461LEADING ARTICLES

Government and Profession

THE LANCETLONDON: : SATURDAY, MARCH 2, 1957

INDIGNATION was justified. In the twelve mouthssince National Health Service doctors outlined theircase for a rise of pay,1 the Government had refused todiscuss its merits but had kept the negotiations inplay. Then, without any kind of warning or con-sultation, they announced that the whole subject ofmedical and dental remuneration is to go to a RoyalCommission-a form of inquiry which takes a verylong time. Members of our profession who would notwish to press their claim at a moment of specialeconomic difficulty were affronted by a decision whichpostponed that claim indefinitely and looked as

though it were intended to absolve this particularGovernment of any further responsibility for action-except on the pay of junior hospital doctors. Happilythe PRIME MINISTERS reply on Monday to Sir RRSSELLBRAIN and Dr. TALBOT ROGERS implies that the needfor an interim settlement is now recognised.

The Government, of course, have their own pointof view. In this country recovery from the war hasnot gone far enough to make everyone better off thanbefore, and the attempt to create a more healthysociety, without gross poverty, lias necessitated a

redistribution of real income which has hit manypeople very hard. Among those now less well-to-doare most of the professional classes (unless attached toindustry); for their earnings have seldom risen enoughto make up for the fall in the value of money, and thefull force of taxation hits them at a level of purchasing-power which gets lower and lower. Responsibleelements in both political parties regret the narrowingand impoverishment of professional life thus caused :Labour, with its special concern for the success of thenationalised industries and services, should have nowish to drive good brains abroad, while the Con-servatives obviously think that redistribution ofwealth has gone too far. But the remedies, thougheasy to prescribe, are difficult to apply. The threemeans by which the professional lot could be alleviatedare reduction of taxation, increase in pay, and haltingofinflation. Nobody can doubt that Mr. MACMILLAN’SGovernment will reduce direct taxation as soon as

they dare; but they cannot yet look to much reliefon Defence, and meanwhile they have to provide forhigher expenditure elsewhere-this year’s estimatefor the National Health Service, for example, being£49 million more than last year’s.2 Though membersof some professions could certainly be helped by givingmore to those on the public pay-roll, a Chancellor ofof the Exchequer who wants to reduce taxes is

understandably loth to add, for instance, t20 millionfor doctors to the £550 million which taxpayers will

1. Lancet, 1956, i, 277.2. See p. 474.

have to find for the N.H.S. next year—especiallyperhaps when he is still under fire for raising only twicethat sum by adding 10d. to the National Insurancecontribution. Thirdly, a Government can undertakemore radical but painful treatment to stop theinflation which is responsible for so many of oursymptoms ; and if they can show that they are reallytrying to do this they are entitled to ask for thepatient’s cooperation. Having incurred, to this end,the unpopularity of the credit squeeze, the presentGovernment will naturally be inclined to turn itsdeafer ear to any small group which is not only askingfor a lot of money but also (it may seem) for a

privileged economic position.Granted, however, that a Government’s duty is to

govern-that they deserve no respect unless they cansay " No

"

to their friends-strength of purpose doesnot excuse unfairness. What has been unfair about theattitude of successive Governments is that in seekingeconomies they have expected a special contributionfrom people who get their livelihood from publicfunds : when the Civil Servant or the person workingin some national undertaking is denied the properrate for the job, because the Government " cannotafford it,’’ he is in fact being forced to make anadditional contribution to the Exchequer, supple-mentary to what he pays in taxes : and the same istrue of the doctor who is asked to accept uncom-pensated depreciation of his income when (even in theNational Health Service itself) the need for com-

pensation of other groups is freely recognised. 3 Whatis unjust is also in the long run unwise, and gravedamage to the service will be averted only if theGovernment demonstrate that they are not as

uninterested or as cynical as they appeared. Particu-

larly in a new service such as the N.H.S., confidenceis vitally important ; and we trust they will be ableto restore it quickly by immediate concessions whichreasonable people will find acceptable. Thereafterit might be possible for the Royal Commission toplan its work with a view to a fairly early interimreport on the general level of medical and dentalremuneration and how this should be maintained.What, it is asked, should be the profession’s attitude

towards the Royal Commission ? Apart altogetherfrom delay, two objections to its appointment havebeen raised. First there is the " melting-pot " objec-tion : everything (it is rightly said) will have to beconsidered afresh-from mileage to merit awards-and Spens will be superseded by a report carryinghigher authority. We admit that in this meltingprocess something may be lost, but we think it atleast equally likely that something will be gained-including, possibly, improvements on some of the pre-sent methods of remuneration. Good though they were,the Spens reports were incomplete and not entirelyconsistent, and for our part we have long wished tosee them reconsidered so that N.H.S. remunerationshould be set on a properly agreed base.4 When itcomes to the point, no responsible inquiry can ignorethe terms on which doctors entered the service, andthe case for preserving the doctor’s accustomed placein the community seems to us so strong that it cansafely be entrusted to the judgment of sensible peoplesuch as usually sit on Royal Commissions. After all,

