- Email: [email protected]
THE CAPITATION FEE
880
patients who
are now left in the medium-stay beds, we find 26 who have physical as well as psychiatric disabilities, 34 potential long-stay patients, and 37 in the tuberculosis unit, whose numbers are shrinking and who are not representative of the usual population of a mental
hospital. Patients in general hospitals also suffer from the present divided service, for some patients at present on acute wards in general hospitals would be more suitably placed in a medium-stay unit. Patients in hospital for any length of time with physical disabilities often have depressive and paranoid reactions, and, under present conditions, a request is often made for their transfer to a psychiatric hospital. The divided nursing service also creates difficulties. Thus a request for the transfer of a physically ill patient, who has become " unmanageable because of "
other psychiatric syndromes, often " means that this so-called " unmanageable patient is moved to a hospital where he is " managed " on a ward which has half the number of nurses, a quarter the number of doctors, and no specific psychiatric treatment facilities that were not available in the general ward. One reason for this, of course, is that far too few general nurses have psychiatric experience, nor have they learnt the therapeutic attitudes needed to manage psychiatric symptoms. Even under present conditions, general hospital nurses are far more likely to have to spend some of their time caring for psychiatric patients-e.g., senile patients, confused patients, or patients admitted following a suicidal attempt-than to be called to deliver a baby; yet the organisation of nursing training suggests the opposite. Another type of patient who would benefit from a medium-stay hospital is the younger " chronic " patient. Some of these find their way to mental hospitals; others go to chronic-sick units, where their companions are almost entirely geriatric patients; and others are managed at home with varying degrees of difficulty. As a rule there are insufficient grounds for their treatment in an acute ward, yet many would benefit by vigorous treatment and rehabilitation over some weeks or months, and the improvement in their morale would increase their chances of subsequent management at home. Some of them, of course, would benefit by further treatment at intervals over the course of their illness. Many of these difficulties would be eased, if we had a type of hospital which would take any patient-whether mentally or physically ill-whose disability seemed likely to last more than a few weeks, or to recur frequently within a year of admission. Particularly suitable for such a hospital would be the patients who need both the facilities of a general hospital and those of a psychiatric unit. Those who at the onset have either a physical or a psychiatric illness may well develop the other later. Psychiatric patients would benefit by the provisions made for the physically ill, including facilities for investigation, physiotherapy, and expert physical nursing; while many physically ill patients would benefit from the community and social life, together with occupational therapy, which has been developed so well in many mental hospitals. Like any other hospital, the medium-stay hospital should serve a local population and be easily accessible by public transport. Ideally, it should be on the same site as the " acute " district hospital. Since patients are likely to be there for several months, it should be pleasantly designed and be as little like an institution as possible. All patients will need a bedroom area, but for the severely
delirium, confusion,
.
or
will be their usual living The wards should be designed to allow the formation of small groups; yet it should be easy to move a patient from one group to another if tensions develop, as is not unlikely in seriously ill patients unable to choose their companions. Many patients-particularly those with only psychiatric disabilities-will be ambulant and will need bedroom space only for sleeping or, occasionally, as a private space to which to retire. They should be able to find their occupational and social areas off the ward. If the hospital is large enough a cafeteria service would be an advantage. Occupational therapy and physiotherapy would be available to all patients. For some this would have to be provided on the ward, but as many as possible should attend the appropriate departments. One of the most demoralising features of hospital life is the lack of change in a patient’s surroundings. Rehabilitation in its widest sense would be an important duty of the medium-stay hospital. Patients should find in the hospital opportunities for rehabilitation for their work, social life, physical activity, and personal relationships. Recent proposals (Mackie 1963) for the organisation of a hospital into residential, treatment, and rehabilitation departments would be particularly suitable for the
physically handicapped this space.
medium-stay patient. REFERENCES
Baker, A. A. (1961) Lancet, i, 656. Kidd C. B. (1962) Brit. med. J. ii, 1491. Mackie, W. (1963) Lancet, i, 211.
