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REGISTRAR ESTABLISHMENTS MINISTRY OF HEALTH STATEMENT
537
Poliomyelitis In England and Wales notifications of poliomyelitis in the week ended Oct. 28 were : paralytic 182 (197), non-paralytic 71 (81) ; total 253 (278). The figures for the previous week are in parentheses. Notifications for the corresponding week in 1947 and 1949 totalled 280 and 367. Total uncorrected notifications for 1950 up to The and including the week under review are 7543. corresponding figures for 1947, 1948, and 1949 were 8022, 1975, and 5259. A gradual reduction in notifications has now been maintained for several weeks.
gave a new low record of 31 per 1000 related live births. For years the Birmingham rate of infant mortality has been below that for England and Wales ; this is a great tribute to local endeavour, for circumstances in this city are not favourable for a low rate.
Infectious Diseases in
Dr. Newsholme’s Retirement Newsholme, who in 1928 succeeded Sir John Robertson as medical officer of health for Birmingham, retired this year. Formerly Birmingham had an unenviable notoriety ; but in Robertson’s time it gained a first-class public-health service which Dr. Newsholme carried on with outstanding success. The school medical service had grown up independently of the public-health service ; and collaboration of these two services, without fusion, was the most notable achievement of Dr. Newsholme’s period of office. Dr. Newsholme’s contributions to public-health theory have been mainly philosophical; but his factual annual reports, with only necessary commentary, have a His last permanent place in public-health history. report-that for 1940-reveals a better state of health in the city than ever before. For the first year on record no child died of diphtheria. Pulmonary tuberculosis showed a slight increase in notification but a reduction in fatality. Maternal mortality was 0-39, or, including deaths from abortion, 0-49, per 1000 live and still births ; and there were no deaths from sepsis. Infant mortality
England
and Wales
Dr. H. P.
Special
Articles
REGISTRAR ESTABLISHMENTS MINISTRY OF HEALTH STATEMENT
important announcement on the future establishment of senior registrars and registrars in England and Wales has been made by the Ministry of Health in a The circular (R.H.B. circular to hospital authorities. [50] 106) is summarised below. AN
1. It has from the outset been made clear that the senior registrar and registrar grades are regarded as training grades for potential consultants (or senior hospital medical or dental officers). It follows that the total number of appointments, particularly in the senior registrar grade, should be closely related to the likely number of openings. 2. It has also been indicated that training should be continued only for those who appear likely to benefit from it, and in particular that promotion from one grade to another should be competitive. The base of the training ladder should be the first year in the registrar grade-a grade which should normally be reached at least 2 years after qualification. The registrar should be reviewed at the end of the first year, and if satisfactory should normally proceed to a second year in this grade. Those wishing to proceed further should seek an appointment in open competition as senior registrar, the number of posts available being considerably less than the number of second-year registrar posts. The senior registrar should also be reviewed at the end of the first and second years. At the end of the third year in a senior registrarship training should be complete ; appointment for a fourth year should be very exceptional, and for the most part confined to certain specialties such as thoracic surgery, neurosurgery, and plastic surgery or to doctors who, having completed training as, for example, general physicians, wish to take up other specialties. LIKELY NUMBER OF VACANCIES
3. For some years to come the number of appointments open to senior registrars who complete their training at
*
Not including late returns.
in England and Wales is unlikely to exceed 150 per annum. This includes, not only consultant and senior hospital medial or dental officer appointments to make good wastage through death or retirement, but also a proportion of additional posts and openings in other services and overseas as well as in hospitals in this country. Thus it appears that the number of should not at present exceed the following : posts training senior registrar, 600 ; registrar, 1100.’ The figure for registrars is a total for those in the first and second years of training, and that for senior registrars the total for those in the first, second, and third years. 4. At present the number in each of these two grades is upwards of 1400. " It is therefore essential to take steps to bring the number of training posts as quickly as possible into line with the numbers required." 5. The objectives should be : (a) To fix for each hospital regional area an establishment of training posts properly distributed between the different
hospitals
specialties and situated in hospitals with suitable facilities. (b) To reduce the present numbers by : (i) making appointments only up to the new establishment figures ; and (ii) discontinuing appointments of senior registrars now in their third or subsequent years as the present year of appointment (See also para. 2 and para. 9 (ii).) If necessary, to make alternative carrying out the work of the hospitals.
ends.
