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Parliament

Entry to General PracticeDr. A. D. D. BROUGHTON took the opportunity of

speaking on the Adjournment, on July 7, to bring tothe notice of the House and the Minister of Healththe difficulties facing doctors who want to enter generalpractice as partners or principals. The old method ofbuying practices, he said, often plunged a young maninto debt for twenty years ; and the abolition of thesale of practices might have been expected to make iteasier for young men and women to enter this importantfield of medical work. They do, in fact, find compara-tively little difficulty in getting assistantships ; butmost of them, particularly the ambitious ones, after aperiod of assistantship want the greater security to begained as a partner or principal.

Vacancies for medical practices are advertised byexecutive councils, but the advertisements are sur-

prisingly few. In the British 31[edical Journal of July 7,he said, there were only 3 such advertisements. A practicewith a list of reasonable size when advertised can attractmore than 50 applicants. Thus, men in their thirties,married, and some of them with young families, menwho served during the war, with good qualifications andconsiderable experience, including general practice, findthemselves unsuccessful applicants ; and after severalfailures some of them begin to feel a sense of inferiority.The majority, however, blame the executive councils,and claim that 90 % of the appointments are "fixed."While Dr. Broughton did not share that view, he saidhe could readily understand a man being driven tobelieve it.The difficulties of entering general medical practice

by means of executive council appointments are so greatthat most medical graduates try to enter as partnerswith established practitioners. But all too often they.find themselves up against what Dr. Broughton saidcan only be called a racket. While a principal can nolonger sell the goodwill of his practice, there is nothingto prevent him insisting that the partner shall occupya certain dwelling-house, and no limit is fixed to theprice he can charge for it. Thus one doctor who answeredan advertisement for a partnership received no replyfrom the doctor, but a house-agent wrote to say thatthe partnership was conditional upon the applicant’spurchase, as a place of residence, of a small bungalowfor 96500. Further, during the first three years of thepartnership, additional expenses would have to beincurred to the amount of .83500, making the total 29000.Is it right, Dr. Broughton asked, that young men orwomen wishing to start in general medical practiceshould be burdened with a debt of that size ? Not alldoctors are trying to rob new entrants in this manner,but he believes that far too many of them are doing so.We are short of doctors, and particularly of generalpractitioners, but it is still far more difficult than itshould be for men and women to gain a foothold inpractice.

Dr. BARNETT STROSS found this problem none the lessdisturbing because the evidence of it may be confinedto a very few examples. Even if one such distressingcase occurs in a year something should be done to makesuch things impossible. Seeing that the Minister haspaid some ;f;66 million for the goodwill of general medicalpractices, Members of Parliament never expected thatpractices would be sold again in the way described. Ifin a back-handed way a medical practice is to be soldtwice that, he suggested, is surely illegal. He quotedsection 35 (3) of the Act, which debars the sale ofpremises used for practice at a price above the fairmarket price. The same should apply, he thought, tothe doctor’s dwelling-house, for those who have workedin general practice know that it is not only the surgerybut the place where one lives which counts.

Mr. ARTHUR BLFNKINSOP, parliamentary secretary tothe Ministry of Health, agreed that, though only a fewcases may be affected in the way Dr. Broughton haddescribed, the Government’s wish is that the oppor-tunities for young men to come into medical practiceshould be made more, rather than less, plentiful. The

reduction of the maximum number of patients on adoctor’s list has encouraged general practitioners toemploy extra assistants or bring new partners intotheir practice. The executive councils have defined andclassified different parts of the county as underdoctoredor overdoctored areas, thus encouraging newcomers toconcentrate their attention on parts of the countrywhere more medical care is needed. They have alsodone their best to persuade doctors to take on assistants,or to enter into partnerships so as to increase the_medicalservices in underdoctored districts. The Medical PracticesCommittee, in their first report, stated that, in theirview, preliminary apprenticeship as an assistant is stillthe best method of entry into general practice. TheGovernment shares that opinion and has encouragedthe appointment of assistants by giving grants. Someincrease in the number of assistantships has been seenover the country as a whole. There is much greateropportunity today for entry into general practice bymerit, Mr. Blenkinsop claimed, than there was underthe old system. While there has been criticism of

