- Email: [email protected]
CENTRAL HEALTH SERVICES COUNCIL
295 The foregoing makes it clear that a hospital suitable for the admission of cases of poliomyelitis in the acute stage must be well provided with experienced medical, nursing, and physiotherapy staff : it must have special equipment and immediate access to certain specialists. As a preliminary step which can be taken without delay in all regions, those who now treat acute polioshould establish close liaison with the ear, nose and throat, anaesthetic, and thoracic surgery departments. The staff of these departments can assist with plans for the application of methods for keeping the air-passages free. Collaboration of this kind might in time result in a most helpful transfer of nurses from special departments to assist with the care of complicated cases.
myelitis
Equipment The equipment provided must be the best available and must include respirators, beds for postural drainage, suckers, cesophageal catheters, oximeter, spirometers, apparatus for providing oxygen and for positive pressure mask breathing. The recovering stage of the disease After the first three weeks of the disease the patient may be moved to a convalescent ward and a decision must be taken as to whether further hospital treatment is necessary. It is not the intention of the present memorandum to deal with the many problems which arise during this stage of the disease. Conclus2ons There is need for planning in the treatment of sporadic and epidemic cases of poliomyelitis. There is scope for variation of the details of the plans in different regions. Discussions between those responsible for drawing up plans in different parts of the country would lead to further improvements in methods.
CENTRAL HEALTH SERVICES COUNCIL IN his introductory remarks to the report1 of the Central Health Services Council for 1952, the Minister of Health, Mr. lain Macleod, gave first place among the council’s various undertakings to the study of medical research in relation to the National Health Service. The report2 of this inquiry, produced jointly by the council’s Standing Medical Advisory Committee and the Medical Research Council, in association with the Advisory Committee on Medical Research in Scotland, has already been published, and the Minister is at present considering with the other Ministers concerned the important issues that it raises. The results of two other inquiries mentioned in the report have also been published earlier-the one dealing3 with the reception and welfare of hospital inpatients and the other with visits to children in hospitals.4 THE MINISTER AND THE REGIONAL BOARDS
Among
the many questions on which he had been advised by the council, Mr. Macleod mentioned " one of general and continuous interest, the relation between the Minister and the hospital authorities." His predecessor had given an assurance that he had no present intention of making any drastic changes in the basic structure of the hospital service ; and, while Mr. Macleod could not anticipate the ultimate recommendations of the recently appointed committee on the cost of the N.H.S. (the Guillebaud Committee), he was glad to repeat the assurance for himself. He entirely agreed with the council’s view that regional hospital boards should be fully consulted on the application of policy in the hospital service. While ultimate direction from the centre was unavoidable, he was satisfied that it should be kept to a minimum and that those responsible 1. Report of Central Health Services Council for the Year Ended Dec. 31, 1952. H.M. Stationery Office. 1953. Pp. 30. 1s. 3d. 2. See Lancet, July 18, 1953, p. 123. 3. Ibid, 1953, i, 227. 4. Ibid, pp. 531, 539.
