- Email: [email protected]
PRIVILEGE AND RESPONSIBILITY
570
alum- containing D.T.P. at 1, 5, and 9 weeks of age; 28 of the 31 produced measurable agglutinin, which generally, but not invariably,9 indicates protection. Miller et awl. were impressed by the declining incidence rising birth-rate; and by the four-yearly increases in the " decreasing notification-rate,! attributing both these changes to the use of pertussis vaccine. The birth-rate has been falling of
pertussis in the face of
a
scale " of the
since 1964. In the years 1970, 1971, and the 53 weeks to Jan. 7, 1975, the notifications (England and Wales) were 15,972, 16,792, and 16,458, respectively. We still do not find their argument
16,000-odd
Only 7 of last year’s Contemporary therapeutic
convincing.
cases were
fatal.
effective. Adequately effective vaccines made of whole killed bacterial bodies which are safe enough to give to children have not yet been prepared against any disease. The M.R.C. are supporting research at Reading University on pertussis vaccines prepared from bacterial constituents, and similar work is in train at the Microbiological Research Establishment. Is it not time for the members of the D.H.S.S. Committee on Vaccination and Immunization to advise the withdrawal of the present inadequately protective, unpleasant, and occasionally mutilating pertussis vaccine until this work produces a satisfactory new one ? The committee would lose no face by such a change of advice. Their West German opposite numbers have just shown them the way.
methods
are
Central Laboratory, St. Mary’s General Hospital, East Wing, Milton Road, Portsmouth P03 6AQ.
J. V. T. GOSTLING D. J. H. PAYNE.
ACTIVE IMMUNISATION AGAINST VARICELLA
SIR,—The investigations of Ferencz published in 1946, of interest in connection with the vaccination experiagainst varicella reported by Takahashi et al. (Nov. 30, p. 1288). Since Ferencz’s work appeared only in Hungarian and in the year immediately after the 1939-45 war, it is not included in the Cumulative Index Medicus, and a brief account of his observations seems justified. He performed vaccination with clear vesicular fluid from varicella patients; this was diluted 20-fold and given intracutaneously into the skin of children exposed to varicella. On the 9th or 10th day a small papule formed at the site of vaccination in children susceptible to varicella; this meant that the vaccinated children were indeed susceptible, but at the Ferencz confirmed the same time were immunised. " efficacy of this " varicellisation procedure by epidemiological observations, and also by complement-binding studies with the vesicular fluid as antigen. I myself have often been able to confirm the efficacy of the Ferencz method in children exposed to and endangered by varicella. From the work of Takahashi et al., I see that even though the method of Ferencz is now open to criticism his observations and conclusions were sound. Although subcutaneous administration of the vaccine of Takahashi et al. appears safe, it would be worth checking Ferencz’s earlier investigations with modern vaccine and methods, since this means of vaccination approximates more closely to natural immunisation, and experience over a number of decades indicates that it is without danger. are
ments
Department of Pediatrics, University of Szeged, H-6725 Szeged, Hungary.
DOMOKOS BODA.
RECOGNITION OF DIPHTHERIA
SiR,—I write in support of Dr McSwiggan and Dr Taylor (March 1, p. 515) in their plea that diphtheria is foremost a clinical and not a bacteriological diagnosis. Last week Dowsett et al.1 gave details of an outbreak erysipelas in which the first patient was treated with ampicillin rather than benzylpenicillin. Subsequent spread was rightly ascribed to this. Some time ago 2 you published an excellent and timely editorial on infectious diseases and their management. These two examples surely show the continuing need for the trained infectious-diseases physician, as well as facilities for isolating infectious patients and suspects. They also emphasise the consequences of the demise of the medical officer of health and his role in the prevention of spread of infection. The new managerial look and the emphasis on " community medicine " have been an unmitigated disaster for infectious diseases. Despite all the encouraging noises that have been made, nothing has been done to halt the decline of the specialty. of
Chadwell Heath Hospital, Grove Road, Romford RM6 4XH.
THE CONSULTANTS’ CONTRACT
SiR.—Your editorial of Feb. 22 (p. 440) would give the impression that you regard Mrs Castle as being reasonable, and the profession’s negotiators as being intransigent. I am sad that a journal priding itself on its scientific objectivity should allow political bias to sway its judgment. Can you honestly say that you believe that medicine would survive as a profession (as opposed to a performing-flea kind of technicians’ association ready to jump smartly at every crooking of the bureaucratic little finger) if it were bullied and limited in the unrealistic, inefficient, and degrading manner suggested in the Minister’s extraordinary document ? I repeat, Sir; can you really think the Minister’s proposals reflect informed, sober, forward-looking, wellbalanced thinking ? I look forward to your reply with some
ii, 454.
interest.
