96
B, Carbone P, Economou S, et al. L-phenalanine mustard (L-PAM) in the management of primary breast cancer. N Engl J Med
1. Fisher
1975; 292: 117-21. 2. Bonadonna
G, Brusamolino E, Valagussa P, et al. Combination chemotherapy as an adjuvant treatment in operable breast cancer. N Engl J Med 1976; 294: 405-10.
3. Ravdin RG, Lewison EF, Slack NH, et al. Results of a clinical trial concerning the worth of prophylactic oophorectomy for breast carcinoma. Surg Gynecol Obstet 1970; 31: 1055-64. 4. Nevinny HB, Nevinny D, Rossoff CB, et al. Prophylactic oophorectomy in breast cancer therapy: a preliminary report. Am J Surg 1969; 117: 531-36. 5. Cole MF. Suppression of ovarian function in primary breast cancer. In: Forrest APM, Kunkler PB, eds. Prognostic factors in breast cancer. Edinburgh: Livingstone, 1968: 146-56. 6. Tengrup I, Tengvall-Nittby L, Landburg T. Prophylactic oophorectomy in the treatment of carcinoma of the breast. Surg Gynecol Obstet 1986; 152: 209-14. 7. Nissen-Meyer R. Suppression of ovarian function in primary breast cancer. In: Forrest APM, Kunkler PB, eds. Prognostic factors in breast cancer. Edinburgh: Livingstone, 1968: 139-45. 8. International Breast Cancer Study Group. Late effects of adjuvant oophorectomy and chemotherapy upon premenopausal breast cancer patients. Ann Oncol 1990; 1: 30-35. 9. Bryant AJS, Weir JA. Prophylactic oophorectomy in operable instances of carcinoma of the breast. Surg Gynecol Obstet 1981; 153: 660-64. 10. Meakin JW, Allt WEC, Beale FA, et al. Ovarian irradiation and prednisone therapy following surgery and radiotherapy for carcinoma of the breast. Can Med Assoc J 1979; 120: 1221-38. 11. Brincker H, Mouridsen HT, Rank F, et al. Evidence of castration mediated effect of adjuvant chemotherapy (CT) in a randomised trial of cyclophosphamide monotherapy versus CMF in premenopausal stage II breast cancer. Proc Am Soc Clin Oncol 1985; 4: 56. 12. Tormey DC. Adjuvant systemic therapy in postoperative node positive patients with breast carcinoma: The CALGB Trial and ECOG premenopausal tnal. Rec Res Cancer Res 1984; 96: 155-65. 13. Padmanabhan N, Howell A, Rubens RD. Mechanism of action of adjuvant chemotherapy in early breast cancer. Lancet 1986; ii: 411-14.
his duties adequately or if he was denied the wherewithal to fulfil them.2 A return to this level of planning is neither probable nor, perhaps, desirable, but the situation has changed dramatically-the mixed economy has taken over with a vengeance. Where this is a synonym for consumer choice, it is probably a good thing. Where it is a euphemism for chaos, it is certainly not. Some districts retain considerable numbers of longer stay beds; some have effectively privatised extended care; some have entered into ingenious partnerships with the private and voluntary sectors; and some have established NHS nursing homes. The arguments for and against private care have been well rehearsed; there is no reason to suppose that the NHS enjoys a monopoly of the skills needed to offer high-quality care, but if public money is to be spent, quality assurance is vital, and so is accessibility for those most in need of care rather than those who would fit well into a particular establishment. A long-term NHS bed is free, except for curtailment of state pension after eight weeks, and even that forfeit does not find its way back into the hospital service. A private nursing home bed generally costs about 400 ($740) a week, a variable amount of which may be met by Department of Social Security income support, so relatives are not always very enthusiastic to embrace the private sector.
Does all this matter? In many places it does, and in 1993. Many patients are receiving
most places it will in
in the UK: do we need it, does it matter, who will pay?
