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INCOMES FOR SPECIALISTS AND GOVERNMENTMEDICAL OFFICERS

SIR,—" Stepchild of the Profession " is to be con-

gratulated on his courage in writing to you last weekregarding the salaries of Government medical officers.May I add a further point which, alas, falls within myown knowledge and experience ?

In 1928 the maximum salary attainable by a regionalmedical officer in the Ministry of Health’s InsuranceMedical Service was £1400, and entrants to the servicewere recruited from general practitioners, who werereceiving a capitation fee of 9s. Today the maximumsalary attainable by a regional medical officer (outsideLondon and one or two big towns) is £1420, and yet thecapitation fee for general practitioners after July 5 isto be approximately 18s.

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REGIONAL MEDICAL UFFICER.

THE COUNTRY DOCTOR

SIR.—There has recently been some discussion in thelay press about the remuneration of dentists, and now theproposed terms for specialists have been published. Butwe still hear nothing of the remuneration of generalpractitioners, who will, after all, bear the brunt of thework before the profession. If this means that theproposals issued by the Minister last December are toremain unaltered there will be a lamentable fall in thestandard of living of a high proportion of general practi-tioners, and men in rural districts especially will begrossly underpaid as compared with their presentearnings.The scope of the country doctor is limited by the

population resident in his district, and in this respecthe is at a disadvantage compared with practitionersin towns, where there is frequently overlapping ofpractices. In country areas the number of wealthierpatients paying high fees is usually rather limited,and much of the income from private practice is derivedfrom dependants of insured persons and others of similarstatus. This is, of course, the type of person who willinevitably claim treatment under the National HealthService. It seems a fairly general experience thatmany patients who might have been expected to remainprivate are in fact joining the scheme, particularly thepeople, and dependants of such people, who are withinthe age-limits for compulsory insurance contributiuns ;they feel they cannot afford to do otherwise. Thus inmany districts the income ’from private practice willsoon be negligible, and the general practitioner will bealmost entirely dependent upon capitation payments.The Minister’s proposals are alleged to be based on theSpens report-but those figures were estimated for thecost of living in 1936-38, and were in fact arrived atafter a study of doctors’ incomes and expenditure forthose years. They are thus quite inadequate for thepresent day.Two points in the calculation of fees appear unjust :(1) The fewer the patients joining the service, the higher

the capitation (158. 2d. for 95% rising to 18s. for 80% ofthe population). This should be reversed, if one couldassume that the fewer in the service the greater the potentialincome from private practice. But if it be argued that thisis to allow for the risk of being called on to attend as Statepatients those who have never registered as such, the Actis not clear on this point. Such a risk obviously involvesloss to the doctor, if the National Health Insurance systemis followed, whereby fees are only payable for patients on hislist at the beginning of the quarter. -Now that patients arefree to change their doctor at any moment without notice,a man may be treated by a succession of doctors, none ofwhom may receive a fee unless payment is calculated from thedate the patient presents his card, or (not having previouslydone so) from the day on which he requests treatment etherthan as a temporary resident on the list of a doctor elsewhere.

(2) A central fund is proposed equal to capitation of 18s. for95 "o of the population. Various deductions are to be madebefore the actual capitation fee is calculated. This is surelyunfa,ir. Mileage and other payments should be from a

separate fund, so that the real fee can be stabilised from timeto time.

We have no intimation as to the amount of mileageallowance. Hitherto this has been regarded as a contribu-

tion to motoring expenses, which in the country areheavier than in towns, in proportion to the number ofpatients it is possible to visit. Now that capitationpayment will be the main source of income, mileageallowance should be at a far higher rate than under theN .H.I. A fairer method would be to make an induce-ment payment to compensate for the limitation of possiblework which distances and scattered populations impose,in addition to a mileage allowance as a contribution tothe higher expenses of the rural practitioner for motoring,&c. A speaker at a B.M.A. meeting once said that ifthe capitation for town doctors were 15s. that for the.country doctors should be 25s., and some such recogni-tion, either by capitation or separate inducement, is surelyjustifiable.The disastrous effect of the existing proposals on rural

practice can be shown by one example, a district I know well.Assuming that the Minister’s proposed 18s. for 95% of thepopulation would cover capitation fees plus mileage and otherpayments, the total gross payments for the whole populationfor all the doctors now practising there would actually beless than the net income (after paying expenses) earned lastyear by exactly half those men, engaged in mixed panel andprivate practice. If the patients were equally divided betweenthem, which they may not be, no man could earn ps much as£1000 a year gross. Can a 50% loss be a fair remunerationfor established practitioners,’ some of over twenty years’standing ?

