were housed initially by the King's Fund but then by the Association of Anaesthetists in Bedford. Square. The study did indeed identify many problems in surgical ...
anaesthesia and published the results in 1982.2 This study shed as much light on surgery as on anaesthesia, since the two activities are so closely interwoven in the care of surgical patients. Nevertheless, neither of two of the bodies that represent surgeons was keen to be involved when they were approached in the planning stage. When the results were analysed it was obvious that deficiencies in anaesthetic care were much less common than those in surgery. The Association of Anaesthetists therefore sought support for a larger study which could serve as a blueprint for a national audit, and we worked hard to ensure that this time it would be a joint anaesthetic-surgical effort. With indications of support from the Association of Surgeons, Professor Michael Rosen and I (as treasurer and president, respectively, of the Association of Anaesthetists) obtained the necessary financial support from the Nuffield Provincial Hospitals Trust and, later, the King Edward's Hospital Fund for London. A joint working party was set up under my chairmanship to plan and execute the study. Mr Devlin was one of four nominees of the Association of Surgeons and was chosen to be one of the two surgical coordinators; the problems of anaesthesia were handled by a single anaesthetic coordinator, Dr John Lunn. The clerical and administrative staff were housed initially by the King's Fund but then by the Association of Anaesthetists in Bedford Square. The study did indeed identify many problems in surgical services,' and both professional associations supported an approach to the Department of Health, which readily provided the funds for the continuing national confidential inquiry into perioperative deaths. Impartial readers may wonder how this story could have been put over without use of the word anaesthesia and with only a single passing reference to "committees of surgeons and anaesthetists"-yet such was the prominent role given to Mr Devlin in the programme that this feat was achieved. No doubt, as Dr Ruta divines, the producer wished to make an "attention grabbing" programme, but one can only marvel at a medium that can transmute a long planned sequence of events, involving the cooperation and good will of hundreds of participants in three major specialties (anaesthesia, surgery, and gvnaecology), the support of charities, and the active encouragement of agovernment department, into one man's crusade to improve the standard of British surgery. Unfortunately, as Dr Ruta's review shows, it is apparently quite easy. I only hope that the programme will not do too much damage to the warm and effective collaboration that has resulted from our initiative. M D VICKERS
Departmcnt of Anaesthetics, University of Wales College of Medicine, Cardiff CF4 4XN I Ruta D. Taking the bait. BAIJ 1991;302:1472-3. (15 June.) 2 I,unn JN, Mlushin WW. .llortalitv associated wih anaesthesia. Iondon: Nuffield Provincial Hospitals Trust, 1982. 3 Buck N, Devlin HB, Lunn JN. Tht report oss a confidential enquirv into perioperative deaths. London: Nuffield Provincial Hospitals Trust and King's Fund Publishing Office, 1987.
Financial risks to fundholding practices SIR,-If the projections made by Dr B J Crump and colleagues concerning the financial effect of random variation in the need for services on fundholding practices materialise such practices should be anxious.' For example, if a fundholding practice overspends its budget by 30% (which seems possible from random variation alone) should it be forced to make the necessary economies from its next year's budget, should it be bailed out by the regional health authority, or should it
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be declared bankrupt? Conversely, if the same practice finds itself underspent by a similar amount, but solely because of random variation, should it be allowed to keep the shortfall for the benefit of its patients? How can anyone decide which savings are due to random variation and which are due to good financial management? Dr Crump and colleagues neatly illustrate that, in terms of reducing random variation, budget management is simpler when the population is larger. This would happen if the health service was truly national. MARK MWCARTNEY Pensilva Health Centre, Liskeard, Cornwall PL14 5RP 1 Crump BJ, Cubbon JE, Drummond MF, Hawkes RA, Marchment MD. Fundholding in general practice and financial risk. BMJ 1991;302:1582-4. (29 June.)
is true, however, that at any subsequent inquiry the pilot may appear as one of the statistics rather than in person. The idea that a colleague should be obliged to spend time with a physician in a busy medical unit as a result of an anonymous report without knowing the name of, or being able to question, his or her reporter is unworkable and could only fail in its object; indeed, CHIRP does not normally investigate unsigned reports as these mean that the events cannot be confirmed or clarified through the reporter. CHIRP is informational, confidential, and educational and does not set itself up as a judge, jury, and jailer. For Dr Parle to equate it to what he suggests should be set up for the medical profession indicates that he has missed both its point and its function. ROBERT M BRUCE-CHWATT
Richmond, Surrey TW 10 6DR
BMJ 1991;302:1547.
