- Email: [email protected]
An Ocean Between Us
481
a
standard temperature, and immersed in hot
water to
depth for an exact period of time. The subjects were not told what they might feel, nor what they should look for. Of 40 subjects, 32 felt both first and second pain, and the other 8 either believed that the hot water was not enough to give rise to pain, or throughout felt the burning sensation typical of second pain. One way to discover what size of nerve-fibre is carrying a stimulus is to compress the nerve trunk, which depresses the function of large fibres before that of smaller ones (ischsemia depresses small fibres first). When compression was applied in the experiments we have described it was found that the time to appreciation of second pain (about 2-1seconds) was constant over 36 minutes of compression, but that after 18-20 minutes the time to appreciation of first pain was increasingly prolonged-from 0-84 seconds to 1-58 seconds. These results support the view that the two pains are genuine peripheral events, and that the second pain is carried in finer and more slowly conducting fibres than the first pain. This explanation accords with that of LEWIS and POCHIN.78 Against a much earlier suggestion, that the first pain was due to stimulation of the nerve-fibre and the second to a chemical,9is the fact that the quality of the second sensation did not alter during compression, although circulatory stasis would concentrate any an exact
chemical irritant. A few years ago an attempt was made to avoid the difficulties of subjective assessment by recording electroencephalographically the changes in (x-rhythm caused by arrival of the pain stimulus.1o The method is not wholly satisfactory, but it showed a clear difference in the times of disturbance of the a-rhythm due to first pain, and to second pain after a period of compression which altogether eliminated first pain. It may be concluded that there are two sets of fine nerve-fibres, one finer than the other, which subserve pain. Why there should be two sets is not clear, but other senses also have a double supply: pricking, various touch sensations, temperature, and itch.ll If we can be reasonably sure about the nervous pathways, we are still far from understanding how the sensory nerves convert the external stimulus into an impulse which can travel along the nerves to the central nervous system.
An Ocean Between Us THE enactment of Medicare legislation 12 will not still the voices in the United States that demand a more drastic reorganisation of the nation’s medical services. The new law merely finances medical care for some of the people for some of the time; it does nothing to improve the quality of care or to lower its cost. Dr. GEORGE BAEHR, chairman of the public health council of the State of New York and a distinguished clinician and research-worker, believes that it is possible Lewis, T., Pochin, E. E. Clin. Sci. 1937, 3, 67. Lewis, T., Pochin, E. E. ibid. 1938, 3, 141. Thunberg, T. Skand. Arch. Physiol. 1902, 12, 394. Gordon, G., Whitteridge, D. Lancet, 1943, ii, 700. Bishop, G. H. in Cutaneous Innervation (edited by W. Montagna); p. 88. Oxford, 1960. 12. Lancet, Aug. 14, 1965, p. 335. 7. 8. 9. 10. 11.
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"
do both without adopting a socialised scheme. In his Michael M. Davis lecture 13 he recalled that independent American studies between 1928 and 1947 recommended that medical care should be financed on a prepayment basis (through insurance, taxes, or both), and provided by organised groups of doctors, dentists, and other health workers, each group based, preferably, on a hospital and providing complete home, office, and hospital care. The hope was that the health professions and Governments would agree and provide the necessary organisations; but, BAEHR says, this vision of the future has thus far proved to be a mirage ". Of the 190,000,000 United States residents, only 4,000,000 are enrolled in comprehensive prepaid schemes for medical care-half of them in the Kaiser Permanent Plan on the West Coast or the Health Insurance Plan (H.I.P.) of Greater New York, which BAEHR helped to found. On the other hand, 145,000,000 people now have voluntary health insurance: but this does not pay for more than 30% of a family’s medical costs. The nation’s expenditure on personal medical care rose from 4-3% of all expenditure on personal consumption in 1948 to 6-3% in 1963. Two main causes of the high cost of medical care are the increasing cost of hospital services and the increasing use of these services by inpatients. BAEHR believes that prepaid schemes such as H.I.P. can reduce both of these. to
"
