of Surgeons highlights the importance of an integrated response to trauma, care before patients reach hospital, and communication between doctors and the emergency services.6 Unfortunately, it does not mention immediate medical care, provided at the scene of accidents throughout. the United Kingdom by over 2000 doctors trained by the British Association of Intermediate Care. Indeed, in their major review of deaths from trauma Anderson et al do not discriminate between victims who have received immediate care before reaching hospital and those who have not.3 All doctors should be trained in emergency medicine at undergraduate as well as postgraduate level." The pattern of trauma is different in the United Kingdom from that elsewhere, and accepting American training methods4 without modification may not be appropriate. Advanced trauma life support has much to offer as a systematic approach to trauma care but is only partially successful in meeting the needs of immediate care doctors, with its focus on x ray investigation, diagnostic peritoneal lavage, urinary catheterisation, and rectal examination, all of which are inappropriate at the scerne of an accident. I look forward to the development of an advanced trauma life support module for immediate care of trauma victims. ANDREW j MOWAT
Heckington, Lincolnshirc NG34 9QP I Nolan JP, Forrest FC, Baskctt PJF. Ads'anced trauma life support courses. BMJf 1992;304:654. (14 M1arch.) 2 Department of Transport. Road accident costs 1989. London: HMiSO, 1990. (Highways economics note, Nos 1990.) 3 Anderson ID, Woodford 1, de Dombal FT, Irving M. Retrospectise study of 1000 deaths from injury in England and Wales. BMJ 1988;2%:1305-8. 4 American College of Surgeons, Committee on Trauma. ATLS course manual. Chicago: American College of Surgeons, 1989. 5 Easton KC. Care of accident sictims. BMJ 1989;298:116. 6 Commission on the Provision of Surgical Services. Report of the working parts on the management of patients with major injuries. London: Royal College of Surgeons of England, 1988. 7 Yates DW. Action for accident sictims. BMJ 1988;297:1419-20. 8 Henry AF. Training family physicians in emergency medicine. Canadian Family Physician 1988;34:2239-42. 9 Chouinard JL. Emergency medical training should be available to all physicians. Can Med Assocjf 1981;124:1358.
Establishment of pregnancy after removal of sperm antibodies in vitro SIR,-Several of Rekha Sharma and colleagues' criticisms' of our paper on the establishment of pregnancy after the removal of sperm antibodies in vitro2 are unsound. Firstly, antibodies do not "bind irreversibly to sperm at ejaculation." The binding of any antibody to antigen is a reversible reaction dependent on non-covalent interactions; the antibody-antigen complex is in equilibrium with the free components, and the affinity constants for these interactions vary widely (from 10'2/mol) and depend on the particular antigen and antibody. Secondly, there is evidence that although IgG attaches to the sperm in a time dependent manner after ejaculation,' this is not true of IgA, which is already present on the sperm before ejaculation. The current view is that either IgA alone or a synergistic combination of IgA and IgG isotypes is principally responsible for the inhibition of fertility by antibodies to sperm.4 Thirdly, it is not true that "the technique is unsuitable for cases in which almost all sperm in the ejaculate are bound to antibodies." The rate of recovery of antibody free sperm from a sample containing antibodies is too high in many of our patients to be accounted for simply by selection of those sperm that were initially antibody free. We recently achieved a pregnancy by using sperm treated as described in our paper; the direct BMJ
VOLUME 304
25 APRIL 1992
immunobead test for the male partner had given initial results of95% positive for both IgG and IgA. Clearly there will be variation among patients in the antigenic sites expressed on the sperm, in the titres and types of antibodies concerned, and in their affinities. We find that the yield of antibody free sperm varies among cases. Nevertheless, we have now established six clinical pregnancies in 17 patients treated; in all of these cases there was a long history of immunological infertility. If the logic expressed by Sharma and colleagues was correct no method that depended on competitive interference of the antigen-antibody interaction for its efficacy would be feasible-and that would apply to their procedures as well as ours. CAROLYN E GRUNDY JOHN ROBINSON KATHARINE A GUTHRIE Hull IVF Unit, Princess Royal Hospital, Hull HU8 9HE
ALAN G GORDON DOUGLAS M HAY
I Sharma R, Bromham DR, Sharma V. Establishment of pregnancy after removal of sperm antibodies in vitro. BMJ7 1992;304:640. (7 March.) 2 Grundy CE, Robinson J, Guthrie KA, Gordon AG, Hav DM. Establishment of pregnancy after removal of sperm antibodies in vitro. BMJ 1992;304:292-3. (I February.) 3 Bronson R, Cooper G, Rosenfeld D. Sperm antibodies: their role in infertility. Fertil Stenrl 1984;42:171-83. 4 Clarke GN, Lopata A, Mcbain JC, Baker HWG, Johnston WIH. Effect of sperm antibodies in males on human in vitro fertilization (IVF). AmJ7 Reprod Immunol 1985;8:62-6.
