BRITISH MEDICAL JOURNAL VOLUME 295 12 SEPTEMBER 1987 667 paid according to their skill rather than their If a lesser rate of interest in medical defence Loading subscriptions on those at risk would seniority, as at present. society subscriptions of 71% per year is applied also unjustly penalise some doctors. The only fair Finally, is it not time to introduce a system in (the increase of the 1987 rates on the 1986 rates) arrangement is for defence costs to be borne which the individual is spared the sometimes this serves to delay by only one year the time when entirely and directly by the Department of Health impossible task of proving blame in order to annual salaries fall behind subscription rates. and Social Security. This would cover only work gain some compensation for a mistake all agree I wonder what the solution is to be. Clearly one done for the NHS and unforeseen events such as occurred? Such a system is not only more just to the has to be found sooner rather than later. roadside emergencies. Private work would require public but now would seem to be cheaper to both an additional subscription by the individual. the state and the medical profession. B C SPINKS Changes to the system must be made soon to Department of Radiology, prevent considerable financial hardship among Northwick Park Hospital, PATRICIA WOODHEAD Harrow, Middx HAI 3UJ junior hospital doctors. I am sure that a mass Department of Radiology, challenge by juniors to their contractural obliga- University College Hospital, tion for defence society membership would facili- London WC1 tate this. SIR,-Your correspondence on medical defence ALAN RUBIN society subscriptions appears to be repeating Edgware, Middlesex HA8 8QB SIR,-Doubtless you will have many doctors writ- familiar questions and arguments. Each group ing about the 87% increase in the medical defence appears to consider only its own reasons for a subscription. Perhaps I may make a few construc- reduction in premium, overlooking the fact that if SIR,-Does Dr John Havard (15 August, p 399) tive criticisms. there are differential risks salaries must also match. mean that defensive medicine is uncommon be- Several doctors and lawyers have argued that the This seems to be hardly possible ifwe are to have a cause it is not encouraged by high damages in more we increase the "pot" the more we will true National Health Service. What seems to be far malpractice cases? He may be right, because there encourage potential litigants. I do wonder whether less considered, however, is a comparison with the is little evidence that defensive medicine is wide- the time has come when we should pay a reduced outside world. In other walks of life employees are spread. subscription associated with a limited liability. not asked to take out insurance to cover themselves Seventy three orthopaedic surgeons answered a Above a certain sum doctors would then be free to when working for their employer. No van driver or questionnaire on defensive medicine earlier this make their own arrangements depending on their electrician would expect to pay for this. If the Post year. It assumed that defensive medicine is seen in circumstances and specialty. By and large I think Office covers its employees, why cannot the health excessive investigation of patients, voluminous this would mean that the high income, high risk service? Instead of pursuing internecine strife we paper work, clinical conservatism, and evasive earners would have to pay a higher premium, should join forces to demand that the government action to avoid criticism and interference by third whereas those working part time, particularly in provides a proper system to compensate formedical parties. the lower risk specialties, would pay less. mishaps. In New Zealand doctors have to pay only There was no evidence, for example, that pre- Flipping through the pages in the BMJ I have £54 to cover themselves. Why not the same here? operative investigations in orthopaedic cases were been concerned to read of salaries of £32 000- excessive, and current practice seemed to agree £35 000 being paid to doctors in the medical GEORGE T WArrs with the recommendations of McKee and Scott.' defence secretariats. These rates of pay are far General Hospital, Birningham B4 6NH However, when investigating clinically low back higher than those of the vast majority of doctors pain of mechanical origin in young and middle working in the National Health Service, and I do aged patients, 84% of the surgeons routinely took wonder how they can be justified. radiographs of the lumbar spine despite evidence Several times over the past year when I have SIR,-The recently announced increase in medical from Currey et al that this is seldom required.2 admitted severely ill patients in the early hours of defence subscriptions places an unfair financial Lumbar spine radiographs then become a routine, the morning I have been concerned over the fitness burden on hospital doctors in the training grades. omission