WHO SHALL HELP THE DOCTOR? ANCILLARIES, PRESCRIPTIONS, AND CERTIFICATES

1173

Views of General Practice

B.M. Oxon., M.R.C.P., D.Obst.R.C.O.G.

properly examined. It would be much better if he saw the doctor every six months by appointment for a full overhaul, at special sessions at which a social worker, dietician, and laboratory technician could be present, and could get prescriptions without waiting to see the doctor. A register of patients with chronic disease would be kept, with details of the diagnosis and treatment, which would authorise the doctor’s receptionist to issue prescriptions.

GENERAL PRACTITIONER, HADDENHAM, BUCKINGHAMSHIRE

CERTIFICATES

can the doctor make the best use of his time ? The general practitioner today has more demands on his time than he can meet. The more work he can hand over to medically unqualified assistants the more time he will have for the work that he alone is qualified to do. How much of a doctor’s work in the surgery can be taken

10-5% of the surgery-attenders came only for certificates of incapacity for work. The figure should be higher: requests for first certificates were not included because it was assumed that the patient needed medical advice as well. This is not always true; were it not for the need for a medical certificate, many people would be happy to look after themselves with influenza or a short attack of diarrhoea. With the present shortage of doctors it is urgent that the regulations for medical certification should be changed. Clearly there should be some safeguard against the abuse of sickness benefit by persons able to work, but the doctor’s time should not be wasted on administrative duties. Examination by the doctor is usually a meaningless formality, since it is the patient who decides when he is fit to work. The doctor has no way of knowing what physical strain is involved in the patient’s work, and would be very unwise to insist on giving a final certificate against protests of unfitness unless the patient is known to be an inveterate lead-swinger. Abuse of certificates is exceptional today, when workers, skilled or unskilled, can earn high wages in industry and have heavy hirepurchase commitments. Certain changes might reduce the load on the doctor. 1. The doctor should be allowed to state on the first certificate that the patient will be able to resume work any time within the next ten days, instead of the present limit of three days. This would enable the patient with influenza or a strained back to take a week offwithout having to return to the doctor once or twice for intermediate certificates. 2. Intermediate certificates for four weeks should be available from the beginning of an illness. 3. The doctor should be allowed to state on the final certificate that the patient will be fit to return to work any time within the next seven days. At present the limit is three days, which often means an extra call for an intermediate certificate. 4. The words " I have examined you " should be omitted from the final certificate, thus enabling the doctor to sign it merely upon information that the patient was well and intending to start work on a certain date. 5. Private certificates for employers should not be necessary for periods of less than seven days. Certificates for one or two days are notoriously open to abuse; they are requested after recovery from and before resumption of work, and the doctor cannot tell whether the patient was ill, suffering from a hangover, or attending a football match. 6. The circumstances in which certificates might be signed by ancillary workers should be further considered. At present nurses are entitled to sign hospital intermediate certificates and midwives certificates of expected confinement.

WHO SHALL HELP THE DOCTOR? ANCILLARIES, PRESCRIPTIONS, AND CERTIFICATES

R. P. C. HANDFIELD-JONES

How

an unqualified worker, and what sort of work she do ? I have not tried to assess how much should secretarial and administrative assistance she can provide. The question this study was planned to answer was: what proportion of the people coming to the surgery really need the doctor’s skills, and what proportion come for something which an ancillary worker can provide ? I have a single-handed rural practice of 2750 patients. The surgery consists of two rooms in my house, and my wife answers the telephone and takes messages at the door. Because of lack of accommodation no nurse or receptionist is employed, and no appointment system can be organised. Surgery sessions are held every morning and on four evenings a week. One afternoon a week is for antenatal and child-welfare work. Up to 25 patients are seen at each session at an average rate of four minutes each, and they may wait up to 45 minutes. From March 30, 1964, to May 15, for 1000 consecutive consultations in the surgery, I recorded what the patient Came for and if, in my opinion, it could have been dealt with by a secretary, nurse, or other worker. The 1000 attendances can be classified as follows:

over

by

For medical advice.......... For treatment that could have been given by a nurse For supplies of drugs (patients on long-term medical

612 132

119 treatment) 105 Solely for certificates For inquiries which could have been answered by a 32 receptionist ............ The reasons for the 132 consultations (13-2%) that could have been treated by a nurse are: 91 Injections ............ 16 Dressing leg-ulcers .......... 13 Syringing wax from ears........ 11 Dressing minor injuries 1 Changing vaginal pessary........ At present I do these tasks. They are time-consuming and the patient has first to wait. They are not technically difficult and certainly do not need the training of the State registered nurse. Injections, dressings, and syringing ears could be taught to an intelligent girl in a fraction of the time she would take to learn shorthand and typing.

treatment) ............ 119 ........

........

