them

Dear

Royal

Commissioners

On May 14 the Royal Commission on the National Health Service, whose chairman is Sir Alec Merrison, declared itself ready to receive evidence. Its terms of reference are: "to consider in the interests both of the patients and of those who work in the National Health Service the best use and management of the financial and manpower resources of the National Health Service. " By now the Royal Commissioners will no doubt be wondering when the flow of evidence will stop mounting and The Lancet has no wish to heap much more on their backs. Nevertheless, we plan to publish in the coming weeks a series of more or less brief items of hitherto unsubmitted evidence to the Royal Commission, sometimes anonymous, sometimes signed, sometimes almost impromptu, from people who know the N.H.S. well. The first submission now follows. HOSPITAL CARE FOR THE ELDERLY The Need for Acute Services

Two of the dominant themes of the recent document, Priorities for Health and Personal Social Services in England, are the increase in the number of elderly people in the community and the need to provide for their medical care and social welfare. The proposal is that the increased requirement for inpatient hospital treatment which is a consequence of this demographic change shall largely be met by reallocation of existing hospital resources from the acute specialties (medicine and surgery). It is acknowledged in the document that these acute beds are at present much used by people over the age of 65, yet the effect of a reduction in the number of these beds upon the care of the elderly is nowhere considered. It is always difficult to set the level for medical care, since provision of facilities is not a direct reflection of need. In short-term projections, however, immediate past utilisation is a guide to future requirement; thus, forecasts can be made of the demand for hospital services up to 1979 on the basis of information available from 1972. It may be useful to examine the present pattern of use by different age-groups of acute medical, surgical, and geriatric resources and the increased demand upon each which will result from the change in the age structure of the population. In 1972, 17% of the adult population were over 65 years. Elderly patients have more need of hospital care (see accompanying figure) and in that year occupied 44% of adult acute medical and surgical beds. These acute specialties coped with 78% of the elderly inpatient sick in fewer than 35 000 beds, whilst the remaining 22% occupied 47 000 beds designated as "geriatric". These figures reflect the numbers of chronic sick for which the geriatric service caters and the consequent longer mean duration of stay in the geriatric beds. It is also evident that the majority of elderly patients admitted into acute medical and surgical beds are rapidly discharged (see figure). It may be inferred, therefore, that these latter patients have in general conditions which can

be

quickly improved by

treatment so as to

allow

to return

home without the need for elaborate sup-

porting arrangements by either the medical or social services. Indeed the population in any year can be divided into three categories: those who do not need treatment in hospital; those who need admission to hospital but who can soon return home; and those who require a prolonged spell in hospital and support from the geriatric and social services. The maximum utilisation of hospital services by these categories in the different age-groups can be estimated on the risible assumption of only one admission a year for each patient (see table t). It is imTABLE 1—HOSPITAL ADMISSION-RATES

mediately obvious from these figures that the vast majority of the elderly are healthy, a very small minority require geriatric care, but a significant, although still small, proportion need acute in-hospital services. Although it is suggested in Priorities for Health that geriatricians are better able to manage acute medical emergencies in the elderly, the evidence, such as duration of hospital admission (see figure), does not sug-

AGE - GROUPS

(y)

Numbers in four different age-groups in England in 1972, their use of different kinds of hospital beds, and the average length of stay in hospital of each age-group in each class of bed.

The figures are all taken from the Report on Hospital In-patient Enquiry and from Health and Personal Social Services Statistics for England 1973. Under acute medicine are included general medtCiM diseases of the chest, dermatology, neurology, cardiology, rheumatu logy, physical medicine, and rehabilitation; acute surgery incorporate; general surgery, traumatic and orthopaedic surgery, and urology.

