- Email: [email protected]
REORGANISATION OF THE N.H.S.
648
In
England Now
If you have the sea in your blood, there is really nothing much you can do about it. All my life I have had to come to terms with a tangle of genes from the distant coasts of Devon stirring up immunological memories on the lymphocytic tide, or from wherever such things are stowed away. I do not normally risk the deliberate provocation of an allergic response, but last Sunday morning coincided with an unguarded moment. I was temporarily laid up in hospital dry dock in a pleasant side-ward overlooking the Lancaster canal. One of my cabin mates, still in his teens, had gone blind in the last couple of years. Quite spontaneously he was telling me that one of his greatest joys now is to go down to the promenade at Grange-over-Sands and listen for the sound of the tide bore surging up Morecambe Bay, and smell and taste the salt spray as it passes. There was no touch of maudlin about it, and I hope he sensed my understanding, even if I was too inadequate to say
so.
But we were jerked out of reverie by a fanfare of trumpets. The Salvation Army had come to brighten Sunday morning with a concert of hymns, starting with the usual old favourites. Then the bandmaster put his head round our sideward door and invited requests. The genes asked if the band could manage " Eternal Father, strong to save ", the one about those in peril on the sea. The effect on the canal The weekend skipper of a passing cabin was startling. cruiser rushed on deck to scan a cloudless sky for signs of an approaching hurricane, then over his stern to check not getting pooped by a tidal wave sweeping in from the deep seas beyond Glasson Dock: a pair of mallards broke the mirror of the canal surface with a ruffled dash for the shelter of the bank. We sailed through the whole lot of verses
regardless. Then came the reckoning. Best pound note’s worth I had ever put in a collection plate, but a problem how to reply to the bandmaster’s query why I had asked for that tune. I fobbed him off by mumbling something about once living near the sea. But the genes were chuckling away inside. Two master mariner grandfathers and a crew of great uncles in Brixham Churchyard still keep their watch on Torbay. In their time most of the sailing trawlers did not have auxiliary engines. Rounding the breakwater to get into harbour on a lee shore, on a wild winter’s night, was sailing pretty near the wind for human endeavour unaided. So sailors afloat and families ashore had no compunction about hedging their bets. The Salvation Army was rigged out in oilskins and huddled against the harbour wall, keeping time with the lighthouse flashes in trumpeting out the invocation over and over again for those in peril on the sea. And it usually did the trick. But how could you tell that sort of story to a bandmaster nowadays ? Luckily I did not have to. Another note of request came fluttering down from the ward above, and there was a pause while the band thought it out. Then, with exotic delicacy, we were treated to an unexpected rendering of Santa Lucia. I do not know if it has any words in English, I only know it in Italian. But what an answer to come so soon: Placida e 1’onda, prospero e il vento. The waves are calm, the wind is fair. Someone in the ward above must have Mediterranean anxmia: a spot diagnosis of thalasssemia minor. Maybe something can be done if you really have the sea in your blood. if
A
said, care
woman "
He’s unit."
*
*
from whom I was inquiring about her husband bad. They’ve got him in the insensitive
ever so
Letters
to
the Editor
REORGANISATION OF THE N.H.S.
SIR,-As medical students, we view with utter dismay the prospects that await us when we enter the Health Service under the terms of the proposed reorganisation in 1974. The white-paper on the reorganisation of the N.H.S. has, in essence, substituted an administrative change for a serious estimation of the needs of the population and the pattern of health care in the coming period. The reorganisation has been masterminded by the management consultants, McKinsey and Company Inc., with Brunel University, under the tutelage of Prof. E. Jaques. Their study, drawing extensively from the work of Jaques with " role occupants " (does he mean people ?) at the Glacier Metal Company, rests on the basis that " There should be maximum delegation downwards matched by accountability upwards, and that a sound management structure be created at all levels" (Consultative Document). Only 10 weeks were given for consultation on the first major change in the N.H.S. for 20 years, and despite 600 recommendations made by interested parties the whitepaper remains firmly based on a rigid chain of appointed command firmly under the control of a central Government Department and the Secretary of State. The comhealth councils fully illustrate this point. Set up to munity " make sure that the public has a full say in what is done in its name " (white-paper), they will have no funds, all members will be appointed, and they will have no statutory powers, serving only to advise the area health authorities which they need meet only once a year. Never has a more flagrant charade of representation been proposed. There is also no reason to doubt that