- Email: [email protected]
THE PLIGHT OF HOSPITAL PHARMACY
146
sick, which
the keynote of their teaching, was until little more than an ideal and a slogan. quite recently One of the main obstacles to the public understanding of psychiatry has been the mental hospital itself ; for, though it occupied the centre of the field, it was geographically and spiritually isolated from the community Reform within the hospitals was it aimed to serve. certainly needed, but it was not at first recognised that this largely depended on the development of external It was necessary to show the public what services. psychiatry had to offer. Only in this way could early treatment be secured, the need for admission to hospital prevented, and overcrowding reduced. It may truly be said of Dr. T. P. Rees that by his work outside Warlingham Park Hospital he made internal reforms possible : in fact by teaching the public he created his own time. The future of psychiatry depends on prevention ; and mental health, like any other social reform, needs promotion, which can be achieved only by contact with society. Dr. Rees’s contributions to was
mental-hospital management are internationally accepted. His concepts of the therapeutic community, respect for the individual patient, and the need for team-work among the staff have set the standard for British mental hospitals. But it is significant that recognition of his work has come not only from within the medical profession but from the people of Croydon. In conferring on Dr. Rees the honorary freedom of their borough its citizens have shown their appreciation of the man and also their understanding of the worth of the community psychiatry he has practised. THE PLIGHT OF HOSPITAL PHARMACY
NEW salary scales have lately been announcedr for hospital pharmacists ; but, so far from attracting recruits to sustain a service on the point of collapse, they are likely to discourage newcomers still further because they compare so unfavourably with salaries in other branches of pharmacy and in the technical colleges and universities, and with those of other hospital staff, especially biochemists, physicists, and supplies officers. The seriousness of the situation is illustrated by what has just happened in the Portsmouth hospitals2 where it has proved impossible to fill two vacancies in Advertisements an establishment of nine pharmacists. produced no replies, and the group secretary sees worse to come because he expects that the hospitals will lose the staff they already have to new pharmaceutical factories in the district. He made it plain that pressure on the overburdened staff was resulting in serious
dangers. For several years hospitals have been losing many of their best pharmacists to retail and manufacturing pharmacy. The new Burnham-scale salaries for teachers in the schools of pharmacy are now likely to cause a further drift of better-qualified pharmacists away from the hospitals. An assistant lecturer’s pay is now considerably better than that of a pharmacist in the basic grade and roughly equivalent to that of a senior pharmacist ; and a lecturer’s salary is better than that of the highest grade of non-teaching-hospital pharmacist. The salary of a senior lecturer is now approximately the same as that of the chief pharmacist of the largest teaching hospitals ; and that of the head of department of one of the colleges of advanced technology is much above anything that the most fortunate teaching-hospital pharmacist can expect from all sources even after many Yet the qualifications, the type of years’ service. knowledge, and the ability required of the chief pharmacist of a large non-teaching hospital, and the responsibility he.shoulders, are comparable to those of 1. H.M.(57)3 and P.H. circular no. 21. 2. Portsmouth Evening News, Jan. 4, 1957.
