NEWS US listens to its citizens on health The bioethics movement is now audible in over a third of the United States. Spurred by citizens' groups that formed in Oregon and New Jersey nearly a decade ago, the movement towards getting a consensus from ordinary people on values and ethical issues in health care is assuming more importance as health care reform reaches the consciousness of many more Americans. The feeling is that if people can understand the complexities of the current system and discuss their attitudes towards health care they may be able to influence legislative changes before it is too late. "The health decisions movement originated as a response to our nation's lack of a just and prudent health policy," says Dr Ralph Crawshaw, founder and project director of Oregon Health Decisions, the citizens' network that played a critical role in shaping the Oregon Health Plan. The plan is still awaiting approval-in the form of waivers of certain federal regulations-from the US government. Dr Crawshaw believes that the public has to reach a consensus over questions such as whether more public funds should be invested in curative medicine relative to health promotion. "The health decisions movement has undertaken the task of articulating grassroots health values through community meetings in pursuit of balanced People worry more about retaining dignity in hei health policy," he says. The various projects of the community worry more about retaining autonomy health decisions movement are based mostly and dignity in health care than about cost containment." One of the other main issues is on volunteers, community organisation skills, and foundation grants. "A paid staff whether health care is a basic human right member is a luxury; most projects are strug- regardless of people's ability to pay. Most gling financially," says Bruce Jennings, leaders in the health decisions movement executive director of the Hastings Center, a believe that citizens have already said yes. bioethics think tank. One of its key goals has been to educate the public on issues such as the allocation of resources, access to health Reasoned decisions needed Now comes the difficult part: thoughtful, care, use of expensive medical technology, reasoned decisions about rationing to replace and advance directives, such as living wills. This aspect of the projects' work took on current rationing ort the basis of ability to increased importance at the end of 1991, when pay. In 1989 Crawshaw wrote: "Neither the the National Patient Self-Determination Act public nor the individual practitioners wishes to learn how much sacrifice lies ahead in went into effect. The law states that workers in health care facilities must inform patients accepting that the infinite demand for health of their rights to refuse treatment and to have care has at last reached the limit of willing advance directives. A patient's medical supply." All of the projects are now sponsoring record must indicate whether an advance directive exists and the facility must comply hundreds of community meetings. Usually with it under state law. Community health educational videotapes are used to promote decisions projects with their trained discus- discussion of a few issues. Participants are sion leaders are proving to be very useful in asked to start assessing their own beliefs by "choosing" among competing health care educating staff and communities. According to Crawshaw and others, ad- alternatives. Volunteers may be asked to fill out a questionnaire that attempts to assess vance directives are the main concern of their values and opinions. many people. "Indeed," he says, "people
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According to Jennings, the projects "remain neutral on the controversial topics they bring before the public" and focus on helping participants of possibly diverse backgrounds search for common ground. "Typically, after about a year of small group meetings, the project convenes a statewide citizens' health care parliament where delegates adopt numerous resolutions," Jennings wrote in his 1988 report. "They are then widely disseminated in a final project report." Eventually, information on public opinion is conveyed to organisations and officials involved in health policy planning and health care delivery. In Orange County this resulted in the allocation of state funds to certain kinds of health care, such as prenatal care, rather than others. One problem is that few links have been made with minority and disadvantaged communities, which all projects are trying to correct. Does lack of input from these large groups invalidate the consensus reached by the rest of the population on health- care issues? Jennings thinks not. "If you look at the history of US social policy you see that change usually occurs only when the middle class becomes aware of a problem, not when 1131
Headlines Restricted use of breast implants: The US Food and Drug Administration has announced that it will restrict the use of silicone gel breast implants for purely cosmetic reasons but will permit implantation for women with breast cancer or who suffer traumatic injury or a congenital disorder. New RCS president: Professor Norman Browse will succeed Sir Terence English as president of the Royal College of Surgeons in July. Professor Browse qualified at St Bartholomew's Hospital Medical College in 1955 and has been professor of surgery at St Thomas's Hospital Medical College since 1981.
Australian health payment abolished: The new Australian prime minister, Paul Keating, has kept his pre-election promise and abolished the controversial Medicare copayment which required patients to pay $2.50 for every consultation. The payment was an attempt to reduce the cost of Medicare by $800m a year.
Fail in motorcycle deaths: In 1990, 659 motorcyclists were killed in British road accidents compared with 1700 in 1960. The Department of Transport reports that in 1990 there were 39 600 accidents in Great Britain involving motorcyclists, who are three times more likely to be killed or seriously injured than pedestrians. Malaria: stili a problem: Malaria is still present in more than 100 countries, with over two billion or 40% of the world's population at risk. There are epidemics in Ethiopia, Madagascar, and northern Sudan. The World Health Organisation plans to convene a ministerial conference on Malaria in Amsterdam in October.
Checking DNA fingerprints: The US National Academy of Sciences' National Research Council has recommended additional studies and measures to strengthen the statistical basis for comparisons ofDNA samples. More samples should be taken to reduce the possibility that ethnic subgroups in populations could distort the chances of finding random matches. Scottish infant death rate fails: The rate of 7-1 infant deaths per 1000 live births in Scotland in 1991 is the lowest recorded. This compares with a rate of 19-6 in 1970. The Scottish Office has also reported the lowest perinatal mortality rate in 1991, of 8-6 deaths per 1000 births.
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just the advocates of the underprivileged bring it out," he says. The latest advance in the community health decisions movement is a two year civic education programme called Condition Critical. Initially a collaboration between health decisions projects in California, New Jersey, and California and the Public Agenda Foundation and WGBH public television in Boston, the programme focuses on the availability, cost, quality, and priorities of health care in the US. Over two years, health decisions groups in the three states will organise hundreds of public meetings, using educational material from the Public Agenda Foundation and aided by extensive media campaigns. The programme was launched on 8 April with a two hour, public television programme featuring all kinds of experts discussing health care and financing, chaired by talk show host Phil Donahue. A studio audience was polled for its opinions. The show worked through a multitude of controversial topics; vignettes were shown to illustrate complex issues (such as the case of an 80 year old man with colon and lung cancer who had just undergone major surgery at the insistence of his family yet would probably never leave the recovery room); and Canada's national health care system was examined. "We're living in a democracy, but the citizen participatory aspect is something we've lost in this country," says Mary Strong, chairman of American Health Decisions and the Citizens' Committee on Biomedical Ethics, Inc in New Jersey. "For many people the feeling is 'whatever I want, I should have' instead of a sense of community, of sharing and caring for others. "Citizens must participate," she says, "because health care providers shouldn't be the gatekeepers. If citizens take a role and say what they want, it will help protect the doctor-patient relationship."-GAIL MCBRIDE, science writer, Chicago
Community health services undermanaged
Some districts spend twice as much per person on community health services as others, yet there is no logical relation between spending and numbers of elderly people or spending on hospital or primary care. Furthermore, no one knows how many individuals have contact with community health services, so units cannot tell whether they are overproviding services to some people while missing others. There is some evidence that they are doing both: a study from Birmingham cited in the report showed wide variations between nursing teams in the length of time patients remained on the caseload and showed that black clients received less care than white ones, and elderly women less than elderly men. The Audit Commission's main concern is that if community services are to meet the challenges of coping with rising numbers of very elderly people and of keeping people in their homes then they need to be much more actively managed. Managers need better information to enable them to assess the right mix of skills needed for caring for individuals. The report suggests that first line supervisors need more support and training and that budgets should be further devolved. Audit should become more widespread, together with a concern for quality assurance. On top of this, community services also need shared strategies with local authorities. For such collaboration to work the report says that the government has to create incentives to make authorities collaborate and devise ways of allowing them to share funds across their organisational boundaries. -JANE SMITH, BMJ
Homeward Bound: A New Course for Community Health is published by HMSO, price £8.50.