(c)
appointments
for
FIXING AN ESTABLISHMENT
6. Each regional board and the related board or boards of governors are asked to consider urgently together what trainee posts should be provided in the area within the maxima indicated below, and to submit their joint proposals by Jan. 31, 1951. In preparing these proposals, the cooperation of the dean or director of postgraduate medical studies of the university should be sought. The proposals should indicate the number of senior registrar and registrar posts proposed for each specialty and the hospitals where these posts are to be held. The Minister will review these proposals as a whole, with particular reference to the distribution between specialties, which can be satisfactorily determined only on a national basis.
538 7. It appears that the maximum total number of posts for each regional area (including teaching hospitals) should be : Senwr .. regU3trar (total for first, second, and third year)
Region
Newcastle Leeds Sheffield East Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South Western Wales.. ’
........
......
..
Birmingham Manchester
......
......
Liverpool
34 36 42 18 75 48 52 83 22 30 28 52 52 28
Registrar
(total for first and second year)
....
....
....
....
....
....
....
....
....
....
....
....
....
....
63 65 76 32 138 86 96 151 42 56 51 96 96 52
The distribution between specialties will vary from to region according to the training facilities ; and the concentration of teaching resources in London will have to be taken into account.
region
REDUCTION IN NUMBERS
addition to fixing total establishments, an distribution in each region of the total into numbers for each year of training must obviously be made, though this may vary slightly at different times. When the distribution of posts by specialty and hospital has been determined, it will be necessary to decide which of the existing first-year registrars or first-year or second-year senior registrars can continue for a further year, and where new appointments in the first year of each grade can be made during the coming year. Regional proposals should therefore include a statement of the number of registrars and senior registrars by specialty in each year of training it is proposed to retain or recruit during the coming year. 9. When the establishment proposals have been approved by the Minister, these should be strictly adhered to. This means that : 8. In
approximate
(i) The number of first-year registrars or senior registrars recruited during the year should be the number (within the approved total) which boards have decided is appropriate. (ii) As the existing second-year registrars and third-year senior registrars reach the end of their personal year of appointment, their appointments should be terminated (except in the exceptional circumstances mentioned in paragraph 2) ; and first-year registrars and first-year and secondyear senior registrars should be reviewed and reappointed for a further year’s training only so far as this is possible within the approved total establishment. 10. From now on, boards should not renew the appointment of any second-year registrar whose personal year of appointment ends, or of any third (or subsequent) year senior registrar except in the exceptional cases mentioned at the end of paragraph 2 or in accordance with the terms of paragraph 11 (a). ALTERNATIVE APPOINTMENTS a board is satisfied that the work of the necessitates an alternative appointment in place of a senior registrar (but not otherwise), the following are among the steps that may be taken :
11. Where
hospital
(a) An existing senior registrar whose appointment as a trainee is not renewed may be offered an appointment for one year only as a temporary senior registrar at his present salary-rate. (b) Alternatively, boards may appoint as part-time clinical assistant a suitably experienced general practitioner (normally one with a higher qualification and experience as a senior registrar or registrar). Remuneration will be announced later.
JUNIOR REGISTRARS
13. In future "
junior registrars " will be known as senior house officers," since this is not regarded as a trainee grade like that of registrar. "
OTHER OPENINGS
An
draws attention to the openings outside the National Health Service. First, the three Armed Forces need 400 specialists, notably in the following specialties :
appendix
anaesthetics, surgery, otology, radiology, psychiatry, pathology, and venereology. In addition there are over 100 vacancies for general-duty officers. Secondly, in the Colonial Service about 200 permanent or temporary posts are available. Thirdly, a number of overseas university and hospital appointments are vacant or will shortly be vacant, principally in the Middle East and South-East Asia ; further information about posts in this third group may be had from the Technical and Scientific Register, York House, Kingsway, London, W.C.2.
dermatology,
Parliament Vivisection and Cancer Research ON the motion for the adjournment in the House of Commons on Oct. 31, Mr. PETER FREEMAN doubted whether experimentation on living animals was of real value in the search for a cure for cancer. In 1904 there were 8292 such experiments, and in 1949 they numbered About two-thirds of these were conducted 75,343. without any anaesthetic for the animals concerned. About 80 % of the animals were allowed to recover and could be experimented upon again. The total number of experiments during the last half-century had exceeded 1,300,000. Yet in 1900 deaths from cancer were 26,721, and last year they were 80,732. As possible causes which might be investigated, in preference to continued experiments on animals, he mentioned the stress of modern industrial life, the increased consumption of alcohol, tobacco, narcotics, animal and artificial foods, pasteurised milk, and patent medicines, and the modern craze for injections, serums, inoculations, and vaccinations. He had no doubt that there would be an overwhelming response to any request for men and women prepared to submit to reasonable experiment. Dr. CHARLES HILL declared that to assert that animal experimentation was futile was to fly in the face of facts. An enormous amount has been achieved, and at least one form of cancer was now curable as a result of animal Dr. Hill preferred to see animals experimentation. rather than human beings used for attempts to induce cancerous
growths.
