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APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
44 in 1947this operation has been done in some 40 of these cases. Very rarely the .exclusion operation may be the method of choice. Otherwise it should be mentioned only to be condemned, for it has no advantage over the Bancroft operation and is usually followed by a second operation to excise the retained antrum. I did, in a small series of eases, use this operation before I came to know how very safe is prepyloric closure with ablation. I did not follow it by a later operation to excise the antrum ; for I believed that, if this retained segment of stomach caused jejunal ulceration, then its excision would cure that ulceration. Oddly these few cases have not yet developed thiscondition, although it is now some years since the
operation
operations were done. Sir Heneage is right when he states that the operation of prepyloric closure with mucosal ablation is slightly untidy." The patient is, however, asleep when the operation is done : he lives only to know its worth. "
HAROLD BURGE.
London, W.1.
SIR,—An article from the pen of Sir Heneage Ogilvie is
invariably refreshing and inspiring. the First Part of the Duodenum is of the tribute paid him by Mr. David
His address
on
fully deserving Patey. Much as I respect Mr. Patey’s surgical views, I am surprised at his strong advocacy of milk-particularly its administration by the drip method-in the treatment of acutely inflamed duodenal ulcer. The giving of milk from " on high " by the drip method certainly -anchors the patient to bed, and often exercises a peculiar fascination have become veritable milkin weaning ! At best, however, milk is a weak antacid, and some of my colleagues and I have found that patients derive just as much benefit from the rest in bed and a mixture of the type advocated by Dr. Arthur Douthwaite as One of the disadvantages a preliminary to operation.1 of milk is that the patient tends to put on so much weight, ,and recently a surgical colleague found to his disgust that he had to deal with the unrepentant ulcer of a patient who had gained three stone after an extended course of this treatment. Incidentally it is remarkable how many doctors there are, afflicted with duodenal ulcer, who are content to have medical treatment for their relapses, rather than .face the prospect of a gastrectomy. MICHAEL J. SMYTH. London, W.I.
for him.
Some of
our cases
drip addicts, offering occasional difficulty
a
large teaching hospital
I
attended this year, three appointments had been made for 10 o’clock and no record of them could be found on the consultant’s appointment-sheet. AUBREY H. CARTER. London, S.W.11. -
AUTOGENOUS VACCINE a patient under my care in hospital for whom I asked the appropriate laboratory to make a -vaccine. I was met with a refusal to do so on the ground that the organisms discovered were not likely to make These organisms were a streptococcus - a useful vaccine. of somewhat indeterminate character and the patient’s He suffers from own brand of Micrococcus catarrhalis. bronchitis and asthma which have proved very resistant to ordinary remedies. Can you, Sir, tell me where I can learn how the potentialities of any particular autogenous vaccine can be discovered otherwise than by its clinical use? -
SIR,—I have
Sevenoaks,
Kent.
1. Douthwaite, A. H.
GORDON WARD. Brit. med. J. 1951, i, 291.
"
Later, in
an
attempt
to
clarify the situation,
th(
Minister of Health issued a circular (R.H.B.59) from which we learn that " for the purpose of costing " th( following services are rated as equivalent to one outpatieni attendance: (1) X-ray examinations enumerated on the basis of the " requests" received from clinicians, irrespective of the number of films used or the time taken to complete the examination ; (2) a single pathological specimen of blood, urine, cerebrospinal fluid, &c.,-regardof the tests performed on it; less of the number or
quality
treatment in the physiotherapy department, simultaneous treatments to be counted as one but -group
SIR,—In the article (May 31) by Brigadier Welch and Mr. Bailey two important factors appear to have been overlooked : (1) patients who make an appointment and fail to arrive ; and (2) patients who make an appointment At
suggest
(3)
APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
which is not recorded.
