NEWS & Political Review American sex survey
cancelled Americans worry that government manageof medicine will mean that scientific questions will get political allswers. Last week, for example, politics had thee last word ment
in
peer review.
More than two years ago two professors from the University of Nofth Carolina grew concerned about the high rates of adolescent pregnancies, venereal diseases, and HIV positivity. One third of 15 year old Americans are sexually active. Last year 490000 children were born to American teenagers. Some of these teenage pregnancies have created infant mortalities in some cities-including Washington-that exceed those of the world's poorest countries. Ronald Rindfuss, professor of sociology, and J Richard Udry, professor of public health, thought that one way to curb pregnancies, illness, and death would be to find out what teenagers were doing and what they thought about sexuality-as well as home, family, friends, church, and school. Their idea was this. Over five years 24000 randomly sampled young people aged 13 to 18 would be interviewed for about 75 minutes. Parents would have to consent for youngsters to participate and would be interviewed as well. The questions would be wide ranging, with a few addressing sexual activity, pregnancy, homosexual sex, sodomy, oral sex, and rape. The study has a price tag of $18m, so the professors applied to the nation's biggest funding agency, the National Institutes of Health. After two years of peer review the National Institute of Child Health and Human Development awarded the grant in May, saying that the research would "provide important information about behaviours that place US adolescents at risk of AIDS and other sexually transmitted diseases" and "extend the frontiers of research on adolescent pregnancy." Politics entered peer review on 16 July, when the Health Secretary, Louis Sullivan, appeared on a conservative talk show and was asked why his agencies were supporting the study that "threatens family values and encourages young people to have sex too early." Dr Sullivan immediately suspended the award, and on 23 July he cancelled it altogether. Dr Sullivan's own 10 year health promotion plan, "Healthy people," calls for a better knowledge ofwhy young people choose early sexual activity and the consequences of their choices. "Additional research is needed to better understand early initiation, its consequences, and how-it might be prevented," says the Health Secretary's report, now less .
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lever know what they're up to
than a year old. Yet last week Dr Sullivan said that he was "concerned by the possible inadvertent message this survey could send." In Congress reaction was swift. Congresswoman Patricia Schroeder, a Democrat from Colorado who makes the family her central theme, said that Dr Sullivan was sending a message of "medical McCarthyism." She called Dr Sullivan's decision a "triumph of ignorance over knowledge." Gary Bauer, president of the conservative Family Research Council, said that the survey was a waste of taxpayers' money. "We know many of our kids are having sex too early, too often, and with too many people. We ought to be spending $18m to figure out how to divert them from that conduct instead. " The two North Carolina researchers thought that they were to do just that. Said Professor Rindfuss: "We are not trying to estimate what fraction of American kids have done this or that. We are trying to understand the broader social world in which they live: why are they engaging in this behaviour that puts them at risk?" Meanwhile, 60-70% of -American teenagers have engaged in sex and only a small minority use contraception. One fifth of all cases of gonorrhoea and pelvic inflammatory disease occur in teenagers, and both these diseases rank behind chlamydial infections. And adolescents are increasingly suspected of being a high risk group for HIV infection.-JOHN ROBERTS, Durham, North
Carolina
Accelerating NHS change Priorities for the NHS in the second year of the reforms were set out last week by the NHS Management Executive after they had been endorsed by the Secretary of State for Health and the NHS Policy Board. They will take the health service a further step into the unknown by moving from the so called "steady state" this year into what is described as "managed change" in 1992-3. Regional general managers are being encouraged by the chief executive, Duncan Nichol, to take the brakes off and accelerate the pace of reform. The NHS high command sees 1992 as a milestone year of profound change, when the NHS begins to break with many of its historic practices and acts on what the "market" is saying, though at a "manageable level of risk." The new priorities fall into three main groups: improving health for the population; securing better services for patients; and achieving more' effective management of NHS resources. The central presumption is that established patterns of referral and treatment will be adjusted-for example, to organise clinical facilities nearer patients' homes. Contracts placed by purchasing districts and fundholding general practitioners for 1992-3 should aim to secure tangible improvements in services. Providers will be given "reason263
Headlines Canadian antismoking campaign setback: Justice Jean-Jude Chabot has ruled in the Quebec superior court in Montreal that the government's ban on cigarette advertising violates the right of freedom of expression. Since the ban was passed in parliament in 1988 cigarette consumption has fallen by a quarter. Tobacco manufacturers have announced that they' plan to resume advertising.
Europe's aging population: Europe's birth rate has fallen by a quarter during the past 30 years, according to a report from the Family Policy Studies Centre. The fertility rate for most European women is now 1-8. By 2020 less than a quarter of the population will be under 20 and more than a quarter will be over 60.
Welsh move on foodborne and waterborne diseases: The Commons Welsh Affairs Committee, reporting on an outbreak of salmonellosis in Delyn in 1989, recommends that a new organisation, based on the Public Health Laboratory Service (PHLS), should have sole statutory responsibility for preventing and controlling foodborne and waterbo'rne disease. Medically qualified directors of the local PHLS would have full responsibility for controlling outbreaks.
American support for artificial hearts: The American National Academy of Sciences says that implantation of artificial hearts should continue to receive federal support despite high costs and clinical complications. Some 70 000 patients might be saved by artificial hearts, and up to 700 000 might benefit from ventricular assist devices, says the academy. Scottish infant mortality falls: The infant mortality in Scotland in 1990 was the lowest recorded- 7-7 per 1000 live births-despite the increase in births to 65 973, which was the first increase since 1987. The details are in the Registrar General for Scotland's' annual report for 1990. CAMR to stay in public sector: The government has decided that for the time being the Centre for Applied Microbiology and Research at Porton Down, which was transferred to the Public Health Laboratory Service (PHLS) in 1979, would remain in the public sector and not be acquired by Porton International. Much of the centre's work is related to the public health functions of the PHLS.
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able warning" of desired changes. Mr Nichol states that this means an acceptance of moves away from historical patterns of service. Some districts have already indicated that they would like to move more quickly in this direction-with implications for more equitable funding. The management therefore intends to start moving towards weighted capitation next year with equity being achieved between 1993 and 1995. Then authorities will be funded entirely on the basis of their home populations. The impact on the London teaching hospitals will be subject to'"managed change" in response to emerging market signals, meaning intervention and control from the management executive if necessary. Priorities for health care next year are to be coronary heart disease and reducing stillbirths and infant deaths.- Strategies to reduce coronary heart disease will include increasing the public's awareness of risk factors. To reduce stillbirths and infant deaths regions are targeting smoking b'y pregnant women and ensuring that labour wards are covered by consultants. Further integration of primary' and secondary care, such as developing protocols The death of Steve Biko in 1977 still haunts the South for the care of patients with diabetes and African medical profession asthma and better coordination of family planning services, is to be encouraged. Next year is to be crucial in the implementation of required it to open proceedings against two of reforms in community care in preparation for the doctors, and in July 1985 the council statutory changes in 1993. It will also see finally found against the two doctors. regions attempting to guarantee maximum The council's original decision caused waiting times in line with the citizen's charter worldwide protest, and both the association and revision of junior doctors' hours. and the journal received many letters. The Districts are to produce their purchasing association responded with replies that Dr plans for 1992-3 in September,but they have Lee describes as displaying a "defensive been told to indicate major changes to hos- 'total onslaught' type of approach combined pitals and other provider units before then. with an apparent determination not to think Regions are to submit their plans for the unthinkable-that authoritarian bodies managed change by 16 December. -JOHN such as the SAMDC and individuals might WARDEN, parliamentary correspondent, BMJ have acted wrongly or mistakenly." The journal, meanwhile, failed to publish any of the letters, using a series of poor excuses. This stance inevitably did huge damage to the journal, but things deteriorated further. "Worst of all from the point of view of the reputation of the SAMJ," writes Dr Lee, "an unsigned editorial was published on 16 August 1980 advancing the argument that the SAMDC should not be criticised for its handling of the Biko affair on the grounds In the June issue of the South Afiican Medical that it had been helpful to MASA in its Journal (SAMJ) the editor, Dr N C Lee, tells negotiations with the Minister of Health the full shameful story of the part played by over the medical tariff structure. A more his -journal and the Medical Association of unfortunate comparison would have been South Africa (MASA) in the Steve Biko hard to make." affair. "The whole appalling Biko episode," Since those dark days South Africa has was, he writes, "an example of what could begun to change, the association has been happen to those putting forward points of through dramatic changes, and the publicaview unpopular with those currently in tions division of the association has also authority." changed. "Present editorial policy," writes Steve Biko, a black antiapartheid activist, Dr Lee, "is that the SAMJ is a forum for died in September 1977 of serious head all shades of opinion across the medical injuries received during an interrogation by spectrum." And all articles are signed. the security police. A complaint was made Dr Lee warns, however, that "hope for the to the South African' Medical and Dental future should not blind us to the mistakes of Council (SAMDC) about the part played by the past, or mislead us into thinking that they three doctors in Biko's death. The council, in can somehow be expunged by declarations of June 1980, decided to take no action and future good intentions.... What happened repeated this decision in April 1983. Two to Steve Biko should never be allowed to years later the Supreme Court of the Trans- happen in any country that regards itself as vaal set aside the decision of the council and civilised."-RICHARD SMITH, BMJ
Confessions of South African Medical Journal.
