Dangers of Uniformity

201

THE LANCET LONDON:SATURDAY, JULY 30, 1949

Dangers

of

Uniformity

long been apparent that one of the effects instituting central control over the formerly independent unit is a loss of elasticity and of power to respond to the diversity of local circumstances. But it is only now beginning to be realised just what this means. All over the country those who administer the hospitals are waking up to find themselves powerless to make common-sense adjustments to salaries and wages of hospital staff of every kind. They are not allowed to pay less than the rates laid down by the Whitley Councils ; that is endurable, for it is the intentional result of the organisation’of hospital workers through their professional organisations and trade unions. But now, under the new dispensation, they are not allowed to pay more ; it would never do, it- is argued, for hospitals dependent on the Exchequer to bid against each other ; therefore all IT has

of

must conform and pay the standard rate.

The

present understanding that the existing rates in fact standard rates is open to two important lines of criticism which will have to be met. Insistence on the rule is laying the hospital services open to the charge of sheer inefficiency. In many fields, hospitals have to compete with commercial employers, and are subject to the limitations of the locality in which they are situated. If a new factory comes and sits down next door they must be in a position to make some response. Circumstances of this kind were difficult enough for the hospitals before the appointed day, for their power of response was then limited. But when it really mattered-when an important worker like a cook was in question -something could be done. Under the new dispensation that ability to respond has disappeared altogether. It would be easy to pile up examples of this kind of inefficiency, of which the handicap as against the commercial competitor is merely one aspect. From another angle it is clear that the rule of uniformity encourages all the best personnel to congregate in the most favoured hospital or the areas most pleasant to live in. All this adds up to a serious charge of sheer are

inefficiency. But there is a second line of thought, which is perhaps not quite so obvious but which (once properly grasped) should be decisive against the present preference for uniformity above almost all other The mechanism of negotiating considerations. between machinery employers and employed depends on a system by which the staff side levers the rates up from one point to another. It first establishes that in such and such circumstances a specified rate can be justified, and then, relying on the principle of equality for all, gets this rate made universal. The

proper

counter

to

these

tactics

is

pretty

well

understood in the industrial world ; it is prompt concession that such and such ajob does require special consideration, coupled with a detailed refusal to admit that the change must be made universal ’(anticipation of a legitimate demand before it becomes a grievance is, of course, one better). In the hospital world this should often mean a rate for a particular hospital-for example on account of the locality. The conduct of the employers’ side of negotiations of this kind is a highly skilled matter, and we suspect that in the hospital world the technique is much better understood by the staff side than by the miscellaneous groups that represent the Minister and the taxpayer. (Has the Minister on his staff a really expert negotiator fully versed in these matters ? We do not know.) The point here is that from the angle of the Minister, anxious to preserve due economy in the administration of the hospital services, the condition that no hospital ought to be allowed to pay more than the scheduled rate is not intelligent ; it is a blunder, as a mere matter of tactics. It is playing into the hands of the other side : it stands therefore doubly condemned-a handicap to the efficiency of the hospital service, and a handy weapon with which to beat the Government. The situation now arising is a challenge to the authorities, and the reputation of the Minister and his advisers will suffer unless steps are promptly taken to meet it. It is not sufficient that they should say " it is a question for the negotiating machinery we have set up," for it is the terms of reference of the negotiating committees that need to be looked at. Enough damage has been done in the nursing world alone by the failure to think clearly on these subjects, and the hospital service is bound to be impaired until the matter has been threshed out. What then should be done ? We would not suggest that we could forthwith revert to -the old system whereby each hospital authority settled these matters for itself. Freedom for the hospital to spend a roundsum " budget " is, it is true, a highly desirable objective ; but as things stand today it would be idle to press this plan so far as to claim freedom for each hospital management committee to settle salaries and wages entirely regardless of what is being done elsewhere. Some central machinery seems to be inevitable ; but it must be tempered with real discretionary power to the people on the spot. A formula-or rather a series of formuloe-must be found to give the hospital management committees some’ authority to exceed the Whitley Council rates whenever it is really necessary.. For example, it might be provided that as regards caterers, cooks, domestics, and other groups where the hospital is in direct competition with non-hospital employers, the hospital management committee might be given authority to exceed the specified rates by as much as 50% provided that the total amount so expended in any one year did not exceed such and such a percentage of the total budget of the management committee. Where such arrangements had to be made permanent the approval of the regional board might be required. In dealing with doctors, nurses, and medical auxiliaries it might be desirable to proceed on different linesi.e., by the method of a regional (or national) fund analogous to that being evolved to induce the general practitioner to work in the less attractive areas.