Change of emphasis on genome project James Watson, the codiscoverer of the double helix strucure of DNA, has resigned as director of the US human genome project. His departure saddened many researchers,
If all district nurses spent as much time with patients as those in the most well organised districts the community health services would gain the equivalent of an extra 400 district nurses. This statistic and its emphasis on productivity highlights one of the main messages of the Audit Commission's latest report-on community health services. Community health services (together with the elderly, disabled, and mentally ill people that they largely serve) have traditionally been the poor relations of the health service. A third of NHS expenditure is spent in the community, including that spent on primary care, but of this £7bn only £1 7bn goes on community services. As a result, the report argues, community health services have been undermanaged, and too little is known about the costs, outcomes, and quality of the services they provide. BMJ VOLUME 304
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who credit him with having guided the project through its difficult early days, but it opens the way for a change in emphasis. Watson's abdication from the Center for Human Genome Research at the National Institutes of Health (NIH) outside Washington, DC, stems from a decision by Dr Bernadine Healy, director of NIH, to investigate possible conflicts of interest arising from Watson's shareholdings in biotechnology companies. In fact, Watson, unlike many other molecular biologists, has not been a great scientific entrepreneur, and this is. the first time his affairs have ever been investigated. Insiders say that in any case the inquiry was just a pretext to unseat Watson. Medical bureaucrats at NIH could not cope with Watson's "scientific charisma" or style of leadership. He was scathing about NIH's plans to patent gene sequences (BM7, 4 April), about which he was not consulted, and opposed the techniques used to obtain the sequences. Watson gave as his reason for resigning the burden of running the genome project, which he has done part time since 1989, at the same time as heading the Cold Spring Harbor laboratory on Long Island, a job he has held since 1968. But he hinted at the underlying personality problems by saying that his resignation allowed Dr Healy "to appoint her own director for the project." Healy accepted Watson's resignation without a word of regret and has named Michael Guttesman, currently head of the Laboratory of Cell Biology at the National Cancer Institute, acting head of the human genome project. Paul Berg, a Nobel laureate like Watson and chair of the genome project's advisory committee, praised Watson's "single mindedness and doggedness." But he also welcomed the opening that Watson's departure signals. Watson violently opposed the cDNA technique for sequencing active genes, saying that there was little point in knowing the sequence of the genes if you didn't know what they did. That technique, however, has been enthusiastically adopted by all the other laboratories working in the human genome programme. Berg expects that, with Watson gone, the NIH's human genome project will become more tolerant of diverse approaches. -JEREMY CHERFAS, science writer, Bristol
AIDS conference shifts focus When the eighth international AIDS conference opens in Amsterdam on 19 July its programme will reflect a large input from the countries most affected. Already, 4875 abstracts and 7000 registrations have been received, well ahead of previous years. Abstracts from developing countries are up by 80%, and Dutch, American, and other Western sources are funding travel by representatives from the Third World. At least 10 000 participants are expected. Eastern Europe and developing countries are a special concern. "Social, political and economic changes increase vulnerability.
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Dutch poster advising: "To be safe, use a condom"
The situation is volatile and it's hard to give good numbers. There are HIV infections in drug users in Poland and Yugoslavia, in homosexuals in different eastern European countries, and in children, especially in Romania," said the chairman of the conference, Jonathan Mann, the head of Harvard AIDS Institute's International AIDS Center. "Because ofeconomic troubles we have seen a marked upswing in prostitution in eastern Europe in the last year or two. There's less money for education and prevention, causing worry about the blood supply because of the need for foreign capital to buy the test kits. At this conference eastern Europe has the opportunity to learn from other people and apply the information." "Eighty five per cent of the epidemic is in the developing world," Dr Mann said. "For the first time the international steering committee involved participants from these countries, people with HIV infection, and representatives of non-governmental organisations. In the past the committees were staffed entirely by the host country, but this year the Havard-Dutch foundation group make up only 25%." Other sponsors of the conference supported the new approach, including Dr Michael Merson of the World Health Organisation and Dr Paul Volberding, chairman of the International AIDS Society. The result is a programme that addresses such issues as the roles of breast feeding and oral sex in the transmission of HIV, alternative and traditional treatments, barriers to the acceptance of condoms, care for orphaned children, the economic impact on households, sex and drugs in prisons, national policies on travel by HIV positive people, notification of partners, and needle exchange programmes. A special effort has been made to reach women, with programmes on rape and transmission of HIV and the empowerment of women in heterosexual relationships. While the conference will have new input from the societies and nations most affected, it will not be a soft science meeting, Dr Mann asserted. "We already have as many scientific abstracts as the 1990 San Francisco meeting had. We are giving equal weight to scientific
and social aspects of HIV. We desperately need the products of science: treatments, a vaccine. But a vaccine won't end the problem. You still have to answer questions of how to deliver it and how to pay for it."-JANICE HOPKINS TANNE, contributing editor, New York
Australia limits overseas doctors On the back of a shrill debate on Australia's high level of immigration, ministers at a meeting last week turned their attention to the oversupply of doctors. The rate of general unemployment is about 10%, and the Australian Medical Association and medical academics have now spoken out for limiting the number of overseas doctors. The country has always been liberal about admitting doctors trained abroad-some 500 settled in 1990-1. It does, however, require most of them to undertake a rigorous examination before registering them to practise. But registration has always been a state matter, and there is no mechanism for planning the medical workforce on a national basis. Nevertheless, the willingness of immigrants to work in rural and outer metropolitan regions-often shunned by Australian graduates-has been a godsend to health planners and politicians. Now the overall imbalance has convinced the health planners in Canberra that the nation's 10 medical schools are producing more graduates than are needed. A draft national health strategy, released in March, proposed that the intake of medical students should be cut by 10% (about 1200 new doctors graduate each year) and that the number of doctors trained overseas who are allowed to sit the preregistration examination should be kept to 10% of the graduate output -that is, about 120 a year. Vice chancellors and deans of medicine have strongly attacked the proposed cut in the intake of medical students, predicting the 1133
closure of one or two medical schools and directing their ire at imnmigrant doctors, whom they accuse of being a "gold rush." The academics claimed that overseas recruitment had failed to address the shortage of doctors in rural areas as many of the immigrants "were working alongside their Australian counterparts in the metropolitan areas." Last month a conference of federal and state health ministers agreed to restrict the number of doctors trained overseas by changing the assessment procedures. A limit of about 200 foreign doctors entering the workforce each year was mentioned. This is an increase in the strategy report's proposal and indicates yet another compromise. A national workforce target of one doctor per 500 people will be adopted. The national health service strategy, which is being sent out for consultation and seems to have the support of the health minister, Brian Howe, also proposed several measures for boosting rural practice: * Financial incentives through increased rebates from the Medicare benefits schedule * Use of restricted and regional registration for new doctors, which would direct new graduates and doctors trained overseas to areas of need * Encouragement for pupils in country high schools to enter medical schools. -PETER POCKLEY, science writer, Sydney
some doctors make far more referrals than others," said Dr Fleming. "This problem is clearly not confined to the UK and probably reflects a deficiency in medical education." Of all Europeans Dutch patients have the most say in their GP's decision to refer them, according to the report. Only half of British and a third of Italian patients influence their doctors' decision to refer. Professor Denis Pereira Gray, honorary editor of the Royal College of General Practitioners' publications, says that this is more to do with the Dutch GPs than patients. "Dutch university departments of general practice put forward the idea of patient participation in consultation, and this is something we'd like to see happening more in the UK," he said. ALISON TONKS, BMJ
The European Study of Referrals From Primary to Secondary Care is available from the sales office, Royal College of General Practitioners, 14 Princes Gate, London SW7 IPU, price £7.50.
