- Email: [email protected]
QUALITY IN GENERAL PRACTICE
534
Letters
National Health Service
QUALITY
MANAGEMENT IN THE NEW N.H.S. PROPOSALS for the management of the reorganised N.H.S. were published earlier this week.l The recommendations come from a Steering Committee under the chairmanship of Permanent Secretary at the D.H.S.S., Sir Philip Rogers. Before final decisions on the proposals are reached there will be consultation with the professional and staff interests concerned. The proposed arrangements have six main
features: at district level.-Here the approach has been to BBith the patient and identify the points at which integration is needed. The proposals aim to facilitate contact between general practitioners and hospitals and to build on the groundwork already laid in establishing community health teams with ancillary staff attached to group practices. The basic operational unit of the new N.H.S. will be the District with a population of between 200,000 and 300,000. Within the District there would be a unified nursing service, one administrative organisation, and a District Medical Committee elected by family doctors and consultants. Participation of clinicians.-General practitioners and consultants will have clinical autonomy but must be directly involved in the developments of the services in which they work because the demands they make on resources have to be reconciled with one another and because their decisions and actions affect the work of others in the Health Service and personal social services. They will do this by taking part individually in making proposals for the development of local services in their particular sphere of interest and by electing two representatives (one a consultant, the other a general practitioner) to the District Management Team. And there will be professional advisory committees at Area and Region levels. Coordination of multidisciplinary teams.-The Steering Committee have concluded that a single hierarchy in which a chief executive would be accountable for the running of health services in a particular location would not be appropriate. This responsibility will rest with " small teams of equals " drawn from the main disciplines providing health care at District, Area, and Region. Clear allocation of authority and accountability.- The obligations of family practitioners will be established by contract with the Family Practitioner Committee of the Area Health Authority. The report suggests that staff employed by the Area Health Authority could be organised in hierarchies-consultants who, like general practitioners, are primarily accountable to their patients, would be an exception but medical administrators would not. The efficacy of the new N.H.S. would depend on having thousands of managers held accountable for their own work and for that of their subordinates. Decentralisation balanced with strategic direction.-There should be greater delegation from the centre and regions to local management. Plans will need adjustment, and the report proposes that revenue reserves should be held at all levels of the service; arrangements are being worked out to allow the new authorities to carry over unspent revenue from one year to the next; and they will also have some freedom to use capital allocations for revenue expenditure and vice versa. The need for flexibility.-Areas and regions differ a lot in size, so there will be a need for flexibility in the adaptation of arrangements to meet local needs.
Integration
start
The proposed constitution of the management teams is follows: at District level a team of six (two elected medical representatives with a district community physician, nursing officer, finance officer, and administrator); at Area level a team of four (medical officer, nursing officer, treasurer, administrator); and at Regional level a team of five (medical officer, nursing officer, works officer, treasurer, and administrator). as
1.
Department of Health and Social Security. Management Arrangements for the Reorganised National Health Service. H.M. Stationery Office. 75p.
to
the Editor
IN GENERAL PRACTICE
SIR,-My paper, though critical, does
stem from a
deep
belief in the value of general practice and a desire to see its standards raised. I am glad you have introduced it in that I cannot, however, accept the way (Aug. 26, p. 411). criticisms you make. You say, first of all, that my review is not " fair " and that I do not pretend to form a " balanced judgment". Yet, when you try to balance the picture, all you can cite is the advent of vocational training and the creation of university departments of general practice. What kind of evidence is that ? My paper is an attempt to assess the work actually done by general practitioners now, not an appraisal of influences which may raise standards 10 years hence. It is true that many of the reports I cited are over 5 years old but, unfortunately, I was forced to use them because they were the latest-and, in many cases, the only-data available. Take, for example, the subject of wash-basins, the most important point I covered. The only data I could find on this subject applied to the year 1963, a period, of course, which antedates the improvements of the past 5 years. The situation may have changed since then, but we have no way of knowing because no later data exist. I cannot, however, dismiss this finding as swiftly as you do. The period to which it applies, after all, was only 9 years ago and no small percentage of the profession was involved. How was it possible, in the middle of the 20th century, for more than 1 out of 3 G.P.S to be practising without any wash-basin at all ? Did not the profession, only a few years earlier, carry out its own inspection to make sure its surgeries were properly equipped ? What, one may justly ask, did those inspections amount to ? And why, when the CartwrightMarshall study appeared in 1965, did no-one call attention to the absence of wash-basins in so many surgeries ? It does not take a medical qualification to assess the importance of this finding, and I have no hesitation in asserting that a doctor who practises without a wash-basin is a danger to the public. Even if only 1 % of the profession now do so, it is a cause for concern, and the percentage involved in 1963 was so high (35%) that we can be sure there are still some G.P.S around who practise in this way. Only 2 weeks ago a rural council in Kent had to issue a warning to some doctors who opened a branch surgery without washing or lavatory facilities.1 Is it enough, in any case, just to know that wash-basins exist ? We know hardly anything at all about the way G.P.S actually use the equipment they do possess. How many microscopes are still in the condition Collings found them - lying unused, gathering dust on surgery shelves ? And how many patients are being referred to hospital simply because G.P.S are not willing to take the time it needs to make urine analyses and blood-tests ? The rise in outpatient attendances no doubt does stem from more than one source, but we do know that much of the work done in hospital could be handled by G.P.S in their own surgeries if they made use of the same equipment that G.P.S in other countries possess. For one reason or another they are not doing the work, and that makes it hard to resist the conclusion that they are partly responsible. If this inference is wrong, then where is the evidence to refute it ? What is the remedy for the malaise in general practice ? No single solution will suffice, and I welcome your call for medical audits. But how can you reject the main theme of my paper-the need for specialist aid to raise the standard 1. Kent
Messenger (East
Kent
edition), Aug. 18, 1972, p. 1.
