reviewed continually, and decisions made as to which worker takes responsibility. This results in low rates of referral to psychiatrists and low prescribing costs (especially for benzodiazepines). We believe that awareness of mental health factors may also enable us to have low referral rates in other specialties. Finally, Professor Sims does not mention the prevention of mental illness. Interested general practitioners are in a key position to detect hidden or early mental health problems. Having the resources, they tackle many of these problems without referral to a psychiatrist. Consultants should remember that primary health care teams, like patients, have different needs. Some may be good at treating varicose ulcers but poor at managing anxiety or vice versa. Consultant services therefore need to be flexible and educational and move out into health centres, thus strengthening the primary health care team and enhancing its capacity to cope. DEREK PHILLIPS Health Centre, Slaithwaite, Huddersfield HD7 5AB 1 Sims A. Even better services: a psychiatric perspective. BRM7 1991;302:1061-3. (4 May.)
SIR,-The initial response' to the articles on community care by Professors Andrew Sims2 and Elaine Murphy' was perhaps not surprising. Professor Murphy's views, heavily criticised in the subsequent correspondence, at least have the merit of appreciating that the politics of community care have been altered by Thatcherism and the Policy Studies Institute. The case for an increase in consultant manpower, which Professor Sims seems to have made the priority of his presidency of the Royal College of Psychiatrists, now looks isolated and outdated. Professor Sims's argument for the supremacy of the consultant psychiatrist in the multidisciplinary team is not accepted by other disciplines. Although the concept of a generic mental health professional has never gained official recognition, it could defuse wasteful interdisciplinary power struggles. I am not underestimating the importance of education and training, as Professor Murphy does. Many able people may be deprived of an adequate training in mental health because of vested disciplinary interests. Democratisation of the multidisciplinary team, though, does enable inexperienced workers to make their own
contribution. Neither Professor Sims nor Professor Murphy really considers the impact of the government's reforms on community care.4 In particular, the introduction of care management with supporting budgetary frameworks could alter provision considerably. Care managers will essentially act as brokers for services and are expected to assume some or all of the responsibility for purchasing services to implement a care programme. Once these arrangements are in place it may become clearer if the real issues have been underfunding, ring fencing of the community care budget, a sole agency for community care, and so on. Understandably, the future is uncertain, but I hope that the vision offered for community care is more than a choice between Professor Sims's plea for an increase in the strength of consultant psychiatrists and Professor Murphy's haphazard and flawed views. DUNCAN DOUBLE
Department of Psychiatrs, University of Sheffield, Northern General Hospital, Sheffield S5 7AU 1 Correspondence. Better mental health services.
1339-40. (1 June.)
BMJ 1991302:
2 Sims A. Eveni bettcr services: a psychiatric perspective. BAiJ 1991;302:1061-3. (4 May.)
1534
3 Murphy E. Community mental health services: a vision for the fttture. BM3' 1991;302:1064-5. (4 May.) 4 Department of Health. Caring for people. Communitt care in the next decade and beyond. London: HMSO, 1990.
SIR,-The correspondence' on community mental health services in response to articles by Professor Andrew Sims2 and Professor Elaine Murphy' is revealing in showing the attitudes of some doctors. The enthusiastic response to Professor Sims's plea for more consultant psychiatrists2 and the defensive attitude to Professor Murphy's article3 is just what many users of mental health services would expect from psychiatrists. As part of our work establishing contracts for mental health services, both in Newcastle and in other places around England, we have attempted to get a range of users to help plan and to comment on contracts. Although not perfectly representative, there is a clear message from clients, patients, and carers in several districts that their priorities for development do not include more consultant psychiatrists. They believe that the immediate need is for more social care along the lines outlined by Professor Murphy. It is interesting that Professor Sims bases his argument on the central importance of the doctorpatient relationship. He does not, however, cite any evidence that this is viewed as a central issue by patients. A recent unpublished study conducted in a children's cancer ward showed the high value that parents and patients place on social contact with a range of non-medical and non-nursing staff, including domestic staff, physiotherapists, and social workers. This is anecdotal evidence that, important as the doctor-patient relationship is, users often place a higher value on other forms of support. It is encouraging to note the complete agreement that community services are the way forward and that the medical profession is vigorously discussing the most appropriate form of provision. The views of users must not be overlooked in this debate, and we all need to improve the mechanisms by which clients and carers can participate in planning. INGRID BARKER
Newcastle Health Atuthority, Newcastle upon Tyne NE2 1EF RICHARD GLEAVE Health Services Management Unit, Newcastle University, Newcastle upon Tyne NEI 7RU 1 Correspondence. Better mental health services. BMJ7 1991;302: 1339-40. (1 June.) 2 Sims A. Even better services: a psychiatric perspective. B.M7 1991;302:1061-3. (4 May.) 3 Murphy E. Community mental health services: a vision for the
titture. BAUJ 1991;302:1064-5. (4 May.)