Strlcter measures needed to ban female circumcision
unit that campaigns on behalf of groups suffering discrimination and prejudice. This report, which updates the group's last publication on the subject in 1987, recommends that the World Health Organisation, Unicef, Unesco, and the United Nations Development Project should all allocate 0 5% of their expenditure until 2000 to programmes to combat female genital mutilation. In the UK the group calls on the Department of Health to educate people working in local authorities and social services departments about the practice. Guidelines defining the circumstances under which a child should be put on the at risk register for child abuse should be extended to include those girls at risk of genital mutilation. The report says that while an estimated population of 80 million girls and women in Africa have undergone some form of genital mutilation, the practice continues after people have migrated to other societies. "It is probable that mutilation of girls has been practised clandestinely on girls living and growing up in Europe and other Western countries, ever since African women moved there from areas where female sexual mutilation was practised." In France children have died as a result of operations performed clandestinely by traditional operators, the report claims. "In the Somali community in the UK, female genital mutilation is known to be practised." A spokesman for the Department ofHealth said that female circumcision is illegal in the UK under the Prohibition of Female Circumcision Act 1985. Yet the report says that families living in Western countries where it is difficult to get qualified doctors to perform the procedure may club together to pay for a traditional "circumciser" to come over from their country of origin, or parents may take their daughters to Africa or the Middle East during the summer holidays. -SHARON KINGMAN, freelance medical journalist, London
Female genital mutilation is a form of child abuse, not a harmless cultural practice, says a report from the Minority Rights Group. The document attacks the "culture of silence and indifference" that some health workers and schoolteachers have built up to avoid tackling the issue. It quotes a female consultant obstetrician and gynaecologist, based in London, who has delivered the babies of women who have been circumcised. This doctor, originally quoted in a national A report published this month by the Royal newspaper article, said: "To me... it is College of General Practitioners shows that horrific, but it is their culture and custom. patients in the UK wait longer to see a If that's the way the women want it, it's up specialist than patients almost anywhere else to them." Female Genital Mutilation: Proposals for Change is The Minority Rights Group is an inter- available from Minority Rights Group International, in Europe. In a study of referral practices in 15 European countries the UK was the worst national research, education, and information 379 Brixton Road, London SW9 7DE, price £3.95. in this respect. Once referred by a family practitioner, only 39% of patients in the UK see a specialist within four weeks compared with 98% in Hungary and 87% in Italy, the two highest ranking countries. British patients also face longer delays for surgery than other Europeans, with 40% still waiting for their operation three months after their hospital appointment. Only Portugal had longer delays. "Obviously our working patterns need to be examined," says Dr Douglas Fleming, national coordinator for the study. He said that the hospital outpatient system in the UK could be partly to blame for the delays and suggested that training juniors also contributed. Referral rates also vary widely in Europe, according to the report, which surveyed 1500 doctors and analysed 44 000 referrals. Family doctors in the Federal Republic of Germany refer 12 patients a week to specialists-twice as many as general practitioners in the UK, Switzerland, and Norway. France's average is only two. "We also found that within each country Female genital mutilation is still practised clandestinely in Europe
Britain has worst referral delays in Europe
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India gets money to fight AIDS India will receive $85m from the World Bank to supplement a $100m national AIDS control programme which started this month. The money will be spent over five years on HIV screening, improving the safety of blood products, and putting into operation the World Health Organisation's strategies for controlling HIV infection. The assistance follows the release of results from India's nationwide surveillance programme in 1991, which looked at the prevalence of HIV in over 1-2 million high risk people. About 7000 people were found to be infected with HIV and over 100 had AIDS. India has had a system of nationwide surveillance for people infected with HIV since 1985, when a study by the Indian Council of Medical Research identified the first cases, found among prostitutes. Further studies showed that HIV was being spread
US issues guidelines for health professionals on managing pain New guidelines from the US Department of Health and Human Services (DHHS) calls on health professionals to work with patients to create plans for individual pain control. According to the DHHS, pain should be frequently assessed during and after procedures, and aggressive efforts should be made to control it. Dr Louis Sullivan, the department's secretary, said, "We know that the most common way of dealing with painleaving orders that a patient be given intramuscular injections of opioid 'as needed'is insufficient for at least half the surgery patients." Dr Daniel Carr, an anaesthetist, who chaired the panel that drew up the guidelines, said that effective pain relief allowed patients to go home earlier after surgery. If they could cough and move about they were less likely to develop pneumonia and other complications. The guidelines note that neither doctors nor patients use sufficient pain relief, partly out of fear of drug addiction. Some states require that patients who take opioids should be registered, and some pharmacies do not like stocking such drugs. The panel suggests that opioid analgesics should be "the cornerstone for management of moderate to severe acute pain" rather than pethidine hydrochloride (often the drug of choice in the US) and gives the green light to drugs for self medication. The guidelines also cover nondrug techniques for relieving pain such as relaxation, hot and cold packs, and massage. The guidelines, which are not binding,
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AIDS in India is a predominantly heterosexual disease
have been tested in hospitals and clinics, and officials predict that they will influence professional standards. The department hopes that hospitals will organise formal programmes for evaluating their procedures for dealing with pain. The DHHS has issued other guidelines on treating urinary incontinence, and in the pipeline are guidelines on disorders of the prostate, cataracts, and sickle cell disease. New panels have begun work on mammography, congestive heart failure, and the treatment of HIV infection. In addition, many medical societies are working on more than 200 new guidelines. The health department hopes that guidelines will improve the quality of health care and cut costs, though the interdisciplinary pain management advocated in the pain management guideline is said to be time consuming and expensive. -GAIL McBRIDE, science writer, Chicago
Anaesthetics and antibiotics win Queen's awards Pharmaceutical companies are well represented in this year's Queen's awards for export and technology, which were announced last week. The manufacturers of cefuroxime axetil, the topical antibiotic mupirocin, and the intravenous anaesthetic agent propofol have all been given Queen's awards for technological achievement. Cefuroxime axetil is an oral cephalosporin, a prodrug of cefuroxime, that, according to its manufacturer, Glaxo, has grossed over £500m in worldwide sales since 1987. It is
