- Email: [email protected]
Liberals Would Spend More on Health
818 MEDICAL METAL DETECTORS ARE NOT NEW
SIR,-Although handy, Mr Leicester and Dr Williams’ use (Aug. 1, p. 232) of a metal detector to localise foreign bodies (i.e., endoscope tips) is not novel. Alexander Graham Bell used a battery, two coils of insulated wire, a circuit breaker, and a telephone to locate the assassin’s bullet in President Garfield’s abdomen in July, 1881.1 Interest in the telephone-cum-metal-detector was shortlived. The "new rays" of Wilhelm Roentgen supplanted it in 1895. However, given the cost-benefit and cost-effectiveness studies now in vogue, coupled with the attractiveness in some quarters of remote telediagnosis, perhaps the entire question should be reopened. Departments of Medicine and Pediatrics,
Georgetown University School of Medicine, Washington, D C. 2007, U.S.A. 1. Roth N.
WILLIAM R. AYERS
Tracking by telephone: Locating the bullet in president Garfield, 1881. Med
Instrum 1981, 15: 190.
Commentary from Westminster Medical Manpower and
Training
AT present, many patients in N.H.S. hospitals never actually meet their consultant and that is "clearly unacceptable", in the view of the all-party back-bench Commons Select Committee on Social Services. After six months’ investigation into medical manpower and training, including evidence from D.H.S.S. Ministers, administrators, medical schools, doctors’ representatives, and other interested bodies, the Social Services Committee concludes: "The consultant who carries responsibility for the patient’s care should be fully aware of the patient’s circumstances, the diagnosis, the course of treatment and the patient’s reaction to that treatment, even if the consultant has not made these decisions personally. It follows that in most hospitals and most specialties there should be an increase in the number of consultants and the number of junior doctors." The report talks of inadequate recruitment to many specialties, notably psychiatry, geriatrics, pathology, and community medicine. In many hospitals staff have to work too hard. Short-term solutions have led to the creation of too many junior posts, the appointment of large numbers of overseas doctors, and thus to dilution of standards of supervision, "blurring" of clinical responsibility, and "grave and continuing distortion" of the medical career structure. Some older consultants have resisted corrective measures through unwillingness to lose their tradition of plentiful junior support; health authorities have been attracted by the apparent cheapness of employing juniors; overseas doctors have been willing to accept junior posts because of the supposed training content. But as a result the real cost of doctors’ salaries has risen "significantly" over the past ten years "largely to’ fuel the increase in juniors". A service with more consultants might in fact be cheaper, the committee thinks. It would result in better productivity, improving standards of care, and would probably reduce waiting lists and the costs of continuing sickness. Patients were entitled to be treated by trained specialists (that is, consultants) and general practitioners. The purpose of junior appointments was to provide training, not service. If there were more consultants, movement through the training grades would then be determined by the doctor’s aptitude, not by the chance availability of scarce senior-registrar and consultant posts.
The grade of senior house officer, the report suggests, should be frozen at its present level, while the Government urges health authorities to increase consultant numbers. Unemployment among doctors is negligible at the moment. But failure to correct the career structure will lead to bottlenecks and unemployment during the training period. Every doctor should have some postgraduate training with old people, babies, and children, and mental illness and distress, the report suggests. The number of training places in each specialty should reflect the demand for partient care in these specialties. A system still had to be found to correlate those needs in the community with the output of the medical schools. Training should also take more account of the needs of women doctors and doctors with domestic commitments, as should career posts. The report comes out against overtime payments to consultants and extra-duty payments to doctors, which "merely provide some compensation for an excessive workload that should not occur". With the change of emphasis proposed by the report, it is conceded that consultants will have to undertake more on-call emergency work, which should fall mainly on the younger members of the team. The committee insists that in the interests of patients, no doctor, junior or consultant, should have to do a full day’s work after coping with emergencies during most of the previous night. Nor, the report adds, should it always be necessary for consultants to move from one job to another to get promotion. The existing distinction award scheme may have to be expanded if a consultant-based scheme is to become the norm. Consultants’ contracts should be held by district health authorities, but the region should control the deployment of consultants to ensure that district medical planning conforms with national agreements. The report also comes out against the creation of a new subconsultant grade and a hospital practitioner mark-11 grade. Both have too many disadvantages, and would undermine progress towards a consultant-based system. Meanwhile, in next year’s planning guidelines the D.H.S.S. should draw up a plan for increasing consultant numbers. The Department should also publish, through the medical press, the results of preliminary studies on how to organise a consultant-based service. The problems discussed in the report "are pressing, and in no sense insoluble". The committee points out, however, that their solution will require that the level of growth money in the N.H.S. should be increased sufficiently, both for the process of this change in career structure to be rapidly accelerated, and for other high priority areas to be adequately funded. The D.H.S.S. itself is now studying the report, and intends to issue a response in due course.
