THE DOCTOR'S FREEDOM
By. GORDON MALET AS he peers ahead into the clouded post-war sky, hoping to catch a glimpse of the kind of life he will live, the average doctor finds his mind filled more with fears than hopes. True enough, the pre-war world was no medical paradise, but it had its compensa- tions. War has seen their number diminish. Each new State control of civil life has entailed exceptions and exemptions which must be vouched for by someone ; and who more fitted to sign the certificate than the doctor? So a never-ending stream of new patients fills his surgery, not because they are sick and need the physician, but because they want extra milk or eggs, or out-size corsets, or exemp- tion from fire-watching or home guard. He sees himself degenerating from a skilled clinician into a filler-up of forms. And since most of these form-needers are workers, the forms must be filled in without charge, as a part of the panel contract. On top of all this, he is sud- denly offered by the Minister of Health an elaborate scheme to extend the panel to the whole community, as a first step in the plan for universal social security, which, if it means anything for the doctor, means a form for every patient for every illness, and a greatly increased incentive to be ill. Nor is this the end of the dis- advantages. If he refuses the offer of a salary and a place in a communal surgery, he will find himself in competition with those who have accepted the lure of a salaried post. Since newcomers to medicine may prefer health-centre work, without the disadvantages of purchasing a practice, his capital investment in his practice may vanish with the absence of prospective purchasers. Finally, over him, at a distance, there will be an arbitrarily appointed Central Medical Board, with power to refuse him admission to certain choice spots where he might like to practise in his declining days, because it is deemed that there arc already enough doctors in these areas. What wonder that the clouds look heavy and the way dark—perhaps heavier and darker than they really are?
These new plans for the future have come in some ways at an unfortunate time. Doctors, along with their fellow-countrymen, are tired. Thoughts of an early finish to the Western European war seem continually to need defending and, with the passage of time since Sir William Beveridge's high hopes for the future were first promulgated, the gilt seems somehow to have slipped off the rapidly- staling gingerbread. Yet this delay was really inevitable. A plan for a comprehensive health service cannot be produced overnight, unless it be a slavish copy of one already put out—and that the White Paper certainly is not. However excellent the plan, one cannot help feeling that there are strong emotional reasons to explain why the doctors, at the moment, should look on it as a long way from Utopia. In a word, the doctors, like the rest of us, are " browned off."
If it is only too easy to see what the doctor does not want, it is more profitable to try and put into words his unexpressed hopes for the future. For if these are seen clearly, it may be possible, with a little minor moulding of the Minister's plan, to ensure that the practice of medicine is improved by the change. First and foremost, the doctor wants to be a free man. Free from the orders and edicts of superiors, whether individuals or committees. Free to speak to his patients as it is sometimes his duty to speak to them, without thought of repercussions. Free to treat them as he believes best, not according to a pamphlet from Whitehall. Free to practise his science and art without making detailed notes of everything he does. Free to change his job if he wishes to do so. Free from the chains- of red tape, typified for him by the unending demands for certificates. Free, finally, to stand on his own two feet, sure of his position and of himself. If he asks one thing more, it is that his income shall be related to his efforts, that it may cover his commitments, particularly his educational commitments, and that he shall have a reasonable something for his wife and himself in his old age.
If we examine these freedoms in detail, we find that they are not in the doctor's interest alone. If he is to serve his patients as he should, he must have no fear of the consequences. Above all, he must take full responsibility for his actions ; unless he chooses to do so, he must not be forced to share it with another doctor placed over him, or with a committee. The doctor who cannot or will not make up his own mind is worse than no doctor at all. And the surest way to produce such doctors is to place them under others. Thus.
we are really facing a single example of what may prove to be the greatest problem of the brave new post-war world. How can the freedom of the individual in his daily work be combined with social and economic efficiency? One would suggest that true efficiency is to be measured not merely in terms of work done but also in the satisfaction of the doer. Since, for a third of our lives we are all doers, the world will be a sorry place if we sacrifice the worker, be he doctor or dustman, on the altar of the end-product.
Organisation and planning of the health services there must be. It is up to the doctors and the Ministry to prove that this does not necessarily mean bureaucracy. This is only possible if there is mutual trust. The first move will have to come from the adminis- trator, since he must be the prime mover in any plan. If he will undertake a self-denying ordinance in respect of returns, if he will ruthlessly scrap every record kept only on the off-chance that it may be useful sometime, if he will plan the few essential forms with common sense and dignity, if finally he will trust the doctors to do their job without having it in writing every time, he will find the doctors ready to meet him more than half way.
Yet freedom from red-tape is not, in itself, the whole story. The White Paper's limitation on the setting up of new public practices in areas already fully stocked with doctors, while other places are still short is an inherently reasonable proposal. But about the actual conditions of general practice the White Paper is a little vague.
What is work in a Health Centre on a salaried basis going to be like?
Many young men will certainly choose it since there will be no premium purchase-price. If the Centre is to be a team of confident and freely associating doctors, then surely it should follow the ex- ample of the voluntary hospitals in one respect ; it should have a medical staff committee, with the right to advise the lay local
authority maintaining the centre on all its medical problems. And, equally, the right to advise the Central Medical Board on problems of personnel.
The attractions of the Health Centre may well penalise the general practitioner who decides to stay out. There are many excellent doctors who are temperamentally unsuited for group practice, yet are first- rate servants of the community. There is no good reason why they should be victimised, nor why their like should be excluded from individual practice for the future. The fact must be faced that the
creation of Health Centres will reduce the capital value of individual practices. A young man may be both inClined and welatted to practise on his own. Yet if he can avoid putting himself in debt by entering a Centre he will do. Surely, it is in the interests of both the public and the doctors that the sale of "public practices" carry- ing with them a substantial panel list, should be abolished and the doctors compensated for loss of invested capital. • The White Paper admits that there is a case, but mentions "great practical difficulties." In comparison with the total cost of the new service, these are hardly likely to be financial. More to the point is the question of individual appointment to every vacancy. Since there are likely to be well under 2,000 vacancies a year, at any rate at first, one can hardly believe that the practical difficulties are really SO great.
It may be argued that the removal of the need to find money for the purchase of a practice outside Health Centres will dry up recruits for the Centres. The answer to this is surely that the con- ditions, both medical and financial, intide the Centres must be so adjusted that doctors who are so inclined choose freely to work in them. An economic sanction, to push the doctors into or out of the Centres, may appeal to the power-politician ; but if we are to get the best out of our doctors, their choice must be a free one, based on something other than hard cash.
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