triazolam. EDITOR,-G Burton and C Carter complain that we did not take into account "the majority of the published infonnation, let alone the unpublished.
unrequited, and we now have another leader on the subject, again failing to face up to real issues.' There is actually not a great deal wrong with the GMC, as Richard Smith might find out if he served on the council, or even attended some of its meetings, and what is wrong is difficult to remedy. Briefly, there are three difficulties. There are not enough young doctors on the council. This is partly due to the fact that it is difficult for them to be elected, as with a proportional representation system it is essential to be relatively well known, and partly because the work is time consuming and young doctors cannot spare the time. The commitment to the disciplinary committee alone involves two or three fortnightly sessions a year, and work on the health committee is hardly less arduous. All the committees require a dedicated commitment which few doctors have the time to give. The workload will be further increased when the recommendations of the performance working party become law. For the public to be reassured that the GMC is not just a closed shop protecting its own there must be adequate lay representation. If, however, the GMC is to be the profession's own self regulating body (which, incidentally, we pay for ourselves), the profession expects a majority of its own elected members to serve on the council. None of Richard Smith's proposals deal effectively with these difficulties. He implies that the GMC is an "expensive talking shop," but for the work it does on behalf of the profession and the public it is not expensive, and if he thinks that it could be run more cheaply he should tell us how. His one contribution to economy is to halve the size of the council, but as this would double the workload of the already overstretched committees it is far from helpful. He acknowledges the role of the lay members but goes on to say that "elected lay members would surely be better than appointed ones." No evidence is offered concerning the implied criticism of existing lay members, no hint as to how they are to be elected, and no suggestions as to who should pay for the electoral process. Constructive criticism is always welcome; ill thought out comments much less so. At a time when medicine is in danger of becoming less of a profession and more of a trade, the role of the GMC becomes ever more important and deserves all the support it can get. TONY KEABLE-ELLIOTIT
Ibstone, Buckinghamshire HP 14 3XX
tIhe GMC: size and public accountability. BMJ 1993;306:1356-7. (22 May.)
1 Smith R.
Women and coronary artery surgery Fewer women referred for investigation EDITOR,-Mark Petticrew and colleagues have elegantly shown that, if myocardial infarction rates are a valid marker for the true prevalence of ischaemic heart disease, then women are being treated by angioplasty or coronary bypass grafts at lower than expected rates compared with men.' They were commendably circumspect about the possible causes. We can complement their inpatient date with information about 5991 consecutive new outpatient referrals to a cardiology unit over one year (1992). Patients were allocated to a diagnostic group on the basis of a "clinical working diagnosis" after they were seen by a cardiologist, but before inpatient investigations have been performed. The table shows the results. There was no significant difference in gender pattern between patients referred directly from the general practitioner or through a general physician.
BMJ VOLUME 306
19 JUNE 1993
Clinlcial working diagniosis of outpattients referred to
cardiology untit, 1992
Category All patients Patients with suspected IHD Patients with other cardiac diagnosis Patients over age 60; suspected IHD
Other cardiac diagnosis
No of patients
Odds ratio, men v women (95°/o confidence interval)
5991 2918
1 55 (1 44 to 1 66) 5 23 (4 70 to 5 88)
3073
0 52 (0-47 to 058)
1199 1000
4l11 (3 41 to4 80) 0.91 (0 76 to 1 08)
IHD=ischaemic heart disease.
It is interesting that the gender disparity is, if anything, greater at the level of initial referral than at the level of invasive investigation or intervention; that there is no difference in pattern between people over and under 60; and that women are more likely than men to be referred for working diagnoses other than ischaemic heart disease. I suspect that at least part of the gender disparity in referral results from patients' different perception of angina symptoms and their implications, particularly by older women, rather than conscious or unconscious bias by doctors.
determine the clinical basis and justification for age and sex bias in access to coronary reperfusion treatment,' the results of our and other studies indicate that health authorities are not currently monitoring whether the services they purchase are delivered both equitably and appropriately. Evidence from health authorities' current purchasing plans suggests that purchasers are using the minimum contract dataset for little other than monitoring efficiency in finance driven exercises. To monitor the equity and appropriateness of delivery of service, health authorities will need to take more interest in providers' information systems and the data they collect as well as identifying methods of enhancing the quality and usefulness of data. Purchasers will also need to consider how they propose to analyse data provided by provider units. This will necessitate developing protocols capable of efficient and effective data analysis for monitoring the equity and effectiveness of delivery of services. If purchasers do not ensure adequate monitoring of the provision of services they cannot know how their values are reflected in the delivery of services, nor can they ensure that groups of patients are not inequitably denied access to services. AZEEM MAJEED ALLYSON M POLLOCK
DAVID DE BONO
Department of Cardiology, University of Leicester, Glenfield General Hospital, Leicester LE3 9QP
Department of Public Health Medicine, Wandsworth Health Authority, London SW17 7DJ
I Petticrew M, McKee M, Jones J. Coronary artery surgery: are women discriminated against? BM3 1993;306: 1164-6. (1 May.)
Health authorities should monitor equity of service EDITOR,-The public health department in Wandsworth Health Authority recently examined access to coronary artery bypass surgery and angioplasty for residents of Wandsworth admitted with a diagnosis of ischaemic heart disease (ICD 410-414) from 1990 to 1992 inclusive. The table shows the number of admissions and the number of patients who had reperfusion treatment, broken down by age group and sex. Men admitted with a diagnosis of ischaemic heart disease were more likely to have reperfusion treatment than women in each age group and were almost twice as likely to have reperfusion treatment overall (MantelHaenszel weighted odds ratio 1-95 (95% confidence interval 1-26 to 3-17); p=0003). The odds of treatment also fell significantly with age (stratified X2 for trend=31-9, p
