on tattooing. Those who decide to have a tattoo should do so with full knowledge of the consequences. In addition, voung people need both the opportunity to reflect on their knowledge and the skills to make and sustain decisions against tattooing if this is their choice. These, and related tasks, should be the prime responsibility of health educators working with and through teachers and others with a responsibility for the education and development of young people. School health educators, however, are a beleaguered group with insufficient resources and support, and no core curriculum time is allocated to their subject. Smith may disagree with our view that doctors are not the most appropriate people to provide education on tattoos for youngsters but, we are sure, will join with us in calling for greater emphasis on health education in schools. ROBERT T McEWAN RAJ S BHOPAL Division of Epidemiology and Ilublic Health, Medical School, Unisersity of Newcastle upon '1'lne, Newcastle upon Tyne NE2 7HHI RAJAN MADHOK Public Health Directorate, South Tees Health Authority, Middlesbrough 1 Smith SR. Tattoos. B.J 1991;303:720. (21 September.) 2 Wallace PG, Brennan PJ, Haines AP. Are general practitioners doing enough to promote a healthy lifestyle? BMJ 1987;294: 940-2. 3 Fullard E, Fowler G, Gray M. Facilitating prevention in primary care. BMJ7 1984;289: 1585-7. 4 McCormick A. Notification of infectious diseases: the effect of increasing the fec paid. Health Trends 1987;19:7-8.
Incentives to fundholding SIR,-I wish to express some concerns about the political and financial incentives that may affect the status of fundholding by general practitioners. It is apparent that political pressure passes down from the NHS Management Executive through the regional health authority to the family health services authorities. One corporate contract for 1991-2 between the management executive and Wessex region sets a "task" of extending the general practice fundholding programme, with a target of 10 additional fundholders in the region. Senior managers are on performance related pay and affected by these contracts. The contract between the same region and an individual family health services authority would probably stipulate one or two fundholding practices as a target for the year. You start to wonder how much of the incentive is a personal one for general managers of family health services authorities; this is one of the weak points of performance related pay. The confidential nature of the performance objectives only adds to the speculation. Management theory recognises that providing extra resources, such as more finance, is an aid to coping with uncertainty. The government through the family health services authority is prepared to spend money to try to make general practice fundholding successful. If fundholding becomes widespread then, in all likelihood, the extra money will decrease and financial constraints tighten. If the fundholding targets are removed from a corporate contract as objectives move on, general managers will have less incentive to cushion fundholders against problems and will redirect family health services authorities' money to other causes.
The extra money being deliberately targeted at individual fundholders is apparent to those working in general practice. The objections about this are often ignored, or managerial pressure is applied to silence critics. The lack of any evaluated pilot studies seems only to polarise views. Implicit in all this is a warning to fundholders in the future. It is one thing to be able to argue for
1136
extra resources at the moment but quite another to manage fundholding through cash limiting and changes of managerial priorities. I also suspect that the apparent independence of fundholders may disappear as family health services authorities filter government policy through imposed management and the availability of resources, or the lack of them. JONATHAN V HOWELL Ditton Marsh,
Westbwy, Wiksbre BAI 3 4DP
Undergraduate medical education SIR,-Recent correspondence on undergraduate medical education' 2 does not address two issues important to potential reviews of curriculums by the General Medical Council. Firstly, dealing with patients inevitably precipitates various emotions and ethical dilemmas for students. It is important that provision is made for continuing work in small groups to discuss these issues. This has been provided at Otago University. An extension of this, which has been initiated at Nottingham University, is for a personal clinical tutor not concerned in a student's assessment to be available for discussion about problems with the course and psychological problems. Secondly, I propose that a curriculum that fails to incorporate such support for its students risks producing professionalisation to an extent that patients' psychosocial needs are neglected by technically efficient and mechanical doctors. This is important particularly in teaching about death and dying and attitudes towards them. RODGER CHARLTON
Department of General Practice, Otago Medical School, University of Otago, PO Box 913, Dunedin, New Zealand
I Thatcher PG. Undergraduate medical education. BMJ 1991; 303:721-2. (21 September.) 2 Correspondence. Undergraduate medical education. BMJ 1991;303:244-6. (27 July.)
