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Acute medical beds could be cut by 30% If all district health authorities in England used their acute medical beds as efficiently as the top 25% then the total number of beds could be reduced by about 30% or 27000, says the Audit Commission in a report published this week. It argues that improved organisation would improve the quality of care.
Despite continuing wide geographical variation in efficiency of use of beds the NHS has increased its efficiency enormously in the past 20 years. Between 1974 and 1989 the number of patients with acute illness treated rose by 22% while the number of beds fell by the same percentage. Yet the number of beds per thousand population varies from under 0-8 in some districts to over 1-6 in others. Throughput per bed varies from under 20 patients a year to over 80. These variations are not explained by gender, age, or case mix. The report has been produced by the commission's staff with an advisory group of clinicians, managers, and health service experts. It is based on an analysis of national, regional, and local data on use of beds, a questionnaire survey of over 100 acute units, detailed studies in 10 hospitals, and a review of published research. Inefficient use of beds occurs at every stage from admission to discharge, says the report, and no one change will increase efficiency. The report analyses the problem in five sections-admission, placement, stay, discharge, and availability and management of beds-and makes recommendations on each
A third to go?
The first problem with placement is delay, support at home. Arranging long term care and the commission found that in the past will need improved links with general pracyear patients had been left overnight on titioners and community services. The commission found that 40% of the trolleys in casualty departments in 5% of hospitals. Patients are then often placed in variation in the number of beds among inappropriate wards, requiring later transfer. districts is explained by variations in age Ninety per cent of hospitals had had to put structures and admission rates, but 60% medical patients into surgical beds in the past of the variation bears no relation to the year. A particular problem arises with elderly population's needs for health care. Historical patients, when it is often unclear whether inequalities have been perpetuated. The stage. they are to be cared for by physicians or report advocates better coordinated managegeriatricians. The report recommends that ment of beds at hospital level but with as hospitals should develop clear policies on much devolution as possible to wards and Inefficiencies at every stage placing and transferring acutely ill patients. clinical directorates. There should be pooling The first problem is that throughout the The first requirement will be much better of beds currently divided by gender and pooling within subspecialties. Hospitals information on the bed state. country the chance of being admitted to The average length of stay in acute medical should also consider five day wards, planned hospital varies, and clearly some patients are admitted inappropriately. This may happen units standardised for gender, age, and case investigation units, and patient hotels. The report is likely to be well received by because admission procedures are poorly mix varies from four days to over 15. This organised and the decision to admit is taken variation arises only partly from problems groups like the BMA, the Royal College of by inexperienced junior doctors, who, under- with data collection. More often it is due to Physicians, the Departments of Health, and standably, are inclined to overadmit. The variation in clinical practice and administra- the Royal College of Nursing, all of which were consulted before publication. The report advocates monitoring of general prac- tive problems such as the timing of ward titioners' referral rates by managers, better rounds and delays in arranging investiga- report ends with detailed suggestions on how communication between general practi- tions. The report recommends regular managers and clinicians can begin to imtioners and consultants, and improved examinations of the average length of stay plement improvements. Over the next year admission procedures. Experienced junior for common conditions for individual con- the commission's local auditors will make an doctors should always be available to decide sultant§. Medical audit, clinical protocols, overall assessment of each hospital's current and resource management will, the commis- use of its medical beds. As Ross Tristem, on admission, and all patients should be seen sion hopes, combine to reduce the variation. director of health studies at the commission, as quickly as possible by consultants. There should also be more observation beds avail- Clinicians and managers should together has said: "Most people in the health service able to avoid doctors having to admit, for improve administrative arrangements for want to change. Our job is to help them."RICHARD SMITH, BMJ instance, all patients with minor head wards rounds and investigations. Discharges are regularly delayed because injuries or who have taken overdoses. At the moinent only a third of acute hospitals have of difficulties in obtaining drugs to take Lying in Wait: The Use of Medical Beds in Acute home, arranging transport, and providing Hospitals is available from HMSO, price £9.50. such beds. BMJ
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Headlines
NHS distribution of funds unfair
US doctors asked to stop silicone breast implants: The Food and Drug Administration (FDA) has asked American doctors to stop using silicone breast implants for 45 days while an advisory committee assesses new information on their safety. The FDA has received 2500 reports of illnesses associated with the implants. The decision by the FDA has been criticised because it is not an outright ban on implants. Acute respiratory infections cause most infant deaths: Acute respiratory infections have replaced diarrhoea as the leading killer of children under 5, according to United Nations health officials. Teaching mothers to recognise early symptoms and making antibiotics available more quickly could reduce the death rate-four million children a year-by one third.
Belgium winning war against rabies: By using a new genetically engineered vaccine and attaching it to bait the Belgians have managed to vaccinate roughly two thirds of the foxes in the Ardennes. The number of cases of livestock rabies, which is a notifiable disease, fell heavily. The Belgian vaccine is reported in last week's Nature.
Record number of abused children: The number of British children placed on at risk registers from March 1990 to March 1991 was 45 200. This represents a 4% rise from previous figures. The number of children in care has fallen from 95 000 to 60 000 since 1980.
Quebec woman granted right to die: A Quebec court has granted a 24 year old woman who is terminally ill the right to be taken off her life support machine. The ruling is claimed by legal experts to make a new distinction between the law against doctors assisting suicide and a patient's right to refuse treatment. California orders motorcyclists to wear helmets: After much controversy among Californians a new law, which makes helmet wearing compulsory for motorcyclists, came into force last week. Opponents argue that the three remaining states without such laws Colorado, Illinois, and Iowa-have lower accident rates.
US health care drug stocks soar: On the New York stock exchange last year the biggest winners were health care and pharmaceutical companies. The biggest gain was seen by North American Vaccines, a company whose stocks rose by 704% after it developed a children's whooping cough vaccine.
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The British government's new formula for distributing the NHS budget to regions and districts means that many health authorities will lose large sums of money unfairly, according to a paper presented to its region by West Birmingham Health Authority. West Birmingham calculates that if its region's capitation policy is implemented in full it stands to lose around £15m, or over 20% of its current budget, by the end of the decade. West Birmingham is not alone in thinking that this loss is unjustified. South Western and North East Thames Regional Health Authorities are investigating ways of making the department's formula for weighted capitation fairer so that it provides a more accurate link between a population's need for health care and a district's financial allocation. The switch to funding on the basis of the resident population rather than the health care services in each authority is only part of the issue. West Birmingham's argument is that the factors used to weight resident populations-to reflect differences in the health care needs of similarly sized populations-are wrong.
West Birmingham argues that basing capitation formulas on estimates of the number of people in inner city districts with highly mobile populations is inaccurate. It claims that the formula gives too much emphasis to the size of districts' elderly populations, the practice of using nationally derived weighting based on age distribution to turn population numbers into financial allocations, and the use of standardised mortality ratios as a proxy for morbidity. Although younger populations may need less health care than older populations, national average age weights may not accurately reflect the health needs of a district. In West Birmingham's view it is wrong that the new formula has no weighting for social deprivation.
