775 Views of General Practice A DESIGN FOR GENERAL PRACTICE I. Reinforcement for the Family Doctor T. S. EIMERL D.S.C., V.R.D., M.D. Lpool GENERAL ...

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Views of General Practice A DESIGN FOR GENERAL PRACTICE I. Reinforcement for the

Family Doctor




R. J. F. H. PINSENT M.A., M.D. Cantab. GENERAL



THE conditions of general practice in Britain ensure that the family doctor of today works at a continuing disadvantage when compared with his colleague in hospital. Among other relevant factors professional isolation is very important. The family doctor of the future must undertake vocational postgraduate training both in hospital and in general practice. He needs time for this which he cannot secure unless he is provided with effective support and help in his daily work. If professional isolation is to be avoided, the conditions under which he works as a principal must compare with those enjoyed by doctors working in hospital. The family doctor requires the help of workers with supporting skills just as does the physician or surgeon in hospital. Assistance of this kind is normally expected by doctors who practise in Canada, the United States of America, Holland, and Sweden. This help is varied and includes: 1. 2. 3.

Help Help Help

with administration and conduct of his practice. with care of patients in their homes. with care of patients in the consulting-room. HELP WITH ADMINISTRATION

Help with practice administration is now recognised as essential to improved family-doctor care. Voluntary bodies and associations such as the British Medical Association, the College of General Practitioners, and the Medical Practitioners’ Union are seeking to devise a practice advisory service and to operate it. This is action by a profession conscious of its own needs; but surely the responsibility for the creation and operation of such a service, available upon request to all family doctors, lies wholly with the National Health Service itself ? An advisory service for general practitioners should be established as a new department by the Ministry of Health, perhaps based on a remodelled Regional Medical Service. Alternatively it might be set up by some other body with Ministry finances. Its activities would be conducted by regional medical advisers who would be wholly separate and distinct from the existing regional medical officers. The Regional Medical Adviser should be a professionally active and experienced colleague able to help any practitioner who desires to improve the effectiveness of his work. His role will be that of education and advice only. His services will be available upon request to any family doctor whether he practises in or out of the Health Service. Medical advisers who are part-time in active general practice themselves will be able to keep abreast of developments in practice and able to understand difficulties experienced by others. A Medical Advisory Service would soon become a repository and source of information on the function of appointments systems, methods of record-keeping, and the organisation of special clinics within the practice, as

A central as on design and planning of premises. organisation would enable exchange of ideas to be freely undertaken, and new improvements would spread more rapidly through general practice.


The decision to use the service or not would rest with the doctor in practice, who would call on the medical adviser only if he wished. It would be no part of the duty of the service to enforce any change, for the medical advisers would have no powers even remotely resembling those of regional medical officers. HELP IN THE HOME

To help with care of the patient at home the family doctor needs the supporting skills of the health visitor, the district nurse, and the State-certified midwife. In addition, other skills included in the disciplines of, for example, the almoner, social case-worker, psychiatric social worker, and mental-welfare officer should normally be identified with the practice. These should be freely available to the doctor in the daily work of his practice.

Although the function of the district nurse, her assistant, and the domiciliary midwife may remain unaltered some of these supplementary skills may be grafted on to the training of the health visitor. A syllabus incorporating these extensions of the present training of the health visitor should be worked out by the Royal College of Nursing and other interested organisations. The health visitor with this further training would then join directly in the work of general practice as a practice sister with status equivalent to that of a senior ward sister. Inservice training in general practice would be an essential part of the training of practice sisters, for much of the special experience required could be gained only in active general practice. Trained practice sisters would be employed by local health or other authorities and seconded to work in partnerships or group practices, thus ensuring that their skills were properly deployed. Employment of senior nursing staff in general practice, with added training, would open up new opportunities for professional women, and perhaps offer attractions to those for whom a senior hospital post is the only present alternative. Inevitably supply could not meet potential demand for some time, but the increasing trend towards group and partnership practices suggests the point at which these skilled services could be best used. The experience of those who have worked in such association with health visitors forms some foundation on which to build a working relation between the family doctor and his practice sister, comparable to that between the hospital physician and the sister with charge of his ward beds. HELP IN THE CONSULTING-ROOM

Help in the consulting-room is a fundamental need of the modern family doctor. Since the work in a practice is part nursing and part secretarial, specific training for either is inappropriate and incomplete by itself. Few practices could find proper and adequate employment for a State-registered nurse as well as a trained secretary, yet all would benefit from nursing and secretarial help combined in one person. Such help is not now easily obtainable. A syllabus of training could be devised with the purpose of producing practice nursing aides. Candidates for this training are likely to be recruited from girls leaving secondary modern schools or from older married women prepared to train for part-time work. The training of the nursing aides would include awareness of the structure and function of the National Health Service,


with particular regard to the part played by the family doctor and other community health-care services. The syllabus would have two main components: a. Nursing.-Duties in the consulting-room; care and use of instruments; dressings; chaperoning; simple laboratory work using modern techniques. b. Secretarial.-Typewriting only (the use of taperecorders diminishes the need for shorthand); receptionist duties and operation of appointment systems designed to meet the needs of general practice; care of N.H.S. and other records; telephone duties.

