- Email: [email protected]
CONSERVING THE SPHINCTERS IN RECTAL CANCER
717
formalin-treated Legionella antigens. These tests still await organisms standardisation internationally, as do those for demonstrating Legionella antigens in body secretions and tissues. As the WHO report indicates, there is need for coordination of these aspects and also of future work, as well as for a designated European centre for of national collation Legionella surveillance to allow recognition of scattered rapid programmes cases associated with single sources. Legionella organisms, perhaps because of their exacting requirements, probably occur only in very small numbers in the aquatic environment, but given a warm and wet ecological niche, they can multiply considerably. Such conditions occur artificially in airconditioning cooling towers and evaporative condensers as well as in piped-water storage systems associated with large buildings. The former have been concerned in several outbreaks of legionnaires’ disease in the USA’—though only clearly in one instance in Britain, whereas piped water has been implicated in several outbreaks in hospitals and hotels in the UK.12-14 In the cooling-water incidents, the risk of infection was directly related to the extent of exposure to the moisture-laden atmospheric drift; in the pipedwater systems, transmission presumably occurred through aerosols created by running taps and showers. L pneumophila is known to survive in experimental aerosols,15 and animal experiments16 further confirm the likelihood of this route of transmission in man. Drinking water itself was implicated in a hospital outbreak in America,17 though a- drop in pressure had affected the appearance and quality of the supply. This outbreak was not controlled by treatment of the airconditioning cooling water but, as in the UK,14 it ceased when the water supply within the hospital was chlorinated. Current work18 suggests that, in the UK, L pneumophila occurs more often and in greater numbers in hot-water systems than in cold-water outlets. Where it actually resides is not yet clear, though hot-water cylinders are a possibility. 19 Nor indeed is its relationship, if any, to the physicochemical nature of the water or of fixtures and fittings in contact with the
with
heat-killed
or
as
10. Band 11
12
13 14
15 16
17
18 19
JD, Laventure M, Davis JP, et al. Epidemic legionnaires’ disease: airborne transmission down a chimney. JAMA 1981; 245: 2404-07. Dondero TJ, Rendtorff RC, Mallison GF, et al. An outbreak of legionnaires’ disease associated with a contaminated air-conditioning cooling tower. N Engl J Med 1980; 302: 365-70. Tobin JO’H, Bartlett CLR, Waitkins S, et al. Legionnaires’ disease: further evidence to implicate water storage and distribution systems as sources. Br Med J1981; 282: 573-74. Tobin JO’H, Beare J, Dunhill MS, et al. Legionnaires’ disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet 1980; ii: 118-21. Fisher-Hoch SP, Bartlett CLR, Tobin JO’H, et al. Investigation and control of an outbreak of legionnaires’ disease in a district general hospital. Lancet 1981; i: 932-36. Hambleton P, Broster MG, Dennis PJ, et al. Survival of virulent Legionella pneumophila in aerosols. J Hyg 1983; 90: 451-60. Baskerville A, Fitzgeorge RB, Broster M, et al. Experimental transmission of legionnaires’ disease by exposure to aerosols of Legionella pneumophila. Lancet 1981; ii: 1389-90. Shands KN, Gorman GW, Meyer RD, et al. Potable water as a source of legionnaires’ disease. Clin Res 1981; 29: 260A (abstr). Dennis PJ, Taylor JA, Fitzgeorge RB, et al. Legionella pneumophila in water plumbing systems. Lancet 1982; i: 949-51. Fisher-Hoch SP, Smith MG, Colbourne JS. Legionella pneumophila in hospital hotwater cylinders. Lancet 1982; i: 1073.
