159
Letters
to
COMPOSITION OF MILKS MADE UP ACCORDING TO INSTRUCTIONS ON PACKETS OR TINS FOR A ONE-MONTH-OLD BABY COMPARED WITH HUMAN AND COWS’ MILK
the Editor
NATIONAL DRIED MILK
SiR,-We have noted that it is uncommon for babies attending paediatric outpatient clinics and child-health clinics to be feeding on National Dried Milk (N.D.M.). This has prompted us to investigate how many babies were being fed on this product in Oxford City before the reorganisation of the National Health Service. Total births in Oxford City for 1955-73 are shown in fig. 1 together with the total sales of N.D.M. in the city over the same period. The percentage of babies feeding on N.D.M. is shown in fig. 2, based on the assumption that a baby would consume 2 tins of powdered milk per week (100 per year). The decline in sales of N.D.M. over this period has resulted in a fall in the percentage of babies fed on this product from 40% in 1956 to 3% in 1973. Why have progressively fewer mothers chosen to feed their babies on N.D.M. ? We do not know the answer to this question, but we would make the following observations. It is not due to an overwhelming increase in breast-feeding since a recent survey in Oxford showed that in one maternity ward only 27% of mothers went home breast-feeding their babies and of these 50% had stopped lactation within two months of birth.! It may be due to the wide range of baby-milk formulas on the market which have been increasingly advertised and are readily available in retail 1.
Sloper, K., McKean, L., Baum, J. D. Archs Dis. Childh. (in the press).
Fig. I-Total births in Oxford City, 1955-73 (A), and total sales of National Dried Milk over the same period (B).
Values expressed in g. milk.’2
or mg. per
100 g.
and meq. per kg. made-up
chemists and supermarkets. N.D.M. is not advertised and in Oxford City is only available in child health clinics. It may also be due to the influence of the maternity hospital which supplies mothers in hospital with preformulated feeds if they are not breast-feeding their babies. The commercial brand used in the hospital is commonly taken by the patient, nursing, and medical staff to be an underwriting of the superiority of that brand over other products on the market. N.D.M. is not available in a preformulated form and could not therefore be used in the hospital as an alternative to commercial products. The various commercial formulas available range in price from 42-lp to 68p retail.* In contrast, N.D.M. costs 20p per tin. There is widespread belief among mothers, midwives, health visitors, retail chemists, and medical staff that N.D.M. is an inferior product. This is not borne out by a comparison of its chemistry with the standard milk preparations available, as illustrated in the accompanying table. For example, N.D.M. has concentrations of protein, sodium, potassium, and phosphorus nearer to human milk than other standard milk preparations; although these values are not as low as in the low solute " humanised " milk preparations such as S.M.A. We do not suggest that N.D.M. is ideal in its composition at present. Clearly, there is room for modification of this product so that it more closely resembles human milk. However, it certainly is not inferior to the commonly used unmodified dried-milk powders such as Cow & Gate Babymilk 2 (Full Cream Cow & Gate milk). We are concerned that while there is an N.D.M. available at a price considerably less than the commercial brands of powdered milk, it is being offered for sale without adequate publicity. We feel there is a case for advertising this product more widely and making it readily available. We would be interested, through the courtesy of your columns, to ask whether other paediatricians and community physicians have met similar trends in sales of N.D.M. in other parts of the country. John Radcliffe Hospital, J. D. BAUM Headington, P. HARKER. Oxford OX3 9DU. A CURE FOR DANGEROUS FEVER
SIR,-The consultants’ dispute, like a dangerous fever, be cured by a reasoned analysis of its cause leading to Mr Macdonald’s an imaginative alteration in treatment. letter (Jan. 4, p. 34) was good on analysis, but not farreaching enough in treatment. Dr Stevenson’s letter" has, I hope, made the consultants’ action less incomprehensible to the general public than your leader of Jan. 4 (p. 21) would can
YEAR
Fig. 2-Percentage of babies fed on National Dried Milk in Oxford City, 1955-73.
