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Foundations for Health Service Management
Publ. Hlth, Lond. (1973) 87, I43-150
Book Reviews SURVIVAL OF THE UNFITTEST,by Bernard lsaacs, Maureen Livingstone & Yvonne Neville. Pp. 170. London, Routledge & Kegan Paul, 1972. £2.50. COmMUNTTYPHYSICIANSare well aware of the acute or chronic social breakdown in old age, often complicated by a medical emergency and urgently demanding a solution which should have been reached weeks earlier. This book explores the subject against the difficult social background of Glasgow. The authors conclude from their clinical and statistical studies that too many of the unfittest have been allowed to survive unprotected into old age and that national policies must now ensure for them a proper environment. This means o f course more specialized housing and more social services, so that the tragic emergencies which we all encounter fi'om time to time can be prevented by early and effective action. This is a very human book, full of experience and wisdom, scientific and statistical enough for most of us, with enough personal case-histories to hold the interest and stir the hearts of lay members of committees. Dr Trevor Howell has compared this book favourably with Sheldon's Social History of OM Age and it may well prove to have an equal impact. Certainly something is needed to awake the national conscience. The hard core, of geriatric disability is an intolerable social evil. Life today generally ends with a prolonged period of dependency and it is useless to shut one's eyes to the fact. Efficient social ,measures applied early enough can remedy this situation. This valuable survey is strongly recommended to every community physician.
HEALTH, MANPOWER AND THE MEDICAL AUXILIARY,by Oscar Gish, Kenneth R. Hill & Kathcrirlc EIliott. Pp. 65. London, Intermediate Technology Group Ltd, 1971. £1.50. IT IS false economics to build an expensive teaching hospital in a poor developing country which can only turn out a few super medical specialists. There is one doctor per 500 people in U.K. compared with one to 150,000 in Northern Nigeria. The authors come down decisively for the alternative spread of many health centres in the rural areas where 80% of the people live, to be manned by medical auxiliaries, if possible, under medical supervision. The medical assistants, because of general lack of higher education in their countries, are more readily available than university doctors, and can be trained and retained much more cheaply. In addition, he is far more acceptable to peasant communities. The few highly trained doctors on the other hand, tend to emigrate to the developed countries, and if they stay, congregate in the few towns. The urgent need is not for original research, but for the application of long established techniques of immunization, pest control, sanitation, nutrition, etc., which can readily be taught to the medical auxiliary, Even in ~he U.K. and U.S.A. there is a reaction against the continued growth of hospital medicine at the expense of community medicine. In developed and developing countries alike there is opposition by doctors to the "dilution" of their services, but in spite of this, health centres arid the attachment of paramedical staff are increasing in Great Britain'. Dr Eiliott has provided a summary of known medical assistant schemes including the "feldsher" of lhe U.S.S.R. and the "peasant doctor" of China. M~: Gish, in addition to a masterly paper on resources in developing countries, has added an excellently annotated bibliography. In the words of Professor H i l l - - " T h e medical profession itself must be prepared to undertake the responsibility for planning the training and the use of medical auxiliaries throughout the world." FOUNDATIONS FOR HEALTH SERVICE MANAGEMENT,by K. E. Bodenhaun & F. Wellman. Pp. 112. London, Oxford University Press, 1972. £1.00. SCIENTIFIC CONTROL SYSTEMSLTD were commissioned by the Scottish Home and Health Department to undertake a preliminary study o f requirements o f a managerial and administration data system for an integrated health service. The chief aim has been to identify more closely the areas of data deserving special attention and the problems to be overcome. The authors state that although
144
PUBLIC HEALTH VOL. 87 NO. 4
health service systems will make increasing use of computers, the review avoids specific mention of them wherever possible. In many ways, however, the report could be seen as an appraisal of methods of using computers in the National ~" ~;ervice. The writers recommend the establishment ~c register of people in an area. This register could form the basis of data on such activi~. ~pital discharges, immunization programmes and notification of special disabilities. The fore~ ,,-~ raises the question of breaches of confidentiality and pleads for a sober debate on the subject, but the question is more fundamental. Do we want a society where every man, woman and child is registered with appropriate supporting information ? This type of data bank would permit the marshalling of individuals and society to a degree not previously possible. Many