NEWS & Political Review
Doctors and torture As the daily news brings ever more gruesome accounts of atrocities in the Middle East Amnesty International has again turned the spotlight on doctors' participation in torture with the publication of its book Doctors and Torture: Collaboration or Resistance? Human rights organisations agree that there has been a steady rise in the use of torture. No country in the Western world can now say that it has no trade with torturing countries-until the invasion of Kuwait last year the United States was Iraq's major trading partner. Over 90 countries in the world presently practise torture. According to Helen Bamber, director of the Medical Foundation for the Care of Victims of Torture, in some countries it has become almost a science. The extent of doctors' involvement in torture is difficult to assess. The fall of the South American dictatorships saw a flood of refugees bearing the physical and psychological scars of torture. With them came stories of doctors' participation. In Uruguay, Brazil, Argentina, and Chile doctors examined patients before torture, patched up victims between torture sessions and for public appearances, and gave advice on victims' weak points that the torturers could exploit. Doctors may be willing, unwitting, or reluctant participants. But the Declaration of Tokyo, drawn up by the World Medical Association in 1975, is uncompromising. It states that no doctor should be present at or do anything to assist acts of torture or punishment. But, said Helen Bamber, fear can cause ''a conspiracy of silence," affecting both the victim and the doctor. "A complicity develops between them. The patient who has recently been tortured is too scared to admit it and invents some story about a car crash or fire. The doctor knows there has been torture but is unwilling to ask questions." It takes enormous courage to speak out, she said. Support for doctors brave enough to stand against the authorities has been "sadly neglected" in the past, according to James Welsh of Amnesty's medical office. "The individual doctor making ethical decisions is a lonely and isolated person," he said. "No decision is quite as simple when you have a gun, actually or metaphorically, pointing at your head." The Chilean Medical Association is realistic about the possibility that doctors may be coerced into cooperating. Its ethical code includes a let out clause. If members are unable to avoid becoming involved in acts of torture, for whatever reason, they should report the circumstances to the medical association. In this way the association hopes
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Electroconvulsive therapy? No -electrical torture, as described by Chilean victim
to catch doctors before they slide irretrievably into compromise and complicity. But does coercion mitigate the crime? The Declaration of Tokyo makes no concessions on this score. And concern has been expressed that in the wrong hands the Chilean clause could become an open charter for doctors to torture and confess, a form of medical ethical absolution. There is a similar hardening of attitude against bogus humanitarianism. Doctors should not assume that it is better to limit suffering that they cannot prevent, an excuse cited by doctors involved in Nazi war crimes. The boundaries are easily broached. Doctors who assist with punitive amputations in countries practising Moslem Sharia'a law could find themselves graduating from amputations of the hand to cross limb amputations, in which the right hand and the left foot are removed. This is the "slippery slope" that Amnesty, the BMA, and other bodies are anxious that doctors should avoid. Narrow definitions of torture have left ethical grey areas, which are now being tackled. Last year there was an outcry over
reports of direct medical involvement in capital punishment in the United States. In the two cases concerned, in Illinois and Missouri, doctors fitted intravenous catheters to allow lethal injections to be given. A protest resolution from the American College of Physicians called on the American Medical Association to clarify and publicise its position on the participation of doctors in corporal and capital punishment as well as in torture. The BMA's second report on torture, to be published early next year, will examine the wider issue of doctors' participation in punitive procedures, including corporal punishment, amputations, floggings, and the death sentence. The need now is for solidarity among doctors. James Welsh believes that the world's medical community should maximise the ability of the doctor to offload personal moral pressure. National law could ensure separation of the doctor from the state. Standard procedures for doctors dealing with detainees could include an obligation to report any injury, removing from the individual the need to make a moral 925
Headlines M
PM launches King's appeal: The Prime Minister, John Major, was due to launch the £40m King's appeal on 18 April in support of the "King's 2000" development programme for King's College Hospital and its medical school. It is believed to be the first appeal of its kind to be so publicly supported by a serving British prime
minister. Nurses' grading appeals: About 40 000 nurses are waiting for grading appeals to be heard in Britain, and the Royal College of Nursing estimates that so far the appeals process has cost £9 5m. To process the outstanding appeals will cost a further £21 *2m. The clinical grading structure was introduced in 1988. New Danish editor: Dr Einar Krag has been appointed editor in chief of the journal of the Danish Medical Association, Ugeskrift for Laeger. He succeeds Professor Povl Riis, who was editor for many years.
French authorise new AIDS drug: The French Ministry of Health has authorised the "compassionate treatment" of AIDS sufferers with Imuthiol, which must be made available free of charge and prescribed in a hospital by a doctor specialising in the treatment of AIDS. This follows a report in JAMA that Imuthiol can reduce the incidence of opportunistic infections in patients with AIDS and retard the evolution of the disease. Eye tests drop by 2*7 million: After charges for eye tests-which average £12.47-were introduced in 1989 the number of tests dropped by 2 7 million to 10-2 million in 1990, according to the Association of Optometrists. About 40% of the population is entitled to a free test, but the association, which represents ophthalmic opticians, argues that the examination can help diagnose glaucoma, diabetes, hypertension, and even brain tumours. -
Junior can pursue case over long hours: Now that the House of Lords has turned down the appeal from Bloomsbury and Islington Health Authority against the decision of the Court of Appeal in December (5 January, p 9) the way is open for Chris Johnstone to pursue his claim against the authority. He is asking for a declaration that he should not have been required to work more than a standard 40 hour week if this created a foreseeable risk to his health. L 926
judgment under difficult conditions. Wide dissemination of ethical codes by medical associations would also help to educate members and-the public. "The more mechanisms in place to take the moral load off the individual doctor the better," he said. "The effects of torture are not healed by time," said Helen Bamber. "In fact, time often compounds the suffering." For this reason there is an urgency about early intervention. Last year the foundation saw nearly 2000 new patients. It continues to see people from South America, mainly Colombians, and has dealt with a "steady trickle" of Iraqi Kurds over the past few years. The foundation also receives an increasing number of requests for help from former prisoners of war of the Japanese, many now in their 70s. Funded entirely from charitable sources, the foundation employs 18 paid staff, including two full time psychiatrists and a child psychotherapist, and 50 voluntary workers. In addition to the psychological scars inflicted on victims and on those forced to witness acts of torture there are the physical injuries. These include "a lot of broken mouths and teeth" from electric shocks and blows from rifle butts. Dentists and an ear, nose, and throat surgeon attend the foundation part time. There are about 40 other small groups around the world, often working in difficult and dangerous conditions. The Medical Foundation for the Care of Victims of Torture organises a conference every two years-the next will take place in Santiago, Chile, in November-to bring these groups together and exchange experience and expertise. "The number of patients doubles each year," said Helen Bamber. The foundation does not wish to medicalise torture or its treatment. But offers of help and support from doctors and health professionals would, she said, be very welcome. -FIONA GODLEE Doctors and Torture: Collaboration or Resistance? London: Bellew, 1991. (Price £8.95.) Medical Foundation for the Care of Victims of Torture, 96-98 Grafton Road, London NW5 3EJ (telephone 071 284 4321). British Medical Group of Amnesty International, 99 Rosebery Avenue, London ECIR 4RE (telephone 071 278 6000). Physicians for Human Rights (Dr Peter Kandela.) Telephone 0784 246033/252027.
