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HEALTH SERVICE AND RESEARCH FINANCE
256 common belief, pethidine can definitely cause a rise intrabiliary pressure. These findings suggest that morphine and amidone are the most effective drugs for relieving biliary pain ; and their central action might be enhanced by the simultaneous administration of amyl nitrite for its spasmolytic effect.
to
in
HEALTH
SERVICE AND
RESEARCH
FINANCE
HOSPITAL expenditure under the National Health Service is criticised in a report by the Committee of Public Accounts,l which suggests that a greater sense of urgency in controlling costs might have produced more prompt economies. The committee remarks that the Ministry of Health, which has arranged for a review, by teams of experts, of hospital establishments, has already received reports that indicate some overstaffing in the administrative and clerical grades. " One team reported in 1950 that the administrative and clerical staffsof a group of hospitals in the Midlands could be cut by a half. Nothing had been done, however, to reduce excessive staffs " when the committee examined the Ministry in May, 1951. The committee observes that even where central negotiating bodies have approved rates of salary, some hospital authorities pay above such rates and do not adjust them when asked by the Ministry to do so. The Ministry intends to use its statutory power to enforce the approved rates. (This action has now been taken by regulations2 the effect of which is to require hospital authorities to bring contracts into line with agreed rates, unless the Minister gives a direction to the contrary. The special arrangements already made for transferred officers and other saving clauses in Whitley agreements or Ministry memoranda are, however, to remain in force.) The committee also examined the expenditure of the Medical Research Council on the new buildings for the National Institute for Medical Research at Mill Hill, London. Estimated in 1938 to cost 220,000, it eventually cost about 970,000. The committee acknowledges that, with the general rise in prices and the need for special equipment not originally foreseen, a heavy increase on the pre-war estimate was inevitable; but it is not convinced that the actual expenditure has been rigorously scrutinised. The committee concludes that the presence on the Council of a Treasury representative, " who could keep in touch with developments and co-operate in the formulation and discussion of demands, might, without at all trespassing on the Council’s responsibility for policy, ensure a much more effective measure of Treasury control, and they recommend that the practicability of making such an appointment should be given careful consideration." N.P.H.
INSULIN
A NEW form of depot insulin is being fairly widely used in the U.S.A. and Canada. It is called N.P.H. -N for neutral (pH 7-2) ; P for protamine ; and H for Hagedorn, in whose laboratories it was developed 3 Originally it was also called N.P.H.50, the 50 referring to its content of 0-50 mg. protamine per 100 units insulin -an amount only just in excess of the minimum required to combine with all the insulin. This protamine insulin combination is crystalline,4 in contrast to protamine zinc (P.z.) insulin, which is amorphous ; but they both form cloudy suspensions when shaken for injection. In use N.P.H. insulin has a very similar time-activity curve 1. Fourth Report from the Committee of Public Accounts : Session 1950-51. H.M. Stationery Office. Pp. 34. 1s. 3d. 2. National Health Service (Remuneration and Conditions of 1951. Service) Regulations, 3. Krayenbühl, C. H., Rosenberg, G. Rep. Steno Mem. Hosp. 1946, 1, 60. 4. Jamieson, M., Lacey, A. H., Fisher, A. M. Canad. med. Ass. J.
1951, 65, 20.
