sought to raise theoretical and political questions about the nature of public health in the nineteenth century. It ends by saying: ... we cannot afford to romanticise the public health movement of the nineteenth century. It achieved certain notable successes, though these were frequently based more upon ideology than science. But, more importantly, its ideological impulses were often subservient to narrow class interests. One of the people to whom I think this particularly applies is Edwin Chadwick, whose heroic role in the mythology of public health in England Dr Ashton implicitly endorsed in an editorial.2 This suggests that when Dr Ashton describes my chapter as idiosyncratic he is simply misleading the reader. The issue is actually our differing historical and political perspectives and their respective implications. By pretending otherwise and hiding behind irrelevant catchwords he is failing to enter into a necessary debate. ERIC B ROSS Programme in Human Ecology, Department of Geographical and Environmental Sciences, Polytechnic of Huddersfield,
Huddersfield, West Yorkshire HD1 3DH 1 Ashton J. At the watershed. BMJ 1991;303:19%-7. (20 July.) 2 Ashton J. Sanitarian becomes ecologist: the new environmental health. BMJ 1991;302:189-90. (26 January.)
Role ofresearch in general practice SIR,-Professor D C Morrell rightly questions the value of screening of healthy adults in general practice.' After the new general practice contract was introduced our practice investigated the usefulness of screening the young male population. Our well man clinic for men aged 35-65, started in 1985, had achieved an attendance rate of 55% by postal invitation and had been a useful adjunct to opportunistic screening. This moderate success has not been repeated for a younger age group. From March 1990 to February 1991 we invited, by letter, 1243 men aged 16-35 for a health check at a clinic held on a weekday evening irrespective of whether they had been seen in the previous three years. Only 219 (17%) attended. Eight patients had an initial blood pressure recording of 150/95 mm Hg, none with a diastolic pressure of > 100 mm Hg. Of these eight men, one has moved from the area, one has not reattended despite a letter suggesting that he should do so, and none of the remaining six men had a diastolic pressure >95 mm Hg. One patient had a systolic pressure > 150 mm Hg. Two patients had appreciable proteinuria, which further investigation showed to be orthostatic, and two patients had trace haematuria not confirmed on examination of a midstream urine specimen. No diabetic patients were discovered. Our results call into question the wisdom of imposing a contractual obligation on general practitioners to screen non-attenders every three years from such a young age. Although it is entirely appropriate that the new contract should emphasise preventive medicine, the measures undertaken should be appropriate to the needs of the different age groups. A sensible compromise would be, firstly, to set a screening interval of 10 years, and, secondly, to start the process at the age of 30, when patients are more likely to attend, the rate of detection of abnormalities will be high enough to justify the efforts, and more notice will be taken of health education. This system would have the advantage of giving enough time to those doctors who prefer to screen their patients opportunistically, leaving relatively small numbers to be sent for at decennial birthdays. The contractual programme must have
BMJ VOLUME 303
7 SEPTEMBER 1991
a sound epidemiological and ethical basis to convince general practitioners and nurses that it is worth while. If it does not it will inevitably be conducted without enthusiasm and will be a spectacular flop. M H DRUCQUER
South Wigston, Leicestershire LE8 2SD I Morrell D. Role of research in development of organisation and structureofgeneral practice. BMJ 1991,302:1313-6. (I June.)
