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duction of a single all-purpose medical certificate to replacethe existing three-first, intermediate, and final.

These changes have not been introduced without

lengthy and searching inquiries, as a report by theNational Insurance Advisory Committee 3 makes plain.The British Medical Association pointed out that many

visits by or to patients were necessitated by certification

requirements, and not by clinical reasons which " should bethe only regulator of medical attendance upon a patient."The Confederation of British Industry thought that the

availability of longer-term certificates might lead to their issueunnecessarily because pressure might be brought to bear ondoctors, which could result in longer sickness absences fromwork. The Trades Union Congress was concerned lest a

patient might be seen only twice by his doctor in a spell ofsickness lasting as long as 17 weeks.The Ministry of Pensions felt that the up-to-7-day certificates

would allow many of the nine million claimants a year, whonow see their doctors for the sole purpose of obtaining a finalcertificate, to omit such attendances. The Health Departmentstold the committee that since 1961 a population increase ofabout 11/4 million had been accompanied by a fall of about 760in the number of general practitioners, and that no earlyreversal of this trend was foreseen. In addition " advances inmedical knowledge were continually extending the scope forbetter service." They therefore " welcomed the contributionwhich the proposed changes in the rules for certification fornational insurance purposes would make towards reducing thedemands on doctors’ time."The committee found that the proposed up-to-7-day rule

was unobjectionable, and was " somewhat surprised " thatthis proposal had not been submitted before. But it was muchless happy about the clinical and psychological aspects ofcertification for up to 28 days in advance in the early stages ofillness, though it appreciated the value of this in ’* reducingthe burden of paperwork on doctors." The committee there-fore obtained assurances from representatives of the medicalprofession " that the relaxation of the rules would not in anyway affect the medical services available to the patient."

Employers, their representatives informed the committee,would be encouraged not to ask for certificates at shorterintervals than those required for sickness benefit purposes.Despite this reassurance, however, the committee recommendedthat the Minister should not hesitate to change the regulationsagain if they were found " to cause hardship to employees."The committee thus underlines our opinion that the successof the new rules must depend partly on the cooperation of theemployers.3. Report of the National Insurance Advisory Committee on the pre-

liminary draft of the National Insurance (Medical Certification)Amendment (No. 2) Regulations 1965. Cmnd. 2875. 1s. 6d. H.M.Stationery Office, 1966.

4. Lancet, 1965, i, 1203.

"... In nineteen hundred years the world has lost 107 kindsof mammals, and close on 100 kinds of birds. The extinction ofplants and the lesser animals is not known but probably vastlyexceeds that of birds and mammals. Nearly 70% of theselosses have occurred in the past century and mostly throughthe activity of man. Here and there throughout the world, onevery continent and on many of the remotest islands, a host ofother species, more than 1000 strong, faces the imminence ofcomplete and final passage from the world’s fauna. Extinctionhas been an essential companion of evolution since the begin-ning of time, and there is no reason to believe that the processis complete. Nevertheless, it is an ideal of conservation that nocreature should pass from the face of the Earth through theinstrumentality of man. If we would pose as the masters of

creation, to prevent extermination of a large and obvious formof life stands as a challenge to our ingenuity and our com-petence."-Dr. IAN McTAGGART Cowerr, Nature, Dec. 18,1965, p. 1145.

Points of View

NO MINISTERING ANGEL. THOU!

THE shortcomings of the National Health Service arereadily identifiable; the remedy is equally plain. Two

persistent myths, however, bedevil the situation: they arethe patient’s idea of the doctor; and the doctor’s idea ofhimself.

The patient likes to think of his doctor as a round-the-clock ministering angel. The doctor must be intimatelyacquainted with the vicissitudes of the family; he mustknow when his charges are ill and what afflicts them; howthe children are to be fed and sent to school when themother is ill; and how to negotiate with local authorities,social service workers, and health visitors. He is expectedto enter into correspondence with consultants and hospitaldoctors, and set in motion the agencies that protect thefamily from the economic consequences of illness. Andhe must undertake these multifarious duties for twenty-four hours a day.

