- Email: [email protected]
How Secure are Figures for Waiting N.H.S. Patients?
1179 PARTIAL ILEAL BYPASS IN FAMILIAL HYPERCHOLESTEROLAEMIA
SIR,-Dr Spengel and colleagues (Oct. 10, p. 768) describe an interesting approach to the treatment of hypercholesterolaemia. However, before we sharpen our knives to blunt the rapid onset of atherosclerosis in these patients a few points should be discussed. What was the diet used, how long was it administered, and what weight reduction, if any, occurred on the diet? Mean weights were above 70 kg, and I wonder if weight was adequately controlled. Lipid lowering is much more effective if weight is reduced to about 5% below the accepted weights found in insurance tables. Why look at the effects of cholestyramine after one month and of ileal bypass after two, particularly since after stress of any kind it is better to wait about three months? Cholesterol levels fall dramatically after any operation. What happens to fractional
catabolic rates of low density lipoprotein after other types of surgery in normal and hypercholesterolaemic subjects? It would have been better to have made comparisons 3-4 months after cholestyramine or bypass surgery. The main question therefore is whether changes after ileal bypass also occur with other forms of stress and, if so, do they revert to "normal" for each patient given a suitable recovery period? If they do, then I would suggest that it is premature to look upon this operation as an alternative to bile sequestrant therapy especially if based upon the data presented by Spengel et al. -
VANADIUM IN BLOOD PLASMA OR SERUM
SIR,-Your Sept. 5 editorial refers to our review on normal plasma levels of trace elements.The mean concentrations of vanadium in human plasma mentioned in our paper ranged from 0 -0005 to 8 -4mol/1. You report the upper limit correctly but misquote the lower by a factor of 10. Controversy surrounds the levels of several trace elements, and the correct reporting of published data is essential. Using neutron activation analysis, we measured levels varying from 0 - 024 to 0 -939 ng/ml (0 -00047 to 0 -018 mol/1), and from 0-016 to 0-139 ng/ml (0-00031 to 0-0027 mol/1), respectively, in apparently healthy men and women.2 Reliable analysis of low vanadium contents requires very tedious contamination-free sample collection and processing and a sensitive detection technique. The experimental detection limit of flameless atomic absorption spectrometry is 0 -2ng/ml (0 -004 mol/1) (data from Perkin-Elmer’s list of detection limits of HGA graphite furnace). This implies that the direct detection by atomic absorption or serum
spectrometry of vanadium in serum of normal individuals is not yet
universally applicable. Laboratory for Analytical Chemistry, Institute for Nuclear Sciences, and Division of Gastroenterology, Department of Internal Medicine, University of Ghent, B-9000 Ghent, Belgium
R. CORNELIS
J. VERSIECK
J, Cornelis R. Normal levels of trace elements in human blood plasma or Analyt Chim Acta 1980; 116: 217-54. 2. Cornelis R, Versieck J, Mees L, Hoste J, Barbier F. The ultra-trace element vanadium in human serum. Biol Trace Element Res 1981; 3: 257-62. 1. Versieck
serum.
Organon Scientific Development Group, Oss, Netherlands
H. N. MAGNANI
Commentary from Westminster How Secure
are
Figures for Waiting N.H.S. Patients?
