- Email: [email protected]
HOSPITAL DOCTORS
769 blemish in technique, she will achieve new diagnostic stature. The physicians have now heard of her. They rather disapprove of the whole business. Unscientific or something.... ’*’
’*’
Letters
’*’
SIR, Your
Most of the criticism of the new translation of the Bible has been directed at changes in language where changes were not essential. When the eminent and to some extent anonymous scholars tackle the Old Testament I hope they will not tamper with Proverbs, XXXI, 5-6, for it has served me as a valuable " second opinion ". Old Mrs. McCue was confined to bed and her progress was slow. Since more orthodox therapy was not producing very rapid results, I thought that a peg of whisky might be advantageous. My suggestion was greeted with horror, and she was adamant in her refusal. The " Good Book " expressly forbade the ingestion of strong drink, and, as she put it, she " had never lipped it ". Like so many of the older generation of Glenroy, she had a Bible on the top of her bedside table. When I asked her if she would accept the authority of the Bible for the use of alcohol in illness she agreed, but she said she knew it didn’t. It did not take a moment to turn up the Book of Proverbs where I read to her:
Evidence for the Royal Commission and the Platt report collected in 1957-58, and at that time the Medical Practitioners’ Union submitted evidence to both these bodies which included a detailed working out of a salary structure for the consultant grade, with extensions downwards to enable a compromise to be reached and time-expired senior registrars to be found a place as junior consultants. In 1961 the Platt working party has rejected this proposal, and I feel that this necessarily follows from the nature of the compromise which this report represents. The views of the professional side on the Joint Consultants Committee should now have been met by the recommendation to review the staff position in all hospital regions, and to put forward proposals for additional consultant appointments to meet the needs of hospitals which are understaffed. Alongside this development for the consultant grade, a new subconsultant grade is to be introduced to meet the wishes of the Ministry who have been anxious to provide a more stable staff structure for regional-board hospitals where the training of senior registrars is not carried out and where insufficient junior staff are available. This new medical assistant grade will enable registrars, who are moving from one two-year post to another, to find a suitable niche, and will enable junior hospital medical officers who have no prospects within the existing structure to seek promotion in the hospital service. These are some of the reasons why every effort should be made to see the implementation of this report without delay. The reorganisation of the consultant grade, with the issue of new contracts where required, will also greatly help certain hospitals.
It worked. She improved; she got on her feet; and I soon able to stop visiting her. However, about a year later I met her son-in-law who complained bitterly that it was costing him a fortune for whisky.
was
’*’
I was washing my hands under the tap in the farmhouse kitchen, a process which sends a fine spray of water down the front of the coat, when the supply was suddenly cut off. " Oh, has it gone off ? " said the farmer’s wife. " That’ll be the cows drinking." By this she meant that a drinking trough up the field, fitted with a ball-tap, took the rising main before the farmhouse; but the incident was symbolic. On a dairy farm the cows come first. I was reminded of a morning when an agitated farmer met me in the stackyard and said, with staggering frankness, You
It
likely that the increase in consultant appointfollowing the review of staff in all areas will absorb many of the time-expired senior registrars. It is also a fact that we are now facing an increased rate of retirement in the consultant grade during the next five years. Taken together these circumstances may lead to a shortage of consultants for available vacancies in some specialties. It is important that all these facts should be made available and published so that senior-registrar posts can be adjusted and young doctors can be encouraged to enter the hospital service to meet its needs.
go on up, doctor. You know where to find the wife. It’ll be her
usual trouble, I’m thinking. Right now I’m more worried about one of the cows. Can’t get her on her feet no how. I’m just waiting here of the vet coming." ’*’
’*’
SUBVERSION AND THE CELL
Carbon (C) and Hydrogen and Nitrogen and 0 Are four among the cleverest of the elements I know: Four quite different valencies and four atomic weights Distinguish C from Oxygen and Nitrogen from H. Distinctive individuals, like four ambitious men, Are Hydrogen and Oxygen and Carbon (C) and NAnd Hydrogen and Nitrogen and Oxygen and C Once set aside their differences and the end-result was But Nature is not simple nor her policies naive, The tricks that she gets up to one might sometimes
seems
ments
"
’*’
HOSPITAL DOCTORS leader of March 25 is a useful stimulus to
was
no more.
