370
BRITISH MEDICAL JOURNAL
heavy-smoking doctors to continue setting a "good example" to the community but also cohorts of graduates who will want the content of medical courses radically changed. This may not be in the profession's best interest. CHARLES CLAOUE Churchill College, Cambridge
The cancer patient: communication and morale SIR,-We note with warmth and interest Dr T B Brewin's article (24-31 December, p 1623) and the subsequent correspondence (21 January, p 178) on this desperately important topic. During last autumn we interviewed a small series of patients with carcinomatosis and, where relevant, their spouses as a project for the general practice part of the clinical curriculum. Our findings were then discussed in a small seminar with other students and doctors. Our patients gave evidence that confirmed our previous impression that full and frank discussion of the diagnosis with both patient and spouse at the same time was eventually warmly appreciated by both sides and facilitated discussion and possibly the effectiveness of symptomatic treatment. Requests for prognosis should be resisted: one patient was still alive and mobile for two years after an outlook of less than three months had been given. Opinion at the subsequent seminar was that the patient's right to know what is wrong should usually override the doctor's very doubtful ability to tell whether the patient is intelligent enough or emotionally strong enough to receive the news. J RossITER Medical student
PETER MOFFITT General practitioner
Bristol
Cimetidine in "chickenpox oesophagitis"
and might therefore be affected by varicella. Another virus, herpes simplex, which typically produces skin vesicles, can also affect the gullet,' and my colleagues in general practice and in infectious diseases hospitals tell me that they have not infrequently encountered retrosternal pain in this illness. Cimetidine is known to be effective in reflux oesophagitis2; I presume I had transient reflux, possibly due to sphincter dysfunction following infection. However, I am unaware of a report on its use in "chickenpox oesophagitis." Perhaps other readers may have come across this condition and have treated it. I would welcome their comments. K D BARDHAN Rotherham Hospital, Rotherham, S Yorks
2
Steisenger, M H, and Fordtran, J S, Gastrointestinal Disease. Philadelphia, Saunders, 1973. Burland, W L, and Simkins, M A, Citnetidine: Proceeditngs of the Second Interniational Symposiul on Histamnine-H5-Receptor Antagotnists. Amsterdam, Excerpta Medica, 1977.
Henry VIII and the NHS SIR,-Mr M J Gilkes in his Personal View (14 January, p 103) makes some interesting comparisons between the present state of the Health Service and the monasteries at the time of their dissolution. I think I can answer some of his queries. In the north at least local people rebelled strongly against these changes. The revolt known as the Pilgrimage of Grace resulted from the dissolution of the smaller monasteries in the north-for example, Sawley. The leaders of this rebellion controlled almost the whole of the north of England and had a greatly superior military strength when they confronted the royal forces at Doncaster. King Henry escaped by agreeing to the rebels' terms and made promises which he never intended to keep. Like other politicians he was more concerned with not being shown to have broken his word than actually keeping it, and the herald who conveyed his promises to the rebels was later executed on a trumped-up charge of treason, a salutary lesson for our negotiators today, who should also remember that this unsuccessful revolt destroyed any hope of preserving the best of the monastic system. There is no evidence that bribery of or co-operation with the establishment saved any of the monasteries, though it might have increased the pensions of some of the "retiring" abbots. Nor did excellent service in the past seem to help; the reason why Ely was saved and Tintern destroyed was that in one case the public at large had a right to use the church and in the other they had not. An excellent example can be seen at Bolton Priory, where the nave alone remains today as a parish church with a solid stone east wall, while the chancel and the rest of the priory are in ruins. The lesson here is that our services to the general public today, and not in the past alone, will count. J S H LODGE
SIR,-I recently had the misfortune to have chickenpox. On the fourth day my general misery was exceeded only by fairly severe retroxiphisternal pain, worsened by lying down. The next day I developed some heartburn; the pain moved higher up and was increased by eating and drinking hot fluids. At this point my cowardice overcame the spirit of scientific inquiry and instead of undergoing endoscopy to confirm a presumed diagnosis of oesophageal involvement by chickenpox vesicles I put myself on cimetidine 1 g daily. The effect was rapid and by the next day I had no pain. Four days later, by which time I had numerous vesicles in my mouth and a sore throat, I stopped the drug. The pain soon returned but disappeared quickly after restarting treatment. A further four days later I was finally able to stop the drug and had no recurrence of the retro- Wetherby, W Yorks
stemal pain. Though I was unable to find any supporting published literature despite computer assistance, it seems quite likely that the oesophagus ban be involved by chickenpox and that it was the cause of my pain. The oesophagus, like the skin, is lined by squamous epithelium
Conciser, but is it nicer? SIR,-Miss Jane Smith, in her admirable account of subediting problems (28 January, p 222), stresses the need for "conciseness."
