- Email: [email protected]
THE NEW N.H.S. CONSULTANT CONTRACT
667 the latter two areas, unsuspecting home occupants had biochemical and clinical evidence of lead poisoning. How much more vulnerable would the hsemodialysis patient be in such situations ? Key areas to look for evidence of possible lead exposure in the haemodialysis patient would be: (1) the tap-water when first turned on in the morning; (2) the dialysis fluid; and (3) the blood leaving the dialysis membranes at the end Even low levels of lead uptake could of a dialysis. accumulate to cause chronic lead poisoning, and subsequent release of lead sequestered by the bones could place a transplanted kidney in jeopardy.lo
in a tooth (let alone several teeth) over a period of half-anhour or more. It would be helpful to know which teeth, or at least which quadrants of the mouth, were affected by which Controls would be improved if acupuncture points. neither the subject nor the physiologist knew which teeth were to be affected. Department of Operative Dental Surgery, School of Dental Surgery, Neurobiology Laboratory, Department of Anatomy, University of Liverpool,
Children’s Medical Research
Foundation, Royal Alexandra Hospital for Children, Sydney, New South Wales 2050, Australia.
JIM MUMFORD.
P.O. Box 147, L69 3BX.
DAVID BOWSHER.
Liverpool
JEANETTE BLOMFIELD. BELL’S PALSY IN PREGNANCY
ELECTRO-ACUPUNCTURE AND PAIN THRESHOLD SIR,-Having completed only a small number of experiments on the effect of electro-acupuncture on perception thresholds in teeth, it was not our intention to publish at this date. However, the intense interest now evinced in the subject, and, particularly, the interesting letter by Professor Andersson and others (Sept. 8, p. 564), prompt us to discuss some preliminary observations for two reasons. First, our results differ from those of the Swedish group, and, second, we should like to underline an important technical point. Our dental experiments were conducted on 4 volunteers (including ourselves) in whom 16 teeth were tested. Acupuncture was performed with stainless-steel acupuncture needles inserted usually at acupuncture points Large Intestine 4 (between the metacarpals of the thumb and forefinger, on the dorsal aspect) and Stomach 44 (in the web between the second and third toes, on the dorsal aspect), either unilaterally with an indifferent electrode on the contralateral leg, or bilaterally. The needles were connected to a stimulator of Chinese manufacture, driven by dry batteries of 7-5 V, delivering a stimulus at 2 Hz. Stimulation was kept up for 15-30 minutes, and caused twitching of the limbs, grimacing, and pallor-an ordeal first suffered by ourselves. The current flowing through the subjects was measured in 3 cases and was found to be 60 mA-an amount of electricity not without risk to the
patient. Pain perception thresholds were measured before and after acupuncture, the mean values being 2-9 A and 3-4 tA, respectively. In one additional subject in whom 6 teeth were tested, mean values of 2-9 A and 4-6 .A were obtained before and after acupuncture. We should mention the great technical difficulty in keeping the tooth surface dry but not desiccated.11-13 If this is not done, wide variations occur in all measurements. Procedures to overcome this difficulty have been tested by one of us over many years. 13, 14 We note that Andersson et al. write: " on many occasions maximum current (about 100 A) from the pulp tests was not sufficient to evoke pain in the tested teeth ". This is the kind of result that occurs when saliva leaks to the dental electrode contact. In our own cases, each tooth was individually prepared for testing before and after acupuncture, as, in our experience, it is difficult to maintain constant conditions Henderson, D. A. Australas. Ann. Med. 1954, 3, 219. Mumford, J. M. Archs oral. Biol. 1963, 8, 493. Mumford, J. M. Br. dent. J. 1963, 121, 178. Mumford, J. M., Bjorn, H. Problems in electric pulp testing and dental algesimetry. Int. dent. J., Lond. 1962, 12, 161. 14. Mumford, J. M. Toothache and Related Pain. London, 1973. 10. 11. 12. 13.
