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Conferences

FILLING MEDICAL APPOINTMENTS

OVERSEAS

A B.M.A. Conference

MANY countries overseas urgently need doctors fromBritain. They need them for medical schools, researchinstitutes, hospitals, public-health projects, and medicalservices during the transition period before there are localdoctors fitted by training and experience to take over. Butrecruitment of British doctors to such posts is impededby fears (1) that their career overseas may be prematurelyterminated by political developments and (2) that whenthey come home again they may find it very hard to getcongenial medical work. Believing these fears to be

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byno means groundless ", the British Medical Associationheld an informal conference in London on Nov. 14 toconsider some of the remedies that have been proposed.Prof. A. P. THOMSON, president Qf the Association, tookthe chair.Two separate problems emerged. The conference

began by considering ways in which more security mightbe given to doctors choosing an overseas career (particu-larly in the Colonial Medical Service) and later turned tosuggestions which might make it easier for doctors inBritish hospitals and universities to go abroad for a fewyears.

THE OVERSEAS CAREER

Prof. D. E. C. MEKIE, chairman of the B.M.A.’s Over-seas Committee, explained how the situation has changed:on the one hand, a career abroad may now be endedabruptly for political reasons, and on the other hand theNational Health Service has made it difficult for return-

ing doctors to take up private practice. Prof. GEORGEMACDONALD (Ross Institute), though not much impressedby the risk of doctors losing their jobs (except in India, hehad not heard of contracts being terminated), pointed outthat in independent countries the British have littlechance of gaining senior administrative posts, and theironly opening for promotion may be to become specialists.Dr. IAN GRANT (College of General Practitioners) hadfound anxiety greatest among the general-duty officers,who, though they are usually doing general practice at ahigh level, are unlikely, when they return to Britain ontheir very small pension, to secure N.H.S. practicesagainst the competition of younger men who have stayedhere and know the ropes. Air Marshal Sir JAMESKILPATRICK (London School of Hygiene) said that forwork whole-time overseas people require both reasonablesecurity and opportunities of refreshing their knowledge.The alternative is to divide the work between serviceabroad and service at home in a parent organisation, as isdone in the Forces. Mr. J. L. GILKS made it clear thatthe rank-and-file medical officer, who is the backboneof the Colonial services, used to be secure but nowis not.The first proposals put before the conference were all

intended to give the overseas doctor a safe base in dùscountry.

1. That a British Overseas Service should be created,managed and remunerated by the United Kingdom Govern-ment, in which a full career would be to all intents andpurposes guaranteed.

Sir CHARLES JEFFRIES (formerly Colonial Office) thoughtthat, given the will, a service operated from this country

is possible; and, provided it has Government support, itneed not necessarily be operated by the Government.A London centre for teaching and research in tropicaldiseases could be the administrative base for overseas

work, affording medical employment for doctors whocome and go.

2. That a Commonwealth Service should be created,managed, and remunerated by a consortium of Common-wealth Governments, in which a full career would be

provided.Mr. BERNARD BRAINE, M.p., said that the need overseas foradministrative and specialist personnel of all kinds is

growing. To fill that need is the only way to make themultiracial Commonwealth a reality, and the creation ofa new service for the purpose would strengthen andinspire the Commonwealth family. But there are difficul-ties. First, the expatriate must be the servant of thecountry which employs him: there must be no doubtabout where his loyalty lies. And secondly, the Common-wealth Governments, all of whom are short of highlyqualified personnel, seem unlikely to be interested in run-ning Territories for which they are not responsible. Mr.Braine saw no valid reason why the pay and pensions ofdoctors working in the various Territories should not beunderwritten by the British Government: indeed thesedoctors could be called members of a Commonwealthservice. But he had become cautious in thinking that aCommonwealth solution is practicable, and so far as

medicine is concerned he doubted whether it is necessary.The Colonial Office, he said, does not at present seem tohave any special difficulty in filling the vacancies (about130) it advertises every year.

3. That the medical branch of H.M. Overseas Civil Serviceshould be merged or linked with the medical branch of theHome Civil Service, so that doctors relinquishing overseasappointments could be absorbed into the medical establish-ments of home departments.

