[from "The Birth of a Service", 2008]

CHAPTER 10

Thirty-two general practitioners finally decided to join the Scheme, but in the first few years six had either retired or left the Island, and it had been decided that as those remaining were sufficient to maintain the level of service, the patients formerly of the six should be re-registered with other doctors. A doctor who had not previously been in practice on the Island was permitted to be taken into partnership with a doctor formerly in a single-handed practice, as he would only be sharing that doctor's list, and therefore not practising in opposition to his fellows. In another instance, on the resignation of a doctor from a partnership, it was agreed that the partnership should be continued by the remaining doctor together with another doctor already practising in the area. The advantages of this were obvious; not only did he inherit the patients of the retiring doctor, but was able to bring his own into the partnership.

A word on practices and partnerships or groups in those days may not be amiss. A partnership or group was only a business, and a convenient arrangement made between the doctors, for remuneration, premises, and coverage for off-duty periods and holidays. The doctors' insistence in 1948 on maintaining traditional attitudes meant that the relationship between the doctor and his patient had to be on a one-to-one basis; a patient could therefore only be registered with a specific doctor, not with a partnership. The registrations on his list constituted what was legally a separate practice, and the doctor's income of his practice from the Health Service, based largely on the size of his list, was personal to him, hence the need to arrange how the total income of the partnership was to be shared. This arrangement would have been of no concern to the Board if there were not the need to know for superannuation purposes. It could, of course, cause difficulties. Practices had to be passed on, so that when the senior partner retired, the incoming successor took over his list, which might well have been the biggest. Should he subsequently have decided to leave, and set up on his own, he could in theory have taken that list with him. It follows that extreme care had to be taken in choosing a new partner, and although it was the Board's Medical and Dental Services Committee which gave the formal approval of entry to the Medical List, due consideration had to be given to the wishes of the remaining partner or partners, who, it must be said, were in a much better position to assess the merits of prospective candidates than were the Committee.

Some young doctors, in private, expressed the view that the older generation of doctors in 1948 were mistaken in perpetuating the traditional practice system, as being regarded as an outmoded concept in terms of today's way of life, and that it would have been better if they had agreed to become servants of the State, salaried and with regular hours. Thus, they argued, working from premises provided and equipped for them, they would have been free to concentrate on doctoring, without having to run a business as well

Relations with the general practitioners continued to be variable. They still smarted at having no choice but to relinquish the right to sell their practices. The total value of the 32 practices had not been finally determined by Tynwald, upon whom the duty rested, until February, 1955, when the sum agreed was 102,222. The Board, however, had been making payments of interest on notional figures up to then, which were then adjusted as necessary, but the rate of interest itself was a matter of dissatisfaction, at 2%, which as a capital investment hardly compared with rates obtainable elsewhere. A young doctor might have had to borrow money to buy his practice, at a considerably higher rate of interest, and so was suffering a continuing loss.

As mentioned, although the Board had undertaken to match the payments applicable in England, it was not always possible to apply some of these exactly to Island conditions, and were the subject of many disagreements.

There was also a certain amount of in-fighting between the doctors with which to contend. For the first time a doctor found his activities subject to regulation and scrutiny by various committees, on which were serving other doctors, with one of whom he might have been on bad terms, raising the suspicion of personal bias. Where it was the Board's duty to appoint a doctor to a committee, or Hospital Administration Committee, it was not unknown for the Medical Society or Hospital Committee to object to its choice.

The doctors also found the going hard. The public had taken the concept of free access to the doctor to their hearts, and made full use of it, to the extent that in February 1949, the Medical and Dental Services Committee decided that the medical cards, which were to be issued to each patient registered, should incorporate a notice pointing out that the doctor was not obliged to visit unless the patient was confined to the house through sickness; that a patient requiring a visit should send for the doctor before he started his morning round; and that they should not trouble him with trivial matters, particularly if they met him on the road.

Another development which caused some concern were the attempts believed to be being made by some patients to coerce the doctors in the choice of drugs or medicine they should be given, refusal often being met with the threat of transfer to another doctor. The doctors were encouraged to resist.

In 1953 the Board became locked in combat with the doctors over their remuneration. In England the Danckwerts Award involved retrospective payments for the period 5th. July 1948 to 31st. March 1953. From 1st. April 1952 a new method of calculating the capitation fee, paid for each patient on the doctor's list, and his main source of income, had been introduced, and from 1st. April 1953, adoption of the Spens Report had increased that fee. Faced with this expense, the Board served notice on the doctors that the undertaking to make payments at English rates would be terminated on 30th. June, 1953, and would in future be subject to negotiation. The basis of its argument was one which has long been dear to Manx politicians whose responsibilities have involved staff employed on a parity with conditions applicable in England, and which has surfaced at intervals through the years: that the lower tax structure of the Island yielded a higher net income than enjoyed by their counterparts in England.

Naturally, the doctors dismissed this out of hand, regarding the Board as having reneged on their assurances of 1948. The only concession they would make was that they might be prepared to take a reduction if it could be proved to their satisfaction that the Island's financial situation was so bad that sacrifices were justified. The dispute dragged on for six years, with intermittent attempts to reach a settlement, the Board finally agreeing to adhere to the English rates. In the interim, in the absence of any other arrangements, they had been obliged to continue the payment of English rates as a temporary expedient, so nothing was gained, but the relationship with the profession had been soured, with some lasting effect.

The Board soon became aware of a problem which has always bedevilled the payment of capitation fees, that of "ghost" patients. These are patients still on a doctor's list, who have left the Island, and never having had a serious condition, their medical histories have not been requested by their new doctors; or women who have married, changing their names and addresses, and frequently their doctors; or even patients who have died in circumstances of which their own doctors were not aware. The original scheme called for a payment into a pool of a sum per head of 95% of the Island's civil population, this figure to be supplied annually by the Registrar General, the total yield being apportioned and paid to each doctor in proportion to the number on his list. When the total on the doctors' lists equalled, or even exceeded the figure for the estimated population, it was obvious that something had gone wrong. It was necessary therefore to have a "purge", the first of many, and resulted in 1954 in the removal from the lists of 2,472 apparently nonexistent patients. The change in the system, when the payment to the doctor was directly linked to the number on his list, did nothing to solve the problem.


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