shall clinically or physically direct a medical exposure except in accordance with accepted diagnostic or therapeutic practice." However, this is not the case at present. Despite this clinicians must take care to follow accepted guidelines and regulations for radiological investigations. Failure to do so may lead to prosecution under the 1985 and 1988 regulations with penalties of up to £2000 or two years in prison for each regulation broken. In the same issue of the BMJ a leading article made the safe prediction that litigation will almost certainly occur for negligent use of radiation.2 Doctors should take note that prosecution under the 1985 and 1988 regulations has already occurred and further prosecutions of doctors and health authorities are taking place. It is therefore of paramount importance that clinicians use radiological investigations with careful consideration of their risks and benefits. Active dose reduction strategies and clinical guidelines such as those being introduced in North Manchester will serve to protect both patients and doctors, and clinicians should encourage their introduction in their own departments. R A L BISSET
North Manchester General Hospital, Manchester M8 6RB 1 Royal College of Radiologists Working Party. A multicentre audit of hospital referral for radiological examination in
England and Wales. BMJ 1991;303:809-12. (5 October.) 2 Chisholm R. Guidelines for radiological investigations. BMJ
1991;303:797-8. (5 October.)
Adolescent smokers seen in general practice SIR,-I wholeheartedly agree with Joy Townsend and colleagues about the need for increased reinforcement of young people's intentions not to become smokers.' As recent figures from the Office of Population Censuses and Surveys show, under 1 in 100 children aged 11 smoke regularly compared with 1 in 4 children aged 15.2 The first years at secondary school certainly seem to be crucial. And although only 8% of young people think that they will be smokers when they leave school, they have yet to discover the folly of underestimating addiction to nicotine. Preventing uptake of smoking in this group is therefore essential. General practice was suggested as an appropriate setting for young people to receive health education, although reaching this age group and then offering continued support are time consuming. General practitioners considering an increased educational role may be interested in liaising with the charity SmokeBusters UK. SmokeBusters is an innovative media based campaign specifically aimed at 9-14 year olds to help them reject the smoking habit. Working through a network of local clubs, SmokeBusters is fun and fashionable and led by its membership. Members are encouraged to participate in running their club and work towards their own smoke free environment. Regular newsletters and activities raise awareness of all issues related to tobacco. The effects of tobacco on the environment and the social and financial implications of smoking are often of more interest to the age group. In no way are the clubs seen as prohibitive or authoritarian. Celebrity endorsements, fun activity days, and various events reinforce the positive message of remaining smoke free and leading a healthy lifestyle. Most of the clubs are organised through health promotion units, local charities, or local groups of Action on Smoking and Health. SmokeBusters has proved to be a popular method for young people to gain information about health.There are now 22 clubs with a collective membership of 100 000, and interest continues to grow. With regard to the long term effectiveness in reducing the uptake of smoking, results of
BMJ
VOLUME
303
14 DECEMBER 1991
evaluation in Manchester and Glasgow are due later this year. CATHEY DUKES
SmokeBusters UK, Birmingham B2 4LS 1 Townsend J, Wilkes H, Haines H, Jarvis M. Adolescent smokers seen in general practice: health, lifestyle, physical measurements and response to antismoking advice. BM7 1991;303: 947-50. (19 October.) 2 Lader D, Matheson J. Smoking among secondarv school children in 1990. London: HMSO, 1991.
