game whose only predictable effect is to enrich the casino owners. BRUCE G CHARLTON
Department of Anatomy, University of Glasgow, Glasgow G12 8QQ 1 Evans MJ. Sacrificed to an archaic training system. BMJ 1991;303:65. (6 July.)
Postgraduate department of general practice based on regional advisers SIR,-In his article on research in general practice Professor Denis Pereira Gray rightly deplores the relative paucity of academic posts in general practice.' I have been surprised over the past few years that no university has to my knowledge followed the example of Exeter in recognising the regional adviser in general practice network as a basis for a postgraduate department of general practice, with the regional adviser as professor and the present associate advisers as senior lecturers. This would identify a cadre of general practitioners of proved educational worth and ability, who could then have the academic authority to promote the discipline and research so necessary to the study of general practice. I appreciate that, in the first instance, these would add only to the proportion of honorary posts, as no university has the wherewithal to fund these posts at present and they would have to remain under the financial aegis of the regional health authorities and the postgraduate deans (most of whom are themselves appropriately honoured with personal chairs). One reason for this failure to reward the academic worth of the postgraduate general practice system may well lie with the regional advisers themselves, in so far as they are clearly the people with the knowledge and influence to institute such negotiations with the universities and yet it is clearly invidious for them to be seen to be pushing themselves forward in this way. I would, however, commend the idea to the medical schools, especially through the postgraduate deans and the professors of undergraduate departments of general practice, as an ideal way to expand and recognise academic general practice. GUY HOUGHTON
Greenbank Surgery, Hall Green, Birmingham B28 8BG 1 Pereira Gray D. Research in general practice: law of inverse opportunity. BMJ 1991;302:1380-2. (8 June.)
Setfing priorities in the NHS SIR,-In his contribution to Mr J R Smith and colleagues' article on the ethics of infertility management, David Seedhouse states that "the law seems to have put the responsibility on clinicians to impose personal judgments on potential clients. This is an unacceptable burden from the point of view of . .. doctors (who are not trained in decision making)."'" In subsequent lines, however, it seems that he does expect doctors to make decisions to treat based on priorities in resource allocation. Undoubtedly, doctors are trained to make such decisions and have to make them often. They will always have to rank patients in order of priority even by allocating a limited amount of their time to any particular patient's problems. With infertility treatment the financial cost of any decision must predominate because the service is not primarily improving the health of the prospective parents. We cannot foresee all the implications of any
BMJ VOLUME 303
20 JULY 1991
medical decision. We see only immediate implications, in this case to the couple and child. What will be the long term social implications? The interactions of all our lives raise too many imponderables for decision making to be made purely by doctors. We all understand that costs must be contained in the NHS, but I do not think it is a doctor's function to make decisions of priority except in his or her particular field. If the NHS could be isolated from government control with built in funding based on inflation and demography I am sure managers and clinical professionals could decide how to spend money wisely. The government must, however, make clear to the population what the health service can and cannot provide. For example, perhaps everybody should pay at least a nominal fee for drug treatment and missed outpatient appointments. Perhaps the NHS drug list needs halving. Should the health service fund fertility treatment for any woman with more than one child? Should upper limits be put on civil liability for negligence in the NHS or our system of tort abolished? Should all operations be done (available) in the NHS? Only by such frankness will inequalities of care be understandable; everybody knows that the NHS can never be totally fair. Recent reforms are at best irrelevant and at worst damaging. They may curtail costs at the expense of care. They may well divide health professionals, and discerning patients will realise that budgetholding general practitioners are not necessarily motivated by altruism in their care and referral of blocks of patients. If a market is to work health professionals must be driven by greed and power. Hospitals will chase after money through patients, failing to assess quality of care adequately. For quality, choosing to be treated privately will be patients' only choice, a freedom lost to most. S TALBOT
The ultimate sanction would be to extract a fee, albeit a modest one, for each item of out of hours service, provided that a safety net was established for the genuinely poor and needy. It would then be necessary to take a close look at the present accident and emergency service, which seems wanting. I W R ANDERSON JAMES STEVENSON Accident and Emergency Department, Victoria Infirmary, Glasgow G42 9TY I Iliffe S, Haug U. Out of hours work in general practice. BMJ 1991;302:1584-6. (29 June.)
