NEWS & Political Review Trials of HIV vaccine planned for developing countries The science is incomplete. The laws are inadequate. The ethical questions-not to mention their answers-have not been defined. But with 40 million people expected to be HIV positive by the end of the decade, the world's AIDS researchers have decided that they can wait no longer to try out vaccines against HIV. In mid-October 400 scientists and policy makers had met in Florida and decided that even though basic research has produced no perfect vaccine, they must plan clinical trials. The World Health Organisation (which officially boycotted the meeting because of American policies that bar immigrants who are HIV positive) will coordinate trials in at least four countries whose emissaries came to Florida to ask for help: Uganda, Rwanda, Thailand, and Brazil. Other trials are being planned for Zaire-if the political turmoil settles down-and the US. The World Health Organisation's role will be difficult. Scores of groups in Europe and the US are at various stages of developing a vaccine. In the US alone four government agencies, at least 18 universities, and a dozen manufacturers are involved. Dr Dan Hoth, chief of the division of AIDS at the National Institutes of Allergy and Infectious Diseases (the group that coordinated the Florida meeting), hopes that the first trials will begin in 1995. But, even before the first pilot study begins, epidemiologists must identify cohorts most at risk and estimate the incidence of infection in countries where the seroprevalence for HIV ranges from 10% to 80%. Then the virus from each country must be sequenced. Finally-perhaps the most difficult task in poor countries-laboratory and clinical facilities for testing a vaccine must be set up. But along this path of scientific inquiry lie ethical and legal hazards. All work done under the umbrella of WHO must comply with the Helsinki Declaration of 1975, which mandates that "concern for the interest of the individual must always prevail over the interests of science and society." To deal with the rush towards trials of HIV vaccines another group-the Council of International Organisations of Medical Sciences, based in WHO offices in Geneva-is grappling with the special ethical questions posed by doing research designed in the West in developing countries. One ethical problem is deciding whether subjects randomised to placebo arms oftrials derive any benefit. The National Institutes of Allergy and Infectious Diseases says that such subjects will get some real BMJ
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benefit-for example, hepatitis B vaccination. But the fundamental ethical issue is the wide variety of religious and moral systems in the countries concerned. Dr Hoth says, "How can we create one set of rules that will work for Buddhists in Thailand, Moslems in Africa, and Christians in Brazil?" For example, in many African countries, there is no concept of the individual beyond one's role in the community. Who will consent for subjects in such cultures? Margaret Somerville, an ethicist from McGill University, points out that in some tribes a woman's sexual activity is dictated by her mother in law. The subjugation of women by their husbands is common throughout Africa. Who will speak for them? Some people from developing countries have called upon Western researchers to meet the ethical standards of both Western countries-where the individual is supremeand the host country-where the tribe rules. But Dr Nicholas Christakis, who has written on the ethics of AIDS trials, calls for "ethical pluralism." Ethics, he says, "is culturally constrained"; thus rules must change a little from place to place and must be respected by Westerners. The tension between different systems of morals cannot be erased, but the scientists who met in Florida believe that they have one 0
answer to the problem. Local scientists-not Westerners-will manage the clinical trials in each country, so that local customs will be respected. Much of the next two years will be spent finding and training local leaders. They also hope that local experts will answer another difficult question-how to explain to people who neither read nor subscribe to germ theories that blood can carry HIV antibodies without carrying a disease. In parts of east Africa a woman who tests positive for HIV antibody is thrown out on to the streets. Another potential danger of the vaccine trials is what one scientist in the US called "rampant egregious entrepreneurism where individuals may.. formulate something in their garage." Professor Somerville wants Western countries to pass laws that hold manufacturers liable for unscrupulous behaviour overseas. "Right now, there is nothing to stop anyone in Canada from going over and doing research in Africa that would clearly be illegal here," she says. The only check is ostracism from the scientific community, which happened to Dr Daniel Zagury after he conducted vaccine trials in Zaire "with the full support of the Zairean ethics committee" but without the support of Western ethics committees. Perhaps the most important and most obvious ethical question arising from the .
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Headlines £2100 of GPs' clawback waived: The government will waive £2100 of the £5951 overpayment made to general practitioners in 1990-1 and has invited the profession to agree on joint evidence to the review body to avoid further overpayment (p 1273). Cancelled operating sessions: In response to a query from the Labour party, which estimated that 77 000 operating sessions were cancelled in the year ending 31 March 1991, the government has stated that more than 81 000 were cancelled.
Coupons not beer money: People are being encouraged to hand out coupons worth 25 cents (1Sp) to those begging in Berkeley, California. These can be redeemed at grocery stores and laundries and on public transport. The aim is to stop the needy spending their money on alcohol and drugs. Women who smoke: One in three women of reproductive age in the US smokes, according to a survey of 39 states by the Centers for Disease Control. The highest rate was in Wisconsin (37%), the lowest in Texas
(21%). Health officials hope that by 2000 no more than 12% of childbearing women will be smokers.
Best health care?: Sweden, the Netherlands, and Canada came top in a study that developed indexes to rank primary care based on infant mortality, life expectancy, and patients' satisfaction with their care in relation to its cost. The report in the J7ournal of the American Medical Association covered 10 Western industrialised nations. The US and West Germany (before unification) tied for last place. Thailand's AIDS figures: Unless there are considerable behavioural changes government officials in Thailand expect that by 2000 two to four million people will be infected with HIV. At present between 200 000 and 400 000 people are infected, according to figures from the World Health Organ-
isation.
Orphaned by AIDS: According to the World Health Organisation, 10-15 million children, mostly in sub-Saharan Africa, will lose their mothers to AIDS by 2000. Women infected with HIV have given birth to nearly one million infected children-of whom over half have developed AIDS or died-and two million uninfected children.
