566

non-parkinsonian patients the feedback from the recepmight actually decrease the activity of the presynaptic neuron and this would be seen in cerebrospinal fluid

Dear

tor

as a decreased accumulation of H.V.A. However, in normal subjects at least, apomorphine, a direct dopaminereceptor stimulator, does not possess psychotomimetic properties.$4 Secondly, the primary defect may lie not in an excess of activity in a dopaminergic system, but in a deficit in a closely related but antagonistic system. In this case dopaminergic activity, although within normal limits, or even somewhat reduced, would be in relative excess, and this excess would be diminished by the effects of neuroleptic drugs. Thus it might be that the residual dopaminergic transmission in parkinson’s disease was still able to exceed the pathologically-diminished activity in the antagonistic system. REFERENCES 1. Connell. P. H. Amphetamine Psychosis. London, 1958. 2. N.I.M.H. Psychotherapy Service Center Collaborative Study Group. Archs gen. Psychiat. 1964, 10, 246. 3. Randrup, A., Munkvad, I. Amphetamines and Related Compounds; p. 695. New York, 1970. 4. Randrup, A., Munkvad, I. Orthomol. Psychiat. 1972, 1, 2. 5. Klawans, H. L., Goetz, C., Westheimer, R. Dis. Nervous Syst. 1972, 33, 711. 6. Matthysse, S. Fedn Proc. 1973, 32, 200. 7. Stevens, J. R. Archs gen. Psychiat. 1973, 29, 177. 8. Snyder, S. H., Banerjee, S. P., Yamamura, H. I., Greenberg, D. Science,

1974, 184, 1243. Jönsson, L-E., Gunne, L-M. Amphetamines and Related Compounds; p. 929. New York, 1970. 10. Rylander, G. Psychiat. Neurol. Neurochir. 1972, 75, 203. 11. Angrist, B. M., Sathananthan, G., Wilk, S., Gershon, S. J. psychiat. Res. 1974, 11, 13. 12. Griffith, J. D., Cavanaugh, J., Held, J., Oates, J. A. Archs gen. Psychiat. 1972, 26, 97. 13. Randrup, A., Munkvad, I. Psychopharmacologia, 1967, 11, 300. 14. Randrup, A., Munkvad, I. Nature, 1966, 211, 540. 15. Creese, I., Iversen, S. D. Brain Res. 1975, 83, 419. 16. Randrup, A., Munkvad, I. Psychopharmacologia, 1965, 7, 416. 17. Espelin, D. E., Done, A. K. N. Engl. J. Med. 1968, 278, 1361. 18. Carlsson, A., Lundqvist, M. Acta pharmac. tox. 1963, 20, 140. 19. Kebabian, J. W., Petzold, G. L., Greengard, P. Proc. natn. Acad. Sci., U.S.A. 1972, 69, 2145. 20. Miller, R. J., Horn, A. S., Iversen, L. L. Mol. Pharmac. 1974, 10, 759. 21. Clement-Cormier, Y., Kebabian, J. W., Petzold, G. L., Greengard, P. Proc. natn. Acad. Sci., U.S.A. 1974, 71, 1113. 22. Davis, J. M. J. psychiat. Res. 1974, 11, 65. 23. Seeman, P., Lee, T. Science, 1975, 188, 1217. 24. Hornykiewicz, O. Pharmac. Rev. 1966, 18, 925. 25. Cole, J. O., Clyde, D. J. Rev. can. Biol. 1961, 20, 565. 26. Bishop, M. P., Gallant, D. M., Sykes, T. F. Archs gen. Psychiat. 1965, 13, 9.

155. 27. Chien, C. P., Di Mascio, A. Am. J. Psychiat. 1967, 123, 1490. 28. Herman, E., Pleasure, H. Dis. Nervous Syst. 1963, 24, 54. 29. Crow, T. J., Gillbe, C. J. psychiat. Res. 1974, 11, 163. 30. Miller, R. J., Hiley, C. R. Nature, 1974, 248, 596. 31. Snyder, S. H., Greenberg, D., Yamamura, H. I. Archs gen. Psychiat.

