Future of Medical Practice July 1942

A PERSONAL VIEW

BY SOMERVILLE HASTINGS, M.S., F.R.C.S.

Surgeon, Ear and Throat Department, Middlesex Hospital, London . Chairman, Hospital and Medical Services Committee, London County Council

Notes of a lecture given to the Leicester branch of the Socialist Medical Association on July 31, 1942.

Future of Medical Practice

In the intervals of war work it is, I think, permissible to plan for the future. I would go further, and say that it was essential, for if we are as little prepared for peace as we were for war, we shall deserve all we get, though we may not like it.

Within the last few months two medical organisations have issued reports of their planning committees. The interim report of the B.M.A. Planning Commission contains some very useful suggestions, but it does not go very far, and, perhaps worst of all, perpetuates the principle by which the doctor’s income is dependent on the impression he makes upon those he treats in sickness. The Medical Practitioners’ Union draft memorandum on “The transition to a State Medical Service” goes further, but has also serious disadvantages.

In considering what advantages would accrue from the introduction of a Socialised Medical Service, it may be useful to enquire what is wrong with our health services to-day and how these evils would be put right under such a service. The present day defects arise, I think, from four main causes, which may be usefully considered seriatim: (1) the lack of planning and organisation; (2) the isolation of the individual doctor; (3) the scant consideration for the prevention of disease; and (4) the financial dependence of the doctor upon his patient.

I. Lack of Planning and Organisation

Much money is being spent and much energy expended upon the treatment of disease by public and private agencies. Most of these services arose irregularly and without plan, usually as the result of popular clamour. Moreover, they have little or no organic relation to one another. A quarter of a century ago it was pointed out that many children were so defective physically that they could not take advantage of the education that was provided for them, and school inspection and treatment were instituted. The high infantile and maternal mortality rate were responsible for the maternity and child welfare clinics. The public conscience was aroused by the high death rate from tuberculosis and a scheme for the treatment of this disease appeared. During the last war the wastage of man-power as a result of V.D. became evident, and clinics for this affection were instituted. Within the last few years the public conscience has again been aroused by the many gaps in the treatment available for cancer, and the Cancer Act has been placed on the Statute Book. But there are other affections that are just as serious and equally amenable to treatment, and just as strong a case can be put up for the provision of treatment for rheumatism and fractures by public authorities as for that of any of the diseases just mentioned. What the State has done is to provide a series of watertight compartments for the treatment’ of certain diseases, and this has been arranged for the most part without any co-operation with the general practitioner, who must inevitably first see the cases. Excellent as these facilities may be, something more is obviously required, and no scheme can be complete unless it includes the general practitioner, on whom must always depend the early and correct diagnosis of any case as well as its direction to the appropriate scheme for treatment.

In connection with hospital treatment, the same lack of planning and inco-ordination is to be seen. It is said that there are two hospital systems—the municipal and the voluntary— treating for the most part the same type of cases, and more or less in competition with one another. In point of fact, the matter would be much simpler if this were correct, since in reality there are some hundreds of hospital systems. Many of the municipal hospital areas are much too small to provide a thoroughly efficient service, and though there are working agreements between some of these the co-operation is rarely close. Nearly every voluntary hospital works as an isolated unit, for the most part treating any cases that come its way regardless of whether it has the necessary staff or equipment to provide the best possible service for the patient.

An extreme, but by no means unique, example of this incoordination is found in the facilities available for the mothers of London, in which a maternity case may be dealt with by a L.C.C. midwife or in the wards of a L.C.C. General Hospital ; by a Borough Council midwife or in the wards of a Borough Council maternity hospital (only in some boroughs); in the maternity ward of a Voluntary General Hospital; or by a midwife attached to that hospital; by a Maternity Charity (either in hospital or by midwife); by a midwife in private practice or by a private doctor, who may be doing much midwifery in a busy practice, or be attending but two or three maternity cases a year.