*
Pre-Budget, November, 1974. Boots the Chemist, Oxford. Shaw, J. C. L., Jones, A., Gunther, M. Br. med. J. 1973, ii, Times, Jan. 6, 1975.
2. 3.
12.
160 suggest. The Presidents of two of the Royal Colleges have stressed the dangers of spread of the dispute and emphasised that there is always room for compromise. The consultants have taken this exceptional step oj sanctions. I hope we will maintain them and obtain a quick settlement because we know we are in the right. The Hippocratic oath (no voluntary acts of mischief whilst continuing to work for the benefit of the sick) has not been broken because the choice has been between two mischiefssanctions on the one hand and agreeing on the other to a " " take it or leave it contract, based on dogmatised error, which is, in our opinion- harmful to the interests of all out patients. We chose the lesser mischief-sanctions, and I
right. Ralph Dahrendorf’s Reith lectures4 outline
am sure we are
some basic should help the Government as well as the consultants. The " take it or leave it " contract is illiberal because it is based on distorted notions of equality. Maintenance of equality of rights does not involve making everyone do the same thing. The breakdown of the National Health Service, with all the intolerable collective misery that this entails, started before our negotiations. Barbara Castle’s provocative intervention of Dec. 20 was unfortunate, because agreement about improving the N.H.S. had almost been reached. (In particular our negotiators had agreed to a considerableabout 14%-whole-time commitment allowance and you were wrong not to stress this fact in your leader of Jan. 4. The extra 1/11th paid at 1times the sessional rate should be worked within the 10/10 contract and should then be an adequate total commitment allowance.) A new approach is now essential, or vital services will soon be withheld because they are no longer available. Demoralisation of the consultants-the engines of the hospital service-and massive emigration of young British-trained doctors from our shores, quite apart from big cuts in hospital expenditure, will bring about this sad state of affairs, unless we get a
principles which
new
A
approach. new
concept of health services is also necessary in
to overcome the present rigidities and allow the patient to enjoy a different improving Health Service. Mrs Castle’s contract is mainly directed against the regional surgeons’ right to private practice as we cannot confine our private operations to the evenings and week-
order
ends. Speaking as a regional surgeon, I feel that oui sanctions are more a visceral reaction against being hemmed in than a response to reduction of our pay. In fact, at present, most of us stand to gain more from a whole-time contract, by an associated increase in pensions with their built-in hedge against inflation. No !We react against the contract because, to use Dahrendorf’s apt illustration, it hems us into a " small, closed room " type of health service. This room has a low floor beneath which no-one will be allowed to fall, but the ceiling is also low and the doors and windows are closed. It maintains rights by making everyone do the same thing. It also ensures that everyone will be equally miserable and poorly looked after. If we go into this room it means we accept a real danger of a third-rate hospital service with increasing cuts for patient care dictated for political rather than medical reasons. We opt instead for a large room with a high floor and ceiling. We want to open the doors and windows and even decorate the walls. I think most regional surgeons would agree that we want a healthy Health Service dealing mainly with major surgery and without queues for either major or minor surgery. We think we can obtain this by supporting and bolstering the Health Service with an expanding private sector heavily subsidised by large industrial firms and also helped by oil sheikhs. We agree with elimination of the injustices in the private sector outlined in your leader of Nov. 16 (p. 4. Listener, Nov. 14, 1974-Jan. 2, 1975.
1184), but many further changes are necessary. The most important change is financial recognition of the whole team which backs up the consultant. A fund to help all hospital workers would be easier to organise than direct fees for each item of service to each nurse, technician, administrator, involved. Consultants should contribute an porter, &c., agreed portion of their fee to this fund, and oil sheikhs and other wealthy grateful patients should be encouraged to make large donations to this fund. The hospital workers would then decide how the fund should be spent. One method would be to use the fund to improve the amenities of life and so help to prevent " hospital staff at all levels giving up and ceasing to care ". These methods of improving the balance between private practice and the N.H.S. are far better than splitting off the private sector completely and returning to all the bad parts of the two-tier pre-1948 Health Service which Mrs Castle is planning for. We want to keep our young doctors in Britain. We opt against drab uniformity in an alienated system and instead, in these difficult and gloomy times, we opt for improvement. All we ask of Mrs Castle is to give us a chance to prove our case. We hope she will retract her " take it or leave it " attitude to negotiations as soon as possible and allow us to concentrate on improvement rather than the production of drab uniformity. The General
Hospital, Sunderland,
Durham SR4 7TP.