Duration of storage of patients' records SIR,-Dr Mary Wingfield's editorial on the daughters of women who took stilboestrol during pregnancy' highlights the epidemiological and legal stupidity of the Department of Health's current guidelines on how long patients' records should be stored. At this time of increasing numbers of increasingly chemically complex and potent drugs with far reaching effects minimum periods of storage suggested- 25 years for obstetric records, up to the 25th birthday for children's records, and eight years for other records that do not come under the Mental Health Act -are obviously inadequate. Unfortunately too, because of pressure on storage space and financial pressures on health authorities minima often become maxima. G W H JARDINE
Radiotherapy Department, Cumberland Infirmary, Carlisle, Cumbria CA2 7HY
Pitney, Langport, Somerset TA10 9AF 1 Smith JR, Kitchen VS, Munday PE, Paintin DB, Forster GE, Hooi YS, et al. Infertility management in HIV positive couples: a dilemma. BMJ 1991;302:1447-5. (15 June.)
Out of hours work in general practice SIR,-Drs Steve Iliffe and Ursula Haug rcently discussed out of hours work in general practice.' The logistics of reorganising out of hours care so that both patients and clinicians are satisfied are daunting. Equally, the proposal to base the service on the existing accident and emergency network is a nightmare and doomed to failure. In our city less than 0-5% of all people attending accident and emergency departments for the first time require any form of resuscitation for acute illness or injury. Altogether 35% of all patients newly referred could quite easily treat themselves or be treated by their family doctor. It is our impression that many inner city departments experience similar problems, and many are overrun. They seem more like the old dispensaries of pre-NHS city hospitals than a modern efficient accident and emergency service. "Neighbourhood casualty departments" should be a thing of the past. What is the solution? The specialty of general practice is the keystone of a well organised system of health care. It would be dismantled at the nation's peril. Large groups ofgeneral practitioners must amalgamate and organise their out of hours commitment to provide cross cover and adequate leisure time. Rural general practitioners face an unenviable prospect. If the public show no restraint and continue to place unrealistic demands on the service it will collapse. Health care has always been rationed.
I Wingfield M. The daughters of stilboestrol. 1414-5. (15 June.)
BMIJ 1991;302:
Anaesthetists' role in introducing audit into surgery SIR,-Dr Danny Ruta's review of the World in Action programme "On the Knife Edge" rightly highlighted for criticism its tabloid excesses.' Sadly, its overemphasis on specific personalities gave a distorted impression of events of which I have personal knowledge. The flavour of the programme can be divined from some relevant quotations. "Brendan Devlin, who probably knows more about NHS failings than anyone alive . . . persuaded his colleagues [in the early 1970s in Stockton on Tees] ... to start monitoring each other's work . .. with the result that in the first three years we were able to dispense with half the surgical beds.... Thinking that what could be achieved in one hospital might be achieved in hundreds, Devlin wondered whether surgeons elsewhere could be persuaded to cooperate in an inquiry into patients dying after surgery. The idea was put to the College of Surgeons and then to individual hospitals. The college wasn't too enthusiastic" but he "eventually persuaded enough of his colleagues for a limited investigation to go ahead. . . The results shocked the medical profession. Devlin later calculated that 1100 patients had died that year because of surgeons' error. It was now impossible for the medical profession to ignore Devlin's work" and the Royal College of Surgeons "took Devlin to its bosom." "He was given a suite of offices, staff, and money to support his fight for better standards." The implication of the programme was that Mr Devlin had pioneered single handedly the introduction of medical audit into surgery. I wish to put the record straight. The Association of Anaesthetists of Great Britain and Ireland conducted a study (funded by the Nuffield Provincial Hospitals Trust) of deaths associated with
189