Mr. GEOFFREY DE FREITAS, under-secretary of State for the Home Department, in reply drew the attention of the House to the stringency of the safeguards under No animal which these experiments were permitted. experiment was permitted without a licence from the Home Secretary, and all were subject to inspection. A further special certificate was required when the animal lived after the experiment. The Home Office inspectors who advised the Home Secretary on the granting of these certificates did so on the basis of wide knowledge of the applicants’ experience and of the suitability of the place of experiment. Most of the animals used were small rodents, chiefly mice, but occasionally rats or guineapigs. In the last two years there had been 24 experiments on cats and 28 on dogs. The most usual experiment was when a substance such as coal tar was applied to a small part of the skin of the mouse or a small-amount was added to the animal’s diet. Each application counted as one experiment, and the large figures quoted related to experiments and not to animals. Mr. de Freitas pointed out that the death-rate from cancer had remained fairly constant for the last thirty years, and there had been a slight reduction each year in the mortality of women. The Medical Research Council held views on the value of animal experiments in cancer research which were directly contrary to those of Mr. Freeman. In a recent report the council said : There seems to be general agreement that most of the advances which have been made recently in our knowledge of the causation and treatment of various forms of cancer would have been impossible without experimental work on animals. Indeed, there is no form of medical research which has been more dependent on animal work.... Substances to which human beings may be exposed can be tested in animals for their tumour producing properties.... This research has made possible the protection of many thousands of industrial workers." A close control of these experiments was exercised by the Home Secretary, and he asked the House to agree that this control was most carefully administered. "
Poliomyelitis In England and Wales notifications of poliomyelitis in the week ended Oct. 28 were : paralytic 182 (197), non-paralytic 71 (81) ; total 253 (278). The figures for the previous week are in parentheses. Notifications for the corresponding week in 1947 and 1949 totalled 280 and 367. Total uncorrected notifications for 1950 up to The and including the week under review are 7543. corresponding figures for 1947, 1948, and 1949 were 8022, 1975, and 5259. A gradual reduction in notifications has now been maintained for several weeks.
gave a new low record of 31 per 1000 related live births. For years the Birmingham rate of infant mortality has been below that for England and Wales ; this is a great tribute to local endeavour, for circumstances in this city are not favourable for a low rate.
Infectious Diseases in
Dr. Newsholme’s Retirement Newsholme, who in 1928 succeeded Sir John Robertson as medical officer of health for Birmingham, retired this year. Formerly Birmingham had an unenviable notoriety ; but in Robertson’s time it gained a first-class public-health service which Dr. Newsholme carried on with outstanding success. The school medical service had grown up independently of the public-health service ; and collaboration of these two services, without fusion, was the most notable achievement of Dr. Newsholme’s period of office. Dr. Newsholme’s contributions to public-health theory have been mainly philosophical; but his factual annual reports, with only necessary commentary, have a His last permanent place in public-health history. report-that for 1940-reveals a better state of health in the city than ever before. For the first year on record no child died of diphtheria. Pulmonary tuberculosis showed a slight increase in notification but a reduction in fatality. Maternal mortality was 0-39, or, including deaths from abortion, 0-49, per 1000 live and still births ; and there were no deaths from sepsis. Infant mortality
England
and Wales
Dr. H. P.
