822
Health
care
funding
in South Africa
SiR,—Iwould like to clarify some of the points mentioned by Professor van Niekerk (June 8, p 1402). The depressed economy of the Republic of South Africa necessitated that Government funding for health care be limited to an increase of 67%, although the inflation rate is currently 10-15%. This resulted in a reduction in funding in real terms. Add to this a population growth rate of 22% and the full extent of the problem will be appreciated. The 115% of Government expenditure allocated to health is reasonable when compared with other countries (UK 12-6%, Australia 96%). However, because of the lower gross national product per caput, this amount of health funding per caput is obviously far smaller in monetary terms. To achieve a more equitable division of health funding, the Government has decided to allocate funds according to a formula based on demographic profiles and health and socioeconomic indicators. This formula was first used in the 1990/91 financial year and has resulted in a redistribution in the division of the health "cake". For example
met only by a greater understanding of human behaviour-yet the behavioural sciences are given no place in the
aims will be
strategy. Non-clinical advisers on the Central Research and Development Committee include epidemiologists, health service researchers, economists, and statisticians, but not health psychologists or medical sociologists, whose remit is the behaviour of patients, health professionals, and organisations. Is it not important to know that patients opting for a new technology such as the insulin pump may be those least suited to manage it,’ or that doctors who feel most confident at resuscitation are not the most competent to carry it out?2 The strategy conjures up exciting new vistas of the routine introduction of innovations through trials backed up by sparkling information technology and cost-effectiveness studies. Yet having the information is less than half the solution,3,4 and costs can be more than financial. The strategy does not fully acknowledge the importance of the unintended effects of implementing innovations in health care. These include increased absenteeism among participants in health screening and stress in those making use of reproductive technologies. Patient and staff responses need to be incorporated in any evaluation of a novel health innovation to increase the likelihood that the intended benefit is achieved and the harm caused is reduced to a minimum. Department of Primary Care, University of Southampton, Aldermoor Health Centre,
ANN-LOUISE KINMONTH
Southampton
This change in the size of the various portions plus the overall decrease in the size of the Government health cake in real terms has resulted in a significant decrease in the funding for the Cape. The severe problem this is causing the Cape health authorities is appreciated, particularly as the Cape health services have been geared to a higher expenditure per head than other areas of South Africa. For example, the physician density per 10 000 population of doctors employed in the public sector in 1990 was 8-9 in the Cape metropolitan area compared with 6-5 in Durban-Pietermaritzburg and 5-2 in Pretoria-Johannesburg. The statement by van Niekerk that private health funding covers only 20% of the population probably stems from a commonly held misconception. Of the total population only 20% is covered by medical insurance schemes, but medical insurance is responsible for 60% of private health funding. The remaining 40% is derived directly from private paying patients, comprising a small upperincome group who pay directly for all health services and a large middle to lower income group who choose a private consultation as the first entry point to the health care system and are referred to public health care if secondary or tertiary care is required. The exact size of the above-mentioned population is not known. A survey in Soweto amongst the mother/guardians of pre-school children in day care revealed approximately equal use of private and Government treatment options. An estimated 30-35% of the population covered by private health care is therefore not unrealistic. Private health care comprises 45% of the total health
expenditure. The inefficiency and increased costs of the fragmented services in South Africa have been recognised and reconstruction of health care provision is in hand. It is hoped that the new allocations will make it possible for all areas in South Africa to provide a health care equal to the good standards achieved in the Cape area. Ministry of National
Health and of Health Services, House of Assembly, Private Bag X399, Pretoria 0001, South Africa
Psychology and health
E. H. VENTER, Minister of National Health and of Health Services
care
evaluation
SIR,-Professor Peckham’s manifesto for research and for the National Health Service (Aug 10, p 367) identifies the need for a research programme bearing on the
development
"effectiveness of clinical practice, the dispersal and use of existing and the best use of human resources". Such laudable
knowledge,
Health
Psychology Unit, Royal Free Hospital School of Medicine, London NW3 2QG, UK 1.
THERESA M. MARTEAU
Bradley C, Gamsu DS, Moses JL, et al. The use of diabetes-specific perceived control and health belief measures to predict treatment choice and efficacy in a feasibility study of continuous subcutaneous insulin infusion pumps. Psychol Health 1987; 1:
133-46. 2. Marteau TM, Wynne G, Kaye W, Evans TR Resuscitation. experience without feedback increases confidence but not skill. Br Med J 1990; 300: 849-50. 3. Mugford M, Banfield P, O’Hanlon M Effects of feedback of information on clinical practice: a review. Br Med J1991; 303: 398-402. 4. Crombie IK, Davies HTO. Computers in audit: servants or sirens? Br Med J 1991; 303: 403-04.
