What they would mean to the doctor . . . and the patient
by a General Practitioner 1/-
ISSUED BY THE SOCIALIST MEDICAL ASSOCIATION, 13, PRINCE OF WALES TERRACE, LONDON, W.8
(undated but probably 1964)
PUBLISHED BY TODAY AND TOMORROW PUBLICATIONS LTD OF THE SAME ADDRESS
The General Practitioners are unhappy. Dissatisfaction over pay and conditions has reached a crisis point and forced the submission of a new pay claim only a year after an (apparently) substantial rise. Around this claim itself there has been confusion and serious disagreement. Even the press and television have taken notice, and recently the Minister of Health was interviewed by a panel of G.P.s on television. Questioned about a salaried service he replied that doctors had chosen the present system and were well satisfied with it, and as a professional man himself, he would understand their position.
Well, are they satisfied? And is a salaried service so outrageous? Before the National Health Service started, a British Medical Association questionnaire showed, amongst those replying, 80 per cent in the Forces and 60 per cent civilian doctors in favour of a salary. More recently, among Scottish G.P.s, despite the years of unfavourable publicity, 25 per cent were still for a salaried service. The health centres promised in the Act of 1948 were shelved for economic reasons and many people now talk as though they were now impossibly Utopian. Yet other solutions canvassed at present seem to us mere sops in face of a serious crisis in general practice.
All doctors would agree that the health service exists to serve the patients, and the doctors’ sole concern is for the patients’ welfare. The Socialist Medical Association has never wavered in its belief that health centres offer the best possible service for the public. We also believe that doctors themselves have nothing to lose and everything to gain by working in such centres, and the General Practitioners’ Group of the S.M.A. here restates its views on the development of general practitioner services.
The National Health Service has not stood still in the past 15 years, despite the gross neglect of the Government. It has an internal dynamic, responsive to the needs of the community. Freedom from a financial barrier between doctor and patient and the ability and duty to provide comprehensive medical care have been two major factors in this. G.P.s themselves have pioneered many changes in practice organisation—out of their own pockets—such as appointment systems, concern with premises and ancillary staff, rotas, research. These aspirations will be contained, developed and available to all in health centres and at no cost to themselves. We are told that health centres have been built and, like the famous Woodberry Down, are a failure. In the excellent survey of health centres for the Medical Practitioners’ Union, Dr. Sluglett showed that none of the doctors in them would go back to their previous isolation. None of the health centres has fulfilled all the criteria we adopt, though the nearer they come to this the more satisfying they have proved (Darbishire House: Harlow).
Above all, it is their use as branch surgeries by doctors not working as a team, the exact opposite of S.M.A. concepts, which has most disillusioned observers. Further, financially embarrassed local authorities have largely been responsible for the building of health centres to date, and they have functioned as isolated islands in a sea of General Practitioners generally indifferent to their success. The buildings were put up first and doctors sought afterwards, instead of planning with the team of doctors from the start. For all these reasons, it is clear that the concept of health centres has never had a chance to develop.
The relative neglect of general practice is shown by its financing. The share of the national income taken by General Medical Services has declined from 0.44 per cent (8s. 10d. in £100 in 1951) to 0.41 per cent in 1961. That on the Pharmaceutical Services has risen from 0.44 per cent in 1951 to 0.47 per cent in 1961. We spend more on drugs than on the doctors who prescribe them, and it is interesting in this context to speculate why the only real interest the Ministry has taken in G.P.s is to bludgeon them into reducing by a decimal point the cost of drugs by advice on costly prescribing.
