Letters Preventive care of elderly people Sir, I was disturbed to read Dr Fox's reply (letters, February Journal, p.80) to Dr Ttlloch's editorial.' He states that in his practice the general practitioners do not engage in screening, but rely upon information from home helps and other carers to tell them of problems. Such practice amply justifies the fears expressed in Dr Wilkinson's letter (February Journal, p.84) that skills acquired during our training may not be put to use once established, leading to the eclipse of medically qualified general practitioners, and their replacement by paramedics. I therefore support Dr Tulloch in advocating better training in preventive care of elderly people. The records for 1984 of my clinic for patients aged over 70 years at Woodside health centre in London showed a reduction in the consulting rate in one year in this age group from 6.6 consultations per patient per year to 3.8. Of 176 elderly patients screened at the clinic preventive care was possible for 8%: two patients were complying with treatment incorrectly. Three patients had developed speech defects as a result of multi-infarct dementia, and when tested for mental status revealed a need for increased care. Three patients had defective hearing aids requiring attention. One hypertensive patient was developing renal failure and was helped by angiotensin-converting enzyme inhibitors and referral to a dietician for a low protein diet. One patient with a low haemoglobin concentration was found to have macrocytosis, confirmed as pernicious anaemia. The patient was able to live a normal life once vitamin B12 deficiency had been corrected by cyanocobalamin injections. One patient who had suffered several falls was found to have numerous empty sherry bottles under the bed. He was socially isolated and depressed. Following introduction to a social club, and having been given antidepressant therapy for three months, no further falls were reported. A 77 year old man who insisted on doing everything for his wife, who had been discharged home with renal failure, was put on small doses of propranolol to reduce the effects of stress; this proved remarkably effective A 94 year old housebound woman was reported to have foot deformities following a visit by the health visitor; these were corrected by surgical boots that improved mobility considerably. A 68 year old woman was caring for her 74 year old sister who had rheumatoid arthritis and was failing to 216
cope. On examination she was found to have a refractory anaemia/myeloid dysplasia for which she was treated; extra assistance was also provided. The informative network of home helps and other carers referred to by Dr Fox is useful, but full reliance on it for preventive care is misplaced and a reminder of earlier times when the needs of the elderly were neglected. M KEITH THOMPSON 28 Steep Hill Stanhope Road Croydon CRO 5QS Reference 1. Tulloch AJ. Preventive care of elderly people: how good is our training? [editorial]. Br J Gen Pract 1991; 41: 354-355.
resource is often not utilized. Many patients are exempt from eye examination charges including children under the age of 16 years, or under 19 years if in full time education, patients on income support, patients registered blind or partially sighted, diabetic patients and patients with glaucoma as well as patients aged 40 years or over who are close relatives of a person with glaucoma. Ideally general practitioners should increase their knowledge of eye conditions and skills in management. However, there is undoubtedly a good case for increased use of existing resources rather than expecting large numbers of general practitioners to undertake training to become confident in managing the 34 eye conditions listed by Featherstone and colleagues. P ADLER
Eye care in general practice Sir, The survey by Featherstone and colleagues (January Journal, p.21) is interesting as it suggests ways of increasing the quantity and quality of eye care in general practice. It focuses on an area in which many general practitioners feel unsure of themselves. The resources available to general practitioners can be divided into 'internal resources' and 'external resources$. Internal resources include the training that they receive at medical school, during vocational training or by subsequent attachment to ophthalmology outpatient departments, while external resources have traditionally consisted of ophthalmological opinion either at a local district hospital or perhaps in a community setting. ' One readily available resource that was not mentioned by Featherstone and colleagues is the optometrist who has had three years of university training followed by a supervised preregistration year in clinical practice. Optometrists are skilled at ophthalmoscopy, which is now mandatory at every eye examination, and most have access to good equipment including tonometers, slit lamps and visual field measuring instruments. Optometrists are well placed to identify and assess eye changes among diabetic patients,2'3 and to provide regular assessments of patients with chronic eye conditions. Indeed, they initiate more positive referrals for glaucoma, for example, than any other professional
group.3'4 Perhaps because of the retail aspect of their practice, optometrists' clinical skills and training are often underestimated by their medical colleagues and therefore this
50 High Street Stotfold Hertfordshire SG5 4LL
M A VINCENT Stotfold Health Centre Hitchin Road Stotfold Hertfordshire
References 1. Dart JKG. Eye disease at a community health centre. BMJ 1986; 293: 1477-1480. 2. Burns-Cox CJ, Dean-Hart JC. Screening of diabetics for retinopathy by ophthalmic opticians. BMJ 1985; 290: 1052-1054. 3. MacKean JM, Elkington AR. Referral routes to hospital for patients with open angle glaucoma. BMJ 1982; 285: 1093-1095. 4. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. BMJ 1988; 297: 1162-1167.
