CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ.
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when- we receive several on the same subject.
Quality management in the NHS SIR,-D M Berwick and colleagues raised many interesting points in their papers on the doctor's role in quality management. ' 2 Their analysis of the NHS and their proposed solutions, however, left me confused on several points. (1) How does their assertion that "a market can, unconsciously (through the 'invisible hand') achieve efficiency and quality levels beyond those attainable by even the most talented planner," correlate with their subsequent affirmation that the "NHS ... has great potential for rational planned action?" (2) One of the three basic components, they state, of the market model is "consistent and rational buyers." How can you have consistent buyers in a market economy? The main working principle of a market is competition. The survival of the providers depends on their capacity to attract purchasers away from other providers. (3) How would the authors justify the need for the NHS to "operate as a seamless whole" with the resultant fragmentation of the service into thousands of independent provider units that the market principle has produced in the current reforms? (4) Total quality management (TQM) seems like a sensible method to improve a health care service. Its introduction, however, based as it is on cooperation and positive motivation, would seem to be starkly at odds with the present culture of incentives, insecurity, and short termism, engendered by the current reforms. (5) The "new clinical skills" that are advocated for doctors to enable them to practice total quality management, on closer scrutiny turn out not to be so new after all. Improving teamwork and continuing audit are now widely accepted by the medical profession as fundamental to good practice. By all means let us, as a profession, take the "risk" and embrace total quality management in the NHS. I think Berwick and colleagues will find that there is no reluctance on our part to better our own practice, to work with others in the service, and continually to seek to improve the quality of the processes and outcomes of medical care. That is whv we are doctors. What we lack in our present working environment is that culture of trust, cooperation, freedom to suggest developments without robbing Peter to pay Paul, and a feeling that our work is valued by those who control the service. "Reducing fear and apprehension in the TFQM world is a job for leaders" -tell that to our political masters. KATE MACKAY
D)cpartmcnt ot 'lltblic Health MNlediicinc, Lothian Hcalth Board 1 Bcrwick 1)M, Enthovent A, B3unik-er Jl'. Qualitv
774
maagatitgmcnt in
the NHS: the doctor's role-I. BM_ 1992;304:235-9. (25 Januarv.) 2 Berwick DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role-I1. BMJ 1992;304:304-8. (1
February. )
AUTHORS' REPLY,-We welcome the opportunity to reply to Dr Mackay's points of confusion. (1) Our statement that "a market can ... achieve efficiency and quality. . ." is simply a statement of classical economic theory underlying market economy. The articles explain why it usually fails in health care but how market, forces can provide incentives for improvement if coupled with "rational planned action." (2) A consistent and rational buyer is one who seeks to purchase the product that offers the best combination of quality and price. Consistency refers to buyers' preferences for product characteristics. It does not imply buying from the same supplier. (3) The NHS "operating as a seamless whole" we envisage as a system with built in incentives that foster an equilibrium between the public's health care needs, access to general medicine, provision of public health, acute hospital services, and available resources. TQM (total quality management) we propose as a method by which 'to assist in the integration of the "thousands of independent provider units," the fragmentation ofwhich existed long before the current reforms. (4) If by "short termism" Dr Mackay implies a policy seeking a quick fix, she is right; this would not be an environment in which TQM would flourish. TQM is for the long haul. "A culture of insecurity" might also be an unfavourable one for TQM, but it is important to appreciate' that too much security, as may have existed in the past, may also be counterproductive. (5) We believe that TQM provides a mechanism for the improvement of care, whatever the fiscal constraints. The goals of TQM are to provide better care at lower price (poor care, as we argue in the articles, usually costs more). The successful implementation