Fewer G.P.s, more work
Again, the number of General Practitioners has risen but far less than the number of consultants (from 17,300 in 1952 to 20,300 in 1962). The number of G.P.s in decade 1949-1959 rose by 18 per cent, while the number of consultants rose by 37 per cent and of registrars by 62 per cent. It is now stationary—last year there were four less G.P.s whilst the population rose by 503,000. Moreover, the doctors are not evenly distributed. Although the average list is 2,300, in a place like St. Helens 60 per cent of patients are on lists of over 3,000. Contrary to popular belief, Titmus (Essays in the Welfare State) has shown that paper work and night calls have decreased compared with the ’30’s. But studies of individual practices have shown that the work load as items of service per patient per year rises steadily as the doctor tries to give a better service. The increase in the proportion of old people, the rising birth rate (from 15 to 18 per 1,000 between 1955 and 1962) the increasing responsibilities of the G.P. and his ability to deal with more serious illness, e.g., by using antibiotics, and the increase in health consciousness of the population (thus consultation rates for ill-defined conditions are higher for the young and middle-aged than the elderly—who still tend to have the attitude “The doctor mustn’t be bothered “—all these factors make for more work.
That the G.P. has responded to this pressure is shown by consumer research studies (e.g., Research Services, P.E.P.) which show a high level of use and acceptability of G.P.s by patients; and private practice insurance schemes have had no success with family doctor services. Yet because of the capitation system which precludes capital investment in the General Medical Services, the G.P. has to pay for any improvement out of his own pocket.
Pay and Expenses
The G.P.s are paid from a global sum or pool calculated by multiplying an average income by the number of doctors and adding total practice expenses. From this pool all payments to individual doctors are made according to a scheme so complex that few can understand it. The discovery in 1963 that the 14 per cent rise was, because the pool had been “overdrawn” in the past year, to be only 5 per cent, precipitated a crisis. Out of this pool come all the monies for work in hospitals by G.P.s, Local Authority payments, Government Departments, maternity medical work, drugs. The harder a G.P. works to earn more, the less his colleagues earn. The payment for expenses is an average, so that the more a doctor spends on his practice the less he earns; the less conscientious he is the better off. Planning on a wide scale for co-operation with ancillary and local authority staff, for further education, for holidays is precluded. The G.P. remains isolated from his colleagues along with his patients—to sink or swim. Out of this crisis there is only one logical path forward, a salaried service and health centres.
The great danger of many of the present alternatives to improve status and conditions is that they are directed to the already conscientious G.P. whose spirit has not yet been broken by circumstances. Surveys in the past (Colling, Taylor, Hadfield) have indicated up to 25 per cent of G.P.s as giving an inadequate service—who never examine a patient, whose patients fill hospital casualty departments (see Nuffield Survey “Hospital Casualty Departments and their Setting “). Paying a doctor his actual expenses, separating capitation from other earnings, encouraging better premises, will be fairer to the good doctor, but will never develop the G.P. service beyond its cottage industry stage. It will only increase the isolation of the G.P.s from each other. Of course, quality and merit require encouragement, but this requires thought, not haphazard money incentives. If we start by examining what a General Practitioner is we shall see how to organise our health centres.
What is a G.P.?
It is no accident that the National Health Service Act based itself on the G.P. as a lynch-pin, and under Section 21 looked forward to health centres. The necessity for the central role of the G.P. has been reiterated by innumerable committees from Spens to Annis Gillie, and although in a changing society the G.P. must change and be provided with adequate facilities, this central role remains.
The G.P. is above all a diagnostician. Every patient comes for help and provides a problem. These may be of the most diverse kind, and unlike, say, a surgeon whose specialist role can be more easily defined, the complexity and range of the G.P.’s work may confuse. Having made a diagnosis, the G.P. can draw on the whole range of health servicss appropriately. Alternative systems in other countries do not do away with initial diagnosis, but merely relegate this, the most skilled of all medical tasks, to a less trained person. Thus the patient may go direct to a specialist—picking the one he thinks he needs. Or he may be referred by a clerk in a polyclinic (and here we can see clearly why a health centre, a team of G.P.s, differs from the polyclinic—a team of specialists).
