This paper reports on a randomised controlled trial comparing the acquisition and retention of cardiopulmonary resuscitation (CPR) skills by lay persons trained in three variations of basic life support. Training was provided either in 1992 European Resuscitation Council (ERC) guidelines, or in the 1997 International Liaison Committee on Resuscitation (ILCOR) Advisory Statement (adopted with minor revisions as 1998 ERC guidelines), and an American Heart Association ‘call first’ version of the 1997 ILCOR statement. Evaluation of manikin CPR using the established Cardiff tests (CARE and VIDRAP) showed that 51% of those trained in the current ILCOR guidelines performed effectively compared with 38% trained in the ERC 1992 guidelines and 25% trained in the ‘call first’ variation (P<0.01). Whilst the current ERC and ILCOR guidelines appeared easiest to learn, retention at 6 months was poor (14% effective) irrespective of method.

We have investigated a method of teaching community CPR in three stages instead of in a single session. These have been designated bronze, silver, and gold stages. The first involves only opening of the airway and chest compression with back blows for choking, the second adds ventilation in a ratio of compressions to breaths of 50:5, and the third is a conversion to conventional CPR. In a controlled randomised trial of 495 trainees we compared the performance in tests immediately after instruction of those who had received a conventional course and those who had had the simpler bronze level tuition. The tests were based on video recordings of simulated resuscitation scenarios and the readouts from recording manikins. Differences occurred as a direct consequence of ventilation being required in one group and not the other, some variation probably followed from unforeseen minor changes in the way that instruction was given, whilst others may have followed from the greater simplicity in the new method of training. A careful approach was followed by slightly more trainees in the conventional group whilst appreciably more in the bronze group remembered to shout for help (44% vs. 71%). A clear advantage was also seen for bronze level training in terms of those who opened the airway as taught (35% vs. 56%), for checking breathing (66% vs. 88%), and for mentioning the need to phone for an ambulance (21% vs. 32%). Little difference was observed in correct or acceptable hand position between the conventional group who were given detailed guidance and the bronze group who were instructed only to push on the centre of the chest. The biggest differences related to the number of compressions given. The mean delay to first compression was 63 s and 34 s, and the mean duration of pauses between compressions was 16 s and 9 s, respectively. Average performed rates were similar in the two groups, but more in the conventional group compressed too slowly whereas more in the bronze group compressed too rapidly. Observations were made for only three cycles of compression, but extrapolating these to the 8 min often considered a watershed for chances of survival for victims of cardiac arrest, an average of 308 compressions would be expected from those using conventional CPR compared with 675 for those using bronze level CPR. The implications of this difference are discussed.

Two independent samples of 800 lay CPR trainees from an original cohort of 7584 were surveyed postally 4 years after training. Only 2% of respondents had used CPR, but 92 had used other aspects of their life support training. Those who had retrained were more confident than those who had not and 89% of those who had not retrained were willing to do so. More than 80% expressed willingness to perform full CPR on casualties who were unknown to them, but this fell to 40% where facial blood was present and 48% where the victim was a gay man.

This paper presents the second part of the validated Cardiff test for one rescuer basic life support skills, based on observation of video recording combined with the Recording Resusci Anne printout (VIDRAP). The authors believe that this is a robust evaluation tool which is capable of assessing the potential value to a casualty of a simulated resuscitation. The adoption of a widely accepted test methodology would facilitate comparison of research in different centres, which is not possible at present.

Basic life support is a crucial part of the Chain of Survival. Unfortunately, however the skill is complex and cannot readily be acquired--let alone retained--in the course of a single training session. Although the problem has long been recognised, no new strategies have been widely implemented to counter the problem. We believe that staged teaching of CPR might provide a solution, and we have devised a program to test this new method. It involves three stages of instruction that we have called bronze, silver, and gold standards. The bronze standard involves opening the airway and providing chest compression without active ventilation: this alone may widen the window of opportunity for successful defibrillation in adult victims in out-of-hospital cardiac arrest. Ventilation is introduced at silver stage using a ratio of 50:5, with emphasis on its value in the resuscitation of children being used as motivation to bring people back for a second period of instruction. The gold stage teaches conventional CPR. A pilot study has been encouraging and a randomized trial on skill acquisition and skill retention is planned.

