767
23. Caroni P, Schwarb ME. Antibody against myelin-associated inhibition of neurite growth neutralises non-permissive substrate properties of CNS white matter. Neurology 1988; 1: 85-96. 24. Schnell L, Schwarb ME. Axonal regeneration in the rat spinal cord produced by an antibody against myelin-associated neurite growth inhibitors. Nature 1990; 343: 269-72. 25. Blakemore WF, Crang AJ, Franklin RJM. Transplantation of glial cell cultures into areas of demyelination of the adult CNS. In: Dunnett SB, Richards S-J (eds). Progr Brain Res 1990; 82: 225-32.
Marine metaphor and the NHS onwards there will be yet more excited talk in the UK of flagships, launches, uncharted waters, and first waves. Those working in the National Health Service and wanting to join this sea of metaphor will report a sinking feeling. Have we not been here before, they will say, with expensive reorganisations imposed on a service not much more generously funded in real terms than in previous years? The detached observer may find some good things in the latest reforms but most NHS employees and patients when asked have opposed the plans and still do. There is a bright side, however-even two. In 1989, when the proposals came outl-3 after much speculation about deeds more drastic, many critics felt that there must be a hidden agenda. At that time no public utility, enterprise, or service was thought unsuitable for placement in the private sector or under some other form of entrepreneurial control. The Conservative Party’s claim that "The NHS is safe in our hands" was greeted with grave suspicion. Stage two, the future dismantling of the NHS and a switch to an insurance-based provision on American lines, really did seem on the cards. Less so in 1991. The Secretary of State for Health has said that "we should put aside the example of America, which is a shambles and wasting money hand over fist".4 US visitors to Britain have sounded warnings5 (another appears on p 778) that market forces do not work with health care and that costs of administration will increase sharply: administration takes up 20% of expenditure on health care in the US.6 In the absence of the insurance element, the NHS will not rise to those dizzy heights. Nonetheless, the 6% or so now spent on administration will certainly increase; already 4000 new non-clinical posts have been created and there will be more to come. Despite experiments going back twenty years, US expenditure remains out of control. After HMOs, HSAs, CONs, PSROs and other toothless attempts at restraint, the American Manufacturers’ Association and other big employers who foot the bill for health care and have failed to tame the persistently rising costs are now saying, in effect, "We give up, let’s try national health insurance". Expenditure in the USA last year was about$650 billion, and that is with an estimated 13% of people wholly uninsured. The other bright side is that the reforms are making clinicians stop and think more about what they are doing and why, about costs and about priorities; and the information technology to do that is slowly being installed.
From
Monday
Neither the big experiment-the "internal market" which is setting health authorities across the negotiating table from clinicians in purchaser and provider roles, respectively, leaving the clinicians’ advisory role uncertain-nor the two so far smaller initiatives stand any chance of success without hard facts on costs and performance. The first wave of self-governing trusts is barely a ripple; 56 units out of 66 which applied have been granted trust status so far and 111 are trying for the coming year. The BMA’s Central Consultants and Specialists Committee has found this first wave unconvincing and unrealistic (eg, applicants making up only 2% of NHS units were seeking 15% of the NHS capital allotment for 1991-92).’ And so far also, only 306 general practices have taken advantage of the opportunity to run their own budgets, a typical one for a combined practice of 9000 patients being 11 million. Such wildly different estimates are being produced by hospitals, even for what ought to be fairly well standardised procedures such as dealing with an ingrowing toenail,that one wonders if the same accounting rules are being followed. A GP wishing to refer for surgery a patient in need of a hip replacement will, in theory, be able to call up all sorts of figures on his computer screencosts, certainly, and waiting times and durations of stay, and postoperative complication rates. Clinical audit, an exercise separate from although relevant to the market and costing 46 million to develop in 1991-92, demands courage and openness, and barriers to it have been breaking down; an accountancy dimension could build resistance up
again. A cautious welcome, then, to the apparent preservation of the NHS as a planned, national service by and large free at the point of use and available to all. And a more effusive response to the idea that much more information on performance indicators in the NHS should be available at the local level and to individual clinicians. So, has The Lancet been converted to the shade, if no longer the substance, of Mrs Thatcher? Not exactly, for questions are legion. Even the former Prime Minister’s best friends would not claim that the changes promote better integration of care and prevention services. Furthermore, the whole idea of market forces remains dubious when the goods will continue to be rationed. The pace of reform has lately been slowed and what is happening amounts to a cementing into contractual form of last year’s referral patterns and work loads. It will be a long time before the effects, if any, on the nation’s health can be assessed, though the burdens being borne by clinicians and managers are all too obvious now. What should trouble those who want to see some good in what is being done is the reluctance of Health Department spokesmen and Ministers to answer any questions specifically and to provide
specific reassurances. Most hospitals in Britain
are not
just
district but
768
In a free market those whose services were not wanted would close. Can that be even contemplated for a large hospital? Already hospitals are thinking that they might not for ever have to provide all the obvious specialties, but what is a also
general.
