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Journal of the Academy of Hospital Administration

Notes, News and Journal Scan

Author(s): Rajiv Kumar Jain*, Sidhartha Satpathy**

Vol. 13, No. 1 (2001-01 - 2001-06)

Complaints Against UK Doctors Rise 50%

The General Medical Council (CMC) released the figures of complaints that it received against doctors during 2000 and 1999 as 4470 and 3000 respectively - a rise of 50%. The sudden rise has been attributed to greater awareness of the GMC, after recent high profile cases, and a tendency in society to become more quality conscious. The General Medical Council has set new standards for dealing with complaints. Since August 2000, 73 non-CMC members have been recruited to help speed up the complaints procedure, and a target has been set of closing 80% of cases within 6 months of them being presented. By the end of January 2001, 77% of cases had been heard and concluded within this time limit. (BMJ 2001, 322:448).

India's Doctors Issue New Hypertension Guidelines

With a rising prevalence of hypertension in the Indian population in the past 50 years and increasing cardiovascular disease, several associations of Indian doctors jointly issued detailed guidelines for hypertension control at the annual conference of the Association of Physicians of India in January 2001.

Indian experts have modified some of the World Health Organization's hypertension guidelines released in 1999. Whereas the WHO recommends starting treatment in low risk hypertension cases 6-12 months after observation and in medium risk cases 6 months after, the Indian guidelines recommend starting treatment 3 months after.

The Indian guidelines also emphasise avoidance of processed foods, pickles, chips, and Indian food items such as poppadums and chutneys. They also emphasize reduced in take of "ghee" (clarified butter) and advocate yoga and meditation.

Whereas the WHO guidelines suggest six classes of drugs as first line of treatment and equally effective, the Indian guidelines give extra weight to low dose diuretics and B blockers. Use of fixed dose formulations is discouraged. ( BMJ 2001; 322:258, 3 February). Too many Monitors Check UK Health Care's Vital Signs:

A typical hospital chief executive has 18 different sets of standards from 18 different bodies to adhere to. A survey of all existing health monitoring units has found that there are 15 different external agencies, more than a score of royal colleges monitoring training, and many more internal agencies. There are five or six separate bodies looking at infection control alone. Other agencies include local authorities with a new oversight role, the health and safety executive the mental health act commission, the National Audit Office, the Audit Commission, and the health Ombudsman - not to mention a clinical negligence scheme.

The scene has become so complicated that not even the professional within it have clear idea of the different bodies and their overlapping remits. A study, commissioned by the Commission for Health Improvement (CMI), revealed that none of the directors (medical, corporate affairs, or planning) in a teaching hospital was able to describe the national situation, name the individual monitoring services or understand the different regulatory roles. [The Lancet 2001;357;1103(April 7)]

Fragmented US Health-Care System Needs Major Reform

The current US health-care system is so fragmented and inefficient that it needs major reform if it is ever to provide Americans with equitable, cost-effective health care, according to a report by the prestigious US National Academy of Sciences Institute of Medicine (IO M) on March 1. Efforts over the past 25 years to reform and restructure the US system have failed to tackle the problems of soaring costs and uneven quality, the report says. The National Academy of Sciences is an independent body established by the US Congress to provide legislators with impartial expert advice on matters concerning technology and science. Although NAS panels have no power to make policy, their reports often have considerable influence on lawmakers.

The report calls on the US Agency for Health Care Research and Quality to identify at least 15 priority chronic health conditions, and work with patients, providers, insurers and other stakeholders, to develop strategies for achieving substantial improvements in quality in the next 5 years for each of the priority conditions. [The Lancet 2001; 357:782 ( March 10)]

English Govt. sets out First National Cancer Standards

National Cancer Standards are being introduced to end variation in quality of care in various hospitals. They form a central part of NHS Cancer Plan- a national strategy designed to improve the management of cancer in UK, where cancer survival rates currently lag behind other developed countries.

They have been set out in the manual of Cancer Services Standards; a 200 page document, providing a "step by step guide for better cancer care, better organisation, and more information for patients".

These cover ten topics, which are designed to span the patient care pathway and organisation of cancer service, patient information, access to specialists, diagnostic and oncology services, communication etc. Report can be accessed at (BMJ 2001,327:192, 27 January)

Hospital tables "should prompt authorities to investigate"

The publication of death rates in hospital trusts throughout Britain has been hailed as a "courageous attempt" to compare the performance of hospitals, but one that offers little help to patients.

The biggest predictor of death rates was the number of doctors in the hospital and the area. The more doctors per bed and the more GPs per head of population, the lower the death rate. The analysis was carried out by Sir Brian Jarman, emeritus professor of primary health care at Imperial College of Science, Technology and Medicine in London.

