of HIV, many decline HIV testing. The objections to testing that we identified could be reduced by
strategies designed to improve patients' knowledge and awareness of specific issues. With regard to the financial implications, the Association of British Insurers has indicated that having an HIV test as part of a recognised screening programme, such as screening before blood donation or as part of antenatal care, will not adversely affect insurance policies, provided that the result is negative.2 We believe that this should be extended to cover all HIV testing and that this assurance needs to be widely publicised. Furthermore, we believe that advertising and counselling that emphasise the confidentiality of test results and the benefits of earlier treatment of HIV infections may increase the acceptability and uptake of HIV antibody testing among heterosexuals. P D KELL M A CRACKNELL S E BARTON
A G LAWRENCE St Stephen's Clinic, London Swlio 9TrH I Delamothe T. New AID)S figures.
BAIj 1991;302:197.
(26 January.) 2 Association of British Insurers. ABI factfile: AIDS and insurers.
London: ABI, 1988. 3 Volberding PA, Lagakos SW, Koch MA, et al. Zidovudine in asymptomatic human immunodeficiency virus infection. N Englj Med 1990;322:941-9.
The Jarman index SIR,-Dr Roy A Carr-Hall and Mr Trevor Sheldon' suggest that the function of the deprivation payments is twofold: to compensate general practitioners for increased workload in socially deprived areas and to act as an incentive to work in these areas, where income may be lower owing to failure to meet targets. In east London the payment achieves neither of these aims. General practitioner workload is a nebulous concept comprising some elements that are easily measurable, such as consultation rates, and others that are much harder to quantify, such as fears of aggression and violence and inadequate staffing and premises. To construct an index that could be validated nationally against such a subjective notion would be impossible. Perceived pressures of work do not relate to the index currently applied. Department of Health figures show that many general practitioners have fallen short of targets in areas where no deprivation payments are made, including areas of heavy workload. Clearly, the payments are not effectively compensating for this. In addition, the index does not truly reflect the characteristics of an area. The variables from which it is calculated can be updated only every 10 years as census data become available. My practice is on the Isle of Dogs in London's docklands, where the structure of the population has changed enormously since 1981 and will continue to change. This is unusual but not unique. Currently, deprivation payments are made for all patients on the list. This contrasts with an adjoining practice where, subjectively, workload is greater but not all patients live within an area that qualifies for payments. My partner and I are in the fortunate position of receiving a guaranteed minimum salary from the family health services authority, which amounts to average net remuneration. Our type 2 practice allowance permits the authority to reimburse the expenses of a new practice in this area of rapid population growth. Irrespective of the level of deprivation payments or the targets we attain, we will not be financially penalised for spending time dealing with the problems that patients present to us.
No form of remuneration will ever be completely fair, but introducing a salaried option would
BMJ VOLUME 302
16 MARCH 1991
reasonably reward work done and get away from payments that may not reflect workload and do not compensate for failure to reach targets. JOANNA RICHARDSON
Island Health, London E14 3BQ I Carr-Hall RA, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ7 1991;302:393-6. (16 February.)
SIR, -Dr George Davey Smith's editorial' and the papers by Dr Robin J Talbot2 and Dr Roy A CarrHill and Mr Trevor Sheldon3 suggest that the Jarman index may be inappropriate for allocating health service resources and paying general practitioners. My colleague and I showed that the Jarman scores correlate more weakly (over 928 postcode sectors in Scotland) with mortality and the measure of permanent sickness in the census than does either the Scottish or Townsend measure.' Jarman scores are correlated more highly with hospital discharges and bed days than are the other two measures because of the influence of the "lone elderly" variable. Readers interested in this debate may wish to examine these data; a fuller dataset is available on request. Needs for primary care are not all determined by mortality and morbidity, but, nevertheless, a measure that shows deficits in respect of these does not provide confidence that it offers an equitable basis for the allocation of enhanced payments to doctors. Areas with high proportions of young children and of people moving into them may benefit at the expense of areas with more severe health problems. The Jarman index needs to be reconstructed not discarded, and the next sweep of the general practitioner workload survey should be designed to assist in its development.5 VERA CARSTAIRS Health Services Research Networks, Edinburgh EFH1 9J T I Smith C,D. Second thoughts on the Jarman index. BMJ 1991;302:359-60. (16 February.) 2 Talbot RJ. Underprivileged areas and health planning: implications of use of Jarman indicators of urban deprivation. BMJ 1991;302:383-6. (16 February.) 3 Carr-Hall RA, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ 1991;302:393-6. (16 February.) 4 Carstairs V, Morris R. Deprivation and health. BMJ 1989;229: 1462. 5 Royal College of General Practitioners, Office of Population Censuses and Surveys, Department of Health and Social Security. Morbidity statisticsfrom general practice, third national study. London: HMSO, 1986. (Series MB.)