THE CAPITATION FEE D. S. LEES M. H. COOPER From the Economics Department,
University of Keele,
Staffordshire IN another paperwe have examined the evidence published since 1945 on the work of general practitioners, Here we relate our main findings-to the present discussion of the capitation system as a method of remuneration.2 The total sum which the State pays the medical profession for maintaining the health of the nation (the Central Pool) is based upon the concept of an " average practitioner ". Put simply, the sum which it is thought reasonable that the average practitioner should earn, multiplied by the number of doctors in practice, yields the total to be paid. This is in accord with the Danckwerts recommendations. By contrast, the Spens Committee recommendations on the distribution of this total sum between the individual members of the profession have not been implemented. The main reason, as the Ministry of Health has pointed out,3 is that, once the capitation system of payment is accepted, any elaborate method of distribution is ruled out. With very minor modifications, the distribution of the Pool is effected by a simple count of patients’ heads. At present, the average net income is E2425 per annum,4 and the average list approximately 2300 patients.5 Adding in average practice expenses, the average gross income becomes about E3700. Deductions for Exchequer superannuation contributions and the likeI reduce this to 1. Lees, D. S., Cooper, M. H. The Work of the G.P.: an analytical survey of studies of general practice. J. Coll. gen. Practrs (in the press). 2. For example, the articles by B. Abel-Smith and J. Hogarth in Medical Care, January-March, 1963. 3. Evidence to the Royal Commission on Doctors’ and Dentists’ Remuneration. Minutes of evidence: questions, 3477, 3898. 4. Raised to £2765 from April 1, 1963. 5. Average number of patients per N.H.S. principal was 2292 in October. 1961. Annual Report of the Ministry of Health for 1961; p. 44. 6. See report of Royal Commission, p. 110.
881 TABLE I-FINDINGS FROM PUBLISHED STUDIES
that, all other things being equal, this represents
a
of the doctor’s work. It is
certainly misleading to go on quoting a particular rate as in some way " representative " of practices as a whole. A recent survey of doubling
around E3100. The capitation fee of 19s. 6d. generates
E2240, and the loading of 14s. for each of 1200 patients between certain listsizes a further E840. The loading payments benefit doctors with medium-sized lists and it is evident that, quantitatively, they are the only important redistributive element in the system. Further, this redistribution has nothing to do with work but recognises the fact that any normal practice has certain overhead expenses which do not increase pro rata after the list has reached a certain size.8 Thus the capitation system equates a doctor’s work to the number of patients on his list, whether these are seen or not and irrespective of the number and kind of services rendered. It is an admittedly crude method of remuneration.9 Our purpose is to illustrate the extent of that crudeness and to make a plea for more systematic inquiry into just how the system works. *
*
*
Our survey showed that consultation-rates per person, the percentage of home visits to total consultations, and the percentage of a doctor’s list seen at least once during any given year were extremely variable as between practices. In fact, the average practice, like the average man, does not exist. In table i, the findings are illustrated. The number of observations under each heading exceeds the number of studies, ranging from (approximately) fifty for home visits to a hundred for consultation-rates per person. 10 The highest percentage of patients consulting during a year was 85, whilst at the other extreme one practice saw only half its list. In one survey alone,l1 in eight practices during a single year there was a range from 58 to 80%, which, other things being equal, represents a variation in work of approximately a third. Even taking the broad band of 60-80% as a criterion of consistency, nearly a fifth of the practices would still remain outside it. Turning to the most obvious and frequently quoted measure of a doctor’s work-the consultation-rate-a range was found of 2-7-9-2. If due allowance could be made for definitional inconsistencies, this range would probably be even greater; for the most restrictive definitions of a consultation were found at the top of the scale and vice versa. Table i suggests that a practice has no more than an even chance of having a consultation-rate of between 3-0 and 3-9. Whilst it is true that 90% of the observations fall between 3-0 and 6-0 it must be stressed 7. Between 401 and 1600 for
single-handed practices and 501 and 1700 for partnerships. 8 Report of Royal Commission para. 320. 9. There was general agreement on this in the evidence to the Royal Commission. Minutes of evidence: Medical Practitioners’ Union (p. 105); General Practice Reform Association (p. 395); Socialist Medical Association (p. 5); Scottish Association of Executive Councils (p. 1183); Royal Faculty of Physicians and Surgeons of Glasgow (p. 497); Joint memorandum of Ministry of Health and the Treasury (pp. 725, 791). Written Evidence: vol. II, Executive Councils Association (England) paras. 25, 26); Fellowship for Freedom in Medicine (p. 113). Appendix: Memorandum prepared by the Assistants and Young Practitioners Subcommittee (B.M.A.) (para. 62). 10. Throughout the paper consultation-rates refer to registered practice populations. 11. Logan, W. P. D. General Register Office. Stud. med. pop. Subj. no. 7.
