- Email: [email protected]
SECURE ACCOMMODATION IN PSYCHIATRIC HOSPITALS
347 consultations with NHS specialists. Since 1976 she has also received treatment
She provided no information on costs though consultations with such therapists cost C7.50 on average (according to the EEC European Health Committee’s study of "unorthodox medicine"). Another patient provided detailed costings (1984-86): Cost
73.50 per weekly session for 7 mo 3000 Acupuncture £ i2 per session, 4 sessions Osteopathy C15 per session, 8 sessions Until receiving this information I had no idea of the extent and Psychoanalysis (private) Allergy clinic (private inpatient)
variety of agencies the patients turned to in attempting to satisfy their health care needs. As a firm believer in the role of the GP as coordinator of specialist advice and treatment, I find that my task is rendered very difficult when alternative therapies are used. Practitioners of additional medicine seem to operate in isolation, with no reference to the medical history as perceived by the GP or to the views of other additional practitioners. Words such as "alternative", "complementary", and "holistic" are smokescreens for the failure to involve the NHS GP, who is all too often unaware whom his/her patients are seeing and what treatment they are receiving.
I am aware of the criticisms proponents of alternative medicine level at the nature of much of general practice and the uncertainties attending many of the conditions treated by the primary care team. My concern here is not whether alternative medicine is beneficial, but the extent and cost of its use and the attitudes of its users. I would therefore make a strong plea on behalf of GPs for the collection of more information about the practices of alternative practitioners who treat NHS patients. Clapham Park Surgery, 72 Clarence Avenue, London SW4 8JP
In the US 500,,to 75°of the assumed to be untreated, drifting former psychiatric patients.2 This increasing patient group is a direct result of the "open door" policy and the community care principles governing current psychiatric practice. Indeed community care is often no more than a euphemism for increasingly inadequate hospital facilities. These patients drift untreated and fall through the net of a mythical community framework, and it is no wonder that their behaviour becomes "criminalised", and they end up in the already overcrowded penal system.3,4 Do we direct this patient group to regional secure units? Perhaps we need to look anew at the admitting policies of psychiatric hospitals.s In the South West Thames Region we have recognised that without adequate continuing care these patients become labelled "forensic" and their clinical condition can remain stagnant because of an increasing reluctance of general psychiatric hospitals to treat them. A service has to be built at the outset to minimise the number of referrals to regional or subnational facilities and to receive back into the community those who did need such a placement. Our statistics of patients awaiting transfer from prison or special hospitals compare favourably with other regions, including those who do have a regional back-up facility. As a consequence we have reduced the size of our regional secure unit from 25 to 15 beds to be built soon at Netheme Hospital. There is increasing anxiety about the size of other regions’ secure facilities. It cannot be emphasised sufficiently that unless a good relationship continues between forensic and general psychiatrists a fate similar to that of patients in special hospitals, as described in your editorial, may await those in regional secure units. A regional secure unit is not the simple solution to the emerging problems in current street
from:
Treatment
population of destitute individuals.
S. SHEPHERD
SECURE ACCOMMODATION IN PSYCHIATRIC HOSPITALS
SiR,—The controversy that surrounds the need for building
regional units to cater for dangerous patients, recognised over ten years ago, persists. It would be naive to represent the controversy as merely being about whether or not a region has a regional secure unit. There has been recent critical television commentary contributing to the debate. Your July 5 editorial rightly points out that it might be a natural progression from Gostin’s recommendation that special hospitals be phased out to the phasing out of regional facilities and their replacement with a district-based service. This reflects our own philosophy regarding the treatment of a difficult group of patients in the South West Thames Region. In the absence of a good community based service for difficult and offender patients, patient transfer to and from the community will be hindered if they are in regional units as currently prevails with the special hospitals. Rehabilitation depends on there being a good relationship between forensic psychiatrists and their general psychiatric colleagues, just as the presence of an interested relative is a positive prognositc variable in the rehabilitation of secure hospital
patients.1 There is a rising tide of chronic behaviourally disturbed patients, the "nuisance" patients, who encounter prejudice in general psychiatric hospitals yet often do not meet the acceptance criteria of special hospitals or regional secure units. These socially inadequate individuals haunt casualty departments and are part of an increasing
derelicts
are
psychiatric practice. Community Forensic Psychiatric Team, St George’s Hospital, London SW17 8PA
T. D. SCANNELL
1. Fairweather G, Sanders D, Tornatzky L. Creating change in mental health
organisations. New York: Pergamon Press, 1974. 2. US General Accounting Office. Returning the mentally disabled to the community: Government needs to do more. Washington DC: US Government Printing Office, 1977. 3. Orr JH. The imprisonment of mentally disordered offenders. Br J Psychiatry 1978; 133: 194-99. 4. Penrose LS. Mental disease and crime: Outline of a comparative study of European statistics. Br J Med Psychol 1939; 18: 1-15. 5. Turner TH, Tofler DS. Indicators of psychiatric disorder among women admitted to prison. Br Med J 1986; 292: 651-53.
