GOVERNMENT AND PROFESSION

689 OBSTETRIC FLYING-SQUADS SIR,—I have read Professor Nixon’s letter in your issue of March 16. I should like to point out that the rules of the Central Midwives Board do not prohibit the administration of ergometrine with the crowning of the head by midwives in

domiciliarv practice.

ARNOLD WALKER

Central Midwives Board, London, S.W.1.

SIR,—As

one

Chairman.

who has for

seven

years worked among

unurbanised tribal Africans in the Belgian Congo, I may

perhaps

be

permitted

to

comment

on

Dr.

Grantly

Dick-Read’s statement last week that postpartum haernor-

rhage is almost absent

in

uncomplicated

labour in such

population. This is definitely not the case. Such well-recognised predisposing factors to postpartum hæmorrhage as multiparity, anaernia, and multiple pregnancy are commonly present in these people. Every year we admit to the Baptist Mission Hospital at Bolobo, Belgian Congo, a number of women who have been reduced to a severe degree of anaemia by postpartum a

haemorrhage. I would agree with Dr. Dick-Read that much serious

postpartum haemorrhage is due to faulty midwifery. It is difficult to imagine conditions under which more faulty midwifery is practised than among primitive Africans. In the area where I work, bearing down in the first stage is universally encouraged by ignorant village midwives. If the placenta does not separate, indiscriminate traction on the cord is practised, and where delivery is delayed interference of the most appalling kinds is indulged in. From experience I can assure Dr. Dick-Read that Africa is not the obstetric Utopia he imagines it to be. J. T. GRAY. EFFECT OF QUINIDINE

ON

POTASSIUM FLUX

SIR,—In their preliminary communication (March 16: the effect of quinidine on potassium flux Dr. Kiirki and his colleagues state that at 37°C " the metabolic processes which drive Na+ out of the cell and which raise the concentration of K+ within the cell were active." Since quinidine is a cell poison, we would expect quinidine (and probably most cell poisons) to have an unfavourable influence on such metabolic processes and It seems to retard the re-entry of K+ into the cell. premature, however, to conclude that " this finding makes it seem likely that the action of quinidine is due to a reduction of the permeability of the cell membrane to potassium." C. K. V. V. DOMMELEN. on

FRACTURES OF THE FEMORAL NECK SIR,—The review by Dr. Murray and Mr. Young (March 23) of the management and results of fractures of the femoral neck is a valuable presentation of fact, and as such is of great interest to all concerned with accident services. A study of the statistics gives a clear idea of the objects of the report, but note must inevitably be made of the high mortality-rate for both conservative and surgical treatment. The mortality for the total of 204 patients is 33%, for patients treated conservatively 48%, and for those operated on 26%. Statistical comparison is often erroneous and in this instance may be invalid owing to unrecorded local factors, but on their face value these figures compare unfavourably with those from other clinics. The average mortality for 564 patients treated surgically, collected from the

literature, was 16-8%. It is surprising to find that these authors conclude by saying that " an emergency operation does not appear to be indicated ... the best time for it probably lies between forty-eight hours and seven days after the fracture was sustained." I believe the that the operation should

reverse

always

to be true-that be regarded as

is, an

emergency unless the

should be performed,

patient is hopelessly moribund. not immediately, but within

It the

first

twenty-four hours. Mervyn Evans,1 reviewing

the surgical treatment for 101 patients from the Birmingham Accident Hospital, gave a mortality-rate of 109%. He wrote: "The best time to nail a trochanteric fracture is on the day of accident or on the followtrochanteric fractures in

and where facilities are such that operation performed early it is probably better not done as a routine." In my experience a careful ansesthetic and Wellconducted operation, within twenty-four hours of injury, kills very few. It is often life-saving and almost invariably promotes a marked improvement both in mental and physical health.

ing day,

cannot be

PHILIP NEWMAN.