SIR,-The arguments of Dr Roy Carr-Hill and Mr Trevor Sheldon that the underprivileged area index is neither clear nor comprehensible' are considerably reinforced by the differential positive skewness of its eight constituent variables. According to my calculations of a skewness statistic, the transformation Jarman uses produces normality only for the "unskilled" variable. Moreover, the three most skewed variables-ethnic minorities, residential mobility, and overcrowding-are precisely the ones given the lowest weights by general practitioners. As skewness introduces additional hidden (but unknown) weights into the calculation of scores,2 the explicit weights of the general practitioners are being at. least partly neutralised and distorted. This helps to explain why the Jarman index is popularly perceived to favour areas with relatively large proportions of ethnic minority residents. In his comments on my recent paper' Professor Jarman has argued that skewness is less problematic if the histograms of the eight variables are weighted by ward populations. His argument implies, however, that the underprivileged area scores should have been calculated using population weighted means and standard deviations for
those variables. Not surprisingly, the population weighted underprivileged area scores I recently calculated (and not in my paper) differ from those in current use. So should the Department of Health be using them to identify deprived wards? Comparing the underprivileged area and Townsend4 indexes' ranking of all 9265 wards in England and Wales, and applying deprivation payment scales for 1991, reveals a more detailed picture than that painted in Dr Robin J Talbot's article.' Although both Professor Jarman's index and Townsend's favour different areas, both cover both northern and southern districts, thus showing that the north-south divide is not clear cut. At the ward scale the Townsend index is more sensitive to deprivation on estates housing overspill populations from the inner cities, while Jarman's index ranks some coastal retirement areas as "deprived" because ther have many elderly people living alone. In some respects criticisms of Professor Jarman are too severe. Firstly, critics complain that census information is out of date, but they do not propose better sources of data of uniform quality throughout Britain. Secondly, Dr Talbot rightly argues that identifying deprived enumeration districts would be preferable to using wards, but he fails to recognise the substantial inaccuracies involved in matching patients' postcodes to such small areas.`x It is also unfair to blame Professor Jarman for the way his underprivileged area scores have been used by the government's health departments. The threshold scores are not only intuitively implausible but are at odds with the continuous gradation of underprivileged area scores. The abrupt changes in payments imply a degree of precision and consensus in demarcating classes of deprivation-or general practitioner workloadimpossible to achieve from census questions and data aggregation. Until, as Dr Carr-Hill and Mr Sheldon conclude, policy is based on the results of scientific tests, a tapered system of deprivation payments would be more sensible. Such a scheme, starting at £1 for the arbitrary score of 16 and proceeding in increments of 10 pence for every unit increase in the score,3 would involve much the same national expenditure (in England) as at present-but may be unwelcome to those general practitioners who profit from the present stepped payment system. MARTYN L SENIOR
Department of Geography, University of Salford, Salford M5 4WT 1 Carr-Hill R, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ 1991;302:393-6. (16 February.) 2 Thunhurst C. The analysis of small area statistics and planning for health. Statistician 1985;34:93-106. 3 Senior ML. Deprivation payments to GPs: not what the doctor ordered. Environment and Planning: Government and Policy
1991;9:61-7. 4 Townsend P, Phillimore P, Beattie A. Inequalities in health in the Northern region: an interim report. Bristol: University of Bristol; Newcastle: Northern Regional Health Authority, 1986. 5 Talbot RJ. Underprivileged areas and health care planning: implications of use of Jarman indicators of urban deprivation. BM7 1991;302:383-6. (16 February.) 6 Gatrell AC. On the spatial representation and accuracy of address-based data in the United Kingdom. International Journal of Geographical Information Systems 1989;3:335-48. 7 Gatrell AC, Dunn CE, Boyle PJ. The relative utility of the central postcode directory and pinpoint address code in applications of geographical information systems. Lancaster University: North West Regional Research Laboratory, 1990. (Research report No 15.) 8 Jarman B. Social depnrvation and health service funding. London: Imperial College of Science, Technology, and Medicine, 1990. (Papers in science, technology, medicine, and public policy No22.)
