Journal of the Royal Society of Medicine Volume 71 January 1978
3
Klein produced very good evidence to suggest that, in fact, there are wide regional variations in the use of health service facilities; this evidence included consultation rates, night visit requests, laboratory usage and outpatient referral rates. He concluded from this variation that the general practitioner positively controls his workload by the way he trains (or educates) his patients to use the health service. The overall steady fall in consultation rates in the United Kingdom since World War II, and especially in home visiting patterns, may be a consequence of this. However, Forsythe pointed out that, parallel to this fall in consultation rates, there has been a steady increase in hospital usage. He emphasized The general practitioner as the responsibility which the general practitioner a health care rationer has in deciding whether to refer a patient for a procedure of doubtful value, e.g. tonsillectomy. If Since its inception, the National Health Service has these patients were not referred, considerably more maintained the philosophy that the best possible hospital beds and operating-theatre time would be treatment should be free at the time and that no freed for a greater number of patients on the one should be penalized financially for having to endless surgical waiting lists. 12% of our popuobtain medical care. In theory, this leads to a lation is admitted to hospital each year, 16% are situation where there is an unlimited demand referred as new cases to outpatient departments which must be met by a limited budget. If one and 20 % use the accident and emergency departaccepts that there must be a limited budget for the ments (Fry 1977). It behoves each general pracfinancing of health care, who is to decide priorities titioner to look very carefully at his hospital and the best way to use the money available? It is referral rates. They vary so widely throughout the unlikely to be the politician, who is too far country that not everyone can be using the system removed from the problem. It certainly will not be efficiently, and certainly there is scope for research the administrators, who are more concerned with in this area of the general practitioner/hospital spending money than saving it! The hospital interface. Many studies have been carried out on the use of consultant staff possibly could accept this role; however, the needs of their particular specialities diagnostic facilities by general practitioners and the necessity of ensuring that they have (Burrows 1971, Green 1973, Patterson et al. 1974), adequate facilities in competition with other hos- and again there is wide variation between the pital departments, tends to make them too inward- general practitioners in any one area, let alone looking. It must, therefore, be the responsibility of nationally. In many instances, the unnecessary use the general practitioner to try and maintain some of diagnostic facilities parallels the increasing rise sort of control of this demand upon limited ser- in prescribing costs, particularly in the psychovices. In fact, he is in the ideal position to do this, tropic field. Can it be that general practitioners are being the person most able to decide on the relative using diagnostic facilities and prescribing merely to priorities of the various needs of the patient. It will appease the patient and as a short cut to end the be he who decides what initial investigations must consultation? It is much quicker to write an X-ray be made in any complaint, what resources of the request form than to examine the chest, and practice team should be used and whether the quicker to prescribe valium than to allow the patient to express his or her anxieties. Of course, patient needs to be referred to hospital at all. 'The general practitioner as a health care the trend towards increasing the diagnostic facilrationer' was the subject of a meeting of the ities available to general practitioners is to be Section of General Practice on 16 March 1977. applauded, but these facilities must be used reKlein, in a thought-provoking paper, postulated sponsibly. Forsythe pointed out that, in a series the argument that free medical care is not nec- of 985 intravenous pyelograms on hypertensive essarily equated with infinite consumer demand. patients, a remediable cause was found in only 2! Klein's views on the training of patients lead to a There has been a great tendency for it to be assumed that general practitioners are overwhel- consideration of the value of health education. A med by the insatiable demands of a greedy public. vast amount of money has been spent over the Puestow K L (1955) Postgraduate Medicine 18, 6 Royston C M S, Dowling B L & Spencer J (1975) British Journal of Surgery 62, 605-607 Skinner D B (1976) Journal of Thoracic and Cardiovascular Surgery 72, 523 Tanner N C & Westerholm P (1968) American Journal of Surgery 115, 449-453 Toledo-Pereyra L H, Michel H, Manifacio G & Humphrey E W (1976) Journal of Thoracic and Cardiovascular Surgery 72, 518-524 Wangenstein 0 H & Levin N L (1949) Surgery, Gynecology and Obstetrics 88, 560-570 Weaver A W, Large A M & Walt A J (1970) American Journal of Surgery 119, 15-18
4
Journal of the Royal Society of Medicine Volume 71 January 1978
years on various health education programmes; Patterson H R, Fraser R C & Peacock E Journal of the Royal College of General only recently, a million leaflets on immunization (1974) Practitioners 24, 237-241 were sent out to mothers by the Health Education Richards CW Council. Much of this money has been spent (1976) Journal of the Royal College of General without any evidence to suggest that the infor- Practitioners 26, 823-827 mation is reaching the public for whom it is intended. Posters and leaflets are read and forgotten, television has a little more impact, but the greatest influence comes from the doctor's surgery during the course of a consultation. If some general practitioners can influence their patients to reduce their demands, as measured by consultation rates and the number of visits, then this influence surely can be extended to the field of preventive medicine. Journal of the A few minutes spent at the appropriate moment can be used to counsel a patient about the dangers Royal Society of Medicine of smoking and obesity, to discuss with a mother For some time the Council of the Royal Society of the value of whooping-cough vaccine, or to raise Medicine has been considering how best it might the subject of