of TQM should, therefore, lead to more and better care within whatever fiscal limits are set. (6) The skills of teamwork that we encourage transcend those currently practised in the United States or Great Britain. Doctors may be reasonably proficient members of teams of doctors in their own specialty. They are less successful in collaboration with doctors in other specialties or with other health professionals and rarely function effectively on problem solving teams with management (for which management must, of course, assume its share of responsibility). New clinical skills in audit were not among those that we proposed, and Dr Mackay is apparently confused as to the central message of the articles: that total quality management, incorporating continuous
quality improvement of all care, should replace medical aiudit's limited objectives of identifying and improving only that medical care that is substandard. The tone of Dr Mackay's letter and particularly her final sentence suggest that she sees the profession's "political masters" as adversaries. There will always be political masters to whom one must be accountable. One of the goals of TQM might reasonably be to enlist them as collaborators, rather than adversaries, in the quest for an across the board improvement in the quality of care. J P BUNKER CRC Clinical Trials Centre, King's College School of Medicine and Dentistry, London SE5 9NU
A ENTHOVEN
Graduate School of Business, Stanford University, Stanford, California 94305 USA
D M BERWICK Harvard Community Health Plan, Boston, AMassachusetts 02115 USA
SIR, -D M Berwick and others propose that total quality management should be used in the NHS. 2 It is not unknown to the NHS, of course; it and allied techniques such as quality circles have been used by health authorities and endorsed by some regions for some time. New, however, is the suggestion that total quality management should be endorsed nationally. Most care in the NHS, in terms of patients treated, is at primary health care level. Berwick and colleagues make some acknowledgment of the future need of general practitioners: "To fulfil their responsibilities as gate keepers and care givers [they] must understand decision analysis and probability theory. They must be able to take advantage of computerised medical information technology and its access to data relevant to the patient at hand in order to refine the decision whether to refer or to provide care.... For this to happen it will . . be necessary to undergo . .. a level of training and expertise perhaps as demanding as that of the specialist consultant." The role of audit is dismissed: they say that it has been the focus of a vast American industry that has had virtually no impact on the quality of care, and that it had been hoped that the results of medical audit and consensus conferences and clinical guidelines would be adopted by the profession to improve the quality of practice, but this has failed to happen. I both agree and disagree with the authors. Medical audit as introduced into the NHS has not yet had one year of life. To condemn our potential for change on the basis of the American experience is to display ignorance of what medical audit advisory groups are already achieving in every part of Britain. The eight new clinical skills defined
BMJ VOLUME 304
21 MARCH 1992
by the authors are prerequisites for any major collaborative audit, and the enthusiasm with which general practitioners in Manchester have accepted the task of improving their standards in the care of diabetes, in collaboration with consultant colleagues, suggests great achievements ahead. We have similar schemes for antenatal care, hypertension, and radiology as well as for facilitating audit in individual practices. Of course, as the authors identified, this work raises educational needs, and we are addressing these. My argument with Berwick and colleagues is that, in the longer term, quality and outcomes as assessed by patients will be seen as clear objectives and that formal audit, though the main tool, may not be all that medical audit advisory groups find themselves asked to do. Already practices are asking for help with organisation and management as well as audit. Perhaps by the end of the decade we shall be restyling ourselves medical quality management groups. ROGER JOHNSON
Chairman, Mianchcster Mtedical AuLdit Advisory Group, Manchester Chest Clinic, MAi\nchcstcr AM13 9N L I Berwick DM1, Enthovcn A, Bunker JP. Quality management in the NHS-1. &MWJ 1992;304:235-9. (25 Januarv.) 2 Berwick DMI, Enthoven A, Bunker JP. Quality management in the NHS-IL. BAIJ 1992;304:304-8. (I February.)
