NE;WS

&

Political Review

Health reforms in New Zealand Last week the New Zealand government's budget laid bare a radical plan for a new health system. The most dramatic changes are the introduction of "user pays" policies, which close the door on free hospital care to all those earning over NZt30 000 (£210 000) a year, and a radical restructuring of the administration of the health service. Overnight, area health boards were abolished in the first move towards separating the purchasers of health care from the providers. The drive for change has been largely economic, with emphasis on cost cutting and value for money. Rising costs for consultations with general practitioners and prescriptions have stretched the health budget despite the closure of many key services. According to the government the new user pays policy will raise welcome revenue and the restructured system will ensure that only the most efficient services will receive central funding. Four regional health authorities replace 14 area health b-oards. These will receive money from the health department, and the amount will be calculated according to a formula based on their population. Each authority will be responsible for purchasing health services, both in primary care and in hospitals for its population. Unlike the area health boards, the regional authorities will not own any hospitals or other facilities and will be free of the conflicts of interests that the old boards faced in using their own, not necessarily most efficient, services. Instead, the health providers in public, private, and voluntary sectors will have to compete for contracts to provide the services required.

Large public hospitals and services now owned by boards on behalf of the government will become autonomous, publicly owned businesses with appointed boards of directors. Small communities will be able to take over their local hospitals and run them as trusts. These services, to be known as crown health enterprises, will be overseen by a special minister.

As a prerequisite to user pays policies New Zealanders have been divided into low, modest, and high income groups. Those in the higher groups will subsidise almost free health care for those with low incomes by paying the full costs of primary care and prescriptions and part of the costs of all hospital based services used, including inpatient, outpatient, casualty, and laboratory services. A ceiling has been set for the maximum amount payable annually for each family or person, depending on income. The levels set for income groups have

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NVew Zealanders think of their health reforms?

come as a surprise to most New Zealanders. Single people earning NZ$17 000 and families earning NZ$28 000 a year are being regarded as high earners. There is already much debate on the government's 'plan to issue green cards to those entitled to free health care. Private health insurance is currently held by only a minority, and the government assures people that it remains an optional extra. Insurance corupanies, however, have been quick to announce increases in premiums of up to 20% and project increases of up to 300% as the new system is introduced. The new system does allow for private health care plans in which families can obtain their

thrown open to public debate, with submissions to be made by the end of November. The impact that these changes will have on the delivery and provision of health care and on medical education and employment in the health service has yet to be determined. So too has the nation's response to being divided into those who pay and those who don't. LYNDY MATTHEWS, psychiatrist, Auckland

Asking about HIV

Should insurance companies ask applicants for life insurance if they have ever been tested allocated health funds from their regional for HIV infection? The Association of British health authorities and transfer the money to a Insurers says yes but that it will not discrimiprivate or other organisation to buy a package nate against those who have been tested. Its of core health services. Patients will decide statement on the subject is: "having had a what services to buy with their money. negative HIV test will not, of itself, prevent The new system is expected to be running someone from obtaining life insurance or by July 1993. Meanwhile, two key bodies will even affect the cost, providing there are no be established to monitor and implement the adverse risk factors present." changes. One of them will also oversee the But, according to a report commissioned establishment of a new public health agency, by the association with the Department of directly responsible to the Department of Health, doctors and AIDS counsellors are Health, which will coordinate and fund either not aware of this statement or do not research and national health programmes believe it. (such as immunisation and antismoking The' report finds that the views of the campaigns). Decision-s about what consti- general public and AIDS workers are in tutes core health services and the. details of conflict. Two thirds of the general public how health care should be paid for have been think that it is'right to ask people if they have 327

Headlines Third wave of trusts for 1993: The Department of Health is inviting units to express an interest in joining the third wave of NHS trusts from April 1993. The successful units out of the 113 that applied to join the second wave from April 1992 will be announced in the autumn. Increase in cholera in Africa: Altogether, 45 150 cases ofcholera in Africa were reported in the first seven months of 1991 compared with 39200 cases reported in the whole of 1990. The World Health Organisation reports that mortality from the ;>disease is 66-10% in some countries but rises to as much as 30% in some parts of Africa.

