I move:
That Seanad Éireann welcomes the proposals contained in the White Paper on the Health Services and their Further Development.
In proposing this motion I do so because I think the White Paper contains very many important improvements, and very many important ideas, which are worthy of the full and free discussion which the Minister requested. Mind you, while the Minister's intentions show up very well and clearly through the maze of Departmental caution, and while I think he deserves great credit for this courageous effort to improve the health services, he has really opened a Pandora's box, and it will take a lot of tact, diplomacy, goodwill and co-operation between the Department of Health, the medical profession, and the various political Parties, to bring this issue to a successful and fruitful conclusion.
There are so many facets of this White Paper that I propose to deal only with the more important ones, and especially those dealing with personnel. The Minister has an antipathy to the southern hemisphere and so, when making comparisons with other countries, I propose to stick to the Northern European countries outside the Iron Curtain. Some of those, particularly the Scandinavian countries, have some points of great similarity with ours in that they have a few centres of very dense population and large areas of difficult terrain and sparse population. When one compares the medical statistics of Ireland with those countries the first thing that becomes obvious is that it is really time we pulled our socks up.
We are the second shortest living people in Northern Europe. From the geriatric point of view that may be gratifying to the Minister but, nevertheless, it is a fact that we are short-living compared with the rest of Northern Europe. Our infant mortality rate is the second highest. This is a worrying point in view of the fact that we have a natural wish to increase our population. Our ratio of doctors per head of the population is good, while our ratio of dentists per head of the population is very bad. The infant mortality graph which is on page 20 of the White Paper and which looks so impressive is really a bit disturbing because from 1960 on it does not show the continuing decrease one would hope.
We know we have very good maternity hospitals in this country. A lot of our midwifery is done in the hospitals but, nevertheless, the Netherlands, who do most of their maternity work on a domiciliary basis, has only approximately half of our infant mortality rate. Sometimes this is blamed on the itinerant problem but I do not think this would account for it. This is a sphere in which we should have a large improvement in both medical and lay approach, especially in the rural areas.
From the point of view of infectious diseases the Department have done very well. Their polio scheme over the past couple of years has been an excellent one and I hope it bears the fruit which we all expect from it. With the rapid introduction of new screening tests especially for phenyketonuria, muscoviscidosis and carcinoma of the cervix, the situation will be very satisfactory.
From the medical point of view, the division of this country into three groups of people on income is quite a reasonable one. The lower income group have all their services free of direct charge, the middle income group have hospitalisation either free of charge or at a nominal rate and will in future have help with regard to drugs. This is an excellent arrangement. Then we have the higher income group who must look after themselves. The present level in the middle income group is perhaps a bit on the high side but no doubt time will take care of that. The Minister must watch in the future that provision is made for all groups and that people in the middle income group will still be able to get private or semi-private accommodation if they so desire or if they wish to pay for it. In other words, I do not think that the Minister would ever intend, or should ever intend, to minimise the private facilities of the country.
One of the best points in the White Paper is the intention of the Minister to very clearly outline the limits of those groups and to give them wide publication. In the past we have had too wide diversification where rich counties, such as Carlow, had 47 per cent of their population on their general medical register, while poor counties, such as Leitrim and Donegal, had only approximately half that number. This was very obviously unfair and depended on local private interpretation. There appears to be no collaboration by the various counties in this matter. There was a lot of chaos and a lot of upset in this matter. The idea that the Minister would appoint a man in each county who would have his own private office and his own private telephone and that his job would be to explain to people just what were the benefits which they could expect is an excellent one, too, and I only hope that, when this starts, the Minister will give this official instructions that he is to be a kind of ombudsman whose bias would be towards the people rather than towards the Department.
The real trouble about all this appears to be the means test. This only seems to arouse a lot of discussion and a lot of discord. I can never really understand this because through all our lives whether we are looking for a loan from the bank to buy a house or getting a car on hire purchase there is always the means test, no matter what class one belongs to. Therefore, the very real grievance which the poor people have about the means test must have something to do with the questionnaire which the assistance officer has to fill up. Perhaps it is the way he goes about the questions or perhaps it is the general approach. It may well be that a few words of explanation to those people beforehand as to why the questions are being asked or perhaps a course in public relations for those officials might go a long way towards solving this difficulty.
