752
BRITISH MEDICAL JOURNAL
To quote an outmoded cliche-"The price of freedom is eternal vigilance." Unless consultants assume responsibilities and the added effort which this entails we shall see more and more examples as quoted by Dr Boulton and others. If medicine is to remain an independent profession we need to set an example to our juniors, who, fortunately, appear to be more aware of the problems which face them than do some of my consultant colleagues. The future of British medicine lies with the younger generation, who are, as Mr J McE Potter (21 August, p 479) says, more intelligent than ever before. They should be accorded the same courtesies as we extend to any colleague. "The fault, dear Dr Boulton, is not in our stars, but in ourselves, that we have allowed ourselves to become underlings" (with apologies to the Bard).
THEo SCHOFIELD Royal United Hospital, Bath
SIR,-I would like to draw attention to an increasing tendency of the new administrators in many areas to a worsening practice of asking for references at very short notice. Today I received, on the precise day allocated for the interview, a request for a reference sent out by second class mail. The letter was delivered within the time allowed by the GPO, but even if it had been sent by first class mail it would have been unlikely to reach me in time to prepare a reference and make sure it arrived at area headquarters by the date it was requested. By the same post one of my staff, for whom the reference was required, received by second class mail and bearing the same postmark and date on the letter a request to attend for interview 100 miles away, a clearly almost impossible task. This casual attitude to a most important matter is discourteous in the extreme and may well cost an applicant a job. In exceptional circumstances a telephone call would prevent such a situation. It also raises the question of the validity of any decision made by a committee under these circumstances. D C BODENHAM Department of Plastic and Jaw Surgery, Frenchay Hospital, Bristol
SIR,-Recent correspondents have rightly expressed criticism and concern over current administrative practices in the request and return of references for medical appointments (24 July, p 236, 14 August, p 424, 21 August, p 478, and 4 September, p 585). We have lately been sent such a request (for the post of surgical registrar) which seemed to us to set altogether new and unwelcome standards. The document was the familiar cyclostyled letter, emanating from the office of the personnel officer of a neighbouring area health authority and returnable to him. The objectionable nine of its 16 lines of text must be quoted verbatim: "In order to protect the public, the post for which application is being made is exempt from Section 4 (2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act, 1974 (Exceptions) Order, 1975. It is not, therefore, in any way contrary to the Act to reveal any information you may have concerning convictions which would otherwise be considered as 'spent,' in relation to this application
and which you consider relevant to the applicant's
suitability for employment. Any such information will be kept in strict confidence, and used only in consideration of the suitability of this applicant for a position where such an exemption is appropriate. "
The innuendo is not only insulting but gratuitously so. The statutory duty to "protect" the public resides with the General Medical Council, which maintains a register of doctors adjudged fit to practise. It is a simple matter for an employing authority to verify the registration of its potential medical staff. The ethical obligation of individual medical referees is then simply to provide an honest testimonial as to an applicant's professional qualities. We agree with your earlier correspondents that, wherever feasible, references should be submitted direct to the consultants concerned, who should be named in the advertisement; but failing that to a named senior medical administrator, not to anonymous lay intermediaries. Such a procedure would sometimes impose yet a further unpaid administrative burden upon clinicians, but the principle that medical matters should be dealt with by medical men is too important to be surrendered out of either indifference or inertia. P J E WILSON J S WATERS Morriston Hospital, Swansea
25 SEPTEMBER 1976
of controlled trials4 5 but then doubt either their practicality or their safety, joining the other group in merely recommending the traveller to rely on the old adages about care with food and water well summarised by the DHSS,6 although I doubt ifmost laymen would understand that the DHSS's coy sentence, "A high standard of personal hygiene is also of the greatest importance," means "the importance of washing the hands after visiting the WC." Certainly Streptotriad (streptomycin, sulphadimidine, sulphadiazine, and sulphathiazole) might "cause crystal deposition in the kidney." However, Sulphatriad was deliberately formulated with three separately soluble sulphonomides (sulphathiazole, sulphadiazine, and sulphamerazine), and May and Baker "have no records of any patient developing crystalluria while taking Streptotriad." (5) Empiricists not only accept the evidence of controlled trials but actually prescribe chemoprophylactics with apparent success for their staff6-8 or their families.9 Clearly we need more controlled trials of chemoprophylaxis to convince groups 1-4. Perhaps the research committee of the British Society of Gastroenterology would arrange one for the next world congress? Not that we should be insular: the 24th Annual Meeting of the BSGE was smitten with travellers' diarrhoea in spite of the large quantities of alcohol British gastroenterologists reluctantly consume before during and after their annual dinners in order to produce the bactericidal gastric acid you demand.
