BRITISH MEDICAL JOURNAL
28 MAY 1977
1417
NEWS
AND NOTES
Vzews As genetic counselling has developed from a researchorientated to a practical service the associated ethical problems have grown in number and complexity. One difficulty is the anxiety and guilt sometimes provoked in individuals who find they are carriers of a gene for an inherited disorder-and with diseases such as cystic fibrosis about 5",, of the population are carriers. Dr J H Edwards argues forcibly in the May issue of Archives of Disease int Childhood that these carriers should be assured that they are as fit if not fitter than average. The very high frequency of the carrier state suggests, he says, that it confers some evolutionary advantage. We know that carriers of the sickle cell gene are resistant to malaria; as yet we have not discovered the advantage conferred by most other carrier states. While we remain ignorant of these explanations we would be unwise to condemn and attempt to eliminate the genes concerned.
Popular articles on the menopause often say that women are unique amtiong mammHlals in ceasing their reproductive life in middle age. Not so; rhesus monkeys kept in comfortable captivity become menopausal in their early 20s, with characteristic changes i7n their hormtional patterns. So far nothitng has been published on their psychological response to the climacteric: nor is it known whether any wild mionkeys live long enough to reach that stagethough one of Jane Goodall's chimpanzees became subfertile in her late teens. Beans may prove to be the most important source of protein for most of the world in the next decade, but in Western society their acceptability is limited by the flatulence they produce. So a report on Food Legumie Processing and Utilisation from the International Development Research Centre in Ottawa is welcome for its attention to research into ways of lowering the flatus effect by reducing the proportion of oligosaccharides in the course of processing. Shall we soon see commercials for flatus-free foods ?
Animals Centre in Carshalton, and provides a means for laboratories to exchange information on the genetically defined rats now so essential for biomedical research. For example, the Rowett Research Institute have discovered an athymic nude mutant in their colony of hooded rats, and if this mutation has similar immunological defects to the nude mouse demand for specimens will be high. Minerva read with pleasure and itnterest John Gunn's review a recent "British J7ournal of Psychiatry" of criminal behaviour. He quotes Penrose's law: the homicide rate, the number of prisoners, the birth rate, the suicide rate, and the general death rate are all lower in countries with a high mental hospital population and vice versa. Here in Britain, as the mental hospitals have emptied the prisons have filled. The conclutsions to be drawn seemti clear. Fit young men rarely have haematuria, so that when a naval surgeon captain saw 18 servicemen with one or more episodes of apparently inexplicable bleeding he began to ask questions. All were runners at distances of 10 000 metres or over; and he has now described (British 7ournal of Urology, 1977, 49, 129) a new syndrome in which running long distances with an empty bladder leads to contusions of its posterior wall. The bruises heal rapidly. "Run with a full bladder," he advised, but the advice was rejected. Most of us think of leptospirosis as an occupational disease of sewer workers, but it may be more common than that. Doctors in St Louis, Missouri, believe ("Pediatrics," 1977, 90,532) that milder variants of the disease may often pass unrecognised in children. Symptoms included fever, anorexia, abdominal pain, headache, nausea, and a maculopapular rash: some degree of jaundice occurred in 7 out of 9 cases. Most were, they believe, traceable to dogs rather than rats, though they did not isolate Leptospira canicola from their patients: the most common serotype was L
icterohaemiorrhagiae. Having heard Dr Geoffrey Marsh explain to a London audience (see p 1374) the ratnge of services provided by nurses, health visitors, and social workers in his group practice, one doctor rose to ask where the money came from. Did not emnploymtient of so many staff with only 700,, reimbursemtent of salaries mean that doctors were paying for preventive medicine out of their own pockets ? Dr Marsh had two answers. Firstlv, doctors in his practice received two or three tinies the average in item of service payments for procedures such as immnunisations and cervical smears; and, secondlv, practice profit had kept ahead of inflation year by year. When a dark blue publication headed Medical Research Council and titled simply Rat News Letter landed on Minerva's desk she had sudden fantasies that all those bright-eyed, scientific rats, pumped full of mind-enhancing drugs and trained to a whisker by daily sessions in ever-more complicated mazes, were demanding their own reading matter. Not so. In prosaic fact, the newsletter is published by the MRC Laboratory
Postmortem examination of the mummy of an Egyptian believed to have died 3200 years ago showed the cause of death to be hepatic schistosomiasis-not very surprising; but the youth also had signs of dust disease of the lungs and pork tapeworm infestation with cysticercosis (American J7ournal of Diseases of Children, 1977, 131, 349). Taenia solium is now rare in Egypt-a tribute to the hygienic provisions of the Muslim religion, but schistosomiasis remains a daunting health problem.
WHO has been looking at irradiated food and has decided that irradiation is analogous to freezing or heating and should not be assessed on the same basis as food additives. The public need to be educated, says WHO (" Wholesomeness of Irradiated Food," technical report No 60) and reassured: and it has now passed as safe standard ways of irradiating potatoes, chickens, mushrooms, rice, and strawberries.
MINERVA
1418
MEDICOLEGAL Coroners and transplants FROM OUR LEGAL CORRESPONDENT
Doubts about the interpretation of the Human Tissue Act 1961 have led to some wellpublicised clashes between coroners and transplant surgeons. Now the Home Secretary, after consulting the Secretary of State for the Social Services, has written to all coroners' expressing the hope that they will never object in principle to a transplant operation, but refuse their consent only where the organ concerned might later be required as evidence or in order to pursue further inquiries. The coroner's role in transplants is a crucial one, since by reason of section 1(5) of the Act when there is reason to believe that an inquest may be held or that the coroner may require a postmortem examination no one may remove any organ without the consent of the coroner. The statute presents the coroner with a very wide, and indeed absolute, discretion to give or withhold his consent, but the Brodrick Committee2 thought that it was not the coroner's function "to place obstacles in the way of the development of medical science or to take moral or ethical decisions." Using the very words of the Brodrick Committee (but, curiously, without attribution), the Home Office circular states that the coroner should refuse his consent only if he is aware that there may be later criminal proceedings in which the organ might be required as evidence or if he believes that the removal of an organ might impede his own further inquiries. The circular also adds that refusal of consent would be justified where the coroner has reason to believe that a defect in the organ itself was the cause, or a contributory cause, of death.
Routine needed The vital need to have the shortest possible time elapse between the death of the donor and the removal of the organ led to suggestions to the Brodrick Committee that the time needed to obtain consent from both the relatives of the deceased and the coroner had made it so difficult to obtain organs that patients had died whose lives could have been saved by transplants. The Home Office circular reminds coroners that for kidney transplants the organ must be removed within half an hour of death and suggests that to ensure that this is possible the coroner and the hospital should work out a suitable routine in advance. Nevertheless, since the coroner has no jurisdiction over a live body he cannot give his consent to a transplant in advance. All that he can do is to indicate an intention, to be fulfilled or not after the death of the proposed donor. The Brodrick Committee considered that, even leaving aside the legal difficulties, it would be quite wrong to put the coroner in a position where it might be thought that his consent to a transplant amounted to permission to switch off a machine that was keeping the donor alive. Anxiety that compliance with the requirements of the Act had made transplants almost impossible led in September 1974 to an operation proceeding at Addenbrooke's Hospital in Cambridge even though neither the relatives of the donor nor the coroner had given their consent. The donor was a 20-year-
BRITISH MEDICAL JOURNAL
old senior aircraftman who had been injured in a late night car crash. A senior surgeon at Addenbrooke's told a subsequent inquest in Cambridge: "Time was of the essence.... I tried to the best of my ability to contact the deceased's relatives and the coroner concerned, but was unable to do so." After the inquest the coroner, Mr Dudley Durell, wrote to Professor Roy Calne, who led the team at Addenbrooke's which was then doing 60 kidney transplants a year. On receiving the letter Professor Calne ceased all transplants and publicly blamed the coroner for any deaths that ensued. The contents of the letter were never made public, but possibly the coroner made the justified point that proceeding without his consent would be a breach of the Act. Whether the transplanters were wrong to have proceeded without the consent of the deceased's relatives is more debatable. According to one newspaper report,4 Mr Durell held the view that the hour between the death of the donor and the removal of the organ was an unrealistic length of time in which to seek the permission of the relatives, and that therefore organs should be removed only where the deceased had been carrying a donor card.
