Think Tank's Thoughts on the Welfare State

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therefore demonstrated that haemophiliacs are still at high risk of hepatitis B infection despite the introduction of screening techniques by the Blood Transfusion Service to detect HBsAg in individual donor plasmas. It is possible that more sensitive methods will reduce the risk in future. These results are of great interest because both the Sydney and Edinburgh patients have been treated predominantly with cryoprecipitate prepared from individual voluntary blood donations. They might therefore be expected to have a lower incidence of hepatitis B infection than haemophiliacs who have received commercial factor VIII concentrates prepared from large plasma pools. The very high prevalence of hepatitis B markers in our patients with severe haemophilia suggests that the use of , cryoprecipitate instead of factor VIII concentrates does not protect against infection. Prospects for haemophiliacs in this regard, however, must now be brighter with the potential for immunising

patients against hepatitis factor VIII

concentrates

protection against viruses

not

Furthermore, if

B.

become

only hepatitis

hepatitis-free generally available, then B but

true

also, non-A, non-B

may become a reality.

Department of Haematology,

Royal Infirmary, Edinburgh

C. A. LUDLAM

Department of Bacteriology, Medical School, Edinburgh

J. F. PEUTHERER

Commentary from Westminster Thoughts on the Welfare State THE search by the Social Services Secretary, Mr Norman Fowler, for a way out of the protracted and bitter dispute over Think Tank’s

pay in the National Health Service has been made no easier this week by confirmation that some powerful elements of the Government are keen to abolish the N.H.S. altogether. The health unions, the T.U.C., and the Labour Party, already locked in combat with the Government, have been further committed to confrontation by news of a study from the

Government’s Central Policy Review Staff, the so-called think tank. This study, circulated to Cabinet Ministers and then leaked to the Press by one of them, explores possible routes towards a drastic reduction in public spending. In effect it considers how the Welfare State might be dismantled by the Government. Unless that is achieved, says the report, over half of Britain’s gross domestic product will go on public spending each year for the forseeable future-and that would only just keep the machine ticking over weakly, as it is now. The N.H.S., the C.P.R.S. ventures, would be phased out fairly rapidly, and individuals would insure themselves for treatment privately. A compulsory minimum level of insurance could be introduced, to prevent people underinsuring. "Hotel" fees for a stay in hospital, fees for visiting a

doctor, and much higher prescription charges combined with fewer

exemptions are also mooted in the C.P.R.S.’s grand design. More than a third of public spending on health would

thus be saved. The study is nothing if not radical. It proposes, for instance, that all higher education should cease to be statefunded and that just 300 000 students a year would get state scholarships; all other students would have to find from their own resources the probable- 12 000 cost of a three-year course. The Government would be ready to lend aspiring students the cost of their education-at the market rate of

interest, naturally.

ACETYLCHOLINE RECEPTOR ANTIBODY TESTS BY POST

SIR,-The acetylcholine receptor (AChR) antibody test has greatly assisted the investigation of patients with myasthenia gravis. However, in most countries the test is available in only a few laboratories. To try and overcome the problems of storage and dispatch of frozen or refrigerated samples to such specialised laboratories we have tested the stability of AChR antibodies in blood samples dried on

paper.

Antibody dried on paper had enhanced heat stability (half-life 12 days compared with 12 h in liquid samples at 60 °C). At room temperature the antibody is stable for at least 2 weeks. The antibody can be readily eluted from paper which permits the assay to be done with the same sensitivity and reproducibility as for liquid serum samples. These results suggest that the assay can be done on a few drops of whole blood, dropped onto paper and posted to a specialised laboratory. This method of storage and dispatch of blood samples may be applicable to other antibody tests, making complex tests available to many areas of the world lacking local specialised laboratory services. Department of Medicine, University of Sydney, Clinical Sciences Building, Concord Hospital, Concord, N.S.W. 2139, Australia