I needed to see my son SIR,-MS Sheila Awooner-Renner's account of her visit to her dead son is a moving reminder to all of us in emergency medicine.' Sadly, the hospital staff confused their need to confirm identification
661
with her strong need to express love-two very different things. Among all deaths the sudden traumatic death of a young person tends to have the greatest impact on the bereaved, who therefore need particularly careful handling. Bereaved people should always be offered the chance to see the body, and generally this should be encouraged. It is an important part of accepting the reality and often helps to dispel the imagined disfigurement. Fact is generally preferable to fantasy, and what right have we to protect bereaved people? The deceased is their relative, and their feelings will tell them what they need to do. We are perhaps just protecting ourselves and hindering them in the process. Seeing the body is also a chance for the people to inspect, touch, hold, kiss, or say goodbye to their loved one. Staff should give permission for these free expressions, as well as allow the chance for bereaved people to be left alone with the body.2 Some may need several visits. Sheila Awooner-Renner was unnecessarily (and cruelly) kept waiting, and when she eventually got to her son she felt inhibited and was watched. There was no need to wait for the coroner's officer. How are we to avoid this well meaning but inappropriate handling of distressed relatives? The hospice movement has led the way, but the acute sector needs a system for coping 24 hours a day. Accident and emergency departments are increasingly recognising the needs of bereaved people, regarding them as unofficial patients (often led by nurses). As well as the senior accident and emergency staff hospital chaplains, social workers, and sometimes bereavement counsellors are available.3 Staff in other emergency specialties, such as intensive and coronary care and neurosurgery, should also have some training and awareness of these matters and be able to integrate their services with those of the hospital and community. Unresolved grief reactions may linger and might be reduced by good, early handling, which should include encouraging the bereaved to express their feelings as they say goodbye to their loved one. CHRIS A J McLAUCHLAN
Derriford Hospital, Plymouth PL6 3DH 1 Awooner-Renner S. I desperately needed to see my son. BMJ7 1991;302:356. (9 February.) 2 McLauchlan CA]. Handling distressed relatives and breaking bad news. BMJ7 1990;301:1145-7. (17 November.) 3 Yates DW, Ellison G, McGuiness S. Care of the suddenly bereaved. BMJ 1990;301:29-31. (7 July.)
maturity.6 The study by Dr Shirley and Ms Bottomley is awaited with interest as the predicted numbers required in such a study to produce valid results range from 12 000 to 46 000.71 DAVID J CAHILL Bristol Maternity Hospital, Bristol BS2 8EG 1 Warden J. Maternity services could do better. B.MJ 1990;300: 833. 2 Warden J. A friend at the top. BM.7 1990;301:1297. (18 December.) 3 Shirley IM, Bottomlev F. Ultrasonography and perinatal mortality rates. BM7 1991;302:408. (16 February.) 4 Bennett MJ, Little G, Dewhurst J, et al. Predictive value of ultrasound measurement in earlv pregnancy: a randomized controlled trial. Bry Obstet Gynaecol 1982;89:338-41. 5 Neilson JP, Whitfield CR, Aitchson TC. Screening for the small for dates fetus: a two stage ultrasound examination schedulc. BMJ 1984;000: 1203-6. 6 Waldenstrom U, Axelsson 0, Nilsson S, et al. Effects of routine one-stage ultrasound screening in pregnancy: a randomised controlled trial. Iancet 1988;ii:585-8. 7 Thacker SB. Quality of controlled clinical trials. The case of imaging ultrasound in obstetrics: a review. Br J Obstet Gynaecol 1985;92:437-44. 8 Lilford RJ, Chard T. The routine use of ultrasound. Br] Obstet
Gynaecol 1985;92:434-6.
Junior doctors' years SIR,-Dr John Roberts suggests that American doctors in training are able to concentrate on learning rather than on patient care because they "have the help of attending (senior) physicians at all times."' Having worked within both systems, I have observed that this is not true. In surgery, obstetrics, and anaesthetics supervision by senior staff is at about the same level in America as it is in Britain. At my present hospital residents often complete whole operating lists without the attending (senior) surgeon ever appearing. How many registrar lists in Britain are completed without the consultant taking a close interest? Dr Roberts states that junior doctors depend on one consultant for a recommendation to the next job. This is also not true. References are not even requested until a candidate has been shortlisted (on the basis of his or her curriculum vitae). The performance of the candidate at interview is clearly the main determinant of whether he or she gets the job. References may not even be examined until after the committee has reached a tentative agreement. Though I have not sat on an interview committee myself, I am told by those who have that examination of the references only rarely results in that decision being changed.
