NEWS Towards a healthier England Last week the government set out its strategy for improving the health of- England in a white paper that nominates five key areas for action: coronary heart disease and stroke, cancers, mental illness, HIV/AIDS and sexual health, and accidents (p 129). For each key area the white paper sets out the overall objective and targets (box). In addition, 10 risk factors for disease-covering smoking, diet and nutrition, blood pressure, and injecting drug misuse-have been targeted for action. In her statement to the House ofCommons Virginia Bottomley, the secretary of state for health, said that targets "give us something real at which to aim, they provide a common focus for action, and they allow us to measure progress." Sixteen possible key areas had been discussed in the green paper on the health of the nation published a year ago, and many more had been suggested in the 2100 responses to that document. The government's task had been to choose key areas "where there is the most serious avoidable loss of life or handicap, and where the work needs to be done and can be done." Targets had to be tough but realistic. It was "folly to set a target so far out of reach that we will never get there, or one which is simply the extrapolation of existing trends," said Mrs Bottomley. Overseeing the new strategy will be a ministerial cabinet committee, chaired by the
Coronary heart disease and stroke To reduce death rates from both coronary heart disease and stroke in people under 65 by at least 40% by 2000 To reduce the death rate from coronary heart disease in people aged 65-74 by at least 30% by 2000 To reduce the death rate from stroke in people aged 65-74 by at least 40% by 2000
Cancers To reduce the death rate from breast cancer in the population invited for screening by at least 25% by 2000 To reduce the incidence of invasive cervical cancer by at least 20% by 2000 (baseline 1986) To reduce the death rate from lung cancer under the age of 75 by at least 30% in men and at least 15% in women by 2010 To halt the year on year increase in the incidence of skin cancer by 2005
*Baseline 1990 unless otherwise stated
BMJ
VOLUME
305
18 JULY 1992
Shaping up for the mtllen1um leader of the house, Tony Newton, and covering 11 government departments. In future government policies will be appraised for their effects on health in the same way that they are now appraised for their effects on the environment.
Mental illness To improve significantly the health and social functioning of mentally ill people To reduce the overall suicide rate by at least 15% by 2000 To reduce the suicide rate of severely mentally ill people by at least 33% by 2000
HIVIAIDS and sexual health To reduce the incidence of gonorrhoea by at least 20% by 1995 as an indicator of HIV/AIDS trends To reduce by at least 50% the rate of conceptions among the under 16s by 2000 (baseline 1989)
Accidents To reduce the death rate from accidents among children under 15 by at least 33% by 2005 To reduce the death rate from accidents among young people aged 15-24 by at least 25% by 2005 To reduce the death rate from accidents among people aged 65 and over by at least 33% by 2005
Nationally, the key areas and targets will be at the core of the overall objectives of the NHS, and its performance will increasingly be measured by its success in improving people's health. Health authorities, hospital and community units, primary and community health care services, local authorities, and voluntary agencies are all expected to have a role. The media will have "an important role to play in providing individuals with the information necessary to make decisions which affect their own health and that of their families." Opportunities to work towards the achievement of the targets will be pursued in settings such as schools, hospitals, and workplaces. The "healthy cities" movement will be boosted. Monitoring the success of the new strategy is regarded as crucial, and periodic progress reports will be published. To this end the government's health and nutrition survey is being expanded to cover more than 150000 people and the prevalence of mental illness in the community will be surveyed. The Central Health Monitoring Unit and Central Health Outcomes Unit have recently been set up by the Department- of Health to coordinate the collection of data. Although the strategy was widely welcomed, two omissions were singled out for particular criticism. Members of the opposition, the BMA, and the King's Fund Institute rounded on the government for omitting poverty as a key area. Responding to the 135
Headlines Dental pay: Sir Kenneth Bloomfield, formerly head of the civil service in Northern Ireland, is to carry out a fundamental review of the dental remuneration system. He will identify options for change and report by the end of the year.
Decrease in abortions: Figures from the Office of Population Censuses and Surveys show that the number of legal abortions in England and Wales in the last three months of 1991 was 42 142, a decrease of 2764 compared with the same period in 1990; 18851 of the abortions were carried out in the NHS. Non-residents accounted for 2804 of the abortions in the last three months of 1991; the figure in 1990 was 2980.
Children ignorant about AIDS: According to a survey by Barnado's, children learn about AIDS mostly from the television. Only one in 10 children first hear about the disease from a parent or teacher. One fifth said that they would avoid contact with a schoolmate with the disease. London hospitals to shed jobs: Failure to win contracts with Tower Hamlets Health Authority could mean hundreds of job losses at the Royal London Trust Hospital. The Middlesex and University College group of hospitals has also announced the loss of 200 jobs and faces a £20m deficit this year.
Fall in traffic accidents: There was a 12% fall from 1330 to 1175 in deaths from motor vehicle accidents in England and Wales in the last quarter of 1991 compared with that of 1990, according to the Office of Population Censuses and Surveys. There was a marked fall for men aged 15 to 24 of 21% from 342 to 270. New RHA chairmen: The secretary of state for health has appointed Professor Marian Hicks, who until 1986 was professor of experimental pathology at Middlesex Hospital Medical School, chairman of South West Thames RHA from November. Ms Rennie Fritchie, chairman of Gloucestershire Health Authority, will chair South Western RHA from next month.
High security hospitals should close: The mental health charity MIND, in a report published this week, calls for the relocation of patients detained in Broadmoor, Ashton, and Rampton hospitals to smaller rehabilitation units. According to the report, high security hospitals are isolated from current humane mental health practices.
136
publication of The Health of the Nation, Robin Cook, the shadow health minister, asked how a white paper on health promotion could be comprehensive when it did not once mention poverty. "Does the secretary of state recognise that by doubling the number of children in poverty the government has increased the number of children brought up on a poor diet?" he asked. "A white paper which does not propose a single measure to combat poverty, homelessness, or unemployment is not a white paper which offers better health to all." Asked by Mr Max Madden, the member for Bradford West, whether she accepted a direct link between poverty and poor health ("Yes or no will do"), Mrs Bottomley replied that she believed that there was an association between several social factors and health. Maximising the health of the nation "involves taking into account a great number of factors," she said. The other omission from the white paper which attracted widespread condemnation was a ban on cigarette advertising, which Robin Cook said would be widely attributed to Imperial Tobacco's supply of 2000 poster sites to the Conservative party during the last election campaign. Mrs Bottomley repeated the government's "absolute comnitment to meeting the targets to reduce smoking"through price, education, stopping the £1 billion subsidy to tobacco growers (from the European Community), preventing the example of tobacco smoking, and continuing to review the role of advertising. -TONY DELAMOTHE, BMj
The Health of The Nation: A Strategy for Health in England (Cm 1986) is available from HMSO, price £13.60.