Does the Minister realise the real anxiety his proposalshave aroused in many of us, and the genuine distresswith which many are faced ? Most doctors have beendriven into the service solely by economic pressure ;they cannot afford to stay out, but are none the lessfaced with serious financial loss when they are in it.Unless some improvement is offered, the Governmentmust be prepared for a serious drop in the number offuture entrants to the profession. Many doctors willnow be unable to afford to put their children intomedicine ; others will refuse to do so owing to theconditions. Non-medical parents may well feel that thisprofession no longer offers a fair return for the time andexpense of the necessary scientific education, so thatpublic-school and university men will look elsewherefor a career. Medicine as a whole and the patients willthus suffer from a shortage, both in numbers and ofthe most suitable type of entrants. With such prospectsfor so many, wholehearted cooperation cannot beexpected, and the service will not be a success.

Hurstpierpoint, Sussex. RALPH GREEN.

Public Health

Recovery of Costs by Local Health AuthoritiesTHE National Health Service Act enables local health

authorities to recover charges for articles and servicesprovided under sections 22, 28, and 29, subject to theMinister of Health’s approval and having regard tothe patient’s means. The Minister of Health has nowissued a circular (100/48) setting out the articles andservices for which charges may be made. They are asfollows :

Under sect-iorz 22 (care of mothers and young children):all articles, including meals supplied and equipment lent foruse in day-nurseries, mother and baby homes, &c., except(a) welfare foods, as defined in the Welfare Foods Order,which may from time to time be supplied by the Ministryof Food for distribution by local health authorities; (b)maternity outfits for expectant mothers and dressings requiredduring the lying-in period ; (c) special cots for prematurebabies ; (d) medicaments ; and (e) dentures, eyeglasses, andsimilar appliances, not being replacements necessitated bylack of care on the part of the person concerned.

Under section 28 (prevention of illness; care and after-care) : all articles of extra nourishment or clothing, all gardenshelters, beds, bedding, nursing requisites, and sick-roomequipment (including that provided for patients being nursedat home) supplied or lent under the authorities’ care andaftercare service.

Under section 29 (domestic help) : all services providedunder the authorities’ approved domestic-help proposals.

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Standard charges for articles issued under sections 22and 28 are not to exceed the actual cost to the authorityplus 10 % for handling expenses. Under section 29 thestandard charge for service per hour or per day is not toexceed the actual cost to the authority, including expensesof operating the service.

It is for the local health authority to determine whetherany, and if so what, charge would be reasonable, havingregard to the means of the person concerned. In orderto achieve reasonable uniformity, the County CouncilsAssociation and the Association of Municipal Corpora-tions, in consultation with the London County Council,have been framing recommendations for the guidance oftheir ‘constituents ; and these. recommendations are toinclude a suggested basis for assessing ability to pay.

Parliament

World Food ScarcityIN the House of Lords on June 16, Viscount BRUCE

OF MELBOURNE said that when the World Food Councilof which he is chairman met in Washington a few weeksago to examine the general food situation they came tothe conclusion that the crop prospects for 1948 weremuch better than when they met last November. Butadverse weather during the next few months could

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completely wipe out the potential gains, and, even ifimprovement did occur, world production would remainfar below the needs for the coming year. In most ofthe war-devastated countries pre-war levels of foodproduction and consumption had not been regained.If all known plans for increased food production, includ-ing the Marshall plan, succeeded (and there was consider-able doubt about that), the world’s food production in1951 would only be approximately that of the immediatepre-war years. But the population of the world wasincreasing at the rate of 20-25 millions a year, and alarge expansion of production was therefore requiredto keep supplies at the present level. Unless action wastaken to achieve such an expansion the level of nutritionand health of the peoples of the world was likely to declineeven below the standards achieved before the war.

Lord Bruce urged that early and vigorous action wasdemanded from all governments, to whose notice thestark facts should be brought.Lord RENNELL had seen nowhere in the pronounce-

ments of the Government any acute sense of awarenessof the food situation. As Sir John Boyd Orr and othershad shown, the problem of food supply was so graveas to put any other problem into the background. Atpresent there did not seem to be any prospect of procuringenough food adequately to feed the people in the worldtoday. The only large area where new production offood on a large scale was possible was in Africa, andeveryone was convinced of the necessity of the schemeswhich were now in progress there. But they were onlyschemes of long-term production andcould not immedi-ately be productive. The immediate prospect after thisyear’s harvest was that there would be more and morepeople to eat less and less. The Marshall plan was onlya palliative, but it could be a direct contribution if itwas agreed that the main object was to produce more food.

