sawtooth pattern might be expected, with low diagnostic accuracy in February and March and in August and September, rising (with a little "noise" from locum cover) towards a peak when doctors were trained. No training effect is seen-at least, none that is clinically useful. It is not credible that the package used in Bangour resulted in junior doctors being trained within the first month of their contract, though that is possible for Mr de Dombal and colleagues' system. One explanation of these results is that where a computer system stimulates consultants' interest in junior doctors' training a useful gain is seen, but where the computer system comes to be a subsitute for that the learning curve

remains flat. GRAHAM C SUTTON

Department of Public Health, Ackton Hospital, Pontefract WF7 6HT

FT, Dallos V, McAdam WAF. Can computer aided teaching packages improve clinical care in patients with acute abdominal pain? BM7 1991;302:1495-7. (22 June.) 2 Sutton GC. How accurate is computer-aided diagnosis? Lancet 1989;ii:905-8. I De Dombal

Computerisation of primary care in Wales

Activities for which 70 general practitioners in Bath and Bristol used computers No of general practitioners

Registering patients (age and sex)

70 9

Appoinitments

Clinical records: Partial

Full Referral letters Repeat prescriptions Analysing prescribing Checking drug interactions Reviewing repeat prescribing Producing labels for dispensed medicines Call and recall for cervical smear testing 63 Call and recall for childhood immunisation schedules Call and recall for blood pressure checks 44 Call and recall for influenza vaccinations in the elderly

57 8 24 66 44 20 50 6 60 48

conclusion that until reimbursements are linked to use of computers, only limited numbers of practitioners are likely to maintain comprehensive clinical records. We are currently analysing the results of a survey of use of computer systems by 1000 community pharmacies. A similar pattern is emerging, showing incomplete use of facilities that are available within the programs. PHILIP J ROGERS GEORGE FLETCHER

School of Pharmacv anid Pharmacology, University of Bath, Bath BA2 7AY

I Goves JR, Davies 'rD, Reilly 'l'R. Computerisation of primary care in Wales. BMJ 1991;303:93-4. (13 July.)

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SIR,-Mr John Warden reports that when, during the proceedings of the House of Commons health committee, midwives were asked to what extent they were prepared to accept responsibility when things went wrong they stated that "they were willing to take that on and to be held just as accountable in law for their actions as are doctors." It is my understanding that the midwives replied that they were already held responsible for their actions. Indeed, midwives have a far higher level of accountability than doctors. The Association for Improvement in the Maternity Services has on record several cases in which midwives have been disciplined and even struck off for their management of pregnancy and labour, whereas in none of the cases was the doctor even investigated -in one case despite the doctor being found guilty in the High Court on 29 counts of negligence. The General Medical Council twice refused to investigate when asked to do so by the father concerned. Interestingly, the midwife was struck off by her professional body because she had falsified the case notes. It is our view that the standards of accountability applied by the General Medical Council are in urgent need of change. BEVERLEY A LAWRENCE BEECH

SIR,-Dr John R Goves and colleagues give information about the use of computers in general practice in Wales.' In February this year, as part of a project for undergraduates, we conducted a similar survey among general medical practitioners in Bath and Bristol. We sent a postal questionnaire to 110 general practitioners, of whom 83 replied (76%). Seventy of the respondents used computers in their practice. The leading two systems were AAH Meditel and VAMP, each of which was used by 15 respondents. The table shows the activities for which a computer was used. Our results reflect those of Dr Goves and colleagues,' and we agree with the authors'

Activits!

Midwives on the march

10 AUGUST 1991

Honorary chair, Association for Improvements in the Maternity Services, Iver, Buckinghamshire SLO 9LH I W'arden J. Midwives on the march.