Presumably the temperature of the selectively encourages the growth of Legionella organisms, unless it is high enough to kill them-as perhaps is the case in Australian hospitals.20 Possibly yet known.
water
water
its occurrence in some domestic water-storage systems could account for sporadic cases without a history of recent travel. But if Legionella organisms are not "new" in the environment, is Legionella pneumonia a modern plumbing-associated infection? Or did Roman legionaries also succumb to it? At least we are fortunate in having erythromycin and rifampicin at our command, though, even given together, they may not be able to reach Legionella multiplying in phagocytes, and they cannot neutralise toxins already formed. Perhaps, like Brucella organisms, they could even become intracellular parasites. As The Lancet said last month,21 the presence of Legionella organisms in water systems, especially in the absence of associated cases of infection, should not be regarded as an indication for instant remedial action-though inspection and review of maintenance procedures to ensure adequate hygiene would at least be prudent. Storage tanks in particular should always be covered, and in water-cooling systems, draining, cleansing, and chemical treatment, including if necessary a biocide, to reduce the accumulation of slime, algae and other accretions should be carried out regularly. In outbreaks, cleaning and disinfection of water-cooling systems, although not ideal, has been used with apparent success as a means of control. In piped-water storage systems, perhaps the simplest measure in addition to continuous disinfection is to ensure that the hot water is indeed hot, and the cold water at least cool. CONSERVING THE SPHINCTERS IN RECTAL CANCER THE rectal
epithelium between 5 and 12 cm from the anal probably the most important cancer-bearing area in Western man. The patient with such a tumour and his medical advisers stand currently in the crossfire of fierce surgical controversy. For the patient the stakes are high. Firstly, he may or may not return from his operation with a permanent colostomy-the typical tumour at 8 cm is a certain candidate in many hospitals but equally certain for a restorative resection in others. Secondly, he stands a high risk of surgical damage to the hypogastric plexuses with consequent impotence and impaired bladder function. Most important of all he has a tumour where variation in cure rates is high: the Large Bowel Cancer Project’ shows that local verge is
recurrence rates
vary between consultants from 5%
to over
25%, and published 5 year survivals after potentially curative resection range from under 30% to over 70%.2,3 Finally, the Peel MM, Rouch GJ. Isolation of Legionella pneumophila from hospital systems in Victoria. Med J Austr 1982; ii: 226-27. 21. Editorial. Waterborne legionella. Lancet 1983; n: 381-83. 1. Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence after "curative" surgery for large bowel cancer-(1) the overall picture. Br J Surg (in 20. Swann
RA,
water
press). Slaney G. Results of treatment of Ca colon and rectum. In: Irvine WT, ed. Modern trends in surgery 3. London: Butterworth, 1971: 69-89. 3. McDermott FT, Hughes ESR, Pihl E, Milne BJ, Price AB. Comparative results of surgical management of single carcinomas of the colon and rectum: a series of 1939 patients managed by one surgeon. Br J Surg 1981; 68: 850-55. 2.
718
patient may or may not be engulfed in the rising tide of adjuvant therapy, the prophylactic value of which remains unproven.
