cardinal symptoms of anxiety state, and most depressions ... men reported not only less anxiety and depression ... provided by the present Tower Hamlets Health.
(35%), less clinically important anxiety (29%), and a similar amount of depression (24%). Whether the high levels of clinically important anxiety are primary or secondary to the development of urinary incontinence they must at least act as exacerbating factors. Urgency and frequency are cardinal symptoms of anxiety state, and most depressions are accompanied by anxiety. The efficacy of imipramine in the treatment of urinary incontinence has always been explained as being due to the anticholinergic action of the drug. But much of the effect may be due to its antidepressant and anxiolytic function in patients with affective illness. A pilot study was performed on six patients with genuine stress incontinence and coexisting anxiety and depression. They were treated with fluoxetine 20 mg each morning. After four weeks four of six men reported not only less anxiety and depression but subjective improvement in their ability to "hold on to the water," and surgery was postponed in these patients. Fluoxetine has no anticholinergic component and thus urinary continence seems to be centrally mediated. It is difficult to understand why our results are so different from those of Dr Norton and colleagues. Perhaps a larger study will be able to elucidate further the pathogenesis of detrusor instability and genuine stress incontinence and indicate whether affective illness is implicated. DOUGLAS TURKINGTON JOHN GRANT PAUL TOPHILL JAMES JOHNSTON
Northern General Hospital, Sheffield S5 7AU
1 Norton KRW, Bhat AV, Stanton SL. Psychiatric aspects of urinary incontinence in women attending an outpatient urodynamic clinic. BrMed3' 1990;301:271-2. (4 August.) 2 Goldberg DP. The detection of psychiatric illness by questnonnaire. London: Oxford University Press, 1972. (Maudsley monograph 2 1.) 3 Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361-70.
taking the midpoint of the 1 to 5 remuneration scale of each of the five new BUPA categories, with the exclusion of minor 1 and 2 from the minor category, as these largely relate to outpatient procedures, and complex major 5 from the complex major category, because this relates to bypass procedures that are outside the practice of general surgeons. The values are important as they allow analysis of case mix of different surgical units for audit purposes, in addition to workload studies. S M JONES C D COLLINS Taunton and Somerset Hospital, Taunton, Somerset TA 1 5DA 1 Jones SM, Collins CD. Caseloa6 or workload? Scoring complexity of operative procedures as a means of analysing workload. BrMedJ7 1990;301:324-5. (11 August.) 2 British United Provident Association. Schedule of procedures 1990. London: BUPA, 1990.
Application for self government SIR,-The Tower Hamlets health services, for which self governing trust status is being sought, are inaccurately described in the article by Dr Tony Delamothe as "the Royal London Hospital group." The proposed trust encompasses all the services provided by the present Tower Hamlets Health Authority. Thus all community, learning difficulties, mental health, and non-acute elderly services will be included in the trust if the application is successful. The emphasis on the hospital rather than the locality exacerbates the unease felt by people in the community, who have shown little enthusiasm for the application for trust status. CHRISTINE SMITH Community Health Council, London El IHE 1 Delamothe T. Applications for self governing trusts. Br Med J 1990;301:307. (11 August.)
Caseload or workload? SIR,-In our paper we recommended that operative workload be categorised on an eight point scale using the British United Provident Association (BUPA) 1989 classification, which relates each operation to an intermediate procedure on the basis of the reimbursement levels recommended for surgeons and anaesthetists.l In July 1990 a new schedule of procedures was published by BUPA, which subdivided operations and procedures into 25 categories.2 This was introduced with a scale of separate benefits for surgeons and anaesthetists. The new BUPA classification could be used for a detailed computer assisted assessment of operative workload by classifying each procedure to one of the 25 groups through the associated Office of Population Censuses and Surveys (4th revision) code. The baseline for such a classification could be intermediate 3 (for example, haemorrhoidectomy, stab avulsions of varicose veins), which is given a value of one in table I of our paper, with the relative values of each of the 24 other categories created by relation of each procedure group's reimbursement rate to the surgeon to that for the intermediate 3 procedure. This assessment may, however, be too complicated for general use. We therefore recommend that for practical comparison and assessment of surgical workloads the five main categories be compared, with the relative value of each group of operations based on the remuneration of each category to the surgeon alone as follows: minor (0 50), intermediate (1-00), major (1-90), major plus (2 43), complex major (4 30). These relative values have been arrived at by BMJ
VOLUME 301
1 SEPTEMBER 1990