Rationing: at the cutting edge SIR,-The discussion about vertical and horizontal resource allocation' raises a series of ethical points, the first being one of truth telling. This is a vital one for those who climb down from the epidemiologists' graphs and become actual patients across the outpatients desk. The change from a statistic to a person rests on looking that person in the eye and coming, in time as a physician, to so care for that person that you are truthful about their condition and lay before them the possibilities of treatment, leaving it to them to choose one way forward or another. The cutting edge is at this point the ethical choice of fudging the issue or not with those "weasel words" so familiar to the nephrologist: "Your condition is such that dialysis or transplantation is inappropriate," or, "You have come to the end of what we can do for you; you have had a good run [ration] of life," or, "It will be too great a strain on your heart [our resources]." In this way patients with end stage renal failure have been deselected for treatment over the years. Each statement may well have an element of truth in it, but is this a sharp cutting edge? Very often the nephrologist has had the difficult task done for him by others in the referral chain, and in this way the demand has been curtailed,2 much to the interest of the American observers of the British scene. The second ethical point is the nature of the contract of the physicians or nurses involved with such decisions in coming into a relationship of trust with the patient, in that they have to take that particular patient's side over that of others in equal need whom they have not yet met. The contract nature of such a relationship has an element of doing the very best for the patient and, if this is not possible, of saying so.5 The cutting edge at this point is not to allow such a contract to be entered into, by restricting open access to all in need, which has been more successful than- any other selection process. When we did a triage exercise for a simulated group of 20 patients some years ago, across the country, asking nephrologists to reject or accept each patient, no one patient was rejected by every one, suggesting that the criteria for rationing were not uniform by any means.6 The final point concerns equity in limiting resource allocation. If rationing has to take place it seems more just to ration treatment than diagnostic facilities as mistakes in diagnosing all renal failure as end stage disease are common enough and not all strokes are due to irreversible causes. In law it seems more acceptable to have got the diagnosis right and then told the patient there are no funds for treatment than to have told the patient that he or she cannot even be admitted for a few weeks to find out what is happening. Arguments have been mounted to say that this is the minimum that a taxpayer should be entitled to expect from a health service free at the point of need. Herein lies a major difficulty in allocation by area or head of population; there is strong evidence that the incidence of renal disease is not uniform across the country. The black population have a high occurrence of diabetes and hypertension, both leading to a high prevalence of renal failure.7 If global targets
are set by a region without taking such factors into account then inappropriate rationing will take place, challenging the concept of equity which the health economist is keen to support. VICTOR PARSONS
Regional Renal Unit, Dulwich Hospital, London SE22 8PT 1 Cochrane M, Ham C, Hegginbotham C, Smith R. Rationing and the cutting edge. BMJ 1991;303:11039-42. (26 October.) 2 Challah S, Wing AJ, Bauer R, Morris RW, Schroeder SA. 'Negative selection of patients for dialysis and transplantation in the United Kingdom. BMJ7 1984;288:119-22. 3 Halper T. The misfortunes of others: end stage renal disease in the UK. Cambridge: Cambridge University Press, 1989. 4 Kilner JF. Who lives, who dies: ethical criteria in patient selection. Cambridge, Massachusetts: Yale University Press, 1990. 5 Smith DH. Medical loyalty: dimensions and problems of a rich idea. Theology and Bioethics. 1985;20:267-82. 6 Parsons V, Lock PM. Triage and the patient with renal failure. JMed Ethics 1980;6:173-6. 7 Smith SR, Svetkey LP, Dennis VW. Racial differences in renal disease. Kidney International 1991;40:815-22.
Bell ringers' bruises and broken bones SIR,-A year ago the paper of A C Lamont and N J M London' attracted public comment and some correspondence in your columns.2 Your readers may therefore be interested to know the summarised results of a 12 month prospective survey recently concluded (31 August 1991) of ringers' injuries in Hertfordshire towers. Fifty three bands were approached and 48 agreed to take part, the total number of ringers being 653-some 85% of the total membership of the county association. Of these 653, 56 were learners (with less than six months' experience); 82 were "newly qualified" (with six to 24 months' experience); and 515 had longer experience. All the bands were active, ringing for weekly services and practices and as necessary for weddings and other special occasions. Each tower secretary was supplied with forms of notification (and guidance) to report any important injury, its nature, the circumstances, and the severity of incapacity. All were requested, regardless of any mishap, for data on numbers of members, hours of ringing, etc. In the 12 months of the survey four accidents causing injury were reported, all of them affecting adults (three men and one woman). One had no connection with actual ringing: a steeplekeeper who suffered a broken thumb while doing maintenance. Of the other three, two affected experienced ringers who were supervising or assisting learners at practice (a "torn calf muscle" and a sprained wrist). The fourth victim was a probationer who suffered a bruised finger after overpulling his rope and breaking the bell stay. During an aggregate of more than 2000 hours of regular service ringing during the year, no accidental injury was reported. The total number of reports in this survey, as in the earlier retrospective one, is so small that no comparative statistical value attaches to either. The Hertfordshire survey does, however, support the accepted view of most ringers: that mishaps generally occur during the learning stage-either to pupil or to teacher-and also that while the mishaps of this esoteric, historic, British pursuit arouse public interest-most notably stimulated by the late Dorothy L Sayers'-serious injuries are not very common. DAVID GULLICK
Welwyn, Hertfordshire AL6 OQG I Lamont AC, London NJM. Bell ringers' bruises and broken bones. BMJ 1990;301:1415-8. 2 Correspondence. Bell ringers' bruises and broken bones. BMJ 1991;302:291-2. 3 Sayers DL. The nine tailors. London: Gollancz, 1934.
