groups would be encouraged to apply for jobs, and 15 did not think a policy would reassure staff in risk groups. It is possible for these principles to be followed without a formal policy being adopted. A firm written policy, however, leaves no room for uncertainty and shows a commitment to what are essentially fair and sensible employment policies. The principle of non-discrimination against people positive for HIV and those at risk should not only be espoused but also be seen to be espoused. If the irrational and hysterical public response to the AIDS and HIV epidemic is to be controlled then the NHS must lead the way by offering model employment policies for other employers to follow.
Response rates oJ potential participants in anonytnous HII' testing bv age and sex. X alzies are proportions (percentages) Mien
Women
18-29 30-39 40-49 50-60
28/175 16) 33/112 ('29 35/115 1,30 42/95 441
42/168 (25) 40/1 19 (34) 47/118 (401 37/89 42)
18-60
138/497 (28)
Age (years)
166/494
/"34)
community by voluntary unnamed testing of people selected at random from general practice age-sex registers. We report details of a pilot study. In all, the names of 1060 people (530 men, 530 KATHERINE BARBER women) aged 18-60 were selected at random from JAMMI NAGARAJ RAO the age-sex registers of eight general practices in JOHN D MIDDLETON England, all of which are members of the Medical Sandwell Health Authority. Research Council's general practice research West Bromwich B70 9LD framework.4 Letters of invitation from practice doctors were sent to potential participants between 1 Richardson R. Laying down the law on AIDS. Br Med J 1989;299:1301. (25 November.) April and September 1988. The letter emphasised 2 Harris D, Haigh R, eds. AIDS: a guide to the law. ILondon: that participation in the study would be anonyTerrence Higgins Trust, 1989. mous and that it would not be possible to link the 3 MiddletonJD. Aidsandhealthworkers-again. TheAIDSLetter names of individual participants with their HIV 1989;9: 1-2. 4 Porter R. Historn says no to the policeman's response to AIDS. test results. Practice nurses tried to contact those Br Medj 1986;293:1589-90. not responding to a second letter either by tele5 World Health Organisation. Guidelines for the development of a phone or by a personal visit. Each participant gave national AIDS prevention and control programme. Geneva: a specimen of clotted blood (5 ml) and was then WHO, 1988. (AIDS series No 1.) 6 World Health Organisation, International Labour Organisation. asked to complete a brief, anonymous, self StatementonAIDS in the workplace. Geneva: WHO/ILO, 1988. administered questionnaire. Samples were tested for the presence of HIV antibodies by three assays-competitive radioimmunoassay,' IgG capture radioimmunoassay,6 and enzyme linked Sweeping away superstition immunoadsorbent assay (ELISA) (Abbott SIR,-It really is very tiresome to be endlessly rDNA). Of those invited to attend for testing, 69 (33 misquoted. Drs K P W J McAdam and Diana Lockwood say that I advised Princess Diana to men, 36 women) had moved from the address wear gloves to prevent the transmission of leprosy.' shown on the age-sex register, leaving a total of 991 This is, quite simply, untrue. I offered no such potential respondents. Overall, 311 (31-4%) advice. In fact, if Drs McAdam and Lockwood had people provided a blood specimen for HIV testing. read my comments on leprosy carefully they would The table shows that in both sexes response rates have seen that I made the point that if Princess increased with age. Below 50 years of age response Diana did wear gloves while shaking hands with rates were higher in men than in women, with lepers she would cause offence. I feel that I some suggestion of the reverse in those aged 50 or more. None of the respondents had positive am entitled to an apology. results. VERNON COLEMAN In a similar study in Finland 41% of 1000 The Sun, London E l 9XP randomly selected people invited for HIV testing participated, and none of those tested were seroI McAdam KPWJ, Lockwood 1). Sweeping away superstition. positive. Again, response rates were generally BrrMedj 1989;299:1465. (9 L)ecember.) higher in women than in men and in older than in ***The relevant passage in "Di shakes hands- younger people. Both of these patterns mav reflect with leper" by Harry Arnold (Sun, 28 September differences in perceived personal risk of acquiring 1989) reads: "She has asked to meet leprosy HIV infection and AIDS. There has been considerable debate about how patients, and I understand she will shake hands best to monitor the spread of HIV infection in the Coleman Vernon with a sufferer. But Sun doctor last night urged Diana: 'Don't do it.' He warned general population.2 `81 Anonymous testing of that shaking hands with a leper was 'ridiculously samples of blood collected for other purposes is foolhardy.' Dr Coleman said: 'People have caught already being carried out in the United States and the disease by touch, so there is definitely a risk- from 15 January will begin in Britain. Because this much more than from an AIDS patient. I think it approach