SIR,-We wonder how Dr Roger Smith arrives at the conclusion that hormone replacement treatment is no longer a first choice for the treatment of osteoporosis in women over 60.' Many women in their 60s have only early osteoporosis and have not yet sustained a fracture. They have a particular need for treatment to maintain and perhaps increase their bone density as their risk of fracture will increase exponentially in the eighth decade and beyond, and oestrogen will still prevent loss of bone at this age.23 Dr Smith states that the intermittent bleeding produced by cyclical progestin is unacceptable for most women aged over 60, but this is not our experience. Many women, certainly under 70, are quite prepared to take hormone replacement therapy provided that they are counselled that the withdrawal bleeds will be quite regular and predictable and usually light (often eventually amounting to little more than spotting) and that any initial breast tenderness will tend to diminish with continued usage. Indeed, the breast tenderness can often be circumvented by starting with a low dose of oestrogen and increasing to the bone sparing dose after a few months. There are a range of oestrogens and progestins available, and it is usually possible to find a combination that is virtually free from side effects. Furthermore, different routes of administration can be used with equal skeletal benefit.4 Continuous combined oestrogen and progestin regimens may avoid uterine bleeding entirely, and such regimens are under study.' Dr Smith claims that the risks of a decade of oestrogen therapy are largely unknown. In fact the available data on the incidence of breast cancer for up to five years' usage of hormones are reassuring; only beyond 10 years is the effect unclear.6 Cardiovascular diseases are the commonest cause of death in postmenopausal women, yet no mention is made of the 50% reduction in the risk of myocardial infarction and stroke observed in oestrogen users.6 When evaluating the treatment of postmenopausal women the skeleton cannot be considered to the exclusion of the other systems. Of course there will be some women who cannot or will not take oestrogen, and for them it is important to have effective alternatives available for their bones, such as calcitonin7'8 and bisphosphonates.' Dr Smith suggests that measurement of bone density should be limited to those with a clinical indication. Such indications have been proposed by the American Society for Bone and Mineral Research'° and include "in estrogen deficient women, to diagnose significantly low bone mass in order to make decisions about hormone replacement therapy." Doctors should not be deterred by negative views of hormone replacement therapy, as more widespread usage would bring large benefits to postmenopausal women, including those over 60. JOHN C STEVENSON Wynn Institute for Metabolic Research, London NW8 9SQ MALCOLM I WHITEHEAD
King's College School of Medicine and Dentistry, London SE5 8RX ROBERT LINDSAY
Helen Hayes Hospital, New York,j United States CLAUS CHRISTIANSEN
Glostrup Hospital, Glostrup, Denmark I Smith R. Osteoporosis after 60. Br Med J7 1990;301:452-3. (8 September.) 2 Jensen GF, Christiansen C, Transbol I. Treatment of postmenopausal osteoporosis. A controlled therapeutic trial comparing oestrogen/gestagen, 1,25-dihydroxyvitamin D3 and calcium. Clin Endocrinql 1982;16:515-24. 3 Lindsay R, Tohme JF. Estrogen treatment of patients with established postmenopausal osteoporosis. Obstet Gynecol 1990;76:290-5. 4 Stevenson JC, Cust MP, Gangar KF, Hillard TC, Lees B, Whitehead MI. Effects of transdermal versus oral hormone replacement therapy on bone density in spine and proximal femur in postmenopausal women. Lancet 1990;336:265-9.
BMJ
VOLUME
301
6 OCTOBER 1990
5 Christiansen C, Riis BJ. 17fi-Estradiol and continuous norethisterone: a unique treatmeit for established osteoporosis in elderly women. J Clin Endocrinol Metab (in press). 6 Gangar KF, Cust M, Whitehead MI. Controversies in the use of hormone replacement therapy. In: Stevenson JC, ed. New techniques in metabolic bone disease. London: Wright, 1990:232-46. 7 Maclntyre I, Stevenson JC, Whitehead MI, Wimalawansa SJ, Banks LM, Healy MJR. Calcitonin for prevention of postmenopausal bone loss. Lancet 1988;i:900-2. 8 Overgaard K, Riis BJ, Christiansen C, Podenphant J, Johansen JS. Nasal calcitonin for treatment ofestablished osteoporosis. Clin Endocrinol 1989;30:435-42. 9 Watts NB, Harris ST, Genant HK, et al. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N EnglJ Med 1990;323:73-9. 10 Johnston CC, Melton LJ, Lindsay R, Eddy DM. Clinical indications for bone mnass measurements. Journal of Bone and Mineral Research 1989;4(suppl 2).
