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SPECIAL ARTICLES

FROM PANEL TO PUBLIC SERVICE

BY SOMERVILLE HASTINGS, M.S. Lond., F.R.C.S.CHAIRMAN OF THE HOSPITALS AND MEDICAL SERVICES

COMMITTEE, LONDON COUNTY COUNCIL

SOME form of state medical service appears to beinevitable in this country fairly soon, and the best wayout of the present chaos, due to the outbreak of thewar, is by the democratic control of hospitals, medicalservices, and the profession. The service should becomplete-i.e., it should provide not only generalpractitioners but also specialists, hospitals, convales-cent homes, pathologists, dentists, and efficient nursingin hospital and at home. It should aim at preventionas well as cure, and the preventive and curativeservices should be much more closely associated thanthey are now. Further, the service would have to betruly democratic and controlled by local authoritiesand not by a central government from Whitehall. Itwould certainly be wise for the smaller counties andcounty boroughs to unite so that the administratedarea could be large. There must be elasticity, how-ever, and opportunity to apply different methods tomeet special needs. Moreover, advantage must betaken of the assistance and advice of all with medicalknowledge and experience in the area. So far mostpeople will agree, but the method of transition is amatter of contention.

It seems clear that the hospital needs of the futurewill be supplied by the large general hospital, and thatthe specialists of this hospital will see cases referredto them by general practitioners in the outpatientdepartments of that hospital and its branches, and thatthese same specialists will see patients in their homesat the request of the general practitioners. What isnot one little bit clear, however, is how we are to passfrom the present mixture of panel and private practiceto a properly organised general-practitioner service.No doubt, at any rate at first, only those with incomesbelow E250 will be entitled to the service; but thesewill constitute about 80 per cent. of the population.Whether the service is to be provided entirely free orpaid for in part by insurance need not trouble us atthe moment.The British Medical Association’s scheme for pro-

viding a general-practitioner service for the whole ofthe less well-to-do members of the community is hardlyworthy of serious consideration, and it is only just tothe association as a whole to add that at the lastannual meeting in August, 1939, a resolution askingfor the consideration of drastic modifications in thescheme was accepted. Much as he would wish other-wise, the doctor under the panel tends to become littlemore than a tradesman, whose main responsibility isto please his customers, and whose practice andremuneration depend almost entirely on how hesucceeds in this and not infrequently on his willingnessto sign insurance and incapacity certificates exactlyas desired by his patients.The immediate effect of the extension of the panel

proposed by the B.M.A. would be to double the com-mercial value of every panel practice, or, in otherwords, immediately to put about £1000 to £2000 inenhanced capital value into the pocket of every panelpractitioner. Panel practices are freely bought andsold and fetch good prices. Indeed, many doctors arecompelled to buy a panel practice-often with bor-rowed money-to make a living. Anyone, therefore,with a minimal qualification and the necessary capital,

or who can borrow it from a money-lender, can acquirea panel practice and, provided he has a suave andpleasant manner, can retain or even increase it, becausethe public mostly cannot appraise the true value ofthe medical services received. To extend the panel tothe dependants of the insured, so that the principalmedical service for 80 per cent. of the population(paid for to a considerable extent by the state) isprovided by appointments sold to the highest bidder,must surely be absolutely impossible in a democraticcountry. If this is granted, as indeed it must be, someother method of transition from the present mixtureof panel and private practice to a salaried general-practitioner service must be found.

SUGGESTED SCHEME

What is to be aimed at eventually is a full-timesalaried general-practitioner service, each member ofwhich should be responsible for the health of a certainnumber of persons, say 2000 in country districts and2500 in towns. The salary would depend to someextent on length of time in service—i.e., seniority-and might reach a maximum at 50, but there would ofnecessity be some supervisory posts. There would alsobe a pension at retiring age, or before if the practi-tioner is certified unfit. In such a service elasticityis essential if it is to attract the best men. It shouldbe possible for members to become clinical assistantsin the special departments (including medicine andsurgery) at the hospital and, after the necessary train-ing and experience, heads of such departments. Theymight also undertake part-time work in hospitals andschool clinics, reducing the number of patients ontheir list accordingly.

There are about sixteen million insured workers,nearly all of whom are on the panel of some doctor.These have about fifteen million dependants. Whenthese last require the services of a general practitionerthey usually get it, if they get it at all, from thepanel doctor of the father or breadwinner of thefamily. It is suggested that an offer should be madeto every panel practitioner that, if on the appointedday he becomes a member of the new home-doctorservice, all his existing panel patients and theirdependants should be placed on his list, and that heshould be paid a salary which is a fraction of thesalary of a whole-time doctor in the home service ofthe same age, the numerator of which fraction is hislist of panel and dependant patients and the denomin-ator 2500 in town and 2000 in country, expressed bythe following formula :-

He would also receive on retirement through age orill health a like proportion of the pension of a full-time doctor in the home service of the same age ashimself, although he might only have been a memberof the service for a few months. Should any of thepatients for whom the state accepts responsibilitybecome tired of their doctor, they could transfer tothe list of any other doctor in the home service whohas a vacancy. Some of the more senior and muchrespected members of the home-doctor service wouldhave waiting-lists, but so have some panel practitionerstoday. Vacancies on the lists of the home doctorswould be filled by persons who desire him as theirdoctor or by others who express no preference; but

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the number on each list on the appointed day wouldnot be exceeded. As existing practitioners die or

retire their lists, so far as the public service is con-cerned, would be amalgamated and taken over byfull-time doctors. Experience of the sale of practicesindicates that about 90 per cent. of these potentialpatients would accept transfer. The remainder couldbe added to the list of the doctor they prefer, so faras vacancies permit. It would be as simple to registerfor medical advice as for bacon and butter.

