BMJ

Regional Versus Local Consultant ContractsAuthor(s): James AndrewsSource: The British Medical Journal, Vol. 281, No. 6237 (Aug. 9, 1980), pp. 457-458Published by: BMJStable URL: http://www.jstor.org/stable/25440934 .

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BRITISH MEDICAL JOURNAL 9 AUGUST 1980 457

most obese (41%), both considerably higher than the mean for those of average weight

(2-7%). This finding raises the question of the effect of weight changes within the average

range on mortality. Any weight changes recorded prospectively in individuals in our

study did not change the weight status of any individual patient to such a degree that they should be classified in a different weight cate

gory. We therefore do not agree that with this

compound patients will be paying a high price in terms of significant weight increases.

R Lindsay Helen Hayes Hospital, New York 10993, USA

D McKay Hart Stobhill General Hospital, Glasgow G21 3UW

1 McKay Hart D, Lindsay R, Purdie D. Front Horm

Res 1978;5:174-91. 2 Sorlie P, Gordon T, Kannel WB. JAMA 1980; 243:1828-31.

Dorsal column stimulation in multiple sclerosis

Sir,?In connection with your recently

published leading article on dorsal column

stimulation in multiple sclerosis (31 May,

p 1287), which lucidly discussed the various

aspects of this intervention, I would like to

bring to the attention of your readers a report

published by Duquette et al on their experience with this technique.1 In a thorough evaluation

of dorsal column stimulation effects in nine

multiple sclerosis patients they observed the

following results : definite amelioration in one

patient, minor amelioration in three, no

change in three, and temporary deterioration

in two, one patient suffering from an acute

exacerbation. As in some other studies, bene

ficial results related mainly to sphincter, motor, and sensory functions j no change was noted in

cerebellar function, and spasticity or paresis of

the lower limbs was occasionally aggravated

during treatment. In their discussion, the

investigators hypothesised that the benefits of

unspecific stimuli such as dorsal column

stimulation may well be limited to functions

controlled through the autonomous nervous

system. F LORTIE-MONETTE

Hull, Quebec J8Y 5Y4 Canada

1 Duquette P, Duquette J, Bouvier G. Union m?d Can

1980;109:890-4.

Corrective shoes for surgery

Sir,?May I say how much I agree with your

leading article comment (28 June, p 1556) on

the uselessness of "corrective" shoes for

children? What a pity your refreshing iconoclasm did not extend to the final sentence.

What evidence is there that: "It is the

constrictive action of tight shoes in infancy that leads to most adult foot deformities ?"

Most infants and children I see wriggle out of

shoes or kick them off if they are uncomfortable

?and often even if they're comfortable. And most are barefoot during sleep, or wear

lovingly knitted and easily stretchable bootees.

I find it hard to accept that intermittent con

striction causes permanent deformity; the

experience of centuries of foot-binding in

China (which, to be effective, had to be

continuous) makes this seem most unlikely. But never mind, knocking down one myth

at a time is pretty good going and I am

grateful to you. A Graham Apley

London WIN 1HH

Student ?lectives overseas

Sir,?The observations on student ?lectives overseas by Ruth A Cruikshank and Dr D B

Walsh (7 June, p 1359), prompted by the

excellent series in the BMJ of articles about

student ?lectives, raises issues which could

affect the way in which they are organised in

future. Doing ?lectives in distant countries is a growing phenomenon and certainly the

cross-pollination of ideas and experiences should be strongly encouraged. Our own

findings confirm the undoubted value of the

elective period and during the past five years a constant 30 % of our students have availed

themselves of the opportunity of doing their

?lectives abroad.1

Electives require much administrative effort

and we assist our own students and visitors

with placements and official documentation.

The proliferation of complex forms required by some institutions to evaluate the performance of visiting students and the apparently excessive weight given to the elective is a

matter of concern to us. We question the

wisdom of this since an elective, in order to

fulfil its purpose, should allow the student a

free choice with wide objectives in which the

main component could be either increasing theoretical knowledge and practical experience, research, or widening social experiences.

It would be a pity if an important freedom

in a generally rigid curriculum became

strangled with red tape.

J P de V van Niekerk

Faculty of Medicine, University of Cape Town, Cape, South Africa

1 van Niekerk JP de V. S Afr MedJ 1979;56:446-7.

Vocational training for general practice

Sir,?Reports in the medical press [and our

report (2 August, p 369)?Ed, BMJ] from the

National General Practitioner Trainee Con

ference in Exeter have revealed some disquiet

ing facts which can only lead to the conclusion

that Britain's GP trainers are taking the

Government's money without delivering the

goods. Britain's trainees, currently costing the

Government ?15 000 each per annum, may be the victims of one of the biggest spoofs in

medical history. Trainers are paid ?2550 per year for

teaching no less than two sessions (seven hours) per week. Yet a survey reveals that 92% of

trainees receive less than four hours' training a

week and 4 % receive none at all. Many are left on call in their practices without back-up and are very obviously being used as unpaid

partners. Large proportions of trainees appear disatisfied in that they are unable to obtain

hospital experience in essential areas such as

paediatrics or obstetrics. Sixty-five per cent of

trainees complain that they fail to get relevant

GP teaching during their two-year hospital stints. These facts, combined with the increase

in patients' complaints against trainees, are an

incredible indictment of vocational training, a

system which has become law without any scientific proof of benefit to our country.

