- Email: [email protected]
APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
1208 should recount and analyse some typical Touch stories" The baby threw my purse in the fire." ",My note" I haven’t case slipped out of my hand down a drain." Here the had a bit of food since Thursday." &c. student would embark on practical work with a series of Chronic Touchers specially engaged to exercise his growing knowledge. In the event of failure no money would be returned. Next we should study the Touch Compulsory, where the student manoeuvres a patient into touching him when he had no intention of so doing. The first axiom of Touching will explain why-simply that once the Touch is concluded the Toucher is never seen again. We all have patients we would gladly never see again, so the chance of perpetual immunity for a modest outlay should not be missed. I have been approached by some students, obviously possessing great natural gifts, with the suggestion that a special prize might be awarded to candidates who extend the Touch Compulsory to the point of effecting a Touch on a would-be Toucher. I have set my face against such proposals. Attack must remain in essence a defence. Attaquer pour mieux recicler, et surtout pas de zèle. Modesty forbids me (unless urged) to give details of my own successes. And I have had my failures. One cannot be perfectly protected at all points. New techniques of Touching are constantly being evolved, for science never stands still. Even a sudden reversion to primitive methods may score an unwelcome success. Just as princes of the turf have fallen victims to a threecard trickster or a common thimble-rigger, so the *advanced student who enjoys a good laugh over a story of ruin on the Stock Exchange may succumb feebly to a pedlar of gold bricks, or a hawker of Spanish treasure. Humility here, as in all branches of knowledge, must be our guiding star. *
*
*
Students of In England lVo2v who have followed our quest for a bat for experimental purposes may well suppose that we ended with a surfeit of bats. In our communique of June 7 the matter was in the hands of our experienced and capable Animal Man, and we had no fear for the future-we had but to visit the Church of the Stuffed Owls and scoop up handfuls of bats. We set off with light hearts, armed with a rat cage, a sack, a powerful torch, and some leather gloves as a protection against bat-scratch fever. The church was small and whitewashed, and the roof timbers irregular enough to hold a profusion of bats ; perched insecurely on the walls were the stuffed owls, putting as nonchalant a face on it as possible. We searched the lower levels systematically, hunting for guano between the pews and the walls, shining our torch inquisitively under the base of the pulpit, and carefully examining the bottom of an empty brandy bottle. We found traces of many pigeons, but no bat spoor ; so we retired to the farm to borrow a ladder to inspect the higher reaches of the chance]. Here we struck a snag : the ladder was at present preventing the egress of a number of large and active pigs, and it appeared that the difficulties of our bat-hunt were as nothing to those of the pig-hunt that would result if the animals ceased, even temporarily, to be confined. We learnt that Incense is Best for Bats, but also that we had underestimated the bat-repellent activity of the stuffed owls. It was doubtful if even a single bat remained. Crestfallen, we withdrew to collect our impedimenta, touching our hats respectfully to the owls as we left. We are still on the trail. Specimens are being reported to us from distances up to 15 miles, and only yesterday we heard of a house in Eire where 300 bats were caught last year. Our travel grant might just run to that. *
*
*
News from School.—"This is what I did on Long Leave Day : Train to Paddington (7s. 6d.), bus to Charing (5d.), water bus to Tower Br. (9d.). Walked about and watched the Bridge open. We were just beside the guns when the 62 (? ) shots were fired for the Queen’s birthday. Went back to Charing (9d.), tube to Regents Park (8d.), Zoo (2s. 6d.), Aquarium (Is.) (?), tea, &c. (3s.) (?), tube (8d.). And so it came to quite a lot of money."
