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RESEARCH IN CONFLICT WITH TEACHING
1128
meeting in 1979,1,2 almost every unit had instituted a CAPD programme. By the end of 1985, 2373 patients were being treated by CAPD in the UK and 5156 in the whole of the rest of Europe. The number of patients taken on to dialysis increased from 19 2 per million of the population in 1978 to 46 9 in 1986.’ The stampede into CAPD was criticised by as some offering second-class treatment. British nephrologists could not afford to be faint hearted, so the article by Dr Gokal and his colleagues in this issue (p 1105) is very encouraging. It shows that the survival of patients up to four years is just as good on CAPD as it is on haemodialysis, even though the patients treated by CAPD may have had serious risk factors. However, some of the consequences of increasing the numbers of patients on CAPD may make it difficult to continue present practices. The workload of each unit will greatly increase even if the number of patients taken on to dialysis each year remains constant. There are now 1-2 units per million of the population in the UK by comparison with 3-9 in France, 5-4 in West Germany, 5-2 in Spain, and 6-9 in Italy. The number of patients being treated per unit is 180 in the UK, 74-7 in France, 56-4 in West Germany, 51.7 in Spain, and 38 4 in Italy. Because of the nature of the treatment, the number will continue to increase until the death rate is the same as the admission rate early next century, and will double in the next five years.5 This expansion will be very difficult to achieve, given that most units are sited in major hospitals where space and resources are under pressure from many different specialties. The study of Dr Gokal and co-workers highlights another cause for concern. The technical failure rate of CAPD proved to be about 10% per annum. Patients then have to be transferred to another form of treatment, the great majority on to haemodialysis in hospital, where there are all too few places. A significant increase in transplantation rate would help, but this has proved remarkably difficult to achieve, mainly because of the reluctance of doctors to ask families about organ donation. Unless the transplantation rate doubles, there is a clear need to increase the number of hospital-based haemodialysis places. This expansion can be achieved only by increasing the number of units, so that each serves no more than half a million people. Even then, Britain would have fewer units per head of the population than other comparable countries. This observation is, of course, not new6-7 but it has provoked remarkably little action, possibly because it is not clear who is responsible for planning the services for the treatment of terminal renal failure in Britain. Should it be the regional health authorities or the DHSS itself? The Government has set a target of 40 patients per million of the population per year-this figure has been achieved, thanks to CAPD. The clear implication of the report of Dr Gokal and his colleagues is that CAPD more
1. Thomson NM, Walker RG, Whiteside G, Scott DF, Atkins RC. Continuous ambulatory dialysis in the treatment of end stage renal failure. Proc EDTA 1979; 16: 171-77. 2 Oreopoulos DG, Clayton S, Dombos N, Zellerman G, Katirtzoglou A. Nineteen months experience with continuous ambulatory peritoneal dialysis. Proc EDTA 1979; 16: 178-83. 3. Broyer M, Brunner FP, Brynger H, et al. Combined report on regular dialysis and transplantation m Europe, 1985. EDTA registry centre survey. Nephrol Dial
Transpl (in press).
demographic data for 1986, provided by EDTA registry, St Thomas’ Hospital, London SE1 7EH. 5. Katikarides M. Forecasting the expected number of patients on renal replacement therapy in the West of Scotland. MSc thesis Strathclyde University, 1986. 6. Wing AJ. Why don’t the British treat more patients with kidney failure. Br Med J
4. UK
7.
1983; 287: 1157-58. Berlyne GM. The British dialysis tragedy revisited. Nephron 1985; 41: 305-06.
alone
cannot
sustain this level of service. For every 1000
CAPD, 100 haemodialysis places must be set aside. If each place is used by 4 patients, there is a need for 25 places or the equivalent of 25 new units each year. The present provision of hospital haemodialysis places is simply inadequate to meet this requirement for much longer. Regional health authorities appear to find it difficult to fund the present level of activities, especially in London and Birmingham. Planning changes on the scale required is surely the responsibility of the DHSS itself. Decisions on
patients
on
the siting of new units and the necessary increase in the number of nephrologists to be trained will have to be made. With 2774 patients on CAPD at the end of 1986these decisions cannot wait. British renal units are very productive and cost-effective-let us have more.