’*’
the Editor
discussion on the report of the Platt working party. Your reference to the possible extension downwards of the consultant grade to absorb senior registrars is an idea which had considerable support in the past.
Give strong drink unto him that is ready to perish, and wine unto those that be of heavy hearts. Let him drink, and forget his poverty, and remember his misery
’*’
to
.
me.
scarce
believe; As soon as we’ve deciphered them she blasts our modest hopes And multiplies our problems by producing isotopes. Yet even this were bearable if H, like C and 0, Were constant and reliable; but not with Nature, no. Alas, that H should masquerade as D and even T When simple N and 0 and C are always N, 0, C !1 For now mistrust is everywhere-cabals and factions growIf N combines with Hydrogen then C allies with 0. Team-spirit is a virtue, but the learned all agree That harm as well as benefit results from NHg. And though one must be grateful, all in all, for CO2 One rightly feels repugnance for the ill CO can do. It’s tempting to imagine that some cells must yearn for troops To quell the wilder radicals and reactionary groups.
It is a matter for regret that it is more than ten years since these problems were first posed, and it is only now that we have before us a workable compromise. The intervening period has been marked by much personal frustration and suffering by a generation of doctors who, having seen military service in the late war, were brought home to believe that a place would be found for them in the new hospital service. The consequences to the whole medical profession have been very serious. Undoubtedly a measure of the blame for these blows must be laid at the door of the responsible authority-the Government. However, since only the profession stood to lose by these delays, it seems to be not unreasonable to suppose that the methods whereby we select our negotiators might be at fault. The very distinguished men at the head of our affairs are not appointed to the presidencies of colleges because of their ability to strike a hard bargain on our behalf. It is doubtful whether they have the necessary ability to negotiate with the highly subtle trained minds who represent the Ministry on these occasions. The need to select and train our own negotiators is a matter of
770
importance. A general overhaul of the negotiating machinery is urgently necessary.
urgent
P. WATNEY ROE.
Bushey, Herts.
SiR,—Your leader of March 25 sees the answer to outpatient waiting-lists in the creation of, in effect, utility appointments-i.e., clinical consultants with limited beds. You make no reference to the fact that we have already many consultants in peripheral hospitals with several years’ experience of such practice. Learning to live with a chronic bed shortage necessitates a complete reorientation to medical and sometimes human values. In this readjustment we may derive benefit from our more objective viewpoint, but this is small consolation compared with the daily problems of bed shortage. Surely there can be no argument that a balance must be struck between inpatient and outpatient work, both in the interests of patient and doctor, and that in many hospitals this balance is top heavy. Such new appointments as you suggest
boards and their advisers will continue to be influenced, in their decisions on new appointments, by many factors of doubtful national significance. 3. The wide scale envisaged for medical assistants win have to take into consideration the close working and social relationships, and the personal equality, of men who may be junior in status to their colleagues but senior in age. Past experience of the financial affairs of those whose status does not allow them to exercise pressure does not encourage
but accentuate this trouble. In certain medical and administrative circles it may be " important to dispel the prevalent respect for number of beds as the clinical consultant’s status symbol ", but this is hardly evidence in support of your views. In the periphery, consultants view hospital beds not as " status symbols " but as
can
a
confidence.
There still remains the need for a solution for those, like myself, who have been left behind in what the working party agrees to be a disadvantageous position in the battle for promotion as against teaching-hospital trainees. If current rumour is accurate it would also appear that those who chose to leave the " training ladder " for S.H.M.O. positions are likely, on present views, to be much better placed. It will not help us that our position will not recur. Unless this consequence of the confused past is cleared up, the profession is going to be left for years with an unhappy group of men, whose persistence in a miserable situation and whose regular reappointment seems to have demon. strated both the will and the ability to become independent members of a hospital staff. TIME-EXPIRED SENIOR REGISTRAR II.
necessity for practice. E. P. MORLEY.
