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Flying Sparks
LEADING
29
ARTICLES
likely to solve its problems of organisation. REVANS does not believe that hospital workers should be like goldfish in a bowl, looked at and reported upon by academics; and he suggests that people in charge of hospitals are THE LANCET best fitted for the job, though they need the help of social scientists. One early fruit of this philosophy has LONDON 6 JANUARY 1968 been the three years’ collaboration at the East Birmingham Hospital of a man of research and a man of administration in a series of venturesdesigned to help the process of change in a neighbouring fever hospital and sanatorium, which, under the hammer of exigency, Flying Sparks were having to transfer themselves almost too rapidly WHENEVER and wherever the rights and wrongs, into one largish district general hospital. A later offmerits or demerits, of the National Health Service are shoot of REVANS’ work is the Hospital Internal Comdiscussed the sparks begin to fly. Reformers are of munications a consortium which 10 hospitals in Project, many kinds. Some are convinced of the need, above all London and the Home Counties have formed for selfelse, to get more money into our hospitals. Suggestions analysis and therapy. For two years members of include the proposals (with their implication of two different professions have worked together to improve standards) for payment per item-of-service and the the service given by their hospitals, to learn how to look extension of private insurance. The philanthropic outside for specialist help, and to pool their experiences. flutterers would pay our doctors out of sweepstake One lively result of these meetings is a report,s written money, while Prof. HENRY MILLER has made a straighta a nurse, an administrator, and forward appeal for another 1% of the national income. jointly by psychiatrist, a teacher of social medicine, describing a survey of Other reformers rely on administration rather than nurses’ and doctors’ reactions to their hospital’s system finance, and they would bring the N.H.S. under a of dealing with emergencies. Another student of the old single authority and strengthen the links which at hospital in the new world is Prof. ROBERT LOGAN, who present join its three divisions only tenuously. The has examined differing patterns of medical activity, not Porritt proposals for autonomous area health boards only in other countries but also, even more closely, in were designed to achieve this in a way which would various parts of Britain.7 He sees the two basic problems deter domination by a local authority biased towards as the gap between care in the home and care in the politics or by a regional board biased towards hospitals. hospital, and the failure to recognise that a changed Many believe that total care would be improved if pattern of disease requires a changed pattern of medical family doctors could move into the local hospital, and if organisation. A similar plea for the redefinition of a hospital doctors would perceive more sensitively the hospital was made last week by Dr. PETER DRAPER8 who patient in his community setting. Others see the gap suggests that community-care units and inpatient units between hospital and family doctor, rooted in old pro- would meet the medical needs of today and tomorrow fessional differences and fed by statute, to be an irre- more realistically than a district general hospital. versible disability. All who look to a restructured Official reports share this awakening interest in Service for a solution will await with eagerness the hospital organisation, though it is perhaps symptomatic Minister’s promised green-paper on the administrative of existing divisions that groups of people, working structure of the N.H.S.2 But it is the actual operation independently, have produced reports which can be of hospitals which is attracting most interest today. translated into action only if they are first made to Much inquiry now concentrates on making the best use interlock. Thus the Farquharson-Lang report9 has of present resources of men, money, and materials. a new perception of the purpose of hospital committees; Applied research is being undertaken in a surprising the Salmon report 10 of the structure of nursing organisanumber of places, and under a diversity of sponsors: tion ; while the proposals 11 of the two working parties lack of coordination makes it difficult to recognise all on the organisation of medical work in hospitals strike this work for what it is-a vigorous movement in the a course between the authoritarian medical superhospitals to make themselves more effective and more intendent and the somewhat ineffectual total democracy responsive to public need. As Dr. HOPKIN remarked of the medical staff committee. The proposed new last week,3 however, this movement must not be medical divisions could well help doctors to manage more allowed to obscure the expensiveness of poor premises their costly effectively hospital assets. That better use of perpetuated by lack of capital to improve or rebuild. our assets needs better medical management is clear not One starting-point was Prof. R. W. REVANS’ pioneer only from the working parties’ reports, but also from the work on morale and effectiveness in some Lancashire
hospitals,4 which showed that the hospital which shaped its style of management so as to recognise the potential contribution of staff to its running was much more 1. See Lancet, 1967, ii, 407. 2. See ibid. 1967, ii, 1047. 3. Hopkin, D. A. B. ibid. 1967, ii, 1417. 4. Revans, R. W. Standards for Morale.