nineteen doctors revealed an annual consultation-rate of 5-4 and this was described as " very similar to the rates estimated in other studies ".12 By contrast, tableI shows that only 14% of practices fall in the 5-0-5-9 range. A rate of 5-4 is not " very similar ", in terms of a doctor’s work, to a rate of 3-0-3-9 given for half the practices in our survey. Other things being equal, it represents 50% more work for the doctors concerned. The greatest dispersion is shown by the percentage of total consultations which took place in the home. The range over the studies reviewed was from 13 to 68%. A fifth of the practices had over half their consultations outside the surgery, and although 20-29% was the modal group of observations, half the practices exceeded this range and about a tenth fell below it. These seem to us surprising results, and a very probable source of large variations in the work done by different general practitioners. An identical consultation-rate for two practices would, at the least, require similar home-visit percentages. The second main group of conclusions follow from finding that patterns of distribution of these rates over agegroupings and between the sexes were consistent and predictable. The general levels of these patterns, however, were found to be extremely variable and tended to nullify any usefulness the patterns might have had for the purposes of modifying the capitation system: The patterns for consultation-rates took the form of a stepladder for females, and a stepladder at a generally lower level, but broken by a marked dip in the 15-45 age-group, for males. The two patterns thus have a tendency to diverge sharply in the 15-45 age-group. Both distributions reached a maximum in the
65-plus
age-groups.
For home visits the distributions for both sexes tended to be similar, both having the " dip " feature, although the percentage difference between the 15-45 group and the 45-65 group tended to be smaller than with consultation-rates.
These patterns, although consistent, are of little help towards modifying the capitation system. This can be best illustrated by considering those members of the doctor’s list over 65 years old. Whilst it is true that those over 65 within each practice consume, on average, more per head of a doctor’s services than the younger people, it is certainly not true that the over65s in one practice invariably consume more per head than the under-65s in another. We found, in fact, a considerable overlap in the distribution of observations for all persons and those for people over 65 only. This can be seen by comparing the figures given in table i for all persons with those in table 11 for people over 65. Thus, a higher capitation payment for old people could result in practices with a low consultation-rate for all persons gaining more than those with a high one. Apart from this, suppose the additional per-capita payment to be 10s. Taking the extreme rates found in our survey, this would represent an additional income of as little as 9d. per consultation at one end and as much as 2s. 6d. per consultation at the other. Table 11 illustrates the spread of observations found. The number of observations is
approximately fifty. Thus it is not simply that the problem of the elderly is a small one compared with the variation of morbidity between different areas ",13 but rather that the very "
12. Forsyth, G. Medical Care, January-March, 13. Royal Commission. Minutes of evidence, p.
1963, p. 11. 106.