Data on vaccine uptake should be checked SIR,-Joanne M White and colleagues report that districts that had changed their child health computer systems recently showed the greatest increase in vaccination coverage,' presumably because the change drew attention to the accuracy and completeness of reporting and the quality of data. In Sandwell, despite a change of computer system in 1989, reported coverage rates have remained low. General practitioners and health visitors have always been sceptical of the accuracy of the data on which these rates were based. Recently, I carried out an exercise that lends support to White and colleagues' suggestion that updating and validating data might further improve recorded coverage. The rates of uptake of vaccination for Sandwell in the various birth cohorts defined by the COVER (cover of vaccination evaluated rapidly) scheme run by the Public Health Laboratory Service2 were generated by running a routine inquiry on the child health computer. I also obtained from the database a list of children in each of the birth cohorts who were recorded as not having been immunised with the relevant antigen. The vaccination status of these children was verified by health visitors by reference to independent manual records. Children who were no longer resident in the district were also identified. The resulting changes in both the numerator (number of children immunised) and denominator (number of children in the cohort) for each antigen led to a revised coverage rate (table). The number of vaccinations performed had been considerably underreported
so that the revised coverage rate was 7% higher than the draft figure for diphtheria and pertussis in the 15-18 month age group. Only a small part of this rise was due to eliminating from the base population children who had moved away. There may be many reasons for doctors failing to notify the computer about immunisations, but in Sandwell the most likely seems to be that general practitioners are paid by the family health services authority on the basis of claims submitted, without reference to the child health computer. Increasingly, general practitioners are tending to manage and schedule the immunisations of children on their lists. Without a financial incentive to do so they are likely to regard as unnecessary the chore of notifying the computer system. With a mobile, inner city deprived population such as Sandwell's, however, there is a strong case for central responsibility for achieving and maintaining high coverage throughout the district. Without accurate and reliable data, I do not think that this responsibility can be discharged satisfactorily. JAMMI NAGARAY RAO Sandwell Health Authority, PO Box 1953, Sandwell District General Hospital, West Bromwich, West Midlands B71 4NA 1 White JM, Gillam SJ, Begg NT, Farrington CP. Vaccine coverage: recent trends and future prospects. BMJ 1992;304: 682-4. (14 March.) 2 Begg NT, Gill ON, White JM. COVER (cover of vaccination evaluated rapidly). Description of the England and Wales scheme. Public Health 1989;103:81-9.