London,
1964.
four diverse contributions
series last month
on
Elliott, J. R. Hospital, 1965, 61, 301, 349, 422. ibid. 1967, 63, 335, 384, 461. Arie, J., Fairey, M. J., Tooley, P. H., Webster, B. ibid. 1967, 63, 377. Logan, R. Studies in the Spectrum of Medical Care. London, 1964. Draper, P. Lancet, 1967, ii, 1406. See ibid. 1966, i, 416. See ibid. p. 1085. See ibid. 1967, ii, 975.
5. Pantall, J., 6. 7. 8. 9. 10. 11.
to our
30
the Doctor as Manager: all agree on the need for doctors to manage medical resources more effectively and to work with administrators and others. Professor ANÐERSON/2 recognising that the limit on the input of resources to the N.H.S. includes the limit on hospital manpower, suggests that revenue-saving need not be confined to the laundry or the boiler-house, but should apply, with some incentives, to medical departments. He believes that hospitals are under-managed, and that we should not be ashamed of spending money on good top management. Professor MORRISON 13 sees the answer in the creation of a specially trained " epidemiologist," a medical administrator who could combine medical, sociological, and statistical skills: this paragon would partner the clinician as a bulwark against bureaucracy. Mr. ELLIOTT 14 shows how the clinician can share with others the task of recognising and remedying defects in the use of resources by using newer management techniques and better statistics; but Dr. FREEMAN 15 retorts unhappily that too many clinicians who have aspired to such a partnership have been encouraged to stick to their stethoscopes. We believe that administrators, other hospital professionals, university teachers, and social scientists can all help to locate faults and produce remedies; but these efforts will come to naught unless the doctor brings his medical knowledge and scientific curiosity to the enterprise, and unless he is prepared to discard an organisation of medical work based, as Dr. HAWKINS 16 puts it, on hunches and on " playing it by ear ". Dr. FRY 1 is insistent that this association must not be limited by the hospitals walls; the family doctor must re-enter the hospital and the hospital doctor the community.
MORRISON emphasises the need for partnership between different sorts of doctor; FRY, ANDERSON, and ELLIOTT advocate a continuing partnership between doctor and non-doctor. But, however the emphasis shifts, and whatever form the partnership takes, the professional administrator must provide the stable centre. Stability, however, is not the same as rigidity, and Sir ARTHUR THOMSON 18 declares it essential for administrators to be able to appreciate and savour the quality of fluent disorder which betokens an active life in contact with reality ". He is suspicious of departmental peace; it may be evidence of virtue or it may reflect the " mental torpor of a dull routine ". Good administrators overcome rather than avoid difficulties; and, Sir ARTHUR admits, they are born to trouble as the sparks fly upward. FRY, too, believes that a spark is needed to show what can be done with imaginative use of present resources. For this the most effulgent spark is probably concerned thought, keen inquiry, and lively research by all the diverse enthusiasts who want the N.H.S. to become better. "
12. 13. 14. 15. 16. 17. 18.
Anderson, T. ibid. p. 1246. Morrison, S. L. ibid. p. 1295. Elliott, J. R. ibid. p. 1248. Freeman, H. ibid. p. 1359. Hawkins, L. A. ibid. Fry, J. ibid. p. 1193. Thomson, A. Postprandial Comments on Administration to the Birmingham Regional Hospital Board’s senior management conference on Sept. 19, 1967.
