BRITISH MEDICAL JOURNAL
837
6 OCTOBER 1979
MEDICAL
Accident and Emergency
PRACTICE
Services
What are accident and emergency departments for? BY A SPECIAL CORRESPONDENT
British Medical Journal, 1979, 2, 837-839
In the last decade or two people have come to expect more of their casualty departments. They know hospitals have splendid equipment, which must be a good thing; they have heard of complications ("I know it's only a blister but it might go septic") and indeed are often urged to seek early advice; and they may believe they have a right to walk in and use the hospital's services ("I pay my taxes"-an approach that causes unpleasantness in many departments). Cars also have made hospitals easily accessible to much of the population. GPs, too, have probably become more inclined to refer patients to the accident and emergency department as they have become more overworked, and perhaps more unsure of themselves in their awareness of medicolegal problems; while the difficulty of making urgent outpatient appointments has also led to their using the department as a convenient "back door" to the hospital. Accidents have, of course, increased over the years; and improvements in management, especially for the severely injured, have made more work for the accident department., Thus the new patients attending at accident and emergency departments in England rose from 114-6 per 1000 population in 1956 to 189-1 per 1000 in 1976.2 In this series of articles, based on visits to 16 accident and emergency departments and other centres, I will be looking at both problems and promising
developments. Who uses accident and emergency departments? The main functions of the accident and emergency department are making an accurate diagnosis or assessment, giving immediate treatment, and arranging for further care if necessaryall of which may require the utmost speed. Open access is essential, but how far is the freedom abused ? The Platt Report (which brought in the term "accident and emergency" rather than "casualty department" as part of the
upgrading process) suggested that 40-600o of the total seen in an urban department may be GP-type cases.3 In general the proportion of serious cases is about 20004; while the proportion of injuries is said to range from as little as 300h (in city centres) to about 800O.I Rutherford concluded that at the Royal Victoria Hospital, Belfast, some 900o of patients seen in the "walking" area were using the service correctly and 5% definitely misusing it, with 500 on the borderline.6 Among the departments I visited, one reported a very low proportion of inappropriate attendances, perhaps about 6%"Losing them would just give us a few more minutes to drink our coffee." This was at a district general hospital in an area of stable population, with a good GP service and nine GP hospitals with casualty departments in outlying areas. At a London teaching hospital the proportion was 10-1500'-they allowed for the fact that many of the patients were commuters or away from home. Another teaching hospital, in a residential area of London, in a 1976 survey found that 240o of patients had no injury or emergency; of these, 90' had no GP and 33% were not happy with his treatment. In the accident service of a city much frequented by tourists 3000 of cases were considered inappropriate but it rigorously redirected them to the cooperative local GPs. The highest figure for inappropriate cases quoted to me was 6000, at a small hospital accepting no ambulance cases, where the local GP service was not considered good. Most (but not all) of the inappropriate attendances are self-referrals, and the habit of cutting out the GP does seem to be increasing. In a large city department the proportion of self-referrals for "acute medical emergencies" had risenfrom 110% in 1966 to 4700 in 1978; the usual proportion of the patients sent home was about 400c . An analysis in Leeds showed higher proportions of self-referrals at the weekend than other days.2 These figures conceal a mixture of cases-those where selfcare would have sufficed (for which a figure of 4% has been suggested7) and conditions, including some of the injuries, that a GP could have treated or referred to the appropriate department. Rutherford, however, regarded all the injuries (820o of his "walking" cases), no matter how minor, as appro-
838 priate for the department., The patient cannot always judge what is serious, and prompt treatment saves later troubles. Reassurance is agreed to be a legitimate function. But not all accident and emergency consultants would agree that they should be dealing with very simple injuries, particularly when they see ones that have occurred a few days or even weeks previously, and hear some of the reasons why their departments are being used.8 "I was just visiting someone here"; "I'm too busy to go to my doctor"; and "I have a date at 4.30 and my GP isn't there till 5" are among those I came across. Nor would all GPs agree. Though many are happy to be relieved of such injuries, especially out of hours, a different view was put strongly by a single-handed London GP who does his own suturing and other minor procedures-and keeps his appointments system flexible. He preferred, he said, to look after his own patients whatever the time of day or night, and if the complaint was minor was concerned to know why the patient was so anxious. He had referred no more than seven cases, three of them injuries, to his local department in five months; and said that not many of his patients referred themselves. A survey in a large accident and emergency department also suggested that the GPs who referred most patients to the department also had the most self-referring patients. Some people, however, go to an accident and emergency department precisely because it is anonymous.9 Most departments, too, have their "regulars"-drunks, drug addicts, social misfits, and so on-for whom it must take some responsibility.7 The social aspect was prominent in the work of a department I visited in a deprived area where some of the patients lived in hostels or slept rough-and where the GPs tended to be unavailable after 5 o'clock. Another large department, near a main-line station, has to deal not only with the miscellaneous ills of travellers and of the peripatetic, disturbed people of a big city but with what they call the "railway station syndrome," in which people become suddenly unable to cope on finding the streets of London are not paved with gold or on facing the realities of a defection from home.
