- Email: [email protected]
THE MINISTER ON EMIGRATION
1293
pigmentation is confined to particular nuclear sites, but nor is it understood why pharmaceutical agents affect some parts of the brain and not others. 74 Gerrard 75 suggested that hypoglycaemic cerebral damage might predispose to kernicterus, but he subsequently withdrew this explanation, 76 although Rozdilsky 77 found that dogs rendered hypoglycaemic were more susceptible to nuclear jaundice. Other factors, such as acid-base balance, state of hydration, and amount of adipose tissue, may also be important, but their possible roles have not been established. The efficiency of the blood-brain barrier 78 has been invoked to explain experimental discrepancies. This barrier is not the same as the blood/cerebrospinal-fluid
barrier, and there is ample evidence that the risk of kernicterus is not closely correlated with the bilirubin level in cerebrospinal fluid (c.s.F.), which is a function of the c.s.F. protein level. The two barriers are related to some extent, for, by giving p-chloromercuribenzoate intracisternally, Ernster et al.79 inactivated the enzyme system on which the blood-brain barrier depends and found that, as pigment appeared in the brain, so the amount of protein and bilirubin in the c.s.F. also increased. These observations have been confirmed by Lee and Hsia .80 Rozdilsky 81 used 1311-labelled albumin to show that the cerebral vessels of newborn animals were not normally permeable to albumin, but that their permeability increased as the plasma-bilirubin concentration rose and was greatest in the pigmented areas of the brain. He wondered whether the bilirubin had a direct effect on capillary endothelium, or whether toxic metabolites from the liver were responsible, as Parsons suggested. 82 A characteristic of the blood-brain barrier is the importance of concentration gradients in determining permeability,77 but conditions across the barrier are also influenced by the firmness with which bilirubin is bound to plasma-albumin (as already discussed in connection with the occurrence of kernicterus in infants receiving sulfisoxazole). The plasma-protein level in premature infants is less than that in mature infants. Further, the bilirubin-binding capacity of
protein 54 is modified by pH changes. Not all animals react in the same way to hyperbilirubinsemia. Rozdilsky 77 has shown that kernicterus occurs in puppies and rabbits only if previous brain damage has been sustained, whereas normal kittens exposed to hyperbilirubinaemia will develop kernicterus. Eyquem, 13 114 however, induced hyperbilirubinamlia in dogs by antisera or by suitable mating, and found that kernicterus occurred even where there was no other brain damage. Rozdilsky 77 has shown that the effect of bilirubin is not restricted to nerve-cells; at least in adult animals, changes also occur in capillary endothelium, serous membranes, gastrointestinal tract, liver, and kidneys. In rats given albumin/ bilirubin complex intravenously, in a dose of 10 mg. per 100 g. body-weight, there developed diarrhaea, circulatory collapse, respiratory distress, pulmonary haemorrhage, and congestion of the kidneys with tubular necrosis-yet no true kernicterus. Bilirubin is cytotoxic to all forms of living tissue 85 and profound reversible changes may be produced in Tetra hymena. A BASIC DIFFICULTY
Lucey 86 has drawn attention to wide differences in the estimated frequency and severity of hyperbilirubinaemia, in necropsy material, the frequency recorded varied from 74.
75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86.
Lathe, G. H. in Recent Advances in Pædiatrics (edited by D. Gairdner). London, 1958. Gerrard, J. W. Brain, 1952, 75, 526. Gerrard, J. W. Arch. Dis. Childh. 1951, 26, 272. Rozdilsky, B. in Kernicterus; p. 161. Toronto, 1961. Lancet, 1961, ii, 1392. Emster, L., Herkin, L., Zetterstrom, R. Pediatrics, 1957, 20, 647. Lee, T. C., Hsia, D. Y. Y. J. lab. clin. Med. 1959, 54, 512. Rozdilsky, B. Arch. Path. (Lab. Med.) 1961, 72, 8. Parsons, L. Lancet, 1947, i, 815. Eyquem, A. Rev. Hemat. 1950, 5, 353. Eyquem, A. Acta neurol. belg. 1949, 49, 965. Day, R. in Kernicterus; p. 167. Toronto, 1961. Lucey, J. F. ibid. p. 29.
