1418
comparable use of a topical sensitiser in modern immunotherapy was in 1968.3 Just as with dinitrochlorobenzene sensitisation,’the Indians used an initial sensitisThe first
tumour
ing dose followed by several challenge doses of the allergen to obtain a remission. Thus we find that the Indians empirically discovered tumour immunology and succeeded in augmenting the host response to a resident neoplasm. In our pride about modern medical accomplishments, we should not forget what sophisticated observers the California Indians were. We are not so advanced that we can afford to ignore the truths gleaned from Nature by those attuned to their natural surroundings. Department of Dermatology, University of California School of Medicine, San Francisco, California, U.S.A.
PETER M. ELIAS
4. Ratner, A. C., Waldorf, D. S., Van Scott, E. J. Cancer, 1968, 21, 83. 5. Catalona, W. J., Taylor, P. T., Rabson, A. S., Chretien, P. B. New J. Med 1972, 286, 399.
Engl.
Commentary from Westminster The Court
Report
FROM A CORRESPONDENT
IT was 1972 when Sir Keith Joseph, the then Social Services Secretary, and Mrs Margaret Thatcher, the then Education Secretary, announced the Government’s intention of setting up a committee to review childhealth services in England and Wales. Since then they have moved on and their Government has moved out. But the committee under Professor Donald Court has been burrowing away and last week its report was published-a massive two-volume document of 669 pages and 232 recommendations. But the intervening four years have seen a sharp change in Britain’s economic climate which alters sharply the background against which this report must be seen. For Professor Court and his colleagues have proposed a thorough reshaping of health services, which they admit would add considerably to the burden on the resources of the National Health Service. Their recommendations, they say, must be taken as a long-term programme, which they define as covering 15-20 years. But they urge the Government to reach an early decision on their key proposals. The report points to spectacular improvements in the health of children this century but nevertheless expresses "profound anxiety" about many aspects of the present state of child health. In particular it mentions: Britain’s failure to keep pace with many other countries in lowering the infant-mortality rate; evidence which suggests that one child in seven has a condition causing moderate or severe handicap sufficient to be a cause of concern in the child’s education; dental decay affecting more than two-thirds of children by the age of five; and the variations in regional services which have remained much the same since 1948. Though the committee accepts the traditional pattern of health services, with first-line care by family doctors, home nurses, and health visitors, it is not convinced that prevention and treatment are going hand in hand. It is neither logical nor in the best interests of children and 1. Fit for the Future.
Report
of the committee on Child Health Services. H. M.
Stationery Office. Cmnd 6684. Vol. 1, pp. 448, £6.50.
Vol 2, pp. 222,
£4.
their families to have prevention and treatment provided by different services, with family doctors giving treatment while other doctors, employed by health authorities and working in separate clinics, survey the health and development of babies and, young children. The report refers to a groundswell of dissatisfaction among parents with many features of health care, as well as a general feeling of uncertainty and disquiet about the relationships between parents and professionals. Too often parents feel themselves passive bystanders rather than active partners in the care of their children. The committee’s answer is an integrated service which follows the child’s development from the early pre-school years, through school and adolescence. Central to this is the proposal for extended training for doctors and nurses and the establishment of primary healthcare teams providing 24-hour first-contact and continuing therapeutic and preventive care for children. The report envisages a new kind of G.P., called a G.P.P. (general-practitioner paediatrician), specialising in children’s health as well as being responsible for health checks on pre-school children and acting as school doctor to one or more local schools. Working with the G.P.P.S would be child-health visitors, another new post suggested by the committee, who would help parents with the nursing of a sick child in the home as well as providing advice on growth and development and the prevention of illness. Asking itself why the idea of G.P.s providing comprehensive care for children has been advocated for 25 years but never implemented, the committee finds the explanations in a failure to define the professional responsibilities involved, to provide the necessary training, and to offer adequate remuneration for the additional services. The committee is anxious lest the same fate should not await its proposals. As for hospital services, the report proposes the establishment of consultant community paediatricians, one in each health district. They would act as consultant to the G.P.P.s and they would have special skills in developmental, social, and educational paediatrics. With this new pattern of G.P.P.s and child-health visitors, the primary health-care team is expected to be able to provide a more skilled service for handicapped children at primary-care level. Although the committee argues that health services for handicapped children should not be separated from those services which all children receive through school life, it calls for special handicap teams to be set up in each district based on the district general hospital. The fluoridation controversy is likely to be revived by the committee’s enthusiastic demand for the Government to take immediate steps to introduce fluoridation on a national scale "if necessary with new legislation". The report describes dental decay as the most prevalent disease in our society, children being much more susceptible than adults, and it declares that if dental caries killed, fluoridation would have been mandatory for 20 years. The committee cannot be accused of not facing up to the considerable manpower requirements which its recommendations would probably involve. It indicates that these would amount to an extra 2000 doctors, 8000 health visitors, 4000 child-health nurses, and 3000 school nurses. But the committee insists that the 1974
