against pertussis infection have been determined. Serum antibody assays merely indicate that a subject has or has not responded to antigens considered to be important and allows comparison between groups of subjects at various times after vaccination or in response to different schedules. We believe that this is a valid approach when the same whole cell vaccine is used for each group. MARY RAMSAY NORMAN BEGG Public Health Laboratory Service Commtunicable Disease Surveillance Centre, London NW9 SEQ M J CORBEL National Institute for Biological Standards and Control, South MNimms, Potters Bar, Hertfordshire EN6 3QG
professionals approach sick people. This is almost certainly because people with AIDS are young or middle aged, but people in the older age groups deserve this just as much. The Royal College of Nursing has recently published a manifesto for health which makes a powerful case for revisiting the question of informed consent to treatment, gives people greater access to information, and allows them to hold their own health records. There are good signs around for people (and patients), but achieving real progress will be difficult. If any readers question the need for action then I would suggest they cast their minds back to their immediate reactions the last time they heard that someone close to them was experiencing a dose of British health care. TREVOR CLAY lIondon NV73 5HTr
I Preston NW. Accclerated immunisation with diphtheria-tetanuspertussis vaccine. BM3r 1991;303:248. (27 July.) 2 World Health Organisation. European advisorv group on the K'HO expantled programme on immunisation (EPI). Report on a W'HO meeting. Copenhagen: WHO Regional Office for Europe, 1986. (WHO report EUR/ICP/EPI 012.) 3 Ramsav MEB, Corbel MJ, Redhead K, Ashworth LAE, Begg NT. Persistence of antibody after accelerated immunisation with diphtheria/tetanus/pertussis vaccine. BJ_ 1991;302: 1489-91. (22 June.) 4 Baraff LJ, Leake RD, Burstyn DG, Payne T, Cody CL, Manclark CR, et al. Immunologic response to early and routine DTP immunisation in infants. Pediatrscs 1984;73:37-42. 5 Sako W. Studies on pertussis immunisation. J Pediatr 1947;30: 29-40. 6 Centers for Disease Control. Recommendation of the Immunisation l'ractices Advisory Committee (ACIP). Diphtheria, tctanus and pertussis: gttidelines for vaccine prophylaxis and other preventive measures. MMW1R 1985;34:405-14,419-24. 7 Miller E, Ashworth LAE, Robinsott A, Waight PA, Irons LI. Double blind phase II trial in three month-old infants of whole cell pertussis vaccine and acellular vaccine containing agglutinogens. Lancet 1991;337:70-3.
What do they want? SIR, -Instead of asking "What do patients want?" David Armstrong would do better to start with the question "What do people want?"' Somewhat surprisingly, "people" is what the act setting up the NHS called them, and turning patients back into people is one of the few heartening possibilities that the current NHS reforms hold out. I've been finding out what people (as opposed to patients) want from my,association with Breathe Easy, the consumer arm of the British Lung Foundation launched this year. Thus far we have heard from over 7000 people who live with long term lung conditions-I prefer the term people who live with, rather than patients who suffer from, but I can't shout it from the hilltops yet because so many people really do suffer. In the letters the recurring themes and phrases are related to the fact that they are "chronic" and this has meant that they have been (or at least they feel) "abandoned" or rejected by doctors and nurses. Many have been given the news of their diagnosis by a consultant or senior registrar leading a very large ward round and have been told "There's nothing more that can be done" or "We've done all we can" or even "You're going to have to learn to live with it"-the pull yourself together brigade is still at large. The simple fact is that there is nearly always something more that can be done and health professionals have to learn what and how. The launch of this group has provided a rare opportunity to enable people who have regular and in depth contacts with the health care system to talk about their treatment and care without having to punctuate every other statement with the phrase "but the doctors/nurses were wonderful." The instances of our not being wonderful are alarmingly high. Individual consumerism in health is going to be difficult to achieve-the only real hope is for groups like Breathe Easy and the community health councils with the invaluable part they play. The AIDS pandemic has begun to bring about a revolution in attitudes regarding the way we health
BMJ VOLUME 303
14 SEPTEMBER 1991
I Armstrong D. What do patients want? BMJ 1991;303:261-2. (3 August.)
