history wrong. When Liston completed the first operation in Britain under ether anaesthesia in 1842 he stepped back and said, "Gentlemen, the Yankee trick beats the French one." He was referring to the quick and slick effect of ether, which had been used two months before by Warren in Boston, as being superior to hypnosis, which had been in common use. I have myself been rightly criticised for using the word hypnosis in relation to acupuncture because it conjures up an image of a trance-like state and a dominant therapist. This documentary showed the patients being trained that their sensations were a product of their own minds and not the therapist's mind. As for an instructed trance-like state, the most startling episode of this documentary for me was when a patient ambled off the table after his varicose vein operation to take part in an obviously unscripted conversation with the witnesses. The proposal that phenomena should not be discussed unless they are attached to some plausible mechanism would lead to a considerable abbreviation of medical education. I am opposed to vacuous mechanical explanations such as "gate control theory" or "endorphins," as I am to gratuitous labelling. An intermediate cliche used here is "mind over matter." Pain is a property of the mind and is not matter. When the exponent of this technique went on to claim that his patients suffered no postoperative infections the medical witnesses immediately and forcefully challenged him for the data because they would be an example of mind over matter. Instead of dismissing this programme we should thank the BBC for a remarkable presentation of startling facts that left the viewer to get to work on meanings rather than to be diverted by irrelevant labels and explanations. PATRICK D WALL
University College London, London WC1E 6BT I McManus C. Only fools and angels. BMJ7 1991;302:1157-8. (11
Elderly and costly patients-Provided that they live within our practice's boundary we accept elderly and costly patients. Once they have registered, however, if we find that they cost considerably more than we originally budgeted for we will ask for, and get, more funds. If an unscrupulous practice refused, say, all patients over 75 this would quickly be picked up by the family health services authority, which would intervene. The "two tier" system-We agree with Mr Neil Kinnock that patients of fundholding practices get a better deal. That is why we joined the scheme and that is why we cannot agree with the Labour party when it says that we should scrap fundholding and all opt for the lower tier. The answer lies in extending the scheme to all practices. Smaller practices could arrange block contracts for surgery to avoid annual fluctuations and still be able to make savings in other spheres. Involvement of the community health council-We have had closer liaison with our community health council than ever before. It will be viewing our improvements shortly, and later in the summer we are meeting to discuss quality of care in the next year's contracts. We conclude that fundholding offers great benefits to patients and the efficiency of the whole NHS and should be encouraged to expand as fast as possible. A C JOHANSSON
Cantilupe Surgery, Hereford HRl 2JB I Association of Community Health Councils. GP fund-holding: profit or loss for patients? London: Association of Community Health Councils, 1991.
Computerised general practice data
SIR,-Further to the correspondence on computerised general practice data I am pleased to note Dr Kieran J McGlade's emphasis on the effort required to build a quality data resource' but surprised that little has been mentioned of the Fundholding general practice resultant benefits or of similar resources already SIR, -I and my partners wish to express our extensively used. Dr McGlade stated that there are no short cuts to concern at the mounting pressure against fundholding by general practitioners. We joined the establishing a general practice dataset. The VAMP scheme in April of this year, and our patients have scheme began in 1987, and the final, 950th practice was recruited in 1990. As most practices were already benefited in several ways. Physiotherapy based in our practice means that computerising from scratch an average of 12 our patients get treated almost immediately rather months was needed to reach an acceptable level of than waiting four weeks, and with less expense. A recording. We were therefore satisfied with the laboratory service at the practice yields a saving of first wave of 75 practices providing quality data by £4.00 per test; our patients also avoid the worry of August 1988.2 Today the research bank contains waiting for results. Testing for urinary infections 3-7 million patients from 575 practices and is still again gives an instant result, so that antibiotics are growing. We agree that quality cannot be achieved not given unnecessarily. The test costs £7.00 less overnight. It must also be maintained-the VAMP than the laboratory's costs. Pregnancy testing team includes nurses, concentrating on quality yields a saving of £5.00 per test. Minor surgery assurance, as well as epidemiologists, doctors, pharmacologists, computer programmers, and a saves £200 per operation. Finally, within the first year we will provide statistician. Dr McGlade continues, "Only well conceived, extra hospital operations for about 120 of our patients. We emphasise that these operations will designed, and supported projects will hold the not be done in our normal quota of operating interest and cooperation of general practitioners in time, and therefore patients of non-fundholding the long term." This has been shown by the practices will not suffer. We will be using spare majority of our practices moving from the no cost theatre capacity, especially during the summer, option (1987-91)2 to the new 25 year research when bed occupancy is usually low. This obviously scheme. While money injected into the no cost results in increased throughput and hence im- option promoted the growth of general practice computing, the new scheme, with a lower initial proved hospital efficiency. Some of the anxieties expressed in the Associa- financial reward, shows that care of patients has tion of Community Health Councils' document been their primary driving force. The benefits provided by multipurpose resources GP Fund-Holding: Profit or Loss for Patients?' can justify the pains of development. Speed and be allayed: The doctor-patient relationship-Money saved is flexibility are byproducts of having a large reusable not going into general practitioners' pockets. database of demographic, prescribing, and medical Patients in our practice see that it is being used to details on standby. Studies are observational, and improve their service, and increased numbers of therefore prescribing and recall are unbiased and patients have registered with the practice recently. many study designs are possible. North American May.)