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Scotland may get fluoride yet Eight years after one of the longest and most expensive court cases in Scottish legal history halted the fluoridation of drinking water, discussions are taking place about reintroducing the chemical into the public supply. The reason is the dreadful condition of children's teeth, particularly in and around Glasgow, where an average 5 year old has three teeth that are decayed, missing, or filled. No other city in western Europe has to anaesthetise so many children to extract their rotten teeth. A recent dental survey of 5 year olds carried out in 200 health districts throughout the United Kingdom found Glasgow and its neighbouring authorities Lanarkshire and Argyll and Clyde occupying three of the bottom seven places. The fact that nine of the 10 best areas had fluoride in the water supply is being used by Greater Glasgow's chief dental officer, Bob McKechnie, as a clear example of the benefits to be gained from fluoridation. But the decision by Greater Glasgow to open talks with the water authority, Strathclyde region, about adding fluoride to tap water has reactivated the dormant campaign of opposition. A legal challenge is being prepared for the European Court of Justice, which will claim that adding fluoride to drinking water amounts to an intrusion of personal liberty. This challenge is being backed by James Wray, the MP for the Glasgow district of Provan, who is president of the Scottish Pure Water Association and vice chairman of the all party antifluoridation committee of MPs. He has criticised the use of the public water supply as a means of mass medication. This, he says, is literally forcing the chemical down the throats of people without them having any choice. The campaign also features some of the people concerned in the highly publicised 204 day court case, which ended in 1983 with a Glasgow pensioner, Mrs Catherine McColl, winning her fight to show that Strathclyde region has no legal power to add fluoride to the water supply. Her solicitor was Peter McCann, a former city Lord Provost, who is acting now on behalf of a retired Glasgow joiner, Mr Willie Maclean, in preparing the case for the European court. Allegations that fluoride can endanger health were heard during the McColl case but dismissed by Lord Jauncey in his judgment, which concluded that there was no evidence to suggest that in the concentrations proposed it would have an adverse effect. He did agree, however, that Strathclyde was acting beyond its powers in adding the chemical. New laws were subsequently passed by parliament, and a
decision earlier this year by ministers at the
Scottish Office to indemnify water authorities
against any legal challenge brought against them has opened the way to its reintroduction. Bob McKechnie points out, "It is probably the most researched public health measure that there has ever been. There's no doubt it works, it is safe, and we really need it." Eight years ago the attack was on two fronts BMJ VOLUME 303
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as questions were posed about the legality of adding fluoride and about its safety. Today the argument is principally about personal liberty, but it is being put by some of the government's own supporters. Earl Ancram, a former Conservative minister in the Scottish Office, has expressed surprise that such a staunch advocate of personal freedom as his former colleague, Scotland's health minister Michael Forsyth, should be supporting a move that amounts to "coercion rather than persuasion, imposition rather than choice." -BRYAN CHRISTIE, health correspondent, Scotsman
Costs fall in NHS Revenue spending on the hospital and community health services in England rose by 15-4% between last year and this-the highest rise for over a decade. The equivalent figures for the family health services and the NHS as a whole are 6-2% and 12-1% respectively. But these cash rises, detailed in the memorandum of evidence from the Department of Health to the House of Commons health committee, conceal accounting changes resulting largely from the introduction of the NHS reforms on 1 April. When the various shifts in money from one part of the NHS to another have been taken into account the cash rise for the hospital and community services, for example, drops nearly 3% to 12-5%. The National Association of Health Authorities and Trusts estimates that health service inflation this year averages 8-8%, so this leaves a real growth in these resources of about 3-4%. This is a significant rise. But as the health committee's third report points out, while the real rise in spending last year was around 4-8% (although 1-4% of this was spent on the NHS reforms), in the previous four years real
rises in spending averaged only 0-73% a year. Not surprisingly, health authorities have found it tough going financially over the past few years. Despite these financial problems hospitals have managed to increase activity in virtually all service areas. The real cost per case for acute patients has fallen by 16% since 197980, to £913 in 1989-90. The key to the NHS's ability to treat more patients with near static budgets lies in reductions in lengths of stay and the growing move towards day case treatment. A question that the health committee may wish to consider posing next year, however, is the extent to which there has been a trade off between these trends and the quality and outcome of care. Have readmission rates risen? Have hospitals shifted part of the burden of care to community services and patients' relatives and friends? Have rates of postoperative infection risen? Apart from determining how much has been spent on the NHS and to what effect, the health committee also ascertained where the money came from in the first place. Over the past 10 years there has been a pronounced shift in the source of NHS funding. In the early 1980s the consolidated fund (taxes plus other government revenues) accounted for
Change in acute inpatient activity and real spending on acute services Spending has grown at an annual average of 0-3% 140
Activity has grown at an annual average of 3 0%
1355 1308 tu t; 125-
o
Inpatient activity
10120CD -
5 c 115)
110
i -105-
O
1979 1981
Spending 1983 1985 1987 1989
The large jump in 1989 was due Io achdse in the way cases were recorded -from cases to finished consuftant episodes
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88% of NHS spending. By 1990-91 this had fallen to 79%. The remainder is now made up of increased income from charges to patients (4 3%), NHS contributions (14-6%), and sales of land (1-6%). Information in the memorandum also confirms that targeting extra money to tackle waiting lists is better than not targeting at all and that targeting using methods developed by John Yates is best of all. -JOHN APPLEBY, economics correspondent, BMY Public Expenditure on Health Matters. Memorandum Received from the Department of Health Containing Wntten Replies to a Wntten Questionnaire from the Committee. London: HMSO, 1991. (HCP 408.)