Johnston4
have compared the lives of with those of patients undergoing restorative excision of tumours at similar heights. They confirm the earlier assertions of Devlin5and others that a colostomy is a high price to pay for cure: accidents and leakage, altered perception of body image, a sense of social isolation, depression-all are common sequelae. In Britain stoma therapists and the acceptance of irrigation techniques are reducing these sources of unhappiness but will not eliminate them. Furthermore, experience in many centres is establishing the value of conserving the pelvic floor, the sphincters, and the lowest few centimetres ofrectum.6,7 Even colo-anal anastomosis leads, after a few months of urgency and frequency, to an acceptable lifestyle for most people.8 A "dignified retreat" to a colostomy is only occasionally necessary for functional failure.9 The movement towards more and lower anterior resections does thus seem desirable. Furthermore the circular stapling devices appear to put the technique within reach of surgeons in district hospitals where most rectal cancers are treated. 10 Two major obstacles remain. Firstly the danger of leakage hovers over the low anastomosis; indeed; few surgeons would regard anastomosis within 5 cm of the anal verge as entirely safe. 11 Attention to the mobility and blood supply of the colon and the avoidance of pelvic haematoma will probably contain this problem, and a temporary loop colostomy can certainly lessen its ill-effects. Much more fundamental and serious is the question of localrecurrence which casts a long shadow over the whole enterprise and generates much conflict and disagreement. The vaunted 5 cm margin has been the easiest aspect of "radicality" to measure but is being increasingly recognised as the least important. Spread along the muscle tube, as in gastric or oesophageal cancer, is mercifully rare and the palpable lower edge and the microscopic edge are seldom more than 0’5cm apart.12,13 Even during an abdominoperineal excision the surgeon must dissect within millimetres around the tumour where most histopathologists believe that local recurrences generally arise from residues of 5 remnants of or tumour in lymphatics, 14 vessels, 15 mesorectum, 16or on the pelvic walls. The enormous variation in recurrence rates after restorative excision (between 1% and 36% in published series) implies that the
Williams and
colostomy patients
Williams NS, Johnston D. The quality of life after rectal excision for low rectal cancer. Br J Surg 1983; 70: 460-62. 5. Devlin HB, Plant JA, Griffen M. Aftermath of surgery of anorectal cancer. Br Med J 1971; iii: 413-18. 6. Goligher JC. Recent trends in the practice of sphincter-saving excision for rectal cancer. Ann Roy Coll Surg 1979; 61: 169-76. 7. Parks AG, Percy JP. Resection and sutured colo-anal anastomosis for rectal carcinoma. Br J Surg 1982; 69: 301-04 8. Lane RHS, Parks AG. Function of the anal sphincters following colo-anal anastomosis. Br J Surg 1977; 64: 596-99 9. McDonald PJ, Heald RJ. A survey of post-operative function after rectal anastomosis with circular stapling devices. Br J Surg (in press). 10. Heald RJ. Towards fewer colostomies-the impact of circular stapling devices on the surgery of rectal cancer in a district hospital. Br J Surg 1980; 67: 198-200. 11. Heald RJ, Leicester RJ The low stapled anastomosis. Br J Surg 1981; 68: 333-57. 12. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg 1983; 70: 150-54. 13. Pollett WJ, Nicholls RJ. Does the extent of distal clearance affect survival after radical anterior resection for cancer of the rectum? Gut 1981; 22: 872. 4.
14.
Rosenberg IL. The aetiology of colonic suture-line recurrence. Ann Roy Coll Surg 1979;
61: 251-57. 15. Talbot IC, Ritchie
S, Leighton MH, Hughes AO, Bussey HJR, Morson BD. The clinical significance of invasion of veins by rectal carcinoma. Br J Surg 1980; 67: 439-42. 16. Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg 1982; 69: 613-16.
pelvic dissection is not only the key to avoiding pelvic nerve damage but also an area where specialisation might improve cure-rates. In the introduction to a book on anterior resection published this month, LockhartMummery and Healdl1’ point to "A real danger that the ’guns’ will lead to the performance of lower anterior resections without commensurate development of skilled low pelvic dissection technique. Such a trend would be disastrous since there is no more important aspect of rectal cancer difficult low
...
surgery than the avoidance of local recurrence".
