from the lmc conference

BMJ

From The LMC ConferenceSource: The British Medical Journal, Vol. 281, No. 6233 (Jul. 12, 1980), pp. 159-166Published by: BMJStable URL: http://www.jstor.org/stable/25440588 .

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BRITISH MEDICAL JOURNAL 12 JULY 1980 159

tr?m the LmC Conference

GMSC chairman reports on pay, certification, and ancillary staff

Reporting on the work of the General Medical Services Com

mittee, Dr R A Keable-Elliott recalled that in 1977 the conference had made two

important decisions?to keep

*mmm^m^HmMw^w tne Review Body system and

about the system and the

juniors walked out of it.

There had been some dissidents among GPs. He remembered

one angry representative coming to the microphone and saying "The trouble with Dr Keable-Elliott and with the GMSC is it is always jam tomorrow." So, said Dr Keable-Elliott, it gave

him pleasure to say that this is jam. day today. The Tenth Report of the Review Body had increased average

net income by 32-15% and practice expenses by 26*85%.

Fortunately, the relationship between practice expenses and

target net income was now so close that it would not be necessary to explain again the difference between gross and net. This was,

he emphasised, the final phase of a catching-up period. The

profession was not overtaking comparable groups; it was

merely drawing level with them. The money was due to doctors.

Every GP present should have an increase of at least ?3000 a

year and for many the increase would be nearer ?4000 or ?5000. The trainees had been disappointed that their supplement

had not been increased. Dr Keable-Elliott pointed out that if

there was medical unemployment the hours worked by juniors would decrease and so would their UMTs and he would not be surprised if in a year or two's time junior hospital doctors were asking for the 15% additional money which GP trainees received. Practice expenses, which now stood at ?6850, reflected far more accurately the true expenses of practitioners.

When the budget had been announced it was obvious that the

increase in petrol and VAT would hit GPs. So he had written to the chairman of the Review Body inviting him to take the additional factors into account when fixing expenses for 1980-1

and the Review Body had agreed. Because of the delay in the

publication of the report the negotiators had been able to

anticipate budget changes and ensure that GPs received a fair

sum. In his view Dr Keable-Elliott said that the new chairman, Sir Robert Clark, was an independent thinker who would not

be unduly influenced by the Government, which was good, and perhaps not unduly influenced by the profession, which

was not so good. In looking to the future he drew attention to three statements

in the report. The first was "Detailed comparisons with earning movements will have a less direct role to play in our delibera

tions." He viewed any move away from the Earnings Survey and comparable earnings with disquiet.

Secondly, there was the statement "Next year we hope to be

able to base our recommendations on a more detailed exam

ination of the value of pension arrangements." Dr Keable

Elliott said he had no reason to believe that doctors would lose

index linking. But there was no doubt that the value of the

pension would be assessed and taken into account. The third statement was "The total remuneration package comprehends levels of direct pay, pension benefits and fringe benefits with

such unquantifiable benefits as job security and job satisfaction."

Not only would the Review Body take into account job satis

faction and job security but possibly the general prestige of

being a doctor. It would, he warned, be necessary to look

closely at the thinking of the new Review Body in the year ahead.

Last year Gateshead had proposed "That

social security certificates for periods of

incapacity of three days or less be abolished

with effect from 1 January 1980." That was

not achieved on 1 January but it had been

achieved now. There would be no three-day certificates and there would be no linkage. It

had been abolished by an Act of Parliament

and it would be law by September. The

profession had not been consulted before the

publication of the Green Paper, which was,

however, a discussion document. It did not

reflect Government policy and the Govern

ment had given an assurance that it would

discuss the details with the profession. At a

preliminary meeting with Mr Reg Prentice,

The Conference of Representatives of

Local Medical Committees met on 25

and 26 June. Dr W B Whowell was in the chair and was re-elected for

1980-1. Dr John Noble was re-elected

deputy chairman. Last week (p 89) we

published some of the conference's

decisions. This week we publish a

report of the speech by the GMSC chairman, Dr R A Keable-Elliott, who

announced his retirement at the con

ference dinner, and reports on some

of the debates.

Minister of State for Social Security, Dr Keable-Elliott said that he had put three

points. Firstly, it remained the objective of the profession if possible to do away with

medical certification altogether. In the short term any legislation introduced by the

Government must lead to a reduction in

certification, and anything that could result in an increase would be totally unacceptable. Secondly, the profession would not agree to the detailed diagnosis of a patient's illness

being statutorily available to the employer. Thirdly, the profession would not accept a

statutory obligation to issue medical certificates

{continued on page 160)



160 BRITISH MEDICAL JOURNAL 12 JULY 1980

Remuneration and expenses

Delay in Review Body report

Kent LMC was unsuccessful in persuading the conference to support its motion regretting "that the Review Body Report was once more

not published at its appointed time," and

reproving the GMSC "for its apparent unconcern at the delay." According to Dr L P

Ribet, the uncertainty caused by not knowing the timing or the content of the report was

wearisome, particularly to GPs. As independent contractors they needed to know what extra

money they could expect in the future. The

GMSC seemed to have done little to try and

expedite publication of the report. Dr Keable

Elliott pointed out that the Review Body's recommendations went to the Prime Minister,

who had to make a decision after consulting the Cabinet and others. That took time. There

would always be a delay of about three weeks

but the negotiators had urged that this delay should be reduced to a minimum. The alterna

tive was for the report to be published in

February or March but the indices on which

incomes were compared did not come out until

late Spring so that if there were an earlier

report the profession would receive less money. Dr D K Bose (Wolverhampton) wanted the

GMSC "to be aware of the gradual increasing differential within the profession when placing their evidence to the Review Body next year."

His LMC was concerned at the gap that had

emerged between the average net target remuneration and the maximum point of

consultants' remuneration. In 1976 it was

?2096; in 1977 ?2079; in 1978 ?2299; in 1979 ?1932; and in 1980 ?3580. Furthermore,

average net target remuneration included a

figure of ?1069 in respect of items not recieved

by all GPs, and just over a third of consultants

From the LMC (continued from page 159)

free of charge to employers. Mr Prentice

wished to come to a satisfactory understanding with the profession. Other people were

concerned and a meeting was being arranged with the CBI and there would also be one

with the TUC. After that negotiators would return to the Government with their views.

