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Notes and News

PHYSICIANS APPROVE MEDICAL AUDIT

VISITING teams from the Royal College of Physicians thatinspect and approve training posts for junior hospital doctors will infuture take account of audit practices within hospitals, andaccreditation of training programmes could be withdrawn orwithheld unless audit is found to be satisfactory. A College reportlconcludes that systematic evaluation of the quality and effectivenessof doctors’ work can now be regarded as an important professionalobligation: all hospitals should hold regular meetings to discuss themanagement of individual patients and methods of dealing withparticular medical problems.The College sees education as the most useful product of audit.

The evaluation of selected case records with a group of colleagueswho can point out deficiencies in records and practice and who canquestion the relevance and value of different procedures is moremeaningful, it suggests, than retrospective exposition of an

"interesting case". The report recommends two approaches toaudit--either discussion about a few cases (randomly selected orspecifically selected in rotation) or examination of a specific activityor process (such as outpatient waiting-times or the management ofmyocardial infarction).The report warns that analysis must be constructive and

supportive. The sensitivity of doctors to criticism, it suggests, canonly be overcome if it is understood that everyone is subject to thesame review procedure and that some mistakes are unavoidable.Economy, says the report, is another benefit of audit. "If

procedures that waste time and resources can be detected andprevented, patient care will be cheaper and better." Butconsideration of costs and the use of resources, the College suggests,must not be allowed to influence choices adversely where clearbenefit to patients can be demonstrated. After studying selectedtopics the College will draw up guidelines for clinical practice.

DRUG INDUSTRY RESPONSE TO WHITE-PAPER

THE Association of the British Pharmaceutical Industry (ABPI)has submitted to the House of Commons Social Services SelectCommittee evidence on the Government’s white-paper on theNational Health Service. The memorandum addresses two specificproposals in the white-paper Working for Patients-namely, theintroduction of drug budgets for all general practices by 1991, and offormularies for general practice and hospitals. The Secretary ofState for Health has stated that the objective of drug budgets is "toplace downward pressure on expenditure on drugs". The ABPIasks "How tightly will the overall ’lid’ be pressed down on themedicines bill?". The association is concerned that if unrealisticallytight restraints are imposed patients may be denied treatments andBritain’s pharmaceutical industry would be damaged. Woulddoctors be discouraged from screening for hypertension andhypercholesterolaemia, for example? Like other critics of the

white-paper, the ABPI wonders if a minority of GPs might bedisinclined to accept elderly and chronically sick patients because ofthe budgetary constraints. The ABPI’s concern over theestablishment of local formularies is that new drugs, offeringsignificant advances in treatment, might not be prescribed becauseof delays in having them admitted to local formularies. "It now takes12 years, on average, to get a new product through all the researchand development (R & D) stages and registration procedures-afurther delay while awaiting admission to various local formularieswould result in yet more attrition of effective patent protection. Thismight well be the straw that breaks the camel’s back in terms ofdisincentive to R & D investment in the UK". Taken together, theABPI claims, the two proposals are potentially damaging to thefuture of pharmaceutical research in the UK. "If the research based

1. Medical audit—a first report; what, why and how? London: Royal College ofPhysicians 1989 £3.

companies, British or foreign owned, sense that the politicalenvironment is hostile towards innovative works they may re-appraise any investment plans they may now have for the UK." TheABPI’s more definitive response to the white-paper will besubmitted to the Health Ministers before the end of May.

RADON CONCERN

HOUSEHOLDERS in Cornwall would be well advised to keep aneye on their barometers. South-west England is notorious for radonexposure, and when atmospheric pressure falls radon-222 finds iteasier to escape from rocks and soil and into homes. Introducing thelatest "British book of doses"1 last week, the director of the NationalRadiological Protection Board, Dr R. H. Clarke, noted that averageradiation exposure in the UK is now 2.5 mSv per year, comparedwith 2 1 mSv when last the NRPB reported. Most of the increase isdue to a reassessment of exposure to indoor radon gas. Thestatement that captured the headlines was the ascription to radon of6% of lung cancer deaths in the UK.z The NRPB, through itssecretary and chairman, Sir Richard Southwood, wants more to bedone about protection against radon, which currently contributesan average 47 % of all radiation exposure in the UK. Compared withthe 1988 UK average exposure of 2-5 mSv, the figure for the UnitedStates (1987) was somewhat higher at 3-6 mSv. The two factorscontributing most to the difference are radon (and thoron) at 0-7mSv and medical exposures, which are 77% higher m the UnitedStates.

GUIDE FOR IMMUNISATION PROGRAMMES

STAFF who manage vaccination programmes in developingcountries and who want to know more than the mechanics of settingup and running such projects will fmd EPI I Essentials3 useful. So willthose who want to lay their hands quickly on recommendedschedules, checklists, and eye-catching illustrated instructions forprocedures such as loading a syringe, giving an oral vaccine, orsterilising instruments. As the preface indicates, the book has triedto give answers to the perplexing whys of immunisation programmedevelopment-for instance, why does the WHO not recommend atwo-dose schedule for a measles vaccination programme (despitethe list of problems encountered in immunising children at 9months of age). Well-organised vaccination clinics are a worthwhileaim-but what about all those missed opportunities for vaccinatingchildren? The book offers food for thought here-eg, fathers shouldreceive information because they are the ones who often makedecisions in the family. The demographic changes that are

occurring cannot be ignored, so the book also touches on planningfor EPI in urban areas. And with modernisation comes

computerisation (of data), which also gets a mention.

AIDS IN THE UK AND WORLD WIDE

FIGURES released by the Department of Health show that therewere 2103 cases of AIDS in the UK up to the end of February, with1116 deaths-an increase of 54 and 27, respectively, over theJanuary figures. In view of the long interval between infection withHIV and the development of AIDS, the trends in AIDS cases anddeaths and their distribution between risk groups do not accuratelyreflect the current of spread of HIV infection.A 200 000 information and education campaign has been

introduced in Scotland to prevent the spread of AIDS and drugmisuse. Information about AIDS will be presented in full-pagenewspaper advertisements and in a free colour magazine for youngpeople; and for professionals there will be leaflets on various aspectsof AIDS and HIV infection and two reprinted booklets, Drugs and

1. Hughes JS, Shaw KB, O’Riordan MC Radiation exposure of the UK population_1988 review (NRPB-R227) London HM Stationery Office. 1989 Pp 96 ISBN0-859513122 £7

2. Clarke RH, Sourhwood TRE Risks from ionising radiation. Nature 1989, 338:197-98.

3. EPI essentials: a guide for program officers. 1988. Pp 169 Available throughResources for Child Health Project (REACH). Price dependent on volume oforders but may be as low as $8 00 plus postage and packing.