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Notes and News

RESOURCE MANAGEMENTd- L_____1- 1____- L___- _1_____- - ._.., _FtFrv more hospitals have been chosen to join the first six in

taking part in the NHS Resource Management Initiative (RMI),even before the experience at the six pilot sites has been fullyassessed-a point deplored by the Joint Consultants Committee(Times, March 21), which is one of the final assessors of the pilotprojects. This initiative, launched in November, 1986, was aimed atproviding doctors and nurses with detailed information on whomthey have treated, how the patients were treated and at what cost,and how their performance compares with that elsewhere. A keyfeature of the RMI is that doctors and nurses would be fullyinvolved in local unit management. The information provided bythe RMI is intended to enable doctors and nurses to provide betterand more cost-effective health care, and managers to plan andmonitor the hospital’s work. More urgently, it would enable

hospitals to price their services, to fulfil some of the requirements ofthe intended reform of the NHS.The six pilot sites (Freeman Hospital, Newcastle upon Tyne;

Royal Infirmary, Huddersfield; Royal Hampshire County Council,Winchester; Guy’s Hospital, London; Arrowe Park Hospital,Wirral; and Pilgrim Hospital, South Lincolnshire) were allowed todevelop their RMI in different ways. The least radical model wasthat adopted by the Royal Infirmary, Huddersfield, which madelittle change to its traditional management structure, whereas Guy’sHospital, the Royal Hampshire County, and Arrowe Park Hospitalscreated clinical directorates, with each directorate being responsbilefor managing all aspects of its affairs. The pilot projects were to beevaluated in three phases-an interim report in autumn 1988 (basedon detailed progress reports from each of the six sites), a spring 1989report by health economists at Brunel University, and an October,1989, assessment by the NHS management board and the JointConsultants Committee (representing the Royal Colleges and theBritish Medical Association). The interim report (with the sixprogress reports) have been published as part of an informationpackage for those who have to take part in the initiative.’ Ian Mills,director of resource management and author of the interim report,says that most of the sites have not yet fully implemented their plans,but some (Royal Hampshire, Guy’s, and Pilgrims) are expected tohave their local information technology systems fully functioning inlarge parts of their hospitals by this month. He also says that themanagement schemes have fully involved clinicians at all six sites;that clinicians have had a positive influence over the management ofresources at Guy’s and Winchester and probably would at the othersites when the structural changes have been implemented; thatinformation systems have already provided data relevant to patientcare at Freeman Hospital and the Royal Infirmary, Huddersfield;and, at these two hospitals, the clinicians think that the time thatthey have put into the schemes has been beneficial to patient care.The information package includes technical guidance notes on

several topics, one of which is how to group cases for treatment-costing systems. The diagnosis-related groups (DRGs) as used inthe USA seem to be suitable in most cases, but there are specialtiessuch as psychiatry and endocrinology, where DRC:rs do not providea "good fit", so difficulties in coding disease is one area that needsrefining.The fifty hospitals chosen for the first "roll-out" phase of the

RMI will take part in the doctors-in-management part of theprogramme, and will be evaluated with the original six in October,1989. From these fifty, twenty will be chosen to implement the mainRMI processes (establishment of information systems), with otherhospitals being drawn into the scheme in waves, so that by 1992 all260 major acute hospitals will be operating RMI schemes. Details ofRMI for community units are expected to be announced later thismonth.

1 Resource Management Initiative. By Ian Mills Available from Department of Health,Room 528, Friars House, 157-168 Blackfriars Road, London, SE1 8EU.

THE FOOD WE EAT

THE British population, according to the summary of the 1988National Food Survey (as yet unpublished) is eating fewer eggs thanin 1980, and only half as much butter. Consumption of red meat(beef, lamb, and pork) has fallen by a quarter, and people are eating alittle more fish and 20% more poultry. Wholemeal bread is

replacing the standard white loaf (the former now accounts for overhalf of household bread purchases, compared with 30% in 1980),consumption of sugar and preserves has fallen by a third since 1980,and 26% of liquid milk now bought is low fat (no figures for 1980).A slight fall in purchases of fresh potatoes and fresh green vegetablesreflects a movement towards more processed vegetables. Fruitconsumption has remained virtually unchanged since 1980, butconsumption of fruit juices has more than doubled.Mr Richard Ryder, parliamentary secretary at the Ministry of

