now outmoded, and both compressor driven and ultrasonic nebulisers are bulky and cumbersome. Dry powder inhalers may provide the answer; the original powder inhalers (Spinhaler and Rotahaler) have the inconvenience that a gelatine capsule containing the drug powder has to be loaded before use, but two new multidose powder inhalers (Diskhaler and Turbohaler) have recently been introduced. The Diskhaler contains eight doses of either salbutamol or beclomethasone dipropionate, while the Turbohaler (known as Turbuhaler in other countries) contains 200 metered doses of terbutaline sulphate in the manner of a metered dose inhaler but without additives of any kind.4 The topical corticosteroid budesonide is available from Turbuhaler in some European countries. Powder inhalers have the further merit that they are breath-
actuated and can be used satisfactorily by patients who cannot use a metered dose inhaler correctly. Turbohaler, Diskhaler, and other future multidose powder inhalers may provide one key to treating asthma in the coming decades. STfEPHEN P NEWMAN Principal Phvsicist, Department of Thoracic Medicine, Royal Free Hospital and School of Medicine, London NW3 2QG
Ncwman SP. 'resstirtscd mctered dosc inhalcrs aid thc ozone laNer. I uropea
Respiratonryournal
in
press:. 2 Molina MIJ. Rowlanid FS. Stratosphcric sink for chlorofluoromethancs: chlorince atomcatalysed
destructiott of'ozonie. .\ature 1974:249:1810-2. 3 (iribbin J. I7it holte int the skY. Man's threat to ihe o(Zone lasver. London: Corgi Books, 1987. 4 Newman SP, Mloren F, Crompton K. 4 ne-ti c(ncept in inthalationt therapy. 13ussum, Tlhc Netherlanids: Medicom, 1987.
Depression and the menopause Oestrogen may alleviate depressed mood but depressive disorder requires psychiatric treatment Depression around the menopause poses three important questions. Is it more frequent than depression at other times of life? Has it special causes, notably lack of oestrogen? Does it need special treatment -that is, oestrogen replacement? Research attempts to answer these questions have often been inconclusive because of three limitations of method. Firstly, the important distinction between depressed mood and depressive disorder has often been overlooked. Depressed mood is the feeling of sadness familiar to everyone. Depressive disorder is a syndrome that is less common but far more serious. It may include depressed mood; loss of interest, energy, and enjoyment; poor concentration; gloomy thoughts of guilt, worthlessness, hopelessness or suicide; disturbances of appetite, weight, sleep, and sex drive; and slow speech or movement. The second limitation has been failure to use standardised measures of known reliability and validity to detect symptoms and to diagnose depressive disorder. The third has been inaccurate specification of the menopause. For example, menopausal state has sometimes been defined by age, although the menopause is not closely correlated with age. The best method is to use precise definitions of the terms premenopausal, menopausal, and postmenopausal based on the time since the last menstrual period. ' Is the frequency of depression increased around the menopause? High rates of depression have been found among women attending menopause clinics2 and among middle aged women attending gynaecology clinics.34 These findings are not surprising as psychiatric symptoms are increased among all hospital outpatients.9 If prevalence is to mean anything it must be assessed in representative samples of the general population. Postal surveys of general population samples have given conflicting results, probably because they are less sensitive than interviews." There have been interview surveys in four countries- Sweden,' England,9 the United States,'0 and Canada."1 All four used large random samples, precise definitions, and standardised methods of case detection. They agreed in finding no excess of depressive disorder at the menopause. Does perimenopausal depression have special causes, either psychological or physical? Psychologically, the menopause may induce depression in a woman if she regrets the loss of her fertility or thinks that she is losing her femininity. Research shows that such reactions are uncommon among women undergoing an "artificial" menopause as a result of BMJ
VOLUME
300
19
MAY
1990