Dr. E. GREY-TURNER (B.M.A.) explained that the CivilService recruits about 30 doctors annually, and about halfof its 550 medical appointments are mainly clinical. In theColonial Service about 95% of doctors are doing purelyclinical work; but among about 600 doctors recruited inthe United Kingdom the average normal number ofretirements is only about 15. Though the Civil Serviceclinical work is less in quantity and scope, and might notattract displaced clinicians from overseas, they might pre-fer any clinical appointment to none at all, and it wouldbe a comfort to them to know that they can always havea Home Civil Service appointment, even if in fact theychoose something else. Dr. Grey-Turner held that actuallyit would be very difficult if not impossible to integratethe Civil Services of 35 separate Territories with our

own; but he thought more use could be made of thespecial list, by which doctors can be employed by theBritish Government and seconded for work abroad. Incase anyone should wonder why the Government does notpromise the returned doctor work in the NationalHealth Service, he pointed out that in such matters theGovernment are not in a position to give instructions tothe boards.

Sir JOHN CHARLES (Ministry of Health) made it clearthat, though about 550 doctors work for Governmentdepartments, there is no single medical service. He

regarded the opportunities for returning doctors to doclinical work in the Civil Service as " a bit limited ";for example, to become a regional medical officer, of whom

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there are 60-70 in the Ministry of Health, at least eightor ten years’ experience of general practice in this countryis thought desirable. The Ministry’s administrative staff,on the other hand, contains 10 doctors returned fromabroad.

SECOND.MENT FROM THE N.H.S. ? z

Speaking on the proposal4. That the medical branch of the Overseas Civil Service

should be linked in some way with the National HealthService,

Prof. ALAN MONCRIEFF (London University) recalledMr. H. J. Seddon’s plan whereby the overseas servicewas to become part of the N.H.S.l But he spoke mainlyon the need for doctors to be seconded overseas fromBritish hospitals and universities. No scheme will suc-ceed, he said, unless the hospital boards and their medicaladvisers appreciate the importance of our doctors work-ing abroad: at present, in Seddon’s words, " they knowlittle and care less "; and they must be persuaded both byofficial memoranda and by personal visits if need be.Secondments so far.have been very few, though propor-tionately more in Scotland: one consultant who asked togo abroad for two years got no encouragement from hisboard and no help over locums; and senior men are apt tosneer at such " missionary " activities. At university levelthere is more support for secondment; but to get it towork at Great Ormond Street a " priming " expenditureof E4000, from endowment funds, was needed in the firstyear. Secondment can mainly cover the supply of special-ists-at present the main problem-and it need cost theregional boards nothing. Appointments could be madeby a body on the lines of the Inter University Council.The best stage for going is usually that of senior registrar;the post can be regarded as a continuation of training, andif the man has children they will probably be youngenough not to rieed education in this country. We musthammer at the boards, said Professor Moncrieff.Mr. E. F. COLLINGWOOD (Newcastle regional board)

said that boards do not prevent men going; they are verywilling to consider secondment provided they do nothave to finance it, which is right outside their responsi-bility. But it is hard enough to get senior registrars tomove from a teaching hospital to a regional one, and tomove them to another country would be harder. Thereason may not be unwillingness, or lack of money incen-tive, but purely domestic.Mr. N. M. AGNEW (Manchester regional board)

doubted whether the senior registrar is the right man togo. Often he is one of a team, to which he may not getback. If anybody goes, it should be the consultant, takingthe registrar with him. As for the difficulty of gettingback, after losing " a place on the ladder ", appointmentsare made, in effect, by advisory committees which aremostly medical. For a board to suggest to its advisorycommittee that a particular man should be appointedwould be most dangerous. If anybody needs educatingabout this it is not the boards but the medical profession.

Prof. A. BROWN (Ibadan) agreed with Professor Mon-crieff that secondment is probably the best solution. Hetalked in terms of secondment for a year-a short time

during which a man can be expected to take the risk oflosing an advertised appointment. But there must be nohumbug; on arrival he must not find himself expected tobuy crockery for his house. Moreover, to avoid explaining

1. Seddon, H. J. Lancet. 1956, i, 46

over and over again, the scheme should be widely known.Overseas service should be regarded as creditable, not asa rather unfortunate lapse.

Dr. B. E. C. HOPWOOD (B.M.A., Uganda) hoped thattemporary secondment of doctors from this country willnot prejudice promotion for men making their career

abroad.

Prof. J. H. F. BROTHERSTON (Edinburgh) said that for apostgraduate school it is an advantage to have teacherswho know conditions in the countries from which the

postgraduates come. Direct relations between two

universities make it possible to build up know-how onboth sides, which helps in quick adjustment of thoseseconded. Perhaps, however, single British universitieshave not all the resources needed by a college overseas.Should such a college perhaps be attached to a consortiumof universities ? The Montreal inter-university conferenceresolved on more interchange between Commonwealthuniversities, which in some ways, being non-political, ispreferable to interchange between Governments.