Educating patients and doctors Granted that such problems are inseparable from accident and emergency departments, how can the general run of inappropriate cases be reduced? Casualty officers and nurses may attempt to persuade "unsuitable" attenders that they should visit their GP. But treating the patient is often easier, especially for a junior doctor; and some departments go no further than displaying an ineffective notice explaining the functions of the department. People need to be told, or reminded,
that rashes, boils, migraine, and influenza are not for the accident and emergency department. The Parliamentary Expenditure Committee recommended more TV "fillers" on the role of accident and emergency departments and more efforts in the press and on television to publicise medical provision during absence from home,'0 recommendations that the Government did not support." But there seems a place for informal publicity (as distinct from didactic campaigns), especially in women's features and magazines, and discussion in schools-and also for posters in surgeries and clinics about when and when not to use the accident and emergency department and about arrangements for emergency cover. In one study 30% of the selfreferred patients who had come straight from their own homes with "acute medical emergencies" had done so believing that the GP (or deputy) was not available after surgery hours.'" GPs may also abuse the accident and emergency servicefor example, "This lady has bronchitis ... She cannot cope at home because she feels depressed. I feel she needs reassurance"; or "Please circumcise this child [a 2-year-old brought in at 4 am]. The parents have been kept awake all night." The staff of many departments take a firm line about their role in their letters to GPs. Return visits A consultant in a specialised accident service expressed pleasure that a man had returned 10 years after his accident to consult him about renewed trouble. I found different policies about return visits, but in general these were kept to a minimum. The larger hospitals tend to have separate clinics for many of the follow-ups, while for minor procedures such as dressings and removal of sutures the patient goes to his GP if practicable. Apart from conditions of interest to a particular consultant, the main exceptions were related to teaching, to which the better departments attach great importance-a junior doctor learns from seeing the results of his handiwork, notably suturing. But a consultant with a low rate of returns (7%) was scathing about this idea, adding that return visits in general tended to be a legacy of accident and emergency departments with "absentee landlords": a junior doctor says "Come back" if he is not sure. In his own department returns had fallen from 23 000 to 4000 in 12 years. Beds The many reports on accident and emergency services have recommended beds within the department (apart from accident beds for definitive care, usually in other departments). This ideal is often neglected even in the better departments. "We'd like our own beds"-or even "We have our own beds"-"but can't spare the nurses to look after them." "Even if we had them," someone said, "they would probably be used just for drunks to dry out." One or two overnight beds are common, or somewhat more short-term observation beds; but they are liable to be taken over as non-specific admission beds or for longer-term use rather than observation. But a department that manages to keep rigorously to the two-day limit for its 16 beds accommodates an impressive total of 3500 patients a year. Only the more specialised accident services have larger and longer-term wards. These are integral to the concept of the comprehensive accident service, in which the department is totally responsible for the patient, bringing other specialists in as required-an advantage for those with multiple injuries, but not feasible in most hospitals. *
The children's waiting area in the accident and emergency department at Wexham Park Hospital, Slough.
6 OCTOBER 1979
BRITISH MEDICAL JOURNAL
*
Accident and emergency departments cannot be all things to all men, as they might sometimes appear, nor is it in patients'
BRITISH MEDICAL JOURNAL
6 OCTOBER 1979
interests that they should try to be. Should the emphasis be on providing a resuscitation service, a specialised trauma service, a "filter" for the rest of the hospital, a haven for the dispossessed, or all of these things and more ? The answers will be affected by local circumstances and will-or should-in turn affect the organisation of services. But everyone must be clear what a particular department is trying to do. I am deeply grateful to all the people in accident and emergency departments and elsewhere who have been so generous with their help.
