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 BMJ. * 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.
Junior doctors' hours SIR,-Last week saw the publication of a package of measures aimed at reducing the hours of duty of doctors in training (pp 1482 and 1483). As joint chairmen of the Technical Group on Junior Doctors' Hours we are confident that these measures will work. The heads of agreement, signed in December 1990, committed the government, NHS management, consultants, doctors in training, and the royal colleges to reduce long hours, both in total and in continuous stretches of duty. The new implementation package is aimed at turning the principles into reality. In particular, it sets specific controls on hours. The maximum average contracted hours of duty for all doctors in training must be reduced to 83 a week as soon as practicable and to 72 a week for those in hard pressed posts by 31 December 1994. Hours of duty for doctors working full or partial shifts will be substantially less. There will be a review in 1993 of the practical implications of bringing maximum average hours down to 72 a week by the end of 1996 for doctors in posts that are not considered to be hard pressed. The new controls also set clear limits on maximum continuous periods of duty and minimum periods of off duty between periods of duty. These will be introduced for all doctors in training by 31 December 1994 and will mean the end of 80 hour "long weekends" on duty. There will be an effective mechanism for implementing and monitoring change. In England regional task forces are charged with ensuring that all training posts are assessed against the new controls on hours, that action plans are developed for reducing hours where necessary, and that new consultant, staff grade, and senior house officer posts are established when no other solution is possible. The task forces will report every six months to the Ministerial and Technical Groups on Junior Doctors' Hours, which will closely monitor regions' progress in reducing hours, as will the NHS Management Executive. Similar arrangements have been introduced in Scotland, Wales, and Northern Ireland with variations to reflect the different circumstances in those countries. In addition, the royal colleges and the universities have a responsibility to ensure that posts meet the controls on hours and are educationally acceptable. Other aspects of the package include guidance on (a) making the best use of the skills of other staff, including nurses and midwives, to help to reduce the hours of work of doctors in training while improving the quality of care for patients; (b) improving the living and working conditions of doctors in training, which should help greatly to improve morale; (c) the scope for cross cover and the minimum level of experience required for a senior house officer to work direct to a consultant, prepared by the Conference of Medical Royal Colle-es and their Facuiilties in the United Kinm-
BMJ VOLUME 302
22 JUNE 1991
dom; and (d) the changing role of consultants in providing emergency cover throughout the 24 hour period and moving to team based working, prepared by the Central Consultants and Specialists Committee. The package of measures does not constitute a single solution to the complex issue of reducing hours; no such solution exists. Rather, it provides a framework for change within which there is freedom to select those approaches that will work best at local level. Consultants and doctors in training have a vital part to play in choosing the most appropriate ways of reducing hours where they work and delivering the changes that we are all determined to see. DIANA WALFORD Medical director NHS Management Executive, Department of Health, LIondon SWIA 2NS A P J ROSS Chairman
Joint Consultants Committce, London WC I H 9JP
Better mental health services SIR,-It is perhaps not surprising that when the president of the Royal College of Psychiatrists argues for an increase in the number of consultant psychiatrists' he is praised for his "rounded, sensible arguments" by colleagues from the same college.2 Professional bodies are bound to promote the interests of their own profession, but that can make their propositions anything but rounded. Professor Sims is right to emphasise the importance of a personal relationship with a caring person for people with mental health problems. But psychiatrists are not always rated highly in this role. Research by MIND and the Roehampton Institute found that 45% of the 500 former inpatients interviewed had not found their psychiatrist easy to talk to, 66% were not satisfied with the explanation they had been given about their condition, and 80% thought that they had been given insufficient information about the proposed treatment.' In 38% of cases the patient had never seen the psychiatrist alone but always during ward rounds, which were often experienced as daunting. In general psychiatrists were perceived as providing less help than nurses, friends, family, and fellow patients.