Deprived populations tend to have fewer elderly people than more affluent areas so the current formula means that they will lose out. When elderly people do use the health service they use it more intensively and hence cost the NHS more than do younger people. But some health authorities still believe that weighting too heavily on the basis of age and ignoring the health care implications of social deprivation is wrong. This issue was recogised by a report by the NHS Management Executive (before the NHS reforms) recommending a revamped Resource Allocation Working Party formula. But the reforms overtook the executive's recommendations, and weighting for social deprivation was not included. Although
the
management
executive's
recognised the limitations of using standardised mortality ratios to calculate the need for health care services, it did not recommend any additional factors to reflect more accurately the need for services for the mentally ill and those with learning disabilities, maternity and neonatal care services, accident and emergency services, report
Too much weight may be attached to age
services for those with certain chronic conditions-all of which are poorly correlated with standardised mortality ratios. In West Birmingham's view, more sensitive proxies are necessary to reflect the need for certain types of health care services. Criticisms of the weighted capitation formula are not new: ever since the Resource Allocation Working Party formula was introduced in the mid-1970s health authorities have complained of the shortcomings of the method for distributing cash to regions and districts. Clearly, however, some regions are now beginning to address these criticisms as far as districts are concerned. Whether the department will follow suit nationally remains to be seen. -JOHN APPLEBY, economic correspondent, BMJ
New Zealand juniors' strike success Junior doctors in New Zealand have finally resolved their dispute over contracts with their employers, but only after taking industrial action. This is the first time that New Zealand's doctors have been on strike. The dispute was due to attempts by the area health boards to alter junior doctors' contracts. In particular, the boards wanted to allow longer periods of continuous duty. The limit on continuous duty is currently 16 hours. Junior doctors claimed that proposed changes would jeopardise patients' safety and their own postgraduate education and
training. When the juniors first threatened strike action some of the smaller area health boards agreed to continue with the existing contracts but the larger boards were less willing to negotiate. Strikes were scheduled for mid-October, but the juniors' representative body, the Resident Doctors' Association, delayed the action because Auckland, the largest area health board, showed an initial willingness to negotiate. When negotiations collapsed the strike went ahead with hospitals cancelling all routine admissions and clinics and consultants covering the wards and emergency admissions. The initial strike was for two days in the first week, building
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up to four days by the third week. In the Bay of Plenty region, where consultants refused to cover, the dispute was resolved in four hours, with the area health board offering to continue existing contracts for the next year. In several areas the dispute became more acrimonious. In Auckland juniors were sent contracts with blank job descriptions despite assurances that no new contracts would be sent out. As the strike entered its fourth week a deal was worked out. Junior doctors will be expected to work no more than 72 hours a week averaged over two weeks and should get at least eight hours off duty every 24 hours. If the area health boards overwork their juniors they will be penalised financially by high overtime rates. Some boards are continuing their existing contracts so that they can see how the new contract works in other areas before adopting it themselves. The solidarity of the juniors during the dispute has impressed the Resident Doctors' Association. It will continue to be important until the area health boards agree to return to a nationally negotiated settlement. Until then there will be an annual round of regional disputes with the likelihood of increasing disparity between doctors' contracts in different areas. The new Employment Contracts Act allows employers to negotiate contracts with individual employees, but it would prove impossible for the area health boards to negotiate individually with over 1600 junior doctors. Doctors who are due to take up appointments in New Zealand should, under the new contract, be offered the collective agreement first. They will, however, also be free to negotiate an individual contract. In the next few months the area health boards will be entering similar negotiations with nurses, paramedical staff, and laboratory staff. -CHARLES ESSEX, New Zealand
Medical aid for the former Soviet Union
Professor Alexander Baranov, the deputy minister of health, sent William Waldegrave, the British health minister, a detailed list of drugs and medical equipment needed. This included antibiotics, cytotoxic drugs, disposable syringes, and scalpels. Professor Baranov also listed possible venues for exchange visits by British doctors, to be arranged by the UK-USSR Medical Exchange Programme. -STEWART BRITTEN, honorary secretary, UK-USSR Medical Exchange Programme For further information on exchanges-for example, spending a week with up to 30 other doctors from Britain at the All-Union Research Centre for Mother and Child Health Care in Moscow-contact Dr Stewart Britten, 9d Stanhope Road, London N6 5NE
AIDS and hepatitis B in the former Soviet Union According to official data, only 627 people in the former Soviet Union were HIV positive last July. Of them, 258 were children infected iatrogenically by contaminated needles used in three epidemics in the southern Soviet Union. These low numbers are not, apparently, for want of screening-one Soviet scientist claims that over 50 million HIV tests have been conducted. One reason for the low prevalence of HIV infection might be the former Soviet Union's policy of compulsory testing for foreign visitors staying more than a month; seropositive visitors are deported. But last summer a delegation sent by the private American foundation People to People International came away with new insights into the union's policies on HIV and hepatitis B virus infections. Some 40 doctors and scientists from North America, Australasia, and Europe visited Moscow and Leningrad (now known as St Petersburg) in July to study the union's services for infectious diseases
and to forge links with Soviet colleagues. The delegation found that six regional centres coordinated services for Soviet patients with HIV infection and AIDS. Since 1986 these centres have screened all blood for transfusion and have tested more than 400 000 drug misusers for HIV infection (without a single positive result) and some 25 million pregnant women (yielding 20 cases of HIV seropositivity confirmed by Western
blotting). Public health education is less prominent in the former Soviet Union than in the West, according to delegates, and at the time of the visit there were no plans for a national campaign on HIV. As one scientist explained, there is a great need for health educationfor example, among teenagers-but little demand because people have generally conservative views. But questionnaire surveys suggest that at least half of the sexually active population does not use condoms and that 4% of men are homosexual. Intravenous drug misuse is not, however, a major form of transmission because poor availability of disposable syringes and needles leads most misusers to smoke, inhale, or chew their
drugs. In Leningrad the delegation met two young homosexual men with AIDS. Both were receiving treatment used in the West, including zidovudine. Unlike HIV infection, hepatitis B is widespread in the former Soviet Union, particularly in the central and southern regions, where its prevalence may be as high as 20%. Hepatitis A, C, D, and E viruses have also been identified. Officially there are one million cases of infectious hepatitis, although one scientist told the delegation that the true prevalence is probably double that. In 1990 hepatitis B caused the deaths of some 5000 people including about 3000 children, most of whom had been born to mothers who were chronic carriers of the disease. Vaccines derived from plasma are still the mainstay of prevention, although recombinant vaccines may be readily available soon. -FRANCIS DROBNIEWSKI, department of gastroenterology, St Bartholomew's Hospital, London
The British Prime Minister, John Major, chairman of the leaders of the group of seven industrialised nations, will oversee the listing of medical requirements for the former Soviet Union this winter. But deciding on those requirements will not be easy, given that Soviet doctors and health service managers have little experience of needs assessment. The World Health Organisation has already suggested what the Soviet health care system needs. These include greater attention to public health medicine with more
epidemiological research, formal assessment of the population's needs, and a new school of public health. WHO believes that the health care system should be decentralised, its financial structure reviewed, and quality assurance established. Last autumn the European Commission approved a budget that included, for the first time, humanitarian aid for health care in the former Soviet Union. In late October BMJ
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z
i ne numoer oj cnuaren wno are Hn v positve may be grossly unaeresntmatea
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Canadian uproar over fees for health care Quebec's health minister, Marc-Yvan Cote, is creating a storm over his proposals to cut health care costs in the province. These include charging a $C5 fee for each visit to a doctor and making hospital patients pay for their room and board. Both of these proposals are apparent violations of the Canada Health Act, which guarantees free health care across the country. Cote's proposals are contained in a 130 page paper, which is expected to touch off a debate when it goes to the floor of the legislature for discussion in February. The discussion may have national implications because other provinces are also facing spiralling health costs at the same time as the federal government is reducing transfer payments.
