CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ'. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment. * Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
What will happen to our freedom to refer? SIR, -It is one of the present freedoms of the NHS that a doctor can refer a patient to whichever hospital he or she feels is most appropriate for the patient. The importance of this freedom has been acknowledged by the government, and the Secretary of State for Health, Mr Kenneth Clarke, has repeatedly promised that it will be preserved. In an attempt to assess how much use is currently made of this freedom in one health authority Tunbridge Wells general practitioners undertook a survey of hospital correspondence. During the eight weeks 16 October to 6 December 1989 all letters sent or received from hospitals outside the district were recorded. Returns were received from 33 out of 39 practices approached, representing 101 general practitioners. Excluding all patients attending casualty departments and those seen in 11 district general hospitals outside the four
Hospital Farnborough
Guy's Orpington St Thomas's Royal East Sussex King's College Moorfields Maidstone General Brook St Bartholomew's Royal Marsden Hospital for Sick Children, Great Ormond Street Middlesex Charing Cross The London Westminster St John's Hospital for Diseases of the Skin Brompton Queen Mary's, Sidcup Bromley Queen Elizabeth Military Hospital National Hospital for Nervous Diseases University College St Mary's Oxted St Peter's Maudsley St George's Buchanan Lewisham Queen Charlotte's Royal National Orthopaedic Dorking Royal Free St Helen's Royal ENT
No of patients 277 236 145 80 78 65 54 51 49 40 33
33 28 25 25 25 24 24 22 22 20 20 15 14 14 13 12 12 12 11 10
10 10 10 10 10
Thames regions, a total of 1728 patients were seen at 109 different hospitals or institutions (see box). The survey gives an idea of the administrative burden facing the health authorities in setting up contracts but also shows the large number of referrals to hospitals that see only a few of a district's patients and for which a contract is unlikely to be negotiated. These referrals would have to be paid for out of the contingency reserve, which is not meant to be an open ended commitment to meet all non-contractual referrals. There is a clear contrast between the current clinical freedom widely exercised by doctors for their patients and the government's proposals with its contracts and budgets. S A HALL
Tunbridge Wells General Practitioner Committee, Tunbridge Wells TN I 2DX
No of Hospital patients Redhill 9 Dulwich 9 St Mark's 9 Bethlem Royal 8 Hammersmith 8 Eastbourne 7 7 Warlingham Park East Surrey 7 Chailey Heritage 7 Kent County Ophthalmic 6 Royal Masonic 6 Elizabeth Garrett Anderson 5 Hospital for Tropical Diseases 5 Addenbrooke's 4 Mayday 4 Beckenham 4 Greenwich 4 Samaritan 4 William Harvey 4 Preston Hall 3 City of London Migraine 3 West Hill, Dartford 3 Queen Mary's, Carshalton 3 National Heart 2 Frimley Park 2 Uckfield 2 St Anthony's 2 Royal Surrey 2 Westminster Children's 2 2 Sydenham Children's Dartford 2 Institute of Child Health 2 Radcliffe 2 1 Benenden Chelsea Hospital for 1 Women 1 Whipps Cross Bloomsbury 1 Rheumatology Umt
Hospital St Bartholomew's,
No of patients
Rochester
Homerton Tadworth Court London Chest Haywards Heath Manor House Newnham Putney Mount Vernon Memorial Hospital, Greenwich Laughton Lodge St Martin's Royal National Hospital for Rheumatic Diseases Haslemere and District Royal Naval, Gosport Thanet St Margaret's St Helier Atkinson Morley's Camberwell Gravesend Medway Chatham Northwick Park Kingston Bexhill Hurstwood Park Crawley Princess Christian's, Windsor Gordon Hospital St Mary Abbott's Bexley Chalfont Centre for Epilepsy Chase Farm Harold Wood Joyce Green
1 1 1 1 1 1 1 1 1 1 1 1 1