Present position
Where a hospital is in possession of the body of a patient who has left written consent to its being used for a transplant it is now almost universally accepted) that (subject to the consent of the coroner) the hospital may proceed to remove the organ. Where the deceased has left such a written request his wishes appear to be paramount. Indeed, according to Lord Edmund Davies in a lecture to the Royal Society of Medicine,' only the person in possession of the body can countermand the request and veto removal of the organ. The DHSS in a guidance circular- to NHS authorities in June 1975 went so far as to state that where there was written consent by the deceased it would be "reasonable" to proceed with the removal of the organ, even though subsequently relatives or executors asked for possession of the body. The necessity to obtain the consent of the deceased's relatives arises only in the absence of written consent by the deceased. Section 1(2) of the Act permits the person lawfully in possession of the body to authorise the removal of an organ for transplantation if, "having made such reasonable inquiry as may be practicable, he has no reason to believe" that the deceased had expressed an objection to his body being so used or that any surviving relative objects. It is important to appreciate that the statute is so worded that it does not impose upon surgeons the obligation to satisfy themselves that the relatives have no objection. On the contrary, all that is required is for the surgeon to make such reasonable inquiry as may be practicable, and if at the end of that inquiry he has no reason to believe that there are objections, then he may proceed. In so far as a coroner laid down that the positive consent of the relatives must be obtained it seems probable that he was misreading the Act. Indeed, there could well be cases where in the minutes available between death and the transplant it was quite impossible to contact any relative. Then, so long as the surgeons had made such reasonable inquiry as might be
28 MAY 1977
practicable, they would seem to be free to proceed. Diagnosis of death The Home Office circular makes no suggestion to coroners as to the diagnosis of death. It merely encloses a copy of the report of the Royal Colleges and Faculties on the diagnosis of brain death and adds that it will be helpful for the hospital to know what evidence the coroner will require as to the diagnosis of death. The Human Tissue Act" merely requires the transplanting doctor to satisfy himself by personal examination of the body that life is extinct. There is no legal definition of death, and it has perhaps been too easily accepted that death is a matter of clinical judgment. After an inquest' at Birmingham in March 1974 on a man who had died 15 hours after reviving in the middle of an operation to remove his kidneys the jury returned a rider that the recommendations of the Maclennan Committee"' on transplant problems should be made law. The jury was particularly concerned that there should be legislation making it compulsory that death should be certified by two doctors, one of at least five years' seniority, and each independent of the transplant team. That the Birmingham jury's concern was not misplaced was shown by a case" '' at the Central Middlesex Hospital earlier this year, when the donor's death was certified only after the transplant. The hospital later disputed the Hornsey coroner's further criticism that the junior doctor who certified death was himself a member of the transplant team. Doctors have often resented over-dramatic press references"' to "body-snatchers," but if one matter above all others leads to public suspicion about transplants it is doubts about the diagnosis of death. Legislation which laid down, not what actually constitutes death, but how death should be certified would protect both doctors and patients. Home Office C'ircular No 65 1977. Report of the Commnsittee on D)eath Certificatiom and
(C'ro>ners. ILondon, HMSO, 1971. T7'he Tiies, 9 Septcmber 1974. Gua,rdian, 15 September 1974. Except by the Medical Defence Union, British Meclical io7oupia? 1975, 4, 66. Proceedings of the Royal Society of Medicine, 1969, 62, 633.
British MIedical lournal, 1975, 3, 107. Human TIissue Act 1961, section 1(4). "Da1ilv Telegraph, 16 March 1974. Report of the Cont,ntklittee oni T'ranisplantt Problems. London, HMSO, 1969.
T'he 'li'mes. 21 January 1977.
Described as 'absolutely astounding" by Professor Leslie Brent: Evening Standard, 20 January 1977. 3Newvs of the WY'orld, 28 September 1975: quoted in British AMedicalyournul, 1975, 4, 66.
12
PARLIAMENT First 1000 pay-beds cut On 19 May the Secretary of State for Social Services gave details in Parliament of the reduction in 1000 pay-bed authorisations under the Health Services Act 1976. In a written reply he said: "My right hon Friends the Secretaries of State for Scotland and Wales and I have issued revised authorisations under Section 1(1) of the Health Services and Public Health Act 1968 giving effect to the 1000 reductions in pay-bed authorisations prescribed
BRITISH MEDICAL JOURNAL
28 MAY 1977
in Schedule 2 of the Health Services Act 1976." Effect on the presenit distribiutiotn
of pay-bed
auithorisations
Regional health authority Northern Yorkshire Trent East Anglia North-west Thames North-east Thames South-east Thames South-west Thames Wessex Oxford South -western West Midlands Mersey
North-western London
No of authorised No of hospitals with authorised pay-beds pay-beds
Before After Before After 20.5.77 20.5.77 20.5.77 20.5.77
169 302 247 156 461 410 433 247 187 215 202 394 164 336 227
117 239 204 126 353 299 319 178 146 184 152 304 126 272 194
49
44
51 26 55 52 68 57 44 33 62 79 38 51 11
43 24 50 48 61 53 44 25 55 73 34 51 11
4150
3213
725
662
234
184
51
46
60
47
23
23
4444
3444
799
731
4Q
6
postgraduate boards of
governors
England Scotland Wales
Gt Britain (total)
(total)
"In 161 instances at the request of the authority concerned authorisation has been given on a group rather than on an individual hospital basis. It is a condition of all such group authorisations that the daily occupancy of authorised pay-beds by paying patients shall not exceed at any one time the authorised number of pay-beds for the group as a whole; subject to this overriding condition a hospital covered by a group authorisation may admit paying patients at any one time up to the limit authorised for the hospital concerned. In most instances the limit for an individual hospital is identical to the number of pay-beds it was authorised to provide when the Health Services Bill received Royal Assent. In eight instances we have approved modifications proposed by health authorities where these reflect more fairly than the former authorisations the present distribution of acute facilities. We are satisfied that these group authorisations will make it easier for the Health Services Board to recommend the progressive withdrawal of remaining pay-bed authorisations. A list of the revised authorisations as they affect individual hospitals has been placed in the Library. "Admissions of paying patients are generally low in relation to the number of authorisations so that the present reduction in authorisations is not likely to have any immediate widespread effect. Where however the reductions lead to an actual decrease in the number of private patients admitted to NHS hospitals resources will be released for general NHS use. It will be for health authorities, whose allocations have been compensated for the estimated loss of income, to consider the use to which such resources are put according to local circumstances."
necessary to give effect to the EEC Medical Directives. It will enable doctors who are nationals of any of the EEC member States and have a recognised qualification awarded in a member State to be authorised to practise in the UK. Corresponding provisions have been or will be made in other member States. As announced by Mr David Ennals, Secretary of State for Social Services on 5 April in the House of Commons (16 April, p 1037), the order includes a provision for the registration of doctors from the EEC to lapse after a period, normally six months, unless the doctor concerned has satisfied the General Medical Council that he has the necessary knowledge of English. The Government press statement says that other provisions of the order follow the lines of the consultative document on the implementation of the Directives which the Government issued to interested bodies in March last year. These include the following: "Doctors from other member states who wish to establish themselves in this country will be registered by the General Medical Council on the same basis as doctors qualifying in the UK. But EEC doctors who wish to provide services here on a temporary basis-for example, when they are called in to treat a patient from another member State who is taken ill while on holiday here and who wants the services of his own doctor-will be entitled to do so without having to go through all the formalities of registration. But they will have to provide certain information to the GMC, who will put their names on a special list. This list will for legal purposes form part of the medical register, and the doctors concerned will, like others registered here, be subject to the GMC's disciplinary rules. "The GMC has already been designatedand this is confirmed in the order-as the authority competent to issue the new certificates of specialist training which will be the recognised UK specialist qualification for the purposes of free movement within the Community. The GMC is to maintain a list, called the 'specialist list,' of doctors who are nationals of any member State and have specialist qualifications entitled to recognition within the Community."
