DOCTORS' REMUNERATION

378 CONCLUSIONS

Dissatisfaction with current procedures for the prescribing and administration of drugs in hospital led to the development of a system in Aberdeen general hospitals in which a single document was used to record drug prescription and administration. As a consequence separate " medicine lists " were abandoned by the nursing staff, and a unified procedure was developed. The system has resulted in greater efficiency and economy of time for the nursing and medical staff. The system is being developed as a basis for checking drug administration and recording the adverse effects of drug usage. We should like to acknowledge the help of the following members of the joint committee on drug prescribing, without whose support and enthusiasm the work could not have been done: Mr. T. L. Carr, Dr. W. N. Rollason, Sister E. M. Bird, Sister 1. Bruce, Sister I. M. Cowie, Sister M. Jamieson, and Sister E. Sangster, the late Mr. H. N. F. Kinniburgh, Mr. J. M. Neil, and Mr. M. H. Carson; Miss L. Brown, matron; Dr. A. M. Michie, medical superintendent; the board of management of the Aberdeen General Hospitals Group; and all medical and nursing staff of the group. We are also indebted to the Waverley Press (Aberdeen) Ltd., Typewriter Services (Aberdeen) Ltd., and Remington Rand Co. Ltd., for assistance. Prof. A. G. Macgregor has given us valuable advice throughout the project and in the

preparation of the manuscript.

(S4550), 3-5% for A (E3425), 10% for B (E2000), and 20% for C (E850). The Review Body would find it difficult to reach final conclusions on the proposals except in the context of a general review of consultants’ earnings, which it is to undertake. Meanwhile it has received evidence that the number of good candidates for B and C awards greatly exceeds the number of vacancies; and it recommends that the total number of B and C awards be increased forthwith from 800 to 850 and of C awards from 1600 to 1700. General Practitioners The profession’s main proposals to the Review Body were based on the following premises: (a) That the payments for other executive-council services and for work for

hospital authorities, local authorities, and Government Departments had risen by proportionately more over the years than the total pool, with the result that payments for main executive-council services, as the residual in the pool calculation, had risen by proportionately less. (b) That the rate of remuneration for main executive-council services had since 1948 been seriously inadequate. (c) That a growing shortage of general practitioners in relation to total population was adding to the workload of the individual practitioner without adding to his remuneration. (d) That the present system of remuneration failed to reward seniority

DOCTORS’ REMUNERATION THE latest reports by the Review Body on Doctors’ and Dentists’ Remuneration, issued on Monday, deal with senior hospital medical and dental officers, consultants’ distinction awards, and general practitioners.1 Senior Hospital Medical Officers Last May a memorandum submitted on behalf of the medical profession asked the Review Body to recommend that the salary scale of senior hospital medical officers should be 80% of the scale of consultants at corresponding points. (A similar proposal had previously been rejected by the Royal Commission on the Remuneration of Doctors and Dentists.) Of this claim the Review Body says: "

We should be justified in recommending a change in the relative position of the senior hospital medical and dental officer grades in the salary structure of the hospital service established by the Royal Commission’s recommendations and maintained by our recommendations last year, only if there had been, since the Royal Commission reported, a change in the organization of the hospital service which materially increased the weight of responsibilities and functions of these grades as a whole compared with other grades of doctors and dentists in the hospital service. We have received no evidence to suggest that there has been such a change. We are therefore unable to recommend any change in the remuneration of the senior hospital medical and dental officer grades." In the Review Body’s opinion the salaries of doctors and dentists in these grades should be reconsidered whenever the salary scale of the medical assistant grade and the

corresponding dental grade is changed. Co?isi4ltatits’ Distinction Awards Since 1960 the number of consultants has risen by nearly 10",: thus the 2800 distinction awards recommended by the Royal Commission, which represented 34" of consultants in 1960, represented 31",, of consultants in 1963. The profession proposed to the Review Body that the number of awards should be increased and should be related once more by fixed percentages to the total number of consultants in the National Health Service. The percentages proposed were: 1’5".. for A-plus 1. Review Body on Doctors’ and Dentists’ Remuneration : third, fourth, and fifth reports Cmnd 2585 H.M Stationery Office, 2s. 3d.