Negligence and shortage of kidneys A man who spent £50 000 on two kidney transplants in Belgium after spending 10 years on NHS waiting lists is suing the North Western Regional Health Authority for negligence for failing to provide the transplants he needed. Christopher Davies, 49, a Manchester businessman and a non-practising solicitor, alleges that the health authority was negligent in not making adequate arrangements for supplying sufficient kidneys. He started dialysis in 1967 and was put on the waiting list for a transplant in 1974. Three years later, when no kidney had been found, he underwent transplantation in Belgium, where the waiting time is only a few months. The new kidney failed in 1981, and he spent a further seven years on the waiting list. When a suitable organ was found in Belgium in December 1987 he was given only four hours' notice and had to charter a private plane. He estimates that each trip cost about £15 000 in hospital costs. The case is believed to be the first in which a patient has sued for damages for failure to provide an organ for transplantation. But Mr Davies is not the first patient to go to law over delays in treatment: several have sought judicial review of decisions to delay or deny operations. In 1979 four patients in the west midlands who had spent years on a waiting list for orthopaedic surgery sought a declaration that the secretary of state and the area and regional health authorities had failed in their duty to provide a comprehensive health service under the National Health Service Act 1977. But the Court of Appeal ruled that the duty was subject to the resources available. In 1987 the parents of a hole in the heart baby whose operation at Birmingham Children's Hospital had been cancelled five times unsuccessfully sought judicial review in an attempt to have the operation expedited. In a third case, also in 1987, a patient with end stage renal failure won legal aid to seek judicial review of a decision by Queen Elizabeth Hospital, Birmingham, to admit no new patients for dialysis, but the case was never heard because the health minister, Tony Newton, gave renal units in Birmingham an extra £250000.-CLARE DYER, legal
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Waiting for Japanese transplants Does declaring a person brain stem dead mean that he or she has really died? For over 20 years most developed countries have accepted that it does, but in Japan this now is under debate. Last June the Japanese Ad Hoc Commission on Brain Death and Organ Transplantation stated in its interim report that brain stem death should mean that the
patient has died. The commission, composed of 15 members and five associate members, including medical doctors, lawyers, and philosophers, started work in March 1990 with the brief of advising the prime minister. It has held 20 meetings to discuss the ethics of organ transplantation and brain stem death and has visited Europe and the US. The interim report gives conditional approval to the idea that brain stem death ought to be regarded as the death of the patient from a medical point of view. "We should not interfere in transplantation from willing donors diagnosed as brain stem dead if recipients cannot maintain their lives without transplant operations," said the report. A recent public opinion poll showed that more than 60% of Japanese people considered brain stem death to mean that the patient had died. But four members of the panel, including a leading philosopher, Takeshi Umehara, disagreed with the majority opinion in the report. The dis-
senters insist that a person with a warm body who still breathes, even with the help of a ventilator, cannot be regarded as a cadaver. There is another obstacle to transplanting organs from brain stem dead donors. Because donors are mostly victims of traffic accidents the police authorities insist on exercising their right to do postmortem examinations. They warn doctors not to remove the organs of brain stem dead victims while their heart is beating. Thus Japanese surgeons have not transplanted organs from Japanese brain stem dead donors yet. On 12 July surgeons of Tokyo Women's Medical College transplanted the liver of a brain stem dead Belgian boy into a 59 year old Japanese woman who had previously received a partial liver transplant from her son. She died a day later. Japanese surgeons have performed 35 liver transplant operations using parts of livers from live donors in the past two years. They have even attempted to transplant livers from donors whose hearts have stopped beating. "Controversy on brain stem death and transplantation in Japan is 20 years behind that in Western countries," said Dr Kiyohiko Dohi, head of surgery at Hiroshima University Hospital, who performed the first operation to transplant a liver from a live adult donor to another adult last June. After the commission has submitted its final report next January a full programme of transplantation may begin. -MASAYA YAMAUCHI, science reporter of the Chugoku Shimbun
The limits of voluntarism Last week visitors to Britain could have witnessed at close quarters the operation of the British voluntary agreement on tobacco advertising and promotion, which government ministers hold out as an example to the rest of Europe. At the entrance to the underground at London's Euston station young women were handing out free Camel cigarettes. Behind them was a formula one racing car, labelled "Camel," obscuring a government health warning on a hoarding behind it. The hoarding did, however, promin-
ently display a warning that smoking on the underground was prohibited, although its impact was limited by its use of the colours and the typescript adopted by Camel in its promotional campaigns. Smokers aged 18 or over were also invited to enter a free competition to win "one of five exclusive Camel Benetton Formula One team jackets." In the event of a tie the winners will be those who best complete the sentence "My idea of 'life in the fast lane' is . . ." in not more than 12 words. -TONY DELAMOTHE, BMJf
Life in the fast lane, Euston station
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New kidneys for old
to fall by a quarter. This was initially thought
"If we retrieved all the potential organs then could meet the waiting list demands." This remark from Gay Hopkins, the transplant coordinator at Addenbrooke's Hospital in Cambridge, illustrates the problem for Britain's transplant programme. Demand for organs has increased, but the number donated has levelled off over the past three years, according to a report on organ transplantation by Richard West published by the Office of Health Economics last week. There are currently 3804 British people waiting for a kidney transplant, but an average of under 2000 kidneys are transplanted each year. Yet kidney transplantation costs only half as much as keeping a patient on haemodialysis for a year. The report looks at the availability, cost, and success of organ transplantation. It estimates that for hearts -at least half of the Kidney surgery has come a long way since "La potential donors are not being used. The Lithotriptie" in 1890 main reason why potential donors do not become actual donors is because their a bed being occupied by someone who is not relatives refuse permission. going to get better." A Gallup poll last year found that although She believes that junior doctors are getting three quarters of people said that they would better at approaching relatives. "It is difficult be willing to donate their organs, only a third for relatives because not only are they conof them had donor cards. Many European fronted with the sudden death of a loved one countries, such as France, Belgium, and but they are also being asked permission for Austria, have an "opting out" system, in organ donation. They may never have which the organs are harvested unless the thought of it before. It is up to transplant patient has a card stating that he or she coordinators to help doctors and nurses to refuses this. These countries have a corres- broach the subject. pondingly higher rate of organ transplanta"Attitudes are changing. People used to tion. resist us taking their relative's heart because Only 12% of British kidney transplants are they had an emotive attitude towards it. Now from live donors. Most come from patients they say to us, 'Use whatever you can.' who fulfil the criteria for brain stem death. LUISA DILINER, BMJ These are usually the victims of road traffic accidents or intracranial haemorrhage. Guy's Organ Transplantation by Richard West is published Hospital is one of the few British transplant by the Office of Health Economics. centres that harvest kidneys from cadavers after cardiac arrests. Other ways of potentially increasing the number of donor organs include cryobiology-preserving organs for longer at very low temperatures-and manufacturing artificial organs. Both are still at experimental stages. Sweden is renowned for its generous state The report concludes that most organ benefits. Now they have become too costly to transplant operations represent value for maintain. The government is increasingly money. This is the case even for heart-lung eager to reduce public spending; the social transplant operations, which cost £15 000, insurance system costs 26% of the country's and liver, transplant operations, which are gross domestic product and is an obvious priced at £20 000. According to Sir Roy target. But the government is not only withCalne, a transplant surgeon at Addenbrooke's drawing its contribution to sickness benefit. Hospital, these sums are small compared Drug charges and the cost of consultations with the cost of repeated admissions to hospital with general practitioners are also under fire. for dying patients. Heart-lung transplants The Nobel prize for medicine should have been particularly successful for people be given to the Swedish finance minister, with cystic fibrosis. The report states that the according to a report in a Gothenburg newswaiting list for these transplants is seven paper-not for any outstanding contributions months, and a quarter of those waiting die to medical science but simply for reducing before a suiitble organ becomes available. sickness benefit. The effect has been as Some hospitals perform elective ventilation dramatic in bringing people back to work as if of patients who are obviously going to die to he had found a cure for the common cold. increase the number of donor organs. But, Last March the Swedish government said Gay Hopkins, "There is resistance to reduced sickness benefit from 90% of an this from some doctors because a patient may employee's salary to 65% for the first three be put on a ventilator and then not meet the days of sick leave. In Gothenburg, Sweden's criteria for brain stem death. Also, intensive second largest city, this has prompted the care units are busy places and staffdo not like number of people claiming sickness benefit we