members on the new controlling bodies will represent the same interests that so effectively dominate present N.H.S. organisation. To take a teaching hospital with which we are associated as an example. As well as being dominated by part-time consultants with offices in Harley Street, the board of governors has on it more than half-a-dozen members with apparently no more than a pecuniary interest in health care. They hold between them some 100 directorships, ranging from property speculation and banking, to the Press, South African goldfields, and, of course; the drug industry. So much for a policy based on the needs of the patients. The " unification " proposed as a mainstay of the whitepaper is also totally inadequate. The social services-an essential part of a comprehensive system of medical care-have been completely neglected. The executive councils remain unchanged except in name. Teaching hospitals will retain the empires they have built: "... the hospital’s individual identity and historic traditions are valuable assets which must and will be preserved when the new organisation is set up ". Our previous example gives some indication as to the nature and scope of these " historic assets ". These proposals come at a time when the basic conceptions behind the N.H.S. are being undermined. The imposition of increased health charges has already effectively castrated the dental service; there has been a vast expansion in private health-insurance schemes, and private practice is openly sanctioned in this latest white-paper; proposals for " hotel " charges for beds and food in hospitals have been made; " harmonisation" with the largely private Continental systems of health care under the Common Market has been rumoured. We are moving towards a period that could well bring about the inception of an effectively two-tiered service-one providing comprehensive care for those that can afford it, while those that
649 cannot
obtain only the subsistence
care
compatible with
the maintenance of a healthy working population. The white-paper seeks to sacrifice both health workers and patients on the altar of " managerial efficiency ". Health care is to become the province of cost-benefit analysis and management consultants who will base their assessment of priorities on the question " How much can be made out of it by putting a fixed amount in ?". On this criterion, the non-productive sections of the population (the old, chronic sick, and mentally ill, &c.) can expect little help. No mention is made of increased financing, and Britain will continue to spend less on health care than the or France. Will it be said by the patients and health workers of the future that the present members of the medical profession were content to sell their Hippocratic birthright for a mess of managerial pottage ?
U.S.A., Canada, Sweden,
St. Mary’s Hospital Medical School, London W.2.
JOHN ROBSON. STEVE ILIFFE,
Middlesex Hospital, London W.1.
President, Middlesex Hospital Medical School Students’ Union.
London Hospital Medical College, E.1.
JAMES LEFANU, Editor, Scope.
AXO-MAMA AND THE EMBRYO
SIR,-Your editorial comment, Neural Tubers (July 29, p. 222), and the interesting hypothesis put forward by Dr. Renwick concerning the possible teratogenic influence of certain forms of blighted potatoes, lead me to wonder if this may be relevant to the disease-picture recorded in the original home of the potato-that is, the mountainous Andean altiplano of the Inca empire, now included in parts of Bolivia, Peru, and Colombia. In this region, both nowadays and particularly in preconquistador times, the potato was the cultural superfood dominating the local diet, agriculture, and religion.22 In this culture, a goddess, Axo-mama, was associated with the potato, as has been the case with most cultural superfoods in all parts of the world. Interestingly, individuals with congenital harelip were considered to be sacrosanct and were dedicated to serve this deity. Even persons deformed by leishmaniasis (espundia) were also included, while volunteers dedicated to this cult were deformed surgically by removal of the mid-upper lip and end of the nose. One explanation for this practice is based on " sympathetic magic "-the naso-oral deformity resembling the so-called " eye " of the potato. Additionally, it is interesting to speculate whether harelip was, and is, particularly common in this region, the homeland of the potato, and even, after Dr. Renwick’s hypothesis,! whether there could be any relationship between harelip and a maternal potato diet, blighted or otherwise. Population, Family and International Health Division, School of Public Health, Los Angeles, California 90024, U.S.A.
DERRICK B.
JELLIFFE.
HEALTH CARE AT WORK " the data an the need for industrial medical strongly suggest service to give men easier access to medical care " should be carefully examined in the light of his criticism of general practice in this country, discussed in your editorial (Aug.
SIR,-Mr. Frank Honigsbaum’s remark 3 that
available
26,
p.
411).
Men seek the advice of 1. 2. 3.
a
general practitioner less often
Renwick, J. H. Br. J. prev. soc. Med. 1972, 26, 67. Jelliffe, D. B. Am. J. clin. Nutr. 1967, 20, 279. Honigsbaum, F. J. R. Coll. gen. Practnrs, 1972, 22, 429.