References I Scott, J C, British Medical_Journal, 1967, 2, 632. 2
A Year in the Life of a Major A and E Department. Accident and Emergency Department, Leeds General Infirmary, and Nuffield Centre for Health Services Studies, University of Leeds, 1977.
839 3Standing Advisory Medical Committee, Accident and Emergency Services. Report of the Subcommittee. London, HMSO, 1962. (Platt Report.) 4Caro, D B, An Integrated Emergency Service. Casualty Surgeons Association, 1973. British Orthopaedic Association, Casualty Departments: The Accident Commitment. London, British Orthopaedic Association, 1973. Rutherford, W H, Ulster Medical_Journal, 1971, 41, 10. 7Rutherford, W H, et al, Accident and Emergency Medicine, ch 1. Tunbridge Wells, Pitman Medical Publishing Company, in press. Christian, M S, in Management of Minor Illness, p 65. London, King Edward's Hospital Fund for London, 1979. Hololan, A M, in The Sociology of the National Health Service, Sociological Review Monograph No 22, ed M Stacey, p 111. University of Keele, 1976. 0 Fourth Report from the Expenditure Committee. Session 1973-74: Accident and Emergency Services, vol I. London, HMSO, 1974. 1 Department of Health and Social Security, Accident and Emergency Services. Government Observations on the Fourth Report on the Employment and Social Services Subcommittee of the Expenditure Committee, Cmnd 5886. London, HMSO, 1975. 12 Patel, A R, British 1971, 1, 281.
Medical_Journal,
MATERIA NON MEDICA The pleasures of music It is one of the pleasures of retirement to be able to listen to music early in the day when one's faculties are more sensitive to the composer's message. These are the hours when a heavenly peace and quiet envelop the household: the workers have long since departed; the early roar of peak-hour traffic has subsided to pianissimo; the whirlwind visitations milkman, postman, and newspaper boy have faded from "the tablets of the mind"; then, "How gracious, how benign, is solitude"-for this is the hour in which, through the medium of hi-fi, one can enjoy the company of a host of geniuses. And not less remarkable is the discovery that music worthy of Haydn or Mozart has in fact been composed by men one had never heard of-splendid, tuneful pieces, as firmly structured as a massive oak or redolent of the grace and charm of the silver birch. It might be supposed that such self-indulgence in retirement could be enhanced by emigrating to the White Highlands of Kenya or to the Bahamas. But to live abroad is to deprive oneself of the music programmes of the BBC; such a fate, worse than death, is one that must immediately extinguish all thought of emigration. Anybody who has spent even a few months in the USA or Africa must have to be able to listen to the best of the BBC, and that, for the music lover means Radio 3. I return to the therapeutic value of music. Sometimes I wonder if those almost infallible men and women who control our music broadcasts ask themselves often enough: "Is this the kind of music people want at this time of the day ?" I am thinking particularly of the mid-day luncheon break. By this time many people have already done a good deal of hard work, attended by not a little stress, disappointment, and frustration. It is at such times that they should be able to depend on Radio 3 for an antidote-something that will meet Macbeth's requirement of the doctor: Cleanse the stuffed bosom of that perilous stuff which weighs upon the heart. In the world of theatre many West End farces are designed to meet the needs of the Tired Businessman. For those who aspire to somewhat higher levels of intellectual activity, one can visualise the production of a series of gramophone records (an album, perhaps) chosen unashamedly to promote detachment from the fret and fury of the working day. The Tired Businessman is almost certainly over the hump, that is to say, aged fifty-plus. At this age, few find pleasure or solace in the apparently bizarre patterns of modern music, however distinguished the composers may be. The aging mind craves for simple, friendly themes; it can no longer assimilate the amorphous and heterogeneous, and it rejects the explosive, the cacophanous, and the aggressive as non-events in the realm of music. That there is virtue in such compositions-hidden though it may be-is readily accepted; but to that pedestrian figure, the man in the street, such esoteric creations are altogether beyond his comprehension. Almost as unacceptable, but for different reasons, are the funeral marches (two broadcast in recent weeks) and dirges or dirge-like pieces. The remedy for unacceptable noises lies, of course, in his own hands: he switches off and takes refuge in what Dr Brodsky, at the Manchester
Royal College of Music, used to call "the eloquence of silence."STANLEY ALSTEAD (Dunblane, Perthshire).