38%. In fifty teaching hospitals in the U.S.A. and Canada the indication for exchange-transfusion in neonatal jaundice was a plasma-bilirubin value varying from 15 to 30 mg. per 100 ml.; in 40% of these hospitals no exchangetransfusion had been needed for a year past. In two hospitals in Burlington, Vermont, which shared a common pasdiatric and nursing service, the indication for exchangetransfusion was a bilirubin level of 20-25 mg. per 100 ml. Bilirubin estimations in the two hospitals were believed to give similar results. Yet, in a 28-month period, 41 out of 173 infants in one hospital received exchange-transfusion but only 4 out of 131 in the other. This difference could only be accounted for on the basis of discrepancies in the results of bilirubin estimation. 0 to
Conference THE MINISTER ON EMIGRATION Conference of Local Medical Committees
AT the Conference of Representatives of Local Medical Committees, held in London on June 6 and 7, the Minister of Health, Mr. ENOCH PowELL, analysed some of the available figures concerning the emigration of
doctors from Britain in recent years. Considerable publicity had been given, he said, to an estimate that the dimensions of this emigration were equivalent to as much as a third of the output of British doctors from our medical schools; and this absurd statement had gained a certain currency on the other side of the Atlantic. In fact, the number of doctors working in the National Health Service was increasing, and had increased every year since the Service began. In general practice the total numbers, including assistants and trainees, had risen by 10% in the past nine years-an average of 240 a year. The numbers of principals (which was perhaps the sounder figure to take) had risen in the same period by 15%, and the series of annual increases has been unbroken. In the hospitals there had been a growth in the contribution, never an unimportant one, made in the junior ranks by nonBritish doctors. But the senior staffs had been growing year by year-by the equivalent of 2000 full-time, or 27% in 1950-61. The junior staffs had also increased yearlyby 3200, or 43%, in the same ten years. This increase greatly exceeded the increase in the number of non-British doctors in hospitals. There were about 3600 of them in junior hospital appointments in 1961; we did not know precisely how many there were in 1950, but they certainly numbered many hundreds. There must therefore have been a big increase, averaging well over 200 and probably nearer 250 a year, in the number of British doctors on hospital staffs. This was a situation, Mr. Powell continued, which was blankly irreconcilable with the allegation of a flight from the Health Service. If we were losing permanently any substantial fraction of the annual output of British doctors from our medical schools, figures like these would be simply impossible, given the fact that the output has not fluctuated substantially over the same period. Information had been collected in the past few months from medical schools about the whereabouts of their recent graduates. Data from a dozen medical schools in London and the provinces shows that of British doctors who graduated from them during the 1950s, between 6 and 7% are now resident abroad. There were variations
1294
reported figures: the medical schools of Wales, Liverpool, and Sheffield gave figures between 3 and 4% abroad, while Westminster and St. Mary’s reported 10 or 12%. But the general picture was remarkably
in the
consistent.
it, the Minister asked, that figures could be quoted showing graduates from our medical schools registering in Commonwealth countries in numbers equivalent to about a third of the output of British graduates? There were several reasons. Firstly, once a doctor had been put on most of the registers he remained there for life, so if he practised in more than one country
How
was
state he was counted twice or more. He was still counted even if he had returned to this country, and most of those graduates who went overseas for even short periods of service or experience registered in the territories to which they went. Secondly, the registrations counted included not only British graduates of our medical schools but non-British graduates and also the graduates of medical schools in Ireland: it was with the loss by emigration of the British graduates from schools in Great Britain that we were concerned, and it was with the British output of these schools that comparison should be made. There was no reason to be disturbed, Mr. Powell concluded, either by the numbers of British doctors who registered abroad or by the increase in their numbers. Indeed, one would be somewhat apprehensive for the future of British medicine if a greater freedom of physical movement than before the war were not discernible today. or
DIFFERENTIAL PAYMENTS TO GENERAL PRACTITIONERS
The conference, whose chairman was Dr. C. J. SwANsoN, gave a buffeting to the Royal Commission’s plan for recognising distinguished general practice by additional remuneration. A joint working party of the Health Departments and the profession had proposed a scheme1 by which a committee, consisting predominantly of general practitioners and appointed by the minister in consultation with the profession, would select doctors to benefit from a special fund of f,500,000 by payments of not less than E500 a year. The committee would be aided by recommendations from local assessors drawn from various branches of the profession. This modest plan did not really get a look in at last week’s conference, because, after a long and lively debate, representatives decided by 99 votes to 70 that they " rejected the principle of differential payments," so the plan was not discussed. This decision devalued some of the work of the General Medical Services Committee, whose duty it is to enact the wishes of the annual conference and who had been pursuing the resolution of the 1960 conference (carried by 105 votes to 100) accepting the principle of differential payments in the remuneration of general practitioners. The G.M.S. committee, though recognising the limitation of the total sum available and the need to ensure that a practitioner in partnership would himself always receive the whole benefit of a payment, had submitted the working party’s plan for the conference’s consideration ; as Dr. A. B. DAVIES, chairman of the G.M.S. Committee put it, it seemed only fair to hear what the working party had to say. Dr. BRUCE CARDEW was alarmed by the signs that the conference were about to change their mind, because he thought rejection of the principle of differential payments would make the profes1. See
Lancet, April 28, 1962, p. 904.
