- Email: [email protected]
Lack of Government Enthusiasm for Griffiths Report on Community Care
717
(CT + RT + CT). In the second study, patients were randomised to receive CT + RT + CT
or
chemotherapy/radical mastectomy/
chemotherapy (CT + S + CT). Complete tumour response at the end of combined therapy was 64 % after CT + RT, 75 % after CT + RT + CT, and 82 % after CT + S + CT. Results are now available at 10 years from the start of primary chemotherapy (table). Freedom from first progression, total survival, and local-regional control were significantly improved by the addition of drug therapy after local-regional treatment. The 10-year results for the entire series of patients were inversely related to tumour size and clinical nodal status, but were not affected by
Our updated results confirm the previous fmdingsl on the role of surgery in locally advanced non-metastatic breast cancer and are
supported by other investigators.2,3 Whether mastectomy can be avoided4 in these patients, once a complete tumour response has been achieved after primary chemotherapy, remains to be evaluated in clinical trials. Istituto Nazionale 20133
PINUCCIA VALAGUSSA MILVIA ZAMBETTI GIANNI BONADONNA
Tumori,
Milan,
Italy
menopausal status. The addition of chemotherapy after surgery or radiotherapy did influence treatment outcome when analysed both singly as well as in the presence of the two prognostic factors, size and nodal status. In our series, patients subjected to radical mastectomy had the best local-regional control of the disease (table) even though freedom from first progression was only marginally superior to that in patients who received local-regional radiotherapy and additional tumour
chemotherapy.
Commentary from Westminster Lack of Government Enthusiasm for Griffiths Report on Community Care THE long-awaited report! by Sir Roy Griffiths on the future of community care in Britain was handled by the Government last week as if it were something rather unpleasant which the cat had just brought in. Ministers had a duty to publish it, but you did not have to be an expert Whitehall-watcher to tell that they did so without enthusiasm. For a start they released it on the day after the Budget when the media’s attention was firmly focused elsewhere. They chose a time when Sir Roy was recovering from an operation and unavailable for comment. And, as one Tory MP complained to the Leader of the House, they even failed to observe the convention of placing a copy in the Commons library, let alone organise the more widespread distribution which is commonplace for this sort of material. From the DHSS the silence was deafening. A statement merely pointed back to an earlier written answer from the Secretary of State which said the Government would consider the report and would "bring forward its own proposals in due course". Sir Roy had clearly seen the way the wind was blowing. In his introduction he said that, if his findings were unacceptable, their "brevity will have been even more
appropriate".
So what was it that Sir Roy perpetrated to earn this ostracism? Is he not the managing director of Sainsbury’s, deputy chairman of the NHS Management Board, and special health adviser to the Prime Minister, the man who is charged with proselytising private sector techniques to improve the efficiency of the public health sector? Were these not the very credentials which made the former Social Services Secretary, Mr Norman Fowler, pick him to carry out the work in the first place, back in December, 1986? All this is true, but Sir Roy’s pedigree is not sufficient to win support for an idea which is a heresy to the present administration. He has actually proposed that local authorities should be given extra responsibilities. The Government has spent much of its energies since 1979 in trying to reduce the power of county and district councils. Its central (so far unsuccessful) objective has been 1.
Community Care Agenda for Action. A report to the Secretary Services. HM Stationery Office 1988. £3.90.
1.
Valagussa P, Zambetti M, Bignami P, et al T3b-T4 breast cancer: factors affecting results in combined modality treatments. Clin Expl Metastasis 1983; 1: 191-202. 2. Feldman LD, Hortobagyi GN, Buzdar AU, Ames FC, Blumenschein GR. Pathological assessment of response to induction chemotherapy in breast cancer Cancer Res 1986; 46: 2578-81. 3. Swam SM, Sorace RA, Bagley CS, et al. Neoadjuvant chemotherapy in the combined modality approach of locally advanced non metastatic breast cancer. Cancer Res
1987; 47: 3889-94. 4. Forrest APM, 840-42.