THE conundrum of the hospital waiting lists (Nov. 14, p. is perhaps a little nearer to making sense. The Government’s claim to have scored a major success by bringing waiting lists down by 122 000 since they took office, is, on the face of it, impressive. But many health workers have voiced doubts about the significance of the achievement. An absence of easily available statistics has not helped. Now an analysis is. offered by one expert which suggests the Government’s claim is not half the success story it seems. Dr Bruce Richards, a Trent Regional Health Authority specialist in community medicine, believes that "the raw waiting list figures the Government appear to be relying on actually mean almost nothing on their own." The true position of those on the waiting lists did not emerge unless many more factors were investigated. If one examined the numbers of patients who had waited more than a year for nonurgent operations, for instance, it might well be that the overall figure had come down. But within that figure there could be a large increase in the numbers who have waited for two or three years, or even four years. Not enough information was collected about these subgroups. Another factor was the problem of patients who were not referred to hospital by G.P.s simply because the waiting lists were already large. "Doctors just don’t refer many cases if they know there is already a long list, so a waiting list may be artificially low because there is a high demand." Waiting times, Dr Richards emphasised, were indeed more significant than raw numbers of people who need operations. "You can have a small waiting list where people wait a long time, or a big waiting list where people don’t wait long at all." In Trent Region, orthopaedic waiting times were definitely rising, and had been doing so for some time. At the same time
1122)
the orthopaedic waiting lists have been slowly falling. In 1977 Trent had 12 112 people waiting for orthopaedic operations, of whom 43% had been waiting more than a year. Twelve months later there were 14 002 waiting and 46% had been waiting more than a year. In 1979 there were still 14 002 people waiting, but 52% had been waiting more than a year. In 1980 there were 13 798 waiting, of whom 50% had been waiting more than a year. In March, 1981, there were 13 8955 waiting, with 52% waiting more than a year. These figures had to be compared to a national average of 30% of waiting
orthopaedic patients waiting
more
than
a
year. But Dr
Richards is confident that all the poorer health regions were keeping well over 30% of their orthopaedic patients waiting more than twelve months. He is not even very impressed with the "fall" in the total national waiting lists. The drop since March, 1979, looks dramatic, but that was an atypical year, because of the "winter of discontent". The general trend since 1968 is upward and it still seems to be upward. He points to a similar dramatic peak in waiting lists in December, 1975, after which there was an apparent fall for a while. "But if you got a mathematician to plot the figures on a graph you would see a clear upward trend all the time, with the fall after December, 1975, and the present fall showing as little hiccups." But Dr Richards points out that neither his figures nor the D.H.S.S. waiting-list figures are any sort of indicator of how
effectively the N.H.S. is dealing with patients. Orthopaedic surgery is an area of rapid growth, largely because of advances in medical technology and surgical. technique. "This has clientele for surgeons. Demand is which is why over the country as a outstripping supply, whole orthopaedic waiting times have deteriorated." Yet at the same time the numbers of admissions for orthopaedic surgery had also been climbing. "We are treating more and more patients. The steady increase in waiting times does not necessarily show a steady deterioration in the service being provided. We are in fact offering a better service all the time, created
a
whole
new
,
1180
but we can’t keep up with the demand." Trent Region’s admission figures support this case. In 1974 Trent treated 31 229 orthopaedic cases; in 1975 they treated 32 176; for each subsequent year the figures have been: 33 735; 34 592;
35 697; 34 031. Dr Richards sees no need for the Government to rely on statistics which seem to him "a bit bogus". They would have done better "to quote the number of admissions as tell people the service is getting better and better," he says. "We tend to be rather secretive and defensive in the N.H.S. When someone attacks the waiting lists we try to defend them on a narrow front instead of explaining why they might not be so bad after all." The Mental Health Bill
proposed reforms in the status of compulsorily patients are to be used by the Labour Opposition as an opportunity to press for wider changes affecting all mental patients. The Social Services Secretary, Mr Norman Fowler, hoped his Mental Health Bill amending the 1959 Mental Health Act would prove noncontroversial. His proposals are acceptable to Opposition spokesman, Mrs Gwyneth Dunwoody, as far as they go. Mr Fowler plans to set up a Mental Health Commission, consisting of 70 members (doctors, nurses, psychologists, lawyers, social workers, and lay people) operating in regional panels. Their job will be to check the correctness of the way compulsory admission procedure is applied, visiting regularly hospitals where patients are compulsorily detained. They will listen to patients’ complaints, and check on records and on staff. They will also draw up a code of practice, listing treatments which should not be given without patients’ consent, or consent from a second opinion in the shape of an independent doctor chosen by the Commission. The Commission will also list treatments to be used only with THE Government’s
