marker alerts the doctor that a child protection case conference has been held and raises the index of awareness and suspicion with regard to the family. We also keep a list of those families on the child protection register and those families of special concern.4 These lists are compiled by the health visitor's clerk and are updated regularly. This information comes from our health visitors and the local social services department. Each consulting room has a copy of this list on the desk so that the general practitioner can refer to it. Each consulting room also has a copy of the local child abuse procedure handbook. These systems help us-in a busy practice of five partners, a trainee, a doctor on the retainer scheme, and locums-to have a heightened awareness of the problem and to monitor those families on our list in which abuse or neglect is known to have occurred or has a high chance of occurring. We suspect that in the study of Drs Lea-Cox and Hall and in our own practice the main reason for non-attendance at case conferences is the large number of them in areas of deprivation. This is a further example of Tudor Hart's "inverse care law" and another reason for targeting resources at where the real needs lie.5 JOY A MAIN PAUL G N MAIN
Hartcliffe Health Centre, Bristol BS13 OJP 1 Lea-Cox C, Hall A. Attendance of general practitioners at child protection case conferences. BAIJ 1991;302:1378-9. (8 June.) 2 Main JA, Main PGN. Twenty four hour care in inner cities. BMJ 1989;299:627. 3 Harris A. General practitioners and child protection case conferences. BAIJ 1991;302:1354. (8 June.) 4 Main PGN. Children on the "at risk" register. Update 1990;40: 528. 5 Main PGN. Is social mobility enough? Lancet 1991;337:495.
Out of hours work in general practice SIR,-Drs Steve Iliffe and Ursula Haug listed various factors as possible reasons for an increase in out of hours work in general practice,' but they did not include the decline in home, visiting. This could be important for elderly people who are housebound. Retrospective studies of random samples of adults dying in 1969 and 1987 found a substantial decline in the number of home visits by general practitioners in the year before death but an increase in the proportion of patients who had received two or more night visits during this time.2 The most frequent criticism of general practitioners in the 1987 study was their reluctance or failure to visit.3 Inadequacies in this type of care may well result in emergencies and calls for help out of hours. ANN CARTWRIGHT
Institute for Social Studies in Medical Care, London NW3 2SB I Iliffe S, Haug U. Out of hours wNork in general practice. BMJ7 1991;302:1584-6. (29 June.' 2 Cartwright A. Changes in liI !sd care in the year before death 1969-1987. Public Healtl .2.. 1991;13:81-7. 3 Cartwright A. The role of the genieral practitioner in caring for people in the last year of their lives. London: King Edward's Hospital Fund, 1990.
How to produce a service specification SIR,-Dr Diana Webster's article on producing service specifications,' though of potential use to providers, gives the misleading impression that it is they who should be leading the contracting process. Though this may represent one opinion on this matter, it can hardly be regarded as a consensus view. In-summary, she asks the question
BMJ VOLUME 303
13 JULY 1991
"What quantity of services does the provider expect the purchaser's residents to require?" and describes a process by which the provider unit sets out what services it believes it ought to be funded to supply. I would argue that this emphasis is at odds with the new function of the health authorities, and it certainly does not follow the approach that is being pursued in Trent region. The essence of the reforms set out in Working for Patients is that it is the duty and responsibility of the authority, advised by its director of public health, to assess its population's health care needs and let contracts to ensure that these needs are met, taking due regard of priorities and available resources.2 The result of this assessment of needs is that it is the health authority that specifies the services that are required and that these specifications form the basis of negotiating contracts. Although there must be a substantial degree of discussion with provider units and wide consultation to ensure that the medical advice from those in the relevant specialties is taken, it is ultimately up to the authority to decide what health care should be provided for its residents. Moreover, it should be the function of those working in public health to provide an unbiased review of the effectiveness, efficiency, equity, acceptability, accessibility, and appropriateness of the services being offered. Indeed, it is hard to imagine how any provider unit is in a position to make the assessments of equity and priority that are required over the whole range of a population's health care needs. Thus, though the article may give some useful advice to provider units, in respect of producing service specifications that advice is not, in my opinion, "how to do it." It is the health authority, and fundholding general practitioners, that must take the lead in determining and describing the services required by their residents and patients. J N PAYNE 'rrent Regional Health Authority, Sheffield S10 3TH 1 Webster D. How to produce a service specification. BMJ7 1991;302:1450-1. (15 June.) 2 Department of Health. Working for patients. London: HMSO, 1989.