that so many disabled people of normal intelligence lead restricted and often isolated lives and have underused potential is due in large part to the low priority given to the services needed. Examples of good practice usually spring from a combination of statutory and other agencies, with the participation of disabled people. Certain general needs were a recurring theme: disabled people should: * Lead an ordinary life in the community * Choose their lifestyle * Take responsibility for their life * Have high though realistic aspirations and expectations. The mission statement of the Leeds young adult team, for example, refers to giving its clients "the opportunity to make an informed choice about the lifestyle they want and helping them achieve it." Before leaving school, whether a special or a mainstream school, disabled youngsters need both expert counselling and vocational assessment, but they do not always get this. The careers officer provides continuity and a point of contact during the transition from school and, said a specialist careers officer, can advocate their needs and promote self advocacy, as well as working to improve career and employment opportunities. Nowhere are choice and autonomy more important than in accommodation and style of living. The living Options in Practice project (of the Prince of Wales Advisory Group on Disability and King's Fund Centre) helps those who plan, provide, and use services to create services that enable severely disabled people to lead full, independent, and ordinary lives with the support in the community that they need. "Multiagency" teams, with development officers and advisers who are themselves disabled, have been set up in eight places. Mobility is the key to independence, and many options exist; but to make use of them
How much choice for disabled people? The "big black hole" that awaits severely disabled young people when they leave school was the starting point of a conference at Keele University, sponsored by the Nuffield Provincial Hospitals Trust, on developing services for physically disabled school leavers and young adults. Surveys of unmet needs should precede the development of services, and one survey in the Exeter area found that half of the severely disabled people aged 19-25 had no daytime occupation. They had a poor self image and little opportunity to meet people or develop autonomy as adults. The fact
A young man with achondroplastic dwarfism using a specially adapted computer keyboard for a temporary job in the wheelchair service of Haywood Hospital, Stoke on Trent, in the course of his employment training. Before he left school 18 months ago he was helped to form a "lifestyle plan" by the North Staffordshire Service for the Young Physically Handicapped Adult
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the disabled youngster needs both information and confidence. Public transport was reported to have improved greatly. For personal transport the range of vehicles and adaptations for even the most disabled is wide, and the Transport and Road Research Laboratory's new peripatetic mobility service (which includes test drives and assessments) was described. Disabled people often do not know where to go for help even when help exists, and social workers and others may not know either. Providing information is a speciality of comprehensive services and self help groups, but the Oxford Disability Information Project, with its multiagency working groups in the region, is exploring ways of improving access to information more generally-through the media, for example, and shops and libraries. Great strides have been made in the integration and independence of disabled people, but when they leave the protection and facilities of school they usually enter a community with no comprehensive services for them, where-as someone put it-what is on offer may be paltry and irrelevant and choice a matter of "take it or leave it."-DAPHNE GLOAG
British children are the third poorest in Europe
Suffer the little children Two and a half million children in Britain wear second hand clothes and do not eat three meals a day. In the same month as these findings were released from a MORI poll of 1800 people, commissioned by London Weekend Television for its series Breadline Britain-1990s, a report published by the European Commission showed that British children are the third poorest in Europe. Both studies conclude that in the past decade children have borne the brunt of the increasing poverty created by unemployment, rising inflation, and changes in social security benefits. The European Commission's report discusses data from all age groups for each country derived from surveys of family budgets performed between 1980 and 1985. The commission defines the poor as "persons whose resources (material, cultural, and social) are so limited as to exclude them from the minimal acceptable way of life in the member state in which they live." The report defines the threshold of poverty as having a disposable income of less than half of the average in the country in question. This places 50 million people in the commission's 12 member states below the poverty line. Ten million of these people live in Britain. In 1980 Britain was the eighth poorest nationwith 2 .8 million households in poverty. By 1985 it had risen to become the second poorest nation with 3 8 million households in poverty. While poverty figures in Spain, Belgium, France, Italy, and Greece have fallen the proportion of children below the poverty line in Britain increased from one in five in 1980 to nearly one in four in 1985.
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London Weekend Television's MORI poll arrived at the same figures for poverty in Britain by a completely different route. It asked its sample population what they considered to be the necessities for a miniimum standard oflife and defined poverty as lacking three of these essentials. The poll revealed that 11 million people were poor, an increase of 50% on figures from an equivalent MORI poll in 1983. The necessities of life defined by the poll's respondents included a refrigerator, fresh vegetables daily, carpets, and out of school activities for children. Both reports showed that poverty was increasingly likely to affect the population groups of working age and their children. The elderly population increased between 1980 and 1985, but poverty in this group fell. The commission's report argues that unemployment and the increase in the number of single parent families have changed the face of poverty. In Britain 13% of families are run by single parents, most of them women. The report cites the lack of child minding facilities as the reason why nearly three quarters of one parent families rely on social security benefits and states that "social assistance does not always provide an income which is sufficient to avoid poverty." Professor Jonathan Bradshaw, author of a study entitled Child Poverty and Deprivation in the UK, funded by the United Nations and published last year, claims that the government has compounded the problem of poverty among children by decreasing levels of universal benefits and introducing more means tested benefits. "We need a child oriented government policy," he argues. "Only 50% of families entitled to family credit claim it. People do not like applying for means tested benefits. There is clear evidence that children's development is affected by poverty. They are
excluded from participating in social events such as swimming or going to the cinema. They are very dependent on the television for entertainment. The government white paper Children Come First intends to make fathers who have separated from their children pay maintenance. This is not going to work and just means that the government will cut benefits to single parent families." In June 1989 John Moore, then the secretary of state for health and social security, claimed that "individuals and organisations concerned with poverty are merely pursuing the political goal of equality." The commission's report and the MORI poll would tend to dispute that. The commission's report concludes that it strives for a Europe "which is not only economically and politically stronger, but also offers more justice and solidarity."-LUISA DILLNER
Health care workers face violence Surprisingly large numbers of nurses, social workers, and clinical psychologists admit that they have been attacked or threatened while carrying out their duties, according to speakers at a symposium at the British Psychological Society's annual conference in Bournemouth last week. Many health care workers now realise that they run an increasing risk of being a victim of verbal or physical assault. The convenor of the symposium, Dr Til Wykes, said that within two months of starting her job as a clinical psychologist she was "thumped by a male patient." A pilot survey conducted in Wandsworth showed that two thirds of psychologists had been physically attacked in 927
the course of their work, and nearly one third had been attacked on at least three occasions. More than 1600 social workers in Surrey were also questioned, with over a third claiming to have been a victim of some kind of violence. Most physical assaults occurred in residential settings, resulting in minor injuries such as bruising and lacerations. Verbal abuse and threats were common. Psychiatric nurses in a London based study were most at risk of attack when stopping a patient from leaving a side room or the ward and, conversely, when encouraging a patient to leave a room. Nurses cited mental illness as a reason for attack in less than 20% of incidents. The symposium also considered the effects that such risks and assaults have on staff. All the professionals attacked showed evidence of distress that lasted several weeks after the event. Almost a quarter of social workers reported effects persisting for more than six months after attacks and sometimes after only threats of violence. Staff may be so severely affected that they suffer recognisable post-traumatic stress disorder. Among nurses "substance use" reactions-the need to smoke and drink-were common in the 24 hours after the assault. After two to three weeks a quarter of those interviewed complained of sleep disturbances such as awakenings and nightmares. More worryingly, many of these health care workers felt unable to talk about the attacks. Incident forms were not completed by almost two thirds of the clinical psychologists. Dr Wykes said that health care professionals are generally reluctant to admit to having problems. "This macho approach," she said, "is not necessarily helpful." And
You can't hear the whistle blowing Self governing trusts may renegotiate the terms and conditions of service of their medical staff; so far most attention has been paid to salaries and workload. How important is retaining paragraph 330, which states that: "A practitioner shall be free, without the prior consent of the employing authority, to publish books, articles etc, and to deliver any lecture or speech, whether on matters arising out of his hospital service or not"? An episode that occurred in Glasgow last summer may convince some doctors that the clause shouldn't be given up without a fight. A sector manager sent the following memorandum to doctors and other members of staff in his unit. Entitled "Management and staff responsibilities in communication" it read: The Unit General Manager has recently been appalled to learn that certain members of staff, some of them senior with substantial management responsibilities within their disciplines, have been communicating, in their official management capacity, with third parties, in response to complaints or to offer personal views and comments on this Unit's service
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affected staff may find it difficult to maintain the same standard of care after incidents. There are few other professional staff who have to deal with such dilemmas regularly. Dr Wykes commented that options for coping were limited either to "toughening up" strategies, such as self defence and weight training, or to withdrawing from threatening situations. The symposium raised questions for health service managers about training and support for staff and about strategies for reducing risks of violence. Perhaps psychologists could take a lead in formulating guidelines for preventing and managing violence at work. -GEOFF LOWE * Nearly 90% of health service workers worry about violence at work, but only 3% of hospitals offer special training to all staff and up to 50% give no training, according to a survey published by the National Union of Public Employees. About 28% of staff had been told how to report violent incidents; the most serious underreporting was of verbal abuse and threats.
