1353
management team since the requirement for consensus all decisions has been replaced by majority decision making.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
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