BMJ VOLUME 302
8 JUNE 1991
data resources, such as the Saskatchewan databases, Group Health Co-operative of Puget Sound, and Medicaid,' have shown these benefits over several years. A general practice database in the United Kingdom includes morbidity events from primary and secondary care linked with community prescribing. Nevertheless, before any study is embarked on the limitations must be consideredfor example, flu is not always reported to a general practitioner, and the research protocol may not require it to be recorded.4 The need for a multipurpose research database in the United Kingdom was highlighted in 1985,5 but its development has been possible only because of computerisation. Currently, the United Kingdom has the only European resource of this kind for studies of drug safety, health economics, epidemiology of diseases, and NHS planning. Would this have happened without the push of private enterprise? GILLIAN HALL VAMP Health, London SW8 3QJ I McGlade KJ. Computerised general practice data. BMJ7 1991;302:1081. (4 May.) 2 Pringle M, Hobbs R. Large computer databases in general practice. BMJ7 1991;302:741-2. (30 March.) 3 Strom BL, ed. Pharmnacoepidemiology. New York: Churchill Livingstone, 1989. 4 Johnson N, Mant D, Jones L, Randall r. Use of computerised general practice data for population surveillance: comparative study of influenza data. BMJ 1991;302:763-5. (30 March.) 5 Grahame-Smith DG. Report of the working party on adverse drug reactions to the Committee on Safety of Medicines. II. London: Department of Health and Social Security, 1985.
GPs' opinions of available health services SIR,-The survey by Drs Nicholas R Hicks and Ian A Baker looking at Bristol and Weston general practitioners' opinions of their local health services' raises important points about the assessment of different aspects of quality in health care.2 Drs Hicks and Baker found that local general practitioners show considerable agreement in identifying which services are adequate in both quality and quantity. We suggest that general practitioners also have a corporate view on which aspects of quality are adequate or lacking in their local services and that this should inform the purchasing authorities' decisions on future contracting.
After an initial study of referral patterns in Tower Hamlets and Newham (commissioned jointly by the local forum and the family health services authority) a questionnaire was developed to obtain the views of general practitioners on aspects of quality. General practitioners were invited to rate local hospital services on a five point scale. They were also encouraged to identify which aspects of service delivery contributed to the rating given. Within Tower Hamlets 66% of general practitioners took part, representing 83% of practices within the health authority. There was considerable agreement over both the highest and the lowest rated services, with most general practitioners rating geriatrics and general surgery as good and ear, nose, and throat medicine and psychiatry as poor. It is worth noting that the geriatric services were rated highly in Tower Hamlets but lower in Newham, confirming that organisational aspects of a department, rather than the nature of the specialty, are being rated. The comments by general practitioners about the services they rated clearly identify accessibility for patients, communication with patients and with general practitioners, and the appropriateness of the service to local needs as the key quality indicators from the perspective of primary care (table). We agree with Drs Hicks and Baker's finding that general practitioners' priorities for
1405
University College London, London WC1E 6BT I McManus C. Only fools and angels. BMJ7 1991;302:1157-8. (11
Elderly and costly patients-Provided that they live within our practice's boundary we accept elderly and costly patients. Once they have registered, however, if we find that they cost considerably more than we originally budgeted for we will ask for, and get, more funds. If an unscrupulous practice refused, say, all patients over 75 this would quickly be picked up by the family health services authority, which would intervene. The "two tier" system-We agree with Mr Neil Kinnock that patients of fundholding practices get a better deal. That is why we joined the scheme and that is why we cannot agree with the Labour party when it says that we should scrap fundholding and all opt for the lower tier. The answer lies in extending the scheme to all practices. Smaller practices could arrange block contracts for surgery to avoid annual fluctuations and still be able to make savings in other spheres. Involvement of the community health council-We have had closer liaison with our community health council than ever before. It will be viewing our improvements shortly, and later in the summer we are meeting to discuss quality of care in the next year's contracts. We conclude that fundholding offers great benefits to patients and the efficiency of the whole NHS and should be encouraged to expand as fast as possible. A C JOHANSSON
Cantilupe Surgery, Hereford HRl 2JB I Association of Community Health Councils. GP fund-holding: profit or loss for patients? London: Association of Community Health Councils, 1991.
