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new yea r 's res 0 I uti 0 n Sir: I would like to see the Code of Ethics of the AMERICAN PHARMACEUTICAL ASSOCIATION reprinted every year in the January issue of the JOuRNAL-as sort of a "New Year's resolution" for all pharmacists across the country. I feel that we all need a reminder that ours is an honorable profession and that we have an obligation to that profession. If all of us lived by the Code of Ethics, we would have no discount house pharmacies, no problem of physicians' samples, no traffic in counterfeit drugs and the "FDA Action" page of your JOURNAL would be a thing of the past. Let us reaffirm our faith in, our duty and our obligation to our profession. J. David Schreiner Anderson, Indiana Editor's note: This excellent suggestion is implemented in this very issue (see page 16).
'a sincere thank you' Dear Friends: Your letters, messages and cards have been received and read with the same emotional feelings which prompted your sending them. But they, together with the other tributes sent to Roy Bird Cook, have been so overwhelming in number that I cannot write each of you a personal letter. The flowers sent both to the funeral and to our home were all beautiful. The contributions to the church have reached such proportions that an individual memorial is being planned there. N ow funds are coming in for a memorial project in his memory at the School of Pharmacy, West Virginia University. The press has been exceedingly kind For every tribute paid to Roy Bird, his daughters and I are deeply appreciative. However, what is most gratifying to us is the knowledge that you were so free with your words of appreciation, so generous with the honors you conferred upon him while he was still living. These enriched his life and stimulated him to worthwhile activity to the very end of his life. By making us feel that you personally share our loss you have made our ordeal much easier to bear. Our gratitude is too great to express in words but it will live long in our hearts. All we can do is say a sincere thank you for recognizing and appreciating Roy Bird Cook. Gratefully yours, Eleanor J. Cook Charleston, West Virginia 2
Journal of the
Postline • • •
's 0 cia liz e d me d i c i n e in Br ita in' Sirs: The article by Dr. E. Lloyd Dawe entitled "I Am a Fugitive from Socialized Medicine in Britain," published in the September 1961 issue of THIS JOURNAL, contains many erroneous statements or conclusions. Among these are the following: Practice under the National Health Service soon became intolerable for me, as it has for thousands of British and European doctors who have left their countries to practice in America.
We have no evidence that since 1948, when the health service began, 1,000 British doctors have left the United Kingdom to practice in America. Can Dr. Dawe supply this evidence? In Britain the amount and kind of drugs were also restricted for the general practitioner. Only doctors on the staffs of hospitals initially could prescribe new drugs not listed in the British Pharmacopoeia or National Formulary.
It is a basic principle of the British health service that a doctor is completely free to prescribe any drug he considers necessary for the treatment of his patients. The only reservation is that he may not prescribe foods or toilet articles. Government-licensed drug houses supplied medicines, which the general practitioners were supposed to prescribe by their generic name.
The statement is nonsense. No drug houses are owned by the government, by the Ministry of Health or by the nation. The only license issued is in respect of substances controlled by the Therapeutic Substances Act and this only applies to those products the purity and potency of which cannot be determined by chemical or physical methods. Nearly every week, a number of doctors would be fined because they prescribed a drug which in their best judgment was needed by a patient but which was not on the government's official list.
The main limitation on prescribing is exercised through the arrangement that any doctor whose average cost per prescription is substantially higher than that of his colleagues in the area, is liable to have his prescribing investigated by a committee of doctors. The doctor can be surcharged for the estimated ex-
AMERICAN PHARMACEUTICAL ASSOCIATION
• • • • • • • • • • • • • • • • • • cessive cost of his prescribing. During 1959 the total number of cases in which money was withheld was nine and the total sum involved was $420. In addition to that positive check, the doctor is provided with advice on how to prescribe economically. The Standing J oint Committee on the Classification of Proprietary Preparations has classified between 4,000 and 5,000 proprietary preparations according to its therapeutic evaluation of them. Doctors are adyised that normally they need not go outside the drugs and preparations in the British Pharmacopoeia, British Pharmaceutical Codex and British N ational Formulary or the committee's own categories N (new drugs of proved value, not yet standard) and P (drugs for which there is a prima facie evidence of therapeutic value but where the committee wants further evidence before firm classification). A standard drug is defined as a preparation described in the British Pharmacopoeia, British Pharmaceutical Codex or British N ational Formulary. Form-filling and correspondence with the government became one of the physician's major functions.