hysterectomy, with or without bilateral oophorectomy.'2 By inference, such reactions are unlikely to be common with the natural menopause. They occur in individual women, however, and should not be missed as causes of depression. It is obvious but worth emphasising that a perimenopausal woman may be depressed for psychological reasons that are unrelated to the menopause. Her parents may be ill or dying; her children may leave home; her husband may be less attentive than previously. She may have the so called redundancy syndrome - the demoralisation resulting from the belief that there is no longer anything useful to do. This is not to say that the challenges and adversities of middle life are any more stressful than those of early parenthood or old age. Nevertheless, research has found that depressed mood and depressive disorder in middle aged women are related less to the menopause than to the vicissitudes of life. '0 13 As a physical agent lack of oestrogen may cause depression either directly as a biochemical effect or indirectly by causing physical symptoms, such as flushes or sweats, that induce depression. A direct biochemical effect has not been proved, but several possible mechanisms have been suggested. For example, lack of oestrogen might cause depressed mood by reducing plasma tryptophan concentration, and thereby brain 5-hydroxytryptamine function,'4 15 or by influencing the action of monoamine oxidase,'6 or by changing the sensitivity of monoamine receptors." An indirect effect through flushes and sweats is also unproved. Two postal surveys found that psychological symptoms such as depression peaked in frequency at an age before that at which vasomotor symptoms peaked.78 On the other hand, a community interview survey of over 500 middle aged women found a significant association between psychiatric symptoms and flushes and sweats'-though this does not prove a causal connection. Clinical experience suggests that vasomotor symptoms may be very distressing to some women. Against this aetiological background an important practical question is whether oestrogen alleviates depression. For depressive disorder the evidence is scanty. In a study of women with severe depressive disorders that had not responded to standard antidepressant drugs the addition of high doses of oestrogen was more effective than placebo in reducing depressive symptoms in some women, though the overall reduction was small in the whole group.'6 The main disadvantages of this approach are that potential responders 1287
cannot be identified and high doses of oestrogen may be dangerous. Among women with depressed mood (as against depressive disorder) oestrogen has been reported as beneficial by some investigators'9-2' but not others.22 Overall, the evidence suggests that oestrogen may alleviate depressed mood and induce a sense of wellbeing. Does perimenopausal depression require special treatment? If the diagnosis is depressive disorder the primary treatment is not oestrogen but standard psychiatric treatment, whether pharmacological or psychological, or both. The psychological treatment will probably be concerned with emotional reactions to the menopause or to the problems of middle life. If the patient has distressing vasomotor symptoms then oestrogen can be given as an adjunct. If the diagnosis is solely depressed mood the treatment will depend on the cause -counselling and social measures will be appropriate for stressful events or circumstances whereas oestrogen is likely to be appropriate for patients with vasomotor symptoms. Finally, it should be said that the menopause can mean a new lease of life to some women, bringing freedom from menstruation and child bearing. Cultural effects are likely to be important here.2" In some societies, for example, postmenopausal women are given enhanced status.24 DENNIS GATH Clinical Reader SUSAN ILES Wellcome Research Fellow
University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX
1 M1cKinlav S, Jefferevs M1, 'I'hompson 1P. An investigation ot' age at menopausc. 7 Bzosoc Sci 1972;4: 161-73. 2 Jonies MJ, Marshall DH, Nordin BEC. Quantitation ot)f menopausal symptomatology and its response to ethin\vI oestradiol and piperazine oestrone stulphate. CursrMedRes (pin 1977;4(suppl 3X: 12-20. 3 Ballinger B. Psychiatric morbidity and the menopatisc: survey of' a gynaecological out-patient clinic. Brj Psvchiatrv 1977;131:83-9. 4 Byrne P. Plsychiatric morbidity in a gvtnaecological clinic. An epiderniological survey. Br 7
Psschiatrv 1985;144:28-34. 5 Mayou R, Hawton K. Psychiatric disorder in the general hospital. Br_7 lassvchiasrv 1986;149:172-90. 6 McKinlay SM, Jefferevs M. 'I'he menopatisal syndrome. Br,7 Prez Soc icd 1974;28:108-15. 7 Ballinger B. Pssvchiatric morbidity and the menopausc; screening of a general popuilation sample.