Don't mention AIDS in the American election campaign "In the United States the presidential campaign is stifling national debate on AIDS as the candidates obviously believe that talking about AIDS will not win votes," said Dr Jonathan Mann, chairman of next month's eighth international AIDS conference, speaking at the 18th world congress of dermatology in New York. The AIDS conference will be held in Amsterdam because of continuing restrictions on entry to the US by people infected with HIV. "Only [probable Democratic candidate] Bill Clinton has spoken about AIDS. He made an impressive statement about -the importance of community organisations in fighting the epidemic. I don't know if Ross Perot has spoken about it. Both Reagan and Bush have had trouble saying the word
AIDS. Reports of the National Commission on AIDS say the single most important thing lacking in this country is leadership. The only thing that's peaked in this epidemic is the response," Dr Mann said. "There is no community or country already affected by the epidemic in which HIV transmission has
Politicians keep quiet despite demonstrations
ceased . . . HIV is spreading . . . to communities and countries which were little affected ... just a few years ago." Dr Mann is the former head of the World Health Organisation's global programme on AIDS. The Harvard AIDS group of international researchers predicts that 20 million people will be infected with HIV and six million will have AIDS by 1995. By 2000 there will be between 38 million and 110 million adults infected with HIV. "Our predictions differ from those of the World Health Organisation, which predicts numbers of infected persons at the lower range-40 million people infected by the year 2000, the same as our lowest, or 'best case' projection." Asked about the discrepancy, Dr Mann replied, "You have to remember that WHO is releasing numbers that have been cleared by member governments." Dr Michael Merson, who now heads WHO's AIDS programme, earlier told the New York Times that he stood by WHO's estimates. Dr Peter Drotman, an epidemiologist at the US Centers for Disease Control (CDC), estimated that there were one million people infected with HIV in the US and about 60% had low CD4 counts, which made them candidates for treatment with zidovudine. More than half of those requiring care, however, do not have conditions that fit with current CDC definitions of AIDS. A revised definition is expected soon. "Heterosexual transmission is increasing at a very rapid rate," he said. AIDS is second only to accidents as the leading cause of death among men aged 25-44 and is the sixth commonest cause of death among women in the same age group in the US. About 4000 new cases of AIDS are diagnosed in the United States each month. Among intravenous drug users cases in women and heterosexual men are climbing rapidly, with about 1000 new cases being reported each month. Dr Mann condemned the "Just Say No" campaign aimed at drug takers in the US as "a sham" for not providing alternatives to drug use and easily available treatment. Dr June E Osborn, chairperson of the US National Commission on AIDS, said
BMJ
VOLUME
305
18 JULY 1992
recently, "While the potential for dramatic reduction in risk behaviour and virus spread has been demonstrated in a few specific contexts, there remain widespread public misperceptions about the epidemic and about specific risks." Last week the debate on AIDS gathered momentum when the US National Commission on AIDS accused President Bush and the health and human services secretary, Dr Louis M Sullivan, of failing to meet their responsibilities in the AIDS epidemic. The government's response was "woefully inadequate," said Dr Osborn, and Dr David E Rogers, vice chairman. The commission's accusation came after a meeting with Dr Sullivan and other officials to discuss the administration's response to the commission's report, America Living with Aids, published last year. The commission recommended increased funding, more support from the government, and removing restrictions on people infected with HIV from entering the US. -JANICE HOPKINS TANNE, contributing editor, New York
ever, do not find the clawback reasonable, especially as the review body-before the general election-recommended an 8-5% rise in their net income. The head of practitioner services at the British Dental Association (BDA), Michael Watson, responded to the 7% cut by saying that dentists no longer had confidence in either the system or the department. "Good performance should be rewarded, not penalised," he said. Under the NHS adults not exempt from charges pay 75% of the cost of treatment up to a ceiling of £225. That is why the recent vote by dentists, by a majority of four to one, not to accept new patients paying NHS charges is important. Although the BDA can only advise its members on the outcome of the ballot and not instruct them, the size of the majority indicates that many practitioners will attempt to force the government to reconsider.
The drift towards further private practice seems inevitable. Derek Watson, the chairman of the General Dental Practitioners
Association, summed up the situation for his members: "We are looking at a smaller health service with pregnant women and children still being treated. The remaining three quarters of patients will be asked to pay the whole amount for their treatment rather than the 75% that they pay now." From the government's point of view one option to maintain NHS dental care is through the family health services authorities, which are responsible for ensuring that it is available. The suggestion by Mrs Bottomley that salaried dentists would be employed to carry out this function seems an unlikely solution. There are only about 100 salaried dentists in the country, and the highest paid is reportedly earning £8000 a year less than the recommended target net income. While requesting a meeting with the prime minister in a final attempt to reverse the cut, the BDA headed its press release announcing the result of the ballot of its members "Bleak future for NHS dentistry"-a sentiment with which 80% of the dental profession seems to agree. -STEPHEN HANCOCKS, FDI Dental World
Dentists vote out NHS Last week 80% of dentists voted against accepting new adult patients paying NHS charges after 8 July, when the government announced that it was imposing a 7% pay cut on dentists. The government claims that dentists have been overpaid for 1991-2 because they registered more patients under -their new contract than the government had anticipated. The pay cut is a result of the complex way in which dentists are paid. Each year the Doctors' and Dentists' Review Body recommends a target annual net income, which the government awards either in full or in stages. The Dental Rates Study Group, composed of dentists and officials of the Department of Health under an independent chairman, then sets fees for each item of treatment and procedure. The level of fees should, on average, provide the target annual gross income. Out of this gross income dentists pay all their expenses. This should leave them the net income recommended by the review body. The contract of October 1990 brought with it two major changes: a capitation scheme for children and a per capita payment for adults who registered with a dentist under a continuing care scheme. At the time the fees necessary to produce the required income could be set only by estimating the number of such adults. The estimate was 24 million, but figures from the Department of Health show that the number actually reached 30 million. The result is that the department now claims that dentists were overpaid. The secretary of state for health, Virginia Bottomley, made it clear that the government wants to recoup the overspending when she said that clawing back 7% was "a fair and reasonable way forward." The dentists, how-
BMJ
VOLUME
305
18 JULY 1992
Leadership and doctors
a
z
z
0
"Leading doctors is a bit like herding cats," said Professor Warren Bennis, one of the world's leading authorities on leadership, on a recent trip to London. Professor Bennis, from the University of Southern California, has advised four United States presidents and written 18 bestselling books on leadership after interviewing some 150 top leaders from both public and private sectors. He was in London to address a meeting of senior managers from the NHS at the King's Fund College. I attended the meeting and interviewed him. Trying to lead doctors is like leading an academic community, said Professor Bennis, who was once president of the University of Cincinnati. "It's organised anarchy." He told a story that he said is told by university presidents everywhere; a president descends to hell and discovers that he is to be president of the University of Hell. "That isn't so bad," says the president, "I did that on earth." "But," says the devil, "the university here has two medical schools." "Doctors are independent and autonomous, and the very reason they selected medicine was because of their fierce desire for autonomy. The idea of a physician-manager is an oxymoron," said Professor Bennis. "But
z some of the best administrators I've ever met have come out of medicine. I would let them 0 run anything. They get from medicine a z sense of system. They don't go for false 0: simplifications. They know how to intervene 0i
without causing harm. All of the best principles of medicine should work in management.
