1144 HERPES ZOSTER OF THE STOMACH
SIR,-Dr Wisl0fT and his colleagues (Nov. 3, p. 953) showed by endoscopy that the zoster virus can attack the mucosa of the stomach. Other unusual manifestations of this disorder are segmental colitis resembling ulcerative colitis,’ dysuria from bladder involvement, and pleurisy. The Ramsey Hunt syndrome and weakness of a limb also sometimes occurs, when the inflammation spreads into motor tracts. Visceral zoster is rare, but possibly other and undiagnosable cases are occurring without skin lesions. A method of boosting the immunity of the elderly will perhaps be achieved in the future, preventing the pain and visual complications of this unpleasant disease. St. Luke’s
Hospital, Guildford, Surrey GU1
3NT
GERALD A. MACGREGOR
ted alternative proposals those proposals had to achieve savings on the same scale. Having decided that the C.H.c. had to be consulted, there was no justification, in Mr Justice Woolf’ss view, on the part of the Commissioners for limiting or circumscribing the role of the council. The Regulations did not provide any limitation on the role of the council. It had to be remembered, however, that as time elapsed it would be more difficult to make the necessary savings. There had been a number of letters giving information passing between the Commissioners and the c.H.c. The Commissioners had examined the c.H.c.’s proposals and the decision to transfer the inpatient service was not taken until late in the afternoon of Oct. 29. Although the time span had been short, there had been proper consultation. The Commissioners might still consider the c.H.c.’s proposal for economies if additional savings were required. The c.H.c.’s application for a judicial review of the matter was dismissed.
Queen’s Bench 1.
Division: Nov. 12-13, 1979.
MacGregor GA. Three reasons for ulcerative colitis. Lancet 1973; i: 825.
MARY BRYN DAVIES
Medicine and the Law
Commentary from Consultation
on
Closure of St Olave’s
Westminster
Hospital
Mr J. T. Nelligan, chairman of Guy’s District Community Health Council, and Mrs C. A. Newman, a member of the Council, sought a judicial review of a decision made by the Commissioners who have replaced the Lambeth, Southwark and Lewisham Area Health Authority (Teaching). The Commissioners decided that inpatient services at St Olave’s Hospital, Rotherhithe, should be suspended temporarily as an economy measure. For the c.H.c. it was submitted that the decision to close was taken hastily and without proper consultation. It was said that the Commissioners had invited the C.H.C. to make alternative proposals. The c.H.c. had submitted proposals to the Commissioners by 8.30 A.M. on Oct. 29. The decision to close had been taken on the same day. The council formed the view that their proposals had been given only a cursory glance by the Commissioners and that there had been no proper consultation at all within the meaning of Regulation 20 of the National Health Service (Community Health Council) Regulations of 1973. Giving judgment, Mr Justice WooLF said that when tier upon tier of administration was required to provide health services, it was important that someone should represent the interests of the public in the locality so as to ensure that the administration had a proper regard to the interests of the local community. Community health councils had an important role in the administration of the N.H.S. The Secretary of State had a statutory duty to establish c.H.c.s in health authorities. It was also clear from the terms of the 1973 Regulations that c.H.c.s and area health authorities were intended to work with one another. The council was a consultative body and had a duty to make recommendations to the authority as it thought fit. The authority was under a duty to consult with the council. That consultation had to be meaningful. The authority had an obligation to give information to the council and was also obliged to give the council reasonable time in which to perform its function. It was reasonable for the area authority to impose time limits, which sometimes had to be relatively short. Length of time for consultation must be judged within the existing circumstances. The Commissioners had no alternative. They had to make substantial economies. On the proposal to transfer the inpatient services at St Olave’s the Commissioners accepted that there had to be consultation with the c.H.c. They invited comment and also suggested to the council that if they submit-
N.H.S. Closures: Temporary or Permanent? THE Department of Health and Social Security is to remind all area health authorities of the difference between temporary and permanent closure of facilities, after Parliamentary complaints that many authorities are deliberately fudging the distinction, so they can steer round consultation rules. But the D.H.S.S. reminder is a gentle one, which will not satisfy sceptical M.P.S. A circular due to go to A.H.A.S from the Health Minister, Dr Gerard Vaughan, will reiterate that if major facilities are "temporarily" closed there must be evidence that the A.H.A. is seriously considering how and when they can be reopened. No change in the rules is proposed however, nor any new procedure for checking the genuineness of the intention to reopen. The complaints surfaced in the Commons when Mr Reg Race, (Lab, Haringey) told Dr Vaughan