1384
BRITISH MEDICAL JOURNAL
Special health care facilities for this stigmatised group will get little further than the pipeline until area health authorities accept responsibility for providing comprehensive medical cover for people in hostels and emergency accommodation. It isn't just fear of antisocial behaviour which prevents health administrators from finding appropriate solutions; the DHSS has itself operated for years a successful health care system for the several thousand homeless men and women using government reception centres. Nor is it the mobility of the group which is the stumbling block; the student health service very adequately takes care of the most mobile group in our population. Health authorities are in danger of making the same mistake as housing and social service authorities-that of failing to plan provision for this group which is present to a greater or lesser extent in every town and city in the country. The Lothian Health Board and a handful of willing doctors on our side of the Border are showing that it really does not require much imagination or expenditure. ANNE DAVIES Assistant Director, CHAR 27 Endell Street, London WC2
SIR,-May I refer to your leading article (30 October, p 1027) ? As a member of CHAR I submitted a minority report to them. I stated that our five little houses had been extremely well provided for by the medical profession in the Merton area. I consulted with my own doctor when the Messenger House Trust was set up; he delegated to one of his junior partners the responsibility for the first house. This worked satisfactorily until we bought our second house. I consulted the young doctor and we agreed that we would involve a different group practice as each new house opened. Consequently there are now at least 20 doctors aware of the group of young, delinquent, aggressive, promiscuous people who are cared for by the trust. Certainly they take more than "average patient" time of my colleagues. Again the consultants and nursery staff in the five hospitals with which I am in contact have shown forebearance and concern for these patients. No colleague has received any fee from my trust for their services. Some have donated not only money but cots, high chairs, and other furniture belonging either to themselves or some of their
patients. In order to save the country money in these times of inflation I would recommend a change of practice so that a letter would not be required from a doctor for these vagrants in casualty departments. I am sure medical students should be taught about the unrealistic demands but real needs of the vagrants, which are bed, food, and warmth. Ideally a small house near the hospital, supervised by volunteers, could accept these vagrants for a few nights while they were on antibiotics or undergoing investigations so that they would not need hospital admission. I would envisage a district nurse calling once a day and the payment of the vagrants' rent direct to the hospital by the DHSS. The Messenger House Trust saves the taxpayer several thousand pounds a year as we provide a service at a third the price of bed and breakfast and use only volunteers. Most hospitals have a league of friends, some of
whom might prefer to use their practical skills in such a venture rather than in fund-raising activities. JOSEPHINE M LOMAX-SIMPSON Messenger House Trust, London SW19
The London hospitals scene
4 DECEMBER 1976
regional scrap. The true problem is better discussed by Dr Arnold Elliott (20 November, p 1252). Transferring money from one region to another on statistical grounds may not help the recipient if the money is inadequate in quantity and badly and hurriedly spent, but it will certainly harm the donor region unless there has been gross overspending and wastage of resources. In the Greenwich and Bexley area, which is not socially overprivileged, the regional health authority has ordained that we should be a donor area, and to this end our area health authority and the districts are drawing up plans for cuts. The establishment of ad hoc health care planning teams has given the illusion of consultation with the consultants and of their complicity in the eventual changes. There are, indeed, certain ways in which money could be saved locally, but many of the proposed cuts are based on dubious statistics and will decimate services, particularly in the acute specialties, without producing true economies. It is the duty of clinicians to make their opposition to the proposed cuts felt at regional and departmental levels unless, of course, they feel that the cuts will improve rather than diminish the service to patients for which the NHS exists. I do not wish to upset my clinical and administrative colleagues locally by cataloguing some of the more ridiculous suggestions that have been made in order to save Clim this year and more in future years, but I do find it interesting that, with the quite reasonable objective of combining two existing two-surgeon units into one larger unit, 70 surgical beds in a well-sited general hospital are to be given over to geriatric use and C1 15 000 has been allocated (starting price!) to complete a new 25-bed plus day-bed surgical ward at another hospital. Furthermore, the RHA has decided that one surgeon who is departing will not be replaced. The loss of 45 beds and one surgeon will not, I feel, improve the waiting time for outpatient appointments or decrease the length of the waiting lists for non-urgent surgery. The final concoction will produce a shortage of acute specialty resources that will have to be experienced from the patient's point of view to be believed. It is, however, not against my local colleagues that I am protesting but against the RHA and the DHSS. The South-east Thames RHA has meekly accepted the instructions of the DHSS and appears to be enforcing them on the same type of statistical grounds, with no evidence of compassion or local understanding. The present levels of NHS funding are inadequate; the Department should admit this fact, abandon ideology, and look for alternative methods of financing the Service. The concept of the NHS is second to none, but its execution is now impossible in a bankrupt nation,.and certainly internal juggling of the books-robbing Peter to pay Paul-is not the answer. ELLIS S FIELD
