- Email: [email protected]
A Small Revolt on Health and Medicines
1411
National Health Service Joint Statement from the Presidents of the Royal College of Physicians, the Royal College of Surgeons, and the Royal College of Obstetricians and Gynaecologists day we learn of new problems in the NHS-beds shut, operating rooms are not available, emergency wards are closed, essential services are shut down in order to make financial savings. In spite of the efforts of doctors, EACH
are
nurses, and other hospital
staff, patient care is deteriorating.
Acute hospital services have almost reached breaking point. Morale is depressingly low. It is not only patient care that is suffering. Financial stringencies have hit academic aspects of medicine in particular, because of the additional burden of reduced University Grants Committee funding. Yet, the future of medicine depends on the quality of our clinical teachers and research workers. Face-saving initiatives such as the allocation of £ 30 million for waiting lists are not the answer. An immediate overall review of acute hospital services is mandatory. Additional and alternative funding must be found. We call on the Government to do something now to save our Health Service, once the envy of the world. RAYMOND HOFFENBERG IAN P. TODD GEORGE PINKER
***The above statement was issued on Dec 7. A letter referring to it appears
on
p 1400.
Commentary from Westminster A Small Revolt on Health and Medicines ONE bewildering fact about the financial crisis in the NHS emerged from Parliament early this week. It was that not one Conservative MP saw fit to vote against the Government on the second reading of the Health and Medicines Bill, the legislative cornerstone of the Cabinet’s strategy for the future funding of the health service. With the current wave of anguish among NHS professionals and the communities they serve across the length and breadth of Britain, it was not unreasonable to expect quite a solid little rebellion-not enough to wreck the Bill, but a warning shot from the Tory ranks that they expected the Treasury to respond with some additional cash in the Budget next spring to restore the present round of cuts. Instead what we got was a clutch of less than a dozen Tory abstentions, leaving the Government with a majority of 98. For political journalists, who like a revolt nearly as much as a Ministerial reshuffle, it was all rather disappointing. For patients and their doctors the more important question is whether this signals Conservative complacency about the troubles of the NHS or whether it suggests that something has been said to convince Tory backbenchers that action will be taken to relieve their anxieties. There is some evidence to suggest that the potentially dissident MPs were not simply guilty of the age-old Parliamentary weakness of being more frightened of the whips than of their constituents. The Health Minister, Tony Newton, has written privately to reassure them that: the Government accepts the need to do something toI ,
combat the shortage of specialist nurses, although it is still not clear whether any interim action will be taken before the pay review process concludes next April. Concerned backbenchers can also reasonably argue that their speeches over the past few weeks have made their views known clearly enough to the Chancellor, without the need to vote against their Government on a three-line whip. Abstention too is an act of defiance; and those who took this course argued that it was the appropriate response to legislation the most part of which they find entirely sensible. Tory criticism of the Bill is essentially confined to two sections that can be regarded as symptomatic of Treasury underfunding-the introduction of charges for eye tests and dental examinations; and the encouragement of commercial activities by hospitals to supplement Exchequer finance. The lack of any Tory votes against the Bill was nonetheless surprising, in the context of Monday’s debate. That morning a powerful indictment of NHS funding had been published by the presidents of the Royal College of Physicians, the Royal College of Surgeons, and the Royal College of Obstetricians and Gynaecologists (reproduced above). Mr George Pinker, president of the RCOG, said: "I have never put my name to anything like this before, but the position of the health service is desperate." Sir Raymond Hoffenberg, president of the RCP, said: "The bottom line is that we had a service which was the envy of the world which we ran very cheaply. We are now trying to run it too cheaply." Mr Ian Todd, president of the RCS, urged the Government to cancel further tax cuts and use the money to support the NHS. He also called for new forms of funding such as a national sweepstake. Strong stuff; and it did not go unnoticed in the Commons. Sir Barney Hayhoe, a former Tory Health Minister, said he. supported much of the Bill but that it was peripheral and superficial to the fundamental problems highlighted by the presidents of the Royal Colleges, which require urgent action not just from the health ministers but also from the Chancellor of the Exchequer and the Prime Minister. Mr Newton responded by declaring: "Nobody is suggesting that there are no pressures or problems and I do not dismiss them. All I ask is that you accept that they are complex problems and they are sometimes reduced to excessivee simplicities by some who put out statements." This was the patronising remark that might finally have nudged the Tory dissidents into