that "a number of health authorities are seeking to use temporary closures to evade completely the responsibility of consultation ... in this way they avoid the need to consult the community health council and to refer the decision to the Minister if the c.H.c. disagrees with the closure." Dr Vaughan replied that he was not aware of any such abuses of temporary closure procedure, but he conceded that the guidelines "may need clarification". Two Conservative members, Mr Toby Jessel (Twickenham) and Mr Michael Neubert (Romford) had similar complaints ; and Mr Race told me he had heard the same story from other M.P.S. A.H.A.S were sometimes using the smokescreen of cash limits to shut down units which, in their long-term plans, they had decided to do away with anyway. But, knowing of local opposition to such closures, some avoided confrontation with local objectors by calling the closures "temporary". "The onus should be very much on health authorities to make firm commitments, saying when they are going to reopen. I suggest there should be a six-month limit after which the
1145
authority should either have to reopen the unit or through the consultation procedure for permanent closure. The fault lies in the present procedure, because there is no firm date beyond which health authorities can’t go," Mr Race declared. He realised health authorities were in a very difficult position because of the need to make savings in the current financial year. But they should not surrender to the temptation to misuse the health
go
temporary closure method.
Allocation of N.H.S. Resources in policy on the equalisation of between N.H.S. regions has gone virtually unannounced, although it follows inevitably from the Conservatives’ public expenditure slow-down. Through the medium of the resources allocation working parties the Labour administration had hoped to get rough equity of resources between the regions within seven or eight years. The strategy was, of course, based on the supposition that the N.H.S. budget would continue to grow, if only at a moderate pace. This week Dr Vaughan was asked what plans he had "to ensure equal access to health care in all parts of the United Kingdom." He replied that "it is our intention to continue the policy of redistribution of resources among health authorities by the process of levelling up rather than levelling down. The rate at which this can be achieved will depend on the amount of new resources available nationally." To a similar question, Dr Vaughan added that the rate of progress was "likely to be slow over the next few years." With shrinking resources, levelling upwards is scarcely much of a possibility. According to Labour’s social services spokesman and ex-Minister, Mr Stan Orme, Dr Vaughan’s words mean that the goal of equalisation between regions has been "pushed into the nevernever". The only way to get equalisation in a no-growth period was to make fiercer cuts in the south than in the North-West or Trent regions, and that was the last thing Mr Orme wanted to see. "I’m not prepared to take part in a fight about sharing the misery." D.H.S.S. Civil Servants are taking a hard look at the way resource allocation works. Although RAWP was scathingly dismissed at the Conservative Party conference (not from the platform) as a method of "equally impoverishing everyone", there is no intention yet to abolish it. Nevertheless it is agreed at D.H.S.S. that RAWP has provided rough justice in many areas, and that the system needs modifying. Clearly the forthcoming white-paper on the future of the N.H.S., responding to the recommendations of the Royal Commission, will be suggesting a new approach to the whole question of resource allocation. A
significant change
resources
Pneumoconiosis Panels Six Labour M.p.s who represent coal-mining constituencies are demanding the abolition of pneumoconiosis medical panels. They complain that the proportion of applications rejected by the panels has risen from 32% in 1953 to 72% in 1978. Many of the panels, they say, reject applications despite evidence from G.P.s, consultants, and coroner’s pathologists. An affirmative diagnosis of pneumoconiosis damage given by a G.P. and a local consultant should be enough to substantiate a
claim, they argue, with the onus of disproof being placed the D.H.S.S. When the disease kills, the word of a coroner and his pathologist should establish the claim; on
the onus of proving the contrary on appeal should rest on the D.H.S.S. Mr Dennis Skinner, from the mining constituency of Bolsover, probably includes more miners than most other constituencies, believes the panels are "a law unto themselves." "They can just ignore a coroner’s report saying a man died mainly from pneumoconiosis, and they often do ignore it. You may find a man gets an 80% disability pension for pneumoconiosis, but when he dies his widow gets nothing because the panel ignores the coroner’s findings." Mr Skinner blames the lack of local knowledge and of local involvement of the panels for what he sees as their capriciousness. But the panels are likely to stay. The Minister -responsible for the disabled, Mr Reg Prentice, has "every confidence in the expertise of the doctors of the pneumoconiosis medical panel, who have the great advantage of being able to correlate their findings in life with those at post-mortem".