Special
Articles
REGISTRAR ESTABLISHMENTS MINISTRY OF HEALTH STATEMENT
important announcement on the future establishment of senior registrars and registrars in England and Wales has been made by the Ministry of Health in a The circular (R.H.B. circular to hospital authorities. [50] 106) is summarised below. AN
1. It has from the outset been made clear that the senior registrar and registrar grades are regarded as training grades for potential consultants (or senior hospital medical or dental officers). It follows that the total number of appointments, particularly in the senior registrar grade, should be closely related to the likely number of openings. 2. It has also been indicated that training should be continued only for those who appear likely to benefit from it, and in particular that promotion from one grade to another should be competitive. The base of the training ladder should be the first year in the registrar grade-a grade which should normally be reached at least 2 years after qualification. The registrar should be reviewed at the end of the first year, and if satisfactory should normally proceed to a second year in this grade. Those wishing to proceed further should seek an appointment in open competition as senior registrar, the number of posts available being considerably less than the number of second-year registrar posts. The senior registrar should also be reviewed at the end of the first and second years. At the end of the third year in a senior registrarship training should be complete ; appointment for a fourth year should be very exceptional, and for the most part confined to certain specialties such as thoracic surgery, neurosurgery, and plastic surgery or to doctors who, having completed training as, for example, general physicians, wish to take up other specialties. LIKELY NUMBER OF VACANCIES
3. For some years to come the number of appointments open to senior registrars who complete their training at
*
Not including late returns.
in England and Wales is unlikely to exceed 150 per annum. This includes, not only consultant and senior hospital medial or dental officer appointments to make good wastage through death or retirement, but also a proportion of additional posts and openings in other services and overseas as well as in hospitals in this country. Thus it appears that the number of should not at present exceed the following : posts training senior registrar, 600 ; registrar, 1100.’ The figure for registrars is a total for those in the first and second years of training, and that for senior registrars the total for those in the first, second, and third years. 4. At present the number in each of these two grades is upwards of 1400. " It is therefore essential to take steps to bring the number of training posts as quickly as possible into line with the numbers required." 5. The objectives should be : (a) To fix for each hospital regional area an establishment of training posts properly distributed between the different
hospitals
specialties and situated in hospitals with suitable facilities. (b) To reduce the present numbers by : (i) making appointments only up to the new establishment figures ; and (ii) discontinuing appointments of senior registrars now in their third or subsequent years as the present year of appointment (See also para. 2 and para. 9 (ii).) If necessary, to make alternative carrying out the work of the hospitals.
ends.
(c)
appointments
for
FIXING AN ESTABLISHMENT
6. Each regional board and the related board or boards of governors are asked to consider urgently together what trainee posts should be provided in the area within the maxima indicated below, and to submit their joint proposals by Jan. 31, 1951. In preparing these proposals, the cooperation of the dean or director of postgraduate medical studies of the university should be sought. The proposals should indicate the number of senior registrar and registrar posts proposed for each specialty and the hospitals where these posts are to be held. The Minister will review these proposals as a whole, with particular reference to the distribution between specialties, which can be satisfactorily determined only on a national basis.
538 7. It appears that the maximum total number of posts for each regional area (including teaching hospitals) should be : Senwr .. regU3trar (total for first, second, and third year)
Region
Newcastle Leeds Sheffield East Anglia North-West Metropolitan North-East Metropolitan South-East Metropolitan South-West Metropolitan Oxford South Western Wales.. ’
........
......
..
Birmingham Manchester
......
......
Liverpool
34 36 42 18 75 48 52 83 22 30 28 52 52 28
Registrar
(total for first and second year)
....
....
....
....
....
....
....
....
....
....
....
....
....
....
63 65 76 32 138 86 96 151 42 56 51 96 96 52
The distribution between specialties will vary from to region according to the training facilities ; and the concentration of teaching resources in London will have to be taken into account.
region
REDUCTION IN NUMBERS
addition to fixing total establishments, an distribution in each region of the total into numbers for each year of training must obviously be made, though this may vary slightly at different times. When the distribution of posts by specialty and hospital has been determined, it will be necessary to decide which of the existing first-year registrars or first-year or second-year senior registrars can continue for a further year, and where new appointments in the first year of each grade can be made during the coming year. Regional proposals should therefore include a statement of the number of registrars and senior registrars by specialty in each year of training it is proposed to retain or recruit during the coming year. 9. When the establishment proposals have been approved by the Minister, these should be strictly adhered to. This means that : 8. In
approximate
(i) The number of first-year registrars or senior registrars recruited during the year should be the number (within the approved total) which boards have decided is appropriate. (ii) As the existing second-year registrars and third-year senior registrars reach the end of their personal year of appointment, their appointments should be terminated (except in the exceptional circumstances mentioned in paragraph 2) ; and first-year registrars and first-year and secondyear senior registrars should be reviewed and reappointed for a further year’s training only so far as this is possible within the approved total establishment. 10. From now on, boards should not renew the appointment of any second-year registrar whose personal year of appointment ends, or of any third (or subsequent) year senior registrar except in the exceptional cases mentioned at the end of paragraph 2 or in accordance with the terms of paragraph 11 (a). ALTERNATIVE APPOINTMENTS a board is satisfied that the work of the necessitates an alternative appointment in place of a senior registrar (but not otherwise), the following are among the steps that may be taken :
11. Where
hospital
(a) An existing senior registrar whose appointment as a trainee is not renewed may be offered an appointment for one year only as a temporary senior registrar at his present salary-rate. (b) Alternatively, boards may appoint as part-time clinical assistant a suitably experienced general practitioner (normally one with a higher qualification and experience as a senior registrar or registrar). Remuneration will be announced later.