GOVERNMENT AND PROFESSION SIR,—Many of us are sick at heart. We feel humiliated,

degraded. We are letting the country down when she can least afford it. In the National press we are classed with the rest of the strikers. The engineers are striking in designated areas only, presumably where they can do most harm. Are they following our suggestions or are we following them ?’? And make no mistake about it, it is a strike we are contemplating, and we are striking at the old and the sick. The British Medical Association say that we may tell the patients that the fees we charge should be reimbursed by the Government ; but isn’t this a gamble, and if it does not come off, who loses ?Not the doctor, who has already pocketed his 5s. or 7s. 6d. Then about medicines. The patient takes his form along to the chemist, and it is the chemist, poor man, who has to take the risk. If he supplies the medicines prescribed by doctors outside the National Health Service, and does not charge the patient, he may not get remunerated by the State, and if this happens it will not take long to ruin a small man. Again, we are not the ones who get hurt, it is either the chemist or the patient. Strikes come. Pay goes up. There is increase in the cost of production, and the cost of living goes up. Strikes again and the circle is complete. Cannot we who do not practise medicine only for a monetary gain but perhaps, too, because we love our work, be the first to stop this

virinna spiral ?

ARMOREL NETTELL.

SiR,-If it is accepted that there is a just case for rise in remuneration, then a settlement of this claim should be pursued. However, the very worse possible outcome of the present situation would be for a general rise of 24% in all our incomes, and I, and a good number of my professional colleagues, feel that our negotiators may be at fault in merely pressing the matter of remuneration whilst neglecting to stress the urgent needs for a reform of the service as a whole. The needs for some reassessment and re-examination of the whole structure and organisation of the service after nearly ten years is very apparent to all those who work in it, and now that a Royal Commission has been formed it would be a pity if the opportunity for some such re-examination was missed. Dealing primarily with matters of remuneration and speaking as a general practitioner, I would like to suggest a few possible measures that might be considered in any readjustment of our remuneration and as possible steps to improve standards and save public money. Before remedies can be discussed certain faults should be accurately defined. a

(a) Equal Pay for Unequal Work Apart from the present capitation an

fees which produce increase in pay with the size of the practice, there is no 1. Evans, E. M. J. Bone Jt Surg. 1951, 33B, 192.

690 of the services that are given by the doctor, and the size of’ a practice is certainly no criterion of the skill of the doctor or how hard he works. (b) Lack of Incentives There are at present no real financial incentives for improving standards. It is all too easy for a doctor to do the minimum of work and get away with it. (c) Lack of Supervision and Control of Standards Freedom of the individual to practise medicine according to his own views and principles must be jealously guarded and maintained, But at the same time since we are being paid out of public monies to care for our patients it seems only right that some steps be taken to ensure that the public is receiving a sufficient standard of medical care. At present, apart from very infrequent visits by the local medical officer of the Ministry and the rather ludicrous attempt at inspection of practices carried out last year (the results of which have never been published) by the local medical committees, there has been no activity to see that the lay public are being cared for properly. No-one likes " controls " or " interference " but, on the other hand, there exist innumerable safeguards in hospital practice to see that suitable standards are being maintained and these are accepted as inevitable and reasonable interferences.

grading

"

.

"

If we are to receive increased -remuneration then we should make it clear that we do not wish to receive it without at the same time endeavouring to remedy some of the faults of the present systems of remuneration and organisation, but the manner in which the claim is being pressed at present offers few such opportunities. Increased remuneration should be selective and in proportion to the work done. Incentives must be provided for better work, and for the achievement and maintenance of high standards in general practice, and so must increased opportunities and scope for registrars in hospitals to climb the consultant ladder. Expenditure must be cut by carrying out a drastic re-appraisal of the whole service and introducing some remedies to the ever-rising cost. Having noted some of the faults what of the possible solutions ?’? The Royal Commission should have its terms of reference broadened to include this re-examination of the N.H.S. and its composition altered to include medical representatives. Regarding future methods of remuneration, I suggest that in general practice this should continue on the present basis of a capitation fee with the increases being obtainable by increasing opportunities and incentives, as follows : to improve standards and at the same time preventive side of general practice it is suggested that the practitioner is paid a fee of, say, 10s. for regularly examining certain of his patients at certain specified periods and completing a form, as is the present case with forms for

