of a million pounds would be raised every year— a sum sufficient to feed, clothe, and educate a thousand students.
Persons desiring to obtain a grant would have to pass an educational test and would have to furnish evidence of good character. The Selection Committee would have no knowledge of the financial resources of the candidate but would be guided solely by their ability and character. It would not be unreasonable for a means test to be applied, but the Grants Committee would be empowered to advance sums sufficient to cover not only the cost of medical education but also grants for complete maintenance during the whole period of study. Recipients might, however, be required to repay any sum advanced with interest over a period after qualifying. If this plan were adopted not only would a post-war difficulty be avoided but it would also bring about true democratisation of the profession.
Meanwhile, however, the plight of the profession immediately after the war must be considered. The present Emergency Medical Service, despite its serious shortcomings, might very well constitute the basis of a permanent co-ordinated National Hospital Service in the immediate post-war period, and it is my belief that the hospitals and special services ,(e.g. the midwifery service), after further re-adjustments and improvements in co-ordination and unification have been made, should not present any serious problems in the future. On the other hand, although the provision of an adequate domiciliary service has been widely discussed, no organisation, in my view, has put forward a completely satisfactory solution.
Four problems invariably come to the forefront whenever a complete domiciliary service is considered:—
- Existing vested interests in general practice;
- “Free choice” of doctor;
- Whether the doctors engaged in domiciliary work should be employed on a full-time or part-time basis, and how they should be paid;
- How the service should be administered.
The last is, of course, a problem common to all branches of the hospitals and medical services.
Let us deal first with the vested interests question. Specialist practices—except in dentistry, ophthalmology, and radiology—have generally no goodwill value, whereas in the case of general practices the goodwill value is considerable and, in fact, may represent a large proportion of the doctor’s total resources. This goodwill value varies considerably with the locality, the class of practice, and whether it is a partnership or death vacancy. The establishment of National Health Insurance substantially increased the goodwill value of a practice, and if N.H.I, were extended to those with higher incomes and to dependents (without reorganisation of the service) the goodwill value would increase still farther because of the greater security offered. Inflation of values due to social legislation—whether it be the value of land, property, or goodwill—is most undesirable.
Another unsatisfactory feature of national health insurance practice from the point of view of the well-being of the public is the fact that any registered practitioner, unless specifically barred by the Minister of Health, may acquire a Panel practice. No special qualification or experience, or even proved ability, are necessary, and a practitioner on. the day he registers may become the principal of a Panel practice with a maximum list. There is only one qualification required for becoming a principal,and that is to have the cash or financial guarantees to acquire a practice or to start a new one.
In a purely private practice this does not matter a great deal because the patients have their own remedy. But though insured persons may transfer to the list of another doctor within a specified period of the sale of a practice, it has been found that fewer than 10 per cent, on an average do so.
Third parties in the form of finance companies are interested in a very considerable number of Panel practices. These companies take an assignment of the Panel cheque as part of their security, and as they have a legal right of foreclosure they are in a position to force a good and popular practitioner who is in financial difficulties to sell out to another whose ability may be of a very low standard. Later in this article I shall suggest a way in which this financial millstone can be removed. I am quite convinced that if this great evil of private vested interests in practices remains unchecked, or if no alternative is provided, it is possible the public will suffer because a large number of doctors, although willing and able to work, will be unemployed because of their poverty.
The next problem— and it is a real bugbear— is what is known as free or open choice. This is one of the first and cardinal points of B.M.A. policy, but it is open to severe criticism. It has been ironically pointed out that in a country practice there is only one person who has free choice of doctor, and that is the doctor’s widow when she is disposing of the practice. Also one may add that it is not free choice of doctor but rather free choice of patient which occurs when a practice is placed on the market. The argument is often advanced that when a patient goes to hospital there is no free choice of doctor there, but actually this is not so conclusive because the relationship between the specialist and patient is of a temporary, character, whereas that between the general practitioner and his patient is permanent and much more personal. In the legal world the same position exists. A person may have a solicitor upon whom he relies for advice on a wide variety of business, but the relationship between the client and the barrister is temporary and indirect, the barrister being chosen by the solicitor for some special branch of Law.
