Probably most people would have started this discussion with the family doctor, who is the first line of defence against disease for the great bulk of people. He is at one and the same time the least liked, best known and most criticised of all medical men. His life is arduous and, in industrial areas, often unremitting and without any great reward, professional or financial. Professionally it rarely reaches the level the doctor himself would wish and, for reasons entirely due to the system, seldom the level that might be attained. Financially it varies from a net income so low as hardly to put him in the “professional” class to figures which are high but represent numbers of patients more than quality of service.
The Bill now under discussion proposes to retain the general practitioner as “the family doctor,” it will consolidate and, on average, improve his financial position, and it will attempt by removing all questions of fees between doctor and patient to establish a relationship of mutual confidence between them. Furthermore, it attempts to provide conditions under which the doctor will be able to do even his best work better.
The new service guarantees to everyone without cost at the time of use “general health care by doctors and dentists whom the patient chooses. These personal practitioner services are. to be available both from new publicly-equipped Health Centres and also from the practitioners’ own surgeries.” The doctor will continue to make his visits in the homes of the patients on his list by request, and the greatest change in his professional life will be in seeing those patients not confined to bed at Health Centres.
The practitioner, as we say, will no longer collect fees from his patients (with a few exceptions, since private practice is not entirely abolished), but will be paid by a new method, receiving a basic salary plus an annual sum for each patient on his list (capitation fee). There will be a “ceiling” on the number of patients which a doctor may have on his list, but below that maximum figure the number will vary according to those who have “chosen” the doctor—he will be paid a fixed “capitation” fee for each.
The precise proportion of the total expected income that will be paid as basic salary has not yet been announced, nor has the capitation fee. The Government has before it a report on the subject, the Spens Report, or more correctly Report on Remuneration of General Practitioners (Cmd. 6810, H.M.S.O., 6d.), published in May, 1946. This does not deal with the precise method of payment but it suggests the range of income within which all doctors should fall. The report is based on information given by thousands of doctors as to their pre-war net incomes. The age group 40-49 years was taken as the basis and showed a distribution of net incomes as follows :—
| Net annual income | Proportion |
|---|---|
|
Under £700
|
20 per cent.
|
|
£700-£1,000
|
22-6 per cent.
|
|
£1,000-£1,300
|
21 per cent.
|
|
£1,300-£1,600
|
17-5 per cent
|
|
£1,600-£2,000
|
10 per cent.
|
|
Over £2,000
|
9 per cent
|
The gross incomes were considerably higher, as the practice expenses of a general practitioner are seldom less than 20 per cent, of the gross income and the great majority of doctors spend between 30 and 40 per cent, of their earnings on running their practices.
The Spens Committee discuss the figures which would, in their view, be appropriate in a new national service, and suggest that in whatever way the incomes are paid, whether by salary, capitation fee, or both, on gross incomes or on net incomes, the result for general practitioners should be that (at 1939 cost of living figures)
- 7 per cent, should receive under £700.
- 20 per cent. „ „ £700—£1,000.
- 24 per cent. „ „ £1,000-£1,300.
- 24 per cent. „ ,, £1,300-£1,600.
- 16 per cent. „ ,, £1,600-£2,000.
- 9 per cent. „ „ over £2,000.
If the addition for cost of living increase is 33 per cent,, this means that the net incomes of half the doctors should be above £1,600, and that the net incomes of half of them should range from £1,300 to £2,100.
If the Government act on this report the doctors will have no ground for complaint at their financial conditions. This century has seen a steady rise in the monetary reward of the family doctor. In 1911 it was reliably estimated that the average G.P. had a net income of £275-£350; National Health Insurance led to an. immediate increase; the 1939 figure was about £1,200; and the proposed figure would be higher still.
The idea of paying a basic salary has a number of purposes. “One is,” Mr. Aneurin Bevan told the House of Commons, “that a young doctor entering practice for the first time needs to be kept alive while he is building up his lists. The present system by which a young man gets a load of debt around his neck in order to practise is an altogether evil one.” Another is that, as the Spens Report recommends, the basic salary can be varied so that “additional remuneration is given in areas which prove so unattractive as not to draw an adequate supply of practitioners.” It can also be used as the method of payment for special responsibilities, for special duties and special qualifications.
The doctor will clearly draw the great bulk of his income from his public practice, and many have pressed for the recognition of this and for the complete removal of financial competition for patients from the service by the institution of a whole-time salaried service. Mr. Aneurin Bevan has, however, taken the view that “the medical profession is not ripe for it and I cannot dispense with the principle that the payment of a doctor must in some degree be a reward for zeal and therefore it is proposed that capitation should remain the main source from which a doctor will obtain his remuneration.”
In addition every doctor will be permitted to accept private fees from patients who seek his advice but are not on his list or on the list of any of his Health Centre partners. The amount of any such fees a doctor will receive is likely to be small, but as medical care is one in which “idiosyncrasies are prevalent” and as transfer from one doctor to another will be easy the tendency to pay privately should not persist.
These changes are all necessitated by the defects of present-day general practice. Outstanding defects are maldistribution leading to overworked doctors in the under-manned areas, lack of equipment and technical assistance, inability to keep completely up-to-date, absence of teamwork and all it means. Maldistribution of specialists has already been noted but it exists in general practice also. “In South Shields, before the war, there were 4,100 persons per doctor, in Bath 1,950; in Dartford nearly 2,000, and in Bromley 1,632; in Swindon 3,100 and in Hastings under 1,200. Such a distribution of general practitioners is most hurtful to the health of our people.”