Compensation for
Vaccine
Damage
This week has also seen an attack on the present sysof awarding compensation to parents of vaccinedamaged children. It is led by Mr Jack Ashley (Lab, Stoke-on-Trent), who was a prime mover in the campaign to establish the compensation scheme. Mr Ashley is deeply disappointed with the way things have turned out. Figures show that only 366 claims have been accepted so far, out of 2525 applications. Mr Ashley and some 60 other M.p.s are now asking the Government to include in the scheme children who are less than 80% disabled, those disabled before 1948, and the parents of children who have died. "The trouble" Mr Ashley believes, "is that the authorities are not giving the benefit of the doubt. They ought to. The assumption appears to be that claimants must first prove it is ’more than probable’ that damage is due to vaccine. But there is always a grey area in issues of this kind." At present there is no sympathy at the D.H.S.S. for widening the scope of the compensation scheme, still less for giving claimants the benefit of the doubt. RODNEY DEITCH tem
Parliament
QUESTION Entrants
to
TIME
Medical Schools and List Sizes
Citing the 6% drop in entrants to medical schools, and pointing out that this will delay the Secretary of State’s commitment to reduce general-practice list sizes, Dr ROGER THOMAS asked him to consider maintaining the current annual intake of medical schools, thereby achieving a considerable reduction in dependence upon doctors trained outside the U.K. Dr VAUGHAN replied that the implications of the Government’s recent white-paper on public expenditure for the size of university intake, including medical school entrants, in 1980-1981, were being considered by the University Grants Committee in conjunction with the universities. The Government’s target would remain at 4080 medical-school entrants, in order to
SIR,-Dr Wisl0fT and his colleagues (Nov. 3, p. 953) showed by endoscopy that the zoster virus can attack the mucosa of the stomach. Other unusual manifestations of this disorder are segmental colitis resembling ulcerative colitis,’ dysuria from bladder involvement, and pleurisy. The Ramsey Hunt syndrome and weakness of a limb also sometimes occurs, when the inflammation spreads into motor tracts. Visceral zoster is rare, but possibly other and undiagnosable cases are occurring without skin lesions. A method of boosting the immunity of the elderly will perhaps be achieved in the future, preventing the pain and visual complications of this unpleasant disease. St. Luke’s
Hospital, Guildford, Surrey GU1
3NT
GERALD A. MACGREGOR
ted alternative proposals those proposals had to achieve savings on the same scale. Having decided that the C.H.c. had to be consulted, there was no justification, in Mr Justice Woolf’ss view, on the part of the Commissioners for limiting or circumscribing the role of the council. The Regulations did not provide any limitation on the role of the council. It had to be remembered, however, that as time elapsed it would be more difficult to make the necessary savings. There had been a number of letters giving information passing between the Commissioners and the c.H.c. The Commissioners had examined the c.H.c.’s proposals and the decision to transfer the inpatient service was not taken until late in the afternoon of Oct. 29. Although the time span had been short, there had been proper consultation. The Commissioners might still consider the c.H.c.’s proposal for economies if additional savings were required. The c.H.c.’s application for a judicial review of the matter was dismissed.
Queen’s Bench 1.
Division: Nov. 12-13, 1979.
MacGregor GA. Three reasons for ulcerative colitis. Lancet 1973; i: 825.
