BRITISH MEDICAL JOURNAL
1251
20 NOVEMBER 1976
CORRESPONDENCE The London hospitals scene H Joules, FRCP; J W Paulley, FRCP; R W Parnell, FRCP; A Elliott, FRCGP ............ 1251 Quis whatsit? M O'Donnell, MB ...................... 1253 Writing and speaking in medicine R G Wilkins; C A H Watts, FRCGP ........ 1253 Refereeing papers E N Wardle, MD ...................... 1253 Professional standards H Ellis, FRCS; J H E Bergin, MB; H Marcovitch, MRCP ...................... 1253 BUPA and the long-stay patient J R Caldwell, MRCGP; D V Damerell ...... 1254 Road safety: BMA comments J D J Havard, MD ...................... 1254 Molar dosage of calcium chloride solutions S M Roden, MSC, and G A Mander, FPS .... 1255 The Framingham study W B Kannel, MD ...................... 1255 Which college? J A Ross, FRCSED .................... 1255 Oral contraceptives and myocardial infarction in older women C G H Maidment, MRCP; J I Mann, DM.... 1255 Diagnosis of brain death Pamela F Prior, MD, and D F Scott, MRCP. 1256
Additives to intravenous fluids R L Parsons, MRCP, and others .......... 1256 New enterotoxinogenic bacteria isolated G M Burnham, MD, and others .......... 1256 Glutethimide and enzyme induction C J C Roberts, MRCP, and others .......... 1256 Progesterone or progestogens? Katharina D Dalton, MRCGP ............ 1257 Low-dose progestogens and ectopic pregnancy P Liukko, MD, and R Erkkola, MD ........ 1257 Prazosin in hypertension A S Turner, FRCP ...................... 1257 Possible association of Madelung's deformity with Huntington's chorea AJ Caro, MB .......................... 1258 Immunofluorescent sperm antibodies in virgins R F Harrison, FRCS .................... 1258 Teaching of anatomy P Glees, DPHIL ........................ 1258 Administration of diazoxide R A Sloane, MRCP ...................... 1259 A further endoscopy problem solved? J B Tracey, MB ........................ 1259 Urinary amyloid fibrils in the absence of amyloidosis R P Linke, MD ........................ 1259
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. The London hospitals scene SIR,-I was extremely interested in Sir Francis Avery Jones's article on differential hospital distribution (30 October, p 1046). I had the good fortune of being on the Central Health Services Council, the board of governors of a teaching hospital, and the NW Metropolitan Regional Hospital Board from 1948 onwards. I was chairman of the Establishment Committee of the regional board for many years. These bodies gave me an insight into the way in which the "carve-up" of the hospitals services was being effected. The teaching hospitals with their influential consultants and perhaps more influential boards of governors asserted a right of dominance. Those who attended the regional board came mainly to enhance the interest of the teaching hospitals at the centre of the board. Meanwhile, Avery, if I may presume to address him thus, having come to the Central Middlesex Hospital in 1940, was very busy building up a world-wide reputation as a gastroenterologist and, of course, had little time for the intricacies of major administra-
tion. I have been in East Anglia for nine years now, not in practice at any time here, but I had the good fortune to be able to wander in the country towns and villages to see their beautiful churches and to visit local public bars here. It is in the latter that very much social medicine can be learnt. I have learnt
much of the social deprivation which exists in these counties which is not entered in any social services records. Meanwhile the teaching hospitals of London have grasped as much power and money as possible for building the huge specialist and other departments of a new hospital such as Charing Cross, which has cost L30m, and I know that London hospitals have at times been unable to fill their beds. Sometimes I wonder whether Charing Cross and St Thomas's are vying with each other to become known as the Taj Mahal of the teaching hospital scene. I learnt with amazement recently that Central Middlesex was about to close 100 acute beds for the winter in order to add more amenities with which we had been able to dispense over the last 40 years that I have known it. Perhaps we could be told whether this ability to close beds results from good- administration or a diminution of demand for hospital services. I have learnt much from being a patient intermittently over the past few years. I had a major operation in a ward of 24 beds in Colchester some three years ago. The hospital situation is almost desperate here and my ward was more hard-pressed than any ward I had ever known in 50 years of hospital life. Cross-infection was rife. I was one of its victims and when I heard that gas gangrene had appeared in an adjacent ward I asked to be allowed to go home as there were two trained