but no medical staff was available, in 11 cases a locum who had not made the referral was available, and in only 20 cases was the referring practitioner or a regular partner available. As in the survey of Dr Bakhai and colleagues, complete failure to make contact by telephone was uncommon. However, the time and effort needed to speak with a general practitioner, who was often not the referring doctor and could not provide the information or see the patient personally when he or she returned to the surgery, might deter attempts by junior hospital staff to communicate directly. This potentially dangerous position increases the need for the prompt dispatch of clear and detailed letters to general practitioners after their patients attend hospital outpatient clinics. S W DAVIES
Caseload or workload?
London Chest Hospital, London E2 9JX
SIR,-Messrs S M Jones and C D Collins in their paper and letter recommend using the BUPA classification for assessing workload.2 This assessment is based on skill and complexity and is used to obtain private fees. The NHS hospital requires workload to be assessed by time needed: the two are not identical. My waiting list, since Telford Hospital opened, has recorded a time dimension-for example, arthroscopy 30 minutes, total hip replacement one and a half hours, revision of total hip replacement two and a half hours. This means that although my waiting list has 113 individual cases, it represents 128 and a half hours' theatre time. This is a more positive way for us to make representations to the unit manager over the need for more elective orthopaedic operating lists. PCMAY Telford Hospital, Telford, Shropshire TF6 6TF 1 Jones SM, Collins CD. Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload. BrMedJ 1990;30l:324-5. (11 August.) 2 Jones SM, Collins CD. Caseload or workload? Br Med J 1990;301:445. (1 September.)
How easy is it to contact the duty doctor responsible for admissions? SIR,-Problems in communication between general practitioners and the hospital services may have serious consequences for patients. Mr Ameet Bakhai and colleagues have provided valuable information on the response times of hospital switchboards and the difficulties in contacting the duty medical doctor responsible for acute admissions.' There are equally serious problems with the flow of information from the hospital back to the general practitioner, and the delays and deficiencies of hospital discharge summaries are well known. Less attention has been paid to the ability of hospital staff to contact a referring general practitioner when it is necessary to clarify details such as previous adverse drug reactions or present treatment or to communicate a change in drugs when important side effects or drug interactions are possible. Although this occurs infrequently, we have performed an audit of 46 such instances over nine months. All telephone calls were made between 9 30 am and 5 30 pm. Communication with the referring doctor on the day on which the patient was seen in clinic was effectively precluded in 19% of cases (no answer in three cases, a recorded message giving a telephone number for emergencies in six cases). In 12 of the 37 remaining instances the line to the practice switchboard was engaged at the first attempt; the overall time taken to contact the practices ranged from 30 seconds to 18 minutes (medium 4½/2 minutes). In six cases a receptionist
I Bakhai A, Goodman F, Juchniewichz H, et al. How easy is it to contact the duty medical doctor responsible for acute admissions? BrMedJ 1990;301:529-31. (15 September.)