1553
North Manchester General Hospital, Manchester M8 6RB 1 Royal College of Radiologists Working Party. A multicentre audit of hospital referral for radiological examination in
England and Wales. BMJ 1991;303:809-12. (5 October.) 2 Chisholm R. Guidelines for radiological investigations. BMJ
1991;303:797-8. (5 October.)
Adolescent smokers seen in general practice SIR,-I wholeheartedly agree with Joy Townsend and colleagues about the need for increased reinforcement of young people's intentions not to become smokers.' As recent figures from the Office of Population Censuses and Surveys show, under 1 in 100 children aged 11 smoke regularly compared with 1 in 4 children aged 15.2 The first years at secondary school certainly seem to be crucial. And although only 8% of young people think that they will be smokers when they leave school, they have yet to discover the folly of underestimating addiction to nicotine. Preventing uptake of smoking in this group is therefore essential. General practice was suggested as an appropriate setting for young people to receive health education, although reaching this age group and then offering continued support are time consuming. General practitioners considering an increased educational role may be interested in liaising with the charity SmokeBusters UK. SmokeBusters is an innovative media based campaign specifically aimed at 9-14 year olds to help them reject the smoking habit. Working through a network of local clubs, SmokeBusters is fun and fashionable and led by its membership. Members are encouraged to participate in running their club and work towards their own smoke free environment. Regular newsletters and activities raise awareness of all issues related to tobacco. The effects of tobacco on the environment and the social and financial implications of smoking are often of more interest to the age group. In no way are the clubs seen as prohibitive or authoritarian. Celebrity endorsements, fun activity days, and various events reinforce the positive message of remaining smoke free and leading a healthy lifestyle. Most of the clubs are organised through health promotion units, local charities, or local groups of Action on Smoking and Health. SmokeBusters has proved to be a popular method for young people to gain information about health.There are now 22 clubs with a collective membership of 100 000, and interest continues to grow. With regard to the long term effectiveness in reducing the uptake of smoking, results of
BMJ
VOLUME
303
14 DECEMBER 1991
evaluation in Manchester and Glasgow are due later this year. CATHEY DUKES
SmokeBusters UK, Birmingham B2 4LS 1 Townsend J, Wilkes H, Haines H, Jarvis M. Adolescent smokers seen in general practice: health, lifestyle, physical measurements and response to antismoking advice. BM7 1991;303: 947-50. (19 October.) 2 Lader D, Matheson J. Smoking among secondarv school children in 1990. London: HMSO, 1991.
Rationing: at the cutting edge SIR,-The discussion about vertical and horizontal resource allocation' raises a series of ethical points, the first being one of truth telling. This is a vital one for those who climb down from the epidemiologists' graphs and become actual patients across the outpatients desk. The change from a statistic to a person rests on looking that person in the eye and coming, in time as a physician, to so care for that person that you are truthful about their condition and lay before them the possibilities of treatment, leaving it to them to choose one way forward or another. The cutting edge is at this point the ethical choice of fudging the issue or not with those "weasel words" so familiar to the nephrologist: "Your condition is such that dialysis or transplantation is inappropriate," or, "You have come to the end of what we can do for you; you have had a good run [ration] of life," or, "It will be too great a strain on your heart [our resources]." In this way patients with end stage renal failure have been deselected for treatment over the years. Each statement may well have an element of truth in it, but is this a sharp cutting edge? Very often the nephrologist has had the difficult task done for him by others in the referral chain, and in this way the demand has been curtailed,2 much to the interest of the American observers of the British scene. The second ethical point is the nature of the contract of the physicians or nurses involved with such decisions in coming into a relationship of trust with the patient, in that they have to take that particular patient's side over that of others in equal need whom they have not yet met. The contract nature of such a relationship has an element of doing the very best for the patient and, if this is not possible, of saying so.5 The cutting edge at this point is not to allow such a contract to be entered into, by restricting open access to all in need, which has been more