Lincoln.
SiR.—Your editorial of March 25 on the Platt report must have heartened many a time-expired senior registrar whose confidence had been shattered by the apparent indifference of this working party to our plight. This indifference may, we fear, be shared by far too many members of the Joint Consultants Committee, a group which it appears the Minister will consult when considering additional consultant appointments and a group which has hitherto done very little to promote additional consultant posts. We have not undergone this long period of training and waiting to find ourselves left at the top of an extremely amorphous mass of " medical assistants ". If this is allowed to happen, it will involve far more exploitation of highly trained skills than was ever achieved by the misuse of the senior hospital medical officer grade. We hope your editorial will stimulate the Minister of Health to find a quick and sensible way of using our skills and ability not only in our chosen profession but also in our chosen specialties. TIME-EXPIRED SENIOR REGISTRAR I.
SIR,-The findings of the Platt working-party are basically acceptable though by no means new. The new grade of medical assistants proposed by the working party must not develop into another s.H.M.o. But if this is to be
complex.
a
number of
problems
remain
to
be solved
prevented:
1. A clear delineation of the " special class " of work suitable for such a grade will be needed. It may be noted that no such class of work was definable for senior registrars. 2 With this goes the assessment of the number of new consultants needed. For such an assessment a specification of consultant responsibility will be required more precise than "
absolute charge of patients " and more comprehensive than visiting two or three times a week ". As soon as a consultant has more beds than he can properly care for, delegation of authority becomes a formality. (I have had simultaneously the experience of signing all the letters of one chief because of his absence and having mine signed by another chief to show his ultimate responsibility.) Without a precise numerical guide, "
BRONCHITIS AND THE MINISTRY OF LABOUR SIR,-In his letter of March 25 Dr. MacLean, principal medical officer of Remploy Ltd., complains that your annotation of Jan. 21 might suggest that in this country very little sheltered work is provided for those with chronic bronchitis. He states that " at the moment about 350 of those disabled by chronic bronchitis and emphysema are employed in Remploy factories ". In the House of Lords on March 14 the Earl of Dundee, in reply to Lord Taylor, stated that there were 43,404 men and women classified as being disabled on account of bronchitis, bronchiectasis, and emphysema. Of these 5500 were registered as unemployed, but no information is available as to how many of the balance were in employment, nor how many were in receipt of sickness benefit". To a further question from Lord Taylor, the Earl of Dundee replied: Altogether, some 82,000 persons were receiving sickness benefit for bronchitis of some kind on May 30, 1959, the latest date for which figures are available, and at this time of the year the number may be "
"
higher." These figures may give some idea of the size of the problem. For those 350 bronchitics referred to by Dr. MacLean Remploy provides a satisfactory solution to their employment, difficulties. It must be obvious, however, that this small number represents only a fraction of those needing help. In a recent survey on the unemployment problems associated with chronic bronchitis 1 we showed that only 1 in 6 of moderately severe bronchitics were registered as disabled with the Ministry of Labour. Furthermore, of 58 bronchitics who were not registered as disabled 18 were considered by their doctors to require sheltered work. The main reason for failure to register was reluctance on the part of the doctor who, from previous experience, regarded it as a waste of time to refer the disabled bronchitic. The Earl of Dundee, again in replyto Lord Taylor, on March 15 stated: "Very large numbers of bronchitics do not register, either because their medical practitioners do not advise them to do it-they do not think it would be worth while-or maybe, because they think itis not much use registering since the opportunities of emplocment are not great enough." The unemployment problem of those disabled by bronchc has been hidden for too long in the sickness benefit figures o the Ministry of Pensions and National Insurance. ManyJ: .
.
1.