Doctors have always had to deal with a number of certificates and forms; under the health service there are about 30 official forms to meet various purposes but fewer than ten of these are in constant use, the others being designed to meet special cases only. The service has relieved family doctors of all the paper work involved in rendering accounts to their patients and collecting (or waiving) outstanding debts. Under the National Health Service, patients not only had no choice of hospitals, they were fortunate to get accommodations at all in jam-packed institutions.
Dr. Dawe makes no statistical comparison between the numbers of people treated in hospitals under the old voluntary system and under the National Health Service although the figures are available. The number of available staffed beds has been increased by about 27,000 since the start of the service, the number of hospital consultants has increased from 4,711 to 6,950 and the total nursing and midwifery staff in hospitals has increased by about 35,000 wholetime and 18,000 part-time. And hospitals can now afford to buy apparatus for diagnosis and treatment which was impossible when flag-days and legacies were the main sources of income. (continued on page 4)
But private or semi-private rooms were almost unheard of.
Most of the teaching hospitals (there are 22 of them) have private wings for the care of patients who wish to pay for treatment.
but I find more significance in the points he evades than in his quibbles. One can only conclude from this that Mr. Fitch tacitly admits that the real criticisms made in my testimony are undeniable.
E. Lloyd Dawe, MD Danbury, Connecticut
There are two or three government clerks for each doctor.
Most of the administration is in the hands of those who serve in an unpaid voluntary capacity-about 10,000 in England and Wales. The administrative costs of the service are about 3 percent of the total expenditure. Apart from the staff of the Ministry of Health (which numbers less than 3,000 and deals with all aspects of health, not only with the administration of the service) there are no other civil servants among the half million people employed in the service. Outside the hospital service there are 22,000 family doctors in general practice, 15,500 pharmacies, 10,000 dentists and 7,000 opticians. The insured must also carry the heavy taxes that pay for the nationalized health plan.
The service is paid for (a) mostly out of national taxation in the same way as this applies to education or the armed forces, (b) about one-seventh of the total cost, from a special health service weekly contribution paid by all active members of the population-amounting for an employed man to 39 cents and 10 cents for his employer (the young and the elderly, make no contribution, but are probably the main beneficiaries) -(c) by a small charge per prescription of 28 cents each. W.K. Fitch London, England Sir: It is always easy to criticize remarks taken out of context, as Mr. Fitch has done, but it is somewhat irresponsible to take exception to statements which were never made. Mr. Fitch, for example, claims that I said at least 1,000 British doctors had left the United Kingdom to practice in America. As anyone can see from the quotation itself, this is not the implication. Most British doctors, it is true, emigrate to the Commonwealth rather than to the U.S., but the total number certainly comes to more than 1,000. I don't know where Mr. Fitch got his statistics, but if he will consult the Jewkes report, "Genesis of the British N.H.S.," he will find statistics that tell a very different story. If, as Mr. Fitch says, "a doctor is completely free to prescribe any drug he considers necessary," etc., why was I unable to prescribe aureomycin in 1953, and why were we surcharged the cost of many drugs (not "foods or toilet articles") disallowed by the government? My testimony was written from my own personal experiences in the N.H.S. Mr. Fitch is a skilled apologist for the system, 4
SURVIVAL FAMILY MEDICAL' NEEDS AS SUGGESTED BY THE
POLK COUNTY PHARMACEUTICAL ASSN. In CQ-operation Wit.h
TilE l'ftLK fOITll\, mHll In~fRlSI ORGi\UZ!\TI'~
civil defense efforts Sir: Enclosed is a pamphlet printed and distributed by the Polk County Pharmaceutical Association in the interest of civil defense. These pamphlets along with large posters, which are the same as the cover of the pamphlet, were furnished to stores in the area at the association's expense . In addition to the pamphlets, the association has purchased an ambulance for the Civil Defense Organization in the county and this ambulance carries the a~sociation's name lettered on the side. The ambulance was used by the Civil Defense authorities and the Red Cross following Hurricane Donna last year. We plan in the future to purchase two walk-in vans for use as mobile pharmacies. We have, at this point, received supplies for these pharmacies from several manufacturers. The supplies are stored here in the county for emergency use. A plan has been worked out for distribution of these supplies in case of an emergency. This plan was worked out prior to Hurricane Donna, but luckily was not needed in this area. Earl H . Pettijohn , secretary Polk County Pharmaceutical Association
