BRITISH MEDICAL JOURNAL

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and that he makes up these two sessions during odd hours throughout the rest of the week. I cannot believe that two whole clinics, operating sessions, or any combination of these, are inserted into the remainder of the week. A part-time anaesthetist does not do one extra session, let alone two, to match his full-time colleague. These arguments are just not honest. If, in fact, one reads the "Terms and Conditions of Service," paragraphs 61-9 clearly state that a maximum part-time consultant is only contracted to work nine three-and-a-half-hour sessions during one week. All consultants work over and above the sessions for which they are paid. The full-time consultant could make exactly the same claim that extra work is fitted in here and there during his other "spare time." The claim that one of these two unpaid sessions should be remunerated is only lessening the total value of any contract, be it nine, 10, or 11 sessions. We have all seen the effect of underpricing our working week in the recent Doctors' and Dentists' Review Body report, which equated 13 sessions as the normal full-time contract, obtaining two extra sessions of work for no increase in salary. Surely we must drop divisive policies and concentrate on negotiations for a contract based on the actual amount of work done and priced realistically. The CCHMS should be persuaded that Barbara-Castle-like policies should be abandoned and that we should all work together for remunerative improvement, bearing in mind that there is no crock of gold left in NHS medicine. B A Ross Norwich NRl 2BB

*** The Secretary writes: "Mr Ross is mistaken in supposing that the CCHMS is attempting to negotiate alterations to the existing consultant contract that would benefit onlv maximum part-timers. The CCHMS's most recent proposals (23 June, p 1730) would benefit all consultants. One of these is to give whole-timers the right to some limited non-NHS practice, which would go some way towards bridging the gap between whole-time consultants and their maximum part-time colleagues."-ED, BM7.

Streamlined hospital administration?

SIR,-I often wonder what my retired colleagues are doing. Some, no doubt, are pleased to have left their hospitals; others have retired to the country and gardening, golf, etc, or they go abroad to sunnier climates. I recall an eminent surgeon-an expert on gastrectomy -who departed at the height of his career to cultivate vines in Portugal, much to the surprise of his colleagues. But many consultants are sad when the time comes to retire: they regret leaving their colleagues and do not want to give up their dedicated work. The change is sudden and disturbing. I think that the hospital service loses a great deal of talent which could be put to constructive use. Even if the consultant has to give up his clinical work he has many years of experience of the problems of a large hospital. When the NHS started there was a great feeling of euphoria. Sadly, there has been a gradual deterioration in morale and standards and we see from our newspapers the discontent that now exists. We do seem to have lost sight of the fact that the most important

25 AUGUST 1979

person in hospital is the patient. All hospital staff are there for the purpose of giving comfort to the patient and his relatives. How can things be put right so that we can all serve our community without strife and bitterness ? The United States has a specialty of hospital administration and the applicants have to have a degree in the subject. Most hospitals have a committee consisting of a member of the consultant staff, the head of the nursing staff, kitchen staff, etc. Each gives the hospital administrator a report on the working problems of his department. These are thrashed out and matters agreed, the administrator being responsible to the hospital governors, who have the final say. Before 1948 some London hospitals, controlled by the London County Council or boards of guardians, had one hospital administrator. Some were excellent and the hospitals in their charge had a good reputation. If this arrangement were readopted today we could do away with many subcommittees where the wheels grind so slowly that they almost stop. A consultant nearing retirement who wished to remain in touch with his hospital could be asked to become the hospital administrator. He is acquainted with his colleagues and has heard their complaints and the problems which face them. Such a person should be able to put his finger on the "inflammatory" points and get any troubles settled immediately. Even if he has not the power to settle a problem himself he should have access to the health authority. In such a way administration could be streamlined and problems and disputes settled quickly and efficiently. One of the grumbles nowadays among ancillary staffand consultants too-is the delay in putting things right: this allows bitterness to grow. Porters, ambulancemen, etc, have my sympathy since they must have been driven to behave as they have done by months of frustration. It was reported in the Daily Telegraph that a patient in an intensive care unit, bleeding postoperatively, needed moving to the x-ray department, but a porter could not be persuaded to move the patient. How can such a thing happen ? He must, somewhere along the line, have been led to believe that he was not part of a team with the aim of saving lives. The hospital with all its staff must be run as a team. I think that this can be achieved by appointing a hospital administrator who has given his services to that hospital over many years-a retired consultant.

