Dr. J.H. Struthers surveys the medical position in Britain and South Afric

Struthers, J.H.

English

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946 S.A. MEDICAL JOURNAL 29 September 1956painful and incapacitating but relief is dramatic if theflexor retinaculum is sectioned.SUMMARYA short review is given of compression of the mediannerve in the carpal tunnel or the so-called carpal-tunnelsyndrome.Two cases of the syndrome are reported and brieflydiscussed.We wish to thank Dr. H. H. D. van Schalkwyk, of Bethlehem,for performing the operation on Case 1.REFERENCES1. Highet, W. B. (1943): Lancet, 1, 227.2. Zachary, R. B. (1945): Surg. Gynec. Obstet., 81, 213.3. Abbott, L. C. and Saunders, J. B. de C. M. (1933): Ibid.,57, 507.4. Cannon, B. W. and Love. J. G. (1946): Surgery, 20, 210.5. Kremer, M., Gilliatt, R. W., Golcting, J. S. R. and Wilson,T. G. (1953): Lancet, 2, 590.6. Wilson, J. . (1954): J. Bone Jt. Surg., 36A, 127.7. Grokoest, A. W. and Demanini, A. W. (1954): J. Amer.Med. Assoc., 155, 635.8. Bailey, D. and Carter, J. F. B. (1955): Lancet, 1, 530.9. Bunnell, S. in discussion on Phalen, G. S., loc. cif." .10. Kellgren, J. H., Ball, J. and Luttori, G. K. (1952): Quart. J.Med., 84, 405.1 t. Michaelis, L S. (1950): Proc. Roy. Soc. Med., 43,414.12. Phalen, G. S. (1951): J. Amer. Med. Assoc., 145, 1128.13. Meadoff, . (1949): . California Med., 70, 252.14. Brain, W. R., Wright, A. D. and Wilkinson, M. (1947):Lancet, 1, 277.IS. Mayer, J. A. and Barry, D. M. (1954): New Engl. J. Med.,251,255.16. Denny-Brown, D. and Brenner, C. (1944): Arch. reurol.Psychiat., 52, 1.17. Fisher, M. (1954): Can. Med. Assoc. J., 71, 121.]8. Gilliatt, R. W. and Wilson, J. G. (1953): Lancet, 2, 595.19. Paine, K. W. E. (1955): Ibid., 1, 654:IMPRESSIONS OF A PRESIDENTIAL YEARDR. J. H. STRUTHERS SURVEYS THE MEDICAL POSITION IN BRITAIN A ID SOUTH AFRICADR. J. H. STRUTHERS,Presidenf Medical Association of Soufh AfricaThe period of my office as President of our Association will beterminating early in October. It would be difficult and would takequite a time to review the many important problems and policies{hat have been examined and ctiscussed during the year. However,as I have been fortunate enough to make an overseas trip duringmy presidential year, I thought I would confine myself to givingyou some impressions which I gained concerning the NationalHealth Service in Britain and also mention one or two of the moreimportant matters which have engaged our attention here.The first and most important event of the Presidential Yearwas the Medical Congress which was held in Pretoria in October1955. This was rightly assessed as a most successful congress.The scientific meetings were very well attended and the stimulus{If our overseas visitors and speakers helped towards a most-stimulating academic week. The very large number of papers:read made it somewhat ctifficult for individuals to choose whichto attend and the interest displayed borh locally and from all{lver the Union, was most gratifying.The Pretoria Branch and especially the Organizing Committee,did a real job of work for the Association and to them we aremost grateful.Since the Congress, I have had a number of invitations to attendBranch functions and I very much regret that I have not beenable to accept these invitations as frequently as I would haveliked. I think that the suggestion that the President should visitthe Branches during his term of office is very sound, and I wasdisappointed that my trip overseas this year made this impossible.During my stay in Britain, I had an opportunity of meetingmembers of the Council of the British Medical Association,including the newly-elected Chairman of the Council, Dr. S. Wand;who had been a fellow student with me 35 years ago; of attendingmeetings of the Representative Body which discusses the problems{If the profession, and finally de~ennines the British MedicalAssociation policy; of meeting numerous medical colleagues andfriends, as wel! as attending the B.M.A. Congress at Brightonas the South African representative.The Congress was well organized; it had its highlights, and thehospitality \ve received both in Brighton and elst'Where was mostgenerous and delightful.From a perusal of the publications of the B.M.A. and fromlistening to the debates of -the Representative Body, I felt thatthe Medical Profession was much more inclined to give a lead onmedical matters in relation to public policy. Joint Committeesare set up to discuss public policies and problems such as theone appointed annual1y by the Councils of the B.M.A. and theMagistrates Association to consider matters of common interestespecially cruelty to and neglect of children.I felt the ctiscussions and debates were more alrruistic and lessinclined to be restricted to purely professional interests. Althoughmedical men were encouraged to give a lead in the communitylife, the profession was no more inclined than we are, to permitsuch activities to become a possible source of advertizing for thedoctor