Erosion of Swedish welfare state
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to be a short term trend, but the fall in the number of claimants has remained constant since March. Rising unemployment has also contributed to the fall in numbers claiming sickness benefit. A survey carried out in 1989 showed that on average a working person took 24 days' sick leave a year. This figure is already estimated to have fallen to 21 days. The government will now pay sickness benefit of 65% of an employee's salary for the first three days, 80% from four days to three months, and 90% after that. Employers can top it up by a maximum of 10%. Previously the rate was 90% for the entire period of sick leave-and topped up by 10% from the employer; employees were just as well off whether they stayed at home or went to work. From January 1992 sickness benefits will be cut even further. The state will no longer provide sickness benefit for the first 14 days of sick leave but will leave all sickness payments to the employer. The changes in the social insurance system have not made the government popular. At the beginning ofthis year there was a storm of opposition when the government virtually doubled the cost of a consultation with a general practitioner. Last month the cost of a prescription rose by 20%. The Swedish government currently pays 80% of the country's drugs bill. It covers drugs for chronic conditions such as diabetes and also meets the full cost of drugs if a patient has to pay for more than 15 prescriptions in 12 months. Knowing that the government will meet the cost of whatever they prescribe has given doctors a considerable amount of freedom, said Dr Ann-Ida Evers, a general practitioner in Gothenburg. But it has also led to ignorance and indifference about prices. Pharmacists are starting to reverse that trend. There is also a proposal to charge patients the full cost of their drugs up to a maximum, after which drugs would be free. If adopted the proposal will not be put into operation for at least another two years. Even so, the Swedish public should brace itself for even less support from the state in future. -ALISON WALKER, Gothenburg
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Letter from Westminster Mr Winterton's war Parliament rose for the summer with the imprecations of Mr Nicholas Winterton ringing in its ears. The chairman of the select committee on health was on the warpath. He raged at the whips, he raged at the government, but most of all he raged at his fellow Conservative MPs on the health committee. By the end of the day the watching nation could see on television that Mr Winterton was very angry, though it might not have been clear exactly what he was angry about. At Westminster, where they know better, it was put down to the sultry heat of the river swamp and end of term tantrums. A select committee chairman has two functions. One is to conduct the public proceedings, which Mr Winterton does extremely well. The other is to be the voice of the committee, which he performs not at all. The Winterton committee now speaks with many voices. It has come asunder in the most partisan divide on a select committee since the employment committee split in 1985. Then it was over the miners' strike. Today it is about the equally controversial issue of NHS trusts. Mr Winterton cried foul because the Tory majority on his committee voted down a 17 page section of his chairman's report dealing with trusts (p 265). He also revealed that a clandestine copy of his draft report had been leaked to the Department of Health. The insinuation was that, forewarned, the department or the whips had pressutrised Tory MPs to emasculate Mr Winterton's report.
Labour MPs took their cue from Mr Winterton to accuse the government of scandalously manipulating a select committee. But old Westminster hands suspect there is less to the incident than meets the eye. As it is, the 17 disputed pages are in no way missing. They are in full public view in the minutes of proceedings which record a five to four vote that they be not read-thus ensuring that they are read most avidly. They deal with the inherited debt problems of the new NHS trusts at Bradford and at Guy's and Lewisham which the committee investigated after an announcement of job losses (1 June, p 1298). In relation to Bradford the finding is that its capital spending plans were overambitious, the financial vetting by the department was inadequate, and it would have been better had the trust remained directly managed. At Guy's and Lewisham hospitals relevant information was absent before the trust was set up.
All this led Mr Winterton to propose that should be given to selecting trusts and that the second wave should be slowed down so that the NHS Management Executive could build up the skills required. The Conservative caucus could not agree on the basis of the limited evidence -and from what it had been saying for weeks it needed no prodding from the whips to vote as it did.
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Instead it substituted a paragraph saying that the committee was sufficiently concerned about the future of trusts to mount a major review when parliament reassembled. Behind the smoke the section of the report which was agreed happens to be one of the best of its kind and deserves attention. There is a timely demand that the government presents reliable and consistent information covering the periods before and after the NHS reforms so as to allow a proper evaluation. The committee is less sanguine than the department that the recent agreement with the Joint Consultants Committee on general practice fundholder contracts will prevent a two tier service with preferential waiting lists. It prefers the guidance issued in Scotland prohibiting quality stipulations in contracts which would give rise to inequality of
care. Nor does the report take at face value the secretary of state's assurance that a general practitioner's clinical judgment on referral cannot be overridden, so long as a health authority can delay it for financial reasons. And in welcoming the new joint NHS and General Medical Services Committee review committee (29 June, p 1560) the report recommends that it should have the authority to commission research. What happens to the committee and its chairman when the dust settles after the long recess is anyone's guess. The assumption is that it will all blow over. In the precedent of 1985 the Tories who were loyal to the government prospered while the others languished. Last week some Tory elders were preparing a black hole for Mr Winterton. JOHN WARDEN, parliamentary correspondent, BMJ
The Week The research community has never simply claimed that throwing more money at research would solve all the problems of research in Britain. While more money is needed (based on international comparisons), researchers also worry about the way research is organised and getting the best out of limited funds. Now that more money for NHS research is promised the worries are emerging that it might not be spent well. The promise of more money comes from Michael Peckham, director of research on the NHS Management Executive. Over the past couple of months he has been explaining his research and development strategy to the scientific and NHS communities (4 May, p 1034). A formal paper is promised, but at present the strategy-and its attractive offer of 1- 5% of the entire NHS budget for spending on research-exists only in a press release. This vagueness worries the research community: they wonder where the money will come from, where bodies such as the MRC, the research charities, and industry fit in, how the research will be directed, and what sort of research it will be. Professor Peckham started off by working out how much the NHS already spends on research, including the locally organised research schemes and SIFTR (service increment for teaching and research). Most academics seem reconciled to the fact that the locally organised research funds will be swallowed up but are more concerned about SIFTR. SIFTR isn't intended to fund research but to cover the extra costs to the NHS of teaching and research. The MRC is also worried that the
Treasury will switch funds from it to the management executive. This prompts a strong sense of deja vu: 15 years ago the Rothschild proposals shifted some MRC money to the Department of Health to use in commissioning specific applied research-and prompted arguments similar to those being heard now about the importance of entrepreneurial research, not bound by a narrow bureaucratic straitjacket. Professor Peckham talks of alliances-between the NHS, the MRC, the universities, the research charitiesbut being part of even an effective alliance isn't going to recompense the MRC for losing a chunk of its budget and possibly some of its responsibilities. A more widespread fear is that the proposed structures for running NHS research aren't up to it. Much of the research will be managed by regional research committees. Many worrv about the lack of skills at regional level and the fact that research policy driven from the centre may be both bureaucratic and political. Evidence from Canada, where there has been a national health services research and development programme for about 20 years, suggests that some useless research gets funded because it is not politically acceptable for one region to get nothing and another to get much more. Many of the fears boil down to the familiar plea that a tried system is being replaced by an untested one. If Peckham is to allay these fears and reassure the research community that much needed health service research won't be done at the expense of good quality science he needs to produce something more substantial than a press release. HART
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cancelled Americans worry that government manageof medicine will mean that scientific questions will get political allswers. Last week, for example, politics had thee last word ment
in
peer review.
