1405 NEW CONSULTANT CONTRACT
SIR,-Many consultants have had feelings of disquiet about the B.M.A.-D.H.S.S. contract which represents above all a fundamental switch from a professional to an "industrial", "work-sensitive" type of contract. We had misgivings about the elimination of the inducement to wholetime commitment and consequent stimulation of private practice. We disliked the further encouragement of the growing notion that one should "just do the work I am paid for", which undermines basic professional ethics and would take consultants down the same road as junior staff. We were unhappy about the increase in bureaucratic control that the new contract would foster; it offers an open invitation to administrative monitoring and gives the D.H.S.S. and its officers unilateral powers to decide how many sessions over the basic ten we would all be offered. This would allow them, in the future, to increase or decrease our sessions (and our income) as they wished, according to the priorities of the service as they saw fit. We were sure that the new contract would adversely affect recruitment into specialties and areas which do not attract much private practice, including most of the shortage specialties. There would also be deleterious effects on academic medicine with profound repercussions on undergraduate and postgraduate teaching. There is also no provision for the part-time consultants’ posts which are increasingly being seen as the most sensible way of keeping women doctors with family commitments properly employed for the benefit of themselves and the service. But, despite all these shortcomings and misgivings, many consultants still feel that the new contract would mean a great deal more money for consultants as a whole, and that, although the financial benefits would be unevenly distributed, no one would fail to benefit. This illusion has been shattered by the Review Body’s pricing which equates thirteen sessions in the new contract with wholetime commitment in the present contract. If the new contract were to be implemented on this basis, many wholetime and academic consultants would stand to lose income in both absolute and relative terms without even having their security of wholetime employment (i.e., thirteen sessions) guaranteed. The B.M.A. has rejected this pricing and asked for the new contract to be shelved while they seek to get maximum part-time consultants paid 10/llths (rather than 9/llths) of the wholetime salary. They are obviously determined to eliminate or erode the wholetime inducement. Their attitude over this should give all wholetime and academic consultants food for thought. In our view the whole ill-conceived package of the new contract should now be dropped completely. It is no use for the B.M.A. to blame the D.H.S.S. or the Review Body over their failure to get the pricing they were after. Our negotiators (like the Grand Old Duke of York) have taken us on a protracted and ill-considered exercise which was doomed from the outset and which has made the profession look both greedy and devious. There is much talk about the need to boost the morale of consultants. Neither a new contract nor the encouragement of private practice are the answers. The new government and the B.M.A. must at all times be reminded that there is a substantial group of consultants who are fully committed to the N.H.S. and its basic concepts. PAUL NOONE, Royal Free Hospital, London NW3 2QG Chairman, N.H.S. Consultants’ Association
SOCIAL INEQUALITIES IN CHILD HEALTH
SiR,—The letter from Professor Morris and Dr Pharoah (June 2, p. 1189) contains much good sense, but seems to perpetuate
a
confusion which is still
surprisingly
common
amongst epidemiologists. They clearly understand the difference between "small-for-dates" and premature babies, since they properly criticise Dr Rao’s criteria (May 5, p. 976) for the former. How then can they associate prematurity-rates in their argument with intrauterine growth which, as far as I am aware, are entirely unconnected? Nor would anyone seek to improve lower-social-class mothers’ nutrition as a means of reducing their high prematurity rates. The burning question is whether high rates of intrauterine growth retardation ("smallfor-dates") may be partly due to poor maternal nutrition in lower social classes, and on this subject more heat has been generated than light. The facts, both experimentally and observationally adduced, are beyond dispute. It is their interpretation which is diverse. The finding cited by Morris and Pharoah-that there is no indication of deficient protein intake among the poorest sections of the population-will not be relevant to the discussion unless it is proposed that protein is likely to be the only limiting factor on fetal growth, and all the nutritional evidence is to the contrary. No theoretical knowledge of altered maternal metabolism during pregnancy, of the complexities of placental transmission, or of the ill-understood accumulation of body constituents in the fetus can, in the end, substitute for wellconducted intervention studies in a sizeable population of "at risk" mothers, however difficult that may be. The proof of the pudding will be in the birth-weight. Department of Child Health,
