1123
of respondents had clinically significant distress levels. Although this was lower than expected, a few individuals with a high exposure to the disaster were still severely distressed. The report recommends that staff should be made aware of the psychological effects of disasters and that staff support services should be established. The provision of such services would form the basis for additional support needed after a disaster. Furthermore, psychological debriefing should be seen as routine, without stigma, and be provided for all staff after any distressing major incidents. 1. Editorial. Psychiatric intervention after disaster. Lancet 1989; ii: 138-39. 2. Psychological support for hospital staff initiated by clinical psychologists in the aftermath of the Hillsborough disaster. By Diana Shapiro and Jane Kunkler. September, 1990. Available from Clinical Psychology, Northern General Hospital, Sheffield S5 7AU. 3.00. Cheques payable to Middlewood Hospital.
Day surgery: better for all concerned Hospital waiting lists in England and Wales could be cut by up to a third with no increase in expenditure if more operations were carried out as day surgery, according to a report from the Audit Commission.1 The commission, in its first study for the National Health Service, reached this conclusion after analysing how 20 common operations, all potentially suitable for day surgery, were carried out in 54 health districts. The operations, which include inguinal hernia repair, cataract extraction, carpal tunnel decompression, circumcision, varicose vein stripping, and excision of breast lumps, account for 40% of procedures in the main surgical specialties (and 30% in all specialties). Howard Davies, controller of the Audit Commission, claimed that the report’s fmdings demonstrate "significant scope for more effective use of resources". "Day surgery is recognised by surgeons to be safe, and patients like it", he said. The commission found a wide variation in the use of day surgery. Inguinal hernia repair showed the narrowest range (0-40%) and carpal tunnel release the widest (0-100%). The commission estimates that if all district health authorities (DHAs) used day surgery for the 20 procedures to the same extent as the 25 % that use it most, an additional 186 000 patients could be treated each year. If other procedures suitable for day surgery are included, 300 000 extra patients could receive treatment. From the patient’s point of view, a shorter wait for an operation may be the main advantage of day surgery, but the report argues that patients will also have greater choice in the date of treatment, since the routine of dedicated day surgery units does not depend on bed availability. Having to spend less time away from home is seen as another benefit for patients. The Audit Commission agrees with the Royal College of Surgeons’ assessment in 1985Z that day surgery is at least as good in terms of clinical outcome as surgery carried out under conventional admission procedures. Audits of day surgery are now to be carried out in every DHA in England and Wales, and auditors will then help managers and clinicians to set their own targets for improving the service. Managers’ objections to developing day surgery included fears that such a move would increase the number of patients treated, with no substitution of day patients for inpatients. Some also thought that clinicians might resist their attempts to "meddle" in clinical matters. Clinicians’ concerns, many of them unfounded, included a belief that patients prefer to be treated as inpatients and that the outcome of treatment would not be as good as that for inpatient surgery. In its guidelines, the Audit Commission says that patients being considered for day surgery should be screened for medical fitness and suitability of home circumstances, and they should be given good written and oral information about each stage of treatment. The commission also suggests that patients’ perceptions should be regularly monitored, and to this end it is developing a questionnaire to assess patient satisfaction.
Malcolm Dean comments on the report on p
1118.
Global health
care
for HIV disease
The rapid progression of HIV disease throughout the world has caused logistic difficulties for governments that want to achieve a balance between provision for the immediate needs of individuals and the development of a long-term strategic plan for the whole
population. A report from the University of York describes how, despite large-scale Government spending, an emphasis on short-term solutions has led to inequalities in funding in the UK.l Allocation of money in England, Scotland, and Wales is hampered by regional differences in the mechanisms of distribution of funds, and this difficulty is compounded by the lack of any clear regional anti-HIV strategy. To prevent duplication and omission (eg, no allowance was made for the expected population growth rate of AIDS patients within and outside London regions) planners must closely audit the
of their current resource allocation to enable them to base distribution upon current requirements and projected demand. This analysis of AIDS funding in the UK seems to contrast with that provided in a report to Congress by the US Agency for International Development (USAID).2 USAID contributed 25% of the total budget of the WHO Global Programme on AIDS in 1989 and supports the immediate and long-term provision of services to 48 developing countries in Africa, Latin America, and Asia. USAID works through a technical support project that gives funding for public health communications, technical assistance, and the Centers for Disease Control. In addition, it assists voluntary and non-governmental organisations that have direct contact with targeted local communities. It also has extensive facilities to monitor the impact of these programmes. Through US ambassadors, an AIDS coordinator is located in each country that receives help; the Federal Co-ordinating Committee on the HIV epidemic has USAID representation; and an Interagency Working Group measures the effectiveness of intervention. The aims of USAID are to provide the epidemiological framework upon which public awareness and knowledge can be increased and prevention programmes implemented. This organisational structure, which involves both government and quasi-autonomous institutions, may offer some lessons for those who plan UK AIDS policy. If future measures are not to flounder, the nettle of long-term planning must be grasped.
