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Page 1: BUT IT SAYS HERE DOCTOR

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MOVE WITH CARE

To many people community care is synonymous with publicexpenditure cuts, the decline of the welfare state, and overhastyclosure of long-stay hospitals-a view generated by news reports ofpatients ill-prepared or unsuitable for independent living beingfound penniless and starving because they cannot manage to budgeton their social security allowances, or deliberately stopping theirmedication so that they can be readmitted to hospital for treatmentof a relapse and there enjoy the "comforts" of food and shelter.’That patients should find themselves in such unfortunatecircumstances is not inconceivable if community care is rushed intobefore the best means of doing so has been worked out, for such careis a complex business.

It was to explore ways of shifting patients from hospital tocommunity care that the government’s Community Care Initiativewas launched in April, 1983. The progress of the 28 projects startedunder this programme has been monitored by the Personal SocialServices Research Unit (PSSRU) at the University of Kent inCanterbury. The projects cover six broad groups of patients: adultswith learning difficulties (11 projects), children with learningdifficulties (1), people with mental illnesses (8), elderly people whoare physically frail (3), elderly mentally infirm people (4), andpeople with physical handicaps (1). By March, 1987,456 people hadmoved out of hospital, out of a planned 896, and the numbersexpected to move out in the later stages of the programme are likelyto accelerate.In Care in the Community: the First Steps2 members of the

PSSRU discuss the background to the policy of community care,outline the progress of the projects, point out the problemsencountered, and describe the financing and logistics of providingaccommodation and support services for those being moved out ofhospital. The authors warn of starting to offer community care onthe cheap by moving the least dependent people out first. Such astrategy could lead to a string of difficulties. Small hospitals wouldclose before large ones, the patients who remain would be the oneswho need skilled care, but brighter members of staff, reading thewriting on the wall, would leave the service, and the result could be alarge pool of the most needy people being looked after by the leasttalented staff in the worst institutions.The authors also warn that the philosophy of "normalisation"

should be applied flexibly-an extreme instance of inflexibilitywould be the acceptance of poor standards of living merely becausenormal people have to endure these conditions.The projects have been funded under the existing system of joint

health and local authority fmancing, and some of the pointsdiscussed may not be relevant if the Government relents and

accepts the Griffiths proposals.3 But no matter how much theresources allocated to community care, it should always be borne inmind that in introducing such care hospital closure should be asecondary feature, not the objective, of its development.

HYPERTROPHIC HORIZONTAL HEARTS

ELECTROCARDIOGRAPHIC (ECG) criteria for the diagnosis of leftventricular hypertrophy are widely used and, despite the advance ofechocardiography, the ECG remains more widely available. Over30 different sets of ECG criteria for the diagnosis of hypertrophyexist-and so their inadequacies are obvious; few, however, makeallowances for body build. A report from Glasgow4 compares foursets of ECG diagnostic criteria for hypertrophy (Sokolow-Lyon,Romhilt-Estes, Gubner-Ungerleider, and "R" wave height in leadaVI) with echocardiographic fmdings in 100 treated hypertensivepatients and 50 controls. All ECG criteria gave fair specificity(89-94%), but poor sensitivity (39-52%). However, sensitivity was

1. Pope N. Outpatients on the scrap heap. Guardian Nov 30, 1988; p 25.2. Care in the Community. The First Steps. By Judy Renshaw, Roger Hampson,

Corinne Thomason, Robin Darton, Ken Judge, and Martin Knapp. Aldershot:Gower, 1988. Pp 201. £23.50. ISBN 0-566057379.

3. Carvel J Lack of Government enthusiasm for Griffiths report on community care.Lancet 1988; i: 717-18.

4. McLenachan JM, Henderson E, Morris KI, Dargie HJ. Electrocardiographicdiagnosis of left ventricular hypertrophy: influence of body build. Clin Sci 1988; 75:589-92.

improved in non-obese subjects by use of criteria that relied on theuse of chest-lead voltages; in obese patients, better results wereobtained when limb-lead voltages were used. Obesity is associatedwith a raised diaphragm, which causes the heart to adopt a moretransverse position, as well as an expanded intravascular volumeand increased preload. The Scottish workers suggest thatstratification by body weight may further improve the sensitivity ofthe ECG in the detection of left ventricular hypertrophy.

BUT IT SAYS HERE DOCTOR...