SIR,-Touched by Sir Francis Avery Jones's cri de coeur (30 October, p 1046), I have studied "Sharing Resources for Health."' I expected, after reading Sir Francis, a short, slapdash Green Paper full of statistical jargon and impossible formulae. Actually it is a carefully argued, modest, short book which in general can be easily understood. No claim is made to have found a satisfactory measure of need-quite the contrary. The authors only claim, given the available evidence, to have produced a formula which would allocate resources more fairly than at present. My only criticism is that they could simplify their formula by replacing "age-structure" and "SMR" by crude death rates. It is also regrettable that they did not discuss the position of Scotland. No doubt its needs are great, but are they 2500 more than ours ? No doubt their terms of reference excluded this. We have been woefully slow in starting research on techniques of measuring need, but it ill behoves Londoners to complain. Many London teaching hospitals have done much to delay the development of research in community medicine. As regards Sir Francis's more specific points, I can find no evidence of increasing SMR with increasing size of conurbation. In Canada recently I met the exact reverse argument that providing health resources for scattered populations was more expensive than providing them for cities. His other point is, I think, covered in part by the great detail in which psychiatric needs are discussed. In addition, I agree with Sir Francis (though he does not actually say it) that there is a need for a similar study of the allocation of social service resources with special reference to London. I agree that the country is for the moment in a bad way and that it would be pleasanter to introduce such changes in times of plenty, but those who were prisoners of war will remember that the hungrier they became the more important it became not only to share the food fairly but also that the shares should be seen to be fair. Londoners seem to forget that provincials have been complaining for many years about the way in which we have to subsidise London, not only in health but in transport, theatres, operas, and general "weighting." It is all justified by a vague hypothesis about London's "excellence." This hypothesis has never been validated and in some medical areas is beginning to look very unlikely. Londoners should remember that provincial morale is at least as important as theirs. St Nicholas Hospital, A L COCHRANE London SE18 Rhoose, Barry, S Glam Department of Health and Social Security, Sharing Resources for Health in England. London, HMSO, 1976.
SIR,-I note the anxiety expressed by Sir Francis Avery Jones (30 October, p 1046) as well as his implied plea for restoration of the usual grant of a large slice of the national cake SIR,-It would be a shame if the excellent to London, in support of which he quotes the article by Sir Francis Avery Jones (30 October, example of special circumstances of urban p 1046) stimulated nothing more than an inter- deprivation and expensive services.
BRITISH MEDICAL JOURNAL
Special health care facilities for this stigmatised group will get little further than the pipeline until area health authorities accept responsibility for providing comprehensive medical cover for people in hostels and emergency accommodation. It isn't just fear of antisocial behaviour which prevents health administrators from finding appropriate solutions; the DHSS has itself operated for years a successful health care system for the several thousand homeless men and women using government reception centres. Nor is it the mobility of the group which is the stumbling block; the student health service very adequately takes care of the most mobile group in our population. Health authorities are in danger of making the same mistake as housing and social service authorities-that of failing to plan provision for this group which is present to a greater or lesser extent in every town and city in the country. The Lothian Health Board and a handful of willing doctors on our side of the Border are showing that it really does not require much imagination or expenditure. ANNE DAVIES Assistant Director, CHAR 27 Endell Street, London WC2
SIR,-May I refer to your leading article (30 October, p 1027) ? As a member of CHAR I submitted a minority report to them. I stated that our five little houses had been extremely well provided for by the medical profession in the Merton area. I consulted with my own doctor when the Messenger House Trust was set up; he delegated to one of his junior partners the responsibility for the first house. This worked satisfactorily until we bought our second house. I consulted the young doctor and we agreed that we would involve a different group practice as each new house opened. Consequently there are now at least 20 doctors aware of the group of young, delinquent, aggressive, promiscuous people who are cared for by the trust. Certainly they take more than "average patient" time of my colleagues. Again the consultants and nursery staff in the five hospitals with which I am in contact have shown forebearance and concern for these patients. No colleague has received any fee from my trust for their services. Some have donated not only money but cots, high chairs, and other furniture belonging either to themselves or some of their
patients. In order to save the country money in these times of inflation I would recommend a change of practice so that a letter would not be required from a doctor for these vagrants in casualty departments. I am sure medical students should be taught about the unrealistic demands but real needs of the vagrants, which are bed, food, and warmth. Ideally a small house near the hospital, supervised by volunteers, could accept these vagrants for a few nights while they were on antibiotics or undergoing investigations so that they would not need hospital admission. I would envisage a district nurse calling once a day and the payment of the vagrants' rent direct to the hospital by the DHSS. The Messenger House Trust saves the taxpayer several thousand pounds a year as we provide a service at a third the price of bed and breakfast and use only volunteers. Most hospitals have a league of friends, some of