Sudden infant death syndrome Sir, I was interested to read Dr Riley's letter (March Journal, p.130) commenting on the factors associated with sudden infant death syndrome and the discussion of its possible prevention, which referred to a previous letter by myself and Dr Brown.1 While agreeing that our statement 'the infant should be kept in the parents' room at night' was contentious, I cannot agree that there is no evidence to support it. The risk of sudden infant death syndrome among the Asian community seems to be considerably lower than for England and Wales as a whole.2'3 In the study by Kyle and colleagues the risk was approximately halved in those of Asian background, independently of other known risk factors.3 A recent investigation in Birmingham looked for socio-
British Journal of General Practice, May 1992
Letters cultural differences in child rearing to explain this and showed the importance of infant positioning.4 However, it also found that 98% of Asian infants slept in their parents' room in the first year of life compared with only 65% of white infants. The high proportion of infants from both groups, sleeping in their parents' room suggests that this does not 'contribute to parental anxiety' as suggested by Dr Riley and in the light of the above evidence, the reverse may be the case. CHRISTOPHER MOULTON Department of Accident and Emergency Medicine Glasgow Royal Infirmary 84 Castle Street Glasgow G4 OSF
References 1. Moulton M, Brown N. Sudden infant death syndrome [letter]. Br J Gen Pract 1991; 41: 431. 2. Balarajan R, Raleigh VS, Botting B. Sudden infant death syndrome and postneonatal mortality in immigrants in England and Wales. BMJ 1989; 296: 716-720. 3. Kyle D, Sunderland R, Stonehouse M, et al. Ethnic differences in incidence of sudden infant death syndrome in Birmingham. Arch Dis Child 1990; 65: 830-833. 4. Farooqi S, Perry IJ, Beevers DG. Ethnic differences in sleeping position and in risk of cot death. Lancet 1991; 388: 1455.
Asthma care Sir, The letter by Dr McCarthy (December Journal, p.522) was critical of the armed services' policy concerning candidates with asthma. As a regimental medical officer responsible for the day to day care of an infantry batallion I was alarmed to read that he felt that 'asthma need in no way be a handicap to any potential candidate' Much of a soldier's time is spent in military training areas which are often inaccessible places; this can make evacuation of the acute asthmatic patient difficult. In times of conflict the regular provision of medication may become a logistic impossibility. An acute episode in such a soldier can then expose both the soldier and his or her colleagues to even more danger than they already face. If adhered to, the guidelines for asthma therapy' improve the quality of our patients' lives but we must not overlook the part played in asthma by environmental factors.23 I would surely be failing an asthmatic patient and his or her coHeagues to prescribe him or her treatment and then expect the soldier to sit in a waterlogged trench on Salisbury Plain in the early hours of a January morning or to undertake arctic warfare training in Norway.
It is heartbreaking to have to tell enthusiastic teenagers that they cannot fulfil what is often a lifelong ambition to become a soldier. In my humble opinion however, this is preferable to placing a soldier who suffers from asthma in an environment where even with the best care he or she faces a greatly increased chance of becoming another statistic in the already tragically high number of asthma deaths.4'5 M C GADD Garrison Medical Centre Tutong Camp BFPO 605 Reference 1. British Thoracic Society. Guidelines for the management of asthma in adults: 1-chronic persistent asthma. BMJ 1990; 301: 651-653. 2. Dudridge S, Stead J. Asthma in perspective. In: RCGP 1989 members' reference book. London: Sterling Publications, 1989. 3. Rea HH, Sears MR, Beaglehole R, et al. Lessons from the national asthma mortality study: circumstances surrounding deaths. N Z Med J 1987; 100: 10-13. 4. British Thoracic Association. Death from asthma in two regions of England. BMJ 1982; 285: 1251-1255. 5. Burney PGJ. Asthma mortality in England and Wales: evidence of a further increase 1974-84. Lancet 1986; 2: 323-326.