Related ancillary staff

On related ancillary staff the profession's view remained what it had always been?

namely, that there should be no differentation

in payment between related and unrelated

staff. But Ministers would not agree to this.

They had shown a duplicity in the matter

which was deplorable. They had declined to

allow 70% reimbursement for related staff.

Two years ago the profession had made a

breakthrough when the related staff of rural

doctors received an allowance. The scheme

had now been extended to the related staff of

all doctors who held a recognised nursing

degree and carried out some nursing duties.

It was totally illogical that it should be

confined to staff with a nursing degree. The

question before the conference was whether

it believed that what the Government had

received a merit award of some form, so the

gap was actually wider.

In principle, Dr Keable-Elliott accepted the motion. Dr Bose had compared the average

net income of the GP with the top of the

consultant grade, whereas the average net

income of a GP was higher than the bottom of

the consultant grade but the GMSC would

look into it. The motion was carried.

Proposing "that the target net income should

relate solely to general medical services," Dr

R V H Jones (Devon) said that general medical

services were what every GP gave and the job had been recognised as a specialty. Target net

income must relate to the everyday work of all

GPs. Unless items of service and other things included in target net income were cut away

GPs' overall income would not rise as they took on more work and responsibility. Dr

Keable-Elliott accepted the motion on the

understanding that the desire was that the

Review Body should make it clear what was

being paid for medical services. The Review

Body compared the medical profession with

other professions and it was to the advantage of GPs that they should be so compared. In

making that comparison other professions took on other duties and responsibilities and

he would not want the Review Body to leave

that out of their calculations in fixing the

medical profession's level of remuneration.

The motion was carried.

Practice expenses

In the section on practice expenses Dr J Ruffell (Kent) moved: "That this conference

has no confidence in the methods used by the

offered should be accepted, which was a

move forward, or whether it should be

rejected. At present the allowance paid was

half of 70% of the average salary. The same

allowance would be paid in the extended

scheme (28 June, p 1638), which was for those

in post on 1 January 1980. It would operate from 1 October but payments would not

start until 1 April 1981 as the Government

had only agreed to the scheme on the under

standing that it would not cost additional

money. The money was coming out of indirect

practice expenses and the Government had

to work out the necessary adjustments. Dr Keable-Elliott said that Dr Gerard

Vaughan had agreed that if patients going abroad required drugs the GP could charge them for issuing the prescription. He had

also agreed in principle that a fee might be

accepted from a third party for work con

nected with referral of patients to a private consultant provided that the GMSC and the

provident associations could reach agreement on how to operate the arrangement. Discussions

were going on and he hoped for a satisfactory outcome later in the year.

In conclusion the GMSC chairman issued

a warning. The pattern of medicine, he said, was changing and the GPs' position had

Review Body on Doctors' and Dentists'

Remuneration to determine practice expenses." The present system used by the Review Body to determine practice expenses, he said, was

insensitive to the rapid monetary fluctuations

of many of the factors affecting expenses, such as motoring expenses, inflation, and fuel costs.

Replying to the criticism, Dr Michael Wilson

explained that the Review Body received

statistical data from the Technical Sub

committee based on Inland Revenue inquiries. These gave firm figures for average expenses of a sample which included 1200 to 1300 tax

returns. But that was two years out of date so

provisional figures for the following year from a sample of approximately 300 returns were

also used. The Review Body then had to

project from 1978-9 to 1979-80 with only the

price movements as a guide and from 1979-80 to 1980-1 with a forecast of the inflation for

the year ahead. Over the 11-year period the

figures from the Inland Revenue inquiry were

a check on the estimates that the Review Body had made of practice expenses each year. The

highest ever was in 1976, when the profession was overpaid by 3-5% on practice expenses.

The motion was lost.

Dr I Smith (Merton, Sutton and Wands

worth) wanted the conference to request the

GMSC "to investigate the possibility of

average expenses reimbursement being cal

culated on an area rather than a national basis."

But this was lost after Dr Wilson had warned

that breaking the information down too much

meant that it was not statistically valid.

Angus Division was successful in its request "that direct reimbursement of expenses for

general practitioners should be investigated."

changed. For him a good GP was one to

whom a patient could turn for help with a

medical or social problem. Giving some

examples of change he said that in the past if a

patient had an obstetric problem she turned to her GP?now many women went to

consultant units; if there were problems over

baby feeding or immunisation mothers would

go to their GP?now they turned first to the

health visitor; if there was a social problem

patients might now turn to a social worker; for a medical problem at an inconvenient

hour they might turn to a deputising service; and if it were a medical problem at a reasonable

hour some might even turn to organisations such as Medicover.

So long as the GP was head of the primary care team, Dr Keable-Elliott declared, he was

not worried. But when he was just a member

of the primary care team and to the patient not the most important member then there were problems ahead. It was sometimes said

that the LMC Conference concerned itself too

much with money and terms and conditions

of service and not enough with the care of

patients. Dr Keable-Elliott did not accept

that, for the former was one of the conference's

tasks. But it should not be a task which was

followed to the preclusion of all else and he

asked the conference to bear that in mind

during the ensuing debates.




National Insurance certification

Vote of censure defeated

From North Tyneside, Dr W K Deegan moved : "That this conference proposes a vote

of no confidence in the chairman of the GMSC

because in his action in unilaterally revoking the policy re certification as laid down by the

profession he exceeded his powers."

Dr Keable-Elliott speaking during the censure motion on certification.

