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Primary care for diabetes under threat

The British Diabetic Association’s task force, Primary Care Diabetes UK, has presented evidence to the 3rd Primary Care Diabetes UK Conference (Bournemouth International Centre, 5–6 November 1998), based on a national survey of general practices, that the much vaunted aims of the St Vincent Declaration to reduce diabetic complications significantly by the year 2000 are increasingly unrealistic predominantly owing to underfunding of primary healthcare needs of the diabetic community. In particular, the problems being faced by doctors and practice nurses in delivering the appropriate services are not being addressed; specifically, the eradication of geographical differences in care and the lack of educational resources for practice nurses, according to Dr Mary Pierce who conducted the research. The survey involved questionnaires being sent to 1872 practices which accounts for about 20% of the total UK practices. In view of the recent results of the UK Prospective Diabetes Study in which the importance of good blood pressure control, in addition to blood glucose control, in the prevention of diabetic complications particularly blindness, has been highlighted it would be particularly short sighted if sufficient funds were not in place to permit this type of optimal primary care to be delivered.

Hemispatial neglect: a possible therapy?

Patients with right hemispheric stroke lesions frequently show hemispatial neglect manifested by neurological defects affecting their left sided space in terms of attention, perception, and even of performing actions in this space. A recent study (Nature1998;395:166) has investigated how to entrain adaptation to a visual distortion produced by prisms which shift the field of interest closer to the midline and thus into the region under the control of “coordinate transformation”. Remarkably, all patients who were tested showed an improvement in their manual body midline demonstration and in their performance on classic psychophysical tests such as object reproduction. The effect lasted for at least 2 hours after removal of the prism and thus showed considerable potential for use in rehabilitation programmes. From a neurophysiological standpoint, the positive effect for both sensorimotor and cognitive spatial functions was attributed to shared multisensory integration—for instance, between cerebellar regions controlling prism adaptation and the posterior parietal cortex where the lesion is localised, in which there was a common level of space representation.

Impact factors and the research assessment exercise

In the run up to the next research assessment exercise (RAE), in which universities in the United Kingdom are assessed on the quality of their research output and given a ranking which determines in part the revenue they are likely to receive for the ensuing five years to continue as research institutions, much emphasis has been placed on the four publications which each nominated research active academic submits as a measure of his/her best work in the preceding five years. The question is how best to assess this published output. The Institute of Scientific Information (ISI) previously under the direction of Eugene Garfield has devised a measure of research quality termed the impact factor. However, this single figure has provoked controversy ever since it was introduced and the now chairman emeritus, Dr Garfield, has cautioned against overinterpretation of impact factors especially if taken out of context. Thirty years ago the Science Citation Index covered 600 journals while it now covers 8000 from more than 150 fields. The size of the discipline thus does not correlate with the impact factor and there can be major positive and negative effects of numbers of citations in any one journal in relation to the field. For ophthalmology, this is particularly relevant since the size of the field will always be restricted and there is limited potential for growth. How this affects the RAE remains to be seen.

The MRC and multidisciplinary research

Multidisciplinary research is a rather loose “catch all” term which aims to provide a focus for attempts by research groups to come together and pool their different forms of expertise to address a specific problem. Representative groups, for instance, might come from the medical disciplines, the social services, the public services, and educational sources. The MRC has announced the opening of a new initiative, the Health Service Research Collaboration (HSRC), into this type of research at Bristol which brings together the largest collaborative effort of health services researchers in the United Kingdom. It includes senior academic doctors, health economists, epidemiologists, nurses, social scientists, and statisticians with the specific purpose of investigating current health service provision. Each discipline with the collaboration will have equal status and the aim is to “improve the likelihood of people receiving the most appropriate, cost effective health care in the right way at the right time” according to project director, Professor Paul Dieppe. Professor George Radda, chief executive of the MRC, indicated that this initiative was very much part of the MRC’s “Health of the Public” scientific strategy and opens up new ways in which the Department of Health and the MRC can work together. Although centred at Bristol University, several other centres are involved in the nationwide project including universities at Aberdeen, Cardiff, Dundee/St Andrews, London (UCL), Newcastle, and York and links directly into the NHS R&D programme. No specific areas of disease have been so far targeted for investigation but rather a broad approach to the healthcare needs of society and the equitable and cost effective provision of this care, together with an evaluation of the expectations of the public in relation to health care, will be the main focus of the project, an altogether very ambitious programme that will require careful guidance.

Cost of cataract surgery in the NHS

A recent government report on the cost of surgical procedures in various hospitals throughout the United Kingdom, otherwise known as the “name and shame” list, has provided interesting information on the cost of cataract surgery with lens implant on the NHS: apparently costs can vary from £337 to £1659 from hospital to hospital. However, overall, 90% of hospital trusts kept within a 20% margin of the national average with only a few outliers.

Fraud in research

According to a study carried out for the UK pharmaceutical industry, fraudulent research occurs at a rate of at least 1% of all clinical research projects undertaken. Cases were divided roughly equally between research projects in general practice and hospital/academic settings. Jointly, the General Medical Council and the Royal College of Physicians are soon to issue recommendations on how best to deal with this apparently increasing flood of dubious activity. So far the Committee on Publication Ethics (COPE) headed by Dr Richard Smith, editor of the BMJ, has offered its own set of recommendations which include setting up systems to investigate fraud within every research centre, establishment of a national standard for investigative procedures in cases of alleged fraud, and drawing up codes of good practice on how to deal with fraud. In addition, a reporting policy has been set up by the pharmaceutical industry to guard against fraud. Meanwhile, the European Union plans to introduce a directive next April which, while not binding, will require member states to take some form of action to minimise fraud in scientific research and, provisionally, the EU is looking to the United Kingdom and Denmark, as two member states who have started tackling the problem, to take a lead.

Global theme issue

The 1999 global theme issue will be “Impact of new technologies in medicine”. Prospective authors please consider submission for this issue.