to globin insulin or a mixture of 2 parts soluble insulin to 1 part P.z. insulin : that is to say, the peak of activity is at about eight hours and the effect lasts about twentyfour hours.6 Like globin insulin, when given shortly before a normal-sized breakfast N.P.H. insulin may not act quickly enough completely to prevent postprandial hyperglycsemia ; but the early effect of N.P.H. can be boosted by mixing with it a small proportion of soluble insulin.66 Herein lies its main advantage over solubleinsulin/F.z.-insulin mixtures, for about 85% of the quick action of soluble insulin is retained when it is mixed with N.P.H., whereas some 90% of it may be lost when mixed with protamine zinc insulin.1I This is because P.z. insulin contains a considerable excess of protamine (1-25-1-50 mg. per 100 units) over the minimum amount required to combine with all the insulin, and moreover this excess is variable. McBride has used a modified N.P.H. insulin, called N.P.50, which contains 25% of the insulin in solution ; but unfortunately this is unsuitable for commercial use since it is not stable. Clinical studies7 with N.p.H. insulin given in a single daily injection have shown that about 95% of cases do as well as, or better than, on soluble insulin and protamine zinc insulin by separate injection. Such results are, however, hard to evaluate since the efficacy of any form of insulin treatment finally depends greatly on accurate adjustment of the dietary intake to the period of insulin action. The main advantage claimed for N.P.H. insulin is its ability often to control diabetes by a single daily injection ; but those whose requirement for a rapidly acting insulin is great in proportion to that for a slowly acting one may need a supplement of soluble insulin mixed in the same syringe. Such an insulin is in greatest demand for diabetic children, but the diabetic state of under-5s tends to be too brittle for good results. Too many sorts of insulin are as undesirable as too few ; and it would seem that no very strong case has been made for adding N.P.H. insulin to the three other insulin preparations now in use in this country. N.P.H. insulin may, nevertheless, be an improved substitute for globin insulin, owing to its better mixing qualities and slightly longer action. REMUNERATION
OF
GENERAL
PRACTITIONERS
AT the end of last month the Conference of Local Medical Committees 15 endorsed the rejection by the General Medical Services Committee 9 of a conditional offer by the Government to add 2 million to the central pool for remuneration of general practitioners. The Conference also agreed that the Government should be asked to refer to arbitration the question of the proper size of the pool. These decisions were conveyed to the Government, and a reply has been sent in the
following
terms :
,
" The Minister of Health and Secretary of State for Scotland have considered your letter of the 19th July on this matter. The Ministers regret that the special conference of local medical committees on the 19th July decided to reject the proposal in their letter of 23rd May, which would have made available an immediate sum to meet the known difficulties of certain types of
practice. " The Ministers have, therefore, agreed to withdraw this proposal and have considered the matter afresh. " They still regard it of the first importance, in the interests both of the general medical service given to the public and of general medical practice itself, that a new 5. Baganz, H. M., Carfagno, S. C., Cowan, B. Y., Dillon, E. S. Amer. J. med. Sci. 1951, 222, 1. 6. Swallow, K. A., Chute, A. L. Canad. med. Ass. J. 1951, 65, 23. 7. White, P. J. Amer. med. Ass. 1949, 141, 312. 8. See Lancet, July 28, 1951, p. 159.
9. Ibid, 1951, i, 1311.
to
in
HEALTH
SERVICE AND
RESEARCH
FINANCE
HOSPITAL expenditure under the National Health Service is criticised in a report by the Committee of Public Accounts,l which suggests that a greater sense of urgency in controlling costs might have produced more prompt economies. The committee remarks that the Ministry of Health, which has arranged for a review, by teams of experts, of hospital establishments, has already received reports that indicate some overstaffing in the administrative and clerical grades. " One team reported in 1950 that the administrative and clerical staffsof a group of hospitals in the Midlands could be cut by a half. Nothing had been done, however, to reduce excessive staffs " when the committee examined the Ministry in May, 1951. The committee observes that even where central negotiating bodies have approved rates of salary, some hospital authorities pay above such rates and do not adjust them when asked by the Ministry to do so. The Ministry intends to use its statutory power to enforce the approved rates. (This action has now been taken by regulations2 the effect of which is to require hospital authorities to bring contracts into line with agreed rates, unless the Minister gives a direction to the contrary. The special arrangements already made for transferred officers and other saving clauses in Whitley agreements or Ministry memoranda are, however, to remain in force.) The committee also examined the expenditure of the Medical Research Council on the new buildings for the National Institute for Medical Research at Mill Hill, London. Estimated in 1938 to cost 220,000, it eventually cost about 970,000. The committee acknowledges that, with the general rise in prices and the need for special equipment not originally foreseen, a heavy increase on the pre-war estimate was inevitable; but it is not convinced that the actual expenditure has been rigorously scrutinised. The committee concludes that the presence on the Council of a Treasury representative, " who could keep in touch with developments and co-operate in the formulation and discussion of demands, might, without at all trespassing on the Council’s responsibility for policy, ensure a much more effective measure of Treasury control, and they recommend that the practicability of making such an appointment should be given careful consideration." N.P.H.