a senior lecturer ; and the same can be said of the chief pharmacist of a teaching hospital when compared with the head of department in a college. There has long been difficulty in filling posts in the basic grade of pharmacists, and this has extended in the past few years to senior staff and to chief pharmacists, Not long ago even to those in the teaching hospitals. the chief pharmacist of one of the big London teaching hospitals resigned to join a pharmaceutical firm. In addition to his higher pharmaceutical qualification, he had an honours degree in physiology with biochemistry as a major subject, and he could have earned a much higher salary as a biochemist. In fact, any honoursgraduate pharmacist who has taken chemistry and pharmacology as finals subjects would do well to enter the hospital service as a biochemist rather than a pharmacist. Several have already done so and some colleges are now advising their graduates of this
possibility. Successive Ministers of Health have expressed their at the state of hospital pharmacy and their anxiety to see pharmacists of the right calibre as chief pharmacists ; but they have done little or nothing to attract staff of the right type. The increases of the past few years have barely met the rise in the cost of living and have not kept pace with increases in comparable professions. The Whitley Council negotiations seem unable to resolve the problem. The staff side, in putting forward a reasoned and moderate claim, pointed out that the last increase had not attracted new recruits into the service, and that there was a 27% deficiency of establishment in a representative sample of 187 hosconcern
In spite of convincing figures comparing pharmacists’ pay with other rates in the 1V.H.S., all that was conceded was roughly a cost-of-living increase. Such experiences will convince many people that the Whitley Council is not used by the Ministry of Health as a negotiating machine and that it has become a method of dictating what salaries shall be. The Whitley Councils have been criticised for the rigidity which bars hospital authorities from making special scales for posts of unusual responsibilityand this objection applies particularly in hospital pharmacy. For example, to assess the chief pharmacist’s salary, hospitals are allowed from 1 to 40 points; but many hospitals, by this method of scoring, can raise double this number of points and yet their pharma.cist’s salary is the same as if they had only 40. Moreover, many pharmacists have been doing the work of group pharmacist since 1948 without extra remuneration, and a group-duties allowance has not yet been made. Elsewhere in the hospital service, biochemists and physicists already have a " special grade" of n900 per annum above the normal " top grade," and hospital authorities have power to make higher scales in Consultants have merit exceptional circumstances. awards ; the new Burnham scales allow for specialresponsibility allowances for teachers in schools of pharmacy, whereby a graduate can command a much higher salary than a non-graduate ; and in the hospital service a catering officer with a dietitian’s certificate Yet the request for a rise gets an extra E40 a year. in the pharmacists’ higher-qualification allowance from E25 to E50 was refused in the recent claim. It is not surprising that few graduate pharmacists enter the hospital service. The pharmaceutical work of the hospitals is at present being maintained by a, dwindling nucleus of established staff, some of whom are too old to embark on another career ; by those who want a few years’ hospital experience before passing to other branches of pharmacy; and by locums, many of whom are temporary visitors from the Commonwealth, and some of whom have little
pitals.
.
147 are often employed for months end at salaries greater than those of established pharmacists who have given the hospitals many years The cumulative damage of the of valuable service. losses is ten becoming increasingly obvious. years’ past Patients and nurses are having to wait longer for drugs, mistakes are commoner than ever before, and there is a general attitude of discontent in the hospital pharmaceutical service. Unless prompt action is taken to raise hospital pharmacy to an attractive career, as recommended by the Linstead report, the service will soon collapse. As we said3 of the radiographers’ situation, the new salary scales will do little to put things right.
hospital experience, yet on
PLEURAL BIOPSY THE unusual
"
"
pleurisy with effusion are an at fairly easily diagnosed early stage,4but the common It has causes are often hard to differentiate rapidly. causes
of
become the custom to consider the condition tuberculous in the young and to suspect malignantt disease in older patients ; and to wait until the results of repeated tests (which may never become positive) or the clinical course decide the issue. With the changing habits of disease, however, tuberculosis is now appearing more often in older patients5 and malignant disease more often in the young. An early diagnosis is thus much more important and, as a result, standard methods of In the investigation are becoming more accurate. effusions eventually believed to be tuberculous, it has been shown6 that the number of positive results is greatly increased by using much larger amounts of the pleural fluid and clot for the bacteriological tests. The methods of searching for malignant cells have also been improved, both by the examination of smearsand by histological section of the sediment, though sometimes the cells are too disrupted for either method. But even so, these methods may be time-consuming and still give no definite results in a fair proportion of cases. Before the days of chemotherapy for tuberculosis, it was too risky to undertake even minor chest operations in patients who might have active tuberculosis ; but it is now possible to remove a biopsy specimen by thoraco9 tomy and examine the tissue histologically. At first,8 this operation required a thoracic surgeon in an operatingtheatre, positive-pressure anaesthesia, and the removal of fluid and air by catheter before the wound was closed ; but it enabled the pleura10 to be observed and a piece of tissue about 1.5 x 3 cm. to be removed for examination.ll Now, Breckler and his colleagues 12 have modified the procedure to remove only a small portion of pleura by special forceps. They point out that though the pleura may be thin and glistening, it may still be involved by granulomatous disease. Even if pneumothorax does result, suction by catheter can be started immediately and no harm is done. An even simpler technique is described by Heller et all (and also used independently by De Francis et al.14 and Katz et al.l5), consisting of needle biopsy, as for biopsy of the liver and kidney. The 3. See Lancet, 4. Pagel, W.,
1956, ii, 1296.
