NEWS & Political Review New initiatives for people with learning disabilities Last week the Department of Health announced that it would try harder to improve services for mentally handicapped people. The smallest, but perhaps most telling, change of emphasis is the department's decision to drop the term mental handicap in favour of "learning disabilities." According to Stephen Dorrell, parliamentary secretary for health, this change "should reflect our commitment to thinking of people with learning disabilities as individuals in their own right ... citizens [and] full members of our society." Speaking at a conference last week organised by MENCAP (the Royal Society for Mentally Handicapped Children and Adults), Mr Dorrell admitted that, while the government's record over the past 20 years "isn't bad," about two thirds of the 25 000 people in long stay mental handicap hospitals may be inappropriately placed. And there are still not enough day services for those who live in the community, 120 000 of whom have no prospect of becoming wholly independent. To underline the government's commitment to such services Mr Dorrell announced three main strategies. Firstly, new draft guidance on providing better general social care and ensuring access to health care has been sent to health and socia4 services authorities. Secondly, specific proposals to bring all facilities for day care up to the level of the People with learning disabilities are citizens too best have been issued. Thirdly, a working aged over 15 with such disabilities live with group chaired by Peter Searle, director general of the Mental Health Foundation (a their parents and that there is a limit to the research charity), will identify what really care that their families can provide. But, makes a successful service for people with according to researchers from the King's learning disabilities who also have psychiatric Fund College, this limit is often obscured by the willingness of parents to make enormous or severe behavioural disturbance. The government's statements coincided efforts to provide lifelong support themwith a flurry of reports criticising current selves. David Towell and Virginia Beardshaw provision of care for people with learning disabilities. MENCAP reported a shortfall of from the King's Fund College explain that up to 30000 day places that leaves many public services for people with learning disapeople with "empty days and empty lives." bilities should have two main aims -enabling The charity has entered a new coalition of and community integration. Enabling is a special interest groups including the British jargon term that means using power and Association of Social Workers, the Royal authority to help communities and interest College of Nursing, and the Confederation of groups to meet challenges in the way that Health Service Employees (COHSE)-that they wish. But community integration, will jointly protest against "the current say Towell and Beardshaw, "can look confusion over services [which] will leave us dangerously like leaving people to fend for with an unacceptable mix of institutions and themselves unaided ... fanciful versions [of grossly inadequate support." the concept] ask more of spontaneous neighTwo other reports confirmed that many bourliness than most of us living in late people with learning disabilities receive in- twentieth century communities would find adequate support from statutory services, as either safe or realistic." do their carers. A study from North West Their report presents clear recommendaThames region showed that 42% of people tions on improving public (that is, health and -

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social) services for people with learning disabilities. In addition to general improvements in training, research, and quality of service, the authors call for a coordinated effort across government departments. An important and overdue part of this renewed effort, says the report, must be the implementation of the various entitlements to assessment and support that have been promised by recent legislation on education, child care, disability, and health.-TRISH GROVES, BMJ Empty Davs ... Empty Lives-a MENCAP Report on Day Services-the Vision and the Reality is available free of charge from MENCAP National Centre, 123 Golden Lane, London EClY ORT. A summary booklet of the report Dimensions of Mental Handicap by Richard Farmer, Jenifer Rhode, and Ben Sacks is available free of charge from the Department of Public Health and Epidemiology, Charing Cross and Westminster Medical School, 17 Horseferry Road, London SW I P 2AR. The full report costs £50. Enabling Community Integration by David Towell and Virginia Beardshaw is available from the King's Fund College, 14 Palace Court, London W2 4HT, price £9.95.

7

Headlines

_ Canada's health care has problems too

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BMA reaffirms opposition to NHS reforms: At its annual meeting this week the BMA'condemned the continued underfunding of the NHS and reaffirmed its opposition to the NHS reforms. It will still monitor their effects and publicise the flaws but also seek constructive dialogue with the government rather than confrontation.

John Dawson Trust: A trust has been set up to honour John Dawson, who guided the BMA in several of its most high profile scientific and ethical campaigns from'1981 until his death in 1990. The trust will promote achievements in social policy and health. Sir Douglas Black is chairman of the trustees; the other trustees are Professor Andy Haines, Dr Stephen Lock, and Mrs Pamela Taylor. Organ removal approved: In a Gallup poll of nearly 1000 people commissioned by'the British Kidney Patient Association six out of 10 said that vital organs should be removed automatically for transplantation after death unless the person has refused beforeha'nd.

