TAXES AND THE N.H.S.

1234 that

on

several

measures

a

congruent. Some husbands will give inacaspects of their drinking. Glatt is takreports view of the alcoholic’s trutha too and stereotyped simple ing fulness, and his arguments on this point seem to us ingenious but unsound. A single piece of research on alcoholism cannot by itself be conclusive. The significance of our study’ must, though, be judged in the context of much other research which points in the same direction, indicating the need for a considerable recasting of alcoholism treatment services toward less intensive and less costly approaches.3-’ We warmly acknowledge the contribution which Glatt has made to the evolution of those services over many years, and we are certain that he does not believe that evolution is yet at an end. reports

were more

curate

on some

Addiction Research Unit, Institute of Psychiatry, London SE5 8AF

GRIFFITH EDWARDS

JIM ORFORD

CONSULTANTS’ CONTRACT

SIR,-Your Parliamentary correspondent (Nov. 26, p. doubts if the proposed new contract for consultants will achieve an increased commitment of consultants to the N.H.S. The fact is that even the present inadequate differential between maximum-part-time and full-time consultants will be removed. The automatic tax benefits enjoyed by the parttimer, especially in respect of car depreciation and petrol, mean that in real terms he will be more than z1000 better off per annum than his full-time colleague before he earns a penny in private practice. Only a negotiating committee dominated by part-time surgeons and anxsthetists could have engineered this situation on what is, according to the Secretary of State for Social Services, a 45% full-time service. Medical politics has come to an extraordinary state when practically half the consultant profession have to be protected from their own negotiating committee by the Secretary of State. Full-timers will applaud his refusal to continue negotiations until this anomaly is corrected, and perhaps one way we could show our support is by joining the N.H.S. Consultants Association which is clearly the only organisation which will protect our interests-and the Health Service.

1141)

X-ray Department, Aberdeen Royal Infirmary, Aberdeen AB9 2ZB

A. F. MACDONALD

the new consultants’ contract seek to do away with the differential between part-time and whole-time salaries. This will open the floodgates of private practice to all consultants and discriminate against specialties where private practice is not appropriate (e.g., geriatrics and mental health) and against consultants in academic units who are not permitted to receive personal fees from private practice. Also, private practice is unevenly spread across the country, there being a disproportionate amount in London and the home counties. These factors tend to cause an unequal geographical distribution of specialist skills in relation to medical need. As a result of the overtime payments granted to junior hospital doctors we have the anomaly that many junior doctors earn more than whole-time consultants and this is why there is a shortage of applicants for consultant posts. I, a consultant anaesthetist and member of the N.H.S. Consultants Association, fear that if this new contract is allowed.to go through we will rapidly move to an insurance-based medical service like that in West Germany, where most people can hardly afford the premiums.

SIR,-The negotiations

3. 4. 5.

The N.H.S., for all its shortcomings, provides treatment free (or almost free) at the point of delivery. It is financed out of general taxation, and the principle that medical need rather then ability to pay determines the service the patients get

was considerably less minority of instances the

wives’ report

favourable than husbands’, while in

on

Edwards, G., Orford, J. Proc. R. Soc. Med. 1977, 70, 344. Cartwright, A. K. J., Shaw, S. J., Spratley, T. A. Report by the Maudsley Alcoholism Pilot Project to D.H.S.S. September, 1975. Orford, J., Edwards, G. Alcoholism. Oxford (in the press).

should remain sacrosanct. 71 Claudian Place, St Albans, Herts

MARGARET M. CLARK

SIR,-I take exception to the last sentence of your Parliamentary correspondent’s review of negotiations on the new contract for consultants as it gives a totally false impression of consultants’ attitudes to waiting-lists. In this district, consultants’ efforts to reduce surgical waiting-lists are constantly frustrated by lack of resources. As chairman of the medical executive committee I am frequently having to pacify irate surgeons when operating-lists are cancelled due to shortage of nursing and ancillary staff. Several surgeons are not routinely working to their full capacity because of lack of and inadequate operating-theatre sessions. The Department of Health and regional and area health authorities set up time-wasting committees to inquire into the reasons for long surgical waiting-lists on the naive assumption that better management will solve the problem. It will not, and further diversion of resources to primary care at the expense of the hospital services will increase, not reduce, the demand for surgical treatment. Peterborough Peterborough

