still depends too much upon circumstance, they happen to live or work, to what or vocation they happen to belong, or what happens to be the matter with them. Nor is the care of health yet wholly divorced from ability to pay for itThe restricted nature of the National Health Insurance service is pointed out, also the uneven distribution of hospital services. Finally, personal health still tends to be regarded as something to be treated when at fault, or perhaps to be preserved from getting at fault, but seldom as something to be positively improved and promoted. Some of the principal of service these deficiencies a comprehensive health should, in the view of the Government, seek to make can

do

so

upon -where group of age

good.

A National Health Service Government Proposals. (The White

Paper Summarized) to the British Medical Journal, i, 26th February, 1944, p. 31)

(From Supplement

The long-promised White Paper on 'A National Health Service' was issued by the Ministry of Health and the Department of Health for Scotland on 17th February. It is a document of 85 pages. After describing the present situation it proceeds to outline a comprehensive service for all citizens, and the central and local administrative structure of such a service. Hospital and consultant services, general practitioner service, and clinic and other services under the new arrangements are considered. There is a chapter on the service in Scotland, where the administrative structure is somewhat different from what it is in England and Wales. Of five appendices one reports the events leading up to the White Paper, drawing atten' tion to the B.MA.'s General Medical Service for the Nation' and the Interim Report of the Medical Planning Commission, which is frequently quoted in the body of the Paper. Another appendix is a financial statement, from which it appears that the total annual cost of the scheme in England and Wales is expected to be ?132,000,000, and in Scotland ?15,800,000, about two-thirds of which will be met from public funds and the remaining cost will fall on the ratepayers. The

objective

The object of the proposals is to ensure that every man, woman and child in the future can rely on getting all the advice and treatment and care which they may need in matters of personal health; that what they get shall be the best medical and other facilities available, and that their getting these shall not depend on whether they, can pay for them or any other factor irrelevant to the real need?namely, the reduction of ill-health and promotion of good health among all citizens. ' The case for it ta comprehensive service] stands on its own merits, irrespective of the war or of other proposals for post-war reorganization, although it must form an essential part of any wider proposals for social insurance which may be put into operation.' It is added that the proposals made in the Paper represent what the Government believe to be the best means of bringing the service into effective operation. The Government want them to be freely examined and discussed. They will welcome constructive criticism of them, in the hope that the legislative proposals which they will be submitting to Parliament may follow quickly and may be largely agreed. The

reason for change

The main reason for change is that the Government believe that, at this stage of social development, the care of personal health should be put on a new footing and made available to everybody as a publicly sponsored service. It is still not\ true to say that everyone can get all the kinds oflmedical and hospital eervice which he or she may require. ' Whether people

There is a certain danger in making personal health the subject of a national service at all?the danger, nameb', of over-organization. Yet if medical services are to be better marshalled for the full and equal service of the public, organization, with public responsibility behind it, there must be. Organization is. the means, never for one moment the end. 'Nor should there be any compulsion into the service, either for the patient or for the doctor. The basis must be that the new service will be there for everyone who wants it but if anyone prefers not to use it, or likes to make private arrangements outside the service, he must be at liberty to do so. Similarly, if any medical practitioner prefers not to take part in the new service and to rely wholly on private work outside it, he also must be at liberty to do so .

.

.

'

'

Comprehensiveness The proposed service must be?comprehensive in two senses?first, that it is available to all people, and, second, that it covers all necessary forms of health care. The service designed must cover the whole field of medical advice and attention at home, in the consulting room, in the hospital or sanatorium, from the personal or family doctor to the specialists and consultants of all kinds, and it must include ancillary services of nursing, midwifery, and the other things which ought to go with medical care. It must secure, first, that everyone can be sure of a general medical adviser to consult as and when need arises, and then that everyone can get access, beyond the general medical adviser, to more specialized branches of medicine or surgery. In two respects the new service will be less complete than was wished. There will not be enough dentists in the country for some years to come to provide a full dental service for the whole population, and there may be similar, though less acute, difficulties in getting a full service in ophthalmology. Mental health services are to be included, although, failing a full restatement of the law of lunacy and mental deficiency, their inclusion presents some difficulty. ' It is added that a comprehensive' service does not mean that there should be no Government or private activity involving the use of the medical expert or having any bearing upon health. Two examples are given. One is factory medical inspection and the employment of works doctors. The enlistment of medical help here is part of the complex machinery of industrial organization and welfare and belongs to that sphere more than to the sphere of the personal doctor and the care of personal health. The other is the school medical service, to which similar considerations apply. The