Travellers' diarrhoea J H BARON SIR,-There seem to be five different current medical attitudes to travellers' diarrhoea. (1) Traditionalists hold that this is basically not an infectious disease and that chemoprophylaxis is therefore not indicated. This view has been restated in the British National Formulary 1976-78: "travellers' diarrhoea is frequently due to non-infective causes" (p 120) and "there is no evidence that antibiotics, sulphonamides or clioquinol are effective in the prophylaxis of travellers' diarrhoea" (p 39). (2) Rationalists such as your contemporary' accept that the recent study2 of participants in the gastroenterology congress at Mexico City confirms the earlier work that travellers' diarrhoea is usually due to enteropathic bacteria, especially Escherichia coli,3 but either deny or ignore the value of chemoprophylaxis. (3) Sceptics, as in your recent leading article (14 August, p 385), accept the evidence for enteropathic bacteria2 3 only reluctantly and then ask for all Koch's postulates, although doubting whether gastroenterologists would volunteer to eat their colleagues' faecal extracts. Fortunately no ethical committee need be asked to approve such a trial since it has occurred involuntarily after the Central Public Health Labroatory isolated E coli 0148K ?H28 from the faeces of 540,, of British troops developing diarrhoea within two weeks of arrival in Aden and never from healthy soldiers or those with shigella or salmonella diarrhoea.3 One of the assistants working on this project developed abdominal pain, profuse watery diarrhoea, malaise, and weakness but no fever. Faeces on the first and second days of his illness grew E coli 0148K ?H28, the diarrhoea stopped within 24 hours of treatment with oral colistin sulphate, and the faeces thereafter failed to grow this
St Charles's Hospital, London W10 1 Lancet, 1976, 2, 30. 2 Merson, M H, et al, New England journal of Medicine, 1976, 294, 1299. 3 Rowe, B, Taylor, J, and Bettelheim, K A, Lancet, 1970, 1, 1. 4 Kean, B H, et al, Journal of the American Medical
Association, 1962, 180, 367. Turner, A C, British Medical Journal, 1967, 4, 653. 6Turner, A C, Practitioner, 1971, 206, 615. Sperry, R N, Bulletin of the British Association of Sports Medicine, 1968, 3, 13. 8Turner, A C, Lancet, 1976, 2, 320. 9 Baron, J H, Lancet, 1976, 2, 143. 5
Emergency medical care
SIR,-Dr Hugh Conway (28 August, p 511) has demonstrated in Paisley that 50-9% of emergency medical ward admissions to his urban district general hospital were referred by general practitioners, while 37-30% were self-referred. Currently in a neighbouring Glasgow teaching hospital, with a large GP health centre adjacent to it, we are studying similarly the mode of referral of such patients. Of the first 200 consecutive medical ward admissions studied, 172 (86%,O) have been emergencies. Of these, 616V° were referred by GPs, 11-6o0 by the doctor deputising service, and 24-4% were self-referrals. The corresponding Paisley figures were 50-9% 6 8%, and 37-3°O. In view of Dr Conway's reference to public concern about the deputising service there may be some reassurance in our finding that in all 20 cases in our preliminary series thus referred there were telephone referral calls and accompanying admission letters compared with 93A4% of the GP referrals. In addition, the preadmission label was broadly in agreement with the discharge diagnosis in all 20 E coli.3 (4) Defeatists such as you accept the evidence cases compared with 92-2% of GP admissions.