MARY BRYN DAVIES
Medicine and the Law
Commentary from Consultation
on
Closure of St Olave’s
Westminster
Hospital
Mr J. T. Nelligan, chairman of Guy’s District Community Health Council, and Mrs C. A. Newman, a member of the Council, sought a judicial review of a decision made by the Commissioners who have replaced the Lambeth, Southwark and Lewisham Area Health Authority (Teaching). The Commissioners decided that inpatient services at St Olave’s Hospital, Rotherhithe, should be suspended temporarily as an economy measure. For the c.H.c. it was submitted that the decision to close was taken hastily and without proper consultation. It was said that the Commissioners had invited the C.H.C. to make alternative proposals. The c.H.c. had submitted proposals to the Commissioners by 8.30 A.M. on Oct. 29. The decision to close had been taken on the same day. The council formed the view that their proposals had been given only a cursory glance by the Commissioners and that there had been no proper consultation at all within the meaning of Regulation 20 of the National Health Service (Community Health Council) Regulations of 1973. Giving judgment, Mr Justice WooLF said that when tier upon tier of administration was required to provide health services, it was important that someone should represent the interests of the public in the locality so as to ensure that the administration had a proper regard to the interests of the local community. Community health councils had an important role in the administration of the N.H.S. The Secretary of State had a statutory duty to establish c.H.c.s in health authorities. It was also clear from the terms of the 1973 Regulations that c.H.c.s and area health authorities were intended to work with one another. The council was a consultative body and had a duty to make recommendations to the authority as it thought fit. The authority was under a duty to consult with the council. That consultation had to be meaningful. The authority had an obligation to give information to the council and was also obliged to give the council reasonable time in which to perform its function. It was reasonable for the area authority to impose time limits, which sometimes had to be relatively short. Length of time for consultation must be judged within the existing circumstances. The Commissioners had no alternative. They had to make substantial economies. On the proposal to transfer the inpatient services at St Olave’s the Commissioners accepted that there had to be consultation with the c.H.c. They invited comment and also suggested to the council that if they submit-
N.H.S. Closures: Temporary or Permanent? THE Department of Health and Social Security is to remind all area health authorities of the difference between temporary and permanent closure of facilities, after Parliamentary complaints that many authorities are deliberately fudging the distinction, so they can steer round consultation rules. But the D.H.S.S. reminder is a gentle one, which will not satisfy sceptical M.P.S. A circular due to go to A.H.A.S from the Health Minister, Dr Gerard Vaughan, will reiterate that if major facilities are "temporarily" closed there must be evidence that the A.H.A. is seriously considering how and when they can be reopened. No change in the rules is proposed however, nor any new procedure for checking the genuineness of the intention to reopen. The complaints surfaced in the Commons when Mr Reg Race, (Lab, Haringey) told Dr Vaughan that "a number of health authorities are seeking to use temporary closures to evade completely the responsibility of consultation ... in this way they avoid the need to consult the community health council and to refer the decision to the Minister if the c.H.c. disagrees with the closure." Dr Vaughan replied that he was not aware of any such abuses of temporary closure procedure, but he conceded that the guidelines "may need clarification". Two Conservative members, Mr Toby Jessel (Twickenham) and Mr Michael Neubert (Romford) had similar complaints ; and Mr Race told me he had heard the same story from other M.P.S. A.H.A.S were sometimes using the smokescreen of cash limits to shut down units which, in their long-term plans, they had decided to do away with anyway. But, knowing of local opposition to such closures, some avoided confrontation with local objectors by calling the closures "temporary". "The onus should be very much on health authorities to make firm commitments, saying when they are going to reopen. I suggest there should be a six-month limit after which the
1145
authority should either have to reopen the unit or through the consultation procedure for permanent closure. The fault lies in the present procedure, because there is no firm date beyond which health authorities can’t go," Mr Race declared. He realised health authorities were in a very difficult position because of the need to make savings in the current financial year. But they should not surrender to the temptation to misuse the health
go
temporary closure method.