Incidentally, while we are discussing the question of “free choice” I think it is necessary to emphasise the need of retaining as far as possible the right of the general practitioner in a complete service to select the specialist or the hospital to which he may send a patient. I think that it would be an error to adhere too rigidly to any proposal that a general practitioner should be strictly attached to one hospital centre.
I feel that too much attention has been devoted to Free Choice and too little to the real essential, which is—”continuity of service.” By continuity I mean that a person should be under the care of his home doctor for all ordinary purposes. Often in a Panel practice a principal’ will “farm out” some of his patients to an assistant, and it is one of the failings of the existing hospital arrangements that a patient may be obliged to see a different doctor in the same out-patient clinic each time he attends. By ensuring “continuity” a great deal of follow-up routine treatment can be carried out by the home doctor, and this will ensure that the hospitals and special clinics become essentially consultative centres.
There is another matter that arises at this point which is worth considering, and that is whether the general practitioner should himself undertake complete and detailed investigation and have in his consulting room all the special apparatus for this purpose. Personally I think that not only is this unnecessary but extremely inadvisable, for it is the specialist’s job to carry out the. special investigations and utilise the special apparatus necessary for these investigations and in my view an appalling amount of bad work would result if the general practitioner undertook this responsibility. Nevertheless, nobody will deny the right of the general practitioner to graduate to a speciality if he has the ability and experience, and every encouragement and assistance should be given him to do so.
The next problem is whether there should be a full-time or part-time domiciliary service and how those employed on a full-time basis, can be equitably rewarded. This is a matter which in my view has not yet been adequately considered. Full-time or part-time employment depends entirely on whether the service is to be available to all or whether there is still to be an income limit.. If the former policy is adopted a full-time service is inevitable, but if there are still some persons outside the scope of the scheme more elasticity will be required and the service would likely to be both full-time and part-time because, in certain districts mixed practices would continue.
My suggestion for full-time service is that payment should be fixed on a minimum salary and capitation basis. The salary would be arranged according to the locality. Each doctor appointed to the service would receive a salary of (say) £400 in an urban area and up to £800 in a scattered rural area. In addition there would be allowances for travelling, surgery accommodation, etc. Regular holidays and off-duty times, and special leave for study or for attendance at hospitals and: clinics would be provided. The fixed salary would cover attendance to (say) a thousand persons on his list; above that number (up to a maximum of 3,000 in an urban area and 2,000 in a rural area) remuneration would be based on a capitation rate similar to that in the N.H.I, scheme. A deduction would be made towards pensions. All those engaged in Panel practice would be given the option of accepting, the new terms of service.
Panel practices would no longer be marketable. Where a practitioner did not accept the new terms his practice (or the insurance part of it) would on his death or retirement be acquired by the State through arbitration and his successor would be appointed on a full-time basis. All appointments would be made by a local Medical Committee, which would also arrange a rota of practitioners for emergency and night calls, for Sunday and other off-duty periods. No doctor would be appointed to take charge of a practice until he had served for at least six months as a probationer on a fixed salary. The probationer, unlike the present assistant, would be under the direction of the Medical Committee. He would act as relief and give assistance during practitioners’ off-duty times, illness, and holidays. After serving his probation he would be eligible to apply for a permanent appointment in control of a practice.
One or two points have to be considered further:—
- What is to be the position of the practitioner who may not have a list sufficiently large to entitle him to the basic salary?— Until his list reaches the number when the capitation fee commences to operate he will be required to perform additional duties such as holiday relief for another practitioner with a larger list.
- How are the pensions to be assessed?—They should, in my opinion, be arranged on the same basis as those already in operation in the Local Government service; but in assessing the pension an average should be taken of the earnings of the practitioner during a fixed period prior to retirement. In the case of older practitioners the pension should be assessed on their average incomes over a period of ten years, with a fixed maximum.
