298 as adequate with some restriction, 172 as only able to perform a few functions, and nine as wholly bedbound or wheelchair bound. Of those visited, 414 were found to have one of the four usually recognised risk factors present (recent bereavement, living alone, hospitalised within last year, confined to home), 164 had two, 31 had three, and six had all four. The visits took between 30 and 45 minutes, and an average of 6-7 were made each day. Our carefully selected and supported nurse visitor works 30 hours a week, and the scheme is managed by a part time administrator. One of us acts as contract holder with the approval of the family health services authority. The current cost to each principal is £53.50 a month and is equivalent to £4.50 per patient over 75 a year. This compares well with the £20 increase in the capitation payment for the over 75s since the inception of the new contract. Our project predated the new general practice contract but satisfies its requirements. In spite of the general criticism of this aspect of the contract, we have found that the programme is practically possible, is acceptable to our patients (87% of those registered have accepted a visit in the first year), identifies previously unmet needs, and, by close liaison with 30 statutory and voluntary agencies, shows that we do not overload any one of them. The benefits of this scheme would not be achieved by offering an assessment in the surgery to those fit enough to attend as our assessment is of functional capacity rather than of medical fitness. Incidentally, the issue of fundholding raised by Ms Eve and Dr Hodgkin is a red herring. Cooperation between practices, whether fundholding or not, in order to define and meet the health care needs of their patients will be particularly important if general practitioners are to respond to the opportunities for improved primary care provided by the many changes occurring in our health care system. We believe that the opportunities for cooperation will increase, and that if we make the most of them then not only will our patients benefit but general practice will be more rewarding for all those who work within it, of whatever discipline. MICHAEL A VARNAM Sneiton Health Centre, Nottingham NG2 4PJ LINDA BREWIN MALCOLM BARKER P BASU M B CHAUDRI JOANNE HOBSON TONY MARSH
PAUL OLIVER JANET POLNAY ROBYN SCOTT DAVID TYERS ALAN WRIGHT
1 Eve R, Hodkin P. In praise of non-fundholding practices. 1991;303:167-8. (20 July.)
BMJ
Environmentally acceptable containers for soft drinks SIR,-In their article on ocular injuries due to exploding bottles of carbonated drinks Messrs P W Sellar and P B Johnston suggest that thick walled returnable glass bottles are less likely to explode and are environmentally acceptable.' Returnable bottles can be considered to be environmentally friendly only if they are returned many times for refilling. This is not always the case. A prime finding of the Boustead and Hancock study into the energy requirements of beverage containers was that no one type of container for soft drinks was inherently any more environmentally friendly than any other.' Manufacturers of soft drinks in the United Kingdom offer a variety of types and sizes of containers to consumers, each with specific benefits. The returnable glass bottle is the traditional container in the industry and is still used in the
650
north of England, Northern Ireland, and Scotland and extensively in the licensed trade. 'rhe decline in the use of returnable bottles is largely attributable to consumers' reluctance to return the bottles to the point of purchase and the major retailers' reluctance to accept the empty bottles as they prefer to devote their space to selling rather than storing products. The British Soft Drinks Association, which represents the soft drinks industry in the United Kingdom, supports the use of refillable bottles and is currently running a campaign in Scotland to promote their use and return. The association also, however, supports the use of all other containers for soft drinks and the recyling schemes established for each packaging material. SALLY HOPKINS British Soft Drinks Association, London WC2B 5UA I Sellar PW, Johnston PB. Ocular in'luries due to exploding bottles of carbonated drinks. BMJ7 1991;303:176-7. (20 July.) 2 British Soft Drinks Association. Boustead and Hancock: layman's guide. St Albans: David Pcrchard, 1990. (Soft Drinks Management International supplement.)
Junior doctors' hours SIR,-Hart writes of his perceptions of the roadshow on junior doctors' hours held in Nottingham. I am alarmed that he makes no mention of discussion of the suggested minimum guaranteed periods of off duty hours. Nor does there seem to have been correspondence on this issue in the
BMJ. I wonder if I am alone in worrying that suggested minimums like these may become norms in the eyes of hospital managers. I believe that it should be possible to guarantee two consecutive days off every week with at least one full weekend off every month. Under the proposed minimums it would be quite possible to be required to work every weekend throughout one's career as a junior doctor, holidays excepted. The junior staff negotiators should be aware that weekends are often the only times when junior doctors can socialise normally with their friends and families. Junior doctors may well be prepared to take action to protect them when they realise the threat. P J TAYLOR
Axminster EX 13 5AG 1 Hart. The week. BM, 1991;303:332. (10 August.)
