678
gest that
combination of local toxicity and hypersensitbe ivity may to blame for loosening of the prosthesis. In their series all 7 patients were sensitive to cobalt and none to nickel or chrome. Metal sensitivity should be suspected when, after a technically successful arthroplasty with a cobalt/chrome implant, a patient complains of pain and there is no evidence of infection. Metal-to-metal bearings such as the McKee hip prosthesis shed many particles, whereas metal-to-plastic joint replacements such as the Charnley hip-joint14 apparently shed none at all. Probably this particle shedding is the primary stimulus for sensitisation. In 39 patients with Charnley arthroplasties skin sensitivity was no more frequent than in a control group awaiting operation.15 Because of the association between metal sensitivity and loosening of hip prostheses the metal-to-plastic type may be best for routine use. Such prostheses have a mechanical advantage too: all-metal joints have much greater frictional resistance which in itself puts a greater strain on the site of fixation. Lately metal sensitivity has also been recorded in relation to a vitallium plate used to secure a fractured ulna. Clearly there is need for further investigation of these clinically important reactions. Does the loosening occur before or after sensitisation to metal?" a
PRIORITIES FOR HEALTH AND PERSONAL SOCIAL SERVICES INTRODUCING this week’s consultative document,18 the Secretary of State for Social Services, Mrs Barbara Castle, said that one of the biggest challenges to effective democratic government was how to reconcile two politically conflicting aims; central government must be able to establish and promote certain national priorities, while the local agencies of government should have the maximum scope for making their own local choices in the light of their local needs. "This document", she added, "seeks to meet this challenge by turning planning into a co-operative enterprise..." The first essential, the document declares, is to maintain the standard of services: to put people before buildings. Within the overall increase in the programmes, capital expenditure will be cut back to allow current expenditure to rise from 1976-77 by 1.8% a year for the N.H.S. and by 2% a year for personal social services. To meet the estimated increase in demand for primary-care services, particularly the extension of family planning and of primary care for the elderly, and to cover the rising cost of the pharmaceutical bill, provision has been made for expenditure on the primary-care services as a whole to rise by about 3 8% a year. Emphasis should be given to encouraging the development of primary health-care teams and better distribution of manpower. A relatively large health-centre capital programme would be maintained. Pharmaceutical costs 14. Swanson, S. A. V., Freeman, M. A. R., Heath, J. C. ibid. 1973, 55B, 759. 15. Benson, M. K. D., Goodwin, P. G., Brostoff, J. Br. med. J. 1975, iv, 374. 16. Halpin, D. S. J. Bone Jt Surg. 1975, 57B, 451. 17. Elves, M. W., Wilson, J. N., Scales, J. T., Kemp, H. B. S. Br. med. J. 1975,
iv, 376. 18. Priorities for Health and Personal Social Services ery Office. Pp. 83. £1.60.
in
England.
H.M. Station-
should be prevented from rising unduly, and better value secured for expenditure on drugs. The level of growth envisaged for general and acute hospital services ( 1 2% a year) is considerably less than they have had in recent years. It would cover the burden on them of an increasing elderly population and allow for some spread of new methods of treatment. It would not permit the degree of improvement needed to meet all the pressures facing the services, particularly the need to reduce waiting-times and to promote new developments, Despite the sharp fall in the number of births in recent years, the cost of hospital maternity provision has considerably increased. A stringent review of maternity services is therefore suggested, with a view to reducing their cost by about 2% a year. The national targets suggested for services used mainly by the elderly include: expansion of the homenursing (and health-visiting) services by 6% a year; an increase in the number of local-authority residential places by 2000 a year and of day-centre places by 600 a year; an additional 1150 hospital geriatric beds a year and the provision of an increasing proportion of geriatric beds in general hospitals; and provision of 2000 beds a year in community hospitals for old people, including those with severe mental infirmity, to replace provision in unsatisfactory long-stay hospitals. In the services for the physically handicapped a high rate of expansion (9% a year) is suggested for home aids and adaptations and other services which contribute to mobility and quality of life. Further local community day-centre places should be provided. On the hospital side, special units for the disabled should have some priority claim on the reduced capital programme. For the mentally handicapped the priorities for the period to 1979-80 should include: maintenance of the target growth of local-authority training centres and residential homes, and improvement of staffing ratios and facilities in hospital services for the mentally handi-
capped. The priorities suggested for services for the mentally ill are: the continued development of community care, with particular emphasis on low-cost solutions; progress towards a district-based psychiatric health service; improving stafling ratios and physical conditions in existing hospital services; the provision of adequate secure accommodation in each region (a special capital allocation of £2.5m a year is being provided for regional security schemes); and the development of health and social services for alcoholics and drug misusers. The personal social services for children are under particular pressure from the growing number of children in trouble with the courts and the growing number who remain in care. The priorities are: improve ments in special care for babies in hospitals; expansion of health-visiting services to allow for improvements in monitoring child health and welfare and support to mothers (an annual increase of 6%); development of day-care services, especially for pre-school children (2.5%); development of services required for more effective implementation of the Children and Young Person Act (including two additional youth treatment centres and a local authority capital programme of about £10m to provide about 500 special community-home placesa year, including secure places for which direct grants will be available.
