and decision making in acute abdpminal pain are among the worst in Europe. : It is difficult to see how conventional education is to cope with the situation outlined above. Eventually, traditional forms of medical education may need to be completely overhauled; meanwhile, the type of system that we described4guiding rather than dictating, and with the emphasis heavily on thorough and "good" (recommended by peers) clinical practice-has a good deal to commend it. Many aphorisms abound regarding the acute abdomen ("if in doubt take it out"), and on the basis of experience with 50 000 cases we would add one more- "do it right; get it right." This (from our studies over the past two decades) is the most important message of all. F T DE DOMBAL V DALLOS W A F McADAM
Clinical Information Science Unit, Leeds University, Leeds L82 9LN 1 Kennedy RL, Harrison RF, Marshall SJ. Computer aided teaching packages. BMJ 1991,303:366. (10 August.) 2 Sutton GC. Computer aided teaching-packages. BMJ 1991,303: 367. (10 August.) 3 Ryan MF, Peters M, Clarke I. Computer aided teaching packages. BMJ 1991;303:366. (10 August.) 4 de Dombal FT, Dallos V, McAdam WAF. Can computer aided teaching packages improve clinical care in patients with acute abdominal pain? BMJ 1991;302:1495-7. (22 June.) 5 Pera C, Garcia-Valdecasas JC, Grande L, de Dombal FT. European Community acute abdominal pain project. Meeting report. Theoretical Surgery 1991;6:188-91.
concerned that there are variations in the standards and shortage of courses in child health reported by general practitioners, as shown by the article by Dr Alison Evans and colleagues.2 We are aware that such courses in some areas have been hastily arranged under pressure from various sources. MUKHLIS M MADLOM
Community Child Health Department, West Lane Hospital, Middlesbrough TS5 4EE 1 Waine C. Child health surveillance lists. BMJ 1991;303:202. (27
July.) 2 Evans A, Maskrey N, Nolan P. Admission to child health surveillance lists: the views of FHSA general managers and general practitioners. BMJ 1991;303:229-32. (27 July.)
An agreement of intent SIR,-With the apparent increase in cooperation required to undertake any work or produce a publication these days it is becoming obvious that problems can arise. Coauthors can be "left off" the final draft or otherwise slighted. In such cases the requirement of editors for signatures from each contributor for copyright reasons is bypassed. A tactful way around this might be for it to be commonly accepted policy for an agreement to be drawn up beforehand. If this was popularised, perhaps with a standard suggested format, it might avoid the rancour that can occur when a "gentleman's agreement" falls through. J D C BENNET-T
Child health surveillance lists SIR,-Dr C Waine mentioned important points in his editorial' which deserve further discussion. The first point is that "general practice is based on local communities, accessible to 95% of the population, and cost effective." The article also refers to the Court Report 1976 "which advocated that child surveillance should increasingly take place in general practice (rather than in the community service)." The problem with general practitioners is that they choose where to work and where to locate their surgeries. They seem to avoid areas of high socioeconomic deprivation, yet it is this 5% or more of the population that most needs child health services. It will be in these and similar areas that community child health services will continue to be the main provider of child health services. Trips to the family doctor often prove expensive, especially when the same services are available at a local community child health service clinic. Parents should be left to choose where to take their child for screening and immunisation. Whoever advises them should give them an honest view as to the merits and availability of services. Any pressure on parents to attend one service or the other would only lead to chronic defaulting. The other point in the article that needs consideration is that "children are an investment in our future; allowing them to achieve their potential is the main purpose of child surveillance." Who would disagree with such a statement? Yet one wonders why suddenly in the last few years child health has become so important. Primary health care would always mean to those who work in community child health, the coordinated team activities of general practice and community based paediatricians. The team members need liaison and coordination, which is happening in some areas and without which the service will continue to be fragmented and disorganised and will be doomed. This liaison and coordination is essential if we were to make sure that the child health surveillance is to reach those needy 5-10% of the