outcome
1. Tolley K, Maynard A Government funding of HIV-AIDS medical and social care. 1990. Obtainable (pnce £3) from the Publication Secretary, Centre for Health Economics, University of York, York YO1 5DD. 2. USAID HIV infection and AIDS. A report to Congress on the USAID program for prevention and control. Washington DC: USAID, 1990.
There but for the grace of God
...
chilling touch of deja vu will be apparent to any doctor who peruses the 1990 annual reports of the Medical Defence Uruon1 and Medical Protection Society (MPS).2 The catalogue of missed fractures, avoidable deaths, and cases of "informed" consent without adequate explanation that lead to legal proceedings doubled between 1985 and 1988. The introduction of differential subscriptions by the MPS and the organisation of the transfer of responsibility for the financial consequences of claims to health authorities (NHS indemnity) have added to this increased A
workload. Defence organisations also have a responsibility to educate doctors through research into the avoidable causes of negligence. The MPS reports on research it has conducted into the causes of obstetric accidents that lead to stillbirths, perinatal, neonatal, and maternal mortality, and neurological damage to children. The errors most frequently found are poor judgment of the time of onset of labour, inadequate fetal heart monitoring, technical errors in use of forceps, and lack of attendance at deliveries by senior obstetricians despite requests from their junior staff.
1 A short cut to better
services: day surgery in England and WalesAudit Commission for Local Authorines and the National Health Service.London: HM Stationery Office.1990.£8.50.ISBN 0-11880305 2.Royal College of Surgeons of England Commission on the Provision of Surgical Services.Guidelines for day-case surgery 1985
Report 1990. London. Medical Defence Union, 3 Devonshire Place, London W1N 2EA. 2 Medical Protection Society Annual Report 1990. London: Medical Protection Society, 50 Hallam Street, London W1N 6DE 1. Medical Defence Union Annual
of respondents had clinically significant distress levels. Although this was lower than expected, a few individuals with a high exposure to the disaster were still severely distressed. The report recommends that staff should be made aware of the psychological effects of disasters and that staff support services should be established. The provision of such services would form the basis for additional support needed after a disaster. Furthermore, psychological debriefing should be seen as routine, without stigma, and be provided for all staff after any distressing major incidents. 1. Editorial. Psychiatric intervention after disaster. Lancet 1989; ii: 138-39. 2. Psychological support for hospital staff initiated by clinical psychologists in the aftermath of the Hillsborough disaster. By Diana Shapiro and Jane Kunkler. September, 1990. Available from Clinical Psychology, Northern General Hospital, Sheffield S5 7AU. 3.00. Cheques payable to Middlewood Hospital.
Day surgery: better for all concerned Hospital waiting lists in England and Wales could be cut by up to a third with no increase in expenditure if more operations were carried out as day surgery, according to a report from the Audit Commission.1 The commission, in its first study for the National Health Service, reached this conclusion after analysing how 20 common operations, all potentially suitable for day surgery, were carried out in 54 health districts. The operations, which include inguinal hernia repair, cataract extraction, carpal tunnel decompression, circumcision, varicose vein stripping, and excision of breast lumps, account for 40% of procedures in the main surgical specialties (and 30% in all specialties). Howard Davies, controller of the Audit Commission, claimed that the report’s fmdings demonstrate "significant scope for more effective use of resources". "Day surgery is recognised by surgeons to be safe, and patients like it", he said. The commission found a wide variation in the use of day surgery. Inguinal hernia repair showed the narrowest range (0-40%) and carpal tunnel release the widest (0-100%). The commission estimates that if all district health authorities (DHAs) used day surgery for the 20 procedures to the same extent as the 25 % that use it most, an additional 186 000 patients could be treated each year. If other procedures suitable for day surgery are included, 300 000 extra patients could receive treatment. From the patient’s point of view, a shorter wait for an operation may be the main advantage of day surgery, but the report argues that patients will also have greater choice in the date of treatment, since the routine of dedicated day surgery units does not depend on bed availability. Having to spend less time away from home is seen as another benefit for patients. The Audit Commission agrees with the Royal College of Surgeons’ assessment in 1985Z that day surgery is at least as good in terms of clinical outcome as surgery carried out under conventional admission procedures. Audits of day surgery are now to be carried out in every DHA in England and Wales, and auditors will then help managers and clinicians to set their own targets for improving the service. Managers’ objections to developing day surgery included fears that such a move would increase the number of patients treated, with no substitution of day patients for inpatients. Some also thought that clinicians might resist their attempts to "meddle" in clinical matters. Clinicians’ concerns, many of them unfounded, included a belief that patients prefer to be treated as inpatients and that the outcome of treatment would not be as good as that for inpatient surgery. In its guidelines, the Audit Commission says that patients being considered for day surgery should be screened for medical fitness and suitability of home circumstances, and they should be given good written and oral information about each stage of treatment. The commission also suggests that patients’ perceptions should be regularly monitored, and to this end it is developing a questionnaire to assess patient satisfaction.
