Sep 28, 2018 - samples of Cookery: "The NHS is magnifi- cent in rescuing .... seeking $lm in damages against the CIA for ... of Psychiatry 1956;112:502-9).
NEWS Anabolic steroids: the power and the glory? The use of androgenic substances to improve physical prowess is not new: in 1889 Brown Sequard attempted to restore his, failing powers of old age with injections of an extract of crushed guinea pig testicles. Later male sex hormones were shown to diminish nitrogen excretion in castrated dogs and eunuchoid men. This led to the hypotheses that such agents might be used to reverse the catabolic effects of trauma and to increase muscle bulk and strength in normally androgenised men. A search for derivatives whose anabolic properties could be dissociated from any androgenic effect followed, and yielded products such as nandrolone, stanozolol, and oxymetholone, which are now used by athletes to improve their performance. Muscles bear androgen receptors apparently identical to those of secondary sex organs, and the pharmacological effects of anabolic steroids include virilisation, suppression of luteinising hormone and testosterone secretion, testicular atrophy with decreased spermatogenesis, and fluid retention as well as their anabolic actions. It is not certain whether anabolic androgens improve physique or athletic performance more than diet and training alone. There have been few satisfactory experimental studies in man, though most double blind trials have failed to show changes in standard tests of strength. These investigations have certainly not dissuaded either steroid users or their coaches. Studies have usually considered muscle strength even though other androgenic effects, particularly aggression and hence competitive instinct, may be more relevant. Methandienone has been shown to increase muscle bulk. Athletes are prepared to take anabolic steroids in many hundreds of times the therapeutic dose, and no trial could ethically mimic such usage. All the anabolic steroids are androgenic and could not be evaluated at conventional doses in female athletes who might be expected to show noticeable improvement in muscle power. Any putative trial would need to include very large numbers of subjects to be reasonably certain not to miss a 1-2% improvement in performance: and it is such What price glory? differences that represent the margin between victory and defeat in international athletic hepatic func tion; increased packed cell events. Indeed, no negative trial is likely to volume valuees; insulin resistance; hyperbe as convincing to athletes as Ben Johnson's cholesterolaermia with an increase in the concentration of the low density lipoprotein performance in the Olympic 100 m final. Claims that the toxic effects of anabolic fraction; an iiincrease in blood pressure, left androgens occur only in patients and not in fit ventricular hyypertrophy, precocious myocarathletes are much easier to refute. Abnormal dial infarcticon, hypogonadotropic hypoBMJ
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gonadism, gynaecomastia, and psychotic states all occur; and carcinoma of rhe liver, prostate, and kidney have been reported in previously fit men who have abused anabolic androgens. Women athletes also show virilism with increased facial hair, acne, deepening of the voice, irregular 877
menses, clitoral enlargement, and increased aggression. In international events drug abuse can be detected by radioimmunoassay and gas chromatography-mass spectrometry, but abuse of anabolic steroids is not confined to the elite competing in the Olympic Games and World Championships. At lesser levels of sport the risks of detection are negligible, and among body builders steroid usage is so widespread as often to include beginners. Body builders and athletes who take anabolic androgens may come to medical attention because of side effects or because they believe that monitoring is prudent. What should doctors do? Obviously, no doctor should prescribe these steroids to athletes for anabolic purposes. There is, however, a large illicit market in products such as nandolone and stanozolol that will continue while drugs bought abroad, or intended for veterinary purposes, are so readily available. Doctors cannot, with real confidence, claim that anabolic steroids have no effect on athletic performance. But they should emphasise the clear and established dangers of these agents both to athletes and (equally forcefully) to their coaches. -R E FERNER and M D RAWLINS, Wolfson Unit of Clinical Pharnacology, University of Newcastle upon Tyne
Caring for the newborn Each year in England and Wales 3500 babies die before they are 1 month old. Many of these deaths, especially those in premature babies, are potentially avoidable, according to a report published on 28 September by the Royal College of Physicians. The report, Medical Care of the Newborn in England and Waks, is the culmination of two years' work by a group of paediatricians,
obstetricians, anaesthetists, pathologists, nurses, and midwives. The report recommends that each region should have one or two specialist centres where neonates who are ill and mothers with high risk pregnancies may be sent. This is in line with the recommendations of the Short report of 1980 (Perinatal and Neonatal Mortality, HMSO). The government reply to that report was that no extra money was available to fund its recommendations and that local health authorities would have to decide whether or not to implement them. As a result services for the newborn have evolved in a haphazard fashion. About 5-10% of births occur in small
maternity units, often staffed by general practitioners and sometimes geographically isolated from major centres. Most district maternity units have special care baby units that can provide short term care for neonates who are ill, but few have the facilities for more prolonged care. There is no widely agreed formula for the number of such cots needed. About 5-7% of babies are born prematurely, but they account for 70-80% of neonatal deaths. About 10% of newborn 878