predominantly through heterosexual activity and by intravenous drug users. In Bombay the proportion of prostitutes infected with the virus rose dramatically from less than 1% in 1986 to one in five in 1990. In some parts of the city 70% of prostitutes were found to be infected. Bombay has the highest number of recorded cases, followed by Madras and Manipur. Under Prime Minister Narasimha Rao the government set up regional AIDS management centres, which offer blood tests, educate the public about the transmission of HIV, and try to alleviate the economic effects of HIV infection. Its 1989 AIDS Prevention Bill, however, has been criticised for going too far. Critics complained that people were harassed to have blood tests, doctors were forced to disclose the names of patients infected with HIV, and people who were found to be positive for the antibody were put in isolation. After complaints from human rights organisations the government has withdrawn the bill for amendments.-ZAKA IMAM, medical writer, Lucknow
marketed as a drug that general practitioners can use against bacterial infections in the community. Professor David Speller, president of the British Society for Antimicrobial Chemo! therapy, has mixed feelings about cefuroxime axetil. "It's an innovative antibiotic," he said, "and it may have a limited place in general practice. But there is still controversy about the reliability of its absorption and like all oral cephalosporins it tends to promote superinfection with micro-organisms like candida." SmithKline Beecham, the manufacturer of the topical antibiotic mupirocin (Bactroban), also won an award for technology last year for the thrombolytic agent anistreplase (Eminase). It launched mupirocin in 1985, and, according to Professor Speller, the drug is useful for eradicating Gram positive cocci from superficial sites such as infected eczema and leg ulcers. "It is a unique compound and the best thing we have for getting rid of methicillin resistant staphylococci from carriers," he said. ICI has been given an award for developing the intravenous anaesthetic agent propofol (Diprivan)-its fifteenth award since 1965. According to ICI, sales exceeded £l00m last year and demand has led to a new manufacturing plant being opened in Italy. "There is no doubt that propofol represents a major advance in intravenous induction agents," said Professor Graham Smith, editor of the British Joumnal of Anaesthesia and professor ofanaesthesia at the University of Leicester. "A major advantage is the speed of recovery associated with it, which makes it eminently suitable for use in day case anaesthesia." ICI is also marketing the drug as an intravenous sedative for use in intensive care units. "This technique is still undergoing evaluation," said Professor Smith, "but it looks promising."-ALISON TONKS, BMJ 1135
Letter from Westminster
New ministers The new ministers at the Department of Health, having been allocated their duties by Virginia Bottomley, the secretary of state for health (p 1183), have the look of a team that is marching in step with the NHS as it enters the post-reform period. It is a time for consolidation rather than controversy and for flair rather than flamboyance. Mrs Bottomley has brought together three men and one woman who she hopes will meet these requirements. The message from Richmond House is for the NHS to take pride in its achievements and to inspire an uplift in morale. In their various ways they are streetwise in the caring services. I described Mrs Bottomley's qualifications on 18 April (p 1004), though it is now appropriate to add her relevant field experience as a psychiatric social worker. Coming in as her deputy and minister for health is Dr Brian Mawhinney, who has a doctorate in radiation biology and is a former senior lecturer in medical physics at the Royal Free Hospital School of Medicine. Dr Mawhinney, who is 51 and has been MP for Peterborough since 1979, has a pivotal role in the new team, having been delegated responsibility not only for community care, the NHS reforms, and general medical services but also for 14 other functions including the government's health strategy.
The department has also acquired
one
extra minister, with three juniors instead of two. The additional parliamentary secretary,
Tim Yeo, who is 47 and a Suffolk MP, is a doctor's son who brings experience as a former director of the Spastics Society, and a former member of the Commons health committee. His extra hand at the Department of Health will be turned towards the social services and community care. Combined with responsibility for the mentally ill and the health aspects of homelessness. In terms of ministerial attention, community care will make more demands in the coming year than the NHS reforms, which have been initially trouble free. The aim is to keep the pace of reform at about its current rate, though as the creation of new NHS trusts and fundholding general practices becomes led by demand and more district authorities want to merge into purchasing consortiums the pace may be forced. The ministerial team is completed with the arrival from the whips' office of Tom Sackville, who is 41, has been MP for Bolton West since 1983, and is a son of Earl de la Warr. He will be responsible mainly for the acute services and the patient's charter. Baroness Cumberlege is health minister in the Lords, with departmental responsibility for women's health and nursing as well as ethnic issues, AIDS, and environmental health. Lady Cumberlege was recently chairman of the South West Thames health
If there is a weakness about the new health team it may be that it lacks weight in the higher reaches of the government compared with, say, the days of Clarke and Mellor. The gentle touch that suits the NHS also suits the Treasury, though for different reasons. This autumn's spending round could be a nervous time. With the new ministers comes a new administrative hierarchy. Graham Hart has taken over as permanent secretary at the department, with Yvonne Moores as chief nursing officer -both come from the Scottish Home and Health Department, as did Dr Kenneth Calman, the chief medical officer,
The
six months earlier. Back in Scotland, meanwhile, the new health minister at the Scottish Office is Lord Fraser, formerly lord advocate, who replaces Michael Forsyth (now at the Department of Employment) in a move presumed to make health issues also less confrontational north of the border. So many new knees under desks would normally carry the risk of change for the sake of change. The incoming regime at Richmond House is likely to resist the temptation. The post-election mood is for continuity ofpolicy. By temperament that is what the new ministers look likely to deliver. -JOHN WARDEN, parliamentary correspondent, BMJ
Week
A leg up for science? One outcome of the general election seems to have slipped by almost unnoticed. For the first time since the 1950s, when Lord Hailsham performed the role, Britain now has a cabinet minister responsible for science. Even more important, perhaps, the job of coordinating science activities has been given to a new Office of Science and Technology. The office will be headed by the government's chief scientist, Professor William Stewart. And the cabinet minister? William Waldegrave. The lowly position that science occupies in Britain's consciousness probably explains why few people seem to know about this change. The political pundits have been much more taken with the new Ministry of Heritage (which means soccer and theme parks rather than Newton and Faraday) and with William Waldegrave's other main responsibility for the Citizen's Charter. The Chancellor of the Duchy of Lancaster-William Waldegrave's official cabinet position-is one of those arcane positions so beloved of the British establishment that confuse the natives and puzzle foreigners. Essentially it means whatever the prime minister of the time wants it to mean. Last time round it was occupied by Chris Patten, who was really chairman of the Conservative party. This time, as well as covering science and the Citizen's Charter, William Waldegrave is also minister for the civil service. Though it appears an odd ragbag, there is in fact some logic to the portfolio. The Office of Science and Technology will sit within the Cabinet Office, already the site of the office of the minister for the civil service and the Citizen's Charter unit. There it will combine the chief scientist's office with the former science branch of the Department of Education and Science