Disappointing organ donor poll: Only half of the British MPs asked abbut organ donor cards responded, and most do not carry a card. MPs said that they were "squeamish" and "not brave enough" and found the idea "distasteful and morbid." Sir Michael McNair-Wilson, a beneficiary of transplantation, says that more education and publicity are needed if waiting lists for transplants are to be reduced.

Hepatitis vaccination and insurance cover: The Public Health Laboratory

Service and the Association of British Insurers have given an assurance that the existing life insurance policies of health care workers who accept the offer of a vaccination against hepatitis B or serological tests will be unaffected. Those taking up new policies should explain the reasons for the test by stating "vaccination programme for health care workers." Voluntary AIDS testing for German doctors: The German health ministry and doctors' associations have agreed to recommend voluntary HIV testing for doctors and dentists. Marfan syndrome gene discovered: A gene on chromosome 15 responsible for making a connective tissue protein is responsible for Marfan syndrome, a potentially fatal inherited disorder affecting one in 10 000 Americans, according to American scientists (Nature 1991;352:279-81). The findings will have immediate use in early diagnosis of patients and in prenatal

diagnosis. New type of genetic defect: A duplication of part of chromosome 17 seems to be responsible for the most common form of Charcot-Marie-Tooth disease, an inherited disorder of the peripheral nerves affecting an estimated 130 000 Europeans.

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either been tested for HIV or counselled for HIV infection or any sexually transmitted disease, on insurance forms. But over two thirds of AIDS workers thought that these questions should not be asked. The same number thought that these questions put people off having tests for HIV. The AIDS workers also considered that the questions would not help insurance companies to categorise high risk people. The report quotes one helpline worker as saying, "At the moment if you are male and unmarried you are positively discriminated against. If the Pope applied for insurance in this country he wouldn't get it." The report concludes that although the questions are not an issue for the general public, they are an issue for AIDS workers and some young people. It states that "it is definitely the case that there are somei people who are put off taking an HIV test because of the questions on insurarxce proposal forms. . . the gross number is unlikely to be small." The position of the insurers is clear. Michael Pickard, chairman of the Association of British Insurers' life insurance council, argues that "without the .., questions the great majority of insurance customers would end up subsidising the very small minority of people who are most at risk of HIV infection." So what are the adverse factors that may result in a person with a negative test result paying a higher premium? According to a press officer at the Association of British Insurers, that person may be charged more for a reason unrelated to the test. "He may be a hang glider," she said. "It's up to individual companies to assess what the high risks are, but it may be the case that they charge a homosexual person more." -LUISA DILLNER,

One of the two surgeons reported having performed surgery on patients with known HIV infection or AIDS. A commentary in Morbidity and Mortality Weekly Report (17 May 1991, pp 309-11) discusses the limitations of the study, the main one being that those who knew that they were HIV positive may have declined to participate-thus leading to an underestimate of the true prevalence of HIV infection. But, given the finding that in the month before the survey 87% of the respondents had had skin contact with a patient's blood and 39% had sustained a needlestick injury or cut from a sharp object contaminated by a patient's blood, the commentary is in no doubt of the need for continuing precautions for all those exposed to blood and body fluids. Will other groups of health workers follow the lead of these orthopaedic surgeons?-TONY DELAMOTHE, BMJ

Water companies may be prosecuted

Many consumers still receive "unwholesome" tap water, and in the past year 35 of Britain's 39 water companies have been issued with enforcement notices to improve water treatment. Four water companies could face prosecution for supplying water "unfit for human consumption," according to a report from the Drinking Water Inspectorate. But, overall, drinking water in Britain is of high quality. Of 3.3 million samples tested, 99% met the required standards. The inspectorate, part of the Department of the Environment, does not carry out its BMJ own tests but scrutiises the results of those AIDS and Life Insurance, by the Department of performed by the water companies. These cover 57 different aspects of water, including Health, is published by HMSO, price £5.75. levels of pesticides and bacteria. In its first annual report since it was set up in January 1990 the inspectorate expresses concern over finding higher than expected levels of bacteria in drinking water. Coli-

Truth or dare?

