690 any other name ... Standard hospital care-free from charge - is to be available to all. Pensioners and the "socially disadvantaged" (euphemism for low-income earners?) are to have free medical care and those who have the means will have to pay 60% of their doctors’ bills and insure privately for special privileges and extra cover. As we say down under-give it a go. 6
Certain bore tube
whole-protein products do pass through the, -fineby continuous gravity drip and may, in most clinical situations, be more appropriate than elemental diets. Roussel Nutritional Division, Roussel Laboratories Ltd., Wembley Park, Middlesex HA9 0NF
J. C. CROW
Aubrey Road,
Northbridge,
New South Wales 2063
CATHERINE G. LEFEVRE
SIR The paper by Dr Metz and his’colleagues is a timely a technique which has been known and used for many years.’ The additional advantage of the current system is the flexible guide wire to position the tube. The push fit of a butterfly needle to join the tube to a flask of liquid feed is in our view clumsy. A male luer fitting should be part of the assembly attached to the proximal end of the narrow-gauge reminder of
NASOENTERIC FEEDING
SIR,—Dr Metz and his colleagues (Aug. 26, p. 454) describe a technique which is growing in clinical usage.’ However, their paper has led to some confusion, both in the U.K. and overseas, about the availability of the components. Although the tubes are manufactured by Portex Ltd. and the guide wires by Cambmac Instruments Ltd., Roussel Nutritional Division market the complete intubation set. The set consists of a guide wire with safety stop which ensures that the flexible distal tip cannot protrude through the open end; five polyvinyl-chloride radio-opaque 1 mm internal diameter tubes with luer fittings; and instructions. The intubation sets come in packs of five (i.e., 25 tubes). 1.
Fowell, E., Lee, H. A., Dickerson, J. W. T. in Nutrition in the Clinical Management of Disease (edited by J. W. T. Dickerson and H. A Lee), p. 341. London, 1978.
Commentary from Westminster From
our
Parliamentary Correspondent
Royal Commission and the Postponed Election THE Prime Minister’s decision to postpone a general election until 1979 may turn out to be embarrassing for The
the Conservatives. For it means that the report of the Royal Commission on the National Health Service could be published before an election, which would confront the Conservatives with the need for some awkward decisions. At the moment the party is avoiding committing itself on a number of sensitive issues on the justifiable grounds that it is awaiting the report of the Royal Commission. Labour’s attacks on Conservative ideas for introducing new health charges and extending private health insurance are parried by playing the Royal Commission card. Last month Mr Patrick Jenkin, Conservative spokesman on social services, answered a challenge from Mr David Ennals, Secretary of State for Social Services, by replying, "Answers to the detailed questions he has posed must await the report of the Royal Commission on the health service". But of course Mr Jenkin was speaking at a time when he confidently expected an October election. Now that this has been put off until the spring, summer, or autumn of next year, Mr Jenkin is faced with the possibility of actually having to answer some of Labour’s questions. The Royal Commission’s report is expected during the first half of 1979 and the earlier it comes the more likely it will be that Mr Jenkin will be forced to commit the Conservatives one way or the other on a number of issues. One of the more moderate members of Mrs
tubing. This fitting can easily be inserted into the tubing of a bladder irrigation set or intravenous infusion set connected to the flask of liquid feed. We recommend strongly that such female-to-male attachment should become standard for enteric feeding. Though inadvertent intravenous infusion of liquid feeds intended for enteric use is unlikely, this tragic complication has been encountered. The two systems--enteric and intravenous-should be obviously incompatible. Academic Surgical Unit, St Mary’s Hospital, London W2 1NY 1.
L. P. FIELDING H. A. F. DUDLEY
Dudley, H. A. F Principles of General Surgical Management. Edinburgh, 1958.