Questions in the Commons
the limited provisions of Section 8 of the Health Services Act 1976 for which the detailed arrangements are currently under discussion. One of the conditions which will apply to these arrangements is that paying patients should be admitted on the basis of medical priority alone. Since I have not yet determined the charges which will be made for these services I cannot make any estimate of the likely revenue which will accrue."
MEDICAL NEWS College report on geriatrics Acute medical and geriatric facilities in district hospitals should be integrated into a single operational unit, says the Royal College of Physicians of London in a report published last week in the Lancet (21 May, p 1092). The working party, which was chaired by Sir Cyril Clarke, suggests that all consultant physicians (including those specialising in geriatric medicine) should have direct access to these acute beds and that geriatricians might take their turn in rotation with other colleagues in dealing with emergency cases. Geriatric services are of uneven quality, says the report, and it comments that the "inferior status" of the specialty results from its association with old and least updated buildings, inferior diagnostic facilities, and junior staff "often inadequate in numbers and quality." Many of these difficulties would be overcome by the integration of the diagnostic and therapeutic services of physicians and geriatricians. The report recommends that geriatric medicine should be given more emphasis in the MRCP examination and that there should be more rotation of junior appointments between geriatric and acute medicine. In future, it suggests, physicians with training in general medicine and geriatrics should be appointed as general physicians with a special interest in geriatric medicine, with a contract stating the number of sessions to be devoted to rehabilitation and long stay units. Differing patterns of care of the elderly should evolve in each area, the report concludes, with the medical profession exploiting the local resources to the full. Its recommendations should be taken only as guidelines.
Pay-beds: revenue from overseas patients
Mr Patrick Jenkin asked the Secretary of State for Social Services for an estimate of the revenue to the NHS from the use of pay-beds by overseas patients in the latest period for which figures are available. He also asked whether it was now his intention that such foreign patients should be admitted on the same conditions as would apply to United Kingdom patients and what estimate he had made of the reduction in revenue which this will involve. In reply, Mr David Ennals stated: "The proportion of pay-bed income derived from overseas patients is not recorded EEC Medical Directives separately. While pay-beds remain in NHS hospitals they will continue to be available for Publication of order in council use by paying patients, whether resident in the UK or not, on the same basis as present. When An order in council was published on 19 pay-beds are phased out admission to NHS May, which comes into effect on 10 June, that hospitals of private patients, whether resident makes the changes in United Kingdom law overseas or in the UK, will be possible under
Health Service Commissioner In his annual report (published 17 May, HMSO, 75p) the Health Service Commissioner says that there was a significant increase in the number of complaints (582) that he received in the year. Two-thirds were outside his jurisdiction, and the remainder were mainly concerned with difficulties in getting patients into hospital, ambulance services, consent to treatment, and detention in mental hospitals. Doctors sometimes questioned the value of investigations into complaints that appear to be trivial, says the Commissioner, but he believed that "confidence in the NHS is of paramount importance and this confidence will be increased if people with genuine grievances know they will be fully and impartially investigated.... Where complaints turn out to be totally unreasonable I have not hesitated in my reports to say so."
1420
BRITISH MEDICAL JOURNAL
Workshop on medical writing
9 Thurs 9 Thurs
Organisation Committee, 10.15 am. New Consultant Contract Working Party (CCHMS), 2 pm. Executive Subcommittee (CCCM), 10.30 am.
There are still a few vacancies for the BMJ 10 Fri workshop on problems with medical writing at the Birmingham Medical Institute on 1 July. Those wishing to participate should be Division Meetings to be Held Members proposing to attend meetings marked * are willing to submit in advance a paper for dis- asked to notify in advance the honorary secretary cussion and tuition and should apply, with a concerned. cheque for £20, to the Editor, British Medical Bromley-At Farnborough Hospital. Thursday. 2 Journal, BMA House, Tavistock Square, June, 8.30 pm, agm. Dryburn Hospital, Monday, 30 May, Durham-At London WClH 9JR. 8.30 pm, Mr J B Secrett: "Washington Wildfowl Refuge." (Preceded by supper, 7 for 7.30 pm.* Guests
are invited.)
Alan Edwards Memorial Fund
Leicestershire and Rutland-At Overstone Solarium, Saturday, 4 Tune, 7.30 for 8 pm, medical
ball. *
The money collected for the above fund (see BM7, 22 May 1976, p 1288) totalled £2098. This was passed to the British Association of Surgical Oncology for an annual essay prize for young surgeons.
COMING EVENTS "Nutritional aspects of gastroenterology"Symposium, 30 June-I July, London. Details from the dean of postgraduate studies, Sr Mark's Hospital, City Road, London EC1V 2PS. (Tel 01-253 1050.) Whipps Cross Hospital-Details and copies of the programme to 30 August are now available from the Medical Education Centre, Whipps Cross Hospital, London Ell. (Tel 01-539 5522 ext 310.) Winchester and Central Hampshire Postgraduate Medical Centre-Details and copies of the programme May to August 1977 are now available from the Centre, Hampshire County Hospital, Winchester. (Tel Winclhester 63535 ext 422.)
SOCIETIES AND LECTURES For attending lectures marked * a fee is charged or a ticket is reqtired. Applications shouild be tnade -first to the institution concerned.
Monday, 30 May INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-At Queen Charlotte's Hospital, 4.30 pm, Dr M de Swiet, Barbara Morgan: Cardiac arrest.
Tuesday, 31 May ROYAL FREE HOSPITAL-1
pm, Dr F J Dudley
(Australia): Glucagon metabolism. Wednesday, 1 June
INSTITUTE OF PSYCHIATRY-5.30 pm, Dr M E Carruthers: Heart attack: egg or ego ? MEDICO-PHARMACEUTICAL FORUM-At Royal Society of Medicine, 3.30 pm, statutory meeting: "The survival of medical journals." ROYAL COLLEGE OF SURGEONS OF ENGLAND-At Royal Victoria Infirmarv, Newcastle, 4 pm, Hunterian lecture by Professor M H Thompson: Histamine H. receptor antagonists and peptic ulcer disease. 5.30 pm, Harris and Gale lecture by Mr D C Britton: The patho-physiological sequelae of peptic ulcer surgery. ROYAL FREE HosPITAL-5 pm, Dr R Hecker (Adelaide): Cimetidine and duodenal ulcer. ROYAL POSTGRADUATE MEDICAL SCHOOL-1 1.45 am, Professor C Alleyene (West Indies): UNIVERSITY OF OXFORD-At John Radcliffe Hospital, 4 pm, Mr Peter Anderson: Sexual attitudes of undergraduates-preliminary report of Oxford study.
Thursday, 2 June ONCOLOGY CLUB-At Guv's Hospital, 6.30 pm, Dr R Rubens: Prospects in the treatment of breast cancer. ST MARY'S HOSPITAL MEDICAL SCHOOL-5.15 pm, Aleck Bourne lecture by Miss Aileen Dickins: The care of the older pregnant woman.
BMA NOTICES Diary of Central Meetings JUNE 2 Thurs 7 Tues
8 Wed
Joint Agenda Committee, 2 pm. Scottish General Medical Services Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.30 am. BMA Council Executive, 1 pm.