for the running of the service should have as much say possible in its development. On this subject, the council has this to say : " There appeared to have been a fairly steady trend, siuce the beginning of the National Health Service, towards greater contral control. This was no doubt due to the desperate need for economy in the service, the shortage of resources for capital dovelopment, demands on manpower for other national purposes and, more generally, the pressure exerted on the Minister, as responsible to Parliament for the service, on all sorts of detailed matters as well as on major issues of policy. We were glad to note that the Minister was restoring to the Regional Boards important powers relating to the estimates and expenditure of Hospital Management Committees and we were informed that he had no intention at the present time of making any drastic changes in the basic structure of the hospital service. " With this decision wo were wholly in sympathy. To make any radical change would, in present circumstances, be dangerous and in our view wrong and we concluded, therefore, that all that was needed was a greater emphasis on the partnership which should exist between the Minister and the hospital authorities who have actually to run the service, a strengthening of that aspect of the agency relationship. On matters of general policy with regard to the hospital service, as with other sections of the National Health Service, we hope that the Minister will continue to come for advice to ourselves and to the Standing -Advisory Committees. We cannot otherwise properly discharge our functions under the Act and there would be danger of confusion if the Minister were to seek too many independent sources of advice on separate parts of the service. But we often cannot advise on the implementation of policy at the administrative and executive levels and here we thought that the Minister might try to establish a rather closer working relationship with his agents, the Regional Hospital Boards." CANCER EDUCATION
council’s Standing Cancer and Radiotherapy Advisory Committee have re-examined the question of cancer publicity, but they decided that it would be unwise to change the advice that they had given previously-namely, that it was undesirable at the present time for any cancer publicity to be carried out by a central government organisation direct to the general public. The committee suggested that the Minister should encourage local authorities and voluntary bodies to undertake exploratory schemes on cancer education in order to expand our of what can be achieved in this way. The education of doctors themselves in the early diagnosis of cancer was a very important part of the plan and one which was still deficient. The
knowledge
TUBERCULOSIS
Waiting-lists for going steadily down
tuberculous patients have been : in 1951 they fell by 25%, from 9578 to 7096, and in 1952 by 13% to 6126. Since the start of the N.H.S. over 7000 additional beds have been provided for the treatment of tuberculosis. The report notes that, though conditions in a few hospital regions are still bad, in some regions there is now no waiting-list at all for early cases and in others the wait is only two to six weeks. Nevertheless, the council has advised the Minister to bring to the notice of regional hospital boards those measures which have been effective in reducing waiting-lists elsewhere, so that the same priority may be given to the admission of treatable cases of pulmonary tuberculosis as is now given to treatable cases of cancer. DENTAL SERVICES
The council describes the dental services in hospitals as " generally most inadequate, for patients and staff alike." The Standing Dental Advisory Committee recognised that, with so much leeway to be made up, a full service for the hospital population could not be provided for a long time. For example, routine examination of all patients on admission, with treatment where necessary, and twice-yearly re-examination and treat-
296 of long-stay patients and staff, would occupy than 1000 full-time dental practitioners. Accordingly the committee made a number of short-term recommendations which could be put into effect in the near future. These included : routine dental examination and treatment ment
In
more
long-stay patients on admission and at yearly intervals ; provision of dental treatment for short-stay patients, but of all
where this was necessary as a part of medical care or for the relief of pain or some other emergency ; special arrangements for outpatient dental treatment of patients with open tuberculosis ; limitation of other outpatient treatment to specialist diagnosis and treatment ; and provision, if possible, of facilities for the treatment of nursing and medical staff. These interim plans would call for about 400 dentists, in addition to specialists, for the general treatment of patients.
only
As a means of improving the administrative organisation of the dental services, the committee recommended the setting up of regional dental advisory committees, and the appointment in every region of an experienced dental officer or adviser. TREATMENT
OF DIABETES
Medical Advisory Committee thought had been made out for the provision of special clinics for the treatment of diabetics and for special arrangements to be made for tuberculous, pregnant, and aged diabetics. Any general physician wishing to take charge of a diabetic clinic should be given an opportunity to obtain further experience at a special centre. A memorandum giving effect to the committee’s recommendations went out to hospital authorities on July 7. The that a
Standing case
MENTAL HEALTH
Studying the question of the institutional treatment and training of high-grade mental defectives, particularly moral defectives, the Standing Mental Health Advisory Committee thought that more hostels for high-grade defectives were needed. These hostels should be established near suitable industrial centres or agricultural areas where there is satisfactory employment for unskilled workers. Special units could be set up in large urban areas for the accommodation of high-grade defectives who are socially maladjusted. NATIONAL ASSISTANCE BOARD THE board’s reportfor 1952 says that the expenditure on national assistance during the year was f:89, 7 55,000. The number of weekly assistance allowances rose by 205,452, and at the end of the year the total was 1,667,078. Assistance paid to the old and sick accounted for over 80% of allowances : of these, more than 1,000,000 were paid to people over pensionable age, of whom 200,000 were over the age of 80. The total amount of assistance granted in 1952 to meet charges raised under the National Health Service was just over :S6QO,000. Of this sum, 209,000 represented the refund of shilling charges for prescriptions. The scale rates of assistance, which indicate the normal level of requirements other than for rent, were raised with effect from June 16, 1952, to meet the rise in the cost of food due to the reductions in food subsidies. These increases made it necessary to alter over 1,500,000 allowances, and the task was further complicated when many of the allowances had again to be adjusted to meet the increases in pensions, family allowances, and insurance benefits which also came into operation last But the board felt that any simplicity that could year. have been obtained by deferring the new rates would have been bought at the cost of too much hardship to the people concerned. Assistance Board. Report for Obtainable from H.M. Stationery Office.
