- Email: [email protected]
COMMUNITY PHYSICIANS AND CIVIL DEFENCE
222
PRIVATE SECTOR/NHS COOPERATION: ONE-WAY TRAFFIC
SIR,-The opening statement of the Secretary of State for Social Services’ paper on Cooperation between the NHS and the Private Sector at District Level (June 11, p 1323)-"Although the private sector of health care is comparatively small, the benefits to the NHS of a partnership with it are disproportionate to its size"-is an opinion based on political dogma without any supporting evidence. Nevertheless it is presented as a justification for all that follows. Seven proposals are made without proper consideration of their implications. For instance to overcome "temporary difficulties" in the NHS-"to tackle a long waiting list"-health authorities can make use of private facilities, presumably hiring private hospital operating theatres. Is it envisaged that the surgeons clearing the lists do so on NHS time or will they require to be paid private scale fees? If the latter, the costs to the NHS will be considerable. Besides which, one of the main reasons for long waiting lists is a shortage of trained staff, especially nurses, as a result of cutbacks imposed by financial restraints. Doctors involved in private work are also not available for NHS work. Is it really intended to invite them to do their NHS work privately? How will standards of accommodation and care be assured? Will the DHSS have to "top up" statutory allowances even further? Will this really be economical? Mr Fowler suggests, glibly, that there should be increasing use of each other’s "high technology" equipment and laboratories by private and public sectors, as though there was some equality of resources. In practice this means the increased use of NHS resources by private sector hospitals (nursing homes) and clinics at nominal charges, as the private sector, contrary to advertisers’, mythology, is not awash with high technology equipment or
expertise. Even more unjustifiable are Mr Fowler’s ideas about staff accommodation and NHS land. To sell them off to private interests is asset stripping of Amersham-type proportions. It would appear that privatisation of the NHS is intended to select out these areas where money can be made for private interests with the public sector as the springboard for these profitable operations. The recently announced financial restraints will mean that the service offered by the public sector will be increasingly poor in provision and quality, stimulating those who can to opt for private insurance health care. It would seem that Mr Fowler’s short term motivation is to fill underused private facilities and ensure the economic viability of a private sector which has increased some of its facilities beyond current demand. William
Harvey Hospital,
Ashford, Kent
ANDREW PORTER, Secretary, NHS Consultants’ Association
Royal Free Hospital,
PAUL NOONE,
London NW3
Chairman, NHSCA
COMMUNITY PHYSICIANS AND CIVIL DEFENCE
SIR,-In your July 9 (p 114) report of a symposium organised by the Medical Campaign Against Nuclear Weapons you slightly misquoted one of us (H. E. Z.). The behaviour used by individuals to avoid the issues raised by nuclear weapons-incomprehension and denial, fascination, helplessness, and social embarrassment-were described by Nicholas Humphrey,not his father, Prof John Humphrey. More importantly, despite the dilemma they face,’ community physicians have not concluded that "until the Government manifested a clear commitment to the prevention of nuclear war (as opposed to ambitions of winning), they would not involve themselves in plans for civil defence". The recommendation from the Annual Conference of Community Medicine2 was to take no further part in civil defence planning until further guidance is issued which takes account of the criticism outlined in the British 1.
Humphrey N. Four minutes to midnight. Br Med J1983; 286: 2086.
2. See
London: Menard Press, 1982..
Medical Association’s
report3on nuclear war; while the Faculty of
in endorsing the conclusions of the BMA report, recommended at its June 23 annual general meeting "that the information and criteria used in any planning exercise should be made known to the public and the subsequent policy should be generated by full public debate". This recommendation takes account of a study of the implications of nuclear weapons for community medicineand last year’s statement by the Faculty Board that planning can make an important contribution to general public awareness of the need for nuclear war to be prevented. Many community physicians, ourselves included, believe that in addition to planning for the consequences of nuclear war there is an urgent need to participate in an active process to prevent such a war. By ensuring a greater public understanding of the immediate and long term medical hazards which would follow such a war, and of emphasising the impossibility of mounting an effective medical response, we can make our own specific contribution. But this will not be sufficient to combat the growing threat to our communities-a threat which arises as much from human fear, mistrust, and pride as from the weapons themselves. As a profession we have a long tradition of working in the international community and in so doing we demonstrate the feasibility of working in harmony with those whose political, ethical, or religious background may be different from our own. By collaborating with the growing number of doctors around the world who share our commitment to the prevention of nuclear war, we could make a small contribution to achieving changes in the human factors which themselves lead to war. We are not the first generation of doctors to face a difficult and controversial issue, but unless we play our part we may be the last.