University of Manchester, Manchester M13 9PT
JOHN DOBBING
CORE LENGTH IN BONE-MARROW BIOPSY
SIR,-My experience of more than 5000 combined boneaspiration and trephine biopsies confirms the point raised by Dr Islam and his colleagues (April 21, p. 878) that increasing sample volume improves the likelihood of demonstrating focal lesions. Examination of the iliac bone will show that the cavity from which the biopsy material is obtained has an anterior to posterior depth of some 10 cm and approximately the same vertical dimensions. Under these circumstances marrow
I believe that the distinction between short core and long core is artificial and the concept should be discarded. In its place I would put a requirement for a core of at least 30 mm from any procedure, a policy we have followed for some time. Routinely at least three levels are cut through the blocks further to extend the amount of marrow studied. The question of two-site biopsy should only apply if inadequate material is obtained. In patients being studied for possible focal lesions a single skin wound is used, and a 2-3 cm specimen is obtained in one direction, after which the same skin wound and puncture through the cortex is re-entered and further tissue obtained in a different direction. Under these circumstances it is simple to obtain upwards of 40 mm of tissue for examination. In our hands this approach has a high degree of patient acceptability. I doubt if plastic embedding is needed since 3 pm sections can be obtained from properly decalcified bone with excellent preservation of cell morphology and a comparative study between methacrylate and wax sections has failed to demonstrate any consistent advantage for methacrylate. It is, in diagnostic terms, advantageous to use wax because the time from biopsy to examination is less than 2 days whereas, with most plastic techniques, 3-4 days are needed for proper processing. Wax sections accept Romanowsky dyes and result in stained sections which approximate more closely to aspirates than do the routine haematoxylin and eosin preparations. In my experience, provided the needles are sharp and well maintained, the Westerman-Jensen needle is every bit as suitable as the Jamshidi, and I would encourage operators to evaluate both techniques and choose the instrument with which they become most comfortable. Very soft bones and friable tissue will often yield a sample with the Westerman-
SIR,-Many consultants have had feelings of disquiet about the B.M.A.-D.H.S.S. contract which represents above all a fundamental switch from a professional to an "industrial", "work-sensitive" type of contract. We had misgivings about the elimination of the inducement to wholetime commitment and consequent stimulation of private practice. We disliked the further encouragement of the growing notion that one should "just do the work I am paid for", which undermines basic professional ethics and would take consultants down the same road as junior staff. We were unhappy about the increase in bureaucratic control that the new contract would foster; it offers an open invitation to administrative monitoring and gives the D.H.S.S. and its officers unilateral powers to decide how many sessions over the basic ten we would all be offered. This would allow them, in the future, to increase or decrease our sessions (and our income) as they wished, according to the priorities of the service as they saw fit. We were sure that the new contract would adversely affect recruitment into specialties and areas which do not attract much private practice, including most of the shortage specialties. There would also be deleterious effects on academic medicine with profound repercussions on undergraduate and postgraduate teaching. There is also no provision for the part-time consultants’ posts which are increasingly being seen as the most sensible way of keeping women doctors with family commitments properly employed for the benefit of themselves and the service. But, despite all these shortcomings and misgivings, many consultants still feel that the new contract would mean a great deal more money for consultants as a whole, and that, although the financial benefits would be unevenly distributed, no one would fail to benefit. This illusion has been shattered by the Review Body’s pricing which equates thirteen sessions in the new contract with wholetime commitment in the present contract. If the new contract were to be implemented on this basis, many wholetime and academic consultants would stand to lose income in both absolute and relative terms without even having their security of wholetime employment (i.e., thirteen sessions) guaranteed. The B.M.A. has rejected this pricing and asked for the new contract to be shelved while they seek to get maximum part-time consultants paid 10/llths (rather than 9/llths) of the wholetime salary. They are obviously determined to eliminate or erode the wholetime inducement. Their attitude