Simmonds, F. A. H., Macdonald, N. Pulmonary Tuberculosis. London, 1953 ; p. 354. 5. Robertson, R. F. Brit. med. J. 1952, i, 133. 6. Close, H. G. Lancet, 1946, i, 193. 7. Papanicolaou, G. N. Atlas of Exfoliative Cytology. London.
1954 and suppl. 1956. Plate series E. & E.P. 8. Klassen, K. P., Anlyan, A. J., Curtis, G. Arch. Surg. 1949, 59, 694. 9. Sutliff, W. D., Hughes, F., Rice, M. L. Dis. Chest, 1954, 26, 551. 10. Lloyd, M. S. Quart. Bull, Sea View Hosp. 1953, 14, 128. 11. Small, M. J., Landman, M. J. Amer. med. Ass. 1955, 158, 907. 12. Breckler, I. A., Hoffman, M. C., Hill, H. E., Hensler, N. M., Hukill, P. B. New Engl. J. Med. 1956, 255, 690. 13. Heller, P., Kellow, W. F., Chomet, B. Ibid, p. 684. 14. De Francis, N., Kiosk, E., Albano, E. Ibid, 1955, 252, 948. 15. Katz, S., Donohoe, R., Mathews, M. J. 15th Veterans’ Administration Army, Navy Conference, Missouri, 1956.
are that it can easily be repeated in another site if the first result is equivocal, and the risk to the patient is negligible. These new methods have enabled a much quicker diagnosis to be made in many cases of pleurisy with effusion, not only between tuberculosis and malignancy but also in several of the more unusual causes. At the same time, -no specific cause could be found in some cases : some showed non-specific fibrosis of the pleura after sulphonamide-treated pneumonia, trauma, or lung infarct ; and a few other conditions were not diagnosed at all but were kept under observation until the condition cleared up. In this last group it was very useful not to have to embark on a full course of antituberculous treatment. In another way these observations are helping towards an understanding of tuberculous pleurisy. In most of the recorded series the finding of tuberculosis by biopsy was sometimes as definite when culture from the pleural fluid was negative as when it was positive ; and negative biopsies were never associated with positive cultures. The implication is that there is widespread tuberculous granulation tissue throughout the pleural cavity when the tubercle bacillus is the cause of the pleurisy and that it is not a question of collateral effusion This point requires much more or hypersensitivity. evidence to be in any way final, although Stead and his colleagues,16who examined tissue removed at decortication from 24 patients with pleural effusion suspected of being tuberculous, found evidence of tuberculosis in only 15-thus emphasising the frequency of non-
advantages
tuberculous effusions. THE REFUGEES
WITH more arrivals in prospect, we may soon have exhausted the jE390 put at our disposal for the relief of Hungarian doctors in this country. We should be very glad to have further contributions-as many as possible, however small-from readers. Of forty-odd Hungarian doctors that have so far arrived in this country, perhaps a third have friends or relations here who are housing them and doing what they can. Of the others the majority are temporarily accommodated in medical households ; but two at least have rented rooms and are living on their own. Some six or eight havegained hospital
appointments. Possibly half these doctors have decided to emigrate, if they can, usually because they believe that overseas the openings are greater or they will establish themselves more quickly. Except for the lucky few who know English, each one needs urgently to learn our language, for until he does so he cannot resume his professional work. The Lancet fund is being used for three main purposes : first, to help clothe the doctors and their families, some of whom arrived with only the clothes they wore ; secondly, to provide for small expenses and to help meet other immediate needs, including the need for prompt tuition in English (through the purchase of special long-playing gramophone records which may be had on loan from this office 17); and thirdly to help maintain the two who are living for the time being in lodgings, supported otherwise only by grants from the National Assistance Fund.
These doctors want above all to work and pay their way ;; and in their present dispiriting period of
own
and
well of their intended for them may be sent to the Editor of The Lancet and marked Hungarian Doctors’ Fund.
dependence
more
secure
uncertainty they deserve colleagues. Contributions
Dr. JOHN McGRATH, Eire and professor of
consulting State pathologist for pathology and bacteriology att
University College, Dublin,
died
on
Jan. 11.