sion look foolish. But talk of " money matters bastardising the profession " and " secret tribunals ", and of the alleged difficulty of choosing the doctors deserving extra payment, proved more persuasive. Dr. J. L. McCALLUM had many supporters when he declared that, though the E500.000 would be lost, the conference should have the guts to send it back if they could not use it. THE RESERVED MILLION
innovation before the conference got a gentler reception-the reservation of Elmillion from the central pool " so that further consideration can be given to methods of making the best possible general medical service available to the public ". A second joint working party had proposed the use ofE250,000 of this annual sum to establish a postgraduate education fund; and the rest of the money would go to a Is. 6d. extra loading on patients 1001-1500 on a doctor’s list. The G.M.S. committee agreed with the principles adopted by the working party in deciding how to distribute this tlmillion: Another
" (1) It should be possible for almost every general practitioner to share in the distribution of the money at some stage of his career. (2) The money should not be distributed in such a way that it could be generally regarded as a merit award or differential payment. (3) It should be distributed as payment in return for work done or services provided, and should not be utilised to enable doctors to provide amenities or facilities in their practices in the future." And the committee endorsed the view that the encouragement of postgraduate education was the only one of the aspects of good general practice that was capable of objective assessment and wholly acceptable as a subject for direct recognition. The other aspects of good practice discussed by the working party were: a list of moderate
size; practice accommodation; practice organisation; employment of ancillary help; practice of preventive medicine; and research. Representatives were generally favourable to the working party’s plan, though they listened attentively to a proposal from Pembrokeshire that the extra loading scheme should be abandoned and that some of the other possibilities (notably, the employment of ancillary help) be re-examined. But the feeling seemed to be that more money was needed from somewhere before the profession could satisfactorily press for support for practice accommodation and ancillary help. The working party’s report on the El million was approved. SOME OTHER DECISIONS
The conference viewed " with dismay" certain recommendations of the Royal College of Obstetricians and Gynaecologists regarding the classes of patients considered by the College to be unsuitable for generalpractitioner maternity units. Such classes included all primigravidae over 30 and all multipart over 35. It declared that a dispensing doctor should retain the right to continue dispensing for his patients " if and when a chemist starts a business in that doctor’s practice area." A motion referred to the G.M.S. Committee stated: " This conference considers that the central pool should suffer no diminution because of general practitioners’
hospital remuneration, and that the most satisfactory way to achieve this would be to exclude such remuneration from the pool." Representatives voted in favour of declaring that " the present relative average general-practitioner remuneration " is so low as to endanger the future of general
1295
practice, and they called for vigorous representations to the Review Body for radical reconsideration and upgrading of remuneration. that the trainee scheme in A subcommittee is studying this matter, and Dr. Davies advised waiting till its report
They rejected a proposal general practice be abolished.
appeared. The conference was not prepared to accept the conclusion of the G.M.S. Committee that reduction of the maximum size of lists was wholly impracticable, and they passed a motion " that in view of the continually increasing content of service, means should be found to reduce the maximum size of lists without loss of income."