535 of general practice ? Many experts, including no less a figure than Sir John Brotherston himself, see this as the key to the quality problem. Why ? Here, I would suggest a simple answer: because, right or wrong, G.P.s do not think they have much to learn from each other. Why else little clinical consultation occur within group and partnerships ? Group practice in Britain is confined to G.P.s and, because of that, it amounts to little more than a rota and financial partnership. Yet this development was foreseen by the British Medical Journal as far back as 1946: " The general practitioner does not so much want consultation with another practitioner in a health centre as with the man who has expert knowledge he does not possess himself."2 This analysis, of course, depends on what you conceive the main function of a G.P. to be: should he be a junior consultant or a senior social worker ? There is nothing necessarily antithetical between these two roles, and a good G.P. will strive to be both. I support strongly the movement to make G.P.S more aware of the social and psychological aspects of medical care. This is needed not only to promote complete care but also to enable G.P.s to distinguish more clearly between organic and other factors. But we must not push this process so far that we turn G.P.s into specialists of social medicine and undermine their generalist competence on the clinical side. That would, indeed, be an ironic reversal of priorities, for a G.P.’s main role is, and must always be, that of a primary diagnostician in clinical medicine. Let me use an example to make my meaning clear. When a patient sees a G.P. and complains of a pain in the stomach, he wants his G.P. to make a proper physical examination and not leap to the conclusion that it was simply due to an argument the patient had with his employer the day before. The danger of the stress now being placed on social work is that it will reinforce the tendency, all too prevalent in British general practice, to make hasty diagnoses without American doctors seem proper physical examinations. much less prone to such methods. This is due partly, of course, to the competitive pressures arising from private practice, but it also owes something to the influence exercised by specialists on the way medicine is practised in America. It is true that general practice has practically disappeared there, but that stems mainly from the country’s failure to create a State system: private practice forced G.P.s to become specialists in order to survive. Only with State aid can they secure the financial security they need to resist such pressure-but that does not mean they have to be removed from the hospital world to do it. Britain, unfortunately, did just that in 1948 to get rid of the G.P. surgeon but, as Brotherston has pointed out, in so doing " we lost the baby with the bath water 11.3 America, when it creates its own State system will, I hope, not make the same mistake. The separation of G.P.S from the hospital world has seriously weakened British medicine. It, more than any other factor, is responsible for the deplorable conditions described in my paper. Health centres, attachment schemes, vocational training, medical audits-all are necessary-but, if we reform general practice without creating close links with the hospital world, we are inviting disappointment. Wewill find, 10 years hence, that our health centres have become not " centres of excellence" but " centres of disillusionment ". does
so
practices
,
26 orthumberland London W.2.
Place,
SiR,—Is it quality or is it time that is lacking ? I’m an anachronism that has so far survived, a dodo that has not yet died. Why ? Because I was defeated by the excessive hours I had to work as a G.P. in the N.H.S., so I resigned on April 1, 1959, with a small nucleus of private patients-about 70, I think-and no private income, took up private practice, and have never regretted it. I think it is the ready availability of a friend in need that makes my practice viable. Not the possession of a haemoglobinometer or a microscope, or any special skills or
gimmicks. For instance, in the past quiet August week, I’ve seen only 88 patients; but I’ve had 116 telephone calls, 77 of which I have answered personally, without having to be defended by a secretary. This method solves a lot of problems without bringing the patient to the surgery, or involving him in any expense beyond that of a telephone call. I’m no better doctor than my colleagues, and I don’t think I waste more time on trivialities, or grovelling to the wealthy; but I do spend more time in general chat, as one tends to with friends. Friendship is a greater incentive to good work than legal contracts or big fees, because you hate to let your friends down: so give us time to make friends of our patients and no-one need worry about the quality of general practice. The Old Orchard, 25 Catherine Road,
Surbiton, Surrey KT6 4HA.