SIR, - Several issues arise from Dr Diana Webster's paper on how to produce a service specification. Firstly, whose task is it to write a specificationthe purchaser's or the provider's? Many will agree with the Department of Health that "the development of service specifications should be an essential step by which DHAs [district health authorities] describe, in a form usable by providers, the nature and quality of the service the DHA wishes to obtain."2 The NHS Management Executive's advice on this issue is ambiguous; it postulates that a district will take the initiative by issuing a statement describing the type of service it requires and the desired quality. The example offered is entitled "purchaser service specification." On the other hand, the same document says that "the provider's draft specification will form the basis of negotiation."' Most interested parties, including the NHS Management Executive, acknowledge, however, that whoever writes specifications will need clinical advice if they are to be meaningful.4 On pragmatic grounds many purchasers will gratefully accept a provider's text, allowing subsequent negotiation on contracts to focus almost exclusively on activity and financial terms. In posing the question "What quantity of service does the provider expect the purchaser's residents to require?" Dr Webster probably implies too passive a role for the purchaser. Secondly, some public health physicians with experience of producing specifications may think that the section headed "What is the quality of the service being offered?" in Dr Webster's article is
significant by virtue of its relative brevity. The aspiration to assess effectiveness, efficiency, equity, acceptability, accessibility, and appropriateness is, for many services, as ambitious as it is laudable. Often we simply do not know how to assess these, let alone define them meaningfully in a service specification without making statements that are axiomatic. In another context, the Department of Health has recently rightly argued that close attention to arrangements for medical audit is a means whereby health authorities should discharge their "responsibility to oversee the quality of services delivered to their population."' The advice that local medical audit committees should include a public health physician in their membership where possible is still current, notwithstanding the purchaser-provider split. This, rather than the production of specifications, may offer the best route for appropriately skilled public health physicians to help clinicians secure improvements in the quality of medical care. D A HUNT
Cheltenham District Health Authority, Cheltenham, Gloucestershire GL50 2QN I Webster D. How to produce a service specification. BMJ 1991;302:1450-1. (15 June.) 2 Department of Health. Developing Districts. London: HMSO, 1990. 3 NHS Management Executive. Contracts for health seruices: operating contracts. London: HMSO, 1990. 4 NHS Management Executive. Involving professional staff in drawing up NHS contracts. London: NHS Management Executive, 1990. (EL(90)221.) 5 Department of Health. Medical audit in the hospital and community health services. Assurtng the quality of medical care: implementation of medical and dental audit in the hospital and community health services. London: Department of Health, 1991. (HC(91)2.)
Benefits of changes in the NHS SIR, -The opinions expressed by Dr A C Johansson and Dr I F Greatorex on fundholding' and on the changes in the NHS2 are mistaken. Dr Johansson, like William Waldegrave, seems not to recognise that his funds have been "top sliced" from the health authority's budget, yet he claims several benefits of fundholding. Firstly, quicker, cheaper physiotherapy in the practice. This amounts to queue jumping by diversion of resources. Secondly, cheaper laboratory testing and savings on minor surgery. My patients have benefited by this, without any recourse to fundholding. Thirdly, "extra" hospital operations by using "spare capacity." How? Where? There is no new money, so who is losing? Fourthly, "Money saved is not going into the general practitioners' pockets." But it is going into their business account. Dr Johansson points to his increasing popularity with patients-at the expense no doubt of smaller, perhaps more personal practices which are presently prevented from holding funds. Fifthly, elderly and costly patients are funded. Dr Johansson states that if his patients cost more than he bargained for he will simply ask for more money. That's just what I, a non-fundholder, would do, but I wouldn't get any. Unsurprisingly, Dr Johansson agrees with Neil Kinnock that a two tier system giving his patients a better deal has been introduced (accounting for all the supposed benefits). Yet he then has the gall to say that scrapping fundholding is opting for the lower tier. If all general practitioners become fundholders then all his benefits disappear and the disadvantages become obvious. The chief loss, of course, is that the general practitioner will be seen to have a direct financial interest in every detail of a patient's care and will never be believed if he or she claims to act only in the patient's medical interest. Dr Greatorex continues the naive assertions about NHS changes on more general themes. He states that "It cannot be argued that the service hitherto has ensured equality of access, relevance to social need, social acceptability, and cost ef-
125
fectiveness." Perhaps not, but it certainly aimed to ensure those features on the basis of need, which market forces patently never had, and never will have, any intention of doing. L S LEWIS Newport, Dyfed SA42 o rJ I Johansson AC. Fundholding general practice. BMJf 1991;302: 1405. (8 June.) 2 Greatorex IF. Changes to the NHS. B,J 1991;302:1406.