The health centre will develop these basic features of the G.P.’s function. He is the first psAon whom the patient sees, easy of access, local, and always available. Not part of an institution he is readily approachable, and there is no barrier to sorting the trivial from the serious and to the continuing and developing relationship between doctor and patient. This continuity of care enables the G.P. to use past experience to judge present symptoms to deal with an illness and particularly to provide varying requirements in a chronic illness. He sees the patient at home, in his family and social background and can see the patient as a person and treat him as such, not a case. He can detect illness at an early stage, deal with a vast uncharted sea of illness not capable of precise diagnosis. He must have wide knowledge and diagnostic ability and time and facilities to read, study, attend refresher courses. He must have time to consider each patient carefully, pick out details, give explanations, and promote positive health.
A great deal has been said about the nesd for a preventive health service but it is unrealistic to expsct the isolated G.P. to promote health education in the context of mass communication and a national lack of education. At the same time people want education when they are ill and can relate it to something concrete, and from someone who has learnt to communicate, and not from the impersonality of a formal “public health” clinic. Health centres ideally combine size and intimacy.
Patience and tact, ability to work in a team, maturity and the ability to reassure confidently, skill in dealing with emotional and psychiatric illness and emotional aspects of physical illness—the ideal G.P. is indeed a paragon. The point is that this ideal can be realistic if it depends on organisation and not individual gifts.
High standards of professional care are implanted in the medical student in his teaching hospital. All too often he is made to feel he is abandoning them when he enters general practice. He sees the N.H.S. as only one source of income amongst private practice police work, and so on. He has no role in developing the general medical services. In a health centre he will be able to keep up the highest standards in the best conditions. He will be a specialist in family doctoring. He will have a higher status, and himself determine policy in the N.H.S., from within it, and not simply in contract to it. He will not have to struggle to set up a business when he starts as a G.P. “nor compete with his fellows, nor be tied for life to one place, nor practise from his own house so that his privacy and leisure have to be fought for, and his wife and family become adjuncts to his work. The doctor’s wife will be liberated from her endless and demanding role of manning the ‘phone and front door for 24 hours a day, seven days a week—unpaid, unrecognised and unthanked.
The structure of a health centre
What will the structure of a health centre be? Essentially it consists of a team of 4—6 doctors, each with an average list at present of 2,500, i.e., serving a population unit of 10,000. Possibly this list may only be 1,500 in the future but we must realise that even the creation of new medical schools and the expansion of existing ones which is certainly an urgent need implies a wait of 7—10 years, and all sections of the N.H.S. require extra manpower. On the other hand, with efficient organisation, a G.P. may be able to cope with more patients than this, and certainly health centres must not serve too small a population both for experience and administration. This team will work with the appropriate ancillary staff, district nurses and midwives, health visitors and social workers, physiotherapist, chiropodist and pharmacist, adequate trained secretarial staff.
The Socialist Medical Association believes that dental practitioners should similarly be salaried and work in health centres where all equipment will be provided, as full members of the health centre team, where dental technicians, under supervision could make their contribution to relieve the serious shortage of dentists in the country. Similarly, ophthalmic opticians could work from the centre. We have included a pharmacist because we believe that the present system of dispensing from chemist shops—largely concerned with toiletry—is wasteful and expensive, and encourages confusion and duplication of proprietories, encourages self-medication and cannot give as efficient and rapid a service as the health centre.
The centre will do all the work of present general medical and local authority services and the occupational health services. Obviously there is no need to be rigid in size or structure which must vary with local needs and conditions, smaller in rural areas, larger in certain urban conditions, with special research or teaching responsibilities or for large factories. Equally, flexibility in building the centre is to be encouraged. Though purpose-designed, and here much valuable work on premises has been done by the Medical Practitioners’ Union and College of General Practitioners, factory-built units on a national scale would be cheaper, and conversions of large houses, local authority clinics, small cottage hospitals are possibilities. With appointment systems (and thus single small waiting rooms) and staggering of consulting hours, great savings in capital cost and overheads will result.