Agriculture, Fisheries and Food, has welcomed this "continuingprogress towards a healthier national diet" as a reflection of "theGovernment’s policy of providing information to consumers onwhat constitutes a healthy and balanced diet and allowing them tomake their own informed choice from the wide variety of foodsavailable". But what sort of triumph is this? Despite a rise in theratio of polyunsaturated to saturated fat in the diet (from 0.24 in1980 to 0 37 in 1988), the proportion of energy derived from fat hashardly changed. At 42% this figure is well above the 35%recommended in 1984 by the Committee on Medical Aspects ofFood Policy.’ And instead of congratulating itself on havingeducated people to buy more low-fat spreads (consumption ofmargarine, as well as butter, has fallen), the Government should askitself why it should want the population to eat a slushy mixture ofhydrogenated fat and water instead of margarine high in

polyunsaturated fats.Despite the efforts of the dairy industry to persuade its customers

to drink calcium-supplemented milk average consumption ofcalcium has fallen substantially since 1980 (from 173 to 159% of therecommended daily amount).

UNSATISFACTORY CONDMONS IN SOUTHAFRICAN HOSPITAL

ON Sept 5, 1987, a letter signed by 101 doctors from the

Department of Medicine at Baragwanath Hospital was published inthe South African Medical _7our),ial. The letter mentioned grossovercrowding in the hospital, inadequate toilet facilities, and ashortage of medical and nursing staff to attend to an overwhelmingnumber of patients, many of whom had no beds. The subsequentcontroversy received much media attention. Doctors who had

signed the letter were refused appointment by the TransvaalProvincial Administration (TPA) to more senior posts and wererequired by the TPA to apologise. Several court actions followed.The medical faculty board and a mass meeting of the medical schoolsupported the Baragwanath doctors. The medical faculty proposedthat a committee of inquiry be appointed to investigate thedifficulties in the medical wards at Baragwanath Hospital. Thecommittee, under chairmanship of Prof D. J. du Plessis, a formervice-chancellor of Wits University, was asked to establish the effectof the problem in the medical wards at Baragwanath Hospital onundergraduate and postgraduate teaching and research and topropose short-term and long-term solutions.The committee identified the shortage of accommodation as the

primary and most urgent problem and recommended that thenumber of beds available to the department of medicine beincreased to ensure that the patients admitted to the medical wardsbe reasonably accommodated. The Committee proposed that newbuildings should be provided so that the medical admissions wardcould be enlarged and the overflow from the medical wards beabsorbed. Although the Transvaal Provincial Administration has aclear responsibility to provide adequate hospital facilities, it has said

1 Committee on Medical Aspects of Food Policy. Diet and cardiovascular diseaseReport on health and social subjects no 28. Department of Health and SocialSecurity London: HM Stationery Office, 1984.

2. Editorial. Calcium supplements: does the milkman know best? Lancet 1987, i: 370.

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repeatedly that it has insufficient funds to relieve the overcrowdingat Baragwanath Hospital. Moreover, it refuses to open the

Johannesburg Hospital, lying half empty, to patients of all races.Because the situation in the medical wards at Baragwanath

Hospital is so desperate, Professor du Plessis and the university areattempting to raise funds to build extensions to 13 existing wards, ata total cost of R3-9 million. This will accommodate 325 very ill

patients who are at present lying on the floor. The scheme has theenthusiastic support of the administrator of the Transvaal, theuniversity, the Baragwanath doctors, and Soweto communityleaders; and so far just under Rl million has been acquired, enablingbuilding to begin soon.Other recommendations of the Du Plessis Committee report

included alternative and improved accommodation for psychiatricpatients, a thorough review of the medical and nursingestablishments to ensure a reasonable staff:patient ratio, the

provision of additional hospital facilities in Soweto, and a long-termplan for the health services of Soweto. All these have been agreed toin substance by the administrator of the Transvaal and his staff. TheDu Plessis Committee’s recommendation that the JohannesburgHospital be opened to patients of all races has, however, beenrejected by the TPA.The medical faculty of Witswatersrand University, which

supports the recommendations of the Du Plessis Committee, pointsout that the basic problem remains the completely unacceptable andhugely wasteful system of apartheid in South African hospitals.