successful than- any other selection process. When we did a triage exercise for a simulated group of 20 patients some years ago, across the country, asking nephrologists to reject or accept each patient, no one patient was rejected by every one, suggesting that the criteria for rationing were not uniform by any means.6 The final point concerns equity in limiting resource allocation. If rationing has to take place it seems more just to ration treatment than diagnostic facilities as mistakes in diagnosing all renal failure as end stage disease are common enough and not all strokes are due to irreversible causes. In law it seems more acceptable to have got the diagnosis right and then told the patient there are no funds for treatment than to have told the patient that he or she cannot even be admitted for a few weeks to find out what is happening. Arguments have been mounted to say that this is the minimum that a taxpayer should be entitled to expect from a health service free at the point of need. Herein lies a major difficulty in allocation by area or head of population; there is strong evidence that the incidence of renal disease is not uniform across the country. The black population have a high occurrence of diabetes and hypertension, both leading to a high prevalence of renal failure.7 If global targets
are set by a region without taking such factors into account then inappropriate rationing will take place, challenging the concept of equity which the health economist is keen to support. VICTOR PARSONS
Regional Renal Unit, Dulwich Hospital, London SE22 8PT 1 Cochrane M, Ham C, Hegginbotham C, Smith R. Rationing and the cutting edge. BMJ 1991;303:11039-42. (26 October.) 2 Challah S, Wing AJ, Bauer R, Morris RW, Schroeder SA. 'Negative selection of patients for dialysis and transplantation in the United Kingdom. BMJ7 1984;288:119-22. 3 Halper T. The misfortunes of others: end stage renal disease in the UK. Cambridge: Cambridge University Press, 1989. 4 Kilner JF. Who lives, who dies: ethical criteria in patient selection. Cambridge, Massachusetts: Yale University Press, 1990. 5 Smith DH. Medical loyalty: dimensions and problems of a rich idea. Theology and Bioethics. 1985;20:267-82. 6 Parsons V, Lock PM. Triage and the patient with renal failure. JMed Ethics 1980;6:173-6. 7 Smith SR, Svetkey LP, Dennis VW. Racial differences in renal disease. Kidney International 1991;40:815-22.
Bell ringers' bruises and broken bones SIR,-A year ago the paper of A C Lamont and N J M London' attracted public comment and some correspondence in your columns.2 Your readers may therefore be interested to know the summarised results of a 12 month prospective survey recently concluded (31 August 1991) of ringers' injuries in Hertfordshire towers. Fifty three bands were approached and 48 agreed to take part, the total number of ringers being 653-some 85% of the total membership of the county association. Of these 653, 56 were learners (with less than six months' experience); 82 were "newly qualified" (with six to 24 months' experience); and 515 had longer experience. All the bands were active, ringing for weekly services and practices and as necessary for weddings and other special occasions. Each tower secretary was supplied with forms of notification (and guidance) to report any important injury, its nature, the circumstances, and the severity of incapacity. All were requested, regardless of any mishap, for data on numbers of members, hours of ringing, etc. In the 12 months of the survey four accidents causing injury were reported, all of them affecting adults (three men and one woman). One had no connection with actual ringing: a steeplekeeper who suffered a broken thumb while doing maintenance. Of the other three, two affected experienced ringers who were supervising or assisting learners at practice (a "torn calf muscle" and a sprained wrist). The fourth victim was a probationer who suffered a bruised finger after overpulling his rope and breaking the bell stay. During an aggregate of more than 2000 hours of regular service ringing during the year, no accidental injury was reported. The total number of reports in this survey, as in the earlier retrospective one, is so small that no comparative statistical value attaches to either. The Hertfordshire survey does, however, support the accepted view of most ringers: that mishaps generally occur during the learning stage-either to pupil or to teacher-and also that while the mishaps of this esoteric, historic, British pursuit arouse public interest-most notably stimulated by the late Dorothy L Sayers'-serious injuries are not very common. DAVID GULLICK
Welwyn, Hertfordshire AL6 OQG I Lamont AC, London NJM. Bell ringers' bruises and broken bones. BMJ 1990;301:1415-8. 2 Correspondence. Bell ringers' bruises and broken bones. BMJ 1991;302:291-2. 3 Sayers DL. The nine tailors. London: Gollancz, 1934.
1553