1974, 32, 58. 32. Andén, N-E., Dahlström, A., Fuxe, K., Larsson, K., Olsen, L., Ungerstedt, U. Acta physiol. scand. 1966, 67, 313. 33. Ungerstedt, U. Acta physiol. scand. 1971, 82, suppl. 367, p. 1. 34. Dahlström, A., Fuxe, K. Acta physiol. scand. 1965, 62, suppl. 232, p. 1. 35. Thierry, A-M., Stinus, L., Blanc, G., Glowinski, J. Brain Res. 1973, 50, 230. 36. Lindvall, O., Björklund, A. Acta physiol. scand. 1974, 92, suppl. 412, p. 1. 37. Crow, T. J., Deakin, J. F. W., Longden, A. Br. J. Pharmac. 1975, 55, 295P. 38. Bunney, B. S., Aghajanian, G. K. Predictiveness in Psychopharmacology; p. 225. New York, 1974. 39. Swanson, L. W., Cowan, W. M. Brain Res. 1975, 92, 324. 40. Slater, E., Beard, A. W., Glithero, E. Br. J. Psychiat. 1963, 109, 95. 41. Korf, J., van Praag, H. M. Brain Res. 1971, 35, 221. 42. Bowers, M. B. Archs gen. Psychiat. 1974, 31, 50. 43. Sjöström, R., Roos, B-E. Europ. J. clin. Pharmac. 1972, 4, 170. 44. Post, R. M., Fink, E., Carpenter, W. T., Goodwin, F. K. Archs gen. Psychiat. 1975, 32, 1063. 45. Crow, T. J., Johnstone, E. C., McClelland, H. A. Psychol. Med. 1976, 6, 227. 46. Fuxe, K., Hökfelt, T., Nilsson, O. Neuroendocrinology, 1969, 5, 257. 47. Kolakowska, T., Wiles, D. H., McNeilly, A. S., Gelder, M. G. Psychol. Med. 1975, 5, 214. 48. Wilson, R. G., Hamilton, J. R., Boyd, W. D., Forrest, A. P. M., Cole, E. N., Boyns, A. R., Griffiths, K. Br. J. Psychiat. 1975, 127, 71.

Continuing

Royal Commissioners

our

collection

been seen by the Health Service. National have

not

of items of evidence which Royal Commission on the

MEDICAL MANPOWER THE planning necessary to meet the country’s needs for medical manpower demands the examination of a complex mixture of facts and assessments: total number of doctors; proper distribution between regions, grades and specialties; training needs, as well as service demands; and the relationship of doctors to other members of the health team. It is easy to become confused by mentally "jumping the tracks" from one issue to another, and by wandering from an analysis of today’s facts to a dream of tomorrow’s possibilities; and the dream itself can soon become a hopeless muddle of mathematical feasibilitv, social theory, professional self-interest, and political intrigue. The real purpose of medical-manpower planning is to achieve better care of individual people and of the

community. A Changing Situation Great Britain produces about 2750 doctors a year and imports about 3500. The "need" for doctors to staff the N.H.S. therefore appears to be approximately 6000 a year. Many overseas doctors stay only a few years and the average loss to the N.H.S. is over 2000 a year; in addition, the annual net emigration of British doctors is probably about 500-600. Most overseas doctors occupy junior hospital posts; the ratio of junior to senior posts is such that if all junior hospital doctors sought promotion and permanent establishment in this country they would overfill both the consultant grade and general practice. Specialist training is not planned; enormous variations exist in quality of training, speed of promotion, and motivation in seeking junior hospital posts. The dependence of the N.H.S. on its "specialist trainees" as a work force is incalculable.

Important quantitative changes are already taking place and the next two or three years will see critical developments. If, in the future, the N.H.S. were to be staffed almost entirely by highly motivated, permanently resident doctors, the large "cushion" of relatively uncommitted junior hospital staff which has given nexibi lity to the system for so long would not exist. We should have to learn the hard lessons of how, without it, to provide both a satisfying job for the doctor and a good service for the patient. It is also obvious that without a continual loss of large numbers of overseas doctors the annual requirement to keep the N.H.S. supplied might well be nearer 2500 than 6000. The fact that we need a lot of doctors every year now does not necessary mean that we always shall. This distinction has never

49. Meltzer, H. Y., Sacher, E. J., Frantz, A. G. Archs gen. Psychiat 1974, 31, 564. 50. Johnstone, E. C., Crow, T. J., Mashiter, K. A. Unpublished. 51. Farley, I. J., Price, K. S., Hornykiewicz, O. Non-Striatal Dopamine. New York (in the press). 52. Ungerstedt, U. Acta physiol. scand. 1971, 82, suppl. 367, p. 69. 53. Costentin, J., Protais, P., Schwartz, J. C. Nature, 1975, 257, 405. 54. Lal, S., De la Vega, C. E. J. Neurol. Neurosurg. Psychiat. 1975, 38, 722.