137
"But most doctors have a hard time with management. I've taught a lot of physicians, and nothing in their education has prepared them for the technology ofcooperation. They are self absorbed and used to personal intervention rather than working in teams. They don't have that literacy of teamwork, collaboration, and empowering other people." "Can you do something about that?" I asked Professor Bennis. "Sure," he answered, "because they're so intelligent. When you start speaking in their metaphors they just lap it up, but the physicians I teach are, of course, self selected." "But a lot of doctors are unhappy," I said, "with how unscientific management seems. There are no controlled trials." "Doctors are socialised in science," answered Professor Bennis, "to look for the correct answer, to dissect and pull apart, and to make decisions on empirical evidence. They are not educated to be synthetic. "What is the job of a leader?" I asked Professor Bennis. "Simply put," he answered, "it is to show direction and generate trust. When you ask people what they want from leaders they use words like vision, dream, direction, mission, goal, and purpose, but also credibility. And to put that in the context of American politics, right now people think that those characteristics are lacking. They see no vision and they have no trust in the traditional political leaders. Not since the late '60s have I seen such a thirst for leadership in my country. The last president we had that was a real leader was Harry Truman. Real leaders shake things up; they make waves not just surf them. Leaders do the right things, whereas managers do things right." "What," I asked, "are the personal characteristics that make for good leaders? Michael Eisner, the chief executive of Walt Disney, says that having a strong point of view is worth 80 points of IQ. One thing that great leaders often have is that they are 'deep generalists': they have a kaleidoscopic holistic view. They have often worked in every part of a business. Another incredibly important quality is a sense of optimism and hope. Leaders have a robust sense of self efficacy: they believe that they can achieve a goal. And to generate trust they need four Cs: consistency, caring, competence, and congruity-what they say, feel,, and do should fit together. Also important are to encourage dissent, to have a bias towards action, and not to be paralysed by a need to analyse."-
of people making applications to the social fund and compared them with people who had not applied to the fund. They conclude that even when people are granted awards by the fund they go without food and clothing to keep up with repayments. The social fund was set up in 1988 to replace the "single payments" system for exceptional needs - such as buying a carpetwhich could not be met from the basic rate of benefit. It has been continually criticised for being poorly funded and unfairly awarded. The fund is discretionary and provides grants for maternity expenses, funeral expenses, and cold weather payments. Most of the applications to the fund, however, are for bedding and cookers, and these payments are loans to be repaid. In 1990-1, £223 million was distributed, representing 0 4% of the total social security budget. Only half of the applications for loans are successful, and the report claims that people are refused crisis loans because of "inability to repay." Nearly 40% of people who had been refused loans were still trying to find money to meet the same needs six months after the event. These needs were often for basics such as food. The report says that it cannot conclude that the social fund is meeting its objective in concentrating "attention and help on those applicants facing greatest difficulties in managing on their income." The report is critical of the poor privacy given to applicants. "They treat you like dirt," one woman is quoted as saying. Nicholas Scott, minister of state for social security, has said that the research work will require careful study. The York study has asked for "a realistic ... policy which will meet the needs of vulnerable people in a timely, efficient and just manner."-LUISA DILLNER, BMJ
Evaluating the Social Fund, by Meg Hulby and Gill Dix, is available from HMSO bookshops, price £22. Working the Social Fund, by Robert Walker, Gill Dix, and Meg Hulby, is available from HMSO bookshops, price £9.
Political doctors' earnings in US Dr James Todd, executive vice president of the American Medical Association (AMA), is chief operating officer of a nati'onal organisation employing 1000 people that represents American doctors. The AMA lobbies for doctors' interests before Congress, provides health information to American consumers, and publishes 11 journals. The AMA claims that it is the world's largest medical publisher. But is Dr Todd, the AMA's head, worth an annual compensation of $421 542 (£221 864)? The latest report of the AMA's board of trustees presented at the AMA's annual meeting last month showed that AMA executives earn between $143 974 (£75 776) and $220 070 (£115 826), and part time trustees and officers are paid on a daily basis for time lost from their practices, at a rate ranging between about $900 (£470) and $1000 (£530) a day. The compensation levels were set after consultation with management consulting firms "to reimburse officers and trustees for time spent on AMA business with the general result of neither profit nor loss to them." If that's what the generals get what about the troops? The median net income of all American doctors, after expenses but before taxes, is $130 000 (£68 400). Primary care specialties, such as general internal medicine, family practice, paediatrics, and obstetrics and gynaecology, provide incomes of $93 000 (£48 900) to $184 000 (£96 800). The troops apparently do not resent the generals' pay. Although only 300 000 physicians-about half of American doctors-are members of the AMA, the AMA actually represents almost all American doctors because its house of delegates includes representatives from specialty societies, state delegations, and military doctors. Dr James Nuckolls, former president of the American Society of Internal Medicine, which represents 'about 25 000 American
RICHARD SMITH, BMJ
Social fund failing The social fund has once again been condemned as a lottery after research commissioned by the Department of Social Security indicated that "people who receive social fund awards are not in greater need than those who are refused." A report from the social policy research unit at York University looked at 39 benefit offices and held simulated interviews with 15 social fund officers. The researchers also commissioned a survey 138
Money still not getting to the right people
BMJ VOLUME 305
18 JULY 1992
doctors, says, "Our compensation range for executives was less, about half of the AMA's.... But the AMA also represents specialty groups such as surgeons, anaesthesiologists, ophthalmologists, radiologists, and orthopaedic surgeons, where a $400 000 (£210 000) salary is in the arena." Both Dr Nuckolls and Dr Frank Walker, a trustee of the AMA, claim that participating in medical politics places a hard load on doctors. If they work in group practices their colleagues, who have to cover for them when they go to meetings, may complain. Doctors in solo practice or in practice in a small partnership may find involvement in a medical association too burdensome. "I've known few AMA presidents who went back to practice" after serving in national office, said an AMA spokesperson. In many cases when patients could not reach their doctor they transferred to someone else. Doctors with interests in the politics of the profession devote at least 35 office days a year to committee meetings while still paying liability insurance and office expenses. Official office in American medicine may be an honour at the end of a doctor's career, but the result may be entrenchment of older ideas. More than half of American doctors are under 44, but their representation in the halls of power is small. -JANICE HOPKINS TANNE, contributing editor, New York
Infant death in Europe Other countries have followed the Netherlands, the United Kingdom, and New Zealand in making official recommendations that, to reduce the risk of cot death, babies should not be put to sleep in the prone position. The second annual conference of the European Society for the Study and Prevention of Infant Death (ESPID), at Travemunde last month, heard that the Swedish Medical Research Council had just issued such a recommendation and that the American Academy of Pediatrics and the German Federal Health Bureau were about to do so. In eastern Germany- it has been official policy since 1972 to place infants to sleep supine-raising the possibility that isolation from the main current of Western medical thinking has occasional benefits. The evidence that the prone position is safer rests on case-control studies (for example, that by Wigfield et al, BMJ 1 Feb, p 282). Many at the conference were still unconvinced of a causal relation between sleeping prone and cot death, believing that confounding factors might be responsible for the reduction in cot deaths that has followed recent prevention campaigns. None of the studies presented, however, suggested any increased risk for healthy term infants sleeping in non-prone positions, and, in common with recent consensus statements, ESPID recommended the non-prone sleeping position for babies. The conference found that rates of infant death were hard to compare throughout
BMJ
VOLUME
305
18 JULY 1992
.4
_4 x X
X
P:04
¢ m
04 %l
>1
.4 CD
Back is best
Europe because of underregistration of early neonatal deaths in some countries and noncomparable populations-Hungary and Czechoslovakia, for example, have particularly high rates of prematurity (nearly 10% of births). Rates of the sudden infant death syndrome were even less comparable because this diagnosis was not accepted in some eastern European countries-at least before the recent political changes. In data on postneonatal mortality presented from one centre in Poland there was no mention of the sudden infant death syndrome but about 30% of the deaths were attributed to infanticide. -DUNCAN KEELEY, general practitioner, Thame