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
recruiting for the future
Sir: Enclosed please find six application forms for new members of the AMERICAN PHARMACEUTICAL ASSOCIATION and two membership dividend report forms. It has been a rewarding experience not only from the "dividends" I have accumulated, but also to learn how many pharmacists feel toward this association, toward pharmacy as a profession, toward the future of pharmacy and about what can be done to improve the profession. I dare say that the majority of the pharmacists are extremely pessimistic about the future of pharmacy, and doubtful if the APHA will be able to do anything to improve standards within the profession. I personally have my own opinion about what potentially this association has the ability to do for the profession. It would be too long to enumerate my ideas in this letter, but you can rest assured that I firmly believe that this association holds the antidote to the toxic problems which are poisoning this profession, and will eventually develop the proper instruments for the effective eradication of these problems. Do not think that these are all the applications which I am going to send in. I still have three days to recruit new members and I shall make every possible effort to reach my quota- and better if possible. There is nothing I would like better than to attend my first national convention as a reward for having been an "active" member of the AMERICAN PHARMACEUTICAL ASSOCIATION. ]( enneth R. Keating Tuckahoe, New York
art i c leo n M D-o w ned pharmacies Sir: I commend to your attention an artide in the November issue of New J1Jedical Materia, page 63, entitled, "Why the Doctor Should Not Own Any Interest in a Retail Pharmacy. " I thought that the author, E.L. Fitzgerald, MD, put it on the line for his fellow-professionals. Howard Hopkins Lexington , Kentucky
Journal informative Sir: I am very proud of my affiliation with the AMERICAN PHARMACEUTICAL AssoCIATION and enjoy the JOURNAL which gives me much information and keeps me abreast of civil and scientific advances in pharmacy. William NIcKinley Woo Macon, Georgia
• ••• • • • • • • • • • • • • • • •
new yea r 's res 0 I uti 0 n Sir: I would like to see the Code of Ethics of the AMERICAN PHARMACEUTICAL ASSOCIATION reprinted every year in the January issue of the JOuRNAL-as sort of a "New Year's resolution" for all pharmacists across the country. I feel that we all need a reminder that ours is an honorable profession and that we have an obligation to that profession. If all of us lived by the Code of Ethics, we would have no discount house pharmacies, no problem of physicians' samples, no traffic in counterfeit drugs and the "FDA Action" page of your JOURNAL would be a thing of the past. Let us reaffirm our faith in, our duty and our obligation to our profession. J. David Schreiner Anderson, Indiana Editor's note: This excellent suggestion is implemented in this very issue (see page 16).
'a sincere thank you' Dear Friends: Your letters, messages and cards have been received and read with the same emotional feelings which prompted your sending them. But they, together with the other tributes sent to Roy Bird Cook, have been so overwhelming in number that I cannot write each of you a personal letter. The flowers sent both to the funeral and to our home were all beautiful. The contributions to the church have reached such proportions that an individual memorial is being planned there. N ow funds are coming in for a memorial project in his memory at the School of Pharmacy, West Virginia University. The press has been exceedingly kind For every tribute paid to Roy Bird, his daughters and I are deeply appreciative. However, what is most gratifying to us is the knowledge that you were so free with your words of appreciation, so generous with the honors you conferred upon him while he was still living. These enriched his life and stimulated him to worthwhile activity to the very end of his life. By making us feel that you personally share our loss you have made our ordeal much easier to bear. Our gratitude is too great to express in words but it will live long in our hearts. All we can do is say a sincere thank you for recognizing and appreciating Roy Bird Cook. Gratefully yours, Eleanor J. Cook Charleston, West Virginia 2
Journal of the
Postline • • •
's 0 cia liz e d me d i c i n e in Br ita in' Sirs: The article by Dr. E. Lloyd Dawe entitled "I Am a Fugitive from Socialized Medicine in Britain," published in the September 1961 issue of THIS JOURNAL, contains many erroneous statements or conclusions. Among these are the following: Practice under the National Health Service soon became intolerable for me, as it has for thousands of British and European doctors who have left their countries to practice in America.
