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Better General Practice
659
LEADING ARTICLES
THE LANCET LONDON:SATURDAY, MARCH 27, 1954
Better General Practice WRITTEN by Dr. STEPHEN TAYLOR for the Nuffield Provincial Hospitals Trust, Good General Practiceis described as a non-statistical survey of practices of general practitioners recognised as good doctors by their colleagues. Unlike COLLINGS2 who described examples of different kinds of practice, and HADFIELD3
sample, TAYLOR deliberately outstanding merit, in the hope sought practices that the lessons they taught could be applied to others. It was, he says, surprisingly easy to find who studied
a
random of
them. He visited 30 in all-15 in industrial areas, 9 in small country towns and rural areas, and 6 in urban residential and mixed areas. These practices were run by 94 doctors, including 81 principals.and 13 assistants, of whom 3 were trainee assistants. Only 3 doctors worked single-handed ; 5 others who were not in partnership had assistants ; and all the rest were in partnership, the number of partners ranging from 2 to 7. In devising his investigation and making his report TAYLOR was supported by a steering committee4 ; and " although the observations were the work of one individual alone, the conclusions drawn from them were not." On the basis of much observation and inquiry," TAYLOR suggests that the quality of general practice follows a normal distribution curve, and that the critical line below which a practice cannot be called satisfactory is such that a quarter of all practice is below it; this quarter includes " a final twentieth for which it is hard to find excuses." Though this certainly accepts a lower standard of what is satisfactory " than COLLINGS would think right, it does not (as TAYLOR owns) justify any complacency about the present state of general practice ; forif the work of a quarter of our general practitioners is for one reason or another not as good as it should be, this means that something like 10 million people cannot count on satisfactory care. Moreover, TAYLOR says-rather disconcertingly-that even among his 30 practices deliberately chosen as outstanding, not all " some could best were " universally excellent " : be described as adequate, and one or two as barely adequate." Which suggests that first-class practices are not quite so easily found after all. But whatever the faults of general practice, and however widespread they may be, TAYLOR has made a serious contribution towards putting them right ; for this book is far less of a survey," in the usual sense, than a handbook of good practice : his findings he sketches with a light pencil, but the lessons to be learnt from them are inked well in. Like COLLINGS he has found the highest level of pra.ctice in country towns, where there are usually one or more partnerships, each with its central surgery and ancillary "
"
"
1. Published for the Trust by the Oxford University Press. London, 1954. Pp. 596. 12s. 6d. 2. Collings. J. S. Lancet, 1950, i, 555. 3. Hadfield, S. J. Brit. med. J. 1953, ii, 683 ; see Lancet, 1953, ii, 659. 4. The members were Sir WILSON JAMESON, Dr. GEOFFREY BARBER, Sir ERNEST ROCK CARLING, Sir HENRY COHEN, Mr. LESLIE FARRER-BROWN, Dr. J. REVANS, Dr. A. TALBOT ROGERS, and Sir JAMES SPENCE.
At the opposite end of the scale are some of the industrial practices, in about half of which (he estimates) surgery premises are dreary and often grossly inefficient : the large well-equipped surgery is rarely seen ; there are few large partnerships ; and the doctor usually-and understandably-lives away from his surgery. Between these two extremes are the urban-residential practices (usually good), the few remaining private practices, the rural practices, and the practices in new housing estates. Such estates might well be used for experiments with health centres, but few such experiments have been made-usually, he thinks, because the housing authority responsible for the estate has not been the local authority. But he is not in favour of providing health centres unless there are good reasons for doing so : good group practice can offer the same
help.
