results comparable to and in some ways superior to more traditional forms of care (W D Savage and R M Cochrane, Nivel international conference on primary care obstetrics and perinatal health, s'Hertogenbosch, 1991). We accept that such a scheme, in which hospital specialists visit local surgeries during their antenatal clinics and in which women therefore need not attend hospital at all, would be inappropriate in some areas. Nevertheless, some may wish to emulate the idea for the benefits outlined above and for the fruitful interprofessional respect that such care engenders. WENDY SAVAGE RUTH COCHRANE SIVA PATHASUNDARAM Academic l)epartment of (iencral Practice and Primars Care, Medical Colleges of St Bartholomcw's and The London Hospitals, London EC 1M 6BO I Chamberlain G. ABC of antenatal care: orgamisationi of antenatal
care. B.lfj 1991;302:647-50. (16 Mtarch.) 2 ravlor R. Satellite clinics in maternity care. Alidwife. Health I isilor and Communitv Nurse 1986;22:287-8. 3 McKee 1. Community antenatal care: the Sighthill community atitenatal care scheme. In: Zander L, Chamberlain G, eds. I're:gnancy%' care for the 1980s. London: RSM, MacMillan, 1984: 19-38. 4 Robson J, Boomia K, Sasage W. Reducing delay in booking for antenatal care. ] R Coll Gen Pract 1986;36:274-5. 5 Newall Al, t)aw EG. Setting up tteighbourhood antenatal clinics: problems cncounitered in the inner city. Practitioner 1984;228: 1089-9 1. 6 Attonymous. Infant and perinatal mortality 1989: l)HAs. OPCS Monitor 1990;No 1, OH3 90/1.
Reporting of fine needle aspiration SIR,-We have three years' experience with fine needle aspiration-at a weekly surgical breast clinic. We would agree with Mr J Michael Dixon that the method is accurate, and prompt reporting allows repeat aspirations if the material initially obtained is inadequate. It reduces the patient's anxiety and avoids unnecessary return outpatient visits. There are many additional advantages not mentioned by Mr Dixon. Fine needle aspiration is a cost effective technique. It facilitates education of junior surgeons in aspiration technique as the cytopathologist provides immediate feedback as to the adequacy of material obtained and will, if required, demonstrate the correct technique of aspiration and preparation of material. A trained counsellor is in attendance and can provide immediate counselling to patients with suspicious or malignant lesions. The presence of a cytopathologist at the clinic provides a useful opportunity for discussion of difficult cases. The aspiration can be performed by either the surgeon or the cytopathologist and this allows a speedier throughput of patients. In general, however, the surgeon will perform the aspiration. We disagree with the statement that a "technician and an experienced cytopathologist have to be available to stain and report the findings." With the Diff Quik stain both staining and reporting are easily done by a cytopathologist. Mr Dixon wonders why the system is not more widely used in Britain. The technique is time consuming, requiring the cytopathologist to attend at the surgical clinic for several hours each week. There is at present a shortage of experienced cytopathologists, and heavy routine work commitments in the laboratory prevent many from being available to provide what is undoubtedly a valuable service. MARIA NAYAGAM JOAN M McCUTCHEON A E YOUNG St 'IThomas's Hospital, London SE 1 7EH
JMNI. Immediate reporting of fine needle aspiration of breast lesions. BM_7 1991;302:428-9. (23 February.)
