BRITISH MEDICAL JOURNAL
1443
11 DECEMBER 1976
do this in Brighton I see no reason why we cannot do it elsewhere with the right sort of management. W S PARKER East Sussex Area Health Authority, Brighton Health District, Brighton, Sussex
The London hospitals scene
SIR,-You are supposed to be the Editor of the British Medical Journal, not the publisher of the Greater London Lobbyist. Some orchestrated ululation over the Resource Allocation Working Party's report' was to be expected (as occurred after the Central Manpower Committee's timid attempt to move a few registrars out of London), but the patronising tone of your leading article (27 November, p 1280) and of Dr W F Whimster's Personal View (p 1318) is extremely offensive to consultants like myself working north of Potters Bar. What scrap of evidence have you for the sneering comment that areas such as this would not be capable of benefiting from the proposed redistribution ? I was recently asked by a local resident (who had just returned from an operation at one of London's "centres of excellence") to change his catheter. Neither his general practitioner nor I had had any letters from this "centre" in the last five years, and repeated requests that a hospital doctor should telephone me first about the recent operation brought no response. Now, Sir, that London department of urology has approximately the same number of beds and, like ours, is staffed by two consultants. These two consultants, are, however, assisted by seven and a half times as many junior staff as we are. The types of disease and treatment do not seem all that dissimilar; surely some economy of staff can be made without any patient suffering? (Maybe someone will have to work a little harder or even slow down the research, neither exactly disastrous.) Before Sir Francis Avery Jones (30 October, p 1046) yet again trundles out his "show slum" let me say that our slums are just as good as his. Perhaps the overambitious proprietors of St Thomas's could follow the example of Mr Harry Hyams, who had to leave that other airconditioned extravagance, Centre Point, unoccupied for a while ? A couple of empty floors viewed from the Palace of Westminster during 1977 might convince some of our present masters that money does not grow on trees, never has, and never will. ROGER HOLE Department of Urology, North Ormesby Hospital,
Middlesbrough, Cleveland
Department of Health and Social Security, Sharing Resources for Health in England. London, HMSO, 1976.
SIR,-Not very long ago envy and covetousness were rightly condemned as among the most self-destructive of human emotions. But that was before contemporary levellers had stoked the fires that lie within most of us to the point where excellence is now an offence and only universal mediocrity is acceptable. In this light the threatened closure of some of our greatest hospitals and medical schools may be seen as the culmination of a long series of DHSS measures designed to "cut down to size" institutions and individuals which have
attained, or have dared to aspire to attain, excellence. Sadly, many of the first moves in the game were not perceived and are still not perceived as threatening by many of those now wringing their hands in lamentation. Some even went out of their way to welcome them. I refer to "overtime pay," excessive study leave with service taking second place, the "Tomato" document, Cogwheel, Salmon, Central Manpower Committee, Hunter, and finally the Grey Book, which set out quite intentionally to undermine the autonomy of the teaching hospitals and, by taking away their separate funding, deprived those clustered in London of the means to survive. Despite the admirable intentions of the Resources Allocation Working Party (Dr J M Forsythe and others, 27 November, p 1320), the report has been seized upon by the petty and the envious as a God-sent opportunity to harass and break. It matters not to these people that it will take years and years to rebuild morale and the traditions of learning elsewhere, and this quite apart from the vast cost of replacing specialised medical school and hospital buildings. I am in full agreement with Sir Francis Avery Jones (27 November, p 1320) about the incalculable damage posed to our diminishing reputation as a "leading medical country." I am also grateful to him for his partial withdrawal of the claim made in his article (30 October, p 1046) that "East Anglia can no longer be described as a deprived area" and can assure him that although there has been easement of deprivation in Cambridge, and to a lesser extent in Norwich, this has not helped other centres in this geographically widespread region; in some respects it has increased them. All the stupidities of NHS reorganisation need to be reversed, but as an early priority teaching hospitals, particularly in London, need to be removed from the whims of AHAs and RHAs and from the malign influence of a few petty, bigoted, and covetous people. J W PAULLEY Ipswich, Suffolk
SIR,-In your leading article (27 November, p 1280) you argue against the proposition that resources should be diverted from parts of the Health Service that have plenty to parts that are in need. The regions of the Health Service that are short of resources have always been so, since 1948. They have lacked enough to give the kind of service available to people living in other parts. A reallocation of resources must seem a good idea to their Health Service workers and especially their patients. In the South-west we have waiting lists for the investigation of cases of suspect carcinoma, and they wait many weeks. Patients wait more than a year for cholecystectomies in our area. A department in this district is still waiting, through lack of funds, for a registrar agreed by the regional board more than six years ago. You describe "devastating effects of the fall in revenue in the Thames regions" as being "clear enough." You suggest that the benefits further north "may be illusory." From what we hear of the conditions up there the benefits will be real enough. If you can give a hardpressed department an extra medical man and some further resources such as adequate secretarial help and an extra nurse in the clinics the benefit will be immediate. Your "fundamental objection" is that "when resources are
growing reallocation can be equitable, but in a period of recession it makes hardships worse." I never heard that argument put back to front before. When times are hard the rich should be aiding the poor (ref Wenceslas, GK, circa AD 920). You are asking "where is the urgency?". The answer lies in patient waiting lists. Seventy per cent of general surgical admissions in this district are emergencies. Patients on lists for urgent investigations barely get a look in. Here is your urgency. At the end of your article, you recommend that reallocation should be, as you so prettily put it, "snap-frozen" until more money is available. Now is the time. T L BRADBEER Department of Otolaryngology, Royal Devon and Exeter Hospital
(Wonford),
Exeter
SIR,-Dr H Joules (20 November, p 1251) rightly puts the other side of the coin in the current controversy over the proposals by the Resources Allocation Working Party which it is suggested will do so much to erode the cause of excellence. I think that the following figures will clearly demonstrate that some people are living and working in a different medical world from the rest of us. For instance, it is revealed from statistics issued by the East Anglian Health Authority that the capital expenditure (1948 to 1974) per head of population was, unbelievably: Health district Great Yarmouth and Waveney Kings Lynn Ipswich .24-38 Norwich .29-39 Peterborough Bury St Edmunds . . Cambridge.
