BRITISH MEDICAL JOURNAL
2 OCTOBER 1976
number of clinical cases is small, and the illnesses appear relatively mild. Even so, the risk can be reduced. The first aim should be to eliminate the hazard arising from outbreaks, and in Britain control and prevention of the disease have been achieved in haemodialysis units, where the numbers of patient carriers of hepatitis B antigen (HBsAg) have been kept to a minimum'1 and a code of practice has been established.12 The background risk to laboratory workers still exists, however, both from patients with hepatitis and (probably more important) from HBsAg carriers with no evidence of hepatitisat least 0 1 °h of the British population.'3 Reduction of infection from these sources depends on laboratory workers themselves: detailed advice on appropriate precautions is available,'4-16 and the laboratory director should issue clear and comprehensive instructions that are not too difficult for staff to put into routine practice. Two points are worth emphasising. All specimens-not only those labelled "high risk"-should be considered potentially infective; and staff must report all accidents to allow the potential danger to be assessed and the indications for prophylaxis to be considered. Human normal immunoglobulin protects against hepatitis A.'7 Trials in the USA of immunoglobulin with high titre antibody to HBsAg have shown good, though incomplete, protection.1819 Supplies of both materials are held by the Public Health Laboratory Service. Kuh, C, and Ward, W W E,3journal of the American Medical Association, 1950, 143, 631. 2 Turnbull, M L, and Greiner, D J, j7ournal of the American Medical Association, 1951, 145, 965. 3Byrne, E B,3journal of the American Medical Association, 1966, 195, 362. 4Marmion, B P, and Tonkin, R W, British Medical Bulletin, 1972, 28, no 2, 169. 5 Harrington, J M, and Shannon, H S, British Medical journal, 1976, 1, 759. 6 Grist, N R,journal of Clinical Pathology, 1975, 28, 255. 7 Grist, N R, journal of Clinical Pathology, 1976, 29, 480. 8 Farrow, L J, et al, British Medicalyjournal, 1974, 3, 83. 9 Pattison, C P, et al, American journal of Epidemiology, 1975, 101, 59. 10 Wruble, L D, et al, Gastroenterology, 1974, 66, 800. 1 Public Health Laboratory Service Survey, British Medical journal, 1976, 1, 1579. 12 Department of Health and Social Security, Scottish Home and Health Department, Welsh Office, Report of the Advisory Group on Hepatitis and the Treatment of Chronic Renal Failure, 1970-72. London, HMSO, 1972. 13 Payne, R W, Barr, A, and Wallace, J, journal of Clinical Pathology, 1974, 27, 125. 14 Revised Report of the Advisory Group on Testing for the Presence of Australia (Hepatitis Associated) Antigen and its Antibody. London, DHSS, 1972. 15 Central Pathology Committee, Safety in Pathology Laboratories. London, DHSS, Welsh Office, 1972. 16 Public Health Laboratory Service Monograph Series No 6. London, HMSO, I
1974.
17 Pollock, T M, Reid, D, and Smith, G V, Lancet, 1969, 1, 281.
18 Seeff, L B, et al, Lancet, 1975, 2, 939. 19 Grady, G F, and Lee, V A, New England journal of Medicine, 1975, 293,
1067.