455 gest that any great saving in hospital resources would result from such a change in policy. Clearly, those geriatric units which admit proportionately more of the acutely ill will have an increased turnover of patients with a shorter mean duration of stay. It is facile, if tempting, to equate statistical changes which result from a reclassification of patients with improved efficiency of care. There is, moreover, a danger in employing such yardsticks : early discharge and a high turnover of patients may result in frequent readmission and no overall

advantage. Between 1972 and 1979 the number of people in England who are over 65 years of age will have increased by 0.6 million.2 Assuming that both the pattern of medical practice and the categorisation of patients remain unchanged over these seven years, it can be anticipated that the consequence of this demographic change will be a rise in hospital admissions: 33 000 acute medical, 35 000 acute surgical, and 22 000 geriatric. Table n sets out estimates of the need for beds in 1979 in all three categories on the optimistic assumption that all acute medical and surgical beds will be occupied for 90% of the time. Thus, by 1979 about 3000 more beds will be needed by all three of these sectors combined; the physicians will need what they have got, the surgeons could manage on fewer (but their waiting-lists will not shorten), and the geriatricians will need about 7000

others should so remain. This requires that their needs for acute hospital care be met promptly. Yet it is this very group who may be most imperilled if the number of beds for the chronic geriatric sick are increased at the expense of the acute medical and surgical sectors. It would be tragic if these proposals resulted in more chronic ill-health and less self-sufficiency among the

elderly. AN HONEST SERVING MAN 1. Priorities for Health and Personal Social Services in England; p. 5.20. H. M. Stationery Office, 1976. 2. ibid. p. 9; and Health and Personal Social Services Statistics for 1973. H. M. Stationery Office. 3. ibid. p. 38. 4. ibid. p. 23, para 4.2 (ii).

The intention

expressed

in Priorities

for Health

is

BETTY R. DAVIS FRANCIS W. HICKMAN

J. J. FARMER, III

Enteric Section, Bureau of Laboratories, Center for Disease Control, Public Health Service, U.S. Department of Health, Education, and Welfare, Atlanta, Georgia 30333, U.S.A. D. B. PRESLEY

geriatric beds, a number which comfortably

exceeds the estimate in table n for the necessary increase over the seven years from 1972. TABLE II-BEDS NEEDED

England

DETECTION OF SERRATIA OUTBREAKS IN HOSPITAL

to

by reallocation of beds from the acute services, inchiding obstetrics, 1150 geriatric beds a year in district general hospitals and a further 2000 a year in the newstyle community hospitals.3 In the three years up to 1979 it is therefore intended to make about 9500 extra

para

Hospital Practice

more.

create

42

Department of Microbiology, University of Alabama, University, Alabama 35486, U.S.A.

(THOUSANDS)

GERALD P. BODEY

Department of Development Therapeutics, M. D. Anderson Hospital and Tumor Institute, Houston, Texas 77025, U.S.A. MARIAN NEGUT Institute-Dr. I.

Catacuzine, Bucharest,

Rumania

R. A. BOBO

*86 occupancy occupancy :9)’; occupancy

There

three principal dangers in this declared policy. First, there will be a great temptation to simulate action by redesignating as "geriatric" that proportion of beds on the acute medical services which are already used by the elderly. Second, geriatric beds created by reallocation from heterogeneous units may be inconvenient in situation and unsuitable in character for their new purpose. Third, the staffing of geriatric units has always been a problem and it will be magnified if these proposals are put into effect; it can be foreseen that there will be especial difficulties in staffing the small, isolated community hospitals, two-thirds of whose pawill be long-stay geriatric and psychogeriatric are

’icnts case.4

of the utmost social importance that the more than 97% of the elderly who are least dependent on It

is

Department of Clinical Pathology, University of Alabama Medical School, Birmingham, Alabama 35233, U.S.A.

Summary

Infections due to Serratia marcescens were studied in 23 different hospitals. A study was done in 4 hospitals; all isolates

retrospective compared by serological typing, antibiograms, bacteriocin production, and bacteriocin sensitivity. 2 of the hospitals were having cross-infection problems due to were

antibiotic-resistant strains, but the other 2 had little or cross-infection. Outbreaks were studied in 19 other hospitals. 9 of these outbreaks were classified as "common source" since contaminated "sterile solutions" were incriminated as the cause in each. One hospital had a "pseudo-outbreak," in which Serratia from E.D.T.A. blood-collecting tubes contaminated blood-cultures as they were collected. All 10 of these strains from common-source outbreaks were generally sensitive to antibiotics. Outbreaks in 9 other hospitals resulted from no

Hospital care for the elderly. The need for acute services.

them Dear Royal Commissioners On May 14 the Royal Commission on the National Health Service, whose chairman is Sir Alec Merrison, declared itself...
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