the Opposition voting lobby. When it comes to excessive simplicities in the health debate, there is no one to match the Prime Minister in her repetitive use of NHS statistics to answer complaints about local crises with a litany of figures to prove real-term growth since 1979. However, all we got was some abstentions, coupled with some grumbling behind the scenes that the Bill would be dealt with more severely at third reading if it was not amended at committee stage. The identifiable abstainers were Sir Barney Hayhoe (Brentford and Isleworth), Dame Jill Knight (Birmingham Edgebaston), Anthony Beaumont Dark (Birmingham Selly Oak), David Gilroy Bevan (Birmingham Yardley), Winston Churchill (Davyhulme), Conal Gregory (York), David Nudd (Falmouth and Cambourne), Nicholas Winterton (Macclesfield), Elizabeth Peacock (Batley and Spen), Terry Dicks (Hayes and Harlington), and Peter Fry (Wellingborough). The Government’s further response to NHS financial problems is still unclear. It now seems likely that the Social Services Secretary John Moore will not return from his sick leave until after the Christmas break; and the committee-
1412
stage battles of the Health and Medicines Bill will not begin until the New Year. Ministers’ private explanation of the present crisis is that it is substantially due to health authorities’ failing to bring forward applications for the closure of redundant facilities at the proper rate. A substantial batch of pending applications was approved by Ministers just after they had got the general election out of the way, since when the flow has almost halted. The argument from the DHSS is that health authorities’ failure to make timely savings from this sort of planned economy has led to unplanned crisis cuts in services where substantial savings can be made most quickly before the end of the financial year-notably in acute services.
The DHAs may complain of the underfunding of the 1987 pay awards, but ministers think the reason for crisis behaviour is that administrators began recruiting nurses in response to increasing demand for services in the spring and were not prepared for the consequential increase in their payrolls in the autumn. It is an interesting analysis, but not one that would justify the underfunding of next year’s pay award. Should that happen, Sir Barney, Dame Jill, and the rest may start revolting in earnest.
Notes and News
programme. The biggest failure of the present system is that many women have never been screened at all. As a matter of urgency, all district health authorities should
FETAL VIABILITY A JOINT report! has recommended that the age of viability of the fetus should be reduced from 28 weeks to 24 weeks, as defined by the Infant Life (Preservation) Act of 1929. The report was drawn up by a committee representing the Royal College of Obstetricians and Gynaecologists, the Royal College of General Practitioners, the British Medical Association, the British Paediatric Association, the Royal College of Midwives, and the Clinical Genetics Society. The report opposes the proposed reduction to 18 weeks in Mr David Alton’s Abortion Amendment Bill, which seeks to make abortions after 18 weeks of pregnancy illegal (with the exception of a termination to save the life of the mother or if the child would be stillborn or so severely handicapped that it would not sustain life). Mr Alton’s Private Member’s Bill is due to be presented to the House of Commons on Jan 22. At a meeting in London on Dec 2, Prof Richard Beard (professor of obstetrics and gynaecology, St Mary’s Hospital Medical School, London) emphasised that reducing the gestational age limit to 18 weeks would discriminate against women most in need of abortion and that such a limit had no scientific basis. Professor Beard pointed out that many major fetal abnormalities were not discovered until 22 or even 24 weeks. Technical and administrative delays could easily arise; and, moreover, many women, particularly very young and disadvantaged women, tended to consult late. Such women might be driven to seek criminal abortion, he warned, should Mr Alton’s Bill become law. Professor Beard hardly needed to remind his listeners that before the 1967 Abortion Act 98 women died in 1966 as a result of clandestine abortions and many suffered untold distress and permanent physical damage. Mr Alton’s proposal would punish those women who, for no fault of their own, were carrying a child with a major abnormality or who were uncertain about their ability to cope with pregnancy.
REPORT OF THE INTERCOLLEGIATE WORKING PARTY ON CERVICAL CYTOLOGY SCREENING IN the UK, the continuing problem of cervical cancer and the increasing number of women at risk with pre-malignant disease has been addressed by a working party representing the Royal College of Obstetricians and Gynaecologists, the Royal College of Pathologists, the Royal College of General Practitioners, and the Faculty of Community Medicine.2 Deficiencies in the existing organisation of cervical screening have been identified. Recommendations for improvement have been made which these organisations feel should be implemented without delay as follows: Through formal public education programmes, everyone should be made aware that it is possible to reduce the incidence of and mortality from cervical cancer by an effective cervical screening 1 Report on the Advantages and Disadvantages of Imposing an 18-week Gestational Age Limit on Legal Abortion. Available from the RCOG, 27 Sussex Place, London NW1 4RG 2.
