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these ideas have been expressed in several other places and aredevelopments of those first current a decade or more ago, theway in which they are presented in this report gives a clear andmoving impression of what could be achieved for the mentallyhandicapped (and for other groups requiring care). Thechapter must be read by "carers" from every discipline, andshould be nailed to every committee-room door, so that

managers and planners of services may digest the message.The National Development Group has produced many of itsown pamphlets for free distribution and could do much worsethan reprint chapter 3 for all those concerned with the care ofthe mentally handicapped.

* * *

Compared with such a flourishing philosophy, the recom-mendations of the committee look pale and wan. It is thereforesad to see that the conclusions in the report have provokedsuch an emotional response, especially among the nurses. Thereport suggests that, in order to follow the philosophy, residen-tial care staff will require a thorough training in how to carefor the physical and emotional needs of the mentally handi-capped, how to encourage independence among their patients,and how to adopt the role of supporters rather than servants.The next step in the development of the argument is the boldor rogue one, depending upon your viewpoint: the committeesuggests that this training should be a specialised part of resi-dential care training, rather than nurse training or educationtraining; it should be supervised by the Central Council forEducation and Training in Social Work and should lead to ac.s.s. (certificate in social service) qualification. With the

exception of one minority report, the committee is opposed toa separate qualification under any existing xgis, on the

grounds that such work is similar to residential care work for. other groups and that separation would isolate the carers of

the mentally handicapped.Surely what matters at the moment is to consolidate the

training and experience of all those with a caring role into onecommon group? This is the predominant view expressed in theresearch sponsored by the committee, which involved nurses inthe mental handicap field. Such consolidation would allow thecarers scope to widen their horizons away from the ward, thehostel, or the special care unit, to include the support of thementally handicapped in all the different possible settings. Ifa commitment were made }o work towards this goal, argu-ments about who runs courses, and what the qualificationshould be called, would then be seen in context as of onlysecondary importance.The encouragement of such a spirit of caring probably

requires a further change which the committee did not recom-mend. Indeed, it actively restricted itself from thinking aboutit. The health and local authority components of the presentservice should be amalgamated, either as a separate service, asin Sweden, or under the existing local authority structure. Theonly health components necessary could be provided in exactlythe same way as health services to other groups of people,without needing to take them over body and soul. The idea ofa separate service for the mentally handicapped has someattractions, but new institutions do not seem to work very wellin our society, whilst old ones have an amazing capacity tochange, and change rapidly, if the motivation or reward is

great enough. Social service departments have not done verywell for the handicapped until now, but this does not meanthat they will not do so in the future, especially if they are in-spired by a new cadre of carers with a feeling of purpose anda belief in an attainable Nirvana.

* * *

The Jay committee says that it has been unashamedly ideal-istic in its recommendations. In terms of philosophy this is

obviously so, but it has returned to the mundane with its ideasabout organisation. It has tried to be radical in its approachto training, without giving sufficient thought to helping peopleto change, or providing a framework for action. There is insuf-ficient stardust and imagination in the report to persuade peo-ple to accept change: it is too easy to fall back into the apathyof "they’ve never changed in all these years, why should theynow?" With one decisive act the committee could have createda breach through which many will pour-to establish the newservice. Without this breach, without the symbolism of thestorming of the Bastille, the troops will lose heart and desertfor home to live life as it was before. The breach is not merelysymbolic. It means the transference of responsibility for all ser-vices for the mentally handicapped to the local authorities.Such a move may involve special funding, but this need not benecessary, since it is possible for central Government to insist,via the rate support grant, that money is spent in certain ways,though they seldom do. Any small part of the service which hasa health function-for instance, for mental illness-can beprovided in the same way as it is to the general public. Withsocial services and education there lies the possibility of realdevelopment, so long as there are some teeth to the enablinglegislation, and a few crusaders to take the oath.

This self-imposed withdrawal from the necessary decisionhas forced the Jay committee to water down their report: itconceives a genius, then stifles it with indecision. It is a pitythat all the emotion and furore that the report is creating can-not be focused on fostering that genius, instead of encouragingsterile introspection as to whether carers ought to be callednurses or not.

