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FUTURE OF GENERAL PRACTICE
542 to the 24-hour responsibility, relief in of sickness, and the abusive patient-should be revised forthwith.
MEDICARE
special reference case
Special
Articles
FUTURE OF GENERAL PRACTICE Mr. Kenneth Robinson, the Minister of Health, said in London last Saturday: We all know that the present troubles of general practice wholly or even perhaps mainly about remuneration. Indeed the B.M.A. itself has been at pains to emphasise this. Remuneration is settled on the advice of an independent Review Body, and I know of no way in which the Government could ensure fairer treatment of doctors, provided the distribution is equitable. are not
What we are now seeing is, I believe, the eruption of a feeling of dissatisfaction with the way general practice is organised in this country, which has been building up over many years. I think that a lot of this dissatisfaction arises because the G.P. is isolated from the rest of medicine and because he can only provide the facilities he needs to do a good job for his patients by depleting his own earnings. This situation stems in large part from the present arrangements for providing familydoctor services, under which each doctor is individually responsible for deciding what to provide and bearing the cost. wants to force general practice into a But it is stereotype. possible to see ways in which it could be helped to evolve faster along lines the profession might agree. Group practice provides answers to many of the difficulties and largely through the doctor’s own efforts is slowly emerging. If we could all agree that this kind of approach can lead to the solution of other problems then the logical thing to do would be to plan development in every area so that doctors could organise their own groups in the right places to match local needs. Local health authorities could join in to place their health visitors, nurses, and midwives at the group-practice centres to work with the doctors, as is already happening in some areas. That would cost the doctors a lot, if they had to find their own capital and had to meet increased running costs themselves. We should aim to meet a situation where doctors, or some of them; might prefer to be relieved of the responsibility for providing and staffing their own premises. If they-or more probably some of them-want to move forward on that path I should be very glad to discuss how and when this could be done. The first principle they have enunciated themselves in a document just issued seems to recognise that organisation, premises, and staff constitute the central problems. There are plenty of places where a beginning has been made and further progress could follow. There are areas where plans are even now being evolved. What we need is a plan and a means of giving effect to it over a period, as individual doctors wish to join in. This sort of thing could remove the sense of isolation and the inequalities of treatment between doctors which cause real and understandable grievances now, and could make it much easier and more attractive professionally for the young doctor to move from his hospital training to general
No-one, I least of all,
practice. If doctors prefer to work from health centres provided by the local authority, then I see no obstacle in the way. Indeed I would gladly do everything possible to encourage local authorities to provide more of them. other alternatives which may be put discussing soon with leaders of the profession. I have repeatedly expressed my willingness to talk and to seek solutions-long before any threat of withdrawal was in the air. But constructive discussion can only take place between parties who are striving, in a calm atmosphere, to reach mutually acceptable agreements.
All these
ideas, and
forward, I hope
to
be
v.
ELDERCARE
FROM A CORRESPONDENT
FOR many years the American Medical Association has suggested no alternative to the Government’s Medicare proposals, insisting that the Kerr-Mills Act, which provides for financial assistance to the " medically indigent " through the States, was enough. This year, however, passage of the Medicare plan seems likely, and the A.M.A. has announced its rival Eldercare scheme. This scheme was adopted at a special meeting of the house of delegates (the fourth in the Association’s history) on Feb. 7-8. In summary, the Eldercare plan would authorise States, at their discretion, to provide premium payments for healthinsurance coverage (through Blue Cross and similar private organisations) to people over 65 with incomes below a certain level, the level to be decided by the State. According to income, the individual would pay all, part, or none of the premiums; he would certify his income to the State health agency (not the welfare
least once a year; the agency would be the certification, but it would be subject to required accept for fraud. Federal Government would raise its The penalties payments to the States for medical aid. The A.M.A. claims many advantages for its plan; opponents perceive drawbacks. Thus Federal bureaucracy would be avoided, but States might not apply the plan satisfactorily. The wealthy, who do not need help, would not be covered, but there would be a means test. Physicians’ and surgeons’ fees to patients in hospital are usually covered by Blue Shield and similar plans (which would be used under the Eldercare Bill) but their coverage of hospital charges is often less complete than that offered by Medicare.
agency)
at
to
The truth is that neither measure provides anything like complete coverage; both probably provide much less than many of the American public realise. A patient of moderate means, covered by either scheme, could still lose a life’s savings in one serious long-term illness. The resistance of the American medical profession to Medicare is not universal. Some groups (such as Physicians Forum, based in Boston) and many individuals favour the Government’s plan; and some have criticised the A.M.A. for spending such large sums on propaganda. Others have suggested modifications of Eldercare-e.g., offering cover to all regardless of age. Most doctors, however, are undoubtedly opposed to Medicare, and some groups are particularly concerned about their own position. Radiologists, for instance, work largely in hospitals, and it is usual for the hospital to charge the patients for radiological services. The radiologist is then paid a percentage of the income of his department. Under the Medicare Bill radiological services would be provided as part of the hospital service (whereas the services of other doctors would
Pathologists, physical-medicine specialists, and are in a similar position, and their professional organisations are seeking to have the Bill not).
sometimes anxsthetists
modified so as to exclude them. Meanwhile the Administration is pursuing some of its other health measures. A Bill has been introduced to broaden the Kerr-Mills Act (which enables States, with Federal assistance, to finance medical care for needy old people) to include children of poor families, their parents, and blind and disabled people. The Bill would consolidate and make more uniform the various State and Federal programmes for such people. The Federal Government would provide matching grants to States for the care provided, which includes medical services not only in hospital but in nursing-homes-i.e., homes providing long-term care for partly disabled old people-outpatient departments, doctors’ offices, or the patient’s home.