Is orthopaedic surgery a risk factor for AIDS among surgeons? North American orthopaedic surgeons, 70% ofwhom either train or practise in places where AIDS is common, have a vested interest in finding out. At their annual meeting earlier this year they were invited to participate in an anonymised survey of the seroprevalence of HIV. Participants received counselling before the test, provided verbal informed consent, and completed a questionnaire to ascertain demographic details and the characteristics of their clinical practice as well as the presence of non-occupational risk factors for HIV infection. Half the surgeons took part in the study, half of whom had previously been tested for HIV. Of the 3420 participants, only two tested positive for HIV: both reported nonoccupational risk factors for HIV infection (as did another 106 participants in the study). Both the HIV positive surgeons were men and reported having performed surgery on patients with risk factors for HIV infection.

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forms were detected in 0 5% of samples and faecal coliforms in 0-1 %. Pathogenic bacteria were found in 529 water treatment works. Bacteria were also found in service reservoirs and water towers and in water from taps. In most cases only a trace of bacteria was found, but some consumers were advised to boil their water. The inspectorate tends to see the presence of coliforms as a warning that other, more pathogenic bacteria may be able to find their way into the supply. The unexpectedly high incidence of bacterial contamination remains unexplained, though it may have had something to do with last year's hot summer. The inspectorate also relies on the water companies to warn it of possible incidents of contamination. Last year it received 79 such warnings, in 54 of which drinking water became contaminated. After investigation the inspectorate thought that only the four companies now facing prosecution had been negligent in allowing contaminated water to reach consumers. The government meanwhile is facing legal action from Friends of the Earth and the European Commission for failing to meet standards set by the European Community. The High Court action being brought by Friends of the Earth concerns the exemption given to Thames Water to continue to exceed the European Community's directive on pesticides until the year 2001. If Friends of the Earth is successful it could bring an end to the system of exemptions by which water companies are given time to comply with standards. -FIONA GODLEE, BMJ

Children harmed by traffic fumes Air pollution from road traffic is damaging children's health, causing an increase in chest infections and asthma, according to a review of scientific research from 10 countries published last month. The report, commissioned by Greenpeace, concludes that "pollutants from traffic exhaust may exacerbate and in some circumstances even initiate asthma." Children are more vulnerable to the adverse effects of air pollution because they breathe more air for a given volume of lung tissue, are more active, and spend more time outside in the summer, when ozone concentrations are high. Ozone, formed by the action of sunlight on hydrocarbons and oxides of nitrogen in traffic fumes, has been linked with impaired lung function in adults and children, especially during exercise. But children are less likely to suffer the warning symptoms of eye and respiratory irritation and so may continue to exercise while being exposed to harmful levels of ozone. The report also examines the harmful effects of sulphur dioxide. In 1987 concentrations in central and western Europe reached a daily average of 111 parts per billion and were associated with a fall in lung function in a group of Dutch children, which persisted for up to a month. Guidelines on air quality from

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Smog leaves cnluaren gasping

the European Community set a daily average of 37-55 parts per billion for sulphur dioxide. This is regularly exceeded in Britain, especially in coal mining areas. Other harmful components of air are carbon monoxide at highest concentrations inside cars; lead; and the carcinogenic hydrocarbons present in traffic fumes. Benzene, for example, has no safe level in the World Health Organisation's guidelines because of its ability to cause cancer in humans. Traffic fumes account for a third of the hydrocarbons, half the nitrogen dioxide, and almost all the carbon monoxide in air. Fossil fuel power stations contribute a third of the nitrogen dioxide and three quarters of the sulphur dioxide. Air pollution from traffic is likely to increase with the projected 142% increase in traffic by 2025. A copy of the report has been sent to Malcolm Rifkind, Secretary of State for Transport. "Children's health is suffering from the government's unwillingness to reduce pollution from traffic," said Charlie Kronick of Greenpeace.-FIONA GODLEE, BMJ