SIR,-I was interested in the account by Dr Grose and others (Aug. 4, p. 231) of Bell’s palsy and infectious mononucleosis. I saw 7 cases of Bell’s palsy in the period April-June, 1971, at the Coventry Maternity Hospital, Warwickshire. They were in patients who were from 30 to 37 weeks 6 gave a history of upper-respiratory-tract pregnant. infection, and in 4 this was associated with a sore throat. None had pre-eclampsia. All made an uneventful recovery, 3 during the pregnancy and 4 by six weeks after the birth of the baby. This association suggests an increased susceptibility during pregnancy, possibly by alteration of the immunological mechanisms. Mononucleosis studies were not done in these cases, but should obviously be undertaken in an effort to determine the aetiology of Bell’s palsy in pregnancy. King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco,
J. D. O’DONOVAN.
Western Australia 6008.
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-Your editorial (Sept. 8, we are
very close to
a
p.
contract, the
was timely since implications of which
546)
Superficially a ten-session week, payment duties, and freedom for all hospital consultants to practise privately may seem attractive, but become less so when examined closely. It is in fact an ingenious plan to seem
for
ominous.
extra
increase the income of consultants without seeming to do so, and the reasons for this are presumably political. Consultants have long been aware that they receive no financial recognition for being on-call, for sitting on committees, for informal teaching, and so forth. More recently they have been made aware that the career earnings of most of them compare unfavourably with that of the average general practitioner, and furthermore that the latter is making a comfortable income ten to fifteen years before the hospital doctors can achieve parity. The carefully fostered myth that all consultants make large incomes from private practice is untrue; a few do, but many do not. In some specialties and in many parts of the country private practice is sparse or non-existent. The figure given for the salary of senior consultants by the then Secretary of State a few years ago carefully avoided mentioning that this was limited to those with top distinction awards (about 4%). Consultants’ actual earnings have therefore been greatly, and I would suggest often deliber-
ately, exaggerated. The embryo contract is,
I believe, wrong in principle and could prove disastrous in practice. For many years I have thought that the function of a consultant is to provide
668 that the concept of notional sessions is a It is in fact impossible for most of us to quantitate our work in this way. A ward round may take anything between 2 and 4 hours, depending on the number and complexity of the patients admitted under one’s care. So it is with operating lists and outpatients sessions. The proposed new contract seeks to remedy the financial situation, but its premises are false. I have already dealt with private practice, and it is clear that a great many fulla
service, and
paper exercise.
time consultants, numbering some 40°o, will not benefit from a ten-session contract even if they opt to practise privately, which many will not. Much more serious, however, is payment for extra duty. The possible evils of this were mentioned in your editorial and need emphasis. When introduced for junior hospital staff it was viewed askance by most consultants and by many junior hospital doctors. How can one quantitate the overtime duties of a consultant ? Some consultants with heavy financial commitments might be tempted to take advantage of such a situation, though to be fair I believe most would not. Additionally, the new contract might seem to solve the problem of attracting the right men and women to those specialties and to those parts of the country where it is proving difficult to fill consultant posts; for the extra-duty payments would be large. But it would be a wrong solution, leading to highly paid overwork. Since we have to countersign the overtime claims of junior staff, it seems fair to ask: quis custodiet ipsos custodes ? Somebody will. Hospital consultants as a whole are highly trained professional men with a sense of duty. Instead of accepting this rather contemptuous method of increasing our remuneration, we should ask for salaries comparable with those in similar responsible positions in other walks of life, and continue, as we have always done, to give of our time voluntarily as part of our service and teaching commitments. Gloucestershire Royal Hospital, Gloucester.