Letters to the Editor APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
SIR,—After reading the article by Brigadier Welch and Bailey (May 31) I must confess to feeling some
Mr.
disappointment.
commendable that they should seek ways of reducing the waiting period in outpatient clinics, but one It is
cannot help feeling that they have taken too mathe. matical a view. Although they suggest that " it is not reasonable to carry this comparison too far," it is a somewhat sad commentary on the times that they do compare at all a ladies’ hairdressing establishment with a consultative clinic. At the hairdresser’s, they state, the discipline of staff and customers is strict"; and, while I have no wish to ascribe to them a meaning which they did not intend, some administrators may clearly be tempted to conclude that a tightening of discipline in hospitals will produce efbcient results. In my experience it is extremely difficult to give any accurate idea of the time required for consultation, if each patient is to be given the benefit of a considered opinion. I have no doubt that many consultants could work more strictly to a time-table, but I am equally sure that, where they do, the quality of their work may suffer : Brigadier Welch’s figures improve, but the standard of service-that elusive quality which is not measurable statistically—will go down. An important aspect of the appointment system, not mentioned by your contributors, is that it may lead to undue delay in getting the patient to the consultant, and this is especially true when a limited number of new appointments is set for each clinic. Some hospitals and consultants are more responsive to the needs of the local practitioners, and they try to avoid any strict limit on the number of new patients seen. In these circumstances there are sometimes unavoidable delays at the clinic, but the patient has the immeasurable advantage of attending hospital after little or no delay. I would submit that most patients would prefer, where possible, to be seen at the next consultative clinic even at the cost of an hour’s waiting. Far be it from me to decry the invaluable discipline of statistics ; but pray let us protect Medicine from wellintended statistical surveys which may encourage tidyminded administrators to forget that the quality of service and the preservation of the doctor-patient "
"
relationship
are our
prime
"
’
concern.
MuELET. Radlett, Hertfordshire.. R. S. MURLEY.
SIR,—In the article by Brigadier Welch and Mr. Bailey the punctuality of patients is analysed and favourably commented upon, but no very adequate analysis is made of the number of patients who book appointments and then default. I have worked in clinics where at times defaulters represented 25% of the whole. This suits me, as I am a lazy type and enjoy teaching students during waiting periods ; but it demonstrates the indifference of a section of the community towards a hospital service that tries to help patients by an appointment system. An analysis (not statistical) of reasons for patients not turning up gave the following answers : (1) forgot, (2) got better, (3) missed the bus, (4) went to the wrong hospital, (5) went to the cinema, (6) mind your own business. The suggestion that the booking clerk should have been informed by telephone that the appoint. ment could be cancelled was regarded by 100% of those questioned as undemocratic and a waste of money. London,
W.I.
J. C. HAWKSLEY. J.
1209
SIR,—Having scarcely recovered from the nagellations by Professor Titmuss,1 we have now to face the results of investigation. yet another apparently lay cause of outpatients waiting At last, it appears, the is given. As a statisThe solution discovered. been has tical review it is, no doubt, unexceptionable. Applied to so. human an under-taking as an outpatient clinic- it seems to assume
the form of
an
exercise in intellectual
speculation. -
Let us look a little closer. First let us pay tribute to the investigation that led to the remarkable discovery that we are unpunctual. We are instructed how to work out, by a process of arithmetic not beyond the powers of the average consultant, the consultation-time per patient. By so doing we can avoid patients having to wait..One is captivated by the very ingenuousness of the theory. How about the practical application*? 1. To examine one individual may take 5 minutes. To do the same for another may well take twice that time, although the complaint is the same. Each requires a different approach. A child may require time and patience, and these must be given, in spite of the statistician’s time-table. 2. Has it occurred to the authors that (especially in the specialties dealing with emergency work) one’s time-table can be somewhat dislocated by urgent work ? After a long morning clinic a visit to the ward to deal with some particular problem may spell lateness for the afternoon. 3. Finally may I refer to what is probably’the most preposterous suggestion of all-why must a long consultation, involving perhaps a colleague, be kept until the end ? Would it not be better (and here I mean for the patients and not for our stop-watch-armed mentors) for the business to be dealt with on the spot ? It might astonish our experts to learn that the homely reason for this is a human one : our colleague may have gone home. Spare us, Sir, these profitless speculations. This itch
to express in terms of figures activities of hospital life is distressing. Is it, I wonder, another manifestation of that malady to which Grant Waugh recently drew
attention-namely,
"
pseudo-scientific meticulosis" ? T. DENNESS.
