Judicial functions of GMC should be abolished

Editor—Attempts are afoot to turn theGeneral Medical Council into an AlanMilburn quango; hence, it has becomenecessary for doctors to know what theywould be deprived of as a consequence.

Currently, the GMC is like a court and istherefore not accountable to ministers orthe public. It is a domestic tribunal with thesole purpose of allowing doctors to sit injudgment over other doctors. Therefore,although the Medical Act 1983 makesprovision for non-doctors to be on thecouncil, it does not oblige the GMC to givethem a judicial role. Also the act ensures thatthe GMC is fully accountable to doctors.

According to schedule 1 of the act, theGMC must first consult individual doctorsbefore it can change the rules governingelections. According to schedule 4 of the act,the GMC must first consult doctors beforemaking any changes to its judicial functions.The act does not even permit the GMC to godirectly to the Privy Council to makechanges to the constitution without firstobtaining a mandate from doctors. ThePrivy Council itself cannot make changeswithout prior consultation with the GMCand its constituent doctors. The GMC is

sowing the seeds of its own destruction bymoving away from its medical roots.

As an elected member of the GMC I amlosing faith in the impartiality of the GMCbecause its judicial function is becoming lesstechnical and more politicised. As anoverseas trained doctor I have no faith in thejudicial impartiality of the GMC. Thestatistics are against me, as confirmed by arecent report prepared by the Policy StudiesInstitute for the GMC on the handling ofcomplaints by the council. It is not really rel-evant that some GMC members may claimto be impartial. I can see the world onlythrough my own eyes and not throughsomeone else’s.

I also know that I cannot have a fair trialbecause those sitting in judgment may haveneither medical nor basic legal training. Thegoalposts keep changing because there areno tariffs for offences and punishments, theGMC is always under pressure to convict,and cases are referred to the GMC primarilyas a means of exacting retribution.

It should not surprise anyone thereforethat I call for the total abolition of thejudicial functions of the GMC.Olusola O A Oni consultant orthopaedic surgeonGlenfield Hospital, Leicester LE3 9QPOlusola.on@uhl.nhs.uk

Inferiority of calcium channelblockers to cheaper drugs

News item was inaccurate on at least twocounts

Editor—The news item by Josefson aboutcalcium channel blockers being inferior tocheaper drugs1 seems to have been takendirectly from the press release by theinvestigators from the Wake Forest UniversitySchool of Medicine. Nowhere is the lesserincidence of stroke with calcium channelblockers and the equality of total mortalitywith these and other drugs mentioned.Moreover, the inappropriate inclusion offlawed data in this meta-analysis should becontrasted with the more careful andcomplete meta-analysis presented by Mac-Mahon and Neal at the International Societyof Hypertension on 24 August 2000 and nowpublished in the Lancet.2 Since this study wasnot hyped by press releases, Josefson wasprobably unaware of its balanced results.

But Josefson goes further. She states thatcalcium channel blockers are inferior toother antihypertensive drugs in elderlypatients with diabetes and systolic hyper-tension, referring incorrectly to two papers.The first shows exactly the opposite: calciumchannel blockers in the Syst-Eur trialprovided better protection than did diureticsin the SHEP trial.3 The second paper is theSHEP data with ne’er a calcium channelblocker in sight.4

The BMJ should insist on at least asmuch accuracy in its news articles as in itspapers.Norman M Kaplan professor of medicineUniversity of Texas, Southwestern Medical Center,5323 Harry Hines Boulevard, J4, 134, Dallas,TX 75390-8586ronald.victor@email.swmed.edu

Competing interests: NMK has been paid honorariafor talks given under the auspices of multiple phar-maceutical companies that market calcium channelblockers, including Bayer, Astra, Merck, and Pfizer.

1 Josefson D. Calcium channel blockers inferior to cheaperdrugs. BMJ 2000;321:590. (9 September.)

2 Blood Pressure Lowering Treatment Trialists’ Collabora-tion. Effects of ACE inhibitors, calcium antagonists, andother blood-pressure-lowering drugs: results of prospec-tively designed overviews of randomised trials. Lancet2000;355:1955-64.

3 Tuomilehto J, Rastenyte D, Birkenhager WH, Thijs L,Antikainen R, Bulpitt CJ, et al. Effects of calcium-channelblockade in older patients with diabetes and systolichypertension. N Engl J Med 1999;340:677-84.

4 Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB,Black H, et al. Effect of diuretic-based antihypertensivetreatment on cardiovascular disease risk in older diabeticpatients with isolated systolic hypertension. JAMA1996;276:1886-92.

Author’s reply

Editor—The literature on calcium channelblockers and the optimal pharmacologicaltreatment of hypertension is long andcontentious, and a full analysis of the litera-ture is beyond the scope of a regular newspiece and this reply. Clearly, antihyperten-sive treatment is complex and dependent onside effects as well as concurrent disease andlifestyle.

Kaplan should realise that in my role ofreporter, I was merely reporting on a studyand not necessarily promoting or defendingany of its results. Moreover, I have nointerest, vested or otherwise, in the studyresults. Since at the time of my news piecethe study from Wake Forest University hadnot yet been published (it was presented at ameeting) and I lacked a paper to scrutinise, Iwas limited in my ability to analyse the dataand based my report on an interview withDr Pahor and on the press release.

None the less, many studies show thatcalcium channel blockers are inferior to otherantihypertensive drugs in preventing some ofthe cardiovascular complications of hyper-

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671BMJ VOLUME 322 17 MARCH 2001 bmj.com

tension. Moreover, concern has been raisedthat a financial incentive may be at workbecause they are heavily promoted abovecheaper and arguably equally effective, if notmore effective, blood pressure drugs.1

Some studies single out short acting cal-cium channel blockers and dihydropyridinederivatives as the culprits. Most people agreethat calcium channel blockers are effectiveantihypertensives and superior to placebo inreducing blood pressure, and I am notsuggesting that patients taking them aban-don their treatment. However, many meta-analyses have shown that when comparedwith other antihypertensive drugs, such asangiotensin converting enzyme inhibitors, âblockers, thiazides, and loop diuretics,calcium channel blockers have a higherrelative risk of myocardial infarction andstroke.2 For example, the ABCD trialcompared nisoldipine, a calcium channelblocker, with enalapril, an angiotensinconverting enzyme inhibitor, in patientswith both non-insulin dependent diabetesand hypertension and also found a greaterincidence of myocardial infarction withcalcium channel blockers.3 The MIDASstudy suggested that the calcium channelblocker isradapine is associated with morestrokes and cardiovascular complicationsthan hydrochlorothiazide.4

Finally, while I acknowledge a mix-upwith the paper by Tuomilehto et al,5 I did notmention the SHEP trial by Curb et al. Kaplanseems to have confused this citation with thatof the MIDAS trial. Moreover, he does notmention that in the study by Tuomilehto et alnitredipine treatment is not completelysegregated from treatment with hydrochloro-thiazide and angiotensin converting enzymeinhibitors. Thus many of the patients weretaking the calcium channel blocker and enal-april or hydrochlorothiazide, or both, so theresults may be confounded.Deborah Josefson pathologist and internistPremier Pathology Laboratories and Sierra ViewDistrict Hospital, 263 N Pearson Drive, Suite 108,Porterville, CA 93257-3333, USA

Competing interests: None declared.