Modular contracts for general practitioners SIR, -General practitioners' salaries are creeping up the agenda, but general practitioners' circumstances and skills vary enormously so that a universal contract may be unattainable. I propose individual contracts to utilise all of a general practitioner's skills, allow better provision of services, permit performance related pay and reaccreditation, end exploitation, and rekindle enthusiasm by providing achievable personal goals. Individually defined "modular contracts" should be introduced for each principal, with modules comprising the job description, targets, pay scale, and defined accreditation. Variations for caseload, deprivation, hours, etc, would apply. Modules might include minor surgery, immunisations, out of hours cover, course organisation and teaching, hospital work, intrapartum care, audit, cover for colleagues, administration, counselling, dispensing, cervical smear testing, committee work, work for nursing homes, research, alternative therapies, and contraception. General practitioners might select eight to 12 modules. Performance bonuses and rates of pay would reflect local priorities and mould work patterns. Local medical committees would shoulder the bargaining, guided by national recommendations. Partnership would be possible, but vulnerability to partners' vagaries, the closet sale of goodwill, and inequitable profit sharing would be extinguished. General practitioners could alter their commitments with six months'
Data on uptake ofvaccination before and after children's vaccination status was verified Draft figures
Cohort and antigen
Third, diphtheria Third, pertussis Third, diphtheria Third, pertussis Measles, mumps, and rubella
Revised figures
No in No Age Rate (months) cohort vaccinated (%)
21-24 21-24 15-18 15-18 24-27
1067 1067 1126 1126 1094
947 899 987 952 938
88-8 84-3 87-7 84-5 85 7
Moved Errors in Revised from No not No Revised Revised district denominator vaccinated vaccinated rate 9 9 10 10 21
1058 1058 1116 1116 1073
56 56 72 72 26
1003 955 1059 1024
964
94-8 90 3 94-9 91-8 89-8
1115
notice. This would accommodate changes in personal or professional circumstances. Family health services authorities could match skills to jobs. Job sharing and mobility would be facilitated. The whole exercise may be construed as a global job share. "Ghettoisation" for either sex would become voluntary rather than imposed by consumers. Family health services authorities' skill banks would offer a wider distribution of services and facilitate planning. Benefits would accrue to consumers and practitioners through a wider choice of service and variety of experience, respectively. Referral to secondary care would probably fall. Modular contracting would allow specialisation within the primary health care team. Specialisation by general practitioners could be extended into "primary consultant" posts: obstetrics, minor surgery, dermatology, psychiatry, rheumatology, diabetes, audit, and geriatrics are obvious candidates. Hospital, Department of Social Security, and industrial appointments could also attract recognition. Modular contracts would offer improved provision of services, easy planning, flexibility, rewards for effort and skill, accreditation, some independence, career planning, and equality of opportunity. STEVEN FORD Haydon Bridge, Northumberland NE47
IHJ
Goya's living skeleton SIR,-I am grateful to Richard and Maureen Park for providing contemporary descriptions of the feet and hands of Claude Seurat, the "living skeleton.-'2 They do not exclude a diagnosis of fibrodysplasia ossificans progressiva as valgus deformities of the great toes and clinodactyly are common features of the condition.3 Ossification within the paraspinal and cervical muscles, so well seen in the drawings of Seurat, is invariable but does not always cause scoliosis or torticollis. About 70% of patients have involvement of the jaw muscles, which would explain why Seurat could eat only small fragments of food. As his bones cannot be examined the diagnosis of Seurat's illness must be speculative, but fibrodysplasia ossificans progressiva remains a strong possibility. GEOFFREY HOOPER Princess Margaret Rose Orthopaedic Hospital, Edinburgh EH1O 7ED I Park R, Park M. Goya's living skeleton. BMJ 1992;304:844.
(28 March.) 2 Park RHR, Park MP. Goya's living skeleton. BMJ 1991;303: 1594-6. (21-28 December.) 3 Connor JM, Evans DAP. Fibrodysplasia ossificans progressiva. J Bonejfoint Surg[Br] 1982;64:76-83.
