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1. Boyd, E. A. D. Brit. med. J. 1962, ii, suppl. p. 197.2. Jones, I. M. ibid. 1962, i, 1540.

Some differential between the earnings of generalpractitioners and consultants may be desirable (andnecessary perhaps for Service doctors). But the case for

reducing the very wide differential that is apparent afterthe age of 50 is incontrovertible.

Methods of PaymentThere is not much agreement on methods. The pool

system has come in for a lot of criticism. But many of thearguments for a fee-for-service are illogical. Boyd 1extols the Canadian system, but his comparison is not

apposite. In Canada the doctors are more satisfiedbecause they are paid more for looking after fewer

patients. No alteration in our system here will of itselferadicate the shortage of doctors. Neither would a changeof system necessarily mean that Parliament would votemore money for it.

Again it is often suggested that an item-of-servicesystem would promote better medicine. But where is theevidence for this ? Our full-time salaried hospital officersset a very high standard indeed-and an exactly contraryview can be argued equally well.But if there are still some doubters let them consider

the predicament of our dental colleagues. What has afee-for-service done for them ? My figure shows only tooclearly how the Government has exploited the speed andindefatigability of the younger dentists and has failed toreward the skills and experience of their more seniorcolleagues.

A Better Pool

The best solution may yet be to improve the presentsystem. The pool is helpful to a Government that has tobudget for its contingencies. The capitation fee is a

useful, if rough, way of determining a practitioner’s salarywithout the disadvantages of a fully salaried service. But,as Ivor Jones 2 has clearly shown, the present pool systemcontains many anomalies-e.g., it fixes a ceiling to generalpractitioner earnings, and Peter must always be robbedif Paul is to be paid any more.

It is not difficult to see however that nearly all the faultsof the pool system would disappear if the pool were nolonger global.Without entering into details, an alternative " G.M.S.

Pool " might be administered on the following principles:1. The pool should be based on the number of patients at

risk instead of the number of doctors.

2. This number multiplied by a fair capitation fee for ageneral practitioner in average circumstances, plus an amountto cover the loading factors, would constitute a new " G.M.S.Pool ".

3. A full complement of loading factors should be enoughfully to cover all the expenses of running a good generalpractice.

4. Capitation fees should be paid to all general practitionerswithout deductions excepting only enough to cover temporaryresidents.

5. Capitation fees should cover only services necessarilyprovided under the practitioner’s contract with the executivecouncil. All other services (innoculations, midwifery, andhospital appointments) and other payments to meet specialcircumstances (e.g., mileage) should be separately paid for onan item-of-service basis or otherwise as appropriate.

6. Additional payment should be made for experience-inorder to counteract the falling income of general practitionersafter the age of 50-perhaps by an addition to the loadingfactor. 1. Lewin, W. S. Memorandum on Head Injuries Prepared for the Accident

Services Review Committee of Great Britain and Ireland. London,1961.

2. Potter, J. M. The Practical Management of Head Injuries. London, 1961.

Such a system is a logical development of the presentone. It would remove most of the anomalies of the gloMpool method. It would, for example, remove the ceilinto earnings of general practitioners. At the same tim;estimates of the probable costs of the service should no;be beyond the powers of the Exchequer: addition;money would only be required when the practitionerswere doing extra work. It would also remove the presentdisincentive to the employment of general practitionersin hospitals-and it could lead to further changes (suchas additional item-of-service payments) without conse.

quent reduction in the basic capitation fee.

Summary1. Apart from any adjustment required in net earnings,

average gross earnings of general practitioners in theNational Health Service fall short by at least E500 of theamount needed to meet the expenses of running a goodgeneral practice.

2. The differential between average net earnings of

general practitioners and of consultants and Servicedoctors is excessive, especially after the age of 50.

3. A method of payment is suggested which wouldremove most of the anomalies of the present global-poolsystem, but which retains its simplicity of administration,

Points of View

SIMPLIFIED MANAGEMENT OF

HEAD INJURIES *

JOHN M. POTTERM.A., M.B. Cantab., F.R.C.S.

CONSULTANT NEUROLOGICAL SURGEON, UNITED OXFORD HOSPITALS

* A paper read to a joint meeting of the Society of British NeurologicalSurgeons and the section of neurological surgery of the PolishSociety of Neurologists and Neurosurgeons in Warsaw onSept. 28, 1962.

THE neurosurgeon’s view of head injuries is naturalspecialised, and may appear complicated to the non-

specialist. It has been estimated from a report 1 that asmany as 90% of the cases of head injury in British hos-pitals are cared for by others than neurosurgeons. Accept-ing this figure as only a rough approximation, I should liketo make a strong plea for the simplest possible basic

approach to head-injury management at the present time.Elaborate methods, controversial and experimentalpractices, and individual whims are perhaps betterrestricted to those specialists who have them, so that thevdo not confuse non-neurosurgeons, who are already busywith the rest of their work (which comes more naturally to

them) and many of whom find head injuries difficultenough already. If neurosurgeons themselves were dealingwith most of these cases-and it is likely to be a long timebefore, if ever, they do-there would be little harm in eachpublicising his own methods.

I am far from suggesting a uniform practice-thatwould stifle any chance of progress-but there is suretneed for an agreed relatively simple and rough basis onwhich the general or orthopaedic surgeon may work,There are, it seems, differences in attitude, approach andpractice from unit to unit, and even within the same neuro.surgical department; and such differences are, one can

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3. Society of British Neurological Surgeons. Analysis of an Enquiryconcerning Acute Head Injuries. 1959.