The value of research Sir, No sooner had I read the editorial (February Journal, p.47) heralding a new document from the Royal College of General Practitioners outlining policies on the management of hyperlipidaemia,l than an editorial appeared in the British Medical Journal castindg doubts on the value of intervention in controlling hyperlipidaemia.2 'Such a coincidence is a suitable opportunity to reflect on the pitfalls inherent in setting policies on the basis of research findings. These pitfalls exist mainly for two reasons. The first is the difficulty, or even logical impossibility, of using the results of specific research into a specific problem to answer a different set of problems. The second reason lies in the nature of scientific enquiry which can only test a hypothesis and refute it and then set up another hypothesis to test and refute in its turn. Such series of hypotheses, tests
and
refutations enhance our understanding of observed phenomena but act like shifting sand when an attempt is made to base management policies on them. It is important to recognize the limitations of our methods before relying on them to build our future. It may be possible to use scientific -findings to
British Journal of General Pnctice, May 1992
interpret past events. The past, however, cannot logically be used as a recipe for the future; though common sense might suggest it is reasonable to do so. It is perfectly acceptable to base decisions on common sense but we should accept that this is the case and cease to hide behind a cloak of science. K R BISHAI Chigwell Medical Centre 300 Fencepiece Road Ilford Essex IG6 2TA
References 1. Royal College of General Practitioners. Guidelines for the management of hyperlipidaemia in general practice towards the primary prevention of coronary heart diseases. Occasional paper 55. London: RCGP, 1992. 2. Oliver FM. Doubts about preventing coronary heart disease. BMJ 1992; 304: 393-394.
Efficient care in general practice Sir, As the person who worked closely with Geoffrey Marsh on the bibliography for Eifficient care in general practice, I must respond to the comments about the adequacy of the references made by Dr Hull in his revie;w (book and video review, February Journal, p.86). To provide a comprehensive bibliography for all areas covered in Geoffrey Marsh's book would have merited a companion volume. As the book is based on the evolution of British general practice over the last 30 years the bibliography runs parallel to that period. As an experienced general practitioner, the reviewer would know the importance of the Dawson report' and the British Medical Association Charter,2 but younger doctors and team members may not. The largest proportion of references cited are to publications (often books) written after 1985. General practice literature grows daily but readers should find adequate starting points for further reading or research in the given citations. MARGARET HAMMOND Harland House Norton Stockton-on-Tees
Referecces 1. Consultative Council on Medical and Allied Services. Dawson of Penn (Chmn). Interim report on the future provision of medical and allied services. London: HMSO, 1920. 2. British Medical Association. Charter for the family doctor. London: BMA, 1965.
217
cope. On examination she was found to have a refractory anaemia/myeloid dysplasia for which she was treated; extra assistance was also provided. The informative network of home helps and other carers referred to by Dr Fox is useful, but full reliance on it for preventive care is misplaced and a reminder of earlier times when the needs of the elderly were neglected. M KEITH THOMPSON 28 Steep Hill Stanhope Road Croydon CRO 5QS Reference 1. Tulloch AJ. Preventive care of elderly people: how good is our training? [editorial]. Br J Gen Pract 1991; 41: 354-355.