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-Dr T W Meade and colleagues state that their pragmatic study proves the effectiveness of chiropractic over traditional hospital treatments, but we believe their conclusions to be flawed.' The exclusion rate was high in each of the groups (86% of those seen in hospital and 88% of those seen by a chiropractor in the sample from two centres). This suggests that the data are based on only 14% and 12% of the total numbers presenting with back pain to hospital and chiropractors. This is not made clear. The number of patients excluded because they wanted chiropractic treatment is much larger than the number excluded because they wanted hospital treatment. This suggests that patients expect chiropractic to be more likely to cure their back pain and it must introduce an element of bias. Patients will have realised that the chiropractic treatment was being paid for and that the hospital treatment was "free" and it would not, therefore, be surprising if their expectations were higher for chiropractic. This study shows that a patient treated in a private institution with all that entails has a better prognosis than one treated in the overcrowded and overworked conditions of the NHS. The conclusion that private chiropractic treatment should be paid for by the NHS is not justified. G P GRAHAM C M DENT J A FAIRCLOUGH Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Cardiff CF2 I SZ 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
1 1 1 1 1 1 1 1 1 1 1
1 1 1
SIR,-Dr T W Meade and colleagues describe the use of straight leg raising for measuring improvement and outcome of chiropractic and hospital outpatient treatment for low back pain.' The interobserver repeatability of straight leg raising is poor, yielding differences of up to 10 degrees.2 At best with one examiner blind to the diagnosis, an observer, and a precision oil filled goniometer a mean repeatability of 1 6 degrees is the reported accuracy.' Diurnal variation may affect vertebral disc pressure and hence signs of nerve root tension detected by the straight leg raising. Similarly, duration of recumbency or upright posture may alter the result of straight leg raising by a mean of 16 degrees in patients who do not proceed to
surgery.'
BMJ
VOLUME
300
23
JUNE
1990
1647
What will happen to our freedom to refer? SIR, -It is one of the present freedoms of the NHS that a doctor can refer a patient to whichever hospital he or she feels is most appropriate for the patient. The importance of this freedom has been acknowledged by the government, and the Secretary of State for Health, Mr Kenneth Clarke, has repeatedly promised that it will be preserved. In an attempt to assess how much use is currently made of this freedom in one health authority Tunbridge Wells general practitioners undertook a survey of hospital correspondence. During the eight weeks 16 October to 6 December 1989 all letters sent or received from hospitals outside the district were recorded. Returns were received from 33 out of 39 practices approached, representing 101 general practitioners. Excluding all patients attending casualty departments and those seen in 11 district general hospitals outside the four
Hospital Farnborough
Guy's Orpington St Thomas's Royal East Sussex King's College Moorfields Maidstone General Brook St Bartholomew's Royal Marsden Hospital for Sick Children, Great Ormond Street Middlesex Charing Cross The London Westminster St John's Hospital for Diseases of the Skin Brompton Queen Mary's, Sidcup Bromley Queen Elizabeth Military Hospital National Hospital for Nervous Diseases University College St Mary's Oxted St Peter's Maudsley St George's Buchanan Lewisham Queen Charlotte's Royal National Orthopaedic Dorking Royal Free St Helen's Royal ENT
No of patients 277 236 145 80 78 65 54 51 49 40 33
33 28 25 25 25 24 24 22 22 20 20 15 14 14 13 12 12 12 11 10
10 10 10 10 10
Thames regions, a total of 1728 patients were seen at 109 different hospitals or institutions (see box). The survey gives an idea of the administrative burden facing the health authorities in setting up contracts but also shows the large number of referrals to hospitals that see only a few of a district's patients and for which a contract is unlikely to be negotiated. These referrals would have to be paid for out of the contingency reserve, which is not meant to be an open ended commitment to meet all non-contractual referrals. There is a clear contrast between the current clinical freedom widely exercised by doctors for their patients and the government's proposals with its contracts and budgets. S A HALL