Ipswich.
SIR,—I read with interest the article by Brigadier Welch and Mr. Bailey. Antenatal clinics at hospitals are probably among the most time-consuming from the patient’s point of view. Three and a half years ago I attended the antenatal clinic at a well-known maternity hospital. There was no appointment system in operation, and every told to be there at 9 A.M. By 9.30 the waitingfull to overcrowding. Consultations never appeared to begin before 9.45 A.M., and one could account oneself lucky On a first visit, which meant a to get away by 11.30 A.M. history, examination, and visit to the almoner, it was more likely to be 1 r.M. Patients were divided roughly into two groups-those who had to undress and those who had not, the latter requiring only weighing, blood-pressure reading, and urine analysis. There was always a good deal of confusion over this division, and patients were always finding themselves in the wrong queues. One of the saving graces of this clinic was a small canteen supplying tea and buns for a few pencemost welcome to patients like myself whose nausea was
patient
was
room was
aggravated by hunger.
Currently I am attending hospital.
the
antenatal clinic
at
another
Here there is
an
kind in operation.
appointment system of a very curious telephoned to make an appointment
I
and was told 10 A.M. This clinic has an outer room with clerk in attendance, and incoming patients sign their names in a book. As their turn came their names were called and ticked off in the book. About 11.30 A.M. I noticed that a number of women who had come in after me had been called. I went and looked at the book and saw that patients who had signed after me had been ticked off. I queried this with the clerk, who said : "It usually takes a bit longer if you have an appointment." I am still wondering why this should be the case. a
1. See Lancet,
May 17 1952, p. 1014.
weeks pregnant I have reached the about an hour in the waiting-room names are called in batches of four or so. We undress in cubicles, and, donning the dressing-gowns provided, sit on little stools until called for examination. On the last occasion I noticed that women who came- in my batch had been seen and had dressed and gone while I and one other still waited. After thirty-five minutes of sitting in a communal-dressinggown I asked the sister if -1 were being forgotten. She explained very kindly that some patients were seen by the consultant, some by the registrar, and some by the midwives. There was only one midwife available that morning, -whom I was supposed to see ; and she also had to look after the weighing of other patients and pass them on to the appropriate
Being now thirty-two undressing stage. After
doctor.
All patients attending these clinics are housewives whose mornings are normally fully occupied with housework and shopping. Many have to bring small children with them to the clinics, where they become bored, restless, and irritable. There are no facilities for amusing them or having them looked after while the mother is examined. In the earlier stages of this pregnancy I attended the local-authority antenatal clinic, which compares very favourably with the hospitals’. In the first place it is held in the afternoon, which is much convenient for most mothers. The appointment system worked fairly well, and delay occurred only when there was a sudden influx of new patients. When this happened the very efficient and courteous reception clerk was most apologetic. Chairs stood round the walls in place of the usual benches, which left a space in the middle of the room where toddlers accompanying their mothers could play. A few toys had strayed in-perhaps from the neighbouring child-guidance clinic. The atmosphere was much more friendly and informal than at the hospitals. more
In
antenatal clinics the length of consultation is easy to predict. I earnestly plead on my own behalf and for countless other mothers that something should be done to stop this inordinate waste of time. ROSEMARY STANFORD. Kingston-on-Thames.