Of course, the psychiatrist's primary role is to provide medical and psychological treatment. But there is no compelling reason to rate the importance of these above other available supports such as social work services, practical help with employment and finance, supported housing, and self help. Our survey found that, though 90% of people conceptualised their mental health problem in social or personal terms (bereavement, housing problems, and the like), they were usually offered
nothing apart from medical treatment in hospital. Altogether 85% had not been offered any choice of service and 60% had received treatments they did not want, almost invariably drug treatment or electroconvulsive therapy. Choice is not available because of the current massive imbalance in favour of medical rather than social care. Increases in the number of consultant posts will almost certainly occur at the further expense of such support services. The case that professional psychiatric services have more to offer than other forms of support has not been made. Professor Sims's statement that "as far as the individual patient is concerned, the personal service of the consultant . . is valued most" is based on assumption, not research. We would therefore be quite wrong to support a call for an increase in the number of consultant posts, especially when other forms of support are known to be more valued by patients. ROS HEPPLEWHITE National director AIIND (National Association for Mental Health), WIN ILondon 2ED 1 Sims A. Even better services: a psychiatric perspective. BM7 1991;302:1061-3. (4 May.) 2 Jollev DJ, Benbow SM. Better mental health services. BM7 1991;302:1339-40. (I June.) 3 MIND. Peoplefirst. London: MIND, 1990.
SIR,-Professor Andrew Sims rightly says that better services for the mentally ill are possible without a massive increase in resources and that multidisciplinary teams are crucial.' Several of his statements or assumptions, however, need to be challenged. He says that "the consultant in the community is the leader of the multidisciplinary team." In fact, leadership may emerge by the consent of the team rather than by self proclamation. Leadership may shift within the team according to a patient's needs. He suggests that "among those not referred are patients who would benefit from . . modern psychiatry." This must be true in some cases, but there are strong reasons for being highly selective in referral to psychiatrists. These may include the preference of the patients, fear, stigma, and the cost of referral. Better accessibility and continuity may also be advantages of primary care. Thirdly, he says that there will be "need for psychiatrists to be skilled in a wide range of psychological treatments." Is this not the job of clinical psychologists and other trained workers? In my experience it is not true that "good practice precludes psychiatric nurses receiving direct referrals of new cases from primary care." Our weekly meetings of the primary health care team include the clinical psychologist who works in the health centre as well as the community psychiatric nurse and social worker. Cases are
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* For letters on scientific subjects we normally reserve our correspondence columns for those relating to issues discussed recently (within six weeks) in the BMJ. * 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.
Junior doctors' hours SIR,-Last week saw the publication of a package of measures aimed at reducing the hours of duty of doctors in training (pp 1482 and 1483). As joint chairmen of the Technical Group on Junior Doctors' Hours we are confident that these measures will work. The heads of agreement, signed in December 1990, committed the government, NHS management, consultants, doctors in training, and the royal colleges to reduce long hours, both in total and in continuous stretches of duty. The new implementation package is aimed at turning the principles into reality. In particular, it sets specific controls on hours. The maximum average contracted hours of duty for all doctors in training must be reduced to 83 a week as soon as practicable and to 72 a week for those in hard pressed posts by 31 December 1994. Hours of duty for doctors working full or partial shifts will be substantially less. There will be a review in 1993 of the practical implications of bringing maximum average hours down to 72 a week by the end of 1996 for doctors in posts that are not considered to be hard pressed. The new controls also set clear limits on maximum continuous periods of duty and minimum periods of off duty between periods of duty. These will be introduced for all doctors in training by 31 December 1994 and will mean the end of 80 hour "long weekends" on duty. There will be an effective mechanism for implementing and monitoring change. In England regional task forces are charged with ensuring that all training posts are assessed against the new controls on hours, that action plans are developed for reducing hours where necessary, and that new consultant, staff grade, and senior house officer posts are established when no other solution is possible. The task forces will report every six months to the Ministerial and Technical Groups on Junior Doctors' Hours, which will closely monitor regions' progress in reducing hours, as will the NHS Management Executive. Similar arrangements have been introduced in Scotland, Wales, and Northern Ireland with variations to reflect the different circumstances in those countries. In addition, the royal colleges and the universities have a responsibility to ensure that posts meet the controls on hours and are educationally acceptable. Other aspects of the package include guidance on (a) making the best use of the skills of other staff, including nurses and midwives, to help to reduce the hours of work of doctors in training while improving the quality of care for patients; (b) improving the living and working conditions of doctors in training, which should help greatly to improve morale; (c) the scope for cross cover and the minimum level of experience required for a senior house officer to work direct to a consultant, prepared by the Conference of Medical Royal Colle-es and their Facuiilties in the United Kinm-