The provision of drugs, which is promised in the White Paper, is a very good innovation. It refers to persons in the middle income group as and when their outlay on drugs becomes too expensive for their income. This is a very wonderful advance because more and more the cost of modern medication is getting out of control. However, I would like to take issue with the wording in paragraph 55. It seems to me that if we have to wait for a person to exceed a certain sum in drug expenditure, then we are allowing hardship to develop before we are doing anything about it.
Furthermore, the using of a fixed sum does not seem equitable because you may have a father of a large family with a moderate income and he may be hit more hardily by this fixed sum than would a bechelor earning around £1,200 a year. Therefore, aid should be given when drugs expenditure exceeds a certain percentage of the weekly or monthly income of the family and this help should always be given promptly and should, in many cases, be retrospective to the date of application. There is a great danger in delays occurring as the person concerned might incur further expenditure while awaiting a reply from the Department. I hope the Minister will include a hardship clause in this section because it occurs to me that there are many people whose incomes are over £1,200 a year who in certain cases need help in this respect and might, in fact, be more in need of it than people in the middle income group.
This provision will mean a national formulary and almost certainly bulk purchasing. I hope that when the national formulary is being prepared as well as academic people in the pharmacological line there will also be general practitioners and working hospital doctors on this board, because very often what is ideal in theory is not half so much in practice. When the purchasing board is formed I hope there will be members of the medical profession on it, because the primary consideration of this board should be quality, with price as the secondary consideration. We have had worrying instances of this in the past, and any drug which is going to be purchased should carry with it a certificate of activity and this certificate should come either from a State-sponsored laboratory or, alternatively, from an outside and independent concern.
We now come to the first of the worrying points about the new legislation. This is to do with the district medical officers. These are going to present, I am afraid, a rather major problem. At the present moment they are a very worried and apprehensive group of men. They just do not know where they stand, and they have the worry that their lives will be turned topsy-turvy. When one looks at their problem one cannot really blame them, because quite a few of them have accepted a rather quiet dull life in the country in return for expected retirement on pension and the security it gives. Many of them have spent years doing a lot of training to get their degrees and diplomas and the experience which was necessary to get them their appointments as dispensary doctors. Quite a few of them have built their houses. Some of them have houses at a low rent from the Department. Others are only in their present post as a stepping stone. They hope to get better areas in the future. These are a very worried group of men because they see themselves frozen into their areas forever and wondering what they will do about the education of their children in the future. DMOs in the country are wondering whether the DMOs in the city will do much better out of this than they are. Many of them feel that they will not be able to adjust to this change-over. They will, therefore, look for some kind of settlement and to get out of the scheme.
They are worrying about this compensation. They are worried about whether it will be a just and equitable one, who will arrange it, whether it will be paid in cash or on some kind of never never system that pertained in England when the practices were taken over. Because of these worries this is a very distressed group at the moment, and even though they have accepted the Minister's assurance —and I do not think they would accept anybody else's—that they will not have any financial loss in this change-over still they are not too happy. They have seen the consultants who have had over the past few years to take on a lot of extra work with what is called compensation, and they have seen recently another 200,000 people being put on to the consultants without any increase in remuneration, and they worry very much about this point.
Personally, I have always felt that in Ireland there are only two big factors that can really cause a stir up in politics. I have said many times that only milk and medicine can stir up things in Ireland. The milk is rather curdled at the present moment, and the medicine, I hope, will not be too unpalatable. There is a kind of spirit of 1916 abroad at the present moment, and DMOs are very acutely sensitive to the vulnerability of their position, worried about pressure coming on them from the Department, and liable to react very violently if they have anything put upon them which they feel to be unjust.
We now come to the nub of this whole problem, and that is the mode of remuneration and the amount of remuneration which the doctors will receive from it. This arises out of this admirable sentiment in paragraph 42, which says: "this proposal involves the substitution for the dispensary service of a service with the greatest practicable choice of doctor and the least practicable distinction between private patients and those availing themselves of the service." This all comes from the Minister's decision, which I believe to be the right one, that he is anxious to give a choice of doctor to the people of this country. At the beginning this seemed very good, because we were told that details of the service would be discussed with representatives of the medical profession before any final decisions were taken.
