British Medical Journal. Supplement : A general medical service for the nation
1938-04-30 1938 1930s 14 pages APRIL 30, 1938 GENERAL MEDICAL SERVICE FOR THE NATION SUPPLEMENT TO THE BRITISH MEDICAL JOURNAL 263 treat persons able to pay and which, in practice, collect payments from a large number of their patients. The field of private practice has inevitably contracte...
| Institution: | MCR - The Modern Records Centre, University of Warwick |
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| Language: | English English |
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[London : British Medical Association]
30 April 1938
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| Online Access: | http://hdl.handle.net/10796/8F9FF409-A1CF-4AFE-B07B-545AD4A5CE35 http://hdl.handle.net/10796/9FA5A3C8-A419-4653-A2D6-2D06A9765F2D |
| Summary: | 1938-04-30
1938
1930s
14 pages
APRIL 30, 1938 GENERAL MEDICAL SERVICE FOR THE NATION SUPPLEMENT TO THE BRITISH MEDICAL JOURNAL 263 treat persons able to pay and which, in practice, collect payments from a large number of their patients. The field of private practice has inevitably contracted, with the result that consultants, and in particular the younger consultants, are finding it increasingly difficult to secure and maintain a standard of living which represents a reasonable reward for their services and which enables them to maintain the highest possible standard of professional efficiency. In the view of the Association there should be remuneration of the medical staff in respect of all medical services in hospital for which payment is made, directly or indirectly, by contributory scheme, by local authority, by employer, by patient, or by massed contribution. In an area where the powers conferred under the Local Government Act are being properly utilized, the voluntary hospital and the county or county borough authority are serving the same section of the community, and the principle of remuneration for services rendered should be adopted in both kinds of hospital. 89. The Committee of the British Hospitals Association and the British Medical Association, under the chairmanship of Lord Linlithgow, set up to examine this subject reported unanimously in the following terms in 1932: "That the time has come to recognize the claim of the visiting medical staffs to some share in the moneys raised for the treatment of patients in hospitals other than those provided by voluntary subscription or donation for the treatment of free patients." 90. In 1937 the Voluntary Hospitals Commission approved, with certain qualifications, the payment of visiting medical staffs, and in referring to the financial problems raised concluded: "The financial effects of such payment would, of course, be considerable, and many cases create difficulties insuperable at the moment; but if the principle is, as we believe, right, and payment justly due, these difficulties should be faced and in time overcome." 91. The Out-patient Department. — The problem of the out-patient has assumed considerable dimensions in recent years. The growth of the contributory scheme has in a large measure been responsible for an increase in the misuse of out-patient departments. Although the majority of contributory schemes in this country are properly run, and although their literature generally makes it clear that a person is entitled to out-patient benefit only when, in the view of the medical staff of the hospital and the patient's doctor, his condition demands it, the public has been slow to realize that the out-patient department should be complementary to, and not a substitute for, the medical care obtainable from private practitioners and certain non-institutional medical agencies. 92. The responsibility for the examination and treatment at the out-patient department of persons who could obtain what they require from their own practitioners or from a consultant in his private capacity rests mainly with the hospital authorities. The desire to maintain or to increase the statistics for out-patient attendances and so to intensify their appeal to the public for financial support plays in some instances a significant part in determining the policy of hospital authorities. Not only does the abuse of out-patient departments constitute an encroachment upon the sphere of the private practitioner, but it damages the efficiency of the hospital itself and the machinery of its out-patient department by the retention of persons who never needed hospital attention or whose condition has reached a stage when they could properly be transferred to other agencies. In the view of the Association the one way of dealing with this problem is to insist that except in emergency all patients should, upon presenting themselves at hospital, produce an introductory letter from their own practitioner. Practitioners should help hospitals by sending to hospital only those patients who need the specialized service available there and who cannot afford to obtain it privately. 93. The Voluntary Hospitals Commission reported on this subject that they agreed that "the chief use of outpatient departments should be for the classes of case stated by the British Medical Association and that hospitals should be encouraged to develop them along these restricted lines." These classes are: (1) casualty cases (mainly accidents and sudden emergencies); (2) cases bringing a recommendation and letter from a medical practitioner for the purpose of consultative opinion; (3) cases which as a result of such consultation are found to require special treatment which can be given conveniently only at the hospital; (4) discharged in-patients who for a further period require special supervision and treatment. 94. The Pay-bed. — It is recognized that the person commonly described as belonging to the middle classes is often unprovided for in regard to institutional provision. His income, while it is above that usually accepted for hospital purposes, with the result that he cannot properly be treated in the public wards of a hospital, is insufficient to allow him to avail himself of the facilities of the nursing home when in need of institutional treatment. The medical profession welcomes the development of pay-beds in association with hospitals at fees within the capacity of the middle-class person to pay. To deal with the purely professional aspect of this problem the Association has taken a number of steps, including the encouragement of provident associations. These associations enable the subscriber to insure against the possible contingency of a form of illness which will require specialist attention in an institution. Although these schemes should be run on a sound actuarial basis and independently of any particular institution, they will have the effect of attracting subscribers to moderately priced pay-beds, providing within reasonable limitations for the cost of institutional accommodation and consultant and specialist services. Pay-beds should be available also to the wealthier classes, the institutional and professional charges varying with the economic standing of the patient. (c) The Domiciliary Public Assistance Medical Service 95. As is made clear in paragraphs 45 and 46, the Association deprecates the separation of the domiciliary public assistance medical service from the general domiciliary service for the community and the denial to this section of the community of the right of free choice of doctor. The Association advocates the absorption of the domiciliary public assistance medical service in a general medical service for the nation. Pending this absorption, the medical service should immediately be reorganized in such a way as to remove these fundamental objections. 96. The arguments which have led the Association to advocate this immediate change are briefly as follows: (a) The Local Government Act of 1929 placed in the hands of local authorities an instrument by which institutional Poor Law medical services could be divorced from the associations of the Poor Law, and henceforth provided, not for one section of the community on social grounds, but for all sections of the community in medical need of these services. Although this important piece of legislation did not enable public assistance domiciliary medical services to escape association with and the stigma of the Poor Law, it is possible within the existing law to remove to a very great extent this association with the Poor Law, which has, by its nature, prejudiced the service and caused many persons needing medical attention to refrain from seeking it. Under Article 8 of the Public Assistance Order, 1930, the Minister of Health can sanction the necessary changes in the Order in its application to a particular area. (b) Under the system commonly adopted to-day a person entitled to medical relief must obtain it not from the doctor of his choice but from a practitioner selected by the local authority to deal with this section of the community in a particular area. The absence of free choice cannot fail
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