Certain special classes of potential patients needfurther consideration. Many people, such as hawkers,cobblers, smallholders, and small shopkeepers, earn lessthan £250 a year, but are not insured. With dependantsthey are said to number about four million. They wouldbe asked to register, indicating the doctor of theirchoice. If he agreed, their names would swell his list ofhome-service patients. If he refused, they would beadded to that of some other part-time or full-time doctorin which vacancies occurred. District medical officers,who are responsible for the care of public-assistancecases, are " senior poor-law officers" and can only bedismissed for some serious neglect of duty. On theirdeath or retirement their patients would be trans-ferred to the home-doctor service.

All the necessary facilities must be provided toassist the doctors in the home service to do the verybest for their patients. Pathological, specialist,nursing, and other services must be available, and itmust be easy to obtain a second opinion. Machinerymust also be provided for the investigation of com-plaints.

ITS ADVANTAGES

What is the essential difference between appointingpart-time home doctors and extending the panel tothe dependants of the insured ? The difference isclearly fundamental. The part-time home doctor,although he may be selected by his patients, will notbe appointed by them. He will be appointed by thelocal authority. When he dies or retires, no one

doctor will have a greater claim to his appointmentthan any other. The post will be advertised, and thebest man who applies will be appointed. In otherwords, the appointment will be no more saleable thanany other civil-service appointment. The importantquestion for the medical profession is whether thisscheme would be fair to those who have invested alarge sum of money in the purchase of their practicesand are trusting that the sum obtainable by their salelater on will provide for their old age. Others havebeen compelled to borrow money to buy a practice.This they are trying to pay off year by year, andthey are hoping that, when the time for retirementcomes, the debt will have been repaid and theirpractice will still be saleable. How will these doctorsview the proposed change ?

First, there are many advantages that are boundto appeal to the harassed and overworked generalpractitioner. He will probably live longer to enjoyhis retirement, for he will have regular holidays andthe certainty of a fixed and secure income if he doeshis work well. He will also have the satisfaction ofbeing able to do better medical work; for it will beeasy to obtain the assistance of his colleagues in allbranches of the profession; he will be able to followup his cases in hospital; and he will have studyleave, opportunities of research, and the satisfactionof helping to prevent disease besides patching up thefallen.The advantages from the financial standpoint are no

less real. Most general practitioners are concernedwith patients who may be divided from the financialstandpoint into three classes: (1) the relatively well-

to-do-i.e., those above the panel income limit ofNational Health Insurance (f:250 a year) ; (2) panelpatients; and (3) dependants of those on the paneland persons of a like financial class. Those with anincome of more than E250 call for no comment,because they will not be affected, and the value ofthe practice, so far as they are concerned, will notbe influenced in any way. As regards the panelpatients, it may be conceded that security of incomeand absence of any risk through the action of a lessscrupulous neighbour who would sign any certificatepresented to him will go some way to compensatefor the saleable value of the panel part of the practice.Most important, however, is the question of pension.As has already been stated, this will depend not onlength of time in the service but on age and willgive absolute security both for old age and retirementdue to ill-health, a security much more certain andassured than that obtainable by investment or bypurchase of an annuity after the sale of a practice.It is generally agreed that the commercial value ofthat section of a practice that results from thedependants of the insured is not great, for the verygood reason that these patients are as a rule onlyable to pay small fees and in not a few cases no feesat all. Under the scheme adumbrated, for the firsttime, reasonable fees and a pension would be receivedon behalf of these people. In this direction, there-fore, the practitioner would greatly benefit.

MEDICINE AND THE LAW

Alleged Impersonation of Medical PractitionerAndrew John Gibson, aged 72, was last week com-

mitted for trial at the next Staffordshire assizes oncharges of manslaughter of a patient at the Stoke-on-Trent maternity hospital, giving false death certifi-cates, forging death certificates, uttering the forgedcertificates, and obtaining money by false pretencesfrom the city. The prosecution alleged that he hasbeen impersonating a medical practitioner resident inSydney named Harry Cecil Rutherford Darling. Theaccused objected in court to being referred to as

Gibson; he said his name was Harry Cecil RutherfordDarling. Alderman Kemp, a chemist, chairman ofthe city health and hospital committee in September,1939, gave evidence that the accused told him he wasa gynaecologist; the witness knew him as Dr. Darling.Dr. Arthur Hancock, resident medical officer, statedthat in October, 1939, Alderman Kemp recommendedhim a locum tenens and instructed him to write to theaccused. He did so and received a reply signedH. C. R. Darling; he handed over his duties at thehospital to the accused on Nov. 23. Cross-examinedby the accused, Alderman Kemp said that all theprescriptions he had received from him while actingas locum tenens were in order; they contained nothingto suggest that they were issued by an unqualifiedman. The manslaughter charge related to the deathof a named woman who was brought to the maternityhospital suffering from haemorrhage. It was allegedthat the accused took no active steps to check thebleeding, but asked the advice of the nurse in charge,and, when she suggested a restorative and a salineinjection, left her to give the treatment. Accordingto a police witness, the defendant, after his detention,stated that he was not qualified to issue a deathcertificate; he claimed, however, to have the necessaryskill and knowledge. The case being now sub judice,comment must be reserved until the result of the trialat assizes is known.