gest that
combination of local toxicity and hypersensitbe ivity may to blame for loosening of the prosthesis. In their series all 7 patients were sensitive to cobalt and none to nickel or chrome. Metal sensitivity should be suspected when, after a technically successful arthroplasty with a cobalt/chrome implant, a patient complains of pain and there is no evidence of infection. Metal-to-metal bearings such as the McKee hip prosthesis shed many particles, whereas metal-to-plastic joint replacements such as the Charnley hip-joint14 apparently shed none at all. Probably this particle shedding is the primary stimulus for sensitisation. In 39 patients with Charnley arthroplasties skin sensitivity was no more frequent than in a control group awaiting operation.15 Because of the association between metal sensitivity and loosening of hip prostheses the metal-to-plastic type may be best for routine use. Such prostheses have a mechanical advantage too: all-metal joints have much greater frictional resistance which in itself puts a greater strain on the site of fixation. Lately metal sensitivity has also been recorded in relation to a vitallium plate used to secure a fractured ulna. Clearly there is need for further investigation of these clinically important reactions. Does the loosening occur before or after sensitisation to metal?" a
PRIORITIES FOR HEALTH AND PERSONAL SOCIAL SERVICES INTRODUCING this week’s consultative document,18 the Secretary of State for Social Services, Mrs Barbara Castle, said that one of the biggest challenges to effective democratic government was how to reconcile two politically conflicting aims; central government must be able to establish and promote certain national priorities, while the local agencies of government should have the maximum scope for making their own local choices in the light of their local needs. "This document", she added, "seeks to meet this challenge by turning planning into a co-operative enterprise..." The first essential, the document declares, is to maintain the standard of services: to put people before buildings. Within the overall increase in the programmes, capital expenditure will be cut back to allow current expenditure to rise from 1976-77 by 1.8% a year for the N.H.S. and by 2% a year for personal social services. To meet the estimated increase in demand for primary-care services, particularly the extension of family planning and of primary care for the elderly, and to cover the rising cost of the pharmaceutical bill, provision has been made for expenditure on the primary-care services as a whole to rise by about 3 8% a year. Emphasis should be given to encouraging the development of primary health-care teams and better distribution of manpower. A relatively large health-centre capital programme would be maintained. Pharmaceutical costs 14. Swanson, S. A. V., Freeman, M. A. R., Heath, J. C. ibid. 1973, 55B, 759. 15. Benson, M. K. D., Goodwin, P. G., Brostoff, J. Br. med. J. 1975, iv, 374. 16. Halpin, D. S. J. Bone Jt Surg. 1975, 57B, 451. 17. Elves, M. W., Wilson, J. N., Scales, J. T., Kemp, H. B. S. Br. med. J. 1975,
iv, 376. 18. Priorities for Health and Personal Social Services ery Office. Pp. 83. £1.60.
in
England.
H.M. Station-
should be prevented from rising unduly, and better value secured for expenditure on drugs. The level of growth envisaged for general and acute hospital services ( 1 2% a year) is considerably less than they have had in recent years. It would cover the burden on them of an increasing elderly population and allow for some spread of new methods of treatment. It would not permit the degree of improvement needed to meet all the pressures facing the services, particularly the need to reduce waiting-times and to promote new developments, Despite the sharp fall in the number of births in recent years, the cost of hospital maternity provision has considerably increased. A stringent review of maternity services is therefore suggested, with a view to reducing their cost by about 2% a year. The national targets suggested for services used mainly by the elderly include: expansion of the homenursing (and health-visiting) services by 6% a year; an increase in the number of local-authority residential places by 2000 a year and of day-centre places by 600 a year; an additional 1150 hospital geriatric beds a year and the provision of an increasing proportion of geriatric beds in general hospitals; and provision of 2000 beds a year in community hospitals for old people, including those with severe mental infirmity, to replace provision in unsatisfactory long-stay hospitals. In the services for the physically handicapped a high rate of expansion (9% a year) is suggested for home aids and adaptations and other services which contribute to mobility and quality of life. Further local community day-centre places should be provided. On the hospital side, special units for the disabled should have some priority claim on the reduced capital programme. For the mentally handicapped the priorities for the period to 1979-80 should include: maintenance of the target growth of local-authority training centres and residential homes, and improvement of staffing ratios and facilities in hospital services for the mentally handi-
capped. The priorities suggested for services for the mentally ill are: the continued development of community care, with particular emphasis on low-cost solutions; progress towards a district-based psychiatric health service; improving stafling ratios and physical conditions in existing hospital services; the provision of adequate secure accommodation in each region (a special capital allocation of £2.5m a year is being provided for regional security schemes); and the development of health and social services for alcoholics and drug misusers. The personal social services for children are under particular pressure from the growing number of children in trouble with the courts and the growing number who remain in care. The priorities are: improve ments in special care for babies in hospitals; expansion of health-visiting services to allow for improvements in monitoring child health and welfare and support to mothers (an annual increase of 6%); development of day-care services, especially for pre-school children (2.5%); development of services required for more effective implementation of the Children and Young Person Act (including two additional youth treatment centres and a local authority capital programme of about £10m to provide about 500 special community-home placesa year, including secure places for which direct grants will be available.