Cramp in the elderly H B Lee, FRCS ........................ 1259 Aortic incompetence in systemic lupus erythematosus A J Isaacs, MRCP; P J Richardson, MRCP, and others; P J Cooper, MB, and others .... 1260 Cigarette smoking and chronic bronchitis T W Astin, MD ........................ 1261 Unpopular specialties J Parkhouse, MD ...................... 1261 Hospital practitioner grade C N Barry, MRCGP ...................... 1261 Consultants' increments A F M S Rahman, MRCPATH, and others.. 1261 Prescribing space F J Darby, MB ......... ............... 1262 Fees for HGV licence examinations T P C Schofield, MRCP .................. 1262 Sailing to ARM M J Gilkes, FRCS ........ .............. 1262 Points from Letters Names of Asian women and babies (H K Ranu); Desert island books (J Sherliker); Health Service charges (T D Lawson); A point for the Royal Commission (D L Rees-Jones) .......................... 1262
nurses near to deal with my suppurating wounds. The demands on the junior medical staff and the insufficiency of the nursing staff were undoubtedly responsible for this crossinfection. I discussed the matter with the surgeon and he agreed that the ward should be closed but stated that in the circumstances of the hospital situation between here and the coast this was impossible. East Anglia is one of the most rapidly growing areas of the country and Colchester is no exception. For 25 years the medical staff and others have been pressing for a new hospital and to date nothing has been done. Meanwhile in the region the same pattern of maldevelopment of hospitals has gone on. The new Addenbrooke's Hospital in Cambridge has been completed at a cost of £25m and a cost per occupied bed per day of £37 19. This mausoleum of medicine of the '50s is of no benefit to the Colchester area whatsoever except for an occasional renal transplant or a rare liver exchange. I hope that Avery can come down to verify this situation, and we are certainly asking Mr David Ennals to take a more active interest in what amounts almost to a public scandal. Meanwhile, if the London teaching hospital chickens are coming home to roost I cannot be very sorry as I fought in every major committee for devolution of hospitals and Qther medical resources to the periphery. The voice cried in vain in the wilderness and I must resist wholeheartedly any attempt to divert any money from the East Anglia area, for the need is extremely great. But of course it has not the publicity value of metropolitan pressure groups. I would conclude by saying that London
1252
BRITISH MEDICAL JOURNAL
has much to learn from East Anglia and illness cannot be treated. As a result there is I have never regretted the transition. intense pressure on relatively few beds in the main district hospitals, which carry a disHORACE JOULES proportionately heavier load of major illness and surgery than in regions with more beds Colchester, Essex and therefore larger revenue allocations. This elementary fact has not yet penetrated the SIR,-My old friend and teacher Sir Francis official mind and as a result we are subjected Avery Jones (30 October, p 1046) may be to the same norm of number of nurses per right about social deprivation in Brent, but he acute bed as the rest of the country. The is wrong when he claims that East Anglia result is as Dr Joules has described. Despite "can no longer be described as a deprived the contribution of the Norwich hip unit area" as far as health services are concerned, mentioned by Sir Francis, waiting time for elective orthopaedic surgery in East Anglia was, particularly hospital services. Had Sir Francis worked in this area as well until recently, so long that it was pointless to as London, I suggest that he would not have refer a patient to an orthopaedic surgeon. been so sanguine on our account. His yard- Some surgical colleagues are once again so stick on Brent is the same as that used by concerned about lack of trained nursing staff Dr Horace Joules, with whom he spent most that in the interest of their patients' safety of his working life at Central Middlesex they are having to restrict operations. Ten Hospital, but who, when interviewed by years ago there were 170,, fewer trained nurses the East Anglian Daily Times on 5 November, per caput in the East Anglia Regional Hospital said, "Sir Francis's account of the London Board than in the average region in the rest scene does not give a proper perspective" of the country; we still have 14 70( fewer. Yet and then went on to speak feelingly of his while more new nurses are now employed recent experience of the hospital service in everywhere the hours worked are fewer and less effective because of the overlapping shift Colchester. East Anglia is immediately adjacent system in the middle of the day, leaving the to Colchester and North Essex and, for bulk of the work to fall on a depleted staff in the same historical reasons of relative the morning and evening. Ever since 1948 East Anglia and Sheffield poverty, low average earnings, low rateable values, and low capital investment, shares (Trent) RHBs have received annual revenue the same shortage of hospital beds, supporting allocations for hospital services between departments, and staff. For the reasons given, one-fifth and one-sixth less than the average both voluntary but especially municipal RHB expressed per caput of population. East hospital building was more restricted here Anglians have therefore "subsidised" areas than in wealthier areas such as the London where average earnings were far higher than and Middlesex County Councils, and, despite they could ever hope to obtain by a sum which, the late Mr Crossman's good intentions in spread over 27 years, must now exceed 