202

T

Our immediate criticism is not so much of the main difficulty lies in diagnosis. It is curious that all to as the modern advances in the treatment of occlusion exercise some central control of attempt crudity in the present arrangements with their reliance and strangulation-suction drainage, antibiotics, and on the simple rule of uniformity. The hospital services intravenous therapy-are directed to overcoming are vast and complex, and the complexity will have to the late features of the obstruction. There is no need be matched in the arrangements made. If you have for them in the great majority of early occlusions an extensive railway system it is necessary to have and strangulations.. Early diagnosis permits safe and a Bradshaw, and the Bradshaw must take accountspeedy surgery on a patient whose physiology is of the gradients of every little branch line. It is no still nearly normal. It is failure on the part either of use to say " we shall assume that all trains run at the the patient to summon medical aid or of the doctor It is no use to say " we same speed everywhere." to achieve a diagnosis that provides the case in shall leave it to each little line to settle matters for which the correct use of modern aids makes the itself." Nor, where hospitals are concerned, is it difference between life and death. The patient is wise to say " we shall assume that everything that often responsible for delay, but doctors still some. is called a hospital is equal to everything else that is times miss strangulated inguinal hernias because they - called a hospital, and anyone working in one hospital have not looked for them, or, with more excuse, mustbe paid just the same as someone working in internal obstructions because they could feel no another "-just because they happen to be graded to fall lumps. To watch a patient with severe colicky pain into the same categories in discussions which set out in the abdomen and vomiting until he shows dis. to discover minima for the various groups. tension, dehydration, shock, and signs of infection is to wait dangerously long. Any patient in whom the symptoms give reasonable ground for suspecting Obstruction obstruction needs to be in hospital. There, doubts OBSTRUCTION of the small intestine is of three main can often be dispelled by a plain X-ray film of the types, which may to some extent overlap. It may be abdomen to reveal distended coils of bowel which an ileus, where the fault lies in the propulsive mechaare not clinically obvious. nism of the gut and no organic obstruction is present ; The patient reaching hospital with a late obstruction it may be an occlusion of the lumen of the bowel ; offers a pretty problem to the surgeon if the cause is or it may be a strangulation, when cessation of the not clear. If there is a tender irreducible hernia, all blood-supply to a segment of the bowel overshadows is reasonably plain sailing. But if the only abnormal in importance the probable concomitant occlusion is a distended abdomen it is difficult to of the lumen. The distinction between these three physical sign know whether to wait, so that suction and intramain classes of obstruction has become of cardinal venous medication can make-the with a bowel importance in the past few years because continuous occlusion safe for surgery, or patient whether to operate gastro- intestinal suction has been shown to be at once and not prejudice the chances of a patient astonishingly successful in the right type of case with an internal strangulation. Two points are but dangerous in the wrong type. In ileus gastroof some help in these circumstances. Localised intestinal suction is the correct and usually the only tenderness in the abdomen, with rebound tenderness, treatment needed-it goes almost without saying indicates infection and therefore strangulation ; and that the water and chlorides removed must be replaced abdominal pain continuing after an hour. or two of intravenously. In occlusion of the bowel lumen gastro-intestinal suction shows that the pain is not due suction is a valuable and often life-saving part of the to colicky contractions of the intestine but to somepreparation for operation ; it may be prolonged and thing else-probably a strangulation. COLLER and occasionally may by itself relieve the occlusion. But BUXTON,2 in reviewing 198 small-bowel obstructions, in strangulation suction is a highly dangerous form contend that even in occlusion operation is indicated of treatment if prolonged for more than the time as soon as possible. They record three cases in which needed to empty the upper reaches of the alimentary suction drainage relieved the symptoms but the tract and so prevent the patient drowning in his bowel perforated at the site of an occluding carcinoma. vomit during induction of the anaesthetic. In in attempts to get a MillerTheir success-rate of strangulation no amount of suction can prevent Abbott tube past the68% will be envied those pylorus organisms and plasma escaping through a dying who have often had to be content with gastricbysuction bowel wall, or stop arterial blood being pumped into because a long tube could not be induced to go a capillary bed from which there is no venous return. further. They found that peritonitis was the comThe sooner this migration of the right things to monest cause of death, and they emphasise again the wrong places is checked by operation the better that early diagnosis is the key to lowered mortality. the patient’s chances. AiRD, who has so lucidly interpreted for surgeons the original work of himself and Platelets and others, has said : " In some quarters the has of IN the early days introduction of suction drainage given a fall haematology almost every in the fatality-rate of occlusion but a rise in that blood-cell was proposed by someone as the mother of strangulation, operation in the latter condition cell of the platelets. In 1906 J. H. WRIGHT contended failure to that sometimes being dangerously delayed by blood-platelets are formed from the cytoplasm it from occlusion." of distinguish megakaryocytes, the giant granular cells of the The principles of treatment for small-bowel obstrucbone-marrow ; he suggested that these cells push tions are easy to understand. Apart from ileus, pseudopodia into the lumen of blood-vessels, and whose cause and presence are usually obvious, the when the pseudopodia break off the fragments form

Small-gut

Megakaryocytes

1

Aird, I.

A

Companion in Surgical Studies. Edinburgh, 1949.

2. Coller, F. A.,

Buxton, R. W. J.

Amer. med. Ass.

1949, 140, 135.