assessment isdisappearing in the quicksand of the internal market."3 This is hardly the background against which to develop a continuous local debate,.
into investigations that are costly and unlikely to influence a patient's management. E M TAYLER
Registrar in public health medicine Department of Public Health and Health Policy, Oxfordshire Health, Oxford OX3 9DZ 1 Peel N, Eastell R. ABC of rheumatology: osteoporosis. BMY 1995;310:989-92. (15 April.) 2 Grady D, Rubin S, Petitti DB, Fox CS, Black D, Ettinger B, et al. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med 1992;117: 1016-37.
The future of fundholding ED1TOR,-An important issue that Chris Ham and Jonathan Shapiro omit from their list of concems about the government's policy for developing fundholding is the importance of fundholders in the development of strategy, either national or local.' If the govemment wishes to see a primary care led NHS then clearly the involvement of general practitioners, both fundholders and nonfundholders, in the development of strategy is crucial. This is highlighted by the publication of a report on cancer by an expert advisory group.2 Similarly, at a local level general practitioners need to help to map out the future of services in their area. Our experience in involving general practitioners in developing strategy has shown two difficulties. Firstly, strategic thinking is foreign to many general practitioners. This is understandble as the essence of general practitioners' role is dealing with the "here and now" rather than thinking five to 10 years ahead. General practitioners' sldlls in thinking strategically need to be developed. The second impediment is an understandable request for general practitioners who work with health authorities to be paid. With the increasing demands made of general practitioners both within their practices and by external agencies, this is hardly surprising. Whereas fundholders can use part of their management allowance for this purpose, engaging non-fundholders and remunerating them for it is more difficult. A clear mechanism needs to be developed to allow non-fundholders to be involved in a range of policies with their health authority. This needs to be done so that there is a clear framework for making necessary payments and to legitimise health authorities' dialogue with non-fundholders in a way that is not seen to cut across the government policy of encouraging all general practitioners to become fundholders. J RWILKNSON Honorary lecturer
Division ofPublic Health, Nuffield Institute for Health, Leeds LS2 9PL 1 Ham C, Shapiro J. The future of fimdholding. BMJ 1995;310: 1150-1. (6May.) 2 Department of Health. A policy framework for commissioning cancersertces. London: DoH, 1995.
Ratioig Local debate is needed EDrroR,-Richard Smith is right to call for the reopening of the debate on rationing,' but he misses the point in asserting that "Britain has not had the . .. prolonged debate on rationing that is needed" because the key level at which this debate is needed is the local one. In the past, decisions on rationing in the NHS have been influenced by institutional factors,2 but now commissioners must ration. It is an uphill struggle for two reasons. Firstly, "the NHS is drowning in organisational tasks while the real work of planning and needs assessment is disappearing in the quicksand of the 264
internal market."3 This is hardly the background against which to develop a continuous local debate, which should promote open and informed argument and draw on a variety of perspectives. Secondly, provision of health care is complex, and relying on economic rationality to solve problems opens us to the risk of failure to value qualities such as good will. Closer working with primary care could provide the right stimulus for improving rationing processes. Some general practitioners have commented that what they want is a "third party rationer" to make decisions-for example, "If I've got to say 'No' then I want to say: 'These are the guidelines ... such and such a committee made up of X, Y, Z ... have decided.' I don't think it should be me specifically who says 'You can't' or 'You can.' It's like playing God."4 Health commissions must take on this third party role, but how? Smith points to Oregon, which, he states, has blended ethics, opinion, and technical processes to produce "a radically new system for rationing care." Such an amalgamation is available for British commissioners now. Since 1992 a software application called PRIoRr= (in which I have no financial, professional, or other stake) has been available to all district health authorities.' This software produces league tables of services according to quality of life valuations, effectiveness, cost, budget available, and demand. As all of the data are local, many of the recognised pitfalls of league tables showing quality adjusted life years are avoided. Decisions are recorded and so are open to modification as local debate, values, and prices change. Active use of the system by commissioners has been modest, which is disappointing, as those who run it find that they must face and answer fundamental questions about why they prefer some services to others and then make their reasoning explicit. Health commissions are in a unique position to blend these activities with advice from local interested parties and must do so before setting priorities. A demonstration that they can deliver on this single issue is needed now: as an underdeveloped system of general practice fundholding is set to take over, tomorrow may be too late. P J AYRES
Senior registrar in public health medicine Nuffield Institute for Health, Leeds LS2 9PL 1 Smith R. Rationing: the debate we have to have. BMJ 1995;310: 682. (18 March.) 2 Grogan CM. Deciding on access and levels of care: a comparison of Canada, Britain, Germany, and the United States. Joumnal of Health Politics, Policy, and Law 1992;17:213-32. 3 Pollock AM, Mejeed F. Community oriented primary care. BM3'
1995;310:481-2. (25 February.) 4 Ayres PJ. Rationing health care: views from general
practice.
