patients not referred to hospital, who would be missed by hospital based research. Such information is essential for developing guidelines for referral and treatment.3 It is therefore of concern that general practitioners who initially seem willing to help often fail to do so. We agree with Tognoni and colleagues that reliance on financial incentives to persuade general practitioners to participate in research would be counterproductive. Are there any other incentives that could be invoked? VIV PETO ANGELA COULTER Health Services Research Unit, University Department of Public Health and Primary Care, Radcliffe Infirmary, Oxford OX2 6HE 1 Tognoni G, Alli C, Avanzini F, Bettelli G, Colombo F, Corso R, et al. Randomised clinical trials in general practice: lessons from a failure. BMJ7 1991;303:969-71. (19 October.) 2 Royal College of General Practitioners, Office of Population Censuses and Surveys, Department of Health and Social Security. 1981-1982 Morbidity statistics frotn general practice. London: HMSO, 1986. 3 Coulter A, Bradlow J, Agass M, Martin-Bates C, Tulloch A. Outcomes of referrals to gynaecology outpatients clinics for menstrual problems: an audit of general practice records. BrJ3 Obstet Gynaecol 1991;98:789-96.
have I been taught the practical principles of administering cytotoxic drugs. As a medical student I sat through numerous lectures about pharmacodynamics, pharmacokinetics, and prescribing but never about administering drugs. While we were house staff many of us were expected to give cytotoxic chemotherapy as part of everyday duties without any supervision from senior staff-we were expected to "get on with it," as it was a "junior" duty. As a former nurse I was examined in the administration of all drugs. The importance of checking drugs with two people and of checking the dose, the correct mixing solution, the mode of administration, side effects, and expiry dates was emphasised. This became second nature, and during my medical career I have been thankful for that training. From my own observation I suspect that few doctors check drugs for intravenous or intrathecal administration with another professional before administration. Perhaps this is because the emphasis in our medical education is on learning lists of drugs rather than on the practical aspects of giving drugs. This principle must become part of our standard medical training before more of us are found guilty of manslaughter. SALLY ANN HAYWARD
Manslaughter convictions for making mistakes SIR,-In her editorial on the two doctors recently convicted of manslaughter Clare Dyer writes: "Bringing the full weight of the criminal law on two fledgling doctors will do little to remedy a system which lets juniors loose on patients with too little training, too little support, and too little sleep."' She is correct in this but, perhaps constrained by her position as legal correspondent, does not go far enough. It is a disgrace that a recently qualified house officer and a senior house officer, both in general medical training, should carry out a specialised invasive procedure-intrathecal injection of cytotoxic drugs in this instance -without experienced supervision and instruction, if indeed they should have been allowed to perform such a procedure at all. Reasons and excuses will be advanced for this sad mistake, but neither of these two doctors is culpable of doing more than mistakenly carrying out a procedure, in good faith and in understandable ignorance. The truth is that in many district general hospitals and units the number of junior staff is inadequate. These staff are inadequately supervised, instructed, and educated; overworked; and expected to cover absences and deficiencies in resources in specialised units. They have to make decisions and judgments and carry out tests and procedures that are beyond their knowledge and competence. It is high time that senior members of this profession stood out against the impossible professional conditions and the absence of proper supervision and help available to sorely tried junior hospital doctors. It would not be surprising if their dedication evaporated. There are too few doctors and too much is expected of them. The profession must take its full share of responsibility for allowing such a state of affairs to have developed and should take steps to rectify it. J R HERON North Staffordshire Royal Infirmary, Stoke on Trent ST4 7LN
Northwick Park Hospital, Harrow, Middlesex HAl 3UJ I Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.)
