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INFECTIOUS DISEASE IN ENGLAND AND WALES
210
Reconstruction ONE THOUSAND BEDS ? FROM A CORRESPONDENT
Mr. ANEURIN BEVAN made one of his most penetrating remarks when, in the standing committee, he declared that the quality of a hospital service is determined not only by the way in which it is financed but also by the quality of the people who work in the hospital, and on their freedom from bureaucratic interference. But it is fair to ask Mr. Bevan, what does he mean by " hospital "? If he means, instead of the common connotation, a 1000-bed unit comprising many hospitals, will such a " hospital " be free of bureaucratic interference? The headquarters of this 1000-bed unit could easily become itself a focus of bureaucracy, in relation to the individual hospital. There is grave danger that the conception of the 1000bed unit may come to be embodied in the new hospital service without adequate examination. ADVANTAGES AND DISADVANTAGES can be said in favour of the idea ? It has been suggested that 1000 beds are needed to constitute a complete unit for hospital purposes, providing -staff and facilities sufficient for all the various specialties to be found in a complete hospital service. It is true, too, that from most of the surveys-the South Wales survey is an instructive example which may well have had a special influence on the Minister-there emerged a clear case for grouping under one control a family of hospitals of varying sizes. The Welsh valleys need a hospital of some consequence in the principal town, with a group of smaller units strung out along the valley. There is in fact a strong case here for unified management, with proper delegation of responsibility for the smaller units to house-committees. In other parts of the country there are further examples which support the view that grouping under a single management committee is a natural and logical development of hospital organisation, leading to economical grouping of consultant staff and special departments. But from the premise that in many cases, and from some angles, grouping is-desirable, and that 1000 beds provide the most convenient unit, it does not necessarily follow that division of the country into 1000-bed units ought to be regarded as an overriding objective. Can it seriously be suggested that the principle of aggregation of units to make up 1000 beds,ought to be pressed as against all other considerations, including convenience of management? For many small towns and -for many suburban areas a hospital of 200-250 beds (including provision for chronic cases and for maternity wards), with perhaps one or two satellite cottage hospitals acting under its control, is much to be preferred. If units of this kind are grouped with anything and everything that may happen to be handy, or if two or three such units are grouped together merely for the sake of securing a 1000-bed unit, no advantage can be expected sufficient to offset the very real loss of convenience of management on the spot by local people. It is one thing arbitrarily to decide what constitutes a complete unit for hospital purposes, but it is quite another thing to assert that this is the only satisfactory unit for purposes of management, - irrespective of the difference in conditions in different parts of the country, and of the fact that in the great majority of cases various special functions must, for a long time to come, be provided where the facilities are at hand.
First, then, what
WHAT IS
REQUIRED
What is undoubtedly required is machinery for ensuring that the hospital service of the locality conforms to a
plan, that services and departments are not unwisely duplicated, and that patients find their way into that hospital which is best fitted to deal with them. To achieve this it is not essential to group hospitals arbitrarily into 1000-bed units regardless of all other considerations. Admittedly smaller units may not be able to offer all the services, but the exercise by a regional board of an effective control of function (as distinct from management) will surely bring about the desired result. The size of the groups should be determined by practical considerations, in which geography and convenience of management must plainly be regarded The provision of 1000-bed units need as all-important. not be given undue weight if regional control of function is accepted as an alternative. It is the less drastic alternative, and it leaves the way open for a subsequent merger of groups if such proves desirable. It does not involve, at the outset, disturbance of personnel ; and it does not involve all the friction that is bound to follow if chairmen and medical superintendents, house-governors and matrons, drawn from different hospitals, have to be thrown together in a single set-up and the one subordinated to the other. The new service establishes conditions in which it is reasonable to hope that, given time, all will work easily together ; but time is essential, and it would be disastrous to suppose that a stroke of the pen is all that is necessary to realise what must often be a slow process of approxiThe circumstances will vary mation and unification. widely, and unification which in some cases can be achieved from the outset may in others require years before fusion is possible. Hence the regional board, in pursuing its object of grouping hospitals into units, should proceed by persuasion rather than by coercion. It should be content to start by providing a management committee for smaller groups or even for each of the existing hospitals -rather than for what might prove to be an artificial unit based on a paper plan. The powers and duties of the regional boards in delegation to local management committees should be drafted accordingly. Against a background of regional control of finance, and regional participation in the appointment of personnel, both of the management committee and of the medical staff, there need be no fear that the Minister will lack the powers needed to bring about a complete fusion wherever such is proved, by experience of working the scheme, to be in the general interest. INFECTIOUS DISEASE IN ENGLAND AND WALES WEEK ENDED JULY 27 Notifications.