- Email: [email protected]
HEALTH SERVICES IN EIRE
646
being developed for various purposes in many hospitals, and for patients with serious heart-attacks they should provide a range of monitoring apparatus, pacing, defibrillating, and other special instruments, with a team
are
of doctors, nurses, and technicians
at
hand.26
Annotations SANS
TEETH, SANS EYES, SANS TASTE, SANS EVERYTHING
THE
practice in some hospitals of removing spectacles, hearing-aids, and dentures from elderly or mentally disordered patients has lately been raised in Parliament 27 and in the lay Press. Many reasons for depriving patients of these articles are given by nurses, administrators, and doctors. They may be lost or damaged, and relatives will complain. Public money will be wasted on replacements and repairs. Dentures get muddled and patients get the wrong set. Hearing-aids need adjusting, and this takes up valuable nursing time. The patients are too demented to appreciate them. It is the custom of the hospital. Some of these excuses are reasonable, others are not. Relatives do complain if patients lose their possessions, but usually accept an adequate explanation. Spectacles and hearing-aids may be damaged, but the cost of replacement or repair is modest. Sorting out dentures and adjusting hearing-aids is probably a better use of nursing time than many traditional rituals which are still faithfully carried out. Spectacles and hearing-aids can easily be marked with a patient’s name. Dentures present a more difficult problem. New sets can be marked by the dental mechanic, but old ones can only be effectively labelled by cutting the name or initials into the plate. A special ink for marking plastic is used in some hospitals, but the marking only lasts for a short period. But not even the most cogent of these reasons justify depriving patients of the means by which they can eat, and remain in contact with their environment. It is inexcusable to claim that any patient is so demented that he cannot understand or appreciate anything; indeed his symptoms may often have been aggravated by lack of these props. Without their teeth old people may become malnourished; without their spectacles and hearing-aids they will withdraw still further from their surroundings. The affront to personal pride is still sharper, for the removal of a hearing-aid or set of dentures is often only one manifestation of a general stripping of all personal property. This is still the practice in some hospitals despite exhortation and example. A rough method of measuring the efficiency of a geriatric ward is to count the number of patients in bed during the day. Another is to compare the number of personal belongings on or near patients with the number in the sister’s office or stores.
LEPROSY
A NEW W.H.O. report 2gives a useful summary of present thinking about various aspects of leprosy. While it is unexcitingly orthodox on controversial issues, it does offer practical guidance and a simplified classification for field 26. Shillingford, J. P. Proc. R. Soc. Med. 1965, 58, 101. 27. See Lancet, March 5, 1966, p. 553. 28. W.H.O. Expert Committee on Leprosy. Third Report. Tech. Rep. Ser. Wld Hlth Org. 1966, no. 319. 3s. 6d. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1.
projects. As for chemotherapy, we are again assured that sulfone therapy is effective in all types of leprosy ", and that relapse in the lepromatous form is not uncommon. It is stated that " even smaller doses " of dapsone than 600 mg. weekly for an adult may be effective: most workers would now regard such a dose as unnecessarily high. There are welcome and salutary reminders in the report that the prevalence-rate of leprosy is at least double the known rate; that leprosy (and not the sequelx of peripheral-nerve damage) is the real enemy; and that it is more desirable from many viewpoints to reduce the contagiousness of the many than to provide expensive inpatient facilities and "
rehabilitative surgery for the few. In the second part of the report, dealing with research, the advances recorded since the publication of the second report (in 1959) are briefly summarised. Limited multiplication of Mycobacterium leprae has been reported in the mouse foot-pad and also in certain cell strains. The report indicates that research into the many unsolved problems of epidemiology, bacteriology, and immunology is urgently needed, and suggests lines of investigation that could prove crucial in the worldwide campaign against leprosy.
