bleep service. Since then we have had 15 women under our care in labour. Of these, 10 women were visited in labour; in three cases the doctor was informed of admission and delivery at 10 am the next day; and in two cases the doctor was informed of admission only when an emergency arose. These figures speak for themselves and refute the allegation that we are not committed to intrapartum care. Despite making known the existence of this direct link with the practice to both the maternity unit and consultants it has been used only once during labour. On questioning the occasions of lack of call during early labour we were told that the midwives were "too busy." Clearly, if general practitioners are not called it is easy to criticise us for not attending our patients. We welcome and support the constructive suggestions of Drs Judith Danby and Katie Simmons' and Dr J Bahrami and local medical committee colleagues to improve obstetric services in Bradford in the interests of our patients. May we reiterate that the key to better maternity services in Bradford is good communication and cooperation among all interested parties-patients, midwives, general practitioners, and consultants. We urge all of our consultant and general practitioner colleagues to move in this direction. J D RHODES H E ROBERTS
C B TEDD W TONKS N R PEARSON
Saltaire Medical Centre, West Yorkshire BD18 4RX I Bryce FC, Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford. BrMedj 1990;300:725. (17 March.) 2 Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE, Bryce FC. General practitioner obstetrics in Bradford. BrMed7 1990;300:939. (7 April.) 3 Danby J, Simmons K. General practitioner obstetrics in Bradford. BrMedj 1990;300:939. (7 April.) 4 Bahrami J, Haywood K, Gisans RJ. General practitioner obstetrics in Bradford. BrMedj 1990;300:873. (31 March.)
Identification of the cystic fibrosis gene SIR, -Dr Joan Slack and colleagues correctly draw attention to the possibility that some couples screened for the AF508 deletion will have an increased risk of having an affected child but will not be eligible for specific prenatal testing.' This situation arises when one partner carries an identifiable mutation and the other does not. Such a finding might cause appreciable anxiety and could be a reason for delaying the introduction of carrier testing in low risk couples. We performed a survey of 144 people (135 women and nine men, mean age 29). Forty nine were women who had recently given birth in a postnatal ward in one hospital, 24 were women attending gynaecological outpatient clinics, 32 were university students, and 39 were hospital staff. They were informed about the prognosis of children with cystic fibrosis and the mode of inheritance and told explicitly that if they underwent carrier testing they might end up with a result indicating an increased risk of cystic fibrosis but not have the possibility of further specific testing. In response to the question "Would you have the carrier test if it was offered?" 115 said yes and a further five were undecided. In response to "Would you wish a CF affected fetus to be terminated?" only 74 said yes and 29 were undecided. There were 22 subjects who stated that they would wish for carrier testing but would not wish for termination of an affected fetus. Only five subjects would have declined carrier testing but would still wish for termination of an affected fetus. These five presumably regarded that the side effects of testing outweighed the advantages in preventing the birth of children with cystic fibrosis. The apparent acceptance rate of carrier testing
BMJ VOLUME 300
28
APRIL
1990
of 80% in this survey is very similar to that reported by Williamson et al, whose survey was conducted before the identification of the AF508 deletion, and the implications of only one member of a couple being identified as a carrier were not made explicit to the respondents.2 This and the fact that the number of respondents who would wish for termination but would decline testing was small suggest that the possibility of an increased risk without the chance of specific testing was of little concern. Whether couples would accept this situation with equanimity if it actually occurred during pregnancy will not be known until screening is introduced on an experimental basis. J G THORNTON K'COSTAIN M THOMAS
J M BLAKEMAN S A HESTER R J LILFORD
Departments of Obstetrics, Gynaecology, and Psychology, St James's Hospital, Leeds LS9 7TFF 1 Slack J, Houlston RS, Marteau T. Identification of the cystic fibrosis gene. BrMedj 1990;300:812. (24 MIarch.) 2 Williamson R, Allison MED, Bently TJ, et al. Community attitudes to cystic fibrosis carrier testing in England: a pilot study. Prenat Diagn 1989;9:727-34.