Malcolm Dean comments on the report on p
1118.
Global health
care
for HIV disease
The rapid progression of HIV disease throughout the world has caused logistic difficulties for governments that want to achieve a balance between provision for the immediate needs of individuals and the development of a long-term strategic plan for the whole
population. A report from the University of York describes how, despite large-scale Government spending, an emphasis on short-term solutions has led to inequalities in funding in the UK.l Allocation of money in England, Scotland, and Wales is hampered by regional differences in the mechanisms of distribution of funds, and this difficulty is compounded by the lack of any clear regional anti-HIV strategy. To prevent duplication and omission (eg, no allowance was made for the expected population growth rate of AIDS patients within and outside London regions) planners must closely audit the
of their current resource allocation to enable them to base distribution upon current requirements and projected demand. This analysis of AIDS funding in the UK seems to contrast with that provided in a report to Congress by the US Agency for International Development (USAID).2 USAID contributed 25% of the total budget of the WHO Global Programme on AIDS in 1989 and supports the immediate and long-term provision of services to 48 developing countries in Africa, Latin America, and Asia. USAID works through a technical support project that gives funding for public health communications, technical assistance, and the Centers for Disease Control. In addition, it assists voluntary and non-governmental organisations that have direct contact with targeted local communities. It also has extensive facilities to monitor the impact of these programmes. Through US ambassadors, an AIDS coordinator is located in each country that receives help; the Federal Co-ordinating Committee on the HIV epidemic has USAID representation; and an Interagency Working Group measures the effectiveness of intervention. The aims of USAID are to provide the epidemiological framework upon which public awareness and knowledge can be increased and prevention programmes implemented. This organisational structure, which involves both government and quasi-autonomous institutions, may offer some lessons for those who plan UK AIDS policy. If future measures are not to flounder, the nettle of long-term planning must be grasped.
outcome
1. Tolley K, Maynard A Government funding of HIV-AIDS medical and social care. 1990. Obtainable (pnce £3) from the Publication Secretary, Centre for Health Economics, University of York, York YO1 5DD. 2. USAID HIV infection and AIDS. A report to Congress on the USAID program for prevention and control. Washington DC: USAID, 1990.
There but for the grace of God
...
chilling touch of deja vu will be apparent to any doctor who peruses the 1990 annual reports of the Medical Defence Uruon1 and Medical Protection Society (MPS).2 The catalogue of missed fractures, avoidable deaths, and cases of "informed" consent without adequate explanation that lead to legal proceedings doubled between 1985 and 1988. The introduction of differential subscriptions by the MPS and the organisation of the transfer of responsibility for the financial consequences of claims to health authorities (NHS indemnity) have added to this increased A
workload. Defence organisations also have a responsibility to educate doctors through research into the avoidable causes of negligence. The MPS reports on research it has conducted into the causes of obstetric accidents that lead to stillbirths, perinatal, neonatal, and maternal mortality, and neurological damage to children. The errors most frequently found are poor judgment of the time of onset of labour, inadequate fetal heart monitoring, technical errors in use of forceps, and lack of attendance at deliveries by senior obstetricians despite requests from their junior staff.
1 A short cut to better
services: day surgery in England and WalesAudit Commission for Local Authorines and the National Health Service.London: HM Stationery Office.1990.£8.50.ISBN 0-11880305 2.Royal College of Surgeons of England Commission on the Provision of Surgical Services.Guidelines for day-case surgery 1985
Report 1990. London. Medical Defence Union, 3 Devonshire Place, London W1N 2EA. 2 Medical Protection Society Annual Report 1990. London: Medical Protection Society, 50 Hallam Street, London W1N 6DE 1. Medical Defence Union Annual