More than two years ago two professors from the University of Nofth Carolina grew concerned about the high rates of adolescent pregnancies, venereal diseases, and HIV positivity. One third of 15 year old Americans are sexually active. Last year 490000 children were born to American teenagers. Some of these teenage pregnancies have created infant mortalities in some cities-including Washington-that exceed those of the world's poorest countries. Ronald Rindfuss, professor of sociology, and J Richard Udry, professor of public health, thought that one way to curb pregnancies, illness, and death would be to find out what teenagers were doing and what they thought about sexuality-as well as home, family, friends, church, and school. Their idea was this. Over five years 24000 randomly sampled young people aged 13 to 18 would be interviewed for about 75 minutes. Parents would have to consent for youngsters to participate and would be interviewed as well. The questions would be wide ranging, with a few addressing sexual activity, pregnancy, homosexual sex, sodomy, oral sex, and rape. The study has a price tag of $18m, so the professors applied to the nation's biggest funding agency, the National Institutes of Health. After two years of peer review the National Institute of Child Health and Human Development awarded the grant in May, saying that the research would "provide important information about behaviours that place US adolescents at risk of AIDS and other sexually transmitted diseases" and "extend the frontiers of research on adolescent pregnancy." Politics entered peer review on 16 July, when the Health Secretary, Louis Sullivan, appeared on a conservative talk show and was asked why his agencies were supporting the study that "threatens family values and encourages young people to have sex too early." Dr Sullivan immediately suspended the award, and on 23 July he cancelled it altogether. Dr Sullivan's own 10 year health promotion plan, "Healthy people," calls for a better knowledge ofwhy young people choose early sexual activity and the consequences of their choices. "Additional research is needed to better understand early initiation, its consequences, and how-it might be prevented," says the Health Secretary's report, now less .
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lever know what they're up to
than a year old. Yet last week Dr Sullivan said that he was "concerned by the possible inadvertent message this survey could send." In Congress reaction was swift. Congresswoman Patricia Schroeder, a Democrat from Colorado who makes the family her central theme, said that Dr Sullivan was sending a message of "medical McCarthyism." She called Dr Sullivan's decision a "triumph of ignorance over knowledge." Gary Bauer, president of the conservative Family Research Council, said that the survey was a waste of taxpayers' money. "We know many of our kids are having sex too early, too often, and with too many people. We ought to be spending $18m to figure out how to divert them from that conduct instead. " The two North Carolina researchers thought that they were to do just that. Said Professor Rindfuss: "We are not trying to estimate what fraction of American kids have done this or that. We are trying to understand the broader social world in which they live: why are they engaging in this behaviour that puts them at risk?" Meanwhile, 60-70% of -American teenagers have engaged in sex and only a small minority use contraception. One fifth of all cases of gonorrhoea and pelvic inflammatory disease occur in teenagers, and both these diseases rank behind chlamydial infections. And adolescents are increasingly suspected of being a high risk group for HIV infection.-JOHN ROBERTS, Durham, North
Carolina
Accelerating NHS change Priorities for the NHS in the second year of the reforms were set out last week by the NHS Management Executive after they had been endorsed by the Secretary of State for Health and the NHS Policy Board. They will take the health service a further step into the unknown by moving from the so called "steady state" this year into what is described as "managed change" in 1992-3. Regional general managers are being encouraged by the chief executive, Duncan Nichol, to take the brakes off and accelerate the pace of reform. The NHS high command sees 1992 as a milestone year of profound change, when the NHS begins to break with many of its historic practices and acts on what the "market" is saying, though at a "manageable level of risk." The new priorities fall into three main groups: improving health for the population; securing better services for patients; and achieving more' effective management of NHS resources. The central presumption is that established patterns of referral and treatment will be adjusted-for example, to organise clinical facilities nearer patients' homes. Contracts placed by purchasing districts and fundholding general practitioners for 1992-3 should aim to secure tangible improvements in services. Providers will be given "reason263
Headlines Canadian antismoking campaign setback: Justice Jean-Jude Chabot has ruled in the Quebec superior court in Montreal that the government's ban on cigarette advertising violates the right of freedom of expression. Since the ban was passed in parliament in 1988 cigarette consumption has fallen by a quarter. Tobacco manufacturers have announced that they' plan to resume advertising.
Europe's aging population: Europe's birth rate has fallen by a quarter during the past 30 years, according to a report from the Family Policy Studies Centre. The fertility rate for most European women is now 1-8. By 2020 less than a quarter of the population will be under 20 and more than a quarter will be over 60.
Welsh move on foodborne and waterborne diseases: The Commons Welsh Affairs Committee, reporting on an outbreak of salmonellosis in Delyn in 1989, recommends that a new organisation, based on the Public Health Laboratory Service (PHLS), should have sole statutory responsibility for preventing and controlling foodborne and waterbo'rne disease. Medically qualified directors of the local PHLS would have full responsibility for controlling outbreaks.
American support for artificial hearts: The American National Academy of Sciences says that implantation of artificial hearts should continue to receive federal support despite high costs and clinical complications. Some 70 000 patients might be saved by artificial hearts, and up to 700 000 might benefit from ventricular assist devices, says the academy. Scottish infant mortality falls: The infant mortality in Scotland in 1990 was the lowest recorded- 7-7 per 1000 live births-despite the increase in births to 65 973, which was the first increase since 1987. The details are in the Registrar General for Scotland's' annual report for 1990. CAMR to stay in public sector: The government has decided that for the time being the Centre for Applied Microbiology and Research at Porton Down, which was transferred to the Public Health Laboratory Service (PHLS) in 1979, would remain in the public sector and not be acquired by Porton International. Much of the centre's work is related to the public health functions of the PHLS.
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able warning" of desired changes. Mr Nichol states that this means an acceptance of moves away from historical patterns of service. Some districts have already indicated that they would like to move more quickly in this direction-with implications for more equitable funding. The management therefore intends to start moving towards weighted capitation next year with equity being achieved between 1993 and 1995. Then authorities will be funded entirely on the basis of their home populations. The impact on the London teaching hospitals will be subject to'"managed change" in response to emerging market signals, meaning intervention and control from the management executive if necessary. Priorities for health care next year are to be coronary heart disease and reducing stillbirths and infant deaths.- Strategies to reduce coronary heart disease will include increasing the public's awareness of risk factors. To reduce stillbirths and infant deaths regions are targeting smoking b'y pregnant women and ensuring that labour wards are covered by consultants. Further integration of primary' and secondary care, such as developing protocols The death of Steve Biko in 1977 still haunts the South for the care of patients with diabetes and African medical profession asthma and better coordination of family planning services, is to be encouraged. Next year is to be crucial in the implementation of required it to open proceedings against two of reforms in community care in preparation for the doctors, and in July 1985 the council statutory changes in 1993. It will also see finally found against the two doctors. regions attempting to guarantee maximum The council's original decision caused waiting times in line with the citizen's charter worldwide protest, and both the association and revision of junior doctors' hours. and the journal received many letters. The Districts are to produce their purchasing association responded with replies that Dr plans for 1992-3 in September,but they have Lee describes as displaying a "defensive been told to indicate major changes to hos- 'total onslaught' type of approach combined pitals and other provider units before then. with an apparent determination not to think Regions are to submit their plans for the unthinkable-that authoritarian bodies managed change by 16 December. -JOHN such as the SAMDC and individuals might WARDEN, parliamentary correspondent, BMJ have acted wrongly or mistakenly." The journal, meanwhile, failed to publish any of the letters, using a series of poor excuses. This stance inevitably did huge damage to the journal, but things deteriorated further. "Worst of all from the point of view of the reputation of the SAMJ," writes Dr Lee, "an unsigned editorial was published on 16 August 1980 advancing the argument that the SAMDC should not be criticised for its handling of the Biko affair on the grounds In the June issue of the South Afiican Medical that it had been helpful to MASA in its Journal (SAMJ) the editor, Dr N C Lee, tells negotiations with the Minister of Health the full shameful story of the part played by over the medical tariff structure. A more his -journal and the Medical Association of unfortunate comparison would have been South Africa (MASA) in the Steve Biko hard to make." affair. "The whole appalling Biko episode," Since those dark days South Africa has was, he writes, "an example of what could begun to change, the association has been happen to those putting forward points of through dramatic changes, and the publicaview unpopular with those currently in tions division of the association has also authority." changed. "Present editorial policy," writes Steve Biko, a black antiapartheid activist, Dr Lee, "is that the SAMJ is a forum for died in September 1977 of serious head all shades of opinion across the medical injuries received during an interrogation by spectrum." And all articles are signed. the security police. A complaint was made Dr Lee warns, however, that "hope for the to the South African' Medical and Dental future should not blind us to the mistakes of Council (SAMDC) about the part played by the past, or mislead us into thinking that they three doctors in Biko's death. The council, in can somehow be expunged by declarations of June 1980, decided to take no action and future good intentions.... What happened repeated this decision in April 1983. Two to Steve Biko should never be allowed to years later the Supreme Court of the Trans- happen in any country that regards itself as vaal set aside the decision of the council and civilised."-RICHARD SMITH, BMJ
Confessions of South African Medical Journal.