Disorders of the shoulder SIR,-Drs K K Chakravarty and M Webley highlighted only conservative treatments of disorders of the shoulder. These are satisfactory for mild inflammation and tendonitis, but 10% of their survey group had osteoarthritis of the glenohumeral or acromioclavicular joint and 6% rupture of the rotator cuff; 9% of the patients had severe pain. Clearly some of these patients might have benefited from replacement or reconstructive shoulder surgery, which has advanced greatly in the past 10 years. Total shoulder replacement and surgical decompression of the acromioclavicular joint are effective treatments in patients with painful osteoarthritic shoulder. These are recent, but proved, methods, as is reconstruction of the rotator cuff. Although this population of patients is elderly, they are of the age group for whom we routinely undertake more massive hip and knee replacement surgery. Patients with degenerative joint disease of the shoulder may suffer great disability, and conservative methods alone are sometimes not enough. Surgical alternatives in patients with disease of this joint should be considered as readily as they are now considered in patients with disease of the hip or knee. DAVID BARRETT
Royal National Orthopaedic Hospital, Stanmore,' Mididlesex HA7 4LI' I Chakravarty KK, Weblev M. Disorders of the shotulder: an often unrecognised (tuse of disability in elderly people. Br Med J 1990;300:848-9. (31 March.
Clinical directorates SIR,-In 1990 I shall finish five years in the position of clinical director of the medical unit at the Royal Hampshire County Hospital, Winchester. My observations are relevant to some of the points raised by Mr J N Johnson' and subsequent correspondents.2 The Royal Hampshire County Hospital, one of the six original resource management initiative sites, has, since 1986, had a hospital management board of eight clinical directors, all consultants, and four other board members, including the director of nursing services and chairman of the medical staff committee. It has not "been a pale shadow of the Guy's experience." Our strength is our sense of corporate responsibility for the running of our hospital. Difficult decisions are more agreeably made by a
group of clinical directors concerned with the overall working of their hospital, and more likely to "stick" with colleagues of a different point of view than those coming from a distant and hierarchical "management." If central government directs regional health authorities to contain spending within preset budgets and regions in turn pass this on to their districts it will be the units, both acute and community, that have to respond. An individual consultant is unlikely to overturn this. A group of clinical directors working together as a hospital management board, who can show tfirough validated information where the budgets they hold go and what clinical activities ensue, can show where "overspending" is truly "underfunding." Even if we cannot convince those higher up in health service management that more resources are needed now at worst we can indicate why clinical activity will have to be held at certain levels and at best be in a position to bid accurately for more resources if they are offered. I shall not share Dr Gordon Jackson's feeling of "emerging from a moderate depressive illness"2 at the end of my time as clinical director. My NHS clinical activity has continued at a high level, but any excursions into private practice-not my forte -have been curtailed. We have had no financial inducements, but, having accepted this limitation in my potential earnings, I have found that time has been the most missed commodity. I agree with Dr Jackson, however, that the support clinical directors receive is very important. We run a triumvirate system in which the business manager is the key person in gathering information and implementation, and I share his fears on difficulties in recruiting and keeping enough people of sufficient calibre to support directorates in all district general hospitals. In our system the third person is the senior nurse manager. While working together in a three person team the consultant and senior nurse manager respect each other's professional areas. Our system of running the clinical directorate is not covered by any of the three models proposed by the Institute of Health Service Management,3 but this is in some ways a disappointing document that almost seems to set out to prove that senior clinicians cannot get involved in hospital management. Mr Johnson's final concern is about consultants' clinical independence and freedom. Clinical freedom, in its old sense, is dead-but long live clinical responsibility based on accurate information and informed opinion. My role in relation to my consultant colleagues has been to gather their opinions and lead the medical unit on their behalf. The role of leadership by the clinical director has been pointed out by Professor Cyril Chantler.4 My consultant colleagues have supported me, and I shall support the next director who emerges from among us. My only direct clash with a colleague has been over requesting magnetic resonance imaging facilities from the private sector, for which we have no budget but which I and others in the directorate think should not be the decision of only one person. The way ahead for the NHS is difficult, under whatever government. All consultants need to participate in decisions that will affect its future. They should also give support to those prepared to act as, and suited to be, clinical directors if this system is seen to be working in their hospital for the good of that hospital and the NHS in general. A P BROOKS
Royal Hampshire County Hospital, Winchester S022 5DG I Johnson JN. Clinical directorates. Br MedJ7 1990;300:488. (24
February.) 2 Correspondence. Clinical directorates. BrMAf edj 1990;300:812-3. (24 March.) 3 Disken S, Dixon M, Halpern S, Schocket G. Models of clinical management. London: Institute of Health Service Management, 1990. 4 Chantler C. How to be a manager. Br Med J 1989;298:1505-8.