Youth treatment advisory group: An advisory group has been set up to ensure that there is an independent and open scrutiny of the care practices in youth treatment centres. The group -will be chaired by Winifred Tumim, chairman of the Royal National Institute for the Deaf. France bans AIDS vaccine trials: France's Minisiry of Health has banned trials of potential AIDS vaccines using recombinant vaccinia virus. This follows an investigation into the deaths of three patients, which concluded that the trial in which they took part was not conducted properly.

Disposing of babies born before 28 weeks: Research by the Stillbirth and Neonatal Death Society shows that 28 of 105 mortuaries surveyed incinerate the bodies of babies born before 28 weeks' gestation. In 20 out of 95 pathology laboratories waste disposal units are used. The organisation wants parents to be offered a choice of what happens to their babies. BMA's new head of science and ethics: Dr Fleur Fisher has been appointed head of the BMA's professional, scientific, and international affairs division. Dr Fisher, who takes up her post in September, has been a unit general manager of the community and mental health unit in Macclesfield and before that was a senior clinical medical officer in family planning.

8

Alarm bells about the future of Canada's system of health care have gone off this spring. There is concern that cuts in funds from the federal government to the provinces will undermine the system. The federal government transfers $28bn annually to the provinces. In the process it plays Robin Hood, giving to the poorer provinces some $8bn in taxes collected from the richer ones like Ontario and British Columbia. That has kept a level standard of 4jealth care across the nation.

Now it intends to cut the funds by a fifth and to give provinces tax credits instead of cash grants. The president of the Canadian Medical Association, Dr Lionel Lavoie, has said this will financially strangle Canadian Medicare; people in the poorer provinces will be the first to suffer. New Brunswick's medical association has warned that the province's health care, already under severe constraint, may not be able to survive. The only hopeful note came last week when federal and provincial health ministers emerged from a closed meeting to declare that they were all committed to preserving the health of Canada's Medicare. The worries about Canada's national health care come at a time when the system has been receiving more attention from the US than ever before in its 20 year history-with good reason. In the US 37 million people have no health care insurance and another 37 million do not have enough. All of Canada's 28 million people are covered by the government' plan. Costs in the US are much higher. It spends almost 12% of its gross national product on health care compared with Canada's 8-6%. Many for profit hospitals in the US are hungry for business. Their occupancy rates have dropped largely because of private American insurers and the government plans covering the old and very poor, which set tight regulations on lengths of stay. A study by economists from Stanford University published last year showed that the spending on health per person in the US was $347 compared with $202 in Canada. It found that if the US spent the same as Canada it would save over $1OObn a year. Not surprisingly, given- the enormous health insurance industry in the US, there has been a strong lobby against an American national health care insurance plan. The opponents' campaign has included sniping at the Canadian system, focusing on its shortcomings. For example, one American television documentary described the plight of a man in Vancouver who was still waiting for coronary bypass surgery five months after his doctor had listed his case as urgent. The failed to mention that the man refused to have a different surgeon perform the operation sooner, preferring to wait for the surgeon of his choice. Nevertheless, Canadian patients do face a longer wait for some treatments than do Americans. In Ontario last year a number of people crossed the border for heart surgery rather than wait. Others went south for programme

treatment for drug addiction: one addict cost the Ontario government $C500 000. The government usually pays the amount that the treatment would cost in Ontario with the patients paying the difference. But hospitals and doctors across the border, eager for business, often accept the Ontario rate as payment in full, although medical fees in the US are up to three times higher than those in Canada. Although there were outcries in the media about Canadians being forced to leave the country to obtain prompt care, there has been no sustained public protest. But waiting lists for elective treatment in hospital are certain to increase because the provinces have put a tight rein on the funding of health care. As a result many hospitals have had' to close beds to stay within their budgets. There is no private medical or hospital care in Canada, so the alternative to waiting for care is to go to the US. In Canada the proliferation of high technology has been curbed by governments and patients face waits for computed tomography, magnetic resonance imaging, and lithotripsy. Though many health economists agree that Canada probably has too little high technology, they argue that the US probably has too much. Canadians are beginning to realise that they cannot expect to have all the bells and whistles available to their American cousins. But few believe that the grass is greener in the health field below the border. -MARILYN DUNLOP, Toronto Star

