272
An Urban and
Integrated
Health Service Plan
CHANDRA MOHAN, M.B., B.S., M.D., (SOC. AND
Medical
MED.),
F.R.S.H.
Officer of Health, City of Lilongwe, Malawi
IN THE history of all standards be
health the year 1948 will landmark. That year the World Health Organization was founded and with it the word ’health’ was defined, giving a new connotation and concept to it. The inclusion of mental and social wellbeing into the ambit of health services was a notable decision. It added new dimensions and threw a challenge to health planners and administrators. Whether this challenge has been accepted or not by various reorganizations of health services all over the world and by giving it an appropriate structure and functional capability is something for researchers to find out, perhaps by performance audits. Only sceptics would differ that much ground has been gained since then in the development of clinical and public health services. I have deliberately avoided to use the word ’medical’ in place of ’clinical’ since ’medicine’ is only a part of wider spectrum of public health services. It is part of the well known five stages of disease and their corresponding levels of prevention. How far have we been able to ingrain this concept in the minds of medical students, medical teachers, clinicians, health administrators and planners can again be only assessed by studying the behaviour and attitudes of such personnel as listed above whether they met with the desired objectives. After all education or any training is meant to do this precisely. The education these men and women have had in their institutions should be reflected in their work. It is saddening for one still to find clear demarcation between clinical medicine and public health schemes. On one hand we have traditional hospitals and general practice delivering pure and simple medical care and on the other we have a wide spectrum of health and health related social services. The presence or otherwise and the size of each colour of such a spectrum depends on resources, conceptual and management skills. Be it a developed country or a developing one the pattern is the same. There may be difference in size. It is admitted that so far as sophistication and specialization are concerned there has been a tremendous improvement both in quality and quantity in such services during the last three decades. In spite of all this notable development if one looks around at the organization of such services one tends to get disillusioned to still see a clear dividing line between curative and preventive services. They are still being delivered at separate places. At some places one would not be surprised to find even health and health related services being delivered by more than a dozen agencies, all specialized but discordinated. At least the curative services are at either GPs surgery or in a hospital
by
PREV.
public
a
(out-patients and in-patient departments). What is lacking in the day to day working of the clinicians is integrating their work with preventive and perhaps
health related social services. It is what is known in public health parlance community medicine approach, therefore, not dealing with a disease problem in its totality. It is perhaps a deficiency in medical education that correct attitudes and behaviour were not
developed. Is it really necessary to deliver integrated curative and preventive services? After all what is wrong in providing such specialized services at separate centres e.g. hospitals and health centres? These and similar questions are brought up from time to time by all professional persons engaged in providing clinical and
health services. All industrial, commercial and business establishments always like to keep operational costs at minimum possible levels and profits at an optimum unlike public sector undertakings. Cost accounting is conspicuous by its absence in governmental departments. If one could be undertaken for the existing separate clinical and public health and health related services and compare to an integrated plan it would show the enormous wastage in former. Much of overlapping and duplication could be avoided in an integrated approach. Of course, the educational syllabi of paramedical and parahealth personnel would need a complete overhaul so as to integrate them into one. What we should aim at multipurpose para-health workers and clinical paramedical staff with more health orientation than at present. Similarly the medical staff would need more orientation in health problems. Though in some medical colleges social and preventive medicine is taught for three or more years but even then it would seem correct behaviour pattern does not evolve. They should be able not only to identify the problem of disease but also relate it to its ecological origin and the treatment should include total care with the assistance of parahealth personnel and health related social workers. This obviously would need them to be near the clinician. Therefore, the necessity of the whole team to be under one roof. I would venture to call the establishment under this roof as an urban health centre complex. Such a Centre should have a Community Physician and GPs along with paramedical and parahealth personnel. In addition, health related social workers should also be there to make the team complete. I am sure such a team would have much better coordination than at present and the problems of disease and health would be solved more expeditiously by cross referral system. At present the disease is medically tackled by a
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
273
hospital
or
by
GPs and the
community
health and
health related social services work separately, may be at times there is a fairly loose liaison amongst them. There have been some attempts to establish urban health centres but without general medical practice being available in them. This again does not meet the need of total health care for an individual. The working relationship between curative and preventive, including promotional services is more in theory and ritualistic