than women, important factors being the nature of men’s work, the distance of work from the home, and the nature of and the patient’s sensitivity to his disabilities, in particular In addition, the absence of gynaecological disorders. working women who have access to occupational health services have higher attendance-rates than men and may take more readily the advice of the nursing or medical authorities to seek early treatment from their general practitioner. Only 10% of our working population have access to occupational health services, but this could be a significant factor in areas where services do exist. Convenience of attendance is important, and it is probably true that women tend to work nearer home than men. General-practice reorganisation has not improved the ease of access for working men, who may lose up to a day’s work, and pay, to attend the doctor for something they may regard as trivial. This has an analogy within the occupational health service-those clinics on site having higher attendance-rates than those at some distance from the work site. The occupational-health doctor has constantly to remind himself that he must not transgress the boundaries of the general practitioner’s responsibility. He is nevertheless aware that quick and available advice for something quite unrelated to a man’s work-for instance, a football injury over the weekend-may result in rapid reduction in symptoms and quicker healing, at the same time possibly eliminating the need to call on the general practitioner or the local hospital casualty department. This is in accord with his responsibility to make a diagnosis if possible and then refer the patient to his general practitioner. The constant presence of a medical unit at a man’s work, whether in a large company or through a group service, could do much to reduce the problem of unrecognised illness and improve early diagnosis, not only assisting the patients’ comfort but also reducing the appalling level of sickness absence in Britain. The one organisational argument which can be levelled against a work-based primary-medical-care service is that, in the event of major illness requiring long-term absence from work or even hospitalisation, the doctor at work would not be in a position to undertake on-going care. While the reality of this is appreciated, it is not necessarily inhibitory to the idea of work-based medical care because, with modern means of communication, the local situation can be dealt with by referral to a local physician in the patient’s home area by an emergency attendance or home visit. This is constantly happening in the work situation: the general practitioner is contacted for both occupationally induced and non-occupational illnesses. Primary medical care at work is not yet possible, but with a gradual acceptance of the concept of the care of workers at work by community doctors the above suggestions could become reality, as they already have in areas where the general practitioners have a special interest in the occupational health care of workers in local industries. The acceptance by general practitioners of their responsibility to workers at work, whether in shop, office, laborThe atory, or production unit, must be striven for. dissociated pattern of medical care in this country, so clearly described by Honigsbaum, is at the root of a lot of needless delay in diagnosis, minor suffering, and major sickness absence. I am not saying that primary medical care of workers should be taken away from the general practitioner: I am suggesting that consideration be given to putting the responsibility for the total health care of the full-time worker at his place of work in the hands of workbased general practitioners with special interest and training in occupational health. Occupational Health Unit, Central Middlesex Hospital, Park Royal, London NW10 7NS.
GEOFFREY FFRENCH.
In
England Now
If you have the sea in your blood, there is really nothing much you can do about it. All my life I have had to come to terms with a tangle of genes from the distant coasts of Devon stirring up immunological memories on the lymphocytic tide, or from wherever such things are stowed away. I do not normally risk the deliberate provocation of an allergic response, but last Sunday morning coincided with an unguarded moment. I was temporarily laid up in hospital dry dock in a pleasant side-ward overlooking the Lancaster canal. One of my cabin mates, still in his teens, had gone blind in the last couple of years. Quite spontaneously he was telling me that one of his greatest joys now is to go down to the promenade at Grange-over-Sands and listen for the sound of the tide bore surging up Morecambe Bay, and smell and taste the salt spray as it passes. There was no touch of maudlin about it, and I hope he sensed my understanding, even if I was too inadequate to say
so.
But we were jerked out of reverie by a fanfare of trumpets. The Salvation Army had come to brighten Sunday morning with a concert of hymns, starting with the usual old favourites. Then the bandmaster put his head round our sideward door and invited requests. The genes asked if the band could manage " Eternal Father, strong to save ", the one about those in peril on the sea. The effect on the canal The weekend skipper of a passing cabin was startling. cruiser rushed on deck to scan a cloudless sky for signs of an approaching hurricane, then over his stern to check not getting pooped by a tidal wave sweeping in from the deep seas beyond Glasson Dock: a pair of mallards broke the mirror of the canal surface with a ruffled dash for the shelter of the bank. We sailed through the whole lot of verses
regardless. Then came the reckoning. Best pound note’s worth I had ever put in a collection plate, but a problem how to reply to the bandmaster’s query why I had asked for that tune. I fobbed him off by mumbling something about once living near the sea. But the genes were chuckling away inside. Two master mariner grandfathers and a crew of great uncles in Brixham Churchyard still keep their watch on Torbay. In their time most of the sailing trawlers did not have auxiliary engines. Rounding the breakwater to get into harbour on a lee shore, on a wild winter’s night, was sailing pretty near the wind for human endeavour unaided. So sailors afloat and families ashore had no compunction about hedging their bets. The Salvation Army was rigged out in oilskins and huddled against the harbour wall, keeping time with the lighthouse flashes in trumpeting out the invocation over and over again for those in peril on the sea. And it usually did the trick. But how could you tell that sort of story to a bandmaster nowadays ? Luckily I did not have to. Another note of request came fluttering down from the ward above, and there was a pause while the band thought it out. Then, with exotic delicacy, we were treated to an unexpected rendering of Santa Lucia. I do not know if it has any words in English, I only know it in Italian. But what an answer to come so soon: Placida e 1’onda, prospero e il vento. The waves are calm, the wind is fair. Someone in the ward above must have Mediterranean anxmia: a spot diagnosis of thalasssemia minor. Maybe something can be done if you really have the sea in your blood. if
A
said, care
woman "
He’s unit."