NIH "confused" about ethics rules An investigation by the Office for Protection from Research Risks, a branch of the American National Institutes of Health (NIH), has found little understanding throughout the NIH of the regulations and policies for protecting human subjects in experiments performed by outsiders and "widespread confusion within NIH" about who is responsible for ensuring that the rules are complied with. The risks office has suggested measures to correct the problem, including the establishment of an intramural office of human subject protection. The NIH is now

creating one. The investigation, which took a year to

perform, was prompted by allegations made in the Chicago Tribune by its reporter, John Crewdson about American AIDS researcher Dr Robert Gallo, of the NIH. Crewdson's original articles supported a French claim that Professor Luc Monteigner, of the Pasteur Institute- rather than Dr Gallo - had first discovered HIV. Although a lawsuit over the issue was settled when the United States and French governments agreed to give equal claim to both researchers, the scientific debate has rivalled the assassination of President Kennedy as a never to be settled mystery. Crewdson's latest revelation-that Dr Gallo helped another French AIDS researcher who did not observe the rules for ethical human research imposed by the American Department of Health and Human Services-has now led to severe restrictions on Gallo's collaborative work in developing an AIDS vaccine. "Effective immediately," wrote the NIH director, Dr Bernadine Healy, to Dr Gallo on 21 June, "any proposed collaboration involving human subjects by you and your staff with scientists or institutions outside the NIH, domestic or foreign, will require review and approval" by five separate NIH offices. Dr Healy imposed the same requirements on two other NIH researchers, Dr Bernard Moss and Dr Takis Papas, who had also collaborated with the French scientist Dr Daniel Zagury, of Pierre and Marie Curie University in Paris, In addition, Dr Healy reaffirmed a previous order banning any collaboration on clinical trials between NIH researchers and Dr Zagury or the institutions in France and Zaire with which Dr Zagury is associated unless the collaboration is first approved by the risks office (13 April, p 930). Between 1986 and 1990 Dr Zagury conducted nine projects in Zaire and France with help in one form or another from NIH researchers, such as the provision of reagents or analysis of blood. In 1986 Dr Zagury became the first researcher in the world to inoculate HIV negative people with an AIDS vaccine. The vaccine used, however, was given to him by Dr Moss for tests on animals, 329

not on humans. Dr Zagury told the risks office that he was not told that it could not also be tested on humans or that he had to comply with American ethical rules in clinicaltrials outside the US. The risks office says that Dr Gallo has been listed as a coauthor with Dr Zagury in at least 14 scientific publications since 1984. "Dr Zagury credits Dr Gallo with making entrance into his present field of research possible and with catalysing a network of colleges to assist him," the report says. The importance of these "collaborations" with Dr Zagury is not an issue for the office. The report concludes: "While some may argue that the contributions of individual intramural scientists to certain projects described above did not constitute 'collaboration,' undisputed settlement of the issue of individual investigator responsibility is not necessary to a determination of institutional responsibility on the part of NIH." Last month, in separate letters to Dr Healy, Drs Moss and Papas responded with spirited defences to the criticisms. Dr Papas, in particular, protested that, "I did not violate any [Department of Health and Human Services'] guidelines." So far, Dr Gallo has been publicly silent on the matter. -RIEX RHEIN, medical journalist, Wa$hington, DC

Able parents

200 disabled mothers had shown that professionals often acted "out of ignorance and anxiety," tending to intervene unnecessarily during pregnancy and labour yet providing little-appropriate support afterwards. Despite their problems many disabled parents proudly say, "we are a normal family," according to Michele Wates, a mother who has multiple sclerosis. At the meeting she presented the findings of a survey that she had conducted, showing that disabled parents appreciated all the "quality time" they have with their children-they often have more time than other parents. Offering choice and explanation before childbirth is as important for disabled pregnant women as for anyone else, said obstetrician Mrs Ruth Cochrane. She emphasised that hospital staff should plan ahead for special needs and problems -for example, certain positions may ease labour, and the woman may need a caesarean section or special postnatal care. Health professionals should understand the nature of the mother's disability and the full range of her ability. She may need individually tailored information about sources of help and extra professional

support-for example, from occupational therapists, obstetric physiotherapists, and home helps. One way to make staff more knowledgeable is through "disability awareness training," preferably run by disabled people.