BRITISH MEDICAL JOURNAL
753
25 SEPTEMBER 1976
Dr Conway has reported a patient preference for self-admission when it is thought the family doctor is unlikely to be available. On the other hand half of our self-referrals were examples of self-poisoning and it is our impression that in the city the influence of drink or drugs is a major reason for patients avoiding the usual admission channels. These two studies suggest that national or even regional admission trends cannot be accurately deduced from single hospital reports. Our experience suggests that the high proportion of self-referrals may not altogether be the result of inadequate family doctor coverage but rather a symptom of change in patient behaviour and attitudes. Whether the deputising service is desirable or not, its standard of medical emergency referral in our district compares favourably with that of the GPs. PETER D'A SEMPLE Medical Unit,
Southern General Hospital, Glasgow
SIR,-Dr Hugh Conway's paper (28 August, p 511) contains much heat but conveys little light on how to deliver primary medical care after hours in urban situations. By his own admission the impetus and justification for his study was his impression of the availability of local general practitioner services, and there is little doubt that his preconceptions have clouded both the design of his project and his interpretation of the results. In the first place, the study of cases arriving at an acute medical .unit does not constitute true appraisal of the primary medical care in a community. In November 1974 working as a GP in an urban area, I saw 546 patients, of whom two were sent to an acute medical receiving unit with a phone call and a letter. This amounted to 0 400 of my primary medical care in that month and illustrates the necessary bias of Dr Conway's view. Furthermore, the interpretation of his results is a little puzzling. Most of his introduction and discussion revolves round the non-availability of GP services, which he claims is the reason for the high rate of selfreferral of patients. Yet it appears that 70(", of the patients admitted made no attempt to contact a GP and only 240" reported difficulty in contacting their doctor. One wonders if Dr Conway accepted the patient's word for this or did he try to verify the statement by contacting the doctor concerned ? Was any attempt made to ascertain whether social class, intelligence, or being the patient of particular practices was a feature of this group ? In fact, if one takes the total number of patients involved, only 6-80, provided unchecked evidence of difficulty in obtaining GP services -a small foundation indeed on which to build the towering edifice of "an entirely hospitalbased emergency medical service in urban areas." The real problem lies not in the nonavailability of GP services but in the fact that patients choose not to use these in urban areas. The reason for the increase in this tendency is obvious from Dr Conway's paper. Ninety-five patients were needlessly admitted to an acute medical ward at immense cost because "it was impossible for various reasons not to accept responsibility for the care of the patient." In other words, the medical registrar could not take the responsibility of sending the patient home when, presumably, the GP, had he seen
the patient, would have taken the responsibility of keeping him at home. If the medical registrar will not take this simple decision, is there any wonder that self-referral is on the increase ? The choice is between a crusty old GP who might give you, at best, some pills or, at worst, a flea in your ear and a bright young medical registrar with a back up of ambulance services, ECG, x-rays, and the promise of a proper examination and a bed for the night. The problem is that the less attractive former proposition is the only one that the Health Service can afford. It is therefore a matter of extreme urgency that the consultants involved either delegate the responsibility of discharge to their registrars or come in and do it themselves. The picture that emerges out of the results is that the family doctors in Paisley are giving a fine service to their patients when they are called upon to give it. I wonder if they receive a letter and a phone call from Dr Conway or his staff when their patients are discharged. That fine service is the foundation on which a good community-based care can and must be built and, from the evidence provided, Paisley needs a few repairs at minimal cost and not the demolition job which is suggested. Urban general practitioners have a difficult enough job operating in deprived areas under difficult conditions without the discouragement which this paper is bound to occasion them.