11 FEBRUARY 1978
Might not "concision" be conciser-and nicer ? PATRICK TREVOR-ROPER London NW1
***Miss Smith replies: "Conciser, yes, but not necessarily nicer. According to the dictionary the primary meaning of concision is 'mutilation' or 'circumcision,' which is not at all what I wanted to suggest."-ED, BMJ. More health education needed
SIR,-During the 30 years of the NHS frequent criticism has been directed at doctors, administrators, and other health workers in their efforts to make the service viable. Intensive antenatal care, early detection of fetal abnormalities, postnatal examination of babies, efficient immunisation, and medical examination of children have all helped to produce a healthier younger generation. Screening procedures have helped in the early detection of disease. Pathological and radiological services have aided diagnosis and modern drugs properly used have produced great advantages in treatment. The doctors and their helpers have done well for the Health Service despite the politicians, but what of the patients? There is disinclination to breast-feed; instead grandma or any other willing helper is left to feed and often overfeed with artificial mixtures while mum goes to work. Schoolchildren return to empty houses, bribed with pocket money which is spent on sweets and fish-and-chips, so starting faulty eating habits. Obesity, smoking, and lack of exercise tend to be corrected only when the first coronary episode has been survived. Painful deformed feet from ill-fitting shoes afflict many women. Lower limb joints ache under the strain of too big a load. I have mentioned only a few of the selfinflicted disabilities, but if only patients took advice as readily as tablets there would be much less cause for criticism of the service. Unfortunately doctors represent only thousands of votes compared with patients' millions, but informed health education could convert the National Disease Service to the National Health Service. LEWIs D RUTTER Leiston, Suffolk
Devolution and the Health Service
SIR,-It is disappointing to read about the controversy surrounding the Scotland Bill on devolution and the alleged effect this may have on abortion availability. Does the BMA really oppose the Scottish Assembly having control of the Health Service in Scotland ? I am a member of the Scottish Council of the BMA and I would not support any attempt to divide up the administration of the service after devolution. I am not in favour of any more devolution at all; I believe it *is economically and politically wrong and in the very short-term financial interest of Scotland, only because of the few years that we shall have North Sea oil. But if we are to have devolution let's have it properly; the Health Service is already suffering from too much administration; attempts to devolve some and not all of it would only add to the difficulties. There will
BRITISH MEDICAL JOURNAL
1 1 FEBRUARY 1978
be many differences between Scottish and English legislation after devolution; surely that is an important part of the concept and abortion is only one of many issues. If there are fears of unilateral traffic flow for abortion let the legislators ensure that the laws are the same in both countries; that is the more logical way to try to ensure that similar services exist throughout what I hope will still be the United Kingdom. R M MILNE Dechmont, W Lothian
***The Scottish Secretary writes: "The Scottish Council of the BMA has considered the Bill not on political but on practical grounds only. It is not expected that devolution as such will advantage the Health Service in Scotland and the Council has urged that remuneration and conditions of service together with standards of health (schedule 10, group 1) should be the same in both England and Scotland. North Sea oil has no relevance."-ED, BM7. SIR,-You report (7 January, p 60) that the Devolution Group of the BMA Scottish Council hopes to amend the Scotland Bill so as "to ensure that the funding of the . . . treatment of . .. mental disorder . . . continues as at present." If this amendment is carried it would seem necessary to bring the hospital provisions for the mentally handicapped in Scotland more into line with those for England if the rest of the Health Service in Scotland is not to suffer. It has recently been proposed that proportionately 500., more hospital beds than in England should be provided, serviced by the appropriate number of general psychiatrists, nurses, etc, thus exacerbating the present inequality in reliance upon the Health Service.' '2 On the assumption that a disproportionate burden is not to continue on the rest of the UK an alternative arrangement would be to provide these extra Health Service provisions through local taxation in Scotland only; it is significant that in your leading article in the same issue (p 1) you point out that "in Scotland local authorities have avoided making any provision at all" in the similar grey area of senile dementia. T L PILKINGTON Mental Handicap Project
(Cleveland), Stockton-on-Tees, Cleveland
Scottish Home and Health Department and Scottish Education Department, Services for the Mentally Handicapped. Edinburgh, SHHD and SED, 1972. 2 Department of Health and Social Security, Better Services for the Mentallv Hanidicapped, Cmnd 4683.