FORTRESS NHS
THIS time last yearl,2 only the rosiest of optimists viewed the future of the National Health Service with good cheer. Since then the electorate has turned out again in support of the Prime Minister’s economic policies in sufficient numbers to ensure that the NHS really has a fight on its hands if its decline is to be halted. In recent months the Lancet’s Parliamentary correspondent has had to record one item of glum news after another. This week (p 748) he tells of renewed, shriller, and even less persuasive attempts by the Secretary of State, Mr Norman Fowler, and the Minister for Health, Mr Kenneth Clarke, to assure the nation that the Government’s actions have not harmed and its plans will not harm standards of patient care. Mr Fowler and others at the DHSS have been engaged in discussions with the Treasury about future funding of the NHS. Mr Fowler’s record while in his present office promotes scant confidence in his inclination or ability to mount even a modestly successful defence of the Service against another round of deprivations. Doctors and others working in and for the NHS must brace themselves and try to do it for him. To equip the barricades, the BMA is inviting doctors to report instances of how reductions imposed by the Government are affecting services provided for patients.3 Another defence lies within the reach of doctors who are opposed to the extension of private practice when its advance weakens the NHS and who are prepared to speak out against its Government-sponsored march. A weapon is also available to those doctors who might become more enthusiastic as sensible managers ofNHS resources, so that, when a prospect of economies that are not too disruptive is still apparent, it can be pursued with their guidance. One of Mr Fowler’s chief worries is the rising cost of the family practitioner service: he might look again at how far item-of-service payments to family doctors have contributed to this part of the NHS bill over the years (p 748) and re-examine the justification for having so many of them. "The NHS is safe with us", the Prime Minister declared before the general election. If the Government holds to its present course that pledge will acquire a particularly hollow reputation. Profitless it will no doubt be to attempt to dissuade the Prime Minister from a path predetermined by a belief that public spending must be relentlessly cut. Nevertheless, the campaign for the protection of the NHS must call again on the Service’s staff, and especially its medical members, to give their own promise: to do all they can to ensure that the NHS is safe with them., 17.
Lockhart-Mummery HE, Heald RJ, Hutchings RT. A colour atlas of
of the rectum. London: Wolfe Medical Publications Ltd, 1983. 1. Editorial. Let those who care speak louder Lancet 1982; ii: 365. 2 Editorial. The state of the NHS. Lancet 1982; ii: 587. 3. Editorial. Trimming fat or cutting bone? Br Med J 1983; 287: 780.
anterior resection
formalin-treated Legionella antigens. These tests still await organisms standardisation internationally, as do those for demonstrating Legionella antigens in body secretions and tissues. As the WHO report indicates, there is need for coordination of these aspects and also of future work, as well as for a designated European centre for of national collation Legionella surveillance to allow recognition of scattered rapid programmes cases associated with single sources. Legionella organisms, perhaps because of their exacting requirements, probably occur only in very small numbers in the aquatic environment, but given a warm and wet ecological niche, they can multiply considerably. Such conditions occur artificially in airconditioning cooling towers and evaporative condensers as well as in piped-water storage systems associated with large buildings. The former have been concerned in several outbreaks of legionnaires’ disease in the USA’—though only clearly in one instance in Britain, whereas piped water has been implicated in several outbreaks in hospitals and hotels in the UK.12-14 In the cooling-water incidents, the risk of infection was directly related to the extent of exposure to the moisture-laden atmospheric drift; in the pipedwater systems, transmission presumably occurred through aerosols created by running taps and showers. L pneumophila is known to survive in experimental aerosols,15 and animal experiments16 further confirm the likelihood of this route of transmission in man. Drinking water itself was implicated in a hospital outbreak in America,17 though a- drop in pressure had affected the appearance and quality of the supply. This outbreak was not controlled by treatment of the airconditioning cooling water but, as in the UK,14 it ceased when the water supply within the hospital was chlorinated. Current work18 suggests that, in the UK, L pneumophila occurs more often and in greater numbers in hot-water systems than in cold-water outlets. Where it actually resides is not yet clear, though hot-water cylinders are a possibility. 19 Nor indeed is its relationship, if any, to the physicochemical nature of the water or of fixtures and fittings in contact with the