one personal in so far as it concerns my practice. I have patients who have been under my care for 30 years. I think it a bit much to have to say to them that, because of my age, if they belong to BUPA, from the end of this year they will not be refunded what they pay me. They don't wish to go to a younger man; if they did they would have gone long ago. In the United Kingdom I am the only' person who corrects severe myopia by inserting an implant into the anterior chamber of the eye without disturbing the crystalline lens, which has a high minus optic. I have done 40 such operations over the past two and a half years; I think I have a duty to keep doing them to benefit patients and so that I can accumulate experience to lay before my colleagues to help them take an informed decision on whether they should start doing this operation themselves. Consultants' potential contributions to the welfare of their patients and their specialty should be considered individually. D P CHOYCE
London WI M 7DG
***We sent Mr Choyce's letter to BUPA, whose reply is given below. SIR,-In declining to pay benefits to members for fees from specialists over the age of 70 BUPA is bringing itself into line with private hospitals and the NHS. Most private hospitals withdraw admitting privileges at the age of 70. Consultants over 70 are permitted to undertake locum posts in the NHS only with the specific permission of the Department of Health. Since the NHS requires specialists to retire at 65 it could be argued that BUPA should have followed suit. The motive for introducing this change has nothing to do with cost containment but is to promote the highest possible quality and most up to date medical advice to BUPA's members. It would be invidious for BUPA to make individual assessments of the practice of consultants over 70. It would take only one untoward incident in which the advice given to a member could not be supported by current medical opinion for the whole system of specialist medical advice to be called into question. Much of the clinical work that individual consultants over 70 have described in correspondence with BUPA seems to be long term follow up and surveillance of patients whose conditions have long since ceased to be "acute episodes of illness or injury." Treatment falling outside this definition is ineligible for reimbursement under the terms of the contract between BUPA and its subscribers. I am unable to comment on the specific procedure that D P Choyce describes other than to note that it seems to be experimental; as such, neither Choyce's services nor the hospital costs are eligible for reimbursement under BUPA's rules. HUGH THELWALL-JONES
Group medical director, BUPA, London WC2R 3AX
BUPA and consultants over 70 SIR,-British United Provident Association (BUPA) has announced that by the end of this year it proposes to make no further payments to insured patients in respect of consultants' fees if the consultant is aged 70 or over. I believe this to be a mean cost cutting exercise dressed up in a mantle of spurious righteousness. I speak as a doctor who has subscribed to BUPA since the day it was born. At the moment none ofthe other private medical contributory schemes are wielding the axe to consultants aged over 70. I suggest that medical practitioners who are under 70 and are currently insured with BUPA should start shopping around and switch their personal insurance to whichever company offers the best deal. I have two specific complaints, one general and
1116
Predictors of general practitioners' workload SIR,-We agree with R Balarajan and colleagues that a scheme for compensating general practitioners for the effects of social deprivation should be based on an objective measure of workload such as consultation rates. The use of the general household survey for this purpose, however, has serious limitations. The data on workload are based only on consultations over two weeks, so that even with a large sample there are wide confidence intervals around the odds ratios for the associations of socioeconomic variables with consultation. No distinction is made between consultations for illness and consultations for preventive pro-
cedures, which are likely to be used by the least deprived groups and for which general practitioners are usually remunerated separately. All consultations are counted equally, the workload generated by a telephone consultation being equated with that generated by a home visit, which people in households without access to a car are especially likely to require. For these reasons the analysis is likely to underestimate the effects of deprivation on workload. We have also examined the effects of deprivation on workload by using consultations from the third national morbidity survey.2 This dataset, linking general practice consultations with the census records of 140 050 subjects aged over 1 year, overcomes the limitations above. Our results, like those of Balarajan and colleagues, emphasise the importance of housing tenure and car ownership as predictors of workload. These two studies provide a basis for a more rational system for compensating general practitioners for the effects of deprivation than the Jarman underprivileged area index. YOAV BEN-SHLOMO IAN WHITE Department of Epidemiology and Public Health, University College and Middlesex School of Medicine, London WC I E 6EA PAUL McKEIGUE Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, London WC 1 E 7HT 1 Balarajan R, Yuen P, Machin D. Deprivation and general practitioner workload. BMJ7 1992;304:529-34. (29 February.) 2 Ben-Shlomo Y, White I, McKeigue PM. Prediction of general practice workload from census-based social deprivation scores.
J Epidemiol Community Health (in press).
