dispatched as often as time allowed (usually every one or two months). Patients and their families were urged to keep their general practitioner informed, particularly when symptoms improved. No restriction was placed on the numbers recruited. The opportunity was seized and the erythropoietin programme rapidly grew. By the time concessionary supplies ceased in August 1990, 46 patients had received erythropoietin. Three of these had successful transplantation and three died (of causes unrelated to erythropoietin). East Birmingham, which looks after about 150 dialysis patients, had received more than £180 000 worth of erythropoietin. General practitioners were then asked to continue prescribing. A number had already volunteered a commitment and others agreed immediately. In a few cases more protracted negotiations were required. Thirty nine patients were transferred to general practitioner prescribing with the fortieth remaining on hospital prescribing because of management problems. Subsequently, to allow more patients to benefit from erythropoietin it was decided to seek earlier general practitioner prescribing, with the hospital's erythropoietin budget funding only a brief initiation. To date there has been only one refusal to participate. Overall, 64 patients have received erythropoietin, and the numbers are steadily increasing. Happily, Birmingham Family Health Services Authority is adopting a constructive stance. What are the lessons from this? If general practitioners are informed and involved they are almost invariably willing to prescribe. Perhaps the "Dundee dilemma" could have been avoided. Perhaps Dr Gabriel should have emphasised communication and involvement as a route to general practitioner prescribing. General practitioners will no doubt resist those nephrologists who seek to use them merely as a prescription writing facility, particularly if there are veiled threats in the
background. S P GIBSON
Renal Unit,
East Birmingham Hospital, Birmingham B9 5ST I Gabriel R. Picking up the tab for erythropoietin. BMJ 1991;302: 248-9. (2 February.) 2 Taylor J, Henderson IS, Mactier RA, Stewart WK. Erythropoietin withdrawal. BMJ 1991;302:272-3. (2 February.)
SIR, -Dr Roger Gabriel's editorial illustrates well the difficulties faced by the hospital consultant wishing to treat patients with effective preparations whose expense cannot be met from the limited NHS funds available through district health authorities.' These difficulties are not confined to erythropoietin; the same considerations apply to growth hormone, various cytotoxic drugs, certain courses of complex hormone treatments (including those used in infertility treatment), and peritoneal dialysis fluids. Dr Gabriel's solution is to pass the clinical care of the patient -and consequently the prescribing of these preparations-over to the general practitioner. As the secretary of a local medical committee in regions where general practitioners have been coerced into prescribing such preparations under the threat of "ifyou don't prescribe then either your patient won't get it and hence will suffer unduly" or "we will have to close yet more beds for other work to fund the preparation" I am only too well aware of the concern Dr Gabriel's proposal will occasion to many general practitioners. As he so clearly states, the general practitioner's position of believing that those who are responsible for continuing clinical care should carry the responsibility of prescribing is reinforced by endless circulars from the Department of Health going back to 1976. To the vast majority of general practitioners with whom I am in contact the management on a week in, week out basis of
408
patients with a need for erythropoietin and other preparations mentioned above is one of such a specialised nature that they believe it should rest with their consultant colleague. A further anxiety is that of legal liability. The defence bodies have made clear that a prescriber carries that responsibility with regard to each and every prescription he or she issues. Most of these preparations are ones of which few general practitioners have much experience. All are not without risk of side effects. Even if general practitioners were to be assiduous in updating themselves on their use, the frequency with which they could expect to see a patient requiring, for example, growth hormone would mean they may have not been to an appropriate refresher course for some 15 years before meeting a case. The real issue has, for a decade or more, been the lack of a central policy for dealing with the problem. With the forthcoming introduction of regional prescribing budgets we have in the NHS a clear opportunity to make sure that those in hospitals who have responsibility for continuing clinical management are properly funded to enable them to care for their patients. Let us hope we have the foresight to grasp that opportunity and not simply pass it on to satisfy the book keepers. JOHN OLDROYD
Secretary, Secretariat for London Local Medical Committees, London WC I H 9HT I Gabriel R. Picking up the tab for ervthropoietin. 248-9. (2 February.:
,A1J7 1991;302:
Ultrasonography and perinatal mortality rates SIR,-The Letter from Westminster recently stated that "the NHS Management Executive has instructed health authorities to review maternity and neonatal services and to set targets for improvement."' This follows the finding by the National Audit Office of wide variations in perinatal mortality rate in Britain in 1988.2 Many factors influence perinatal mortality rate in maternity units, including the number of babies born with major congenital malformations. In our district general hospital we have found that the introduction in July 1986 of ultrasound screening of all pregnancies at 19 weeks' gestation has had an important effect in substantially reducing our perinatal mortality rate by identifying fetuses with anatomical anomalies, as shown in the table. The detailed fetal anatomical scanning is performed to an agreed protocol by departmental radiographers holding the diploma of medical ultrasound and led by a superintendent radiographer (FB). Supervision is given by a consultant radiologist (IMS), who sees all patients with suspected fetal anomalies for confirmation of abnormality, full diagnosis, and counselling. Standard departmental equipment is used. The necessary additional sessions using a radiographer were funded jointly by the maternity and radiology departments from existing budgets. On being informed of the presence of a serious fetal anomaly, many parents opt for termination of pregnancy, but another important benefit of our scheme has been to enable appropriate management planning of the remainder of the pregnancy, the delivery, and early medical and surgical treatment in those infants with important remediable abnormalities. The use of both these
approaches continues to have an important effect on our perinatal mortality rate. As most pregnant women in Britain now have at least one ultrasound scan' we suggest that this is an important area where health authorities could look for improvement. Our detailed results are currently being prepared for publication. As far as we are aware, no study of antenatal ultrasound screening by radiographers of a non-selected population has yet been published. ISABEL M SHIRLEY FIONA BOTTOMLEY
Department of Radiology, Hillingdon Hospital, Uxbridge UB8 3NN 1 Warden J. A friend at the top. BMJ7 1990;301:1297. (8 December.) 2 Warden J. Maternity services could do better. BMJ 1990;300: 833. (31 March.) 3 Royal College of Obstetricians and Gynaecologists Workinlg Party on Routine Ultrasound Examination in Pregnancy. Report. London: RCOG, 1984.