Viscount ADDISON, Lord Privy Seal, agreed thatprobably the most urgent world problem today was theimmediate shortage of food. But while it was easy torecognise the grim facts it was much more difficult todetermine what we as a nation could do about it. We ewere bound to recognise the immense shortages whichconfronted us in machinery and fertilisers and in skill andthe application of science. Nevertheless, the Governmentwere fully seized of the vital importance of the topic.They had planned for increased production during thenext three or four years, and they were striving stillfurther to expand that programme. During the lasttwo years the most complete and informed survey everundertaken had been made of the possibilities of develop-ment of our Colonial territories, including Africa. Butnobody could expect that those possibilities would bequickly realised. We must do the best we could withthe shortages which now oppressed us. Lord Addisonappealed to noble Lords, whatever political appellation

they applied to themselves, not to be afraid of suchSocialism as was necessary to achieve some rationalsystem of price stabilisation and control which, heaffirmed, was essential if we were to carry through aplan of increased food production.

New National Assistance Allowances

In the House of Commons on June 16 Mr. ToM STEELE,parliamentary secretary to the Ministry of NationalInsurance, moved that the Draft National AssistanceRegulations, 1948, be approved. These regulations, hesaid, would govern the general level of assistance payableto not far short of one million citizens. They wouldapply to people at present helped by the AssistanceBoard, mainly under unemployment assistance andsupplementary pensions regulations, and by localauthorities by way of outdoor relief and under thePoor Law blind domiciliary assistance or tuberculosistreatment allowances. For the first time a bewilderingvariety of relief scales and tests of need would bereplaced by a uniform standard which would applyall over the country, but which, of course, would besubject to adjustment in relation to individual circum-stances. The new scale was intended to provide areasonable standard of living for those requiring long-term assistance. The single householder’s rate wouldbe 24s., and for a married couple 40s. ; to both a rent-allowance could be added.

The new regulations prescribed for people who hadgiven up work to undergo treatment for tuberculosisof the respiratory system; and also for the blind, ratesof 39s. for a single person and 55s. for a married couple(both plus rent). The Assistance Board intended toadminister assistance to tuberculous persons in closecooperation with the medical authorities, and the Board’slocal officers would keep in touch with the tuberculosisofficers at the local dispensaries.The new regulations, if approved, would come into

effect on July 5. The additional cost to the communityof substituting the new standards now proposed wouldbe £9 million a year, without allowing for a probableincrease in the numbers applying for assistance. Thewhole cost in future would come from the Exchequer.The motion to approve the regulations was agreed to.

QUESTION TIME

Payment of Tuberculosis AllowancesDr. SANTO JEGER asked the Minister of National Insurance

whether he was aware that it was proposed after July 5 torequire tuberculosis patients to draw their allowances frompost offices ; and whether, in view of the recognised necessityfor maintaining close contact between these people andtheir local tuberculosis care committees and the undesirabilityof asking tuberculosis patients to stand in queues with thegeneral public, he would make it possible for them to receivetheir payments through the care committees.-Mr. JAMESGRIFFITHS replied : Assistance under the National AssistanceAct to persons undergoing treatment for tuberculosis will inthe great majority of cases be paid in supplementation ofsickness benefit under the National Insurance Act which isnormally payable by orders cashable at a post office. It is notessential for the patient to attend personally at the post office.If he signs the order he can authorise someone else to cashit on his behalf.

Pensions Entitlement in Cancer Cases

Mr. D. L. LIPSON asked the Minister of Pensions how manyapplications for a pension had been refused in respect ofex-Servicemen suffering from cancer ; and would he arrangefor all these to be automatically reviewed in the light of therecent judicial decision.-Mr. GEORGE BUCHANAN replied :The number of applications in respect of cancer which havebeen rejected is estimated to be about 5500. Pensions havebeen granted in respect of cancer in about 1000 cases. Mr.LIPSON: Is the Minister referring to the cases that weregranted before the recent judicial decision ?—Mr. BUCHANAN:Although the learned judge arrived at that decision, wewere operating that plan before he came to that decision.In the judge’s case there was a conflict of facts, but we havebeen operating it for some time. Wherever a person sufferingfrom cancer could link that disability up with another diseaseand it could be proved that that was as a result of war service,