The first necessity, then, for an efficient health service is unification of all the existing agencies under a real Ministry of Health, which would be concerned exclusively with health matters, but would deal with them in every department of State. This reconstituted Ministry of Health would, of course, have the duty of enforcing upon local authorities the decisions of Parliament, but for efficient health administration the local authorities must themselves be large—much larger, in fact, than most of those that exist at present. The country might be divided up into a dozen or more areas of administration, each to consist of one or more counties with included county boroughs. It would be best for each of these areas to be controlled by a popularly elected body which would deal not only with health but other local government activities as well. On the health committee there should be room for the co-option of doctors and others who have made a study of health problems or had experience of health administration. The final decision on all questions must, however, be made by the consumer, that is by the elected representatives of the people, who must consequently be in a majority on all the main committees. Some experience of health administration has convinced me that there are many intelligent lay men and women who have a much greater insight into health questions than many doctors would give them credit for.

2.Isolation of the Doctor

If we speak truly we must regretfully admit that some of the medical work carried out to-day is not of the best. If we make careful enquiries as to the reasons for this we shall find that there is usually one of two explanations. Some work is bad because it is hurried, and other work is not of the best because it is undertaken where there are insufficient facilities or where the individual concerned has not had the necessary training and experience. Both, on careful analysis, are seen to be most often the result of isolation. The doctor working from a health centre as part of a team would only be hurried in the case of a severe epidemic. The doctor in a cottage hospital who undertakes an operation for which he has neither the skill nor the equipment available would be much less inclined to do this if machinery existed for the easy transference of his patient to another hospital where everything necessary was readily at hand.

It is all too easy for the doctor working alone in private or panel practice to acquire an entirely erroneous idea of his own ability and importance. By his industry and self-sacrifice he has won the affection and respect of his patients, who regard his word as law. But even those who are unable to look upon him in this extremely favourable light may regard it as desirable in their own interest to accept this outlook, for it is universally thought to be a dangerous thing to offend one’s doctor, and especially is this so in country districts where there may be, to all intents and purposes, no second choice. It is all too easy, therefore, for a doctor working alone or with only a junior partner or assistant to regard himself as well-nigh infallible.

On the other hand it is useful to remember that the average doctor possesses in a marked degree the “herd instinct.” He really likes to meet his colleagues, and if he takes a genuine interest in his work, as nearly all doctors do, he is certain to discuss his cases at such a meeting. Doctors tend to talk “shop” perhaps more than the members of any other profession, to the advantage of all concerned, and most of all, perhaps, of their patients. The doctor who constantly comes into close contact with other doctors in a hospital or health centre cannot possibly regard himself as omniscient. He soon discovers that there is something of value to be learned from every one of his colleagues, that two heads are very often better than one, and that a specialist who knows his job can be of real assistance in both diagnosis and treatment.

The general practitioners of the future will accordingly work from health centres. In urban areas eight or ten doctors will be working together, but in rural areas perhaps only two or three. Each doctor will be in charge of the health of perhaps 2,000 people. There is no reason why a person coming into the district should not be able to choose his doctor from those whose lists are not already full, and if unable to obtain his first choice at once his name could go down on the waiting list of the doctor he prefers. I suspect, however, that when a vacancy occurs and a change of doctor becomes possible, but few will wish to take advantage of it. What, however, is essential, is that both doctor and patient should have an opportunity of changing if they do not find in practice that they get on well together, and this should prove an easy matter, for it must be rare for any patient to have a rooted objection to all the doctors of a health centre. In the centre the records of patients will be kept, clerical assistance will be provided, and the other preventive and curative services will be organised and made available.

Although, as previously stated, I feel that it is important that the Administrative Region for the health services should be a large one, I believe that it is desirable for practical working to sub-divide the region into divisions of such a size that all the doctors in each, both general practitioners and specialists, should know each other and get used to working together. The ideal unit or division might have a population of about 100,000, and the simplest unit to consider is a small country town with the surrounding country district. This would need a hospital of about 1,000 beds, near the traffic centre, for almost every type of case, and the specialists attached to this hospital would also be available to see patients in consultation with the general practitioners or home doctors at the health centres or in their homes. It will probably be convenient to have the main health centre (divisional) in close association with the divisional hospital, and here perhaps most of the cases referred by the home doctors will be seen by the specialists. There will also be local health centres in both urban and rural districts.

Another misfortune resulting from the isolation of the doctor is that under present conditions his work makes it very difficult for him to have any spare time or private life. Most general practitioners have but little time for holidays, reading, postgraduate study, or research. Doctors working from the health centres as part of a socialised medical service would have definite times of duty for dealing with casualties and urgent cases. When a patient already under the care of a doctor suddenly requires his assistance during his off duty time the decision should rest with him whether he goes to the patient himself or gets his colleague who is on duty to go in his place. The work of a doctor will be made more interesting and less laborious by his having clerical assistants at the health centre who keep the records of his cases and make appointments for him. It should be possible also for home doctors who are interested in any branch of medicine to become clinical assistants at hospital and take up the specialty of their choice.