BrMedj 1975;iii:344-6. 8 Hallstrom T, Samuelsson S. Mental health in the climacteric. The longitudinal study of women in Gothenburg. Acta Obsiet Gyvnecol Scand[Suppl] 1985;130:13-8. 9 (Gath D, Osborn M., Bungav G, ei al. Psychiatric disorder and gytuaccological symptoms iIn middlc aged women: a community survey. Br Medj 1987;294:213-8. 10 McKinlay JB, McKinlay SM, Brambila D. The relative contributionis of endocrinc changes and social circuimstances to depression in middle-aged women. ]7 Healih Soc Behaz, 1987;28:345-63. 11 Kaufert PA, Gilbert P, Hassaret T. Researching the symptoms of menopatuse: an exercise in methodology. Maturiias 1988;10: 117-3 1. 12 Gath D, Cooper Pa, Bond A, Edmonds G. Hysterectomy and psychiatric disorder. II. D)emographic and physical factors in relation to psyrchiatric outcome. Br.7Psychiatrv 1982;140:343-511. 13 Greene JS, Cooke DJ. Life stress and symptoms at the climacterium. Br]7 Psvuhiasrs' 1980;136: 486-9 1. 14 Aylward M. Estrogens, plasma tryptophani levels in perimenopausal patients. In: Campbell S, ed. The management of the menopause and post-menopausal years. Manchester: MTri Press, 1976; 135-47. 15 Coppen A, Bishop M, Beard RJ. Effects of piperazine oestorone sulphate on plasma trvptophati, oestrogen, gonadotrophins and psychological functioning in women following hysterectomy. CurrMAed Res Opin 1977;4(suppl 3):29-36. 16 Klaiber EL, Broverman DM, Vogel W, Kobayashi Y. Estrogen therapy for severe persistent depressions in women. Arch (ren Psychiatry 1979;36:550-4. 17 Chalmers JS, Fulli-Lemaire I, Cowen PJ. Effects of the contraceptive pill on sedative responses to clonidine and dapomorphine in normal women. Psychol Med 1985;15:363-7. 18 Bungay GT, Vessey MIP, McPherson CK. Studv of symptoms in middle-life with special referencc to the menopatise. BrMedJ 1980;281:181-3. 19 Brincat M, Studd JWW, O'Dowd T, Magos A, Cardoza 1L1), Wardle Pl. Subcutancous hormoltc implants for control of climacteric symptoms. Lancet 1984;i: 16-8. 20 Sherwin B, Gelfatnd M. Sex steroids and affect in the surgical menopause: a dotible-blind, crossover study. Psv,choneuroendocrtnology 1985;10:325-35. 21 Sherwin B. Af'fective changes with oestrogen and androgen replacement therapy in surgically menopausal women. 7 AffectiVe Disord 1988;14:177-87. 22 latrakis G, Haronis N, Sakellaropoulos G, Kourkabas A, (Gallos Al. Iasvchosomatic symptoms of, postmenopausal wsomen swith or withosit hormonal trcatment. PssYchother Psvchosom 1966;46:
116-21. 23 Bevene Y. Cultural significance and physiological manif'cstations o' inenopausc. A biocultural analysis. Culat ed Pssvchuatrv 1986;10:47-71. 24 (ieorge T. Menopause: some interpretations of the results of a study autaoitg non-western groups.
Mfaturitas 1988;10:109-16.
The empty theatre Better use ofoperating theatres requires better management Inefficient use of resources is one of the government's most publicised perceptions of the problems of the NHS, and it was the mainspring of its current plans for restructuring the service. In respect of operating theatres a report by the National Audit Office in 1987 seemed to confirm this view, claiming that 40% of operating time was unused during the working day.' The report did not examine the reasons for this in detail, leaving the field clear for the media to add its own interpretations. Of the various options the "missing consultant" explanation attracted the most enthusiasm. Against that background the NHS Management Executive commissioned a thorough study of the use of operating theatres under the guidance of a steering committee chaired by Professor Peter Bevan of the Royal College of Surgeons of England. Its report was published in December 1989 after a detailed analysis of the working of the theatres in 12 hospitals.2 The findings paralleled those of the National Audit Office study-namely, the rate of use of operating theatres ranged between 50% and 80% depending on the criteria. The report highlighted the myriad of predictable causes, primarily shortages-shortage of beds, shortage of staff, and shortage of other resources. Additionally it spelled out firmly and with detail a potentially more remedial cause: undermanagement. Planned theatre sessions cost approximately £150 an hour to run, and failure to use planned sessions represents a substantial waste of money-probably in excess of £1 5Om a year. 1288