G. R. FEARNLEY.
is very easy from the comfort of an editorial chair, working on a 9-5 basis. You ask how many consultants really want a new The answer is the majority, I am sure, of contract. those consultants whose duties involve emergency work. Over the years the regional boards have appeared to read into a simple statement of 11 sessions, an idea that this indicated overall availability for 7 days a week. It could be, of course, that the rather detached attitude of many consultants to the hours that their junior staff work and the tendency at one time to expect one’s house-surgeon or house-physician to be tied to a job for 6 months has encouraged them in this erroneous idea. The fact, however, is that there is a need to have a limitation on the hours of actual work that can be expected for a salary covering only 35-40 hours. I would have thought your editorial would have drawn attention to the statement issued recently that the European Community is considering making it illegal for anyone to work more than 40 hours, without overtime, within the community. I have noticed several letters from whole timers indicating their disquiet at the contract. There are two points I think they should consider: (1) Whether it is actually ethical to insist that a patient can only see you in the way you want them to and whether it is not more within the traditions of our profession to accommodate ourselves to the patient and that if we are in an area where patients want to see us privately then we are in honour bound to make arrangements in that way. Obviously a whole-time consultant coming on to 10 sessions would not expect a loss in earnings, and I think we could trust our negotiators to see that this does not occur.
SIR,-Consideration of the
new
contract
(2) I think it is time that we indicated the absolute fact that, of all the workers in this country, the hospital consultants have come off worst in this long battle of inflation. I was amused last night at a medical-staff committee to find that the shilling one used to get in 1939 for notifying infectious disease has been increased five times to 25p, and as the administration has therefore formally admitted that the present cost of living is at least five times what it was in 1939 then the standard wage of should be at least Eel 2,000. Abbey Avenue, St. Stephens, St. Albans, Herts.
10-session consultant
a
4
A. F. RUSHFORTH.
IgA DEFICIENCY AND INFANTILE ATOPY SIR,-Dr Taylor and his colleagues (July 21, p. Ill) present very interesting evidence about the role of transient IgA deficiency in the development of atopy. This work was like a missing link for the answer to the question, " Why are allergies increasing ? ". Peltonen
et
al.l observed almost twenty years ago in
a
sample of Finnish schoolchildren that there were more allergies among people born in the 1940s than among those born in the 1930s, the incidence increasing from year to year.
It
was
also observed in the
same
material that
people from high social classes and living well had more allergies than those from opposite social conditions. The biological chain between these phenomena was not clear. There are also opposite findings about the relationship of allergy frequency and the social level 2.3which show that the pure social-class effect is questionable. In Finland the breast-feeding rate began to decrease in the early 1940s and first in the higher social classes. Johnstone and Duttondemonstrated that potentially allergic children develop many fewer allergies when placed on a diet free of wheat, cow, and chicken products during the first months of life than those with a free diet. From a recent study of Finnish asthmatic children evidence was presented that asthma begins later in children with long breast-feeding than in those with short breast-feeding. What is the effect of breast milk, which decreases the incidence of allergies, except that it may be considered " non-allergenic with no real substitute ? Mata and Wyatt 6 have shown that human breast-milk contains considerable amounts of secretory IgA. The concentration of IgA is 400 mg. per 100 ml. in colostrum, about 200 mg. per 100 ml. during the lst to 52nd weeks after parturition, and thereafter it increases to the level observed in colostrum. Secretory IgA (two monomers of IgA-secretory piece) is resistant to acid environment and proteolytic digestion and is thus capable of surviving in the intestine. It probably can function in the same way as the baby’s own secretory IgA, to be an immunological bairier against foreign antigens of food. All these observations brought together (increased incidence of allergies, decreased rate of breast-feeding up to 3-6 months, increased allergy-rates with short breastfeeding, the relationship between transitory IgA deficiency and increased occurrence of atopy, and the presence of considerable amounts of IgA in breast-milk) seem to form a reasonable chain of biological evidence which may to a "
1.
2. 3. 4. 5.
6.
