CORRESPONDENCE * All letters must be typed with double spacing and signed by all authors. * No letter should be more than 400 words. * For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BM3r. * We do not routinely acknowledge letters. Please send a stamped addressed envelope ifyou would like an acknowledgment.
* Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Crisis in admission beds SIR,-The 48 acute psychiatric units in Greater London were contacted by telephone during the Easter and May bank holiday weekends. Duty staff provided the numbers of acute admission beds for adults, vacancies, and "extra" patients-for example, those sleeping in beds of patients on leave. Thus we obtained a comprehensive picture of bed state availability for the 6-9 million population of Greater London' (29 health authority districts, including 28 hospitals serving 13 inner London districts and 23 hospitals from 16 outer London districts). The mean total bed occupancy for Greater London was 95-7% (table). One third of districts were running at 100% bed occupancy or greater; one district had 117% occupancy. Twenty three districts in Greater London were running at over 85% occupancy on both survey days despite recognition that the optimal occupancy level for efficient use should be 85%.' Bed occupancy in London regions and number of districts with more than 100% occupancy on two bank holiday weekends
been an acceleration in the rate of closure of beds without adequate increase in provision of services and especially of day care. The inexorable closure of hospital wards with the transfer of beds to a community starved of resources affects the capability of the acute psychiatric services. Remedial measures might include a large injection of resources and an increase in admission beds in selected hospitals across inner London while community care is being established. DORIS HOLLANDER ROBERT TOBIANSKY Friern Hospital, London N lI 3BP
ROBIN POWELL
Maudsley Hospital, London SE5 1 Office of Population Censuses and Surveys. Mid-year population estimates 1988. London: HMSO, 1989. 2 Hirsch SR, Gerrard B, Malin H, et al. Psychiatric beds and resources: factors influencing bed use and service planning. London: Royal College of Psychiatrists, 1988. 3 Department of Health and Social Security. Mental health statistics forEngland 1984. London: DHSS, 1986. 4 Minister of Health's Speech. House of Commons Official Report (Hansard) 1989 July 12;156:cols 975-98. (No 141.)
% Of beds occupied (No of districts > 100%)
Date of survey 15 April 27May Meanoftwodays
Greater London (n=29)
Outer London (n= 16)
Inner London (n= 13)
92-7 (5)
96-8 (5) 94-8 (10) 99-5 (7) 96-6 (9) 98-1 95-7
93-5(2) 93-1
Significant differences in bed occupancy between inner and outer London might reflect differences in psychiatric morbidity, social isolation, and deprivation. Bed occupancy figures for the four regional health authorities were remarkably similar, indicating that the pressure on beds is a phenomenon common to all London regions. Increased strain on beds suggests that resources have not developed sufficiently rapidly in the community. The closure of rehabilitation wards has removed a resource for overflow of inpatients and may be resulting in earlier discharge and, possibly, earlier readmission. Widespread pressure on beds and overcrowding allows less scope for admission of other than the most severely disturbed patients.3 A case can be envisaged in which the most needy are denied access to emergency care. Escalating strain on families, carers, general practitioners, social services, and fledgling community services may lead to the community's newly acquired sympathy being sorely tested at a time when increased tolerance is needed. Central government has given assurances that the programme of closure of mental hospitals is under review.4 We think, however, that there has
664
General practitioner maternity units SIR,-Dr Vanessa Sangala and colleagues have produced another hostile empire building obstetric paper, which was presumably written by the woman registrar to help her to a consultant job in the male world of obstetrics.t Heaven help the woman, professional or pregnant, who steps out of line.23
I have to concede that it is a much more powerful paper than the now notorious Bradford paper,4 but, unless I misunderstand, it does not quite reach significance. The differences may have arisen by chance. Where are the data for the past three years? Why have they been omitted? Why is there no general practitioner author? Is there not one general practitioner in Bath who agrees with them? Also, as usual we are surrounded by confounding variables-for instance, did the women who opted for care in the peripheral units do so because they did not have access to a car, and does that introduce a social class bias? The discussion at the end of the paper is in fact a polemic, a manifesto stating an intention to obliterate the peripheral units. The strategy is to make obstetrics so unattractive to general practitioners-district health authority contracts, constant hostile pressure, etc-that no one will want to do it. We are, after all, a long way down this path already. General practitioner obstetrics in Bradford is all anxiety and very little satisfaction,