Tunbridge Wells General Practitioner Committee, Tunbridge Wells TN I 2DX
No of Hospital patients Redhill 9 Dulwich 9 St Mark's 9 Bethlem Royal 8 Hammersmith 8 Eastbourne 7 7 Warlingham Park East Surrey 7 Chailey Heritage 7 Kent County Ophthalmic 6 Royal Masonic 6 Elizabeth Garrett Anderson 5 Hospital for Tropical Diseases 5 Addenbrooke's 4 Mayday 4 Beckenham 4 Greenwich 4 Samaritan 4 William Harvey 4 Preston Hall 3 City of London Migraine 3 West Hill, Dartford 3 Queen Mary's, Carshalton 3 National Heart 2 Frimley Park 2 Uckfield 2 St Anthony's 2 Royal Surrey 2 Westminster Children's 2 2 Sydenham Children's Dartford 2 Institute of Child Health 2 Radcliffe 2 1 Benenden Chelsea Hospital for 1 Women 1 Whipps Cross Bloomsbury 1 Rheumatology Umt
Hospital St Bartholomew's,
No of patients
Rochester
Homerton Tadworth Court London Chest Haywards Heath Manor House Newnham Putney Mount Vernon Memorial Hospital, Greenwich Laughton Lodge St Martin's Royal National Hospital for Rheumatic Diseases Haslemere and District Royal Naval, Gosport Thanet St Margaret's St Helier Atkinson Morley's Camberwell Gravesend Medway Chatham Northwick Park Kingston Bexhill Hurstwood Park Crawley Princess Christian's, Windsor Gordon Hospital St Mary Abbott's Bexley Chalfont Centre for Epilepsy Chase Farm Harold Wood Joyce Green
1 1 1 1 1 1 1 1 1 1 1 1 1
Low back pain: comparison of chiropractic and hospital outpatient treatment SIR,-Dr T W Meade and colleagues state that their pragmatic study proves the effectiveness of chiropractic over traditional hospital treatments, but we believe their conclusions to be flawed.' The exclusion rate was high in each of the groups (86% of those seen in hospital and 88% of those seen by a chiropractor in the sample from two centres). This suggests that the data are based on only 14% and 12% of the total numbers presenting with back pain to hospital and chiropractors. This is not made clear. The number of patients excluded because they wanted chiropractic treatment is much larger than the number excluded because they wanted hospital treatment. This suggests that patients expect chiropractic to be more likely to cure their back pain and it must introduce an element of bias. Patients will have realised that the chiropractic treatment was being paid for and that the hospital treatment was "free" and it would not, therefore, be surprising if their expectations were higher for chiropractic. This study shows that a patient treated in a private institution with all that entails has a better prognosis than one treated in the overcrowded and overworked conditions of the NHS. The conclusion that private chiropractic treatment should be paid for by the NHS is not justified. G P GRAHAM C M DENT J A FAIRCLOUGH Department of Traumatic and Orthopaedic Surgery, Cardiff Royal Infirmary, Cardiff CF2 I SZ 1 Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. Br Med J
1990;300:1431-7. (2 June.)
1 1 1 1 1 1 1 1 1 1 1
1 1 1
SIR,-Dr T W Meade and colleagues describe the use of straight leg raising for measuring improvement and outcome of chiropractic and hospital outpatient treatment for low back pain.' The interobserver repeatability of straight leg raising is poor, yielding differences of up to 10 degrees.2 At best with one examiner blind to the diagnosis, an observer, and a precision oil filled goniometer a mean repeatability of 1 6 degrees is the reported accuracy.' Diurnal variation may affect vertebral disc pressure and hence signs of nerve root tension detected by the straight leg raising. Similarly, duration of recumbency or upright posture may alter the result of straight leg raising by a mean of 16 degrees in patients who do not proceed to
surgery.'
BMJ
VOLUME
300
23
JUNE
1990
1647
