BRITISH MEDICAL JOURNAL
393
15 NOVEMBER 1975
half-hour drive back to Bath), but students almost invariably express pleasure at the pattern of medicine practised, the happy and easy doctor-patient relationship, and the satisfactory holistic approach at clinical level to the total problems the patients present. The Lancet IO urged the need for audit of outpatient facilities and efficiency, and Glass"' contended that, despite difficulties, cost-benefit analysis of medical work should be attempted. We have already shown that such clinics are favourable from the point of view of cost-benefit. This paper shows that nearly 98% of such consultations were satisfactory from the medical point of view. This demonstrates that the benefit of cost and convenience is not bought at the price of an inferior service to the patient. In fact, in many ways the service at peripheral clinics may be better. The numbers failing to attend are lower at country clinics and problems of communication are generally less. These aspects are under further detailed investigation. These clinics could be conducted quite as adequately in a health centre or the premises of a group practice,2 with the added advantage of a close liaison with the family doctor. This would, however, demand more time per patient to allow for discussion-in other words, for the teaching role of such a clinic. It would, therefore, not be possible to see so many patients.
The information here reported should be supplemented by similar surveys in other specialties, so that the value of consultant work in peripheral hospitals, health centres, or in practitioners' premises may be more clearly seen. Such data should be of considerable value for planners. The expenses of this survey were met by a grant from the Bath Area Medical Research Trust, for which I am most grateful. I also thank the family doctors and medical records officers, who helped so willingly.
References Kerr, H M, Lawson, C W, and Weller, S D V, submitted for publication. Marsh, G N, and Tompkins, A B, British Medical Journal, 1969, 2, 106. 3 Gruer, R, Lancet, 1971, 1, 390. 4 Bailey, S M, Evans, D W, and Fleming, H A, Lancet, 1975, 2, 57. 5 Leonard, J V, Clayton, B E, and Colley, J R T, British Medical Journal, 1975, 2, 662. 6 Forsyth, G, and Logan, R F L, Gateway or Dividing Line? London, Oxford University Press, 1968. 7 Hampton, J R, et al, British Medical3Journal, 1975, 2, 486. 8 Shapland, D, World Medicine, 1975, 10, 45. 9 Smith, J W, et al, British Medical_Journal, 1973, 2, 471. 0 Lancet, 1973, 2, 137. 1' Glass, N J, Health Trends, 1973, 5, 51. 1 2
Letter from . . . Zurich The 8th of December 1974 PETER PAUL RICKHAM British Medical Journal, 1975, 4, 393-394
I am still surprised that the happenings of the 8th of December 1974 did not cause even a ripple amongst medical men outside Switzerland. Certainly I have not yet met a British doctor who had any idea that something extraordinary happened then. Perhaps with galloping inflation and unemployment coupled with the rapid decline of the last remnants of the National Health Service, British doctors have other things to think about. Nevertheless, I thought that they might momentarily have stood still and wondered. Before I tell you about the 8th of December I must very briefly explain the workings of Swiss democracy. Switzerland is a direct democracy: government and parliament can propose new laws, they can debate and vote on them; but they cannot pass them. Only the people, aptly called here the "sovereign," can pass laws. New laws can be proposed by government and parliament, but they can also be proposed by individuals or groups of individuals-for example, a political party-asking for a referendum, provided they have enough signatures to support their petition. Switzerland is the land of free enterprise and the medical services are no exception. Ninety-five per cent of the people
Kinderspital, Zurich PETER PAUL RICKHAM, MS FRCS, professor of paediatric surgery
are insured by private insurance companies for ambulant and hospital treatment. I have no doubt that the standard of medical care is superior to that of any country I have visited, but there are imperfections in the system. There has long been friction between insurance companies and general practitioners about some payments. Hospital charges have doubled since 1970 and so insurance premiums have had to be raised and the state has had to pay a larger and larger share of the costs. For a long time the socialist party, one of the three large parties in this country, has vociferously agitated for a state medical service. Enough signatures for their petition were quickly collected. They wisely refrained from saying in detail how much this would cost the tax payer (already the proportion of the gross national income spent on health is much higher in Switzerland than in Great Britain) and, although they suggested that the insurance companies could somehow be incorporated in their scheme, there was no doubt in anybody's mind that what they were after was a state medical service similar to that in Britain or Sweden. The coalition government was apparently worried that the referendum might succeed and, as they usually do, put up counterproposals. What, they asked, did the doctors suggest ? To an outside observer the reaction of the doctors was rather bewildering. The medical profession was disunited. Different health service plans sprouted like mushrooms after the rain. For somebody who had experienced 1948 in Britain there was a sense of deja vu. Every doctor I talked to privately was convinced that the present system offered much better patient care than any of the new schemes, but to say it loudly was not progressive and would harm the medical man's "image."
