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The BMA and The Lancet
THE LANCET
The BMA and The Lancet SIR—Macara (Oct 19, p 1108)1 maintains that “The Lancet is well known for its antipathy towards the British Medical Association” (BMA), and he seems to ascribe this attitude to a long line of Lancet editors. During the early years of my time on its editorial staff (1952–88) The Lancet was certainly prone to rebuke the BMA when its actions threatened to disrupt and even demolish the National Health Service (NHS): actions such as the collection of undated resignations from members and a scheme for private general practitioner insurance. Such threats were prominent at many of the Association’s annual representative meetings I attended, as Lancet reporter, in the 1950s and 1960s. I believe the journal was absolutely right to voice the widespread alarm throughout the country about the security of the NHS should the BMA pursue the courses it was contemplating so vehemently. An alarm that Macara might, I suspect, have shared. The Lancet’s stance was a defence of the NHS—not an unreasonable BMA-directed “antipathy”. In the late 1970s and early 1980s came a welcome change: the emergence of a new generation of BMA leaders who had been brought up in the NHS and who valued it and were resolved to preserve and improve it. This transformation, incidentally, enabled The Lancet to concentrate its strictures on a grave new danger confronting the NHS—the new Conservative Prime Minister. Ian Munro Oakwood, Bayley’’s Hill, Sevenoaks, Kent TN14 6HS, UK
1
Macara AW. UK academy of medicine. Lancet 1996; 348: 1108.
Training of medical specialists—is there a hidden agenda? SIR—The British government’s eagerness to implement the European Council’s directive on the training of medical specialists raises some concerns. Curiously, arrangements for general practitioners are not included in these provisions and are the subject of separate UK legislation.1 On face value, the directive seems to be a welcome attempt to improve the quality of training and, in turn, the quality of medical service to patients. The Medical Royal Colleges have generally supported this policy with a view to having more structured programmes of training, with better appraisal and supervision. Commendable as these intentions are, there are nevertheless major differences between delivery of medical services in the various European countries and the UK’s National Health Service (NHS), the main difference being that the services in continental Europe rely to varying extent on private funding. The European directive looks to the establishment of a socalled specialist grade. At issue is how those emerging as specialists under the scheme would be employed at the end of their shortened training period. Given the lack of funds, it seems unlikely that the UK hospital trusts will be able to afford to employ many more traditional consultants; therefore, not all emerging specialists would be able to find a niche within the NHS—they would have to find work outside the hospital setting. Where but the private sector? Private medical insurers would then seek specialist consultations and treatment at bargain rates. Economies in fee payments will enable the insurers to reduce their policy premiums; in turn more people would be able to afford to participate in these schemes. Under these circumstances, specialist consultation would be similar to that in many European countries and
1590
would be funded primarily from the private sector. The monitoring of specialist care standards would become more difficult—and influenced more by accounting considerations, rather than by overriding concern for patients’ needs. We believe that, in following the European example, the UK would end up with a multitiered health care system in which the patient’s ability to pay—not his or her clinical need—would be decisive. The UK government’s long-term intentions to limit public expenditure, as evidenced by the increased efficiency savings targets in the health sector, are well served by the European directive. *S T Al-Jawad, I Z Kovar, R G Wilson *Kingston Hospital, Kingston KT2 7QB, UK; and Chelsea and Westminster Hospital, London
1
The Specialist Training Authority of the Medical Royal Colleges, Wimpole Street, London W1. General Information Sheet 1, June 1996.
Treatment of Turner’s syndrome SIR—We share Masters’ concern (Sept 7, p 681)1 about oestrogen replacement therapy in Turner’s syndrome, an issue that continues to cause anxiety in adulthood. Indeed, there are many young women with disorders of the hypothalamus, pituitary, and ovary who are committed to 40 or more years of oestrogen use but who have to rely on rather meagre data comparing the risks and benefits of the various oestrogen preparations derived from the study of women who usually use oestrogen replacement therapy for only 2–3 years. In Turner’s syndrome, in which cardiac disease, hypertension, and obesity are prevalent, the potency of exogenous oestrogen needs especially careful consideration.2 As Masters points out, paediatricians have traditionally used ethinyloestradiol in children needing oestrogen and, with the lack of structured care in adulthood for conditions such as Turner’s syndrome, this choice is rarely reassessed. We have analysed the use of oestrogen in our adult Turner clinic at the Middlesex Hospital (n=111) and in the adult Turner register, held in conjunction with the Turner Society (n=270). Not only do a distressing number of women take no oestrogen replacement (24%, figure), but also the most frequently used formulation continues to be ethinyloestradiol (39%) in this age group (median 29 years, range 18–64). implants 2% tibolone 1%
none 24%
ethinyloestradiol (OC) 39%
patches 6%
natural oestrogens 28%
Figure: Oestrogen use in adult women with Turner’s syndrome OC=oral contraceptive
Vol 348 • December 7, 1996
The BMA and The Lancet SIR—Macara (Oct 19, p 1108)1 maintains that “The Lancet is well known for its antipathy towards the British Medical Association” (BMA), and he seems to ascribe this attitude to a long line of Lancet editors. During the early years of my time on its editorial staff (1952–88) The Lancet was certainly prone to rebuke the BMA when its actions threatened to disrupt and even demolish the National Health Service (NHS): actions such as the collection of undated resignations from members and a scheme for private general practitioner insurance. Such threats were prominent at many of the Association’s annual representative meetings I attended, as Lancet reporter, in the 1950s and 1960s. I believe the journal was absolutely right to voice the widespread alarm throughout the country about the security of the NHS should the BMA pursue the courses it was contemplating so vehemently. An alarm that Macara might, I suspect, have shared. The Lancet’s stance was a defence of the NHS—not an unreasonable BMA-directed “antipathy”. In the late 1970s and early 1980s came a welcome change: the emergence of a new generation of BMA leaders who had been brought up in the NHS and who valued it and were resolved to preserve and improve it. This transformation, incidentally, enabled The Lancet to concentrate its strictures on a grave new danger confronting the NHS—the new Conservative Prime Minister. Ian Munro Oakwood, Bayley’’s Hill, Sevenoaks, Kent TN14 6HS, UK
1
Macara AW. UK academy of medicine. Lancet 1996; 348: 1108.