(to be renamed Department of Education). It will be responsible for the science budget and for the five research councils, together with the Advisory Committee on Science and Technology (ACOST) and the Advisory Board for the Research Councils. Research funding for the universities, however, will remain at the Department of Education. One puzzle is why the government had decided to create this new responsibility: a minister ofcabinet rank was a promise in the Labour party's manifesto, not the Conservative's. According to the Cabinet Office, the aim is to bring together an issue that cuts across several departmental boundaries, and the prime minister is said to have an interest in science. Scientists have cautiously welcomed the changes, though they would have preferred a minister whose only brief was science. And Save British Science, which argues that British science needs a further £400m of government funding, has welcomed William Waldegrave's appointment. Although he's not a scientist, he is a fellow of All Souls, and his junior minister, Robert Jackson, was formerly responsible for science at the Department of Education. Many hope too that the new office may strengthen the hand of the chief scientist. What else may be read into the new arrangements? Britain now has a proper minister to represent science in Europe, to match other European ministers of science of cabinet rank. The appointment may too be a sign that the government wants to heal the wounds with a sector of society that has felt badly bruised over the past few years. Nevertheless, it will take more than just a minister with a bright mind and a pleasing manner to stem the decline in British science. HART
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According to Jennings, the projects "remain neutral on the controversial topics they bring before the public" and focus on helping participants of possibly diverse backgrounds search for common ground. "Typically, after about a year of small group meetings, the project convenes a statewide citizens' health care parliament where delegates adopt numerous resolutions," Jennings wrote in his 1988 report. "They are then widely disseminated in a final project report." Eventually, information on public opinion is conveyed to organisations and officials involved in health policy planning and health care delivery. In Orange County this resulted in the allocation of state funds to certain kinds of health care, such as prenatal care, rather than others. One problem is that few links have been made with minority and disadvantaged communities, which all projects are trying to correct. Does lack of input from these large groups invalidate the consensus reached by the rest of the population on health- care issues? Jennings thinks not. "If you look at the history of US social policy you see that change usually occurs only when the middle class becomes aware of a problem, not when 1131
Headlines Restricted use of breast implants: The US Food and Drug Administration has announced that it will restrict the use of silicone gel breast implants for purely cosmetic reasons but will permit implantation for women with breast cancer or who suffer traumatic injury or a congenital disorder. New RCS president: Professor Norman Browse will succeed Sir Terence English as president of the Royal College of Surgeons in July. Professor Browse qualified at St Bartholomew's Hospital Medical College in 1955 and has been professor of surgery at St Thomas's Hospital Medical College since 1981.
Australian health payment abolished: The new Australian prime minister, Paul Keating, has kept his pre-election promise and abolished the controversial Medicare copayment which required patients to pay $2.50 for every consultation. The payment was an attempt to reduce the cost of Medicare by $800m a year.
Fail in motorcycle deaths: In 1990, 659 motorcyclists were killed in British road accidents compared with 1700 in 1960. The Department of Transport reports that in 1990 there were 39 600 accidents in Great Britain involving motorcyclists, who are three times more likely to be killed or seriously injured than pedestrians. Malaria: stili a problem: Malaria is still present in more than 100 countries, with over two billion or 40% of the world's population at risk. There are epidemics in Ethiopia, Madagascar, and northern Sudan. The World Health Organisation plans to convene a ministerial conference on Malaria in Amsterdam in October.
Checking DNA fingerprints: The US National Academy of Sciences' National Research Council has recommended additional studies and measures to strengthen the statistical basis for comparisons ofDNA samples. More samples should be taken to reduce the possibility that ethnic subgroups in populations could distort the chances of finding random matches. Scottish infant death rate fails: The rate of 7-1 infant deaths per 1000 live births in Scotland in 1991 is the lowest recorded. This compares with a rate of 19-6 in 1970. The Scottish Office has also reported the lowest perinatal mortality rate in 1991, of 8-6 deaths per 1000 births.
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just the advocates of the underprivileged bring it out," he says. The latest advance in the community health decisions movement is a two year civic education programme called Condition Critical. Initially a collaboration between health decisions projects in California, New Jersey, and California and the Public Agenda Foundation and WGBH public television in Boston, the programme focuses on the availability, cost, quality, and priorities of health care in the US. Over two years, health decisions groups in the three states will organise hundreds of public meetings, using educational material from the Public Agenda Foundation and aided by extensive media campaigns. The programme was launched on 8 April with a two hour, public television programme featuring all kinds of experts discussing health care and financing, chaired by talk show host Phil Donahue. A studio audience was polled for its opinions. The show worked through a multitude of controversial topics; vignettes were shown to illustrate complex issues (such as the case of an 80 year old man with colon and lung cancer who had just undergone major surgery at the insistence of his family yet would probably never leave the recovery room); and Canada's national health care system was examined. "We're living in a democracy, but the citizen participatory aspect is something we've lost in this country," says Mary Strong, chairman of American Health Decisions and the Citizens' Committee on Biomedical Ethics, Inc in New Jersey. "For many people the feeling is 'whatever I want, I should have' instead of a sense of community, of sharing and caring for others. "Citizens must participate," she says, "because health care providers shouldn't be the gatekeepers. If citizens take a role and say what they want, it will help protect the doctor-patient relationship."-GAIL MCBRIDE, science writer, Chicago
Community health services undermanaged
Some districts spend twice as much per person on community health services as others, yet there is no logical relation between spending and numbers of elderly people or spending on hospital or primary care. Furthermore, no one knows how many individuals have contact with community health services, so units cannot tell whether they are overproviding services to some people while missing others. There is some evidence that they are doing both: a study from Birmingham cited in the report showed wide variations between nursing teams in the length of time patients remained on the caseload and showed that black clients received less care than white ones, and elderly women less than elderly men. The Audit Commission's main concern is that if community services are to meet the challenges of coping with rising numbers of very elderly people and of keeping people in their homes then they need to be much more actively managed. Managers need better information to enable them to assess the right mix of skills needed for caring for individuals. The report suggests that first line supervisors need more support and training and that budgets should be further devolved. Audit should become more widespread, together with a concern for quality assurance. On top of this, community services also need shared strategies with local authorities. For such collaboration to work the report says that the government has to create incentives to make authorities collaborate and devise ways of allowing them to share funds across their organisational boundaries. -JANE SMITH, BMJ
Homeward Bound: A New Course for Community Health is published by HMSO, price £8.50.