1 Stelfox HT, Chua G, O’Rourke K, Detsky AS. Conflict ofinterest in the debate over calcium-channel antagonists.N Engl J Med 1998;338:101-6.

2 Psaty BM, Heckbert SR, Koepsell TD, et al. The risk ofincident myocardial infarction associated with anti-hypertensive drug therapies. Circulation 1995;91:925.

3 Estacio RO, Jeffers BW, Hiatt WR, Biggerstaff SL, GiffordN, Schrier RW. The effect of nisoldipine as compared withenalapril on cardiovascular outcomes in patients withnon-insulin-dependent diabetes and hypertension. N EnglJ Med 1998;338:645-52.

4 Borhani NO, Mercuri M, Borhani PA, Buckalew VM,Canossa-Terris M, Carr A, et al. Final outcome results ofthe Multicenter Isradipine Diuretic Atherosclerosis Study(MIDAS). A randomized controlled trial. JAMA1996;276:785-9.

5 Tuomilehto J, Rastenyte D, Birkenhager WH, Thijs L,Antikainen R, Bulpitt CJ, et al. Effects of calcium-channelblockade in older patients with diabetes and systolichypertension. N Engl J Med 1999;340:677-84.

Use of long acting calcium channelblockers is not deleterious in elderlyhypertensive patients

Editor—We read with concern the newsitem by Josefson which highlighted thebelief that calcium channel blockers may beless effective in elderly patients with diabetes

and systolic hypertension.1 We are worriednot only that the article was inaccurate butthat it may be misinterpreted by the laypress, leading to widespread concern amongpatients and sometimes discontinuation ofantihypertensive treatment without propermedical supervision and advice, as has hap-pened previously.2

Both diabetes and isolated systolichypertension are associated with a high riskof cardiovascular events. Two recent placebocontrolled studies have shown, unequivo-cally, that reducing blood pressure in elderlypatients with isolated systolic hypertensionreduces cardiovascular morbidity and mor-tality. The SHEP study used a diuretic basedregimen3 and the Syst-Eur trial used thelong acting dihydropyridine calcium chan-nel blocker nitrendipine.4 Josefson incor-rectly states that calcium channel blockersare less effective in patients with diabetesand systolic hypertension and cites asubgroup analysis of the Syst-Eur study.4 Asthe Syst-Eur study was placebo controlled, itis impossible to draw any conclusions aboutthe relative efficacy of calcium channelblockers compared with other agents inolder patients with isolated systolic hyper-tension. Moreover, the subgroup analysisshowed a greater reduction in cardiovas-cular mortality among the 492 diabeticpatients included in the trial.4 Interestingly, asimilar observation was also made in theSHEP study, which included 583 diabeticpatients, who had a 34% reduction incardiovascular disease compared with theplacebo group.3

To date, there have been no comparativestudies of antihypertensive treatment in eld-erly patients with isolated systolic hyper-tension, with or without diabetes mellitus.However, the STOP-2 trial, which studied alarge cohort of elderly patients withhypertension, (systolic pressure > 180 mmHg or diastolic > 105 mm Hg, or both),compared a conventional regimen (diureticor â blocker, or both) with “modern”treatment with an angiotensin convertingenzyme inhibitor or a calcium channelblocker.5 At the end of the study the primaryend point of cardiovascular mortality wasnot significantly different between the twogroups.

Therefore, like the authors of theSyst-Eur study,4 we believe that the currentevidence does not support the hypothesisthat the use of long acting calcium channelblockers is deleterious in elderly hyperten-sive patients. We agree, however, that theimportant issue of potential differences inefficacy between antihypertensive drugs inelderly patients and patients with diabetesdeserves specific attention in future large,randomised, controlled trials.J R Cockcroft senior lecturerWales Heart Research Institute, University of WalesCollege of Medicine, Cardiff CF14 4XN

I B Wilkinson senior lecturerDepartment of Clinical Pharmacology,Addenbrooke’s Hospital, Cambridge CB2 2QQ

Competing interests: None declared.

1 Josefson D. Calcium channel blockers inferior to cheaperdrugs. BMJ 2000;321:590. (9 September.)

2 Leonard S. 1m take “wrong” high blood pressure drug.Sunday Times 2000 Mar 19.

3 Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB,Black H, et al. Effect of diuretic-based antihypertensivetreatment on cardiovascular disease risk in older diabeticpatients with isolated systolic hypertension. JAMA1996;276:1886-92.

4 Tuomilehto J, Rastenyte D, Birkenhager WH, Thijs L,Antikainen R, Bulpitt CJ, et al. Effects of calcium-channelblockade in older patients with diabetes and systolichypertension. N Engl J Med 1999;340:677-84.

5 Hansson L, Lindholm LH, Ekbom T, Dahlof B, Lanke J,Schersten B, et al. Randomised trial of old and new antihy-pertensive drugs in elderly patients: cardiovascularmortality and morbidity the Swedish Trial in Old Patientswith Hypertension-2 study. Lancet 1999;354:1751-6.

Testing night vision for drivingEditor—The paper by Currie et al, whoconclude that Snellen visual acuity is notnecessarily an accurate measure of aperson’s ability to meet the required visualstandard for driving, and the accompanyingeditorial will be welcomed by those partici-pating in the assessment of a person’s visualability to drive.1 2 These tests are, however,carried out during daytime only. In Octobereach year in the United Kingdom the clocksgo back one hour and the onset of darknessbecomes earlier, which should alert us to thenecessity of night vision testing as anadditional requirement for a licence to driveon the roads. As far as I know, only Germanyhas this second standard.