GRAND MULTIPLE PREGNANCIES AND DEMAND FOR NEONATAL INTENSIVE CARE
Sm,—In the UK there is a serious shortage of facilities for neonatal intensive care.1 Consequently the delivery of a grand multiple pregnancy of four, five, or six fetuses cannot be planned for in any British neonatal unit without putting at risk the existing occupants of intensive care cots. The woman carrying quadruplets, quintuplets, or sextuplets constitutes a potential neonatal disaster, quite apart from the many social problems that may beset the unfortunate family. The treatment of infertility has achieved impressive results over the past decade but the resultant increase in grand multiple pregnancies has not been closely monitored by obstetricians or neonatologists. The Office of Population and Census Surveys (OPCS) has collected figures on multiple pregnancies since 1938 and they show an interesting trend (see figure). Multiple pregnancies as a proportion of all pregnancies in the six 5-year periods from 1956 to 1985 fell up to the 1976 quinquennium and then rose slightly in the latest 5-year period. However, the number of pregnancies comprising four, five, or six fetuses has risen sharply. 1961-65 saw only 6 grand multiple pregnancies (all quadruplets) but in 1985 alone there were 7 sets of quadruplets with 2 quintuplet pregnancies and 1 sextuplet pregnancy. There has been a 13 fold increase in the number of such pregnancies in the past 20 years and the increase is continuing. Obstetricians must be aware of the effects on the neonatal services of their treatment. The fact that many babies delivered after multiple pregnancies are now surviving puts more pressure on the tleonatologist to treat these babies at increasingly more immature gestations. There seem to be two solutions. First, infertility should
She provided no information on costs though consultations with such therapists cost C7.50 on average (according to the EEC European Health Committee’s study of "unorthodox medicine"). Another patient provided detailed costings (1984-86): Cost
73.50 per weekly session for 7 mo 3000 Acupuncture £ i2 per session, 4 sessions Osteopathy C15 per session, 8 sessions Until receiving this information I had no idea of the extent and Psychoanalysis (private) Allergy clinic (private inpatient)
variety of agencies the patients turned to in attempting to satisfy their health care needs. As a firm believer in the role of the GP as coordinator of specialist advice and treatment, I find that my task is rendered very difficult when alternative therapies are used. Practitioners of additional medicine seem to operate in isolation, with no reference to the medical history as perceived by the GP or to the views of other additional practitioners. Words such as "alternative", "complementary", and "holistic" are smokescreens for the failure to involve the NHS GP, who is all too often unaware whom his/her patients are seeing and what treatment they are receiving.
I am aware of the criticisms proponents of alternative medicine level at the nature of much of general practice and the uncertainties attending many of the conditions treated by the primary care team. My concern here is not whether alternative medicine is beneficial, but the extent and cost of its use and the attitudes of its users. I would therefore make a strong plea on behalf of GPs for the collection of more information about the practices of alternative practitioners who treat NHS patients. Clapham Park Surgery, 72 Clarence Avenue, London SW4 8JP
In the US 500,,to 75°of the assumed to be untreated, drifting former psychiatric patients.2 This increasing patient group is a direct result of the "open door" policy and the community care principles governing current psychiatric practice. Indeed community care is often no more than a euphemism for increasingly inadequate hospital facilities. These patients drift untreated and fall through the net of a mythical community framework, and it is no wonder that their behaviour becomes "criminalised", and they end up in the already overcrowded penal system.3,4 Do we direct this patient group to regional secure units? Perhaps we need to look anew at the admitting policies of psychiatric hospitals.s In the South West Thames Region we have recognised that without adequate continuing care these patients become labelled "forensic" and their clinical condition can remain stagnant because of an increasing reluctance of general psychiatric hospitals to treat them. A service has to be built at the outset to minimise the number of referrals to regional or subnational facilities and to receive back into the community those who did need such a placement. Our statistics of patients awaiting transfer from prison or special hospitals compare favourably with other regions, including those who do have a regional back-up facility. As a consequence we have reduced the size of our regional secure unit from 25 to 15 beds to be built soon at Netheme Hospital. There is increasing anxiety about the size of other regions’ secure facilities. It cannot be emphasised sufficiently that unless a good relationship continues between forensic and general psychiatrists a fate similar to that of patients in special hospitals, as described in your editorial, may await those in regional secure units. A regional secure unit is not the simple solution to the emerging problems in current street
from:
Treatment
population of destitute individuals.