Doctors and control of major releases of chemicals SIR,-Though they are rare, major disasters leading to the release of poisonous gases have occurred. That health authorities should plan for disasters has been stated several times in the recent past.'3 Chemical disasters, however, pose additional problems to those posed by other disasters in that poisonous gases can drift, causing morbidity and death over several kilometres.3 Prompt control of a release of toxic gas and the protection of the surrounding population demand the coordinated work of several authorities and emergency services. Recently we have participated, as medical officers, in a planning exercise to control a hypothetical major release of chemicals. The incident medical officer has a dual role in such exercises. He or she will communicate with the local health authority and also be the source of medical advice to the incident control team. He or she will be the person best able to assess the possible health care needs of victims involved in the incident and then communicate this to the relevant health authority, hospitals, and general practitioners. In addition, the medical officer will be the only site based source of medical skill for the incident control team. Whether or not to evacuate populations depends ultimately on the health gain or loss resulting from evacuation compared with no evacuation. This decision tends to be taken by the senior police officer or senior executive of the district local authority, neither of whom is likely to have the training or skill to make such judgments on his or her own. Deciding when to evacuate a population is not easy and requires a strong medical input. That public health doctors should have a central role in planning for, and managing, disasters has been emphasised.45 Assessment of the health risks to the general population in releases of chemicals requires the skills of public health doctors. We suggest that in the United Kingdom the most appropriate public health doctor is the consultant
BMJ VOLUME 304
25 APRIL 1992
Heckington, Lincolnshirc NG34 9QP I Nolan JP, Forrest FC, Baskctt PJF. Ads'anced trauma life support courses. BMJf 1992;304:654. (14 M1arch.) 2 Department of Transport. Road accident costs 1989. London: HMiSO, 1990. (Highways economics note, Nos 1990.) 3 Anderson ID, Woodford 1, de Dombal FT, Irving M. Retrospectise study of 1000 deaths from injury in England and Wales. BMJ 1988;2%:1305-8. 4 American College of Surgeons, Committee on Trauma. ATLS course manual. Chicago: American College of Surgeons, 1989. 5 Easton KC. Care of accident sictims. BMJ 1989;298:116. 6 Commission on the Provision of Surgical Services. Report of the working parts on the management of patients with major injuries. London: Royal College of Surgeons of England, 1988. 7 Yates DW. Action for accident sictims. BMJ 1988;297:1419-20. 8 Henry AF. Training family physicians in emergency medicine. Canadian Family Physician 1988;34:2239-42. 9 Chouinard JL. Emergency medical training should be available to all physicians. Can Med Assocjf 1981;124:1358.
Establishment of pregnancy after removal of sperm antibodies in vitro SIR,-Several of Rekha Sharma and colleagues' criticisms' of our paper on the establishment of pregnancy after the removal of sperm antibodies in vitro2 are unsound. Firstly, antibodies do not "bind irreversibly to sperm at ejaculation." The binding of any antibody to antigen is a reversible reaction dependent on non-covalent interactions; the antibody-antigen complex is in equilibrium with the free components, and the affinity constants for these interactions vary widely (from 10'2/mol) and depend on the particular antigen and antibody. Secondly, there is evidence that although IgG attaches to the sperm in a time dependent manner after ejaculation,' this is not true of IgA, which is already present on the sperm before ejaculation. The current view is that either IgA alone or a synergistic combination of IgA and IgG isotypes is principally responsible for the inhibition of fertility by antibodies to sperm.4 Thirdly, it is not true that "the technique is unsuitable for cases in which almost all sperm in the ejaculate are bound to antibodies." The rate of recovery of antibody free sperm from a sample containing antibodies is too high in many of our patients to be accounted for simply by selection of those sperm that were initially antibody free. We recently achieved a pregnancy by using sperm treated as described in our paper; the direct BMJ
VOLUME 304
25 APRIL 1992
immunobead test for the male partner had given initial results of95% positive for both IgG and IgA. Clearly there will be variation among patients in the antigenic sites expressed on the sperm, in the titres and types of antibodies concerned, and in their affinities. We find that the yield of antibody free sperm varies among cases. Nevertheless, we have now established six clinical pregnancies in 17 patients treated; in all of these cases there was a long history of immunological infertility. If the logic expressed by Sharma and colleagues was correct no method that depended on competitive interference of the antigen-antibody interaction for its efficacy would be feasible-and that would apply to their procedures as well as ours. CAROLYN E GRUNDY JOHN ROBINSON KATHARINE A GUTHRIE Hull IVF Unit, Princess Royal Hospital, Hull HU8 9HE
ALAN G GORDON DOUGLAS M HAY
I Sharma R, Bromham DR, Sharma V. Establishment of pregnancy after removal of sperm antibodies in vitro. BMJ7 1992;304:640. (7 March.) 2 Grundy CE, Robinson J, Guthrie KA, Gordon AG, Hav DM. Establishment of pregnancy after removal of sperm antibodies in vitro. BMJ 1992;304:292-3. (I February.) 3 Bronson R, Cooper G, Rosenfeld D. Sperm antibodies: their role in infertility. Fertil Stenrl 1984;42:171-83. 4 Clarke GN, Lopata A, Mcbain JC, Baker HWG, Johnston WIH. Effect of sperm antibodies in males on human in vitro fertilization (IVF). AmJ7 Reprod Immunol 1985;8:62-6.