before patients in the UK begin to visit their medical attendants for certificates enabling them to avoid wearing belts. I am not subject to such requests, but one of my colleagues presents a legally drafted "release form" absolving him from all liability for injury or death caused or contributed to by non-use of seat belts for signature by those of his patients who ask for such certificates, whether or not he considers the request reasonable. So far as I am aware only one patient to date has signed the release form and received a certificate. Earlier this year a woman was ejected from a car involved in a collision in Toronto and was then run over and killed by another vehicle. She had a certificate that she was unable to wear seat belts on the ground, so I have heard, that she suffered from claustrophobia. Legal action is, I understand, being taken against the person whose signature is on the certificate. It is obvious that such certificates should be signed only after due regard is paid to the consequences of so doing, as with any other issued by a physician, and my colleague feels that the effort involved in having his lawyer draw up the release form was well worth while. F B SINGLETON
J C MURDOCH
SIR,-As an industrial pharmacist and regular reader of the BMJ I feel I must spring to the defence of my colleagues in retail pharmacy who may not have had the opportunity to see Dr J N Graham-Evans's comments about them (4 September, p 585). To presume that the pharmacist (dispensing chemist) is merely a clerk armed with a pocket calculator and automatic electronic tablet counter shows a total ignorance of the work of this honourable profession. Unlike your correspondent, many members of the public have great faith in their local pharmacist and often a visit to him or her is preferred rather than one to the local general practitioner. The pharmacist does not have a register of patients on which his salary is based and therefore his advice to customers is essentially free. His approachability and accessibility to members of the general public ensure that his advice is freely sought and given. At the moment I can think of no other members of a profession who give their advice in this manner and this is perhaps one of the reasons why pharmacy is not given the due respect it deserves by members of such professions. Another, more obvious, reason for disrespect is a purely financial one. The costs of running a modern day pharmacy are high and because the prescription pricing system ensures an inadequate return for purely professional services retail pharmacy can survive only by the sale of non-medical items. Fortunately, in most circumstances the sale of these items does not detract from the quality of the pharmaceutical services offered. Most retail pharmacists can recall many harrowing stories about the over-prescribing of medicines, particularly for such products as barbiturates and appetite suppressants, and they have played an active part in counteracting the abuses of these substances. Responsible members of both the pharmaceutical and medical professions are currently co-operating with the DHSS to find more acceptable ways of reducing dispensing costs than those suggested and I am sure that the
Lenzie, Strathclyde
Compulsory seat belts SIR,-I am astonished by the attitude expressed by Mr J A E Primrose (14 August, p 422) to the compulsory wearing of seat belts. The idea that laws restricting personal freedom or which "the police do not like" "cannot be enforced" is completely negative. Surely, in view of the undoubted facts concerning their use and effects, from Australia and elsewhere, every medical practitioner ought to do his utmost to support both the wearing of belts and the legislation requiring that belts be worn. In particular, if it is true that "the police do not like" seat-belt legislation, which I do not believe is true of all policemen, every effort ought to be made to change that attitude, remembering that it was a US highway policeman who first referred to the "second collision," which occurs when unrestrained car occupants hit the inside of a vehicle which has collided with something else. Those people who talk about their personal freedom to risk death or serious injury without hindrance should be reminded, gently or otherwise, that many of us would prefer not to be roused from our beds to deal with injuries which are sometimes entirely due to the lack of restraint and, if the subject of beltinduced injuries is raised, also informed that in such cases the victim would almost certainly not have survived without the belts. After years of listening to people prating about their freedom I could not feel greatly concerned about them. What does concern me and ought to concern all those who think about it is the enormous cost of death and injury which falls upon us all in the long run, since the cost is effectively deducted from the gross national product of any country. Since I now hear that the legislation has been considerably delayed it will be some time
Kingston, Ontario
Economy in prescribing
BRITISH MEDICAL JOURNAL
To quote an outmoded cliche-"The price of freedom is eternal vigilance." Unless consultants assume responsibilities and the added effort which this entails we shall see more and more examples as quoted by Dr Boulton and others. If medicine is to remain an independent profession we need to set an example to our juniors, who, fortunately, appear to be more aware of the problems which face them than do some of my consultant colleagues. The future of British medicine lies with the younger generation, who are, as Mr J McE Potter (21 August, p 479) says, more intelligent than ever before. They should be accorded the same courtesies as we extend to any colleague. "The fault, dear Dr Boulton, is not in our stars, but in ourselves, that we have allowed ourselves to become underlings" (with apologies to the Bard).
