1291 either in their teaching or research, but all radiologists have dissected the body. Now that G. N. Hounsfield, F.R.S., has developed an X-ray machine which can cut transverse sections at any level from the top of the head to the soles of the feet, and display organs without the aid of a contrast medium, surely the medical Establishment will be roused to review Let us hope that Sir John the teaching of anatomy. Brotherston’s education committee of the General Medical Councilwill give the matter urgent attention. My heart bleeds for the three Oxford undergraduates from Pembroke College crying in the wilderness (May 17, p. 1138), wanting to learn the sort of anatomy which will help them to be good clinicians. I am sure they would like to be taught which side the spleen is on! Lysholm Radiological Department, National Hospital, Queen Square,

JAMES BULL.

London WC1N 3BG.

THE PILL OFF PRESCRIPTION

SIR,-As your editorial suggests (May 24, p. 1173), Huntingford may well be correct intellectually in pressing for the pill to be totally removed from prescription. In practice it is unlikely that any politician would accept the responsibility for such action in the near future. The need to consult a doctor, general practitioner or clinic doctor, does inhibit some women, and basically just those who are least articulate and well-educated, from using efficient contraception. Any action which would reduce Peter

these inhibitions would reduce the numbers of unwanted pregnancies and abortions. We should nearly all agree that the routine supervision of a woman on the pill does not require a doctor’s skills. Nurses are perfectly able to watch blood-pressure readings, &c., and to refer those women whose history or symptoms suggest that a medical consultation would be advisable. Midwives already have the right to administer drugs far more dangerous than the pill. One reason why the authors of The Pill off Prescription are to be supported is that there are only somewhat less than 24,000 general practitioners in the U.K., whereas in England and Wales alone there are 20,000 midwives, 13,000 district nurses, and 6000 health visitors actually practising, and many thousands of qualified nurses who are not practising at present as well as many thousands in the hospital service. Clearly, access to the pill would be far easier if all these nurses were able to prescribe it. 10 Campden Hill Square, PETER DIGGORY. London W8 7LB.

THE COST OF DEATH

SIR,-In their letter (May 24, p. 1186) on the article by Mr Longmore and Miss Rehahn on " the cumulative cost of death " (May 3, p. 1023), Peter Preston and Richard Smith make a number of valid points. Perhaps, being medical students, they see more clearly than the rest of us. However, there are some points about the article they do not make, involving its implicit assumptions. The latter are: that a high gross national product (G.N.P.) is desirable; that the G.N.P. is going to increase year after year, and this is desirable too (a curious assumption by the numerate, for, after all, the world and its resources are clearly finite, and presumably they would not wish to deprive any country of the purported advantages of an ever-increasing G.N.P.); that the process producing the increased G.N.P. does not also and inevitably increase our present diseases and provide new ones; that the answer to ischsemic heart-disease lies in late-stage treatment

rather than in primary prevention (as the latter would probably mean an attack on that cachectic sacred cow, the automobile industry, this is understandable); that the treatment ofischaemic heart-disease is not simply a paradigm of the mechanisms involved in its causation (the high technology of the production of television sets, motor-cars, cigarettes, packaged fat, refined carbohydrate foods with good keeping qualities, &c., &c.); that most things, including life, can be quantified in cash terms, and that what can’t is best kept out of the argument. These are assumptions that some people, including myself, do not accept. I have two other comments. The authors of the article " wrote: Doctors have, to their shame, sat on committees to decide who shall live and who shall die ". I am not such a doctor, but I think the remark was unnecessary and hurtful. By definition, in any ordering of society the best treatment for many conditions at any one time-like the best in many other spheres-cannot be made available to all in need of it, and sometimes this position becomes so acute that overt rationing is inevitable. Finally, the authors’ question " Can the community afford to allow any working citizens to die ? " calls for no answer as it belongs to some world other than the one they and I inhabit. ...

Garraway House, How Caple, Hereford.

Report, 1974.

S. BRADSHAW.

AN

ASSISTANT IN THE HOUSE ? SiR,—Your somewhat acerbic comment on " an important British publication "1 (April 12, p. 842) was undeserved and does not acknowledge the difficulties in promoting change against current opinion-or should I The thrust of the document was to say shibboleths ? emphasise the importance of primary health care-and the need to reflect upon the role, function, and composition of the primary-health-care team and of its individual members. A restructuring of the teams and a reallocation of functions among the team members is certainly dueperhaps overdue-including further devolution. The reorganisation of the N.H.S. has given due emphasis to community medicine, to the role of the community physician, and to the reintroduction of the community hospital. But there are still two major handicaps to be overcome. The first is financial resources, and, like all health services, until the community expresses its national will for better health more distinctly and emphatically, little additional largess can be envisaged. Only a redeployment of existing resources, allowing for inevitable creep, can be expected-and realistic planning must take cognisance of this prospect. The second factor is that a mere change in the delivery system, without a change in personnel roles, functions, and responsibilities, will also achieve little progress. Medical manpower is desperately short-witness the high proportion of immigrant physicians and nurses in hospitals, the consultants’ work overload, and the edict to medical schools to expand their student intake. Redeployment of existing manpower and womanpower could offer a less costly solution; could provide for more continuity of care; and could reinforce and improve the role of the primary-care physician, whilst at the same time satisfying the clamour for expanded roles of the health personnel in primary care. I would suggest that the general practitioner should become the primary-care physician, responsible for the family at all times, whether at home in the hospital. The primary-care physician would retain responsibility and spend part time in hospital prac-

or

1.

4. General Medical Council Annual

JOHN

Report of the Panel on Primary Health Care Teams. British Medical Association, August, 1974.

Letter: The pill off prescription.

1291 either in their teaching or research, but all radiologists have dissected the body. Now that G. N. Hounsfield, F.R.S., has developed an X-ray mac...
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