Multiple sclerosis: what can and cannot be done.

veloped mostly in the past five years, and he is convinced that although an expensive specialty it should be protected from cuts. "There is no doubt that neonatal intensive care saves the lives of many babies and that is of incalculable value, but perhaps more important in an unemotional economic sense is the improved quality of the babies that survive." Institutional care of the physically and mentally handicapped is enormously expensive. Neonatal intensive care reduces the number of brain-damaged babies and therefore, although expensive, can ultimately save large amounts of money. "Cuts here would be self-defeating." Turning to conventional paediatrics, Dr Horace thinks that there is more room for saving here. "The first thing to do is to use hospital time, which is expensive, more efficiently. Paediatrics has always been a specialty that aimed to keep patients out of hospital as much as possible, but even so there is room for improvement." Day beds are already much used but could be used more. Every time a consultant admits a child he should ask himself whether the admission is really necessary. And then once patients are in the hospital the time should be used as efficiently as possible. Tests should be arranged before the child is admitted, and he should be allowed out as soon as possible and not be kept waiting for results or the arrival of a tertiary care specialist. And patients should be allowed out at the weekend whenever possible. Outpatient clinics could be used much more efficiently as well. "Consultants have tended to move too far away from the genuine consultation. They should see a patient referred by a general practitioner, give the GP an opinion, and leave the continuing management to him." Clinics tend to fill up with patients having follow-ups who could usefully be discharged. This is often because the follow-up patients are seen by junior staff, who are understandably rather timid about discharging. "Consultants should intervene in these clinics and discharge more patients." Although consultants are paid a fee for domiciliary visits, Dr Horace believes that the visits often result in a saving for the Health Service. If a GP is worried about a child acutely ill then he has the choice of sending the child up to the hospital to be seen by a registrar or calling a consultant out. A registrar will often feel obliged to admit the child, but a consultant …