28 MAY 1977
HIarrison, M W Kanan, A S McNeish, J W Paterson, L A Salako, A Seaton, R D H Boyd, J D Carroll, A C F Kenmure, C A E H Loehry, M W Moncrieff, T C Northfield, Major-General R A Smart, R Balcon, JM H Buckler, J H Keen, B J Prout, P C Robertson, P Rodin, W J Cunliffe, D Gardner-Medwin, A H Rubenstein, W J Makene, R C Turner, P E Gower, j L Ngu, B N C Prichard, R M McLellan, T-K Chan, R N Maini, G R Serjeant, C E Sissons, C W M Adams, J D Baum. D A Warrell, C Chantler, D Ogston. Anne G Ferguson, J 0 M Pobee, J C Crawhill, D L Davies, F J Macartney, M D Rawlins, T J McElwain, A Viriyavejakul, D J Kinloch, I MacIntyre, M Swash, W R ILee, G P McNicol, M Friedman, J Landon, E J L Lowbury, P Alwyn-Smith, A Herxheimer, A C Kennedy, J G McLeod, D C Morley, Elsie R Rue, I G Taylor, E D Williams. The following were elected fellows under Bye-Law 39(c)-N Islam, Group Captain P Howard, A M Adelstein, B R Jones, J G Widdicombe, M Caplin, W E Miall, R D Catterall. The following were elected fellows under Bye-Law 39(b)-B G Alton, J A F Ambrose, J W Black, R M Cherniack, Sir Stanley Clayton, W 0 Creutzfeldt, R A Gregory, J T Shepherd. The following were elected members under Bye-Law 124(d)-R G Batey, F B Crimmins, A H Waters. The following were elected members under Bye-Law 117-E A Barker, J R Clamp, A M Geddes, A Ghareeb, Rolth F Harris, R A Joske, A K Mant. J W Thompson.
Manchester-At Boyd House, Tuesdav, 31 Mav, 8 for 8.30 pm, Dr P H Smith: "Assessment of a new antirheumatic sulindac (Clinoril) in general practice."* (Supper provided.) North and South Camden Divisions-At Kenwood House, Thursday, 2 June, 7.15 for 8 pm, jubilee dinner.* (Guests are welcome.) Northern Region-At Crest Motel, Carlisle, Monday, 30 Mav, 7.15 for 7.30 pm, council meeting. North-west Essex-At Princess Alexandra Hospital. Thursday, 2 June, 8 for 8.30 pm, agm. South Middlesex-At Queen Mary Sailing Club, Thtursday, 2 Jutne, 7.30 pm, supper dance.* South Tees-At Marton Hotel and Country Club, Thursday, 2 June, 7.30 pm, agm followed by annual dinner. Wirral-At Clatterbridge Hospital, Thursday, 2 June, 8 pm, meeting to disculss agenda for ARM.
following consultants have been appointed: Mr G G Mitchell (obstetrics and gynaecology); Dr P D Mohr (neurology).
UNIVERSITIES AND COLLEGES
Corrections
CAMBRIDGE MD-W A D Griffiths, C J Oon, D J Powell-Jackson.
Advances in the treatment of kidney disease: An introduction In this article bv Dr J R Curtis (14 May, p 1270) under sub-heading "Peripheral neuropathy and chronic renal failure," the last sentence of the third paragraph should begin "Mvo-inositol has recently attracted attention
SOUTHAMPTON The title of reader in clinical epidemiology and community medicine has been conferred on Dr D J P Barker.
LONDON MD-A W P du V'ivier, B J B Grant, A G Morgan. A Sedaghat. MS-J F Colin, A N Nicolaides. ROYAL COLILEGE OF PHYSICIANS OF EDINBURGH At a quarterly meeting of the college held on Thursday, 5 Mav, with the president, Dr R F Robertson. in the chair, Lillian M Pickford and R Van Furth were elected Fellows under the Laws of the College, Cap II, 10. Dr Catriona Irvine was awarded a Hill PattisonStruthers bursarv for 1977. The Medical Commission on Accident Prevention Prize Essay, 1977. was awarded to Dr C J Scott.
ROYAL COLLEGE OF PHYSICIANS OF
APPOINTMENTS SALFORD AREA HEALTH AUTHORITY (TEACHING)-The
Annual Report of Council (Appendix VII: Amendment to the Second Schedule to the By-laws) The sentence "1 to be nominated by the Council of the British Dental Association" under nonvoting members of the General Medical Services Committee (7 May, p 1236) should be deleted and a new paragraph inserted which should read "1 representative appointed by the Council of the British Dental Association."
LONDON
The following have been elected to fellowship of the college: N Jungalwalla, L G Hannah, G H Valentine, A Divaris, H Grusin, I F Hayali, I P Jaffe, I P Sparks, N C Begg, J H Deakin, J H Pratt-Johnson, R E Beamish, D M Abelson, E Sanders, L B Sunn, Margaret Eastwood, Surg-Rear Admiral S G Rainsford, D'A Kok, K S Milligen, R I Eakin, L I Phillips, T B Brewin, F E Dische, Brenda D Van Leuven, M J D Newman, P M Higgins, A R H Worssam, T C K Marr, Rosemary A Cooper, D J Gudex, W B Hennessy, Katharine M Dormandy, F H Burns, A J Goble, W M I Maxwell, R Slome, D J Attvgalle, J H Allison, A D Forrest, I J Pinto. T H S Kirkland, I D Thomas, P Ebeling, P F Benson, J F Hare, Patricia J Lindop, I B Hales, R S Mibashan, R H Culpan, I R Ferguson, J M Duggan, J S Garfield, G A Hunter, V F Weinstein, L H Opie, M Greenberg, M J Pritchard, K F R Schiller, Shelagh M Tighe, J G Sloman, H B Griffith, E N Glick. P M Last, G Michell, M D Ravson, J M Costello, Rosemarv Stephens, P T Pickens, W D Stone, E E Jones, H J Liebeschuetz, Valerie J Marrian, 0 H D Portsmouth, D Gooptu, J L James, D P Mullan, D F Scott, R M Norris, K P Goldman, Betty L Priestley, H A Rees, R P Ashfield, N J B Evans, C J Goodwill, M R Lee, M A Newton, G B Wyatt, D C Fluck, C Tasman-Jones, E S Paykel, P L Boardman, J F Harrison, A C Ikeme, P N L eslie, Clara Lowv, A B Shrank, E S Garnett, B A Latham, S M Rosen, A H Henderson, R G Luke, S D B Mohamed, J Perkins, B K Samtani, Mary Corbett, T P Ormerod, E K M Smith, R W Emmerson, G I Nicholson, M J Smith, G C Sutton, M Thomas, G J Thorpe, E G Anderson, W I Austad. C J Burns-Cox, A R R Cain, J W H Doar, Margaret E R Stoneman, Shirley H Wrav, D B Grant, J J F Hamblin, D H W Kelly, A D Ferguson, T M Hayes, D M Hill, Elizabeth A Hills, J K L Jones, M P Mahoney, N Peters, E B Raftery, I D B Rennie, Evan M Kohner, J P O'Loughlin, G S Spathis, 0 H Amin, S S Bleehen, A K Brown, G F Cohen, H1 L H Frankel, R L Himsworth, P J R B Keelan, M S Kanpp, A H Roberts, M D Sanders, G M Sterling, J D Swales, J A Walker-Smith, A T Bevan, K D Buchanan, P Cannon, F J Goodwin, C R M Prentice, G P Sechiari, P Sharpstone, Wing Commander G C Turner, E T Young, A S Abraham, T M Barratt, E M R Critchley, Winifred N Kaine, R Marks, S Ramachandran, G Russell, H Savage, S P Allison, R G Brackenridge, C K Connolly, B M Greenwood, M J G
From the CCHMS In the third paragraph of the report from the chairman ("From the CCHMS", 21 May, p 1368) "Nuffield Provincial Hospitals Trust" should read "Nuffield Nursing Homes Trust." We apologise for this error.
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical J7ournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical J'ournal, BMA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC 1H 9JR, on receipt of proofs. t British Medical Journal 1977 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British
Medical_Journal.