(8 June.)
Homeless people and psychiatric care
WILLIAM NOTCUTT
James Paget Hospital, Great Yarmouth, Norfolk NR3 1 6LA I Crombie IK, Davies HTO. Audit of outpatients: entering the loop. BMJ 1991;302:1437-9. (15 June.)
Consultants, contracts, and fundholders SIR,-I notice that in his editorial on the impact of general practice fundholding on hospital practice Mr A P J Ross carefully avoided the one thing that prevents the consultants mounting an effective (and much needed) campaign against the new NHS arrangements.' That is, of course, the fact that so many consultants already operate a two tier system of private and NHS practice in which clinical need seems not to get the priority accorded to it in the editorial. This means that the consultants as a group have little or no moral authority on the issue. M D STEVENSON
SIR,-The last paragraph of Dr S L George and colleagues' paper on their census ofsingle homeless people in Sheffield gives the impression that large numbers of long stay patients in psychiatric hospitals have been discharged to live in "reception centres, in substandard rented accommodation, or on the street."' By contrast, we did not find that any of the long stay patients in hospital in the same city in 1982 were homeless at follow up eight years later.2 Evidence is accumulating that the outcome of resettling long stay psychiatric patients is perhaps not as bad as some campaigning organisations feared. For example, in New South Wales not one of 208 long stay patients discharged into supported accommodation had drifted to a refuge for the homeless at follow up at 21 months.' In a companion study, similar in design to the census in Sheffield, hospital records for a cohort of homeless men in a refuge showed that only three of the 22 residents with schizophrenia had had a prolonged admission to a psychiatric hospital.4 Admissions for the remaining 19 had been brief and frequent, but the duration of stay in hospital had not altered appreciably over the years. It would be interesting if psychiatric records for the people studied in the Sheffield census were available for comparison. They may show that the population in the census did not generally come from long stay wards. In evaluating evidence about homelessness and the fate of discharged psychiatric patients it is important to distinguish between the needs of long stay patients who have been discharged and the needs of people who may no longer be able to get psychiatric care. My concern is that the results of surveys of homeless people are being interpreted as showing that traditional psychiatric hospitals should be preserved.5 Government policy recognises the need for "asylum," but this can be arranged in smaller, well staffed units. DUNCAN DOUBLE Department of Psychiatry, Northern General Hospital, Sheffield S5 7AU 1 George SL, Shanks NJ, Westlake L. Census of single homeless people in Sheffield. BM3' 1991;302:1387-9. (8 June.) 2 Double DB, Wong TI. What's happened to patients from long-stay psychiatric wards? Psvchiatric Bulletin (in press). 3 Andrews G, Teesson M, Stewart G, Hoult J. Communitv placement of the chronic mentally ill. Hosp Community
Psychiatry 1990;41:184-8. 4 Teesson M, Buhrich N. Prevalence of schizophrenia in a refuge for homeless men: a five year follow-up. Psychiatric Bulletin
1990;14:597-600. 5 Weller MPI. Mental illness-who cares? Nature 1989;339: 249-52.