16. Stead, W. W., Eichenholz, A., Sta11SS, H. K. --Inter. Rer. 7’iibe)-c. 1955, 71, 473. 17. See Lancet, Jan. 12, 1957, p. 88.
sick, which
the keynote of their teaching, was until little more than an ideal and a slogan. quite recently One of the main obstacles to the public understanding of psychiatry has been the mental hospital itself ; for, though it occupied the centre of the field, it was geographically and spiritually isolated from the community Reform within the hospitals was it aimed to serve. certainly needed, but it was not at first recognised that this largely depended on the development of external It was necessary to show the public what services. psychiatry had to offer. Only in this way could early treatment be secured, the need for admission to hospital prevented, and overcrowding reduced. It may truly be said of Dr. T. P. Rees that by his work outside Warlingham Park Hospital he made internal reforms possible : in fact by teaching the public he created his own time. The future of psychiatry depends on prevention ; and mental health, like any other social reform, needs promotion, which can be achieved only by contact with society. Dr. Rees’s contributions to was
mental-hospital management are internationally accepted. His concepts of the therapeutic community, respect for the individual patient, and the need for team-work among the staff have set the standard for British mental hospitals. But it is significant that recognition of his work has come not only from within the medical profession but from the people of Croydon. In conferring on Dr. Rees the honorary freedom of their borough its citizens have shown their appreciation of the man and also their understanding of the worth of the community psychiatry he has practised. THE PLIGHT OF HOSPITAL PHARMACY
NEW salary scales have lately been announcedr for hospital pharmacists ; but, so far from attracting recruits to sustain a service on the point of collapse, they are likely to discourage newcomers still further because they compare so unfavourably with salaries in other branches of pharmacy and in the technical colleges and universities, and with those of other hospital staff, especially biochemists, physicists, and supplies officers. The seriousness of the situation is illustrated by what has just happened in the Portsmouth hospitals2 where it has proved impossible to fill two vacancies in Advertisements an establishment of nine pharmacists. produced no replies, and the group secretary sees worse to come because he expects that the hospitals will lose the staff they already have to new pharmaceutical factories in the district. He made it plain that pressure on the overburdened staff was resulting in serious
dangers. For several years hospitals have been losing many of their best pharmacists to retail and manufacturing pharmacy. The new Burnham-scale salaries for teachers in the schools of pharmacy are now likely to cause a further drift of better-qualified pharmacists away from the hospitals. An assistant lecturer’s pay is now considerably better than that of a pharmacist in the basic grade and roughly equivalent to that of a senior pharmacist ; and a lecturer’s salary is better than that of the highest grade of non-teaching-hospital pharmacist. The salary of a senior lecturer is now approximately the same as that of the chief pharmacist of the largest teaching hospitals ; and that of the head of department of one of the colleges of advanced technology is much above anything that the most fortunate teaching-hospital pharmacist can expect from all sources even after many Yet the qualifications, the type of years’ service. knowledge, and the ability required of the chief pharmacist of a large non-teaching hospital, and the responsibility he.shoulders, are comparable to those of 1. H.M.(57)3 and P.H. circular no. 21. 2. Portsmouth Evening News, Jan. 4, 1957.
