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THE PAY FREEZE
434
In
England
Now
Letters
A Running
Commentary by Peripatetic Correspondents As an experimentalist I never cease to wonder at the success achieved by medicines administered with so little regard to body-weight. The instructions on dosage of medicines often x ", without state quite simply that the dose for an adult is mention of body-weight which may vary threefold between individual adults. For children the B.N.F. 1966 recognises that " the dose is most reliably based on body weight ", but because " often this is not accurately known it employs an age basis. Such inaccuracies are unimportant in the case of preparations which are both ineffective and non-toxic, but they may be of considerable importance if best benefit is to be obtained from potentially toxic drugs. The hazards of the situation can be increased by the vehicle of administration, and one interesting feature of the new look, partially metric B.N.F. is that in it the days of the domestic spoon as a measure of liquid medicines are numbered. Gone too, by 1968, will be "
"
the need for doctors to know that a minim is the volume occupied by 0-971 grains of water at 16’7°C. By then the fluid drachm (which all of us know is 3-55152 ml.) will be a museum piece. Nervous and surface tensions will remain, but the shape and capacity of the smaller dosing vessel will be forever enshrined in a British Standard, clear, polystyrene spoon stamped 5 ml. and B.S. 3221/4. But what are we to call it? "Teaspoon" should be discouraged and " Take two B.S. 3221/4s" before bed " sounds ridiculous. How about " medispoons for the genre with " mini-med " for the 5 ml. variety; reserving " " king-med for any later and larger vessel ? *
*
*
I have great nostalgia for the days when everybody else at home or came by train. In the mid-’twenties, when the motor industry was very young, we came to the Devonshire coast in an American car which generated more heat than power. On long hills it boiled, and by boiling I don’t mean the mild retention with overflow incontinence that occasionally occurs nowadays. A thermometer was built into the radiator cap with the red-spirit column facing backwards. Aside from Arctic weather or heavy rain, the reading was, when running, well above the 3/4 mark. Consequently, as an early warning sign it was useless; a sudden rise in the red and violent boiling happened simultaneously. The cap had to be hastily unscrewed with a thickly gloved hand, when boiling water would gush out as from a spring. My father would stand, hands solemnly held together, while a quart or so of water spilled on to the road and the boiling stopped. But the roads were clear and the air fresh. We arrived at our destination exhilarated, triumphant, and were greeted as heroes. The car was parked on the road outside the boarding-house, a status symbol that was the envy of other landladies in the road. This year we arrived exhausted, having crawled in third gear for the last two hours behind Gilbert’s Glorious ToursTelephone Stoke-on-Trent 3257. " Ample parking space for guests’ cars " was a claustrophobic patch of broken ground merging with a builder’s yard. One side of the car was completely blocked; we emerged from the other side into an inchdeep lake of liquid cement. A service charge of 10% on the bill meant no porter and a vacant reception-desk.
stayed
*
*
*
When did the surgeon first dress up in white ? Is there an earlier record than 1266 when, at the siege of Kenilworth, the Archbishop of Canterbury and two bishops appeared before the castle walls and solemnly excommunicated the defenders ? In reply, their surgeon, Master Phillip Porpies, dressed up in white vestments to represent a legate, and from the castle wall he in turn excommunicated the King and all those who supported his cause. It is clear that psychological warfare had no effect upon either side, for the defenders did not surrender until six months later, when they were defeated by starvation and
dysentry.
