Feb 26, 1977 - I can assure them that regional centres are not the only ... their tablet identificationcard with which they illustrate their article ... causing muscle weakness. S MICHAEL .... I believe, a member of the BMA Council and is ... It is a pity to see the gradual souring by ... if he had any strength of character or honour.
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etc. I can assure them that regional centres are tablet which is different in colour and appearnot the only neonatal units that have such ance from the diuretics which are frequently attributes. taken at the same time. In summary, where the neonatal unit is over If these two simple rules are adhered to 2.1 h from the regional centre I cannot agree a simple list of the drugs with their identifying that babies with respiratory distress syndrome characteristics, such as shape or colour, does (RDS) should be transferred to the regional help to improve compliance. centre. By the time the infant is one that requires ventilation the risk of travel is much E MALCOLM Fox greater than the risk of staying. I do agree with Macclesfield, Cheshire the standards Professor Davis and Dr Chiswick lay down for the care of these babies and agree that any unit treating RDS babies should adopt them. I also agree that, if fit to travel, babies Low-dose progestogens and ectopic with surgical and cardiac problems should be pregnancy transferred to the regional centre. SIR,-Confirmation by Drs P Liukko and R H DAVIES R Erkkola (5 February, p 379) that the three groups in their study (20 November, p 1257) St David's Hospital, on the relative risk of ectopic pregnancy with Bangor, Gwynedd different progestogens were of a comparable nature re-emphasises the greater efficacy and safety of 0-5 mg lynoestrenol as a "Salt tablets" progestogen-only contraceptive. The delay SIR,-I was interested to read the article by in the diagnosis of ectopic pregnancy in Drs I Wallace and J W Davie on improving association with continuous low-dose prodrug compliance in the elderly (5 February, gestogen therapy' 2 adds to the dangers of this condition and increases the importance of p 359). I notice that on both their drug calendar and considering the relative risk of this complicatheir tablet identification card with which they tion when choosing a progestogen-only illustrate their article they refer to Slow-K contraceptive. In response to the comments of Drs (slow-release potassium chloride) as a "salt tablet." This is potentially confusing to the Liukko and Erkkola concerning the relative elderly patients it is intended to enlighten, as progestational activity of the three agents used the following anecdote illustrates. When I was in their study, we did of course consider this a medical student I once accompanied a con- aspect. Using the comparative data obtained sultant in geriatric medicine on a domiciliary from assessing the relative progestational visit to an elderly man. While we were there activity of different progestogens by the postthe patient's wife asked us about the "salt ponement of menses test:'-5 we could find no tablets" which were making her sick. She correlation between the relative potency of showed us her supply of Slow-K. She was not the three progestogens in the Finnish study taking them, but instead she was putting extra and the observed risk of ectopic pregnancy. table salt in her cooking. Of course, she was This feature, however, would support the inference by Drs Liukko and Erkkola that the still taking her frusemide. The obvious consequence of her miscon- increased efficacy of lynoestrenol lies beyond struction of the nature of these tablets was that a "conventional" action on the uterine she was unprotected from hypokalaemia while endometrium and cervical mucus. Their her increased sodium intake exacerbated her reference to an ovarian effect is of considerable interest, but perhaps even more so is the fluid retention. To people with no knowledge of chemistry indication by Friederich and his colleagues6 the term "salt" refers to what we know as that lynoestrenol has a particularly competent sodium chloride. Potassium supplements influence at the central level, possibly from a should be given with the advice that they are blockade of the oestradiol receptors of the intended to stop the "water tablets" from pituitary and/or hypothalamus. causing muscle weakness. R CORCORAN M W RIZK S MICHAEL CRAWFORD Liverpool
Drug compliance in the elderly
SIR,-With reference to the article by Drs I Wandless and J W Davie (5 February, p 359). many general practitioners like myself who see patients in their own homes are often conscious of the small proportion of the prescribed drugs which are taken by patients, especially those who are elderly. In my opinion, every attempt should be made to restrict medication to not more than three different preparations, even if this means using one of the combined preparations which are so unpopular with the pharmacists and academics. Normally, in my experience, I have found it very useful to try to make sure that when a number of drugs are prescribed these have distinctive colours. For instance, on occasions
St Catherine's Hospital, Birkenhead, Merseyside IBonnar, J, British Medical Journal, 1974, 1, 287. 2 Corcoran, R, and Howard, R, Lancet, 1977, 1, 98. 3Greenblatt, R B, and Mahesh, V B, Metabolism, 1965, 14, 320. 4Greenblatt, R B, Medical Science, 1967, May, p 37. Macdonald, R R, Scientific Basis of Obstetrics and Gynaecology, p 356. London, Churchill. 1971. Friederich, E, et al, American Journal of Obstetrics and Gynecology, 1975, 122, 642.