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Scotland may get fluoride yet Eight years after one of the longest and most expensive court cases in Scottish legal history halted the fluoridation of drinking water, discussions are taking place about reintroducing the chemical into the public supply. The reason is the dreadful condition of children's teeth, particularly in and around Glasgow, where an average 5 year old has three teeth that are decayed, missing, or filled. No other city in western Europe has to anaesthetise so many children to extract their rotten teeth. A recent dental survey of 5 year olds carried out in 200 health districts throughout the United Kingdom found Glasgow and its neighbouring authorities Lanarkshire and Argyll and Clyde occupying three of the bottom seven places. The fact that nine of the 10 best areas had fluoride in the water supply is being used by Greater Glasgow's chief dental officer, Bob McKechnie, as a clear example of the benefits to be gained from fluoridation. But the decision by Greater Glasgow to open talks with the water authority, Strathclyde region, about adding fluoride to tap water has reactivated the dormant campaign of opposition. A legal challenge is being prepared for the European Court of Justice, which will claim that adding fluoride to drinking water amounts to an intrusion of personal liberty. This challenge is being backed by James Wray, the MP for the Glasgow district of Provan, who is president of the Scottish Pure Water Association and vice chairman of the all party antifluoridation committee of MPs. He has criticised the use of the public water supply as a means of mass medication. This, he says, is literally forcing the chemical down the throats of people without them having any choice. The campaign also features some of the people concerned in the highly publicised 204 day court case, which ended in 1983 with a Glasgow pensioner, Mrs Catherine McColl, winning her fight to show that Strathclyde region has no legal power to add fluoride to the water supply. Her solicitor was Peter McCann, a former city Lord Provost, who is acting now on behalf of a retired Glasgow joiner, Mr Willie Maclean, in preparing the case for the European court. Allegations that fluoride can endanger health were heard during the McColl case but dismissed by Lord Jauncey in his judgment, which concluded that there was no evidence to suggest that in the concentrations proposed it would have an adverse effect. He did agree, however, that Strathclyde was acting beyond its powers in adding the chemical. New laws were subsequently passed by parliament, and a
decision earlier this year by ministers at the
Scottish Office to indemnify water authorities
against any legal challenge brought against them has opened the way to its reintroduction. Bob McKechnie points out, "It is probably the most researched public health measure that there has ever been. There's no doubt it works, it is safe, and we really need it." Eight years ago the attack was on two fronts BMJ VOLUME 303
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LoCh Iatrtne's water ts jamously pure, out the ilaswegian children who drink tt have --dreadful" teeth
as questions were posed about the legality of adding fluoride and about its safety. Today the argument is principally about personal liberty, but it is being put by some of the government's own supporters. Earl Ancram, a former Conservative minister in the Scottish Office, has expressed surprise that such a staunch advocate of personal freedom as his former colleague, Scotland's health minister Michael Forsyth, should be supporting a move that amounts to "coercion rather than persuasion, imposition rather than choice." -BRYAN CHRISTIE, health correspondent, Scotsman
Costs fall in NHS Revenue spending on the hospital and community health services in England rose by 15-4% between last year and this-the highest rise for over a decade. The equivalent figures for the family health services and the NHS as a whole are 6-2% and 12-1% respectively. But these cash rises, detailed in the memorandum of evidence from the Department of Health to the House of Commons health committee, conceal accounting changes resulting largely from the introduction of the NHS reforms on 1 April. When the various shifts in money from one part of the NHS to another have been taken into account the cash rise for the hospital and community services, for example, drops nearly 3% to 12-5%. The National Association of Health Authorities and Trusts estimates that health service inflation this year averages 8-8%, so this leaves a real growth in these resources of about 3-4%. This is a significant rise. But as the health committee's third report points out, while the real rise in spending last year was around 4-8% (although 1-4% of this was spent on the NHS reforms), in the previous four years real
rises in spending averaged only 0-73% a year. Not surprisingly, health authorities have found it tough going financially over the past few years. Despite these financial problems hospitals have managed to increase activity in virtually all service areas. The real cost per case for acute patients has fallen by 16% since 197980, to £913 in 1989-90. The key to the NHS's ability to treat more patients with near static budgets lies in reductions in lengths of stay and the growing move towards day case treatment. A question that the health committee may wish to consider posing next year, however, is the extent to which there has been a trade off between these trends and the quality and outcome of care. Have readmission rates risen? Have hospitals shifted part of the burden of care to community services and patients' relatives and friends? Have rates of postoperative infection risen? Apart from determining how much has been spent on the NHS and to what effect, the health committee also ascertained where the money came from in the first place. Over the past 10 years there has been a pronounced shift in the source of NHS funding. In the early 1980s the consolidated fund (taxes plus other government revenues) accounted for
Change in acute inpatient activity and real spending on acute services Spending has grown at an annual average of 0-3% 140
Activity has grown at an annual average of 3 0%
1355 1308 tu t; 125-
o
Inpatient activity
10120CD -
5 c 115)
110
i -105-
O
1979 1981
Spending 1983 1985 1987 1989
The large jump in 1989 was due Io achdse in the way cases were recorded -from cases to finished consuftant episodes
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88% of NHS spending. By 1990-91 this had fallen to 79%. The remainder is now made up of increased income from charges to patients (4 3%), NHS contributions (14-6%), and sales of land (1-6%). Information in the memorandum also confirms that targeting extra money to tackle waiting lists is better than not targeting at all and that targeting using methods developed by John Yates is best of all. -JOHN APPLEBY, economics correspondent, BMY Public Expenditure on Health Matters. Memorandum Received from the Department of Health Containing Wntten Replies to a Wntten Questionnaire from the Committee. London: HMSO, 1991. (HCP 408.)