Unemployment rates: an alternative to the Jarman index? SIR,-I agree with Dr Doreen A Campbell and colleagues that using unemployment as a measure of deprivation has some advantages. ' It is available monthly at electoral ward level from the Department of Employment, and it shares with other suggested individual variables (such as lacking a car, working class status, living in local authority housing, being off sick) the advantage of being easy to calculate mathematically without the complicated statistical manipulations that are needed for composite indices. At district health authority level in England it is one of the variables most highly correlated with standardised mortality ratios. It also correlates strongly with the percentage of the economically active population temporarily or permanently sick, although this may be expected because these are the people who are receiving sick notes from their general practitioners. There are, however, serious drawbacks with the unemployment variable. Firstly, it applies only to the economically active population and does not include children and elderly people, the main users of health services. People over 60, disabled people, lone parents, and those who are short or long term sick do not need to be available for work to receive income support; in practice, if these groups are
unemployed they would be likely to claim income support and therefore not appear in the unemployment statistics, according to the Department of Employment's current definition of unemployment. Secondly, in addition to the inaccuracies in the numerator needed to calculate the unemployment rate, there are also problems with the denominator because there are no routinely available estimates of the economically active population at ward level between censuses. There are arguments in favour of using more than one variable in order to capture the multidimensional nature of deprivation. The underprivileged area (UPA) score was developed as a measure of general practitioners' opinions of factors that increase their workload or put pressure on their services, with the aim of concentrating general practice resources more into underprivileged areas. It includes variables, such as the mobility of the population, which do not correlate strongly with standardised mortality ratios but which are nevertheless considered important by general practitioners. It happens to have the highest correlation, at district level, of all composite indices and a wide range of individual variables, with infant mortality rate; but it was not developed for this reason. For the purpose for which the measure was developed, it seemed necessary to use an approach such as that used for the UPA score. One should perhaps also bear in mind the practical aspects of using deprivation indices which are not intended as academic exercises but, usually, for concentrating resources to areas of assessed greater need.2 It may not prove easy to persuade general practitioners, for instance, that a single variable-unemployment-would be a satisfactory indicator to use. BRIAN JARMAN
Department of General Practice, St Mary's Hospital Medical School, Lisson Grove Health Centre, London NW8 8EG I Campbell DA, Radford JMC, Burton P. Unemployment rates: an alternative to the Jarman index? BMJ 1991;303:750-5. (28 September.) 2 Jarman B, Townsend P, Carstairs V. Deprivation indices. BMJ 1991;303:523. (31 August.)
The "Q" in QALYs SIR,-Drs Roy A Carr-Hill and Jenny Morris rightly question the method used to determine the "Q" in QALYs.' They seem, however, to accept two underlying assumptions: that there is a "quality" of life which can be measured; and that this quantity, which is necessarily derived from a population sample, can be applied prospectively to an individual. There is no agreed underlying unitary construct of the quality of life,2 primarily because most people do not use a coherent model of the consequences of disabling illness.3 Simple inspection of the variety of instruments used to measure quality of life4 shows that they usually measure one or more of: mood (depression), disability (dependence on others), pain, or distress. Moreover, they may give different emphases to different aspects. In practice many so called quality of life indices, including that of Rosser and Kind,5 are primarily measures of disability. Therefore at best they give DALYs (disability adjusted life years), not QALYs. Some indices, such as that of Rosser and Kind, give the weighted values to different states, but the methodology is questionable at best: often the people used are unrepresentative of either the general population or the ill population; very small samples have been used; and there is good evidence of major variability and unreliability in the measures.67 The first step for health economists (and health service managers) is to become familiar with the
BMJ VOLUME 303
2 NOVEMBER 1991
Incentives to fundholding SIR,-I wish to express some concerns about the political and financial incentives that may affect the status of fundholding by general practitioners. It is apparent that political pressure passes down from the NHS Management Executive through the regional health authority to the family health services authorities. One corporate contract for 1991-2 between the management executive and Wessex region sets a "task" of extending the general practice fundholding programme, with a target of 10 additional fundholders in the region. Senior managers are on performance related pay and affected by these contracts. The contract between the same region and an individual family health services authority would probably stipulate one or two fundholding practices as a target for the year. You start to wonder how much of the incentive is a personal one for general managers of family health services authorities; this is one of the weak points of performance related pay. The confidential nature of the performance objectives only adds to the speculation. Management theory recognises that providing extra resources, such as more finance, is an aid to coping with uncertainty. The government through the family health services authority is prepared to spend money to try to make general practice fundholding successful. If fundholding becomes widespread then, in all likelihood, the extra money will decrease and financial constraints tighten. If the fundholding targets are removed from a corporate contract as objectives move on, general managers will have less incentive to cushion fundholders against problems and will redirect family health services authorities' money to other causes.