Audit, peer review, and intellectual
conformity SIR,"If it comes to prohibiting, there is not ought more likely to be prohibited than truth it self, whose first appearance to our eyes, blear’d and dimm’d with prejudice and custom, is more unsightly and more plausible than many errors."-John Milton (1644)
The heart of clinical peer review is conformity to accepted medical practice. How should a knowledgeable physician act if he is the first to suspect that standard practice is incorrect and would harm his patient? Our doctor can be guided only by experience and intuition. He can cite no published work, nor can he ask his patient to return in 5 or 10 years, when physicians might know more. Even a brief historical survey is anything but reassuring. The first medical application of statistics, shortly after the French Revolution, revealed that patients treated by bleeding did no better, and even somewhat worse, than those unbled. The first physician who, in 1853, positively pointed to the mosquito as the spreader of yellowfever, who showed that absence of mosquitoes precluded the disease, and who prescribed the ready means to stamp it out by fumigation and by preventing bites, was investigated by a commission, which found his views inadmissible and all but declared him insane.1 Semmelweis ordered his students to wash in chlorinated lime between the dissecting room and the maternity ward. A medical editor wrote that it was time to stop such nonsense.’ Z In our own day George Crile, Jr, who departed from the traditional Halsted mastectomy, was reprimanded by the Cleveland Academy of Medicine.3 In 1934 a chest surgeon who urged 300
823
colleagues to support measures to curb smoking was laughed off the floor.4 We no longer keep myocardial infarction patients heavily sedated and in bed for several weeks, and we suspect that removal of dietary fibre, which had been the treatment for diverticular disease, is in fact its cause. The benefit of annual check-up, hitherto unquestioned in the United States, is now thought to be limited. The peer review offence is deviation per se, so it is no defence to show that an innovative treatment worked better than a standard one. Yet we are ethically and, in New York state, legally obliged to use our best judgment.5,6 In the absence of harm there is no cause of action for malpractice, while adherence to accepted medical practice which was not the doctor’s best judgment has been expressly rejected as a malpractice defence.6,7 Compelled adherence to authority, to dogma, is stultifying and profoundly deprofessionalising. Intellectual coercion is medieval and scholastic;8 gone are the Renaissance and the Enlightenment. Dissent becomes heresy; reputation, career, and livelihood go to the stake. At a time when millions of people have broken their shackles the medical profession is snapping them on. 17 Main Street, Sayville, NY 11782, USA 1.
Capsticks Solicitors, General Accident Building, 77/83 Upper Richmond Road,
BRIAN CAPSTICK PETER EDWARDS
London SW15 2TT, UK
Public health
reporting year
SIR,-Dr Dunlop (Aug 31, p 584) denigrates the use of the fiscal year for public health purposes in the UK. This is puzzling because directors of are
striving
public health and the National Health Service as a whole to strengthen the link between health and financial
information in their efforts
to
make the best
use
of funds. What is
important is for the same time period to be used for the fiscal and ROBERT CARLEN
Agramonte A. The inside story of a great medical discovery. Sci Monthly 1915 (Dec); I, 209-37. Reprinted in: Yellow fever studies: public health in America (New York:
Amo Press, Inc, 1977). 2. Anon. The New Encyclopedia Britannica, 15th ed, 1986. X: 627-28. 3. Crile G Jr. Surgery, in the days of controversy. JAMA 1989; 262: 256-58. 4. New York Times, July 19, 1990: D19. 5. Pike v Honsinger, 155 NY 201, 49 NE 760 (1898). 6. Toth v Community Hospital at Glen Cove 22 NY 2d 255; 292 NYS 2d 440 (1968). 7. Wickline v State of California, 239 Cal Rptr 810 (Cal App 2Dist 1986). 8. Osler W. Harvey and his discovery. In: The collected writings of Sir William Osler. Birmingham, Alabama: Classics of Medicine Library, 1985; see JAMA 1987; 258: 1522.