Negligence and shortage of kidneys A man who spent £50 000 on two kidney transplants in Belgium after spending 10 years on NHS waiting lists is suing the North Western Regional Health Authority for negligence for failing to provide the transplants he needed. Christopher Davies, 49, a Manchester businessman and a non-practising solicitor, alleges that the health authority was negligent in not making adequate arrangements for supplying sufficient kidneys. He started dialysis in 1967 and was put on the waiting list for a transplant in 1974. Three years later, when no kidney had been found, he underwent transplantation in Belgium, where the waiting time is only a few months. The new kidney failed in 1981, and he spent a further seven years on the waiting list. When a suitable organ was found in Belgium in December 1987 he was given only four hours' notice and had to charter a private plane. He estimates that each trip cost about £15 000 in hospital costs. The case is believed to be the first in which a patient has sued for damages for failure to provide an organ for transplantation. But Mr Davies is not the first patient to go to law over delays in treatment: several have sought judicial review of decisions to delay or deny operations. In 1979 four patients in the west midlands who had spent years on a waiting list for orthopaedic surgery sought a declaration that the secretary of state and the area and regional health authorities had failed in their duty to provide a comprehensive health service under the National Health Service Act 1977. But the Court of Appeal ruled that the duty was subject to the resources available. In 1987 the parents of a hole in the heart baby whose operation at Birmingham Children's Hospital had been cancelled five times unsuccessfully sought judicial review in an attempt to have the operation expedited. In a third case, also in 1987, a patient with end stage renal failure won legal aid to seek judicial review of a decision by Queen Elizabeth Hospital, Birmingham, to admit no new patients for dialysis, but the case was never heard because the health minister, Tony Newton, gave renal units in Birmingham an extra £250000.-CLARE DYER, legal
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Waiting for Japanese transplants Does declaring a person brain stem dead mean that he or she has really died? For over 20 years most developed countries have accepted that it does, but in Japan this now is under debate. Last June the Japanese Ad Hoc Commission on Brain Death and Organ Transplantation stated in its interim report that brain stem death should mean that the
patient has died. The commission, composed of 15 members and five associate members, including medical doctors, lawyers, and philosophers, started work in March 1990 with the brief of advising the prime minister. It has held 20 meetings to discuss the ethics of organ transplantation and brain stem death and has visited Europe and the US. The interim report gives conditional approval to the idea that brain stem death ought to be regarded as the death of the patient from a medical point of view. "We should not interfere in transplantation from willing donors diagnosed as brain stem dead if recipients cannot maintain their lives without transplant operations," said the report. A recent public opinion poll showed that more than 60% of Japanese people considered brain stem death to mean that the patient had died. But four members of the panel, including a leading philosopher, Takeshi Umehara, disagreed with the majority opinion in the report. The dis-
senters insist that a person with a warm body who still breathes, even with the help of a ventilator, cannot be regarded as a cadaver. There is another obstacle to transplanting organs from brain stem dead donors. Because donors are mostly victims of traffic accidents the police authorities insist on exercising their right to do postmortem examinations. They warn doctors not to remove the organs of brain stem dead victims while their heart is beating. Thus Japanese surgeons have not transplanted organs from Japanese brain stem dead donors yet. On 12 July surgeons of Tokyo Women's Medical College transplanted the liver of a brain stem dead Belgian boy into a 59 year old Japanese woman who had previously received a partial liver transplant from her son. She died a day later. Japanese surgeons have performed 35 liver transplant operations using parts of livers from live donors in the past two years. They have even attempted to transplant livers from donors whose hearts have stopped beating. "Controversy on brain stem death and transplantation in Japan is 20 years behind that in Western countries," said Dr Kiyohiko Dohi, head of surgery at Hiroshima University Hospital, who performed the first operation to transplant a liver from a live adult donor to another adult last June. After the commission has submitted its final report next January a full programme of transplantation may begin. -MASAYA YAMAUCHI, science reporter of the Chugoku Shimbun
The limits of voluntarism Last week visitors to Britain could have witnessed at close quarters the operation of the British voluntary agreement on tobacco advertising and promotion, which government ministers hold out as an example to the rest of Europe. At the entrance to the underground at London's Euston station young women were handing out free Camel cigarettes. Behind them was a formula one racing car, labelled "Camel," obscuring a government health warning on a hoarding behind it. The hoarding did, however, promin-
ently display a warning that smoking on the underground was prohibited, although its impact was limited by its use of the colours and the typescript adopted by Camel in its promotional campaigns. Smokers aged 18 or over were also invited to enter a free competition to win "one of five exclusive Camel Benetton Formula One team jackets." In the event of a tie the winners will be those who best complete the sentence "My idea of 'life in the fast lane' is . . ." in not more than 12 words. -TONY DELAMOTHE, BMJf
Life in the fast lane, Euston station
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New kidneys for old
to fall by a quarter. This was initially thought
"If we retrieved all the potential organs then could meet the waiting list demands." This remark from Gay Hopkins, the transplant coordinator at Addenbrooke's Hospital in Cambridge, illustrates the problem for Britain's transplant programme. Demand for organs has increased, but the number donated has levelled off over the past three years, according to a report on organ transplantation by Richard West published by the Office of Health Economics last week. There are currently 3804 British people waiting for a kidney transplant, but an average of under 2000 kidneys are transplanted each year. Yet kidney transplantation costs only half as much as keeping a patient on haemodialysis for a year. The report looks at the availability, cost, and success of organ transplantation. It estimates that for hearts -at least half of the Kidney surgery has come a long way since "La potential donors are not being used. The Lithotriptie" in 1890 main reason why potential donors do not become actual donors is because their a bed being occupied by someone who is not relatives refuse permission. going to get better." A Gallup poll last year found that although She believes that junior doctors are getting three quarters of people said that they would better at approaching relatives. "It is difficult be willing to donate their organs, only a third for relatives because not only are they conof them had donor cards. Many European fronted with the sudden death of a loved one countries, such as France, Belgium, and but they are also being asked permission for Austria, have an "opting out" system, in organ donation. They may never have which the organs are harvested unless the thought of it before. It is up to transplant patient has a card stating that he or she coordinators to help doctors and nurses to refuses this. These countries have a corres- broach the subject. pondingly higher rate of organ transplanta"Attitudes are changing. People used to tion. resist us taking their relative's heart because Only 12% of British kidney transplants are they had an emotive attitude towards it. Now from live donors. Most come from patients they say to us, 'Use whatever you can.' who fulfil the criteria for brain stem death. LUISA DILINER, BMJ These are usually the victims of road traffic accidents or intracranial haemorrhage. Guy's Organ Transplantation by Richard West is published Hospital is one of the few British transplant by the Office of Health Economics. centres that harvest kidneys from cadavers after cardiac arrests. Other ways of potentially increasing the number of donor organs include cryobiology-preserving organs for longer at very low temperatures-and manufacturing artificial organs. Both are still at experimental stages. Sweden is renowned for its generous state The report concludes that most organ benefits. Now they have become too costly to transplant operations represent value for maintain. The government is increasingly money. This is the case even for heart-lung eager to reduce public spending; the social transplant operations, which cost £15 000, insurance system costs 26% of the country's and liver, transplant operations, which are gross domestic product and is an obvious priced at £20 000. According to Sir Roy target. But the government is not only withCalne, a transplant surgeon at Addenbrooke's drawing its contribution to sickness benefit. Hospital, these sums are small compared Drug charges and the cost of consultations with the cost of repeated admissions to hospital with general practitioners are also under fire. for dying patients. Heart-lung transplants The Nobel prize for medicine should have been particularly successful for people be given to the Swedish finance minister, with cystic fibrosis. The report states that the according to a report in a Gothenburg newswaiting list for these transplants is seven paper-not for any outstanding contributions months, and a quarter of those waiting die to medical science but simply for reducing before a suiitble organ becomes available. sickness benefit. The effect has been as Some hospitals perform elective ventilation dramatic in bringing people back to work as if of patients who are obviously going to die to he had found a cure for the common cold. increase the number of donor organs. But, Last March the Swedish government said Gay Hopkins, "There is resistance to reduced sickness benefit from 90% of an this from some doctors because a patient may employee's salary to 65% for the first three be put on a ventilator and then not meet the days of sick leave. In Gothenburg, Sweden's criteria for brain stem death. Also, intensive second largest city, this has prompted the care units are busy places and staffdo not like number of people claiming sickness benefit we