The end of excellence? Throughout the world there are a few hospital complexes where the quality of the care given to patients, the teaching, and the academic research reach the highest possible standards. They take many years, even some generations, to build up, and in Britain for historical reasons a disproportionate number are in the London region. Such centres are relatively few, because excellence requires not only a concentration of medical talent and technological hardware but also enough staff to provide the time needed for the germination and ex-
779
change ofideas, criticism, and consultation. They are expensive, yet the contribution they make to the improvement of standards and advancement of medicine extends far beyond their boundaries. It is for that reason that the new DHSS programme1 for sharing resources more fairly among the population of England could prove a tragedy, for it could very easily lead to the decline and fall of the best of English medicine. The working party that drew up the programme started with the objective of sharing out the resources available to the NHS in such a way "that there would eventually be equal opportunity of access to health care for people at equal risk." In general they have set out to redress the inequalities caused by the excess of doctors and hospitals in the south and east of England and the excess of ill health in the north and west. This imbalance is most marked in London, which has a declining population but still has many of the biggest and newest hospitals housing 12 of the 20 English medical schools. The proposals for redistribution of both revenue and capital are based on population numbers and morbidity; but clearly, too, account has to be taken of the expense to each region of maintaining its teaching hospitals. A complex formula is proposed in the report for a "service increment for teaching" to cover the additional costs to the NHS of providing facilities for clinical teaching. The working party's calculations showed that in teaching hospitals the annual additional cost per student ranged from £3300 to £19 100. Even after allowance had been made for their high local costs the London schools were all found to be more expensive than the provincial ones with the exception of Oxford, which ranked third in the league table. So the programme also includes a redistribution scheme to bring the costs of the 20 schools closer to average. No specific proposals have been made for the postgraduate institutes and their associated hospitals, but the report suggests that they should be treated in a similar way. The overall effect will be that the four Thames regions which contain the London teaching hospitals will receive a lower proportion of the national spending on the NHS-at a time when every region is struggling to balance its budget. "There is no escaping the fact," says the working party, "that one centre's excellence may be bought at the price of another's deprivations." This reflects a complete misunderstanding of the influence that centres of excellence have throughout the country. Even so, when resources are limited it seems equitable that they should be shared on the basis of need rather than historical accident: and it is true that since the NHS began the Thames regions have had the thickest slices of the national cake. What is wrong with the working party's plan is that it deals only with resources. The reason the Thames regions have proved so expensive is that London contains not only the teaching and research centres that attract visitors from all over the world but also many more hospitals, doctors, and other staff than can be justified by the needs of its own population. The fantasy solution would be physically to move some of these hospitals-with their staff, equipment, and costs-to the underprivileged regions in the north and west, so reducing the costs of the metropolitan regions to closer to the national average. That is not, however, what the working party has proposed. Hospital closure is not even mentioned in the report, which stresses that its proposals should be brought into effect slowly: "adjustments should be carefully phased to avoid putting important services at risk." Certainly the transfer of resources that the report has recommended could lead to closure of hospitals in some regions and building of new ones elsewhere (as an extreme example, the "excess costs" of all 12 London
780
medical schools could be saved by closing one of them); but in the absence of any clear guidelines to that effect it seems unlikely that any of the metropolitan regions will solve its financial dilemma by such draconic measures. Even at a less dramatic level regions know from experience what to expect. Attempts to close hospitals (the Elizabeth Garrett Anderson, for instance) bring opposition from pressure groups and unions, questions in Parliament, and endless appeals and inquiries. Cutting budgets by an equal "fair" amount all round is administratively easier and less provocative: the effects are spread widely and protests cannot be so specific. Some small hospital closures may be inevitable in the metropolitan area, but major closures and movements of medical staff will be needed to redress the historic imbalance. This is the missing element in the report, and without it the programme could be disastrous. The only way that centres of excellence can survive in London with a shrinking share of the NHS budget is for the number of major hospitals to be reduced. That is not a policy that the regions can be expected to push through without a lead from the top. Does the DHSS want the numbers of hospital beds (including teaching hospital beds) in London reduced ? If so it should say so unequivocally and support the policy. If not, its proposals will inevitably lead to a remorseless drain of resources and morale from London's medicine, to the detriment of the whole country. DHSS, Sharing resources for health in England. Report of the Resource Allocation Working Party. London, HMSO, 1976, £1.70.
