FUTURE OF MENTAL SUBNORMALITY HOSPITALS

1243 FUTURE OF REGIONAL ALCOHOLIC UNITS out some of Committee on in of the the report Advisory shortcomings Alcoholism.’ This report seems to me to be a covert attack on the disease concept of alcoholism. There is nothing sacred about such concepts; they should be subject to scrutiny, but when an attack is made it should be explicit. Apart from this attack on the disease concept of alcoholism there are a number of other ideas around about alcoholism. One is that some alcoholics can return to controlled or social drinking-i.e., it is not necessary for every alcoholic to have to choose to remain abstinent to avoid trouble. There is published evidence to support this view, but it is not borne out by experience, and for the moment it should be taken as an interesting and challenging suggestion rather than as the basis for action. Another idea is that those addicted to alcohol do not do any better on elaborate treatment than with simple counselling. If sound support for this view were forthcoming, it would prompt a careful look at current services. However, while all of us caring for alcoholics treat many of our patients as outpatients or as day-patients, we know that a proportion need to be admitted to hospital for help, not only through the withdrawal but also through the initial phase of abstinence. The report also suggests that lay or other professional counselling is as effective as medical intervention. This is sometimes presented as a startling idea, but had the medical profession felt that it had exclusive claim on the treatment of alcoholics the close collaboration that has grown up between many alcoholism units and Alcoholics Anonymous, very much a lay organisation, would have been impossible. This regional unit admits patients who have been severely dependent for many years, perhaps a decade or more, and most have serious difficulties-for example, they have lost their jobs and, through divorce or separation, their families. Services developing in district general hospitals see patients at a different stage in their illness: they are younger, they are still in their original jobs, and their families and marriages are intact. For these alcoholics outpatient and day-patient treatment can be used from choice. The patients we see-and we also serve as a reception centre for homeless alcoholics and admit men from prison-have very different prognoses and very different treatment needs. We should avoid sweeping generalisations, such as those included in the report on services for problem drinkers.’ What we need is more information about the patients we are trying to serve and less controversy between people who are treating different patients. To start dismantling the regional services for alcoholism would be disastrous. These services do need to change and develop, and this is happening, quite independently of the Advisory Committee’s work.

SIR,-Dr Glatt (April 14, p. 814) has pointed

the

Regional Alcoholism and Drug Dependence Unit, St. Bernard’s Hospital, Southall, Middlesex

D. H.

change. Twyver Unit, Coney Hill Hospital, Gloucester GL4 7QJ

JACK BAVIN

CHALLENGE OF GENERAL PRACTICE

SIR,-The resignation of an excellent general-practitioner colleague in this valley has led to an advertised practice vacancy. Three applicants have been short-listed for interview, of them British. One of them rang conversation ensued: none

me

and the

following

"Can you tell me anything about this place Blaengwynfi?" "Have you had a look at it?" "No. But if not appointed I will have wasted my journey." "Where do you work now?" "I’m a principal in the ... valley [about 30 minutes’ drive from here]. I thought the Afan valley might be better." "Better in what way?" .

"Well, it’s closer vice." Thus

to

Swansea, and there

a

deputising ser-

Welsh valley as much as community anyone to producing British medical students at a cost of about f40 000 each. In your issue of May 12 Dr Barritt wonders whether general practice will in the future hold sufficient challenge for his valuable generation. Perhaps it holds too much; but I refer to the real challenge of creating excellence where for too long there was none, not to the rewards and excitements of pursuing excellence where it already exists. The continued failure, over many years, of good British graduates to apply for vacancies in the South Wales valleys is a shame and a dishonour to our medical schools and the philosophy they transmit. The case is arguable, but with feet, not tongues. Serious applicants will receive a welcome warmer than they can conceive. are

disposed

in

the lives of 2600

might

be

people in

a

1979, though they have contributed

SA13 3BL

JULIAN TUDOR HART

MARJOT

SIR,-Mr Loring (May 12, p. 1033) seems to think that my article (April 28, p. 918) proposed measures aimed at retaining

large subnormality hospitals in an improved form. I did not intend to imply my approval (or disapproval) of any particular model of service for the mentally handicapped, and I apologise for any lack of clarity. The measures proposed were aimed at solving what I think is the fundamental cause of our continuing problems-namely, insufficient innovative drive consequent upon medical, nursing, and administrative leadership of mediocre (and sometimes worse) calibre. Given invigorated leadership and improved recruitment, I believe solutions would follow, and that hospitals would rapidly improve their service to satisfactory levels, Range of Service for Problem Drinkers: visory Committee on Alcoholism. H.M. Stationery Office,

standards. There is little disagreement about the ideal of community integration of the mentally handicapped, but much argument about the most effective strategy, and some about how far the ideal is realisable. I have detailed elsewhere (Nursing Times, May 17 and 24, 1979) my criticisms of the Jay Committee report and described a practicable and tested alternative which I am sure would meet with Mr Loring’s approval. We do need a variety of forms of care, but above all we need an effective organisation which will translate plans into reality without delay. Too much effort has been devoted to arguing over elusive ideals, and too little to improving the mechanism of

Glyncorrwg Health Centre, near Port Talbot, Glamorgan

FUTURE OF MENTAL SUBNORMALITY HOSPITALS

1. The Pattern and

or not they survive as institutions in the long-term. Continuing denigration of the present hospitals and their staff will by itself only lead to further demoralisation and falling

whether

report of the Ad1977.

EDITORIAL INDEPENDENCE OF PRESCRIBERS’

JOURNAL SiR,-I suspect that the cool approach by Dr Hamer and Professor Turner (May 26, p. 1150) to the censorship of Dr Hamer’s article for Prescribers’ Journal covers a good deal of seething outrage. If I am right in that then I think that they are wrong, and they had better join me in qualified rejoicing. What in effect has happened is that a notional "yellow card" has been issued recording an undesirable but entirely predictable side-effect of the Government’s well-meaning apparatus for controlling medicines. As a warning it has three fortunate characteristics. First, no-one has yet been damaged. Second, it comes early enough in the relationship of the profession to these bureaucracies for there still to be hope of change. Third, the incident in itself is so beguilingly comic that one waits eagerly for someone to attempt to defend it while keeping his face straight. In saying this, I do not blame my colleagues who