only relief not *to be in trouble again. Lots of general practitioners have been scared off. Women are given no say in the matter. There are, however, apart from medical power struggles real problems to be solved, yet general practitioners seem to understand this better than consultants. Consider the role of the caesarean section; if perinatal deaths were the only consideration most babies would be born by this method. The fact that there are many other considerations requires honest analysis, mature judgment, good communications, and imaginative solutions,5 but in this paper the hospital doctors propose bureaucratic changes that do not address these problems. What were the avoidable causes of death? Was delayed availability of a caesarean section a factor? We must honestly recognise that staffing levels and working practices6 are such that even in a hospital the delay can be fatal. In Bradford one registrar covers two hospitals, 4 km apart, and he or she may be required to do a caesarean at 4 am after 45 hours of duty without sleep. This, I understand, is commonplace. Do mothers know that? When risks are small, and here the excess risk if it exists at all is of the order of 1 in 1000, then in a service sensitive to patients there must be other considerations, and the options must be discussed with the parents, other doctors, and midwives honestly and openly. SETH JENKINSON
Baildon, Shipley BD17 5NH 1 Sangala V, Dunster G, Bohin S, Osborne JP. Perinatal mortality rates in isolated general practitioner maternity units. Br MedJ3 1990;301:418-20. (1 September.) 2 Savage W. A savage enquiry. London: Virago, 1986. 3 Oakley A. The captive womb. Oxford: Blackwell, 1984. 4 Bryce FC, Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford. BrMedJ7 1990;300:725-7. (17 March.) 5 Ross M, Brooke M, Connolly J, et al. General practitioner obstetrics in Bradford. BrMedJ 1990;300:1139-40. (28 April.) 6 Ennis M, Vincent CA. Obstetric accidents: a review of 64 cases.
BrMedJ7 1990;300:1365-7. (26 May.)
SIR,-The study by Dr Vanessa Sangala and colleagues is seriously flawed in several respects.' No precise description is given of how the authors assigned the intended place of delivery, but clearly they were not blind to the outcome. This in itself violates a fundamental principle of good study design-namely, that steps are taken to eliminate bias. On these grounds alone the study should be rejected. For instance, the authors could have asked another investigator who was blind to the outcome to assign intended place of delivery. In view of the small number of deliveries studied only a little bias in assigning the intended place of delivery is necessary to create the observed differences, even if the underlying rates were the same.
BMJ VOLUME 301
29 SEPTEMBER 1990
* Because we receive many more letters than we can publish we may shorten those we do print, particularly when we receive several on the same subject.
Crisis in admission beds SIR,-The 48 acute psychiatric units in Greater London were contacted by telephone during the Easter and May bank holiday weekends. Duty staff provided the numbers of acute admission beds for adults, vacancies, and "extra" patients-for example, those sleeping in beds of patients on leave. Thus we obtained a comprehensive picture of bed state availability for the 6-9 million population of Greater London' (29 health authority districts, including 28 hospitals serving 13 inner London districts and 23 hospitals from 16 outer London districts). The mean total bed occupancy for Greater London was 95-7% (table). One third of districts were running at 100% bed occupancy or greater; one district had 117% occupancy. Twenty three districts in Greater London were running at over 85% occupancy on both survey days despite recognition that the optimal occupancy level for efficient use should be 85%.' Bed occupancy in London regions and number of districts with more than 100% occupancy on two bank holiday weekends
been an acceleration in the rate of closure of beds without adequate increase in provision of services and especially of day care. The inexorable closure of hospital wards with the transfer of beds to a community starved of resources affects the capability of the acute psychiatric services. Remedial measures might include a large injection of resources and an increase in admission beds in selected hospitals across inner London while community care is being established. DORIS HOLLANDER ROBERT TOBIANSKY Friern Hospital, London N lI 3BP
ROBIN POWELL
Maudsley Hospital, London SE5 1 Office of Population Censuses and Surveys. Mid-year population estimates 1988. London: HMSO, 1989. 2 Hirsch SR, Gerrard B, Malin H, et al. Psychiatric beds and resources: factors influencing bed use and service planning. London: Royal College of Psychiatrists, 1988. 3 Department of Health and Social Security. Mental health statistics forEngland 1984. London: DHSS, 1986. 4 Minister of Health's Speech. House of Commons Official Report (Hansard) 1989 July 12;156:cols 975-98. (No 141.)
