State, of the individual to provide for himself interests of the profession as a whole"-a things will not improve. concern, incidentally, which is not confined to H CAIRNS the older generation. Not all doctors are idealists, but most have been influenced to a Cardiff greater or lesser degree by idealistic motives in choosing medicine as their life's work. This needs to be borne in mind in any attempt to understand the "aetiology" of the present juniors' contract dispute dissatisfaction and the pursuit of "limited, SIR,-Further strike action by junior doctors sometimes conflicting ends." There must be plays straight into the hands of those in an explanation of these symptoms. Government wishing to restrict professional Many of us have long ago reached the confreedom. Outwardly we may appear to strike, clusion that the assumptions on which our but no doctor can walk out leaving sick present system is founded are unsound and patients. In all hospitals taking action there are based on a misunderstanding of the fundamedical staff available for those urgently in mental nature and purpose of medicine in need of attention. human society. The reasons for reaching this The strike may be used successfully by those conclusion are set out in a paper published 10 in industry, who can truly down tools, but it years ago.' is a useless weapon in the hands of a doctor. If this conclusion is right, then Sir George's It becomes either ineffective industrial action advice to us that "it is surely our duty and or frankly unethical. What is more, by self-interest to help [the NHS] to survive as appearing to be irresponsible we actively best it may" is tantamount to saying "make antagonise our greatest ally, the general public. the best of a bad job." Could this not be Despite our previous behaviour, most of the described as a "policy of despair" ? population still have a high opinion of the The medical potential of Britain is as high as any in the world; it is this, not the NHS, juniors. We have done ourselves a great disservice by which is "an asset to the public and profession failing to reveal the recent governmental alike." Our common aim-doctors, patients, double-cross and the deplorable state of the and legislators alike-should be to establish NHS to those who both use and pay for the conditions which, to the greatest practicable service. We should buy space in the papers and extent, will promote the realisation of this time on commercial television to present a fair potential. In my view it is most unlikely that but none the less aggressive statement of the we can achieve this aim under the existing facts. These alone provide us with enough legislation-chiefly because the relationship ammunition to achieve not only improved pay between, and the respective roles of, governand conditions but, most of all, a better service ment and doctors inherent in it are basically for our patients. unsound. R F MASSEY E R C WALKER Guy's Hospital.


London SE1


It is easier to attempt to quantify if not to define subconsultant work in surgery than in other specialties. If his figures are taken at face value then, as some 4000 of surgical operations are regarded as subconsultant in type, there must be too many consultant surgeons now in post. The figures also show that they were performed not by medical assistants (sic), but by registrars, senior house officers, and clinical assistants, none of whom are permanent. The same reasoning applies to anaesthetists but with even greater force. To a non-surgeon like myself the figures of Gilmore et all are equally revealing. In a study of appendicitis they quoted 87 655 as the number of appendicectomies done in England and Wales in 1972, of which 60 000 were emergencies. They concluded that a quarter of such operations showed a normal organ and that in England and Wales in 1972 15 000 unnecessary operations may have been done. Who performed them ? They reported that 444 patients were admitted in 1972 to the Royal Berkshire and Battle Hospitals, Reading, with a diagnosis of acute appendicitis. They were operated upon by 26 doctors from house surgeon to consultant. Eight juniors did more than 25 operations, their diagnostic accuracy varying from 54%" to 95o". Sixteen emergencies were performed by consultants, two being normal. Thus it would appear that the more junior the surgeon, the more likely it is that an unnecessary operation will be done. What, therefore, is the cost of experience ? Mr Doran is surely correct when he says that the definition of subconsultant work is personal, arbitrary, and subjective. It should therefore have no place in a profession purporting to value human life and to set a model of fairness and consideration for others.


SIR,-We of the Royal Gwent Hospital, Newport, would like to state publicly how grateful we are to have as medical officer to the Gwent Area Health Authority Dr N H N Mills, who has such obviously outstanding capabilities that, as stated in his letter (14 August, p 424), modestly addressed from Ebbw Vale he managed to understand the Government proposals for the new junior contract with ease despite the inability of 600% of area health authorities and 100%' of clinical doctors to do so.

We would like to inquire respectfully, however, why such an obvious interpretation of the proposals was not made more clear by him to both our uegotiating representative in Gwent and the doctors at this hospital before we signed our new contracts, because, having read his letter, we now feel that we have all been hoodwinked by him. Perhaps he is trying to foster a more respectful relationship between administrators and their inferior clinical colleagues ? K J TAYTON and 16 others

Royal Gwent Hospital, Newport, Gwent

NHS (Scotland) Review Committee, An Historical Account (1966-67). Available from BMA Scottish House, 7 Drumsheugh Gardens, Edinburgh EH3 7QP.


Gilmore, 0 J A, et al, Lancet, 1975, 2, 421.

Private practice and the NHS SIR,-Mr D P Choyce (21 August, p 479) is probably correct in his forecast that many senior consultants with substantial private practice income will resign from the NHS if they have to make the choice (which they may well have to) between private and NHS practice. However, the more junior consultants will not be able to afford to give up their NHS income and they will either emigrate or stay in the NHS and make the best of it. The most severe depletion of manpower will occur at registrar and senior registrar level. It is inconceivable that senior registrars will apply for consultant posts and accept a lower income with no possibility of supplementing it in the private sector. As has been pointed out many times in your columns, the NHS consultant is low in the world earnings league, and while the opportunity to practise abroad exists our potential recruits will leave in droves. KENNETH T H MOORE Northern General Hospital, Sheffield

United profession

SIR,-I imagine that many, probably most, of your older readers, like Sir George Godber (31 July, p 303), "have not known a time of comparable dissatisfaction" in our profession and will share his concern "with the ... greater

I M LIBRACH Geriatric Unit, Chadwell Heath Hospital, Romford, Essex

Medical manpower and hospital staffing

Professional unity SIR,-With reference to the letter from Dr D C Banks (4 September, p 589), when I was reported as having said that the hospital practitioner grade was "negotiated by general practitioners for general practitioners" I was not implying that GPs went ahead and negotiated an agreement with the DHSS independently of the hospital doctors. In fact the grade was negotiated jointly by both hospital doctors and GPs because it concerned both sections of the profession. The objective was to define a grade peculiar to GPs and to suit

only them. Those doctors who work exclusively or predominately in the hospital service must look to their own negotiators if they want new conditions of service and a different scale of remuneration, and I understand that the plight of part-time medical officers (clinical assistants) is already under active consideration by the Central Committee for Hospital Medical Services. This is not the remit of my committee, which is limited to negotiating terms and conditions of service for general practitioners. TONY KEABLE-ELLIOTT

SIR,-Mr F S A Doran is a persuasive advocate, not least in his letter (28 August, p 531) BMA House, on hospital staffing. London WC1

Chairman, General Medical Services Committee

Medical manpower and hospital staffing.

646 BRITISH MEDICAL JOURNAL State, of the individual to provide for himself interests of the profession as a whole"-a things will not improve. conce...
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