The strong wording of the motion, Dr

Deegan said, reflected his LMC's long

standing feeling of intense dissatisfaction with

the GMSC's handling of certification. It also

ensured that the motion would be lost. Had

the information given by Dr Keable-Elliott in

his speech (p 159) been available earlier it was

unlikely that the motion would have been

tabled. On two occasions in the past six years the GMSC had had clear mandates to act. On

neither occasion had it done so by the stipulated date and his LMC had thought that the GMSC

was not prepared to enter into a conflict with

the DHSS on the matter. The latest informa

tion now proved that such concerns had been

misplaced. As a matter of principle, however, the

GMSC and its leadership had the power to

reverse major policy decisions without first

consulting LMCs. The general practitioners of North Tyneside were the staunchest

supporters in any action instigated by the

GMSC. Perhaps they might be forgiven the

luxury of a little loss of confidence when

confronted with the facts which had been

available to them at the time. Dr Deegan said

that he moved the motion "with no pleasure." Saddened to see the motion on the agenda,

Dr I Bogle (Liverpool) said that mud, once

cast, would stick if the matter was not debated*

His committee believed in the abolition of

short-term certification but what would have

be?n the consequences if unilateral action had

been taken on 1 January? It would have

jeopardised the negotiations and it would have

made certain that the Government would not

have agreed to implement the Review* Body award. If the conference wanted* the GMSC

chairman to be an "unthinking?puppet" then

he wanted to be counted out. They needed, and had, a man of'Vision and integrity. The

motion was untimely; unfair, and totally

unacceptable.

According to Dr J H Marks (GMSC), the motion showed a monumental misunderstand

ing of the powers of the GMSC chairman.

He could not deny that the GMSC had not

carried out the conference's policy to the letter

but the motion spoke of the "unilateral action

of the chairman." It had been the unanimous

view of the GMSC that the profession should

be recommended not4 to stop certifying on 1

January. Dr Keable-Elliott expressed his gratitude to

the conference and to the mover of the motion for the temperate way he had put it. The

Government had agreed that three-day certification and linkage should be abolished.

This would be done by Act'of Parliament at

the earliest convenient moment. Had this been

thrown back the Minister of Health and his

party would have been alienated and it would

have given ammunition to the Opposition, who

would vote against the bill. Any doctor who

did not issue a certificate would have been in

breach of his terms of service. Remuneration

would have been withheld. To have taken

industrial action in support of individual

doctors would have severely prejudiced the

Review Body report. There was another reason. In January junior doctors and some of

their consultant colleagues had been taking action at Charing Cross Hospital to break

industrial action by workers who were trying to prevent oil going in. Where would the

profession have stood if GPs had started

industrial action at a time when their colleagues were trying to break it ? Not one person on the

GMSC had dissented from the action pro

posed. He had written to every GP setting out

the position. If North Tyneside GPs had felt so

strongly they could have invited him or one

of the negotiators to explain the position.

They could have asked for a special conference.

He was saddened at the motion but did not

want the conference to vote against it on

emotive grounds. The motion was lost unanimously and the

GMSC chairman given a standing ovation.

Another motion from North Tyneside was

also turned down unanimously: "That this

conference is appalled at the action of the

chairman and members of the GMSC in

failing to apply the mandate given them to

cease short-term certification on 1 January 1980. We demand that the policy regarding short-term certification as passed by con

ference be instituted forthwith." Dr Deegan said that he was pleased that the second part of

the motion was already in hand. Dr A Lask

(Ealing, Hammersmith, and Hounslow)

opposed the motion, which asked for some

thing to be done straight away. He was against short-term certification but the conference

should not "upset the applecart and stop

signing these wretched certificates." Dr W

Keith Davidson (GMSC) pointed out that it was because of pressure from the GMSC that

legislation was now going through the House

of Commons which virtually abolished short term certification. It would be folly to ask for an immediate decision. By September it

would be the law of the land.

Then Dr D J Strath (Devon) proposed: "That it is deplored that the abolition of

short-term NHS certificates has not yet been

achieved." Dr Keable-Elliott pointed out

that in the Bill [Health Services Bill] now

going through Parliament anybody who was

sick for three days would not be entitled to a

certificate; anyone sick for three days in one

week and three days in the following week

would still not be entitled to one. If a person was ill for four days in one week then he would

be entitled to a certificate but would only get sickness benefit for one day. If he was ill for

three days in the following week there was no

linkage and he would not be entitled to a

certificate. If, on the other hand, he was

sick for four days or more within a subsequent six-week period he would get linkage in the

sense that he would receive enhanced benefits

but the certification remained the same. On

being put to the vote the motion was lost.

From Cornwall and the Isles of Stilly

..W????????; ^B^m??????mm??Hm/ / :LJr ,.....,J.. K* - j

mm ' ̂ HmHHHv i ^ wW^f '%.% ^b?:?m

Thtf secretary of the GMSC, M&s Lavin?a M?ddings; the chairman of the conference, Dr Brian Whowell^ and the deputy chairman, Dr John Noble.




Dr D J Hudson proposed: "That this con

ference demands the removal from the terms

of service of all National Insurance certifica

tion." The GMSC had not made much

progress, he said, because so long as there was a National Insurance scheme somebody had to give certificates. GPs were the best

people but the terms under which they were

given were debatable. Opposing the motion, Dr

M J Illingworth (Forth Valley) thought that in

certain circumstances it was right and proper that a patient's entitlement to benefit should

be certified expeditiously. Having looked at

his own certification for a week recently,

however, he had found that of 10 issued on a

Monday morning, nine were to allow the

patient to go back to work the following

Monday; most of them were not ill. Dr B D

Morgan Williams (Warwickshire) asked repre sentatives to remind themselves how much

time they spent on certification. If they were

not burdened with this paperwork they would be able to see many more patients. What was in the motion had been conference

policy not long ago. That policy had been

rescinded so that progress could be made

with the actual form of the certificate.

But Dr J Alcock (Fife) supported the motion. All certification was a gross waste of a

GP's time. It caused friction between patients and doctors. If a patient was adamant that he

was unfit for work few doctors would argue. The motion was a difficult one, Dr Keable

Elliott said. If GPs stopped issuing certificates

it would cost the country a lot of money, which would be taken out of the running costs

of the NHS and conceivably out of doctors'

pay packets. He opposed the motion but if it

were passed then it had to be on the under

standing that it was a long-term objective. The motion was lost.

