These skills have in common that thev can be acquired by many reasonably intelligent and empathic people: they are not the exclusive preserve of any one profession and, indeed, may be most economically used by non-professionals. The danger of internecine strife among the caring professions regarding the ownership of these various techniques is great, and the danger of overprofessionalisation of their practice even more so.
The Samaritans, Relate, and other voluntary agencies, self help groups, and special interest groups all provide competent counselling. It was shown many years ago that the average general practice could identify enough unmet need to employ a full time social work team. There is good evidence to suggest that of the quarter of the community with appreciable symptoms of distress, less than half are recognised by general practitioners and less than 10% ever reach the psychiatric service. If we were to try to provide a comprehensive psychotherapy or counselling service for all those for whom a need could be identified we would require a massive redeployment of resources to the detriment of many more essential and already underresourced services. Medical practitioners, social workers, and psychologists all have specific skills that can make important contributions to the care of the sick and distressed. They all share, to a greater or less degree, the skills discussed above. Their specific skills should have priority in the provision of NHS services, and they should use their knowledge of psychotherapy and counselling to enhance the service they provide. Those who seek counselling or psychotherapy whose need does not arise from their use of specific NHS services should seek that help from other services or from the voluntary or private sector.
Newcastle.' As cystitis occurs more commonly in women and as P mirabilis is the second commonest bacterial cause of urinary tract infections, after Escherichia coli, the suggestion that proteus may have a role in causing rheumatoid arthritis is at least compatible with the specificity features of this disease. Therapeutic trials aimed at eliminating proteus and reducing antibodies to proteus not only could answer the question whether proteus causes rheumatoid arthritis but may be of benefit to patients. Clearly, a bacterial cause of the disease would seem to have at least as much merit as the suggestion that the disease is caused by some as yet unidentified viruses. ALAN EBRINGER
Immunology Section, Division of Biomolecular Sciences, King's College, University of London, London W8 7AH I Silman AJ. Is rheumatoid arthritis an infectious disease? BM,7 1991;303:200-1. (27 July.) 2 Dixon B. Bacteria and arthritis. BMJ 1990;301:1043. 3 Ebringer A. The cross-tolerance hypothesis, HLA-B27 and ankylosing spondylitis. Brj Rheum 1983;22(suppl 2):53-66. 4 Ebringer A, Ptaszynska T, Corbett M, Wilson C, Miacafee Y, Avakian H, et al. Antibodies to Proteus in rheumatoid arthritis.
Lancet 1985;ii:305-7. 5 Ebringer A, Khalafpour S, Wilson C. Rheumatoid arthritis and Proteus: a possible aetiological association. Rheumatol Int 1989;9:223-8. 6 Ebringer A, Cox NL, Abuliadayel I, Ghuloom M, Khalafpour S, Ptaszvnska T, et al. Klebsiella antibodies in ankylosing spondylitis and Proteus antibodies in rhcumatoid arthritis. Brj Rheum 1988;27(suppl 2):72-85. 7 Rogers P, Hassan J, Bresnihan B, Feighery C, Whelan A. Antibodies to Proteus in rheumatoid arthritis. BrJ Rheum 1988;27 (suppl 2):90-4. 8 Gray JW, Deighton CM, Cavanagh G, Bint AJ, Walker DJ. AntiProteus antibodies in rheumatoid arthritis same-sexed sibships. Brj Rheum 1990;29(suppl 2):102. (Abstract.)
SYDNEY BRANDON
University of Leicester School of Medicine, Leiccster Royal Infirmary, Leicester LE2 7LX I Margison F. Psychological therapy in the NHS. BMJ 1991;303:
Not research and development but dissemination and application
5-6. (6 July.)