28 MAY 1977
1417
NEWS
AND NOTES
Vzews As genetic counselling has developed from a researchorientated to a practical service the associated ethical problems have grown in number and complexity. One difficulty is the anxiety and guilt sometimes provoked in individuals who find they are carriers of a gene for an inherited disorder-and with diseases such as cystic fibrosis about 5",, of the population are carriers. Dr J H Edwards argues forcibly in the May issue of Archives of Disease int Childhood that these carriers should be assured that they are as fit if not fitter than average. The very high frequency of the carrier state suggests, he says, that it confers some evolutionary advantage. We know that carriers of the sickle cell gene are resistant to malaria; as yet we have not discovered the advantage conferred by most other carrier states. While we remain ignorant of these explanations we would be unwise to condemn and attempt to eliminate the genes concerned.
Popular articles on the menopause often say that women are unique amtiong mammHlals in ceasing their reproductive life in middle age. Not so; rhesus monkeys kept in comfortable captivity become menopausal in their early 20s, with characteristic changes i7n their hormtional patterns. So far nothitng has been published on their psychological response to the climacteric: nor is it known whether any wild mionkeys live long enough to reach that stagethough one of Jane Goodall's chimpanzees became subfertile in her late teens. Beans may prove to be the most important source of protein for most of the world in the next decade, but in Western society their acceptability is limited by the flatulence they produce. So a report on Food Legumie Processing and Utilisation from the International Development Research Centre in Ottawa is welcome for its attention to research into ways of lowering the flatus effect by reducing the proportion of oligosaccharides in the course of processing. Shall we soon see commercials for flatus-free foods ?
Animals Centre in Carshalton, and provides a means for laboratories to exchange information on the genetically defined rats now so essential for biomedical research. For example, the Rowett Research Institute have discovered an athymic nude mutant in their colony of hooded rats, and if this mutation has similar immunological defects to the nude mouse demand for specimens will be high. Minerva read with pleasure and itnterest John Gunn's review a recent "British J7ournal of Psychiatry" of criminal behaviour. He quotes Penrose's law: the homicide rate, the number of prisoners, the birth rate, the suicide rate, and the general death rate are all lower in countries with a high mental hospital population and vice versa. Here in Britain, as the mental hospitals have emptied the prisons have filled. The conclutsions to be drawn seemti clear. Fit young men rarely have haematuria, so that when a naval surgeon captain saw 18 servicemen with one or more episodes of apparently inexplicable bleeding he began to ask questions. All were runners at distances of 10 000 metres or over; and he has now described (British 7ournal of Urology, 1977, 49, 129) a new syndrome in which running long distances with an empty bladder leads to contusions of its posterior wall. The bruises heal rapidly. "Run with a full bladder," he advised, but the advice was rejected. Most of us think of leptospirosis as an occupational disease of sewer workers, but it may be more common than that. Doctors in St Louis, Missouri, believe ("Pediatrics," 1977, 90,532) that milder variants of the disease may often pass unrecognised in children. Symptoms included fever, anorexia, abdominal pain, headache, nausea, and a maculopapular rash: some degree of jaundice occurred in 7 out of 9 cases. Most were, they believe, traceable to dogs rather than rats, though they did not isolate Leptospira canicola from their patients: the most common serotype was L
icterohaemiorrhagiae. Having heard Dr Geoffrey Marsh explain to a London audience (see p 1374) the ratnge of services provided by nurses, health visitors, and social workers in his group practice, one doctor rose to ask where the money came from. Did not emnploymtient of so many staff with only 700,, reimbursemtent of salaries mean that doctors were paying for preventive medicine out of their own pockets ? Dr Marsh had two answers. Firstlv, doctors in his practice received two or three tinies the average in item of service payments for procedures such as immnunisations and cervical smears; and, secondlv, practice profit had kept ahead of inflation year by year. When a dark blue publication headed Medical Research Council and titled simply Rat News Letter landed on Minerva's desk she had sudden fantasies that all those bright-eyed, scientific rats, pumped full of mind-enhancing drugs and trained to a whisker by daily sessions in ever-more complicated mazes, were demanding their own reading matter. Not so. In prosaic fact, the newsletter is published by the MRC Laboratory
Postmortem examination of the mummy of an Egyptian believed to have died 3200 years ago showed the cause of death to be hepatic schistosomiasis-not very surprising; but the youth also had signs of dust disease of the lungs and pork tapeworm infestation with cysticercosis (American J7ournal of Diseases of Children, 1977, 131, 349). Taenia solium is now rare in Egypt-a tribute to the hygienic provisions of the Muslim religion, but schistosomiasis remains a daunting health problem.
WHO has been looking at irradiated food and has decided that irradiation is analogous to freezing or heating and should not be assessed on the same basis as food additives. The public need to be educated, says WHO (" Wholesomeness of Irradiated Food," technical report No 60) and reassured: and it has now passed as safe standard ways of irradiating potatoes, chickens, mushrooms, rice, and strawberries.
MINERVA
1418
MEDICOLEGAL Coroners and transplants FROM OUR LEGAL CORRESPONDENT
Doubts about the interpretation of the Human Tissue Act 1961 have led to some wellpublicised clashes between coroners and transplant surgeons. Now the Home Secretary, after consulting the Secretary of State for the Social Services, has written to all coroners' expressing the hope that they will never object in principle to a transplant operation, but refuse their consent only where the organ concerned might later be required as evidence or in order to pursue further inquiries. The coroner's role in transplants is a crucial one, since by reason of section 1(5) of the Act when there is reason to believe that an inquest may be held or that the coroner may require a postmortem examination no one may remove any organ without the consent of the coroner. The statute presents the coroner with a very wide, and indeed absolute, discretion to give or withhold his consent, but the Brodrick Committee2 thought that it was not the coroner's function "to place obstacles in the way of the development of medical science or to take moral or ethical decisions." Using the very words of the Brodrick Committee (but, curiously, without attribution), the Home Office circular states that the coroner should refuse his consent only if he is aware that there may be later criminal proceedings in which the organ might be required as evidence or if he believes that the removal of an organ might impede his own further inquiries. The circular also adds that refusal of consent would be justified where the coroner has reason to believe that a defect in the organ itself was the cause, or a contributory cause, of death.
Routine needed The vital need to have the shortest possible time elapse between the death of the donor and the removal of the organ led to suggestions to the Brodrick Committee that the time needed to obtain consent from both the relatives of the deceased and the coroner had made it so difficult to obtain organs that patients had died whose lives could have been saved by transplants. The Home Office circular reminds coroners that for kidney transplants the organ must be removed within half an hour of death and suggests that to ensure that this is possible the coroner and the hospital should work out a suitable routine in advance. Nevertheless, since the coroner has no jurisdiction over a live body he cannot give his consent to a transplant in advance. All that he can do is to indicate an intention, to be fulfilled or not after the death of the proposed donor. The Brodrick Committee considered that, even leaving aside the legal difficulties, it would be quite wrong to put the coroner in a position where it might be thought that his consent to a transplant amounted to permission to switch off a machine that was keeping the donor alive. Anxiety that compliance with the requirements of the Act had made transplants almost impossible led in September 1974 to an operation proceeding at Addenbrooke's Hospital in Cambridge even though neither the relatives of the donor nor the coroner had given their consent. The donor was a 20-year-
BRITISH MEDICAL JOURNAL
old senior aircraftman who had been injured in a late night car crash. A senior surgeon at Addenbrooke's told a subsequent inquest in Cambridge: "Time was of the essence.... I tried to the best of my ability to contact the deceased's relatives and the coroner concerned, but was unable to do so." After the inquest the coroner, Mr Dudley Durell, wrote to Professor Roy Calne, who led the team at Addenbrooke's which was then doing 60 kidney transplants a year. On receiving the letter Professor Calne ceased all transplants and publicly blamed the coroner for any deaths that ensued. The contents of the letter were never made public, but possibly the coroner made the justified point that proceeding without his consent would be a breach of the Act. Whether the transplanters were wrong to have proceeded without the consent of the deceased's relatives is more debatable. According to one newspaper report,4 Mr Durell held the view that the hour between the death of the donor and the removal of the organ was an unrealistic length of time in which to seek the permission of the relatives, and that therefore organs should be removed only where the deceased had been carrying a donor card.