3. Scant Consideration for Prevention

As things are to-day, both doctor and hospital treat only declared disease when the symptoms are sufficiently severe to cause inconvenience to the patient or interfere with his working capacity. It is not the doctor’s business to prevent disease or to keep his patient well, and as a student he gets but little training in this direction. He is not concerned with seeking out the causes of disease and trying to remove them, nor is he in close touch with the environmental services which are mainly concerned with the prevention of disease. It should be the doctor’s business to do his best to find out why his patient is ill and remove the cause, and he should make every illness an excuse for a dissertation upon the laws of health, which will be the more appreciated and remembered because it has an obvious practical application.

It should further be the business of the doctor to encourage persons of all ages who are on his list to come for periodical medical examinations. The experience of the Peckham Health Centre seems to indicate that there may be something wrong physically or psychologically with nearly 90 per cent, of ordinary people who regard themselves as in fair average health. Periodical medical examinations on an extensive scale will open up a new branch of the healing art—the recognition of the earliest beginnings of disease.

4. The Financial Dependence of the Doctor on his Patient

It would be best, I think, for all health services to be free to the individual and paid for through the rates and taxes, but I see no great objection to some of the cost being covered by some form of insurance. The essential thing is, of course, that there must be no question of direct and immediate payment which might cause delay in seeking medical advice. So often one has heard of cases in which a poor but honest family that has for some reason or other a rooted objection to recourse to the Poor Law Medical Service putting off calling in the doctor until treatment is of no avail, or much less successful than if carried out directly symptoms appeared.

From the doctor’s, point of view financial dependence means that all sorts of extraneous matters besides the best interests of the patient from the health point of view have to be considered. One of the best general practitioners I know once told me that he got greater satisfaction from the treatment of his panel patients than from any others. He said that if he did not visit frequently, his patients were apt to say that they supposed he was too busy with his wealthy clients to bother about them; if, on the other hand, his visits were more frequent people were all too ready to suggest that he was wishing to run up a bill. Certainly it is undesirable that the doctor’s income should depend entirely on the valuation of his services by his patients, as must happen in private and panel practice. Moreover, instead of working together as a team the struggle for patients results too often in jealousy and suspicion.

All doctors should be full-time workers in receipt of a salary. If their services were free, or covered by insurance during part of their time, while a fee had to be paid for consultation at another time, one cannot conceive how any patient would go to his doctor at any other time than the free time, unless, of course, he expected to get a better service for direct payment, which would obviously be contrary to the ethics of the medical profession, and should be impossible;

To get the best work out of the doctor he must be free from financial worry, and feel that if he works well he has nothing to fear from sickness or old age, and that his wife and family will be equally safe, and this can be best secured if the doctor becomes a full-time officer.

Another result of the financial dependence of the doctor on his patients is that the distribution of the doctors is such that where they are most needed fewest are to be found. A doctor does not desire to settle in a well-to-do district only because the fees are higher, but because the higher fees make it possible for him to give more time to his cases and do better work.

But perhaps the most iniquitous of the results of the financial dependence of the doctor upon his patients is the sale of practices. It is the tradition of the medical profession that a doctor must do his very best for each individual patient who is under his care, and I am convinced that this tradition is genuinely observed by 99 per cent, of the profession, within, of course, the limit of the conditions under which they have to work. But there must inevitably come a time for retirement, and the patient will say to his doctor: “What shall I do without you ? I do hope that the practitioner who is taking your place will be as clever as you are and as good and kind to me.” The doctor, if he speaks the truth, will reply: “I neither know nor care; all I can tell you about him is that he is the man who offered most for my practice.” The sale of practices makes it very difficult for the man without capital. He often has to buy a practice on borrowed money, and the payment of interest and sinking fund in his early years may not only cripple him severely, but also distract his attention from his most important duty to himself and his patients, i.e., the increase of his knowledge and skill as a doctor. Moreover, the moneylender generally takes power to sell the practice over the doctor’s head if for any reason the payments are not regularly maintained.