1141
C B TEDD W TONKS N R PEARSON
Saltaire Medical Centre, West Yorkshire BD18 4RX I Bryce FC, Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE. General practitioner obstetrics in Bradford. BrMedj 1990;300:725. (17 March.) 2 Clayton JK, Rand RJ, Beck I, Farquharson DIM, Jones SE, Bryce FC. General practitioner obstetrics in Bradford. BrMed7 1990;300:939. (7 April.) 3 Danby J, Simmons K. General practitioner obstetrics in Bradford. BrMedj 1990;300:939. (7 April.) 4 Bahrami J, Haywood K, Gisans RJ. General practitioner obstetrics in Bradford. BrMedj 1990;300:873. (31 March.)
Identification of the cystic fibrosis gene SIR, -Dr Joan Slack and colleagues correctly draw attention to the possibility that some couples screened for the AF508 deletion will have an increased risk of having an affected child but will not be eligible for specific prenatal testing.' This situation arises when one partner carries an identifiable mutation and the other does not. Such a finding might cause appreciable anxiety and could be a reason for delaying the introduction of carrier testing in low risk couples. We performed a survey of 144 people (135 women and nine men, mean age 29). Forty nine were women who had recently given birth in a postnatal ward in one hospital, 24 were women attending gynaecological outpatient clinics, 32 were university students, and 39 were hospital staff. They were informed about the prognosis of children with cystic fibrosis and the mode of inheritance and told explicitly that if they underwent carrier testing they might end up with a result indicating an increased risk of cystic fibrosis but not have the possibility of further specific testing. In response to the question "Would you have the carrier test if it was offered?" 115 said yes and a further five were undecided. In response to "Would you wish a CF affected fetus to be terminated?" only 74 said yes and 29 were undecided. There were 22 subjects who stated that they would wish for carrier testing but would not wish for termination of an affected fetus. Only five subjects would have declined carrier testing but would still wish for termination of an affected fetus. These five presumably regarded that the side effects of testing outweighed the advantages in preventing the birth of children with cystic fibrosis. The apparent acceptance rate of carrier testing
BMJ VOLUME 300
28
APRIL
1990
of 80% in this survey is very similar to that reported by Williamson et al, whose survey was conducted before the identification of the AF508 deletion, and the implications of only one member of a couple being identified as a carrier were not made explicit to the respondents.2 This and the fact that the number of respondents who would wish for termination but would decline testing was small suggest that the possibility of an increased risk without the chance of specific testing was of little concern. Whether couples would accept this situation with equanimity if it actually occurred during pregnancy will not be known until screening is introduced on an experimental basis. J G THORNTON K'COSTAIN M THOMAS
J M BLAKEMAN S A HESTER R J LILFORD
Departments of Obstetrics, Gynaecology, and Psychology, St James's Hospital, Leeds LS9 7TFF 1 Slack J, Houlston RS, Marteau T. Identification of the cystic fibrosis gene. BrMedj 1990;300:812. (24 MIarch.) 2 Williamson R, Allison MED, Bently TJ, et al. Community attitudes to cystic fibrosis carrier testing in England: a pilot study. Prenat Diagn 1989;9:727-34.
