Sustainable waste management in the UK: the public health role.

This paper discusses waste management in the UK and its relationship with health. It aims to outline the role of health professionals in the promotion of waste management, and argues for a change in their role in waste management regulation to help make the process more sustainable. The most common definition of sustainable development is that by the Brundtland commission, i.e. "development that meets the needs of the present without compromising the ability of future generations to meet their own needs". Managing waste sites in a manner that minimises toxic impacts on the current and future generations is obviously a crucial part of this. Although the management of waste facilities is extremely complex, the Integrated Pollution Prevention and Control regime, which requires the input of public health professionals on the regulation of such sites, means that all waste management installations should now be operating in a fashion that minimises any toxicological risks to human health. However, the impacts upon climate change, resource use and health inequalities, as well as the effects of waste transportation, are currently not considered to be part of public health professionals' responsibilities when dealing with these sites. There is also no requirement for public health professionals to become involved in waste management planning issues. The fact that public health professionals are not involved in any of these issues makes it unlikely that the potential impacts upon health are being considered fully, and even more unlikely that waste management will become more sustainable. This paper aims to show that by only considering direct toxicological impacts, public health professionals are not fully addressing all the health issues and are not contributing towards sustainability. There is a need for a change in the way that health professionals deal with waste management issues.

Health care technology in the United Kingdom.

The UK National Health Service (NHS) is based on the principle that everyone is entitled to any kind of medical treatment for any condition, free of charge. The NHS is funded primarily from general tax revenues. The health service is presently in the middle of a profound change in philosophy and practice. Health authorities have been given specific responsibility for identifying their population's health needs and for using public money to buy services under a specific contract so as to meet those needs. Health care technology assessment (TA) has also developed very rapidly in the UK recently. While the limited budgets of the NHS have controlled expenditures for health care, there has not been a coherent policy for technology development until very recently. During the past decade, awareness of the concepts of appropriateness, effectiveness, and cost-benefit analysis have moved to center stage on the agenda of policy makers. A new R&D strategy in the NHS is emphasizing technology assessment as an aid to choice and management of technology. The increased necessity for making choices, and the increasing availability of results from health care TA, seem to indicate that such research will have an increasing impact on health care and its management.

What did audit achieve? Lessons from preliminary evaluation of a year's medical audit.

OBJECTIVE: To evaluate the experience of a year's audit of care of medical inpatients. DESIGN: Audit of physicians by monthly review of two randomly selected sets of patients' notes by 12 reviewers using a detailed questionnaire dedicated to standards of medical records and to clinical management. Data were entered into a database and summary statistics presented quarterly at audit meetings. Assessment by improvement in questionnaire scores and by interviewing physicians. SETTING: 1 District general hospital. PARTICIPANTS: About 40 consultant physicians, senior registrars, and junior staff dealing with 140 inpatient records. MAIN OUTCOME MEASURES: Median scores (range 1 to 9) for each item in the questionnaire; two sets of notes were discussed monthly at "general" audit meetings and clinical management of selected common conditions at separate monthly meetings. RESULTS: A significant overall increase in median scores for questions on record keeping occurred after the start of the audit (p less than 0.01), but interobserver variation was high. The parallel audit meetings on clinical management proved to be more successful than the general audits in auditing medical care and were also considered to be more useful by junior staff. CONCLUSIONS AND ACTION: Medical audit apparently resulted in appreciable improvements in aspects of care such as clerking and record keeping. Analysis of the scores of the general audits has led to the introduction of agreed standards that can be objectively measured and are being used in a further audit, and from the results of the audits of clinical management have been developed explicit guidelines, which are being further developed for criterion based audit.

An evaluation of the costs and outcome of adult intensive care in two units in the UK.

To test the feasibility and value of an economic appraisal of intensive care, a retrospective follow-up study was performed in two intensive care units in England. Clinical activity data was extracted from the records of 100 consecutive admissions to each unit and used to cost the care received by each patient during their stay in the units. Outcome was measured in terms of survival and quality of life six months after admission. Mortality at discharge from the units was 25% and 15% rising to 31% and 38% respectively six months after admission. Between one-third and one-half of patients alive at six months reported that their health continued to restrict aspects of their daily activities and one-fifth reported serious disability or distress. Total costs averaged 2,000 pounds and 2,280 pounds, equivalent to 525 pounds and 465 pounds per in-patient day. Poor outcome was associated, though not always significantly, with increased age, severity of illness and increased costs. The small sample size and heterogeneous nature of intensive care prevent firm conclusions being drawn from this study but the results indicate that such investigations are both feasible and potentially rewarding.