detained mental
caution. Treatments the Commission will have to categorise include electroconvulsion therapy, brain surgery such as leucotomy, and courses of powerful psychotropic drugs. Mr Fowler will choose the Commission’s members. Mr Fowler also intends to allow detained patients twice as frequent access as at present to the Mental Health Review Tribunals, and to double the frequency of reviews of individual cases. More than 7000 patients are affected by these changes. The D.H.S.S. expects the number of Tribunal hearings to rise from 904 in 1980 to 4500 a year. Although the measure will be law by the end of next summer, administrative problems will delay its full implementation until the autumn of 1983. But the D.H.S.S. intends to increase the frequency of reviews, by administrative action, as soon as the Bill is law. The plan is to sweep away the 1959 restriction that prevents mentally handicapped or psychopathic people over 21 years old being compulsorily detained. Instead prospective compulsory patients will be subject to a test of treatability, administered by a psychiatrist nominated by the Mental Health Commission. If the patient is deemed treatable he may be detained. The Government hopes this change will further reduce the numbers compulsorily detained. The psychiatrist named by the Commission will also have the power to compel treatment when a patient is considered capable of giving consent but is unwilling to do so, or is unable to understand what is involved in giving consent. But Mrs Dunwoody says the measure does not deal with enough aspects of the mental hospital system. She wants more consideration of secure units and the way they are run; more thought about the position on non-detained patients; consideration of the best way to deal with juvenile offenders extreme
who need treatment. "This Bill is only being introduced," she says, "because of the judgments of the European Court of Human Rights, which has severely criticised Britain... But it is a very limited Bill. A lot of people don’t believe the new arrangements will be an improvement." RODNEY DEITCH
Medicine and the Law Damages for Personal Injuries Payable to Young Child AT the time of assessment, the plaintiff was a child aged under 5. He had been normal and healthy when born on July 24, 1976, at University College Hospital, London. When he was a few days old he had persistent vomiting and was readmitted to the hospital. 6 days later, when 17 days old, he was given a serious overdose of anaesthetic in preparation for an operation to cure the vomiting. The consequences of the overdose were tragic and ter. rible. He was now a very severely abnormal child with a mental age of between 15 and 18 months. He was subject to epilepsy and had had four or five attacks already and one of those had lasted for 1’/z hours. He would be unable to earn a living and not be in a position to marry. He needed constant care and attention, which his parents, who were unusually devoted, were willing to give him; he was the middle of five children under 10. Though he had walked since he was 2, he was bandy-legged, could not walk far, and stumbled and fell, frequently hurting himself. He was doubly incontinent by day and by night, could speak only a few words, had little sustained attention, could not feed himself, and slobbered. He could be aggressive to the other children and had to be fully assisted with washing and dressing. He was hyperactive, obstructive, and destructive and had to be supervised all the time. He had a squint attributable to the brain damage inflicted by the excessive anaesthetic, and he woke frequently during the night and with him the whole family at 5.30 a.m. His parents were worthy ofthe highest praise; he slept in their bedroom and the only peace they had was in termtime when he attended a special school for handicapped children. He was also liable to colds and coughs and ear infections. He was, however, very affectionate and friendly towards his parents and those he knew. His feelings ran to an understanding of the affection and disapproval shown him. He would appreciate more and more as time went on that other children were different from him and able to do things he could not. He was likely to experience deep unhappiness and frustration and to worry about his incontinence of faeces and urine and to have an awareness of his plight. His total life span had been shortened to an estimated 271f2 years. The Area Health Authority admitted liability for negligence, but disputed the amount of damages. Mr Justice Comyn awarded damages under the following heads: 1. Pain and suffering and loss of amenities 2. Cost of future care and attention 3. Loss of earnings 4. Agreed special damages 5. Loss of earnings during lost years
50 000 156 000 7500 5667 nil
Total 220 007+interest
Under head 5, it was held that a young child could claim damages under the head of loss of earnings during lost years and that such a claim was not limited to exceptional cases where the child was already earning at the time of the accident, such as a child television star. Accordingly, the plaintiff was qualified to claim under that head of damage, but on the material before the court the claim would be assessed as nil. Pickettv British Rail Engineering Ltd (1979) 1 All ER 774 and Gammellv Wilson (1981) 1 All ER 578 were considered.
Connolly v Camden and Islington Area Health Authority. 1981. Reported in (1981) 3 All ER 250.
