265
Commentary from Westminster Expenditure Cut:
Income Raised
FROM A CORRESPONDENT
The method selected is based on the Calbiochem glucose no. 869204) and the Calbiochem LC 340 B
pack (catalogue
single-wavelength portable spectrophotometer (Calbiochem Ltd., Hereford). Approximately 1001 of peripheral blood was obtained by fiugerprick and transferred to a microcentrifuge tube containing 2 fll of anticoagulant solution (polyanetholesulphonic acid 50 flglml, Calbiochem). After centrifugation 10 1 of plasma were removed using a syringe pipette and transferred to a disposable 1 cm spectrophotometer cuvette containing 1.5 ml of glucose reagent. After mixing and incubation at room temperature for 3 min the optical density (O.D.) of the cuvette was read against a glucose reagent blank. A facderived from the extinction coefficient of reduced and used to calculate the plasma-glucose concentration (o.D.x437=mg glucose/dl; o.D.x24.3=mmol glucose/1). The instrument and reagents were checked at intervals using a control serum (’Caltrol- 350 Normal’). Glucose was measured by this method and on the central laboratory autoanalyser on 110 patients who attended the diabetic clinic over a two-day period, and the construction of a linear regression graph from ihe results (see figure) gave a correlation coefficient of r=0.96. Using this technique a single technician can measure plasma-glucoses at a rate of 25/h. tor was N.A.D.P.
We thank Dr T. M. Hayes, operation in this study.
Department
of
University Hospital of Wales, for his
co-
T. CLARK A. B. PARKES E. REYNOLDS
Medicine,
Welsh National School of Medicine, Cardiff CF4 4XN
UREA METABOLISM IN AN AZOTÆMIC WOMAN WITH NORMAL RENAL FUNCTION
SIR,-An error in the calculation of urea-synthesis rate in the paper by Richards and Brown’ resulted in underestimation of urea synthesis and therefore of urea metabolism (breakdown). This error obscured the fact that urea metabolism had in fact increased in proportion to the synthesis-rate, breakdown being the same proportion of the synthesis-rate as in healthy individuals. The correct figures are: urea synthesis 97 mmoL/h, urea metabolised 18.3 mmoi/h, metabolism 19% of synthesis, and urea metabolised in 24 h 3% of pool. St George’s Hospital and Medical London SW 1
1 Richards,
School,
P, Brown, C. L. Lancet, 1975, ii, 207.
PETER RICHARDS SUSAN ELL
THE cuts in the Health Service announced last week by the Chancellor were a mixture of the tried and untried-on the one hand, familiar recourse to cutting capital expenditure, and, on the other, new sources of major revenue from road-accident charges. Clearly Mr David Ennals, Secretary of State for Social Services, was less mauled in Cabinet than he might have been. But this will be little consolation to local health authorities who are being asked again to re-examine their spending programmes for 1977-78. When it became clear to Mr Ennals that he was going to have to find savings in the health and personal social services programme, his main objective was to protect the hard-pressed revenue allocations of the health authorities. This enabled him to say at the end of the operation that, despite reductions of ,E70 million in the programme in 1977-78, there would be no cuts in services provided for patients in the N.H.S. But, having ruled out cuts in revenue allocations Mr Ennals had to look elsewhere. A whole series of options was then examined, including a number of charges which would have been new to the N.H.S. But in the end these were all rejected as potentially unacceptable to the Labour Party both inside and outside Parliament. For the same reason prescription charges were left unchanged. These reservations did not apply to substantially increased dental and ophthalmic charges, and road-accident charges, despite Mr Ennals’ comment: "Most of these charges I find most unpleasant and I regret we are having to increase those that we are". Legislation to recoup mainly from insurance companies the full cost to the N.H.S. of treating road-accident cases will be introduced in the next Parliamentary. session. In a full year it is expected to bring in between ,E40 million and 45 million, but since the Bill is unlikely to get onto the Statute Book until half-way through next session, the income in 1977-78 is expected to be only about l20 million. The resulting levy is expected to work out at a rough average of 3 a year per motorist. Mr Ennals will now discuss with insurance companies the best way of collecting the charge. The legislation is unlikely to be opposed by the Tories, who, fortuitously have been considering similar increases among a whole series of higher charges they are planning. Both they and the Government have been attracted by the buoyancy of finance from this charge which could even protect the N.H.S. from future damag-
