1 OCTOBER 1948, Page 9



THE new National Health Service has now been functioning for three months—long enough to indicate whether or not it is going to work, if not long enough to demonstrate how it is going to ,work in all its details. In general the new machinery seems to be running smoothly for both doctors and patients. The figures recently given by the Minister of Health for the country as a whole are borne out in the county of which I have direct experience ; that is to say, more than ninety per cent. of the population, and a higher proportion of doctors than was expected, have signed on, and it is reasonable to assume that the present trickle of new entrants will continue until virtually everybody is included. The chaos of the week or two before and after July 5th, when most patients and some doctors were uncertain exactly what they ought to be doing, sorted itself out more quickly than might have been expected, thanks very largely to the devoted work of the staffs of the Executive Councils.

No doctor, however, will be able to give anything approaching a final judgement on the scheme until at least one major uncertainty has been cleared up. This is, of course, the amount of the capitation fee, or, in plainer words, until he knows what his income is going to be. The original figure suggested was ISs. a year, which, after certain deductions had been made, it was hoped would work out at at least 175. for each name on the doctor's list. On this basis a doctor who had his full quota of 4,000 names would get a reasonable income, even if he kept on no private patients. But in my area no doctor has reached, or is likely to reach, anything like the full quota, and most doctors will have to be content with about half the maximum, and many with even fewer.

I think it is clear, therefore, that there will have to be a reduction of the maximum list with a substantial increase in the capitation fee, or a very substantial increase in the " Inducement Fund " of L400p00 which is supposed to meet cases where there is little chance of a doctor getting a full list. Most of the doctors in my area gave service under the old National Health Insurance Act, and on July 5th their first recruits were usually the dependants of their former panel patients. The hardest-hit doctors under the new scheme are undoubtedly those who had no panel work to serve as a nucleus for the new service and whoseincome was mainly derived from private practice ; these, unless they succeed in keeping on their private patients, and augmenting their incomes by putting in part-time work for factories, schools, insurance companies or as general practitioner specialists, are facing disaster. A good deal has been heard of the methods some doctors are said to have used to induce people to continue as paying patients—warning them, for example, that only by so doing will They get the consideration, care and attention to which they have been accustomed. There have certainly been a few cases of this sort of unjustified pressure. But they have been very few indeed, and I am convinced that the great majority are playing the game. It is interesting to note that the people who have insisted on remaining private patients are not necessarily the richest members of the community. They are often the natural conservatives who refuse to have anything to do with what they consider "mass doctoring," or persons who wish to

remain private patients in order that they may still be free to ask the doctor to suit their convenience rather than always have to conform to fixed hours.

Already the new• system has resulted in considerably more con- sultations for most doctors, and in particular more children are being brought to the doctor (instead of being " doctored " by their mothers), a state of affairs which every doctor will welcome. Not only has the increased number of attendances for examination, advice and treatment added very considerably to the doctor's work and prolonged his surgery hours, but so also to an even greater extent has the necessity of arranging for admissions to hospitals, consultations and correspondence with specialists, and the signing of certificates giving entitlement to benefits which before July 5th were available to only a few, but are now open to anyone. In the past many doctors employed dispenser-secretaries, but now, with the giving up of dispensing, they have ceased to do so, so that a large amount of the secretarial work has to be performed by the doctor himself.

Consideration is now being given to the question of who should receive a basic salary. The original intention was that it should form part of the remuneration of every G.P., but owing to the opposition of the profession this proposal was dropped, and now the salary is only to be drawn in cases of financial hardship—for example, by the young man setting up in practice, the doctor whose income has been adversely affected by the new Health Act, and the doctor nearing retirement who might reasonably wish to limit his work. It must be remembered that the basic salary is a first charge on the local pool from which capitation fees are paid, so that every case in which it is granted means some reduction in the capitation fee of all the other doctors. The average practitioner is quite prepared to make this sacrifice except when it means subsidising a rival setting up in practice in his own area, where owing to the number of potential patients he already has difficulty in making a decent living. About one-fifth of the doctors in my area have applied for the basic salary, and their claims are being considered.