may yield biased estimates of prevalence would be better for her not to go. The lepers would and changes in prevalence, however, it is important be offended if she refused to shake hands or did it that a community based approach to monitoring is wearing rubber gloves. There's only a 1,000 to one attempted. Recent evidence from a survey in general pracchance that she will catch it, but it's not worth the tice" suggests that participation might be imrisk. "'-ED, BMJ proved considerably by adopting an approach opposite to the one used here-that is, by offering to inform participants of the results of their HIV Monitoring the prevalence tests. This proposition needs to be tested. of HIV We thank the doctors and nurses in the participating framework practices in Sutton, Beckenham, SIR,-Dr 0 N Gill and colleagues rightly empha- Bristol, Coleford, Bath, Romsey, Guisborough, and sise the importance of a programme to monitor the Wakefield. T E ROHAN prevalence of HIV.' The prevalence of HIV seroT W MEADE positivity in the general population is still un- MIRC Epidemiology and Medical Care Unit, known,2 and it is important that attempts be made Northwick Park Hospital, to estimate it.' In June 1987 informal discussion Harrowr HAI 3UJ P P MORTIMER with the (then) Department of Health and Social Virus Reference Laboratory, Security led to a study of the feasibility of measur- Central Public Health Laboratorv ing the prevalence of HIV seropositivity in the London NW'9 SHT
50
I (Gill ON. Adler MINW), Day NE. Mlonitoring the prevalence of HIV. Br.Mled,7 1989;299:1295-8. 25 November.) 2 W'orkiing Group on the Alonitoring and Surveillance of HIX' Inlection and AID)S. Report. London: Department ot Health anid Social Securitv, 1988. 3 Kiuigman J, Durbin J, Cox 1), Healy MJR. Statistical rcquiretcnts of the AIDS epidemtc. Journal oft/c Royal Statistical .osicivN, Series.4 1988;151:127-30. 4 Anonymous. General practice research framework. Br Med J
1987;295:1490.
S Mortimer PP. Jesson Wj, Vandervelde EM, Pereira MS. Prevaletice of antibodv to human T lymphotropic virus type III by risk group and area, United Kingdom 1978-84.
BrAledj 1985;290:1176-8. 6 Parry JV. An immuoioglobulin G capturc assay (GACRIA) for anti-HTLV III/I.AV and its use as a confirmatory test.] Med Virol 1986;19:387-97. 7 lPotika A, Cantcll K, Kantanci MI-L, ct al. Community screening for HIV intetction itn Finland. Am J Public Health
1989;79:522. 8 Doll R. A proposal for doing prevalence studies of AIDS. lBr.led] 1987;294:244. 9 Anonvmous. HIV seroepidermiology [Editorial]. Lancet 1987; i259. 1I( (,illon R. ''esting for HI'V swithout permission. Br Med J
1987;294:821-3. 11 Joiies KI, Preece WJ. (iculeral practitioners' attitudes towards AIDS. Br Med] 1989;299:321-2.
Audit in general practice SIR,-In his editorial on the subject of audit' Professor D H H Metcalfe makes the point that different bodies-doctors, government, and managers-are likely to make varying interpretations of what is required and may therefore have different goals when audit becomes de rigeur under the provisions of the white paper. He goes on to suggest a "two track" system of internal and external audits in which general practitioners pursue their own interpretation-"closing the gap between what they think they are doing and what actually gets done"-while the others (family practitioner committee managers and the like) presumably plough their own furrow. He may well be right, for with the momentous changes which the family practitioner committees are being asked to implement, I believe that they are unlikely to be in a position to challenge or replace a credible and convincing system of audit, which many general practitioners already have in operation. It is up to the medical profession to take a lead now and show that audit can have a positive effect on standards of patient care. With this in mind, the general practitioner trainers of Devon and Cornwall at their annual conference this November set about devising a system of audit that could be expected to provide valid answers to relevant questions concerning their everyday practice. The result was a series of criteria that they suggested should be satisfied before an audit project was undertaken: (1) There should be potential benefits in terms of better care or the elimination of wasteful use of resources. (2) The audit should represent efficient use of time and financial resources. (3) The audit must be ethically acceptable to doctor and patient. (4) There should be a willingness to make changes in the light of the result of an audit. (5) Standards should be set and aims agreed by the participants. (6) There should be an appropriate sample size and selection. (7) Data collection must be accurate and honest. (8) The results must be confidential to the participants unless agreed otherwise. I report the outcome of this conference in the hope that general practitioners might find these criteria helpful when they come to audit their work in earnest. M N J RUSCOE
Manor Surgery, Redruth, Cornwall TR15 2BY I Metcalfe DHH. Audit in general practice. Br Med 1293-4. (25 November.)
