- Email: [email protected]
PARIS French patients will get protease inhibitors
DISPATCHES LONDON
Are
big casualty departments better?
ust how many intensive-care beds UK National are in the ealth Service remains in doubt.
there
Even the Health Secretary does not know, partly because of the problem of definition, but is thinking of setting up a national register. What noone now disputes is that there are too few beds. A succession of individual tragedies has only helped underline the shortfall for the public. Last week’s report from the Audit Commission (By Accident or Design) suggests that new attendances have risen on average by 2% a year since 1981. About 15% need to be admitted immediately as patients. Many of these patients are acutely ill, placing a disproportionate demand on accident and emergency (A&E)
nursing In anticipation resources.
of the Audit Commission’s report, Stephen Dorrell, the Health Secretary, announced a series of changes before publication day: an immediate review of paediatric intensive-care beds requiring health authorities to report on their plans to increase them; new guidelines to improve the use of intensive-care beds and better coordination between hospitals; and an instruction to develop more "highdependency units", a halfway house between general and intensive-care wards, with one nurse overseeing two beds instead of the 1:ratio of intensive care. There are already
PARIS
French
tt
high-dependency year each, C250 000 for a
with the intensive care. They are liked by managers because of their flexibility as a "step-up" from the general ward
compared
"criticised ministers for leaving too much to the market instead of setting up
a
central, strategic planning unit" or
"step down" from intensive care. Ministers also promised a new
Patient’s Charter standard for the assessment of the casualty patient. The present standard,which requires to be seen immediately, is circumvented by having a nurse greet the patient, who is then left for hours before a proper assessment. The medical world derided the Dorrell package because of its failure to provide extra funds. Sir Leslie Turnberg, president of the Royal College of Physicians, declared: "We were hoping for more. The thrust towards high-dependency care is welcome, but we still need more intensive-care beds as well". Sir Leslie criticised the new guidelines for being too imprecise about admission to and discharge from a highdependency unit. A spokesman for NHS managers criticised ministers for leaving too much to the market
patients
instead of setting up
gic planning unit
a
central,
strate-
to ensure an even
distribution of intensive-care beds across the country. Urging health authorities and hospitals to improve their coordination was insufficient. The ministerial package was in line with the Audit Commission’s recommendations, but did not go as far. The Commission’s redeployment proposals included more use of nurses in place of junior doctors. This followed its study of 11 hospitals, where it found most A&E injuries were cuts, bruises, and grazes. It noted that, although nurse practitioners may not be cheaper than junior doctors, they can offer greater experience, speed, and continuity of care. More controversially the Commission want a reconfiguration of existing services, which would involve closing 30 smaller departments. A Health Department report earlier this month on a large pilot trauma centre in North Staffordshire expressed scepticism about the benefits of size in a rural region. It concluded : "The indisputable fact is that, with little or no penetrating injuries arising from gunshots and knife wounds, and a lower road traffic accident death rate, the incidence of major trauma is much less than in the US". The debate is far from over.
Malcolm Dean
patients will get protease inhibitors
and how France can to supply AIDS the new with protease patients ritonavir inhibitors (Abbott’s [Norvir] and Merck’s indinavir [Crixivan]) has barely been out of the news these past 2 weeks. The controversy was triggered by the National AIDS Council proposal that choice of recipient be made by national lottery. The immediate outcry by AIDS groups led the Prime Minister to openly dismiss the lottery idea. The inability of Abbott France to provide a timetable for supply of its drug helped sustain the outpourings by AIDS groups against Abbott’s commercial strategies. The question of a lottery was clarified on March 7, when the National Advisory Ethics Committee stated that a lottery should be a last resort and held
hether afford
about 300 of these
beds, costing 150 000
at local hospital level when choice could not be made on medical criteria. March 11saw a new development, when a group of five AIDS associations announced that Abbot and Merck were preparing supplies sufficient to meet all prescriptions. This point was confirmed by the government 2 days later. Abbot will supply ritonavir for 4500 patients now and for at least 15 000 by July/August, while Merck had promised drugs for 3000 patients in
only
April, rising to 18 000 in a year. They will be prescribed under authorisations for temporary use (similar to the US investigational
drug programme). Saquinavir (Hoffmann La Roche) has been
new
available under this scheme since Jan 25. An expert group is to define eligibility criteria for these new
protease inhibitors-possibly
ing with
CD4
counts
start-
of below
20/mL What can we learn from this affair? First, what is acceptable in the USA, where a lottery for protease inhibitors has been operating for a year, may not be so in France. We also learn how much influence AIDS associations can wield. Their negotiations with the drug firms quickly forced the government to declare that efforts would be made to provide the drugs despite the costs. But costs there will be. Negotiations are still in progress. Judging by prices given in the USA, ritonavir could cost US$6500 per year per patient, and indinavir
$4380.