1. Cmnd. 7468. See Lancet, March 17, 1979, p. 623.

Medical Education

THE ABERDEEN SURGICAL TRAININGPROGRAMME

THE number of senior registrars in general surgery in theU.K. is in phase with the anticipated consultant vacancies butthere are at least twice as many registrars as there are seniorregistrar posts likely to be vacated over the next five years. Toolittle is known about the fate of the registrars lately in trainingand how their training relates to what they eventually do. Forthis reason, with the hope of stimulating others to publish thisinformation, I review here the Aberdeen surgical programmeand its results in 16 years.

In its present form the programme is based on the Aberdeen

teaching hospitals. There are 12 registrar posts. Applicantsmust have the primary F.R.C.s. examination and usually a yearas a senior house officer in general surgery. After appointmentthere is an annual review of progress. If this is satisfactory thetraining is continued to a maximum of 4 years. Each year ismade up of 6 months in general surgery and 6 months in aspecialist unit, the choice being made from orthopaedics(including accident and emergency), neurosurgery, cardio-

thoracic, plastic, urology, and pxdiatrics. Towards the end ofthe registrar period the trainee may be seconded for a year toa particular field of research, to a fellowship at Harvard, or toa hospital at Inverness or Dumfries, centres where under-graduate and postgraduate teaching for the University ofAberdeen Medical School is undertaken and the consultant

surgeons are senior lecturers in the University of Aberdeen.Inverness, Dumfries, and Harvard rotate one of their registrars

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yearly in exchange with the Aberdeen teaching hospitalsgroup. This scheme has been running now for more than tenyears.

In addition to these registrar posts, the North-east RegionalHospital Board since 1970 has financed a secondment appoint-ment to the clinical units through which a surgeon who hasgone through the training scheme can have one of his traineesappointed as a registrar in Aberdeen for a year. This oppor-tunity is taken usually by surgeons practising outside the U.K.Also passing through the registrar scheme, usually under theUniversity’s aegis, are men from centres abroad supported bytheir country of origin who usually come to the U.K. throughthe British Council and other national agencies.

After four years the registrar has the chance of competingwith those not trained locally for one of seven senior registrarposts in Aberdeen and Inverness. The occupants of these postshave both N.H.S. and university responsibilities, all being lec-turers in surgery. Similarly, all registrars are tutors in the uni-versity. Registrars and senior registrars are on the same salaryscale. The senior registrars are also reviewed yearly and, if

satisfactory, are appointed for 4 years during which they areexpected to obtain a higher degree and the certificate of com-pletion of training in the specialty of general surgery. Indeed,some at present are qualifying in an additional specialty-aprocess which must prove beneficial to the health service. Thetrainee is attached to a general unit in Aberdeen or Invernessfor a minimum of 1 year, up to 2 years if he wishes. Men fromthe armed forces may also be accepted as senior registrars forhigher surgical training. All the senior registrars in turn pro-vide consultant cover for Orkney and Shetland.

The senior registrars’ progress and rotation is surveyed bya committee composed of all the consultant surgeons involved.The chairman and secretary are senior men who are availableto discuss and advise on any individual’s programme. Theseare long-term voluntary appointments and much of the successof the training scheme is due to the devoted service of the staffsurgeons who have held these posts.

What are the results of this training programme? 155trainees have been on the programme, 113 at the registrarstage, 14 joining at the senior registrar stage, and 28 as

exchange registrars (6 from Dumfries, 11 from Inverness, and11 from Harvard). Of the 113 registrars, 18 are at present inpost or are locums or are untraced. 83 became senior registrarsand/or consultants in general surgery at home and abroad. 9transferred to other branches of surgery, and 1 each to radiol-

ogy, pathology, and general practice. 5 of the 9 remained in

training in Aberdeen as senior registrars in their newlyadopted branch of surgery, 3 in orthopxdics, 1 in accident andemergency, and 1 in otorhinolaryngology. All became consul-tants.