Data on vaccine uptake should be checked SIR,-Joanne M White and colleagues report that districts that had changed their child health computer systems recently showed the greatest increase in vaccination coverage,' presumably because the change drew attention to the accuracy and completeness of reporting and the quality of data. In Sandwell, despite a change of computer system in 1989, reported coverage rates have remained low. General practitioners and health visitors have always been sceptical of the accuracy of the data on which these rates were based. Recently, I carried out an exercise that lends support to White and colleagues' suggestion that updating and validating data might further improve recorded coverage. The rates of uptake of vaccination for Sandwell in the various birth cohorts defined by the COVER (cover of vaccination evaluated rapidly) scheme run by the Public Health Laboratory Service2 were generated by running a routine inquiry on the child health computer. I also obtained from the database a list of children in each of the birth cohorts who were recorded as not having been immunised with the relevant antigen. The vaccination status of these children was verified by health visitors by reference to independent manual records. Children who were no longer resident in the district were also identified. The resulting changes in both the numerator (number of children immunised) and denominator (number of children in the cohort) for each antigen led to a revised coverage rate (table). The number of vaccinations performed had been considerably underreported
so that the revised coverage rate was 7% higher than the draft figure for diphtheria and pertussis in the 15-18 month age group. Only a small part of this rise was due to eliminating from the base population children who had moved away. There may be many reasons for doctors failing to notify the computer about immunisations, but in Sandwell the most likely seems to be that general practitioners are paid by the family health services authority on the basis of claims submitted, without reference to the child health computer. Increasingly, general practitioners are tending to manage and schedule the immunisations of children on their lists. Without a financial incentive to do so they are likely to regard as unnecessary the chore of notifying the computer system. With a mobile, inner city deprived population such as Sandwell's, however, there is a strong case for central responsibility for achieving and maintaining high coverage throughout the district. Without accurate and reliable data, I do not think that this responsibility can be discharged satisfactorily. JAMMI NAGARAY RAO Sandwell Health Authority, PO Box 1953, Sandwell District General Hospital, West Bromwich, West Midlands B71 4NA 1 White JM, Gillam SJ, Begg NT, Farrington CP. Vaccine coverage: recent trends and future prospects. BMJ 1992;304: 682-4. (14 March.) 2 Begg NT, Gill ON, White JM. COVER (cover of vaccination evaluated rapidly). Description of the England and Wales scheme. Public Health 1989;103:81-9.
Modular contracts for general practitioners SIR, -General practitioners' salaries are creeping up the agenda, but general practitioners' circumstances and skills vary enormously so that a universal contract may be unattainable. I propose individual contracts to utilise all of a general practitioner's skills, allow better provision of services, permit performance related pay and reaccreditation, end exploitation, and rekindle enthusiasm by providing achievable personal goals. Individually defined "modular contracts" should be introduced for each principal, with modules comprising the job description, targets, pay scale, and defined accreditation. Variations for caseload, deprivation, hours, etc, would apply. Modules might include minor surgery, immunisations, out of hours cover, course organisation and teaching, hospital work, intrapartum care, audit, cover for colleagues, administration, counselling, dispensing, cervical smear testing, committee work, work for nursing homes, research, alternative therapies, and contraception. General practitioners might select eight to 12 modules. Performance bonuses and rates of pay would reflect local priorities and mould work patterns. Local medical committees would shoulder the bargaining, guided by national recommendations. Partnership would be possible, but vulnerability to partners' vagaries, the closet sale of goodwill, and inequitable profit sharing would be extinguished. General practitioners could alter their commitments with six months'
Data on uptake ofvaccination before and after children's vaccination status was verified Draft figures
Cohort and antigen
Third, diphtheria Third, pertussis Third, diphtheria Third, pertussis Measles, mumps, and rubella
Revised figures
No in No Age Rate (months) cohort vaccinated (%)
21-24 21-24 15-18 15-18 24-27
1067 1067 1126 1126 1094
947 899 987 952 938
88-8 84-3 87-7 84-5 85 7
Moved Errors in Revised from No not No Revised Revised district denominator vaccinated vaccinated rate 9 9 10 10 21
1058 1058 1116 1116 1073
56 56 72 72 26