general hospital without, say, paediatrics or with expert advice remotely placed in some laboratory combine? What will really happen when a budgetholding practice runs out of money? More important, since there have been some ominous signs of GPs sanitising their lists to remove potential high consumers of care, what will happen when patients move? Budgets may not be rigidly fixed at so much per patient but the figure will not easily be adjusted year on year to take account of a chronically sick family moving from one part of the country to another. Will budget holders have such leverage over their peers that they can demand priority for hospital appointments and admissions? In all the talk of budgets and trusts, community medical services have been neglected. So have research and teachingessential functions that until recent years were happily and pragmatically accommodated within the NHS. What about salaries? Will not local negotiations mean that successful units will prosper even more and afford more, and the reverse? And who is going to monitor the success or failure of these experiments, and how? After all, we seem to be heading towards four sorts of health service, not one-internal markets everywhere but with no budget holders or trusts for miles or with one or the other or sometimes both. A recipe for chaos. The Health Departments are already talking of an era when few hospitals are not trusts.9 Education is the latest arm of Britain’s Welfare State in which inducements are being offered to those seeking self governing status, but in the NHS the slush fund for bribes and coercions ought to be exhausted by now. The NHS reforms ran up a bill of 390 million, including controversial "sweeteners" for the first trusts, before anything really happened.10 Let us pause and see how the few pioneers get on. Those remaining sceptical will be on the lookout for a sign so far unknown in the NHS-the patient with a thick file of notes carrying the dismal codicil, "overdrawn". 1. Editorial. Curtains up on the NHS review. Lancet 1989; i: 247-49. 2. Anon. Working papers on the NHS review. Lancet 1989; i: 454. 3. A booklet by C. Ham, R. Robinson, and M. Benzeval (Health Check. London: King’s Fund Institute. 1990. Pp 112. ISBN 1 870607 18 X. £9.95) and a paper by P. Day and R. Klein entitled Britain’s Health Care Experiment (Health Affairs in press) provide useful background for the non-UK reader. 4. Smith R. William Waldegrave: thinking. Br Med J 1991; 302: 636-40. 5. Scheffler R. Adverse selection: the Achilles heel of the NHS reforms. Lancet 1989; i: 950-52. 6. Organisation for Economic Cooperation and Development. Health care systems in transition. Paris: OECD, 1990. 7. Anon. NHS trusts. CCSC Newsl S3 1990-91: 2-3. 8. Dean M. The new NHS supermarket. Lancet 1989; 337: 721. 9. Anon. Working for patients: NHS trusts, a working guide. CCSC Newsl S1 1990-91. 10. Glasman D. Row over government’s "sweeteners" to new trusts. Health Serv J 1991, March 21: 5.
