NEWS California says no to euthanasia While rejecting President Bush on 3 November voters in California also threw out, by 53% to 47%, a state ballot initiative that would have legalised suicide assisted by a doctor. Proposition 161, also known as the "California Death With Dignity Act," would have freed doctors from criminal liability if they assisted in the death of mentally competent adults who had been diagnosed by two doctors as having less than six months to live. Last year (BMJ 1991;303:1223) voters in Washington state rejected a similar measure, by 55% to 45%, primarily because it "lacked adequate safeguards," according to Dr Michael Anne Browne, who chairs the California Medical Association's committee on evolving trends in society affecting life. "As part of a propaganda ploy, those who are for [Proposition 161] say it is materially different from Washington's initiative," she said. C, 0 Unlike Washington's ballot initiative, n California's proposition would have required patients to express their wishes for aid in (A (A dying more than once within the six months. Pt These requests would have had to be expressed in writing by the patients and Bush, Clinton, Perot, or euthanasia? signed in the presence of two people who were neither relatives nor beneficiaries of the patient. Requests-could be withdrawn at any Michigan, where Dr Jack Kevorkian has surgeon time. The measure would also have required crystallised the issue with his controversial doctors and hospital managers to report to "self execution" machine (BMJr 1992;304:9), a California's Department of Health Services, has such a bill come near to being passed. In Michigan legislation introduced by citing the age, diagnosis, and date of death of Representative Lynne Jondahl that would court the patient but not the method of death. Proposition 161 was put to the ballot by allow doctors to administer lethal injections An army surgeon who claims that his career Califomians Against Human Suffering, after a 30 day waiting period has passed the was blocked by a specialist advisory comwhich is headed by a Los Angeles attorney, state's senate and also the House Judiciary mittee of the Royal College of Surgeons has Robert L Risley, whose wife died of ovarian Committee's subcommittee on death and won the go ahead to take the committee to the cancer in 1985. The measure was supported dying. The Michigan legislature will re- High Court. Lieutenant Colonel Stephen by the American Civil Liberties Union convene for a post-election session at the end Milner has been given leave to bring judicial of Southern California, which has long of November, when supporters hope the bill review proceedings against the specialist advisory committee in plastic surgery. The championed patient autonomy. The union's will become law. In September Dr Kevorkian met with the case is likely to be heard in December or executive director, Ramona Ripston, said that the initiative "guarantees the right of Michigan State Medical Society's board of January. The surgeon's counsel, Jeremy McMullan, personal choice in avoiding prolonged and directors and its bioethics committee to "outline his plan to make Michigan the told Mr Justice Otton: "It is claimed the unnecessary suffering at the end of life." The California Medical Association, the nation's suicide center," according to the 5 committee sees as a threat the training of American Cancer Society, and Roman October issue of American Medical News. armed services' surgeons-that threat being Catholic churches throughout the state The paper said that the society's board chose that they will come into private practice in opposed Proposition 161. "Many physicians last January to support state legislation that civilian life through the back door and the feel it is against the Hippocratic oath," said would have declared physician assisted market for consultant plastic surgeons will be Dr Browne. "There are some who feel in suicide a felony, but the house of delegates, at enlarged." Granting leave, the judge said: some circumstances it would be okay, but its annual meeting in May, disagreed. The "Whether or not it is legitimate for decision there is no consensus on what those circum- delegates also referred back to the board its makers to take market forces into account recommendation that the society should and discriminate between armed forces stances are," she says. California is not the only state to introduce adopt the policy on physician assisted suicide officers and their NHS counterparts is a such an initiative this year. Bills on aid of the American Medical Association, which matter of entirely legitimate investigation by in dying were proposed in Iowa, Maine, considers the practice unethical.-REGINALD the courts." The case is the second challenge in recent Michigan, and New Hampshire. But only in RHEIN, medical journalist, Washington, DC
Plastic takes royal college to
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Headlines US employer cuts health cover: The United States Supreme Court has allowed an employer to drastically cut insurance cover for people with AIDS, maintaining that an employer has an absolute right to alter the terms of its group medical cover plan. The decision could leave uninsured millions of Americans who become seriously ill with cancer or other costly diseases. AIDS definition extended: The United States Centers for Disease Control has added pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer to the definition of AIDS illnesses. This brings in an additional 160 000 people and could affect disability and other benefits for people infected with HIV.
London ambulance inquiry: The inquiry into the London ambulance service will examine management and staff relations as well as the breakdown of the computer aided dispatch system on three occasions, the secretary of state for health has announced. The inquiry will be led by Mr Don Page, chief executive of the south Yorkshire ambulance service. Further fall in cot deaths: The number of cot deaths in England and Wales fell from 1593 in 1988 to 1008 in 1991, reported the Office of Population Censuses and Surveys. This was the third consecutive fall.
Abortion gag barred: The United States court of appeals has barred the enforcement of the rule restricting abortion counselling in federally funded clinics. The court ruled that the Department of Health and Human Services must get public comment on the rule before it can be put into effect.
Warning to asthma sufferers: The British government's Advisory Group on- the Medical Aspects of Air Pollution Episodes has advised that when levels of sulphur dioxide exceed 400 parts per billion sufferers from asthma may experience tightness of the chest, coughing, and breathlessness. They should limit their exposure out of doors. Nicotine patch available over the counter: A nicotine patch (Nicorette Patch) is now available in Britain over the counter for people who want to stop smoking. It is the first transdermal system designed to be worn during the day and removed at night, so there is no unnecessary delivery of nicotine during sleep.
