Future of UK GP research database?

take legal action against Ottawa. Alberta has allowed the proliferation of semiprivate clinics and stands to lose about$5 million per year in federal deductions. Federal Health Minister Diane Marleau The province maintains that allowing peohas moved to stem partly the tide of ple to pay for quicker service at clinics two-tiered publicly funded healthcare than they would receive in hospitals is not (Medicare) in Canada, by threatening a violation of the Canada Health reductions in federal transfer payment to which prohibits doctors from charging provinces that provide any form of fundmore for a service than the amount set ing to semi-private clinics charging out in a provincial fee schedule. Alberta : contends it meets the conditions of the patients facility fees. After a year of hand-wringing and Act because medically necessary services veiled threats, Marleau has written to are still being provided under the rubric provincial health ministers informing of the publicly funded system. them that if facility fees charged by clinics But British Columbia last week to cover such costs as supplies, rent, and announced that it will move to legislate operating room overheads are not disconagainst user fees charged by semi-privately . tinued by Oct 15, Ottawa will deduct owned clinics, saying that a set of health those charges, dollar for dollar, from fedfacilities for the rich and another for eral transfer payments given to provinces everyone else is unacceptable. to help cover medicare and tertiary education costs. : In response, Alberta is threatening to Wayne Kondro

Future of UK GP research database?

fees for Canada’s semi-private clinics No

user

The General Practice Research Database, pioneered by VAMP Health, has for two years been managed by the Office of Population Censuses and Surveys on a custodial basis with representatives of par-

Act,

ticipating general practitioners (GPs)

;

;

Brazil’s

anonymity.

by people being interviewed on television or by characters in television soap operas, restricts cigarette advertising to the period which took government,

healthy prospect

Brazil’s new office on Jan 1, has started to modernise health legislation and signalled the possibility of some controversial changes. Moreover, it intends not only to keep but also to accelerate implementation of the current policy to decentralise administration of the public health system. : Even before he became President, Fernando Henrique Cardoso, a respected sociologist from the University of Sao Paulo, had said that he would gather several "jatenes" as ministers, taking the name of his Minister of Health as a noun for someone competent and honest. Indeed, Adib Jatene himself, despite being a member of a right-wing party (and once Minister of Health under another government), has agreed to serve under the new: social-democrat President. : The prospects are good: Jatene has appointed perhaps the best person as the ministry’s secretary of health surveillance, Elisaldo Carlini, who last year became president of the WHO’s International Control of Narcotics Board. Carlini was one of the men in charge of a technical commission that has done several studies : on the Brazilian drug industry, some of which prompted new ministerial regulations (see Lancet 1994; 343: 50 and 344: 741 and 1076). Within days of taking charge, he announced his aim of setting up a new registry of all pharmaceutical companies in the country and of closing those that do not meet the accepted criteria for drug manufacturing. Another measure that Jatene has taken is to try to save a controversial and, as critics say, opportunistic resolution issued by the outgoing minister, which almost banned cigarettes from being shown on television. The resolution bans smoking

between 11 pm and 6 am, and requires that a health warning against smoking remain on screen during the advertisement. Tobacco lobbies, the press, and lawyers claim that such a measure should be passed by the Congress, and that it : might be unconstitutional since it affects freedom of speech (especially the ruling on soap operas, very popular in Brazil). Jatene, who favours the restrictions, suspended the decision for 15 days and is trying to correct the political clumsiness of his predecessor, who announced the measure without previous discussions with relevant bodies. Jatene said he would revoke the measure only if legally forced

:

to.

Jatene has also started talks with the new Minister of Justice, Nelson Jobim, who has announced that he is in favour of decriminalising drugs. He has made it ; clear that he sees a drug addict as a victim, not a criminal. It is the first time in Brazil that a minister has advocated such a view, and he has the support of the President. Cardoso’s and Jatene’s major task is to accomplish the decentralisation of the public health system. Although praised by virtually all professionals and politicians, : the health system is still plagued by corruption and inefficiency. A report released last week estimates that US$1.6 billionabout 14% of the federal budget-was wasted in 1994. Despite decentralisation, the federal government is still the main payer for services. It is expected that the present administrators will be better than their predecessors in making the decentralised system more efficient.