University of Leeds, School of Public Health, 1993. (Submission for the degree of master of public health.) 5 Hudson P. A rational approach to the use of health resources. Parliamentary Brief 1994;Oct:66.
Medical profession should develop consensus on health priorities via debates EDr1OR,-I wish to suggest a way forward with regard to rationing.' I have had professional experience of rationing with extracontractual referrals,2 and it seems invidious to make medical professionals responsible for local rationing in a national health service. Medical practitioners have an opportunity to take the lead in the debate on rationing in the absence of leadership by the government, and we should begin by using the emerging consensus on medicine's core values3 linked to a reaffirmation of the principle of the NHS. The next stage would be to examine current activities using a systematic methodology-for example, marginal analysis.4 The medical profession is being encouraged to discuss with patients and populations its professional judgments. We should take the opening
offered by these demands for discussions to encourage vociferous local debates through the regional machinery of the BMA. In practice this would mean clinicians, clinical directors, and medical directors of NHS trusts and units debating the issues from the perspective of specialists; general medical practitioners participating in those debates from the perspective of primary care; and the public health medicine advisers of purchasing health authorities participating from the perspective of the population. The outcomes of these debates would be a broad consensus on the priorities for health care based on our values and principles, supported by our populations, and would enable us to lobby central government for the appropriate resources. Is the medical profession prepared to take up this challenge? IAIN J ROBBE Senior lecturer in public health medicine Centre for Applied Public Health Medicine, University of Wales College of Medicine, CardiffCFl 3NW 1 Smith R. Rationing: the debate we have to have. BMJ 1995;310: 682. (18 March.) 2 Referral freedoms under threat. BMA New Review 1991 ;Oct: 1 1. 3 Smith R. Medicine's core values. BMJ 1994;309:1247-8. (1 2 November.) 4 Cohen D. Marginal analysis in practice-an altemative to needs assessment for contractinghealth care. BMY 1994;309:781-5.
Treatment oflupus syndromes EDrrOR,-In reviewing the use of antimalarial drugs in systemic lupus erythematosus Elaine M Hay and Michael L Snaith allude to disagreement between rheumatologists and ophthalmologists about the need for routine retinal screening.' Datasheets for antimalarial drugs still recommend such screening every few months. For once, in this age of "evidence based medicine," data are available to refute the need for this time consuming routine and expose as myths and suggestions that hydroxychloroquine is safer than chloroquine and antimalarial toxicity is a function of cumulative dose,2 which the article perpetuates. Mackenzie, adhering to a safe antimalarial regimen, found no evidence of maculopathy in a series of 900 patients followed up for an average of seven years.3 Morsman et al corroborated this finding in patients with rheumatoid arthritis receiving less than 6 5 mg hydroxychloroqine/kg ideal body mass for over 18 months.4 It is prudent, however, to assess the retina initially to exclude retinitis pigmentosa (a contraindication to treatment) and establish any pre-existing eye disease that might subsequently be wrongly attributed to the antimalarial treatment. Thereafter, as a dermatologist, I would commend a dosage based on ideal body mass as the best way to avoid maculopathy and conflict between rheumatologists and ophthalmologists. ANDREW J CARMICHAEL Consultant dermatologist
Department ofDermatology, South Cleveland Hospital, Middlesbrough, Cleveland TS4 3BW 1 Hay EM, Snaith ML. Systemic lupus erythematosus and lupus-
like syndromes. BMJ 1995;310:1257-61. (13 May.) 2 Carmichael AJ. Hydroxychloroquine: a guide to usage. Journal of
Dermatological Treatment 1992;3:103-6. 3 Mackenzie AH. Dose refinements in long-term therapy of rheumatoid arthritis with antimalarials. Am J Med 1983;
75(suppl):40-5.
Richarns IM, Jessop JD, Mills PV. Screening for hydroxychloroquine retinal toxicity: is it necessary? Eye 1990;4:572-6.
4 Morsman CDG, Livesey SJ,
Author's reply EDrroR,-Andrew J Carmichael makes a fair point. Although there has been evidence in the past BMJ voLuz.311
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