1003 955 1059 1024
964
94-8 90 3 94-9 91-8 89-8
1115
notice. This would accommodate changes in personal or professional circumstances. Family health services authorities could match skills to jobs. Job sharing and mobility would be facilitated. The whole exercise may be construed as a global job share. "Ghettoisation" for either sex would become voluntary rather than imposed by consumers. Family health services authorities' skill banks would offer a wider distribution of services and facilitate planning. Benefits would accrue to consumers and practitioners through a wider choice of service and variety of experience, respectively. Referral to secondary care would probably fall. Modular contracting would allow specialisation within the primary health care team. Specialisation by general practitioners could be extended into "primary consultant" posts: obstetrics, minor surgery, dermatology, psychiatry, rheumatology, diabetes, audit, and geriatrics are obvious candidates. Hospital, Department of Social Security, and industrial appointments could also attract recognition. Modular contracts would offer improved provision of services, easy planning, flexibility, rewards for effort and skill, accreditation, some independence, career planning, and equality of opportunity. STEVEN FORD Haydon Bridge, Northumberland NE47
IHJ
Goya's living skeleton SIR,-I am grateful to Richard and Maureen Park for providing contemporary descriptions of the feet and hands of Claude Seurat, the "living skeleton.-'2 They do not exclude a diagnosis of fibrodysplasia ossificans progressiva as valgus deformities of the great toes and clinodactyly are common features of the condition.3 Ossification within the paraspinal and cervical muscles, so well seen in the drawings of Seurat, is invariable but does not always cause scoliosis or torticollis. About 70% of patients have involvement of the jaw muscles, which would explain why Seurat could eat only small fragments of food. As his bones cannot be examined the diagnosis of Seurat's illness must be speculative, but fibrodysplasia ossificans progressiva remains a strong possibility. GEOFFREY HOOPER Princess Margaret Rose Orthopaedic Hospital, Edinburgh EH1O 7ED I Park R, Park M. Goya's living skeleton. BMJ 1992;304:844.
(28 March.) 2 Park RHR, Park MP. Goya's living skeleton. BMJ 1991;303: 1594-6. (21-28 December.) 3 Connor JM, Evans DAP. Fibrodysplasia ossificans progressiva. J Bonejfoint Surg[Br] 1982;64:76-83.
one personal in so far as it concerns my practice. I have patients who have been under my care for 30 years. I think it a bit much to have to say to them that, because of my age, if they belong to BUPA, from the end of this year they will not be refunded what they pay me. They don't wish to go to a younger man; if they did they would have gone long ago. In the United Kingdom I am the only' person who corrects severe myopia by inserting an implant into the anterior chamber of the eye without disturbing the crystalline lens, which has a high minus optic. I have done 40 such operations over the past two and a half years; I think I have a duty to keep doing them to benefit patients and so that I can accumulate experience to lay before my colleagues to help them take an informed decision on whether they should start doing this operation themselves. Consultants' potential contributions to the welfare of their patients and their specialty should be considered individually. D P CHOYCE
London WI M 7DG
***We sent Mr Choyce's letter to BUPA, whose reply is given below. SIR,-In declining to pay benefits to members for fees from specialists over the age of 70 BUPA is bringing itself into line with private hospitals and the NHS. Most private hospitals withdraw admitting privileges at the age of 70. Consultants over 70 are permitted to undertake locum posts in the NHS only with the specific permission of the Department of Health. Since the NHS requires specialists to retire at 65 it could be argued that BUPA should have followed suit. The motive for introducing this change has nothing to do with cost containment but is to promote the highest possible quality and most up to date medical advice to BUPA's members. It would be invidious for BUPA to make individual assessments of the practice of consultants over 70. It would take only one untoward incident in which the advice given to a member could not be supported by current medical opinion for the whole system of specialist medical advice to be called into question. Much of the clinical work that individual consultants over 70 have described in correspondence with BUPA seems to be long term follow up and surveillance of patients whose conditions have long since ceased to be "acute episodes of illness or injury." Treatment falling outside this definition is ineligible for reimbursement under the terms of the contract between BUPA and its subscribers. I am unable to comment on the specific procedure that D P Choyce describes other than to note that it seems to be experimental; as such, neither Choyce's services nor the hospital costs are eligible for reimbursement under BUPA's rules. HUGH THELWALL-JONES
Group medical director, BUPA, London WC2R 3AX