Training of medical specialists—is there a hidden agenda? SIR—The British government’s eagerness to implement the European Council’s directive on the training of medical specialists raises some concerns. Curiously, arrangements for general practitioners are not included in these provisions and are the subject of separate UK legislation.1 On face value, the directive seems to be a welcome attempt to improve the quality of training and, in turn, the quality of medical service to patients. The Medical Royal Colleges have generally supported this policy with a view to having more structured programmes of training, with better appraisal and supervision. Commendable as these intentions are, there are nevertheless major differences between delivery of medical services in the various European countries and the UK’s National Health Service (NHS), the main difference being that the services in continental Europe rely to varying extent on private funding. The European directive looks to the establishment of a socalled specialist grade. At issue is how those emerging as specialists under the scheme would be employed at the end of their shortened training period. Given the lack of funds, it seems unlikely that the UK hospital trusts will be able to afford to employ many more traditional consultants; therefore, not all emerging specialists would be able to find a niche within the NHS—they would have to find work outside the hospital setting. Where but the private sector? Private medical insurers would then seek specialist consultations and treatment at bargain rates. Economies in fee payments will enable the insurers to reduce their policy premiums; in turn more people would be able to afford to participate in these schemes. Under these circumstances, specialist consultation would be similar to that in many European countries and
1590
would be funded primarily from the private sector. The monitoring of specialist care standards would become more difficult—and influenced more by accounting considerations, rather than by overriding concern for patients’ needs. We believe that, in following the European example, the UK would end up with a multitiered health care system in which the patient’s ability to pay—not his or her clinical need—would be decisive. The UK government’s long-term intentions to limit public expenditure, as evidenced by the increased efficiency savings targets in the health sector, are well served by the European directive. *S T Al-Jawad, I Z Kovar, R G Wilson *Kingston Hospital, Kingston KT2 7QB, UK; and Chelsea and Westminster Hospital, London
1
The Specialist Training Authority of the Medical Royal Colleges, Wimpole Street, London W1. General Information Sheet 1, June 1996.
Treatment of Turner’s syndrome SIR—We share Masters’ concern (Sept 7, p 681)1 about oestrogen replacement therapy in Turner’s syndrome, an issue that continues to cause anxiety in adulthood. Indeed, there are many young women with disorders of the hypothalamus, pituitary, and ovary who are committed to 40 or more years of oestrogen use but who have to rely on rather meagre data comparing the risks and benefits of the various oestrogen preparations derived from the study of women who usually use oestrogen replacement therapy for only 2–3 years. In Turner’s syndrome, in which cardiac disease, hypertension, and obesity are prevalent, the potency of exogenous oestrogen needs especially careful consideration.2 As Masters points out, paediatricians have traditionally used ethinyloestradiol in children needing oestrogen and, with the lack of structured care in adulthood for conditions such as Turner’s syndrome, this choice is rarely reassessed. We have analysed the use of oestrogen in our adult Turner clinic at the Middlesex Hospital (n=111) and in the adult Turner register, held in conjunction with the Turner Society (n=270). Not only do a distressing number of women take no oestrogen replacement (24%, figure), but also the most frequently used formulation continues to be ethinyloestradiol (39%) in this age group (median 29 years, range 18–64). implants 2% tibolone 1%
none 24%
ethinyloestradiol (OC) 39%
patches 6%
natural oestrogens 28%
Figure: Oestrogen use in adult women with Turner’s syndrome OC=oral contraceptive
Vol 348 • December 7, 1996