bodies such as were found in their patients are often reversible with abstinence from alcohol, it has been shown in several studies that these histological features in drinkers are independently predictive of cirrhosis. Indeed, in one long term prospective study 28% of patients with severe steatosis alone and without histological features of alcoholic hepatitis developed cirrhosis over a period of 10-13 years. The authors concluded that steatosis was a risk factor for the subsequent development of cirrhosis -despite its reversibility I In our view, a liver biopsy should be carried out if raised y-glutamyltransferase activity persists after abstinence for three to six months, allowing early reversible changes to clear-usually by the time referral to hospital and further assessment have been arranged. GEORGE BIRD ROGER WILLIAMS Institute of Liver Studies, King's College School of Medicine and Dentistry, London SE5 9PJ 1 Ireland A, Hartley L, Ryley N, McGee JOD, Trowell JM, Chapman WR. Raised y-glutamvltransferase activity and the need for liver biopsy. BMIJ 1991;302:388-9. (16 February.) 2 Sorensen TIA, Orholm M, Bentsen KD, Hoybye G, Eghoje K, Christoffersen P. Prospective evaluation of alcohol abuse and alcoholic liver injury in men as predictors of development of cirrhosis. Lancet 1984;ii:241-4.
Doctors, the onus is on you SIR,-MS Caroline White reports that patients appreciate facts about their illnesses and the opportunity to ask questions at consultation. One easy way to give information is to supply patients with copies of their clinic correspondence. We are currently analysing data derived from our questionnaire survey of patients' clinic letters. Each patient received a copy of a letter from an outpatient consultation, together with a short questionnaire. The letters mentioned recent clinical details, treatment, and outlook. Of 202 patients surveyed over 12 months, 91% requested copies of further letters. Supplying such information must assist in patients' understanding of their conditions and compliance with their treatment. WENDY RUTHERFORD ROGER GABRIEL St Mary's Hospital, London W2 INY 1 White C. Doctors, the onus is on you. BM7 1991;302:369. ( 16 February.)
PETER C STRIDE
Ultrasonography and perinatal mortality rates
John Sealy Hospital, Galveston, Texas 77550, United States
SIR, -Though variations in perinatal mortality rates among health authorities do occur,' and it is right to seek improvement in the services provided,2 caution must be exercised in planning any such improvement. Dr Isabel M Shirley and Ms Fiona Bottomley outline the programme of fetal surveillance that, they suggest, is responsible for a reduction in perinatal mortality rates in their unit.3 Their claim for an improvement in perinatal mortality rates is at best only in the uncorrected rate, whereas most units quote perinatal mortality rates corrected for fetal anomaly. A single screening test at 19 weeks such as they suggest will identify major congenital anomalies. This does not, however, allow much time for counselling and treatment if termination is considered. The results of other studies of the efficacy of ultrasonography in pregnancy have not been encouraging. Such screening has not been shown to have any benefit either as a single or as a two stage procedure,4' apart from reducing the number of patients induced for incorrectly diagnosed post-
I Roberts J. Junior doctors' years: training, not education. BMJ7
662
1991;302:225-8. (26 January.)
Need for liver biopsy in alcoholic liver disease SIR, -In the recent retrospective study concerning the need for liver biopsy in patients with suspected alcoholic liver disease in whom there is raised serum y-glutamyltransferase activity but otherwise normal serum transaminase activity, Dr A Ireland and colleagues found only reversible histological changes (steatosis and Mallory bodies), although fibrosis or cirrhosis was a common finding in patients with additional abnormalities of serum liver biochemistry. ' The authors offered no comment on whether histological examination was indicated in patients with raised activity of y-glutamyltransferase only, although they imply that there is no need for a liver biopsy. It should be pointed out, however, that although histological changes of steatosis and Mallory
BMA's guidelines on advertising SIR,-The principles governing the General Medical Council's guidance on advertising' concern the maintenance of good relationships between doctors and the protection of patients "from unscrupulous claims which could be contained in promotional material."2 The unfortunate result has been that until recently patients were denied written information on matters such as the facilities in general practice: information they want,3 need,4 and benefit from.5 The medical profession responded to the changing public mood late, somewhat unwillingly and patchily. Now a contractual obligation for NHS doctors to provide practice information leaflets is included in the 1989 terms of service. Dr A W Macara's assertion6 that the BMA and the General Medical Council have publicised the need for information to patients for some years is undeniable, but the external pressure from patients,' consumers' organisations, the Monopolies and Mergers Commission,2 and the new contract for general practice has given
BMJ VOLUME 302
16 MARCH 1991
strategies designed to improve patients' knowledge and awareness of specific issues. With regard to the financial implications, the Association of British Insurers has indicated that having an HIV test as part of a recognised screening programme, such as screening before blood donation or as part of antenatal care, will not adversely affect insurance policies, provided that the result is negative.2 We believe that this should be extended to cover all HIV testing and that this assurance needs to be widely publicised. Furthermore, we believe that advertising and counselling that emphasise the confidentiality of test results and the benefits of earlier treatment of HIV infections may increase the acceptability and uptake of HIV antibody testing among heterosexuals. P D KELL M A CRACKNELL S E BARTON
A G LAWRENCE St Stephen's Clinic, London Swlio 9TrH I Delamothe T. New AID)S figures.