_
to
the Editor
THE PAY FREEZE you and the British Medical Journal conclude your editorials on the economic crisis by referring to the opinion that sources of money other than taxation may have to be found to help pay for the National Health Service. Like many other people who are trying to make a small part of our Health Service work, I came to the conclusion some time ago that Exchequer funds can never provide us with a modern hospital system, or with decent conditions for professional staff of all kinds. Despite the recurring crises, the standard of living of our population in general is rising steadily, and with it their level of expectations. This applies particularly to what they regard as adequate medical care. The National Health Service has only managed to struggle on up to now because most people are not sufficiently bourgeois in outlook to demand what it is notionally supposed to provide. But in fact, while the shibboleth of" free medicine " continues to be repeated, we may soon be finding that its quality is becoming steadily more second-rate. The recent hospital building programme, though it has got away from the never-never land of the 1962 Plan, makes it clear that only a very small proportion of our sick people are likely to be treated in modern hospitals by 1975. This means that most of those now working in the Health Services face the prospect of seeing very little improvement in their hospitals for most of their professional lives. Successive Governments have refused to consider raising money for this purpose from other sources. But in view of the immense sums spent on non-essentials by almost the whole range of society, it is surely reasonable to suggest that part of this might be devoted to improving the quality of medical care. Small charges for different services could add up to very substantial sums, which might transform the whole morale of the N.H.S. People could insure themselves against .these charges at very modest cost. It should also be possible for extra resources to be provided by personal choice, and these could act as a stimulus rather than as a threat to the basic structure that comes from the State. These, at least, would be exempt from the cuts that come with each down-turn in the economic cycle. If it was finally admitted that an ever-accelerating demand for better medical care from a growing population cannot be met out of taxation, this would allow some imaginative rethinking. But as a recent B.M.A. report pointed out, no-one up to now has shown any interest in educating the public on the reality of Health Service finances. HUGH FREEMAN. Manchester 3.
SiR,-Last week both
seen by all doctors as a matter of vital to the future of the N.H.S, Not everyone else saw it in this light. Some people, very unfortunately, got the idea that all doctors were getting another E1000 a year, and were bitterly disappointed with so little. This may well have been one factor in the seamen’s strike; this strike was certainly one factor in the national economic crisis, which has produced a wage-freeze for, among others, doctors. And so the vicious circle may go on. Consultants who have counselled restraint have been attacked as better able to afford it than many other doctors and this may be partly true. Most doctors surely agree on two points : the plight of the junior hospital staff; and the need to help general practitioners to improve their service, without losing in doing so. These have been rightly stressed by the B.M.A. leaders, and the Minister is probably sympathetic, but he cannot make exceptions for fear of setting up another vicious circle. Yet if co help is given, more doctors may emigrate, and practices -4 deteriorate. Can anything be done within our own profession to help’ If the 13,000 junior hospital staff have their rise delayed for. six months, they will lose some f:l/4 million; but some 40< 01 this would have gone back in tax anyhow. Is it quite impossible
SiR,-The pay award was simple justice (or less), and
435 that
a
fund of
some
El 50,000 could be raised within the
profession, from those who feel they can afford to contributenot only consultants-and distributed to junior hospital staff the next three months ? Such a gesture would show our own profession not only that we cared for each other, and tried to help with each others’ patients, but also that we understood the overriding national need. No doubt there would be practical difficulties, but I cannot believe they would be insuperable. I have no wish for a sword on the shoulder-or a knife in the back-as a reward for this suggestion, so I simply sign over
myself CONSULTANT.
SIR,-After a splendid effort in which it succeeded in frightening considerably the hospital junior staff group of the B..M.A. and the committees to which it is permitted to submit suggestions, I am distressed to see the Action Group meekly following the B.M.A. line on the recent Government freeze on our salaries. Can it be that they lack funds, or can it be that they agree with the B.M.A. ? If it is the former then a contribution from the hospital junior staff group, most of whom are non-B.M.A. members, should surely "
"
be forthcoming.
It should be
brought home by every means possible that the monopoly employer of hospital staff, cannot evade its responsibility. If it had not been for delays, for which the Ministry of Health must take much responsibility, the
Government,
as a
increase in pay would have been effected months before the "freezewas introduced, and it is a bitter blow for all of us, so underpaid for so long, to be the first victims of what will undoubtedly become not a nation-wide freeze of wages but a freeze of wages of Government employees. Long will the emigration of hospital staff continue. Blackhill, Consett, REGISTRAR. Co. Durham.
SiR—1 believe that the Government, in refusing to pay the profession the money due under the recent agreement, has not made it clear to the public that it is not enforcing an income standstill but is quite simply repudiating a debt outstanding for the past two months. We should surely spare no pains to make our position clear, even if we decide, because of the financial crisis, to take no action in the face of this dishonourable act.
Dane End, Ware, Hertfordshire.
ALAN S. CLARK.