advantages. true group
Though partnerships are common, practice is still rare. Among those he groups included 3 or more partners and
visited, the the most successful groups were likely to have not more than 7. The doctors worked from a single with two or more ancillaries, and each building, had some special medical interest. They consulted each other, seeing each other’s patients on request ; and they planned their work so that they had enough time off duty. There are advantages and drawbacks to the system ; but on the whole TAYLOR gained the impression that the doctors in a successful group were giving a better service than they would have done if dispersed as individuals. He therefore gives much information on the forming of such groups ; and, like COLLINGS, 25 he believes that a determined drive towards group practice in industrial areas is likely to do more good than any universal healthcentre programme, if only because it could be quickly realised. The work of individual doctors varies widely. Not only are there differences in the rate at which they work, but some under-visit while some overvisit ; and some are young and active-and some are old and tired. Again, there is more serious ill health in some areas than others. TAYLOR suggests that the maximum permitted list might well decrease as the morbidity of an area increases : thus, if the " average optimal list " was about 2750, the maximum in high-morbidity areas might be 2000, and in lowmorbidity areas 3500, with compensating differences in the capitation fee. This would mean that the number of doctors in unhealthy under-doctored and those working in areas would be augmented ; such areas would be relieved of the excessive pressure of work which makes for bad doctoring. In some areas doctors have already taken measures to relieve themselves from this kind of strain bydeveloping rota systems, so that they can get some regular offduty time while still providing a guaranteed emergency service for patients. This development has been possible because, under the National Health Service, they no longer feel they are in fierce competition with one another for patients. TAYLOR suggests that the size a of rota is such that each member optimum should have no more than one full night on duty a week, apart from weekends. The minimum size is thus 5, but a rota of 3 or 4 is better than no rota at all. 5. Collings,
J. S.
Lancet, 1953, ii, 31, 611, 875.
660
In one area without open access to hospital laboratories a doctor has organised a laboratory service, with a paid technician, for members of his rota group ;; and this works well. All the members share in the cost. Open access to the laboratory services in the hospitals is being granted only slowly by the teaching hospitals, and in the great cities. Yet the extra work is not excessive : clinical pathologists are surprised, they have told TAYLOR, at the small size of the addition to their load. One open-access laboratory had found that on an average one general practitioner needed 43 hours a year of a technician’s time : so one technician was able to serve about 45 doctors. Doctors in a practice making good use of open access found that they asked for about 280 investigations a year for every 1000 patients on their list. A clinical pathologist can add considerably to the knowledge of practitioners in his area, especially, perhaps, if he is one of those who like to TAYLOR see the patient rather than the specimen. suggests that-since the clinical laboratory is the familiar haunt of general practitioners visiting hospital-the clinical pathologist may well become the link between them and the hospital, and may play a special part in arranging refresher courses for them. That general practitioners should have a place, and an important place, in hospitals, TAYLOR takes for granted ; but he doubts whether general-practitioner beds provide the right answer. In his opinion clinical-assistant posts probably offer the best opportunities for building up relations between general practitioners and hospital staff, and these should be available in all the main departments of all general hospitals. There are also a few specialties in which the trained and experienced general practitioner can give service comparable with that of the fulltime specialist (TAYLOR cites physical medicine, dermatology, venereal diseases, geriatrics, and the care of fever patients) and others in which he can cover a substantial part of the field if not the whole. But keeping to time presents great difficulties to the part-time specialist in general practice, who should therefore not demand more than he can properly deal with. The book offers much practical advice on surgery accommodation, equipment, and furnishing ; methods of organising paper work ; convenient ways of filing and storing medical record cards ; ways of planning the doctor’s day to avoid confusion and unnecessary fatigues ; and the contents of the doctor’s bag or bags-all things which closely affect performance. TAYLOR does not suggest that good doctoring is only done in handsome well-equipped surgeries, or that method is more important than humanity ; but, taking it broadly, the men who have arranged their work methodically and their workrooms well can get through more without undue fatigue. The same applies to the use made of ancillaries (whether directly employed by the doctor or not) : the secretary-receptionist (the helper most needed in many practices), the surgery nurse, the dispenser, the district nurse, the midwife, the health visitor, the physiotherapist, and-although she is not mentioned here-the hospital almoner. All these, used in friendship, can lighten the doctor’s load, and he should use such help to the full.
As to the future, he reminds general practitioners that they can help to form it. One interesting change in recent years has been the reversion to them of many diseases which for a time they had lost to the
hospitals-e.g., pneumonia, pernicious anaemia, most subcutaneous purulent infections, and most infections of the ears, pharynx, lungs, and bowels. Diabetes and thyrotoxicosis may soon belong to them again, and many another disease may drug given in the surgery.
yet submit At the
to
same
an
effective
time special may detect
techniques (such as mass radiography) the early stages of disease long before a patient has thought of complaining to his doctor. The form of practice must be flexible enough to adapt to these and other trends in a rapidly changing society; and the future of general practice is thus rich with oppor. tunity. If practitioners are lazy, or too attentive to their desks, their pens, and their certificates, they will lose their skills, and become relatively unimportant outposts in the hospital service. Their freedom, their right to criticise authority, make for the health of the National Health Servicebut this freedom, he rightly says, must be earned and won by the standards of work and the conduct of the practitioners themselves. The alternative is organisation at the hands of others, and organisation, though not to be belittled, always carries a risk of tyranny ; nor are tyrants any the less tyrants because they are well intentioned. The book is thus a call to personal action. It is also a reference work on standards into which the best general practitioner can dip with profit.