SIR,-The problem highlighted by the recent conviction of two doctors for manslaughter is not one of equipment' 2; it is a problem of training and supervision, and its solutions must go to the heart of the way in which medical practice is organised in the NHS. Paul Crawshaw suggests modifications to hardware as a response to the problems of inadvertent intrathecal injections.3 This solution, apart from the major logistical problems it would pose, would do juniors and patients a major disservice in once again providing a sticking plaster to treat a major wound. The problems of this case are those of inappropriate delegation, inability to decline a delegated task, inadequate training in the detail of procedures, and poor awareness of risks. All are perpetuated by a system that promotes learning by experience alone, discourages refusal of duties by institutionalised job insecurity, and maintains that "it would not be appropriate for consultants to have routinely to undertake work which is easily within the competence of other doctors."4 The solutions are set out in a recent study by the Standing Committee on Postgraduate Medical Education; they lie in increased job security and a commitment to proper training by hospitals, which will not be forthcoming until the investment stops disappearing every six months.5 The recommendations of this report should be adopted by the NHS and the profession forthwith. Given the overwhelming importance of this issue for junior doctors, I am astonished to have seen no reaction from the leaders of the Junior Doctors' Committee. The timing, with the convictions coinciding with the publication of the standing committee's study5 and forthcoming changes in postgraduate medical education, would seem to offer hope that some good may arise from the ashes of these two unfortunate careers. I await some sign of leadership. GRAHAM HENDERSON London E14 3DE
1 Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.)
SIR,-Clare Dyer's editorial on two doctors found guilty of manslaughter raised some important issues.' At no time-at medical school or since-
1550
1 Dyer C. Doctors convicted of manslaughter. BMJ 1991;303: 1157. (9 November.) 2 Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.) 3 Crawshaw P. Doctors convicted of manslaughter. BMJ 1991; 303:1400. (30 November.) 4 NHS Management Executive: 3unior doctors-the new deal:
guidance from the Central Consultants and Specialists Committee. London: Department of Health, 1991. 5 Standing Committee on Postgraduate Medical Education. Improving the experience: good practice in senior house officer training. London: SCOPME, 1991.
Health of the nation: obesity SIR,-Jane Wardle may be correct in believing that the measures I suggested to control obesity would be ineffective and that it would be better to "promote healthy patterns of eating and activity throughout society and across all weights,"' but she does not explain how this idea is to be achieved. Her reasons for rejecting my plan are not compelling. It is true that most obese people know that they are obese, but many do not know the health hazards of obesity or the best way to avoid them.2 With surprising logic, she is against trying to prevent obesity in children "until the efficacy of treatment is improved," whereas many people might think that the case for prevention is all the stronger if treatment is ineffective. It is true that not all obese people aged 36 were obese children, which is why we must not rely purely on prevention in primary schools to abolish the problem of obesity. In the study she cites, however, weight status at age 11 years was as good a predictor of obesity at age 36 as was weight status at age 20.' I wrote in the article that Wardle criticises: "This strategy also needs the backing of those in primary health care, who could easily sabotage the scheme by hostility or even indifference."I Wardle's letter provides a good example of the hostility and destructive criticism that, for obscure reasons, seem to be caused by plans to do something about obesity in the United Kingdom. I agree with her that recommendations for reducing the prevalence of obesity must not be accepted uncritically, but I believe that the time has come to put a best guess into action as a pilot study and see what happens rather than forever putting off a decision to do anything. JOHN GARROW St Bartholomew's Hospital, London EC1A 7BE 1 Wardle J. Health of the nation.
BMJ7 1991;303:1333. (23
November.) 2 Health Education Authority. Weight loss and maintenance. London: Health Education Authority, 1991. 3 Braddon FE, Rodgers B, Wadsworth ME, Davies JM. Onset of obesity in a 36 year birth cohort study. BMJ 1986;293: 299-301. 4 Garrow JS. Importance of obesity. BMJ 1991;303:704-6. (21
September.)