BITTERNESS AND BODY, STINKERS AND QUAKERS"THERE is no other known agent in man’s environment which

has been as frequently associated with such a variety of chronicdegenerative diseases". The disorders range from cardiovasculardiseases to cancers and birth defects. Not true, asserts the thirdvolume in a series, from which the quote is taken, on the

suspect—coffee.1 Caffeine, of course, is the most active constituent.Compounds such as furfurylmercaptan and kahweofuran givearoma, and pyridines, pyrroles, and furans give bitterness and body.Short-chain aliphatic esters and acids are the "stinkers" and

"quakers" that give a putrid smell to defective beans. Anothernatural constituent, trigonelline, is transformed on roasting intoseveral volatile substances and into nicotinic acid, which maycontribute, per cup, up to 15% of the recommended daily intake.Coffee is a negligible (less than 0-5%) dietary source of polycyclicaromatic hydrocarbons, including the skin carcinogenbenzo[a]pyrene, which can be formed if the beans are scorchedduring roasting. Pesticides and mycotoxins, including the

hepatocarcinogen aflatoxin Bl, should not find their way into thecup if manufacturing practices are good. This volume is

intriguingly entitled Physiology, as if the word pharmacology is sovalue-laden as to imply an adverse effect just by its mention. Oncethe smoke about the possible harmful effects of coffee has cleared,the authors in this book are sure about who has won the day: there isno firm evidence to link coffee consumption with increased

mortality in hypertensive patients, with kidney, bladder, or

pancreatic cancer, with fibrocystic breast disease, or with changes incholesterol metabolism. Nor does coffee pose a teratogenic ormutagenic threat to man; it is not mutagenic in in-vivo tests, and itsweak in-vitro mutagenicity is deactivated by mammalian

detoxifying enzyme systems. And in the best traditions of marketing(eight of the fifteen contributors and one of the editors are, or were,employed in the food industry, mostly a coffee company) attentionis shifted to the possible nutritional benefits of drinking coffee.Unfortunately this is mainly because we contaminate the brew withmilk and sugar, although the nicotinic acid content may be

important for those on a poor diet. Kahweol and cafestol palmitates,two of the lipids in coffee, inhibit tumour formation in rodentsexposed to carcinogens, but we drink too little coffee for this to be ofimportance. The real benefit is, of course, that coffee smells andtastes good.

1 Coffee. Volume 3: Physiology. Edited by R. J. Clarke and R. Macrae. London:Elsevier Applied Science. 1988. Pp 388. £52 00. ISBN 1-851661867.

HAVE AN HIV TEST TODAY

"HAVE you ever had any counselling, investigation or treatmentin connection with any sexually transmitted disease includingAIDS?" This question on insurance application forms-with itsimplication that the answer Yes will lead to endless difficulties withmortgages and the like-must have deterred many an individualwho had excellent reasons for wanting to know his or her HIVstatus. The Department of Health says that knowledge of HIVstatus is of no particular advantage to the individual, since there is noeffective treatment for HIV infection. Robert Pritchard, emeritusprofessor of genetics, Leicester University, argues (Guardian,March 20) that this notion is misguided because it ignores theinfluence of knowledge on behaviour. The existing health educationcampaign is likely to fail, he writes, because it aims to create fear of arisk (that of infection by unprotected intercourse) which is

perceived to be small. Better, he says, base your campaign onsomething that will be perceived as a near certainty-namely, that ifyou are HIV positive and engage in needle-sharing or unsafe sex,you will pass the infection on. Pritchard calls for open access to

anonymous HIV testing, coupled with a campaign (slogan, "Don’tinfect others; have a test today") directed at the two groups whopresent the greatest hazard-needle-sharing drug users andindividuals who participate in anal intercourse. What about theinsurance companies? His solution is that government should footthe bill for pay-outs on policies taken out when the subject wasHIV-negative, if the subsequent cause of death is AIDS. In view ofthe vast human, social, and economic costs of each new infection,this might not be a high price to pay for an effective strategy.