882 TABLE II-MALES AND FEMALES OVER
65
major conclusion that seems to emerge from is that widely differing amounts of work are survey done by individual practices for any given annual income. The distributive effects of the capitation system seem to be far cruder than has been supposed. Nor does our evidence indicate that refinements will be easy to introduce. The popular notion of higher capitation payments for old people and for women might well result in a more, not less, unequal distribution. Though the capitation system has been in operation for more than fifty years, its relation to the doctor’s work remains largely unexplored. Lack of knowledge is a poor foundation on which to base the distribution of financial rewards of an ancient profession. What is urgently needed is an intensive study of a large group of practices in a given area. realised. A
YEARS OLD
our
large variation between practices themselves, regardless problem of the elderly. With hardly any exception women were found to make
of area, dwarfs the
demand on their doctor’s services than the men on the same list. But a higher capitation-rate for women would be open to the objection that the female rates of some practices are lower than the male rates of others. More generally, any attempt to modify the capitation sytem in the light of differing consultation-rates would have to face the difficulty that the consultation-rate is itself no more than a crude approximation of a doctor’s work. At the very least, account would have to be taken of the fact that one practice may have seven in every ten consultations in the patient’s home, whilst another has only one in every ten. Nor can we assume that " the consultation " is a homogeneous unit. Surprisingly, only two studies deal at length with the time taken over various services by the doctor. 14 Does, for example, the time per consultation vary inversely with the consultation-rate ? If it does, then the variations in work suggested by the wide ranges of consultation-rates would at least be mitigated. Unfortunately, there is not enough evidence at present even to speculate on this crucial point. What evidence there is suggests that a consultation in the home takes two or three times as long as a consultation in the surgery. more
*
*
*
The Royal Commission made it known that it would be concerned with the size of the Pool rather than with detailed schemes for distribution.15 It was thus natural that the British Medical Association submitted no critical examination of the capitation system. However, dissatisfaction with the tenuous link between work done and financial reward was expressed by several bodies 16 and uneasiness was expressed by the Commission itself 17 and by Professor Jewkes in his minority report 18-an uneasiness echoed, more recently, by the Porritt Committee.19 The Treasury and the Ministry of Health summed up the prevalent feeling when they said: " The system is not without its disadvantages but these are thought to be less than those of alternative methods of remuneration so far considered."20 Our own work suggests that the scope of these " disadvantages " may prove to be far greater than is commonly 14.
15.
Crombie, D. L., Cross, K. W. Brit. J. prev. soc. Med. 1956, 10, 41; Wood, L. A. C. J. Coll. gen. Practrs. 1962, 36, 379. Royal Commission. Minutes of evidence: B.M.A., p. 1286. Report: para. 342.
Royal Commission. Minutes of evidence: Medical Practitioners’ Union, p. 107; Scottish Association of Executive Councils, para. 1183. Written Evidence: vol. II, Fellowship for Freedom in Medicine, pp. 113, 116. Appendix: memorandum prepared by the Assistants and Young Practitioners Subcommittee (B.M.A.), para. 62. 17. Royal Commission. Report, para. 342. 18. Royal Commission. Minority report, para. 74. 19. A Review of Medical Services in Great Britain; para. 196. London, 16.
1962. 20.
Royal Commission. Minutes of evidence: joint memorandum of Ministry of Health and the Treasury, para. 117.
the
grateful to the editor of the Journal of the College of General permission to use material from the article he is publishing. We are
Practitioners for
THE MATERNITY SERVICES FROM A CORRESPONDENT
FOR some years there has been crisis in the maternity services and, unless changes are made, this seems likely to grow worse rather than better. The National Institute of Economic and Social Researchbelieves that the official estimates of future births have been consistently too low, and that we may need an increase of nearly 60% in maternity beds by 1970-i.e., 32,500 beds by 1970 instead of 27,000 by 1975 as envisaged by the Hospital Plan.2 Meanwhile, the Perinatal Survey is revealing many defects in our existing maternity services and standards of ante-natal care. The Birthday Trust3 has become a forum for discussion on the best means of meeting this urgent situation, and it may be useful to summarise some of the facts and opinions so far put forward, and the questions being asked. *
*
*
Clearly, maternity beds are no use without midwives staff them, and the shortage of midwives is one of the biggest problems. Yet we have about 20,000 trained midwives not in practice, mostly for domestic reasons. Many are emigrating, particularly to the United States, where they are offered higher pay. Those who remain are often deterred from practising by lack of housing, by unsatisfactory off-duty hours, and by the pressure of work-due not only to the shortage of staff but also to the greater turnover of patients in the maternity hospitals. Thus vicious circles are set up. It has also been suggested that midwifery is so normal nowadays that many midwives are unsatisfied and return to general nursing where they can nurse more patients who are really ill. Moreover, many pupils are worried by the strain of the " assembly belt "; for patients are being admitted and discharged so to
"
"
fast that there is no time to get to know them. But, in spite of the shortage, trained midwives are sometimes still used for unsuitable tasks such as cleaning out cupboards and serving meals. How much, it is asked, do today’s fit and active mothers really need the aid of midwives during the puerperium ?For instance, does the 1. National Institute Economic Review, November, 1962, p. 22. 2. A Hospital Plan for England and Wales. Cmnd. 1604. H.M. Stationery Office, 1962. 3. National Birthday Trust Fund, 57, Lower Belgrave Street, London,
S.W.1.
