Words and Money for The

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.

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