Comyn J. April8.
DIANA BRAHAMS Barrtster-at-Law
SIR,-Dr Spengel and colleagues (Oct. 10, p. 768) describe an interesting approach to the treatment of hypercholesterolaemia. However, before we sharpen our knives to blunt the rapid onset of atherosclerosis in these patients a few points should be discussed. What was the diet used, how long was it administered, and what weight reduction, if any, occurred on the diet? Mean weights were above 70 kg, and I wonder if weight was adequately controlled. Lipid lowering is much more effective if weight is reduced to about 5% below the accepted weights found in insurance tables. Why look at the effects of cholestyramine after one month and of ileal bypass after two, particularly since after stress of any kind it is better to wait about three months? Cholesterol levels fall dramatically after any operation. What happens to fractional
catabolic rates of low density lipoprotein after other types of surgery in normal and hypercholesterolaemic subjects? It would have been better to have made comparisons 3-4 months after cholestyramine or bypass surgery. The main question therefore is whether changes after ileal bypass also occur with other forms of stress and, if so, do they revert to "normal" for each patient given a suitable recovery period? If they do, then I would suggest that it is premature to look upon this operation as an alternative to bile sequestrant therapy especially if based upon the data presented by Spengel et al. -
VANADIUM IN BLOOD PLASMA OR SERUM
SIR,-Your Sept. 5 editorial refers to our review on normal plasma levels of trace elements.The mean concentrations of vanadium in human plasma mentioned in our paper ranged from 0 -0005 to 8 -4mol/1. You report the upper limit correctly but misquote the lower by a factor of 10. Controversy surrounds the levels of several trace elements, and the correct reporting of published data is essential. Using neutron activation analysis, we measured levels varying from 0 - 024 to 0 -939 ng/ml (0 -00047 to 0 -018 mol/1), and from 0-016 to 0-139 ng/ml (0-00031 to 0-0027 mol/1), respectively, in apparently healthy men and women.2 Reliable analysis of low vanadium contents requires very tedious contamination-free sample collection and processing and a sensitive detection technique. The experimental detection limit of flameless atomic absorption spectrometry is 0 -2ng/ml (0 -004 mol/1) (data from Perkin-Elmer’s list of detection limits of HGA graphite furnace). This implies that the direct detection by atomic absorption or serum
spectrometry of vanadium in serum of normal individuals is not yet
universally applicable. Laboratory for Analytical Chemistry, Institute for Nuclear Sciences, and Division of Gastroenterology, Department of Internal Medicine, University of Ghent, B-9000 Ghent, Belgium
R. CORNELIS
J. VERSIECK
J, Cornelis R. Normal levels of trace elements in human blood plasma or Analyt Chim Acta 1980; 116: 217-54. 2. Cornelis R, Versieck J, Mees L, Hoste J, Barbier F. The ultra-trace element vanadium in human serum. Biol Trace Element Res 1981; 3: 257-62. 1. Versieck
serum.
Organon Scientific Development Group, Oss, Netherlands
H. N. MAGNANI
Commentary from Westminster How Secure
are
Figures for Waiting N.H.S. Patients?