population. For the sake of the children and families receiving the surveillance programme one must be
996
Queen Elizabeth Military Hospital, London SE18 4QH
Vocational training in general practice SIR,-Professor Roger Higgs succinctly turns the spotlight back on to education for general practice trainees in a well balanced definition of the present problems.' But we have taken stock many times in the past. There seems to be an enormous inertia to effect change in the present system, particularly concerning the hospital component of training. Change takes time (except when government directed). We do need to take action. The impetus for change occurs at the individual, local, and national levels. The organisation of the 1990 general practitioner- -trainee conference attempted to provide an impetus by motivating individual trainees through small group work, generating solutions to these problems, and in the plenary session motivating the invited representatives of our academic and regulatory bodies. Individual efforts at instituting change are effective, but these efforts are hampered by problems of apathy, lack of continuity in short term jobs, and poor communication. Communication, assessment, and feedback are the main instruments of change at this level. For change at a local level trainee groups are valuable, but there has been no increase in the number of such groups in the past 10 years. These groups encourage camaraderie, shared experience, and consensus views and enable the appointment of regional and national representatives. Course organisers should be responsible for facilitating the formation and continuation of such groups. They also have a responsibility to ensure an adequate educational standard for hospital posts, and they would be greatly helped by the adoption at a national level of improved minimum criteria for approval of posts. As regards change at a national level, accreditation of jobs by the Joint Committee for Postgraduate Training for General Practice and respective royal colleges relies heavily on feedback obtained during visits. The college regional organ-
isation provides a structure through which trainee representatives can make their voices heard. These opportunities should not be met with apathy. With the prospect of locally rather than nationally agreed job contracts, doctors' education must not be forgotten. The recommendations of our academic bodies need to be heeded rather than buried in the library bookshelves. There should be adequate protected time for education explicit in junior and consultant job contracts and remuneration for teaching. These changes should be compulsory and monitored by the setting of minimum standards, assessment, and being accountable to an effective regulatory body. Professor Higgs's editorial will hopefully have sustained the motivation of those individual trainees, representatives, and members of regulatory bodies to implement the changes that will preserve and enhance our education. JOHN HEATHER Exeter EX3 OQY 1 Higgs R. Vocational training in general practice. BMJ 1991; 303:480-1. (31 August.)
Total knee replacements and wheelchairs SIR,-Releasing young adults from the confines of their wheelchairs to a more independent existence by means of knee replacement is a laudable aim.' There are, however, many young adults for whom no such escape exists but whose independence would be increased considerably by the provision of an indoor-outdoor powered wheelchair. The McColl report highlighted this problem of underprovision of powered chairs controlled by their occupant,2 yet five years on, despite a successful pilot study with such chairs in Newcastle and Manchester, the NHS continues to neglect the independent mobility needs of this group of patients. The reason is that providing these chairs is too expensive,3 even though they cost only about £1500 each. It therefore seems strange that an operation for a knee or hip replacement that costs £1000 or more is not also considered to be too expensive for the NHS. Such an obviously unjust anomaly in the provision of health care for young disabled adults should be rectified. N J DUDLEY
Department of Geriatric Medicine, St Luke's Hospital, Bradford BDS ONA 1 Noble J, Hilton RC. Total knee replacement. BM7 1991;303: 262. (3 August.) 2 Revnev of the artificial limb and appliance centre services. Vols I and II. London: Department of Health and Social Security, 1986.
(McColl report.) 3 HouseofLordsOfficialReport(Hansard) 1991 January 14;524:cols 1057-80. (No 25.)