We were a little bit put off then to discover that certain succeeding sentences in the White Paper suggested that a very definite trend was in the mind of the Department, and that their intentions were already focussed on one particular type of scheme. We were told that any eligible person would have the right to be attended by any doctor participating in the scheme who was living within a reasonable distance, who was willing to take him on as a patient, and who had not already a full list of patients. This was still pretty reasonable, but then we were told that a capitation scheme seemed the most practicable. "Practicable" is a worrying word because it is very hard to interpret. You are not sure whether it means the best or the cheapest or the easiest to administer, and the point about the doctor participating in the scheme resolves this same sentence later into the fact that not all the doctors would be participating in the scheme, that if a capitation scheme went through as envisaged only a certain number of doctors would be able to participate because of the need to get and keep worthwhile panels of patients. This changed choice of doctor immediately into choice of Department's doctor. It looked as if a patient who was eligible might never be able to get the doctor of his or her choice.
All this was worrying. It led to uncertainty as to where we were going because apparently we were following the path first trodden by Lloyd George in England in 1911 and perpetuated by Aneurin Bevan in 1948 against the wishes of the Labour Party, who wanted a salaried service scheme but were prepared, in their haste to get overall national legislation, to accept a capitation service.
I shall now deal with the three types of service available to us. The salaried service is an excellent system and has worked very well but it has the disadvantage that choice of patient is not practicable in it. The other two services are fee-per-service and capitation. Fee-per-service gives a choice of any doctor. It is basically simple. The doctor is paid for the work he does. He gets so much for a house call, so much for a surgery consultation and the fee varies between night and day work. It is as straightforward as that. The point behind it is that the work done is paid for.
Capitation, on the other hand, means the State gives a certain amount per person. They give their cards to the doctor who draws the money for all the cards he handles. He gets paid for this group of people whether sick or not and whether he looks after them or not and whether they are in hospital or under his care. Most important, no matter how much service he gives them he gets only the same amount so that the tendency is towards a minimal service.
I think it is fair to state at this point that of different countries in northern Europe—France, Germany, Austria, Switzerland, Denmark, Holland and England — only England has the capitation system. Holland and Denmark have it to a slight degree. The remainder favour a fee-per-service and since 1948 all these countries have been going away from capitation mainly towards fee-per-service, though one tiny section has favoured salaries. From the general trend point of view, if we were to move to capitation we would be moving against the trend in northern Europe and it seems unlikely that they could be so much wrong and we so much right that this would be the right answer for us.
In any new scheme of health services that is being brought forward, the Department of Health are obviously expected to provide certain things. First, they should provide a choice of doctor. Secondly, there should be adequate coverage of the people concerned and the medical services provided should be efficient. Thirdly, the service should be reasonable, predictable and reasonably easy to administer. This is what the Department could expect. The profession, on the other hand, could expect certain things as well. They could expect that patients should have a choice of doctor and that it should be the doctor of their choice. We should be able to expect that the profession would receive adequate remuneration and that remuneration would bear a relationship to the work done and to other factors of that nature. We could expect that there would be no interference with the doctor—patient relationship, and nowadays we can expect that a norm will be set down for what is the ordinary working week of the doctor—that once and for all we can decide how many hours in the week a doctor is expected to work and that beyond that he need only work if he wishes and if there is no medical coverage available for accident or emergency. Finally, I think the profession are entitled in doing State work to have reasonable consideration given for holiday leave, sick leave and study leave.
They are the two sides of the coin. The point on which there is the most likely disagreement will be on the mode of remuneration and on the amount ultimately. The mode of remuneration, I am afraid, will be the important issue. Capitation is obviously a very easy solution for the Department. It is easy to administer and it is predictable. It makes certain that the Department know from year to year just how things are going and they can always work out in advance just what their liabilities will be next year. That is an important point in favour of capitation.
Fee-per-service, however, causes worries in Departmental ears because the Department feel there will be no predictability of expenses and that there is great danger of doctors over-visiting their patients and thereby running up expenses. I do not think this is a valid argument because it can be very easily controlled. These things tend to scare the Department away from any notion of fee-per-service. The medical profession, however, by a very great majority in this country, are anxious for fee-per-service. Many of their members have worked under capitation in England and they know its troubles. They know it certainly does not lead to good work, there is no incentive to work and there is a great tendency for abuse of the doctors.