Helicobacter pylon infection and gastric cancer SIR,-Dr D Forman and colleagues concluded that there was a higher specific Helicobacter pylon IgG concentration in patients who subsequently developed gastric cancer than in controls.' They were unable to suggest possible mechanisms by which H pylon infection could induce gastric carcinoma.
We have recently shown the immunohistochemical expression of growth regulatory peptides in gastric mucosa in 56 subjects (paper submitted for publication). Epidermal growth factor has a potential for oncogenic action in the stomach.' We have shown that it is present in greater density in or near the proliferative zone in inflamed antral mucosa than in uninflamed antral mucosa. H pylon was present in 82% of patients with antral inflammation compared with 34% of patients without antral oc!tritis-figures similar to those found in other studies.' Moreover, there is an association
between expression of epidermal growth factor and the presence of lymphocytes, but not neutrophils, in the inflamed mucosa. Possibly lymphocytes may induce expression of epidermal growth factor in gastric epithelial cells by release of cytokines.4 We believe, therefore, that if H pylorn indeed has a role in gastric carcinogenesis the infection may induce gastric neoplasia indirectly as a result of increased expression of epidermal growth factor in the gastric epithelium. JANUSZ JANKOWSKI Gastrointestinal Unit, Ninewells Hospital, Dundee DDl 9SY 1 Forman D, Newell DG, Fullerton F, Yarnell JWG, Stacey AR, Wald N, et al. Association between infection with Helicobacter pylori and risk of gastric cancer: evidence from a prospective investigation. BM, 1991;302:1302-4. (I June.) 2 Tahara E, Yasui W, Ochiai A, Yamamoto T, Hata J, Yokozakio H, et al. Interaction between epidermal growth factor and its receptor in progression of human gastric carcinomas. Prog Cancer Res Ther 1988;35:536-9. 3 Ormand JE, Talley NJ, Shorter RG, Conley CR, Carpenter HA, Fich A, et al. Prevalence of Helicobacter pylori in specific forms of gastritis. Dig Dis Sci 1991;36:142-5. 4 Correa P. Chronic gastritis (non specific). In: Whitehead R, ed. Gastroinlestinal and oesophageal pathology. Edinburgh: Churchill Iivingstone, 1989:402-21.
Helicobacter pylon infection and duodenal ulcer SIR,-Dr A R Axon's editorial on duodenal ulcer succinctly reviews the evidence that convinces many that Helicobacter pylorn is an important agent in duodenal ulcer disease.' Furthermore, he reiterates the views of the working party convened by the World Congress of Gastroenterology that attempts to eradicate H pylori should be made only in patients with peptic ulcers in whom management problems arise and that in these patients triple treatment-namely, bismuth and two antibiotics (usually amoxycillin or tetracycline and metronidazole)-should be used. The working party itself went on to recommend that "H pylorn therapy should be reserved for those groups of patients where it has been shown unequivocally to have an advantage over the currently available cytoprotective and acid suppressive drugs."2 Regrettably, this rational and well thought out policy has not been adopted by Gist-brocades, the major retailer of bismuth salts in this country. In recent promotional literature put out in support of this bismuth preparation the company recommends that patients with ulcers that relapse or who require maintenance treatment should receive treatment with bismuth for eight weeks and metronidazole or tinidazole for two weeks. Undoubtedly, this regimen will produce better eradication rates than a regimen of bismuth alone, but the results are likely to be less satisfactory than those obtained with the triple treatment regimen advocated by the working party of the World Congress of Gastroenterology, which concluded that "the indiscriminate use of antibiotics is to be discouraged" and "if H pylort therapy is undertaken, the most effective treatment regimen should be employed. The Working Party recommends a triple combination." Furthermore, the promotional literature in question does not include evidence that dual treatment is beneficial in healing and reducing relapse of ulcers. Although there is some limited evidence that this is so, the case is far from proved.' Eradication of H pylori may not be the only factor responsible for the effectiveness of treatment regimens in duodenal ulcer as antibacterial agents seem to have some efficacy in peptic disease probably independent of any effect on H pylon.4 The main concern about using dual treatment regimens-namely, bismuth and metronidazole or tinidazole-is the risk of the development of resistant H pylori/. At present, in most European countries about 20% of H pylon organisms are
BMJ VOLUME 302
22 JUNE 1991