Diet and the diabetic Even the threat of dietary restriction is unwelcome to most of us; yet physicians have traditionally emphasised the importance of diet in the treatment of a whole variety of diseases. Its special importance in diabetes has long been recognised,' and even since the introduction of insulin dietary control has continued to be an essential part of management. The chief purpose of dieting for the insulin-treated diabetic is the -relief of symptoms of uncontrolled diabetes while avoiding those of hypoglycaemia. This can be achieved only by maintaining the daily carbohydrate allowance constant and taking it at regular times. Good metabolic control, however, means much more than just the elimination of symptoms,2 for poor control causes retardation of growth in children3 and high fetal mortality in pregnancy.4 In extreme cases years of inadequate treatment may result in dwarfism. Growth rates certainly accelerate with better control, though childhood diabetics still suffer some stunting of growth even when clinical control seems satisfactory.5 The benefit of good control on the development of diabetic complications is less certain. Apart from the possible advantage in some cases of lowering plasma lipid concentrations, there is no scientific proof that prevention or reversal of complications can be achieved by improving diabetic control. This controversial question has been reviewed by Fajans6 and Keen and Jarrett.7 The composition of the ideal diet for insulin-treated patients is continually debated. In the pre-insulin era the Allen diets were virtually free of carbohydrate, having instead a very high fat content. Over the last 50 years the carbohydrate allowance
BRITISH MEDICAL JOURNAL
2 OCTOBER 1976
has increased. Compared with the average intake for normal British men of about 380 grams8 (some racial groups, notably West Indians, take much more), most diabetics are recommended to take between 100 and 250 grams daily, depending on age, weight, activity, and previous dietary habit. Very restricted carbohydrate diets have the disadvantage that many patients add to them by increasing their fat intake, and this has led to the suspicion that such diets may increase the risk of atherosclerosis. A generous carbohydrate intake is more acceptable to most patients and, on an isocaloric basis, means that less fat is eaten. One problem of a high carbohydrate diet may be the need for much larger doses of insulin. Nevertheless, it seems that the insulin requirement may be relatively little affected by an increase in carbohydrate intake provided that the calorie total remains unchanged,9 10 though further observations are needed. The use of higher carbohydrate diets was discussed at a recent symposium in Australia,'" and has been recommended in the USA,12 but patients need to be told that simply increasing the carbohydrate intake without restriction of total calories leads to a deterioration of control. Many of them can recognise the recurrence of symptoms which follow dietary indiscretion. When diabetics fail to keep to the recommended regimen"3 14 (though those on insulin are more assiduous than others) this may sometimes be the fault of the presentation of diabetic diets,'5 which is not always helpful and in some instances inaccurate.'6 There is still debate on the right size of the carbohydrate "portion," but in practice the 10-gram portion recommended by the British Diabetic Association seems the simplest and the best. Patients should be left in no doubt that a constant daily intake of carbohydrate should be taken at regular times. The amount of carbohydrate should be tailored to meet individual needs, but it may be more generous than in the past,'217 with consequent restriction of fat intake. Partial substitution of saturated fats by polyunsaturated fats and vegetable oils has recently been suggested for the diabetic (as it has for the whole community'7), though the evidence does not warrant dogmatism. The exact balance of fat and carbohydrate may need to be determined by reference to plasma lipid concentrations. Protein intake should be normal. There is no place for the "free" diets, which have sometimes been recommended for children. Any attempt at control is then doomed to failure. Continuing education is required to maintain interest and motivation.'8 1
Wood, F C, and Bierman, E L, Nutrition Today, 1972, 7, 4. 2 Alberti, K G M M, and Hockaday, T D R, in Complications of Diabetes, eds H Keen and J Jarrett, p 222. London, Arnold, 1975. 3 Pond, H, Postgraduate Medical Journal, 1970, 46, 616. 4Essex, N, British Journal of Hospital Medicine, 1976, 15, 333. 5 Tattersall, R B, and Pyke, D A, Lancet, 1973, 2, 1105. 6 Fajans, S S, Diabetes, 1972, 21, suppl 2, 678. 7Complications of Diabetes, eds H Keen and J Jarrett. London, Arnold, 1975. 8 Widdowson, E M, Journal of Hygiene, 1936, 36, 269. 9 Himsworth, H P, Clinical Science, 1935, 2, 67 10 Kempner, W, Peschel, R L, and Schlayer, C, Postgraduate Medicine, 1958, 24, 359. 11 Whyte, H M, Medical Journal of Australia, 1976, 1, 836. 12 Bierman, E L, et al, Diabetes, 1971, 20, 633. 13 Tunbridge, R, and Wetherill, J H, British Medical3Journal, 1970, 2, 78. 14 West, K M, Annals of Internal Medicine, 1973, 79, 425. 16 Truswell, A S, Thomas, B J, and Brown, A M, British Medical Journal, 1975, 4, 7. 16 Thomas, B J, Truswell, A S, and Brown, A M, Nutrition, 1974, 28, 357. 17 Royal College of Physicians of London and the British Cardiac Society, Journal of the Royal College of Physicians of London, 1976, 10, 214. 18 Teuscher, A, Acta Diabetologica Latina, 1972, 9, suppl 1, 546.
