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MORTALITY, MORBIDITY, AND RESOURCE ALLOCATION
1054 This finding, if substantiated, and if reflected in neonatal blood, could confound any simple interpretation of the relabetween lead levels in haviour in childhood.
tionship
infancy
Department of Pharmacy, University of Aston,
Birmingham B4 7ET. Birmingham Maternity Hospital and University of Birmingham, Birmingham B 15 2TG.
and
morbidity
or
be-
D. G. WIBBERLEY A. K. KHERA
J. H. EDWARDS D. I. RUSHTON
CENTRES FOR LEUKÆMIA TREATMENT the Medical Research Council from the Committee on Leukxmia in 1971 showed that children treated by doctors specialising in this condition survived considerably longer than those treated outside specialised centres.’ This improved survival was thought to be due not to any special treatment regimen but to the availability of special facilities and skills. The Committee recommended that children with acute leukaemia should be referred to a special centre as soon as possible since even a short course of inadequate therapy can have a deleterious effect. A subsequent review2 in 1973 showed that in some cases symptom-free survival was possible for over fifteen years, and many would now talk of the probability of cure in a proportion of cases. In adult acute leukaemia the prognosis is still poor, but a comparison of today’s results with those of ten years ago also shows that considerable advances have been made.3.4 We gave evidence to the Welsh Office in 1974 that in the period 1970-73 adults treated at a regional centre had a median survival five times greater than those treated in non-specialist district hospitals. For these reasons we were surprised to read in a recent report from the Welsh Office on resource allocation that the treatment of leukaemia should no longer be regarded as regional or subregional. The report recommends that leukaemia treatment should be provided at any large acute hospital. While a nihilistic approach to leuksemia therapy may have been justified in the past we do not think this is acceptable today. Even if it were desirable we cannot believe that it is the Health Departments’ policy to provide full facilities and staffing for leukaemia treatment in all health areas. In any case, we would hope that before implementing such a remarkable change in policy some consultation might take place with those who treat leukaemia patients.
SIR,-A report
to
Departments of Hæmatology and Child Health, Welsh National School of Medicine, Cardiff CF4 4XN
ALLAN JACOBS E. N. THOMPSON J. A. WHITTAKER
A HEALTH RATE PRECEPT
SIR,-One deficiency in the structure of the National Health Service is that it offers insufficient scope for local opinion to be effectively reflected. Finance, structure, and participation by the public are three aspects of the Service with which the Royal Commissioners are grappling, and I wish to advance a notion which bears on all three. Under this scheme, the local authority at district level would be at liberty to invite the corresponding health authority to spend a "health rate" precept on a programme of the district council’s choosing, with a guarantee of funding for at least ten years. Supposing, for example, a locality strongly objected to closure of the casualty 1. Medical Research Council Committee on Leukæmia Br. med. J. 1971, iv, 7. 7. 2. Till, M. M., Hardisty, R. M., Pike, M. C. Lancet, 1973, i, 534. 3. Powles, R. L., Russel, J., Lister, T. A., Oliver, T., Whitehouse, J. M. A., Malpas, J., Chapius, B., Crowther, D., Alexander, P. Br. J. Cancer, 1977,
35, 265. 4. Gale, R. P.,
Cline, M. J. Lancet, 1977, i, 497.
department in the cottage hospital. The health authority, hard-pressed for money, might well justify the proposal on rationalisation grounds and here it could get the support of the Department of Health. The saving from transferring the casualty services to the nearest major accident unit some fifteen miles away would be, say, £ 25 000. But, to the distnct council this might seem an acceptable price to pay-equivalent to the income from a half-penny rate-to keep the local service going. If such a precept and transfer of funds were allowable, the local population could expect their elected representatives to respond to local views on health services. There might be pressure for new developments-a county kidney unit, say, or a day unit for the mentally handicapped. Health authorities, for their part, would need to be certain that the funds would continue to come in. It is one thing to raise ;m for a new centre, another to run and staff it for half that sum each year. At present, those who care about the shortcomings of the Health Service have no effective way of expressing their wishes: community health councils, created to reflect public opinion, have no financial resources and rely on persuasion or pressure. If public representatives had the health rate precept behind them, arguments about local services would lose some of their
present
sterility.