Report available from the Royal College of Obstetricians 27 Sussex Place, London NW1 4RG.
JOHN CARVEL
institute an effective systematic cervical cytology screening programme. Every adult woman should be personally invited to be screened. The examination should be repeated at three-yearly intervals on women between 20 and 64 years of age. There should be no upper age limit for women who have never had a smear. All women should be informed of the result of their test. All women with a positive test should be referred for further
investigative treatment. The achievement of these aims will require: 1. The replacement of opportunistic screening
by planned screening; 2. A comprehensive education programme for training general practitioners and other health personnel in taking smears, to ensure that all adult women are offered screening; 3. An appropriate management scheme; 4. Appropriate resources for the taking and examination of smears including adequate pathology and computer facilities; 5. Urgent steps to correct the relative deficiency of trained cytopathologists and laboratory staff in the UK; 6. Adequate provision of colposcopy facilities. It is essential that computerised monitoring facilities are provided and that results achieved -by those involved in the service are monitored at regular intervals. The implementation of these recommendations will not be possible within current NHS budgeting.
THE CONTENT OF PROCESSED FOOD 1 HE past tew years have
Gynaecologists,
remarkable
change
m
public
labelling.
1 and
seen a
of the importance of diet. Many people have made efforts to reduce their consumption of fats, especially saturated fats of animal origin. At a press conference held on Dec 3 by the Coronary Prevention Group, Prof Geoffrey Rose (Department of Epidemiology, London School of Hygiene and Tropical Medicine) suggested that some of the unwanted fat is finding its way surreptitiously into processed foods. In the British diet 43% of food energy still comes from fat, whereas the Committee on Medical Aspects of Food Policy, in its 1984 report, favoured 35 %. For real dietary change, Professor Rose emphasised, the consumer requires a proper breakdown of the nutritional content of all processed foods. The Coronary Prevention Group has produced a report’ analysing the Government’s attitude towards food According to the CPG, there are some very obvious discrepancies. It seems as though the Government has accepted that the health lobby won the battle with the dairy industry: a draft proposal for making labelling of the fat content (total and saturated) of food awareness
Barrier or Scapegoat’ An Analysis of the UK Govemment’s Position on Nutrition Labelling. Available from the Coronary Prevention Group, 60 Great Ormond Street, London WC1N 3HR (01-833 3687)
European Community
National Health Service Joint Statement from the Presidents of the Royal College of Physicians, the Royal College of Surgeons, and the Royal College of Obstetricians and Gynaecologists day we learn of new problems in the NHS-beds shut, operating rooms are not available, emergency wards are closed, essential services are shut down in order to make financial savings. In spite of the efforts of doctors, EACH
are
nurses, and other hospital
staff, patient care is deteriorating.
Acute hospital services have almost reached breaking point. Morale is depressingly low. It is not only patient care that is suffering. Financial stringencies have hit academic aspects of medicine in particular, because of the additional burden of reduced University Grants Committee funding. Yet, the future of medicine depends on the quality of our clinical teachers and research workers. Face-saving initiatives such as the allocation of £ 30 million for waiting lists are not the answer. An immediate overall review of acute hospital services is mandatory. Additional and alternative funding must be found. We call on the Government to do something now to save our Health Service, once the envy of the world. RAYMOND HOFFENBERG IAN P. TODD GEORGE PINKER
***The above statement was issued on Dec 7. A letter referring to it appears
on
p 1400.