resource is often not utilized. Many patients are exempt from eye examination charges including children under the age of 16 years, or under 19 years if in full time education, patients on income support, patients registered blind or partially sighted, diabetic patients and patients with glaucoma as well as patients aged 40 years or over who are close relatives of a person with glaucoma. Ideally general practitioners should increase their knowledge of eye conditions and skills in management. However, there is undoubtedly a good case for increased use of existing resources rather than expecting large numbers of general practitioners to undertake training to become confident in managing the 34 eye conditions listed by Featherstone and colleagues. P ADLER
Eye care in general practice Sir, The survey by Featherstone and colleagues (January Journal, p.21) is interesting as it suggests ways of increasing the quantity and quality of eye care in general practice. It focuses on an area in which many general practitioners feel unsure of themselves. The resources available to general practitioners can be divided into 'internal resources' and 'external resources$. Internal resources include the training that they receive at medical school, during vocational training or by subsequent attachment to ophthalmology outpatient departments, while external resources have traditionally consisted of ophthalmological opinion either at a local district hospital or perhaps in a community setting. ' One readily available resource that was not mentioned by Featherstone and colleagues is the optometrist who has had three years of university training followed by a supervised preregistration year in clinical practice. Optometrists are skilled at ophthalmoscopy, which is now mandatory at every eye examination, and most have access to good equipment including tonometers, slit lamps and visual field measuring instruments. Optometrists are well placed to identify and assess eye changes among diabetic patients,2'3 and to provide regular assessments of patients with chronic eye conditions. Indeed, they initiate more positive referrals for glaucoma, for example, than any other professional
group.3'4 Perhaps because of the retail aspect of their practice, optometrists' clinical skills and training are often underestimated by their medical colleagues and therefore this
50 High Street Stotfold Hertfordshire SG5 4LL
M A VINCENT Stotfold Health Centre Hitchin Road Stotfold Hertfordshire
References 1. Dart JKG. Eye disease at a community health centre. BMJ 1986; 293: 1477-1480. 2. Burns-Cox CJ, Dean-Hart JC. Screening of diabetics for retinopathy by ophthalmic opticians. BMJ 1985; 290: 1052-1054. 3. MacKean JM, Elkington AR. Referral routes to hospital for patients with open angle glaucoma. BMJ 1982; 285: 1093-1095. 4. Harrison RJ, Wild JM, Hobley AJ. Referral patterns to an ophthalmic outpatient clinic by general practitioners and ophthalmic opticians and the role of these professionals in screening for ocular disease. BMJ 1988; 297: 1162-1167.
Sudden infant death syndrome Sir, I was interested to read Dr Riley's letter (March Journal, p.130) commenting on the factors associated with sudden infant death syndrome and the discussion of its possible prevention, which referred to a previous letter by myself and Dr Brown.1 While agreeing that our statement 'the infant should be kept in the parents' room at night' was contentious, I cannot agree that there is no evidence to support it. The risk of sudden infant death syndrome among the Asian community seems to be considerably lower than for England and Wales as a whole.2'3 In the study by Kyle and colleagues the risk was approximately halved in those of Asian background, independently of other known risk factors.3 A recent investigation in Birmingham looked for socio-
British Journal of General Practice, May 1992
Letters cultural differences in child rearing to explain this and showed the importance of infant positioning.4 However, it also found that 98% of Asian infants slept in their parents' room in the first year of life compared with only 65% of white infants. The high proportion of infants from both groups, sleeping in their parents' room suggests that this does not 'contribute to parental anxiety' as suggested by Dr Riley and in the light of the above evidence, the reverse may be the case. CHRISTOPHER MOULTON Department of Accident and Emergency Medicine Glasgow Royal Infirmary 84 Castle Street Glasgow G4 OSF
References 1. Moulton M, Brown N. Sudden infant death syndrome [letter]. Br J Gen Pract 1991; 41: 431. 2. Balarajan R, Raleigh VS, Botting B. Sudden infant death syndrome and postneonatal mortality in immigrants in England and Wales. BMJ 1989; 296: 716-720. 3. Kyle D, Sunderland R, Stonehouse M, et al. Ethnic differences in incidence of sudden infant death syndrome in Birmingham. Arch Dis Child 1990; 65: 830-833. 4. Farooqi S, Perry IJ, Beevers DG. Ethnic differences in sleeping position and in risk of cot death. Lancet 1991; 388: 1455.
Asthma care Sir, The letter by Dr McCarthy (December Journal, p.522) was critical of the armed services' policy concerning candidates with asthma. As a regimental medical officer responsible for the day to day care of an infantry batallion I was alarmed to read that he felt that 'asthma need in no way be a handicap to any potential candidate' Much of a soldier's time is spent in military training areas which are often inaccessible places; this can make evacuation of the acute asthmatic patient difficult. In times of conflict the regular provision of medication may become a logistic impossibility. An acute episode in such a soldier can then expose both the soldier and his or her colleagues to even more danger than they already face. If adhered to, the guidelines for asthma therapy' improve the quality of our patients' lives but we must not overlook the part played in asthma by environmental factors.23 I would surely be failing an asthmatic patient and his or her coHeagues to prescribe him or her treatment and then expect the soldier to sit in a waterlogged trench on Salisbury Plain in the early hours of a January morning or to undertake arctic warfare training in Norway.