particular appointments, the procedure adopted by theexecutive councils has on the whole brought little, com-plaint, and has been widely regarded as a desirablemethod of appointing new practitioners. The buildingup of new practices is being encouraged by the payment,in many cases, of a basic salary of ;13300 a year, and bymeans of the Special Inducement Fund, on which claimscan be made by doctors setting up practice in particularlydifficult and underdoctored areas.The Government appreciates, however, that there are

still very real difficulties, among them the problem ofaccommodation, to the young doctor. Sometimes adoctor appointed by an executive council cannot acceptthe appointment because another doctor has alreadysecured the use of the surgery on the outgoing doctor’spremises. If any excessive price is being charged for ahouse which includes the surgery it is an attempt to

evade the provisions of the Act, and should be reportedto the Medical Practices Committee. Where the houseis separate from the surgery the position is rather moredifficult to define. The matter is largely one of profes-sional conduct in which the Government would hope toget the cooperation of the profession itself in insistingthat this kind of conduct should be condemned. Theywould wish to gain the cooperation of the British MedicalAssociation in trying to ensure that this practice shouldbe ended by the voluntary action of the practitionersthemselves. It might be rather difficult to interpret theAct in such a way as to cover the ordinary living accom-modation of a doctor if it is quite distinct and separatefrom the surgery. But he is prepared, he said, to examinethe matter further. The difficulty some doctors find intaking up practices to which they have been appointed,because of lack of accommodation, is already beingdiscussed with the B.M.A., and he hoped that a waywill be found to overcome this trouble. The Governmentis most anxious to try to help in every way it can toencourage the setting up of additional medical practices.

QUESTION TIME ,

Mentally Deficient Children .

Mr. W. R. S. PRESCOTT asked the Minister of Health how

many mentally deficient children were awaiting admissionto institutions ; what were the comparable figures at thesame date for 1947, 1948, and 1949 ; and what steps hewas taking to expedite admission.-Mr. A. BEVAN replied:Figures in regard to mentally defective children are not

separately shown. Within the resources available we are,of course, adding to the accommodation available. I amquite aware of the seriousness of the problem, and if wecould make more accommodation available I would be

delighted.Hospital Transport Scheme

Mr. SAMUEL STOREY asked the Minister if he had consideredthe report of the West Manchester Hospital ManagementCommittee upon their transport scheme for industrial workersattending hospital outpatient department ; and whether, inview of the saving of man-hours to industry achieved, heproposed to extend the experiment to other areas.-Mr.BEVAN replied : I am arranging for a report on this schemeto ascertain whether equal savings could be secured by other

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means. This is a very imaginative and enterprising schemeby the local people responsible and I am examining it withgreat interest.

Medical Distinction Awards

Colonel MALCOLM STODDABT-ScoTT asked the Minister how

long the committee which dealt with merit awards for medicalconsultants had been sitting ; how many times it had met ;who was its chairman ; and the salary or fee he had beenpaid.-Mr: BEVAN replied : The committee was appointedon Dec. 23, 1948. It has held 24 meetings. Its chairmanis the Lord Moran of Manton. He has received 3000 guineasfor the first year’s service, and will receive 2500 guineas forthe second year.

B.C.G. Vaccination

, Dr. CHARLES HILL asked the Minister how many local

health authorities were in possession of adequate suppliesof B.C.G. ; and whether he was satisfied that this methodof prevention was being made available on an adequatescale and as rapidly as the paramount necessity of preventingtuberculosis demanded.-Mr. BEVAN replied: 116 out of145 authorities in England and Wales have so far had arrange-ments approved for B.C.G. vaccination at the discretion ofchest physicians. They receive the vaccine as they need itsince it cannot be stored. As to the second part of thequestion, I would refer to the reply I gave on June 15 [seeLancet, June 24, p. 1174].