Doctors dictate variations in health care Why do such large variations in medical practice exist? For example, as far back as 1959 the chief medical officer noted that tonsillectomy rates varied from 0 5% in Merthyr Tydfil to 16-3% in Chester. A discussion paper released this month from
provision. These communications range from a client being told (inaccurately) that service provision was being withdrawn from a group of special needs children to a letter on Unit headed stationery being sent to government ministers complaining about staffing levels. You should ensure that within 24 hours of your receipt of this letter all personnel reporting directly to you know that such behaviour will not be accepted and in all cases disciplinary action will be taken. This clear message must be communicated to all staff. On no account will any member of staff, whilst acting as a Board employee, make unauthorised comment on any aspect of this Unit's service to any client or client group, or to any part of the media, or to any other authority, body or person. If a problem in service provision does arise, either myself or a Senior Officer must be informed of the problem, when an appropriate decision will be made on the standards and/or level of service. . I cannot emphasise enough the seriousness of this matter, and how utterly irresponsible it is for any member of staff to indulge their personal and/or "professional" views in this way. Everyone should be aware that such conduct risks summary dismissal.
When the implications of paragraph 330 were pointed out to the Greater Glasgow
Health Board by the BMA's industrial relations officer in Glasgow, Mr Stephen Smith, the board's initial response was
Aberdeen University's health economics research unit argues that variations exist because of doctors' individual preferences for treatment. Its authors, Mandy Ryan and Gavin Mooney, believe that, even when confronted with variations in practice, doctors do not respond. The paper states: "the existence of clinical freedom ... at best provides a defence for doctors to practise differently, and at worst encourages them to do so. It may be argued even more simply that we are dealing with a conservative body of individuals who are resistant to change." There are variations nationally and internationally. American doctors, the report argues, are more likely to give chemotherapy for metastatic disease than British doctors. It quotes a British oncologist as saying that for American patients "it is becoming increasingly hard to escape chemotherapy." British doctors are more likely to believe that only a few patients will benefit and not offer it. The paper argues that variations in health practices imply that there is suboptimal use of NHS resources. It suggests that research is needed to determine why doctors behave so differently and what incentives can be used to make them change their habits. When there is disagreement about the benefit of a procedure variations are higher. There are more variations in the number of hysterectomies performed than in the number of hernia repairs. Other factors influencing variations include the supply of services, the demand for them, and the morbidity of the population. These are considered to be less important. The paper cites a study (K McPherson et al. J Epidemiol Community Health 1985;39:
I "When I look at paragraph 330 of the Conditions of Service I cannot see how our letter runs contrary to this at all." Eventually the board backed down blaming an "internal administrative misunderstanding." The memorandum still stands for all other non-medical staff. TONY DELAMOTHE
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179-82) which found that differences in the supply of services could not explain variations in the rate of cholecvstectomies in nine British towns. The prevalence of gall stones, however, was different among the areas studied. The unit is anxious that further research examines clinicians' attitudes to the risks of treatments. It argues that unless the right hypothesis is tested no one will be any the wiser as to why variations in medical practice still exist. -LUISA DILLNER Research on Aledical Practice V'ariation: W`here Now? is avaailable from Mrs D Ellis, HERU, University of Aberdeen, AB9 2ZD, price £3 if payment sent with order.
Explaining variations in health care to FHSAs What does an ordinary member of a family health services authority do when faced with data on referral rates in general practitioners' annual reports? How does she make the best use of the information-and what does it actually mean? A basic guide on the subject, to be sent to all family health services authorities, warns them firmly not to interpret the data simplistically. GP Referrals to Hospital, produced by three of Britain's experts on referral rates, does more than that: it provides a short, clear, and practical guide to the complexities of referral rates. Family health services authorities have to issue guidance on the way they want referral data provided, and the booklet suggests some standard definitionsfor example, that data should be provided for practices not GPs and for each referral episode; referrals should include out of hours and emergency referrals and domiciliary consultations; and attendances at accident and emergency departments should be recorded from the discharge note. The guide also explains what these data will leave out-all the hospital attendances made other than through GP referrals-and hence why hospital and general practice data do not tally. On interpreting these data, the guide
happropriate referrals
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explains how to calculate referral rates, how to account for chance variation (including a table to be used to calculate chance variation for any given referral rate and practice size), and what to do about small specialties, where small numbers distort the data. Even when chance variation and differences in the age structure of practices have been taken into account some patients are still four times more likely than others to be referred to a specialist there are no convincing systematic differences in the structure of practices, use of investigations, or characteristics of GPs that account for these differences. The most promising explanations lie in personal factors such as tolerance of uncertainty and perception of risks. Nor can a family health services authority know what the "right" referral rate might be. The guide provides some questions that might be asked for practices at the extremes of the range, but its main suggesition is that data on referral patterns can be used only to identify issues for audit. Unlike with prescribing patterns, there is no professional consensus on what is desirable -only a series of questions. -JANE SMITH
Waiting lists out, booking system in Proposals out for consultation in the South Western Regional Health Authority could revolutionise the "outdated, insensitive process of putting people on a waiting list." Drawn up by the regional medical advisory committees, which represent hospital doctors and general practitioners, the document recommends a booked admissions system for non-emergency surgery so that patients know when their operation will take place. Most would be given a date within six weeks, though some might have to wait a year. At present there are patients on lists who do not need surgery while others will not need an operation until some time in the future-for example, those with cataracts or varicose veins. The director of public health for the region, Alistair Mason, says that the waiting list is often used as "a punchball for personal and political ends." Under the proposals there would be clinical assessment of when patients should have their operations. Patients would either be booked direct for admission; booked for preadmission clinics; if willing, put on a short notice call list but guaranteed admission during a specified period; or given an outpatient appointment for further review (figure). There are more than 55 000 patients on the region's waiting lists; more than 12 500 have been waiting for over a vear. Dr Mason and his colleagues believe that the new system, which would include more day surgery, would reduce waiting lists because surgeons would be committed to a tight schedule of operations that would be worked out months in advance. The consultation document sets out the obligations on consultants and general practitioners for the radical proposals to work.