a senior lecturer ; and the same can be said of the chief pharmacist of a teaching hospital when compared with the head of department in a college. There has long been difficulty in filling posts in the basic grade of pharmacists, and this has extended in the past few years to senior staff and to chief pharmacists, Not long ago even to those in the teaching hospitals. the chief pharmacist of one of the big London teaching hospitals resigned to join a pharmaceutical firm. In addition to his higher pharmaceutical qualification, he had an honours degree in physiology with biochemistry as a major subject, and he could have earned a much higher salary as a biochemist. In fact, any honoursgraduate pharmacist who has taken chemistry and pharmacology as finals subjects would do well to enter the hospital service as a biochemist rather than a pharmacist. Several have already done so and some colleges are now advising their graduates of this
possibility. Successive Ministers of Health have expressed their at the state of hospital pharmacy and their anxiety to see pharmacists of the right calibre as chief pharmacists ; but they have done little or nothing to attract staff of the right type. The increases of the past few years have barely met the rise in the cost of living and have not kept pace with increases in comparable professions. The Whitley Council negotiations seem unable to resolve the problem. The staff side, in putting forward a reasoned and moderate claim, pointed out that the last increase had not attracted new recruits into the service, and that there was a 27% deficiency of establishment in a representative sample of 187 hosconcern
In spite of convincing figures comparing pharmacists’ pay with other rates in the 1V.H.S., all that was conceded was roughly a cost-of-living increase. Such experiences will convince many people that the Whitley Council is not used by the Ministry of Health as a negotiating machine and that it has become a method of dictating what salaries shall be. The Whitley Councils have been criticised for the rigidity which bars hospital authorities from making special scales for posts of unusual responsibilityand this objection applies particularly in hospital pharmacy. For example, to assess the chief pharmacist’s salary, hospitals are allowed from 1 to 40 points; but many hospitals, by this method of scoring, can raise double this number of points and yet their pharma.cist’s salary is the same as if they had only 40. Moreover, many pharmacists have been doing the work of group pharmacist since 1948 without extra remuneration, and a group-duties allowance has not yet been made. Elsewhere in the hospital service, biochemists and physicists already have a " special grade" of n900 per annum above the normal " top grade," and hospital authorities have power to make higher scales in Consultants have merit exceptional circumstances. awards ; the new Burnham scales allow for specialresponsibility allowances for teachers in schools of pharmacy, whereby a graduate can command a much higher salary than a non-graduate ; and in the hospital service a catering officer with a dietitian’s certificate Yet the request for a rise gets an extra E40 a year. in the pharmacists’ higher-qualification allowance from E25 to E50 was refused in the recent claim. It is not surprising that few graduate pharmacists enter the hospital service. The pharmaceutical work of the hospitals is at present being maintained by a, dwindling nucleus of established staff, some of whom are too old to embark on another career ; by those who want a few years’ hospital experience before passing to other branches of pharmacy; and by locums, many of whom are temporary visitors from the Commonwealth, and some of whom have little
pitals.
.
147 are often employed for months end at salaries greater than those of established pharmacists who have given the hospitals many years The cumulative damage of the of valuable service. losses is ten becoming increasingly obvious. years’ past Patients and nurses are having to wait longer for drugs, mistakes are commoner than ever before, and there is a general attitude of discontent in the hospital pharmaceutical service. Unless prompt action is taken to raise hospital pharmacy to an attractive career, as recommended by the Linstead report, the service will soon collapse. As we said3 of the radiographers’ situation, the new salary scales will do little to put things right.
hospital experience, yet on
PLEURAL BIOPSY THE unusual
"
"
pleurisy with effusion are an at fairly easily diagnosed early stage,4but the common It has causes are often hard to differentiate rapidly. causes
of
become the custom to consider the condition tuberculous in the young and to suspect malignantt disease in older patients ; and to wait until the results of repeated tests (which may never become positive) or the clinical course decide the issue. With the changing habits of disease, however, tuberculosis is now appearing more often in older patients5 and malignant disease more often in the young. An early diagnosis is thus much more important and, as a result, standard methods of In the investigation are becoming more accurate. effusions eventually believed to be tuberculous, it has been shown6 that the number of positive results is greatly increased by using much larger amounts of the pleural fluid and clot for the bacteriological tests. The methods of searching for malignant cells have also been improved, both by the examination of smearsand by histological section of the sediment, though sometimes the cells are too disrupted for either method. But even so, these methods may be time-consuming and still give no definite results in a fair proportion of cases. Before the days of chemotherapy for tuberculosis, it was too risky to undertake even minor chest operations in patients who might have active tuberculosis ; but it is now possible to remove a biopsy specimen by thoraco9 tomy and examine the tissue histologically. At first,8 this operation required a thoracic surgeon in an operatingtheatre, positive-pressure anaesthesia, and the removal of fluid and air by catheter before the wound was closed ; but it enabled the pleura10 to be observed and a piece of tissue about 1.5 x 3 cm. to be removed for examination.ll Now, Breckler and his colleagues 12 have modified the procedure to remove only a small portion of pleura by special forceps. They point out that though the pleura may be thin and glistening, it may still be involved by granulomatous disease. Even if pneumothorax does result, suction by catheter can be started immediately and no harm is done. An even simpler technique is described by Heller et all (and also used independently by De Francis et al.14 and Katz et al.l5), consisting of needle biopsy, as for biopsy of the liver and kidney. The 3. See Lancet, 4. Pagel, W.,
1956, ii, 1296.