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months to the system of training for consultants' posts. Dr Anthony Goldstein, who holds a European Community specialist certificate in rheumatology but has been refused accreditation by the Joint Committee on Higher Medical Training, has mounted a series of court actions over what he describes as a system based on "patronage and restrictive practices." He is bringing judicial review proceedings against the Department of Health for failing to implement EC directives allowing qualified specialists to practise in any member state (BMJ 1992;304:165 1). Colonel Milner, a career officer aged 43, was a senior registrar in general surgery in 1989 when the army approved him for specialist training in plastic surgery. He resigned his general surgery post after receiving a letter from the specialist advisory committee confirming his enrolment on a three year training course at Addenbrooke's Hospital in Cambridge. The offer failed to materialise and the committee decided that he should undertake a four year course, including a year as a senior house officer. But it later refused to recognise his time as a senior house officer and registrar at Stoke Mandeville Hospital or five months as a bums and plastic surgeon during the Gulf war, claiming that he had never been enrolled. The committee visited the plastic surgery unit at Stoke Mandeville and expressed doubts about its training abilities because of bed shortages. On Colonel Milner's return from three months at Harvard University on a burns and plastic surgery scholarship a consultant at Stoke Mandeville advised him to go to another unit where the training would be better. Colonel Milner said that offers from two units were withdrawn within a short time because the specialist advisory committee refused to approve them for his training. Questions were raised about his references "suddenly at the last minute," he said. The committee's counsel, Philip Havers, told Mr Justice Otton that references from three army and three NHS consultants were unsatisfactory. Colonel Milner said that requests from his solicitors and the Medical Protection Society to see the references had been turned down. Now carrying out research on burns at Porton Down, he said: "My main interest is burns and reconstructive surgery. I have no interest whatsoever in cosmetic surgery."-CLARE DYER, legal correspondent, BMJ
Family drowns in doctors' business cards Doctors who receive a chain letter asking them to send their business cards to "sevenyear-old Craig Shergold" should ignore the request. Marion Shergold, Craig's mother, is appealing to people to stop sending him business cards, many of which have arrived from doctor§ in recent weeks. Craig became famous when he appealed for get well cards while receiving treatment
for a brain tumour. He wanted to beat the record in the Guiness Book of Records, which he did by May 1990 with 16250692 cards. The total has since reached 33 million. After beating the record he asked for no more get well cards to be sent to him, and the rate at which they are arriving has dropped off. But business cards have taken their place, although no one knows how or why the chain letter asking for business cards began. The letter says: "This seven-year-old boy has a non-operable brain tumour and only a short time to live." It asks the recipient to send a business card and pass the letter on to 10 colleagues. But there are several inaccuracies in the letter: Craig is now 13 and was 9 when he fell ill, not 7. After an operation in the US for a brain tumour he is now back at school. The address is also spelt incorrectly. Mrs Shergold says that she is grateful for people's kindness in sending get well cards and business cards. But the continued arrival of business cards has caused practical problems. During last week 11 sacks of post had arrived by Thursday. The chain letter frequently arrives with lists attached of people who have already sent their business cards to Craig. In the case of one letter which arrived at Hull Royal Infirmary the lists included doctors and medical researchers at Duke University Medical Center, University of California at San Diego, the Karolinska Institute, Johns Hopkins Hospital, the Salk Institute, the Pasteur Institute, the Imperial Cancer Research Fund, and universities in France, Austria, Japan, Italy, Germany, and Australia-as well as hospitals in the United Kingdom. Dr John Bennett, a consultant physician at Hull Royal Infirmary who has received at least two copies of the business card chain letters said, "I don't normally touch chain letters but there was no money involved, it was a simple and touching appeal, and it came from a friend with a list of well known people attached to it-so I did it." Mrs Shergold said that recycling the get well cards and saving the stamps for charities had made it possible to raise C53 000 for research into leukaemia and guide dogs for the blind. But business cards were too small to recycle and because offices used franking machines there were no stamps to save. "So if you do get one of these letters please ignore it," she said.-SHARON KINGMAN, freelance journalist, London
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RHA told to reinstate "redundant" Helen Zeidin A consultant haematologist who was made redundant at 24 hours' notice after speaking out about nursing shortages at her hospital had her appeal upheld last week by the health secretary, Virginia Bottomley. In a Commons written answer Mrs Bottomley said that Dr Helen Zeitlin's employment with West Midlands Regional Health Authority should continue. Dr Zeitlin's reinstatement follows an 18 month battle with the authority over what she claimed was a ploy to get rid of her for blowing the whistle about nurse staffing levels at Alexandra Hospital, Redditch (BMJ 1992;304:203.) On 28 February 1991 Dr Zeitlin was told that she was being made redundant because the hospital had too little work for its two consultant haematologists. She was put on "special paid leave" from the next day. The redundancy notice came less than two months after the authority started disciplinary proceedings against Dr Zeitlin, which were subsequently dropped. One of the charges related to a public meeting in January 1990, where she had criticised nurse staffing levels and predicted that the situation would worsen if the hospital became a self governing trust. Bromsgrove and Redditch Health Authority was keen for Alexandra Hospital to become its first NHS trust hospital. At the two day appeal hearing last August -the first to be held in public-the authority said that Dr Zeitlin was perceived as being "disruptive and malicious." There had been up to 20 complaints against her and a history of trouble between her and a colleague, Dr Daisy Obeid. But Dr Zeitlin claimed that there had been a systematic campaign to get rid of her since she spoke out about health service reforms at the meeting in January 1990 and circulated a secret report about low nursing levels at the hospital. As the BMJ went to press it was unclear
whether Dr Zeitlin would be offered her old job back-she acknowledged that returning to work at Alexandra Hospital would be "uncomfortable"-or redeployed elsewhere in the region. She was due to attend a meeting on 11 November to discuss possible options. The decision comes amid growing concern about excessive secrecy and lack of protection for whistleblowers in the NHS, particularly in hospital trusts, where secrecy clauses are standard terms in employment contracts. The Department of Health has issued draft guidelines on whistleblowing, providing for- employees to take up grievances internally (24 October, p 977). But those dissatisfied after taking such steps can still be disciplined if they go public.CLARE DYER, legal correspondent, BMJ
Tainted blood affair threatens French government The revelations that blood was collected in French prisons as late as 1990 despite warnings that inmates were at risk of being contaminated with HIV and that a government producer of controlled vaccine and serum continued to sell non-heat treated blood extracts until October 1985 have exacerbated the controversy over the "tainted blood affair." The resurgence of the scandal may even lead to a reform of the French constitution so that high officials, including former prime minister Laurent Fabius and former social affairs minister Georgina Dufoix, may answer charges that they procrastinated for several months in banning blood extracts which they knew could be contaminated. Dr Michel Garetta, former director of the National Blood Transfusion Centre, has returned from the United States. He has been sentenced to four years in jail for knowingly having distributed blood extracts contaminated with HIV (31 October, p 1047).