I Dixon
BMJ
VOLUME
302
13
APRIL
1991
Diagnosing breast carcinoma in young women
cvtological diagnosis of breast cancer in young women. Br] Surg 1989;76:835-7. 4 Barrows GM, Anderson TJ, Lamb J, Dixon JM. Fine needle aspiration of breast cancer: relationship of clinical factors to cytology results in 689 primary malignancies. Cancer 1986;58:
SIR,-Based on a 19 year review of the diagnosis of breast carcinoma in young women, Dr A Yelland and colleagues seem to recommend that all discrete lumps in young women should be excised.' Diagnostic techniques have clearly improved over recent years and conclusions from this review must be questioned. The authors have confirmed our previously published findings that clinical examination and mammography have a low sensitivity for detecting breast cancer in young women.' Although they indicate that ultrasonography has been used in their centre, they do not present any results for this investigation, which is disappointing as this investigation is clearly useful in young women, in whom the sensitivity of mammography is low.' Of greatest concern, however, are their results for fine needle aspiration cytology. We have looked at the factors influencing the accuracy of fine needle aspiration cytology and have not found age to be an important factor.24 It is clear from our results that the accuracy of fine needle aspiration cytology has increased significantly over the past decade. Of the last 30 women with palpable breast cancer under the age of 36 years treated in our unit over the past three and a half years, all had fine needle aspiration and the findings reported as malignant in 27, suspicious in two, and acellular in one. If the unsatisfactory specimen is included then this gives a sensitivity for fine needle aspiration cytology of 97%. Sensitivity is usually calculated after excluding unsatisfactory aspirates, and if this is done the sensitivity for breast cancer in young women treated in our unit is 100% (compared with 78% reported by the group at St George's). These results are similar to those published recently by the group from Southampton.' It would be important to know what the results of cytology were over the past five years in the unit at St George's. If they are similar to our own and those of the Southampton group then the whole message of the paper by Dr Yelland and colleagues is undermined. Our current management in young women with clinically benign breast lumps is to perform a fine needle aspirate on all women. If the fine needle aspirate confirms that the lesion is benign then the patient is reviewed. Most patients who have discrete lumpy areas are usually then reassured and discharged, and an unnecessary biopsy is avoided. This approach has been shown to be safe.' Patients who have a clinical and cytological diagnosis of a fibroadenoma are offered the opportunity of having their lump removed under local anaesthesia or of keeping the lump under observation. Those patients who elect to keep their lump then undergo an ultrasound examination, which allows confirmation of the benign nature of the lesion and measurement of its size. The lesions are then scanned at three months, six months, and one year as we are currently monitoring the course of fibroadenomas. Increase in size is an indication for excision, but as yet we have not identified any patient whose lump has got bigger and therefore had to be excised. Over 90% of patients are currently opting for observation only, and this figure is similar to that reported in a study from Oxford.' The view that young women with breast lumps wish to have them excised is therefore clearly incorrect.
1493-8. 5 Dixon JM, Clarke PJ, Crucioli V, Dehn 'I'CB, Lee ECG, Greenall MJ. Reduction in the biopsy rate in benign breast disease using fine needle aspiration cytology with immediate reporting. Br] Surg 1987;74:1014-6.
J MICHAEL DIXON Royal Infirmary, Edinburgh EH3 9YW' A, G.raham MsD, Trott PA, c1t al. Diagnosing breast carcinoma in young women. BMJf 1991;302:618-20. (16 March.) 2 Dixon JMW, Anderson TJ, Lee D. Stewart HJ. Fine needle aspiration cytology in relationship to clinical examination and mammography in the diagnosis of a solid breast mass. BrJ Surg 1954;74: 593-6. 3 Ashley S, Royle GT, Corder A, et al. Clinical, radiolttgical and
1
Ytelland
AUTHORS' REPLY,-We compliment Mr J Michael Dixon and his colleagues on the extreme accuracy of diagnosis of cancer of the breast in patients under 36 in a small series of 30 patients. However, we would respectfully draw his attention again to the last paragraph of our paper, which states: "We suggest that centres not possessing adequate cytological and combined mammographic facilities should excise all discrete breast masses in this age group without previous investigation. We also suggest that the poor detection rate by general practitioners warrants all young patients presenting with a breast lump being referred to a surgeon with an interest in breast disease."' We think that it is a matter for discussion as to whether one can safely leave a presumed fibroadenoma in the breast with the added anxiety of repeated assessment and evaluation. We agree that most patients who have discrete lumpy areas can usually be reassured after evaluation. However, we were discussing a discrete mass. The workload of long term follow up in our unit would become prohibitive. Finally, a 100% accuracy in diagnosing carcinoma by cytological, radiological, and clinical means is a laudable aim but, in our opinion, is rarely achieved. R C COOMBES H T FORD J-C GAZET St George's Hospital, London SW 17 OQT 1 Yelland A, Graham MD, Trott PA. Diagnosing breast carcinoma in young women. BMJ 1991;302:618-20. (16 March.)
