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Conference

"Effectiveness" research and health gain

On Nov 18, 1991, the NHS Management Executiveorganised a meeting on Bridging the Gap BetweenEffectiveness Research and Contracting for Health Gain.This was at the Royal Society of Medicine, in London, incollaboration with the California based Institute for MedicalRisks Studies (IMRS). The aim was to explore whetherpaying for the measurement of health care efficacy andoutcomes would itself be cost effective and improve thequality of health care systems which used it. The 75 or soparticipants did not include any patients’ representatives orclinicians, who presumably were not invited. The messageof the platform speakers was aimed at the purchasers andproviders of new NHS "internal market". The meeting waschaired by Dr Geoffrey Rivett (deputy head of the NHSManagement Executive), who, with Dr Orley Lindgrenfrom the IMRS, set out the aims of the seminar.

It is curious that while concern mounts in the USA over failuresof health care delivery the UK’s Department of Health nonethelessfeels there were important management lessons to be learned fromAmerica. The IMRS is keen to offer the reformed NHS (andperhaps private medical services) the benefits of its research andideas. Should there be a joint enterprise between the UK and USsystems, sharing research and experience? And would that improveoutcome for patients using the NHS?

Baroness Hooper, a health minister in the House of Lords, saidthat the Government wanted to ensure the delivery of care wasbased on good research which would enable purchasers andproviders to get their priorities correct and achieve value for money.NHS decision making at all levels had exposed to critical analysis.Dr Robert Brook (professor of medicine and public health at UCLAand director of the health programme at the Rand Corporation)extolled the benefits to be had from shared research. He detected a

"cognitive dissonance"which should be a concern for everyone, andespecially for the purchasers and providers of health care. Ideally ahealth care system should provide all necessary care for everybody;he defined "necessary" in clinical terms as: care that was

appropriate and offered benefit; that, if not provided, would renderthe doctor liable; and that, if not offered, would upset clinicians,who might even go "on strike". There were suggestions that anational system which aimed to cover everyone might not be able toprovide all the care that all its citizens migh want so that only themost "necessary" care might be included, "top-up" beingpurchased by the patient. This is already happening to a smallextent in the UK. Dr Brook said that doctors needed better skills in

epidemiology so that they could evaluate what was on offer and howservices were being applied. To illustrate "necessary care", he gavethree examples: a cervical smear once every three years; bypasssurgery for left main coronary artery disease; and bone marrowtransplantation for aplastic anaemia.Having drawn attention to benefits of shared research projects,

Brook warned that more information did not always lead to changesin practice. Doctors need incentives, he sad, financial or otherwise.It was a sad fact, he noted, that most US doctors do not want to readjournals: what they wanted was no more than two sentences tellingthem what best to do in a given clinical situation, generally withoutreasons being offered. The doctor of the future would have acomputer carrying not only data on patients but also a program tohelp him make good clinical decisions. Patients needed to beeducated not to mistrust a doctor who looked things up in a book oron a computer. Why, Brook wondered, did people who werecontent, indeed relieved, to see their lawyer or accountant refer tolearned tomes and computers lose confidence if their doctor seemednot to have an instant solution.Dr Alex Gatherer, who has recently founded the Oxford Centre

for Medical Risk Studies (in association with IMRS) and is directorof public health for the Oxford Health Authority, summed up the

message of the day’s meeting. There was a gap between the amountof information available and the supply of treatment provided;purchasers and providers should be aware of country-wideunevenness in the use of services which were available; and therewas a need for audit. The obstacles were provider dominance andpurchaser weakness, lack of research funding, short-term thinkingon priorities, political pressures, and the pragmatism of managers.Also mitigating against the achievement of the goals that everyonewanted was the fluctuating balance between science and the politicalwill to utilise science. There already was a lot of information; itneeded to be extracted, and for that investment was required.

After Dr Gatherer’s address questioners expressedconcern about undue emphasis on marketing criteria, whichwere very difficult to apply to services such as psychiatricand geriatric provision and to general practitioner services.Baroness Hooper agreed that it would be wrong to

overstress the analogy between the marketplace and all typesof health care. It was also important to have preventivemeasures and health education; and she accepted that mostdoctors would not change without incentives. She pointedout that NHS trust hospitals were free to respondindividually to the needs of those seeking services and toreward staff appropriately. She agreed that what patientsoften needed most was the doctor’s time. It was thus ironicalwhen Dr Brook spoke of reducing the time spent with apatient from 1 hour to 30 minutes or from 30 minutes to 15minutes. An NHS patient will be fortunate if he or she getsmore than 10, and then only after a long wait.Any commercial supplier who fails to take account of the

views of consumers will not stay long in business, if there arealternatives available. To exclude patients and cliniciansfrom seminars such as this is a grave mistake. Patient andclinician satisfaction must be monitored, as well as efficacy.