administrative structure

The new responsibility for providing the comprehensive service will be placed upon an organization in which both central and local authority take part, central responsibility lying with the Minister, and local responsibility with the major local government authorities (county and county borough councils) operating, for some purposes, severally over their existing areas, and for other purposes jointly over larger areas formed by combination. Both at the centre and locally special new consultative bodies are proposed for

?

of ensuring professional guidance and the enlistment the expert view. At the centre, in addition, a new and mainly professional body i3 to be created to Perform important executive functions in regard to general medical practice. Central organization new to Parliament for the service will rest on the Minister of Health and in Scotland on the Secretary of State. At the side of the created Minister, but independent of him, there will be Central professional statutory body to be called the health Services Council. Its function will be to express the expert view on any general technical aspect of the service. It will be entitled to advise on matters referred to it by the Minister and on any other matters within its province. Any general regulations which the Minister may make will be referred to it. It, is assumed that this Council will be primarily uiedical in its composition, but not wholly medical for for Jt will be required to provide an expert view on,

Direct responsibility

example, hospital administration, nursing, pharmacy, a&d other subjects. It is thought that it might consist medical ?f 30 or 40 members, representing the main organizations, voluntary and municipal hospitals, Medical teaching, and professions like dentistry and the nursing. The members would be appointedandbyother Minister in consultation with the professional concerned.

or^nizations

,

There will, also be set up a central Medical Board to perform executive functions in the day-to-day lng of the general practitioner service. It will be

medical

composed, in the main, of members of the Profession and will be the employer' body with which the general practitioner enters into contract in the new service. The distribution and welfare of practitioners and assistants will be its concern. '

The local authority The local organization is more complex. The new service has to include hospital and institutional services infectious ?r the sick in general, for mental cases, for diseases and tuberculosis, for maternity, and for every general and special hospital subject. The White Paper Puts aside the suggestions which have been made in favour of a new kind of local authority of a vocational or technical character. The principles of democratic be responsibility and of professional guidance must to the local as to the central organization. The Government have no intention to supersede the it Present local government system; on the contrary, Proposes to take as the basis of the local administration of the new service the county 'and county borough councils. But the sizes of counties and county boroughs in vary enormously, and there are some requirements the new service, particularly in so far as they relate cannot to hospitals, which counties and county boroughs its act separately, each for as fulfil so

^Pplied

long

independent

they

area.

In many branches of hospital administration the need for larger areas has long been recognized by local authorities in their regional developments. Various alternatives for the form of authority for these larger hospital areas are examined in one of the appendices, out in the Government's view the only course possible at the present time is the creation of the larger_ area authorities by combining for this purpose the existing county and county borough councils in joint boards operating over areas to be settled by the Minister after consultation with local interests. In some exceptional cases, of which the County of London is the most obvious, no combination will be necessary. This does uot mean that standard-sized areas can be prescribed for hospital services. Local conditions must determine

and shape. Reasons are given why infectious diseases hospitals must in future form part of the general hospital system. 'The small isolation hospital of the past century is not only uneconomic in days of rapid transPort, but cannot be expected to keep abreast of modern methodsOne result of the new outlook will be the size