have been rising at the rate of 7-10% a year, and no end is in sight. The rise is partly due to salary increases for hospital employees and to advances in medicine that demand more expensive services: but much money could be saved, BAEHR believes, by organisation of the health services, including regional alignment of hospitals. This could prevent duplication of expensive equipment in small hospitals close to each other, and could permit the economical use of automatic and electronic laboratory equipment, which, although expensive to install, can do hundreds of estimations cheaply, accurately, and very quickly. Money could also be saved if hospitals functioned fully seven days a week: at present a private patient admitted on a Friday is likely to spend two days more in hospital than a patient admitted on a Tuesday; for the laboratories, X-ray departments, and operatingtheatres serve only emergencies at weekends. Surely it would be possible for large hospitals or hospital
Hospital
costs
organise
seven-day working-week. These measures would enable hospital beds to be used more economically. What could be done to reduce the number of beds needed ? Despite such efforts as the formation by hospital staffs of hospital utilisation committees ", overuse of costly inpatient services congroups
to
a
"
tinues to increase: every year the admission-rate per 1000 persons rises. Here BAEHR might have mentioned the influence of the typical Blue Cross plan, which is based on a fee-for-service system and which pays more liberally for inpatient than for outpatient 13. Medical Care: Old Goals and New Horizons. By GEORGE BAEHR, M.D. The 1965 Michael M. Davis Lecture, published by the Center for Health Administration Studies, Graduate School of Business, University of Chicago, Chicago 37, I11. No charge.
482
care; he does remark that the cost of comprehensive medical care cannot be covered by insurance so long as singlehanded practice on a fee-for-service basis prevails. Prepayment schemes can and do reduce the demand for hospital beds. BAEHR sets out figures which show impressively that, on the average, members of H.I.P. and similar plans are admitted to hospital less often, and spend much less time in hospital, than people in the same area who have fee-for-service schemes; and their chance of having an operation is about half that of the others. It could of course be argued that these figures indicate that poorer care is given in the prepayment plans:but such indices as the perinatal mortality-rate indicate that H.I.P. patients in fact get better care than those whose doctors receive a fee for each service. Moreover, organised schemes such as H.I.P. are better able to provide screening services to detect, for example, glaucoma and carcinoma of the cervix, and opportunities for research into the natural history of disease. Another advantage of group practice is that family physicians, through close association with the specialists in the group, have more opportunity for continuing education, and, through their role in the group as specialists in family-counselling rather than as " general practitioners ", can enhance their professional status. Group practice, BAEHR holds, will help to attract fine doctors into family practicewhere at present the shortage is so great that the emergency services of American hospitals are flooded with patients who can find no satisfactory family
practitioner. What has prevented the formation of more schemes like H.I.P. ? Though the American Medical Association no longer opposes group practice, many State and county medical societies do, and many States even have laws prohibiting prepaid group practice. Although the Federal Government can grant money to help such schemes, voluntary hospitals and private referral clinics have been slow to expand their activities into the community-perhaps for fear of antagonising the private doctors who refer patients to them. Few teaching hospitals have schemes for comprehensive family care, but they may well be obliged to start them as more and more people have health insurance and the source of indigent " clinical material " begins to dry up; moreover, public opinion may stimulate Federal action if medical costs continue to rise. BAEHR’S suggestions will no doubt receive the careful consideration they merit in the United States. They could also be profitably studied in Britain. For example, although the National Health Service has done much to ensure rational use of hospitals, expensive equipment could often be used more efficiently and beds more intensively and intelligently. Traditionally we all like to have a day or two off at the weekend rather than in midweek, and to introduce a seven-day hospital operation programme would mean the reorganisation of people’s ideas as well as their timetables. Nonetheless, in order to save money-and probably lives-the effort is worth serious thought.