-Smallpox, 0 ; scarlet fever, 994 ;
whooping-cough, 2468 ; diphtheria, 308 ; paratyphoid, 14 ; typhoid, 8 ; measles (excluding rubella), 3741 ; pneumonia (primary or influenzal), 363 ; cerebro-spinal fever, 41 ; poliomyelitis, 18 ; polio-encephalitis, 0 ; encephalitis lethargica, 1 ; dysentery, 90 ; puerperal pyrexia, 145 ; ophthalmia neonatorum, 72. No case of cholera, plague, or typhus was notified during the week. The number of service and civilian sick in the Infectious Hospitals of the London County Council on July 24 was 1155. During the previous week the following cases were admitted : scarlet fever, 48 ; diphtheria, 29 ; measles, 86 ; whooping-cough, 24.
Deaths.—In 126 great towns there were no deaths from enteric fever or scarlet fever, 4 (0) from measles, 8 (1) from whooping-cough, 2 (0) from diphtheria, 38 (1) from diarrhoea and enteritis under two years, and 1 (0) from influenza.’ The figures in parentheses are those for London itself. The number of stillbirths notified during the week was 285 (corresponding to a rate of 31 per thousand total births), including 37 in London. Sir Comyns Berkeley from his estate of £123,000 has made residual bequest to Gonville and Caius College, Cambridge, for the provision of medical fellowships. a
Reconstruction ONE THOUSAND BEDS ? FROM A CORRESPONDENT
Mr. ANEURIN BEVAN made one of his most penetrating remarks when, in the standing committee, he declared that the quality of a hospital service is determined not only by the way in which it is financed but also by the quality of the people who work in the hospital, and on their freedom from bureaucratic interference. But it is fair to ask Mr. Bevan, what does he mean by " hospital "? If he means, instead of the common connotation, a 1000-bed unit comprising many hospitals, will such a " hospital " be free of bureaucratic interference? The headquarters of this 1000-bed unit could easily become itself a focus of bureaucracy, in relation to the individual hospital. There is grave danger that the conception of the 1000bed unit may come to be embodied in the new hospital service without adequate examination. ADVANTAGES AND DISADVANTAGES can be said in favour of the idea ? It has been suggested that 1000 beds are needed to constitute a complete unit for hospital purposes, providing -staff and facilities sufficient for all the various specialties to be found in a complete hospital service. It is true, too, that from most of the surveys-the South Wales survey is an instructive example which may well have had a special influence on the Minister-there emerged a clear case for grouping under one control a family of hospitals of varying sizes. The Welsh valleys need a hospital of some consequence in the principal town, with a group of smaller units strung out along the valley. There is in fact a strong case here for unified management, with proper delegation of responsibility for the smaller units to house-committees. In other parts of the country there are further examples which support the view that grouping under a single management committee is a natural and logical development of hospital organisation, leading to economical grouping of consultant staff and special departments. But from the premise that in many cases, and from some angles, grouping is-desirable, and that 1000 beds provide the most convenient unit, it does not necessarily follow that division of the country into 1000-bed units ought to be regarded as an overriding objective. Can it seriously be suggested that the principle of aggregation of units to make up 1000 beds,ought to be pressed as against all other considerations, including convenience of management? For many small towns and -for many suburban areas a hospital of 200-250 beds (including provision for chronic cases and for maternity wards), with perhaps one or two satellite cottage hospitals acting under its control, is much to be preferred. If units of this kind are grouped with anything and everything that may happen to be handy, or if two or three such units are grouped together merely for the sake of securing a 1000-bed unit, no advantage can be expected sufficient to offset the very real loss of convenience of management on the spot by local people. It is one thing arbitrarily to decide what constitutes a complete unit for hospital purposes, but it is quite another thing to assert that this is the only satisfactory unit for purposes of management, - irrespective of the difference in conditions in different parts of the country, and of the fact that in the great majority of cases various special functions must, for a long time to come, be provided where the facilities are at hand.