Compensation for medical accidents SIR,-The article by Mr Brian Capstick and colleagues on compensation for medical accidents raises a number of interesting issues-dealth with, adequately I believe, by my NHS (Compensation) Bill. He raises the problem of causation. It has been asserted by those opposed to the introduction of a no fault scheme that victims of medical accidents have as much difficulty in establishing causation as they do in proving negligence. As a result, they argue, no fault compensation will not assist them as they will still be required to prove a causal link between medical care received and resulting injury. I, and all those who supported my bill, dispute this. Unless one introduces a general disability compensation scheme, compensating individuals on the basis of need and not on the basis of how they acquired their disability, there will always be a need to prove causation. There will always be some worthy cases that do not qualify. The main hurdle under the present tort based system is the need to prove negligence. Many injuries result from "reasonable" care. They deserve compensation. My bill would have ensured that. My bill would not have resulted in a flood of trivial claims or a massive increase in costs. The 1948 Law Reform (Personal Injuries) Act would have been amended to ensure that when awarding damages a court could have taken into account the availability of NHS care rather than having to base an award on provision of private care. The bill also provided for periodic payments of awards. The Medical Injury Compensation Board established
911
by the bill would have been able to recoup money paid out to victims of accidents attributable to third parties-for example, the drug companies. It is impossible to put an exact figure on the cost of a no fault scheme because one cannot cost the present system, but savings in legal fees and legal aid payments would be substantial. I can scarcely believe the assertion by Mr Capstick and colleagues that a no fault scheme would not ensure proper accountability for the medical profession. I would not have let a bill that did not deal adequately with this issue go forward in my name. The bill allowed the Medical Injury Compensation Board to investigate claims fully, give explanations, and where appropriate seek apologies and refer matters to other authorities, including disciplinary bodies. Lessons would have been learnt and accountability ensured. Mr Capstick and colleagues are also somewhat critical of my decision not to prevent claimants from choosing the current legal process if they desire. Under my bill, those dissatisfied with the board's offer could have refused it and pursued a claim in the courts. The board's offer would then have fallen. My view is that most claimants would rather pursue a claim with the board than entrust themselves to the vagaries of the legal process. One of the major deterrents to pursuing a tort action in the courts is the time it takes to complete the process. I am sure that most people would rather receive "less" now than take the risk of "more" later. As the government has implicitly accepted the concept of no fault compensation in their award to those haemophiliacs who contracted HIV from infected factor VIII there is no good reason not to extend the principle to all those suffering as a result of medical accidents. If £4bn can be found to save the government's face over the fiasco of the poll tax then the estimated £1 OOm needed to establish a no fault compensation scheme can, I am sure, be found immediately-financed perhaps by an increase in VAT? ROSIE BARNES House of Commons, London SW IA OAA
1 Capstick B, Edwards P, Mason 1). F^or debate: compensatiorn for medical accidents. BMJ 1991;302:230-2. (26 January.)
Re: VAMP revamp SIR,-Ms Linda Beecham's article on the crisis in VAMP' reminds me that the history of computing is littered with company failures and subsequently unsupported systems. The problem is that the failed company usually retains the software source code and documentation, thus rendering the system almost unsupportable even by a computer expert. A resource is available, however, that would overcome many of the traumas of software companies going out of business: an escrow agreement. None of the general practitioner computing companies seem to offer their customers the facility of placing their software in escrow; neither have any of the guides to buying a general practitioner computer system that I have seen mentioned this facility. Briefly, in an escrow agreement the supplier deposits its program's source code with a third partv, such as a solicitor or the National Computing Centre. The supplier contracts to supply the third party with all software updates and documentation.
If a supplier stops trading the escrow agreement is enforceable and the users who have subscribed to it have access to the source code and documentation to support and maintain their systems. Suppliers retain the copyright of their software while they are trading. Both users and suppliers normally contribute towards the costs of escrow.
912
In the case of general practitioner computer systems, the user group would seem ideally placed to negotiate an escrow agreement with the supplier. Should the supplier cease to trade, the user group could hire computer experts to support and maintain general practitioners' systems. I have only once had to enforce an escrow agreement when a system supplier ceased trading; the transition was not painless, but it enabled us to maintain the software until a suitable successor system was available. JOHN L BERRY Cheadle, Cheshire SK8 5HJ 1 Beecham L. Re: VAMP revamp.
March.)