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trials is who should get the tested vaccines. In the words of one ethicist, "Those that bear the burden of risk must be the first to benefit from its product." But, because all the vaccines being developed in the US are the property of corporations, there is no guarantee yet that Rwandans, Ugandans, Thais, and Brazilians will get any vaccine without paying. The National Institutes of Allergy and Infectious Diseases and WHO, however, will use the next two to three years to get guarantees of some sort. "We'll act as brokers to help poor countries get the vaccines from the makers," said Dr Hoth. -JOHN ROBERTS, clinical epidemiologist, North Carolina
Mass demonstration by French health professionals The largest demonstration ever of French health professionals is taking place in Paris this week to oppose the government's health policies. The demonstration will be led by doctors protesting against the freezing of medical fees and against an agreement made between the Caisse Nationale d'Assurances Maladies (CNAM), the health insurance branch of the social security system, and the government to limit medical costs. Doctors have no say in the agreement and are particularly incensed by the government's proposal to trim the budget by financially penalising doctors who exceed their share of consultations and prescriptions. Dr Jacques Monod, president of the Centre National des Professions de Sante, has denounced the agreement as a form of rationing that threatens the quality of health care and the civil liberties of patients and doctors. Monod wants doctors to participate in negotiations on limiting the increase in national health insurance costs, which rose 7-2% between August 1990 and August 1991. Dr Jacques Beaupere, president of the Confederation des Syndicats Medicaux Francais, the largest medical union in France, said that the agreement was "unacceptable to physicians" because decisions might be taken against doctors' interests. The social affairs minister, Jean-Louis Bianco, maintains that the decisions should be taken by the CNAM and the government but confirms that the advice of health professionals will be taken into consideration. Doctors were also irritated by the CNAM's recent release of statistics showing that doctors have no reason to complain about their earnings. While the earning power of French professionals has fallen by nearly 6% in the past 10 years, that of doctors has increased by nearly 14%. The average monthly income is about Fr 24 000 for general practitioners, Fr 36000 for specialists, and only Fr 19 000 for non-medical professionals. And although many young doctors earn much less, the CNAM points out that for most of them low earnings are only temporary. Doctors say that these figures do not take into account long working hours-for
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French health professionals will be consulted about cost cutting, says_Jean-Louis Bianco, social affairs minister
example, 56 hours a week for general practitioners. Last week several hundred nurses in Paris joined a procession leading to the Ministry of Health, where a coffin was incinerated. But this week most nurses' unions have agreed to an offer of premiums for work on Sundays, gradual salary increases, and appointments of 5500 more nurses and assistants over three years. By 1993 nurses will earn Fr 10760 a month after five years' practice. Finally, the government is struggling to keep its head above water in the blood transfusion "scandal." Last week, a fourth health official, Dr Jean-Pierre Allain, former head of research at the Centre National de Transfusion Sanguine, was indicted on charges of omitting to warn blood transfusion patients of the risk of contamination with HIV. -ALEXANDER DOROZYNSKI, medical journalist, Paris
Ray of hope on European manpower Medical manpower in Europe, currently oversupplied, could stabilise in the early part of the next century because doctors who entered medicine during the "big bang" in manpower in the 1960s will begin retiring. This is the main message of the Permanent Working Group of Junior Hospital Doctors' report on manpower, Medical Manpower in Europe, From Surplus to Deficit?, launched at a conference in Florence last month. The aims of the study were to discover the numbers and distribution of doctors within western Europe and to make forecasts of manpower for 2000. With statistics computed from 15 of the group's 17 member states Dr Peter Saugmann-Jensen from Denmark and his colleagues have estimated that the number of doctors will increase in the 1990s by an average of 1-85% a year, less than half the average annual growth rate in the 1980s. The workforce will age, and by 2000 the growth
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will probably be zero. Because doctors spend an average of 36-2 years in practice those who graduated in 1965 will be retiring in 2001. There will, however, be no dramatic fall in numbers. In 1991, 45000 doctors will graduate and 14000 will retire. Not until 2003 could input equal output. There are, of course, many variables. The study's authors estimate that in countries already hit by medical unemployment the position will stay the same or get worse until 1995. Over 60 000 doctors are unemployed in western Europe. Two thirds of them live in Italy, where there will be a problem of oversupply for another 20 years, according to the director general of the Italian hospital service. Nearly a quarter of German doctors and a tenth of Spanish doctors are unemployed. Overproduction of doctors is educationally harmful, damaging to standards of practice, and economically wasteful. Many unemployed Italian doctors drive taxis. Although the secretary of the European Commission's Advisory Committee on Medical Training, Mr Sidney Allman, played down the problem of migration and cited the small number of doctors who had migrated since the 1975 medical directives allowed free movement in the European Community, other speakers were not so sanguine. With the opening up of eastern Europe many more doctors might wish to work in the West and this could well undermine prospects for a balance in manpower. A doctor from Latvia who spoke at the conference explained why he and his colleagues might wish to migrate. He explained that low salaries-the equivalent of $10 a month-forced doctors to look for supplementary employment, such as farming, to make even a basic living. Dr Martin Teilmann from Denmark, who put the manpower problem in its economic context, warned that it was difficult to forecast more than three years ahead with such variables as medical advances, economic constraints, and the introduction of market elements. Dr Andrew Carney and Dr Ruth
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Gilbert from the United Kingdom added demographic changes and the changing nature of doctors' work as other variables that should be taken into account in manpower planning. Another Danish contributor, Dr Svend Christensen, asked whether government planning was the key. In the United Kingdom and Scandinavia, with their state health schemes, it is certainly easier to plan manpower. But the United Kingdom has overworked junior doctors and overlong training and Scandinavian countries are unable to fill all their medical posts. The Permanent Working Group hopes that the report will be studied by European doctors and by the European authorities (summaries will be available shortly from the BMA secretariat). Although health care has a relatively low profile in the European Commission, with no one department having specific responsibility for manpower, things may change. With 1992 looming the commission may well try to develop a health policy for member countries. Mr Alhman advised the group that it should be ready to give its views on manpower, training, and service demands. If doctors fail to tell Brussels of their own ideas on manpower planning and health the bureaucrats may do it for them. LINDA BEECHAM, BMJ
Voters in US want health care for all "If criminals have a right to a lawyer American workers should have a right to a doctor," said Mr Harris Wofford, an almost unknown Pennsylvania Democrat running in the US Senate election last week. His argument on health care won him the seat in a
surprise victory. In June opinion polls on voters' intentions showed Mr Wofford trailing the former Republican attorney general and governor of Pennsylvania, Dick Thornburgh, by 20% to 67%. By fighting a campaign based on national health insurance Mr Wofford beat Mr Thornburgh 55% to 45%. But Pennsylvanians usually vote Republican, and the victory has prompted President Bush to cancel a trip to Asia to concentrate on health care reforms. The Democrats are keen to make health care their theme for the election. A former senator in Massachusetts, Paul Tsongas, is arguing that employers should be forced to buy health insurance for their- workers. A devotee of market forces, Mr Tsongas thinks that employers would shop for the best and least expensive insurance schemes. In Nebraska Senator Robert Kerrey favours a government run system, which he claims would cut the massive administration costs now plaguing hospitals, employers, and workers. He believes that a tax based system with annual budgets would be the most effective way to provide care. On the Republican side Mr Bush now says that he will announce major health reforms before next year's election, probably focus-
ing on minor changes to health insurance and an overhaul of systems dealing with medical malpractice. -JOHN ROBERTS, clinical epidemiologist, North Carolina
