had to work uinder. The success of those first years-success measured in fiscal terms at any rate-was due in large part to the personal commitment and zeal of Cyril Chantler himself, to the increasingly embattled determination to survive as an institution, and to the "holy grail" of phase III of Guy's rebuilding, which was seen as the prize for success. All of this was long before the white paper, but in retrospect perhaps it was an unsuspected lead up to it. There was a touch of heroics about it, a kind of Dunkirk grim-gayness, but also an emerging new feeling of a genuine clinical ownership of the hospital's decision making and direction finding. Clinicians were setting priorities and lay managers and administrators lending their efforts to achieve these. We at last began to be able to show in a reasonably quantitative way what we were doing and in grossed-up terms how much it cost to do, where the shortfalls lay, and what was. needed to meet them. Directors carry budgetary responsibility for their directorates-mine is for £4.8 m a year. Like some other directorates I have split this among 10 subdirectorate clinical groups, each with its nominated group leader. These are natural working units within the directorate: admitting firms, specialty groups, and the like. They play this very serious game to a set of rules, its punctuation argued over as fiercely as in any High Court. Relationships of trust and confidence between colleagues have built up and a sense of common professional purpose has emerged. A key feature of the installation of clinical management was the decentralisation of much of the central professional administrative apparatus to the directorates and in particular the emergence of the directorate business manager. This important post has been occupied in medicine by two successive excellent people with whom it has been a pleasure to work. The directorate structure itself has evolved and our arrangements in medicine (nephrology, neurosciences, oncology, and cardiology have their own directorates) may be of interest. Backing myself and my business manager, my deputy director, a source of great support, takes on a defined segment of management (for example, junior medical staff) and is working up our use of new information systems. The consultant geriatrician (as the leader of the largest of the clinical groups) also serves, along with a changing consultant without portfolio and the current senior registrar in medicine. The nursing interest is represented by a senior nursing officer. The directorate is also served by a visiting finance officer who owes prime allegiance to the central finance department. This group meets regularly for two hours or so every week with frequent ad hoc and special meetings. I spend, I estimate, between one and one and a half days a week working at it. I feel myself to be truly and rather fiercely responsible for my directorate and am answerable for it to a clinical management board. It is the loss of this clinical board with its sense of prime clinical purpose and its subjugation to a prime financial purpose that is to my mind a major subversion threatened by the white paper directives. A new layer of direction will inevitably be laid over the clinical board and clinical ownership will be lost. Clinical management is certainly not without its problems. Much power has been delegated to directorate level, perhaps too much for the liking of "the centre." The clinical board does not vote. It advises and the chairman decides. The Guy's "parliament" of its old medical and dental committee, composed of all consultants (but with no nursing or other representation) has been an important counterweight-a vital one in the present white paper management processing-to a potentially authoritarian, even autocratic style of management that could fall totally into the hands of business led administration. True clinical management of the sort we now have seems much more likely to survive in an autworitv administered hospital where the new streamlined board of


business directors will be at least at arm's length.

Clinicians will continue to determine their own destiny and make clinically led decisions about the conduct of their hospitals. H KEEN l)ivision ol Medicine. United Medical and lDental Schools ot Gotv's and St Thomas's Hospitals, London SEiI 9RT I Johnson JN. Clinical directorates. Br Med j 1990;300:488. 24 FCbruarv.) 2 Chantler C. How to be a manager. Br Medu 1989;298: 1 505-8.