Abnormal Nerve
even
Impulses
IN 1842 MATTEUCCI devised an experiment now known to many as the " rheoscopic frog." Two frog muscles with their nerves are prepared, and the nerve of A is laid across the muscle of B. When muscle B is made to contract it stimulates the nerve of A and muscle A contracts. MATTEUCCI found, also, that activity could be induced in a nerve by laying it In across the beating ventricle of a frog heart.l is if the nerve warm-blooded animals, phrenic placed on the ventricle of the exposed and beating heart, diaphragmatic contractions synchronous with the heart-beat may be seen.2 The way in which an impulse begins somewhere along the course of a nerve-fibre and not at its origin from the nerve-cell body is now partly understood, When a nerve becomes active there is a change in electrical potential between the inside and outside of the fibre. Inevitably this causes local circuits to appear, in which the direction of the current, out or in, of the active fibre must be the reverse of that of the resting neighbour alongside. One direction of current depresses excitability, the other increases it. The inactive fibre, then, is subjected to alternating differences in potential-in-out, out-in-as the circuits relating to the front and rear of the impulse pass along the active nerve.3 Normally, endoneurium offers such resistance that the changes of potential are much attenuated before reaching the resting fibre : so the induced variations are subliminal and no impulse is propagated. Impulse propagation is accom1. Matteucci, C. Cours d’Électro-Physiologie. Paris, 1858. 2. Sharpey-Schafer, E. Experimental Physiology. London, 1912. 3. Arvanitaki, A. J. Neurophysiol. 1942, 5, 89.
LEADING ARTICLES
THE LANCET LONDON:SATURDAY, MARCH 27, 1954
Better General Practice WRITTEN by Dr. STEPHEN TAYLOR for the Nuffield Provincial Hospitals Trust, Good General Practiceis described as a non-statistical survey of practices of general practitioners recognised as good doctors by their colleagues. Unlike COLLINGS2 who described examples of different kinds of practice, and HADFIELD3
sample, TAYLOR deliberately outstanding merit, in the hope sought practices that the lessons they taught could be applied to others. It was, he says, surprisingly easy to find who studied
a
random of
them. He visited 30 in all-15 in industrial areas, 9 in small country towns and rural areas, and 6 in urban residential and mixed areas. These practices were run by 94 doctors, including 81 principals.and 13 assistants, of whom 3 were trainee assistants. Only 3 doctors worked single-handed ; 5 others who were not in partnership had assistants ; and all the rest were in partnership, the number of partners ranging from 2 to 7. In devising his investigation and making his report TAYLOR was supported by a steering committee4 ; and " although the observations were the work of one individual alone, the conclusions drawn from them were not." On the basis of much observation and inquiry," TAYLOR suggests that the quality of general practice follows a normal distribution curve, and that the critical line below which a practice cannot be called satisfactory is such that a quarter of all practice is below it; this quarter includes " a final twentieth for which it is hard to find excuses." Though this certainly accepts a lower standard of what is satisfactory " than COLLINGS would think right, it does not (as TAYLOR owns) justify any complacency about the present state of general practice ; forif the work of a quarter of our general practitioners is for one reason or another not as good as it should be, this means that something like 10 million people cannot count on satisfactory care. Moreover, TAYLOR says-rather disconcertingly-that even among his 30 practices deliberately chosen as outstanding, not all " some could best were " universally excellent " : be described as adequate, and one or two as barely adequate." Which suggests that first-class practices are not quite so easily found after all. But whatever the faults of general practice, and however widespread they may be, TAYLOR has made a serious contribution towards putting them right ; for this book is far less of a survey," in the usual sense, than a handbook of good practice : his findings he sketches with a light pencil, but the lessons to be learnt from them are inked well in. Like COLLINGS he has found the highest level of pra.ctice in country towns, where there are usually one or more partnerships, each with its central surgery and ancillary "
"
"
1. Published for the Trust by the Oxford University Press. London, 1954. Pp. 596. 12s. 6d. 2. Collings. J. S. Lancet, 1950, i, 555. 3. Hadfield, S. J. Brit. med. J. 1953, ii, 683 ; see Lancet, 1953, ii, 659. 4. The members were Sir WILSON JAMESON, Dr. GEOFFREY BARBER, Sir ERNEST ROCK CARLING, Sir HENRY COHEN, Mr. LESLIE FARRER-BROWN, Dr. J. REVANS, Dr. A. TALBOT ROGERS, and Sir JAMES SPENCE.