The law should be changed to makenight vision testing a requirement in obtain-ing a driving licence. This can be done byusing a modification of the Snellen letterchart, the Pelli-Robson chart, which showsletters of decreasing blackness. These chartscould easily be available to all outletscurrently using the Snellen chart. They arereliable and give readily reproducibleresults. It would be impractical to ask topatients to assess their own night vision outof doors.William Jory consultant ophthalmologistLondon Centre for Refractive Surgery, LondonW1G 6HZinfo@lcrs.co.uk

1 Currie Z, Bhan A, Pepper I. Reliability of Snellen charts fortesting visual acuity for driving: prospective study andpostal questionnaire. BMJ 2000:321:990-2. (21 October.)

2 Westlake W. Another look at visual standards and driving.BMJ 2000:321:972-3. (21 October.)

Registry for torsades de pointeswith drug treatment existsEditor—The editorial by Yap and Cammprovided an excellent overview of thesubject of medication-induced long QT syn-drome and made two important practicalrecommendations, regarding which we wishto report progress.1

They recommended that any adverseevent suggestive of cardiac arrhythmiasrelated to drug treatment should be urgentlyreported to drug safety authorities and drugmanufacturers. Since the editorial appeared,an International Registry for Drug-InducedArrhythmias has been launched, and Cammis a member of the scientific advisory

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committee. The aim is to collect, study, andcorrelate the clinical information, electro-cardiograms, and DNA of such cases. Thehope is that this will allow development ofimproved methods for identifying at riskindividuals, so that important drugs such ascisapride can continue to be used withgreater safety. Practitioners are thereforeurged to submit all cases, past or present, ofprobable torsades de pointes related to drugtreatment (associated with any drug, cardiacor non-cardiac) to the registry. To save prac-titioners from spending time sending infor-mation to multiple agencies, the registry willpass on, where appropriate, details ofsubmitted cases to relevant drug safetyauthorities and manufacturers. We believethat most patients or families who haveexperienced torsades de pointes will be gladto contribute to the effort of preventing thesame thing from happening to others.

Yap and Camm also noted that whenprescribing a QT prolonging drug, it ishelpful to give the patient a warning cardlisting precautions, contraindications forco-prescriptions, and risk factors, particu-larly including other drugs that prolong QT.A regularly updated, searchable and down-loadable list of drugs that can prolong QT isavailable via the registry’s internet website atwww.qtdrugs.org (alternative direct linkwww.torsades.org).Michael J Kilborn senior research fellowKilbornM@georgetown.edu

Raymond L Woosley associate dean of clinicalresearchCenter for Education and Research inTherapeutics, Divisions of Cardiology and ClinicalPharmacology, Georgetown University MedicalCenter, Washington, DC 20007-2195, USA

1 Yap YG, Camm J. Risk of torsades de pointes withnon-cardiac drugs. BMJ 2000:320:1158-9. (29 April.)

Glucosamine and chondroitinmay help in osteoarthritisEditor—Several recent lay publicationsenthusiastically promote the benefits of glu-cosamine and chondroitin preparations inosteoarthritis.1 This has led to a surge ofinterest among patients and spectacular suc-cess in the marketplace; sales in the UnitedStates approach $1bn. The medical commu-nity has been reluctant to endorse theseproducts, principally because of concernsabout the quality of the evidence availablefrom clinical trials.

Since the completion of our review,there have been several research develop-ments. The issue of trial quality was recentlyreviewed by McAlindon et al.2 From 37identified placebo controlled clinical trials ofsymptom relief in osteoarthritis with glu-cosamine and chondroitin preparations, 15fulfilled predefined quality inclusion criteriafor their meta-analysis. It was the authors’overall conclusion that the clinical trialsdemonstrated substantial effects on symp-tom relief in osteoarthritis, but that attend-ant methodological biases were likely toexaggerate the size of these benefits. The

chondroprotective properties of gluco-samine sulphate have been evaluated in tworecent randomised controlled trials.3 4 Thedata from each of these are currentlyavailable only as abstracts, but both studiesshow a significant reduction in joint spacenarrowing among patients receiving1500 mg of glucosamine sulphate daily,compared with placebo, over three years offollow up. These agents are safe and arereadily available to patients in health foodshops and by mail order. As a consequence,they have great potential utility in themanagement of osteoarthritis, even if onlymodestly effective. Further data on efficacyand cost utility are eagerly awaited.Karen Walker-Bone clinical research fellow inrheumatologykwb@mrc.soton.ac.uk

Kassim Javid senior house officer in rheumatologyNigel Arden senior lecturer in rheumatologyCyrus Cooper professor of rheumatologyMedical Research Council Unit, SouthamptonGeneral Hospital, Southampton SO16 6YD

1 Theodosakis J, Adderly B, Fox B. The arthritis cure. NewYork, NY: St Martin’s Press, 1997.

2 McAlindon TE, LaValley MP, Gulin JP, Felson DT.Glucosamine and chondroitin for treatment of osteoar-thritis. JAMA 2000;283:1469-75.

3 Reginster J-Y, Deroisy R, Paul I, Lee RL, Henroitoin Y,Giacovelli G, et al. Glucosamine sulfate significantlyreduces progression of knee osteoarthritis over 3 years: alarge, randomised, placebo-controlled, prospective trial.Arthritis Rheum 1999;42:S400.

4 Pavelka K, Olejarova M, Machacek S, Giacovelli G, RovatiLC. Glucosamine sulfate decreases progression of kneeosteoarthritis in a long-term randomised placebo-controlled trial. Arthritis Rheum 2000;43:S384.

Secondary prevention mayhelp intermittent claudicationEditor—We agree with Davies that inter-mittent claudication is underrecognised as arisk factor for coronary and cerebrovascularevents, and that large proportions ofpatients with claudication are not receivingaspirin or cholesterol management.1 Wehave analysed data from the 20 year followup of the British regional heart study,collected between 1998 and 2000, to investi-gate the extent to which aspirin is used andblood cholesterol concentration monitoredin patients with a reported diagnosis ofintermittent claudication.2

Among the 4425 men aged 60-79 (74%of survivors completing the questionnaire)186 men (4.4%) recorded a diagnosis ofclaudication. Rates of secondary preventionwere compared between patients withclaudication who did not have other cardio-vascular conditions (n = 91) and patientswith claudication who did (n = 95). Theresults showed that among those who hadother cardiovascular conditions (heartattack, angina, or stroke) 71% took dailyaspirin, and 68% recalled a blood choles-terol check; among those who did not haveother conditions the corresponding figureswere 40% and 45%, respectively.