anaesthesia and published the results in 1982.2 This study shed as much light on surgery as on anaesthesia, since the two activities are so closely interwoven in the care of surgical patients. Nevertheless, neither of two of the bodies that represent surgeons was keen to be involved when they were approached in the planning stage. When the results were analysed it was obvious that deficiencies in anaesthetic care were much less common than those in surgery. The Association of Anaesthetists therefore sought support for a larger study which could serve as a blueprint for a national audit, and we worked hard to ensure that this time it would be a joint anaesthetic-surgical effort. With indications of support from the Association of Surgeons, Professor Michael Rosen and I (as treasurer and president, respectively, of the Association of Anaesthetists) obtained the necessary financial support from the Nuffield Provincial Hospitals Trust and, later, the King Edward's Hospital Fund for London. A joint working party was set up under my chairmanship to plan and execute the study. Mr Devlin was one of four nominees of the Association of Surgeons and was chosen to be one of the two surgical coordinators; the problems of anaesthesia were handled by a single anaesthetic coordinator, Dr John Lunn. The clerical and administrative staff were housed initially by the King's Fund but then by the Association of Anaesthetists in Bedford Square. The study did indeed identify many problems in surgical services,' and both professional associations supported an approach to the Department of Health, which readily provided the funds for the continuing national confidential inquiry into perioperative deaths. Impartial readers may wonder how this story could have been put over without use of the word anaesthesia and with only a single passing reference to "committees of surgeons and anaesthetists"-yet such was the prominent role given to Mr Devlin in the programme that this feat was achieved. No doubt, as Dr Ruta divines, the producer wished to make an "attention grabbing" programme, but one can only marvel at a medium that can transmute a long planned sequence of events, involving the cooperation and good will of hundreds of participants in three major specialties (anaesthesia, surgery, and gvnaecology), the support of charities, and the active encouragement of agovernment department, into one man's crusade to improve the standard of British surgery. Unfortunately, as Dr Ruta's review shows, it is apparently quite easy. I only hope that the programme will not do too much damage to the warm and effective collaboration that has resulted from our initiative. M D VICKERS
Departmcnt of Anaesthetics, University of Wales College of Medicine, Cardiff CF4 4XN I Ruta D. Taking the bait. BAIJ 1991;302:1472-3. (15 June.) 2 I,unn JN, Mlushin WW. .llortalitv associated wih anaesthesia. Iondon: Nuffield Provincial Hospitals Trust, 1982. 3 Buck N, Devlin HB, Lunn JN. Tht report oss a confidential enquirv into perioperative deaths. London: Nuffield Provincial Hospitals Trust and King's Fund Publishing Office, 1987.
Financial risks to fundholding practices SIR,-If the projections made by Dr B J Crump and colleagues concerning the financial effect of random variation in the need for services on fundholding practices materialise such practices should be anxious.' For example, if a fundholding practice overspends its budget by 30% (which seems possible from random variation alone) should it be forced to make the necessary economies from its next year's budget, should it be bailed out by the regional health authority, or should it
190
be declared bankrupt? Conversely, if the same practice finds itself underspent by a similar amount, but solely because of random variation, should it be allowed to keep the shortfall for the benefit of its patients? How can anyone decide which savings are due to random variation and which are due to good financial management? Dr Crump and colleagues neatly illustrate that, in terms of reducing random variation, budget management is simpler when the population is larger. This would happen if the health service was truly national. MARK MWCARTNEY Pensilva Health Centre, Liskeard, Cornwall PL14 5RP 1 Crump BJ, Cubbon JE, Drummond MF, Hawkes RA, Marchment MD. Fundholding in general practice and financial risk. BMJ 1991;302:1582-4. (29 June.)
is true, however, that at any subsequent inquiry the pilot may appear as one of the statistics rather than in person. The idea that a colleague should be obliged to spend time with a physician in a busy medical unit as a result of an anonymous report without knowing the name of, or being able to question, his or her reporter is unworkable and could only fail in its object; indeed, CHIRP does not normally investigate unsigned reports as these mean that the events cannot be confirmed or clarified through the reporter. CHIRP is informational, confidential, and educational and does not set itself up as a judge, jury, and jailer. For Dr Parle to equate it to what he suggests should be set up for the medical profession indicates that he has missed both its point and its function. ROBERT M BRUCE-CHWATT
Richmond, Surrey TW 10 6DR
BMJ 1991;302:1547.
