87
munity hospitals can only flourish if they are part of the district complex, and for that the nucleus must come first. We cannot get out of our present difficulties by managerial sleight of hand. If we intend to have a modem N.H.S., then ultimately it must have the needed investment. The people who work in it are more important than the buildings and they have done nobly under the difficulties Dr Owen himself described. But they cannot go on for ever compensating for the deficiencies in the tools with which they are provided. There must be assurance that the need is recognised and will be met as soon as possible. When the new chance comes, it must be some of the English regions that gain the preferential treatment hitherto given to other parts of the U.K. 21 Almoners Avenue,
Cambridge.
GEORGE GODBER
SIR,-There should, I believe, be justifiable concern about of the statements regarding community hospitals which you attributed (Dec. 20, p. 1248) to Dr David Owen. He was rightly critical of the large district general hospital, which as
district. Only in this way can the need for acute district general or nucleus hospitals be estimated. It is important to avoid confusion between hospital design, which seemed to be what Dr Owen was primarily talking about, and hospital function, which is what the communityhospital concept is all about. Clearly, design is important, but it follows upon decisions about function. There is a further danger which would follow misinterpretation of Dr Owen’s statement. Many area health authorities are constantly reviewing the hospitals in their area, and, in the financial climate, seeking to dispose of what might appear to be redundant hospitals. We have shownthat the majority of general practitioners wish to work in a community hospital, but that it is necessary, particularly in urban areas, to site community hospitals with care. If area health authorities are deterred by a misinterpretation of what Dr Owen has said, then not only will the enthusiasm of general practitioners be left unharnessed but also uniquely situated sites may be lost forever.
one
a theoretical concept is impeccable, but which, like so many theoretical concepts, is in practice a nightmare to administrators, medical staff, and not least to many patients. He said that new district general hospitals could not be built in one phase in the present economic climate and, in pleading for a fresh appraisal of the role of the acute hospital, he introduced the concept of the "nucleus" hospital as an acute 300-bed intensively used hospital of standardised but flexible basic design which would not predetermine the eventual size. Dr Owen saw the community hospital as providing a complementary role to that of the nucleus hospital and "it was important to hold on to the concept of the community hospital as an active hospital closely integrated with other acute hospitals in the district and forming part of a district general hospital." Even the staunchest advocate of the community hospital could not quarrel with the view that the community hospital should be closely integrated with the other hospital services. Indeed, the concept derived from a recognition of the need for alternative care for some patients who are now admitted to the district general hospital, but the words of Dr Owen can be interpreted as viewing the community hospital as an extension of the nucleus or district general hospital rather than, as Bennett’ has advocated, as an extension of primary care. The origins of the community hospital have always been associated with the primary-care services. The Dawson report’ of 1920 described fairly accurately the modem idea of the community hospital and called it a primary health centre. The report of the committee on the organisation of group practice, discussing the role of the general practitioner in the hospital, recommended a functional review of the role of the cottage hospital and advocated the creation of community nursing units intimately linked to the primary-care services. The danger of the statement made by Dr Owen is that it is not precise: it can be interpreted according to the preconceived ideas of different people and it is clear, at any rate to me, that many people have interpreted the community hospital as an extension of the district general hospital. If this view were to be given credence because of what Dr Owen has said, then the community hospital could be put back many years. It is arguable that if sufficient community-hospital beds were available, there would not be a need for any more district general hospitals. Experience of short-stay delivery units in the maternity services tends to confirm this. The order of priority seems to be to establish, in the first instance, community hospitals linked firmly to the primary-care services, but also integrated with the rest of the hospitals in a
1. Bennett, A. E. Hlth Trends, 1975, 7, 66. 2. Ministry of Health. Consultation Council on Medical and Allied Services: interim report on the future provision of medical and allied services. H.M.
Stationery Office, 1920. 3. Central Health Service Council: Standing Medical Advisory Committee, Organisation of Group Practice. H.M. Stationery Office, 1971.