3. See Lancet, Feb. 2, 1957, p. 258.4. Ibid, 1954, i, 1277.

462

at worst, when the commission has reported, the pro-fession will be entitled, if it wishes, to hold to theletter of the bargains it reached with the Governmentin 1946 and 1948. It will be uncommitted by whatthe commission says. So too, of course, will be theGovernment ; and it is the Government’s freedom topay no attention to the commission’s report that isthe other big objection raised to the present plan.The outcome here, we believe, depends largely on publicopinion. Even among other professional people, theresponse to the present medical claim has been dis-tinctly ambivalent ; and, so far from being thankedfor giving a lead, our profession is often held to betaking a selfish line. One reason for this is that,intent on their present wrongs, doctors have sometimesseemed to underestimate the difficulties of many other

professional people, which may be at least as serious.According to the Financial Times,5 the" average "practitioner with a wife and two children, earningS938 in 1938 and E2222 in 1956, has sustained a lossof real income (after paying taxes) of 27%. But the

university professor (arts) runs him close at 24%, andthe estimated loss of the headmaster of a largegrammar school and of the assistant secretary in theCivil Service are higher at 32% and 43% respectively.As for the general public-many of whom still thinkthat the whole of their weekly National Insurancecontribution goes straight into their family physician’spocket-they do not readily understand how doctorsjustify an average " wage claim " for an additional£10 a week, which is more than many of them earnaltogether. They would feel differently perhaps if theysaw the calculation 6 that for consultation or visitthe doctor now gets an average of half a crown.

Perhaps no completely satisfactory arrangements canbe made until the public, as well as the Government,understand that they cannot continue to have reallygood doctors unless they are prepared to pay for reallygood doctors.But we would add that the future of the profession

ultimately depends not on what the public think, or onwhat the Government say, but on what the professionitself does ; and, since the immediate outlook remainsuncertain, we must state our opinion of the currentproposal that professional action should take the formof pressure on the Government through an under-taking by practitioners to withdraw from the NationalHealth Service. In our view this proposal is wrong :we think that even if it were 100% successful suchaction would still do great harm to the profession-more harm than could be done by any Government.In offering this opinion we do not mean that doctorsneed remain in a service in which they lose con-

fidence : we think that those who, now or later, wantto leave the N.H.S. should certainly do so ; and we

agree that if any substantial exodus were in prospectthe professional organisations would need to do all

they could to help both their members and the publicto overcome the difficulties thus arising. But a

genuine decision by individual doctors to return toprivate practice would be quite different from a

withdrawal, or the threat of a withdrawal, organisedfor political ends. This we regard as an alien pro-cedure, out of keeping with the character of anyprofession, and especially that of medicine.

5. Financial Times, Feb. 22, 1957, pp. 1 and 6.6. Cardew, B. Times, Feb. 16, 1957.

HypophosphatasiaIN 1948 RATHBUN1 drew attention to an osteo-

dystrophy in infants which resembled severe ricketsin many respects, but in which there was a greatreduction in the level of serum-alkaline-phosphataseactivity : he called the syndrome hypophosphatasia.Further reports have appeared of what appears tobe the same disorder, and a clearer picture of thisremarkable new bone disease is beginning to emerge.The disorder may be clinically apparent at birth

or soon afterwards. RATHBUN’S patient was 3 weeksold when first admitted to hospital, with multipleabnormalities and defective mineralisation of theskeleton ; and MCCANCE et al.2 have lately describedan infant who was certainly affected at birth and whohad indeed been recognised as abnormal in utero

by X-ray examination. At birth the bony craniumwas very poorly developed and there were widelypatent and communicating fontanelles. The chestwas flattened at the sides, and beading of the costo-chondral junctions could be felt. The lower ends of theforearms were much widened, and the long boneswere soft and easily bent. An older sister had beenshown to have the same condition; from which shehad died at 14 weeks. But by no means all cases areapparent as early as this : ENGFELDT and ZETTER.STR6M’S patient 3 seemed to have developed quitesatisfactorily until she was 3 months old ; thena failure to thrive and the generalised skeletal fi-order resembling rickets first became apparent.SoBEL et al.’s patient 4 had evidently progressedwell during the first year of life and medical advicewas not sought till she was 19 months old. During thepreceding 2 months several teeth had been shed, andincreasing rickety deformities of the limbs had

developed. A similar variation in the age of apparentonset is seen in the three hypophosphatasic childrendescribed by ScHLESINGER et awl. 5 Two brothers,aged 10 and 13, were admitted to hospital for ortho-paedic correction of genu valgum and were found tohave very low levels of serum-alkaline-phosphatase 6 -;they probably had an even milder form of the condi-tion. When the disease appears in infancy the out-standing features are failure to thrive, early rachitic-type bone deformities, and very poor calcificationof the skeleton. The fontanelle is often tense and

bulging, though the cause of this sign is obscure.The teeth are hypoplastic and are commonly shedprematurely. Very often there is hypercalcæmia andsometimes consequent renal damage. It is possiblethat these infants are hypersensitive to vitamin Dand that even relatively low doses may raise theserum-calcium level.The prognosis seems poor when the disorder is

clearly manifest at birth or soon afterwards; butotherwise it is more hopeful, and the bones slowlycalcify, symptoms abate, and growth advances,though varying degrees of bony deformity persist.A surprising complication in some patients is pre-mature craniostenosis, which may necessitate cranio-1. Rathbun, J. C. Amer. J. Dis. Child. 1948, 75, 822.2. McCance, R. A., Fairweather, D. V. I., Barrett, E. M., Morrison,

A. B. Quart. J. Med. 1956, 25, 523.3. Engfeldt, B., Zetterström, R. J. Pediat. 1954, 45, 125.4. Sobel, E. H., Clark, L. C. jun., Fox, R. P., Robinow, M.

Pediatrics, 1953, 11, 309.5. Schlesinger, B., Luder, J., Bodian, M. Arch. Dis. Childh. 1955,

30, 265.6. Schneider, R. W., Corcoran, A. C. J. Lab. clin. Med. 1950,

36, 985.