BMJ 1991;302:1488. (22

June.)

dicated that they had found the report of interest, 13 said that it was easy to understand, and 11 had found it useful. Nevertheless, it was disappointing that such a small proportion of the participating practices responded; the report contained data on their own practice populations that they were unlikely to have already and that are relevant to the development of health promotion in primary health care,4 a key element of the new contract.6 My findings and those of Mr Burchett and Mr Morris have important implications for the way in which survey research involving general practitioners is conducted in the future. The solution to this problem may lie in the use of different methods (for example, personal interviews) or in remuneration for the efforts of practice staff.2 Whatever the costs, good will needs to be maintained if the mutually beneficial relationship that exists among academics, hospital doctors, and general practitioners is to continue. MARTIN WHITE Division of Epidemiology and Public Health, School of Health Care Sciences, Medical School, Newcastle upon Tvne NE2 4HH I Burchett N. Charging for responding to a postal questionnaire survey. BMJ7 1991;302:1406. (8 June.) 2 Morris K. General practitioners' response toapostal questionnaire survey. BMJ 1991;302:1606. (29 June.) 3 White M, Bhopal RS. The politics of inadequate registers. BMJ

1989;299:567. 4 White M. A survey of CHD prevention in primary care. In: Health in Northumberland. Annual report of the dtrector of public

health 1990. Morpeth: Northumberland Health Authority, 1990. 5 Pill RM, Jones-Elwyn G, Stott NCH. Opportunistic health promotion: quantity or quality? J R Coll Gen Pract 1989;39:

1%-200. 6 Department of Health. General practice in the NHS: a newv contract. London: DoH, 1989.

General practitioners' response to a postal questionnaire survey SIR,-The experiences of Mr Niru Burchett' and Mr Kevin Morris2 when undertaking surveys of general practices have been reflected recently in Newcastle upon Tyne. In June 1989 I conducted a pilot study for a population survey of health and lifestyles (unpublished MFPHM thesis). The family practitioner committee register was used to select a sample of residents from the lists of 10 practices. Lists of those selected were sent to the practices for checking, a technique found to improve accuracy considerably.3 The updated sample was then sent a postal questionnaire. The amount of work entailed for the practices was not inconsiderable, but their help was willingly given without payment. More recently, I have provided feedback of the results of the survey to practices. A report containing a set of results specific to each practice was sent to the 10 participating practices, and a similar report, but with simulated practice results, was sent to the remaining 36 practices. These were posted with an evaluation questionnaire on 18 March 1991. By 19 April only six responses had been received (one from a participating practice and five from other practices), so a reminder letter and a further questionnaire were sent to nonrespondents. By 30 May only eight further questionnaires had been returned (two from participating practices and six from other practices). At this stage the remaining non-respondents among the 10 participating practices were telephoned and asked to respond. No further replies were received. Although I have not performed any subsequent follow up, comments received in returned questionnaires and the views of local colleagues confirm Mr Burchett's and Mr Morris's findings,'2 suggesting that this poor response may be related to general practitioners' increasing workload since the introduction of the new contract on 1 April this year, rather than to lack of good will or interest. In the 14 responses that I received, all the practices in-

General practitioner outpatient referrals SIR,-Dr T R G Howard is correct in noting differences in perceptions of appropriate referral' but misquotes the study criteria that I stated had been used for classifying a referral as inappropriate, poses two questions, and arrives at a conclusion at variance with that intended.' Studies of perceptions of the appropriateness of referral have consistently shown a lack ofconsensus among general practitioners, hospital doctors, and patients,'4 though this was not the issue being studied. Patients in whom no otolaryngological disease was diagnosed at the time of the consultation, who did not have any investigation or receive any treatment, and who were discharged after the first outpatient consultation were classified as having been referred inappropriately. The outcome of the consultation and the diagnoses entertained by the hospital clinician were used collectively as indicators of the clinician's perception of the appropriateness of the referral, primarily to allow intergroup comparisons independent of the individual clinician's report of appropriateness. The general tasks of reassuring and educating patients are, I hope, still undertaken. Patients' perception of the benefit derived from the outpatient consultation is probably a useful indicator of the clinician's success in these tasks. No attempt was made to collect this information, and thus I cannot comment. The patients mentioned by Dr Howard were found not to have any disease, which implies that physical signs were absent at outpatient evaluation. In the study to which I referred patients for whom the working diagnosis was globus pharyngeus (hystericus) were classified as having otolaryngological disease and had thus been appropriately referred. Physical signs in dizzy patients referred to a general hospital are uncommon, and many working diagnoses are made in the absence of such