Is it permissible to edit medical records? SIR,-Drs Andrew Markus and Michael Lockwood's timely reminder of how doctors complying with patients' wishes could fall foul of either the General Medical Council or the Department of Health should not be allowed to detract from their final conclusion that the issue is a moral one of the ownership ofinformation. ' Does revealing personal information about oneself convey with it the right of access for everyone else with whom a person may come in contact? Turning to the corner of the first page of the BM7, the small print shows that the editor reserves the right to govern the dissemination of information contained in it. Thus there is nothing novel in the principle that a person or organisation may govern how information may be used. What is novel is the idea that patients, and neither doctors nor the Department of Health, are the arbiters of how this should be done. I have suggested elsewhere that physicians should willingly allow those patients who want it greater access to their records2; thus the authors' proposal to include patients in making this decision is laudable. One way to achieve this objective, using their two examples, would have been to forestall later conflict by using their professional expertise in identifying those areas that might later be the cause of concern and discussing at the outset how the information was to be handled and then showing them what had been done. Although I would not wish to condone either the public's or the profession's frequently adverse attitude to mental disease or HIV positivity, the fact is we all now know the potential harmful social effect of recording this type of sensitive information. It would require little foresight to take preventive action, thereby avoiding the conflicts of conscience and duty that practitioners might later encounter when deciding whether to revise a patient's records. BRIAN J KIRBY Postgraduate Medical School, University of Exeter, Exeter EX2 5DW 1 Markus A, Lockwood M. Is it permissible to edit medical records? BM7 1991;303:349-51. (1O August.) 2 Kirby BJ. Patient access to medical records. J R Coll Physictans Lond 1991;25:240-2.
The BMA in agony SIR,-Certain matters are better not aired in public. The opinion of members of the BMA, and particularly of members of its council, of the affairs of the association itself is one of them. The comments in the national press on the correspondence that began in these columns on 10 August confirm the sagacity of that statement.' It follows that damage has begun to be inflicted, and that damage must now be contained. At the council meeting in Inverness-which was not held in public-I stated in effect that I had confidence in Jeremy Lee-Potter as chairman of council in his handling of BMA affairs since he took over last year and that I had complete confidence in his suitability for the tasks ahead,
given the players on the political side of the current medicopolitical stage. I considered the semiclandestine goings on that were undermining his position to be reprehensible, and I still consider the same goings on to be reprehensible, only more so, because having given the appearance immediately after that council meeting of being united behind the chairman, the council now obviously is not. Those outside the council who criticise the handling of BMA affairs are quite entitled to do so-but they cannot be expected to appreciate, from what they will have read, the way in which the association is now being led. We have a chairman of council who has been elected according to the rules and given a vote of confidence; it is up to him, supported by the secretariat, to carry out our policy as he considers most appropriate. It is my opinion that his methods and philosophy are the most appropriate for the current scene, and I am deeply concerned that this view is apparently not being supported anything like strongly enough. If it was, then much of the criticism expressed in the letters by Dr J Findlater and Dr S W V Davies would not have needed stating. Let it be seen that a pragmatic, realistic, conciliatory-yes, conciliatory-tone is indeed the right way in which to do our current business with the government. Let us take heart from the fact that we have in Dr Lee-Potter a highly competent and appropriate chairman of council, readily able to fulfil this method of business and to defuse the criticism, which I still believe should never have been expressed publicly in the first place. FRANK WELLS Member of BMA Council,
Tuddenham, Ipswich, Suffolk IP6 9BW 1 Correspondence. The BMA in agony. BMJ 1991;303:368. (10 August.)
SIR,-On 10 August you published a clutch of letters for and against the NHS changes, and the BMA's consequent role.' Within a day of their appearing, the Daily Telegraph was quoting at length from those hostile to the BMA under the headline "Political GPs 'led BMA to defeat'."2 This gives a good illustration of the political game. In the face of a stream of unusually hostile editorials and articles against doctors in the Daily Telegraph I have written repeatedly, and I believe not badly, pointing out errors of fact or poor argument. None, or similar, have been published. But once a whiff ofdissension appears in our ranks, letters are quoted at second hand, with ill concealed relish. Colleagues, such as Drs J Findlater and S W V Davies, who criticise the BMA's political role' are either mistaken in their argument or happen to dislike the BMA's stance on this particular issue. The white paper has all to do with the provision of health care and specifies the nature of that care, sometimes in ludicrous detail. It is also changing fundamentally the contract between doctor and patient and between doctor and employer. Furthermore, the government has from the start made great play of involving clinicians in management, and Mr Waldegrave makes this a specific commendation for the spread of independent trust hospitals (despite the fact of doctors' increasing exclusion). How then can, or should, doctors or their organisations keep out of political expression? For many doctors this is their only political activity, but as they engage they are seen to be amateurs in a highly professional arena. The way in which the BMJ publishes letters on both sides illustrates this, and we would not wish it otherwise. But at least let us not ask for political abstention while giving ammunition to those who would muzzle us. I have never been an apologist for the association (described recently by the Daily Telegraph as a
585
Huddersfield, West Yorkshire HD1 3DH 1 Ashton J. At the watershed. BMJ 1991;303:19%-7. (20 July.) 2 Ashton J. Sanitarian becomes ecologist: the new environmental health. BMJ 1991;302:189-90. (26 January.)
