principle on which government funded research is based directing one of the department's research units can never have been comfortable for her. Nevertheless, it is disappointing to hear that a strained relationship has progressively deteriorated. Any tensions that exist would be understandable as researchers inevitably prefer to follow their own inclinations rather than respond to the department's policy driven needs. But the relationship does work, as I have found in reviewing the units with independent advisers over the four years that I have been the department's chief scientist. I shall not enlarge here on the kinds of unit most likely to be able to meet the department's future needs, but Dr Cartwright makes two assertions that call for comment. Firstly, she says that the department's research requirement is narrowly policy based. It is certainly policy based-that is, its purpose and those responsible would quickly be called to account if it were not. Whether it is narrow in the sense of being blinkered rather than directed can be judged from the range of work reported in the most recent Research and Development Yearbook. Dr Cartwright's second and more serious charge is to doubt that the department is still concerned about good research. It is hard to believe that anyone is interested in supporting bad research certainly not those who are paying for it. If some of the research the department commissions turns out to be less than excellent that was not the intention in commissioning it. Almost 20 years ago Lord Rothschild concluded that the quest for excellence in research did not naturally generate the kind of applied research that government departments need, and his proposals were intended to enable them to shop around for the best research that fitted their requirement. In the case of health research the shops proved to be few and far between, and then sparsely stocked. To boost the research base the department has needed to function not only as customer but as contractors' sponsor by establishing and fostering research units. I am conifident that my successor, the director of research and development, will wish to continue with and indeed develop this form of support. The department supports units in their quest for excellence; but it expects also to be able to turn to them for work in support of its policy needs. They remain a major research resource for the department, and the standing and output of many of them are testimony to the department's desire to support good research. They will not continue to be a vital force for long if all changes in their nature, make up, and disposition are to be resisted. F W O GRADY
Department of Health. London SEl 6BY
Northwick Park Hospital, Harrow HAI 3UJ
part played by general practitioners.2 Three district health authority hostels were visited regularly for a year. In total 26 residents aged 22-77, mostly institutionalised with chronic schizophrenia, were looked after by house teams of psychiatric nurses and care assistants. All the residents were registered with general practitioners and were also seen by local psychiatrists. The patterns of medical care in the three hostels varied widely. In one the general practitioner looked after physical complaints and the psychiatrist concentrated on psychological problems. In the second the psychiatrist, by visiting regularly, provided both sorts of care and the general practitioners were barely consulted. In the third hostel the general practitioners developed closer relationships with the residents and the pattern of care approximated to that of primary care in the NHS. Although the consultation rates with the general practitioners were high (in two hostels each patient saw a doctor at least eight times a year on average), the problems presented were not essentially different from those being dealt with every day by the doctors in their practices. And because of the good living conditions and excellent staff, who dealt with many of the problems themselves, these patients were easier to look after than mentally disabled people living independently in the community with intractable social problems as well as serious medical needs. At the end of the year the general practitioners were asked for their views. None had had difficult problems to deal with or difficult decisions to make. Out of hours work was minimal. Only one out of the 11 general practitioners regretted his involvement. Difficulties mainly concerned lack of a clearly defined role and inadequate communication systems - both essential in interdisciplinary work. Continuing supervision of such patients is essential because without it much can go wrong. The standard of medical care in all three hostels was high and all three patterns of care seemed to be working well. But surely, if these former hospital patients are to be as much as possible part of the community institutional habits should be discarded and they should be cared for in the same way as the rest of us. Many general practitioners are interested in psychiatric work and some have special training, and the care of this group of chronically sick people is well within their capabilities. They can provide continuity and are relatively close and accessible, both to the residents and, equally importantly, to the staff of hostels. Whether they will feel able to accept this type of work at a time of great stress and uncertainty is an open question. ELIZABETH HORDER
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-Trhe B1I did not show us five of the letters that appeared in the issue of 23 June above our authors' reply. We wish to respond to some of the comments made. Mr P Hope's' use of selected figures from our paperI is muddled and inaccurate. He overlooks the considerable clinical benefit represented by a difference of 7% points (not 7%) on the Oswestry scale, which we exemplified in table II of our paper. This difference resulted from an improvement of about 9 points in patients treated in hospital compared with 16 points in those treated by chiropractic, which represents not far short of VOLUME
T W MEADE A 0 FRANK
1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. BrMedJ7 1990;300:1647-50. (23