No certificates for seven days or less

A motion from Enfield and Haringey

demanding "the removal from the terms of

service of the requirement to issue National

Insurance certificates for periods of sickness of

less than 14 days," was lost after Dr Keable

Elliott had reminded the conference that the

Government wanted to reduce certification to a

minimum but that 75% of all certificates were

for 14 days or less and that was the period where the heavy financial burden fell. Dr J

Margaret Foot (Croydon) was, however, successful in persuading the meeting to

support "the removal from the terms of

service of the requirement to issue National

Insurance certificates for periods of sickness of

seven days or less."

Dr P M Kinloch (Liverpool), who supported the motion, said that there were times where

it was necessary to give a certificate?some

times even when the patient did not want it. In

an area of high redundancy and unemployment

people sometimes wanted NI certificates for

short periods so that they would not lose their

jobs. If the rules stated three days with no

certificate then people would just stay off for

four days but they would think twice about

staying off for a week.

Asked if after the Bill which related to

three-day certification became law the period could be altered to seven days or 14 days by

regulation, Dr Keable-Elliott, who supported

Croydon's proposal, explained that the

Health Services Bill included a provision for

the abolition of the three-day certificate and

M ' '^ gar

LMC representatives in the Great Hall at BMA House.

linkage. The Bill that the Government would

introduce in the autumn would be an entirely new one covering the whole question of

certification and making radical changes. A

decision would have to be made as to whether

certification was statutory and, if so, for what

periods. "That the terms of service must not be

changed to include the provision of certificates

for the use of employers." Proposing this, Dr G R Outwin said that whatever changes were made two things had to be made plain. Doctors should never accept an obligation to

disclose the cause of incapacity to an employer and the provision of certificates for the

employers' use must not be included in the

terms of service. Dr Keable-Elliott reminded

the conference that it had already agreed that

certification should continue. If the Govern

ment changed it so that certificates were

required by employers instead of th? DHSS

then there would be a potential conflict. If

the employers were prepared to pay a sub

stantial sum of money for this quite a number

of GPs might be prepared to go on issuing certificates. He asked for the motion to be

passed as a reference; Dr Outwin did not

agree and the meeting carried it as a sub

stantive motion.

Resignation rider rejected

Dr B L Alexander then wanted to add as a

rider to the motion, "Such a change

unilaterally enacted by Government would be a resignation issue." This was the first

opportunity, he said, that the conference had

had to discuss the Green Paper, Income

During Initial Sickness: A New Strategy. The

negotiators had told the Secretary of State of

the profession's abhorrence of the proposal to

alter the terms of service in order to enforce

the issue of certificates to employers. He asked

the conference to support the rider to

strengthen the arm of the GMSC chairman.

But Dr Keable-Elliott denied that it would

do so and asked the meeting to oppose the

rider, which it did.

Dr P Stanesby (Enfield and Haringey) moved: "That in the opinion of this con

ference the proposals in the Government's

Green Paper offer no prospect of a realistic reduction in the certification load and are

therefore unacceptable." The regulations had been changed but unfortunately he did not

think that the information had got through to

employers and patients, who were still being pressed by management to provide certificates within two days of being ill. Many employers no doubt felt that they needed documentary evidence for the initial four days in case they subsequently had to pay sickness benefit.

Dr Jane Richards (GMSC) considered that the Green Paper was a licence for every

employer to demand a certificate whenever he wanted one after three days' sickness and it would encourage a vast increase in work load.

In her opinion the proposals could not

realistically reduce work load and should be

completely rejected. As an independent contractor she wanted to provide general

medical services and not a certification service. Dr Keable-Elliott could not accept the motion. The Green Paper was a discussion document and the Government was prepared to discuss it in detail with the profession. The

motion was lost.

Dr G Jones was successful with his motion from Dyfed rejecting paragraph 35 of the

Green Paper, which reads : "If a member of an

occupational sick pay scheme wishes to claim he will normally, as under the State scheme, submit a statement on which his doctor has advised him not to work and indicated the nature of his incapacity. The Government consider it would clearly be right for this

arrangement to continue and they have in mind to propose to the medical profession an

amendment to doctors' terms of service

whereby statements will be available without

charge to people claiming the payment which would be obligatory for a sick pay scheme to

make."

Dr R W Smith (Redbridge and Waltham

Forest) moved: "That this conference con

siders that certificates provided under any new arrangements for sickness certification should not be provided by GPs free of

charge." One or two speakers were against the

motion. But Dr Keable-Elliott was surprised at the opposition. If a doctor did not wish to

charge it was up to him. He accepted the

general principle of the motion and it was

carried. -




Vocational training

Dr S E Josse told the meeting that the

GMSC had managed to agree with the

DHSS that a single certificate of prescribed or

equivalent experience would be issued by the

Joint Committee for Postgraduate Training. A recent modification of the Statement of Fees

and Allowances meant that the appointment of

a trainer between one approval date and the

next could be reviewed in the light of cir

cumstances by the GP Advisory Committee.

One matter still unresolved was the position of

doctors unable to become GP trainees because

they had been in practice in the British Isles

for more than a year. The first amendment in the section was

from the Junior Members Forum: "That

vocational training in general practice should

not be a legal requirement." At one time, Dr Alison Hill said, she thought it distasteful

that vocational training should be governed by statute. But there was still a tendency for

general practice to be thought of as a happy rest

ing place for the hospital specialist who did not

make it to the top of Lord Moran's ladder.

Until general practice had the respectability of the hospital specialties and until the RCGP

had acquired the necessary stature to command

that respect, some sort of regulation was

necessary to cement efforts at raising standards.

If vocational training were not mandatory, no

provision would be made to provide and

maintain good training posts in hospital. Dr J W Chisholm (GMSC) said the proposal

was the sort of thing that could only discredit

the Junior Members Forum. If ever an

amendment sought to shut the stable door

after the horse had bolted, this was it. The

Vocational Training Act had been passed and

regulations laid before Parliament.

But Dr M H Stuart (Essex) supported the

amendment. He favoured adequate training and vocational training programmes but the

increasing number of rules and regulations

governing every facet of life was stultifying. The doctor who equipped himself properly for general practice received a vocational

training allowance but that would be lost once

vocational training regulations were in full

swing.