Community Medicine,
182 Kimbolton Road,
Bedford
D. S.
Tipperlinn Road, Edinburgh
H. E. ZEALLEY
JOSEPHS
12
THE SOUTH WALES NTD SCREENING EXPERIENCE
SIR,-The South Wales Anencephaly and Spina Bifida Screening Group appeared disappointed with the efficacy of serum-a. fetoprc,tein (AFP) screening in lowering birth incidences of neural tube defects (NTD) (June 11, p 1315). The group are to be congratulated on a well planned and lucidly presented project, but I do not believe that their gloomy conclusions are justified. The study population contained 27 cases of open spina bifida, the interest. Of these 27, 5 were in unscreened 5 of the 22 screened were not detected; 6 of the 17 pregnancies; detected were not terminated; and 11 affected pregnancies were detected and terminated. The efficacy, 11/27 (4 1%), certainly gives little cause for celebration, but the various points at which the system failed bear some scrutiny. The detection rate amongst those screened is 17/22 (77%). This is not greatly different from the 79% achieved in the UK Collaborative The parameters of the AFP assay have been and a carefully set out and intensively studied by several detection rate for open spina bifida of about 80% is much in line with expectation. Less predictably, 6 of the 17 cases detected (35%) were not terminated. In 5 of the 6, patient and obstetrician confusion appears to have been generated by conflict between abnormal AFP levels and apparently normal findings on ultrasound, sometimes combined with equivocal amniotic fluid AFP levels. In contrast to the well studied AFP assay, ultrasound scanning has not been thoroughly tested objectively, and its error rates in the detection of spina bifida are not well defined. It is generally believed that a
category of
most
Study.1
3. The medical effects of nuclear
groups,]
war: Report of the BMA’s Board of Science and Education. London: John Wiley and Sons, 1983. 4. Implication of nuclear weapons for community medicine. Report of a study group. Commun Med 1982; 4: 3439. 1. UK Collaborative Study on Alpha-Fetoprotein in Relation to Neural-Tube Defects Maternal serum-alpha-fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy. Lancet 1977; ii: 1323-32.
PRIVATE SECTOR/NHS COOPERATION: ONE-WAY TRAFFIC
SIR,-The opening statement of the Secretary of State for Social Services’ paper on Cooperation between the NHS and the Private Sector at District Level (June 11, p 1323)-"Although the private sector of health care is comparatively small, the benefits to the NHS of a partnership with it are disproportionate to its size"-is an opinion based on political dogma without any supporting evidence. Nevertheless it is presented as a justification for all that follows. Seven proposals are made without proper consideration of their implications. For instance to overcome "temporary difficulties" in the NHS-"to tackle a long waiting list"-health authorities can make use of private facilities, presumably hiring private hospital operating theatres. Is it envisaged that the surgeons clearing the lists do so on NHS time or will they require to be paid private scale fees? If the latter, the costs to the NHS will be considerable. Besides which, one of the main reasons for long waiting lists is a shortage of trained staff, especially nurses, as a result of cutbacks imposed by financial restraints. Doctors involved in private work are also not available for NHS work. Is it really intended to invite them to do their NHS work privately? How will standards of accommodation and care be assured? Will the DHSS have to "top up" statutory allowances even further? Will this really be economical? Mr Fowler suggests, glibly, that there should be increasing use of each other’s "high technology" equipment and laboratories by private and public sectors, as though there was some equality of resources. In practice this means the increased use of NHS resources by private sector hospitals (nursing homes) and clinics at nominal charges, as the private sector, contrary to advertisers’, mythology, is not awash with high technology equipment or
expertise. Even more unjustifiable are Mr Fowler’s ideas about staff accommodation and NHS land. To sell them off to private interests is asset stripping of Amersham-type proportions. It would appear that privatisation of the NHS is intended to select out these areas where money can be made for private interests with the public sector as the springboard for these profitable operations. The recently announced financial restraints will mean that the service offered by the public sector will be increasingly poor in provision and quality, stimulating those who can to opt for private insurance health care. It would seem that Mr Fowler’s short term motivation is to fill underused private facilities and ensure the economic viability of a private sector which has increased some of its facilities beyond current demand. William
Harvey Hospital,
Ashford, Kent
ANDREW PORTER, Secretary, NHS Consultants’ Association
Royal Free Hospital,
PAUL NOONE,
London NW3
Chairman, NHSCA
COMMUNITY PHYSICIANS AND CIVIL DEFENCE
SIR,-In your July 9 (p 114) report of a symposium organised by the Medical Campaign Against Nuclear Weapons you slightly misquoted one of us (H. E. Z.). The behaviour used by individuals to avoid the issues raised by nuclear weapons-incomprehension and denial, fascination, helplessness, and social embarrassment-were described by Nicholas Humphrey,not his father, Prof John Humphrey. More importantly, despite the dilemma they face,’ community physicians have not concluded that "until the Government manifested a clear commitment to the prevention of nuclear war (as opposed to ambitions of winning), they would not involve themselves in plans for civil defence". The recommendation from the Annual Conference of Community Medicine2 was to take no further part in civil defence planning until further guidance is issued which takes account of the criticism outlined in the British 1.