Labour looks beyond Clarke
babies need specialised care and about 2-3% intensive care. In 1984 there were only 473 fully staffed and equipped intensive care cots in the United Kingdom compared with a recommended number of 729. Many infants at risk are now transferred before birth, and regional centres must provide both specialist obstetric and neonatal services. A further 70-80 consultants specialising in neonatal intensive care are needed, continues the report, and there are shortages of junior doctors and nurses in this subject. There are also deficiencies in the provision of laboratory services to back up the units. The training needs of doctors and nurses in neonatal intensive care are not being met. Staff shortages and restricted budgets make it difficult to allow staff to attend courses, and pressure of work reduces the opportunities for and value of cotside teaching. The report draws attention to the anomaly of providing resources to overcome infertility while failing to provide for the babies produced. Improved methods of monitoring and supporting ill babies, a better response to treatment, and improvements in obstetric care all increase the requirements for neonatal intensive care. Increasing numbers of low birthweight babies and multiple births Robin Cook add to the problems. In England and Wales the rate of survival of babies weighing less than 1000 g at birth has doubled from 21% in The Labour party is temporarily without a 1975 to 48% in 1985. Improvements in health policy for the 1990s-its conference at neonatal surgery have increased the number Blackpool this week deferred decisions-but of babies operated on for congenital that did not subdue Robin Cook, its wily shadow minister. He rounded off a personally successful summer by producing a 12 000 word green paper on health policy. This had the twin purpose of filling * All maternity units should have staff Labour's gap and pre-empting Kenneth and facilities for the immediate resuscitation and short term intensive care of Clarke's speech at the Tory conference next Thursday. Mr Cook assumes that the governneonates ment's review has failed to identify alterna* Where special care is provided the cots tive sources of health funding and that Mr should be recognised as $uch and staffed Clarke will have to root around for a form of accordingly words to cover the retreat. * The number of underused cots in But Mr Cook believes that two reforms special care units should be reduced in survived "among the rubble" and he have number parallel with an expansion in the disapproves of both. One is the internal of designated intensive care cots market enabling hospitals to buy and sell * District health authorities should this as giving power to develop community paediatric services to treatment. He sees direct to patients to a paradministrators who babies of allow for the early discharge ticular hospital. The other anticipated innohave needed specialor intensive care vation is tax relief for private medical cover* Long term intensive care should only which he denounces as a wasteful method of be done in appropriately staffed and subsidising inefficient health care. equipped units Having discounted the government's @ 1-5 intensive care cots should be Mr Cook embarks on what Labour review, births. live 1000 each for provided might do. Mostly it is ground covered by * Regions should establish working tank, though relieved by parties to examine the provision of peri- many a ofthink "The NHS is magnifiCookery: samples natal care cent in rescuing people from the grave, but * Regional centres should provide politely bored with them if they merely have audit, teaching, and research facilities a back pain," he writes on the problem of * Regional working parties should adapting to the advent of a large elderly monitor research, preventive measures, population that will need more caring than and the outcome of treatment. curing. A stronger Labour flavour comes through abnormalities, which places another burden in ideas for a Health Quality Inspectorate (to on the system. The report recommends that evaluate medical standards) and a Health the provision of intensive care cots should be Technology Commission (to assess high tech based on an allowance of 1-5 cots for each medicine). Control of drug costs could mean 1000 live births to take account of recent that the NHS manufactures its own generic trends. At present the shortfall is about 500 substitutes. It might also bring a ban on lavish hospitality for doctors on Meditercots. -STELLA LOWRY
Recommendations
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ranean islands in the guise of drug company seminars. (Mr Cook cites one example.) Indeed, the progression would be allowed no soft life. Consultants would be made subject to peer review, minimum workloads, and curbs on private practice, perhaps losing merit awards into the bargain. Mr Cook emphasises that Labour is not committed to his proposals, which he puts in the form of questions. He also asks whether regional health authorities should be dissolved and family practitioner committees absorbed. And he has pointed questions about whether performance related pay for general managers should be geared not to cost cutting but to rewarddeclining waiting lists and reduced mortality. Mr Cook is clear that Labour would ensure that health authorities had most members drawn from the town halls, health unions, and voluntary agencies -reflecting "political balance"-whereas at present, he claims, "the NHS is being ruthlessly converted to an internal one party state." Towards the private sector, he promises that it will feel the chill of "robust and fair competition" with the NHS, believing that without subsidy from public funds private health care cannot compete. Mr Cook plans two more green papers before the end of the year: one on community care and the other on health inequalities. JOHN WARDEN