553

A NATIONAL HEALTH SERVICE

Nov., 1944]

development, in addition to the larger isolation hospital serving the densely populated area, of accommodation for infectious diseases in blocks forming part of the general hospitals. Local clinic service for centralizing all administration in one authority over the larger area does not hold to the same extent in the case of services given in local clinics Nevertheless, this services or by domiciliary visiting. should be regarded in future as the related parts of a wider whole, and should fit in with all the other branches of a comprehensive service in their planning and distribution. The new joint authority will therefore be charged to examine the general needs of the area from the point of view of the health service as a whole, including in addition to hospitals, these more local services. Normally, however, their provision and maintenance will rest with the individual councils, and the joint authority will be concerned only to watch that the general area arrangement proves to be the right one when put into actual operations. Some forms of local clinic service, like tuberculosis dispensaries, mental clinics, and cancer diagnostic centres, are in essence out-patient activities of the hospital and consultant services, and these should usually be the responsibility of the same authority as is responsible for the hospitals and consultants over the larger area. But, generally speaking, no hard-andfast rule can be applied. Special considerations apply to the general practitioner branch of the new service, which is reviewed in detail later in this summary. The main aspects of the service which affect the individual practitioner, including the terms of his participation, the protection of his professional interests and his general personal relationship to the new service, will be governed by central arrangements applicable to the country as a whole. But there is no question of excluding this branch of the health service from the concern of the new joint authorities to plan for the requirements of their services. The provision and maintenance of health centres for grouped medical practice would be a function appropriate to individual county and county borough councils. The

case

Professional guidance Just as there is to be centrally a Health Services Council so there should be similar consultative machinery for local administration. The purpose of the Local Health Services Council will be to provide a medium for expressing the expert point of view on technical aspects of the service. Provided that all the professional interests are fairly represented, there is no reason why the pattern of these bodies should be uniform throughout the country. The Government turn down the proposal that on the local administrative authorities themselves there should be a number of members appointed by professional organizations, with or without voting powers. The risk of impairing the principle of public responsibility, that effective decisions on'policy must lie with elected representatives answerable to the people, is held to be too

great.

Hospitals

:

An

end to anomalies

' The term hospital services' in the White Paper includes all forms of institutional care of every kind of sickness and injury. It includes also out-patient treatment and treatment at sanatoria and rehabilitation centres. The inclusion of mental hospitals and mental deficiency institutions presents many problems, calling for some degree of special organization to meet them. The present hospital services are detailed in an appendix to the Paper, in which the need for' coordination and better distribution is pointed out. The anomalies of large waiting lists in one hospital and suitable beds empty at another, and of two hospitals in the same area running duplicated specialist centres which could be better concentrated in one more highly equipped and staffed centre for the area, are largely

THE INDIAN MEDICAL GAZETTE

554

a situation in which hospital services are people's business but nobody's full responsibility Two main problems are presented : to bring together in suitable areas the activities of the various separate and independent hospitals, and to enable two quite different hospital systems (the voluntary hospitals and the municipal) to join forces in future in a single

the result of

many

service.

The

.

voluntary hospital in the plan

It is acknowledged that without the collaboration of the voluntary hospitals it would be many years before the new joint authorities could build up a system adequate for the needs of the whole population. From that point of view alone, therefore, the co-operation of the voluntary hospitals is a necessity. But the matter cannot be regarded from that point of view alone. ' The voluntary hospital movement not only represents the oldest-established hospital system of the country, but it attracts the active personal interest and support of a large number of people who believe in it is a social organization and who wish to see it maintained side by side with the hospitals which are directly provided out of public funds. It is not merely that the best of the voluntary hospitals have, in a degree so far unsurpassed, developed specialist and general hospital resources which they will be able at once to make available [but], most of the rest of the voluntary hospitals have experience and an existing organization which it will be obviously sensible to enlist. It is certainly not the wish of the Government to destroy or to diminish a system which is so well rooted in the good will of its supporters.' Yet the responsibility for a comprehensive service accepted by the community may affect fundamentally the position of the voluntary hospitals. A new universal public hospital service, says the White Paper, might have the gradual effect of undermining the foundations on which the voluntary hospitals are based. If this is not to happen a way must be found of combining the general responsibility of the new joint authority for the service with the continued participation in that service of the voluntary movement as such. The whole service must be brought under one ultimate public responsibility without destroying the independence and traditions to which the voluntary hospitals attach value. The Government believe that this can be done. Self-sufficient