Scandal threatens French blood transfusion service Grave errors were committed that led to HIV infection in several hundred patients with haemophilia treated with contaminated blood extracts in France. Bruno Durieux, French minister delegate for health, has admitted as much openly, and an investigation has been started to establish responsibility for the contaminations that took place in 1985 and perhaps even later. Contrary to French legislation, several people and

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companies seem to have made profits in the blood trade, and Jean-Louis Bianco, the new minister of social affairs and integration, declared, "If there has been wrongdoing appropriate sanctions will be taken without hesitation." The investigation will undoubtedly be lengthy and complex, involving not only French companies set up to supply the National Centre of Blood Transfusion (CNTS) with services, blood products, and equipment but foreign companies, which are looking forward to the end of the de facto non-profit monopoly of the CNTS on I January 1993. The victims of errors and suspected wrongdoings are the 1200 people with haemophilia, out of a total of about 3000, who have been infected with HIV. Some of them were infected after the CNTS was warned that blood extracts that were not heat treated were potentially dangerous. In addition, it seems that plasma contaminated with HIV was used in some small provincial hospitals and clinics until last year simply because a thorough recall system had not been put into effect. Methods of compensating patients and their families have been vigorously criticised. Compensation has come from two funds. One, of Fr2Om (about £2m) was set up by the government to distribute sick pay. Another, the so called "private solidarity fund" of Frl70m, was created by the CNTS and its insurers with the agreement of the French Association of Haemophiliacs and the Ministry of Health. The fund sent each patient infected with HIV or his family a letter offering compensation of FrlO 000 (HO 000) on condition that he or she surrendered all claims against transfusion centres and insurance companies. An audit-and a report from the general inspectorate of social affairs are expected. ALEXANDER DOROZYNSKI, medical journalist, Paris

Health reforms in Europe Britain is not alone: most of the rest of Europe is in the throes of cost containing health reforms too. And doctors throughout Europe have been expressing concern that radical changes in the financing and delivery of care are being introduced with insufficient evidence that they will improve care. In Belgium reforms in the early 1980s have resulted in the closure of over 130 hospitals and a 14% reduction in acute beds, a Meeting in Brussels organised by the European Health Policy Forum heard earlier this month. Some 6000 psychiatric beds have closed. Financial incentives have encouraged hospitals to merge, and those with fewer than 150 beds have had to do so or close. The average length of stay in hospital has decreased by 19%, while admission rates have gone up by 30%. Savings in acute hospital services have enabled the provision of places in rest and nursing homes for the elderly to be doubled. Despite this switch of resources from acute

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hospitals to the community, the cost of caring for the elderly-together with a drastic shortage of nurses-is still seen to be a key problem for Belgium's health services. Global budgets have been introduced for hospitals, pharmacies, and laboratory services, and their adjustment to take account of case mix and performance is (slowly) "being pursued." Hospital care now consumes 24-6% of the health care budget compared with 27% in 1980, and laboratory tests 9% compared with 12%. But if Belgium has problems, the address given by a French health economist suggested that these are as nothing compared with those facing France. Biannual "rationalisation plans" over the past two decades have failed to control the cost of health care. Although reforms in the 1980s succeeded in controlling expenditure in public hospitals by setting global budgets, attempts to control costs in private clinics and in fee for service ambulatory care (office based specialist and primary care) failed. Demand for care in the private sector, especially from specialists has risen steadily despite the equally steady increase in the proportion of costs borne by the patient. Currently France spends 8-9% of its gross domestic product on health. Controversial reforms proposed in France this month include setting global budgets for laboratory services and private clinics based on diagnosis related group payments (15 June, p 1419). Attempts to close the estimated 60 000 "excess" hospital beds and some poorly performing renal, in vitro fertilisation, and liver transplant centres are likely. How the 20 000 "excess" general practitioners will be dealt with is not clear. The salaried public seems to have acepted the 0-9% increase in their contributions from 4 June, but the struggle to convince doctors that these reforms are a good thing is far from over. Health economists in Germany have problems of a different kind, stemming from reunification. Provision of health services in the five eastern states is low and many of the hospitals and ambulatory care facilities outdated. An estimated DM 25-30m is needed to bring the hospitals up to the standard of the West. The whole philosophy and structure of the old centralised system of the east is

moving towards that of western Germnany with self governing institutions, managed competition, and statutory health insurance. Ambitious reforms in The Netherlands which were initiated in 1988 have been slow to get off the ground. Key proposals such as compulsory national health insurance for all with a premium related to income have not been introduced and may not be realised for another 25 years. But steps to make sickness funds, the purchasers of health care, more cost conscious are underway. From 1 January 1992 each will have a fixed risk adjusted budget and will be allowed to place contracts with preferred providers. Regulations governing the opening of new general practices and centres for private day surgery centres will be waived to promote competition with hospital providers. -TESSA RICHARDS, BMJ Further information about the European Health Policy Forum may be obtained from its headquarters, PO Box 214, 300 Leuven, Belgium. (Tel (0) 16 216978, fax 32 (0) 50 220541.)

