PRESCRIBING IN GENERAL PRACTICE

1204

ence ? Loss of occupation can be a major problem (in a large hospital there are usually jobs for willing workers), as well as loss of friends (or enforced friendships with incompatible individuals) in a much reduced social environment. One of our brighter deaf residents left his hospital dormitory only to share a room in a private hostel with a severely autistic individual who did nothing to help his communication problem. In some ways he was much more isolated there than in our large hospital, and not surprisingly he has returned. Ironically there may be less contact with relatives and the rest of the community after hospital discharge, and the possibility of occupational exploitation in the private sector must not be forgotten. Psychiatric help, especially brief inpatient care, is often virtually impossible to obtain from the generic service. I know of adolescent mentally handicapped persons who had to be admitted long-term because there were no acute beds available to them. The often untrained staff in private hostels may not be the best people to regulate and stock a drug

cupboard or dispense from it (they are certainly not required to keep adequate records). Monitoring of Care What protection does the discharged client have against exploitation and neglect? Those living at home who have never been in hospital may suffer non-accidental injury (mentally handicapped children are at a higher-than-average risk of physical abuse), and resistance to, or non-compliance with, medical treatment by the parent may lead to serious consequences. I have known homosexually inclined patients to be discharged by arrangement with their hospital social worker to a homosexual household, with the clinicians unaware of the move. In another unit buggery was committed against a severely handicapped man, but the incident was not reported to the police or the victim’s parents. Several of our ex-patients have lived for many years with a dementing old lady and were eventually found to have no savings, despite many years of lucrative employment. Since Seebohm, social workers may no longer inspect such premises every few months. The new jargon is: "self-care is the most important care of all", but more independence for the client can mean more neglect. CONCLUSIONS

Privatisation may be all right for the laundry, transport, or tea-bag services in the NHS but may not be the best option for clinical care of a patient. If we must have privatisation we must ensure it does not mean privation. The solution may be to establish equivalents of such bodies as the national development team and community health councils to monitor standards of care in the voluntary organisation and private sectors, where there seems little supervision other than checking that the fire regulations are up to scratch. Why should community placement be given anything more than a trial? There is enough evidence (such as difficulty in obtaining psychiatric treatment"," and high suicide rates among discharged mental patientsl7) that current community-care policies are inadequate.18-20 That forced normalisation will not work is becoming all too apparent. Large mental illness and mental handicap hospitals were established because the community could not cope. If I understand the situation correctly, that the community is again finding it impossible to cope, then we certainly need a new non-political, clinically oriented approach to the care of the mentally disabled. Otherwise there will be an enormous waste of resources as well as inferior care.

The public should, and matter, particularly when order of the day.

will,

be the final arbiters in this haste seems to be the

unseemly

REFERENCES 1 Confederation of Health Service

2. 3 4. 5. 6. 7.

8.

Employees special report Health Services 1983; 39(1):

4-5. Andrews K Private rest homes in the care ofthe elderly. Br Med J 1984, 288:1518-20. Welsh Office. A good home. Consultative document, 1982. Godber C. Private rest homes: Answers needed. Br Med J1984, 288: 1473-74 COHSE cites new evidence in attack on community care. Nursing Times 1984 July 4: 5 Dell S, Smith A. Changes in the sentencing of diminished responsibility homicides. Br J Psychiatry 1983; 142: 29-34. Mental wards closure plan under attack. The Observer 1984 May 20: 4. Major J. Community care. The sham behind the slogan. BullR Coll Psychiatrists 1984,

