1080
peptic ulcer. There was often no proof that the patients treated conservatively in the series cited above had in fact perforated, although the evidence often pointed strongly that way. What operation gives the best results ? We have several cases which have leaked from the site of simple closure or have subsequently perforated from another site. We now favour resection of the ileum, including in the segment resected the site of perforation and any other areas which appear friable or in danger of perforating. Nevertheless, several surgeons at our hospital have continued with more conservative surgery, such as simple closure, or more radical procedures, such as right hemicolectomy. The high frequency of reperforation (on 7 occasions in 6 cases out of 50) does not correspond with the findings of Archampong2 who found that necropsies on non-survivors showed no subsequent perforation. Dickson et al. had 3 patients who died from further perforation after operation. In our series leakage or reperforation after operation was always fatal. Only 1 of the patients with multiple perforations or perforation with incipient perforation at another site died: multiple perforations do not seem to worsen the prognosis. seen
-
Points of View ANOTHER NEW START FOR THE HEALTH SERVICE?
JOHN E. LUNN University Department of Community Medicine, Beech Hill Road, Sheffield S10 2RX
THE reorganised Health Service has now been running for one year, and even this short period has demonstrated the inadvisability of putting an extra administrative tier into the Service. The extra tier has produced overlapping of functions and has caused confusion in decision-making between the regional, area, and district authorities. Furthermore, the " maximum delegation downwards, matched by accountability upwards " through the tiers, which is handled by a large number of committees and teams, is said to have slowed decision-making to the extent that simple non-controversial decisions may take four months and’more involved decisions may get held up in the system because of modifications made by one committee which prove unacceptable to another committee. The overall result of the reorganisation has been to In table 11 we compare the results of the various limit the effectiveness of the regions, areas, and districts surgical procedures. "Surgical failure" is one in while leaving the D.H.S.S. in control at the top and the which leakage after closure or anastomosis occurred, service delivery tier of the health centre or hospital relaproducing postoperative peritonitis. A " satisfactory tively free at the bottom. The freedom at the bottom, surgical outcome " refers to technical success: if death however, is limited in the sense that clinical work has to ensued it was not directly attributable to a failure of be done within the confines of the financial policy dictated Of those from the top. treated patients Consequently the new organisation is technique. by simple centralised and in this respect has features reminiclosure 36 % died from a surgical failure whereas of the highly of scent Edwin Chadwick’s " New Poor Law " of 1834. 39 patients treated by more extensive surgery only 5 is hard to see how this centralised pseudo-democratic It died from a surgical failure (13 %). Health Service can ever succeed in its task of planning and Our current practice, which accords fairly closely providing personal medical services to a modem demowith that of Dawson,9 is to recommend that the tercratic society. minal ileum is carefully examined. If there is only Apparently the extra tier was introduced into the Service one perforation (invariably on the anti-mesenteric against the advice of the management consultants involved in the reorganisation,l and it is not difficult to see why border) and all the remaining bowel seems healthy, the they wished to do without it. Comparisons between counperforation should be widely excised and the ileum tries with nationalised medical services show the natural closed in two layers (wedge excision). If there are number of tiers required; for instance, a small country multiple perforations or any other areas of the bowel such as Sweden (population 7i million) functions on three seem unhealthy or liable to perforate, a length of small tiers (a Central Board of Health, the local authorities, and bowel should be resected, including all the diseased the communes at the delivery level). A moderate-sized parts, and a two-layer anastomosis be performed. country such as our own (population 55 million) funcThere does not appear to be any indication to perform tioned on four tiers so far as the Hospital Service was a right hemicolectomy unless there is associated concerned before April 1, 1974 (D.H.S.S., regional boards, to be due to an ulcer in the haemorrhage thought hospital management committees, and the delivery level). A large country such as Russia (population 233 million) caecum or ascending colon. functions on five tiers (the Moscow Ministry, the Union