Chetty U, Miller WR, et al. A human tumour model. Lancet 1986; ii:
their expenditure. For a while this was pursued by a variety of increasingly complex changes to the grant system to reward parsimony. Then came rate-capping and the abolition of the Greater London Council and metropolitan counties. Soon we are about to see the death of domestic rates and the introduction of the flat-rate poll tax, which is designed to increase the financial burden on lower-income citizens and to encourage them to vote in lower-spending councils. The idea of extending local government responsibilities into an area of burgeoning expenditure needs such as community care is anathema to the administration. Sir Roy, it can be assumed, would not have advanced this unpalatable solution if there had been a more ideologically convenient alternative available. His purpose has been to introduce some coherent planning into the system which presently spends c6 billion of public funds each year on non-acute long-term care and support for about 1 -5 million people who are elderly, mentally ill, or mentally or physically handicapped. Half of this sum is provided by the NHS, taking up a third of its entire hospital and community health budget. An objective of policy has been to move as many of these patients as possible out of hospitals and into the community on the twin grounds that this would be better for them as individuals and cheaper for the public purse. In a report2 in December, 1986, the Audit Commission observed that it typically costs public funds about 135 a week to keep a frail elderly person at home with day and domiciliary support; the same person would cost about 295 in an NHS geriatric ward. The problem arises because of a chronic lack of coordination in the system to get the right sort of care for the individual in the most cost-effective manner. Sir Roy observes: "At the centre, community care has been talked of for 30 years and in few areas can the gap between political rhetoric and policy on the one hand, or between policy and reality in the field on the other hand, have been so great". One of the most obvious anomalies is that the DHSS provides benefit much more readily to finance relatively expensive private residential care than to support a local authority’s community provision. Another problem is that the councils are penalised through the grant system for building up the community services which are necessary if
to cut
of State for Social 2
Making a Reality of Community Care.
HM
Stationery Office.
1986
718
the NHS is
reduce its load. Sir Roy observes that is "everybody’s distant relative, but community He nobody’s baby". argues that the solution cannot be found in direction from the centre,which would "shrivel the varied pattern of local activity". He also accepts that local reorganisation to create co-terminous health authorities, social services authorities, and family practitioner committees would be disruptive and unrealistic. "Elected local authorities are best placed, in my judgment, to assess local needs, set local priorities and monitor local performance", he says. "What is needed is a strengthening and buttressing of their capacity to do this, by clarifying and where necessary adjusting responsibilities; and to hold them accountable." The report recommends that the Government should appoint a Minister with clear personal responsibility for community care. He or she would set overall objectives and standards and would monitor local authority performance. The councils would submit programmes for approval which would have to show that there was a coherent value-formoney approach to local needs, including adequate provision for voluntary groups, support for informal carers, and liaison with the appropriate housing and health authorities. Sir Roy suggests that between 40% and 50% of the cost of an approved programme should be funded by way of a specific Government grant. The rest would be raised by the councils from local taxation. Tighter rules would be established for the payment of social security benefit, with a fixed maximum sum, substantially lower than at present, being provided for people in residential care. The objective would be to put the social services authority in a position of financial neutrality in deciding what form of care would be in the best interests of the individual. The package has many features which should commend themselves to the Government. For example, councils are told that their role should be to ensure that services are provided economically and efficiently, not necessarily by the councils themselves. There would be an onus on the authorities to show that the private sector was being fully encouraged and that competitive tenders were being taken. But Sir Roy has produced a blueprint which fails to mesh with what Ministers have in mind for the future of local authorities. He does not produce any numbers to show how the financial burden of his scheme would fall and it is not clear whether, for a given level of total expenditure, central Government would pay more or less than at present. The upshot of his scheme, however, is that a large and expanding load is being placed on payers of the poll tax which is being introduced in Scotland next year and in England and Wales in 1990. Ministers want the poll tax because they believe it will encourage local people to use their votes to force down spending. Under Sir Roy’s scheme, however, the basic level of provision would be determined by the community-care Minister, who would approve the local plan. If it was inadequate, the Government would take the blame. If it was adequate and if the Government determined how much was to be financed centrally through specific grants, the local people would have no option but to pay their due share. It is a fact of bureaucratic life that council service chiefs and central Government departments have a vested interest in improving the quality of their own service. The likely result is an expanding community care budget, cripplingly high levels of poll tax, and blame on the Government. This is not what they have in mind. to
Medicine and the Law
care
JOHN CARVEL
Medical
Negligence: a Suitable Case for Treatment?