More money for the NHS Next year the government plans to spend nearly £34bn on the NHS-around £600 for every person in the United Kingdom. But despite the proximity of the general election and the current political importance of the NHS next year's settlement for the health service is not as generous as this year's. In his autumn statement setting out the government's spending intentions for the next three years, the chancellor, Norman Lamont, revised plans for next year and added a further £5 *6bn to an existing commitment of £22 1bn for total government spending. The cash increase over this year's spending (as opposed to the addition to the planned increase) will be just over £1 lbn. The main recipients will be social security (largely because of higher unemployment), transport, education, and health. The NHS is the third largest recipient after social security and support for local government. The cash increases for the NHS in the whole of the United Kingdom will be £2-7bn, a rise of about 8-7%. Wales, Scotland, and Northern Ireland will share about £500m. Further details will be available in due course. More detail is known, however, about spending on the NHS in Englandserved by the Department of Health. The English NHS will receive an extra £2-2bn, which, based on the governments forecasts of inflation of 4 5%, is equivalent to a real increase of 4-2%. As ever, the totals, the assumptions underpinning the spending, the details of actual distribution, and, not least, the jargon of the Treasury tend to obscure the eventual financial reality for the NHS. And the actual effect on health care (let alone health) is buried even deeper. The extra amount provided to the English NHS next year will be distributed among the hospital and community health services, the family health services, capital, and revenue. The hospital and community health services will receive a real increase of 5% and the family health services a real increase of 1-7%. With efficiency savings raising £200m, the Department of Health reckons that the hospital and community health services will have a real increase of 6% in revenue resources. Money for hospital building is planned to increase to £1 6bn-a case rise of 9-8% (a real rise of 5 0%). Land sales are expected to add another 9% to this figure. All the "real" figures quoted are based on the government's estimate of inflation of 4 5% next year. The NHS estimates that the health inflation rate will be around 6% to 6 6%. If this estimate turns out to be correct the overall real rise will be nearer to 2% than 4-2%.-JOHN APPLEBY, economic correspondent, BMJ 1221
Heart valve records falsified
in the valve struts should probably not have is now at the same level as it was in 1948. He been rewelded at all. After discovering this described that as a considerable achievement, Shiley halted rewelding in 1983 and dis- given the massive rise in the volume of carded valves with cracks from then on. traffic in the past 40 years, and he said that Around 55 000 people worldwide are still better vehicles, better roads, and advances in The Bjork-Shiley convexoconcave mechanical heart valve, withdrawn from the market in fitted with the valve, and the death toll medical care were responsible. He argued 1986, is at the centre of controversy again, continues to mount. Of 86000 valves im- that education is still needed to reduce the with claims by former employees at the plant planted, about 450 have fractured so far, basic human errors involved in most acciwhere the device was made that production leading to nearly 300 deaths. Last month a 32 dents. The government has announced that it records in the early 1980s were falsified. year old man from Dundee became the 35th Former workers at Shiley's plant in Cali- British victim and the fifth this year. Shiley wants to reduce road accidents by a third fornia claimed in the Wall StreetJournal last has already agreed to a confidential out of by the year 20.00. Random breath testing week that valves sent back for rewelding of court settlement (subsequently found to be might help. A Scottish judge, Sheriff John cracked metal struts were sometimes signed for £350 000) for the man's wife and daughter. Wheatley, has raised fines for drink-drivers in an attempt at deterrence that has had off as having been rewelded when the proce- -CLARE DYER, legal correspondent, BMJ little effect. Sheriff Wheatley said that the dure was never carried out. vast majority of people drink and drive in Philip Hedger, of Shiley's European diviThe : ven.,watr.......d vaI*.: m. ih; the belief that they will not be caught. He sion, said, "We believe that probably was K.. gdom h...have th f. ..Uied argued that random breath testing would happening, but we don't believe any senior change that belief. -BRYAN CHRISTIE, health management were aware of it." Shiley, which correspondent of The Scotsman :29MBRC16IRi8 433RC4GI36i has launched its own investigation, said that 29MBRC40390 3MB.4(I38t the company and its parent, Pfizer, remained 4 29MBC0438 "deeply concerned" about the findings of 29M-1wC4O;4l; . "paperwork problems." The Wall Street Journal tracked down and resigns interviewed the "phantom welder," Manuel over Vizcarra, whose work records, which came to light through litigation over the valve, first revealed the practice. Some 1900 valves on The turbulence of the first year of the recorded as having been rewelded by Mr Commons health committee was sustained Vizcarra turned out to have been manu- Road accidents result in the greatest number last week when Jerry Hayes, a Conservative factured months after he left the company. of lost years of productive life but attract a member, resigned from the committee. Mr Mr Vizcarra told the Wall StreetJournal that fraction of the research money devoted to Hayes had accepted responsibility for last he never welded a single valve. His job was to cancer and AIDS according to Professor summer's leak to the Department of Health polish out scratches. Neil Brooks, of Glasgow University's depart- of a draft report compiled by the committee's Another employee, Larry Gendreau, says ment of psychological medicine. Professor chairman, Nicholas Winterton, on the NHS he believes that some workers, under pro- Brooks, speaking at a symposium organised reforms (3 August, p 268). duction pressures-Shiley had cornered over by the insurance group General Accident The mystery was solved when Mr Hayes half the world market for mechanical heart earlier this month argued that the public discovered that one of his staff, an American valves by 1983-polished out cracks rather unquestioningly accepts the death toll on researcher, had passed on the draft report. than subject valves to a chancy rewelding. Britain's roads. Every year around 5000 Blaming himself for not being vigilant Valves whose struts developed cracks during people are killed, 68 000 are seriously injured, enough, Mr Hayes wrote, "The only honourmanufacturing were sent back for rewelding. and the total cost to the country in lost pro- able course available to me is to apologise Only surface scratches were meant to be duction, treatment, and damage to property unreservedly and offer my resignation from the committee." polished out. Valves went round the produc- and vehicles is put at some £4 5bn. tion line in a bag attached to a card on The circumstances ofthe leak are set out in But, according to David Crichton, General which the welder was supposed to enter his Accident's commercial motor manager, the a special report which will now go to the employee number after completing the re- death rate from road accidents is falling and committee of privileges. In it, the health welding. committee concludes that the leak was a The newspaper quotes from an interngl potentially grave interference in its work miemo from a supervisor to his boss comand states, "The possibility of government plaining that valves were signed off as redepartments being in possession of an unwelded even though most cracks had been authorised copy of a draft report of a select polished or blended. "I think we should only committee implies that the government be signing off operations actually performed. could seek to influence the private proceedSecondly, if QC [quality control] is identifyings of a select committee and seriously ing valid cracks, then polishing is merely an disrupt its work." Indeed, 17 pages of the draft report, relating to NHS trusts, were appearance Band-Aid. I think we are hiding -our most serious defect." voted out of the final version, allegedly at the Shiley has been ordered by the US Food government' s instigation. and Drug Administration to try to track Letters between Mr Winterton and Mr down patients who were fitted with a batch of Waldegrave disclose that the leaked report 500 large valves attributed to the phantom was destroyed on the secretary of state's order when it was discovered not to be an welder, which have proved particularly authorised communication. This was learnt prone to fracture. So far 32 have fractured, when an official tried to correct "inaccukilling 20 patients. Of the 500 potentially faulty valves, 35 racies" in the document. With the go between revealed as Mr were distributed in the United Kingdom. In all but seven cases the company has tracked Waldegrave's parliamentary private secredown the surgeons who received the valves. tary, Ian Taylor, the trail narrowed to the It has written to all cardiac surgeons listing researcher, who has since returned to the the serial numbers of the untraced valves (see United States. Mr Hayes said that he knows the researcher would have acted in total innobox). The Wall Street Journal has also unearthed The government aims to cut road accidents by a third by the cence of the consequences. -JOHN WARDEN, evidence suggesting that the metal alloy used year 2000 parliamentary correspondent, BMJ
MP from committee leak
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First trust for Northern Ireland The Royal group of hospitals in Belfast is to become the first health and social services trust in Northern Ireland on 1 April 1993. The group and the Eastern Health and Social Services Board has been given a year to "come to grips" with its projected end of year deficit of £1 5m and its problems of keeping within the budget. The unit general manager, William McKee, said, "I believe the financial shortfall could be made up without any reduction in the level of services." The unions doubt this, citing the problems at the flagship Guy's and Lewisham NHS trust in London, which started to shed jobs soon after opting out. The reforms in the Northern Ireland Health Service have lagged behind those in England and Wales by one year. On 1 April 1992 the four area boards will become pur-
chasers on behalf of the population of 1-5 million people, and in April 1993 general practice fundholding will begin. Until April 1993 the Eastern board will retain overall managerial responsibility for the unit but a shadow board for the trust will be headed by Dr George Quigley, currently director of the Ulster Bank and previously the permanent secretary of the Northern Ireland Department of Finance and Personnel. The Royal group includes the Royal Victoria Hospital, the Royal Maternity Hospital, the Royal Belfast Hospital for Sick Children, and the School of Dentistry. Most staff have opposed trust status, and in a ballot in June most consultants voted against the bid or for trust status to be deferred for one year. Most political parties in Northern Ireland are opposed to trust status too, with the only political support for the plan coming from the small, three year old Conservative party. -MARY BLACK, Department of Public Health Medicine, Eastern Health and Social Services Board, Belfast
