1050

TREATMENT FOR RENAL FAILURE IN THE WESTMIDLANDS

S:R,—Dr Michael and Dr Adu (Oct. 30, p. 990) have described thecrisis that has developed in the treatment of end-stage renal failure atthe Queen Elizabeth Hospital (Q.E.H.), Birmingham. These twoconsultant nephrologists have been forbidden by the CentralBirmingham Health Authority to treat any new patients by chronicambulatory peritoneal dialysis. Since the Q.E.H. haemodialysisprogramme is already full, the edict effectively stops all expansion ofdialysis treatment.Last year the West Midlands Regional Health Authority

requested its Regional Advisory Committee on Dialysis andTransplantation to prepare detailed two year and five year plans forthe treatment of renal failure. The plan was submitted in December,1981, and, although it was considered by the regional team ofofficers, it had not been seen by the members of the R.H.A. beforethe June, 1982 meeting. The decision of the R.H.A. was that thereport should be accepted in principle but that only very limitedfunds would be available in 1982-83 for the Coventry renal unit totake on new patients for dialysis and for the Stoke renal unit to set uptissue typing to support their new renal transplantation activities.Thus no money was offered for the treatment by dialysis of newpatients in the renal units at Stoke, East Birmingham, or WordsleyHospitals or Q.E.H. or for transplantation at Q.E.H. Themembers of the advisory committee regarded the latter decision asunacceptable and informed the regional medical officer that theyintended to continue treating any patients in end-stage renal failurewhom they deemed to be medically suitable. So far district healthauthorities have viewed the clinicians’ decision sympathetically.

It is our contention that the ban on additional dialysis treatment atthe Q.E.H. is also unacceptable and we fully support the twonephrologists in their decision to contest the D.H.A.’s instructions.To accede to the directive would mean that clinicians would acceptresponsibility for withholding life-saving treatment, based on

exclusively financial, non-clinical grounds.The level of provision of treatment of renal failure in the West

Midlands region is one of the lowest in the U.K., and we considerthe funding to be totally inadequate. We intend to continue ourpressure on the R.H.A. both directly and through our D.H.A.s toprovide the necessary funds. The R.H.A.’s decision is very

disquieting not only because it denies patients a life-savingtreatment with very good long-term results but also because it maybe the first of several attempts to save money by similar means inother clinical areas.

’

North Staffordshire Royal Infirmary,Stoke-on-Trent ST4 7LN

East Birmingham Hospital

Children’s Hospital, Birmingham

Queen Elizabeth Hospital,Birmingham

Wordsley Hospital

Walsgrave Hospital, Coventry

North Staffordshire Royal Infirmary,Stoke-on-Trent

East Birmingham Hospital

P. NAISH

J. B. HAWKINS

M. H. WINTERBORN

P. MCMASTERA. D. BARNES

D. D. HILTON

D. C. DUKES

M. E. FRENCHG. M. ABER

B. H. B. ROBINSON

SMOKING AND THE CANCER CHARITIES

SIR,-The Cancer Research Campaign (C.R.C.), as one ofBritain’s leading cancer research charities, was presumably in themind of your editorialist (Oct. 16) when, referring to the voluntaryagreement between the Government and the tobacco companies,reference was made to the fact that the large medical charities whosestated aims included research into the prevention of cancer andheart disease had remained strangely silent and had so far done littleto press the Government to take effective action.

Although for some years the C.R.C. has funded research intoaspects of smoking control, including education of the young, it is

true that it has not hitherto played a major role in endeavouring toreduce the incidence of mortality from lung cancer and othercigarette smoking related cancers. There is, however, a rapidlymounting feeling of disappointment and frustration within theC.R.C. that this major success in cancer research, if not the majorsuccess, is taking so very long to make an impact. The Campaign isplanning therefore to widen its activities in this field of prevention.Plans include a public information programme to help changeattitudes, especially via our supporters in over 1000 localcommittees and youth action committees; an increase in ourresearch activities related to smoking habits, especially amongchildren, and the education of the young in schools and colleges; andattempts to influence those in authority who have the ability (andresponsibility) to reduce the impact of cigarette smoking on health.In fact, a meeting with the Parliamentary Under Secretary forHealth preceded your Oct. 16 editorial.The terms of the new voluntary agreement between the

Government and tobacco industry have now been announced andthe Campaign, whilst welcoming the further restrictions on

advertising, regrets that the agreement has not been more forcefullystrengthened. An important opportunity has again been lost to helpreduce cigarette consumption and sales and to counter the

impression given by the industry that smoking is acceptable,desirable, and safe. The C.R.C. can only interpret the establishmentof the Health Promotion Research Trust, whose objectivescuriously exclude studies aimed directly or indirectly at the useand effects of tobacco products, as an attempt to divert attentionfrom the disastrous effects of smoking on the life and health of thepopulation.However, the prime purpose of this letter is to report that at least

one of the large medical charities has begun to take a more active rolein the control of smoking and to reassure your readers that theC.R.C. considers that smoking in any form or to any degree ispotentially harmful and welcomes all efforts to discourage it.

Cancer Research Campaign,2 Carlton House Terrace,London SW1Y 5AR

N. H. KEMPT. A. HINCER. MOHUNE. D. SKINNER

CONSENT TO RANDOMISED TREATMENT

SIR,-With all respect to Dr Brewin (Oct. 23, p. 919), there is aworld of difference between a randomised controlled trial of two orthree established and widely used treatments and one where aprincipal aim is to try to refine further a highly experimentaltreatment with dangerous drugs by eliminating one drug from oneof the treatment arms to see if it was a combination of heparin andfluorouracil (in the case at issue) or heparin on its own that wasproving beneficial. The trial may also have been comparingconventional treatment with new and experimental treatment, butin my view the treatment given to this woman was trulyexperimental.Dr Brewin adopts the cosy idealistic attitude so beloved of

doctor/writers ("Meanwhile, there is perhaps no harm in

reaffirming the view that... ready to discuss anything with patientswho wish it."). In the case that seems to have prompted Dr Brewinto writel there was no evidence of long and careful discussion witheither the 84-year-old patient or her daughters, with whom she wasvery close, though all of them knew she had cancer. At the inquest itemerged that, though the daughters visited every day, they neversaw a doctor until, when it was clear that their mother’s conditionwas seriously deteriorating, one of them stated that she would notleave the hospital until she had seen a doctor. A houseman wascalled; three weeks’ qualified he had not been told that blood countsshould be done every day in accordance with trial protocol. Whenthe patient died-an event not, surely, unforeseeable by the medicalstaff-her daughters were not at her bedside because, they said, theyhad not been summoned in time.

1. Brahams D Death of a patient who was unwitting subject of randomised controlledtrial of cancer treatment. Lancet 1982, i: 1028-29