Computers For many years I have been fascinated by computers, and intermittently I daydreamed of the time when I could own one. The day arrived a month or so ago. My 7-year-old son and I unpacked our new computer with great excitement. Having no knowledge of programming I expected that it would take some months to learn, and it was with great delight that we both found how simple and easy the BASIC computer language is, even for complete beginners. Within half an hour we had written programmes for the computer to play number-guessing games, and in the next hour it was setting us random arithmetical sums, marking them right or wrong, and recording the time for 10 correct answers. Two or three hours more and a programme was written and running to play Mastermind. Over the next weekend my son managed to write programmes on his own to play simple number games and conversational games of the type, "I am a doctor, what is the matter with you ?" Answer: Dizziness. Reply: Go and lie down. Answer: Broken leg. Reply: Put it in plaster. Answer: Coryza. Reply: I am sorry, I do not know about coryza. I hope your coryza is soon better. His delight at this achievement by itself made the expenditure worth while. Two or three hours next week had a more useful problem dealt with. There are three practices in our health centre. The emergency visiting figures of those practices were recorded on tape and presented as three side-by-side labelled histograms, with averages per patient available at the touch of a key. The next afternoon's thought considered how could I get the practice disease index on the computer. At the moment we run a modified disease index, recording 10 diseases of interest. A programme to classify patients, identified by code numbers of the form S for sex, YY for year of birth, and NN for serial number, under the 10 diseases, was written, and, on testing, this run perfectly. I then realised that a simple computerised "E book" recording every consultation by diagnosis was equally possible, for the computer can contain up to 7000 patient codes in its memory at any one time-about six months' records. Other spare moments over the past month have been spent thinking of, and programming, games. Although this may sound childish, the value for the budding programmer in appreciating the computer's ways and its language can hardly be overstated. The television is unwatched, the weeds grow apace in the garden, the computer is unadulterated pleasure.-DAVID MELDRUM (general practitioner, Ipswich).
837
6 OCTOBER 1979
MEDICAL
Accident and Emergency
PRACTICE
Services
What are accident and emergency departments for? BY A SPECIAL CORRESPONDENT
British Medical Journal, 1979, 2, 837-839
In the last decade or two people have come to expect more of their casualty departments. They know hospitals have splendid equipment, which must be a good thing; they have heard of complications ("I know it's only a blister but it might go septic") and indeed are often urged to seek early advice; and they may believe they have a right to walk in and use the hospital's services ("I pay my taxes"-an approach that causes unpleasantness in many departments). Cars also have made hospitals easily accessible to much of the population. GPs, too, have probably become more inclined to refer patients to the accident and emergency department as they have become more overworked, and perhaps more unsure of themselves in their awareness of medicolegal problems; while the difficulty of making urgent outpatient appointments has also led to their using the department as a convenient "back door" to the hospital. Accidents have, of course, increased over the years; and improvements in management, especially for the severely injured, have made more work for the accident department., Thus the new patients attending at accident and emergency departments in England rose from 114-6 per 1000 population in 1956 to 189-1 per 1000 in 1976.2 In this series of articles, based on visits to 16 accident and emergency departments and other centres, I will be looking at both problems and promising
developments. Who uses accident and emergency departments? The main functions of the accident and emergency department are making an accurate diagnosis or assessment, giving immediate treatment, and arranging for further care if necessaryall of which may require the utmost speed. Open access is essential, but how far is the freedom abused ? The Platt Report (which brought in the term "accident and emergency" rather than "casualty department" as part of the