At the opposite end of the scale are some of the industrial practices, in about half of which (he estimates) surgery premises are dreary and often grossly inefficient : the large well-equipped surgery is rarely seen ; there are few large partnerships ; and the doctor usually-and understandably-lives away from his surgery. Between these two extremes are the urban-residential practices (usually good), the few remaining private practices, the rural practices, and the practices in new housing estates. Such estates might well be used for experiments with health centres, but few such experiments have been made-usually, he thinks, because the housing authority responsible for the estate has not been the local authority. But he is not in favour of providing health centres unless there are good reasons for doing so : good group practice can offer the same
help.
advantages. true group
Though partnerships are common, practice is still rare. Among those he groups included 3 or more partners and
visited, the the most successful groups were likely to have not more than 7. The doctors worked from a single with two or more ancillaries, and each building, had some special medical interest. They consulted each other, seeing each other’s patients on request ; and they planned their work so that they had enough time off duty. There are advantages and drawbacks to the system ; but on the whole TAYLOR gained the impression that the doctors in a successful group were giving a better service than they would have done if dispersed as individuals. He therefore gives much information on the forming of such groups ; and, like COLLINGS, 25 he believes that a determined drive towards group practice in industrial areas is likely to do more good than any universal healthcentre programme, if only because it could be quickly realised. The work of individual doctors varies widely. Not only are there differences in the rate at which they work, but some under-visit while some overvisit ; and some are young and active-and some are old and tired. Again, there is more serious ill health in some areas than others. TAYLOR suggests that the maximum permitted list might well decrease as the morbidity of an area increases : thus, if the " average optimal list " was about 2750, the maximum in high-morbidity areas might be 2000, and in lowmorbidity areas 3500, with compensating differences in the capitation fee. This would mean that the number of doctors in unhealthy under-doctored and those working in areas would be augmented ; such areas would be relieved of the excessive pressure of work which makes for bad doctoring. In some areas doctors have already taken measures to relieve themselves from this kind of strain bydeveloping rota systems, so that they can get some regular offduty time while still providing a guaranteed emergency service for patients. This development has been possible because, under the National Health Service, they no longer feel they are in fierce competition with one another for patients. TAYLOR suggests that the size a of rota is such that each member optimum should have no more than one full night on duty a week, apart from weekends. The minimum size is thus 5, but a rota of 3 or 4 is better than no rota at all. 5. Collings,
J. S.
Lancet, 1953, ii, 31, 611, 875.