Role ofresearch in general practice SIR,-Professor D C Morrell rightly questions the value of screening of healthy adults in general practice.' After the new general practice contract was introduced our practice investigated the usefulness of screening the young male population. Our well man clinic for men aged 35-65, started in 1985, had achieved an attendance rate of 55% by postal invitation and had been a useful adjunct to opportunistic screening. This moderate success has not been repeated for a younger age group. From March 1990 to February 1991 we invited, by letter, 1243 men aged 16-35 for a health check at a clinic held on a weekday evening irrespective of whether they had been seen in the previous three years. Only 219 (17%) attended. Eight patients had an initial blood pressure recording of 150/95 mm Hg, none with a diastolic pressure of > 100 mm Hg. Of these eight men, one has moved from the area, one has not reattended despite a letter suggesting that he should do so, and none of the remaining six men had a diastolic pressure >95 mm Hg. One patient had a systolic pressure > 150 mm Hg. Two patients had appreciable proteinuria, which further investigation showed to be orthostatic, and two patients had trace haematuria not confirmed on examination of a midstream urine specimen. No diabetic patients were discovered. Our results call into question the wisdom of imposing a contractual obligation on general practitioners to screen non-attenders every three years from such a young age. Although it is entirely appropriate that the new contract should emphasise preventive medicine, the measures undertaken should be appropriate to the needs of the different age groups. A sensible compromise would be, firstly, to set a screening interval of 10 years, and, secondly, to start the process at the age of 30, when patients are more likely to attend, the rate of detection of abnormalities will be high enough to justify the efforts, and more notice will be taken of health education. This system would have the advantage of giving enough time to those doctors who prefer to screen their patients opportunistically, leaving relatively small numbers to be sent for at decennial birthdays. The contractual programme must have
BMJ VOLUME 303
7 SEPTEMBER 1991
a sound epidemiological and ethical basis to convince general practitioners and nurses that it is worth while. If it does not it will inevitably be conducted without enthusiasm and will be a spectacular flop. M H DRUCQUER
South Wigston, Leicestershire LE8 2SD I Morrell D. Role of research in development of organisation and structureofgeneral practice. BMJ 1991,302:1313-6. (I June.)
Is it permissible to edit medical records? SIR,-Drs Andrew Markus and Michael Lockwood's timely reminder of how doctors complying with patients' wishes could fall foul of either the General Medical Council or the Department of Health should not be allowed to detract from their final conclusion that the issue is a moral one of the ownership ofinformation. ' Does revealing personal information about oneself convey with it the right of access for everyone else with whom a person may come in contact? Turning to the corner of the first page of the BM7, the small print shows that the editor reserves the right to govern the dissemination of information contained in it. Thus there is nothing novel in the principle that a person or organisation may govern how information may be used. What is novel is the idea that patients, and neither doctors nor the Department of Health, are the arbiters of how this should be done. I have suggested elsewhere that physicians should willingly allow those patients who want it greater access to their records2; thus the authors' proposal to include patients in making this decision is laudable. One way to achieve this objective, using their two examples, would have been to forestall later conflict by using their professional expertise in identifying those areas that might later be the cause of concern and discussing at the outset how the information was to be handled and then showing them what had been done. Although I would not wish to condone either the public's or the profession's frequently adverse attitude to mental disease or HIV positivity, the fact is we all now know the potential harmful social effect of recording this type of sensitive information. It would require little foresight to take preventive action, thereby avoiding the conflicts of conscience and duty that practitioners might later encounter when deciding whether to revise a patient's records. BRIAN J KIRBY Postgraduate Medical School, University of Exeter, Exeter EX2 5DW 1 Markus A, Lockwood M. Is it permissible to edit medical records? BM7 1991;303:349-51. (1O August.) 2 Kirby BJ. Patient access to medical records. J R Coll Physictans Lond 1991;25:240-2.