Primary hyperparathyroidism 1,25-dihydroxyvitamin D
and
Primary hyperparathyroidism has been recognised more frequently since the inclusion of calcium measurements in routine biochemical testing. The far
varied manifestations of this condition include renal stones or nephrocalcinosis, non-specific gastrointestinal symptoms, proximal muscle weakness, and occasionally psychiatric complaints. Elderly patients may present with acute hypercalcaemic crisis characterised by confusion and dehydration. Bone disease is seen in less than 10% of cases. Hypercalcaemia is not invariably present and serum phosphate concentration is often low or low normal. Serum alkaline phosphatase activity is usually normal. Inappropriately raised concentrations of parathyroid hormone confirm the diagnosis. Symptomatic primary hyperparathyroidism is treated by surgery, since in 80% of patients there is a single adenoma. Conservative management can be entertained in those who do not have overt
complications.1 Target organs for parathyroid hormone are bone and kidney. The hormone increases bone resorption; in the kidney it alters the handling of calcium and phosphate ions, and enhances the activity of lahydroxylase, leading to increased formation of 1,25dihydroxyvitamin D from 25-hydroxyvitamin D. Extracellular calcium ion concentration, among other factors, also influences renal 1,25(OH)P production.2 1,25(OH)2D can reduce parathyroid hormone synthesis; it inhibits expression of the parathyroid hormone gene by a direct and calciumindependent effect. 3,4 In patients with primary hyperparathyroidism,
1,25(OH)2D concentrations may be increased, normal, or even decreased.5,6 Shaker and colleagues’ serum
described a patient with very high concentrations of intact parathyroid hormone, severe hypercalcaemia, and low circulating concentrations of 1,25(OH)D. Her daily calcium intake exceeded 2 g. Serum calcium returned to normal with calcium restriction alone, and there was a concomitant pronounced rise in serum 1,25(OH)2D and a dramatic fall in circulating parathyroid hormone. In this patient the parathyroid glands were apparently insensitive to the increased serum calcium
lately
but
suppressive effects of 1,25(OH)2D. the inhibitory effect of Presumably, hypercalcaemia on renal 1 a-hydroxylase activity was relieved by dietary calcium restriction, the stimulatory effect of parathyroid hormone on renal lahydroxylase activity was restored. Restoration to not to
the
once
normal of serum 1,25(OH)ZD concentrations led to a fall in parathyroid hormone secretion. These observations illustrate a possible role for 1,25(OH)2D in the treatment of primary hyperparathyroidism; 1,25(OH)2D has already been used in the conservative
23. Caroni P, Schwarb ME. Antibody against myelin-associated inhibition of neurite growth neutralises non-permissive substrate properties of CNS white matter. Neurology 1988; 1: 85-96. 24. Schnell L, Schwarb ME. Axonal regeneration in the rat spinal cord produced by an antibody against myelin-associated neurite growth inhibitors. Nature 1990; 343: 269-72. 25. Blakemore WF, Crang AJ, Franklin RJM. Transplantation of glial cell cultures into areas of demyelination of the adult CNS. In: Dunnett SB, Richards S-J (eds). Progr Brain Res 1990; 82: 225-32.
Marine metaphor and the NHS onwards there will be yet more excited talk in the UK of flagships, launches, uncharted waters, and first waves. Those working in the National Health Service and wanting to join this sea of metaphor will report a sinking feeling. Have we not been here before, they will say, with expensive reorganisations imposed on a service not much more generously funded in real terms than in previous years? The detached observer may find some good things in the latest reforms but most NHS employees and patients when asked have opposed the plans and still do. There is a bright side, however-even two. In 1989, when the proposals came outl-3 after much speculation about deeds more drastic, many critics felt that there must be a hidden agenda. At that time no public utility, enterprise, or service was thought unsuitable for placement in the private sector or under some other form of entrepreneurial control. The Conservative Party’s claim that "The NHS is safe in our hands" was greeted with grave suspicion. Stage two, the future dismantling of the NHS and a switch to an insurance-based provision on American lines, really did seem on the cards. Less so in 1991. The Secretary of State for Health has said that "we should put aside the example of America, which is a shambles and wasting money hand over fist".4 US visitors to Britain have sounded warnings5 (another appears on p 778) that market forces do not work with health care and that costs of administration will increase sharply: administration takes up 20% of expenditure on health care in the US.6 In the absence of the insurance element, the NHS will not rise to those dizzy heights. Nonetheless, the 6% or so now spent on administration will certainly increase; already 4000 new non-clinical posts have been created and there will be more to come. Despite experiments going back twenty years, US expenditure remains out of control. After HMOs, HSAs, CONs, PSROs and other toothless attempts at restraint, the American Manufacturers’ Association and other big employers who foot the bill for health care and have failed to tame the persistently rising costs are now saying, in effect, "We give up, let’s try national health insurance". Expenditure in the USA last year was about$650 billion, and that is with an estimated 13% of people wholly uninsured. The other bright side is that the reforms are making clinicians stop and think more about what they are doing and why, about costs and about priorities; and the information technology to do that is slowly being installed.