while he was taking Chuifong Toukuwan NanLien obtained from Hong Kong. This was found to contain phenylbutazone, phenacetin, aminopyrine, and mercuric sulphide. They inferred that different agents are put into different batches of tablets sold under the same label. Despite a restriction on the importation of Chinese herbal preparations into Australia, patients are nevertheless able to obtain them without difficulty, while they are sold over the counter in the USA and are also available in Europe. Neither the labels on these remedies nor the enclosed literature disclose their contents and they may therefore contain potentially toxic ingredients.1 2 An alternative explanation for the absence of agranulocytosis in the Chinese population of San Francisco could be that they are less susceptible than Europeans, the difference representing a racial variation in drug metabolism. Perhaps there is an analogy with ibufenac, which preceded ibuprofen and which was withdrawn because of hepatotoxicity,' but was, I understand, marketed in Japan without problems. The advertising literature enclosed with Chuifong Toukuwan Nan-Lien' suggested that "rheumatism results from the invasion of the effect of the wind, the cold, the dampness from the exterior etc." This aetiological concept of arthritis achieves expression in the proposed mode of action of Chuei-Fong-TouGeu-Wan tablets, which may "chase-the-

MAURICE LEE

SIR,-The report by Dr P J G Forster and others (4 August, p 308) of the use of ChueiFong-Tou-Geu-Wan, a Chinese "herbal" medicine, in rheumatoid arthritis was interesting and, finally, scrutable. Although no Oriental city, Athens is nevertheless the seat of a very ancient culture and your readers may be interested to know of a presentation there in 19771 of some equally "astonishing" results following the use in rheumatoid arthritis of a substance (vitamin K3) which can also be regarded as occurring naturally in herbs. In that series, however, no corticosteroids or non-steroidal anti-inflammatory drugs were added. Can it be that Dr Forster and his colleagues have thrown out the baby with the bathwater ?

London WIM 7AB

"Herbal" medicines and rheumatoid arthritis

SIR,-Dr P J G Forster and others (4 August, p 308) remind us of the potential dangers

wind-through-the-bones." Dr Forster's paper also serves to remind us that a longstanding bete noire of many rheumatologists-namely, the combining of a non-steroidal anti-inflammatory agent and a steroid-still persists even in this country. MIMS currently lists only one such preparation-that is, phenylbutazone 50 mg in combination with prednisone 125 mg. Until January of last year it was possible to prescribe chloroquine, prednisone, and aspirin in combination and, although that preparation has been discontinued in the UK, patients are still obtaining it abroad. V MARTIN Department of Rheumatology, Whittington Hospital, London N19 5NF

'Ries, C A, and Sahud, M A, journal of the American Medical Association, 1975, 231, 352. 2 Brooks, P M, and Lowenthal, R M, Medical Journal of Australia, 1977, 2, 860. 3 Thompson, M, et al, Annals of the Rheumatic Diseases, 1964, 23, 397.

associated with Chinese herbal medicines. The remedy obtained by their patient may be unusual in that it contained a non-steroidal anti-inflammatory agent in combination with a steroid (indomethacin and dexamethasone). Previous reports indicate that similar Chinese remedies have contained aminopyrine and phenylbutazone.' 2 The implication that the composition of B CASHMAN Chuei-Fong-Tou-Geu-Wan apparently varies Bedford General Hospital, is interesting. Brooks and Lowenthal2 reported Bedford MK42 9DJ from Australia an episode of agranulocytosis in 'Cashman, B, and Hawkes, J, OpOoire&xa Xpovixa a rheumatoid arthritic patient which occurred Aaxirnmciou Bo?)Xa;, 1977, 2, 73.

Streamlined hospital administration?

BRITISH MEDICAL JOURNAL 504 and that he makes up these two sessions during odd hours throughout the rest of the week. I cannot believe that two whol...
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