All the other defects were best summarised by the Medical Planning Commission of the British Medical Association in a much-quoted message which says, “The days when a doctor armed only with his stethoscope and his drugs could offer a complete medical service are gone. He cannot now be all-sufficient. For efficient work he must have at his disposal modern facilities for diagnosis and treatment, and often these cannot be provided by a private individual or installed in a private surgery. There must be close collaboration amongst local general practitioners themselves, for their different interests and experience can be of value to each other there is general agreement that co-operation amongst individual general practitioners is essential to efficient practice the principle of the organisation of general practice on a group or co-operative basis is widely approved.”
Chief criticism of existing general practice comes from patients, both panel and fee-paying, who realise that crowded surgeries and waiting rooms are not conducive to accurate scientific diagnosis. There is a widespread impression that two standards of treatment are given.; and in addition “very many people who need a doctor’s attention, especially housewives and young people, are still debarred by poverty from going to him. Poverty makes a huge gap in the nation’s defences—a gap not even the most devoted and self sacrificing of doctors can fill by himself.”
Doctors themselves criticise the system because it deprives them of the one thing most needed in medicine — time. Time is necessary for full examination of individual patients and for the assimilation of new medical advances and contact with colleagues, especially those in hospital practice.
The family doctor also complains of his isolation. “The G.P., quite often, practises in loneliness, in intellectual isolation, and does not come into sufficiently intimate association with his fellow craftsmen and has not the stimulus of that association.” In addition the family doctor is expected to be on call every minute of the day and every day of the year. This is not only bad for the doctor but in the long run is bad for the patients as well.
To remove all these defects will take time, but the National Health Service Bill makes one big proposal which will open the way to better distribution, to co-operation and to better organisation generally. This is that the buying and selling of medical practices shall be abolished. Redistribution of doctors is impossible so long as the entry to practice is dependent on ability to pay for a particular kind of practice. As the Minister of Health puts it, “If we are to get the doctors where we need them we cannot possibly allow a new doctor to go in because he has bought somebody’s practice. Proper distribution kills by itself the sale and purchase of practices.”
This sale and purchase of practices is almost entirely confined to Great Britain, and to the general public has always appeared as an evil in itself. “It is tantamount to the sale and purchase of patients.” It has been condemned over and over again, and although the B.M.A. in 1946 want the system maintained, the Medical Planning Commission of the B.M.A. in 1942 recommended that ” the sale and purchase of practices by practitioners within the scheme should cease . . . and . . . they would be offered compensation for the loss of capital, in the form of guaranteed n on-contributory retirement and death pensions.”
The Bill accepts this view, put forward by the most representative medical body ever convened,, and couples the abolition of sale and purchase with the payment of compensation. The figures proposed have been accepted by the B.M.A. as satisfactory (if the scheme goes through) and it is certainly high enough. Before the war it was estimated that not more than £40 millions was invested in medical practices; the Government proposes to pay a maximum sum of £66 millions, which fully justifies the Minister’s suggestion that “everyone will admit that the doctors are being treated generously.”
The prohibition on the sale of practices applies only to those practices which are absorbed in the national service; and the compensation will be paid to those practitioners who enter the service or retire from practice on the day on which the new service begins.
The exact payment, and method of payment, “shall be left in the main to the profession itself, and the Minister will accept any reasonable proposals within the total sum. Normally compensation will be paid on the retirement or death of a doctor “unless a plea of hardship (e.g., outstanding debts) is made, and interest at 2 ¾ per cent, per annum will be added.
The entry of doctors to practice in the National Health Service, their proper distribution and other matters concerning general practice will be controlled by new central and local bodies. At the centre will be the Medical Practices Committee, composed mainly of doctors. Its main duty will be to decide if and when there are vacancies for general practitioners in the different areas.
The immediate control of general practice will be in the hands of local Executive Councils, of which there will be one for every local health authority area. The local Executive Council will draw half its members from the local authorities and half from doctors, dentists and pharmacists. Each Executive Council will be required “to make as respects their area arrangements with medical practitioners for the provision, whether at a health centre or otherwise, of personal medical services for all persons in the area who wish to take advantage of the arrangements.”
The Executive Councils will pay the family doctors according to national arrangements. They have also to arrange for dentists, pharmacists and others. They will not control the health centres, which will be built, equipped and staffed as regards their lay personnel by the local health authority. The Executive Councils will not have disciplinary powers over doctors but have the duty, if they consider that ” the continued inclusion of any practitioner would be prejudicial to the efficiency of the services,” to report to a Tribunal which will have such powers.
This scheme for general practitioners is an attempt to meet all conceivable points of view within the medical profession while providing as complete a service as possible for every citizen. It will enable equitable distribution to be achieved, it leaves the doctor under contract to a semi-professional body and not employed as a Civil Servant, it gives the possibility of greatly improved facilities for patients and doctors through Health Centres, and it removes the debt of borrowed purchase money, the financial barriers, and bad debts which have led to the accusation that medicine has become more a financial business than, the great healing profession it should be.