BAIj 1991;302:197.
(26 January.) 2 Association of British Insurers. ABI factfile: AIDS and insurers.
London: ABI, 1988. 3 Volberding PA, Lagakos SW, Koch MA, et al. Zidovudine in asymptomatic human immunodeficiency virus infection. N Englj Med 1990;322:941-9.
The Jarman index SIR,-Dr Roy A Carr-Hall and Mr Trevor Sheldon' suggest that the function of the deprivation payments is twofold: to compensate general practitioners for increased workload in socially deprived areas and to act as an incentive to work in these areas, where income may be lower owing to failure to meet targets. In east London the payment achieves neither of these aims. General practitioner workload is a nebulous concept comprising some elements that are easily measurable, such as consultation rates, and others that are much harder to quantify, such as fears of aggression and violence and inadequate staffing and premises. To construct an index that could be validated nationally against such a subjective notion would be impossible. Perceived pressures of work do not relate to the index currently applied. Department of Health figures show that many general practitioners have fallen short of targets in areas where no deprivation payments are made, including areas of heavy workload. Clearly, the payments are not effectively compensating for this. In addition, the index does not truly reflect the characteristics of an area. The variables from which it is calculated can be updated only every 10 years as census data become available. My practice is on the Isle of Dogs in London's docklands, where the structure of the population has changed enormously since 1981 and will continue to change. This is unusual but not unique. Currently, deprivation payments are made for all patients on the list. This contrasts with an adjoining practice where, subjectively, workload is greater but not all patients live within an area that qualifies for payments. My partner and I are in the fortunate position of receiving a guaranteed minimum salary from the family health services authority, which amounts to average net remuneration. Our type 2 practice allowance permits the authority to reimburse the expenses of a new practice in this area of rapid population growth. Irrespective of the level of deprivation payments or the targets we attain, we will not be financially penalised for spending time dealing with the problems that patients present to us.
No form of remuneration will ever be completely fair, but introducing a salaried option would
BMJ VOLUME 302
16 MARCH 1991
reasonably reward work done and get away from payments that may not reflect workload and do not compensate for failure to reach targets. JOANNA RICHARDSON
Island Health, London E14 3BQ I Carr-Hall RA, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ7 1991;302:393-6. (16 February.)
SIR, -Dr George Davey Smith's editorial' and the papers by Dr Robin J Talbot2 and Dr Roy A CarrHill and Mr Trevor Sheldon3 suggest that the Jarman index may be inappropriate for allocating health service resources and paying general practitioners. My colleague and I showed that the Jarman scores correlate more weakly (over 928 postcode sectors in Scotland) with mortality and the measure of permanent sickness in the census than does either the Scottish or Townsend measure.' Jarman scores are correlated more highly with hospital discharges and bed days than are the other two measures because of the influence of the "lone elderly" variable. Readers interested in this debate may wish to examine these data; a fuller dataset is available on request. Needs for primary care are not all determined by mortality and morbidity, but, nevertheless, a measure that shows deficits in respect of these does not provide confidence that it offers an equitable basis for the allocation of enhanced payments to doctors. Areas with high proportions of young children and of people moving into them may benefit at the expense of areas with more severe health problems. The Jarman index needs to be reconstructed not discarded, and the next sweep of the general practitioner workload survey should be designed to assist in its development.5 VERA CARSTAIRS Health Services Research Networks, Edinburgh EFH1 9J T I Smith C,D. Second thoughts on the Jarman index. BMJ 1991;302:359-60. (16 February.) 2 Talbot RJ. Underprivileged areas and health planning: implications of use of Jarman indicators of urban deprivation. BMJ 1991;302:383-6. (16 February.) 3 Carr-Hall RA, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ 1991;302:393-6. (16 February.) 4 Carstairs V, Morris R. Deprivation and health. BMJ 1989;229: 1462. 5 Royal College of General Practitioners, Office of Population Censuses and Surveys, Department of Health and Social Security. Morbidity statisticsfrom general practice, third national study. London: HMSO, 1986. (Series MB.)
