- Email: [email protected]
GOVERNMENT CONFUSION
401
taking a different type of drug (or even not using drugs regularly at all). This point is even more relevant now that taking heroin by smoking or "snorting" (nasal inhalation) instead of by injection is becoming so prevalent. Urine testing cannot directly result in clinical improvement; nor does absence of such a back-up directly cause deterioration. However, the ability to detect early relapse or deterioration in clinical presentation is crucial. The availability of regular urine testing can in no way replace close liaison with the general practitioner and other colleagues and adherence to the requirements of the Misuse of Drugs Act 1973 and to regulations on the notification of the supply to addicts. However, even a small number of episodes of abuse can have a very harmful effect on the reputation of a drug dependence unit. One impact of regular urine testing and physical examination is the development ofa more positive therapeutic relationship because the clinician becomes less suspicious of possible abuse of his service and can deal with hard data, not hearsay. A laboratory service has to compete with funds for more clinically oriented services, and the routine screening of urine might seem an area where money can be saved. However, the dangers of abuse of a service for problem drug users are real enough to warrant the inclusion of safeguards, and in the absence of a urine monitoring service clinicians may feel that, even though a supervised outpatient withdrawal regimen might seem clinically indicated, it would not be appropriate to make such an uncontrolled service available.
refuted both versions of the preformation theory in the same year.2 The epigenetic theory itself was disproved experimentally by dividing the two-cell embryo, each giving rise to a normal whole embryo3 (or, in real-life, identical twins). The question was finally answered in 1838 when Schleiden and Schwann enunciated the cell theory of life, which soon led to the realisation that the embryo developed from a single cell, the zygote.This theory remains valid, despite advances in cell and molecular biology. One result of this theory was the realisation that many small animals are unicellular-hence the phylum Protozoa.4No biologist doubts the existence of unicellular animals yet medicine does not seem to accept that there is a unicellular human being, that becomes multicellular and complex very quickly. The ethical problem is covered in the Declaration of Geneva (1948)- the International Medical Code of Ethics-which asks all doctors to maintain the utmost respect for human life, from the time of its conception, even under threat..."The exceptions, such as ectopic pregnancy, where there is a grave threat to the mother’s life and almost no hope of extrauterine fetal viability, do not diminish our respect for human life when we terminate that fetal life. The same cannot be said of the general practice of abortion, early and late. Neath General
Hospital,
PATRICK W. GILL
Neath, Glamorgan SA11 2LQ
Regional Drug Dependence Unit, Prestwich Hospital, Manchester M25 7BL
JOHN STRANG
OCCULT BLOOD TESTS AND GENERAL PRACTITIONERS
SlR,-Professor Hardcastle and colleagues (July 2, p 1) report that a postal invitation to ’Haemoccult’ faecal blood testing was improved by preliminary education by letter or interview and also by the invitation coming from the patient’s own general practitioner. The highest compliance (51 -6%) was obtained where the invitation was preceded by an interview. Further improvement in compliance is possible if the invitation to perform the test forms part of a routine general practice consultation. In a 3 month period while a general practice trainee in a rural practice I offered the haemoccult test to 322 consecutive patients over the age of 35 years who were attending routine consultations. The invitation to perform the test was preceded by a one minute introduction during which colorectal cancer was discussed. There were no immediate refusals and 209 (64 - 9%) completed the test, of whom 4 were found to be positive. Given that a high compliance rate would markedly improve the cost-effectiveness of the test and that in a 5-year period more than 90% of the public will consult their general practitioner, there is a strong case for the use of the test as part of the general practice consultation. acceptance of
Area Department of Community Medicine, Northern Health and Social Services Board, Ballymena, BT42 IQB
GABRIEL SCALLY
WHEN DOES LIFE BEGIN?
