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and this included keeping their secrets under all circum-stances. Failure to maintain any part of this essential

setting would be malpractice of the same order as if thegeneral practitioner had advised his pneumonia patient toget out of bed with a temperature of 105° and come to the

surgery for treatment. My professional code applieswhenever I receive anyone as a patient, whether it wassomeone who had attended regularly for years, or someonewho had come only once, perhaps just to see what a

psychoanalyst looks like.To the judge’s query whether I would still object if

the patient " gave permission, I answered with an

example: suppose a patient had been in treatment forsome time and was going through a temporary phase ofadmiring and depending on me; he might therefore feelit necessary to sacrifice himself and give permission, butit might not be proper for me to act on this.

This example involves a vital principle. Some of theUnited States have a law prohibiting psychiatrists fromgiving evidence about a patient without the patient’swritten permission, but this honourable attempt to protectthe patient misses the essential point that he may not beaware of unconscious motives impelling him to givepermission. It may take months or years to understand

things said or done during analysis, and until this isachieved it would belie all our knowledge of the workingsof the unconscious mind if we treated any attitude arisingin the analytic situation as if it were part of ordinary socialinterchange. If we allow and help people to say thingswith the ultimate aim of helping them to understand thereal meanings underlying what may well be a temporaryattitude engendered by the transference, it would be thecrassest dishonour and dishonesty to permit unwarrantedadvantage to be taken of their willingness to avail them-selves of the therapeutic situation. It would be as ifa physician invited a patient to undress to be examined,and then allowed the Law to see him naked and to arresthim for exhibiting himself. Where no permission has beengiven, the rule to maintain discretion is, of course,

similarly inviolable. Patients attend us on the implicitunderstanding that anything they reveal is subject to aspecial protection. Unless we explicitly state that this isnot so, we are parties to a tacit agreement, and anybetrayal of it only dishonours us. That the agreementmay not be explicit is no excuse. Part of our work isto put into words things that are not being said. We eare the responsible parties in the relationship, so surely it iswe who should pay, if there is any price to be paid, becausesomething has not been said clearly.But should there be any price to pay ? Was I arrogating

to myself an unwarrantable freedom from the ordinaryresponsibilities of a citizen by refusing to give evidence ?Was it not rather that the attitude of responsibility towardspatients was also one of responsibility towards the Law ?The fact that in theory people having analysis " telleverything " should not give rise to the misleading ideathat we analysts are necessarily the repositories of secretsthat could help the Courts if only we would divulge them.The concern of psychoanalysis is with the ever-developingunravelling of the unconscious conflicts of our patients.We know that these can affect the patient’s perceptionsand judgements while they are operative, hence the advicesometimes given to avoid major decisions during analysis.We are not seeking the " objective reality " the Courtswant, and generally we are not in a position to give it tothem. Over the years we may hear a number of different

versions of the same event, each completely sincere, butvarying with the changing emotional focus of the analy-sand, each version being a clue to another level of uncon-scious conflict. To report on whichever is momentarily inthe ascendant could mislead a Court as, for example,a report on an applicant’s blood-pressure after a night ofvomiting could mislead an insurance company. I would

suggest that in principle there may be less conflict betweenour moral obligations to the Law and to the rules ofprofessional conduct than would appear at first sight. Ifa psychoanalyst or psychotherapist wished to offer a

patient’s description of an event as objective evidence, itwould be necessary to produce every version of the event,explaining the differences by detailing all the known

underlying meanings; with the misleading probable resultof the Court’s either accepting one version unequivocally,or discrediting therapist or patient as unreliable. Justice,as well as our ethic, is likely to be served best by silence.

X.

Special Articles

DISCUSSIONS ON GENERAL PRACTICE

THE second report on the joint discussions between theMinister of Health and representatives of general practi-tioners is issued this week.The discussions have centred on the profession’s

" charter for the family doctor service ".1 The first report,issued in June included proposals for a substantialreduction in the amount of National Insurance certifica-

tion, a direct contribution towards expenditure on ancillarystaff, and the establishment of a General Practice FinanceCorporation. The latest report deals with methods cfpayment and the basis of the new contract for serviceswhich will need to be considered by the Review Body onDoctors’ and Dentists’ Remuneration when it reviewsremuneration in the coming months. Discussions willcontinue on other matters, including details of terms ofservice and service committee procedure, superannuation,compensation for loss of right to sell practice goodwill,access to hospital diagnostic services, and dispensing.

In the latest report the Government rejects the pro-fession’s suggestion that work load should be reducedby a charge for the doctor’s services,3 because it considers" that this would deter patients who need medicalattention from seeking it". On the other hand, theGovernment has all along admitted that excessive workload should be taken into account in fixing remuneration;and it is concerned to do all that it can, short of imposinga charge for services, to reduce the load.

" This reduction, given the impossibility of a rapid increasein the number of doctors, is in the long run very largely amatter of practice organisation, with direct support of thedoctor by non-medical professional staff-especially nurses-and such organisation can best be achieved by doctors workingin groups from centralised premises with ancillary help. TheGovernment have said that it will continue to be their policyto encourage these developments. More immediately theproposed reductions in certification, for both National Insur-ance and private purposes, will significantly reduce work load,and with the same object in view the Government are mount-ing an intensive publicity campaign to educate the public in theuse of the doctor’s time. Steps are also being taken to obtain thehelp of more married women doctors in general practice."

1. See Lancet, 1965, i, 590, 594.2. ibid. pp. 1203, 1212.3. ibid. July 24, 1965, p. 165.

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In summary the proposals in the latest report are asfollows:

Modified Capitation SchemeThis would consist of the following main elements:

1. A basic practice allowance, including a separatelyidentified element in respect of holidays and study leave.

2. A capitation fee for services other than those given atnight and at weekends, the rate for elderly patients beingabout a third higher than for other patients.

