Apr 4, 1987 - Open access to orthopaedic appliances for ... Snadden); The elusive orthopaedic senior ..... the traction type (it had been inserted at another.
BRITISH MEDICAL JOURNAL
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VOLUME 294
4 APRIL 1987
CORRESPONDENCE Drums begin to beat in the waiting list jungle Sir Anthony Alment, FRCOG; W A Wallace, FRCSED; C M Ward, FRCS........................... 898 Dangers from dissolution of latex in Celestin endo-oesophageal tube L R Celestin, FRCS; S A Hussain, FRcs, and others; G J Poston, FRCS............................ 899 Assault on a GP F Wells, MB; N J Cooling, MRCPSYCH; J A Wall, MRCS ............................................ 900 Effect of chloroquine on insulin and glucose homoeostasis in normal subjects and patients with non-insulin dependent diabetes meilitus R G Rees, MRCP, and M J Smith, FRCP; A Peiris, MRCP, and A H Kissebah, MD ............ 900 Alcohol and violence D W Yates, FRCS, and H Chambers, RSCN ...... 901 Effect of dietary cholesterol on plasma cholesterol concentration P J Nestel, FRAcP ................................. 901 Better reporting of adverse drug reactions GJones, FRCP, and R D Mann, MRCS ............ 901 Adverse reaction monitoring using cohort identification W H W Inman, FRCP, and N S B Rawson, MSC 902
Father fails in attempt to stop girlfriend's Social future of elderly admitted to acute care abortion hospital C H Paine, FRCP ............................. ........ 902 C Reisner, MRCP ..................................... Neuropathy of the feet due to running on cold What contribution has cardiac surgery made surfaces to the decline in mortality from coronary T R Whelan, MB, and R P Craig, FRCS ........... 902 heart disease? Future of the pathologist in an era of R Beaglehole, FRACP ................................ technological change and cost containment Eczema herpeticum: a potentially fatal disease T A Gray, MRCPATH, and others; M G Rinsler, J A Dudgeon, FRcP ................................. FRCPATH............................................. 902 Outbreak of Weil's disease in a food fad What's new in the new editions? commune in India D M Hadley, FRCR; I Isherwood, FRCR ......... 903 D K Srivastava, MD ................................. Open access to orthopaedic appliances for Immunoscintigraphy of metastases with general practitioners radiolabelled human antibodies J A Reardon, MRCP.................................. 903 K C Ballantyne, FRCS ............................... Restless legs syndrome Late abortions M L Robinson, MRCPSYCH ........................ 903 V Argent, MRCOG................................. Epidural morphine-for outpatients with severe anginal pain Points AIDS and intravenous drug use (D J W G Notcutt, FFARCS; S E Clemensen, MD, Goldberg); Child abuse (Geraldine R and others ................................. 903 Boocock); Syringe driver in terminal care (D The Liverpool urban obstetric flying squad Snadden); The elusive orthopaedic senior G M Kidd, MRCOG, and T Ryan, FFARCS ........ 904 house officer (J K Anand); Poor start for the rreating postural hypotension Health Education Authority (C F Donovan) I B Davies, MRCP; R D S Watson, MRCP ........ 904 Macrocytic anaemia in patients treated with Corrections: Osteoporosis: cause and managesulphasalazine for rheumatoid arthritis ment (Fowler); Why doctors must grapple P Prouse, MB ......................................... 904 with health economics (Storring) ................
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Because we receive many more letters than we have room to publish we may shorten those that we do publish to allow readers as wide a selection as possibk. In particular, when we receive several letters on the same topic we reserve the right to abridge individual letters. Our usual policy is to reserve our correspondence columnsfor letters commenting on issues discussed recently (within six weeks) in the BMJ. Letters critical ofa paper may be sent to the authors of the paper so that their reply may appear in the same issue. We may also forward letters that we decide not to publish to the authors of the paper on which they comment. Letters should not exceed 400 words and should be typed double spaced and signed by all authors, who should include their main degree.