The decision to make the Royal group ofhospitals a trust is unpopular
4 November, John Cardinal O'Connor of Community directive on labelling specifies New York said that he found it "shocking "at least 4%." The judge, Mr Justice Roch, is that in this land in which we claim the three expected to refer the case to Europe at a rejects euthanasia dominant freedoms of life, liberty, and the hearing next month. In the mean time the pursuit of happiness there is an incredible parties must formulate the exact question to Voters in Washington state in a referendum drive to destroy life." He compared the be put to the European court, which is initiative to the small beginnings of Nazi already considering a case from Italy on on 5 November threw out Initiative Measure whether a state may require more than one No 119, which would have legalised doctor genocide. On 8 October the California secretary warning to be put on a packet. The two cases assisted suicide. Doctors would have been able to give "aid in dying" to terminally ill of state announced that supporters of an are likely to be dealt with together. When the case comes back from Europe patients who asked for such help. Doctors initiative, "Terminal Illness. Assistance in providing this "service" would have been Dying," have until 5 March to submit nearly the tobacco companies will ask for a declarimmune from prosecution for criminal or 400 000 registered signatures and thereby get ation that requirements in the new regulations unprofessional conduct, and doctors who did the issue on the California ballot in 1992. The for warnings to cover at least 6% of British not wish to comply with such requests would statute would allow doctors to "terminate cigarette packets are unlawful. The directive specifies that warnings "shall have had to make a "good faith effort" to life in [a] painless, humane, and dignified transfer a patient to a doctor who would manner" after diagnosis of a terminal illness. cover at least 4% of each large surface of the -MICHAEL MORRIS, Royal College of Psy- unit packet" and that statements of tar and comply. nicotine yields must cover at least 4% of the Euthanasia has been catapulted to the chiatrists travelling fellow, Indianapolis sides. The companies argue that "at least forefront of national debate on social policy 4%" is a specific requirement which member in the US since the controversial referendum states must bring into their national laws, was announced. Some 223 000 signatures not a minimum requirement which member of support were collected last year by the states have a discretion to increase. group Washington Citizens for Death with They point to article B of the directive, Dignity, which has attracted considerable which states: "Member states may not, for international attention. Supporters of the reasons of labelling, prohibit or restrict the measure, many of them from outside the sale of products which comply with this state, raised about $1-6m, the largest ever directive." A packet whose warnings occupy campaign fund seen in the state on a ballot issue. The Oregon based Hemlock Society, Three tobacco companies are expected to 4% of the surfaces complies with the directive, whose book Final Exit is a bestseller (24 go to the European Court of Justice they say, and a more onerous requirement August, p 431), was one of the major pro- in Luxembourg as the first step in their would restrict sales. Cigarettes made in other member states ponents of the referendum, together with the challenge to new government health warnings American Civil Liberties Union of Washing- on cigarette packets. The High Court last may be imported into the United Kingdom if week granted Gallaher, Imperial Tobacco, their warnings are in English and comply ton. They said that the change was necessary and Rothmans leave to bring judicial review with the labelling requirements of their to expand freedom of choice. The main opponents of the initiative were proceedings against the health secretary, country of origin. The result of the 6% the medical profession (especially the Ameri- William Waldegrave, over part of the requirement, the companies contend, would Tobacco Products Labelling (Safety) Regu- be to put British cigarettes in an uncomcan Geriatrics Society and the Washington petitive position compared with imports Medical Association) and the Catholic church lations 1991. The companies and the minister have carrying warnings covering only 4% of the (especially the National Conference of Bishops). They argued that the initiative agreed that the case should first be referred to packet. This would be inconsistent with the would undermine the moral integrity of the European court for a ruling on the point directive, which is intended to harmonise the medical profession and that it ran contrary of law at issue: whether member states have a labelling requirements throughout the discretion to require warnings to cover more European Community.-CLARE DYER, legal to moral and social prohibitions against killing. According to the New York Times on than 4% of a packet when a European correspondent, BMJ
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Letter from Westminster
Names and numbers Whatever the effect to be felt in the wards and surgeries from the government's future spending plans for the NHS, their effect on Westminster is simply to increase the stockpile of statistics. The chancellor's autumn statement served merely to feed an insatiable political appetite for number crunching. The amorphous millions may add up to a plus for the NHS, though that has done nothing to stop the haggling over decimal points (p 1221). I confine myself to two conveniently round figures. These show that the health service now accounts for 15% of government spending compared with only 10% devoted to defence. It is comforting to know that the most warlike noises in these times are no more than a barrage of statistics. As a diversionary tactic last week the opposition fired off a salvo aimed at the list of chairmen and directors of second wave NHS trusts. To Labour's delight the 500 names included two Tory former ministers, the wives of two Tory MPs, and the husband of another. The Prime Minister was asked if he was trying to turn the NHS into a "family business for card carrying Conservatives." But whether it's names or numbers, each side is armed to the teeth. Mr Major replied by citing the example of Lady Callaghan, wife of the former Labour premier-an excellent chairman of the Hospital for Sick Children, Great Ormond Street, he said. The health secretary, William Waldegrave, took a swipe at Lord Ennals for being a director of a private health care company while remaining Labour's health spokesman in the Lordsa position from which Lord Ennals has resigned, though denying any conflict of interest with his nursing home directorship. Mrs Virginia Bottomley, the health minister, scored a direct hit when she was invited by the Labour MP, Dennis Skinner, to. condemn the appointment of "Tory spouses" to NHS trusts. No, she said, because no one had cast smears against an aunt of hers who was once chairman of a health authority. She was of course referring to Peggy Jay, wife of the former Labour cabinet minister, Douglas Jay. Statistics took over again when Mrs Bottomley later gave evidence to the Commons health committee in its continuing inquiryv into maternity services. The committee wanted to know why only 1% of babies in the United Kingdom were born at home compared with 35% in the Netherlands. The committee suspects a government bias towards hospital confinements. Officials from the Department of Health had followed in the committee's footsteps to Holland and came back with a different slant. They were told that home confinements were going down in the Netherlands because quality and safety of hospital births, which is something that has already happened in Britain. The questioning then turned to the matter
women there were recognising the
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of remunerating general practitioners for maternity medical services. Out of the blue the chairman, Nicholas Winterton, asked if the Department of Health had any plans to review the separate fees for general practitioners for providing maternity care. Had it considered instead a capitation payment based on the number of patients on a general practitioner's list who were women of childbearing age? Mrs Bottomley replied that the department had not considered such an option, though it might be prepared to do so, adding "General practitioners' remuneration is a matter of ongoing discussion. If this committee makes a recommendation in that area
we will look at it very carefully." Make of that what you will, for no more was said. But the question was undoubtedly rooted in the tension between doctors and midwives, which gives rise to the latter sometimes asserting that general practitioners are being paid for work which the midwives do. On a happier note, the minister had news of a fresh start between the Royal College of Midwives and the Royal College of General Practitioners in an attempt to resolve their interprofessional tension. I shall be in a position to report further next week, after the committee has heard from the colleges about the peace talks. -JOHN WARDEN, parliamentary correspondent, BMJ