over this should give all wholetime and academic consultants food for thought. In our view the whole ill-conceived package of the new contract should now be dropped completely. It is no use for the B.M.A. to blame the D.H.S.S. or the Review Body over their failure to get the pricing they were after. Our negotiators (like the Grand Old Duke of York) have taken us on a protracted and ill-considered exercise which was doomed from the outset and which has made the profession look both greedy and devious. There is much talk about the need to boost the morale of consultants. Neither a new contract nor the encouragement of private practice are the answers. The new government and the B.M.A. must at all times be reminded that there is a substantial group of consultants who are fully committed to the N.H.S. and its basic concepts. PAUL NOONE, Royal Free Hospital, London NW3 2QG Chairman, N.H.S. Consultants’ Association
SOCIAL INEQUALITIES IN CHILD HEALTH
SiR,—The letter from Professor Morris and Dr Pharoah (June 2, p. 1189) contains much good sense, but seems to perpetuate
a
confusion which is still
surprisingly
common
amongst epidemiologists. They clearly understand the difference between "small-for-dates" and premature babies, since they properly criticise Dr Rao’s criteria (May 5, p. 976) for the former. How then can they associate prematurity-rates in their argument with intrauterine growth which, as far as I am aware, are entirely unconnected? Nor would anyone seek to improve lower-social-class mothers’ nutrition as a means of reducing their high prematurity rates. The burning question is whether high rates of intrauterine growth retardation ("smallfor-dates") may be partly due to poor maternal nutrition in lower social classes, and on this subject more heat has been generated than light. The facts, both experimentally and observationally adduced, are beyond dispute. It is their interpretation which is diverse. The finding cited by Morris and Pharoah-that there is no indication of deficient protein intake among the poorest sections of the population-will not be relevant to the discussion unless it is proposed that protein is likely to be the only limiting factor on fetal growth, and all the nutritional evidence is to the contrary. No theoretical knowledge of altered maternal metabolism during pregnancy, of the complexities of placental transmission, or of the ill-understood accumulation of body constituents in the fetus can, in the end, substitute for wellconducted intervention studies in a sizeable population of "at risk" mothers, however difficult that may be. The proof of the pudding will be in the birth-weight. Department of Child Health,
University of Manchester, Manchester M13 9PT
JOHN DOBBING
CORE LENGTH IN BONE-MARROW BIOPSY
SIR,-My experience of more than 5000 combined boneaspiration and trephine biopsies confirms the point raised by Dr Islam and his colleagues (April 21, p. 878) that increasing sample volume improves the likelihood of demonstrating focal lesions. Examination of the iliac bone will show that the cavity from which the biopsy material is obtained has an anterior to posterior depth of some 10 cm and approximately the same vertical dimensions. Under these circumstances marrow
I believe that the distinction between short core and long core is artificial and the concept should be discarded. In its place I would put a requirement for a core of at least 30 mm from any procedure, a policy we have followed for some time. Routinely at least three levels are cut through the blocks further to extend the amount of marrow studied. The question of two-site biopsy should only apply if inadequate material is obtained. In patients being studied for possible focal lesions a single skin wound is used, and a 2-3 cm specimen is obtained in one direction, after which the same skin wound and puncture through the cortex is re-entered and further tissue obtained in a different direction. Under these circumstances it is simple to obtain upwards of 40 mm of tissue for examination. In our hands this approach has a high degree of patient acceptability. I doubt if plastic embedding is needed since 3 pm sections can be obtained from properly decalcified bone with excellent preservation of cell morphology and a comparative study between methacrylate and wax sections has failed to demonstrate any consistent advantage for methacrylate. It is, in diagnostic terms, advantageous to use wax because the time from biopsy to examination is less than 2 days whereas, with most plastic techniques, 3-4 days are needed for proper processing. Wax sections accept Romanowsky dyes and result in stained sections which approximate more closely to aspirates than do the routine haematoxylin and eosin preparations. In my experience, provided the needles are sharp and well maintained, the Westerman-Jensen needle is every bit as suitable as the Jamshidi, and I would encourage operators to evaluate both techniques and choose the instrument with which they become most comfortable. Very soft bones and friable tissue will often yield a sample with the Westerman-