DOCTORS and clerics are no longer perceived by the populace asfounts of all wisdom. Few doctors can have failed to observe how

many newspapers and magazines contain health-related items;some general practitioners will tell you that a large part of theirnon-emergency practice can be correlated with the appearance ofsuch pieces ("I’m sure I’ve got ME doctor; I was reading that..."),and others firmly believe that patients know far too much abouttheir pathophysiology. Although few patients are sufficientlyknowledgeable to challenge their doctor’s interpretation of anelectrocardiogram, most are most willing to ask pertinent questionsand less ready to accept trite answers and vague reassurance. Nowthe Consumer’s Association, with its launch of Which? Way toHealth,l a bimonthly successor to its quarterly Self Health, willprovide more fodder for health-conscious minds. The mix isfamiliar-abstracted papers from learned journals and detailedcoverage of certain popular topics (eg, hormone replacementtherapy, smoking, melanoma); the illustrations are glossy if

occasionally inappropriate (Down syndrome and gene therapy-surely not?). Readers are invited to find controversy within thecovers-and if they ask a psychiatrist to prescribe an antimicrobialfor a relative with schizophrenia ("psychiatrists currently favour aninfective cause" of the disorder) they are likely to fmd it.

Progress in Cervical CytologyA survey conducted by the National Association of Health

Authorities (NAHA) shows that all district health authorities

(DHAs) have started a call-and-recall screening programme forcervical cytology, and 94 % were able to have the system running bythe Government’s target date of April 1,1988. Over 90% of the 158DHAs would be calling all women between ages 20 and 64 yearswithin the next five years. 60% would be recalling women at5-yearly intervals and 40% at 3-yearly intervals. 100 DHAs

reported a backlog in their laboratories, and over half of thesereported a delay of getting results within 1 month back to the doctorwho took the smear. Call and Recall: Report of a survey of theimplementation of cervical cytology call and recall in England andWales is available from: National Association of Health Authorities,Garth House, 47 Edgbaston Park Road, Birmingham B15 2RS,price 3.50, including postage.

Supply of Donor OrgansFrom Jan 1, 1989, health authorities in England are to keep

records of the number of deaths in intensive care units and whether

any organs were used for transplantation. The records will showwhether relatives were asked to consider donation, and the reasonsin cases where there was no donation. The Government has askedhealth authorities to draw up written procedures for the guidance ofhospital staff on identifying potential donors, requesting donation,and arranging transplantation.

John Humphrey Memorial Trust

This Trust, in memory of the distinguished immunologist andworker for peace and human rights, who died a year ago, is intended,in the first place, to institute two annual invited lectures on subjectsrelated to his work, one to be given in London and the other at the

1. Which? Way to Health Available on subscription from the Subscription Department,Consumers Association, PO Box 44, Hertford SG14 1SH

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alternating biennial international and European Congresses ofInternational Physicians for the Prevention of Nuclear War.Further details may be had from Dr Martin Hartog, Department ofMedicine, Southmead Hospital, Bristol BS 10 5NB. Donations maybe sent to Dr Humphrey Hodgson, Department of Medicine, RoyalPostgraduate MedicaTTSchool, Hammersmith Hospital, LondonW12 OHS (from whom forms of covenant can be obtained).

Foulkes Foundation FellowshipsThe fellowships provide fmancial support for recently qualified

science graduates with research experience who want additionally totake a medical degree, or medical graduates wanting to take a lifescience degree. In both cases the graduate must intend to do medicalresearch after qualification. Application forms and furtherinformation can be obtained by sending a stamped, addressedenvelope to the Fellowship Registrar, Foulkes Foundation

Fellowship, 37 Ringwood Avenue, London N2 9NT. Completedforms must be returned by March 15.

Diploma in Sports Medicine

The Society of Apothecaries of London is to institute anexamination and award a diploma in sports medicine, which will beopen to registered medical practitioners who have worked in sportsmedicine or have had other definite experience and attended arecognised course of instruction. The first examination is to be heldin June, 1989. The regulations and syllabus for the examination maybe obtained from the Registrar, Society of Apothecaries, BlackfriarsLane, London EC4V 6EJ.

Oral and Dental Research Trust

This trust has been set up to increase public awareness of, and toraise funds for, research on diseases and disabilities affecting themouth and teeth, including oral cancer, the sixth most commonmalignancy in the world. The chairman of the trustees is SirGordon Wolstenholme, Harveian librarian, Royal College ofPhysicians. Further particulars may be obtained from the Director,Oral and Dental Research Trust, Keats’ House, St Thomas Street,London, SE1 9RN.

Coronary Heart Disease Video

Leicestershire Health Authority Health Education Video Unithas produced a 34-minute videotape on coronary heart disease. Thevideo, which is suitable for general audiences, deals with the biologyof the heart, prevention, and clinical aspects, and is obtainable from:Health Education Video Unit, Clinical Sciences Building, LeicesterRoyal Infirmary, PO Box 65, Leicester LE2 7LX (0533 550461),price Cll5 (VHS, Betamax) or [138 (U-matic).