SiR,—Dr Potts (July 23, p 223), citing the examples of molar choriocarcinoma, seems to doubt that a new human
pregnancy and
life begins at fertilisation. The question-When does a new human life begin?-has exercised doctors and scientists since the time of Aristotle. The preformation theory was widely accepted in the 17th and 18th centuries until Spallanzani, around 1775, showed that both ovum and sperm were necessary for development of a new individual.1 The epigenetic theory was advanced by Wolff in 1759, after he had
GOVERNMENT CONFUSION
SIR,-Dr Owen’s comment about setting family doctors and the hospital at each other’s throats by financial manipulation is apt (July 30, p 292). Permit me to provide an example. I have often found it difficult to persuade family doctors to maintain patients with severe ulcer disease on long-term treatment with histamine H2 blockers. The resistance occurs largely because as prescription costs rise doctors, understandably, fear being penalised. Yet this treatment policy has resulted in nearly an 80% reduction in elective ulcer surgery in Rotherham and few patients lose time from work nowadays because of ulcer symptoms. Also, as treatment is started only in those patients in whom ulcer disease is proved by endoscopy and continued provided patients attend for regular follow-up, including check endoscopy in the symptom-free (to detect non-healing ulcers or silent ulcer recurrences), the drugs are not wasted. The general practitioners often ask me to provide the drug on the grounds that I am still seeing the patients, albeit with intervals of months (notwithstanding the fact that the diabetics and hypertensives I also see regularly get their repeat prescriptions almost exclusively from their own doctors). But the hospital cannot help since it works on a fixed budget. Finally, to minimise prescribing costs, only enough drugs may be issued to last a fortnight; this makes it inconvenient for the patient. The absurdity is that it is indeed cheaper for the hospital to provide the drugs. I appealed to the Trent Regional Health Authority but, since I had no success, I asked the former Secretary of State for Social Services to help by asking if such treatment could be given from hospitals, with budget adjustments, or, if that were not feasible, if GPs could be allowed to prescribe adequate amounts of the drugs without fear of penalty provided that the patients remain under close supervision. After months, and a reminder, the reply I received was not positive. Consequently the status quo remains. Although with the passage of time more GPs accept the treatment policy (albeit reluctantly), the occasional family doctor and I are sometimes at each other’s throats-though in the nicest possible way.
’
District General
Hospital,
Rotherham, S6O 2UD
K. D. BARDHAN
2. Moore KL. The developing human. London: WB Saunders, 1973: 8 3. Villee CA, Dethier VG. Biological principles and processes. London: WB
Saunders,
1971: 8. 4. Villee
1. Moore KL. The developing human. London: WB Saunders, 1973: 9.
CA, Dethier VG. Biological principles and processes. London: WB Saunders,
1971: 319.
taking a different type of drug (or even not using drugs regularly at all). This point is even more relevant now that taking heroin by smoking or "snorting" (nasal inhalation) instead of by injection is becoming so prevalent. Urine testing cannot directly result in clinical improvement; nor does absence of such a back-up directly cause deterioration. However, the ability to detect early relapse or deterioration in clinical presentation is crucial. The availability of regular urine testing can in no way replace close liaison with the general practitioner and other colleagues and adherence to the requirements of the Misuse of Drugs Act 1973 and to regulations on the notification of the supply to addicts. However, even a small number of episodes of abuse can have a very harmful effect on the reputation of a drug dependence unit. One impact of regular urine testing and physical examination is the development ofa more positive therapeutic relationship because the clinician becomes less suspicious of possible abuse of his service and can deal with hard data, not hearsay. A laboratory service has to compete with funds for more clinically oriented services, and the routine screening of urine might seem an area where money can be saved. However, the dangers of abuse of a service for problem drug users are real enough to warrant the inclusion of safeguards, and in the absence of a urine monitoring service clinicians may feel that, even though a supervised outpatient withdrawal regimen might seem clinically indicated, it would not be appropriate to make such an uncontrolled service available.
