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are subsequently transferred to the ward. ICU is a major, ifnot the major, contributor to the cost of cardiac surgery;availability of ICU beds is also the limiting factor for thenumber of cases operated upon. Staffing an ICU in Oxfordneeds 7-3 nurses per bed, whereas the cardiac surgeryrecovery area (CSRA) requires 4-6 nurses per bed. TheOxford cardiac surgeons believe that the CSRA has enabledthem to increase their case-load considerably despite theusual budgetary limitations.

Finally, an example of how audit worked to the patients’advantage came from a retrospective audit of coronary carein Plymouth, which showed that a low proportion ofpatients aged over 64 years received thrombolytic therapy.Guidelines for thrombolysis were reiterated and nursingstaff were instructed to question the action of junior medicalstaff when thrombolytics were not prescribed. A secondprospective audit showed a significant increase in

proportion receiving thrombolytic therapy-from 12% to46%.

A correspondent

Noticeboard

Global demographyThe first half of 1991 has seen an accelerating number of natural

and man-made catastrophes. Food production and income arefalling in many nations and 36 countries will not be able to feedthemselves by the end of the decade. The UN has just revised itsbest estimates for global population upwards; by the year 2001 thetotal will be 6.4 billion.

The State of World Population 19911 presents the United NationsPopulation Fund (LJNFPA) summary of global demographicproblems and the Fund’s vision of solutions. It is a business-like andbalanced document that does not judge the magnitude of

contemporary population growth, while underscoring the successesachieved with family planning in the developing world. In EastAsia, for example, the number of births per woman has fallen from6.1 in 1960-65 to 2-7 in 1985-90. Of the several interactions between

family planning and development covered in the report, one of themost impressive is the positive linkage between family planning andthe welfare of women: the daughters of small families are more likelyto enter and stay in school, and literate mothers have smaller familiesthan those who have not had the opportunity of education.Dr Nafis Sadik, Executive Director of the UNFPA, is optimistic

in opening the report with the statement, "Targets in fertility andfamily planning for the end of the decade are for the first time part ofinternational development strategies". This statement may soundlike bureaucratic rhetoric but it is a realistic assertion and responseto population issues. The graphs in the report show how theproportion of women in developing countries wanting no morechildren has risen, and how desired family size has fallen. Invirtually every country the demand for family planning outstripsthe services.To achieve targets for the year 2000 the number of couples using

contraceptives in developing countries needs to rise from today’s381 million to 567 million by the end of the decade; in terms of"contraceptive prevalence" the rise need only be from 51 % to 59%.Moreover, family programmes have the support of political andsocial leaders. The programmes have been well managed and thereport gives examples of the ideas used in the distribution ofcontraceptives. Grenada may have no Virgin Megastore, but aguitar maker’s workshop serves just as well. And sales at Nigeria’smarket stalls show not only that distribution there is better thanthrough the family planning association, but also how brandedproducts, promoted by an advertising jungle, outsold unbrandedand unpromoted ones. Contraceptive supplies alone will cost

US$600 million a year, and family planning services in total could

cost US$9 billion annually (double today’s expenditure) by the endof the decade. Most of this money will come directly fromconsumers themselves and from the tax revenue of Third World

nations, but first-world donors will also need to increase theirsupport (currently just over US$600 million a year) to severalbillion a year.For many people billions of dollars and billions of people appear

as mind-boggling figures representing an overwhelming problemthat requires unobtainable sums of money to solve. In reality,population trends are well understood, proven solutions exist, andthe costs are trivial at a global level. For comparison, Philip Morris,the US tobacco conglomerate, has an annual advertising budget ofUS$2 billion, while the industrialised nations spend US$2 billion aday on defence.

1. Sadik N. The State of World Population, 1991. New York: United Nations PopulationFund. 1991. Pp 48.

Are patients satisfied?

To help health authorities assess patients’ satisfaction with theservice they receive, the Audit Commission asked the HealthServices Research Unit of the London School of Hygiene andTropical Medicine to develop a questionnaire for use by healthservice managers and clinicians. Three questionnaires for assessingviews on surgery-before surgery, and at one week and one monthpostoperatively-were field tested.! The field trials showed thatonly one questionnaire,2 with variants for adults and for parents ofchildren undergoing operations, is needed. At least 350

questionnaires should be sent out in any survey to obtain the 200responses necessary for a statistically valid analysis. They are bestsent out to arrive about 3 weeks after the operation. TheCommission has also prepared a computer disk2 containingready-formatted files for entering or tabulating data from thequestionnaires. In addition, it has asked the Health ServicesResearch Unit to assemble a national database of the results of

surveys using the questionnaires, so that comparative data areavailable and more detailed analyses will be possible.

1. Audit Commission for Local Authorities and the National Health Service m Englandand Wales. Measuring quality the patient’s view of day surgery. London: HMStationery Office. 1991. Pp 19. £5. ISBN 0118860569.

2. Available, with computer disk, from Publications Section, Audit Commission,Nicholson House, Lime Kiln Close, Stoke Gifford, Bristol BS12 6SU

Environmentally friendly NHSThe National Health Service, which is the largest employer in the

UK, has enormous potential for contributing to a cleanerenvironment. The measures that health authorities can take werediscussed at a meeting held in Oxford a year ago (see Lancet 1990,335: 783). Last week, at another NHS Greening Conference (inSouthsea), the Government’s commitment to helping the healthservice to reduce environmental pollution was emphasised by MrStephen Dorrell, Parliamentary Secretary for Health, whoannounced that the Government will provide funds to help theCentre for Greening the NHS to produce a workbook on goodpractice in environmental protection for health authorities. Thecentre, based at the Radcliffe Infirmary, Oxford, was set up after theOxford conference, and aims to coordinate efforts to clean up theenvironment through projects with other organisations (eg, theBritish Institute of Radiology and the Royal College of GeneralPractitioners); through its newsletter, which is being produced withmoney from the King’s Fund and which will be launched nextmonth; and through seminars.Mr Dorrell also called on the health authorities to use their vast

purchasing power to stimulate demand for environmentallyfriendly products. Other steps that the Government is takinginclude: the issue of guidance on waste management; the productionof a manual on implementing smoking policies in health carefacilities to be distributed later this year; completing the changeoverto unleaded fuel for NHS vehicles by 1992/93; and the setting of atarget saving in energy of 15% within the NHS over the next 5years. Since 1977/78 there has been a 30% reduction in total energy