Dr Josse regretted that there was no

representative from the forum. He suspected that it had come as a shock to many hospital oriented doctors that easy access to general

practice would no longer be possible. The

regulations were flexible. Any type of

experience anywhere in the world could be

considered by the joint committee. The crux of

the matter was that no evidence existed to

suggest that without mandatory requirements all doctors would train to the standard

required. The amendment was lost but the meeting

approved a motion from Leeds which noted

with concern "the rigidity of the regulations for entry into general practice for some

doctors fully registered before December

1979," and asked for their future consideration.

Dr B D Morgan Williams (Warwickshire)

proposed: "That there should be more than

one body in charge of any assessment process deemed necessary for accreditation to any future specialist register for general practi tioners." One of the glories of general practice

was its infinite variety, which had depended on the many portals through which a doctor

could make his way to qualification. He

warned the conference that it was open to any academic organisation to set up a course in

higher general practice and for it to become

customary for it to be essential to hold that

qualification before entering practice. It was

never too soon to be on guard against some

thing which would damage the body politic or

the care of patients. Dr Morgan Williams seemed to be saying,

Dr Josse thought, that the RCGP should not

be the body to assess; if so, that was fair. So

far as he was aware, it was no part of the

policy of the GMSC or the Joint Committee

for Postgraduate Training that there should

be terminal assessment. Nor was there any

suggestion that there should be a specialist

register for general practice. The motion was carried.

The conference affirmed its support of the

principle that the number of potential GP

trainees should place no limitation on the

number of GPs approved as trainers, and

instructed the GMSC "to ascertain the

various criteria used in different regions in

respect of the selection of trainers and to

report them to next year's conference."

Dr S M Parrack (Sefton) moved: "That

this conference supports the efforts of the

GMSC in its efforts to secure more training

posts, particularly in obstetrics and paedia trics." Leeds wanted to add "provided that

college approval is maintained," to ensure

that a post continued to be recognised for

educational purposes. Dr J G Ball (GMSC)

opposed the amendment because he said that

the conference had just agreed that there may be several bodies providing approval.

The amendment was lost by 98 votes to 81

and the motion was carried.

Dr M G F Crowe (Leicester) called the

following motion from Clwyd unnecessary: "That this conference ensures that where they are required additional SHO posts should be

made available for vocational training in

general practice by the redesignation of

existing posts." The DHSS and the Man

power Planning Commission, Dr Crowe said, should have sorted out the inevitable con

sequences of obligatory vocational training. Consultants who controlled existing posts seemed to believe that all their SHOs would

try to specialise. They forgot that in the past at least half had become GPs. Dr G Caplan

(Manchester) also opposed the motion. If an

increased number of posts were necessary to

support a training programme, they should be new posts and in sufficient number so that

hospital experience took two years and no

longer. Dr Josse was confused by what was meant

by redesignation of existing posts. If it were

simply a question of altering the nomenclature

of the post it might be acceptable, provided the underlying educational remit within the

post was maintained. Nationally there were

sufficient hospital junior posts to suffice for

the vocational training of GPs, though there were pockets where there were difficulties,

particularly in obstetrics and gynaecology and

paediatrics. Only about half of those doctors

going into general practice in fact were likely to go through the vocational training scheme.

The other half would do their own thing and

provide their own course.

The motion was lost.

The conference . . .

instructed the GMSC to negotiate superannuate remunera

tion for GPs on district or area management teams irrespective of whether this is attainable for consultants.

decided that patients' signatures should not be required on

night visit forms as this gave a distorted picture of the number

of visits carried out.

asked for an expansion of the panel of doctors available to

act as advisers to the Secretary of State at oral hearings, appeals, and medical advisory committees.

agreed without debate to a request for an investigation of

direct reimbursement of all expenses.

invited the GMSC to negotiate a fee for doctors providing a

casualty service at their surgeries.

regarded the maintenance of an efficient flying squad service

for obstetric emergencies as essential.

GMS defence trusts

Good response from LMCs

DrWGA Riddle, deputy treasurer of the GMS defence trusts, reported that despite an increase in total income of

?37 000 in 1979 only ?31 000 had been transferred to the accumulated fund compared with ?34 000 in the previous year. It had been agreed that the quota to be paid by LMCs would be increased on 1 July 1980 by ?57 000 and,

in the first full year-?1981-?by ?115 000. Even so, because of rising costs, he could give no guarantee that

contributions from local medical committees could be

held at the present level. Of just under ?250 000 due in 1979, only ?874 remained outstanding from two LMCs.

Out of a quota of ?307 000 for 1980 Dr Riddle reported that he had already received over ?150 000. The defence trusts assets exceeded ?l-3m.




Rural practice: Clothier standstill supported s,^

Dr J C Oakley (Kent) moved: "That this conference considers that the present Clothier

standstill agreement* should be terminated."

The agreement had become a farce, he said. It was obstructive to the doctor, the pharmacist, and the patient. It was not law and would not

stand up if current regulations were enforced. Dr B D Morgan Williams (Warwickshire) said he had never liked the standstill. It was a

fix between two professions to the dis

advantage of the patient. But he opposed the

motion because if the standstill were to be

disrupted by the profession it would stir up a

hornet's nest.

Dr Michael Wilson, chairman of the Rural Practices Subcommittee.

Dr A J Rowe (GMSC) thought the stand still had led to a much more stable position than had ever existed between the two

professions. The standstill had not been a

farce, Dr Michael Wilson said. It had been

extremely successful. Those concerned had

worked patiently over the last five years to secure agreement in the Clothier Committee, and he urged the conference to be patient a little longer. The motion was lost.

The conference endorsed a motion from

Cambridgeshire calling on the GMSC "to give its unequivocal reassurance that adequate

compensation will be obtained by any doctor

whose right to dispense is curtailed." Dr Michael Wilson, chairman of the Rural

Practices Subcommittee, pointed out that the

GMSC did not have funds to compensate doctors but it was the policy that adequate

compensation should be achieved for any doctor whose right to dispense was curtailed.