Spring balance Health authorities had to balance their books by 31 March this year so that competition within the reformed NHS could take place on a "level playing field." A survey by the National Association of Health Authorities and Trusts (NAHAT) with a response rate of 51% gives an indication of their success. Of the 106 health authorities responding to NAHAT's questionnaire, 54 had balanced their books. Of the remainder, 30 were overspent (by an average of £615000 per district) and 21 were underspent (by an average of £310000). Some 32 districts (including some that had "balanced income and expenditure") carried over creditor liabilities worth £15-8m into 1991-2 to avoid overdrawing last year's cash limits. Funding of hospital and community health services increased by 10% last year. Taking NHS inflation into account NAHAT estimated that the effective increase in resources was about 1 6%. This year's real increase in funding looks like being twice as large: gross

Where will Europe's health reforms lead?

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spending will increase by 120o, with NHS inflation accounting for 8.7% of this. Of these extra resources NAHAT'5 director, Philip Hunt, said that, "In addition to the normal demands on NHS services including those caused by medical advances and the particular needs of elderly people, these resources will also be neeeded to meet the continued cost of NHS reforms and to deal with inevitable uncertainties within the new system such as the extent of extra contractual referrals." Health authorities vary widely in how much they have put aside for extracontractual referrals, ranging from 0 1% to 7% of cash limits. Many health authorities are also holding back contingency reserves, ranging from 02% to 3-1% of cash limits, to meet claims for medical negligence, higher than anticipated inflation, and possibly higher than forecast financial commitments arising from changes in contracted activity and costs. -TONY DELAMOTHE, BMJ

Academic disparity

The Royal Postgraduate Medical School (RPMS) and the Hammersmith Hospital, London, are due for a round of changes. Dr James Scott, currently head of the division of molecular medicine at the Medical Research Council's Clinical Research Centre (CRC) at Northwick Park, is to move to the RPMS to take over from Professor Sir Colin Dollery as professor of medicine at the Hammersmith. Professor Dollery is vacating the chair, which he has occupied since 1987, to become dean of the RPMS when the current dean, Professor David Kerr, retires in October. Dr Scott, who trained at the London Hospital and has been with the CRC since 1982, will take with him 40 researchers, whose academic interests include the regulation of blood cholesterol concentrations, tumour suppressor factors, and congenital malformations. Negotiations for laboratory space and funding may delay the move until early next year. -FIONA GODLEE, BMJ

The principle of parity of pay between clinical academic staff and NHS doctors, established in 1968, can no longer be maintained. That was the message from the Committee of Vice Chancellors and Principals (CVCP) at a meeting with the Clinical Academic Staff Salaries Committee on 28 June. Doctors in the NHS were awarded an average increase of 10- 10% by the review body on doctors' and dentists' remuneration, an award that the government phased to 7-5% from 1 April and 2.6% from 1 December. Medical academic staff have always had to wait for the CVCP to agree that the award should be translated. This year it says that it will not be able to do so. Along with other academic staff, doctors in universities have received an increase of 5% from 1 April, but the CVCP has said that it will pay no more than a total of 7.4%, the maximum amount currently on offer to non-clinical staff. The chairman of the BMA's Medical Academic Staff Committee, Colin Smith, called the decision "disgraceful." It meant a crisis for academic medicine and turning the clock back to the bad old days. Colin Smith went on: "The vice chancellors' refusal to honour the agreement on parity is bound to affect recruitment and retention of medical academic staff, and this in turn threatens the future education of doctors and the provision of services in the NHS. Medical academics cannot accept that they should be treated differently from NHS colleagues with whom they work side by side every day." On the first morning of the BMA's annual representative meeting in Inverness the following emergency motion was unanimously endorsed: "That this meeting is extremely concerned about the implications of the statement by the Committee of Vice Chancellors and Principals that they will not translate this year's NHS pay award for clinical academic staff and advises doctors not to apply for clinical academic posts until such time as parity is restored." Colin Smith had the full support of the chairman of the Central Consultants and Specialists Committee, John Chawner, and from a general practitioner, Alison Hill, who works at Southampton University in an academic department of general practice that will soon be reduced from eight to five