The Conseil de l'Ordre des Medecins, the French medical association, has expelled Garetta for life-making it illegal for him to practise medicine in France and other European Community countries. Last week the general inspectorate of health released its report on the collection of blood in state prisons. The report contained the draft of a memorandum warning that inmates were at high risk ofinfectious diseases and should not be included among donors. A health official crossed out the warning from the final version of the memorandum. The inspectorate canvassed prisons and sometimes offered prisoners certificates of good behaviour if they donated blood. By October 1985 only one of the nine penitentiary administrations in France had banned such "donations" by inmates. It is estimated that in 1985 blood collected in prisons accounted for a quarter of blood contaminated with HIV in France. It was also reported that the Institut Merieux, a subsidiary of the state controlled company Rh6ne-Poulenc, sold unheated blood extracts to European countries until November 1985. During that year Merieux exported 4-6 million units of factor VIII, of which 3-2 million units were untreated. A spokesman for the company, Alain Merieux, said that he had had no instructions to the contrary from the government, adding that there were no reports of HIV contamination. The National Assembly debated the responsibilities of the government in the affair, and parliamentarians called for a reexamination of the roles and responsibilities of administrators, scientific experts, and political leaders. Laurent Fabius, prime minister in 1985, wrote an article in La Monde calling for the constitution to be amended so that ministers could be judged "in ordinary conditions." Arguing that the High Court was not appropriate to judge high government officials' responsibilities in the affair, he said that he would be willing to answer questions before a "jury of honour." Later, Prime Minister Beregovoy agreed that "ministers, like other citizens, should answer for their actions" and said that he would be willing to propose constitutional amendments if the National Assembly reached a consensus on the matter. Whatever the outcome of the affair, it is likely to weigh heavily against the Socialist government as it prepares for parliamentary elections next March.-ALEXANDER DOROZYNSKI, medical journalist, Paris
Vocal women GPs want more part time opportunities If some of the stories told at a conference on women in general practice last weekend are to be believed many women doctors are working in general practice fdr a pittance while bowing to the whims of their selfish and autocratic male colleagues. The 250 participants at the oversubscribed conference BMJ VOLUME 305
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organised by the BMA's General Medical Services Committee were vocal, and angry, and the 60 who booked for confidential counselling kept five experts busy all day. The meeting was convened to discuss the problems women face in general practice. Three quarters of general practice principals are men. Nearly half have never worked with a woman principal and two thirds have never worked with a part time principal. Speakers in the workshops and the plenary session confirmed the dearth of part time profit sharing partnerships. For many the choice was often between full time partnerships with on call duties, or poorly paid salaried partnerships or assistantships. The last two options usually proved career culs de sacs, with the escape route barred by male prejudice rather than by domestic commitments. The outcome of the conference was a series of recommendations to the GMSC to * Ensure that all doctors have access to continued and affordable medical education and consider the needs of doctors on the retainer scheme ! Recognise that women need to be trained in the financial, organisational, and management aspects of general practice * Develop comprehensive undergraduate and postgraduate career guidance * Recommend flexible arrangements for career breaks and return to work packages for all doctors * Give a higher profile to prepartnership advice and conciliation in partnership disputes * Explore altemative ways to provide high quality out of hours primary care to recognise the difficulty in combining a 24 hour professional commitment with domestic responsibilities. The conference confirmed the findings in the latest survey of part time work in general practice. In Part-time Working in General Practice, published this week by the Policy Studies Institute, Isobel Allen found that 93% of the 600 women surveyed (and 74% of the men) wanted more opportunities for part time training. Half the women (and 8% of the men) were working less than full time in clinical medicine, but apart from the 4% of women on matemity leave, only one woman in 50 was at home full time.-TRISHA GREENHALGH,.general practitioner, London
people. One chapter by Suzi Leather, a This is discriminatory."-SHARON KINGMAN, member of the consumer panel which advises freelance medical journalist, London the Ministry of Agriculture, Fisheries and Your Food: Whose Choice? is available from HMSO Food, says that people on low incomes know bookshops, price £10.95. what they should buy but cannot afford it. Faced with the impossible task of paying for everything out of their "woefully inadequate" state benefits, some families cut the amount they spend on food, she says. Although it has often been assumed that healthy eating is cheaper than unhealthy eating, the evidence suggests otherwise, the Russian authorities have stepped in to prevent book says. Leather quotes a report from the Policy what is feared to be a flourishing trade in Studies Institute in London which found that organs for transplantation. In the first such many people are struggling to make ends attempt at introducing controls the parliameet on a weekly budget "that many people ment has passed a law setting out conditions would not think twice about spending on a and procedures for transplant surgery meal in a restaurant." She says that while the coupled with penalties for those who break average family in the UK spends 12-4% of its them. Recent months have seen persistent income on food eaten at home, those living on reports in the Russian press of backstreet income support would have to spend about organ transplant surgery being carried out in 36% of their income on food if they followed the growing number of medical cooperatives. Under the new law passed earlier this a healthy diet costing £10 a week. A recent survey by the National Children's month it is forbidden to buy and sell human Home found that one in five parents and one organs and tissues. Transplants from people in 10 children had sometimes gone without with leaming disabilities or from donors food in the previous month because of lack of under the age of 18-with the exception of money. None of those taking part in the bone marrow-are also banned. So too is the survey was eating a healthy diet, but the removal of organs and tissues from people reason was not ignorance. When parents who are somehow dependent on the recipient. The law, which takes into account recomwere asked what they would buy if they had an extra £10 to spend on food for their child mendations made by the World Health 60% said more fruit, 500/o more lean fresh Organisation, says that transplants should meat, and 38% more vegetables. Fewer than be carried out "only if other medical means one in 10 said that they would buy more cannot guarantee the preservation of a person's life or the restoration of his or her cakes, biscuits, ice cream, and snack foods. The Ministry of Agriculture, Fisheries and health." The passage of the law coincided with Food has constructed a diet, which it calls the Generations of British children will suffer "low cost healthy diet," costing £10 per the surprise sacking of the Russian health stunted growth and heart disease unless the person per week. The diet includes eight minister, Andrei Vorobyov, who collapsed govemment tackles the problem of poverty slices of bread each day, but only three would with an apparent heart attack after presenting and poor diet, Lady Wilcox, who chairs the have even a thin spread of margarine or plans for the reform of the health service at a National Consumer Council, said last week. butter, the rest being eaten dry. The diet stormy session of the cabinet. Vorobyov She was speaking at the launch of Your Food: excludes yoghurt and other dairy products was attacked by fellow ministers over his Whose Choice?, which is published by the apart from a quarter of a slice of processed proposals, which included the introduction of compulsory insurance and the privatisation National Consumer Council and calls for a cheese and less than half a pint ofmilk. Leather says: "In essence, poor consumers of certain sectors of the health service.review of the level of state benefits. The book examines the evidence on would be expected to adopt a totally different PETER CONRADI, Moscow correspondent, whether a healthy diet is possible for poor eating culture from the rest of the population. European