At ?15 000 per head per annum, if vocational

training for general practice ceased tomorrow

would there be a significant deterioration in

patient care ?

Adrian Rogers Exeter, Devon

Changing to A4 folders

Sir,?Drs G N Marsh and J R Thornham in

their article about conversion to A4 folders in

general practice (19 July, p 215) unfortunately omitted to discuss the problem of reconverting A4 folders to the FP5/6 envelope when patients

leave the practice. In this practice we have

long been on the waiting list for A4 folders, and while wishing to follow their final advice and go ahead with an A4 system we feel that

this would be impractical while the FPC refuse to handle records of A4 size. This

problem must be common to many practices with a high patient turnover, and I would

hope the BMA will bear this in mind when the General Medical Services Committee is

negotiating for the wider provision of A4

folders.

J M Hayward

Health Centre, Thatcham, Newbury, Berks

Regional versus local consultant contracts

Sir,?Aneurin Bevan, when the Health Service was inaugurated, made sure that the consul tants were employed by ? regional authority and not locally. He realised the dangers of

parochialism creeping into appointments, from his detailed knowledge of the Welsh

mining valleys (incidentally, having worked

there and in suburban London I realise that there is even more parochialism in London).

Mr Patrick Jenkin's "desire for more autonomy at local level"1 is exactly what is not needed here. In the same way that Sir Keith Joseph

made grave and expensive errors in 1974, it

looks as if Mr Jenkin is going to make gross errors in the second reorganisation.

The reasons against local employment of

consultants in the Health Service are very

cogent. Firstly, there is a serious danger of

"favourite sons" being appointed on account

of their local personal connections rather than

their professional ability. This criticism is often made in educational appointments. Secondly,

the consultants who find grossly inadequate services for the community they are looking after, if they are employed locally and make

constructive criticisms, may well be frightened of either being dismissed from their jobs or

having their jobs made unworkable by their

local employers. This would often prevent them, in the public interest, emphasising the

grossly inadequate local medical services?

which applies particularly to the Cinderella

specialties of psychiatry and geriatrics. In the Health Service structure it would be

still worse if consultants were to be employed

locally by bodies which were not even demo

cratically elected. At least if they were em

ployed by local government there would be a

possibility of changing the representation at

the next election. In the new proposed District

Authorities there would be no such opportunity. The lack of interest shown by the consultant

body as a whole in this matter suggests I may hold a minority view. Before reorganisation the hospital management committee wanted to dismiss me on account of criticism I was

making about its grossly inadequate service;

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458 BRITISH MEDICAL JOURNAL 9 AUGUST 1980

but, of course, it was unable to do so because I

was then employed by a regional authority.

James Andrews

Geriatric Service, Hounslow Health District, West Middlesex Hospital,

Isleworth, Middx TW7 6AF

1 The Times 24 July 1980.

***The Annual Representative Meeting de

bated Patients First, including the question of

where consultant contracts should be held.

The meeting insisted by an overwhelming

majority "that all contracts and related moneys for senior hospital staff be held at regional level_"?Ed, BMJ.

The hospital practitioner grade

Sir,?I was disappointed in the ARM debate, as reported in the BMJ (26 July, p 334), about

the hospital practitioner grade. The report is

obviously short but it appears as though ex

cathedra statements were made without any

opposing view being put. I fail to understand why, if the CCHMS

has a policy to introduce a similar grade for

people ineligible for the present one, it cannot

do so by simply widening the field of those

who can apply. I also do not understand why Mr G S McCune is frightened that these posts will be filled by members with domestic com

mitments. The medical assistant post which it

replaces in many instances is already filled

by such people, and by denying them the *ight to apply for these jobs a differential has been

introduced which seems unfair to me. The

comment from Mr J NJohnson that this would

create a subconsultant grade does not really hold water, as few people would take on a

five-session appointment as their sole occupa

tion?financially they could not afford to do so, unless they have other commitments such as a

family to run.

It seems to me that the BMA is going out of

its way to make life as difficult as possible for

people who have domestic commitments, and

is specifically favouring those who already have a full-time job in general practice.

DC Banks

City Hospital, Nottingham MG5 1PB

Dental surgeons without medical

qualifications

Sir,?In answer to Mr Peter Davis's questions (12 July, p 150): (1) yes, a patient having

major oral surgery is entitled to assume that

his surgeon has received the appropriate

training and passed the appropriate examina

tions, and yes, the dental surgeon without

medical qualifications has appropriate training and has passed the appropriate examinations.

(2) The area health authority is legally and

technically justified in allowing treatment by such dental surgeons as their medical training for that branch of surgery can be considered

adequate. (3) The answer to a complaint by a

patient alleging negligence would be the same

as in the case of a medically qualified dental

surgeon. I wholeheartedly applaud the view expressed

by Mr F D Beggs (26 July, p 313). Thank you, Mr Beggs.