COMMUNICATIONS FOR CHILDREN IN HOSPITAL SIR,-In 1961 and 1962 an inquiry was held at this hospital to elucidate problems or difficulties experienced by mothers of children who had been discharged after periods of between one day and eight months in hospital. The inquiry was designed by one of us (J. J. F.), and the case-work was carried out by the social workers of the Invalid Children’s Aid Association. 100 mothers were visited in their homes some six weeks after the discharge of their children; these represent about a quarter of the first admissions during this period. Boys and girls were m roughly equal numbers, and all types of medical and surgical treatment at this hospital were included. Inquiries were made about reception on arrival, visiting, and arrangements for discharge; and comments on ease or difficulty of obtaining information about illness, and upon the care and ’aanagement of the child, and opinions as to the emotional Jormality or otherwise of the child upon discharge, were nought. The object was thus to uncover any remediable dtScuhies and attempt to correct them. It is now two years since the report upon this perhaps unique investigation was compiled, and it might be useful to see what gains seem to have
suited. pepilee
Difficulties experienced upon reception or discharge were reianvely slight; and criticism of nursing-care, treatment, and
general management of the children was negligible. Indeed was an overwhelming preponderance of grateful and approving comments. 40 mothers, however, had experienced difficulties over visiting: expense, distance, care of other children in the home, and time off work were understandable, especially in long-term admissions to hospital when the family was large. But many mothers had impressions of the visiting arrangements which were at variance with the stated policy of the hospital at the time. About a quarter of the mothers were
there
dissatisfied with the amount of information or advice made available to them. Age, personality, or intelligence in the " complaining " group seemed not to be relevant, but perhaps a slightly higher social class might be correlated with a greater sense of need for facts and information. Some 30 or so mothers would have welcomed an invitation to be admitted to the hospital with their children had this been possible, and over 20 more would have done so if arrangements could have been made for the care of other children or if these had not been so young. Of the 100 children, 64 had operations, 21 had splinting or plaster casts, and 15 others had treatment or investigations. 28, of whom 25 were under 5 years of age, had been regarded their mothers as emotionally normal before admission but by " disturbed " afterwards. Measures Taken The facts were reported to the medical staff and board of governors and were fully discussed. The views of the nursing, teaching, and administrative staff and the almoner’s department were also elicited. Following all this, brochures for all on admission to a waitinglist were modified to give clear information of the ease of daily visiting at times to be arranged individually with the ward sisters. The surgeons, almoners, and sisters arranged to tell mothers or relations about a residential building (one capable of taking up to 5 relations at any one time had been provided already by the board of governors), especially when young children or those to undergo serious operations or who had had a serious accident were to be admitted. Relations could stay, for periods covering operation or serious anxiety, within a short distance of the children’s wards and the accident unit. Arrangements to ensure any necessary improvement in communication of information were discussed and then left to the individual surgeons and their firms. A member of the consulting staff was given the responsibility of holding a watching brief in the interests of parents and children, with power to act or to draw attention to any matter as he thought fit.
