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(2) PATIENT
EXPECTATIONS OF CARE MAY
EXCEED GOVERNMENT
TARGETS
(3) MONITORING
DEATHS IN GENERAL PRACTICE
WOULD HELP
MAINTAIN PUBLIC TRUST
(4) ASSISTED SUICIDE BY NON-PHYSICIANS
(5) LEGAL
JUDGEMENT HAS GRAVE
IMPLICATIONS
FOR THE NHS >
(1) SIZE AT BIRTH
LINKED WITH RISK OF BREAST
CANCER IN WOMEN UNDER 50
(Fetal growth and subsequent risk
of breast cancer:
results from long term follow up
of Swedish cohort)
http://bmj.com/cgi/content/full/326/7383/248
A study in the BMJ this week finds an association
between size at birth and risk of pre-menopausal
breast
cancer.
Over 5,000 women born in Sweden during
1915-29
were included in the study, of which 63
had breast
cancer before the age of 50. There were
strong positive
associations between measures of birth
size and rates of
breast cancer at pre-menopausal ages,
even when other
adult risk factors were taken into account.
Birth length
and head circumference had stronger associations
with
pre-menopausal breast cancer than birth
weight.
In addition, a shorter period of pregnancy
was
independently associated with an increased
risk of breast
cancer before the age of 50, indicating
that "the rate of
fetal growth may underlie the association
between birth
size and risk of early breast cancer"
suggest the authors.
There was no evidence of an association
between birth
size and breast cancer in post-menopausal
women, of
which 296 had breast cancer.
However, the authors explain that in public
health terms,
if the findings were real, large birth
size would be
responsible for only a small proportion
of the total
number of cases of breast cancer in any
population, as
the incidence at premenopausal ages is
low. Moreover,
this association should be considered
in light of its
opposite association with heart disease,
a much more
common condition, they conclude.
Contact:
Valerie McCormack, Research Fellow, Department
of
Epidemiology and Population Health, London
School of
Hygiene and Tropical Medicine, London,
UK
Email: valerie.mccormack@lshtm.ac.uk
(2) PATIENT EXPECTATIONS
OF CARE MAY
EXCEED GOVERNMENT TARGETS
(Setting standards based on patients'
views on access
and continuity: secondary analysis
of data from the
general practice assessment survey)
http://bmj.com/cgi/content/full/326/7383/258
Patients may have expectations for access
to primary
care in excess of current government targets,
finds a
study in this week's BMJ. Patients also
have high
expectations of continuity of care.
Researchers analysed data from general
practice
research studies and routine quality assessment
activities
undertaken by practices and primary care
trusts. The
analysis involved 21,905 patients.
Satisfactory standards of access were next
day
appointments with general practitioners
and a 6-10
minute wait for consultations to begin.
A satisfactory
level of continuity was seeing the same
general
practitioner "a lot of the time."
Standards varied with the analytical methods
used and
by sociodemographic group. Patients from
ethnic
minorities generally had higher standards
whereas older
patients (aged 46 to 60 years or more)
had lower
standards.
Patients have high expectations relating
to access of
care, which may support or exceed current
government
targets, including the standard for waiting
times by 2004
of seeing a general practitioner within
48 hours, say the
authors.
However, it is unclear the degree to which
such
standards are reliable or valid, how conflicts
between
access and continuity should be resolved,
or how these
standards relate to other priorities of
patients, they
conclude.
Contact:
Alison Hollinshead, Communications Officer
or Laura
Blake, Director of Communications, University
of
Manchester, UK
Email: alison.hollinshead@man.ac.uk
(3) MONITORING
DEATHS IN GENERAL PRACTICE
WOULD HELP MAINTAIN PUBLIC TRUST
(Monitoring mortality rates in general
practice after
Shipman)
http://bmj.com/cgi/content/full/326/7383/274
Harold Shipman's murderous career led to
demands that
steps be taken to prevent any recurrence,
but devising an
acceptable and workable method of monitoring
death
rates in individual general practices
is not
straightforward. In this week's BMJ, researchers
discuss
the key issues in designing such a monitoring
system.
Except for a few local schemes, monitoring
systems are
not yet established, report the authors.
They suggest that
procedures for investigating abnormal
patterns need to
be agreed, and that a monitoring system
could detect
high death rates by using valid comparative
data.