Measures of performance in Scottish maternity hospitals SIR,-In their study Mr A H Leyland and colleagues failed to acknowledge one factor in the varying performances of Scottish maternity hospitals.' While consultants retain personal clinical freedom the idiosyncrasies of individual people may have a considerable influence on measured variables, at least in small units. This may explain the observed variations in caesarean section rates. A single consultant in a three consultant unit, for example, who electively repeats all caesarean sections will increase that unit's rate above the expected figure, even if his or her two colleagues follow more standard practice. In these circumstances comparison between individual consultants might be more valid than between different hospitals. CHRISTOPHER E LENNOX William Smellie Memorial Hospital, Lanark MLI 1 9HN I Levland AH, Pritchard CW', McLoone P, Boddy FA. Measures of performance in Scottish maternity hospitals. BMJf 1991; 303:389-93. (17 August.)
Computers in audit: servants or sirens SIR,-Dr lain K Crombie and Mr Huw T O Davies argue that computers obscure medical audit.' Their case rests on the irrelevance to audit of many data on demography and routine activity. Irrelevant data may, however, also exist in manual systems. Disparaging information technology may mean ignoring the effect of scale on statistical inference and objectivity. An insistent problem of clinical quality control is type II statistical error. While audit of small samples shows large deviations from accepted standards of care, measuring small differences in practice across the United Kingdom requires large samples. When variation in case mix has to be allowed for the necessary size of samples grows larger still. Condensing and statistically analysing this large amount of data then become tasks of daunting scale. This has resulted in computers being used, often with great success." Hitherto the problem in the United Kingdom has been the nature of the commercial software. Much of the software already supplied is oriented towards administration, demanding large datasets, which are not easily changed to keep up with changing needs. When the processing of audit data is combined with, for example, producing discharge sum-
maries, systems may become too expensive and integrated to be modified easily. In business company auditors operate separately from management accountants, being divided by "Chinese walls." Medical audit also needs separate, confidential, and flexible information technology systems. The basis for this has to be the personal computer and one of the general purpose database packages available for it. This must be divorced from the need to produce discharge letters, theatre lists, or other housekeeping routines and should be set within a framework that ensures control and ownership by the profession. In the Odyssey Ulysses made secure arrangements to hear the Siren voices and sailed safely on. Medical auditors need not be browbeaten into using large datasets. They should understand the advantages of information technology and take control of the technology before it and its hegemony take control of them. A N HAMLYN
Dudley Health District Audit Committee, Wordsley Hospital, Stourbridge, West Midlands DY8 5QX I Crombie IK, Davies HTO. Computers in audit: servants or sirens? BMJ 1991;303:403-4. (17 August.) 2 Barnes C, Moynihan C. Accuracy ofgeneric screens in identifying quality problems. Topics in Health Record Management 1988;9:72-80. 3 Brennan TA, Hebert LE, Laird NM, Lawthers A, Thorpe KE, Leape LL, et al. Hospital characteristics associated with adverse events and substandard care.jAMA 1991;265:3265-9.
Interpratztice collaboration for functional assessment in the elderly SIR,-Ms Rosalind Eve and Dr Paul Hodgkin correctly state that non-fundholding practices can develop the services they provide through collaboration with each other.' In November 1989 we inaugurated a programme to provide each patient over the age of 75 registered with seven small inner city practices in Nottingham with the opportunity of a home assessment carried out by a nurse, whom we employed jointly. Our combined total of patients over the age of 75 was 1196, 5 4% of our total registered population of 22 000. This is lower than the local average of 6 5%. All but 53 of our over 75s lived at home and were therefore considered to be more at risk than those of practices where a large number of the elderly live in institutions. We considered and rejected the medical case finding approach as well as the model of visits by health visitors, with or without initial screening questionnaires, and the use of volunteers. Our reading of the literature confirmed the importance of a functional, rather than a medical, model of approach. In the first 1000 visits undertaken, 172 patients were already receiving community care aid, 77 were receiving meals on wheels, 49 attended a day centre, seven attended a chiropodist, and eight were hospitalised. A total of 723 of those visited required no additional referral. The table gives a breakdown of the referrals that were made. Of the first 1000 patients visited, 521 were assessed as having complete functional capacity, Referrals made as a result of assessment No (%) referred (n= 1000) Referral to social services Referral to general practitioner Referral to social security Referral re housing Referral to district nurse Referral to chiropodist Referral to voluntary organisation Need for carers support group Referral to practice nurse