RACIAL EQUALITY IN HEALTH CARE

HOT on the heels of a National Association of Health Authorities

report that outlined a new strategy for improving health services forblack and ethnic minority groups (Jan 21, p 172) is a King’s Fundreport’ of the attempts of one London health authority to improveservices to its multiracial community and also to address equalopportunities in health care employment. Issues of race and qualityof service were tackled by Haringey Health Authority with the helpof an ethnic minorities development worker, whose remit was todevelop an equal opportunities policy; to provide education,training, and advice to health authority staff and to the community,to review services and their accessibility to Haringey’s black andethnic minority communities; to help managers develop policiesand implement change; and to begin the process of involvingminority groups in planning services. The project concentrated onservices for the mentally ill and for elderly patients. The report doesnot claim to analyse the role of such developmental workers inhealth services nor is it a blueprint for health authorities to follow;rather it is an example from which other health authorities can learnabout implementing change in a sensitive area.

SPEND MORE TO SAVE MORE

USE expensive drugs. The National Health Service (NHS)should save money. Two statements that seem to be mutuallyexclusive--not so, according to the latest briefing from the Office ofHealth Economics (OHE),2 founded by the Association of theBritish Pharmaceutical Industry. The appropriate use of modernand expensive medicines can save money, not only for the NHS butalso for the economy as a whole. Although medicines often do notreduce actual expenditure, they release resources that can be used inother ways in the health service and thuse save money overall. Forexample, use of carboplatin (205.71 per treatment cycle) instead ofthe cheaper drug, cisplatin (£17.90), for cancer treatment can, in thelong term, be less expensive: total costs for treatments are reducedfrom /J347.90 for cisplatin to £228.77 for carboplatin by allowingoutpatient therapy to replace costly inpatient treatment. The wider

1. Kalsi N, Constantinides P. Working towards racial equality in health care the

Haringey experience. London. King’s Fund Centre. 1989. Pp 46. ISBN0-903060078. Available from The King’s Fund Centre. 126 Albert Street, LondonNW1 7NF £5 including postage and packing.

2 Office of Health Economics Briefing No 25 The inpact of new medicines on healthcare costs. London: Office of Health Economics, March 1989

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implications of pharmaceutical progress are also acknowledged-ie,benefits to society, quality of life, and contributions to the economy.However, the OHE does recognise that many treatments do raiseoverall costs; for example, effective medicines for heart transplantand AIDS patients prolong the period of even more expensiveterminal care of patients.

University of London

The University’s Senate has decided that clinical teaching staff,after fulfilling their academic commitments in teaching andresearch and service commitments to the National Health Service,should be able (if they wish and their school agrees) to undertakeprivate practice in their own hospital or medical school for theequivalent of half a day each week. The income from privatepractice, after institutional overheads, would be shared equallybetween the institution and the clinical academic up to a maximum

personal entitlement of 10% of the individual’s total salary,including any merit award, after which all earnings would accrue tothe institution for research. This means that if a university seniorlecturer in medicine with an NHS honorary consultant contract,currently earning an average of £ 31 500, earns a further 6300 fromprivate practice, half of this would be retained by the medical school,college, or institute, and half would become the individual’s

personal taxable income. Above this level of earning all the proceedswould go to the institution. The move has been prompted by theincreasing disadvantage suffered by university clinical staff in

comparison with NHS staff.

Aleksandr Romanovich LuriyaThe distinguished Soviet psychologist and physician, Aleksandr

Luriya, who died in 1977, corresponded widely with friends andcolleagues outside the Soviet Union. His scientific autobiographycontains important gaps, and his daughter, now writing a furtherbiography, is eager to hear from anyone with personal recollectionsor correspondence with her father. Could anyone with access tomemoirs or other material please write direct to Dr YelenaAleksandrovna Luriya, Gemaleya Institute of Epidemiology andMicrobiology, u. Gamalei 18, Moscow 12098, USSR.

Medical Campaign Against Nuclear WeaponsSir Raymond Hoffenberg, past president of the Royal College of

Physicians, has agreed to become president of the campaign. Hesucceeds the late John Humphrey, who died in December, 1987.

Royal Free Hospital School of Medicine

Prof Arie Zuckerman, professor of microbiology in the

University of London and director of the World Health

Organisation collaborating centre for reference and research on viralhepatitis, London School of Hygiene and Tropical Medicine, hasbeen appointed dean with effect from Oct 1. He will succeed DrBruce MacGillivray, who is to retire.