Present position
Where a hospital is in possession of the body of a patient who has left written consent to its being used for a transplant it is now almost universally accepted) that (subject to the consent of the coroner) the hospital may proceed to remove the organ. Where the deceased has left such a written request his wishes appear to be paramount. Indeed, according to Lord Edmund Davies in a lecture to the Royal Society of Medicine,' only the person in possession of the body can countermand the request and veto removal of the organ. The DHSS in a guidance circular- to NHS authorities in June 1975 went so far as to state that where there was written consent by the deceased it would be "reasonable" to proceed with the removal of the organ, even though subsequently relatives or executors asked for possession of the body. The necessity to obtain the consent of the deceased's relatives arises only in the absence of written consent by the deceased. Section 1(2) of the Act permits the person lawfully in possession of the body to authorise the removal of an organ for transplantation if, "having made such reasonable inquiry as may be practicable, he has no reason to believe" that the deceased had expressed an objection to his body being so used or that any surviving relative objects. It is important to appreciate that the statute is so worded that it does not impose upon surgeons the obligation to satisfy themselves that the relatives have no objection. On the contrary, all that is required is for the surgeon to make such reasonable inquiry as may be practicable, and if at the end of that inquiry he has no reason to believe that there are objections, then he may proceed. In so far as a coroner laid down that the positive consent of the relatives must be obtained it seems probable that he was misreading the Act. Indeed, there could well be cases where in the minutes available between death and the transplant it was quite impossible to contact any relative. Then, so long as the surgeons had made such reasonable inquiry as might be
28 MAY 1977
practicable, they would seem to be free to proceed. Diagnosis of death The Home Office circular makes no suggestion to coroners as to the diagnosis of death. It merely encloses a copy of the report of the Royal Colleges and Faculties on the diagnosis of brain death and adds that it will be helpful for the hospital to know what evidence the coroner will require as to the diagnosis of death. The Human Tissue Act" merely requires the transplanting doctor to satisfy himself by personal examination of the body that life is extinct. There is no legal definition of death, and it has perhaps been too easily accepted that death is a matter of clinical judgment. After an inquest' at Birmingham in March 1974 on a man who had died 15 hours after reviving in the middle of an operation to remove his kidneys the jury returned a rider that the recommendations of the Maclennan Committee"' on transplant problems should be made law. The jury was particularly concerned that there should be legislation making it compulsory that death should be certified by two doctors, one of at least five years' seniority, and each independent of the transplant team. That the Birmingham jury's concern was not misplaced was shown by a case" '' at the Central Middlesex Hospital earlier this year, when the donor's death was certified only after the transplant. The hospital later disputed the Hornsey coroner's further criticism that the junior doctor who certified death was himself a member of the transplant team. Doctors have often resented over-dramatic press references"' to "body-snatchers," but if one matter above all others leads to public suspicion about transplants it is doubts about the diagnosis of death. Legislation which laid down, not what actually constitutes death, but how death should be certified would protect both doctors and patients. Home Office C'ircular No 65 1977. Report of the Commnsittee on D)eath Certificatiom and
(C'ro>ners. ILondon, HMSO, 1971. T7'he Tiies, 9 Septcmber 1974. Gua,rdian, 15 September 1974. Except by the Medical Defence Union, British Meclical io7oupia? 1975, 4, 66. Proceedings of the Royal Society of Medicine, 1969, 62, 633.
British MIedical lournal, 1975, 3, 107. Human TIissue Act 1961, section 1(4). "Da1ilv Telegraph, 16 March 1974. Report of the Cont,ntklittee oni T'ranisplantt Problems. London, HMSO, 1969.
T'he 'li'mes. 21 January 1977.
Described as 'absolutely astounding" by Professor Leslie Brent: Evening Standard, 20 January 1977. 3Newvs of the WY'orld, 28 September 1975: quoted in British AMedicalyournul, 1975, 4, 66.
12
PARLIAMENT First 1000 pay-beds cut On 19 May the Secretary of State for Social Services gave details in Parliament of the reduction in 1000 pay-bed authorisations under the Health Services Act 1976. In a written reply he said: "My right hon Friends the Secretaries of State for Scotland and Wales and I have issued revised authorisations under Section 1(1) of the Health Services and Public Health Act 1968 giving effect to the 1000 reductions in pay-bed authorisations prescribed
BRITISH MEDICAL JOURNAL
28 MAY 1977
in Schedule 2 of the Health Services Act 1976." Effect on the presenit distribiutiotn
of pay-bed
auithorisations
Regional health authority Northern Yorkshire Trent East Anglia North-west Thames North-east Thames South-east Thames South-west Thames Wessex Oxford South -western West Midlands Mersey
North-western London
No of authorised No of hospitals with authorised pay-beds pay-beds
Before After Before After 20.5.77 20.5.77 20.5.77 20.5.77
169 302 247 156 461 410 433 247 187 215 202 394 164 336 227
117 239 204 126 353 299 319 178 146 184 152 304 126 272 194
49
44
51 26 55 52 68 57 44 33 62 79 38 51 11
43 24 50 48 61 53 44 25 55 73 34 51 11
4150
3213
725
662
234
184
51
46
60
47
23
23
4444
3444
799
731
4Q
6
postgraduate boards of
governors
England Scotland Wales
Gt Britain (total)
(total)
"In 161 instances at the request of the authority concerned authorisation has been given on a group rather than on an individual hospital basis. It is a condition of all such group authorisations that the daily occupancy of authorised pay-beds by paying patients shall not exceed at any one time the authorised number of pay-beds for the group as a whole; subject to this overriding condition a hospital covered by a group authorisation may admit paying patients at any one time up to the limit authorised for the hospital concerned. In most instances the limit for an individual hospital is identical to the number of pay-beds it was authorised to provide when the Health Services Bill received Royal Assent. In eight instances we have approved modifications proposed by health authorities where these reflect more fairly than the former authorisations the present distribution of acute facilities. We are satisfied that these group authorisations will make it easier for the Health Services Board to recommend the progressive withdrawal of remaining pay-bed authorisations. A list of the revised authorisations as they affect individual hospitals has been placed in the Library. "Admissions of paying patients are generally low in relation to the number of authorisations so that the present reduction in authorisations is not likely to have any immediate widespread effect. Where however the reductions lead to an actual decrease in the number of private patients admitted to NHS hospitals resources will be released for general NHS use. It will be for health authorities, whose allocations have been compensated for the estimated loss of income, to consider the use to which such resources are put according to local circumstances."
necessary to give effect to the EEC Medical Directives. It will enable doctors who are nationals of any of the EEC member States and have a recognised qualification awarded in a member State to be authorised to practise in the UK. Corresponding provisions have been or will be made in other member States. As announced by Mr David Ennals, Secretary of State for Social Services on 5 April in the House of Commons (16 April, p 1037), the order includes a provision for the registration of doctors from the EEC to lapse after a period, normally six months, unless the doctor concerned has satisfied the General Medical Council that he has the necessary knowledge of English. The Government press statement says that other provisions of the order follow the lines of the consultative document on the implementation of the Directives which the Government issued to interested bodies in March last year. These include the following: "Doctors from other member states who wish to establish themselves in this country will be registered by the General Medical Council on the same basis as doctors qualifying in the UK. But EEC doctors who wish to provide services here on a temporary basis-for example, when they are called in to treat a patient from another member State who is taken ill while on holiday here and who wants the services of his own doctor-will be entitled to do so without having to go through all the formalities of registration. But they will have to provide certain information to the GMC, who will put their names on a special list. This list will for legal purposes form part of the medical register, and the doctors concerned will, like others registered here, be subject to the GMC's disciplinary rules. "The GMC has already been designatedand this is confirmed in the order-as the authority competent to issue the new certificates of specialist training which will be the recognised UK specialist qualification for the purposes of free movement within the Community. The GMC is to maintain a list, called the 'specialist list,' of doctors who are nationals of any member State and have specialist qualifications entitled to recognition within the Community."