98 (958) 64 (6-4) 29 (2-9) 22 (2-2) 17 (1 7) 16 (1-6) 14 (14) 11(1 1 ) 6 (0-6)
649
professionals approach sick people. This is almost certainly because people with AIDS are young or middle aged, but people in the older age groups deserve this just as much. The Royal College of Nursing has recently published a manifesto for health which makes a powerful case for revisiting the question of informed consent to treatment, gives people greater access to information, and allows them to hold their own health records. There are good signs around for people (and patients), but achieving real progress will be difficult. If any readers question the need for action then I would suggest they cast their minds back to their immediate reactions the last time they heard that someone close to them was experiencing a dose of British health care. TREVOR CLAY lIondon NV73 5HTr
I Preston NW. Accclerated immunisation with diphtheria-tetanuspertussis vaccine. BM3r 1991;303:248. (27 July.) 2 World Health Organisation. European advisorv group on the K'HO expantled programme on immunisation (EPI). Report on a W'HO meeting. Copenhagen: WHO Regional Office for Europe, 1986. (WHO report EUR/ICP/EPI 012.) 3 Ramsav MEB, Corbel MJ, Redhead K, Ashworth LAE, Begg NT. Persistence of antibody after accelerated immunisation with diphtheria/tetanus/pertussis vaccine. BJ_ 1991;302: 1489-91. (22 June.) 4 Baraff LJ, Leake RD, Burstyn DG, Payne T, Cody CL, Manclark CR, et al. Immunologic response to early and routine DTP immunisation in infants. Pediatrscs 1984;73:37-42. 5 Sako W. Studies on pertussis immunisation. J Pediatr 1947;30: 29-40. 6 Centers for Disease Control. Recommendation of the Immunisation l'ractices Advisory Committee (ACIP). Diphtheria, tctanus and pertussis: gttidelines for vaccine prophylaxis and other preventive measures. MMW1R 1985;34:405-14,419-24. 7 Miller E, Ashworth LAE, Robinsott A, Waight PA, Irons LI. Double blind phase II trial in three month-old infants of whole cell pertussis vaccine and acellular vaccine containing agglutinogens. Lancet 1991;337:70-3.
What do they want? SIR, -Instead of asking "What do patients want?" David Armstrong would do better to start with the question "What do people want?"' Somewhat surprisingly, "people" is what the act setting up the NHS called them, and turning patients back into people is one of the few heartening possibilities that the current NHS reforms hold out. I've been finding out what people (as opposed to patients) want from my,association with Breathe Easy, the consumer arm of the British Lung Foundation launched this year. Thus far we have heard from over 7000 people who live with long term lung conditions-I prefer the term people who live with, rather than patients who suffer from, but I can't shout it from the hilltops yet because so many people really do suffer. In the letters the recurring themes and phrases are related to the fact that they are "chronic" and this has meant that they have been (or at least they feel) "abandoned" or rejected by doctors and nurses. Many have been given the news of their diagnosis by a consultant or senior registrar leading a very large ward round and have been told "There's nothing more that can be done" or "We've done all we can" or even "You're going to have to learn to live with it"-the pull yourself together brigade is still at large. The simple fact is that there is nearly always something more that can be done and health professionals have to learn what and how. The launch of this group has provided a rare opportunity to enable people who have regular and in depth contacts with the health care system to talk about their treatment and care without having to punctuate every other statement with the phrase "but the doctors/nurses were wonderful." The instances of our not being wonderful are alarmingly high. Individual consumerism in health is going to be difficult to achieve-the only real hope is for groups like Breathe Easy and the community health councils with the invaluable part they play. The AIDS pandemic has begun to bring about a revolution in attitudes regarding the way we health
BMJ VOLUME 303
14 SEPTEMBER 1991
I Armstrong D. What do patients want? BMJ 1991;303:261-2. (3 August.)