Keenly debated during informal discussion was claimshandling. The US group made it clear that if they were tobecome involved in the UK they would wish not only toimprove clinical management but also to contain legal claimsafter the event. They would hope to avoid expensive andbitter litigation but they would defend claims vigorously ifneed be. The Californian experience of acting as quasiassessors and loss adjusters and advisers to insurers andlawyers will stand them in good stead provided they adjustto the differences in the English/Scottish and US systems.Wisely, they wish to take account of plaintiff lawyers’experience besides that of those who usually act fordefendants.

Diana Brahams

Noticeboard

Alzheimer and aluminium conundrum

Aluminium is a neurotoxin that can impair cognition, and itinterferes with more than sixty neurochemical reactions, several ofwhich are altered in Alzheimer’s disease, but whether or not it playsa part in the pathogenesis of the disorder is still far from clear. Asindicated at a press conference held at the end of a Ciba Foundation

symposium on aluminium in biology and medicine, there are widelydiffering interpretations of existing data-ranging from theconclusion that they are strong enough to justify public healthaction to reduce exposure to aluminium, to their being too weak toindicate any influence of aluminium on the pathogenesis ofAlzheimer’s disease.The point that nearly all the epidemiological studies on

aluminium in drinking water and prevalence of Alzheimer’s diseasehave shown a correlation is cited as favouring the possibility of alink, even though the relation is weak (1-5-4 times excess risk

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associated with high concentrations of aluminium) and each of thestudies has deficiencies (in the accuracy of identification of patientswith Alzheimer’s dementia, for example). Other difficulties with theepidemiological evidence are that only a small proportion of dietaryaluminium comes from drinking water and that the content of silicicacid, an ubiquitous environmental compound that strongly affectsbioavailability of aluminium, was not measured in the

epidemiological studies.Those supporting a pathogenetic role for aluminium place weight

on reports that sensitive assay methods reveal increasedconcentrations of aluminium in Alzheimer brains. Others point toconflicting evidence or prefer to hold judgment until assay

equipment and techniques have been standardised. Another view isthat differences in aluminium distribution in the brain do not helpin distinguishing cause from effect. A trial in which desferrioxamineslowed the rate of progression of dementia in patients withAlzheimer’s disease is also cited as evidence of a possible link, butaluminium is not the only element chelated by the drug.The clinical difference between dialysis dementia associated with

exposure to aluminium and Alzheimer’s dementia and the absenceof neurofibrillary tangles in patients who have undergone dialysisfor 15-16 years are said to be points against a pathogenetic linkbetween the metal and Alzheimer’s disease. So is the absence of

signs of aluminium overload such as microcytic anaemia andosteodystrophy in Alzheimer patients. The metabolic changes thatoccur in renal failure, though, are said to make the two conditionsnot strictly comparable.

It will probably be some time yet before substantial agreement isreached on the worrying possibility that aluminium is an avoidableenvironmental risk factor for the development of Alzheimer’sdisease. And who is to say that silicon rather than aluminium mightnot turn out to be the element that prophylactic measures should befocused on?

The smoking epidemicA packet of cigarettes in the UK will cost 3 by 1995 if

the Government follows a Health Education Authorityrecommendation, published this week in its report, The SmokingEpidemic-Counting the Cost.1 Increasing the price of cigarettesabove inflation would be the single most effective way to reducesmoking, said the HEA’s chairman, Sir Donald Maitland,introducing the report. The HEA also calls for greater restrictionson tobacco advertising and promotion but not, curiously, theoutright ban recommended in its response to the Government’sdiscussion document, The Health of the Nation.The 14-volume report, a detailed statistical survey of the impact

of smoking on the health of the British people district by district,shows that smoking-related diseases are causing 111 000 deathseach year in the UK-or 1 in every 6 deaths. 285 000 people areadmitted to hospital because of smoking-related diseases (andoccupy an average of 9500 beds each day): treating them costs theNational Health Service 437 million a year. The report estimatesthe total cost of smoking (including money paid out in sicknessbenefit and the cost to industry of 21 million working days lostthrough diseases such as bronchitis and emphysema) to be close tothe c6 billion tax revenue generated by the sale of tobacco products.