Doctors and the Children Act SIR,-In her editorial Jane Tuke discusses what the Children Act 1989 will mean for doctors. I would point out that the "Gillick principle" may be embodied in the act, but many doctors seem still to be reluctant to apply it to medical treatment.' The act states that "due consideration" must be given to a child's views, but there is much doubt among academic lawyers over what weight will be attached to these, especially when they conflict with the views of interested adults; it would be possible to go through the motion of ascertaining the child's views only to ignore them on account of supposed immaturity or because they are outweighed by other factors.2 Tuke does not mention that this statutory scheme may afford less protection to the child, especially regarding medical treatment, than the common law wardship jurisdiction, which is no longer available to children in care. In particular, wardship afforded very rapid decisions in urgent cases. A judge was available, by telephone, 24 hours a day. Recently a decision was reached about a 12 year old pregnant girl 13 days after diagnosis, within
BMJ VOLUME 303
14 DECEMBER 1991
one day of the time limit for abortion. Her mother opposed an abortion, which both the girl and her carers requested and were granted. Whether this could be achieved now remains to be seen. The judiciary seems, however, to be inconsistent in its application of the Gillick principle and has tended to support the wishes of others rather than of the child, and even to override expert opinion, under the "best interests" guise, especially when mental disability is involved. Recently the Court of Appeal denied a 15 year old mentally ill girl the right to refuse further treatment despite psychiatric evidence supporting her ability to take her own decisions.4 Would the outcome in these two cases, both of which concerned wards in care, be different if they were presented now? Service providers will be obliged to work in partnership with parents; what weight would be attached to the wishes of the pregnant girl's mother? Would the court be obliged to take more notice of the psychiatric report on the mentally ill girl? Greater consideration needs to be given to the implications of the act regarding medical treatment, to alleviate the uncertainty, for the benefit of the children (many already at a disadvantage in society), their medical practitioners, and their carers. DIANA WHEELER
Radyr, Cardiff CF4 8BQ 1 Tuke J. Doctors and the Children Act. BMJ 1991;303:868-9. (12 October.) 2 Bainham A. The Children Act 1989-adolescence and children's rights. Family Law 1990 August:311. 3 Power to invite official solicitor. Family division. In re B (a minor). Times 1991 May 27:28. 4 Dyer C. Consent to treatment for disturbed young people. BMJ 1991;303:153. (20 July.)
AUTHOR'S REPLY,-The anomalies presented by Diana Wheeler, commenting on child care practice under previous legislation, highlight some of the factors that led to the Children Act 1989. In future, recourse to wardship proceedings should be a rare path taken only when the child's welfare cannot be ensured by the orders found in section 8 of the act. Applications for "section 8 orders," like other applications concerning child care, will be made to the local Family Proceedings Courts, which may be convened at short notice (within an hour if necessary) to deal with matters of immediate concern. This will ensure the principle of avoiding delays in decision making enshrined within the act. Both prohibited steps orders and specific issue orders contained within section 8 of the act are concerned with "single issues" and are modelled on the wardship jurisdiction. The purpose of the prohibited steps order, however, is to approve a specific restriction on the exercise of parental responsibility instead of the vague requirement in wardship that no "important step" be taken in respect of the child without the court's consent. ' In all child care cases the child's welfare shall be the court's paramount consideration,2 and to ensure that the "whole child" is considered a checklist of factors that a court must take into consideration when making a decison is given. The welfare checklist requires the court to have regard in particular to (1) the ascertainable wishes and feelings of the child concerned (considered in the light of his or her age and understanding); (2) his physical, emotional, and educational needs; (3) the likely effect on him of any change in his circumstances; (4) his age, sex, and backgound and any characteristics that the court considers to be relevant; (5) any harm that he has suffered or is at risk of suffering; (6) how capable each of his parents, and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs; and (7) the range of powers available to the court under this act in the proceed-
ings in question.'
BMJ VOLUME 303
14 DECEMBER 1991
It is significant that the "child's voice" is in first place on the checklist contained within part 1, section 1 of the act. The legal framework is now clear; how it is implemented depends largely on motivation. Wheeler may be reassured that we have the appropriate tools; it is now our duty to complete the task. JANE TUKE
Social Services Department, Suffolk County Council, Ipswich, Suffolk IP4 I LH 1 The Children Act 1989. Guidance and regulations. Vol 1. Court orders. London: HMSO, 1991:2.31. 2 The Children Act 1989. London: HMSO, 1991.