8(6): 112-14. Programme. ITV. 1984 June 23 10 Fitchew J. Doctors to boycott talks over psychiatric community care. Hosp Doctor 1984 June 14: 3. 11. Bicknell J. Comment on ’Mental handicap: Policies and priorities’. Bull R Coll Psychiatrists 1984; 8 (5): 84-85. 12. Staite S, Torpy DM. Who can live alone? Mental Handicap 1983; 11: 94. 13 Keep mentally handicapped out. Surrey Herald 1984 June 15. 14. CSP claims community physio services in scandalous state. Remedial Therapist 1984;7 (17): 1. 15 Richmond Fellowship. Mental health and the community Report of the Richmond Fellowship Enquiry. London: Richmond Fellowship Press, 1983. 16. Harris CM. Mental illness in central London. Br Med J 1984; 288: 1425-26. 17. Roy A. Suicide in chronic schizophrenia. Br J Psychiatry 1982; 141: 171-77. 18. Ticking time-bombs who stalk streets. Sunday Times 1983 July 24; 11. 19 Handicapped seek to escape inadequate care in the community. Guardian 1984 May 15 20. Mental health care: 3: Doctors protest over cost of hospital cash cuts Times 1984 9 The London

March 28.

Wasted Resources PRESCRIBING IN GENERAL PRACTICE MOST

most of the time get better without Yet the annual bill for prescriptions by GPs is more than 1500 million. In 1979 there were 44 million prescriptions for psychotropic drugs in England (population 46 million). Cough mixtures, diarrhoea mixtures, lozenges, and gargles are useless, yet vast numbers are prescribed. In the long run anorectic drugs do more harm than good. Clearcut indications for antibiotics are few, yet they are prescribed on a huge scale. They are often given for sore throats, yet, even when sore throats are due to haemolytic streptococci, antibiotics have no significant effect. If the peripheral vasodilators disappeared altogether mankind-apart from a few people with the Raynaud phenomenon-would be unharmed. No preparation can properly be called a tonic and very few people need vitamins yet these are widely prescribed. And many GPs prescribe proprietary drugs when generic equivalents would be just as effective and far cheaper.

patients

treatment.

The main reason GPs give for prescribing so freely is that patients expect to be given medicine. But a large number of patients do not take this view. A commonly heard complaint is that doctors do not listen to what the patient says but hands over a prescription, usually for a psychotropic drug. The BBC television programme "That’s Life" on May 13, 1984, made most painful viewing. Patient after patient complained that their doctor hardly talked to them but promptly prescribed ’Valium’ or some other benzodiazepine. Yet if patients with acute, self-limited illnesses are told that the only remedy needed is time, most will accept this. Moreover, if a GP regularly gives "treatment" for patients with, say, a common cold, when they next have a cold they will naturally visit the doctor again for more. ’

Some GPs do not hand out prescriptions to all’and sundry. The prescription costs of Ryde,l for example, were about 20% of the national average. Yet his patients were mostly of social classes IV and v living in a London suburb, the very

1205 groups who are popularly supposed to demand medicine especially. He believes there is a strong case against placebos and that a doctor’s prescribing costs are inversely proportional to his grasp of the problems and his understanding of the patient. If all GPs took this approach, can anyone doubt that patients would be far better served? At the same time the savings would be enormous-though large numbers of pharmacists would go bankrupt. 5 The

Close,

Tilford Road, Farnham, Surrey

JOHN W. TODD

GU9 8DR REFERENCE

1.

Ryde

D. Does the

patient really need a prescription?

Practitioner 1976, 216: 557-59.

Treatment of Cancer REVIEW OF MORTALITY RESULTS IN RANDOMISED TRIALS IN EARLY BREAST CANCER No firm conclusions have previously emerged about the effects on mortality of adjuvant systemic therapy in early (ie, operable non-metastatic) breast cancer. This might be partly because the results of the many different therapeutic trials have often been considered almost in isolation from each other. A meeting was therefore held in London on Oct 24-26 of-representatives of almost all the trial organisations that had conducted randomised trials of the treatment of early breast cancer by adjuvant systemic therapy, testing either (i) the anti-oestrogen agent tamoxifen, or (ii) some form oflong-term (ie, two or. more months of scheduled treatment) cytotoxic chemotherapy. Trials were included if two of their schedules differed from each other only by the addition of the systemic therapy to be assessed. Many trial organisations generously provided unpublished interim mortality from past and current randomised studies, in the hope that an overview of the results from many studies might yield an estimate of the effects of these treatments that was more accurate than that provided by any single study. An overview of the data on mortality by allocated treatment from all available such trials-based on over 16 000 women randomised into tamoxifen trials, and over 10 000 women randomised into chemotherapy trials-was presented. It was analysed by standard methods,’ which compare patients in one trial only with other patients in that same trial, and not with patients in other trials. This analysis indicated that among women with early breast cancer there was a clearly significant reduction in short-term mortality in those receiving either form of adjuvant therapy (p<0 00in each