Caplin, M., Silver,
C. P. Brit. J. Dis.
Chest, 1960, 54, 297.
’*’
Letters
’*’
SIR, Your
Most of the criticism of the new translation of the Bible has been directed at changes in language where changes were not essential. When the eminent and to some extent anonymous scholars tackle the Old Testament I hope they will not tamper with Proverbs, XXXI, 5-6, for it has served me as a valuable " second opinion ". Old Mrs. McCue was confined to bed and her progress was slow. Since more orthodox therapy was not producing very rapid results, I thought that a peg of whisky might be advantageous. My suggestion was greeted with horror, and she was adamant in her refusal. The " Good Book " expressly forbade the ingestion of strong drink, and, as she put it, she " had never lipped it ". Like so many of the older generation of Glenroy, she had a Bible on the top of her bedside table. When I asked her if she would accept the authority of the Bible for the use of alcohol in illness she agreed, but she said she knew it didn’t. It did not take a moment to turn up the Book of Proverbs where I read to her:
Evidence for the Royal Commission and the Platt report collected in 1957-58, and at that time the Medical Practitioners’ Union submitted evidence to both these bodies which included a detailed working out of a salary structure for the consultant grade, with extensions downwards to enable a compromise to be reached and time-expired senior registrars to be found a place as junior consultants. In 1961 the Platt working party has rejected this proposal, and I feel that this necessarily follows from the nature of the compromise which this report represents. The views of the professional side on the Joint Consultants Committee should now have been met by the recommendation to review the staff position in all hospital regions, and to put forward proposals for additional consultant appointments to meet the needs of hospitals which are understaffed. Alongside this development for the consultant grade, a new subconsultant grade is to be introduced to meet the wishes of the Ministry who have been anxious to provide a more stable staff structure for regional-board hospitals where the training of senior registrars is not carried out and where insufficient junior staff are available. This new medical assistant grade will enable registrars, who are moving from one two-year post to another, to find a suitable niche, and will enable junior hospital medical officers who have no prospects within the existing structure to seek promotion in the hospital service. These are some of the reasons why every effort should be made to see the implementation of this report without delay. The reorganisation of the consultant grade, with the issue of new contracts where required, will also greatly help certain hospitals.
It worked. She improved; she got on her feet; and I soon able to stop visiting her. However, about a year later I met her son-in-law who complained bitterly that it was costing him a fortune for whisky.
was
’*’
I was washing my hands under the tap in the farmhouse kitchen, a process which sends a fine spray of water down the front of the coat, when the supply was suddenly cut off. " Oh, has it gone off ? " said the farmer’s wife. " That’ll be the cows drinking." By this she meant that a drinking trough up the field, fitted with a ball-tap, took the rising main before the farmhouse; but the incident was symbolic. On a dairy farm the cows come first. I was reminded of a morning when an agitated farmer met me in the stackyard and said, with staggering frankness, You
It
likely that the increase in consultant appointfollowing the review of staff in all areas will absorb many of the time-expired senior registrars. It is also a fact that we are now facing an increased rate of retirement in the consultant grade during the next five years. Taken together these circumstances may lead to a shortage of consultants for available vacancies in some specialties. It is important that all these facts should be made available and published so that senior-registrar posts can be adjusted and young doctors can be encouraged to enter the hospital service to meet its needs.
go on up, doctor. You know where to find the wife. It’ll be her
usual trouble, I’m thinking. Right now I’m more worried about one of the cows. Can’t get her on her feet no how. I’m just waiting here of the vet coming." ’*’
’*’
SUBVERSION AND THE CELL
Carbon (C) and Hydrogen and Nitrogen and 0 Are four among the cleverest of the elements I know: Four quite different valencies and four atomic weights Distinguish C from Oxygen and Nitrogen from H. Distinctive individuals, like four ambitious men, Are Hydrogen and Oxygen and Carbon (C) and NAnd Hydrogen and Nitrogen and Oxygen and C Once set aside their differences and the end-result was But Nature is not simple nor her policies naive, The tricks that she gets up to one might sometimes
seems
ments
"
’*’
HOSPITAL DOCTORS leader of March 25 is a useful stimulus to
was
no more.