,
per head of population 10 90 20-32 35-34 37-21 61-47
An equally interesting and startling revelation appears if one looks at the attendances for accident and emergency per 1000 head of population for 1974: Great Yarmouth and Waveney .339-1 Peterborough .246-3 Ipswich .185-2 Bury St Edmunds Kings Lynn Norwich .136
153-7 144-2
Cambridge .133-2
It is not, of course, the simple differences which are so startling but what is called in financial circles the gearing: the ratio, in other words, revealed by these figures. What possible justification can there be for a ratio of six comparing Cambridge with Great Yarmouth and the further fact that this gross disproportion has continued since 1948. I would hazard a guess that a similar discovery could be made in districts such as Scarborough, Bridlington, and Whitby and Barnstaple, Bideford, and Ilfracombe, plus many others too. Clearly the NHS goodies are distributed in inverse proportion to the distance from the administrative headquarters. To put it in another way by a method of exponential decay, how does one justify the near squalor at one end and the Health Service Hiltons at the other? One naturally expects that a teaching hospital will be more expensive, but a magnificent ratio of sax . .. J P N HICKS Lowestoft, Suffolk
1443
11 DECEMBER 1976
do this in Brighton I see no reason why we cannot do it elsewhere with the right sort of management. W S PARKER East Sussex Area Health Authority, Brighton Health District, Brighton, Sussex
The London hospitals scene
SIR,-You are supposed to be the Editor of the British Medical Journal, not the publisher of the Greater London Lobbyist. Some orchestrated ululation over the Resource Allocation Working Party's report' was to be expected (as occurred after the Central Manpower Committee's timid attempt to move a few registrars out of London), but the patronising tone of your leading article (27 November, p 1280) and of Dr W F Whimster's Personal View (p 1318) is extremely offensive to consultants like myself working north of Potters Bar. What scrap of evidence have you for the sneering comment that areas such as this would not be capable of benefiting from the proposed redistribution ? I was recently asked by a local resident (who had just returned from an operation at one of London's "centres of excellence") to change his catheter. Neither his general practitioner nor I had had any letters from this "centre" in the last five years, and repeated requests that a hospital doctor should telephone me first about the recent operation brought no response. Now, Sir, that London department of urology has approximately the same number of beds and, like ours, is staffed by two consultants. These two consultants, are, however, assisted by seven and a half times as many junior staff as we are. The types of disease and treatment do not seem all that dissimilar; surely some economy of staff can be made without any patient suffering? (Maybe someone will have to work a little harder or even slow down the research, neither exactly disastrous.) Before Sir Francis Avery Jones (30 October, p 1046) yet again trundles out his "show slum" let me say that our slums are just as good as his. Perhaps the overambitious proprietors of St Thomas's could follow the example of Mr Harry Hyams, who had to leave that other airconditioned extravagance, Centre Point, unoccupied for a while ? A couple of empty floors viewed from the Palace of Westminster during 1977 might convince some of our present masters that money does not grow on trees, never has, and never will. ROGER HOLE Department of Urology, North Ormesby Hospital,
Middlesbrough, Cleveland
Department of Health and Social Security, Sharing Resources for Health in England. London, HMSO, 1976.