RESEARCH IN CONFLICT WITH TEACHING AT a recent
University Urants committee (UGC; visit to
London medical school, the students were invited to comment on their course. They said that the teachers seemed more interested in their research than their teaching. The balance between these two activities in medical schools has never been easy. For clinical academics, duties to their patients must always take first place. Recent National Health Service and university economies have given most clinicians an appreciably larger clinical work load, with progressively less time for teaching or research. Yet the students’ criticism was not confined to clinical staff. Government policy, in general, implies that money for social and educational services should be distributed according to observed needs and demonstrated achievements. In response to the latter aim, the UGC published in 1986 gradings for all medical schools. These gradings were based almost entirely on the ability of schools to obtain research grants and publish original scientific work of high calibre. London University now distributes its Court Grant differentially to medical schools according to their UGC gradings. What was thought to be hard money is in fact soft. There have always been university staff who prefer teaching to research, sometimes exclusively so. Presumably they prefer the respect and affection of their students to the different satisfactions of scientific achievement. In medicine they also know that they provide, anonymously, inestimable benefit to the future patients of those students. It seems that such people can no longer be afforded, since the basic financing, indeed survival, of a school depends overwhelmingly on the ability to compete for funds in the scientific arena. The result is simple-patients first; research second; teaching third. The students were right. A remedy for this situation will not be found in the tram-line thinking of the present Government. It will not emerge from the tedious and sterile competition between the Department of Education and Science and the Department of Health and Social Security, where Ministers endeavour to transfer the clinical teaching responsibilities of both to the budget of the other. Yet for the sake of future patients, a solution must be found. It seems that the General Medical Council may be the only body that can approach the problem. The attack which it must now launch will test its courage, as it will test the independence and sense of responsibility of the Privy Council, to which the GMC is a
responsible.
meeting in 1979,1,2 almost every unit had instituted a CAPD programme. By the end of 1985, 2373 patients were being treated by CAPD in the UK and 5156 in the whole of the rest of Europe. The number of patients taken on to dialysis increased from 19 2 per million of the population in 1978 to 46 9 in 1986.’ The stampede into CAPD was criticised by as some offering second-class treatment. British nephrologists could not afford to be faint hearted, so the article by Dr Gokal and his colleagues in this issue (p 1105) is very encouraging. It shows that the survival of patients up to four years is just as good on CAPD as it is on haemodialysis, even though the patients treated by CAPD may have had serious risk factors. However, some of the consequences of increasing the numbers of patients on CAPD may make it difficult to continue present practices. The workload of each unit will greatly increase even if the number of patients taken on to dialysis each year remains constant. There are now 1-2 units per million of the population in the UK by comparison with 3-9 in France, 5-4 in West Germany, 5-2 in Spain, and 6-9 in Italy. The number of patients being treated per unit is 180 in the UK, 74-7 in France, 56-4 in West Germany, 51.7 in Spain, and 38 4 in Italy. Because of the nature of the treatment, the number will continue to increase until the death rate is the same as the admission rate early next century, and will double in the next five years.5 This expansion will be very difficult to achieve, given that most units are sited in major hospitals where space and resources are under pressure from many different specialties. The study of Dr Gokal and co-workers highlights another cause for concern. The technical failure rate of CAPD proved to be about 10% per annum. Patients then have to be transferred to another form of treatment, the great majority on to haemodialysis in hospital, where there are all too few places. A significant increase in transplantation rate would help, but this has proved remarkably difficult to achieve, mainly because of the reluctance of doctors to ask families about organ donation. Unless the transplantation rate doubles, there is a clear need to increase the number of hospital-based haemodialysis places. This expansion can be achieved only by increasing the number of units, so that each serves no more than half a million people. Even then, Britain would have fewer units per head of the population than other comparable countries. This observation is, of course, not new6-7 but it has provoked remarkably little action, possibly because it is not clear who is responsible for planning the services for the treatment of terminal renal failure in Britain. Should it be the regional health authorities or the DHSS itself? The Government has set a target of 40 patients per million of the population per year-this figure has been achieved, thanks to CAPD. The clear implication of the report of Dr Gokal and his colleagues is that CAPD more
1. Thomson NM, Walker RG, Whiteside G, Scott DF, Atkins RC. Continuous ambulatory dialysis in the treatment of end stage renal failure. Proc EDTA 1979; 16: 171-77. 2 Oreopoulos DG, Clayton S, Dombos N, Zellerman G, Katirtzoglou A. Nineteen months experience with continuous ambulatory peritoneal dialysis. Proc EDTA 1979; 16: 178-83. 3. Broyer M, Brunner FP, Brynger H, et al. Combined report on regular dialysis and transplantation m Europe, 1985. EDTA registry centre survey. Nephrol Dial
Transpl (in press).