Change of emphasis on genome project James Watson, the codiscoverer of the double helix strucure of DNA, has resigned as director of the US human genome project. His departure saddened many researchers,
If all district nurses spent as much time with patients as those in the most well organised districts the community health services would gain the equivalent of an extra 400 district nurses. This statistic and its emphasis on productivity highlights one of the main messages of the Audit Commission's latest report-on community health services. Community health services (together with the elderly, disabled, and mentally ill people that they largely serve) have traditionally been the poor relations of the health service. A third of NHS expenditure is spent in the community, including that spent on primary care, but of this £7bn only £1 7bn goes on community services. As a result, the report argues, community health services have been undermanaged, and too little is known about the costs, outcomes, and quality of the services they provide. BMJ VOLUME 304
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who credit him with having guided the project through its difficult early days, but it opens the way for a change in emphasis. Watson's abdication from the Center for Human Genome Research at the National Institutes of Health (NIH) outside Washington, DC, stems from a decision by Dr Bernadine Healy, director of NIH, to investigate possible conflicts of interest arising from Watson's shareholdings in biotechnology companies. In fact, Watson, unlike many other molecular biologists, has not been a great scientific entrepreneur, and this is. the first time his affairs have ever been investigated. Insiders say that in any case the inquiry was just a pretext to unseat Watson. Medical bureaucrats at NIH could not cope with Watson's "scientific charisma" or style of leadership. He was scathing about NIH's plans to patent gene sequences (BM7, 4 April), about which he was not consulted, and opposed the techniques used to obtain the sequences. Watson gave as his reason for resigning the burden of running the genome project, which he has done part time since 1989, at the same time as heading the Cold Spring Harbor laboratory on Long Island, a job he has held since 1968. But he hinted at the underlying personality problems by saying that his resignation allowed Dr Healy "to appoint her own director for the project." Healy accepted Watson's resignation without a word of regret and has named Michael Guttesman, currently head of the Laboratory of Cell Biology at the National Cancer Institute, acting head of the human genome project. Paul Berg, a Nobel laureate like Watson and chair of the genome project's advisory committee, praised Watson's "single mindedness and doggedness." But he also welcomed the opening that Watson's departure signals. Watson violently opposed the cDNA technique for sequencing active genes, saying that there was little point in knowing the sequence of the genes if you didn't know what they did. That technique, however, has been enthusiastically adopted by all the other laboratories working in the human genome programme. Berg expects that, with Watson gone, the NIH's human genome project will become more tolerant of diverse approaches. -JEREMY CHERFAS, science writer, Bristol
AIDS conference shifts focus When the eighth international AIDS conference opens in Amsterdam on 19 July its programme will reflect a large input from the countries most affected. Already, 4875 abstracts and 7000 registrations have been received, well ahead of previous years. Abstracts from developing countries are up by 80%, and Dutch, American, and other Western sources are funding travel by representatives from the Third World. At least 10 000 participants are expected. Eastern Europe and developing countries are a special concern. "Social, political and economic changes increase vulnerability.
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Dutch poster advising: "To be safe, use a condom"
The situation is volatile and it's hard to give good numbers. There are HIV infections in drug users in Poland and Yugoslavia, in homosexuals in different eastern European countries, and in children, especially in Romania," said the chairman of the conference, Jonathan Mann, the head of Harvard AIDS Institute's International AIDS Center. "Because ofeconomic troubles we have seen a marked upswing in prostitution in eastern Europe in the last year or two. There's less money for education and prevention, causing worry about the blood supply because of the need for foreign capital to buy the test kits. At this conference eastern Europe has the opportunity to learn from other people and apply the information." "Eighty five per cent of the epidemic is in the developing world," Dr Mann said. "For the first time the international steering committee involved participants from these countries, people with HIV infection, and representatives of non-governmental organisations. In the past the committees were staffed entirely by the host country, but this year the Havard-Dutch foundation group make up only 25%." Other sponsors of the conference supported the new approach, including Dr Michael Merson of the World Health Organisation and Dr Paul Volberding, chairman of the International AIDS Society. The result is a programme that addresses such issues as the roles of breast feeding and oral sex in the transmission of HIV, alternative and traditional treatments, barriers to the acceptance of condoms, care for orphaned children, the economic impact on households, sex and drugs in prisons, national policies on travel by HIV positive people, notification of partners, and needle exchange programmes. A special effort has been made to reach women, with programmes on rape and transmission of HIV and the empowerment of women in heterosexual relationships. While the conference will have new input from the societies and nations most affected, it will not be a soft science meeting, Dr Mann asserted. "We already have as many scientific abstracts as the 1990 San Francisco meeting had. We are giving equal weight to scientific
and social aspects of HIV. We desperately need the products of science: treatments, a vaccine. But a vaccine won't end the problem. You still have to answer questions of how to deliver it and how to pay for it."-JANICE HOPKINS TANNE, contributing editor, New York
Australia limits overseas doctors On the back of a shrill debate on Australia's high level of immigration, ministers at a meeting last week turned their attention to the oversupply of doctors. The rate of general unemployment is about 10%, and the Australian Medical Association and medical academics have now spoken out for limiting the number of overseas doctors. The country has always been liberal about admitting doctors trained abroad-some 500 settled in 1990-1. It does, however, require most of them to undertake a rigorous examination before registering them to practise. But registration has always been a state matter, and there is no mechanism for planning the medical workforce on a national basis. Nevertheless, the willingness of immigrants to work in rural and outer metropolitan regions-often shunned by Australian graduates-has been a godsend to health planners and politicians. Now the overall imbalance has convinced the health planners in Canberra that the nation's 10 medical schools are producing more graduates than are needed. A draft national health strategy, released in March, proposed that the intake of medical students should be cut by 10% (about 1200 new doctors graduate each year) and that the number of doctors trained overseas who are allowed to sit the preregistration examination should be kept to 10% of the graduate output -that is, about 120 a year. Vice chancellors and deans of medicine have strongly attacked the proposed cut in the intake of medical students, predicting the 1133
closure of one or two medical schools and directing their ire at imnmigrant doctors, whom they accuse of being a "gold rush." The academics claimed that overseas recruitment had failed to address the shortage of doctors in rural areas as many of the immigrants "were working alongside their Australian counterparts in the metropolitan areas." Last month a conference of federal and state health ministers agreed to restrict the number of doctors trained overseas by changing the assessment procedures. A limit of about 200 foreign doctors entering the workforce each year was mentioned. This is an increase in the strategy report's proposal and indicates yet another compromise. A national workforce target of one doctor per 500 people will be adopted. The national health service strategy, which is being sent out for consultation and seems to have the support of the health minister, Brian Howe, also proposed several measures for boosting rural practice: * Financial incentives through increased rebates from the Medicare benefits schedule * Use of restricted and regional registration for new doctors, which would direct new graduates and doctors trained overseas to areas of need * Encouragement for pupils in country high schools to enter medical schools. -PETER POCKLEY, science writer, Sydney
some doctors make far more referrals than others," said Dr Fleming. "This problem is clearly not confined to the UK and probably reflects a deficiency in medical education." Of all Europeans Dutch patients have the most say in their GP's decision to refer them, according to the report. Only half of British and a third of Italian patients influence their doctors' decision to refer. Professor Denis Pereira Gray, honorary editor of the Royal College of General Practitioners' publications, says that this is more to do with the Dutch GPs than patients. "Dutch university departments of general practice put forward the idea of patient participation in consultation, and this is something we'd like to see happening more in the UK," he said. ALISON TONKS, BMJ
The European Study of Referrals From Primary to Secondary Care is available from the sales office, Royal College of General Practitioners, 14 Princes Gate, London SW7 IPU, price £7.50.