hospital areas

The joint authority will assess in detail the hospital needs of its area and the resources available; then it will work out a plan of hospital arrangements, based on using, adapting, and, where necessary, supplementing existing resources. The plan must ensure, for instance, that the various special treatments are concentrated in centres competent and_ convenient to provide them, not dispersed haphazard in uneconomic and overlapping units. The area will be made as self-sufficient as possible. The joint authority will secure the necessary service for its area partly through its own hospitals and institutions and partly through contractual arrangements made with the voluntary hospitals. The plan will be submitted to the Minister for approval, and the Minister will have regard to its relation to the country No voluntary hospital will be compelled as a whole. to participate. If it does agree to participate it will do so under certain conditions, which will apply also to the authority's own hospitals; for example, each hospital will agree :? _

(1) To maintain the services which it undertakes to provide under the plan; (2) To observe national requirements with regard to payment and condition^ of its nursing and domestic staff; /f^\ (3) To conform with any national arrangements in appointing senior medical and surgical staff; (4) To be open to visiting and inspection in respect of its part in the public service;

[Nov.,

1944

(5) To have reasonable uniformity in accounts and audit. (This applies to voluntary hospitals; the presentation of accounts of municipal hospitals is largely subject to central direction.) It is the aim of the Government to enable voluntary to take their important part in the service without loss of identity or autonomy. But they must still look substantially to their own financial resources, to personal benefactions, and the continuing support of those who believe in the voluntary movement. This being understood, the financial relation between the joint authority and the individual voluntary hospital must be that of an agreement to pay a specified sum in return for services rendered, and this should not be assessed as a total reimbursement of costs incurred. In addition both the municipal and the voluntary hospitals will receive a direct grant from public funds which will include the share attributable to hospital services of any sum allocated towards the cost of the comprehensive health service from the contributions of the public to any scheme of social insurance. For the inspection of hospitals?a formidable task seeing that there will be hundreds of them under different managements taking part in a public service-? a suggestion is made for the appointment of a body of persons, some on a wholetime and others on a parttime basis, and grouped in suitable panels for operating

hospitals

over an area.

Consultants

:

Plan

not yet ready

One of the duties of the joint authority will be to ensure that, through the various hospitals taking part, there will be provided an adequate consultant service available to all general practitioners working under the plan. The local service payments to hospitals will be based on the assumption of a consultant staff properly remunerated to enable the hospital to fulfil its tasks. The Government are awaiting the report of Sir William Goodenough's Committee on Medical Schools before proposing in detail a form of consultant service. There is need, says the Paper, for more consultants and a better distribution of them. One of the aims of the service will be to encourage more doctors of the right type to enter this branch of medicine or surgery and to provide means for their training. The consultant service will still need to be organized with the medical teaching centre as its focus, but it must be spread over a wider area. The consultant taking part in the service must be associated with his particular hospital or hospitals on a much more regular basis. His function will be normally one of regular and frequent visiting of his hospitals, both for in-patient and out-patient consultation, and of visiting outlying 'general practitioner' hospitals. Remuneration may be on either a full-time or a part-time basis; there will be no need to make either form of appointment a universal rule. Some degree of control of the discretion of individual hospital authorities> in making appointments to senior clinical posts will be required. The ' danger of in-breeding' under existing practice is recognized. An expert advisory panel should recommend a number of suitable candidates, from whom the hospital authority would make the final choice. One or more representatives of the appointing hospital could join the panel dealing with the sifting of candidates, the panel being based broadly on the medical teaching centres and representing both consultants and teaching

organizations.