Defensive obstetric
midwives choose to "wait and see" when a trace is abnormal. If such a decision is not recorded, it will appear in retrospect as a negligent failure to respond. It is therefore necessary to record wait and see decisions, as well as decisions to intervene, as evidence that attention was being paid to the issue. It is increasingly difficult for obstetricians to resist the pressure for greater intervention, and a few measures of this type would go some way to reducing the pressure from litigation.
practice
SiR,—The obstetrician’s belief, reported by Dr Ennis and Dr Orr (Sept 7, p 616), that carrying out tests of uncertain reliability is somehow a shield against litigation is at odds with the experience of
legal team. major claims arise from the allegation that some abnormality in a test for fetal wellbeing was not acted upon in time. Where a test is inherently unreliable, or only reveals part of the clinical picture, there is a greater likelihood that no immediate action our
Most
will be taken on the basis of an aberration and thus a greater risk that the plaintiff, with the benefit of hindsight, will be able to seize on some adverse or merely equivocal result as the basis for a claim. The position is well illustrated by cardiotocography traces; far from being a shield against litigation these traces may well be a sword turned against the doctor. The volume of litigation suggests the following guidelines for electronic fetal heart monitoring
(EFHM): (1) Ascertain the reliability of results. One reason why EFHM has become a cause of litigation is the lack of consensus in the medical profession as to how far one may rely on its results as an indication of fetal distress. There is a great need for a prospective study to assess the reliability of EFHM as an indication of a poor outcome, whether or not in conjunction with fetal scalp blood sampling. (2) Train people in its use. Experts who deal with EFHM-related claims see many traces where the abnormality is both obvious and gross, yet no-one intervened. The explanation is sometimes that no-one believed the results (see above) and sometimes that no-one understood them. Methodical training with a clear message would avoid many instances of this second type. (3) Limit use to cases where EFHM is positively indicated and properly supported. There may be a case for limiting the use of EFHM to those instances where it is positively indicated and can be properly supported by trained staff, the availability of consultant advice, and facilities for fetal scalp blood sampling and for doing emergency caesarean sections. There is little benefit medically in the ritual use of equipment in cases where it is not likely to be needed and where facilities for interpreting the results and acting on them if a crisis develops are lacking. Legally, such a ritual is no benefit at all. (4) Record decisions to "wait and see". Because of the high proportion of false positives from EFHM, many doctors and
health information on which managers make their local decisions. The most practical way of achieving this is for the NHS to change to the fiscal year to fit in with most of the rest of the public sector. A well-designed information system should easily be able to provide figures for either time period, to please everyone. Dunlop’s objections in respect of cross-national studies would be more persuasive if he had cited examples, particularly in view of the imprecision of the data, where comparisons across fiscal and calendar years have led to different conclusions. Department of Public Health Medicine, North Bedfordshire Health Authority, Bedford MK40 2NU, UK
PAUL A. KITCHENER GARY JACKSON
Incidents in intensive
care
SIR,-A "critical incident" is just another name for an accident, and the underlying principles must be the same whether the accident involves an aircraft, a nuclear reactor, or an intensive-care unit. All accidents are due to human error, whether it is the designer of the aircraft, the manufacturer, or the pilot. Procedures are devised to ensure safe operation provided that the level of human performance exceeds an easily achievable level. There is an optimum state of arousal (ie, failure is more likely when the operator is either drowsy or in a state of panic) that is reduced as the task gets harder. The pilot generally gets the blame since there is only one of him and he is often dead, whereas the manufacturers are numerous and can afford the best lawyers. Take, for example, a landing with the undercarriage up. Here pilots are divided into two groups, those who have landed with their aircraft’s undercarriage up and those who have not done so, yet. In a jumbo jet it cannot be done; the undercarriage comes out automatically or the aircraft refuses to land. Reading the paper by Dr Wright and colleagues (Sept 14, p 676) I was struck that two of the five incidents discussed involved three-way taps. If these were of the small disposable variety, I think it fair to point out that they can be hard to read, and I would hate to think that a doctor carries a load of guilt or has a blighted career because of one of those things. Their design has not been brought to a level of perfection. After an accident there is always the feeling that with a little more care or better training it could have been avoided. I think this is wrong: we should blame the equipment. Could the equipment have been designed so that this accident would have been impossible? Nearly always the answer is "yes". Cherry Orchard, Marlow Common, Buckinghamshire SL7 2QP, UK
Use of cost-benefit analysis in material
BRENNIG
JAMES
promotional
SiR,—The question you raise in your Aug 17 editorial about the legality of pharmaceutical companies using cost-benefit data in their promotional material is intriguing and will no doubt be debated by others well versed in the relevant national and European Community legislation.