SIR,-Mr. Honigsbaum1 has indeed afforded a service general practice, as your leading article (Aug. 26, p. 411) makes clear. Mr. Honigsbaum, however, is stronger on to
criticism than he is on answers: yet the fact that his fierce and unpalatable critique was printed at all, so close to the " cosy corridors of the College 2 (of General Practitioners) is itself powerful evidence that general practice is finding its feet, and coming of age. Your advocacy of " medical auditing " is obviously the only viable solution in a hazardous situation. Yet how practicable a solution is it ? Just how many practising clinicians would be prepared to submit themselves to close and expert scrutiny ? How many of your readers, for example, would be prepared to record their daily clinical work in a format susceptible to detailed medical auditing ? Or how many would simply hide their professional timidity behind complaints of the trouble and expense of such an innovation ? If you knew the answer to these questions, you would know for certain whether or not general practice is going to survive in the National Health Service. For myself, I have been using a similar system for the past 2 years. It costs around E50 a year net. The opportunity to determine whether my clinical activities have been beneficial with respect to my patients’ symptoms, or not, is most stimulating. The practice of medicine, after all, is concerned fundamentally with the alleviation of suffering: it should therefore also be concerned with finding out how successful it has been in this regard. Will medical auditing come soon to save general practice-and by implication the enough National Health Service itself ? "
_
16c
FRANK HONIGSBAUM.
CHARLES STEER.
Clough Lane, Grasscroft,
ROBERT
Oldham OL4 4EW. 2 Br. med. J. 1946, i, 612. 3. Brotherston, J. in Management and the Health Services A. Gatherer and M. D. Warren); p. 1. Oxford, 1971.
(edited by
1. Honigsbaum, F. 2. ibid. p. 425.
J. R. Coll.
gen.
Practns, 1972, 22,
JOHNSON.
429.
_
Letters
National Health Service
QUALITY
MANAGEMENT IN THE NEW N.H.S. PROPOSALS for the management of the reorganised N.H.S. were published earlier this week.l The recommendations come from a Steering Committee under the chairmanship of Permanent Secretary at the D.H.S.S., Sir Philip Rogers. Before final decisions on the proposals are reached there will be consultation with the professional and staff interests concerned. The proposed arrangements have six main
features: at district level.-Here the approach has been to BBith the patient and identify the points at which integration is needed. The proposals aim to facilitate contact between general practitioners and hospitals and to build on the groundwork already laid in establishing community health teams with ancillary staff attached to group practices. The basic operational unit of the new N.H.S. will be the District with a population of between 200,000 and 300,000. Within the District there would be a unified nursing service, one administrative organisation, and a District Medical Committee elected by family doctors and consultants. Participation of clinicians.-General practitioners and consultants will have clinical autonomy but must be directly involved in the developments of the services in which they work because the demands they make on resources have to be reconciled with one another and because their decisions and actions affect the work of others in the Health Service and personal social services. They will do this by taking part individually in making proposals for the development of local services in their particular sphere of interest and by electing two representatives (one a consultant, the other a general practitioner) to the District Management Team. And there will be professional advisory committees at Area and Region levels. Coordination of multidisciplinary teams.-The Steering Committee have concluded that a single hierarchy in which a chief executive would be accountable for the running of health services in a particular location would not be appropriate. This responsibility will rest with " small teams of equals " drawn from the main disciplines providing health care at District, Area, and Region. Clear allocation of authority and accountability.- The obligations of family practitioners will be established by contract with the Family Practitioner Committee of the Area Health Authority. The report suggests that staff employed by the Area Health Authority could be organised in hierarchies-consultants who, like general practitioners, are primarily accountable to their patients, would be an exception but medical administrators would not. The efficacy of the new N.H.S. would depend on having thousands of managers held accountable for their own work and for that of their subordinates. Decentralisation balanced with strategic direction.-There should be greater delegation from the centre and regions to local management. Plans will need adjustment, and the report proposes that revenue reserves should be held at all levels of the service; arrangements are being worked out to allow the new authorities to carry over unspent revenue from one year to the next; and they will also have some freedom to use capital allocations for revenue expenditure and vice versa. The need for flexibility.-Areas and regions differ a lot in size, so there will be a need for flexibility in the adaptation of arrangements to meet local needs.