Russia tightens up on transplants
Children eat poorly on state benefits
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members packed to go home to seek reelection, $20m was inserted into a bill for $1 5bn for defence spending. That bill, perennially passed in the closing days of Congress, is often a receptacle for "pork barrel" items -projects that appeal to the electorate but do If young American medical entrepreneurs not reflect real need. The New York Times have trouble selling their products to the called the manoeuvre "Medical Madness on scientific community where do they tum? Capitol Hill." Mad is exactly the emotion expressed by Apparently, they hire a Washington lobbyist, who tums to members of Congress, which America's scientific elite when they heard writes a few million dollars into a huge that Congress had stepped over the sacred budget for the US army. That is exactly why line that separates partisan politics from the US army has been told by Congress to peer review. Congress always sets national spend $20m on a vaccine against HIV that is research agendas (such as those for cancer produced by a private manufacturer, Micro- and AIDS), but until now it has not told scientists exactly what to study, how to do it, GeneSys. In 1985 MicroGeneSys used clones from and what products they should use. Dr Bemadine Healy, director of the NIH, the National Institutes of Health (NIH) and developed a process to produce large said, "I don't know how you can go to a patient and say, 'We're giving you this drug amounts of the HIV viral envelope, gp 160. Later, with the help of researchers from the because a lobbyist chose it."' Her anger was US army, the company set up a trial in echoed by Dr David Kessler (director of 30 patients and showed that gp 160 could- the Food and Drug Administration), many increase CD4 T cell counts in HIV positive researchers in academic centres, and reprepatients. The data, which suggested that sentatives of AIDS foundations. Lobbyists have responded that the scientists are upset gp 160 might be used as a vaccine against HIV, were published in June last year in the because the $20m did not go to them. Congress itself has been embarrassed by New England Journal of Medicine. Several the manoeuvre. The chief sponsor of the scientists criticised the outcome measures used and pointed out that the trial failed to bill, Senator Sam Nunn, a Democrat from Georgia, denied accusations of pork barrel show that gp 160 prolonged life. At about the same time Franklin Volvovitz, politics, saying that the $20m had been the president of MicroGeneSys, apparently recommended by another Senate committee. frustrated with the sluggish scientific peer Mr Nunn, however, was one of the senators review system of the NIH, tumed to one visited by Mr Long, the lobbyist for Microof Washington's most powerful lobbyists, GeneSys. The army, despite its support of MicroRussell Long. Mr Long began prompting certain GeneSys's first small trial, denied that it sought the extra $20m, and its spokespeople senators to push the NIH to approve gp 160. During a Senate hearing in the summer of now say that its researchers believe that large last year Dr Anthony Fauci, director of the trials would be premature. That is exactly National Institute of Allergy and Infectious what Dr Healy believes, and she has conDiseases and one of the nation's most senior vened a panel of scientists, including Dr researchers on HIV, was grilled by Senator Kessler, to try to sort out what seems to Tom Harkin about why gp 160 had not been be a new relationship between Congress and the scientific community. approved for large clinical trials. This issue may be settled soon. Congress The issue quietened down on Capitol Hill last year. According to several investigative has agreed that if Dr Healy, Dr Kessler, and reports, however, Mr Long and executives of the army certify in writing that the project is MicroGeneSys did not. Senators continued now unworthy the entire $20m will be withdrawn from MicroGeneSys and put back into to be lobbied, and this September, as
system
We wanted to give you this vaccine because a
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the army's general budget for research into AIDS-which would swell it by 40% from its present $50m. But Dr Healy has pointed out that resolving the MicroGeneSys fiasco will not prevent future encroachments by Congress into medical research, especially into AIDS, which is both a politically volatile and a lucrative subject.-JOHN ROBERTS, clinical epidemiologist, Baltimore
Menopausal women still badly treated The effects of the menopause on women are poorly understood and inadequately treated, data from two recent surveys suggest. One survey, of British companies' knowledge of and provision for the effects of the menopause on their female staff, showed that more than 90% of companies had no formal policy on the issue; 40% of personnel departments surveyed were unaware that reduced productivity, memory lapses, and fainting spells are menopausal symptoms. The survey, carried out by Private Patients Plan, questioned 168 companies of varying tumover and location, drawn at random from, among others, construction, manufacturing, and service industries. Half the companies surveyed did not have a nurse or doctor on site at least once a week, and 43% of those with a tumover in excess of £50m admitted that they did not provide this facility for their staff. Commenting on the survey's findings, Mr Malcolm Whitehead, a consultant gynaecologist at King's College Hospital, London, said, "Menopausal symptoms ... impair the concentration of all women. You don't have to be a high flier to be made miserable by the menopause." Another survey, carried out by the Amarant Trust, an independent charity that seeks to promote a broader understanding of the menopause and hormone replacement therapy (HRT), found that 80% of respondents thought that their general practitioners had spent too little time with them at their first consultation for HRT, with almost half claiming that it had lasted less than 10 minutes. Just over half of the 3000 women who responded to the questionnaire had been treated by their general practitioner. Speaking on behalf of the Royal College of General Practitioners, Dr Jean Coope, a general practitioner in Cheshire who runs an HRT clinic, said, "Most general practitioners are not giving enough time [to HRT prescribing] because they have so many constraints on their practices, and many simply can't afford to run HRT clinics." Running such a clinic, suggested Dr Coope, costs between £ 15 and £20 an hour. One hundred and thirty seven of the respondents who had not had a hysterectomy were receiving oestrogen only preparations, thereby running an increased risk of endometrial cancer. Only 1 1%/ of the women surveyed expressed concems about taking HRT, but 62% of them were worried about the risk of breast cancer.-CAROLINE WHITE, technical editor, Journal of Clinical Pathology 1179