DONALD HANCOCK.
SANCTIONS AND THE N.H.S. SIR,-Sanctions are not in fact primarily in defence of large private-practice incomes: those with such would be only marginally affected by the new contracts offered. The phasing-out of private beds from the N.H.S. appears inevitable, and this will greatly reduce the facilities available to the majority of part-time consultants. Regarded in this light the proposed option is quite punitive; surely it is not much to suggest that one should be free to practise privately out of hours and where appropriate to give up a number of sessions on a pro rata basis (as is in fact suggested for those with a large practice). 11 North Park
Road, Roundhay, Leeds LS8,ljD.
D. S. EASTWOOD.
THE CONSULTANTS’ CONTRACT
SIR,-Mr Houghton (Dec. 28, p. 1566) suggests that men " have expressed a " high ethical
only " laboratory
standard". One could equally argue that most of the " militant " consultants are part-time surgeons. But if Mr Houghton would carefully re-read my letter of Dec. 14, (p. 1446) he will find this was not the point I wished to make. May I reiterate that both full-time and part-time consultants could have achieved a fair deal by negotiation on the basis of the Department’s proposals. Worthing Hospital, Worthing, Sussex.
K. S. RODAN.
LITHIUM IN THYROTOXICOSIS
SIR,-We share the concern expressed by Professor Hall and Dr Evered (Dec. 21, p. 1521) that lithium should be used routinely in patients who exhibit sensitivity to carbimazole or in those with thyroid crisis. We suggested that lithium could (rather than should) be administered to patients allergic to the thiocarbamides. We did not mention its use in thyroid crisis because we have no personal experience nor are there any published reports of its use in this condition.
Letters
to
COMPOSITION OF MILKS MADE UP ACCORDING TO INSTRUCTIONS ON PACKETS OR TINS FOR A ONE-MONTH-OLD BABY COMPARED WITH HUMAN AND COWS’ MILK
the Editor
NATIONAL DRIED MILK
SiR,-We have noted that it is uncommon for babies attending paediatric outpatient clinics and child-health clinics to be feeding on National Dried Milk (N.D.M.). This has prompted us to investigate how many babies were being fed on this product in Oxford City before the reorganisation of the National Health Service. Total births in Oxford City for 1955-73 are shown in fig. 1 together with the total sales of N.D.M. in the city over the same period. The percentage of babies feeding on N.D.M. is shown in fig. 2, based on the assumption that a baby would consume 2 tins of powdered milk per week (100 per year). The decline in sales of N.D.M. over this period has resulted in a fall in the percentage of babies fed on this product from 40% in 1956 to 3% in 1973. Why have progressively fewer mothers chosen to feed their babies on N.D.M. ? We do not know the answer to this question, but we would make the following observations. It is not due to an overwhelming increase in breast-feeding since a recent survey in Oxford showed that in one maternity ward only 27% of mothers went home breast-feeding their babies and of these 50% had stopped lactation within two months of birth.! It may be due to the wide range of baby-milk formulas on the market which have been increasingly advertised and are readily available in retail 1.
Sloper, K., McKean, L., Baum, J. D. Archs Dis. Childh. (in the press).
Fig. I-Total births in Oxford City, 1955-73 (A), and total sales of National Dried Milk over the same period (B).
