NEWS

Here come the helicopters

Transferring a seriously ill patient from Berwick on Tweed to Newcastle by road may take up to an hour and a half. By helicopter it takes 12 minutes. Impressed by the dif- ference, the Northumbria Ambulance Service is about to acquire an Aerospatiale Twin Squirrel helicopter for a three month trial, which takes to four the number of dedicated air ambulances operating in Britain. That figure could double within a year. First off the mark in April 1987 was the Cornwall and Scilly Isles Ambulance Service with an MMB Bolkow 105 helicopter, which has now completed 1600 missions. The London Hospital was next, taking delivery of an Aerospatiale Dauphin last December and transporting its first patient six months "Taking the high road" has a new meaningfor those taken seriously ill in out ofthe way parts ofScotland ago. Also completing its first six months in operation is another MMB Bolkow 105, which is based in Dundee and attached to the Scottish Ambulance Service. Peter Bond, of Bond Helicopters, holds early stage there are competing claims by About all the four ambulances have in up West Germany as the best international rival helicopter operators about the right common is their funding, which is charitable model. Carefully monitored since its incep- helicopter for the task (three different heli- and helped out to varying extents by the tion in 1970, the German network now copters have been used in four different helicopter company concerned. Northum- provides a helicopter rescue service for the operations) and fierce arguments over bria's experiment will cost £42 000 a month whole country with about 40 helicopters whetherhelicopters should be fullyintegrated to provide cover 24 hours a day, seven days based at large hospitals throughout Germany. into existing ambulance services or could a week-McAlpine, Aerospatiale's distri- Thenetworkisrunjointly bythegovernment, be run successfully as more free standing butors, will be putting up more than half of the military, a private rescue organisation, operations. With a single helicopter costing that in what McAlpine's Roger Palmer freely and ADAC (the German equivalent of the some hundreds ofthousands ofpounds a year admits is "a risk venture." Bond Helicopters Automobile Association), and most accidents to run there are good reasons for getting the helped out Cornwall's scheme in its early can be reached in less than 15 minutes. answer right first time. -TONY DELAMOTHE days (although the public now fully funds it) Here all but The London Hospital's and made up the shortfall in British Telecom's helicopter are part of the ambulance service funding of Scotland's scheme. United and carry ambulance officers who have Newspapers, the publisher of the Daily received "extended training" (in drug ad- Express, is picking up the tab for The ministration, cannulation, defibrillation, London's helicopter: a fairly common ar- and intubation). The London Hospital's Words and money rangement between media interests and helicopter differs in carrying, in addition, a emergency services in other countries. specially trained surgical registrar and is for the NHS So far no clear criteria have been agreed for independent of the London Ambulance evaluating emergency helicopter services Service, although the service provides the Whenever the government is challenged other than comparing transit times and final common pathway for all its calls. about the amount Britain spends on the NHS "therapy free intervals" with those of other Last year the Royal College of Surgeons' it asserts that substantial increases in revenue means of transport. Enthusiasts bolster the working party on the managemnent ofpatients -£900m a year by 1988-9-have come from case for their wider use in Britain by pointing with major injuries reported that it was yet to "cost improvements." to the presence of emergency helicopter be convinced of the value of helicopters in What exactly are cost improvements? And services in virtually every other comparable primary evacuation. They are cramped and have they generated real extra money for the country. noisy, making it essential that patients are NHS? These questions have been examined Experiences elsewhere, however, have not well stabilised: initiating complex treatment in a study set up by the Institute of Health all been good. In the early 1970s in the on board was difficult, it said. In addition, Services Management, the King's Fund United States free market conditions pre- helicopters are expensive to run, may not be Institute, and the National Association of vailed: helicopter operators tuned in to usable in bad weather or at night, and are Health Authorities, and its report, Efficiency emergency frequencies and raced to acci- themselves more prone to mishap than in the NHS, was published last week by the dents, with insurance companies rewarding other forms of ambulance transport. If King's Fund Institute. only the winner. Pilots flew a range of a centralised trauma centre was to be estab- The concept and the term "cost improve- helicopters of varying suitability for the lished, however, then "the use of helicopters ment programme" first appeared in the purpose, sometimes in dangerous conditions. should be explored." Griffiths report on general management in Regulations have since meant an end to the Exploration has clearly begun, without the 1983. It was later defined by the Department free for all. corresponding trauma centres. Even at this of Health and Social Security as "measures