IN claims based on medical negligence or drug-induced illnesses the plaintiff must prove, on a balance of probabilities, that the defendant’s negligence caused or materially contributed to his or her injury. In Wilsher v Essex Area Health Authority’ the House of Lords ordered the retrial of the causation issue in a case in which the infant plaintiff had been awarded compensation of c 116 119 by the trial judge. The plaintiff had been born 3 months prematurely in 1978. Hospital staff had made an error in sampling the baby’s blood and his oxygen status had been misinterpreted. Retrolental fibroplasia (RLF) subsequently developed. In 19841 the trial judge had concluded that the artificial administration of oxygen had "materially increased the risk of RLF", but Lord Bridge, delivering the judgment of the House of Lords earlier this month, found that this was a misunderstanding of the evidence. The trial judge had applied a 1973 House of Lords judgment in McGhee v National Coal Board.3 An employee had contracted dermatitis after being in contact with brick dust from a kiln. The defendant had failed to provide washing facilities so the plaintiff returned home caked in dust. The issue was whether the absence of showers had caused or materially contributed to the dermatitis. The medical evidence was inconclusive, although it was accepted that sweating would soften the outer layer of the skin allowing the dust to penetrate. By a majority the House of Lords decided that the breach of duty had materially increased the risk of injury to the plaintiff, and that this amounted to a finding that the breach had materially
contributed to the injury. When Wilsher was heard by the Court of AppealMustill LJhad interpreted the McGhee judgment as saying that if the defendants created or increased a risk they would be liable if the plaintiff suffered an injury of the kind to which the risk related "even though the existence and extent of the contribution made by the breach cannot be ascertained". However, the House of Lords thought that the lower courts had attached too much significance to McGhee. The decision on causation in that case had been justified on the evidence presented, but there had been only one possible cause of injury-brick dust on the plaintiffsweating skin. In Wilsher there were several possible causes. Could the defendants be said to have caused the injury because they had materially increased the risk of injury? It seems not: the defendants’ negligence had merely added another factor to those which might have led to RLF. Which factor had caused the injury had not been established and it was for the plaintiff to show what part, if any, the negligence had played. After 7 years of litigation this outcome highlights, in Lord Bridge’s words, "the shortcomings of a system in which the victim of some grievous misfortune will recover substantial compensation or none at all, according to the unpredictable hazards of the forensic
process". Many observers will feel sympathy for Lord Wilberforce’s minority view in McGhee that, where a defendant has created a risk and the injury which materialises is within the scope of that risk, the burden should be on the defendant to show that the risk created did contribute to the injury. The courts, however, are wary of endorsing principles that might increase litigation. The conclusion of the Pearson report,4 in which one idea was that the burden of proof be reversed in all cases of medical injury, was that such a step would encourage a "large increase in claims ... many of them groundless". The Wilsher judgment will fuel the debate on "no fault" compensation for victims of medical injury.s The Department of Health and Social Security is to consider a pilot study on a no fault compensation system. Whether such a system would improve the chances of plaintiffs such as Martin Wilsher recovering compensation would depend on the terms of the scheme. In Sweden some claims are rejected where a causal link has not been established3-indeed Action for the Victims of Medical Accidents has stated, of the House of Lords judgment, that "The issue of not cause or
(CT + RT + CT). In the second study, patients were randomised to receive CT + RT + CT
or
chemotherapy/radical mastectomy/