Liberals Would
Spend More on Health
In any Liberal/Social Democrat administration after the general election, the Liberals would press for the country to spend a substantially higher level of national income on health, according to the party’s health spokesman, Lord Winstanley, speaking at the Liberals’ annual assembly at Llandudno. A large increase in such spending would only take Britain up to the general level of most of our European neighbours. "If such spending meant more taxes we would still do it. The voters would vote for it." He attacked the "lunacy" of Government cuts in spending which actually cost money. By cutting home-helps and services to the elderly and the chronic sick, the Government was forcing more next
819
people to remain in expensive hospital care. Lord Winstanley spoke ofup to 40 health authorities in the country failing now to provide the level of care which they are statutorily obliged to give.
Obituary LEYBOURNE STANLEY PATRICK DAVIDSON Kt, M.D., Hon LL.D.Edin., F.R.C.P.E., F.R.C.P.
Code of Practice for N.H.S. Trade Unions There should be no sudden withdrawals of emergency ambulance cover this winter, and no more picketing of fuel deliveries to hospitals, if health-service unions abide by a new code of practice drawn up by the T.U.C.’s health-services committee. Under the code, any withdrawal of emergency services during a dispute, if it endangered "life, limb, or ultimate safety of a patient", would be officially condemned by the T.U.C. The code has been drawn up by the T.U.C. in response to a suggestion in the Royal Commission’s 1979 report on the N.H.S. that the T.U.C. should start working out a national procedure for health-service disputes. The T.U.C. now hopes to discuss the scheme with Ministers at the D.H.S.S., Employment Department, and Treasury, since the code is intended to cover wage bargaining as well as other disputes. The unions are asking for a much more central role in and pay planning in the N.H.S. At present their pay negotiations are conducted in the light of previously decided cash allocations to the N.H.S. They want to reverse the process. "The outcome of negotiations should be fed into expenditure planning," the report argues. An N.H.S. databank should be established, so that wage comparisons could be made within the N.H.S. and with relevant outside groups. All disputes should, if not quickly settled, be referred to an N.H.S. arbitration tribunal. resources
The report states: "We believe that responsible Trade Union activity must include respect for human life, and the prevention of suffering in sick people, who are in no way responsible for the actions that caused the breakdown of negotiations." The following code, it goes on, "should be observed to the letter." But it adds that observance of the code is "contingent on a sensible local management response which does not exacerbate and inflame a difficult local situation". Management actions, such as suspension, or refusal to negotiate on or pay for emergency cover, could constitute such an inflammatory response. Emergency services "protected" by the code are given as: "Those which directly involve the life, limb, or ultimate safety of a patient, for example 999, renal dialysis, terminal discharges, maternity, radiotherapy or serious accident patients." Highly dependent
protected, such as children, severely mentally handicapped people, or elderly patients. Delivery and distribution of drugs, food, oxygen and fuel "should not be impeded". patients
are
also
After
publication of the report, the T.U.C. assistant general secretary and working party chairman, Mr Kenneth Graham, said the wage needs of N.H.S. staff ought to be considered in the early stages of the forthcoming Government review of public expenditure. The Government must recognise that the N.H.S. was part of its macroeconomic policy. Of the industrial relations code, Mr Graham remarked that "we want relations in the N.H.S."
to
take the hassle
out
of industrial
RODNEY DEITCH
THE death of Sir Stanley Davidson at the age of 87 has removed from the Edinburgh scene one of the medical giants of this century. The Davidson and Dunlop combination in the Medical School gave the benefit of two very different personalities working in harmony at a time of great advances in medical investigation and treatment,
Stanley Davidson was born in Ceylon, the second son of the late Leybourne Davidson, the family home being at Huntly Lodge,
Sir
Aberdeenshire. From Cheltenham College he went to Trinity College, Cambridge, with the purpose of becoming a medical graduate, but in August, 1914, he enlisted as a combatant in the Gordon Highlanders. Within three months of enlistment and at the age of 20 he was a captain in the front-line trenches in Belgium. He was twice time the second wounded, seriously, and his batman died at his side. He himself was first believed to have been killed at Festubert, but, afterhaving lain in the open for twenty-four hours, he was found and admitted to the gas-gangrene ward of the Boulogne Base Hospital. These experiences conditioned his actions for the rest of his life and gave him the determination to improve the lot of those who survived and, in turn, that of their families.