BMJ VOLUME 299 9 SEPTEMBER 1989 639 which are aimed at releasing cash or man- patients moved into voluntary homes jointly the figures quoted do not reflect genuine power used in providing a service by getting funded by a housing association, a voluntary additional sources of finance, this must the same service output for a smaller input agency, government benefits, and a grant provide part of the explanation for the severe of resource; or improving productivity by from the district health authority. Ward funding problems faced by many health getting a higher output for the same input (or closures in the acute unit took place at authorities in recent years."-TONY SMITH for a less than proportionate increase in Christmas and Easter and in the summer. In input)." Examples offered were savings 1988-9 a medical ward was closed completely, from competitive tendering and cheaper saving another £193 000. purchasing. Crucial to the concept was the The report analysed the cost improvement maintenance of the level of service; thus a programmes in the three districts and its Mlianserin reaches "rationalisation" that cut costs but also conclusions identified three causes for Court of Appeal reduced the service to patients could not be concern. described as a cost improvement programme. Firstly, the valuation of such programmes The continuing legal battle between the A review of the operation of cost improve- was often a matter of opinion and judgment. Department ofHealth and the manufacturers ment programmes was published by the This was especially true for savings that came of the antidepressant mianserin reaches the National Audit Office in 1986. This drew from rationalisation programmes. The study Court of Appeal on 10 September. The attention to the practice in some districts of group thought that measurement of the value department is appealing against a High Court simply setting lower budgets and expecting of the programmes was so imprecise that ruling last February that quashed its decision managers to keep to them. "In such cases," it seemed most unlikely that cumulative to vary the product licence of the drug to said the Audit Office, "it was not always clear savings could be cited with the certainty that restrict its use in patients aged over 65. whether savings had been made without appeared in official statements. The case, the first court challenge to the corresponding reductions in the standards of Secondly, the group was worried about so statutory procedures for regulating drug health care provided." called recurrent savings. Although cost safety, made headlines when the manu- improvement programmes usually applied to facturers, Organon Laboratories, won an Savings and their consequences more than one year, they rarely went on for injunction blocking a warning in Current ever-yet districts found the saving did Problems about hazards of the drug for the Three years later the joint study found become incorporated into the budget for over 65s, pending the court hearing. The that this practice was still going on. Little ever. department is appealing against the High attention was being paid, says the report, to Thirdly, the group was concerned that Court's decision that the Medicines Commis- the service implications ofbudget reductions. questionable savings were not being chal- sion was wrong to exclude the comparative For example, ward closures during holidays lenged by the auditing process. The Depart- safety in overdose of the drug as a factor in were in part rationalisation, but they also ment of Health told the social services deciding to vary the licences. diminished the service offered to the com- committee that all proposals and financial Mianserin, a non-tricyclic antidepressant munity. results were "thoroughly audited by the marketed by Organon as Bolvicon and by The study group based its report on a management board" and were also subject to Beecham under licence as Norval, featured detailed examination of three NHS districts. audit by the statutory auditors. In practice, in a notice in Current Problems in 1985 The table shows the savings made in 1987-8 says the report, the monitoring of savings about haematological reactions notified in one of these, a large mixed rural and urban from cost improvement programmes is seen to the committee through the yellow card district covering one main town and several as a regional responsibility and is carried system. By July 1985, 113 reactions (mainly small ones. It is in a region gaining under out through bilateral discussions between leucopenia and agranulocytosis) had been the Resource Allocation Working Party's members of the management board and reported, 12 ofwhich were fatal; by