THE STATE AND THE DOCTOR

New Zealand Listener, Volume 14, Issue 355, 12 April 1946, Page 7

THE STATE AND THE DOCTOR

Od British White Paper on a National Health Service has been followed by a Bill that is now before ) the House of Commons. Some of our readers may have heard Geoffrey Cox, a New Zealander, explaining the proposals the other night in a BBC broadcast. Since the most contentious point is the position of the private medical practitioner, we print these extracts from a debate by two doctors which the BBC broadcast a few weeks after the White Paper was first circulated.

R. STARK MURRAY: I think it is agreed that we are going to have some sort of new service, and it is essential for you and me to get down to principles right away. Now I want, first of all, to establish a clear principle as to the availability of the new service, as it has got to be complete, available for everyone-in other words, a 100 per cent. service provided for 100 per cent. of the people. Dr. Charles Hill: With mych of that I agree. I want a service which is complete in all its details, and I want no one prevented by lack of money from enjoying what they need in that service. But, I know you will agree, it’s the form of the service which really matters, Murray: I agree. And so let’s start with the general practitioner’s service. After all, you will agree that the general practitioners are the first line of any medical service. Hill: They are. Murray: And to my mind, at the present moment, they are very often overworked; they lack .essential equipment; and, in fact, I don’t think they do the job as well as it could be done. It is for that reason that I think they need a new kind of organisation so that they can do the job better than they have ever done it before. Above all, I want to see them having an opportunity for team work, You will agree that this is one of the things that is drummed into every medical student. Team work is the basis of modern medicine, and, in order to have team work, the doctors have got to get together in a place of

work which I call, and which most people to-day agree should be called, a health centre. Hill: This health centre conception is the doctor’s own conception, and in general a good one. Mind you, I don’t like the White Paper health centre-that is a collection of doctors’ surgeries. I want something better. I want a place where diagnostic aids can be brought to help the general practitioner. That is what he needs above all, But there are dangers in all this, I don’t want a marble hall, with chromium fittings and platinum blondes, and a queue here for your records, and a queue there for medicine. I want the doctor to be the servant of individual people. You want him to be a civil servant. Murray: Harley Street offers plenty of chromium plating and _ imitation platinum blondes. Of course, they have no queues in Harley Street. By proper organisation you can rid of queues and

there will be no queues in any health centre that I visualise. But let us go on to this other point that you made about the civil servant. You know you are introduging the State as if the State

were a bogy-man; somebody who is determined. to interfere with everything that we do, and above all, to "take away our doctor from us." Now the State is not a bogy-man. The State in this country is the people. Hill: As I know the State as a citizen, the State is certain people in jobs doing a particular job of work according to

their lights: to me the State is the income tax collector, the inspector, the official, the man who replies to me when I write to a Government departmentor doesn’t. I know, and people know, that the State can be harsh, can be cold, can be slow, can be unkind, can be inhuman. The doctor-patient relationship is too precious to be put into the hands of the State as we know it to-day. Murray: It is true that in the past we have had harsh decisions, But we are making progress, we are learning how to do these jobs better. And so far as medicine is concerned, what is absolutely essential is to take the money element out of medical practice. You have got to take medicine out of the market-place, and you have got to get rid of the present financial position which inevitably leads to the possibility, at least, of a dual standard of treatment, and a dual standard of medical care. Hill: What are you hinting at? Murray: I am hinting at the fact that, so long as .we have two different systems, a doctor, no matter how careful he is, no matter how much he wants to be fair-and square, is inevitably compelled to give two standards of medical care to his two financial classes of patients. Hill: You know, navies, you are very good at bespattering your profession with mud. Murray: I knew you would suggest something like that, Hill, but I am not, because if I was doing so, I should be bespattering myself, After all, I am very proud of being a member of the medical profession, and what I am attacking is the system, a system in which a patient who pays more :for anything-