2 OCTOBER 1976
number of clinical cases is small, and the illnesses appear relatively mild. Even so, the risk can be reduced. The first aim should be to eliminate the hazard arising from outbreaks, and in Britain control and prevention of the disease have been achieved in haemodialysis units, where the numbers of patient carriers of hepatitis B antigen (HBsAg) have been kept to a minimum'1 and a code of practice has been established.12 The background risk to laboratory workers still exists, however, both from patients with hepatitis and (probably more important) from HBsAg carriers with no evidence of hepatitisat least 0 1 °h of the British population.'3 Reduction of infection from these sources depends on laboratory workers themselves: detailed advice on appropriate precautions is available,'4-16 and the laboratory director should issue clear and comprehensive instructions that are not too difficult for staff to put into routine practice. Two points are worth emphasising. All specimens-not only those labelled "high risk"-should be considered potentially infective; and staff must report all accidents to allow the potential danger to be assessed and the indications for prophylaxis to be considered. Human normal immunoglobulin protects against hepatitis A.'7 Trials in the USA of immunoglobulin with high titre antibody to HBsAg have shown good, though incomplete, protection.1819 Supplies of both materials are held by the Public Health Laboratory Service. Kuh, C, and Ward, W W E,3journal of the American Medical Association, 1950, 143, 631. 2 Turnbull, M L, and Greiner, D J, j7ournal of the American Medical Association, 1951, 145, 965. 3Byrne, E B,3journal of the American Medical Association, 1966, 195, 362. 4Marmion, B P, and Tonkin, R W, British Medical Bulletin, 1972, 28, no 2, 169. 5 Harrington, J M, and Shannon, H S, British Medical journal, 1976, 1, 759. 6 Grist, N R,journal of Clinical Pathology, 1975, 28, 255. 7 Grist, N R, journal of Clinical Pathology, 1976, 29, 480. 8 Farrow, L J, et al, British Medicalyjournal, 1974, 3, 83. 9 Pattison, C P, et al, American journal of Epidemiology, 1975, 101, 59. 10 Wruble, L D, et al, Gastroenterology, 1974, 66, 800. 1 Public Health Laboratory Service Survey, British Medical journal, 1976, 1, 1579. 12 Department of Health and Social Security, Scottish Home and Health Department, Welsh Office, Report of the Advisory Group on Hepatitis and the Treatment of Chronic Renal Failure, 1970-72. London, HMSO, 1972. 13 Payne, R W, Barr, A, and Wallace, J, journal of Clinical Pathology, 1974, 27, 125. 14 Revised Report of the Advisory Group on Testing for the Presence of Australia (Hepatitis Associated) Antigen and its Antibody. London, DHSS, 1972. 15 Central Pathology Committee, Safety in Pathology Laboratories. London, DHSS, Welsh Office, 1972. 16 Public Health Laboratory Service Monograph Series No 6. London, HMSO, I
1974.
17 Pollock, T M, Reid, D, and Smith, G V, Lancet, 1969, 1, 281.
18 Seeff, L B, et al, Lancet, 1975, 2, 939. 19 Grady, G F, and Lee, V A, New England journal of Medicine, 1975, 293,
1067.