Peltonen, M.-L., Kasanen, A., Peltonen, T. E. Ann. pœdiat. Fenn. 1955, 1, 119. Dawson, B., Horobin, G., Illsley, R., Mitchell, R. Lancet, 1969, i, 827. Mitchell, R. G., Dawson, B. Archs Dis. Childh. 1973, 48, 467. Johnstone, D. E., Dutton, A. M. New Engl. J. Med. 1966, 274, 715. Koivikko, A. Unpublished. Mata, L. J., Wyatt, R. G. Am. J. clin. Nutr. 1971, 24, 976.
in a tooth (let alone several teeth) over a period of half-anhour or more. It would be helpful to know which teeth, or at least which quadrants of the mouth, were affected by which Controls would be improved if acupuncture points. neither the subject nor the physiologist knew which teeth were to be affected. Department of Operative Dental Surgery, School of Dental Surgery, Neurobiology Laboratory, Department of Anatomy, University of Liverpool,
Children’s Medical Research
Foundation, Royal Alexandra Hospital for Children, Sydney, New South Wales 2050, Australia.
JIM MUMFORD.
P.O. Box 147, L69 3BX.
DAVID BOWSHER.
Liverpool
JEANETTE BLOMFIELD. BELL’S PALSY IN PREGNANCY
ELECTRO-ACUPUNCTURE AND PAIN THRESHOLD SIR,-Having completed only a small number of experiments on the effect of electro-acupuncture on perception thresholds in teeth, it was not our intention to publish at this date. However, the intense interest now evinced in the subject, and, particularly, the interesting letter by Professor Andersson and others (Sept. 8, p. 564), prompt us to discuss some preliminary observations for two reasons. First, our results differ from those of the Swedish group, and, second, we should like to underline an important technical point. Our dental experiments were conducted on 4 volunteers (including ourselves) in whom 16 teeth were tested. Acupuncture was performed with stainless-steel acupuncture needles inserted usually at acupuncture points Large Intestine 4 (between the metacarpals of the thumb and forefinger, on the dorsal aspect) and Stomach 44 (in the web between the second and third toes, on the dorsal aspect), either unilaterally with an indifferent electrode on the contralateral leg, or bilaterally. The needles were connected to a stimulator of Chinese manufacture, driven by dry batteries of 7-5 V, delivering a stimulus at 2 Hz. Stimulation was kept up for 15-30 minutes, and caused twitching of the limbs, grimacing, and pallor-an ordeal first suffered by ourselves. The current flowing through the subjects was measured in 3 cases and was found to be 60 mA-an amount of electricity not without risk to the
patient. Pain perception thresholds were measured before and after acupuncture, the mean values being 2-9 A and 3-4 tA, respectively. In one additional subject in whom 6 teeth were tested, mean values of 2-9 A and 4-6 .A were obtained before and after acupuncture. We should mention the great technical difficulty in keeping the tooth surface dry but not desiccated.11-13 If this is not done, wide variations occur in all measurements. Procedures to overcome this difficulty have been tested by one of us over many years. 13, 14 We note that Andersson et al. write: " on many occasions maximum current (about 100 A) from the pulp tests was not sufficient to evoke pain in the tested teeth ". This is the kind of result that occurs when saliva leaks to the dental electrode contact. In our own cases, each tooth was individually prepared for testing before and after acupuncture, as, in our experience, it is difficult to maintain constant conditions Henderson, D. A. Australas. Ann. Med. 1954, 3, 219. Mumford, J. M. Archs oral. Biol. 1963, 8, 493. Mumford, J. M. Br. dent. J. 1963, 121, 178. Mumford, J. M., Bjorn, H. Problems in electric pulp testing and dental algesimetry. Int. dent. J., Lond. 1962, 12, 161. 14. Mumford, J. M. Toothache and Related Pain. London, 1973. 10. 11. 12. 13.