London, HMSO, 1971.
Is your treatment really necessary? SIR,-In the present state of antagenism between the medical profession and the Government there is more need than ever before to demonstrate our professional responsibilities and concern over national problems. Because of the national need to control inflation and keep expenses down all over the country there are regional, area, and district committees that include doctors striving and scraping to cut their expenditure. Building programmes are being scrapped, staff is being reduced, and administrative economies are
being made. Doctors' clinical actions and behaviour appear to be sacrosanct and have not been interfered with and clinical freedom still reigns. Surely it is time for the medical profession to examine what is going on clinically within the NHS to arrive at priorities on what is necessary, what is useful, and what is useless and unnecessary. For example, with prescribing costs by general practitioners in 1977 at about L500m or L20 000 per GP it is only right that a critical evaluation be made of the true needs and benefits of such expensive medication. The number of persons attending our hospitals is increasing annually; 1 1 % of our population are admitted, 16 ' are referred to outpatient departments for the first time (probably as many are reattending), and 20% attend accident and emergency departments each year. Are all their admissions and visits really necessary? The use of diagnostic radiology and pathology is going up, up, and up annually, to what real purpose ? Some of the intensive and extensive care received in our hospitals today is truly amazing. It is by no means unusual for old persons (and they are a growing proportion of inpatients) to be referred back to their GPs with no fewer than six different sets of pills for conditions which scarcely need treatment at their age, let alone exposing them to confusion over taking them and risking unpleasant side effects. Are all reattendances at outpatient departments really necessary ? Particularly when the patient is seen by a different junior doctor each time. Sooner or later someone is going to question what we do. Surely it is better that we do the questioning and correcting than leave it to outsiders. JOHN FRY Beckenham, Kent
Wasted women doctors
SIR,-Although Dr Peter Richards (14 January, p 95) and Dr Anne Gruneberg (28 January, p 239) are to be congratulated for their welljustified plea to rearrange NHS careers structure in order to avoid the senseless and costly wastage of medical womanpower, there is one important omission in their arguments. The need to create part-time posts and training facilities arises largely from the fact that child-rearing is both regarded and designated as an entirely female task. Yet there are many fathers who would wish to participate further in the upbringing of their children and who would also benefit from a more humanely organised career structure that would enable both fathers and mothers to take time off to be with their family. This applies in particular to the majority of hospital doctors, who, because of long working hours, miss so much of their children's early development. It is right to press for part-time posts, but if we continue to regard them as the sole preserve of women doctors we could well be creating a new generation of second-class doctors who will always be regarded as less equal than others. One of the simplest and most important means of generating equality of job opportunity in the Health Service is to provide child care facilities in all hospitals and health centres. This would enable both men and women working in the Health Service to spend a full working day if they wished without the inevitable feeling of guilt over "abandoning" their children at home. It is incongruous
371
at the very least that the Health Service, which is ostensibly devoted to the preservation of the health of the British family, should be among the slowest to respond to the fundamental need for child care provisions. We of the Middlesex Hospital Women and Health Group are campaigning for such facilities to be made available to all NHS employees on the hospital premises. We would be pleased to receive information from any hospital that already provides such a service. BOBBIE JACOBSON Convener, Middlesex Hospital WHG Middlesex Hospital Medical School London WI