The end of excellence? Throughout the world there are a few hospital complexes where the quality of the care given to patients, the teaching, and the academic research reach the highest possible standards. They take many years, even some generations, to build up, and in Britain for historical reasons a disproportionate number are in the London region. Such centres are relatively few, because excellence requires not only a concentration of medical talent and technological hardware but also enough staff to provide the time needed for the germination and ex-
779
change ofideas, criticism, and consultation. They are expensive, yet the contribution they make to the improvement of standards and advancement of medicine extends far beyond their boundaries. It is for that reason that the new DHSS programme1 for sharing resources more fairly among the population of England could prove a tragedy, for it could very easily lead to the decline and fall of the best of English medicine. The working party that drew up the programme started with the objective of sharing out the resources available to the NHS in such a way "that there would eventually be equal opportunity of access to health care for people at equal risk." In general they have set out to redress the inequalities caused by the excess of doctors and hospitals in the south and east of England and the excess of ill health in the north and west. This imbalance is most marked in London, which has a declining population but still has many of the biggest and newest hospitals housing 12 of the 20 English medical schools. The proposals for redistribution of both revenue and capital are based on population numbers and morbidity; but clearly, too, account has to be taken of the expense to each region of maintaining its teaching hospitals. A complex formula is proposed in the report for a "service increment for teaching" to cover the additional costs to the NHS of providing facilities for clinical teaching. The working party's calculations showed that in teaching hospitals the annual additional cost per student ranged from £3300 to £19 100. Even after allowance had been made for their high local costs the London schools were all found to be more expensive than the provincial ones with the exception of Oxford, which ranked third in the league table. So the programme also includes a redistribution scheme to bring the costs of the 20 schools closer to average. No specific proposals have been made for the postgraduate institutes and their associated hospitals, but the report suggests that they should be treated in a similar way. The overall effect will be that the four Thames regions which contain the London teaching hospitals will receive a lower proportion of the national spending on the NHS-at a time when every region is struggling to balance its budget. "There is no escaping the fact," says the working party, "that one centre's excellence may be bought at the price of another's deprivations." This reflects a complete misunderstanding of the influence that centres of excellence have throughout the country. Even so, when resources are limited it seems equitable that they should be shared on the basis of need rather than historical accident: and it is true that since the NHS began the Thames regions have had the thickest slices of the national cake. What is wrong with the working party's plan is that it deals only with resources. The reason the Thames regions have proved so expensive is that London contains not only the teaching and research centres that attract visitors from all over the world but also many more hospitals, doctors, and other staff than can be justified by the needs of its own population. The fantasy solution would be physically to move some of these hospitals-with their staff, equipment, and costs-to the underprivileged regions in the north and west, so reducing the costs of the metropolitan regions to closer to the national average. That is not, however, what the working party has proposed. Hospital closure is not even mentioned in the report, which stresses that its proposals should be brought into effect slowly: "adjustments should be carefully phased to avoid putting important services at risk." Certainly the transfer of resources that the report has recommended could lead to closure of hospitals in some regions and building of new ones elsewhere (as an extreme example, the "excess costs" of all 12 London
780
medical schools could be saved by closing one of them); but in the absence of any clear guidelines to that effect it seems unlikely that any of the metropolitan regions will solve its financial dilemma by such draconic measures. Even at a less dramatic level regions know from experience what to expect. Attempts to close hospitals (the Elizabeth Garrett Anderson, for instance) bring opposition from pressure groups and unions, questions in Parliament, and endless appeals and inquiries. Cutting budgets by an equal "fair" amount all round is administratively easier and less provocative: the effects are spread widely and protests cannot be so specific. Some small hospital closures may be inevitable in the metropolitan area, but major closures and movements of medical staff will be needed to redress the historic imbalance. This is the missing element in the report, and without it the programme could be disastrous. The only way that centres of excellence can survive in London with a shrinking share of the NHS budget is for the number of major hospitals to be reduced. That is not a policy that the regions can be expected to push through without a lead from the top. Does the DHSS want the numbers of hospital beds (including teaching hospital beds) in London reduced ? If so it should say so unequivocally and support the policy. If not, its proposals will inevitably lead to a remorseless drain of resources and morale from London's medicine, to the detriment of the whole country. DHSS, Sharing resources for health in England. Report of the Resource Allocation Working Party. London, HMSO, 1976, £1.70.