It is heartbreaking to have to tell enthusiastic teenagers that they cannot fulfil what is often a lifelong ambition to become a soldier. In my humble opinion however, this is preferable to placing a soldier who suffers from asthma in an environment where even with the best care he or she faces a greatly increased chance of becoming another statistic in the already tragically high number of asthma deaths.4'5 M C GADD Garrison Medical Centre Tutong Camp BFPO 605 Reference 1. British Thoracic Society. Guidelines for the management of asthma in adults: 1-chronic persistent asthma. BMJ 1990; 301: 651-653. 2. Dudridge S, Stead J. Asthma in perspective. In: RCGP 1989 members' reference book. London: Sterling Publications, 1989. 3. Rea HH, Sears MR, Beaglehole R, et al. Lessons from the national asthma mortality study: circumstances surrounding deaths. N Z Med J 1987; 100: 10-13. 4. British Thoracic Association. Death from asthma in two regions of England. BMJ 1982; 285: 1251-1255. 5. Burney PGJ. Asthma mortality in England and Wales: evidence of a further increase 1974-84. Lancet 1986; 2: 323-326.
The value of research Sir, No sooner had I read the editorial (February Journal, p.47) heralding a new document from the Royal College of General Practitioners outlining policies on the management of hyperlipidaemia,l than an editorial appeared in the British Medical Journal castindg doubts on the value of intervention in controlling hyperlipidaemia.2 'Such a coincidence is a suitable opportunity to reflect on the pitfalls inherent in setting policies on the basis of research findings. These pitfalls exist mainly for two reasons. The first is the difficulty, or even logical impossibility, of using the results of specific research into a specific problem to answer a different set of problems. The second reason lies in the nature of scientific enquiry which can only test a hypothesis and refute it and then set up another hypothesis to test and refute in its turn. Such series of hypotheses, tests
and
refutations enhance our understanding of observed phenomena but act like shifting sand when an attempt is made to base management policies on them. It is important to recognize the limitations of our methods before relying on them to build our future. It may be possible to use scientific -findings to
British Journal of General Pnctice, May 1992
interpret past events. The past, however, cannot logically be used as a recipe for the future; though common sense might suggest it is reasonable to do so. It is perfectly acceptable to base decisions on common sense but we should accept that this is the case and cease to hide behind a cloak of science. K R BISHAI Chigwell Medical Centre 300 Fencepiece Road Ilford Essex IG6 2TA
References 1. Royal College of General Practitioners. Guidelines for the management of hyperlipidaemia in general practice towards the primary prevention of coronary heart diseases. Occasional paper 55. London: RCGP, 1992. 2. Oliver FM. Doubts about preventing coronary heart disease. BMJ 1992; 304: 393-394.
Efficient care in general practice Sir, As the person who worked closely with Geoffrey Marsh on the bibliography for Eifficient care in general practice, I must respond to the comments about the adequacy of the references made by Dr Hull in his revie;w (book and video review, February Journal, p.86). To provide a comprehensive bibliography for all areas covered in Geoffrey Marsh's book would have merited a companion volume. As the book is based on the evolution of British general practice over the last 30 years the bibliography runs parallel to that period. As an experienced general practitioner, the reviewer would know the importance of the Dawson report' and the British Medical Association Charter,2 but younger doctors and team members may not. The largest proportion of references cited are to publications (often books) written after 1985. General practice literature grows daily but readers should find adequate starting points for further reading or research in the given citations. MARGARET HAMMOND Harland House Norton Stockton-on-Tees
Referecces 1. Consultative Council on Medical and Allied Services. Dawson of Penn (Chmn). Interim report on the future provision of medical and allied services. London: HMSO, 1920. 2. British Medical Association. Charter for the family doctor. London: BMA, 1965.
217