Complaints against family practitioners
SIR,-Mr Rudolf Klein's comments in his article "The Health Commissioner: no cause for complaint" (22 January, p 248) act as a goad to anybody with experience in the administration of the procedure for investigating complaints against family practitioners. Mr Klein quotes the incidence of about 70 complaints against family practitioners I prescribed cedilanid (lanatoside C) instead which were raised with the Health Commisof digoxin so that there is a distinctive pink sioner in each of the years 1974-5 and 1975-6,
and rejected as outside his jurisdiction. He goes on to say: "These figures . . suggest that the machinery for dealing with complaints against family practitioners may not be working as well as it should, though ignorance as well as dissatisfaction may help to explain the number of cases affecting GPs referred to the Health Commissioner. This seems to support the case for changing the current family practitioner committee procedures for dealing with complaints along the lines proposed by the Council on Tribunals, by introducing independent, legal chairmen and neutral clerks."
It does not "seem to support" any such thing. There is, for a start, no indication of how many of these, if any, had any bearing on the practitioners' contract nor how many concerned doctors. There are 90 family practitioner committees in England and thus an average of less than one complaint about family practitioner services for each area was lodged in error with the Health Commissioner rather than with the appropriate committee. This incidence is extremely low and could quite well be explained by ignorance; but ignorance would not be cured by Mr Klein's suggestion. Presumably still referring to the recommendation for introducing "legal chairmen and neutral clerks," Mr Klein says: .. . the experience of the Health Commissioner would suggest that a judicious style of investigation offers as much protection to the health care professionals as to consumers."
It is, in my view, infamous for Mr Klein to suggest that the impartial advice given to would-be complainants and the careful consideration given by lay chairmen of service committees throughout the country and by lay and professional members of service committees themselves to the investigation of complaints in any way fails to be judicious. Even if Mr Klein meant to say "judicial" the introduction of a judicial investigation along these lines would be far from a step forward; but it would introduce an expensive, unwieldy, and over-legalistic element into what is essentially a procedure designed to elicit facts and make recommendations based on common-sense principles and impartial arbitration. The legal profession does not have a monopoly of these essentials. Sometimes I feel the need for a procedure for investigating complaints against self-styled, self-appointed experts in procedures of which they have no practical experience. R WRIGHT Administrator to
Croydon Family Practitioner Committee Croydon, Surrey
***We sent a copy of this letter to Mr Klein, whose reply is printed below.-ED, BMJ. SIR,-I entirely agree with the concluding paragraph of Mr Wright's letter. I too would welcome a procedure for investigating complaints against "self-styled, self-appointed experts." As one myself, I believe that this would offer me protection against ill-informed and ill-tempered criticism of the kind offered by Mr Wright. For my credentials in writing about this subject I would only refer him to my book Complaints against Doctors.' This was based on conversations with a great many executive council clerks (as they were then) and I may therefore have a rather wider perspective on the subject than Mr Wright himself.
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Indeed, Mr Wright's reaction seems to make the case for outsiders like myself to inquire into policy issues: while we lack "practical experience," we also lack the biases of those involved in running the NHS and may thus contribute a more temperate and objective point of view. RUDOLF KLEIN Centre for Studies in Social Policy, London WC1
Klein, R, Comtiplaints Against Doctors. London, Charles Knight, 1973.
Evidence to Royal Commission
SIR,-About a year ago the BMA began the task of preparing evidence for presentation to the Royal Commission on the National Health Service. This preparation soon affected many of the members of the Association's central committees as well as thousands of ordinary BMA members up and down the land. A good deal of the time of the secretariat has been devoted to this exercise. And indeed persons entirely outside the Association, some with little sympathy for many of its past activities, were nevertheless persuaded to contribute to the process so that at least the arguments could be displayed in full. In the case of our own central committee a working party spent many hundreds of man-hours commissioning, reading, occasionally writing, and editing the evidence it received. Eventually this, together with all the other "preliminary" BMA evidence, disappeared into the six panels and has reemerged entitled "draft evidence" (29 January, p 299) in the form of perhaps the largest collection of sacred cows ever herded together by the Association. We are not sure quite how the BMA might have gone about the task of producing evidence which showed that for once the medical profession was closely identified with the health needs of the people at large. What is apparent, however, is that much time, effort, and money would have been saved had the secretariat simply been empowered to string together the familiar collection of specious claims, essential prejudices, tired old shibboleths, etc, which now constitute the evidence. We suggest that in future files be maintained at Tavistock Square specifically for purposes such as this and that once every 100-200 years they be updated. SPENCER HAGARD Glasgow
STEPHEN D HORSLEY Harrogate
Trainee Representatives, Central Committee for Community Medicine