30 of the senior registrars joined from the registrar trainingcadre while 14 had done their registrarship elsewhere. Of thefirst group, 24 are now consultants, 5 are in post, and 1 hasdied. Of the second group 1 is in post, 4 have gone back to dutyin the Royal Navy, 8 are consultants in general surgery in theU.K., and 1 is a general practitioner/surgeon. There is 1

vacancy.

Trainees have also achieved academic distinction. Therehave emerged 7 full professors, 8 readers or associate profes-sors, and 27 senior lecturers or assistant professors. Thetrainees have obtained 5 M.D.s, 2 doctorates in medicine, 22CH.M. and M.S., 1 D.SC., and 14 PH.D.S.

From this review it is clear that trainees taking part in theAberdeen scheme have met with little difficulty in finding aconsultant post in which to exercise their surgical skills.Department of Surgery,University Medical Buildings,Foresterhill,Aberdeen AB9 2ZD GEORGE SMITH

Intercepted Letter

A DAY ON THE MATERNITY WARD

DEAR MARY,We had quite a day recently in our maternity hospital. Of

course, the annual deliveries are well down from ten years ago,and this is reflected in the staffing level and in the morale ofthe staff we have got. There is no doubt that people work morehappily in a thriving department with plenty of bustle and goabout. Man, and woman, both are at their best when fightingfearful odds, but the effort has to be fairly sustained. If thenight staff have become accustomed to viewing their hours ofduty as an opportunity for finishing their new winter cardigan,or that tricky piece of petit point, then they are not going towelcome the intrusion of labouring ladies. I do have some sym-pathy with them, but I also have a lot with the ladies. In factI went to bed boiling.We started with four patients for induction in the morning,

all very reasonable criteria. By midday we had acquired twofurther clients, one of whom was an "elective epidural"-thatis to say, she had been offered and accepted in the antenatalclinic this relief of pain. In this area the epidurals are done bythe anaesthetists, and they arrived promptly and proceeded toinsert the catheter with great skill. Two of the women were bythen in some distress, inadequately relieved by drugs. "Wouldthey," I enquired, "do two further epidurals while they wereabout it"? "Certainly". "Certainly not", said Sister: theyhadn’t the facilities for nursing them, the beds didn’t tilt. Sothat was that. They laboured on, inadequately relieved forwhat I felt were rather inadequate reasons.

In the morning a young primagravida was admitted. Shewas a healthy girl, barely in labour. The os just took onefinger. "She’s very hungry," said her husband, "she hasn’thad anything to east since last night. Can I get her something?""You’d better check with Sister," I said. Maybe he didn’tbecause about an hour later there was an outraged shriek froma familiar voice. "Who?" it bellowed, with a drive behind it

that carried well outside the labour suite, "who gave the casein room 1 a sandwich?"

About eight in the evening I slipped off for my own coffeeand sandwich. I walked back behind the night sisters who werecomplaining in parade-ground voices about the amount ofwork that awaited them. I went first to see a young girl in thesecond stage. "She’ll never deliver, doctor," boomed Sisterbehind me, "you’ll have to put the forceps on." I looked. Thegirl lay lonely on the bed, a young pupil sitting frightened andsilent beside her. "Let’s see. Come on now, legs up. Push, goon, once more. I can see the baby’s hair, it’s black, now push!"And out popped the baby, not even a perineal tear.

Finally, I went to examine the last patient. It was only asmall thing, but it upset me. This time I was assisted by Sister2, who chewed gum noisily throughout the procedure. "Put abit of hot water in that," as I held out the bowl of ice-cold anti-septic fluid I was offered to swab the perineum. "Can’t," shereplied, "it won’t be sterile."When I eventually got to bed I lay and thought of the fate

of today’s mothers. To be lain flat on their backs, strapped tomonitoring machines, starved and periodically douched withicy water, and maybe ending with an assisted delivery becauseno-one had shown any enthusiasm or even concern about theoutcome of their labour. It hardly needs to be said that thebabies, when eventually delivered, are efficiently weighed,washed, clothed, and popped into a cot, sometimes without themothers even seeing them.Now in case you should be thinking, Mary, that I have

fallen into a particularly dismal dump, may I say that this par-ticular hospital has a better reputation, and I think deservedh.