SIR,-Hart raised yet again the problem of junior doctors' hours of work,' and I particularly like the suggestion that the health service should have an economic incentive to do something about it. The problem, however, does not lie solely in the hours on duty but in the hours worked. A small survey in Nottingham found that preregistration house officers slept for three hours or less during 15 7% of all duties, while for senior house officers the figure was 21-1%.2 It is surprising that the recent package from the NHS Management Executive does not deal more specifically with the need for time off after repeated interruption of sleep,' although the Faculty of Dental Surgery does mention this.4 Comments like "as a guide [doctors in training] should have a reasonable expectation of 8 hours rest during a period of 32 hours on duty" are not very helpful.' Does the senior house officer who sleeps through the night for 79% of the time have a reasonable expectation of rest? It is time we addressed the admittedly difficult problem of what to do when the trainee has been up all night. Lack of sleep is serious. The consensus report on catastrophes, sleep, and public policy states, "industries and services affecting public safety
should address the physiological needs of workers and the safety requirements of society at large. Management should limit active duty hours for all personnel to ensure that adequate time for sleep is obtained between successive periods of duty."' Perhaps the BMA could hold a conference on sleep deprivation similar to the NATO seminar on sleep and its applications for the military held in Lyons in 1987. The problems caused by sleep deprivation in doctors are not taken sufficiently seriously, presumably because they are not widely understood. A M B GOLDING
Editor, Health and Hvgiene, London WIIN 4DE 1 Hart. The week. BMJ 1991;303:332. (10 Auguist.) 2 Tstirnbull NB, Miles NA, Gallen IW. Junior doctors' on call activities: differences in workload and work patterns among grades. AMJ 1990;301:1191-2. 3 NHS Management Executive. The newv deal. Hours of work of doctors in training. Working arrangements of doctors and dentists in training. London: NHS M\anagement Executive, 1991. 4 NHS Management Executive. The newz deal. Hours of work of doctors in training. Guidance from the Conference of Medical Roval Colleges and their faculties in the UK. London: NHS Management Executive, 1991. 5 Mitler MN, Carskadon NA, Czeisler CA, Dement WC, Dinges DF, Graber RC. Catastrophes, sleep and public policy consensus report. Sleep 1988;11: 100-8.
Joy riding SIR, -Over recent months joy riding has become a common activity in and around Oxford, where high performance stolen cars are raced on public roads at high speeds, often involving displays of stunt driving. Large crowds of onlookers are attracted to watch these displays, and this has led to recent public disturbances. Inevitably crashes occur, and serious injuries are not uncommon. In the past six months four joy riders have suffered serious injuries after separate incidents. They were all male, age range 14 to 24. Two were drivers of vehicles, one was a rear seat passenger, and the other a front seat passenger. Three had isolated close femoral shaft fractures. One had a lateral compression fracture of the pelvis sustained after rolling a three wheeled Reliant Robin (known among joy riders as a "plastic pig"). He was 14 years old and seems to have been emulating the activities of his joy riding elders. After resuscitation the three joy riders with femoral shaft fractures were treated with locked intramedullary nail fixation. The pelvic fracture required inpatient treatment for five weeks. As yet we have encountered injuries only in car occupants, but if these activities continue serious injury to bystanders seems inevitable. C L M H GIBBONS A J CARR P H WORLOCK
Accident Service, John Radcliffe Hospital, Oxford OX3 9DU
Completing the feedback loop SIR,-We agree with Ms Miranda Mugford and colleagues on the importance of completing the feedback loop for effective audit to have any chance. ' Their review of 36 studies is unlikely to be typical of everyday audit activities, reflecting the work of enthusiasts for audit and publication bias.2 We undertook a regional survey (response rate 75%) in July 1989,' just after the publication of details of the government's reforms,4 to ascertain the degree of audit activities. Some form of activity was reported by 85% of all general medical and surgical firms in 13 districts, yet just over half of these schemes reported keeping no record of discussions or conclusions, making it impossible
BMJ VOLUME 303
14 SEPTEMBER 1991
PAUL OLIVER JANET POLNAY ROBYN SCOTT DAVID TYERS ALAN WRIGHT
1 Eve R, Hodkin P. In praise of non-fundholding practices. 1991;303:167-8. (20 July.)
BMJ
Environmentally acceptable containers for soft drinks SIR,-In their article on ocular injuries due to exploding bottles of carbonated drinks Messrs P W Sellar and P B Johnston suggest that thick walled returnable glass bottles are less likely to explode and are environmentally acceptable.' Returnable bottles can be considered to be environmentally friendly only if they are returned many times for refilling. This is not always the case. A prime finding of the Boustead and Hancock study into the energy requirements of beverage containers was that no one type of container for soft drinks was inherently any more environmentally friendly than any other.' Manufacturers of soft drinks in the United Kingdom offer a variety of types and sizes of containers to consumers, each with specific benefits. The returnable glass bottle is the traditional container in the industry and is still used in the
650
north of England, Northern Ireland, and Scotland and extensively in the licensed trade. 'rhe decline in the use of returnable bottles is largely attributable to consumers' reluctance to return the bottles to the point of purchase and the major retailers' reluctance to accept the empty bottles as they prefer to devote their space to selling rather than storing products. The British Soft Drinks Association, which represents the soft drinks industry in the United Kingdom, supports the use of refillable bottles and is currently running a campaign in Scotland to promote their use and return. The association also, however, supports the use of all other containers for soft drinks and the recyling schemes established for each packaging material. SALLY HOPKINS British Soft Drinks Association, London WC2B 5UA I Sellar PW, Johnston PB. Ocular in'luries due to exploding bottles of carbonated drinks. BMJ7 1991;303:176-7. (20 July.) 2 British Soft Drinks Association. Boustead and Hancock: layman's guide. St Albans: David Pcrchard, 1990. (Soft Drinks Management International supplement.)