BMJ VOLUME 300
]f 1989;299:
6 JANUARY 1990
Response rates oJ potential participants in anonytnous HII' testing bv age and sex. X alzies are proportions (percentages) Mien
Women
18-29 30-39 40-49 50-60
28/175 16) 33/112 ('29 35/115 1,30 42/95 441
42/168 (25) 40/1 19 (34) 47/118 (401 37/89 42)
18-60
138/497 (28)
Age (years)
166/494
/"34)
community by voluntary unnamed testing of people selected at random from general practice age-sex registers. We report details of a pilot study. In all, the names of 1060 people (530 men, 530 KATHERINE BARBER women) aged 18-60 were selected at random from JAMMI NAGARAJ RAO the age-sex registers of eight general practices in JOHN D MIDDLETON England, all of which are members of the Medical Sandwell Health Authority. Research Council's general practice research West Bromwich B70 9LD framework.4 Letters of invitation from practice doctors were sent to potential participants between 1 Richardson R. Laying down the law on AIDS. Br Med J 1989;299:1301. (25 November.) April and September 1988. The letter emphasised 2 Harris D, Haigh R, eds. AIDS: a guide to the law. ILondon: that participation in the study would be anonyTerrence Higgins Trust, 1989. mous and that it would not be possible to link the 3 MiddletonJD. Aidsandhealthworkers-again. TheAIDSLetter names of individual participants with their HIV 1989;9: 1-2. 4 Porter R. Historn says no to the policeman's response to AIDS. test results. Practice nurses tried to contact those Br Medj 1986;293:1589-90. not responding to a second letter either by tele5 World Health Organisation. Guidelines for the development of a phone or by a personal visit. Each participant gave national AIDS prevention and control programme. Geneva: a specimen of clotted blood (5 ml) and was then WHO, 1988. (AIDS series No 1.) 6 World Health Organisation, International Labour Organisation. asked to complete a brief, anonymous, self StatementonAIDS in the workplace. Geneva: WHO/ILO, 1988. administered questionnaire. Samples were tested for the presence of HIV antibodies by three assays-competitive radioimmunoassay,' IgG capture radioimmunoassay,6 and enzyme linked Sweeping away superstition immunoadsorbent assay (ELISA) (Abbott SIR,-It really is very tiresome to be endlessly rDNA). Of those invited to attend for testing, 69 (33 misquoted. Drs K P W J McAdam and Diana Lockwood say that I advised Princess Diana to men, 36 women) had moved from the address wear gloves to prevent the transmission of leprosy.' shown on the age-sex register, leaving a total of 991 This is, quite simply, untrue. I offered no such potential respondents. Overall, 311 (31-4%) advice. In fact, if Drs McAdam and Lockwood had people provided a blood specimen for HIV testing. read my comments on leprosy carefully they would The table shows that in both sexes response rates have seen that I made the point that if Princess increased with age. Below 50 years of age response Diana did wear gloves while shaking hands with rates were higher in men than in women, with lepers she would cause offence. I feel that I some suggestion of the reverse in those aged 50 or more. None of the respondents had positive am entitled to an apology. results. VERNON COLEMAN In a similar study in Finland 41% of 1000 The Sun, London E l 9XP randomly selected people invited for HIV testing participated, and none of those tested were seroI McAdam KPWJ, Lockwood 1). Sweeping away superstition. positive. Again, response rates were generally BrrMedj 1989;299:1465. (9 L)ecember.) higher in women than in men and in older than in ***The relevant passage in "Di shakes hands- younger people. Both of these patterns mav reflect with leper" by Harry Arnold (Sun, 28 September differences in perceived personal risk of acquiring 1989) reads: "She has asked to meet leprosy HIV infection and AIDS. There has been considerable debate about how patients, and I understand she will shake hands best to monitor the spread of HIV infection in the Coleman Vernon with a sufferer. But Sun doctor last night urged Diana: 'Don't do it.' He warned general population.2 `81 Anonymous testing of that shaking hands with a leper was 'ridiculously samples of blood collected for other purposes is foolhardy.' Dr Coleman said: 'People have caught already being carried out in the United States and the disease by touch, so there is definitely a risk- from 15 January will begin in Britain. Because this much more than from an AIDS patient. I think it approach may yield biased estimates of prevalence would be better for her not to go. The lepers would and changes in prevalence, however, it is important be offended if she refused to shake hands or did it that a community based approach to monitoring is wearing rubber gloves. There's only a 1,000 to one attempted. Recent evidence from a survey in general