ing cuts. The increases in dental and ophthalmic charges, which will bring in an extra l20 million, have been described by Mr Ennals as "very steep"-a sentiment which is echoed by a number of Labour 4.p.s who may refuse to support the Government when the regulations come before the Commons. Although the charges were due to be raised in line with rising costs, the announced increases go much higher. The defence used by Mr Ennals is that those who have to pay for spectacles or
266
do not normally suffer any drop in income at the time they need these services. And in addition there are the normal exemptions which would cover about half of all patients treated. But perhaps the most vulnerable spot for Mr Ennals is the C20 million reduction in expenditure on capital and local authority social services. Mr Patrick Jenkin, the Opposition’s health spokesman, has been quick to point out that this is about the same amount which will be lost to the N.H.S. through the abolition of pay beds from the service. Mr Ennals says he will examine where capital projects can be postponed in a way which will cause the minimum modification to the priorities set out by the Government in its consultative document earlier this year. Among the schemes he will be looking at are health centres. Mrs Barbara Castle has not been slow to embarrass her successor. She claimed in the Commons that this z20 million cut would mean practically a total moratorium on all new hospital building, including many long-overdue developments of high priority. The Chancellor’s reply was that it was far better for savings to come from capital programmes than in the reduction in services to patients. The other areas where the Government has found savings are N.H.S. overheads and the pharmaceutical industry. A total of 10 million is to be found by cutting
dentistry
Obituary DOUGLAS WILLIAM CLARIDGE NORTWIELD M.S. Lond., F.R.C.S., F.R.C.P.
Mr Douglas Northfield, formerly consultant neurosurgeon to the London Hospital, died on July 18 at the age of 74; his death removes a distinguished but somewhat solitary figure from British neurosurgery. He received his medical training at Guy’s Hospital, London, first in dentistry in 1923, and then in medicine in 1925. He was demonstrator in anatomy at Guy’s before moving to the London Hospital in 1934. His career extended from the beginnings of neurological surgery as a specialty in this country in the 1930s, until 1967, when he retired. His interest in it continued unabated, however, until he became ill earlier this year. The high regard in which Douglas Northfield was held professionally is shown by the many important offices he held. He was secretary and later president of the Society of British Neurological Surgeons, president of the Section of Neurology of the Royal Society of Medicine, secretary of the third International Congress of Neurosurgery in Copenhagen in 1965, and on the editorial board of Brain and of the Journal of Neurosurgery. But the important part of his career was his clinical work at the London Hospital, and it was here that he deeply influenced many colleagues, both junior and senior. This influence was exemplified in his ward-rounds, always small affairs in which he was accompanied only by a pre-registration houseman and a senior registrar. The care with which he examined notes, elaborated any doubtful points by acute questions, made his masterly examination, dictated to the houseman, and ended with a decisive opinion, must be a permanent memory of him to a generation of house-surgeons. This was all conducted on a modest scale; outside his weekly ward-round he frequently saw patients in other wards by himself. He preferred a small department, where he could supervise the work personally. Its quality was recognised interna-
qualifying
financed overheads, such as pruning the research programme and re-examining projects, and by curbs on the drugs bill. In particular, action will be taken to see that drug companies cut down on their considerable sales promotional expenditure which the N.H.S. pays for indirectly through the price of drugs. Mr Ennals says he will be disallowing excessive promotional expenditure under the voluntary price regulation scheme, which will mean less glossy literature, fewer free samples, and less hospitality for doctors. In addition discussions will be held with the medical profession to find out what further steps they may be willing to take to limit excess prescribing. After months of hard negotiations with the pharmaceutical industry, savings of around k5 million from a budget of more than ,500 million have disappointed a number of people. But Mr Ennals has indicated that further action can be expected. He does not accept that the drugs bill should go on rising at an annual rate of 11%. "It is the only bit of expenditure in the whole of the N.H.S. which is in no way controlled. It is quite impossible as of now to say that we can maintain control over that expenditure by such action as we have now taken. If one is going to plan expenditure of a service like the N.H.S. we need to be able to anticipate much more carefully what the increases will be".
