1/- ISSUED BY THE SOCIALIST MEDICAL ASSOCIATION, 13, PRINCE OF WALES TERRACE, LONDON, W.8
PUBLISHED BY TODAY AND TOMORROW PUBLICATIONS LTD OF THE SAME ADDRESS 1965
THE time is ripe for a fresh look at the whole subject of health, and for a great step forward by British medicine through improvements and developments in the National Health Service. General Practitioners are dissatisfied with their way of work, their expenses and their remuneration; hospital-building is too slow to rid us of Poor Law slums in this century; research awaits new stimuli to solve the problems of our great killing diseases. The medical profession has been disturbed out of its conservative apathy by these and other factors, and calls for great and rapid changes. This ill-understood ferment must be so used that socialist thought pervades the discussion and socialist planning finds the right solution.
Why a Crisis?
First we must ask why there has been a ” crisis in general practice.” To those who have studied general practice it was no surprise. The seeds of the present discontent were there before 1948 and their continued growth is one reason why the Socialist Medical Association has argued for great changes in general practice.
The British Medical Association believes that ” the family doctor service is breaking down.” It demands that:—
” To give the best service to his patients, the family doctor must:
- Have adequate time for every patient.
- Be able to keep up to date.
- Have complete clinical freedom.
- Have adequate, well-equipped premises.
- Have at his disposal all the diagnostic aids, social services and ancillary help he needs.
- Be encouraged to acquire skills and experience in special fields.
- Be adequately paid by a method acceptable to him which encourages him to do his best for his patients.
- Have a working day which leaves him some time for leisure.”
None of this is new. It could all have been said, and was in fact said by the SMA before World War II. Much of it was also said in 1942 by the BMA’s own Medical Planning Commission. It is well to recall the conditions under which General Practitioners worked prior to the introduction of the NHS. At that time general practice was still conducted by individual doctors in out-of-date premises, with only rudimentary contact with local authority and other social and nursing services. Three-fifths of the population were treated as private patients and the rest were “panel” patients. In the century preceding 1948, little change had taken place in the pattern of general practice, except for the “panel” system of 1911, introduced to cover those in employment but below a certain income level. Medical incomes were relatively not very high, and there was little done in the way of re-education and less in the provision of services.
Basic Socialist Principles
So the SMA campaigned for a comprehensive NHS, free to the patient at the time of use and staffed by full-time salaried health workers, including doctors, both in hospitals and general practice. General Practitioners, the SMA declared, should work from health centres. The family doctor would work in close collaboration with his colleagues and would head a team of nurses, technicians and other health and ancillary workers, and have access to all necessary diagnostic facilities. There would be a close liaison with hospital, local authority and other health and social services.
Advances not realised
The role of the family doctor as the lynch-pin of the NHS, as intended in the NHS Act (1948) has not been fulfilled. The reverse position has gradually developed, and general practice, part of one of our oldest professions, is now frequently described as a ” cottage industry.” This is due to the stagnation of general practice during the past thirty years. The responsibility for continuing neglect of this sector of the NHS rests with successive governments, content with providing a family doctor service “on the cheap.” General Practitioners, by rejecting health centres and a salaried service as offered in the NHS Act, and opting for a capitation method of payment, also bear responsibility for the present situation.
The NHS has been a major social advance despite many defects. These are capable of solution only by co-operation between the Government and the medical profession, with a watching brief held by an enlightened public. In a continually changing social pattern, general practice must evolve to meet new conditions. The sooner this is recognised by medical practitioners, the more quickly a satisfactory planned structure of general practice will be created. To further this aim, a larger allocation of national resources will be required for necessary capital investment in the NHS, with particular reference to the general medical services. More money must be found to improve the conditions, terms of service and pay for all health workers, including doctors.
THE BMA “CHARTER”
The “Charter” offers a basis for negotiation between the Government and the medical profession, and incorporates a number of proposals advocated by the SMA, in different words and greater detail, for many years. However, it gives the impression of having been hastily assembled, and at times is contradictory. For example. Paragraph 15 insists on preserving the position of the single-handed practitioner and yet favours the encouragement of group practice. Paragraph 21 recommends that “Every family doctor should be free to dispense for his patients if he so wishes and to continue to do so.” This is a time-wasting business, yet in Paragraph 14 reference is made to the need to reduce the time-wasting procedure of certification.
The SMA welcomes the sentiment expressed by the BMA Council that “More money is not the only consideration.” The BMA “Charter,” on the other hand, lays major stress on financial aspects. Not sufficient emphasis is laid on the need for radical reorganisation of general practice, with closer co-operation between GPs, local authority medical and social services, and hospitals.