PROLEPTIC APPOINTMENT

Prof. CHARLES WELLS (Royal College of Surgeons)thought secondment satisfactory for consultants, and

perhaps for younger men in limited fields, such as

pxdiatrics, where their seniors can make sure that they getcredit for work abroad. But in general medicine or

surgery this is impossible, and anyone seconded runs agrave risk of losing his place on the ladder. On thisladder the vital step is appointment as consultant, anduntil this is passed the young doctor dare not move away.So it is that, though there is a large superabundance ofsuitable people here, who are much needed abroad, theycannot go. To meet the situation he proposed:

5. That consultant appointments in the N.H.S. shouldnormally be made two years ahead of the vacancies arising.Thus a group of consultants-designate would be createdwho could be encouraged to take service abroad for theperiod which would then elapse before they assumed theirappointments in the N.H.S.

For the first time since he became a medical student,the man thus appointed would be free to adventure-perhaps taking a post abroad. But if he did not want todo so, he could spend his two years very usefully as locumfor consultants. The scheme would cost nothing, for theperson appointed would not be paid till he was employed.Nor would it need any organisation. But it would give achance for the natural operation of the law of supply anddemand; for, until they know that they can get somebody,the schools and hospitals abroad are unlikely to ask. TheMinistry of Health could put the plan into action at onceby a simple instruction to boards-not educating thembut telling them.Mr. E. R. EDMONDS (Colonial Office) described this

proposal as very attractive. But in the Colonial serviceselection of directors of medical services two years aheadhas proved impossible : " you don’t know what the fieldwill be ". He thought that an insuperable difficulty.Commenting on this later, Prof. IAN AIRD (PostgraduateMedical School) pointed out that, though one may missa good man by appointing too early, one may also miss agood man by appoipting too late. In point of fact, thesuccessful applicant for an appointment is often knownmore than two years in advance.

Mr. G. I. CRAWFORD (Ministry of Health) askedwhether it would be fair to competitors to close certain

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openings before they exist. He was clear that prolepticappointments, as proposed by Professor Wells, are

beyond the scope of the legal instruments.Mr. ROGER BREARLEY (Registrars’ Group, B.M.A.)

thought that this obstacle could be surmounted bymaking new regulations, which would distinguish betweenbeing appointed to a post and actually holding one.

Professor Wells’ scheme has the great merit, he said, ofbeing based on freedom-not on pushing people around.Those in training for a specialty feel confined-like sheepgoing through a narrowing pen to be dipped. The

proleptic appointment offers a man two years’ freedom toget outside the hurdles and do what he wants-to vegetateor to mature. Moreover, if appointments are hastened bytwo years, some of the registrars now overdue for senior-registrar posts can be appointed. He thought that a

non-official agency should be established-possibly byone of the philanthropic trusts-to put available peoplein touch with those who need them. Such a body,declaring that it is now in the market for doctors, wouldpay them salaries and arrange for them to work where

they are wanted.

SUPERNUMERARY POSTS

PROF. K. R. HILL (Royal Free Hospital) proposed:6. That supernumerary appointments should be created

on the staffs of universities and hospitals in the United

Kingdom and that the holders of these appointments shouldbe seconded to universities and appointments overseas.

Universities in the Colonies, he had found, favour second-ment and exchange, especially at registrar level. Headsof departments here have been responsive but have said:" I haven’t got the staff to spare, and I haven’t got the

money." To meet this situation and enable young doctorsto come to this country without interfering with the workof its hospital, Ibadan might appoint several supernumer-ary registrars; and a plan could be devised for jointappointments by the Royal Free Hospital pathologydepartment and Ibadan, which guarantee the holder ayear or two in his home department when he came backfrom secondment to West Africa. To provide four super-numerary registrars for each of six overseas colleges wouldcost perhaps E56,000 a year : allowing for payment bysome of the colleges, Professor Hill reckoned the netexpense to this country at rather over E30,000-a modestsum in relation to the value of the scheme both to the

colleges and to British medicine.Discussing this plan, Mr. BREARLEY deprecated the

appointment of supernumerary registrars on the groundthat there are already too many people in the penultimatestage. Professor AIRD thought it might be very suitablefor preclinical departments and possibly for clinicians too.