Cote's paper has already produced criticisms from opposition parties. The separatist Parti Quebecois's health critic, Remy Trudel, called the proposals "disguised taxes" and said that they constituted "a list showing how to pick taxpayers' pockets." He said that the basis of the Parti Quebecois's policy is "universal, accessible health care through public financing." An aid to the federal health minister, Benoit Bouchard, called the move "fundamentally disquieting" and said that the federal position has been that charging people who use the system "will discourage the poor from seeking health care." Dr Augustin Roy, head of the Quebec Corporation of Physicians, said that the province's health care system is one of the world's best provided at one of the lowest costs-about 8 5% of Quebec's total income. "The crisis is over the fact that the government is bankrupt." But Cote says that he must cut costs because the health system will be $C1-2bn in debt within five years. And Ottawa is insist-
yuebec-could it weather a storm over health care? 72
ing that the provinces maintain national standards for accessibility of health care in spite of the federal government cutting transfer payments and trying to force special programmes on the provinces, such as those for the disabled and for women's shelters. The minister's cost cutting list includes adding to individuals' taxable income the cost of health services they use during the year, charging for some pharmaceutical products currently covered by health insurance, and eliminating free dental and optometry services except for preventive ones such as annual dental examinations. Doctors will be encouraged to reduce defensive medical practices such as ordering unnecessary medical tests by the setting up of a government malpractice insurance fund, and health care institutions will have to purchase special equipment jointly through a province wide procedure. Cote says that the poor would be protected through refundable tax credits. But the executive director of the Comite Provincial des Malades, Michelle Lamquin-Ethier, says that the chronically ill "already pay more and get less and less." The Federation of Quebec Nurses warned that the changes may bring American style privatisation of medical care nearer, and the Quebec Federation of Labor said that they "have the effect of penalising the sick and jeopardising [illness] preventions."-DAVID SPURGEON, scientific and medical journalist,
Quebec
Elderly homeless ignored Nearly a third of homeless people in Britain are aged over 50. But elderly people are often ignored as the media focus on homeless youngsters. Older homeless people are seen as unappealing and an embarrassment, according to Gordon Peters, of the King's Fund College, speaking at a conference organised by Age Concern last month. The conference followed a report published at the end of last year that emphasised the problems of coping with the dual disadvantages of old age and homelessness. Based on interviews with 15 organisations caring for elderly homeless people, the report argued that the risk of becoming homeless in old age can be increased by breakdown of relationships, bereavement, poor health, unemployment, loss of tied accommodation, discharge from the armed forces, and admission to hospital. Vulnerability as a result of old age is a criterion for statutory rehousing, but people still slip through the net. Many local authorities use the state retirement age as the threshold for assuming vulnerability due to age, but this ignores the fact that homelessness tends to exacerbate the effects of aging. High rents and restricted availability of accommodation mean that the private rented sector is not an option for many elderly homeless people. The government's "right to buy" legislation has creamed off some of the best public sector housing,
D'Oubly adsaavantagea-ola ana nomeless
leaving much that is unsuitable for older people. Even the choice of temporary accommodation is restricted as some hostels have age restrictions or are unsuitable for elderly residents. Unemployed homeless people are less likely to find a job if they are old. Homeless people living on the streets are excluded from claiming certain premiums on their income support payments. If they are not registered with a general practitioner they are unable to obtain a medical certificate and are excluded from claiming various benefits. Old people are especially at risk from assault, and the report cites examples of their being victimised by young people, including being set alight or attacked with broken bottles. The specific problems of elderly homeless people have been ignored for a long time. Sheila McKechnie, director of the housing charity Shelter, told the conference that "This report has made me realise how very little Shelter has done to promote the needs of older homeless people." She suggested that the complexity of the problems frightened people off. It was easier to resolve the problems of those who had been on the streets for only a short time. This was supported by Joanna Wade, chairwoman of the charity Crisis, who suggested that "The public wants success stories-it is easier to 'sell' young homeless people." The report does, however, make various recommendations about how this neglect can be rectified, including: * Central government should have an explicit policy, backed by resources, to reduce homelessness among elderly people and improve services for elderly homeless people * There should be a commitment to providing integrated primary health care for homeless elderly people * Government funding should be given for more high care housing schemes for older homeless people. -STELLA LOWRY, BM37 Older Homeless People in London is available from Rosalyn Blackman, 54 Knatchbull Road, London SE5 9QY, price £5.
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M
Qdiea a.cad.emiics'
falling Mnorale .despite
jbot satisfaction Nearly two thr of respondents in a survey of Briish medical- acodemic staff said that their job-'sA0ifa94t Was high, but nearly half vgjd that theirpmnle ha4 declined in, the past yr.. Ne~ly twothirds pd that they would r,c
areer
acdemic medicime
s~a~~ry betwten clinical academiics Nw did not exist. The replies caine in response to a questionby the BMA's econoxnic naire devise if parity Qf doct an4
research unit fQr the Medical Academic Staf Coinmittee. The response rate was 47-2%, and 2698 forms were dispatched. The committee decided to canvas academic staff because during last year's dispute over pay the principle of parity seemed to be
threatea
ed.
vJaly
the
a,ward for NHS doctor wa$s salaries p 589).