than being actually practised. The concept of a health centre is not new. In very many countries of the developing world the concept has been introduced by establishing rural health centres, doctored or otherwise. In the free developed world because of the process of industrialization, urbanization has spread in rural areas to an extent that classic rural panorama has ceased to exist. In developing countries of Asia and Africa an attempt has been made to provide comprehensive and integrated health services at such rural health centres. But because of various constraints financial, manpower, managerial skills and absence of administrative will the results have not been as spectacular as one would have wished. These centres provide mostly curative medical service though theoretically it was also intended to include comprehensive health services. For some unknown reasons this concept of integrated medical care with comprehensive health services was not first attempted in the cities instead of introducing it in rural areas first. In the cities we still find traditional medical care through hospitals, GPs (if present) and clinics. If at any places urban health centres have been established they are mostly providing various preventive and health related social services. It has been seen in case of any cultural renaissance and administrative innovations that they tend to percolate from urban to rural communities than vice versa. Therefore, this concept of health centres should also have started from the cities to towns and then to villages. This would have had additional advantage of better possibilities of operational research and experimentation so as to come to correct conclusions. Thus we have come to a pass that the desired objectives have not been achieved, at considerable expense of the movement. It is, therefore, imperative at least now, to think in terms of planning urban health services on a pattern which would not only give adequate coverage in terms of the definition of ’health’ but also set an example to be emulated by semi-urban and rural communities. The present position in most cities is that the governments provide medical care through traditional hospitals with casualty, out-patient and in-patient services. At some places clinics with predominantly curative services have been established in residential areas. These efforts have been supplemented by various kinds of health insurance schemes. In addition as stated earlier, some other agencies like local authorities have established health centres providing preventive and health related social services. The responsibility of providing environment health services have basically remained with local authorities. In between the government and the local authorities have been divided the other health services. In advanced and developed countries the social services have also a fair share of providing health related services. Thus the general pattern is multiple agency system of bringing under their umbrella as much of total care as possible depending on resources, conceptual and management abilities. The ground rules are quite ill-defined and have plenty of scope for action or otherwise -
-
individual enterprise. Likewise superviMuch is naturally left to individual’s initiative. The lines of command are hazy. Naturally people do not get the optimum utilization of services, which they would if all the services were integrated under one command and more of clarity in functions, orders and supervision. At present a total approach is absent. The present system of providing out-patient services divorced from health, including environment, in a broader sense (physical, biological and psycho-social) and health related social services needs a revolutionary change in the first place by abolishing out-patient services from traditional hospitals. The hospitals may retain casualty, diagnostic, specialist and ambulance services. Even some of these could also perhaps be decentralized depending on resources, size of the catchment area of the hospital and availability of suitable buildings etc. Instead, urban health centre complexes should be established within residential areas so that people do not have to travel to go to hospitals for GP consultation and also get all requisite services either consequent to such a consultation or vice versa at the same place. Generally the catchment area of a hospital is much more than its immediate neighbourhood. It would therefore be necessary to have an urban health centre complex within the hospital campus catering to the needs of people in its immediate neighbourhood and other such centres spread out in the rest of the catchment area. Such centres should provide GP consultation for medical services and all health and health related social services. Cross referral system amongst all the staff of the centre should be the rule than exception. The health problems, which in fact have resulted in disease, should be taken to their legitimate conclusion. Depending on resources again establishment of sub-urban health centres may be considered for smaller populations. I should think an urban health centre complex should cater to about 50,000-100,000 persons in a compact city. As stated earlier some of the remaining services of the hospital e.g., ambulance, minor casualty, diagnostic services and a few observation beds could be also a part of such an urban health on depending sion is not
possible.
complex. relationship of the urban health centre with the hospital as against its predecessor, the out-patient department, had, can perhaps be better expressed by centre
The
the
diagram
below. At present the O.P.D. is part
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
274
parcel of hospital with common staff and other supportive services. The urban health centre complex, on the other hand should be an ancillary and adjunct and
institution. An urban health centre complex would therefore be more community minded than the present out-patient department. It should provide the following services :-
(i) Out-patient
GP consultation
including
dental
care.