Letter from Westminster Speaking out in the NHS The British tradition of secrecy in govern- being invoked to discriminate against those ment makes life hazardous for whistleblowers who attempt to raise issues in public. The issue of the guidance raises the in the public service. It is not so long ago that civil servants were prosecuted-and jailed- question of whether the health service should for leaking official secrets which troubled be a special case. Other public or private their conscience. More recently govemments corporations-the BBC for instance-are far have tried in their faltering way to come to harsher on disloyal employees. The NHS acknowledges a higher duty to the sick, and terms with a more open society. The reinstatement last week of Dr Helen the new rules are based on that principle. In Zeitlin (p 1177) is seen as a triumph for that case should there perhaps be new legal whistleblowers, although the reasoning rights to protect whistleblowers who sound behind it remains unpublished and shrouded off about standards of care? in official secrecy. Her case has prompted the Department of Health to produce a whistleblower's charter (24 October, p 977). Commendably, the draft underpins the "right and duty" of NHS staff to raise issues of concern about patient care. The key principle, it states, is that the interests of patients are of paramount importance. Moreover, all employees have a duty to report anything that may be damaging to patients' interests. Under no circumstances are staff to be penalised for airing genuine concerns. And all NHS employers are enjoined to make sure that these "rights and duties" are fully catered for. Correct procedures will need to be established, and the sequence of informal and formal channels as complaints are referred upwards has merits. Most staff may find it intimidating to take their case right to the top, but by that time they would have sought the help of their professional body or trade union as the guidance suggests. There can be no quibble that confidentiality to patients has to be protected, on pain of discipline. Doubts begin to creep in about whether the procedures are too prescriptive. The right and duty to speak out is conditional on whether the local procedures permit it. If the machinery is made to look daunting it can itself become a gag. The main risk of gagging is in relation to disclosures to the media. Access to the press or television is allowed for as a "last resort," but the guidance leaves no doubt about the possible consequences of such an action: "Employees have, under common law, an implied duty of confidence and fidelity to their employer. Breach of this duty may result in disciplinary action. Any disclosure to the media without consent might be seen by the employer as damaging and would therefore represent a potentially serious breach of contract." That threat virtually proscribes disclosure to the media and puts a cork in all but the loudest whistle. Not surprisingly, there is pressure to change it. Labour's health spokesman, Mr David Blunkett, objects to the concept of "commercial confidentiality" being applied to the health service. He accepts that proper lines of reporting should be followed but is concerned that the law is 1180
It may be more a question of good will than good guidelines. The trick is to create the right culture of mutual trust in the NHS, and the guidance wisely places a duty to do so directly on managers. Ultimately, however, there is always a place for whistleblowers if the health service is to be fully accountable to the public. The new guidelines tacitly recognise this. Fortunately, no amount of government guidance can ever call the tune for the genuine whistleblower.-JOHN WARDEN, parliamentary correspondent, BMJ
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Headlines US employer cuts health cover: The United States Supreme Court has allowed an employer to drastically cut insurance cover for people with AIDS, maintaining that an employer has an absolute right to alter the terms of its group medical cover plan. The decision could leave uninsured millions of Americans who become seriously ill with cancer or other costly diseases. AIDS definition extended: The United States Centers for Disease Control has added pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer to the definition of AIDS illnesses. This brings in an additional 160 000 people and could affect disability and other benefits for people infected with HIV.
London ambulance inquiry: The inquiry into the London ambulance service will examine management and staff relations as well as the breakdown of the computer aided dispatch system on three occasions, the secretary of state for health has announced. The inquiry will be led by Mr Don Page, chief executive of the south Yorkshire ambulance service. Further fall in cot deaths: The number of cot deaths in England and Wales fell from 1593 in 1988 to 1008 in 1991, reported the Office of Population Censuses and Surveys. This was the third consecutive fall.
Abortion gag barred: The United States court of appeals has barred the enforcement of the rule restricting abortion counselling in federally funded clinics. The court ruled that the Department of Health and Human Services must get public comment on the rule before it can be put into effect.
Warning to asthma sufferers: The British government's Advisory Group on- the Medical Aspects of Air Pollution Episodes has advised that when levels of sulphur dioxide exceed 400 parts per billion sufferers from asthma may experience tightness of the chest, coughing, and breathlessness. They should limit their exposure out of doors. Nicotine patch available over the counter: A nicotine patch (Nicorette Patch) is now available in Britain over the counter for people who want to stop smoking. It is the first transdermal system designed to be worn during the day and removed at night, so there is no unnecessary delivery of nicotine during sleep.
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months to the system of training for consultants' posts. Dr Anthony Goldstein, who holds a European Community specialist certificate in rheumatology but has been refused accreditation by the Joint Committee on Higher Medical Training, has mounted a series of court actions over what he describes as a system based on "patronage and restrictive practices." He is bringing judicial review proceedings against the Department of Health for failing to implement EC directives allowing qualified specialists to practise in any member state (BMJ 1992;304:165 1). Colonel Milner, a career officer aged 43, was a senior registrar in general surgery in 1989 when the army approved him for specialist training in plastic surgery. He resigned his general surgery post after receiving a letter from the specialist advisory committee confirming his enrolment on a three year training course at Addenbrooke's Hospital in Cambridge. The offer failed to materialise and the committee decided that he should undertake a four year course, including a year as a senior house officer. But it later refused to recognise his time as a senior house officer and registrar at Stoke Mandeville Hospital or five months as a bums and plastic surgeon during the Gulf war, claiming that he had never been enrolled. The committee visited the plastic surgery unit at Stoke Mandeville and expressed doubts about its training abilities because of bed shortages. On Colonel Milner's return from three months at Harvard University on a burns and plastic surgery scholarship a consultant at Stoke Mandeville advised him to go to another unit where the training would be better. Colonel Milner said that offers from two units were withdrawn within a short time because the specialist advisory committee refused to approve them for his training. Questions were raised about his references "suddenly at the last minute," he said. The committee's counsel, Philip Havers, told Mr Justice Otton that references from three army and three NHS consultants were unsatisfactory. Colonel Milner said that requests from his solicitors and the Medical Protection Society to see the references had been turned down. Now carrying out research on burns at Porton Down, he said: "My main interest is burns and reconstructive surgery. I have no interest whatsoever in cosmetic surgery."-CLARE DYER, legal correspondent, BMJ
Family drowns in doctors' business cards Doctors who receive a chain letter asking them to send their business cards to "sevenyear-old Craig Shergold" should ignore the request. Marion Shergold, Craig's mother, is appealing to people to stop sending him business cards, many of which have arrived from doctor§ in recent weeks. Craig became famous when he appealed for get well cards while receiving treatment