General

practitioner

arrangements

The 'Front Line' of the Service ' The most difficult problem of all' is the arrangement for general medical practice in the comprehensive medical service, partly because this is the ' front line of the service, and, partly because, notwithstanding National Health Insurance experience, the covering of the whole population creates many new problems. The doctors working a service which is free to the people and looking to public funds for their remuneration, must be in some contractual relationship with public

8

Nov., 1944]

A NATIONAL HEALTH SERVICE

The state must therefore take a greater p in future in regard to medical practice. ^vo=PTit Two principles are to be observed : thei p > freedom of choice must not be generally dum? / and the continued practice of medicine as an in and personal art, impatient of regimentation, , aoCTorb the ensured. 'Whatever the organization taking part must remain free to direct their o +up:r knowledge and personal skill for the benefit patients in the way they feel to be best ?rv11VV, The White Paper dismisses the system under which all doctors taking part in the service would be employees of the state or local authorities an remunerated by salary. It is a system which c organized, but it opens up much .controversy, many doctors would hold that it infringed the of-the two principles just stated. A universal change > to a salaried system is not, in the Governmen to the efficiency of the service. , necessary ' a to make unnecessarily so total and abrupt change in the customary form of general medic.tnaxP tice would offend against the principle ; new service should be achieved not by tearing up established arrangements and starting afresh, iut evolving and adapting the present to suit the a They [the Government] are averse from o total salaried service merely for the sake trative tidiness.' , Q ^Vinlp As for extending the 'panel' system to the wftoie ' Population there are two main objections. P npr la at present no effective means of ensuring fulbur the distribution of doctors, and (2) ^ is likely to be away from the idea ?f .the a ^ doctor working alone and towards & T>pn0rt R grouped practice and team work. The. Interim exp of the Medical Planning Commission is quoted, , sively on this point. The Government fully gr arrangea grouped practices, to which numerous privately the way, Partnerships are already pointing ser a high place in the planning of the new en ?haDe. grouped practices cannot represent its "^ore' There has not yet been enough expenmen , y uere over the system could not be adopted

authority.

,

.

,

...

.

.

,

.

^posing

.

.

-

J51???

?

the new intend, therefore, that service shall be based on a combination of_ gro P ^ practice and ' separate ' practice side b> side, jpnse]y being likely to be found more suitable

TheaiGovemment

Populated

areas.

National negotiations All doctors in general practice who join a be relationship with their patients must similar footing, and the conditions to be nati0nally the rights to be enjoyed by th?m h a been the negotiated. It is pointed out that this ha , practice under National Health Insura rvjce Insurance Committees play a part in 1 > Government aree is in fact The centralized. highly convinced that, broadly, the system questions matters of negotiation between ^ ment and representatives of the professio

^eated o^

?j!s

,

r^ht

555

(4) County and county borough councils will normally have the function of providing premises such as Health Centres which are approved in the area plan. (5) The doctor in his contract with the Board will be required to observe the arrangements of the area plan. Grouped general practice The idea of the Health Centre as advocated by the Medical Planning Commission is approved by the Government, although it may be desirable also to encourage the idea of grouped practice without special premises. They intend to design the new service so as to give scope for a full trial of this new method. The object will be to provide the doctors with firstclass premises and equipment and assistance. (In the financial statement it is estimated that the running costs of the centres, excluding the remuneration of the doctors, would probably not exceed ?1,000,000 a year; the Government propose a 50 per cent grant for this new service, the other 50 per cent presumably being The doctors will be freed from met out of the rates.) the necessity of providing these things at their own cost. Limitation of the permitted number of patients, whatever that may be, will apply both in the centre and outside it. Patients may continue to see their own doctor after he has joined the centre, or they may, if they prefer, select a Health Centre as such rather than a particular doctor. It need not be assumed that a doctor at the centre will be on duty only at stated periods and that at other times his patients will be attended by other doctors. The doctor will have his consulting hours and visit his patients as at present. But the grouping of practices will make a certain fluidity possible. A patient in emergency Will be sure of attention even if his own doctor is not present, and arrangements will be possible for reasonable holidays and attendance at refresher courses. The actual provision of a Health Centre will be the responsibility of the county or county borough council, but it will be for the joint authority in the first instance, in consultation with the local medical profession, to formulate proposals for centres as part of the area plan, and to submit them to the Minister. The terms and conditions of service will be settled centrally for all doctors taking part of the new service, whether in group practice or not, and -all doctors will contract of service with the central enter into a organization. The doctor practising in a centre will not be debarred from private practice outside it for those patients who do not wish to take advantage of the There is, however, one important question new facility. with regard to the method of remuneration of a doctor when practising at a centre which does not arise in the same way when he is in 'separate ' practice outside. Inside_ a centre the grouped doctors should not be in If individual financial competition for patients. remuneration is based on mutual competition, the matter will become unduly complicated. It is considered, therefore, that there is a strong case for basing future practice in a Health Centre on a salaried remuneration or on some similar alternative which will not involve mutual competition within the centre.