SIR,-The arguments of Dr Roy Carr-Hill and Mr Trevor Sheldon that the underprivileged area index is neither clear nor comprehensible' are considerably reinforced by the differential positive skewness of its eight constituent variables. According to my calculations of a skewness statistic, the transformation Jarman uses produces normality only for the "unskilled" variable. Moreover, the three most skewed variables-ethnic minorities, residential mobility, and overcrowding-are precisely the ones given the lowest weights by general practitioners. As skewness introduces additional hidden (but unknown) weights into the calculation of scores,2 the explicit weights of the general practitioners are being at. least partly neutralised and distorted. This helps to explain why the Jarman index is popularly perceived to favour areas with relatively large proportions of ethnic minority residents. In his comments on my recent paper' Professor Jarman has argued that skewness is less problematic if the histograms of the eight variables are weighted by ward populations. His argument implies, however, that the underprivileged area scores should have been calculated using population weighted means and standard deviations for
those variables. Not surprisingly, the population weighted underprivileged area scores I recently calculated (and not in my paper) differ from those in current use. So should the Department of Health be using them to identify deprived wards? Comparing the underprivileged area and Townsend4 indexes' ranking of all 9265 wards in England and Wales, and applying deprivation payment scales for 1991, reveals a more detailed picture than that painted in Dr Robin J Talbot's article.' Although both Professor Jarman's index and Townsend's favour different areas, both cover both northern and southern districts, thus showing that the north-south divide is not clear cut. At the ward scale the Townsend index is more sensitive to deprivation on estates housing overspill populations from the inner cities, while Jarman's index ranks some coastal retirement areas as "deprived" because ther have many elderly people living alone. In some respects criticisms of Professor Jarman are too severe. Firstly, critics complain that census information is out of date, but they do not propose better sources of data of uniform quality throughout Britain. Secondly, Dr Talbot rightly argues that identifying deprived enumeration districts would be preferable to using wards, but he fails to recognise the substantial inaccuracies involved in matching patients' postcodes to such small areas.`x It is also unfair to blame Professor Jarman for the way his underprivileged area scores have been used by the government's health departments. The threshold scores are not only intuitively implausible but are at odds with the continuous gradation of underprivileged area scores. The abrupt changes in payments imply a degree of precision and consensus in demarcating classes of deprivation-or general practitioner workloadimpossible to achieve from census questions and data aggregation. Until, as Dr Carr-Hill and Mr Sheldon conclude, policy is based on the results of scientific tests, a tapered system of deprivation payments would be more sensible. Such a scheme, starting at £1 for the arbitrary score of 16 and proceeding in increments of 10 pence for every unit increase in the score,3 would involve much the same national expenditure (in England) as at present-but may be unwelcome to those general practitioners who profit from the present stepped payment system. MARTYN L SENIOR
Department of Geography, University of Salford, Salford M5 4WT 1 Carr-Hill R, Sheldon T. Designing a deprivation payment for general practitioners: the UPA(8) wonderland. BMJ 1991;302:393-6. (16 February.) 2 Thunhurst C. The analysis of small area statistics and planning for health. Statistician 1985;34:93-106. 3 Senior ML. Deprivation payments to GPs: not what the doctor ordered. Environment and Planning: Government and Policy
1991;9:61-7. 4 Townsend P, Phillimore P, Beattie A. Inequalities in health in the Northern region: an interim report. Bristol: University of Bristol; Newcastle: Northern Regional Health Authority, 1986. 5 Talbot RJ. Underprivileged areas and health care planning: implications of use of Jarman indicators of urban deprivation. BM7 1991;302:383-6. (16 February.) 6 Gatrell AC. On the spatial representation and accuracy of address-based data in the United Kingdom. International Journal of Geographical Information Systems 1989;3:335-48. 7 Gatrell AC, Dunn CE, Boyle PJ. The relative utility of the central postcode directory and pinpoint address code in applications of geographical information systems. Lancaster University: North West Regional Research Laboratory, 1990. (Research report No 15.) 8 Jarman B. Social depnrvation and health service funding. London: Imperial College of Science, Technology, and Medicine, 1990. (Papers in science, technology, medicine, and public policy No22.)