Like so much that sustains us in this hard world, thisnotion that the patient entertains of his doctor is a

romantic myth. This ideal doctor exists; he existed beforethe Health Service came into being; no doubt he alwayswill exist. But he never formed the majority, and he neverwill. The horse-and-buggy doctor (who typifies the

patient’s ideal doctor) setting forth in rain or snow todeliver the baby or to sit by the bedside of the sick childlike Luke Fildes’ doctor, with watch in hand waiting forthe crisis-the family friend ever-present in sickness orsorrow, sympathetic, wise, and understanding-this doctorexisted. But so did the others-the overworked, under-paid men in the mining villages and industrial slums (the" sixpenny doctors " of Shaw’s play), their surgeriesbulging with panel patients waiting for their certificatesand their bottles of medicine-these doctors, too, existed.If the Health Service has brought blessed improvement,there still remains a vast gap between what doctors withmiddle-class practices can provide and the two-minuteconsultations that the majority of patients must expectfrom harassed doctors working single-handed in theirovercrowded surgeries.

The truth is that there is no easy way of mass-producingministering angels, no more than there is an easy way ofmass-producing wise men and women. Doctors are menand women, sharing all the day-to-day burdens of othermen and women. They tire when they are overworked;they, too, can be struck down by illness; they, their wives,and their children, too, need holidays, leisure, and relaxa-tion. And no serried ranks of committee can conjure upa corps of samurai who will at all times ignore theselimitations.

The other obstructive myth is the doctor’s idea ofhimself. He cherishes his status as an " independentcontractor ". He asserts that the relation between himselfand the patient is personal, and that the patient must have" free choice " of doctor (which is a sort of sub-myth).He wants no directive from any source that will intrudeon this relationship, and at the drop of a hat he will trotout the Hippocratic oath. He sees himself therefore, if notas a lone wolf, then at least as a seeing-eye dog. He

complains that this close doctor/patient relationship is

disturbed when the patient goes to hospital. His status,

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he maintains, has become that of a signer of certificates,an automatic prescriber of drugs, and an agent for thereferral of patients to hospitals and consultants. The

remedy, the doctor says, is to allow him " free access " tohospitals and to integrate his work with that of the

hospital. In the context of present-day circumstances,this is bunkum.

If, in fact, hospitals did open their doors wide to G.P.s,they would have an unmitigated nuisance on their hands.As it is, hospitals are overfull of personnel, what withspecialists, their assistants, registrars, housemen, students,clinical assistants, nurses, technicians, secretaries, main-tenance staff, and visitors. Add to this a swarm of

eager-beaver G.P.s and all hell will really be let loose.What are they going to do in hospitals ? Are they to becontent with hanging around to see what happens to theirpatients ? Are they to be glorified medical students,standing beside ward beds, looking over the shoulders ofpathologists and radiologists, and listening to the interroga-tion of patients in the outpatient department ? And whileall this is going on, what is to happen to their patientswaiting to be seen in their homes and in the doctors’surgeries ?Medical work, in common with every other kind of

work, is no longer a cottage industry. The division oflabour that characterises modern society applies equally tomedicine. The doctor’s vision of himself as a journeymancraftsman is medieval, because competent medical caretoday calls for the services of a host of people, each skilledin his own craft.

What the patient needs, then, is not a ministering angel.He needs someone who can tell him what is wrong andcan get him well (if this is possible) as soon as possible.Against the sentimentality of kindness-is-all, one mustassert the hard reality that illness is an infernal nuisance.Protracted illness enfeebles the patient; it also taxes theforbearance and spirit of the people around him. Facedwith the choice between impersonal competence andaccommodating themselves to myths, most people wouldprefer to discard the myth.What the doctor needs, on the other hand, is a sensible

and secure life and the opportunity to practise twentieth-century medicine. Once the myths are set aside, one canbegin the much-needed overhaul of the National HealthService (a noble experiment, but, for all that, an experi-ment). The Health Service must be unified; it must besalaried; and it must be firmly based on health centres andhospitals with clearly defined functions.A unified and salaried service takes account of the

division of labour among equal skills in modern medicine.It does away at one stroke with the bedlam of conflictingclaims of hospital staffs (junior and senior), generalpractitioners, and public-health officials. The pathologistis as essential in modern medicine as the physician. Theanaesthetist is needed as much as the public-health doctor.The psychiatrist’s services are as useful as those of thesurgeon. The work of the cardiac surgeon and the neuro-

surgeon is as momentous as that of the abdominal surgeonand the urologist. And the role of the general practitioneris no less (and no more) important. In sum, there are no

privates in this army. Everyone is a specialist. The

disparity in reward and status among medical workers istherefore illogical. So is the arbitrary tripartite division ofdoctors into general practitioners, local-authority healthofficials, and the staff of regional hospital boards.