relatively
RECOVERY WARDS
SIR,—With reference to the article by Dr. Davies and Dr. Hunter (April 26), I experienced the value of a recovery ward when I was stationed at Bir Yacow Military Hospital in Palestine (at other times known as the 12th British and the 15th Scottish Military Hospital). This 1200-bed hutted hospital was originally built at a time when dispersal was thought to be the best protection against air-raids, and some of the wards were more than half a mile from the operating-theatres. Accommodation had, therefore, to be provided close to the theatres where ambulances could deposit lying patients previous to operation and from which they could collect them afterwards. One hut was built contiguous to the theatres and directly connected to them by a short passage-way. It was furnished with a nominal 24 beds which were supernumerary to the normal bed complement and which did not appear on any bed list. This ward, although primarily intended only as a collecting and dispersal point, was, in fact, the making of the hospital from the surgical point of view. It served not only as a recovery and resuscitation ward where all necessary equipment could be concentrated and immediately available, but for many other purposes when patients required special care. Having once experienced its value, no member of the staff, whether medical or nursing, had the slightest doubt that such a ward should be available in every general hospital : 1. Operation cases were transferred to this ward well before the time of operation so that all preoperative preparations could be carried out by an experienced staff under the
*
*
Students of In England lVo2v who have followed our quest for a bat for experimental purposes may well suppose that we ended with a surfeit of bats. In our communique of June 7 the matter was in the hands of our experienced and capable Animal Man, and we had no fear for the future-we had but to visit the Church of the Stuffed Owls and scoop up handfuls of bats. We set off with light hearts, armed with a rat cage, a sack, a powerful torch, and some leather gloves as a protection against bat-scratch fever. The church was small and whitewashed, and the roof timbers irregular enough to hold a profusion of bats ; perched insecurely on the walls were the stuffed owls, putting as nonchalant a face on it as possible. We searched the lower levels systematically, hunting for guano between the pews and the walls, shining our torch inquisitively under the base of the pulpit, and carefully examining the bottom of an empty brandy bottle. We found traces of many pigeons, but no bat spoor ; so we retired to the farm to borrow a ladder to inspect the higher reaches of the chance]. Here we struck a snag : the ladder was at present preventing the egress of a number of large and active pigs, and it appeared that the difficulties of our bat-hunt were as nothing to those of the pig-hunt that would result if the animals ceased, even temporarily, to be confined. We learnt that Incense is Best for Bats, but also that we had underestimated the bat-repellent activity of the stuffed owls. It was doubtful if even a single bat remained. Crestfallen, we withdrew to collect our impedimenta, touching our hats respectfully to the owls as we left. We are still on the trail. Specimens are being reported to us from distances up to 15 miles, and only yesterday we heard of a house in Eire where 300 bats were caught last year. Our travel grant might just run to that. *
*
*
News from School.—"This is what I did on Long Leave Day : Train to Paddington (7s. 6d.), bus to Charing (5d.), water bus to Tower Br. (9d.). Walked about and watched the Bridge open. We were just beside the guns when the 62 (? ) shots were fired for the Queen’s birthday. Went back to Charing (9d.), tube to Regents Park (8d.), Zoo (2s. 6d.), Aquarium (Is.) (?), tea, &c. (3s.) (?), tube (8d.). And so it came to quite a lot of money."
Letters to the Editor APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
SIR,—After reading the article by Brigadier Welch and Bailey (May 31) I must confess to feeling some
Mr.
disappointment.
commendable that they should seek ways of reducing the waiting period in outpatient clinics, but one It is
cannot help feeling that they have taken too mathe. matical a view. Although they suggest that " it is not reasonable to carry this comparison too far," it is a somewhat sad commentary on the times that they do compare at all a ladies’ hairdressing establishment with a consultative clinic. At the hairdresser’s, they state, the discipline of staff and customers is strict"; and, while I have no wish to ascribe to them a meaning which they did not intend, some administrators may clearly be tempted to conclude that a tightening of discipline in hospitals will produce efbcient results. In my experience it is extremely difficult to give any accurate idea of the time required for consultation, if each patient is to be given the benefit of a considered opinion. I have no doubt that many consultants could work more strictly to a time-table, but I am equally sure that, where they do, the quality of their work may suffer : Brigadier Welch’s figures improve, but the standard of service-that elusive quality which is not measurable statistically—will go down. An important aspect of the appointment system, not mentioned by your contributors, is that it may lead to undue delay in getting the patient to the consultant, and this is especially true when a limited number of new appointments is set for each clinic. Some hospitals and consultants are more responsive to the needs of the local practitioners, and they try to avoid any strict limit on the number of new patients seen. In these circumstances there are sometimes unavoidable delays at the clinic, but the patient has the immeasurable advantage of attending hospital after little or no delay. I would submit that most patients would prefer, where possible, to be seen at the next consultative clinic even at the cost of an hour’s waiting. Far be it from me to decry the invaluable discipline of statistics ; but pray let us protect Medicine from wellintended statistical surveys which may encourage tidyminded administrators to forget that the quality of service and the preservation of the doctor-patient "
"
relationship
are our
prime
"
’
concern.