Decision made that elective admission required
Cannot be admitted within period
Further
Can be admitted within period
outpatient
Preadmission clinic
appointment
appointment
Date booked
Date booked
inpatient
hort call list
or day case admission
Date
Informed
booked
of month
Informed of month by when
Consultants would have to * Take ownership of a booking system and commit themselves to making it work * Use agreed criteria for intervention for common surgical conditions and audit their practices against them * Achieve a balance between outpatient referrals and the number of decisions made to operate * Organise their availability for theatre sessions realistically, taking into account study and annual leave. General practitioners would have to be involved in decisions about the range of services to be provided. They would also have to adopt realistic and appropriate referral policies for patients with common surgical conditions. To do this they would have to be told about the scope of the services offered by each provider, details of waiting experience, and the criteria being used to decide whether an operation was necessary. The operational units in the NHS and in self governing trusts would have to * Create a climate that encouraged consultants to adopt a booking system * Provide the appropriate infrastructure to run a booking system and to organise other aspects of clinical work * Guarantee that a suitable balance of resources was available with appropriate policies to ensure that elective and emergency admissions were dealt with equitably * Ensure that facilities were used effectively rather than merely kept full. Emergency cases will continue to be admitted immediately as at present.-LINDA BEECHAM
Benefits of booking system For patients: * Reduces uncertaintv and abilitv to make plans for admission * Removes temptation to defer admissions because the condition is routine or uninteresting For hospitals: * Reduces the number of patients failing to arrive for admission * Reduces the costs of sending for patients
* Reduces the average length of stay
Providinig High Quality Se-vices: Elective Admissions is available from the South Western Regional Health Authority, King Square House, 26-27 King Square, Bristol BS2 8EF.
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French AIDS researcher cleared Dr Daniel Zagury of the Universit6 Pierre et Marie Curie in Paris has been cleared by his government of charges of unethical vaccine testing on human subjects. Zagury, who won notoriety in 1987 by testing a potential AIDS vaccine on himself and on volunteers in Zaire, later collaborated with Dr Robert C Gallo and other researchers at the United States National Cancer Institute in trials of a potential vaccine on seronegative volunteers and of active immunotherapy in patients with AIDS. Last March the National Institutes of Health's Office for Protection from Research Risks found that scientists at the National Cancer Institute who collaborated with Zagury had failed "to provide and document adequate protections" for the subjects and suspended the collaboration. Francois Stosse, director general of the Assistance Publique, the administration of Paris public hospitals, has investigated the clinical trials carried out at the Saint-Antoine hospital in Paris, and last week Bruno Durieux, Minister of Health, announced that "the results of the investigation show that legislative texts, procedures, and the recommendations of ethical committees have been respected by the teams that carried out the trials." The report points out that the national ethics committee approved trials of a potential AIDS vaccine in June 1988 and again in September 1990. All the synthetic vaccines were prepared in France. The committee also approved, in May 1987, active immunotherapy trials on patients whose chances of survival beyond 12 months would be practically nil with available therapeutic means and for whom treatment with zidovudine was contraindicated because of leucopenia and neutropenia. These trials started in March 1989, and in May 1990 the hospital's own ethical committee authorised comparative trials of immunotherapy alone versus immunotherapy associated with zidovudine. Reagents of both French and American origin were used after approval by the French Ministry of Health in November 1988 and the National Institutes of Health in February 1989. -ALEXANDER DOROZYNSKI
Universities full Universities must receive more funding from the government or standards will drop, according to a report published last week by the Committee of Vice Chancellors and Principals of the Universities of the United Kingdom. Unless extra funds are provided universities face a choice between allowing more
students to study in second rate departdenying a university education to
ments or many.
During the 1980s the universities maintained standards and expanded their role against a background of reduced government support. In 1989-90 there were nearly 45 000 more full time and 11 000 more part time students than in 1984-5, despite a sharp 930
decrease in the number of 18 year olds in the population. Yet British universities still turn away more than half the applicants. During the 1980s universities increased their teaching by 15%, and research by 30% while their income from the government fell in real terms. Universities now have a deficit of £23m. In 1988 the University Grants Committee estimated that £250m was needed to improve existing buildings, and in 1990 the Advisory Board for the Research Councils estimated that it would cost £450m to provide the equipment needed to maintain research standards. All political parties want a doubling of students in higher education in the next 25
years. In 1991-2 the universities will be asked to take on 10% more students. The government has offered a cash increase of about 10-5%Y,, but with inflation predicted to be running at 7% this will mean a rise of only 3.5%S to cope with the extra intake. The vice chancellors have warned that this is simply not possible unless government policy changes. -ST ELLA LOWRY
This week's contributors include: Alexander Dorozynski, medical journalist, Paris Daphne Gloag, staff editor, BMJ Geoff Lowe, psychologist, Hull University
The Week An article in the Daily Mirror last week claimed that John Major was about to launch a campaign to raise money for a new casualty department at King's College Hospital, London. The Labour party immediately accused the Prime Minister of hypocrisy for trying to get the public to pay directly for NHS facilities that the government had refused to fund. What interested me was that this looked like a knight's move in the complicated politics of London's hospital services. William Waldegrave has declared that he or one of his successors will have to make some hard decisions about London hospitals-indeed, he hopes that the internal market will throw up the information on which those decisions can be based. No one seriously thinks that they don't include the closure of at least one London teaching hospital. Speculation about which hospital should close has been rife since the 1960s,' though the odds on individual hospitals have kept changing as health authority boundaries have changed and alliances shifted. Although its not generally thought to be the most vulnerable, some are laying odds on King's because of decisions by nearby fundholders to send patients to cheaper hospitals that are more easily accessible by public transprt. Whether or not those odds are accurate,MrMrajor's support for one London teachtng hospital (a long way from his own cons'tituency) will make his secretary of state's job harder when the difficult decisions have to be made. Or perhaps the Prinme Minister doesn't expect either of them to be in power in a year or two. By then even harder political debates may be raging. Doctors have long bemoaned the influence of narrow minded politics on health. That is one reason why they were intent in 1948 that the new NHS should not fall into the hands of local government and why no one was sorry to see area health authorities vanish in 1982. It is also one reason why this govern-ment has removed overt political representation from health authorities (though it has not prevented the govern-
ment from including many of its supporters as health authority members). Nevertheless, health, like education, is a political issue-and if the government succeeds in getting the health service to assess needs more explicitly and examine outcomes the public debate will become much more intense. The tacit assumption behind the "new managerialism" in the NHS is that the decisions will be uncontentious. Health authorities will simply assess the needs of their populations and meet them in the most cost effective way possible within the funds available. But assessing needs is a massive task, tools like QALYs (quality adjusted life years) are still in their infancy, the data on outcomes are inadequate, and even when the data become much improved the room for argument over values will be enormous. Experience in Oregon has shown that it is possible to pull together a priority list of conditions and treatments that reflects cost benefits and the public's valuing of outcomes. But Oregon's listing is not comprehensive, which procedures will not be funded has yet to be decided, and, as Rudolf Klein has pointed out, Oregon's list should be seen against the background of America's health care system, where many people do not qualify for any health care at all and where rationing affects only the poor. The debate in Britain will be different, and much will depend on how well the medical profession plays its part. Despite a succession of attempts -from cogwheel to clinical directorates-clinicians still aren't too good about living with consensus when it affects their interestslook at the recent interleukin 2 case in Manchester. Doctors in Britain will have to develop ways of assessing the evidence for themselves and deciding what they should and should not do. They should be worried that the first steps towards considering what the NHS might not do came not from a wide ranging debate within the North East Thames region or even from the director of public health but from the general manager. HART