with
heat-killed
or
as
10. Band 11
12
13 14
15 16
17
18 19
JD, Laventure M, Davis JP, et al. Epidemic legionnaires’ disease: airborne transmission down a chimney. JAMA 1981; 245: 2404-07. Dondero TJ, Rendtorff RC, Mallison GF, et al. An outbreak of legionnaires’ disease associated with a contaminated air-conditioning cooling tower. N Engl J Med 1980; 302: 365-70. Tobin JO’H, Bartlett CLR, Waitkins S, et al. Legionnaires’ disease: further evidence to implicate water storage and distribution systems as sources. Br Med J1981; 282: 573-74. Tobin JO’H, Beare J, Dunhill MS, et al. Legionnaires’ disease in a transplant unit: Isolation of the causative agent from shower baths. Lancet 1980; ii: 118-21. Fisher-Hoch SP, Bartlett CLR, Tobin JO’H, et al. Investigation and control of an outbreak of legionnaires’ disease in a district general hospital. Lancet 1981; i: 932-36. Hambleton P, Broster MG, Dennis PJ, et al. Survival of virulent Legionella pneumophila in aerosols. J Hyg 1983; 90: 451-60. Baskerville A, Fitzgeorge RB, Broster M, et al. Experimental transmission of legionnaires’ disease by exposure to aerosols of Legionella pneumophila. Lancet 1981; ii: 1389-90. Shands KN, Gorman GW, Meyer RD, et al. Potable water as a source of legionnaires’ disease. Clin Res 1981; 29: 260A (abstr). Dennis PJ, Taylor JA, Fitzgeorge RB, et al. Legionella pneumophila in water plumbing systems. Lancet 1982; i: 949-51. Fisher-Hoch SP, Smith MG, Colbourne JS. Legionella pneumophila in hospital hotwater cylinders. Lancet 1982; i: 1073.
Presumably the temperature of the selectively encourages the growth of Legionella organisms, unless it is high enough to kill them-as perhaps is the case in Australian hospitals.20 Possibly yet known.
water
water
its occurrence in some domestic water-storage systems could account for sporadic cases without a history of recent travel. But if Legionella organisms are not "new" in the environment, is Legionella pneumonia a modern plumbing-associated infection? Or did Roman legionaries also succumb to it? At least we are fortunate in having erythromycin and rifampicin at our command, though, even given together, they may not be able to reach Legionella multiplying in phagocytes, and they cannot neutralise toxins already formed. Perhaps, like Brucella organisms, they could even become intracellular parasites. As The Lancet said last month,21 the presence of Legionella organisms in water systems, especially in the absence of associated cases of infection, should not be regarded as an indication for instant remedial action-though inspection and review of maintenance procedures to ensure adequate hygiene would at least be prudent. Storage tanks in particular should always be covered, and in water-cooling systems, draining, cleansing, and chemical treatment, including if necessary a biocide, to reduce the accumulation of slime, algae and other accretions should be carried out regularly. In outbreaks, cleaning and disinfection of water-cooling systems, although not ideal, has been used with apparent success as a means of control. In piped-water storage systems, perhaps the simplest measure in addition to continuous disinfection is to ensure that the hot water is indeed hot, and the cold water at least cool. CONSERVING THE SPHINCTERS IN RECTAL CANCER THE rectal
epithelium between 5 and 12 cm from the anal probably the most important cancer-bearing area in Western man. The patient with such a tumour and his medical advisers stand currently in the crossfire of fierce surgical controversy. For the patient the stakes are high. Firstly, he may or may not return from his operation with a permanent colostomy-the typical tumour at 8 cm is a certain candidate in many hospitals but equally certain for a restorative resection in others. Secondly, he stands a high risk of surgical damage to the hypogastric plexuses with consequent impotence and impaired bladder function. Most important of all he has a tumour where variation in cure rates is high: the Large Bowel Cancer Project’ shows that local verge is
recurrence rates
vary between consultants from 5%
to over
25%, and published 5 year survivals after potentially curative resection range from under 30% to over 70%.2,3 Finally, the Peel MM, Rouch GJ. Isolation of Legionella pneumophila from hospital systems in Victoria. Med J Austr 1982; ii: 226-27. 21. Editorial. Waterborne legionella. Lancet 1983; n: 381-83. 1. Phillips RKS, Hittinger R, Blesovsky L, Fry JS, Fielding LP. Local recurrence after "curative" surgery for large bowel cancer-(1) the overall picture. Br J Surg (in 20. Swann
RA,
water
press). Slaney G. Results of treatment of Ca colon and rectum. In: Irvine WT, ed. Modern trends in surgery 3. London: Butterworth, 1971: 69-89. 3. McDermott FT, Hughes ESR, Pihl E, Milne BJ, Price AB. Comparative results of surgical management of single carcinomas of the colon and rectum: a series of 1939 patients managed by one surgeon. Br J Surg 1981; 68: 850-55. 2.