BMJ7
1991;302:489-90. (2
SIR,-That practices "receive the basic computer system and £500 a month on average in return for supplying anonymised morbidity and prescription information"' is a common misconception, probably because the scheme was originally called a "no cost option." In reality, practices either buy the computer system or lease it from a leasing company independent of VAMP, paying the standard purchase and maintenance costs. In a separate agreement they then sell anonymised data for VAMP in return for a regular monthly payment. This payment is not for the computer, it is in respect of the increased work incurred in collecting data of a quality that is useful for morbidity analysis and research. It is important to get this matter straight for three reasons. Firstly, it is not the hardware and software development side of VAMP that was in financial trouble but the data payments side of the company-largely because the level of data payments had been extremely generous in the early stages. Secondly, it should be clear that, because the payment is for the work involved in producing data and not for the computers, practices on the research panel should not be excluded from direct reimbursement for computer purchase and maintenance costs. Thirdly, the scheme shows the value that the company has put on high quality data. For these routinely collected data to be useful they have to have a high level of completeness and accuracy, and this requires record keeping by the participating practices far above that normally required for the provision of general medical services. The profession is fortunate that independent companies have taken the initiative to build up such a research database, which is currently being validated; it might otherwise never have been realised. Although general practitioners will always prefer large fees with no risk, it may well be that the new profit sharing scheme will provide even greater incentives to good record keeping than the original one. M S LAWRENCE
West Steet Surgery. Chipping Norton, Oxfordshire OX7 5AA 1 Beecham L. Re: VAMP revamp. B.M7 1991;302:489-90. (2 March. )
Large computer databases SIR,-The recent editorial entitled "Large computer databases in general practice" is highly misleading as it relates to the VAMP database.' The VAMP validation study we reported in the BMJ was begun in mid- 1989, at a time when only a small fraction of practices enrolled in the VAMP research program had completed the 12 months of training for proper recording of clinical data.2 As noted in our paper, most practices entered the plan
between July 1989 and June 1990 and had not completed their training when the study was initiated. Thus the reported results related only to the practices enrolled earliest in the program. Currently over 500 VAMP practices encompassing some three riillion patients are considered to be up to standard, and our most recent studies indicate that the quality of the information available from practices which have come up to standard since the time of our validation study have continued to show a high standard of data quality. It is most important to understand that practices which come up to standard differ in principle from practices which do not only in regard to how thoroughly they record relevant data, not in terms of the effects of the drugs they prescribe. In studies of drug safety based on computer data it is critical that relevant data items be recorded routinely. The a priori standardised exclusion of data of inferior quality in no way influences the results of studies that are based on data of high quality. The suggestion that drug safety studies should be based on inadequately collected data as well as properly collected data simply to achieve the purpose of including a representative sample of doctors is a nonsense. It is simply not correct to state that drug safety studies should include a representative sample of doctors because such studies evaluate how drugs behave, not how doctors behave.3 We have no experience with the AAH Meditel data resource, but there is no a priori reason to assume that it is of the same quality as the VAMP data resource simply because they are both derived from general practice. The editorial concludes, based in part on our report, that "Early hopes for large databases have not been fulfilled" and that the VAMP data are of "poor quality";. but we conclude, based on our considerable firsthand experience with the VAMP data resource, that reasonable hopes for its utility have been surpassed by the high quality and size of the data available for research. HERSHEL JICK SUSAN S JICK LAURA E DERBY Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Lexington, Massachusetts 02173-5207, United States 1 Pringle M, Hobbs R. Large computer databases in general practice. BMJ7 1991;302:741-2. (30 March.) 2 Jick H, Jick SS, Derby LE. Validation of information recorded on general practitioner based computerised data resource in United Kingdom. BMJ7 1991;302:766-8. (30 March.) 3 Jick H, Vessey MP. Case-control studies in the evaluation of drug-induced illness. Am7 Epidemiol 1978;107:1-7.