Erosion of Swedish welfare state
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to be a short term trend, but the fall in the number of claimants has remained constant since March. Rising unemployment has also contributed to the fall in numbers claiming sickness benefit. A survey carried out in 1989 showed that on average a working person took 24 days' sick leave a year. This figure is already estimated to have fallen to 21 days. The government will now pay sickness benefit of 65% of an employee's salary for the first three days, 80% from four days to three months, and 90% after that. Employers can top it up by a maximum of 10%. Previously the rate was 90% for the entire period of sick leave-and topped up by 10% from the employer; employees were just as well off whether they stayed at home or went to work. From January 1992 sickness benefits will be cut even further. The state will no longer provide sickness benefit for the first 14 days of sick leave but will leave all sickness payments to the employer. The changes in the social insurance system have not made the government popular. At the beginning ofthis year there was a storm of opposition when the government virtually doubled the cost of a consultation with a general practitioner. Last month the cost of a prescription rose by 20%. The Swedish government currently pays 80% of the country's drugs bill. It covers drugs for chronic conditions such as diabetes and also meets the full cost of drugs if a patient has to pay for more than 15 prescriptions in 12 months. Knowing that the government will meet the cost of whatever they prescribe has given doctors a considerable amount of freedom, said Dr Ann-Ida Evers, a general practitioner in Gothenburg. But it has also led to ignorance and indifference about prices. Pharmacists are starting to reverse that trend. There is also a proposal to charge patients the full cost of their drugs up to a maximum, after which drugs would be free. If adopted the proposal will not be put into operation for at least another two years. Even so, the Swedish public should brace itself for even less support from the state in future. -ALISON WALKER, Gothenburg
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Letter from Westminster Mr Winterton's war Parliament rose for the summer with the imprecations of Mr Nicholas Winterton ringing in its ears. The chairman of the select committee on health was on the warpath. He raged at the whips, he raged at the government, but most of all he raged at his fellow Conservative MPs on the health committee. By the end of the day the watching nation could see on television that Mr Winterton was very angry, though it might not have been clear exactly what he was angry about. At Westminster, where they know better, it was put down to the sultry heat of the river swamp and end of term tantrums. A select committee chairman has two functions. One is to conduct the public proceedings, which Mr Winterton does extremely well. The other is to be the voice of the committee, which he performs not at all. The Winterton committee now speaks with many voices. It has come asunder in the most partisan divide on a select committee since the employment committee split in 1985. Then it was over the miners' strike. Today it is about the equally controversial issue of NHS trusts. Mr Winterton cried foul because the Tory majority on his committee voted down a 17 page section of his chairman's report dealing with trusts (p 265). He also revealed that a clandestine copy of his draft report had been leaked to the Department of Health. The insinuation was that, forewarned, the department or the whips had pressutrised Tory MPs to emasculate Mr Winterton's report.
Labour MPs took their cue from Mr Winterton to accuse the government of scandalously manipulating a select committee. But old Westminster hands suspect there is less to the incident than meets the eye. As it is, the 17 disputed pages are in no way missing. They are in full public view in the minutes of proceedings which record a five to four vote that they be not read-thus ensuring that they are read most avidly. They deal with the inherited debt problems of the new NHS trusts at Bradford and at Guy's and Lewisham which the committee investigated after an announcement of job losses (1 June, p 1298). In relation to Bradford the finding is that its capital spending plans were overambitious, the financial vetting by the department was inadequate, and it would have been better had the trust remained directly managed. At Guy's and Lewisham hospitals relevant information was absent before the trust was set up.
All this led Mr Winterton to propose that should be given to selecting trusts and that the second wave should be slowed down so that the NHS Management Executive could build up the skills required. The Conservative caucus could not agree on the basis of the limited evidence -and from what it had been saying for weeks it needed no prodding from the whips to vote as it did.
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Instead it substituted a paragraph saying that the committee was sufficiently concerned about the future of trusts to mount a major review when parliament reassembled. Behind the smoke the section of the report which was agreed happens to be one of the best of its kind and deserves attention. There is a timely demand that the government presents reliable and consistent information covering the periods before and after the NHS reforms so as to allow a proper evaluation. The committee is less sanguine than the department that the recent agreement with the Joint Consultants Committee on general practice fundholder contracts will prevent a two tier service with preferential waiting lists. It prefers the guidance issued in Scotland prohibiting quality stipulations in contracts which would give rise to inequality of
care. Nor does the report take at face value the secretary of state's assurance that a general practitioner's clinical judgment on referral cannot be overridden, so long as a health authority can delay it for financial reasons. And in welcoming the new joint NHS and General Medical Services Committee review committee (29 June, p 1560) the report recommends that it should have the authority to commission research. What happens to the committee and its chairman when the dust settles after the long recess is anyone's guess. The assumption is that it will all blow over. In the precedent of 1985 the Tories who were loyal to the government prospered while the others languished. Last week some Tory elders were preparing a black hole for Mr Winterton. JOHN WARDEN, parliamentary correspondent, BMJ
The Week The research community has never simply claimed that throwing more money at research would solve all the problems of research in Britain. While more money is needed (based on international comparisons), researchers also worry about the way research is organised and getting the best out of limited funds. Now that more money for NHS research is promised the worries are emerging that it might not be spent well. The promise of more money comes from Michael Peckham, director of research on the NHS Management Executive. Over the past couple of months he has been explaining his research and development strategy to the scientific and NHS communities (4 May, p 1034). A formal paper is promised, but at present the strategy-and its attractive offer of 1- 5% of the entire NHS budget for spending on research-exists only in a press release. This vagueness worries the research community: they wonder where the money will come from, where bodies such as the MRC, the research charities, and industry fit in, how the research will be directed, and what sort of research it will be. Professor Peckham started off by working out how much the NHS already spends on research, including the locally organised research schemes and SIFTR (service increment for teaching and research). Most academics seem reconciled to the fact that the locally organised research funds will be swallowed up but are more concerned about SIFTR. SIFTR isn't intended to fund research but to cover the extra costs to the NHS of teaching and research. The MRC is also worried that the
Treasury will switch funds from it to the management executive. This prompts a strong sense of deja vu: 15 years ago the Rothschild proposals shifted some MRC money to the Department of Health to use in commissioning specific applied research-and prompted arguments similar to those being heard now about the importance of entrepreneurial research, not bound by a narrow bureaucratic straitjacket. Professor Peckham talks of alliances-between the NHS, the MRC, the universities, the research charitiesbut being part of even an effective alliance isn't going to recompense the MRC for losing a chunk of its budget and possibly some of its responsibilities. A more widespread fear is that the proposed structures for running NHS research aren't up to it. Much of the research will be managed by regional research committees. Many worrv about the lack of skills at regional level and the fact that research policy driven from the centre may be both bureaucratic and political. Evidence from Canada, where there has been a national health services research and development programme for about 20 years, suggests that some useless research gets funded because it is not politically acceptable for one region to get nothing and another to get much more. Many of the fears boil down to the familiar plea that a tried system is being replaced by an untested one. If Peckham is to allay these fears and reassure the research community that much needed health service research won't be done at the expense of good quality science he needs to produce something more substantial than a press release. HART
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