Disorders of the shoulder SIR,-Drs K K Chakravarty and M Webley highlighted only conservative treatments of disorders of the shoulder. These are satisfactory for mild inflammation and tendonitis, but 10% of their survey group had osteoarthritis of the glenohumeral or acromioclavicular joint and 6% rupture of the rotator cuff; 9% of the patients had severe pain. Clearly some of these patients might have benefited from replacement or reconstructive shoulder surgery, which has advanced greatly in the past 10 years. Total shoulder replacement and surgical decompression of the acromioclavicular joint are effective treatments in patients with painful osteoarthritic shoulder. These are recent, but proved, methods, as is reconstruction of the rotator cuff. Although this population of patients is elderly, they are of the age group for whom we routinely undertake more massive hip and knee replacement surgery. Patients with degenerative joint disease of the shoulder may suffer great disability, and conservative methods alone are sometimes not enough. Surgical alternatives in patients with disease of this joint should be considered as readily as they are now considered in patients with disease of the hip or knee. DAVID BARRETT
Royal National Orthopaedic Hospital, Stanmore,' Mididlesex HA7 4LI' I Chakravarty KK, Weblev M. Disorders of the shotulder: an often unrecognised (tuse of disability in elderly people. Br Med J 1990;300:848-9. (31 March.
Clinical directorates SIR,-In 1990 I shall finish five years in the position of clinical director of the medical unit at the Royal Hampshire County Hospital, Winchester. My observations are relevant to some of the points raised by Mr J N Johnson' and subsequent correspondents.2 The Royal Hampshire County Hospital, one of the six original resource management initiative sites, has, since 1986, had a hospital management board of eight clinical directors, all consultants, and four other board members, including the director of nursing services and chairman of the medical staff committee. It has not "been a pale shadow of the Guy's experience." Our strength is our sense of corporate responsibility for the running of our hospital. Difficult decisions are more agreeably made by a
group of clinical directors concerned with the overall working of their hospital, and more likely to "stick" with colleagues of a different point of view than those coming from a distant and hierarchical "management." If central government directs regional health authorities to contain spending within preset budgets and regions in turn pass this on to their districts it will be the units, both acute and community, that have to respond. An individual consultant is unlikely to overturn this. A group of clinical directors working together as a hospital management board, who can show tfirough validated information where the budgets they hold go and what clinical activities ensue, can show where "overspending" is truly "underfunding." Even if we cannot convince those higher up in health service management that more resources are needed now at worst we can indicate why clinical activity will have to be held at certain levels and at best be in a position to bid accurately for more resources if they are offered. I shall not share Dr Gordon Jackson's feeling of "emerging from a moderate depressive illness"2 at the end of my time as clinical director. My NHS clinical activity has continued at a high level, but any excursions into private practice-not my forte -have been curtailed. We have had no financial inducements, but, having accepted this limitation in my potential earnings, I have found that time has been the most missed commodity. I agree with Dr Jackson, however, that the support clinical directors receive is very important. We run a triumvirate system in which the business manager is the key person in gathering information and implementation, and I share his fears on difficulties in recruiting and keeping enough people of sufficient calibre to support directorates in all district general hospitals. In our system the third person is the senior nurse manager. While working together in a three person team the consultant and senior nurse manager respect each other's professional areas. Our system of running the clinical directorate is not covered by any of the three models proposed by the Institute of Health Service Management,3 but this is in some ways a disappointing document that almost seems to set out to prove that senior clinicians cannot get involved in hospital management. Mr Johnson's final concern is about consultants' clinical independence and freedom. Clinical freedom, in its old sense, is dead-but long live clinical responsibility based on accurate information and informed opinion. My role in relation to my consultant colleagues has been to gather their opinions and lead the medical unit on their behalf. The role of leadership by the clinical director has been pointed out by Professor Cyril Chantler.4 My consultant colleagues have supported me, and I shall support the next director who emerges from among us. My only direct clash with a colleague has been over requesting magnetic resonance imaging facilities from the private sector, for which we have no budget but which I and others in the directorate think should not be the decision of only one person. The way ahead for the NHS is difficult, under whatever government. All consultants need to participate in decisions that will affect its future. They should also give support to those prepared to act as, and suited to be, clinical directors if this system is seen to be working in their hospital for the good of that hospital and the NHS in general. A P BROOKS
Royal Hampshire County Hospital, Winchester S022 5DG I Johnson JN. Clinical directorates. Br MedJ7 1990;300:488. (24
February.) 2 Correspondence. Clinical directorates. BrMAf edj 1990;300:812-3. (24 March.) 3 Disken S, Dixon M, Halpern S, Schocket G. Models of clinical management. London: Institute of Health Service Management, 1990. 4 Chantler C. How to be a manager. Br Med J 1989;298:1505-8.
1141