367

signs. I cannot determine whether the dizzy patient and the dysphonic patient mentioned by Dr Howard would have been classified as having been inappropriately referred according to the criteria of the study as details of the otolaryngologist's working diagnosis and the outcome of the consultation are not available. It is not my intention that the term "inappropriate referral" should imply that such patients should not be seen by an otolaryngologist. The absence of inappropriate referrals as defined would suggest that general practitioners were pursuing a policy of referring only patients requiring hospital treatment and using a high threshold for referral, with the result that some patients requiring treatment were being denied access. This would be a policy of debatable merit. High referral rates are not necessarily an indication of less critical referral behaviour by general practitioners.

representing 42% of the popular vote. This permits legislation without consultation shielded by an unrepresentative majority. Secondly, the method by which the BMA council elects its chairman is also in need of reform. The farce of alternating among crafts in the manner of Buggins's turn is clearly ridiculous. Dr Lee-Potter may be the best man for the job, but that will not be thanks to the electoral system. Any member of council should feel free to stand if proposed, and the election should be held by proportional representation with a single transferable vote. This would ensure that the successful candidate would start his or her term of office, be it one year or three (and that should be looked at), with the support of the majority of the council. CHRISTOPHER TIARKS Member of Council,

BMA, London 'CIH 9JP

DESMOND A NUNEZ Ear, Nose, and Throat Department,

University of Leeds, Leeds General Infirmarv, Leeds LSI 3EX 1 Howard TRG. General practitioner outpatient referrals. BRAJ 1991;303:59-60. (6 July .) 2 Nunez DA. General practitioner outpatient referrals. B1J 1991;302:1468. (15 June.) 3 Grace JF, Armstrong D. Referral to hospital: perceptions of patients, general practitioners and consultants about necessity and suitability of referral. Fam Pract 1987;3:170-5. 4 Roland MO, Porter RW, Matthews JG, Redden JF, Simonds GW, Bewley B. Improving care: a studv of orthopaedic outpatient referrals. BM7 1991;302:1124-8. (11 May.)

The BMA in agony SIR,-The chairman of any board, council, or executive body must be prepared to take the brickbats as well as the plaudits that stem from performance as judged by members, shareholders, or interested parties. It was no surprise, therefore, that Dr Jeremy Lee-Potter's standing as chairman of the BMA's council came under debate at the recent council meeting.' This reflects the visibly poor showing of the association in the past year in its dealings, or lack of dealings, with the government vis a vis the damaging parts of the legislation on the NHS now enacted. As Dr Richard Smith says, the council heavyweights dutifully lined up behind the chairman.' Opponents of the association say that it has shown a reactionary style in its general opposition to the white paper and subsequent events. This performance made me wonder if we were really anxious as a body about NHS trusts and fundholding practices or whether we have slid into the comfortable pragmatism shown by so many political commentators who, now the bill has become law, think that perhaps it is not so bad after all. I hope not, and I expect that most doctors share this view. Because we are also being proactive in preparing a health manifesto, which none of us should gainsay, does not mean that the political campaign should not continue with vigour. The two are not mutually exclusive, and this government is more likely to listen now than in 13 months' time should it be re-elected. Perhaps this was the message being given to Dr Lee-Potter. The vote of confidence and the annual representative meeting's policies have given him the mandate to continue the campaign. Let us hope that we are not holding a similar debate this time next year. The first sentence of the penultimate paragraph of Dr Smith's editorial trivialised the debate. Poor achievement can be related to poor performance; not always can it be blamed on the opposition. It was important that the debate was held and the best possible outcome achieved. This whole episode underlines two truths about representation. Firstly, our method of electing governments is clearly in need of reform to avoid having a government with a majority of 100

368

1 Smith R. I'hec BA1A in agony. BM 1991;303:74. (13 July.)

SIR,-The BMA clearly is in agony.' Worse, its pain is largely self inflicted. The leadership was comparable with that of the first war generals; the membership allowed itself to be incited to frenzy, the more intense for being impotent. It was obviously stupid (some of us said so at the time or tried to but were suppressed as being not "politically correct") for the association to hurl itself howling at the government, as it did in the late 1980s, demanding money with menaces. This was "steaming" if you like; Stephen Lock in his celebrated (ill conceived would be a better description) editorial was "pot calling kettle black."2 No government could abdicate to such a ferociously partisan pressure group as the BMA had become, which was saying that all the government should negotiate was terms of surrender. Any government backed into that corner would have to take up the gauntlet. Now the association's funds have been seriously depleted, wasted in misjudged and sometimes reprehensible propaganda. Attempts will be made to extract higher subscriptions from us, which are likely to be squandered as before. The whole atmosphere is tainted by rancour and distaste, and it is difficult to see an honourable way forward. Even now there seems no disposition to face up to reality. If the BMA endorses a monopoly health service funded by the state it must accept the totality, not just the bits it likes. The NHS is but one of several government departments with a responsible minister. This minister carries out policies determined by the Cabinet of party politicians in power, who rotate their "big ideas" and priorities for expenditure. Whether the BMA likes it or not primacy is with elected politicians, consulting as little or as much as they judge necessary. Bevan showed that, as Kenneth Clarke and William Waldegrave have been doing and Robin Cook would, given the chance, which heaven forbid. J FINDLATER