Drums begin to beat in the waiting list jungle SIR,-Dr Maureen Dalziel and Mr J Kerr have heard drums in the waiting list jungle (21 March, p 722), but there is little sign yet that the wood is distinguished from the trees. The vast chopping exercise now on its way will certainly create clearings, but how fast will new growth replace it? Concentrating on variations of supply without closer examination of demand will not produce a lasting solution. Redistribution certainly makes surgery available sooner, at the cost of travel, with some districts even willing to trade off whole groups of patients (such as those requiring abortions) to accommodate others. While that is a tolerable expedient if the whole problem is being faced, it is nevertheless a negation of the principle by which doctors cooperate within their community to meet its needs. The personal contract between the patient, the general practitioner, and the surgeon, seen as one of the benefits of private care, is fading fast in some National Health Service specialties to the point where, being unattainable, it is no longer seen as desirable. The equilibrium which can exist in some specialties, whereby large waiting lists seldom vary, undoubtedly generates private facilities and the growth of the insurance industry that services them. Timing, rather than privacy or the choice of the surgeon, is probably the most valued commodity offered by the private sector, especially to group industrial and commercial clients. The fact that many surgeons thus gain substantial added income both confirms the true market value of their skills (though there are signs that the insurers
are restive) and exposes them to criticism about the time they devote to the NHS. A waiting list marks the acceptance of responsibility between the events of consultation and admission, and as it broadly distinguishes.surgical from medical specialties it is a major cause of tension in the competition for resources. The surgeon who sees his potential contribution severely limited by circumstances beyond his control is rightly disaffected and frustrated. With no clear understanding of who should carry the responsibility between the general practitioner and the hospital for rationing access to treatment, the burden falls on the shoulders of many, from admission clerks to managers. In view of the growing gap between tomorrow's medicine and today's resources the importance of both cost effectiveness and medical priorities is clear. The fundamental question is how closely the decisions made at consultation reflect the availability of resources. Some new consultants do adapt as is shown by the growth curves of their waiting lists from zero to plateau when the curve of learning about resource realities levels off. Nevertheless, the two basic conditions of surgical facilities geared to the agreed current and changing needs of a specific community and a steady feedback from general to specialist practice about the effectiveness of specialist care remain unfulfilled. There has been little study of the differences between referral rates of individual general practitioners or groups, though the few contributions have generally been of high quality and show that
the outcome of consultation and treatment may be perceived very differently by the general practitioner and the specialist.' How far a surgeon may vary the level and quality of care for patients depends on firm trust that his conscience is clear and that he will not be exposed in the courts for the lack of clothes the service does not provide. Current attacks on filing cabinet waiting lists, mounted with large sums of money thrust into the system at short notice, are more a political than a medical remedy. They encourage temporary purchasing outside the NHS, regardless of the long term consequences. The uncontrolled waiting list is fundamentally a problem of clinical management, and 'its remedy lies with the individual consultant, or a group, or doctors in the district as a whole. To transfer its management away from doctors to managers is to distance the source from the remedy. But unless there is a new thrust of concern and cooperation from those who originate waiting lists from primary medical care there will be no lasting solution. It is yet another example of a divided health service. ANTHONY ALMENT Boughton, Northampton NN2 8RR I Kamien M. An Australian's impression of general practice in the United Kingdom. I R Coll Gen Pract 1987;37:36-8.
SIR,-The analogy drawn by Dr Maureen Dalziel and Mr R Kerr (21 March, p 722) between waiting lists and the travel business is most appropriate.
BRITISH MEDICAL JOURNAL
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As anyone who goes abroad knows, some holidays are much more successful than others and tend to be booked up well in advance, with the good hotels receiving the earliest bookings. Good travel firms tend to use reliable locations and hotels with a good reputation, whereas cheap package holidays do not always provide a good quality holiday. Though surgical care in the National Health Service is generally very good, standards do vary, and, as in the travel business, the centres with a good reputation tend to have the greater number of advance bookings. I think, however, that the analogy ends as soon as the holiday is over. The holiday is either good or bad, and after it normal life resumes. This is not the case with surgical operations, where the long term effect of a bad operation may be disastrous for the patient. In my particular specialty joint replacement is the prime example. When a joint replacement is carried out badly the result may be years of suffering for the unfortunate patient. Though the general concept of shipping patients around the country may be appealing in the short term, it is important to identify how complications would be, managed and what formal follow up arrangements would be made for these patients over the subsequent years. If we are to move patients around the country for joint replacements computerised follow up will have to be introduced, with consultant orthopaedic surgeons being graded according to their success and complication rates. Once such a system is introduced the patient will be able to move confidently from one centre to another for joint replacement, and presumably long term follow up, with some knowledge of how successful particular consultants are in this specialty. W A WALLACE Department of Orthopaedic and Accident Surgery, University Hospital, Queen's Medical Centre, Nottingham NG7 2UH