and

experience.

profession proposed that: (1) the pool should relate solely to main executive-council services; (2) all payments outside the revised pool should be regarded as net of expenses save for the payments by executive councils for dispensing which should be regarded as including the cost of drugs dispensed, and all practice expenses hitherto reimbursed through the pool save for the cost of drugs dispensed should continue to be reimbursed through the pool; (3) the average net income from main executivecouncil services to be used in calculating the revised pool The

should be E2765, the same as the present average net income from all official sources; (4) additional payments should be made to reward maturity and experience. The Review Body says that the effect of the profession’s proposal on amount of remuneration would be to increase the average net income of " unrestricted " principals under 70 years of age from main executive-council services by E645 (30%) from an estimated E2120 in 1964-65 to E2765, and that all other payments should remain as they are. This would increase average net income (before tax) from all official sources by about 23% from E2765 to f 3410. The Review Body estimates the cost to the Exchequer at about E15 million a year. To this must be added the cost of the seniority payments, estimated at about E5 million a

year.

The Review

Body recommends that payments to general practitioners by hospital authorities, local authorities, and Government departments should be excluded from the pool; but that payments for other executive-council services should continue to be included in the pool. As to the amount of remuneration, Though we do not question the sincerity of the conviction of general practitioners that remuneration has been seriously inadequate "

since 1948, we find no evidence to support it and do share it." Moreover " We should hesitate to propose any increase in the remuneration of general practitioners on recruitment grounds. ever

not

"

Since the total supply of newly

registered doctors between and 1971 cannot now be increased, any increase in the number of doctors entering general practice in the next few years would be largely at the expense of the number taking up careers in the hospital service. Neither the profession nor the now

379 Health departments argued before us that that was an objective which we should seek to achieve by our recommendations." The development of more sophisticated diagnostic aids and of new drugs may make the work of a general practitioner technically more complex; on the other hand it may also shorten and even simplify treatment. The increase in workload from persistent reduction in the ratio of general practitioners to population of patients is another matter; and the Review Body considers that some increase of

remuneration on this score is justifiable. The Review Body recommends that from April 1, 1965, the average net income for executive-council services credited to the pool, as revised by the Body’s recommendations, for every principal under 70 who gives unrestricted services, should be E2775. This is estimated to be equivalent to an average net income from all official sources of just over E3000 (before tax) and would represent an increase of about E250, or just under 10%, in the amount credited to the pool for each doctor in respect of average net income for executive-council services only. In making these recommendations, the Review Body has in mind the desirability of introducing as soon as possible schemes for partial direct reimbursement of certain practice expenses. "

In sum, the total remuneration of principals under seventy providing unrestricted general medical services will be increased by about f51/2 m., of which about three-quarters will be distributed in proportion to the total expenditure on ancillary help and on practice premises which qualifies for direct reimbursement under the new schemes and the remainder will be distributed according to whatever arrangements may be agreed between the Government and representatives of the profession."

The Review Body remains strongly convinced that any system of differential payments for general practitioners should be based on the concept of merit, not on the concept of mere seniority. It would regard an acceptable scheme of merit payments as a most welcome and encouraging development, and if necessary it would be ready to recommend, in order to finance it, a sum substantially greater than that recommended by the Royal Commission. On compensation for loss of practice goodwill, the Review Body hopes that the Government is giving sympathetic consideration to the profession’s proposal for fixing an age at which a doctor would qualify for his compensation even if he had not retired.