These figures suggest that most patientswith intermittent claudication alone are notreceiving secondary prevention. Clearguidelines on secondary prevention inpatients with peripheral vascular disease are

included in the recently published nationalservice framework for coronary heartdisease, which may help to improve the situ-ation.3 The framework advises the prescrib-ing of aspirin and management of choles-terol levels in all patients at high risk ofcoronary events, which includes those withperipheral vascular disease.A Vass London Academic Training Scheme academicfellowa.vass@ucl.ac.uk

G Leng senior lecturer in public healthO Papacosta research statisticianM Walker senior lecturer in epidemiologyL Lennon research assistantP H Whincup professor of cardiovascular epidemiologyDepartment of Primary Care and PopulationSciences, Royal Free and University CollegeMedical School, London NW3 2PF

1 Davies A. The practical management of claudication. BMJ2000;321:911-2. (14 October.)

2 Walker M, Shaper AG, Lennon L, Whincup PH. Twentyyear follow up of a cohort based in general practice intwenty four British towns. J Public Health Med 2000 (inpress).

3 Department of Health. National service framework for coron-ary heart disease. London: DoH, 2000.

Vision is needed to addressproblem of global healthinformationEditor—If the problem were a new operahouse for Sydney, we would hold a competi-tion for architects to show their designs.These designs are visions of the future. Simi-larly, vision is what we need now to addressthe problem of global health information.

Pakenham-Walsh notes that internationalagencies, non-governmental organisations,publishers, libraries, training schools, andothers all are seeking to improve access toinformation for healthcare workers.1 Collec-tively they bring a wealth of skills, but theiroverall effectiveness has been limited by,ironically, lack of communication. Tan-TorresEdejer observes that the long list of initiativesis impressive but asks whether any effort hasbeen been made to get them to worksynergistically.2 That role, she says, is mostappropriate for the nations themselves withthe cooperation of international organisa-tions and donor agencies.2 We now need avision for how these organisations mightwork together, and to what end. The globalhealth information problem is so complexand formidable—far more so than the Sydneyopera house—that providing a focused, realis-tic vision would make a useful contribution.Without a vision, effective action will beimpossible. As the saying goes, “If you don’tknow where you are going, any wind will takeyou there.” A coherent vision would providefocus for debate, and motivate subsequentconcerted action on the part of key players.

Godlee et al identify two key criteria bywhich such a vision should be judged—sustainability and multidirectionality ofinformation flow (for example, flow not onlyfrom developed to developing countries butalso from developing to developed coun-tries and perhaps most importantly amongdeveloping countries themselves).3 They are

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also right to suggest that the globalinequities of health information are part ofthe problem of global inequities in health,arguably the most important ethical prob-lem in the world.4 The next step towards asolution is to provide a vision of a global alli-ance for health information.Peter A Singer directorUniversity of Toronto Joint Centre for Bioethics,Toronto, Canada M5G-1L4peter.singer@utoronto.ca

Competing interests: PS is the author of an articlecontaining a vision of a global alliance for healthinformation.

1 Pakenham-Walsh N. Improving access to reliable infor-mation in developing countries. BMJ 2000;321:831.(30 September.)

2 Tan-Torres Edejer T. Disseminating health information todeveloping countries: the role of the internet. BMJ2000;321:797-800. (30 September.)

3 Godlee F, Horton R, Smith R. Global information flow.BMJ 2000;321:776-7. (30 September.)

4 Singer PA. Medical ethics. BMJ 2000;321:282-5. (29 July.)

Data collection barriers can beovercome by schemes such asMEDICSEditor—McColl and Roland say that a vali-dated method by which practices can obtainand use clinical information is needed inorder to meet some of the demands on pri-mary care.1 This is particularly relevant inthe light of the national service frameworkfor coronary heart disease, which requiresthat general practitioners identify theirpatients with ischaemic heart disease andcreate disease registers by April 2001, and ofthe requirements of clinical governanceframeworks, personal medical services con-tracts, and local health improvement plans.

Such a system is already in place inNorthumberland, where MEDICS (Morbid-ity and Epidemiology Data Interchange andComparison Scheme) has recently beenawarded NHS beacon status. Practices havespent five years working to overcome datacollection barriers. Coverage now includesall 53 practices in all four primary caregroups in the district, representing apopulation of almost 314 000 patients. Allpatients diagnosed with, for example, coron-ary heart disease are identified. Collectively,we now have over 15 000 patients beingmonitored. Clinical governance has becomea major lever to promote accurate codingfor managing chronic disease.

This scheme is one of the first in thecountry with such a wide coverage, with par-ticipants in all but three practices usingMIQUEST (Morbidity Information Queryand Export Syntax)2 to extract the data.Altogether 54 clinical indicators areretrieved from each practice, all serving toaddress the challenges set out in thenational service framework, clinical govern-ance targets, and personal medical servicescontracts. The monitoring for clinical gov-ernance does not require any additionalwork from the practices in order to addressthese new challenges, as the data are alreadycollected as part of the existing biannualdata trawl. Northumberland MEDICS is also

piloting the collection of data for diabetes,which will require the addition of severalmore indicators.

The value of such a tool should not beunderestimated. It has an immense impacton the performance of each individual andeach practice, encourages systematic andaccurate recording of clinical data, helps inthe development of a complete disease reg-ister for coronary heart disease, enablespractices to identify gaps and weaknessesand to remedy them, builds on goodpractice, compares practice performance,delivers better care, and addresses thechallenges of primary care today. Thepatients benefit directly so this system is sup-ported by clinical staff. Through MEDICS,clinical governance becomes a carrot ratherthan a stick.Sharon Lamont research and development facilitatorsharon.lamont@email.nhumberld-ha.northy.nhs.uk

Paul Murphy primary care information managerStephen Singleton director of public healthNorthumberland Health Authority, EastCottingwood, Morpeth, NorthumberlandNE61 2PD

1 McColl A, Roland M. Clinical governance in primary care:knowledge and information for clinical governance. BMJ2000;321:871-4. (7 October.)

2 Allan K. Health data collection from general practice: achanging world. In: Richards B, ed. Conference proceedings:Current perspectives in healthcare computing. Harrogate:BJHC, 1994.

Hospital accreditation isimportantEditor—Essex believes that awards such asthe Charter Mark and the King’s Fundorganisational audit are merely “administra-tive baubles” and a waste of time.1 I cannotspeak for the Charter Mark award but mustpoint out that the King’s Fund organisa-tional audit was reconfigured as the HealthQuality Service in 1999; I am chairman of itsadvisory council.

The Health Quality Service is just that: aservice for those who seek to use modernmethods to improve the quality of the healthcare they provide. We lay emphasis ondevelopment and education rather thaninspection, by providing a thorough reviewof all aspects of an institution’s structure, sys-tems, and processes, with particular empha-sis on what patients experience. We supportthe groundwork that will enable theadoption of more efficient and effectiveprocesses, leading in turn to improvedoutcomes.