We thank Dr Kenrad E. Nelson of the University of Republic Ministries, and regional, district, and delivery Illinois for his help with the paper and the statistical analysis. tiers). How then are we to get rid of our superfluous tier? The usual procedure is to identify the tier that Requests for reprints should be addressed to N. C. M. . must go. Lambert favours removal of the regions since each regional health authority has, already, a matching REFERENCES administrative structure within the D.H.S.S. The dis1. Webb-Johnson, A. E. Lancet, 1917, ii, 813. advantage of this solution would be increased centralisa2. Archampong, E. Q. Br. med. J. 1969, iii, 273. tion and more power for the D.H.S.S. since the 90 health 3. Huckstep, R. V. Typhoid Fever and Other Salmonella Infections; areas are too small and weak to stand up for themselves. p. 190. London, 1962. Removal of the areas would be difficult since they were 4. Bailey, H. Emergency Surgery; p. 959. Bristol, 1967. introduced for the prime purpose of coordinating activity 5. Li, F. W. P. Br. J. Surg. 1963, 50, 976. the medical services and the environmental and between 6. Manson-Bahr, P. H. Manson’s Tropical Diseases; p. 272. London, social services of the new coterminous Metropolitan coun1965. ties and districts. Removal of the health districts would 7. Woodward, T. E., Smadel, J. E. Ann. intern. Med. 1964, 60, 144. also be difficult since these are nearer to the natural size 8. Dickson, J. A. S., Cole, G. J. Br. J. Surg. 1964, 51, 893. for planning and administering personal medical services. 9. Dawson, J. H. Am. Surg. 1972, 36, 620. ’
z
1081 At this stage we appear to have reached an impasse and it becomes necessary to consider a new start. This spring the Government is to publish a white-paper on devolution, and the questions have been asked 2 whether this could mean three Health Services in the place of one and whether it would be a change for the better. Rather than three Health Services based on national assemblies in Scotland, Wales, and England, it would seem more realistic to recognise cultural differences by thinking in terms of regional assemblies for populations varying between three and ten million people. Some natural divisions that immediately come to mind are Scotland, Wales, Northern England, the Midlands, and London. Other divisions might be more difficult to determine, but the new regional assemblies (say eight or nine in number) would represent distinctive geographical areas and distinctive groups of cultures. Having changed the organisation of the United Kingdom to this extent, it would be feasible to go further and produce new, smaller local-authority areas within the devoluted regions, more suited in size for the planning, and delivery of social services than the present large and cumbersome Metropolitan counties and districts. Coterminous with these new local authorities, but administered separately, could be the new health areas. The resulting Health Service would thus have four tiers (D.H.S.S., regional authorities responsible for planning and administration at the regional assembly level, the new health areas, and the delivery level of hospitals and health centres). In effect the new situation would be as if the D.H.S.S. had eight or nine Swedish-style Health Services to supervise, and the organisation would permit considerable latitude in determining regional policies for such vastly dissimilar populations as live in London, the Midlands, or Scotland. Such an organisation would have a far better chance of success than the present unnatural system which has been imposed upon us and which is steadily destroying the initiative and good will of administrators and clinicians alike. REFERENCES 1. Lambert, H. Sunday Times, March 9, 1975. 2. B.M.A. News, March 1975, pp. 40, 42.
Round the World United States ABRUPT ABANDONMENT
Members of the medical profession who insure against claims for medical malpraxis have become quite used here to being abruptly and without warning abandoned by their insurers, or faced with monstrously inflated premiums. They have loudly and longly complained. But the same medical profession has, through its associations, loudly trumpeted the advantages of the health needs of this country being covered by the same type of private insurance companies who have been abruptly abandoning malpraxis insurance as its profitability waned or disappeared. This dichotomy seems to have elicited little remark here until recently, when the editor himself of one of our most distinguished medical journals found himself just as abruptly abandoned by his private health insurance coverers. One is glad to note that this was not due to adverse health experience, for he has never submitted a claim. But now, older than he was, he has to shop around for health coverage, just as others have to shop around under conditions less favourable than before for malpraxis coverage. If this can happen to a distinguished editor, what protection have we lesser folk ?