P Narain

London N13 4AG

One hundred, not out

Sir,?At the Annual Representative Meeting at Newcastle (26 July, p 325) "The Council

wisely resolved that deficit budgeting must

cease . . . and recommended an increase in the

standard subscription to ?90 in 1981." The

Representative Body, however, subsequently resolved that the increase should be to ?100.

Why do all the world's finest cricketers

spend so long in the 90s before achieving their

magical century ? Surely it is because they find

the significance of "three figures" so daunting. The smallest tradesman knows that his wares

will sell quicker for 99?p than ?1 and the

Rolls-Royce salesman offers his cars at ?14 900

in preference to ?15 000. Significantly, the

medical defence bodies drew back from the

brink when earlier this year they increased

the standard premium to only ?95.

How, therefore, could the Representative

Body be so shortsighted as to take such a

monumental step, contrary to the advice of the

Council, and increase the BMA subscription to

?100 ? Will there be an unprecedented number

of unrenewed subscriptions this year ?

Robert Talbot

St James's Hospital, London SW12 8HW

***By a narrow majority the BMA Council in

March resolved to recommend to the ARM a

standard subscription of ?90 from 1 January 1981 and it was clear from the debate that

preceded the decision that the "daunting"

significance of three figures was in the minds of

many Council members (29 March, p 953). So

the Representative Body was presumably well aware of the circumstances when it decided to increase the Council's recommendation to

?100.?Ed, BMJ.

Review of social services organisation needed?

Sir,?Dr H A F Mackay is by no means alone

BMJ (26 July, p 313). Doctors are increasingly frustrated by the administrative and financial

chasm between health and social services

which operates so expensively against, the best

interests of those in need.

In seeking a more effective organisation it is

profitable to look at some of those minority of authorities which, prior to the doctrinaire

Seebohm reorganisation, were sufficiently

enlightened to run community health and a

large part of social services by means of a single combined department. Eastbourne, until the

wanton destruction of the county boroughs, was one such. Here was provided an efficient

comprehensive service greatly appreciated by the general practitioners and their patients,

with a minimum of staff compared with the

vast empire-building departments now created

by some of the county council social services

departments. In geriatric care in particular, in view of the

predominance of the medical problems, all

social work was undertaken by geriatric health visitors attached to general practice

supported by welfare assistants. The residen

tial homes provided were invariably in the

charge of matrons or superintendents with

nursing qualifications, enabling long-term care

to be provided for substantial degrees of physi cal and mental infirmity as a humane alterna

tive to hospital admission.

It is not suggested that doctors necessarily

have a divine right to administer the whole of

health and welfare in the community. It is

suggested, however, that the medical prob lems are so consistent in much of what is now

described as social work, including mental

illness and mental subnormality, that we may not yet have found a more effective adminis tration than that formerly provided by medical

officers of health, whose medical training

undoubtedly enabled them effectively to

distinguish between those who cannot help themselves and those who will not.

It is also ironic, in the light of the current

spate of gaffes in regard to child abuse, that

it was a great political furore generated around a case of child neglect, soon after the second

world war, in an understaffed health visiting section of a health department which led to

the panic legislation of the Children Acts and

separate departments?and later much of the

misguided Seebohm philosophy.

Charles M Dunlop

Kenneth Vickery

Eastbourne District Management Team, Eastbourne, Sussex BN21 2BH

Sir,?I share the sentiments expressed by Dr H A F Mackay in his letter (26 July, p 313) concerning the need for a review of social

service organisation. There is an increasing tendency among

social workers to regard themselves as

"scientific officers" of a highly specialised

discipline rather than accept an ancillary role.

As to the performance, while on the one hand

there is marked reluctance to offer help to the

elderly (as they do not fit the "medical

model"), on the other side there can be too

much?and quite erratic?enthusiasm for

diagnosing non-accidental injury in children.

This has not infrequently led to harassment and feelings of persecution by the parents,

resulting in great distress for the entire

families involved. No one can deny that a high index of suspicion must be exercised if non

accidental injury is to be prevented in children, but to ignore the opinions of the family

practitioners in such cases and to shuttle the

children to the accident and emergency

department of the local hospital without the

GP's knowledge or the parents' consent must

surely be taking things too far. In deprived areas violence is a "social fact" and a "way of

life." It is better tolerated in some quarters than others. If our patients are to be helped then we should try to view non-accidental

injury in their context rather than project ours

on to them.

The "case conferences," which ought to be

held in the health centres or surgeries, and at

times convenient to the family practitioners, are invariably held at hours and venues

dictated by and convenient only to social

workers. Frequently these hours clash with

surgery hours and some clinics. The family

practitioners are not consulted about the time

or place of the conference nor are they informed

of the details of the cases to be discussed in

advance. For these reasons is it surprising that

about 95% of these conferences are not blessed

by the presence of the GP ? Social services

should perhaps also shift the emphasis from

preparing extensive dossiers and from tossing about fancy jargon to "prompt action and

sustaining practical help" . (within the re

sources available) for those in real need.

When, and if, it comes to reviewing the rule

and organisation of social services (and it is

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