whom might prefer to use their practical skills in such a venture rather than in fund-raising activities. JOSEPHINE M LOMAX-SIMPSON Messenger House Trust, London SW19
The London hospitals scene
4 DECEMBER 1976
regional scrap. The true problem is better discussed by Dr Arnold Elliott (20 November, p 1252). Transferring money from one region to another on statistical grounds may not help the recipient if the money is inadequate in quantity and badly and hurriedly spent, but it will certainly harm the donor region unless there has been gross overspending and wastage of resources. In the Greenwich and Bexley area, which is not socially overprivileged, the regional health authority has ordained that we should be a donor area, and to this end our area health authority and the districts are drawing up plans for cuts. The establishment of ad hoc health care planning teams has given the illusion of consultation with the consultants and of their complicity in the eventual changes. There are, indeed, certain ways in which money could be saved locally, but many of the proposed cuts are based on dubious statistics and will decimate services, particularly in the acute specialties, without producing true economies. It is the duty of clinicians to make their opposition to the proposed cuts felt at regional and departmental levels unless, of course, they feel that the cuts will improve rather than diminish the service to patients for which the NHS exists. I do not wish to upset my clinical and administrative colleagues locally by cataloguing some of the more ridiculous suggestions that have been made in order to save Clim this year and more in future years, but I do find it interesting that, with the quite reasonable objective of combining two existing two-surgeon units into one larger unit, 70 surgical beds in a well-sited general hospital are to be given over to geriatric use and C1 15 000 has been allocated (starting price!) to complete a new 25-bed plus day-bed surgical ward at another hospital. Furthermore, the RHA has decided that one surgeon who is departing will not be replaced. The loss of 45 beds and one surgeon will not, I feel, improve the waiting time for outpatient appointments or decrease the length of the waiting lists for non-urgent surgery. The final concoction will produce a shortage of acute specialty resources that will have to be experienced from the patient's point of view to be believed. It is, however, not against my local colleagues that I am protesting but against the RHA and the DHSS. The South-east Thames RHA has meekly accepted the instructions of the DHSS and appears to be enforcing them on the same type of statistical grounds, with no evidence of compassion or local understanding. The present levels of NHS funding are inadequate; the Department should admit this fact, abandon ideology, and look for alternative methods of financing the Service. The concept of the NHS is second to none, but its execution is now impossible in a bankrupt nation,.and certainly internal juggling of the books-robbing Peter to pay Paul-is not the answer. ELLIS S FIELD
SIR,-Touched by Sir Francis Avery Jones's cri de coeur (30 October, p 1046), I have studied "Sharing Resources for Health."' I expected, after reading Sir Francis, a short, slapdash Green Paper full of statistical jargon and impossible formulae. Actually it is a carefully argued, modest, short book which in general can be easily understood. No claim is made to have found a satisfactory measure of need-quite the contrary. The authors only claim, given the available evidence, to have produced a formula which would allocate resources more fairly than at present. My only criticism is that they could simplify their formula by replacing "age-structure" and "SMR" by crude death rates. It is also regrettable that they did not discuss the position of Scotland. No doubt its needs are great, but are they 2500 more than ours ? No doubt their terms of reference excluded this. We have been woefully slow in starting research on techniques of measuring need, but it ill behoves Londoners to complain. Many London teaching hospitals have done much to delay the development of research in community medicine. As regards Sir Francis's more specific points, I can find no evidence of increasing SMR with increasing size of conurbation. In Canada recently I met the exact reverse argument that providing health resources for scattered populations was more expensive than providing them for cities. His other point is, I think, covered in part by the great detail in which psychiatric needs are discussed. In addition, I agree with Sir Francis (though he does not actually say it) that there is a need for a similar study of the allocation of social service resources with special reference to London. I agree that the country is for the moment in a bad way and that it would be pleasanter to introduce such changes in times of plenty, but those who were prisoners of war will remember that the hungrier they became the more important it became not only to share the food fairly but also that the shares should be seen to be fair. Londoners seem to forget that provincials have been complaining for many years about the way in which we have to subsidise London, not only in health but in transport, theatres, operas, and general "weighting." It is all justified by a vague hypothesis about London's "excellence." This hypothesis has never been validated and in some medical areas is beginning to look very unlikely. Londoners should remember that provincial morale is at least as important as theirs. St Nicholas Hospital, A L COCHRANE London SE18 Rhoose, Barry, S Glam Department of Health and Social Security, Sharing Resources for Health in England. London, HMSO, 1976.
SIR,-I note the anxiety expressed by Sir Francis Avery Jones (30 October, p 1046) as well as his implied plea for restoration of the usual grant of a large slice of the national cake SIR,-It would be a shame if the excellent to London, in support of which he quotes the article by Sir Francis Avery Jones (30 October, example of special circumstances of urban p 1046) stimulated nothing more than an inter- deprivation and expensive services.