Welsh National School of Medicine, General Practice Unit, Health Centre, Maelfa, Llanedeyrn, Cardiff CF3 7PN.
R. HARVARD DAVIS
PAY BEDS
SIR,-Before it is too late, I think the issue of the siting of private beds should be raised. If, irrespective of individual political beliefs, one accepts the premise that legislation forbidding any private practice in the U.K. is a non-starter then it is essential that any private emergency, investigational, and surgical beds must be sited where their geographical location: (1) Does not detract in practice (rather than in theory) from the consultant’s maximal availability to his N.H.S. patients. (2) Does not place the private patient in grave danger when unexpected emergency situations arise through the lack of the immediate availability of a doctor and X-ray and pathological services. This makes it obvious that geographical full-time appointments, with private beds within the campus of the district hospitals, are essential. This has been brought out lately by Mr H. C. de Castella in The Times (Dec. 2) and by Prof. R. Y. Calne in the Daily Telegraph (Dec. 22). This geographical full-time concept is generally accepted throughout the "developed" world. The Department of Health positively turns its back on this concept, and the British Medical Association may well negatively do so by accepting with eagerness some completely segregated arrangement for private beds proposed by the Government. As a byproduct, such a scheme would produce a separate huge non-productive bureaucracy to run the
private sector. Are the public, and the medical profession in particular, so reactionary and insular as to think that in the present state of -
the Health Service the British have a better solution problem than the rest of the developed world? West Middlesex
to
this
Hospital,
Isleworth,
JAMES ANDREWS
Middlesex TW7 6AF.
HOW BAREFOOT? of S!R,—The point View expressed by Professor Backett and Dr England (Dec. 6, p. 1137) is a long overdue public statement of the need to consider the global convergence of interests in medical training. Both the developing and Western worlds now have generally acknowledged the potential of the physician’s assistant/medical auxilary/&c., although the into of effective medical-care systems degree incorporation varies. The next stage is to explore the possibilities of more self-care, particularly in Western countries where, despite good 4.
Davis,
R.
H., Richards,
R.
M., Williams, K. Unpublished.
88 standards of general education, disproportionate amounts of medical manpower are located. It has been shown that persons with a little training can care for a wide range of diseases. For example, diabetics can monitor their insulin requirements, parents can administer antihaemophilic factor to their afflicted children, and hypertensives can take their blood-pressure and regulate their medication
satisfactorily. Various methods suggest themselves to further facilitate self
help: (1) Safe drugs with clear instructions could become widely available via slot-machines (e.g., contraceptive pills). (2) Adult education and secondary-school courses in self-care could be established. Such courses could be an extension of the common first-aid course with additional attention to the prevention, recognition, and treatment of common illnesses. On passing the course the
graduate should have access to simple pathology tests (e.g. Papanicolaou smear) and drugs such as penicillin or oral contraceptives. It might be hoped that the general practitioner would be at the centre of any teaching programme and that both he and the health authorities would see this as a stimulating new way to provide primary and personal care. Department of Community Medicine, University of Papua New Guinea, Kainantu, E.H.P.,
PACEMAKERS: THE LONG-TERM COST
SiR,—There has been considerable discussion of the
cost
of
implanted pacemakers, and of whether the Health Service can sustain the cost of units incorporating the improved lithium/
battery.!
It is difficult
SIR,--Griffith Edwards’ article’ is a most significant and important communication. Nevertheless, the situation throughout the country is not quite as hopeless as it may seem from his communication. In the area in which I work, Buckinghamshire, the "four wise men" have functioned for many years. Problems which have arisen have been dealt with in a most sympathetic fashion, based on the premises that the doctor himself needs help and that the patient needs protection, and that such help and protection should emanate from medical sources rather than administrative or legal ones. I feel sure that there are other "wise men" who function in a similar capacity in other areas, though I know of one instance of an alcoholic problem where hospital doctors did not function in the interests of both the profession and the patients, and were said to have stuck together and "protected" a very disabled colleague for many years. St
John’s Hospital, Stone,
Aylesbury, Bucks HP17 8PP.
