- Email: [email protected]
HOSPITAL ADMINISTRATOR'S PARADOX
1026 MENTAL HANDICAP AND THE COMMUNITY
S]R,—A note in your issue of Sept 10 (p 637) discusses the dilemma of clinical responsibility for mentally handicapped patients in the light of community care policies being adopted by health authorities. Since 1983 Wales has been implementing a strategy for the mentally handicappedl and similar problems are being encountered. The Mid-Glamorgan Health Authority, which manages Hensol Hospital, a large hospital caring for the long-term needs of mentally handicapped patients from three counties, has adopted a plan which, if successful, may not only answer the "whose responsibility?" question but also release for work in the community a significant amount of specialists’ time which is being wasted on bureaucratic procedures attached to so-called "patient care and responsibility". All the 400 or so patients/residents in Hensol Hospital have been reviewed by the consultants responsible for their care. Those who need "clinical or consultant care and treatment" (ie, those who have mental illness, severe behaviour problems, and other psychiatric disorders) are "patients" and those who do not need clinical care on the above criteria and had been admitted only for their mental handicap are "residents". This review revealed that 3 out of every 4 of those in Hensol Hospital are residents, not patients. The care and treatment of patients will remain under consultant supervision while the care for the residents will be provided by a community medical officer with experience of mental handicap, who will act as proxy general practitioner. The medical officer will provide general medical care and liaise with the unit’s general manager, with psychologists, and with social services departments and other voluntary and statutory agencies to expedite transfer to residential placements in the community. Whenever there is a need for specialist help consultant advice can be sought through the internal referral system. In this way specialist time is released to support the developing community-based services. We hope that this approach will prove to be a practical and acceptable alternative to the obsolete bureaucratic system that makes consultants in mental handicap responsible for many irrelevant processes and the care of people who are not "patients" on any clinical criteria but long-term residents who had been inappropriately admitted years ago for social rather than psychiatric reasons. It should also reduce the conflict of leadership between doctors and other members of the mental handicap teams that have the task of rehabilitating these long-term residents. The clinical responsibility (and, therefore, leadership) for clinically defined patients would be the task of the consultant in the multidisciplinary team.
contains an implicit premise which, if inserted, makes the administrator’s stance appear dubious and at the same time makes the clinician’s position vulnerable. The complete argument should read: (1) there is a finite amount of disease within a community which we, as doctors and patients, perceive needs treatment; (2) there is a finite amount of money available within hospitals to treat that disease; (3) therefore if a cheaper method of treating a specific disease becomes available more patients with that disease are treated. One could argue at our use of the word "finite"; nevertheless the analogy of a hospital service as an engine for producing more health in the community is not unreasonable. If any part of it works more effectively then the whole, theoretically, should not be less efficient. However, if the argument is modified by leaving out the first premise, the administrator’s paradox can easily be generated: (1)-; (2) since there is a finite amount of money to be used by the hospital and (3) since there is a new cheaper method for treating disease, it follows that (4) all you have achieved is an increase in turnover without saving money. This situation was illustrated in one episode of the BBC TV comedy series Yes, Minister in which a "hospital administrator" argued that to introduce patients into a new hospital could only serve to reduce efficiency. The paradox can only be produced when doctors and administrators forget why they are working in a health service. How do doctors view premise (1) -is there a finite amount of disease within the community? Logic dictates that there is, but just how much of that disease should be treated is in the perception of the doctor treating and the patient treated. On this count most surgeons with special interests (varicose veins, hips, tonsils) should plead "guilty". Many discrepancies in waiting lists can be explained by differing efficiency but many can be equally well explained by differing perceptions of what should be treated. Rather than block developments the shrewd administrator might do better to ask clinicians whether or not such a disease does need treating. In the private sector the argument leads to the uncomfortable conclusion that if a cheaper method of treating a specific disease becomes available, then (corollary of premise 3 in the first argument) the potential for profit goes up. This means that the potential for profit is a function of the practitioner’s perception of disease (premise 1). In other words the consumer led approach can itself result in overtreatment. The involvement of clinicians in both public and private sectors has always been an uncomfortable one but if the above analysis is correct it accounts for the absence of the excesses sometimes found in alternative systems. By looking down the telescope both ends at once (public and private) a balance of consumerism and budgetary realism is achieved.