and this was most jealously guarded.'ATtONAL HEALTH SCHEME'The National Health Scheme has been in existence in Britain forthe past 8 years, and I was most anxious to fonn some estimateof its success. The Medical Secretary of the B.M.A. said hecould give no estimate as to whether the profession as a wholeapproved it. It certainly has lors of supporters, both in and outof the profession, but it also has its critics.Amongst the public, the young married people, especially withfamilies, seemed to consider it was excellent. Their doctor gavethem a good service and to have no financial worries in illnessand in producing babies and in rearing children, was a Godsend.On the other hand, some of the older people, especially those ofthe middle class, were very much less enthusiastic. Apparently aconsultation with a specialist meant a visit to the Out-Patientdepartment of the hospital, not to the specialist's consultingrooms, which was what they had been accustomed to.If the general practitioner could justify a consultation with thespecialist at the patient's house, this was more satisfactory as thepatient was happier and the specialist got a fee from the HealthService of £4 4s. Od. If hospitalization was advised, then there wasusually a long wait for a bed which, however, could be obviatedby the patient becoming a private patient and so paying for theaccommodation and the Ireatment.It is interesting to note that the British United ProvidentAssociation, under the Presidency of the Right HonourableViscount Nuffield was formed by the amalgamation of a numberof Provident Associations in 1947. It is a non-profit associationto shield subscribers against specialist treatment and hospitalS.A. TYDSKRIF VIR GE.TEESKUNDE29 September 1956and nursing-home costs. Benefits paid in 1950 amounted to£86,000. In 1954 they amounted to £800,000 and now they areover £1,000,000 annually. This does suggest that a considerablenumber of people consider some provisions of the Health ServiceScheme are inadequate.As regards the medical profession, it would appear that estab-lished general practitioners are probably reasonably satisfiedfinancially and assistants are often available to them without itbeing a crippling expense. Consultants have been appointedoften to combined posts in the smaller urban and more ruralhospitals which has been of help to both patient and doctor inthese areas.There was a tendency for doctors in assessing practices, tocount heads. The loss of a dissatisfied patient was only a loss of£1 per annum-a comforting thought. However, many disad-vantages were apparent. The mobility of the general practitionerseemed to have disappeared. Once in a practice, there seemed nomeans of moving. The chance of up-grading oneself by trans-ferring from a strenuous working class area to a more pleasantresidential town, perhaps after many years of practice, just did notexist.Also, no doctor could expect his son to succeed him in hispractice unless he had got permission to take him in as a partnerwhilst he himself was still fit and well.PR....CTtCES COl'-'TROLLEDAll practices are controlled by local committees which includesenior general practitioners. There might be 150 or more applicantsfor a vacant practice, and in one case discussed, this numberincluded 37 applicants with higher degrees.However, as generaL practice is sometimes considered a specialityof its own, a man with a higher degree and some years as a registrarwas often not shortlisted, as he might not be considered trainedfor general practitioner work.The problems for the young doctor were very great and itseemed that his best chance was to find some principal whom hecould persuade was overworked, required a partner, and wouldinvite him into partnership. Otherwise you had to be extremelylucky to get in.Other disadvantages were that there were no advantages or'merit awards' to the general practitioner, no matter what he didto increase efficiency or gain experience. The newly startingdoctor gets the same in every particular as the most highly qualifiedand experienced general practitioner. Also, the provision of ex-cellent clinic and consulting accommodation was merely anadditional expense on the doctor which almost resulted in apremium on inefficiency.As far as specialists were concerned, the established consultantwith a senior hospital appointment seemed satisfied. Privatepractice could still satisfactorily augment hospital part-timesalaries and registrars diminished the stress of hospital routine.Further, the knowledge that medical investigation and treatmentwas available to everybody through the National Health Servicewas very satisfying. .There are roughly 20,000 general practitioners in the BritiShHealth Service. The specialists and consultants in the Service allhold paid posts on one or other of the hospitals. There are 3,000senior registrars who are fully trained specialists, many of whomhave been acting as consultants for 3 or 4 years or more, whocannot get promotion to hospital pests, as