to see
how the
proposed
recent
expenditure by the Government2 on isotopic (238PU) pacemakers can be justified, at a time when the need for this radioactive energy source is being reduced by the increasing production of long-life lithium-powered pacemakers, which pose no environmental pollution problems. Any realistic assessment of the cost to the Health Service of these improved units must take into consideration the cost of surgical implantation and the further cost of reimplantation at intervals as widely different as three years and ten years. The cost to the Health Service of one patient pacing for unit time is the figure of importance, and a comparison of this figure, calculated for the four main short and long term energy sources now available, confirms that the lithium-powered unit is the most economic. The estimated implantation cost of ,E400 is modest by other standards.3 COST PER PACING PATIENT WEEK OF PACEMAKERS POWERED BY SEVERAL
IRVING SHRIBMAN
ISOCALORIC DIETS AND SLEEP
B. HOCKING
P.N.G.
iodine
THE ALCOHOLIC DOCTOR
SiR,—Iwas interested to read the paper by Miss Phillips and others (Oct. 18, p. 723) reporting the effect that changes in the composition of isocaloric diets had on sleep patterns. A relation between nutrition and sleep is emerging as more research is undertaken. However, the claimed correlation between carbohydrate content of the diet and the amount of slow-wave-sleep (s.w.s.) and rapid-eye-movement (R.E.M.) sleep are reduced in credibility by the unbalanced design. Statistical tests cannot overcome adaptation effects. Hence the comparisons made between the normal diet and either of the experimental diets are of diminished value. In the experiment subjects attended the sleep laboratory on four consecutive nights, the first serving for adaptation and the second as the night recorded after the "normal" diet. It is usual for subjects to sleep relatively badly on their first night at the sleep laboratory, and the following night is often also atypical. Thus, only the comparisons made between the two experimental diets have any validity, but here the statistical significance of these findings is also in doubt. This doubt arises from table n where the value of N = 16 was quoted when only eight subjects were recorded. It would be helpful if the St. George’s workers would tell us the results of recalculations based on N=8.
ENERGY SOURCES
Sleep Laborator , University Department of Psychiatry, Edinburgh EH10 5HF
*
*
____________’I
I
I
I
I
The accompanying table shows that the mercury/zinc powered unit is the most expensive, and, at a time when the utmost economies are being urged upon us, there would seem to be little justification for its continued use. The fact that it remains the unit which the Health Service prefers to have implanted confirms a view I have earlier expressed4-that the concept of high initial purchase price which is offset by low annual servicing costs is not one which fits easily into the D.H.S.S. fiscal system. Department of Clinical Measurement, National Heart Hospital, London W1M 8BA. 1. 2.
Oxford Times, Nov. 14, 1975.
Times, Nov. 11, 1975. 3. Flood, M. New Scientist, Nov. 20, 1975. 4. Norman, J. Bio-engineeringin Britain, August, 1975.
JOHN NORMAN
KIRSTINE ADAM
* Miss Adam’s letter has been shown to the St workers, whose reply follows.-ED. L.
George’s
SIR,-We are aware of the problems of an unbalanced design. However, in our study we were mainly concerned with
comparing the two experimental diets (i.e.,
the
high-carbohyd-
rate/low-fat and the low-carbohydrate/high-fat isocaloric diets). Since temporal effects (i.e., periods, days, and their interactions) were not significant it seemed reasonable to compare the normal balanced diet with the two experimental diets Nevertheless, as stated in our paper, we would not deny the shortcomings in these comparisons. We have since done experiments which are better controlled in this respect, and these will be described elsewhere. N=16 in our table u refers to 16 observation nights on eight subjects. Since temporal effects were not significant we felt it was unnecessary to jam the table with figures for the two experimental nights, and we apologise for 1.