Thatcher’s shadow cabinet, Mr Jenkin has steered his party away from adopting an extreme stand on health policy. Despite Labour charges that the Conservatives are out to "smash the N.H.S.", Mr Jenkin has repeatedly made it clear that he has no wish to dismantle the service. He supports the concept of a national health service. Having conceded the errors of the 1974 reorganisation, he rejects another wholesale shake-up. He has also managed to preserve the N.H.S. from the public-expenditure cuts which a Conservative Government would embark on, although he has said there would be no possibility of extra money. In all these respects Mr Jenkin has won the argument inside the Conservative Party over the future of the N.H.S. Where party policy has been left deliberately vague is in the areas of alternative finance. There is little doubt that a Conservative Government would immediately increase prescription charges, a prospect which Labour M.p.s are quick to condemn, despite the fact that the present Government has increased optical and dental charges on more than one occasion. The question of new charges, such as a hospital bed or meal charge, has been examined by the Conservatives and turned down "for the moment". But with a number of Conservative Nt.P.s favouring new charges, the Royal Commission’s report is likely to reopen the argument. Likewise the introduction of an element of health insurance into the financing of the N.H.S. has been pushed to one side by the Conservatives to await a verdict from the Royal Commission. Although the party favours the idea as a long-term aim, its statements on the matter remain deliberately vague. Mr Jenkin has always moved cautiously on the issues of health charges and private insurance. He recognises their extreme political sensitivity and the fact that Labour ht.P.s can be expected to make the most of the issues in an election
691
campaign. While the Royal Commission deliberates, Mr Jenkin can afford to be vague. But once the Commission reports the Conservatives will be expected to come up with some straight answers.
Notes and News MEDICAL STAFFING IN THE YEAR 2000
White-paper on Mental Health A Parliamentary campaign to introduce the legal concept that mental patients have a right to treatment is likely to follow lastweek’s white-paper’ reviewing the Reactions to the
1959 Mental Health Act. The Government’s failure to recommend this reform has been criticised by the National Association for Mental Health (MIND), which is now seeking support from M.p.s for a change in the law. Mr Ennals was more or less pleased with the reception given to the white-paper. He took the view that the criticism from MIND was only to be expected from a campaigning organisation. As a former campaign director of MIND, Mr Ennals admitted that he too would have chided the Government for not going far enough. Criticism in varying degrees came from several directions-the British Medical Association, the Confederation of Health Service Employees, the British Association of Social Workers. But the main expressions of disappointment came from MIND, with whom the Government had worked extraordinarily closely in reviewing the law. Mr Larry Gostin, of MIND, called it "a very unimaginative white-paper without any new direction for the mental health services either in terms of the patients’ rights or their needs". He was particularly disappointed about the lack of discussion on the need for positive rights at a time when a guaranteed right to treatment was being conceded in many other countries. He believed that, at the moment, if someone was admitted to hospital for treatment under section 26 of the Act and that treatment was not forthcoming, then continued detention would be unlawful. Treatment should be given as of right and not as of favour. Although recourse to the courts would be one way of testing the issue, the Parliamentary route is the one MIND would prefer to use. MIND’s detailed criticism of the white-paper will be put to Mr Ennals when the two sides meet shortly. The questions raised include the Home Secretary’s continuing power to detain patients indefinitely in psychiatric hospitals against the advice of medical opinion and mental health tribunals, and the white-paper’s failure to recommend changes in the law which allows people with psychopathic disorders not susceptible to treatment to be detained in hospital. The Government’s argument that this power should be retained because of possible future is not acceptable to MIND. There is criticism that the mentally handicapped should continue to come within the Act and finally, on the question of consent to treatment, MIND is not happy that the proposal for a second opinion on all hazardous treatments will work. Who, for instance, is to decide whether a treatment is hazardous in the first place? The proposed new multi-disciplinary panels which will give these second opinions are also regarded as unworkable by the B.M.A. The Conservative Party, equally disappointed at the white-paper’s failure to tackle what it regards as the real issues, will be pressing for an early debate on the subject when Parliament returns in November.
developments
1. See Lancet,
Sept. 16, 1978, p. 639
NO-ONE has got it right yet, and there is no reason to suppose that Maynard and Walker’ will succeed where Guillebaud, Willink, Todd, and others have failed. But at least the Royal Commission on the N.H.S., at whose request Maynard and Walker are writing, will be aware, if they were not
of the conflict between career structure and service needs which, were it not for the overseas doctors, would have come to a head years ago. "The pattern of medical practice in hospitals has at its core the notion of a team of doctors led by the consultant ... The notion of one junior doctor for every three to five consultants is not consistent with this style of practice." Something has to give, and the implication is that it will be the pattern of clinical practice. In predicting the manpower stock of the U.K. at the turn of the century, Maynard and Walker calculate what the "supply" will be with the postTodd medical-school expansion and with necessary, but difficult, assumptions about women doctors and immigration and emigration rates. As economists they might have been expected to look at "demand" from viewpoints other than the demographic, though in their conclusion their order of events should be policy then service implications then manpower requirements. Their estimates for the year 2000 range from 72 134 to 98 606, the "best guess" being 89 765 or 39% more than in 1975. When resource allocation is challenged a common argument is that Peter should get smaller increments than, but not be robbed to pay, Paul. If the privileged doctor/ population of Scotland were the target the upgrading would require 23 500 more doctors by 1990 while the increase in supply by that year would be only 14 000 or so. Differential growth-rates in career and junior posts might achieve a better balance at the top of the training ladder but would generate an intolerable number of elderly registrars. The message of this report is that medical manpower planning is essential but that the policies generated could be unpalatable in the short term.