Improving outpatient services SIR,-As reported, the National Audit Office recently published a review of NHS outpatient services, which was then the subject of discussion by the parliamentary Public Accounts Committee on 27 February.' In our review we examined the management of outpatient services in a sample of 10 hospitals. These hospitals also undertook surveys of a number of clinics for us, recording among other criteria the staffing levels, patients' waiting time in clinic, and the incidence of missing patient records. We found that many patients had to wait a long time after their arrival at the clinic before they were seen by the doctor-in 53% of clinics patients' average waiting time was less than 30 minutes, but in 40% it was between 30 minutes and an hour, and in 7% it exceeded an hour. We were therefore interested to read Dr M Jennings's account of his introduction of a new appointments system and its beneficial impact on patients' waiting times in clinics.2 Realistic appointment arrangements are clearly a great step towards achieving improvements. Studies like ours cannot prescribe ideal
BMJ VOLUME 302
13 APRIL 1991
care. B.lfj 1991;302:647-50. (16 Mtarch.) 2 ravlor R. Satellite clinics in maternity care. Alidwife. Health I isilor and Communitv Nurse 1986;22:287-8. 3 McKee 1. Community antenatal care: the Sighthill community atitenatal care scheme. In: Zander L, Chamberlain G, eds. I're:gnancy%' care for the 1980s. London: RSM, MacMillan, 1984: 19-38. 4 Robson J, Boomia K, Sasage W. Reducing delay in booking for antenatal care. ] R Coll Gen Pract 1986;36:274-5. 5 Newall Al, t)aw EG. Setting up tteighbourhood antenatal clinics: problems cncounitered in the inner city. Practitioner 1984;228: 1089-9 1. 6 Attonymous. Infant and perinatal mortality 1989: l)HAs. OPCS Monitor 1990;No 1, OH3 90/1.
Reporting of fine needle aspiration SIR,-We have three years' experience with fine needle aspiration-at a weekly surgical breast clinic. We would agree with Mr J Michael Dixon that the method is accurate, and prompt reporting allows repeat aspirations if the material initially obtained is inadequate. It reduces the patient's anxiety and avoids unnecessary return outpatient visits. There are many additional advantages not mentioned by Mr Dixon. Fine needle aspiration is a cost effective technique. It facilitates education of junior surgeons in aspiration technique as the cytopathologist provides immediate feedback as to the adequacy of material obtained and will, if required, demonstrate the correct technique of aspiration and preparation of material. A trained counsellor is in attendance and can provide immediate counselling to patients with suspicious or malignant lesions. The presence of a cytopathologist at the clinic provides a useful opportunity for discussion of difficult cases. The aspiration can be performed by either the surgeon or the cytopathologist and this allows a speedier throughput of patients. In general, however, the surgeon will perform the aspiration. We disagree with the statement that a "technician and an experienced cytopathologist have to be available to stain and report the findings." With the Diff Quik stain both staining and reporting are easily done by a cytopathologist. Mr Dixon wonders why the system is not more widely used in Britain. The technique is time consuming, requiring the cytopathologist to attend at the surgical clinic for several hours each week. There is at present a shortage of experienced cytopathologists, and heavy routine work commitments in the laboratory prevent many from being available to provide what is undoubtedly a valuable service. MARIA NAYAGAM JOAN M McCUTCHEON A E YOUNG St 'IThomas's Hospital, London SE 1 7EH
JMNI. Immediate reporting of fine needle aspiration of breast lesions. BM_7 1991;302:428-9. (23 February.)
I Dixon
BMJ
VOLUME
302
13
APRIL
1991
Diagnosing breast carcinoma in young women
cvtological diagnosis of breast cancer in young women. Br] Surg 1989;76:835-7. 4 Barrows GM, Anderson TJ, Lamb J, Dixon JM. Fine needle aspiration of breast cancer: relationship of clinical factors to cytology results in 689 primary malignancies. Cancer 1986;58:
SIR,-Based on a 19 year review of the diagnosis of breast carcinoma in young women, Dr A Yelland and colleagues seem to recommend that all discrete lumps in young women should be excised.' Diagnostic techniques have clearly improved over recent years and conclusions from this review must be questioned. The authors have confirmed our previously published findings that clinical examination and mammography have a low sensitivity for detecting breast cancer in young women.' Although they indicate that ultrasonography has been used in their centre, they do not present any results for this investigation, which is disappointing as this investigation is clearly useful in young women, in whom the sensitivity of mammography is low.' Of greatest concern, however, are their results for fine needle aspiration cytology. We have looked at the factors influencing the accuracy of fine needle aspiration cytology and have not found age to be an important factor.24 It is clear from our results that the accuracy of fine needle aspiration cytology has increased significantly over the past decade. Of the last 30 women with palpable breast cancer under the age of 36 years treated in our unit over the past three and a half years, all had fine needle aspiration and the findings reported as malignant in 27, suspicious in two, and acellular in one. If the unsatisfactory specimen is included then this gives a sensitivity for fine needle aspiration cytology of 97%. Sensitivity is usually calculated after excluding unsatisfactory aspirates, and if this is done the sensitivity for breast cancer in young women treated in our unit is 100% (compared with 78% reported by the group at St George's). These results are similar to those published recently by the group from Southampton.' It would be important to know what the results of cytology were over the past five years in the unit at St George's. If they are similar to our own and those of the Southampton group then the whole message of the paper by Dr Yelland and colleagues is undermined. Our current management in young women with clinically benign breast lumps is to perform a fine needle aspirate on all women. If the fine needle aspirate confirms that the lesion is benign then the patient is reviewed. Most patients who have discrete lumpy areas are usually then reassured and discharged, and an unnecessary biopsy is avoided. This approach has been shown to be safe.' Patients who have a clinical and cytological diagnosis of a fibroadenoma are offered the opportunity of having their lump removed under local anaesthesia or of keeping the lump under observation. Those patients who elect to keep their lump then undergo an ultrasound examination, which allows confirmation of the benign nature of the lesion and measurement of its size. The lesions are then scanned at three months, six months, and one year as we are currently monitoring the course of fibroadenomas. Increase in size is an indication for excision, but as yet we have not identified any patient whose lump has got bigger and therefore had to be excised. Over 90% of patients are currently opting for observation only, and this figure is similar to that reported in a study from Oxford.' The view that young women with breast lumps wish to have them excised is therefore clearly incorrect.
1493-8. 5 Dixon JM, Clarke PJ, Crucioli V, Dehn 'I'CB, Lee ECG, Greenall MJ. Reduction in the biopsy rate in benign breast disease using fine needle aspiration cytology with immediate reporting. Br] Surg 1987;74:1014-6.
J MICHAEL DIXON Royal Infirmary, Edinburgh EH3 9YW' A, G.raham MsD, Trott PA, c1t al. Diagnosing breast carcinoma in young women. BMJf 1991;302:618-20. (16 March.) 2 Dixon JMW, Anderson TJ, Lee D. Stewart HJ. Fine needle aspiration cytology in relationship to clinical examination and mammography in the diagnosis of a solid breast mass. BrJ Surg 1954;74: 593-6. 3 Ashley S, Royle GT, Corder A, et al. Clinical, radiolttgical and
1
Ytelland
AUTHORS' REPLY,-We compliment Mr J Michael Dixon and his colleagues on the extreme accuracy of diagnosis of cancer of the breast in patients under 36 in a small series of 30 patients. However, we would respectfully draw his attention again to the last paragraph of our paper, which states: "We suggest that centres not possessing adequate cytological and combined mammographic facilities should excise all discrete breast masses in this age group without previous investigation. We also suggest that the poor detection rate by general practitioners warrants all young patients presenting with a breast lump being referred to a surgeon with an interest in breast disease."' We think that it is a matter for discussion as to whether one can safely leave a presumed fibroadenoma in the breast with the added anxiety of repeated assessment and evaluation. We agree that most patients who have discrete lumpy areas can usually be reassured after evaluation. However, we were discussing a discrete mass. The workload of long term follow up in our unit would become prohibitive. Finally, a 100% accuracy in diagnosing carcinoma by cytological, radiological, and clinical means is a laudable aim but, in our opinion, is rarely achieved. R C COOMBES H T FORD J-C GAZET St George's Hospital, London SW 17 OQT 1 Yelland A, Graham MD, Trott PA. Diagnosing breast carcinoma in young women. BMJ 1991;302:618-20. (16 March.)