chemotherapy (CT + S + CT). Complete tumour response at the end of combined therapy was 64 % after CT + RT, 75 % after CT + RT + CT, and 82 % after CT + S + CT. Results are now available at 10 years from the start of primary chemotherapy (table). Freedom from first progression, total survival, and local-regional control were significantly improved by the addition of drug therapy after local-regional treatment. The 10-year results for the entire series of patients were inversely related to tumour size and clinical nodal status, but were not affected by
Our updated results confirm the previous fmdingsl on the role of surgery in locally advanced non-metastatic breast cancer and are
supported by other investigators.2,3 Whether mastectomy can be avoided4 in these patients, once a complete tumour response has been achieved after primary chemotherapy, remains to be evaluated in clinical trials. Istituto Nazionale 20133
PINUCCIA VALAGUSSA MILVIA ZAMBETTI GIANNI BONADONNA
Tumori,
Milan,
Italy
menopausal status. The addition of chemotherapy after surgery or radiotherapy did influence treatment outcome when analysed both singly as well as in the presence of the two prognostic factors, size and nodal status. In our series, patients subjected to radical mastectomy had the best local-regional control of the disease (table) even though freedom from first progression was only marginally superior to that in patients who received local-regional radiotherapy and additional tumour
chemotherapy.
Commentary from Westminster Lack of Government Enthusiasm for Griffiths Report on Community Care THE long-awaited report! by Sir Roy Griffiths on the future of community care in Britain was handled by the Government last week as if it were something rather unpleasant which the cat had just brought in. Ministers had a duty to publish it, but you did not have to be an expert Whitehall-watcher to tell that they did so without enthusiasm. For a start they released it on the day after the Budget when the media’s attention was firmly focused elsewhere. They chose a time when Sir Roy was recovering from an operation and unavailable for comment. And, as one Tory MP complained to the Leader of the House, they even failed to observe the convention of placing a copy in the Commons library, let alone organise the more widespread distribution which is commonplace for this sort of material. From the DHSS the silence was deafening. A statement merely pointed back to an earlier written answer from the Secretary of State which said the Government would consider the report and would "bring forward its own proposals in due course". Sir Roy had clearly seen the way the wind was blowing. In his introduction he said that, if his findings were unacceptable, their "brevity will have been even more
appropriate".
So what was it that Sir Roy perpetrated to earn this ostracism? Is he not the managing director of Sainsbury’s, deputy chairman of the NHS Management Board, and special health adviser to the Prime Minister, the man who is charged with proselytising private sector techniques to improve the efficiency of the public health sector? Were these not the very credentials which made the former Social Services Secretary, Mr Norman Fowler, pick him to carry out the work in the first place, back in December, 1986? All this is true, but Sir Roy’s pedigree is not sufficient to win support for an idea which is a heresy to the present administration. He has actually proposed that local authorities should be given extra responsibilities. The Government has spent much of its energies since 1979 in trying to reduce the power of county and district councils. Its central (so far unsuccessful) objective has been 1.
Community Care Agenda for Action. A report to the Secretary Services. HM Stationery Office 1988. £3.90.
1.
Valagussa P, Zambetti M, Bignami P, et al T3b-T4 breast cancer: factors affecting results in combined modality treatments. Clin Expl Metastasis 1983; 1: 191-202. 2. Feldman LD, Hortobagyi GN, Buzdar AU, Ames FC, Blumenschein GR. Pathological assessment of response to induction chemotherapy in breast cancer Cancer Res 1986; 46: 2578-81. 3. Swam SM, Sorace RA, Bagley CS, et al. Neoadjuvant chemotherapy in the combined modality approach of locally advanced non metastatic breast cancer. Cancer Res
1987; 47: 3889-94. 4. Forrest APM, 840-42.