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Doctors and torture As the daily news brings ever more gruesome accounts of atrocities in the Middle East Amnesty International has again turned the spotlight on doctors' participation in torture with the publication of its book Doctors and Torture: Collaboration or Resistance? Human rights organisations agree that there has been a steady rise in the use of torture. No country in the Western world can now say that it has no trade with torturing countries-until the invasion of Kuwait last year the United States was Iraq's major trading partner. Over 90 countries in the world presently practise torture. According to Helen Bamber, director of the Medical Foundation for the Care of Victims of Torture, in some countries it has become almost a science. The extent of doctors' involvement in torture is difficult to assess. The fall of the South American dictatorships saw a flood of refugees bearing the physical and psychological scars of torture. With them came stories of doctors' participation. In Uruguay, Brazil, Argentina, and Chile doctors examined patients before torture, patched up victims between torture sessions and for public appearances, and gave advice on victims' weak points that the torturers could exploit. Doctors may be willing, unwitting, or reluctant participants. But the Declaration of Tokyo, drawn up by the World Medical Association in 1975, is uncompromising. It states that no doctor should be present at or do anything to assist acts of torture or punishment. But, said Helen Bamber, fear can cause ''a conspiracy of silence," affecting both the victim and the doctor. "A complicity develops between them. The patient who has recently been tortured is too scared to admit it and invents some story about a car crash or fire. The doctor knows there has been torture but is unwilling to ask questions." It takes enormous courage to speak out, she said. Support for doctors brave enough to stand against the authorities has been "sadly neglected" in the past, according to James Welsh of Amnesty's medical office. "The individual doctor making ethical decisions is a lonely and isolated person," he said. "No decision is quite as simple when you have a gun, actually or metaphorically, pointing at your head." The Chilean Medical Association is realistic about the possibility that doctors may be coerced into cooperating. Its ethical code includes a let out clause. If members are unable to avoid becoming involved in acts of torture, for whatever reason, they should report the circumstances to the medical association. In this way the association hopes
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Electroconvulsive therapy? No -electrical torture, as described by Chilean victim
to catch doctors before they slide irretrievably into compromise and complicity. But does coercion mitigate the crime? The Declaration of Tokyo makes no concessions on this score. And concern has been expressed that in the wrong hands the Chilean clause could become an open charter for doctors to torture and confess, a form of medical ethical absolution. There is a similar hardening of attitude against bogus humanitarianism. Doctors should not assume that it is better to limit suffering that they cannot prevent, an excuse cited by doctors involved in Nazi war crimes. The boundaries are easily broached. Doctors who assist with punitive amputations in countries practising Moslem Sharia'a law could find themselves graduating from amputations of the hand to cross limb amputations, in which the right hand and the left foot are removed. This is the "slippery slope" that Amnesty, the BMA, and other bodies are anxious that doctors should avoid. Narrow definitions of torture have left ethical grey areas, which are now being tackled. Last year there was an outcry over
reports of direct medical involvement in capital punishment in the United States. In the two cases concerned, in Illinois and Missouri, doctors fitted intravenous catheters to allow lethal injections to be given. A protest resolution from the American College of Physicians called on the American Medical Association to clarify and publicise its position on the participation of doctors in corporal and capital punishment as well as in torture. The BMA's second report on torture, to be published early next year, will examine the wider issue of doctors' participation in punitive procedures, including corporal punishment, amputations, floggings, and the death sentence. The need now is for solidarity among doctors. James Welsh believes that the world's medical community should maximise the ability of the doctor to offload personal moral pressure. National law could ensure separation of the doctor from the state. Standard procedures for doctors dealing with detainees could include an obligation to report any injury, removing from the individual the need to make a moral 925
Headlines M
PM launches King's appeal: The Prime Minister, John Major, was due to launch the £40m King's appeal on 18 April in support of the "King's 2000" development programme for King's College Hospital and its medical school. It is believed to be the first appeal of its kind to be so publicly supported by a serving British prime
minister. Nurses' grading appeals: About 40 000 nurses are waiting for grading appeals to be heard in Britain, and the Royal College of Nursing estimates that so far the appeals process has cost £9 5m. To process the outstanding appeals will cost a further £21 *2m. The clinical grading structure was introduced in 1988. New Danish editor: Dr Einar Krag has been appointed editor in chief of the journal of the Danish Medical Association, Ugeskrift for Laeger. He succeeds Professor Povl Riis, who was editor for many years.
French authorise new AIDS drug: The French Ministry of Health has authorised the "compassionate treatment" of AIDS sufferers with Imuthiol, which must be made available free of charge and prescribed in a hospital by a doctor specialising in the treatment of AIDS. This follows a report in JAMA that Imuthiol can reduce the incidence of opportunistic infections in patients with AIDS and retard the evolution of the disease. Eye tests drop by 2*7 million: After charges for eye tests-which average £12.47-were introduced in 1989 the number of tests dropped by 2 7 million to 10-2 million in 1990, according to the Association of Optometrists. About 40% of the population is entitled to a free test, but the association, which represents ophthalmic opticians, argues that the examination can help diagnose glaucoma, diabetes, hypertension, and even brain tumours. -
Junior can pursue case over long hours: Now that the House of Lords has turned down the appeal from Bloomsbury and Islington Health Authority against the decision of the Court of Appeal in December (5 January, p 9) the way is open for Chris Johnstone to pursue his claim against the authority. He is asking for a declaration that he should not have been required to work more than a standard 40 hour week if this created a foreseeable risk to his health. L 926
judgment under difficult conditions. Wide dissemination of ethical codes by medical associations would also help to educate members and-the public. "The more mechanisms in place to take the moral load off the individual doctor the better," he said. "The effects of torture are not healed by time," said Helen Bamber. "In fact, time often compounds the suffering." For this reason there is an urgency about early intervention. Last year the foundation saw nearly 2000 new patients. It continues to see people from South America, mainly Colombians, and has dealt with a "steady trickle" of Iraqi Kurds over the past few years. The foundation also receives an increasing number of requests for help from former prisoners of war of the Japanese, many now in their 70s. Funded entirely from charitable sources, the foundation employs 18 paid staff, including two full time psychiatrists and a child psychotherapist, and 50 voluntary workers. In addition to the psychological scars inflicted on victims and on those forced to witness acts of torture there are the physical injuries. These include "a lot of broken mouths and teeth" from electric shocks and blows from rifle butts. Dentists and an ear, nose, and throat surgeon attend the foundation part time. There are about 40 other small groups around the world, often working in difficult and dangerous conditions. The Medical Foundation for the Care of Victims of Torture organises a conference every two years-the next will take place in Santiago, Chile, in November-to bring these groups together and exchange experience and expertise. "The number of patients doubles each year," said Helen Bamber. The foundation does not wish to medicalise torture or its treatment. But offers of help and support from doctors and health professionals would, she said, be very welcome. -FIONA GODLEE Doctors and Torture: Collaboration or Resistance? London: Bellew, 1991. (Price £8.95.) Medical Foundation for the Care of Victims of Torture, 96-98 Grafton Road, London NW5 3EJ (telephone 071 284 4321). British Medical Group of Amnesty International, 99 Rosebery Avenue, London ECIR 4RE (telephone 071 278 6000). Physicians for Human Rights (Dr Peter Kandela.) Telephone 0784 246033/252027.