S. SHEPHERD
SECURE ACCOMMODATION IN PSYCHIATRIC HOSPITALS
SiR,—The controversy that surrounds the need for building
regional units to cater for dangerous patients, recognised over ten years ago, persists. It would be naive to represent the controversy as merely being about whether or not a region has a regional secure unit. There has been recent critical television commentary contributing to the debate. Your July 5 editorial rightly points out that it might be a natural progression from Gostin’s recommendation that special hospitals be phased out to the phasing out of regional facilities and their replacement with a district-based service. This reflects our own philosophy regarding the treatment of a difficult group of patients in the South West Thames Region. In the absence of a good community based service for difficult and offender patients, patient transfer to and from the community will be hindered if they are in regional units as currently prevails with the special hospitals. Rehabilitation depends on there being a good relationship between forensic psychiatrists and their general psychiatric colleagues, just as the presence of an interested relative is a positive prognositc variable in the rehabilitation of secure hospital
patients.1 There is a rising tide of chronic behaviourally disturbed patients, the "nuisance" patients, who encounter prejudice in general psychiatric hospitals yet often do not meet the acceptance criteria of special hospitals or regional secure units. These socially inadequate individuals haunt casualty departments and are part of an increasing
derelicts
are
psychiatric practice. Community Forensic Psychiatric Team, St George’s Hospital, London SW17 8PA
T. D. SCANNELL
1. Fairweather G, Sanders D, Tornatzky L. Creating change in mental health
organisations. New York: Pergamon Press, 1974. 2. US General Accounting Office. Returning the mentally disabled to the community: Government needs to do more. Washington DC: US Government Printing Office, 1977. 3. Orr JH. The imprisonment of mentally disordered offenders. Br J Psychiatry 1978; 133: 194-99. 4. Penrose LS. Mental disease and crime: Outline of a comparative study of European statistics. Br J Med Psychol 1939; 18: 1-15. 5. Turner TH, Tofler DS. Indicators of psychiatric disorder among women admitted to prison. Br Med J 1986; 292: 651-53.
GRAND MULTIPLE PREGNANCIES AND DEMAND FOR NEONATAL INTENSIVE CARE
Sm,—In the UK there is a serious shortage of facilities for neonatal intensive care.1 Consequently the delivery of a grand multiple pregnancy of four, five, or six fetuses cannot be planned for in any British neonatal unit without putting at risk the existing occupants of intensive care cots. The woman carrying quadruplets, quintuplets, or sextuplets constitutes a potential neonatal disaster, quite apart from the many social problems that may beset the unfortunate family. The treatment of infertility has achieved impressive results over the past decade but the resultant increase in grand multiple pregnancies has not been closely monitored by obstetricians or neonatologists. The Office of Population and Census Surveys (OPCS) has collected figures on multiple pregnancies since 1938 and they show an interesting trend (see figure). Multiple pregnancies as a proportion of all pregnancies in the six 5-year periods from 1956 to 1985 fell up to the 1976 quinquennium and then rose slightly in the latest 5-year period. However, the number of pregnancies comprising four, five, or six fetuses has risen sharply. 1961-65 saw only 6 grand multiple pregnancies (all quadruplets) but in 1985 alone there were 7 sets of quadruplets with 2 quintuplet pregnancies and 1 sextuplet pregnancy. There has been a 13 fold increase in the number of such pregnancies in the past 20 years and the increase is continuing. Obstetricians must be aware of the effects on the neonatal services of their treatment. The fact that many babies delivered after multiple pregnancies are now surviving puts more pressure on the tleonatologist to treat these babies at increasingly more immature gestations. There seem to be two solutions. First, infertility should