and in this case we are discussing the time .of a doctor-naturally gets more, and I think that that system is wrong, This question of the doctor-patient rela« tionship is important, but I think that you can have a really good relationship. between doctor and patient when the doctors in this service are salaried officers who have not got to think of the financial and social position of their patient at all. Hill: There are two points I Want to make in reply, and the first is this: The record of our profession provides sufficient answer on one aspect. Our profession has given very freely of its. sere vices to the poor; it has put its service first and its income second. The record of voluntary hospital staffs of doctors in industrial areas will prove that. And my second point is this: If it is true, as you argue, that in fact private practice has been better because people have paid for private practice in the: past, . . I should have thought the ‘logical conclusion of that was to enable all people to obtain private practice. If they lack the money to obtain medical ser- vice or food, or clothing, or any of the essentials of life, provide them with the money. : Murray: Well, that is my whole philosophy. : Hill: But it isn’t. You don’t trust them. You don’t provide them with the money. Oh no! You want to control the service. You want it to be done by insurance. By all means let it be done by insurance, but let the essentially private arrangement stand, that the patient is inthe commanding position. I do not want any upper body-any person or (continued on next page)

| (continued from previous page) body from without-interfering. I want the doctor-patient relationship there, and, what is more, I want the free choice of the patient, the right to choose the doctor, the right to reject the doctor, preserved. _ Murray: We have not given the best service, and, to my mind, free choice is just as possible under a salaried service | as under any other form. _ Hill: Do you honestly believe that free choice of doctor is essential to a good medical service? Murray: I believe that it is important for those who want it. Hill: You don’t think it absolutely essential that the patient should have full right to choose or reject the doctor? Murray: Ah, yes. Reject, of course. Every patient must have the full right to reject. But only those who want to choose will make use of the right, as is the case to-day. And don’t forget that there are natural limitations to this free choice. There is a limitation according to the doctor’s capacity to do work, and that is the rule to-day. You cannot allow the doctor to take an infinite number of patients. He can only take a certain number. The’ other limitation, of course, is for emergency purposes, if we are to give a really efficient service, there must be a limitation on free choice in that particular circumstance. Hill: I agree. There must be a limitation of numbers, and, of course, doctors must have time off, but whatever you do, don’t introduce the shift system into medicine, with one doctor on duty from nine till five and another on duty after five. Continuity of medical care is of great importance, Don’t let us pretend that his work can be organised as can the work in a factory. We don’t want factory-made medicine; we want a human service. : Murray: But you ca®& have continuity of service without having the same doctor on duty the whole time. There are other ways in which you can give the patient continuous service. After all, we are asking a forty-hour week for miners and railwaymen, byt it is still the rule that the doctor has got to be on duty twenty-hour hours out of the twentyfour, and works a hundred-and-twenty-hour week. That won’t do. Hill: But, Murray, belly-ache doesn’t proceed according to the clock. You cannot organise a medical service on a time system or a clock system. This service is not for the convenience of the doctors; it is,for the convenience of the patients, and human disease is a little uncertain in the way it attacks people. As for human beings as units, they are human-patients come first in this matter. Murray: Of course they do. That is the whole point. Patients come first, and the patient with the belly-ache wants to have that belly-ache attended to at the very first possible moment, by a doctor who is in the very best condition, not a doctor who was up the night before and who is going to be up the night after, who is going to be out on a difficult maternity case, who is tired, who cannot do his job better. What we

have to do is to save the doctor. We have got to take the rough-and-tumble out of general practice. Hill: I agree to a. certain extent with that, but I want, where possible, my doctor, not a doctor arranged by som& body else. He is my friend; he understands me. I want him whenever possible, consistent with a reasonable stretch of work for him. Murray: For the great majority of illnesses and accidents, that will still be possible under an organised system. But

we have got to have a plan by which the doctor is set free from much of the difficulty of to-day, so that he really can give every attention to the patient: And to do that we have