Hensol
Hospital, Pontyclun, Mid-Glamorgan, and Mental Handicap Services, Llwyneryr Unit, Morriston, Swansea SA6 6AH
Royal South Hants Hospital,
Southampton
SO9 4PE
A. D. B. CHANT S. BIRCH
T. HARI SINGH
1. Welsh Office. All Wales strategy for the development of services for mentally handicapped people. Cardiff: Welsh Office, 1983.
HOSPITAL ADMINISTRATOR’S PARADOX
SiR,—The argument behind the "hospital administrator’s paradox" (cheaper treatment costs more) is superficially plausible. Treatment A enables a patient to be treated more cheaply than treatment B. Theoretically therefore substitution of A for B will save money. "Not so," says the defensive adminstrator "for if you make the change, throughput increases, more patients are treated, and any
savings are immediately swallowed up. The only way you can save money is to close beds, thereby preventing the resources that have been freed from being used for other patients". Thus the paradox is generated. Working more efficiently does not save money. This is clearly contrary to commonsense but there will be few UK hospital clinicians who have not encountered the argument in one form or another over the past decade. Now arguments are valid according to the logic which connects the premises and validity of each premise. The above argument
FIVE MILLION SLIDES
SIR,-Mr Gibson (Oct 15, p 909) writes: "Thousands of excellent slides are made every year and these are rarely shared" and "Medical teachers in the developing world could use these slides if they could find them". TALC (Teaching Aids at Low Cost, Box 49, St Albans AL4AX) has been trying to meet exactly this need for twenty years and has just despatched its 5 millionth slide. TALC, a non-profit making organisation, can supply a strip of 24 carefully selected transparencies, with cardboard mounts, a detailed text which describes each image and includes teacher’s notes, a handviewer, and packing and postage by seamail, for 2.75 ($5), which is less than half the price of a colour slide film in most countries. 86 titles are available, and about 1000 sets are distributed every month all over the world. New sets appear regularly, and the first of three on HIV infection has just been produced. As Gibson points out, the labour of choosing and copying individual transparencies is prohibitive, and single slides are rarely useful. But a selected set of 24, with a carefully prepared text, written in English appropriate for those to whom it is a second language, is a most valuable aid. It can be used either as a complete lecture, or as a source of ideas and images from which the teacher
S]R,—A note in your issue of Sept 10 (p 637) discusses the dilemma of clinical responsibility for mentally handicapped patients in the light of community care policies being adopted by health authorities. Since 1983 Wales has been implementing a strategy for the mentally handicappedl and similar problems are being encountered. The Mid-Glamorgan Health Authority, which manages Hensol Hospital, a large hospital caring for the long-term needs of mentally handicapped patients from three counties, has adopted a plan which, if successful, may not only answer the "whose responsibility?" question but also release for work in the community a significant amount of specialists’ time which is being wasted on bureaucratic procedures attached to so-called "patient care and responsibility". All the 400 or so patients/residents in Hensol Hospital have been reviewed by the consultants responsible for their care. Those who need "clinical or consultant care and treatment" (ie, those who have mental illness, severe behaviour problems, and other psychiatric disorders) are "patients" and those who do not need clinical care on the above criteria and had been admitted only for their mental handicap are "residents". This review revealed that 3 out of every 4 of those in Hensol Hospital are residents, not patients. The care and treatment of patients will remain under consultant supervision while the care for the residents will be provided by a community medical officer with experience of mental handicap, who will act as proxy general practitioner. The medical officer will provide general medical care and liaise with the unit’s general manager, with psychologists, and with social services departments and other voluntary and statutory agencies to expedite transfer to residential placements in the community. Whenever there is a need for specialist help consultant advice can be sought through the internal referral system. In this way specialist time is released to support the developing community-based services. We hope that this approach will prove to be a practical and acceptable alternative to the obsolete bureaucratic system that makes consultants in mental handicap responsible for many irrelevant processes and the care of people who are not "patients" on any clinical criteria but long-term residents who had been inappropriately admitted years ago for social rather than psychiatric reasons. It should also reduce the conflict of leadership between doctors and other members of the mental handicap teams that have the task of rehabilitating these long-term residents. The clinical responsibility (and, therefore, leadership) for clinically defined patients would be the task of the consultant in the multidisciplinary team.
