Search

1992-3, without a parallel increase in activity. Last year, providers' deadlines for issuing prices slipped several times, causing chaos to purchasers. East Birmingham's last contract was signed in August instead of the preceding March. The new regional edict is: "There are deadlines; we do not accept changes thereafter." Howard Shaw was less enthusiastic than his director of corporate management about the workings of the intemal market. "We're two months ahead of last year, but I'm not sure we've leamt that much. I don't think we've understood how to play the market, or even if the market's to be played because of the whole complexity of the system. We've got 20 units providing 50 specialties-for inpatients, day cases, and outpatients. There's a price and a volume for each of these, and you can have price and volume variance on all these contracts. So you've got this mass of data, and we can't make head or tail of it." His opinion was echoed by Robert Marriott. He did not think that you could decide at this stage whether the outcome of the reforms was good or bad. "Mostly it seems confusion-because of the demands being made on both purchasers and providers." Perhaps in a year's time things will be clearer.

Editor—The Vigabatrin Paediatric Advisory Group, which in 1998 produced a guideline to “help clinicians when prescribing vigabatrin in children,” has now revised it.1,2 We, the steering committee of the United Kingdom infantile spasm study (UKISS), responded to the original guideline.3 Our opinion was that there is no evidence that vigabatrin is a better treatment of infantile spasms than hormonal treatments, such as prednisolone and synthetic adrenocorticotrophic hormone preparations. When we challenged the claim that vigabatrin is the drug of choice, the advisory group offered no rebuttal. Now the claim is stated again, without any appropriate new evidence being produced. Indeed, the finding that visual field losses attributable to vigabatrin occur in children as well as adults strengthens any challenge to the guideline's claim. We stand by our argument that no one has yet determined the best first line treatment for infantile spasms. To back our challenge we cited the one randomised trial that has compared vigabatrin and adrenocorticotrophic hormone; confidence intervals for this suggest that vigabatrin is unlikely to have a superior treatment effect.4 Also, we pointed to a lack of studies using neurodevelopmental outcome measures and to new and emerging information about the safety of vigabatrin. Our desire to gather reliable data is shared by many paediatricians and paediatric neurologists: consultants in over 140 health districts are helping our study to collect evidence about these treatments. Before clinicians can decide if any of the first line treatments for infantile spasms might reasonably be described as the drug of choice they will need to examine (when they become available) the results of studies such as the United Kingdom infantile spasm study.