SIR,-In discussing quality management D M Berwick and colleagues emphasise the importance of studying the processes by which health care is delivered as well as the content of such care.' The unidisciplinary approach of medical or nursing audit, though appropriate in other contexts, is of limited use in this. We should examine how well the different professional and functional components of service delivery fit together as a whole for patients. In these respects the Audit Commission's recent reports concerning the organisation of inpatient care in acute hospitals are disappointing.2 Readers are left struggling to bring together and make sense of two analyses which are not comparable and are based on different units of organisation: the ward for nurses and the bed for consultants. There seems to have been little attempt to deal with these difficulties either in the design of the studies or in the reports. Two separate programmes of audit will now go ahead, which, if they follow the commission's recommendations, will ignore crucial issues about the boundaries and relations between the roles, organisation, and coordination of nursing and medical care on acute wards. This will do little to encourage fundamental questions about the costs and benefits of perpetuating these differences. My recent experience of studying the role and management of junior house officers brought home the relevance of total quality management to the design of high quality care.4 Ward sisters and general managers as well as preregistration house officers, consultants, and other staff groups were interviewed. Without such a design we would probably have missed the point that patients may sometimes be dangerously exposed by the misalignment of the different units of work organisation of nurses and doctors and that this misalignment can contribute considerably to the work problems and problems of supervision of junior house officers as well as waste resources. SUE DOWLING
Departmenit of Epidemiology and Plublic Health Medicine, University of Bristol, Bristol BS8 3PR
DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role. B.MJ7 1992;304:235-9 (25 January), 304-8. (I February.) 2 Audit Commission. The, virtzue of patients: making the best use of ward nursing resources. London: HAISO, 1991. 3 Audit Commission. Lving in wait: the uise of-medical beds in aciute hospitals. London: HMSO, 1992. 1 Berwick
BMJ
VOLUME
304
21
MARCH
1992
4 Dowlinig S, Barrett S. Doctors in the making. The experience ol the,
pre-registrationi ear. Bristol Universit: SAUS Publications, 1991.
Reducing risks in the sudden infant death syndrome SIR, -In their editorial on the sudden infant death syndrome D P Southall and M P Samuels did not consider an alternative hypothesis: that the risk of sudden infant death increases in proportion to the amount of time an infant spends asleep out of parental earshot.' I worked for two years as the paediatrician in a hospital in Zimbabwe that served an urban black African population of about 300 000. About a fifth of the population was under 5 years old. Ours was the only hospital in the town. The only legal way of registering the death of a child was through the hospital mortuary. In two years neither I nor the single police officer who interviewed the parents of all children brought in dead ever heard of a "cot death"-of an infant put to sleep well and found dead. African colleagues told me that they could not think of any cultural reason why a story of sudden unexplained infant death might be withheld by parents. Black Zimbabwean infants almost invariably sleep with their mothers, at least until they are 6 months and often until 1 year. Sudden infant death may result from trivial embarrassments-upper respiratory tract infection, overheating, regurgitation and aspiration, and so on. It may begin with unremarkable episodes of distress, which, if they had been witnessed, might have been simply attended to and thought little of. My hypothesis is consistent with the finding of a lower incidence of the sudden infant death syndrome in overcrowded communities. A small questionnaire study among women attending an antenatal clinic in Birmingham found that 22% of Asian babies were put to sleep on their backs compared with 3% of white babies. It also found, however, that 98% of the Asian babies slept in the same room as their parents for the first year, 34% in the same bed.' Only 65% of white infants slept in the same room as their parents. Existing databases on the sudden infant death syndrome'should be interrogated with respect to this hypothesis, and prospective studies should be designed to address it. If the hypothesis were true a simple piece of advice-that babies should sleep next to their parents for the first six months of life-might make an important contribution to reducing the incidence of the syndrome. I have no doubt that parents whose baby is even trivially unwell should be advised to let the baby sleep with them. DUNCAN KEELEY
Thame, Oxfordshire I Sotithall DP, Samuels MP. Reducing risks in the suddcit infant death svndrome. B1AJ 1992;304:265-6. Februarv). 2 Lee NN, Chan YE, Davics DP, Lau F, Yip DC. Scidden inl:ant death sN-ndrome in Hong Kong: confirmation of low incidencc. B,ll 1989;298:721. 3 Faroooqi S, Perrv IJ, Beevers DG. Ethnic difftrences in slecpitig position and in risk of cot death. Latncet 1991;338:1455.