Health
care
funding
in South Africa
SiR,—Iwould like to clarify some of the points mentioned by Professor van Niekerk (June 8, p 1402). The depressed economy of the Republic of South Africa necessitated that Government funding for health care be limited to an increase of 67%, although the inflation rate is currently 10-15%. This resulted in a reduction in funding in real terms. Add to this a population growth rate of 22% and the full extent of the problem will be appreciated. The 115% of Government expenditure allocated to health is reasonable when compared with other countries (UK 12-6%, Australia 96%). However, because of the lower gross national product per caput, this amount of health funding per caput is obviously far smaller in monetary terms. To achieve a more equitable division of health funding, the Government has decided to allocate funds according to a formula based on demographic profiles and health and socioeconomic indicators. This formula was first used in the 1990/91 financial year and has resulted in a redistribution in the division of the health "cake". For example
met only by a greater understanding of human behaviour-yet the behavioural sciences are given no place in the
aims will be
strategy. Non-clinical advisers on the Central Research and Development Committee include epidemiologists, health service researchers, economists, and statisticians, but not health psychologists or medical sociologists, whose remit is the behaviour of patients, health professionals, and organisations. Is it not important to know that patients opting for a new technology such as the insulin pump may be those least suited to manage it,’ or that doctors who feel most confident at resuscitation are not the most competent to carry it out?2 The strategy conjures up exciting new vistas of the routine introduction of innovations through trials backed up by sparkling information technology and cost-effectiveness studies. Yet having the information is less than half the solution,3,4 and costs can be more than financial. The strategy does not fully acknowledge the importance of the unintended effects of implementing innovations in health care. These include increased absenteeism among participants in health screening and stress in those making use of reproductive technologies. Patient and staff responses need to be incorporated in any evaluation of a novel health innovation to increase the likelihood that the intended benefit is achieved and the harm caused is reduced to a minimum. Department of Primary Care, University of Southampton, Aldermoor Health Centre,
ANN-LOUISE KINMONTH
Southampton
This change in the size of the various portions plus the overall decrease in the size of the Government health cake in real terms has resulted in a significant decrease in the funding for the Cape. The severe problem this is causing the Cape health authorities is appreciated, particularly as the Cape health services have been geared to a higher expenditure per head than other areas of South Africa. For example, the physician density per 10 000 population of doctors employed in the public sector in 1990 was 8-9 in the Cape metropolitan area compared with 6-5 in Durban-Pietermaritzburg and 5-2 in Pretoria-Johannesburg. The statement by van Niekerk that private health funding covers only 20% of the population probably stems from a commonly held misconception. Of the total population only 20% is covered by medical insurance schemes, but medical insurance is responsible for 60% of private health funding. The remaining 40% is derived directly from private paying patients, comprising a small upperincome group who pay directly for all health services and a large middle to lower income group who choose a private consultation as the first entry point to the health care system and are referred to public health care if secondary or tertiary care is required. The exact size of the above-mentioned population is not known. A survey in Soweto amongst the mother/guardians of pre-school children in day care revealed approximately equal use of private and Government treatment options. An estimated 30-35% of the population covered by private health care is therefore not unrealistic. Private health care comprises 45% of the total health
expenditure. The inefficiency and increased costs of the fragmented services in South Africa have been recognised and reconstruction of health care provision is in hand. It is hoped that the new allocations will make it possible for all areas in South Africa to provide a health care equal to the good standards achieved in the Cape area. Ministry of National
Health and of Health Services, House of Assembly, Private Bag X399, Pretoria 0001, South Africa
Psychology and health
E. H. VENTER, Minister of National Health and of Health Services
care
evaluation
SIR,-Professor Peckham’s manifesto for research and for the National Health Service (Aug 10, p 367) identifies the need for a research programme bearing on the
development
"effectiveness of clinical practice, the dispersal and use of existing and the best use of human resources". Such laudable
knowledge,
Health
Psychology Unit, Royal Free Hospital School of Medicine, London NW3 2QG, UK 1.
THERESA M. MARTEAU
Bradley C, Gamsu DS, Moses JL, et al. The use of diabetes-specific perceived control and health belief measures to predict treatment choice and efficacy in a feasibility study of continuous subcutaneous insulin infusion pumps. Psychol Health 1987; 1:
133-46. 2. Marteau TM, Wynne G, Kaye W, Evans TR Resuscitation. experience without feedback increases confidence but not skill. Br Med J 1990; 300: 849-50. 3. Mugford M, Banfield P, O’Hanlon M Effects of feedback of information on clinical practice: a review. Br Med J1991; 303: 398-402. 4. Crombie IK, Davies HTO. Computers in audit: servants or sirens? Br Med J 1991; 303: 403-04.