Home Treatment of the Tuberculous

Dr. HILL asked the Minister whether he would instruct

regional hospital boards to arrange for the home treatmentof tuberculosis patients for whom there were no sanatoriumbeds vacant, by making available to them in their homesthe services of chest specialists, portable X-ray facilities,and any other facilities necessary for adequate and continuoustreatment.-Mr. BEVAN replied : It is part of the normal workof the boards’ chest specialists, with the resources of thehospital service available to them, to take part in the hometreatment of tuberculosis patients.

Efficacy of DisinfectantsDr. HILL asked the Minister if he would consult the Medical

Research Council, with a view to taking steps to ensurethat disinfectants produced by manufacturers satisfiedminimum standards of efficacy.-Mr. BEVAN replied : I am

already in touch with the Medical Research Council, but,as the hon. Member is aware, this is a very difficult andtechnical subject.

Dr. HILL: Will the Minister bear in mind, in any consul-tation he has, that there is a wide difference between theeffectiveness of the various disinfectants on the marketwhich is unknown to purchasers, and that there is an importantpublic-health problem involved ?-Mr. BEVAN : That is thereason why we have asked the technical authorities to laydown standards, but although this matter has now been

pursued for very nearly five years no standards have yetbeen achieved because of the intricacy of the problem.

’

Supply of Aural Aids

Replying to questions about delays between the time oftesting and the time of issue of hearing-aids, Mr. BEVANsaid the waiting period varied much according to individualneeds, and averages had no meaning. The mechanicalgenius available in this country had been used to tacklethis problem for the first time in English history. Between80,000 and 90,000 aural aids had already been issued. Thelimitation was not the mechanical genius of the country,because we were producing them from the industry fasterthan technicians could give them to the patients.Mr. SOMERVILLE HASTINGS : Am I right in assuming that

it was the genius of the Post Office engineers which wasmainly responsible for this wonderful instrument ?-Mr.BEVAN : It was the cooperation between the physicians onthe one hand and the Post Office engineers on the otherthat produced this aural aid.

Hospital and Specialist ServicesMr. HASTINGS asked the Minister what would be the

approximate annual saving to the nation if only whole-time

medical officers were employed under Part II (Hospital andSpecialist Services) of the National Health Service Act, 1946.- Mr. BEVAN replied : I regret that the information is notavailable.

Mr. HASTINGS : Am I right in assuming that there willbe a saving of about 20%, and, if so, will the Ministercommunicate this to the boards of governors when they arereappointing officers in future ?-Mr. BEVAN : As I do notknow what the figures are, I cannot say whether 20% isaccurate or inaccurate.

Mr. HASTINGS asked the Minister what steps he took toensure that part-time medical officers engaged under Part II(Hospital and Specialist Services) of the National HealthService Act, 1946, were actually employed for the numberof notional half-days for which they were paid.-Mr. BEVANreplied : It is the responsibility of hospital boards andcommittees to see that officers carry out the duties for which

they are remunerated.Mr. HASTINGS : Is the Minister aware that some officers

are paid for sessions for which they never turn up ?-Mr.BEVAN : I should like to have information as to that, becauseit seems to me rather extraordinary.

Dr. HILL: Will the Minister resist such general allega-tions without a shred of evidence being produced in theirsupport ?-Mr. BEVAN : As I said, I should like to see theprecise information.

Clinical AssistantshipsMr. READER HARRIS asked the Minister if he was aware

that regional hospital boards had not yet begun to offerclinical assistantships to general practitioners;- and whataction he proposed taking.-Mr. BEVAN replied : I knowthat appointments of this kind have been offered wherethe needs of the service demand it. If the hon. Memberhas any particular case in mind I shall be glad to hearof it. -----

Mr. -HASTINGS: Does the Minister realise how importantit is from everybody’s point of view to keep general prac-titioners in close contact with their local hospital ?-Mr.BEVAN : I am very well aware of that, and part of the difficultyis to try to bring about a reconciliation between the con-flicting claims of the general practitioner on the one handand the specialist on the other.