As

a measure

stressing

the

vaccination and immunisation-at birth, in infants at 1 and 3 years of age ; in children at 5, 10, and 15 ;in adults around the vulnerable middle age ; in the elderly at retiring age of 60-65 ; and in the aged at 70 and then at regular 6 or 12 monthly intervals. In this way the average G.r. with a list of around 2500 will increase his remuneration by some £450. A much more delicate matter that is somewhat allied to " merit awards " might be the provision of some such system whereby the practitioner who is providing a high standard of care would have a scale of increased remuneration based on some agreed standards. Thus, this scale might be based on the types of accommodation provided, on the organisation of the practice, including secretarial arrangements and record-keeping, on the provisions for investigations, on group practices, and so on. The manner in which this assessment is carried out would require further thought.

To balance these increased opportunities for remunerative rewards there must also be some saving of money. With

the practitioners undertaking an ever-increasing of routine school and infant examinations then there would be no need for the present local

proportion eventually

infant-welfare and school clinics. This would be

a

considerable

public saving.

Prescribing costs must be reduced and methods for this purpose should be explored, beginning with an examination of the whole principles of therapy. A good deal of unnecessary and irrational prescribing undoubtedly occurs, especially in connection with the newest and most expensive drugs and it might be well to consider the reimposition of some brake on the excessive use of the broad-spectrum antibiotics and the corticosteroids by the reintroduction of the restrictions to their use to certain specific cliseases. In hospitals junior residents should not bo allowed to use these and other expensive drugs haphazardly without the specific permission of the consultant in charge of the case. The Cohen committee might also undertake a stricter revision of the categories of drugs allowable on E.C.10s. The hospital services account for the largest bulk of the service and it is here that large measures of economy could be considered. It is surely reasonable to expect inpatients to contribute something towards their board residence. Time-and-motion studies should be carried out by " business efficiency " experts to see where further cuts can be made in the administrative services, for it is quite common to hear of hospitals where the administrative staffs have increased by as much as 200% since the N.H.S. began, without any increase in the clinical work of the hospital. I feel sure that I am expressing the opinions of many of my colleagues in voicing my concern over the course of the present disagreements between the profession and the (jrovernment and in deploring the stress that is being laid on remuneration and the lack of mention, in official circles, of the needs for a complete reappraisal of the service. JOHN FRY.

Parliament The Government and the Social Services IN opening this debate on March 19, Dr. EDITH SUNNERSKILL criticised the Government’s social policy on the grounds that it placed an undue and increasing burden on those least able to bear it," and would, if continued, seriously weaken the country’s social services. As examples of this retrogressive trend she cited the reduction of the food subsidies, the increases in the price of school meals and milk, especially welfare milk, and the increased prescription charges. Yet though the Government had found time to introduce these econornies, nothing had been done about the cost of proprietary drugs. Doctors, for instance, were still receiving lavish samples of tranquillisers, a practice which she described as " not only extravagant but harmful to the whole nation." She considered that the Government’s policy revealed a characteristic disregard of the needs of the poorest and a lack of coordination among its own ’’

departments. Mr. DENNIS VOSPER, the Minister of Health, maintained that the Government’s policy recognised that the amount which could be spent on the social services was not unlimited. It was therefore important to eliminate waste and inefficiency and to make sure that the services were available to those most in need. He suggested that the Opposition when they were in power had failed to establish these priorities and as a result spread their resources in social services too thinly. Turning to his own department for examples of irnprovements made possible by this realistic policy, Mr. Vosper said that the money allocated to hospital building would be £20 million in 1956-58 and he hoped that it would be possible to keep on allocating increased sums. Waiting-lists, though still too big, had fallen from 526,000 in 1953 to 433,000 in 1956. This was due to a better use of beds, which was in turn dependent on better recruitment. Every category of hospital staff had added to its members in the past few years. During the past five years 2000 more generalpractitioners had joined the service, and, though no-one could be complacent about the shortage of dentists, the number now practising was the highest ever known. The number of courses of dental treatment for 195(3-5’7 for England and Wales was 11-1