To provide this service we have the helpof staff in the institution being surveyed. It istrue that these staff may be away from otherduties for a time, but the alternative is toallow healthcare institutions to continue tostruggle without the benefit of modernmethods of quality improvement.

I must also disabuse Essex that theKing’s Fund organisational audit and HealthQuality Service were thought up by “anadministrative mindset.” The first suchscheme was initiated by Dr Ernest Codmanin the United States in 1910 and led to thefounding of the American College of

Surgeons in 1913 and the Hospital Stand-ardization Program in 1917. This pro-gramme sought to ensure that “thoseinstitutions having the highest ideals mayhave proper recognition before the profes-sion, and that those of inferior equipmentand standard should be stimulated to raisethe quality of their work.”

The Health Quality Service does notseek to control as Essex suggests; on thecontrary, we seek to coach. A plaque is onoffer for those institutions that are accred-ited, but it need not be used—nor need thefact of accreditation be announced. Manyhospitals are proud of gaining accreditationand use the opportunity to encourage theirstaff to do better still.

There is a long history of cynicism aboutthe value of hospital accreditation, but after90 years it is clearly here to stay. We areencouraged that the government has initi-ated the Commission for Health Improve-ment, which will have a statutory responsi-bility to ensure that NHS hospitals areproperly engaged in modern qualityimprovement.Richard Rawlins chairman, Health Quality Serviceadvisory councilBedford General Hospital, Bedford MK42 9DJRichardR@wlins.demon.co.uk

1 Essex C. Baubles are a waste of time. BMJ 2000;321:905.(7 October.)

Insulin-like growth factor-I canbe helpful towards end of lifeEditor—In their editorial Smith et al reviewthe literature relating high circulating con-centrations of insulin-like growth factor-I tothe risk of developing certain malignancies.1

They warn of the dangers of the use of exog-enous insulin-like growth factor-I by athletes,in whom the additional lifetime risk of devel-oping an associated cancer may be increased.Towards the end of life, however, maybe theanabolic anti-apoptotic properties of insulin-like growth factor-I be should be consideredin a different light.

Cardiac cachexia is a devastating pheno-type of chronic heart failure associated withhigh morbidity and reduced survival.2 Highconcentrations of growth hormone andinappropriately low concentrations ofinsulin-like growth factor-I are recognisedfeatures of this syndrome and suggest that astate of growth hormone resistance per-vades.3 The finding that skeletal muscle bulkalso correlates inversely with concentrationsof insulin-like growth factor-I hints at apathophysiological link between these find-ings.4 Furthermore, in dogs with heartfailure, which have a high incidence ofcachexia, those with raised concentrations ofcirculating insulin-like growth factor-I actu-ally show an advantage in survival.5 Thesefindings perhaps reflect the possible advan-tages of higher concentrations of insulin-likegrowth factor-I in chronic disease alluded toby Smith et al.1

In patients with chronic wasting dis-eases approaching the end of life, when the

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theoretical risk of treatment associatedmalignancy can reasonably be ignored,higher concentrations of insulin-likegrowth factor-I may be beneficial. There is,therefore, a valid argument for the use ofexogenous, anabolic, anti-apoptotic com-pounds, such as insulin-like growth factor-I,in catabolic states where mortality is highand even short term benefits are elusive.Such new approaches to the treatment of acrippling syndrome such as cardiaccachexia would be most welcomed.Aidan Bolger research fellowa.bolger@ic.ac.uk

Wolfram Doehner research fellowStefan D Anker research associateDepartment of Clinical Cardiology, National Heartand Lung Institute, London SW3 6LY

1 Smith GD, Gunnell D, Holly J. Cancer and insulin-likegrowth factor-I. BMJ 2000;321:847-8. (7 October.)

2 Anker SD, Ponikowski P, Varney S, Chua TP, Clark AL,Webb-Peploe KM, et al. Wasting as independent risk factorfor mortality in chronic heart failure. Lancet1997;349:1050-3.

3 Anker SD, Chua TP, Ponikowski P, Harrington D, Swan JW,Kox WJ, et al. Hormonal changes and catabolic/anabolicimbalance in chronic heart failure and their importancefor cardiac cachexia. Circulation 1997;96:526-34.

4 Niebauer J, Pflaum C-D, Clark AL, Strasburger CJ, HooperJ, Poole-Wilson PA, et al. Deficient insulin-like growthfactor-1 in chronic heart failure predicts altered bodycomposition, cytokine and neurohormonal activation.J Am Coll Cardiol 1998;32:393-7.

5 Freeman LM, Rush JE, Kehayias JJ, Ross JN Jr, MeydaniSN, Brown DJ, et al. Nutritional alterations and the effect offish oil supplementation in dogs with heart failure. J VetIntern Med 1998;12:440-8.

Drug development meanseconomics in the endEditor—Garattini and Liberati state, “Mil-lions of people suffer from tropical diseases(malaria, leprosy, schistosomiasis), and yetno one designs realistic strategies to tacklethem.”1 But surely the authors are beingeither naive or disingenuous if they thinkthat the cure for this is to take the responsi-bility for drug development from those whoanswer to Wall Street to those who answer toBrussels. Would we not still see breastcancer, heart disease, diabetes, asthma,Alzheimer’s disease, etc as being the diseasesattracting funding rather than bilharzia?

Similarly, the authors state, “The use oftreatments should not be extended by anal-ogy from one group of patients to anotherwithout randomised controlled trials.” I disa-gree. We make such extensions all the time,from people treated in 1992-4, when thetrial was run, to those being treated in thethird millennium; from Protestants toCatholics; and even, and justifiably on occa-sion, from men to women. If you find a use-ful treatment in lung cancer you will havedone so using a majority of male patients. Ifyou insist on repeating your study in onlywomen you are being neither ethical noreconomical.

Whatever distortions brought about cur-rent economic arrangements, everyone whoworks in drug development will have to faceeconomics in the end. In any case, thenotion of generalisability depending on therepresentative nature of the patients studiedis hopeless and wrong. The typical meta-

analyst agonises about whether patients withmoderate and severe hypertension can bepooled but places all â blockers together inone pot without even noting unit doses anddose schedules. But anybody who hasworked in the pharmaceutical industryknows that even a change in the formulationof a drug can alter its potency.