Commentary from Westminster A Small Revolt on Health and Medicines ONE bewildering fact about the financial crisis in the NHS emerged from Parliament early this week. It was that not one Conservative MP saw fit to vote against the Government on the second reading of the Health and Medicines Bill, the legislative cornerstone of the Cabinet’s strategy for the future funding of the health service. With the current wave of anguish among NHS professionals and the communities they serve across the length and breadth of Britain, it was not unreasonable to expect quite a solid little rebellion-not enough to wreck the Bill, but a warning shot from the Tory ranks that they expected the Treasury to respond with some additional cash in the Budget next spring to restore the present round of cuts. Instead what we got was a clutch of less than a dozen Tory abstentions, leaving the Government with a majority of 98. For political journalists, who like a revolt nearly as much as a Ministerial reshuffle, it was all rather disappointing. For patients and their doctors the more important question is whether this signals Conservative complacency about the troubles of the NHS or whether it suggests that something has been said to convince Tory backbenchers that action will be taken to relieve their anxieties. There is some evidence to suggest that the potentially dissident MPs were not simply guilty of the age-old Parliamentary weakness of being more frightened of the whips than of their constituents. The Health Minister, Tony Newton, has written privately to reassure them that: the Government accepts the need to do something toI ,
combat the shortage of specialist nurses, although it is still not clear whether any interim action will be taken before the pay review process concludes next April. Concerned backbenchers can also reasonably argue that their speeches over the past few weeks have made their views known clearly enough to the Chancellor, without the need to vote against their Government on a three-line whip. Abstention too is an act of defiance; and those who took this course argued that it was the appropriate response to legislation the most part of which they find entirely sensible. Tory criticism of the Bill is essentially confined to two sections that can be regarded as symptomatic of Treasury underfunding-the introduction of charges for eye tests and dental examinations; and the encouragement of commercial activities by hospitals to supplement Exchequer finance. The lack of any Tory votes against the Bill was nonetheless surprising, in the context of Monday’s debate. That morning a powerful indictment of NHS funding had been published by the presidents of the Royal College of Physicians, the Royal College of Surgeons, and the Royal College of Obstetricians and Gynaecologists (reproduced above). Mr George Pinker, president of the RCOG, said: "I have never put my name to anything like this before, but the position of the health service is desperate." Sir Raymond Hoffenberg, president of the RCP, said: "The bottom line is that we had a service which was the envy of the world which we ran very cheaply. We are now trying to run it too cheaply." Mr Ian Todd, president of the RCS, urged the Government to cancel further tax cuts and use the money to support the NHS. He also called for new forms of funding such as a national sweepstake. Strong stuff; and it did not go unnoticed in the Commons. Sir Barney Hayhoe, a former Tory Health Minister, said he. supported much of the Bill but that it was peripheral and superficial to the fundamental problems highlighted by the presidents of the Royal Colleges, which require urgent action not just from the health ministers but also from the Chancellor of the Exchequer and the Prime Minister. Mr Newton responded by declaring: "Nobody is suggesting that there are no pressures or problems and I do not dismiss them. All I ask is that you accept that they are complex problems and they are sometimes reduced to excessivee simplicities by some who put out statements." This was the patronising remark that might finally have nudged the Tory dissidents into the Opposition voting lobby. When it comes to excessive simplicities in the health debate, there is no one to match the Prime Minister in her repetitive use of NHS statistics to answer complaints about local crises with a litany of figures to prove real-term growth since 1979. However, all we got was some abstentions, coupled with some grumbling behind the scenes that the Bill would be dealt with more severely at third reading if it was not amended at committee stage. The identifiable abstainers were Sir Barney Hayhoe (Brentford and Isleworth), Dame Jill Knight (Birmingham Edgebaston), Anthony Beaumont Dark (Birmingham Selly Oak), David Gilroy Bevan (Birmingham Yardley), Winston Churchill (Davyhulme), Conal Gregory (York), David Nudd (Falmouth and Cambourne), Nicholas Winterton (Macclesfield), Elizabeth Peacock (Batley and Spen), Terry Dicks (Hayes and Harlington), and Peter Fry (Wellingborough). The Government’s further response to NHS financial problems is still unclear. It now seems likely that the Social Services Secretary John Moore will not return from his sick leave until after the Christmas break; and the committee-
1412
stage battles of the Health and Medicines Bill will not begin until the New Year. Ministers’ private explanation of the present crisis is that it is substantially due to health authorities’ failing to bring forward applications for the closure of redundant facilities at the proper rate. A substantial batch of pending applications was approved by Ministers just after they had got the general election out of the way, since when the flow has almost halted. The argument from the DHSS is that health authorities’ failure to make timely savings from this sort of planned economy has led to unplanned crisis cuts in services where substantial savings can be made most quickly before the end of the financial year-notably in acute services.
The DHAs may complain of the underfunding of the 1987 pay awards, but ministers think the reason for crisis behaviour is that administrators began recruiting nurses in response to increasing demand for services in the spring and were not prepared for the consequential increase in their payrolls in the autumn. It is an interesting analysis, but not one that would justify the underfunding of next year’s pay award. Should that happen, Sir Barney, Dame Jill, and the rest may start revolting in earnest.