1. National
1952. 2s.
Cmd.
8900.
A
England Now
Running Commentary by Peripatetic Correspondent8
Two HUNDRED years ago we used to burn our witches the village green. Nowadays we have the same local geriatric problems. The way we deal with them has changed, but the end-results are much the same. The scene is all too familiar. The old man or woman who lives alone becomes increasingly unable to cope with The men usually pack up for the the daily round. shelter of their relatives or the welfare hostel, but the old women cling tenaciously to their independence. The downhill path of solitude is a way of no return. Unwashed and ill-fed at the best, verminous and disabled at the worst, the old body drags on, begrimed, misshapen, muttering hostile curses, abroad at night in senile confusion, and living in a veritable witch’s den of cats and filthy furniture. The village does not like it. I am invited to invoke the benevolence of our laws for compulsory removal, whereby sane and unconvicted adults can be deprived of liberty on the grounds that it is in their own interests or those of other people. My experience is that the Act is a virtual deathwarrant in spite of all the good intentions. And I have become rather cynical about some of the good intentions. The landlord wants his tenant out, youngsters want the house, the petty feuds of neighbours, the interference of the village busybodies, the obsession for a tidy community, misguided charity, call it what you will, and the walls of an Englishman’s castle are breached. Take these old folks from home against their will, wash them, deprive them of their few tattered and cherished possessions,. and the will to live is quenched. Does tidiness count for so much at eventide ? When the Act was passed I thought it a fine thing; now I am not so sure. I had an old beggarman who sublet his house to a young couple after the war, keeping just one room for himself. He was a dirty old man who spent his charity on drink and came rolling home to be sick, and worse, on the stairs. The subtenants did not like it and said so. The old man was removed compulsorily to the welfare hostel-the old workhouse round the corner. He died, but you do not write on a death certificate that he died of a broken heart. If I had my chance again it would be the subtenants who would on
move.
In another village I had to put on wellingtons to enter the home of an old woman who littered every room of a modern house with filth and garbage until she set herself She was ailing but independent; our on fire one night. interview went smoothly until the question of removal to a hostel was mooted. Then she was rejuvenated with the fire of wrath. I was barricaded out of her house, and discretion counselled that it would be better to keep out of range of the domestic equivalent of the boiling oil which medieval defenders poured down on the heads of besiegers of their castle. I was with her in spirit. Surely it was better to risk the strictures of the coroner than be a party to the deliberate hastening of her end. Dozens of these cases now suggest that compulsory removal should be reserved only for the bedfast case, where proper treatment and nursing care cannot be given " in the home. " Is it in the interests of the patient? is a question which needs a lot of heart-searching on a busy day. To use the law to remove these old folk for the sake of others is to take another path of no returnthe path which led to Ravensbruck and Dachau. Perhaps the stake on our village green was more merciful, *.
