Doctors' Dilemmas
KENNETH ROBINSON, MP, writes : The family doctor must weary of being told that he is the cornerstone (or lynch-pin, or pivot) of our National Health Service. The doctors themselves seem unconvinced. A casual study of the medical journals, or of the proceedings of doctors in conference, reveals the general practitioner as beset with doubts and anxieties. He is worried about a number of things, real or imagined: the lack of proper recognition of his work; his diminishing status both in the community and inside his own profession; his sense of isolation from other branches of the Health Service and uncertainty about his future role within it; insufficient time to give proper attention to his patients; the pay-differential be- tween GPs and consultants; and a sense of inadequacy in face of the increasing complexity of medical techniques.
All these anxieties, and others, are faithfully reflected in the report of a committee comprising
* THE FIELD OF WORK OF THE FAMILY DOCTOR.
(H.M.S.O., 4s. 6d.) . mainly family doctors, under the chairman- ship of Dr. Annis Gillie, a distinguished London practitioner, which was published last week.* After two years' study of the problems of general practice, they have produced an unusually frank report and made a number of sound proposals. It may be a measure of the complexity of the problem that there are, in the course of a fairly concise report (fifty pages), no fewer than eighty-five recommendations.
It would be wrong to blame the National Health Service, as many doctors are inclined to do, for all these troubles. The 'personal doctor' everywhere in the world faces much the same difficulties, and the NHS may have done no more than throw them into sharper focus. There has, for example, been no deliberate policy to exclude the GP from the hospital, as some of them suspect. The radical reorganisation of the hospital service has merely produced a new (and perhaps too rigid) pattern of medical staffing, into which the GP does not fit easily. There is now general agreement that he must somehow be fitted in, and the Annis Gillie Com- mittee suggests ways in which this might be done. The very improvement of hospital services, with the great increase in out-patient facilities, has removed some of the load from the GP's surgery. At the same time it has tended to make his work less interesting and less satisfying.
Not all family doctors feel these anxieties with equal intensity. The complaints come most often • from the older ones, and from those in single- handed practice. Many of the younger GPs, in particular those operating group practices, seem to possess a sharper awareness of their changing role and more confidence in their ability to per- ' form it. The Committee clearly shares the belief that group practice may be the solution of many of the current difficulties.
A group practice is more than a partnership, in that a number of doctors agree not only to share expenses but to function from a single surgery or group practice centre. Each retains an individual list of patients, thus preserving the patient's right to choose his doctor. The advan- tages, to both doctor and patient, are manifest. A group practice can employ staff—such as a nurse-receptionist and a secretary—and install diagnostic equipment on a scale which would be wholly uneconomic for a doctor practising on his own. Rota arrangements for night-calls, weekends, holidays and sickness take care of the locum problem and avoid recourse to any impersonal 'deputising' service. The patient gains by being able to see his doctor, by appointment, in comfortable, well-equipped surroundings, and by having more of his minor ailments dealt with on the spot instead of at the hospital out- patient clinic. The local authority can attach one of its health visitors to such a group and thus establish an important liaison. The absence of contact between GP and local authority is' one of the weaknesses of the Health Service.
Group practices comprise between three and ten or more doctors, the optimum size being generally thought of as five or six. Such a group is large enough to permit the economical use of staff, but not so large as to become impersonal. I heard recently of one outsize group practice which had earned the dubious nickname of 'Aspirin House.'
Though now groups are constantly being formed (only a quarter of Britain's GPs practise singly today), there are serious obstacles in the way. Interest-free loans for the acquisition of premises are provided by the Government, but on an insufficient scale. Worse still, the whole system of reimbursing practice expenses penalises all doctors who aim at giving the patient a better service. The method is complex, but in simplified terms all GPs' expenses allowed by the Inland Revenue for tax purposes are aggregated, and distributed to individual doctors according, not to what they have actually spent, but to the number of patients on their list. It would be hard to devise a system more favourable to the doctor who provides the minimum of service, or more penal to those who aim at the highest standards of general practice. This is the situa- tion somewhat lamely described by the Minister of Health last week as a 'conundrum,' to which he could offer no solution. At long last the pro- fession itself is beginning to demand a change in these ludicrous arrangements.
The Annis Gillie Committee considers, as do most people, that the size of doctors' lists— present maximum is 3,500 patients, the average 2,300—should be reduced when there are more doctors in general practice. It also recognises that changes are needed in medical education to equip the GP for his task, with more emphasis on social and psychological medicine and more post-graduate study in general practice itself.
Perhaps our family doctors have been crying down their wares too much, Preoccupation with their frustrations and grievances may have led them to undervalue their role as the patient's counsellor- and friend, as well as his front-line, defence against illness. Other nations whose medical services are based primarily on the hos- pital or polyclinic are beginning to see the virtues of the personal doctor. For Britain any other pattern is unthinkable. It is for these reasons that we should welcome the Annis Gillie Committee's analysis of the GP's problems and its convincing definition of his new role in a
'Take me to your leader.'
comprehensive Health Service. To make this Rile a reality will demand much effort over a long period from government, medical schools and profession alike. Failure to do so will bring about a falling-off in recruitment to general practice and a steady deterioration in the service.
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