Humphrey N. Four minutes to midnight. Br Med J1983; 286: 2086.
2. See
London: Menard Press, 1982..
Medical Association’s
report3on nuclear war; while the Faculty of
in endorsing the conclusions of the BMA report, recommended at its June 23 annual general meeting "that the information and criteria used in any planning exercise should be made known to the public and the subsequent policy should be generated by full public debate". This recommendation takes account of a study of the implications of nuclear weapons for community medicineand last year’s statement by the Faculty Board that planning can make an important contribution to general public awareness of the need for nuclear war to be prevented. Many community physicians, ourselves included, believe that in addition to planning for the consequences of nuclear war there is an urgent need to participate in an active process to prevent such a war. By ensuring a greater public understanding of the immediate and long term medical hazards which would follow such a war, and of emphasising the impossibility of mounting an effective medical response, we can make our own specific contribution. But this will not be sufficient to combat the growing threat to our communities-a threat which arises as much from human fear, mistrust, and pride as from the weapons themselves. As a profession we have a long tradition of working in the international community and in so doing we demonstrate the feasibility of working in harmony with those whose political, ethical, or religious background may be different from our own. By collaborating with the growing number of doctors around the world who share our commitment to the prevention of nuclear war, we could make a small contribution to achieving changes in the human factors which themselves lead to war. We are not the first generation of doctors to face a difficult and controversial issue, but unless we play our part we may be the last.
Community Medicine,
182 Kimbolton Road,
Bedford
D. S.
Tipperlinn Road, Edinburgh
H. E. ZEALLEY
JOSEPHS
12
THE SOUTH WALES NTD SCREENING EXPERIENCE
SIR,-The South Wales Anencephaly and Spina Bifida Screening Group appeared disappointed with the efficacy of serum-a. fetoprc,tein (AFP) screening in lowering birth incidences of neural tube defects (NTD) (June 11, p 1315). The group are to be congratulated on a well planned and lucidly presented project, but I do not believe that their gloomy conclusions are justified. The study population contained 27 cases of open spina bifida, the interest. Of these 27, 5 were in unscreened 5 of the 22 screened were not detected; 6 of the 17 pregnancies; detected were not terminated; and 11 affected pregnancies were detected and terminated. The efficacy, 11/27 (4 1%), certainly gives little cause for celebration, but the various points at which the system failed bear some scrutiny. The detection rate amongst those screened is 17/22 (77%). This is not greatly different from the 79% achieved in the UK Collaborative The parameters of the AFP assay have been and a carefully set out and intensively studied by several detection rate for open spina bifida of about 80% is much in line with expectation. Less predictably, 6 of the 17 cases detected (35%) were not terminated. In 5 of the 6, patient and obstetrician confusion appears to have been generated by conflict between abnormal AFP levels and apparently normal findings on ultrasound, sometimes combined with equivocal amniotic fluid AFP levels. In contrast to the well studied AFP assay, ultrasound scanning has not been thoroughly tested objectively, and its error rates in the detection of spina bifida are not well defined. It is generally believed that a
category of
most
Study.1
3. The medical effects of nuclear
groups,]
war: Report of the BMA’s Board of Science and Education. London: John Wiley and Sons, 1983. 4. Implication of nuclear weapons for community medicine. Report of a study group. Commun Med 1982; 4: 3439. 1. UK Collaborative Study on Alpha-Fetoprotein in Relation to Neural-Tube Defects Maternal serum-alpha-fetoprotein measurement in antenatal screening for anencephaly and spina bifida in early pregnancy. Lancet 1977; ii: 1323-32.