*
:x
,
The essence of light verse is that it should contain neither lines that are forced nor rhymes that are false; it should seem to flow effortlessly. Only those who have it know how difficult it is to produce attempted to write " that effect. That chap couldn’t even write poetry, let alone light verse " said the late " Dum-Dumof Punch who could speak with authority. Re-reading Don Juan which, though quizzical, is often very good and sometimes great poetry-and what a capital, if unseemly, story it is-one realises that it would never pass muster as light verse and wonders why Byron chose He certainly bit off more than he so difficult a metre.
myelitis
Equipment The equipment provided must be the best available and must include respirators, beds for postural drainage, suckers, cesophageal catheters, oximeter, spirometers, apparatus for providing oxygen and for positive pressure mask breathing. The recovering stage of the disease After the first three weeks of the disease the patient may be moved to a convalescent ward and a decision must be taken as to whether further hospital treatment is necessary. It is not the intention of the present memorandum to deal with the many problems which arise during this stage of the disease. Conclus2ons There is need for planning in the treatment of sporadic and epidemic cases of poliomyelitis. There is scope for variation of the details of the plans in different regions. Discussions between those responsible for drawing up plans in different parts of the country would lead to further improvements in methods.
CENTRAL HEALTH SERVICES COUNCIL IN his introductory remarks to the report1 of the Central Health Services Council for 1952, the Minister of Health, Mr. lain Macleod, gave first place among the council’s various undertakings to the study of medical research in relation to the National Health Service. The report2 of this inquiry, produced jointly by the council’s Standing Medical Advisory Committee and the Medical Research Council, in association with the Advisory Committee on Medical Research in Scotland, has already been published, and the Minister is at present considering with the other Ministers concerned the important issues that it raises. The results of two other inquiries mentioned in the report have also been published earlier-the one dealing3 with the reception and welfare of hospital inpatients and the other with visits to children in hospitals.4 THE MINISTER AND THE REGIONAL BOARDS
Among
the many questions on which he had been advised by the council, Mr. Macleod mentioned " one of general and continuous interest, the relation between the Minister and the hospital authorities." His predecessor had given an assurance that he had no present intention of making any drastic changes in the basic structure of the hospital service ; and, while Mr. Macleod could not anticipate the ultimate recommendations of the recently appointed committee on the cost of the N.H.S. (the Guillebaud Committee), he was glad to repeat the assurance for himself. He entirely agreed with the council’s view that regional hospital boards should be fully consulted on the application of policy in the hospital service. While ultimate direction from the centre was unavoidable, he was satisfied that it should be kept to a minimum and that those responsible 1. Report of Central Health Services Council for the Year Ended Dec. 31, 1952. H.M. Stationery Office. 1953. Pp. 30. 1s. 3d. 2. See Lancet, July 18, 1953, p. 123. 3. Ibid, 1953, i, 227. 4. Ibid, pp. 531, 539.
for the running of the service should have as much say possible in its development. On this subject, the council has this to say : " There appeared to have been a fairly steady trend, siuce the beginning of the National Health Service, towards greater contral control. This was no doubt due to the desperate need for economy in the service, the shortage of resources for capital dovelopment, demands on manpower for other national purposes and, more generally, the pressure exerted on the Minister, as responsible to Parliament for the service, on all sorts of detailed matters as well as on major issues of policy. We were glad to note that the Minister was restoring to the Regional Boards important powers relating to the estimates and expenditure of Hospital Management Committees and we were informed that he had no intention at the present time of making any drastic changes in the basic structure of the hospital service. " With this decision wo were wholly in sympathy. To make any radical change would, in present circumstances, be dangerous and in our view wrong and we concluded, therefore, that all that was needed was a greater emphasis on the partnership which should exist between the Minister and the hospital authorities who have actually to run the service, a strengthening of that aspect of the agency relationship. On matters of general policy with regard to the hospital service, as with other sections of the National Health Service, we hope that the Minister will continue to come for advice to ourselves and to the Standing -Advisory Committees. We cannot otherwise properly discharge our functions under the Act and there would be danger of confusion if the Minister were to seek too many independent sources of advice on separate parts of the service. But we often cannot advise on the implementation of policy at the administrative and executive levels and here we thought that the Minister might try to establish a rather closer working relationship with his agents, the Regional Hospital Boards." CANCER EDUCATION