Other features that confounded attempts at efficient use were late starting (32% of lists), late finishing (20%), and both (9%). The report is being presented at the Healthcare Exhibition at the National Exhibition Centre (22-24 May), where it will be discussed by an audience drawn from all of the health professions. They will be told that the report clearly identified a need for firm management as the way to solve the problems. In doing so its authors were at pains to point out that managers will need primarily to have managerial skills and should not be appointed solely on the basis of their professional background. The unspoken rider to this was that there is no reason why theatre managers should be drawn from the nursing hierarchy. One of the first tasks for the theatre managers will be to break down the notion that a theatre is the fiefdom of the consultant who uses it, underuses it, overuses it, or abuses it at will. To assist the transfer of managerial control the new manager will need to be backed up by two resources: good information and clinical muscle. Accurate and timely information on theatre usage, case duration, staff availability, and so on, will be needed, and the complexity of those data is such that relatively advanced computer systems will need to be installed. The strong clinical support might come, the Bevan report suggested, from the somewhat old fashioned concept of a theatre users' committee; a more modern view of manageBMJ VOLUME 300
19 MAY 1990
actuated and can be used satisfactorily by patients who cannot use a metered dose inhaler correctly. Turbohaler, Diskhaler, and other future multidose powder inhalers may provide one key to treating asthma in the coming decades. STfEPHEN P NEWMAN Principal Phvsicist, Department of Thoracic Medicine, Royal Free Hospital and School of Medicine, London NW3 2QG
Ncwman SP. 'resstirtscd mctered dosc inhalcrs aid thc ozone laNer. I uropea
Respiratonryournal
in
press:. 2 Molina MIJ. Rowlanid FS. Stratosphcric sink for chlorofluoromethancs: chlorince atomcatalysed
destructiott of'ozonie. .\ature 1974:249:1810-2. 3 (iribbin J. I7it holte int the skY. Man's threat to ihe o(Zone lasver. London: Corgi Books, 1987. 4 Newman SP, Mloren F, Crompton K. 4 ne-ti c(ncept in inthalationt therapy. 13ussum, Tlhc Netherlanids: Medicom, 1987.
Depression and the menopause Oestrogen may alleviate depressed mood but depressive disorder requires psychiatric treatment Depression around the menopause poses three important questions. Is it more frequent than depression at other times of life? Has it special causes, notably lack of oestrogen? Does it need special treatment -that is, oestrogen replacement? Research attempts to answer these questions have often been inconclusive because of three limitations of method. Firstly, the important distinction between depressed mood and depressive disorder has often been overlooked. Depressed mood is the feeling of sadness familiar to everyone. Depressive disorder is a syndrome that is less common but far more serious. It may include depressed mood; loss of interest, energy, and enjoyment; poor concentration; gloomy thoughts of guilt, worthlessness, hopelessness or suicide; disturbances of appetite, weight, sleep, and sex drive; and slow speech or movement. The second limitation has been failure to use standardised measures of known reliability and validity to detect symptoms and to diagnose depressive disorder. The third has been inaccurate specification of the menopause. For example, menopausal state has sometimes been defined by age, although the menopause is not closely correlated with age. The best method is to use precise definitions of the terms premenopausal, menopausal, and postmenopausal based on the time since the last menstrual period. ' Is the frequency of depression increased around the menopause? High rates of depression have been found among women attending menopause clinics2 and among middle aged women attending gynaecology clinics.34 These findings are not surprising as psychiatric symptoms are increased among all hospital outpatients.9 If prevalence is to mean anything it must be assessed in representative samples of the general population. Postal surveys of general population samples have given conflicting results, probably because they are less sensitive than interviews." There have been interview surveys in four countries- Sweden,' England,9 the United States,'0 and Canada."1 All four used large random samples, precise definitions, and standardised methods of case detection. They agreed in finding no excess of depressive disorder at the menopause. Does perimenopausal depression have special causes, either psychological or physical? Psychologically, the menopause may induce depression in a woman if she regrets the loss of her fertility or thinks that she is losing her femininity. Research shows that such reactions are uncommon among women undergoing an "artificial" menopause as a result of BMJ
VOLUME
300
19
MAY
1990