SIR,-I was interested in the account by Dr Grose and others (Aug. 4, p. 231) of Bell’s palsy and infectious mononucleosis. I saw 7 cases of Bell’s palsy in the period April-June, 1971, at the Coventry Maternity Hospital, Warwickshire. They were in patients who were from 30 to 37 weeks 6 gave a history of upper-respiratory-tract pregnant. infection, and in 4 this was associated with a sore throat. None had pre-eclampsia. All made an uneventful recovery, 3 during the pregnancy and 4 by six weeks after the birth of the baby. This association suggests an increased susceptibility during pregnancy, possibly by alteration of the immunological mechanisms. Mononucleosis studies were not done in these cases, but should obviously be undertaken in an effort to determine the aetiology of Bell’s palsy in pregnancy. King Edward Memorial Hospital for Women, 374 Bagot Road, Subiaco,
J. D. O’DONOVAN.
Western Australia 6008.
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-Your editorial (Sept. 8, we are
very close to
a
p.
contract, the
was timely since implications of which
546)
Superficially a ten-session week, payment duties, and freedom for all hospital consultants to practise privately may seem attractive, but become less so when examined closely. It is in fact an ingenious plan to seem
for
ominous.
extra
increase the income of consultants without seeming to do so, and the reasons for this are presumably political. Consultants have long been aware that they receive no financial recognition for being on-call, for sitting on committees, for informal teaching, and so forth. More recently they have been made aware that the career earnings of most of them compare unfavourably with that of the average general practitioner, and furthermore that the latter is making a comfortable income ten to fifteen years before the hospital doctors can achieve parity. The carefully fostered myth that all consultants make large incomes from private practice is untrue; a few do, but many do not. In some specialties and in many parts of the country private practice is sparse or non-existent. The figure given for the salary of senior consultants by the then Secretary of State a few years ago carefully avoided mentioning that this was limited to those with top distinction awards (about 4%). Consultants’ actual earnings have therefore been greatly, and I would suggest often deliber-
ately, exaggerated. The embryo contract is,
I believe, wrong in principle and could prove disastrous in practice. For many years I have thought that the function of a consultant is to provide
668 that the concept of notional sessions is a It is in fact impossible for most of us to quantitate our work in this way. A ward round may take anything between 2 and 4 hours, depending on the number and complexity of the patients admitted under one’s care. So it is with operating lists and outpatients sessions. The proposed new contract seeks to remedy the financial situation, but its premises are false. I have already dealt with private practice, and it is clear that a great many fulla
service, and
paper exercise.
time consultants, numbering some 40°o, will not benefit from a ten-session contract even if they opt to practise privately, which many will not. Much more serious, however, is payment for extra duty. The possible evils of this were mentioned in your editorial and need emphasis. When introduced for junior hospital staff it was viewed askance by most consultants and by many junior hospital doctors. How can one quantitate the overtime duties of a consultant ? Some consultants with heavy financial commitments might be tempted to take advantage of such a situation, though to be fair I believe most would not. Additionally, the new contract might seem to solve the problem of attracting the right men and women to those specialties and to those parts of the country where it is proving difficult to fill consultant posts; for the extra-duty payments would be large. But it would be a wrong solution, leading to highly paid overwork. Since we have to countersign the overtime claims of junior staff, it seems fair to ask: quis custodiet ipsos custodes ? Somebody will. Hospital consultants as a whole are highly trained professional men with a sense of duty. Instead of accepting this rather contemptuous method of increasing our remuneration, we should ask for salaries comparable with those in similar responsible positions in other walks of life, and continue, as we have always done, to give of our time voluntarily as part of our service and teaching commitments. Gloucestershire Royal Hospital, Gloucester.
