105 it essential that repeated folin some cases. This is no simmaintained is years low-up ple consultation; it is the observation of a changing scene from which parent, child, family doctor, and education service can gain, and it is one of the ways by which paediatricians learn. "Stamp collecting" is an unkind term for the process by which a consultant continues to learn by observation of special cases. Paediatrics is full of new things, and their evolution is often slow.
The
development aspect makes over
Pædiatric Department, Royal Albert Edward Infirmary,
Wigan WN 1
2NN
justice. Most people, given free choice, would opt to travel a few miles rather than do without or endure a long waiting period. It would be unfortunate if equity is pursued to the point of ignoring hospital performance. The present financial stringency is forcing management to question more closely than hitherto the cost and benefit of both old and new policies. We should not miss this unique opportunity of setting up a financial
which will promote the
growth
of greater
Oxford
Regional Health Authority, Headington, Oxford OX3 7LF
A. BARR
R. M. FORRESTER
PLASMA-PROPRANOLOL IN INFLAMMATORY DISEASE
DOCTORS ON COMMITTEES
SIR,-One’s heart bleeds for Professor Brumfitt and his colwhose administration duties include membership of "not less than 15 local hospital and medical-school committees and working-parties". My personal experience in the periphery, where committees are also found, leads me to suppose that only an aggressive attitude will prevent this activity taking over time which should be devoted to the care of patients, basically a more agreeable exercise. One simply refuses to go to committee meetings which clash with outpatients or ward rounds, or evening meetings which interfere with such life-enhancing activities as playing hockey, relearning a musical instrument, or, if one is in desperate case, spending time with the family. One finds that one is then going only to the really essential committees and that the other ones are looked after by one’s colleagues who may be more tolerant than oneself, or else the committee just packs up.
leagues’
Southend
structure
efficiency.
SIR,-Propranolol in a single oral dose of up to 40 mg undergoes first-pass metabolism such that about 80% is metabolised to 4-hydroxy propranolol.’ (Above 40 mg there is a fairly linear relationship between dose and plasma level.) 4-hydroxy propranolol is a p-blocker of similar potency to the parent drug, the main difference being an intrinsic sympathomimetic effect of similar degree to oxprenolol. The clinical significance of propranolol blood levels can only be judged in relation to 4-hydroxy propranolol levels. This does not explain why inflammatory diseases modify propranolol pharmakokinetics, but without information on 4-hydroxy propranolol levels the work by Mrs Babb and her colleagues2 cannot be interpreted. 18 Sutherland Avenue,
Jacobs Well, near
Guildford
A.
Surrey GU4 7QX
J. F. FLETCHER
Hospital,
Westchff-on-Sea, Essex SS0 0RY
ANTHONY J. P. WILLIS
REALLOCATION OF RESOURCES
StR,-Barnard and Ham2 rightly draw attention to the similarity between current revenue allocation problems and those facing regional hospital boards twenty years ago. Some of the anomalies present at nationalisation have been rectified or ameliorated through the capital building programme and by other means. Of course, some remain because it is impossible, in a mammoth service like the N.H.S. with its enormous investments and deeply rooted traditions, to change quickly. Evolution, rather than revolution, is the keynote. The method of allocating revenue (now c4000 million per annum for England) between the 14 regional health authorities on a basis of weighted population and hospital case load seems fair, though, at present, it ignores special factors associated with high risk and deprived areas which may justify preferential consideration. What has received less consideration and publicity is the allocation within regions. The Resource Allocation Working Party3 has suggested that R.H.A.S should follow the method used nationally. Superficially this seems logical and fair. Further reflection, however, leads to the belief that such a policy could adversely affect the volume of patient care.
