Memorandum on a Domiciliary Medical Service

Dr Charles Wortham Brook


Having been engaged for a long period in general practice, originally from personal choice, and having, as a member of a local authority learned to appreciate the viewpoint of the permanent official, I can perhaps claim to enjoy the advantage of being able to consider the problem of the future Domiciliary Medical Service with some ability to recognise certain difficulties which may not be generally appreciated.

My belief in the need of a full-time salaried service has in no way diminished, but I think that this may take a little longer to achieve than I at any rate originally contemplated, mainly because of certain prejudices, held, not merely by doctors, but also by the general public. The arguments advanced on behalf of “free choice” are easy to dispose of in a debate or discussion, although I must confess that 1 am myself extremely partial to a particular dentist. He knows my reactions to his drill and he knows what to talk about in order to keep me properly relaxed and in a reasonable state of mind when I am in his chair. I recognise that the B.M.A. can exploit “free choice” because the general public is still very gullible and can be easily frightened at the thought that a strange and unwanted doctor may be sent to their homes. Furthermore, it must be appreciated that the B.M.A. is in a stronger position than it was in 1911, for whereas in 1911 the Association’s leaders opposed the establishment of the Panel, it now seemingly agrees that this service should be extended to about 90% of the population. But the B.M.A. in its opposition to a salaried service can still whip up hostility to such a service not only among the older members of the profession who are conservative in outlook, but also among some of the younger doctors who are now in the Services and who imagine that employment on a full-time basis will perpetuate the restrictions which they are now experiencing.

To me it is strange that the B.M.A. has not laid more emphasis on the fact that it might be very difficult to have a sufficiency of doctors to man a complete full-time service, and that this deficiency may take some time to meet. But it is even stranger that the B.M.A. has not so far played what is really a very strong card. This is that while the cost of an extended panel service can be easily computed, the cost of a full-time domiciliary service with a complete chain of Health Centres is not so easy to determine, and it seems possible to envisage the attitude of the Treasury, which having to meet heavy demands for expansion by other social services and at the same time encounter a clamour for economy, might show a decided preference for a cheaper scheme of known cost to a better but more expensive scheme, the cost of which might be difficult to determine.

Then there is a psychological and ethnological problem, which as far as I know, has never been taken into consideration.

My friend, Dr. David Stark Murray, has written some excellent books on the subject of the medical services of the future. The scheme that he outlines is perfect and fool-proof to criticism, except for one important fact and that is that Dr. Murray is himself an extremely efficient, methodical and tidy-minded Scot, and he seems to presume that every other doctor has similar characteristics. Unfortunately this is not the case. Scotsmen are fine teamsters and this is undoubtedly the reason why they occupy so many posts in the Public Health Service. I venture to suggest that at least 90% of Scotsmen would fit into a State Medical Service and would make a complete success of their jobs.

But it must not be overlooked that a considerable number of general practitioners in this country are Eireans, for doctors and nurses are among the principal exports of Eire. While of course there are exceptions, it is not usual to find that doctors from Eire are good team workers, but they have succeeded as general practitioners, especially in working-class districts. The secrets of their success is that they have a pleasant genial and affable manner—a qualification which if not scientific has at least some psychological value. Although their professional work and their personal behaviour are at times erratic, their moral code is high and because of this they are successful as family doctors. I have no statistics of disciplinary cases heard by the General Medical Council but I think that I am correct in stating that while many Eireans have been charged with insobriety, it is very seldom that they are proceeded against for adultery with their patients or for performing illegal operations.

Welsh general practitioners are temperamental but very adaptable, and there is no doubt that the majority of those working in industrial areas would be very willing to accept full-time service. A doctor who has practised in South Wales knows the meaning of an industrial depression and of course it follows that he would prefer a secure income.

In England the best G.P’s are generally to be found in the provinces, and the worst in London, where the medical population is cosmopolitan and competition is keen.

Country G.P’s are a fine body of men and they fill me with wonder and admiration. A long journey in the middle of the night through a snow drift to an isolated cottage, there to make a decision without any chance of a second opinion being obtained is an experience beyond the comprehension of the average doctor practising in an urban area. The majority of country doctors are country bred and have a special vocation for their job. They deserve special consideration in any future planning.

Arising from these observations it would appear perfectly simple to establish at once a full-time service in Scotland and Wales, because of the willingness of the majority of Scottish and Welsh G.P.s to co­operate, and this is shown by the result of local polls held in the industrial areas of these two countries.

