Health care contracts in Britain and the United States: a case for technology transfer?*

One unexpected point of convergence between the British and North American health care systems is the increased use of negotiated contracts to govern relationships between purchasers and providers. In Britain, the internal market reforms introduced a special regime of National Health Service (NHS) contracts; in the United States there has been a move from disorganization towards integration with the emergence of larger purchasing coalitions and provider organizations. While, in the past, US patients were simply billed for services or assigned claims to the provider, it is now common for payments to be made directly from purchaser to provider and for the terms of these transactions to be set out in contracts. This paper draws on the reading of contracts, interviews with contracting parties, and ongoing research on NHS contracting in Wales to compare contracting practice within the two systems. It examines how the very different environments of the public, hierarchically-regulated NHS and the private health care market of the US influence the detailed content of contract clauses. The analysis passes over similarities, different solutions to common problems, and fundamental differences of approach, before considering the possibilities for transfers of contracting ‘technology’.     

Parathyroid hormone-related protein in tissues of the emerging frog (Rana temporaria): immunohistochemistry and in situ hybridisation

Using antiserum to human parathyroid hormone-related protein (1–16) [PTHrP(1–16)] we have examined tissues of the common frog ( Rana temporaria ) for the presence of immunoreactive PTHrP (irPTHrP) at the stage of emergence from water to land. irPTHrP was detected in dorsal and ventral stratum granulosum of the skin, in the developing ovary, striated muscle and the choroid plexus epithelium of the brain as well as in the olfactory gland epithelium and olfactory lobe neurons of the brain. In the pituitary and hypothalamus irPTHrP protein could be demonstrated in the median eminence, infundibular stem and principally in the neural lobe and pars distalis of the pituitary with weak reaction in the pars intermedia. In situ hybridisation of the same tissues with an oligonucleotide probe to chicken PTHrP 55–65 clearly showed the presence of mRNA for PTHrP-like molecule in all the tissues containing irPTHrP. There was a major inconsistency in the pituitary in that the highest level of gene expression, assessed by in situ hybridisation, was found in the pars intermedia with only very low expression in the pars distalis and neural lobe and undetectable levels in the infundibular stem and median eminence. These observations suggest that tissues of the frog synthesise a PTHrP-like molecule but that in the pituitary the pars intermedia cells may export the protein to cells in other regions of the pituitary and hypothalamus.     

Fatal pulmonary embolism following spinal anaesthesia for Caesarean section

Pulmonary embolism remains one of the commonest causes of maternal death. Regional blockade is reported to decrease the incidence of postoperative thrombo-embolic disease. We describe a case in which a fatal pulmonary embolism followed an emergency Caesarean section for which the patient was given a spinal anaesthetic. We believe it to be the first time this has been reported.     

CONTINUOUS SUBARACHNOID INFUSION OF 0.125% BUPIVACAINE FOR ANALGESIA DURING LABOUR

We have studied 20 primiparous women requesting pain relieffor labour, to determine the feasibility of subarachnoid infusionsof bupivacaine for analgesia. A 28-gauge catheter was insertedinto the subarachnoid space through a modified 22-gauge Sprotteneedle. After a bolus dose of up to 7.5 ml of 0.25% bupivacaine,a continuous infusion of 0.725 % bupivacaine was commenced.If analgesia became inadequate, additional 0.5-ml boluses of0.25% bupivacaine were given (mean number of top-ups 2.8; range0–6). Persistent perineal pain occurred in four womenand this was relieved by 0.5% hyperbaric bupivacaine. Analgesiawas good or excellent in 75 of 20 mothers within 70 min andin 79 of 20 within 30 min, and it remained good or excellentthroughout labour and delivery. Motor block was complete inthree of the women who needed hyperbaric 0.5% bupivacaine. Therewere no difficulties with insertion of the catheter, no episodesof significant hypotension (systolic arterial pressure lessthan 700 mm Hg) or postdural puncture headache. Seven mothersdelivered their babies vaginally, eight required assistancewith forceps and five needed a Caesarean section.