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Hardship

THE LANCETLONDON: SATURDAY, MAY 13, 1950

OF the doctors whose fortunes were changed bythe coming of the National Health Service, one groupwas particularly hard hit financially. These werethe general practitioners with numerically small

practices. They were working either in the country-side or in towns where, before the appointed day,private practice had been relatively remunerative.The number of patients they looked after was belowthe average number in a doctor’s care throughoutthe country ; but their load of work was not

proportionately less, because more attention was

expected of them by their patients.The Act gave all principals established in general

practice the right to continue in practice in theirown area-a wise decision not only because it was

obviously undesirable to uproot a proportion of theestablished doctors, but also because a man who hasserved for some years in a community is a greaterasset to that community than he could for some timebe to any other. Most practitioners exercised theirright to stay in their own practice area, and manythen found that the almost universal acceptanceof the national service by their patients reducedtheir income without reducing the load of work.This situation had been foreseen in so far as sparselypopulated and truly rural areas were concerned, andearly adjustment of the mileage and inducementfunds did much to ease initial hardships here. Butthese measures offered the urban practitioner withthe small practice no relief at all, and it becameharder and harder for such practitioners to meettheir fixed commitments. A few of the youngerones gave up practice in the well-doctored areas

where they had been practising and sought placesas partners or assistants to doctors in underdoctoredareas, many of whom now found their practicesexceeding the statutory size. It was not so easy,however, for older men to do this. Their personaland family ties were stronger in the towns they hadso long served, and even when they were willing tomove it proved hard to find alternative places inwhich to practise. The busy doctor looking for helpwith an impossibly large practice prefers a young andenergetic assistant to someone his own age or older-particularly someone who has grown up in theless hurried atmosphere of a small practice. Evenexecutive councils have shown themselves unwillingto award a vacant practice to an older man if a

capable younger man is available, as he almost

always is. So most of the doctors with smallpractices stayed on, trusting that relief might comewhen the negotiations for the increase in the practi-tioners’ pool were completed. As their hopes ofhelp from this quarter fell, and the continued hard-ship they were experiencing became more apparentto all, it was decided last year that claims might bemade against the moneys remaining in the Induce-ment Fund to alleviate this hardship. If the doctors

would send in a statement of their incomes and

expenses before and after the appointed day, andwould make a claim for help, their position wouldbe considered, and where appropriate a grant wouldbe made. But this was all rather vague, and itsavoured too much of charity. Nobody had anyclear picture of what constituted hardship, and fewpractitioners seemed willing to appeal for this type ofhelp. Moreover, those that did appeal often foundobstacles in their way. Some were told that thearea in which they were practising was not an

" induce-ment area " and so they did’ not qualify for grant.Others who had experienced heavy falls in income wereregarded as not suffering hardship, because their netincome still exceeded an empirically fixed basicminimum. Even when a claim was agreed, it wasnot very clear how the sums granted were assessed,except that they were expected to be sufficient tobring the doctor’s income back to this same universallyapplied invariable minimum., Altogether the schemewas felt to be neither equitable nor sufficient, and itwas little used.The Ministry of Health, after consultation with the

General Medical Services Committee, has now placedthese hardship grants on a very different and muchmore satisfactory basis. But, though a circularletter has gone out from executive councils notifyingall practitioners of the new conditions of grant, itdoes not seem that the advantages of the alteredscheme are yet well appreciated by many of thosewhom it is meant to help. The important changesthat have been made are that claims will now beentertained from all areas, and not only from areaswhich would normally attract an inducement pay-ment ; that hardship will be measured not on netincome remaining but on the difference in net incomebefore and after the appointed day ; and that theamount of relief given will bear a definite relationto this fall in net income.

" The intention," to quote from the circular letter,its to assist a practitioner who has suffered a severeloss of income as a result of the introduction of theService, by making good some part of the loss and sohelping to tide over a difficult transitional period.The circumstances of all such cases will be reviewedannually, and, though it is recognised that paymentsmay have to be made in certain cases over a number ofyears while the doctors adjust themselves to the newcircumstances, it is contemplated that such paymentswill be on a descending scale."

This quotation shows clearly the purpose of the

grants. They are meant to give immediate assistanceto the general practitioners who have been hit mosthard. The claims are to be dealt with in the greatestpossible confidence by a small subcommittee of theexecutive council and the local medical committee,and retrospective payments back to the appointedday are contemplated.

It is to be hoped that as many doctors as are

entitled to benefit from this award will apply to theirexecutive councils for the appropriate claim forms,and will make their claims without delay. Butthese grants, however welcome as short-term relief,are in no way a permanent solution of the problemof enabling the doctor giving diligent service to asmaller-than-average list to earn an adequate income.For one thing they are on a diminishing scale and sogive no lasting help ; for another they apply only

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to established doctors who can prove loss of netincome, and will therefore be of no avail to thenewcomer to practice. The eventual answer willprobably be found to lie in a graded capitation fee,allowing proportionately more for the first 1000(or other agreed figure) on a principal’s list of patients.This seemed to be within reach, and would have beenintroduced if money had been available to augmentthe practitioners’ pool. But even without suchaugmentation the Conference of Local MedicalCommittees must soon consider whether in equityit should not still propose modification of the dis-tribution scheme so as to alleviate the lot of thedoctors in areas where lists are small and static. Thenew grants should be a very present help, but theywill not in themselves banish that sense of hope-lessness and frustration felt by so many who findthemselves working quite as hard as before, and

usually harder, to earn an income which per-sistently remains below their needs. Such men andwomen can fairly expect that ways will be foundto pay them properly for their work. If thiswere done, hardship grants would not be needed,for real hardship would no longer exist.