Questions in the Commons
the limited provisions of Section 8 of the Health Services Act 1976 for which the detailed arrangements are currently under discussion. One of the conditions which will apply to these arrangements is that paying patients should be admitted on the basis of medical priority alone. Since I have not yet determined the charges which will be made for these services I cannot make any estimate of the likely revenue which will accrue."
MEDICAL NEWS College report on geriatrics Acute medical and geriatric facilities in district hospitals should be integrated into a single operational unit, says the Royal College of Physicians of London in a report published last week in the Lancet (21 May, p 1092). The working party, which was chaired by Sir Cyril Clarke, suggests that all consultant physicians (including those specialising in geriatric medicine) should have direct access to these acute beds and that geriatricians might take their turn in rotation with other colleagues in dealing with emergency cases. Geriatric services are of uneven quality, says the report, and it comments that the "inferior status" of the specialty results from its association with old and least updated buildings, inferior diagnostic facilities, and junior staff "often inadequate in numbers and quality." Many of these difficulties would be overcome by the integration of the diagnostic and therapeutic services of physicians and geriatricians. The report recommends that geriatric medicine should be given more emphasis in the MRCP examination and that there should be more rotation of junior appointments between geriatric and acute medicine. In future, it suggests, physicians with training in general medicine and geriatrics should be appointed as general physicians with a special interest in geriatric medicine, with a contract stating the number of sessions to be devoted to rehabilitation and long stay units. Differing patterns of care of the elderly should evolve in each area, the report concludes, with the medical profession exploiting the local resources to the full. Its recommendations should be taken only as guidelines.
Pay-beds: revenue from overseas patients
Mr Patrick Jenkin asked the Secretary of State for Social Services for an estimate of the revenue to the NHS from the use of pay-beds by overseas patients in the latest period for which figures are available. He also asked whether it was now his intention that such foreign patients should be admitted on the same conditions as would apply to United Kingdom patients and what estimate he had made of the reduction in revenue which this will involve. In reply, Mr David Ennals stated: "The proportion of pay-bed income derived from overseas patients is not recorded EEC Medical Directives separately. While pay-beds remain in NHS hospitals they will continue to be available for Publication of order in council use by paying patients, whether resident in the UK or not, on the same basis as present. When An order in council was published on 19 pay-beds are phased out admission to NHS May, which comes into effect on 10 June, that hospitals of private patients, whether resident makes the changes in United Kingdom law overseas or in the UK, will be possible under
Health Service Commissioner In his annual report (published 17 May, HMSO, 75p) the Health Service Commissioner says that there was a significant increase in the number of complaints (582) that he received in the year. Two-thirds were outside his jurisdiction, and the remainder were mainly concerned with difficulties in getting patients into hospital, ambulance services, consent to treatment, and detention in mental hospitals. Doctors sometimes questioned the value of investigations into complaints that appear to be trivial, says the Commissioner, but he believed that "confidence in the NHS is of paramount importance and this confidence will be increased if people with genuine grievances know they will be fully and impartially investigated.... Where complaints turn out to be totally unreasonable I have not hesitated in my reports to say so."
1420
BRITISH MEDICAL JOURNAL
Workshop on medical writing
9 Thurs 9 Thurs
Organisation Committee, 10.15 am. New Consultant Contract Working Party (CCHMS), 2 pm. Executive Subcommittee (CCCM), 10.30 am.
There are still a few vacancies for the BMJ 10 Fri workshop on problems with medical writing at the Birmingham Medical Institute on 1 July. Those wishing to participate should be Division Meetings to be Held Members proposing to attend meetings marked * are willing to submit in advance a paper for dis- asked to notify in advance the honorary secretary cussion and tuition and should apply, with a concerned. cheque for £20, to the Editor, British Medical Bromley-At Farnborough Hospital. Thursday. 2 Journal, BMA House, Tavistock Square, June, 8.30 pm, agm. Dryburn Hospital, Monday, 30 May, Durham-At London WClH 9JR. 8.30 pm, Mr J B Secrett: "Washington Wildfowl Refuge." (Preceded by supper, 7 for 7.30 pm.* Guests
are invited.)
Alan Edwards Memorial Fund
Leicestershire and Rutland-At Overstone Solarium, Saturday, 4 Tune, 7.30 for 8 pm, medical
ball. *
The money collected for the above fund (see BM7, 22 May 1976, p 1288) totalled £2098. This was passed to the British Association of Surgical Oncology for an annual essay prize for young surgeons.
COMING EVENTS "Nutritional aspects of gastroenterology"Symposium, 30 June-I July, London. Details from the dean of postgraduate studies, Sr Mark's Hospital, City Road, London EC1V 2PS. (Tel 01-253 1050.) Whipps Cross Hospital-Details and copies of the programme to 30 August are now available from the Medical Education Centre, Whipps Cross Hospital, London Ell. (Tel 01-539 5522 ext 310.) Winchester and Central Hampshire Postgraduate Medical Centre-Details and copies of the programme May to August 1977 are now available from the Centre, Hampshire County Hospital, Winchester. (Tel Winclhester 63535 ext 422.)
SOCIETIES AND LECTURES For attending lectures marked * a fee is charged or a ticket is reqtired. Applications shouild be tnade -first to the institution concerned.
Monday, 30 May INSTITUTE OF OBSTETRICS AND GYNAECOLOGY-At Queen Charlotte's Hospital, 4.30 pm, Dr M de Swiet, Barbara Morgan: Cardiac arrest.
Tuesday, 31 May ROYAL FREE HOSPITAL-1
pm, Dr F J Dudley
(Australia): Glucagon metabolism. Wednesday, 1 June
INSTITUTE OF PSYCHIATRY-5.30 pm, Dr M E Carruthers: Heart attack: egg or ego ? MEDICO-PHARMACEUTICAL FORUM-At Royal Society of Medicine, 3.30 pm, statutory meeting: "The survival of medical journals." ROYAL COLLEGE OF SURGEONS OF ENGLAND-At Royal Victoria Infirmarv, Newcastle, 4 pm, Hunterian lecture by Professor M H Thompson: Histamine H. receptor antagonists and peptic ulcer disease. 5.30 pm, Harris and Gale lecture by Mr D C Britton: The patho-physiological sequelae of peptic ulcer surgery. ROYAL FREE HosPITAL-5 pm, Dr R Hecker (Adelaide): Cimetidine and duodenal ulcer. ROYAL POSTGRADUATE MEDICAL SCHOOL-1 1.45 am, Professor C Alleyene (West Indies): UNIVERSITY OF OXFORD-At John Radcliffe Hospital, 4 pm, Mr Peter Anderson: Sexual attitudes of undergraduates-preliminary report of Oxford study.
Thursday, 2 June ONCOLOGY CLUB-At Guv's Hospital, 6.30 pm, Dr R Rubens: Prospects in the treatment of breast cancer. ST MARY'S HOSPITAL MEDICAL SCHOOL-5.15 pm, Aleck Bourne lecture by Miss Aileen Dickins: The care of the older pregnant woman.
BMA NOTICES Diary of Central Meetings JUNE 2 Thurs 7 Tues
8 Wed
Joint Agenda Committee, 2 pm. Scottish General Medical Services Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.30 am. BMA Council Executive, 1 pm.