THEo SCHOFIELD Royal United Hospital, Bath
SIR,-I would like to draw attention to an increasing tendency of the new administrators in many areas to a worsening practice of asking for references at very short notice. Today I received, on the precise day allocated for the interview, a request for a reference sent out by second class mail. The letter was delivered within the time allowed by the GPO, but even if it had been sent by first class mail it would have been unlikely to reach me in time to prepare a reference and make sure it arrived at area headquarters by the date it was requested. By the same post one of my staff, for whom the reference was required, received by second class mail and bearing the same postmark and date on the letter a request to attend for interview 100 miles away, a clearly almost impossible task. This casual attitude to a most important matter is discourteous in the extreme and may well cost an applicant a job. In exceptional circumstances a telephone call would prevent such a situation. It also raises the question of the validity of any decision made by a committee under these circumstances. D C BODENHAM Department of Plastic and Jaw Surgery, Frenchay Hospital, Bristol
SIR,-Recent correspondents have rightly expressed criticism and concern over current administrative practices in the request and return of references for medical appointments (24 July, p 236, 14 August, p 424, 21 August, p 478, and 4 September, p 585). We have lately been sent such a request (for the post of surgical registrar) which seemed to us to set altogether new and unwelcome standards. The document was the familiar cyclostyled letter, emanating from the office of the personnel officer of a neighbouring area health authority and returnable to him. The objectionable nine of its 16 lines of text must be quoted verbatim: "In order to protect the public, the post for which application is being made is exempt from Section 4 (2) of the Rehabilitation of Offenders Act, 1974, by virtue of the Rehabilitation of Offenders Act, 1974 (Exceptions) Order, 1975. It is not, therefore, in any way contrary to the Act to reveal any information you may have concerning convictions which would otherwise be considered as 'spent,' in relation to this application
and which you consider relevant to the applicant's
suitability for employment. Any such information will be kept in strict confidence, and used only in consideration of the suitability of this applicant for a position where such an exemption is appropriate. "
The innuendo is not only insulting but gratuitously so. The statutory duty to "protect" the public resides with the General Medical Council, which maintains a register of doctors adjudged fit to practise. It is a simple matter for an employing authority to verify the registration of its potential medical staff. The ethical obligation of individual medical referees is then simply to provide an honest testimonial as to an applicant's professional qualities. We agree with your earlier correspondents that, wherever feasible, references should be submitted direct to the consultants concerned, who should be named in the advertisement; but failing that to a named senior medical administrator, not to anonymous lay intermediaries. Such a procedure would sometimes impose yet a further unpaid administrative burden upon clinicians, but the principle that medical matters should be dealt with by medical men is too important to be surrendered out of either indifference or inertia. P J E WILSON J S WATERS Morriston Hospital, Swansea
25 SEPTEMBER 1976
of controlled trials4 5 but then doubt either their practicality or their safety, joining the other group in merely recommending the traveller to rely on the old adages about care with food and water well summarised by the DHSS,6 although I doubt ifmost laymen would understand that the DHSS's coy sentence, "A high standard of personal hygiene is also of the greatest importance," means "the importance of washing the hands after visiting the WC." Certainly Streptotriad (streptomycin, sulphadimidine, sulphadiazine, and sulphathiazole) might "cause crystal deposition in the kidney." However, Sulphatriad was deliberately formulated with three separately soluble sulphonomides (sulphathiazole, sulphadiazine, and sulphamerazine), and May and Baker "have no records of any patient developing crystalluria while taking Streptotriad." (5) Empiricists not only accept the evidence of controlled trials but actually prescribe chemoprophylactics with apparent success for their staff6-8 or their families.9 Clearly we need more controlled trials of chemoprophylaxis to convince groups 1-4. Perhaps the research committee of the British Society of Gastroenterology would arrange one for the next world congress? Not that we should be insular: the 24th Annual Meeting of the BSGE was smitten with travellers' diarrhoea in spite of the large quantities of alcohol British gastroenterologists reluctantly consume before during and after their annual dinners in order to produce the bactericidal gastric acid you demand.