The centre will be fully equipped and must have complete access to pathology and radiology services and where it lacks its own staff, to physiotherapy, chiropody, occupational therapy and rehabilitation, community mental health services, if necessary by co-ordinating with neighbouring centres. The centre will be self-administering, the whole staff to meet at appropriate intervals and determine policy and elect a committee to run day-to-day affairs. The doctors will arrange their work, holidays, rotas, post-graduate study, case conferences, as with a partnership. Part-time sessional work is possible, e.g. for married women doctors or those with hospital appointments, and flexibility and mobility are feasible for the first time. At one stroke the present unrealistic terms of service will be overcome. G.P.s, like consultants, will have six weeks’ holiday, and locums will be provided where necessary, through rotas, and by a national locum service—for these will be employed direct by the N.H.S. and would be guaranteed work.
At present, doctors feel imposed on by the pressure of work and a 24-hour 7-day week. A tired doctor is a bad doctor. No doctor need work the day after a night or weekend duty and the centre can overcome the present split shift system of evening surgeries every day and still provide a 24-hour- service. To be keyed up all day is both tiring and inefficient.
The chain of administration will now run from the Minister to Regional Health authorities if these are set up, or direct to area health committees consisting of full-time administrative staff and elected members from the local authority and the centres, in areas equivalent to present local executive councils. Smaller units within the area would be formed by, perhaps, groups of 10 centres who would administer rotas, or their own radiology and pathology facilities or maternity unit or cottage hospital where there was no convenient general hospital.
The centres would not be run by local authorities direct, and although experience in existing Health Centres has not confirmed the fears of bureaucracy which so many doctors have, nevertheless these fears must not be dismissed, and we must encourage the fullest democracy in the development of health centres. For the same reason we believe in the value of patients associations which would help the welfare work of the centre, and facilitate awareness of community needs and aspirations and communication between doctor and patient—health education, in fact.
Estimates based on the cost of present small health centres show that for perhaps £100 million—only 10 per cent of the capital cost of the new hospital plan and less than the cost of many a failed military weapon, the whole country would be provided with centres.
The transitional stage
Once it is decided to go ahead with building health centres, the transitional stage can be planned. The new area health committees, or failing this, ad hoc committees of present local health authority and local medical committee would carefully assess the distribution of doctors, population and sites. In discussion with the doctors of any given district, health centres would be set up. All doctors who wished it, should work from them forthwith, taking their practices with them, and practising solely from the centre. They would, of course, be compensated properly for any capital loss on their previous practice. Entry would thus be voluntary. Other doctors could continue on capitation as before, but strong encouragement would be given to joining health centres. All doctors must be able to opt for a salary immediately, irrespective of health centres. Loadings would be greatly increased to favour group practices. Payments for work other than general medical services must be separate. Expenses for certain items such as secretarial helps appointment systems, would be direct. Assistants would no longer be permitted. Present powers held by executive committees to ensure minimum standards of practice should be exercised. Entry into practice by newly-qualified doctors would normally be exclusively into health centres, transforming the present trainee scheme (trainees, by the way, are salaried now). In new housing developments and under-doctored areas where more doctors are required they would practise solely from health centres.
The area committees would be given direct financial control and the appropriate monies to build the centres. The whole country would rapidly be covered by a network of centres in this way. Of course, private practice could not be carried out from the centre, although it would be permitted outside it, but its raison d’etre— the buying of a doctor’s time,—should have been swept away.
Why a salaried service?
Why do we lay such stress on a salaried service from centres? Without salaries, doctors will remain, in spirit and often in practice, in competition. They will not see the centre as theirs—to develop community health services, but merely as an aspect of their income, perhaps only as a branch surgery. They can never develop as a team, united. They would have to pay a rent to the centre if not salaried, and this could only be the economic rent which would be crippling and a discouragement to joining the centre.
Some doctors fear that a salary means bureaucracy, control. Yet hospital doctors are happily salaried. This is the mentality of the small shopkeeper who would rather stand 24 hours a day in his shop for a miserable profit and “to be his own boss.” They fear that a salaried doctor would slack, and be a burden to his colleagues. It is difficult to see a doctor failing in this way, with his sense of professional vocation and in face of the team spirit of his peers and, above all, the exciting challenge of practising medicine under the conditions of a health centre.