Aureomycin and GrowthTHE borderland between bacteriology and nutrition

is attracting many investigators these days, and theirfindings seem likely to have valuable practical applica-tions in stock-breeding as well as in medicine. Last

year STOKSTAD and his co-workers 1 in New Yorkreported that the addition to the diet of a factorobtained from cultures of Streptomyces aureofaciens,the organism which produces Aureomycin,’ wouldenhance the growth of chicks receiving a feed withsoybean meal as the source of protein and an adequateamount of vitamin B12. The same effect was observedby others in young pigs 2 and young turkeys.3 Now,at the national meeting of the American ChemicalSociety in Philadelphia, STOKSTAD and JuKES havereported some important further work on this subject.The growth-promoting effect was observed with

whole cultures of the aureomycin-producing mould,with fractions that contained and others that didnot contain aureomycin, and, though less regularly,with crystalline aureomycin in very small quantities- 12 mg. of aureomycin in 1 lb. of food produceda well-marked response. The effect was quite distinctfrom that attributable to vitamin Bi2, which culturesof the mould contain. This was clearly establishedby including adequate amounts of vitamin B12 inthe experimental diets, and also by showing thataureomycin enhanced the growth of animals fed ondiets with fish meal as the source of protein and there-fore rich in "

animal-protein factor," with whichvitamin B12 seems to be identical. In seeking toexplain how aureomycin increased the growth of

young chickens, pigs, and turkeys, STOKSTAD andJUKES observed that the growth response was greatestwhen aureomycin was added to diets providingsuboptimal amounts of vitamin B,2. This led them to

1. Stokstad, E. L. R., Jukes, T. H., Pierce, J. V., Page, A. C. jun.,Franklin, A. L. J. biol. Chem. 1949, 180, 647.

2. Cunha, T. J., Buruside, J. E., Buschman, D. M., Glasscock, R. S.,Pearson, A. M., Shealey, A. L. Arch. Biochem. 1949, 23, 324.

3. McGinnis, J., Stephenson, E. L., Levadie, B. T., Carver, J. S.,Garibaldi, J. A., Ijichi, K., Snell, N. S., Lewis, J. C. Abstr.Amer. chem. Soc. September, 1949, p. 42.

think that aureomycin somehow reduced the animals’requirement for vitamin B12. Following up theobservation of MooxtE et al.,4 that succinylsulpha-thiazole hastened the growth of animals given a syn-thetic diet, STOKSTAD and JuKES confirmed that

succinylsulphathiazole also increased the growth ofchicks given one of their experimental diets, thoughthe response was less than with aureomycin. Byanalogy, therefore, STOKSTAD and JuKES argue thataureomycin may act not by supplying an unknownnutrient but by altering the intestinal microfloraso that a smaller amount of vitamin B12 has to besupplied in the food.The economic importance of this work is clear,

for in 3-4 weeks young, rapidly growing animalsreceiving a small quantity of aureomycin were in mostexperiments 25-50% heavier than those not givenaureomycin. The scientific implications are also

important. Nutrition is a meeting-ground of manyscientific disciplines, and this work is a challenge tothe inadequacy of our understanding of the roleof the intestinal microflora in nutrition. Here theproblem is to devise adequate methods of charac-terising the bacterial population of the intestinaltract, and so identifying the changes that resultfrom alterations in the diet. In this difficult task,as MASSON 5 and NASR 6 demonstrated to the Nutrition

Society at Aberdeen, there is much to be learntfrom the proper use of modern microscopical andhistochemical methods. BAKER has long insistedthat the application of such methods, and an intel-ligent interpretation of their results, is the most

helpful starting-point and an essential control for thecultural and biochemical studies necessary to completeour knowledge of the nutritional consequences of

changes in the intestinal microflora. At presentthese consequences seem more often to be vaguelypostulated than demonstrated.

Protomedicus AnglorumIF the preposterous Austrian title of protomedicus

were revived for England and Wales, the man withthe best claim to it would be, of course, a Scot.Sir WILSON JAMESON, chief medical officer to theMinistries of Health and Education, retired on May 11after ten years’ service covering the most profoundchanges in medical organisation that this countryhas seen. Happily, when he took office in November,1940, at the shortest notice, he had qualifications noteven exceeded by those of his first and most distin-guished forerunner, Sir JOHN SIMON. Well groundedin the practice of local public health through servicein four London boroughs, in his period as dean of theLondon School of Hygiene and Tropical Medicine andprofessor of public health in London University he hadbeen brought into personal touch with both theacademic and administrative sides of medicine to anextent hitherto unknown. Add to that a wide

experience as medical adviser to the Colonial Office(an experience by no means limited to a desk in

Whitehall) ; the co-authorship of the standard text-book on public health ; a gift for establishing har-4. Moore, P. R., Evenson, A., Luckey, T. D., McCoy, E., Elvehjem,

C. A., Hart, E. B. J. biol. Chem. 1946, 165, 437.5. Masson, Marjorie. Brit. J. Nutrition, 1950, 4. Proceedings of the

60th Scientific Meeting of the Nutrition Society (in the press).6. Nasr, Hamed. Ibid (in the press).7. Baker, F., Nasr, H. J. R. microscop. Soc. 1947, 67, 27.