centrally
D.H.S.S. D.H.S.S.
tionally, but relatively few
had the opportunity to see the His skill as an operator was more standing. widely on view, for he had many visitors from abroad. The character of each piece of surgery was as much due to its overall conception as to the technical craftsmanship, which even the most inexperienced could appreciate. He seemed to be able to do more and to do it more gracefully and economically than one had imagined possible. But always the interests of the individual patient guided the course of the procedure. His technical skill, his intellect, and his enormous and carefully worked-over experience were the foundations upon which his surgical judgment rested. This was manifest as much in the ward as in the operating-theatre. His ability to see each case as something new enabled him frequently to throw new light upon a difficult problem. His advice was sought as much by physicians as by surgeons, by his peers as well as his juniors, and from without as well as within the London. To many his personality appeared stern, and it is true that when engaged in his work he abhorred looseness of thought and expression and idle talk. But those who worked to his satisfaction found in him a warmth and humour which showed at the end of their spell on duty, and they could always look to him in later years for support and wise advice. The discipline and self-criticism which characterised Douglas Northfield’s work were also seen in his writings which, considering his standing, were relatively sparse. Like his formal teaching, they were excellent in their way, but never seemed to me quite to show the real man. But in 1973, after ten years of labour, he produced The Surgery of the Central Nervous System; lucidity of style, clarity of thought, and a keenly critical spirit inform the book, which is based on a lifetime of carefully considered experience, and he allowed himself the luxury he seldom permitted during his working life of being discursive. The result is not only the best book available on neurosurgery in English, but a monument to his life’s work. He did not leave a large school of neurosurgeons behind, but there is a relatively small group of people still living who worked as his first assistants, who were profoundly influenced by him, and who think that they will not look upon his like reason
for its
again.
T. T. K
Commentary from Westminster Expenditure Cut:
Income Raised
FROM A CORRESPONDENT
The method selected is based on the Calbiochem glucose no. 869204) and the Calbiochem LC 340 B
pack (catalogue
single-wavelength portable spectrophotometer (Calbiochem Ltd., Hereford). Approximately 1001 of peripheral blood was obtained by fiugerprick and transferred to a microcentrifuge tube containing 2 fll of anticoagulant solution (polyanetholesulphonic acid 50 flglml, Calbiochem). After centrifugation 10 1 of plasma were removed using a syringe pipette and transferred to a disposable 1 cm spectrophotometer cuvette containing 1.5 ml of glucose reagent. After mixing and incubation at room temperature for 3 min the optical density (O.D.) of the cuvette was read against a glucose reagent blank. A facderived from the extinction coefficient of reduced and used to calculate the plasma-glucose concentration (o.D.x437=mg glucose/dl; o.D.x24.3=mmol glucose/1). The instrument and reagents were checked at intervals using a control serum (’Caltrol- 350 Normal’). Glucose was measured by this method and on the central laboratory autoanalyser on 110 patients who attended the diabetic clinic over a two-day period, and the construction of a linear regression graph from ihe results (see figure) gave a correlation coefficient of r=0.96. Using this technique a single technician can measure plasma-glucoses at a rate of 25/h. tor was N.A.D.P.
We thank Dr T. M. Hayes, operation in this study.
Department
of
University Hospital of Wales, for his
co-
T. CLARK A. B. PARKES E. REYNOLDS
Medicine,
Welsh National School of Medicine, Cardiff CF4 4XN
UREA METABOLISM IN AN AZOTÆMIC WOMAN WITH NORMAL RENAL FUNCTION
SIR,-An error in the calculation of urea-synthesis rate in the paper by Richards and Brown’ resulted in underestimation of urea synthesis and therefore of urea metabolism (breakdown). This error obscured the fact that urea metabolism had in fact increased in proportion to the synthesis-rate, breakdown being the same proportion of the synthesis-rate as in healthy individuals. The correct figures are: urea synthesis 97 mmoL/h, urea metabolised 18.3 mmoi/h, metabolism 19% of synthesis, and urea metabolised in 24 h 3% of pool. St George’s Hospital and Medical London SW 1
1 Richards,
School,
P, Brown, C. L. Lancet, 1975, ii, 207.
