With head and heart and hand
  Portraits of 20th century British doctors by Nick Sinclair

BMJ No 7089 Volume 314 Saturday 26 April 1997

This Week in BMJ | Editor's Choice | Press releases | Advertisement details

Editorials

1211 Modern treatments for internal haemorrhoids John L Pfenninger

1212 The future of locality commissioning Nicholas Mays

1213 Is one arterial graft enough? Malcolm Underwood, Graham Cooper, Bruce Keogh

1214 The private finance initiative Seán Boyle

1215 Drug treatment for benign prostatic hyperplasia Andrew Farmer, Jeremy Noble

News

1217 US tobacco companies discuss $300bn deal * Health ministers face BMJ questions * Private finance initiative attacked * Canada softens tobacco legislation * Dose blunder leads to £2m payout * Young doctors feel isolated * GMC criticises medical training * Doctors accused of not discussing risks * AIDS drug trials criticised * US doctors rush to join unions

Papers

1225 Prospective cohort study of predictors of incident low back pain in nurses Julia Smedley, Peter Egger, Cyrus Cooper, David Coggon

1229 Association of mutations in mannose binding protein gene with childhood infection in consecutive hospital series John A Summerfield, Michiko Sumiya, Michael Levin, Malcolm W Turner

1232 Is the clinical course of HIV-1 changing? Cohort study A Sinicco, R Fora, R Raiteri, M Sciandra, G Bechis, M M Calvo, P Gioannini

1238 Meta-analysis of prophylactic or empirical antifungal treatment versus placebo or no treatment in patients with cancer complicated by neutropenia Peter C Gøtzsche, Helle Krogh Johansen

1244 Impact of a dedicated service for male mentally disordered remand prisoners in north west London: retrospective study Tim Weaver, Fiona Taylor, Barbara Cunningham, Shane Kavanagh, Anthony Maden, Sian Rees, Adrian Renton

General practice

1246 What does locality commissioning in Avon offer? Retrospective descriptive evaluation Christine E Hine, Max O Bachmann

1250 Are the Health of the Nation's targets attainable? Postal survey of general practitioners' views Philip Cheung, A Pali S Hungin, Jo Verrill, Andrew J Russell, Helen Smith

Information in practice

1252 Evaluation of a decision support system for initiation and control of oral anticoagulation in a randomised trial B Vadher, D L H Patterson, M Leaning

1257 Netlines Mark Pallen

Clinical review

1258 Science, medicine, and the future: Hypertension Morris J Brown

1262 ABC of clinical haematology: Haematological disorders at the extremes of life Adrian C Newland, Tyrrell G J R Evans

Education and debate

1266 What happens when the private sector plans hospital services for the NHS: three case studies under the private finance initiative Allyson M Pollock, Matthew Dunnigan, Declan Gaffney, Alison Macfarlane, F Azeem Majeed on behalf of the NHS Consultants' Association, Radical Statistics Health Group, and the NHS Support Federation

1271 Socioeconomic determinants of health: Life expectancy, economic inequality, homicide, and reproductive timing in Chicago neighbourhoods Margo Wilson, Martin Daly

Letters

1275 Bureaucracy of purchaser-provider split delays treatment I Hutchison and others

1275 Counting the cost of social disadvantage in primary care D P Kernick; C A West; A Worrall and others

1276 Community mental health teams in London are being increasingly stretched B Hannigan and others

1277 Cervical screening S Williamson and V Wadehra; C M Anderson; A Herbert

1278 Home medical students account for less than half the full registrants Britain requires E W L Fletcher

1278 Recommendations for improving national data on congenital anomalies are being implemented E Alberman and B Botting

1278 Crisis in London's mental health services S Weich; N Bouras and G Holt; A Beadsmoore and P Hardy; D Goldberg and G Thornicroft; R Duffett and J Cookson; L Lessof and S Hatch

1280 Bodybuilders find it easy to obtain insulin to help them in training S L Elkin and others

1280 Dangers of sunbeds are greater in the commercial sector A Wright and others

1281 Junior surgeons are becoming deskilled as result of Calman proposals D Skidmore

1281 New government must reassess its criminal justice policy T McClintock

1281 Prophylaxis of venous thromboembolism T H S Dent and M A Dent; T M Cook and others; M Verstraete

1283 Not all those who died after Hillsborough did so by 3.15 pm E Walker

1283 Concussive convulsions J Stephenson; D Chadwick

Obituaries

1284 H W C Fuller, P M A Harnarayan, R W Knowlton, P G L Parry, S C Woodhouse

Medicopolitical digest

1285 BMA wants to meet new government on review body * Staff grade doctors * BUPA's partnership plan * Guide on GP pilots * BMA

Views & reviews
Soundings

1286 A-wake? Liam Farrell

Personal views

1286 The system must change Helen Gibson

Electronic nagging Geoffrey Bunch

Medicine and books

1288 Multiple Sclerosis (Clinical and Pathogenetic Basis) Ed C S Raine, H F McFarland, W W Tourtellotte
P K Newman

1288 Mould's Medical Anecdotes, Omnibus Edition R F Mould
Liam Farrell

Minerva

1290

S2 Career Focus Classified supplement

Developing skills for the broadcast media Paul Stillman

Editor's choice

Vote, vote, vote for...

"We therefore appeal with all the emphasis in our power to those who have not yet voted to do so without an hour's delay." So said the BMJ in 1897 (p 1245), exhorting doctors to vote in General Medical Council election. The journal bemoaned low turnouts and said that it made "the cause of direct representation appear weak, indeed almost ridiculous." Democracy depends on people voting. That's one thing politicians can agree about. Next week Britain has a general election, and we have been besieged by people wanting to get material published before the election. This is the time when politicians must listen to the people, and the people have things to say.

One study looks at the private finance initiative, a government scheme to bring private capital and management skills into the National Health Service and other parts of the public sector (p 1266). One conclusion is that commercial sensitivity has meant that much of Britain's health service is now being planned in secret with inadequate accountability. A second conclusion is that the plans being prepared may be built on highly doubtful assumptions. An editorial observes: "There is almost universal agreement that the private finance initiative has failed as an alternative source of capital funds for the NHS." (p 1214)

More successful has been "locality commissioning," an alternative to fundholding where general practitioners come together to influence health service commissioning. Evaluations of these schemes are rare, but authors from Bristol have studied the Avon scheme (p 1246). Their conclusion is that locality commissioning has changed local services - and at lower cost than fundholding. An editorial looks at challenges to the spread of locality commissioning: persuading practices to work together and ensuring that the practices share the health authority's responsibility for managing resources (p 1212).

Other messages for an incoming government occur elsewhere. A group from Durham shows that general practitioners are sceptical about the attainability of national targets for improving health (p 1250). A group of surgeons collected data on 119 patients whose health authorities refused to fund their treatment at their trust (p 1275). Patients waited 19 weeks to be turned down. A series of letters worry that London's mental health services are collapsing (p 1276), while a psychiatrist asks politicians to think again about policies that lead to a growth in the prison population and so increasing damage to prisoners (p 1281).

The politicians have their say in response to questions we have asked them (p 1218). Real differences emerge in the answers. The British electorate may be cynical about politicians, but we get the politicians we deserve. And if we don't vote we may get something still worse.