not truly accountable to the electorate, and it would therefore be wholly inappropriate that they should be able to affect the decisions of council other than by contributing to any debate. I believe that the special representative meeting to be held in March will uphold the honour and integrity of the profession and that Keable-Elliott's fears are unfounded. CHRISTOPHER TIARKS Small Isles Medical Practice, Isle of Eigg PH42 4RL I Keable-Elliott T. Special representatives meeting and the political process. BMJ 1991;303:997. (19 October.)

Changing patterns of work SIR,-I was disappointed that Peter Doyle stated that "The major implications of the introduction of shift systems are for manpower, the organisation of clinical services, and teaching" without mentioning the consequences for doctors' lives.' The suggested shift systems entail working every other weekend and every evening for two weeks in four. Shift systems will always threaten family and social life but may be compensated for by longer work free periods in those jobs that demand a more acceptable level of commitment. These benefits disappear once the average weekly hours of work rise towards those expected of junior doctors. Add to the loss of social life a reduction in salary consequent on reduced hours and the continuing process of demoralisation will be complete. The only way of reducing hours of work for the benefit of both patients and doctors is to accept that pay for out of hours work should be at higher than standard rates.

SIR,-As a recently appointed consultant anaesthetist I still remember vividly the problems of long hours of work and am glad that they are at last being addressed. I have reservations, however, about the shift systems outlined by Peter Doyle.' All my junior posts had either a one in two or a one in three rota, except for a six month post as a senior house officer in accident and emergency medicine, which had a 64 hour week shift system. This was by far the most unsettling and tiring of all my jobs. It was poorly paid, and taking my annual leave or covering that of colleagues was difficult. On a one in four shift rota you have only two weekends in every four free, and arrangements for prospective cover make this worse. Each junior is entitled to five weeks' annual leave and four weeks' study leave, reducing staffing to one in three for 36 weeks of the year. Time off during the week does not equate with a free weekend. The proposed shift systems would also make childcare a nightmare without a resident nanny as no childminder or nursery will take children at 6 30 am to accommodate a 7 am start or, the next week, keep them until 10 30 pm or 11 30 pm to allow late shift working. The problems faced by a medical couple who are both working shifts seems awesome-never see each other-or never see your children. Having always managed to work full time despite having two children and a medical spouse, I do not envy the new juniors their deal. JULIA K MOORE Arrowe Park Hospital,


Wirral, Merseyside L49 SPE 1 Doyle P. Changing patterns of work. BMJ 1991;303:982-4. (19 October.)


Northwick Park Hospital, Harrow, Middlesex HAl 3UJ 1 Doyle P. Changing patterns of work. BMJ 1991;303:982-4. (19 October.)

SIR,-In trying to solve the problem of junior doctors' hours the emphasis has been on reducing the number of hours worked. There has been no real consideration of the quality of leisure time. If a shift system is adopted the quality of juniors' leisure time is eroded even further. Peter Doyle illustrates this perfectly in suggesting that shifts are inherently flexible, allowing night shifts to be lengthened to 16 hours where the workload is not onerous and juniors may snatch a few hours' sleep.' This leaves eight hours in which to sleep, eat, and try to maintain the semblance of a normal life. A week of late or night shifts is not compensated by a week of day shifts. A one in four rota, whereby you are on call one weekend in four, is preferable to split weekend shifts, which disrupt two if not three weekends each month. Being on call 24 hours once or twice a week is preferable to a whole week of night or late shifts. Shift systems make organising a social life extremely difficult and a commitment to a regular weekly activity impossible. I think that the answer to the onerous hours worked by juniors lies not in shift systems but in keeping the old system and ensuring that the maximum rota is one in four without prospective cover. This gives a reasonable number of hours worked with quality leisure time, ensuring that juniors are refreshed, maintain their enthusiasm and commitment, and thus have quality professional time too. SARAH VELLENOWETH