But there were problems. He accepted the

motion but the GMSC was unable to give the

unequivocal reassurance asked for. The

motion was carried.

When the National Joint Committee of the Medical and Pharmaceutical Professions on the

Dispensing of NHS Prescriptions in Rural Areas

(Clothier Committee) reported in 1977 there had

already been a voluntary standstill on rural

dispensing arrangements since October 1975. The two professions had agreed that the stand still should continue so long as progress was

being made towards implementing the recom

mendations of the Clothier Report. A clause has been included in the Health Services Bill, now

going through Parliament, which will enable the recommendations to be implemented through regulations.

Dr M J L Mort (Highland) asked the GMSC "to negotiate the application, of the

formula used by the Scottish Medical Practices

Committee (in assessing whether or not an

area is underdoctored) in calculating list size to determine eligibility for full basic practice,

supplementary practice, group practice

allowances, etc." He referred to the problem of

the singlehanded doctor with a list of about

1500 up to but not exceeding 2000, especially if the work load was increased by temporary residents. The work was too much for one

man. As things stood with a list of less than

2000 it was impossible to get a basic practice

allowance, and without it such a practice was

not viable for two men.

If the motion was passed, Dr R S C

Fergusson (Scottish GMSC) suggested, it

would do more to raise morale and take the

pressure off a number of singlehanded practi tioners than any other motion on the agenda.

Of the 80 odd practitioners in Scotland who

would be eligible, only about 50 would take

advantage of it because the Scottish MPC

Speaking to one of the motions, D.r B D Morgan Williams from Warwick shire.

still had to be satisfied that there was a need

for another doctor.

Dr Michael Wilson said that there were

about 500 doctors in Britain?urban and

rural?who did not receive a full basic practice allowance. If every one received it the cost

would be about ?160 000. The motion was

carried.

Cameron Fund seeks co-operation of LMCs

The general activity of the Cameron

Fund, which was set up 10 years ago to relieve poverty, hardship, and

distress among general practitioners and their dependants, showed a

' marked increase in the past year and

reached its highest level to date. The number of new applicants for assist

ance more than doubled when com

pared with the previous year and

nearly 50 visits were made to families

in different parts of the country. For

the first time disbursements totalled more than ?80 000, representing an

increase of 30% over the previous

year. Income also increased, though at a lower rate. At the annual general

meeting of the Cameron Fund during the LMC Conference the chairman,

Dr P J Bryce-Curtis, emphasised that LMCs should notify the fund if they knew of families who could benefit.

Related ancillary staff

In his opening speech Dr Keable-Elliott had

explained the latest proposals to extend the

related ancillary staff scheme to ,all doctors

(p 160). The following motion from North

umberland had been submitted before the

announcement: "That this conference ex

presses concern at the failure of Government

to agree equitable arrangements for the direct

reimbursement of related ancillary staff and

calls upon the Secretary of State to remove

this injustice forthwith." Dr B D Morgan Williams (Warwickshire) wanted to amend the

motion to add: "and decline to accept the

present DHSS proposals until they shall have

been fully considered by LMCs." Information

on the matter was fragmentary and insufficient,

he said. He was suspicious when the DHSS

conceded something late in the day. If the

amendment was accepted, Dr Keable-Elliott

warned, there would inevitably be a delay. There was no prospect of getting the views of

LMCs back in time to unscramble the process.

According to Dr J H Marks (GMSC), the GMSC had followed the conference's policy

right the way through. It now had to choose to

accept what was offered or to wait. But Dr

R S C Ferguson (Scottish GMSC) said that he could not expect Scottish GPs to accept the

offer without more information. There seemed

no reason why the conference should be

stampeded by the motion. But the amendment

was lost and the main motion carried, though Dr Keable-Elliott thought it was too temperate and Dr B L Alexander thought the piecemeal

approach should be rejected. MPs, he said, were directly reimbursed for the salary they

paid their secretaries and nobody asked whether

they were related, ancillary, or anything else.




Underprivileged areas

Dr Mervyn Goodman had chaired a working

party on underdoctored areas and the GMSC

had just considered its report (28 June, p 1639). He said that many of the problem areas were

neither underdoctored nor inner cities and the

working party had suggested that the term

"underprivileged" should be used. GPs should

make inner cities their first choice as they were

areas of high patient demand generated

primarily by social environment. The main,

though not the only, solution was financial and

his working party had considered that payment should be related in some way to the degree of

underprivilege. So it was suggested that a large section of the payments would depend on

where the patient lived rather than on where

the doctor practised. To achieve that an

enhanced capitation fee was proposed based on

enumerated districts of a particular area

representing about 150 families.

In addition there were social factors which

affected the vulnerability of doctors, their

premises, and their possessions. There were

also the local amenities?schools and the

unattractiveness of an area. So the working

party had suggested there should be fixed

allowances. The first was an initial allowance

to attract doctors into the area; one for the

singlehanded practitioner to get him to set up

practice premises of good standard and the

other to compensate a partnership for tem

porary loss of income when it took in another

doctor. Having established themselves in

practice, the doctors should receive a con

tinuing allowance to keep them in the area

and the allowance paid for as long as they remained.

A high turnover of patients was another

factor that increased doctors' work load and

therefore it was appropriate to introduce a

registration fee. That would, of course, be for

the country as a whole. Because of the stress in

those areas it was felt that GPs should be able

to retire at 55 and the pricing of the package should at least reflect a total superannuate income at 55 equal to that of the average GP

at 65, as well as being able to cover other

aspects in those areas, such as the repair of

vandalised property and high wages that had

to be faced.

The following 'A' motion from Sunderland

was carried: "That this conference recognises the urgency of implementing the views of the

working group on underdoctored areas, both

in identifying the factors peculiar to those areas

and in providing financial and other incentives

to doctors who work in them."

Then Dr I Bogle (Liverpool) proposed:

Some conference debates in brief...

Reimbursement for all ancillary staff

was supported by the conference. Proposing

this, Dr D Hunter (Orkney) said that greater reliance was put on ancillary staff in country areas and particularly the Scottish islands.