Cross London W6
Charing
Hospital,
NIGEL WEAVER
MORTALITY, MORBIDITY, AND RESOURCE ALLOCATION
SIR,-Like Dr Forster (May 7, p. 997) our researches have indicated the problems that the Resource Allocation Working Party report has introduced by using standardised mortality ratios (S.M.R.S). The problem of finding morbidity data is well known, but Dr Forster shows that using S.M.R.s as a proxy has many difficulties. These difficulties become even more obvious below regional level, and if, as the Department of Health now seems to be insisting, they are applied at district level, there will be yet more errors, not just statistically based but related to the whole question of how far S.M.R.s reflect the morbidity and needs of the community for health care. If the S.M.R. does not reflect this need then the implications for health services are
profound.
Bottomless pits may be created as long as the S.M.R. is used. This will mean that there will be no change in the S.M.R. due to the application of RAWP, and the RAWP report itself indicates that this could happen. If it does, below-target areas and regions will never show an improvement in their s.M.R.s no matter how much money they are given. Most of us suspect (and the RAWP report indicates) that the S.M.R. is probably related not to health-service input but to social needs. If this is so, then the use of the S.M.R. is based not on sound statistical reasoning but on a quasipolitical wish to put resources into
socially deprived areas. That there are inequalities in resource distribution is indisputable. Whether s.M.R.s and their use in the RAWP formula will correct this is in doubt. Crude death-rates
might be more
appropriate and they might be a better measure of morbidity; their use might give emphasis to care-demanding aged populations. Hereford and Worcester Area Health Authority, Worcester WR1 3BZ
H.P. FERRER
ANION GAP IN THE ELDERLY
SIR,-We read with interest your editorial on anion gap p. 785). It may be true in young patients that the
(April 9,
anion gap
gives
a
clue
to
the presence and nature of many a
tionship
infancy
Department of Pharmacy, University of Aston,
Birmingham B4 7ET. Birmingham Maternity Hospital and University of Birmingham, Birmingham B 15 2TG.
and
morbidity
or
be-
D. G. WIBBERLEY A. K. KHERA
J. H. EDWARDS D. I. RUSHTON
CENTRES FOR LEUKÆMIA TREATMENT the Medical Research Council from the Committee on Leukxmia in 1971 showed that children treated by doctors specialising in this condition survived considerably longer than those treated outside specialised centres.’ This improved survival was thought to be due not to any special treatment regimen but to the availability of special facilities and skills. The Committee recommended that children with acute leukaemia should be referred to a special centre as soon as possible since even a short course of inadequate therapy can have a deleterious effect. A subsequent review2 in 1973 showed that in some cases symptom-free survival was possible for over fifteen years, and many would now talk of the probability of cure in a proportion of cases. In adult acute leukaemia the prognosis is still poor, but a comparison of today’s results with those of ten years ago also shows that considerable advances have been made.3.4 We gave evidence to the Welsh Office in 1974 that in the period 1970-73 adults treated at a regional centre had a median survival five times greater than those treated in non-specialist district hospitals. For these reasons we were surprised to read in a recent report from the Welsh Office on resource allocation that the treatment of leukaemia should no longer be regarded as regional or subregional. The report recommends that leukaemia treatment should be provided at any large acute hospital. While a nihilistic approach to leuksemia therapy may have been justified in the past we do not think this is acceptable today. Even if it were desirable we cannot believe that it is the Health Departments’ policy to provide full facilities and staffing for leukaemia treatment in all health areas. In any case, we would hope that before implementing such a remarkable change in policy some consultation might take place with those who treat leukaemia patients.