Need for pain relief services SIR,-The study by Dr lain K Crombie and Mr Huw T 0 Davies on outpatient pain relief clinics shows that there is no clear consensus about the requirement for this type of service.' A similar variation occurs across our region (from Hospital Activity Analysis statistics). Our clinic has a higher throughput (of new and old patients) than any in 126
Dr Crombie and Mr Davies's study, yet our waiting lists are steadily growing. What is clear is that no one really knows how many people in the community have chronic pain. Hence the new purchasers have few (if any) guidelines on the level of service required. The need for pain relief services must be realistically assessed urgently; then pain relief will start to be placed on a sound financial footing.
Bootlc, Millom, Cumbria LA19 5TH
Compulsory immunisation SIR, -In common with most general practitioners I still bitterly resent the manner in which the new contract was imposed last April by an administration that preferred to confront rather than consult. The government's present difficulties with the health reforms are clearly the price to be paid for failing to win the support of health professionals, who generally continue to try to do the best for patients despite the worst that politicians can throw at them. In my opinion one of the worst aspects of the contract is the inherent philosophy that responsibility for a person's health rests primarily with the doctor rather than with that person. Does this not run counter to all Tory doctrine? This perverse principle is epitomised in the concept of targets for smear testing and immunisation. In our practice we have sweated blood to increase uptake of immunisation, but our main hurdles remain apathy and fear among a subgroup of patients, many of whom believe the vaccines to be intrinsically unsafe. We have done our utmost to persuade them otherwise. Paradoxically, I now find that the harder we try the less they trust us after all, they have read that we receive a "bonus" for reaching our targets. Did anyone in the Department of Health anticipate this erosion of confidence? I believe that a sea change in the opinions of these patients will be achieved only by vigorous publicity campaigns combined with an element of compulsion as now exists in many countries-for example, France, the US, and Sweden. Under such a system a child cannot attend school without a certificate of full immunisation (or valid exemption). The merits of this approach seem so obvious that I cannot believe we are still waiting .for its introduction here. Indeed, I have not even heard it debated at high level. At a stroke the public would see that full immunisation should be the normindeed, that to allow an unimmunised child to mingle with other children is socially irresponsible. It would also release literally millions of doctor and nurse hours per week to be spent on other tasks (I spend five hours a week persuading patients on this topic). Most importantly of all, it would save much cost (in human suffering, time, and money) currently incurred by these diseases and their treatment. With the planned introduction of the influenza vaccine to the schedule in 1992 and hepatitis B. vaccine possibly close behind the overall schedule is soon to become much more complex. Without adequate public education and an element of compulsion there is a danger that the whole programme could disintegrate in confusion. The recent health reforms threaten to introduce to our shores some of the worse aspects of the -American health care system. Why not instead adopt one of its best? L KING
Wakefield WF1 I SU
1 Ross APJ. Consultants, contracts, and fundholders. HBM 1991;302:1479-80. (22 Junc.)
Assessing protective effect of sunscreen products SIR, -Drs Robin Russell Jones and Ian R White discuss methods of assessing the protection that sunscreen products afford against ultraviolet A radiation and ways of labelling products.' It is true that Boots will introduce early next year a system of labelling to attempt to standardise the increasingly confusing claims made on packs regarding protection against ultraviolet A radiation. The system is intended to aid customers' selection of sunscreen products without diminishing the importance ofthe sun protection factor, which is generally regarded by the photobiological community and regulatory bodies as the major descriptor of protection against the sun. As Drs Russell Jones and White point out, international groups are discussing different methods of assessing the protection of sunscreens against ultraviolet A radiation, including the Boots method. The recent meeting in San Antonio on ultraviolet A radiation did not favour or reject any one method, and further discussion and investigation will be needed before a common position is reached internationally. It is therefore likely to be 1993-4 before consumers could benefit from such agreement by seeing consistent information on packs. Boots is participating in many of the current discussions on sun protection, both nationally and internationally, and will continue to do so; the aim is to define a common international method for testing and labelling. Meanwhile, in an effort to prevent the proliferation of a variety of protection factors relating to ultraviolet A radiation and claims based on different methodologies appearing on packs in our stores, in April 1992 we propose to introduce a consistent labelling system, which we believe will provide the following benefits to our customers: firstly, it will give a single standard by which they can compare the protection offered by each product; secondly, it will retain the sun protection factor as the primary factor in the selection of products; and, thirdly, it will avoid further confusion among customers which. could result if more than one method of measuring ultraviolet A was used on packs. As a company we are committed to providing our customers with the best possible choice of sun protection products and a high quality of information to support these. Our intention is to improve their ability to make an informed purchase. G M HOUSTON