contains an implicit premise which, if inserted, makes the administrator’s stance appear dubious and at the same time makes the clinician’s position vulnerable. The complete argument should read: (1) there is a finite amount of disease within a community which we, as doctors and patients, perceive needs treatment; (2) there is a finite amount of money available within hospitals to treat that disease; (3) therefore if a cheaper method of treating a specific disease becomes available more patients with that disease are treated. One could argue at our use of the word "finite"; nevertheless the analogy of a hospital service as an engine for producing more health in the community is not unreasonable. If any part of it works more effectively then the whole, theoretically, should not be less efficient. However, if the argument is modified by leaving out the first premise, the administrator’s paradox can easily be generated: (1)-; (2) since there is a finite amount of money to be used by the hospital and (3) since there is a new cheaper method for treating disease, it follows that (4) all you have achieved is an increase in turnover without saving money. This situation was illustrated in one episode of the BBC TV comedy series Yes, Minister in which a "hospital administrator" argued that to introduce patients into a new hospital could only serve to reduce efficiency. The paradox can only be produced when doctors and administrators forget why they are working in a health service. How do doctors view premise (1) -is there a finite amount of disease within the community? Logic dictates that there is, but just how much of that disease should be treated is in the perception of the doctor treating and the patient treated. On this count most surgeons with special interests (varicose veins, hips, tonsils) should plead "guilty". Many discrepancies in waiting lists can be explained by differing efficiency but many can be equally well explained by differing perceptions of what should be treated. Rather than block developments the shrewd administrator might do better to ask clinicians whether or not such a disease does need treating. In the private sector the argument leads to the uncomfortable conclusion that if a cheaper method of treating a specific disease becomes available, then (corollary of premise 3 in the first argument) the potential for profit goes up. This means that the potential for profit is a function of the practitioner’s perception of disease (premise 1). In other words the consumer led approach can itself result in overtreatment. The involvement of clinicians in both public and private sectors has always been an uncomfortable one but if the above analysis is correct it accounts for the absence of the excesses sometimes found in alternative systems. By looking down the telescope both ends at once (public and private) a balance of consumerism and budgetary realism is achieved.
Hensol
Hospital, Pontyclun, Mid-Glamorgan, and Mental Handicap Services, Llwyneryr Unit, Morriston, Swansea SA6 6AH
Royal South Hants Hospital,
Southampton
SO9 4PE
A. D. B. CHANT S. BIRCH
T. HARI SINGH
1. Welsh Office. All Wales strategy for the development of services for mentally handicapped people. Cardiff: Welsh Office, 1983.
HOSPITAL ADMINISTRATOR’S PARADOX
SiR,—The argument behind the "hospital administrator’s paradox" (cheaper treatment costs more) is superficially plausible. Treatment A enables a patient to be treated more cheaply than treatment B. Theoretically therefore substitution of A for B will save money. "Not so," says the defensive adminstrator "for if you make the change, throughput increases, more patients are treated, and any
savings are immediately swallowed up. The only way you can save money is to close beds, thereby preventing the resources that have been freed from being used for other patients". Thus the paradox is generated. Working more efficiently does not save money. This is clearly contrary to commonsense but there will be few UK hospital clinicians who have not encountered the argument in one form or another over the past decade. Now arguments are valid according to the logic which connects the premises and validity of each premise. The above argument
FIVE MILLION SLIDES
SIR,-Mr Gibson (Oct 15, p 909) writes: "Thousands of excellent slides are made every year and these are rarely shared" and "Medical teachers in the developing world could use these slides if they could find them". TALC (Teaching Aids at Low Cost, Box 49, St Albans AL4AX) has been trying to meet exactly this need for twenty years and has just despatched its 5 millionth slide. TALC, a non-profit making organisation, can supply a strip of 24 carefully selected transparencies, with cardboard mounts, a detailed text which describes each image and includes teacher’s notes, a handviewer, and packing and postage by seamail, for 2.75 ($5), which is less than half the price of a colour slide film in most countries. 86 titles are available, and about 1000 sets are distributed every month all over the world. New sets appear regularly, and the first of three on HIV infection has just been produced. As Gibson points out, the labour of choosing and copying individual transparencies is prohibitive, and single slides are rarely useful. But a selected set of 24, with a carefully prepared text, written in English appropriate for those to whom it is a second language, is a most valuable aid. It can be used either as a complete lecture, or as a source of ideas and images from which the teacher