ofwhich might be regarded as negligent, to practise of the junior hospital doctors accepting The defence societies have seen fit to offer reduced and it therefore becomes imprudent to omit them; my patients. On a couple of occasions the doctor subscriptions to doctors within the first six years of this is defensive medicine but the surgeons were fell asleep on the end of the telephone and the qualification. This seems a totally arbitrary conces- not necessarily obtaining the radiographs for this switchboard had to send somebody to wake him sionary period and is not based on sound financial reason. up. Many junior doctors still seem to be working considerations when applied to junior hospital Excessive paper work has not usually been a 80-90 hours a week. People have a right to expect doctors. Surely it makes much more sense to offer feature of British surgery and this at least has not that their doctors can at least stay awake while concessionary rates to all those in training grades changed. Only 27% ofsurgeons insisted notes were treating them. I do think that the medical defence irrespective ofthe length oftime fromqualification. made every time their inpatients were seen, only societies together with the BMA bear a heavy I would further suggest that there should be only 46% always took the trouble to get "informed responsibility for allowing this state of affairs to four concessionary rates, for house officer, senior consent" before surgery, and only 18% always continue. A bland statement that medical defence house officer, registrar, and senior registrar, with "recorded informed consent" in the notes. What- cover would automatically cease after a doctor had no grade paying more than 75% of the full rate. ever the defence societies may think of all this it worked say 60 hours in one week would concen- This would also have the effect of avoiding the certainly isn't defensive medicine. trate administrative minds wonderfully; and right incongruous situation whereby juniors actually We have no information either that defensive a wrong that has bedevilled the health service from end up more out of pocket from paying defence medicine leads to avoidance ofhigh risk treatment. its inception. subscriptions than their more highly paid consult- Indeed, there is abundant evidence in every A A STEPHEN who are also more likely to receive higher rate in Linden Medical Centre, ants, operating theatre that doctors are not deterred Kettering NN15 7NX tax reliefon the subscriptions. For those of us who desperate cases from doing their best however have been qualified for more than six years and risky the procedure. It is more likely perhaps that have no means of privately supplementing our defensive medicine raises the threshold of indica- income because we are employed in academic posts tion for well tried procedures in more mundane SIR,-A few minutes with a calculator shows how the new full rate of defence subscription now complaints; increasing age leads to the reflection the current rate of increase in medical defence amounts to a full month's salary. that this is only the result of experience teaching society subscriptions could get out ofcontrol. that no operation is without its complications and The top rate of the NHS consultant salary scale H P DAvIs that patients are well advised to "earn" their Department of Haematology, is now £32 840 a year and the highest subscription Charing Cross Hospital, operation. rate for 1988 is £1080. If subscription rates con- London W6 8RF The ethical aspects of defensive medicine were tinue to rise annually by 87% (the increase of the apparently least important to the questionnaire 1988 rates on the 1987 rates) and medical salaries respondents but must be of increasing concern in increase by 10% each year (probably a generous intensive care, obstetrics, and paediatrics. The estimate) then in seven years the medical defence SIR,-Clearly increased defence society subscrip- temptation, for example, to avoid interference, society subscription will have overtaken the top tions have become an unacceptable burden on criticism, and even legal action in the care of the annual salary of a consultant (the figures being junior hospital doctors, many of whom will not be incurable and in child abuse cases will be an £86 360.47 and £63 995.87 respectively). For those able to give up such a large proportion of their increasing burden to be borne by our colleagues in like myself still employed in the NHS in a training salaries. The present system is also unfair in that these specialties. Before long it could be that only grade seven or more years after qualification then those unable or unwilling to do private practice the absolutely watertight child abuse case will be the top subscription will exceed the annual salary a are subsidising those practising privately, whose worth getting involved in. year or two earlier. damages are never shared by health authorities. Defensive medicine means different things to