A survey was taken a couple of years ago in England and on a straight questionnaire it was shown that nine per cent of the population went to doctors for no good medical reasons, five per cent went to get value for their money and four per cent did not know why they went. One in ten went because the system was there. Furthermore, we know that under the scheme envisaged for this country only approximately 45 per cent of the people will be under the capitation service. Now, one of the objects of this White Paper is to get rid of the second class citizen—the one who gets poorer service—yet we are about to create a new group of cardholders who will perpetuate this inferiority complex and the snob value system which have caused so much friction in the health services in the past.
It was not so bad in England where everybody, 100 per cent of the population were put on the capitation system. Here, however, we propose to put only 45 per cent under the system and we shall thereby immediately create this second group again. Furthermore, this 45 per cent will be the poor people, the large families with poor incomes, the elderly whom nobody is anxious to take on because of their tendency to illness. The next point that dawns is that the system will have to be selective of the doctors who will be eligible to go on the scheme. I can foresee this leading to all kinds of trouble. In some areas the most popular doctors may not want to go on it because they are going into the low class, high risk group. No doctor may want to go on it and all doctors may want to go on it. Who will decide? Who will decide who is to take a group of doctors in a town or a city and say: "You and you go on it?" This will lead to the most serious friction. I have no doubt about that.
If the number of doctors to whom patients may go is restricted, a monopoly will be created. The panels will be full, the patients cannot move, there are minimal chances of their moving from one doctor to another. Group practices will be encouraged and the funny thing about them is that they will be the one thing that will tend to limit choice of doctor because in a group practice you will get the doctor who is on duty, not the one you want. What will happen now is they will be frozen. It will be harder than ever to place doctors in the rural areas. Look at the situation in the Rhonnda Valley in Wales which is an unpopular area where there are 100,000 patients. There are 38 doctors, nine of whom are between 60 and 70 years of age, one of 77 years and another of 92 years. So, you have 25 doctors catering for 100,000 people and one doctor for 4,000 people. This is an appalling figure. This is because of the reluctance of people to settle down just anywhere.
Under capitation you will have all the friction that arises in England, like that over capitation culminating last year in the Birmingham upset where the Minister was forced to plug the gap with Commonwealth doctors to each of whom he had to guarantee a salary of £4,000 per year. He had to plug the gap where other doctors would not work.
Furthermore, the capitation scheme favours and encourages hospitalisation. The Nuffield report shows that 27,500 patients were unnecessarily admitted to the major hospitals in England in the year in question. This is understandable because doctors do not lose anything if the patient goes to hospital. In fact, the doctor gains. He cuts down on his work regarding a patient he goes to see every day. If he has a dubious or troublesome patient he is no worse off. He gets rid of responsibility; he gets paid and he is very happy to enforce hospitalisation.
Now, what about the fee-per-service system today. There are disadvantages. First of all, more paper work will be involved and secondly, they may be asked in the future why they visited patients so often. I think that is not unfair. In the past they may have been asked why they did not visit patients; they may have had to explain perhaps why they did not visit patients, and so on. These objections would be well out-weighed by the points in their favour. There is an incentive to work; there is a minimal tendency to hospitalise; all doctors may participate and young doctors can set up—these are usually the enthusiastic doers— whereas under the capitation scheme doctors cannot set up because the area is full. Patients may go to whatever doctor they want. Work will be related to remuneration and there will be much less tendency towards the creation of a second-class citizen because the patient can go where he wants, sign a slip for the doctor on which he may collect his fees. There will be much less tendency towards hospitalisation.
The biggest worry from the Department's point of view is that doctors may over-visit and overwork and there would have to be very strict control. This is fair enough but it is not impossible. This is a small country of 2,800,000 people. The Manchester area alone is bigger than this and a baby computer could easily cope with all the administrative work. Furthermore, this computer could pick up and give weekly returns which would very rapidly show up any doctor who was doing over and above the national average. It would stick out like a sore thumb. It would be quite easy for the Department to check with the regional body and they would very quickly tap the doctor on the shoulder and bring him to heel.
This is one of the advantages of having a local medical body. They would be able to do that much better than members of a civil service body. Even if there were unnecessary visitings it would take 20 to 25, or even 50 extra visits of a doctor per week to make up for one week in hospital of a patient. I do not believe no matter how much over-visiting there is the bill will equal hospitalisation.
The problem of the mode of remuneration to the general practitioners was reviewed by the Minister in his reply to the Dáil on 31st March, 1966, in volume 222, columns 459 to 464 of the Official Report. This reply was a source of great worry to us because we knew the Minister had been energetically going up and down the country, asking questions trying to get information and generally trying to get a bird's eye view of the subject. Yet, some aspects of his reply showed evidence of rather poor briefing.
