- Email: [email protected]
HOME, HOSPITAL, OR BIRTHROOM
749 IMPROVED USE OF MEDICAL RESOURCES
SiR,—Your Aug 9 editorial implies that the duty to improve the lies with hospital doctors. Experience in the West Midlands leads me to think that we are doing our duty and will shortly be resenting continuous criticism and advice. Gynaecologists have to accept that many of their patients have to be treated as day cases, only to find that a significant number are not fit to return home in the evening after, for example, laparoscopy or cone biopsy. Hysterectomy involves a shorter and shorter inpatient stay. The patient has to be fit for operation and fit to go home on the sixth day. Cynics might think it is only the fit and well who can tolerate this production-line surgery. Encouraged to run a good cervical cancer screening service, we do-and are then criticised for long clinics and burdened with the problem of the repeat smear. Our management of infertility is criticised nationally and the sketchy regional in vitro fertilisation and artificial insemination services remain seriously underfunded. So the suggestion of use of medical resources
’
"guidelines" will fall on deaf ears unless the guidelines are very simple and practical-for example, routine preoperative chest X-rays and electrocardiograms are not indicated unless there is a definite clinical reason. To manage an increasing amount of work have fewer nurses; those we have are as dedicated as ever. Surely some of the burden must be shared with the community and family practitioner services. This is not happening. In Sandwell District General Hospital, for example, outpatient prescriptions costing 100 000 per annum had to be stopped to prevent ward closure, but the cost in maternal morbidity, perinatal mortality, and gynaecological suffering has yet to be met. The annual bill for drugs prescribed by general practitioners for the population served by the hospital is estimated at 11million. This serious restriction of a hospital consultant’s ability to prescribe directly is a poor reward for a new district general hospital that is providing a great service for a socially deprived area. The waiting list for hip replacement is virtually non-existent thanks to stout efforts by orthopaedic consultants given good facilities. Patients are coming to the hospital from out of the area for such operations, thus increasing the cost to the hospital. Napoleon, who knew about medals, would have provided such a hospital with at least acknowledgment, a state visit, and financial reward. Our national administrators should recognise the need of such a hospital for rerouted funds, and should see that money is spent where it is most needed and most useful, which is in the acute medical service. Nearly all West Midlands hospitals, full of 19th century decay, need upgrading. An explosive Englishmanl wrote "desperate diseases require desperate remedies". Before it comes to that it would seem right that some general adjustment of Health Service funds are made throughout the whole country. In Wolverhampton this might result in more general nurses; more porters to bring patients to theatre (prolonged stops between patients rot the morale of any surgeon); new house-surgeons in general surgery (we are short of five); the drainage of many excellent doctors into general practice might cease-but above all we need improvement in morale. Nearly every day a gynaecologist meets seriously meant criticism and relies more and more on help from his medical defence union. We are encircled, embattled but not yet embittered and need practical encouragement. we
8 Summerfield
Road,
Wolverhampton WV1 4PR
ALAN M. SMITH
1. Fawkes G
(1606). In: Cohen JM, Cohen MJ, eds. Penguin dictionary of quotations. Harmondsworth: Penguin Books, 1960.
COMPULSORY CONTINUING MEDICAL EDUCATION
SIR,-Dr Gray’s paper on continuing education (Aug 23, p 447) does not go far enough. UK medical insurance subscriptions for 1987 will be 70% higher than this year; is this not a "teachable moment" to improve our professional image? The clear need is for compulsory education without which registration can be withdrawn. Critics of such a step often invoke the notion of clinical freedom, but a look at the American scene, where insurance and legal advisers
already control much of medical practice, should make them think again. Unless the medical profession takes action it will be foisted upon us, by unsympathetic agencies. Furthermore, the need to recognise and remedy medical incompetence has been recently discussed,l and it is typically the lazy or unmotivated doctor who does not attend the usual educational meetings. Yet such doctors do create the tone of public disaffection with medicine, even though they may avoid overt negligence cases by simply not being around very much. Who can keep up with the advances in pharmacotherapy, technology, diagnostic ideas, and research outside of one’s own specialty? Not only could refresher courses be excitingly educational, but also they would provide a forum for personal contact, informed debate, and professional coherence. A lecture format, as Gray has shown, would not be helpful, but learning based on seminar discussion, clinical cases, personal experience, and the practical application of new techniques can lead to improved patient Is this not a welcome prospect for all? Or are there too many entrenched interests that benefit from doctors’ ignorance? care.
Institute of Psychiatry, London SE5 8AF 1. Rhodes P.