of academic sta
review body's tslated to the
(5 October 1991,
Seventy thrqe per cent of the respondents held a consultant post in the NHS; 17% were senior registrars and 6% registrars. Two thirds said that the most attractive aspect of academic medicine was that it allowed time to do research. A quarter thought that they had a higher workload than doctors who worked only the NHS. In response to a question on whether they would recommend academic medicine as a career only ju%t over half of the respondents si4 tat tey would and over wo ,fths said that they would not. The ma reasons given were:
Medieal
new
lieutenant governor, James C Gardner, ordered the deletions to gain support from the tobacco industry for his efforts to become governor this year. The educational materials, describing the parity of salary. effects of substance misuse, are part harmful Commenting on the survey, the chairman of a multimedia campaign called "First Step" of the MASC, Dr Colin Smith, said: "The to lower North Carolina's infant mortality. In and results of this survey reveal the bitterness highest rate in the second had the state 1988 disillusion felt by medical academics after America with 12-5 infant deaths 1000 most The dispute. last year's damgng imn- compared with a national average ofper 10-0 portant factor in this is the need to find a long 1000. Except for the brochure and poster,per all term solution for clinical academics' pay. It is other materials used in the campaigna sad reflection on the current state of affairs including radio and television "spot" anthat almost one fifth said that they either nouncements and public service advertiseregretted gong into medicine altogether or ments-describe tobacco use by pregnant regretted choosing academic medicine." harmful. potentially as women Dr Smith said that he feared for the long General AssemWhen Carolina the North if for medicine academic term consequences for the substance 000 $205 approved bly pay parity was not guaranteed. "Ministers education programme it gave control must realise that in order to attract and retain misuse the expenditures to the state's Drug the best doctors in academic medicine there over which is chaired by the lieutenant Cabinet, no financial to choosdisadvantage be must The Drug Cabinet distributed the governor. inlg it as a career. -LINDA BEECHAM, BMJ money to the North Carolina Department of Environmental Health and Natural Resources, which contracted Sally Johns, a graphic designer in Raleigh, to create the materials. Advice on what to put in them came from a committee that included government and private organisations concerned with child and maternal health. Johns told the BMJ that the committee's Any references to smoking as a cause of initial planning included references to tobacco infant mortality and low birthweight babies among other "substances of misuse" that were deleted from a brochure and poster could injure the fetus. On orders from her prepared by a fetal and child health pro- client, however, tobacco was soon eliminated, gramme in North Carolina, the state that she said. At a final meeting, on 8 February last year, produces 40% of America's tobacco crop. Groups sponsoring the nationally recognised the Drug Cabinet's director, Janet Pueschel, programme, aid a major state newspaper, attempted to explain to increasingly angry have suggested that North Carolina's committee members why tobacco had been * Uncertain or poor career prospects * Difficulties in obtaining adequate funding for research * Uncertainty over the maintenance of
Tobacco state keeps quiet on risk to fetus
ye-,ar hoours
MrJ L Dawson
Ti£zeiWuQIblly o9wnued ca4i,lphQracic sugeop-2Professor Ma-di Yacub, who has- wo~ed at are>field liospitl since 1969, re4eivd a kpighthpod the new year honours anxouncesd last week. Professor Yacoub has developd innovatioms in h-ear and lug transplantsand w.Y*X.itt$ nuous papers on the subject. Ag$e 5,h is a consultant surgeon at the Natiopal Heart Hospital and has BMJ VOLUME 304
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e professor of cardiothoracic surgery at the National Heart and Lung Institute since 1986. Two surgeons to the Queen have also been honoured. Mr Rodney Sweetnam, consultant orthopaedic surgeon at the Middlesex Hospital since 1960 becomes a Wight commander of the Royal Victorian Order, and Mr J L Dawson, who has been a surgeon at King's College Hospital
since 1964, becomes a commander of the Royal Victorian Order. Mr Dawson is dean of the faculty -of clinical medicine at King's College School of Medicine and Dentistry. Professor Michael Rutter, professor of child psychiatry at the University of London's Institute of Psychiatry and a fellow of the Royal Society receives a knighthood. 73
omitted from the brochure and poster. "Her explanation was that all they were concerned about was cocaine, 'crack,' heroin, and alcohol," said Johns. Pueschel she said, had stated that there was no chance tobacco would be included. According to Johns, Pueschel told the committee: "Not now, not ever." Another participant at that meeting, Linda DeShazo, lead health educator for Guilford County Health Department's Family Planning and Maternity programme, said she too had heard Pueschel make the statement. Pueschel, however, denied to BMJ that she had ever used those words. "I did not make those statements," she declared. "There are some individuals who would like the Drug Cabinet to deal with smoking, and we don't." In fact, Pueschel said, "we didn't have anything to do with the brochures." Pueschel is supported by Don Follmer, director ofpublic affairs in the North Carolina Department of Environmental Health and Natural Resources, who said that the department had simply carried out the General Assembly's mandate to educate women about the hazards of drug and alcohol misuse, not smoking. "We've got plenty of materials on smoking available," he pointed out. The state has recently received $5m from the National Institutes of Health as part of its "Project Assist" to aid state health authorities' efforts at "voluntary cessation of tobacco use" by, among others, pregnant women. But Kay James, director of the eastern North Carolina chapter of the March of Dimes Birth Defects Foundation in Raleigh, said that "those of us who have worked through this partnership were all under the impression that this would be an all inclusive, global piece. The omission of smoking made it very inconsistent with the message we'd been putting out that smoking during pregnancy has been shown to have harmful effects on the development of the fetus." The posters and brochures are widely disseminated throughout North Carolina, and other states are using them as models, according to several participants in the programme. But some health departments are rebelling against the state's censorship efforts. The poster shows a fetus with the different substances-excluding cigarettes-that can harm it. A lot of health departments have pasted pictures of cigarettes on it. -REX RHEIN, medical journalist, Washington, DC
is one year less than the European Community's original proposal. The British government, however, had wanted a 13 year maximum to allow the NHS to benefit sooner from cheaper generic alternatives. The existing nominal 20 year patent protection is effectively halved for pharmaceuticals by the time taken for research and development and market approval. The European Community's resolution is to create a supplementary protection certificate for medicinal products that will compensate at least partially for the patent life lost in obtaining market authorisation. The British government is satisfied with the 15 year compromise, especially as it won its argument for a maximum five year extension rather than the 10 years initially proposed. All drugg introduced since 1988 will be covered. Committees in both houses of parliament last year urged the government to support the more generous European Community proposal. The government was defeated in a vote in the European standing committee last
June. And in December the Lords select committee on the European Community came out in favour of the longer patent extension. The Lords committee was particularly concerned that the research that could suffer most from a patent expiring would be that relating to "incurable" diseases such as motor neurone disease, Alzheimer's disease, and multiple sclerosis. This concern is echoed by the drug companies. They argue that the complex research into degenerative diseases will be adversely affected by the reduced maximum extension of five years. The Association of the British Pharmaceutical Industry, while giving a qualified welcome to the 15 year compromise, said that the five year maximum extension will discriminate against products that take longer to test and evaluate-"the very ones that should be given every possible encouragement." The European Community's draft regulation now goes to the European parliament before coming into force.-JOHN WARDEN, parliamentary correspondent, BM]
European Community agrees on drug patents The European Community has compromised on extending the patent life of medicinal products to allow pharmaceutical companies a proper return on their investment in research and development. At a ministerial meeting in Brussels last month there was political agreement on a formula that will in practice allow 15 years' patent protection for most new drugs. This
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Acute medical beds could be cut by 30% If all district health authorities in England used their acute medical beds as efficiently as the top 25% then the total number of beds could be reduced by about 30% or 27000, says the Audit Commission in a report published this week. It argues that improved organisation would improve the quality of care.