The SMA would like to see the inclusion of proposals for a preventive health service as opposed to a purely curative one. Research in hypertension, heart disease, use of new drugs, early detection of diabetes, cervical cancer, bronchitis and so on, would be included in a family doctor’s “remit.” A fully-equipped health centre staffed, as already mentioned, with nursing and other ancillary staff would offer opportunities for the family doctor which are not even hinted at in the BMA “Charter.”
Premises for the GP
The BMA “Charter” on this point is remarkably ambiguous. Paragraph 18 says “The family doctor needs comfortable, convenient and up-to-date premises to provide the standards of service that he would wish to give to the public.” Note how the words which would most aptly describe what is needed, “health centres,” are avoided. Instead, a demand is made to “build and lease purpose-built premises.”
Recent surveys show that a sizeable minority of doctors favours working in health centres. Opportunity for the early building of these units exist in the ” under-doctored ” industrial regions. New Towns and redevelopment areas. Under the ten-year local authority plan, about 1,230 Local Authority clinics will be built. These could include accommodation for family doctors with ready-made access to and co-operation with the local authority health and social services. It can also be shown that the joint building would be cheaper than any scheme to build them separately.
Where possible, health centres should be planned in consultation with the Local Medical Committee or equivalent body. These centres should preferably be staffed by salaried doctors. However, if doctors opt for a capitation method of payment, they should have the opportunity of renting health-centre accommodation at a moderate rental—even if this has to be subsidised from public funds. The health centres must not be used as branch surgeries, and we must not repeat the unhappy experience of Woodberry Down Health Centre.
The lending of public money to family doctors for the purchase of private practice premises would tend to perpetuate current anomalies and anachronisms. The acquisition of practice premises by a public body for leasing or rental is a possible alternative. The SMA is also opposed to the sale of practice premises, purchased with public money, to family doctors.
A loan could be granted for the improvement of existing practice premises only after an independent survey had agreed on its suitability. Many existing premises would defy any attempt at suitable conversion.
Compensation should be paid at market value for any loss involved in the transfer from privately- to publicly-owned premises.
The provision of suitable practice premises would incur considerable capital outlay, but this would eventually more than compensate the nation in terms of an efficient service and improved health. The SMA rejects any proposals for charging the patient extra, either directly or indirectly, for the additional money required. A larger “slice” of the “national cake” for the NHS is the only appropriate measure.
METHOD OF PAYMENT
The “pool” system should be abolished, for reasons which are now well-known. Payment in general practice should be adequate and reasonable. General Practice is widely recognised as being one of the most onerous in medicine, and the pay of the GP should be closely comparable to that of the consultant.
The SMA reiterates the desirability of a salaried service. This method offers: —
- The possibility of erecting an equitable career structuresimilar to the one enjoyed by hospital and public health service doctors.
- Salaries would remove the unhealthy element of economiccompetition between colleagues and reduce the existing isolation of GPs,
- Unity among doctors would be facilitated, and approximate to the cohesion shown by the consultants in negotiation with the Ministry.
- Holidays, rotas, post-graduate study, a national locum service and other advantages become realisable.
- Superannuation, as with consultants, should be based on the best years and not, as at present, on the average earned in NHS practice.
Where doctors choose payment by capitation they should, if possible, work from premises publicly owned and equipped. Midwives, nurses, health visitors and other health workers, wherever possible, should be attached to these premises, where secretarial and other ancillary help is also provided.
Alternatively, where premises are privately owned by doctors receiving capitation payment, the former should conform to agreed standards.
Item of service payment
The SMA regards this proposal as retrograde and, therefore, unacceptable. It would lead to increased paper-work and possible abuses, and imply some loss of professional freedom, for example the position of dentists in relation to the Dental Estimates Board. The Royal Commission on Doctors’ and Dentists’ Remuneration (1957-1960) expressed a similar opinion.
GP Hospital Beds
In rural areas some justification for GP hospital beds exists. The potential scope of the family doctor is so extensive and varied that additional hospital duties would be detrimental to the GP’s primary role. In towns and cities it would not be in the doctor’s interest to divide his time between attention to GP hospital beds and general practice. This does not invalidate the desirability of giving doctors “ positive inducement to acquire additional skills and experience in special fields (BMA “Charter”); nor does it exclude clinical assistantships and consultations between hospital officers and GPs who visit their own patients in hospital.
Reduction of Lists
The SMA has suggested that an optimum list of patients per GP should be about 1,500. At present this figure is not possible. On the other hand, with a radical reorganisation of general practice based on health centres and adequate ancillary help, the GP will be able to maintain the present service at a higher standard until the new and expanded medical schools have provided new recruits.