Results We in the hospital believe that" communications " have been improved. The use of the " mothers’ home " has increased on an average by some three times, but it could still be used at least twice as much as it is now, without strain upon accommodation, but apparently we tend still to choose, for giving information about the home, parents of children we think of as suitable-i.e., those awaiting big operations, and/or under5-year-olds. We wonder whether wider dissemination of information would not uncover a different group with genuine need. There is evidence to suggest that children, and indeed adults, of any age may be disturbed by hospital experiences. Therefore, perhaps, there is always scope for further investigation of this matter. Visiting arrangements are clearly easier, and any afternoon there are 4 or 5 mothers caring for their own children in the young-children’s ward. It must be realised that in many cases mothers with other children cannot take advantage of what is offered. The older children also have schooling in the day-time, and this has its own very real importance. A lecture from Dr. Dermod MacCarthy (who runs a unit which admits mothers together with their children to a cubicle wing) to senior nursing staff, teachers, and almoners, and visits from ward sisters of other children’s units, have broadened attitudes of mind to a wider recognition of emotional needs. The
of the hospital, Miss J. Loader, to whom we owe for her interest and cooperation throughout, has
matron
gratitude
In
England
Now
Letters
A Running
Commentary by Peripatetic Correspondents As an experimentalist I never cease to wonder at the success achieved by medicines administered with so little regard to body-weight. The instructions on dosage of medicines often x ", without state quite simply that the dose for an adult is mention of body-weight which may vary threefold between individual adults. For children the B.N.F. 1966 recognises that " the dose is most reliably based on body weight ", but because " often this is not accurately known it employs an age basis. Such inaccuracies are unimportant in the case of preparations which are both ineffective and non-toxic, but they may be of considerable importance if best benefit is to be obtained from potentially toxic drugs. The hazards of the situation can be increased by the vehicle of administration, and one interesting feature of the new look, partially metric B.N.F. is that in it the days of the domestic spoon as a measure of liquid medicines are numbered. Gone too, by 1968, will be "
"
the need for doctors to know that a minim is the volume occupied by 0-971 grains of water at 16’7°C. By then the fluid drachm (which all of us know is 3-55152 ml.) will be a museum piece. Nervous and surface tensions will remain, but the shape and capacity of the smaller dosing vessel will be forever enshrined in a British Standard, clear, polystyrene spoon stamped 5 ml. and B.S. 3221/4. But what are we to call it? "Teaspoon" should be discouraged and " Take two B.S. 3221/4s" before bed " sounds ridiculous. How about " medispoons for the genre with " mini-med " for the 5 ml. variety; reserving " " king-med for any later and larger vessel ? *
*
*
I have great nostalgia for the days when everybody else at home or came by train. In the mid-’twenties, when the motor industry was very young, we came to the Devonshire coast in an American car which generated more heat than power. On long hills it boiled, and by boiling I don’t mean the mild retention with overflow incontinence that occasionally occurs nowadays. A thermometer was built into the radiator cap with the red-spirit column facing backwards. Aside from Arctic weather or heavy rain, the reading was, when running, well above the 3/4 mark. Consequently, as an early warning sign it was useless; a sudden rise in the red and violent boiling happened simultaneously. The cap had to be hastily unscrewed with a thickly gloved hand, when boiling water would gush out as from a spring. My father would stand, hands solemnly held together, while a quart or so of water spilled on to the road and the boiling stopped. But the roads were clear and the air fresh. We arrived at our destination exhilarated, triumphant, and were greeted as heroes. The car was parked on the road outside the boarding-house, a status symbol that was the envy of other landladies in the road. This year we arrived exhausted, having crawled in third gear for the last two hours behind Gilbert’s Glorious ToursTelephone Stoke-on-Trent 3257. " Ample parking space for guests’ cars " was a claustrophobic patch of broken ground merging with a builder’s yard. One side of the car was completely blocked; we emerged from the other side into an inchdeep lake of liquid cement. A service charge of 10% on the bill meant no porter and a vacant reception-desk.
stayed
*
*
*
When did the surgeon first dress up in white ? Is there an earlier record than 1266 when, at the siege of Kenilworth, the Archbishop of Canterbury and two bishops appeared before the castle walls and solemnly excommunicated the defenders ? In reply, their surgeon, Master Phillip Porpies, dressed up in white vestments to represent a legate, and from the castle wall he in turn excommunicated the King and all those who supported his cause. It is clear that psychological warfare had no effect upon either side, for the defenders did not surrender until six months later, when they were defeated by starvation and
dysentry.