SIR,-The initial response' to the articles on community care by Professors Andrew Sims2 and Elaine Murphy' was perhaps not surprising. Professor Murphy's views, heavily criticised in the subsequent correspondence, at least have the merit of appreciating that the politics of community care have been altered by Thatcherism and the Policy Studies Institute. The case for an increase in consultant manpower, which Professor Sims seems to have made the priority of his presidency of the Royal College of Psychiatrists, now looks isolated and outdated. Professor Sims's argument for the supremacy of the consultant psychiatrist in the multidisciplinary team is not accepted by other disciplines. Although the concept of a generic mental health professional has never gained official recognition, it could defuse wasteful interdisciplinary power struggles. I am not underestimating the importance of education and training, as Professor Murphy does. Many able people may be deprived of an adequate training in mental health because of vested disciplinary interests. Democratisation of the multidisciplinary team, though, does enable inexperienced workers to make their own
contribution. Neither Professor Sims nor Professor Murphy really considers the impact of the government's reforms on community care.4 In particular, the introduction of care management with supporting budgetary frameworks could alter provision considerably. Care managers will essentially act as brokers for services and are expected to assume some or all of the responsibility for purchasing services to implement a care programme. Once these arrangements are in place it may become clearer if the real issues have been underfunding, ring fencing of the community care budget, a sole agency for community care, and so on. Understandably, the future is uncertain, but I hope that the vision offered for community care is more than a choice between Professor Sims's plea for an increase in the strength of consultant psychiatrists and Professor Murphy's haphazard and flawed views. DUNCAN DOUBLE
Department of Psychiatrs, University of Sheffield, Northern General Hospital, Sheffield S5 7AU 1 Correspondence. Better mental health services.
1339-40. (1 June.)
BMJ 1991302:
2 Sims A. Eveni bettcr services: a psychiatric perspective. BAiJ 1991;302:1061-3. (4 May.)
1534
3 Murphy E. Community mental health services: a vision for the fttture. BM3' 1991;302:1064-5. (4 May.) 4 Department of Health. Caring for people. Communitt care in the next decade and beyond. London: HMSO, 1990.
SIR,-The correspondence' on community mental health services in response to articles by Professor Andrew Sims2 and Professor Elaine Murphy' is revealing in showing the attitudes of some doctors. The enthusiastic response to Professor Sims's plea for more consultant psychiatrists2 and the defensive attitude to Professor Murphy's article3 is just what many users of mental health services would expect from psychiatrists. As part of our work establishing contracts for mental health services, both in Newcastle and in other places around England, we have attempted to get a range of users to help plan and to comment on contracts. Although not perfectly representative, there is a clear message from clients, patients, and carers in several districts that their priorities for development do not include more consultant psychiatrists. They believe that the immediate need is for more social care along the lines outlined by Professor Murphy. It is interesting that Professor Sims bases his argument on the central importance of the doctorpatient relationship. He does not, however, cite any evidence that this is viewed as a central issue by patients. A recent unpublished study conducted in a children's cancer ward showed the high value that parents and patients place on social contact with a range of non-medical and non-nursing staff, including domestic staff, physiotherapists, and social workers. This is anecdotal evidence that, important as the doctor-patient relationship is, users often place a higher value on other forms of support. It is encouraging to note the complete agreement that community services are the way forward and that the medical profession is vigorously discussing the most appropriate form of provision. The views of users must not be overlooked in this debate, and we all need to improve the mechanisms by which clients and carers can participate in planning. INGRID BARKER
Newcastle Health Atuthority, Newcastle upon Tyne NE2 1EF RICHARD GLEAVE Health Services Management Unit, Newcastle University, Newcastle upon Tyne NEI 7RU 1 Correspondence. Better mental health services. BMJ7 1991;302: 1339-40. (1 June.) 2 Sims A. Even better services: a psychiatric perspective. B.M7 1991;302:1061-3. (4 May.) 3 Murphy E. Community mental health services: a vision for the
titture. BAUJ 1991;302:1064-5. (4 May.)