SIR,-The falling incidence of the sudden infant death syndrome in Avon in 1990 and 1991,' which paralleled a reduction in prone sleeping practices, is further evidence that supine or lateral posture during sleep reduces the risk of sudden infant death. However, we seek reassurance that sleeping position was the only risk factor to vary over the study period. An important mechanism underlying the sudden infant death syndrome is failure of respiratory control at a vulnerable stage of development: more a "physiological syndrome" than a disease in the accepted sense. Disturbance to this delicate equilibrium might upset the regulation of breath-
ing, leading sometimes to death. Epidemiological risk factors are somehow linked with destabilising influences to breathing, and by avoiding or modulating these the risk of death can be reduced. We wonder whether some of these influences can be found in a baby's immediate environment. The practice of placing infants to sleep on their own for relatively long periods, a common practice in Western countries has few historical or cultural parallels. Babies left alone, particularly at night, might lose external sensory stimulation which may help stabilise breathing patterns. Experimental work with mothers and infants cosleeping in sleep laboratories is showing how patterns of breathing may interact.' Alertness of the babies' carers to early symptoms of illness might also be blunted. In Hong Kong, where the sudden infant death syndrome is very uncommon,' babies sleep lying supine but are never left alone. In Britain sudden infant death is much less common in Asian families than in white or Afro-Caribbean families.4 Asian babies are also more likely to be placed to sleep on their backs and in their parents' bedroom." Any fall in the incidence of the sudden infant death syndrome is welcome. However, we share some of Southall and Samuels' caution that we should not be too hasty in attributing the improvement solely to changes in sleeping posture. Any intervention programme which attempts to reduce the incidence of the syndrome has to consider the broad range of infant care practices which could also reduce risk. D P DAVIES MADELEINE GANTLEY
University of Wales College of Mledicine,
Cardiff'CF4 4XN ANN MURCOTT London School oflHygiene and rropical M\edicinc, London WC1E 7HT I Wigfield RE, Fleming PJ, Beorg PJ, Rudd PT, Golding J. Can the f;all in Avon's sudden infant death rate be explained by chaniges in sleeping position? BM_7 1992;304:282-3. I
February.)
2 McKenna JJ, Mosko S. Evolution and the sudden infant death syndrome. III. Intfant arousal and parent-infant co-sleeping. Human Nature 1990;1:291-330. 3 Lee NNY, Chan YF, Davies DP, Lau E, Yip DCCP. Sudden int'ant death syndrome in Hong Kong: confirmation of low incidence. BMJ 1989;298:721. 4 Balarajan R, Soni RV, Botting B. Sudden infant death syndrome and postnatal mortality in immigrants in England and Wales.
BA3M 1989;298:716-20. 5 Kyle D, Sunderland R, Stonehouse M, Cutnmings C, Ross 0. Ethnic differences in incidence of sudden infant death in Birmingham. Arch D)is Child 1990;65:830-3. 6 Farooqi S, Perry IJ, Beevers DG. Ethnic differences in sleeping position and in risk of cot death. ILancet 1991;338:1455. 7 Southall DP, Samuels MT. Reducing risks in the sudden infant death syndrome. BMJ7 1992;304:265-6. (I Februtary.)
Monitoring cot death rates SIR,-The postneonatal mortality rate for England and Wales ranged between 4 0 and 4 5/1000 live births in 1978-88. In 1989 it fell to 3 7/1000 and in 1990, which is the latest available, to 3-3/1000. Presumably this was due to a fall in numbers of cot deaths, which are responsible for a half of all postneonatal deaths. Stanton reported a 50% fall in the cot death rate of Scarborough district after parents were advised not to overwarm their small infants (the "Keep cool, baby" campaign).' Wigfield and others reported a similar reduction in four other districts by advice against letting the infant sleep in the prone position.2 Now the Foundation for the Study of Infant Deaths and the Department of Health recommend both procedures-supine sleeping and not overwarming.' To monitor the effect it is important to have accurate figures on the cot death rate. Since most cot deaths occur between 1 and 4 months of age and neonatal deaths are now part of the perinatal mortality rate it is best to concentrate on postneonatal mortality only. T he Office of Population
775
* We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when- we receive several on the same subject.