Prostaglandins PROSTAGLANDINS are long-chain fatty-acids with one or more free unesterified alcoholic-OH groups which are essential for their biological activity. In low concentration they have a strong action on smooth muscle, causing either contraction or relaxation according to dose, site, and the particular prostaglandin used. They are found in various tissues, and, though present in only small amounts, they can be identified by their great activity. The name indicates that they were first found in seminal fluid.’ They are absorbed membrane the mucous and, possibly, vaginal through their function here is to decrease uterine tone and thus aid the migration of spermatozoa into the uterine cavity. Today the chemical characteristics of these substances have been fairly thoroughly " examined. There seem to be six primary prostaglandins with the long chains so arranged that they contain a 5-membered ring formed by Cg to C12, and they differ from each other by the position and number of -OH groups and the presence or absence of one or two cis double bonds.2 A combination of chromatographic and biological methods has shown that the prostaglandins can be identified in a number of different tissues, including pancreas, brain, kidney, iris, human menstrual fluid,and possibly others, in addition to semen 2; and on p. 22 Dr. WILLIAMS and his colleagues report the finding of prostaglandins in tumout tissue from 4 out of 7 cases of medullary carcinoma of the thyroid, which may account for the association of diarrhoea with this tumour. Of the seminal fluids examined, only those of man, monkey, sheep, and goat contain prostaglandins, and of these the fluid of man contains the highest concentration. Not all six prostaglandins are present in all tissues, but a number of related substances, which are possibly metabolites, are usually present. The liver and lungs of laboratory animals can remove almost all the prostaglandins passing through them.33 When tritium-labelled prostaglandins are injected, autoradiographs show that they lodge temporarily in a number of tissues, especially connective tissues, some in the uterus, and little or none in the smooth muscle of the intestines. The reasons for and the significance of this distribution are unknown. The prostaglandins are easily formed in tissues by enzyme action on suitable precursors, which are essential fatty-acids. The six primary prostaglandins fall into two groups containing three members each, and are labelled the PGE or E and the PGF or F groups. The two groups do not seem to be interconvertible in any of the tissue homogenates so far examined. The ratio of E to F compounds formed can be varied in vitro and presumably also in vivo. In-vivo changes must be of physiological importance since the two types of compounds have different biological properties. Thus, both groups stimulate the intestinal smooth-muscle of rabbits, but the E substances are ten times more active in reducing blood-pressure by "
1. 2. 3.
Euler, U. S. Arch. exp. Path. Pharmak. 1934, 175, 78. Bergstrom, S. Science, N. Y. 1967, 157, 382. Ferreira, S. H., Vane, J. R. Nature, Lond. 1967, 216, 868.
von
29
ARTICLES
likely to solve its problems of organisation. REVANS does not believe that hospital workers should be like goldfish in a bowl, looked at and reported upon by academics; and he suggests that people in charge of hospitals are THE LANCET best fitted for the job, though they need the help of social scientists. One early fruit of this philosophy has LONDON 6 JANUARY 1968 been the three years’ collaboration at the East Birmingham Hospital of a man of research and a man of administration in a series of venturesdesigned to help the process of change in a neighbouring fever hospital and sanatorium, which, under the hammer of exigency, Flying Sparks were having to transfer themselves almost too rapidly WHENEVER and wherever the rights and wrongs, into one largish district general hospital. A later offmerits or demerits, of the National Health Service are shoot of REVANS’ work is the Hospital Internal Comdiscussed the sparks begin to fly. Reformers are of munications a consortium which 10 hospitals in Project, many kinds. Some are convinced of the need, above all London and the Home Counties have formed for selfelse, to get more money into our hospitals. Suggestions analysis and therapy. For two years members of include the proposals (with their implication of two different professions have worked together to improve standards) for payment per item-of-service and the the service given by their hospitals, to learn how to look extension of private insurance. The philanthropic outside for specialist help, and to pool their experiences. flutterers would pay our doctors out of sweepstake One lively result of these meetings is a report,s written money, while Prof. HENRY MILLER has made a straighta a nurse, an administrator, and forward appeal for another 1% of the national income. jointly by psychiatrist, a teacher of social medicine, describing a survey of Other reformers rely on administration rather than nurses’ and doctors’ reactions to their hospital’s system finance, and they would bring the N.H.S. under a of dealing with emergencies. Another student of the old single authority and strengthen the links which at hospital in the new world is Prof. ROBERT LOGAN, who present join its three divisions only tenuously. The has examined differing patterns of medical