INSULIN
A NEW form of depot insulin is being fairly widely used in the U.S.A. and Canada. It is called N.P.H. -N for neutral (pH 7-2) ; P for protamine ; and H for Hagedorn, in whose laboratories it was developed 3 Originally it was also called N.P.H.50, the 50 referring to its content of 0-50 mg. protamine per 100 units insulin -an amount only just in excess of the minimum required to combine with all the insulin. This protamine insulin combination is crystalline,4 in contrast to protamine zinc (P.z.) insulin, which is amorphous ; but they both form cloudy suspensions when shaken for injection. In use N.P.H. insulin has a very similar time-activity curve 1. Fourth Report from the Committee of Public Accounts : Session 1950-51. H.M. Stationery Office. Pp. 34. 1s. 3d. 2. National Health Service (Remuneration and Conditions of 1951. Service) Regulations, 3. Krayenbühl, C. H., Rosenberg, G. Rep. Steno Mem. Hosp. 1946, 1, 60. 4. Jamieson, M., Lacey, A. H., Fisher, A. M. Canad. med. Ass. J.
1951, 65, 20.
to globin insulin or a mixture of 2 parts soluble insulin to 1 part P.z. insulin : that is to say, the peak of activity is at about eight hours and the effect lasts about twentyfour hours.6 Like globin insulin, when given shortly before a normal-sized breakfast N.P.H. insulin may not act quickly enough completely to prevent postprandial hyperglycsemia ; but the early effect of N.P.H. can be boosted by mixing with it a small proportion of soluble insulin.66 Herein lies its main advantage over solubleinsulin/F.z.-insulin mixtures, for about 85% of the quick action of soluble insulin is retained when it is mixed with N.P.H., whereas some 90% of it may be lost when mixed with protamine zinc insulin.1I This is because P.z. insulin contains a considerable excess of protamine (1-25-1-50 mg. per 100 units) over the minimum amount required to combine with all the insulin, and moreover this excess is variable. McBride has used a modified N.P.H. insulin, called N.P.50, which contains 25% of the insulin in solution ; but unfortunately this is unsuitable for commercial use since it is not stable. Clinical studies7 with N.p.H. insulin given in a single daily injection have shown that about 95% of cases do as well as, or better than, on soluble insulin and protamine zinc insulin by separate injection. Such results are, however, hard to evaluate since the efficacy of any form of insulin treatment finally depends greatly on accurate adjustment of the dietary intake to the period of insulin action. The main advantage claimed for N.P.H. insulin is its ability often to control diabetes by a single daily injection ; but those whose requirement for a rapidly acting insulin is great in proportion to that for a slowly acting one may need a supplement of soluble insulin mixed in the same syringe. Such an insulin is in greatest demand for diabetic children, but the diabetic state of under-5s tends to be too brittle for good results. Too many sorts of insulin are as undesirable as too few ; and it would seem that no very strong case has been made for adding N.P.H. insulin to the three other insulin preparations now in use in this country. N.P.H. insulin may, nevertheless, be an improved substitute for globin insulin, owing to its better mixing qualities and slightly longer action. REMUNERATION
OF
GENERAL
PRACTITIONERS
AT the end of last month the Conference of Local Medical Committees 15 endorsed the rejection by the General Medical Services Committee 9 of a conditional offer by the Government to add 2 million to the central pool for remuneration of general practitioners. The Conference also agreed that the Government should be asked to refer to arbitration the question of the proper size of the pool. These decisions were conveyed to the Government, and a reply has been sent in the
following
terms :
,
" The Minister of Health and Secretary of State for Scotland have considered your letter of the 19th July on this matter. The Ministers regret that the special conference of local medical committees on the 19th July decided to reject the proposal in their letter of 23rd May, which would have made available an immediate sum to meet the known difficulties of certain types of
practice. " The Ministers have, therefore, agreed to withdraw this proposal and have considered the matter afresh. " They still regard it of the first importance, in the interests both of the general medical service given to the public and of general medical practice itself, that a new 5. Baganz, H. M., Carfagno, S. C., Cowan, B. Y., Dillon, E. S. Amer. J. med. Sci. 1951, 222, 1. 6. Swallow, K. A., Chute, A. L. Canad. med. Ass. J. 1951, 65, 23. 7. White, P. J. Amer. med. Ass. 1949, 141, 312. 8. See Lancet, July 28, 1951, p. 159.
9. Ibid, 1951, i, 1311.