upgrading process) suggested that 40-600o of the total seen in an urban department may be GP-type cases.3 In general the proportion of serious cases is about 20004; while the proportion of injuries is said to range from as little as 300h (in city centres) to about 800O.I Rutherford concluded that at the Royal Victoria Hospital, Belfast, some 900o of patients seen in the "walking" area were using the service correctly and 5% definitely misusing it, with 500 on the borderline.6 Among the departments I visited, one reported a very low proportion of inappropriate attendances, perhaps about 6%"Losing them would just give us a few more minutes to drink our coffee." This was at a district general hospital in an area of stable population, with a good GP service and nine GP hospitals with casualty departments in outlying areas. At a London teaching hospital the proportion was 10-1500'-they allowed for the fact that many of the patients were commuters or away from home. Another teaching hospital, in a residential area of London, in a 1976 survey found that 240o of patients had no injury or emergency; of these, 90' had no GP and 33% were not happy with his treatment. In the accident service of a city much frequented by tourists 3000 of cases were considered inappropriate but it rigorously redirected them to the cooperative local GPs. The highest figure for inappropriate cases quoted to me was 6000, at a small hospital accepting no ambulance cases, where the local GP service was not considered good. Most (but not all) of the inappropriate attendances are self-referrals, and the habit of cutting out the GP does seem to be increasing. In a large city department the proportion of self-referrals for "acute medical emergencies" had risenfrom 110% in 1966 to 4700 in 1978; the usual proportion of the patients sent home was about 400c . An analysis in Leeds showed higher proportions of self-referrals at the weekend than other days.2 These figures conceal a mixture of cases-those where selfcare would have sufficed (for which a figure of 4% has been suggested7) and conditions, including some of the injuries, that a GP could have treated or referred to the appropriate department. Rutherford, however, regarded all the injuries (820o of his "walking" cases), no matter how minor, as appro-
838 priate for the department., The patient cannot always judge what is serious, and prompt treatment saves later troubles. Reassurance is agreed to be a legitimate function. But not all accident and emergency consultants would agree that they should be dealing with very simple injuries, particularly when they see ones that have occurred a few days or even weeks previously, and hear some of the reasons why their departments are being used.8 "I was just visiting someone here"; "I'm too busy to go to my doctor"; and "I have a date at 4.30 and my GP isn't there till 5" are among those I came across. Nor would all GPs agree. Though many are happy to be relieved of such injuries, especially out of hours, a different view was put strongly by a single-handed London GP who does his own suturing and other minor procedures-and keeps his appointments system flexible. He preferred, he said, to look after his own patients whatever the time of day or night, and if the complaint was minor was concerned to know why the patient was so anxious. He had referred no more than seven cases, three of them injuries, to his local department in five months; and said that not many of his patients referred themselves. A survey in a large accident and emergency department also suggested that the GPs who referred most patients to the department also had the most self-referring patients. Some people, however, go to an accident and emergency department precisely because it is anonymous.9 Most departments, too, have their "regulars"-drunks, drug addicts, social misfits, and so on-for whom it must take some responsibility.7 The social aspect was prominent in the work of a department I visited in a deprived area where some of the patients lived in hostels or slept rough-and where the GPs tended to be unavailable after 5 o'clock. Another large department, near a main-line station, has to deal not only with the miscellaneous ills of travellers and of the peripatetic, disturbed people of a big city but with what they call the "railway station syndrome," in which people become suddenly unable to cope on finding the streets of London are not paved with gold or on facing the realities of a defection from home.
Educating patients and doctors Granted that such problems are inseparable from accident and emergency departments, how can the general run of inappropriate cases be reduced? Casualty officers and nurses may attempt to persuade "unsuitable" attenders that they should visit their GP. But treating the patient is often easier, especially for a junior doctor; and some departments go no further than displaying an ineffective notice explaining the functions of the department. People need to be told, or reminded,