SIR,-Not very long ago envy and covetousness were rightly condemned as among the most self-destructive of human emotions. But that was before contemporary levellers had stoked the fires that lie within most of us to the point where excellence is now an offence and only universal mediocrity is acceptable. In this light the threatened closure of some of our greatest hospitals and medical schools may be seen as the culmination of a long series of DHSS measures designed to "cut down to size" institutions and individuals which have
attained, or have dared to aspire to attain, excellence. Sadly, many of the first moves in the game were not perceived and are still not perceived as threatening by many of those now wringing their hands in lamentation. Some even went out of their way to welcome them. I refer to "overtime pay," excessive study leave with service taking second place, the "Tomato" document, Cogwheel, Salmon, Central Manpower Committee, Hunter, and finally the Grey Book, which set out quite intentionally to undermine the autonomy of the teaching hospitals and, by taking away their separate funding, deprived those clustered in London of the means to survive. Despite the admirable intentions of the Resources Allocation Working Party (Dr J M Forsythe and others, 27 November, p 1320), the report has been seized upon by the petty and the envious as a God-sent opportunity to harass and break. It matters not to these people that it will take years and years to rebuild morale and the traditions of learning elsewhere, and this quite apart from the vast cost of replacing specialised medical school and hospital buildings. I am in full agreement with Sir Francis Avery Jones (27 November, p 1320) about the incalculable damage posed to our diminishing reputation as a "leading medical country." I am also grateful to him for his partial withdrawal of the claim made in his article (30 October, p 1046) that "East Anglia can no longer be described as a deprived area" and can assure him that although there has been easement of deprivation in Cambridge, and to a lesser extent in Norwich, this has not helped other centres in this geographically widespread region; in some respects it has increased them. All the stupidities of NHS reorganisation need to be reversed, but as an early priority teaching hospitals, particularly in London, need to be removed from the whims of AHAs and RHAs and from the malign influence of a few petty, bigoted, and covetous people. J W PAULLEY Ipswich, Suffolk
SIR,-In your leading article (27 November, p 1280) you argue against the proposition that resources should be diverted from parts of the Health Service that have plenty to parts that are in need. The regions of the Health Service that are short of resources have always been so, since 1948. They have lacked enough to give the kind of service available to people living in other parts. A reallocation of resources must seem a good idea to their Health Service workers and especially their patients. In the South-west we have waiting lists for the investigation of cases of suspect carcinoma, and they wait many weeks. Patients wait more than a year for cholecystectomies in our area. A department in this district is still waiting, through lack of funds, for a registrar agreed by the regional board more than six years ago. You describe "devastating effects of the fall in revenue in the Thames regions" as being "clear enough." You suggest that the benefits further north "may be illusory." From what we hear of the conditions up there the benefits will be real enough. If you can give a hardpressed department an extra medical man and some further resources such as adequate secretarial help and an extra nurse in the clinics the benefit will be immediate. Your "fundamental objection" is that "when resources are
growing reallocation can be equitable, but in a period of recession it makes hardships worse." I never heard that argument put back to front before. When times are hard the rich should be aiding the poor (ref Wenceslas, GK, circa AD 920). You are asking "where is the urgency?". The answer lies in patient waiting lists. Seventy per cent of general surgical admissions in this district are emergencies. Patients on lists for urgent investigations barely get a look in. Here is your urgency. At the end of your article, you recommend that reallocation should be, as you so prettily put it, "snap-frozen" until more money is available. Now is the time. T L BRADBEER Department of Otolaryngology, Royal Devon and Exeter Hospital
(Wonford),
Exeter
SIR,-Dr H Joules (20 November, p 1251) rightly puts the other side of the coin in the current controversy over the proposals by the Resources Allocation Working Party which it is suggested will do so much to erode the cause of excellence. I think that the following figures will clearly demonstrate that some people are living and working in a different medical world from the rest of us. For instance, it is revealed from statistics issued by the East Anglian Health Authority that the capital expenditure (1948 to 1974) per head of population was, unbelievably: Health district Great Yarmouth and Waveney Kings Lynn Ipswich .24-38 Norwich .29-39 Peterborough Bury St Edmunds . . Cambridge.
,
per head of population 10 90 20-32 35-34 37-21 61-47
An equally interesting and startling revelation appears if one looks at the attendances for accident and emergency per 1000 head of population for 1974: Great Yarmouth and Waveney .339-1 Peterborough .246-3 Ipswich .185-2 Bury St Edmunds Kings Lynn Norwich .136
153-7 144-2
Cambridge .133-2
It is not, of course, the simple differences which are so startling but what is called in financial circles the gearing: the ratio, in other words, revealed by these figures. What possible justification can there be for a ratio of six comparing Cambridge with Great Yarmouth and the further fact that this gross disproportion has continued since 1948. I would hazard a guess that a similar discovery could be made in districts such as Scarborough, Bridlington, and Whitby and Barnstaple, Bideford, and Ilfracombe, plus many others too. Clearly the NHS goodies are distributed in inverse proportion to the distance from the administrative headquarters. To put it in another way by a method of exponential decay, how does one justify the near squalor at one end and the Health Service Hiltons at the other? One naturally expects that a teaching hospital will be more expensive, but a magnificent ratio of sax . .. J P N HICKS Lowestoft, Suffolk