HEALTH SERVICES IN EIRE
THE Government of Eire has put out a white-paper1 describing the origins of health services in the country, the pattern of present services, and proposals for the future. The existing structure has grown from three original stems,. based on the Poor Law, control of infectious diseases, and mental treatment services. There was a movement towards unification under legislation passed since 1923, but not until the late 1940s did the modern concept of a group of services specially organised and coordinated come into being. The Health Act, 1953, provided for extension of some important services to a much wider class than that previously entitled to them; thus,
general-hospital and specialist services, which had been available only to those who could establish entitlement strict means test, were extended at that time to 85% of the people. To determine the availability of health services, the population is divided into three income groups-lower, middle, and higher. The first is made up of people who can satisfy the local authorities of their inability to pay for these services. The middle group includes persons insured under the Social Welfare Acts; other persons in nonmanual work over 16 years of age whose yearly income, assessed on a husband-plus-wife basis, does not exceed (as now proposed) El 200; and other persons whose income is derived mainly from farming, the rateable value of the farm being E60 or less. This middle income group covers about 60% of the population. All three groups are eligible for the infectious-diseases and rehabilitation services, but only the lower income group for general medical services, maternity cash grants, milk for mothers and children, and maintenance in county homes. At present each local authority is obliged under the Health Act, 1953, to make available " a general practitioner medical and surgical service, medicine, and medical and surgical appliances " without charge for all the lower income group. This is provided through a dispensary service by district medical officers, who are usually provided with residences by the health authorities and are free to under
a
some
1. The Health Services and their Further Stationery Office, 1966. 4s.
Development.
Pr 8653. Dublin:
647
engage in private practice. The Government proposes that in future the general-practitioner services should be rearranged, so that those whose medical care is paid for by the health authorities will be able to get the same kind of service as others can now get by private arrangement. This involves substituting for the present dispensary arrangement a service with the greatest practicable choice of doctor, and the least practicable distinction between private patients and those availing themselves of the service. Payment of doctors would be on a basis to be negotiated with the medical organisations: "a capitation Because it system seems the most practicable". would be preferable if those who use the service were able to obtain medicines through the same channels as private patients, it is hoped to arrange for prescriptions to be dispensed by retail chemists from stocks supplied by the health authority. Arrangements will be made to assist persons in the middle income group to obtain particularly expensive drugs; but the Government proposes that the limits of eligibility for the new general medical service should not be such as to include a high proportion of the population, for " the evidence that is available would indicate that hardship is seldom caused in the middleincome group through family doctors’ bills ". As soon as practicable, ophthalmic and aural services would be extended to the middle income group generally, with charges up to half the cost, or up to E5for hearingaids. Legislation would permit health centres to arrange, without reference to income groups, programmes for screening for symptoms of specified diseases, in accordance with regulations made by the Minister for Health. The district nursing service would be available, free of charge, to members of the middle income group for home nursing of the aged and chronic sick. A home-help service would be introduced, with the cooperation of voluntary organisations. The intention is to improve geriatric services and to encourage local coordination of the various public and voluntary resources available to the
The administration of health services, the white-paper suggests, should be transferred from existing local health authorities to special regional boards, partly appointed by the Minister for Health and partly elected by county and county-borough councils. The regional, county, and district hospitals would be transferred to the boards, but the voluntary hospitals would remain in their present ownership. Within the limits of available resources, the regional boards would have considerable freedom in administering and developing the service. In future, the white-paper concludes, the Department of Health should be concerned more with forward planning in the general context of social and economic developments.
aged.
applications and, as herbicides, bactericides, fungicides, molluscicides, and insecticides, they have proved invaluable. By their success in timber preservation alone, they have established themselves. Many an ancient building, and many others that are not so antique, have been saved by this means from inexorable damage. Moreover, in Britain at least, their record of safety, despite widespread
At present persons in the middle income group may be to 10s. a day while in hospital, and this charge will be retained. Where an eligible person opts to go into an approved hospital or nursing-home of his own choice, the health authority will make a payment to that hospital equivalent to what the local authority would pay for a patient it had sent there, less 10s. a day. To stimulate the use of hospital outpatient services, charges for specialist services there (e.g., X-rays) will be abolished. The Government will continue to encourage the work of the Voluntary Hospital Insurance Board set up in 1957 to offer insurance against major medical expenditure: about 250,000 persons are insured with the Board. The total cost of the health services has risen from E5-7 million in 1948 to E30 million now, and the cost of the various proposals put forward in the white-paper is estimated at E4-2 million. The State at present meets half the annual running cost of the service, and the plan is that this additional cost should not be a charge on local rates. The main source of funds for capital expenditure on the health service has been the Irish hospital sweepstakes. Over the past seventeen years, capital expenditure on hospitals and other institutions was E34-9 million, of which E21-6 million was provided from sweepstakes, E6-0 million by local authorities, and E7-3 million by the State; but no-one expects that money from the sweepstakes will now be sufficient to meet the cost of the programme.