Increases in BMA subscriptions SIR,-In his replies to correspondents writing about the increases in BMA subscriptions the secretary of the BMA gives the reasons for the increases and explains the adjustments made to various concessionary rates.'2 He compares the subscription rates for junior doctors with those for retired doctors, but he fails to complete the equation by making it clear that the benefits received by the two groups are vastly different. Junior doctors, with their lives before them, receive many benefits from the BMA, but retired doctors receive hardly anything, as is evident from the association's most recent booklet on the benefits of membership.3 In the introduction to this booklet the BMA's secretary states that "If there are benefits which you would like us to consider, we should be happy
BMJ VOLUME 303
19 OCTOBER 1991
Clinical Information Science Unit, Leeds University, Leeds L82 9LN 1 Kennedy RL, Harrison RF, Marshall SJ. Computer aided teaching packages. BMJ 1991,303:366. (10 August.) 2 Sutton GC. Computer aided teaching-packages. BMJ 1991,303: 367. (10 August.) 3 Ryan MF, Peters M, Clarke I. Computer aided teaching packages. BMJ 1991;303:366. (10 August.) 4 de Dombal FT, Dallos V, McAdam WAF. Can computer aided teaching packages improve clinical care in patients with acute abdominal pain? BMJ 1991;302:1495-7. (22 June.) 5 Pera C, Garcia-Valdecasas JC, Grande L, de Dombal FT. European Community acute abdominal pain project. Meeting report. Theoretical Surgery 1991;6:188-91.
concerned that there are variations in the standards and shortage of courses in child health reported by general practitioners, as shown by the article by Dr Alison Evans and colleagues.2 We are aware that such courses in some areas have been hastily arranged under pressure from various sources. MUKHLIS M MADLOM
Community Child Health Department, West Lane Hospital, Middlesbrough TS5 4EE 1 Waine C. Child health surveillance lists. BMJ 1991;303:202. (27
July.) 2 Evans A, Maskrey N, Nolan P. Admission to child health surveillance lists: the views of FHSA general managers and general practitioners. BMJ 1991;303:229-32. (27 July.)
An agreement of intent SIR,-With the apparent increase in cooperation required to undertake any work or produce a publication these days it is becoming obvious that problems can arise. Coauthors can be "left off" the final draft or otherwise slighted. In such cases the requirement of editors for signatures from each contributor for copyright reasons is bypassed. A tactful way around this might be for it to be commonly accepted policy for an agreement to be drawn up beforehand. If this was popularised, perhaps with a standard suggested format, it might avoid the rancour that can occur when a "gentleman's agreement" falls through. J D C BENNET-T
Child health surveillance lists SIR,-Dr C Waine mentioned important points in his editorial' which deserve further discussion. The first point is that "general practice is based on local communities, accessible to 95% of the population, and cost effective." The article also refers to the Court Report 1976 "which advocated that child surveillance should increasingly take place in general practice (rather than in the community service)." The problem with general practitioners is that they choose where to work and where to locate their surgeries. They seem to avoid areas of high socioeconomic deprivation, yet it is this 5% or more of the population that most needs child health services. It will be in these and similar areas that community child health services will continue to be the main provider of child health services. Trips to the family doctor often prove expensive, especially when the same services are available at a local community child health service clinic. Parents should be left to choose where to take their child for screening and immunisation. Whoever advises them should give them an honest view as to the merits and availability of services. Any pressure on parents to attend one service or the other would only lead to chronic defaulting. The other point in the article that needs consideration is that "children are an investment in our future; allowing them to achieve their potential is the main purpose of child surveillance." Who would disagree with such a statement? Yet one wonders why suddenly in the last few years child health has become so important. Primary health care would always mean to those who work in community child health, the coordinated team activities of general practice and community based paediatricians. The team members need liaison and coordination, which is happening in some areas and without which the service will continue to be fragmented and disorganised and will be doomed. This liaison and coordination is essential if we were to make sure that the child health surveillance is to reach those needy 5-10% of the
population. For the sake of the children and families receiving the surveillance programme one must be
996
Queen Elizabeth Military Hospital, London SE18 4QH