Compensation for medical accidents SIR,-The article by Mr Brian Capstick and colleagues on compensation for medical accidents raises a number of interesting issues-dealth with, adequately I believe, by my NHS (Compensation) Bill. He raises the problem of causation. It has been asserted by those opposed to the introduction of a no fault scheme that victims of medical accidents have as much difficulty in establishing causation as they do in proving negligence. As a result, they argue, no fault compensation will not assist them as they will still be required to prove a causal link between medical care received and resulting injury. I, and all those who supported my bill, dispute this. Unless one introduces a general disability compensation scheme, compensating individuals on the basis of need and not on the basis of how they acquired their disability, there will always be a need to prove causation. There will always be some worthy cases that do not qualify. The main hurdle under the present tort based system is the need to prove negligence. Many injuries result from "reasonable" care. They deserve compensation. My bill would have ensured that. My bill would not have resulted in a flood of trivial claims or a massive increase in costs. The 1948 Law Reform (Personal Injuries) Act would have been amended to ensure that when awarding damages a court could have taken into account the availability of NHS care rather than having to base an award on provision of private care. The bill also provided for periodic payments of awards. The Medical Injury Compensation Board established
911
by the bill would have been able to recoup money paid out to victims of accidents attributable to third parties-for example, the drug companies. It is impossible to put an exact figure on the cost of a no fault scheme because one cannot cost the present system, but savings in legal fees and legal aid payments would be substantial. I can scarcely believe the assertion by Mr Capstick and colleagues that a no fault scheme would not ensure proper accountability for the medical profession. I would not have let a bill that did not deal adequately with this issue go forward in my name. The bill allowed the Medical Injury Compensation Board to investigate claims fully, give explanations, and where appropriate seek apologies and refer matters to other authorities, including disciplinary bodies. Lessons would have been learnt and accountability ensured. Mr Capstick and colleagues are also somewhat critical of my decision not to prevent claimants from choosing the current legal process if they desire. Under my bill, those dissatisfied with the board's offer could have refused it and pursued a claim in the courts. The board's offer would then have fallen. My view is that most claimants would rather pursue a claim with the board than entrust themselves to the vagaries of the legal process. One of the major deterrents to pursuing a tort action in the courts is the time it takes to complete the process. I am sure that most people would rather receive "less" now than take the risk of "more" later. As the government has implicitly accepted the concept of no fault compensation in their award to those haemophiliacs who contracted HIV from infected factor VIII there is no good reason not to extend the principle to all those suffering as a result of medical accidents. If £4bn can be found to save the government's face over the fiasco of the poll tax then the estimated £1 OOm needed to establish a no fault compensation scheme can, I am sure, be found immediately-financed perhaps by an increase in VAT? ROSIE BARNES House of Commons, London SW IA OAA
1 Capstick B, Edwards P, Mason 1). F^or debate: compensatiorn for medical accidents. BMJ 1991;302:230-2. (26 January.)
Re: VAMP revamp SIR,-Ms Linda Beecham's article on the crisis in VAMP' reminds me that the history of computing is littered with company failures and subsequently unsupported systems. The problem is that the failed company usually retains the software source code and documentation, thus rendering the system almost unsupportable even by a computer expert. A resource is available, however, that would overcome many of the traumas of software companies going out of business: an escrow agreement. None of the general practitioner computing companies seem to offer their customers the facility of placing their software in escrow; neither have any of the guides to buying a general practitioner computer system that I have seen mentioned this facility. Briefly, in an escrow agreement the supplier deposits its program's source code with a third partv, such as a solicitor or the National Computing Centre. The supplier contracts to supply the third party with all software updates and documentation.
If a supplier stops trading the escrow agreement is enforceable and the users who have subscribed to it have access to the source code and documentation to support and maintain their systems. Suppliers retain the copyright of their software while they are trading. Both users and suppliers normally contribute towards the costs of escrow.
912
In the case of general practitioner computer systems, the user group would seem ideally placed to negotiate an escrow agreement with the supplier. Should the supplier cease to trade, the user group could hire computer experts to support and maintain general practitioners' systems. I have only once had to enforce an escrow agreement when a system supplier ceased trading; the transition was not painless, but it enabled us to maintain the software until a suitable successor system was available. JOHN L BERRY Cheadle, Cheshire SK8 5HJ 1 Beecham L. Re: VAMP revamp.
March.)