Audit, peer review, and intellectual
conformity SIR,"If it comes to prohibiting, there is not ought more likely to be prohibited than truth it self, whose first appearance to our eyes, blear’d and dimm’d with prejudice and custom, is more unsightly and more plausible than many errors."-John Milton (1644)
The heart of clinical peer review is conformity to accepted medical practice. How should a knowledgeable physician act if he is the first to suspect that standard practice is incorrect and would harm his patient? Our doctor can be guided only by experience and intuition. He can cite no published work, nor can he ask his patient to return in 5 or 10 years, when physicians might know more. Even a brief historical survey is anything but reassuring. The first medical application of statistics, shortly after the French Revolution, revealed that patients treated by bleeding did no better, and even somewhat worse, than those unbled. The first physician who, in 1853, positively pointed to the mosquito as the spreader of yellowfever, who showed that absence of mosquitoes precluded the disease, and who prescribed the ready means to stamp it out by fumigation and by preventing bites, was investigated by a commission, which found his views inadmissible and all but declared him insane.1 Semmelweis ordered his students to wash in chlorinated lime between the dissecting room and the maternity ward. A medical editor wrote that it was time to stop such nonsense.’ Z In our own day George Crile, Jr, who departed from the traditional Halsted mastectomy, was reprimanded by the Cleveland Academy of Medicine.3 In 1934 a chest surgeon who urged 300
823
colleagues to support measures to curb smoking was laughed off the floor.4 We no longer keep myocardial infarction patients heavily sedated and in bed for several weeks, and we suspect that removal of dietary fibre, which had been the treatment for diverticular disease, is in fact its cause. The benefit of annual check-up, hitherto unquestioned in the United States, is now thought to be limited. The peer review offence is deviation per se, so it is no defence to show that an innovative treatment worked better than a standard one. Yet we are ethically and, in New York state, legally obliged to use our best judgment.5,6 In the absence of harm there is no cause of action for malpractice, while adherence to accepted medical practice which was not the doctor’s best judgment has been expressly rejected as a malpractice defence.6,7 Compelled adherence to authority, to dogma, is stultifying and profoundly deprofessionalising. Intellectual coercion is medieval and scholastic;8 gone are the Renaissance and the Enlightenment. Dissent becomes heresy; reputation, career, and livelihood go to the stake. At a time when millions of people have broken their shackles the medical profession is snapping them on. 17 Main Street, Sayville, NY 11782, USA 1.
Capsticks Solicitors, General Accident Building, 77/83 Upper Richmond Road,
BRIAN CAPSTICK PETER EDWARDS
London SW15 2TT, UK
Public health
reporting year
SIR,-Dr Dunlop (Aug 31, p 584) denigrates the use of the fiscal year for public health purposes in the UK. This is puzzling because directors of are
striving
public health and the National Health Service as a whole to strengthen the link between health and financial
information in their efforts
to
make the best
use
of funds. What is
important is for the same time period to be used for the fiscal and ROBERT CARLEN
Agramonte A. The inside story of a great medical discovery. Sci Monthly 1915 (Dec); I, 209-37. Reprinted in: Yellow fever studies: public health in America (New York:
Amo Press, Inc, 1977). 2. Anon. The New Encyclopedia Britannica, 15th ed, 1986. X: 627-28. 3. Crile G Jr. Surgery, in the days of controversy. JAMA 1989; 262: 256-58. 4. New York Times, July 19, 1990: D19. 5. Pike v Honsinger, 155 NY 201, 49 NE 760 (1898). 6. Toth v Community Hospital at Glen Cove 22 NY 2d 255; 292 NYS 2d 440 (1968). 7. Wickline v State of California, 239 Cal Rptr 810 (Cal App 2Dist 1986). 8. Osler W. Harvey and his discovery. In: The collected writings of Sir William Osler. Birmingham, Alabama: Classics of Medicine Library, 1985; see JAMA 1987; 258: 1522.
