4 SEPTEMBER 1942, Page 8


By OUR MEDICAL CORRESPONDENT Each way of entrance has had its advocates and successes ; astonishingly few doctors seem to have failed to obtain some sort of a living ; and likely applicants for shares in a well-established practice have usually been able to find insurance societies willing to advance a proportion of the requisite capital. Various estimates have been made of the average financial rewards of general practice. But the personal factor and other conditions have been too various for any very accurate generalisations. Roughly speaking, it has seldom been possible, even in a prosperous neighbourhood, for a general practitioner, whether single-handed or in partnership, to earn as much as £4,000 a year, without grossly overworking. Many would have regarded themselves as reasonably successful with a gross income of half that amount. Bearing in mind that the medical education is probably the longest and most expensive of any, and allowing for the initial outlay in beginning practice, the medical profession is clearly not one to be adopted for primarily financial reasons. Nor is it probable that many of its entrants have embraced it from that motive.

During the last thirty years various factors have emerged to help the general practitioner. The advent of the small motor-car has been an unmitigated blessing to him. The medical inspection of school- children and other part-time salaried work in connexion with the national social services has provided many general practitioners with additional sources of income ; and in spite of its imperfections and the opposition with which it was first encountered, the National Health Insurance Scheme has been of undoubted financial benefit to general practitioners in urban and industrial areas. There have also been other changes, such as the increase in size of medical partnerships or firms, even to the extent, in some small towns, of including all their doctors. In such firms there has begun the tendency for each partner to develop and educate himself in some particular speciality, so that the firm can become self-sufficient, as it were, for all but the rarest and most difficult cases. But the basic principles of general practice have remained unaltered. Partners in a firm usually retain their own personal patients. But such patients are always at .liberty, if they desire to do so, to call in one of the other partners, or to seek the advice of some other,doctor. Panel patients, under the National Health Insurance Scheme, can also, at stated periods, transfer, if they wish, to some other panel doctor.

Now, as the result of the war, changes in national and social out- look, doubts about future finance and various other considerations, the future of general practice in these islands is being studied and written about from many different points of view. A responsible, representative body of doctors, under the aegis of the British Medical Association, has issued an interim and tentative report on the subject, and a completion of it is to come. There seems to be a consensus of opinion that changes are inevitable, though the general public has not yet been heard on this point, and that such changes will be away from the old individual, so-called competitive, tradition.

To judge from the immense amount of correspondence that has been filling the columns of the medical journals during the last two years, a very considerable body of medical men favour an out-and- out salaried State medical service, to be available for the whole population, and to be paid for out of some national contributory tax or rate. The advantages claimed for this, once established, are its comparative simplicity of administration and finance ; and it is believed that many doctors, especially the younger ones, would welcome the assured income, regular hours, regular holidays, and ultimate pension provid..:d for under such an arrangement. They would also welcome cordially the emancipation from book- keeping, the sending out and collection of accounts ; and it is also claimed that—freed from the temptation to " placate " patients for bread-and-butter reasons—they would be able to practise an honester and more scientific medicine to the benefit of all concerned.

The enormous initial difficulty of transferring many thousands of existing doctors of all ages, abilities, and degrees of experience, to their appropriate niches in such a service is no doubt realised by some, at any rate, of its advocates—but it is probably assumed that this could_ be overcome, or that it should not, in any case, be allowed to stand in the way of a beneficent reform. The great objection that such a service would either abolish or severely restrict —from the patient's point of, view—the free choice of a doctor is dismissed on the grounds that a free choice is even now, especially in many country districts, hardly possible ; that it is already con- tentedly accepted, as regards hospital treatment, as practically non-existent ; and that the general benefits accruing would in any case outweigh its loss.

Another very considerable number of doctors, while opposed to a salaried State service on the grounds of the alleged loss of pro- fessional independence and integrity that it would entail, the stifling of personality that would ensue from bureaucratic control, and the inevitable manufacture of medical yes-men, with an eye on promotion, would nevertheless like to see an increase in the number of people includable in the National Health Insurance Scheme, and the extension of this to their families and dependants. But massive as the correspondence on such subjects has been, the great bulk of the profession, whether in general practice or at present in the services, does not write letters to the medical Press, and has—like the general public—yet to be heard from.

Such, then, is the position, at the moment, and meanwhile the general practitioner, with partners and neighbours withdrawn into the various services, and more being called up as the services grow, is probably working harder than ever before. And whatever the future may hold in the way of a State medical service, partial or complete, it is probably safe to say that some body of independent general practitioners and consultants will and should remain. How- ever efficient a State service, it would need outside, unbiassed, independent medical critics if that efficiency is to be maintained. However able its individual members, there would always probably be a few dissatisfied or unwilling patients for whom an alternative supply of doctors must exist, if only as a safety-valve. There would always probably be young men and women desirous of becoming doctors, but not necessarily and inevitably salaried State servants. There would always probably be doctors within the State service itself who would be found temperamentally, or for some other reason, unsuited to it ; and if there were no alternative professional field open to them their retirement or dismissal from the State Service would be a disaster tantamount, as regards their professional future, to removal from the Medical Register. For these and other reasons, therefore, it seems-unlikely that general practice, as it exists at present, will entirely disappear in any immediate future.