General practitioners' awareness of colorectal cancer SIR,-Mr A R Dixon and colleagues suggest that delays in the presentation of colorectal cancer are attributable to both the patient and the family doctor' but do not state at which point the delay occurs. This delay can occur before the patient presents to his or her general practitioner, before the general practitioner refers the patient to hospital, or before the hospital consultant sees or operates on the patient. My study of the delay in diagnosing colorectal cancer in 172 patients operated on in Trafford hospitals from 1982 to 1984 looked specifically into the duration of delay, where it occurred, and its association with the prognosis of the disease.2 Sixty five per cent of the patients had had symptoms for less than three months before attending their general practitioner, a shorter mean duration of symptoms than that reported in some other studies34 but similar to that reported by Holliday and Hardcastle.5 In 91 of the 172 patients the time from presentation to referral was less than one week, and a further 39 were referred within four weeks. Thus three quarters of the patients were referred quickly by their general practitioner. Three quarters of patients were operated on within 13 weeks after their first presentation to their general practitioner with symptoms. My study confirmed that there was no association
between the length of delay and the stage of the disease (and hence the prognosis). General practitioners were aware of the possibility of colorectal cancer and in most cases referred patients with minimal delay. Finally, and crucially, reduced delay had no real part to play in reducing the morbidity and mortality associated with colorectal cancer. Our efforts must be directed to diagnosis before symptoms occur if we wish to make any progress in combating this devastating and common disease. DEREK M SEEX
Manchester, M 16 7WT 1 Dixon AR, Thornton-Holmes J, Cheetham NM. General practitioners' awareness of colorectal cancer: a 10 year review. BrMed3r 1990;301:152-3. (21 July.) 2 Seex DM. Delay in the diagnosis of colorectal cancer and its prognostic implications. Leeds: University of Leeds, 1985. (MMedSci thesis.) 3 Keddie N, Hargreaves A. Symptoms of carcinoma of the colon and rectum. Lancet 1968;ii:749-50. 4 Williams D. A screening scheme for colorectal cancer. General Practitioner 1985 Feb 1:16. 5 Holliday HW, Hardcastle JD. Delay in diagnosis and treatment of cancer of the colon and rectum. Lancet 1979;i:309-1 1.
SIR,-Mr A R Dixon and colleagues found that although there had been an improvement in referrals for colorectal cancer by general practitioners over the past decade, an accurate rectal examination would have improved matters further.' Another study showed that doctors who perform a rectal or other relevant examination refer their patients earlier in the course of the disease.2 Roughly 95% of all Danes are registered with an individual general practitioner working in the National Health Service. Data from the service can thus supply exact information about the working methods of each doctor.34 Over 12 months we collected data on 93 doctors in single practices and 188 doctors in 71 group practices in North Jutland. The information comprised the number of registered patients, number of consultations during office hours (as a measure of their workload), number of proctoscopies performed, and number of examinations of stools for blood performed in own laboratory. Eighteen practices were excluded from the statistical analysis as they had either been closed or had changed to another form of practice during the study. The analysed practices had 95 patients with cancer of the rectum, all of whom were identified from the national cancer registry. We calculated proctoscopy activity, defined as the number of proctoscopies per 1000 consultations per year, and practice activity, the number of consultations per 1000 patients per year. The number of proctoscopies performed annually by each general practitioner varied from 0 to 107. Group practices performed proctoscopies more often than single practices (95 5% v 81-0%). There was no correlation or trend between Dukes's stage of growth at the time of diagnosis and workload, number of registered patients, practice activity, proctoscopy activity, or examination of stool specimens for blood. Thus increased use of proctoscopy does not necessarily result in a lower Dukes's stage at the time of diagnosis. HENRIK TOFT S0RENSEN EJLER EJLERSEN JENS M0LLER-PETERSEN HENRIK H0JGXRD RASMUSSEN
Aalborg Hospital, 9000 Aalborg,
Denmark FREDE OLESEN
University of Aarhus, 8000 Aarhus C, Denmark 1 Dixon AR, Thornton-Holmes J, Cheetham NM. General practitioners' awareness of colorectal cancer: a 10 year review. BrMedJ7 1990;301:152-3. (21 July.)
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2 MacArthur C, Smith A. Factors associated with speed of diagnosis, referral and treatment in colorectal cancer. J Epidemiol Community Health 1984;38:122-6. 3 Sorensen HT, Christensen B. Referrals from general practice to specialists in Denmark. I R Coll Gen Pract 1986;36:190-1. 4 Christensen B, Sorensen HT, Mabeck CE. Differences in referral rates from general practice. Fam Pract 1989;6:19-22.
Prognosis of abdominal aortic aneurysm SIR,-Professor R M Greenhalgh's editorial implies that small (