Advance directive bill A private member's bill that aims to give legal status to advance directives is likely to be introduced into the House of Lords by Lord Winstanley later this year. The bill would allow patients to stipulate in a written declaration what treatment they do or do not want to have if they become too ill to make decisions on treatment. The declaration may include instructions for doctors to withdraw nasogastric feeding and intravenous fluids to hasten death. While acknowledging that advance directives have substantial benefits, the BMA will be opposing the bill. According to Anne Sommerville, secretary of the BMA's medical ethics committee, the association is not in favour of any legislation on advance directives because this can be dangerous. "Legislation is open to interpretation in ways we can't necessarily anticipate," she said. "For example, although Lord Winstanley says that his bill won't make advance directives legally binding, there is always the possibility that the wording of the bill will be interpreted this way in court. The legal situation as it
stands is perfectly satisfactory and we have no evidence to suggest that patients are not getting what they want when they have made it clear in advance to doctors." Ms Simmy Viinikka, solicitor to the Terrence Higgins Trust, agrees that legislation is unnecessary. "It is perfectly right that doctors should comply with patients' wishes when they have been expressed in advance, and many people already do this. There is no need for legislation to protect doctors from prosecution because they are simply not liable." The Terrence Higgins Trust will launch a "living will" in September, which covers advance directives and the appointment of a close friend or relative as a proxy decision maker. The trust has no plans to seek a change in the law. According to Dr Tony Hope, honorary consultant psychiatrist at John Radcliffe Hospital, Oxford, and project leader of the Oxford practice skills project, there are still unresolved questions surrounding advance directives. "Can a competent person in any realistic way imagine what it is like to be incompetent? When I go through a ward of patients with severe dementia there is no reason for me to believe that they want to die, but these are the very people being urged to make advance directives."'-ALISON TONKS, BMJ
Whipped to a frenzy Nicholas Winterton, the robust Conservative MP who was chairman of the Commons health committee in the last parliament, was the spectacular victim of a Westminster putsch last week when he was dropped from the successor committee for the present
parliament. Mr Winterton had no hesitation in detecting a plot by government whips in retribution for his past breaches of party discipline (he was one of only two Tory MPs to vote against 139
the NHS reforms). He owed his election as health committee chairman in 1991 to a coup by Labour members, and proceeded to embarrass the government with a critical report on NHS trusts, which in turn created a further row when a copy was leaked to the Department of Health and brought the resignation of a Conservative member of the
Labour member, claimed that a committee "packed" with whips' nominees would be unable to conduct an honest scrutiny of the NHS. -JOHN WARDEN, parliamentary correspondent, BM-]
committee.
Doctors break confidentiality in public interest
The instrument of the establishment's revenge was the committee of selection. This year it invented a new rule that MPs should serve for no more than three parliaments on a select committee. The rule caught not only the long serving Mr Winterton but several other MPs as well, so that it could not be claimed that Mr Winterton was being singled out. Resentment at Mr Winterton's treatment spawned parallel grievances about the composition of other select committees, setting the scene for a potential revolt earlier this week. Mr Winterton took his complaint to 10 Downing Street but lost his battle, when the House of Commons opposed his reinstatement by 220 votes to 14. Of the six Conservative MPs nominated for the 11 strong health committee, only Mr Roger Sims, a member of the General Medical Council, remains from the former committee. Mrs Audrey Wise, the senior
wider public interest-in this case, the detection of serious crime. The General Medical Council's bhie book makes it clear that a doctor's duty of confidentiality is not absolute but may be overridden in the public interest. In W v Edgell the Court of Appeal held that a psychiatrist was justified in sending a copy of a report on a patient seeking a transfer from a secure hospital to the hospital authorities, against the instructions of the patient's solicitors. The patient had been sent to the secure hospital 10 years previously after killing five people and wounding two others, and the psychiatrist believed that it Hospital staff who had refused to name a would be unsafe to transfer him to a less suspected drug courier disclosed the man's secure unit. The patient's claim for damages identity last week after police obtained a for breach of confidence was rejected by the court order. The man was then arrested, Appeal Court, which held that the disclosure 12 days after he. presented to the casualty was justified in the interests of public safety. department of North Staffordshire Royal The blue book points out that doctors who Infirmary, where he vomited 31 rubber breach confidentiality must be prepared to packets containing heroin. Doctors passed justify their action to the General Medical the heroin, estimated to have a street value of Council or the court. The officials of the £40 000, to police but refused to name the hospital in Staffordshire played safe by patient. He had threatened to leave the requiring police to obtain an order under the hospital-which would have endangered his Drug Trafficking Act. They were surprised, life -if his identity was not protected. however, that the police took 12 days to The case highlights starkly the dilemma obtain the order, by which time the that doctors face in reconciling their duty suspected drug smuggler had left hospital.to protect patients' confidentiality with the CLARE DYER, legal correspondent, B,7
Letter from Westminster Health trilogy Anyone wishing to study changes in Britain's health services now has the complete text to hand. The final chapter was put in place last week with the white paper The Health of the Nation. Its appearance rounds off a series of policy documents on the evolution of the contemporary NHS. The series began with Promoting Better Health (1987), which restructured primary health care. Then came Working for Patients (1989) with its radical reforms in the organisation of the hospital service. The Health of the Nation adds the third leg of health promotion to those of treatment and rehabilitation. Taken together, the white papers are unusual because they represent a continuum in government policy spanning three parliaments and five secretaries of state. Such coherence may owe as much to chance as design, but as a conceptual feat it can rarely have been equalled in the realm of public administration. What is more, the plans set out in Promoting Better Health and Working for Patients have already been put into effect with a vigour and determination that confound their critics. The government's resolve to act on its proposals in The Health of the Nation should not be underestimated. For a start, the NHS 140
Management Executive is now hooked on setting targets so as to focus resources and monitor performance in the delivery ofhealth care at all levels. Because of the initial success of targeting in Promoting Better Health the existing 90% national target for childhood immunisation is being raised to 95%. Mrs Virginia Bottomley said that targeting is at the heart of the new policy. The second change to be taken into account is the contracts between purchasers and providers which followed Working for Patients. Health authorities now have to take strategic decisions about the health needs of their local populations. In future the targets in The Health of the Nation will be built into contracts, dictating how providers organise care, counselling, clinics, or health promotion. The management review process will assess performance in terms of improvement in health. Thirdly, there is to be a cabinet committee chaired by the lord president of the council, Tony Newton, to supervise the whole enterprise, so that The Health of the Nation influences wider policies on housing, education, and food safety. Mrs Bottomley said that the ministerial committee will "hold all ministers to account to ensure they achieve progress and meet targets." The reality is
more problematic. A minister who expects to be on the committee, thinking aloud to me, foresaw a situation in which the minister of agriculture nods approvingly in the committee over the need to lower the consumption of red meat, but goes off to applaud farmers
for their record beef production. Although largely in favour of the white paper, MPs criticised the health secretary for failing to acknowledge the link between poverty and ill health and refusing to ban tobacco advertising-allegedly because the Conservatives are hard on the poor and soft on the tobacco companies. But the strategy to reduce smoking does break important new ground. It acknowledges that progress would be undermined if the real price of tobacco was to fall. The government therefore undertakes at least to maintain the real level of taxes on tobacco products. Though short of an outright "health tax" on tobacco, it means that the Treasury is now committed to increase tobacco duties each year at least in line with inflation. It was not always so when chancellors were more concerned to peg down the retail price index. No longer will they be so inhibited. Next year's budget will put the white paper to its first test. -JOHN WARDEN, parliamentary correspondent, BM-] BMJ VOLUME 305
18 JULY 1992
Coronary heart disease and stroke To reduce death rates from both coronary heart disease and stroke in people under 65 by at least 40% by 2000 To reduce the death rate from coronary heart disease in people aged 65-74 by at least 30% by 2000 To reduce the death rate from stroke in people aged 65-74 by at least 40% by 2000
Cancers To reduce the death rate from breast cancer in the population invited for screening by at least 25% by 2000 To reduce the incidence of invasive cervical cancer by at least 20% by 2000 (baseline 1986) To reduce the death rate from lung cancer under the age of 75 by at least 30% in men and at least 15% in women by 2010 To halt the year on year increase in the incidence of skin cancer by 2005
*Baseline 1990 unless otherwise stated
BMJ
VOLUME
305
18 JULY 1992
Shaping up for the mtllen1um leader of the house, Tony Newton, and covering 11 government departments. In future government policies will be appraised for their effects on health in the same way that they are now appraised for their effects on the environment.