February proposals (RAWP), but its own budget is their counterparts in the regional health this year the figures were 137 reactions, 18 of more or less neutral in terms of RAWP. authorities. The study group was not con- which were fatal. Over half the savings came from four vinced that questionable items were neces- The department prop'osed to vary the schemes. In the mental health unit a gradual sarily withdrawn. licences and data sheets to limit the use of the reduction in workload was achieved by Accountants nowadays talk about the drug in the over 65s to patients who failed to transferring the care of patients to the com- bottom line. The bottom line of the study respond to other antidepressants and those munity services. Ward closures occurred as group's report appears in its press release: "If with glaucoma or symptoms of prostatic hypertrophy. A new notice to this effect was to appear in Current Problems. But after the Savings (£000) from cost improvement programmes in one district, 1987-8 High Court ruling the department agreed Acute unit Local hospital closure 155 with Organon to omit the warning about the Holiday ward closures 20 Child health review 9 over 65s from the bulletin. Only the figures Ward budgeting 11 Office rationalisation 6 for haematological reactions appeared. Medical records rationalisation 13 The department is concerned that if the Maintenance weekend cover 10 Mental health unit decision is not reversed on appeal it could be Review ofplanned regular maintenance 5 Local hospital obliged to consider evidence of safety in Reduction of x ray cover to * Night nursing; introduction of neighbourhood 4 unified management 28 overdose for hundreds of drugs. It argues Local hospital * Portering 17 that the wording of the Medicines Act places * Works 5 * Administration 23 a duty on the Medicines Commission to * Plaster orderly 2 * Catering 40 advise the department whether a drug can Non-pay savings (budget increases * Energy savings 199 safely be administered "for the purposes reduced by 1%) 97 * Ward closure; staffing cost indicated in the licence," and that suicide is Pharmacy post 9 reductions during year 123 not an indicated purpose. Reduction of"on call" pathology 17 Reduced reliance on out of district An even stronger point in its favour, the Moratorium on vacancies 59 facilities 130 department believes, is a directive from the Fuel savings 19 Competitive tendering-domestic Regional services contract 32 European Commission, which states that 13 a product licence may be suspended or Community units District offices revoked (which, the department argues, by Nursing structure: staffreduction 7 Competitive tendering 73 implication also includes varied) only if the Unit management: staffreduction 13 Regional services 4 product proves to be harmful "in normal Hospital telephone exchange: staff Total 1188 conditioinis of use." reduction 20 The case might well be referred to the Furniture budget reduction 5 Taken with permission from Efficiency in the NHS, London, European Court of Justice in Luxembourg Fuel savings 19 King's Fund Institute, 1989. for a ruling on this point. -CLARE DYER

640 BMJ VOLUME 299 9 SEPTEMBER 1989 be deported to face renewed persecution, cants for asylum last year did get this) we Tackling torture torture, and probable death. When we finally celebrate," said one worker, reflecting the win their trust and get them to relate their tangible concern and commitment of an "We'll grab a seat in the office, there's no experiences they often break down. organisation that makes this corner ofyester- room anywhere else, it's Kurdish day," "In the examination we look out for day's NHS a second home to so many oftheir explained the press officer as we squeezed scarring and any other signs that corroborate clients. The pressure of acting as a lifeline to along the corridor past 20 Turkish Kurds. a history of torture-for example, of falakar, an increasing number of such outstandingly The hubbub seemed all the more prominent repeated beating on the feet, or hanging, disadvantaged people (the numbers seen for being confined to a corner of the now especially bythe so calledPalestinian method. have doubled each year) is telling. The deserted National Temperance Hospital, This can cause cervical and lumbosacral disc foundation is in need of more support and is where the Medical Foundation for the Care lesions and damage to the shoulder joint. especially keen to recruit more doctors; there of Victims of Torture is based. Launched in Hearing loss and dental abnormalities after can scarcely be more harrowing-or re- 1986, the foundation, a registered charity, repeated blows to the head are common." warding-work on offer. -TESSA RICHARDS grew out of the medical group of Amnesty The psychological effects of torture are Medical Foundation for the Care of Victims of International, whose members recognised invariably the most debilitating. "All our Torture. National Temperance Hospital, 110 Hamp- the need for a centre to help people who had patients are suffering from depression or stead Road, London NW1 2LT. (01 388 8204.) been