Chetty U, Miller WR, et al. A human tumour model. Lancet 1986; ii:
their expenditure. For a while this was pursued by a variety of increasingly complex changes to the grant system to reward parsimony. Then came rate-capping and the abolition of the Greater London Council and metropolitan counties. Soon we are about to see the death of domestic rates and the introduction of the flat-rate poll tax, which is designed to increase the financial burden on lower-income citizens and to encourage them to vote in lower-spending councils. The idea of extending local government responsibilities into an area of burgeoning expenditure needs such as community care is anathema to the administration. Sir Roy, it can be assumed, would not have advanced this unpalatable solution if there had been a more ideologically convenient alternative available. His purpose has been to introduce some coherent planning into the system which presently spends c6 billion of public funds each year on non-acute long-term care and support for about 1 -5 million people who are elderly, mentally ill, or mentally or physically handicapped. Half of this sum is provided by the NHS, taking up a third of its entire hospital and community health budget. An objective of policy has been to move as many of these patients as possible out of hospitals and into the community on the twin grounds that this would be better for them as individuals and cheaper for the public purse. In a report2 in December, 1986, the Audit Commission observed that it typically costs public funds about 135 a week to keep a frail elderly person at home with day and domiciliary support; the same person would cost about 295 in an NHS geriatric ward. The problem arises because of a chronic lack of coordination in the system to get the right sort of care for the individual in the most cost-effective manner. Sir Roy observes: "At the centre, community care has been talked of for 30 years and in few areas can the gap between political rhetoric and policy on the one hand, or between policy and reality in the field on the other hand, have been so great". One of the most obvious anomalies is that the DHSS provides benefit much more readily to finance relatively expensive private residential care than to support a local authority’s community provision. Another problem is that the councils are penalised through the grant system for building up the community services which are necessary if
to cut
of State for Social 2
Making a Reality of Community Care.
HM
Stationery Office.
1986
718
the NHS is
reduce its load. Sir Roy observes that is "everybody’s distant relative, but community He nobody’s baby". argues that the solution cannot be found in direction from the centre,which would "shrivel the varied pattern of local activity". He also accepts that local reorganisation to create co-terminous health authorities, social services authorities, and family practitioner committees would be disruptive and unrealistic. "Elected local authorities are best placed, in my judgment, to assess local needs, set local priorities and monitor local performance", he says. "What is needed is a strengthening and buttressing of their capacity to do this, by clarifying and where necessary adjusting responsibilities; and to hold them accountable." The report recommends that the Government should appoint a Minister with clear personal responsibility for community care. He or she would set overall objectives and standards and would monitor local authority performance. The councils would submit programmes for approval which would have to show that there was a coherent value-formoney approach to local needs, including adequate provision for voluntary groups, support for informal carers, and liaison with the appropriate housing and health authorities. Sir Roy suggests that between 40% and 50% of the cost of an approved programme should be funded by way of a specific Government grant. The rest would be raised by the councils from local taxation. Tighter rules would be established for the payment of social security benefit, with a fixed maximum sum, substantially lower than at present, being provided for people in residential care. The objective would be to put the social services authority in a position of financial neutrality in deciding what form of care would be in the best interests of the individual. The package has many features which should commend themselves to the Government. For example, councils are told that their role should be to ensure that services are provided economically and efficiently, not necessarily by the councils themselves. There would be an onus on the authorities to show that the private sector was being fully encouraged and that competitive tenders were being taken. But Sir Roy has produced a blueprint which fails to mesh with what Ministers have in mind for the future of local authorities. He does not produce any numbers to show how the financial burden of his scheme would fall and it is not clear whether, for a given level of total expenditure, central Government would pay more or less than at present. The upshot of his scheme, however, is that a large and expanding load is being placed on payers of the poll tax which is being introduced in Scotland next year and in England and Wales in 1990. Ministers want the poll tax because they believe it will encourage local people to use their votes to force down spending. Under Sir Roy’s scheme, however, the basic level of provision would be determined by the community-care Minister, who would approve the local plan. If it was inadequate, the Government would take the blame. If it was adequate and if the Government determined how much was to be financed centrally through specific grants, the local people would have no option but to pay their due share. It is a fact of bureaucratic life that council service chiefs and central Government departments have a vested interest in improving the quality of their own service. The likely result is an expanding community care budget, cripplingly high levels of poll tax, and blame on the Government. This is not what they have in mind. to
Medicine and the Law
care
JOHN CARVEL
Medical
Negligence: a Suitable Case for Treatment?
