The article on stress in general practice examined the relationship between GPs and practice nurses, and between GPs and practice managers, but did not examine one of the fundamental determinants of those relationships.

It regrets that many practice managers are prevented from exercising their management skills due to GPs' reluctance to relinquish management control.

It also acknowledges that GPs are independent contractors, but then did not explore the financial consequences: GPs are given only a maximum of 70 per cent reimbursement for staff salaries. So long as it is the GPs who are paying their practice managers to run practices as the GPs want them run, such situations will prevail. It is not comparable to earlier years' struggle between clinicians and managers over the running of our hospitals, where an objective best-for-the-service view could be taken.

The same factor applies in the case of practice nurses and other administrative and clerical staff; not only clinically and managerially accountable to the GPs, but paid out of their pockets as well. He who pays the piper. . .

JG Hetherington Bexleyheath Kent