Strlcter measures needed to ban female circumcision
unit that campaigns on behalf of groups suffering discrimination and prejudice. This report, which updates the group's last publication on the subject in 1987, recommends that the World Health Organisation, Unicef, Unesco, and the United Nations Development Project should all allocate 0 5% of their expenditure until 2000 to programmes to combat female genital mutilation. In the UK the group calls on the Department of Health to educate people working in local authorities and social services departments about the practice. Guidelines defining the circumstances under which a child should be put on the at risk register for child abuse should be extended to include those girls at risk of genital mutilation. The report says that while an estimated population of 80 million girls and women in Africa have undergone some form of genital mutilation, the practice continues after people have migrated to other societies. "It is probable that mutilation of girls has been practised clandestinely on girls living and growing up in Europe and other Western countries, ever since African women moved there from areas where female sexual mutilation was practised." In France children have died as a result of operations performed clandestinely by traditional operators, the report claims. "In the Somali community in the UK, female genital mutilation is known to be practised." A spokesman for the Department ofHealth said that female circumcision is illegal in the UK under the Prohibition of Female Circumcision Act 1985. Yet the report says that families living in Western countries where it is difficult to get qualified doctors to perform the procedure may club together to pay for a traditional "circumciser" to come over from their country of origin, or parents may take their daughters to Africa or the Middle East during the summer holidays. -SHARON KINGMAN, freelance medical journalist, London
Female genital mutilation is a form of child abuse, not a harmless cultural practice, says a report from the Minority Rights Group. The document attacks the "culture of silence and indifference" that some health workers and schoolteachers have built up to avoid tackling the issue. It quotes a female consultant obstetrician and gynaecologist, based in London, who has delivered the babies of women who have been circumcised. This doctor, originally quoted in a national A report published this month by the Royal newspaper article, said: "To me... it is College of General Practitioners shows that horrific, but it is their culture and custom. patients in the UK wait longer to see a If that's the way the women want it, it's up specialist than patients almost anywhere else to them." Female Genital Mutilation: Proposals for Change is The Minority Rights Group is an inter- available from Minority Rights Group International, in Europe. In a study of referral practices in 15 European countries the UK was the worst national research, education, and information 379 Brixton Road, London SW9 7DE, price £3.95. in this respect. Once referred by a family practitioner, only 39% of patients in the UK see a specialist within four weeks compared with 98% in Hungary and 87% in Italy, the two highest ranking countries. British patients also face longer delays for surgery than other Europeans, with 40% still waiting for their operation three months after their hospital appointment. Only Portugal had longer delays. "Obviously our working patterns need to be examined," says Dr Douglas Fleming, national coordinator for the study. He said that the hospital outpatient system in the UK could be partly to blame for the delays and suggested that training juniors also contributed. Referral rates also vary widely in Europe, according to the report, which surveyed 1500 doctors and analysed 44 000 referrals. Family doctors in the Federal Republic of Germany refer 12 patients a week to specialists-twice as many as general practitioners in the UK, Switzerland, and Norway. France's average is only two. "We also found that within each country Female genital mutilation is still practised clandestinely in Europe
Britain has worst referral delays in Europe
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India gets money to fight AIDS India will receive $85m from the World Bank to supplement a $100m national AIDS control programme which started this month. The money will be spent over five years on HIV screening, improving the safety of blood products, and putting into operation the World Health Organisation's strategies for controlling HIV infection. The assistance follows the release of results from India's nationwide surveillance programme in 1991, which looked at the prevalence of HIV in over 1-2 million high risk people. About 7000 people were found to be infected with HIV and over 100 had AIDS. India has had a system of nationwide surveillance for people infected with HIV since 1985, when a study by the Indian Council of Medical Research identified the first cases, found among prostitutes. Further studies showed that HIV was being spread
US issues guidelines for health professionals on managing pain New guidelines from the US Department of Health and Human Services (DHHS) calls on health professionals to work with patients to create plans for individual pain control. According to the DHHS, pain should be frequently assessed during and after procedures, and aggressive efforts should be made to control it. Dr Louis Sullivan, the department's secretary, said, "We know that the most common way of dealing with painleaving orders that a patient be given intramuscular injections of opioid 'as needed'is insufficient for at least half the surgery patients." Dr Daniel Carr, an anaesthetist, who chaired the panel that drew up the guidelines, said that effective pain relief allowed patients to go home earlier after surgery. If they could cough and move about they were less likely to develop pneumonia and other complications. The guidelines note that neither doctors nor patients use sufficient pain relief, partly out of fear of drug addiction. Some states require that patients who take opioids should be registered, and some pharmacies do not like stocking such drugs. The panel suggests that opioid analgesics should be "the cornerstone for management of moderate to severe acute pain" rather than pethidine hydrochloride (often the drug of choice in the US) and gives the green light to drugs for self medication. The guidelines also cover nondrug techniques for relieving pain such as relaxation, hot and cold packs, and massage. The guidelines, which are not binding,
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AIDS in India is a predominantly heterosexual disease
have been tested in hospitals and clinics, and officials predict that they will influence professional standards. The department hopes that hospitals will organise formal programmes for evaluating their procedures for dealing with pain. The DHHS has issued other guidelines on treating urinary incontinence, and in the pipeline are guidelines on disorders of the prostate, cataracts, and sickle cell disease. New panels have begun work on mammography, congestive heart failure, and the treatment of HIV infection. In addition, many medical societies are working on more than 200 new guidelines. The health department hopes that guidelines will improve the quality of health care and cut costs, though the interdisciplinary pain management advocated in the pain management guideline is said to be time consuming and expensive. -GAIL McBRIDE, science writer, Chicago
Anaesthetics and antibiotics win Queen's awards Pharmaceutical companies are well represented in this year's Queen's awards for export and technology, which were announced last week. The manufacturers of cefuroxime axetil, the topical antibiotic mupirocin, and the intravenous anaesthetic agent propofol have all been given Queen's awards for technological achievement. Cefuroxime axetil is an oral cephalosporin, a prodrug of cefuroxime, that, according to its manufacturer, Glaxo, has grossed over £500m in worldwide sales since 1987. It is
predominantly through heterosexual activity and by intravenous drug users. In Bombay the proportion of prostitutes infected with the virus rose dramatically from less than 1% in 1986 to one in five in 1990. In some parts of the city 70% of prostitutes were found to be infected. Bombay has the highest number of recorded cases, followed by Madras and Manipur. Under Prime Minister Narasimha Rao the government set up regional AIDS management centres, which offer blood tests, educate the public about the transmission of HIV, and try to alleviate the economic effects of HIV infection. Its 1989 AIDS Prevention Bill, however, has been criticised for going too far. Critics complained that people were harassed to have blood tests, doctors were forced to disclose the names of patients infected with HIV, and people who were found to be positive for the antibody were put in isolation. After complaints from human rights organisations the government has withdrawn the bill for amendments.-ZAKA IMAM, medical writer, Lucknow