?ne'

the new it would be a mistake to apply to general practitioner service the normal can government administration.' What is proposed is as follows : (1) Central negotiation of major terms an .?,onv tions will remain. Insurance Committees ?+jon abolished, and doctors will be in contractual later;, with a Central Medical Board (to be described to which they will look for their remuneration. (2) Other functions of Insurance Committees fall to the Board but to. avoid over-centralization, minor functions will be discharged through local committee, on which there will be members of the -

.

authority.

.,

,

for joint authority will, provide linking of general practitioners with hospital an

(3) The

new

suit ant and other services in the

area.

..

th me

'Separate'

general practice

' In separate' practice the general framework of the National Health Insurance scheme will be retained, but there will have to be some important changes. A ' doctor in separate' practice will work from his own consulting room and with his own equipment, but he will be backed by the new organized service of consultants, specialists, hospitals and clinics, which he will be expected to use in accordance with the area plan. He will receive his remuneration from public ' funds on a capitation system, though even in separate' practice there may be circumstances in which it will be possible to remunerate him on a salaried or similar basis if he so desires, as, for example, in the case of a single doctor responsible for all the work in a

sparsely populated

area.

9

TOE INDIAN MEDICAL GAZETTE

556 '/"There will be

no interference with the right of a doctor to go on practising where he is now and to take part in the public service in the area. But an unrestricted right to any doctor to enter any new practice and claim public remuneration at his own discretion would make it impossible to fulfil the--new undertaking to assure a service for all. Under a scheme whereby the whole population are to be entitled to a general practitioner sendee, a much heavier responsibility will be thrown on the Government to see that the needs of the whole population are met. ' This implies some degree of regulation of the distribution of medical resources, at least to the extent of securing that a doctor does not in future take up practice in the public service (whether by purchasing a practice or by squatting) in a locality which is already fully or overmanned. Such control can be left in the profession's own hands as far as possible, -though it must be guided by public policy. A suitable machinery will be to vest it in the Central Medical Board.

Any practitioner wishing to set up a new?or an existing public service practice in a particular area will sqek the consent of the Board. The Board will then have regard to the need of doctors in the public service in that area in relation to the country as a whole and to the general policy for the time being affecting the distribution of public medical practice. If it is considered that the area has sufficient or more than sufficient doctors in public practice while other areas need many doctors, consent will be refused. Otherwise. it will usually be given without question.' .

.

take

.

over

Remuneration

of general practitioners

of general practitioners is the appendix. It is assumed that in future the bulk of general practitioners will look to the new service for the whole, or substantially the whole, of their professional earnings. Hence whatever methods of payment are adopted?whether by capitation fee, by salary, or in some other way?the question at issue must be seen in a new light as compared with present payments for insurance work. It becomes- a question of what is, on ordinary professional standards, a The