394
The government was naturally bewildered and finally drew up their own proposals, going at least halfway toward nationalisation but leaving some scope for the insurance companies. They did, however, state their proposals would mean a contribution of up to 3% of the taxpayer's money. The proposals were somewhat complicated and vague and would probably have led to full nationalisation some time after being put into practice.
The people vote The date of the referendum was approaching and the Swiss Medical Association had to make a belated decision. They patched up their quarrel with the insurance companies and chose to support the government's counterproposals wholeheartedly, but the sceptical observer might have wondered whether the doctors were choosing the lesser of two evils. Among a barrage of propaganda from all parties and the mass media the 8th of December came and the people voted. The socialist proposals were rejected by 72-500 of the voters, while 66% rejected the government's counterproposals. The crashing majority of "Njets" was wholly unexpected. The government was not too worried. The socialist party fulminated. And the medical men? Shall we say they looked a little sheepish? What was the reason for this vehement rejection of socialised medicine? Obviously there were many factors, and opinions about the underlying causes vary. The vote did at least partly express the dislike of the individual Swiss for centralised government and governmental interference. The Swiss are good businessmen, if nothing else, and they saw that acceptance of either proposal would cost them a good deal of money without improving the health service at all. The disastrous effects on overall patient care brought about by the British National Health Service are not unknown here. It was also argued that the
Is there any treatment for multiple small cysts of the retina, probably secondary to a chronic vasculitis of unknown origin, and causing deterioration of vision ? Small peripheral retinal cysts do not require any active treatment but if, as is suggested by the deterioration of vision, the cystic changes are at the macula they are probably secondary to chronic inflammation in the retinal periphery and ciliary body. The only treatment in this case is to suppress the inflammation with corticosteroids. If the cystic changes are accompanied by retinal oedema some improvement may result as the oedema settles, but the cystic degeneration implies permanent visual damage.
Can dangerous anaphylaxis occur from ingestion of a drug ? If one is very, very doubtful of the story of a person's sensitivity to penicillin, what are the dangers of giving a trial dose of an oral penicillin preparation ? What are the usual reactions to sensitivity to oral penicillin apart from rash, or urticaria, or both ? An anaphylactoid reaction has been observed after oral penicillin, though the reaction occurs more often after injection. If there is any doubt about the sensitivity of the patient to penicillin, the group of drugs, and particularly benzyl penicillin (penicillin G), should be avoided. An alternative drug such as erythromycin should be prescribed. If one is very, very doubtful of the history of a hypersensitivity reaction the risk of a serious reaction occurring may be small but it must be emphasised that fatal episodes of anaphylaxis have followed the ingestion of very small doses of drugs of the penicillin group. The usual reactions, apart from rash and urticaria, include rashes of all types-scarlatiniform, morbilliform, urticarial, vesicular, and bullous. Contact dermatitis, exfoliative dermatitis, and exudative erythema multiforme are other cutaneous manifestations of hypersensitivity. Other reactions include oral lesions, drug fever, eosinophilia, serum sickness, and reactions of the Arthus type.
BRITISH MEDICAL JOURNAL
15 NOVEMBER 1975
proposals were too complicated for the average voter to understand; that the counterproposal promoted the double no; and that two noes really make a yes. These and many other fanciful explanations were forthcoming in the press and in parliament. But the fact remains that the relentless spread of socialised medicine to more and more countries was at least temporarily halted by the people of this small nation. Somehow I cannot help feeling that there was a wider issue here. I am a sincere sceptic and pessimist. Born during the first world war and still able to cerebrate, how could I react differently ? I don't need the club of Rome to tell me about the obvious direction in which humanity is travelling. I believe that socialism and not religion is the opium of the people of the 20th century. True, our times have been characterised by the dictators, but even they, from Hitler to Stalin and from Castro to Idi Amin, could only succeed as well as they did (and are doing) by blending nationalism-the expression of the inferiority complexes of their followers-with the illusion of socialism. I am old-fashioned enough still to believe that the ideals of European civilisation, which suddenly blazed from the shores of the small, rocky, poor peninsuia in the Eastern Mediterranean over two and a half millennia ago, were the greatest achievement of humanity. We are told that all this died a long time ago. Perhaps not entirely. In this equally small and rocky (but no longer poor) country the remains of the only true democracy left in this world still linger on. Foreigners may mock it, and one cannot open a Swiss newspaper without reading the veiled suggestion that direct democracy is an anachronism and doomed to failure in modern times, but I wonder. Perhaps on the 8th of December the Swiss electorate voted as they did for the wrong reasons, but no honest medical man can doubt that they made the right choice. Perhaps among these mountains there are still some embers left of the great Greek fire of old ? If this is so, long may they smoulder!