Travellers' diarrhoea J H BARON SIR,-There seem to be five different current medical attitudes to travellers' diarrhoea. (1) Traditionalists hold that this is basically not an infectious disease and that chemoprophylaxis is therefore not indicated. This view has been restated in the British National Formulary 1976-78: "travellers' diarrhoea is frequently due to non-infective causes" (p 120) and "there is no evidence that antibiotics, sulphonamides or clioquinol are effective in the prophylaxis of travellers' diarrhoea" (p 39). (2) Rationalists such as your contemporary' accept that the recent study2 of participants in the gastroenterology congress at Mexico City confirms the earlier work that travellers' diarrhoea is usually due to enteropathic bacteria, especially Escherichia coli,3 but either deny or ignore the value of chemoprophylaxis. (3) Sceptics, as in your recent leading article (14 August, p 385), accept the evidence for enteropathic bacteria2 3 only reluctantly and then ask for all Koch's postulates, although doubting whether gastroenterologists would volunteer to eat their colleagues' faecal extracts. Fortunately no ethical committee need be asked to approve such a trial since it has occurred involuntarily after the Central Public Health Labroatory isolated E coli 0148K ?H28 from the faeces of 540,, of British troops developing diarrhoea within two weeks of arrival in Aden and never from healthy soldiers or those with shigella or salmonella diarrhoea.3 One of the assistants working on this project developed abdominal pain, profuse watery diarrhoea, malaise, and weakness but no fever. Faeces on the first and second days of his illness grew E coli 0148K ?H28, the diarrhoea stopped within 24 hours of treatment with oral colistin sulphate, and the faeces thereafter failed to grow this
St Charles's Hospital, London W10 1 Lancet, 1976, 2, 30. 2 Merson, M H, et al, New England journal of Medicine, 1976, 294, 1299. 3 Rowe, B, Taylor, J, and Bettelheim, K A, Lancet, 1970, 1, 1. 4 Kean, B H, et al, Journal of the American Medical
Association, 1962, 180, 367. Turner, A C, British Medical Journal, 1967, 4, 653. 6Turner, A C, Practitioner, 1971, 206, 615. Sperry, R N, Bulletin of the British Association of Sports Medicine, 1968, 3, 13. 8Turner, A C, Lancet, 1976, 2, 320. 9 Baron, J H, Lancet, 1976, 2, 143. 5
Emergency medical care
SIR,-Dr Hugh Conway (28 August, p 511) has demonstrated in Paisley that 50-9% of emergency medical ward admissions to his urban district general hospital were referred by general practitioners, while 37-30% were self-referred. Currently in a neighbouring Glasgow teaching hospital, with a large GP health centre adjacent to it, we are studying similarly the mode of referral of such patients. Of the first 200 consecutive medical ward admissions studied, 172 (86%,O) have been emergencies. Of these, 616V° were referred by GPs, 11-6o0 by the doctor deputising service, and 24-4% were self-referrals. The corresponding Paisley figures were 50-9% 6 8%, and 37-3°O. In view of Dr Conway's reference to public concern about the deputising service there may be some reassurance in our finding that in all 20 cases in our preliminary series thus referred there were telephone referral calls and accompanying admission letters compared with 93A4% of the GP referrals. In addition, the preadmission label was broadly in agreement with the discharge diagnosis in all 20 E coli.3 (4) Defeatists such as you accept the evidence cases compared with 92-2% of GP admissions.