that so many disabled people of normal intelligence lead restricted and often isolated lives and have underused potential is due in large part to the low priority given to the services needed. Examples of good practice usually spring from a combination of statutory and other agencies, with the participation of disabled people. Certain general needs were a recurring theme: disabled people should: * Lead an ordinary life in the community * Choose their lifestyle * Take responsibility for their life * Have high though realistic aspirations and expectations. The mission statement of the Leeds young adult team, for example, refers to giving its clients "the opportunity to make an informed choice about the lifestyle they want and helping them achieve it." Before leaving school, whether a special or a mainstream school, disabled youngsters need both expert counselling and vocational assessment, but they do not always get this. The careers officer provides continuity and a point of contact during the transition from school and, said a specialist careers officer, can advocate their needs and promote self advocacy, as well as working to improve career and employment opportunities. Nowhere are choice and autonomy more important than in accommodation and style of living. The living Options in Practice project (of the Prince of Wales Advisory Group on Disability and King's Fund Centre) helps those who plan, provide, and use services to create services that enable severely disabled people to lead full, independent, and ordinary lives with the support in the community that they need. "Multiagency" teams, with development officers and advisers who are themselves disabled, have been set up in eight places. Mobility is the key to independence, and many options exist; but to make use of them
How much choice for disabled people? The "big black hole" that awaits severely disabled young people when they leave school was the starting point of a conference at Keele University, sponsored by the Nuffield Provincial Hospitals Trust, on developing services for physically disabled school leavers and young adults. Surveys of unmet needs should precede the development of services, and one survey in the Exeter area found that half of the severely disabled people aged 19-25 had no daytime occupation. They had a poor self image and little opportunity to meet people or develop autonomy as adults. The fact
A young man with achondroplastic dwarfism using a specially adapted computer keyboard for a temporary job in the wheelchair service of Haywood Hospital, Stoke on Trent, in the course of his employment training. Before he left school 18 months ago he was helped to form a "lifestyle plan" by the North Staffordshire Service for the Young Physically Handicapped Adult
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the disabled youngster needs both information and confidence. Public transport was reported to have improved greatly. For personal transport the range of vehicles and adaptations for even the most disabled is wide, and the Transport and Road Research Laboratory's new peripatetic mobility service (which includes test drives and assessments) was described. Disabled people often do not know where to go for help even when help exists, and social workers and others may not know either. Providing information is a speciality of comprehensive services and self help groups, but the Oxford Disability Information Project, with its multiagency working groups in the region, is exploring ways of improving access to information more generally-through the media, for example, and shops and libraries. Great strides have been made in the integration and independence of disabled people, but when they leave the protection and facilities of school they usually enter a community with no comprehensive services for them, where-as someone put it-what is on offer may be paltry and irrelevant and choice a matter of "take it or leave it."-DAPHNE GLOAG
British children are the third poorest in Europe
Suffer the little children Two and a half million children in Britain wear second hand clothes and do not eat three meals a day. In the same month as these findings were released from a MORI poll of 1800 people, commissioned by London Weekend Television for its series Breadline Britain-1990s, a report published by the European Commission showed that British children are the third poorest in Europe. Both studies conclude that in the past decade children have borne the brunt of the increasing poverty created by unemployment, rising inflation, and changes in social security benefits. The European Commission's report discusses data from all age groups for each country derived from surveys of family budgets performed between 1980 and 1985. The commission defines the poor as "persons whose resources (material, cultural, and social) are so limited as to exclude them from the minimal acceptable way of life in the member state in which they live." The report defines the threshold of poverty as having a disposable income of less than half of the average in the country in question. This places 50 million people in the commission's 12 member states below the poverty line. Ten million of these people live in Britain. In 1980 Britain was the eighth poorest nationwith 2 .8 million households in poverty. By 1985 it had risen to become the second poorest nation with 3 8 million households in poverty. While poverty figures in Spain, Belgium, France, Italy, and Greece have fallen the proportion of children below the poverty line in Britain increased from one in five in 1980 to nearly one in four in 1985.
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London Weekend Television's MORI poll arrived at the same figures for poverty in Britain by a completely different route. It asked its sample population what they considered to be the necessities for a miniimum standard oflife and defined poverty as lacking three of these essentials. The poll revealed that 11 million people were poor, an increase of 50% on figures from an equivalent MORI poll in 1983. The necessities of life defined by the poll's respondents included a refrigerator, fresh vegetables daily, carpets, and out of school activities for children. Both reports showed that poverty was increasingly likely to affect the population groups of working age and their children. The elderly population increased between 1980 and 1985, but poverty in this group fell. The commission's report argues that unemployment and the increase in the number of single parent families have changed the face of poverty. In Britain 13% of families are run by single parents, most of them women. The report cites the lack of child minding facilities as the reason why nearly three quarters of one parent families rely on social security benefits and states that "social assistance does not always provide an income which is sufficient to avoid poverty." Professor Jonathan Bradshaw, author of a study entitled Child Poverty and Deprivation in the UK, funded by the United Nations and published last year, claims that the government has compounded the problem of poverty among children by decreasing levels of universal benefits and introducing more means tested benefits. "We need a child oriented government policy," he argues. "Only 50% of families entitled to family credit claim it. People do not like applying for means tested benefits. There is clear evidence that children's development is affected by poverty. They are
excluded from participating in social events such as swimming or going to the cinema. They are very dependent on the television for entertainment. The government white paper Children Come First intends to make fathers who have separated from their children pay maintenance. This is not going to work and just means that the government will cut benefits to single parent families." In June 1989 John Moore, then the secretary of state for health and social security, claimed that "individuals and organisations concerned with poverty are merely pursuing the political goal of equality." The commission's report and the MORI poll would tend to dispute that. The commission's report concludes that it strives for a Europe "which is not only economically and politically stronger, but also offers more justice and solidarity."-LUISA DILLNER
Health care workers face violence Surprisingly large numbers of nurses, social workers, and clinical psychologists admit that they have been attacked or threatened while carrying out their duties, according to speakers at a symposium at the British Psychological Society's annual conference in Bournemouth last week. Many health care workers now realise that they run an increasing risk of being a victim of verbal or physical assault. The convenor of the symposium, Dr Til Wykes, said that within two months of starting her job as a clinical psychologist she was "thumped by a male patient." A pilot survey conducted in Wandsworth showed that two thirds of psychologists had been physically attacked in 927
the course of their work, and nearly one third had been attacked on at least three occasions. More than 1600 social workers in Surrey were also questioned, with over a third claiming to have been a victim of some kind of violence. Most physical assaults occurred in residential settings, resulting in minor injuries such as bruising and lacerations. Verbal abuse and threats were common. Psychiatric nurses in a London based study were most at risk of attack when stopping a patient from leaving a side room or the ward and, conversely, when encouraging a patient to leave a room. Nurses cited mental illness as a reason for attack in less than 20% of incidents. The symposium also considered the effects that such risks and assaults have on staff. All the professionals attacked showed evidence of distress that lasted several weeks after the event. Almost a quarter of social workers reported effects persisting for more than six months after attacks and sometimes after only threats of violence. Staff may be so severely affected that they suffer recognisable post-traumatic stress disorder. Among nurses "substance use" reactions-the need to smoke and drink-were common in the 24 hours after the assault. After two to three weeks a quarter of those interviewed complained of sleep disturbances such as awakenings and nightmares. More worryingly, many of these health care workers felt unable to talk about the attacks. Incident forms were not completed by almost two thirds of the clinical psychologists. Dr Wykes said that health care professionals are generally reluctant to admit to having problems. "This macho approach," she said, "is not necessarily helpful." And
You can't hear the whistle blowing Self governing trusts may renegotiate the terms and conditions of service of their medical staff; so far most attention has been paid to salaries and workload. How important is retaining paragraph 330, which states that: "A practitioner shall be free, without the prior consent of the employing authority, to publish books, articles etc, and to deliver any lecture or speech, whether on matters arising out of his hospital service or not"? An episode that occurred in Glasgow last summer may convince some doctors that the clause shouldn't be given up without a fight. A sector manager sent the following memorandum to doctors and other members of staff in his unit. Entitled "Management and staff responsibilities in communication" it read: The Unit General Manager has recently been appalled to learn that certain members of staff, some of them senior with substantial management responsibilities within their disciplines, have been communicating, in their official management capacity, with third parties, in response to complaints or to offer personal views and comments on this Unit's service
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affected staff may find it difficult to maintain the same standard of care after incidents. There are few other professional staff who have to deal with such dilemmas regularly. Dr Wykes commented that options for coping were limited either to "toughening up" strategies, such as self defence and weight training, or to withdrawing from threatening situations. The symposium raised questions for health service managers about training and support for staff and about strategies for reducing risks of violence. Perhaps psychologists could take a lead in formulating guidelines for preventing and managing violence at work. -GEOFF LOWE * Nearly 90% of health service workers worry about violence at work, but only 3% of hospitals offer special training to all staff and up to 50% give no training, according to a survey published by the National Union of Public Employees. About 28% of staff had been told how to report violent incidents; the most serious underreporting was of verbal abuse and threats.
