1303
representing a complete hue circle in approximately equal steps. The samples are placed in four boxes and the subject is asked to arrange the colours in each box between two reference colours at each end, starting from a random sequence. Lighting conditions must be standardized,3a requirement not entirely satisfied in this study by seating the subjects at a north-facing window between 1100 and 1200 hours during the month of September at an unspecified location in
Bristol, England. The investigation found that
of the twentypathologists had serious defects in colour perception; this result accords with the known prevalence of colour defects in the general population. About 8% of caucasian males and 0-5% of females have a congenital colour defect affecting red-green discrimination, although other defects are rare.4 Rigby et al claim that the two pathologists with seriously defective colour vision might have been unable to interpret various stains, and that their findings imply that "among a group of people in whom the ability to discriminate colours is a vital part of their professional life there will be individuals with an unrecognised inability to do so". This study was prompted by the inability of one of the authors to distinguish the subtle differences in colour between colonic mucins stained by a technique familiar only to aficionados of mucin histochemistry. It seems unwarranted to extrapolate from this trifling shortcoming (albeit validated by his poor showing in the 100-hue test) to the recommendation of routine eye-tests for aspiring two
three male
histopathologists. routine staining method in diagnostic histopathology, and one applied almost universally, is haematoxylin and eosin, which yields a restricted range of colours from dark blue through purple to bright red. People with impaired colour vision do not generally confuse blue and red. Protans (individuals in whom the long-wave sensitive photopigment is either missing or abnormal) have diminished sensitivity to red light and may confuse red and black, while those individuals with defects in short-wave rare photopigment and a loss of sensitivity to blue light (tritans) may confuse blue and black.4Difficulties would be far more likely to arise if a red-yellow-green staining combination such as Masson trichrome was widely used for diagnosis. Structure and staining density from light to dark are much more important than colour differences in histological diagnosis; some of the most valuable handbooks in histopathology continue to have black and white illustrations. Colour differences largely provide redundant information and much histopathological diagnosis could be achieved in monochrome. Moreover, diagnosis is not simply a question of accurate observation: knowledge and judgment are essential. Thus colour deficiency is not a ground for concern in the selection and training of histopathologists. Greater benefit to the public would be achieved by checking that general practitioners can accurately
The
interpret the colour changes in dip-stick tests for glycosuria and proteinuria; others might argue that it is much more important that their dentist can match the subtle shade of yellow required for their prosthetic incisor.s By comparison, the colour perception of the person peering down a microscope at a biopsy specimen is an irrelevance. Vingrys AJ, Cole BL. Are colour vision standards justified for the transport industry? Ophthal Physiol Opt 1988; 8: 257-74. 2. Rigby HS, Warren BF, Diamond J, Carter C, Bradfield JWB. Colour perception in pathologists: the Famsworth-Munsell 100-hue test. J Clin Pathol 1991; 44: 745-48. 3. Birch J. Use of the Farnsworth-Munsell 100-hue test in the examination of congenital colour vision defects. Ophthal Physiol Opt 1989; 9: 1.
156-62. 4. Birch J. A practical guide for colour-vision examination: report of the standardization committee of the international research group on colour-vision deficiencies. Ophthal Physiol Opt 1985; 5: 265-85. 5. Davison
dental
SP, Myslinski NR. Shade selection by color vision-defective personnel. J Prosthet Dent 1990; 63: 97-101.
Who
cares
about homecare?