SIR,-I agree with Jane Tuke that the Children Act is a most forward looking piece of social legislation.' I very much doubt, however, that its wide provisions will be implemented in view of the lack of resources for that purpose. Although the Minister for Health states that more money has been allocated to local authorities, there is a shortage of trained social workers, certainly in London, and they are having difficulties in coping with their present statutory obligations. For example, at the last count 800 children on at risk registers in London had not been allocated a social worker. Tuke's editorial rightly points out that the act will result in a large increase in work for general practitioners through the ascertainment of deprived children and the enhanced responsibilities for boarding schools, day nurseries, and so on. I have not noticed any arrangements being made for training or financing general practitioners for the extra duties that they will be called on to
perform. ARNOLD ELLIOTT
During the trial the diet was intensified to be more rigorous than the step 1 diet. Despite all this the net fall in serum cholesterol concentration was only 2%. What more could be done to "make people eat what we want them to"?6 Such resources are not available to ordinary doctors, at least in the United Kingdom. Marckmann and Sandstrom6 cite a "strictly controlled long term trial" to support the efficacy of diet.8 This was in fact an uncontrolled trial lasting three months, in which meals were supplied and supervised by a nutrition research centre. This has no relevance to the management of hyperlipidaemia in ordinary practice. General practitioners continue to receive misleading advice on the efficacy of diet. In an otherwise balanced bulletin on treating hyperlipidaemia two trials are cited.9 One is inevitably the Oslo study, where the 13% reduction in cholesterol concentration featured prominently.'0 There is no mention that the diet was more rigorous than any now recommended or that the subjects were very highly selected.3 The other study cited is the multiple risk factor intervention trial.7 Although the results were described as "largely disappointing," there is no mention that the net reduction in cholesterol concentration was only 2% despite the remarkably intensive intervention described above and despite tightening of the diet during the trial. These omissions were doubtless unintentional but nevertheless conceal the truth from readers of the bulletin. No further controlled trials germane to current recommendations have been drawn to our attention. The estimated 2% reduction in cholesterol concentration with the step 1 diet, derived from well designed studies in over 10000 high risk people in eight countries, remains unchallenged. We invite some response from those who have published guidelines implying a 10-25% reduction in concentration by diet. Do they have the evidence from these controlled trials under consideration?
London N2 ONH
L E RAMSAY W W YEO P R JACKSON
1 Tuke J. Doctors and the Children Act. BMJ 1991;303:868-9.
(12 October.)
University Department of Medicine and Pharmacology, Section of Pharmacology and Therapeutics, Royal Hallamshire Hospital, Sheffield S 10 2JF
Dietary reduction of serum cholesterol concentration SIR, - Several letters have been published commenting on our paper on dietary reduction of serum cholesterol concentration.' In reply to Petr Skrabanek,2 we are aware that reducing the cholesterol concentration has not lowered total mortality, and this important question needs to be resolved. Nevertheless, available evidence does indicate that reducing the cholesterol concentration prevents coronary events. In reply to David Wainwright Evans,3 his trial was, as he says, uncontrolled and did not examine the diet currently recommended.4 His inadvertent restriction of monounsaturated fatty acids may not, however, have been such a bad idea.5 Peter Marckmann and Brittmarie Sandstrom misinterpret our views slightly.6 We do not advocate "giving up" dietary strategies for preventing coronary heart disease; we simply point out that the strategy now recommended has no worthwhile effect on serum cholesterol concentration. We will welcome any diet that proves effective and feasible in sound long term controlled trials. We did deal with the question of adherence to the prescribed diet. If a diet is not effective it matters little from a practical point of view whether the cause is inadequate diet or inadequate adherence. In the multiple risk factor intervention trial men and their spouses first attended 10 small group sessions at weekly intervals, then had individual counselling planned and executed by a team that included a behavioural scientist, nutritionists, nurses, physicians, and general health counsellors.7
1 Ramsay LE, Yeo WW, Jackson PR. Dietary reduction of serum cholesterol concentration: time to think again? BMJ 1991;303:953-7. (19 October.) 2 Skrabanek P. Dietary reduction of serum cholesterol concentration. BM3r 1991;303:1332. (23 November.) 3 Evans DW. Dietary reduction of serum cholesterol concentration. BMJ 1991;303:1332. (23 November.) 4 Evans DW, Turner SM, Ghosh P. Feasibility of long-term cholesterol reduction by diet. Lancet 1972;i: 172-4. 5 Grundy SM. Trans monounsaturated fatty acids and serum cholesterol levels. N EnglJ3Med 1990;323:480-1. 6 Marckmann P, Sandstrom B. Dietary reduction of serum cholesterol concentration. BMJ 1991;303:1331-2. (23
November.) 7 Multiple Risk Factor Intervention Trial Research Group. Multiple risk factor intervention trial. Risk factor changes and mortality results. JAMA 1982;248:1465-77. 8 Hallfrisch J, West S, Fisher C, Reiser S, Mertz W, Prather ES, et al. Modification of the United States' diet to effect changes in blood lipids and lipoprotein distribution. Atherosclerosis 1985;57: 179-88. 9 Medicines Resource Centre. Hyperlipidaemia (part 1). MeReC Bulletin 1991;2:33-5. 10 Hjermann I, Velve Byre K, Holme I, Leren P. Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo study group of a randomized trial in healthy men. Lancet 1981;ii: 1303-10.