these are limited andfilled, and who therefore have to exist on a salary of little morethan £ I,000 per annum.In England, to practice as a specialist or consultant in theHealth Service, a doctor must hold a hospital post in his speciality-these are limited in number and all are filled save for normalwastage.The effect of this on South Africa is interesting. ConsultantHeads of Departments in the British Hospitals are loath to appointregistrars from Britain unless they find they can guarantee aconsultant hospital post at the end of the specialist training.The hospitals, however, still require an adequate complementof Registrars and so a South African or any other overseas candi-date with a higher degree stands quite a good chance of gettingsuch a post, providing they are ultimately returning to SouthAfrica or their own country to practice.947QUESTlO.' OF OVER PRODUCTIONThis now links up with a problem which has concerned both theprofession and the Federal Council of our Association and thatis the question of over-production both of doctors and specialists.'ew medical schools have been established without perhaps,very much reference to or investigation of, the requirements ofSouth Africa as far as doctors are concerned, and there is a grow-ing feeling that already, at any rate in the economic field as thingsnow stand, saturation poim may have been reached.Regarding specialists, South African hospitals are now traininga large quota of specialists and if to these are added an increasingnumber of doctors who can fulfil the specialist register require-ments with overseas appointments. it may be that serious practicaland economical problems are going to arise from the po sib!eover-production of specialists. This is also a problem which isworthy of consideration and perhaps investigation by the pro-fession.One very important subject that has been discussed by theprofession in the branches and in the Federal Council during thisyear, has been Insurance against sickness, and in April this year,Federal Council accepted the report of its Sub-committee on theEconomics of Medical Practice and decided it would sponsor sucha plan.Sickness insurance has existed in South Africa for a very longtime in two main fonns:(a) Benefit Societies which provided a service on a salaryor a per capita payment basis and which in consequencegives a limited choice of doctor or no choice, to thepatient, but makes no further financial demand on thepatient beyond his monthly contributions;(b) Medical Aid Societies which pay the doctor on a perservice basis, gives an entirely free choice of doctor tothe patient, as in private practice, but may imposecertain controls upon the patient and or the doctor.The Medical AssociatIOn completely supports the free choice ofdoctor principle and has, for the past 10 years, encouraged andfostered the medical aid plans as providing a better service and abetter doctor/patiem relationship.This second plan pre-supposes the creation of a completeschedule of fees. Ten years ago, when a schedule was drawn up,the profession agreed to a preferential tariff somewhat belowprivate fees, because they wished to encourage lower-paid workersto insure against sickness. During the last 10 years, two importantchanges have occurred:I. The cost of living has doubled but the tariff has been up-graded very little and then only in the face of great oppositionfrom the Association of Medical Aid Societies.2. The range of membership of these societies has so increasedas to now include the majority of those who were, 10 years ago,the nortDal private patient.DOCTORS' FEESIt would thus appear that what is required today, is not so muchinsurance for the lower and lower-middle income groups atreduced fees, but adequate comprehensive insurance againstsickness for the whole population as far as they wish, at adequate'per service' fees for the doctor, which shall bear proper relation-ship to standard private medical fees.It will be for Federal Council, with wisdom and foresight, totry and convert this into practical application.I would stress that a complete schedule of fees is essential tosuch a scheme and to assess the fees of each speciality i;\ properand reasonable relationship to each other is of first importanceand our ability to do this may very well become the indicationof oUl unity as a profession. I believe that unity in the profe ionmakes for strength.I would like now to thank all the members of the Associationfor the splendid support they have given during this year. Especi-ally would I like to mention the Medical Secretary, Dr. Tonkin.who has always been so helpful and my partner, Dr. KelseyLoveday, who made my overseas trip possible. And in expres ingto you all my thanks, I would like to wish the Medical Associationof South Africa a continuing programme of fruitful achievement.

Impressions of a presidential year

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Impressions of a presidential year

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