patients who
are now left in the medium-stay beds, we find 26 who have physical as well as psychiatric disabilities, 34 potential long-stay patients, and 37 in the tuberculosis unit, whose numbers are shrinking and who are not representative of the usual population of a mental
hospital. Patients in general hospitals also suffer from the present divided service, for some patients at present on acute wards in general hospitals would be more suitably placed in a medium-stay unit. Patients in hospital for any length of time with physical disabilities often have depressive and paranoid reactions, and, under present conditions, a request is often made for their transfer to a psychiatric hospital. The divided nursing service also creates difficulties. Thus a request for the transfer of a physically ill patient, who has become " unmanageable because of "
other psychiatric syndromes, often " means that this so-called " unmanageable patient is moved to a hospital where he is " managed " on a ward which has half the number of nurses, a quarter the number of doctors, and no specific psychiatric treatment facilities that were not available in the general ward. One reason for this, of course, is that far too few general nurses have psychiatric experience, nor have they learnt the therapeutic attitudes needed to manage psychiatric symptoms. Even under present conditions, general hospital nurses are far more likely to have to spend some of their time caring for psychiatric patients-e.g., senile patients, confused patients, or patients admitted following a suicidal attempt-than to be called to deliver a baby; yet the organisation of nursing training suggests the opposite. Another type of patient who would benefit from a medium-stay hospital is the younger " chronic " patient. Some of these find their way to mental hospitals; others go to chronic-sick units, where their companions are almost entirely geriatric patients; and others are managed at home with varying degrees of difficulty. As a rule there are insufficient grounds for their treatment in an acute ward, yet many would benefit by vigorous treatment and rehabilitation over some weeks or months, and the improvement in their morale would increase their chances of subsequent management at home. Some of them, of course, would benefit by further treatment at intervals over the course of their illness. Many of these difficulties would be eased, if we had a type of hospital which would take any patient-whether mentally or physically ill-whose disability seemed likely to last more than a few weeks, or to recur frequently within a year of admission. Particularly suitable for such a hospital would be the patients who need both the facilities of a general hospital and those of a psychiatric unit. Those who at the onset have either a physical or a psychiatric illness may well develop the other later. Psychiatric patients would benefit by the provisions made for the physically ill, including facilities for investigation, physiotherapy, and expert physical nursing; while many physically ill patients would benefit from the community and social life, together with occupational therapy, which has been developed so well in many mental hospitals. Like any other hospital, the medium-stay hospital should serve a local population and be easily accessible by public transport. Ideally, it should be on the same site as the " acute " district hospital. Since patients are likely to be there for several months, it should be pleasantly designed and be as little like an institution as possible. All patients will need a bedroom area, but for the severely
delirium, confusion,
.
or
will be their usual living The wards should be designed to allow the formation of small groups; yet it should be easy to move a patient from one group to another if tensions develop, as is not unlikely in seriously ill patients unable to choose their companions. Many patients-particularly those with only psychiatric disabilities-will be ambulant and will need bedroom space only for sleeping or, occasionally, as a private space to which to retire. They should be able to find their occupational and social areas off the ward. If the hospital is large enough a cafeteria service would be an advantage. Occupational therapy and physiotherapy would be available to all patients. For some this would have to be provided on the ward, but as many as possible should attend the appropriate departments. One of the most demoralising features of hospital life is the lack of change in a patient’s surroundings. Rehabilitation in its widest sense would be an important duty of the medium-stay hospital. Patients should find in the hospital opportunities for rehabilitation for their work, social life, physical activity, and personal relationships. Recent proposals (Mackie 1963) for the organisation of a hospital into residential, treatment, and rehabilitation departments would be particularly suitable for the
physically handicapped this space.
medium-stay patient. REFERENCES
Baker, A. A. (1961) Lancet, i, 656. Kidd C. B. (1962) Brit. med. J. ii, 1491. Mackie, W. (1963) Lancet, i, 211.