Diet and the diabetic Even the threat of dietary restriction is unwelcome to most of us; yet physicians have traditionally emphasised the importance of diet in the treatment of a whole variety of diseases. Its special importance in diabetes has long been recognised,' and even since the introduction of insulin dietary control has continued to be an essential part of management. The chief purpose of dieting for the insulin-treated diabetic is the -relief of symptoms of uncontrolled diabetes while avoiding those of hypoglycaemia. This can be achieved only by maintaining the daily carbohydrate allowance constant and taking it at regular times. Good metabolic control, however, means much more than just the elimination of symptoms,2 for poor control causes retardation of growth in children3 and high fetal mortality in pregnancy.4 In extreme cases years of inadequate treatment may result in dwarfism. Growth rates certainly accelerate with better control, though childhood diabetics still suffer some stunting of growth even when clinical control seems satisfactory.5 The benefit of good control on the development of diabetic complications is less certain. Apart from the possible advantage in some cases of lowering plasma lipid concentrations, there is no scientific proof that prevention or reversal of complications can be achieved by improving diabetic control. This controversial question has been reviewed by Fajans6 and Keen and Jarrett.7 The composition of the ideal diet for insulin-treated patients is continually debated. In the pre-insulin era the Allen diets were virtually free of carbohydrate, having instead a very high fat content. Over the last 50 years the carbohydrate allowance
BRITISH MEDICAL JOURNAL
2 OCTOBER 1976
has increased. Compared with the average intake for normal British men of about 380 grams8 (some racial groups, notably West Indians, take much more), most diabetics are recommended to take between 100 and 250 grams daily, depending on age, weight, activity, and previous dietary habit. Very restricted carbohydrate diets have the disadvantage that many patients add to them by increasing their fat intake, and this has led to the suspicion that such diets may increase the risk of atherosclerosis. A generous carbohydrate intake is more acceptable to most patients and, on an isocaloric basis, means that less fat is eaten. One problem of a high carbohydrate diet may be the need for much larger doses of insulin. Nevertheless, it seems that the insulin requirement may be relatively little affected by an increase in carbohydrate intake provided that the calorie total remains unchanged,9 10 though further observations are needed. The use of higher carbohydrate diets was discussed at a recent symposium in Australia,'" and has been recommended in the USA,12 but patients need to be told that simply increasing the carbohydrate intake without restriction of total calories leads to a deterioration of control. Many of them can recognise the recurrence of symptoms which follow dietary indiscretion. When diabetics fail to keep to the recommended regimen"3 14 (though those on insulin are more assiduous than others) this may sometimes be the fault of the presentation of diabetic diets,'5 which is not always helpful and in some instances inaccurate.'6 There is still debate on the right size of the carbohydrate "portion," but in practice the 10-gram portion recommended by the British Diabetic Association seems the simplest and the best. Patients should be left in no doubt that a constant daily intake of carbohydrate should be taken at regular times. The amount of carbohydrate should be tailored to meet individual needs, but it may be more generous than in the past,'217 with consequent restriction of fat intake. Partial substitution of saturated fats by polyunsaturated fats and vegetable oils has recently been suggested for the diabetic (as it has for the whole community'7), though the evidence does not warrant dogmatism. The exact balance of fat and carbohydrate may need to be determined by reference to plasma lipid concentrations. Protein intake should be normal. There is no place for the "free" diets, which have sometimes been recommended for children. Any attempt at control is then doomed to failure. Continuing education is required to maintain interest and motivation.'8 1
Wood, F C, and Bierman, E L, Nutrition Today, 1972, 7, 4. 2 Alberti, K G M M, and Hockaday, T D R, in Complications of Diabetes, eds H Keen and J Jarrett, p 222. London, Arnold, 1975. 3 Pond, H, Postgraduate Medical Journal, 1970, 46, 616. 4Essex, N, British Journal of Hospital Medicine, 1976, 15, 333. 5 Tattersall, R B, and Pyke, D A, Lancet, 1973, 2, 1105. 6 Fajans, S S, Diabetes, 1972, 21, suppl 2, 678. 7Complications of Diabetes, eds H Keen and J Jarrett. London, Arnold, 1975. 8 Widdowson, E M, Journal of Hygiene, 1936, 36, 269. 9 Himsworth, H P, Clinical Science, 1935, 2, 67 10 Kempner, W, Peschel, R L, and Schlayer, C, Postgraduate Medicine, 1958, 24, 359. 11 Whyte, H M, Medical Journal of Australia, 1976, 1, 836. 12 Bierman, E L, et al, Diabetes, 1971, 20, 633. 13 Tunbridge, R, and Wetherill, J H, British Medical3Journal, 1970, 2, 78. 14 West, K M, Annals of Internal Medicine, 1973, 79, 425. 16 Truswell, A S, Thomas, B J, and Brown, A M, British Medical Journal, 1975, 4, 7. 16 Thomas, B J, Truswell, A S, and Brown, A M, Nutrition, 1974, 28, 357. 17 Royal College of Physicians of London and the British Cardiac Society, Journal of the Royal College of Physicians of London, 1976, 10, 214. 18 Teuscher, A, Acta Diabetologica Latina, 1972, 9, suppl 1, 546.