Parliament Pills and Bread ON June 6, Lord CASEY in opening a discussion on population problems in Asia stressed our responsibility to help. More than 80% of the population of the Commonwealth lived in Asia where the average national income per head was S23 per year. Demographers and scientists were agreed that the only solution to the problem was some form of family planning. Already there were 2000 birth-control clinics in India and more were planned, but they had only the methods of the past to work on and these were not adequate, appropriate, or effective for Indian conditions. They were waiting impatiently for science to evolve something better. The biological contraceptives developed so far were not suitable for Asian conditions, because they had to be taken 20 times a month, a practice that was unlikely to be observed by illiterate women in villages. Compared with other forms of medical research, little work was being done on population control. It could be effectively done only in countries with large resources of scientific personnel and money. Possibly the most important help which we could give India and the other Asian countries was to encourage scientific research towards the discovery of a contraceptive suitable for Asian conditions Baroness SUMMERSKILL shared Lord Casey’s concern, but did not believe that oral contraceptives were the right answer to the problem. She regarded birth control as an important form of preventive medicine, but she thought it unwise to encourage the pharmaceutical industry hastily to produce new products which could only be effective by inhibiting ovulation. She quoted endocrinologists who feared that the continued use of these compounds might have unforeseen and undesirable side-effects. She regretted that the Family Planning Association had not shown greater caution in using them. She assured Lord Casey that the pharmaceutical firms were not waiting for encouragement from the Government to produce a cheaper pill for the Asian market. In this country the pill was given only under medical supervision, but in Asia there were so few doctors that they would be able to exercise little control and offer little protection. Lord MILVERTON felt that no scientific solution to the problem could be other than an adjunct to education and economic and cultural influences, these must be long-term methods. The Earl of LYTTON pointed out that it was not absolute numbers of population that were in question, but the relationship between people, food, and power. He believed that our contribution to the East should be trade and capital investment. As it was the Asian peoples asked us for bread and we gave them a pill. In his view that did not seem to be right. Lord BRAIN said that the population problem was a crisis in human affairs which would determine the future of civilisation. He hoped that this debate would persuade the Government that they had some responsibility in the matter and should take action. The population of the world was increasing more rapidly then ever before-by about 50 million people a year.
The chief difficulty was to feed this growing mass. Nor did we start from scratch. Between a third and a half of the people already alive were not getting enough to eat. He agreed that food production was the most urgent need but he could not share the optimism of those who said that we need not bother to restrict the population as well. Furthermore the population question was not solely a matter of food for the body. Unless population growth was controlled millions of people would continue to live in conditions on which the full development of man’s nature, and even his education, were impossible. What any country did about its
population was primarily its Help was likely to be accepted when it was asked for. But right action presupposed knowledge, and knowledge was still largely lacking. Surely it could not be right own concern.
that in this country the State took no interest in birth control. Contraception had entered a phase of rapid advance; it was of the greatest social and personal importance. Yet we had to depend for research on a small private fund and the pharmaceutical industry, and to rely for the clinical testing of these new and powerful biochemical agents on a voluntary association to which the State contributed neither guidance nor money. The course of events had imposed on the Family Planning Association, of which he was president, a great responsibility. Was it not time that the State shared it ? He would urge the Government to hold a watching brief on the clinical tests of all contraceptives or better still, to sponsor such tests themselves. The urgency of the problem was, after all, of our own making. Had we freed men from disease only to let them die of hunger ? Lord WALSTON was anxious that the problem should be tackled by more comprehensive research. He wanted to see the Government sponsor an institute of demographic research which would cover ecological, nutritional, economic, and public health problems.
The Duke of DEVONSHIRE, parliamentary under-secretary of State for Commonwealth Relations, said that the ways in which the problems of rapidly rising populations could be solved should not be merely negative, and within the Colombo plan we had contributed about E300 million towards increasing, directly or indirectly, the food-supplies of Asian countries. Research into methods of contraception could not be done in isolation from other research and a great deal of work on the physiology of reproduction and on infertility was being undertaken in university departments and by the Medical and Agricultural Research Councils, as well as research aimed directly at the control of conception which was being carried out by industrial enterprises. For obvious reasons, this work did not relate to conditions in Asian countries, and in the Government’s view their problems would best be tackled in their own hospital and research institutions. The Government would be ready to respond to requests for collaboration from this country. Until we received such requests probably our best contribution was to go on spending as much as we could afford on capital aid and technical assistance under the Colombo Plan. QUESTION TIME Health and the Cabinet Mr. F. G. BowLES asked the Prime Minister whether he would promote the Minister of Health to full Cabinet rank.-Mr. HAROLD MACMILLAN replied: It is not possible to include in the Cabinet all Ministers in charge of Departments. But it has been made clear, I think by successive Administrations, that it should not be inferred from this that the Government underrate the importance of the matters for which Ministers outside the Cabinet are responsible. Mr. BowLES: Would the Prime Minister realise-as I gather he does-that a tremendous number of people depend upon a really powerful Minister of Health for their welfare and hospitals and so on, and will he reconsider this matter when he has his next reshuffle of the Cabinet ? Mr. MACMILLAN: Qf course, we have a very excellent Minister of Health. What particular Minister should or should not be in the Cabinet is not a matter of rule. It is a matter of arrangements at any particular time.