Helicobacter pylon infection and gastric cancer SIR,-Dr D Forman and colleagues concluded that there was a higher specific Helicobacter pylon IgG concentration in patients who subsequently developed gastric cancer than in controls.' They were unable to suggest possible mechanisms by which H pylon infection could induce gastric carcinoma.
We have recently shown the immunohistochemical expression of growth regulatory peptides in gastric mucosa in 56 subjects (paper submitted for publication). Epidermal growth factor has a potential for oncogenic action in the stomach.' We have shown that it is present in greater density in or near the proliferative zone in inflamed antral mucosa than in uninflamed antral mucosa. H pylon was present in 82% of patients with antral inflammation compared with 34% of patients without antral oc!tritis-figures similar to those found in other studies.' Moreover, there is an association
between expression of epidermal growth factor and the presence of lymphocytes, but not neutrophils, in the inflamed mucosa. Possibly lymphocytes may induce expression of epidermal growth factor in gastric epithelial cells by release of cytokines.4 We believe, therefore, that if H pylorn indeed has a role in gastric carcinogenesis the infection may induce gastric neoplasia indirectly as a result of increased expression of epidermal growth factor in the gastric epithelium. JANUSZ JANKOWSKI Gastrointestinal Unit, Ninewells Hospital, Dundee DDl 9SY 1 Forman D, Newell DG, Fullerton F, Yarnell JWG, Stacey AR, Wald N, et al. Association between infection with Helicobacter pylori and risk of gastric cancer: evidence from a prospective investigation. BM, 1991;302:1302-4. (I June.) 2 Tahara E, Yasui W, Ochiai A, Yamamoto T, Hata J, Yokozakio H, et al. Interaction between epidermal growth factor and its receptor in progression of human gastric carcinomas. Prog Cancer Res Ther 1988;35:536-9. 3 Ormand JE, Talley NJ, Shorter RG, Conley CR, Carpenter HA, Fich A, et al. Prevalence of Helicobacter pylori in specific forms of gastritis. Dig Dis Sci 1991;36:142-5. 4 Correa P. Chronic gastritis (non specific). In: Whitehead R, ed. Gastroinlestinal and oesophageal pathology. Edinburgh: Churchill Iivingstone, 1989:402-21.
Helicobacter pylon infection and duodenal ulcer SIR,-Dr A R Axon's editorial on duodenal ulcer succinctly reviews the evidence that convinces many that Helicobacter pylorn is an important agent in duodenal ulcer disease.' Furthermore, he reiterates the views of the working party convened by the World Congress of Gastroenterology that attempts to eradicate H pylori should be made only in patients with peptic ulcers in whom management problems arise and that in these patients triple treatment-namely, bismuth and two antibiotics (usually amoxycillin or tetracycline and metronidazole)-should be used. The working party itself went on to recommend that "H pylorn therapy should be reserved for those groups of patients where it has been shown unequivocally to have an advantage over the currently available cytoprotective and acid suppressive drugs."2 Regrettably, this rational and well thought out policy has not been adopted by Gist-brocades, the major retailer of bismuth salts in this country. In recent promotional literature put out in support of this bismuth preparation the company recommends that patients with ulcers that relapse or who require maintenance treatment should receive treatment with bismuth for eight weeks and metronidazole or tinidazole for two weeks. Undoubtedly, this regimen will produce better eradication rates than a regimen of bismuth alone, but the results are likely to be less satisfactory than those obtained with the triple treatment regimen advocated by the working party of the World Congress of Gastroenterology, which concluded that "the indiscriminate use of antibiotics is to be discouraged" and "if H pylort therapy is undertaken, the most effective treatment regimen should be employed. The Working Party recommends a triple combination." Furthermore, the promotional literature in question does not include evidence that dual treatment is beneficial in healing and reducing relapse of ulcers. Although there is some limited evidence that this is so, the case is far from proved.' Eradication of H pylori may not be the only factor responsible for the effectiveness of treatment regimens in duodenal ulcer as antibacterial agents seem to have some efficacy in peptic disease probably independent of any effect on H pylon.4 The main concern about using dual treatment regimens-namely, bismuth and metronidazole or tinidazole-is the risk of the development of resistant H pylori/. At present, in most European countries about 20% of H pylon organisms are
BMJ VOLUME 302
22 JUNE 1991