BRITISH MEDICAL JOURNAL
753
25 SEPTEMBER 1976
Dr Conway has reported a patient preference for self-admission when it is thought the family doctor is unlikely to be available. On the other hand half of our self-referrals were examples of self-poisoning and it is our impression that in the city the influence of drink or drugs is a major reason for patients avoiding the usual admission channels. These two studies suggest that national or even regional admission trends cannot be accurately deduced from single hospital reports. Our experience suggests that the high proportion of self-referrals may not altogether be the result of inadequate family doctor coverage but rather a symptom of change in patient behaviour and attitudes. Whether the deputising service is desirable or not, its standard of medical emergency referral in our district compares favourably with that of the GPs. PETER D'A SEMPLE Medical Unit,
Southern General Hospital, Glasgow
SIR,-Dr Hugh Conway's paper (28 August, p 511) contains much heat but conveys little light on how to deliver primary medical care after hours in urban situations. By his own admission the impetus and justification for his study was his impression of the availability of local general practitioner services, and there is little doubt that his preconceptions have clouded both the design of his project and his interpretation of the results. In the first place, the study of cases arriving at an acute medical .unit does not constitute true appraisal of the primary medical care in a community. In November 1974 working as a GP in an urban area, I saw 546 patients, of whom two were sent to an acute medical receiving unit with a phone call and a letter. This amounted to 0 400 of my primary medical care in that month and illustrates the necessary bias of Dr Conway's view. Furthermore, the interpretation of his results is a little puzzling. Most of his introduction and discussion revolves round the non-availability of GP services, which he claims is the reason for the high rate of selfreferral of patients. Yet it appears that 70(", of the patients admitted made no attempt to contact a GP and only 240" reported difficulty in contacting their doctor. One wonders if Dr Conway accepted the patient's word for this or did he try to verify the statement by contacting the doctor concerned ? Was any attempt made to ascertain whether social class, intelligence, or being the patient of particular practices was a feature of this group ? In fact, if one takes the total number of patients involved, only 6-80, provided unchecked evidence of difficulty in obtaining GP services -a small foundation indeed on which to build the towering edifice of "an entirely hospitalbased emergency medical service in urban areas." The real problem lies not in the nonavailability of GP services but in the fact that patients choose not to use these in urban areas. The reason for the increase in this tendency is obvious from Dr Conway's paper. Ninety-five patients were needlessly admitted to an acute medical ward at immense cost because "it was impossible for various reasons not to accept responsibility for the care of the patient." In other words, the medical registrar could not take the responsibility of sending the patient home when, presumably, the GP, had he seen
the patient, would have taken the responsibility of keeping him at home. If the medical registrar will not take this simple decision, is there any wonder that self-referral is on the increase ? The choice is between a crusty old GP who might give you, at best, some pills or, at worst, a flea in your ear and a bright young medical registrar with a back up of ambulance services, ECG, x-rays, and the promise of a proper examination and a bed for the night. The problem is that the less attractive former proposition is the only one that the Health Service can afford. It is therefore a matter of extreme urgency that the consultants involved either delegate the responsibility of discharge to their registrars or come in and do it themselves. The picture that emerges out of the results is that the family doctors in Paisley are giving a fine service to their patients when they are called upon to give it. I wonder if they receive a letter and a phone call from Dr Conway or his staff when their patients are discharged. That fine service is the foundation on which a good community-based care can and must be built and, from the evidence provided, Paisley needs a few repairs at minimal cost and not the demolition job which is suggested. Urban general practitioners have a difficult enough job operating in deprived areas under difficult conditions without the discouragement which this paper is bound to occasion them.