Repeatable prescriptions SIR, -The current system of repeat prescriptions in general practice is out of date and wastes time and money for both patients and doctors. The traditional routine of monthly consultations for monthly prescriptions has largely been replaced by "repeats" printed by computer and issued every one, three, or six months. But the regular chore of checking, signing, and handing out prescriptions
1551
have I been taught the practical principles of administering cytotoxic drugs. As a medical student I sat through numerous lectures about pharmacodynamics, pharmacokinetics, and prescribing but never about administering drugs. While we were house staff many of us were expected to give cytotoxic chemotherapy as part of everyday duties without any supervision from senior staff-we were expected to "get on with it," as it was a "junior" duty. As a former nurse I was examined in the administration of all drugs. The importance of checking drugs with two people and of checking the dose, the correct mixing solution, the mode of administration, side effects, and expiry dates was emphasised. This became second nature, and during my medical career I have been thankful for that training. From my own observation I suspect that few doctors check drugs for intravenous or intrathecal administration with another professional before administration. Perhaps this is because the emphasis in our medical education is on learning lists of drugs rather than on the practical aspects of giving drugs. This principle must become part of our standard medical training before more of us are found guilty of manslaughter. SALLY ANN HAYWARD
Manslaughter convictions for making mistakes SIR,-In her editorial on the two doctors recently convicted of manslaughter Clare Dyer writes: "Bringing the full weight of the criminal law on two fledgling doctors will do little to remedy a system which lets juniors loose on patients with too little training, too little support, and too little sleep."' She is correct in this but, perhaps constrained by her position as legal correspondent, does not go far enough. It is a disgrace that a recently qualified house officer and a senior house officer, both in general medical training, should carry out a specialised invasive procedure-intrathecal injection of cytotoxic drugs in this instance -without experienced supervision and instruction, if indeed they should have been allowed to perform such a procedure at all. Reasons and excuses will be advanced for this sad mistake, but neither of these two doctors is culpable of doing more than mistakenly carrying out a procedure, in good faith and in understandable ignorance. The truth is that in many district general hospitals and units the number of junior staff is inadequate. These staff are inadequately supervised, instructed, and educated; overworked; and expected to cover absences and deficiencies in resources in specialised units. They have to make decisions and judgments and carry out tests and procedures that are beyond their knowledge and competence. It is high time that senior members of this profession stood out against the impossible professional conditions and the absence of proper supervision and help available to sorely tried junior hospital doctors. It would not be surprising if their dedication evaporated. There are too few doctors and too much is expected of them. The profession must take its full share of responsibility for allowing such a state of affairs to have developed and should take steps to rectify it. J R HERON North Staffordshire Royal Infirmary, Stoke on Trent ST4 7LN
Northwick Park Hospital, Harrow, Middlesex HAl 3UJ I Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.)
SIR,-The problem highlighted by the recent conviction of two doctors for manslaughter is not one of equipment' 2; it is a problem of training and supervision, and its solutions must go to the heart of the way in which medical practice is organised in the NHS. Paul Crawshaw suggests modifications to hardware as a response to the problems of inadvertent intrathecal injections.3 This solution, apart from the major logistical problems it would pose, would do juniors and patients a major disservice in once again providing a sticking plaster to treat a major wound. The problems of this case are those of inappropriate delegation, inability to decline a delegated task, inadequate training in the detail of procedures, and poor awareness of risks. All are perpetuated by a system that promotes learning by experience alone, discourages refusal of duties by institutionalised job insecurity, and maintains that "it would not be appropriate for consultants to have routinely to undertake work which is easily within the competence of other doctors."4 The solutions are set out in a recent study by the Standing Committee on Postgraduate Medical Education; they lie in increased job security and a commitment to proper training by hospitals, which will not be forthcoming until the investment stops disappearing every six months.5 The recommendations of this report should be adopted by the NHS and the profession forthwith. Given the overwhelming importance of this issue for junior doctors, I am astonished to have seen no reaction from the leaders of the Junior Doctors' Committee. The timing, with the convictions coinciding with the publication of the standing committee's study5 and forthcoming changes in postgraduate medical education, would seem to offer hope that some good may arise from the ashes of these two unfortunate careers. I await some sign of leadership. GRAHAM HENDERSON London E14 3DE
1 Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.)