Quality management in the NHS SIR,-D M Berwick and colleagues raised many interesting points in their papers on the doctor's role in quality management. ' 2 Their analysis of the NHS and their proposed solutions, however, left me confused on several points. (1) How does their assertion that "a market can, unconsciously (through the 'invisible hand') achieve efficiency and quality levels beyond those attainable by even the most talented planner," correlate with their subsequent affirmation that the "NHS ... has great potential for rational planned action?" (2) One of the three basic components, they state, of the market model is "consistent and rational buyers." How can you have consistent buyers in a market economy? The main working principle of a market is competition. The survival of the providers depends on their capacity to attract purchasers away from other providers. (3) How would the authors justify the need for the NHS to "operate as a seamless whole" with the resultant fragmentation of the service into thousands of independent provider units that the market principle has produced in the current reforms? (4) Total quality management (TQM) seems like a sensible method to improve a health care service. Its introduction, however, based as it is on cooperation and positive motivation, would seem to be starkly at odds with the present culture of incentives, insecurity, and short termism, engendered by the current reforms. (5) The "new clinical skills" that are advocated for doctors to enable them to practice total quality management, on closer scrutiny turn out not to be so new after all. Improving teamwork and continuing audit are now widely accepted by the medical profession as fundamental to good practice. By all means let us, as a profession, take the "risk" and embrace total quality management in the NHS. I think Berwick and colleagues will find that there is no reluctance on our part to better our own practice, to work with others in the service, and continually to seek to improve the quality of the processes and outcomes of medical care. That is whv we are doctors. What we lack in our present working environment is that culture of trust, cooperation, freedom to suggest developments without robbing Peter to pay Paul, and a feeling that our work is valued by those who control the service. "Reducing fear and apprehension in the TFQM world is a job for leaders" -tell that to our political masters. KATE MACKAY
D)cpartmcnt ot 'lltblic Health MNlediicinc, Lothian Hcalth Board 1 Bcrwick 1)M, Enthovent A, B3unik-er Jl'. Qualitv
774
maagatitgmcnt in
the NHS: the doctor's role-I. BM_ 1992;304:235-9. (25 Januarv.) 2 Berwick DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role-I1. BMJ 1992;304:304-8. (1
February. )
AUTHORS' REPLY,-We welcome the opportunity to reply to Dr Mackay's points of confusion. (1) Our statement that "a market can ... achieve efficiency and quality. . ." is simply a statement of classical economic theory underlying market economy. The articles explain why it usually fails in health care but how market, forces can provide incentives for improvement if coupled with "rational planned action." (2) A consistent and rational buyer is one who seeks to purchase the product that offers the best combination of quality and price. Consistency refers to buyers' preferences for product characteristics. It does not imply buying from the same supplier. (3) The NHS "operating as a seamless whole" we envisage as a system with built in incentives that foster an equilibrium between the public's health care needs, access to general medicine, provision of public health, acute hospital services, and available resources. TQM (total quality management) we propose as a method by which 'to assist in the integration of the "thousands of independent provider units," the fragmentation ofwhich existed long before the current reforms. (4) If by "short termism" Dr Mackay implies a policy seeking a quick fix, she is right; this would not be an environment in which TQM would flourish. TQM is for the long haul. "A culture of insecurity" might also be an unfavourable one for TQM, but it is important to appreciate' that too much security, as may have existed in the past, may also be counterproductive. (5) We believe that TQM provides a mechanism for the improvement of care, whatever the fiscal constraints. The goals of TQM are to provide better care at lower price (poor care, as we argue in the articles, usually costs more). The successful implementation of TQM should, therefore, lead to more and better care within whatever