Tory hurrah for NHS If the government is listening to its supporters in the Conservative party it will hear no demand for ideological reform of the National Health Service. On the contrary, the dominant sound from the grass roots is a hurrah for the NHS to continue as a tax funded and universal service. Resolutions to the party conference serve to transmit signals to the high command. The agenda for the Conservative conference at Brighton next week contains some 60 resolutions on the NHS, most of which endorse its basic principles. There is little discernible support for solving its problems with a swing to private medicine. The motion chosen for debate is proposed by the Conservative Women's National Committee. It underlines the need for the NHS to deliver effective health care to everyone who requires it. The resolution urges the government to introduce reforms to ensure that health authorities are meeting-and are seen to be meeting -their responsibilities in full. This will be the cue for Mr Kenneth Clarke, Secretary of State for Health, to make his first definitive statement since he was appointed in July. He winds up the health debate in the morning session on 13 October, which happens to be the Prime Minister's birthday. The speech is billed as an exposition of the fundamental review of the NHS that Mrs Thatcher initiated eight months ago. If that is so Mr Clarke has no mandate from his party to compromise the fundamental principle of free health care available to all at BMJ
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the time of need. No fewer than 45 of the resolutions submitted by constituency associations can be read as supporting the NHS. Several urge more government funding, and others would abolish the regional health authorities. Even the few resolutions that encourage a stronger private sector specify a partnership with the NHS. Interestingly, only five resolutions, or 8% of the total, advocate tax relief on private health subscriptions. On other health topics there is some support for compulsory testing for AIDS and for more exemptions from the proposed charges for optical and dental checks. -JOHN WARDEN
Unwitting victims In the 1950s many ordinary Americans were worried about brainwashing by the Communist nations. So was the Central Intelligence Agency. Few would have suspected, however, that for most of the 'fifties the CIA was funding studies in "behaviour modification" on hundreds of North Americans, often without their consent. A court case, due to start this week in Washington DC, may shed a little light on one such study. It has taken nearly eight years for the case of Mrs Velma Orlikow, the wife of a Canadian member of parliament, to get to court. She is seeking $lm in damages against the CIA for negligently financing a course of experiments performed on her while she was a patient of psychiatrist Dr Ewen Cameron at Montreal's Allan Memorial Institute in the late 1950s. Since initiating proceedings she has been joined by another eight former patients of Cameron who allege that they suffered from
treatments that were part of a covert programme bv the CIA to collect information on
brainwashing techniques. That the patients received the course of treatmcnts is not in doubt (see box). Nor is the source of some of Dr Cameron's funding:
documents released under America's Freedom of Information Act show hat the CIA (through a front organisation, tie Society for the Investigation of Human Ecologv) contributed some $84 000 to Cameron's projjects. What is in doubt is whether the course of research was conceived, designed, and managed by Cameron or whether the CIA influenced the direction of the research in some way. The agencv has always maintained that it was simply buying goods "off the shelf." No one knows whether Cameron knew of the CIA connection. Certainly he made no secret of what he was doing. Cameron promoted his methods enthusiastically at meetings and published accounts of them in North American and British journals-for example, the Journal of Mental Science. If his colleagues had any misgivings about his methods they never made them public. Part of this may have been explained by Cameron's position in Canadian psychiatry. Although originally qualifying in medicine from the University of Glasgow, he came to Montreal in 1943 to chair the department of psychiatry at McGill University and to direct the Allan Memorial Institute, a psvchiatric clinic administered jointly bv McGill University and the Royal Victoria Hospital. By the time of his death (in 1967) Cameron had been president of the Quebec, Canadian, and American Psychiatric Associations. In 1961 he had cofounded and been first president of the World Psychiatric Association. The CIA was attracted by Cameron's article "Psychic Driving" (American Journal of Psychiatry 1956;112:502-9). In it he
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Allan Memorial Institute, Montreal (previouslv Ravenscrag)
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Psychic driving One way of preparing patients for "psychic driving" was to put them into a state of sleep for about 10 days by prolongqi. using vaous drugs. Then a course of electrocoAvulsive therapy would begin,
sometimes 20-30 times as intense as "normal" electroconvulsive therapy. This "depatterning" would then be maintained for about another week, with shocks being reduced to three each week. This was followed by reorganisation, during which patients would undergo considerable anxiety and be given chlorpromazine and amylobarbitone. Sensory deprivation, sometimes for as long as 16 days, was an alternative form of preparation for psychic driving.