Silverdale, Carnforth, Lancashire LAS OTT I Smith R. The BAA in agonY. BMJ 1991;303:74. (13 julv. 2 Lock S. Steaming through the NHS. BMJ 1989;298:619-20.

SIR,-The BMA has only itself to blame for the poor image that it and the medical profession present to the public, even though good individual doctor-patient relationships persist. I think that the defective picture shown to the population is a direct result of the infiltration of the association by politically motivated doctors. These have availed themselves of the democratic nature of the organisation to challenge loudly all attempts by the government of the day to reform the NHS. Many

have taken on key positions in the peripheral bodies of the BMA and others have assiduously attended meetings. Giving the media every opportunity to report what they say, they profess to want a well organised hospital and domiciliary service while frustrating cooperation between the profession and the government by fomenting suspicion on all sides. I attended a meeting called to discuss the reforms of the NHS and to send suggestions for further consideration to "headquarters." Only seven members attended, of whom I and two others were retired from active practice. It does not matter what was decided, but I was surprised by remarks made by a few doctors during our deliberations. The remarks would have occasioned pleasure in a gathering of the Militant Tendency in Liverpool. I tendered the opinion that we were being too political for the health of the BMA to my neighbour, who held a specialist position in the hospital. Her response was that of course we were being political and that she and her friends were going to use whatever ammunition the proposed government reforms presented to do their utmost to get rid of "that woman" and all for which she stood. The difficulties that the NHS had daily to contend with offered excellent and frequent opportunities to embarrass the Thatcher government. None of the many Tory and Labour administrations has been much different from any other in its dealings with the medical profession, as those of us who have worked in the NHS since its inception know only too well. The Militant infiltrators do much harm, and I suspect that they would be only too happy to cause difficulties for a government led by Mr Kinnock. It is time that the BMA clearly defined the limits of medical politics and curbed the activities of the Militants, otherwise the general public will continue to have a low regard for the profession and this could destroy the trust between doctor and patient. If the public once gets the opinion that what counts with doctors is money and leisure then a floodgate of litigation for malpractice will descend on us, as in the United States. The legal profession will reap a bonanza. S W V DAVIES

Flushing. Cornwall TRI1 5TG 1 Smith R. The BMA in agony. BAt7 1991;303:74. (13 Julv.)

SIR,-Dr Richard Smith is quite right in his editorial': the BMA bull is in agony, though not simply because it charged the toreador and missed but because he then plunged in his sword, causing a haemorrhage of good will towards its political masters. But soon it will start losing its clinical acumen too, when fundholding general practitioners and hospital trusts will have to forget the question on which we were brought up-"Is this treatment or investigation in the best interests of the patient?"-and begin asking instead, where any doubt exists, "Can we afford it?" If the government wishes to show its good will to the profession and public it should now state clearly that it will not approve the second wave of applications for fundholding and trust status until it has had sufficient time to assess the progress of the first (as indeed, unless I am very much mistaken, the secretary of state promised to do when he attended the meeting of the Central Consultants and Specialists Committee last December). After it has shown this mark of good faith we could sit down with the secretary of state and see how together we can prevent the NHS sinking into chaos, which would not serve the interests of the government, health workers, or, above all, our patients. Herein lies our dilemma. MYER GOLDMAN

Fazakerley Hospital, Liverpool 1.9 7AL 1 Smith R. The BMA in agony. BM_ 1991;303:74. (13 July.)

BMJ VOLUME 303

10 AUGUST 1991

General practitioner outpatient referrals.

sawtooth pattern might be expected, with low diagnostic accuracy in February and March and in August and September, rising (with a little "noise" from...
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