Doctors dictate variations in health care Why do such large variations in medical practice exist? For example, as far back as 1959 the chief medical officer noted that tonsillectomy rates varied from 0 5% in Merthyr Tydfil to 16-3% in Chester. A discussion paper released this month from
provision. These communications range from a client being told (inaccurately) that service provision was being withdrawn from a group of special needs children to a letter on Unit headed stationery being sent to government ministers complaining about staffing levels. You should ensure that within 24 hours of your receipt of this letter all personnel reporting directly to you know that such behaviour will not be accepted and in all cases disciplinary action will be taken. This clear message must be communicated to all staff. On no account will any member of staff, whilst acting as a Board employee, make unauthorised comment on any aspect of this Unit's service to any client or client group, or to any part of the media, or to any other authority, body or person. If a problem in service provision does arise, either myself or a Senior Officer must be informed of the problem, when an appropriate decision will be made on the standards and/or level of service. . I cannot emphasise enough the seriousness of this matter, and how utterly irresponsible it is for any member of staff to indulge their personal and/or "professional" views in this way. Everyone should be aware that such conduct risks summary dismissal.
When the implications of paragraph 330 were pointed out to the Greater Glasgow
Health Board by the BMA's industrial relations officer in Glasgow, Mr Stephen Smith, the board's initial response was
Aberdeen University's health economics research unit argues that variations exist because of doctors' individual preferences for treatment. Its authors, Mandy Ryan and Gavin Mooney, believe that, even when confronted with variations in practice, doctors do not respond. The paper states: "the existence of clinical freedom ... at best provides a defence for doctors to practise differently, and at worst encourages them to do so. It may be argued even more simply that we are dealing with a conservative body of individuals who are resistant to change." There are variations nationally and internationally. American doctors, the report argues, are more likely to give chemotherapy for metastatic disease than British doctors. It quotes a British oncologist as saying that for American patients "it is becoming increasingly hard to escape chemotherapy." British doctors are more likely to believe that only a few patients will benefit and not offer it. The paper argues that variations in health practices imply that there is suboptimal use of NHS resources. It suggests that research is needed to determine why doctors behave so differently and what incentives can be used to make them change their habits. When there is disagreement about the benefit of a procedure variations are higher. There are more variations in the number of hysterectomies performed than in the number of hernia repairs. Other factors influencing variations include the supply of services, the demand for them, and the morbidity of the population. These are considered to be less important. The paper cites a study (K McPherson et al. J Epidemiol Community Health 1985;39:
I "When I look at paragraph 330 of the Conditions of Service I cannot see how our letter runs contrary to this at all." Eventually the board backed down blaming an "internal administrative misunderstanding." The memorandum still stands for all other non-medical staff. TONY DELAMOTHE
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179-82) which found that differences in the supply of services could not explain variations in the rate of cholecvstectomies in nine British towns. The prevalence of gall stones, however, was different among the areas studied. The unit is anxious that further research examines clinicians' attitudes to the risks of treatments. It argues that unless the right hypothesis is tested no one will be any the wiser as to why variations in medical practice still exist. -LUISA DILLNER Research on Aledical Practice V'ariation: W`here Now? is avaailable from Mrs D Ellis, HERU, University of Aberdeen, AB9 2ZD, price £3 if payment sent with order.
Explaining variations in health care to FHSAs What does an ordinary member of a family health services authority do when faced with data on referral rates in general practitioners' annual reports? How does she make the best use of the information-and what does it actually mean? A basic guide on the subject, to be sent to all family health services authorities, warns them firmly not to interpret the data simplistically. GP Referrals to Hospital, produced by three of Britain's experts on referral rates, does more than that: it provides a short, clear, and practical guide to the complexities of referral rates. Family health services authorities have to issue guidance on the way they want referral data provided, and the booklet suggests some standard definitionsfor example, that data should be provided for practices not GPs and for each referral episode; referrals should include out of hours and emergency referrals and domiciliary consultations; and attendances at accident and emergency departments should be recorded from the discharge note. The guide also explains what these data will leave out-all the hospital attendances made other than through GP referrals-and hence why hospital and general practice data do not tally. On interpreting these data, the guide
happropriate referrals
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Maxi' um benefit Chantgitng the curve ntor the Iate. 7 hte most efficient uise oj' resources is r,epresenzted bv litne X}Y. Curve .4 represents the positi'on n1ow: simply increasinlg ithe overall rate would i.ncrease niot otnl/v appropriate rejferrals buit also inapproe
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explains how to calculate referral rates, how to account for chance variation (including a table to be used to calculate chance variation for any given referral rate and practice size), and what to do about small specialties, where small numbers distort the data. Even when chance variation and differences in the age structure of practices have been taken into account some patients are still four times more likely than others to be referred to a specialist there are no convincing systematic differences in the structure of practices, use of investigations, or characteristics of GPs that account for these differences. The most promising explanations lie in personal factors such as tolerance of uncertainty and perception of risks. Nor can a family health services authority know what the "right" referral rate might be. The guide provides some questions that might be asked for practices at the extremes of the range, but its main suggesition is that data on referral patterns can be used only to identify issues for audit. Unlike with prescribing patterns, there is no professional consensus on what is desirable -only a series of questions. -JANE SMITH
Waiting lists out, booking system in Proposals out for consultation in the South Western Regional Health Authority could revolutionise the "outdated, insensitive process of putting people on a waiting list." Drawn up by the regional medical advisory committees, which represent hospital doctors and general practitioners, the document recommends a booked admissions system for non-emergency surgery so that patients know when their operation will take place. Most would be given a date within six weeks, though some might have to wait a year. At present there are patients on lists who do not need surgery while others will not need an operation until some time in the future-for example, those with cataracts or varicose veins. The director of public health for the region, Alistair Mason, says that the waiting list is often used as "a punchball for personal and political ends." Under the proposals there would be clinical assessment of when patients should have their operations. Patients would either be booked direct for admission; booked for preadmission clinics; if willing, put on a short notice call list but guaranteed admission during a specified period; or given an outpatient appointment for further review (figure). There are more than 55 000 patients on the region's waiting lists; more than 12 500 have been waiting for over a vear. Dr Mason and his colleagues believe that the new system, which would include more day surgery, would reduce waiting lists because surgeons would be committed to a tight schedule of operations that would be worked out months in advance. The consultation document sets out the obligations on consultants and general practitioners for the radical proposals to work.