DrJames Scott

employer, although over two thirds of its workforce are women. A report by the NHS Management Executive suggests that, compared with banks and private companies, the NHS has made only patchy progress in recruiting women with families. If the fall

Spring Financial Survey 1991: A Financial Survey of District and Family Health Services Authorities is available from NAHAT, Birmingham Research Park, Vincent Drive, Birmingham B 15 2SQ, price £10.00.

New professor of medicine for the Hammersmith

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The doctor may be "woman friendly" but her employer isn't

in the number of school leavers continues health authorities will have trouble filling their posts. The report highlights the wastage of skill, stating that less than a fifth of nurses return to work after having a baby compared with over half of the employees of Midland Bank. Women make up 95% of the nurses and midwives in the NHS but less than half of doctors. Women are concentrated in the poorer paid and less prestigious jobs. They are almost absent among managers, accounting for less than 4% of top managers. Men hold over a third of nursing officer posts but constitute only 8% of nurses. The report agrees with a body of research that suggests that poorer childcare facilities and inflexible hours prevent women from returning to work after childbirth and gaining promotion. It suggests that improving both of these and encouraging women to become managers would make the NHS more

"woman friendly." In providing £1 5m for part time training posts, especially in surgical specialties, the Department of Health hopes to look as though it is taking the problem seriously. The NHS's women employees are not convinced. "It's a good idea, but so far only one of the five available part time surgical posts has been filled," claims Mrs Margaret Ghilchick, a consultant in general surgery at St principals. Hospital, London. "The men are Colin Smith and the chairman of the BMA Charles's worried that a woman will slip in through so council, Jeremy Lee-Potter, will raise the the back door that they apply higher criteria matter of academics' pay when they meet the than to the they would normally. I have posts health secretary, William Waldegrave, on 9 heard of very talented women being refused July. -LINDA BEECHAM, BMJr part time work. They can only apply for these jobs once a year. It's a national lottery. This isn't the way to encourage women." According to Dr Angela Thomas, a senior Winning over women registrar in haematology at the Charing Cross and Westminster Hospital, increasing the The NHS is not seen as a "woman friendly" number of women managers could make the

NHS more aware of women's problems. "Even men who are fathers don't appreciate the problems of child care," she claims. "I have constantly been made to feel guilty for leaving work early to collect my child from nursery. Flexible hours would help. Mothers

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often find it easier to get in early. Workplace nurseries are very attractive to women, but only a- few health authorities provide them because they are so expensive." The Equal Opportunities Commission is ccurrently investigating practices in the NHS and will report later this year. -LUISA DILLNER, BMJ Goss S, Brown H. Equal Opportunities for Women in the NHS. London: NHS Management Executive, 1991.

BMJ developments The BMY this week contains various changes designed to make it still more accessible, useful, and readable. * The Middles section is to be renamed Education and Debate as part of an attempt to give the section a clearer focus and develop still further our commitment to education. Scientific papers with structured abstracts will now appear exclusively in the Papers section, and regular reviews will be moved from their current position after Editorials into the renamed section. One advantage of moving regular reviews will be that we can illustrate them more easily and generously; we- begin this week with the first of a two part review on magnetic resonance imaging. * Practice Observed is to be renamed General Practice. Many readers seem to have been confused by the old tide, and we hope that the new title will make clear the section's purpose of publishing research and exploring issues in general practice. * Obituaries will now be signed with the full name of the authors rather than just initials. * The back of the journal has been redesigned to try to produce a section that is