I should like to deal with some of the Minister's points in detail. In one of his first points the Minister said:
In a fee-for-service system for which the public authority pays the full charge to the doctor it will be necessary to have very stringent control to prevent abuse. This might involve interference with professional freedom and is one of the reasons I am not inclined to regard this as the best system of payment in our circumstances.
This is a reasonable approach but I do not think the Minister need be too worried about the need for professional freedom because if doctors were working under this rule I am quite sure they would be reasonable.
Furthermore, during the Dáil debate practically all the Deputies who spoke praised the Irish country doctor and the dispensary doctor and mentioned especially their lack of monetary interest. I think it would be a pity if the Minister did not take this report from his men in the field and balance it against the rather suspicious forebodings of the Department.
The Minister then went on to say that there had been a very detailed review of the whole system of paying general practitioners in England. In the supplement to the British Medical Journal of 13th January, 1965, there was published the collected report of the Chairmen of the various regional conferences. This document reported as the Minister quoted:
If the capitation fee were sufficient, much of the present discontent of the method of payment would disappear
and again:
a careful study of reports of the regional meetings indicate that the capitation system is still preferred by the majority of family doctors.
Again, speaking of the fee-for-service system the report did say:
There was some but not much support for such a scheme.
The Minister then went on to say, and I quote:
When a reasonable body like the British Medical Association sets up working parties and goes to different regions in Great Britain and then comes up with this report—well, I do not know.
The trouble about this report was that it was not all it appeared to be and the facts leading up to this are documented in the British Medical Journal of 1964, the year before the report mentioned by the Minister was published. It became evident that the gentlemen concerned with this report were not in touch with general practitioner opinion and, in fact, they were senior people who had the soft end of the work in their own practices and who were, so to speak, prepared to settle for a little more money and a little more help. That state of affairs is very much like that which would exist if one were to call a meeting of our own senior dispensary doctors at the present moment. They would be happy with a little more money and a little more help.
But, as I have mentioned, this fact had been recognised the previous year at the annual conference of representatives of local medical committees held in 1964 when a resolution was passed, and I quote:
Having regard to the serious deficiencies in the machinery for ascertaining, mobilising and representing general practitioner opinion, as revealed by the present crisis, this conference instructs the General Medical Service Committee to institute an immediate review of its own constitution....
This overhaul is still proceeding and so it is the report from which the Minister quotes is suspect and this fact is borne out by reading the recurring reports of the "Assistants and Young Practitioners Committee" throughout the past year in which recurring emphasis is laid on a change from capitation to fee-per-service system. Furthermore, at the actual meeting to which this report was made the President of the Medical Practitioners' Union, which was a body strong enough to have two representatives on this committee, stated that in his opinion the committee was gravely out of touch with the periphery if it feels that remuneration is the only problem confronting general practitioners today. The editorials in the British Medical Journal were, in the meanwhile, giving an inkling of the true state of affairs. On the 26th December, 1964, it stated:
Discontent is bound to grow until someone agrees to simplify what has become so complex; that is the method of relating work done to the rewards that should come from it.
Then in the issue of 27th February 1965, it is stated that no one must be left in any doubt:
Of the profound dissatisfaction of general practitioners with their conditions of work and the pay they receive for it. We think this is the correct order in which to place these two elements of the present outburst. Indeed, it could be said that so dissatisfied are the general practitioners with the way in which they have to do their work, their principal compensation for this is to seek for more money.
So, the pressure in each of these articles was on the capitation system.
At that time this particular negotiation broke down and the General Medical Service Committee did a complete volte face and unanimously recommended that the British Medical Guild be asked to advise all general practitioners to place their resignations in the hands of the British Medical Guild. They requested that immediate negotiations be opened with the Minister of Health with a view to devising an entirely new contract for general practitioners involving a fundamental change in the method of remuneration. Six weeks later the British Medical Association produced a Charter and this is very much recommended reading because it states:
A doctor's pay must be related directly and realistically to his work load and responsibility.
and it goes on to state:
The method of payment must be flexible.
Groups of family doctors should be given a choice of payment by capitation fee, fee-per-service or some form of salary. So that a few weeks earlier, having had one opinion and publishing it in this report, the British Medical Association now makes those statements.