REMOVAL OF HANDICAPS

Professor Hill also made three other proposals.7. That, for consultants appointed to the N.H.S., service

overseas of recognised standing should count in its entiretytowards seniority, and the limit of four years’ senioritywhich can be granted at present should be removed.

8. That selection boards for appointments in the N.H.S.should not ignore a candidate merely because he is stationedoverseas, but should short-list him if his qualities are

sufficiently worthy and should pay his travel expenses to andfrom the United Kingdom in order to interview him.

The knowledge that candidates abroad are liable to becalled for interview would, in Professor Hill’s view, givea boost to morale. Expenditure of perhaps S300 on air

fares should be weighed against expenditure on thefuture consultant’s salary-possibly E60,000 to E100,000.

Prof. H. W. RODGERS (Belfast) agreed that this woulddo a great deal of good; but Dr. E. R. BOLAND (Guy’sHospital) thought that, with applications from perhaps30 candidates, of whom at least 10 would be excellent forthe post, a board could hardly be expected to pay forsomeone to come from abroad. There would have to bea fund for the purpose.

9. That universities and employing authorities in theN.H.S. should advertise senior appointments at least threeor four months in advance of the closing dates in order thatoverseas candidates might have a full opportunity of applyingfor such posts.

Professor Hill spoke of protests from Hong Kong aboutthe shortness of the notice given. Perhaps two monthswould do. For 23 N.H.S. posts advertised in the previousweek the average was 24 days, and one teaching hospitalgave a date only 9 days ahead.

MONEY

Prof. MELVILLE ARNOTT (Birmingham) had no doubtof the immense value of arranging that doctors at alllevels are able to spend time overseas. But water will notrun uphill, and they will not go to their own disadvantage.A fund must be created to enable them to go without loss.For an established consultant (without merit award) at leastE3000-E3300 is required, plus an adequate disturbanceallowance. Sir JAMES KILPATRICK also emphasised thata scheme of secondment requires solid financial backing-with allowances for education of children, for example.

Dr. BoLerrn thought that most of the problems aresoluble by money. The staff of some of the colleges over-seas, he said, are grossly underpaid by English standards.Professor BROWN explained that Ibadan salary scales arealmost identical with those in English universities; butdoctors in West Africa may have to send their childrento boarding-schools in this country, at perhaps E400 each;and this may oblige them to leave. Some have beenasked to pay income-tax in both countries because theyhave a cttage here. Pensions are inadequate, and theacademic staff have no parent organisation to help them,as missionaries have. A different salary structure shouldbe devised, so that a valuable lecturer, unable to getpromotion in a small school, will nevertheless reach areasonable competence.

Professor Brown also mentioned the need to give goodopportunities to investigators from this country who mightwant to do part of their research abroad, where medicalfacilities are in fact much better than is generally supposed.Professor RODGERS, disagreeing with Professor Arnottthat water always flows downhill, said that people willnot go abroad for more security; but they will go becausethey get a chance to do work they think themselves capableof doing, but cannot do here, or because they want to doresearch-though not necessarily research alone.

Professor BROTHERSTON pointed out that colleges over-seas cannot be expected to pay men from Britain morethan they pay their own staff, and it would be easier ifvisitors were supported from home. But he was not surethat money is the greatest difficulty: perhaps it could befound through the Colombo Plan. The real difficulty isto get the right people to go. But " we mustn’t," he added,"

express our benevolence at the expense of young menwho haven’t been at our conference ". A man should goabroad not because his seniors know that it will make him

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a better man but because he himself sees that it would be

advantageous. The moment it is found that posts aremore likely to be given to someone who has been abroad,the demand for secondment may be overwhelming.

Speaking of the doctors who want to make their careeroverseas, Professor MACDONALD said that the materialadvantages of doing so are now nothing like what theywere. When he went abroad the commencing salary inWest Africa was E600; today it has not doubled, and thereis income-tax to pay on it.

THE SITUATION

Professor AIRD could not see how general-duty medicalofficers returning from Colonial services can fit in any-where at any level in our medical service here. These

people, Dr. HOPWOOD said, are not concerned with losingtheir place on a ladder but with getting any job at all;and Dr. JOHN REVANS declared that the conference hadsuggested nothing for them. Professor THOMSON agreedthat there had been no concrete proposal: but the securityof these doctors, he said, is a Government responsibility,and the profession, as organised, can do little to help.Putting this in another way, Dr. GRANT had pointed outthat, if men are expected to go and work in the Colonialservice, arrangements must be made for when they comeback.On the academic side, Professor BROWN saw the prob-

lem as self-limiting, because the appointments will in duecourse be filled by local people. At Ibadan it will besolved as regards registrars in five years and as regardsmore senior men in ten. (" How very convenient,"remarked Mr. BREARLEY, since the senior-registrar prob-lem, too, will sort itself out in five to eight years’ time,and meanwhile the one need fits the other.) Till then,said Professor BROWN,

" the situation remains plastic ".Professor THOMSON, in his concluding remarks, said

that, though five or ten years may be true of the Ibadancollege, it cannot apply generally to the vast territorieseven of Nigeria. The overseas colleges have to train notonly doctors but also technologists and technicians.