charged up
PENTACHLOROPHENOL
IN Britain pentachlorophenol and the related watersoluble pentachlorophenates are not listed statutorily as poisons-but that is not to say they are entirely innocuous. According to Hayes/ these substances, which are used to preserve timber and other materials, can be absorbed by the skin as well as by ingestion and inhalation. On the skin and eyes they have an irritant, burning effect. Systemically, they seem to resemble the dinitrophenols and, by an uncoupling action on cellular oxidation and phosphorylation, they increase metabolism. The symptoms and signs of overexposure are weakness, loss of weight, dyspnoea, and excessive sweating. The bodytemperature is raised, sometimes considerably, the pulse is rapid, dehydration follows, and ultimately there may be coma and collapse. Post mortem there are no distinctive changes, though the chemical may be detected in the tissues and in the urine. From this account, the pentachlorophenates seem to be sinister indeed, and it might seem reasonable to use them only when absolutely necessary and to handle them with the utmost respect. Yet in practice they have many
use, is almost unblemished-if one excepts a misadventure to a child, who fortunately suffered no serious harm.2 Elsewhere, however, accidents have been recorded, some of them fatal .3-1 What is the explanation of this geographical discrepancy ? Simply, perhaps, that adequate precautions in handling are better advertised and more carefully followed in Britain. Thus, so far as herbicide application is concerned in this country, the Ministry of Agriculture, Fisheries and Food has issued, under its notification scheme for chemicals used in " agriculture and food storage, a recommendation sheet " specifying: the wearing of gloves and face-shield when the concentrate is handled; washing of gloves inside and out after use; immediate removal of heavily contaminated clothing; avoidance of all contact by mouth, and no 1. 2. 3. 4. 5. 6. 7.
Hayes, W. J., Jr. Clinical Handbook on Economic Poisons. U.S. Department of Health, Education and Welfare. Atlanta, Georgia, 1963. Chapman, J. B., Robson, P. Lancet, 1965, i, 1266. Truhaut, R., L’Epee, P., Boussemart, E. Archs Mal. prof. Méd. trav. 1952, 13, 567. Nomura, S. J. Sci. Labour, Tokyo, 1953, 29, 474. Gordon, D. Med. J. Aust. 1956, ii, 485. Menon, J. A. Br. med. J. 1958, i, 1156. Shaw, G. A. ibid. 1958, ii, 105.
being developed for various purposes in many hospitals, and for patients with serious heart-attacks they should provide a range of monitoring apparatus, pacing, defibrillating, and other special instruments, with a team
are
of doctors, nurses, and technicians
at
hand.26
Annotations SANS
TEETH, SANS EYES, SANS TASTE, SANS EVERYTHING
THE
practice in some hospitals of removing spectacles, hearing-aids, and dentures from elderly or mentally disordered patients has lately been raised in Parliament 27 and in the lay Press. Many reasons for depriving patients of these articles are given by nurses, administrators, and doctors. They may be lost or damaged, and relatives will complain. Public money will be wasted on replacements and repairs. Dentures get muddled and patients get the wrong set. Hearing-aids need adjusting, and this takes up valuable nursing time. The patients are too demented to appreciate them. It is the custom of the hospital. Some of these excuses are reasonable, others are not. Relatives do complain if patients lose their possessions, but usually accept an adequate explanation. Spectacles and hearing-aids may be damaged, but the cost of replacement or repair is modest. Sorting out dentures and adjusting hearing-aids is probably a better use of nursing time than many traditional rituals which are still faithfully carried out. Spectacles and hearing-aids can easily be marked with a patient’s name. Dentures present a more difficult problem. New sets can be marked by the dental mechanic, but old ones can only be effectively labelled by cutting the name or initials into the plate. A special ink for marking plastic is used in some hospitals, but the marking only lasts for a short period. But not even the most cogent of these reasons justify depriving patients of the means by which they can eat, and remain in contact with their environment. It is inexcusable to claim that any patient is so demented that he cannot understand or appreciate anything; indeed his symptoms may often have been aggravated by lack of these props. Without their teeth old people may become malnourished; without their spectacles and hearing-aids they will withdraw still further from their surroundings. The affront to personal pride is still sharper, for the removal of a hearing-aid or set of dentures is often only one manifestation of a general stripping of all personal property. This is still the practice in some hospitals despite exhortation and example. A rough method of measuring the efficiency of a geriatric ward is to count the number of patients in bed during the day. Another is to compare the number of personal belongings on or near patients with the number in the sister’s office or stores.