THE CAPITATION FEE D. S. LEES M. H. COOPER From the Economics Department,
University of Keele,
Staffordshire IN another paperwe have examined the evidence published since 1945 on the work of general practitioners, Here we relate our main findings-to the present discussion of the capitation system as a method of remuneration.2 The total sum which the State pays the medical profession for maintaining the health of the nation (the Central Pool) is based upon the concept of an " average practitioner ". Put simply, the sum which it is thought reasonable that the average practitioner should earn, multiplied by the number of doctors in practice, yields the total to be paid. This is in accord with the Danckwerts recommendations. By contrast, the Spens Committee recommendations on the distribution of this total sum between the individual members of the profession have not been implemented. The main reason, as the Ministry of Health has pointed out,3 is that, once the capitation system of payment is accepted, any elaborate method of distribution is ruled out. With very minor modifications, the distribution of the Pool is effected by a simple count of patients’ heads. At present, the average net income is E2425 per annum,4 and the average list approximately 2300 patients.5 Adding in average practice expenses, the average gross income becomes about E3700. Deductions for Exchequer superannuation contributions and the likeI reduce this to 1. Lees, D. S., Cooper, M. H. The Work of the G.P.: an analytical survey of studies of general practice. J. Coll. gen. Practrs (in the press). 2. For example, the articles by B. Abel-Smith and J. Hogarth in Medical Care, January-March, 1963. 3. Evidence to the Royal Commission on Doctors’ and Dentists’ Remuneration. Minutes of evidence: questions, 3477, 3898. 4. Raised to £2765 from April 1, 1963. 5. Average number of patients per N.H.S. principal was 2292 in October. 1961. Annual Report of the Ministry of Health for 1961; p. 44. 6. See report of Royal Commission, p. 110.
881 TABLE I-FINDINGS FROM PUBLISHED STUDIES
that, all other things being equal, this represents
a
of the doctor’s work. It is
certainly misleading to go on quoting a particular rate as in some way " representative " of practices as a whole. A recent survey of doubling
around E3100. The capitation fee of 19s. 6d. generates
E2240, and the loading of 14s. for each of 1200 patients between certain listsizes a further E840. The loading payments benefit doctors with medium-sized lists and it is evident that, quantitatively, they are the only important redistributive element in the system. Further, this redistribution has nothing to do with work but recognises the fact that any normal practice has certain overhead expenses which do not increase pro rata after the list has reached a certain size.8 Thus the capitation system equates a doctor’s work to the number of patients on his list, whether these are seen or not and irrespective of the number and kind of services rendered. It is an admittedly crude method of remuneration.9 Our purpose is to illustrate the extent of that crudeness and to make a plea for more systematic inquiry into just how the system works. *
*
*
Our survey showed that consultation-rates per person, the percentage of home visits to total consultations, and the percentage of a doctor’s list seen at least once during any given year were extremely variable as between practices. In fact, the average practice, like the average man, does not exist. In table i, the findings are illustrated. The number of observations under each heading exceeds the number of studies, ranging from (approximately) fifty for home visits to a hundred for consultation-rates per person. 10 The highest percentage of patients consulting during a year was 85, whilst at the other extreme one practice saw only half its list. In one survey alone,l1 in eight practices during a single year there was a range from 58 to 80%, which, other things being equal, represents a variation in work of approximately a third. Even taking the broad band of 60-80% as a criterion of consistency, nearly a fifth of the practices would still remain outside it. Turning to the most obvious and frequently quoted measure of a doctor’s work-the consultation-rate-a range was found of 2-7-9-2. If due allowance could be made for definitional inconsistencies, this range would probably be even greater; for the most restrictive definitions of a consultation were found at the top of the scale and vice versa. Table i suggests that a practice has no more than an even chance of having a consultation-rate of between 3-0 and 3-9. Whilst it is true that 90% of the observations fall between 3-0 and 6-0 it must be stressed 7. Between 401 and 1600 for
single-handed practices and 501 and 1700 for partnerships. 8 Report of Royal Commission para. 320. 9. There was general agreement on this in the evidence to the Royal Commission. Minutes of evidence: Medical Practitioners’ Union (p. 105); General Practice Reform Association (p. 395); Socialist Medical Association (p. 5); Scottish Association of Executive Councils (p. 1183); Royal Faculty of Physicians and Surgeons of Glasgow (p. 497); Joint memorandum of Ministry of Health and the Treasury (pp. 725, 791). Written Evidence: vol. II, Executive Councils Association (England) paras. 25, 26); Fellowship for Freedom in Medicine (p. 113). Appendix: Memorandum prepared by the Assistants and Young Practitioners Subcommittee (B.M.A.) (para. 62). 10. Throughout the paper consultation-rates refer to registered practice populations. 11. Logan, W. P. D. General Register Office. Stud. med. pop. Subj. no. 7.