I needed to see my son SIR,-MS Sheila Awooner-Renner's account of her visit to her dead son is a moving reminder to all of us in emergency medicine.' Sadly, the hospital staff confused their need to confirm identification
661
with her strong need to express love-two very different things. Among all deaths the sudden traumatic death of a young person tends to have the greatest impact on the bereaved, who therefore need particularly careful handling. Bereaved people should always be offered the chance to see the body, and generally this should be encouraged. It is an important part of accepting the reality and often helps to dispel the imagined disfigurement. Fact is generally preferable to fantasy, and what right have we to protect bereaved people? The deceased is their relative, and their feelings will tell them what they need to do. We are perhaps just protecting ourselves and hindering them in the process. Seeing the body is also a chance for the people to inspect, touch, hold, kiss, or say goodbye to their loved one. Staff should give permission for these free expressions, as well as allow the chance for bereaved people to be left alone with the body.2 Some may need several visits. Sheila Awooner-Renner was unnecessarily (and cruelly) kept waiting, and when she eventually got to her son she felt inhibited and was watched. There was no need to wait for the coroner's officer. How are we to avoid this well meaning but inappropriate handling of distressed relatives? The hospice movement has led the way, but the acute sector needs a system for coping 24 hours a day. Accident and emergency departments are increasingly recognising the needs of bereaved people, regarding them as unofficial patients (often led by nurses). As well as the senior accident and emergency staff hospital chaplains, social workers, and sometimes bereavement counsellors are available.3 Staff in other emergency specialties, such as intensive and coronary care and neurosurgery, should also have some training and awareness of these matters and be able to integrate their services with those of the hospital and community. Unresolved grief reactions may linger and might be reduced by good, early handling, which should include encouraging the bereaved to express their feelings as they say goodbye to their loved one. CHRIS A J McLAUCHLAN
Derriford Hospital, Plymouth PL6 3DH 1 Awooner-Renner S. I desperately needed to see my son. BMJ7 1991;302:356. (9 February.) 2 McLauchlan CA]. Handling distressed relatives and breaking bad news. BMJ7 1990;301:1145-7. (17 November.) 3 Yates DW, Ellison G, McGuiness S. Care of the suddenly bereaved. BMJ 1990;301:29-31. (7 July.)
maturity.6 The study by Dr Shirley and Ms Bottomley is awaited with interest as the predicted numbers required in such a study to produce valid results range from 12 000 to 46 000.71 DAVID J CAHILL Bristol Maternity Hospital, Bristol BS2 8EG 1 Warden J. Maternity services could do better. B.MJ 1990;300: 833. 2 Warden J. A friend at the top. BM.7 1990;301:1297. (18 December.) 3 Shirley IM, Bottomlev F. Ultrasonography and perinatal mortality rates. BM7 1991;302:408. (16 February.) 4 Bennett MJ, Little G, Dewhurst J, et al. Predictive value of ultrasound measurement in earlv pregnancy: a randomized controlled trial. Bry Obstet Gynaecol 1982;89:338-41. 5 Neilson JP, Whitfield CR, Aitchson TC. Screening for the small for dates fetus: a two stage ultrasound examination schedulc. BMJ 1984;000: 1203-6. 6 Waldenstrom U, Axelsson 0, Nilsson S, et al. Effects of routine one-stage ultrasound screening in pregnancy: a randomised controlled trial. Iancet 1988;ii:585-8. 7 Thacker SB. Quality of controlled clinical trials. The case of imaging ultrasound in obstetrics: a review. Br J Obstet Gynaecol 1985;92:437-44. 8 Lilford RJ, Chard T. The routine use of ultrasound. Br] Obstet
Gynaecol 1985;92:434-6.
Junior doctors' years SIR,-Dr John Roberts suggests that American doctors in training are able to concentrate on learning rather than on patient care because they "have the help of attending (senior) physicians at all times."' Having worked within both systems, I have observed that this is not true. In surgery, obstetrics, and anaesthetics supervision by senior staff is at about the same level in America as it is in Britain. At my present hospital residents often complete whole operating lists without the attending (senior) surgeon ever appearing. How many registrar lists in Britain are completed without the consultant taking a close interest? Dr Roberts states that junior doctors depend on one consultant for a recommendation to the next job. This is also not true. References are not even requested until a candidate has been shortlisted (on the basis of his or her curriculum vitae). The performance of the candidate at interview is clearly the main determinant of whether he or she gets the job. References may not even be examined until after the committee has reached a tentative agreement. Though I have not sat on an interview committee myself, I am told by those who have that examination of the references only rarely results in that decision being changed.