Rates of pay should be geared to levels that will attractenough entrants. This would diminish the lure of emigra-tion to countries which offer prospects of higher pay. If,notwithstanding, there are doctors who want to bemerchant adventurers and who are irresistibly drawn tothe glittering prizes of private-enterprise medicine else-where, let them go to it. All contracts between the HealthService and individual doctors should come up for

quinquennial review. If the doctor is not carrying outhis job satisfactorily he should be fired. Specialisationshould offer doctors a choice of work, and not the

prospect of higher pay. In this scheme of things, secretmerit awards have no place, though the acquisition ofhigher diplomas and the undertaking of postgraduatecourses of study should be rewarded by an increasein salary.As things stand, many doctors, perhaps the majority,

are opposed to payment by salary. The principle, theysay, affronts their independence. Why they should

imagine that salaried payment menaces their freedom toa greater degree than that of almost everyone else in thecommunity is only explained by their obsession witha romantic concept of their profession. If the changeoverfrom payment by capitation to payment by salary amountsto a revolution it epitomises the best sort of revolution-one that ensures the even and efficient application offundamental traditions to the whole community. Thefear that a salaried service will do away with the humanitythat the ideal family doctor stands for is groundless.Medicine concerns people, and not things. Humanity doesnot fly out of the window just because the doctor’s workbecomes rational and organised.Good doctoring derives from emulation, from seeing

others doing good work and in learning from them, andemulation is far removed from competition. Self-esteemand self-criticism are potent incentives-far, far greaterthan financial gain. But they can come into operation onlywhen the quality of one’s work is there for all to see. Thisis the crux.

Bad doctoring is a product of isolation. The G.P.

complains that he is isolated; so he is. He has always tobe conscious of his responsibility for the care of sick peoplewhose first symptoms, though trivial, may neverthelessherald grave illness. If he is conscientious, or for thatmatter, if he is disinclined to shoulder the burden, hepasses the responsibility on to the hospital or the privateconsultant. If he does this often enough his clinical

judgment will become atrophied. But it is by no meansonly the G.P. who works in isolation. The patient whotrustingly consults a specialist is just as likely to come upagainst bad doctoring as the patient of the generalpractitioner; for in his private practice the specialist, too,is isolated. The great man operates, and the patient is

lucky if he sees him again. If complications set in, thepatient far too often becomes the responsibility of thesurgeon’s registrar or assistant who is the last man to

question the surgeon’s judgment or sense of dedication toduty.The logical place, then, for the doctor’s work is the

health centre or the hospital. The Englishman’s home ishis castle-except, it seems, when he is a doctor. Lawyers,plumbers, dentists, stockbrokers, engineers, and hair-dressers are not expected to turn their homes into placesof business. Why on earth should this be expected ofdoctors ?To end isolation, to provide the stimulus of association,

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discussion, and shared responsibility, the centre must bea fully cooperative enterprise-a Harley Street of the

suburbs, if you like, but without the bogus trimmings,with arranged appointments and enough doctors to devoteenough time to each patient.

Teaching of medical students in the health centreswill form an obligatory part of their curriculum. This willfamiliarise them with their work after graduation andwill do away with the criticism that hospital teaching doesnot prepare them sufficiently for the practice of medicineoutside.

Since centres must be closely linked with the neighbour-hood hospital, rotation of staff between them should

present no difficulty. In this way the outpatient andcasualty departments of hospitals will be relieved of muchof the pressure on them. The hospital can then becomewhat it ought to be-a place where work is done thatcannot be done elsewhere. This vast expansion of

domiciliary care will save millions of pounds in hospitalexpenditure. One could build twenty centres in the timethat it takes to put up one hospital.

All this will meet with opposition from the advocates of" free enterprise " medicine who point to the growingpopularity of voluntary insurance for nursing-home andconsultation fees in justification of their stand. But the

increasing vogue of these schemes stems from imper-fections in the Health Service. Nursing-homes, in anyevent, are an anachronism. Most doctors in their rightsenses would choose to go to a hospital rather than toa nursing-home if they had to undergo an operation orwere in need of constant medical supervision. Few

nursing-homes have resident doctors; few are modernlyequipped. If they are, they are no longer nursing-homes;they are miniature (and expensive) hospitals.

Given the prospect of a career with regular hours,good pay, paid holidays, a pension, and the opportunityto practise medicine under the best conditions, thechances are that the opposition of doctors to a salariedservice will disappear. The only way to test the matteris to begin somewhere and to show that the systemworks.