The Week As survey after survey of consultants has shown, most of those who have supported trust status for their own hospitals have done so not as a positive act but resignedly. They have supported applications because the independent status of trusts has seemed to offer more protection for the work they do, a greater likelihood of getting the capital developments they need, and the prospect of less bureaucracy. Few have supported trusts because they thought they might do better financially from the freedom that trusts have to determine their own pay and conditions of service. Yet as key professionals in any hospital consultants might be expected to do rather well. Indeed, several senior NHS managers are on record as saying that they are underpaid. But consultants themselves actually feel that they may do rather badly-because what they value about their contracts does not revolve entirely around money. Consultants have, of course, long been used to negotiating with managers about service developments, how to squeeze an extra piece of equipment out of this budget or an extra nurse out of that. What they haven't done for a long time is haggle about their salaries or conditions of employment. Conditions of service negotiated centrally and review body pay awards have ensured that locally consultants and managers have been able to devote most of their time to service issues rather than employment issues. Not any longer. Though some trust managers don't see renegotiating consultant contracts as a high priority, many others are trying to pin down consultants to more specific contracts. Last week saw the first meeting at BMA House ofconsultants elected to sit on local negotiating committees in trusts committees the BMA has been busy setting up to represent medical staff. The
meeting aimed at making consultants think about the value of the elements in their existing contract: what they should go to the wall to keep and what they might be willing to bargain away -for a price. The list of elements that consultants would go to the wall for is interesting, and managers should mark it well because it suggests that simply offering consultants more money won't be enough. Top of the consultants' list are freedom of speech, tenure of consultant posts, flexibility of working, and the right to do private practice. Yet confidentiality clauses, contracts subject to review, and 100% commitment to the employing trust are already appearing in the contracts of new consultants. Given their value to consultants, managers should ask themselves whether these elements are worth the battle. As Jim Johnson, a consultant's negotiator, pointed out, most consultants have used the independence given to them by flexibility of working to work far more than their contracted hours for the NHS. Freedom of speech too is not an unconstrained right: consultants can still be brought to book for libel or breaching patient confidentiality. Some oblique support for the consultants' stance also came last week from a study by a team at Warwick University looking at the characteristics of managements that successfully managed change in the NHS. One characteristic was good teamwork with members who had time for "deviants and heretics" prepared to say the unsayable. Another was good relationships between managers and clinicians, with both groups understanding each other's problems and values. Will the need to haggle over conditions of employment damage those good relationships (where they exist)? Or will managers who value their consultants be more likely to listen to what their consultants value? HART
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benefit-for example, hepatitis B vaccination. But the fundamental ethical issue is the wide variety of religious and moral systems in the countries concerned. Dr Hoth says, "How can we create one set of rules that will work for Buddhists in Thailand, Moslems in Africa, and Christians in Brazil?" For example, in many African countries, there is no concept of the individual beyond one's role in the community. Who will consent for subjects in such cultures? Margaret Somerville, an ethicist from McGill University, points out that in some tribes a woman's sexual activity is dictated by her mother in law. The subjugation of women by their husbands is common throughout Africa. Who will speak for them? Some people from developing countries have called upon Western researchers to meet the ethical standards of both Western countries-where the individual is supremeand the host country-where the tribe rules. But Dr Nicholas Christakis, who has written on the ethics of AIDS trials, calls for "ethical pluralism." Ethics, he says, "is culturally constrained"; thus rules must change a little from place to place and must be respected by Westerners. The tension between different systems of morals cannot be erased, but the scientists who met in Florida believe that they have one 0
answer to the problem. Local scientists-not Westerners-will manage the clinical trials in each country, so that local customs will be respected. Much of the next two years will be spent finding and training local leaders. They also hope that local experts will answer another difficult question-how to explain to people who neither read nor subscribe to germ theories that blood can carry HIV antibodies without carrying a disease. In parts of east Africa a woman who tests positive for HIV antibody is thrown out on to the streets. Another potential danger of the vaccine trials is what one scientist in the US called "rampant egregious entrepreneurism where individuals may.. formulate something in their garage." Professor Somerville wants Western countries to pass laws that hold manufacturers liable for unscrupulous behaviour overseas. "Right now, there is nothing to stop anyone in Canada from going over and doing research in Africa that would clearly be illegal here," she says. The only check is ostracism from the scientific community, which happened to Dr Daniel Zagury after he conducted vaccine trials in Zaire "with the full support of the Zairean ethics committee" but without the support of Western ethics committees. Perhaps the most important and most obvious ethical question arising from the .
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Headlines £2100 of GPs' clawback waived: The government will waive £2100 of the £5951 overpayment made to general practitioners in 1990-1 and has invited the profession to agree on joint evidence to the review body to avoid further overpayment (p 1273). Cancelled operating sessions: In response to a query from the Labour party, which estimated that 77 000 operating sessions were cancelled in the year ending 31 March 1991, the government has stated that more than 81 000 were cancelled.
Coupons not beer money: People are being encouraged to hand out coupons worth 25 cents (1Sp) to those begging in Berkeley, California. These can be redeemed at grocery stores and laundries and on public transport. The aim is to stop the needy spending their money on alcohol and drugs. Women who smoke: One in three women of reproductive age in the US smokes, according to a survey of 39 states by the Centers for Disease Control. The highest rate was in Wisconsin (37%), the lowest in Texas
(21%). Health officials hope that by 2000 no more than 12% of childbearing women will be smokers.
Best health care?: Sweden, the Netherlands, and Canada came top in a study that developed indexes to rank primary care based on infant mortality, life expectancy, and patients' satisfaction with their care in relation to its cost. The report in the J7ournal of the American Medical Association covered 10 Western industrialised nations. The US and West Germany (before unification) tied for last place. Thailand's AIDS figures: Unless there are considerable behavioural changes government officials in Thailand expect that by 2000 two to four million people will be infected with HIV. At present between 200 000 and 400 000 people are infected, according to figures from the World Health Organ-
isation.
Orphaned by AIDS: According to the World Health Organisation, 10-15 million children, mostly in sub-Saharan Africa, will lose their mothers to AIDS by 2000. Women infected with HIV have given birth to nearly one million infected children-of whom over half have developed AIDS or died-and two million uninfected children.
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trials is who should get the tested vaccines. In the words of one ethicist, "Those that bear the burden of risk must be the first to benefit from its product." But, because all the vaccines being developed in the US are the property of corporations, there is no guarantee yet that Rwandans, Ugandans, Thais, and Brazilians will get any vaccine without paying. The National Institutes of Allergy and Infectious Diseases and WHO, however, will use the next two to three years to get guarantees of some sort. "We'll act as brokers to help poor countries get the vaccines from the makers," said Dr Hoth. -JOHN ROBERTS, clinical epidemiologist, North Carolina
Mass demonstration by French health professionals The largest demonstration ever of French health professionals is taking place in Paris this week to oppose the government's health policies. The demonstration will be led by doctors protesting against the freezing of medical fees and against an agreement made between the Caisse Nationale d'Assurances Maladies (CNAM), the health insurance branch of the social security system, and the government to limit medical costs. Doctors have no say in the agreement and are particularly incensed by the government's proposal to trim the budget by financially penalising doctors who exceed their share of consultations and prescriptions. Dr Jacques Monod, president of the Centre National des Professions de Sante, has denounced the agreement as a form of rationing that threatens the quality of health care and the civil liberties of patients and doctors. Monod wants doctors to participate in negotiations on limiting the increase in national health insurance costs, which rose 7-2% between August 1990 and August 1991. Dr Jacques Beaupere, president of the Confederation des Syndicats Medicaux Francais, the largest medical union in France, said that the agreement was "unacceptable to physicians" because decisions might be taken against doctors' interests. The social affairs minister, Jean-Louis Bianco, maintains that the decisions should be taken by the CNAM and the government but confirms that the advice of health professionals will be taken into consideration. Doctors were also irritated by the CNAM's recent release of statistics showing that doctors have no reason to complain about their earnings. While the earning power of French professionals has fallen by nearly 6% in the past 10 years, that of doctors has increased by nearly 14%. The average monthly income is about Fr 24 000 for general practitioners, Fr 36000 for specialists, and only Fr 19 000 for non-medical professionals. And although many young doctors earn much less, the CNAM points out that for most of them low earnings are only temporary. Doctors say that these figures do not take into account long working hours-for
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French health professionals will be consulted about cost cutting, says_Jean-Louis Bianco, social affairs minister