Despite continuing wide geographical variation in efficiency of use of beds the NHS has increased its efficiency enormously in the past 20 years. Between 1974 and 1989 the number of patients with acute illness treated rose by 22% while the number of beds fell by the same percentage. Yet the number of beds per thousand population varies from under 0-8 in some districts to over 1-6 in others. Throughput per bed varies from under 20 patients a year to over 80. These variations are not explained by gender, age, or case mix. The report has been produced by the commission's staff with an advisory group of clinicians, managers, and health service experts. It is based on an analysis of national, regional, and local data on use of beds, a questionnaire survey of over 100 acute units, detailed studies in 10 hospitals, and a review of published research. Inefficient use of beds occurs at every stage from admission to discharge, says the report, and no one change will increase efficiency. The report analyses the problem in five sections-admission, placement, stay, discharge, and availability and management of beds-and makes recommendations on each
A third to go?
The first problem with placement is delay, support at home. Arranging long term care and the commission found that in the past will need improved links with general pracyear patients had been left overnight on titioners and community services. The commission found that 40% of the trolleys in casualty departments in 5% of hospitals. Patients are then often placed in variation in the number of beds among inappropriate wards, requiring later transfer. districts is explained by variations in age Ninety per cent of hospitals had had to put structures and admission rates, but 60% medical patients into surgical beds in the past of the variation bears no relation to the year. A particular problem arises with elderly population's needs for health care. Historical patients, when it is often unclear whether inequalities have been perpetuated. The stage. they are to be cared for by physicians or report advocates better coordinated managegeriatricians. The report recommends that ment of beds at hospital level but with as hospitals should develop clear policies on much devolution as possible to wards and Inefficiencies at every stage placing and transferring acutely ill patients. clinical directorates. There should be pooling The first problem is that throughout the The first requirement will be much better of beds currently divided by gender and pooling within subspecialties. Hospitals information on the bed state. country the chance of being admitted to The average length of stay in acute medical should also consider five day wards, planned hospital varies, and clearly some patients are admitted inappropriately. This may happen units standardised for gender, age, and case investigation units, and patient hotels. The report is likely to be well received by because admission procedures are poorly mix varies from four days to over 15. This organised and the decision to admit is taken variation arises only partly from problems groups like the BMA, the Royal College of by inexperienced junior doctors, who, under- with data collection. More often it is due to Physicians, the Departments of Health, and standably, are inclined to overadmit. The variation in clinical practice and administra- the Royal College of Nursing, all of which were consulted before publication. The report advocates monitoring of general prac- tive problems such as the timing of ward titioners' referral rates by managers, better rounds and delays in arranging investiga- report ends with detailed suggestions on how communication between general practi- tions. The report recommends regular managers and clinicians can begin to imtioners and consultants, and improved examinations of the average length of stay plement improvements. Over the next year admission procedures. Experienced junior for common conditions for individual con- the commission's local auditors will make an doctors should always be available to decide sultant§. Medical audit, clinical protocols, overall assessment of each hospital's current and resource management will, the commis- use of its medical beds. As Ross Tristem, on admission, and all patients should be seen sion hopes, combine to reduce the variation. director of health studies at the commission, as quickly as possible by consultants. There should also be more observation beds avail- Clinicians and managers should together has said: "Most people in the health service able to avoid doctors having to admit, for improve administrative arrangements for want to change. Our job is to help them."RICHARD SMITH, BMJ instance, all patients with minor head wards rounds and investigations. Discharges are regularly delayed because injuries or who have taken overdoses. At the moinent only a third of acute hospitals have of difficulties in obtaining drugs to take Lying in Wait: The Use of Medical Beds in Acute home, arranging transport, and providing Hospitals is available from HMSO, price £9.50. such beds. BMJ
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Headlines
NHS distribution of funds unfair
US doctors asked to stop silicone breast implants: The Food and Drug Administration (FDA) has asked American doctors to stop using silicone breast implants for 45 days while an advisory committee assesses new information on their safety. The FDA has received 2500 reports of illnesses associated with the implants. The decision by the FDA has been criticised because it is not an outright ban on implants. Acute respiratory infections cause most infant deaths: Acute respiratory infections have replaced diarrhoea as the leading killer of children under 5, according to United Nations health officials. Teaching mothers to recognise early symptoms and making antibiotics available more quickly could reduce the death rate-four million children a year-by one third.
Belgium winning war against rabies: By using a new genetically engineered vaccine and attaching it to bait the Belgians have managed to vaccinate roughly two thirds of the foxes in the Ardennes. The number of cases of livestock rabies, which is a notifiable disease, fell heavily. The Belgian vaccine is reported in last week's Nature.
Record number of abused children: The number of British children placed on at risk registers from March 1990 to March 1991 was 45 200. This represents a 4% rise from previous figures. The number of children in care has fallen from 95 000 to 60 000 since 1980.
Quebec woman granted right to die: A Quebec court has granted a 24 year old woman who is terminally ill the right to be taken off her life support machine. The ruling is claimed by legal experts to make a new distinction between the law against doctors assisting suicide and a patient's right to refuse treatment. California orders motorcyclists to wear helmets: After much controversy among Californians a new law, which makes helmet wearing compulsory for motorcyclists, came into force last week. Opponents argue that the three remaining states without such laws Colorado, Illinois, and Iowa-have lower accident rates.
US health care drug stocks soar: On the New York stock exchange last year the biggest winners were health care and pharmaceutical companies. The biggest gain was seen by North American Vaccines, a company whose stocks rose by 704% after it developed a children's whooping cough vaccine.
70
The British government's new formula for distributing the NHS budget to regions and districts means that many health authorities will lose large sums of money unfairly, according to a paper presented to its region by West Birmingham Health Authority. West Birmingham calculates that if its region's capitation policy is implemented in full it stands to lose around £15m, or over 20% of its current budget, by the end of the decade. West Birmingham is not alone in thinking that this loss is unjustified. South Western and North East Thames Regional Health Authorities are investigating ways of making the department's formula for weighted capitation fairer so that it provides a more accurate link between a population's need for health care and a district's financial allocation. The switch to funding on the basis of the resident population rather than the health care services in each authority is only part of the issue. West Birmingham's argument is that the factors used to weight resident populations-to reflect differences in the health care needs of similarly sized populations-are wrong.
West Birmingham argues that basing capitation formulas on estimates of the number of people in inner city districts with highly mobile populations is inaccurate. It claims that the formula gives too much emphasis to the size of districts' elderly populations, the practice of using nationally derived weighting based on age distribution to turn population numbers into financial allocations, and the use of standardised mortality ratios as a proxy for morbidity. Although younger populations may need less health care than older populations, national average age weights may not accurately reflect the health needs of a district. In West Birmingham's view it is wrong that the new formula has no weighting for social deprivation.