If the B.M.A. persists in being obstreperous, then in my opinion it should, for the time being, be allowed to stew in its own juice. If the Panel is extended to cover the whole population it will not be very long before many G.P.s will begin to feel the pinch. Country doctors practising in sparsely populated areas, e.g., the Lake District or Dartmoor, will find that their panel cheques, which may be their only source of’ income, will be quite inadequate. Pitiful stories will appear in the medical press of their struggles and of their dire plight and poverty, and then will follow demands that there should be state subsidies or that they should become salaried officers. When doctors now in the Services return to their practices and to their imaginary freedom, they may find it quite impossible to meet their commitments. They too will soon demand to be taken over by the State. It is my convinced opinion that the more progressive leaders of the B.M.A. know that an extended Panel is but a temporary expedient.

I agree that there is probably an inadequate number of doctors to man a full-time Service but during the next ten years it should be possible to make up this deficiency, not only by wider recruitment to the medical profession, but also by “dilution” for there is much work that is to-day regarded as the sole perquisite of the profession, but which could be done quite as efficiently by others. I have the most healthy respect for the efficient Health Visitor and District Nurse, and those who have held responsible posts in Infectious Diseases hospitals are of tremendous help to the busy G.P. during an epidemic.

Whatever decision may be taken as to the form of the future Domiciliary Service, it appears to be very essential that there should be a very considerable number of full time District Medical Officers or Referees, in order to ensure public accountability when public funds and concessions are involved. There is far too much loose medical certification, but for this the medical profession is not entirely blameworthy. Doctors with well-to-do patients are literally subjected to a process of continuous blackmail. Proper refusal to issue a certificate may mean the loss of a rich and influential patient. Many people have acquired the habit of dictating to their doctors the form of the certificate they desire to receive. It was therefore with interest and pleasure that I found that when I raised this matter at a recent meeting of my own B.M.A.. Division, there was complete unanimity that this abuse should be stopped, and there was special support from older practitioners, who, although conservative in outlook and unwilling to accept the principle of a unified full-time service, have a high ethical code and believe that a doctor owes a duty, not only to his individual patient, but also to the community. It was, however, pointed out that the General Medical Council has the necessary powers to deal with loose and improper certification, but in actual practice the G.M.C. does little beyond circularising “Warning Notices,” because these cases are very difficult to prove and a patient who has provoked such an offence and has thereby obtained a favour is unlikely to bring his doctor to justice. It is of course much better to prevent crimes and remove the temptation to commit them. That is why it appears to be so necessary to appoint a considerable number of full-time District Medical Officers, who would not only act as official referees, but who should also supervise the work of all publicity-paid general practitioners in their district. This step would certainly not lead to a deterioration of the doctor-patient re­lationship, but would improve it.

Another   branch   of   full-time   service   which   could  be   inaugurated with no difficulty is an Emergency Domiciliary Medical Service.    I have already  prepared   a   Memorandum   on  the   need  for   such   a   service   in war-time.     I   really   don’t   know  why  the   scheme   was   rejected,  except that it might have been through the influence of the B.M.A. which no doubt realised that it would be a success but suspected that it might be a potential thin end of the  wedge of a complete  full-time  domiciliary service.    If an E.D.M.S. had been established, it would, I am confident, have gone far to solve the problem of providing a sufficiency of general practitioners   for   the   civilian   population   in   war-time,  for   in  a  real emergency if the  acutely ill  can be adequately cared for, the  chronics can be left to look after themselves.  I suggest that this Service could and  should  be  operated  in  peace-time  and be  staffed on  a  full-time basis  by newly-qualified  practitioners  still  attached  to hospitals.    This would ensure that every new entrant to the medical profession, whatever his or her future career might be, would acquire some knowledge and experience of seeing patients in their own homes— an experience which is unfortunately  denied  to  those  who  become  specialists  and  whose  professional lives will be spent in the hospital, laboratory or consulting room. The provision of an adequate number of Health Centres is not likely to be such a simple matter as many appear to imagine.    I disagree with those  who  are  of the  opinion that this  is  a matter  which  has  passed the experimental stage and I consider that some time must elapse before generally agreed  models can be  accepted.  Recently I  read  an  article dealing  with this  subject  and  I  came  across the  following paragraph. “the exterior view of the building itself will be largely composed of windows, much larger windows than are usual to-day except in some of  the   modern   school and  factory  buildings.  These   can be surrounded by stone, brick, concrete or one of a great variety of plastics and other materials.   Some will prefer a local stone or of warm red brick    .    .    .”

All very nice on paper and no doubt a useful guide to architects, but it is possible that when erected, this type of building might prove to be quite unsuitable. I still believe that at the outset, and particularly during the immediate post-war period when the building industry will be fully occupied, to make use of prefabricated structures, which can be easily extended.