_
to
the Editor
THE PAY FREEZE you and the British Medical Journal conclude your editorials on the economic crisis by referring to the opinion that sources of money other than taxation may have to be found to help pay for the National Health Service. Like many other people who are trying to make a small part of our Health Service work, I came to the conclusion some time ago that Exchequer funds can never provide us with a modern hospital system, or with decent conditions for professional staff of all kinds. Despite the recurring crises, the standard of living of our population in general is rising steadily, and with it their level of expectations. This applies particularly to what they regard as adequate medical care. The National Health Service has only managed to struggle on up to now because most people are not sufficiently bourgeois in outlook to demand what it is notionally supposed to provide. But in fact, while the shibboleth of" free medicine " continues to be repeated, we may soon be finding that its quality is becoming steadily more second-rate. The recent hospital building programme, though it has got away from the never-never land of the 1962 Plan, makes it clear that only a very small proportion of our sick people are likely to be treated in modern hospitals by 1975. This means that most of those now working in the Health Services face the prospect of seeing very little improvement in their hospitals for most of their professional lives. Successive Governments have refused to consider raising money for this purpose from other sources. But in view of the immense sums spent on non-essentials by almost the whole range of society, it is surely reasonable to suggest that part of this might be devoted to improving the quality of medical care. Small charges for different services could add up to very substantial sums, which might transform the whole morale of the N.H.S. People could insure themselves against .these charges at very modest cost. It should also be possible for extra resources to be provided by personal choice, and these could act as a stimulus rather than as a threat to the basic structure that comes from the State. These, at least, would be exempt from the cuts that come with each down-turn in the economic cycle. If it was finally admitted that an ever-accelerating demand for better medical care from a growing population cannot be met out of taxation, this would allow some imaginative rethinking. But as a recent B.M.A. report pointed out, no-one up to now has shown any interest in educating the public on the reality of Health Service finances. HUGH FREEMAN. Manchester 3.
SiR,-Last week both
seen by all doctors as a matter of vital to the future of the N.H.S, Not everyone else saw it in this light. Some people, very unfortunately, got the idea that all doctors were getting another E1000 a year, and were bitterly disappointed with so little. This may well have been one factor in the seamen’s strike; this strike was certainly one factor in the national economic crisis, which has produced a wage-freeze for, among others, doctors. And so the vicious circle may go on. Consultants who have counselled restraint have been attacked as better able to afford it than many other doctors and this may be partly true. Most doctors surely agree on two points : the plight of the junior hospital staff; and the need to help general practitioners to improve their service, without losing in doing so. These have been rightly stressed by the B.M.A. leaders, and the Minister is probably sympathetic, but he cannot make exceptions for fear of setting up another vicious circle. Yet if co help is given, more doctors may emigrate, and practices -4 deteriorate. Can anything be done within our own profession to help’ If the 13,000 junior hospital staff have their rise delayed for. six months, they will lose some f:l/4 million; but some 40< 01 this would have gone back in tax anyhow. Is it quite impossible
SiR,-The pay award was simple justice (or less), and
435 that
a
fund of
some
El 50,000 could be raised within the
profession, from those who feel they can afford to contributenot only consultants-and distributed to junior hospital staff the next three months ? Such a gesture would show our own profession not only that we cared for each other, and tried to help with each others’ patients, but also that we understood the overriding national need. No doubt there would be practical difficulties, but I cannot believe they would be insuperable. I have no wish for a sword on the shoulder-or a knife in the back-as a reward for this suggestion, so I simply sign over
myself CONSULTANT.
SIR,-After a splendid effort in which it succeeded in frightening considerably the hospital junior staff group of the B..M.A. and the committees to which it is permitted to submit suggestions, I am distressed to see the Action Group meekly following the B.M.A. line on the recent Government freeze on our salaries. Can it be that they lack funds, or can it be that they agree with the B.M.A. ? If it is the former then a contribution from the hospital junior staff group, most of whom are non-B.M.A. members, should surely "
"
be forthcoming.
It should be
brought home by every means possible that the monopoly employer of hospital staff, cannot evade its responsibility. If it had not been for delays, for which the Ministry of Health must take much responsibility, the
Government,
as a
increase in pay would have been effected months before the "freezewas introduced, and it is a bitter blow for all of us, so underpaid for so long, to be the first victims of what will undoubtedly become not a nation-wide freeze of wages but a freeze of wages of Government employees. Long will the emigration of hospital staff continue. Blackhill, Consett, REGISTRAR. Co. Durham.
SiR—1 believe that the Government, in refusing to pay the profession the money due under the recent agreement, has not made it clear to the public that it is not enforcing an income standstill but is quite simply repudiating a debt outstanding for the past two months. We should surely spare no pains to make our position clear, even if we decide, because of the financial crisis, to take no action in the face of this dishonourable act.
Dane End, Ware, Hertfordshire.
ALAN S. CLARK.
