748

thromboxane B2 (TxB2) levels in the plasma of patients withRaynaud’s phenomenon and systemic sclerosis. The blood sampleswere kindly provided by Dr S. Grimes (Department of Derma-tology, St Bartholomew’s Hospital Medical School, London). Themeasurements were done by radioimmunoassay, using antibodiesprovided by the Institut Pasteur. The blood samples were drawninto syringes pretreated with indomethacin to block PG synthesis.The results, in comparison to those in normal individuals of similarage, are as follows (mean ±SEM, pg/ml): .

Group TxB2 PGE, PGE2Normal 122.7+7.5 5 23.5±5.8 8 12.1±2.5 5

Raynaud’s 1900±’’20 1930±110 860±90

Instead of the expected low levels, we found very high values forall three substances (p<10-6) with no overlap between the

Raynaud’s and the groups. There are many problems with PGassays and considerable caution must be invoked when dealing withmarginal differences. However, these changes are so large that theyare unlikely to be due to artifact. This suggests that patients withRaynaud’s phenomenon are resistant to the actions of PGs and thatvery large amounts may be required to produce vasodilation. If theresistance were to vasodilators in general, this would fit with theproposals of Lafferty et al on histamine.

Efamol Research Institute,Annapolis Valley Industrial ParkKentville, Nova Scotia,Canada B4N 4H8

D. F. HORROBINK. JENKINSM. S. MANKU

Commentary from Westminster

Continued Pressure on DHSS SpendingTHE Social Services Secretary, Mr Norman Fowler, and

the Health Minister, Mr Kenneth Clarke, have embarked onan aggressive propaganda offensive, intended to blunt theincreasingly sharp criticism of their policies, which is nowcoming from all sections of the NHS. The latest

pronouncements from the Ministers on the subject are madein a bellicose tone hitherto absent from their speeches.Mr Clarke told a receptive audience of lady Conservatives

in his own constituency that the time had come to "challengesome of those with vested interests in resisting change, whoare trying to frighten the public into believing that moreefficiency cannot be achieved without harming patients". Hewas not referring primarily to the unions in the NHS, but todoctors and health administrators. To these people,according to Mr Clarke, it came as a "culture shock" to betold that the country could not afford to increase spending"even on the worthwhile ends of a free health service". Such

people’s "favourite claim" was that staff could be saved onlyby closing wards or not opening new units in hospitals. Lessthan honestly, Mr Clarke insisted that "the same people"were making "ridiculous attacks" on the Government’sdesire to privatise hospital ancillary services. (In fact, theweightiest medical voices opposing spending cuts have beenutterly and sensibly silent on the subject of privatisation.) ButMr Clarke’s audience was reassured to hear him promise to"shake up some parts of the NHS" and to hear that he is"confident that we can improve the efficiency of the NHSwithout damaging its high standards".Mr Fowler chose a less bullying tone of voice for his recent

speech to the British Pharmaceutical Conference, but themessage was the same. The NHS was not immune toeconomic reality, could not stand in isolation from the

economy, and must live within the nation’s means. He

applied this standpoint to the family practitioner service,where "we must adopt the same rigorous approach to thequest for value for money". Cost control was a challenge hewas determined to face. It was no longer enough to say merelythat the FPS budget was demand-determined. "We have tomake sure we know what determines expenditure... and putourselves in a position to influence more directly the factorsby which expenditure is determined". There would have tobe a re-examination of the way in which services are provided.Mr Clarke’s angry tone and Mr Fowler’s dark hints

actually result less from irritation at public attacks on theirpolicy than from the tremendous pressure their Departmentis now facing from the Treasury and the Prime Minister.

This week Mr Fowler had his first meeting with the ChiefSecretary to the Treasury, Mr Peter Rees, in the series ofbilateral inter-Departmental meetings which comprise theannual public expenditure review. The Treasury lopped &pound; 97million from this year’s health spending in a recent

emergency measure, and it is hoping to chop another largeamount from future planned spending. The main targets ofthe Treasury strategy for the NHS are the cost of manpowerand the mushrooming expense of the Family PractitionerService. Out of a total NHS expenditure in Great Britain in1982-83 of 14 670 million, the FPS accounted for 3291million, which was &pound; 1594 million more than in 1978-79, theyear the present Government came to office.Mr Fowler has already instructed health authorities to lose

about 1’ .5% of their current manpower by next April. DHSSplanners are now looking at ways of changing the paynegotiation systems of the NHS in a way that would giveMinisters more control over pay offers and conditions ofservice. At the same time, he is pondering how to respondmost effectively to the independent management consultants’report on the FPS, criticising financial control. He is

planning a rearrangement of the Pharmaceutical PriceReview Scheme which will reduce the profit which drugcompanies make from their NHS contracts. It is hoped thatthe cost of the FPS in the current financial year will turn outto be about &pound; 3453 million, &pound;162 million up on last year. Theincrease between 1981-82 and 1982-83 was 411 million.But in spite of these economies, the Treasury is stilldetermined to keep squeezing health expenditure. Mr Fowlerknows that the pressure on his Department’s budget willsteadily increase.One element of the cost of the FPS that has not come under

review at the DHSS is the item-of-service payments to generalpractitioners. In this area there has been a dramatic rise overrecent years, and some GPs openly describe how they use thesystem to increase practice remuneration. In 1982-83 GPs inEngland received from the DHSS the following payments:for vaccinations and immunisation, &pound; 11 million; cervical

cytology tests &pound; 2.3 3 m; contraceptive advice, &pound; 15.6 m;inserting IUDs, &pound;2.9 9 m; maternity services, &pound;29.7 7 m;emergency treatment, &pound; 0. 6 m; night visits, &pound;8 m; and dentalhaemorrhage, &pound;0. 1m, making a total of about 70 million.

Children Who Smoke

Schoolchildren aged 11-16 are smoking nearly 60 millionworth of cigarettes a year, according to a Government-commissioned survey (see p 751), and the DHSS Under-Secretary Mr John Patten, is very concerned about thesituation. The children’s teachers and their parents must

intensify their efforts to explain to children the dangers of