Pointing out other doctors' mistakes
I Parle JV. He that is without sin. (22 June.)
SIR,-I disagree with Dr J V Parle's suggestion, in his personal view, that a covert complaints board should be set up.' This would achieve little. The function of audit is to educate doctors and to discuss mistakes so that others can learn from them. Regrettably, every doctor has made an error of clinical judgment in his or her lifetime. It is easy to be wise about others' mistakes, and I believe that secret complaints serve no purpose; indeed, such a system is open to abuse. Far better to have regular clinical meetings about patients and treatment with an open discussion. We are, after all, on the same side in this game.
Future of long term care of dependent elderly people
KARIN ENGLEHART
Guildford, Surrey GUI 2DA I Parle JV. He that is without sin. (22 June.)
BAfj 1991;302:1547.
SIR,-In his personal view Dr J V Parle suggests a discreet medical reporting system,' cross referring, I believe, to the confidential human factors incident reporting programme (CHIRP) run by the Institute of Aviation Medicine, Royal Aircraft Establishment Farnborough, to which pilots and air traffic controllers may write. He is incorrect in stating that the report is sent to a superior not directly concerned, who can then act to investigate the incident and the pilot or air traffic controller concerned. The Institute of Aviation Medicine is an independent information gathering centre and acts to clarify the incident rather than the standards of the pilot by its investigation. It is looking for trends of errors and failures due to human factors, interpretation of instruments, standard operating procedures, and other factors that for various reasons people might be reluctant to disclose. Often the reporting is done by the person who made the error, to prevent others from emulating him or her. This system is also confidential so far as the person reporting the incident is concerned, and it is eventually anonymous as the name of the reporter, once the incident has been investigated, is removed from the file. Thus when a file is closed there are no names, only events, circumstances, and conclusions. The details, depending on the seriousness of the incident, may be published in the institute's magazine, Feedback, in the hope that this may jog a memory and perhaps prevent other people repeating the error. With CHIRP there is no question of educational retraining as Dr Parle suggests should happen with doctors, although an error by a pilot may kill many hundreds more people than an error by a doctor. It
SIR,-In contrast to the noisy debate about the reforms of the NHS almost total silence surrounds the future of long term care of highly dependent elderly people. This is a matter of importance well beyond the bounds of geriatrics as any shortage profoundly affects community care and most other acute hospital departments. In this part of the United Kingdom we are very disadvantaged in terms of the level of provision and have a "mixed economy," which makes life difficult for hospital staff and, I am sure, general practitioners. To explain to relatives that, yes, there are NHS beds for this purpose where, apart from loss of pension, care and accommodation are free, but, as there are nothing like enough and we suspect that the family may be able to afford it, could they please consider trying to find a private nursing home bed at £350 or more a week is to invite derision. There are several possible options for the future of long term care. The first option is privatisation, which, thanks to the estimated £1 2 billion spent each year on income support by the Department of Health, has taken over in some parts of the country, with the NHS virtually withdrawing from this type of care. Quality is variable; the future is insecure, and public money is spent on patients who are not necessarily those most appropriately placed there. Secondly, a partnership between private and public sectors is possible. The third option is provision of care by the NHS. This is not always above criticism, especiallv in terms of the legacy of the former workhouses originally intended to deter those on the outside rather than afford a pleasant environment to those within. An alternative to the old long stay wards are NHS nursing homes, but they are few and of unproved superiority except in terms of bricks and mortar. Moreover, provision of care by the NHS is far from cheap. Even in today's cost conscious era estimates vary from £350 to £500 a week, though it remains difficult to be certain of the cosI. The final option is a deliberately mixed economy, with the NHS trying to provide centres of excellence. This might mean people having to accept that, although the basic tenet of the NHS-free medical and nursing attention -should still apply, free board and lodging through the accident of infirmity (whether long term or short term) is illogical and unaffordable. Hotel charges seem to have disappeared from the political agenda but may be inevitable. A means test would provide a safety net: the income generated would help the NHS to survive, and having to compete might
BMJ VOLUME 303
20 JULY 1991
Department of Anatomy, University of Glasgow, Glasgow G12 8QQ 1 Evans MJ. Sacrificed to an archaic training system. BMJ 1991;303:65. (6 July.)