For many years the SMA has advocated the recruitment of medical students from all sections of our population. At present the majority of doctors stem from a limited section, mainly with a Public School background. A large pool of able material is available if the expensive medical training is made free. Some new medical schools are needed, but meanwhile the number of students should be increased, and experiments in new methods of teaching and a wider curriculum should be arranged. Teaching in the Regional Board hospitals should be expanded and senior medical students should be encouraged to assist there during vacations. In England and Wales the teaching hospitals and Regional Board hospitals should be amalgamated, as in Scotland.
There should also be more professional chairs of General Practice, and consideration should be given to the SMA’s original suggestion that at least one period of six months in a health centre or group practice should be accepted as part of the pre-registration period. The use of assistants by practitioners on ill-defined but often meagre incomes should be prohibited: and assistants in health centres should be paid an adequate salary.
Although considerable improvement in the distribution of doctors has been achieved and few areas are as seriously under-doctored or as largely over-doctored as before 1948, there is still a great deal to be done to ensure that enough doctors work in the areas of greatest morbidity and mortality. To attract doctors to such areas, whether rural or industrial, by additional payments is an accepted technique, but one which requires to be used to a greater extent and with much more appreciation of the problems that exist in some areas.
Many Omissions from BMA Charter
The BMA document was, as everyone knows, prepared hurriedly, and that may be in the main why so much is omitted. We have already mentioned the absence of any reference to intensifying the battle to prevent disease. This is something in which the GP must play a bigger part. It has many repercussions in terms of organisation, for the GP cannot really co-operate with public health officers so long as he is paid only for looking after the sick.
Nor can he join very effectively in campaigns to educate the public in matters of health. He is in competition with his nearest colleagues and cannot do any public work which might be construed as “advertising.” This makes it difficult for him to address groups of his own patients and impossible to speak to groups of patients of other doctors. Yet it is essential, if the family doctor is to retain his place, that he “lives with his patients,” and that means talking to them.
But the greatest omission from the BMA Charter is any mention of, and therefore any understanding of the need for the medical profession to undertake collective responsibility for the health of the nation, and more precisely for every group of doctors to assume collective responsibility for the health of the community or unit of population they serve. This has important philosophical and political aspects, but it is vital for any new contract for General Practitioners.
In the case of hospital officers, whether they understand it or not, they have achieved their status, their organised way of work, their regular hours or sessions of work, their salaried incomes entirely separated from their expenses and the cost of the service they give, because they are responsible for a unit of population. The GP is still responsible only for those individuals who have chosen him as their doctor; and he cannot escape from the difficulties of that position, which are the cause of the present crisis, unless he accepts the need for a way of work which makes him one of a team of people dedicated to their own community; and only then can he escape the isolation, the capitation fee system, the drudgery and wasted time of which he complains, the lack of communication with others who are also engaged in the battle for health.
But he must then accept both the Health Centre and the salaried form of service, a method of payment that can be both equitable and separated from all questions of expenses.
So far we have discussed some of the problems facing medicine today. There are socialist solutions to all of them and we hope to see them not only in the socialist charter which follows but in operation at a very early date.
A SOCIALIST CHARTER FOR HEALTH
- The National Health Service must continue to develop on comprehensive lines giving to all citizens, free at the time of use, the highest available standard of medical care in all fields, preventive, curative, educative, against a background of research in disease and study of health. The responsibility of the Minister of Health to provide all this must never be forgotten.
- Within that Service, all health workers must be given the best terms of service the country’s over-all position permits: and in addition to good financial rewards, must provide full scope for those whose ideal is service; the service should provide a basis for continued teamwork as well as individual brilliance; and should provide all the necessary “tools for the job,” whether buildings, equipment or aid.
- All doctors must therefore be offered terms and conditions of service which will encourage all forms of group medical activity, and should find within the NHS both such financial returns and professional opportunities that there is no incentive to set up a second standard of medical care by undertaking private practice.
- The salaried method of payment for all hospital officers, already the rule for 17 years, must be directed to the point where everyone is on a wholetime salary, that is to say whether working full-time or part-time, paid for the whole of the time they give to medicine by a single salary payment. This would not end private practice, but would move it outside the NHS, which presently subsidises it at considerable national expense.
- Salaried hospital officers necessarily work in teams within the hospitals, but must be encouraged to regard themselves as part of the team which serves patients at home and in industry also; and must play such a part in the post-graduate education of all doctors and the education of the public that all artificial barriers between the hospital service and other sections are broken down.
- The General Practitioner must be given a new contract, a new way of work, an opportunity to give the best medical care he can give in surroundings and circumstances that permit this: and which make him part of a great medical team rather than an individualist.