already,
SCANNER ECONOMICS AGAIN LIKE British commentators2 the Office of Technology Asof the U.S. Congress3 sees in the computerised tomographic scanner a means of illustrating the questions that health-care providers should be asking of developments in medical technology. Some of the figures in this review (which, unlike the British one,2 is more concerned with the brain scanner than the whole-body one) are staggering, especially those provided by the firm of J. Lloyd Johnson Associates. By 1976 the United States had over 400 scanners, with running costs of around$300 000 per annum each but still yielding annual profits to owners of between$51 000 and$291 000 (11-65% of purchase price). If diagnostic power is the criterion for use then the case potential for c.T. head scans in the U.S.A. could be four million a year, a figure arrived at by the inclusion of patients with strokes and headaches, even though the diagnosis and management of a stroke would probably not be affected by the news the C.T. scanner bore and despite the fact that a patient with a severe headache is very unlikely to have a primary brain tumour. Both in the public and in the private sector those holding the purse strings have tried to check the efficacy of c.T. scanning before approving the procedure, but both Medicare and Blue Shield, acting on advice from the Busessment
Manpower 1975-2000. By ALAN MAYNARD and ARTHUR WALKER, University of York. H. M. Stationery Office. Pp. 60. £1.50. 2. Stocking, B., Morrison, S L. The Image and the Reality. Oxford, 1978; see Lancet, Sept 9, 1978, p. 587 3. Office of Technology Assessment. Policy Implications of the Computed Tomography (CT) Scanner. U.S. Government Printing Office $4
1 Doctor
Certain bore tube
whole-protein products do pass through the, -fineby continuous gravity drip and may, in most clinical situations, be more appropriate than elemental diets. Roussel Nutritional Division, Roussel Laboratories Ltd., Wembley Park, Middlesex HA9 0NF
J. C. CROW
Aubrey Road,
Northbridge,
New South Wales 2063
CATHERINE G. LEFEVRE
SIR The paper by Dr Metz and his’colleagues is a timely a technique which has been known and used for many years.’ The additional advantage of the current system is the flexible guide wire to position the tube. The push fit of a butterfly needle to join the tube to a flask of liquid feed is in our view clumsy. A male luer fitting should be part of the assembly attached to the proximal end of the narrow-gauge reminder of
NASOENTERIC FEEDING
SIR,—Dr Metz and his colleagues (Aug. 26, p. 454) describe a technique which is growing in clinical usage.’ However, their paper has led to some confusion, both in the U.K. and overseas, about the availability of the components. Although the tubes are manufactured by Portex Ltd. and the guide wires by Cambmac Instruments Ltd., Roussel Nutritional Division market the complete intubation set. The set consists of a guide wire with safety stop which ensures that the flexible distal tip cannot protrude through the open end; five polyvinyl-chloride radio-opaque 1 mm internal diameter tubes with luer fittings; and instructions. The intubation sets come in packs of five (i.e., 25 tubes). 1.
Fowell, E., Lee, H. A., Dickerson, J. W. T. in Nutrition in the Clinical Management of Disease (edited by J. W. T. Dickerson and H. A Lee), p. 341. London, 1978.