Edwards, G. Lancet, 1975, ii, 1297.
munity hospitals can only flourish if they are part of the district complex, and for that the nucleus must come first. We cannot get out of our present difficulties by managerial sleight of hand. If we intend to have a modem N.H.S., then ultimately it must have the needed investment. The people who work in it are more important than the buildings and they have done nobly under the difficulties Dr Owen himself described. But they cannot go on for ever compensating for the deficiencies in the tools with which they are provided. There must be assurance that the need is recognised and will be met as soon as possible. When the new chance comes, it must be some of the English regions that gain the preferential treatment hitherto given to other parts of the U.K. 21 Almoners Avenue,
Cambridge.
GEORGE GODBER
SIR,-There should, I believe, be justifiable concern about of the statements regarding community hospitals which you attributed (Dec. 20, p. 1248) to Dr David Owen. He was rightly critical of the large district general hospital, which as
district. Only in this way can the need for acute district general or nucleus hospitals be estimated. It is important to avoid confusion between hospital design, which seemed to be what Dr Owen was primarily talking about, and hospital function, which is what the communityhospital concept is all about. Clearly, design is important, but it follows upon decisions about function. There is a further danger which would follow misinterpretation of Dr Owen’s statement. Many area health authorities are constantly reviewing the hospitals in their area, and, in the financial climate, seeking to dispose of what might appear to be redundant hospitals. We have shownthat the majority of general practitioners wish to work in a community hospital, but that it is necessary, particularly in urban areas, to site community hospitals with care. If area health authorities are deterred by a misinterpretation of what Dr Owen has said, then not only will the enthusiasm of general practitioners be left unharnessed but also uniquely situated sites may be lost forever.
one
a theoretical concept is impeccable, but which, like so many theoretical concepts, is in practice a nightmare to administrators, medical staff, and not least to many patients. He said that new district general hospitals could not be built in one phase in the present economic climate and, in pleading for a fresh appraisal of the role of the acute hospital, he introduced the concept of the "nucleus" hospital as an acute 300-bed intensively used hospital of standardised but flexible basic design which would not predetermine the eventual size. Dr Owen saw the community hospital as providing a complementary role to that of the nucleus hospital and "it was important to hold on to the concept of the community hospital as an active hospital closely integrated with other acute hospitals in the district and forming part of a district general hospital." Even the staunchest advocate of the community hospital could not quarrel with the view that the community hospital should be closely integrated with the other hospital services. Indeed, the concept derived from a recognition of the need for alternative care for some patients who are now admitted to the district general hospital, but the words of Dr Owen can be interpreted as viewing the community hospital as an extension of the nucleus or district general hospital rather than, as Bennett’ has advocated, as an extension of primary care. The origins of the community hospital have always been associated with the primary-care services. The Dawson report’ of 1920 described fairly accurately the modem idea of the community hospital and called it a primary health centre. The report of the committee on the organisation of group practice, discussing the role of the general practitioner in the hospital, recommended a functional review of the role of the cottage hospital and advocated the creation of community nursing units intimately linked to the primary-care services. The danger of the statement made by Dr Owen is that it is not precise: it can be interpreted according to the preconceived ideas of different people and it is clear, at any rate to me, that many people have interpreted the community hospital as an extension of the district general hospital. If this view were to be given credence because of what Dr Owen has said, then the community hospital could be put back many years. It is arguable that if sufficient community-hospital beds were available, there would not be a need for any more district general hospitals. Experience of short-stay delivery units in the maternity services tends to confirm this. The order of priority seems to be to establish, in the first instance, community hospitals linked firmly to the primary-care services, but also integrated with the rest of the hospitals in a
1. Bennett, A. E. Hlth Trends, 1975, 7, 66. 2. Ministry of Health. Consultation Council on Medical and Allied Services: interim report on the future provision of medical and allied services. H.M.
Stationery Office, 1920. 3. Central Health Service Council: Standing Medical Advisory Committee, Organisation of Group Practice. H.M. Stationery Office, 1971.