Values expressed in g. milk.’2
or mg. per
100 g.
and meq. per kg. made-up
chemists and supermarkets. N.D.M. is not advertised and in Oxford City is only available in child health clinics. It may also be due to the influence of the maternity hospital which supplies mothers in hospital with preformulated feeds if they are not breast-feeding their babies. The commercial brand used in the hospital is commonly taken by the patient, nursing, and medical staff to be an underwriting of the superiority of that brand over other products on the market. N.D.M. is not available in a preformulated form and could not therefore be used in the hospital as an alternative to commercial products. The various commercial formulas available range in price from 42-lp to 68p retail.* In contrast, N.D.M. costs 20p per tin. There is widespread belief among mothers, midwives, health visitors, retail chemists, and medical staff that N.D.M. is an inferior product. This is not borne out by a comparison of its chemistry with the standard milk preparations available, as illustrated in the accompanying table. For example, N.D.M. has concentrations of protein, sodium, potassium, and phosphorus nearer to human milk than other standard milk preparations; although these values are not as low as in the low solute " humanised " milk preparations such as S.M.A. We do not suggest that N.D.M. is ideal in its composition at present. Clearly, there is room for modification of this product so that it more closely resembles human milk. However, it certainly is not inferior to the commonly used unmodified dried-milk powders such as Cow & Gate Babymilk 2 (Full Cream Cow & Gate milk). We are concerned that while there is an N.D.M. available at a price considerably less than the commercial brands of powdered milk, it is being offered for sale without adequate publicity. We feel there is a case for advertising this product more widely and making it readily available. We would be interested, through the courtesy of your columns, to ask whether other paediatricians and community physicians have met similar trends in sales of N.D.M. in other parts of the country. John Radcliffe Hospital, J. D. BAUM Headington, P. HARKER. Oxford OX3 9DU. A CURE FOR DANGEROUS FEVER
SIR,-The consultants’ dispute, like a dangerous fever, be cured by a reasoned analysis of its cause leading to Mr Macdonald’s an imaginative alteration in treatment. letter (Jan. 4, p. 34) was good on analysis, but not farreaching enough in treatment. Dr Stevenson’s letter" has, I hope, made the consultants’ action less incomprehensible to the general public than your leader of Jan. 4 (p. 21) would can
YEAR
Fig. 2-Percentage of babies fed on National Dried Milk in Oxford City, 1955-73.
*
Pre-Budget, November, 1974. Boots the Chemist, Oxford. Shaw, J. C. L., Jones, A., Gunther, M. Br. med. J. 1973, ii, Times, Jan. 6, 1975.
2. 3.
12.
160 suggest. The Presidents of two of the Royal Colleges have stressed the dangers of spread of the dispute and emphasised that there is always room for compromise. The consultants have taken this exceptional step oj sanctions. I hope we will maintain them and obtain a quick settlement because we know we are in the right. The Hippocratic oath (no voluntary acts of mischief whilst continuing to work for the benefit of the sick) has not been broken because the choice has been between two mischiefssanctions on the one hand and agreeing on the other to a " " take it or leave it contract, based on dogmatised error, which is, in our opinion- harmful to the interests of all out patients. We chose the lesser mischief-sanctions, and I
right. Ralph Dahrendorf’s Reith lectures4 outline
am sure we are
some basic should help the Government as well as the consultants. The " take it or leave it " contract is illiberal because it is based on distorted notions of equality. Maintenance of equality of rights does not involve making everyone do the same thing. The breakdown of the National Health Service, with all the intolerable collective misery that this entails, started before our negotiations. Barbara Castle’s provocative intervention of Dec. 20 was unfortunate, because agreement about improving the N.H.S. had almost been reached. (In particular our negotiators had agreed to a considerableabout 14%-whole-time commitment allowance and you were wrong not to stress this fact in your leader of Jan. 4. The extra 1/11th paid at 1times the sessional rate should be worked within the 10/10 contract and should then be an adequate total commitment allowance.) A new approach is now essential, or vital services will soon be withheld because they are no longer available. Demoralisation of the consultants-the engines of the hospital service-and massive emigration of young British-trained doctors from our shores, quite apart from big cuts in hospital expenditure, will bring about this sad state of affairs, unless we get a
principles which
new
A
approach. new
concept of health services is also necessary in