4. Lancet, 1961, i, 384.

deduce from our British Society’s recent analysis,3 withoutmuch effect on the results obtained by each unit. If this is

so, some cherished procedures may be unimportant andunnecessary. The need for our non-neurosurgical col-leagues is surely for straightforward, practical guidance inmethods that are generally acknowledged to be effectiveand, most important, simple and appropriate to the facili-ties at their disposal. This general thesis may be illus-trated by brief reference to five methods of investigationand treatment used in head injury work.

Cerebral AngiographyMost neurosurgeons would agree that cerebral angio-

graphy is useful in head injuries, although some, includingmyself, believe that its usefulness has been exaggerated.Besides saving some unnecessary burr-holes it may lead

(especially when practised by relatively inexperiencedworkers) to unnecessary operations which may cause

added damage, particularly in the not uncommon casewhere there is contusion and swelling of a temporal lobethat may well resolve spontaneously.The important practical question here is whether we

think that every hospital admitting head injuries should beequipped with a 24-hour angiography service. I personallydo not think so, and I believe that others will agree withme; but what are the surgeons in these hospitals to thinkwhen they read in a Lancet leader 4 that " angiography isessential to the diagnosis of severe brain injury "; or, in apaper, that some patients may be lost for lack of angio-graphy and that it seems preferable to multiple burr-holes ? It is hard on a busy general surgeon or an ortho-pedic surgeon, who has accepted the need to make

diagnostic burr-holes when necessary in his cases of headinjury, to be told later that there is a better method ofinvestigation which his’hospital does not possess. It is

confusing; it does not help him; and I doubt very muchwhether it would help him or his patients to have such a24-hour angiography service.

Lumbar Puncture

Among neurosurgeons lumbar puncture in relation tohead injuries is a controversial subject, so need we worryother surgeons with it ? Having been brought up in theorthodox view that lumbar puncture was an important partof the investigation of head injuries, I now seldom practiseit and do not miss the change. I do not believe that theinformation it gives is of any practical help to the non-specialist. Moreover, there are dangers which are fearedmore by some than by others. We should, however, I amsure, emphasise how promptly lumbar puncture should beperformed whenever meningitis is suspected, but this is adifferent matter from looking for blood in the fluid ormeasuring the pressure.

HypothermiaThe use of hypothermia is another controversial matter.

After some ten years we seem to be no nearer to decidingwhether this is a valuable form of treatment or not.

Perhaps it has a small place in our armament, but if itwere an important advance in therapy I think we shouldall have noticed this by now. Controlled experiments inhead-injury treatment (where hardly any two cases arealike) are not possible, and one has to be content with therather unsatisfactory, but perhaps too much despisedclinical impression. In this connection, I would contrast

5. Marshall, J., Spalding, J. M. K. Lancet, 1953, ii, 1022.

the uncertain impression that we gain from the use ofhypothermia with the favourable view that we have oftracheostomy, the beneficial effects of which few of us candoubt after a few years of clinical use.

I do not think, therefore, that we should bother ourcolleagues with any elaborate and time-consumingmethods of hypothermia; but, again, there must be aproviso: I am not, of course, referring to the prophylacticreduction of the body-temperature to normal when thereis the threat of dangerous hyperpyrexia-an importantand a rational precaution. These two quite differentprinciples of management are still often confused..Extra JMf<2/ Hremorrhage

Sometimes neurosurgeons prefer, if there is time, toturn a bone flap when dealing with an extradural clot.But surely it is not right to encourage a general surgeon oran orthopasdic surgeon to think that this is the only properway to deal with this condition, when it is more expedi-tious and simpler for him to do a craniectomy.

TracheostomyThe life-saving hole in the windpipe seems to be in

danger of becoming ritualised; for there is much scope forelaboration here. Several types of tube have their various

advocates, and methods for humidifying the inspired airvary, from the relatively inefficient piece of wet gauzeto nebulisers and the machine of Marshall and Spalding 5which produces 100% humidification. But we do not reallyknow yet how necessary humidification is, or whetherit need be as high as 100%. And then the wearing ofrubber gloves by nurses, each time they suck out a

tracheostomy tube, has been advocated to reduce infection,but this can be quite impracticable in a busy ward withoutan unusual allocation of nurses. Until more is knownabout these details, I do not think that much stress shouldbe laid on them. Probably the most important thing isthat the operation itself should be properly and welldone.

I should like to make it clear that I am not advocatingtwo standards of management for patients with headinjuries; I am merely recognising and emphasising thattwo different types of service in fact exist in our country(and, it seems, in most other countries). The first type isthat provided by neurosurgeons, with the specialisedfacilities, such as neuroradiology, that are an integral partof their units. This service, however, is provided for onlya ’small proportion of patients with head injuries. Thesecond type of service is that of hospitals with no specialneurosurgical facilities, and my point is that, since thesedeal with most of the patients, neurosurgeons are likely tocontribute far more to the results of head-injury treatmentby aiming at an extra, an intermediate service (which manyin fact give at present). This may be achieved by helping,and by having sound liaison with those who work in thesehospitals, by keeping our advice as simple as possible, andby incessant propaganda about extradural haemorrhageand the nursing of unconscious patients. I suggestthat in this way we are likely to do more good thanif we concentrate on our own little percentage of thesecases.

"... The Imperial Tobacco Company’s preliminary profitstatement for the 12 months to October 31 makes an excellentshowing in spite of the cancer scare, which reached its peaklast year."-Times, Feb. 6, 1963, p. 16.