T. H. TURNER
Incompetence in medical practice. Br Med J 1986; 292: 1293-94.
HOME, HOSPITAL, OR BIRTHROOM SIR,-It is an important advance that in your Aug 30 editorial based on evidence presented at the annual scientific meeting of the Faculty of Community Medicine and in the British Journal of Obstetrics and.Gynaecology, you acknowledge that neither the lack of safety of birth at home nor the greater safety of birth in hospital can be proved. You must therefore agree that there is no justification for denying mothers the facilities for delivery at home and for the insistent propaganda that has frightened them into obstetric hospitals (which are the reasons why so few births take place at home) or for the costly provision of high-technology facilities for all births. Like Prof
Geoffrey Chamberlain, you view favourably the compromise proposal of home-like birthrooms, within the curtilage of the obstetric hospital but separate from it, where uncomplicated deliveries, the great majority, could take place under the care of community midwives and general practitioners. This is an extension of your editorial recommendation of Aug 24,1985, that "a maternity service should aim
to deliver low-risk women either at in small low-technology units" and that the key role of community midwives should be developed, the policy recommended also by the World Health Organisation.1 The only objection to re-establishing a full, safe domiciliary service that Professor Chamberlain could suggest is that it would be too expensive. It is not obvious that establishing birthrooms would cost less. Thereafter their running costs might be similar to those in a general practice unit where, according to previous estimates, they are lower than those in a consultant hospital but considerably higher than those at home. But is it really concern about financial costs to the health service which makes obstetricians and other professionals oppose reorganisation of maternity care? If most births were to take place with low-technology care, the need would be much reduced for high-technology facilities, for obstetricians, anaesthetists, neonatologists, and for makers of equipment and those who service it. Like all other occupational groups whose job prospects and prestige are threatened, they will probably strive to maintain the status quo, but the medical profession and the public should understand that this is to serve their sectional interests and not the interests of mothers and babies.
home
or
Orthopaedic and Accident Surgery, Queen’s Medical Centre, Nottingham NG7 2UH
MARJORIE TEW
1. World Health Organisation Office for Europe. Having a baby in Europe. (Publ Health Europe no 26). Copenhagen: WHO, 1986. 1. Stilwell JA. Relative costs of home and hospital confinement. Br Med J 1979; ii: 257-59.
SiR,—Your Aug 9 editorial implies that the duty to improve the lies with hospital doctors. Experience in the West Midlands leads me to think that we are doing our duty and will shortly be resenting continuous criticism and advice. Gynaecologists have to accept that many of their patients have to be treated as day cases, only to find that a significant number are not fit to return home in the evening after, for example, laparoscopy or cone biopsy. Hysterectomy involves a shorter and shorter inpatient stay. The patient has to be fit for operation and fit to go home on the sixth day. Cynics might think it is only the fit and well who can tolerate this production-line surgery. Encouraged to run a good cervical cancer screening service, we do-and are then criticised for long clinics and burdened with the problem of the repeat smear. Our management of infertility is criticised nationally and the sketchy regional in vitro fertilisation and artificial insemination services remain seriously underfunded. So the suggestion of use of medical resources
’
"guidelines" will fall on deaf ears unless the guidelines are very simple and practical-for example, routine preoperative chest X-rays and electrocardiograms are not indicated unless there is a definite clinical reason. To manage an increasing amount of work have fewer nurses; those we have are as dedicated as ever. Surely some of the burden must be shared with the community and family practitioner services. This is not happening. In Sandwell District General Hospital, for example, outpatient prescriptions costing 100 000 per annum had to be stopped to prevent ward closure, but the cost in maternal morbidity, perinatal mortality, and gynaecological suffering has yet to be met. The annual bill for drugs prescribed by general practitioners for the population served by the hospital is estimated at 11million. This serious restriction of a hospital consultant’s ability to prescribe directly is a poor reward for a new district general hospital that is providing a great service for a socially deprived area. The waiting list for hip replacement is virtually non-existent thanks to stout efforts by orthopaedic consultants given good facilities. Patients are coming to the hospital from out of the area for such operations, thus increasing the cost to the hospital. Napoleon, who knew about medals, would have provided such a hospital with at least acknowledgment, a state visit, and financial reward. Our national administrators should recognise the need of such a hospital for rerouted funds, and should see that money is spent where it is most needed and most useful, which is in the acute medical service. Nearly all West Midlands hospitals, full of 19th century decay, need upgrading. An explosive Englishmanl wrote "desperate diseases require desperate remedies". Before it comes to that it would seem right that some general adjustment of Health Service funds are made throughout the whole country. In Wolverhampton this might result in more general nurses; more porters to bring patients to theatre (prolonged stops between patients rot the morale of any surgeon); new house-surgeons in general surgery (we are short of five); the drainage of many excellent doctors into general practice might cease-but above all we need improvement in morale. Nearly every day a gynaecologist meets seriously meant criticism and relies more and more on help from his medical defence union. We are encircled, embattled but not yet embittered and need practical encouragement. we
8 Summerfield
Road,
Wolverhampton WV1 4PR
ALAN M. SMITH
1. Fawkes G
(1606). In: Cohen JM, Cohen MJ, eds. Penguin dictionary of quotations. Harmondsworth: Penguin Books, 1960.