contraception with a diffident girl. In improve and bring up to date its journal this way the future expenditure of limited resources Proceedings of the Royal Society of Medicine, on the unnecessary and avoidable consequences of which has appeared continuously, with only minor modifications, since 1907. From this issue it will patients' actions may be reduced. The general practitioner's influence on costs can have a new look and a new title, Journal of the be extended into many other fields, such as the Royal Society of Medicine. It is published by the efficient use of members of the practice team. The RSM and Academic Press, with whom the Society supportive roles of the health visitor, district has been collaborating since January 1977. The aim of the new journal will be not only to nurse, occupational therapist and social worker, judiciously used by the general practitioner, will maintain the literary and scientific interest of enable many patients, particularly the elderly, to Proceedings, but also to enlarge its scope: in be managed at home rather than in hospital - addition to publishing the more important papers which is, of course, far. more cost effective. The communicated at meetings of the Society's trend to early discharge from hospital is dependent Sections and the texts of the Society's main lectures, the Journal will publish other papers of a upon the efficient use of such resources. The general practitioner's central role in con- high medicoscientific standard, as well as signed trolling the resources of the National Health editorials, Section news, letters to the Editor, and Service has never been so apparent as it is today. other topical features. Thus the Journal of the This places a considerable responsibility on him to Royal Society of Medicine will have a wide medical decide priorities for the patient. It also emphasizes interest which should appeal to a large readership: the importance of training doctors for entry into it will reflect current advances in the science and general practice. One of these doctors has drawn practice of medicine, as well as being the forum for attention to the influence which he had on the cost reporting on the Society's own expanding of resources used (Richards 1976) and it is impera- activities. The arrangements for editing the Journal have tive, if the National Health Service is to remain viable, that all general practitioners are aware of been revised so as to keep in step with its expanded scope, and the Society has been happy to appoint their responsibilities in this connection. K J Bolden Dr Victor Bloom as Editor. Since January 1976, Department ofGeneral Practice Dr Bloom, with the help of two Honorary Editors University of Exeter and an Editorial Board of six Fellows of the Society, has been entrusted with the challenging task of producing a medical journal of outstanding References merit. As President of the Society I am confident Burrows W L that he and his colleagues will be able to meet this Practitioner 810-814 206, (1971) challenge and that the new journal will fulfil the Fry J (1977) Proceedings of the Royal Society of Medicine 70, 69 Society's highest expectations. Green R H John Dacie (1973) Journal of the Royal College of General President, Royal Society of Medicine Practitioners 23, 316-325
3
Klein produced very good evidence to suggest that, in fact, there are wide regional variations in the use of health service facilities; this evidence included consultation rates, night visit requests, laboratory usage and outpatient referral rates. He concluded from this variation that the general practitioner positively controls his workload by the way he trains (or educates) his patients to use the health service. The overall steady fall in consultation rates in the United Kingdom since World War II, and especially in home visiting patterns, may be a consequence of this. However, Forsythe pointed out that, parallel to this fall in consultation rates, there has been a steady increase in hospital usage. He emphasized The general practitioner as the responsibility which the general practitioner a health care rationer has in deciding whether to refer a patient for a procedure of doubtful value, e.g. tonsillectomy. If Since its inception, the National Health Service has these patients were not referred, considerably more maintained the philosophy that the best possible hospital beds and operating-theatre time would be treatment should be free at the time and that no freed for a greater number of patients on the one should be penalized financially for having to endless surgical waiting lists. 12% of our popuobtain medical care. In theory, this leads to a lation is admitted to hospital each year, 16% are situation where there is an unlimited demand referred as new cases to outpatient departments which must be met by a limited budget. If one and 20 % use the accident and emergency departaccepts that there must be a limited budget for the ments (Fry 1977). It behoves each general pracfinancing of health care, who is to decide priorities titioner to look very carefully at his hospital and the best way to use the money available? It is referral rates. They vary so widely throughout the unlikely to be the politician, who is too far country that not everyone can be using the system removed from the problem. It certainly will not be efficiently, and certainly there is scope for research the administrators, who are more concerned with in this area of the general practitioner/hospital spending money than saving it! The hospital interface. Many studies have been carried out on the use of consultant staff possibly could accept this role; however, the needs of their particular specialities diagnostic facilities by general practitioners and the necessity of ensuring that they have (Burrows 1971, Green 1973, Patterson et al. 1974), adequate facilities in competition with other hos- and again there is wide variation between the pital departments, tends to make them too inward- general practitioners in any one area, let alone looking. It must, therefore, be the responsibility of nationally. In many instances, the unnecessary use the general practitioner to try and maintain some of diagnostic facilities parallels the increasing rise sort of control of this demand upon limited ser- in prescribing costs, particularly in the psychovices. In fact, he is in the ideal position to do this, tropic field. Can it be that general practitioners are being the person most able to decide on the relative using diagnostic facilities and prescribing merely to priorities of the various needs of the patient. It will appease the patient and as a short cut to end the be he who decides what initial investigations must consultation? It is much quicker to write an X-ray be made in any complaint, what resources of the request form than to examine the chest, and practice team should be used and whether the quicker to prescribe valium than to allow the patient to express his or her anxieties. Of course, patient needs to be referred to hospital at all. 