BMJ VOLUME 302
22 JUNE 1991
dom; and (d) the changing role of consultants in providing emergency cover throughout the 24 hour period and moving to team based working, prepared by the Central Consultants and Specialists Committee. The package of measures does not constitute a single solution to the complex issue of reducing hours; no such solution exists. Rather, it provides a framework for change within which there is freedom to select those approaches that will work best at local level. Consultants and doctors in training have a vital part to play in choosing the most appropriate ways of reducing hours where they work and delivering the changes that we are all determined to see. DIANA WALFORD Medical director NHS Management Executive, Department of Health, LIondon SWIA 2NS A P J ROSS Chairman
Joint Consultants Committce, London WC I H 9JP
Better mental health services SIR,-It is perhaps not surprising that when the president of the Royal College of Psychiatrists argues for an increase in the number of consultant psychiatrists' he is praised for his "rounded, sensible arguments" by colleagues from the same college.2 Professional bodies are bound to promote the interests of their own profession, but that can make their propositions anything but rounded. Professor Sims is right to emphasise the importance of a personal relationship with a caring person for people with mental health problems. But psychiatrists are not always rated highly in this role. Research by MIND and the Roehampton Institute found that 45% of the 500 former inpatients interviewed had not found their psychiatrist easy to talk to, 66% were not satisfied with the explanation they had been given about their condition, and 80% thought that they had been given insufficient information about the proposed treatment.' In 38% of cases the patient had never seen the psychiatrist alone but always during ward rounds, which were often experienced as daunting. In general psychiatrists were perceived as providing less help than nurses, friends, family, and fellow patients.
Of course, the psychiatrist's primary role is to provide medical and psychological treatment. But there is no compelling reason to rate the importance of these above other available supports such as social work services, practical help with employment and finance, supported housing, and self help. Our survey found that, though 90% of people conceptualised their mental health problem in social or personal terms (bereavement, housing problems, and the like), they were usually offered
nothing apart from medical treatment in hospital. Altogether 85% had not been offered any choice of service and 60% had received treatments they did not want, almost invariably drug treatment or electroconvulsive therapy. Choice is not available because of the current massive imbalance in favour of medical rather than social care. Increases in the number of consultant posts will almost certainly occur at the further expense of such support services. The case that professional psychiatric services have more to offer than other forms of support has not been made. Professor Sims's statement that "as far as the individual patient is concerned, the personal service of the consultant . . is valued most" is based on assumption, not research. We would therefore be quite wrong to support a call for an increase in the number of consultant posts, especially when other forms of support are known to be more valued by patients. ROS HEPPLEWHITE National director AIIND (National Association for Mental Health), WIN ILondon 2ED 1 Sims A. Even better services: a psychiatric perspective. BM7 1991;302:1061-3. (4 May.) 2 Jollev DJ, Benbow SM. Better mental health services. BM7 1991;302:1339-40. (I June.) 3 MIND. Peoplefirst. London: MIND, 1990.
SIR,-Professor Andrew Sims rightly says that better services for the mentally ill are possible without a massive increase in resources and that multidisciplinary teams are crucial.' Several of his statements or assumptions, however, need to be challenged. He says that "the consultant in the community is the leader of the multidisciplinary team." In fact, leadership may emerge by the consent of the team rather than by self proclamation. Leadership may shift within the team according to a patient's needs. He suggests that "among those not referred are patients who would benefit from . . modern psychiatry." This must be true in some cases, but there are strong reasons for being highly selective in referral to psychiatrists. These may include the preference of the patients, fear, stigma, and the cost of referral. Better accessibility and continuity may also be advantages of primary care. Thirdly, he says that there will be "need for psychiatrists to be skilled in a wide range of psychological treatments." Is this not the job of clinical psychologists and other trained workers? In my experience it is not true that "good practice precludes psychiatric nurses receiving direct referrals of new cases from primary care." Our weekly meetings of the primary health care team include the clinical psychologist who works in the health centre as well as the community psychiatric nurse and social worker. Cases are
1533