SIR,-Clare Dyer's editorial on two doctors found guilty of manslaughter raised some important issues.' At no time-at medical school or since-
1550
1 Dyer C. Doctors convicted of manslaughter. BMJ 1991;303: 1157. (9 November.) 2 Dyer C. Manslaughter convictions for making mistakes. BMJ 1991;303:1218. (16 November.) 3 Crawshaw P. Doctors convicted of manslaughter. BMJ 1991; 303:1400. (30 November.) 4 NHS Management Executive: 3unior doctors-the new deal:
guidance from the Central Consultants and Specialists Committee. London: Department of Health, 1991. 5 Standing Committee on Postgraduate Medical Education. Improving the experience: good practice in senior house officer training. London: SCOPME, 1991.
Health of the nation: obesity SIR,-Jane Wardle may be correct in believing that the measures I suggested to control obesity would be ineffective and that it would be better to "promote healthy patterns of eating and activity throughout society and across all weights,"' but she does not explain how this idea is to be achieved. Her reasons for rejecting my plan are not compelling. It is true that most obese people know that they are obese, but many do not know the health hazards of obesity or the best way to avoid them.2 With surprising logic, she is against trying to prevent obesity in children "until the efficacy of treatment is improved," whereas many people might think that the case for prevention is all the stronger if treatment is ineffective. It is true that not all obese people aged 36 were obese children, which is why we must not rely purely on prevention in primary schools to abolish the problem of obesity. In the study she cites, however, weight status at age 11 years was as good a predictor of obesity at age 36 as was weight status at age 20.' I wrote in the article that Wardle criticises: "This strategy also needs the backing of those in primary health care, who could easily sabotage the scheme by hostility or even indifference."I Wardle's letter provides a good example of the hostility and destructive criticism that, for obscure reasons, seem to be caused by plans to do something about obesity in the United Kingdom. I agree with her that recommendations for reducing the prevalence of obesity must not be accepted uncritically, but I believe that the time has come to put a best guess into action as a pilot study and see what happens rather than forever putting off a decision to do anything. JOHN GARROW St Bartholomew's Hospital, London EC1A 7BE 1 Wardle J. Health of the nation.
BMJ7 1991;303:1333. (23
November.) 2 Health Education Authority. Weight loss and maintenance. London: Health Education Authority, 1991. 3 Braddon FE, Rodgers B, Wadsworth ME, Davies JM. Onset of obesity in a 36 year birth cohort study. BMJ 1986;293: 299-301. 4 Garrow JS. Importance of obesity. BMJ 1991;303:704-6. (21
September.)
Doctors and the Children Act SIR,-In her editorial Jane Tuke discusses what the Children Act 1989 will mean for doctors. I would point out that the "Gillick principle" may be embodied in the act, but many doctors seem still to be reluctant to apply it to medical treatment.' The act states that "due consideration" must be given to a child's views, but there is much doubt among academic lawyers over what weight will be attached to these, especially when they conflict with the views of interested adults; it would be possible to go through the motion of ascertaining the child's views only to ignore them on account of supposed immaturity or because they are outweighed by other factors.2 Tuke does not mention that this statutory scheme may afford less protection to the child, especially regarding medical treatment, than the common law wardship jurisdiction, which is no longer available to children in care. In particular, wardship afforded very rapid decisions in urgent cases. A judge was available, by telephone, 24 hours a day. Recently a decision was reached about a 12 year old pregnant girl 13 days after diagnosis, within
BMJ VOLUME 303
14 DECEMBER 1991
one day of the time limit for abortion. Her mother opposed an abortion, which both the girl and her carers requested and were granted. Whether this could be achieved now remains to be seen. The judiciary seems, however, to be inconsistent in its application of the Gillick principle and has tended to support the wishes of others rather than of the child, and even to override expert opinion, under the "best interests" guise, especially when mental disability is involved. Recently the Court of Appeal denied a 15 year old mentally ill girl the right to refuse further treatment despite psychiatric evidence supporting her ability to take her own decisions.4 Would the outcome in these two cases, both of which concerned wards in care, be different if they were presented now? Service providers will be obliged to work in partnership with parents; what weight would be attached to the wishes of the pregnant girl's mother? Would the court be obliged to take more notice of the psychiatric report on the mentally ill girl? Greater consideration needs to be given to the implications of the act regarding medical treatment, to alleviate the uncertainty, for the benefit of the children (many already at a disadvantage in society), their medical practitioners, and their carers. DIANA WHEELER
Radyr, Cardiff CF4 8BQ 1 Tuke J. Doctors and the Children Act. BMJ 1991;303:868-9. (12 October.) 2 Bainham A. The Children Act 1989-adolescence and children's rights. Family Law 1990 August:311. 3 Power to invite official solicitor. Family division. In re B (a minor). Times 1991 May 27:28. 4 Dyer C. Consent to treatment for disturbed young people. BMJ 1991;303:153. (20 July.)