A 73-year-old woman developed complete heart block which was treated by a pacemaker. This has proved eflective, but she has been persistently troubled by recurrent, distressing "thumiing." What action would you advise?
The thumping is probably caused by spontaneous ectopic beats, which are sensed by the pacemaker and therefore followed by a pause before the next beat. This post-ectopic beat is felt as a "thumping." An alternative explanation is that the patient has returned to sinus rhythm and is competing with a fixed rate pacemaker. In either case, a small dose of propranolol should remove the symptoms. Provided the pacemaker is functioning correctly, this will not produce tachycardia and unless it is contraindicated because of heart failure, it is the most effective treatment. Other antiarrhythmics, such as procainamide, may be effective in suppressing ectopic beats. This symptom does not usually persist beyond two or three weeks after pacemaker implantation and therapy may then be discontinued. Possibly the thumping is in the region of the pacemaker and is due to skeletal muscle contraction, but this seems to be less likely.
What medical risk is attached to drinking water from the domestic hot water supply in urban areas ? Given that the main supply is epidemiologically satisfactory the hot water should be safe to drink, but it is generally considered to taste "flat" and may contain traces of metals such as lead, copper, zinc, and iron picked up from the piping and fittings. The feed-cistern and hotwater cylinder should be accessible and regularly inspected; thby should be constructed and protected from contamination and the elements according to bylaw specifications. If the supply is in an urban area in Britain it will probably be connected to a public water supply. The better alternative and the safest procedure would be to use the water from the cold tap for drinking.
393
15 NOVEMBER 1975
half-hour drive back to Bath), but students almost invariably express pleasure at the pattern of medicine practised, the happy and easy doctor-patient relationship, and the satisfactory holistic approach at clinical level to the total problems the patients present. The Lancet IO urged the need for audit of outpatient facilities and efficiency, and Glass"' contended that, despite difficulties, cost-benefit analysis of medical work should be attempted. We have already shown that such clinics are favourable from the point of view of cost-benefit. This paper shows that nearly 98% of such consultations were satisfactory from the medical point of view. This demonstrates that the benefit of cost and convenience is not bought at the price of an inferior service to the patient. In fact, in many ways the service at peripheral clinics may be better. The numbers failing to attend are lower at country clinics and problems of communication are generally less. These aspects are under further detailed investigation. These clinics could be conducted quite as adequately in a health centre or the premises of a group practice,2 with the added advantage of a close liaison with the family doctor. This would, however, demand more time per patient to allow for discussion-in other words, for the teaching role of such a clinic. It would, therefore, not be possible to see so many patients.
The information here reported should be supplemented by similar surveys in other specialties, so that the value of consultant work in peripheral hospitals, health centres, or in practitioners' premises may be more clearly seen. Such data should be of considerable value for planners. The expenses of this survey were met by a grant from the Bath Area Medical Research Trust, for which I am most grateful. I also thank the family doctors and medical records officers, who helped so willingly.