Simmonds, F. A. H., Macdonald, N. Pulmonary Tuberculosis. London, 1953 ; p. 354. 5. Robertson, R. F. Brit. med. J. 1952, i, 133. 6. Close, H. G. Lancet, 1946, i, 193. 7. Papanicolaou, G. N. Atlas of Exfoliative Cytology. London.
1954 and suppl. 1956. Plate series E. & E.P. 8. Klassen, K. P., Anlyan, A. J., Curtis, G. Arch. Surg. 1949, 59, 694. 9. Sutliff, W. D., Hughes, F., Rice, M. L. Dis. Chest, 1954, 26, 551. 10. Lloyd, M. S. Quart. Bull, Sea View Hosp. 1953, 14, 128. 11. Small, M. J., Landman, M. J. Amer. med. Ass. 1955, 158, 907. 12. Breckler, I. A., Hoffman, M. C., Hill, H. E., Hensler, N. M., Hukill, P. B. New Engl. J. Med. 1956, 255, 690. 13. Heller, P., Kellow, W. F., Chomet, B. Ibid, p. 684. 14. De Francis, N., Kiosk, E., Albano, E. Ibid, 1955, 252, 948. 15. Katz, S., Donohoe, R., Mathews, M. J. 15th Veterans’ Administration Army, Navy Conference, Missouri, 1956.
are that it can easily be repeated in another site if the first result is equivocal, and the risk to the patient is negligible. These new methods have enabled a much quicker diagnosis to be made in many cases of pleurisy with effusion, not only between tuberculosis and malignancy but also in several of the more unusual causes. At the same time, -no specific cause could be found in some cases : some showed non-specific fibrosis of the pleura after sulphonamide-treated pneumonia, trauma, or lung infarct ; and a few other conditions were not diagnosed at all but were kept under observation until the condition cleared up. In this last group it was very useful not to have to embark on a full course of antituberculous treatment. In another way these observations are helping towards an understanding of tuberculous pleurisy. In most of the recorded series the finding of tuberculosis by biopsy was sometimes as definite when culture from the pleural fluid was negative as when it was positive ; and negative biopsies were never associated with positive cultures. The implication is that there is widespread tuberculous granulation tissue throughout the pleural cavity when the tubercle bacillus is the cause of the pleurisy and that it is not a question of collateral effusion This point requires much more or hypersensitivity. evidence to be in any way final, although Stead and his colleagues,16who examined tissue removed at decortication from 24 patients with pleural effusion suspected of being tuberculous, found evidence of tuberculosis in only 15-thus emphasising the frequency of non-
advantages
tuberculous effusions. THE REFUGEES
WITH more arrivals in prospect, we may soon have exhausted the jE390 put at our disposal for the relief of Hungarian doctors in this country. We should be very glad to have further contributions-as many as possible, however small-from readers. Of forty-odd Hungarian doctors that have so far arrived in this country, perhaps a third have friends or relations here who are housing them and doing what they can. Of the others the majority are temporarily accommodated in medical households ; but two at least have rented rooms and are living on their own. Some six or eight havegained hospital
appointments. Possibly half these doctors have decided to emigrate, if they can, usually because they believe that overseas the openings are greater or they will establish themselves more quickly. Except for the lucky few who know English, each one needs urgently to learn our language, for until he does so he cannot resume his professional work. The Lancet fund is being used for three main purposes : first, to help clothe the doctors and their families, some of whom arrived with only the clothes they wore ; secondly, to provide for small expenses and to help meet other immediate needs, including the need for prompt tuition in English (through the purchase of special long-playing gramophone records which may be had on loan from this office 17); and thirdly to help maintain the two who are living for the time being in lodgings, supported otherwise only by grants from the National Assistance Fund.
These doctors want above all to work and pay their way ;; and in their present dispiriting period of
own
and
well of their intended for them may be sent to the Editor of The Lancet and marked Hungarian Doctors’ Fund.
dependence
more
secure
uncertainty they deserve colleagues. Contributions
Dr. JOHN McGRATH, Eire and professor of
consulting State pathologist for pathology and bacteriology att
University College, Dublin,
died
on
Jan. 11.
16. Stead, W. W., Eichenholz, A., Sta11SS, H. K. --Inter. Rer. 7’iibe)-c. 1955, 71, 473. 17. See Lancet, Jan. 12, 1957, p. 88.