*
*
from whom I was inquiring about her husband bad. They’ve got him in the insensitive
ever so
Letters
to
the Editor
REORGANISATION OF THE N.H.S.
SIR,-As medical students, we view with utter dismay the prospects that await us when we enter the Health Service under the terms of the proposed reorganisation in 1974. The white-paper on the reorganisation of the N.H.S. has, in essence, substituted an administrative change for a serious estimation of the needs of the population and the pattern of health care in the coming period. The reorganisation has been masterminded by the management consultants, McKinsey and Company Inc., with Brunel University, under the tutelage of Prof. E. Jaques. Their study, drawing extensively from the work of Jaques with " role occupants " (does he mean people ?) at the Glacier Metal Company, rests on the basis that " There should be maximum delegation downwards matched by accountability upwards, and that a sound management structure be created at all levels" (Consultative Document). Only 10 weeks were given for consultation on the first major change in the N.H.S. for 20 years, and despite 600 recommendations made by interested parties the whitepaper remains firmly based on a rigid chain of appointed command firmly under the control of a central Government Department and the Secretary of State. The comhealth councils fully illustrate this point. Set up to munity " make sure that the public has a full say in what is done in its name " (white-paper), they will have no funds, all members will be appointed, and they will have no statutory powers, serving only to advise the area health authorities which they need meet only once a year. Never has a more flagrant charade of representation been proposed. There is also no reason to doubt that members on the new controlling bodies will represent the same interests that so effectively dominate present N.H.S. organisation. To take a teaching hospital with which we are associated as an example. As well as being dominated by part-time consultants with offices in Harley Street, the board of governors has on it more than half-a-dozen members with apparently no more than a pecuniary interest in health care. They hold between them some 100 directorships, ranging from property speculation and banking, to the Press, South African goldfields, and, of course; the drug industry. So much for a policy based on the needs of the patients. The " unification " proposed as a mainstay of the whitepaper is also totally inadequate. The social services-an essential part of a comprehensive system of medical care-have been completely neglected. The executive councils remain unchanged except in name. Teaching hospitals will retain the empires they have built: "... the hospital’s individual identity and historic traditions are valuable assets which must and will be preserved when the new organisation is set up ". Our previous example gives some indication as to the nature and scope of these " historic assets ". These proposals come at a time when the basic conceptions behind the N.H.S. are being undermined. The imposition of increased health charges has already effectively castrated the dental service; there has been a vast expansion in private health-insurance schemes, and private practice is openly sanctioned in this latest white-paper; proposals for " hotel " charges for beds and food in hospitals have been made; " harmonisation" with the largely private Continental systems of health care under the Common Market has been rumoured. We are moving towards a period that could well bring about the inception of an effectively two-tiered service-one providing comprehensive care for those that can afford it, while those that
649 cannot
obtain only the subsistence
care
compatible with
the maintenance of a healthy working population. The white-paper seeks to sacrifice both health workers and patients on the altar of " managerial efficiency ". Health care is to become the province of cost-benefit analysis and management consultants who will base their assessment of priorities on the question " How much can be made out of it by putting a fixed amount in ?". On this criterion, the non-productive sections of the population (the old, chronic sick, and mentally ill, &c.) can expect little help. No mention is made of increased financing, and Britain will continue to spend less on health care than the or France. Will it be said by the patients and health workers of the future that the present members of the medical profession were content to sell their Hippocratic birthright for a mess of managerial pottage ?
U.S.A., Canada, Sweden,
St. Mary’s Hospital Medical School, London W.2.
JOHN ROBSON. STEVE ILIFFE,
Middlesex Hospital, London W.1.
President, Middlesex Hospital Medical School Students’ Union.
London Hospital Medical College, E.1.
JAMES LEFANU, Editor, Scope.