14 Carden Place, Aberdeen.
DOUGLAS NEEDHAM, Whole-time consultant physician.
** * We have found it hard, as Dr Needham clearly has, to maintain strict scientific objectivity in a matter of medicine and politics. We do not judge that any of the Government’s proposals concerning new closed contracts for N.H.S. consultants (a type of contract for which their representatives have for years been pleading) are sufficiently ill-informed, intemperate, regressive, or unbalanced to justify the furious response they have received; or, even less, to merit the adoption of sanctions which could harm patients. Last week (p. 506) we suggested that some consultants might not have thought out the full implications of a closed contract and the actual loss of independence which it might entail. In the letter which follows, Mr Lythgoe makes the point better than we did.-ED. L.
PRIVILEGE AND RESPONSIBILITY
SiR,—Iam sure that I am not alone in the disquiet I feel at the lingering campaign of sanctions by N.H. S. consultants. Under our present contract we enjoy a degree of privilege Dowsett, E. G., Herson, R. N., Maxted, W. R., Widdowson, J. P. Br. med. J. March 1, 1975, p. 500. 2. Lancet, 1974, ii, 1051. 1.
9. Medical Research Council. Br. med. J. 1956, 10. Ferencz, P. Népégészségügy, 1946, 8, 497.
I. M. LIBRACH.
571
which is unique among salaried employees anywhere. We may
come
and go
please and arrange our work, outside normal hours, entirely as we as we
whether inside or think fit. All but the
obtuse have now come to of this arrangement. However, if we continue to abuse our privileges we shall certainly lose them. We have already seen how abuses in the private sector by a small minority of consultants have caused the backlash against pay beds. Now that we are resolved to keep the present contract, it must be clear that the less it is modified the better. The more additional fees we accept for specific services, the greater the likelihood of scrutiny and control.
appreciate
the
most
advantages
Consultants have a strong case for a salary increase to compensate for the ravages of inflation over many years. This is widely recognised and our case is before the Review Body. To persist with sanctions before the Review Body has reported is both irresponsible and inexpedient. We shall have only ourselves to blame if we end up by forfeiting both our privileges and the respect of the community which we still enjoy. Department of Surgery, Sharoe Green Hospital, Fulwood, Preston PR2 4DU.
J. P. LYTHGOE.
REPRESENTATION OF COMMUNITY HEALTH COUNCILS IN HEALTH-CENTRE MANAGEMENT SIR,-On Oct. 22, 1974, health workers at Glyncorrwg Health Centre met members of the district health team, at the latter’s invitation, to form an advisory committee to help in managing the centre; this was a very welcome
development. In discussing composition of this committee it was suggested, with unanimous support of all local health workers, that the local community health council be represented. This was opposed by representatives of the district team, as setting a precedent requiring a decision from higher bodies; we were unconvinced by this argument, because we thought it was up to all of us to define the content of the 1974 reorganisation in terms of our local experience and instincts, and where no guidelines were already laid down, we felt their definition should be by local opinion. In spite of this a week later we received a letter advising us that in the district administrator’s opinion representation of the community health council would be inappropriate, as the meetings are intended to discuss matters of interest to the professional users of the Health Centre". Who actually runs health centres ? Who decides what is of interest to professional users and why should they not be interested in consumer opinion ? If those doctors who oppose consumer participation in the running of local health services have the right not only to refuse representation, but even a right of entry to their premises to the community health councils (as they have been reassured by the Department of Health) is there not also a right for those doctors who think otherwise to invite such participation ? We can hardly believe that we have gone so far along the "
road
to a corporate State that our experience could be universal, and we think it is time that more of us with either positive or negative experiences of attempts to involve patients or their representatives in some degree of control of local health services should pool their experience, and begin to build a progressive body of Case Law.
Health Centre, Port Talbot,
Glyncorrwg near
Glamorgan, Wales SA13 3BL.
J. TUDOR HART A. P. HAINES.
V.I.P.s IN HOSPITAL Donald Douglas (Feb. 15, p. 389) correctly SIR,-Sir draws attention to the fact that the leaders of our society need, and should have, privacy when in N.H.S. hospitals. All people are equal but some are more equal than others; we need to recognise a person’s status, not his purse, when he comes into hospital. This would be met by a substantial increase in amenity beds, and the fact that they are available should be widely advertised to the public. The cost of such a room should be nominal, and I see no reason at all why any Government should object to this paid-for
privacy. 24 North
Parade, Aberystwyth, Cards. SY23 2NQ.