for a brain tumour. He wanted to beat the record in the Guiness Book of Records, which he did by May 1990 with 16250692 cards. The total has since reached 33 million. After beating the record he asked for no more get well cards to be sent to him, and the rate at which they are arriving has dropped off. But business cards have taken their place, although no one knows how or why the chain letter asking for business cards began. The letter says: "This seven-year-old boy has a non-operable brain tumour and only a short time to live." It asks the recipient to send a business card and pass the letter on to 10 colleagues. But there are several inaccuracies in the letter: Craig is now 13 and was 9 when he fell ill, not 7. After an operation in the US for a brain tumour he is now back at school. The address is also spelt incorrectly. Mrs Shergold says that she is grateful for people's kindness in sending get well cards and business cards. But the continued arrival of business cards has caused practical problems. During last week 11 sacks of post had arrived by Thursday. The chain letter frequently arrives with lists attached of people who have already sent their business cards to Craig. In the case of one letter which arrived at Hull Royal Infirmary the lists included doctors and medical researchers at Duke University Medical Center, University of California at San Diego, the Karolinska Institute, Johns Hopkins Hospital, the Salk Institute, the Pasteur Institute, the Imperial Cancer Research Fund, and universities in France, Austria, Japan, Italy, Germany, and Australia-as well as hospitals in the United Kingdom. Dr John Bennett, a consultant physician at Hull Royal Infirmary who has received at least two copies of the business card chain letters said, "I don't normally touch chain letters but there was no money involved, it was a simple and touching appeal, and it came from a friend with a list of well known people attached to it-so I did it." Mrs Shergold said that recycling the get well cards and saving the stamps for charities had made it possible to raise C53 000 for research into leukaemia and guide dogs for the blind. But business cards were too small to recycle and because offices used franking machines there were no stamps to save. "So if you do get one of these letters please ignore it," she said.-SHARON KINGMAN, freelance journalist, London
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RHA told to reinstate "redundant" Helen Zeidin A consultant haematologist who was made redundant at 24 hours' notice after speaking out about nursing shortages at her hospital had her appeal upheld last week by the health secretary, Virginia Bottomley. In a Commons written answer Mrs Bottomley said that Dr Helen Zeitlin's employment with West Midlands Regional Health Authority should continue. Dr Zeitlin's reinstatement follows an 18 month battle with the authority over what she claimed was a ploy to get rid of her for blowing the whistle about nurse staffing levels at Alexandra Hospital, Redditch (BMJ 1992;304:203.) On 28 February 1991 Dr Zeitlin was told that she was being made redundant because the hospital had too little work for its two consultant haematologists. She was put on "special paid leave" from the next day. The redundancy notice came less than two months after the authority started disciplinary proceedings against Dr Zeitlin, which were subsequently dropped. One of the charges related to a public meeting in January 1990, where she had criticised nurse staffing levels and predicted that the situation would worsen if the hospital became a self governing trust. Bromsgrove and Redditch Health Authority was keen for Alexandra Hospital to become its first NHS trust hospital. At the two day appeal hearing last August -the first to be held in public-the authority said that Dr Zeitlin was perceived as being "disruptive and malicious." There had been up to 20 complaints against her and a history of trouble between her and a colleague, Dr Daisy Obeid. But Dr Zeitlin claimed that there had been a systematic campaign to get rid of her since she spoke out about health service reforms at the meeting in January 1990 and circulated a secret report about low nursing levels at the hospital. As the BMJ went to press it was unclear
whether Dr Zeitlin would be offered her old job back-she acknowledged that returning to work at Alexandra Hospital would be "uncomfortable"-or redeployed elsewhere in the region. She was due to attend a meeting on 11 November to discuss possible options. The decision comes amid growing concern about excessive secrecy and lack of protection for whistleblowers in the NHS, particularly in hospital trusts, where secrecy clauses are standard terms in employment contracts. The Department of Health has issued draft guidelines on whistleblowing, providing for- employees to take up grievances internally (24 October, p 977). But those dissatisfied after taking such steps can still be disciplined if they go public.CLARE DYER, legal correspondent, BMJ
Tainted blood affair threatens French government The revelations that blood was collected in French prisons as late as 1990 despite warnings that inmates were at risk of being contaminated with HIV and that a government producer of controlled vaccine and serum continued to sell non-heat treated blood extracts until October 1985 have exacerbated the controversy over the "tainted blood affair." The resurgence of the scandal may even lead to a reform of the French constitution so that high officials, including former prime minister Laurent Fabius and former social affairs minister Georgina Dufoix, may answer charges that they procrastinated for several months in banning blood extracts which they knew could be contaminated. Dr Michel Garetta, former director of the National Blood Transfusion Centre, has returned from the United States. He has been sentenced to four years in jail for knowingly having distributed blood extracts contaminated with HIV (31 October, p 1047).
The Conseil de l'Ordre des Medecins, the French medical association, has expelled Garetta for life-making it illegal for him to practise medicine in France and other European Community countries. Last week the general inspectorate of health released its report on the collection of blood in state prisons. The report contained the draft of a memorandum warning that inmates were at high risk ofinfectious diseases and should not be included among donors. A health official crossed out the warning from the final version of the memorandum. The inspectorate canvassed prisons and sometimes offered prisoners certificates of good behaviour if they donated blood. By October 1985 only one of the nine penitentiary administrations in France had banned such "donations" by inmates. It is estimated that in 1985 blood collected in prisons accounted for a quarter of blood contaminated with HIV in France. It was also reported that the Institut Merieux, a subsidiary of the state controlled company Rh6ne-Poulenc, sold unheated blood extracts to European countries until November 1985. During that year Merieux exported 4-6 million units of factor VIII, of which 3-2 million units were untreated. A spokesman for the company, Alain Merieux, said that he had had no instructions to the contrary from the government, adding that there were no reports of HIV contamination. The National Assembly debated the responsibilities of the government in the affair, and parliamentarians called for a reexamination of the roles and responsibilities of administrators, scientific experts, and political leaders. Laurent Fabius, prime minister in 1985, wrote an article in La Monde calling for the constitution to be amended so that ministers could be judged "in ordinary conditions." Arguing that the High Court was not appropriate to judge high government officials' responsibilities in the affair, he said that he would be willing to answer questions before a "jury of honour." Later, Prime Minister Beregovoy agreed that "ministers, like other citizens, should answer for their actions" and said that he would be willing to propose constitutional amendments if the National Assembly reached a consensus on the matter. Whatever the outcome of the affair, it is likely to weigh heavily against the Socialist government as it prepares for parliamentary elections next March.-ALEXANDER DOROZYNSKI, medical journalist, Paris
Vocal women GPs want more part time opportunities If some of the stories told at a conference on women in general practice last weekend are to be believed many women doctors are working in general practice fdr a pittance while bowing to the whims of their selfish and autocratic male colleagues. The 250 participants at the oversubscribed conference BMJ VOLUME 305