demographic data for 1986, provided by EDTA registry, St Thomas’ Hospital, London SE1 7EH. 5. Katikarides M. Forecasting the expected number of patients on renal replacement therapy in the West of Scotland. MSc thesis Strathclyde University, 1986. 6. Wing AJ. Why don’t the British treat more patients with kidney failure. Br Med J
4. UK
7.
1983; 287: 1157-58. Berlyne GM. The British dialysis tragedy revisited. Nephron 1985; 41: 305-06.
alone
cannot
sustain this level of service. For every 1000
CAPD, 100 haemodialysis places must be set aside. If each place is used by 4 patients, there is a need for 25 places or the equivalent of 25 new units each year. The present provision of hospital haemodialysis places is simply inadequate to meet this requirement for much longer. Regional health authorities appear to find it difficult to fund the present level of activities, especially in London and Birmingham. Planning changes on the scale required is surely the responsibility of the DHSS itself. Decisions on
patients
on
the siting of new units and the necessary increase in the number of nephrologists to be trained will have to be made. With 2774 patients on CAPD at the end of 1986these decisions cannot wait. British renal units are very productive and cost-effective-let us have more.
RESEARCH IN CONFLICT WITH TEACHING AT a recent
University Urants committee (UGC; visit to
London medical school, the students were invited to comment on their course. They said that the teachers seemed more interested in their research than their teaching. The balance between these two activities in medical schools has never been easy. For clinical academics, duties to their patients must always take first place. Recent National Health Service and university economies have given most clinicians an appreciably larger clinical work load, with progressively less time for teaching or research. Yet the students’ criticism was not confined to clinical staff. Government policy, in general, implies that money for social and educational services should be distributed according to observed needs and demonstrated achievements. In response to the latter aim, the UGC published in 1986 gradings for all medical schools. These gradings were based almost entirely on the ability of schools to obtain research grants and publish original scientific work of high calibre. London University now distributes its Court Grant differentially to medical schools according to their UGC gradings. What was thought to be hard money is in fact soft. There have always been university staff who prefer teaching to research, sometimes exclusively so. Presumably they prefer the respect and affection of their students to the different satisfactions of scientific achievement. In medicine they also know that they provide, anonymously, inestimable benefit to the future patients of those students. It seems that such people can no longer be afforded, since the basic financing, indeed survival, of a school depends overwhelmingly on the ability to compete for funds in the scientific arena. The result is simple-patients first; research second; teaching third. The students were right. A remedy for this situation will not be found in the tram-line thinking of the present Government. It will not emerge from the tedious and sterile competition between the Department of Education and Science and the Department of Health and Social Security, where Ministers endeavour to transfer the clinical teaching responsibilities of both to the budget of the other. Yet for the sake of future patients, a solution must be found. It seems that the General Medical Council may be the only body that can approach the problem. The attack which it must now launch will test its courage, as it will test the independence and sense of responsibility of the Privy Council, to which the GMC is a
responsible.