Despite recent improvements in society's

approach to disability Mukti Jain Campion's shows that disabled mothers often Steeotpesofisale-peol dresearch Stereotypes of disabled people do not include carry the "enormous and unnecessary burden their caring for others, said Micheline Mason of having to prove that they can cope better

of the Integration Alliance, a mother who is than anyone else."-DAPHNE GLOAG, staff seriously disabled. Yet many disabled people editor, BMJ are capable parents. She was speaking at the Maternity Alliance's meeting on "Able The Maternity Alliance is at 15 Britannia Street, parents: disability, pregnancy, and mother- London WC1X 9JP. hood," held last month in London. Disabled parents, according to television producer and writer Mukti Jain Campion, are only a small proportion of the disabled adults who would like to have been parents but whose wishes "were kept submerged by the ocean of ignorance and prejudice of Infections with HIV and AIDS are rapidly those around them." Her research on over becoming the most common fatal complications of cocaine use, according to Dr Don des Jarlais, of the Beth Israel Medical Center, New York, speaking at a symposium convened last month in London by the CIBA

Cocaine and HIV

Foundation. Recent studies in the US have shown consistently that among people who inject both heroin and cocaine it is the cocaine injection that carries the higher risk of exposure to HIV. The exact explanation for this finding is unclear, but observational field research suggests that the reason is the sheer frequency of injecting during binges of cocaine use-up to 15 to 25 times in a single day. Some people, injecting every 10-15 minutes, were reported to leave the needle sitting in their vein and to top-it up every few minutes. Despite estimates that there are 60 000 HIV positive drug users in New York alone distribution of clean needles and syringes is still illegal in the US and there is little likelihood of this changing. Dr Rees The pleasures of normal family life often outweigh the problems ofdisability

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Jones, of the University of California and Los Angeles, San Francisco, stated that "treat-

National addiction centre Creating greater public understanding of the problems of addicts and their addic-

tions is one of the aims of the new National Addiction Centre opened in London last month. The centre is intended to contribute both to scientific understanding and to treatment and prevention of all kinds of substance addictions. The aim is to integrate research, teaching, training, and education and to allow cross fertilisation of ideas between researchers working with different addictions-alcohol, drugs, nicotine, and tranquillisers. Funded by Action on Addiction, the Bethlem Royal and Maudsley Hospitals, and the Institute of Psychiatry, the centre is the first multi-addiction research centre in Britain. The first phase, opened last month, is the Addiction Sciences Building at the Maudsley Hospital, but the centre will also include a community drug centre in south London, a residential rehabilitation centre at the Bethlem Royal Hospital, and inpatient facilities at both hospitals. -MICHAEL FARRELL, senior registrar in psychiatry, London

ment and prevention policies in the US are constrained by what is politically correct [and] expedient and by a federal policy of 'zero tolerance' for any illicit psychoactive drug use. Alternative strategies should address fundamental problems in ghetto life:

violence, poverty, poor health, no education, no jobs and few reasons for not taking drugs." In South America, too, HIV infection is occurring in those who inject cocaine. Researchers report rates of HIV infection among injectors in Rio de Janeiro of 36%, in Santos of 57%, in Buenos Aires of 44%, and in Rosario of 40%. Use of non-injected cocaine is also associated with HIV exposure, particularly through the exchange of sex for crack. -MICHAEL FARRELL, Drug Dependence Clinical Research and Treatment Unit, London SE5 8AF

Waiting list muddle John Major's citizen's charter is exerting pressure from the top to reduce hospital waiting lists. Further pressure was applied from below last week when MPs on the Commons public accounts committee recorded "profound concern" about worsening waiting times for outpatient appointments.

They were commenting on

evidence from

the National Audit Office that patients may wait up to 72 weeks for a first outpatient

appointment (23 February, p 435).