tortured. The thrust of this help was, post-traumatic stress disorder," said Dr firstly, to verify and document the extent of Caroline Umsworth, a psychiatrist who is their injuries and, secondly, to provide shortly to work full time for the foundation. medical and psychiatric care, social support, "Those who suffer most are the ones who and long term rehabilitation. have been subjected to repeated mock execu- "The trouble is," said Helen Bamber, tions or have been forced to watch others, Party time again director of the foundation, "we've been often family and friends, being tortured and The party conference season begins today swamped [the foundation has only nine full killed. You can never get over such experi- with debates on the NHS high on every time staff and 50 part time volunteers] and ences. All we can do is take the edge off their agenda. Attendant policy documents have our original aim ofconcentrating on rehabili- depression, occasionally with antidepres- already appeared: Prescription for Health tation has been overtaken by the issue sants, more commonly with psychotherapy, from the Social and Liberal Democrats and of asylum. This has become particularly and help them to understand what has Self-GoverningDistrict Health Trusts from the pressing since the arrival in Britain of 3700 happened and work towards accepting Social Democratic Party. Turkish Kurds in May. It's as much as we it. The very process of unburdening their The two papers illustrate how far the can do to keep abreast of the streams of experiences, having them documented, and former Alliance partners have drifted apart requests to see these people, and we are above all being believed is therapeutic in since the 1987 general election. Then the seeing people from some 20 or so other itself." Alliance manifesto was notable, not to say countries too. Our work centres on inter- The foundation's attempts at providing prescient, in endorsing the concept of an viewing them and preparing reports here or, long term psychotherapeutic care are be- NHS internal market in which health increasingly, in prison or detention centres." devilled by the fact that on average an authorities buy and sell treatment to each Just how influential these detailed reports are application for asylum takes 13 months to be other. the foundation is not prepared to say, but it processed. During this time the applicant is Today, in Prescription for Health the SLD is evident that the Home Office attaches living under constant dread of deportation. wants nothing to do with an internal market considerable weight to an independent verifi- "This does not enhance their physical and in any form. Dr David Owen's SDP, how- cation of a claim of persecution and torture. psychological wellbeing," said Helen ever, is if anything more enthusiastic than "Preparing reports is not easy," said Dr Bamber with irony. "We do what we can, ever and suggests it as a way for the govern- Tom Landau, who works part time (and but often this amounts to concentrating on ment to get offits selfimpaled hook. unpaid) for the foundation. "A full history is providing housing, food, clothes-and The SDP proposes the creation of a net- essential, and this is difficult to obtain when companionship." Even when a decision on work of self managed district health trusts to you have to use an interpreter or if you are asylum has been made people may not be that provide hospital, community health, and seeing someone in prison or in a detention much better off for the majority get only general practitioner services. The trusts centre. There you are in a threatening en- exceptional leave to remain for a year, renew- would have the same funding and flexibility vironment in the presence of uniformed men able annually at the discretion of the Home- as the government is currently proposing for and these people have a deep fear and distrust Office. In effect this merely perpetuates the NHS self governing hospital trusts. They of authority. They are also demoralised, uncertainty. would be free to purchase services from depressed, and desperate. They know that if "When one of our clients gets refugee other districts, raise their own revenue, and their application for asylum fails they will status (and only a quarter of the 5015 appli- negotiate staff pay. About a dozen district -7.. F.c...... --.. health authorities have already applied to be self governing, but the SDP accuses the government of trying to block them out of deference to the regions, which the SDP would abolish. The SLD, by contrast, would keep the existingNHS structure intact and guarantee it a sustained increase in funds of 2% above inflation every year. Patients would have a right to hospital treatment within a specified time. There would be more general prac- titioners so that list sizes could be reduced. Alternative medicine would be encouraged. SLD support for theiphased abolition of all NHS charges reverses the 1987 Alliance policy of imcreasing them in line with in- flation. The Labour party, meanwhile, presses on with its summer campaign to discredit the government?s reforms. Mr Robin Cook's Helen Bamber, director, Medical Foundation for the Care of Victims of Torture, interviewing a client contribution a fortnight ago was a survey of Helen Bamber, director, Medical Foundationfor the Care ofVictims ofTorture, interviewving a client what patients' organisations-from the