We have no evidence that since 1948, when the health service began, 1,000 British doctors have left the United Kingdom to practice in America. Can Dr. Dawe supply this evidence? In Britain the amount and kind of drugs were also restricted for the general practitioner. Only doctors on the staffs of hospitals initially could prescribe new drugs not listed in the British Pharmacopoeia or National Formulary.
It is a basic principle of the British health service that a doctor is completely free to prescribe any drug he considers necessary for the treatment of his patients. The only reservation is that he may not prescribe foods or toilet articles. Government-licensed drug houses supplied medicines, which the general practitioners were supposed to prescribe by their generic name.
The statement is nonsense. No drug houses are owned by the government, by the Ministry of Health or by the nation. The only license issued is in respect of substances controlled by the Therapeutic Substances Act and this only applies to those products the purity and potency of which cannot be determined by chemical or physical methods. Nearly every week, a number of doctors would be fined because they prescribed a drug which in their best judgment was needed by a patient but which was not on the government's official list.
The main limitation on prescribing is exercised through the arrangement that any doctor whose average cost per prescription is substantially higher than that of his colleagues in the area, is liable to have his prescribing investigated by a committee of doctors. The doctor can be surcharged for the estimated ex-
AMERICAN PHARMACEUTICAL ASSOCIATION
• • • • • • • • • • • • • • • • • • cessive cost of his prescribing. During 1959 the total number of cases in which money was withheld was nine and the total sum involved was $420. In addition to that positive check, the doctor is provided with advice on how to prescribe economically. The Standing J oint Committee on the Classification of Proprietary Preparations has classified between 4,000 and 5,000 proprietary preparations according to its therapeutic evaluation of them. Doctors are adyised that normally they need not go outside the drugs and preparations in the British Pharmacopoeia, British Pharmaceutical Codex and British N ational Formulary or the committee's own categories N (new drugs of proved value, not yet standard) and P (drugs for which there is a prima facie evidence of therapeutic value but where the committee wants further evidence before firm classification). A standard drug is defined as a preparation described in the British Pharmacopoeia, British Pharmaceutical Codex or British N ational Formulary. Form-filling and correspondence with the government became one of the physician's major functions.
Doctors have always had to deal with a number of certificates and forms; under the health service there are about 30 official forms to meet various purposes but fewer than ten of these are in constant use, the others being designed to meet special cases only. The service has relieved family doctors of all the paper work involved in rendering accounts to their patients and collecting (or waiving) outstanding debts. Under the National Health Service, patients not only had no choice of hospitals, they were fortunate to get accommodations at all in jam-packed institutions.
Dr. Dawe makes no statistical comparison between the numbers of people treated in hospitals under the old voluntary system and under the National Health Service although the figures are available. The number of available staffed beds has been increased by about 27,000 since the start of the service, the number of hospital consultants has increased from 4,711 to 6,950 and the total nursing and midwifery staff in hospitals has increased by about 35,000 wholetime and 18,000 part-time. And hospitals can now afford to buy apparatus for diagnosis and treatment which was impossible when flag-days and legacies were the main sources of income. (continued on page 4)
But private or semi-private rooms were almost unheard of.
Most of the teaching hospitals (there are 22 of them) have private wings for the care of patients who wish to pay for treatment.
but I find more significance in the points he evades than in his quibbles. One can only conclude from this that Mr. Fitch tacitly admits that the real criticisms made in my testimony are undeniable.
E. Lloyd Dawe, MD Danbury, Connecticut
There are two or three government clerks for each doctor.
Most of the administration is in the hands of those who serve in an unpaid voluntary capacity-about 10,000 in England and Wales. The administrative costs of the service are about 3 percent of the total expenditure. Apart from the staff of the Ministry of Health (which numbers less than 3,000 and deals with all aspects of health, not only with the administration of the service) there are no other civil servants among the half million people employed in the service. Outside the hospital service there are 22,000 family doctors in general practice, 15,500 pharmacies, 10,000 dentists and 7,000 opticians. The insured must also carry the heavy taxes that pay for the nationalized health plan.