Marc Gozlan
821
Are
big casualty departments better?
ust how many intensive-care beds UK National are in the ealth Service remains in doubt.
there
Even the Health Secretary does not know, partly because of the problem of definition, but is thinking of setting up a national register. What noone now disputes is that there are too few beds. A succession of individual tragedies has only helped underline the shortfall for the public. Last week’s report from the Audit Commission (By Accident or Design) suggests that new attendances have risen on average by 2% a year since 1981. About 15% need to be admitted immediately as patients. Many of these patients are acutely ill, placing a disproportionate demand on accident and emergency (A&E)
nursing In anticipation resources.
of the Audit Commission’s report, Stephen Dorrell, the Health Secretary, announced a series of changes before publication day: an immediate review of paediatric intensive-care beds requiring health authorities to report on their plans to increase them; new guidelines to improve the use of intensive-care beds and better coordination between hospitals; and an instruction to develop more "highdependency units", a halfway house between general and intensive-care wards, with one nurse overseeing two beds instead of the 1:ratio of intensive care. There are already
PARIS
French
tt
high-dependency year each, C250 000 for a
with the intensive care. They are liked by managers because of their flexibility as a "step-up" from the general ward
compared
"criticised ministers for leaving too much to the market instead of setting up
a
central, strategic planning unit" or
"step down" from intensive care. Ministers also promised a new
Patient’s Charter standard for the assessment of the casualty patient. The present standard,which requires to be seen immediately, is circumvented by having a nurse greet the patient, who is then left for hours before a proper assessment. The medical world derided the Dorrell package because of its failure to provide extra funds. Sir Leslie Turnberg, president of the Royal College of Physicians, declared: "We were hoping for more. The thrust towards high-dependency care is welcome, but we still need more intensive-care beds as well". Sir Leslie criticised the new guidelines for being too imprecise about admission to and discharge from a highdependency unit. A spokesman for NHS managers criticised ministers for leaving too much to the market
patients
instead of setting up
gic planning unit
a
central,
strate-
to ensure an even
distribution of intensive-care beds across the country. Urging health authorities and hospitals to improve their coordination was insufficient. The ministerial package was in line with the Audit Commission’s recommendations, but did not go as far. The Commission’s redeployment proposals included more use of nurses in place of junior doctors. This followed its study of 11 hospitals, where it found most A&E injuries were cuts, bruises, and grazes. It noted that, although nurse practitioners may not be cheaper than junior doctors, they can offer greater experience, speed, and continuity of care. More controversially the Commission want a reconfiguration of existing services, which would involve closing 30 smaller departments. A Health Department report earlier this month on a large pilot trauma centre in North Staffordshire expressed scepticism about the benefits of size in a rural region. It concluded : "The indisputable fact is that, with little or no penetrating injuries arising from gunshots and knife wounds, and a lower road traffic accident death rate, the incidence of major trauma is much less than in the US". The debate is far from over.
Malcolm Dean
patients will get protease inhibitors
and how France can to supply AIDS the new with protease patients ritonavir inhibitors (Abbott’s [Norvir] and Merck’s indinavir [Crixivan]) has barely been out of the news these past 2 weeks. The controversy was triggered by the National AIDS Council proposal that choice of recipient be made by national lottery. The immediate outcry by AIDS groups led the Prime Minister to openly dismiss the lottery idea. The inability of Abbott France to provide a timetable for supply of its drug helped sustain the outpourings by AIDS groups against Abbott’s commercial strategies. The question of a lottery was clarified on March 7, when the National Advisory Ethics Committee stated that a lottery should be a last resort and held
hether afford
about 300 of these
beds, costing 150 000
at local hospital level when choice could not be made on medical criteria. March 11saw a new development, when a group of five AIDS associations announced that Abbot and Merck were preparing supplies sufficient to meet all prescriptions. This point was confirmed by the government 2 days later. Abbot will supply ritonavir for 4500 patients now and for at least 15 000 by July/August, while Merck had promised drugs for 3000 patients in
only
April, rising to 18 000 in a year. They will be prescribed under authorisations for temporary use (similar to the US investigational
drug programme). Saquinavir (Hoffmann La Roche) has been
new
available under this scheme since Jan 25. An expert group is to define eligibility criteria for these new
protease inhibitors-possibly
ing with
CD4
counts
start-
of below
20/mL What can we learn from this affair? First, what is acceptable in the USA, where a lottery for protease inhibitors has been operating for a year, may not be so in France. We also learn how much influence AIDS associations can wield. Their negotiations with the drug firms quickly forced the government to declare that efforts would be made to provide the drugs despite the costs. But costs there will be. Negotiations are still in progress. Judging by prices given in the USA, ritonavir could cost US$6500 per year per patient, and indinavir
$4380.
Marc Gozlan
821