Accordingly,
he resumed his medical
studies, this time
at
Edinburgh, in 1917, and two years later he graduated with first-class honours (a classification that no longer exists). After he had held house posts, he became an assistant to the professor of bacteriology, claiming later that he owed his success there to the fact that he was always able to keep a step ahead of the class when preparing his lectures. He had further clinical experience at Leith Hospital and the Royal Infirmary and in 1925 he received a gold medal for an M.D. thesis
on
immunisation and antibody reactions.
In 1930 he produced, with Prof. George Gulland, a large book on pernicious anaemia and, since this was published about the time of the acceptance of the use of liver extracts in treatment, he developed a personal research interest in this and related anaemias. He wrote many papers about megaloblastic anaemias up to the time of his retiral in 1959. Having been elected to the regius chair of medicine at Aberdeen in 1932, he returned to Edinburgh as professor of
medicine in 1938. At that time those of us who were medical students were forewarned by the Aberdeen students that a forceful personality was coming our way. We were delighted by the arrival of this outspoken professor who did not make dogmatic pronouncements and was obviously enthusiastic, full of curiosity, compassionate towards his patients, and lucid as a teacher. Later experience as his house-physician gave ample confirmation of the fact that he was a first-class clinician, and that he showed as much concern for his patients from model lodging houses as for those with titles. He had no real interest in private practice and was one of the first fulltime professors of medicine in this country. One
frequently
had
to
make allowance for
exaggeration
in his
stories, and there were times when it was felt that his strange oaths
might frighten the faint-hearted. Nevertheless, he appreciated those who argued back, and, on occasion, after some disagreement he would arrive at the home of a member of his staff with a peace offering, such as a brace of pheasants.
SIR,-Although handy, Mr Leicester and Dr Williams’ use (Aug. 1, p. 232) of a metal detector to localise foreign bodies (i.e., endoscope tips) is not novel. Alexander Graham Bell used a battery, two coils of insulated wire, a circuit breaker, and a telephone to locate the assassin’s bullet in President Garfield’s abdomen in July, 1881.1 Interest in the telephone-cum-metal-detector was shortlived. The "new rays" of Wilhelm Roentgen supplanted it in 1895. However, given the cost-benefit and cost-effectiveness studies now in vogue, coupled with the attractiveness in some quarters of remote telediagnosis, perhaps the entire question should be reopened. Departments of Medicine and Pediatrics,
Georgetown University School of Medicine, Washington, D C. 2007, U.S.A. 1. Roth N.
WILLIAM R. AYERS
Tracking by telephone: Locating the bullet in president Garfield, 1881. Med
Instrum 1981, 15: 190.
Commentary from Westminster Medical Manpower and
Training
AT present, many patients in N.H.S. hospitals never actually meet their consultant and that is "clearly unacceptable", in the view of the all-party back-bench Commons Select Committee on Social Services. After six months’ investigation into medical manpower and training, including evidence from D.H.S.S. Ministers, administrators, medical schools, doctors’ representatives, and other interested bodies, the Social Services Committee concludes: "The consultant who carries responsibility for the patient’s care should be fully aware of the patient’s circumstances, the diagnosis, the course of treatment and the patient’s reaction to that treatment, even if the consultant has not made these decisions personally. It follows that in most hospitals and most specialties there should be an increase in the number of consultants and the number of junior doctors." The report talks of inadequate recruitment to many specialties, notably psychiatry, geriatrics, pathology, and community medicine. In many hospitals staff have to work too hard. Short-term solutions have led to the creation of too many junior posts, the appointment of large numbers of overseas doctors, and thus to dilution of standards of supervision, "blurring" of clinical responsibility, and "grave and continuing distortion" of the medical career structure. Some older consultants have resisted corrective measures through unwillingness to lose their tradition of plentiful junior support; health authorities have been attracted by the apparent cheapness of employing juniors; overseas doctors have been willing to accept junior posts because of the supposed training content. But as a result the real cost of doctors’ salaries has risen "significantly" over the past ten years "largely to’ fuel the increase in juniors". A service with more consultants might in fact be cheaper, the committee thinks. It would result in better productivity, improving standards of care, and would probably reduce waiting lists and the costs of continuing sickness. Patients were entitled to be treated by trained specialists (that is, consultants) and general practitioners. The purpose of junior appointments was to provide training, not service. If there were more consultants, movement through the training grades would then be determined by the doctor’s aptitude, not by the chance availability of scarce senior-registrar and consultant posts.
