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British support for Caribbean research SIR,-Your Round the World correspondent (March 16, p 667) paints an unjustifiably gloomy picture interspersed with inaccuracies. Dr White has already addressed the question of British support for CAREC (April 27, p 1040) and we have just returned from a meeting of the Commonwealth Caribbean Medical Research Council at which, rather than the purported withdrawal of an annual £ 30 000 subvention, the UK Overseas Development Administration indicated a willingness to consider research support of up to [,160000 per annum for the next 3 years. However, it is the "failure of the British Medical Research Council unit [presumably the MRC laboratories in Jamaica] to train able local graduates" that I must address, as its director. This is a small unit with six medically qualified staff (currently three British, one American, one Jamaican, one Guyanese) working in sickle cell disease. From 1974 a special medical post was created, reserved for a graduate of the University of West Indies, to gain experience in clinical research, and this post has never been vacant. Traditionally aligned with the university department of child health, this post has trained twenty paediatricians for periods between 6 month and 2 years. The unit has also participated in research with members of the departments of medicine, surgery, obstetrics, radiology, genitourinary surgery, psychiatry, physiology, and anaesthetics, and the Tropical Metabolism Research Unit. None of these trained graduates had pursued a career in research-and here the problems are more complex, including lack of research tradition, the local standing of clinical research, and research career structures in the Caribbean. This unit offers elective opportunities to medical students yet, despite active local proselytising, attracts a West Indian student from the Caribbean only once in every 2-3 years. At the same time 30-40 students from other countries annually avail themselves of the opportunity, including West Indians in the UK, Canada, and the USA. The problem is perhaps buried in local attitudes to research which will take longer to address and for which there are no simple remedies. Undergraduates and postgraduates need exposure to the excitement of clinical research and such experience must be recognised and encouraged by the local medical authorities. Research career structures need development. In the meantime, the MRC will continue to do its utmost to promote the training of local research scientists. MRC Laboratories (Jamaica), University of the West Indies, Mona, Kingston 7, Jamaica

G. R. SERJEANT

Qualifications and quality of

care

SIR,- Professor Pereira Gray (April 27, p 1025) addresses the issue of doctors’ qualifications and the quality of patient care. His article seems to have been sparked off by the decision of a commercial medical negligence insurer, the Medical Insurance Agency, to offer a discount to fellows and members of the Royal College of General Practitioners on the grounds that they are believed to be at lower risk of claims of medical negligence than those who are not members. The Medical Protection Society-a non-profit-making mutual organisation of doctors and dentists-has no evidence to support the assertion that general practitioners differ in risk on the basis of postgraduate qualifications. It is the society’s view that qualifications per se do not prevent specific criticisms of professional conduct or competence. How defensible any complaint or claim is depends on the standard of care provided by the doctor on a particular occasion. The society has a policy of charging differential membership subscriptions on the basis of risk. Thus, private practitioner members in the high-risk surgical specialties pay higher subscriptions than general practitioners. It might become necessary to charge a higher subscription to general practitioners who do certain surgical procedures, but, as a member of the council of the Medical Protection Society and chairman of its general practice advisory board, I note that there are at present no plans or intention to do so. Pereira Gray’s comparison of the subscription charged by the medical defence organisations and the Medical Insurance Agency in

respect of annual indemnity arrangements is somewhat misleading since the provision of indemnity for acts of medical negligence is only one of the many benefits of membership of the Medical Protection Society. Most of the society’s work on behalf of members involves advice and assistance with a wide range of other professional matters such as disciplinary hearings, inquests and fatal accident inquiries, ethical matters, General Medical Council proceedings, libel, health service commissioner and public inquiries, insurance report writing, criminal matters arising from medical practice, and courts martial. The Medical Protection Society and the Medical Insurance Agency also differ in respect of the basis for the provision of indemnity. Members of the former who are in benefit at the time of an incident can seek the Society’s assistance in the defence of any claim that may follow. In retirement, neither the member nor his or her estate will need to pay further subscriptions. The Medical Insurance Agency, on the other hand, offers a contract of insurance that is based on the need to have a valid policy in force on the date on which the claim is made. Thus, doctors who wish to maintain cover for incidents that have occurred but are, as yet, unknown, can purchase "run off" cover for, as the agency states, "a premium... ultimately reducing to 20% of the rates then applicable". Unfortunately, "ultimately", insofar as medical negligence litigation is concerned, can often mean decades because of the sometimes very long interval between the clinical event and the initiation of legal proceedings. Membership of the Medical Protection Society avoids the need to pay subscriptions well into retirement and beyond. Additionally, the society sets no upper limit on the indemnity for any one claim. In times of claims inflation, fixed levels of indemnity may prove to be insufficient to meet the costs of a practitioner’s liability, especially if the limit of cover includes both the defendant’s and plaintiffs legal costs. General practitioners are not immune from high claims. Grove Health Centre, London W12 8EJ, UK