1419
reorganisation of the N.H.S. has introduced an element of urgency into the situation. The preventive childhealth services are described as less than adequate and facing increasing problems in medical recruitment. "The preventive health services for children cannot be allowed to wither away", pleads the report. But, realising that its uninhibited recommendations may have to await Britain’s economic recovery, the committee sets out its own order of priorities for action. Top of the list is the reorganisation and staffing of the primary-care services for children at the earliest possible moment. In order of priority come the appointment of child-health visitors, since even now they need to be increased by 50%, and of general-practitioner paediatricians, and a progressive provision of consultant community paediatricians. And just to jog Government support the report concludes by pointing out that its priority recommendations are in line with the Government’s own proposals in its priorities document. Reaction from the Conservatives to the report was concerned with the considerable amount of resources it would require. Dr Gerard Vaughan, an Opposition spokesman on health, believed that too much legislation had recently been implemented without the necessary resources and he hoped the Government would not start to legislate on the Court proposals until it had looked very closely at what the total cost would be. He feared an unnecessary bureaucracy would result from the appointment of consultant
community paediatricians.
Obituary M.D.
THOMAS NEILLSON FRASER Glasg., F.R.C.P., F.R.C.P.E., F.R.C.P.G.
Dr T. N. Fraser, formerly senior consultant physician in the Western Infirmary, Glasgow, died on Dec. 2 at the age of 66. Born in Glasgow, he was educated at Glasgow Academy and Morrison’s Academy, Crieff. He studied medicine at Glasgow University, graduating M.B. in 1933, and M.D. in 1948. He was awarded his colours in both cricket and rugby at the university. In 1932 he was awarded the Royal Humane Society Certificate for Bravery for saving a woman from drowning. After house-officer posts, he was appointed Hall fellow in the Glasgow University department of medicine in the Western Infirmary, and was later appointed to the staff. He pursued his research interests in rheumatology and in 1946 was elected member of the Heberden Society; he was a founder member of the Scottish Society of Physicians. He performed much fundamental research in rheumatology and was responsible for the first controlled trial of gold therapy in rheumatoid arthritis. He was appointed consultant physician to the Western Infirmary at the inception of the National Health Service in 1948, and was appointed to administrative charge of wards in the Western Infirmary in 1955. He served for some years on the Board of Management of the Western Infirmary. In addition, he established the rheumatology unit in Killearn Hospital. He had been senior consultant physician to the Western Infirmary for several years at the time of his retirement in March, 1975. Dr Fraser was an unassuming man who endeared himself to his colleagues by his integrity, his kindly ways, and his quiet sense of humour. He was a wise teacher and a gifted physician, who never failed to treat his patients as individuals. He is survived by his wife and a daughter and a son. R.T.S.G.
Notes and News
M. D. EUROPE MUTUAL recognition of medical qualifications in the European Economic Community officially came into force on Dec. 19, though in practice unresolved difficulties over matters such as linguistic proficiency may hold up the process. In the U.K. the necessary Order in Council has not yet been approved. The freedom of movement is granted to nationals of a member State with a basic medical qualification acquired in a member State, but to no-one else. The documentation required is formidable. So far 300 inquiries have been received, and there have been 25 firm applications for specialist certificates from the General Medical Council. The E.E.C. could be heading for a surplus of doctors in the 1980s, but this is clearly not going to deter the British Medical Association from using European salary differentials as a bargaining point in negotiations with Government. The B.M.A.’s European experts in London last week spoke of substantial emigration by specialists if N.H.S. terms and conditions of service were not improved. The doctors are the first in a q1 tue of forty professions for whom similar freedoms are being regotiated: hard on their heels are barristers, architects, nurses, midwives, and dentists. MORE N.H.S. CUTS THE
of State for Social Services, Mr David on the pre-Christmas Budget as -it affects the National Health Service. The public-expenditure white-paper published last February set the hospital and community health services capital programme for England at about £280 million for both 1977-78 and 1978-79. The cuts announced in July reduced the programme for 1977-78 by £14 million, and the December measures include a further cut of £8½million in 1977-78 and D4 million in 1978-79. Every scheme already started will continue, but many major projects due to start next year will have to be postponed. Reductions in non-capital N.H.S. expenditure will be £4 200 000 in 1977-78 and 4 300 000 in 1978-79: "These cuts will not directly affect services to patients. They will be achieved by economies in the drugs bill and by continuing efforts to get better value for money in the N.H.S.."