They then went on to demand a capitation fee of 62/8 per head, based on the lowest possible payment made by Government Departments for certain services given to the public. They were prepared to modify this sum of 62/8 and reduce it to 36/- if the Government were prepared to alter the conditions of service and negotiations were then started. These negotiations are not yet complete. They have not yet been accepted by the members of the British Medical Association but what has been given away to date has been quite amazing. First of all, while the Government would not agree to a fee-per-service for the main work, they agreed to a fee-per-service for maternity, innoculations, vaccinations, servical smears and for night work originating and being carried out between 12 midnight and 7 a.m. They also agreed that pilot schemes would be discussed, would be set up in different parts of the country and that these pilot schemes would be tried out using the fee-per-service system. They also agreed to the use of salaries as a method of payment and have passed a Bill through Parliament permitting this. So, in these negotiations the first major crack in the capitation structure took place.
In the payment line they have made immense concessions. They agreed, first of all, to a 5½ day week for doctors, finishing at 7 p.m. in the evening on weekdays and 1 p.m. on Saturday. They agreed that doctors would not have to work outside this if they did not want to and provided there was medical service available. If doctors wanted to work outside it they would be paid a special standby fee and a supplementary capitation fee. They also agreed that from 12 midnight to 7 a.m. there would be a fee-per-service system. They went further. They agreed to basic sums for doctors and these sums would be varied according to the location in which the doctor worked and, more important, would vary according to seniority, experience and qualifications, so that the merit system has been introduced for general practitioners.
They agreed further that elderly patients would carry a special capitation rate, thereby admitting the persons of a high risk group. They also agreed payments for nurses, secretaries, rent, rates, repairs, etc. Having got all these conditions, they were then sent to be priced by the review board. This was accepted by the Government and so worried were they about the scheme in England, they accepted it without resorting to the Prices and Incomes Board, even though it far exceeded the three per cent which they had been prepared to give before that. It is now in the hands of the general practitioners as to whether or not they will accept it. They probably will accept it but it will only last a couple of years before there is a further breakdown because even with the increased remuneration I am still sure that emigration will take 350 doctors a year. England will certainly not get back the 2,000 doctors she is below par and the overwork will not decrease. Therefore, remuneration will not tend to make up for it. This increase in remuneration, however, may have quite serious repercussions in this country, as a large number of doctors who might have come home will probably go to stay in England now.
The Minister also stated that it was only "hot-heads" and "wildcatters" in the Irish Medical Association and the Irish Medical Union who were pressing for the fee-per-service system. This is not, I think, quite accurate. We have our "hot-heads" and "wild-catters"—any profession has—and there is no doubt that the Minister has received a certain amount of information which might lead him to believe that this is so but I think there is a genuine desire on the part of the majority of the doctors in Ireland for a fee-per-service system. A survey was made by an organisation in this country and they have recently released their figures for the different methods of payment which are as follows:—
For direct payment—47 per cent; for fee-per-service—39 per cent; for salary—9 per cent; for capitation— 2 per cent; and no view expressed —3 per cent.
I was quite worried about this problem myself so, during the Easter holidays, I sent out over 100 letters to different doctors throughout the country to ascertain their opinions. The figures I got back were:
82 per cent in favour of fee-per-service, and 18 per cent in favour of salary or capitation.
There was also an argument that, perhaps, capitation did not favour hospitalisation as much as it appeared to and that in the opinion of the medical profession this was a pointer against capitation not being a valid system. The Minister quoted figures from New Zealand in the year 1961-62 which showed a hospitalisation figure of 10.8 per cent of the population, whereas in Ireland in the same year we had 9.4 per cent of the population.
Now, this was not really a very good comparison because what we should really be doing is comparing fee-per-service countries with capitation countries, or, conversely, we should be trying to estimate what number of patients in Ireland would be hospitalised if we went on to capitation as against fee-per-service, so that there is no real comparison of the effect that might take place if we went on to capitation.
Apart from this, there are five reasons why patients would go into hospital. First of all, there is valid hospital admission for illness. Secondly, there is admission for a supersophisticated piece of diagnosis. Thirdly, there is admission for routine diagnosis which should not occur if there are facilities outside the hospitals. Fourthly, there is admission because social conditions at home make this necessary. This is really a different problem. It is a problem of the social services. Fifthly, there is admission because the doctor is lazy or careless or does not want to be bothered by the patient. It is the last kind that we want to prevent, and it is the last kind that will flourish under the capitation system.