pigmentation is confined to particular nuclear sites, but nor is it understood why pharmaceutical agents affect some parts of the brain and not others. 74 Gerrard 75 suggested that hypoglycaemic cerebral damage might predispose to kernicterus, but he subsequently withdrew this explanation, 76 although Rozdilsky 77 found that dogs rendered hypoglycaemic were more susceptible to nuclear jaundice. Other factors, such as acid-base balance, state of hydration, and amount of adipose tissue, may also be important, but their possible roles have not been established. The efficiency of the blood-brain barrier 78 has been invoked to explain experimental discrepancies. This barrier is not the same as the blood/cerebrospinal-fluid
barrier, and there is ample evidence that the risk of kernicterus is not closely correlated with the bilirubin level in cerebrospinal fluid (c.s.F.), which is a function of the c.s.F. protein level. The two barriers are related to some extent, for, by giving p-chloromercuribenzoate intracisternally, Ernster et al.79 inactivated the enzyme system on which the blood-brain barrier depends and found that, as pigment appeared in the brain, so the amount of protein and bilirubin in the c.s.F. also increased. These observations have been confirmed by Lee and Hsia .80 Rozdilsky 81 used 1311-labelled albumin to show that the cerebral vessels of newborn animals were not normally permeable to albumin, but that their permeability increased as the plasma-bilirubin concentration rose and was greatest in the pigmented areas of the brain. He wondered whether the bilirubin had a direct effect on capillary endothelium, or whether toxic metabolites from the liver were responsible, as Parsons suggested. 82 A characteristic of the blood-brain barrier is the importance of concentration gradients in determining permeability,77 but conditions across the barrier are also influenced by the firmness with which bilirubin is bound to plasma-albumin (as already discussed in connection with the occurrence of kernicterus in infants receiving sulfisoxazole). The plasma-protein level in premature infants is less than that in mature infants. Further, the bilirubin-binding capacity of
protein 54 is modified by pH changes. Not all animals react in the same way to hyperbilirubinsemia. Rozdilsky 77 has shown that kernicterus occurs in puppies and rabbits only if previous brain damage has been sustained, whereas normal kittens exposed to hyperbilirubinaemia will develop kernicterus. Eyquem, 13 114 however, induced hyperbilirubinamlia in dogs by antisera or by suitable mating, and found that kernicterus occurred even where there was no other brain damage. Rozdilsky 77 has shown that the effect of bilirubin is not restricted to nerve-cells; at least in adult animals, changes also occur in capillary endothelium, serous membranes, gastrointestinal tract, liver, and kidneys. In rats given albumin/ bilirubin complex intravenously, in a dose of 10 mg. per 100 g. body-weight, there developed diarrhaea, circulatory collapse, respiratory distress, pulmonary haemorrhage, and congestion of the kidneys with tubular necrosis-yet no true kernicterus. Bilirubin is cytotoxic to all forms of living tissue 85 and profound reversible changes may be produced in Tetra hymena. A BASIC DIFFICULTY
Lucey 86 has drawn attention to wide differences in the estimated frequency and severity of hyperbilirubinaemia, in necropsy material, the frequency recorded varied from 74.
75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86.
Lathe, G. H. in Recent Advances in Pædiatrics (edited by D. Gairdner). London, 1958. Gerrard, J. W. Brain, 1952, 75, 526. Gerrard, J. W. Arch. Dis. Childh. 1951, 26, 272. Rozdilsky, B. in Kernicterus; p. 161. Toronto, 1961. Lancet, 1961, ii, 1392. Emster, L., Herkin, L., Zetterstrom, R. Pediatrics, 1957, 20, 647. Lee, T. C., Hsia, D. Y. Y. J. lab. clin. Med. 1959, 54, 512. Rozdilsky, B. Arch. Path. (Lab. Med.) 1961, 72, 8. Parsons, L. Lancet, 1947, i, 815. Eyquem, A. Rev. Hemat. 1950, 5, 353. Eyquem, A. Acta neurol. belg. 1949, 49, 965. Day, R. in Kernicterus; p. 167. Toronto, 1961. Lucey, J. F. ibid. p. 29.