nineteen doctors revealed an annual consultation-rate of 5-4 and this was described as " very similar to the rates estimated in other studies ".12 By contrast, tableI shows that only 14% of practices fall in the 5-0-5-9 range. A rate of 5-4 is not " very similar ", in terms of a doctor’s work, to a rate of 3-0-3-9 given for half the practices in our survey. Other things being equal, it represents 50% more work for the doctors concerned. The greatest dispersion is shown by the percentage of total consultations which took place in the home. The range over the studies reviewed was from 13 to 68%. A fifth of the practices had over half their consultations outside the surgery, and although 20-29% was the modal group of observations, half the practices exceeded this range and about a tenth fell below it. These seem to us surprising results, and a very probable source of large variations in the work done by different general practitioners. An identical consultation-rate for two practices would, at the least, require similar home-visit percentages. The second main group of conclusions follow from finding that patterns of distribution of these rates over agegroupings and between the sexes were consistent and predictable. The general levels of these patterns, however, were found to be extremely variable and tended to nullify any usefulness the patterns might have had for the purposes of modifying the capitation system: The patterns for consultation-rates took the form of a stepladder for females, and a stepladder at a generally lower level, but broken by a marked dip in the 15-45 age-group, for males. The two patterns thus have a tendency to diverge sharply in the 15-45 age-group. Both distributions reached a maximum in the
65-plus
age-groups.
For home visits the distributions for both sexes tended to be similar, both having the " dip " feature, although the percentage difference between the 15-45 group and the 45-65 group tended to be smaller than with consultation-rates.
These patterns, although consistent, are of little help towards modifying the capitation system. This can be best illustrated by considering those members of the doctor’s list over 65 years old. Whilst it is true that those over 65 within each practice consume, on average, more per head of a doctor’s services than the younger people, it is certainly not true that the over65s in one practice invariably consume more per head than the under-65s in another. We found, in fact, a considerable overlap in the distribution of observations for all persons and those for people over 65 only. This can be seen by comparing the figures given in table i for all persons with those in table 11 for people over 65. Thus, a higher capitation payment for old people could result in practices with a low consultation-rate for all persons gaining more than those with a high one. Apart from this, suppose the additional per-capita payment to be 10s. Taking the extreme rates found in our survey, this would represent an additional income of as little as 9d. per consultation at one end and as much as 2s. 6d. per consultation at the other. Table 11 illustrates the spread of observations found. The number of observations is
approximately fifty. Thus it is not simply that the problem of the elderly is a small one compared with the variation of morbidity between different areas ",13 but rather that the very "
12. Forsyth, G. Medical Care, January-March, 13. Royal Commission. Minutes of evidence, p.
1963, p. 11. 106.