before patients in the UK begin to visit their medical attendants for certificates enabling them to avoid wearing belts. I am not subject to such requests, but one of my colleagues presents a legally drafted "release form" absolving him from all liability for injury or death caused or contributed to by non-use of seat belts for signature by those of his patients who ask for such certificates, whether or not he considers the request reasonable. So far as I am aware only one patient to date has signed the release form and received a certificate. Earlier this year a woman was ejected from a car involved in a collision in Toronto and was then run over and killed by another vehicle. She had a certificate that she was unable to wear seat belts on the ground, so I have heard, that she suffered from claustrophobia. Legal action is, I understand, being taken against the person whose signature is on the certificate. It is obvious that such certificates should be signed only after due regard is paid to the consequences of so doing, as with any other issued by a physician, and my colleague feels that the effort involved in having his lawyer draw up the release form was well worth while. F B SINGLETON
J C MURDOCH
SIR,-As an industrial pharmacist and regular reader of the BMJ I feel I must spring to the defence of my colleagues in retail pharmacy who may not have had the opportunity to see Dr J N Graham-Evans's comments about them (4 September, p 585). To presume that the pharmacist (dispensing chemist) is merely a clerk armed with a pocket calculator and automatic electronic tablet counter shows a total ignorance of the work of this honourable profession. Unlike your correspondent, many members of the public have great faith in their local pharmacist and often a visit to him or her is preferred rather than one to the local general practitioner. The pharmacist does not have a register of patients on which his salary is based and therefore his advice to customers is essentially free. His approachability and accessibility to members of the general public ensure that his advice is freely sought and given. At the moment I can think of no other members of a profession who give their advice in this manner and this is perhaps one of the reasons why pharmacy is not given the due respect it deserves by members of such professions. Another, more obvious, reason for disrespect is a purely financial one. The costs of running a modern day pharmacy are high and because the prescription pricing system ensures an inadequate return for purely professional services retail pharmacy can survive only by the sale of non-medical items. Fortunately, in most circumstances the sale of these items does not detract from the quality of the pharmaceutical services offered. Most retail pharmacists can recall many harrowing stories about the over-prescribing of medicines, particularly for such products as barbiturates and appetite suppressants, and they have played an active part in counteracting the abuses of these substances. Responsible members of both the pharmaceutical and medical professions are currently co-operating with the DHSS to find more acceptable ways of reducing dispensing costs than those suggested and I am sure that the
Lenzie, Strathclyde
Compulsory seat belts SIR,-I am astonished by the attitude expressed by Mr J A E Primrose (14 August, p 422) to the compulsory wearing of seat belts. The idea that laws restricting personal freedom or which "the police do not like" "cannot be enforced" is completely negative. Surely, in view of the undoubted facts concerning their use and effects, from Australia and elsewhere, every medical practitioner ought to do his utmost to support both the wearing of belts and the legislation requiring that belts be worn. In particular, if it is true that "the police do not like" seat-belt legislation, which I do not believe is true of all policemen, every effort ought to be made to change that attitude, remembering that it was a US highway policeman who first referred to the "second collision," which occurs when unrestrained car occupants hit the inside of a vehicle which has collided with something else. Those people who talk about their personal freedom to risk death or serious injury without hindrance should be reminded, gently or otherwise, that many of us would prefer not to be roused from our beds to deal with injuries which are sometimes entirely due to the lack of restraint and, if the subject of beltinduced injuries is raised, also informed that in such cases the victim would almost certainly not have survived without the belts. After years of listening to people prating about their freedom I could not feel greatly concerned about them. What does concern me and ought to concern all those who think about it is the enormous cost of death and injury which falls upon us all in the long run, since the cost is effectively deducted from the gross national product of any country. Since I now hear that the legislation has been considerably delayed it will be some time
Kingston, Ontario
Economy in prescribing