More widespread public debate on rationing is essentialEditor-We find it significant that none of the clinicians who contributed to the conference "Rationing in the NHS: Time to Get Real" signed the open letter to Frank Dobson. 1 In the letter, rationing is defined as occurring when not all health services can be provided to everybody who might benefit from them, a definition so broad that it can be said always to have existed.Yet most British clinicians would not recognise the examples given as rationing.A young woman with high cholesterol as a single risk factor for coronary heart disease may be "denied" drug treatment and given dietary advice instead simply because the risks of side effects outweigh the marginal benefit; this is rational, not rationing.Again, "denying" magnetic resonance imaging for uncomplicated migraine in a young person has nothing to do with cost: the risks of iatrogenic anxiety and distress are far greater than any possible benefit from such intervention.The authors do the cause of so called smart rationing a disservice by these examples.This debate is too important to be "dumbed down" in this way.Whenever rationing is discussed there is a tension between those whose professional discipline (health economics, medical ethics, or policy analysis) allows them to work with broad underlying principles and those who are constantly brought face to face with the limitations of these principles through daily contact with patients.The former are much more likely to believe that it is possible and appropriate to base all rationing decisions on a series of well argued principles.Life for the latter is far messier: it is often impossible to apply broad principle to individual cases, let alone find a "currency of comparison" 2 that will enable the claims of, for example, a dying older person on an understaffed geriatric ward to be ranked against those of a patient with multiple sclerosis who might benefit from interferon beta.Struggling to make these sorts of comparisons is painful; the examples given in the open letter tax no one and thereby offer false hope of easy solutions.It is because the choices are difficult that more widespread public debate is essential.Only through such a debate can we all, as citizens, realise what is happening to the NHS, consider if that is the NHS that we want, and decide how much of our taxes an NHS worthy of the name deserves.

Members of the public recruited by means of a local newspaper campaign for basic life support instruction by mass training sessions. Six hundred and seventy-two were trained and a random sample of 241 completed a questionnaire on their attitudes and willingness to attempt cardiopulmonary resuscitation in an emergency. At the end of the course almost all (99%) approved the concept of community training and 198 (82%) believed themselves capable of saving a life using the techniques they had been taught. Sixty-seven percent of respondents were related to someone with a heart problem and more than 97% expressed willingness to resuscitate a relative. Half would be willing to attempt resuscitation in unpleasant circumstances, but only a quarter thought that they might do so if the casualty had vomited. The campaign was successful in recruiting members of the public related to those with a higher risk of cardiac arrest and producing life supporters who intended to use their skills, should they be required.

Members of the public were recruited by means of a local newspaper campaign for basic life support instruction by mass training sessions. Six hundred and seventy two were trained and a random sample of 241 completed a questionnaire on their attitudes and willingness to attempt cardiopulmonary resuscitation in an emergency. At the end of the course almost all (99%) approved the concept of community training and 198 (82%) believed themselves capable of saving a life using the techniques they had been taught. Sixty-seven percent of respondents were related to someone with a heart problem and more than 97% expressed willingness to resuscitate a relative. Half would be willing to attempt resuscitation in unpleasant circumstances, but only a quarter thought that they might do so if the casualty had vomited. The campaign was successful in recruiting members of the public related to those with a higher risk of cardiac arrest and producing life supporters who intended to use their skills, should they be required.

The value of instructing members of the public in CPR is now widely recognised, but community training schemes which rely largely on volunteers may fail to reach their targets. CPR training for lay people is often a once only activity and it has been shown that, without revision, skills deteriorate rapidly. By teaching CPR in secondary schools all social classes and ethnic groups could be reached, and retention of skills improved by regular revision. Health education has shown that it may be beneficial to use older pupils as instruction assistants.