example, 56 hours a week for general practitioners. Last week several hundred nurses in Paris joined a procession leading to the Ministry of Health, where a coffin was incinerated. But this week most nurses' unions have agreed to an offer of premiums for work on Sundays, gradual salary increases, and appointments of 5500 more nurses and assistants over three years. By 1993 nurses will earn Fr 10760 a month after five years' practice. Finally, the government is struggling to keep its head above water in the blood transfusion "scandal." Last week, a fourth health official, Dr Jean-Pierre Allain, former head of research at the Centre National de Transfusion Sanguine, was indicted on charges of omitting to warn blood transfusion patients of the risk of contamination with HIV. -ALEXANDER DOROZYNSKI, medical journalist, Paris
Ray of hope on European manpower Medical manpower in Europe, currently oversupplied, could stabilise in the early part of the next century because doctors who entered medicine during the "big bang" in manpower in the 1960s will begin retiring. This is the main message of the Permanent Working Group of Junior Hospital Doctors' report on manpower, Medical Manpower in Europe, From Surplus to Deficit?, launched at a conference in Florence last month. The aims of the study were to discover the numbers and distribution of doctors within western Europe and to make forecasts of manpower for 2000. With statistics computed from 15 of the group's 17 member states Dr Peter Saugmann-Jensen from Denmark and his colleagues have estimated that the number of doctors will increase in the 1990s by an average of 1-85% a year, less than half the average annual growth rate in the 1980s. The workforce will age, and by 2000 the growth
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will probably be zero. Because doctors spend an average of 36-2 years in practice those who graduated in 1965 will be retiring in 2001. There will, however, be no dramatic fall in numbers. In 1991, 45000 doctors will graduate and 14000 will retire. Not until 2003 could input equal output. There are, of course, many variables. The study's authors estimate that in countries already hit by medical unemployment the position will stay the same or get worse until 1995. Over 60 000 doctors are unemployed in western Europe. Two thirds of them live in Italy, where there will be a problem of oversupply for another 20 years, according to the director general of the Italian hospital service. Nearly a quarter of German doctors and a tenth of Spanish doctors are unemployed. Overproduction of doctors is educationally harmful, damaging to standards of practice, and economically wasteful. Many unemployed Italian doctors drive taxis. Although the secretary of the European Commission's Advisory Committee on Medical Training, Mr Sidney Allman, played down the problem of migration and cited the small number of doctors who had migrated since the 1975 medical directives allowed free movement in the European Community, other speakers were not so sanguine. With the opening up of eastern Europe many more doctors might wish to work in the West and this could well undermine prospects for a balance in manpower. A doctor from Latvia who spoke at the conference explained why he and his colleagues might wish to migrate. He explained that low salaries-the equivalent of $10 a month-forced doctors to look for supplementary employment, such as farming, to make even a basic living. Dr Martin Teilmann from Denmark, who put the manpower problem in its economic context, warned that it was difficult to forecast more than three years ahead with such variables as medical advances, economic constraints, and the introduction of market elements. Dr Andrew Carney and Dr Ruth
Most ofEurope's unemployed doctors live in Italy
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Gilbert from the United Kingdom added demographic changes and the changing nature of doctors' work as other variables that should be taken into account in manpower planning. Another Danish contributor, Dr Svend Christensen, asked whether government planning was the key. In the United Kingdom and Scandinavia, with their state health schemes, it is certainly easier to plan manpower. But the United Kingdom has overworked junior doctors and overlong training and Scandinavian countries are unable to fill all their medical posts. The Permanent Working Group hopes that the report will be studied by European doctors and by the European authorities (summaries will be available shortly from the BMA secretariat). Although health care has a relatively low profile in the European Commission, with no one department having specific responsibility for manpower, things may change. With 1992 looming the commission may well try to develop a health policy for member countries. Mr Alhman advised the group that it should be ready to give its views on manpower, training, and service demands. If doctors fail to tell Brussels of their own ideas on manpower planning and health the bureaucrats may do it for them. LINDA BEECHAM, BMJ
Voters in US want health care for all "If criminals have a right to a lawyer American workers should have a right to a doctor," said Mr Harris Wofford, an almost unknown Pennsylvania Democrat running in the US Senate election last week. His argument on health care won him the seat in a
surprise victory. In June opinion polls on voters' intentions showed Mr Wofford trailing the former Republican attorney general and governor of Pennsylvania, Dick Thornburgh, by 20% to 67%. By fighting a campaign based on national health insurance Mr Wofford beat Mr Thornburgh 55% to 45%. But Pennsylvanians usually vote Republican, and the victory has prompted President Bush to cancel a trip to Asia to concentrate on health care reforms. The Democrats are keen to make health care their theme for the election. A former senator in Massachusetts, Paul Tsongas, is arguing that employers should be forced to buy health insurance for their- workers. A devotee of market forces, Mr Tsongas thinks that employers would shop for the best and least expensive insurance schemes. In Nebraska Senator Robert Kerrey favours a government run system, which he claims would cut the massive administration costs now plaguing hospitals, employers, and workers. He believes that a tax based system with annual budgets would be the most effective way to provide care. On the Republican side Mr Bush now says that he will announce major health reforms before next year's election, probably focus-
ing on minor changes to health insurance and an overhaul of systems dealing with medical malpractice. -JOHN ROBERTS, clinical epidemiologist, North Carolina
More money for the NHS Next year the government plans to spend nearly £34bn on the NHS-around £600 for every person in the United Kingdom. But despite the proximity of the general election and the current political importance of the NHS next year's settlement for the health service is not as generous as this year's. In his autumn statement setting out the government's spending intentions for the next three years, the chancellor, Norman Lamont, revised plans for next year and added a further £5 *6bn to an existing commitment of £22 1bn for total government spending. The cash increase over this year's spending (as opposed to the addition to the planned increase) will be just over £1 lbn. The main recipients will be social security (largely because of higher unemployment), transport, education, and health. The NHS is the third largest recipient after social security and support for local government. The cash increases for the NHS in the whole of the United Kingdom will be £2-7bn, a rise of about 8-7%. Wales, Scotland, and Northern Ireland will share about £500m. Further details will be available in due course. More detail is known, however, about spending on the NHS in Englandserved by the Department of Health. The English NHS will receive an extra £2-2bn, which, based on the governments forecasts of inflation of 4 5%, is equivalent to a real increase of 4-2%. As ever, the totals, the assumptions underpinning the spending, the details of actual distribution, and, not least, the jargon of the Treasury tend to obscure the eventual financial reality for the NHS. And the actual effect on health care (let alone health) is buried even deeper. The extra amount provided to the English NHS next year will be distributed among the hospital and community health services, the family health services, capital, and revenue. The hospital and community health services will receive a real increase of 5% and the family health services a real increase of 1-7%. With efficiency savings raising £200m, the Department of Health reckons that the hospital and community health services will have a real increase of 6% in revenue resources. Money for hospital building is planned to increase to £1 6bn-a case rise of 9-8% (a real rise of 5 0%). Land sales are expected to add another 9% to this figure. All the "real" figures quoted are based on the government's estimate of inflation of 4 5% next year. The NHS estimates that the health inflation rate will be around 6% to 6 6%. If this estimate turns out to be correct the overall real rise will be nearer to 2% than 4-2%.-JOHN APPLEBY, economic correspondent, BMJ 1221
Heart valve records falsified