JOHN H. HUGHES.
HOSPITALS FOR THE MENTALLY HANDICAPPED Medical SiR,—The Directory 1974 lists over 210 hospitals for the mentally handicapped in England and Wales; there are just under 20 hospitals for mental deficiency in Scotland. The number of beds in these hospitals ranges from 14 to 1954. Over half the hospitals for mental handicap in England and Wales have under 100 beds (17 with under 25 beds, 44 with 25-50 beds, 45 with 50-100 beds). No hospital now has more than 2000 beds; 5 have over 1500 beds, 8 hospitals have 1000-1500 beds, 24 have between 500 and 1000, over 30 have between 200 and 500, and over 30 have between 100 and 200 beds. The South Western Region and the Trent Region each have over 30 hospitals for mental handicap, many of which are small units. The North-West Thames, South-West Thames, Mersey, and North Western Regions each have a smaller number of hospitals, some of which are very large. Scotland has no very large hospitals and fewer small units; most of its hospitals are in the 100-500 bed range. In terms of their location, hospitals for the mentally handicapped fall into the following broad groups:
(1) Large hospitals (over 200 beds) on the fringe of a centre of population or conurbation; where these are situated within 5 miles of the centre, the majority of the population served lives near the hospital, but many others are more remote from the population served. (2) Large hospitals (over 200 beds) in or near country towns or villages; these usually serve large areas and are remote from most of the population served. (3) Small hospitals (under 200 beds) in country towns and villages; these units are often associated with larger hospitals, and most of them lack the range of facilities necessary to serve the local population near them. In the reorganised National Health Service the new area health authorities are generally coterminous with the reorganised local-government areas. The distribution of hospitals for mental handicap within these areas is very uneven-while one health district will contain many units, another will have none. Hardly anywhere do the present hospitals for the mentally handicapped meet in number, size, or location the current ideal of small units serving the local
population. Where small hospitals are near a centre of population there is the possibility of their continued use to offer a more locally based service. The large hospitals situated near to the centre of the population served could continue to provide a local service. But the retention of large hospitals in country areas remote from the population served is harder to justify, although many such hospitals have received relatively recent extensions and rerovation. To change the pattern of the present hospital provision for the mentally handicapped would, however, be an enormous and formidable task, in respect both of the financial implications
alum- containing D.T.P. at 1, 5, and 9 weeks of age; 28 of the 31 produced measurable agglutinin, which generally, but not invariably,9 indicates protection. Miller et awl. were impressed by the declining incidence rising birth-rate; and by the four-yearly increases in the " decreasing notification-rate,! attributing both these changes to the use of pertussis vaccine. The birth-rate has been falling of
pertussis in the face of
a
scale " of the
since 1964. In the years 1970, 1971, and the 53 weeks to Jan. 7, 1975, the notifications (England and Wales) were 15,972, 16,792, and 16,458, respectively. We still do not find their argument
16,000-odd
Only 7 of last year’s Contemporary therapeutic
convincing.
cases were
fatal.
effective. Adequately effective vaccines made of whole killed bacterial bodies which are safe enough to give to children have not yet been prepared against any disease. The M.R.C. are supporting research at Reading University on pertussis vaccines prepared from bacterial constituents, and similar work is in train at the Microbiological Research Establishment. Is it not time for the members of the D.H.S.S. Committee on Vaccination and Immunization to advise the withdrawal of the present inadequately protective, unpleasant, and occasionally mutilating pertussis vaccine until this work produces a satisfactory new one ? The committee would lose no face by such a change of advice. Their West German opposite numbers have just shown them the way.
methods
are
Central Laboratory, St. Mary’s General Hospital, East Wing, Milton Road, Portsmouth P03 6AQ.
J. V. T. GOSTLING D. J. H. PAYNE.
ACTIVE IMMUNISATION AGAINST VARICELLA
SIR,—The investigations of Ferencz published in 1946, of interest in connection with the vaccination experiagainst varicella reported by Takahashi et al. (Nov. 30, p. 1288). Since Ferencz’s work appeared only in Hungarian and in the year immediately after the 1939-45 war, it is not included in the Cumulative Index Medicus, and a brief account of his observations seems justified. He performed vaccination with clear vesicular fluid from varicella patients; this was diluted 20-fold and given intracutaneously into the skin of children exposed to varicella. On the 9th or 10th day a small papule formed at the site of vaccination in children susceptible to varicella; this meant that the vaccinated children were indeed susceptible, but at the Ferencz confirmed the same time were immunised. " efficacy of this " varicellisation procedure by epidemiological observations, and also by complement-binding studies with the vesicular fluid as antigen. I myself have often been able to confirm the efficacy of the Ferencz method in children exposed to and endangered by varicella. From the work of Takahashi et al., I see that even though the method of Ferencz is now open to criticism his observations and conclusions were sound. Although subcutaneous administration of the vaccine of Takahashi et al. appears safe, it would be worth checking Ferencz’s earlier investigations with modern vaccine and methods, since this means of vaccination approximates more closely to natural immunisation, and experience over a number of decades indicates that it is without danger. are
ments
Department of Pediatrics, University of Szeged, H-6725 Szeged, Hungary.