Computerised general practice data
SIR,-Further to the correspondence on computerised general practice data I am pleased to note Dr Kieran J McGlade's emphasis on the effort required to build a quality data resource' but surprised that little has been mentioned of the Fundholding general practice resultant benefits or of similar resources already SIR, -I and my partners wish to express our extensively used. Dr McGlade stated that there are no short cuts to concern at the mounting pressure against fundholding by general practitioners. We joined the establishing a general practice dataset. The VAMP scheme in April of this year, and our patients have scheme began in 1987, and the final, 950th practice was recruited in 1990. As most practices were already benefited in several ways. Physiotherapy based in our practice means that computerising from scratch an average of 12 our patients get treated almost immediately rather months was needed to reach an acceptable level of than waiting four weeks, and with less expense. A recording. We were therefore satisfied with the laboratory service at the practice yields a saving of first wave of 75 practices providing quality data by £4.00 per test; our patients also avoid the worry of August 1988.2 Today the research bank contains waiting for results. Testing for urinary infections 3-7 million patients from 575 practices and is still again gives an instant result, so that antibiotics are growing. We agree that quality cannot be achieved not given unnecessarily. The test costs £7.00 less overnight. It must also be maintained-the VAMP than the laboratory's costs. Pregnancy testing team includes nurses, concentrating on quality yields a saving of £5.00 per test. Minor surgery assurance, as well as epidemiologists, doctors, pharmacologists, computer programmers, and a saves £200 per operation. Finally, within the first year we will provide statistician. Dr McGlade continues, "Only well conceived, extra hospital operations for about 120 of our patients. We emphasise that these operations will designed, and supported projects will hold the not be done in our normal quota of operating interest and cooperation of general practitioners in time, and therefore patients of non-fundholding the long term." This has been shown by the practices will not suffer. We will be using spare majority of our practices moving from the no cost theatre capacity, especially during the summer, option (1987-91)2 to the new 25 year research when bed occupancy is usually low. This obviously scheme. While money injected into the no cost results in increased throughput and hence im- option promoted the growth of general practice computing, the new scheme, with a lower initial proved hospital efficiency. Some of the anxieties expressed in the Associa- financial reward, shows that care of patients has tion of Community Health Councils' document been their primary driving force. The benefits provided by multipurpose resources GP Fund-Holding: Profit or Loss for Patients?' can justify the pains of development. Speed and be allayed: The doctor-patient relationship-Money saved is flexibility are byproducts of having a large reusable not going into general practitioners' pockets. database of demographic, prescribing, and medical Patients in our practice see that it is being used to details on standby. Studies are observational, and improve their service, and increased numbers of therefore prescribing and recall are unbiased and patients have registered with the practice recently. many study designs are possible. North American May.)
BMJ VOLUME 302
8 JUNE 1991
data resources, such as the Saskatchewan databases, Group Health Co-operative of Puget Sound, and Medicaid,' have shown these benefits over several years. A general practice database in the United Kingdom includes morbidity events from primary and secondary care linked with community prescribing. Nevertheless, before any study is embarked on the limitations must be consideredfor example, flu is not always reported to a general practitioner, and the research protocol may not require it to be recorded.4 The need for a multipurpose research database in the United Kingdom was highlighted in 1985,5 but its development has been possible only because of computerisation. Currently, the United Kingdom has the only European resource of this kind for studies of drug safety, health economics, epidemiology of diseases, and NHS planning. Would this have happened without the push of private enterprise? GILLIAN HALL VAMP Health, London SW8 3QJ I McGlade KJ. Computerised general practice data. BMJ7 1991;302:1081. (4 May.) 2 Pringle M, Hobbs R. Large computer databases in general practice. BMJ7 1991;302:741-2. (30 March.) 3 Strom BL, ed. Pharmnacoepidemiology. New York: Churchill Livingstone, 1989. 4 Johnson N, Mant D, Jones L, Randall r. Use of computerised general practice data for population surveillance: comparative study of influenza data. BMJ 1991;302:763-5. (30 March.) 5 Grahame-Smith DG. Report of the working party on adverse drug reactions to the Committee on Safety of Medicines. II. London: Department of Health and Social Security, 1985.
GPs' opinions of available health services SIR,-The survey by Drs Nicholas R Hicks and Ian A Baker looking at Bristol and Weston general practitioners' opinions of their local health services' raises important points about the assessment of different aspects of quality in health care.2 Drs Hicks and Baker found that local general practitioners show considerable agreement in identifying which services are adequate in both quality and quantity. We suggest that general practitioners also have a corporate view on which aspects of quality are adequate or lacking in their local services and that this should inform the purchasing authorities' decisions on future contracting.
After an initial study of referral patterns in Tower Hamlets and Newham (commissioned jointly by the local forum and the family health services authority) a questionnaire was developed to obtain the views of general practitioners on aspects of quality. General practitioners were invited to rate local hospital services on a five point scale. They were also encouraged to identify which aspects of service delivery contributed to the rating given. Within Tower Hamlets 66% of general practitioners took part, representing 83% of practices within the health authority. There was considerable agreement over both the highest and the lowest rated services, with most general practitioners rating geriatrics and general surgery as good and ear, nose, and throat medicine and psychiatry as poor. It is worth noting that the geriatric services were rated highly in Tower Hamlets but lower in Newham, confirming that organisational aspects of a department, rather than the nature of the specialty, are being rated. The comments by general practitioners about the services they rated clearly identify accessibility for patients, communication with patients and with general practitioners, and the appropriateness of the service to local needs as the key quality indicators from the perspective of primary care (table). We agree with Drs Hicks and Baker's finding that general practitioners' priorities for
1405