’*’
the Editor
discussion on the report of the Platt working party. Your reference to the possible extension downwards of the consultant grade to absorb senior registrars is an idea which had considerable support in the past.
Give strong drink unto him that is ready to perish, and wine unto those that be of heavy hearts. Let him drink, and forget his poverty, and remember his misery
’*’
to
.
me.
scarce
believe; As soon as we’ve deciphered them she blasts our modest hopes And multiplies our problems by producing isotopes. Yet even this were bearable if H, like C and 0, Were constant and reliable; but not with Nature, no. Alas, that H should masquerade as D and even T When simple N and 0 and C are always N, 0, C !1 For now mistrust is everywhere-cabals and factions growIf N combines with Hydrogen then C allies with 0. Team-spirit is a virtue, but the learned all agree That harm as well as benefit results from NHg. And though one must be grateful, all in all, for CO2 One rightly feels repugnance for the ill CO can do. It’s tempting to imagine that some cells must yearn for troops To quell the wilder radicals and reactionary groups.
It is a matter for regret that it is more than ten years since these problems were first posed, and it is only now that we have before us a workable compromise. The intervening period has been marked by much personal frustration and suffering by a generation of doctors who, having seen military service in the late war, were brought home to believe that a place would be found for them in the new hospital service. The consequences to the whole medical profession have been very serious. Undoubtedly a measure of the blame for these blows must be laid at the door of the responsible authority-the Government. However, since only the profession stood to lose by these delays, it seems to be not unreasonable to suppose that the methods whereby we select our negotiators might be at fault. The very distinguished men at the head of our affairs are not appointed to the presidencies of colleges because of their ability to strike a hard bargain on our behalf. It is doubtful whether they have the necessary ability to negotiate with the highly subtle trained minds who represent the Ministry on these occasions. The need to select and train our own negotiators is a matter of
770
importance. A general overhaul of the negotiating machinery is urgently necessary.
urgent
P. WATNEY ROE.
Bushey, Herts.
SiR,—Your leader of March 25 sees the answer to outpatient waiting-lists in the creation of, in effect, utility appointments-i.e., clinical consultants with limited beds. You make no reference to the fact that we have already many consultants in peripheral hospitals with several years’ experience of such practice. Learning to live with a chronic bed shortage necessitates a complete reorientation to medical and sometimes human values. In this readjustment we may derive benefit from our more objective viewpoint, but this is small consolation compared with the daily problems of bed shortage. Surely there can be no argument that a balance must be struck between inpatient and outpatient work, both in the interests of patient and doctor, and that in many hospitals this balance is top heavy. Such new appointments as you suggest
boards and their advisers will continue to be influenced, in their decisions on new appointments, by many factors of doubtful national significance. 3. The wide scale envisaged for medical assistants win have to take into consideration the close working and social relationships, and the personal equality, of men who may be junior in status to their colleagues but senior in age. Past experience of the financial affairs of those whose status does not allow them to exercise pressure does not encourage
but accentuate this trouble. In certain medical and administrative circles it may be " important to dispel the prevalent respect for number of beds as the clinical consultant’s status symbol ", but this is hardly evidence in support of your views. In the periphery, consultants view hospital beds not as " status symbols " but as
can
a
confidence.
There still remains the need for a solution for those, like myself, who have been left behind in what the working party agrees to be a disadvantageous position in the battle for promotion as against teaching-hospital trainees. If current rumour is accurate it would also appear that those who chose to leave the " training ladder " for S.H.M.O. positions are likely, on present views, to be much better placed. It will not help us that our position will not recur. Unless this consequence of the confused past is cleared up, the profession is going to be left for years with an unhappy group of men, whose persistence in a miserable situation and whose regular reappointment seems to have demon. strated both the will and the ability to become independent members of a hospital staff. TIME-EXPIRED SENIOR REGISTRAR II.
necessity for practice. E. P. MORLEY.