still very much part of the BMJ but also has its own character. The reviews of books and presentations in the media, Minerva (now to be called just that rather than Views as it has been), Personal Views, and pieces by our columnists all have in common that they are more subjective than objective and aim at interesting readers through originality of thought and quality of writing. * Part of the new section will be two weekly columns called -Soundings. The articles will be written by regular columnists (see figure), many of whom are already well known to readers. They include Colin Douglas, an Edinburgh doctor and novelist; David Widgery, a general practitioner from Tower Hamlets; George Dunea, a nephrologist in Chicago; Bernard Dixon, a former editor of New Scientist and well known science writer; Trisha Greenhalgh, a general practitioner in London; Tony Smith, an associate editor of the BMJ and former medical editor of The Times; James Owen Drife, a professor of obstetrics and gynaecology from Leeds; and Julie Welch, a playwright and former football writer for the Observer. We have selected these people because they write well, have interesting things to say, and represent a broad range of opinion, professional backgrounds, and age. They will each write briefly once a month. * Finally, the Medicine and Books section contains a new feature-a personal selection of the best books for undergraduates, generalists, and specialists in particular subjects. John Rees begins with chest medicine. The choice will appear monthly, and we will work our way methodically through medicine. We hope that readers will appreciate these changes, and we are always interested to hear what people like and dislike. -RICHARD SMITH, BMJ

Unfitness to plead A private member's bill to reform the way the criminal law deals with mentally vulnerable people received royal assent last week after passing unopposed through both houses of parliament. The Criminal Procedure (Insanity and Unfitness to Plead) Act 1991 abolishes automatic detention for an indefinite period for defendants found unfit to plead, which lawyers and psychiatrists have long regarded as an injustice. Under the old law those considered unfit to plead were detained in hospital without any finding as to whether they had or had not committed the offence. The Law Society, which sponsored the bill, cites the case of a mentally handicapped woman who confessed under questioning to the murder of her father. She was committed to hospital and released much later only when the real killer came to light. In another case a deaf and dumb man, who was unable to communicate even through sign language, was charged with petty theft and found unfit to plead. He was detained in a psychiatric hospital and discharged three months later only when his solicitor put his case to a mental health review tribunal. An earlier bill in 1986 failed through lack of government support. But the latest bill, introduced by John Greenway MP, received support from all parties, government backing, and the support of MENCAP (the Royal Society for Mentally Handicapped Children and Adults), and other voluntary organisations. Under the new act courts will hold a "trial of facts" to determine whether the person found unfit to plead actually committed the offence. All defendants will be entitled to representation by an advocate. If the defendant is found guilty, or not guilty by reason of insanity, the court will be able to choose from a range of orders to meet his or her needs. These are a hospital order, a guardianship order, a supervision and treatment order, or an absolute discharge. Defendants may, therefore, be allowed to remain in their own homes. The act will also help people with epilepsy who commit offences during or in the aftermath of a fit. Until now the only plea available to them (apart from guilty) has been not guilty by reason of insanity, which has led to automatic detention in hospital. The new range of orders will be available for people with epilepsy and others found not guilty because of "a disease of the mind." For more serious offences the court may impose restrictions on discharge from hospital to protect the public from harm. In cases ofmurder a hospital order without limit of time will be the only option. -CLARE DYER, legal correspondent, BMJ

Late delivery of BMJ We apologise that readers may have received last week's BMJ a day or two late. The delay was caused by machine problems at our mailing house.

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Letter from Westminster A worm's eye view of a column like this must be that the reader may ask "What does he know about the real world? Does he have any idea what life is like in the wards?" An exalted position at the summit gives a fine view of what's going on at the top but is a long way from the- foothills. Now a personal episode has intervened to ease that sense of isolation and afford a glimpse of what things are like out there. For once I have been brought into close contact with the NHS in its delivery of nursing and clinical care. The experience centres on an elderly relative who had had a stroke. There came a point at which further medical intervention was pointless. Who would have blamed the doctors if they had lost interest? The point is that they did not. The case entailed distant communication between consultant geriatricians in Lothian and London. It imposed on the tolerance of medical staff because of domestic complications, which were more our problem than theirs. And it gave me a twinge of guilt to realise that I was mentally scoring points for future reference -less than fair, surely, to an overworked staff to be put on secret trial. If I felt a worm I was grateful for the worm's eye view. So I am happy to report that everyone in my private survey passed the test with honour in terms of dedication, consideration, kindness, and high professional standards. On the basis of my observations I would be proud to match the NHS against any care system in the world. In short, I have joined the 82% of those with recent experience of the NHS who declare themselves fully satisfied. Yet this was merely one small triumph out of six million every year. But meticulous care at the grassroots sometimes goes wrong. In a week when all is quiet at the summit I stay down below to pick a few such stories from the ombudsman's latest casebook. Case I -A dying woman who needed to go to hospital had to wait over six hours for an ambulance. At about 10 15 am a general practitioner asked for an ambulance "the sooner the better" but agreed an admission time up to 3 pm. The woman's condition got worse, and attempts were made to speed things up. No ambulance came until 4 30 pm, and the woman died in hospital soon afterwards. The ombudsman found that there was no common understanding between general practitioners and the ambulance staff of what constituted an urgent call. As a result the ambulance service apologised and agreed to Any

writer

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review staff training.