718
patient may or may not be engulfed in the rising tide of adjuvant therapy, the prophylactic value of which remains unproven.
Johnston4
have compared the lives of with those of patients undergoing restorative excision of tumours at similar heights. They confirm the earlier assertions of Devlin5and others that a colostomy is a high price to pay for cure: accidents and leakage, altered perception of body image, a sense of social isolation, depression-all are common sequelae. In Britain stoma therapists and the acceptance of irrigation techniques are reducing these sources of unhappiness but will not eliminate them. Furthermore, experience in many centres is establishing the value of conserving the pelvic floor, the sphincters, and the lowest few centimetres ofrectum.6,7 Even colo-anal anastomosis leads, after a few months of urgency and frequency, to an acceptable lifestyle for most people.8 A "dignified retreat" to a colostomy is only occasionally necessary for functional failure.9 The movement towards more and lower anterior resections does thus seem desirable. Furthermore the circular stapling devices appear to put the technique within reach of surgeons in district hospitals where most rectal cancers are treated. 10 Two major obstacles remain. Firstly the danger of leakage hovers over the low anastomosis; indeed; few surgeons would regard anastomosis within 5 cm of the anal verge as entirely safe. 11 Attention to the mobility and blood supply of the colon and the avoidance of pelvic haematoma will probably contain this problem, and a temporary loop colostomy can certainly lessen its ill-effects. Much more fundamental and serious is the question of localrecurrence which casts a long shadow over the whole enterprise and generates much conflict and disagreement. The vaunted 5 cm margin has been the easiest aspect of "radicality" to measure but is being increasingly recognised as the least important. Spread along the muscle tube, as in gastric or oesophageal cancer, is mercifully rare and the palpable lower edge and the microscopic edge are seldom more than 0’5cm apart.12,13 Even during an abdominoperineal excision the surgeon must dissect within millimetres around the tumour where most histopathologists believe that local recurrences generally arise from residues of 5 remnants of or tumour in lymphatics, 14 vessels, 15 mesorectum, 16or on the pelvic walls. The enormous variation in recurrence rates after restorative excision (between 1% and 36% in published series) implies that the
Williams and
colostomy patients
Williams NS, Johnston D. The quality of life after rectal excision for low rectal cancer. Br J Surg 1983; 70: 460-62. 5. Devlin HB, Plant JA, Griffen M. Aftermath of surgery of anorectal cancer. Br Med J 1971; iii: 413-18. 6. Goligher JC. Recent trends in the practice of sphincter-saving excision for rectal cancer. Ann Roy Coll Surg 1979; 61: 169-76. 7. Parks AG, Percy JP. Resection and sutured colo-anal anastomosis for rectal carcinoma. Br J Surg 1982; 69: 301-04 8. Lane RHS, Parks AG. Function of the anal sphincters following colo-anal anastomosis. Br J Surg 1977; 64: 596-99 9. McDonald PJ, Heald RJ. A survey of post-operative function after rectal anastomosis with circular stapling devices. Br J Surg (in press). 10. Heald RJ. Towards fewer colostomies-the impact of circular stapling devices on the surgery of rectal cancer in a district hospital. Br J Surg 1980; 67: 198-200. 11. Heald RJ, Leicester RJ The low stapled anastomosis. Br J Surg 1981; 68: 333-57. 12. Williams NS, Dixon MF, Johnston D. Reappraisal of the 5 centimetre rule of distal excision for carcinoma of the rectum: a study of distal intramural spread and of patients’ survival. Br J Surg 1983; 70: 150-54. 13. Pollett WJ, Nicholls RJ. Does the extent of distal clearance affect survival after radical anterior resection for cancer of the rectum? Gut 1981; 22: 872. 4.