WILLIAM MCN. STYLES

SIR,—Professor Pereira Gray indulges in the sport of navelgazing. As it has ever been since the beginning of the Royal College of General Practitioners, there are some excellent general practitioners who are not members and some awful ones who are. There are three criteria for avoiding litigation and disciplinary action: an ability to get on with people, conscientiousness, and luck. None are satisfactorily examined in the RCGP’s membership examination. My advice to the professor and the RCGP is: take the money and run, before the Medical Insurance Agency realises. "Vesey’s", Corpus Christi Lane, Godmanchester PE18 8HW, UK

Health

KEITH STEWART

professionals in NHS management

SIR,—The new business-style National Health Service health authorities represent a welcome return to consensus management but it is flawed by the lack of representation of the health professions. The authorities created by the NHS and Community Care Act have two features with profound implications for the way they will work and for the accountability of their members, especially the executive members. Furthermore, non-executive members are now paid; the concept of membership has thus changed from that of the more or less independent representative of some group or interest to that of an officer accountable to the health authority’s chairman. The only real difference between nonexecutive and executive members is the time they have available for health authority work. An equally profound change has befallen those senior officers (directors) who have become executive members. They have taken on corporate responsibility for the authority in its purchasing and, where applicable, direct management roles. They now have equal status with the general manager who thus reverts to the coordinator role that the administrator held in the old consensus management team. Nonetheless, the new-style health authority is not strictly a

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management team since the requirement for consensus all decisions has been replaced by majority decision making. That was how effective consensus management teams worked in former years except on rare matters of major principle when true consensus on

consensus was

required.

However, what at first sight looks like the rebirth of the old model be something else for the new consensus team is seriously flawed. The old consensus management teams were dominated by professionals-one or three doctors depending upon the tier and one nurse-on the principle that NHS management required to tap the knowledge and secure the commitment of the main groups of care providers. The administrator fulfilled an important coordinating role and the treasurer provided financial information and advice. Leadership often came from the professional members, usually one of the doctors. There appeared to be at least implicit recognition of what has long been recognised in German industry, for examplenamely, that those who are trained and experienced in the main business of the enterprise are best fitted to lead and manage it. Now top management may not necessarily include any representatives of those who deliver health services. Automatic representation of the medical and nursing professions in nonexecutive membership does not apply. Automatic executive membership is limited to the general manager and finance officer. The director of public health-the senior representative of the management arm of the medical profession and the chief advisor on what pattern and quantity of services the authority should provide-may or may not be an executive member. A potential improvement in health services management has thus been seriously undermined by deprofessionalisation. turns out to

membership

Department of

Public Health Medicine, Norwich Health Authority, St Andrew’s Hospital (North Side), Norwich NR7 0SS, UK

PAUL WALKER

Loss of communication skills after social isolation SIR,-I was obliged for personal reasons to spend six months in excellent rest home for old people. I had the opportunity to observe in several normal subjects what I would call an "isolation syndrome". These subjects only seldom, if at all, received visits from relatives or friends. Their behaviour seemed normal, but on closer observation their body movements and facial expressions were restrained, or even rigid, and never changed. When asked to choose their meals, they seemed to have some thought and speech inhibition, which sometimes gave the wrong impression of confusion, and was overcome only after a few minutes. Their answers were slow but normal, and expressed in a stenographic style, as short as possible. Then they relapsed into their former an

.