Many doctors believe that the capitation system is an incentive to work and relates payment to work done. This is fallacious. Already loadings and the muddle of the pool tend towards a salary with none of a salary’s advantages. The size of list is not related to merit, for 90 per cent of patients choose their doctor because he is the nearest. Capitation says nothing about the quality of work. Estimating work load as items of service, the total, as Taylor showed, varies widely with morbidity in different areas, and with the nature of the practice (old people and children giving disproportionately more). The list can vary dramatically due to factors outside a doctor’s control—e.g., slum clearance. Above all, it makes the doctor feel insecure and interferes with an open and frank attitude to the patient. How much over-prescribing is due to an unconscious desire to placate the patient?
For all these reasons, group practices, which the Socialist Medical Association itself pioneered, are not the final answer, for they are still businesses, in competition with other doctors, concerned with earnings outside the general medical services. There is no reason why they should be democratic, the senior partner can dominate, the new entrant suffer heavy capital outlay. Group loans are still only loans and the need for capital a burden. They are not integrated with preventive and local authority services, and if staff is seconded to them, other practitioners can fairly claim discrimination. But certainly they are a step in the right direction, though we must remember that in 1962 only one-third of doctors were in practices of three or more and one-quarter were still single-handed. Truly, group practices are a rarity.
Freedom of choice
One further problem—freedom of choice. The community expects a good service for all its members, yet some doctors suit some patients and not others, and freedom of movement for both doctor and patient should be conserved. Patients will normally see their ” own ” doctor at the centre and fears of dragooning are absurd. On the whole, patients appreciate partnerships as they realise that they have the benefit of more than one opinion and of consultation between them. The question of choice deserves further examination. If “A” is a good doctor, how do we know he is better than “B”? How do doctors know, let alone patients? What about the service “B’s” patients get, how can we improve this?
What makes patients want to change their doctor? The reasons may be emotional not rational, as Clyne showed in a study of such transfers. (Max Clyne and others, “N” and “X” transfers in Middlesex.) Have patients really free choice of doctor in rural or under-doctored areas, or where the doctors of an area are working in poor circumstances and are thus disinterested? Equally, the doctor has difficult patients and must be protected from aggression. The present disciplinary procedure is unsatisfactory as it is felt by him to be punitive. What we want is surely marriage guidance and not divorce courts for the doctor-patient relationship. The complexities of this relationship will bear scientific sociological study. The health centre must develop communication between doctor and patient and never become an institution, authoritative or paternalistic.
An enormous proportion of the G.P.’s work relates to emotional disturbance and for this we need doctors who listen, and have the tune and training to listen. The present system has not been notably successful in developing this side of a G.P.’s work which, again, has been pioneered by only a handful of individuals.
What should the salary scale be? The actual levels must be left to negotiation, but certainly they will be closely comparable with other specialists, i.e., consultants. There will be a basic salary, with increments for age, seniority, special experience and responsibility for area, e.g., rural or under-doctored areas, or high morbidity. Doctors would be able to move freely, to leave and return to the G.P. service, e.g., to hospital, research, or through W.H.O. to underdeveloped countries. Meaningful incentives would be built into the pay structure without contradicting the essential equality and security of a salary.
The present unfortunate discrimination against G.P.s superannuation would also disappear, for like whole-time consultants it would be based on their best years, and not on the average of the past 20. Equally, the older G.P. need not fear a fall in income as his physical capacity declines.