council’s Standing Cancer and Radiotherapy Advisory Committee have re-examined the question of cancer publicity, but they decided that it would be unwise to change the advice that they had given previously-namely, that it was undesirable at the present time for any cancer publicity to be carried out by a central government organisation direct to the general public. The committee suggested that the Minister should encourage local authorities and voluntary bodies to undertake exploratory schemes on cancer education in order to expand our of what can be achieved in this way. The education of doctors themselves in the early diagnosis of cancer was a very important part of the plan and one which was still deficient. The
knowledge
TUBERCULOSIS
Waiting-lists for going steadily down
tuberculous patients have been : in 1951 they fell by 25%, from 9578 to 7096, and in 1952 by 13% to 6126. Since the start of the N.H.S. over 7000 additional beds have been provided for the treatment of tuberculosis. The report notes that, though conditions in a few hospital regions are still bad, in some regions there is now no waiting-list at all for early cases and in others the wait is only two to six weeks. Nevertheless, the council has advised the Minister to bring to the notice of regional hospital boards those measures which have been effective in reducing waiting-lists elsewhere, so that the same priority may be given to the admission of treatable cases of pulmonary tuberculosis as is now given to treatable cases of cancer. DENTAL SERVICES
The council describes the dental services in hospitals as " generally most inadequate, for patients and staff alike." The Standing Dental Advisory Committee recognised that, with so much leeway to be made up, a full service for the hospital population could not be provided for a long time. For example, routine examination of all patients on admission, with treatment where necessary, and twice-yearly re-examination and treat-
296 of long-stay patients and staff, would occupy than 1000 full-time dental practitioners. Accordingly the committee made a number of short-term recommendations which could be put into effect in the near future. These included : routine dental examination and treatment ment
In
more
long-stay patients on admission and at yearly intervals ; provision of dental treatment for short-stay patients, but of all
where this was necessary as a part of medical care or for the relief of pain or some other emergency ; special arrangements for outpatient dental treatment of patients with open tuberculosis ; limitation of other outpatient treatment to specialist diagnosis and treatment ; and provision, if possible, of facilities for the treatment of nursing and medical staff. These interim plans would call for about 400 dentists, in addition to specialists, for the general treatment of patients.
only
As a means of improving the administrative organisation of the dental services, the committee recommended the setting up of regional dental advisory committees, and the appointment in every region of an experienced dental officer or adviser. TREATMENT
OF DIABETES
Medical Advisory Committee thought had been made out for the provision of special clinics for the treatment of diabetics and for special arrangements to be made for tuberculous, pregnant, and aged diabetics. Any general physician wishing to take charge of a diabetic clinic should be given an opportunity to obtain further experience at a special centre. A memorandum giving effect to the committee’s recommendations went out to hospital authorities on July 7. The that a
Standing case
MENTAL HEALTH
Studying the question of the institutional treatment and training of high-grade mental defectives, particularly moral defectives, the Standing Mental Health Advisory Committee thought that more hostels for high-grade defectives were needed. These hostels should be established near suitable industrial centres or agricultural areas where there is satisfactory employment for unskilled workers. Special units could be set up in large urban areas for the accommodation of high-grade defectives who are socially maladjusted. NATIONAL ASSISTANCE BOARD THE board’s reportfor 1952 says that the expenditure on national assistance during the year was f:89, 7 55,000. The number of weekly assistance allowances rose by 205,452, and at the end of the year the total was 1,667,078. Assistance paid to the old and sick accounted for over 80% of allowances : of these, more than 1,000,000 were paid to people over pensionable age, of whom 200,000 were over the age of 80. The total amount of assistance granted in 1952 to meet charges raised under the National Health Service was just over :S6QO,000. Of this sum, 209,000 represented the refund of shilling charges for prescriptions. The scale rates of assistance, which indicate the normal level of requirements other than for rent, were raised with effect from June 16, 1952, to meet the rise in the cost of food due to the reductions in food subsidies. These increases made it necessary to alter over 1,500,000 allowances, and the task was further complicated when many of the allowances had again to be adjusted to meet the increases in pensions, family allowances, and insurance benefits which also came into operation last But the board felt that any simplicity that could year. have been obtained by deferring the new rates would have been bought at the cost of too much hardship to the people concerned. Assistance Board. Report for Obtainable from H.M. Stationery Office.