Psychologists warn over community charge SIR,-A working party ofthe British Psychological Society has expressed anxiety over the fact that the Mental Health Act 1983 and the Local Government Finance Act 1988 used the term "severe mental impairment" for quite different purposes.' This report seems to suggest that mentally ill patients who were certified as severely mentally impaired under the terms of the 1988 act might suffer consequences associated with the use of the term under the 1983 act. In my experience all professionals dealing with mentally ill people who may be exempted from paying a community charge are quite aware of the two uses of the term severe mental impairment. Those patients of mine who have been exempted on these grounds are quite happy about the use of this term. Dr Alison Walker's comment did not mention whether the British Psychological Society's report quoted evidence that individuals have suffered as a result of the differing uses of this term. If not I cannot understand what they were worried about. I was also concerned about the apparent suggestion that severe mental impairment should be diagnosed on the basis of an IQ test. I would hope that any person suspected of suffering from severe mental impairment would get the benefit of a properly comprehensive multidisciplinary assessment. G 0 DUBOURG King's Mill Hospital, Sutton in Ashfield, Nottinghamshire NG17 4JL I Walker A. Psychologists warn oser community charge. BM7 1991;302:135. (19 January.)
SIR,-I read with increasing worry the news item about the report of the British Psychological Society in regard to the community charge.' The form for exemption from the community charge states very clearly that this is only to be associated with the Government Finance Act of 1988 and I regard this as having no connection with the Mental Health Act of 1983. In any case, the worry that the people so delineated would lose their civil liberties is really quite extraordinary and has no
Effect of introduction of ultrasound screening (July 1986) on perinatal mortality rates
No of deliveries Perinatalmortality rate Fetal anomalies detected by ultrasound Terminations of pregnancy
1983
1984
1985
1986
1987
1988
1989
2532 11-5
2735 11-3
2860 12 9 4 1
2843 88 12 8
3130 7-1 18 12
3341 7-8 19 7
3096 7-7 27 15
BMJ VOLUME 302
16 FEBRUARY 1991
background. S P GIBSON
Renal Unit,
East Birmingham Hospital, Birmingham B9 5ST I Gabriel R. Picking up the tab for erythropoietin. BMJ 1991;302: 248-9. (2 February.) 2 Taylor J, Henderson IS, Mactier RA, Stewart WK. Erythropoietin withdrawal. BMJ 1991;302:272-3. (2 February.)