HOSPITAL COSTING SIR,—Your leading article on this subject (June 21) pointed out some deficiencies of the present method of hospital costing. In particular, you questioned the creden. tials, of thepractice of counting .five outpatient atten. dances -as the costing equivalent of one inpatient day. I that a source of greater error is the failure to adopt a standard unit to measure equivalent amounts of Reference to work done in the various departments. note (ii) on page 6 of the report Hospital Costing Returns1 shows that "one outpatient attendance " is not, for the purpose of costing, the same as " one patient attending the Out-Patient Dept. once." Other items such as "treatments or examinations in physiotherapy, patho. logical, radiological and similar departments " are also included. This report refers to the financial year ending March 31, 1951, and the statistics on which the costing is based were obtained mainly from various returns of the Ministry of Health for the year ending Dec. 31, 1950. At that time there was considerable confusion both at the Ministry and in the hospitals as to what constituted a unit " in pathological and similar departments. As the Ministry had not been able to produce satisfactory definitions to cover these points, there was great diversity in interpretation which led to the same examinations and treatments being valued at different rates in different hospitals. This invalidates the costing figures based on these statistics, since an elementary rule of comparative costing is to compare " like with like." The instructions on how to compile these costing figures issued by the Ministry (R.H.B.[50]66) to boards and management com. mittees should have been included in full in the report since the merits of any statistical report can only be judged on the reliability of the source data ; and not everyone who may wish to use this report will have easy access to official files.
a
treatments counted
(e.g., remedial gymnastic classes), to be for each patient attending ; (4) even more
as one
surprisingly,
a
necropsy is
counted
as
one
outpatient
other special examinations should be counted as one for each organ even where more than one block or specimen is examined from the same In view of this heterogeneous collection of so-called organ. " units " you will no doubt agree that the exact ratio employed to -equate these to one inpatient day is hardly It is well to note that the of practical importance. for the statistics financial year ending March 31, costing 1952, will-be based on figures compiled in accordance with these instructions. Whether or not the Ministry will have revised its definitions of costing units in time for the 1952/53 financial report is as yet unknown. There is a tendency among the members of the medical profession to regard all questions relating to costing as the concern of the administrative side of the hospital service. But in fact it is the concern of us all ; for in these days of financial stringency the whole policy of administration of the health service may depend on costing statistics. At no time in-the foreseeable future will
attendance, but histological
or
1. National Health Service : Hospital Costing Returns, ended March 31, 1951. H.M. Stationery Office, 1952.
year
operation
operations were done. Sir Heneage is right when he states that the operation of prepyloric closure with mucosal ablation is slightly untidy." The patient is, however, asleep when the operation is done : he lives only to know its worth. "
HAROLD BURGE.
London, W.1.
SIR,—An article from the pen of Sir Heneage Ogilvie is
invariably refreshing and inspiring. the First Part of the Duodenum is of the tribute paid him by Mr. David
His address
on
fully deserving Patey. Much as I respect Mr. Patey’s surgical views, I am surprised at his strong advocacy of milk-particularly its administration by the drip method-in the treatment of acutely inflamed duodenal ulcer. The giving of milk from " on high " by the drip method certainly -anchors the patient to bed, and often exercises a peculiar fascination have become veritable milkin weaning ! At best, however, milk is a weak antacid, and some of my colleagues and I have found that patients derive just as much benefit from the rest in bed and a mixture of the type advocated by Dr. Arthur Douthwaite as One of the disadvantages a preliminary to operation.1 of milk is that the patient tends to put on so much weight, ,and recently a surgical colleague found to his disgust that he had to deal with the unrepentant ulcer of a patient who had gained three stone after an extended course of this treatment. Incidentally it is remarkable how many doctors there are, afflicted with duodenal ulcer, who are content to have medical treatment for their relapses, rather than .face the prospect of a gastrectomy. MICHAEL J. SMYTH. London, W.I.
for him.