1970 to bring East Anglia and Trent (Shef- ;,50m. The unfairness of this was recognised field Regional Hospital Board) over 10 years by Mr Crossman, because, try as one may, to parity with the average of other regions it is impossible to provide a comparable in the country, so far little has been done. And service with inequalities of funding of this now, here is Sir Francis urging that the first order. Sir Francis stresses the inadequacy of Brent attempt to do so be halted. His grounds for doing so are based on lower mortality rates bedsitters as a reason for maintaining present in East Anglia for diseases such as duodenal revenue allocations to the hospital service ulcer and coronary heart disease and bron- there. One can sympathise with this in the chitis, but mortality rates do not measure short term, but there is surely a case for morbidity and it can be argued that the older identifying as soon as possible these social the population the more frequently will it take needs rather than continuing to use hospitals ill and break its bones, especially the neck of as convalescent homes. My father, a general practitioner on the the femur. It is also a fact that East Anglia has a higher than average incidence of Norfolk/Suffolk border before the war, rheumatism and arthritis and about the same always maintained that relatively there was rate of malignant disease as the rest of the worse slum housing in East Anglia than in the country. Sir Francis goes on to cite attend- great cities. Now, 35 years later, there are still ances at accident and emergency departments many houses without a bath, running water, or to support his case that East Anglians are drainage, while in a nearby town the last fitter and therefore need less money for their ceremonial journey by the night soil cart took hospitals than the inhabitants of Brent. This place only five years ago and now the fortunate is very marshy ground, because it is no secret residents are luxuriating in their chemical loos. that the use of accident and emergency On nearly all counts East Anglia is still the departments is inversely proportional to the deprived area which Sir Francis Avery Jones willingness of patients' general practitioners denies. J W PAULLEY to deal with minor injuries and the distance a of Medicine, patient has to travel. Rather than encourage Department more use and abuse of accident and emergency Ipswich Hospital, Ipswich, Suffolk departments it would be better to encourage Geriatric service for Birmingham and rest of region general practitioners in the cities to do this work, which they always used to do and which 1966 general practitioners in rural and semirural Discharges Average areas continue to do. and beds The state of affairs to which Dr Joules deaths available (D) (B) referred in his interview is primarily due to the fact that this area, like Sheffield, has fewer Birmingham city 5330 1957 4354 9688 acute hospital beds, approximately 3 0/1000 Rest of region
population against approximately 4-0/1000 in London and elsewhere, and many of the beds are also in cottage hospitals where major
Whole region
15 018
6311
Figures derived from Birmingham Regional Statistics
20 NOVEMBER 1976
SIR,-Sir Francis Avery Jones in his pertinent article (30 October, p 1046) suggests that there may be a difference between the health needs of a city and more rural communities such as East Anglia. He may well be right and will be interested in the differences shown in the geriatric services of England's second city, Birmingham, when 1975 figures are compared with those for 1966 (see table below). During this decade, although the average number of beds available showed little change in the city, the annual turnover of geriatric patients fell from 2 72 to 2 27 discharges per bed. In the remainder of the region, which includes the more rural areas in Worcestershire, Herefordshire, Shropshire, Staffordshire, and Warwickshire, geriatric turnover rose from 2 23 in 1966 to 3 19 in 1975 and there was a small overall reduction in the number of beds. Although the more rural parts of the region started with a bed coverage above the national norm, the 43%, increase in turnover reflects great credit on the geriatric services concerned. By contrast, in the city of Birmingham geriatric bed coverage has been closer to the national average throughout the period and the progressive fall in geriatric turnover could be due in part to the national norm being too low for cities like Birmingham. Between 1966 and 1975, although the number of geriatric beds hardly changed in the city, the population of people aged 65 and over increased by about 18% and against this background falling turnover rates imply a falling standard of service, with hospital beds blocked by longerstay patients and additional pressure on the acute services. I referred to this process in 1972 as a vicious spiral.' However, in making his special plea for the acute services I fear Sir Francis may be going too far in saying that the mathematical approach should be abandoned. It would be better to modify it and include a special factor for cities. This would reduce the debt of "overspending" to be paid off in subsequent years. R W PARNELL West Midlands I
Parnell, R W, British Medical Journal, 1972, 2, 760.