The service is paid for (a) mostly out of national taxation in the same way as this applies to education or the armed forces, (b) about one-seventh of the total cost, from a special health service weekly contribution paid by all active members of the population-amounting for an employed man to 39 cents and 10 cents for his employer (the young and the elderly, make no contribution, but are probably the main beneficiaries) -(c) by a small charge per prescription of 28 cents each. W.K. Fitch London, England Sir: It is always easy to criticize remarks taken out of context, as Mr. Fitch has done, but it is somewhat irresponsible to take exception to statements which were never made. Mr. Fitch, for example, claims that I said at least 1,000 British doctors had left the United Kingdom to practice in America. As anyone can see from the quotation itself, this is not the implication. Most British doctors, it is true, emigrate to the Commonwealth rather than to the U.S., but the total number certainly comes to more than 1,000. I don't know where Mr. Fitch got his statistics, but if he will consult the Jewkes report, "Genesis of the British N.H.S.," he will find statistics that tell a very different story. If, as Mr. Fitch says, "a doctor is completely free to prescribe any drug he considers necessary," etc., why was I unable to prescribe aureomycin in 1953, and why were we surcharged the cost of many drugs (not "foods or toilet articles") disallowed by the government? My testimony was written from my own personal experiences in the N.H.S. Mr. Fitch is a skilled apologist for the system, 4
SURVIVAL FAMILY MEDICAL' NEEDS AS SUGGESTED BY THE
POLK COUNTY PHARMACEUTICAL ASSN. In CQ-operation Wit.h
TilE l'ftLK fOITll\, mHll In~fRlSI ORGi\UZ!\TI'~
civil defense efforts Sir: Enclosed is a pamphlet printed and distributed by the Polk County Pharmaceutical Association in the interest of civil defense. These pamphlets along with large posters, which are the same as the cover of the pamphlet, were furnished to stores in the area at the association's expense . In addition to the pamphlets, the association has purchased an ambulance for the Civil Defense Organization in the county and this ambulance carries the a~sociation's name lettered on the side. The ambulance was used by the Civil Defense authorities and the Red Cross following Hurricane Donna last year. We plan in the future to purchase two walk-in vans for use as mobile pharmacies. We have, at this point, received supplies for these pharmacies from several manufacturers. The supplies are stored here in the county for emergency use. A plan has been worked out for distribution of these supplies in case of an emergency. This plan was worked out prior to Hurricane Donna, but luckily was not needed in this area. Earl H . Pettijohn , secretary Polk County Pharmaceutical Association
Journal of the AMERICAN PHARMACEUTICAL ASSOCIATION
recruiting for the future
Sir: Enclosed please find six application forms for new members of the AMERICAN PHARMACEUTICAL ASSOCIATION and two membership dividend report forms. It has been a rewarding experience not only from the "dividends" I have accumulated, but also to learn how many pharmacists feel toward this association, toward pharmacy as a profession, toward the future of pharmacy and about what can be done to improve the profession. I dare say that the majority of the pharmacists are extremely pessimistic about the future of pharmacy, and doubtful if the APHA will be able to do anything to improve standards within the profession. I personally have my own opinion about what potentially this association has the ability to do for the profession. It would be too long to enumerate my ideas in this letter, but you can rest assured that I firmly believe that this association holds the antidote to the toxic problems which are poisoning this profession, and will eventually develop the proper instruments for the effective eradication of these problems. Do not think that these are all the applications which I am going to send in. I still have three days to recruit new members and I shall make every possible effort to reach my quota- and better if possible. There is nothing I would like better than to attend my first national convention as a reward for having been an "active" member of the AMERICAN PHARMACEUTICAL ASSOCIATION. ]( enneth R. Keating Tuckahoe, New York
art i c leo n M D-o w ned pharmacies Sir: I commend to your attention an artide in the November issue of New J1Jedical Materia, page 63, entitled, "Why the Doctor Should Not Own Any Interest in a Retail Pharmacy. " I thought that the author, E.L. Fitzgerald, MD, put it on the line for his fellow-professionals. Howard Hopkins Lexington , Kentucky
Journal informative Sir: I am very proud of my affiliation with the AMERICAN PHARMACEUTICAL AssoCIATION and enjoy the JOURNAL which gives me much information and keeps me abreast of civil and scientific advances in pharmacy. William NIcKinley Woo Macon, Georgia