Deprived populations tend to have fewer elderly people than more affluent areas so the current formula means that they will lose out. When elderly people do use the health service they use it more intensively and hence cost the NHS more than do younger people. But some health authorities still believe that weighting too heavily on the basis of age and ignoring the health care implications of social deprivation is wrong. This issue was recogised by a report by the NHS Management Executive (before the NHS reforms) recommending a revamped Resource Allocation Working Party formula. But the reforms overtook the executive's recommendations, and weighting for social deprivation was not included. Although
the
management
executive's
recognised the limitations of using standardised mortality ratios to calculate the need for health care services, it did not recommend any additional factors to reflect more accurately the need for services for the mentally ill and those with learning disabilities, maternity and neonatal care services, accident and emergency services, report
Too much weight may be attached to age
services for those with certain chronic conditions-all of which are poorly correlated with standardised mortality ratios. In West Birmingham's view, more sensitive proxies are necessary to reflect the need for certain types of health care services. Criticisms of the weighted capitation formula are not new: ever since the Resource Allocation Working Party formula was introduced in the mid-1970s health authorities have complained of the shortcomings of the method for distributing cash to regions and districts. Clearly, however, some regions are now beginning to address these criticisms as far as districts are concerned. Whether the department will follow suit nationally remains to be seen. -JOHN APPLEBY, economic correspondent, BMJ
New Zealand juniors' strike success Junior doctors in New Zealand have finally resolved their dispute over contracts with their employers, but only after taking industrial action. This is the first time that New Zealand's doctors have been on strike. The dispute was due to attempts by the area health boards to alter junior doctors' contracts. In particular, the boards wanted to allow longer periods of continuous duty. The limit on continuous duty is currently 16 hours. Junior doctors claimed that proposed changes would jeopardise patients' safety and their own postgraduate education and
training. When the juniors first threatened strike action some of the smaller area health boards agreed to continue with the existing contracts but the larger boards were less willing to negotiate. Strikes were scheduled for mid-October, but the juniors' representative body, the Resident Doctors' Association, delayed the action because Auckland, the largest area health board, showed an initial willingness to negotiate. When negotiations collapsed the strike went ahead with hospitals cancelling all routine admissions and clinics and consultants covering the wards and emergency admissions. The initial strike was for two days in the first week, building
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up to four days by the third week. In the Bay of Plenty region, where consultants refused to cover, the dispute was resolved in four hours, with the area health board offering to continue existing contracts for the next year. In several areas the dispute became more acrimonious. In Auckland juniors were sent contracts with blank job descriptions despite assurances that no new contracts would be sent out. As the strike entered its fourth week a deal was worked out. Junior doctors will be expected to work no more than 72 hours a week averaged over two weeks and should get at least eight hours off duty every 24 hours. If the area health boards overwork their juniors they will be penalised financially by high overtime rates. Some boards are continuing their existing contracts so that they can see how the new contract works in other areas before adopting it themselves. The solidarity of the juniors during the dispute has impressed the Resident Doctors' Association. It will continue to be important until the area health boards agree to return to a nationally negotiated settlement. Until then there will be an annual round of regional disputes with the likelihood of increasing disparity between doctors' contracts in different areas. The new Employment Contracts Act allows employers to negotiate contracts with individual employees, but it would prove impossible for the area health boards to negotiate individually with over 1600 junior doctors. Doctors who are due to take up appointments in New Zealand should, under the new contract, be offered the collective agreement first. They will, however, also be free to negotiate an individual contract. In the next few months the area health boards will be entering similar negotiations with nurses, paramedical staff, and laboratory staff. -CHARLES ESSEX, New Zealand
Medical aid for the former Soviet Union
Professor Alexander Baranov, the deputy minister of health, sent William Waldegrave, the British health minister, a detailed list of drugs and medical equipment needed. This included antibiotics, cytotoxic drugs, disposable syringes, and scalpels. Professor Baranov also listed possible venues for exchange visits by British doctors, to be arranged by the UK-USSR Medical Exchange Programme. -STEWART BRITTEN, honorary secretary, UK-USSR Medical Exchange Programme For further information on exchanges-for example, spending a week with up to 30 other doctors from Britain at the All-Union Research Centre for Mother and Child Health Care in Moscow-contact Dr Stewart Britten, 9d Stanhope Road, London N6 5NE
AIDS and hepatitis B in the former Soviet Union According to official data, only 627 people in the former Soviet Union were HIV positive last July. Of them, 258 were children infected iatrogenically by contaminated needles used in three epidemics in the southern Soviet Union. These low numbers are not, apparently, for want of screening-one Soviet scientist claims that over 50 million HIV tests have been conducted. One reason for the low prevalence of HIV infection might be the former Soviet Union's policy of compulsory testing for foreign visitors staying more than a month; seropositive visitors are deported. But last summer a delegation sent by the private American foundation People to People International came away with new insights into the union's policies on HIV and hepatitis B virus infections. Some 40 doctors and scientists from North America, Australasia, and Europe visited Moscow and Leningrad (now known as St Petersburg) in July to study the union's services for infectious diseases
and to forge links with Soviet colleagues. The delegation found that six regional centres coordinated services for Soviet patients with HIV infection and AIDS. Since 1986 these centres have screened all blood for transfusion and have tested more than 400 000 drug misusers for HIV infection (without a single positive result) and some 25 million pregnant women (yielding 20 cases of HIV seropositivity confirmed by Western
blotting). Public health education is less prominent in the former Soviet Union than in the West, according to delegates, and at the time of the visit there were no plans for a national campaign on HIV. As one scientist explained, there is a great need for health educationfor example, among teenagers-but little demand because people have generally conservative views. But questionnaire surveys suggest that at least half of the sexually active population does not use condoms and that 4% of men are homosexual. Intravenous drug misuse is not, however, a major form of transmission because poor availability of disposable syringes and needles leads most misusers to smoke, inhale, or chew their
drugs. In Leningrad the delegation met two young homosexual men with AIDS. Both were receiving treatment used in the West, including zidovudine. Unlike HIV infection, hepatitis B is widespread in the former Soviet Union, particularly in the central and southern regions, where its prevalence may be as high as 20%. Hepatitis A, C, D, and E viruses have also been identified. Officially there are one million cases of infectious hepatitis, although one scientist told the delegation that the true prevalence is probably double that. In 1990 hepatitis B caused the deaths of some 5000 people including about 3000 children, most of whom had been born to mothers who were chronic carriers of the disease. Vaccines derived from plasma are still the mainstay of prevention, although recombinant vaccines may be readily available soon. -FRANCIS DROBNIEWSKI, department of gastroenterology, St Bartholomew's Hospital, London
The British Prime Minister, John Major, chairman of the leaders of the group of seven industrialised nations, will oversee the listing of medical requirements for the former Soviet Union this winter. But deciding on those requirements will not be easy, given that Soviet doctors and health service managers have little experience of needs assessment. The World Health Organisation has already suggested what the Soviet health care system needs. These include greater attention to public health medicine with more
epidemiological research, formal assessment of the population's needs, and a new school of public health. WHO believes that the health care system should be decentralised, its financial structure reviewed, and quality assurance established. Last autumn the European Commission approved a budget that included, for the first time, humanitarian aid for health care in the former Soviet Union. In late October BMJ
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z
i ne numoer oj cnuaren wno are Hn v positve may be grossly unaeresntmatea
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Canadian uproar over fees for health care Quebec's health minister, Marc-Yvan Cote, is creating a storm over his proposals to cut health care costs in the province. These include charging a $C5 fee for each visit to a doctor and making hospital patients pay for their room and board. Both of these proposals are apparent violations of the Canada Health Act, which guarantees free health care across the country. Cote's proposals are contained in a 130 page paper, which is expected to touch off a debate when it goes to the floor of the legislature for discussion in February. The discussion may have national implications because other provinces are also facing spiralling health costs at the same time as the federal government is reducing transfer payments.