described a course of treatment that would implant a repeated message in a patient's mind for long after the treatment. At the time the CIA was interested in anything that might increase its understanding of brainwashing-the automaton like behaviour of some defendants at Soviet show trials had unnerved it. So too, closer to home, had that of American prisoners of war returning from Korea: according to John Marks's The CIA and Mind Control, by the end of the Korean War 70% of the 7190 American prisoners held by China had either made confessions or signed petitions calling for an end to the American war effort, and another 15% had fully collaborated with the Chinese. According to the New York Times (which first published the story of the CIA's funding of Cameron's work in August 1977), the CIA wanted ways of rendering people subservient to external control. Another of its goals was to be able to induce amnesia. The agency wanted to be able to interrogate foreign agents without either them or their superiors knowing what had happened. And they wanted to be able to wipe clean the memories of their own agents after certain missions, and especially on their retirement. To this end the CIA set up a programme called MKULTRA, for "ultrasensitive work" in behaviour control. The topics that Cameron were investigating were of particular interest to the CIA, and it was keen that difficulties with funding should not prevent his work from continuing. Despite funding him for three years the CIA never got anything of use out of Cameron's programme of psychic driving. According to Don Gillmor's I Swear by Apollo: DrEwen Cameron and the CIA Brainwashing Experiments, Cameron himself admitted the failure of the method in 1963 at a meeting of the American Psychopathological Association (of which he was president). What is known of the CIA's 25. year $25m attempts in behaviour modification suggest that little progress was made. Nevertheless, evaluation is difficult: on leaving the CIA, director Richard Helms ordered that all documents pertaining to behaviour control research, specifically MKULTRA documents, should be destroyed. In the decade since the appearance of the 880
Psychic driving consisted of messages played on tape recorders and repeated to the patients thousands of times. For 16 hours a day for the first 10 days the patients would receive negative messages, which were then followed by 10 days of positive messages. To keep the patient receptive to the messages injections of curare and beeswax were given. Lysergide (LSD) was sometimes given. Psychic driving was used mainly with psychoneurotic patients. From: Opinion of George Cooper, QC, Regarding Canadian Government Funding of the Allan Memorial Institute in the 1950s and 1960s, Minister of Supply and Services Canada, 1986.
articles in the New York Times the main response of the Canadian government to the CIA's funding of research on its subjects (a breach of its sovereignty, if nothing else) has been to commission an independent legal opinion from a Halifax QC, George Cooper. Although criticising Cameron's methods, he found no serious impropriety. The Canadian government has, however, offered to contribute towards the legal expenses of the defendants in the Washington trial. The Canadian psychiatric fraternity has been remarkably coy about the episode. Its psychiatric association has issued a statement pointing out that the results of Cameron's experiments were submitted to and accepted by peer reviewed journals, and, although his research would not be accepted by today's standards of ethical and scientific inquiry, this cannot be used as a retrospective critique of his work. Much progress has been made in ethical standards and the conduct of medical research since then, it argues. I could not find this statement published in the Canadian Journal of Psychiatry up to June 1988. Other Canadian medical journals have been similarly reticent to discuss the many ethical, political, and medical issues raised by this episode. "Why stir things up?" the representative of one asked me recently. If anyone comes out of this episode With any credit it is the "non-professional" press, which has ferreted out the unhappy details in the face of official displeasure and noncooperation. -TONY DELAMOTHE
Simple solutions David Morley, professor of tropical child health at the Institute of Child Health, is marking his approaching retirement by taking on yet another new project: he is helping to set up a unit of growth promotion. Professor David Morley studied medicine at Cambridge and St Thomas's Hospital, London, and it was during his national service in Malaya that his eyes were opened to the inequalities of health care.