(ii) Under-5 child clinics. (iii) Maternal health services (iv) Health education (v) Speech therapy and behaviour problems (vi) Geriatrics (vii) Sexually transmitted diseases (viii) Immunisations (ix) Environmental health (x) Occupational health (xi) Health related social services, e.g., geriatric social services, domicilliary visitations, adolescent and adult behaviour problems, alcoholism, drugaddiction, marriage counselling, family life education, home economics, food and nutrition education etc. etc.
5
HOYLE, M., KENNEDY, A., PRIOR, A. L. and THOMAS, G. E. (1977). Small bowel ischaemia and infarction in young women taking oral contraceptives and progestational agents, British Journal of Surgery, 64, 533. 6 LEE, H. A. and DICKERSON, J. W. T. (1978). Diet in the management of cardiovascular disease, Ch. 7 in ’Nutrition in the Clinical Management of Disease’, Eds. J. W. T. Dickerson and H. A. Lee, London: Edward Arnold. 7 SPITTLE, C. (1971). Atherosclerosis and vitamin C, Lancet, 2, 1280.
GINTER, E. (1973). Cholesterol: vitamin C controls its
trans-
formation to bile
9
10
11
12
13
14
15
16
17
18
salts, Science, 179, 702. WYNN, V., DOAR, J. W. H., MILLS, G. L. and STOKES, T. (1969). serum Fasting triglyceride, cholesterol, and lipoprotein levels during oral contraceptive therapy, Lancet, 2, 756.
TABACCHI, M. H. and KIRKSEY, A. (1973). Influence of dietary
lipids on plasma and hepatic lipids and on blood clotting properties in rats fed oral contraceptives, Journal of Nutrition, 103, 1270. ADAMS, P. W., FOLKARD, J., WYNN, V. and SEED, M. (1976). Influence of oral contraceptives, pyridoxine, and tryptophan
metabolism, , Lancet, 1 759. RIVERS, J. M. (1975). Oral contraceptives and ascorbic acid,
American Journal of Clinical Nutrition, 28, 550. KINSMAN, R. A. and HOOD, J. (1971). Some behavioural effects of ascorbic acid deficiency, American Journal of Clinical Nutrition, 24, 455. SANPITOK, N. and CHAYUTI-MONKUL, L. (1974). Oral contraceptives and riboflavine nutrition, Lancet, i, 836. BRAIN and WALTON, J. N. (1969). ’Brain’s diseases of the nervous system’, London: Oxford University Press. LABADARIOS, D., OBUWA, G., LUCAS, E. G., DICKERSON, J. W. T. and PARKE, D. V. (1978). The effects of chronic drug administration on hepatic enzyme induction and folate metabolism, British Journal of Clinical Pharmacology, 5, 167. DICKERSON, J. W. T., HEALD, M. and TORRENS, P. E. (1974). Dietary intakes of elderly patients at Graylingwell Hospital, Chichester, Report to South West Thames Regional Health Author-
ity.
CHANARIN, I. (1978). Anaemias and coagulation disorders of
nutritional origin, Ch 11 in ’Nutrition in the Clinical Management of Disease’. Eds. J. W. T. Dickerson and H. A. Lee, London: 19
20
complex. To a certain extent the above Plan would mean going back to pre-1974 position in U.K. but if the intention is to provide total health care to a community there is perhaps no way than to accept gracefully that whatever has been done in the past has been to provide highly skilled services in various fields all too apart to each other and though related to the problems of the community they do not serve the purpose of an individual and the community. It is like an assembly of eminent singers singing the same tune but not in chorus, the tune being the welfare of the community.
21
FOOD AND FOREIGN SUBSTANCES’ Continued from page 265
8
The above list is not claimed to be complete but it a fair idea of the functions of the u.h.c. complex. Such a centre should be headed by a community physician and on his staff would be GPs, including dental GPs, community and general nurses, pharmacists, health educationist, medico-social workers, environment and occupational health officers, speech therapists, and if resources permit psychiatrist. With proper relationship developed with the hospital a system of bilateral cross referral system could evolve so that clinical needs e.g., specialist consultation, diagnostic services could be available to people attending u.h.c. complex and the community health needs of the patients admitted to the hospital were also met by u.h.c.
gives
Edward Arnold. LABADARIOS, D. (1975). Studies on the effects of drugs on nutritional status, PhD. Thesis, University of Surrey. STAMP. T. C. B., ROUND, J. M., ROWE, D. J. F. and HADDAD, J. G. Jr. (1972). Plasma levels and therapeutic efficacy of 25-
hydroxycholecalciferol in epileptic patients taking anti-convulsant drugs, British Medical Journal, 2, 9.