people see a conflict between democracy and efficiency. There could be a conflict between efficiency and personal freedom. The book is clear and gives a lucid account of many of the fields in which the computer can be used. Perhaps the phasing of developments could be regarded as the most controversial suggestion made because first priority is given to facts associated with functional activities such as processing of prescription data to pay chemists, and the second to management criteria such as the collection and processing of data on staff, and third priority is given to research. It may well be that the greatest benefit of the extended use of the computer could be obtained at the interface between research and management. The proper evaluation of techniques at present in vogue might lead to a complete re-orientation of parts of the new National Health Service. It is a useful book, clear, concise and well written, and if considered in depth is certainly thoughtprovoking. ENVIRONMENTAL LEGISLATION, by William D. Hurley. Pp. 81. Springfield, Illinois, 1971. $6.50. THIS ROOKfurnishes a concise statement of the modern legal efforts to control water, air and waste products pollution in the U.S.A. The relationship between federal, state and local governments is considered with particular reference to a restricted rule enforcement by the administering authorities without federal financial assistance, because of insufficient trained officers, opposition from ir.dustry and reluctance to institute legal proceedings. Water and waste disposal are dealt with in toto but air pollution does not include domestic smoke as in Britain. They consider that petrol and diesel fumes form the major problem. An interesting book, affording comparison with our own anti-pollution efforts. THE PREVENTION OF PE,RINATAL MORBIDITY AND MORTALITY. Report o n a Seminar, Tours, April
1969. Pp. 97. Geneva, World Health Organization, 1971.60p. Tins' SEMINARwas attended by 45 participants from 29 European countries in which the perinatal mortality varies between 19 and 43 per 1000 births. Some of the variations are due to differences in recording. There was general agreement as to the underlying causes of perinatal death and the methods of prevention. The factors influencing perinatal mortality were summarized as follows: (I) social and biological history of mother---height, parity, age, socio-ecoaomic status; (2) obstetric history; (3) course of gestation and (4) birth weight of baby. Ante-partum deaths should be reduced by better ante-natal care and early diagnosis of abnormalities. Intra-partum deaths should be reduced by better obstetric technique and the identification and specialist treatment of high risk patients. Early neonatal deaths are associated with low birth weight and congenital malformation. Malformations account for 10 to 3 0 ~ perinatal deaths. Twenty per cent of them are operable. Several interesting points were stressed. Low birth weight was associated with mother's weight and diet, with heavy smoking in pregnancy an6 in living at high altitudes. Premature delivery was sotnetimes associated with cervical dilation following one or more terminations. Some general recommendations were made on the organization of care: (1) improvement of the general health of the population, of social conditions and of education; (2) improved ante-natal surveillance, especially of high risk pregnancies; (3) improved facilities for delivery and resu~itation and care of newborn; (4) post-natal surveillance of high risk babies and (5) undergraduate a ~ post-
Book Reviews SURVIVAL OF THE UNFITTEST,by Bernard lsaacs, Maureen Livingstone & Yvonne Neville. Pp. 170. London, Routledge & Kegan Paul, 1972. £2.50. COmMUNTTYPHYSICIANSare well aware of the acute or chronic social breakdown in old age, often complicated by a medical emergency and urgently demanding a solution which should have been reached weeks earlier. This book explores the subject against the difficult social background of Glasgow. The authors conclude from their clinical and statistical studies that too many of the unfittest have been allowed to survive unprotected into old age and that national policies must now ensure for them a proper environment. This means o f course more specialized housing and more social services, so that the tragic emergencies which we all encounter fi'om time to time can be prevented by early and effective action. This is a very human book, full of experience and wisdom, scientific and statistical enough for most of us, with enough personal case-histories to hold the interest and stir the hearts of lay members of committees. Dr Trevor Howell has compared this book favourably with Sheldon's Social History of OM Age and it may well prove to have an equal impact. Certainly something is needed to awake the national conscience. The hard core, of geriatric disability is an intolerable social evil. Life today generally ends with a prolonged period of dependency and it is useless to shut one's eyes to the fact. Efficient social ,measures applied early enough can remedy this situation. This valuable survey is strongly recommended to every community physician.