On his return to England he participated in the thousand families project in Newcastle. This long term study of child health in the home followed the progress of the first 1000 children born on Tyneside during May and June 1947. The work showed that most illnesses, even in Britain, are treated by non-professionals. Professor Morley later extended this idea when he showed that in Nigeria infant mortality could be cut by over 80% by education and the intelligent use of available resources. In Imisi local women were trained to immunise the children, and measles was eradicated. On a budget of less than £1.00 for
David Morley
each person each year Professor Morley found that the most important resource was people. He has consistently promoted the education of women and has proved that a literate mother protects and nurtures her child better than an illiterate one. Among Professor Morley's achievements are the "road to health" charts, which provide a simple daily record of infant growth so that malnutrition can be detected in the early stages. His idea of clinics for children under 5 was the basis for a worldwide improvement in child health. He also devised a "child to child" programme, in which older children were taught to care for younger ones. Children learnt to monitor their peers for signs of malnutrition and to teach each other by means of simple games about how to reduce the effects of infectious diseases. The result is, paradoxically, both measurable and incalculable. Child mortality has been reduced by nearly two thirds in places such as Turkey and Botswana, and measles is now almost unknown in Zimbabwe. Oral rehydration treatment has been widely accepted and has reduced the cost of treatment and taken it from the sphere of professional skill to the hands of mothers. Harder to measure has been the educational benefit of Professor Morley's ideas. Only when the whole community acknowledges a hazard will dangerous practices be abandoned. In 1965 Professor Morley
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founded TALC-teaching aids at low costan organisation that has promoted health education at village level by using cheap but effective tools such as pamphlets and flannel graphs. Professor Morley has already shown the inportance of literacy, but now he aims at tackling innumeracy so that progress can be monitored. Already weighing scales that incorporate a device for recording directly on to a card and height-weight charts that take no account of age have been developed. At times Professor Morley has had to suffer the scorn of colleagues in medicine and politics who have argued that his ideas are too simple to be effective. Time and again they have been proved wrong. -ANNE SAVAGE, London
MRC directed research on AIDS The Medical Research Council's directed programme on AIDS research is going extremely well and may serve as a model for organising research on other topics, said Dr Geoffrey Schild, director of the programme, at a press briefing last week. The programme is, said Dr Schild, unmatched internationally for its coherence and is currently being studied by the French. Dr Dai Rees, secretary of the MRC emphasised that the council had never before organised a directed programme on such a scale and said that it had served to increase greatly the impact of British AIDS research. The directed programme is, however, only one part of the research effort on AIDS. It is concerned with producing vaccines and antiviral agents, while the rest of the programme -the strategic programme-is concerned with epidemiology, clinical research, public
Reverse transcriptase into space As part of the British research effort to combat AIDS last week's American shuttle took into space some reverse transcriptase produced in Britain. Crystals of reverse transcriptase, the enzyme that allows RNA viruses like the human immunodeficiency virus (HIV) to make DNA, were first produced about a year ago by the antiviral research group of Wellcome. The hope is that much better quality crystals will be produced in space so allowing crystallographers from the laboratory of molecular bio physics at Oxford University to achieve a better understanding of the three dimensional structure of reverse transcriptase. Such an understanding may then allow synthetic chemists to manufacture a drug that will block the enzyme, so producing a treatment for AIDS and HIV infection. This exciting project illustrates how the AIDS directed programme of the MRC is working. Wellcome came to the MRC and asked it to help with getting x ray analysis of the crystals. The MRC devised a contract and put it out to tender. Britain has a strong tradition in crystallography, and several groups tendered for the contract,
health research, and research on AIDS in Africa. Dr Rees said that this sort of research did not lend itself to direction-it had to be more responsive to developments that were unpredictable. It is therefore organised in the conventional way through the council's boards and grants committees. The MRC is now spending about £5m a year on its directed programme, which began in early 1987. The government originally
Plan of MRC's directed programme of research on AIDS Enabling research
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Preparation of candidate vaccines and antiviral agents
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Precfinical evaluation
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Characterisation of human immunodeficiency virus (HIV) and immunodeficiency viruses of animals, including studies of virus variation. Characterisation of virus components: physical and chemical properties, biological function. Immunological studies of individuals with HIV infection. Cell biology: studies of cell surface receptors, cell and tissue tropisms. Study of HIV regulatory genes and their products. Cloning and expression of genes of HIV and other immunodeficiency viruses. Preparation of candidate vaccines and adjuvant materials. Chemical synthesis of candidate antivirals; extraction and modification of natural products. More speculative approaches to treatment (for example, antisense oligonucleotides, inhibitors of frameshifting). Testing immune responses to vaccines in small animals. Use of animal models of infection for evaluating vaccines and treatments.