AXO-MAMA AND THE EMBRYO
SIR,-Your editorial comment, Neural Tubers (July 29, p. 222), and the interesting hypothesis put forward by Dr. Renwick concerning the possible teratogenic influence of certain forms of blighted potatoes, lead me to wonder if this may be relevant to the disease-picture recorded in the original home of the potato-that is, the mountainous Andean altiplano of the Inca empire, now included in parts of Bolivia, Peru, and Colombia. In this region, both nowadays and particularly in preconquistador times, the potato was the cultural superfood dominating the local diet, agriculture, and religion.22 In this culture, a goddess, Axo-mama, was associated with the potato, as has been the case with most cultural superfoods in all parts of the world. Interestingly, individuals with congenital harelip were considered to be sacrosanct and were dedicated to serve this deity. Even persons deformed by leishmaniasis (espundia) were also included, while volunteers dedicated to this cult were deformed surgically by removal of the mid-upper lip and end of the nose. One explanation for this practice is based on " sympathetic magic "-the naso-oral deformity resembling the so-called " eye " of the potato. Additionally, it is interesting to speculate whether harelip was, and is, particularly common in this region, the homeland of the potato, and even, after Dr. Renwick’s hypothesis,! whether there could be any relationship between harelip and a maternal potato diet, blighted or otherwise. Population, Family and International Health Division, School of Public Health, Los Angeles, California 90024, U.S.A.
DERRICK B.
JELLIFFE.
HEALTH CARE AT WORK " the data an the need for industrial medical strongly suggest service to give men easier access to medical care " should be carefully examined in the light of his criticism of general practice in this country, discussed in your editorial (Aug.
SIR,-Mr. Frank Honigsbaum’s remark 3 that
available
26,
p.
411).
Men seek the advice of 1. 2. 3.
a
general practitioner less often
Renwick, J. H. Br. J. prev. soc. Med. 1972, 26, 67. Jelliffe, D. B. Am. J. clin. Nutr. 1967, 20, 279. Honigsbaum, F. J. R. Coll. gen. Practnrs, 1972, 22, 429.
than women, important factors being the nature of men’s work, the distance of work from the home, and the nature of and the patient’s sensitivity to his disabilities, in particular In addition, the absence of gynaecological disorders. working women who have access to occupational health services have higher attendance-rates than men and may take more readily the advice of the nursing or medical authorities to seek early treatment from their general practitioner. Only 10% of our working population have access to occupational health services, but this could be a significant factor in areas where services do exist. Convenience of attendance is important, and it is probably true that women tend to work nearer home than men. General-practice reorganisation has not improved the ease of access for working men, who may lose up to a day’s work, and pay, to attend the doctor for something they may regard as trivial. This has an analogy within the occupational health service-those clinics on site having higher attendance-rates than those at some distance from the work site. The occupational-health doctor has constantly to remind himself that he must not transgress the boundaries of the general practitioner’s responsibility. He is nevertheless aware that quick and available advice for something quite unrelated to a man’s work-for instance, a football injury over the weekend-may result in rapid reduction in symptoms and quicker healing, at the same time possibly eliminating the need to call on the general practitioner or the local hospital casualty department. This is in accord with his responsibility to make a diagnosis if possible and then refer the patient to his general practitioner. The constant presence of a medical unit at a man’s work, whether in a large company or through a group service, could do much to reduce the problem of unrecognised illness and improve early diagnosis, not only assisting the patients’ comfort but also reducing the appalling level of sickness absence in Britain. The one organisational argument which can be levelled against a work-based primary-medical-care service is that, in the event of major illness requiring long-term absence from work or even hospitalisation, the doctor at work would not be in a position to undertake on-going care. While the reality of this is appreciated, it is not necessarily inhibitory to the idea of work-based medical care because, with modern means of communication, the local situation can be dealt with by referral to a local physician in the patient’s home area by an emergency attendance or home visit. This is constantly happening in the work situation: the general practitioner is contacted for both occupationally induced and non-occupational illnesses. Primary medical care at work is not yet possible, but with a gradual acceptance of the concept of the care of workers at work by community doctors the above suggestions could become reality, as they already have in areas where the general practitioners have a special interest in the occupational health care of workers in local industries. The acceptance by general practitioners of their responsibility to workers at work, whether in shop, office, laborThe atory, or production unit, must be striven for. dissociated pattern of medical care in this country, so clearly described by Honigsbaum, is at the root of a lot of needless delay in diagnosis, minor suffering, and major sickness absence. I am not saying that primary medical care of workers should be taken away from the general practitioner: I am suggesting that consideration be given to putting the responsibility for the total health care of the full-time worker at his place of work in the hands of workbased general practitioners with special interest and training in occupational health. Occupational Health Unit, Central Middlesex Hospital, Park Royal, London NW10 7NS.
GEOFFREY FFRENCH.