refuted both versions of the preformation theory in the same year.2 The epigenetic theory itself was disproved experimentally by dividing the two-cell embryo, each giving rise to a normal whole embryo3 (or, in real-life, identical twins). The question was finally answered in 1838 when Schleiden and Schwann enunciated the cell theory of life, which soon led to the realisation that the embryo developed from a single cell, the zygote.This theory remains valid, despite advances in cell and molecular biology. One result of this theory was the realisation that many small animals are unicellular-hence the phylum Protozoa.4No biologist doubts the existence of unicellular animals yet medicine does not seem to accept that there is a unicellular human being, that becomes multicellular and complex very quickly. The ethical problem is covered in the Declaration of Geneva (1948)- the International Medical Code of Ethics-which asks all doctors to maintain the utmost respect for human life, from the time of its conception, even under threat..."The exceptions, such as ectopic pregnancy, where there is a grave threat to the mother’s life and almost no hope of extrauterine fetal viability, do not diminish our respect for human life when we terminate that fetal life. The same cannot be said of the general practice of abortion, early and late. Neath General
Hospital,
PATRICK W. GILL
Neath, Glamorgan SA11 2LQ
Regional Drug Dependence Unit, Prestwich Hospital, Manchester M25 7BL
JOHN STRANG
OCCULT BLOOD TESTS AND GENERAL PRACTITIONERS
SlR,-Professor Hardcastle and colleagues (July 2, p 1) report that a postal invitation to ’Haemoccult’ faecal blood testing was improved by preliminary education by letter or interview and also by the invitation coming from the patient’s own general practitioner. The highest compliance (51 -6%) was obtained where the invitation was preceded by an interview. Further improvement in compliance is possible if the invitation to perform the test forms part of a routine general practice consultation. In a 3 month period while a general practice trainee in a rural practice I offered the haemoccult test to 322 consecutive patients over the age of 35 years who were attending routine consultations. The invitation to perform the test was preceded by a one minute introduction during which colorectal cancer was discussed. There were no immediate refusals and 209 (64 - 9%) completed the test, of whom 4 were found to be positive. Given that a high compliance rate would markedly improve the cost-effectiveness of the test and that in a 5-year period more than 90% of the public will consult their general practitioner, there is a strong case for the use of the test as part of the general practice consultation. acceptance of
Area Department of Community Medicine, Northern Health and Social Services Board, Ballymena, BT42 IQB
GABRIEL SCALLY
WHEN DOES LIFE BEGIN?
SiR,—Dr Potts (July 23, p 223), citing the examples of molar choriocarcinoma, seems to doubt that a new human
pregnancy and
life begins at fertilisation. The question-When does a new human life begin?-has exercised doctors and scientists since the time of Aristotle. The preformation theory was widely accepted in the 17th and 18th centuries until Spallanzani, around 1775, showed that both ovum and sperm were necessary for development of a new individual.1 The epigenetic theory was advanced by Wolff in 1759, after he had
GOVERNMENT CONFUSION
SIR,-Dr Owen’s comment about setting family doctors and the hospital at each other’s throats by financial manipulation is apt (July 30, p 292). Permit me to provide an example. I have often found it difficult to persuade family doctors to maintain patients with severe ulcer disease on long-term treatment with histamine H2 blockers. The resistance occurs largely because as prescription costs rise doctors, understandably, fear being penalised. Yet this treatment policy has resulted in nearly an 80% reduction in elective ulcer surgery in Rotherham and few patients lose time from work nowadays because of ulcer symptoms. Also, as treatment is started only in those patients in whom ulcer disease is proved by endoscopy and continued provided patients attend for regular follow-up, including check endoscopy in the symptom-free (to detect non-healing ulcers or silent ulcer recurrences), the drugs are not wasted. The general practitioners often ask me to provide the drug on the grounds that I am still seeing the patients, albeit with intervals of months (notwithstanding the fact that the diabetics and hypertensives I also see regularly get their repeat prescriptions almost exclusively from their own doctors). But the hospital cannot help since it works on a fixed budget. Finally, to minimise prescribing costs, only enough drugs may be issued to last a fortnight; this makes it inconvenient for the patient. The absurdity is that it is indeed cheaper for the hospital to provide the drugs. I appealed to the Trent Regional Health Authority but, since I had no success, I asked the former Secretary of State for Social Services to help by asking if such treatment could be given from hospitals, with budget adjustments, or, if that were not feasible, if GPs could be allowed to prescribe adequate amounts of the drugs without fear of penalty provided that the patients remain under close supervision. After months, and a reminder, the reply I received was not positive. Consequently the status quo remains. Although with the passage of time more GPs accept the treatment policy (albeit reluctantly), the occasional family doctor and I are sometimes at each other’s throats-though in the nicest possible way.
’
District General
Hospital,
Rotherham, S6O 2UD
K. D. BARDHAN
2. Moore KL. The developing human. London: WB Saunders, 1973: 8 3. Villee CA, Dethier VG. Biological principles and processes. London: WB
Saunders,
1971: 8. 4. Villee
1. Moore KL. The developing human. London: WB Saunders, 1973: 9.
CA, Dethier VG. Biological principles and processes. London: WB Saunders,
1971: 319.