Postgraduate department of general practice based on regional advisers SIR,-In his article on research in general practice Professor Denis Pereira Gray rightly deplores the relative paucity of academic posts in general practice.' I have been surprised over the past few years that no university has to my knowledge followed the example of Exeter in recognising the regional adviser in general practice network as a basis for a postgraduate department of general practice, with the regional adviser as professor and the present associate advisers as senior lecturers. This would identify a cadre of general practitioners of proved educational worth and ability, who could then have the academic authority to promote the discipline and research so necessary to the study of general practice. I appreciate that, in the first instance, these would add only to the proportion of honorary posts, as no university has the wherewithal to fund these posts at present and they would have to remain under the financial aegis of the regional health authorities and the postgraduate deans (most of whom are themselves appropriately honoured with personal chairs). One reason for this failure to reward the academic worth of the postgraduate general practice system may well lie with the regional advisers themselves, in so far as they are clearly the people with the knowledge and influence to institute such negotiations with the universities and yet it is clearly invidious for them to be seen to be pushing themselves forward in this way. I would, however, commend the idea to the medical schools, especially through the postgraduate deans and the professors of undergraduate departments of general practice, as an ideal way to expand and recognise academic general practice. GUY HOUGHTON
Greenbank Surgery, Hall Green, Birmingham B28 8BG 1 Pereira Gray D. Research in general practice: law of inverse opportunity. BMJ 1991;302:1380-2. (8 June.)
Setfing priorities in the NHS SIR,-In his contribution to Mr J R Smith and colleagues' article on the ethics of infertility management, David Seedhouse states that "the law seems to have put the responsibility on clinicians to impose personal judgments on potential clients. This is an unacceptable burden from the point of view of . .. doctors (who are not trained in decision making)."'" In subsequent lines, however, it seems that he does expect doctors to make decisions to treat based on priorities in resource allocation. Undoubtedly, doctors are trained to make such decisions and have to make them often. They will always have to rank patients in order of priority even by allocating a limited amount of their time to any particular patient's problems. With infertility treatment the financial cost of any decision must predominate because the service is not primarily improving the health of the prospective parents. We cannot foresee all the implications of any
BMJ VOLUME 303
20 JULY 1991
medical decision. We see only immediate implications, in this case to the couple and child. What will be the long term social implications? The interactions of all our lives raise too many imponderables for decision making to be made purely by doctors. We all understand that costs must be contained in the NHS, but I do not think it is a doctor's function to make decisions of priority except in his or her particular field. If the NHS could be isolated from government control with built in funding based on inflation and demography I am sure managers and clinical professionals could decide how to spend money wisely. The government must, however, make clear to the population what the health service can and cannot provide. For example, perhaps everybody should pay at least a nominal fee for drug treatment and missed outpatient appointments. Perhaps the NHS drug list needs halving. Should the health service fund fertility treatment for any woman with more than one child? Should upper limits be put on civil liability for negligence in the NHS or our system of tort abolished? Should all operations be done (available) in the NHS? Only by such frankness will inequalities of care be understandable; everybody knows that the NHS can never be totally fair. Recent reforms are at best irrelevant and at worst damaging. They may curtail costs at the expense of care. They may well divide health professionals, and discerning patients will realise that budgetholding general practitioners are not necessarily motivated by altruism in their care and referral of blocks of patients. If a market is to work health professionals must be driven by greed and power. Hospitals will chase after money through patients, failing to assess quality of care adequately. For quality, choosing to be treated privately will be patients' only choice, a freedom lost to most. S TALBOT
The ultimate sanction would be to extract a fee, albeit a modest one, for each item of out of hours service, provided that a safety net was established for the genuinely poor and needy. It would then be necessary to take a close look at the present accident and emergency service, which seems wanting. I W R ANDERSON JAMES STEVENSON Accident and Emergency Department, Victoria Infirmary, Glasgow G42 9TY I Iliffe S, Haug U. Out of hours work in general practice. BMJ 1991;302:1584-6. (29 June.)