The grade of senior house officer, the report suggests, should be frozen at its present level, while the Government urges health authorities to increase consultant numbers. Unemployment among doctors is negligible at the moment. But failure to correct the career structure will lead to bottlenecks and unemployment during the training period. Every doctor should have some postgraduate training with old people, babies, and children, and mental illness and distress, the report suggests. The number of training places in each specialty should reflect the demand for partient care in these specialties. A system still had to be found to correlate those needs in the community with the output of the medical schools. Training should also take more account of the needs of women doctors and doctors with domestic commitments, as should career posts. The report comes out against overtime payments to consultants and extra-duty payments to doctors, which "merely provide some compensation for an excessive workload that should not occur". With the change of emphasis proposed by the report, it is conceded that consultants will have to undertake more on-call emergency work, which should fall mainly on the younger members of the team. The committee insists that in the interests of patients, no doctor, junior or consultant, should have to do a full day’s work after coping with emergencies during most of the previous night. Nor, the report adds, should it always be necessary for consultants to move from one job to another to get promotion. The existing distinction award scheme may have to be expanded if a consultant-based scheme is to become the norm. Consultants’ contracts should be held by district health authorities, but the region should control the deployment of consultants to ensure that district medical planning conforms with national agreements. The report also comes out against the creation of a new subconsultant grade and a hospital practitioner mark-11 grade. Both have too many disadvantages, and would undermine progress towards a consultant-based system. Meanwhile, in next year’s planning guidelines the D.H.S.S. should draw up a plan for increasing consultant numbers. The Department should also publish, through the medical press, the results of preliminary studies on how to organise a consultant-based service. The problems discussed in the report "are pressing, and in no sense insoluble". The committee points out, however, that their solution will require that the level of growth money in the N.H.S. should be increased sufficiently, both for the process of this change in career structure to be rapidly accelerated, and for other high priority areas to be adequately funded. The D.H.S.S. itself is now studying the report, and intends to issue a response in due course.
Liberals Would
Spend More on Health
In any Liberal/Social Democrat administration after the general election, the Liberals would press for the country to spend a substantially higher level of national income on health, according to the party’s health spokesman, Lord Winstanley, speaking at the Liberals’ annual assembly at Llandudno. A large increase in such spending would only take Britain up to the general level of most of our European neighbours. "If such spending meant more taxes we would still do it. The voters would vote for it." He attacked the "lunacy" of Government cuts in spending which actually cost money. By cutting home-helps and services to the elderly and the chronic sick, the Government was forcing more next
819
people to remain in expensive hospital care. Lord Winstanley spoke ofup to 40 health authorities in the country failing now to provide the level of care which they are statutorily obliged to give.
Obituary LEYBOURNE STANLEY PATRICK DAVIDSON Kt, M.D., Hon LL.D.Edin., F.R.C.P.E., F.R.C.P.
