More Controversy about Appointments to Health Authorities

1482

ACQUISITION OF RENAL CYSTS DURING PERITONEAL DIALYSIS

SIR,-Acquired multiple renal cysts are increasingly recognised in patients on long-term maintenance haemodialysis. These cysts become larger and more numerous during long-term haemodialysis, and in advanced cases the kidney may even resemble that found in familial polycystic kidney disease (PCK). Their clinical importance has recently been highlighted.1 for cyst formation are not understood. The suggestion has been made that the cysts may be caused by a substance leached out of the plastic dialysis circuit, such as the plasticiser di-2-ethylhexylphthalate (DEHP).2 Alternatively the cysts may be caused by a metabolite which accumulates in uraemia and which is inadequately removed by dialysis. 3,4 This would explain the development of cysts in chronically uraemic patients before they started dialysis.5 We postulate that this or a similar metabolite may also cause cyst formation in familial PCK.6 Reports to date have been largely limited to haemodialysis patients. This prompted us to investigate those of our patients with an established non-cystic primary renal diagnosis and who had been on continuous ambulatory dialysis (CAPD) for longer than 3 years. There were eight such patients (see table) on treatment between 36 and 72 months. Only one of them (patient 8) had previously been on haemodialysis (7 years). All underwent ultrasound examination except patient 1, who had had bilateral nephrectomy for uncontrollable hypertension after 36 months of The

reasons

peritoneal

dialysis. DETAILS OF PATIENTS I

I

,--------- I

GN = glomerulonephritis, CPN = chronic pyelonephritis. *Haemodialysis for 84 mo previously. nephrectomy specimen. we have examined only a few patients, our findings that the development, extent, and size of acquired renal suggest is related to the length of time on peritoneal dialysis. No cysts correlation was found between cyst development and haemoglobin

Although

level.7

Our findings do not clarify the cause of

acquired renal cysts, since integral part of CAPD and the possibility of elution of toxic substances remains. Our findings do, however, suggest that haemodialysis and heparinisation are not a

plastic dialysate delivery system is

an

themselves the cause. We recommend that all patients on long-term maintenance dialysis, irrespective of dialysis mode, should undergo regular screening for renal cyst development, since a small proportion of these cysts undergo malignant change and more commonly cause

haemorrhage.

More

Controversy about Appointments to Health Authorities

WITH the Conservatives’ reorganisation of the NHS’s management structure half completed (under the Griffiths plan for introducing more professional talent), the Labour Party is now calling for another even bigger upheaval in the NHS. They want the members of the Service’s 14 health regions and 192 health districts to be directly elected. A future Labour Government will give the idea very serious consideration, according to the party’s shadow Social Services Secretary, Mr Michael Meacher, who has just produced a large report on what he claims is the Conservatives’ increasingly shameless political manipulation of their Governmental power to appoint health authority members and chairmen. Health authorities spent this year some L12 billion of the NHS’s money. According to Mr Meacher’s report, over 3000 people served on these authorities, yet not one of them was there because they had been democratically elected by the communities about whose health needs they would be taking important and in some cases irreversible decisions. The Secretary of State had in his power the direct appointment of all regional health authority members, and through this power he also indirectly appointed most DHA members too, Mr Meacher declared. These powers were being seriously misused, he contended. There was now a need for an urgent review of the way in which health authorities were constituted. In many instances, if Mr Meacher’s research and interpretation are to be believed, the Secretary of State is using his powers to suppress criticism of‘Government policies by the obvious expedient of replacing known Labour supporters on authorities with Tory sympathisers.

The accusation is made on the basis of the replies Mr Meacher got to inquiries which he sent to 74 DHAs and 9 RHAs. Questions were asked about the voting record, party membership, age, sex, and occupation of DHA chairmen. Mr Meacher says that the replies proved that 60% of chairmen were Conservatives, 9% Labour, and the rest unknown. It was therefore likely that the numbers of DHA chairmen generally identified with the Conservative Party was considerably in excess of those who might be identified with other parties. Mr Meacher concedes that many Conservatives in such a position had the respect and confidence of even the non-Conservative members of their health authorities. But a significant number did not. With the same disconcerting lack of precision, Mr Meacher also claimed there was now a growing practice of appointing prominent Conservative Association members to DHA chairmanships.