On the administrative side of the scheme, I think there can be little doubt that the new Executive Councils are much more satis- factory bodies than the old Insurance Committees. The professions —doctors, dentists and chemists—are properly represented on them, and the type of laymen nominated as members by the Minister and the County Councils are as a rule better qualified and capable of taking a wider view of their responsibilities. In my area the work of the Council is very seriously hampered by the entirely inadequate accommodation provided. After a struggle lasting over a year we have at last managed to get the Ministry's approval for building new premises. The various sub-committees of the Executive Council have been set up and are ready to function when required, and the County Councils have for the most part appointed medical representatives on the County Health Committees, but the position with regard to the Local Health Authorities Health Com- mittees is not so satisfactory, as these for the_most part have refused to admit representatives of the local .profession.

On the vexed question of Health Centres there is, of course, little to report. They are still a much-talked-of development which everybody approves of in theory ; but in spite of the guidance given in a very good report recently published by the B.M.A. 'there are quot homines tot sententiae as to the form they should take. In my own area the County Council has practically decided to set up a Health Centre in a particular district which would include under the same roof all the services for which the Council itself is responsible, and a meeting of the local doctors was called to obtain their views, but for one reason or another few of them turned up. Appreciation was expressed of the advantages of working in a Health Centre where secretarial and nursing help was available, but fears were expressed that in order to retain on their lists those patients who lived near the doctors but at a distance from the centres doctors would be compelled to see patients as well in their old surgeries. The ideal staffing of a Health Centre would be by doctors in partnership, but the whole question of the obligations contained in partnership agreements is still undecided, and until this is settled naany practitioners are very diffident about entering new partner- fihips ; indeed a number have been dissolved. •

On the hospital side, it is fair to say that the work of hospitals is being carried on practically on the same lines as before and the change of management has not produced any serious dislocation, but this is only because a number of important questions have been tacitly left in suspense and because the staffs of • hospitals have been willing to accept temporary contracts without any knowledge as to their future prospects. It should be here pointed out that the acceptance by doctors of work under both the G.P. and hospital divisions of the Service without haggling, and indeed without a very clear view as to what would be their remuneration, must be regarded as a public-spirited gesture without which it would have been impossible to bring the Service into being on the* appointed day. Hospital administration is an obvious example. Many hospitals are very uncertain of the role they will have to play in the future or what will be their status. No hospital really knows where it is, or where it is likely to be in twelve months' time. Existing contracts have been renewed until March next year, by which time it is hoped that the Reviewing Committee, which is being set up, will have finished its work and laid down some lines for future action. Meanwhile the group Hospital Committees have not had a chance to get to grips with the individual hospitals in their group, and without guidance from their Regional Board, are perforce carrying on as best they can according to their own lights. Senior members of the staffs of hospitals are operating in an almost complete vacuum. The remuneration now paid on a sessional basis for attendance at their hospital does little to compe:nsate them for the loss of private practice by patients' taking advantage of treatment in the general wards or for the shortage of private beds in hospitals and nursing homes. On the other hand, younger specialists are finding life easier because more posts, which were formerly unpaid, now carry a salary.

The National Health Service obviously can be worked. Its early stages have proved that a great deal of avoidable confusion and hardship was caused by the Government's determination to intro- duce a complete plan for the whole population in one stage instead of gradually expanding the old National Health Insurance scheme until it brought everybody in, and extended to its Members all necessary services. But in so far as it is practidable, the Service is operating as well as could reasonably be expected. Defects will become obvious as time goes on, but with the willing co-operation of the profession and- lay bodies concerned and wise and helpful guidance from the Centre, these can be remedied and the Service made one of which the nation may justly be proud.