882 TABLE II-MALES AND FEMALES OVER
65
major conclusion that seems to emerge from is that widely differing amounts of work are survey done by individual practices for any given annual income. The distributive effects of the capitation system seem to be far cruder than has been supposed. Nor does our evidence indicate that refinements will be easy to introduce. The popular notion of higher capitation payments for old people and for women might well result in a more, not less, unequal distribution. Though the capitation system has been in operation for more than fifty years, its relation to the doctor’s work remains largely unexplored. Lack of knowledge is a poor foundation on which to base the distribution of financial rewards of an ancient profession. What is urgently needed is an intensive study of a large group of practices in a given area. realised. A
YEARS OLD
our
large variation between practices themselves, regardless problem of the elderly. With hardly any exception women were found to make
of area, dwarfs the
demand on their doctor’s services than the men on the same list. But a higher capitation-rate for women would be open to the objection that the female rates of some practices are lower than the male rates of others. More generally, any attempt to modify the capitation sytem in the light of differing consultation-rates would have to face the difficulty that the consultation-rate is itself no more than a crude approximation of a doctor’s work. At the very least, account would have to be taken of the fact that one practice may have seven in every ten consultations in the patient’s home, whilst another has only one in every ten. Nor can we assume that " the consultation " is a homogeneous unit. Surprisingly, only two studies deal at length with the time taken over various services by the doctor. 14 Does, for example, the time per consultation vary inversely with the consultation-rate ? If it does, then the variations in work suggested by the wide ranges of consultation-rates would at least be mitigated. Unfortunately, there is not enough evidence at present even to speculate on this crucial point. What evidence there is suggests that a consultation in the home takes two or three times as long as a consultation in the surgery. more
*
*
*
The Royal Commission made it known that it would be concerned with the size of the Pool rather than with detailed schemes for distribution.15 It was thus natural that the British Medical Association submitted no critical examination of the capitation system. However, dissatisfaction with the tenuous link between work done and financial reward was expressed by several bodies 16 and uneasiness was expressed by the Commission itself 17 and by Professor Jewkes in his minority report 18-an uneasiness echoed, more recently, by the Porritt Committee.19 The Treasury and the Ministry of Health summed up the prevalent feeling when they said: " The system is not without its disadvantages but these are thought to be less than those of alternative methods of remuneration so far considered."20 Our own work suggests that the scope of these " disadvantages " may prove to be far greater than is commonly 14.
15.
Crombie, D. L., Cross, K. W. Brit. J. prev. soc. Med. 1956, 10, 41; Wood, L. A. C. J. Coll. gen. Practrs. 1962, 36, 379. Royal Commission. Minutes of evidence: B.M.A., p. 1286. Report: para. 342.
Royal Commission. Minutes of evidence: Medical Practitioners’ Union, p. 107; Scottish Association of Executive Councils, para. 1183. Written Evidence: vol. II, Fellowship for Freedom in Medicine, pp. 113, 116. Appendix: memorandum prepared by the Assistants and Young Practitioners Subcommittee (B.M.A.), para. 62. 17. Royal Commission. Report, para. 342. 18. Royal Commission. Minority report, para. 74. 19. A Review of Medical Services in Great Britain; para. 196. London, 16.
1962. 20.
Royal Commission. Minutes of evidence: joint memorandum of Ministry of Health and the Treasury, para. 117.
the
grateful to the editor of the Journal of the College of General permission to use material from the article he is publishing. We are
Practitioners for
THE MATERNITY SERVICES FROM A CORRESPONDENT
FOR some years there has been crisis in the maternity services and, unless changes are made, this seems likely to grow worse rather than better. The National Institute of Economic and Social Researchbelieves that the official estimates of future births have been consistently too low, and that we may need an increase of nearly 60% in maternity beds by 1970-i.e., 32,500 beds by 1970 instead of 27,000 by 1975 as envisaged by the Hospital Plan.2 Meanwhile, the Perinatal Survey is revealing many defects in our existing maternity services and standards of ante-natal care. The Birthday Trust3 has become a forum for discussion on the best means of meeting this urgent situation, and it may be useful to summarise some of the facts and opinions so far put forward, and the questions being asked. *
*
*
Clearly, maternity beds are no use without midwives staff them, and the shortage of midwives is one of the biggest problems. Yet we have about 20,000 trained midwives not in practice, mostly for domestic reasons. Many are emigrating, particularly to the United States, where they are offered higher pay. Those who remain are often deterred from practising by lack of housing, by unsatisfactory off-duty hours, and by the pressure of work-due not only to the shortage of staff but also to the greater turnover of patients in the maternity hospitals. Thus vicious circles are set up. It has also been suggested that midwifery is so normal nowadays that many midwives are unsatisfied and return to general nursing where they can nurse more patients who are really ill. Moreover, many pupils are worried by the strain of the " assembly belt "; for patients are being admitted and discharged so to
"
"
fast that there is no time to get to know them. But, in spite of the shortage, trained midwives are sometimes still used for unsuitable tasks such as cleaning out cupboards and serving meals. How much, it is asked, do today’s fit and active mothers really need the aid of midwives during the puerperium ?For instance, does the 1. National Institute Economic Review, November, 1962, p. 22. 2. A Hospital Plan for England and Wales. Cmnd. 1604. H.M. Stationery Office, 1962. 3. National Birthday Trust Fund, 57, Lower Belgrave Street, London,
S.W.1.