Talking Politics FLUORIDATION
Toby Jessel, Conservative M.p. for Twickenham, brave, not to say a foolhardy man. He has just embarked on a one-man campaign to galvanise the Government into fluoridating the nation’s watersupplies in the interests of stronger teeth. What he may not know, but will certainly soon find out, is that Mr
is
a
down that road lies a formidable pressure group, rich or sophisticated perhaps but extremely resourceful, which has flourished a fair set of teeth of its own at successive Governments, and is certainly not going to capitulate now before the assaults of Mr Jessel. Mr Jessel had an adjournment debate on fluoridation on April 11 which he must have found hugely encouraging, for his own fluoridating fervour was clearly matched by that of Dr David Owen, Minister of State for Health. Fluoridation, said the Minister, was almost every reputable body in the whole supported by of field public health. " In my judgment as a health minister, over 20 years of careful and intensive epidemiological studies have demonstrated the safety of controlled water fluoridation as cónsistently as its effectiveness in preventing dental decay." It would cost only a few pence per year per head of the population to fluoridate water-supplies, and that would be a small amount in the light of the advantages it could bring. The figures now available for dental decay among children were " shattering ": two-thirds of 13,000 children aged between 5 and 15 examined in a new survey required treatment: a quarter of the 5 to 8 year olds and one ir- eight of the rest had five or more actively decaying teeth. That didn’t mean, however, that the Government was ready to interfere with the long tradition of having these things locally decided. It was for the area health authorities to make the choice, and for the regional water boards to act upon their findings. And that (as Dr Owen has explained in a series of written answers) means that the health authorities involved must be unanimous. It only needs one health authority within the region to say " no " to the water board, and the rest will be thwarted. In this respect, the odds have shifted somewhat against the anti-fluoridators since the reorganisation of the local authority and health service structures. This used to be a Town Hall matter: and in many a town hall over the past 20 years it has been debated with awe-inspiring passion. The great strength of the anti-fluoride lobby in those days was that you only needed to turn one local council against fluoride to keep a whole area free from it. There are far fewer health authorities involved now than there were town councils under the old pattern, which means that opponents of fluoridation must be more than ever on their toes. They remain, however, in good heart. Mr Andrew Bowden, chairman of the House of Commons antifluoridation group, warned Mr Jessel and Dr Owen in the April 11 debate that he now had 85 members behind him, and they did not intend to stand idly by in face of a resort to compulsory mass medication.
not
peptic ulcer. There was often no proof that the patients treated conservatively in the series cited above had in fact perforated, although the evidence often pointed strongly that way. What operation gives the best results ? We have several cases which have leaked from the site of simple closure or have subsequently perforated from another site. We now favour resection of the ileum, including in the segment resected the site of perforation and any other areas which appear friable or in danger of perforating. Nevertheless, several surgeons at our hospital have continued with more conservative surgery, such as simple closure, or more radical procedures, such as right hemicolectomy. The high frequency of reperforation (on 7 occasions in 6 cases out of 50) does not correspond with the findings of Archampong2 who found that necropsies on non-survivors showed no subsequent perforation. Dickson et al. had 3 patients who died from further perforation after operation. In our series leakage or reperforation after operation was always fatal. Only 1 of the patients with multiple perforations or perforation with incipient perforation at another site died: multiple perforations do not seem to worsen the prognosis. seen
-
Points of View ANOTHER NEW START FOR THE HEALTH SERVICE?