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Clinical evaluation
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Laboratory testing of antiviral agents in a wide variety of in vitro systems. Development of reagents and assays. Development of technical, practical, and ethical guidance for the conduct of AIDS vaccine trials. Planning and execution of AIDS vaccine trials protocols.
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Crystals of reverse transcriptase from human immunodeficiency virus
which was eventually awarded to the Oxford group.
gave extra funding of £14-5m over three years. The council hopes to increase spending on the directed programme to £9m a year by 1990-91 and is currently negotiating with the government for extra funding. A decision is expected by December. The directed programme is now supporting about 70 projects and 350 people, and, said Dr Schild, "it will need to grow." Organisation-The "wider aspects" of the MRC's research on AIDS are overseen by a special committee of the council, while a special steering committee oversees the directed programme. The programme has a scientific plan (see box) and only projects falling within the plan are funded. There is a fast track system for processing grant applications relevant to the programme, and -unusually for the MRC-scientists are helped to raise the standard of their applications. Scientists and laboratories are invited into the programme, and 10 informal working groups that meet three to four times a year are of central importance in monitoring progress and spotting opportunities. Dr Schild aims at balancing cooperation and competition (always important in science) and at avoiding too much duplication of effort but allowing some overlap. Central provision-An important part of the directed programme is the central provision of reagents, virus strains, and cell lines. Antiviral testing and testing of vaccines and drugs in animals is also centralised. Clinical evaluation will also be centralised when it begins, and committees have been set up to prepare general guidance on both the scientific and ethical aspects of testing vaccines. Training-Shortage of trained staff, especially postdoctoral scientists, has held back the programme, and so 20 research
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studentships have been awarded in virology and immunology. Periods of training abroad are also being arranged. International collaboration-Dr Schild's laboratory at the National Institute for Biological Standards and Control is one of three centres in tit world that holds a comprehensive collecti of virus strains, cell lines, and biological agnts. It cooperates with the
The
Collaboration with industry-In line with the political spirits of the times the programme has many collaborations with industry. The MRC recognises that it will be industry that eventually develops and markets both vaccines and drugs. An example of how the MRC, industry, and academia can work together is shown in the second box. -
private sector was given "greater emphasis at the expense of the more efficient NHS then value for money could well fall." The opportunity is also taken-and who can blame the Scots for doing so?-to remind readers that Scotland already "leads the field in key areas," quoting one example as the higher rates of immunisation and paediatric screening than in England and Wales. (If I qualify this commendable achievement by daring to mention again that each year Scotland receives more funds per citizen for the NHS than England or Wales I shall be ambushed at Hadrian's Wall next time I venture across the border.) Claiming that many if not most of the initiatives and developments within the NHS have been led by the medical profession, the BMA in Scotland argues that improvements should come from fine tuning the service rather than by radical surgery. Slightly enhanced funding and the profession working together with management and the government are the suggested remedies. Not too much to disagree with there, except that consultants in Birmingham (see below) would judge "slightly enhanced funding" as being somewhat understating the case.
penalising increased productivity with a lockout ofthe labour force and closure ofthe plant, despite residual demand." Their report explains why at the Queen Elizabeth Hospital, Birmingham, 146 beds have been closed (including five in intensive care), surgeons operate only six weeks out of seven, and clinicians in 1987-8 were asked to do no more than 90% of the work carried out in 1986-7. This all adds up to a call for more funds, and consultants in Birmingham have set an example to others by making a case for these instead of just shouting for more moneyshroud waving as some managers sourly describe it.