AUTHOR'S REPLY,-The anomalies presented by Diana Wheeler, commenting on child care practice under previous legislation, highlight some of the factors that led to the Children Act 1989. In future, recourse to wardship proceedings should be a rare path taken only when the child's welfare cannot be ensured by the orders found in section 8 of the act. Applications for "section 8 orders," like other applications concerning child care, will be made to the local Family Proceedings Courts, which may be convened at short notice (within an hour if necessary) to deal with matters of immediate concern. This will ensure the principle of avoiding delays in decision making enshrined within the act. Both prohibited steps orders and specific issue orders contained within section 8 of the act are concerned with "single issues" and are modelled on the wardship jurisdiction. The purpose of the prohibited steps order, however, is to approve a specific restriction on the exercise of parental responsibility instead of the vague requirement in wardship that no "important step" be taken in respect of the child without the court's consent. ' In all child care cases the child's welfare shall be the court's paramount consideration,2 and to ensure that the "whole child" is considered a checklist of factors that a court must take into consideration when making a decison is given. The welfare checklist requires the court to have regard in particular to (1) the ascertainable wishes and feelings of the child concerned (considered in the light of his or her age and understanding); (2) his physical, emotional, and educational needs; (3) the likely effect on him of any change in his circumstances; (4) his age, sex, and backgound and any characteristics that the court considers to be relevant; (5) any harm that he has suffered or is at risk of suffering; (6) how capable each of his parents, and any other person in relation to whom the court considers the question to be relevant, is of meeting his needs; and (7) the range of powers available to the court under this act in the proceed-
ings in question.'
BMJ VOLUME 303
14 DECEMBER 1991
It is significant that the "child's voice" is in first place on the checklist contained within part 1, section 1 of the act. The legal framework is now clear; how it is implemented depends largely on motivation. Wheeler may be reassured that we have the appropriate tools; it is now our duty to complete the task. JANE TUKE
Social Services Department, Suffolk County Council, Ipswich, Suffolk IP4 I LH 1 The Children Act 1989. Guidance and regulations. Vol 1. Court orders. London: HMSO, 1991:2.31. 2 The Children Act 1989. London: HMSO, 1991.
SIR,-I agree with Jane Tuke that the Children Act is a most forward looking piece of social legislation.' I very much doubt, however, that its wide provisions will be implemented in view of the lack of resources for that purpose. Although the Minister for Health states that more money has been allocated to local authorities, there is a shortage of trained social workers, certainly in London, and they are having difficulties in coping with their present statutory obligations. For example, at the last count 800 children on at risk registers in London had not been allocated a social worker. Tuke's editorial rightly points out that the act will result in a large increase in work for general practitioners through the ascertainment of deprived children and the enhanced responsibilities for boarding schools, day nurseries, and so on. I have not noticed any arrangements being made for training or financing general practitioners for the extra duties that they will be called on to
perform. ARNOLD ELLIOTT
During the trial the diet was intensified to be more rigorous than the step 1 diet. Despite all this the net fall in serum cholesterol concentration was only 2%. What more could be done to "make people eat what we want them to"?6 Such resources are not available to ordinary doctors, at least in the United Kingdom. Marckmann and Sandstrom6 cite a "strictly controlled long term trial" to support the efficacy of diet.8 This was in fact an uncontrolled trial lasting three months, in which meals were supplied and supervised by a nutrition research centre. This has no relevance to the management of hyperlipidaemia in ordinary practice. General practitioners continue to receive misleading advice on the efficacy of diet. In an otherwise balanced bulletin on treating hyperlipidaemia two trials are cited.9 One is inevitably the Oslo study, where the 13% reduction in cholesterol concentration featured prominently.'0 There is no mention that the diet was more rigorous than any now recommended or that the subjects were very highly selected.3 The other study cited is the multiple risk factor intervention trial.7 Although the results were described as "largely disappointing," there is no mention that the net reduction in cholesterol concentration was only 2% despite the remarkably intensive intervention described above and despite tightening of the diet during the trial. These omissions were doubtless unintentional but nevertheless conceal the truth from readers of the bulletin. No further controlled trials germane to current recommendations have been drawn to our attention. The estimated 2% reduction in cholesterol concentration with the step 1 diet, derived from well designed studies in over 10000 high risk people in eight countries, remains unchallenged. We invite some response from those who have published guidelines implying a 10-25% reduction in concentration by diet. Do they have the evidence from these controlled trials under consideration?