Managing director, Boots The Chemists, Nottingham NG2 3AA
1 Russell Jones R, White IR. Assessing protective effect of sunscrecn products. BM7 1991302:52. (6 July.)
BMJ
VOLUME
303
13 JULY 1991
Hartcliffe Health Centre, Bristol BS13 OJP 1 Lea-Cox C, Hall A. Attendance of general practitioners at child protection case conferences. BAIJ 1991;302:1378-9. (8 June.) 2 Main JA, Main PGN. Twenty four hour care in inner cities. BMJ 1989;299:627. 3 Harris A. General practitioners and child protection case conferences. BAIJ 1991;302:1354. (8 June.) 4 Main PGN. Children on the "at risk" register. Update 1990;40: 528. 5 Main PGN. Is social mobility enough? Lancet 1991;337:495.
Out of hours work in general practice SIR,-Drs Steve Iliffe and Ursula Haug listed various factors as possible reasons for an increase in out of hours work in general practice,' but they did not include the decline in home, visiting. This could be important for elderly people who are housebound. Retrospective studies of random samples of adults dying in 1969 and 1987 found a substantial decline in the number of home visits by general practitioners in the year before death but an increase in the proportion of patients who had received two or more night visits during this time.2 The most frequent criticism of general practitioners in the 1987 study was their reluctance or failure to visit.3 Inadequacies in this type of care may well result in emergencies and calls for help out of hours. ANN CARTWRIGHT
Institute for Social Studies in Medical Care, London NW3 2SB I Iliffe S, Haug U. Out of hours wNork in general practice. BMJ7 1991;302:1584-6. (29 June.' 2 Cartwright A. Changes in liI !sd care in the year before death 1969-1987. Public Healtl .2.. 1991;13:81-7. 3 Cartwright A. The role of the genieral practitioner in caring for people in the last year of their lives. London: King Edward's Hospital Fund, 1990.
How to produce a service specification SIR,-Dr Diana Webster's article on producing service specifications,' though of potential use to providers, gives the misleading impression that it is they who should be leading the contracting process. Though this may represent one opinion on this matter, it can hardly be regarded as a consensus view. In-summary, she asks the question
BMJ VOLUME 303
13 JULY 1991
"What quantity of services does the provider expect the purchaser's residents to require?" and describes a process by which the provider unit sets out what services it believes it ought to be funded to supply. I would argue that this emphasis is at odds with the new function of the health authorities, and it certainly does not follow the approach that is being pursued in Trent region. The essence of the reforms set out in Working for Patients is that it is the duty and responsibility of the authority, advised by its director of public health, to assess its population's health care needs and let contracts to ensure that these needs are met, taking due regard of priorities and available resources.2 The result of this assessment of needs is that it is the health authority that specifies the services that are required and that these specifications form the basis of negotiating contracts. Although there must be a substantial degree of discussion with provider units and wide consultation to ensure that the medical advice from those in the relevant specialties is taken, it is ultimately up to the authority to decide what health care should be provided for its residents. Moreover, it should be the function of those working in public health to provide an unbiased review of the effectiveness, efficiency, equity, acceptability, accessibility, and appropriateness of the services being offered. Indeed, it is hard to imagine how any provider unit is in a position to make the assessments of equity and priority that are required over the whole range of a population's health care needs. Thus, though the article may give some useful advice to provider units, in respect of producing service specifications that advice is not, in my opinion, "how to do it." It is the health authority, and fundholding general practitioners, that must take the lead in determining and describing the services required by their residents and patients. J N PAYNE 'rrent Regional Health Authority, Sheffield S10 3TH 1 Webster D. How to produce a service specification. BMJ7 1991;302:1450-1. (15 June.) 2 Department of Health. Working for patients. London: HMSO, 1989.