I Cartwright A. Whv directing a L)oH fttnlded research unit is no lotiger attractive. BrAMed.7 1990;300: 140)5. 26 Ma. )
BMJ
twice as much improvement. His reference to costs is misleading in omitting not only our own suggestion that the benefit of chiropractic may be achieved with fewer treatments but also the savings in lost output and social security payments to which we drew attention. He has also exaggerated the proportion of centres in which hospitals and chiropractors achieved similar results and cites mishaps after cervical-not lumbar-manipulation to make insinuations against chiropractic treatment for low back pain. The debate about this important but obviously controversial topic must be carried out at a higher level. There is no reason to believe that properly trained chiropractors are any less able than physiotherapists to identify patients in whom manipulation may be harmful. In passing, the conduct of the British Chiropractic Association in seeking and taking advice about the evaluation of chiropractic treatment and in allowing the trial to be carried out quite independently was impeccable. It should be an example to those, including several of the correspondents, who are suddenly so certain about the different trials that should have been carried out but who, until our results appeared, have done virtually nothing to initiate these trials themselves. Our trial was not designed to evaluate open access or duration of treatment so that confident conclusions by Mr Hope and Ms Joyce Wise' that the results can be explained in one or other of these ways are inappropriate and entirely speculative. The bias suggested by Dr Keith Bush' did not occur. Those treated either in hospital or by chiropractors were represented equally by those who had initially attended either hospital or chiropractors. Two small studies cited by Dr Bush,'4 which deal with nerve root compression and failed conservative management, are irrelevant as both these circumstances contributed to ineligibility for our trial. Whether to go to hospital or to a chiropractor is a question faced by hundreds of patients with back pain every week. We doubt whether these patients will feel that our trial "answered no question of practical importance," as Dr Roderic MacDonald claims.' The small, short term trials of other techniques that he cites have little or no bearing on the explanation or practical implications of the surprisingly long term benefit conferred by chiropractic treatment. We share the concern of several of the correspondents that further work is needed to identify the factors - therapeutic or organisational-that militate against successful management in the NHS.
300
30
JUNE
1990
London NW1 8UG
June.) 2 Meade TW, Dyer S, Braune W, Townsend J, Frank AO. Low back pain of mechanical origin: randomiscd comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ridlev MG, Kingsley GH, Gibson T, et al. Outpatient lumbar epidural corticosteroid injection in the management of sciatica. Br] Rheumatol 1988;27:295-9. 4 Onglev MJ, Klein RG, Dorman TA, Ike BC, Hubert LJ. A new approach to the treatment ot chronic low back pain. Lancet 1987;ii: 143-6.
After the asylums: the role of the GP SIR,-Dr Trish Groves notes that some general practitioners are not clear about their role in caring for psychiatrically disabled people in the community.' While much has now been written about residential care there is less information about the medical needs of these patients. In north London an inquiry was set up in 1986 to investigate this topic, focusing especially on the
I Groves T. The local picture. Br Med J 1990;300:1128-30. (28 April.) 2 Horder E. Medical care in three psychiatric hostels. London: Hampstead and South Barnet General Practice Forum and Hampstead Department of Community Medicine, 1990.
Tuberculosis in Britain SIR,-The code of practice from the Joint Tuberculosis Committee of the British Thoracic Society recommends that new NHS employees with a Heaf test grade 3 or 4 reaction and those without a BCG vaccination scar with a Heaf test grade 2 reaction should have chest radiography.' This is not the current practice in our departments: we accept a scar as evidence that there will be a positive tuberculin skin reaction,2 and we require chest radiography only in individuals with respiratory symptoms. What are the implications of the recommendations for our practice and what is the evidence that they are justified?
1723
Department of Health. London SEl 6BY
Northwick Park Hospital, Harrow HAI 3UJ
part played by general practitioners.2 Three district health authority hostels were visited regularly for a year. In total 26 residents aged 22-77, mostly institutionalised with chronic schizophrenia, were looked after by house teams of psychiatric nurses and care assistants. All the residents were registered with general practitioners and were also seen by local psychiatrists. The patterns of medical care in the three hostels varied widely. In one the general practitioner looked after physical complaints and the psychiatrist concentrated on psychological problems. In the second the psychiatrist, by visiting regularly, provided both sorts of care and the general practitioners were barely consulted. In the third hostel the general practitioners developed closer relationships with the residents and the pattern of care approximated to that of primary care in the NHS. Although the consultation rates with the general practitioners were high (in two hostels each patient saw a doctor at least eight times a year on average), the problems presented were not essentially different from those being dealt with every day by the doctors in their practices. And because of the good living conditions and excellent staff, who dealt with many of the problems themselves, these patients were easier to look after than mentally disabled people living independently in the community with intractable social problems as well as serious medical needs. At the end of the year the general practitioners were asked for their views. None had had difficult problems to deal with or difficult decisions to make. Out of hours work was minimal. Only one out of the 11 general practitioners regretted his involvement. Difficulties mainly concerned lack of a clearly defined