The ideal siting of local Health Centres is, in my opinion, on ground adjacent to the principal Primary School of the district for this would lead to many economies and there could be close co-operation between the Ministries of Health aand Education in any future planning. I still adhere to my view that these local Health Centres should for a certain period be experimental and of such construction that they would be easily adaptable for any extensions or alterations that might be found necessary. The Kent Education Committee are fine builders and I understand that it is their practice to arrange for one section of a new school to be of temporary constructions that when subsequent needs are more accurately determined the permanent structure can be complete. This principal should be applied in the designing of Health Centres.

My one fear is that Health Centres might during periods of epidemics easily become “Infection Centres,” for it is not difficult to envisage that in a large building cross-infections may become the principal problem and may even destroy the whole object of the scheme. It therefore seems necessary to emphasise that sick children should not be seen in the same part of the Health Centre as is used for an Infant Welfare Clinic, and that the greatest care should be taken to segregate the sick from the healthy, but this does appear to have been generally overlooked by those who have written about the “Modern Health Centre.”

The equipping of local Health Centres is another point upon which there is a divergence of opinion, but in my view this should not present any serious difficulties. Special equipment requires the supervision of technical experts and a hospital is the proper place for specialised investigations. Should the Tuberculosis Dispensary (or Chest Clinic) be attached to the Hospital or the Health Centre? To what extent should Health Centres be used as “Follow-up Clinics”? Should an electro-therapeutic department be attached to a Health Centre? What facilities for pathological investigations should be provided at a Health Centre? These are a few questions that remain to be answered, and until they are I cannot see that the claim that Health Centres have now passed the experimental stage, is in any way correct. While I do not under­estimate the very great importance of Health Centres, I regard the provision of efficient, rapid and free transport between the patient’s home and the hospital as a more pressing necessity. Suitable sites for all the required Health Centres have still to be selected, designs have still to be drafted preparatory to the buildings being erected, but there is already in existence a magnificent Auxiliary Ambulance Service with. a fully trained personnel. This could be very easily, on the cessation of hostilities, be transformed into aNational Ambulance Service, and it would provide permanent employment for a very large number of skilled and fully trained workers.

Domiciliary Medical Service

It is surprising that so many people who have been elaborating ideas about the future medical services, overlook the essential function of the Domiciliary section of the service. As its name implies it is essentially a Home Service, but many appear to think that it should be a Health Centre Service. It is a fact that even moderately well-to-do patients seldom visit their doctor, but expect to be visited at their homes. But this practice is not carried out in working-class districts, for in the case of a private patient a surgery consultation is cheaper than a home visit, while it has always been the custom for panel patients to call at the doctor’s surgery unless they are too ill to do so. This is encouraged by Insurance Committees, for on the back of each insured person’s Medical Card there is the following notice:

” He shall, whenever his condition permits, attend at the surgery or place   of   residence   of   the   practitioner,   attending   him   on   such days and at such hours as may be appointed by the practitioner.”

The   statement   “whenever   his   condition   permits”   is   subject   to  wide interpretation, but the tendency has been for insured persons to make every  possible  effort  to  get  to  the  doctor’s  surgery,  although  in  very many instances it would be better for them to remain at home and ask for a visit. Under existing arrangements, a change in policy, although very desirable, is scarcely practicable, because it would mean that a doctor with a very large panel would never be able to cope with the work. This is, incidentally, a serious condemnation of the present system. I of course agree that the Home Doctor would require a consulting room and this should be at a Health Centre, where also all the patients records would be kept. Patients who are convalescent and those suffering from non-infectious minor ailments could, with greater convenience to the doctor, be seen at the Health Centre, and also those patients who desire to discuss confidential matters not in the hearing of other persons. But the fact remains that at the present time too many people suffering from infectious complaints like the Common Cold or Influenza do frequent the over-crowded surgeries and this kind of thing must be discouraged and prevented when Health Centres are established, for otherwise they will become “Infection Centres.”

In raising a number of points which have not received adequate consideration, I hope that the views which I have expressed are constructive in character, for I appreciate that some compromise may be inevitable. One of the main difficulties confronting Medical Planners is that a very considerable proportion of senior general practitioners are confirmed individualists. Although they grumble about their long hours, disturbed nights, irregular meals and harassed lives, they really love it all. As a doctor, now in the R.A.M.C., said to me the other day,” When I am demobilised, I want to get back into general practice where the great joy is that you are always waiting for the unexpected.” That’s not my idea of an ideal life but “chacun a son gout.”