BMJ7
1991;302:489-90. (2
SIR,-That practices "receive the basic computer system and £500 a month on average in return for supplying anonymised morbidity and prescription information"' is a common misconception, probably because the scheme was originally called a "no cost option." In reality, practices either buy the computer system or lease it from a leasing company independent of VAMP, paying the standard purchase and maintenance costs. In a separate agreement they then sell anonymised data for VAMP in return for a regular monthly payment. This payment is not for the computer, it is in respect of the increased work incurred in collecting data of a quality that is useful for morbidity analysis and research. It is important to get this matter straight for three reasons. Firstly, it is not the hardware and software development side of VAMP that was in financial trouble but the data payments side of the company-largely because the level of data payments had been extremely generous in the early stages. Secondly, it should be clear that, because the payment is for the work involved in producing data and not for the computers, practices on the research panel should not be excluded from direct reimbursement for computer purchase and maintenance costs. Thirdly, the scheme shows the value that the company has put on high quality data. For these routinely collected data to be useful they have to have a high level of completeness and accuracy, and this requires record keeping by the participating practices far above that normally required for the provision of general medical services. The profession is fortunate that independent companies have taken the initiative to build up such a research database, which is currently being validated; it might otherwise never have been realised. Although general practitioners will always prefer large fees with no risk, it may well be that the new profit sharing scheme will provide even greater incentives to good record keeping than the original one. M S LAWRENCE
West Steet Surgery. Chipping Norton, Oxfordshire OX7 5AA 1 Beecham L. Re: VAMP revamp. B.M7 1991;302:489-90. (2 March. )
Large computer databases SIR,-The recent editorial entitled "Large computer databases in general practice" is highly misleading as it relates to the VAMP database.' The VAMP validation study we reported in the BMJ was begun in mid- 1989, at a time when only a small fraction of practices enrolled in the VAMP research program had completed the 12 months of training for proper recording of clinical data.2 As noted in our paper, most practices entered the plan
between July 1989 and June 1990 and had not completed their training when the study was initiated. Thus the reported results related only to the practices enrolled earliest in the program. Currently over 500 VAMP practices encompassing some three riillion patients are considered to be up to standard, and our most recent studies indicate that the quality of the information available from practices which have come up to standard since the time of our validation study have continued to show a high standard of data quality. It is most important to understand that practices which come up to standard differ in principle from practices which do not only in regard to how thoroughly they record relevant data, not in terms of the effects of the drugs they prescribe. In studies of drug safety based on computer data it is critical that relevant data items be recorded routinely. The a priori standardised exclusion of data of inferior quality in no way influences the results of studies that are based on data of high quality. The suggestion that drug safety studies should be based on inadequately collected data as well as properly collected data simply to achieve the purpose of including a representative sample of doctors is a nonsense. It is simply not correct to state that drug safety studies should include a representative sample of doctors because such studies evaluate how drugs behave, not how doctors behave.3 We have no experience with the AAH Meditel data resource, but there is no a priori reason to assume that it is of the same quality as the VAMP data resource simply because they are both derived from general practice. The editorial concludes, based in part on our report, that "Early hopes for large databases have not been fulfilled" and that the VAMP data are of "poor quality";. but we conclude, based on our considerable firsthand experience with the VAMP data resource, that reasonable hopes for its utility have been surpassed by the high quality and size of the data available for research. HERSHEL JICK SUSAN S JICK LAURA E DERBY Boston Collaborative Drug Surveillance Program, Boston University Medical Center, Lexington, Massachusetts 02173-5207, United States 1 Pringle M, Hobbs R. Large computer databases in general practice. BMJ7 1991;302:741-2. (30 March.) 2 Jick H, Jick SS, Derby LE. Validation of information recorded on general practitioner based computerised data resource in United Kingdom. BMJ7 1991;302:766-8. (30 March.) 3 Jick H, Vessey MP. Case-control studies in the evaluation of drug-induced illness. Am7 Epidemiol 1978;107:1-7.
Improving outpatient services SIR,-As reported, the National Audit Office recently published a review of NHS outpatient services, which was then the subject of discussion by the parliamentary Public Accounts Committee on 27 February.' In our review we examined the management of outpatient services in a sample of 10 hospitals. These hospitals also undertook surveys of a number of clinics for us, recording among other criteria the staffing levels, patients' waiting time in clinic, and the incidence of missing patient records. We found that many patients had to wait a long time after their arrival at the clinic before they were seen by the doctor-in 53% of clinics patients' average waiting time was less than 30 minutes, but in 40% it was between 30 minutes and an hour, and in 7% it exceeded an hour. We were therefore interested to read Dr M Jennings's account of his introduction of a new appointments system and its beneficial impact on patients' waiting times in clinics.2 Realistic appointment arrangements are clearly a great step towards achieving improvements. Studies like ours cannot prescribe ideal
BMJ VOLUME 302
13 APRIL 1991