Hospitals vary greatly in the efficiency with which they use their resources.45 Curtailing the budget of an efficient hospital will restrict or even reduce the number of patients treated while there is no automatic guarantee that the transferred money will result in a commensurate increase in output of the benefiting hospital. Shifting revenue from efficient to less efficient hospitals, therefore, amounts to a false sense of territorial 1 Brumfitt, W. Hoffbrand, A. V., Wills, M. R. Lancet, 1976, i, 1072 2 Barnard K., Ham, C Lancet, 1976, i. 1399. 3. First Interim Report of the Resource Allocation Working Party. Department of Health and Social Security. 1975 4 Feldstein, M S. Economic Analysis for Health Service Efficiency Amsterdam. 1967. 5. Barr, A Lancet, 1968, i, 353
*** The legend to the table in the letter Birmingham workers should have read: "... patients with inflammatory disease (E.S.R.>20 mm/h)". We apologise to Mrs Babb and her colleagues for this mistake.-ED. L.
by the
PYOGENIC LIVER ABSCESS a misleading impression of the involved in this uncommon infection. Although Escherichia coli and Streptococcus fcecalis have been, in many series, the commonest organisms isolated, it is highly likely that the lack of adequate anaerobic cultures accounted for the frequently reported finding of "sterile" pus. An extensive review by Sabbaj et al. has emphasised the vital role of anaerobic bacteria in the pathogenesis of liver abscess. Anaerobic organisms are often found as the sole pathogen but also in mixed cultures with such organisms as E. coli and Strep. faecalis. Improved anaerobic culture techniques are providing the answer to the "sterile" liver abscess. We agree that surgical drainageof a pyogenic liver abscess is mandatory, but would emphasise that anaerobic bacteria require very different antibiotic therapy from that appropriate for E. coli and Strep. faecalis, and their isolation and identification are therefore an essential part of the successful management of this dangerous disease. The source of the bacteria responsible for a pyogenic liver abscess is, as you point out, seldom found, but in our opinion it is an unimportant factor in determining the patient’s prognosis.
SiR,-Your editorial3 gives
pathogens
Departments of Microbiology and Medicine, St Thomas’s Hospital Medical School, London SE1 7EH
IAN PHILLIPS SUSANNAH EYKYN NIGEL BATEMAN
1.
Riess, W.,
2
by W. Schweizer), p. 276. Bern, 1974 Babb, J., Bishop, H., Schneider, R. E., Hawkins, C. F., Hoare,
and others in
&bgr;-blockers;
Present Status and Future
Prospects
edited
A. M. Lan-
1976, i, 1413. 3. Lancet, 1976, i, 1170. 4 Sabbaj, J., Sutter, V. L., Finegold, S. M. Ann intern. Med. 1972, 77, 629. cet,
The
development aspect makes over
Pædiatric Department, Royal Albert Edward Infirmary,
Wigan WN 1
2NN
justice. Most people, given free choice, would opt to travel a few miles rather than do without or endure a long waiting period. It would be unfortunate if equity is pursued to the point of ignoring hospital performance. The present financial stringency is forcing management to question more closely than hitherto the cost and benefit of both old and new policies. We should not miss this unique opportunity of setting up a financial
which will promote the
growth
of greater
Oxford
Regional Health Authority, Headington, Oxford OX3 7LF
A. BARR
R. M. FORRESTER
PLASMA-PROPRANOLOL IN INFLAMMATORY DISEASE
DOCTORS ON COMMITTEES
SIR,-One’s heart bleeds for Professor Brumfitt and his colwhose administration duties include membership of "not less than 15 local hospital and medical-school committees and working-parties". My personal experience in the periphery, where committees are also found, leads me to suppose that only an aggressive attitude will prevent this activity taking over time which should be devoted to the care of patients, basically a more agreeable exercise. One simply refuses to go to committee meetings which clash with outpatients or ward rounds, or evening meetings which interfere with such life-enhancing activities as playing hockey, relearning a musical instrument, or, if one is in desperate case, spending time with the family. One finds that one is then going only to the really essential committees and that the other ones are looked after by one’s colleagues who may be more tolerant than oneself, or else the committee just packs up.
leagues’
Southend
structure
efficiency.
SIR,-Propranolol in a single oral dose of up to 40 mg undergoes first-pass metabolism such that about 80% is metabolised to 4-hydroxy propranolol.’ (Above 40 mg there is a fairly linear relationship between dose and plasma level.) 4-hydroxy propranolol is a p-blocker of similar potency to the parent drug, the main difference being an intrinsic sympathomimetic effect of similar degree to oxprenolol. The clinical significance of propranolol blood levels can only be judged in relation to 4-hydroxy propranolol levels. This does not explain why inflammatory diseases modify propranolol pharmakokinetics, but without information on 4-hydroxy propranolol levels the work by Mrs Babb and her colleagues2 cannot be interpreted. 18 Sutherland Avenue,
Jacobs Well, near
Guildford
A.