remuneration

subject of

an

reasonable and proper remuneration for the wholetime services of a general practitioner working in a public, service. Whether this should be worked out in terms of gross or net earnings, whether superannuation rights are to be taken into account, what adjustments are to be made for part-time work, are matters of comparative detail. When once the main figures have been satisfactorily settled, not only remuneration by capitation fee but remuneration under the salaried or partsalaried systems could be easily determined. .While a universal salaried system is not contemplated, the Government propose that doctors taking part in the public service should be remunerated on the basis of salaries or the equivalent in any part of the service in which this form of payment is necessary to efficiency. Whether payment is on a salaried or part-salaried system or on a basis of capitation fees, two principles will be observed. (1) The doctor must be assured of an adequate and appropriate income. (2) The system must be flexible enough to allow for proper variations attributable to extra qualifications and extra energy and interest, as well as representing the reasonable and normal expectations of general practice at all its stages. No."figures are given for remuneration except that in the appendix dealing with the finance-of the scheme it is estimated in the roughest way that the cost of the -extended general practitioner service will amount to ?30,000,000 a year in England and Wales for doctors and chemists together. This figure may be compared with ?8,400.000 for some 17,000" general practitioners and ?2,400,000 for chemists m respect of 17,800,000 insured persons under National'Health Insurance in 1938. This ?30,000,000, by the way, will be met Wholly :

[Nov.,

from central funds. The Scotland is ?3,200,000. ?

corresponding

1944

figure

for

1

Private treatment remains In the new service there will be prescribed limits to the number of patients whose care any one doctor can properly undertake. 'It is not the wish of the Government to debar anyone who prefers not to avail himself of the public service from obtaining treatment privately, nor to prohibit a doctor in the public service from carrying on any private practice, but it will be necessary to ensure that the interests of the patients in the public service do not suffer thereby.' A doctor with an unusually large amount of private work, 01* with appointments in other branches of the public service, will be expected to work to a lower permitted limit than one who is entirely free from outside activity and is able to give his whole time to general practitioner work in the new service. There is a strong case,, especially when medical practice is remunerated from public funds, for requiring all young doctors entering practice to serve an ' apprenticeship' as assitants to more experienced practitioners. There will be manjrr opportunities to employ such assistants in health centres where terms and conditions can be regulated. In 'separate' practices the Central Medical Board must be empowered to satisfy itself as to the proposed arrangements for the employment of an assistant. Compensation It is recognized that these new proposals will, in certain cases, destroy the value of existing practices. In such cases, compensation will be paid. A just claim would arise in the case of an outgoing doctor in an ' over-doctored' area, when the Board had refused consent to the sale of the practice. Another legitimate case would be that of a doctor who gave up his separate public practice to work in a Health Centre. It would be incompatible with the conception of a Health Centre that individual practices within the centre should be bought and sold, so that a doctor entering a centre will exchange a practice having a realizable value for On the one which he will be debarred from selling. other hand, a doctor entering a centre will acquire superannuation rights and other facilities of considerable value. It is a case for striking a fair balance between gain and loss and compensating him accordingly. This whole question will be discussed with the profession, together with the difficult ' question of instituting superannuation for doctors in separate' practices. The Government also intend to discuss the question of total abolition of sale and purchase of publicly remunerated practices. It is recognized that abolition would involve great practical difficulty, and it is not essential to the working of the new service now proposed. The creation of Health Centres in itself will do much to limit the scope of the present system and afford a wide opportunity to young doctors to enter the profession without financial burdens. The doctor's

contract

The Central Medical Board to which reference has already been made, will be a special executive body created at the centre from the profession and will undertake some of the administrative work of the service requiring a specially intimate link with the profession. The Board will have to be subject to the general direction of the Minister, but it. will be the organization with which the doctor will deal as the ' in the service. Whether he is in employer' element ' grouped or separate' practice he will be in contract with it (though in Health Centre practice the local authority-will be joined in the contract). The details of the contract will be for discussion with the representatives of the profession, but it will- need

to

provide

r

sr.

...r~

give all normal professional advice and service within his competence; (1) -For the doctor

to

A NATIONAL HEALTH SERVICE

Nov., 1944]

^-^^and"hospital

with (2) F

A National Health Service. Government Proposals (The White Paper Summarized).

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