role and inadequate communication systems - both essential in interdisciplinary work. Continuing supervision of such patients is essential because without it much can go wrong. The standard of medical care in all three hostels was high and all three patterns of care seemed to be working well. But surely, if these former hospital patients are to be as much as possible part of the community institutional habits should be discarded and they should be cared for in the same way as the rest of us. Many general practitioners are interested in psychiatric work and some have special training, and the care of this group of chronically sick people is well within their capabilities. They can provide continuity and are relatively close and accessible, both to the residents and, equally importantly, to the staff of hostels. Whether they will feel able to accept this type of work at a time of great stress and uncertainty is an open question. ELIZABETH HORDER
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-Trhe B1I did not show us five of the letters that appeared in the issue of 23 June above our authors' reply. We wish to respond to some of the comments made. Mr P Hope's' use of selected figures from our paperI is muddled and inaccurate. He overlooks the considerable clinical benefit represented by a difference of 7% points (not 7%) on the Oswestry scale, which we exemplified in table II of our paper. This difference resulted from an improvement of about 9 points in patients treated in hospital compared with 16 points in those treated by chiropractic, which represents not far short of VOLUME
T W MEADE A 0 FRANK
1 Correspondence. Low back pain: comparison of chiropractic and hospital outpatient treatment. BrMedJ7 1990;300:1647-50. (23
I Cartwright A. Whv directing a L)oH fttnlded research unit is no lotiger attractive. BrAMed.7 1990;300: 140)5. 26 Ma. )
BMJ
twice as much improvement. His reference to costs is misleading in omitting not only our own suggestion that the benefit of chiropractic may be achieved with fewer treatments but also the savings in lost output and social security payments to which we drew attention. He has also exaggerated the proportion of centres in which hospitals and chiropractors achieved similar results and cites mishaps after cervical-not lumbar-manipulation to make insinuations against chiropractic treatment for low back pain. The debate about this important but obviously controversial topic must be carried out at a higher level. There is no reason to believe that properly trained chiropractors are any less able than physiotherapists to identify patients in whom manipulation may be harmful. In passing, the conduct of the British Chiropractic Association in seeking and taking advice about the evaluation of chiropractic treatment and in allowing the trial to be carried out quite independently was impeccable. It should be an example to those, including several of the correspondents, who are suddenly so certain about the different trials that should have been carried out but who, until our results appeared, have done virtually nothing to initiate these trials themselves. Our trial was not designed to evaluate open access or duration of treatment so that confident conclusions by Mr Hope and Ms Joyce Wise' that the results can be explained in one or other of these ways are inappropriate and entirely speculative. The bias suggested by Dr Keith Bush' did not occur. Those treated either in hospital or by chiropractors were represented equally by those who had initially attended either hospital or chiropractors. Two small studies cited by Dr Bush,'4 which deal with nerve root compression and failed conservative management, are irrelevant as both these circumstances contributed to ineligibility for our trial. Whether to go to hospital or to a chiropractor is a question faced by hundreds of patients with back pain every week. We doubt whether these patients will feel that our trial "answered no question of practical importance," as Dr Roderic MacDonald claims.' The small, short term trials of other techniques that he cites have little or no bearing on the explanation or practical implications of the surprisingly long term benefit conferred by chiropractic treatment. We share the concern of several of the correspondents that further work is needed to identify the factors - therapeutic or organisational-that militate against successful management in the NHS.
300
30
JUNE
1990
London NW1 8UG
June.) 2 Meade TW, Dyer S, Braune W, Townsend J, Frank AO. Low back pain of mechanical origin: randomiscd comparison of chiropractic and hospital outpatient treatment. Br Med J 1990;300:1431-7. (2 June.) 3 Ridlev MG, Kingsley GH, Gibson T, et al. Outpatient lumbar epidural corticosteroid injection in the management of sciatica. Br] Rheumatol 1988;27:295-9. 4 Onglev MJ, Klein RG, Dorman TA, Ike BC, Hubert LJ. A new approach to the treatment ot chronic low back pain. Lancet 1987;ii: 143-6.
After the asylums: the role of the GP SIR,-Dr Trish Groves notes that some general practitioners are not clear about their role in caring for psychiatrically disabled people in the community.' While much has now been written about residential care there is less information about the medical needs of these patients. In north London an inquiry was set up in 1986 to investigate this topic, focusing especially on the
I Groves T. The local picture. Br Med J 1990;300:1128-30. (28 April.) 2 Horder E. Medical care in three psychiatric hostels. London: Hampstead and South Barnet General Practice Forum and Hampstead Department of Community Medicine, 1990.
Tuberculosis in Britain SIR,-The code of practice from the Joint Tuberculosis Committee of the British Thoracic Society recommends that new NHS employees with a Heaf test grade 3 or 4 reaction and those without a BCG vaccination scar with a Heaf test grade 2 reaction should have chest radiography.' This is not the current practice in our departments: we accept a scar as evidence that there will be a positive tuberculin skin reaction,2 and we require chest radiography only in individuals with respiratory symptoms. What are the implications of the recommendations for our practice and what is the evidence that they are justified?
1723
