188 
MAJORITY REPORT. 
439. The theory that competition for patients is sufficient by 
itself to secure a satisfactory service, clearly does not apply in 
those areas in which there is, in fact, no freedom of choice, and 
where, therefore, no competition exists. In many rural and semi- 
rural areas the geographical distribution of doctors is such that 
insured people have no real choice, while at the other end of the 
scale there are congested urban areas in which the number of 
available doctors is so limited that they want no more patients than 
they have already. But even in the areas in which there is a 
real freedom of choice, we see no sufficient grounds for assuming 
that the right of transfer would be by itself a sufficient protection 
to the patient. Before the Act came into operation there was 
unlimited freedom of choice in urban areas, but it can hardly 
be contended that the resulting competition produced a satis- 
factory level of service in the poorer areas, which had become 
accustomed to a low standard of professional work. 
440. Apart from the special difficulty of the rural areas and 
the more congested and less attractive urban areas, we are not 
convinced that it is fair to assume, as a general proposition, thas 
patients who feel dissatisfied with their treatment will seek 
another doctor. We agree that a wise doctor will not seek to 
retain a patient who has lost faith in him, but it does not follow 
that a transfer is always made either pleasant or easy. In any 
case, the inertia of a large proportion of the insured population 
will operate to prevent persons from making a change, though 
they may have legitimate grounds for dissatisfaction. Hven 
with free choice, the percentage of changes at any time is, 
relatively, small, and it would be too large an assumption to 
suppose that among the vast majority who do not change there 
are none who have good reason for wishing to do so. 
441. Even were the insured person in a better position than 
we believe him to be for securing the efficient discharge of his 
insurance practitioner's duties towards him, we consider that 
to place upon him, in effect, the entire responsibility in this 
matter, would be fundamentally inconsistent with the whole 
scheme of medical benefit, under which the Insurance Com- 
mittee is primarily responsible for securing efficiency of the 
medical service within its area, subject to the general respon- 
sibility of the Minister. We find nothing in the Act to justify 
excluding from the questions of efficiency of the service for which 
the Insurance Committee and the Minister are responsible 
questions of the kind which the British Medical Association 
desire to have excluded. If, therefore, such proposals were to 
be brought into operation, this could only be done, as it appears 
to us, through amending legislation which would be so incon- 
sistent with accepted principles of public administration and 
Parliamentary responsibility that we cannot recommend imita- 
tion.