JOHN E. LUNN University Department of Community Medicine, Beech Hill Road, Sheffield S10 2RX
THE reorganised Health Service has now been running for one year, and even this short period has demonstrated the inadvisability of putting an extra administrative tier into the Service. The extra tier has produced overlapping of functions and has caused confusion in decision-making between the regional, area, and district authorities. Furthermore, the " maximum delegation downwards, matched by accountability upwards " through the tiers, which is handled by a large number of committees and teams, is said to have slowed decision-making to the extent that simple non-controversial decisions may take four months and’more involved decisions may get held up in the system because of modifications made by one committee which prove unacceptable to another committee. The overall result of the reorganisation has been to In table 11 we compare the results of the various limit the effectiveness of the regions, areas, and districts surgical procedures. "Surgical failure" is one in while leaving the D.H.S.S. in control at the top and the which leakage after closure or anastomosis occurred, service delivery tier of the health centre or hospital relaproducing postoperative peritonitis. A " satisfactory tively free at the bottom. The freedom at the bottom, surgical outcome " refers to technical success: if death however, is limited in the sense that clinical work has to ensued it was not directly attributable to a failure of be done within the confines of the financial policy dictated Of those from the top. treated patients Consequently the new organisation is technique. by simple centralised and in this respect has features reminiclosure 36 % died from a surgical failure whereas of the highly of scent Edwin Chadwick’s " New Poor Law " of 1834. 39 patients treated by more extensive surgery only 5 is hard to see how this centralised pseudo-democratic It died from a surgical failure (13 %). Health Service can ever succeed in its task of planning and Our current practice, which accords fairly closely providing personal medical services to a modem demowith that of Dawson,9 is to recommend that the tercratic society. minal ileum is carefully examined. If there is only Apparently the extra tier was introduced into the Service one perforation (invariably on the anti-mesenteric against the advice of the management consultants involved in the reorganisation,l and it is not difficult to see why border) and all the remaining bowel seems healthy, the they wished to do without it. Comparisons between counperforation should be widely excised and the ileum tries with nationalised medical services show the natural closed in two layers (wedge excision). If there are number of tiers required; for instance, a small country multiple perforations or any other areas of the bowel such as Sweden (population 7i million) functions on three seem unhealthy or liable to perforate, a length of small tiers (a Central Board of Health, the local authorities, and bowel should be resected, including all the diseased the communes at the delivery level). A moderate-sized parts, and a two-layer anastomosis be performed. country such as our own (population 55 million) funcThere does not appear to be any indication to perform tioned on four tiers so far as the Hospital Service was a right hemicolectomy unless there is associated concerned before April 1, 1974 (D.H.S.S., regional boards, to be due to an ulcer in the haemorrhage thought hospital management committees, and the delivery level). A large country such as Russia (population 233 million) caecum or ascending colon. functions on five tiers (the Moscow Ministry, the Union We thank Dr Kenrad E. Nelson of the University of Republic Ministries, and regional, district, and delivery Illinois for his help with the paper and the statistical analysis. tiers). How then are we to get rid of our superfluous tier? The usual procedure is to identify the tier that Requests for reprints should be addressed to N. C. M. . must go. Lambert favours removal of the regions since each regional health authority has, already, a matching REFERENCES administrative structure within the D.H.S.S. The dis1. Webb-Johnson, A. E. Lancet, 1917, ii, 813. advantage of this solution would be increased centralisa2. Archampong, E. Q. Br. med. J. 1969, iii, 273. tion and more power for the D.H.S.S. since the 90 health 3. Huckstep, R. V. Typhoid Fever and Other Salmonella Infections; areas are too small and weak to stand up for themselves. p. 190. London, 1962. Removal of the areas would be difficult since they were 4. Bailey, H. Emergency Surgery; p. 959. Bristol, 1967. introduced for the prime purpose of coordinating activity 5. Li, F. W. P. Br. J. Surg. 1963, 50, 976. the medical services and the environmental and between 6. Manson-Bahr, P. H. Manson’s Tropical Diseases; p. 272. London, social services of the new coterminous Metropolitan coun1965. ties and districts. Removal of the health districts would 7. Woodward, T. E., Smadel, J. E. Ann. intern. Med. 1964, 60, 144. also be difficult since these are nearer to the natural size 8. Dickson, J. A. S., Cole, G. J. Br. J. Surg. 1964, 51, 893. for planning and administering personal medical services. 9. Dawson, J. H. Am. Surg. 1972, 36, 620. ’
z
1081 At this stage we appear to have reached an impasse and it becomes necessary to consider a new start. This spring the Government is to publish a white-paper on devolution, and the questions have been asked 2 whether this could mean three Health Services in the place of one and whether it would be a change for the better. Rather than three Health Services based on national assemblies in Scotland, Wales, and England, it would seem more realistic to recognise cultural differences by thinking in terms of regional assemblies for populations varying between three and ten million people. Some natural divisions that immediately come to mind are Scotland, Wales, Northern England, the Midlands, and London. Other divisions might be more difficult to determine, but the new regional assemblies (say eight or nine in number) would represent distinctive geographical areas and distinctive groups of cultures. Having changed the organisation of the United Kingdom to this extent, it would be feasible to go further and produce new, smaller local-authority areas within the devoluted regions, more suited in size for the planning, and delivery of social services than the present large and cumbersome Metropolitan counties and districts. Coterminous with these new local authorities, but administered separately, could be the new health areas. The resulting Health Service would thus have four tiers (D.H.S.S., regional authorities responsible for planning and administration at the regional assembly level, the new health areas, and the delivery level of hospitals and health centres). In effect the new situation would be as if the D.H.S.S. had eight or nine Swedish-style Health Services to supervise, and the organisation would permit considerable latitude in determining regional policies for such vastly dissimilar populations as live in London, the Midlands, or Scotland. Such an organisation would have a far better chance of success than the present unnatural system which has been imposed upon us and which is steadily destroying the initiative and good will of administrators and clinicians alike. REFERENCES 1. Lambert, H. Sunday Times, March 9, 1975. 2. B.M.A. News, March 1975, pp. 40, 42.