Defensive obstetric
midwives choose to "wait and see" when a trace is abnormal. If such a decision is not recorded, it will appear in retrospect as a negligent failure to respond. It is therefore necessary to record wait and see decisions, as well as decisions to intervene, as evidence that attention was being paid to the issue. It is increasingly difficult for obstetricians to resist the pressure for greater intervention, and a few measures of this type would go some way to reducing the pressure from litigation.
practice
SiR,—The obstetrician’s belief, reported by Dr Ennis and Dr Orr (Sept 7, p 616), that carrying out tests of uncertain reliability is somehow a shield against litigation is at odds with the experience of
legal team. major claims arise from the allegation that some abnormality in a test for fetal wellbeing was not acted upon in time. Where a test is inherently unreliable, or only reveals part of the clinical picture, there is a greater likelihood that no immediate action our
Most
will be taken on the basis of an aberration and thus a greater risk that the plaintiff, with the benefit of hindsight, will be able to seize on some adverse or merely equivocal result as the basis for a claim. The position is well illustrated by cardiotocography traces; far from being a shield against litigation these traces may well be a sword turned against the doctor. The volume of litigation suggests the following guidelines for electronic fetal heart monitoring
(EFHM): (1) Ascertain the reliability of results. One reason why EFHM has become a cause of litigation is the lack of consensus in the medical profession as to how far one may rely on its results as an indication of fetal distress. There is a great need for a prospective study to assess the reliability of EFHM as an indication of a poor outcome, whether or not in conjunction with fetal scalp blood sampling. (2) Train people in its use. Experts who deal with EFHM-related claims see many traces where the abnormality is both obvious and gross, yet no-one intervened. The explanation is sometimes that no-one believed the results (see above) and sometimes that no-one understood them. Methodical training with a clear message would avoid many instances of this second type. (3) Limit use to cases where EFHM is positively indicated and properly supported. There may be a case for limiting the use of EFHM to those instances where it is positively indicated and can be properly supported by trained staff, the availability of consultant advice, and facilities for fetal scalp blood sampling and for doing emergency caesarean sections. There is little benefit medically in the ritual use of equipment in cases where it is not likely to be needed and where facilities for interpreting the results and acting on them if a crisis develops are lacking. Legally, such a ritual is no benefit at all. (4) Record decisions to "wait and see". Because of the high proportion of false positives from EFHM, many doctors and
health information on which managers make their local decisions. The most practical way of achieving this is for the NHS to change to the fiscal year to fit in with most of the rest of the public sector. A well-designed information system should easily be able to provide figures for either time period, to please everyone. Dunlop’s objections in respect of cross-national studies would be more persuasive if he had cited examples, particularly in view of the imprecision of the data, where comparisons across fiscal and calendar years have led to different conclusions. Department of Public Health Medicine, North Bedfordshire Health Authority, Bedford MK40 2NU, UK
PAUL A. KITCHENER GARY JACKSON
Incidents in intensive
care
SIR,-A "critical incident" is just another name for an accident, and the underlying principles must be the same whether the accident involves an aircraft, a nuclear reactor, or an intensive-care unit. All accidents are due to human error, whether it is the designer of the aircraft, the manufacturer, or the pilot. Procedures are devised to ensure safe operation provided that the level of human performance exceeds an easily achievable level. There is an optimum state of arousal (ie, failure is more likely when the operator is either drowsy or in a state of panic) that is reduced as the task gets harder. The pilot generally gets the blame since there is only one of him and he is often dead, whereas the manufacturers are numerous and can afford the best lawyers. Take, for example, a landing with the undercarriage up. Here pilots are divided into two groups, those who have landed with their aircraft’s undercarriage up and those who have not done so, yet. In a jumbo jet it cannot be done; the undercarriage comes out automatically or the aircraft refuses to land. Reading the paper by Dr Wright and colleagues (Sept 14, p 676) I was struck that two of the five incidents discussed involved three-way taps. If these were of the small disposable variety, I think it fair to point out that they can be hard to read, and I would hate to think that a doctor carries a load of guilt or has a blighted career because of one of those things. Their design has not been brought to a level of perfection. After an accident there is always the feeling that with a little more care or better training it could have been avoided. I think this is wrong: we should blame the equipment. Could the equipment have been designed so that this accident would have been impossible? Nearly always the answer is "yes". Cherry Orchard, Marlow Common, Buckinghamshire SL7 2QP, UK
Use of cost-benefit analysis in material
BRENNIG
JAMES
promotional
SiR,—The question you raise in your Aug 17 editorial about the legality of pharmaceutical companies using cost-benefit data in their promotional material is intriguing and will no doubt be debated by others well versed in the relevant national and European Community legislation.