DOMOKOS BODA.
RECOGNITION OF DIPHTHERIA
SiR,—I write in support of Dr McSwiggan and Dr Taylor (March 1, p. 515) in their plea that diphtheria is foremost a clinical and not a bacteriological diagnosis. Last week Dowsett et al.1 gave details of an outbreak erysipelas in which the first patient was treated with ampicillin rather than benzylpenicillin. Subsequent spread was rightly ascribed to this. Some time ago 2 you published an excellent and timely editorial on infectious diseases and their management. These two examples surely show the continuing need for the trained infectious-diseases physician, as well as facilities for isolating infectious patients and suspects. They also emphasise the consequences of the demise of the medical officer of health and his role in the prevention of spread of infection. The new managerial look and the emphasis on " community medicine " have been an unmitigated disaster for infectious diseases. Despite all the encouraging noises that have been made, nothing has been done to halt the decline of the specialty. of
Chadwell Heath Hospital, Grove Road, Romford RM6 4XH.
THE CONSULTANTS’ CONTRACT
SiR.—Your editorial of Feb. 22 (p. 440) would give the impression that you regard Mrs Castle as being reasonable, and the profession’s negotiators as being intransigent. I am sad that a journal priding itself on its scientific objectivity should allow political bias to sway its judgment. Can you honestly say that you believe that medicine would survive as a profession (as opposed to a performing-flea kind of technicians’ association ready to jump smartly at every crooking of the bureaucratic little finger) if it were bullied and limited in the unrealistic, inefficient, and degrading manner suggested in the Minister’s extraordinary document ? I repeat, Sir; can you really think the Minister’s proposals reflect informed, sober, forward-looking, wellbalanced thinking ? I look forward to your reply with some
ii, 454.
interest.
14 Carden Place, Aberdeen.
DOUGLAS NEEDHAM, Whole-time consultant physician.
** * We have found it hard, as Dr Needham clearly has, to maintain strict scientific objectivity in a matter of medicine and politics. We do not judge that any of the Government’s proposals concerning new closed contracts for N.H.S. consultants (a type of contract for which their representatives have for years been pleading) are sufficiently ill-informed, intemperate, regressive, or unbalanced to justify the furious response they have received; or, even less, to merit the adoption of sanctions which could harm patients. Last week (p. 506) we suggested that some consultants might not have thought out the full implications of a closed contract and the actual loss of independence which it might entail. In the letter which follows, Mr Lythgoe makes the point better than we did.-ED. L.
PRIVILEGE AND RESPONSIBILITY
SiR,—Iam sure that I am not alone in the disquiet I feel at the lingering campaign of sanctions by N.H. S. consultants. Under our present contract we enjoy a degree of privilege Dowsett, E. G., Herson, R. N., Maxted, W. R., Widdowson, J. P. Br. med. J. March 1, 1975, p. 500. 2. Lancet, 1974, ii, 1051. 1.
9. Medical Research Council. Br. med. J. 1956, 10. Ferencz, P. Népégészségügy, 1946, 8, 497.
I. M. LIBRACH.
571
which is unique among salaried employees anywhere. We may
come
and go
please and arrange our work, outside normal hours, entirely as we as we
whether inside or think fit. All but the
obtuse have now come to of this arrangement. However, if we continue to abuse our privileges we shall certainly lose them. We have already seen how abuses in the private sector by a small minority of consultants have caused the backlash against pay beds. Now that we are resolved to keep the present contract, it must be clear that the less it is modified the better. The more additional fees we accept for specific services, the greater the likelihood of scrutiny and control.
appreciate
the
most
advantages
Consultants have a strong case for a salary increase to compensate for the ravages of inflation over many years. This is widely recognised and our case is before the Review Body. To persist with sanctions before the Review Body has reported is both irresponsible and inexpedient. We shall have only ourselves to blame if we end up by forfeiting both our privileges and the respect of the community which we still enjoy. Department of Surgery, Sharoe Green Hospital, Fulwood, Preston PR2 4DU.