Mental illness To improve significantly the health and social functioning of mentally ill people To reduce the overall suicide rate by at least 15% by 2000 To reduce the suicide rate of severely mentally ill people by at least 33% by 2000
HIVIAIDS and sexual health To reduce the incidence of gonorrhoea by at least 20% by 1995 as an indicator of HIV/AIDS trends To reduce by at least 50% the rate of conceptions among the under 16s by 2000 (baseline 1989)
Accidents To reduce the death rate from accidents among children under 15 by at least 33% by 2005 To reduce the death rate from accidents among young people aged 15-24 by at least 25% by 2005 To reduce the death rate from accidents among people aged 65 and over by at least 33% by 2005
Nationally, the key areas and targets will be at the core of the overall objectives of the NHS, and its performance will increasingly be measured by its success in improving people's health. Health authorities, hospital and community units, primary and community health care services, local authorities, and voluntary agencies are all expected to have a role. The media will have "an important role to play in providing individuals with the information necessary to make decisions which affect their own health and that of their families." Opportunities to work towards the achievement of the targets will be pursued in settings such as schools, hospitals, and workplaces. The "healthy cities" movement will be boosted. Monitoring the success of the new strategy is regarded as crucial, and periodic progress reports will be published. To this end the government's health and nutrition survey is being expanded to cover more than 150000 people and the prevalence of mental illness in the community will be surveyed. The Central Health Monitoring Unit and Central Health Outcomes Unit have recently been set up by the Department- of Health to coordinate the collection of data. Although the strategy was widely welcomed, two omissions were singled out for particular criticism. Members of the opposition, the BMA, and the King's Fund Institute rounded on the government for omitting poverty as a key area. Responding to the 135
Headlines Dental pay: Sir Kenneth Bloomfield, formerly head of the civil service in Northern Ireland, is to carry out a fundamental review of the dental remuneration system. He will identify options for change and report by the end of the year.
Decrease in abortions: Figures from the Office of Population Censuses and Surveys show that the number of legal abortions in England and Wales in the last three months of 1991 was 42 142, a decrease of 2764 compared with the same period in 1990; 18851 of the abortions were carried out in the NHS. Non-residents accounted for 2804 of the abortions in the last three months of 1991; the figure in 1990 was 2980.
Children ignorant about AIDS: According to a survey by Barnado's, children learn about AIDS mostly from the television. Only one in 10 children first hear about the disease from a parent or teacher. One fifth said that they would avoid contact with a schoolmate with the disease. London hospitals to shed jobs: Failure to win contracts with Tower Hamlets Health Authority could mean hundreds of job losses at the Royal London Trust Hospital. The Middlesex and University College group of hospitals has also announced the loss of 200 jobs and faces a £20m deficit this year.
Fall in traffic accidents: There was a 12% fall from 1330 to 1175 in deaths from motor vehicle accidents in England and Wales in the last quarter of 1991 compared with that of 1990, according to the Office of Population Censuses and Surveys. There was a marked fall for men aged 15 to 24 of 21% from 342 to 270. New RHA chairmen: The secretary of state for health has appointed Professor Marian Hicks, who until 1986 was professor of experimental pathology at Middlesex Hospital Medical School, chairman of South West Thames RHA from November. Ms Rennie Fritchie, chairman of Gloucestershire Health Authority, will chair South Western RHA from next month.
High security hospitals should close: The mental health charity MIND, in a report published this week, calls for the relocation of patients detained in Broadmoor, Ashton, and Rampton hospitals to smaller rehabilitation units. According to the report, high security hospitals are isolated from current humane mental health practices.
136
publication of The Health of the Nation, Robin Cook, the shadow health minister, asked how a white paper on health promotion could be comprehensive when it did not once mention poverty. "Does the secretary of state recognise that by doubling the number of children in poverty the government has increased the number of children brought up on a poor diet?" he asked. "A white paper which does not propose a single measure to combat poverty, homelessness, or unemployment is not a white paper which offers better health to all." Asked by Mr Max Madden, the member for Bradford West, whether she accepted a direct link between poverty and poor health ("Yes or no will do"), Mrs Bottomley replied that she believed that there was an association between several social factors and health. Maximising the health of the nation "involves taking into account a great number of factors," she said. The other omission from the white paper which attracted widespread condemnation was a ban on cigarette advertising, which Robin Cook said would be widely attributed to Imperial Tobacco's supply of 2000 poster sites to the Conservative party during the last election campaign. Mrs Bottomley repeated the government's "absolute comnitment to meeting the targets to reduce smoking"through price, education, stopping the £1 billion subsidy to tobacco growers (from the European Community), preventing the example of tobacco smoking, and continuing to review the role of advertising. -TONY DELAMOTHE, BMj
The Health of The Nation: A Strategy for Health in England (Cm 1986) is available from HMSO, price £13.60.