Surrey GU4 7QX
J. F. FLETCHER
Hospital,
Westchff-on-Sea, Essex SS0 0RY
ANTHONY J. P. WILLIS
REALLOCATION OF RESOURCES
StR,-Barnard and Ham2 rightly draw attention to the similarity between current revenue allocation problems and those facing regional hospital boards twenty years ago. Some of the anomalies present at nationalisation have been rectified or ameliorated through the capital building programme and by other means. Of course, some remain because it is impossible, in a mammoth service like the N.H.S. with its enormous investments and deeply rooted traditions, to change quickly. Evolution, rather than revolution, is the keynote. The method of allocating revenue (now c4000 million per annum for England) between the 14 regional health authorities on a basis of weighted population and hospital case load seems fair, though, at present, it ignores special factors associated with high risk and deprived areas which may justify preferential consideration. What has received less consideration and publicity is the allocation within regions. The Resource Allocation Working Party3 has suggested that R.H.A.S should follow the method used nationally. Superficially this seems logical and fair. Further reflection, however, leads to the belief that such a policy could adversely affect the volume of patient care.
Hospitals vary greatly in the efficiency with which they use their resources.45 Curtailing the budget of an efficient hospital will restrict or even reduce the number of patients treated while there is no automatic guarantee that the transferred money will result in a commensurate increase in output of the benefiting hospital. Shifting revenue from efficient to less efficient hospitals, therefore, amounts to a false sense of territorial 1 Brumfitt, W. Hoffbrand, A. V., Wills, M. R. Lancet, 1976, i, 1072 2 Barnard K., Ham, C Lancet, 1976, i. 1399. 3. First Interim Report of the Resource Allocation Working Party. Department of Health and Social Security. 1975 4 Feldstein, M S. Economic Analysis for Health Service Efficiency Amsterdam. 1967. 5. Barr, A Lancet, 1968, i, 353
*** The legend to the table in the letter Birmingham workers should have read: "... patients with inflammatory disease (E.S.R.>20 mm/h)". We apologise to Mrs Babb and her colleagues for this mistake.-ED. L.
by the
PYOGENIC LIVER ABSCESS a misleading impression of the involved in this uncommon infection. Although Escherichia coli and Streptococcus fcecalis have been, in many series, the commonest organisms isolated, it is highly likely that the lack of adequate anaerobic cultures accounted for the frequently reported finding of "sterile" pus. An extensive review by Sabbaj et al. has emphasised the vital role of anaerobic bacteria in the pathogenesis of liver abscess. Anaerobic organisms are often found as the sole pathogen but also in mixed cultures with such organisms as E. coli and Strep. faecalis. Improved anaerobic culture techniques are providing the answer to the "sterile" liver abscess. We agree that surgical drainageof a pyogenic liver abscess is mandatory, but would emphasise that anaerobic bacteria require very different antibiotic therapy from that appropriate for E. coli and Strep. faecalis, and their isolation and identification are therefore an essential part of the successful management of this dangerous disease. The source of the bacteria responsible for a pyogenic liver abscess is, as you point out, seldom found, but in our opinion it is an unimportant factor in determining the patient’s prognosis.
SiR,-Your editorial3 gives
pathogens
Departments of Microbiology and Medicine, St Thomas’s Hospital Medical School, London SE1 7EH
IAN PHILLIPS SUSANNAH EYKYN NIGEL BATEMAN
1.
Riess, W.,
2
by W. Schweizer), p. 276. Bern, 1974 Babb, J., Bishop, H., Schneider, R. E., Hawkins, C. F., Hoare,
and others in
&bgr;-blockers;
Present Status and Future
Prospects
edited
A. M. Lan-
1976, i, 1413. 3. Lancet, 1976, i, 1170. 4 Sabbaj, J., Sutter, V. L., Finegold, S. M. Ann intern. Med. 1972, 77, 629. cet,