1. National
1952. 2s.
Cmd.
8900.
A
England Now
Running Commentary by Peripatetic Correspondent8
Two HUNDRED years ago we used to burn our witches the village green. Nowadays we have the same local geriatric problems. The way we deal with them has changed, but the end-results are much the same. The scene is all too familiar. The old man or woman who lives alone becomes increasingly unable to cope with The men usually pack up for the the daily round. shelter of their relatives or the welfare hostel, but the old women cling tenaciously to their independence. The downhill path of solitude is a way of no return. Unwashed and ill-fed at the best, verminous and disabled at the worst, the old body drags on, begrimed, misshapen, muttering hostile curses, abroad at night in senile confusion, and living in a veritable witch’s den of cats and filthy furniture. The village does not like it. I am invited to invoke the benevolence of our laws for compulsory removal, whereby sane and unconvicted adults can be deprived of liberty on the grounds that it is in their own interests or those of other people. My experience is that the Act is a virtual deathwarrant in spite of all the good intentions. And I have become rather cynical about some of the good intentions. The landlord wants his tenant out, youngsters want the house, the petty feuds of neighbours, the interference of the village busybodies, the obsession for a tidy community, misguided charity, call it what you will, and the walls of an Englishman’s castle are breached. Take these old folks from home against their will, wash them, deprive them of their few tattered and cherished possessions,. and the will to live is quenched. Does tidiness count for so much at eventide ? When the Act was passed I thought it a fine thing; now I am not so sure. I had an old beggarman who sublet his house to a young couple after the war, keeping just one room for himself. He was a dirty old man who spent his charity on drink and came rolling home to be sick, and worse, on the stairs. The subtenants did not like it and said so. The old man was removed compulsorily to the welfare hostel-the old workhouse round the corner. He died, but you do not write on a death certificate that he died of a broken heart. If I had my chance again it would be the subtenants who would on
move.
In another village I had to put on wellingtons to enter the home of an old woman who littered every room of a modern house with filth and garbage until she set herself She was ailing but independent; our on fire one night. interview went smoothly until the question of removal to a hostel was mooted. Then she was rejuvenated with the fire of wrath. I was barricaded out of her house, and discretion counselled that it would be better to keep out of range of the domestic equivalent of the boiling oil which medieval defenders poured down on the heads of besiegers of their castle. I was with her in spirit. Surely it was better to risk the strictures of the coroner than be a party to the deliberate hastening of her end. Dozens of these cases now suggest that compulsory removal should be reserved only for the bedfast case, where proper treatment and nursing care cannot be given " in the home. " Is it in the interests of the patient? is a question which needs a lot of heart-searching on a busy day. To use the law to remove these old folk for the sake of others is to take another path of no returnthe path which led to Ravensbruck and Dachau. Perhaps the stake on our village green was more merciful, *.
*
:x
,
The essence of light verse is that it should contain neither lines that are forced nor rhymes that are false; it should seem to flow effortlessly. Only those who have it know how difficult it is to produce attempted to write " that effect. That chap couldn’t even write poetry, let alone light verse " said the late " Dum-Dumof Punch who could speak with authority. Re-reading Don Juan which, though quizzical, is often very good and sometimes great poetry-and what a capital, if unseemly, story it is-one realises that it would never pass muster as light verse and wonders why Byron chose He certainly bit off more than he so difficult a metre.