Europe is ageing rapidly, and none too well. Given the choice, many elderly or frail people would far prefer to live in their own homes than in institutions such as rest homes, nursing homes, or long-stay geriatric hospitals. Provision of services that enable them to remain at home for as long as possible should therefore improve their quality of life and reduce the need for institutional care. The UK Government is not alone (and later than some) in recognising the deficiencies in community care,l-4 and likewise it is not unique in failing to deliver homecare services efficiently, equitably, and according to need. How does the UK compare with other countries in the European Community? Age Care Research Europe, a project funded by the EC, have looked at the provision of homecare services in Belgium, Denmark, France, Greece, Germany, Ireland, Italy, the Netherlands, and the UK. They found that there was little awareness of the practices, and even the principles, that were pursued in other countries,5,6 and that national services had arisen out of local culture, ideology, history, and political expediency and not from any rational process of design or of intranational 6 or international comparison of efficacy.6 In many countries the starting point was parishbased support schemes. In Germany, for example, health insurance for working people was introduced in the 1880s, but such facilities were not extended to the elderly until 1941. Although homecare and home nursing were introduced in 1911 as a substitute for hospital treatment, homecare was not widely available with government support until social welfare legislation in the early 1960s. In France, private associations were set up to help mothers in the 1920s, but again only since the 1960s has there been large-scale government support for community services for the elderly. The Netherlands has had
1304
church and charitable homecare support since the 1900s, but there and in Belgium most emphasis after the 1940s was on provision of institutional facilities; expansion of the welfare state into community services for the
elderly
only during the 1960s. A seen in Denmark, although
occurred
similar pattern was services for ill mothers were set up in in Italy few homecare services existed whereas 1949, before the 1970s. In the UK, the Maternity and Child Welfare Act 1918 set up community services for ill mothers and these services were extended to elderly people in the early 1940s so that younger family carers were freed for war work; this policy also enabled the government to economise on the building of institutions. These services were incorporated into the National Health Service at its foundation; by the 1960s, three-quarters of state home-support services were received by elderly people. One of the main attractions of homecare for governments is that effective facilities might reduce costs-the risk is that such statutory provision might discourage neighbours and relatives from providing free assistance and that calls on acute healthcare services (usually the most expensive) might increase. There is little evidence for or against such benefits in any EC country, largely because of fragmentation of services, divided responsibilities, and inadequate audit. For example, the services that might be required include nursing care (change of catheters, wound dressing), personal care (help with getting up or going to bed, dressing and undressing, and bathing), and housekeeping (tasks such as shopping, cooking, cleaning, filling in forms, gardening). In the UK, France, and Denmark there is some overlap between nursing and personal care and between personal care and housekeeping; in Belgium and the Netherlands there is a clear demarcation between personal care and housekeeping. What people need in the way of local or national government support, and of family, community, voluntary, and private care also varies greatly-almost as much within countries as between them. In all the EC nations studied, provision of such services differed by at least 100% in various parts of the country.6 Different countries also have different goals for homecare. France and Germany tend to emphasise the importance of reducing demand on hospital beds;elsewhere the need to reduce the proportion of the population in residential homes is highlighted. Funding for community services for the elderly is also influenced by the availability of institutional alternatives, which vary widely within the EC. The proportion of the population aged 65 years and over who are in residential care, excluding hospitals and sheltered housing, ranges from a startling 12% in the Netherlands, through 5-7% in Denmark, Belgium, France, Germany, and the UK, to 1-2% in Italy.66 Some common scenes emerge from these comparisons. Division of responsibilities between several agencies leads to inefficiency and
community
inappropriate provision of care. Such overlaps might geographically (national vs local government), between government departments (eg, health or social security), within departments (eg, local nursing and occur
social services authorities), and between statutory and voluntary or private providers of care. There have been few attempts to find out who might need support: most arrangements are made after admission to hospital or after relatives, friends, or neighbours finally give up the struggle and call on medical or social services for help. Care is thus inefficiently targeted by request rather than absolute need, and because of delays in initial assessment insufficient help is provided when it is first, and usually most urgently, needed. At one extreme, vain attempts are made to keep people at home when the prospect is clearly hopeless; at the other extreme, those who might do well in their own homes are never offered such services. People who require homecare and their relatives seldom have the opportunity to meet the officials who take the decisions about these services, and home visits by care managers are infrequent and rarely by the same person. The availability of services, what an individual service entails, and "qualifications" for provision of that service are often obscure; similarly, a decision taken by one agency might affect the care provided by another. Care can rarely be arranged outside normal office hours, the carers often change, and patients are not usually reassessed to see whether the need for care has altered. Above all, individual priorities seldom enter the equation-ie, what makes continued living at home worth while. Has the private sector been better at providing effective homecare services? In the UK, the answer is probably yes. Over 500 licensed homecare organisations now care for some 45 000 people who are elderly or disabled. Yet despite the setting up of a code of practice by the UK Home Care Assocation,9 many concerns remain. There is little effective central statutory coordination; private agencies’ control and training of their own staff are hugely variable; and liaison between private and public homecare services is patchy. Whatever the system or country, homecare services are here to stay and must be properly coordinated. 1. Audit Commission.
Stationery Office,
Making a reality of community
care.
London: HM
1986.
2. Audit Commission.
effectively. 3. Griffiths R.
Managing social services for the elderly more Stationery Office, 1985. Community care: an agenda for action. London: HM
London: HM
Stationery Office, 1988. Department of Health. Caring for people. London: HM Stationery Office, 1989. 5. Illsley R. Pathways into and through services for the elderly in Europe: a research design. Rev Epidemiol Santé Publique 1987; 35: 339-48. 6. Jamieson A, ed. Home care for older people in Europe: a comparison of policies and practices. Oxford: Oxford University Press. 1991. £45. 4.