Redundant doctors SIR,-Your leading article under this heading (21 January, p 131) prompts me to ask what the profession intends to do about clarifying the matter of when a doctor's training is complete. As it is the senior members of our profession who are responsible for appointments to consultant grade, presumably they are the people who decide when training is complete. The Department of Health and Social Security is not involved in this decision, My observations on Merseyside over the years lead me to believe that this decision is entirely arbitrary. There are consultants with no experience at senior registrar level, while senior registrars with over five years' experience are passed over for the same appointments. Surely it is time for the profession to put its house in order and institute a proper career structure with security of tenure for senior registrars. Obviously such changes would take time to implement and could not assist Dr Baksi in his present predicament. As a colleague of Dr Baksi I would make the comment that, as he has had the courage to put the Employment Protection Act to the test on behalf of the profession, surely it would be opportune for the profession to recognise his contribution by ensuring that justice is seen to be done. B A B THURLOW Aughton, nr Ormskirk, Lancs
Appointments in Iran SIR,-We have received disquieting reports about the conditions of employment of some doctors who have been recruited to work in Iran. The purpose of this letter is to alert any other doctors who may be contemplating going to work in that country in the near future. Before accepting any appointments with the Government of Iran medical practitioners are advised to communicate with me. I cannot stress too strongly the importance of obtaining a clear statement of terms and conditions of service in writing before accepting overseas appointments, and members should seek the advice of the Association before they depart from this country. They should also register with the British Consulate on arrival. E GREY-TURNER Secretary, BMA BMA House, London WC1
BRITISH MEDICAL JOURNAL
heavy-smoking doctors to continue setting a "good example" to the community but also cohorts of graduates who will want the content of medical courses radically changed. This may not be in the profession's best interest. CHARLES CLAOUE Churchill College, Cambridge
The cancer patient: communication and morale SIR,-We note with warmth and interest Dr T B Brewin's article (24-31 December, p 1623) and the subsequent correspondence (21 January, p 178) on this desperately important topic. During last autumn we interviewed a small series of patients with carcinomatosis and, where relevant, their spouses as a project for the general practice part of the clinical curriculum. Our findings were then discussed in a small seminar with other students and doctors. Our patients gave evidence that confirmed our previous impression that full and frank discussion of the diagnosis with both patient and spouse at the same time was eventually warmly appreciated by both sides and facilitated discussion and possibly the effectiveness of symptomatic treatment. Requests for prognosis should be resisted: one patient was still alive and mobile for two years after an outlook of less than three months had been given. Opinion at the subsequent seminar was that the patient's right to know what is wrong should usually override the doctor's very doubtful ability to tell whether the patient is intelligent enough or emotionally strong enough to receive the news. J RossITER Medical student
PETER MOFFITT General practitioner
Bristol
Cimetidine in "chickenpox oesophagitis"
and might therefore be affected by varicella. Another virus, herpes simplex, which typically produces skin vesicles, can also affect the gullet,' and my colleagues in general practice and in infectious diseases hospitals tell me that they have not infrequently encountered retrosternal pain in this illness. Cimetidine is known to be effective in reflux oesophagitis2; I presume I had transient reflux, possibly due to sphincter dysfunction following infection. However, I am unaware of a report on its use in "chickenpox oesophagitis." Perhaps other readers may have come across this condition and have treated it. I would welcome their comments. K D BARDHAN Rotherham Hospital, Rotherham, S Yorks
2
Steisenger, M H, and Fordtran, J S, Gastrointestinal Disease. Philadelphia, Saunders, 1973. Burland, W L, and Simkins, M A, Citnetidine: Proceeditngs of the Second Interniational Symposiul on Histamnine-H5-Receptor Antagotnists. Amsterdam, Excerpta Medica, 1977.