Cortisone

Mr. BARNET JANNER asked the Minister whether he wasaware that Cortisone’ had been made available for itsfirst widespread distribution to United States hospitals ;and whether any action was being contemplated for its usein United Kingdom hospitals.-Mr. BEVAN replied : I amaware that the production of cortisone in the United Stateshas been increased. Clinical trials are being conducted inthis country by the Medical Research Council, and the resultsof these trials will determine the conditions for which thedrug is made available here.

Employment of EpilepticsMr. SoMERVILLE HASTINGS asked the Minister of Labour

what provision he had made for the employment of manualand clerical workers who suffered from epilepsy but wereotherwise capable of taking their normal part in industry.-Mr. GEORGE ISAACS replied: Sufferers from epilepsy, likeother handicapped persons, can readily get advice and guidanceabout their employment difficulties from disablement resettle-ment officers who have been able by special approach toemployers to place a considerable number in suitable employ-ment. To assist in this work explanatory notes about epilepsyhave been issued by my department to employers for theirinformation and guidance. A number of the more severecases have been placed in employment under shelteredconditions in Remploy factories.

Motor-cars for District Nurses

Mr. A. C. MANUEL asked the Secretary of State for Scotlandwhat information he had as to the progress made by the localauthorities since they became responsible for the nursingservice in the provision of motor-cars for district nurses.-Mr. H. McNEIL replied : During 1949, 100 additional cars wereprovided for nurses engaged in home nursing services. Ofthe 908 nurses so engaged in county areas at the end of 1949,586 had cars at their disposal.

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Pneumoconiosis in South Wales

Mr. DAVID WILLIAMS asked the Minister of Fuel and Powerhow many miners in South Wales had continued their under-ground employment after being certified to be suffering frompneumoconiosis.-Mr. PHILIP NOEL-BAKER replied : OnDec. 31, 1949, 2372 men who had been given an assessment inrespect of pneumoconiosis under the Industrial InjuriesAct, 1948, were employed underground in the South Walescoalfield.

Quarantine Medical Certificates

Major HowARD JOHNSON asked the Minister of NationalInsurance whether she was aware that a certificate givenby a general medical practitioner placing a person in quarantinecould not be accepted for a benefit claim ; and, in view ofthe fact that this cast a slur upon such a practitioner, whethershe would amend the National Insurance (Unemploymentand Sickness Benefit) Regulations in this respect.-Dr.EDITH SuMMERSEiLL replied: The medical officer of healthis responsible for action to prevent the spread of infectiousdisease, and it is in accordance with the recommendation ofthe National Insurance Advisory Committee that he is alsothe authority for the issue of insurance certificates in thesecases. This implies no slur on general practitioners and Isee no reason to alter the present provision.

Medicine and the Law

The Wrong BottleAT an inquest in Blyth last month the evidence showed

that a woman, aged 23, had died through the inadvertentuse of potassium citrate in an injection.A staff nurse with over twenty years’ experience

explained to the coroner that, when working at a clinic,she noticed that her flask of distilled water was almostempty. She took it upstairs and asked an orderly torefill it ; she held the flask while he filled it ; she didnot particularly notice the bottle which he used. On thedoctor’s instructions she had to prepare two injectionsfor a patient. For the second injection she filled a

syringe and handed it to the doctor, assisting him whilehe injected the contents into the patient’s arm. The

patient, sitting in a chair, siumped forward and collapsed.Attempts at artificial respiration failed and deathfollowed.The jury returned a verdict of death from misadventure.

The Duty to Inform the CoronerAt another inquest last month the resident surgical

officer gave evidence that a woman was admitted to aSurrey hospital with general peritonitis. - An operationwas conducted but nothing obvious was found to accountfor her condition ; she died two days later. At a limitednecropsy an- object was discovered which he at first

thought was a piece of bamboo ; it was suggestedthat it was the bone of a skate. He signed a deathcertificate.The coroner commented that the death certificate

was useless ; no registrar would have accepted it ; itmeant that there was considerable delay before hehimself -was informed and considerable difficulty in

carrying out a further necropsy. The pathologist whogave evidence of this further examination said that hewas unable to decide the cause of death because the bodyhad been treated with embalming fluid ; he thought thesplinter looked like vegetable fibre of some sort. Thecoroner stated that death obviously resulted from

perforation of the bowel by an object 3 in. long andpointed at both ends ; " it may possibly be a fish-bone,but I doubt it." He told the resident surgical officer thathe should have informed the coroner’s officer forthwithas soon as it was known that death was not due tonatural causes. " You seem," he said, " to have donea number of things which do not commend themselvesto me." A verdict of accidental death was recorded.