Commentary from Westminster From
our
Parliamentary Correspondent
Royal Commission and the Postponed Election THE Prime Minister’s decision to postpone a general election until 1979 may turn out to be embarrassing for The
the Conservatives. For it means that the report of the Royal Commission on the National Health Service could be published before an election, which would confront the Conservatives with the need for some awkward decisions. At the moment the party is avoiding committing itself on a number of sensitive issues on the justifiable grounds that it is awaiting the report of the Royal Commission. Labour’s attacks on Conservative ideas for introducing new health charges and extending private health insurance are parried by playing the Royal Commission card. Last month Mr Patrick Jenkin, Conservative spokesman on social services, answered a challenge from Mr David Ennals, Secretary of State for Social Services, by replying, "Answers to the detailed questions he has posed must await the report of the Royal Commission on the health service". But of course Mr Jenkin was speaking at a time when he confidently expected an October election. Now that this has been put off until the spring, summer, or autumn of next year, Mr Jenkin is faced with the possibility of actually having to answer some of Labour’s questions. The Royal Commission’s report is expected during the first half of 1979 and the earlier it comes the more likely it will be that Mr Jenkin will be forced to commit the Conservatives one way or the other on a number of issues. One of the more moderate members of Mrs
tubing. This fitting can easily be inserted into the tubing of a bladder irrigation set or intravenous infusion set connected to the flask of liquid feed. We recommend strongly that such female-to-male attachment should become standard for enteric feeding. Though inadvertent intravenous infusion of liquid feeds intended for enteric use is unlikely, this tragic complication has been encountered. The two systems--enteric and intravenous-should be obviously incompatible. Academic Surgical Unit, St Mary’s Hospital, London W2 1NY 1.
L. P. FIELDING H. A. F. DUDLEY
Dudley, H. A. F Principles of General Surgical Management. Edinburgh, 1958.
Thatcher’s shadow cabinet, Mr Jenkin has steered his party away from adopting an extreme stand on health policy. Despite Labour charges that the Conservatives are out to "smash the N.H.S.", Mr Jenkin has repeatedly made it clear that he has no wish to dismantle the service. He supports the concept of a national health service. Having conceded the errors of the 1974 reorganisation, he rejects another wholesale shake-up. He has also managed to preserve the N.H.S. from the public-expenditure cuts which a Conservative Government would embark on, although he has said there would be no possibility of extra money. In all these respects Mr Jenkin has won the argument inside the Conservative Party over the future of the N.H.S. Where party policy has been left deliberately vague is in the areas of alternative finance. There is little doubt that a Conservative Government would immediately increase prescription charges, a prospect which Labour M.p.s are quick to condemn, despite the fact that the present Government has increased optical and dental charges on more than one occasion. The question of new charges, such as a hospital bed or meal charge, has been examined by the Conservatives and turned down "for the moment". But with a number of Conservative Nt.P.s favouring new charges, the Royal Commission’s report is likely to reopen the argument. Likewise the introduction of an element of health insurance into the financing of the N.H.S. has been pushed to one side by the Conservatives to await a verdict from the Royal Commission. Although the party favours the idea as a long-term aim, its statements on the matter remain deliberately vague. Mr Jenkin has always moved cautiously on the issues of health charges and private insurance. He recognises their extreme political sensitivity and the fact that Labour ht.P.s can be expected to make the most of the issues in an election
691
campaign. While the Royal Commission deliberates, Mr Jenkin can afford to be vague. But once the Commission reports the Conservatives will be expected to come up with some straight answers.
Notes and News MEDICAL STAFFING IN THE YEAR 2000
White-paper on Mental Health A Parliamentary campaign to introduce the legal concept that mental patients have a right to treatment is likely to follow lastweek’s white-paper’ reviewing the Reactions to the
1959 Mental Health Act. The Government’s failure to recommend this reform has been criticised by the National Association for Mental Health (MIND), which is now seeking support from M.p.s for a change in the law. Mr Ennals was more or less pleased with the reception given to the white-paper. He took the view that the criticism from MIND was only to be expected from a campaigning organisation. As a former campaign director of MIND, Mr Ennals admitted that he too would have chided the Government for not going far enough. Criticism in varying degrees came from several directions-the British Medical Association, the Confederation of Health Service Employees, the British Association of Social Workers. But the main expressions of disappointment came from MIND, with whom the Government had worked extraordinarily closely in reviewing the law. Mr Larry Gostin, of MIND, called it "a very unimaginative white-paper without any new direction for the mental health services either in terms of the patients’ rights or their needs". He was particularly disappointed about the lack of discussion on the need for positive rights at a time when a guaranteed right to treatment was being conceded in many other countries. He believed that, at the moment, if someone was admitted to hospital for treatment under section 26 of the Act and that treatment was not forthcoming, then continued detention would be unlawful. Treatment should be given as of right and not as of favour. Although recourse to the courts would be one way of testing the issue, the Parliamentary route is the one MIND would prefer to use. MIND’s detailed criticism of the white-paper will be put to Mr Ennals when the two sides meet shortly. The questions raised include the Home Secretary’s continuing power to detain patients indefinitely in psychiatric hospitals against the advice of medical opinion and mental health tribunals, and the white-paper’s failure to recommend changes in the law which allows people with psychopathic disorders not susceptible to treatment to be detained in hospital. The Government’s argument that this power should be retained because of possible future is not acceptable to MIND. There is criticism that the mentally handicapped should continue to come within the Act and finally, on the question of consent to treatment, MIND is not happy that the proposal for a second opinion on all hazardous treatments will work. Who, for instance, is to decide whether a treatment is hazardous in the first place? The proposed new multi-disciplinary panels which will give these second opinions are also regarded as unworkable by the B.M.A. The Conservative Party, equally disappointed at the white-paper’s failure to tackle what it regards as the real issues, will be pressing for an early debate on the subject when Parliament returns in November.