World Medical Association SIR,-Dr E B Lewis (5 February, p 394) is, I believe, a member of the BMA Council and is presumably one of the members who voted that the BMA should withdraw its support from the World Medical Association. You quote him as saying that "a World Medical Association which did not include the Soviet Union, China, and the USA was merely a grandiose title of a sounding board for wind-
bags, which the WMA had become." I entirely agree with him that the WMA can hardly claim to represent the doctors of the world if the Chinese, Russian, and American medical associations are not members. But I
fail to see how withdrawing BMA support will help to put this right. If Dr Lewis had been at the WMA Assembly at Sao Paulo last October, as I and several other BMA members were, he would know that it was decided, following a motion put up by the Scandinavian medical associations, to seek ways and means of bringing in the Eastern-bloc medical associations. As for the American Medical Association, there are already signs that they are feeling left out in the cold (for example, American doctors had no opportunity to present their views on interrogation to the United Nations Commission on Human Rights). Does Dr Lewis want us to be similarly left out of the mainstream of developments ? If he wants the WMA to be stronger and more influential he is not being very helpful. The WMA costs each BMA member but two Swiss francs per annum. Is there a single doctor who begrudges that contribution ? J RIBEIRO
public health service, latterly called the community health service, that sought to speak for the total population it served. There will shortly be a virtual monopoly of medicine by the Department of Health and Social Security and the bureaucrats who run it. If the present Government succeeds in its object the only practising doctors who will not be whole-time servants of the DHSS will be, firstly, some general practitioners, and secondly, those hospital doctors employed by the universities and the Medical Research Council, and they too hold honorary contracts with the DHSS. I submit, therefore, that "Charles Hastings," if he had any strength of character or honour within the profession, should not have been so cowardly as to hide behind a pseudonym. Already we are ruled not by our consciences but by politics and expediency. Practitioners must not be afraid to acknowledge their opinions, or their opinions will not be worth acknowledging. SONIA G BOLTON
Child Health Service, Central School Clinic. Portsmouth
Revising the salary structure SIR,-This would appear to be the year of the "differentials." In the immediate past salary negotiations for doctors working in the NHS have become fragmented. Surely, in considering the claims of any particular group, the whole salary structure should be examined and reviewed. The professional ladder must be seen to be worth climbing to encourage the ambition of the many talented younger doctors. Starting at the top, salaries for junior, newly appointed consultants should start at £25 000, rising to £35 000 with seniority. The higher the top rung, the better for the many on the lower rungs. A general practitioner for 27 years, I am impressed by the younger generation of hospital consultants. They marry their expertise in modern medicine to wit, culture, and charm. It is a pity to see the gradual souring by frustration and dismay at their abysmal reward. J A CHISHOLM Nottingham
Profession and Government
SIR,-I deprecate your decision to print the "Charles Hastings" letters under a pseudonym. Much of what was said was contentious and parts, particularly of the third letter (22 January, p 246) were malicious. Over the past decade British medical practitioners have been subject to both political and professional pressures from within and from outside the medical profession, and it is particularly necessary at this time that practitioners should not tolerate anonymity of speakers on political and professional matters, particularly in a leading professional journal. The vital care of patients is too important for it to be put at such a stake. Over the last few years we have seen the introduction of health centres, the discouragement of single-handed practices, the reorganisation of the NHS, and now the imminent introduction of the recommendations of the Court Report. By these moves the Government has cut off financial support for the profession from local government sources and has stifled and virtually extinguished the opinions of the
Dispensing practices-unfair pricing SIR,-Some doctors may be unaware that during the past 12 months the profitability of dispensing has decreased progressively as the wholesale prices of drugs have increased. This is because manufacturers' price rises taking place before the 8th of a given month are not taken into account by the pricing bureau until the following month, and those taking place after the 8th not until the next following month. As some rises of the order of 200 have taken place recently the profitability has almost vanished altogether. If doctors will check the figures supplied to them on form FP 34 (part B) they will find the average pricing of a prescriptioi, by dividing item 1 by the number of prescriptions shown alongside. This has risen from approximately £1-10 in January 1976 to £140 in October 1976. The pricing of drugs should take into account this effect of inflation and should correspond with the wholesale prices current at the time of dispensing each prescription. Otherwise some doctors will find t1 2mselves dispensing at a loss in the near future. H K DAVISON Billesdon, Lcicester
SIR,-A member of the Association for 50 years, I have hitherto resisted any impulse to write to you, but I am now impelled to support Dr W H Gossip (12 February, p 448). The delays in implementation of increases of pension are frustrating. The BMA's acceptance in principle of the Health Departments' proposals for war service increase in pension was announced in the BMJ of 20 September 1975 (p 720). In the BMJ of 27 November 1976 (p 1337) it was stated that amending regulations were "not likely to appear in print before about March 1977." This date now appears to be "about May 1977." Many of those who could have received an increase in pension have died. It is difficult to understand why women widowed since