Duration of storage of patients' records SIR,-Dr Mary Wingfield's editorial on the daughters of women who took stilboestrol during pregnancy' highlights the epidemiological and legal stupidity of the Department of Health's current guidelines on how long patients' records should be stored. At this time of increasing numbers of increasingly chemically complex and potent drugs with far reaching effects minimum periods of storage suggested- 25 years for obstetric records, up to the 25th birthday for children's records, and eight years for other records that do not come under the Mental Health Act -are obviously inadequate. Unfortunately too, because of pressure on storage space and financial pressures on health authorities minima often become maxima. G W H JARDINE
Radiotherapy Department, Cumberland Infirmary, Carlisle, Cumbria CA2 7HY
Pitney, Langport, Somerset TA10 9AF 1 Smith JR, Kitchen VS, Munday PE, Paintin DB, Forster GE, Hooi YS, et al. Infertility management in HIV positive couples: a dilemma. BMJ 1991;302:1447-5. (15 June.)
Out of hours work in general practice SIR,-Drs Steve Iliffe and Ursula Haug rcently discussed out of hours work in general practice.' The logistics of reorganising out of hours care so that both patients and clinicians are satisfied are daunting. Equally, the proposal to base the service on the existing accident and emergency network is a nightmare and doomed to failure. In our city less than 0-5% of all people attending accident and emergency departments for the first time require any form of resuscitation for acute illness or injury. Altogether 35% of all patients newly referred could quite easily treat themselves or be treated by their family doctor. It is our impression that many inner city departments experience similar problems, and many are overrun. They seem more like the old dispensaries of pre-NHS city hospitals than a modern efficient accident and emergency service. "Neighbourhood casualty departments" should be a thing of the past. What is the solution? The specialty of general practice is the keystone of a well organised system of health care. It would be dismantled at the nation's peril. Large groups ofgeneral practitioners must amalgamate and organise their out of hours commitment to provide cross cover and adequate leisure time. Rural general practitioners face an unenviable prospect. If the public show no restraint and continue to place unrealistic demands on the service it will collapse. Health care has always been rationed.
I Wingfield M. The daughters of stilboestrol. 1414-5. (15 June.)
BMIJ 1991;302:
Anaesthetists' role in introducing audit into surgery SIR,-Dr Danny Ruta's review of the World in Action programme "On the Knife Edge" rightly highlighted for criticism its tabloid excesses.' Sadly, its overemphasis on specific personalities gave a distorted impression of events of which I have personal knowledge. The flavour of the programme can be divined from some relevant quotations. "Brendan Devlin, who probably knows more about NHS failings than anyone alive . . . persuaded his colleagues [in the early 1970s in Stockton on Tees] ... to start monitoring each other's work . .. with the result that in the first three years we were able to dispense with half the surgical beds.... Thinking that what could be achieved in one hospital might be achieved in hundreds, Devlin wondered whether surgeons elsewhere could be persuaded to cooperate in an inquiry into patients dying after surgery. The idea was put to the College of Surgeons and then to individual hospitals. The college wasn't too enthusiastic" but he "eventually persuaded enough of his colleagues for a limited investigation to go ahead. . . The results shocked the medical profession. Devlin later calculated that 1100 patients had died that year because of surgeons' error. It was now impossible for the medical profession to ignore Devlin's work" and the Royal College of Surgeons "took Devlin to its bosom." "He was given a suite of offices, staff, and money to support his fight for better standards." The implication of the programme was that Mr Devlin had pioneered single handedly the introduction of medical audit into surgery. I wish to put the record straight. The Association of Anaesthetists of Great Britain and Ireland conducted a study (funded by the Nuffield Provincial Hospitals Trust) of deaths associated with
189