Long-term
care
On April 16, 1836, the clerk of Huntingdon Union (the workhouse) wrote to Mr Theo Spencer, baker, of Biggleswade, to inform him that the Board of Guardians "were satisfied that he was of sufficient ability to maintain his mother" and that "all further relief to his mother would be discontinued and that legal proceedings would be taken against him unless he immediately supplied his mother with proper maintenance". On October 10, 1991, and subsequently, readers of the correspondence columns of the Guardian learned of numerous instances of relatives being informed of their obligation to find alternative accommodation for elderly patients currently occupying National Health Service hospital beds.1 There was, inbetween times, an era, less than a decade ago, when almost every health district had a comprehensive unified geriatric service comprising acute, rehabilitation, and extended-care wards, together with outpatient clinics and day hospital; when there were widely accepted norms for numbers of such beds per 1000 population; when the geriatrician accepted the responsibility of finding and supervising a suitable bed for all those needing one within his traditional catchment population; and when bodies such as the (then) Hospital Service could comment freely if he failed to
Advisory discharge
inappropriate care, some are receiving inadequate community care when institutionalisation would be the only viable humane option,4 and irreversibly high-dependency patients occupy acute hospital beds where they are to an extent neglected or even resented and where their presence contributes to lengthening waiting lists for important elective surgery. The amount of public money going into income support is escalating dizzily;5 were it to be directed to the NHS it would make a considerable difference. But 1993 will see the full implementation of the NHS and Community Care Bill. Under its provisions, the local authority social services department will be responsible for assessing its clients’ needs and will then purchase whatever level of care is deemed necessary from whichever provider it favours. These enormous sums (estimated at 1200 to C1300 million for the year 1990/91) will be diverted to local authorities, to spend on purchasing care-or roads, or schools, or whatever takes their
fancy. Perhaps it is unrealistic to turn the clock back. NHS long-term care is vastly expensive: five years ago it was estimated to cost almost C300 per patient per week.6 If this figure is now 400, a patient occupying a bed for a year costs the hospital service c20 000, one of the most expensive interventions that hospital consultants have at their disposal, and also the most difficult intervention to evaluate in terms of the measurable outcomes and health gains that are now being
97
If the mixed economy is to continue, of degree equity between the sectors is essential, and health authorities have been urged to come clean about their responsibilities in this respect.8 Is community care a viable option? There comes a level of infirmity at which such care turns into
ernphasised.’ some
expensive community neglect.4 Many people over ninety years of age lead active and independent lives,9 and it has been argued that preventive medicine and increasing affluence will lead to a compression of morbidity and a reduction in end-of-life dependency.10 But the fact that the numbers of people in their eighties and nineties are rising inevitably means that there will be more irreversibly disabled and dependent individuals who are likely to spend longer periods of time requiring 24-hour support.11.12 The dwindling stock of extended-care beds and local authority residential home places leaves the health and social services departments exceedingly poorly equipped to face the "geriatric imperative" .13,14 Private long-term-care insurance has not been successful in the USA and there is no reason to suppose it would do any better in the UK.15 There is no doubt that we will continue to need long-term care, both for physical and for psychiatric dependency, and that it matters greatly-to patients and their carers and to primary-care teams and acute hospital services. The question of who will pay requires urgent attention. 1. Anon. Increased suffering for the elderly on the NHS. Guardian, Oct 10, 1991. 2. Coni NK. Alive and well: geriatric medicine in the UK in 1984. Health Policy 1985; 5: 173-81. 3. Philp I, Mutch WJ, Ballinger BR, Boyd L. A comparison of care in private nursing homes, geriatric and psychogeriatric hospitals. Int J Genatr Psychiatry 1991; 6: 253-58. 4. Optit LJ. Domiciliary care for the elderly sick—economy or neglect? Br Med J 1977; i: 30-33. 5. Henwood M, Jowell T, Wistow G. Briefing paper 12: all things come (to those who wait). Causes and consequences of the community care delays. London: King’s Fund, 1991. 6. Audit Commission. Making a reality of community care. London: HM Stationery Office, 1986. 7. Livesley B. Cost-benefit consideration in the treatment of elderly people. Drugs Aging 1991; 1: 249-53. 8. Health and Social Security Select Committees. The financing of private residential care and nursing home fees. London: HM Stationery Office, 1991. 9. Bury M, Holme A. Life after ninety. London: Routledge, 1991. 10. Fries JF. Aging, natural death and the compression of morbidity. N Engl J Med 1980; 303: 130-35. 11. Stout RW, Crawford V. Active life expectancy and terminal dependency: trends in long term geriatric care over 33 years. Lancet 1988; i: 281-83. 12. Brody JA. Prospects for an ageing population. Nature 1985; 315: 463-66. 13. Laing W, Hall M. Agenda for health 1991: the challenges of ageing. London: Association of British Pharmaceutical Industries, 1991. 14. Anon. Discontinuing care. London: Age Concern, 1991. 15. Driver D. Successful ageing. The Times, Nov 4, 1991.