LEPROSY
A NEW W.H.O. report 2gives a useful summary of present thinking about various aspects of leprosy. While it is unexcitingly orthodox on controversial issues, it does offer practical guidance and a simplified classification for field 26. Shillingford, J. P. Proc. R. Soc. Med. 1965, 58, 101. 27. See Lancet, March 5, 1966, p. 553. 28. W.H.O. Expert Committee on Leprosy. Third Report. Tech. Rep. Ser. Wld Hlth Org. 1966, no. 319. 3s. 6d. Obtainable from H.M. Stationery Office, P.O. Box 569, London, S.E.1.
projects. As for chemotherapy, we are again assured that sulfone therapy is effective in all types of leprosy ", and that relapse in the lepromatous form is not uncommon. It is stated that " even smaller doses " of dapsone than 600 mg. weekly for an adult may be effective: most workers would now regard such a dose as unnecessarily high. There are welcome and salutary reminders in the report that the prevalence-rate of leprosy is at least double the known rate; that leprosy (and not the sequelx of peripheral-nerve damage) is the real enemy; and that it is more desirable from many viewpoints to reduce the contagiousness of the many than to provide expensive inpatient facilities and "
rehabilitative surgery for the few. In the second part of the report, dealing with research, the advances recorded since the publication of the second report (in 1959) are briefly summarised. Limited multiplication of Mycobacterium leprae has been reported in the mouse foot-pad and also in certain cell strains. The report indicates that research into the many unsolved problems of epidemiology, bacteriology, and immunology is urgently needed, and suggests lines of investigation that could prove crucial in the worldwide campaign against leprosy.
HEALTH SERVICES IN EIRE
THE Government of Eire has put out a white-paper1 describing the origins of health services in the country, the pattern of present services, and proposals for the future. The existing structure has grown from three original stems,. based on the Poor Law, control of infectious diseases, and mental treatment services. There was a movement towards unification under legislation passed since 1923, but not until the late 1940s did the modern concept of a group of services specially organised and coordinated come into being. The Health Act, 1953, provided for extension of some important services to a much wider class than that previously entitled to them; thus,
general-hospital and specialist services, which had been available only to those who could establish entitlement strict means test, were extended at that time to 85% of the people. To determine the availability of health services, the population is divided into three income groups-lower, middle, and higher. The first is made up of people who can satisfy the local authorities of their inability to pay for these services. The middle group includes persons insured under the Social Welfare Acts; other persons in nonmanual work over 16 years of age whose yearly income, assessed on a husband-plus-wife basis, does not exceed (as now proposed) El 200; and other persons whose income is derived mainly from farming, the rateable value of the farm being E60 or less. This middle income group covers about 60% of the population. All three groups are eligible for the infectious-diseases and rehabilitation services, but only the lower income group for general medical services, maternity cash grants, milk for mothers and children, and maintenance in county homes. At present each local authority is obliged under the Health Act, 1953, to make available " a general practitioner medical and surgical service, medicine, and medical and surgical appliances " without charge for all the lower income group. This is provided through a dispensary service by district medical officers, who are usually provided with residences by the health authorities and are free to under
a
some
1. The Health Services and their Further Stationery Office, 1966. 4s.
Development.
Pr 8653. Dublin:
647
engage in private practice. The Government proposes that in future the general-practitioner services should be rearranged, so that those whose medical care is paid for by the health authorities will be able to get the same kind of service as others can now get by private arrangement. This involves substituting for the present dispensary arrangement a service with the greatest practicable choice of doctor, and the least practicable distinction between private patients and those availing themselves of the service. Payment of doctors would be on a basis to be negotiated with the medical organisations: "a capitation Because it system seems the most practicable". would be preferable if those who use the service were able to obtain medicines through the same channels as private patients, it is hoped to arrange for prescriptions to be dispensed by retail chemists from stocks supplied by the health authority. Arrangements will be made to assist persons in the middle income group to obtain particularly expensive drugs; but the Government proposes that the limits of eligibility for the new general medical service should not be such as to include a high proportion of the population, for " the evidence that is available would indicate that hardship is seldom caused in the middleincome group through family doctors’ bills ". As soon as practicable, ophthalmic and aural services would be extended to the middle income group generally, with charges up to half the cost, or up to E5for hearingaids. Legislation would permit health centres to arrange, without reference to income groups, programmes for screening for symptoms of specified diseases, in accordance with regulations made by the Minister for Health. The district nursing service would be available, free of charge, to members of the middle income group for home nursing of the aged and chronic sick. A home-help service would be introduced, with the cooperation of voluntary organisations. The intention is to improve geriatric services and to encourage local coordination of the various public and voluntary resources available to the
The administration of health services, the white-paper suggests, should be transferred from existing local health authorities to special regional boards, partly appointed by the Minister for Health and partly elected by county and county-borough councils. The regional, county, and district hospitals would be transferred to the boards, but the voluntary hospitals would remain in their present ownership. Within the limits of available resources, the regional boards would have considerable freedom in administering and developing the service. In future, the white-paper concludes, the Department of Health should be concerned more with forward planning in the general context of social and economic developments.