Welsh National School of Medicine, General Practice Unit, Health Centre, Maelfa, Llanedeyrn, Cardiff CF3 7PN.
R. HARVARD DAVIS
PAY BEDS
SIR,-Before it is too late, I think the issue of the siting of private beds should be raised. If, irrespective of individual political beliefs, one accepts the premise that legislation forbidding any private practice in the U.K. is a non-starter then it is essential that any private emergency, investigational, and surgical beds must be sited where their geographical location: (1) Does not detract in practice (rather than in theory) from the consultant’s maximal availability to his N.H.S. patients. (2) Does not place the private patient in grave danger when unexpected emergency situations arise through the lack of the immediate availability of a doctor and X-ray and pathological services. This makes it obvious that geographical full-time appointments, with private beds within the campus of the district hospitals, are essential. This has been brought out lately by Mr H. C. de Castella in The Times (Dec. 2) and by Prof. R. Y. Calne in the Daily Telegraph (Dec. 22). This geographical full-time concept is generally accepted throughout the "developed" world. The Department of Health positively turns its back on this concept, and the British Medical Association may well negatively do so by accepting with eagerness some completely segregated arrangement for private beds proposed by the Government. As a byproduct, such a scheme would produce a separate huge non-productive bureaucracy to run the
private sector. Are the public, and the medical profession in particular, so reactionary and insular as to think that in the present state of -
the Health Service the British have a better solution problem than the rest of the developed world? West Middlesex
to
this
Hospital,
Isleworth,
JAMES ANDREWS
Middlesex TW7 6AF.
HOW BAREFOOT? of S!R,—The point View expressed by Professor Backett and Dr England (Dec. 6, p. 1137) is a long overdue public statement of the need to consider the global convergence of interests in medical training. Both the developing and Western worlds now have generally acknowledged the potential of the physician’s assistant/medical auxilary/&c., although the into of effective medical-care systems degree incorporation varies. The next stage is to explore the possibilities of more self-care, particularly in Western countries where, despite good 4.
Davis,
R.
H., Richards,
R.
M., Williams, K. Unpublished.
88 standards of general education, disproportionate amounts of medical manpower are located. It has been shown that persons with a little training can care for a wide range of diseases. For example, diabetics can monitor their insulin requirements, parents can administer antihaemophilic factor to their afflicted children, and hypertensives can take their blood-pressure and regulate their medication
satisfactorily. Various methods suggest themselves to further facilitate self
help: (1) Safe drugs with clear instructions could become widely available via slot-machines (e.g., contraceptive pills). (2) Adult education and secondary-school courses in self-care could be established. Such courses could be an extension of the common first-aid course with additional attention to the prevention, recognition, and treatment of common illnesses. On passing the course the
graduate should have access to simple pathology tests (e.g. Papanicolaou smear) and drugs such as penicillin or oral contraceptives. It might be hoped that the general practitioner would be at the centre of any teaching programme and that both he and the health authorities would see this as a stimulating new way to provide primary and personal care. Department of Community Medicine, University of Papua New Guinea, Kainantu, E.H.P.,
PACEMAKERS: THE LONG-TERM COST
SiR,—There has been considerable discussion of the
cost
of
implanted pacemakers, and of whether the Health Service can sustain the cost of units incorporating the improved lithium/
battery.!
It is difficult
SIR,--Griffith Edwards’ article’ is a most significant and important communication. Nevertheless, the situation throughout the country is not quite as hopeless as it may seem from his communication. In the area in which I work, Buckinghamshire, the "four wise men" have functioned for many years. Problems which have arisen have been dealt with in a most sympathetic fashion, based on the premises that the doctor himself needs help and that the patient needs protection, and that such help and protection should emanate from medical sources rather than administrative or legal ones. I feel sure that there are other "wise men" who function in a similar capacity in other areas, though I know of one instance of an alcoholic problem where hospital doctors did not function in the interests of both the profession and the patients, and were said to have stuck together and "protected" a very disabled colleague for many years. St
John’s Hospital, Stone,
Aylesbury, Bucks HP17 8PP.