660
In one area without open access to hospital laboratories a doctor has organised a laboratory service, with a paid technician, for members of his rota group ;; and this works well. All the members share in the cost. Open access to the laboratory services in the hospitals is being granted only slowly by the teaching hospitals, and in the great cities. Yet the extra work is not excessive : clinical pathologists are surprised, they have told TAYLOR, at the small size of the addition to their load. One open-access laboratory had found that on an average one general practitioner needed 43 hours a year of a technician’s time : so one technician was able to serve about 45 doctors. Doctors in a practice making good use of open access found that they asked for about 280 investigations a year for every 1000 patients on their list. A clinical pathologist can add considerably to the knowledge of practitioners in his area, especially, perhaps, if he is one of those who like to TAYLOR see the patient rather than the specimen. suggests that-since the clinical laboratory is the familiar haunt of general practitioners visiting hospital-the clinical pathologist may well become the link between them and the hospital, and may play a special part in arranging refresher courses for them. That general practitioners should have a place, and an important place, in hospitals, TAYLOR takes for granted ; but he doubts whether general-practitioner beds provide the right answer. In his opinion clinical-assistant posts probably offer the best opportunities for building up relations between general practitioners and hospital staff, and these should be available in all the main departments of all general hospitals. There are also a few specialties in which the trained and experienced general practitioner can give service comparable with that of the fulltime specialist (TAYLOR cites physical medicine, dermatology, venereal diseases, geriatrics, and the care of fever patients) and others in which he can cover a substantial part of the field if not the whole. But keeping to time presents great difficulties to the part-time specialist in general practice, who should therefore not demand more than he can properly deal with. The book offers much practical advice on surgery accommodation, equipment, and furnishing ; methods of organising paper work ; convenient ways of filing and storing medical record cards ; ways of planning the doctor’s day to avoid confusion and unnecessary fatigues ; and the contents of the doctor’s bag or bags-all things which closely affect performance. TAYLOR does not suggest that good doctoring is only done in handsome well-equipped surgeries, or that method is more important than humanity ; but, taking it broadly, the men who have arranged their work methodically and their workrooms well can get through more without undue fatigue. The same applies to the use made of ancillaries (whether directly employed by the doctor or not) : the secretary-receptionist (the helper most needed in many practices), the surgery nurse, the dispenser, the district nurse, the midwife, the health visitor, the physiotherapist, and-although she is not mentioned here-the hospital almoner. All these, used in friendship, can lighten the doctor’s load, and he should use such help to the full.
As to the future, he reminds general practitioners that they can help to form it. One interesting change in recent years has been the reversion to them of many diseases which for a time they had lost to the
hospitals-e.g., pneumonia, pernicious anaemia, most subcutaneous purulent infections, and most infections of the ears, pharynx, lungs, and bowels. Diabetes and thyrotoxicosis may soon belong to them again, and many another disease may drug given in the surgery.
yet submit At the
to
same
an
effective
time special may detect
techniques (such as mass radiography) the early stages of disease long before a patient has thought of complaining to his doctor. The form of practice must be flexible enough to adapt to these and other trends in a rapidly changing society; and the future of general practice is thus rich with oppor. tunity. If practitioners are lazy, or too attentive to their desks, their pens, and their certificates, they will lose their skills, and become relatively unimportant outposts in the hospital service. Their freedom, their right to criticise authority, make for the health of the National Health Servicebut this freedom, he rightly says, must be earned and won by the standards of work and the conduct of the practitioners themselves. The alternative is organisation at the hands of others, and organisation, though not to be belittled, always carries a risk of tyranny ; nor are tyrants any the less tyrants because they are well intentioned. The book is thus a call to personal action. It is also a reference work on standards into which the best general practitioner can dip with profit.
Abnormal Nerve
even
Impulses
IN 1842 MATTEUCCI devised an experiment now known to many as the " rheoscopic frog." Two frog muscles with their nerves are prepared, and the nerve of A is laid across the muscle of B. When muscle B is made to contract it stimulates the nerve of A and muscle A contracts. MATTEUCCI found, also, that activity could be induced in a nerve by laying it In across the beating ventricle of a frog heart.l is if the nerve warm-blooded animals, phrenic placed on the ventricle of the exposed and beating heart, diaphragmatic contractions synchronous with the heart-beat may be seen.2 The way in which an impulse begins somewhere along the course of a nerve-fibre and not at its origin from the nerve-cell body is now partly understood, When a nerve becomes active there is a change in electrical potential between the inside and outside of the fibre. Inevitably this causes local circuits to appear, in which the direction of the current, out or in, of the active fibre must be the reverse of that of the resting neighbour alongside. One direction of current depresses excitability, the other increases it. The inactive fibre, then, is subjected to alternating differences in potential-in-out, out-in-as the circuits relating to the front and rear of the impulse pass along the active nerve.3 Normally, endoneurium offers such resistance that the changes of potential are much attenuated before reaching the resting fibre : so the induced variations are subliminal and no impulse is propagated. Impulse propagation is accom1. Matteucci, C. Cours d’Électro-Physiologie. Paris, 1858. 2. Sharpey-Schafer, E. Experimental Physiology. London, 1912. 3. Arvanitaki, A. J. Neurophysiol. 1942, 5, 89.