IN claims based on medical negligence or drug-induced illnesses the plaintiff must prove, on a balance of probabilities, that the defendant’s negligence caused or materially contributed to his or her injury. In Wilsher v Essex Area Health Authority’ the House of Lords ordered the retrial of the causation issue in a case in which the infant plaintiff had been awarded compensation of c 116 119 by the trial judge. The plaintiff had been born 3 months prematurely in 1978. Hospital staff had made an error in sampling the baby’s blood and his oxygen status had been misinterpreted. Retrolental fibroplasia (RLF) subsequently developed. In 19841 the trial judge had concluded that the artificial administration of oxygen had "materially increased the risk of RLF", but Lord Bridge, delivering the judgment of the House of Lords earlier this month, found that this was a misunderstanding of the evidence. The trial judge had applied a 1973 House of Lords judgment in McGhee v National Coal Board.3 An employee had contracted dermatitis after being in contact with brick dust from a kiln. The defendant had failed to provide washing facilities so the plaintiff returned home caked in dust. The issue was whether the absence of showers had caused or materially contributed to the dermatitis. The medical evidence was inconclusive, although it was accepted that sweating would soften the outer layer of the skin allowing the dust to penetrate. By a majority the House of Lords decided that the breach of duty had materially increased the risk of injury to the plaintiff, and that this amounted to a finding that the breach had materially
contributed to the injury. When Wilsher was heard by the Court of AppealMustill LJhad interpreted the McGhee judgment as saying that if the defendants created or increased a risk they would be liable if the plaintiff suffered an injury of the kind to which the risk related "even though the existence and extent of the contribution made by the breach cannot be ascertained". However, the House of Lords thought that the lower courts had attached too much significance to McGhee. The decision on causation in that case had been justified on the evidence presented, but there had been only one possible cause of injury-brick dust on the plaintiffsweating skin. In Wilsher there were several possible causes. Could the defendants be said to have caused the injury because they had materially increased the risk of injury? It seems not: the defendants’ negligence had merely added another factor to those which might have led to RLF. Which factor had caused the injury had not been established and it was for the plaintiff to show what part, if any, the negligence had played. After 7 years of litigation this outcome highlights, in Lord Bridge’s words, "the shortcomings of a system in which the victim of some grievous misfortune will recover substantial compensation or none at all, according to the unpredictable hazards of the forensic
process". Many observers will feel sympathy for Lord Wilberforce’s minority view in McGhee that, where a defendant has created a risk and the injury which materialises is within the scope of that risk, the burden should be on the defendant to show that the risk created did contribute to the injury. The courts, however, are wary of endorsing principles that might increase litigation. The conclusion of the Pearson report,4 in which one idea was that the burden of proof be reversed in all cases of medical injury, was that such a step would encourage a "large increase in claims ... many of them groundless". The Wilsher judgment will fuel the debate on "no fault" compensation for victims of medical injury.s The Department of Health and Social Security is to consider a pilot study on a no fault compensation system. Whether such a system would improve the chances of plaintiffs such as Martin Wilsher recovering compensation would depend on the terms of the scheme. In Sweden some claims are rejected where a causal link has not been established3-indeed Action for the Victims of Medical Accidents has stated, of the House of Lords judgment, that "The issue of not cause or