These days most patients in this category are cared for in secure regional units, general NHS psychiatric inpatient acute units, and independent sector hospitals. "These institutions operate far more liberal regimes but with no less safety and without the problems that have dogged the special hospitals," writes the author, Professor Elaine Murphy.

Professor Murphy, Chairman of City and Hackney Community Health Services Trust and former vice chairman of the Mental Health Act Commission, says that the Commission's reports since 1984 have repeatedly commented on the " impoverished regime, overly restrictive and often petty security regulations, the emphasis on mechanical security rather than on the safer strategy of getting to know patients well, and the lack of therapeutic optimism of staff." The blame for such conditions has been laid at the feet of a core group of members of the Prison Officers' Association which has exercised enormous power, she says.

"What those involved find particularly depressing is that heroic attempts have in fact been made in recent years to improve the hospitals; first rate chief executives were appointed, some joint academic appointments made, some new blood' ward managers were brought in from outside. Most importably, the sole negotiating rights of service held by the Prison Officers' Association were ended, and staff who wished to ally themselves with the quite different culture and values of the Royal College of Nursing and Unison were at last able to sit at the staff-management negotiating forum," says the author.

But since the special hospitals joined the NHS as three separate health authorities in April last year, the Prison Officers' Association's response has been "to go back to their old ways" according to a senior staff member at Broadmoor. "In all three hospitals a hard core (at Broadmoor estimated to be 150 or so) are believed to be behind a new wave of hate mail, intimidation of new staff, victimisation of non-members, and threats to senior managers (a toy grenade was found under a senior executive's car last month)" writes Professor Murphy.

"Put bluntly, if such a union has a role in a civilised society, it is surely not working in hospitals caring for seriously mentally ill people. The choice is a stark one; either the hospitals must change or they must close completely.......Derecognition of the union's right to negotiate on its members' behalf would be a first step to removing it from the institutions, a move which all the authorities would welcome."

Last year, says Professor Murphy, the three special hospitals chief executives asked Ken Jarrold, of the NHS Executive, whether the executive would support derecognition of the union. Mr Jarrold felt that such a move would only be supported by ministers after the election. "Let us hope that the new secretary of state for health will have the courage to support such a decision", she writes.

Contact: Professor Elaine Murphy

City and Hackney Community Health Services Trust

Tel: 0171 301 300
Fax: 0171 739 8455

Steroid injections are the best tolerated as well as the most effective way of treating shoulder complaints in general practice, says a paper in this week's BMJ. Jan Winters and colleagues from the University of Groningen, The Netherlands, studied patients with different types of shoulder disorders; synovial (originating from the lining of the shoulder joint cavity), or shoulder girdle (relating to disorders of the spine or upper ribs).

Patients in the synovial group were randomised to receive corticosteroid injection, manipulation, or physiotherapy, while those in the shoulder girdle group received either manipulation or physiotherapy. In the first group, those receiving injection showed the quickest recovery and only 17% dropped out because of treatment failure, compared with 51% in the physiotherapy group and 59% who received manipulation.

The duration of complaints in the shoulder girdle group was significantly shorter among those who received manipulation, with only a 20% drop out rate compared with 45% in those randomised to physiotherapy.

"Of 22 comparative studies that investigated corticosteroid injection for treating shoulder complaints, only five describe success with injection. We consider our positive results with corticosteroid injection were helped by our setting in general practice (no patient selection by referral)" say the authors.

"To our knowledge, no other published study has described the positive effects of manipulation in treating shoulder complaints. The results of our study suggest that manipulation is to be preferred to physiotherapy for treating shoulder complaints originating from the shoulder girdle in general practice."

Contact: Dr Jan Winters

University of Groningen

Tel: 00 31 50 406 1394
Fax: 00 31 50 406 1398

Over the last few years some services previously provided by hospitals have been taken over by GPs. This primary care led NHS' has potential to increase GPs' workload, says a paper in this weeks BMJ.

Lone Lund Pedersen and Brenda Leese, from the National Primary Care Research and Development Centre, University of Manchester, say that there is little more than anecdotal evidence to support claims of greatly increased workloads, and that it is insufficient to make informed decisions about remunerating GPs for the extra work resulting from the changes. "Lack of evidence does not, however, mean there is no problem with workload. It will be increasingly important to identify mechanisms for ensuring that resources follow workload" they say.

The paper identifies 15 areas in which secondary (hospital) care activities have been transferred to GPs. These include minor surgery, pre-operative assessment and work up, follow-up after surgery. Shifts to community based care and changed discharge practices such as reduction in long stay provision and relocation of long term patients to community based care are likely to have a knock-on effect for GPs, say the authors.

Although there have been some studies into the effect of these changes on GP workload, they are limited in scope, and only evaluated schemes with well designed protocols and well resourced and organised facilities. "This will not always be the case," say the authors, "and these are not the schemes that general practitioners are most worried about." Evidence is still lacking on, for example, the impact of early discharge from hospital, and of GPs taking over care of patients who might otherwise have been cared for in hospital - including visits to those in nursing and residential homes, where the elderly residents require more of the GPs time than do those over 65 living independently.

More research is needed to identify changes in workload to ensure that remuneration for increases is based on evidence and not anecdote.

Contact: Lone Pedersen

University of Manchester