38%. In fifty teaching hospitals in the U.S.A. and Canada the indication for exchange-transfusion in neonatal jaundice was a plasma-bilirubin value varying from 15 to 30 mg. per 100 ml.; in 40% of these hospitals no exchangetransfusion had been needed for a year past. In two hospitals in Burlington, Vermont, which shared a common pasdiatric and nursing service, the indication for exchangetransfusion was a bilirubin level of 20-25 mg. per 100 ml. Bilirubin estimations in the two hospitals were believed to give similar results. Yet, in a 28-month period, 41 out of 173 infants in one hospital received exchange-transfusion but only 4 out of 131 in the other. This difference could only be accounted for on the basis of discrepancies in the results of bilirubin estimation. 0 to
Conference THE MINISTER ON EMIGRATION Conference of Local Medical Committees
AT the Conference of Representatives of Local Medical Committees, held in London on June 6 and 7, the Minister of Health, Mr. ENOCH PowELL, analysed some of the available figures concerning the emigration of
doctors from Britain in recent years. Considerable publicity had been given, he said, to an estimate that the dimensions of this emigration were equivalent to as much as a third of the output of British doctors from our medical schools; and this absurd statement had gained a certain currency on the other side of the Atlantic. In fact, the number of doctors working in the National Health Service was increasing, and had increased every year since the Service began. In general practice the total numbers, including assistants and trainees, had risen by 10% in the past nine years-an average of 240 a year. The numbers of principals (which was perhaps the sounder figure to take) had risen in the same period by 15%, and the series of annual increases has been unbroken. In the hospitals there had been a growth in the contribution, never an unimportant one, made in the junior ranks by nonBritish doctors. But the senior staffs had been growing year by year-by the equivalent of 2000 full-time, or 27% in 1950-61. The junior staffs had also increased yearlyby 3200, or 43%, in the same ten years. This increase greatly exceeded the increase in the number of non-British doctors in hospitals. There were about 3600 of them in junior hospital appointments in 1961; we did not know precisely how many there were in 1950, but they certainly numbered many hundreds. There must therefore have been a big increase, averaging well over 200 and probably nearer 250 a year, in the number of British doctors on hospital staffs. This was a situation, Mr. Powell continued, which was blankly irreconcilable with the allegation of a flight from the Health Service. If we were losing permanently any substantial fraction of the annual output of British doctors from our medical schools, figures like these would be simply impossible, given the fact that the output has not fluctuated substantially over the same period. Information had been collected in the past few months from medical schools about the whereabouts of their recent graduates. Data from a dozen medical schools in London and the provinces shows that of British doctors who graduated from them during the 1950s, between 6 and 7% are now resident abroad. There were variations
1294
reported figures: the medical schools of Wales, Liverpool, and Sheffield gave figures between 3 and 4% abroad, while Westminster and St. Mary’s reported 10 or 12%. But the general picture was remarkably
in the
consistent.
it, the Minister asked, that figures could be quoted showing graduates from our medical schools registering in Commonwealth countries in numbers equivalent to about a third of the output of British graduates? There were several reasons. Firstly, once a doctor had been put on most of the registers he remained there for life, so if he practised in more than one country
How
was
state he was counted twice or more. He was still counted even if he had returned to this country, and most of those graduates who went overseas for even short periods of service or experience registered in the territories to which they went. Secondly, the registrations counted included not only British graduates of our medical schools but non-British graduates and also the graduates of medical schools in Ireland: it was with the loss by emigration of the British graduates from schools in Great Britain that we were concerned, and it was with the British output of these schools that comparison should be made. There was no reason to be disturbed, Mr. Powell concluded, either by the numbers of British doctors who registered abroad or by the increase in their numbers. Indeed, one would be somewhat apprehensive for the future of British medicine if a greater freedom of physical movement than before the war were not discernible today. or
DIFFERENTIAL PAYMENTS TO GENERAL PRACTITIONERS
The conference, whose chairman was Dr. C. J. SwANsoN, gave a buffeting to the Royal Commission’s plan for recognising distinguished general practice by additional remuneration. A joint working party of the Health Departments and the profession had proposed a scheme1 by which a committee, consisting predominantly of general practitioners and appointed by the minister in consultation with the profession, would select doctors to benefit from a special fund of f,500,000 by payments of not less than E500 a year. The committee would be aided by recommendations from local assessors drawn from various branches of the profession. This modest plan did not really get a look in at last week’s conference, because, after a long and lively debate, representatives decided by 99 votes to 70 that they " rejected the principle of differential payments," so the plan was not discussed. This decision devalued some of the work of the General Medical Services Committee, whose duty it is to enact the wishes of the annual conference and who had been pursuing the resolution of the 1960 conference (carried by 105 votes to 100) accepting the principle of differential payments in the remuneration of general practitioners. The G.M.S. committee, though recognising the limitation of the total sum available and the need to ensure that a practitioner in partnership would himself always receive the whole benefit of a payment, had submitted the working party’s plan for the conference’s consideration ; as Dr. A. B. DAVIES, chairman of the G.M.S. Committee put it, it seemed only fair to hear what the working party had to say. Dr. BRUCE CARDEW was alarmed by the signs that the conference were about to change their mind, because he thought rejection of the principle of differential payments would make the profes1. See
Lancet, April 28, 1962, p. 904.