case). Among

first diagnosed after 50 years of age, the reductions in short-term mortality were only moderate. For example, where, after a variable period of follow-up (ranging from under one year to over five years), about 20% of control women had died, adjuvant systemic treatment with either agent might typically reduce this to 16-18%. It is, of course, not known how long this short-term reduction in mortality will persist. The proportional reduction (though not the absolute reduction) appeared to be similar whether the axillary lymph nodes were involved or not. Among women diagnosed before 50 years of age, no net effects of tamoxifen therapy were apparent (although this might have been merely because too few women in this age women

studied). However, the net effects of cytotoxic therapy on early mortality among women diagnosed under the age of 50 were highly significant (p<0 0001), and appeared to be almost twice as great as in the group had been

older group. In neither age range was it clear whether the addition of tamoxifen to cytotoxic therapy produced any additional benefit. Among the cytotoxic regimens examined, the most promising appeared to be some variant of the "CMF" regimen described2in 1976 and later adapted in various ways in many other trials. But this apparently greater promise of CMF could be due to less data currently being available on other regimens. Although these preliminary analyses achieved a high degree of statistical significance, many uncertainties remain about their exact meaning and about their practical implications. First, although about 80(!) randomised trials were reviewed, a few more may have been overlooked, and even among those reviewed no external check was available on the completeness of reporting of patient numbers or of deaths. Second, no information was available on any differences there may have been in the management of recurrent disease. Finally, many of the chemotherapeutic regimens tested are very toxic even in experienced hands, and in other hands might involve an appreciable risk of iatrogenic death. So, even if a proportion of women may benefit from them, many-particularly with stage-I disease-will not, and until a similar overview of long-term survival can emerge it may be difficult to know which categories of women should be offered such toxic agents. Despite these uncertainties, however, the very high degree of statistical significance suggested by this overview shows that where many trials have addressed related questions, a semi-formal overview of their findings (in cancer, as in heart disease3) may produce reliable evidence long before this would have emerged from the usual processes of separate analysis and publication. Since the future treatment of many women might be importantly affected by this-or a further-overview of all available trials, those meeting agreed to explore the possibility of extending their collaboration to include central review of individual patient data (to help explore the likely duration of any short-term reduction in mortality, to help discover which individuals are most likely to have a worthwhile prolongation of life, and for many other purposes). It was also agreed that a full report of the present overview should be published, once the data have been revalidated. In the meantime, however, the present highly significant evidence of reductions in early mortality may be of interim guidance to those managing early breast cancer or conducting or planning controlled randomised studies of systemic therapy in this disease. The meeting was convened jointly by the UK Breast Cancer Trials Coordinating Subcommittee of the UK and the Project on Controlled Therapeutic Trials of the UICC. It was financed by the Cancer Research Campaign, London, the Imperial Cancer Research Fund Cancer Studies Unit, Oxford, the Union Internationale Contre le Cancer, Geneva, and the World Health Organisation Cancer Office, Geneva. Details of trials and participants are available from the Cancer Studies Unit, Radcliffe Infirmary, Oxford, UK. for example: Editorial. Aspirin after myocardial infarction. Lancet 1980; i: 1172-73. 2 Bonadonna G, Brusamolino E, Valagussa P, et al Combination chemotherapy as an adjuvant treatment in operable breast cancer. N Engl J Med 1976, 294: 405-10. 3. Editorial Long-term and short-term beta-blockade after myocardial infarction. Lancet 1982; i: 1159-61.

1. See,