SIR, - Several issues arise from Dr Diana Webster's paper on how to produce a service specification. Firstly, whose task is it to write a specificationthe purchaser's or the provider's? Many will agree with the Department of Health that "the development of service specifications should be an essential step by which DHAs [district health authorities] describe, in a form usable by providers, the nature and quality of the service the DHA wishes to obtain."2 The NHS Management Executive's advice on this issue is ambiguous; it postulates that a district will take the initiative by issuing a statement describing the type of service it requires and the desired quality. The example offered is entitled "purchaser service specification." On the other hand, the same document says that "the provider's draft specification will form the basis of negotiation."' Most interested parties, including the NHS Management Executive, acknowledge, however, that whoever writes specifications will need clinical advice if they are to be meaningful.4 On pragmatic grounds many purchasers will gratefully accept a provider's text, allowing subsequent negotiation on contracts to focus almost exclusively on activity and financial terms. In posing the question "What quantity of service does the provider expect the purchaser's residents to require?" Dr Webster probably implies too passive a role for the purchaser. Secondly, some public health physicians with experience of producing specifications may think that the section headed "What is the quality of the service being offered?" in Dr Webster's article is
significant by virtue of its relative brevity. The aspiration to assess effectiveness, efficiency, equity, acceptability, accessibility, and appropriateness is, for many services, as ambitious as it is laudable. Often we simply do not know how to assess these, let alone define them meaningfully in a service specification without making statements that are axiomatic. In another context, the Department of Health has recently rightly argued that close attention to arrangements for medical audit is a means whereby health authorities should discharge their "responsibility to oversee the quality of services delivered to their population."' The advice that local medical audit committees should include a public health physician in their membership where possible is still current, notwithstanding the purchaser-provider split. This, rather than the production of specifications, may offer the best route for appropriately skilled public health physicians to help clinicians secure improvements in the quality of medical care. D A HUNT
Cheltenham District Health Authority, Cheltenham, Gloucestershire GL50 2QN I Webster D. How to produce a service specification. BMJ 1991;302:1450-1. (15 June.) 2 Department of Health. Developing Districts. London: HMSO, 1990. 3 NHS Management Executive. Contracts for health seruices: operating contracts. London: HMSO, 1990. 4 NHS Management Executive. Involving professional staff in drawing up NHS contracts. London: NHS Management Executive, 1990. (EL(90)221.) 5 Department of Health. Medical audit in the hospital and community health services. Assurtng the quality of medical care: implementation of medical and dental audit in the hospital and community health services. London: Department of Health, 1991. (HC(91)2.)
Benefits of changes in the NHS SIR, -The opinions expressed by Dr A C Johansson and Dr I F Greatorex on fundholding' and on the changes in the NHS2 are mistaken. Dr Johansson, like William Waldegrave, seems not to recognise that his funds have been "top sliced" from the health authority's budget, yet he claims several benefits of fundholding. Firstly, quicker, cheaper physiotherapy in the practice. This amounts to queue jumping by diversion of resources. Secondly, cheaper laboratory testing and savings on minor surgery. My patients have benefited by this, without any recourse to fundholding. Thirdly, "extra" hospital operations by using "spare capacity." How? Where? There is no new money, so who is losing? Fourthly, "Money saved is not going into the general practitioners' pockets." But it is going into their business account. Dr Johansson points to his increasing popularity with patients-at the expense no doubt of smaller, perhaps more personal practices which are presently prevented from holding funds. Fifthly, elderly and costly patients are funded. Dr Johansson states that if his patients cost more than he bargained for he will simply ask for more money. That's just what I, a non-fundholder, would do, but I wouldn't get any. Unsurprisingly, Dr Johansson agrees with Neil Kinnock that a two tier system giving his patients a better deal has been introduced (accounting for all the supposed benefits). Yet he then has the gall to say that scrapping fundholding is opting for the lower tier. If all general practitioners become fundholders then all his benefits disappear and the disadvantages become obvious. The chief loss, of course, is that the general practitioner will be seen to have a direct financial interest in every detail of a patient's care and will never be believed if he or she claims to act only in the patient's medical interest. Dr Greatorex continues the naive assertions about NHS changes on more general themes. He states that "It cannot be argued that the service hitherto has ensured equality of access, relevance to social need, social acceptability, and cost ef-
125
fectiveness." Perhaps not, but it certainly aimed to ensure those features on the basis of need, which market forces patently never had, and never will have, any intention of doing. L S LEWIS Newport, Dyfed SA42 o rJ I Johansson AC. Fundholding general practice. BMJf 1991;302: 1405. (8 June.) 2 Greatorex IF. Changes to the NHS. B,J 1991;302:1406.