The

committee wants the NHS Management Executive to ensure that all regions set broad standards for waiting times and to monitor the targets systematically rather than on the present basis of spot checks. The report says that management should

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help to cut waiting times by introducing clinics run by nurses and by taking steps to reduce the number of patients who fail to keep appointments-currently about five million each year. The committee also expects purchasers to set measurable targets for waiting times in their contracts with providers. The real point of this report, however, is that it examines for the first time a potentially serious constitutional issue arising from the NHS reforms. This is what it calls the "fundamental contradiction" between the devolved management of the reformed NHS and accountability to parliament for what is happening at individual hospitals. The contradiction was illustrated by Mr Duncan Nichol, NHS chief executive, when he told the committee that because decisions were now delegated to local management he was unable to provide detailed information (9 March, p 554). The MPs have come down on the side of central supremacy. While recognising a need for delegation and that accounting officers cannot be expected to be familiar with detailed matters throughout the service, the committee reports that, "Nevertheless we do expect the senior managers of the NHS to ensure that they are in a position to monitor the way in which other tiers of management have exercised their responsibilities, and to take action where appropriate. We also expect witnesses appearing before this committee to have up to date information on the specific matters we are investigating." -JOHN WARDEN, parliamentary correspondent, BMJ NHS Outpatient Services by the Committee of Public Accounts is available from HMSO, price £10.30.

Unequal opportunities Discrimination against women working in the NHS is "deeply engrained," and it will be a long time before the NHS can claim to be an equal opportunities employer. These are the conclusions ofthe Equal Opportunities Commission's report on women in the NHS. The report, based on the findings of 231 questionnaires sent to all the regional and district health authorities, will make depressing reading for the 910 442 women employed by the NHS. Although over 90% of health authorities have an equal opportunities policy, most of their definitions of "unlawful discrimination" are inaccurate. The commission claims that neither managers nor employees are likely to understand them. Three quarters of the policies do not mention sexual harassment, and nearly a quarter of health authorities still have job application forms that ask about marital status and children. The commission says that these are potentially "unlawful, dis-

criminatory questions." The strongest evidence of the NHS's lack of commitment to the policies comes from the fact that two thirds of health authorities have no monitoring systems for them. The report blames the NHS's high turnover of

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Hand in glove

Some NHS staff are less equal than others

staff on "its failure. . . to address issues of sex and marital discrimination." The report argues that women in the NHS are concentrated in lower paid and lower graded posts. Only 4% ofdistrict and regional managers and only 1% of consultant general surgeons are women. Women are denied access to training because it conflicts with family commitments. Part time work is scarce. Fewer than 1% of senior house officers currently work part time. The commission claims that whereas successful men in the NHS have families successful women are likely to be single and childless. The report states, "the assumption that motherhood and career are incompatible in the NHS becomes a reality when rigid working hours are the norm, and opportunities for part time work and job sharing are limited." The report attacks the reduction in junior doctors' hours as doing "little to help junior doctors who are parents." Although half the health authorities provided some facilities for child care, there were enough places in creches for fewer than 1% of the employees who needed them. There are still disparities in pay, claims the commission. State enrolled nurses, a grade in which many black and part time nurses are concentrated, are particularly poorly paid for their level of responsibility. The commission warns that the NHS can no longer neglect these issues. It recommends that policies and objectives for equal opportunities should be written and distributed to employees and managers and that committees or appointed officials should monitor their progress. It states that the lead should come from the top. The NHS Management Executive is asked to publish statistics showing employment trends by sex, grade, and ethnic origin and to investigate pay structures. The commission strongly recommends that the Department of Health should establish an equal opportunities unit as other government departments, notably the Cabinet, have done.-LUISA DILLNER, BMJ

Equality Management: Women's Employment in the NHS is available from the Equal Opportunities Comniission, Manchester M3 3HN.