S. F. BEARDSWORTH

H. J. GOLDSMITH Sefton General Hospital, Liverpool L15 2HE

Commentary from Westminster

R. AHMAD G. LAMB

1 Ratcliffe PJ, Dunnill MS, Oliver DO. Clinical importance of acquired cystic disease of the kidneys in patients undergoing dialysis. Br Med J 1983; 287: 1855-58. 2. Crocker JFS, Sak SH An animal model of haemodialysis induced polycystic kidney disease (PKD) (abstract). Ann CRMCC 1984, 17: 338. 3 Evan AP, Gardner KD. Nephron obstruction in nordihydro-guaiaretic acid-induced renal cystic disease. Kidney Int 1979; 15: 7-19 4 Editorial. Acquired renal cystic disease of the kidney. Lancet 1977; ii: 1063. 5 Mickisch O, Bommer J, Bachmann S, et al. Multicystic transformation of kidneys in chronic renal failure. Nephron 1984, 38: 93-99. 6 Darmady EM, Offer J, Woodhouse MA. Toxic metabolic defect in polycystic disease of the kidney. Lancet 1970; i: 547. 7 Goldsmith HJ, Ahmad R, Raichura N, et al Association between rising haemoglobin concentration and renal cyst formation in patients on longterm regular haemodialysis treatment Proc Eur Dial Transplant Assoc 1982; 19: 313-18

That the Secretary of State should exercise his powers of political patronage in this manner, at a time when there was in any case a growing rebellion from many health authority members against his policies, was quite unacceptable to Mr Meacher. He was now calling for the establishment of a "watchdog body" to ensure that health authorities operated as democratically as possible-which appears to Mr Meacher to mean supporting the Government when it is a Labour one, but not when it is Conservative. The Conservative backing of the RHAs began in 1982 with the dismissal of five regional

chairmen, three of whom

at least were ardent Labour supporters, Mr Meacher went on. Now, he thinks, to the best of his knowledge, there remained only one RHA chairman

1483 of the Labour Party. He histories of apparent political bias in appointments. For instance, he describes at York RHA a Labour Party member in his early 50’s, with a record of campaigning against cuts in local health services who was not reappointed by the Secretary of State. Until his removal he had been the elected vice-chairman of the authority, and therefore must have had the support and confidence of other members of the authority. A similar process had been applied to DHAs, Mr Meacher added, which raised important questions as to the extent to which they can possibly understand local health needs. Mr Meacher complains that his survey proves that most DHA members are white, male, and mostly near to retirement age. The age imbalance contravenes DHSS guidelines, and moreover the health needs of young people are clearly going to be quite different from those of retired people. There were disproportionately few women on DHAs and an even greater dearth of what Mr Meacher calls "ethnic members"; thus he comments that it is hardly surprising that the particular health needs of the black community, such as facilities to treat sickle-cell anaemia were largely missing from the agenda of the NHS. He complains further that very few health authority members come from other than professional backgrounds. There were virtually no manual or semi-skilled workers on DHAs, nor any unemployed people. If the majority of health authority members were in well-paid professional jobs, or retired on generous pensions, the impact of unemployment on their community’s health needs was not likely to be readily apparent to them. Thus Mr Meacher recommends that the Government should advertise health authority vacancies widely, encouraging women, young people, manual workers, members of the ethnic communities, and the unemployed to apply. There should be a complaints procedure for DHA members who wish to attack their chairmen. The watchdog body should monitor the political activities of healthauthority candidates before they were appointed, to ensure even-handedness. But the most important change on Mr Meacher’s mind was the idea of elections to most of the RHA and DHA posts, so that the NHS could be run by elected and accountable authorities. It is expected that this proposal will soon be added to Labour’s official policy. None of this seems to cut much ice with the Health Minister, Mr Kenneth Clarke. In response, he claimed that Mr Meacher’s "half-baked" statistics were cobbled together from Labour supporters in a minority of health authorities, and in no sense fairly represented the position.