MEDICARE
special reference case
Special
Articles
FUTURE OF GENERAL PRACTICE Mr. Kenneth Robinson, the Minister of Health, said in London last Saturday: We all know that the present troubles of general practice wholly or even perhaps mainly about remuneration. Indeed the B.M.A. itself has been at pains to emphasise this. Remuneration is settled on the advice of an independent Review Body, and I know of no way in which the Government could ensure fairer treatment of doctors, provided the distribution is equitable. are not
What we are now seeing is, I believe, the eruption of a feeling of dissatisfaction with the way general practice is organised in this country, which has been building up over many years. I think that a lot of this dissatisfaction arises because the G.P. is isolated from the rest of medicine and because he can only provide the facilities he needs to do a good job for his patients by depleting his own earnings. This situation stems in large part from the present arrangements for providing familydoctor services, under which each doctor is individually responsible for deciding what to provide and bearing the cost. wants to force general practice into a But it is stereotype. possible to see ways in which it could be helped to evolve faster along lines the profession might agree. Group practice provides answers to many of the difficulties and largely through the doctor’s own efforts is slowly emerging. If we could all agree that this kind of approach can lead to the solution of other problems then the logical thing to do would be to plan development in every area so that doctors could organise their own groups in the right places to match local needs. Local health authorities could join in to place their health visitors, nurses, and midwives at the group-practice centres to work with the doctors, as is already happening in some areas. That would cost the doctors a lot, if they had to find their own capital and had to meet increased running costs themselves. We should aim to meet a situation where doctors, or some of them; might prefer to be relieved of the responsibility for providing and staffing their own premises. If they-or more probably some of them-want to move forward on that path I should be very glad to discuss how and when this could be done. The first principle they have enunciated themselves in a document just issued seems to recognise that organisation, premises, and staff constitute the central problems. There are plenty of places where a beginning has been made and further progress could follow. There are areas where plans are even now being evolved. What we need is a plan and a means of giving effect to it over a period, as individual doctors wish to join in. This sort of thing could remove the sense of isolation and the inequalities of treatment between doctors which cause real and understandable grievances now, and could make it much easier and more attractive professionally for the young doctor to move from his hospital training to general
No-one, I least of all,
practice. If doctors prefer to work from health centres provided by the local authority, then I see no obstacle in the way. Indeed I would gladly do everything possible to encourage local authorities to provide more of them. other alternatives which may be put discussing soon with leaders of the profession. I have repeatedly expressed my willingness to talk and to seek solutions-long before any threat of withdrawal was in the air. But constructive discussion can only take place between parties who are striving, in a calm atmosphere, to reach mutually acceptable agreements.
All these
ideas, and
forward, I hope
to
be
v.
ELDERCARE
FROM A CORRESPONDENT
FOR many years the American Medical Association has suggested no alternative to the Government’s Medicare proposals, insisting that the Kerr-Mills Act, which provides for financial assistance to the " medically indigent " through the States, was enough. This year, however, passage of the Medicare plan seems likely, and the A.M.A. has announced its rival Eldercare scheme. This scheme was adopted at a special meeting of the house of delegates (the fourth in the Association’s history) on Feb. 7-8. In summary, the Eldercare plan would authorise States, at their discretion, to provide premium payments for healthinsurance coverage (through Blue Cross and similar private organisations) to people over 65 with incomes below a certain level, the level to be decided by the State. According to income, the individual would pay all, part, or none of the premiums; he would certify his income to the State health agency (not the welfare
least once a year; the agency would be the certification, but it would be subject to required accept for fraud. Federal Government would raise its The penalties payments to the States for medical aid. The A.M.A. claims many advantages for its plan; opponents perceive drawbacks. Thus Federal bureaucracy would be avoided, but States might not apply the plan satisfactorily. The wealthy, who do not need help, would not be covered, but there would be a means test. Physicians’ and surgeons’ fees to patients in hospital are usually covered by Blue Shield and similar plans (which would be used under the Eldercare Bill) but their coverage of hospital charges is often less complete than that offered by Medicare.
agency)
at
to
The truth is that neither measure provides anything like complete coverage; both probably provide much less than many of the American public realise. A patient of moderate means, covered by either scheme, could still lose a life’s savings in one serious long-term illness. The resistance of the American medical profession to Medicare is not universal. Some groups (such as Physicians Forum, based in Boston) and many individuals favour the Government’s plan; and some have criticised the A.M.A. for spending such large sums on propaganda. Others have suggested modifications of Eldercare-e.g., offering cover to all regardless of age. Most doctors, however, are undoubtedly opposed to Medicare, and some groups are particularly concerned about their own position. Radiologists, for instance, work largely in hospitals, and it is usual for the hospital to charge the patients for radiological services. The radiologist is then paid a percentage of the income of his department. Under the Medicare Bill radiological services would be provided as part of the hospital service (whereas the services of other doctors would
Pathologists, physical-medicine specialists, and are in a similar position, and their professional organisations are seeking to have the Bill not).
sometimes anxsthetists
modified so as to exclude them. Meanwhile the Administration is pursuing some of its other health measures. A Bill has been introduced to broaden the Kerr-Mills Act (which enables States, with Federal assistance, to finance medical care for needy old people) to include children of poor families, their parents, and blind and disabled people. The Bill would consolidate and make more uniform the various State and Federal programmes for such people. The Federal Government would provide matching grants to States for the care provided, which includes medical services not only in hospital but in nursing-homes-i.e., homes providing long-term care for partly disabled old people-outpatient departments, doctors’ offices, or the patient’s home.