PRESCRIPTIONS

11-9% of the patients came to replenish their supply of drugs for chronic diseases requiring months’, years’, or possibly lifelong treatment-e.g., arthritis, hypertension, chronic bronchitis, asthma, epilepsy, diabetes, peptic ulcer, and heart-disease. The care of these patients is a very important part of general practice, but too often it is inadequate. The patient waits half an hour to spend five minutes with the doctor in order to obtain a prescription, and does this every fortnight for years without ever being

CONCLUSIONS

Of 1000 attendances at were

for medical advice.

a

doctor’s surgery only 61.2% were for treatment which

13-2%

1174 a nurse could provide, 11-9% were for supplies of drugs for the long-term therapy of chronic diseases, 10-5% were for certificates, and 3-2% were inquiries which a receptionist could answer-most of which work could be taken over by a medically unqualified assistant with elementary nursing training. This is possible only in a properly designed surgery building with accommodation for the ancillary worker. For the single-handed general practitioner, therefore, financial assistance towards surgery building is urgently needed. This study suggests that about a third of his work does not need the doctor’s skills. If less of his time was taken up with consultations that start " Sorry to bother you doctor, it’s only a cold, but I need a certificate " or " Can I have some more of those tiny white tablets you said Granny was never to be without ", there would be more time for patients needing investigation, and for taking cervical smears and other preventive measures.

Occasional Book DRUGS IN SOCIETY in the public image of the pharmaceutical held in the United States and Britain is remarkindustry able. Suspicion, mistrust, and cynicism are relatively much more widespread on the other side of the Atlanticabout excessive profits, administered prices, monopolistic practices, fraudulent advertising, " molecular manipulation ", inadequate clinical testing, irresponsible promotion and marketing, interlocking financial ties of drug houses, advertising agencies with drug accounts and laboratories which test drugs, and about the financial relationships of the industry with organised medicine, medical journals and the profession itself. The British scene, by comparison, is one of dignity and responsibility. Government and industry cooperate voluntarily on schemes for the supervision of toxicity testing, clinical trials, and price THE

contrast

regulation. In the United States the Drug Amendments Act of 1962 placed immensely punishing powers in the hands of government. The burden of proving the effectiveness as well as the safety of a drug has been shifted to the manufacturers. Since June this year these far-reaching powers have been extended to include almost all drugs introduced for human use since 1938. The consumer, through his Government, has assumed control. The price of this control, according to some leaders of the industry, could be the eventual destruction in the United States of further scientific advances in medical therapeutics. Para" doxically, the country of socialised medicine " is now being seen in some quarters of the American industry as the haven of therapeutic voluntaryism. A statement by the president of the Pharmaceutical Manufacturers’ Association earlier this year suggested that " a significant segment " of the industry was considering expanding their research work and clinical testing in Britain and Western

Europe.l Is the contrast in general a true one ? Are standards of ethical behaviour in the industry and the profession so much higher in Britain than in the United States ? Why does the theory and the practice of market-place economics produce such very different results in the two countries ? Or do we know much less in Britain about the subtleties of the social and economic variables in these relationships ? 1.

Observer, Jan. 5, 1964.

These questions are prompted by a re-reading of Drugs in Our Society, a collection of essays edited by Prof. Paul Tallalay and published by the Johns Hopkins University School of Medicine. Here are 21 papers, together with a summary of the discussions, contributed to a conference at Johns Hopkins at the end of 1963. Historians and legislators, drug manufacturers and legal experts, representatives of government and of professional groups, physicians and pharmacologists, patent experts and economists, sociologists and moral philosophers composed the membership of the conference. The participants, numbering about 50, were all drawn from the United States except for Sir George Pickering, Prof. J. H. Gaddum, and the writer. The essays fall into four groups. The first are concerned with the progress and present limitations of drug therapy, and with the problems of evaluating drug effectiveness and safety. The next group discuss the responsibilities of the pharmaceutical industry and the functions of government in the drug field. The third group range over the problems of drug economics-including incentives, drug costs, and advertising to consumer and doctor. The last group of essays explore some of the sociological, legal, and ethical problems of modern drugs. Understandably, most of the papers and much of the discussion that followed were set in the context of American institutions and pharmaceutical history. The coherence and consistency of the major themes pursued makes the collection of absorbing interest, not only for the light that it throws on the American scene but because so many of the problems that have erupted with the therapeutic explosion of the last quarter of a century are international in character. It is abundantly clear that the United States now knows much more about its drug industry than any other Western country. Knowledge of the impact of the drug industry on the American economy, on the doctor-patient relationship, and on organised medicine itself is the product of barely six years of,intensive research and inquiry. This expose, as it has been called, all began at the end of 1958 when the late Senator Kefauver, " the Sisyphus of Capitol Hill ", became interested in the drug industry because it seemed to him to illustrate some of the American evils of economic concentration—monopoly power, the exploitation of the consumer, and the erosion of ethical standards. With Kefauver as chairman, the Senate Subcommittee on Antitrust and Monopoly began its investigations in 1959. They lasted for twenty-six weary months and produced 12,885 pages of fact and testimony-a veritable mine of medical, economic, and sociological lore. Then came a draft Bill; the thalidomide tragedy; the news that over 21/2 million thalidomide tablets, in a variety of colours and sizes, had been distributed to 1267 American doctors in containers that bore nothing more than directions for use; the discovery that the head of the Antibiotics Division of the Food and Drug Administration had received $287,142 in seven years as honoraria from the pharmaceutical industry; and growing public awareness of the implications of the fact that every year approximately $750,000,000 was being spent by some 60 drug firms in order to reach, persuade, cajole, pamper, outwit, and sell to one of America’s smallest markets-180,000 doctors. The American drug industry was in the dock-and with it some sections of the profession and the American Medical Association which had bitterly opposed the draft Bill. The reaction of a shocked and frightened public forced through the Drug Amendments Act of 1962 con-