A gauntlet for senior house officers SIR,-Trisha Greenhalgh's description of the "cocky breed of on take senior house officers" was a missed opportunity.' Has she actually considered why people who have been carefully chosen for their intellectual and social skills are, on occasion, unhelpful-rude even-to other doctors outside the hospital? Typically, admitting senior house officers are: (1) overworked; (2) chronically tired; (3) badly fed and physically underexercised; (4) caught between patients, nurses, relatives, administrators, general practitioners, laboratory technicians, consultants, and the bleep, all of whom seem to conspire to make life even more impossible; (5) inadequately trained or experienced to be making the decisions they are expected to make; (6) surrounded by colleagues with whom they must compete at work, at interviews, and in the examination room; (7) socially isolated, with little time for anything other than studying, working, sleeping, and worrying; (8) ambitious. Whom can junior doctors share their anxieties with when many have no life outside medicine and any admission of failure or doubt is interpreted as weakness and unsuitability for their chosen profession? Is it surprising then that this group occasionally malfunctions when dealing with someone who is perceived as having no influence other than adding to the burden? DOUGLAS SALMON

Stanley, Wakefield

Birmingham B17 9SD

I Doyle P. Changing patterns of work. BMJ 1991;303:982-4.

I Greenhalgh T. A gauntlet for senior house officers. BMJ 1991;303:1069. (26 October.)

(19 October.)


SIR,-I do not know which incident stung Trisha Greenhalgh into writing her piece on senior house officers' rudeness to general practitioners,' but it merits a reply. I too am trained as a general practitioner, though I currently work as a general medical senior house officer. In common with other doctors I can dredge up anecdotal reports, in my case from both sides of Greenhalgh's divide, of rudeness and inappropriate referral. The issue here should not be the patronising of general practitioners by senior house officers or vice versa but rather that the working hours, practice, and experience of others should be respected by professional colleagues both senior and junior. Trisha Greenhalgh's article did nothing to further this end. It was offensive and she should apologise. JAMES W GERRARD

Frenchay, Bristol BS16 ILR I Greenhalgh T. A gauntlet for senior house officers. BMJ 1991;303:1069. (26 October.)

Winter pressure on hospital medical beds SIR,-Though I support Professor A S Douglas and colleagues in their concern over pressure on acute medical beds during the winter and accept their careful analysis of the situation in the Grampian region,' I think it important that those planning acute services should not extrapolate their detailed conclusions uncritically to the rest of the United Kingdom. Acute general medicine is unique. General surgical facilities are buffered by being able to reduce non-emergency -admissions at times ofpeak acute demand, and geriatric medicine acts as a governor on the system by not taking any further patients once its beds are full. Our catchment population of 710 000 is served by two district hospitals, to which all acute medical em,ergencies are admitted. In Nottingham during 1990-1, in contrast to the experience in Grampian, the number of acute medical admissions in the quarter January-March rose by 20% compared with the summer nadir in June-August. The respective lengths of stay were 6 5 and 6 1 days, in contrast with the much longer stay that Scottish resources seem to allow. It is not, however, just the numbers of admissions and lengths of stay that cause the problem but also the peak numbers and the amplitude of the fluctuation in numbers. Between April and December weekly admissions never exceeded 300, whereas in the January-March quarter this figure was exceeded on six occasions. The peak to trough amplitude in the winter was also twice that in the summer quarter. If medicine is allotted a finite number of beds the only way that such peaks can be accommodated is by letting patients overflow into general surgical beds, which happens regularly every winter in many hospitals and is an important contributory factor to lengthening surgical waiting lists. More important than beds is the excessive demand that such overflow makes on junior medical and nursing staff. The junior medical staff may be responsible for patients on at most two wards in summer but have patients scattered all over the hospital in winter. Such considerations have not so far figured very highly in plans for allocating resources. In view of the justifiable concern over junior doctors' hours and conditions of work, standards of care, and the medicolegal risks of nursing seriously ill acute medical patients in general surgical wards, this situation must change. S P ALLISON

Department of Medicine, University Hospital, Nottingham NG7 2UH 1 Douglas AS, Rawles JM, Alexander E, Allan TM. Winter pressure on hospital medical beds. BMJ 1991;303:508-9. (31 August.)



Winter pressure on hospital beds.

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