Pointing out other doctors' mistakes
I Parle JV. He that is without sin. (22 June.)
SIR,-I disagree with Dr J V Parle's suggestion, in his personal view, that a covert complaints board should be set up.' This would achieve little. The function of audit is to educate doctors and to discuss mistakes so that others can learn from them. Regrettably, every doctor has made an error of clinical judgment in his or her lifetime. It is easy to be wise about others' mistakes, and I believe that secret complaints serve no purpose; indeed, such a system is open to abuse. Far better to have regular clinical meetings about patients and treatment with an open discussion. We are, after all, on the same side in this game.
Future of long term care of dependent elderly people
KARIN ENGLEHART
Guildford, Surrey GUI 2DA I Parle JV. He that is without sin. (22 June.)
BAfj 1991;302:1547.
SIR,-In his personal view Dr J V Parle suggests a discreet medical reporting system,' cross referring, I believe, to the confidential human factors incident reporting programme (CHIRP) run by the Institute of Aviation Medicine, Royal Aircraft Establishment Farnborough, to which pilots and air traffic controllers may write. He is incorrect in stating that the report is sent to a superior not directly concerned, who can then act to investigate the incident and the pilot or air traffic controller concerned. The Institute of Aviation Medicine is an independent information gathering centre and acts to clarify the incident rather than the standards of the pilot by its investigation. It is looking for trends of errors and failures due to human factors, interpretation of instruments, standard operating procedures, and other factors that for various reasons people might be reluctant to disclose. Often the reporting is done by the person who made the error, to prevent others from emulating him or her. This system is also confidential so far as the person reporting the incident is concerned, and it is eventually anonymous as the name of the reporter, once the incident has been investigated, is removed from the file. Thus when a file is closed there are no names, only events, circumstances, and conclusions. The details, depending on the seriousness of the incident, may be published in the institute's magazine, Feedback, in the hope that this may jog a memory and perhaps prevent other people repeating the error. With CHIRP there is no question of educational retraining as Dr Parle suggests should happen with doctors, although an error by a pilot may kill many hundreds more people than an error by a doctor. It
SIR,-In contrast to the noisy debate about the reforms of the NHS almost total silence surrounds the future of long term care of highly dependent elderly people. This is a matter of importance well beyond the bounds of geriatrics as any shortage profoundly affects community care and most other acute hospital departments. In this part of the United Kingdom we are very disadvantaged in terms of the level of provision and have a "mixed economy," which makes life difficult for hospital staff and, I am sure, general practitioners. To explain to relatives that, yes, there are NHS beds for this purpose where, apart from loss of pension, care and accommodation are free, but, as there are nothing like enough and we suspect that the family may be able to afford it, could they please consider trying to find a private nursing home bed at £350 or more a week is to invite derision. There are several possible options for the future of long term care. The first option is privatisation, which, thanks to the estimated £1 2 billion spent each year on income support by the Department of Health, has taken over in some parts of the country, with the NHS virtually withdrawing from this type of care. Quality is variable; the future is insecure, and public money is spent on patients who are not necessarily those most appropriately placed there. Secondly, a partnership between private and public sectors is possible. The third option is provision of care by the NHS. This is not always above criticism, especiallv in terms of the legacy of the former workhouses originally intended to deter those on the outside rather than afford a pleasant environment to those within. An alternative to the old long stay wards are NHS nursing homes, but they are few and of unproved superiority except in terms of bricks and mortar. Moreover, provision of care by the NHS is far from cheap. Even in today's cost conscious era estimates vary from £350 to £500 a week, though it remains difficult to be certain of the cosI. The final option is a deliberately mixed economy, with the NHS trying to provide centres of excellence. This might mean people having to accept that, although the basic tenet of the NHS-free medical and nursing attention -should still apply, free board and lodging through the accident of infirmity (whether long term or short term) is illogical and unaffordable. Hotel charges seem to have disappeared from the political agenda but may be inevitable. A means test would provide a safety net: the income generated would help the NHS to survive, and having to compete might
BMJ VOLUME 303
20 JULY 1991