District Hospital, PE3 6DA

D. J. C. FELTON Chairman, Medical Executive Committee,

Peterborough

District

Hospitals

SiR,-I agree that the new contract must very greatly improve the morale of consultants. The salary rise must, therefore, be considerable, up to parity with that of the regional medical officers. On the matter of waiting-lists your Westminster correspondent is as naive as many administrators. Waiting-lists can only be altered by surgery; there are no medical waiting-lists. Surgery requires operating-theatres, operating-time, and theatre nurses, and all these have to be provided to shorten waitinglists. In many cases these have been the matters which have caused the waiting-lists, although nowadays shortage of hospital beds due to the ridiculous notion by some authorities that they cannot afford to pay for nurses, is a further factor. 79 Harley Street, London W1 1DF

A. F. RUSHFORTH

TAXES AND THE N.H.S.

SIR,-What does Mr Skidmore (Nov. 12, p. 1032) mean by "increased payment to general practitioners for treatment of minor ailments". Since there is no payment by the patient to his doctor, how can this be increased? Who is to define "minor ailments", and what would be the cost of recording and collecting the payments? Such a retrograde step might discourage so many from seeking early diagnosis that the increased morbidity, mortality, and hospital admissions might increase the cost on

One

ing

the public purse. can

to test

only

assume

reaction

to

a piece of political kite-flyerosion of our Health Service.

that this is

gradual

1

Cambridge Gardens, Edinburgh6 5DHDH

PETER A. HILL

*** This letter has been shown follows.-ED.L.

SIR,-It is because

to

Mr

Skidmore, whose reply

involved in the management of beyond the purse of any ordinary citizen, that I have suggested that maximum financial priority be given to seriously ill patients. I am, thereI

am

cancer, where treatment costs would be

1235 to suggest that patients who visit their general with minor conditions should make a direct paypractitioner ment of a consultation charge. Furthermore, employed people requiring a routine check-up (e.g., for hypertension) or repeat prescriptions for night sedation, should also pay a fee. Dr Hill suggests that such a "retrograde step" might discourage some ttenders; if we consider that payment for service rendered is immoral, then perhaps an all-wise Government should pay our domestic recurring costs for gas, television licences, and so on. The only erosion I wish to see in the National Health Service is that of relentless increases in the cost of administration and the salaries of staff whose work does not benefit the sick. On Nov. 22 the Daily Mail published a National Opinion Poll survey which suggests that the general public would be prepared to make direct financial contributions for their health

fore, prepared

care.

Christie Hospital & Holt Radium Institute, Manchester M20 9BX

F. D. SKIDMORE

MEDIA’S VIEWS ON HEALTH

other large "anti-health" advertisements which were published on the very same pages seems not only legitimate but desirable. Finally, we hope that your correspondent’s reservations will not deter other doctors (or journalists) from reading the book. Public discussion of medical issues seems to pose sufficient problems for some doctors to take seriously the sociologically oriented studies of mass communication. A little effort to master unfamiliar terminology does not seem an unreasonable burden-and only one of us (J.D.) is a sociologist by training. Unit for Study of Health Policy, Department of Community Medicine, GORDON BEST Guy’s Hospital Medical School, JOHN DENNIS 8 Newcomen Street, London SE1 1YR PETER DRAPER

***In their book Dr Draper and his colleagues make

a strong for their view that many of the media’s activities overlook and even obscure the deeper issues in health care. We believe, however, that the two criticisms by our Parliamentary correspondent (who certainly expressed much sympathy with the book’s central themes and who did not use the word "jargon") will coincide with the reactions of many journalists and editors.-ED.L.