Juniors' hours of work SIR,-The arguments for a reduction in hours for doctors are clearly made in Dr Tony Delamothe's editorial.! Reducing the hours alone, however, may divert attention from the equally great need to reduce the stress of the work. Attempts to reduce doctors' hours in isolation have not produced the expected benefit in terms of reduction of stress and increased wellbeing.2 A cut in hours may uncover the stress that the doctors are under rather than reduce it. Increasingly there are changes in hospitals that introduce new causes of stress. Now, particularly when they are on call, a considerable amount of doctors' time and effort will be taken up trying to find beds for patients. This puts them in competition with each other and at risk of conflict with general practitioners whose patients they are unable to admit. Junior doctors have neither the time nor the skills to juggle beds in this way. Escalating defence fees are evidence of the increasing threat oflitigation. Obviously, negligent doctors must be identified and patients or relatives who have suffered unnecessarily must be compensated, but the vast majority of conscientious, hard working doctors must be reassured and the burden of potential negligence lifted from them. This requires more support from within the profession, a more open dialogue with patients, and the introduction of no fault compensation. Junior doctors are in training posts. Therefore they should have time to learn and receive feedback on their performance. Not only is there no time to study, however, but feedback usually consists of the occasional subjective comment. Over the past 20 years general practice has developed its own training programmes. Furthermore, certain general practitioners have undertaken further training to supervise the trainees and provide them with regular teaching and objective feedback while the trainees are undertaking a real workload in their general practices. If real training can be done in general practice why not in hospitals, where the grouping together of doctors could allow for economies of effort? To cope with stress we must first acknowledge that we are suffering from it. Our present system, however, seems to regard the voicing of distress as a sign of weakness. In America "wellbeing committees" have been established to take on the threat to the health, both physical and psychological, of senior students and junior doctors.' The committees provide telephone help lines for the doctors and opportunities to discuss personal and professional problems. New courses have been established to help medical students understand the pressures that they are under in their medical training. Such committees could be established in this country and could also take on the supervision of the educational needs of junior hospital doctors. General practitioners, with their counselling and educational skills, could play a key part on such committees. PAUL KINNERSLEY

1)epartment of General Practice, ULniiersitv of Manchester, Manchester Al 14 5NP

I D)larnothc 'F. Juiniors' hoturs ott workl.

BrAledj 1990(;300:621-4.

1I).10arch. 2 Xerurer ER, Kursch B1M. In: Shapiro (., Lowcnsteiln M, eds. Becoming a phvsician: dvc% lopmcnt of attitudes in medic in Ness York: Ballinger Publishing. 1979. 3 Weinstein HMil. A committce on welt-being ol miiedical studenits and houisc statf. 7 ,1d Eduic 1983:58:373-8 1.

SIR,-In his leading article on junior doctors' hours of work Dr Tonv Delamothe discusses comprehensively the points already raised on this difficult topic.' So far, however, little progress has been made on reducing the hours, and legislation is unlikely to be included in the NHS bill that is currently going through the parliamentary process. The hours actually worked when on call vary tremendously, depending on grade, from specialtv to specialty; within the same specialty in different hospitals; and even within the same specialty in the same hospital. In many posts where the rotas are one in three (84 hours a week) there is little work done out of hours, and in others that nominally require the same number of hours on call the work is such that doctors rarely get to bed. When a single blanket legislation is being considered for such a dichotomy of working patterns universal support will not be obtained and legislation may not be a good answer. A way forward would be for the relevant colleges and royal colleges to take action on hours of work for the doctors whose training they oversee. In every hospital they could assess the work done out of hours and recommend the maximum number of hours that should be undertaken in a particular post to ensure that persistent or repeated fatigue and its effect on performance and learning are avoided. Hospitals that do not obey the recommendation could have their training recognition withdrawn. This would entail considerable work, but a similar process has recently been completed by the regional medical manpower committees, which looked at hours of work in all specialties in all hospitals. In Wessex, in those posts where the rota was to remain more onerous than one in three, work diaries were obtained from the doctors concerned in which they recorded their out of hours work for a period of one month. This could be done by all junior doctors and after collation of the information could be acted on by the appropriate college. This approach would avoid cross cover by junior doctors into specialties in which they have no postgraduate training. The pitfalls of blanket legislation, including its effect on numbers of junior doctors, would be avoided, allowing the excellent initiative of Achieving a Balance to be retained. Finally, the prestige in which the colleges and royal colleges are held would be enhanced, both in the eyes of junior hospital doctors and also, importantly, in the eyes of the government. JOHN STUBBING

Bodesv, Hampshire S03 2FZ Delamothe T. Juniors' hours of work. Briled 1990;300:623-4.

(10 Mlarch.)

Inadvertent duplicate publication We regret that the letter entitled "Scottish consultative committees could take action" by Mr Drummond Hunter (10 March, p 682) was substantially the same as that published in the Lancet entitled "Illegal acts of Scottish Health Minister" (17 February, p 414). Although the same letter was submitted to both journals neither editor was informed. We regret this inadvertent duplicate publication. (A reply to Mr Hunter by Dr J W Crawford appeared in the Lancet of 10 March, p 609.)


7 APRIL 1990

Juniors' hours of work.

had to work uinder. The success of those first years-success measured in fiscal terms at any rate-was due in large part to the personal commitment and...
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