that rashes, boils, migraine, and influenza are not for the accident and emergency department. The Parliamentary Expenditure Committee recommended more TV "fillers" on the role of accident and emergency departments and more efforts in the press and on television to publicise medical provision during absence from home,'0 recommendations that the Government did not support." But there seems a place for informal publicity (as distinct from didactic campaigns), especially in women's features and magazines, and discussion in schools-and also for posters in surgeries and clinics about when and when not to use the accident and emergency department and about arrangements for emergency cover. In one study 30% of the selfreferred patients who had come straight from their own homes with "acute medical emergencies" had done so believing that the GP (or deputy) was not available after surgery hours.'" GPs may also abuse the accident and emergency servicefor example, "This lady has bronchitis ... She cannot cope at home because she feels depressed. I feel she needs reassurance"; or "Please circumcise this child [a 2-year-old brought in at 4 am]. The parents have been kept awake all night." The staff of many departments take a firm line about their role in their letters to GPs. Return visits A consultant in a specialised accident service expressed pleasure that a man had returned 10 years after his accident to consult him about renewed trouble. I found different policies about return visits, but in general these were kept to a minimum. The larger hospitals tend to have separate clinics for many of the follow-ups, while for minor procedures such as dressings and removal of sutures the patient goes to his GP if practicable. Apart from conditions of interest to a particular consultant, the main exceptions were related to teaching, to which the better departments attach great importance-a junior doctor learns from seeing the results of his handiwork, notably suturing. But a consultant with a low rate of returns (7%) was scathing about this idea, adding that return visits in general tended to be a legacy of accident and emergency departments with "absentee landlords": a junior doctor says "Come back" if he is not sure. In his own department returns had fallen from 23 000 to 4000 in 12 years. Beds The many reports on accident and emergency services have recommended beds within the department (apart from accident beds for definitive care, usually in other departments). This ideal is often neglected even in the better departments. "We'd like our own beds"-or even "We have our own beds"-"but can't spare the nurses to look after them." "Even if we had them," someone said, "they would probably be used just for drunks to dry out." One or two overnight beds are common, or somewhat more short-term observation beds; but they are liable to be taken over as non-specific admission beds or for longer-term use rather than observation. But a department that manages to keep rigorously to the two-day limit for its 16 beds accommodates an impressive total of 3500 patients a year. Only the more specialised accident services have larger and longer-term wards. These are integral to the concept of the comprehensive accident service, in which the department is totally responsible for the patient, bringing other specialists in as required-an advantage for those with multiple injuries, but not feasible in most hospitals. *
The children's waiting area in the accident and emergency department at Wexham Park Hospital, Slough.
6 OCTOBER 1979
BRITISH MEDICAL JOURNAL
*
Accident and emergency departments cannot be all things to all men, as they might sometimes appear, nor is it in patients'
BRITISH MEDICAL JOURNAL
6 OCTOBER 1979
interests that they should try to be. Should the emphasis be on providing a resuscitation service, a specialised trauma service, a "filter" for the rest of the hospital, a haven for the dispossessed, or all of these things and more ? The answers will be affected by local circumstances and will-or should-in turn affect the organisation of services. But everyone must be clear what a particular department is trying to do. I am deeply grateful to all the people in accident and emergency departments and elsewhere who have been so generous with their help.
References I Scott, J C, British Medical_Journal, 1967, 2, 632. 2
A Year in the Life of a Major A and E Department. Accident and Emergency Department, Leeds General Infirmary, and Nuffield Centre for Health Services Studies, University of Leeds, 1977.
839 3Standing Advisory Medical Committee, Accident and Emergency Services. Report of the Subcommittee. London, HMSO, 1962. (Platt Report.) 4Caro, D B, An Integrated Emergency Service. Casualty Surgeons Association, 1973. British Orthopaedic Association, Casualty Departments: The Accident Commitment. London, British Orthopaedic Association, 1973. Rutherford, W H, Ulster Medical_Journal, 1971, 41, 10. 7Rutherford, W H, et al, Accident and Emergency Medicine, ch 1. Tunbridge Wells, Pitman Medical Publishing Company, in press. Christian, M S, in Management of Minor Illness, p 65. London, King Edward's Hospital Fund for London, 1979. Hololan, A M, in The Sociology of the National Health Service, Sociological Review Monograph No 22, ed M Stacey, p 111. University of Keele, 1976. 0 Fourth Report from the Expenditure Committee. Session 1973-74: Accident and Emergency Services, vol I. London, HMSO, 1974. 1 Department of Health and Social Security, Accident and Emergency Services. Government Observations on the Fourth Report on the Employment and Social Services Subcommittee of the Expenditure Committee, Cmnd 5886. London, HMSO, 1975. 12 Patel, A R, British 1971, 1, 281.