PETER RICHARDS SUSAN ELL
THE cuts in the Health Service announced last week by the Chancellor were a mixture of the tried and untried-on the one hand, familiar recourse to cutting capital expenditure, and, on the other, new sources of major revenue from road-accident charges. Clearly Mr David Ennals, Secretary of State for Social Services, was less mauled in Cabinet than he might have been. But this will be little consolation to local health authorities who are being asked again to re-examine their spending programmes for 1977-78. When it became clear to Mr Ennals that he was going to have to find savings in the health and personal social services programme, his main objective was to protect the hard-pressed revenue allocations of the health authorities. This enabled him to say at the end of the operation that, despite reductions of ,E70 million in the programme in 1977-78, there would be no cuts in services provided for patients in the N.H.S. But, having ruled out cuts in revenue allocations Mr Ennals had to look elsewhere. A whole series of options was then examined, including a number of charges which would have been new to the N.H.S. But in the end these were all rejected as potentially unacceptable to the Labour Party both inside and outside Parliament. For the same reason prescription charges were left unchanged. These reservations did not apply to substantially increased dental and ophthalmic charges, and road-accident charges, despite Mr Ennals’ comment: "Most of these charges I find most unpleasant and I regret we are having to increase those that we are". Legislation to recoup mainly from insurance companies the full cost to the N.H.S. of treating road-accident cases will be introduced in the next Parliamentary. session. In a full year it is expected to bring in between ,E40 million and 45 million, but since the Bill is unlikely to get onto the Statute Book until half-way through next session, the income in 1977-78 is expected to be only about l20 million. The resulting levy is expected to work out at a rough average of 3 a year per motorist. Mr Ennals will now discuss with insurance companies the best way of collecting the charge. The legislation is unlikely to be opposed by the Tories, who, fortuitously have been considering similar increases among a whole series of higher charges they are planning. Both they and the Government have been attracted by the buoyancy of finance from this charge which could even protect the N.H.S. from future damag-
ing cuts. The increases in dental and ophthalmic charges, which will bring in an extra l20 million, have been described by Mr Ennals as "very steep"-a sentiment which is echoed by a number of Labour 4.p.s who may refuse to support the Government when the regulations come before the Commons. Although the charges were due to be raised in line with rising costs, the announced increases go much higher. The defence used by Mr Ennals is that those who have to pay for spectacles or
266
do not normally suffer any drop in income at the time they need these services. And in addition there are the normal exemptions which would cover about half of all patients treated. But perhaps the most vulnerable spot for Mr Ennals is the C20 million reduction in expenditure on capital and local authority social services. Mr Patrick Jenkin, the Opposition’s health spokesman, has been quick to point out that this is about the same amount which will be lost to the N.H.S. through the abolition of pay beds from the service. Mr Ennals says he will examine where capital projects can be postponed in a way which will cause the minimum modification to the priorities set out by the Government in its consultative document earlier this year. Among the schemes he will be looking at are health centres. Mrs Barbara Castle has not been slow to embarrass her successor. She claimed in the Commons that this z20 million cut would mean practically a total moratorium on all new hospital building, including many long-overdue developments of high priority. The Chancellor’s reply was that it was far better for savings to come from capital programmes than in the reduction in services to patients. The other areas where the Government has found savings are N.H.S. overheads and the pharmaceutical industry. A total of 10 million is to be found by cutting
dentistry
Obituary DOUGLAS WILLIAM CLARIDGE NORTWIELD M.S. Lond., F.R.C.S., F.R.C.P.