hysterectomy, with or without bilateral oophorectomy.'2 By inference, such reactions are unlikely to be common with the natural menopause. They occur in individual women, however, and should not be missed as causes of depression. It is obvious but worth emphasising that a perimenopausal woman may be depressed for psychological reasons that are unrelated to the menopause. Her parents may be ill or dying; her children may leave home; her husband may be less attentive than previously. She may have the so called redundancy syndrome - the demoralisation resulting from the belief that there is no longer anything useful to do. This is not to say that the challenges and adversities of middle life are any more stressful than those of early parenthood or old age. Nevertheless, research has found that depressed mood and depressive disorder in middle aged women are related less to the menopause than to the vicissitudes of life. '0 13 As a physical agent lack of oestrogen may cause depression either directly as a biochemical effect or indirectly by causing physical symptoms, such as flushes or sweats, that induce depression. A direct biochemical effect has not been proved, but several possible mechanisms have been suggested. For example, lack of oestrogen might cause depressed mood by reducing plasma tryptophan concentration, and thereby brain 5-hydroxytryptamine function,'4 15 or by influencing the action of monoamine oxidase,'6 or by changing the sensitivity of monoamine receptors." An indirect effect through flushes and sweats is also unproved. Two postal surveys found that psychological symptoms such as depression peaked in frequency at an age before that at which vasomotor symptoms peaked.78 On the other hand, a community interview survey of over 500 middle aged women found a significant association between psychiatric symptoms and flushes and sweats'-though this does not prove a causal connection. Clinical experience suggests that vasomotor symptoms may be very distressing to some women. Against this aetiological background an important practical question is whether oestrogen alleviates depression. For depressive disorder the evidence is scanty. In a study of women with severe depressive disorders that had not responded to standard antidepressant drugs the addition of high doses of oestrogen was more effective than placebo in reducing depressive symptoms in some women, though the overall reduction was small in the whole group.'6 The main disadvantages of this approach are that potential responders 1287
cannot be identified and high doses of oestrogen may be dangerous. Among women with depressed mood (as against depressive disorder) oestrogen has been reported as beneficial by some investigators'9-2' but not others.22 Overall, the evidence suggests that oestrogen may alleviate depressed mood and induce a sense of wellbeing. Does perimenopausal depression require special treatment? If the diagnosis is depressive disorder the primary treatment is not oestrogen but standard psychiatric treatment, whether pharmacological or psychological, or both. The psychological treatment will probably be concerned with emotional reactions to the menopause or to the problems of middle life. If the patient has distressing vasomotor symptoms then oestrogen can be given as an adjunct. If the diagnosis is solely depressed mood the treatment will depend on the cause -counselling and social measures will be appropriate for stressful events or circumstances whereas oestrogen is likely to be appropriate for patients with vasomotor symptoms. Finally, it should be said that the menopause can mean a new lease of life to some women, bringing freedom from menstruation and child bearing. Cultural effects are likely to be important here.2" In some societies, for example, postmenopausal women are given enhanced status.24 DENNIS GATH Clinical Reader SUSAN ILES Wellcome Research Fellow
University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX
1 M1cKinlav S, Jefferevs M1, 'I'hompson 1P. An investigation ot' age at menopausc. 7 Bzosoc Sci 1972;4: 161-73. 2 Jonies MJ, Marshall DH, Nordin BEC. Quantitation ot)f menopausal symptomatology and its response to ethin\vI oestradiol and piperazine oestrone stulphate. CursrMedRes (pin 1977;4(suppl 3X: 12-20. 3 Ballinger B. Psychiatric morbidity and the menopatisc: survey of' a gynaecological out-patient clinic. Brj Psvchiatrv 1977;131:83-9. 4 Byrne P. Plsychiatric morbidity in a gvtnaecological clinic. An epiderniological survey. Br 7
Psschiatrv 1985;144:28-34. 5 Mayou R, Hawton K. Psychiatric disorder in the general hospital. Br_7 lassvchiasrv 1986;149:172-90. 6 McKinlay SM, Jefferevs M. 'I'he menopatisal syndrome. Br,7 Prez Soc icd 1974;28:108-15. 7 Ballinger B. Pssvchiatric morbidity and the menopausc; screening of a general popuilation sample.