activity, not Porritt proposals for autonomous area health boards only in other countries but also, even more closely, in were designed to achieve this in a way which would various parts of Britain.7 He sees the two basic problems deter domination by a local authority biased towards as the gap between care in the home and care in the politics or by a regional board biased towards hospitals. hospital, and the failure to recognise that a changed Many believe that total care would be improved if pattern of disease requires a changed pattern of medical family doctors could move into the local hospital, and if organisation. A similar plea for the redefinition of a hospital doctors would perceive more sensitively the hospital was made last week by Dr. PETER DRAPER8 who patient in his community setting. Others see the gap suggests that community-care units and inpatient units between hospital and family doctor, rooted in old pro- would meet the medical needs of today and tomorrow fessional differences and fed by statute, to be an irre- more realistically than a district general hospital. versible disability. All who look to a restructured Official reports share this awakening interest in Service for a solution will await with eagerness the hospital organisation, though it is perhaps symptomatic Minister’s promised green-paper on the administrative of existing divisions that groups of people, working structure of the N.H.S.2 But it is the actual operation independently, have produced reports which can be of hospitals which is attracting most interest today. translated into action only if they are first made to Much inquiry now concentrates on making the best use interlock. Thus the Farquharson-Lang report9 has of present resources of men, money, and materials. a new perception of the purpose of hospital committees; Applied research is being undertaken in a surprising the Salmon report 10 of the structure of nursing organisanumber of places, and under a diversity of sponsors: tion ; while the proposals 11 of the two working parties lack of coordination makes it difficult to recognise all on the organisation of medical work in hospitals strike this work for what it is-a vigorous movement in the a course between the authoritarian medical superhospitals to make themselves more effective and more intendent and the somewhat ineffectual total democracy responsive to public need. As Dr. HOPKIN remarked of the medical staff committee. The proposed new last week,3 however, this movement must not be medical divisions could well help doctors to manage more allowed to obscure the expensiveness of poor premises their costly effectively hospital assets. That better use of perpetuated by lack of capital to improve or rebuild. our assets needs better medical management is clear not One starting-point was Prof. R. W. REVANS’ pioneer only from the working parties’ reports, but also from the work on morale and effectiveness in some Lancashire
hospitals,4 which showed that the hospital which shaped its style of management so as to recognise the potential contribution of staff to its running was much more 1. See Lancet, 1967, ii, 407. 2. See ibid. 1967, ii, 1047. 3. Hopkin, D. A. B. ibid. 1967, ii, 1417. 4. Revans, R. W. Standards for Morale.
London,
1964.
four diverse contributions
series last month
on
Elliott, J. R. Hospital, 1965, 61, 301, 349, 422. ibid. 1967, 63, 335, 384, 461. Arie, J., Fairey, M. J., Tooley, P. H., Webster, B. ibid. 1967, 63, 377. Logan, R. Studies in the Spectrum of Medical Care. London, 1964. Draper, P. Lancet, 1967, ii, 1406. See ibid. 1966, i, 416. See ibid. p. 1085. See ibid. 1967, ii, 975.
5. Pantall, J., 6. 7. 8. 9. 10. 11.
to our
30
the Doctor as Manager: all agree on the need for doctors to manage medical resources more effectively and to work with administrators and others. Professor ANÐERSON/2 recognising that the limit on the input of resources to the N.H.S. includes the limit on hospital manpower, suggests that revenue-saving need not be confined to the laundry or the boiler-house, but should apply, with some incentives, to medical departments. He believes that hospitals are under-managed, and that we should not be ashamed of spending money on good top management. Professor MORRISON 13 sees the answer in the creation of a specially trained " epidemiologist," a medical administrator who could combine medical, sociological, and statistical skills: this paragon would partner the clinician as a bulwark against bureaucracy. Mr. ELLIOTT 14 shows how the clinician can share with others the task of recognising and remedying defects in the use of resources by using newer management techniques and better statistics; but Dr. FREEMAN 15 retorts unhappily that too many clinicians who have aspired to such a partnership have been encouraged to stick to their stethoscopes. We believe that administrators, other hospital professionals, university teachers, and social scientists can all help to locate faults and produce remedies; but these efforts will come to naught unless the doctor brings his medical knowledge and scientific curiosity to the enterprise, and unless he is prepared to discard an organisation of medical work based, as Dr. HAWKINS 16 puts it, on hunches and on " playing it by ear ". Dr. FRY 1 is insistent that this association must not be limited by the hospitals walls; the family doctor must re-enter the hospital and the hospital doctor the community.