COMPULSORY CONTINUING MEDICAL EDUCATION
SIR,-Dr Gray’s paper on continuing education (Aug 23, p 447) does not go far enough. UK medical insurance subscriptions for 1987 will be 70% higher than this year; is this not a "teachable moment" to improve our professional image? The clear need is for compulsory education without which registration can be withdrawn. Critics of such a step often invoke the notion of clinical freedom, but a look at the American scene, where insurance and legal advisers
already control much of medical practice, should make them think again. Unless the medical profession takes action it will be foisted upon us, by unsympathetic agencies. Furthermore, the need to recognise and remedy medical incompetence has been recently discussed,l and it is typically the lazy or unmotivated doctor who does not attend the usual educational meetings. Yet such doctors do create the tone of public disaffection with medicine, even though they may avoid overt negligence cases by simply not being around very much. Who can keep up with the advances in pharmacotherapy, technology, diagnostic ideas, and research outside of one’s own specialty? Not only could refresher courses be excitingly educational, but also they would provide a forum for personal contact, informed debate, and professional coherence. A lecture format, as Gray has shown, would not be helpful, but learning based on seminar discussion, clinical cases, personal experience, and the practical application of new techniques can lead to improved patient Is this not a welcome prospect for all? Or are there too many entrenched interests that benefit from doctors’ ignorance? care.
Institute of Psychiatry, London SE5 8AF 1. Rhodes P.
T. H. TURNER
Incompetence in medical practice. Br Med J 1986; 292: 1293-94.
HOME, HOSPITAL, OR BIRTHROOM SIR,-It is an important advance that in your Aug 30 editorial based on evidence presented at the annual scientific meeting of the Faculty of Community Medicine and in the British Journal of Obstetrics and.Gynaecology, you acknowledge that neither the lack of safety of birth at home nor the greater safety of birth in hospital can be proved. You must therefore agree that there is no justification for denying mothers the facilities for delivery at home and for the insistent propaganda that has frightened them into obstetric hospitals (which are the reasons why so few births take place at home) or for the costly provision of high-technology facilities for all births. Like Prof
Geoffrey Chamberlain, you view favourably the compromise proposal of home-like birthrooms, within the curtilage of the obstetric hospital but separate from it, where uncomplicated deliveries, the great majority, could take place under the care of community midwives and general practitioners. This is an extension of your editorial recommendation of Aug 24,1985, that "a maternity service should aim
to deliver low-risk women either at in small low-technology units" and that the key role of community midwives should be developed, the policy recommended also by the World Health Organisation.1 The only objection to re-establishing a full, safe domiciliary service that Professor Chamberlain could suggest is that it would be too expensive. It is not obvious that establishing birthrooms would cost less. Thereafter their running costs might be similar to those in a general practice unit where, according to previous estimates, they are lower than those in a consultant hospital but considerably higher than those at home. But is it really concern about financial costs to the health service which makes obstetricians and other professionals oppose reorganisation of maternity care? If most births were to take place with low-technology care, the need would be much reduced for high-technology facilities, for obstetricians, anaesthetists, neonatologists, and for makers of equipment and those who service it. Like all other occupational groups whose job prospects and prestige are threatened, they will probably strive to maintain the status quo, but the medical profession and the public should understand that this is to serve their sectional interests and not the interests of mothers and babies.
home
or
Orthopaedic and Accident Surgery, Queen’s Medical Centre, Nottingham NG7 2UH
MARJORIE TEW
1. World Health Organisation Office for Europe. Having a baby in Europe. (Publ Health Europe no 26). Copenhagen: WHO, 1986. 1. Stilwell JA. Relative costs of home and hospital confinement. Br Med J 1979; ii: 257-59.