UK-USSR Medical Exchange ProgrammeThe programme is organising a specialist tour on oncology,

radiology, and associated research topics to visit the institutes inLeningrad, Kiev, and Moscow, Sept 9-24,1989. Details from ProfJ. W. Boag, Flat 1, 40 Overton Road, Sutton, Surrey SM2 6QR.

St Bartholomew’s Hospital Medical CollegeProf Peter Armstrong, professor and vice-chairman, Depart-

ment of Radiology, University of Virginia Medical Center,Charlottesville, Virginia, USA, has been appointed to the newMercers’ chair in diagnostic radiology from June 1, 1989.

University of GlasgowProf James McEwen, professor of community medicine at King’s

College School of Medicine and Dentistry, London, has beenappointed to the Henry Mechan chair of public health, with effectfrom June 1, 1989.

The British Association for Service to the Elderly (BASE) isorganising a number of study days during February: BASE, 119 HassellStreet, Newcastle, Staffs, ST5 IAX (0782 661033).

Prof Andre Capron will give a paper on Immunity in Schistosomiasisat a meeting of the Royal Society of Tropical Medicine and Hygiene at 6 pmon Thursday, Jan 19, at Manson House, 26 Portland Place, London WIN4EY (01-580 2127).

Birmingham Consultants for Rescue of the NHS are to hold a debateon The Case for and against using Quality Adjusted Life Years for AllocatingResources at 6.30 pm on Thursday, Jan 19, at the Postgraduate MedicalCentre, Queen Elizabeth Hospital, Metchley Park Road, Edgbaston,Birmingham: Dr K. G. Taylor, Dudley Road Hospital, Birmingham(021-5543801).

The Neuropsychiatry of Movement Disorders is the title of thewinter meeting of the British Neuropsychiatry Association, to be held on Jan26 at the Wolfson Theatre, Institute of Psychiatry, De Crespigny Park,Denmark Hill, London SE5 8AF: Dr J. M. Bird, Secretary, BurdenNeurological Hospital, Stoke Lane, Stapleton, Bristol (0272 701212 ext2925).

A workshop entitled Grief Counselling will take place at St

Christopher’s Hospice, London, on Friday, Feb 3, and Friday, March 17:Mrs Sandra Munday, Wates Study Centre, St Christopher’s Hospice, 51-59Lawrie Park Road, Sydenham, London SE26 6DZ (01-778 9252).

A lecture on Simple Thoughts on Complex Genomes will be given byDr Sydney Brenner in the Clinical Lecture Theatre, Northwick Park, onThursday, Feb 9: Director’s Office, Clinical Research Centre, NorthwickPark, Watford Road, Harrow, Middlesex HA1 3UJ (01-864 5311 ext 2026).

A conference entitled Positive Smear-a Positive Approach is to beheld at Robin Brook Centre, St Bartholomew’s Hospital, London, on Friday,March 3: Monika Schwartz, Women and Medical Practice, 666 High Road,Tottenham, London N17 (01-885 2277).

A meeting on Drug Formularies-the Way Forward will be held atthe Royal Society of Medicine on Friday, March 17: Barbara Komoniewska,Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE (01-4082119 ext 301). ).

3rd meeting of the British Opioid Colloquium is to take place at theUniversity of Reading on March 21-23: Dr J. R. Traynor, Department ofChemistry, Loughborough University, Leicestershire LE11 3TU (0509-222584).

A meeting entitled Social Support and Pregnancy Outcome is to takeplace at the Royal Society of Medicine on Tuesday, April 25: BarbaraKomoniewska, Royal Society of Medicine, 1 Wimpole Street, London W 1M8AE (01-408 2119 ext 301).

47th annual congress of the British Institute of Radiology will takeplace at the Institute on May 4-6: BIR Conference Office, 36 Portland Place,London WIN 4AT (01-580 4085).

International Diary

World congress on Chronic Ronchopathy: Barcelona, Spain, May 22-24(Secretariat, Barcelona Relaciones Publicas, SA, Edificio Layetana, C PauClaris 138, 7°4, 08009 Barcelona).

International workshop forum on New Visions for Pregnancy, Birth andEarly Life for Practitioners: Amsterdam, The Netherlands, June 1-3 (DeKosmos, Prins Hendrikkade 142, 1011 AT Amsterdam).

1 st annual meeting of the International Society for Applied CardiovascularBiology: Gothenburg, Sweden, June 5-7 (Secretariat, First Congress of TheInternational Society for Applied Cardiovascular Biology, CongressGoteborg, PO Box 5222, S-402 24 Gothenburg).

3rd international symposium on Coronary Arteriography: Rotterdam,Netherlands, June 18-20 (Office for Post Graduate Medical Education,Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam).

International conference on Emergency Health Care Development:Washington DC, USA, Aug 15-18 (EHC Conference, Medical CareDevelopment International, 1742 R St NW, Washington, DC 20009).