sion look foolish. But talk of " money matters bastardising the profession " and " secret tribunals ", and of the alleged difficulty of choosing the doctors deserving extra payment, proved more persuasive. Dr. J. L. McCALLUM had many supporters when he declared that, though the E500.000 would be lost, the conference should have the guts to send it back if they could not use it. THE RESERVED MILLION
innovation before the conference got a gentler reception-the reservation of Elmillion from the central pool " so that further consideration can be given to methods of making the best possible general medical service available to the public ". A second joint working party had proposed the use ofE250,000 of this annual sum to establish a postgraduate education fund; and the rest of the money would go to a Is. 6d. extra loading on patients 1001-1500 on a doctor’s list. The G.M.S. committee agreed with the principles adopted by the working party in deciding how to distribute this tlmillion: Another
" (1) It should be possible for almost every general practitioner to share in the distribution of the money at some stage of his career. (2) The money should not be distributed in such a way that it could be generally regarded as a merit award or differential payment. (3) It should be distributed as payment in return for work done or services provided, and should not be utilised to enable doctors to provide amenities or facilities in their practices in the future." And the committee endorsed the view that the encouragement of postgraduate education was the only one of the aspects of good general practice that was capable of objective assessment and wholly acceptable as a subject for direct recognition. The other aspects of good practice discussed by the working party were: a list of moderate
size; practice accommodation; practice organisation; employment of ancillary help; practice of preventive medicine; and research. Representatives were generally favourable to the working party’s plan, though they listened attentively to a proposal from Pembrokeshire that the extra loading scheme should be abandoned and that some of the other possibilities (notably, the employment of ancillary help) be re-examined. But the feeling seemed to be that more money was needed from somewhere before the profession could satisfactorily press for support for practice accommodation and ancillary help. The working party’s report on the El million was approved. SOME OTHER DECISIONS
The conference viewed " with dismay" certain recommendations of the Royal College of Obstetricians and Gynaecologists regarding the classes of patients considered by the College to be unsuitable for generalpractitioner maternity units. Such classes included all primigravidae over 30 and all multipart over 35. It declared that a dispensing doctor should retain the right to continue dispensing for his patients " if and when a chemist starts a business in that doctor’s practice area." A motion referred to the G.M.S. Committee stated: " This conference considers that the central pool should suffer no diminution because of general practitioners’
hospital remuneration, and that the most satisfactory way to achieve this would be to exclude such remuneration from the pool." Representatives voted in favour of declaring that " the present relative average general-practitioner remuneration " is so low as to endanger the future of general
1295
practice, and they called for vigorous representations to the Review Body for radical reconsideration and upgrading of remuneration. that the trainee scheme in A subcommittee is studying this matter, and Dr. Davies advised waiting till its report
They rejected a proposal general practice be abolished.
appeared. The conference was not prepared to accept the conclusion of the G.M.S. Committee that reduction of the maximum size of lists was wholly impracticable, and they passed a motion " that in view of the continually increasing content of service, means should be found to reduce the maximum size of lists without loss of income."