SIR,-Dr Maureen Dalziel and Mr R Kerr (21 March, p 722), quite rightly appeal for a change in traditional attitudes and practice among surgeons in an effort to reduce waiting lists. A report in the same issue (p 783) discussed the government sponsored seminar, "Action on Waiting Lists and Times," at which Sir Roy Griffiths also called for management and medical will to effect these changes. As was evident at a meeting on 20 January at the Royal Society of Medicine on "Day Surgical Treatment," however, there seems to be little incentive and no reward for those who have the will and who have already changed their managerial practice to shorten inpatient stay, increase patient throughput, and reduce waiting lists. It still seems that a short waiting list may be regarded only as a sign of low patient referral, not of efficient surgical practice, whereas a long waiting list indicates only a greater clinical workload, not inefficiency.' The cynical observer might be forgiven for believing that it is an advantage to a surgeon to have a long waiting list. It certainly does no harm to his private practice, and he may now have the excess patients on his National Health Service waiting list treated in another hospital, with the help of a £25m government handout that in itself does nothing to solve the basic waiting list problem and has yet to prove anything other than a preelection lollipop. The first priority should be to attract nurses back to work in the hospitals. Only when the nursing establishment is restored can we realistically implement proposals for all staff concerned in the care of surgical patients to encourage greater efficiency. In such circumstances, the £25m might have been put to better use in solving the long term
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problem of waiting lists in bonus and incentive monitor patients with Celestin tubes regularly. We schemes. believe that the tube in our report may have been of CHRISTOPHER M WARD the traction type (it had been inserted at another hospital); but there are always some patients who Department of Plastic and Reconstructive Surgery, are lost to follow up. West Middlesex Hospital, Checking a Celestin tube when it is in place can Middlesex TW7 6AP be difficult. Close inspection with fibreoptic endoI Sherman J. The ills of inefficiency. The Times 1987 Mar 19:15, scopes or contrast radiological studies may fail to cols 1-5. show small cracks in the tube. These may herald the breaking up ofa tube, which can happen at any time despite close follow up. It seems that none of Dangers from dissolution of latex in Celestin the three choices ofmaterial given by Mr Celestinendo-oesophageal tube that is, plastic, silicone, and latex-is entirely SIR,-The case report of Mr S A Hussain and satisfactory. colleagues (14 February, p 412) raises many points of clinical, medicolegal, and technical importance. It must be assumed that as the patient was deemed unfit for surgery a Pulsion tube was inserted. Since 1983 these tubes have carried a radio-opaque nylon spiral that is easily visible on radiography of the abdomen, and it is bad clinical practice not to monitor them regularly or change them every six months if necessary. They have been produced in both latex and silicone. Furthermore, in patients with benign oesophageal strictures tubes should be removed after about six months as their purpose is to determine a final matured size of the lumen at the level of the stricture. Endo-oesophageal tubes of all kinds are used, and whenever an obvious cause-for example, appendicitis-is not found for abdominal pain in a patient who has had a tube inserted the doctor should request radiography of the chest and abdomen. Abnormal linear opacities in the abdomen should immediately suggest the possibility of migration of the prosthesis. The authors recommend a change in the construction of such tubes. This, however, is easier said than done. Three main substances are available for the manufacture of these tubes: plastic, silicone, and latex. Both plastic and silicone harden with Abdominal radiograph showing opaque linear marks time and may lead to ulceration at the lip of in left hypochondrium and suprapubic regions, V shaped funnels, with disastrous results. Silicone indicating break up of Celestin tube. tubes have to be moulded, and the inclusion of air bubbles in their shaft cannot always be avoided. Our purpose in reporting this case was to point This may lead to blistering and blocking of the lumen. Plastic and silicone are hydrophobic, and out that unexplained acute abdominal pain in food particles cling to the walls of such tubes, a patient with a Celestin tube should suggest increasing the incidence of blockage. For the same the possibility of tube fracture, as AMr Celestin reason, flexible endoscopes pass through them emphasises. Abdominal radiographs showing less easily than through latex tubes. Latex opaque linear marks, indicating tube migration or tubes, however, are hydrophilic and swell break up (figure), may help in the diagnosis. after insertion, gripping a tumour or stricture more S A HUSSAIN closely and reducing migration. These tubes are R HUGHES produced by a process of layering, and if the E GROSS innermost layer is damaged by the use of an incorrect introducer deterioration may occur. Department of Surgery, Latex softens with time, but this usually takes at Victoria Hospital, Bumley, least six months. The manufacturer therefore Lancashire BBIO 3HP recommends that the tube be checked after six months. To have left a tube in situ for 20 months is not sound clinical practice. Most endo-oesophageal tubes are meant for inoperable malignant cases, SIR, As Mr S A Hussain and colleagues point and if a patient survives intubation for considerably out, the disintegration of Celestin tubes is not a more than six months he or she has probably been new phenomenon; I reported three similar cases in 1983.' As in the case described by Mr Hussain selected inappropriately. When used judiciously intubation has an import- and colleagues, our patients presented with ant role in inoperable dysphagia, and much thought symptoms not immediately ascribable to their has gone into the design of tubes and the choice of oesophageal tube. One patient suffered three weeks of symptoms before dying, the diagnosis not material. L R CELESTIN being established until necropsy. This report by Mr Hussain and coworkers Department of Gastroenterology, the number of patients in Britain who are brings Frenchay Hospital, known to have suffered disintegration of a Celestin Bristol BS16 1LE type tube inserted to manage dysphagia to 14. Four of these patients died either as a result of, or shortly AUToRS' REPLY-We agree with Mr Celestin that after, intervention 'for disintegration of the tube. a Pulsion tube should be changed every six months The practice of placing a Celestin type tube for if necessary and that it is better clinical practice to long term palliation (more than six months) should