The GMSC has been urged to make arrange ments to include physiotherapists in the

ancillary staff reimbursement scheme, after

Dr Keable-Elliott said that he rejected the

argument put up by the DHSS that as there

was a shortage of physiotherapists they would

be better employed if hospital-based. Kent

was unsuccessful in its request that

"reimbursement of the employer's 'reasonable*

contribution to private pensions for GP

ancillary staff be structured on a unified

scheme, based on the one operating for

schemes which were accepted by FPCs for

100% reimbursement." Dr L P Ribet pointed out that some GPs were reimbursed 100% and

some 70%. But the matter was not negotiable, the GMSC chairman told him. If a doctor

took on new staff who did not have a pension scheme there was nothing to stop him paying them more than older members of staff so

that they had additional money for their own

pension scheme.

Casualty services provided by GPs in

their surgeries should be paid for just as GPs

receive a fee for casualty services in GP

hospitals. The position now was an anomaly, said Dr M J L Mort (Highland). Rural GPs treated casualties and should continue to do so

because it removed the need for long journeys to hospital. Dr P J Enoch (GMSC) supported the motion. GPs should be encouraged to

provide an accident service if they wanted to.

They should be given nursing help and

financial compensation. Casualty work was

part of the work commitment and should be

paid for, in the view of Dr M F Hudson

(Cheshire). It would encourage more GPs to

do it and in the long run would save money. Dr Keable-Elliott sympathised with the

motion; but what was a casualty ? Some people

might consider a fly in the eye a casualty but

he supposed the motion was referring to deep lacerations and even fractures. There might be a different solution for rural and urban areas.

He suggested the motion should be passed as a

reference and the meeting agreed.

GP obstetricians should not be absolved

from responsibility when women insisted on

being delivered at home in direct contradiction

to medical advice nor absolved from any

liability to the child born at such a confine

ment. The meeting confirmed the status quo in

defeating a motion from East Sussex. Dr M H

Knott wanted the terms of service to be

amended as fewer GPs did home deliveries and

the practical obstetric experience at under

graduate level had decreased. But most of the

speakers opposed the motion. Dr S E Josse

(GMSC) said that providing maternity services implied more than delivery at home; the DHSS could not absolve the doctor from

this provision. Dr L Kopelowitz pointed out

that doctors did not have to accept patients for maternity services if they did not wish.

The only obligation was under paragraph 13

of the terms of service, where they were

required to give services in an emergency. If a

doctor signed someone on for maternity

"That this conference believes that social criteria can be identified in the 'underdoctored' areas and in this respect disagrees with the

report of the joint working party." Once

again, Dr Bogle said, he was addressing the conference in his role as Liverpool's expert on stolen ballcocks, doctor mugging, and obscene

graffiti. The joint working party had rejected the idea of being able to obtain, update, or use

meaningfully social indices with a view to

negotiating a weighting payment. It had stated that it had not been able to devise any single comprehensive criterion and therefore did not

think such payments practicable at present. Educational priority areas had existed for the last eight years. This had resulted in increased income to the teachers concerned and such a

system could be applied to primary health care.

In medically deprived areas the state of

employment, or lack of it; sickness benefit

paid; housing; family size; delinquency; and medical factors, such as mortality rates and

morbidity statistics, could be used. Dr M Wilks (GMSC) welcomed the motion.

As a member of the original working party he

said that recommendations had been submitted to the GMSC which based several allowances and inducement payments for underprivileged areas on social criteria which had yet to be

fully investigated. Dr Goodman said that he was prepared to accept the motion and it was

carried.

services and subsequently regretted it under

regulation 12 he could apply to the FPC to

have that contract terminated; that application could not be refused without the LMC being consulted.

FPCs should inspect premises regularly,

suggested Dr Lionel Kopelowitz (GMSC). He was speaking against a motion calling for

procedures to ensure that FPCs were told

when a GP was practising below the minimum

standards acceptable to be discussed with the

DHSS. If a GP did not provide proper and

sufficient accommodation the FPC already had

the power to bring the matter to the service

committee as a breach of the terms of service.

The conference, however, passed the motion as

a reference to the GMSC on the understanding that it referred to premises after hearing that

Dr G F E Edmondson-Jones (Leicester) had

had to accompany the FPC administrator to

premises which he called "appalling and

filthy." He argued that it was a problem for

the LMC to tackle. The FPC, after consulting the LMC, should be given power to withhold

reimbursement under the rent and rates

scheme and, if necessary, the power to close

the premises.

Community health councils ought not

to be abolished, the conference decided by 114 votes to 79. Dr H C Palin's LMC?

Lancashire?did not support the view in the

annual report that CHCs played an important

part in maintaining good relations between




patients and the NHS. In many cases they had initiated complaints to FPCs on behalf of

patients against GPs. In his view they wasted more than their ?4m estimated cost by, for

instance, publicising themselves by giving away T shirts and even beer mats in pubs. Lay

members of the FPC represented the

consumers. But the chairman of the Trainees

Subcommittee, Dr J W Chisholm, pointed out

that doctors lived in an age of consumerism.

CHCs could form a useful line in the fight to

move resources from secondary to primary care. Dr Palin had some support from Dr G W

Taylor (GMSC), who did not believe that the

NHS could afford even a small sum for an

organisation which was not helpful and could

not justify its existence in terms of value to

patients. Dr Keable-Elliott thought it would

be a pity to do away with allies who opposed the closure of GP hospitals and GP obstetric

units. There were one or two unsatisfactory CHCs but it would not be politic to recom

mend this abolition.

Notional rents should be equated to their

equivalent commercial value forthwith and

the conference deplored the lack of progress in

achieving this. Owner occupiers, according to

Dr W S S Maclay (Surrey), were being

prevented from securing equitable payments for their premises. The initial system of

assessing the notional rent was fair. Then the

proposed rent went to the district valuer for

approval; dissatisfied doctors could appeal to

the Secretary of State but he was advised by the valuer who had set the rent. An in

dependent appeal mechanism was one of the

negotiators' goals, Dr John Ball, GMSC

deputy chairman, said, but it was important for the GP to take independent advice himself.