to overcome the present rigidities and allow the patient to enjoy a different improving Health Service. Mrs Castle’s contract is mainly directed against the regional surgeons’ right to private practice as we cannot confine our private operations to the evenings and week-
order
ends. Speaking as a regional surgeon, I feel that oui sanctions are more a visceral reaction against being hemmed in than a response to reduction of our pay. In fact, at present, most of us stand to gain more from a whole-time contract, by an associated increase in pensions with their built-in hedge against inflation. No !We react against the contract because, to use Dahrendorf’s apt illustration, it hems us into a " small, closed room " type of health service. This room has a low floor beneath which no-one will be allowed to fall, but the ceiling is also low and the doors and windows are closed. It maintains rights by making everyone do the same thing. It also ensures that everyone will be equally miserable and poorly looked after. If we go into this room it means we accept a real danger of a third-rate hospital service with increasing cuts for patient care dictated for political rather than medical reasons. We opt instead for a large room with a high floor and ceiling. We want to open the doors and windows and even decorate the walls. I think most regional surgeons would agree that we want a healthy Health Service dealing mainly with major surgery and without queues for either major or minor surgery. We think we can obtain this by supporting and bolstering the Health Service with an expanding private sector heavily subsidised by large industrial firms and also helped by oil sheikhs. We agree with elimination of the injustices in the private sector outlined in your leader of Nov. 16 (p. 4. Listener, Nov. 14, 1974-Jan. 2, 1975.
1184), but many further changes are necessary. The most important change is financial recognition of the whole team which backs up the consultant. A fund to help all hospital workers would be easier to organise than direct fees for each item of service to each nurse, technician, administrator, involved. Consultants should contribute an porter, &c., agreed portion of their fee to this fund, and oil sheikhs and other wealthy grateful patients should be encouraged to make large donations to this fund. The hospital workers would then decide how the fund should be spent. One method would be to use the fund to improve the amenities of life and so help to prevent " hospital staff at all levels giving up and ceasing to care ". These methods of improving the balance between private practice and the N.H.S. are far better than splitting off the private sector completely and returning to all the bad parts of the two-tier pre-1948 Health Service which Mrs Castle is planning for. We want to keep our young doctors in Britain. We opt against drab uniformity in an alienated system and instead, in these difficult and gloomy times, we opt for improvement. All we ask of Mrs Castle is to give us a chance to prove our case. We hope she will retract her " take it or leave it " attitude to negotiations as soon as possible and allow us to concentrate on improvement rather than the production of drab uniformity. The General
Hospital, Sunderland,
Durham SR4 7TP.
DONALD HANCOCK.
SANCTIONS AND THE N.H.S. SIR,-Sanctions are not in fact primarily in defence of large private-practice incomes: those with such would be only marginally affected by the new contracts offered. The phasing-out of private beds from the N.H.S. appears inevitable, and this will greatly reduce the facilities available to the majority of part-time consultants. Regarded in this light the proposed option is quite punitive; surely it is not much to suggest that one should be free to practise privately out of hours and where appropriate to give up a number of sessions on a pro rata basis (as is in fact suggested for those with a large practice). 11 North Park
Road, Roundhay, Leeds LS8,ljD.
D. S. EASTWOOD.
THE CONSULTANTS’ CONTRACT
SIR,-Mr Houghton (Dec. 28, p. 1566) suggests that men " have expressed a " high ethical
only " laboratory
standard". One could equally argue that most of the " militant " consultants are part-time surgeons. But if Mr Houghton would carefully re-read my letter of Dec. 14, (p. 1446) he will find this was not the point I wished to make. May I reiterate that both full-time and part-time consultants could have achieved a fair deal by negotiation on the basis of the Department’s proposals. Worthing Hospital, Worthing, Sussex.
K. S. RODAN.
LITHIUM IN THYROTOXICOSIS
SIR,-We share the concern expressed by Professor Hall and Dr Evered (Dec. 21, p. 1521) that lithium should be used routinely in patients who exhibit sensitivity to carbimazole or in those with thyroid crisis. We suggested that lithium could (rather than should) be administered to patients allergic to the thiocarbamides. We did not mention its use in thyroid crisis because we have no personal experience nor are there any published reports of its use in this condition.