While that is going through my mind there is another point. We want to reduce the long stays and slow processing in hospitals. Those are points that could also be helped even within our existing medical set up. The main issue is that increased hospitalisation due to careless or inadequate doctoring is the type we want to cut down, and that is that type that will increase under the capitation system.
One of the problems that always arises when medicine is under some kind of review or change is that doctors always appear to be looking for more money and to be rather mean and grasping. I do not think that is really a very fair statement, because if one examines doctors' incomes over the past half century, one finds that we have certainly gone down the scale more than any other profession. At present in the voluntary hospitals group, which do most of the important specialist work in the country, the specialist pool is only four per cent of the cost. The district medical officers, the dispensary doctors, cost the country only £1 million a year which, out of a total of £31 million spent on health, is really a very small amount. They are the backbone of the whole medical system of the country. I hope, indeed, that arbitration machinery for professional people will come to fruition, and that in future doctors' salaries will be negotiated by some independent tribunal. I feel we would do better out of it and get a fairer approach.
Over the years we have always been rather sympathetic towards the Department in that they did not have much money, and their officials were not too well paid, but there has been such a change in the past few years with everyone's salary going up so much, that the profession is rather resentful at the moment at the way its salaries are lagging behind everyone else's.
I can give some examples which are really quite serious and tragic. One came to my notice recently. There is a doctor in a moderate sized town who looks after the county home. There are 147 beds in the county home, 80 of which are acute medical beds, in other words, beds which have to deal with medical cases, pneumonia, coronary thrombosis, pleurisy and so on. The man in question is a well qualified man. He has various degrees and diplomas. He is interested in geriatrics and does courses in geriatrics. It is his duty to spend 15 hours a week in this hospital. He must visit it every day which he does. He is on call for emergencies at any time. Now, 15 hours a week should represent about two-fifths of anyone's working week, and certainly by any scale of comparison with a reasonably employed professional man, that position should be worth about £1,000 a year.
In England a comparable general practitioner doing this kind of work would not, first of all, be allowed to look after 147 beds. Secondly, his minimal salary for this work would be over £1,000 a year. In this particular post the man is paid £240 a year which, at £20 a month for 15 hours a week, works out at 6/8d an hour, not including emergency work. Recently he was offered an increase of £80 a year which would still only bring him up to another 2/2d. an hour, which is really appalling. Now, I feel that this approach to medical personnel, and to the staffing of institutions, has had a good deal to do with some of our problems. I have a notion that if the medical personnel were used more freely, and perhaps paid a bit better, a great deal of our problems could be solved without great expenditure in bricks and mortar and equipment.
In paragraph 72 of the White Paper there is a table which shows that the greatest increase in hospital patients occurred in the larger hospital groups, in the voluntary teaching hospitals and in the regional hospitals. Linking these two groups together is rather unusual because normally the voluntary hospitals and the regional hospitals are, so to speak, poles apart. Thanks to the courtesy of the Minister I was able to obtain the figures for the regional hospitals so far as beds are concerned, during the period 1957 to 1964. Using these against the Hospitals Commission figures for voluntary hospitals, some interesting facts emerge.
In 1957, if we were to take the turnover of the regional hospitals as a base line, then we should have expected the voluntary hospitals that year, having due regard to the bed ratios, to have dealt with 60,000 patients. In actual fact, they coped with over 78,000 patients. In 1964, and by then bed compliment of the regional hospitals had increased by 25 per cent, while in the voluntary hospitals it had increased by only ten per cent, using the regional hospitals once again as a base line for admissions, the voluntary hospitals should have put through their hands 70,000 patients, but in fact they had 101,000 patients. Now, this demonstrates the point I made before that the voluntary hospitals do a disproportionate amount of the specialist work in this country, and this can be attributed, in fact, to the very much higher staff ratio per patient there is in the voluntary hospitals as compared with the regional hospitals.
Compared with the Regional Hospitals the voluntary hospitals would appear to be grossly overstaffed but, in fact, this is not so in the sense that we get through a lot more patients and, therefore, show a much more economic return. One wonders is this return really economic? It is very hard to compare doctors' work but there is one side one can compare very well, and that is surgery. Surgery is like any other job, like making a table or mending a pipe.