ISBN 0-192620509. 7. Bulmer M. The social basis of community care. London: Unwin Hyman, 1987. 8. Victor CR. Health and health care in later life. Buckingham: Open University Press. 1991. £10.99. ISBN 0-335092837. 9. UK Homecare Association. Code of practice. Sowerby Bridge, West Yorks: UKHCA, 1990.
representing a complete hue circle in approximately equal steps. The samples are placed in four boxes and the subject is asked to arrange the colours in each box between two reference colours at each end, starting from a random sequence. Lighting conditions must be standardized,3a requirement not entirely satisfied in this study by seating the subjects at a north-facing window between 1100 and 1200 hours during the month of September at an unspecified location in
Bristol, England. The investigation found that
of the twentypathologists had serious defects in colour perception; this result accords with the known prevalence of colour defects in the general population. About 8% of caucasian males and 0-5% of females have a congenital colour defect affecting red-green discrimination, although other defects are rare.4 Rigby et al claim that the two pathologists with seriously defective colour vision might have been unable to interpret various stains, and that their findings imply that "among a group of people in whom the ability to discriminate colours is a vital part of their professional life there will be individuals with an unrecognised inability to do so". This study was prompted by the inability of one of the authors to distinguish the subtle differences in colour between colonic mucins stained by a technique familiar only to aficionados of mucin histochemistry. It seems unwarranted to extrapolate from this trifling shortcoming (albeit validated by his poor showing in the 100-hue test) to the recommendation of routine eye-tests for aspiring two
three male
histopathologists. routine staining method in diagnostic histopathology, and one applied almost universally, is haematoxylin and eosin, which yields a restricted range of colours from dark blue through purple to bright red. People with impaired colour vision do not generally confuse blue and red. Protans (individuals in whom the long-wave sensitive photopigment is either missing or abnormal) have diminished sensitivity to red light and may confuse red and black, while those individuals with defects in short-wave rare photopigment and a loss of sensitivity to blue light (tritans) may confuse blue and black.4Difficulties would be far more likely to arise if a red-yellow-green staining combination such as Masson trichrome was widely used for diagnosis. Structure and staining density from light to dark are much more important than colour differences in histological diagnosis; some of the most valuable handbooks in histopathology continue to have black and white illustrations. Colour differences largely provide redundant information and much histopathological diagnosis could be achieved in monochrome. Moreover, diagnosis is not simply a question of accurate observation: knowledge and judgment are essential. Thus colour deficiency is not a ground for concern in the selection and training of histopathologists. Greater benefit to the public would be achieved by checking that general practitioners can accurately
The
interpret the colour changes in dip-stick tests for glycosuria and proteinuria; others might argue that it is much more important that their dentist can match the subtle shade of yellow required for their prosthetic incisor.s By comparison, the colour perception of the person peering down a microscope at a biopsy specimen is an irrelevance. Vingrys AJ, Cole BL. Are colour vision standards justified for the transport industry? Ophthal Physiol Opt 1988; 8: 257-74. 2. Rigby HS, Warren BF, Diamond J, Carter C, Bradfield JWB. Colour perception in pathologists: the Famsworth-Munsell 100-hue test. J Clin Pathol 1991; 44: 745-48. 3. Birch J. Use of the Farnsworth-Munsell 100-hue test in the examination of congenital colour vision defects. Ophthal Physiol Opt 1989; 9: 1.
156-62. 4. Birch J. A practical guide for colour-vision examination: report of the standardization committee of the international research group on colour-vision deficiencies. Ophthal Physiol Opt 1985; 5: 265-85. 5. Davison
dental
SP, Myslinski NR. Shade selection by color vision-defective personnel. J Prosthet Dent 1990; 63: 97-101.
Who
cares
about homecare?