Henry VIII and the NHS SIR,-Mr M J Gilkes in his Personal View (14 January, p 103) makes some interesting comparisons between the present state of the Health Service and the monasteries at the time of their dissolution. I think I can answer some of his queries. In the north at least local people rebelled strongly against these changes. The revolt known as the Pilgrimage of Grace resulted from the dissolution of the smaller monasteries in the north-for example, Sawley. The leaders of this rebellion controlled almost the whole of the north of England and had a greatly superior military strength when they confronted the royal forces at Doncaster. King Henry escaped by agreeing to the rebels' terms and made promises which he never intended to keep. Like other politicians he was more concerned with not being shown to have broken his word than actually keeping it, and the herald who conveyed his promises to the rebels was later executed on a trumped-up charge of treason, a salutary lesson for our negotiators today, who should also remember that this unsuccessful revolt destroyed any hope of preserving the best of the monastic system. There is no evidence that bribery of or co-operation with the establishment saved any of the monasteries, though it might have increased the pensions of some of the "retiring" abbots. Nor did excellent service in the past seem to help; the reason why Ely was saved and Tintern destroyed was that in one case the public at large had a right to use the church and in the other they had not. An excellent example can be seen at Bolton Priory, where the nave alone remains today as a parish church with a solid stone east wall, while the chancel and the rest of the priory are in ruins. The lesson here is that our services to the general public today, and not in the past alone, will count. J S H LODGE
SIR,-I recently had the misfortune to have chickenpox. On the fourth day my general misery was exceeded only by fairly severe retroxiphisternal pain, worsened by lying down. The next day I developed some heartburn; the pain moved higher up and was increased by eating and drinking hot fluids. At this point my cowardice overcame the spirit of scientific inquiry and instead of undergoing endoscopy to confirm a presumed diagnosis of oesophageal involvement by chickenpox vesicles I put myself on cimetidine 1 g daily. The effect was rapid and by the next day I had no pain. Four days later, by which time I had numerous vesicles in my mouth and a sore throat, I stopped the drug. The pain soon returned but disappeared quickly after restarting treatment. A further four days later I was finally able to stop the drug and had no recurrence of the retro- Wetherby, W Yorks
stemal pain. Though I was unable to find any supporting published literature despite computer assistance, it seems quite likely that the oesophagus ban be involved by chickenpox and that it was the cause of my pain. The oesophagus, like the skin, is lined by squamous epithelium
Conciser, but is it nicer? SIR,-Miss Jane Smith, in her admirable account of subediting problems (28 January, p 222), stresses the need for "conciseness."