Don't mention AIDS in the American election campaign "In the United States the presidential campaign is stifling national debate on AIDS as the candidates obviously believe that talking about AIDS will not win votes," said Dr Jonathan Mann, chairman of next month's eighth international AIDS conference, speaking at the 18th world congress of dermatology in New York. The AIDS conference will be held in Amsterdam because of continuing restrictions on entry to the US by people infected with HIV. "Only [probable Democratic candidate] Bill Clinton has spoken about AIDS. He made an impressive statement about -the importance of community organisations in fighting the epidemic. I don't know if Ross Perot has spoken about it. Both Reagan and Bush have had trouble saying the word
AIDS. Reports of the National Commission on AIDS say the single most important thing lacking in this country is leadership. The only thing that's peaked in this epidemic is the response," Dr Mann said. "There is no community or country already affected by the epidemic in which HIV transmission has
Politicians keep quiet despite demonstrations
ceased . . . HIV is spreading . . . to communities and countries which were little affected ... just a few years ago." Dr Mann is the former head of the World Health Organisation's global programme on AIDS. The Harvard AIDS group of international researchers predicts that 20 million people will be infected with HIV and six million will have AIDS by 1995. By 2000 there will be between 38 million and 110 million adults infected with HIV. "Our predictions differ from those of the World Health Organisation, which predicts numbers of infected persons at the lower range-40 million people infected by the year 2000, the same as our lowest, or 'best case' projection." Asked about the discrepancy, Dr Mann replied, "You have to remember that WHO is releasing numbers that have been cleared by member governments." Dr Michael Merson, who now heads WHO's AIDS programme, earlier told the New York Times that he stood by WHO's estimates. Dr Peter Drotman, an epidemiologist at the US Centers for Disease Control (CDC), estimated that there were one million people infected with HIV in the US and about 60% had low CD4 counts, which made them candidates for treatment with zidovudine. More than half of those requiring care, however, do not have conditions that fit with current CDC definitions of AIDS. A revised definition is expected soon. "Heterosexual transmission is increasing at a very rapid rate," he said. AIDS is second only to accidents as the leading cause of death among men aged 25-44 and is the sixth commonest cause of death among women in the same age group in the US. About 4000 new cases of AIDS are diagnosed in the United States each month. Among intravenous drug users cases in women and heterosexual men are climbing rapidly, with about 1000 new cases being reported each month. Dr Mann condemned the "Just Say No" campaign aimed at drug takers in the US as "a sham" for not providing alternatives to drug use and easily available treatment. Dr June E Osborn, chairperson of the US National Commission on AIDS, said
BMJ
VOLUME
305
18 JULY 1992
recently, "While the potential for dramatic reduction in risk behaviour and virus spread has been demonstrated in a few specific contexts, there remain widespread public misperceptions about the epidemic and about specific risks." Last week the debate on AIDS gathered momentum when the US National Commission on AIDS accused President Bush and the health and human services secretary, Dr Louis M Sullivan, of failing to meet their responsibilities in the AIDS epidemic. The government's response was "woefully inadequate," said Dr Osborn, and Dr David E Rogers, vice chairman. The commission's accusation came after a meeting with Dr Sullivan and other officials to discuss the administration's response to the commission's report, America Living with Aids, published last year. The commission recommended increased funding, more support from the government, and removing restrictions on people infected with HIV from entering the US. -JANICE HOPKINS TANNE, contributing editor, New York
ever, do not find the clawback reasonable, especially as the review body-before the general election-recommended an 8-5% rise in their net income. The head of practitioner services at the British Dental Association (BDA), Michael Watson, responded to the 7% cut by saying that dentists no longer had confidence in either the system or the department. "Good performance should be rewarded, not penalised," he said. Under the NHS adults not exempt from charges pay 75% of the cost of treatment up to a ceiling of £225. That is why the recent vote by dentists, by a majority of four to one, not to accept new patients paying NHS charges is important. Although the BDA can only advise its members on the outcome of the ballot and not instruct them, the size of the majority indicates that many practitioners will attempt to force the government to reconsider.
The drift towards further private practice seems inevitable. Derek Watson, the chairman of the General Dental Practitioners
Association, summed up the situation for his members: "We are looking at a smaller health service with pregnant women and children still being treated. The remaining three quarters of patients will be asked to pay the whole amount for their treatment rather than the 75% that they pay now." From the government's point of view one option to maintain NHS dental care is through the family health services authorities, which are responsible for ensuring that it is available. The suggestion by Mrs Bottomley that salaried dentists would be employed to carry out this function seems an unlikely solution. There are only about 100 salaried dentists in the country, and the highest paid is reportedly earning £8000 a year less than the recommended target net income. While requesting a meeting with the prime minister in a final attempt to reverse the cut, the BDA headed its press release announcing the result of the ballot of its members "Bleak future for NHS dentistry"-a sentiment with which 80% of the dental profession seems to agree. -STEPHEN HANCOCKS, FDI Dental World
Dentists vote out NHS Last week 80% of dentists voted against accepting new adult patients paying NHS charges after 8 July, when the government announced that it was imposing a 7% pay cut on dentists. The government claims that dentists have been overpaid for 1991-2 because they registered more patients under -their new contract than the government had anticipated. The pay cut is a result of the complex way in which dentists are paid. Each year the Doctors' and Dentists' Review Body recommends a target annual net income, which the government awards either in full or in stages. The Dental Rates Study Group, composed of dentists and officials of the Department of Health under an independent chairman, then sets fees for each item of treatment and procedure. The level of fees should, on average, provide the target annual gross income. Out of this gross income dentists pay all their expenses. This should leave them the net income recommended by the review body. The contract of October 1990 brought with it two major changes: a capitation scheme for children and a per capita payment for adults who registered with a dentist under a continuing care scheme. At the time the fees necessary to produce the required income could be set only by estimating the number of such adults. The estimate was 24 million, but figures from the Department of Health show that the number actually reached 30 million. The result is that the department now claims that dentists were overpaid. The secretary of state for health, Virginia Bottomley, made it clear that the government wants to recoup the overspending when she said that clawing back 7% was "a fair and reasonable way forward." The dentists, how-
BMJ
VOLUME
305
18 JULY 1992
Leadership and doctors
a
z
z
0
"Leading doctors is a bit like herding cats," said Professor Warren Bennis, one of the world's leading authorities on leadership, on a recent trip to London. Professor Bennis, from the University of Southern California, has advised four United States presidents and written 18 bestselling books on leadership after interviewing some 150 top leaders from both public and private sectors. He was in London to address a meeting of senior managers from the NHS at the King's Fund College. I attended the meeting and interviewed him. Trying to lead doctors is like leading an academic community, said Professor Bennis, who was once president of the University of Cincinnati. "It's organised anarchy." He told a story that he said is told by university presidents everywhere; a president descends to hell and discovers that he is to be president of the University of Hell. "That isn't so bad," says the president, "I did that on earth." "But," says the devil, "the university here has two medical schools." "Doctors are independent and autonomous, and the very reason they selected medicine was because of their fierce desire for autonomy. The idea of a physician-manager is an oxymoron," said Professor Bennis. "But
z some of the best administrators I've ever met have come out of medicine. I would let them 0 run anything. They get from medicine a z sense of system. They don't go for false 0: simplifications. They know how to intervene 0i
without causing harm. All of the best principles of medicine should work in management.
