BMJ Vol 313 No 7064 Saturday 26 October 1996
The British government acted last week to outlaw handguns and also agreed to examine a more active role for doctors in new procedures for granting shotgun licences. This would entail an applicant's general practitioner supplying information to a police surgeon.
The proposal arises from a report by the Scottish judge Lord Cullen into the shootings at Dunblane primary school last March, when Thomas Hamilton killed a teacher and 16 infant pupils. New gun laws to be passed by Christmas will ban all handguns, except possibly low calibre Olympic style pistols kept in gun clubs.
But this leaves 145 000 shotgun licences to be dealt with each year, and the report revives the debate over the role of doctors in screening applicants. Lord Cullen states that he is entirely satisfied that general practitioners cannot reliably assist in identifying those who pose a risk of violence. Medical information can provide warning signs in some cases, but there is no certain means of excluding the onset of a mental illness that poses danger, the report says.
The report removes one issue of contention by recommending that applications for firearm licences need not be countersigned by a "person of standing." The BMA's annual meeting this year advised doctors not to countersign. A doctor's signature might be taken as endorsing the applicant as medically fit to be entrusted with a firearm. The government has agreed to replace countersigning by a system requiring two references.
Lord Cullen then looked at the provision of medical and psychological information. He accepts the doubts of forensic psychiatrists and clinical psychologists about their ability to predict violent behaviour. But he finds merit in a proposal by the Association of Police Surgeons for an applicant's doctor to supply a police surgeon on request with a medical history, on the lines of a life assurance questionnaire. The doctor would be able but not bound to comment on the suitability of the applicant. The police surgeon or forensic medical examiner would assess the application and recommend to the chief constable whether the applicant was suitable from a medical point of view.
Lord Cullen says that his method could screen out at least some medically unsuitable applicants and enable general practitioners to exchange information with a fellow professional who would have the responsibility of deciding on further action. He has reservations about doctors being under a duty to report adverse changes in the condition of a licence holder since it might be difficult to know when such a duty arose. Lord Cullen recommends full consultation with professional bodies to see if such a system is feasible and the government has agreed to this.
Although it welcomed the proposed drastic reduction in firearms, the BMA said that it was disappointed that neither the government nor Lord Cullen had accepted its recommendation for a confidential telephone helpline for doctors to disclose information about a perceived risk of violence. It will continue to pursue this (see also p 1030)
JOHN WARDEN,
parliamentary correspondent,
BMJ
Photo: PHILIP WOLMUTH
General practitioners in Britain are to start refusing to carry out activities that are not considered to be their core work unless there is appropriate remuneration.
Last week the General Medical Services Committee (GMSC) agreed by 55 votes to seven that its document on core services should go out to all family doctors. The committee's chairman, Dr Ian Bogle, said that the document was intended to protect the role of the generalist and was an attempt to stop the uncontrolled transfer of unresourced or underresourced work into general practice.
The document comes only a week after the government's white paper Choice and Opportunity, which will loosen contractual restraints on extending general medical services (19 October, p 959).
The GMSC document took account of the views of this year's special local medical committee conference (22 June, p 1559). It identifies the services that general practitioners are obliged to provide under their terms of service and a wide range of non-core services outside these terms. Examples of non-core work include the medical care of highly dependent patients living in the community for example, in nursing or residential homes and work that requires specialist skills, such as postoperative care and phlebotomy.
Accompanying the document is a standard letter to health authorities containing a list of services with boxes for doctors to tick to indicate that they are no longer prepared to continue to provide the service from the beginning of the contracting year-for example, 1 April 1997-without a formal arrangement or that they would be prepared to tender for such a service if invited to do so.
There is also a model letter to nursing homes, explaining that from a certain date a practice will no longer be willing to register their patients because the care needed tends to go beyond general medical services and impacts on the care of other patients registered with the practice.
The document contains guidance on how to decide a price for non-core work when negotiating with health authorities. General practitioners can ask local medical committees for help in this, but they cannot set prices locally as this could put them in breach of the Monopolies and Mergers Commission.
The GMSC will meet local medical committee representatives next month to discuss the implications of the document.
JACQUI WISE,
BMJ
| The GMSC definitions of core and non-core work |
| Core services
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| Non-core services
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Photo: MIKE WYNDHAM
Professor Jean-Francois Girard, director general for health, has asked the ministry of justice to look into the "legal vacuum" concerning advertising on the Internet, and the customs department of the Ministry of Economy and Finance to identify which foreign companies are selling drugs in this way in France.
"We are beginning to do it, but it's difficult," said Gilles Montagnat-Rentier, a chief customs inspector at the Ministry of Economy and Finance. French law is explicit: it is illegal to order drugs from abroad without special authorisation. "We regularly seize or return to the sender parcels and commercial freight containing pharmaceuticals, but advertising through a new means of communication is difficult to control," said Mr Montagnat-Rentier.
Richard Lerat, secretary general of the French syndicate of pharmaceutical manufacturers, said companies cannot control whole- salers, particularly those outside France: wholesalers can legally import prescription medicine and then sell it to whomever they choose at any price they choose.
In addition, several web sites now give specific information on the use of hallucinogenic substances such as Ecstasy and LSD. Other sites even sell psychotropic substances such as GHB (gammahydroxybutyrate; sodium oxybate), which is used in the United States as a tranquilliser for weight control but has a euphoric effect when mixed with alcohol.
Synthetic dehydroepiandrosterone (DHEA) is also advertised as being available for immediate shipment, with the suggestion to "take one or two capsules a day, preferably one with breakfast and one eight hours later." Only a few words of caution are added, such as: "Consult your physician if you are pregnant. Generally not recommended for individuals under 30 years old." The drug most frequently seized by French customs officials in recent months is melatonin.
The Ministry of Justice will address the problem shortly, but most experts agree that French authorities will find no effective solution unless there is concerted action on the part of health customs authorities and the pharmaceutical industry on an international scale
ALEXANDER DOROZYNSKI,
medical journalist,
Paris