Parliament Pills and Bread ON June 6, Lord CASEY in opening a discussion on population problems in Asia stressed our responsibility to help. More than 80% of the population of the Commonwealth lived in Asia where the average national income per head was S23 per year. Demographers and scientists were agreed that the only solution to the problem was some form of family planning. Already there were 2000 birth-control clinics in India and more were planned, but they had only the methods of the past to work on and these were not adequate, appropriate, or effective for Indian conditions. They were waiting impatiently for science to evolve something better. The biological contraceptives developed so far were not suitable for Asian conditions, because they had to be taken 20 times a month, a practice that was unlikely to be observed by illiterate women in villages. Compared with other forms of medical research, little work was being done on population control. It could be effectively done only in countries with large resources of scientific personnel and money. Possibly the most important help which we could give India and the other Asian countries was to encourage scientific research towards the discovery of a contraceptive suitable for Asian conditions Baroness SUMMERSKILL shared Lord Casey’s concern, but did not believe that oral contraceptives were the right answer to the problem. She regarded birth control as an important form of preventive medicine, but she thought it unwise to encourage the pharmaceutical industry hastily to produce new products which could only be effective by inhibiting ovulation. She quoted endocrinologists who feared that the continued use of these compounds might have unforeseen and undesirable side-effects. She regretted that the Family Planning Association had not shown greater caution in using them. She assured Lord Casey that the pharmaceutical firms were not waiting for encouragement from the Government to produce a cheaper pill for the Asian market. In this country the pill was given only under medical supervision, but in Asia there were so few doctors that they would be able to exercise little control and offer little protection. Lord MILVERTON felt that no scientific solution to the problem could be other than an adjunct to education and economic and cultural influences, these must be long-term methods. The Earl of LYTTON pointed out that it was not absolute numbers of population that were in question, but the relationship between people, food, and power. He believed that our contribution to the East should be trade and capital investment. As it was the Asian peoples asked us for bread and we gave them a pill. In his view that did not seem to be right. Lord BRAIN said that the population problem was a crisis in human affairs which would determine the future of civilisation. He hoped that this debate would persuade the Government that they had some responsibility in the matter and should take action. The population of the world was increasing more rapidly then ever before-by about 50 million people a year.
The chief difficulty was to feed this growing mass. Nor did we start from scratch. Between a third and a half of the people already alive were not getting enough to eat. He agreed that food production was the most urgent need but he could not share the optimism of those who said that we need not bother to restrict the population as well. Furthermore the population question was not solely a matter of food for the body. Unless population growth was controlled millions of people would continue to live in conditions on which the full development of man’s nature, and even his education, were impossible. What any country did about its
population was primarily its Help was likely to be accepted when it was asked for. But right action presupposed knowledge, and knowledge was still largely lacking. Surely it could not be right own concern.
that in this country the State took no interest in birth control. Contraception had entered a phase of rapid advance; it was of the greatest social and personal importance. Yet we had to depend for research on a small private fund and the pharmaceutical industry, and to rely for the clinical testing of these new and powerful biochemical agents on a voluntary association to which the State contributed neither guidance nor money. The course of events had imposed on the Family Planning Association, of which he was president, a great responsibility. Was it not time that the State shared it ? He would urge the Government to hold a watching brief on the clinical tests of all contraceptives or better still, to sponsor such tests themselves. The urgency of the problem was, after all, of our own making. Had we freed men from disease only to let them die of hunger ? Lord WALSTON was anxious that the problem should be tackled by more comprehensive research. He wanted to see the Government sponsor an institute of demographic research which would cover ecological, nutritional, economic, and public health problems.
The Duke of DEVONSHIRE, parliamentary under-secretary of State for Commonwealth Relations, said that the ways in which the problems of rapidly rising populations could be solved should not be merely negative, and within the Colombo plan we had contributed about E300 million towards increasing, directly or indirectly, the food-supplies of Asian countries. Research into methods of contraception could not be done in isolation from other research and a great deal of work on the physiology of reproduction and on infertility was being undertaken in university departments and by the Medical and Agricultural Research Councils, as well as research aimed directly at the control of conception which was being carried out by industrial enterprises. For obvious reasons, this work did not relate to conditions in Asian countries, and in the Government’s view their problems would best be tackled in their own hospital and research institutions. The Government would be ready to respond to requests for collaboration from this country. Until we received such requests probably our best contribution was to go on spending as much as we could afford on capital aid and technical assistance under the Colombo Plan. QUESTION TIME Health and the Cabinet Mr. F. G. BowLES asked the Prime Minister whether he would promote the Minister of Health to full Cabinet rank.-Mr. HAROLD MACMILLAN replied: It is not possible to include in the Cabinet all Ministers in charge of Departments. But it has been made clear, I think by successive Administrations, that it should not be inferred from this that the Government underrate the importance of the matters for which Ministers outside the Cabinet are responsible. Mr. BowLES: Would the Prime Minister realise-as I gather he does-that a tremendous number of people depend upon a really powerful Minister of Health for their welfare and hospitals and so on, and will he reconsider this matter when he has his next reshuffle of the Cabinet ? Mr. MACMILLAN: Qf course, we have a very excellent Minister of Health. What particular Minister should or should not be in the Cabinet is not a matter of rule. It is a matter of arrangements at any particular time.