Integration
start
The proposed constitution of the management teams is follows: at District level a team of six (two elected medical representatives with a district community physician, nursing officer, finance officer, and administrator); at Area level a team of four (medical officer, nursing officer, treasurer, administrator); and at Regional level a team of five (medical officer, nursing officer, works officer, treasurer, and administrator). as
1.
Department of Health and Social Security. Management Arrangements for the Reorganised National Health Service. H.M. Stationery Office. 75p.
to
the Editor
IN GENERAL PRACTICE
SIR,-My paper, though critical, does
stem from a
deep
belief in the value of general practice and a desire to see its standards raised. I am glad you have introduced it in that I cannot, however, accept the way (Aug. 26, p. 411). criticisms you make. You say, first of all, that my review is not " fair " and that I do not pretend to form a " balanced judgment". Yet, when you try to balance the picture, all you can cite is the advent of vocational training and the creation of university departments of general practice. What kind of evidence is that ? My paper is an attempt to assess the work actually done by general practitioners now, not an appraisal of influences which may raise standards 10 years hence. It is true that many of the reports I cited are over 5 years old but, unfortunately, I was forced to use them because they were the latest-and, in many cases, the only-data available. Take, for example, the subject of wash-basins, the most important point I covered. The only data I could find on this subject applied to the year 1963, a period, of course, which antedates the improvements of the past 5 years. The situation may have changed since then, but we have no way of knowing because no later data exist. I cannot, however, dismiss this finding as swiftly as you do. The period to which it applies, after all, was only 9 years ago and no small percentage of the profession was involved. How was it possible, in the middle of the 20th century, for more than 1 out of 3 G.P.S to be practising without any wash-basin at all ? Did not the profession, only a few years earlier, carry out its own inspection to make sure its surgeries were properly equipped ? What, one may justly ask, did those inspections amount to ? And why, when the CartwrightMarshall study appeared in 1965, did no-one call attention to the absence of wash-basins in so many surgeries ? It does not take a medical qualification to assess the importance of this finding, and I have no hesitation in asserting that a doctor who practises without a wash-basin is a danger to the public. Even if only 1 % of the profession now do so, it is a cause for concern, and the percentage involved in 1963 was so high (35%) that we can be sure there are still some G.P.S around who practise in this way. Only 2 weeks ago a rural council in Kent had to issue a warning to some doctors who opened a branch surgery without washing or lavatory facilities.1 Is it enough, in any case, just to know that wash-basins exist ? We know hardly anything at all about the way G.P.S actually use the equipment they do possess. How many microscopes are still in the condition Collings found them - lying unused, gathering dust on surgery shelves ? And how many patients are being referred to hospital simply because G.P.S are not willing to take the time it needs to make urine analyses and blood-tests ? The rise in outpatient attendances no doubt does stem from more than one source, but we do know that much of the work done in hospital could be handled by G.P.S in their own surgeries if they made use of the same equipment that G.P.S in other countries possess. For one reason or another they are not doing the work, and that makes it hard to resist the conclusion that they are partly responsible. If this inference is wrong, then where is the evidence to refute it ? What is the remedy for the malaise in general practice ? No single solution will suffice, and I welcome your call for medical audits. But how can you reject the main theme of my paper-the need for specialist aid to raise the standard 1. Kent
Messenger (East
Kent
edition), Aug. 18, 1972, p. 1.