Decision made that elective admission required
Cannot be admitted within period
Further
Can be admitted within period
outpatient
Preadmission clinic
appointment
appointment
Date booked
Date booked
inpatient
hort call list
or day case admission
Date
Informed
booked
of month
Informed of month by when
Consultants would have to * Take ownership of a booking system and commit themselves to making it work * Use agreed criteria for intervention for common surgical conditions and audit their practices against them * Achieve a balance between outpatient referrals and the number of decisions made to operate * Organise their availability for theatre sessions realistically, taking into account study and annual leave. General practitioners would have to be involved in decisions about the range of services to be provided. They would also have to adopt realistic and appropriate referral policies for patients with common surgical conditions. To do this they would have to be told about the scope of the services offered by each provider, details of waiting experience, and the criteria being used to decide whether an operation was necessary. The operational units in the NHS and in self governing trusts would have to * Create a climate that encouraged consultants to adopt a booking system * Provide the appropriate infrastructure to run a booking system and to organise other aspects of clinical work * Guarantee that a suitable balance of resources was available with appropriate policies to ensure that elective and emergency admissions were dealt with equitably * Ensure that facilities were used effectively rather than merely kept full. Emergency cases will continue to be admitted immediately as at present.-LINDA BEECHAM
Benefits of booking system For patients: * Reduces uncertaintv and abilitv to make plans for admission * Removes temptation to defer admissions because the condition is routine or uninteresting For hospitals: * Reduces the number of patients failing to arrive for admission * Reduces the costs of sending for patients
* Reduces the average length of stay
Providinig High Quality Se-vices: Elective Admissions is available from the South Western Regional Health Authority, King Square House, 26-27 King Square, Bristol BS2 8EF.
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French AIDS researcher cleared Dr Daniel Zagury of the Universit6 Pierre et Marie Curie in Paris has been cleared by his government of charges of unethical vaccine testing on human subjects. Zagury, who won notoriety in 1987 by testing a potential AIDS vaccine on himself and on volunteers in Zaire, later collaborated with Dr Robert C Gallo and other researchers at the United States National Cancer Institute in trials of a potential vaccine on seronegative volunteers and of active immunotherapy in patients with AIDS. Last March the National Institutes of Health's Office for Protection from Research Risks found that scientists at the National Cancer Institute who collaborated with Zagury had failed "to provide and document adequate protections" for the subjects and suspended the collaboration. Francois Stosse, director general of the Assistance Publique, the administration of Paris public hospitals, has investigated the clinical trials carried out at the Saint-Antoine hospital in Paris, and last week Bruno Durieux, Minister of Health, announced that "the results of the investigation show that legislative texts, procedures, and the recommendations of ethical committees have been respected by the teams that carried out the trials." The report points out that the national ethics committee approved trials of a potential AIDS vaccine in June 1988 and again in September 1990. All the synthetic vaccines were prepared in France. The committee also approved, in May 1987, active immunotherapy trials on patients whose chances of survival beyond 12 months would be practically nil with available therapeutic means and for whom treatment with zidovudine was contraindicated because of leucopenia and neutropenia. These trials started in March 1989, and in May 1990 the hospital's own ethical committee authorised comparative trials of immunotherapy alone versus immunotherapy associated with zidovudine. Reagents of both French and American origin were used after approval by the French Ministry of Health in November 1988 and the National Institutes of Health in February 1989. -ALEXANDER DOROZYNSKI
Universities full Universities must receive more funding from the government or standards will drop, according to a report published last week by the Committee of Vice Chancellors and Principals of the Universities of the United Kingdom. Unless extra funds are provided universities face a choice between allowing more
students to study in second rate departdenying a university education to
ments or many.
During the 1980s the universities maintained standards and expanded their role against a background of reduced government support. In 1989-90 there were nearly 45 000 more full time and 11 000 more part time students than in 1984-5, despite a sharp 930
decrease in the number of 18 year olds in the population. Yet British universities still turn away more than half the applicants. During the 1980s universities increased their teaching by 15%, and research by 30% while their income from the government fell in real terms. Universities now have a deficit of £23m. In 1988 the University Grants Committee estimated that £250m was needed to improve existing buildings, and in 1990 the Advisory Board for the Research Councils estimated that it would cost £450m to provide the equipment needed to maintain research standards. All political parties want a doubling of students in higher education in the next 25
years. In 1991-2 the universities will be asked to take on 10% more students. The government has offered a cash increase of about 10-5%Y,, but with inflation predicted to be running at 7% this will mean a rise of only 3.5%S to cope with the extra intake. The vice chancellors have warned that this is simply not possible unless government policy changes. -ST ELLA LOWRY
This week's contributors include: Alexander Dorozynski, medical journalist, Paris Daphne Gloag, staff editor, BMJ Geoff Lowe, psychologist, Hull University
The Week An article in the Daily Mirror last week claimed that John Major was about to launch a campaign to raise money for a new casualty department at King's College Hospital, London. The Labour party immediately accused the Prime Minister of hypocrisy for trying to get the public to pay directly for NHS facilities that the government had refused to fund. What interested me was that this looked like a knight's move in the complicated politics of London's hospital services. William Waldegrave has declared that he or one of his successors will have to make some hard decisions about London hospitals-indeed, he hopes that the internal market will throw up the information on which those decisions can be based. No one seriously thinks that they don't include the closure of at least one London teaching hospital. Speculation about which hospital should close has been rife since the 1960s,' though the odds on individual hospitals have kept changing as health authority boundaries have changed and alliances shifted. Although its not generally thought to be the most vulnerable, some are laying odds on King's because of decisions by nearby fundholders to send patients to cheaper hospitals that are more easily accessible by public transprt. Whether or not those odds are accurate,MrMrajor's support for one London teachtng hospital (a long way from his own cons'tituency) will make his secretary of state's job harder when the difficult decisions have to be made. Or perhaps the Prinme Minister doesn't expect either of them to be in power in a year or two. By then even harder political debates may be raging. Doctors have long bemoaned the influence of narrow minded politics on health. That is one reason why they were intent in 1948 that the new NHS should not fall into the hands of local government and why no one was sorry to see area health authorities vanish in 1982. It is also one reason why this govern-ment has removed overt political representation from health authorities (though it has not prevented the govern-
ment from including many of its supporters as health authority members). Nevertheless, health, like education, is a political issue-and if the government succeeds in getting the health service to assess needs more explicitly and examine outcomes the public debate will become much more intense. The tacit assumption behind the "new managerialism" in the NHS is that the decisions will be uncontentious. Health authorities will simply assess the needs of their populations and meet them in the most cost effective way possible within the funds available. But assessing needs is a massive task, tools like QALYs (quality adjusted life years) are still in their infancy, the data on outcomes are inadequate, and even when the data become much improved the room for argument over values will be enormous. Experience in Oregon has shown that it is possible to pull together a priority list of conditions and treatments that reflects cost benefits and the public's valuing of outcomes. But Oregon's listing is not comprehensive, which procedures will not be funded has yet to be decided, and, as Rudolf Klein has pointed out, Oregon's list should be seen against the background of America's health care system, where many people do not qualify for any health care at all and where rationing affects only the poor. The debate in Britain will be different, and much will depend on how well the medical profession plays its part. Despite a succession of attempts -from cogwheel to clinical directorates-clinicians still aren't too good about living with consensus when it affects their interestslook at the recent interleukin 2 case in Manchester. Doctors in Britain will have to develop ways of assessing the evidence for themselves and deciding what they should and should not do. They should be worried that the first steps towards considering what the NHS might not do came not from a wide ranging debate within the North East Thames region or even from the director of public health but from the general manager. HART
BMJ
VOLUME
302
20
APRIL
1991