in the valve struts should probably not have is now at the same level as it was in 1948. He been rewelded at all. After discovering this described that as a considerable achievement, Shiley halted rewelding in 1983 and dis- given the massive rise in the volume of carded valves with cracks from then on. traffic in the past 40 years, and he said that Around 55 000 people worldwide are still better vehicles, better roads, and advances in The Bjork-Shiley convexoconcave mechanical heart valve, withdrawn from the market in fitted with the valve, and the death toll medical care were responsible. He argued 1986, is at the centre of controversy again, continues to mount. Of 86000 valves im- that education is still needed to reduce the with claims by former employees at the plant planted, about 450 have fractured so far, basic human errors involved in most acciwhere the device was made that production leading to nearly 300 deaths. Last month a 32 dents. The government has announced that it records in the early 1980s were falsified. year old man from Dundee became the 35th Former workers at Shiley's plant in Cali- British victim and the fifth this year. Shiley wants to reduce road accidents by a third fornia claimed in the Wall StreetJournal last has already agreed to a confidential out of by the year 20.00. Random breath testing week that valves sent back for rewelding of court settlement (subsequently found to be might help. A Scottish judge, Sheriff John cracked metal struts were sometimes signed for £350 000) for the man's wife and daughter. Wheatley, has raised fines for drink-drivers in an attempt at deterrence that has had off as having been rewelded when the proce- -CLARE DYER, legal correspondent, BMJ little effect. Sheriff Wheatley said that the dure was never carried out. vast majority of people drink and drive in Philip Hedger, of Shiley's European diviThe : ven.,watr.......d vaI*.: m. ih; the belief that they will not be caught. He sion, said, "We believe that probably was K.. gdom h...have th f. ..Uied argued that random breath testing would happening, but we don't believe any senior change that belief. -BRYAN CHRISTIE, health management were aware of it." Shiley, which correspondent of The Scotsman :29MBRC16IRi8 433RC4GI36i has launched its own investigation, said that 29MBRC40390 3MB.4(I38t the company and its parent, Pfizer, remained 4 29MBC0438 "deeply concerned" about the findings of 29M-1wC4O;4l; . "paperwork problems." The Wall Street Journal tracked down and resigns interviewed the "phantom welder," Manuel over Vizcarra, whose work records, which came to light through litigation over the valve, first revealed the practice. Some 1900 valves on The turbulence of the first year of the recorded as having been rewelded by Mr Commons health committee was sustained Vizcarra turned out to have been manu- Road accidents result in the greatest number last week when Jerry Hayes, a Conservative factured months after he left the company. of lost years of productive life but attract a member, resigned from the committee. Mr Mr Vizcarra told the Wall StreetJournal that fraction of the research money devoted to Hayes had accepted responsibility for last he never welded a single valve. His job was to cancer and AIDS according to Professor summer's leak to the Department of Health polish out scratches. Neil Brooks, of Glasgow University's depart- of a draft report compiled by the committee's Another employee, Larry Gendreau, says ment of psychological medicine. Professor chairman, Nicholas Winterton, on the NHS he believes that some workers, under pro- Brooks, speaking at a symposium organised reforms (3 August, p 268). duction pressures-Shiley had cornered over by the insurance group General Accident The mystery was solved when Mr Hayes half the world market for mechanical heart earlier this month argued that the public discovered that one of his staff, an American valves by 1983-polished out cracks rather unquestioningly accepts the death toll on researcher, had passed on the draft report. than subject valves to a chancy rewelding. Britain's roads. Every year around 5000 Blaming himself for not being vigilant Valves whose struts developed cracks during people are killed, 68 000 are seriously injured, enough, Mr Hayes wrote, "The only honourmanufacturing were sent back for rewelding. and the total cost to the country in lost pro- able course available to me is to apologise Only surface scratches were meant to be duction, treatment, and damage to property unreservedly and offer my resignation from the committee." polished out. Valves went round the produc- and vehicles is put at some £4 5bn. tion line in a bag attached to a card on The circumstances ofthe leak are set out in But, according to David Crichton, General which the welder was supposed to enter his Accident's commercial motor manager, the a special report which will now go to the employee number after completing the re- death rate from road accidents is falling and committee of privileges. In it, the health welding. committee concludes that the leak was a The newspaper quotes from an interngl potentially grave interference in its work miemo from a supervisor to his boss comand states, "The possibility of government plaining that valves were signed off as redepartments being in possession of an unwelded even though most cracks had been authorised copy of a draft report of a select polished or blended. "I think we should only committee implies that the government be signing off operations actually performed. could seek to influence the private proceedSecondly, if QC [quality control] is identifyings of a select committee and seriously ing valid cracks, then polishing is merely an disrupt its work." Indeed, 17 pages of the draft report, relating to NHS trusts, were appearance Band-Aid. I think we are hiding -our most serious defect." voted out of the final version, allegedly at the Shiley has been ordered by the US Food government' s instigation. and Drug Administration to try to track Letters between Mr Winterton and Mr down patients who were fitted with a batch of Waldegrave disclose that the leaked report 500 large valves attributed to the phantom was destroyed on the secretary of state's order when it was discovered not to be an welder, which have proved particularly authorised communication. This was learnt prone to fracture. So far 32 have fractured, when an official tried to correct "inaccukilling 20 patients. Of the 500 potentially faulty valves, 35 racies" in the document. With the go between revealed as Mr were distributed in the United Kingdom. In all but seven cases the company has tracked Waldegrave's parliamentary private secredown the surgeons who received the valves. tary, Ian Taylor, the trail narrowed to the It has written to all cardiac surgeons listing researcher, who has since returned to the the serial numbers of the untraced valves (see United States. Mr Hayes said that he knows the researcher would have acted in total innobox). The Wall Street Journal has also unearthed The government aims to cut road accidents by a third by the cence of the consequences. -JOHN WARDEN, evidence suggesting that the metal alloy used year 2000 parliamentary correspondent, BMJ
MP from committee leak
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First trust for Northern Ireland The Royal group of hospitals in Belfast is to become the first health and social services trust in Northern Ireland on 1 April 1993. The group and the Eastern Health and Social Services Board has been given a year to "come to grips" with its projected end of year deficit of £1 5m and its problems of keeping within the budget. The unit general manager, William McKee, said, "I believe the financial shortfall could be made up without any reduction in the level of services." The unions doubt this, citing the problems at the flagship Guy's and Lewisham NHS trust in London, which started to shed jobs soon after opting out. The reforms in the Northern Ireland Health Service have lagged behind those in England and Wales by one year. On 1 April 1992 the four area boards will become pur-
chasers on behalf of the population of 1-5 million people, and in April 1993 general practice fundholding will begin. Until April 1993 the Eastern board will retain overall managerial responsibility for the unit but a shadow board for the trust will be headed by Dr George Quigley, currently director of the Ulster Bank and previously the permanent secretary of the Northern Ireland Department of Finance and Personnel. The Royal group includes the Royal Victoria Hospital, the Royal Maternity Hospital, the Royal Belfast Hospital for Sick Children, and the School of Dentistry. Most staff have opposed trust status, and in a ballot in June most consultants voted against the bid or for trust status to be deferred for one year. Most political parties in Northern Ireland are opposed to trust status too, with the only political support for the plan coming from the small, three year old Conservative party. -MARY BLACK, Department of Public Health Medicine, Eastern Health and Social Services Board, Belfast
The decision to make the Royal group ofhospitals a trust is unpopular
4 November, John Cardinal O'Connor of Community directive on labelling specifies New York said that he found it "shocking "at least 4%." The judge, Mr Justice Roch, is that in this land in which we claim the three expected to refer the case to Europe at a rejects euthanasia dominant freedoms of life, liberty, and the hearing next month. In the mean time the pursuit of happiness there is an incredible parties must formulate the exact question to Voters in Washington state in a referendum drive to destroy life." He compared the be put to the European court, which is initiative to the small beginnings of Nazi already considering a case from Italy on on 5 November threw out Initiative Measure whether a state may require more than one No 119, which would have legalised doctor genocide. On 8 October the California secretary warning to be put on a packet. The two cases assisted suicide. Doctors would have been able to give "aid in dying" to terminally ill of state announced that supporters of an are likely to be dealt with together. When the case comes back from Europe patients who asked for such help. Doctors initiative, "Terminal Illness. Assistance in providing this "service" would have been Dying," have until 5 March to submit nearly the tobacco companies will ask for a declarimmune from prosecution for criminal or 400 000 registered signatures and thereby get ation that requirements in the new regulations unprofessional conduct, and doctors who did the issue on the California ballot in 1992. The for warnings to cover at least 6% of British not wish to comply with such requests would statute would allow doctors to "terminate cigarette packets are unlawful. The directive specifies that warnings "shall have had to make a "good faith effort" to life in [a] painless, humane, and dignified transfer a patient to a doctor who would manner" after diagnosis of a terminal illness. cover at least 4% of each large surface of the -MICHAEL MORRIS, Royal College of Psy- unit packet" and that statements of tar and comply. nicotine yields must cover at least 4% of the Euthanasia has been catapulted to the chiatrists travelling fellow, Indianapolis sides. The companies argue that "at least forefront of national debate on social policy 4%" is a specific requirement which member in the US since the controversial referendum states must bring into their national laws, was announced. Some 223 000 signatures not a minimum requirement