;

i

Cláudio

Csillag

on

the board. The commercial future of the database is now said to have been market tested and the GP trustees are concerned that another agency taking it over might demand licence fees affordable only by commercial organisations. Access to such a valuable research tool by academic and research departments with limited budgets could be prejudiced. The use of data remains under the control of an ethics committee, with safeguards regarding This database, which the Department of Health acquired at no cost 2 years ago when Reuters took over VAMP, represents over 10 million years of patient records and 4-4 million patients registered with 2333 GPs in 680 practices. The unique strength of the database is based on the fact that, to gain access to free primary care and hospital services, United Kingdom residents should register on change of address with a local GP. Since 98% of the population comply, the structure of the community under study is well defined and there is no need for denominator estimates, a time-consuming and difficult task in other countries. Although GPs are still obliged to keep notes on non-standard stationery, smaller than A5 (which fitted into surplus ammunition boxes from the Boer War of 1900), UK general practice now leads the world in processing clinical information. Efforts to computerise practice data began in 1976, when a Devon general practice went on line to an NHS mainframe. The first GP microcomputer exhibition took place in 1980. Large computer suppliers offered packages built round accounting systems irrelevant to primary care. Keen GPs programmed their own systems. Innovation was stifled when the government backed two computer companies and launched the "Micros for GPs" scheme in 1982. Most practices were satisfied with the computer taking over issuing repeat prescriptions. Within three years the two companies withdrew from the market and alternative arrangements had to be made for computer support. Systems were expensive; hard disks cost 1000 per megabyte, with 150 per annum maintenance, and tended to be unreliable (reliable storage now costs 30p per megabyte). In this climate few GPs could afford computers. Dr Alan Dean, a GP, working with a programmer, designed a system that GPs could understand. Together with business

185

and

marketing associates who raised city other research studies matched the GP UK’s specialist registrars capital, he launched VAMP (Value Added database. : Medical When it came to marketing the dataProducts). GP enthusiasts The two training grades for hospital docbank, legal issues regarding ownership of tors (registrar and senior registrar) grades bought minimalist systems from VAMP, but the market remained sluggish. ; the information was challenged by theare to be replaced by the specialist registrar VAMP directors perceived information health department, but never tested in the grade (SpR). A framework’ within which as power with a monetary value. To this courts. VAMP hit cash-flow problems and this unified grade, recommended by the end they sold basic systems to GPs and ifits GP users came to the rescue and Calman Report (Hospital doctors: training such doctors chose to supply clinical data agreed to forfeit their claims for reimfor the future, 1993), will operate has been to a

research databank with full confiden-

bursement.

User group

representatives

circulated for consultation until Feb 23.

tiality safeguards, they received a monthly were elected to the main board and the: The appointment of and training for sum matching computer costs. Quality VAMP Research Unit. They regarded the Sprs is to be more structured than for the assurance was an initial problem in that continuation of the databank of such current grades of trainees. The frameGP enthusiasts had difficulty persuading importance to health care that they agreed work calls for structured appraisal reports their partners to enter every prescription to continue collecting and forwarding data and references at the appointment stage. and diagnosis (much of this was due to in the expectation that if there were any The assessments to be made during trainlack of keyboard knowledge). Close future profits they would expect a modest ing should include at least the following VAMP’s in-house reward for their efforts over and above the epidemisupervision by two types-formative (educational) for ologists and the Centre for Medicines delivery of NHS care. and summaeducation needs, identifying Research addressed the issue and extra training was arranged. Validation with