Perhaps even more important is BAEHR’s picture of the general practitioner. Working alone and isolated from hospital-based specialists, he may easily become, according to his energy and ambition, either an unmasterly Jack-of-all-trades or a sorting-station for the outpatient clinic. As a member of a hospital-based group he could become a family counsellor (or, in Fox’s phrase 14 a personal doctor ", though Fox did not see him as a member of a group), cooperating daily with other specialists on a basis of merited equality. "
Annotations THE MIXTURE TOO NEARLY THE SAME
THE reactions to the Government’s whitepaper on The Child, The Family and The Young Offender, 15 have been diverse. The Howard League welcomes its proposals for courts for young offenders (aged 16-21 years); the Sunday Times 16 "feels that these will " blur the distinctions of responsiblity in the offender’s mind; Lady Wootton 1’ thinks the proposed move from the court’s sphere of influence too limited; the National Association of Probation Officers fears the shift from judicial responsibility in matters affecting the liberty of the individual. Some of these opinions reflect the classical dilemma of punishment versus treatment as the ideal basis for social control; others reflect inconsistencies in the scheme itself. So far," however, all focus on the proposed changes and few have commented on the equally significant areas of nonchange. Firstly, the age (and concept) of criminal responsibility is not mentioned, and presumably is to remain at the age of 10. Secondly, the revised system of family councils and family courts retains all the powers (except that of the fine) of the present juvenile court. Thirdly, the proposed system relies basically on the same type and number of institutions and social workers, though some are to be reshuffled and relabelled. The whitepaper is vague about criminal responsibility. It is nowhere specifically discussed, but some phrasesWhere it is thought, by any person who can now e.g., a bring child or young person before a juvenile court, that a child or young person under the age of 16 had committed what in an older person would be an offence he would report the circumstances to the family council " -seem to imply uncertainty. Those who expected the whitepaper to combine the recommendations of the Longford and Kilbrandon reports (and even these left the notion of responsibility an a priori and arbitrary concept) had hoped that the age of criminal responsibility would be raised to at least 13 years, and ideally to 16 years. The proposed two-tier system of family councils and courts retains all the sanctions of the juvenile court, while pushing its safeguards (to the offender) into the background. For instance, the whitepaper states confidently that " In most cases, there would be no disagreement as to the facts alleged. Where, however, the facts were disputed by the child or his parents, the case would be referred to the family court in order that the facts might be judicially determined ". The councils would be composed of " social workers of the children’s service and other persons selected for their understanding "
...
14. Fox, T. F. Lancet, 1960, i, 743. 15. Cmd. 2742. H.M. Stationery Office. 16. Sunday Times, Aug. 29, 1965. 17. Observer, Aug. 29, 1965.
1s. 6d.
a
standard temperature, and immersed in hot
water to
depth for an exact period of time. The subjects were not told what they might feel, nor what they should look for. Of 40 subjects, 32 felt both first and second pain, and the other 8 either believed that the hot water was not enough to give rise to pain, or throughout felt the burning sensation typical of second pain. One way to discover what size of nerve-fibre is carrying a stimulus is to compress the nerve trunk, which depresses the function of large fibres before that of smaller ones (ischsemia depresses small fibres first). When compression was applied in the experiments we have described it was found that the time to appreciation of second pain (about 2-1seconds) was constant over 36 minutes of compression, but that after 18-20 minutes the time to appreciation of first pain was increasingly prolonged-from 0-84 seconds to 1-58 seconds. These results support the view that the two pains are genuine peripheral events, and that the second pain is carried in finer and more slowly conducting fibres than the first pain. This explanation accords with that of LEWIS and POCHIN.78 Against a much earlier suggestion, that the first pain was due to stimulation of the nerve-fibre and the second to a chemical,9is the fact that the quality of the second sensation did not alter during compression, although circulatory stasis would concentrate any an exact
chemical irritant. A few years ago an attempt was made to avoid the difficulties of subjective assessment by recording electroencephalographically the changes in (x-rhythm caused by arrival of the pain stimulus.1o The method is not wholly satisfactory, but it showed a clear difference in the times of disturbance of the a-rhythm due to first pain, and to second pain after a period of compression which altogether eliminated first pain. It may be concluded that there are two sets of fine nerve-fibres, one finer than the other, which subserve pain. Why there should be two sets is not clear, but other senses also have a double supply: pricking, various touch sensations, temperature, and itch.ll If we can be reasonably sure about the nervous pathways, we are still far from understanding how the sensory nerves convert the external stimulus into an impulse which can travel along the nerves to the central nervous system.