J. P. LYTHGOE.
REPRESENTATION OF COMMUNITY HEALTH COUNCILS IN HEALTH-CENTRE MANAGEMENT SIR,-On Oct. 22, 1974, health workers at Glyncorrwg Health Centre met members of the district health team, at the latter’s invitation, to form an advisory committee to help in managing the centre; this was a very welcome
development. In discussing composition of this committee it was suggested, with unanimous support of all local health workers, that the local community health council be represented. This was opposed by representatives of the district team, as setting a precedent requiring a decision from higher bodies; we were unconvinced by this argument, because we thought it was up to all of us to define the content of the 1974 reorganisation in terms of our local experience and instincts, and where no guidelines were already laid down, we felt their definition should be by local opinion. In spite of this a week later we received a letter advising us that in the district administrator’s opinion representation of the community health council would be inappropriate, as the meetings are intended to discuss matters of interest to the professional users of the Health Centre". Who actually runs health centres ? Who decides what is of interest to professional users and why should they not be interested in consumer opinion ? If those doctors who oppose consumer participation in the running of local health services have the right not only to refuse representation, but even a right of entry to their premises to the community health councils (as they have been reassured by the Department of Health) is there not also a right for those doctors who think otherwise to invite such participation ? We can hardly believe that we have gone so far along the "
road
to a corporate State that our experience could be universal, and we think it is time that more of us with either positive or negative experiences of attempts to involve patients or their representatives in some degree of control of local health services should pool their experience, and begin to build a progressive body of Case Law.
Health Centre, Port Talbot,
Glyncorrwg near
Glamorgan, Wales SA13 3BL.
J. TUDOR HART A. P. HAINES.
V.I.P.s IN HOSPITAL Donald Douglas (Feb. 15, p. 389) correctly SIR,-Sir draws attention to the fact that the leaders of our society need, and should have, privacy when in N.H.S. hospitals. All people are equal but some are more equal than others; we need to recognise a person’s status, not his purse, when he comes into hospital. This would be met by a substantial increase in amenity beds, and the fact that they are available should be widely advertised to the public. The cost of such a room should be nominal, and I see no reason at all why any Government should object to this paid-for
privacy. 24 North
Parade, Aberystwyth, Cards. SY23 2NQ.
JOHN H. HUGHES.
HOSPITALS FOR THE MENTALLY HANDICAPPED Medical SiR,—The Directory 1974 lists over 210 hospitals for the mentally handicapped in England and Wales; there are just under 20 hospitals for mental deficiency in Scotland. The number of beds in these hospitals ranges from 14 to 1954. Over half the hospitals for mental handicap in England and Wales have under 100 beds (17 with under 25 beds, 44 with 25-50 beds, 45 with 50-100 beds). No hospital now has more than 2000 beds; 5 have over 1500 beds, 8 hospitals have 1000-1500 beds, 24 have between 500 and 1000, over 30 have between 200 and 500, and over 30 have between 100 and 200 beds. The South Western Region and the Trent Region each have over 30 hospitals for mental handicap, many of which are small units. The North-West Thames, South-West Thames, Mersey, and North Western Regions each have a smaller number of hospitals, some of which are very large. Scotland has no very large hospitals and fewer small units; most of its hospitals are in the 100-500 bed range. In terms of their location, hospitals for the mentally handicapped fall into the following broad groups:
(1) Large hospitals (over 200 beds) on the fringe of a centre of population or conurbation; where these are situated within 5 miles of the centre, the majority of the population served lives near the hospital, but many others are more remote from the population served. (2) Large hospitals (over 200 beds) in or near country towns or villages; these usually serve large areas and are remote from most of the population served. (3) Small hospitals (under 200 beds) in country towns and villages; these units are often associated with larger hospitals, and most of them lack the range of facilities necessary to serve the local population near them. In the reorganised National Health Service the new area health authorities are generally coterminous with the reorganised local-government areas. The distribution of hospitals for mental handicap within these areas is very uneven-while one health district will contain many units, another will have none. Hardly anywhere do the present hospitals for the mentally handicapped meet in number, size, or location the current ideal of small units serving the local
population. Where small hospitals are near a centre of population there is the possibility of their continued use to offer a more locally based service. The large hospitals situated near to the centre of the population served could continue to provide a local service. But the retention of large hospitals in country areas remote from the population served is harder to justify, although many such hospitals have received relatively recent extensions and rerovation. To change the pattern of the present hospital provision for the mentally handicapped would, however, be an enormous and formidable task, in respect both of the financial implications