Medicine and the Law The Doctor and the Witness THE

appellant, T., and

other men were tried on a charge of assault with intent to rob M., a youth of 16. All pleaded not guilty. The jury disagreed; and a second trial took place before another trial judge and jury. two

At both trials the prosecution case was the same, being based mainly on the evidence of M. Two police officers also gave evidence of finding the accused and M. in a dark alleyway, M. being dishevelled and hysterical and asking for help, while the accused were denying the assault as an hysterical invention. The case for the defence at both trials was also the samea denial of the assault-save that at the first trial a police surgeon, who had examined M. shortly after the alleged assault, gave evidence for the accused, saying that when examined M. had been in a state of hysteria. The doctor on being asked his opinion as to the part alcohol played in M.’s hysterical state, replied that it would exacerbate hysteria. He was also asked what he would consider M.’s normal behaviour to be, and he gave his opinion that M. might well be more prone to hysteria than the normal person.

Before the doctor was called at the second trial, the trial judge ruled that he would not allow the doctor to give that opinion as evidence, on the ground that to allow it would be contrary to Rex v. Gunewardene1 (in which an appellant was not allowed to call a doctor to say that he had examined a witness and formed the opinion that the witness was suffering from a disease of the mind such that the doctor would regard his testimony as unreliable). The jury found all the accused guilty, and T. was sentenced to two years’ imprisonment. The Court of Criminal Appeal, being bound by the decision in Gunewardene’s case, dismissed T.’s appeal, but certified that a point of law of general public importance was involved. T. appealed to the House of Lords.

Lord REID, Lord MORRIS, and Lord HODSON agreed with the opinion of Lord PEARCE that the appeal be allowed and the conviction quashed. Lord PEARCE said that two points arose. The first was whether the medical evidence which the trial judge excluded was admissible as relevant to the facts in issue at the trial; and the second was whether it was admissible as showing that M.’s evidence was unreliable. On the first point, the real question to be determined at the trial was whether, as the prosecution alleged, the episode (in the alleyway) created M.’s hysteria or whether, as the defence alleged, M.’s hysteria created the episode. To that issue medical evidence as to the hysteric and unstable nature of the alleged victim M. was relevant. On that ground the defence was entitled to have the excluded evidence considered by the jury. The second question raised a wider and more important problem which applied to evidence in criminal and civil cases alike. Throughout Gunewardene’s case the Court had dealt with the problem created by the mental disease and abnormality of the witness as if it were identical with the problem of moral discredit and unveracity; and the Court had used-wrongly, his Lordship thought-cases dealing with bad character and reputation as guides to the admissibility of medical evidence concerning illness or abnormality affecting the mind of a witness and reducing his capacity to give reliable evidence.

When a witness through physical (in which must be included mental) disease or abnormality was not capable of giving a true or reliable account to the jury, it must surely be allowable for medical science to reveal that vital hidden fact to them. It must be allowable to call medical evidence of mental illness which made a witness incapable of giving reliable evidence, whether through the existence of delusions or otherwise. It was in the interests of justice that such evidence should be available. Counsel for the prosecution had very fairly said that he could support the judgment in Gunewardene’s case, since, in the Crown’s view, the important thing was that the jury should be enabled to arrive at the truth and do justice. In Pedrini’s case,2 without opposition from the Crown, the Court had considered the evidence of three doctors as to the mental condition at the relevant time of a witness who had subsequently become insane. The Court was right in not excluding the medical evidence in that case. Gunewardene’s case was, in his Lordship’s opinion, wrongly decided. Medical evidence was admissible to show that a witness suffered from some disease or defect or abnormality of mind that affected the reliability of his evidence. Such evidence was not to be confined to a general opinion of the unreliability of the witness, but might give all the matters necessary to show not only the foundation of and reasons for the diagnosis but also the extent to which the credibility of the witness was affected. The appeal should be allowed. Lord DONOVAN agreed. not

Toohey v. Metropolitan Police Commissioner. House of Lords: (Lord Reid, Lord Morris of Borth-y-Gest, Lord Hodson, Lord Pearce, and Lord Donovan). Feb. 1, 1965. Counsel and solicitors: Edward Terrell, Q.c., and H. Ni. Self (H. Ragol-Levy); J. H. Buzzard and R. J. Lowry (J. S. Williams’-. M. M. HILL Barrister-at-Law. 1. 2.

(1951) 2 K.B. 600. Times, July 29, 1964.