CERTIFICATION AND STATE SERVICE
1
30 equally modern, but without a medical school and with fewer specialties represented, staffed partly by whole- time specialists and partly by local GPs as assistant physicians and surgeons. Each of these second-grade hospitals has under its wing the neighbouring health centres. The health centres are not the robot institu- tions pictured by many correspondents in the medical press. They are convenient buildings in which the neighbouring GPs will have their consulting-rooms, complete with such modern medical necessities as dispensers, nurses and secretaries. Domiciliary practice continues as it is today. These three grades of institu- tion are governed by their medical staffs, strengthened ’ in the case of the hospitals by representatives of the patients. All the medical services, including public health, in a region are coordinated by a regional committee which consists of elected representatives of the doctors of all kinds and of other relevant groups including local governments. Medical members should be a powerful minority. Medical officers of health are employed by the Regional Committee and not by local governments. At the head of the Regional Committees is the National Board of Health. The chairman is a layman and a cabinet minister, called if you like the Minister cf Health. Some of. the members are laymen, appointed by the Privy Council ; some are ex-officio (for instance, the presidents of the Royal Colleges) ; the remainder are the chairmen of a number of consultative committees. These consultative committees (General Practice, Hos- pital, Public Health, Medical Education, Propaganda, &c.) consist of practising doctors elected by their peers on a regional basis. The members are part-time and well paid and are re-elected (or not) every five years. They are subjected, during their terms of office, to the continual criticism of their constituents in clubs and pubs and hospitals and are unable to shelter themselves behind that thick cloak of anonymity which today en- shrouds the civil servant. They know, through their chairman, what goes on in the National Board of Health, and they pass on the information to those whom they represent. They control the civil servants who do the day-to-day administration and are not controlled by them. The National Board of Health is directly controlled by Parliament, in fact by the people, and this is the anwer to your criticism. Neither the local grocer nor the "’" shadowy civil servant controls our doings. Through Parliament at our head, through the lay members of the National Board and Regional and Hospital Com- mittees, our patients have the ultimate rule and final voice. But in technical matters and in our daily life we retain our personal responsibility and the dignity off) HT*T1< TtT*r<fK!on. Whitchurch, Bucks. RAYMOND GREENE. CERTIFICATION AND STATE SERVICE SIR,-Though not an enthusiast for a state medical service as something intrinsically desirable, I cannot see how a Beveridge plan is possible without one. And I am inclined to think that if Sir William Beveridge were " put to the question " under ’ Pentothal sodium ’ he would confess to the same conviction. No man can serve two masters. The state must have accurate disinterested certification of unfitness for work and it must have the most rapid possible return to fitness to work. Hence the rehabilitation centres. Now, in unalloyed private practice the patient’s wishes are paramount. He may not wish for an accurate- perhaps brutally accurate-diagnosis. He may’not be in a hurry to get well, and he usually wants a say in how he is to be made well. Very often he secretly or openly wants his doctor for a friend, confidant and even father- confessor. He likes to feel that if his wishes are not. met he can change his doctor. If he pays for his doctor and for the expenses of his illness, he is probably right to demand this sort of service, and the doctor is content to supply it; even if he sometimes rebels inwardly at his -. slightly servile condition. As long as Free Choice of Doctor is retained, so long will the patient expect and obtain a friendly, complaisant, slightly servile medical man. I leave you to guess how long it would take a " free " medical profession to bankrupt the Beveridge plan. As to regional medical officers supervising certification, I feel sure from experience that it would fail. They will not, take the responsibility of certifying that a man is fit, and I don’t blame them. It is one of the most difficult tasks in medicine, and you have to know the patient and his circumstances well to come to the right conclusion. General practitioners are good at it, but it does not pay them to use their skill. Also it would be very humiliating for general practi- tioners to be supervised and overridden by certification officials, supposing you could recruit good men for such a dull job. No, far better free GPs from their servile con- dition, and then they would soon deal with scrimshankers and prevent the terrifying output of neurotics. They would be more efficient and make fewer mistakes than specialists and consultants. Remember I It was not GPs who invented the effort syndrome-that answer to the neurotic’s prayer. The fact is, the amount of neurotic illness is already great. Of all aetiological factors concerned in this disorder in peace-time, I should put Freedom from Want first, and next in order I should put a servile medical pro- fession. A " free " medical profession plus the Beveridge plan would populate England with a multitude of neurotic, spineless pension and dole