Tracing recipients of hepatitis C infected blood The UK Department of Health is to embark on a "look-back" exercise to trace patients who received hepatitis C infected blood before donor screening for the infection was introduced in September, 1991. The positivity rate on screening has been about 1 in 2000. The department estimates that there are about 3000 transfusion recipients now alive in the UK who might have been affected. : The UK introduced donor screening some 18 months after other European countries started to do so. There was concern within the transfusion service about the potential impact of the high false-positive rate of the early tests on donor pool, as well as the service implications of having to counsel large numbers of people about a test result whose significance in healthy donors was unclear. These concerns expressed in 1989 (Lancet 1989; ii:

British

surgeons’ private practice

Bregulatory)

tor

determining compe-

proceed to the next stage of the training. Postgraduate deans and pro-

tence to

505) and

on a Panorama programme on C screened on Monday. However, Dr J S Metters, Deputy Chief Medical Officer, and chairman of the Advisory Committee on the Microbiological of Blood and Tissues for Transplantation asserts, in a letter to the editor of Panora- : ma, that the committee’s advice was based on the unreliability of the tests then, and that costs of tests and impact on stocks : were not determining factors. The Department of Health also says that a look-back exercise had not been introduced earlier because until recently there was no treatment on offer for those who might be affected (interferon-a2 was licensed for the treatment of chronic hepatitis C last November) and because it was believed that such an exercise would be very difficult. The SE Scotland transfusion centre has, however, done a pilot look-back study, which showed its

hepatitis

Safety

i

gramme directors should seek feedback on the programmes from trainees (confidentially) and from organisations concerned with specialist training.

Trainees are seen as a valuable resource that should not be wasted. Special provision-in the form of a limited extension of the SpR contract-is to be made for trainees who qualify for the Certificate of Completion of Specialist Training but who, "despite reasonable attempts", areunable to obtain a consultant post. Considerable expansion of consultant numbers is seen as important to the success of the proposed programme. In the transitional period, priority is to be given to existing trainees, and senior registrars can expect automatic right of entry. Vivien Choo

Department of Health. Report of the Working Party on the Unified Training Grade, 1994.

1

feasibility. Vivien Choo should be

very

The veil that for many years has been discreetly drawn over how much time NHS consultants spend in their private consulting rooms was tweaked aside this week by the preliminary findings of a respected I : expert in NHS management.’ John Yates looked at whether the wait NHS patients can have for operations is caused in part by their consultants taking on excessive amounts of private work during normal working hours. Since the NHS was founded in 1948. Consultants have been able to barter a fraction of their NHS salary (presently one-eleventh) for . the freedom to carry out private work with no cap on their non-NHS earnings. But as Yates points out, despite the then Chief Executive of the NHS’s 1990 statement that no maximum part-time consultant

long

186

tive

Bob Bowles

spending more than half a day patient waiting times in England, is likely (a "session" ) a week on private work, s to be spending an average of three halfthere has still, until now, been much e days a week in the private sector". So surwoolliness over consultants’ contracts and prised was he by these results that he how they divide their time between the employed private investigators to follow two health-care sectors. : consultants and confirm his findings. With funding from the Joseph Rowntree This unorthodox research technique was Foundation, Yates, based at the Health : highlighted in a television programme on Yates’ work that was broadcast this Services Management Centre at the Uniweek. versity of Birmingham, undertook a repreYates asks why there is such reluctance sentative sample survey of consultant to set rules on consultants’ contractual surgeons in orthopaedics (177) and ophthalmology (66) throughout England. responsibilities to the NHS (and thus to But the most striking finding from his taxpayers) and, while conceding that telephone inquiries to private hospitals his preliminary data do not warrant immediate changes to the system, urges was that, on average, 58% of the surgeons that there should be further inquiry. studied spent two or more sessions per week at their private consulting rooms, operating time would be in addition. Yates says that this evidence "suggests that the Sarah Ramsay average NHS surgeon on a ’maximum part-time’ contract, in two of the special-

ties that have

some

of the

worst

NHS

out-

1

Yates J.

Serving two masters. Available from Dispatches, PO Box 4000, London W3 6XJ.