References Kerr, H M, Lawson, C W, and Weller, S D V, submitted for publication. Marsh, G N, and Tompkins, A B, British Medical Journal, 1969, 2, 106. 3 Gruer, R, Lancet, 1971, 1, 390. 4 Bailey, S M, Evans, D W, and Fleming, H A, Lancet, 1975, 2, 57. 5 Leonard, J V, Clayton, B E, and Colley, J R T, British Medical Journal, 1975, 2, 662. 6 Forsyth, G, and Logan, R F L, Gateway or Dividing Line? London, Oxford University Press, 1968. 7 Hampton, J R, et al, British Medical3Journal, 1975, 2, 486. 8 Shapland, D, World Medicine, 1975, 10, 45. 9 Smith, J W, et al, British Medical_Journal, 1973, 2, 471. 0 Lancet, 1973, 2, 137. 1' Glass, N J, Health Trends, 1973, 5, 51. 1 2
Letter from . . . Zurich The 8th of December 1974 PETER PAUL RICKHAM British Medical Journal, 1975, 4, 393-394
I am still surprised that the happenings of the 8th of December 1974 did not cause even a ripple amongst medical men outside Switzerland. Certainly I have not yet met a British doctor who had any idea that something extraordinary happened then. Perhaps with galloping inflation and unemployment coupled with the rapid decline of the last remnants of the National Health Service, British doctors have other things to think about. Nevertheless, I thought that they might momentarily have stood still and wondered. Before I tell you about the 8th of December I must very briefly explain the workings of Swiss democracy. Switzerland is a direct democracy: government and parliament can propose new laws, they can debate and vote on them; but they cannot pass them. Only the people, aptly called here the "sovereign," can pass laws. New laws can be proposed by government and parliament, but they can also be proposed by individuals or groups of individuals-for example, a political party-asking for a referendum, provided they have enough signatures to support their petition. Switzerland is the land of free enterprise and the medical services are no exception. Ninety-five per cent of the people
Kinderspital, Zurich PETER PAUL RICKHAM, MS FRCS, professor of paediatric surgery
are insured by private insurance companies for ambulant and hospital treatment. I have no doubt that the standard of medical care is superior to that of any country I have visited, but there are imperfections in the system. There has long been friction between insurance companies and general practitioners about some payments. Hospital charges have doubled since 1970 and so insurance premiums have had to be raised and the state has had to pay a larger and larger share of the costs. For a long time the socialist party, one of the three large parties in this country, has vociferously agitated for a state medical service. Enough signatures for their petition were quickly collected. They wisely refrained from saying in detail how much this would cost the tax payer (already the proportion of the gross national income spent on health is much higher in Switzerland than in Great Britain) and, although they suggested that the insurance companies could somehow be incorporated in their scheme, there was no doubt in anybody's mind that what they were after was a state medical service similar to that in Britain or Sweden. The coalition government was apparently worried that the referendum might succeed and, as they usually do, put up counterproposals. What, they asked, did the doctors suggest ? To an outside observer the reaction of the doctors was rather bewildering. The medical profession was disunited. Different health service plans sprouted like mushrooms after the rain. For somebody who had experienced 1948 in Britain there was a sense of deja vu. Every doctor I talked to privately was convinced that the present system offered much better patient care than any of the new schemes, but to say it loudly was not progressive and would harm the medical man's "image."
394
The government was naturally bewildered and finally drew up their own proposals, going at least halfway toward nationalisation but leaving some scope for the insurance companies. They did, however, state their proposals would mean a contribution of up to 3% of the taxpayer's money. The proposals were somewhat complicated and vague and would probably have led to full nationalisation some time after being put into practice.
The people vote The date of the referendum was approaching and the Swiss Medical Association had to make a belated decision. They patched up their quarrel with the insurance companies and chose to support the government's counterproposals wholeheartedly, but the sceptical observer might have wondered whether the doctors were choosing the lesser of two evils. Among a barrage of propaganda from all parties and the mass media the 8th of December came and the people voted. The socialist proposals were rejected by 72-500 of the voters, while 66% rejected the government's counterproposals. The crashing majority of "Njets" was wholly unexpected. The government was not too worried. The socialist party fulminated. And the medical men? Shall we say they looked a little sheepish? What was the reason for this vehement rejection of socialised medicine? Obviously there were many factors, and opinions about the underlying causes vary. The vote did at least partly express the dislike of the individual Swiss for centralised government and governmental interference. The Swiss are good businessmen, if nothing else, and they saw that acceptance of either proposal would cost them a good deal of money without improving the health service at all. The disastrous effects on overall patient care brought about by the British National Health Service are not unknown here. It was also argued that the
Is there any treatment for multiple small cysts of the retina, probably secondary to a chronic vasculitis of unknown origin, and causing deterioration of vision ? Small peripheral retinal cysts do not require any active treatment but if, as is suggested by the deterioration of vision, the cystic changes are at the macula they are probably secondary to chronic inflammation in the retinal periphery and ciliary body. The only treatment in this case is to suppress the inflammation with corticosteroids. If the cystic changes are accompanied by retinal oedema some improvement may result as the oedema settles, but the cystic degeneration implies permanent visual damage.