London N2 ONH
L E RAMSAY W W YEO P R JACKSON
1 Tuke J. Doctors and the Children Act. BMJ 1991;303:868-9.
(12 October.)
University Department of Medicine and Pharmacology, Section of Pharmacology and Therapeutics, Royal Hallamshire Hospital, Sheffield S 10 2JF
Dietary reduction of serum cholesterol concentration SIR, - Several letters have been published commenting on our paper on dietary reduction of serum cholesterol concentration.' In reply to Petr Skrabanek,2 we are aware that reducing the cholesterol concentration has not lowered total mortality, and this important question needs to be resolved. Nevertheless, available evidence does indicate that reducing the cholesterol concentration prevents coronary events. In reply to David Wainwright Evans,3 his trial was, as he says, uncontrolled and did not examine the diet currently recommended.4 His inadvertent restriction of monounsaturated fatty acids may not, however, have been such a bad idea.5 Peter Marckmann and Brittmarie Sandstrom misinterpret our views slightly.6 We do not advocate "giving up" dietary strategies for preventing coronary heart disease; we simply point out that the strategy now recommended has no worthwhile effect on serum cholesterol concentration. We will welcome any diet that proves effective and feasible in sound long term controlled trials. We did deal with the question of adherence to the prescribed diet. If a diet is not effective it matters little from a practical point of view whether the cause is inadequate diet or inadequate adherence. In the multiple risk factor intervention trial men and their spouses first attended 10 small group sessions at weekly intervals, then had individual counselling planned and executed by a team that included a behavioural scientist, nutritionists, nurses, physicians, and general health counsellors.7
1 Ramsay LE, Yeo WW, Jackson PR. Dietary reduction of serum cholesterol concentration: time to think again? BMJ 1991;303:953-7. (19 October.) 2 Skrabanek P. Dietary reduction of serum cholesterol concentration. BM3r 1991;303:1332. (23 November.) 3 Evans DW. Dietary reduction of serum cholesterol concentration. BMJ 1991;303:1332. (23 November.) 4 Evans DW, Turner SM, Ghosh P. Feasibility of long-term cholesterol reduction by diet. Lancet 1972;i: 172-4. 5 Grundy SM. Trans monounsaturated fatty acids and serum cholesterol levels. N EnglJ3Med 1990;323:480-1. 6 Marckmann P, Sandstrom B. Dietary reduction of serum cholesterol concentration. BMJ 1991;303:1331-2. (23
November.) 7 Multiple Risk Factor Intervention Trial Research Group. Multiple risk factor intervention trial. Risk factor changes and mortality results. JAMA 1982;248:1465-77. 8 Hallfrisch J, West S, Fisher C, Reiser S, Mertz W, Prather ES, et al. Modification of the United States' diet to effect changes in blood lipids and lipoprotein distribution. Atherosclerosis 1985;57: 179-88. 9 Medicines Resource Centre. Hyperlipidaemia (part 1). MeReC Bulletin 1991;2:33-5. 10 Hjermann I, Velve Byre K, Holme I, Leren P. Effect of diet and smoking intervention on the incidence of coronary heart disease. Report from the Oslo study group of a randomized trial in healthy men. Lancet 1981;ii: 1303-10.
Repeatable prescriptions SIR, -The current system of repeat prescriptions in general practice is out of date and wastes time and money for both patients and doctors. The traditional routine of monthly consultations for monthly prescriptions has largely been replaced by "repeats" printed by computer and issued every one, three, or six months. But the regular chore of checking, signing, and handing out prescriptions
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