HAHN T. J., HENDIN, B. A. SCHARP, C. R. and HADDAD, J. G. (1972). Effect of chronic anticonvulsant therapy on serum 25hydroxycalciferol levels in adults, New England Journal of Medicine, 287, 900. 22 HAHN, T. J., HENDIN, B. A. SCHARP, C. R., BOISSEAU, V. C. and HADDAN, J. G. (1975). Serum 25-hydroxycalciferol levels and bone mass in children on anti-convulsant therapy, New England Journal of Medicine, 292, 550. 23 WU, A., CHANARIN, I., SLAVIN, G. and LEVI, A. J. (1975). Folate its relationship to clinical and deficiency in the alcoholic haematological abnormalities, liver disease and folate stores, British Journal of Haematology, 29, 469. 24 MARKS, V. and MEDD, W. E. (1964). Alcohol-induced hypoglycaemia, British Journal Psychiatry, 110, 228. 25 DICKERSON, J. W. T. (1974). Nutrition and Mental Illness, Nutrition, 28, 181. 26 BARTHOLOMEW, C. (1972). Rheumatoid arthritis and prednisoneinduced scurvy, Postgraduate Medical Journal, 48, 243. 27 SAHUD, M. A. and COHEN, R. J. (1971). Effect of aspirin ingestion on ascorbic acid levels in rheumatoid arthritis, Lancet, 1, 937. 28 LOH, H. S., WATTERS. K. and WILSON, C. W. M. (1973). The effects of aspirin on the metabolic of ascorbic acid in human beings, Journal o f Clinical Pharmacology, 13, 480. 29 BASU, T. K. (1977). Possible toxicological aspects of megadoses of ascorbic acid, Chemico-Biological Interactions, 16, 247. 30 HOUSTON, J. B. and LEVY, G. (1975). Modification of drug biotransformation by vitamin C in man, Nature, 255, 78. 31 CORRIGAN, J. J. and MARCUS, F. I. (1974). Coagulopathy associated with vitamin E ingestion, Journal of the American Medical Association, 230, 1300. 32 BASU, T. K., DICKERSON, J. W. T., RAVEN, R. W. and WILLIAMS, D. C. (1974). The thiamine status of patients with cancer as determined by the red cell transketolase activity, International Journal for Vitamin and Nutrition Research, 44, 53. 33 ANTON, E. and BRANDES, D., (1968). Lysosomes in mice mammary tumours treated with cyclophosphamide: Distribution related to course of disease, Cancer, 21, 483. 34 EXTON-SMITH, A. N. (1978). Nutrition in the Elderly, Ch. 4. In ’Nutrition in the Clinical Management of Disease’. Eds. J. W. T. Dickerson and H. A. Lee, London: Edward Arnold. 35 DAVIES, L., HASTROP, K. and BENDER. A. E. (1973), Potassium intake of the elderly, Modern Geriatrics, 3, 482. 36 JUDGE, T. G. (1968). Hypokalaemia in the elderly, Gerontologia Clinica, 10, 102. 37 WOOD, P. H. N, HARVEY-SMITH, E. A. and DIXON, A. ST. J. (1962). Salicylates and gastrointestinal bleeding, British Medical Journal, 1, 669. —
availability
These papers
were
presented at the Health Congress,
April 1978.
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
Bournemouth 25
An Urban and
Integrated
Health Service Plan
CHANDRA MOHAN, M.B., B.S., M.D., (SOC. AND
Medical
MED.),
F.R.S.H.