(8 June.)
Homeless people and psychiatric care
WILLIAM NOTCUTT
James Paget Hospital, Great Yarmouth, Norfolk NR3 1 6LA I Crombie IK, Davies HTO. Audit of outpatients: entering the loop. BMJ 1991;302:1437-9. (15 June.)
Consultants, contracts, and fundholders SIR,-I notice that in his editorial on the impact of general practice fundholding on hospital practice Mr A P J Ross carefully avoided the one thing that prevents the consultants mounting an effective (and much needed) campaign against the new NHS arrangements.' That is, of course, the fact that so many consultants already operate a two tier system of private and NHS practice in which clinical need seems not to get the priority accorded to it in the editorial. This means that the consultants as a group have little or no moral authority on the issue. M D STEVENSON
SIR,-The last paragraph of Dr S L George and colleagues' paper on their census ofsingle homeless people in Sheffield gives the impression that large numbers of long stay patients in psychiatric hospitals have been discharged to live in "reception centres, in substandard rented accommodation, or on the street."' By contrast, we did not find that any of the long stay patients in hospital in the same city in 1982 were homeless at follow up eight years later.2 Evidence is accumulating that the outcome of resettling long stay psychiatric patients is perhaps not as bad as some campaigning organisations feared. For example, in New South Wales not one of 208 long stay patients discharged into supported accommodation had drifted to a refuge for the homeless at follow up at 21 months.' In a companion study, similar in design to the census in Sheffield, hospital records for a cohort of homeless men in a refuge showed that only three of the 22 residents with schizophrenia had had a prolonged admission to a psychiatric hospital.4 Admissions for the remaining 19 had been brief and frequent, but the duration of stay in hospital had not altered appreciably over the years. It would be interesting if psychiatric records for the people studied in the Sheffield census were available for comparison. They may show that the population in the census did not generally come from long stay wards. In evaluating evidence about homelessness and the fate of discharged psychiatric patients it is important to distinguish between the needs of long stay patients who have been discharged and the needs of people who may no longer be able to get psychiatric care. My concern is that the results of surveys of homeless people are being interpreted as showing that traditional psychiatric hospitals should be preserved.5 Government policy recognises the need for "asylum," but this can be arranged in smaller, well staffed units. DUNCAN DOUBLE Department of Psychiatry, Northern General Hospital, Sheffield S5 7AU 1 George SL, Shanks NJ, Westlake L. Census of single homeless people in Sheffield. BM3' 1991;302:1387-9. (8 June.) 2 Double DB, Wong TI. What's happened to patients from long-stay psychiatric wards? Psvchiatric Bulletin (in press). 3 Andrews G, Teesson M, Stewart G, Hoult J. Communitv placement of the chronic mentally ill. Hosp Community
Psychiatry 1990;41:184-8. 4 Teesson M, Buhrich N. Prevalence of schizophrenia in a refuge for homeless men: a five year follow-up. Psychiatric Bulletin
1990;14:597-600. 5 Weller MPI. Mental illness-who cares? Nature 1989;339: 249-52.
Need for pain relief services SIR,-The study by Dr lain K Crombie and Mr Huw T 0 Davies on outpatient pain relief clinics shows that there is no clear consensus about the requirement for this type of service.' A similar variation occurs across our region (from Hospital Activity Analysis statistics). Our clinic has a higher throughput (of new and old patients) than any in 126
Dr Crombie and Mr Davies's study, yet our waiting lists are steadily growing. What is clear is that no one really knows how many people in the community have chronic pain. Hence the new purchasers have few (if any) guidelines on the level of service required. The need for pain relief services must be realistically assessed urgently; then pain relief will start to be placed on a sound financial footing.