Diabetes practice: the information gap For those whose clinical practice includes a substantial proportion of diabetic patients the workload seems to increase inexorably without a concomitant change in resources. Yet we are told that
developed countries diabetic patients may be responsible for 4-5 % of national health care expenditure.1-3 So is the impression illusory? Is it merely that there has been a huge change in diabetes care during the past decade-eg, with respect to blood sugar monitoring, diet, intensified insulin therapy, treatment of complications, diabetes specialist nurses, patient education, management of diabetic pregnancy, and organisation of diabetes care? Perhaps it is a consequence of the scramble to keep ahead of the startling proliferation of charters, guidelines, and consensus statements.4-8 Or maybe there is an increasing mismatch between expectations and in
The truth is that most of us have not the faintest idea because we spend all our time reacting to a rapidly and unpredictably changing world. We seldom take even a few moments to consider whether we are doing what we should be doing now, far less ponder the future. This pattern is equally true for funding agencies. Such a passive approach is unlikely to achieve the best use of available resources. A report commissioned in 1988 by the Dutch Government attempts to address many of these issues.9 Discussion of the views of health care professionals on organisation and outcome of diabetes health care is mostly unexceptional, reflecting existing knowledge and opinion on best practice. Quality of life, which is often overlooked in chronic disease management, is’identified as a key focus for services, in addition to traditional medical outcomes such as blindness and amputation. Disappointingly, however, no patients’ views were sought. Diabetic patients are knowledgeable consumers who are in lifelong contact with the services provided for them; their opinions are important for policy developments. Diabetes in pregnancy is also largely ignored. Nevertheless, four key points emerge that are of general relevance to the future provision of diabetes care. First, there is a need for government policies with respect to diabetes mellitus. The Dutch are probably entirely representative in having none. The report suggests that central policy objectives should include measures that lead to increased self-care and early detection of complications. Diabetes specialist nurses, better patient education and information facilities, community-based dieticians, regular clinic review for evaluation of metabolic control, and early detection of complications and extra training of medical and paramedical health care professionals are given as examples of proven systems. This conclusion is entirely consistent with all the existing charters, consensus documents, protocols, &c. Nevertheless, central support is essential if patchy practice is to be made more consistent. Second, the report identifies the likelihood of a very considerable increase in the number of diabetic patients during the next fifteen years. Calculations were based on the reasonable assumption that the incidence of insulin-dependent diabetes mellitus (IDDM) would continue to increase slowly in young resources.
B, Carbone P, Economou S, et al. L-phenalanine mustard (L-PAM) in the management of primary breast cancer. N Engl J Med
1. Fisher
1975; 292: 117-21. 2. Bonadonna
G, Brusamolino E, Valagussa P, et al. Combination chemotherapy as an adjuvant treatment in operable breast cancer. N Engl J Med 1976; 294: 405-10.
3. Ravdin RG, Lewison EF, Slack NH, et al. Results of a clinical trial concerning the worth of prophylactic oophorectomy for breast carcinoma. Surg Gynecol Obstet 1970; 31: 1055-64. 4. Nevinny HB, Nevinny D, Rossoff CB, et al. Prophylactic oophorectomy in breast cancer therapy: a preliminary report. Am J Surg 1969; 117: 531-36. 5. Cole MF. Suppression of ovarian function in primary breast cancer. In: Forrest APM, Kunkler PB, eds. Prognostic factors in breast cancer. Edinburgh: Livingstone, 1968: 146-56. 6. Tengrup I, Tengvall-Nittby L, Landburg T. Prophylactic oophorectomy in the treatment of carcinoma of the breast. Surg Gynecol Obstet 1986; 152: 209-14. 7. Nissen-Meyer R. Suppression of ovarian function in primary breast cancer. In: Forrest APM, Kunkler PB, eds. Prognostic factors in breast cancer. Edinburgh: Livingstone, 1968: 139-45. 8. International Breast Cancer Study Group. Late effects of adjuvant oophorectomy and chemotherapy upon premenopausal breast cancer patients. Ann Oncol 1990; 1: 30-35. 9. Bryant AJS, Weir JA. Prophylactic oophorectomy in operable instances of carcinoma of the breast. Surg Gynecol Obstet 1981; 153: 660-64. 10. Meakin JW, Allt WEC, Beale FA, et al. Ovarian irradiation and prednisone therapy following surgery and radiotherapy for carcinoma of the breast. Can Med Assoc J 1979; 120: 1221-38. 11. Brincker H, Mouridsen HT, Rank F, et al. Evidence of castration mediated effect of adjuvant chemotherapy (CT) in a randomised trial of cyclophosphamide monotherapy versus CMF in premenopausal stage II breast cancer. Proc Am Soc Clin Oncol 1985; 4: 56. 12. Tormey DC. Adjuvant systemic therapy in postoperative node positive patients with breast carcinoma: The CALGB Trial and ECOG premenopausal tnal. Rec Res Cancer Res 1984; 96: 155-65. 13. Padmanabhan N, Howell A, Rubens RD. Mechanism of action of adjuvant chemotherapy in early breast cancer. Lancet 1986; ii: 411-14.