535 of general practice ? Many experts, including no less a figure than Sir John Brotherston himself, see this as the key to the quality problem. Why ? Here, I would suggest a simple answer: because, right or wrong, G.P.s do not think they have much to learn from each other. Why else little clinical consultation occur within group and partnerships ? Group practice in Britain is confined to G.P.s and, because of that, it amounts to little more than a rota and financial partnership. Yet this development was foreseen by the British Medical Journal as far back as 1946: " The general practitioner does not so much want consultation with another practitioner in a health centre as with the man who has expert knowledge he does not possess himself."2 This analysis, of course, depends on what you conceive the main function of a G.P. to be: should he be a junior consultant or a senior social worker ? There is nothing necessarily antithetical between these two roles, and a good G.P. will strive to be both. I support strongly the movement to make G.P.S more aware of the social and psychological aspects of medical care. This is needed not only to promote complete care but also to enable G.P.s to distinguish more clearly between organic and other factors. But we must not push this process so far that we turn G.P.s into specialists of social medicine and undermine their generalist competence on the clinical side. That would, indeed, be an ironic reversal of priorities, for a G.P.’s main role is, and must always be, that of a primary diagnostician in clinical medicine. Let me use an example to make my meaning clear. When a patient sees a G.P. and complains of a pain in the stomach, he wants his G.P. to make a proper physical examination and not leap to the conclusion that it was simply due to an argument the patient had with his employer the day before. The danger of the stress now being placed on social work is that it will reinforce the tendency, all too prevalent in British general practice, to make hasty diagnoses without American doctors seem proper physical examinations. much less prone to such methods. This is due partly, of course, to the competitive pressures arising from private practice, but it also owes something to the influence exercised by specialists on the way medicine is practised in America. It is true that general practice has practically disappeared there, but that stems mainly from the country’s failure to create a State system: private practice forced G.P.s to become specialists in order to survive. Only with State aid can they secure the financial security they need to resist such pressure-but that does not mean they have to be removed from the hospital world to do it. Britain, unfortunately, did just that in 1948 to get rid of the G.P. surgeon but, as Brotherston has pointed out, in so doing " we lost the baby with the bath water 11.3 America, when it creates its own State system will, I hope, not make the same mistake. The separation of G.P.S from the hospital world has seriously weakened British medicine. It, more than any other factor, is responsible for the deplorable conditions described in my paper. Health centres, attachment schemes, vocational training, medical audits-all are necessary-but, if we reform general practice without creating close links with the hospital world, we are inviting disappointment. Wewill find, 10 years hence, that our health centres have become not " centres of excellence" but " centres of disillusionment ". does
so
practices
,
26 orthumberland London W.2.
Place,
SiR,—Is it quality or is it time that is lacking ? I’m an anachronism that has so far survived, a dodo that has not yet died. Why ? Because I was defeated by the excessive hours I had to work as a G.P. in the N.H.S., so I resigned on April 1, 1959, with a small nucleus of private patients-about 70, I think-and no private income, took up private practice, and have never regretted it. I think it is the ready availability of a friend in need that makes my practice viable. Not the possession of a haemoglobinometer or a microscope, or any special skills or
gimmicks. For instance, in the past quiet August week, I’ve seen only 88 patients; but I’ve had 116 telephone calls, 77 of which I have answered personally, without having to be defended by a secretary. This method solves a lot of problems without bringing the patient to the surgery, or involving him in any expense beyond that of a telephone call. I’m no better doctor than my colleagues, and I don’t think I waste more time on trivialities, or grovelling to the wealthy; but I do spend more time in general chat, as one tends to with friends. Friendship is a greater incentive to good work than legal contracts or big fees, because you hate to let your friends down: so give us time to make friends of our patients and no-one need worry about the quality of general practice. The Old Orchard, 25 Catherine Road,
Surbiton, Surrey KT6 4HA.
SIR,-Mr. Honigsbaum1 has indeed afforded a service general practice, as your leading article (Aug. 26, p. 411) makes clear. Mr. Honigsbaum, however, is stronger on to
criticism than he is on answers: yet the fact that his fierce and unpalatable critique was printed at all, so close to the " cosy corridors of the College 2 (of General Practitioners) is itself powerful evidence that general practice is finding its feet, and coming of age. Your advocacy of " medical auditing " is obviously the only viable solution in a hazardous situation. Yet how practicable a solution is it ? Just how many practising clinicians would be prepared to submit themselves to close and expert scrutiny ? How many of your readers, for example, would be prepared to record their daily clinical work in a format susceptible to detailed medical auditing ? Or how many would simply hide their professional timidity behind complaints of the trouble and expense of such an innovation ? If you knew the answer to these questions, you would know for certain whether or not general practice is going to survive in the National Health Service. For myself, I have been using a similar system for the past 2 years. It costs around E50 a year net. The opportunity to determine whether my clinical activities have been beneficial with respect to my patients’ symptoms, or not, is most stimulating. The practice of medicine, after all, is concerned fundamentally with the alleviation of suffering: it should therefore also be concerned with finding out how successful it has been in this regard. Will medical auditing come soon to save general practice-and by implication the enough National Health Service itself ? "
_
16c
FRANK HONIGSBAUM.
CHARLES STEER.
Clough Lane, Grasscroft,
ROBERT
Oldham OL4 4EW. 2 Br. med. J. 1946, i, 612. 3. Brotherston, J. in Management and the Health Services A. Gatherer and M. D. Warren); p. 1. Oxford, 1971.
(edited by
1. Honigsbaum, F. 2. ibid. p. 425.
J. R. Coll.
gen.
Practns, 1972, 22,
JOHNSON.
429.
_