THE conundrum of the hospital waiting lists (Nov. 14, p. is perhaps a little nearer to making sense. The Government’s claim to have scored a major success by bringing waiting lists down by 122 000 since they took office, is, on the face of it, impressive. But many health workers have voiced doubts about the significance of the achievement. An absence of easily available statistics has not helped. Now an analysis is. offered by one expert which suggests the Government’s claim is not half the success story it seems. Dr Bruce Richards, a Trent Regional Health Authority specialist in community medicine, believes that "the raw waiting list figures the Government appear to be relying on actually mean almost nothing on their own." The true position of those on the waiting lists did not emerge unless many more factors were investigated. If one examined the numbers of patients who had waited more than a year for nonurgent operations, for instance, it might well be that the overall figure had come down. But within that figure there could be a large increase in the numbers who have waited for two or three years, or even four years. Not enough information was collected about these subgroups. Another factor was the problem of patients who were not referred to hospital by G.P.s simply because the waiting lists were already large. "Doctors just don’t refer many cases if they know there is already a long list, so a waiting list may be artificially low because there is a high demand." Waiting times, Dr Richards emphasised, were indeed more significant than raw numbers of people who need operations. "You can have a small waiting list where people wait a long time, or a big waiting list where people don’t wait long at all." In Trent Region, orthopaedic waiting times were definitely rising, and had been doing so for some time. At the same time
1122)
the orthopaedic waiting lists have been slowly falling. In 1977 Trent had 12 112 people waiting for orthopaedic operations, of whom 43% had been waiting more than a year. Twelve months later there were 14 002 waiting and 46% had been waiting more than a year. In 1979 there were still 14 002 people waiting, but 52% had been waiting more than a year. In 1980 there were 13 798 waiting, of whom 50% had been waiting more than a year. In March, 1981, there were 13 8955 waiting, with 52% waiting more than a year. These figures had to be compared to a national average of 30% of waiting
orthopaedic patients waiting
more
than
a
year. But Dr
Richards is confident that all the poorer health regions were keeping well over 30% of their orthopaedic patients waiting more than twelve months. He is not even very impressed with the "fall" in the total national waiting lists. The drop since March, 1979, looks dramatic, but that was an atypical year, because of the "winter of discontent". The general trend since 1968 is upward and it still seems to be upward. He points to a similar dramatic peak in waiting lists in December, 1975, after which there was an apparent fall for a while. "But if you got a mathematician to plot the figures on a graph you would see a clear upward trend all the time, with the fall after December, 1975, and the present fall showing as little hiccups." But Dr Richards points out that neither his figures nor the D.H.S.S. waiting-list figures are any sort of indicator of how
effectively the N.H.S. is dealing with patients. Orthopaedic surgery is an area of rapid growth, largely because of advances in medical technology and surgical. technique. "This has clientele for surgeons. Demand is which is why over the country as a outstripping supply, whole orthopaedic waiting times have deteriorated." Yet at the same time the numbers of admissions for orthopaedic surgery had also been climbing. "We are treating more and more patients. The steady increase in waiting times does not necessarily show a steady deterioration in the service being provided. We are in fact offering a better service all the time, created
a
whole
new
,
1180
but we can’t keep up with the demand." Trent Region’s admission figures support this case. In 1974 Trent treated 31 229 orthopaedic cases; in 1975 they treated 32 176; for each subsequent year the figures have been: 33 735; 34 592;
35 697; 34 031. Dr Richards sees no need for the Government to rely on statistics which seem to him "a bit bogus". They would have done better "to quote the number of admissions as tell people the service is getting better and better," he says. "We tend to be rather secretive and defensive in the N.H.S. When someone attacks the waiting lists we try to defend them on a narrow front instead of explaining why they might not be so bad after all." The Mental Health Bill
proposed reforms in the status of compulsorily patients are to be used by the Labour Opposition as an opportunity to press for wider changes affecting all mental patients. The Social Services Secretary, Mr Norman Fowler, hoped his Mental Health Bill amending the 1959 Mental Health Act would prove noncontroversial. His proposals are acceptable to Opposition spokesman, Mrs Gwyneth Dunwoody, as far as they go. Mr Fowler plans to set up a Mental Health Commission, consisting of 70 members (doctors, nurses, psychologists, lawyers, social workers, and lay people) operating in regional panels. Their job will be to check the correctness of the way compulsory admission procedure is applied, visiting regularly hospitals where patients are compulsorily detained. They will listen to patients’ complaints, and check on records and on staff. They will also draw up a code of practice, listing treatments which should not be given without patients’ consent, or consent from a second opinion in the shape of an independent doctor chosen by the Commission. The Commission will also list treatments to be used only with THE Government’s