11 FEBRUARY 1978
Might not "concision" be conciser-and nicer ? PATRICK TREVOR-ROPER London NW1
***Miss Smith replies: "Conciser, yes, but not necessarily nicer. According to the dictionary the primary meaning of concision is 'mutilation' or 'circumcision,' which is not at all what I wanted to suggest."-ED, BMJ. More health education needed
SIR,-During the 30 years of the NHS frequent criticism has been directed at doctors, administrators, and other health workers in their efforts to make the service viable. Intensive antenatal care, early detection of fetal abnormalities, postnatal examination of babies, efficient immunisation, and medical examination of children have all helped to produce a healthier younger generation. Screening procedures have helped in the early detection of disease. Pathological and radiological services have aided diagnosis and modern drugs properly used have produced great advantages in treatment. The doctors and their helpers have done well for the Health Service despite the politicians, but what of the patients? There is disinclination to breast-feed; instead grandma or any other willing helper is left to feed and often overfeed with artificial mixtures while mum goes to work. Schoolchildren return to empty houses, bribed with pocket money which is spent on sweets and fish-and-chips, so starting faulty eating habits. Obesity, smoking, and lack of exercise tend to be corrected only when the first coronary episode has been survived. Painful deformed feet from ill-fitting shoes afflict many women. Lower limb joints ache under the strain of too big a load. I have mentioned only a few of the selfinflicted disabilities, but if only patients took advice as readily as tablets there would be much less cause for criticism of the service. Unfortunately doctors represent only thousands of votes compared with patients' millions, but informed health education could convert the National Disease Service to the National Health Service. LEWIs D RUTTER Leiston, Suffolk
Devolution and the Health Service
SIR,-It is disappointing to read about the controversy surrounding the Scotland Bill on devolution and the alleged effect this may have on abortion availability. Does the BMA really oppose the Scottish Assembly having control of the Health Service in Scotland ? I am a member of the Scottish Council of the BMA and I would not support any attempt to divide up the administration of the service after devolution. I am not in favour of any more devolution at all; I believe it *is economically and politically wrong and in the very short-term financial interest of Scotland, only because of the few years that we shall have North Sea oil. But if we are to have devolution let's have it properly; the Health Service is already suffering from too much administration; attempts to devolve some and not all of it would only add to the difficulties. There will
BRITISH MEDICAL JOURNAL
1 1 FEBRUARY 1978
be many differences between Scottish and English legislation after devolution; surely that is an important part of the concept and abortion is only one of many issues. If there are fears of unilateral traffic flow for abortion let the legislators ensure that the laws are the same in both countries; that is the more logical way to try to ensure that similar services exist throughout what I hope will still be the United Kingdom. R M MILNE Dechmont, W Lothian
***The Scottish Secretary writes: "The Scottish Council of the BMA has considered the Bill not on political but on practical grounds only. It is not expected that devolution as such will advantage the Health Service in Scotland and the Council has urged that remuneration and conditions of service together with standards of health (schedule 10, group 1) should be the same in both England and Scotland. North Sea oil has no relevance."-ED, BM7. SIR,-You report (7 January, p 60) that the Devolution Group of the BMA Scottish Council hopes to amend the Scotland Bill so as "to ensure that the funding of the . . . treatment of . .. mental disorder . . . continues as at present." If this amendment is carried it would seem necessary to bring the hospital provisions for the mentally handicapped in Scotland more into line with those for England if the rest of the Health Service in Scotland is not to suffer. It has recently been proposed that proportionately 500., more hospital beds than in England should be provided, serviced by the appropriate number of general psychiatrists, nurses, etc, thus exacerbating the present inequality in reliance upon the Health Service.' '2 On the assumption that a disproportionate burden is not to continue on the rest of the UK an alternative arrangement would be to provide these extra Health Service provisions through local taxation in Scotland only; it is significant that in your leading article in the same issue (p 1) you point out that "in Scotland local authorities have avoided making any provision at all" in the similar grey area of senile dementia. T L PILKINGTON Mental Handicap Project
(Cleveland), Stockton-on-Tees, Cleveland
Scottish Home and Health Department and Scottish Education Department, Services for the Mentally Handicapped. Edinburgh, SHHD and SED, 1972. 2 Department of Health and Social Security, Better Services for the Mentallv Hanidicapped, Cmnd 4683.
London, HMSO, 1971.