BUPA and consultants over 70 SIR,-British United Provident Association (BUPA) has announced that by the end of this year it proposes to make no further payments to insured patients in respect of consultants' fees if the consultant is aged 70 or over. I believe this to be a mean cost cutting exercise dressed up in a mantle of spurious righteousness. I speak as a doctor who has subscribed to BUPA since the day it was born. At the moment none ofthe other private medical contributory schemes are wielding the axe to consultants aged over 70. I suggest that medical practitioners who are under 70 and are currently insured with BUPA should start shopping around and switch their personal insurance to whichever company offers the best deal. I have two specific complaints, one general and
1116
Predictors of general practitioners' workload SIR,-We agree with R Balarajan and colleagues that a scheme for compensating general practitioners for the effects of social deprivation should be based on an objective measure of workload such as consultation rates. The use of the general household survey for this purpose, however, has serious limitations. The data on workload are based only on consultations over two weeks, so that even with a large sample there are wide confidence intervals around the odds ratios for the associations of socioeconomic variables with consultation. No distinction is made between consultations for illness and consultations for preventive pro-
cedures, which are likely to be used by the least deprived groups and for which general practitioners are usually remunerated separately. All consultations are counted equally, the workload generated by a telephone consultation being equated with that generated by a home visit, which people in households without access to a car are especially likely to require. For these reasons the analysis is likely to underestimate the effects of deprivation on workload. We have also examined the effects of deprivation on workload by using consultations from the third national morbidity survey.2 This dataset, linking general practice consultations with the census records of 140 050 subjects aged over 1 year, overcomes the limitations above. Our results, like those of Balarajan and colleagues, emphasise the importance of housing tenure and car ownership as predictors of workload. These two studies provide a basis for a more rational system for compensating general practitioners for the effects of deprivation than the Jarman underprivileged area index. YOAV BEN-SHLOMO IAN WHITE Department of Epidemiology and Public Health, University College and Middlesex School of Medicine, London WC I E 6EA PAUL McKEIGUE Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, London WC 1 E 7HT 1 Balarajan R, Yuen P, Machin D. Deprivation and general practitioner workload. BMJ7 1992;304:529-34. (29 February.) 2 Ben-Shlomo Y, White I, McKeigue PM. Prediction of general practice workload from census-based social deprivation scores.
J Epidemiol Community Health (in press).
Doctors and control of major releases of chemicals SIR,-Though they are rare, major disasters leading to the release of poisonous gases have occurred. That health authorities should plan for disasters has been stated several times in the recent past.'3 Chemical disasters, however, pose additional problems to those posed by other disasters in that poisonous gases can drift, causing morbidity and death over several kilometres.3 Prompt control of a release of toxic gas and the protection of the surrounding population demand the coordinated work of several authorities and emergency services. Recently we have participated, as medical officers, in a planning exercise to control a hypothetical major release of chemicals. The incident medical officer has a dual role in such exercises. He or she will communicate with the local health authority and also be the source of medical advice to the incident control team. He or she will be the person best able to assess the possible health care needs of victims involved in the incident and then communicate this to the relevant health authority, hospitals, and general practitioners. In addition, the medical officer will be the only site based source of medical skill for the incident control team. Whether or not to evacuate populations depends ultimately on the health gain or loss resulting from evacuation compared with no evacuation. This decision tends to be taken by the senior police officer or senior executive of the district local authority, neither of whom is likely to have the training or skill to make such judgments on his or her own. Deciding when to evacuate a population is not easy and requires a strong medical input. That public health doctors should have a central role in planning for, and managing, disasters has been emphasised.45 Assessment of the health risks to the general population in releases of chemicals requires the skills of public health doctors. We suggest that in the United Kingdom the most appropriate public health doctor is the consultant
BMJ VOLUME 304
25 APRIL 1992