Code of Practice for N.H.S. Trade Unions There should be no sudden withdrawals of emergency ambulance cover this winter, and no more picketing of fuel deliveries to hospitals, if health-service unions abide by a new code of practice drawn up by the T.U.C.’s health-services committee. Under the code, any withdrawal of emergency services during a dispute, if it endangered "life, limb, or ultimate safety of a patient", would be officially condemned by the T.U.C. The code has been drawn up by the T.U.C. in response to a suggestion in the Royal Commission’s 1979 report on the N.H.S. that the T.U.C. should start working out a national procedure for health-service disputes. The T.U.C. now hopes to discuss the scheme with Ministers at the D.H.S.S., Employment Department, and Treasury, since the code is intended to cover wage bargaining as well as other disputes. The unions are asking for a much more central role in and pay planning in the N.H.S. At present their pay negotiations are conducted in the light of previously decided cash allocations to the N.H.S. They want to reverse the process. "The outcome of negotiations should be fed into expenditure planning," the report argues. An N.H.S. databank should be established, so that wage comparisons could be made within the N.H.S. and with relevant outside groups. All disputes should, if not quickly settled, be referred to an N.H.S. arbitration tribunal. resources
The report states: "We believe that responsible Trade Union activity must include respect for human life, and the prevention of suffering in sick people, who are in no way responsible for the actions that caused the breakdown of negotiations." The following code, it goes on, "should be observed to the letter." But it adds that observance of the code is "contingent on a sensible local management response which does not exacerbate and inflame a difficult local situation". Management actions, such as suspension, or refusal to negotiate on or pay for emergency cover, could constitute such an inflammatory response. Emergency services "protected" by the code are given as: "Those which directly involve the life, limb, or ultimate safety of a patient, for example 999, renal dialysis, terminal discharges, maternity, radiotherapy or serious accident patients." Highly dependent
protected, such as children, severely mentally handicapped people, or elderly patients. Delivery and distribution of drugs, food, oxygen and fuel "should not be impeded". patients
are
also
After
publication of the report, the T.U.C. assistant general secretary and working party chairman, Mr Kenneth Graham, said the wage needs of N.H.S. staff ought to be considered in the early stages of the forthcoming Government review of public expenditure. The Government must recognise that the N.H.S. was part of its macroeconomic policy. Of the industrial relations code, Mr Graham remarked that "we want relations in the N.H.S."
to
take the hassle
out
of industrial
RODNEY DEITCH
THE death of Sir Stanley Davidson at the age of 87 has removed from the Edinburgh scene one of the medical giants of this century. The Davidson and Dunlop combination in the Medical School gave the benefit of two very different personalities working in harmony at a time of great advances in medical investigation and treatment,
Stanley Davidson was born in Ceylon, the second son of the late Leybourne Davidson, the family home being at Huntly Lodge,
Sir
Aberdeenshire. From Cheltenham College he went to Trinity College, Cambridge, with the purpose of becoming a medical graduate, but in August, 1914, he enlisted as a combatant in the Gordon Highlanders. Within three months of enlistment and at the age of 20 he was a captain in the front-line trenches in Belgium. He was twice time the second wounded, seriously, and his batman died at his side. He himself was first believed to have been killed at Festubert, but, afterhaving lain in the open for twenty-four hours, he was found and admitted to the gas-gangrene ward of the Boulogne Base Hospital. These experiences conditioned his actions for the rest of his life and gave him the determination to improve the lot of those who survived and, in turn, that of their families.
Accordingly,
he resumed his medical
studies, this time
at
Edinburgh, in 1917, and two years later he graduated with first-class honours (a classification that no longer exists). After he had held house posts, he became an assistant to the professor of bacteriology, claiming later that he owed his success there to the fact that he was always able to keep a step ahead of the class when preparing his lectures. He had further clinical experience at Leith Hospital and the Royal Infirmary and in 1925 he received a gold medal for an M.D. thesis
on
immunisation and antibody reactions.
In 1930 he produced, with Prof. George Gulland, a large book on pernicious anaemia and, since this was published about the time of the acceptance of the use of liver extracts in treatment, he developed a personal research interest in this and related anaemias. He wrote many papers about megaloblastic anaemias up to the time of his retiral in 1959. Having been elected to the regius chair of medicine at Aberdeen in 1932, he returned to Edinburgh as professor of
medicine in 1938. At that time those of us who were medical students were forewarned by the Aberdeen students that a forceful personality was coming our way. We were delighted by the arrival of this outspoken professor who did not make dogmatic pronouncements and was obviously enthusiastic, full of curiosity, compassionate towards his patients, and lucid as a teacher. Later experience as his house-physician gave ample confirmation of the fact that he was a first-class clinician, and that he showed as much concern for his patients from model lodging houses as for those with titles. He had no real interest in private practice and was one of the first fulltime professors of medicine in this country. One
frequently
had
to
make allowance for
exaggeration
in his
stories, and there were times when it was felt that his strange oaths
might frighten the faint-hearted. Nevertheless, he appreciated those who argued back, and, on occasion, after some disagreement he would arrive at the home of a member of his staff with a peace offering, such as a brace of pheasants.