From
Monday
Neither the big experiment-the "internal market" which is setting health authorities across the negotiating table from clinicians in purchaser and provider roles, respectively, leaving the clinicians’ advisory role uncertain-nor the two so far smaller initiatives stand any chance of success without hard facts on costs and performance. The first wave of self-governing trusts is barely a ripple; 56 units out of 66 which applied have been granted trust status so far and 111 are trying for the coming year. The BMA’s Central Consultants and Specialists Committee has found this first wave unconvincing and unrealistic (eg, applicants making up only 2% of NHS units were seeking 15% of the NHS capital allotment for 1991-92).’ And so far also, only 306 general practices have taken advantage of the opportunity to run their own budgets, a typical one for a combined practice of 9000 patients being 11 million. Such wildly different estimates are being produced by hospitals, even for what ought to be fairly well standardised procedures such as dealing with an ingrowing toenail,that one wonders if the same accounting rules are being followed. A GP wishing to refer for surgery a patient in need of a hip replacement will, in theory, be able to call up all sorts of figures on his computer screencosts, certainly, and waiting times and durations of stay, and postoperative complication rates. Clinical audit, an exercise separate from although relevant to the market and costing 46 million to develop in 1991-92, demands courage and openness, and barriers to it have been breaking down; an accountancy dimension could build resistance up
again. A cautious welcome, then, to the apparent preservation of the NHS as a planned, national service by and large free at the point of use and available to all. And a more effusive response to the idea that much more information on performance indicators in the NHS should be available at the local level and to individual clinicians. So, has The Lancet been converted to the shade, if no longer the substance, of Mrs Thatcher? Not exactly, for questions are legion. Even the former Prime Minister’s best friends would not claim that the changes promote better integration of care and prevention services. Furthermore, the whole idea of market forces remains dubious when the goods will continue to be rationed. The pace of reform has lately been slowed and what is happening amounts to a cementing into contractual form of last year’s referral patterns and work loads. It will be a long time before the effects, if any, on the nation’s health can be assessed, though the burdens being borne by clinicians and managers are all too obvious now. What should trouble those who want to see some good in what is being done is the reluctance of Health Department spokesmen and Ministers to answer any questions specifically and to provide
specific reassurances. Most hospitals in Britain
are not
just
district but
768
In a free market those whose services were not wanted would close. Can that be even contemplated for a large hospital? Already hospitals are thinking that they might not for ever have to provide all the obvious specialties, but what is a also
general.