Cote's paper has already produced criticisms from opposition parties. The separatist Parti Quebecois's health critic, Remy Trudel, called the proposals "disguised taxes" and said that they constituted "a list showing how to pick taxpayers' pockets." He said that the basis of the Parti Quebecois's policy is "universal, accessible health care through public financing." An aid to the federal health minister, Benoit Bouchard, called the move "fundamentally disquieting" and said that the federal position has been that charging people who use the system "will discourage the poor from seeking health care." Dr Augustin Roy, head of the Quebec Corporation of Physicians, said that the province's health care system is one of the world's best provided at one of the lowest costs-about 8 5% of Quebec's total income. "The crisis is over the fact that the government is bankrupt." But Cote says that he must cut costs because the health system will be $C1-2bn in debt within five years. And Ottawa is insist-
yuebec-could it weather a storm over health care? 72
ing that the provinces maintain national standards for accessibility of health care in spite of the federal government cutting transfer payments and trying to force special programmes on the provinces, such as those for the disabled and for women's shelters. The minister's cost cutting list includes adding to individuals' taxable income the cost of health services they use during the year, charging for some pharmaceutical products currently covered by health insurance, and eliminating free dental and optometry services except for preventive ones such as annual dental examinations. Doctors will be encouraged to reduce defensive medical practices such as ordering unnecessary medical tests by the setting up of a government malpractice insurance fund, and health care institutions will have to purchase special equipment jointly through a province wide procedure. Cote says that the poor would be protected through refundable tax credits. But the executive director of the Comite Provincial des Malades, Michelle Lamquin-Ethier, says that the chronically ill "already pay more and get less and less." The Federation of Quebec Nurses warned that the changes may bring American style privatisation of medical care nearer, and the Quebec Federation of Labor said that they "have the effect of penalising the sick and jeopardising [illness] preventions."-DAVID SPURGEON, scientific and medical journalist,
Quebec
Elderly homeless ignored Nearly a third of homeless people in Britain are aged over 50. But elderly people are often ignored as the media focus on homeless youngsters. Older homeless people are seen as unappealing and an embarrassment, according to Gordon Peters, of the King's Fund College, speaking at a conference organised by Age Concern last month. The conference followed a report published at the end of last year that emphasised the problems of coping with the dual disadvantages of old age and homelessness. Based on interviews with 15 organisations caring for elderly homeless people, the report argued that the risk of becoming homeless in old age can be increased by breakdown of relationships, bereavement, poor health, unemployment, loss of tied accommodation, discharge from the armed forces, and admission to hospital. Vulnerability as a result of old age is a criterion for statutory rehousing, but people still slip through the net. Many local authorities use the state retirement age as the threshold for assuming vulnerability due to age, but this ignores the fact that homelessness tends to exacerbate the effects of aging. High rents and restricted availability of accommodation mean that the private rented sector is not an option for many elderly homeless people. The government's "right to buy" legislation has creamed off some of the best public sector housing,
D'Oubly adsaavantagea-ola ana nomeless
leaving much that is unsuitable for older people. Even the choice of temporary accommodation is restricted as some hostels have age restrictions or are unsuitable for elderly residents. Unemployed homeless people are less likely to find a job if they are old. Homeless people living on the streets are excluded from claiming certain premiums on their income support payments. If they are not registered with a general practitioner they are unable to obtain a medical certificate and are excluded from claiming various benefits. Old people are especially at risk from assault, and the report cites examples of their being victimised by young people, including being set alight or attacked with broken bottles. The specific problems of elderly homeless people have been ignored for a long time. Sheila McKechnie, director of the housing charity Shelter, told the conference that "This report has made me realise how very little Shelter has done to promote the needs of older homeless people." She suggested that the complexity of the problems frightened people off. It was easier to resolve the problems of those who had been on the streets for only a short time. This was supported by Joanna Wade, chairwoman of the charity Crisis, who suggested that "The public wants success stories-it is easier to 'sell' young homeless people." The report does, however, make various recommendations about how this neglect can be rectified, including: * Central government should have an explicit policy, backed by resources, to reduce homelessness among elderly people and improve services for elderly homeless people * There should be a commitment to providing integrated primary health care for homeless elderly people * Government funding should be given for more high care housing schemes for older homeless people. -STELLA LOWRY, BM37 Older Homeless People in London is available from Rosalyn Blackman, 54 Knatchbull Road, London SE5 9QY, price £5.
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M
Qdiea a.cad.emiics'
falling Mnorale .despite
jbot satisfaction Nearly two thr of respondents in a survey of Briish medical- acodemic staff said that their job-'sA0ifa94t Was high, but nearly half vgjd that theirpmnle ha4 declined in, the past yr.. Ne~ly twothirds pd that they would r,c
areer
acdemic medicime
s~a~~ry betwten clinical academiics Nw did not exist. The replies caine in response to a questionby the BMA's econoxnic naire devise if parity Qf doct an4
research unit fQr the Medical Academic Staf Coinmittee. The response rate was 47-2%, and 2698 forms were dispatched. The committee decided to canvas academic staff because during last year's dispute over pay the principle of parity seemed to be
threatea
ed.
vJaly
the
a,ward for NHS doctor wa$s salaries p 589).