Europe is ageing rapidly, and none too well. Given the choice, many elderly or frail people would far prefer to live in their own homes than in institutions such as rest homes, nursing homes, or long-stay geriatric hospitals. Provision of services that enable them to remain at home for as long as possible should therefore improve their quality of life and reduce the need for institutional care. The UK Government is not alone (and later than some) in recognising the deficiencies in community care,l-4 and likewise it is not unique in failing to deliver homecare services efficiently, equitably, and according to need. How does the UK compare with other countries in the European Community? Age Care Research Europe, a project funded by the EC, have looked at the provision of homecare services in Belgium, Denmark, France, Greece, Germany, Ireland, Italy, the Netherlands, and the UK. They found that there was little awareness of the practices, and even the principles, that were pursued in other countries,5,6 and that national services had arisen out of local culture, ideology, history, and political expediency and not from any rational process of design or of intranational 6 or international comparison of efficacy.6 In many countries the starting point was parishbased support schemes. In Germany, for example, health insurance for working people was introduced in the 1880s, but such facilities were not extended to the elderly until 1941. Although homecare and home nursing were introduced in 1911 as a substitute for hospital treatment, homecare was not widely available with government support until social welfare legislation in the early 1960s. In France, private associations were set up to help mothers in the 1920s, but again only since the 1960s has there been large-scale government support for community services for the elderly. The Netherlands has had
1304
church and charitable homecare support since the 1900s, but there and in Belgium most emphasis after the 1940s was on provision of institutional facilities; expansion of the welfare state into community services for the
elderly
only during the 1960s. A seen in Denmark, although
occurred
similar pattern was services for ill mothers were set up in in Italy few homecare services existed whereas 1949, before the 1970s. In the UK, the Maternity and Child Welfare Act 1918 set up community services for ill mothers and these services were extended to elderly people in the early 1940s so that younger family carers were freed for war work; this policy also enabled the government to economise on the building of institutions. These services were incorporated into the National Health Service at its foundation; by the 1960s, three-quarters of state home-support services were received by elderly people. One of the main attractions of homecare for governments is that effective facilities might reduce costs-the risk is that such statutory provision might discourage neighbours and relatives from providing free assistance and that calls on acute healthcare services (usually the most expensive) might increase. There is little evidence for or against such benefits in any EC country, largely because of fragmentation of services, divided responsibilities, and inadequate audit. For example, the services that might be required include nursing care (change of catheters, wound dressing), personal care (help with getting up or going to bed, dressing and undressing, and bathing), and housekeeping (tasks such as shopping, cooking, cleaning, filling in forms, gardening). In the UK, France, and Denmark there is some overlap between nursing and personal care and between personal care and housekeeping; in Belgium and the Netherlands there is a clear demarcation between personal care and housekeeping. What people need in the way of local or national government support, and of family, community, voluntary, and private care also varies greatly-almost as much within countries as between them. In all the EC nations studied, provision of such services differed by at least 100% in various parts of the country.6 Different countries also have different goals for homecare. France and Germany tend to emphasise the importance of reducing demand on hospital beds;elsewhere the need to reduce the proportion of the population in residential homes is highlighted. Funding for community services for the elderly is also influenced by the availability of institutional alternatives, which vary widely within the EC. The proportion of the population aged 65 years and over who are in residential care, excluding hospitals and sheltered housing, ranges from a startling 12% in the Netherlands, through 5-7% in Denmark, Belgium, France, Germany, and the UK, to 1-2% in Italy.66 Some common scenes emerge from these comparisons. Division of responsibilities between several agencies leads to inefficiency and
community
inappropriate provision of care. Such overlaps might geographically (national vs local government), between government departments (eg, health or social security), within departments (eg, local nursing and occur
social services authorities), and between statutory and voluntary or private providers of care. There have been few attempts to find out who might need support: most arrangements are made after admission to hospital or after relatives, friends, or neighbours finally give up the struggle and call on medical or social services for help. Care is thus inefficiently targeted by request rather than absolute need, and because of delays in initial assessment insufficient help is provided when it is first, and usually most urgently, needed. At one extreme, vain attempts are made to keep people at home when the prospect is clearly hopeless; at the other extreme, those who might do well in their own homes are never offered such services. People who require homecare and their relatives seldom have the opportunity to meet the officials who take the decisions about these services, and home visits by care managers are infrequent and rarely by the same person. The availability of services, what an individual service entails, and "qualifications" for provision of that service are often obscure; similarly, a decision taken by one agency might affect the care provided by another. Care can rarely be arranged outside normal office hours, the carers often change, and patients are not usually reassessed to see whether the need for care has altered. Above all, individual priorities seldom enter the equation-ie, what makes continued living at home worth while. Has the private sector been better at providing effective homecare services? In the UK, the answer is probably yes. Over 500 licensed homecare organisations now care for some 45 000 people who are elderly or disabled. Yet despite the setting up of a code of practice by the UK Home Care Assocation,9 many concerns remain. There is little effective central statutory coordination; private agencies’ control and training of their own staff are hugely variable; and liaison between private and public homecare services is patchy. Whatever the system or country, homecare services are here to stay and must be properly coordinated. 1. Audit Commission.
Stationery Office,
Making a reality of community
care.
London: HM
1986.
2. Audit Commission.
effectively. 3. Griffiths R.
Managing social services for the elderly more Stationery Office, 1985. Community care: an agenda for action. London: HM
London: HM
Stationery Office, 1988. Department of Health. Caring for people. London: HM Stationery Office, 1989. 5. Illsley R. Pathways into and through services for the elderly in Europe: a research design. Rev Epidemiol Santé Publique 1987; 35: 339-48. 6. Jamieson A, ed. Home care for older people in Europe: a comparison of policies and practices. Oxford: Oxford University Press. 1991. £45. 4.
ISBN 0-192620509. 7. Bulmer M. The social basis of community care. London: Unwin Hyman, 1987. 8. Victor CR. Health and health care in later life. Buckingham: Open University Press. 1991. £10.99. ISBN 0-335092837. 9. UK Homecare Association. Code of practice. Sowerby Bridge, West Yorks: UKHCA, 1990.