British surgeons hold out their hands for one particular make of surgical gloves. This means a monopoly in the supply of gloves at a cost to the NHS that is at least 50% more than it would be in a competitive market. All attempts by the NHS to break the monopoly-and the surgeons of their habithave so far failed. The situation is being investigated by the Office of Fair Trading. At a recent hearing of the Commons public accounts committee officials from the Department of Health spoke of budding surgeons forming an early attachment to one special brand of glove made by the London Rubber Company costing up to 58p a pair. The NHS had tried to find alternative brands and had encouraged other companies to supply gloves used throughout Europe, but without success. The department has looked into the possibility that the London Rubber Company might be providing surgeon's gloves free to key teaching hospitals and has found no evidence to justify any such claims. -JOHN WARDEN, parliamentary correspondent, BAM7

Murder on antidepressants A man given a life sentence for the savage killing of his wife and a family friend probably carried out the killing while in a manic state induced by a common tricyclic antidepressant, a leading psychiatrist told the Court of Appeal last month.. Christopher Roberts may have been experiencing a rare side effect of an overdose of amitriptyline when he perpetrated the killings, Griffith Edwards, professor of addiction behaviour at London University's Institute of Psychiatry, said. Professor Edwards is supporting Mr Roberts's appeal against a life sentence imposed at the Old Bailey in March 1990. He pleaded guilty to manslaughter on the grounds of diminished responsibility. On Friday his counsel, Ronald Trott, argued that he posed no danger to society and ought to be freed in the near future. The case, described by the deputy chief justice, Lord Justice Watkins, as "one of the most unusual," is believed to be only the fourth in which the court has heard fresh evidence in an appeal against sentence only. After hearing Professor Edwards's testimony the judges ordered that his report should be shown to the two forensic psychiatrists who gave evidence at Mr Roberts's trial. If they disagreed with it the court would be reconvened in the autumn to hear their evidence. Mr Roberts, 44, a former minicab driver with no criminal convictions, was given amitriptyline by his general practitioner for mild depression. He went berserk, hitting his victims with an iron bar and attempting to sever their heads with a kitchen knife. Afterwards, 16 amitriptyline tablets were found to be missing and his blood concentration of the drug was higher than expected.

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There are believed to be no reported cases of killings after an overdose of a tricyclic antidepressant. But Professor Edwards said that there were published warnings that the drug could cause a reaction similar to belladonna poisoning, with delusions and hallucinations. It could also make people hypomanic. This would not require a massive dose of amitriptyline because people reacted differently to the same drug. There was some suggestion that Mr Roberts had a capacity to have hypomanic episodes, and this would make him vulnerable to a reaction. The case was a peculiar one because of the speed of onset and disappearance of manic illness, Professor Edwards said. Mr Roberts had been sent to Broadmoor, but within days his behaviour had returned to normal. "When you have a swift onset and swift offset of raving madness you have got to explain it; you are in unusual pastures," Professor Edwards added. "It immediately alerts me to drug poisoning. Mental illness is something which doesn't come like a thunderclap and doesn't disappear like a summer's day. "From a not very worrying condition, he is mentally about as ill as he can get. It is very difficult to see anything to explain it except drug poisoning."-CLARE DYER, legal correspondent, BMJ

Wardship court enforces treatment A disturbed 15 year old girl was not competent to make her own decisions about whether to accept or refuse treatment with antipsychotic drugs, the Court of Appeal ruled last month. Lord Donaldson, Master of the Rolls, and Lord Justice Staughton and Lord Justice Farquharson were giving their reasons for authorising the treatment earlier this month. The judgment is an important one for those doctors who treat mentally disturbed youngsters. The judges gave guidance on how the House of Lords judgment in the Gillick case-which laid down the test for deciding whether a child under 16 is capable of giving valid consent to treatment -should be applied in cases of mental illness. The judges also considered whether the wardship court can override the wishes of a child who is competent to take a decision on treatment-a point never before considered by the Court of Appeal-and decided that it can. This confirms that doctors can use wardship when an older child refuses treatment even if the child is not mentally disturbed and is capable of making his or her own choices.