G. A. NICHOLSON

The future set out for the N.H.S. is exactly the future which Mr Fowler has been at great pains to reject since he took office. He shelved similar suggestions made by the Department’s own Working Party on Alternative Finances for the N.H.S. He told the Social Services Committee of the Commons that this was "not a road down which the Government intends to go". It is not surprising, then, that the Cabinet saw a small-scale revolt when the Chancellor, Sir Geoffrey Howe, proposed a detailed Cabinet examination of the C.P.R.S. report. All the "wet" Ministers insisted that the study was so misconceived as to be not worth discussing. Blocked, but not defeated, Sir Geoffrey is now mulling the matter over. He is not the C.P.R.S.’s only champion in the Cabinet. The Prime Minister herself, Sir Keith Joseph, (Secretary for Industry), and the former Social Services Secretary Mr Patrick Jenkin are among those who insist that the Government’s long-term success hinges on bigger spending cuts than anything so far contemplated. Soon after the C.P.R.S. study was leaked, and two weeks after the crucial Cabinet meeting, the Treasury Secretary, Mr Leon Brittan, returned to the theme. In a speech which had plainly been discussed with Sir Geoffrey, Mr Brittan pointed out that the Government could offer the voters no hope of a sustained tax-cutting programme (on which platform it was, after all, elected in 1979) unless the growth of public spending were greatly slowed down: "Radical options have not been ruled out. The whole area of Government expenditure has to be re-examined to see if we can identify ways in which we might reverse the past inexorable rise in public expenditure". Mr Brittan criticised those who refuse to face uncomfortable facts. The Social Services Secretary, it appears, belongs to that category. The day after Mr Brittan spoke, Mr Fowler told a symposium at the Office of Health Economics that he wanted to "take this opportunity to state firmly once more this Government’s commitment to the N.H.S". He repeated his promise to Parliament last July that the Government has no plans to change the present system of financing the N.H.S. An internecine ideological battle is now raging in the Cabinet. On one hand the wets, or traditionalists, say they

778

stomach such a thorough-going reversal ofour present system. They know that most of the party’s backbenchers support them. They do not relish fighting a General Election (probably next autumn) on such a programme. The radicals, on the other hand, are sure that the safest way to get re-elected is-by promises of long-term tax-cuts-down eventually, they hope, to a basic rate of no more than 25p in the pound. They want to put money into people’s pockets, but say it can be done only if the C.P.R.S. is heeded. Neither side, for the moment, looks like giving way. cannot

Frank McElhone Mr Frank McElhone, Labour M.P. for Glasgow (Queens Park) died on Sept. 22, of a heart-attack. He had been attending a T.U.C. rally in support of the Health Service

Obituary JOHN BERNARD KINMONTH M.S. Lond.,

F.R.C.S., hon. F.R.C.R., hon. F.A.C.S

Professor Kinmonth, who died on Sept. 17, will be remembered as one of the outstanding academic surgeons of the century. His undergraduate and early postgraduate career followed the formal pattern of the times, .culminating in his appointment as resident assistant surgeon at St Thomas’ and then wartime service in the R.A.F. However, when he returned to civilian life he was appointed to a research assistantship in the surgical professorial unit at St Bartholomew’s Hospital under the direction of Sir James Paterson Ross. This was the start of his career in surgical research. His first interest, stimulated by his clinical experience of the complications of bony trauma, was traumatic vasospasm. He extended this work in collaboration with F. A. Simeone, whilst seconded to the Massachusetts General Hospital. The results of their work had a profound affect on the surgical approach to vascular injuries. They described the sympathetic innervation of major arteries and found that vasospasm could be relieved by the local application of papaverine, but also noted that vasospasm was rare and that the arterial obstruction in such cases was more often caused by intramural haematoma or intimal flaps than by spasm. When he returned to the surgical unit at Barts he was appointed assistant director. These were the early pioneering days of vascular surgery, when the surgeon had a sewing machine in the operating theatre so that a nurse could cut and sew suitable pieces of terylene shirt tail into tubes for aortic replacements. At this time a chance remark by Sir James Paterson Ross about our inability to display the lymphatics set him off on his life’s work. Working first in the animal laboratory he investigated ways of injecting the lymphatics and then performed the first X-ray lymphograms in man using a watersoluble contrast material-an achievement comparable to the introduction of arteriography and phlebography. This work stimulated others to look for alternative materials and the introduction of an oil-based material (lipiodol) set the scene for thirty years of research into the lymphatics and their diseases. In 1955 John moved home to the chair of surgery at St Thomas’ Hospital and from then on, despite a short diversion into cardiac surgery to get it started at Thomas’, he devoted his entire research efforts to lymphatic disease, on which he became the world’s foremost authority. Patients came to him from all parts with the most bizarre syndromes. Most were new problems, many never properly investigated before, with no accepted form of treatment. All were studied, evaluated, and treated in the best ways that he could devise. A fraction of his clinical experience is contained in his book The Lymphatics, the second edition of which he was determined to see published before his death, an object which he