- Can any compensation be paid if there is a reduction of income through the practitioner accepting the new terms of service?— It would be a fair basis if the compensation paid equalled twice the difference between his new income and his average net income from his practice returned for income tax purposes. Thus, if his income had dropped from £1,250 to £1,000, the amount payable to him in compensation would be £500.
- Would the acceptance of private fees be permitted?—No, not if the practitioner had accepted the new terms of service. Any fees paid to him would have to be transferred by him to the controlling authority, as is the position now in the Local Government hospital services.
Taking everything into consideration, I consider that the method of remuneration that I have outlined is the most equitable one. It must be remembered that a domiciliary medical service is quite unlike a hospital service, because in the hospital the medical staff can be graded in seniority and be paid accordingly. The only fair method of remuneration in general practice is for work done.
I now come to the problem of how the new service should be controlled and administered. In schemes published hitherto there appeared to be unanimity that the local authorities should be the supervising bodies, but personally I think that not only would it be a grave mistake for local authorities to be given any direct control of the domiciliary service, but that these authorities should be deprived of their present functions of control of hospitals and medical services.
All the services should essentially be “national.” One of the great advantages of the present National Health Insurance scheme is that, as its name implies, it is national. Wherever an insured person moves to his medical records follow him, and wherever a Panel doctor practises there is the same uniformity in such things as the Pharmacopoeia (known as the National Formulary) and there is little variation in remuneration and certificates. The Minister of Health appears to exercise far greater control over the N.H.I, service than over any of the other services under his jurisdiction. On the other hand, there is enormous disparity in the standard of efficiency of the local government health services. In the general and special municipal hospitals and in the tubercular, infant welfare, maternity and school medical services local autonomy has literally run riot. The Minister exercises very little control, and the efficiency varies with the political complexion of the authority and with the enthusiasm and personality of the medical officer of health.
I can speak from personal experience on this matter because for nearly ten years I have been a member of a local authority. In the hospitals those who are actually engaged in the work have little or no voice in their management and, except for the lower grades represented on the Joint Industrial Council, have no means of putting forward proposals for improving the service. Furthermore there is far too much lay control over senior staff appointments. This compares very unfavourably with the system now operating in the majority of the voluntary hospitals whereby the medical committees have complete control over matters affecting medical staff appointments and the clinical work of the hospitals. In the local administration of the medical benefits of the National Health service the Insurance Committees are the. bodies responsible. Every interested party, including the local authority, is represented on the committee; no single group can dominate, it. All the doctors and pharmacists engaged in National Health Insurance work have not only direct representation on the Insurance Committees but also have their own committees— the local Medical and Panel Committees and the Pharmaceutical Committees— which have certain important autonomous powers.
What appears to me to be essential for a complete, unified, and co-ordinated national medical service is that in all its branches, whether it be hospitals or special medical services like the domiciliary service, those engaged in the service shall enjoy a large share in its control. The medical profession has shown that it can control and manage its own affairs through the General Medical Council; the Panel Committees and the medical committees of the voluntary hospitals have demonstrated the value of entrusting considerable administrative responsibility to those actually engaged in the clinical work, either in the hospital or in the patient’s home.
I have deliberately raised many points which are controversial but which must be carefully considered before any completely satisfactory domiciliary medical service can be put into operation. In my view the essential requirements are that:—
- The service must be a national one, and not placed under the local authorities;
- The doctors engaged in the service must be given very considerable responsibility in its administration and control;
- Private financial resources shall not be necessary for any doctor entering the service, and the buying and selling of practices shall cease;
- A probationary period will have to be served on entry;
- Those employed full time in the service shall be paid on the basis of a variable basic salary plus capitation, and they shall have ample off-duty time, study leave, facilities for graduating to a .speciality, and full pension rights;
- There shall be continuity in the relationship between doctor and patient, and as far as possible those now engaged in National Health Insurance practice shall when entering the service retain on their lists their existing Panel patients and their dependents.