general hospital without, say, paediatrics or with expert advice remotely placed in some laboratory combine? What will really happen when a budgetholding practice runs out of money? More important, since there have been some ominous signs of GPs sanitising their lists to remove potential high consumers of care, what will happen when patients move? Budgets may not be rigidly fixed at so much per patient but the figure will not easily be adjusted year on year to take account of a chronically sick family moving from one part of the country to another. Will budget holders have such leverage over their peers that they can demand priority for hospital appointments and admissions? In all the talk of budgets and trusts, community medical services have been neglected. So have research and teachingessential functions that until recent years were happily and pragmatically accommodated within the NHS. What about salaries? Will not local negotiations mean that successful units will prosper even more and afford more, and the reverse? And who is going to monitor the success or failure of these experiments, and how? After all, we seem to be heading towards four sorts of health service, not one-internal markets everywhere but with no budget holders or trusts for miles or with one or the other or sometimes both. A recipe for chaos. The Health Departments are already talking of an era when few hospitals are not trusts.9 Education is the latest arm of Britain’s Welfare State in which inducements are being offered to those seeking self governing status, but in the NHS the slush fund for bribes and coercions ought to be exhausted by now. The NHS reforms ran up a bill of 390 million, including controversial "sweeteners" for the first trusts, before anything really happened.10 Let us pause and see how the few pioneers get on. Those remaining sceptical will be on the lookout for a sign so far unknown in the NHS-the patient with a thick file of notes carrying the dismal codicil, "overdrawn". 1. Editorial. Curtains up on the NHS review. Lancet 1989; i: 247-49. 2. Anon. Working papers on the NHS review. Lancet 1989; i: 454. 3. A booklet by C. Ham, R. Robinson, and M. Benzeval (Health Check. London: King’s Fund Institute. 1990. Pp 112. ISBN 1 870607 18 X. £9.95) and a paper by P. Day and R. Klein entitled Britain’s Health Care Experiment (Health Affairs in press) provide useful background for the non-UK reader. 4. Smith R. William Waldegrave: thinking. Br Med J 1991; 302: 636-40. 5. Scheffler R. Adverse selection: the Achilles heel of the NHS reforms. Lancet 1989; i: 950-52. 6. Organisation for Economic Cooperation and Development. Health care systems in transition. Paris: OECD, 1990. 7. Anon. NHS trusts. CCSC Newsl S3 1990-91: 2-3. 8. Dean M. The new NHS supermarket. Lancet 1989; 337: 721. 9. Anon. Working for patients: NHS trusts, a working guide. CCSC Newsl S1 1990-91. 10. Glasman D. Row over government’s "sweeteners" to new trusts. Health Serv J 1991, March 21: 5.
Primary hyperparathyroidism 1,25-dihydroxyvitamin D
and
Primary hyperparathyroidism has been recognised more frequently since the inclusion of calcium measurements in routine biochemical testing. The far
varied manifestations of this condition include renal stones or nephrocalcinosis, non-specific gastrointestinal symptoms, proximal muscle weakness, and occasionally psychiatric complaints. Elderly patients may present with acute hypercalcaemic crisis characterised by confusion and dehydration. Bone disease is seen in less than 10% of cases. Hypercalcaemia is not invariably present and serum phosphate concentration is often low or low normal. Serum alkaline phosphatase activity is usually normal. Inappropriately raised concentrations of parathyroid hormone confirm the diagnosis. Symptomatic primary hyperparathyroidism is treated by surgery, since in 80% of patients there is a single adenoma. Conservative management can be entertained in those who do not have overt
complications.1 Target organs for parathyroid hormone are bone and kidney. The hormone increases bone resorption; in the kidney it alters the handling of calcium and phosphate ions, and enhances the activity of lahydroxylase, leading to increased formation of 1,25dihydroxyvitamin D from 25-hydroxyvitamin D. Extracellular calcium ion concentration, among other factors, also influences renal 1,25(OH)P production.2 1,25(OH)2D can reduce parathyroid hormone synthesis; it inhibits expression of the parathyroid hormone gene by a direct and calciumindependent effect. 3,4 In patients with primary hyperparathyroidism,
1,25(OH)2D concentrations may be increased, normal, or even decreased.5,6 Shaker and colleagues’ serum
described a patient with very high concentrations of intact parathyroid hormone, severe hypercalcaemia, and low circulating concentrations of 1,25(OH)D. Her daily calcium intake exceeded 2 g. Serum calcium returned to normal with calcium restriction alone, and there was a concomitant pronounced rise in serum 1,25(OH)2D and a dramatic fall in circulating parathyroid hormone. In this patient the parathyroid glands were apparently insensitive to the increased serum calcium
lately
but
suppressive effects of 1,25(OH)2D. the inhibitory effect of Presumably, hypercalcaemia on renal 1 a-hydroxylase activity was relieved by dietary calcium restriction, the stimulatory effect of parathyroid hormone on renal lahydroxylase activity was restored. Restoration to not to
the
once
normal of serum 1,25(OH)ZD concentrations led to a fall in parathyroid hormone secretion. These observations illustrate a possible role for 1,25(OH)2D in the treatment of primary hyperparathyroidism; 1,25(OH)2D has already been used in the conservative