137
"But most doctors have a hard time with management. I've taught a lot of physicians, and nothing in their education has prepared them for the technology ofcooperation. They are self absorbed and used to personal intervention rather than working in teams. They don't have that literacy of teamwork, collaboration, and empowering other people." "Can you do something about that?" I asked Professor Bennis. "Sure," he answered, "because they're so intelligent. When you start speaking in their metaphors they just lap it up, but the physicians I teach are, of course, self selected." "But a lot of doctors are unhappy," I said, "with how unscientific management seems. There are no controlled trials." "Doctors are socialised in science," answered Professor Bennis, "to look for the correct answer, to dissect and pull apart, and to make decisions on empirical evidence. They are not educated to be synthetic. "What is the job of a leader?" I asked Professor Bennis. "Simply put," he answered, "it is to show direction and generate trust. When you ask people what they want from leaders they use words like vision, dream, direction, mission, goal, and purpose, but also credibility. And to put that in the context of American politics, right now people think that those characteristics are lacking. They see no vision and they have no trust in the traditional political leaders. Not since the late '60s have I seen such a thirst for leadership in my country. The last president we had that was a real leader was Harry Truman. Real leaders shake things up; they make waves not just surf them. Leaders do the right things, whereas managers do things right." "What," I asked, "are the personal characteristics that make for good leaders? Michael Eisner, the chief executive of Walt Disney, says that having a strong point of view is worth 80 points of IQ. One thing that great leaders often have is that they are 'deep generalists': they have a kaleidoscopic holistic view. They have often worked in every part of a business. Another incredibly important quality is a sense of optimism and hope. Leaders have a robust sense of self efficacy: they believe that they can achieve a goal. And to generate trust they need four Cs: consistency, caring, competence, and congruity-what they say, feel,, and do should fit together. Also important are to encourage dissent, to have a bias towards action, and not to be paralysed by a need to analyse."-
of people making applications to the social fund and compared them with people who had not applied to the fund. They conclude that even when people are granted awards by the fund they go without food and clothing to keep up with repayments. The social fund was set up in 1988 to replace the "single payments" system for exceptional needs - such as buying a carpetwhich could not be met from the basic rate of benefit. It has been continually criticised for being poorly funded and unfairly awarded. The fund is discretionary and provides grants for maternity expenses, funeral expenses, and cold weather payments. Most of the applications to the fund, however, are for bedding and cookers, and these payments are loans to be repaid. In 1990-1, £223 million was distributed, representing 0 4% of the total social security budget. Only half of the applications for loans are successful, and the report claims that people are refused crisis loans because of "inability to repay." Nearly 40% of people who had been refused loans were still trying to find money to meet the same needs six months after the event. These needs were often for basics such as food. The report says that it cannot conclude that the social fund is meeting its objective in concentrating "attention and help on those applicants facing greatest difficulties in managing on their income." The report is critical of the poor privacy given to applicants. "They treat you like dirt," one woman is quoted as saying. Nicholas Scott, minister of state for social security, has said that the research work will require careful study. The York study has asked for "a realistic ... policy which will meet the needs of vulnerable people in a timely, efficient and just manner."-LUISA DILLNER, BMJ
Evaluating the Social Fund, by Meg Hulby and Gill Dix, is available from HMSO bookshops, price £22. Working the Social Fund, by Robert Walker, Gill Dix, and Meg Hulby, is available from HMSO bookshops, price £9.
Political doctors' earnings in US Dr James Todd, executive vice president of the American Medical Association (AMA), is chief operating officer of a nati'onal organisation employing 1000 people that represents American doctors. The AMA lobbies for doctors' interests before Congress, provides health information to American consumers, and publishes 11 journals. The AMA claims that it is the world's largest medical publisher. But is Dr Todd, the AMA's head, worth an annual compensation of $421 542 (£221 864)? The latest report of the AMA's board of trustees presented at the AMA's annual meeting last month showed that AMA executives earn between $143 974 (£75 776) and $220 070 (£115 826), and part time trustees and officers are paid on a daily basis for time lost from their practices, at a rate ranging between about $900 (£470) and $1000 (£530) a day. The compensation levels were set after consultation with management consulting firms "to reimburse officers and trustees for time spent on AMA business with the general result of neither profit nor loss to them." If that's what the generals get what about the troops? The median net income of all American doctors, after expenses but before taxes, is $130 000 (£68 400). Primary care specialties, such as general internal medicine, family practice, paediatrics, and obstetrics and gynaecology, provide incomes of $93 000 (£48 900) to $184 000 (£96 800). The troops apparently do not resent the generals' pay. Although only 300 000 physicians-about half of American doctors-are members of the AMA, the AMA actually represents almost all American doctors because its house of delegates includes representatives from specialty societies, state delegations, and military doctors. Dr James Nuckolls, former president of the American Society of Internal Medicine, which represents 'about 25 000 American
RICHARD SMITH, BMJ
Social fund failing The social fund has once again been condemned as a lottery after research commissioned by the Department of Social Security indicated that "people who receive social fund awards are not in greater need than those who are refused." A report from the social policy research unit at York University looked at 39 benefit offices and held simulated interviews with 15 social fund officers. The researchers also commissioned a survey 138
Money still not getting to the right people
BMJ VOLUME 305
18 JULY 1992
doctors, says, "Our compensation range for executives was less, about half of the AMA's.... But the AMA also represents specialty groups such as surgeons, anaesthesiologists, ophthalmologists, radiologists, and orthopaedic surgeons, where a $400 000 (£210 000) salary is in the arena." Both Dr Nuckolls and Dr Frank Walker, a trustee of the AMA, claim that participating in medical politics places a hard load on doctors. If they work in group practices their colleagues, who have to cover for them when they go to meetings, may complain. Doctors in solo practice or in practice in a small partnership may find involvement in a medical association too burdensome. "I've known few AMA presidents who went back to practice" after serving in national office, said an AMA spokesperson. In many cases when patients could not reach their doctor they transferred to someone else. Doctors with interests in the politics of the profession devote at least 35 office days a year to committee meetings while still paying liability insurance and office expenses. Official office in American medicine may be an honour at the end of a doctor's career, but the result may be entrenchment of older ideas. More than half of American doctors are under 44, but their representation in the halls of power is small. -JANICE HOPKINS TANNE, contributing editor, New York
Infant death in Europe Other countries have followed the Netherlands, the United Kingdom, and New Zealand in making official recommendations that, to reduce the risk of cot death, babies should not be put to sleep in the prone position. The second annual conference of the European Society for the Study and Prevention of Infant Death (ESPID), at Travemunde last month, heard that the Swedish Medical Research Council had just issued such a recommendation and that the American Academy of Pediatrics and the German Federal Health Bureau were about to do so. In eastern Germany- it has been official policy since 1972 to place infants to sleep supine-raising the possibility that isolation from the main current of Western medical thinking has occasional benefits. The evidence that the prone position is safer rests on case-control studies (for example, that by Wigfield et al, BMJ 1 Feb, p 282). Many at the conference were still unconvinced of a causal relation between sleeping prone and cot death, believing that confounding factors might be responsible for the reduction in cot deaths that has followed recent prevention campaigns. None of the studies presented, however, suggested any increased risk for healthy term infants sleeping in non-prone positions, and, in common with recent consensus statements, ESPID recommended the non-prone sleeping position for babies. The conference found that rates of infant death were hard to compare throughout
BMJ
VOLUME
305
18 JULY 1992
.4
_4 x X
X
P:04
¢ m
04 %l
>1
.4 CD
Back is best
Europe because of underregistration of early neonatal deaths in some countries and noncomparable populations-Hungary and Czechoslovakia, for example, have particularly high rates of prematurity (nearly 10% of births). Rates of the sudden infant death syndrome were even less comparable because this diagnosis was not accepted in some eastern European countries-at least before the recent political changes. In data on postneonatal mortality presented from one centre in Poland there was no mention of the sudden infant death syndrome but about 30% of the deaths were attributed to infanticide. -DUNCAN KEELEY, general practitioner, Thame