aged.
applications and, as herbicides, bactericides, fungicides, molluscicides, and insecticides, they have proved invaluable. By their success in timber preservation alone, they have established themselves. Many an ancient building, and many others that are not so antique, have been saved by this means from inexorable damage. Moreover, in Britain at least, their record of safety, despite widespread
At present persons in the middle income group may be to 10s. a day while in hospital, and this charge will be retained. Where an eligible person opts to go into an approved hospital or nursing-home of his own choice, the health authority will make a payment to that hospital equivalent to what the local authority would pay for a patient it had sent there, less 10s. a day. To stimulate the use of hospital outpatient services, charges for specialist services there (e.g., X-rays) will be abolished. The Government will continue to encourage the work of the Voluntary Hospital Insurance Board set up in 1957 to offer insurance against major medical expenditure: about 250,000 persons are insured with the Board. The total cost of the health services has risen from E5-7 million in 1948 to E30 million now, and the cost of the various proposals put forward in the white-paper is estimated at E4-2 million. The State at present meets half the annual running cost of the service, and the plan is that this additional cost should not be a charge on local rates. The main source of funds for capital expenditure on the health service has been the Irish hospital sweepstakes. Over the past seventeen years, capital expenditure on hospitals and other institutions was E34-9 million, of which E21-6 million was provided from sweepstakes, E6-0 million by local authorities, and E7-3 million by the State; but no-one expects that money from the sweepstakes will now be sufficient to meet the cost of the programme.
charged up
PENTACHLOROPHENOL
IN Britain pentachlorophenol and the related watersoluble pentachlorophenates are not listed statutorily as poisons-but that is not to say they are entirely innocuous. According to Hayes/ these substances, which are used to preserve timber and other materials, can be absorbed by the skin as well as by ingestion and inhalation. On the skin and eyes they have an irritant, burning effect. Systemically, they seem to resemble the dinitrophenols and, by an uncoupling action on cellular oxidation and phosphorylation, they increase metabolism. The symptoms and signs of overexposure are weakness, loss of weight, dyspnoea, and excessive sweating. The bodytemperature is raised, sometimes considerably, the pulse is rapid, dehydration follows, and ultimately there may be coma and collapse. Post mortem there are no distinctive changes, though the chemical may be detected in the tissues and in the urine. From this account, the pentachlorophenates seem to be sinister indeed, and it might seem reasonable to use them only when absolutely necessary and to handle them with the utmost respect. Yet in practice they have many
use, is almost unblemished-if one excepts a misadventure to a child, who fortunately suffered no serious harm.2 Elsewhere, however, accidents have been recorded, some of them fatal .3-1 What is the explanation of this geographical discrepancy ? Simply, perhaps, that adequate precautions in handling are better advertised and more carefully followed in Britain. Thus, so far as herbicide application is concerned in this country, the Ministry of Agriculture, Fisheries and Food has issued, under its notification scheme for chemicals used in " agriculture and food storage, a recommendation sheet " specifying: the wearing of gloves and face-shield when the concentrate is handled; washing of gloves inside and out after use; immediate removal of heavily contaminated clothing; avoidance of all contact by mouth, and no 1. 2. 3. 4. 5. 6. 7.
Hayes, W. J., Jr. Clinical Handbook on Economic Poisons. U.S. Department of Health, Education and Welfare. Atlanta, Georgia, 1963. Chapman, J. B., Robson, P. Lancet, 1965, i, 1266. Truhaut, R., L’Epee, P., Boussemart, E. Archs Mal. prof. Méd. trav. 1952, 13, 567. Nomura, S. J. Sci. Labour, Tokyo, 1953, 29, 474. Gordon, D. Med. J. Aust. 1956, ii, 485. Menon, J. A. Br. med. J. 1958, i, 1156. Shaw, G. A. ibid. 1958, ii, 105.