COMMUNICATIONS FOR CHILDREN IN HOSPITAL SIR,-In 1961 and 1962 an inquiry was held at this hospital to elucidate problems or difficulties experienced by mothers of children who had been discharged after periods of between one day and eight months in hospital. The inquiry was designed by one of us (J. J. F.), and the case-work was carried out by the social workers of the Invalid Children’s Aid Association. 100 mothers were visited in their homes some six weeks after the discharge of their children; these represent about a quarter of the first admissions during this period. Boys and girls were m roughly equal numbers, and all types of medical and surgical treatment at this hospital were included. Inquiries were made about reception on arrival, visiting, and arrangements for discharge; and comments on ease or difficulty of obtaining information about illness, and upon the care and ’aanagement of the child, and opinions as to the emotional Jormality or otherwise of the child upon discharge, were nought. The object was thus to uncover any remediable dtScuhies and attempt to correct them. It is now two years since the report upon this perhaps unique investigation was compiled, and it might be useful to see what gains seem to have
suited. pepilee
Difficulties experienced upon reception or discharge were reianvely slight; and criticism of nursing-care, treatment, and
general management of the children was negligible. Indeed was an overwhelming preponderance of grateful and approving comments. 40 mothers, however, had experienced difficulties over visiting: expense, distance, care of other children in the home, and time off work were understandable, especially in long-term admissions to hospital when the family was large. But many mothers had impressions of the visiting arrangements which were at variance with the stated policy of the hospital at the time. About a quarter of the mothers were
there
dissatisfied with the amount of information or advice made available to them. Age, personality, or intelligence in the " complaining " group seemed not to be relevant, but perhaps a slightly higher social class might be correlated with a greater sense of need for facts and information. Some 30 or so mothers would have welcomed an invitation to be admitted to the hospital with their children had this been possible, and over 20 more would have done so if arrangements could have been made for the care of other children or if these had not been so young. Of the 100 children, 64 had operations, 21 had splinting or plaster casts, and 15 others had treatment or investigations. 28, of whom 25 were under 5 years of age, had been regarded their mothers as emotionally normal before admission but by " disturbed " afterwards. Measures Taken The facts were reported to the medical staff and board of governors and were fully discussed. The views of the nursing, teaching, and administrative staff and the almoner’s department were also elicited. Following all this, brochures for all on admission to a waitinglist were modified to give clear information of the ease of daily visiting at times to be arranged individually with the ward sisters. The surgeons, almoners, and sisters arranged to tell mothers or relations about a residential building (one capable of taking up to 5 relations at any one time had been provided already by the board of governors), especially when young children or those to undergo serious operations or who had had a serious accident were to be admitted. Relations could stay, for periods covering operation or serious anxiety, within a short distance of the children’s wards and the accident unit. Arrangements to ensure any necessary improvement in communication of information were discussed and then left to the individual surgeons and their firms. A member of the consulting staff was given the responsibility of holding a watching brief in the interests of parents and children, with power to act or to draw attention to any matter as he thought fit.
Results We in the hospital believe that" communications " have been improved. The use of the " mothers’ home " has increased on an average by some three times, but it could still be used at least twice as much as it is now, without strain upon accommodation, but apparently we tend still to choose, for giving information about the home, parents of children we think of as suitable-i.e., those awaiting big operations, and/or under5-year-olds. We wonder whether wider dissemination of information would not uncover a different group with genuine need. There is evidence to suggest that children, and indeed adults, of any age may be disturbed by hospital experiences. Therefore, perhaps, there is always scope for further investigation of this matter. Visiting arrangements are clearly easier, and any afternoon there are 4 or 5 mothers caring for their own children in the young-children’s ward. It must be realised that in many cases mothers with other children cannot take advantage of what is offered. The older children also have schooling in the day-time, and this has its own very real importance. A lecture from Dr. Dermod MacCarthy (who runs a unit which admits mothers together with their children to a cubicle wing) to senior nursing staff, teachers, and almoners, and visits from ward sisters of other children’s units, have broadened attitudes of mind to a wider recognition of emotional needs. The
of the hospital, Miss J. Loader, to whom we owe for her interest and cooperation throughout, has
matron
gratitude