Is your treatment really necessary? SIR,-In the present state of antagenism between the medical profession and the Government there is more need than ever before to demonstrate our professional responsibilities and concern over national problems. Because of the national need to control inflation and keep expenses down all over the country there are regional, area, and district committees that include doctors striving and scraping to cut their expenditure. Building programmes are being scrapped, staff is being reduced, and administrative economies are
being made. Doctors' clinical actions and behaviour appear to be sacrosanct and have not been interfered with and clinical freedom still reigns. Surely it is time for the medical profession to examine what is going on clinically within the NHS to arrive at priorities on what is necessary, what is useful, and what is useless and unnecessary. For example, with prescribing costs by general practitioners in 1977 at about L500m or L20 000 per GP it is only right that a critical evaluation be made of the true needs and benefits of such expensive medication. The number of persons attending our hospitals is increasing annually; 1 1 % of our population are admitted, 16 ' are referred to outpatient departments for the first time (probably as many are reattending), and 20% attend accident and emergency departments each year. Are all their admissions and visits really necessary? The use of diagnostic radiology and pathology is going up, up, and up annually, to what real purpose ? Some of the intensive and extensive care received in our hospitals today is truly amazing. It is by no means unusual for old persons (and they are a growing proportion of inpatients) to be referred back to their GPs with no fewer than six different sets of pills for conditions which scarcely need treatment at their age, let alone exposing them to confusion over taking them and risking unpleasant side effects. Are all reattendances at outpatient departments really necessary ? Particularly when the patient is seen by a different junior doctor each time. Sooner or later someone is going to question what we do. Surely it is better that we do the questioning and correcting than leave it to outsiders. JOHN FRY Beckenham, Kent
Wasted women doctors
SIR,-Although Dr Peter Richards (14 January, p 95) and Dr Anne Gruneberg (28 January, p 239) are to be congratulated for their welljustified plea to rearrange NHS careers structure in order to avoid the senseless and costly wastage of medical womanpower, there is one important omission in their arguments. The need to create part-time posts and training facilities arises largely from the fact that child-rearing is both regarded and designated as an entirely female task. Yet there are many fathers who would wish to participate further in the upbringing of their children and who would also benefit from a more humanely organised career structure that would enable both fathers and mothers to take time off to be with their family. This applies in particular to the majority of hospital doctors, who, because of long working hours, miss so much of their children's early development. It is right to press for part-time posts, but if we continue to regard them as the sole preserve of women doctors we could well be creating a new generation of second-class doctors who will always be regarded as less equal than others. One of the simplest and most important means of generating equality of job opportunity in the Health Service is to provide child care facilities in all hospitals and health centres. This would enable both men and women working in the Health Service to spend a full working day if they wished without the inevitable feeling of guilt over "abandoning" their children at home. It is incongruous
371
at the very least that the Health Service, which is ostensibly devoted to the preservation of the health of the British family, should be among the slowest to respond to the fundamental need for child care provisions. We of the Middlesex Hospital Women and Health Group are campaigning for such facilities to be made available to all NHS employees on the hospital premises. We would be pleased to receive information from any hospital that already provides such a service. BOBBIE JACOBSON Convener, Middlesex Hospital WHG Middlesex Hospital Medical School London WI
Redundant doctors SIR,-Your leading article under this heading (21 January, p 131) prompts me to ask what the profession intends to do about clarifying the matter of when a doctor's training is complete. As it is the senior members of our profession who are responsible for appointments to consultant grade, presumably they are the people who decide when training is complete. The Department of Health and Social Security is not involved in this decision, My observations on Merseyside over the years lead me to believe that this decision is entirely arbitrary. There are consultants with no experience at senior registrar level, while senior registrars with over five years' experience are passed over for the same appointments. Surely it is time for the profession to put its house in order and institute a proper career structure with security of tenure for senior registrars. Obviously such changes would take time to implement and could not assist Dr Baksi in his present predicament. As a colleague of Dr Baksi I would make the comment that, as he has had the courage to put the Employment Protection Act to the test on behalf of the profession, surely it would be opportune for the profession to recognise his contribution by ensuring that justice is seen to be done. B A B THURLOW Aughton, nr Ormskirk, Lancs
Appointments in Iran SIR,-We have received disquieting reports about the conditions of employment of some doctors who have been recruited to work in Iran. The purpose of this letter is to alert any other doctors who may be contemplating going to work in that country in the near future. Before accepting any appointments with the Government of Iran medical practitioners are advised to communicate with me. I cannot stress too strongly the importance of obtaining a clear statement of terms and conditions of service in writing before accepting overseas appointments, and members should seek the advice of the Association before they depart from this country. They should also register with the British Consulate on arrival. E GREY-TURNER Secretary, BMA BMA House, London WC1