his duties adequately or if he was denied the wherewithal to fulfil them.2 A return to this level of planning is neither probable nor, perhaps, desirable, but the situation has changed dramatically-the mixed economy has taken over with a vengeance. Where this is a synonym for consumer choice, it is probably a good thing. Where it is a euphemism for chaos, it is certainly not. Some districts retain considerable numbers of longer stay beds; some have effectively privatised extended care; some have entered into ingenious partnerships with the private and voluntary sectors; and some have established NHS nursing homes. The arguments for and against private care have been well rehearsed; there is no reason to suppose that the NHS enjoys a monopoly of the skills needed to offer high-quality care, but if public money is to be spent, quality assurance is vital, and so is accessibility for those most in need of care rather than those who would fit well into a particular establishment. A long-term NHS bed is free, except for curtailment of state pension after eight weeks, and even that forfeit does not find its way back into the hospital service. A private nursing home bed generally costs about 400 ($740) a week, a variable amount of which may be met by Department of Social Security income support, so relatives are not always very enthusiastic to embrace the private sector.
Does all this matter? In many places it does, and in 1993. Many patients are receiving
most places it will in
in the UK: do we need it, does it matter, who will pay?
Long-term
care
On April 16, 1836, the clerk of Huntingdon Union (the workhouse) wrote to Mr Theo Spencer, baker, of Biggleswade, to inform him that the Board of Guardians "were satisfied that he was of sufficient ability to maintain his mother" and that "all further relief to his mother would be discontinued and that legal proceedings would be taken against him unless he immediately supplied his mother with proper maintenance". On October 10, 1991, and subsequently, readers of the correspondence columns of the Guardian learned of numerous instances of relatives being informed of their obligation to find alternative accommodation for elderly patients currently occupying National Health Service hospital beds.1 There was, inbetween times, an era, less than a decade ago, when almost every health district had a comprehensive unified geriatric service comprising acute, rehabilitation, and extended-care wards, together with outpatient clinics and day hospital; when there were widely accepted norms for numbers of such beds per 1000 population; when the geriatrician accepted the responsibility of finding and supervising a suitable bed for all those needing one within his traditional catchment population; and when bodies such as the (then) Hospital Service could comment freely if he failed to
Advisory discharge
inappropriate care, some are receiving inadequate community care when institutionalisation would be the only viable humane option,4 and irreversibly high-dependency patients occupy acute hospital beds where they are to an extent neglected or even resented and where their presence contributes to lengthening waiting lists for important elective surgery. The amount of public money going into income support is escalating dizzily;5 were it to be directed to the NHS it would make a considerable difference. But 1993 will see the full implementation of the NHS and Community Care Bill. Under its provisions, the local authority social services department will be responsible for assessing its clients’ needs and will then purchase whatever level of care is deemed necessary from whichever provider it favours. These enormous sums (estimated at 1200 to C1300 million for the year 1990/91) will be diverted to local authorities, to spend on purchasing care-or roads, or schools, or whatever takes their
fancy. Perhaps it is unrealistic to turn the clock back. NHS long-term care is vastly expensive: five years ago it was estimated to cost almost C300 per patient per week.6 If this figure is now 400, a patient occupying a bed for a year costs the hospital service c20 000, one of the most expensive interventions that hospital consultants have at their disposal, and also the most difficult intervention to evaluate in terms of the measurable outcomes and health gains that are now being
97
If the mixed economy is to continue, of degree equity between the sectors is essential, and health authorities have been urged to come clean about their responsibilities in this respect.8 Is community care a viable option? There comes a level of infirmity at which such care turns into
ernphasised.’ some