JUNIOR REGISTRARS
13. In future "
junior registrars " will be known as senior house officers," since this is not regarded as a trainee grade like that of registrar. "
OTHER OPENINGS
An
draws attention to the openings outside the National Health Service. First, the three Armed Forces need 400 specialists, notably in the following specialties :
appendix
anaesthetics, surgery, otology, radiology, psychiatry, pathology, and venereology. In addition there are over 100 vacancies for general-duty officers. Secondly, in the Colonial Service about 200 permanent or temporary posts are available. Thirdly, a number of overseas university and hospital appointments are vacant or will shortly be vacant, principally in the Middle East and South-East Asia ; further information about posts in this third group may be had from the Technical and Scientific Register, York House, Kingsway, London, W.C.2.
dermatology,
Parliament Vivisection and Cancer Research ON the motion for the adjournment in the House of Commons on Oct. 31, Mr. PETER FREEMAN doubted whether experimentation on living animals was of real value in the search for a cure for cancer. In 1904 there were 8292 such experiments, and in 1949 they numbered About two-thirds of these were conducted 75,343. without any anaesthetic for the animals concerned. About 80 % of the animals were allowed to recover and could be experimented upon again. The total number of experiments during the last half-century had exceeded 1,300,000. Yet in 1900 deaths from cancer were 26,721, and last year they were 80,732. As possible causes which might be investigated, in preference to continued experiments on animals, he mentioned the stress of modern industrial life, the increased consumption of alcohol, tobacco, narcotics, animal and artificial foods, pasteurised milk, and patent medicines, and the modern craze for injections, serums, inoculations, and vaccinations. He had no doubt that there would be an overwhelming response to any request for men and women prepared to submit to reasonable experiment. Dr. CHARLES HILL declared that to assert that animal experimentation was futile was to fly in the face of facts. An enormous amount has been achieved, and at least one form of cancer was now curable as a result of animal Dr. Hill preferred to see animals experimentation. rather than human beings used for attempts to induce cancerous
growths.
Mr. GEOFFREY DE FREITAS, under-secretary of State for the Home Department, in reply drew the attention of the House to the stringency of the safeguards under No animal which these experiments were permitted. experiment was permitted without a licence from the Home Secretary, and all were subject to inspection. A further special certificate was required when the animal lived after the experiment. The Home Office inspectors who advised the Home Secretary on the granting of these certificates did so on the basis of wide knowledge of the applicants’ experience and of the suitability of the place of experiment. Most of the animals used were small rodents, chiefly mice, but occasionally rats or guineapigs. In the last two years there had been 24 experiments on cats and 28 on dogs. The most usual experiment was when a substance such as coal tar was applied to a small part of the skin of the mouse or a small-amount was added to the animal’s diet. Each application counted as one experiment, and the large figures quoted related to experiments and not to animals. Mr. de Freitas pointed out that the death-rate from cancer had remained fairly constant for the last thirty years, and there had been a slight reduction each year in the mortality of women. The Medical Research Council held views on the value of animal experiments in cancer research which were directly contrary to those of Mr. Freeman. In a recent report the council said : There seems to be general agreement that most of the advances which have been made recently in our knowledge of the causation and treatment of various forms of cancer would have been impossible without experimental work on animals. Indeed, there is no form of medical research which has been more dependent on animal work.... Substances to which human beings may be exposed can be tested in animals for their tumour producing properties.... This research has made possible the protection of many thousands of industrial workers." A close control of these experiments was exercised by the Home Secretary, and he asked the House to agree that this control was most carefully administered. "