Allocation of N.H.S. Resources in policy on the equalisation of between N.H.S. regions has gone virtually unannounced, although it follows inevitably from the Conservatives’ public expenditure slow-down. Through the medium of the resources allocation working parties the Labour administration had hoped to get rough equity of resources between the regions within seven or eight years. The strategy was, of course, based on the supposition that the N.H.S. budget would continue to grow, if only at a moderate pace. This week Dr Vaughan was asked what plans he had "to ensure equal access to health care in all parts of the United Kingdom." He replied that "it is our intention to continue the policy of redistribution of resources among health authorities by the process of levelling up rather than levelling down. The rate at which this can be achieved will depend on the amount of new resources available nationally." To a similar question, Dr Vaughan added that the rate of progress was "likely to be slow over the next few years." With shrinking resources, levelling upwards is scarcely much of a possibility. According to Labour’s social services spokesman and ex-Minister, Mr Stan Orme, Dr Vaughan’s words mean that the goal of equalisation between regions has been "pushed into the nevernever". The only way to get equalisation in a no-growth period was to make fiercer cuts in the south than in the North-West or Trent regions, and that was the last thing Mr Orme wanted to see. "I’m not prepared to take part in a fight about sharing the misery." D.H.S.S. Civil Servants are taking a hard look at the way resource allocation works. Although RAWP was scathingly dismissed at the Conservative Party conference (not from the platform) as a method of "equally impoverishing everyone", there is no intention yet to abolish it. Nevertheless it is agreed at D.H.S.S. that RAWP has provided rough justice in many areas, and that the system needs modifying. Clearly the forthcoming white-paper on the future of the N.H.S., responding to the recommendations of the Royal Commission, will be suggesting a new approach to the whole question of resource allocation. A
significant change
resources
Pneumoconiosis Panels Six Labour M.p.s who represent coal-mining constituencies are demanding the abolition of pneumoconiosis medical panels. They complain that the proportion of applications rejected by the panels has risen from 32% in 1953 to 72% in 1978. Many of the panels, they say, reject applications despite evidence from G.P.s, consultants, and coroner’s pathologists. An affirmative diagnosis of pneumoconiosis damage given by a G.P. and a local consultant should be enough to substantiate a
claim, they argue, with the onus of disproof being placed the D.H.S.S. When the disease kills, the word of a coroner and his pathologist should establish the claim; on
the onus of proving the contrary on appeal should rest on the D.H.S.S. Mr Dennis Skinner, from the mining constituency of Bolsover, probably includes more miners than most other constituencies, believes the panels are "a law unto themselves." "They can just ignore a coroner’s report saying a man died mainly from pneumoconiosis, and they often do ignore it. You may find a man gets an 80% disability pension for pneumoconiosis, but when he dies his widow gets nothing because the panel ignores the coroner’s findings." Mr Skinner blames the lack of local knowledge and of local involvement of the panels for what he sees as their capriciousness. But the panels are likely to stay. The Minister -responsible for the disabled, Mr Reg Prentice, has "every confidence in the expertise of the doctors of the pneumoconiosis medical panel, who have the great advantage of being able to correlate their findings in life with those at post-mortem".
Compensation for
Vaccine
Damage
This week has also seen an attack on the present sysof awarding compensation to parents of vaccinedamaged children. It is led by Mr Jack Ashley (Lab, Stoke-on-Trent), who was a prime mover in the campaign to establish the compensation scheme. Mr Ashley is deeply disappointed with the way things have turned out. Figures show that only 366 claims have been accepted so far, out of 2525 applications. Mr Ashley and some 60 other M.p.s are now asking the Government to include in the scheme children who are less than 80% disabled, those disabled before 1948, and the parents of children who have died. "The trouble" Mr Ashley believes, "is that the authorities are not giving the benefit of the doubt. They ought to. The assumption appears to be that claimants must first prove it is ’more than probable’ that damage is due to vaccine. But there is always a grey area in issues of this kind." At present there is no sympathy at the D.H.S.S. for widening the scope of the compensation scheme, still less for giving claimants the benefit of the doubt. RODNEY DEITCH tem
Parliament
QUESTION Entrants
to
TIME
Medical Schools and List Sizes
Citing the 6% drop in entrants to medical schools, and pointing out that this will delay the Secretary of State’s commitment to reduce general-practice list sizes, Dr ROGER THOMAS asked him to consider maintaining the current annual intake of medical schools, thereby achieving a considerable reduction in dependence upon doctors trained outside the U.K. Dr VAUGHAN replied that the implications of the Government’s recent white-paper on public expenditure for the size of university intake, including medical school entrants, in 1980-1981, were being considered by the University Grants Committee in conjunction with the universities. The Government’s target would remain at 4080 medical-school entrants, in order to