pracchance that she will catch it, but it's not worth the tice" suggests that participation might be imrisk. "'-ED, BMJ proved considerably by adopting an approach opposite to the one used here-that is, by offering to inform participants of the results of their HIV Monitoring the prevalence tests. This proposition needs to be tested. of HIV We thank the doctors and nurses in the participating framework practices in Sutton, Beckenham, SIR,-Dr 0 N Gill and colleagues rightly empha- Bristol, Coleford, Bath, Romsey, Guisborough, and sise the importance of a programme to monitor the Wakefield. T E ROHAN prevalence of HIV.' The prevalence of HIV seroT W MEADE positivity in the general population is still un- MIRC Epidemiology and Medical Care Unit, known,2 and it is important that attempts be made Northwick Park Hospital, to estimate it.' In June 1987 informal discussion Harrowr HAI 3UJ P P MORTIMER with the (then) Department of Health and Social Virus Reference Laboratory, Security led to a study of the feasibility of measur- Central Public Health Laboratorv ing the prevalence of HIV seropositivity in the London NW'9 SHT
50
I (Gill ON. Adler MINW), Day NE. Mlonitoring the prevalence of HIV. Br.Mled,7 1989;299:1295-8. 25 November.) 2 W'orkiing Group on the Alonitoring and Surveillance of HIX' Inlection and AID)S. Report. London: Department ot Health anid Social Securitv, 1988. 3 Kiuigman J, Durbin J, Cox 1), Healy MJR. Statistical rcquiretcnts of the AIDS epidemtc. Journal oft/c Royal Statistical .osicivN, Series.4 1988;151:127-30. 4 Anonymous. General practice research framework. Br Med J
1987;295:1490.
S Mortimer PP. Jesson Wj, Vandervelde EM, Pereira MS. Prevaletice of antibodv to human T lymphotropic virus type III by risk group and area, United Kingdom 1978-84.
BrAledj 1985;290:1176-8. 6 Parry JV. An immuoioglobulin G capturc assay (GACRIA) for anti-HTLV III/I.AV and its use as a confirmatory test.] Med Virol 1986;19:387-97. 7 lPotika A, Cantcll K, Kantanci MI-L, ct al. Community screening for HIV intetction itn Finland. Am J Public Health
1989;79:522. 8 Doll R. A proposal for doing prevalence studies of AIDS. lBr.led] 1987;294:244. 9 Anonvmous. HIV seroepidermiology [Editorial]. Lancet 1987; i259. 1I( (,illon R. ''esting for HI'V swithout permission. Br Med J
1987;294:821-3. 11 Joiies KI, Preece WJ. (iculeral practitioners' attitudes towards AIDS. Br Med] 1989;299:321-2.
Audit in general practice SIR,-In his editorial on the subject of audit' Professor D H H Metcalfe makes the point that different bodies-doctors, government, and managers-are likely to make varying interpretations of what is required and may therefore have different goals when audit becomes de rigeur under the provisions of the white paper. He goes on to suggest a "two track" system of internal and external audits in which general practitioners pursue their own interpretation-"closing the gap between what they think they are doing and what actually gets done"-while the others (family practitioner committee managers and the like) presumably plough their own furrow. He may well be right, for with the momentous changes which the family practitioner committees are being asked to implement, I believe that they are unlikely to be in a position to challenge or replace a credible and convincing system of audit, which many general practitioners already have in operation. It is up to the medical profession to take a lead now and show that audit can have a positive effect on standards of patient care. With this in mind, the general practitioner trainers of Devon and Cornwall at their annual conference this November set about devising a system of audit that could be expected to provide valid answers to relevant questions concerning their everyday practice. The result was a series of criteria that they suggested should be satisfied before an audit project was undertaken: (1) There should be potential benefits in terms of better care or the elimination of wasteful use of resources. (2) The audit should represent efficient use of time and financial resources. (3) The audit must be ethically acceptable to doctor and patient. (4) There should be a willingness to make changes in the light of the result of an audit. (5) Standards should be set and aims agreed by the participants. (6) There should be an appropriate sample size and selection. (7) Data collection must be accurate and honest. (8) The results must be confidential to the participants unless agreed otherwise. I report the outcome of this conference in the hope that general practitioners might find these criteria helpful when they come to audit their work in earnest. M N J RUSCOE
Manor Surgery, Redruth, Cornwall TR15 2BY I Metcalfe DHH. Audit in general practice. Br Med 1293-4. (25 November.)
BMJ VOLUME 300
]f 1989;299:
6 JANUARY 1990