Interpretation and management of PACT (prescribing analysis and cost) data on formularies SIR,-Dr M L Anderson and colleagues emphasise the overall high expense to the NHS of prescribing loss leaders through hospital pharmacies.' They show how drug companies recoup the discount that they give to hospital pharmacies many-fold when the otherwise expensive drug continues to be prescribed in the community. Out of the soup of current Clarke jargon self governing, independent, opting out, and self financing are terms that give little hope that hospitals are being encouraged to adopt the broader view. It will make sense to no unit -manager to increase the costs in his or her hospital in order that the community might pay less. Individual hospital pharmacies are always under financial pressure. They manage by having formularies and driving bargains with drug companies, and most will dispense only one week's treatment. This is annoying to patient and general practitioner alike. To see and represcribe within the week takes two people's time and incurs a further prescription charge to the patient and the higher cost of the drug to the non-hospital pharmacy. Given this arrangement the hospital pharmacies often find themselves squeezed between the prescribing doctor on the one hand and their budget on the other. In an audit of outpatient prescribing in our dermatology departmnent we found that in 80 of 429 prescriptions more than the minimum pack size or week of tablets had been prescribed. In 19 of these the pharmacy chose to stay within its policy and dispense less than was requested. After an initial glow of frustration we realised that within the limitations of the current resource allocation pharmacies have to do this to survive. At Guy's Hospital all except exclusively hospital or urgent drugs are to be prescribed by the general practitioner as directed by a note from the outpatient department. They will have no routine outpatient dispensing. The pressures on pharmacy costs, and even their existence, completely dominate broader considerations like cost to the community. What kind of "working for patients" is it to make patients wait in two waiting rooms in one week and charge them two prescription charges when one of each would have been quite feasible and possibly even cheaper to the NHS as a whole? I completely agree with Dr Anderson and colleagues and believe strongly that "market forces" should not be allowed to put a wedge 817
King's College School of Medicine and Dentistry, London SE5 8RX ROBERT LINDSAY
Helen Hayes Hospital, New York,j United States CLAUS CHRISTIANSEN
Glostrup Hospital, Glostrup, Denmark I Smith R. Osteoporosis after 60. Br Med J7 1990;301:452-3. (8 September.) 2 Jensen GF, Christiansen C, Transbol I. Treatment of postmenopausal osteoporosis. A controlled therapeutic trial comparing oestrogen/gestagen, 1,25-dihydroxyvitamin D3 and calcium. Clin Endocrinql 1982;16:515-24. 3 Lindsay R, Tohme JF. Estrogen treatment of patients with established postmenopausal osteoporosis. Obstet Gynecol 1990;76:290-5. 4 Stevenson JC, Cust MP, Gangar KF, Hillard TC, Lees B, Whitehead MI. Effects of transdermal versus oral hormone replacement therapy on bone density in spine and proximal femur in postmenopausal women. Lancet 1990;336:265-9.
BMJ
VOLUME
301
6 OCTOBER 1990
5 Christiansen C, Riis BJ. 17fi-Estradiol and continuous norethisterone: a unique treatmeit for established osteoporosis in elderly women. J Clin Endocrinol Metab (in press). 6 Gangar KF, Cust M, Whitehead MI. Controversies in the use of hormone replacement therapy. In: Stevenson JC, ed. New techniques in metabolic bone disease. London: Wright, 1990:232-46. 7 Maclntyre I, Stevenson JC, Whitehead MI, Wimalawansa SJ, Banks LM, Healy MJR. Calcitonin for prevention of postmenopausal bone loss. Lancet 1988;i:900-2. 8 Overgaard K, Riis BJ, Christiansen C, Podenphant J, Johansen JS. Nasal calcitonin for treatment ofestablished osteoporosis. Clin Endocrinol 1989;30:435-42. 9 Watts NB, Harris ST, Genant HK, et al. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N EnglJ Med 1990;323:73-9. 10 Johnston CC, Melton LJ, Lindsay R, Eddy DM. Clinical indications for bone mnass measurements. Journal of Bone and Mineral Research 1989;4(suppl 2).
but no medical staff was available, in 11 cases a locum who had not made the referral was available, and in only 20 cases was the referring practitioner or a regular partner available. As in the survey of Dr Bakhai and colleagues, complete failure to make contact by telephone was uncommon. However, the time and effort needed to speak with a general practitioner, who was often not the referring doctor and could not provide the information or see the patient personally when he or she returned to the surgery, might deter attempts by junior hospital staff to communicate directly. This potentially dangerous position increases the need for the prompt dispatch of clear and detailed letters to general practitioners after their patients attend hospital outpatient clinics. S W DAVIES
Caseload or workload?