Case 2-Five days after a woman's admishospital her son discovered that her clinical record indicated that she was "not for 222"-meaning that if she suffered a cardiac arrest she would not be revived. In the event the woman made good progress and went home. Her son asked the health authority why the decision not to revive her had been taken; why he had not been informed; and sion to

12

what the policy on resuscitation was. The ombudsman found that the decision had been taken on admission but that junior medical staff did not realise that it had been cancelled by the consultant the next day. The change had not been entered in the medical records. The health authority has now ordered that decisions not to revive a patient must be reviewed daily and be time limited. The ombudsman has drawn the general principles involved to the attention of the Department of Health. Case 3 -An elderly man anxious about surgical treatment that he had received wanted a representative of the community health council to go with him to discuss his

The

concerns with the consultant. The surgeon would not see the man unless he was on his own or accompanied by a relative. The ombudsman found the consultant's attitude unreasonable and at odds with NHS guidance. In the end the consultant agreed to the man's request and the health authority apologised for the difficulties he had encountered. The ombudsman, Mr William Reid, observes that a better understanding of patients' worries is needed and that poor communication in clinical settings is the bugbear of the NHS. He toils in the hope that all NHS staff can learn how to do even better. -JOHN WARDEN, parliamentary correspondent, BMJ7

Week

In Washington, unlike London, the hoopla over health care reform has quietened down somewhat. Last week the politicians in Washington took pause to raise their fingers discreetly to test the public winds. Two polls that came out last week suggested a climatic shift in public attitudes. The first, conducted by the Wall Street Journal and NBC News, showed that 40% of Americans believe that fiealth care is the first or second most important national issue-topping education, drugs, and crime, among others. Down at state level governors, too, are worried. A Gallup poll of 46 of the 50 governors revealed that over half thought that health care was their main budgetary problem. Newsweek magazine, which sponsored the poll, observed that the costs of Medicaid (the bare boned government health insurance for the very poorest citizens) were approaching one fifth of states' budgets. But perhaps the most important revelation was the fact that 60% of conservative voters favoured a national health system based on the Canadian model. Republicans, especially in congress, are taking note. "It's a revolt of the 'haves'," said one Republican congressman, observing that the middle class has joined the poor as victims of the patchwork insurance system. As a result Republican legislators have begun quietly huddling together with conservative think tanks to develop health reforms. Meanwhile, the chief Republican over at the White House remains reticent. Several newspapers have reported that a split has developed among the President's advisers, and he seems to be listening to those led by John Sununu, his chief of staff. Sununu points out that those who are most upset with medical care are the poor, the uninsured, the blacks, and the Hispanics-all solid Democratic blocs.

Put simply, health care reform is just not a Republican issue. The President is reticent, but not silent. On the same day that he pledged continued support for research at the National Institutes of Health (total cost of $7 billion last year) the New York Times reported he cancelled a $91 million emergency plan to step up childhood immunisations. US immunisation rates are below those of many Third World countries, and last year 27 600 cases of measles were reported. Outbreaks are worst in big cities, where the Public Health Service planned an emergency programme. But the White House says that is too much for now. If the polls are correct the man who created and carried out a Desert Storm may become a victim of a tempest surrounding his government. The harbinger may be Senator John D Rockefeller IV, whose sole source of fame until last year was his family name. Nowadays, he is seen as the visionary of the Democratic party. Last week he was again in the headlines when his National Commission on Children recommended a child tax credit of $1000 and full health coverage for children and pregnant women. Senator Rockefeller broke into national headlines last fall when his commission on health recommended full medical insurance coverage for all Americans. He since has become the major sponsor of the Democratic bill that would require all employers either to insure their workers or to pay into a national health pool. Mr Rockefeller's visions may go even further. Three months ago the Democrats had all but forsaken a serious run for the White House in 1992. Last week a request for an interview with Senator Rockefeller got a hurried response from his press secretary: "There's no way. He's too busy. You know, he's seriously weighing running for President." HART

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6 JULY 1991

Scandal threatens French blood transfusion service.

NEWS & Political Review New initiatives for people with learning disabilities Last week the Department of Health announced that it would try harder to...
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