28 MAY 1977
HIarrison, M W Kanan, A S McNeish, J W Paterson, L A Salako, A Seaton, R D H Boyd, J D Carroll, A C F Kenmure, C A E H Loehry, M W Moncrieff, T C Northfield, Major-General R A Smart, R Balcon, JM H Buckler, J H Keen, B J Prout, P C Robertson, P Rodin, W J Cunliffe, D Gardner-Medwin, A H Rubenstein, W J Makene, R C Turner, P E Gower, j L Ngu, B N C Prichard, R M McLellan, T-K Chan, R N Maini, G R Serjeant, C E Sissons, C W M Adams, J D Baum. D A Warrell, C Chantler, D Ogston. Anne G Ferguson, J 0 M Pobee, J C Crawhill, D L Davies, F J Macartney, M D Rawlins, T J McElwain, A Viriyavejakul, D J Kinloch, I MacIntyre, M Swash, W R ILee, G P McNicol, M Friedman, J Landon, E J L Lowbury, P Alwyn-Smith, A Herxheimer, A C Kennedy, J G McLeod, D C Morley, Elsie R Rue, I G Taylor, E D Williams. The following were elected fellows under Bye-Law 39(c)-N Islam, Group Captain P Howard, A M Adelstein, B R Jones, J G Widdicombe, M Caplin, W E Miall, R D Catterall. The following were elected fellows under Bye-Law 39(b)-B G Alton, J A F Ambrose, J W Black, R M Cherniack, Sir Stanley Clayton, W 0 Creutzfeldt, R A Gregory, J T Shepherd. The following were elected members under Bye-Law 124(d)-R G Batey, F B Crimmins, A H Waters. The following were elected members under Bye-Law 117-E A Barker, J R Clamp, A M Geddes, A Ghareeb, Rolth F Harris, R A Joske, A K Mant. J W Thompson.
Manchester-At Boyd House, Tuesdav, 31 Mav, 8 for 8.30 pm, Dr P H Smith: "Assessment of a new antirheumatic sulindac (Clinoril) in general practice."* (Supper provided.) North and South Camden Divisions-At Kenwood House, Thursday, 2 June, 7.15 for 8 pm, jubilee dinner.* (Guests are welcome.) Northern Region-At Crest Motel, Carlisle, Monday, 30 Mav, 7.15 for 7.30 pm, council meeting. North-west Essex-At Princess Alexandra Hospital. Thursday, 2 June, 8 for 8.30 pm, agm. South Middlesex-At Queen Mary Sailing Club, Thtursday, 2 Jutne, 7.30 pm, supper dance.* South Tees-At Marton Hotel and Country Club, Thursday, 2 June, 7.30 pm, agm followed by annual dinner. Wirral-At Clatterbridge Hospital, Thursday, 2 June, 8 pm, meeting to disculss agenda for ARM.
following consultants have been appointed: Mr G G Mitchell (obstetrics and gynaecology); Dr P D Mohr (neurology).
UNIVERSITIES AND COLLEGES
Corrections
CAMBRIDGE MD-W A D Griffiths, C J Oon, D J Powell-Jackson.
Advances in the treatment of kidney disease: An introduction In this article bv Dr J R Curtis (14 May, p 1270) under sub-heading "Peripheral neuropathy and chronic renal failure," the last sentence of the third paragraph should begin "Mvo-inositol has recently attracted attention
SOUTHAMPTON The title of reader in clinical epidemiology and community medicine has been conferred on Dr D J P Barker.
LONDON MD-A W P du V'ivier, B J B Grant, A G Morgan. A Sedaghat. MS-J F Colin, A N Nicolaides. ROYAL COLILEGE OF PHYSICIANS OF EDINBURGH At a quarterly meeting of the college held on Thursday, 5 Mav, with the president, Dr R F Robertson. in the chair, Lillian M Pickford and R Van Furth were elected Fellows under the Laws of the College, Cap II, 10. Dr Catriona Irvine was awarded a Hill PattisonStruthers bursarv for 1977. The Medical Commission on Accident Prevention Prize Essay, 1977. was awarded to Dr C J Scott.
ROYAL COLLEGE OF PHYSICIANS OF
APPOINTMENTS SALFORD AREA HEALTH AUTHORITY (TEACHING)-The
Annual Report of Council (Appendix VII: Amendment to the Second Schedule to the By-laws) The sentence "1 to be nominated by the Council of the British Dental Association" under nonvoting members of the General Medical Services Committee (7 May, p 1236) should be deleted and a new paragraph inserted which should read "1 representative appointed by the Council of the British Dental Association."
LONDON
The following have been elected to fellowship of the college: N Jungalwalla, L G Hannah, G H Valentine, A Divaris, H Grusin, I F Hayali, I P Jaffe, I P Sparks, N C Begg, J H Deakin, J H Pratt-Johnson, R E Beamish, D M Abelson, E Sanders, L B Sunn, Margaret Eastwood, Surg-Rear Admiral S G Rainsford, D'A Kok, K S Milligen, R I Eakin, L I Phillips, T B Brewin, F E Dische, Brenda D Van Leuven, M J D Newman, P M Higgins, A R H Worssam, T C K Marr, Rosemary A Cooper, D J Gudex, W B Hennessy, Katharine M Dormandy, F H Burns, A J Goble, W M I Maxwell, R Slome, D J Attvgalle, J H Allison, A D Forrest, I J Pinto. T H S Kirkland, I D Thomas, P Ebeling, P F Benson, J F Hare, Patricia J Lindop, I B Hales, R S Mibashan, R H Culpan, I R Ferguson, J M Duggan, J S Garfield, G A Hunter, V F Weinstein, L H Opie, M Greenberg, M J Pritchard, K F R Schiller, Shelagh M Tighe, J G Sloman, H B Griffith, E N Glick. P M Last, G Michell, M D Ravson, J M Costello, Rosemarv Stephens, P T Pickens, W D Stone, E E Jones, H J Liebeschuetz, Valerie J Marrian, 0 H D Portsmouth, D Gooptu, J L James, D P Mullan, D F Scott, R M Norris, K P Goldman, Betty L Priestley, H A Rees, R P Ashfield, N J B Evans, C J Goodwill, M R Lee, M A Newton, G B Wyatt, D C Fluck, C Tasman-Jones, E S Paykel, P L Boardman, J F Harrison, A C Ikeme, P N L eslie, Clara Lowv, A B Shrank, E S Garnett, B A Latham, S M Rosen, A H Henderson, R G Luke, S D B Mohamed, J Perkins, B K Samtani, Mary Corbett, T P Ormerod, E K M Smith, R W Emmerson, G I Nicholson, M J Smith, G C Sutton, M Thomas, G J Thorpe, E G Anderson, W I Austad. C J Burns-Cox, A R R Cain, J W H Doar, Margaret E R Stoneman, Shirley H Wrav, D B Grant, J J F Hamblin, D H W Kelly, A D Ferguson, T M Hayes, D M Hill, Elizabeth A Hills, J K L Jones, M P Mahoney, N Peters, E B Raftery, I D B Rennie, Evan M Kohner, J P O'Loughlin, G S Spathis, 0 H Amin, S S Bleehen, A K Brown, G F Cohen, H1 L H Frankel, R L Himsworth, P J R B Keelan, M S Kanpp, A H Roberts, M D Sanders, G M Sterling, J D Swales, J A Walker-Smith, A T Bevan, K D Buchanan, P Cannon, F J Goodwin, C R M Prentice, G P Sechiari, P Sharpstone, Wing Commander G C Turner, E T Young, A S Abraham, T M Barratt, E M R Critchley, Winifred N Kaine, R Marks, S Ramachandran, G Russell, H Savage, S P Allison, R G Brackenridge, C K Connolly, B M Greenwood, M J G
From the CCHMS In the third paragraph of the report from the chairman ("From the CCHMS", 21 May, p 1368) "Nuffield Provincial Hospitals Trust" should read "Nuffield Nursing Homes Trust." We apologise for this error.
Notice to authors When original articles and letters for publication are not submitted exclusively to the British Medical J7ournal this must be stated. For detailed instructions to authors see page 6 of the issue dated 1 January 1977. Correspondence on editorial business should be addressed to the Editor, British Medical J'ournal, BMA House, Tavistock Square, London WC1H 9JR. Telephone: 01-387 4499. Telegrams: Aitiology, London WC1. Communications will not be acknowledged unless a stamped addressed postcard or an international reply coupon is enclosed. Authors wanting reprints of their articles should notify the Publishing Manager, BMA House, Tavistock Square, WC 1H 9JR, on receipt of proofs. t British Medical Journal 1977 All Rights Reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
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