- To this aim, the profession should declare it accepts and understands its “collective responsibility” for the health of the community it serves. Only in this way can it get away from the “365 days a year” contract of the capitation fee system; and offer the opportunities for leisure, both recreative and educative, which the GP needs.
- Within that “collective responsibility ” the GP has a special place, for he must combine it with continuing responsibility for the care of those who have chosen him as their professional physician and whom he has accepted on his list.
- The place of work for GPs must be both modern as a building and a focus for the teamwork of both the GPs and all other health personnel working in the same fields and for such ancillary aids as the GP needs.
- This means the provision of Health Centres, and these should be provided by the community for which the doctors have assumed collective responsibility.
- This will require a combination of Government money, health authority planning and building, with a large measure of decision as to planning and size of each health centre by agreement with Local Executive Councils and their medical committee.
- It is essential that no health authority should build a clinic without considering whether, and in most cases deciding, to make it also a Health Centre. This would be economic in terms of building; and would automatically have the preventive and domiciliary services in the same building as the GP, and would enable new services yet to be developed to start off in the closest co-operation with the GPs.
- It is for these reasons the spending of money should be in the hands of the local health authorities; but this in no way implies clinical or organisational control of the GP. Clinically he must have personal responsibility and authority, as his salaried hospital colleagues have: and details of day-to-day organisation must be left to the Health Centre medical team with their clerical and other staff.
- Ideally, GPs should be paid by salary, free of all expense, which must be by basic rate, as for consultants, with such extra payments for “merit” (if the profession likes that concept), special payments for special skills, responsibilities, administrative duties and so on, as negotiated by the profession and the Ministry of Health.
- Those doctors who still opt to be paid by capitation fee must nevertheless be able to have the great advantages of health centre practice, and must be able to achieve a similar net income to that earned by salaried GPs, but must not be able to earn more.
- There should be no “item of service,” overtime and other payments, which detract from the principles of teamwork and collective responsibility. Incomes must be calculated to cover these, as consultants’ salaries are calculated to cover emergencies.
- GPs may have part-time positions in hospitals and an occupational health service; and their list of patients, health centre responsibilities and so on must be varied to take these into account. Even the man who insists on continuing single-handed should be enabled to do such work, subject to his total load being adjusted to a fair amount.
- GPs must not be given hospital posts as a cover for private practice: and hospital arrangements should be such that patients get the conditions they deserve and GPs the hospital assistance they need. New hospitals should no longer build communal (large) wards, but should so far as possible and desirable provide personal beds (single and small-number rooms) so that the single room is no longer a privilege but an acknowledged right.
- Speaking of doctors as male in this document is for convenience only. Women doctors already have equal terms; but married women doctors should be encouraged to take part-time salaried posts in the health service, but in such circumstances should not also do private practice.
- Health Centres, as elaborated in the SMA documents, will require a considerable capital investment, and therefore standardisation should be sought so as to reduce costs. But the investment will pay dividends in greatly improved services for patients, and conditions for doctors and all health workers.
At the moment of writing negotiations, which are likely to be prolonged, are still in progress between the Minister and the BMA. This does not represent all the interested parties and views. Many GPs differ from the leadership of the BMA, and we believe that there is a substantial section which is interested in the SMA ideas for health centres and salaries, and we hope they will join with us in making their views felt.
All patients, and particularly those within the Labour movement, need to insist that the NHS develops along more democratic lines; and by “democracy” we mean active participation in the control and development of the service.
Whatever the results of the negotiations—and they will inevitably be a compromise—they must not be seen as a “final solution” but, on the contrary, as the opening of a new era for the NHS in which change and development will be the most striking feature. We must end the stagnation of the past 13 years. Many problems will remain for the future. The confusion in the public mind over the recent crisis in an index of the complexity of the political and organisational issues now involved in comprehensive medical care. The interest aroused in the NHS must not be allowed to subside, for without debate and argument on these vital questions, no advance is possible. In particular, the increased priority for the NHS for which we are calling will not be realised unless the community shows it is concerned to claim it.
The crisis in general practice has been only the tip of the iceberg of malaise throughout the NHS. No living organism can survive unharmed unless it changes, and for 13 years the NHS has been dying of hypothemia—a combination of malnutrition and exposure to the blasts of neglect.
There are, therefore, many more aspects of medical care we would like to take up and for which, in fact, the SMA has policies— care of old people, psychiatric services both in the hospital and the home, the maternity services, the development of an occupational health service—to name a few of the leading ones.
We believe this Charter could be the prelude to major advances in all fields, and call upon the people of the country to support us in campaigning for it.
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