Secretary
Ennals, has expanded
INDUSTRIAL BLADDER CANCER IDENTIFICATION of bladder carcinogens, withdrawal from of products containing them, action under the Industrial Injuries Act and Carcinogenic Substances Act, and monitoring of workers still at risk might be thought to complete a chapter in occupational medicine. However, Fox and Collier’s work suggests that this story is not yet over.Men who worked in factories which never used bladder carcinogens or who joined such factories on Jan. 1, 1950, or later ought not to be at risk of cancer of the bladder, but they are. A significant excess of deaths due to all cancers was picked up in an earlier study of 40 867 men, 2271 of whom died in the years 1967-712.= The excess was significant for lung and stomach,’ but not bladder: follow-up to 1972-741 confirms the lungcancer findings, denies the increase in gastric cancer, and introduces a significant excess for carcinoma of the bladder. The excesses were significant for men who had worked in carcinogen-using industries and for newcomers to former users, the standardised mortality ratio being of the order of 200 in each case (as it was, though not significantly, in men working in factories never using bladder carcinogens). The problem seems to
manufacturing industry
1. Fox, A. 2. Fox, A.
J., Collier, P. F. Br. J. ind. J., Lindars, D. C., Owen, R.
Med. 1976, 33, 249. ibid. 1974, 31, 140.
comparable use of a topical sensitiser in modern immunotherapy was in 1968.3 Just as with dinitrochlorobenzene sensitisation,’the Indians used an initial sensitisThe first
tumour
ing dose followed by several challenge doses of the allergen to obtain a remission. Thus we find that the Indians empirically discovered tumour immunology and succeeded in augmenting the host response to a resident neoplasm. In our pride about modern medical accomplishments, we should not forget what sophisticated observers the California Indians were. We are not so advanced that we can afford to ignore the truths gleaned from Nature by those attuned to their natural surroundings. Department of Dermatology, University of California School of Medicine, San Francisco, California, U.S.A.
PETER M. ELIAS
4. Ratner, A. C., Waldorf, D. S., Van Scott, E. J. Cancer, 1968, 21, 83. 5. Catalona, W. J., Taylor, P. T., Rabson, A. S., Chretien, P. B. New J. Med 1972, 286, 399.
Engl.
Commentary from Westminster The Court
Report
FROM A CORRESPONDENT
IT was 1972 when Sir Keith Joseph, the then Social Services Secretary, and Mrs Margaret Thatcher, the then Education Secretary, announced the Government’s intention of setting up a committee to review childhealth services in England and Wales. Since then they have moved on and their Government has moved out. But the committee under Professor Donald Court has been burrowing away and last week its report was published-a massive two-volume document of 669 pages and 232 recommendations. But the intervening four years have seen a sharp change in Britain’s economic climate which alters sharply the background against which this report must be seen. For Professor Court and his colleagues have proposed a thorough reshaping of health services, which they admit would add considerably to the burden on the resources of the National Health Service. Their recommendations, they say, must be taken as a long-term programme, which they define as covering 15-20 years. But they urge the Government to reach an early decision on their key proposals. The report points to spectacular improvements in the health of children this century but nevertheless expresses "profound anxiety" about many aspects of the present state of child health. In particular it mentions: Britain’s failure to keep pace with many other countries in lowering the infant-mortality rate; evidence which suggests that one child in seven has a condition causing moderate or severe handicap sufficient to be a cause of concern in the child’s education; dental decay affecting more than two-thirds of children by the age of five; and the variations in regional services which have remained much the same since 1948. Though the committee accepts the traditional pattern of health services, with first-line care by family doctors, home nurses, and health visitors, it is not convinced that prevention and treatment are going hand in hand. It is neither logical nor in the best interests of children and 1. Fit for the Future.