G. R. FEARNLEY.
is very easy from the comfort of an editorial chair, working on a 9-5 basis. You ask how many consultants really want a new The answer is the majority, I am sure, of contract. those consultants whose duties involve emergency work. Over the years the regional boards have appeared to read into a simple statement of 11 sessions, an idea that this indicated overall availability for 7 days a week. It could be, of course, that the rather detached attitude of many consultants to the hours that their junior staff work and the tendency at one time to expect one’s house-surgeon or house-physician to be tied to a job for 6 months has encouraged them in this erroneous idea. The fact, however, is that there is a need to have a limitation on the hours of actual work that can be expected for a salary covering only 35-40 hours. I would have thought your editorial would have drawn attention to the statement issued recently that the European Community is considering making it illegal for anyone to work more than 40 hours, without overtime, within the community. I have noticed several letters from whole timers indicating their disquiet at the contract. There are two points I think they should consider: (1) Whether it is actually ethical to insist that a patient can only see you in the way you want them to and whether it is not more within the traditions of our profession to accommodate ourselves to the patient and that if we are in an area where patients want to see us privately then we are in honour bound to make arrangements in that way. Obviously a whole-time consultant coming on to 10 sessions would not expect a loss in earnings, and I think we could trust our negotiators to see that this does not occur.
SIR,-Consideration of the
new
contract
(2) I think it is time that we indicated the absolute fact that, of all the workers in this country, the hospital consultants have come off worst in this long battle of inflation. I was amused last night at a medical-staff committee to find that the shilling one used to get in 1939 for notifying infectious disease has been increased five times to 25p, and as the administration has therefore formally admitted that the present cost of living is at least five times what it was in 1939 then the standard wage of should be at least Eel 2,000. Abbey Avenue, St. Stephens, St. Albans, Herts.
10-session consultant
a
4
A. F. RUSHFORTH.
IgA DEFICIENCY AND INFANTILE ATOPY SIR,-Dr Taylor and his colleagues (July 21, p. Ill) present very interesting evidence about the role of transient IgA deficiency in the development of atopy. This work was like a missing link for the answer to the question, " Why are allergies increasing ? ". Peltonen
et
al.l observed almost twenty years ago in
a
sample of Finnish schoolchildren that there were more allergies among people born in the 1940s than among those born in the 1930s, the incidence increasing from year to year.
It
was
also observed in the
same
material that
people from high social classes and living well had more allergies than those from opposite social conditions. The biological chain between these phenomena was not clear. There are also opposite findings about the relationship of allergy frequency and the social level 2.3which show that the pure social-class effect is questionable. In Finland the breast-feeding rate began to decrease in the early 1940s and first in the higher social classes. Johnstone and Duttondemonstrated that potentially allergic children develop many fewer allergies when placed on a diet free of wheat, cow, and chicken products during the first months of life than those with a free diet. From a recent study of Finnish asthmatic children evidence was presented that asthma begins later in children with long breast-feeding than in those with short breast-feeding. What is the effect of breast milk, which decreases the incidence of allergies, except that it may be considered " non-allergenic with no real substitute ? Mata and Wyatt 6 have shown that human breast-milk contains considerable amounts of secretory IgA. The concentration of IgA is 400 mg. per 100 ml. in colostrum, about 200 mg. per 100 ml. during the lst to 52nd weeks after parturition, and thereafter it increases to the level observed in colostrum. Secretory IgA (two monomers of IgA-secretory piece) is resistant to acid environment and proteolytic digestion and is thus capable of surviving in the intestine. It probably can function in the same way as the baby’s own secretory IgA, to be an immunological bairier against foreign antigens of food. All these observations brought together (increased incidence of allergies, decreased rate of breast-feeding up to 3-6 months, increased allergy-rates with short breastfeeding, the relationship between transitory IgA deficiency and increased occurrence of atopy, and the presence of considerable amounts of IgA in breast-milk) seem to form a reasonable chain of biological evidence which may to a "
1.
2. 3. 4. 5.
6.
Peltonen, M.-L., Kasanen, A., Peltonen, T. E. Ann. pœdiat. Fenn. 1955, 1, 119. Dawson, B., Horobin, G., Illsley, R., Mitchell, R. Lancet, 1969, i, 827. Mitchell, R. G., Dawson, B. Archs Dis. Childh. 1973, 48, 467. Johnstone, D. E., Dutton, A. M. New Engl. J. Med. 1966, 274, 715. Koivikko, A. Unpublished. Mata, L. J., Wyatt, R. G. Am. J. clin. Nutr. 1971, 24, 976.