Officer of Health, City of Lilongwe, Malawi
IN THE history of all standards be
health the year 1948 will landmark. That year the World Health Organization was founded and with it the word ’health’ was defined, giving a new connotation and concept to it. The inclusion of mental and social wellbeing into the ambit of health services was a notable decision. It added new dimensions and threw a challenge to health planners and administrators. Whether this challenge has been accepted or not by various reorganizations of health services all over the world and by giving it an appropriate structure and functional capability is something for researchers to find out, perhaps by performance audits. Only sceptics would differ that much ground has been gained since then in the development of clinical and public health services. I have deliberately avoided to use the word ’medical’ in place of ’clinical’ since ’medicine’ is only a part of wider spectrum of public health services. It is part of the well known five stages of disease and their corresponding levels of prevention. How far have we been able to ingrain this concept in the minds of medical students, medical teachers, clinicians, health administrators and planners can again be only assessed by studying the behaviour and attitudes of such personnel as listed above whether they met with the desired objectives. After all education or any training is meant to do this precisely. The education these men and women have had in their institutions should be reflected in their work. It is saddening for one still to find clear demarcation between clinical medicine and public health schemes. On one hand we have traditional hospitals and general practice delivering pure and simple medical care and on the other we have a wide spectrum of health and health related social services. The presence or otherwise and the size of each colour of such a spectrum depends on resources, conceptual and management skills. Be it a developed country or a developing one the pattern is the same. There may be difference in size. It is admitted that so far as sophistication and specialization are concerned there has been a tremendous improvement both in quality and quantity in such services during the last three decades. In spite of all this notable development if one looks around at the organization of such services one tends to get disillusioned to still see a clear dividing line between curative and preventive services. They are still being delivered at separate places. At some places one would not be surprised to find even health and health related services being delivered by more than a dozen agencies, all specialized but discordinated. At least the curative services are at either GPs surgery or in a hospital
by
PREV.
public
a
(out-patients and in-patient departments). What is lacking in the day to day working of the clinicians is integrating their work with preventive and perhaps
health related social services. It is what is known in public health parlance community medicine approach, therefore, not dealing with a disease problem in its totality. It is perhaps a deficiency in medical education that correct attitudes and behaviour were not
developed. Is it really necessary to deliver integrated curative and preventive services? After all what is wrong in providing such specialized services at separate centres e.g. hospitals and health centres? These and similar questions are brought up from time to time by all professional persons engaged in providing clinical and
health services. All industrial, commercial and business establishments always like to keep operational costs at minimum possible levels and profits at an optimum unlike public sector undertakings. Cost accounting is conspicuous by its absence in governmental departments. If one could be undertaken for the existing separate clinical and public health and health related services and compare to an integrated plan it would show the enormous wastage in former. Much of overlapping and duplication could be avoided in an integrated approach. Of course, the educational syllabi of paramedical and parahealth personnel would need a complete overhaul so as to integrate them into one. What we should aim at multipurpose para-health workers and clinical paramedical staff with more health orientation than at present. Similarly the medical staff would need more orientation in health problems. Though in some medical colleges social and preventive medicine is taught for three or more years but even then it would seem correct behaviour pattern does not evolve. They should be able not only to identify the problem of disease but also relate it to its ecological origin and the treatment should include total care with the assistance of parahealth personnel and health related social workers. This obviously would need them to be near the clinician. Therefore, the necessity of the whole team to be under one roof. I would venture to call the establishment under this roof as an urban health centre complex. Such a Centre should have a Community Physician and GPs along with paramedical and parahealth personnel. In addition, health related social workers should also be there to make the team complete. I am sure such a team would have much better coordination than at present and the problems of disease and health would be solved more expeditiously by cross referral system. At present the disease is medically tackled by a
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
273
hospital
or
by
GPs and the
community
health and
health related social services work separately, may be at times there is a fairly loose liaison amongst them. There have been some attempts to establish urban health centres but without general medical practice being available in them. This again does not meet the need of total health care for an individual. The working relationship between curative and preventive, including promotional services is more in theory and ritualistic