BrMedj 1975;iii:344-6. 8 Hallstrom T, Samuelsson S. Mental health in the climacteric. The longitudinal study of women in Gothenburg. Acta Obsiet Gyvnecol Scand[Suppl] 1985;130:13-8. 9 (Gath D, Osborn M., Bungav G, ei al. Psychiatric disorder and gytuaccological symptoms iIn middlc aged women: a community survey. Br Medj 1987;294:213-8. 10 McKinlay JB, McKinlay SM, Brambila D. The relative contributionis of endocrinc changes and social circuimstances to depression in middle-aged women. ]7 Healih Soc Behaz, 1987;28:345-63. 11 Kaufert PA, Gilbert P, Hassaret T. Researching the symptoms of menopatuse: an exercise in methodology. Maturiias 1988;10: 117-3 1. 12 Gath D, Cooper Pa, Bond A, Edmonds G. Hysterectomy and psychiatric disorder. II. D)emographic and physical factors in relation to psyrchiatric outcome. Br.7Psychiatrv 1982;140:343-511. 13 Greene JS, Cooke DJ. Life stress and symptoms at the climacterium. Br]7 Psvuhiasrs' 1980;136: 486-9 1. 14 Aylward M. Estrogens, plasma tryptophani levels in perimenopausal patients. In: Campbell S, ed. The management of the menopause and post-menopausal years. Manchester: MTri Press, 1976; 135-47. 15 Coppen A, Bishop M, Beard RJ. Effects of piperazine oestorone sulphate on plasma trvptophati, oestrogen, gonadotrophins and psychological functioning in women following hysterectomy. CurrMAed Res Opin 1977;4(suppl 3):29-36. 16 Klaiber EL, Broverman DM, Vogel W, Kobayashi Y. Estrogen therapy for severe persistent depressions in women. Arch (ren Psychiatry 1979;36:550-4. 17 Chalmers JS, Fulli-Lemaire I, Cowen PJ. Effects of the contraceptive pill on sedative responses to clonidine and dapomorphine in normal women. Psychol Med 1985;15:363-7. 18 Bungay GT, Vessey MIP, McPherson CK. Studv of symptoms in middle-life with special referencc to the menopatise. BrMedJ 1980;281:181-3. 19 Brincat M, Studd JWW, O'Dowd T, Magos A, Cardoza 1L1), Wardle Pl. Subcutancous hormoltc implants for control of climacteric symptoms. Lancet 1984;i: 16-8. 20 Sherwin B, Gelfatnd M. Sex steroids and affect in the surgical menopause: a dotible-blind, crossover study. Psv,choneuroendocrtnology 1985;10:325-35. 21 Sherwin B. Af'fective changes with oestrogen and androgen replacement therapy in surgically menopausal women. 7 AffectiVe Disord 1988;14:177-87. 22 latrakis G, Haronis N, Sakellaropoulos G, Kourkabas A, (Gallos Al. Iasvchosomatic symptoms of, postmenopausal wsomen swith or withosit hormonal trcatment. PssYchother Psvchosom 1966;46:
116-21. 23 Bevene Y. Cultural significance and physiological manif'cstations o' inenopausc. A biocultural analysis. Culat ed Pssvchuatrv 1986;10:47-71. 24 (ieorge T. Menopause: some interpretations of the results of a study autaoitg non-western groups.
Mfaturitas 1988;10:109-16.
The empty theatre Better use ofoperating theatres requires better management Inefficient use of resources is one of the government's most publicised perceptions of the problems of the NHS, and it was the mainspring of its current plans for restructuring the service. In respect of operating theatres a report by the National Audit Office in 1987 seemed to confirm this view, claiming that 40% of operating time was unused during the working day.' The report did not examine the reasons for this in detail, leaving the field clear for the media to add its own interpretations. Of the various options the "missing consultant" explanation attracted the most enthusiasm. Against that background the NHS Management Executive commissioned a thorough study of the use of operating theatres under the guidance of a steering committee chaired by Professor Peter Bevan of the Royal College of Surgeons of England. Its report was published in December 1989 after a detailed analysis of the working of the theatres in 12 hospitals.2 The findings paralleled those of the National Audit Office study-namely, the rate of use of operating theatres ranged between 50% and 80% depending on the criteria. The report highlighted the myriad of predictable causes, primarily shortages-shortage of beds, shortage of staff, and shortage of other resources. Additionally it spelled out firmly and with detail a potentially more remedial cause: undermanagement. Planned theatre sessions cost approximately £150 an hour to run, and failure to use planned sessions represents a substantial waste of money-probably in excess of £1 5Om a year. 1288
Other features that confounded attempts at efficient use were late starting (32% of lists), late finishing (20%), and both (9%). The report is being presented at the Healthcare Exhibition at the National Exhibition Centre (22-24 May), where it will be discussed by an audience drawn from all of the health professions. They will be told that the report clearly identified a need for firm management as the way to solve the problems. In doing so its authors were at pains to point out that managers will need primarily to have managerial skills and should not be appointed solely on the basis of their professional background. The unspoken rider to this was that there is no reason why theatre managers should be drawn from the nursing hierarchy. One of the first tasks for the theatre managers will be to break down the notion that a theatre is the fiefdom of the consultant who uses it, underuses it, overuses it, or abuses it at will. To assist the transfer of managerial control the new manager will need to be backed up by two resources: good information and clinical muscle. Accurate and timely information on theatre usage, case duration, staff availability, and so on, will be needed, and the complexity of those data is such that relatively advanced computer systems will need to be installed. The strong clinical support might come, the Bevan report suggested, from the somewhat old fashioned concept of a theatre users' committee; a more modern view of manageBMJ VOLUME 300
19 MAY 1990