"dumb" attitude and were unable to make social contacts or to ask

spontaneously for help. However, after insisting on speaking to them for an appreciable time, I noted a gradual release of their body movements, facial expression, and speech, which after a few days became fluent and normal with respect to choice of words. This isolation syndrome does not seem specific for old age, but in my opinion could also be present in younger people without sufficient social contacts. Since this behaviour can sometimes simulate parkinsonian disorders or serious psychopathological conditions, it should be recognised by the simple use of prolonged conversation, to avoid the prescription of unnecessary drugs. Via Santa Croce 16, 12100

Cuneo, Italy

FRANCESCO FISCHER

Informed consent in clinical trials SIR,—The "less expensive options" for clinical trials in Eastern

Europe to which your correspondent Jane Feinmann refers (May 11, p 1154) should be looked at very carefully from the ethical point of view. Some countries do

not have ethical committees nor any tradition of informed consent in ordinary medical practice.

In 1989, a team of American psychiatrists visited the Soviet Union. Their report, with Soviet comments, has been published.1 They noted the absence of the idea of consent and of discussion of treatment between doctors and patients. The official Soviet1 reply to this was: "In Soviet medical practice in general, and not only in psychiatry, it is not customary to discuss with patients their method of treatment, except in cases where the patient is a physician. The question of how justified this is should, we believe, be a topic for forthcoming discussion. In this connection, the American experience is very interesting". The principle of informed consent is expressed in new proposals for Soviet mental health legislation, but this is very far from being implemented. However, I am assured that the position stated in the Soviet reply is a correct description of the present position. There would be considerable educational advantages arising from the introduction of clinical trials in the USSR, but only if such trials were accompanied by strict ethical considerations. Pharmaceutical companies should give a lead in these matters and not take advantage of new and cheap markets as yet unencumbered by ethical obstacles.

Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG, UK 1. Roth

J. L. T. BIRLEY

LH, Regier DA, Reshetov Y, Keith SJ. Report of the US delegation to assess changes in Soviet psychiatry and the Soviet response. Schizophr Bull 1989;

recent

15

(suppl):

1-218.

Medical kits

on

airliners

SIR,-Lancet correspondence has lately highlighted the difficulties facing doctors who try to assist sick airline passengers when they fmd aircraft medical equipment deficient. Our highly trained cabin crew are required to make a full report on every medical incident and the data are constantly reviewed and updated. Using the information and the comments of assisting doctors, we have recently introduced a new medical emergency kit in all our aircraft which contains augmented diagnostic equipment, first-aid supplies, and a range of 25 drugs, some of which can be given by the crew and others which are for use only by a doctor. The more important of these are carried in an emergency kit known as the M5, only to be opened with the captain’s permission. The major items it contains are: Equipment Sphygmomanometer and stethoscope Laerdal resuscitator/masks and airways Inflatable splints and dressings Tourniquets, catheters, obstetric packs Syringes, needles, scalpels, and sutures Injections (doctor’s use only) Nalbuphine, adrenaline, atropine, aminophylline, diazepam, digoxin, promethazine, hyoscine, metoclopromide, dexamethasone, glucagon, frusemide, sodium bicarbonate, isoprenaline, calcium chloride, dextrose, metaraminol, water. Oral drugs

(doctor’s use only) Buprenorphine, lorazepam, salbutamol, isosorbide dinitrate. Some of the oral

drugs and others, including antidiarrhoeals, antimalarials, antihypoglycaemics, and general antisymptomatics, are available in other emergency kits for use by trained cabin crew with or without the assistance of passenger nurses or doctors. Such equipment far exceeds the legal requirement and is inevitably demanding in space, weight, and financial provisions. However, such enhanced kits are invaluable in protecting the health of passengers whilst they are in our care, particularly when doctors, such as your correspondents, are altruistic enough to respond to requests for assistance. Health Services, British Airways, PO Box 10, Heathrow Airport,

Hounslow TW6 2JA, UK

D. M. DAVIES

Health professionals in NHS management.

1352 British support for Caribbean research SIR,-Your Round the World correspondent (March 16, p 667) paints an unjustifiably gloomy picture interspe...
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