than being actually practised. The concept of a health centre is not new. In very many countries of the developing world the concept has been introduced by establishing rural health centres, doctored or otherwise. In the free developed world because of the process of industrialization, urbanization has spread in rural areas to an extent that classic rural panorama has ceased to exist. In developing countries of Asia and Africa an attempt has been made to provide comprehensive and integrated health services at such rural health centres. But because of various constraints financial, manpower, managerial skills and absence of administrative will the results have not been as spectacular as one would have wished. These centres provide mostly curative medical service though theoretically it was also intended to include comprehensive health services. For some unknown reasons this concept of integrated medical care with comprehensive health services was not first attempted in the cities instead of introducing it in rural areas first. In the cities we still find traditional medical care through hospitals, GPs (if present) and clinics. If at any places urban health centres have been established they are mostly providing various preventive and health related social services. It has been seen in case of any cultural renaissance and administrative innovations that they tend to percolate from urban to rural communities than vice versa. Therefore, this concept of health centres should also have started from the cities to towns and then to villages. This would have had additional advantage of better possibilities of operational research and experimentation so as to come to correct conclusions. Thus we have come to a pass that the desired objectives have not been achieved, at considerable expense of the movement. It is, therefore, imperative at least now, to think in terms of planning urban health services on a pattern which would not only give adequate coverage in terms of the definition of ’health’ but also set an example to be emulated by semi-urban and rural communities. The present position in most cities is that the governments provide medical care through traditional hospitals with casualty, out-patient and in-patient services. At some places clinics with predominantly curative services have been established in residential areas. These efforts have been supplemented by various kinds of health insurance schemes. In addition as stated earlier, some other agencies like local authorities have established health centres providing preventive and health related social services. The responsibility of providing environment health services have basically remained with local authorities. In between the government and the local authorities have been divided the other health services. In advanced and developed countries the social services have also a fair share of providing health related services. Thus the general pattern is multiple agency system of bringing under their umbrella as much of total care as possible depending on resources, conceptual and management abilities. The ground rules are quite ill-defined and have plenty of scope for action or otherwise -
-
individual enterprise. Likewise superviMuch is naturally left to individual’s initiative. The lines of command are hazy. Naturally people do not get the optimum utilization of services, which they would if all the services were integrated under one command and more of clarity in functions, orders and supervision. At present a total approach is absent. The present system of providing out-patient services divorced from health, including environment, in a broader sense (physical, biological and psycho-social) and health related social services needs a revolutionary change in the first place by abolishing out-patient services from traditional hospitals. The hospitals may retain casualty, diagnostic, specialist and ambulance services. Even some of these could also perhaps be decentralized depending on resources, size of the catchment area of the hospital and availability of suitable buildings etc. Instead, urban health centre complexes should be established within residential areas so that people do not have to travel to go to hospitals for GP consultation and also get all requisite services either consequent to such a consultation or vice versa at the same place. Generally the catchment area of a hospital is much more than its immediate neighbourhood. It would therefore be necessary to have an urban health centre complex within the hospital campus catering to the needs of people in its immediate neighbourhood and other such centres spread out in the rest of the catchment area. Such centres should provide GP consultation for medical services and all health and health related social services. Cross referral system amongst all the staff of the centre should be the rule than exception. The health problems, which in fact have resulted in disease, should be taken to their legitimate conclusion. Depending on resources again establishment of sub-urban health centres may be considered for smaller populations. I should think an urban health centre complex should cater to about 50,000-100,000 persons in a compact city. As stated earlier some of the remaining services of the hospital e.g., ambulance, minor casualty, diagnostic services and a few observation beds could be also a part of such an urban health on depending sion is not
possible.
complex. relationship of the urban health centre with the hospital as against its predecessor, the out-patient department, had, can perhaps be better expressed by centre
The
the
diagram
below. At present the O.P.D. is part
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
274
parcel of hospital with common staff and other supportive services. The urban health centre complex, on the other hand should be an ancillary and adjunct and
institution. An urban health centre complex would therefore be more community minded than the present out-patient department. It should provide the following services :-
(i) Out-patient
GP consultation
including
dental
care.
(ii) Under-5 child clinics. (iii) Maternal health services (iv) Health education (v) Speech therapy and behaviour problems (vi) Geriatrics (vii) Sexually transmitted diseases (viii) Immunisations (ix) Environmental health (x) Occupational health (xi) Health related social services, e.g., geriatric social services, domicilliary visitations, adolescent and adult behaviour problems, alcoholism, drugaddiction, marriage counselling, family life education, home economics, food and nutrition education etc. etc.