who was also cited several

supportive generally case

Screening for Cancer of the

Cervix

More than 2000 women die each year in Britain from of the cervix. Although the figure has been falling in recent years, it has not fallen as dramatically as in other countries, such as Scandinavia, where, it is said, more effective screening schemes have made all the difference. According to Labour’s shadow Health Minister, Mr Frank Dobson, the Government is largely to blame, for failing to lay down guidelines and set standards for a national system of locally based call and recall of women for screening. This was what the Committee for Gynaecological Cytology proposed, when the former national recall scheme was, in 1981, judged to have failed. If the guidelines had been implemented, there was no reason, in Mr Dobson’s view, why the same success should not have been achieved here as in Scandinavia. cancer

But evidence which Mr Dobson has gathered from family practitioner committees round Britain suggests that no screening programme has much prospect of success until the FPCs can work from efficient computerised records. This is unlikely to be possible in the forseeable future, despite the Government’s recent report on future FPC computerisation, commissioned from management consultants, Arthur Andersen Ltd. The Government is not expected to provide much more than exhortation towards financing the computerisation which they accept as vital. There is another problem. Mr Dobson quotes from a letter from the Royal College of Obstetricains and Gynaecologists, whose honorary secretary, Mr R. D. Atlay, says that many of his colleagues are worried about the poor uptake of cancer smear tests, and there was a huge amount of evidence to show that women screened regularly had an excellent chance of any disease process being detected at its very early stage, while it was still possible to have a complete cure. "Most of us still feel that insufficient numbers of smears are being done throughout the female population." The BMA, too, has written to Mr Dobson calling for more screening of younger women. But the BMA and its negotiators have made it clear to the DHSS that they expect doctors to be paid for every smear test they perform, as an item-of-service. More tests, more payments. Not surprisingly the Health Minister, Mr Kenneth Clarke, believes this attitude of the doctors to be little short of a shameless form of blackmail. RODNEY DEITCH ...

International

Diary

1985

University of California San Diego review course on Anesthesiology: San Diego, California, May 17-22 (Ms Kathleen Naughton, Department of Anesthesia [M-029], UCSD, La Jolla, CA 92093, USA). symposium on Coronary Arteriography: Rotterdam, 22 (Prof P. G. Hugenholtz, Department of Cardiology, Universiteit Rotterdam, Postbus 1738, 3000 DR Rotterdam).

Satellite

Netherlands, May Erasmus

11th international conference

on

Improving University Teaching:

Utrecht, Netherlands, July 2-5 (Improving University Teaching, University of Maryland University College, University Boulevard at Adelphi Road, College Park, MD 20742, USA). International symposium

on

Nuclear Medicine and Related Medical

Applications of Nuclear Techniques in Developing Countries: Vienna, Austria, Aug 26-30 (Secretariat, c/o International Atomic Energy Agency, IAEA-SM-283, Vienna International Centre, PO Box 100, A 1400 Vienna). International symposium on Toxicological Applications of Cytochemistry, Histochemistry and Immunohistochemistry: Cambridge, UK, Sept 24-27 (Dr P. H. Bach, Robens Institute of Health and Safety, University of Surrey, Guildford, Surrey GU2 5XH). 1 st world congress on Drugs and Alcohol: Tel Aviv, Israel, Dec 15-19(lst World Congress on Drugs and Alcohol, PO Box 394, Tel Aviv 61003, Israel).

1986 IERE diamond jubilee international conference on The Application of Electronics in Medicine and Biology: Nottingham, UK, April 7-10 (Conference Secretariat), Institution of Electronic and Radio Engineers, 99 Gower Street, London W’CIE 6AZ). 6th international conference on Prostaglandins and Related Compounds: Florence, Italy, June 3-6 (Fondazione Giovanni Lorenzim, Via Monte Napoleone 23, 20121 Milan, Italy). 10th international congress on Neuropathology: Stockholm, Sweden, Sept 7-12 (10th International Congress of Neuropathology, c/o Stockholm Convention Bureau, PO Box 1617, S-111 86 Stockholm).