Funding for Salmonella Research

The Government is to spend c million a year on new researchinto salmonella following the recommendations of the joint workingparty set up by the Ministry of Agriculture, Fisheries and Food, theDepartment of Health, and the British Egg Information Council.The research will address possible contamination of eggs and thepathogenicity of the salmonella organism, as well as the growth andsurvival of the pathogen in processed eggs and egg products.

International Planned Parenthood Federation

Dr Halfdan Mahler, former director-general of the World HealthOrganisation, has been appointed secretary-general of the

federation.

Henry Blair Essay Prize

The topic for this year’s essay prize of C250 is How We MayImprove the Care of Patients with Asthma. The competition is opento doctors and other health care professionals. Details are availablefrom the Director, Asthma Society, 300 Upper Street, London N1 I2XX.

World Health Day

The theme chosen for this year’s World Health Day, on April 7, isLet’s Talk Health. An information pack containing guidelines fordiscussions on important health issues with people of all ages can beobtained from the World Health Organisation, 1211 Geneva 27,Switzerland.

Sports Medicine

The Football Association has formed a partnership with theRoyal College of Surgeons of Edinburgh to do research in sportsmedicine. Their first joint venture will be their inaugural medicalconference at the Sports Council’s National Sports Centre at

Lilleshall, Shropshire, on April 29-30, at which the topics to becovered include knee injuries, spondylolisthesis, and stress lesions.In the pipeline is an investigation into the relation between injuriesand playing surfaces.

Three Microsurgical Workshops will be held at the MRC ClinicalResearch Centre, Harrow, Middlesex, on April 3-7, April 10-14, and April17-21: Dr C. J. Green, Section of Surgical Research, MRC Clinical ResearchCentre, Northwick Park Hospital, Harrow, Middlesex HAl 3UJ (01-8645311 ext 2511).

A course on Assessment in Medical Education is to take place at theCentre for Medical Education, Ninewells Hospital and Medical School,Dundee, on April 3-7: Mrs M. Hutton, Course Administrator, Level 8,Ninewells Hospital and Medical School, Dundee, Scotland DD1 9SY(0382-60111 ext 3090).

Mr C. M. Fergusson will give an Arris and Gale lecture entitled Geneticsof Osteoarthritis at the Royal College of Surgeons of England onWednesday, Apnl 5: Secretary, R. H. E. Duffett, Royal College of Surgeons,Lincoln’s Inn Fields, London WC2A 3PN (01-405 3474 ext 4004).

A conference on Monoclonal Antibodies and Immunoconjugates inCancer Treatment is to be held at the Royal Society of Medicine, London,on Apnl 6-7: Miss Barbara Komoniewska, Royal Society of Medicine, 1

Wimpole Street, London W1M 8AE ,01-408 2119).

2nd international symposium on Gynaecological Endoscopy is to takeplace in the John Radcliffe Hospital, Oxford, on April 7-9: SymposiumOrganiser, MetaPhor Conferences & Meetings, 21 Kirkless Close, Farsley,Pudsey, West Yorkshire LS28 5TF (0532-550752).

A meeting on Discharge from Hospital will be held in the Nene College,Northampton, on Tuesday, April 11: British Association for Service to theElderly, 119 Hassell Street, Newcastle, Staffs ST5 1AX (0782-661033).

A symposium on IND in Europe ... Fact or Fiction?-A FutureGlobal Research Strategy will take place at the Royal Society of Medicine,London, on Tuesday, April 11: Ms E. C. Richardson, Administrator, BntishAssociation of Pharmaceutical Physicians, 1 Wimpole Street, London WIM8AE (01-491 8610).

Annual session of the American College of Physicians is to be held inMoscone Center, San Francisco, California, USA, on April 13-16: AmericanCollege of Physicians, 4200 Pine Street, Philadelphia, PA 19104, USA(215-243 1200 ext 1229).

A joint conference on Housing and Health--Care in the Communityis to take place at the Robin Brook Centre, St Bartholomew’s Hospital, WestSmithfield, London, On Monday, April 17: Secretary, Royal Institute ofPublic Health and Hygiene, 28 Portland Place, London WIN 4 DE (01-5802731). ).

Correction

Aleningococcù! Aleuinguzs.-In paragraph four, line fourteen of thiseditorial (March 25, p 647) the designation of the meningococcus should haveread B:4:Pl.15 (not B:14).