Rheumatoid arthritis as an infectious disease SIR,-The question posed in Dr Alan J Silman's editorial "Is rheumnatoid arthritis an infectious disease?" deserves further comment. ' The author answered the question by suggesting that "a viral cause for rheumatoid arthritis is the strongest candidate," although seroepidemiological studies have failed to incriminate any particular virus. Recent studies, however, indicate that a much better case can be proposed for a bacterial rather than a viral agent as a possible cause of rheumatoid arthritis.2 Any aetiological agent proposed as a causative factor must explain two specificity features of the disease: its higher prevalence in women and the higher frequency of people positive for HLA-DR4 with severe disease. Previous studies from our group have suggested that "molecular mimicry" between HLA-B27 and the microbe Klebsiella can be used to explain the higher prevalence of HLA-B27 in patients with ankylosing spondylitis.' A similar approach has been adopted to study rheumatoid arthritis. Results of studies with xenogeneic serum and allogeneic anti-DR4 tissue typing serum have suggested partial molecular mimicry between HLA-DR4 and the commensal, Gram negative microbe Proteus mirabilis. We have shown increased levels of antibodies to proteus in patients with rheumatoid arthritis from London4 and Winchester,6 and similar results have been obtained by other groups in Dublin7 and
524
SIR,-The recent appointment of Professor Mike Peckham as the Department of Health's first director of research and development has, rightly, focused attention on the need to bring some coherence and direction to the amorphous organism that is health services and public health research in the United Kingdom. Few would argue with a more systematic approach to research and development at the Department of Health. And few would disagree with the need to establish an infrastructure for it at regional level and below. The failure of regions to comprehend their role in promoting and coordinating research and development, particularly in health services and public health, is difficult to understand. Even more important than establishing such a framework for research and development, however, is the need to do something about what some would see as a greater weakness of the service-namely, the failure to disseminate and apply existing knowledge. It is not research and development that we need in the NHS so much as dissemination and application. One of the benefits of having a national health service is that a countrywide mechanism is, in theory, available to ensure that best practice and relevant research findings are communicated throughout the service and to monitor their application. Paradoxically, the sheer size and bureaucracy of the national service seem to have had the opposite effect. Each health authority is an island reinventing its own wheels, wasting precious resources, and delivering substandard care as a result. In this the service has, needless to say, followed the time honoured medical model with each consultant and general practitioner cocooned in his or her own clinical autonomy.
What should be done to develop a mechanism and culture for dissemination and application within the service? Each discipline clearly has a responsibility to keep up to date with developments and research in its own domain and to ensure that, where appropriate, local practices are altered accordingly. Currently, however, this responsibility is not explicitly acknowledged and is not assigned to specific people. As a first step, therefore, dissemination and application should be added to the management agenda and individual officers given responsibility to establish mechanisms for developing it. PAUL WALKER
Department of Public Health Medicine, Norwich Health Authority, St Andrew's Hospital, Norwich NR7 OSS
Twenty five years of case finding and audit SIR,-I congratulate Dr Julian Tudor Hart and colleagues for their article on 25 years of case finding and audit in a socially deprived community.' Analysis of the Office of Population Censuses and Surveys' public records on death shows further evidence of differences in the two practice populations that require further comment. Infant mortality is a good indicator of provision of primary care; the data show only one infant death among 206 live births for Glyncorrwg during 1981-9 (expected 1 8, calculated from infant mortality for West Glamorgan for each year and aggregated) compared with three infant deaths among 219 live births in Aber/Blaengwynfi (expected 1-9). The differences between the two practice populations in the number of deaths below age 65 can be better shown by calculating the proportional mortality ratio. When there is doubt about the availability of a sound denominator for calculating age and cause specific standardised mortality ratios an age adjusted proportional mortality can be derived.2 The expected number of deaths for a defined population can be calculated by taking deaths from specific causes as a proportion of deaths from all causes and then applying this figure to the total number of deaths in the study population. Then: Proportional mortalitv ratio=
sum of observed deaths X 100. sum of expected deaths
Total deaths below age 65 (potentially avoidable deaths) for the period 1981-9 were 28 (proportional mortality ratio 88) and 60 (proportional mortality ratio 107) for Glyncorrwg and Aber/Blaengwynfi respectively. The proportional mortality ratios shown in the table for circulatory and respiratory causes of death-conditions in which primary care is most likely to be effective-are lower for Glyncorrwg than for Aber/Blaengwynfi. Intervention with respect to risk factors is likely to result in a change in the proportions of deaths due to different diseases. This may explain the comparatively high proportional mortality ratios associated with cancer and external causes of death in Glyncorrwg. These differences observed over a reasonably Cause and age specific proportional mortality ratios below age 65 forAber/Blaengwynfi and Glyncorrwg aggregated over 1981-9 Cause of death*
Aber/Blaengwynfi (Glyncorrwg
Extemal causes Other causes
91 104 118 82 108
120 91 62 140 84
All deaths below age 65
107
88
Cancer
Circulatory system Respiratory system
*Three digit categories in ICD ninth revision.