developments
1. See Lancet,
Sept. 16, 1978, p. 639
NO-ONE has got it right yet, and there is no reason to suppose that Maynard and Walker’ will succeed where Guillebaud, Willink, Todd, and others have failed. But at least the Royal Commission on the N.H.S., at whose request Maynard and Walker are writing, will be aware, if they were not
of the conflict between career structure and service needs which, were it not for the overseas doctors, would have come to a head years ago. "The pattern of medical practice in hospitals has at its core the notion of a team of doctors led by the consultant ... The notion of one junior doctor for every three to five consultants is not consistent with this style of practice." Something has to give, and the implication is that it will be the pattern of clinical practice. In predicting the manpower stock of the U.K. at the turn of the century, Maynard and Walker calculate what the "supply" will be with the postTodd medical-school expansion and with necessary, but difficult, assumptions about women doctors and immigration and emigration rates. As economists they might have been expected to look at "demand" from viewpoints other than the demographic, though in their conclusion their order of events should be policy then service implications then manpower requirements. Their estimates for the year 2000 range from 72 134 to 98 606, the "best guess" being 89 765 or 39% more than in 1975. When resource allocation is challenged a common argument is that Peter should get smaller increments than, but not be robbed to pay, Paul. If the privileged doctor/ population of Scotland were the target the upgrading would require 23 500 more doctors by 1990 while the increase in supply by that year would be only 14 000 or so. Differential growth-rates in career and junior posts might achieve a better balance at the top of the training ladder but would generate an intolerable number of elderly registrars. The message of this report is that medical manpower planning is essential but that the policies generated could be unpalatable in the short term.
already,
SCANNER ECONOMICS AGAIN LIKE British commentators2 the Office of Technology Asof the U.S. Congress3 sees in the computerised tomographic scanner a means of illustrating the questions that health-care providers should be asking of developments in medical technology. Some of the figures in this review (which, unlike the British one,2 is more concerned with the brain scanner than the whole-body one) are staggering, especially those provided by the firm of J. Lloyd Johnson Associates. By 1976 the United States had over 400 scanners, with running costs of around$300 000 per annum each but still yielding annual profits to owners of between$51 000 and$291 000 (11-65% of purchase price). If diagnostic power is the criterion for use then the case potential for c.T. head scans in the U.S.A. could be four million a year, a figure arrived at by the inclusion of patients with strokes and headaches, even though the diagnosis and management of a stroke would probably not be affected by the news the C.T. scanner bore and despite the fact that a patient with a severe headache is very unlikely to have a primary brain tumour. Both in the public and in the private sector those holding the purse strings have tried to check the efficacy of c.T. scanning before approving the procedure, but both Medicare and Blue Shield, acting on advice from the Busessment
Manpower 1975-2000. By ALAN MAYNARD and ARTHUR WALKER, University of York. H. M. Stationery Office. Pp. 60. £1.50. 2. Stocking, B., Morrison, S L. The Image and the Reality. Oxford, 1978; see Lancet, Sept 9, 1978, p. 587 3. Office of Technology Assessment. Policy Implications of the Computed Tomography (CT) Scanner. U.S. Government Printing Office $4
1 Doctor