By all means let us have criticism of thepharmaceutical industry. But any alternativeapproach to drug development will have towork within the priorities of the society thatfunds it and will have to take a realisticapproach to costs and needs. You can tryand take profits out of drugs if you want, butyou can’t do without economics.Stephen Senn professor of pharmaceutical and healthstatisticsUniversity College London, London WC1E 6BTstephens@public-health.ucl.ac.uk

Competing interests: SS is a consultant to the phar-maceutical industry.

1 Garattini S, Liberati A. The risk of bias from omittedresearch. BMJ 2000;321:845-6. (7 October.)

When response rates do matterEditor—I read Minerva’s contributionabout the importance of achieving a 55%response rate in general practitioner sur-veys.1 There is evidence to suggest that muchhigher response rates are necessary and thatthe traditional requirement of a 70%response rate is inadequate. In our survey ofgeneral practitioners in a commissioninggroup, we achieved a 100% response rate.2

The initial response was 74% and theremainder were persuaded to respond afterdirect visiting or telephone contact. Wenoted a significant difference in replies ofthe prompt responders compared to thereluctant responders—whose replies wouldhave been missed in more traditionalsurveys. The reluctant responders were lesscommitted to the commissioning group andless likely to think that it would be successful.

Their prescribing characteristics alsodiffered. Reluctant responders were lesslikely to think that their prescribing was highquality and less likely to be happy to let oth-ers view their prescribing data. These resultspoint to the importance of eliciting the fullrange of opinion in any survey of attitudesamong general practitioners. By accepting70% response rates, the results may bebiased toward a more optimistic conclusionthan is justified. Non-responders already feelless sense of belonging and by ignoring theiropinions may end up further marginalised.Primary care organisations have a responsi-bility to represent all their general prac-titioner members and not just those whoanswer questionnaires.Mark Ashworth research fellowGuy’s, King’s, and St Thomas’ Department ofGeneral Practice, Kings College, London SE11 6SPmark.ashworth@gp-G85053.nhs.uk

1 Minerva. BMJ 2000;321:1358. (25 November.)2 Armstrong D, Ashworth M. When response rates do mat-

ter: a survey of general practitioners and their views ofNHS changes. Br J Gen Pract 2000;50:479-80.

Census of availability ofneonatal intensive care shouldhave used differentdenominatorEditor—Parmanum et al documented thenumber of maternal and neonatal transfersoccurring from referral centres in theUnited Kingdom during a specified threemonth period.1 They attempt to give someepidemiological perspective to the observednumbers, but the denominator that theyused to calculate the rate per 1000deliveries, at least in Wessex, is the totalnumber of deliveries in the whole regionrather than the number occurring in South-ampton, which was the centre involved inthe study.

The university hospital in Southamptonprovides several tertiary services relating toneonates, but the neonatal medical unit isnot funded as a regional referral centre.Most of the neonatal intensive care withinWessex takes place in the nine districtgeneral hospitals in the region, all of whichoffer level 1 neonatal intensive care.

A more representative denominator,therefore, would be the number of deliveriestaking place within Southampton—4837during the year of the study. The rate oftransfers out then becomes 11.6 per 1000deliveries, rather than 1.4 per 1000, and itbecomes more apparent that this representsa substantial proportion of the district’s atrisk delivery population.M Hall consultant paediatricianmh10@doctors.org.uk

R Thwaites consultant paediatricianNeonatal Unit, St Mary’s Hospital, PortsmouthPO3 6AD

Melanie J Gompels regional CESDI (ConfidentialEnquiry into Stillbirths and Deaths in Infancy)coordinatorWessex Institute for Health Research andDevelopment, University of Southampton,Mailpoint 727, Southampton SO16 7PX

1 Parmanum J, Field D, Rennie J, Steer P. National census ofavailability of neonatal intensive care. BMJ 2000;321:727-9. (23 September.)

Drugs may have reduced effectof falls interventionEditor—Van Haastregt et al’s study of theeffects of a programme of multifactorialhome visits on falls did not mention thedrug history of the people who received theprogramme.1 The authors also did notmention whether there was any interventionwith psychotropic drugs that are associatedwith falls.2

Interventional studies in elderly peoplereceiving long term care have found thatpsychotropic drugs contribute to 85% offalls; reducing doses or stopping the drugsaltogether and giving buspirone instead ofother conventional psychotropics mayreduce falls by up to 75% over one year.3 Therate of falls and admissions to hospitalbecause of falls has been directly correlatedwith the number of psychotropic drugs used

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long term (Cooper JW, Horner MR,American Society of Health-System Phar-macists mid-year clinical meeting, Las Vegas,December 2000; abstract P-511E). A recentstudy of withdrawing treatment with psycho-tropic drugs and using a home basedexercise programme reduced the risk of fallsby two thirds over 44 weeks.4

Readers could understand better why an18 month multifactorial interventional pro-gramme had no effect on falls if there was arecord of drugs taken over that period.James W Cooper professor of clinical andadministrative sciencesUniversity of Georgia College of Pharmacy, Athens,GA 30602-2354, USAjcooper@rx.uga.edu

1 Van Haastregt JCM, Diederiks JPM, van Rossum E, deWitte LP, Voorhoeve PM, Crebolder HFJM. Effects of aprogramme of multifactorial home visits on falls andmobility impairments in elderly people at risk: randomisedcontrolled trial. BMJ 2000;321:994-8. (21 October.)

2 Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls inolder people: a systematic review and meta-analysis. I. Psy-chotropic drugs. J Am Geriatr Soc 1999;47:30-9.

3 Cooper JW. Reducing falls among patients in nursinghomes. JAMA 1997;278:1742.

4 Campbell AJ, Robertson MC, Gardner MM, Norton RN,Buchner DM. Psychotropic medication withdrawal and ahome-based exercise program to prevent falls: arandomized, controlled trial. J Am Geriatr Soc 1999;47:850-3.

Tampons could be used todiagnose sexually transmitteddiseasesEditor—Gottlieb in his news item reportedthat tampons could be used to diagnosesexually transmitted diseases.1 This reportrelates to work performed and recentlydelivered at a meeting in Toronto, Canada,by Dr Patrick Sturm of the University ofNatal in South Africa. In a population of1030 asymptomatic women it was foundthat a sample collected on a tampon, whenused to detect sexually transmitted infec-tions by polymerase chain reaction (PCR)technology, was more sensitive than conven-tional diagnostic methods.1

We would like to underscore the findingsof the value of self collected specimens. Weintroduced and validated the use of tamponsas specimens collected by patients, initiallyas a sensitive method for the detection ofhuman papillomavirus by PCR, when wewere examining the role of sexual transmis-sion in the epidemiology of the virus.2 3 Thiswas a suitable, yet unintrusive method ofcollecting genital samples from a virginalpopulation.3 We then showed the value ofthis method for detection of Chlamydiatrachomatis by PCR.4 By increasing our menuof pathogens to include Neisseria gonor-rhoeae, Trichomonas vaginalis, and herpessimplex virus, we showed that, in contrast totraditional culture techniques, this method ismore accurate and avoids the need forendocervical sampling and stringent criteriafor transport.