In England Now

A Running Commentary by Peripatetic Correspondents

BLOODSHOT

Wintrobe O’Landsteiner Wiener FitzKahnLay in his lab on a satin divan

And sipping his saline he passed in reviewThe things he had almost decided to do,

Like writing his thesis on " Proof of a Theorem

Disproving that Serum is Plasma (or Serum)."He thought of the days in the dawn of his youthWhen, asking no more than Pursuit of the Truth,

With lenses all dirty and eyepieces scratched,He counted corpuscles before they were hatched,

And many a time made a clear diagnosisOf Multiple Red-cell Erythrocytosis.

(He turned to a female technician and beat herUntil she remembered the height of the titre.He bade her get up and go dance a pavaneFor TTintrobe O’Landsteiner TViener FitzKahn).

Landsteiner Wintrobe O’Kahn de MacWiener .

Arose and announced with unruffled demeanour," My private researches have recently shownA way by which blood can be drawn from a stone

And pure inexhaustible rivers of goreExtracted from crude sanguiniferous ore."" This tide of affairs we shall take at the floodAnd pluck off the leeches who live on our blood-

Agglutinin courses the vessels of menRemorselessly seeking agglutinogen-

So Fate in fulfilment now fittingly sendsThese bloodsucking bleeders to bloodthirsty ends ! "

(The sauce for the gander is sauce for the goose ;The pips are as bitter as sweet is the juice-" That donor will faint e’er he gets any greener!"Said Landsteiner TVintrobe O’Kahn de l4Taell’iener.)

* * *

" A swan can break a man’s arm with a blow of hiswing " : thus traditional childhood lore led me and myfellows in my very young days in the Thames Valleyto regard these lordly birds with respect and even fear.Increasing stature and experience of the vulnerabilityof the cock swan to a sharp poke in the neck with anoar or paddle led to modification of these feelings, andfor years past I have looked on the swan merely as apleasant adjunct to the landscape so long as he keptin his right place, and as an easily disposed of nuisancewhen he didn’t. But once again I have had occasionto modify my views.

It was a lovely June day : my daughter and I wereexploring, in a punt, a hitherto unvisited reach of riverwith a view to a bathe. We found the reach ended ina steep weir, and it was easy to slide down its weed-covered cement into the mild turbulence of the waterat its foot. Fifty yards away was the opposite banktowards which we swam and where we found a pair ofswans with a brood of newly hatched cygnets receivingthe attentions of a picnic party-a charming sight.I left my daughter admiring it while I swam out into thepool. A shout from the bank made me look round tofind the cock bird bearing down upon me-neck feathersruffled and wings half outspread so as to make him looktwice his size, head proudly poised and with a malignantgleam in his beady eyes, viewed from the level of thewater he presented a noble and formidable spectacle.My immediate, and quite irrational, apprehension wasof the beak in my eyes, and my reaction to shout " shoo

"

and splash at the downbearing menace. The nextmoment the air above me was full of wings and I received ,

a blow on the side of the head that knocked me silly.When I was again in a position to observe events I foundthe malevolent fowl bearing down upon me from anotherangle. To present’ my feet to the onslaught and tokick violently seemed sound tactics, but merely resultedin a further whirlwind of wings and a couple of blows onmy right arm which numbed it from the shoulder down.The next and subsequent attacks I evaded by diving andswimming under water towards the shallows, and thissomewhat ignominous procedure seemed to be thecorrect tactical answer. Once in the shallows it waseasy to heave a few stones in his direction-a threat