Some of
our cases
drip addicts, offering occasional difficulty
a
large teaching hospital
I
attended this year, three appointments had been made for 10 o’clock and no record of them could be found on the consultant’s appointment-sheet. AUBREY H. CARTER. London, S.W.11. -
AUTOGENOUS VACCINE a patient under my care in hospital for whom I asked the appropriate laboratory to make a -vaccine. I was met with a refusal to do so on the ground that the organisms discovered were not likely to make These organisms were a streptococcus - a useful vaccine. of somewhat indeterminate character and the patient’s He suffers from own brand of Micrococcus catarrhalis. bronchitis and asthma which have proved very resistant to ordinary remedies. Can you, Sir, tell me where I can learn how the potentialities of any particular autogenous vaccine can be discovered otherwise than by its clinical use? -
SIR,—I have
Sevenoaks,
Kent.
1. Douthwaite, A. H.
GORDON WARD. Brit. med. J. 1951, i, 291.
"
Later, in
an
attempt
to
clarify the situation,
th(
Minister of Health issued a circular (R.H.B.59) from which we learn that " for the purpose of costing " th( following services are rated as equivalent to one outpatieni attendance: (1) X-ray examinations enumerated on the basis of the " requests" received from clinicians, irrespective of the number of films used or the time taken to complete the examination ; (2) a single pathological specimen of blood, urine, cerebrospinal fluid, &c.,-regardof the tests performed on it; less of the number or
quality
treatment in the physiotherapy department, simultaneous treatments to be counted as one but -group
SIR,—In the article (May 31) by Brigadier Welch and Mr. Bailey two important factors appear to have been overlooked : (1) patients who make an appointment and fail to arrive ; and (2) patients who make an appointment At
suggest
(3)
APPOINTMENT SYSTEMS IN HOSPITAL OUTPATIENT DEPARTMENTS
which is not recorded.
HOSPITAL COSTING SIR,—Your leading article on this subject (June 21) pointed out some deficiencies of the present method of hospital costing. In particular, you questioned the creden. tials, of thepractice of counting .five outpatient atten. dances -as the costing equivalent of one inpatient day. I that a source of greater error is the failure to adopt a standard unit to measure equivalent amounts of Reference to work done in the various departments. note (ii) on page 6 of the report Hospital Costing Returns1 shows that "one outpatient attendance " is not, for the purpose of costing, the same as " one patient attending the Out-Patient Dept. once." Other items such as "treatments or examinations in physiotherapy, patho. logical, radiological and similar departments " are also included. This report refers to the financial year ending March 31, 1951, and the statistics on which the costing is based were obtained mainly from various returns of the Ministry of Health for the year ending Dec. 31, 1950. At that time there was considerable confusion both at the Ministry and in the hospitals as to what constituted a unit " in pathological and similar departments. As the Ministry had not been able to produce satisfactory definitions to cover these points, there was great diversity in interpretation which led to the same examinations and treatments being valued at different rates in different hospitals. This invalidates the costing figures based on these statistics, since an elementary rule of comparative costing is to compare " like with like." The instructions on how to compile these costing figures issued by the Ministry (R.H.B.[50]66) to boards and management com. mittees should have been included in full in the report since the merits of any statistical report can only be judged on the reliability of the source data ; and not everyone who may wish to use this report will have easy access to official files.
a
treatments counted
(e.g., remedial gymnastic classes), to be for each patient attending ; (4) even more
as one
surprisingly,
a
necropsy is
counted
as
one
outpatient
other special examinations should be counted as one for each organ even where more than one block or specimen is examined from the same In view of this heterogeneous collection of so-called organ. " units " you will no doubt agree that the exact ratio employed to -equate these to one inpatient day is hardly It is well to note that the of practical importance. for the statistics financial year ending March 31, costing 1952, will-be based on figures compiled in accordance with these instructions. Whether or not the Ministry will have revised its definitions of costing units in time for the 1952/53 financial report is as yet unknown. There is a tendency among the members of the medical profession to regard all questions relating to costing as the concern of the administrative side of the hospital service. But in fact it is the concern of us all ; for in these days of financial stringency the whole policy of administration of the health service may depend on costing statistics. At no time in-the foreseeable future will
attendance, but histological
or
1. National Health Service : Hospital Costing Returns, ended March 31, 1951. H.M. Stationery Office, 1952.
year