5
HOYLE, M., KENNEDY, A., PRIOR, A. L. and THOMAS, G. E. (1977). Small bowel ischaemia and infarction in young women taking oral contraceptives and progestational agents, British Journal of Surgery, 64, 533. 6 LEE, H. A. and DICKERSON, J. W. T. (1978). Diet in the management of cardiovascular disease, Ch. 7 in ’Nutrition in the Clinical Management of Disease’, Eds. J. W. T. Dickerson and H. A. Lee, London: Edward Arnold. 7 SPITTLE, C. (1971). Atherosclerosis and vitamin C, Lancet, 2, 1280.
GINTER, E. (1973). Cholesterol: vitamin C controls its
trans-
formation to bile
9
10
11
12
13
14
15
16
17
18
salts, Science, 179, 702. WYNN, V., DOAR, J. W. H., MILLS, G. L. and STOKES, T. (1969). serum Fasting triglyceride, cholesterol, and lipoprotein levels during oral contraceptive therapy, Lancet, 2, 756.
TABACCHI, M. H. and KIRKSEY, A. (1973). Influence of dietary
lipids on plasma and hepatic lipids and on blood clotting properties in rats fed oral contraceptives, Journal of Nutrition, 103, 1270. ADAMS, P. W., FOLKARD, J., WYNN, V. and SEED, M. (1976). Influence of oral contraceptives, pyridoxine, and tryptophan
metabolism, , Lancet, 1 759. RIVERS, J. M. (1975). Oral contraceptives and ascorbic acid,
American Journal of Clinical Nutrition, 28, 550. KINSMAN, R. A. and HOOD, J. (1971). Some behavioural effects of ascorbic acid deficiency, American Journal of Clinical Nutrition, 24, 455. SANPITOK, N. and CHAYUTI-MONKUL, L. (1974). Oral contraceptives and riboflavine nutrition, Lancet, i, 836. BRAIN and WALTON, J. N. (1969). ’Brain’s diseases of the nervous system’, London: Oxford University Press. LABADARIOS, D., OBUWA, G., LUCAS, E. G., DICKERSON, J. W. T. and PARKE, D. V. (1978). The effects of chronic drug administration on hepatic enzyme induction and folate metabolism, British Journal of Clinical Pharmacology, 5, 167. DICKERSON, J. W. T., HEALD, M. and TORRENS, P. E. (1974). Dietary intakes of elderly patients at Graylingwell Hospital, Chichester, Report to South West Thames Regional Health Author-
ity.
CHANARIN, I. (1978). Anaemias and coagulation disorders of
nutritional origin, Ch 11 in ’Nutrition in the Clinical Management of Disease’. Eds. J. W. T. Dickerson and H. A. Lee, London: 19
20
complex. To a certain extent the above Plan would mean going back to pre-1974 position in U.K. but if the intention is to provide total health care to a community there is perhaps no way than to accept gracefully that whatever has been done in the past has been to provide highly skilled services in various fields all too apart to each other and though related to the problems of the community they do not serve the purpose of an individual and the community. It is like an assembly of eminent singers singing the same tune but not in chorus, the tune being the welfare of the community.
21
FOOD AND FOREIGN SUBSTANCES’ Continued from page 265
8
The above list is not claimed to be complete but it a fair idea of the functions of the u.h.c. complex. Such a centre should be headed by a community physician and on his staff would be GPs, including dental GPs, community and general nurses, pharmacists, health educationist, medico-social workers, environment and occupational health officers, speech therapists, and if resources permit psychiatrist. With proper relationship developed with the hospital a system of bilateral cross referral system could evolve so that clinical needs e.g., specialist consultation, diagnostic services could be available to people attending u.h.c. complex and the community health needs of the patients admitted to the hospital were also met by u.h.c.
gives
Edward Arnold. LABADARIOS, D. (1975). Studies on the effects of drugs on nutritional status, PhD. Thesis, University of Surrey. STAMP. T. C. B., ROUND, J. M., ROWE, D. J. F. and HADDAD, J. G. Jr. (1972). Plasma levels and therapeutic efficacy of 25-
hydroxycholecalciferol in epileptic patients taking anti-convulsant drugs, British Medical Journal, 2, 9.
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availability
These papers
were
presented at the Health Congress,
April 1978.
Downloaded from rsh.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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