Monitoring should also be practical, and
not be unduly
complex or costly to administer. A monitoring
system
must be:
Sensitive
Specific
Provide meaningful data for both general
practitioners
and public health Physicians
Require a minimum of expertise and resources
to
maintain
Be acceptable to practitioners and patients
They admit that there will still be limitations.
For instance,
monitoring subgroups of GPs, such as locums,
assistants
and those caring for people in hospices
would be
difficult, and in practices where individual
patients are
treated by more than one doctor, analysis
would have to
be by practice rather than by doctor.
"Monitoring mortality rates among general
practitioners'
patients would help maintain public trust,"
they say.
"Better information about mortality rates
in general
practice could also facilitate the planning
and monitoring
of clinical policies to gradually reduce
mortality."
Contact:
Professor Richard Baker, Department of
General
Practice and Primary Care, University
of Leicester,
Leicester General Hospital, Leicester,
UK
Email: rb14@le.ac.uk
(4) ASSISTED SUICIDE BY NON-PHYSICIANS
(Assisted suicide and euthanasia
in Switzerland: allowing
a role for non-physicians)
http://bmj.com/cgi/content/full/326/7383/271
Sharp controversy surrounds assisted suicide
in
Switzerland, say researchers in this week's
BMJ.
Swiss law does not prohibit assisting suicide
as long as
the motive is altruistic. Also, it does
not give physicians a
special status in assisting suicide. This
means that
whether assisted voluntary death should
ever be allowed
has been discussed without exclusive reference
to
physicians. Physicians have separately
debated their role
at the end of life.
The few existing data do suggest public
support for
assisted suicide. In a 1999 survey of
the Swiss public,
four fifths agreed that "a person suffering
from an
incurable disease and who is in intolerable
physical and
psychological suffering has the right
to ask for death and
to obtain help for this purpose." Legislation
to allow
euthanasia was favoured by 71%.
However, resources for palliative care
in Switzerland are
not yet available to all terminally ill
patients. This remains
a strong argument against decriminalising
euthanasia.
Despite acceptance of assisted suicide,
support for
palliative care is growing, as end of
life issues are kept in
the public eye, say the authors. Further
research on
public attitudes and on practices at the
end of life in this
unique situation is important, they conclude.
Contact:
Samia Hurst, Post-doctoral Fellow, Department
of
Clinical Bioethics, National Institutes
of Health,
Bethesda, USA
Email: shurst@cc.nih.gov
(5) LEGAL JUDGEMENT
HAS GRAVE
IMPLICATIONS FOR THE NHS
(The BetterCare judgement±a challenge
to health care)
http://bmj.com/cgi/content/full/326/7383/236
A landmark decision by the United Kingdom's
Competition Commission could make all
contracting out
and commissioning of health care by NHS
and social
services subject to European Union competition
law,
rather than a matter for national public
health policy.
This may leave the NHS vulnerable to legal
challenge
from international healthcare corporations,
argue
researchers in this week's BMJ.
In November 2000, the BetterCare Group
(a private
company selling nursing and residential
care in Northern
Ireland) used the United Kingdoms' competition
law to
challenge the contract price for private
nursing home
beds in Northern Ireland. BetterCare alleged
that the
contract price was set too low because
the trust was
abusing its dominant market position in
violation of
competition rules.
The Office of Fair Trading rejected BetterCare's
claim,
arguing that competition law does not
cover health care
commissioning. But a tribunal of the UK's
Competition
Commission upheld the company's appeal
against this
decision and BetterCare is now free to
use competition
law to challenge the contract price for
nursing home
beds.
The judgement has important implications,
say the
authors. It allows private companies to
challenge the
purchasing power of the NHS and local
authorities. It
also puts in question policy statements
by the
government on user charges in the NHS,
and gives
commercial hospitals and foreign investors
a mechanism
for challenging the prices paid for secondary
and tertiary
inpatient care.
Private healthcare companies are already
planning to
exploit this ruling, they warn.
"As the NHS moves inexorably towards the
market
place for the provision of care, officials
of the
Department of Health need to discuss with
trade officials
the extent to which competition policy
and trade rules
may be used to undermine the principles
of the NHS and
its funding and leave the NHS vulnerable
to legal
challenge from international healthcare
corporations,"
they conclude.
Contact:
Professor Allyson Pollock, Public Health
Policy Unit,
School of Public Policy, University College
London, UK
Email: allyson.pollock@ucl.ac.uk
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