BMJ VOLUME 303
31 AUGUST 1991
The Samaritans, Relate, and other voluntary agencies, self help groups, and special interest groups all provide competent counselling. It was shown many years ago that the average general practice could identify enough unmet need to employ a full time social work team. There is good evidence to suggest that of the quarter of the community with appreciable symptoms of distress, less than half are recognised by general practitioners and less than 10% ever reach the psychiatric service. If we were to try to provide a comprehensive psychotherapy or counselling service for all those for whom a need could be identified we would require a massive redeployment of resources to the detriment of many more essential and already underresourced services. Medical practitioners, social workers, and psychologists all have specific skills that can make important contributions to the care of the sick and distressed. They all share, to a greater or less degree, the skills discussed above. Their specific skills should have priority in the provision of NHS services, and they should use their knowledge of psychotherapy and counselling to enhance the service they provide. Those who seek counselling or psychotherapy whose need does not arise from their use of specific NHS services should seek that help from other services or from the voluntary or private sector.
Newcastle.' As cystitis occurs more commonly in women and as P mirabilis is the second commonest bacterial cause of urinary tract infections, after Escherichia coli, the suggestion that proteus may have a role in causing rheumatoid arthritis is at least compatible with the specificity features of this disease. Therapeutic trials aimed at eliminating proteus and reducing antibodies to proteus not only could answer the question whether proteus causes rheumatoid arthritis but may be of benefit to patients. Clearly, a bacterial cause of the disease would seem to have at least as much merit as the suggestion that the disease is caused by some as yet unidentified viruses. ALAN EBRINGER
Immunology Section, Division of Biomolecular Sciences, King's College, University of London, London W8 7AH I Silman AJ. Is rheumatoid arthritis an infectious disease? BM,7 1991;303:200-1. (27 July.) 2 Dixon B. Bacteria and arthritis. BMJ 1990;301:1043. 3 Ebringer A. The cross-tolerance hypothesis, HLA-B27 and ankylosing spondylitis. Brj Rheum 1983;22(suppl 2):53-66. 4 Ebringer A, Ptaszynska T, Corbett M, Wilson C, Miacafee Y, Avakian H, et al. Antibodies to Proteus in rheumatoid arthritis.
Lancet 1985;ii:305-7. 5 Ebringer A, Khalafpour S, Wilson C. Rheumatoid arthritis and Proteus: a possible aetiological association. Rheumatol Int 1989;9:223-8. 6 Ebringer A, Cox NL, Abuliadayel I, Ghuloom M, Khalafpour S, Ptaszvnska T, et al. Klebsiella antibodies in ankylosing spondylitis and Proteus antibodies in rhcumatoid arthritis. Brj Rheum 1988;27(suppl 2):72-85. 7 Rogers P, Hassan J, Bresnihan B, Feighery C, Whelan A. Antibodies to Proteus in rheumatoid arthritis. BrJ Rheum 1988;27 (suppl 2):90-4. 8 Gray JW, Deighton CM, Cavanagh G, Bint AJ, Walker DJ. AntiProteus antibodies in rheumatoid arthritis same-sexed sibships. Brj Rheum 1990;29(suppl 2):102. (Abstract.)
SYDNEY BRANDON
University of Leicester School of Medicine, Leiccster Royal Infirmary, Leicester LE2 7LX I Margison F. Psychological therapy in the NHS. BMJ 1991;303:
Not research and development but dissemination and application
5-6. (6 July.)