detained mental
caution. Treatments the Commission will have to categorise include electroconvulsion therapy, brain surgery such as leucotomy, and courses of powerful psychotropic drugs. Mr Fowler will choose the Commission’s members. Mr Fowler also intends to allow detained patients twice as frequent access as at present to the Mental Health Review Tribunals, and to double the frequency of reviews of individual cases. More than 7000 patients are affected by these changes. The D.H.S.S. expects the number of Tribunal hearings to rise from 904 in 1980 to 4500 a year. Although the measure will be law by the end of next summer, administrative problems will delay its full implementation until the autumn of 1983. But the D.H.S.S. intends to increase the frequency of reviews, by administrative action, as soon as the Bill is law. The plan is to sweep away the 1959 restriction that prevents mentally handicapped or psychopathic people over 21 years old being compulsorily detained. Instead prospective compulsory patients will be subject to a test of treatability, administered by a psychiatrist nominated by the Mental Health Commission. If the patient is deemed treatable he may be detained. The Government hopes this change will further reduce the numbers compulsorily detained. The psychiatrist named by the Commission will also have the power to compel treatment when a patient is considered capable of giving consent but is unwilling to do so, or is unable to understand what is involved in giving consent. But Mrs Dunwoody says the measure does not deal with enough aspects of the mental hospital system. She wants more consideration of secure units and the way they are run; more thought about the position on non-detained patients; consideration of the best way to deal with juvenile offenders extreme
who need treatment. "This Bill is only being introduced," she says, "because of the judgments of the European Court of Human Rights, which has severely criticised Britain... But it is a very limited Bill. A lot of people don’t believe the new arrangements will be an improvement." RODNEY DEITCH
Medicine and the Law Damages for Personal Injuries Payable to Young Child AT the time of assessment, the plaintiff was a child aged under 5. He had been normal and healthy when born on July 24, 1976, at University College Hospital, London. When he was a few days old he had persistent vomiting and was readmitted to the hospital. 6 days later, when 17 days old, he was given a serious overdose of anaesthetic in preparation for an operation to cure the vomiting. The consequences of the overdose were tragic and ter. rible. He was now a very severely abnormal child with a mental age of between 15 and 18 months. He was subject to epilepsy and had had four or five attacks already and one of those had lasted for 1’/z hours. He would be unable to earn a living and not be in a position to marry. He needed constant care and attention, which his parents, who were unusually devoted, were willing to give him; he was the middle of five children under 10. Though he had walked since he was 2, he was bandy-legged, could not walk far, and stumbled and fell, frequently hurting himself. He was doubly incontinent by day and by night, could speak only a few words, had little sustained attention, could not feed himself, and slobbered. He could be aggressive to the other children and had to be fully assisted with washing and dressing. He was hyperactive, obstructive, and destructive and had to be supervised all the time. He had a squint attributable to the brain damage inflicted by the excessive anaesthetic, and he woke frequently during the night and with him the whole family at 5.30 a.m. His parents were worthy ofthe highest praise; he slept in their bedroom and the only peace they had was in termtime when he attended a special school for handicapped children. He was also liable to colds and coughs and ear infections. He was, however, very affectionate and friendly towards his parents and those he knew. His feelings ran to an understanding of the affection and disapproval shown him. He would appreciate more and more as time went on that other children were different from him and able to do things he could not. He was likely to experience deep unhappiness and frustration and to worry about his incontinence of faeces and urine and to have an awareness of his plight. His total life span had been shortened to an estimated 271f2 years. The Area Health Authority admitted liability for negligence, but disputed the amount of damages. Mr Justice Comyn awarded damages under the following heads: 1. Pain and suffering and loss of amenities 2. Cost of future care and attention 3. Loss of earnings 4. Agreed special damages 5. Loss of earnings during lost years
50 000 156 000 7500 5667 nil
Total 220 007+interest
Under head 5, it was held that a young child could claim damages under the head of loss of earnings during lost years and that such a claim was not limited to exceptional cases where the child was already earning at the time of the accident, such as a child television star. Accordingly, the plaintiff was qualified to claim under that head of damage, but on the material before the court the claim would be assessed as nil. Pickettv British Rail Engineering Ltd (1979) 1 All ER 774 and Gammellv Wilson (1981) 1 All ER 578 were considered.
Connolly v Camden and Islington Area Health Authority. 1981. Reported in (1981) 3 All ER 250.
Comyn J. April8.
DIANA BRAHAMS Barrtster-at-Law