The extra money being deliberately targeted at individual fundholders is apparent to those working in general practice. The objections about this are often ignored, or managerial pressure is applied to silence critics. The lack of any evaluated pilot studies seems only to polarise views. Implicit in all this is a warning to fundholders in the future. It is one thing to be able to argue for
1136
extra resources at the moment but quite another to manage fundholding through cash limiting and changes of managerial priorities. I also suspect that the apparent independence of fundholders may disappear as family health services authorities filter government policy through imposed management and the availability of resources, or the lack of them. JONATHAN V HOWELL Ditton Marsh,
Westbwy, Wiksbre BAI 3 4DP
Undergraduate medical education SIR,-Recent correspondence on undergraduate medical education' 2 does not address two issues important to potential reviews of curriculums by the General Medical Council. Firstly, dealing with patients inevitably precipitates various emotions and ethical dilemmas for students. It is important that provision is made for continuing work in small groups to discuss these issues. This has been provided at Otago University. An extension of this, which has been initiated at Nottingham University, is for a personal clinical tutor not concerned in a student's assessment to be available for discussion about problems with the course and psychological problems. Secondly, I propose that a curriculum that fails to incorporate such support for its students risks producing professionalisation to an extent that patients' psychosocial needs are neglected by technically efficient and mechanical doctors. This is important particularly in teaching about death and dying and attitudes towards them. RODGER CHARLTON
Department of General Practice, Otago Medical School, University of Otago, PO Box 913, Dunedin, New Zealand
I Thatcher PG. Undergraduate medical education. BMJ 1991; 303:721-2. (21 September.) 2 Correspondence. Undergraduate medical education. BMJ 1991;303:244-6. (27 July.)
Unemployment rates: an alternative to the Jarman index? SIR,-I agree with Dr Doreen A Campbell and colleagues that using unemployment as a measure of deprivation has some advantages. ' It is available monthly at electoral ward level from the Department of Employment, and it shares with other suggested individual variables (such as lacking a car, working class status, living in local authority housing, being off sick) the advantage of being easy to calculate mathematically without the complicated statistical manipulations that are needed for composite indices. At district health authority level in England it is one of the variables most highly correlated with standardised mortality ratios. It also correlates strongly with the percentage of the economically active population temporarily or permanently sick, although this may be expected because these are the people who are receiving sick notes from their general practitioners. There are, however, serious drawbacks with the unemployment variable. Firstly, it applies only to the economically active population and does not include children and elderly people, the main users of health services. People over 60, disabled people, lone parents, and those who are short or long term sick do not need to be available for work to receive income support; in practice, if these groups are
unemployed they would be likely to claim income support and therefore not appear in the unemployment statistics, according to the Department of Employment's current definition of unemployment. Secondly, in addition to the inaccuracies in the numerator needed to calculate the unemployment rate, there are also problems with the denominator because there are no routinely available estimates of the economically active population at ward level between censuses. There are arguments in favour of using more than one variable in order to capture the multidimensional nature of deprivation. The underprivileged area (UPA) score was developed as a measure of general practitioners' opinions of factors that increase their workload or put pressure on their services, with the aim of concentrating general practice resources more into underprivileged areas. It includes variables, such as the mobility of the population, which do not correlate strongly with standardised mortality ratios but which are nevertheless considered important by general practitioners. It happens to have the highest correlation, at district level, of all composite indices and a wide range of individual variables, with infant mortality rate; but it was not developed for this reason. For the purpose for which the measure was developed, it seemed necessary to use an approach such as that used for the UPA score. One should perhaps also bear in mind the practical aspects of using deprivation indices which are not intended as academic exercises but, usually, for concentrating resources to areas of assessed greater need.2 It may not prove easy to persuade general practitioners, for instance, that a single variable-unemployment-would be a satisfactory indicator to use. BRIAN JARMAN
Department of General Practice, St Mary's Hospital Medical School, Lisson Grove Health Centre, London NW8 8EG I Campbell DA, Radford JMC, Burton P. Unemployment rates: an alternative to the Jarman index? BMJ 1991;303:750-5. (28 September.) 2 Jarman B, Townsend P, Carstairs V. Deprivation indices. BMJ 1991;303:523. (31 August.)
The "Q" in QALYs SIR,-Drs Roy A Carr-Hill and Jenny Morris rightly question the method used to determine the "Q" in QALYs.' They seem, however, to accept two underlying assumptions: that there is a "quality" of life which can be measured; and that this quantity, which is necessarily derived from a population sample, can be applied prospectively to an individual. There is no agreed underlying unitary construct of the quality of life,2 primarily because most people do not use a coherent model of the consequences of disabling illness.3 Simple inspection of the variety of instruments used to measure quality of life4 shows that they usually measure one or more of: mood (depression), disability (dependence on others), pain, or distress. Moreover, they may give different emphases to different aspects. In practice many so called quality of life indices, including that of Rosser and Kind,5 are primarily measures of disability. Therefore at best they give DALYs (disability adjusted life years), not QALYs. Some indices, such as that of Rosser and Kind, give the weighted values to different states, but the methodology is questionable at best: often the people used are unrepresentative of either the general population or the ill population; very small samples have been used; and there is good evidence of major variability and unreliability in the measures.67 The first step for health economists (and health service managers) is to become familiar with the
BMJ VOLUME 303
2 NOVEMBER 1991