Singapore said that, however much it stepped up itsteaching, it must for a generation rely partly on staff fromoutside. As to the ways in which doctors can be enabledto go abroad for a time, Professor Thomson was astonishedby the passion for uniformity which the conference

revealed: "everybody wants a uniform scheme ". (Forthirty years Birmingham, by means of a private fund, hasbeen making proleptic appointments, so that the successfulcandidate can have a year abroad. Why always twoyears ? Why not sometimes three ?) He believed thatCommonwealth universities may be more helpful thanCommonwealth Governments, and he recalled the offerof McGill University to adopt the University College ofthe West Indies. He felt that the relations of the overseascolleges have been a little too closely with London: itwould be better if each of them were linked with two orthree universities here, which would feel a specialresponsibility for them.The most significant thing said at the conference, in

Professor Thomson’s opinion, was Professor Brown’sremark that the state of medicine in these overseas

countries is now plastic but will soon set. He was certainthat, unless the opportunity is taken now, the influencemoulding them will not be British. " We’ve got to domuch more ", said Mr. JOHN TILNEY, M.P., "if this

country is to survive as a motherland country in theCommonwealth."

Special Articles

AN INJECTION UNIT USED INSTEAD OFTHE HYPODERMIC SYRINGE

CHARLES M. FLOODM.D. Lond., M.R.C.O.G.

CONSULTANT OBSTETRICIAN, THE WEIR MATERNITY HOSPITAL; HON.ASSISTANT OBSTETRICIAN AND GYNÆCOLOGIST, HOSPITAL OF ST. JOHN

AND ST. ELIZABETH, LONDON, N.W.8

ADVANCES in the discovery and development of drugshave far outstripped advances in the methods of theiradministration. In the 1947 revision of the U.S. Phar-

macopeia 17% of the items were for parenteral injection,compared with less than 2% in 1905; and the use ofhypodermic syringes is now so widespread as to be takenfor granted. Yet these syringes have some evident dis-advantages. To be safe and efficient they must comefrom a central syringe service with a skilled staff, who willservice and sterilise each syringe and needle after eachinjection: only in this way can infective hepatitis-socommon with syringes

" sterilised " on the ward or inthe operating-theatre-be reduced to a minimum. Buta syringe service is costly. Moreover, it has been ascer-tained that the average life of a syringe and of a needle isrespectively 73 and 45 injections before replacement is

necessary through damage or wear.

DISPOSABLE INJECTION UNIT

An alternative means of injection, devised some yearsago, is marketed under the name of Ampin’. It is asterile disposable injec-tion unit, with its own

needle, attached to an am-poule containing the drug(see figure).

1. The ampoule is of glass,with a long thin neck, andcontains the drug solutionand an inert gas. In manu-

facture, after the solutionhas been inserted, the am-poule is pressurised at 2

atmospheres and sealed.The volume of the ampouleis always twice the volumeof the solution. Hence,with an initial pressure of2 atmospheres, no surpluspressure remains in the

ampoule after the solutionhas been ejected. The inertgas used is nitrogen, argon,nature of the drug solution.

or sterile air, depending on the

2. The needle unit is made up of the cannula, the filter, andthe glass needle-cover. The cannula is made of stainless steelof exactly the same quality as is used in an ordinary hypodermicor intramuscular needle; but, instead of being mounted in ametal hub, it is mounted in glass. The needle cover is scoredso that it can be easily snapped off, exposing the needle readyfor use. The filter is made of very fine balloon fabric, or (if thesolution is viscous) of very fine gauze. It is there for tworeasons: (1) it prevents any glass spicules from the brokenampoule neck from blocking the needle or reaching the tissues,and (2) if the needle is in a vein and the ampin is aspirated,blood which runs back up the needle will be readily seen onthe filter fabric.

3. These two parts of the ampin are joined by a flexibleplastic tubing. The thin neck of the ampoule can be broken in