fiscal limits are set. (6) The skills of teamwork that we encourage transcend those currently practised in the United States or Great Britain. Doctors may be reasonably proficient members of teams of doctors in their own specialty. They are less successful in collaboration with doctors in other specialties or with other health professionals and rarely function effectively on problem solving teams with management (for which management must, of course, assume its share of responsibility). New clinical skills in audit were not among those that we proposed, and Dr Mackay is apparently confused as to the central message of the articles: that total quality management, incorporating continuous
quality improvement of all care, should replace medical aiudit's limited objectives of identifying and improving only that medical care that is substandard. The tone of Dr Mackay's letter and particularly her final sentence suggest that she sees the profession's "political masters" as adversaries. There will always be political masters to whom one must be accountable. One of the goals of TQM might reasonably be to enlist them as collaborators, rather than adversaries, in the quest for an across the board improvement in the quality of care. J P BUNKER CRC Clinical Trials Centre, King's College School of Medicine and Dentistry, London SE5 9NU
A ENTHOVEN
Graduate School of Business, Stanford University, Stanford, California 94305 USA
D M BERWICK Harvard Community Health Plan, Boston, AMassachusetts 02115 USA
SIR, -D M Berwick and others propose that total quality management should be used in the NHS. 2 It is not unknown to the NHS, of course; it and allied techniques such as quality circles have been used by health authorities and endorsed by some regions for some time. New, however, is the suggestion that total quality management should be endorsed nationally. Most care in the NHS, in terms of patients treated, is at primary health care level. Berwick and colleagues make some acknowledgment of the future need of general practitioners: "To fulfil their responsibilities as gate keepers and care givers [they] must understand decision analysis and probability theory. They must be able to take advantage of computerised medical information technology and its access to data relevant to the patient at hand in order to refine the decision whether to refer or to provide care.... For this to happen it will . . be necessary to undergo . .. a level of training and expertise perhaps as demanding as that of the specialist consultant." The role of audit is dismissed: they say that it has been the focus of a vast American industry that has had virtually no impact on the quality of care, and that it had been hoped that the results of medical audit and consensus conferences and clinical guidelines would be adopted by the profession to improve the quality of practice, but this has failed to happen. I both agree and disagree with the authors. Medical audit as introduced into the NHS has not yet had one year of life. To condemn our potential for change on the basis of the American experience is to display ignorance of what medical audit advisory groups are already achieving in every part of Britain. The eight new clinical skills defined
BMJ VOLUME 304
21 MARCH 1992
by the authors are prerequisites for any major collaborative audit, and the enthusiasm with which general practitioners in Manchester have accepted the task of improving their standards in the care of diabetes, in collaboration with consultant colleagues, suggests great achievements ahead. We have similar schemes for antenatal care, hypertension, and radiology as well as for facilitating audit in individual practices. Of course, as the authors identified, this work raises educational needs, and we are addressing these. My argument with Berwick and colleagues is that, in the longer term, quality and outcomes as assessed by patients will be seen as clear objectives and that formal audit, though the main tool, may not be all that medical audit advisory groups find themselves asked to do. Already practices are asking for help with organisation and management as well as audit. Perhaps by the end of the decade we shall be restyling ourselves medical quality management groups. ROGER JOHNSON
Chairman, Mianchcster Mtedical AuLdit Advisory Group, Manchester Chest Clinic, MAi\nchcstcr AM13 9N L I Berwick DM1, Enthovcn A, Bunker JP. Quality management in the NHS-1. &MWJ 1992;304:235-9. (25 Januarv.) 2 Berwick DMI, Enthoven A, Bunker JP. Quality management in the NHS-IL. BAIJ 1992;304:304-8. (I February.)