An Ocean Between Us THE enactment of Medicare legislation 12 will not still the voices in the United States that demand a more drastic reorganisation of the nation’s medical services. The new law merely finances medical care for some of the people for some of the time; it does nothing to improve the quality of care or to lower its cost. Dr. GEORGE BAEHR, chairman of the public health council of the State of New York and a distinguished clinician and research-worker, believes that it is possible Lewis, T., Pochin, E. E. Clin. Sci. 1937, 3, 67. Lewis, T., Pochin, E. E. ibid. 1938, 3, 141. Thunberg, T. Skand. Arch. Physiol. 1902, 12, 394. Gordon, G., Whitteridge, D. Lancet, 1943, ii, 700. Bishop, G. H. in Cutaneous Innervation (edited by W. Montagna); p. 88. Oxford, 1960. 12. Lancet, Aug. 14, 1965, p. 335. 7. 8. 9. 10. 11.
"
"
do both without adopting a socialised scheme. In his Michael M. Davis lecture 13 he recalled that independent American studies between 1928 and 1947 recommended that medical care should be financed on a prepayment basis (through insurance, taxes, or both), and provided by organised groups of doctors, dentists, and other health workers, each group based, preferably, on a hospital and providing complete home, office, and hospital care. The hope was that the health professions and Governments would agree and provide the necessary organisations; but, BAEHR says, this vision of the future has thus far proved to be a mirage ". Of the 190,000,000 United States residents, only 4,000,000 are enrolled in comprehensive prepaid schemes for medical care-half of them in the Kaiser Permanent Plan on the West Coast or the Health Insurance Plan (H.I.P.) of Greater New York, which BAEHR helped to found. On the other hand, 145,000,000 people now have voluntary health insurance: but this does not pay for more than 30% of a family’s medical costs. The nation’s expenditure on personal medical care rose from 4-3% of all expenditure on personal consumption in 1948 to 6-3% in 1963. Two main causes of the high cost of medical care are the increasing cost of hospital services and the increasing use of these services by inpatients. BAEHR believes that prepaid schemes such as H.I.P. can reduce both of these. to
"
have been rising at the rate of 7-10% a year, and no end is in sight. The rise is partly due to salary increases for hospital employees and to advances in medicine that demand more expensive services: but much money could be saved, BAEHR believes, by organisation of the health services, including regional alignment of hospitals. This could prevent duplication of expensive equipment in small hospitals close to each other, and could permit the economical use of automatic and electronic laboratory equipment, which, although expensive to install, can do hundreds of estimations cheaply, accurately, and very quickly. Money could also be saved if hospitals functioned fully seven days a week: at present a private patient admitted on a Friday is likely to spend two days more in hospital than a patient admitted on a Tuesday; for the laboratories, X-ray departments, and operatingtheatres serve only emergencies at weekends. Surely it would be possible for large hospitals or hospital
Hospital
costs
organise
seven-day working-week. These measures would enable hospital beds to be used more economically. What could be done to reduce the number of beds needed ? Despite such efforts as the formation by hospital staffs of hospital utilisation committees ", overuse of costly inpatient services congroups
to
a
"
tinues to increase: every year the admission-rate per 1000 persons rises. Here BAEHR might have mentioned the influence of the typical Blue Cross plan, which is based on a fee-for-service system and which pays more liberally for inpatient than for outpatient 13. Medical Care: Old Goals and New Horizons. By GEORGE BAEHR, M.D. The 1965 Michael M. Davis Lecture, published by the Center for Health Administration Studies, Graduate School of Business, University of Chicago, Chicago 37, I11. No charge.