SIR,-I am a family doctor working in a deprived district in the most "over-provided" region in the country, the NE Thames Region. I must applaud Sir Francis Avery Jones (30 October, p 1046) for his magnificently argued plea to the Secretary of State to abandon mathematical formulations for the reallocation of resources in the Health Service. Our region seems to be rushing ahead of the rest of the country. Not only are we on a nil growth rate but we have already planned for a 1J10, reduction of resources. The closure of many hospitals is in an advanced state of planning. In my own area the closure of an acute hospital of some 120 beds is scheduled to save, in theory, the best part of ,lm,
1975
Discharges and deaths
Average beds available
D/B
2-72 2-23
4438 13 710
1952 4295
2-27
2-38
18 148
6247
2-91
D/B
(D)
(B)
3-19
1251
20 NOVEMBER 1976
CORRESPONDENCE The London hospitals scene H Joules, FRCP; J W Paulley, FRCP; R W Parnell, FRCP; A Elliott, FRCGP ............ 1251 Quis whatsit? M O'Donnell, MB ...................... 1253 Writing and speaking in medicine R G Wilkins; C A H Watts, FRCGP ........ 1253 Refereeing papers E N Wardle, MD ...................... 1253 Professional standards H Ellis, FRCS; J H E Bergin, MB; H Marcovitch, MRCP ...................... 1253 BUPA and the long-stay patient J R Caldwell, MRCGP; D V Damerell ...... 1254 Road safety: BMA comments J D J Havard, MD ...................... 1254 Molar dosage of calcium chloride solutions S M Roden, MSC, and G A Mander, FPS .... 1255 The Framingham study W B Kannel, MD ...................... 1255 Which college? J A Ross, FRCSED .................... 1255 Oral contraceptives and myocardial infarction in older women C G H Maidment, MRCP; J I Mann, DM.... 1255 Diagnosis of brain death Pamela F Prior, MD, and D F Scott, MRCP. 1256
Additives to intravenous fluids R L Parsons, MRCP, and others .......... 1256 New enterotoxinogenic bacteria isolated G M Burnham, MD, and others .......... 1256 Glutethimide and enzyme induction C J C Roberts, MRCP, and others .......... 1256 Progesterone or progestogens? Katharina D Dalton, MRCGP ............ 1257 Low-dose progestogens and ectopic pregnancy P Liukko, MD, and R Erkkola, MD ........ 1257 Prazosin in hypertension A S Turner, FRCP ...................... 1257 Possible association of Madelung's deformity with Huntington's chorea AJ Caro, MB .......................... 1258 Immunofluorescent sperm antibodies in virgins R F Harrison, FRCS .................... 1258 Teaching of anatomy P Glees, DPHIL ........................ 1258 Administration of diazoxide R A Sloane, MRCP ...................... 1259 A further endoscopy problem solved? J B Tracey, MB ........................ 1259 Urinary amyloid fibrils in the absence of amyloidosis R P Linke, MD ........................ 1259
Correspondents are urged to write briefly so that readers may be offered as wide a selection of letters as possible. So many are being received that the omission of some is inevitable. Letters should be signed personally by all their authors. The London hospitals scene SIR,-I was extremely interested in Sir Francis Avery Jones's article on differential hospital distribution (30 October, p 1046). I had the good fortune of being on the Central Health Services Council, the board of governors of a teaching hospital, and the NW Metropolitan Regional Hospital Board from 1948 onwards. I was chairman of the Establishment Committee of the regional board for many years. These bodies gave me an insight into the way in which the "carve-up" of the hospitals services was being effected. The teaching hospitals with their influential consultants and perhaps more influential boards of governors asserted a right of dominance. Those who attended the regional board came mainly to enhance the interest of the teaching hospitals at the centre of the board. Meanwhile, Avery, if I may presume to address him thus, having come to the Central Middlesex Hospital in 1940, was very busy building up a world-wide reputation as a gastroenterologist and, of course, had little time for the intricacies of major administra-
tion. I have been in East Anglia for nine years now, not in practice at any time here, but I had the good fortune to be able to wander in the country towns and villages to see their beautiful churches and to visit local public bars here. It is in the latter that very much social medicine can be learnt. I have learnt