case

SIR,-Your Parliamentary correspondent’s review (Nov. 12, p. 1039) of our paperback, Health, the Mass Media and the National Health Service, seems to agree with the central themes of the book, but we were surprised by two of his criticisms. He objects to the jargon-to the sociological terms we used, particularly in the chapter explaining what researchers into mass communication have to say about the reporting of news and current affairs. For example, the term "cognitive-ideological school of thought" apparently strikes several clinicians who have read our books as neither unnecessary nor "irritating" when seen in context and with the explanation that we gave. It is, after all, an intelligible shorthand term for a large and amorphous body of sociological work-and complex, detailed work at that. Is your correspondent really irritated by sociology-any sociology-rather than the reviewing and discussion of sociologically oriented studies of mass communication? Furthermore, it seems strange for a medical journal to criticise others for the use of jargon. If social issues are to receive systematic study it does not seem unreasonable, theoretically, eventually to expect perhaps as many technical terms as biological issues seem to merit. Clearly we are nowhere near that point. Medical criticism of sociology simply on the grounds of the language being technical and sometimes inaccessible carries the danger of providing too ready an excuse for the casual and superficial study of the social problems of medicine. Perhaps many of the problems that we are now having to cope with-from reorganisation of the N.H.S. to an "anti-public sector" economic policy-have arisen because medicine has taken its social (and economic) context too much for granted and failed to articulate its own experience of organisational issues, with the unhappy result that a motley crew of outside advisers has held undue influence. The second main criticism alleges that we "may have failed to understand how the media actually work" by "confusing news reporting with comment and mixing it all up with newspaper advertisements". As we understand the criticism of television news advanced by Birt and Jay (discussed in our book), one of the main points in their argument is that news "facts" cannot be neatly separated from news choices, value judgments, and interpretations. One may or may not agree with this view, but it seems inaccurate to accuse either Birt and Jay or us of "confusing reporting with comment". As to the charge that we are not only confusing reports with comments but also "mixing it all up with newspaper advertisements", it seems to us that it is the newspaper industry itself that is responsible for the mixing. To draw attention, for example, to the contrast between the very short Press reports of the publication of the consultative document on prevention and the tobacco and

ANIMAL EXPERIMENTS

SIR,-I have been named as being responsible for the idea that 3ymillion licensed animal experiments each year "are not done for medical purposes but to test the safety of commercial products such as cosmetics" (Oct. 29, p. 913). As you point out, I never said this. What I wrote in Victims of Science (1975) was that "less than a third of all licensed experiments on animals can be seen to be medical". Nobody knows exactly how many experiments are for medical purposes each year. Prof. Sam Shuster does not know (his information being based upon a non-representative pilot sample of returns from only 146 out of a total of 18 666 licensed experimenters), nor does the Home Office, nor do I. Much depends upon a realistic definition of "medical", but if medical science wishes to be associated with the routine toxicity testing of new toiletries, then so be it. Fortunately, the Home Office is now trying to gather more information about the purposes of the research, and within a year or two we may have some reliable data. The confusion has arisen because of the chance coincidence of two separate statistics: (1) The Home Office annual returns under the Cruelty to Animals Act 1876 show that 31.6% of the 5 300 000 licensed experiments in 1973 fell into the total of the medical categories of "diagnostic procedures" (4.1%), "mandatory tests for the standardisation of sera,- vaccines or drugs" (20.1%), and "cancer research" (7.5%). These categories have been for years the only breakdown of the figures by purpose of experiment, and they cover what are almost certainly the three major medical areas in which animals are used. This explains my statement that less than a third "can be seen to be medical". The exact purpose of the remaining 3 700 000 experiments remains unknown. (The latest returns show that the comparable total for these three medical categories for 1976 was 32.8% of all licensed experiments.) (2) In the same year (1973) 61.5% of all licensed experiments were "for or under a grant from commercial undertakings" (answer to Parliamentary question given by Dr S. Summerskill, March 8, 1976). In subsequent years the commercial proportion of all experiments has been higher, ranging from 65.7% in 1974 to 64-6% in 1976. This category explains my contention that about two-thirds of all licensed experiments on animals have been for commercial undertakings. It does not follow that (1) (about a third) and (2) (about two-thirds) are mutually exclusive, but some journalists have made this understandable error. Most drug experiments, for

.