As a tool for screening of sexually trans-mitted infections and for surveillancepurposes, particularly in populations thatare difficult to reach or in groups that do

not readily access medical services, wefound self collected sampling, together withPCR detection, not only highly sensitive butassociated with high patient compliance.4 Inone study of women living in remotecommunities in northern Australia, detec-tion of N gonorrhoeae , C trachomatis , and Tvaginalis by PCR on self collected tamponswas 11%, 5% , and 16%, respectively, yet byconventional methods detection of thesepathogens was 1%, 3%, and 9%, respec-tively.4 The method was also found accept-able when determining the prevalence ofsexually transmitted infections in femaleattendees of an outpatient clinic in Ulaan-baatar, Mongolia, in a population of home-less youths, and in sex workers.5

Suzanne M Garland visiting professorReproductive Health Research, Family andCommunity Health, World Health Organization,CH-1211 Geneva, Switzerland

Sepehr N Tabrizi senior research scientistDepartment of Microbiology and InfectiousDiseases, Royal Womens’ and Royal Children’sHospitals, Women’s and Children’s Health,Melbourne, Victoria 3053, Australia

Christopher K Fairley headInfectious Disease Epidemiology Unit, Departmentof Epidemiology and Preventive Medicine, MonashUniversity, Victoria 3181, Australia

Francis J Bowden directorCanberra Sexual Health Centre, Garran, AustralianCapital Territory 2606, Australia

1 Gottlieb S. Tampons could be used to diagnose STDs. BMJ2000;321:978. (21 October.)

2 Fairley CK, Chen S, Tabrizi S, Quinn MA, McNeil JJ,Garland SM. Tampons: a novel patient-administeredmethod for the assessment of genital human papillomavi-rus infection. J Infect Dis 1992;165:1103-6.

3 Fairley CK, Chen S, Tabrizi S, Quinn M, Leeton K, McNeilJJ, et al. The absence of genital human papillomavirusDNA in virginal women. Int J STD AIDS 1992;3:414-7.

4 Tabrizi SN, Paterson B, Fairley CK, Bowden FJ, GarlandSM. A self-administered technique for the detection ofsexually transmitted diseases in remote communities.J Infect Dis 1997;176:289-92.

5 Garland SM, Tabrizi SN, Chen S, Byambaa C, Davaajav K.Prevalence of STDs in a female outpatient clinic in Ulaan-baatar, Mongolia. Infect Dis Obstet Gynaecol (in press).

Putting patients first will helpinterprofessional educationEditor—We read Finch’s paper on inter-professional education with interest butwere surprised that there was little referenceto the needs of patients.1 We too strugglewith the definition and true meaning of inter-professional and with the logistical barriersto getting learners, both before and afterqualification, together. The regional collabo-rative of the NHS Executive South Westrecently defined interprofessional learningand development as a process in which twoor more professional groups come togetherand learn from and about each other inorder to develop collaborative practice andachieve health improvements.2

Finch continues the traditional dividebetween higher education and those pro-viding the service, but there is a need to takea systemic view and see interprofesssionalworking as the way we work together, notjust something we teach students. Wheninterprofessional teams work together witha focus on developing or redesigning a

service to improve the way they meet theneeds of their patients, much significantlearning happens. If our learners put meet-ing the needs of their patients or clients atthe heart of their drive for improvement,they will naturally work interprofessionally,with different professionals complementingand supporting each other.3

By guiding teams to reflect on this proc-ess of working together—for example, byusing the methods of continuous qualityimprovement—the different professionals inthe team become aware of the roles andunderpinning values and models of boththeir own profession and those with whichthey are working. Nurses, doctors, or socialworkers will understand more about theirprofessional identity, as well as learningabout the strengths, perspectives, and skillsof their fellow professionals. The trueinterprofessional team is not a seamless gar-ment of nondescript khaki but a colourfulpatchwork with strong seams holding thewhole together, as advocated by Heath.4

Our challenge is to give learners theopportunity to work in vibrant and effectiveinterprofessional teams, actively improvingthe service patients receive, and also to givethem space and guidance to reflect andlearn from the experience. Our experienceso far shows us that overcoming thelogistical barriers is worth while for thelearners recognise the relevance of learningwhere the driver and integrator is continu-ously improving the match between whatthey provide and the needs of those whodepend on them.5

Charles Campion-Smith general practitionerPeter Wilcock chartered clinical psychologistInstitute of Health and Community Studies,Bournemouth University, Royal London House,Christchurch Road, Bournemouth BH1 3LT

1 Finch J. Interprofessional education and teamworking: aview from the education providers. BMJ 2000;321:1138-40. (4 November.)

2 NHS Executive South West. Achieving health and social careimprovements through interprofessional education. Report of theseventh meeting. 2000.

3 Headrick LA, Wilcock PW, Batalden PB, Interprofessionalworking and continuing medical education. BMJ 1998;316:771-4.

4 Heath I. A seamless service. BMJ 1998;317:1723-14.5 Campion-Smith C, Wilcock P, Interprofessional learning

and continuous quality improvement in primary care: theDorset Seedcorn project. CAIPE Bulletin 2000;18:11-2.

It is time to dismiss calls to banDDTEditor—In his commentary in the ethicaldebate on banning DDT (dichlorodiphenyl-trichloromethane) Liroff hides behind aveneer of reason in arguing to reduce its usecarefully, but the final sentence exposes theessence of his priorities.1 He writes that weneed “protection from both malaria andDDT,” which effectively equates a plague thathas ravaged human populations throughouthistory2 with the theoretical risks touted byenvironmental organisations.

DDT is the king of chemical benefactors,with its stunning success against typhus inthe second world war, its association with aNobel prize, and the increase in food

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production when it is used as an agriculturalpesticide. Reputations are made by killingheroes, and environmentalist groups madetheir reputations by lobbying to have DDTbanned in the United States; they have alarge stake in suppressing the good newsabout DDT and magnifying theoretical risks.Through the years, when one accusation wasdisproved they unabashedly moved on toother accusations: from animal populationsto cancer to the latest theory that DDT is anendocrine disrupter.