First, then, what
WHAT IS
REQUIRED
What is undoubtedly required is machinery for ensuring that the hospital service of the locality conforms to a
plan, that services and departments are not unwisely duplicated, and that patients find their way into that hospital which is best fitted to deal with them. To achieve this it is not essential to group hospitals arbitrarily into 1000-bed units regardless of all other considerations. Admittedly smaller units may not be able to offer all the services, but the exercise by a regional board of an effective control of function (as distinct from management) will surely bring about the desired result. The size of the groups should be determined by practical considerations, in which geography and convenience of management must plainly be regarded The provision of 1000-bed units need as all-important. not be given undue weight if regional control of function is accepted as an alternative. It is the less drastic alternative, and it leaves the way open for a subsequent merger of groups if such proves desirable. It does not involve, at the outset, disturbance of personnel ; and it does not involve all the friction that is bound to follow if chairmen and medical superintendents, house-governors and matrons, drawn from different hospitals, have to be thrown together in a single set-up and the one subordinated to the other. The new service establishes conditions in which it is reasonable to hope that, given time, all will work easily together ; but time is essential, and it would be disastrous to suppose that a stroke of the pen is all that is necessary to realise what must often be a slow process of approxiThe circumstances will vary mation and unification. widely, and unification which in some cases can be achieved from the outset may in others require years before fusion is possible. Hence the regional board, in pursuing its object of grouping hospitals into units, should proceed by persuasion rather than by coercion. It should be content to start by providing a management committee for smaller groups or even for each of the existing hospitals -rather than for what might prove to be an artificial unit based on a paper plan. The powers and duties of the regional boards in delegation to local management committees should be drafted accordingly. Against a background of regional control of finance, and regional participation in the appointment of personnel, both of the management committee and of the medical staff, there need be no fear that the Minister will lack the powers needed to bring about a complete fusion wherever such is proved, by experience of working the scheme, to be in the general interest. INFECTIOUS DISEASE IN ENGLAND AND WALES WEEK ENDED JULY 27 Notifications.-Smallpox, 0 ; scarlet fever, 994 ;
whooping-cough, 2468 ; diphtheria, 308 ; paratyphoid, 14 ; typhoid, 8 ; measles (excluding rubella), 3741 ; pneumonia (primary or influenzal), 363 ; cerebro-spinal fever, 41 ; poliomyelitis, 18 ; polio-encephalitis, 0 ; encephalitis lethargica, 1 ; dysentery, 90 ; puerperal pyrexia, 145 ; ophthalmia neonatorum, 72. No case of cholera, plague, or typhus was notified during the week. The number of service and civilian sick in the Infectious Hospitals of the London County Council on July 24 was 1155. During the previous week the following cases were admitted : scarlet fever, 48 ; diphtheria, 29 ; measles, 86 ; whooping-cough, 24.
Deaths.—In 126 great towns there were no deaths from enteric fever or scarlet fever, 4 (0) from measles, 8 (1) from whooping-cough, 2 (0) from diphtheria, 38 (1) from diarrhoea and enteritis under two years, and 1 (0) from influenza.’ The figures in parentheses are those for London itself. The number of stillbirths notified during the week was 285 (corresponding to a rate of 31 per thousand total births), including 37 in London. Sir Comyns Berkeley from his estate of £123,000 has made residual bequest to Gonville and Caius College, Cambridge, for the provision of medical fellowships. a