Advance directive bill A private member's bill that aims to give legal status to advance directives is likely to be introduced into the House of Lords by Lord Winstanley later this year. The bill would allow patients to stipulate in a written declaration what treatment they do or do not want to have if they become too ill to make decisions on treatment. The declaration may include instructions for doctors to withdraw nasogastric feeding and intravenous fluids to hasten death. While acknowledging that advance directives have substantial benefits, the BMA will be opposing the bill. According to Anne Sommerville, secretary of the BMA's medical ethics committee, the association is not in favour of any legislation on advance directives because this can be dangerous. "Legislation is open to interpretation in ways we can't necessarily anticipate," she said. "For example, although Lord Winstanley says that his bill won't make advance directives legally binding, there is always the possibility that the wording of the bill will be interpreted this way in court. The legal situation as it
stands is perfectly satisfactory and we have no evidence to suggest that patients are not getting what they want when they have made it clear in advance to doctors." Ms Simmy Viinikka, solicitor to the Terrence Higgins Trust, agrees that legislation is unnecessary. "It is perfectly right that doctors should comply with patients' wishes when they have been expressed in advance, and many people already do this. There is no need for legislation to protect doctors from prosecution because they are simply not liable." The Terrence Higgins Trust will launch a "living will" in September, which covers advance directives and the appointment of a close friend or relative as a proxy decision maker. The trust has no plans to seek a change in the law. According to Dr Tony Hope, honorary consultant psychiatrist at John Radcliffe Hospital, Oxford, and project leader of the Oxford practice skills project, there are still unresolved questions surrounding advance directives. "Can a competent person in any realistic way imagine what it is like to be incompetent? When I go through a ward of patients with severe dementia there is no reason for me to believe that they want to die, but these are the very people being urged to make advance directives."'-ALISON TONKS, BMJ
Whipped to a frenzy Nicholas Winterton, the robust Conservative MP who was chairman of the Commons health committee in the last parliament, was the spectacular victim of a Westminster putsch last week when he was dropped from the successor committee for the present
parliament. Mr Winterton had no hesitation in detecting a plot by government whips in retribution for his past breaches of party discipline (he was one of only two Tory MPs to vote against 139
the NHS reforms). He owed his election as health committee chairman in 1991 to a coup by Labour members, and proceeded to embarrass the government with a critical report on NHS trusts, which in turn created a further row when a copy was leaked to the Department of Health and brought the resignation of a Conservative member of the
Labour member, claimed that a committee "packed" with whips' nominees would be unable to conduct an honest scrutiny of the NHS. -JOHN WARDEN, parliamentary correspondent, BM-]
committee.
Doctors break confidentiality in public interest
The instrument of the establishment's revenge was the committee of selection. This year it invented a new rule that MPs should serve for no more than three parliaments on a select committee. The rule caught not only the long serving Mr Winterton but several other MPs as well, so that it could not be claimed that Mr Winterton was being singled out. Resentment at Mr Winterton's treatment spawned parallel grievances about the composition of other select committees, setting the scene for a potential revolt earlier this week. Mr Winterton took his complaint to 10 Downing Street but lost his battle, when the House of Commons opposed his reinstatement by 220 votes to 14. Of the six Conservative MPs nominated for the 11 strong health committee, only Mr Roger Sims, a member of the General Medical Council, remains from the former committee. Mrs Audrey Wise, the senior
wider public interest-in this case, the detection of serious crime. The General Medical Council's bhie book makes it clear that a doctor's duty of confidentiality is not absolute but may be overridden in the public interest. In W v Edgell the Court of Appeal held that a psychiatrist was justified in sending a copy of a report on a patient seeking a transfer from a secure hospital to the hospital authorities, against the instructions of the patient's solicitors. The patient had been sent to the secure hospital 10 years previously after killing five people and wounding two others, and the psychiatrist believed that it Hospital staff who had refused to name a would be unsafe to transfer him to a less suspected drug courier disclosed the man's secure unit. The patient's claim for damages identity last week after police obtained a for breach of confidence was rejected by the court order. The man was then arrested, Appeal Court, which held that the disclosure 12 days after he. presented to the casualty was justified in the interests of public safety. department of North Staffordshire Royal The blue book points out that doctors who Infirmary, where he vomited 31 rubber breach confidentiality must be prepared to packets containing heroin. Doctors passed justify their action to the General Medical the heroin, estimated to have a street value of Council or the court. The officials of the £40 000, to police but refused to name the hospital in Staffordshire played safe by patient. He had threatened to leave the requiring police to obtain an order under the hospital-which would have endangered his Drug Trafficking Act. They were surprised, life -if his identity was not protected. however, that the police took 12 days to The case highlights starkly the dilemma obtain the order, by which time the that doctors face in reconciling their duty suspected drug smuggler had left hospital.to protect patients' confidentiality with the CLARE DYER, legal correspondent, B,7
Letter from Westminster Health trilogy Anyone wishing to study changes in Britain's health services now has the complete text to hand. The final chapter was put in place last week with the white paper The Health of the Nation. Its appearance rounds off a series of policy documents on the evolution of the contemporary NHS. The series began with Promoting Better Health (1987), which restructured primary health care. Then came Working for Patients (1989) with its radical reforms in the organisation of the hospital service. The Health of the Nation adds the third leg of health promotion to those of treatment and rehabilitation. Taken together, the white papers are unusual because they represent a continuum in government policy spanning three parliaments and five secretaries of state. Such coherence may owe as much to chance as design, but as a conceptual feat it can rarely have been equalled in the realm of public administration. What is more, the plans set out in Promoting Better Health and Working for Patients have already been put into effect with a vigour and determination that confound their critics. The government's resolve to act on its proposals in The Health of the Nation should not be underestimated. For a start, the NHS 140
Management Executive is now hooked on setting targets so as to focus resources and monitor performance in the delivery ofhealth care at all levels. Because of the initial success of targeting in Promoting Better Health the existing 90% national target for childhood immunisation is being raised to 95%. Mrs Virginia Bottomley said that targeting is at the heart of the new policy. The second change to be taken into account is the contracts between purchasers and providers which followed Working for Patients. Health authorities now have to take strategic decisions about the health needs of their local populations. In future the targets in The Health of the Nation will be built into contracts, dictating how providers organise care, counselling, clinics, or health promotion. The management review process will assess performance in terms of improvement in health. Thirdly, there is to be a cabinet committee chaired by the lord president of the council, Tony Newton, to supervise the whole enterprise, so that The Health of the Nation influences wider policies on housing, education, and food safety. Mrs Bottomley said that the ministerial committee will "hold all ministers to account to ensure they achieve progress and meet targets." The reality is
more problematic. A minister who expects to be on the committee, thinking aloud to me, foresaw a situation in which the minister of agriculture nods approvingly in the committee over the need to lower the consumption of red meat, but goes off to applaud farmers
for their record beef production. Although largely in favour of the white paper, MPs criticised the health secretary for failing to acknowledge the link between poverty and ill health and refusing to ban tobacco advertising-allegedly because the Conservatives are hard on the poor and soft on the tobacco companies. But the strategy to reduce smoking does break important new ground. It acknowledges that progress would be undermined if the real price of tobacco was to fall. The government therefore undertakes at least to maintain the real level of taxes on tobacco products. Though short of an outright "health tax" on tobacco, it means that the Treasury is now committed to increase tobacco duties each year at least in line with inflation. It was not always so when chancellors were more concerned to peg down the retail price index. No longer will they be so inhibited. Next year's budget will put the white paper to its first test. -JOHN WARDEN, parliamentary correspondent, BM-] BMJ VOLUME 305
18 JULY 1992