much of the social deprivation which exists in these counties which is not entered in any social services records. Meanwhile the teaching hospitals of London have grasped as much power and money as possible for building the huge specialist and other departments of a new hospital such as Charing Cross, which has cost L30m, and I know that London hospitals have at times been unable to fill their beds. Sometimes I wonder whether Charing Cross and St Thomas's are vying with each other to become known as the Taj Mahal of the teaching hospital scene. I learnt with amazement recently that Central Middlesex was about to close 100 acute beds for the winter in order to add more amenities with which we had been able to dispense over the last 40 years that I have known it. Perhaps we could be told whether this ability to close beds results from good- administration or a diminution of demand for hospital services. I have learnt much from being a patient intermittently over the past few years. I had a major operation in a ward of 24 beds in Colchester some three years ago. The hospital situation is almost desperate here and my ward was more hard-pressed than any ward I had ever known in 50 years of hospital life. Cross-infection was rife. I was one of its victims and when I heard that gas gangrene had appeared in an adjacent ward I asked to be allowed to go home as there were two trained
Cramp in the elderly H B Lee, FRCS ........................ 1259 Aortic incompetence in systemic lupus erythematosus A J Isaacs, MRCP; P J Richardson, MRCP, and others; P J Cooper, MB, and others .... 1260 Cigarette smoking and chronic bronchitis T W Astin, MD ........................ 1261 Unpopular specialties J Parkhouse, MD ...................... 1261 Hospital practitioner grade C N Barry, MRCGP ...................... 1261 Consultants' increments A F M S Rahman, MRCPATH, and others.. 1261 Prescribing space F J Darby, MB ......... ............... 1262 Fees for HGV licence examinations T P C Schofield, MRCP .................. 1262 Sailing to ARM M J Gilkes, FRCS ........ .............. 1262 Points from Letters Names of Asian women and babies (H K Ranu); Desert island books (J Sherliker); Health Service charges (T D Lawson); A point for the Royal Commission (D L Rees-Jones) .......................... 1262
nurses near to deal with my suppurating wounds. The demands on the junior medical staff and the insufficiency of the nursing staff were undoubtedly responsible for this crossinfection. I discussed the matter with the surgeon and he agreed that the ward should be closed but stated that in the circumstances of the hospital situation between here and the coast this was impossible. East Anglia is one of the most rapidly growing areas of the country and Colchester is no exception. For 25 years the medical staff and others have been pressing for a new hospital and to date nothing has been done. Meanwhile in the region the same pattern of maldevelopment of hospitals has gone on. The new Addenbrooke's Hospital in Cambridge has been completed at a cost of £25m and a cost per occupied bed per day of £37 19. This mausoleum of medicine of the '50s is of no benefit to the Colchester area whatsoever except for an occasional renal transplant or a rare liver exchange. I hope that Avery can come down to verify this situation, and we are certainly asking Mr David Ennals to take a more active interest in what amounts almost to a public scandal. Meanwhile, if the London teaching hospital chickens are coming home to roost I cannot be very sorry as I fought in every major committee for devolution of hospitals and Qther medical resources to the periphery. The voice cried in vain in the wilderness and I must resist wholeheartedly any attempt to divert any money from the East Anglia area, for the need is extremely great. But of course it has not the publicity value of metropolitan pressure groups. I would conclude by saying that London
1252
BRITISH MEDICAL JOURNAL