'The general practitioner as a health care the trend towards increasing the diagnostic facilrationer' was the subject of a meeting of the ities available to general practitioners is to be Section of General Practice on 16 March 1977. applauded, but these facilities must be used reKlein, in a thought-provoking paper, postulated sponsibly. Forsythe pointed out that, in a series the argument that free medical care is not nec- of 985 intravenous pyelograms on hypertensive essarily equated with infinite consumer demand. patients, a remediable cause was found in only 2! Klein's views on the training of patients lead to a There has been a great tendency for it to be assumed that general practitioners are overwhel- consideration of the value of health education. A med by the insatiable demands of a greedy public. vast amount of money has been spent over the Puestow K L (1955) Postgraduate Medicine 18, 6 Royston C M S, Dowling B L & Spencer J (1975) British Journal of Surgery 62, 605-607 Skinner D B (1976) Journal of Thoracic and Cardiovascular Surgery 72, 523 Tanner N C & Westerholm P (1968) American Journal of Surgery 115, 449-453 Toledo-Pereyra L H, Michel H, Manifacio G & Humphrey E W (1976) Journal of Thoracic and Cardiovascular Surgery 72, 518-524 Wangenstein 0 H & Levin N L (1949) Surgery, Gynecology and Obstetrics 88, 560-570 Weaver A W, Large A M & Walt A J (1970) American Journal of Surgery 119, 15-18
4
Journal of the Royal Society of Medicine Volume 71 January 1978
years on various health education programmes; Patterson H R, Fraser R C & Peacock E Journal of the Royal College of General only recently, a million leaflets on immunization (1974) Practitioners 24, 237-241 were sent out to mothers by the Health Education Richards CW Council. Much of this money has been spent (1976) Journal of the Royal College of General without any evidence to suggest that the infor- Practitioners 26, 823-827 mation is reaching the public for whom it is intended. Posters and leaflets are read and forgotten, television has a little more impact, but the greatest influence comes from the doctor's surgery during the course of a consultation. If some general practitioners can influence their patients to reduce their demands, as measured by consultation rates and the number of visits, then this influence surely can be extended to the field of preventive medicine. Journal of the A few minutes spent at the appropriate moment can be used to counsel a patient about the dangers Royal Society of Medicine of smoking and obesity, to discuss with a mother For some time the Council of the Royal Society of the value of whooping-cough vaccine, or to raise Medicine has been considering how best it might the subject of contraception with a diffident girl. In improve and bring up to date its journal this way the future expenditure of limited resources Proceedings of the Royal Society of Medicine, on the unnecessary and avoidable consequences of which has appeared continuously, with only minor modifications, since 1907. From this issue it will patients' actions may be reduced. The general practitioner's influence on costs can have a new look and a new title, Journal of the be extended into many other fields, such as the Royal Society of Medicine. It is published by the efficient use of members of the practice team. The RSM and Academic Press, with whom the Society supportive roles of the health visitor, district has been collaborating since January 1977. The aim of the new journal will be not only to nurse, occupational therapist and social worker, judiciously used by the general practitioner, will maintain the literary and scientific interest of enable many patients, particularly the elderly, to Proceedings, but also to enlarge its scope: in be managed at home rather than in hospital - addition to publishing the more important papers which is, of course, far. more cost effective. The communicated at meetings of the Society's trend to early discharge from hospital is dependent Sections and the texts of the Society's main lectures, the Journal will publish other papers of a upon the efficient use of such resources. The general practitioner's central role in con- high medicoscientific standard, as well as signed trolling the resources of the National Health editorials, Section news, letters to the Editor, and Service has never been so apparent as it is today. other topical features. Thus the Journal of the This places a considerable responsibility on him to Royal Society of Medicine will have a wide medical decide priorities for the patient. It also emphasizes interest which should appeal to a large readership: the importance of training doctors for entry into it will reflect current advances in the science and general practice. One of these doctors has drawn practice of medicine, as well as being the forum for attention to the influence which he had on the cost reporting on the Society's own expanding of resources used (Richards 1976) and it is impera- activities. The arrangements for editing the Journal have tive, if the National Health Service is to remain viable, that all general practitioners are aware of been revised so as to keep in step with its expanded scope, and the Society has been happy to appoint their responsibilities in this connection. K J Bolden Dr Victor Bloom as Editor. Since January 1976, Department ofGeneral Practice Dr Bloom, with the help of two Honorary Editors University of Exeter and an Editorial Board of six Fellows of the Society, has been entrusted with the challenging task of producing a medical journal of outstanding References merit. As President of the Society I am confident Burrows W L that he and his colleagues will be able to meet this Practitioner 810-814 206, (1971) challenge and that the new journal will fulfil the Fry J (1977) Proceedings of the Royal Society of Medicine 70, 69 Society's highest expectations. Green R H John Dacie (1973) Journal of the Royal College of General President, Royal Society of Medicine Practitioners 23, 316-325