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organised by the BMA's General Medical Services Committee were vocal, and angry, and the 60 who booked for confidential counselling kept five experts busy all day. The meeting was convened to discuss the problems women face in general practice. Three quarters of general practice principals are men. Nearly half have never worked with a woman principal and two thirds have never worked with a part time principal. Speakers in the workshops and the plenary session confirmed the dearth of part time profit sharing partnerships. For many the choice was often between full time partnerships with on call duties, or poorly paid salaried partnerships or assistantships. The last two options usually proved career culs de sacs, with the escape route barred by male prejudice rather than by domestic commitments. The outcome of the conference was a series of recommendations to the GMSC to * Ensure that all doctors have access to continued and affordable medical education and consider the needs of doctors on the retainer scheme ! Recognise that women need to be trained in the financial, organisational, and management aspects of general practice * Develop comprehensive undergraduate and postgraduate career guidance * Recommend flexible arrangements for career breaks and return to work packages for all doctors * Give a higher profile to prepartnership advice and conciliation in partnership disputes * Explore altemative ways to provide high quality out of hours primary care to recognise the difficulty in combining a 24 hour professional commitment with domestic responsibilities. The conference confirmed the findings in the latest survey of part time work in general practice. In Part-time Working in General Practice, published this week by the Policy Studies Institute, Isobel Allen found that 93% of the 600 women surveyed (and 74% of the men) wanted more opportunities for part time training. Half the women (and 8% of the men) were working less than full time in clinical medicine, but apart from the 4% of women on matemity leave, only one woman in 50 was at home full time.-TRISHA GREENHALGH,.general practitioner, London
people. One chapter by Suzi Leather, a This is discriminatory."-SHARON KINGMAN, member of the consumer panel which advises freelance medical journalist, London the Ministry of Agriculture, Fisheries and Your Food: Whose Choice? is available from HMSO Food, says that people on low incomes know bookshops, price £10.95. what they should buy but cannot afford it. Faced with the impossible task of paying for everything out of their "woefully inadequate" state benefits, some families cut the amount they spend on food, she says. Although it has often been assumed that healthy eating is cheaper than unhealthy eating, the evidence suggests otherwise, the Russian authorities have stepped in to prevent book says. Leather quotes a report from the Policy what is feared to be a flourishing trade in Studies Institute in London which found that organs for transplantation. In the first such many people are struggling to make ends attempt at introducing controls the parliameet on a weekly budget "that many people ment has passed a law setting out conditions would not think twice about spending on a and procedures for transplant surgery meal in a restaurant." She says that while the coupled with penalties for those who break average family in the UK spends 12-4% of its them. Recent months have seen persistent income on food eaten at home, those living on reports in the Russian press of backstreet income support would have to spend about organ transplant surgery being carried out in 36% of their income on food if they followed the growing number of medical cooperatives. Under the new law passed earlier this a healthy diet costing £10 a week. A recent survey by the National Children's month it is forbidden to buy and sell human Home found that one in five parents and one organs and tissues. Transplants from people in 10 children had sometimes gone without with leaming disabilities or from donors food in the previous month because of lack of under the age of 18-with the exception of money. None of those taking part in the bone marrow-are also banned. So too is the survey was eating a healthy diet, but the removal of organs and tissues from people reason was not ignorance. When parents who are somehow dependent on the recipient. The law, which takes into account recomwere asked what they would buy if they had an extra £10 to spend on food for their child mendations made by the World Health 60% said more fruit, 500/o more lean fresh Organisation, says that transplants should meat, and 38% more vegetables. Fewer than be carried out "only if other medical means one in 10 said that they would buy more cannot guarantee the preservation of a person's life or the restoration of his or her cakes, biscuits, ice cream, and snack foods. The Ministry of Agriculture, Fisheries and health." The passage of the law coincided with Food has constructed a diet, which it calls the Generations of British children will suffer "low cost healthy diet," costing £10 per the surprise sacking of the Russian health stunted growth and heart disease unless the person per week. The diet includes eight minister, Andrei Vorobyov, who collapsed govemment tackles the problem of poverty slices of bread each day, but only three would with an apparent heart attack after presenting and poor diet, Lady Wilcox, who chairs the have even a thin spread of margarine or plans for the reform of the health service at a National Consumer Council, said last week. butter, the rest being eaten dry. The diet stormy session of the cabinet. Vorobyov She was speaking at the launch of Your Food: excludes yoghurt and other dairy products was attacked by fellow ministers over his Whose Choice?, which is published by the apart from a quarter of a slice of processed proposals, which included the introduction of compulsory insurance and the privatisation National Consumer Council and calls for a cheese and less than half a pint ofmilk. Leather says: "In essence, poor consumers of certain sectors of the health service.review of the level of state benefits. The book examines the evidence on would be expected to adopt a totally different PETER CONRADI, Moscow correspondent, whether a healthy diet is possible for poor eating culture from the rest of the population. European
Russia tightens up on transplants
Children eat poorly on state benefits
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US Congress bypasses peer review
members packed to go home to seek reelection, $20m was inserted into a bill for $1 5bn for defence spending. That bill, perennially passed in the closing days of Congress, is often a receptacle for "pork barrel" items -projects that appeal to the electorate but do If young American medical entrepreneurs not reflect real need. The New York Times have trouble selling their products to the called the manoeuvre "Medical Madness on scientific community where do they tum? Capitol Hill." Mad is exactly the emotion expressed by Apparently, they hire a Washington lobbyist, who tums to members of Congress, which America's scientific elite when they heard writes a few million dollars into a huge that Congress had stepped over the sacred budget for the US army. That is exactly why line that separates partisan politics from the US army has been told by Congress to peer review. Congress always sets national spend $20m on a vaccine against HIV that is research agendas (such as those for cancer produced by a private manufacturer, Micro- and AIDS), but until now it has not told scientists exactly what to study, how to do it, GeneSys. In 1985 MicroGeneSys used clones from and what products they should use. Dr Bemadine Healy, director of the NIH, the National Institutes of Health (NIH) and developed a process to produce large said, "I don't know how you can go to a patient and say, 'We're giving you this drug amounts of the HIV viral envelope, gp 160. Later, with the help of researchers from the because a lobbyist chose it."' Her anger was US army, the company set up a trial in echoed by Dr David Kessler (director of 30 patients and showed that gp 160 could- the Food and Drug Administration), many increase CD4 T cell counts in HIV positive researchers in academic centres, and reprepatients. The data, which suggested that sentatives of AIDS foundations. Lobbyists have responded that the scientists are upset gp 160 might be used as a vaccine against HIV, were published in June last year in the because the $20m did not go to them. Congress itself has been embarrassed by New England Journal of Medicine. Several the manoeuvre. The chief sponsor of the scientists criticised the outcome