% Of beds occupied (No of districts > 100%)
Date of survey 15 April 27May Meanoftwodays
Greater London (n=29)
Outer London (n= 16)
Inner London (n= 13)
92-7 (5)
96-8 (5) 94-8 (10) 99-5 (7) 96-6 (9) 98-1 95-7
93-5(2) 93-1
Significant differences in bed occupancy between inner and outer London might reflect differences in psychiatric morbidity, social isolation, and deprivation. Bed occupancy figures for the four regional health authorities were remarkably similar, indicating that the pressure on beds is a phenomenon common to all London regions. Increased strain on beds suggests that resources have not developed sufficiently rapidly in the community. The closure of rehabilitation wards has removed a resource for overflow of inpatients and may be resulting in earlier discharge and, possibly, earlier readmission. Widespread pressure on beds and overcrowding allows less scope for admission of other than the most severely disturbed patients.3 A case can be envisaged in which the most needy are denied access to emergency care. Escalating strain on families, carers, general practitioners, social services, and fledgling community services may lead to the community's newly acquired sympathy being sorely tested at a time when increased tolerance is needed. Central government has given assurances that the programme of closure of mental hospitals is under review.4 We think, however, that there has
664
General practitioner maternity units SIR,-Dr Vanessa Sangala and colleagues have produced another hostile empire building obstetric paper, which was presumably written by the woman registrar to help her to a consultant job in the male world of obstetrics.t Heaven help the woman, professional or pregnant, who steps out of line.23
I have to concede that it is a much more powerful paper than the now notorious Bradford paper,4 but, unless I misunderstand, it does not quite reach significance. The differences may have arisen by chance. Where are the data for the past three years? Why have they been omitted? Why is there no general practitioner author? Is there not one general practitioner in Bath who agrees with them? Also, as usual we are surrounded by confounding variables-for instance, did the women who opted for care in the peripheral units do so because they did not have access to a car, and does that introduce a social class bias? The discussion at the end of the paper is in fact a polemic, a manifesto stating an intention to obliterate the peripheral units. The strategy is to make obstetrics so unattractive to general practitioners-district health authority contracts, constant hostile pressure, etc-that no one will want to do it. We are, after all, a long way down this path already. General practitioner obstetrics in Bradford is all anxiety and very little satisfaction,
only relief not *to be in trouble again. Lots of general practitioners have been scared off. Women are given no say in the matter. There are, however, apart from medical power struggles real problems to be solved, yet general practitioners seem to understand this better than consultants. Consider the role of the caesarean section; if perinatal deaths were the only consideration most babies would be born by this method. The fact that there are many other considerations requires honest analysis, mature judgment, good communications, and imaginative solutions,5 but in this paper the hospital doctors propose bureaucratic changes that do not address these problems. What were the avoidable causes of death? Was delayed availability of a caesarean section a factor? We must honestly recognise that staffing levels and working practices6 are such that even in a hospital the delay can be fatal. In Bradford one registrar covers two hospitals, 4 km apart, and he or she may be required to do a caesarean at 4 am after 45 hours of duty without sleep. This, I understand, is commonplace. Do mothers know that? When risks are small, and here the excess risk if it exists at all is of the order of 1 in 1000, then in a service sensitive to patients there must be other considerations, and the options must be discussed with the parents, other doctors, and midwives honestly and openly. SETH JENKINSON
Baildon, Shipley BD17 5NH 1 Sangala V, Dunster G, Bohin S, Osborne JP. Perinatal mortality rates in isolated general practitioner maternity units. Br MedJ3 1990;301:418-20. (1 September.) 2 Savage W. A savage enquiry. London: Virago, 1986. 3 Oakley A. The captive womb. Oxford: Blackwell, 1984. 4 Bryce FC, Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford. BrMedJ7 1990;300:725-7. (17 March.) 5 Ross M, Brooke M, Connolly J, et al. General practitioner obstetrics in Bradford. BrMedJ 1990;300:1139-40. (28 April.) 6 Ennis M, Vincent CA. Obstetric accidents: a review of 64 cases.
BrMedJ7 1990;300:1365-7. (26 May.)
SIR,-The study by Dr Vanessa Sangala and colleagues is seriously flawed in several respects.' No precise description is given of how the authors assigned the intended place of delivery, but clearly they were not blind to the outcome. This in itself violates a fundamental principle of good study design-namely, that steps are taken to eliminate bias. On these grounds alone the study should be rejected. For instance, the authors could have asked another investigator who was blind to the outcome to assign intended place of delivery. In view of the small number of deliveries studied only a little bias in assigning the intended place of delivery is necessary to create the observed differences, even if the underlying rates were the same.
BMJ VOLUME 301
29 SEPTEMBER 1990