In the UK smoking kills 20 times more people than road trafficaccidents, 25 times more than suicide, and 40 times more thaninfectious diseases. World wide, smoking-related deaths will reach10 million a year by the end of the 2020s, if present trends continue.The Smoking Epidemic, an updated and expanded sequel to The

Big Kill, published in 1985 by the HEA’s predecessor, the HealthEducation Council, includes data on three new categories ofsmoking-related disease. The report notes that 80-90% of all lungcancer deaths are attributable to smoking.The proportion of adults who smoke has fallen slowly over the

past 20 years, but the proportion of 19-year-old smokers hasremained static at 30%. If today’s 19-year-olds continue to smokeinto their 20s and later the number of adult smokers may cease tofall.

The Big Kill introduced the memorable and much-quoted

phrase, "Smoking is the largest single cause of preventable,premature death". The figures reported in The Smoking Epidemicshow that little has changed in the past six years. Smoking,concludes the report, "continues to be an epidemic of massiveproportions".

1. The Smoking Epidemic-counting the cost London: Health Education Authority, 1991

The world pauses...

AIDS is both a public health crisis and a personal tragedy. Thisyear, World AIDS Day (Dec 1) focuses on the difficulties andchallenges that face entire communities. While treatments are beingrefined and vaccines are undergoing phase I trials, how will societyeducate succeeding generations about AIDS and embrace thosewho already have HIV disease?There is now an urgent need to dissipate the stigma and

discrimination that attaches to those with HIV infection and thosewhose lifestyles might predispose them to such infection. In a boldmove that attempts to break some of these taboos, AmnestyInternational has recently altered its policy on gay prisoners ofconscience: it will now investigate people who are imprisoned forhomosexual acts between consenting adults in private. Thesehuman-rights issues are now at the centre of world debate.The World Health Organisation’s European programme on

AIDS will concentrate on central and eastern Europe, where HIVinfection began to spread only recently. Emphasis will be placed onthe positive effects of AIDS: improved training of health-careworkers, improved hospital hygiene, and greater priority on healtheducation. The central message of World AIDS Day, however, isthat each individual has a responsibility to stop the spread of HIV.

Renal service needs

The UK Government, in its Patient’s Charter, reaffirmed itscommitment that the National Health Service will providetreatment for any patient who needs it. In that case, as pointed out atthe launch of a report! on renal services in the UK, it should beprepared to provide sufficient facilities for renal replacementtherapy for patients with end-stage renal failure (ESRF). Thereport, drawn up by a Renal Association subcommittee on behalf ofthe Association and the Royal College of Physicians of London,puts the number of adults likely to benefit from renal replacementtherapy at 80 new patients per million population (services forchildren will be covered in a report by the British Association forPaediatric Nephrology). The current intake of new patients is 60 permillion for the UK but there is a regional variation of 30 to 80. As thecriteria for eligibility for therapy widens, the prediction is that, ofthe various forms of dialysis, the greatest increase in demand will befor hospital-based dialysis. The setting up of satellite units is seen asthe most feasible way of meeting numerical and geographicaldemand. Such units are staffed by nurses with access to off-sitemedical cover and they cater for the lower risk patients but ought tobe flexible enough for staffing and other arrangements to adapt topatient needs.To cope with a new acceptance rate of 80 per million for renal

replacement therapy and other nephrology consultations thenumber of consultants will have to increase from the presentnumber of 65 whole-time equivalents to 150. Cost of treatment is tobe examined by a separate working group. What planners will haveto take into account is that as intake increases, so will the stock ofpatients on renal replacement therapy. The present stock of 330 permillion is likely to double when acceptance of new patients reach 80per million.The Government has promised the Department of Health an

extra C 1 -3 billion for next year. How much of this can those wholook after renal patients persuade, perhaps with the help of thisreport, NHS managers to allocate to renal services?

1. Renal Association. Provision of services for adult patients with renal disease in the

United Kingdom. 1991. Pp 29. Available from Renal Association, c/o Pear TreeCottage, Dalton, Borton-in-Kendal, Camforth LA6 1NN. £3 00 includingpostage and packing