SIR, -Dr Roger Gabriel's editorial illustrates well the difficulties faced by the hospital consultant wishing to treat patients with effective preparations whose expense cannot be met from the limited NHS funds available through district health authorities.' These difficulties are not confined to erythropoietin; the same considerations apply to growth hormone, various cytotoxic drugs, certain courses of complex hormone treatments (including those used in infertility treatment), and peritoneal dialysis fluids. Dr Gabriel's solution is to pass the clinical care of the patient -and consequently the prescribing of these preparations-over to the general practitioner. As the secretary of a local medical committee in regions where general practitioners have been coerced into prescribing such preparations under the threat of "ifyou don't prescribe then either your patient won't get it and hence will suffer unduly" or "we will have to close yet more beds for other work to fund the preparation" I am only too well aware of the concern Dr Gabriel's proposal will occasion to many general practitioners. As he so clearly states, the general practitioner's position of believing that those who are responsible for continuing clinical care should carry the responsibility of prescribing is reinforced by endless circulars from the Department of Health going back to 1976. To the vast majority of general practitioners with whom I am in contact the management on a week in, week out basis of
408
patients with a need for erythropoietin and other preparations mentioned above is one of such a specialised nature that they believe it should rest with their consultant colleague. A further anxiety is that of legal liability. The defence bodies have made clear that a prescriber carries that responsibility with regard to each and every prescription he or she issues. Most of these preparations are ones of which few general practitioners have much experience. All are not without risk of side effects. Even if general practitioners were to be assiduous in updating themselves on their use, the frequency with which they could expect to see a patient requiring, for example, growth hormone would mean they may have not been to an appropriate refresher course for some 15 years before meeting a case. The real issue has, for a decade or more, been the lack of a central policy for dealing with the problem. With the forthcoming introduction of regional prescribing budgets we have in the NHS a clear opportunity to make sure that those in hospitals who have responsibility for continuing clinical management are properly funded to enable them to care for their patients. Let us hope we have the foresight to grasp that opportunity and not simply pass it on to satisfy the book keepers. JOHN OLDROYD
Secretary, Secretariat for London Local Medical Committees, London WC I H 9HT I Gabriel R. Picking up the tab for ervthropoietin. 248-9. (2 February.:
,A1J7 1991;302:
Ultrasonography and perinatal mortality rates SIR,-The Letter from Westminster recently stated that "the NHS Management Executive has instructed health authorities to review maternity and neonatal services and to set targets for improvement."' This follows the finding by the National Audit Office of wide variations in perinatal mortality rate in Britain in 1988.2 Many factors influence perinatal mortality rate in maternity units, including the number of babies born with major congenital malformations. In our district general hospital we have found that the introduction in July 1986 of ultrasound screening of all pregnancies at 19 weeks' gestation has had an important effect in substantially reducing our perinatal mortality rate by identifying fetuses with anatomical anomalies, as shown in the table. The detailed fetal anatomical scanning is performed to an agreed protocol by departmental radiographers holding the diploma of medical ultrasound and led by a superintendent radiographer (FB). Supervision is given by a consultant radiologist (IMS), who sees all patients with suspected fetal anomalies for confirmation of abnormality, full diagnosis, and counselling. Standard departmental equipment is used. The necessary additional sessions using a radiographer were funded jointly by the maternity and radiology departments from existing budgets. On being informed of the presence of a serious fetal anomaly, many parents opt for termination of pregnancy, but another important benefit of our scheme has been to enable appropriate management planning of the remainder of the pregnancy, the delivery, and early medical and surgical treatment in those infants with important remediable abnormalities. The use of both these
approaches continues to have an important effect on our perinatal mortality rate. As most pregnant women in Britain now have at least one ultrasound scan' we suggest that this is an important area where health authorities could look for improvement. Our detailed results are currently being prepared for publication. As far as we are aware, no study of antenatal ultrasound screening by radiographers of a non-selected population has yet been published. ISABEL M SHIRLEY FIONA BOTTOMLEY
Department of Radiology, Hillingdon Hospital, Uxbridge UB8 3NN 1 Warden J. A friend at the top. BMJ7 1990;301:1297. (8 December.) 2 Warden J. Maternity services could do better. BMJ 1990;300: 833. (31 March.) 3 Royal College of Obstetricians and Gynaecologists Workinlg Party on Routine Ultrasound Examination in Pregnancy. Report. London: RCOG, 1984.
Psychologists warn over community charge SIR,-A working party ofthe British Psychological Society has expressed anxiety over the fact that the Mental Health Act 1983 and the Local Government Finance Act 1988 used the term "severe mental impairment" for quite different purposes.' This report seems to suggest that mentally ill patients who were certified as severely mentally impaired under the terms of the 1988 act might suffer consequences associated with the use of the term under the 1983 act. In my experience all professionals dealing with mentally ill people who may be exempted from paying a community charge are quite aware of the two uses of the term severe mental impairment. Those patients of mine who have been exempted on these grounds are quite happy about the use of this term. Dr Alison Walker's comment did not mention whether the British Psychological Society's report quoted evidence that individuals have suffered as a result of the differing uses of this term. If not I cannot understand what they were worried about. I was also concerned about the apparent suggestion that severe mental impairment should be diagnosed on the basis of an IQ test. I would hope that any person suspected of suffering from severe mental impairment would get the benefit of a properly comprehensive multidisciplinary assessment. G 0 DUBOURG King's Mill Hospital, Sutton in Ashfield, Nottinghamshire NG17 4JL I Walker A. Psychologists warn oser community charge. BM7 1991;302:135. (19 January.)
SIR,-I read with increasing worry the news item about the report of the British Psychological Society in regard to the community charge.' The form for exemption from the community charge states very clearly that this is only to be associated with the Government Finance Act of 1988 and I regard this as having no connection with the Mental Health Act of 1983. In any case, the worry that the people so delineated would lose their civil liberties is really quite extraordinary and has no
Effect of introduction of ultrasound screening (July 1986) on perinatal mortality rates
No of deliveries Perinatalmortality rate Fetal anomalies detected by ultrasound Terminations of pregnancy
1983
1984
1985
1986
1987
1988
1989
2532 11-5
2735 11-3
2860 12 9 4 1
2843 88 12 8
3130 7-1 18 12
3341 7-8 19 7
3096 7-7 27 15
BMJ VOLUME 302
16 FEBRUARY 1991