bodies such as were found in their patients are often reversible with abstinence from alcohol, it has been shown in several studies that these histological features in drinkers are independently predictive of cirrhosis. Indeed, in one long term prospective study 28% of patients with severe steatosis alone and without histological features of alcoholic hepatitis developed cirrhosis over a period of 10-13 years. The authors concluded that steatosis was a risk factor for the subsequent development of cirrhosis -despite its reversibility I In our view, a liver biopsy should be carried out if raised y-glutamyltransferase activity persists after abstinence for three to six months, allowing early reversible changes to clear-usually by the time referral to hospital and further assessment have been arranged. GEORGE BIRD ROGER WILLIAMS Institute of Liver Studies, King's College School of Medicine and Dentistry, London SE5 9PJ 1 Ireland A, Hartley L, Ryley N, McGee JOD, Trowell JM, Chapman WR. Raised y-glutamvltransferase activity and the need for liver biopsy. BMIJ 1991;302:388-9. (16 February.) 2 Sorensen TIA, Orholm M, Bentsen KD, Hoybye G, Eghoje K, Christoffersen P. Prospective evaluation of alcohol abuse and alcoholic liver injury in men as predictors of development of cirrhosis. Lancet 1984;ii:241-4.
Doctors, the onus is on you SIR,-MS Caroline White reports that patients appreciate facts about their illnesses and the opportunity to ask questions at consultation. One easy way to give information is to supply patients with copies of their clinic correspondence. We are currently analysing data derived from our questionnaire survey of patients' clinic letters. Each patient received a copy of a letter from an outpatient consultation, together with a short questionnaire. The letters mentioned recent clinical details, treatment, and outlook. Of 202 patients surveyed over 12 months, 91% requested copies of further letters. Supplying such information must assist in patients' understanding of their conditions and compliance with their treatment. WENDY RUTHERFORD ROGER GABRIEL St Mary's Hospital, London W2 INY 1 White C. Doctors, the onus is on you. BM7 1991;302:369. ( 16 February.)
PETER C STRIDE
Ultrasonography and perinatal mortality rates
John Sealy Hospital, Galveston, Texas 77550, United States
SIR, -Though variations in perinatal mortality rates among health authorities do occur,' and it is right to seek improvement in the services provided,2 caution must be exercised in planning any such improvement. Dr Isabel M Shirley and Ms Fiona Bottomley outline the programme of fetal surveillance that, they suggest, is responsible for a reduction in perinatal mortality rates in their unit.3 Their claim for an improvement in perinatal mortality rates is at best only in the uncorrected rate, whereas most units quote perinatal mortality rates corrected for fetal anomaly. A single screening test at 19 weeks such as they suggest will identify major congenital anomalies. This does not, however, allow much time for counselling and treatment if termination is considered. The results of other studies of the efficacy of ultrasonography in pregnancy have not been encouraging. Such screening has not been shown to have any benefit either as a single or as a two stage procedure,4' apart from reducing the number of patients induced for incorrectly diagnosed post-
I Roberts J. Junior doctors' years: training, not education. BMJ7
662
1991;302:225-8. (26 January.)
Need for liver biopsy in alcoholic liver disease SIR, -In the recent retrospective study concerning the need for liver biopsy in patients with suspected alcoholic liver disease in whom there is raised serum y-glutamyltransferase activity but otherwise normal serum transaminase activity, Dr A Ireland and colleagues found only reversible histological changes (steatosis and Mallory bodies), although fibrosis or cirrhosis was a common finding in patients with additional abnormalities of serum liver biochemistry. ' The authors offered no comment on whether histological examination was indicated in patients with raised activity of y-glutamyltransferase only, although they imply that there is no need for a liver biopsy. It should be pointed out, however, that although histological changes of steatosis and Mallory
BMA's guidelines on advertising SIR,-The principles governing the General Medical Council's guidance on advertising' concern the maintenance of good relationships between doctors and the protection of patients "from unscrupulous claims which could be contained in promotional material."2 The unfortunate result has been that until recently patients were denied written information on matters such as the facilities in general practice: information they want,3 need,4 and benefit from.5 The medical profession responded to the changing public mood late, somewhat unwillingly and patchily. Now a contractual obligation for NHS doctors to provide practice information leaflets is included in the 1989 terms of service. Dr A W Macara's assertion6 that the BMA and the General Medical Council have publicised the need for information to patients for some years is undeniable, but the external pressure from patients,' consumers' organisations, the Monopolies and Mergers Commission,2 and the new contract for general practice has given
BMJ VOLUME 302
16 MARCH 1991