which member of support were collected last year by the states have a discretion to increase. group Washington Citizens for Death with They point to article B of the directive, Dignity, which has attracted considerable which states: "Member states may not, for international attention. Supporters of the reasons of labelling, prohibit or restrict the measure, many of them from outside the sale of products which comply with this state, raised about $1-6m, the largest ever directive." A packet whose warnings occupy campaign fund seen in the state on a ballot issue. The Oregon based Hemlock Society, Three tobacco companies are expected to 4% of the surfaces complies with the directive, whose book Final Exit is a bestseller (24 go to the European Court of Justice they say, and a more onerous requirement August, p 431), was one of the major pro- in Luxembourg as the first step in their would restrict sales. Cigarettes made in other member states ponents of the referendum, together with the challenge to new government health warnings American Civil Liberties Union of Washing- on cigarette packets. The High Court last may be imported into the United Kingdom if week granted Gallaher, Imperial Tobacco, their warnings are in English and comply ton. They said that the change was necessary and Rothmans leave to bring judicial review with the labelling requirements of their to expand freedom of choice. The main opponents of the initiative were proceedings against the health secretary, country of origin. The result of the 6% the medical profession (especially the Ameri- William Waldegrave, over part of the requirement, the companies contend, would Tobacco Products Labelling (Safety) Regu- be to put British cigarettes in an uncomcan Geriatrics Society and the Washington petitive position compared with imports Medical Association) and the Catholic church lations 1991. The companies and the minister have carrying warnings covering only 4% of the (especially the National Conference of Bishops). They argued that the initiative agreed that the case should first be referred to packet. This would be inconsistent with the would undermine the moral integrity of the European court for a ruling on the point directive, which is intended to harmonise the medical profession and that it ran contrary of law at issue: whether member states have a labelling requirements throughout the discretion to require warnings to cover more European Community.-CLARE DYER, legal to moral and social prohibitions against killing. According to the New York Times on than 4% of a packet when a European correspondent, BMJ
Washington state
Tobacco companies challenge health
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Letter from Westminster
Names and numbers Whatever the effect to be felt in the wards and surgeries from the government's future spending plans for the NHS, their effect on Westminster is simply to increase the stockpile of statistics. The chancellor's autumn statement served merely to feed an insatiable political appetite for number crunching. The amorphous millions may add up to a plus for the NHS, though that has done nothing to stop the haggling over decimal points (p 1221). I confine myself to two conveniently round figures. These show that the health service now accounts for 15% of government spending compared with only 10% devoted to defence. It is comforting to know that the most warlike noises in these times are no more than a barrage of statistics. As a diversionary tactic last week the opposition fired off a salvo aimed at the list of chairmen and directors of second wave NHS trusts. To Labour's delight the 500 names included two Tory former ministers, the wives of two Tory MPs, and the husband of another. The Prime Minister was asked if he was trying to turn the NHS into a "family business for card carrying Conservatives." But whether it's names or numbers, each side is armed to the teeth. Mr Major replied by citing the example of Lady Callaghan, wife of the former Labour premier-an excellent chairman of the Hospital for Sick Children, Great Ormond Street, he said. The health secretary, William Waldegrave, took a swipe at Lord Ennals for being a director of a private health care company while remaining Labour's health spokesman in the Lordsa position from which Lord Ennals has resigned, though denying any conflict of interest with his nursing home directorship. Mrs Virginia Bottomley, the health minister, scored a direct hit when she was invited by the Labour MP, Dennis Skinner, to. condemn the appointment of "Tory spouses" to NHS trusts. No, she said, because no one had cast smears against an aunt of hers who was once chairman of a health authority. She was of course referring to Peggy Jay, wife of the former Labour cabinet minister, Douglas Jay. Statistics took over again when Mrs Bottomley later gave evidence to the Commons health committee in its continuing inquiryv into maternity services. The committee wanted to know why only 1% of babies in the United Kingdom were born at home compared with 35% in the Netherlands. The committee suspects a government bias towards hospital confinements. Officials from the Department of Health had followed in the committee's footsteps to Holland and came back with a different slant. They were told that home confinements were going down in the Netherlands because quality and safety of hospital births, which is something that has already happened in Britain. The questioning then turned to the matter
women there were recognising the
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of remunerating general practitioners for maternity medical services. Out of the blue the chairman, Nicholas Winterton, asked if the Department of Health had any plans to review the separate fees for general practitioners for providing maternity care. Had it considered instead a capitation payment based on the number of patients on a general practitioner's list who were women of childbearing age? Mrs Bottomley replied that the department had not considered such an option, though it might be prepared to do so, adding "General practitioners' remuneration is a matter of ongoing discussion. If this committee makes a recommendation in that area
we will look at it very carefully." Make of that what you will, for no more was said. But the question was undoubtedly rooted in the tension between doctors and midwives, which gives rise to the latter sometimes asserting that general practitioners are being paid for work which the midwives do. On a happier note, the minister had news of a fresh start between the Royal College of Midwives and the Royal College of General Practitioners in an attempt to resolve their interprofessional tension. I shall be in a position to report further next week, after the committee has heard from the colleges about the peace talks. -JOHN WARDEN, parliamentary correspondent, BMJ
The Week As survey after survey of consultants has shown, most of those who have supported trust status for their own hospitals have done so not as a positive act but resignedly. They have supported applications because the independent status of trusts has seemed to offer more protection for the work they do, a greater likelihood of getting the capital developments they need, and the prospect of less bureaucracy. Few have supported trusts because they thought they might do better financially from the freedom that trusts have to determine their own pay and conditions of service. Yet as key professionals in any hospital consultants might be expected to do rather well. Indeed, several senior NHS managers are on record as saying that they are underpaid. But consultants themselves actually feel that they may do rather badly-because what they value about their contracts does not revolve entirely around money. Consultants have, of course, long been used to negotiating with managers about service developments, how to squeeze an extra piece of equipment out of this budget or an extra nurse out of that. What they haven't done for a long time is haggle about their salaries or conditions of employment. Conditions of service negotiated centrally and review body pay awards have ensured that locally consultants and managers have been able to devote most of their time to service issues rather than employment issues. Not any longer. Though some trust managers don't see renegotiating consultant contracts as a high priority, many others are trying to pin down consultants to more specific contracts. Last week saw the first meeting at BMA House ofconsultants elected to sit on local negotiating committees in trusts committees the BMA has been busy setting up to represent medical staff. The
meeting aimed at making consultants think about the value of the elements in their existing contract: what they should go to the wall to keep and what they might be willing to bargain away -for a price. The list of elements that consultants would go to the wall for is interesting, and managers should mark it well because it suggests that simply offering consultants more money won't be enough. Top of the consultants' list are freedom of speech, tenure of consultant posts, flexibility of working, and the right to do private practice. Yet confidentiality clauses, contracts subject to review, and 100% commitment to the employing trust are already appearing in the contracts of new consultants. Given their value to consultants, managers should ask themselves whether these elements are worth the battle. As Jim Johnson, a consultant's negotiator, pointed out, most consultants have used the independence given to them by flexibility of working to work far more than their contracted hours for the NHS. Freedom of speech too is not an unconstrained right: consultants can still be brought to book for libel or breaching patient confidentiality. Some oblique support for the consultants' stance also came last week from a study by a team at Warwick University looking at the characteristics of managements that successfully managed change in the NHS. One characteristic was good teamwork with members who had time for "deviants and heretics" prepared to say the unsayable. Another was good relationships between managers and clinicians, with both groups understanding each other's problems and values. Will the need to haggle over conditions of employment damage those good relationships (where they exist)? Or will managers who value their consultants be more likely to listen to what their consultants value? HART
BMJ VOLUME 303
16 NOVEMBER 1991