Vocational training in general practice SIR,-Professor Roger Higgs succinctly turns the spotlight back on to education for general practice trainees in a well balanced definition of the present problems.' But we have taken stock many times in the past. There seems to be an enormous inertia to effect change in the present system, particularly concerning the hospital component of training. Change takes time (except when government directed). We do need to take action. The impetus for change occurs at the individual, local, and national levels. The organisation of the 1990 general practitioner- -trainee conference attempted to provide an impetus by motivating individual trainees through small group work, generating solutions to these problems, and in the plenary session motivating the invited representatives of our academic and regulatory bodies. Individual efforts at instituting change are effective, but these efforts are hampered by problems of apathy, lack of continuity in short term jobs, and poor communication. Communication, assessment, and feedback are the main instruments of change at this level. For change at a local level trainee groups are valuable, but there has been no increase in the number of such groups in the past 10 years. These groups encourage camaraderie, shared experience, and consensus views and enable the appointment of regional and national representatives. Course organisers should be responsible for facilitating the formation and continuation of such groups. They also have a responsibility to ensure an adequate educational standard for hospital posts, and they would be greatly helped by the adoption at a national level of improved minimum criteria for approval of posts. As regards change at a national level, accreditation of jobs by the Joint Committee for Postgraduate Training for General Practice and respective royal colleges relies heavily on feedback obtained during visits. The college regional organ-
isation provides a structure through which trainee representatives can make their voices heard. These opportunities should not be met with apathy. With the prospect of locally rather than nationally agreed job contracts, doctors' education must not be forgotten. The recommendations of our academic bodies need to be heeded rather than buried in the library bookshelves. There should be adequate protected time for education explicit in junior and consultant job contracts and remuneration for teaching. These changes should be compulsory and monitored by the setting of minimum standards, assessment, and being accountable to an effective regulatory body. Professor Higgs's editorial will hopefully have sustained the motivation of those individual trainees, representatives, and members of regulatory bodies to implement the changes that will preserve and enhance our education. JOHN HEATHER Exeter EX3 OQY 1 Higgs R. Vocational training in general practice. BMJ 1991; 303:480-1. (31 August.)
Total knee replacements and wheelchairs SIR,-Releasing young adults from the confines of their wheelchairs to a more independent existence by means of knee replacement is a laudable aim.' There are, however, many young adults for whom no such escape exists but whose independence would be increased considerably by the provision of an indoor-outdoor powered wheelchair. The McColl report highlighted this problem of underprovision of powered chairs controlled by their occupant,2 yet five years on, despite a successful pilot study with such chairs in Newcastle and Manchester, the NHS continues to neglect the independent mobility needs of this group of patients. The reason is that providing these chairs is too expensive,3 even though they cost only about £1500 each. It therefore seems strange that an operation for a knee or hip replacement that costs £1000 or more is not also considered to be too expensive for the NHS. Such an obviously unjust anomaly in the provision of health care for young disabled adults should be rectified. N J DUDLEY
Department of Geriatric Medicine, St Luke's Hospital, Bradford BDS ONA 1 Noble J, Hilton RC. Total knee replacement. BM7 1991;303: 262. (3 August.) 2 Revnev of the artificial limb and appliance centre services. Vols I and II. London: Department of Health and Social Security, 1986.
(McColl report.) 3 HouseofLordsOfficialReport(Hansard) 1991 January 14;524:cols 1057-80. (No 25.)
Increases in BMA subscriptions SIR,-In his replies to correspondents writing about the increases in BMA subscriptions the secretary of the BMA gives the reasons for the increases and explains the adjustments made to various concessionary rates.'2 He compares the subscription rates for junior doctors with those for retired doctors, but he fails to complete the equation by making it clear that the benefits received by the two groups are vastly different. Junior doctors, with their lives before them, receive many benefits from the BMA, but retired doctors receive hardly anything, as is evident from the association's most recent booklet on the benefits of membership.3 In the introduction to this booklet the BMA's secretary states that "If there are benefits which you would like us to consider, we should be happy
BMJ VOLUME 303
19 OCTOBER 1991
