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output of Canadian specialists migrate to the USA wherethey provide primary care. There have been suggestions thatGPs in Canada are tending to withdraw from hospitalpractice.8 Technological changes in areas such as intensivecare make it difficult for the GP to play more than asupporting role. Lastly, medicolegal considerations makesome GPs less willing to take so much responsibility in thehospital.Peel Memonal Hospital,Brampton, Ontario, Canada J.K.McCONNON

1 Editorial. A promising package on hospital staffing. Br Med J 1986; 293: 87-88.2. Reiteneier RJ, Spittell J, Weeks R, et al. Participation by internists in primary care

Arch Intern Med 1975; 135: 255-573. Mendenhall RC, Tarlov A, Girard R, et al. A national study of internal medicine and

its subspecialties: II Primary care in internal medicine. Ann Intern Med 1979; 91:275-87.

4. McConnon J, Shah CP. Patterns of practice in internal medicine in Ontario. Can MedAssoc J 1977; 116: 1269-73.

5. Pollett GL, Shah CP, McConnon JK. Consultant obstetricians/gynaecologistspractice profiles in an Ontario community. Can Fam Physician 1984; 30: 343-46

6. Pollett GL, Shah CP, McConnon JK. Comparison of consultant paediatricians in anOntario community with their provincial counterparts. Can Fam Physician 1983;29: 799-802

7 Mueller CB. Some effects of health insurance in Canada-from private enterprisetoward public accountability. N Engl J Med 1978, 298: 535-39

8. McWhinney IR Is academic Canadian family medicine at a watershed? Can MedAssoc J 1985; 133: 897-900.

In England Now

I HAD thought to keep quiet about my brief stay in our justlyfamous teaching hospital, because the truth was going to let horridsecrets out of the bag. But then I read about the poor chap (Nov 29,p 1271) whose morning pee was interrupted by at least 35 people.His story and mine provide a parallel too good to miss.

Here, is one typical scenario. A semi-private ward at 7.30 am.Enter Nurse A to say that, because I am to go down for a bariummeal, I must have nothing by the mouth. Two minutes later, incomes Nurse B with "Here’s your breakfast" and a gorgeouslyaromatic plate of bacon and egg. I manfully resisted this, and eventhe later squad of brisk do-good ladies with a trolley and thejollying-up tones of "Would you care for anything to eat?" Butdehydration and hypoglycaemia must have addled my conscience,because when after a long interval Nurse C sweetly asked whether Itook tea or coffee, I could hold out no longer. "Coffee, please," Ianswered joyously, "with lots of sugar."When I eventually reached the radiographer, she said the coffee

had done no harm, indeed she had no idea why it was forbidden. "Iexpect" she volunteered "that it’s just one of those old rules that’snever been countermanded."

’

I could quote other scenes of similar haphazardness. Everyonewho attended to me was individually efficient and caring, but thevarious parts did not add up to any definition of care. On the theorythat the first step in getting to the root of any disorder is to put aname to it I have christened this the Fragmentation Syndrome.

* * *

I HAVE a friend who is a zoologist. One of his responsibilities is tobuild up the definitive collection of skeletons of his department, atask in which he is very assiduous. He collects any dead creature hefinds. He has people acting as agents all over the world, so thatparcels of various sizes and odours arrive for him at work. When hehears of a new specimen, all else goes from his mind and time isforgotten. He is also known to dig up long-buried farm animals,especially if they happen to be of breeds now very rare, though hehas been less keen on this since the time he excavated the skeletonsof four cows buried sixty years ago. He asked the farmer whether heknew what they had died of. "Oh yes, it was anthrax." The publichealth people got quite upset about it all, I gather.When I met him the other day, he was looking very angry.

Apparently he had had a message from a Scandinavian contact,announcing that he had obtained the corpses of two reindeer and he

was arranging for them to be flown to England forthwith; could myfriend find out what time the flight would arrive and pick them up?Excited, he phoned the airport, and told them he was expecting acouple of reindeer that night. Then, to his surprise and anger, hehad been treated most rudely. The man on the other end of the linehad told him, before slamming down the receiver, that he was verybusy, he was sick to death of practical jokers, and would my friendbe kind enough to go away-or words to that effect. Why were theyso rude, he complained, in the face of a perfectly civil inquiry? Igently pointed out that it had been Christmas Eve.

* * *

HEALTH CARE PROGRAMMES

"HCPs are a logical development in the NHS which will ensurethat limited resources are shared out fairly and rationally"."HCPs are the latest management gimmick designed to lull

health workers into tolerating government cuts in the health

budget".Both these thoughts crossed my mind while I was at a district

workshop for health professionals and managers on HCPs. It is arare event for such a cross-section of the NHS to sit down together(cardiothoracic surgeon with geriatric nurse, accounting assistantwith special-care baby-unit sister, radiographer with stats officer... the potential for collaboration is intriguing). Why do we not gettogether for the sake of the patients? The exercise seemed to bedesigned to convince the audience that management (who organisedit) is good for you-since only they can help us to cope with the cuts.The opening statement from the district general manager wasrevealing: "resource imbalance will always be with us, regardless ofGovernment". Is this not reminiscent of the social worker who

helps the family living in poverty and inadequate housing, and with30% local unemployment, to "cope" with their predicament bybetter budgeting?Many of the ideas behind HCP can only be to the benefit of the

NHS, which has always lacked coordination between planning,implementation, and control in organising its services. The messagewhich came over loud and clear was that clinicians, instead ofcomplaining about managers and their cost cutting, must join themand work together on the budget exercise. We were led through theprinciples of management by the US trained expert, starting withHenry Ford and ending with Robert MacNamara-from situationanalysis to contingency planning. "Strategic management" meansfinding ways of circumventing constraints wherever they occur,whether in service, in management, in organisation, in finance, orindeed in the environment. To achieve management budgeting wemust escape from the separate power groups of medicine, nursing,and public works departments (the "functions") and look instead atour budgets in multidisciplinary groups. For example, in the field ofgeriatric care, the medical, nursing, and support service inputswould be assessed by a group (the health care planning team). Itwould certainly help patients if those delivering the service mettogether more often. But I have two big worries about the way thiskind of approach is being put over. The system seems to be a verticalone, administered from top down and with no means of

incorporating the consumer perspective (except by lip service to"identifying the environmental constraints"). This is especially truefor those working in the community, and surely primary health careshould be at the centre of our system, not at the periphery? Healthdepends on more than health service delivery and if we are in thebusiness of helping people to be healthier, then we should seek ahorizontal power base which gives the people who use the servicemore say in management.My worry is over what happens if (when?) cuts really begin to

hurt patients. Protest becomes muted if we adopt managers’caps-and general managers are unlikely to be at the front of aprotest march to the Elephant and Castle.Maybe I overstate the case and there are managers about who

recognise the political (small p) content of many decisions taken inthe NHS. If so it would be good for their voices to become moreaudible. My fear is that the year 2000 will bring us either health forall or a Beeching-style health service-but not both.