SIR,-A report
to
Departments of Hæmatology and Child Health, Welsh National School of Medicine, Cardiff CF4 4XN
ALLAN JACOBS E. N. THOMPSON J. A. WHITTAKER
A HEALTH RATE PRECEPT
SIR,-One deficiency in the structure of the National Health Service is that it offers insufficient scope for local opinion to be effectively reflected. Finance, structure, and participation by the public are three aspects of the Service with which the Royal Commissioners are grappling, and I wish to advance a notion which bears on all three. Under this scheme, the local authority at district level would be at liberty to invite the corresponding health authority to spend a "health rate" precept on a programme of the district council’s choosing, with a guarantee of funding for at least ten years. Supposing, for example, a locality strongly objected to closure of the casualty 1. Medical Research Council Committee on Leukæmia Br. med. J. 1971, iv, 7. 7. 2. Till, M. M., Hardisty, R. M., Pike, M. C. Lancet, 1973, i, 534. 3. Powles, R. L., Russel, J., Lister, T. A., Oliver, T., Whitehouse, J. M. A., Malpas, J., Chapius, B., Crowther, D., Alexander, P. Br. J. Cancer, 1977,
35, 265. 4. Gale, R. P.,
Cline, M. J. Lancet, 1977, i, 497.
department in the cottage hospital. The health authority, hard-pressed for money, might well justify the proposal on rationalisation grounds and here it could get the support of the Department of Health. The saving from transferring the casualty services to the nearest major accident unit some fifteen miles away would be, say, £ 25 000. But, to the distnct council this might seem an acceptable price to pay-equivalent to the income from a half-penny rate-to keep the local service going. If such a precept and transfer of funds were allowable, the local population could expect their elected representatives to respond to local views on health services. There might be pressure for new developments-a county kidney unit, say, or a day unit for the mentally handicapped. Health authorities, for their part, would need to be certain that the funds would continue to come in. It is one thing to raise ;m for a new centre, another to run and staff it for half that sum each year. At present, those who care about the shortcomings of the Health Service have no effective way of expressing their wishes: community health councils, created to reflect public opinion, have no financial resources and rely on persuasion or pressure. If public representatives had the health rate precept behind them, arguments about local services would lose some of their
present
sterility.
Cross London W6
Charing
Hospital,
NIGEL WEAVER
MORTALITY, MORBIDITY, AND RESOURCE ALLOCATION
SIR,-Like Dr Forster (May 7, p. 997) our researches have indicated the problems that the Resource Allocation Working Party report has introduced by using standardised mortality ratios (S.M.R.S). The problem of finding morbidity data is well known, but Dr Forster shows that using S.M.R.s as a proxy has many difficulties. These difficulties become even more obvious below regional level, and if, as the Department of Health now seems to be insisting, they are applied at district level, there will be yet more errors, not just statistically based but related to the whole question of how far S.M.R.s reflect the morbidity and needs of the community for health care. If the S.M.R. does not reflect this need then the implications for health services are
profound.
Bottomless pits may be created as long as the S.M.R. is used. This will mean that there will be no change in the S.M.R. due to the application of RAWP, and the RAWP report itself indicates that this could happen. If it does, below-target areas and regions will never show an improvement in their s.M.R.s no matter how much money they are given. Most of us suspect (and the RAWP report indicates) that the S.M.R. is probably related not to health-service input but to social needs. If this is so, then the use of the S.M.R. is based not on sound statistical reasoning but on a quasipolitical wish to put resources into
socially deprived areas. That there are inequalities in resource distribution is indisputable. Whether s.M.R.s and their use in the RAWP formula will correct this is in doubt. Crude death-rates
might be more
appropriate and they might be a better measure of morbidity; their use might give emphasis to care-demanding aged populations. Hereford and Worcester Area Health Authority, Worcester WR1 3BZ
H.P. FERRER
ANION GAP IN THE ELDERLY
SIR,-We read with interest your editorial on anion gap p. 785). It may be true in young patients that the
(April 9,
anion gap
gives
a
clue
to
the presence and nature of many a