The first clarion came from Rachel Car-son’s Silent Spring, telling of declining birdpopulations and rivers filled with dead fish.No one ever questioned her impliedcomparison of DDT’s benefit to humansagainst her charges of its harm to avian andpiscine populations, but they needn’tbother. Her lyrical paean to nature, wrongon so many points, was wrong on thoseas well.3

There were charges of a link with breastcancer, refuted several times.4 5 In 1997 theNew England Journal of Medicine publishedan editorial that railed against sensational-ism and called for “scientists, the media, leg-islators, and regulators to distinguishbetween scientific evidence and hypothesis,and not allow a ‘paparazzi science’ approachto [resolving] these problems.”4

Affluent nations can afford the folly ofoverspending in order to prevent imaginedrisks; demanding that poorer nationsengage in such quixotic adventures isarrogance. It is time to dismiss these calls toban DDT.Fredric M Steinberg chairman of board of directorsAmerican Council on Science and Health,1995 Broadway Second Floor, New York, NY,10023-5860, USAfmsteinberg@pol.net

1 Attaran A, Maharaj R, Liroff R. Ethical debate: Doctoringmalaria, badly: the global campaign to ban DDT. BMJ2000;321:143-5. (2 December.)

2 Cartwright FF. Diseases and history. New York: Dorset Press,1991:141-3.

3 Jukes TH. Insecticides in health, agriculture and theenvironment. Naturwissenschaften 1974;61:6-16.

4 Safe SH. Xenoestrogens and breast cancer. N Engl J Med1997;337:1303-4.

5 Smith AG. How toxic is DDT? Lancet 2000;356:267-8.

Proposals for preventingcommunity violence are naiveEditor—The issues that Shepherd et al raisein their editorial on using injury data forviolence prevention should be more widelydebated,1 particularly because the govern-ment has suggested that its plans to tackleviolence will be based partly on injury dataderived from accident and emergencydepartments.2

Shepherd et al suggest that accident andemergency departments should give thepolice assault data on a regular basis. Theynote something that the accident and emer-gency community knows well: manyassaulted people who present to thesedepartments never inform the police, sopolice statistics are inadequate.

The authors say that particular licensedpremises are hotspots for violence, and theyclaim that a reduction in violence will occurif police activity concentrates on them. As aprofessor of maxillofacial surgery, Shepherddoes not have the responsibility for ensuringthat the community perceives the hospital,and particularly the accident and emergencydepartment, as independent from thepolice. If people realise that the departmentis going to provide data to the police theymay assume that these data can be traced tothem personally. If they are arrested andreleased on bail they might well vent theiranger about the arrest on the accident andemergency staff. Far too much violence isdirected at accident and emergency staffalready, without this additional hazard.

Injury data are indeed more completethan police data, but this is not new. Teanbyeven found that the police were unaware ofsome pedestrian deaths.3 Even if CardiffPolice’s data were incomplete, statisticallythey should still be distributed in the sameway. The data would be equally bad abouteverywhere, so the same hotspots wouldappear.

Some aspects of Shepherd et al’seditorial, such as the suggestion of havingpolice hotlines in accident and emergencydepartments, deserve our support. But Iremain uneasy. Firstly, this solution to theproblem is simplistic and fraught with risk,including to our staff and to us. Secondly,and possibly more worryingly, is it the thinend of the wedge? Once the accident andemergency community has accepted thatthese data are passed, will requirements onother potential crimes follow? Surely patientconfidentiality is one of the bedrocks onwhich good medical practice is based. Theseproposals risk eroding that part of thedoctor-patient relationship unacceptably.Rowland Cottingham consultant in accident andemergency medicineEmergency Unit, Eastbourne District GeneralHospital, Eastbourne, East Sussex BN21 2UDrowley@cix.co.uk

1 Shepherd JP, Sivarajasingam V, Rivara FP. Using injurydata for violence prevention. BMJ 2000;321:1481-2.(16 December.)

2 Simmons J. Review of crime statistics: a discussion document.London: Home Office, 2000.

3 Teanby D. Underreporting of pedestrian road accidents.BMJ 1992;304:422.

Is this the end of the line forflu vaccine as we know it?Editor—Last autumn money was mobilisedto try to prevent flu becoming one of themany winter pressures in the UnitedKingdom, whereas flu in the southern hemi-sphere was negligible. Lacking in theprocess was any consideration of previousyears’ vaccine uptake, the efficacy of fluvaccine in preventing flu in elderly people,and whether bribery was likely to achieveany further uptake. Little was done toconsider the management of flu in thosewho might refuse vaccination (or in those inwhom vaccination was less effective).

In 2000 in East Sussex (where a largeproportion of the population is elderly) theuptake of flu vaccine was 62% among thoseaged over 65 compared with 57% in 1999.To achieve this general practitioners werepaid £591 000, a cost per additional personvaccinated of £81. The best rate of effective-ness for induction of immunity in elderlypeople is only 58% of those vaccinated, sothe cost per additional person immunisedrises to £140. If the circulating flu had a rateof infectivity of 10% the cost becomes £1400per patient protected.

To raise immunity to levels sufficient tomake vaccination cost effective amongelderly people requires a considerableamount of effort and enthusiasm. Despitemultiple reminder letters and a range ofopportunities, a hard core of patients, repre-senting 20% of those aged over 65,remained unvaccinated in this practice.

Flu vaccine is considered to be the firstline of defence against influenza on theassumption that the circulating influenzastrain is that predicted by the World HealthOrganization. The WHO receives littleinformation from countries where thedensity of population is high and theeconomic status low, countries where influ-enza can replicate and recode undetected.Vaccination is useless as the only means ofdefence, and it takes weeks, if not months todevelop a vaccine against a newly emergentstrain.

Attempting to raise vaccination rates byitem of service payments has done little toincrease immunity among elderly people inthe United Kingdom. Vaccine may havebeen diverted away from other patients atrisk who did not attract a payment but whowould have developed better immunitythrough being younger. Education aboutcorrect self diagnosis and the need for earlytreatment in those at high risk should be anational priority. Facilitating telephone hot-lines and cooperation between practitionersshould be encouraged locally to decreaseimpact on primary care teams. Thereshould be better understanding of the rolesof antiviral agents that inhibit flu virus activ-ity at an early stage before respiratory tractdamage occurs.

Further funds should now be mobilisedto develop policies to manage flu.Nigel Higson general practitionerGoodwood Court Medical Centre, Hove BN3 3DXsurgery@goodwoodcourt.org

Ming He clinical medical studentUniversity College, London WC1E 6BT

Correspondence submitted electronicallyis available on our website

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