Rheumatoid arthritis as an infectious disease SIR,-The question posed in Dr Alan J Silman's editorial "Is rheumnatoid arthritis an infectious disease?" deserves further comment. ' The author answered the question by suggesting that "a viral cause for rheumatoid arthritis is the strongest candidate," although seroepidemiological studies have failed to incriminate any particular virus. Recent studies, however, indicate that a much better case can be proposed for a bacterial rather than a viral agent as a possible cause of rheumatoid arthritis.2 Any aetiological agent proposed as a causative factor must explain two specificity features of the disease: its higher prevalence in women and the higher frequency of people positive for HLA-DR4 with severe disease. Previous studies from our group have suggested that "molecular mimicry" between HLA-B27 and the microbe Klebsiella can be used to explain the higher prevalence of HLA-B27 in patients with ankylosing spondylitis.' A similar approach has been adopted to study rheumatoid arthritis. Results of studies with xenogeneic serum and allogeneic anti-DR4 tissue typing serum have suggested partial molecular mimicry between HLA-DR4 and the commensal, Gram negative microbe Proteus mirabilis. We have shown increased levels of antibodies to proteus in patients with rheumatoid arthritis from London4 and Winchester,6 and similar results have been obtained by other groups in Dublin7 and
524
SIR,-The recent appointment of Professor Mike Peckham as the Department of Health's first director of research and development has, rightly, focused attention on the need to bring some coherence and direction to the amorphous organism that is health services and public health research in the United Kingdom. Few would argue with a more systematic approach to research and development at the Department of Health. And few would disagree with the need to establish an infrastructure for it at regional level and below. The failure of regions to comprehend their role in promoting and coordinating research and development, particularly in health services and public health, is difficult to understand. Even more important than establishing such a framework for research and development, however, is the need to do something about what some would see as a greater weakness of the service-namely, the failure to disseminate and apply existing knowledge. It is not research and development that we need in the NHS so much as dissemination and application. One of the benefits of having a national health service is that a countrywide mechanism is, in theory, available to ensure that best practice and relevant research findings are communicated throughout the service and to monitor their application. Paradoxically, the sheer size and bureaucracy of the national service seem to have had the opposite effect. Each health authority is an island reinventing its own wheels, wasting precious resources, and delivering substandard care as a result. In this the service has, needless to say, followed the time honoured medical model with each consultant and general practitioner cocooned in his or her own clinical autonomy.
What should be done to develop a mechanism and culture for dissemination and application within the service? Each discipline clearly has a responsibility to keep up to date with developments and research in its own domain and to ensure that, where appropriate, local practices are altered accordingly. Currently, however, this responsibility is not explicitly acknowledged and is not assigned to specific people. As a first step, therefore, dissemination and application should be added to the management agenda and individual officers given responsibility to establish mechanisms for developing it. PAUL WALKER
Department of Public Health Medicine, Norwich Health Authority, St Andrew's Hospital, Norwich NR7 OSS
Twenty five years of case finding and audit SIR,-I congratulate Dr Julian Tudor Hart and colleagues for their article on 25 years of case finding and audit in a socially deprived community.' Analysis of the Office of Population Censuses and Surveys' public records on death shows further evidence of differences in the two practice populations that require further comment. Infant mortality is a good indicator of provision of primary care; the data show only one infant death among 206 live births for Glyncorrwg during 1981-9 (expected 1 8, calculated from infant mortality for West Glamorgan for each year and aggregated) compared with three infant deaths among 219 live births in Aber/Blaengwynfi (expected 1-9). The differences between the two practice populations in the number of deaths below age 65 can be better shown by calculating the proportional mortality ratio. When there is doubt about the availability of a sound denominator for calculating age and cause specific standardised mortality ratios an age adjusted proportional mortality can be derived.2 The expected number of deaths for a defined population can be calculated by taking deaths from specific causes as a proportion of deaths from all causes and then applying this figure to the total number of deaths in the study population. Then: Proportional mortalitv ratio=
sum of observed deaths X 100. sum of expected deaths
Total deaths below age 65 (potentially avoidable deaths) for the period 1981-9 were 28 (proportional mortality ratio 88) and 60 (proportional mortality ratio 107) for Glyncorrwg and Aber/Blaengwynfi respectively. The proportional mortality ratios shown in the table for circulatory and respiratory causes of death-conditions in which primary care is most likely to be effective-are lower for Glyncorrwg than for Aber/Blaengwynfi. Intervention with respect to risk factors is likely to result in a change in the proportions of deaths due to different diseases. This may explain the comparatively high proportional mortality ratios associated with cancer and external causes of death in Glyncorrwg. These differences observed over a reasonably Cause and age specific proportional mortality ratios below age 65 forAber/Blaengwynfi and Glyncorrwg aggregated over 1981-9 Cause of death*
Aber/Blaengwynfi (Glyncorrwg
Extemal causes Other causes
91 104 118 82 108
120 91 62 140 84
All deaths below age 65
107
88
Cancer
Circulatory system Respiratory system
*Three digit categories in ICD ninth revision.
BMJ VOLUME 303
31 AUGUST 1991