MORRISON emphasises the need for partnership between different sorts of doctor; FRY, ANDERSON, and ELLIOTT advocate a continuing partnership between doctor and non-doctor. But, however the emphasis shifts, and whatever form the partnership takes, the professional administrator must provide the stable centre. Stability, however, is not the same as rigidity, and Sir ARTHUR THOMSON 18 declares it essential for administrators to be able to appreciate and savour the quality of fluent disorder which betokens an active life in contact with reality ". He is suspicious of departmental peace; it may be evidence of virtue or it may reflect the " mental torpor of a dull routine ". Good administrators overcome rather than avoid difficulties; and, Sir ARTHUR admits, they are born to trouble as the sparks fly upward. FRY, too, believes that a spark is needed to show what can be done with imaginative use of present resources. For this the most effulgent spark is probably concerned thought, keen inquiry, and lively research by all the diverse enthusiasts who want the N.H.S. to become better. "
12. 13. 14. 15. 16. 17. 18.
Anderson, T. ibid. p. 1246. Morrison, S. L. ibid. p. 1295. Elliott, J. R. ibid. p. 1248. Freeman, H. ibid. p. 1359. Hawkins, L. A. ibid. Fry, J. ibid. p. 1193. Thomson, A. Postprandial Comments on Administration to the Birmingham Regional Hospital Board’s senior management conference on Sept. 19, 1967.
Prostaglandins PROSTAGLANDINS are long-chain fatty-acids with one or more free unesterified alcoholic-OH groups which are essential for their biological activity. In low concentration they have a strong action on smooth muscle, causing either contraction or relaxation according to dose, site, and the particular prostaglandin used. They are found in various tissues, and, though present in only small amounts, they can be identified by their great activity. The name indicates that they were first found in seminal fluid.’ They are absorbed membrane the mucous and, possibly, vaginal through their function here is to decrease uterine tone and thus aid the migration of spermatozoa into the uterine cavity. Today the chemical characteristics of these substances have been fairly thoroughly " examined. There seem to be six primary prostaglandins with the long chains so arranged that they contain a 5-membered ring formed by Cg to C12, and they differ from each other by the position and number of -OH groups and the presence or absence of one or two cis double bonds.2 A combination of chromatographic and biological methods has shown that the prostaglandins can be identified in a number of different tissues, including pancreas, brain, kidney, iris, human menstrual fluid,and possibly others, in addition to semen 2; and on p. 22 Dr. WILLIAMS and his colleagues report the finding of prostaglandins in tumout tissue from 4 out of 7 cases of medullary carcinoma of the thyroid, which may account for the association of diarrhoea with this tumour. Of the seminal fluids examined, only those of man, monkey, sheep, and goat contain prostaglandins, and of these the fluid of man contains the highest concentration. Not all six prostaglandins are present in all tissues, but a number of related substances, which are possibly metabolites, are usually present. The liver and lungs of laboratory animals can remove almost all the prostaglandins passing through them.33 When tritium-labelled prostaglandins are injected, autoradiographs show that they lodge temporarily in a number of tissues, especially connective tissues, some in the uterus, and little or none in the smooth muscle of the intestines. The reasons for and the significance of this distribution are unknown. The prostaglandins are easily formed in tissues by enzyme action on suitable precursors, which are essential fatty-acids. The six primary prostaglandins fall into two groups containing three members each, and are labelled the PGE or E and the PGF or F groups. The two groups do not seem to be interconvertible in any of the tissue homogenates so far examined. The ratio of E to F compounds formed can be varied in vitro and presumably also in vivo. In-vivo changes must be of physiological importance since the two types of compounds have different biological properties. Thus, both groups stimulate the intestinal smooth-muscle of rabbits, but the E substances are ten times more active in reducing blood-pressure by "
1. 2. 3.
Euler, U. S. Arch. exp. Path. Pharmak. 1934, 175, 78. Bergstrom, S. Science, N. Y. 1967, 157, 382. Ferreira, S. H., Vane, J. R. Nature, Lond. 1967, 216, 868.
von