Heading the league table for fewest deaths was University College London Hospitals, which boasted 63 doctors for every 100 hospital beds, whereas Walsall Hospitals performed the worst, with just 23 doctors per 100 beds.

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, praised the research, calling it "a courageous attempt to try to compare the quality of hospitals".

But he expressed concern about the methods used to compile the statistics, which took acount only of deaths in hospitals and number of admissions while omitting 30 day mortality, multiple admissions, and whether there was a hospice close to the hospital.

Professor McKee added that, although patients may not find the figures very helpful-"a hospital that is performing poorly is generally known to the local population" - results should prompt health authorities and primary care trusts to question why one hospital is performing less well than another. (BMJ 2001,322:127, 20 January)

Beyond Helsenki : A Vision for Global Health Ethics

The fifth revision of the 1964 Declaration of Helsinki, published in October 2000, sets out international standards for conducting medical research with human subjects. Revisions of this or any other research ethics code are unlikely to make research more ethical throughout the world, however, without some means of strengthening capacity to promote and implement such standards.

Strengthened capacity in research ethics is needed in both developed and developing countries, though the need is particularly acute in developing countries. A recent Washington Post investigation into research in developing countries revealed " a booming, poorly regulated testing system that is dominated by private interests and that far too often betrays its promises to patients and consumers".

Research in developing countries was a flash point of the fifth revision of Helsinki because the declaration retains the requirement that new treatment should be tested against the "best current" treatment. Critics argue that this standard does not allow the testing of low cost, sustainable treatments, such as aspirin for coronary artery disease, which might yield substantial health improvements in developing countries but are inferior to the best current treatment in developed countries. Bloom has argued convincingly that global health would be better served by adopting a standard of the "highest attainable", and we have offered an expanded concept of the standard of care in research, advocating that visiting researchers need a deeper understanding of the social, economic, and political context of trials in developing countries.

But even another revision of Helsinki that incorporated these recommendations would not, in isolation, improve the ethics of research in developing countries. Rather, people are the key to apply international codes to local circumstances, develop and enforce national codes, staff research ethics boards, and implement research ethics processes.

The Forgarty International Center of the US National Institutes of Health is spearheading the movement to strengthen capacity in research ethics by committing $5.6m over four years to train faculty from developing countries in bioethics. These North-South partnerships will be further strengthened by South-South regional networks (such as the Forum for Ethical Review Committees in Asia and the Western Pacific) and global networks, such as the Global Forum for Bioethics in Research, which brings together researchers in developing countries and organisations that support clinical research.

Important questions remain about how to sustain this vision; the career paths of the trainees; selecting the centres; how communities, non-governmental organisations, and international organisations could be involved; and how to evaluate the effort. Moreover, how would this effort integrate with a broader vision of public health, and the process of strengthening national health-and health research-system? (BMJ 2001,322:747, 31 March)

International effort to find AIDS vaccine for India

India's health ministry and the International AIDS Vaccine initiative have signed an agrement to accelerate efforts to develop and test an AIDS vaccine against HIV subtype C, the predominant strain in India.

Under the agreement, the initiative-which was set up in 1996 with money from UNAIDS (the joint United Nations programme on HIV and AIDS), individual governments, and private foundations-will invest serveral million dollars in the development of an AIDS vaccine in India. It will be similar to the modified vaccinia Ankara vaccine against HIV designed by researchers at the Medical Research Council's human immunology unit in Oxford, but appropriate for use in India.

This new initiative will work along-side India's four AIDS vaccine projects. Therion will work closely with a team of Indian researchers led by Sekhar Chakrabarti from the National Institute for Cholera and Enteric Diseases (Calcutta, India). Together they will develop a preventive AIDS vaccine based on the Modified Vaccinia Ankara (MVA) pox virus vector. Chakrabarti was one of the first scientists to work with MVA as a vaccine vector. The partnership hopes that, pending regulatory approval, the vaccine may be ready for human testing within 2 years.

Essentially, the International AIDS Vaccine Initiative will facilitate the transfer of technology so India can acquire a vaccine based on the modified vaccinia Ankara vector," Dr. J.V. Prasada Rao, director of the National AIDS Control Organisation in India told the BMJ.

The initiative will fund the US company Therion Biologics in Cambridge, Massachusetts, to design a recombinant vaccine based on the modified vaccinia Ankara vector and containing gene sequences cloned by Indian scientists from HIV sub-type C in India. (BMJ 2001,322:755, 31 March; The Lancet 2001; 357:1024, 31 March)

* Deputy Chief Medical Director,
Indian Railway Medical Service
Res.: 480, Sector 37, Faridabad-121003, Haryana,
India E-mail: [email protected]

** Assistant Professor, Department of Hospital Administration, AIIMS,
Ansari Nagar, New Delhi-110029,
India E-mail: [email protected]

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