Every encouragement should be given to experiments such as that undertaken by the Medical Practitioners’ Union which is working on a correspondence course for the training of practice assistants of this kind; but it may be felt that theoretical training alone is not enough. The details of a full syllabus could be worked out by the Royal College of Nursing and the Ministry of Education, making use of the facilities offered by hospital outpatient departments, nursing training centres, and colleges of further education. Part of the training course should comprise in-service work in a group or partnership practice in which several family doctors work together. The course might be offered by the Royal College of Nursing and successful completion carry the right to the


might later be followed by nursing aides would be but their salaries (including employed directly by doctors, all necessary National Insurance payments) would be repaid in full by the executive council with which the doctor was in professional relationship. title " nursing aide ". This State enrolment. Trained







of doctors differs between

countries, according to local tradition, the level of medical science, and particularly the social system. Poland is one of the countries which, having ensured general protection of their citizens’ health, have sought to secure that this

protection is

on the highest possible level. In the field of health protection postgraduate training embraces doctors, dentists, and pharmacists, and other workers such as biochemists, physicists, biologists,. and bacteriologists. Doctors, however, constitute the basic and largest group for which postgraduate training is

organised. Postgraduate training

of all physicians in Poland may be subdivided into two kinds: training carried out in the course of professional work; and specially organised


In hospitals the responsibility for training rests with the director and ward heads. Regular periodic scientific conferences in particular wards as well as general hospital conferences are held. The programme of training at these conferences is arranged by the hospital management, but it is )supervised by national specialists’ teams from the relevant branches of medical science. This form of training, which is generally accepted throughout the world, in Poland has considerable bearing upon the professional level of doctors in hospitals. Half the total number of doctors in Poland are hospital practitioners. Cooperation between general practitioner and specialist working in a clinic is continuous and direct in big urban centres. General practitioners working in the countryside have less opportunity for frequent con-





doctor’s skill and time when he types or writes six letters hospitals himself or if he has to spend time preparing for, performing, and clearing up after dressing a wound. Reinforcement of the general practitioner, .releasing him from work which he need not and should not do, would enable his proper training to be put to its proper use. In a world in which professional skills are scarce and becoming scarcer steps must be taken to enable us to use our medical resources to their utmost efficiency. to

sultations of this kind. For them county and regional hospitals fill the role of consultation and instruction centres. Ward heads in these hospitals are obliged to act as on-the-spot consultants if this is necessary. ORGANISED TRAINING



hospitals in matters of organisation ; and this undoubtedly impairs its efficiency, recently described by Brotherston as that of a cottage industry. General practitioners have accustomed themselves to makeshifts and improvisations, making do to an extent quite unrecognised by those with no experience of practice. It is no proper use of a


well known

alike, general practice has lagged behind practice in

In Poland two institutions provide organised trainingthe national specialists and the postgraduate medical school.



In all the main divisions of medicine the Minister of Health appoints outstanding specialists to act as chief advisers to the Ministry. Their responsibility is to ensure that the level of medical care in Poland, within the scope of their specialty, is adequate. From this responsibility derives the duty to train doctors working on different professional levels. Each province has a specialist in each field of medicine; hence each national specialist has a This team of 22 regional specialists in his specialty. over the medical of system professional supervision service in our country renders considerable service to

postgraduate training. Postgraduate Medical School, Training in the course of professional work cannot possibly meet all the requirements of postgraduate teaching. For this reason a Postgraduate Medical School established in 1953. The school is not concerned with the current postgraduate training of all the 30,000 Polish doctors since this would be hardly feasible. It trains leading members of the profession-ward heads and specialists. It also undertakes the postgraduate trainingg of doctors who need additional training because of the progress made in their fields or because of changing requirements of the health service in Poland. Much attention is paid to training in new medical centres where predominantly young doctors work, and also to training doctors who work in distant provincial centres. These in turn later train their fellow doctors in their local city.