Measures of performance in Scottish maternity hospitals SIR,-In their study Mr A H Leyland and colleagues failed to acknowledge one factor in the varying performances of Scottish maternity hospitals.' While consultants retain personal clinical freedom the idiosyncrasies of individual people may have a considerable influence on measured variables, at least in small units. This may explain the observed variations in caesarean section rates. A single consultant in a three consultant unit, for example, who electively repeats all caesarean sections will increase that unit's rate above the expected figure, even if his or her two colleagues follow more standard practice. In these circumstances comparison between individual consultants might be more valid than between different hospitals. CHRISTOPHER E LENNOX William Smellie Memorial Hospital, Lanark MLI 1 9HN I Levland AH, Pritchard CW', McLoone P, Boddy FA. Measures of performance in Scottish maternity hospitals. BMJf 1991; 303:389-93. (17 August.)
Computers in audit: servants or sirens SIR,-Dr lain K Crombie and Mr Huw T O Davies argue that computers obscure medical audit.' Their case rests on the irrelevance to audit of many data on demography and routine activity. Irrelevant data may, however, also exist in manual systems. Disparaging information technology may mean ignoring the effect of scale on statistical inference and objectivity. An insistent problem of clinical quality control is type II statistical error. While audit of small samples shows large deviations from accepted standards of care, measuring small differences in practice across the United Kingdom requires large samples. When variation in case mix has to be allowed for the necessary size of samples grows larger still. Condensing and statistically analysing this large amount of data then become tasks of daunting scale. This has resulted in computers being used, often with great success." Hitherto the problem in the United Kingdom has been the nature of the commercial software. Much of the software already supplied is oriented towards administration, demanding large datasets, which are not easily changed to keep up with changing needs. When the processing of audit data is combined with, for example, producing discharge sum-
maries, systems may become too expensive and integrated to be modified easily. In business company auditors operate separately from management accountants, being divided by "Chinese walls." Medical audit also needs separate, confidential, and flexible information technology systems. The basis for this has to be the personal computer and one of the general purpose database packages available for it. This must be divorced from the need to produce discharge letters, theatre lists, or other housekeeping routines and should be set within a framework that ensures control and ownership by the profession. In the Odyssey Ulysses made secure arrangements to hear the Siren voices and sailed safely on. Medical auditors need not be browbeaten into using large datasets. They should understand the advantages of information technology and take control of the technology before it and its hegemony take control of them. A N HAMLYN
Dudley Health District Audit Committee, Wordsley Hospital, Stourbridge, West Midlands DY8 5QX I Crombie IK, Davies HTO. Computers in audit: servants or sirens? BMJ 1991;303:403-4. (17 August.) 2 Barnes C, Moynihan C. Accuracy ofgeneric screens in identifying quality problems. Topics in Health Record Management 1988;9:72-80. 3 Brennan TA, Hebert LE, Laird NM, Lawthers A, Thorpe KE, Leape LL, et al. Hospital characteristics associated with adverse events and substandard care.jAMA 1991;265:3265-9.
Interpratztice collaboration for functional assessment in the elderly SIR,-Ms Rosalind Eve and Dr Paul Hodgkin correctly state that non-fundholding practices can develop the services they provide through collaboration with each other.' In November 1989 we inaugurated a programme to provide each patient over the age of 75 registered with seven small inner city practices in Nottingham with the opportunity of a home assessment carried out by a nurse, whom we employed jointly. Our combined total of patients over the age of 75 was 1196, 5 4% of our total registered population of 22 000. This is lower than the local average of 6 5%. All but 53 of our over 75s lived at home and were therefore considered to be more at risk than those of practices where a large number of the elderly live in institutions. We considered and rejected the medical case finding approach as well as the model of visits by health visitors, with or without initial screening questionnaires, and the use of volunteers. Our reading of the literature confirmed the importance of a functional, rather than a medical, model of approach. In the first 1000 visits undertaken, 172 patients were already receiving community care aid, 77 were receiving meals on wheels, 49 attended a day centre, seven attended a chiropodist, and eight were hospitalised. A total of 723 of those visited required no additional referral. The table gives a breakdown of the referrals that were made. Of the first 1000 patients visited, 521 were assessed as having complete functional capacity, Referrals made as a result of assessment No (%) referred (n= 1000) Referral to social services Referral to general practitioner Referral to social security Referral re housing Referral to district nurse Referral to chiropodist Referral to voluntary organisation Need for carers support group Referral to practice nurse
98 (958) 64 (6-4) 29 (2-9) 22 (2-2) 17 (1 7) 16 (1-6) 14 (14) 11(1 1 ) 6 (0-6)
649