Report
of the committee on Child Health Services. H. M.
Stationery Office. Cmnd 6684. Vol. 1, pp. 448, £6.50.
Vol 2, pp. 222,
£4.
their families to have prevention and treatment provided by different services, with family doctors giving treatment while other doctors, employed by health authorities and working in separate clinics, survey the health and development of babies and, young children. The report refers to a groundswell of dissatisfaction among parents with many features of health care, as well as a general feeling of uncertainty and disquiet about the relationships between parents and professionals. Too often parents feel themselves passive bystanders rather than active partners in the care of their children. The committee’s answer is an integrated service which follows the child’s development from the early pre-school years, through school and adolescence. Central to this is the proposal for extended training for doctors and nurses and the establishment of primary healthcare teams providing 24-hour first-contact and continuing therapeutic and preventive care for children. The report envisages a new kind of G.P., called a G.P.P. (general-practitioner paediatrician), specialising in children’s health as well as being responsible for health checks on pre-school children and acting as school doctor to one or more local schools. Working with the G.P.P.S would be child-health visitors, another new post suggested by the committee, who would help parents with the nursing of a sick child in the home as well as providing advice on growth and development and the prevention of illness. Asking itself why the idea of G.P.s providing comprehensive care for children has been advocated for 25 years but never implemented, the committee finds the explanations in a failure to define the professional responsibilities involved, to provide the necessary training, and to offer adequate remuneration for the additional services. The committee is anxious lest the same fate should not await its proposals. As for hospital services, the report proposes the establishment of consultant community paediatricians, one in each health district. They would act as consultant to the G.P.P.s and they would have special skills in developmental, social, and educational paediatrics. With this new pattern of G.P.P.s and child-health visitors, the primary health-care team is expected to be able to provide a more skilled service for handicapped children at primary-care level. Although the committee argues that health services for handicapped children should not be separated from those services which all children receive through school life, it calls for special handicap teams to be set up in each district based on the district general hospital. The fluoridation controversy is likely to be revived by the committee’s enthusiastic demand for the Government to take immediate steps to introduce fluoridation on a national scale "if necessary with new legislation". The report describes dental decay as the most prevalent disease in our society, children being much more susceptible than adults, and it declares that if dental caries killed, fluoridation would have been mandatory for 20 years. The committee cannot be accused of not facing up to the considerable manpower requirements which its recommendations would probably involve. It indicates that these would amount to an extra 2000 doctors, 8000 health visitors, 4000 child-health nurses, and 3000 school nurses. But the committee insists that the 1974
1419
reorganisation of the N.H.S. has introduced an element of urgency into the situation. The preventive childhealth services are described as less than adequate and facing increasing problems in medical recruitment. "The preventive health services for children cannot be allowed to wither away", pleads the report. But, realising that its uninhibited recommendations may have to await Britain’s economic recovery, the committee sets out its own order of priorities for action. Top of the list is the reorganisation and staffing of the primary-care services for children at the earliest possible moment. In order of priority come the appointment of child-health visitors, since even now they need to be increased by 50%, and of general-practitioner paediatricians, and a progressive provision of consultant community paediatricians. And just to jog Government support the report concludes by pointing out that its priority recommendations are in line with the Government’s own proposals in its priorities document. Reaction from the Conservatives to the report was concerned with the considerable amount of resources it would require. Dr Gerard Vaughan, an Opposition spokesman on health, believed that too much legislation had recently been implemented without the necessary resources and he hoped the Government would not start to legislate on the Court proposals until it had looked very closely at what the total cost would be. He feared an unnecessary bureaucracy would result from the appointment of consultant
community paediatricians.
Obituary M.D.
THOMAS NEILLSON FRASER Glasg., F.R.C.P., F.R.C.P.E., F.R.C.P.G.
