966

soon combined into a single organisation. From a file-card index inhis drawing room in 1965 it has grown into an international

organisation that holds the records of over a third of a millionpatients and that made medical audit familiar to renal physicianstwo decades before it became the health service buzz word. Inretirement he recruited Frank Parsons and John Maher to join himin publishing Replacement of Renal Function by Dialysis, which hasremained the unchallenged authority on the treatment of renalfailure since it appeared in 1978. His chapter on the history ofdialysis is the definitive account.

David Kerr

Noticeboard

Assessing health technologyNew forms of treatment should be paid for by the National

Health Service only if they are being offered as part of a researchprogramme to evaluate their effects, says a report published by theDepartment of Health.! In Assessing the Effects of HealthTechnologies, an advisory group appointed by Prof MichaelPeckham, director of the department’s Research and DevelopmentDivision, argues that methods of diagnosis and disease prevention,medical and surgical treatments, and other components of healthcare should be rigorously assessed to determine their efficacy,safety, cost-effectiveness, and social impact. "If an approach isbeneficial, cost-effective and affordable for particular patients itshould be widely available to them", says the report. "If it is not,then it should be abandoned." Professor Peckham said that the

Department of Health is developing a coherent policy for theevaluation of health care in the light of the report’s findings.Health-technology assessment, he said, is a "key factor" in the NHSresearch and development strategy. By 1996 1-5% of the NHannual budget will be allocated to research and development.As an example of the need for evaluation the group points to a

fivefold variation between European countries in the use of

cholesterol-lowering drugs. Another example is how referral ratesin the UK for specialist consultation and admission to hospital varyat least threefold between adjacent general practices.A systematic approach to health-technology assessment would

begin, for each area of health care, with a "shopping list" of researchquestions that deserve priority funding. The lists would be drawnup by research workers, clinicians, and lay people. Studies of theimpact of any technological development on mortality must beproperly randomised, analysed, and interpreted, says the report,and they may need to be very large. A trial involving 17 000 patientswith suspected myocardial infarction was required to show thatlow-dose aspirin could reduce premature death by one-fifth.2 Thesame trial demonstrated that streptokinase could reduce mortalityby a quarter, an effect that over twenty smaller trials had failed topick up.

Mortality would clearly be the appropriate outcome measure fora development designed to save lives; other measures, such as theeffects on progression of a disease, the financial costs of a disease andits treatment, the patient’s quality of life, and how a patient’s diseaseor disability affects his or her family would be fitting in somecircumstances. Assessment should be backed up by a nationalnetwork of research centres, registers of trials in different specialties,and mechanisms for making results widely available, says the

report. The advisory group claims that much research is neverpublished and that underreporting distorts the evidence that is

publicly available. Routine assessment would need to be supportedby training and a career structure for staff. The report notes thatopportunities for people wishing to learn about technologyassessment are very limited.

1. Assessing the effects of health technologies principles, practice, proposals. Availablefree from Research and Development Division, Department of Health, RichmondHouse, 79 Whitehall, London SW1A 2NS (telephone 071-210 5963/5224, fax071-210 5433/5434).

2 ISIS-2 (Second International Study of Infarct Survival) Collaborative GroupRandomised trial of intravenous streptokinase, oral aspirin, both, or neither among17 187 cases of suspected myocardial infarction (ISIS-2). Lancet 1988, ii 349-60

Cost of smokingLast year the health education and health promotion bodies in the

UK published a 14-volume set of booklets on the impact of smokingby health district. This year the 9 volumes1 giving, by UK andEuropean parliamentary constituency, the cost of smoking in termsof morbidity, mortality, and hospital usage, includes a chapter onpassive smoking. It draws special attention to exposure to passivesmoking at home. 49% of all children in the UK are exposed totobaco smoke at home, the proportion varying from 42% in theSouth East to 58% in Wales. For adults the figures are 53% passiveexposure at home for men and 57% for women. The figures forprenatal exposure are similarly high-29% of pregnant womensmoke (13% smoke and live with a partner who smokes) and 19%do not smoke but live with smokers. Overall, the report says, thefigures indicate that throughout life, from conception onwards, onein two people are placed at risk from the harmful effects of smoke.

In Maidstone, the constituency with the lowest proportion ofsmoking-related deaths (13-1%), c550000 a year is spent on

hospital treatment of people with smoking-related diseases. In theUK as a whole k437 million is spent on hospital treatment for thesedisorders, with 9500 beds being used up daily.

1. The smoking epidemic—a manifesto for acnon. Six volumes for England from theHealth Education Authority; and one each for Northerm Ireland, Wales andScotland from the Northern Ireland Health Promotion Agency, the Welsh HealthPromotion Authority, and the Health Education Board for Scotland, respectively.

What’s risk?

" ... the research map of risk management is a bit like the

population map of Australia, with almost everything clusteredround the edges and hardly anything in the central conceptual areas.And the ’edges’ themselves are more like an archipelago of scatteredspecialisms isolated from one another than a single land mass ... ".So says the last chapter of what had been intended to be a RoyalSociety report, an update of its 1983 Study Group Report on RiskAssessment. The report has now been issued as a collection of six

independent chapters, partly to avoid holding up publication andpartly to encourage the debate that might be pre-empted if anattempt had been made to resolve the issues raised. This publicationplaces more emphasis than did its predecessor on risk perceptionand risk management, two complex topics. Individual risk

perception differs from group risk perception; and both areinfluenced by a host of factors, among them what people areprepared to tolerate. Hence safety policies may be based on theprinciple of ALARP (as low as is reasonably possible), of ALARA(as low as is reasonably attainable), or ofBATNEEC (best availabletechnology not entailing excessive costs). As for risk management,what the term means varies enormously with context-fromfinancial provision for risks (in a business context), to the handlingof issues that may affect a government’s electoral fortunes (in apolitical context). It is not surprising then that in the past decade anew discipline has emerged-that of risk communication. Thereassurance-arousal paradox refers to the need for some messages toreassure and at the same time to warn.

1. Risk: analysis, perception and management. Report of a Royal Society Study Group.London Royal Society. 1992 Pp 201. £15.50. ISBN 0-85403-467-6.

Differences in bioequivalenceTwenty-eight countries have been participating in a study

initiated by the Central Laboratory of German Pharmacistscomparing how well generics drug manufacturers meet

bioequivalence specifications. The drug chosen for the study(Pharrn Ztg 1992; 137: 3144 9), which was conducted incollaboration with the Netherlands-based Federation InternationalPharmaccutique (FIP), was glibenclamide. The variables examinedincluded total amount absorbed and speed at which the compoundis released from the tablet, the agreed standard for the latter being atleast 80% within 10 min. Although the pharmacopoeialrequirements (British Pharrnacopoeia 1988) concerning identity,purity, content, and precision of dose were invariably met, there was