The BMA in agony SIR,-Certain matters are better not aired in public. The opinion of members of the BMA, and particularly of members of its council, of the affairs of the association itself is one of them. The comments in the national press on the correspondence that began in these columns on 10 August confirm the sagacity of that statement.' It follows that damage has begun to be inflicted, and that damage must now be contained. At the council meeting in Inverness-which was not held in public-I stated in effect that I had confidence in Jeremy Lee-Potter as chairman of council in his handling of BMA affairs since he took over last year and that I had complete confidence in his suitability for the tasks ahead,
given the players on the political side of the current medicopolitical stage. I considered the semiclandestine goings on that were undermining his position to be reprehensible, and I still consider the same goings on to be reprehensible, only more so, because having given the appearance immediately after that council meeting of being united behind the chairman, the council now obviously is not. Those outside the council who criticise the handling of BMA affairs are quite entitled to do so-but they cannot be expected to appreciate, from what they will have read, the way in which the association is now being led. We have a chairman of council who has been elected according to the rules and given a vote of confidence; it is up to him, supported by the secretariat, to carry out our policy as he considers most appropriate. It is my opinion that his methods and philosophy are the most appropriate for the current scene, and I am deeply concerned that this view is apparently not being supported anything like strongly enough. If it was, then much of the criticism expressed in the letters by Dr J Findlater and Dr S W V Davies would not have needed stating. Let it be seen that a pragmatic, realistic, conciliatory-yes, conciliatory-tone is indeed the right way in which to do our current business with the government. Let us take heart from the fact that we have in Dr Lee-Potter a highly competent and appropriate chairman of council, readily able to fulfil this method of business and to defuse the criticism, which I still believe should never have been expressed publicly in the first place. FRANK WELLS Member of BMA Council,
Tuddenham, Ipswich, Suffolk IP6 9BW 1 Correspondence. The BMA in agony. BMJ 1991;303:368. (10 August.)
SIR,-On 10 August you published a clutch of letters for and against the NHS changes, and the BMA's consequent role.' Within a day of their appearing, the Daily Telegraph was quoting at length from those hostile to the BMA under the headline "Political GPs 'led BMA to defeat'."2 This gives a good illustration of the political game. In the face of a stream of unusually hostile editorials and articles against doctors in the Daily Telegraph I have written repeatedly, and I believe not badly, pointing out errors of fact or poor argument. None, or similar, have been published. But once a whiff ofdissension appears in our ranks, letters are quoted at second hand, with ill concealed relish. Colleagues, such as Drs J Findlater and S W V Davies, who criticise the BMA's political role' are either mistaken in their argument or happen to dislike the BMA's stance on this particular issue. The white paper has all to do with the provision of health care and specifies the nature of that care, sometimes in ludicrous detail. It is also changing fundamentally the contract between doctor and patient and between doctor and employer. Furthermore, the government has from the start made great play of involving clinicians in management, and Mr Waldegrave makes this a specific commendation for the spread of independent trust hospitals (despite the fact of doctors' increasing exclusion). How then can, or should, doctors or their organisations keep out of political expression? For many doctors this is their only political activity, but as they engage they are seen to be amateurs in a highly professional arena. The way in which the BMJ publishes letters on both sides illustrates this, and we would not wish it otherwise. But at least let us not ask for political abstention while giving ammunition to those who would muzzle us. I have never been an apologist for the association (described recently by the Daily Telegraph as a
585