Dr T. N. Fraser, formerly senior consultant physician in the Western Infirmary, Glasgow, died on Dec. 2 at the age of 66. Born in Glasgow, he was educated at Glasgow Academy and Morrison’s Academy, Crieff. He studied medicine at Glasgow University, graduating M.B. in 1933, and M.D. in 1948. He was awarded his colours in both cricket and rugby at the university. In 1932 he was awarded the Royal Humane Society Certificate for Bravery for saving a woman from drowning. After house-officer posts, he was appointed Hall fellow in the Glasgow University department of medicine in the Western Infirmary, and was later appointed to the staff. He pursued his research interests in rheumatology and in 1946 was elected member of the Heberden Society; he was a founder member of the Scottish Society of Physicians. He performed much fundamental research in rheumatology and was responsible for the first controlled trial of gold therapy in rheumatoid arthritis. He was appointed consultant physician to the Western Infirmary at the inception of the National Health Service in 1948, and was appointed to administrative charge of wards in the Western Infirmary in 1955. He served for some years on the Board of Management of the Western Infirmary. In addition, he established the rheumatology unit in Killearn Hospital. He had been senior consultant physician to the Western Infirmary for several years at the time of his retirement in March, 1975. Dr Fraser was an unassuming man who endeared himself to his colleagues by his integrity, his kindly ways, and his quiet sense of humour. He was a wise teacher and a gifted physician, who never failed to treat his patients as individuals. He is survived by his wife and a daughter and a son. R.T.S.G.
Notes and News
M. D. EUROPE MUTUAL recognition of medical qualifications in the European Economic Community officially came into force on Dec. 19, though in practice unresolved difficulties over matters such as linguistic proficiency may hold up the process. In the U.K. the necessary Order in Council has not yet been approved. The freedom of movement is granted to nationals of a member State with a basic medical qualification acquired in a member State, but to no-one else. The documentation required is formidable. So far 300 inquiries have been received, and there have been 25 firm applications for specialist certificates from the General Medical Council. The E.E.C. could be heading for a surplus of doctors in the 1980s, but this is clearly not going to deter the British Medical Association from using European salary differentials as a bargaining point in negotiations with Government. The B.M.A.’s European experts in London last week spoke of substantial emigration by specialists if N.H.S. terms and conditions of service were not improved. The doctors are the first in a q1 tue of forty professions for whom similar freedoms are being regotiated: hard on their heels are barristers, architects, nurses, midwives, and dentists. MORE N.H.S. CUTS THE
of State for Social Services, Mr David on the pre-Christmas Budget as -it affects the National Health Service. The public-expenditure white-paper published last February set the hospital and community health services capital programme for England at about £280 million for both 1977-78 and 1978-79. The cuts announced in July reduced the programme for 1977-78 by £14 million, and the December measures include a further cut of £8½million in 1977-78 and D4 million in 1978-79. Every scheme already started will continue, but many major projects due to start next year will have to be postponed. Reductions in non-capital N.H.S. expenditure will be £4 200 000 in 1977-78 and 4 300 000 in 1978-79: "These cuts will not directly affect services to patients. They will be achieved by economies in the drugs bill and by continuing efforts to get better value for money in the N.H.S.."
Secretary
Ennals, has expanded
INDUSTRIAL BLADDER CANCER IDENTIFICATION of bladder carcinogens, withdrawal from of products containing them, action under the Industrial Injuries Act and Carcinogenic Substances Act, and monitoring of workers still at risk might be thought to complete a chapter in occupational medicine. However, Fox and Collier’s work suggests that this story is not yet over.Men who worked in factories which never used bladder carcinogens or who joined such factories on Jan. 1, 1950, or later ought not to be at risk of cancer of the bladder, but they are. A significant excess of deaths due to all cancers was picked up in an earlier study of 40 867 men, 2271 of whom died in the years 1967-712.= The excess was significant for lung and stomach,’ but not bladder: follow-up to 1972-741 confirms the lungcancer findings, denies the increase in gastric cancer, and introduces a significant excess for carcinoma of the bladder. The excesses were significant for men who had worked in carcinogen-using industries and for newcomers to former users, the standardised mortality ratio being of the order of 200 in each case (as it was, though not significantly, in men working in factories never using bladder carcinogens). The problem seems to
manufacturing industry
1. Fox, A. 2. Fox, A.
J., Collier, P. F. Br. J. ind. J., Lindars, D. C., Owen, R.
Med. 1976, 33, 249. ibid. 1974, 31, 140.