The National Health Service is ripe for overhaul. It is

possible to ignore the need for overhaul, but the price isendless committees, endless squabbling among doctors;and the persistence of a patchwork service.

TEACHER.

Public Health

Family-doctor Health Team

SOME Salford doctors who work in groups of three or morealready benefit from the part-time attachment of health visitor,district nurse, and midwife from the staff of Dr. J. L. Burn, thecity’s medical officer of health. To this family-doctor healthteam has now been added a psychosocial worker from the com-munity mental health services who is trained as a social case-worker. He will try to help the doctor’s patients who havesevere physical and mental disorders with housing and financialallowances, and will put them in touch with communityresources such as clubs and voluntary organisations, andprovide a link with child-guidance services. Dr. Burn clearlyhopes that the team will now be better able " to change thetotal environment to fit the needs of the patients ".

In England Now

A Running Commentary by Peripatetic Correspondents" I’M changing ’em all over," she said. " You have to sign

all ten of my cards and I have to take ’em round to him."" I must confess," I said, " to feeling hurt, and dismayed,

at this abrupt termination of a relationship carefully nurturedthrough ten years and eight pregnancies, during which wehave, together, successfully weathered the assaults of almostall known human pathogens on your masochistically suscep-tible children. Battles fought, I must point out, at a net lossto myself of E37 14s. 7d. in petrol and ballpoint pens. Is allthis to be so lightly swept aside ? " .

" Nothing personal," she said. " I’m sure, but my husbandsays you’re not scientific enough. He says there’s a computerput its plate up in Bougainvillea Crescent and we ought tochange to him. He says it’s very clever, nothing it don’t know."

" Cleverness," I said, " and being very scientific is onething, but what about sympathy and understanding. Surelythis is the unique contribution of the family doctor."

" Talk about sympathy," she said, " cries his eyes out this

computer does. My friend’s little girl only had a cough and itcried so much they had to put their wellingtons on. Talkabout understanding ... it understands everything. Youknow you said my sister’s boy Glenn was just tired from goingto bed so late ? The computer worked out it had been handeddown from his grandfather being bitten by a tsetse fly in

Epping Forest in 1908 when he was on a picnic."" Ha, ha," I said, " but who is to take care of you in the

dark hours of the night. Supposing you take sick then ?"" I hear they have a little Japanese one on wheels," she said,

" it comes round anytime. But I thought I’d have you if itwas ever being recharged ... for the night calls that is."

" Thank you so much," I said, " it’s nice to know one’sefforts have been appreciated."

’*’ ’*’ ’*’

Our next-door neighbour is a genial rotund diabetic. He, orat least his diabetes, could perhaps have been controlled bydiet alone; but he preferred the narrow view that diet is food,while drink is drink-and often the twain did meet. He greetedthe marketing of diabetic mineral waters with such enthusiasmthat several free samples appeared upon my desk. Of coursehe drank them unadulterated, and of course I believed him,until his tests moved firmly into the green-and stayed there.The diet was checked and drink forsworn, but the tests

remained at green. An increased dose of tablets failed, andseveral blood-sugar tests were normal. Renal glycosuria wasthe answer; until one day the bathroom froze, and kitchen testswere blue. Dr. Watson would probably also have missed thepoint. But that keen amateur chemist, Sherlock Holmes, wouldcertainly have known the apparent colour of a clear blue

liquid when seen against a newly painted yellow bathroom wall.’*’ ’*’ ’*’

Swine-fever struck our hospital farm with dramatic sudden-ness. Within a week over a thousand pigs had been slaughtered,old ones, young ones, pregnant ones, fattened ones; thedisinfection squads swept through the empty styes and all wassilent. Rounding up the litters for the executioners had beena traumatic experience for the farm manager. Compensation,yes; but what could replace those friendly sows with theirhuman eyes and intelligent faces; what could replace years ofselective breeding with its rich reward of efficient andproductive mothers ?But most important of all, how could the virus have got in ?

Swine-fever had not been in the district for months and all theswill was boiled. And yet it must be the swill. Our discussionturned to the reliability of the pigmen. The old pigman wholeft recently had been a devil for overtime, the manager recalled,and the swill had never been boiled long enough by the end ofnormal time. The new man was less interested in overtime.It could be that those extra hours pay had been money wellspent, for the swine-fever virus is a tough customer, and onereally does need to turn the heat on to knock him out.