RICHARD SMITH
Week
More
reports on NHS
Next week, assuming the political astrologers are correct, we will be told something about
the Prime Minister's review of the NHS. Will Kenneth Clarke, Secretary of State for Health, reveal a tantalising proposal or two for his Conservative colleagues at their annual meeting in Brighton or will he offer full frontal exposure of the government's plans? Perhaps he and the Prime Minister have not yet decided, given the unpredictable political winds that shape the shifting sands of a party conference. Meanwhile reports on NHS funding continue to fall on us like autumn leaves, the authors no doubt hopeful that their ideas may yet encourage or dissuade the ideologues in and around 10 Downing Street from recasting the health service. The biggest report this week-and the one least likely to deflect the government from whatever path it has chosen -is a 12 000 word green paper, Questions of Health, from the Labour party, whose annual conference will have ended by the time many of you read this page. John Warden, the BM7's parliamentary correspondent, reviews this discussion paper at p 878. Whether or not the government dismisses the Labour party's document and despite the persistent political diagnosis that Labour is unelectable the profession should study it. Robin Cook, main author and his party's health spokesman, is an able politician who asks many valid and provocative questions about the future of the NHS. His ideas could affect your future. Another report-or, more accurately, a statement -comes from the BMA in Scotland and was unveiled at a press conference on 3 October by Dr Angus Ford, chairman of the Scottish council. Commitment of Care: Choices for the Future challenges the government's (and management's) claims that the NHS is inefficient and costly. Counterattacking, the BMA claims that the NHS's greatest success has been its ability to provide a high quality service "so very cheaply." In global terms it is "one of the most cost effective in the world." To highlight this efficiency the statement quotes one of Edwina Currie's many ministerial pronouncements in which she reported that the cost of an operation on varicose veins in the NHS was £600 compared with around £1000 in the private sector. The BMA warns that if the 882
World Health Organisation in distributing samples. The MRC also has broader links with WHO and has signed a formal agreement for cooperation in AIDS research with the French government agency responsible for medical research. An agreement is also expected with West Germany, and links with the United States agencies are extensive if less formalised.
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The third report this week comes from the Birmingham Consultants for the Rescue of the NHS. Earlier this year they drew the public's attention to the travails of the hospital service in the West Midlands. This time they have embarked on a broader if well worn theme: "The case for better funding for the NHS." I mean no disrespect when I say that what they argue has no great originality. Yet it is well nigh impossible to put forward new ideas so long and loud has the subject been discussed, and the Birmingham consultants make their case succinctly. They emphasise that the relative purchasing power of the NHS has declined because health costs have risen faster than the retail price index, the key figures used by the Treasury for deciding the annual rise in NHS funding. They go on to identify the "efficiency traps," arguing that "in any other sector of the economy, increased productivity would reduce marginal costs and raise profits." In the NHS, they continue, "underfunding has penalised increased productivity by imposing cuts in order to contain the total wage billthe equivalent in manufacturing industry of
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In BMA House the superannuation committee met and re-elected Benny Alexander, chairman of the representative body, for his 10th term of office as chairman. Two more familiar BMA faces were also re-elected chairmen of their respective committees: Colin Smith, senior lecturer in medicine from Southampton, will lead the Medical Academic Staff Committee, and David Farrow will preside over rural practice. The medical academics covered many subjects at their meeting (30 September), but the financial squeeze on medical schools prompted them to survey the effects of bed cuts on education. (At least this year the perennial anxieties about pay parity with NHS colleagues was assuaged as this has already been conceded by the government. Sadly, though, the problem of paying preclinical academic staff competitive salaries to attract suitably qualified (medical) doctors remains as intractable as ever.) Another subject that raised the temperature a littleMASC is not by nature an exuberant gathering-was rising defence society subscriptions, and the council will be debating that and the potentially divisive proposal for differential subscriptions at its meeting on 5 October (after the BMJ has gone to press). Finally, still in BMA House, but at the lunch table, where I heard of a prestigious London postgraduate teaching hospital that attracted only three applicants for a consultant anaesthetist post and of a partnership vacancy in a rural practice in the north of England that attracted around 90 applicants, five of them practising consultants in their mid-40s. Freak occuTrences or straws in the wind? SCRUTATOR
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