14.
Rosenberg IL. The aetiology of colonic suture-line recurrence. Ann Roy Coll Surg 1979;
61: 251-57. 15. Talbot IC, Ritchie
S, Leighton MH, Hughes AO, Bussey HJR, Morson BD. The clinical significance of invasion of veins by rectal carcinoma. Br J Surg 1980; 67: 439-42. 16. Heald RJ, Husband EM, Ryall RDH. The mesorectum in rectal cancer surgery-the clue to pelvic recurrence? Br J Surg 1982; 69: 613-16.
pelvic dissection is not only the key to avoiding pelvic nerve damage but also an area where specialisation might improve cure-rates. In the introduction to a book on anterior resection published this month, LockhartMummery and Healdl1’ point to "A real danger that the ’guns’ will lead to the performance of lower anterior resections without commensurate development of skilled low pelvic dissection technique. Such a trend would be disastrous since there is no more important aspect of rectal cancer difficult low
...
surgery than the avoidance of local recurrence".
FORTRESS NHS
THIS time last yearl,2 only the rosiest of optimists viewed the future of the National Health Service with good cheer. Since then the electorate has turned out again in support of the Prime Minister’s economic policies in sufficient numbers to ensure that the NHS really has a fight on its hands if its decline is to be halted. In recent months the Lancet’s Parliamentary correspondent has had to record one item of glum news after another. This week (p 748) he tells of renewed, shriller, and even less persuasive attempts by the Secretary of State, Mr Norman Fowler, and the Minister for Health, Mr Kenneth Clarke, to assure the nation that the Government’s actions have not harmed and its plans will not harm standards of patient care. Mr Fowler and others at the DHSS have been engaged in discussions with the Treasury about future funding of the NHS. Mr Fowler’s record while in his present office promotes scant confidence in his inclination or ability to mount even a modestly successful defence of the Service against another round of deprivations. Doctors and others working in and for the NHS must brace themselves and try to do it for him. To equip the barricades, the BMA is inviting doctors to report instances of how reductions imposed by the Government are affecting services provided for patients.3 Another defence lies within the reach of doctors who are opposed to the extension of private practice when its advance weakens the NHS and who are prepared to speak out against its Government-sponsored march. A weapon is also available to those doctors who might become more enthusiastic as sensible managers ofNHS resources, so that, when a prospect of economies that are not too disruptive is still apparent, it can be pursued with their guidance. One of Mr Fowler’s chief worries is the rising cost of the family practitioner service: he might look again at how far item-of-service payments to family doctors have contributed to this part of the NHS bill over the years (p 748) and re-examine the justification for having so many of them. "The NHS is safe with us", the Prime Minister declared before the general election. If the Government holds to its present course that pledge will acquire a particularly hollow reputation. Profitless it will no doubt be to attempt to dissuade the Prime Minister from a path predetermined by a belief that public spending must be relentlessly cut. Nevertheless, the campaign for the protection of the NHS must call again on the Service’s staff, and especially its medical members, to give their own promise: to do all they can to ensure that the NHS is safe with them., 17.
Lockhart-Mummery HE, Heald RJ, Hutchings RT. A colour atlas of
of the rectum. London: Wolfe Medical Publications Ltd, 1983. 1. Editorial. Let those who care speak louder Lancet 1982; ii: 365. 2 Editorial. The state of the NHS. Lancet 1982; ii: 587. 3. Editorial. Trimming fat or cutting bone? Br Med J 1983; 287: 780.
anterior resection