of academic sta
review body's tslated to the
(5 October 1991,
Seventy thrqe per cent of the respondents held a consultant post in the NHS; 17% were senior registrars and 6% registrars. Two thirds said that the most attractive aspect of academic medicine was that it allowed time to do research. A quarter thought that they had a higher workload than doctors who worked only the NHS. In response to a question on whether they would recommend academic medicine as a career only ju%t over half of the respondents si4 tat tey would and over wo ,fths said that they would not. The ma reasons given were:
Medieal
new
lieutenant governor, James C Gardner, ordered the deletions to gain support from the tobacco industry for his efforts to become governor this year. The educational materials, describing the parity of salary. effects of substance misuse, are part harmful Commenting on the survey, the chairman of a multimedia campaign called "First Step" of the MASC, Dr Colin Smith, said: "The to lower North Carolina's infant mortality. In and results of this survey reveal the bitterness highest rate in the second had the state 1988 disillusion felt by medical academics after America with 12-5 infant deaths 1000 most The dispute. last year's damgng imn- compared with a national average ofper 10-0 portant factor in this is the need to find a long 1000. Except for the brochure and poster,per all term solution for clinical academics' pay. It is other materials used in the campaigna sad reflection on the current state of affairs including radio and television "spot" anthat almost one fifth said that they either nouncements and public service advertiseregretted gong into medicine altogether or ments-describe tobacco use by pregnant regretted choosing academic medicine." harmful. potentially as women Dr Smith said that he feared for the long General AssemWhen Carolina the North if for medicine academic term consequences for the substance 000 $205 approved bly pay parity was not guaranteed. "Ministers education programme it gave control must realise that in order to attract and retain misuse the expenditures to the state's Drug the best doctors in academic medicine there over which is chaired by the lieutenant Cabinet, no financial to choosdisadvantage be must The Drug Cabinet distributed the governor. inlg it as a career. -LINDA BEECHAM, BMJ money to the North Carolina Department of Environmental Health and Natural Resources, which contracted Sally Johns, a graphic designer in Raleigh, to create the materials. Advice on what to put in them came from a committee that included government and private organisations concerned with child and maternal health. Johns told the BMJ that the committee's Any references to smoking as a cause of initial planning included references to tobacco infant mortality and low birthweight babies among other "substances of misuse" that were deleted from a brochure and poster could injure the fetus. On orders from her prepared by a fetal and child health pro- client, however, tobacco was soon eliminated, gramme in North Carolina, the state that she said. At a final meeting, on 8 February last year, produces 40% of America's tobacco crop. Groups sponsoring the nationally recognised the Drug Cabinet's director, Janet Pueschel, programme, aid a major state newspaper, attempted to explain to increasingly angry have suggested that North Carolina's committee members why tobacco had been * Uncertain or poor career prospects * Difficulties in obtaining adequate funding for research * Uncertainty over the maintenance of
Tobacco state keeps quiet on risk to fetus
ye-,ar hoours
MrJ L Dawson
Ti£zeiWuQIblly o9wnued ca4i,lphQracic sugeop-2Professor Ma-di Yacub, who has- wo~ed at are>field liospitl since 1969, re4eivd a kpighthpod the new year honours anxouncesd last week. Professor Yacoub has developd innovatioms in h-ear and lug transplantsand w.Y*X.itt$ nuous papers on the subject. Ag$e 5,h is a consultant surgeon at the Natiopal Heart Hospital and has BMJ VOLUME 304
11 jANuAjY 1992
e professor of cardiothoracic surgery at the National Heart and Lung Institute since 1986. Two surgeons to the Queen have also been honoured. Mr Rodney Sweetnam, consultant orthopaedic surgeon at the Middlesex Hospital since 1960 becomes a Wight commander of the Royal Victorian Order, and Mr J L Dawson, who has been a surgeon at King's College Hospital
since 1964, becomes a commander of the Royal Victorian Order. Mr Dawson is dean of the faculty -of clinical medicine at King's College School of Medicine and Dentistry. Professor Michael Rutter, professor of child psychiatry at the University of London's Institute of Psychiatry and a fellow of the Royal Society receives a knighthood. 73
omitted from the brochure and poster. "Her explanation was that all they were concerned about was cocaine, 'crack,' heroin, and alcohol," said Johns. Pueschel she said, had stated that there was no chance tobacco would be included. According to Johns, Pueschel told the committee: "Not now, not ever." Another participant at that meeting, Linda DeShazo, lead health educator for Guilford County Health Department's Family Planning and Maternity programme, said she too had heard Pueschel make the statement. Pueschel, however, denied to BMJ that she had ever used those words. "I did not make those statements," she declared. "There are some individuals who would like the Drug Cabinet to deal with smoking, and we don't." In fact, Pueschel said, "we didn't have anything to do with the brochures." Pueschel is supported by Don Follmer, director ofpublic affairs in the North Carolina Department of Environmental Health and Natural Resources, who said that the department had simply carried out the General Assembly's mandate to educate women about the hazards of drug and alcohol misuse, not smoking. "We've got plenty of materials on smoking available," he pointed out. The state has recently received $5m from the National Institutes of Health as part of its "Project Assist" to aid state health authorities' efforts at "voluntary cessation of tobacco use" by, among others, pregnant women. But Kay James, director of the eastern North Carolina chapter of the March of Dimes Birth Defects Foundation in Raleigh, said that "those of us who have worked through this partnership were all under the impression that this would be an all inclusive, global piece. The omission of smoking made it very inconsistent with the message we'd been putting out that smoking during pregnancy has been shown to have harmful effects on the development of the fetus." The posters and brochures are widely disseminated throughout North Carolina, and other states are using them as models, according to several participants in the programme. But some health departments are rebelling against the state's censorship efforts. The poster shows a fetus with the different substances-excluding cigarettes-that can harm it. A lot of health departments have pasted pictures of cigarettes on it. -REX RHEIN, medical journalist, Washington, DC
is one year less than the European Community's original proposal. The British government, however, had wanted a 13 year maximum to allow the NHS to benefit sooner from cheaper generic alternatives. The existing nominal 20 year patent protection is effectively halved for pharmaceuticals by the time taken for research and development and market approval. The European Community's resolution is to create a supplementary protection certificate for medicinal products that will compensate at least partially for the patent life lost in obtaining market authorisation. The British government is satisfied with the 15 year compromise, especially as it won its argument for a maximum five year extension rather than the 10 years initially proposed. All drugg introduced since 1988 will be covered. Committees in both houses of parliament last year urged the government to support the more generous European Community proposal. The government was defeated in a vote in the European standing committee last
June. And in December the Lords select committee on the European Community came out in favour of the longer patent extension. The Lords committee was particularly concerned that the research that could suffer most from a patent expiring would be that relating to "incurable" diseases such as motor neurone disease, Alzheimer's disease, and multiple sclerosis. This concern is echoed by the drug companies. They argue that the complex research into degenerative diseases will be adversely affected by the reduced maximum extension of five years. The Association of the British Pharmaceutical Industry, while giving a qualified welcome to the 15 year compromise, said that the five year maximum extension will discriminate against products that take longer to test and evaluate-"the very ones that should be given every possible encouragement." The European Community's draft regulation now goes to the European parliament before coming into force.-JOHN WARDEN, parliamentary correspondent, BM]
European Community agrees on drug patents The European Community has compromised on extending the patent life of medicinal products to allow pharmaceutical companies a proper return on their investment in research and development. At a ministerial meeting in Brussels last month there was political agreement on a formula that will in practice allow 15 years' patent protection for most new drugs. This
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