to see
how the
proposed
recent
expenditure by the Government2 on isotopic (238PU) pacemakers can be justified, at a time when the need for this radioactive energy source is being reduced by the increasing production of long-life lithium-powered pacemakers, which pose no environmental pollution problems. Any realistic assessment of the cost to the Health Service of these improved units must take into consideration the cost of surgical implantation and the further cost of reimplantation at intervals as widely different as three years and ten years. The cost to the Health Service of one patient pacing for unit time is the figure of importance, and a comparison of this figure, calculated for the four main short and long term energy sources now available, confirms that the lithium-powered unit is the most economic. The estimated implantation cost of ,E400 is modest by other standards.3 COST PER PACING PATIENT WEEK OF PACEMAKERS POWERED BY SEVERAL
IRVING SHRIBMAN
ISOCALORIC DIETS AND SLEEP
B. HOCKING
P.N.G.
iodine
THE ALCOHOLIC DOCTOR
SiR,—Iwas interested to read the paper by Miss Phillips and others (Oct. 18, p. 723) reporting the effect that changes in the composition of isocaloric diets had on sleep patterns. A relation between nutrition and sleep is emerging as more research is undertaken. However, the claimed correlation between carbohydrate content of the diet and the amount of slow-wave-sleep (s.w.s.) and rapid-eye-movement (R.E.M.) sleep are reduced in credibility by the unbalanced design. Statistical tests cannot overcome adaptation effects. Hence the comparisons made between the normal diet and either of the experimental diets are of diminished value. In the experiment subjects attended the sleep laboratory on four consecutive nights, the first serving for adaptation and the second as the night recorded after the "normal" diet. It is usual for subjects to sleep relatively badly on their first night at the sleep laboratory, and the following night is often also atypical. Thus, only the comparisons made between the two experimental diets have any validity, but here the statistical significance of these findings is also in doubt. This doubt arises from table n where the value of N = 16 was quoted when only eight subjects were recorded. It would be helpful if the St. George’s workers would tell us the results of recalculations based on N=8.
ENERGY SOURCES
Sleep Laborator , University Department of Psychiatry, Edinburgh EH10 5HF
*
*
____________’I
I
I
I
I
The accompanying table shows that the mercury/zinc powered unit is the most expensive, and, at a time when the utmost economies are being urged upon us, there would seem to be little justification for its continued use. The fact that it remains the unit which the Health Service prefers to have implanted confirms a view I have earlier expressed4-that the concept of high initial purchase price which is offset by low annual servicing costs is not one which fits easily into the D.H.S.S. fiscal system. Department of Clinical Measurement, National Heart Hospital, London W1M 8BA. 1. 2.
Oxford Times, Nov. 14, 1975.
Times, Nov. 11, 1975. 3. Flood, M. New Scientist, Nov. 20, 1975. 4. Norman, J. Bio-engineeringin Britain, August, 1975.
JOHN NORMAN
KIRSTINE ADAM
* Miss Adam’s letter has been shown to the St workers, whose reply follows.-ED. L.
George’s
SIR,-We are aware of the problems of an unbalanced design. However, in our study we were mainly concerned with
comparing the two experimental diets (i.e.,
the
high-carbohyd-
rate/low-fat and the low-carbohydrate/high-fat isocaloric diets). Since temporal effects (i.e., periods, days, and their interactions) were not significant it seemed reasonable to compare the normal balanced diet with the two experimental diets Nevertheless, as stated in our paper, we would not deny the shortcomings in these comparisons. We have since done experiments which are better controlled in this respect, and these will be described elsewhere. N=16 in our table u refers to 16 observation nights on eight subjects. Since temporal effects were not significant we felt it was unnecessary to jam the table with figures for the two experimental nights, and we apologise for 1.
Edwards, G. Lancet, 1975, ii, 1297.