BMJ VOLUME 299 9 SEPTEMBER 1989 641 Asthma Society to the Spastics Society- are the ones out of whom you cannot turn a fears of a move towards commercialised think ofthe white paper Workingfor Patients. profit. They are the patients who will be medicine. What was most in the minds of By nearly 40 to one they came down against pushed aside in the brave new competitive management was how they could make both self governing hospitals and indicative NHS. Epilepsy is not a cost effective condi- money for the hospitals. drug budgets. tion." Labour is steadily chipping away at the Public service is being replaced by sales- Astutely ignoring the point that many government's parliamentary base, and Mr manship, he said. Some hospitals saw ad- interest groups are born out ofdissatisfaction Cook claimed that patients' associations are vantages in expanding private practice, while with their present treatment, Mr Cook more united in opposing the white paper than Yorkshire region had instructed managers to challenged the Secretary of State for Health Tory backbenchers are united in supporting consider "marketing aggression." to find a matching number of patient associa- it. Mr Cook detected a profound change in tions who support the white paper changes Labour has also surveyed 95 of the 178 the ethos of the health service-a move away and added pointedly: "Kenneth Clarke hospitals or other units which in June ex- from meeting medical need and towards cannot shake off this survey by accusing pressed interest in self governing status. Mr market strategy and competitiveness. -JOHN patients of reaching for their wallets. They Cook said the replies confirmed his worst WARDEN New imaging techniques Two new imaging techniques were re- ported at the Royal Society recently. The Medical Research Council's Cyclotron Unit at Hammersmith Hospital showed images (some three dimensional) of the heart and brain obtained by positron emission tomography. This technique, unlike computed tomography or mag- netic resonance imaging, provides information on function. The figure (right) shows a series of positron emission tomograms of the uptake of radioactivity into the caudate and putamen after the injection of a tracer, "F-DOPA. This tracer images the capacity of the nigrostriatal neurons to take up and store the radioactivity, which is principally in the form of "F-dopamine. Positron emission tomograms ofthe brain This provides a measure ofthese neurons' integrity in vivo. Uptakes in a healthy Dynamic video imaging (be~low) uses single living cells. With up to 25 images a person (top) and in a patient with Parkin- video cameras that were orig,inally de- second it detects very rapid changes in the son's disease (bottom) show that in veloped for astronomers to loc)k at faint intracellular environment, providing Parkinson's disease the loss ofnigrostriatal stars. Scientists from the ALgriculture new insight into cell function and its neurons, which approaches 80% when and Food Research Council Institute regulation. symptoms become apparent, is accom- of Animal Physiology and Geinetics Re- The sensitive video camera interfaced panied by a considerable decline in the search and engineers from a British with a computer allows scientists to look uptake of xF-DOPA. The impairment in company (Joyce Loebi ofGatesihead) have simultaneously at several different cells the putamen exceeds that in the caudate, adapted the technique to look at faintly in the same field and to analyse these which is, however, also affected. fluorescent chemical probes placed inside quantitatively. The growing number of probes available-calcium, pH, sodium, chloride, and membrane potential- suggest an almost unlimited number of uses for video imaging of single cells. Scientists are already using similar ap- proaches to examine the control of the activity ofsmooth muscle cells, regulation of human pituitary tumour cells, the activity of cultured neurons in neuro- logical diseases, and the processes leading to fertilisation of eggs. This figure shows the effect of thyro- trophin releasing hormone on the intra- cellular concentration ofionised calcium. The hormone increases the concentration of inositol trisphosphate, which releases calciumc from the intracellular stores g of these cells. Later in the experiment dopamine-an inhibitor of prolactin secretion-was applied, and this reduced intracellular calcium concentration. i The two lower panels show intracellular calcium before and after application of thyrotrophin releasing hormone. Red shading of the video signal indicates the areas of highest calcium concentration and blue shading the very low concentra- tions of intracellular calcium.-JANE Effect ofTRH and dopamine on isolated bovine prolactin cells shown by dynamic video imaging DAWSON

642 BMJ VOLUME 299 9 SEPTEMBER 1989