The teenager, known only as R, was in care after exhibiting disturbed behaviour, including hallucinations and suicidal tendencies. She absconded from a children's home and returned to her own home, where she damaged the building and furniture, savagely attacked her father, and assaulted her mother. She was sectioned under the 332

Mental Health Act and spent a week in a general hospital psychiatric ward before being discharged to an adolescent psychiatric unit. The local authority at first consented to the administration of antipsychotic drugs in the unit but then withdrew consent after a social worker received a lucid telephone call from the girl, who stated that she did not want to take the drugs. The girl was made a ward of court, and a High Court judge ruled that the drugs should be given despite evidence from a consultant psychiatrist that she was capable at the time he saw her of understanding the nature and implications of the treatmentthe test in the Gillick case -although at other times she would not have been. Lord Donaldson said that the psychiatrist's evidence showed that the Gillick test was

capable of being misunderstood. There was no suggestion that the extent of a child's competence to understand could fluctuate day by day or week by week. The test had to be modified in cases of "fluctuating mental disability." The child would have to understand not merely the nature of the proposed treatment-in this case compulsory medication-but the possible side effects and the anticipated consequences of a failure to treat. It was far from certain that the psychiatrist was saying that the girl understood the implications of withholding the treatment. And even if on a good day she met the Gillick criteria, on other days she was not only not competent to decide but actually sectionable. No child in that situation could be described as competent under the Gillick test. -CLARE DYER, legal correspondent, BMy

The Week Juniors' hours have been "tackled" before. What makes the current attempts different is the fact that all the many players in this game-the juniors themselves, the seniors, the colleges, the department, the minister, NHS managers-have very publicly committed themselves to stated reductions in hours and to mechanisms for achieving the reductions. There is detailed guidance on shift systems, there are regional task forces to work out the details-and there are roadshows. The roadshows are being run by the Department of Health to explain the changes, and I and about a dozen juniors joined a hall full of consultants, managers, and nurses at the one in Nottingham last week. Trent's regional task force is clearly taking its job seriously. Over the next three months its members will visit all 44 units in the region, Dr Derek Cullen, the royal colleges' representative on the task force, told the roadshow. The teams will be led by a management consultant accompanied by a junior and a consultant, and they will spend at least a day in each unit. The task force has already started identifying training posts and has sent out a questionnaire on juniors' working environment: it wants to know whether their units employ ward clerks and phlebotomists and what catering facilities are available out of hours. Dr Cullen claimed that Trent was the first region to allocate £250 000 to improve juniors' living conditions. An extra 14 consultants and four staff grade doctors will be in post by March 1992, and the task force will be able to recommend the need for further doctors and redistribute posts. Dr Cullen and his colleagues are prepared to knock heads together, but they hope to encourage rather than coerce. Other speakers at the roadshow reaffirmed their commitment to the deal. Brian Edwards, the regional general manager, promised that the problem of

juniors' hours would be brought to the top of the list of priorities, and Peter Doyle, a senior medical officer at the department, expounded the advantages of moving to systems of full or partial shifts. The negotiators understandably see the deal as a real advance, but if the comments from the roadshow's audience represent a widespread view many consultants, nurses, and juniors themselves remain to be convinced. There were the familiar anxieties about cross cover in small specialties, about senior registrars being forced to agree to work more than 72 hours "when it would be to the benefit of their training and they wish to do so," and about career grade doctors doing inappropriate work if they took over work now done by juniors. Peter Doyle dismissed this last complaint. At present, he said, 60% of patients were treated by junior doctors and 40% by consultants; that had to be reversed at least. He also dismissed the fear that junior doctors might do locums in their new spare time to make up for the loss of units of medical time and so end up working just as long as before. "Tired doctors," he said, "cannot provide quality care," and a hospital that employed locums who had already worked their maximum hours would not have a leg to stand on. But the questioner had a point. Money will probably be the making or unmaking of this deal. The BMA and the department have now given (separate) evidence to the review body, which should recommend pay scales to match the new rotas and shifts in October. Some juniors are still sceptical of the effect of a mere commitment to reduce juniors' hours and have long argued that legislation is the only way to force authorities to cut long hours. The other way-in a health service that is fast becoming responsive to economic incentives -is to price them out of existence. HART

BMJ

VOLUME

303

10 AUGUST 1991