has much to learn from East Anglia and illness cannot be treated. As a result there is I have never regretted the transition. intense pressure on relatively few beds in the main district hospitals, which carry a disHORACE JOULES proportionately heavier load of major illness and surgery than in regions with more beds Colchester, Essex and therefore larger revenue allocations. This elementary fact has not yet penetrated the SIR,-My old friend and teacher Sir Francis official mind and as a result we are subjected Avery Jones (30 October, p 1046) may be to the same norm of number of nurses per right about social deprivation in Brent, but he acute bed as the rest of the country. The is wrong when he claims that East Anglia result is as Dr Joules has described. Despite "can no longer be described as a deprived the contribution of the Norwich hip unit area" as far as health services are concerned, mentioned by Sir Francis, waiting time for elective orthopaedic surgery in East Anglia was, particularly hospital services. Had Sir Francis worked in this area as well until recently, so long that it was pointless to as London, I suggest that he would not have refer a patient to an orthopaedic surgeon. been so sanguine on our account. His yard- Some surgical colleagues are once again so stick on Brent is the same as that used by concerned about lack of trained nursing staff Dr Horace Joules, with whom he spent most that in the interest of their patients' safety of his working life at Central Middlesex they are having to restrict operations. Ten Hospital, but who, when interviewed by years ago there were 170,, fewer trained nurses the East Anglian Daily Times on 5 November, per caput in the East Anglia Regional Hospital said, "Sir Francis's account of the London Board than in the average region in the rest scene does not give a proper perspective" of the country; we still have 14 70( fewer. Yet and then went on to speak feelingly of his while more new nurses are now employed recent experience of the hospital service in everywhere the hours worked are fewer and less effective because of the overlapping shift Colchester. East Anglia is immediately adjacent system in the middle of the day, leaving the to Colchester and North Essex and, for bulk of the work to fall on a depleted staff in the same historical reasons of relative the morning and evening. Ever since 1948 East Anglia and Sheffield poverty, low average earnings, low rateable values, and low capital investment, shares (Trent) RHBs have received annual revenue the same shortage of hospital beds, supporting allocations for hospital services between departments, and staff. For the reasons given, one-fifth and one-sixth less than the average both voluntary but especially municipal RHB expressed per caput of population. East hospital building was more restricted here Anglians have therefore "subsidised" areas than in wealthier areas such as the London where average earnings were far higher than and Middlesex County Councils, and, despite they could ever hope to obtain by a sum which, the late Mr Crossman's good intentions in spread over 27 years, must now exceed 1970 to bring East Anglia and Trent (Shef- ;,50m. The unfairness of this was recognised field Regional Hospital Board) over 10 years by Mr Crossman, because, try as one may, to parity with the average of other regions it is impossible to provide a comparable in the country, so far little has been done. And service with inequalities of funding of this now, here is Sir Francis urging that the first order. Sir Francis stresses the inadequacy of Brent attempt to do so be halted. His grounds for doing so are based on lower mortality rates bedsitters as a reason for maintaining present in East Anglia for diseases such as duodenal revenue allocations to the hospital service ulcer and coronary heart disease and bron- there. One can sympathise with this in the chitis, but mortality rates do not measure short term, but there is surely a case for morbidity and it can be argued that the older identifying as soon as possible these social the population the more frequently will it take needs rather than continuing to use hospitals ill and break its bones, especially the neck of as convalescent homes. My father, a general practitioner on the the femur. It is also a fact that East Anglia has a higher than average incidence of Norfolk/Suffolk border before the war, rheumatism and arthritis and about the same always maintained that relatively there was rate of malignant disease as the rest of the worse slum housing in East Anglia than in the country. Sir Francis goes on to cite attend- great cities. Now, 35 years later, there are still ances at accident and emergency departments many houses without a bath, running water, or to support his case that East Anglians are drainage, while in a