Lincoln.
SiR.—Your editorial of March 25 on the Platt report must have heartened many a time-expired senior registrar whose confidence had been shattered by the apparent indifference of this working party to our plight. This indifference may, we fear, be shared by far too many members of the Joint Consultants Committee, a group which it appears the Minister will consult when considering additional consultant appointments and a group which has hitherto done very little to promote additional consultant posts. We have not undergone this long period of training and waiting to find ourselves left at the top of an extremely amorphous mass of " medical assistants ". If this is allowed to happen, it will involve far more exploitation of highly trained skills than was ever achieved by the misuse of the senior hospital medical officer grade. We hope your editorial will stimulate the Minister of Health to find a quick and sensible way of using our skills and ability not only in our chosen profession but also in our chosen specialties. TIME-EXPIRED SENIOR REGISTRAR I.
SIR,-The findings of the Platt working-party are basically acceptable though by no means new. The new grade of medical assistants proposed by the working party must not develop into another s.H.M.o. But if this is to be
complex.
a
number of
problems
remain
to
be solved
prevented:
1. A clear delineation of the " special class " of work suitable for such a grade will be needed. It may be noted that no such class of work was definable for senior registrars. 2 With this goes the assessment of the number of new consultants needed. For such an assessment a specification of consultant responsibility will be required more precise than "
absolute charge of patients " and more comprehensive than visiting two or three times a week ". As soon as a consultant has more beds than he can properly care for, delegation of authority becomes a formality. (I have had simultaneously the experience of signing all the letters of one chief because of his absence and having mine signed by another chief to show his ultimate responsibility.) Without a precise numerical guide, "
BRONCHITIS AND THE MINISTRY OF LABOUR SIR,-In his letter of March 25 Dr. MacLean, principal medical officer of Remploy Ltd., complains that your annotation of Jan. 21 might suggest that in this country very little sheltered work is provided for those with chronic bronchitis. He states that " at the moment about 350 of those disabled by chronic bronchitis and emphysema are employed in Remploy factories ". In the House of Lords on March 14 the Earl of Dundee, in reply to Lord Taylor, stated that there were 43,404 men and women classified as being disabled on account of bronchitis, bronchiectasis, and emphysema. Of these 5500 were registered as unemployed, but no information is available as to how many of the balance were in employment, nor how many were in receipt of sickness benefit". To a further question from Lord Taylor, the Earl of Dundee replied: Altogether, some 82,000 persons were receiving sickness benefit for bronchitis of some kind on May 30, 1959, the latest date for which figures are available, and at this time of the year the number may be "
"
higher." These figures may give some idea of the size of the problem. For those 350 bronchitics referred to by Dr. MacLean Remploy provides a satisfactory solution to their employment, difficulties. It must be obvious, however, that this small number represents only a fraction of those needing help. In a recent survey on the unemployment problems associated with chronic bronchitis 1 we showed that only 1 in 6 of moderately severe bronchitics were registered as disabled with the Ministry of Labour. Furthermore, of 58 bronchitics who were not registered as disabled 18 were considered by their doctors to require sheltered work. The main reason for failure to register was reluctance on the part of the doctor who, from previous experience, regarded it as a waste of time to refer the disabled bronchitic. The Earl of Dundee, again in replyto Lord Taylor, on March 15 stated: "Very large numbers of bronchitics do not register, either because their medical practitioners do not advise them to do it-they do not think it would be worth while-or maybe, because they think itis not much use registering since the opportunities of emplocment are not great enough." The unemployment problem of those disabled by bronchc has been hidden for too long in the sickness benefit figures o the Ministry of Pensions and National Insurance. ManyJ: .
.
1.
Caplin, M., Silver,
C. P. Brit. J. Dis.
Chest, 1960, 54, 297.