gatherers. Bridlington. P. D. H. CHAPMAN. THE NURSE WITH TUBERCLE SIR,—When I was a patient in a sanatorium I could not help but be struck by the apparently high incidence of tuberculosis in nurses. This led me to undertake, later, some careful investigations and I have made notes on the working capacity and financial position of 59 tuberculous nurses with whom I have been in touch. Of this small personal series : 8 have died ; 18 are ill at home or in sanatoriums ; 4 have returned to work at their own hospitals ; 13 are nursing in sanatoriums ; 8 are at home, fairly well but not working, and 2 of these have married ; 1 is working at civil defence ; 7 I have not been able to trace and I think it likely that 3 of these have died. I have no definite information about the financial position of many of them, but I know 15 (4 of whom have since died)-were in economic difficulty serious enough to affect their health unfavourably. Thus 7 had no income at all, 2 only NHI benefit (15s. weekly) and 4 a proportion of total disablement benefit amounting in one case to 2s. a week, in another 2s. 6d., in another 3s. 6d. and another 6s. Approved societies have the right to withhold a part of benefit until the patient is discharged from hospital ; I know of one nurse whose condition was hopeless over whom the society exercised this right: she subsisted on 3s. 6d. a week for the last 5 years of her life, being given the shelter of a sanatorium. When she died t25 had accumulated and the society advertised to try to find the next of kin. I am not myself a nurse but I am interested in the conditions under which nurses work. Fulham, S.W.6. E. D. ANDREWS. TREATMENT OF OSTEOCLASTOMA SiR,—I hesitate to criticise Dr. Brailsford, for all of us who have much to do with bone pathology owe him a great debt. Nevertheless, one feels that a scientific paper based on case-reports should be so presented that the conclusions in the discussion are adequately supported by the cases dealt with. Dr. Brailsford describes five cases, of which nos. 3 and 4 were not osteoclastomata, but were examples of chondrosarcoma. Case 2, which was also stated to be radiologically typical of osteo- clastoma, has no report on the histological findings of the material removed at operation. Case 5 had no operation , at all, so that though "’ the radiogram showed a typical osteoclastoma " we have no knowledge that it was, in fact, of this type. , I do not think Dr. Brailsford has given satisfactory scientific reason for believing that " the diagnosis can be established by radiography, and biopsy is neither neces- sary nor desirable " ; nor for the statement that the treatment of choice, whatever the site, is X radiation. He may be right, but one would like to have better evidence in support of his views. Exeter. NORMAN CAPENER.
Transcript of CERTIFICATION AND STATE SERVICE
30
equally modern, but without a medical school and withfewer specialties represented, staffed partly by whole-time specialists and partly by local GPs as assistantphysicians and surgeons. Each of these second-gradehospitals has under its wing the neighbouring healthcentres. The health centres are not the robot institu-tions pictured by many correspondents in the medicalpress. They are convenient buildings in which theneighbouring GPs will have their consulting-rooms,complete with such modern medical necessities as
dispensers, nurses and secretaries. Domiciliary practicecontinues as it is today. These three grades of institu-tion are governed by their medical staffs, strengthened
’ in the case of the hospitals by representatives of thepatients.
All the medical services, including public health, ina region are coordinated by a regional committee whichconsists of elected representatives of the doctors of allkinds and of other relevant groups including localgovernments. Medical members should be a powerfulminority. Medical officers of health are employed bythe Regional Committee and not by local governments.At the head of the Regional Committees is the National
Board of Health. The chairman is a layman and acabinet minister, called if you like the Minister cf Health.Some of. the members are laymen, appointed by thePrivy Council ; some are ex-officio (for instance, thepresidents of the Royal Colleges) ; the remainder arethe chairmen of a number of consultative committees.These consultative committees (General Practice, Hos-pital, Public Health, Medical Education, Propaganda,&c.) consist of practising doctors elected by their peerson a regional basis. The members are part-time andwell paid and are re-elected (or not) every five years.They are subjected, during their terms of office, to thecontinual criticism of their constituents in clubs andpubs and hospitals and are unable to shelter themselvesbehind that thick cloak of anonymity which today en-shrouds the civil servant. They know, through theirchairman, what goes on in the National Board of Health,and they pass on the information to those whom theyrepresent. They control the civil servants who do theday-to-day administration and are not controlled bythem.The National Board of Health is directly controlledby Parliament, in fact by the people, and this is theanwer to your criticism. Neither the local grocer nor the
"’"
shadowy civil servant controls our doings. ThroughParliament at our head, through the lay members ofthe National Board and Regional and Hospital Com-mittees, our patients have the ultimate rule and finalvoice. But in technical matters and in our daily lifewe retain our personal responsibility and the dignityoff) HT*T1< TtT*r<fK!on.
Whitchurch, Bucks. RAYMOND GREENE.
