Jan 22, 1977 - a 13-mile return journey to and from the base hospital plus a four-mile trip between the two hospitals in that city on two of the three days.
BRITISH MEDICAL JOURNAL
22 JANUARY 1977
St Augustine's Hospital is a psychiatric unit in Kent that has suffered bitterly as a result of the above philosophy. Ironically, in the same week in which we heard of the appointment of the area works officer we were also told that the appointment of a sorely needed senior registrar at St Augustine's, approved by the Department, could not go ahead because there were no funds. In the same week, while discussing staffing of a new district general hospital due for commissioning next year, we were told: "You must appreciate that there is a freeze on new senior registrar posts and a virtual freeze on new registrar posts." Where does the patient stand in all this ? (Delete "Administrative freeze": substitute "Medical freeze.") J A GIRLING
employer wins financially on all counts, although I win in every other respect, not least the very pleasant physical exercise, much of it through open countryside, half an hour each way on three days each week. It is certainly a much more pleasant and relaxing form of exercise than jogging or use of a training (skipping) rope, which appear to me to be the only alternative ways of ensuring that one takes one's quota of exercise not less than five days each week. ANTHONY A VICKERS Worcester
Points from Letters The London hospitals scene
Medical Executive Committee, South-east Kent Health District Folkestone
Expense allowances for self-powered transport SIR,-Scrutator (25 December, p 1570) describes at some length an attempt by a family doctor to obtain travelling expenses or allowances in connection with a course to and from which he proposed to run 17 miles each way. There are not dissimilar precedents. About 18 months ago I was reflecting in exasperation upon the fact that over a period of more than 25 years I had been driving a car between 12 000 and 15 000 miles each year, representing no less than about 300 000 miles or more than 12 times the distance round the equator of the earth. About half of this mileage represented official "on the job" travelling, for which expenses have been claimed. If I was averaging 40 miles an hour for those 12 circumferences it would have taken me rather more than 7000 hours or the equivalent of 300 days of continuous 24-hour travelling-not far off a year out of my life wasted, doing nothing useful, not even sleeping. After a lot of thought I decided that I would try bicycling on those days when I do not require a car to travel outside the bounds of the city in which I normally work-that is, on three working days each week. It involves a 13-mile return journey to and from the base hospital plus a four-mile trip between the two hospitals in that city on two of the three days. When I rang up the treasurer's department and stated my query I was told that I was two years too late, that two consultants had been paid for bicycling within Birmingham for about two years, and that the standard rate was llp per mile. I duly started sending in my travelling claim forms with the bicycling mileages indicated separately, including my home-to-office bicycling mileage, which my contract allows when I need private transport between hospitals. My claims for the appropriate mileages amount to some 100-170 miles each month and have never been queried-except that a flat maximum sum appears to have been imposed of Ll 10. Perhaps they think I am only really fit to cycle 100 miles each month. Should I take up with the cyclists' equivalent of the AA the matter of how much it really costs to run a bicycle? Certainly with my rear tyre lasting me not more than 1200 miles of cycling and no breakdown service to come and help me when I do get a puncture I think that my
Mr J S MARTIN (Hull, Humberside) writes: The correspondence on this subject depresses me. To the numerous other divisions in the profession-BMA v HCSA, whole-time v part-time, teaching v non-teaching, etc-we now have The Rest v London. The almost gloating "cut London down to size" tone of some contributors is particularly disagreeable. Those of us who practise in hospitals outside London ... need have no inferiority complex; the NHS, for all its faults, levelled up hospital standards. The London teaching hospitals have a great anduniversally recognisedtradition and this is still important in medicine. There are very few of us who have not derived some benefit directly or indirectly from the London teaching hospitals or institutions. Inevitably there are inequalities in distribution of resources nationally, as there are in districts and indeed in individual hospitals. I suspect that much of the present deprivation is due to lack of initiative when the going was good in the past....
tion (or of the lack of it) is a further unproductive expense. Central London therefore requires additional expenditure per head relative to other parts of the country, because the "head" will not stay still. To reduce this differential, as is now proposed, will mean that all those of us involved in patient care will have to run even faster in order to stay still. ... Mr M C ALDRIDGE (St Mary's Hospital Medical School, London W2) writes: As a medical student at one of London's "centres of excellence" I disagree with Dr W J Lockley (1 January, p 46) when he says that our "teaching material . .. is suspect, giving . .. an entirely false idea of the prevalence and relative importance of the rarer diseases." This statement may have been true 50 years ago but not today. As students we are made very aware of the so-called "minor" illness in the community through frequent "social work visits" to homes in London. These visits form an increasing part of many of our courses from paediatrics to psvchiatry. With courses which now include geriatric medicine and time spent in general practice, the student is exposed to an unending barrage of "real-life" medicine. The teaching material is in no way suspect and, by being centred in London, students have a unique opportunity to see a wide spectrum of social extremes which they may not see in the periphery. . . Finally, in reply to Dr Lockley's point about the "poverty" of the peripheral hospitals, at St Mary's our department of obstetrics and gynaecology and the school of nursing are housed in converted stables which used to belong to Paddington station and our department of general practice is located in a building on the premises of a second-hand car dealer.
Allergic reactions to penicillamine Dr ROBERT LEFEVER (London SW7) writes: A practical point overlooked by your correspondents concems the high turnover of population in central London. The dynamic as opposed to static statistics of a population can be of considerable significance to the quality of health care at the point of delivery. In my general practice I lose 35O' of my total of 3500 patients every year. This figure does not include hotel guests and those who stay in my area for less than one year; those patients are seen as temporary residents. Therefore the figure of 3500 turnover per annum refers to the "stable" population. Inevitably this involves very considerable administrative work and expense that will not be reflected in improvement in patterns of morbidity. Firstly, administration of itself is not a cure for any disease process, and, secondly, my patients do not remain in the area for long enough for me to see much practical benefit (as would be expressed in morbidity or mortality statistics) as a result of my work. These figures of turnover of population are easily monitored in general practice because of the system of registration of patients with one and only one GP at any one time. It may not be immediately apparent that the turnover of population and the unproductive expense involved must also affect hospital patients in central London because they are, for the most part, the same patients. A further complication in the hospital sphere is that patients may, and often do, attend several different hospitals and the cost of communica-
Drs S P DEACON and R R MASTERS (Pilgrim Hospital, Boston, Lincs) write: . . . Recently we started penicillamine therapy (250 mg four times a day) in a 21-year-old man with newly diagnosed Wilson's disease. He developed a diffuse erythematous rash associated with fever which recurred after withdrawal of the drug followed by gradual increase of the dose to the required amount. However, there are three commercially available preparations of penicillamine: Depamine, Distamine, and Cuprimine. Since trace impurities may sometimes be implicated in drug-induced allergic reactions it was decided to rechallenge this patient with a different preparation of penicillamine. His penicillamine therapy was changed from Distamine to Cuprimine and no further allergic reactions occurred. We suggest that patients who develop penicillamine-induced allergic reactions might benefit from a trial of therapy with a different pharmaceutical preparation.
Vaccination against EB virus Dr A R KITTERMASTER (Kent and Sussex Hospital, Tunbridge Wells, Kent) writes: Your leading article of 18 December (p 1467) with the above title was of great interest. Perhaps it had escaped your notice that it covered much the same ground as an article "First the Vaccine, then the Proof" by Dr Geoff Watts in World Medicine, 16 July 1975.