marketed as a drug that general practitioners can use against bacterial infections in the community. Professor David Speller, president of the British Society for Antimicrobial Chemo! therapy, has mixed feelings about cefuroxime axetil. "It's an innovative antibiotic," he said, "and it may have a limited place in general practice. But there is still controversy about the reliability of its absorption and like all oral cephalosporins it tends to promote superinfection with micro-organisms like candida." SmithKline Beecham, the manufacturer of the topical antibiotic mupirocin (Bactroban), also won an award for technology last year for the thrombolytic agent anistreplase (Eminase). It launched mupirocin in 1985, and, according to Professor Speller, the drug is useful for eradicating Gram positive cocci from superficial sites such as infected eczema and leg ulcers. "It is a unique compound and the best thing we have for getting rid of methicillin resistant staphylococci from carriers," he said. ICI has been given an award for developing the intravenous anaesthetic agent propofol (Diprivan)-its fifteenth award since 1965. According to ICI, sales exceeded £l00m last year and demand has led to a new manufacturing plant being opened in Italy. "There is no doubt that propofol represents a major advance in intravenous induction agents," said Professor Graham Smith, editor of the British Joumnal of Anaesthesia and professor ofanaesthesia at the University of Leicester. "A major advantage is the speed of recovery associated with it, which makes it eminently suitable for use in day case anaesthesia." ICI is also marketing the drug as an intravenous sedative for use in intensive care units. "This technique is still undergoing evaluation," said Professor Smith, "but it looks promising."-ALISON TONKS, BMJ 1135
Letter from Westminster
New ministers The new ministers at the Department of Health, having been allocated their duties by Virginia Bottomley, the secretary of state for health (p 1183), have the look of a team that is marching in step with the NHS as it enters the post-reform period. It is a time for consolidation rather than controversy and for flair rather than flamboyance. Mrs Bottomley has brought together three men and one woman who she hopes will meet these requirements. The message from Richmond House is for the NHS to take pride in its achievements and to inspire an uplift in morale. In their various ways they are streetwise in the caring services. I described Mrs Bottomley's qualifications on 18 April (p 1004), though it is now appropriate to add her relevant field experience as a psychiatric social worker. Coming in as her deputy and minister for health is Dr Brian Mawhinney, who has a doctorate in radiation biology and is a former senior lecturer in medical physics at the Royal Free Hospital School of Medicine. Dr Mawhinney, who is 51 and has been MP for Peterborough since 1979, has a pivotal role in the new team, having been delegated responsibility not only for community care, the NHS reforms, and general medical services but also for 14 other functions including the government's health strategy.
The department has also acquired
one
extra minister, with three juniors instead of two. The additional parliamentary secretary,
Tim Yeo, who is 47 and a Suffolk MP, is a doctor's son who brings experience as a former director of the Spastics Society, and a former member of the Commons health committee. His extra hand at the Department of Health will be turned towards the social services and community care. Combined with responsibility for the mentally ill and the health aspects of homelessness. In terms of ministerial attention, community care will make more demands in the coming year than the NHS reforms, which have been initially trouble free. The aim is to keep the pace of reform at about its current rate, though as the creation of new NHS trusts and fundholding general practices becomes led by demand and more district authorities want to merge into purchasing consortiums the pace may be forced. The ministerial team is completed with the arrival from the whips' office of Tom Sackville, who is 41, has been MP for Bolton West since 1983, and is a son of Earl de la Warr. He will be responsible mainly for the acute services and the patient's charter. Baroness Cumberlege is health minister in the Lords, with departmental responsibility for women's health and nursing as well as ethnic issues, AIDS, and environmental health. Lady Cumberlege was recently chairman of the South West Thames health
If there is a weakness about the new health team it may be that it lacks weight in the higher reaches of the government compared with, say, the days of Clarke and Mellor. The gentle touch that suits the NHS also suits the Treasury, though for different reasons. This autumn's spending round could be a nervous time. With the new ministers comes a new administrative hierarchy. Graham Hart has taken over as permanent secretary at the department, with Yvonne Moores as chief nursing officer -both come from the Scottish Home and Health Department, as did Dr Kenneth Calman, the chief medical officer,
The
six months earlier. Back in Scotland, meanwhile, the new health minister at the Scottish Office is Lord Fraser, formerly lord advocate, who replaces Michael Forsyth (now at the Department of Employment) in a move presumed to make health issues also less confrontational north of the border. So many new knees under desks would normally carry the risk of change for the sake of change. The incoming regime at Richmond House is likely to resist the temptation. The post-election mood is for continuity ofpolicy. By temperament that is what the new ministers look likely to deliver. -JOHN WARDEN, parliamentary correspondent, BMJ
Week
A leg up for science? One outcome of the general election seems to have slipped by almost unnoticed. For the first time since the 1950s, when Lord Hailsham performed the role, Britain now has a cabinet minister responsible for science. Even more important, perhaps, the job of coordinating science activities has been given to a new Office of Science and Technology. The office will be headed by the government's chief scientist, Professor William Stewart. And the cabinet minister? William Waldegrave. The lowly position that science occupies in Britain's consciousness probably explains why few people seem to know about this change. The political pundits have been much more taken with the new Ministry of Heritage (which means soccer and theme parks rather than Newton and Faraday) and with William Waldegrave's other main responsibility for the Citizen's Charter. The Chancellor of the Duchy of Lancaster-William Waldegrave's official cabinet position-is one of those arcane positions so beloved of the British establishment that confuse the natives and puzzle foreigners. Essentially it means whatever the prime minister of the time wants it to mean. Last time round it was occupied by Chris Patten, who was really chairman of the Conservative party. This time, as well as covering science and the Citizen's Charter, William Waldegrave is also minister for the civil service. Though it appears an odd ragbag, there is in fact some logic to the portfolio. The Office of Science and Technology will sit within the Cabinet Office, already the site of the office of the minister for the civil service and the Citizen's Charter unit. There it will combine the chief scientist's office with the former science branch of the Department of Education and Science
(to be renamed Department of Education). It will be responsible for the science budget and for the five research councils, together with the Advisory Committee on Science and Technology (ACOST) and the Advisory Board for the Research Councils. Research funding for the universities, however, will remain at the Department of Education. One puzzle is why the government had decided to create this new responsibility: a minister ofcabinet rank was a promise in the Labour party's manifesto, not the Conservative's. According to the Cabinet Office, the aim is to bring together an issue that cuts across several departmental boundaries, and the prime minister is said to have an interest in science. Scientists have cautiously welcomed the changes, though they would have preferred a minister whose only brief was science. And Save British Science, which argues that British science needs a further £400m of government funding, has welcomed William Waldegrave's appointment. Although he's not a scientist, he is a fellow of All Souls, and his junior minister, Robert Jackson, was formerly responsible for science at the Department of Education. Many hope too that the new office may strengthen the hand of the chief scientist. What else may be read into the new arrangements? Britain now has a proper minister to represent science in Europe, to match other European ministers of science of cabinet rank. The appointment may too be a sign that the government wants to heal the wounds with a sector of society that has felt badly bruised over the past few years. Nevertheless, it will take more than just a minister with a bright mind and a pleasing manner to stem the decline in British science. HART
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