got to have a pian to cover the whol service, Hill; Organisation there must be but, you know, you dreamy planners, your plan, as I understand it, is (in the interests of a neat and tidy plan) to make an independent profession-one of fine traditions and a fine record of service to the community-a branch of the Civil service with doctors on the same salaries, employed as civil servants in the atmosphere of civil service, with increments of remuneration in proportion to grey hairs. You want to introduce the whole atmosphere of the civil service in this essentially human and expert service. It is a very depressing picture. I don’t want Post Office medicine; I want an independent profession with initiative, not a profession which is merely a branch of the Government service. It isn’t good enough for the people. Murray: I think it will be better than anything they have ever known before. You can paint a depressing picture when you like, but the picture to me is very different indeed. After all, the Post Office does its job and does it very well, and in any case we are not suggesting that sort of service. I want the doctor to be so free from all his present difficulties that he will be able to understand his patients better, to know them better, and he will be given a real chance to get down to his job. Hill: But human understanding and’ knowledge are not attributes of our friends in the civil service. We are not criticising them, but examining the civil service atmosphere. Will people in that atmosphere be more human, more standingMurray: I am _ not suggesting that doctors should become civil servants in that sense. Hill: What other sense is there that we know of? Murray: There are plenty of other senses, There are many people who do whole-time salaried jobs, or who are in an organised service, and -who are still very human. But let us get on to this point about an independent profession and the way in which the doctors will be paid; that was what you were just speaking about. Of course the doctor must be paid according to his capacity. I am not suggesting a flat level of remuneration, but I think you will agree

that among our 20,000 general practitioners, for example, there need not be such a wide range of variation as your words may have suggested. Hill: I want the number of persons who choose a particular doctor to determine his remuneration. Murray: The patient is not really the Person to judge this particular matter. I think that we can devise many better methods than that. Hill: You think very little of the patient, don’t you? I think patients are not always capable of judging what the letters mean, but they know the value of that human being to them. I would rather have their judgment, however imperfect, than the judgment of any committee or official at the town hall. I want them to decide. Murray: I am not suggesting that the town hall should do this. I think that most of this assessment should be done by the doctor’s own colleagues; that within the health centre we have all sorts of ways in which we can judge capacity and capabilities. Hill: I want the patient to command the situation. Murray: I want the patient and the doctor to agree together and to run this service in the best possible way. The doctor has to look after two or three thousand in some areas, and even a higher number of patients. What does the patient get? He gets a three-minute consultation after a two hours’ wait in a@ waiting-room, and the doctor, of\ course, no matter how altruistic he may be, has got other allegiances. He is very often tied by the debts that he had to accrue to set up in practice. Hill: As I understand it, your argument is that he is not my doctor because he is responsible for, say, three thousand other persons. But that is nonsense. While he is treating me, he is my doctor, and I want the relationship to exist. And of course I expect him to be in a similar relationship with three thousand

other persons. But I don’t want him to be under the control of some employing body, whether it is the Government or the local authority. Murray: So do I. I don’t want his responsibility to be diluted by debt, diluted by allegiances to all sorts of people, to all sorts of things that have nothing to do with medicine. But speaking of loyalties, what is going to be the position if we still have private practice inside the new service? Hill; There will be people who don’t want tg use this service; whatever their reasons are, there are some people who think that something they arrange for themselves and pay for themselves is better for them; who want, for one reason or another, to do things privately. Now if there are such people, I want them to have as good a service available to them as the people who use the service. I want them to be able to obtain the services of the people they want, the people they need, whether they are inside the service or not.

' Murray: Yes. But every citizen fs going to pay for the service, and I think it is too dangerous altogether to allow the possibilitity of the doctor carrying on two kinds of practice at one and the same time. You will get back to two standards of medical care. Hill: In effect, you deny the private patient the right to the range of ser-

vice which you are seeking for those who decide to use the service. That is not fair. Murray: No. I am not suggesting that at all, because this person can get the whole of the service free. He can get the very best and everything he requires without paying for it and without muddling up the doctor’s relationship by paying for a part of the service or for paying one doctor and not another. Hill: No one would deny that the State has enormous functions to-day in relation to housing and nutrition and the aiding of medical research and the organisation of medical services. The resources of the State should be made available; organisation should be made available, but whatever you do, don’t attempt to build up your new health services by destroying an independent group, an- independent profession, and bringing it into the Civil Service. That would be wrong. Let medicine be free to develop. Murray: I think that we are going to be able to let the State do its proper job of providing the service and still give the individual doctor all the freedom, all the initiative, that he requires. Hill: That is where we must agree to disagree. I don’t believe that the State has yet learned how to conduct services of this kind wisely and sensibly and humanly. I would rather leave it ‘with the individual group. Heaven forbid that the individual and his responsibilities and his capacities should be lost in all this business.