expensive community neglect.4 Many people over ninety years of age lead active and independent lives,9 and it has been argued that preventive medicine and increasing affluence will lead to a compression of morbidity and a reduction in end-of-life dependency.10 But the fact that the numbers of people in their eighties and nineties are rising inevitably means that there will be more irreversibly disabled and dependent individuals who are likely to spend longer periods of time requiring 24-hour support.11.12 The dwindling stock of extended-care beds and local authority residential home places leaves the health and social services departments exceedingly poorly equipped to face the "geriatric imperative" .13,14 Private long-term-care insurance has not been successful in the USA and there is no reason to suppose it would do any better in the UK.15 There is no doubt that we will continue to need long-term care, both for physical and for psychiatric dependency, and that it matters greatly-to patients and their carers and to primary-care teams and acute hospital services. The question of who will pay requires urgent attention. 1. Anon. Increased suffering for the elderly on the NHS. Guardian, Oct 10, 1991. 2. Coni NK. Alive and well: geriatric medicine in the UK in 1984. Health Policy 1985; 5: 173-81. 3. Philp I, Mutch WJ, Ballinger BR, Boyd L. A comparison of care in private nursing homes, geriatric and psychogeriatric hospitals. Int J Genatr Psychiatry 1991; 6: 253-58. 4. Optit LJ. Domiciliary care for the elderly sick—economy or neglect? Br Med J 1977; i: 30-33. 5. Henwood M, Jowell T, Wistow G. Briefing paper 12: all things come (to those who wait). Causes and consequences of the community care delays. London: King’s Fund, 1991. 6. Audit Commission. Making a reality of community care. London: HM Stationery Office, 1986. 7. Livesley B. Cost-benefit consideration in the treatment of elderly people. Drugs Aging 1991; 1: 249-53. 8. Health and Social Security Select Committees. The financing of private residential care and nursing home fees. London: HM Stationery Office, 1991. 9. Bury M, Holme A. Life after ninety. London: Routledge, 1991. 10. Fries JF. Aging, natural death and the compression of morbidity. N Engl J Med 1980; 303: 130-35. 11. Stout RW, Crawford V. Active life expectancy and terminal dependency: trends in long term geriatric care over 33 years. Lancet 1988; i: 281-83. 12. Brody JA. Prospects for an ageing population. Nature 1985; 315: 463-66. 13. Laing W, Hall M. Agenda for health 1991: the challenges of ageing. London: Association of British Pharmaceutical Industries, 1991. 14. Anon. Discontinuing care. London: Age Concern, 1991. 15. Driver D. Successful ageing. The Times, Nov 4, 1991.
Diabetes practice: the information gap For those whose clinical practice includes a substantial proportion of diabetic patients the workload seems to increase inexorably without a concomitant change in resources. Yet we are told that
developed countries diabetic patients may be responsible for 4-5 % of national health care expenditure.1-3 So is the impression illusory? Is it merely that there has been a huge change in diabetes care during the past decade-eg, with respect to blood sugar monitoring, diet, intensified insulin therapy, treatment of complications, diabetes specialist nurses, patient education, management of diabetic pregnancy, and organisation of diabetes care? Perhaps it is a consequence of the scramble to keep ahead of the startling proliferation of charters, guidelines, and consensus statements.4-8 Or maybe there is an increasing mismatch between expectations and in
The truth is that most of us have not the faintest idea because we spend all our time reacting to a rapidly and unpredictably changing world. We seldom take even a few moments to consider whether we are doing what we should be doing now, far less ponder the future. This pattern is equally true for funding agencies. Such a passive approach is unlikely to achieve the best use of available resources. A report commissioned in 1988 by the Dutch Government attempts to address many of these issues.9 Discussion of the views of health care professionals on organisation and outcome of diabetes health care is mostly unexceptional, reflecting existing knowledge and opinion on best practice. Quality of life, which is often overlooked in chronic disease management, is’identified as a key focus for services, in addition to traditional medical outcomes such as blindness and amputation. Disappointingly, however, no patients’ views were sought. Diabetic patients are knowledgeable consumers who are in lifelong contact with the services provided for them; their opinions are important for policy developments. Diabetes in pregnancy is also largely ignored. Nevertheless, four key points emerge that are of general relevance to the future provision of diabetes care. First, there is a need for government policies with respect to diabetes mellitus. The Dutch are probably entirely representative in having none. The report suggests that central policy objectives should include measures that lead to increased self-care and early detection of complications. Diabetes specialist nurses, better patient education and information facilities, community-based dieticians, regular clinic review for evaluation of metabolic control, and early detection of complications and extra training of medical and paramedical health care professionals are given as examples of proven systems. This conclusion is entirely consistent with all the existing charters, consensus documents, protocols, &c. Nevertheless, central support is essential if patchy practice is to be made more consistent. Second, the report identifies the likelihood of a very considerable increase in the number of diabetic patients during the next fifteen years. Calculations were based on the reasonable assumption that the incidence of insulin-dependent diabetes mellitus (IDDM) would continue to increase slowly in young resources.