A panel was to be set up to advise GPs. Some

progress, however, had been made: from

1972 to 1980 net remuneration had increased

threefold, whereas the return on premises

paid to doctors had risen fourfold.

Exemption from prescription charges was the subject of a motion from Cambridge shire. The LMC wanted the GMSC "to

review the regulations whereby patients obtain

exemption from prescription charges for

certain specified conditions." Cambridgeshire welcomed the provision made for expectant and nursing mothers and children and the

assistance given to those on supplementary benefit. But why, the proposer asked, should

someone suffering from diabetes or epilepsy take precedence over a sufferer from ulcerative

colitis or hypertension. Dr D A Richardson

(Hertfordshire) opposed the motion. If the

Government wanted to exempt some people from prescription charges the doctors could

offer professional advice but it would be

dangerous to breach the principle that they were not responsible for the way that the

provision of NHS resources was carried out.

Agreeing that the category had been wished

on doctors by politicians, Dr J S Happel

(Hampshire) did not want the categories

extended, though there was an excellent case

for abolishing them altogether. The proposer

pointed out that the motion did not ask for an

extension of the list, only that it should be

reviewed, and that was carried.

Professional advisory committees for

deputising services should not be financed by a statutory levy imposed by the LMC, nor

should subscribers to the services finance the

committees, the conference decided. As they were approved by and accountable to the

LMC, Dr M Hamid Husain (GMSC) thought that they should be paid for by the LMC to

ensure their independence. But as independent contractors GPs should be responsible for their own affairs was the view of Dr A Nawrocki

(Croydon). Dr G R Outwin (GMSC) pointed out that the independence of PACs did not

depend on who paid for them but on by whom

they were nominated. As they were nominated

by the LMC their independence could be

guaranteed. It was unjust, he thought, that by

contributing to the statutory levy doctors

would be contributing to services they would not all use. Some LMCs dealt with rural

problems and city doctors had to bear the cost

of that part of the LMC financing even though rural work did not apply to them, Dr Lionel

Kopelowitz told him. Dr Kopelowitz is chair man of the BMA's Central Advisory Committee

for the BMA Deputising Services. He said

that to say there should be "a charge against the income derived from subscribers" was too

inflexible and he urged rejection.

Paediatric surveillance was the job of the

GP, who should be paid for it. The DHSS had agreed to this in principle, Dr Keable

Elliott reported, and as the RCGP had the same view he hoped that there would soon be some result. Dr D J Godfrey (Leeds) wanted

support for his motion "that a scale of fees for

paediatric developmental assessment should be

introduced urgently." Dr Arnold Elliott

agreed with the word "urgently." Some

people thought the work should be done by

paediatricians and clinical medical officers.

Developmental assessment was not being done as thoroughly throughout the country as it should, Dr J W Chisholm said. The work

belonged in the province of GPs but it was new work and not currently an integral part of general medical services. So new money had to be provided on an item-of-service

basis. But Dr J C Oakley (Kent) disliked the

principle of fragmentation; he thought looking after a child was part of general

medical services. The GMSC chairman said that because some GPs did not do the work the DHSS appointed other doctors. It was a

job for general practice; it required special

expertise and should be paid for.

EEC directives on postgraduate

training for general practice should not be

any less demanding than those of vocational

training regulations in the United Kingdom.

Proposing this motion, which was carried, Dr R B L Ridge (Enfield and Haringey) congratulated Dr Alan Rowe, chairman of the

Committee on the EEC, for his work. The

draft directives referred to two years' vocational training, which compared with

three years in this country. Dr Alan Rowe

explained that nine countries had to agree on

minimum standards?some had no vocational

training, some had four years. A compromise had not yet been reached. The Advisory Committee on Medical Training had recom

mended that the EEC Commission should act on one of the directives that already existed

?namely, that the host country should

require the migrant to carry out the training of the host country, taking into account the amount of training the doctor had done in his own country. The Commission had dis

regarded this and jumped ahead saying the directive should be based on two years.

Nevertheless, Dr Rowe emphasised that the matter was still at the consultative stage and he

supported the motion.

Practice attachment of supporting staff was preferable to geographical zoning.

This is GMSC policy and the conference endorsed it. For financial reasons some

administrators were agitating for a return to

zoning, Dr R W Smith (Redbridge and Waltham Forest) said. In Barnsley, Dr W Ashmore told the meeting, some doctors had to contact up to 10 nurses and health visitors

which meant there was not the same rapport as with the attached nurse. Dr A A Clark

(Scottish GMSC) pointed out that it had taken a long time to achieve the attachment of district nurses, health visitors, and, sometimes, social workers. Only by the proper use of such

members of primary health care teams could modern general practice be achieved.

A4 record folders should be available to GPs who want to use them. Proposing this

motion, which was carried, Dr J Ivory (Northumberland) said that at present the folders were available on request. Dr J C

Oakley (Kent) opposed the idea. All GPs

might be forced to change, which would be a

contradiction of 1974 policy. But, supporting the proposal, Dr D J Hudson (Cornwall and Isles of Scilly) referred to a recent RCGP

report which had suggested that all records would be computerised in the next decade. It

had, however, taken 30 years to persuade the Government to change the present archaic

system. Computerisation was a red herring: it would take 90 years to introduce computers into general practice.

Development of commercial organisa tions which advertise private medical services

was condemned. The proposer, Dr D Lynch (Ealing, Hammersmith and Hounslow), said that he was aware of the possible implications on other organisations such as pregnancy

testing services but he wanted the advertising habits checked. The words "without the constraint of the General Medical Council"

were removed after Dr J S Happel had pointed out that all registered practitioners came under the GMC's surveillance. Anyone could make a

complaint to the GMC but it had to be

supported by evidence and a statutory declara tion. Medicover was not mentioned in the

motion but Dr M H Stuart (Essex) referred to

it and said that if people thought they were

getting a raw deal from the NHS and wished to pay for care they should be free to do so.

Rather than being protective, GPs should make sure they were providing a good service, and

he opposed the motion.



from the lmc conference

Documents