happily achieved.

"day of action". Mr McElhone was Labour’s chief spokesman in the Commons on Overseas Development. He was respected and admired by M.P.s of all parties, who acknowleged his commitment to improving the lives of the hungry and sick in the Third World. He was not at all a keen party politician; he was far more interested in helping to get decent drinking water piped into African villages. He was an enthusiastic instigator of research work on the needs of people in the Third World, and thanks to him Labour’s policy on overseas development does not see the hungry millions merely as future markets for British industry. Doctors who worked with him to research that policy will testify to Mr McElhone’s gift in motivating them. He was a good man. workers’

RODNEY DEITCH

He

was

a

quiet sincere

man,

never

conceited, and

never

derogatory of the efforts of others. He was always ready to listen and learn, and regularly came back from scientific meetings with new ideas. His guiding professional principles were patience, perseverance, and the pursuit of excellence. He strongly believed that the university teaching hospitals should be centres of national excellence and serve a national as well as a local role. He showed how this could be done, and how worth while such excellence is to the advancement of medical science, through his work on the lymphatics. He was honoured by many national and international societies in his lifetime and many generations of physicians and surgeons yet to be will learn-the name of John Kinmonth. N. L. B. N. D. W. LIONEL

M.B.Ceylon F.R.C.P.E., F.CeylonC.P.

_

Prof N. D. W. Lionel, head of the department of pharmacology, University of Colombo, and the outstanding clinical pharmacologist of Sri Lanka, died on Aug. 29 at the age of 56. After a brilliant school career obtained his M.B. at Colombo in 1953, and from 1955 he was attached to the department of pharmacology at the Colombo Faculty, first as demonstrator and

at

St Joseph’s College, Lionel

lecturer. In 1958 he proceeded to Edinburgh and gained the M.R.C.P. with then

as

pharmacology as a special subject; whereupon the late Professor Bibile arranged for him to

work in D. R. Laurence’s

i

department at University College’; Hospital Medical School. This his initiation into clinical In 1969, while on a year’s W.H.O. fellowship in Britain, Lionel was attached to Laurence’s department and to the London Hospital Medical School, participating in research and teaching in these institutions, where he acquired a host of friends. In due course, Lionel addressed his attention to the rationalisation of drug use in Sri Lanka, building upon and extending the foundations laid by Bibile. He became the pivot of the National Formulary Committee and its publication, The Prescriber. His opinions as a director of the State Pharmaceuticals Corporation were greatly valued. As secretary of the subcommittee for the approval of import and manufacture of drugs in Sri Lanka, his task was more difficult than that ofa counterpart in a developed country. A bane of developing countries is their vulnerability to the dumping of spurious pharmaceuticals. Lionel’s up-to-date knowledge effectively kept such nostrums out of Sri Lanka. He was on the first W.H.O. Expert Panel on Essential Drugs and was regularly invited was

pharmacology.