Bootlc, Millom, Cumbria LA19 5TH
Compulsory immunisation SIR, -In common with most general practitioners I still bitterly resent the manner in which the new contract was imposed last April by an administration that preferred to confront rather than consult. The government's present difficulties with the health reforms are clearly the price to be paid for failing to win the support of health professionals, who generally continue to try to do the best for patients despite the worst that politicians can throw at them. In my opinion one of the worst aspects of the contract is the inherent philosophy that responsibility for a person's health rests primarily with the doctor rather than with that person. Does this not run counter to all Tory doctrine? This perverse principle is epitomised in the concept of targets for smear testing and immunisation. In our practice we have sweated blood to increase uptake of immunisation, but our main hurdles remain apathy and fear among a subgroup of patients, many of whom believe the vaccines to be intrinsically unsafe. We have done our utmost to persuade them otherwise. Paradoxically, I now find that the harder we try the less they trust us after all, they have read that we receive a "bonus" for reaching our targets. Did anyone in the Department of Health anticipate this erosion of confidence? I believe that a sea change in the opinions of these patients will be achieved only by vigorous publicity campaigns combined with an element of compulsion as now exists in many countries-for example, France, the US, and Sweden. Under such a system a child cannot attend school without a certificate of full immunisation (or valid exemption). The merits of this approach seem so obvious that I cannot believe we are still waiting .for its introduction here. Indeed, I have not even heard it debated at high level. At a stroke the public would see that full immunisation should be the normindeed, that to allow an unimmunised child to mingle with other children is socially irresponsible. It would also release literally millions of doctor and nurse hours per week to be spent on other tasks (I spend five hours a week persuading patients on this topic). Most importantly of all, it would save much cost (in human suffering, time, and money) currently incurred by these diseases and their treatment. With the planned introduction of the influenza vaccine to the schedule in 1992 and hepatitis B. vaccine possibly close behind the overall schedule is soon to become much more complex. Without adequate public education and an element of compulsion there is a danger that the whole programme could disintegrate in confusion. The recent health reforms threaten to introduce to our shores some of the worse aspects of the -American health care system. Why not instead adopt one of its best? L KING
Wakefield WF1 I SU
1 Ross APJ. Consultants, contracts, and fundholders. HBM 1991;302:1479-80. (22 Junc.)
Assessing protective effect of sunscreen products SIR, -Drs Robin Russell Jones and Ian R White discuss methods of assessing the protection that sunscreen products afford against ultraviolet A radiation and ways of labelling products.' It is true that Boots will introduce early next year a system of labelling to attempt to standardise the increasingly confusing claims made on packs regarding protection against ultraviolet A radiation. The system is intended to aid customers' selection of sunscreen products without diminishing the importance ofthe sun protection factor, which is generally regarded by the photobiological community and regulatory bodies as the major descriptor of protection against the sun. As Drs Russell Jones and White point out, international groups are discussing different methods of assessing the protection of sunscreens against ultraviolet A radiation, including the Boots method. The recent meeting in San Antonio on ultraviolet A radiation did not favour or reject any one method, and further discussion and investigation will be needed before a common position is reached internationally. It is therefore likely to be 1993-4 before consumers could benefit from such agreement by seeing consistent information on packs. Boots is participating in many of the current discussions on sun protection, both nationally and internationally, and will continue to do so; the aim is to define a common international method for testing and labelling. Meanwhile, in an effort to prevent the proliferation of a variety of protection factors relating to ultraviolet A radiation and claims based on different methodologies appearing on packs in our stores, in April 1992 we propose to introduce a consistent labelling system, which we believe will provide the following benefits to our customers: firstly, it will give a single standard by which they can compare the protection offered by each product; secondly, it will retain the sun protection factor as the primary factor in the selection of products; and, thirdly, it will avoid further confusion among customers which. could result if more than one method of measuring ultraviolet A was used on packs. As a company we are committed to providing our customers with the best possible choice of sun protection products and a high quality of information to support these. Our intention is to improve their ability to make an informed purchase. G M HOUSTON
Managing director, Boots The Chemists, Nottingham NG2 3AA
1 Russell Jones R, White IR. Assessing protective effect of sunscrecn products. BM7 1991302:52. (6 July.)
BMJ
VOLUME
303
13 JULY 1991
