549

The committee took an extremely serious view of the arrange-ment, which amounted to a conspiracy and was admitted tohave extended over a substantial period, Lord Cohen said.Dr. Cassels-Brown issued a large number of National Health

Service prescriptions on E.C. 10 forms for patients whom he hadnever seen for that purpose, or for patients whom he had notseen or examined with a view to treatment. He was thus inbreach of his Terms of Service as a general medical practitionerin the National Health Service, which required that he shouldnot use Health Service forms for a person other than a patientunder treatment by him. Moreover, in consequence of thearrangement which was made, money was paid to him frompublic funds by way of capitation payments for patients whowould not otherwise have sought his professional services, andfor whom he was not providing the normal range of general-practitioner services.Dr. Bell and Dr. Chisholm both were enabled to benefit their

practices by extending to private patients facilities which theywere not entitled to offer them. A further consequence was that

public funds were applied for purposes for which they were notintended-namely, the provision of drugs and other items underthe National Health Service for persons who were in fact beingtreated as private patients.

" In order that there may be no misunderstanding," con-tinued the Chairman, " the committee desire me to add thatthey have been concerned in this case solely with the questionsof professional conduct which have arisen. They are in no wayconcerned with the issue, which has for long been publiclydebated, whether the National Health Service should bemodified so as to entitle a patient to receive, as a National HealthService benefit, drugs prescribed by a private practitioner." The committee have, however, taken note of the regret

which has been expressed on behalf of each of you, and also ofthe favourable testimonials which have been submitted. Thecommittee have been rightly reminded that this is the first caseof the kind which the committee have been called upon toconsider. Because of this and because they are prepared tobelieve that the warning given by these proceedings will in eachcase be sufficient and be generally heeded, they have not directedthe Registrar to erase any of your names from the Register.That concludes the case."

Conference

COMMUNITY PSYCHIATRYFROM A CORRESPONDENT

THE annual conference of the National Association forMental Health was held in London on Feb. 28.

Prof. H. L. A. HART pointed to the convergence of mentalscience and criminal law, progress in science having underminedsome of our faith in the law. Both crime and mental disorderwere far commoner than the public realised, and in dealingwith them-despite the haziest knowledge of cause-there wasa conviction that institutional segregation should be a thing ofthe past for both. Perhaps public ignorance and miscon-ception accounted for the very low economic value put on thesetwo services. Professor Hart thought it important to considerthe fundamental philosophy : why take trouble to raise those oflower achievement levels and mental health ? He thought thereshould be " bread for all before there is jam for any ", and thatif ordinary people thought that these resources increasedhappiness and diminished suffering in the community, thenno obstacles would be raised.

In a characteristically provocative and farsighted address,Prof. G. M. CARSTAIRS called for refresher courses inpsychiatry not only for general practitioners but also forconsultants in other specialties. His fear, however, was not somuch of the resistance of such doctors but of the mass ofpsychiatric patients likely to be referred from medical, ortho-pedic, and even surgical clinics. Turning to world trends, hedeplored the " lunatic dialogue " of threats of mutual extermina-

tion. People suppressed the fear that these engendered, butProfessor Carstairs took seriously the effect they might have onmental health. On the changing pattern of care, he observedthat first admissions for affective and personality disorderswere particularly on the rise, and this was good, for it meantthat more people who needed treatment were coming early on.While applauding the trend to reintegrate psychiatry into

medicine, he pointed out that psychiatric and general medicaltreatments differed a good deal-the psychiatrist needed moreroom and a longer time, and when general hospitals got to knowtheir work and patients better they might like psychiatrists less.Too much effort in these hospitals, too, might mean a declinein the standards of mental hospitals. He described a monthlycoordinating committee in Edinburgh with the medical officerof health, outcomes of which had been information to G.P.Sby a monthly broadsheet and a system whereby they wereimmediately notified when patients were discharged what drugsthey should be taking. The shortage of psychiatric socialworkers (only 5 in the city) was being overcome by the use of" aids ", 95 in all. A special ward for attempted suicide caseshad revealed far greater numbers than had been suspectedbefore the change in the law: 1 in every 1000 of the city’spopulation went through the ward annually.Dame OLIVE WHEELER called for adult educational courses

and creative activities of all kinds to overcome the pathogeniceffects of repetitive occupation, lacking in initiative.

Dr. H. L. FREEMAN favoured a working partnership betweenhospital and family, with mutual respect for what the othercould uniquely contribute. Doctors, who may be ill-equippedby professional training and because of social-class difference,must be willing to go into the home and see what was going on.Support for the mentally ill patient within the family dependedon an extended and coherent family structure which the modernsmall 2-generation unit (created often by the public housingpolicy) could not easily provide. Failure of the family to givesuch support called for extended community services-homehelps, day nurseries, old folk’s homes. Chronic patients athome must not be allowed to lie inactively in a " one-patientward ".Miss NESTA ROBERTS said that the rosy view of early propa-

ganda of community psychiatry had become tarnished realisa-tion of the solemn facts. Education of the public in healthierattitudes had made enormous strides, but psychiatric progresswas peculiarly’like the illness it treats in being cyclical ".

Dr. RUSSELL BARTON said that, though most consultants wereon top of their job, the slack and incompetent ones were dis-heartening to their juniors and demoralising to the laity. Therewere drawbacks, too, in the teaching of psychiatrists, whoshould be obliged to care for adequate numbers of representa-tative patients during their training. G.P. training was alsolacking in that London teaching hospitals between themhad only 83 psychiatric beds (5 hospitals had none), and thesepatients were for the most part out of sight in annexes.

Dr. Barton postulated a form of Parkinson’s Law whereby aspsychiatric beds increased, the number of patients wouldexpand to fill them, until maybe 10% of the population wouldbe behind bars. He also called attention to the influence of lovewhich relatives so often showed for an elderly incapacitatedpatient: such people were indeed " a burden on the com-munity ", but so were babies and so were a great many otherpeople, including greedy dealers in property.

Offering the views of a family doctor, Dr. H. S. PASMOREremarked that in 350 B.C. Plato had said: " If a man is insanehe shall not be at large in the city, but his relations shall keephim at home in any way which they can." The burdens whichchronic psychiatric patients imposed on the G.P. were great,and the N.H.S. did not allow him to give the continued supportand supervision which were needed.

If the G.P. had the direct help of a psychiatric social worker,many more doctors would be prepared to do more for thesepatients. Praising the role of discussion groups in teaching theG.P., Dr. Pasmore said that " reassuring " the neurotic patientregarding organic illness too often just meant that one wasreassuring oneself.