Can dangerous anaphylaxis occur from ingestion of a drug ? If one is very, very doubtful of the story of a person's sensitivity to penicillin, what are the dangers of giving a trial dose of an oral penicillin preparation ? What are the usual reactions to sensitivity to oral penicillin apart from rash, or urticaria, or both ? An anaphylactoid reaction has been observed after oral penicillin, though the reaction occurs more often after injection. If there is any doubt about the sensitivity of the patient to penicillin, the group of drugs, and particularly benzyl penicillin (penicillin G), should be avoided. An alternative drug such as erythromycin should be prescribed. If one is very, very doubtful of the history of a hypersensitivity reaction the risk of a serious reaction occurring may be small but it must be emphasised that fatal episodes of anaphylaxis have followed the ingestion of very small doses of drugs of the penicillin group. The usual reactions, apart from rash and urticaria, include rashes of all types-scarlatiniform, morbilliform, urticarial, vesicular, and bullous. Contact dermatitis, exfoliative dermatitis, and exudative erythema multiforme are other cutaneous manifestations of hypersensitivity. Other reactions include oral lesions, drug fever, eosinophilia, serum sickness, and reactions of the Arthus type.
BRITISH MEDICAL JOURNAL
15 NOVEMBER 1975
proposals were too complicated for the average voter to understand; that the counterproposal promoted the double no; and that two noes really make a yes. These and many other fanciful explanations were forthcoming in the press and in parliament. But the fact remains that the relentless spread of socialised medicine to more and more countries was at least temporarily halted by the people of this small nation. Somehow I cannot help feeling that there was a wider issue here. I am a sincere sceptic and pessimist. Born during the first world war and still able to cerebrate, how could I react differently ? I don't need the club of Rome to tell me about the obvious direction in which humanity is travelling. I believe that socialism and not religion is the opium of the people of the 20th century. True, our times have been characterised by the dictators, but even they, from Hitler to Stalin and from Castro to Idi Amin, could only succeed as well as they did (and are doing) by blending nationalism-the expression of the inferiority complexes of their followers-with the illusion of socialism. I am old-fashioned enough still to believe that the ideals of European civilisation, which suddenly blazed from the shores of the small, rocky, poor peninsuia in the Eastern Mediterranean over two and a half millennia ago, were the greatest achievement of humanity. We are told that all this died a long time ago. Perhaps not entirely. In this equally small and rocky (but no longer poor) country the remains of the only true democracy left in this world still linger on. Foreigners may mock it, and one cannot open a Swiss newspaper without reading the veiled suggestion that direct democracy is an anachronism and doomed to failure in modern times, but I wonder. Perhaps on the 8th of December the Swiss electorate voted as they did for the wrong reasons, but no honest medical man can doubt that they made the right choice. Perhaps among these mountains there are still some embers left of the great Greek fire of old ? If this is so, long may they smoulder!
A 73-year-old woman developed complete heart block which was treated by a pacemaker. This has proved eflective, but she has been persistently troubled by recurrent, distressing "thumiing." What action would you advise?
The thumping is probably caused by spontaneous ectopic beats, which are sensed by the pacemaker and therefore followed by a pause before the next beat. This post-ectopic beat is felt as a "thumping." An alternative explanation is that the patient has returned to sinus rhythm and is competing with a fixed rate pacemaker. In either case, a small dose of propranolol should remove the symptoms. Provided the pacemaker is functioning correctly, this will not produce tachycardia and unless it is contraindicated because of heart failure, it is the most effective treatment. Other antiarrhythmics, such as procainamide, may be effective in suppressing ectopic beats. This symptom does not usually persist beyond two or three weeks after pacemaker implantation and therapy may then be discontinued. Possibly the thumping is in the region of the pacemaker and is due to skeletal muscle contraction, but this seems to be less likely.
What medical risk is attached to drinking water from the domestic hot water supply in urban areas ? Given that the main supply is epidemiologically satisfactory the hot water should be safe to drink, but it is generally considered to taste "flat" and may contain traces of metals such as lead, copper, zinc, and iron picked up from the piping and fittings. The feed-cistern and hotwater cylinder should be accessible and regularly inspected; thby should be constructed and protected from contamination and the elements according to bylaw specifications. If the supply is in an urban area in Britain it will probably be connected to a public water supply. The better alternative and the safest procedure would be to use the water from the cold tap for drinking.