measures used and pointed out that the trial failed to bill, Senator Sam Nunn, a Democrat from Georgia, denied accusations of pork barrel show that gp 160 prolonged life. At about the same time Franklin Volvovitz, politics, saying that the $20m had been the president of MicroGeneSys, apparently recommended by another Senate committee. frustrated with the sluggish scientific peer Mr Nunn, however, was one of the senators review system of the NIH, tumed to one visited by Mr Long, the lobbyist for Microof Washington's most powerful lobbyists, GeneSys. The army, despite its support of MicroRussell Long. Mr Long began prompting certain GeneSys's first small trial, denied that it sought the extra $20m, and its spokespeople senators to push the NIH to approve gp 160. During a Senate hearing in the summer of now say that its researchers believe that large last year Dr Anthony Fauci, director of the trials would be premature. That is exactly National Institute of Allergy and Infectious what Dr Healy believes, and she has conDiseases and one of the nation's most senior vened a panel of scientists, including Dr researchers on HIV, was grilled by Senator Kessler, to try to sort out what seems to Tom Harkin about why gp 160 had not been be a new relationship between Congress and the scientific community. approved for large clinical trials. This issue may be settled soon. Congress The issue quietened down on Capitol Hill last year. According to several investigative has agreed that if Dr Healy, Dr Kessler, and reports, however, Mr Long and executives of the army certify in writing that the project is MicroGeneSys did not. Senators continued now unworthy the entire $20m will be withdrawn from MicroGeneSys and put back into to be lobbied, and this September, as
system
We wanted to give you this vaccine because a
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the army's general budget for research into AIDS-which would swell it by 40% from its present $50m. But Dr Healy has pointed out that resolving the MicroGeneSys fiasco will not prevent future encroachments by Congress into medical research, especially into AIDS, which is both a politically volatile and a lucrative subject.-JOHN ROBERTS, clinical epidemiologist, Baltimore
Menopausal women still badly treated The effects of the menopause on women are poorly understood and inadequately treated, data from two recent surveys suggest. One survey, of British companies' knowledge of and provision for the effects of the menopause on their female staff, showed that more than 90% of companies had no formal policy on the issue; 40% of personnel departments surveyed were unaware that reduced productivity, memory lapses, and fainting spells are menopausal symptoms. The survey, carried out by Private Patients Plan, questioned 168 companies of varying tumover and location, drawn at random from, among others, construction, manufacturing, and service industries. Half the companies surveyed did not have a nurse or doctor on site at least once a week, and 43% of those with a tumover in excess of £50m admitted that they did not provide this facility for their staff. Commenting on the survey's findings, Mr Malcolm Whitehead, a consultant gynaecologist at King's College Hospital, London, said, "Menopausal symptoms ... impair the concentration of all women. You don't have to be a high flier to be made miserable by the menopause." Another survey, carried out by the Amarant Trust, an independent charity that seeks to promote a broader understanding of the menopause and hormone replacement therapy (HRT), found that 80% of respondents thought that their general practitioners had spent too little time with them at their first consultation for HRT, with almost half claiming that it had lasted less than 10 minutes. Just over half of the 3000 women who responded to the questionnaire had been treated by their general practitioner. Speaking on behalf of the Royal College of General Practitioners, Dr Jean Coope, a general practitioner in Cheshire who runs an HRT clinic, said, "Most general practitioners are not giving enough time [to HRT prescribing] because they have so many constraints on their practices, and many simply can't afford to run HRT clinics." Running such a clinic, suggested Dr Coope, costs between £ 15 and £20 an hour. One hundred and thirty seven of the respondents who had not had a hysterectomy were receiving oestrogen only preparations, thereby running an increased risk of endometrial cancer. Only 1 1%/ of the women surveyed expressed concems about taking HRT, but 62% of them were worried about the risk of breast cancer.-CAROLINE WHITE, technical editor, Journal of Clinical Pathology 1179
Letter from Westminster Speaking out in the NHS The British tradition of secrecy in govern- being invoked to discriminate against those ment makes life hazardous for whistleblowers who attempt to raise issues in public. The issue of the guidance raises the in the public service. It is not so long ago that civil servants were prosecuted-and jailed- question of whether the health service should for leaking official secrets which troubled be a special case. Other public or private their conscience. More recently govemments corporations-the BBC for instance-are far have tried in their faltering way to come to harsher on disloyal employees. The NHS acknowledges a higher duty to the sick, and terms with a more open society. The reinstatement last week of Dr Helen the new rules are based on that principle. In Zeitlin (p 1177) is seen as a triumph for that case should there perhaps be new legal whistleblowers, although the reasoning rights to protect whistleblowers who sound behind it remains unpublished and shrouded off about standards of care? in official secrecy. Her case has prompted the Department of Health to produce a whistleblower's charter (24 October, p 977). Commendably, the draft underpins the "right and duty" of NHS staff to raise issues of concern about patient care. The key principle, it states, is that the interests of patients are of paramount importance. Moreover, all employees have a duty to report anything that may be damaging to patients' interests. Under no circumstances are staff to be penalised for airing genuine concerns. And all NHS employers are enjoined to make sure that these "rights and duties" are fully catered for. Correct procedures will need to be established, and the sequence of informal and formal channels as complaints are referred upwards has merits. Most staff may find it intimidating to take their case right to the top, but by that time they would have sought the help of their professional body or trade union as the guidance suggests. There can be no quibble that confidentiality to patients has to be protected, on pain of discipline. Doubts begin to creep in about whether the procedures are too prescriptive. The right and duty to speak out is conditional on whether the local procedures permit it. If the machinery is made to look daunting it can itself become a gag. The main risk of gagging is in relation to disclosures to the media. Access to the press or television is allowed for as a "last resort," but the guidance leaves no doubt about the possible consequences of such an action: "Employees have, under common law, an implied duty of confidence and fidelity to their employer. Breach of this duty may result in disciplinary action. Any disclosure to the media without consent might be seen by the employer as damaging and would therefore represent a potentially serious breach of contract." That threat virtually proscribes disclosure to the media and puts a cork in all but the loudest whistle. Not surprisingly, there is pressure to change it. Labour's health spokesman, Mr David Blunkett, objects to the concept of "commercial confidentiality" being applied to the health service. He accepts that proper lines of reporting should be followed but is concerned that the law is 1180
It may be more a question of good will than good guidelines. The trick is to create the right culture of mutual trust in the NHS, and the guidance wisely places a duty to do so directly on managers. Ultimately, however, there is always a place for whistleblowers if the health service is to be fully accountable to the public. The new guidelines tacitly recognise this. Fortunately, no amount of government guidance can ever call the tune for the genuine whistleblower.-JOHN WARDEN, parliamentary correspondent, BMJ
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