London Chest Hospital, London E2 9JX
SIR,-Messrs S M Jones and C D Collins in their paper and letter recommend using the BUPA classification for assessing workload.2 This assessment is based on skill and complexity and is used to obtain private fees. The NHS hospital requires workload to be assessed by time needed: the two are not identical. My waiting list, since Telford Hospital opened, has recorded a time dimension-for example, arthroscopy 30 minutes, total hip replacement one and a half hours, revision of total hip replacement two and a half hours. This means that although my waiting list has 113 individual cases, it represents 128 and a half hours' theatre time. This is a more positive way for us to make representations to the unit manager over the need for more elective orthopaedic operating lists. PCMAY Telford Hospital, Telford, Shropshire TF6 6TF 1 Jones SM, Collins CD. Caseload or workload? Scoring complexity of operative procedures as a means of analysing workload. BrMedJ 1990;30l:324-5. (11 August.) 2 Jones SM, Collins CD. Caseload or workload? Br Med J 1990;301:445. (1 September.)
How easy is it to contact the duty doctor responsible for admissions? SIR,-Problems in communication between general practitioners and the hospital services may have serious consequences for patients. Mr Ameet Bakhai and colleagues have provided valuable information on the response times of hospital switchboards and the difficulties in contacting the duty medical doctor responsible for acute admissions.' There are equally serious problems with the flow of information from the hospital back to the general practitioner, and the delays and deficiencies of hospital discharge summaries are well known. Less attention has been paid to the ability of hospital staff to contact a referring general practitioner when it is necessary to clarify details such as previous adverse drug reactions or present treatment or to communicate a change in drugs when important side effects or drug interactions are possible. Although this occurs infrequently, we have performed an audit of 46 such instances over nine months. All telephone calls were made between 9 30 am and 5 30 pm. Communication with the referring doctor on the day on which the patient was seen in clinic was effectively precluded in 19% of cases (no answer in three cases, a recorded message giving a telephone number for emergencies in six cases). In 12 of the 37 remaining instances the line to the practice switchboard was engaged at the first attempt; the overall time taken to contact the practices ranged from 30 seconds to 18 minutes (medium 4½/2 minutes). In six cases a receptionist
I Bakhai A, Goodman F, Juchniewichz H, et al. How easy is it to contact the duty medical doctor responsible for acute admissions? BrMedJ 1990;301:529-31. (15 September.)
Interpretation and management of PACT (prescribing analysis and cost) data on formularies SIR,-Dr M L Anderson and colleagues emphasise the overall high expense to the NHS of prescribing loss leaders through hospital pharmacies.' They show how drug companies recoup the discount that they give to hospital pharmacies many-fold when the otherwise expensive drug continues to be prescribed in the community. Out of the soup of current Clarke jargon self governing, independent, opting out, and self financing are terms that give little hope that hospitals are being encouraged to adopt the broader view. It will make sense to no unit -manager to increase the costs in his or her hospital in order that the community might pay less. Individual hospital pharmacies are always under financial pressure. They manage by having formularies and driving bargains with drug companies, and most will dispense only one week's treatment. This is annoying to patient and general practitioner alike. To see and represcribe within the week takes two people's time and incurs a further prescription charge to the patient and the higher cost of the drug to the non-hospital pharmacy. Given this arrangement the hospital pharmacies often find themselves squeezed between the prescribing doctor on the one hand and their budget on the other. In an audit of outpatient prescribing in our dermatology departmnent we found that in 80 of 429 prescriptions more than the minimum pack size or week of tablets had been prescribed. In 19 of these the pharmacy chose to stay within its policy and dispense less than was requested. After an initial glow of frustration we realised that within the limitations of the current resource allocation pharmacies have to do this to survive. At Guy's Hospital all except exclusively hospital or urgent drugs are to be prescribed by the general practitioner as directed by a note from the outpatient department. They will have no routine outpatient dispensing. The pressures on pharmacy costs, and even their existence, completely dominate broader considerations like cost to the community. What kind of "working for patients" is it to make patients wait in two waiting rooms in one week and charge them two prescription charges when one of each would have been quite feasible and possibly even cheaper to the NHS as a whole? I completely agree with Dr Anderson and colleagues and believe strongly that "market forces" should not be allowed to put a wedge 817