nearby town the last fitter and therefore need less money for their ceremonial journey by the night soil cart took hospitals than the inhabitants of Brent. This place only five years ago and now the fortunate is very marshy ground, because it is no secret residents are luxuriating in their chemical loos. that the use of accident and emergency On nearly all counts East Anglia is still the departments is inversely proportional to the deprived area which Sir Francis Avery Jones willingness of patients' general practitioners denies. J W PAULLEY to deal with minor injuries and the distance a of Medicine, patient has to travel. Rather than encourage Department more use and abuse of accident and emergency Ipswich Hospital, Ipswich, Suffolk departments it would be better to encourage Geriatric service for Birmingham and rest of region general practitioners in the cities to do this work, which they always used to do and which 1966 general practitioners in rural and semirural Discharges Average areas continue to do. and beds The state of affairs to which Dr Joules deaths available (D) (B) referred in his interview is primarily due to the fact that this area, like Sheffield, has fewer Birmingham city 5330 1957 4354 9688 acute hospital beds, approximately 3 0/1000 Rest of region
population against approximately 4-0/1000 in London and elsewhere, and many of the beds are also in cottage hospitals where major
Whole region
15 018
6311
Figures derived from Birmingham Regional Statistics
20 NOVEMBER 1976
SIR,-Sir Francis Avery Jones in his pertinent article (30 October, p 1046) suggests that there may be a difference between the health needs of a city and more rural communities such as East Anglia. He may well be right and will be interested in the differences shown in the geriatric services of England's second city, Birmingham, when 1975 figures are compared with those for 1966 (see table below). During this decade, although the average number of beds available showed little change in the city, the annual turnover of geriatric patients fell from 2 72 to 2 27 discharges per bed. In the remainder of the region, which includes the more rural areas in Worcestershire, Herefordshire, Shropshire, Staffordshire, and Warwickshire, geriatric turnover rose from 2 23 in 1966 to 3 19 in 1975 and there was a small overall reduction in the number of beds. Although the more rural parts of the region started with a bed coverage above the national norm, the 43%, increase in turnover reflects great credit on the geriatric services concerned. By contrast, in the city of Birmingham geriatric bed coverage has been closer to the national average throughout the period and the progressive fall in geriatric turnover could be due in part to the national norm being too low for cities like Birmingham. Between 1966 and 1975, although the number of geriatric beds hardly changed in the city, the population of people aged 65 and over increased by about 18% and against this background falling turnover rates imply a falling standard of service, with hospital beds blocked by longerstay patients and additional pressure on the acute services. I referred to this process in 1972 as a vicious spiral.' However, in making his special plea for the acute services I fear Sir Francis may be going too far in saying that the mathematical approach should be abandoned. It would be better to modify it and include a special factor for cities. This would reduce the debt of "overspending" to be paid off in subsequent years. R W PARNELL West Midlands I
Parnell, R W, British Medical Journal, 1972, 2, 760.
SIR,-I am a family doctor working in a deprived district in the most "over-provided" region in the country, the NE Thames Region. I must applaud Sir Francis Avery Jones (30 October, p 1046) for his magnificently argued plea to the Secretary of State to abandon mathematical formulations for the reallocation of resources in the Health Service. Our region seems to be rushing ahead of the rest of the country. Not only are we on a nil growth rate but we have already planned for a 1J10, reduction of resources. The closure of many hospitals is in an advanced state of planning. In my own area the closure of an acute hospital of some 120 beds is scheduled to save, in theory, the best part of ,lm,
1975
Discharges and deaths
Average beds available
D/B
2-72 2-23
4438 13 710
1952 4295
2-27
2-38
18 148
6247
2-91
D/B
(D)
(B)
3-19