MuELET. Radlett, Hertfordshire.. R. S. MURLEY.
SIR,—In the article by Brigadier Welch and Mr. Bailey the punctuality of patients is analysed and favourably commented upon, but no very adequate analysis is made of the number of patients who book appointments and then default. I have worked in clinics where at times defaulters represented 25% of the whole. This suits me, as I am a lazy type and enjoy teaching students during waiting periods ; but it demonstrates the indifference of a section of the community towards a hospital service that tries to help patients by an appointment system. An analysis (not statistical) of reasons for patients not turning up gave the following answers : (1) forgot, (2) got better, (3) missed the bus, (4) went to the wrong hospital, (5) went to the cinema, (6) mind your own business. The suggestion that the booking clerk should have been informed by telephone that the appoint. ment could be cancelled was regarded by 100% of those questioned as undemocratic and a waste of money. London,
W.I.
J. C. HAWKSLEY. J.
1209
SIR,—Having scarcely recovered from the nagellations by Professor Titmuss,1 we have now to face the results of investigation. yet another apparently lay cause of outpatients waiting At last, it appears, the is given. As a statisThe solution discovered. been has tical review it is, no doubt, unexceptionable. Applied to so. human an under-taking as an outpatient clinic- it seems to assume
the form of
an
exercise in intellectual
speculation. -
Let us look a little closer. First let us pay tribute to the investigation that led to the remarkable discovery that we are unpunctual. We are instructed how to work out, by a process of arithmetic not beyond the powers of the average consultant, the consultation-time per patient. By so doing we can avoid patients having to wait..One is captivated by the very ingenuousness of the theory. How about the practical application*? 1. To examine one individual may take 5 minutes. To do the same for another may well take twice that time, although the complaint is the same. Each requires a different approach. A child may require time and patience, and these must be given, in spite of the statistician’s time-table. 2. Has it occurred to the authors that (especially in the specialties dealing with emergency work) one’s time-table can be somewhat dislocated by urgent work ? After a long morning clinic a visit to the ward to deal with some particular problem may spell lateness for the afternoon. 3. Finally may I refer to what is probably’the most preposterous suggestion of all-why must a long consultation, involving perhaps a colleague, be kept until the end ? Would it not be better (and here I mean for the patients and not for our stop-watch-armed mentors) for the business to be dealt with on the spot ? It might astonish our experts to learn that the homely reason for this is a human one : our colleague may have gone home. Spare us, Sir, these profitless speculations. This itch
to express in terms of figures activities of hospital life is distressing. Is it, I wonder, another manifestation of that malady to which Grant Waugh recently drew
attention-namely,
"
pseudo-scientific meticulosis" ? T. DENNESS.
Ipswich.
SIR,—I read with interest the article by Brigadier Welch and Mr. Bailey. Antenatal clinics at hospitals are probably among the most time-consuming from the patient’s point of view. Three and a half years ago I attended the antenatal clinic at a well-known maternity hospital. There was no appointment system in operation, and every told to be there at 9 A.M. By 9.30 the waitingfull to overcrowding. Consultations never appeared to begin before 9.45 A.M., and one could account oneself lucky On a first visit, which meant a to get away by 11.30 A.M. history, examination, and visit to the almoner, it was more likely to be 1 r.M. Patients were divided roughly into two groups-those who had to undress and those who had not, the latter requiring only weighing, blood-pressure reading, and urine analysis. There was always a good deal of confusion over this division, and patients were always finding themselves in the wrong queues. One of the saving graces of this clinic was a small canteen supplying tea and buns for a few pencemost welcome to patients like myself whose nausea was
patient
was
room was
aggravated by hunger.