anaesthesia and published the results in 1982.2 This study shed as much light on surgery as on anaesthesia, since the two activities are so closely interwoven in the care of surgical patients. Nevertheless, neither of two of the bodies that represent surgeons was keen to be involved when they were approached in the planning stage. When the results were analysed it was obvious that deficiencies in anaesthetic care were much less common than those in surgery. The Association of Anaesthetists therefore sought support for a larger study which could serve as a blueprint for a national audit, and we worked hard to ensure that this time it would be a joint anaesthetic-surgical effort. With indications of support from the Association of Surgeons, Professor Michael Rosen and I (as treasurer and president, respectively, of the Association of Anaesthetists) obtained the necessary financial support from the Nuffield Provincial Hospitals Trust and, later, the King Edward's Hospital Fund for London. A joint working party was set up under my chairmanship to plan and execute the study. Mr Devlin was one of four nominees of the Association of Surgeons and was chosen to be one of the two surgical coordinators; the problems of anaesthesia were handled by a single anaesthetic coordinator, Dr John Lunn. The clerical and administrative staff were housed initially by the King's Fund but then by the Association of Anaesthetists in Bedford Square. The study did indeed identify many problems in surgical services,' and both professional associations supported an approach to the Department of Health, which readily provided the funds for the continuing national confidential inquiry into perioperative deaths. Impartial readers may wonder how this story could have been put over without use of the word anaesthesia and with only a single passing reference to "committees of surgeons and anaesthetists"-yet such was the prominent role given to Mr Devlin in the programme that this feat was achieved. No doubt, as Dr Ruta divines, the producer wished to make an "attention grabbing" programme, but one can only marvel at a medium that can transmute a long planned sequence of events, involving the cooperation and good will of hundreds of participants in three major specialties (anaesthesia, surgery, and gvnaecology), the support of charities, and the active encouragement of agovernment department, into one man's crusade to improve the standard of British surgery. Unfortunately, as Dr Ruta's review shows, it is apparently quite easy. I only hope that the programme will not do too much damage to the warm and effective collaboration that has resulted from our initiative. M D VICKERS
Departmcnt of Anaesthetics, University of Wales College of Medicine, Cardiff CF4 4XN I Ruta D. Taking the bait. BAIJ 1991;302:1472-3. (15 June.) 2 I,unn JN, Mlushin WW. .llortalitv associated wih anaesthesia. Iondon: Nuffield Provincial Hospitals Trust, 1982. 3 Buck N, Devlin HB, Lunn JN. Tht report oss a confidential enquirv into perioperative deaths. London: Nuffield Provincial Hospitals Trust and King's Fund Publishing Office, 1987.
Financial risks to fundholding practices SIR,-If the projections made by Dr B J Crump and colleagues concerning the financial effect of random variation in the need for services on fundholding practices materialise such practices should be anxious.' For example, if a fundholding practice overspends its budget by 30% (which seems possible from random variation alone) should it be forced to make the necessary economies from its next year's budget, should it be bailed out by the regional health authority, or should it
190
be declared bankrupt? Conversely, if the same practice finds itself underspent by a similar amount, but solely because of random variation, should it be allowed to keep the shortfall for the benefit of its patients? How can anyone decide which savings are due to random variation and which are due to good financial management? Dr Crump and colleagues neatly illustrate that, in terms of reducing random variation, budget management is simpler when the population is larger. This would happen if the health service was truly national. MARK MWCARTNEY Pensilva Health Centre, Liskeard, Cornwall PL14 5RP 1 Crump BJ, Cubbon JE, Drummond MF, Hawkes RA, Marchment MD. Fundholding in general practice and financial risk. BMJ 1991;302:1582-4. (29 June.)
is true, however, that at any subsequent inquiry the pilot may appear as one of the statistics rather than in person. The idea that a colleague should be obliged to spend time with a physician in a busy medical unit as a result of an anonymous report without knowing the name of, or being able to question, his or her reporter is unworkable and could only fail in its object; indeed, CHIRP does not normally investigate unsigned reports as these mean that the events cannot be confirmed or clarified through the reporter. CHIRP is informational, confidential, and educational and does not set itself up as a judge, jury, and jailer. For Dr Parle to equate it to what he suggests should be set up for the medical profession indicates that he has missed both its point and its function. ROBERT M BRUCE-CHWATT
Richmond, Surrey TW 10 6DR
BMJ 1991;302:1547.