567

adequately appreciated; it explains the fact that while some "experts" urge the need for yet more medical-school places, others give dire warning of future unemployment. been

How to get from the present into the future? Doctors wishing to enter the United Kingdom will face new pro-

blems ; if, as a result, they do not continue to come, then perhaps more of the present incumbents will try to stay. Nobody knows. Those who did wish to stay would have to prove themselves suitable to occupy senior positions, and those most keen to remain might not be the most likely to achieve promotion. There is also the matter of distribution; few people would wish to see whole cities, or specialties such as geriatrics, staffed almost exclusively by overseas doctors. The more general difficulties of maldistribution, between regions and specialties, are as yet completely unresolved. It is not hard to think of reasons why gynaecology is preferred to geriatrics, or Bournemouth to Barnsley; and a newer Machiavelli might observe that the art of running a successful N.H.S. is to ensure, by adjustment of the terms and conditions of service, that what doctors most want to do is what most needs to be done. There is more to this than simply flooding the market with doctors and hoping for the best. Poverty may force the N.H.S. to stop growing, at least temporarily, thus having an enormous effect on the need for new doctors: up to now more new consultants have been required in some specialties to cope with expansion than to balance retirement and other losses. Then there is the question of how the presently increasing number of women doctors will affect the manpower situation, and the largely unknown quantity of the E.E.C. with its "free movement" of doctors from December of this year. Several of these factors are capable of making not a 3% or 4% difference but a 20% or 30% difference to our annual need for new graduates. What Must be Done Certain things must clearly be done. First, we must study events during the next two or three years in great detail, and the necessary data must be available immediately. Until we know what is going to happen to inflow and outflow of doctors, including our own medical graduates, and to the N.H.S. demand for doctors, we cannot make any reasonable estimates of the need for medical-school places. Second, we must think more about the proper function of the doctor, how he can use his time most efficiently, and how he can be helped by medical auxiliaries and other specially trained people of various kinds. There must also be an appraisal of what the N.H.S. is for: do we really need twice as many doctors or do we need half as many patients? What constitutes a "good buy" for the public? Third, we should think seriously about the efficiency of postgraduate training and the proper use of our great potential for this. Positive and well-designed programmes for foreign doctors wishing to come to Britain specifically for specialist training would be attractive and valuable. The proper role of the trainee, both home and foreign, could be better defined if we gave recognition to a specialist grade, as distinct from consultant status. This would remove the need for numbers of "trainees" plus consultants to be tied always to an inexorable workload. It would also clarify our relationship

to

the systems of other countries.

planning mechanism must, for developed. D.H.S.S. figures are based on essentially numbers of people rather than on targets for numbers of posts. Although this has some advanFinally,

an

effective

the first time, be

tages, it makes for a poor definition of establishment and there is no clear understanding of whether manpower objectives are set on the basis of what is really needed or what is likely to be available. Despite the agreed objective of preferential growth of the consultant grade, the latest figures show that between 1974 and 1975 the numbers of junior hospital staff in England and Wales increased by 7%-8% and of consultants by only 2%. On the face of it only three conclusions are possible: either the D.H.S.S. does not know what is happening in the N.H.S., or else it does know and either condones it or has no power to prevent it, or else the data are incorrect or at least misleading. As indicators of the quality of management there is little to choose between the alternative explanations. The D.H.S.S. would maintain that it does not "run" the N.H.S., that it is regions and areas which employ staff and provide services. In fact, despite the existence of Central and Regional Manpower Committees it is difficult to know the basis on which essential decisions are made, and to understand what lies between decision making and the events of everyday life. Those who supposedly control the system are proved incompetent by their own statistics. It takes 10-15 years to produce a fully trained medical specialist, so that short-lived Government plans, with stop-go policies on medical staffing and quickly changing priorities for different kinds of doctors, will inevitably lead to frustration and disillusionment. Yet rigid longterm policies are rarely appropriate; there must always be enough flexibility to respond to short-term changes in supply and demand, both locally and in specific areas of work. The encouragement of initiative in the individual practice or hospital is supremely important. In such a context it need hardly be said that the science of manpower planning, if such it be, has limitations; but it has plenty to offer if it is well carried out and intelligently used. We attract the best young people into our medical schools. Potentially, they are the most dedicated members of society. The practice of medicine has never in the history of the world been so exciting for the doctor and so rewarding for the patient. Our medical education is universally envied. Britain could, and should, be a good place to live and work in. Those who teach medicine and those who learn it deserve better planning policies than they have had so far-to say nothing of the

public who hope to benefit from their services. Department of Anæsthetics, University Hospital of South Manchester, Withington Hospital, Manchester M20 8LR

JAMES PARKHOUSE

July 18 we watched a Camberwell Beauty and Red besporting themselves in an abandoned croft garden at Gardie, on the island of Bressay, Shetland in marvellous warm weather. Migrant from Norway? In 1912 my father, on leave from the Navy, visited his brother-in-law, Sir Squire Sprigge, MD, editor of the Lancet, in his offices above the Strand in London. They saw a Camberwell Beauty on a fruit barrow in the street below, ran down and caught it in a top

"... On

Admiral

hat."—ELIZABETH M. SCOTT. Letter Times, Sept. 3.

to

the Editor of The