CERTIFICATION AND STATE SERVICE
SIR,-Though not an enthusiast for a state medicalservice as something intrinsically desirable, I cannot seehow a Beveridge plan is possible without one. And I aminclined to think that if Sir William Beveridge were" put to the question " under ’ Pentothal sodium ’ hewould confess to the same conviction.No man can serve two masters. The state must have
accurate disinterested certification of unfitness for workand it must have the most rapid possible return to fitnessto work. Hence the rehabilitation centres.Now, in unalloyed private practice the patient’s wishes
are paramount. He may not wish for an accurate-perhaps brutally accurate-diagnosis. He may’not bein a hurry to get well, and he usually wants a say in howhe is to be made well. Very often he secretly or openlywants his doctor for a friend, confidant and even father-confessor. He likes to feel that if his wishes are not.met he can change his doctor. If he pays for his doctorand for the expenses of his illness, he is probably right todemand this sort of service, and the doctor is content tosupply it; even if he sometimes rebels inwardly at his -.
slightly servile condition. As long as Free Choice ofDoctor is retained, so long will the patient expect andobtain a friendly, complaisant, slightly servile medicalman. I leave you to guess how long it would take a" free " medical profession to bankrupt the Beveridgeplan.
As to regional medical officers supervising certification,I feel sure from experience that it would fail. They willnot, take the responsibility of certifying that a man is fit,and I don’t blame them. It is one of the most difficulttasks in medicine, and you have to know the patient andhis circumstances well to come to the right conclusion.General practitioners are good at it, but it does not paythem to use their skill.
Also it would be very humiliating for general practi-tioners to be supervised and overridden by certificationofficials, supposing you could recruit good men for sucha dull job. No, far better free GPs from their servile con-dition, and then they would soon deal with scrimshankersand prevent the terrifying output of neurotics. Theywould be more efficient and make fewer mistakes thanspecialists and consultants. Remember I It was notGPs who invented the effort syndrome-that answer tothe neurotic’s prayer.The fact is, the amount of neurotic illness is already
great. Of all aetiological factors concerned in this disorderin peace-time, I should put Freedom from Want first,and next in order I should put a servile medical pro-fession. A " free " medical profession plus the Beveridgeplan would populate England with a multitude ofneurotic, spineless pension and dole gatherers.
Bridlington. P. D. H. CHAPMAN.
THE NURSE WITH TUBERCLE
SIR,—When I was a patient in a sanatorium I could nothelp but be struck by the apparently high incidence oftuberculosis in nurses. This led me to undertake, later,some careful investigations and I have made notes on theworking capacity and financial position of 59 tuberculousnurses with whom I have been in touch. Of this smallpersonal series : 8 have died ; 18 are ill at home or insanatoriums ; 4 have returned to work at their ownhospitals ; 13 are nursing in sanatoriums ; 8 are at home,fairly well but not working, and 2 of these have married ;1 is working at civil defence ; 7 I have not been able totrace and I think it likely that 3 of these have died. Ihave no definite information about the financial positionof many of them, but I know 15 (4 of whom have sincedied)-were in economic difficulty serious enough to affecttheir health unfavourably. Thus 7 had no income at all,2 only NHI benefit (15s. weekly) and 4 a proportion oftotal disablement benefit amounting in one case to 2s. aweek, in another 2s. 6d., in another 3s. 6d. and another 6s.Approved societies have the right to withhold a part ofbenefit until the patient is discharged from hospital ;I know of one nurse whose condition was hopeless overwhom the society exercised this right: she subsisted on3s. 6d. a week for the last 5 years of her life, being giventhe shelter of a sanatorium. When she died t25 hadaccumulated and the society advertised to try to find thenext of kin.
I am not myself a nurse but I am interested in theconditions under which nurses work.
Fulham, S.W.6. E. D. ANDREWS.
TREATMENT OF OSTEOCLASTOMA
SiR,—I hesitate to criticise Dr. Brailsford, for all of uswho have much to do with bone pathology owe him agreat debt. Nevertheless, one feels that a scientificpaper based on case-reports should be so presented thatthe conclusions in the discussion are adequately supportedby the cases dealt with. Dr. Brailsford describes fivecases, of which nos. 3 and 4 were not osteoclastomata,but were examples of chondrosarcoma. Case 2, whichwas also stated to be radiologically typical of osteo-clastoma, has no report on the histological findings of thematerial removed at operation. Case 5 had no operation ,
at all, so that though "’ the radiogram showed a typicalosteoclastoma " we have no knowledge that it was, infact, of this type.
, I do not think Dr. Brailsford has given satisfactory
scientific reason for believing that " the diagnosis can beestablished by radiography, and biopsy is neither neces-sary nor desirable " ; nor for the statement that thetreatment of choice, whatever the site, is X radiation.He may be right, but one would like to have betterevidence in support of his views.
Exeter. NORMAN CAPENER.
