632

Journal of the Royal Society of Medicine Volume 84 October 1991

Costs are dear to the heart of the accountants who are now driving the NHS: the crucial question now is whether we get value for money. The cost of board and lodging allowances for the elderly in England and Wales has increased in the last 7 years from £8 000 000 to £1 200 000 000. In the 1970s we talked of rationing resources, in the 1980s we grappled with the problem of community vs long-term residential care. Community care is still of relevance, the majority of the old still live at home, many receiving no extra help at all, even when severely disabled, so measures of the demands on services are no help whatsoever when we try to estimate need. There is a tested synthetic model which will allow statisticians to relate clinical to demographic data and thus to predict what the real needs are from basic information on age break downs. Questions from the floor came at their usual rate. One was to do with the possible affinity between the very young and the old, to which the answer was that it is easy to be romantic about this, the key is the negotiated obligation. A similar answer was given to the next question which was concerned with the way in which the middle-aged are irritated by the elderly:

if one can build up a mutual obligation over time all will be well. Community care was further discussed, the point being made that families should be counselled against taking in their elderly relatives to live with them; community care should mean enabling people to stay where they are. Getting down to the particular, one member of the audience observed that much has been done to help people with incontinence, bringing the reply that while this is true the big need is to identify those who suffer. At one point a questioner, and I paraphrase his remark, commented that if we are thinking about social services and are not confused we cannot be thinking clearly. As the reply noted, we must move from the anecdotal towards an historical perspective. It would not have been possible to have a meeting like this at the RSM in the 1940s. A meeting then might not, either, have been so cheerful or so informative.

Richard Lansdown Editorial Representative, Open Section

The author replies below:

Letters to the Editor Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double-spaced.

Medical helicopter systems As someone who during their career as a medical officer in the Army gained experience in helicopter casualty evacuation, I was very interested in reading the Report on 'Medical helicopter systems recommended minimum standards for patient management' (April 1991 JRSM, p242). However, I am concerned that in the list of minimal acceptable equipment no mention is made of a chest tube drain with a Heimlich valve for the management of a tension pneumothorax, a condition we know could seriously endanger the life of a patient if in its presence positive pressure ventilation is used in the absence of chest tube drainage. Equipment for the establishment of a cricothyrotomy or if preferred a tracheostomy in cases where endotracheal intubation is not feasible in the presence of severe maxillo-facial injuries including burns was also omitted from the list. Finally, I wondered why no mention was made of splints and dressings. A P DIGNAN 182 Beckenham Hill Road Kent BR3 1SZ

Careful consideration was given to the list of minimum equipment. We decided to only include items that should always be on the helicopter regardless of the type of mission (primary or secondary) or level of staff (doctor, nurse or paramedic). The items in Dr Dignan's letter were therefore excluded, but I believe that the involvement of the medical director, as defined in our recommendations, would result in such equipment being carried where it was relevant. Nevertheless, Dr Dignan's letter does provide a valuable reminder of the benefit of such equipment in the right hands, especially in relation to a tension pneumothorax. A BRISTOW St Bartholomew's Hospital West Smithfield, London EClA 7BE

The war on cancer Temple and Burkitt (February 1991 JRSM, p 95) discuss the effect of cancer therapy with regard to early diagnosis assuming that the total survival time will not change despite early detection and therapy. The therapeutic effect will be therefore in many cancers 'zero'. But this idea was discussed previously by Oeserl in 1974. Radiotherapists, oncologists, as well as all doctors involved in cancer management did not catch on to this thesis. It is very difflcult to find untreated cancer patients in numbers great enough for any comparison2. H-J MAURER

Department of Radiology University Hospital 59100 Kuala Lumpur

Medical helicopter systems.

632 Journal of the Royal Society of Medicine Volume 84 October 1991 Costs are dear to the heart of the accountants who are now driving the NHS: the...
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