A Rewarding Career
The future of the G.P. can be viewed with enthusiasm as an intellectually stimulating and rewarding career if one has a clear picture of his work in a health centre. He is practising clinical medicine under the best conditions. He is developing preventive medicine and relates his work to the health of the community as a whole. He is not syringing ears, signing certificates, putting on sticking plaster, filing notes, battling with the impossible and incorrigible under constant pressure. He is relieved of tasks better done by others. He is working with nursing and ancillary staff whose status, capacities and opportunities are also being improved. He has excellent record keeping, age-sex registers, and conducts surveys into disease incidence and other epidemiological research, for example—
- heart disease and occupation;
- hypertension obesity, stress, smoking;
- geographical variation of cancer;
- drugs, maternal infections and congenital abnormality;
- accidents and accident prevention;
- industrial illness;
- clinical trials of drugs;
- early detection of diabetes, cervical cancer, chronic bronchitis, and the development of screening techniques as for anaemia in whole populations;
- the use of groups for dieting, anti-smoking campaigns, physiotherapy in asthma and arthritis;
- psychotherapy, behaviour therapy;
- the development of community mental health;
- treatment of psychiatric illness in the community, and child guidance;
- annual checks for geriatric patients including the use of a mobile surgery to reach them in their homes with adequate equipment;
- the development of social work and family care unit for problem families;
- the co-ordination of school health services, routine local authority work, handicapped and educationally sub-normal children;
- family planning, maternity work, the use of methods of natural and painless childbirth;
The doctor in a health centre will have no problems about new and special equipment; he will conduct minor surgery in a properly equipped theatre; he will have the use of a good library and be able to pursue research.
Threat of extinction
There is evidence that recruitment to general practice is proving increasingly less attractive to newly qualified doctors. The G.P. service is at a crossroads. The public is becoming increasingly health conscious. If it fails to get the service it needs from family doctors, it will turn to the hospitals as it has in other countries; the G.P. will become as extinct as the dinosaur and the patient and the medical profession will be the losers.
The pattern of pay, planning, and capital development in the N.H.S. shows clearly that the general medical services have lagged behind. This situation must be changed.
We believe that relations between G.P.s and the hospital would be greatly improved by the co-ordination possible between district general hospitals and health centres. With improved status and facilities the present tendency to mutual suspicion would be reversed. Many hospital admissions are for routine investigation or to provide nursing facilities not available at home, and the G.P. could be more involved with the care of such patients and, indeed, with all his in-patients. Domiciliary consultations, or even sessions by the consultant in the health centre, G.P. beds and clinical assistantships should all be encouraged and experimented with.
We have already mentioned the need for an expansion of medical schools and this holds true for dental schools and for training nursing and ancillary workers. The Socialist Medical Association has always held that such workers should be available for selection to medical schools and so qualify as doctors.
The whole question of medical training needs review. There has been a great deal of comment on lack of orientation towards general practice and the new chair at Edinburgh is greatly to be welcomed. The teaching of medicine must become much more integrated so that the patient is seen in his social context, and the work of general practice, social, epidemiological and psychiatric factors clearly understood. G.P. teaching units must be encouraged, and the student given a broader training.
Similarly post-graduate education needs more thought, it is often not related to the needs of a G.P. who rarely wants an academic lecture. If refresher courses are to become a regular feature of the G.P.’s life they must be properly planned.
Now is the time
The existence of health centres on a large scale would enable a six-month pre-registration period to be spent in general practice, for instance by all doctors intending hospital specialisation, which would be valuable experience for them and assist the co-operation between centre and hospital and the integration of the N.H.S.
This plan for the future of general practice is put forward because we are confident the family doctor service is essential for the proper development of the National Health Service, and that General Practitioners can and will respond to the challenge if they are given the reforms for which, if only piecemeal so far, they have been asking.
The country must face the fact that they have been getting the N.H.S. on the cheap, and that, like everything else, it has to be paid for.
We are equally confident that the country, made aware of the needs —and it is surely our responsibility to make them aware—will respond willingly and support the campaign for health centres. It is 16 years since the N.H.S. Act promised them. These 16 years have confirmed the need for that promise to be kept, and the time is ripe, as never before, for its implementation.
IS YOUR GP REALLY NECESSARY? by Dr. CYRIL TAYLOR 1s.
Issued by: THE SOCIALIST MEDICAL ASSOCIATION
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