Notes and News
programme. The biggest failure of the present system is that many women have never been screened at all. As a matter of urgency, all district health authorities should
FETAL VIABILITY A JOINT report! has recommended that the age of viability of the fetus should be reduced from 28 weeks to 24 weeks, as defined by the Infant Life (Preservation) Act of 1929. The report was drawn up by a committee representing the Royal College of Obstetricians and Gynaecologists, the Royal College of General Practitioners, the British Medical Association, the British Paediatric Association, the Royal College of Midwives, and the Clinical Genetics Society. The report opposes the proposed reduction to 18 weeks in Mr David Alton’s Abortion Amendment Bill, which seeks to make abortions after 18 weeks of pregnancy illegal (with the exception of a termination to save the life of the mother or if the child would be stillborn or so severely handicapped that it would not sustain life). Mr Alton’s Private Member’s Bill is due to be presented to the House of Commons on Jan 22. At a meeting in London on Dec 2, Prof Richard Beard (professor of obstetrics and gynaecology, St Mary’s Hospital Medical School, London) emphasised that reducing the gestational age limit to 18 weeks would discriminate against women most in need of abortion and that such a limit had no scientific basis. Professor Beard pointed out that many major fetal abnormalities were not discovered until 22 or even 24 weeks. Technical and administrative delays could easily arise; and, moreover, many women, particularly very young and disadvantaged women, tended to consult late. Such women might be driven to seek criminal abortion, he warned, should Mr Alton’s Bill become law. Professor Beard hardly needed to remind his listeners that before the 1967 Abortion Act 98 women died in 1966 as a result of clandestine abortions and many suffered untold distress and permanent physical damage. Mr Alton’s proposal would punish those women who, for no fault of their own, were carrying a child with a major abnormality or who were uncertain about their ability to cope with pregnancy.
REPORT OF THE INTERCOLLEGIATE WORKING PARTY ON CERVICAL CYTOLOGY SCREENING IN the UK, the continuing problem of cervical cancer and the increasing number of women at risk with pre-malignant disease has been addressed by a working party representing the Royal College of Obstetricians and Gynaecologists, the Royal College of Pathologists, the Royal College of General Practitioners, and the Faculty of Community Medicine.2 Deficiencies in the existing organisation of cervical screening have been identified. Recommendations for improvement have been made which these organisations feel should be implemented without delay as follows: Through formal public education programmes, everyone should be made aware that it is possible to reduce the incidence of and mortality from cervical cancer by an effective cervical screening 1 Report on the Advantages and Disadvantages of Imposing an 18-week Gestational Age Limit on Legal Abortion. Available from the RCOG, 27 Sussex Place, London NW1 4RG 2.
Report available from the Royal College of Obstetricians 27 Sussex Place, London NW1 4RG.
JOHN CARVEL
institute an effective systematic cervical cytology screening programme. Every adult woman should be personally invited to be screened. The examination should be repeated at three-yearly intervals on women between 20 and 64 years of age. There should be no upper age limit for women who have never had a smear. All women should be informed of the result of their test. All women with a positive test should be referred for further
investigative treatment. The achievement of these aims will require: 1. The replacement of opportunistic screening
by planned screening; 2. A comprehensive education programme for training general practitioners and other health personnel in taking smears, to ensure that all adult women are offered screening; 3. An appropriate management scheme; 4. Appropriate resources for the taking and examination of smears including adequate pathology and computer facilities; 5. Urgent steps to correct the relative deficiency of trained cytopathologists and laboratory staff in the UK; 6. Adequate provision of colposcopy facilities. It is essential that computerised monitoring facilities are provided and that results achieved -by those involved in the service are monitored at regular intervals. The implementation of these recommendations will not be possible within current NHS budgeting.
THE CONTENT OF PROCESSED FOOD 1 HE past tew years have
Gynaecologists,
remarkable
change
m
public
labelling.
1 and
seen a
of the importance of diet. Many people have made efforts to reduce their consumption of fats, especially saturated fats of animal origin. At a press conference held on Dec 3 by the Coronary Prevention Group, Prof Geoffrey Rose (Department of Epidemiology, London School of Hygiene and Tropical Medicine) suggested that some of the unwanted fat is finding its way surreptitiously into processed foods. In the British diet 43% of food energy still comes from fat, whereas the Committee on Medical Aspects of Food Policy, in its 1984 report, favoured 35 %. For real dietary change, Professor Rose emphasised, the consumer requires a proper breakdown of the nutritional content of all processed foods. The Coronary Prevention Group has produced a report’ analysing the Government’s attitude towards food According to the CPG, there are some very obvious discrepancies. It seems as though the Government has accepted that the health lobby won the battle with the dairy industry: a draft proposal for making labelling of the fat content (total and saturated) of food awareness
Barrier or Scapegoat’ An Analysis of the UK Govemment’s Position on Nutrition Labelling. Available from the Coronary Prevention Group, 60 Great Ormond Street, London WC1N 3HR (01-833 3687)
European Community