SIR,-In discussing quality management D M Berwick and colleagues emphasise the importance of studying the processes by which health care is delivered as well as the content of such care.' The unidisciplinary approach of medical or nursing audit, though appropriate in other contexts, is of limited use in this. We should examine how well the different professional and functional components of service delivery fit together as a whole for patients. In these respects the Audit Commission's recent reports concerning the organisation of inpatient care in acute hospitals are disappointing.2 Readers are left struggling to bring together and make sense of two analyses which are not comparable and are based on different units of organisation: the ward for nurses and the bed for consultants. There seems to have been little attempt to deal with these difficulties either in the design of the studies or in the reports. Two separate programmes of audit will now go ahead, which, if they follow the commission's recommendations, will ignore crucial issues about the boundaries and relations between the roles, organisation, and coordination of nursing and medical care on acute wards. This will do little to encourage fundamental questions about the costs and benefits of perpetuating these differences. My recent experience of studying the role and management of junior house officers brought home the relevance of total quality management to the design of high quality care.4 Ward sisters and general managers as well as preregistration house officers, consultants, and other staff groups were interviewed. Without such a design we would probably have missed the point that patients may sometimes be dangerously exposed by the misalignment of the different units of work organisation of nurses and doctors and that this misalignment can contribute considerably to the work problems and problems of supervision of junior house officers as well as waste resources. SUE DOWLING
Departmenit of Epidemiology and Plublic Health Medicine, University of Bristol, Bristol BS8 3PR
DM1, Enthoven A, Bunker JP. Quality management in the NHS: the doctor's role. B.MJ7 1992;304:235-9 (25 January), 304-8. (I February.) 2 Audit Commission. The, virtzue of patients: making the best use of ward nursing resources. London: HAISO, 1991. 3 Audit Commission. Lving in wait: the uise of-medical beds in aciute hospitals. London: HMSO, 1992. 1 Berwick
BMJ
VOLUME
304
21
MARCH
1992
4 Dowlinig S, Barrett S. Doctors in the making. The experience ol the,
pre-registrationi ear. Bristol Universit: SAUS Publications, 1991.
Reducing risks in the sudden infant death syndrome SIR, -In their editorial on the sudden infant death syndrome D P Southall and M P Samuels did not consider an alternative hypothesis: that the risk of sudden infant death increases in proportion to the amount of time an infant spends asleep out of parental earshot.' I worked for two years as the paediatrician in a hospital in Zimbabwe that served an urban black African population of about 300 000. About a fifth of the population was under 5 years old. Ours was the only hospital in the town. The only legal way of registering the death of a child was through the hospital mortuary. In two years neither I nor the single police officer who interviewed the parents of all children brought in dead ever heard of a "cot death"-of an infant put to sleep well and found dead. African colleagues told me that they could not think of any cultural reason why a story of sudden unexplained infant death might be withheld by parents. Black Zimbabwean infants almost invariably sleep with their mothers, at least until they are 6 months and often until 1 year. Sudden infant death may result from trivial embarrassments-upper respiratory tract infection, overheating, regurgitation and aspiration, and so on. It may begin with unremarkable episodes of distress, which, if they had been witnessed, might have been simply attended to and thought little of. My hypothesis is consistent with the finding of a lower incidence of the sudden infant death syndrome in overcrowded communities. A small questionnaire study among women attending an antenatal clinic in Birmingham found that 22% of Asian babies were put to sleep on their backs compared with 3% of white babies. It also found, however, that 98% of the Asian babies slept in the same room as their parents for the first year, 34% in the same bed.' Only 65% of white infants slept in the same room as their parents. Existing databases on the sudden infant death syndrome'should be interrogated with respect to this hypothesis, and prospective studies should be designed to address it. If the hypothesis were true a simple piece of advice-that babies should sleep next to their parents for the first six months of life-might make an important contribution to reducing the incidence of the syndrome. I have no doubt that parents whose baby is even trivially unwell should be advised to let the baby sleep with them. DUNCAN KEELEY
Thame, Oxfordshire I Sotithall DP, Samuels MP. Reducing risks in the suddcit infant death svndrome. B1AJ 1992;304:265-6. Februarv). 2 Lee NN, Chan YE, Davics DP, Lau F, Yip DC. Scidden inl:ant death sN-ndrome in Hong Kong: confirmation of low incidencc. B,ll 1989;298:721. 3 Faroooqi S, Perrv IJ, Beevers DG. Ethnic difftrences in slecpitig position and in risk of cot death. Latncet 1991;338:1455.