482
care; he does remark that the cost of comprehensive medical care cannot be covered by insurance so long as singlehanded practice on a fee-for-service basis prevails. Prepayment schemes can and do reduce the demand for hospital beds. BAEHR sets out figures which show impressively that, on the average, members of H.I.P. and similar plans are admitted to hospital less often, and spend much less time in hospital, than people in the same area who have fee-for-service schemes; and their chance of having an operation is about half that of the others. It could of course be argued that these figures indicate that poorer care is given in the prepayment plans:but such indices as the perinatal mortality-rate indicate that H.I.P. patients in fact get better care than those whose doctors receive a fee for each service. Moreover, organised schemes such as H.I.P. are better able to provide screening services to detect, for example, glaucoma and carcinoma of the cervix, and opportunities for research into the natural history of disease. Another advantage of group practice is that family physicians, through close association with the specialists in the group, have more opportunity for continuing education, and, through their role in the group as specialists in family-counselling rather than as " general practitioners ", can enhance their professional status. Group practice, BAEHR holds, will help to attract fine doctors into family practicewhere at present the shortage is so great that the emergency services of American hospitals are flooded with patients who can find no satisfactory family
practitioner. What has prevented the formation of more schemes like H.I.P. ? Though the American Medical Association no longer opposes group practice, many State and county medical societies do, and many States even have laws prohibiting prepaid group practice. Although the Federal Government can grant money to help such schemes, voluntary hospitals and private referral clinics have been slow to expand their activities into the community-perhaps for fear of antagonising the private doctors who refer patients to them. Few teaching hospitals have schemes for comprehensive family care, but they may well be obliged to start them as more and more people have health insurance and the source of indigent " clinical material " begins to dry up; moreover, public opinion may stimulate Federal action if medical costs continue to rise. BAEHR’S suggestions will no doubt receive the careful consideration they merit in the United States. They could also be profitably studied in Britain. For example, although the National Health Service has done much to ensure rational use of hospitals, expensive equipment could often be used more efficiently and beds more intensively and intelligently. Traditionally we all like to have a day or two off at the weekend rather than in midweek, and to introduce a seven-day hospital operation programme would mean the reorganisation of people’s ideas as well as their timetables. Nonetheless, in order to save money-and probably lives-the effort is worth serious thought.
Perhaps even more important is BAEHR’s picture of the general practitioner. Working alone and isolated from hospital-based specialists, he may easily become, according to his energy and ambition, either an unmasterly Jack-of-all-trades or a sorting-station for the outpatient clinic. As a member of a hospital-based group he could become a family counsellor (or, in Fox’s phrase 14 a personal doctor ", though Fox did not see him as a member of a group), cooperating daily with other specialists on a basis of merited equality. "
Annotations THE MIXTURE TOO NEARLY THE SAME
THE reactions to the Government’s whitepaper on The Child, The Family and The Young Offender, 15 have been diverse. The Howard League welcomes its proposals for courts for young offenders (aged 16-21 years); the Sunday Times 16 "feels that these will " blur the distinctions of responsiblity in the offender’s mind; Lady Wootton 1’ thinks the proposed move from the court’s sphere of influence too limited; the National Association of Probation Officers fears the shift from judicial responsibility in matters affecting the liberty of the individual. Some of these opinions reflect the classical dilemma of punishment versus treatment as the ideal basis for social control; others reflect inconsistencies in the scheme itself. So far," however, all focus on the proposed changes and few have commented on the equally significant areas of nonchange. Firstly, the age (and concept) of criminal responsibility is not mentioned, and presumably is to remain at the age of 10. Secondly, the revised system of family councils and family courts retains all the powers (except that of the fine) of the present juvenile court. Thirdly, the proposed system relies basically on the same type and number of institutions and social workers, though some are to be reshuffled and relabelled. The whitepaper is vague about criminal responsibility. It is nowhere specifically discussed, but some phrasesWhere it is thought, by any person who can now e.g., a bring child or young person before a juvenile court, that a child or young person under the age of 16 had committed what in an older person would be an offence he would report the circumstances to the family council " -seem to imply uncertainty. Those who expected the whitepaper to combine the recommendations of the Longford and Kilbrandon reports (and even these left the notion of responsibility an a priori and arbitrary concept) had hoped that the age of criminal responsibility would be raised to at least 13 years, and ideally to 16 years. The proposed two-tier system of family councils and courts retains all the sanctions of the juvenile court, while pushing its safeguards (to the offender) into the background. For instance, the whitepaper states confidently that " In most cases, there would be no disagreement as to the facts alleged. Where, however, the facts were disputed by the child or his parents, the case would be referred to the family court in order that the facts might be judicially determined ". The councils would be composed of " social workers of the children’s service and other persons selected for their understanding "
...
14. Fox, T. F. Lancet, 1960, i, 743. 15. Cmd. 2742. H.M. Stationery Office. 16. Sunday Times, Aug. 29, 1965. 17. Observer, Aug. 29, 1965.
1s. 6d.