Junior doctors' hours SIR,-Hart writes of his perceptions of the roadshow on junior doctors' hours held in Nottingham. I am alarmed that he makes no mention of discussion of the suggested minimum guaranteed periods of off duty hours. Nor does there seem to have been correspondence on this issue in the
BMJ. I wonder if I am alone in worrying that suggested minimums like these may become norms in the eyes of hospital managers. I believe that it should be possible to guarantee two consecutive days off every week with at least one full weekend off every month. Under the proposed minimums it would be quite possible to be required to work every weekend throughout one's career as a junior doctor, holidays excepted. The junior staff negotiators should be aware that weekends are often the only times when junior doctors can socialise normally with their friends and families. Junior doctors may well be prepared to take action to protect them when they realise the threat. P J TAYLOR
Axminster EX 13 5AG 1 Hart. The week. BM, 1991;303:332. (10 August.)
SIR,-Hart raised yet again the problem of junior doctors' hours of work,' and I particularly like the suggestion that the health service should have an economic incentive to do something about it. The problem, however, does not lie solely in the hours on duty but in the hours worked. A small survey in Nottingham found that preregistration house officers slept for three hours or less during 15 7% of all duties, while for senior house officers the figure was 21-1%.2 It is surprising that the recent package from the NHS Management Executive does not deal more specifically with the need for time off after repeated interruption of sleep,' although the Faculty of Dental Surgery does mention this.4 Comments like "as a guide [doctors in training] should have a reasonable expectation of 8 hours rest during a period of 32 hours on duty" are not very helpful.' Does the senior house officer who sleeps through the night for 79% of the time have a reasonable expectation of rest? It is time we addressed the admittedly difficult problem of what to do when the trainee has been up all night. Lack of sleep is serious. The consensus report on catastrophes, sleep, and public policy states, "industries and services affecting public safety
should address the physiological needs of workers and the safety requirements of society at large. Management should limit active duty hours for all personnel to ensure that adequate time for sleep is obtained between successive periods of duty."' Perhaps the BMA could hold a conference on sleep deprivation similar to the NATO seminar on sleep and its applications for the military held in Lyons in 1987. The problems caused by sleep deprivation in doctors are not taken sufficiently seriously, presumably because they are not widely understood. A M B GOLDING
Editor, Health and Hvgiene, London WIIN 4DE 1 Hart. The week. BMJ 1991;303:332. (10 Auguist.) 2 Tstirnbull NB, Miles NA, Gallen IW. Junior doctors' on call activities: differences in workload and work patterns among grades. AMJ 1990;301:1191-2. 3 NHS Management Executive. The newv deal. Hours of work of doctors in training. Working arrangements of doctors and dentists in training. London: NHS M\anagement Executive, 1991. 4 NHS Management Executive. The newz deal. Hours of work of doctors in training. Guidance from the Conference of Medical Roval Colleges and their faculties in the UK. London: NHS Management Executive, 1991. 5 Mitler MN, Carskadon NA, Czeisler CA, Dement WC, Dinges DF, Graber RC. Catastrophes, sleep and public policy consensus report. Sleep 1988;11: 100-8.
Joy riding SIR, -Over recent months joy riding has become a common activity in and around Oxford, where high performance stolen cars are raced on public roads at high speeds, often involving displays of stunt driving. Large crowds of onlookers are attracted to watch these displays, and this has led to recent public disturbances. Inevitably crashes occur, and serious injuries are not uncommon. In the past six months four joy riders have suffered serious injuries after separate incidents. They were all male, age range 14 to 24. Two were drivers of vehicles, one was a rear seat passenger, and the other a front seat passenger. Three had isolated close femoral shaft fractures. One had a lateral compression fracture of the pelvis sustained after rolling a three wheeled Reliant Robin (known among joy riders as a "plastic pig"). He was 14 years old and seems to have been emulating the activities of his joy riding elders. After resuscitation the three joy riders with femoral shaft fractures were treated with locked intramedullary nail fixation. The pelvic fracture required inpatient treatment for five weeks. As yet we have encountered injuries only in car occupants, but if these activities continue serious injury to bystanders seems inevitable. C L M H GIBBONS A J CARR P H WORLOCK
Accident Service, John Radcliffe Hospital, Oxford OX3 9DU
Completing the feedback loop SIR,-We agree with Ms Miranda Mugford and colleagues on the importance of completing the feedback loop for effective audit to have any chance. ' Their review of 36 studies is unlikely to be typical of everyday audit activities, reflecting the work of enthusiasts for audit and publication bias.2 We undertook a regional survey (response rate 75%) in July 1989,' just after the publication of details of the government's reforms,4 to ascertain the degree of audit activities. Some form of activity was reported by 85% of all general medical and surgical firms in 13 districts, yet just over half of these schemes reported keeping no record of discussions or conclusions, making it impossible
BMJ VOLUME 303
14 SEPTEMBER 1991