3. For services at night and at weekends: (a) a standbypayment, to be paid as a supplement to the basic practiceallowance; (b) a supplementary capitation fee for patientsin excess of 1000 on the list of each doctor; and (c) a uniformfee for visits between midnight and 7 A.M.

4. Additions to the basic practice allowance for seniority,experience, and special qualifications; practice in groups;and service in unattractive areas.

5. A postgraduate training allowance on the lines of thepresent scheme.

6. Fees for certain items of service carried out in pursu-ance of public policy (e.g., cervical smears, vaccinations, andimmunisations).

7. Fees for maternity medical services.8. Temporary resident fees, and emergency treatment fees.9. Rural practice payments and dispensing fees.

10. Direct payments on account of expenditure on

ancillary staff, rent and rates, and locum or other deputynecessarily employed during the practitioner’s own sickness.

SalarySalaried contracts will be offered to selected groups of doctors

who prefer this method of payment, as soon as conditions forsalaried service can be worked out.

Payment by Fee for ServiceThe Government are not at present satisfied that this is a

feasible method of payment for the general run of the doctor’swork; but it is willing to consider further with the professionwhether mutually acceptable safeguards can be devised for alimited experiment.Method of Pricing and New PaymentsAs was explained in the first report on the discussions,2

the Government has felt that the Review Body should be askedto recommend levels of remuneration under the proposed newscheme. It agrees with the representatives of the professionthat the Review Body should be invited to price separately atleast the major items in the modified capitation system. Sincethese will be gross fees, it will be necessary to ensure that theymake proper allowance for practice expenses. It will be for theReview Body to consider how this should be done; but theGovernment and the profession’s representatives intend todiscuss together what statistical material can be supplied forthis purpose, and how it can be kept up to date. The ReviewBody will be consulted on the form and level of salariedremuneration.The proposals, says the report, involve a fundamental

recasting of the system of remuneration, and in theGovernment’s view represent a major advance in the con-ditions under which general practice is provided under theNational Health Service. Agreement on new methods ofpayment will enable the Government to agree to abolish theCentral Pool with its automatic limitation of net earnings.The profession’s representatives regret that they have

been unable to obtain from the Government that full

flexibility of payment sought in the charter." But they consider that the Government have, within the

scope of this present document, shown a willingness to meetthe other essential requirements of the contract proposed in theCharter, and that the proposals ... do introduce in a differentway a substantial element of flexibility. The profession’s repre-sentatives have no mandate to agree to certain of the Govern-ment’s proposals which are not included in the Charter, butthey do appreciate the powerful arguments in their favour."

An appendix says that the Government attaches greatimportance to financial recognition of special experienceand service to general practice.

" The Review Body have indicated their readiness to recom-mend additional money for this purpose, and have recom-mended that the profession and the Departments should try todevise an acceptable scheme. The profession’s representativesmade it clear that no such proposal appeared in the Charter andthat they had no mandate to agree. Nevertheless, the Govern-ment think that the case for such a development is so strongthat the modified capitation scheme should contain provisionfor it. Indeed, they would regard it as a necessary comple-ment to payments for seniority, which the profession havefavoured in the past. They accordingly propose that furtheradditions for special experience and service to general practicewill be paid to selected doctors over the age of 45.... Selectionwill be in a manner and on the basis of criteria to be agreedbetween the profession and the Health Ministers. Additionsof this kind will not normally be paid to a doctor beyond theage of 65. It is contemplated that payments should be made toabout 30% of those eligible. There will be two levels of pay-ment and the Review Body will be asked to determine a fixednumber of payments at each level. The payment will include a

very limited number at the higher level, which will be sub-stantially above the lower."

Use of the Doctor’s ServicesIn order to reduce unnecessary demands on doctors’ time in

the coming winter, the Minister of Health will launch a

national campaign to educate the public in making the best useof their family doctors. He will make a general appeal with thehelp of the Press and television. Short films to illustrate waysin which patients can help their doctors will be televised, and apostmark slogan will be used during the winter.A leaflet Helping Your Doctor has been prepared. In it,

patients needing a visit are asked to send for the doctor beforehe starts his rounds, and to explain why the visit is needed.They are asked not to call him if they can attend his surgery,or ask him for household remedies, or arrive late, or sendunaccompanied children to see him. The leaflet points outthat it is for the doctor and not the patient to decide whether avisit is necessary. It distinguishes clearly between emergenciesfor which doctors must be prepared at all times, and routinework which they are entitled to fit into reasonable hours.

Conferences

ASSOCIATION OF CLINICAL PATHOLOGISTSAT the 75th general meeting of the Association of

Clinical Pathologists at Imperial College, London, onSept. 30 and Oct. 1-2, the proceedings included a sym-posium on sterilisation and disinfection in hospitals, towhich we refer in an annotation on p. 780. We publishbelow summaries of a few of the many other contributions.

Iron Deficiency and MenstruationDr. A. JACOBS said that menstrual blood loss was a major

factor in producing negative iron balance in otherwise normalwomen. A loss of 40 ml. of blood per month was equivalent toa loss of 0-6 mg. of iron daily, in addition to a constant loss fromdesquamating epithelial surfaces of up to 1 mg. The averageamount of iron in the diet was about 14 mg. per day, of whichabout 10°o was retained in the body. About a third of

apparently normal women had a menstrual loss of morethan 40 ml. Unless their dietary intake of iron was aboveaverage they were likely to develop a state of negative balance.Women with iron deficiency anaemia would tend to have a greatermenstrual blood loss than others. In the series described themean normal loss was 34-7 ml., and the mean loss in anaemicpatients was 85-5 ml. After the anxmic patients had been fullytreated with iron and were hmmatologically normal some of