HEALTH, MANPOWER AND THE MEDICAL AUXILIARY,by Oscar Gish, Kenneth R. Hill & Kathcrirlc EIliott. Pp. 65. London, Intermediate Technology Group Ltd, 1971. £1.50. IT IS false economics to build an expensive teaching hospital in a poor developing country which can only turn out a few super medical specialists. There is one doctor per 500 people in U.K. compared with one to 150,000 in Northern Nigeria. The authors come down decisively for the alternative spread of many health centres in the rural areas where 80% of the people live, to be manned by medical auxiliaries, if possible, under medical supervision. The medical assistants, because of general lack of higher education in their countries, are more readily available than university doctors, and can be trained and retained much more cheaply. In addition, he is far more acceptable to peasant communities. The few highly trained doctors on the other hand, tend to emigrate to the developed countries, and if they stay, congregate in the few towns. The urgent need is not for original research, but for the application of long established techniques of immunization, pest control, sanitation, nutrition, etc., which can readily be taught to the medical auxiliary, Even in ~he U.K. and U.S.A. there is a reaction against the continued growth of hospital medicine at the expense of community medicine. In developed and developing countries alike there is opposition by doctors to the "dilution" of their services, but in spite of this, health centres arid the attachment of paramedical staff are increasing in Great Britain'. Dr Eiliott has provided a summary of known medical assistant schemes including the "feldsher" of lhe U.S.S.R. and the "peasant doctor" of China. M~: Gish, in addition to a masterly paper on resources in developing countries, has added an excellently annotated bibliography. In the words of Professor H i l l - - " T h e medical profession itself must be prepared to undertake the responsibility for planning the training and the use of medical auxiliaries throughout the world." FOUNDATIONS FOR HEALTH SERVICE MANAGEMENT,by K. E. Bodenhaun & F. Wellman. Pp. 112. London, Oxford University Press, 1972. £1.00. SCIENTIFIC CONTROL SYSTEMSLTD were commissioned by the Scottish Home and Health Department to undertake a preliminary study o f requirements o f a managerial and administration data system for an integrated health service. The chief aim has been to identify more closely the areas of data deserving special attention and the problems to be overcome. The authors state that although
144
PUBLIC HEALTH VOL. 87 NO. 4
health service systems will make increasing use of computers, the review avoids specific mention of them wherever possible. In many ways, however, the report could be seen as an appraisal of methods of using computers in the National ~" ~;ervice. The writers recommend the establishment ~c register of people in an area. This register could form the basis of data on such activi~. ~pital discharges, immunization programmes and notification of special disabilities. The fore~ ,,-~ raises the question of breaches of confidentiality and pleads for a sober debate on the subject, but the question is more fundamental. Do we want a society where every man, woman and child is registered with appropriate supporting information ? This type of data bank would permit the marshalling of individuals and society to a degree not previously possible. Many people see a conflict between democracy and efficiency. There could be a conflict between efficiency and personal freedom. The book is clear and gives a lucid account of many of the fields in which the computer can be used. Perhaps the phasing of developments could be regarded as the most controversial suggestion made because first priority is given to facts associated with functional activities such as processing of prescription data to pay chemists, and the second to management criteria such as the collection and processing of data on staff, and third priority is given to research. It may well be that the greatest benefit of the extended use of the computer could be obtained at the interface between research and management. The proper evaluation of techniques at present in vogue might lead to a complete re-orientation of parts of the new National Health Service. It is a useful book, clear, concise and well written, and if considered in depth is certainly thoughtprovoking. ENVIRONMENTAL LEGISLATION, by William D. Hurley. Pp. 81. Springfield, Illinois, 1971. $6.50. THIS ROOKfurnishes a concise statement of the modern legal efforts to control water, air and waste products pollution in the U.S.A. The relationship between federal, state and local governments is considered with particular reference to a restricted rule enforcement by the administering authorities without federal financial assistance, because of insufficient trained officers, opposition from ir.dustry and reluctance to institute legal proceedings. Water and waste disposal are dealt with in toto but air pollution does not include domestic smoke as in Britain. They consider that petrol and diesel fumes form the major problem. An interesting book, affording comparison with our own anti-pollution efforts. THE PREVENTION OF PE,RINATAL MORBIDITY AND MORTALITY. Report o n a Seminar, Tours, April
1969. Pp. 97. Geneva, World Health Organization, 1971.60p. Tins' SEMINARwas attended by 45 participants from 29 European countries in which the perinatal mortality varies between 19 and 43 per 1000 births. Some of the variations are due to differences in recording. There was general agreement as to the underlying causes of perinatal death and the methods of prevention. The factors influencing perinatal mortality were summarized as follows: (I) social and biological history of mother---height, parity, age, socio-ecoaomic status; (2) obstetric history; (3) course of gestation and (4) birth weight of baby. Ante-partum deaths should be reduced by better ante-natal care and early diagnosis of abnormalities. Intra-partum deaths should be reduced by better obstetric technique and the identification and specialist treatment of high risk patients. Early neonatal deaths are associated with low birth weight and congenital malformation. Malformations account for 10 to 3 0 ~ perinatal deaths. Twenty per cent of them are operable. Several interesting points were stressed. Low birth weight was associated with mother's weight and diet, with heavy smoking in pregnancy an6 in living at high altitudes. Premature delivery was sotnetimes associated with cervical dilation following one or more terminations. Some general recommendations were made on the organization of care: (1) improvement of the general health of the population, of social conditions and of education; (2) improved ante-natal surveillance, especially of high risk pregnancies; (3) improved facilities for delivery and resu~itation and care of newborn; (4) post-natal surveillance of high risk babies and (5) undergraduate a ~ post-