Round the World United States ABRUPT ABANDONMENT
Members of the medical profession who insure against claims for medical malpraxis have become quite used here to being abruptly and without warning abandoned by their insurers, or faced with monstrously inflated premiums. They have loudly and longly complained. But the same medical profession has, through its associations, loudly trumpeted the advantages of the health needs of this country being covered by the same type of private insurance companies who have been abruptly abandoning malpraxis insurance as its profitability waned or disappeared. This dichotomy seems to have elicited little remark here until recently, when the editor himself of one of our most distinguished medical journals found himself just as abruptly abandoned by his private health insurance coverers. One is glad to note that this was not due to adverse health experience, for he has never submitted a claim. But now, older than he was, he has to shop around for health coverage, just as others have to shop around under conditions less favourable than before for malpraxis coverage. If this can happen to a distinguished editor, what protection have we lesser folk ?
Talking Politics FLUORIDATION
Toby Jessel, Conservative M.p. for Twickenham, brave, not to say a foolhardy man. He has just embarked on a one-man campaign to galvanise the Government into fluoridating the nation’s watersupplies in the interests of stronger teeth. What he may not know, but will certainly soon find out, is that Mr
is
a
down that road lies a formidable pressure group, rich or sophisticated perhaps but extremely resourceful, which has flourished a fair set of teeth of its own at successive Governments, and is certainly not going to capitulate now before the assaults of Mr Jessel. Mr Jessel had an adjournment debate on fluoridation on April 11 which he must have found hugely encouraging, for his own fluoridating fervour was clearly matched by that of Dr David Owen, Minister of State for Health. Fluoridation, said the Minister, was almost every reputable body in the whole supported by of field public health. " In my judgment as a health minister, over 20 years of careful and intensive epidemiological studies have demonstrated the safety of controlled water fluoridation as cónsistently as its effectiveness in preventing dental decay." It would cost only a few pence per year per head of the population to fluoridate water-supplies, and that would be a small amount in the light of the advantages it could bring. The figures now available for dental decay among children were " shattering ": two-thirds of 13,000 children aged between 5 and 15 examined in a new survey required treatment: a quarter of the 5 to 8 year olds and one ir- eight of the rest had five or more actively decaying teeth. That didn’t mean, however, that the Government was ready to interfere with the long tradition of having these things locally decided. It was for the area health authorities to make the choice, and for the regional water boards to act upon their findings. And that (as Dr Owen has explained in a series of written answers) means that the health authorities involved must be unanimous. It only needs one health authority within the region to say " no " to the water board, and the rest will be thwarted. In this respect, the odds have shifted somewhat against the anti-fluoridators since the reorganisation of the local authority and health service structures. This used to be a Town Hall matter: and in many a town hall over the past 20 years it has been debated with awe-inspiring passion. The great strength of the anti-fluoride lobby in those days was that you only needed to turn one local council against fluoride to keep a whole area free from it. There are far fewer health authorities involved now than there were town councils under the old pattern, which means that opponents of fluoridation must be more than ever on their toes. They remain, however, in good heart. Mr Andrew Bowden, chairman of the House of Commons antifluoridation group, warned Mr Jessel and Dr Owen in the April 11 debate that he now had 85 members behind him, and they did not intend to stand idly by in face of a resort to compulsory mass medication.
not