Mr Douglas Northfield, formerly consultant neurosurgeon to the London Hospital, died on July 18 at the age of 74; his death removes a distinguished but somewhat solitary figure from British neurosurgery. He received his medical training at Guy’s Hospital, London, first in dentistry in 1923, and then in medicine in 1925. He was demonstrator in anatomy at Guy’s before moving to the London Hospital in 1934. His career extended from the beginnings of neurological surgery as a specialty in this country in the 1930s, until 1967, when he retired. His interest in it continued unabated, however, until he became ill earlier this year. The high regard in which Douglas Northfield was held professionally is shown by the many important offices he held. He was secretary and later president of the Society of British Neurological Surgeons, president of the Section of Neurology of the Royal Society of Medicine, secretary of the third International Congress of Neurosurgery in Copenhagen in 1965, and on the editorial board of Brain and of the Journal of Neurosurgery. But the important part of his career was his clinical work at the London Hospital, and it was here that he deeply influenced many colleagues, both junior and senior. This influence was exemplified in his ward-rounds, always small affairs in which he was accompanied only by a pre-registration houseman and a senior registrar. The care with which he examined notes, elaborated any doubtful points by acute questions, made his masterly examination, dictated to the houseman, and ended with a decisive opinion, must be a permanent memory of him to a generation of house-surgeons. This was all conducted on a modest scale; outside his weekly ward-round he frequently saw patients in other wards by himself. He preferred a small department, where he could supervise the work personally. Its quality was recognised interna-
qualifying
financed overheads, such as pruning the research programme and re-examining projects, and by curbs on the drugs bill. In particular, action will be taken to see that drug companies cut down on their considerable sales promotional expenditure which the N.H.S. pays for indirectly through the price of drugs. Mr Ennals says he will be disallowing excessive promotional expenditure under the voluntary price regulation scheme, which will mean less glossy literature, fewer free samples, and less hospitality for doctors. In addition discussions will be held with the medical profession to find out what further steps they may be willing to take to limit excess prescribing. After months of hard negotiations with the pharmaceutical industry, savings of around k5 million from a budget of more than ,500 million have disappointed a number of people. But Mr Ennals has indicated that further action can be expected. He does not accept that the drugs bill should go on rising at an annual rate of 11%. "It is the only bit of expenditure in the whole of the N.H.S. which is in no way controlled. It is quite impossible as of now to say that we can maintain control over that expenditure by such action as we have now taken. If one is going to plan expenditure of a service like the N.H.S. we need to be able to anticipate much more carefully what the increases will be".
centrally
D.H.S.S. D.H.S.S.
tionally, but relatively few
had the opportunity to see the His skill as an operator was more standing. widely on view, for he had many visitors from abroad. The character of each piece of surgery was as much due to its overall conception as to the technical craftsmanship, which even the most inexperienced could appreciate. He seemed to be able to do more and to do it more gracefully and economically than one had imagined possible. But always the interests of the individual patient guided the course of the procedure. His technical skill, his intellect, and his enormous and carefully worked-over experience were the foundations upon which his surgical judgment rested. This was manifest as much in the ward as in the operating-theatre. His ability to see each case as something new enabled him frequently to throw new light upon a difficult problem. His advice was sought as much by physicians as by surgeons, by his peers as well as his juniors, and from without as well as within the London. To many his personality appeared stern, and it is true that when engaged in his work he abhorred looseness of thought and expression and idle talk. But those who worked to his satisfaction found in him a warmth and humour which showed at the end of their spell on duty, and they could always look to him in later years for support and wise advice. The discipline and self-criticism which characterised Douglas Northfield’s work were also seen in his writings which, considering his standing, were relatively sparse. Like his formal teaching, they were excellent in their way, but never seemed to me quite to show the real man. But in 1973, after ten years of labour, he produced The Surgery of the Central Nervous System; lucidity of style, clarity of thought, and a keenly critical spirit inform the book, which is based on a lifetime of carefully considered experience, and he allowed himself the luxury he seldom permitted during his working life of being discursive. The result is not only the best book available on neurosurgery in English, but a monument to his life’s work. He did not leave a large school of neurosurgeons behind, but there is a relatively small group of people still living who worked as his first assistants, who were profoundly influenced by him, and who think that they will not look upon his like reason
for its
again.
T. T. K