SIR,-The falling incidence of the sudden infant death syndrome in Avon in 1990 and 1991,' which paralleled a reduction in prone sleeping practices, is further evidence that supine or lateral posture during sleep reduces the risk of sudden infant death. However, we seek reassurance that sleeping position was the only risk factor to vary over the study period. An important mechanism underlying the sudden infant death syndrome is failure of respiratory control at a vulnerable stage of development: more a "physiological syndrome" than a disease in the accepted sense. Disturbance to this delicate equilibrium might upset the regulation of breath-
ing, leading sometimes to death. Epidemiological risk factors are somehow linked with destabilising influences to breathing, and by avoiding or modulating these the risk of death can be reduced. We wonder whether some of these influences can be found in a baby's immediate environment. The practice of placing infants to sleep on their own for relatively long periods, a common practice in Western countries has few historical or cultural parallels. Babies left alone, particularly at night, might lose external sensory stimulation which may help stabilise breathing patterns. Experimental work with mothers and infants cosleeping in sleep laboratories is showing how patterns of breathing may interact.' Alertness of the babies' carers to early symptoms of illness might also be blunted. In Hong Kong, where the sudden infant death syndrome is very uncommon,' babies sleep lying supine but are never left alone. In Britain sudden infant death is much less common in Asian families than in white or Afro-Caribbean families.4 Asian babies are also more likely to be placed to sleep on their backs and in their parents' bedroom." Any fall in the incidence of the sudden infant death syndrome is welcome. However, we share some of Southall and Samuels' caution that we should not be too hasty in attributing the improvement solely to changes in sleeping posture. Any intervention programme which attempts to reduce the incidence of the syndrome has to consider the broad range of infant care practices which could also reduce risk. D P DAVIES MADELEINE GANTLEY
University of Wales College of Mledicine,
Cardiff'CF4 4XN ANN MURCOTT London School oflHygiene and rropical M\edicinc, London WC1E 7HT I Wigfield RE, Fleming PJ, Beorg PJ, Rudd PT, Golding J. Can the f;all in Avon's sudden infant death rate be explained by chaniges in sleeping position? BM_7 1992;304:282-3. I
February.)
2 McKenna JJ, Mosko S. Evolution and the sudden infant death syndrome. III. Intfant arousal and parent-infant co-sleeping. Human Nature 1990;1:291-330. 3 Lee NNY, Chan YF, Davies DP, Lau E, Yip DCCP. Sudden int'ant death syndrome in Hong Kong: confirmation of low incidence. BMJ 1989;298:721. 4 Balarajan R, Soni RV, Botting B. Sudden infant death syndrome and postnatal mortality in immigrants in England and Wales.
BA3M 1989;298:716-20. 5 Kyle D, Sunderland R, Stonehouse M, Cutnmings C, Ross 0. Ethnic differences in incidence of sudden infant death in Birmingham. Arch D)is Child 1990;65:830-3. 6 Farooqi S, Perry IJ, Beevers DG. Ethnic differences in sleeping position and in risk of cot death. ILancet 1991;338:1455. 7 Southall DP, Samuels MT. Reducing risks in the sudden infant death syndrome. BMJ7 1992;304:265-6. (I Februtary.)
Monitoring cot death rates SIR,-The postneonatal mortality rate for England and Wales ranged between 4 0 and 4 5/1000 live births in 1978-88. In 1989 it fell to 3 7/1000 and in 1990, which is the latest available, to 3-3/1000. Presumably this was due to a fall in numbers of cot deaths, which are responsible for a half of all postneonatal deaths. Stanton reported a 50% fall in the cot death rate of Scarborough district after parents were advised not to overwarm their small infants (the "Keep cool, baby" campaign).' Wigfield and others reported a similar reduction in four other districts by advice against letting the infant sleep in the prone position.2 Now the Foundation for the Study of Infant Deaths and the Department of Health recommend both procedures-supine sleeping and not overwarming.' To monitor the effect it is important to have accurate figures on the cot death rate. Since most cot deaths occur between 1 and 4 months of age and neonatal deaths are now part of the perinatal mortality rate it is best to concentrate on postneonatal mortality only. T he Office of Population
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