Pointing out other doctors' mistakes
I Parle JV. He that is without sin. (22 June.)
SIR,-I disagree with Dr J V Parle's suggestion, in his personal view, that a covert complaints board should be set up.' This would achieve little. The function of audit is to educate doctors and to discuss mistakes so that others can learn from them. Regrettably, every doctor has made an error of clinical judgment in his or her lifetime. It is easy to be wise about others' mistakes, and I believe that secret complaints serve no purpose; indeed, such a system is open to abuse. Far better to have regular clinical meetings about patients and treatment with an open discussion. We are, after all, on the same side in this game.
Future of long term care of dependent elderly people
KARIN ENGLEHART
Guildford, Surrey GUI 2DA I Parle JV. He that is without sin. (22 June.)
BAfj 1991;302:1547.
SIR,-In his personal view Dr J V Parle suggests a discreet medical reporting system,' cross referring, I believe, to the confidential human factors incident reporting programme (CHIRP) run by the Institute of Aviation Medicine, Royal Aircraft Establishment Farnborough, to which pilots and air traffic controllers may write. He is incorrect in stating that the report is sent to a superior not directly concerned, who can then act to investigate the incident and the pilot or air traffic controller concerned. The Institute of Aviation Medicine is an independent information gathering centre and acts to clarify the incident rather than the standards of the pilot by its investigation. It is looking for trends of errors and failures due to human factors, interpretation of instruments, standard operating procedures, and other factors that for various reasons people might be reluctant to disclose. Often the reporting is done by the person who made the error, to prevent others from emulating him or her. This system is also confidential so far as the person reporting the incident is concerned, and it is eventually anonymous as the name of the reporter, once the incident has been investigated, is removed from the file. Thus when a file is closed there are no names, only events, circumstances, and conclusions. The details, depending on the seriousness of the incident, may be published in the institute's magazine, Feedback, in the hope that this may jog a memory and perhaps prevent other people repeating the error. With CHIRP there is no question of educational retraining as Dr Parle suggests should happen with doctors, although an error by a pilot may kill many hundreds more people than an error by a doctor. It
SIR,-In contrast to the noisy debate about the reforms of the NHS almost total silence surrounds the future of long term care of highly dependent elderly people. This is a matter of importance well beyond the bounds of geriatrics as any shortage profoundly affects community care and most other acute hospital departments. In this part of the United Kingdom we are very disadvantaged in terms of the level of provision and have a "mixed economy," which makes life difficult for hospital staff and, I am sure, general practitioners. To explain to relatives that, yes, there are NHS beds for this purpose where, apart from loss of pension, care and accommodation are free, but, as there are nothing like enough and we suspect that the family may be able to afford it, could they please consider trying to find a private nursing home bed at £350 or more a week is to invite derision. There are several possible options for the future of long term care. The first option is privatisation, which, thanks to the estimated £1 2 billion spent each year on income support by the Department of Health, has taken over in some parts of the country, with the NHS virtually withdrawing from this type of care. Quality is variable; the future is insecure, and public money is spent on patients who are not necessarily those most appropriately placed there. Secondly, a partnership between private and public sectors is possible. The third option is provision of care by the NHS. This is not always above criticism, especiallv in terms of the legacy of the former workhouses originally intended to deter those on the outside rather than afford a pleasant environment to those within. An alternative to the old long stay wards are NHS nursing homes, but they are few and of unproved superiority except in terms of bricks and mortar. Moreover, provision of care by the NHS is far from cheap. Even in today's cost conscious era estimates vary from £350 to £500 a week, though it remains difficult to be certain of the cosI. The final option is a deliberately mixed economy, with the NHS trying to provide centres of excellence. This might mean people having to accept that, although the basic tenet of the NHS-free medical and nursing attention -should still apply, free board and lodging through the accident of infirmity (whether long term or short term) is illogical and unaffordable. Hotel charges seem to have disappeared from the political agenda but may be inevitable. A means test would provide a safety net: the income generated would help the NHS to survive, and having to compete might
BMJ VOLUME 303
20 JULY 1991