Medical_Journal,
MATERIA NON MEDICA The pleasures of music It is one of the pleasures of retirement to be able to listen to music early in the day when one's faculties are more sensitive to the composer's message. These are the hours when a heavenly peace and quiet envelop the household: the workers have long since departed; the early roar of peak-hour traffic has subsided to pianissimo; the whirlwind visitations milkman, postman, and newspaper boy have faded from "the tablets of the mind"; then, "How gracious, how benign, is solitude"-for this is the hour in which, through the medium of hi-fi, one can enjoy the company of a host of geniuses. And not less remarkable is the discovery that music worthy of Haydn or Mozart has in fact been composed by men one had never heard of-splendid, tuneful pieces, as firmly structured as a massive oak or redolent of the grace and charm of the silver birch. It might be supposed that such self-indulgence in retirement could be enhanced by emigrating to the White Highlands of Kenya or to the Bahamas. But to live abroad is to deprive oneself of the music programmes of the BBC; such a fate, worse than death, is one that must immediately extinguish all thought of emigration. Anybody who has spent even a few months in the USA or Africa must have to be able to listen to the best of the BBC, and that, for the music lover means Radio 3. I return to the therapeutic value of music. Sometimes I wonder if those almost infallible men and women who control our music broadcasts ask themselves often enough: "Is this the kind of music people want at this time of the day ?" I am thinking particularly of the mid-day luncheon break. By this time many people have already done a good deal of hard work, attended by not a little stress, disappointment, and frustration. It is at such times that they should be able to depend on Radio 3 for an antidote-something that will meet Macbeth's requirement of the doctor: Cleanse the stuffed bosom of that perilous stuff which weighs upon the heart. In the world of theatre many West End farces are designed to meet the needs of the Tired Businessman. For those who aspire to somewhat higher levels of intellectual activity, one can visualise the production of a series of gramophone records (an album, perhaps) chosen unashamedly to promote detachment from the fret and fury of the working day. The Tired Businessman is almost certainly over the hump, that is to say, aged fifty-plus. At this age, few find pleasure or solace in the apparently bizarre patterns of modern music, however distinguished the composers may be. The aging mind craves for simple, friendly themes; it can no longer assimilate the amorphous and heterogeneous, and it rejects the explosive, the cacophanous, and the aggressive as non-events in the realm of music. That there is virtue in such compositions-hidden though it may be-is readily accepted; but to that pedestrian figure, the man in the street, such esoteric creations are altogether beyond his comprehension. Almost as unacceptable, but for different reasons, are the funeral marches (two broadcast in recent weeks) and dirges or dirge-like pieces. The remedy for unacceptable noises lies, of course, in his own hands: he switches off and takes refuge in what Dr Brodsky, at the Manchester
Royal College of Music, used to call "the eloquence of silence."STANLEY ALSTEAD (Dunblane, Perthshire).
Computers For many years I have been fascinated by computers, and intermittently I daydreamed of the time when I could own one. The day arrived a month or so ago. My 7-year-old son and I unpacked our new computer with great excitement. Having no knowledge of programming I expected that it would take some months to learn, and it was with great delight that we both found how simple and easy the BASIC computer language is, even for complete beginners. Within half an hour we had written programmes for the computer to play number-guessing games, and in the next hour it was setting us random arithmetical sums, marking them right or wrong, and recording the time for 10 correct answers. Two or three hours more and a programme was written and running to play Mastermind. Over the next weekend my son managed to write programmes on his own to play simple number games and conversational games of the type, "I am a doctor, what is the matter with you ?" Answer: Dizziness. Reply: Go and lie down. Answer: Broken leg. Reply: Put it in plaster. Answer: Coryza. Reply: I am sorry, I do not know about coryza. I hope your coryza is soon better. His delight at this achievement by itself made the expenditure worth while. Two or three hours next week had a more useful problem dealt with. There are three practices in our health centre. The emergency visiting figures of those practices were recorded on tape and presented as three side-by-side labelled histograms, with averages per patient available at the touch of a key. The next afternoon's thought considered how could I get the practice disease index on the computer. At the moment we run a modified disease index, recording 10 diseases of interest. A programme to classify patients, identified by code numbers of the form S for sex, YY for year of birth, and NN for serial number, under the 10 diseases, was written, and, on testing, this run perfectly. I then realised that a simple computerised "E book" recording every consultation by diagnosis was equally possible, for the computer can contain up to 7000 patient codes in its memory at any one time-about six months' records. Other spare moments over the past month have been spent thinking of, and programming, games. Although this may sound childish, the value for the budding programmer in appreciating the computer's ways and its language can hardly be overstated. The television is unwatched, the weeds grow apace in the garden, the computer is unadulterated pleasure.-DAVID MELDRUM (general practitioner, Ipswich).