Currently I am attending hospital.
the
antenatal clinic
at
another
Here there is
an
kind in operation.
appointment system of a very curious telephoned to make an appointment
I
and was told 10 A.M. This clinic has an outer room with clerk in attendance, and incoming patients sign their names in a book. As their turn came their names were called and ticked off in the book. About 11.30 A.M. I noticed that a number of women who had come in after me had been called. I went and looked at the book and saw that patients who had signed after me had been ticked off. I queried this with the clerk, who said : "It usually takes a bit longer if you have an appointment." I am still wondering why this should be the case. a
1. See Lancet,
May 17 1952, p. 1014.
weeks pregnant I have reached the about an hour in the waiting-room names are called in batches of four or so. We undress in cubicles, and, donning the dressing-gowns provided, sit on little stools until called for examination. On the last occasion I noticed that women who came- in my batch had been seen and had dressed and gone while I and one other still waited. After thirty-five minutes of sitting in a communal-dressinggown I asked the sister if -1 were being forgotten. She explained very kindly that some patients were seen by the consultant, some by the registrar, and some by the midwives. There was only one midwife available that morning, -whom I was supposed to see ; and she also had to look after the weighing of other patients and pass them on to the appropriate
Being now thirty-two undressing stage. After
doctor.
All patients attending these clinics are housewives whose mornings are normally fully occupied with housework and shopping. Many have to bring small children with them to the clinics, where they become bored, restless, and irritable. There are no facilities for amusing them or having them looked after while the mother is examined. In the earlier stages of this pregnancy I attended the local-authority antenatal clinic, which compares very favourably with the hospitals’. In the first place it is held in the afternoon, which is much convenient for most mothers. The appointment system worked fairly well, and delay occurred only when there was a sudden influx of new patients. When this happened the very efficient and courteous reception clerk was most apologetic. Chairs stood round the walls in place of the usual benches, which left a space in the middle of the room where toddlers accompanying their mothers could play. A few toys had strayed in-perhaps from the neighbouring child-guidance clinic. The atmosphere was much more friendly and informal than at the hospitals. more
In
antenatal clinics the length of consultation is easy to predict. I earnestly plead on my own behalf and for countless other mothers that something should be done to stop this inordinate waste of time. ROSEMARY STANFORD. Kingston-on-Thames.
relatively
RECOVERY WARDS
SIR,—With reference to the article by Dr. Davies and Dr. Hunter (April 26), I experienced the value of a recovery ward when I was stationed at Bir Yacow Military Hospital in Palestine (at other times known as the 12th British and the 15th Scottish Military Hospital). This 1200-bed hutted hospital was originally built at a time when dispersal was thought to be the best protection against air-raids, and some of the wards were more than half a mile from the operating-theatres. Accommodation had, therefore, to be provided close to the theatres where ambulances could deposit lying patients previous to operation and from which they could collect them afterwards. One hut was built contiguous to the theatres and directly connected to them by a short passage-way. It was furnished with a nominal 24 beds which were supernumerary to the normal bed complement and which did not appear on any bed list. This ward, although primarily intended only as a collecting and dispersal point, was, in fact, the making of the hospital from the surgical point of view. It served not only as a recovery and resuscitation ward where all necessary equipment could be concentrated and immediately available, but for many other purposes when patients required special care. Having once experienced its value, no member of the staff, whether medical or nursing, had the slightest doubt that such a ward should be available in every general hospital : 1. Operation cases were transferred to this ward well before the time of operation so that all preoperative preparations could be carried out by an experienced staff under the