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MEDICAL SERVICE IN THE THIRD WORLD
102 CLINICIANS IN MANAGEMENT
SIR,-Mr Chant (June 23, p 1398) argues that clinicians should participate in hospital management because a conflict of interest
not
may arise between the allocation of resources and the needs of their own patients. It is important to recognise this dilemma; failure to do so may compromise the primary duty of a doctor to his patient, or lead to resource allocations which are unfair to individuals whose needs are less acute or who are represented by less persuasive doctors. However, I am not convinced that the solution is to opt out completely: Parliament would be poorer if members had no special interests and experience to declare. Advice from a medical committee involves responsibility, and responsibility without power is as frustrating as power without responsibility is dangerous. Hospital doctors are only too well aware
of the
disorganisation that they witness daily but are powerless to Large hospitals are too complex to be managed by a central
correct.
and uniform administrative system. The time has come to decentralise, and for clinical units to manage their own services; this approach has been a resounding success in at least one The power to organise a service in the interests of the patients is commensurate with the acceptance of financial and administrative responsibility, but this need not compromise the interests of individual patients. Indeed, that is precisely why the decisions should be taken by practising clinicians rather than by professional administrators, medically qualified or not. We do not need medical superintendents but rather surgeons organising surgical services,
hospital.l
medical services, community physicians community so on. Resource allocation is then determined by consultations within the clinical unit, and by discussions between the heads of these units, the district health authority, and in the light of NHS priorities. The delivery of health care within the setting of modern medicine is complex; administrative systems which have failed in the past, whether pre-1948, post-1948, or post-1974, should not be resuscitated but rather we should adopt new ideas, evaluate, refine, and then change them as necessary.
physicians
services, and
Guy’s Hospital Medical School, Department of Paediatrics, London SE1 9RT
people who refuse to go to the clinic but this could be dealt with by telephone system. When patients do not have telephones then wasted journeys will occur with or without computerisation.
upon
CYRIL CHANTLER
1. Heyssel RM, Gaintner JR, Kues IW, Jones AA, Lipstein SH. Decentralized management in a teaching hospital. Ten years at Johns Hopkins. N Engl J Med 1984; 310: 1477-80.
THE COST OF BROKEN NHS APPOINTMENTS
SIR,-The assertion in Commentary from Westminster (June 23) that the NHS may be losing as much as 266 million a year because of patients’ failures to attend outpatient clinics is, as with so many other cost assumptions in the NHS, based on the idea that the Service is like any other financial organisation. If a health authority were to receive an income based on work done then every outpatient attendance would add to that income and failures to attend would indeed cause a loss. However, this is not the case and the rate of attendance at the outpatient clinic does not influence the income ofa health authority. What members of Parliament meant was that L266 million worth of medical time was wasted each year, and they envisaged that when the patient does not turn up at the outpatient clinic the doctors and nurses sit back and take a break. Most doctors will realise that this is not the true state of affairs and they know that between 10% and 20% of outpatients do not turn up. Although these non-attendances may be news to MPs they are incorporated into working arrangements at outpatient clinics: most doctors organise their numbers in the expectation of a certain non-attendance rate, and if all patients do turn up the clinics run late. The failure of a patient to arrive at the clinic usually means that he or she has got better, and I make a point of telling people not to bother attending if they have recovered, asking them to telephone the appointments desk to give this information in advance. Were these patients to turn up then it would be a complete waste of their time but would certainly make the outpatient attendance figures look much better, a familiar dodge of boosting figures for the benefit of no-one in particular. The problem simply does not exist. I can understand concern about the waste of ambulance journeys when an ambulance calls
Postgraduate Medical Centre, Royal Infirmary, Blackburn, Lancs BB2 3LR
DAVID S. GRIMES
MEDICAL SERVICE IN THE THIRD WORLD
SIR,-Third World medical work is largely time wasted (Dr Bion; June 30, p 1473) in relation to a resumed hospital career in the National Health Service. What the unemployed (Dr Attanasio; May 19, p 1125), bored, disillusioned, prematurely retired, dedicated, selfless doctor is quite likely to find when he gets out there is not a broadening of experience but the same persistent demand for immediate symptomatic treatment with drugs which practice in Europe has only too well trained him to give. On a recent assignment in southern Somalia, the preponderant conditions I saw, as elsewhere, were malaria, schistosomiasis, infantile diarrhoea, intestinal worms, gonorrhoea, infected scabies, malnutrition, dehydration, and injuries from preventable accidents. None of them conditions in which the overall picture could ever be much altered by "treatment" of relatively few affected individuals. The same issue of The Lancet (June 30) in which Bion replies to Attanasio, spells out the true needs-an end to "the misdirection and ineffectiveness so evident in international programmes" (Dr Silver, p 1459), and the training of a great number of indigenous community health workers (review of Beyond the Dispensary, p 1484). No one wants to denigrate the efforts or intentions of doctors who go to work in the Third World, but the transient help they bring to individuals bears no relation to, and may distract attention from, the large-scale eradication and improvement measures which are necessary. So perhaps UK junior hospital doctors worrying about the cosmic disaster of a hospital career ruined by interruption should meditate instead on the effects of absence of clean water, latrines, dry ventilated shelter, and basic food for millions of the earth’s inhabitants. It may be a blessing in disguise that Western doctors are given so little material incentive, for, while they continue to go, politicians, finance controllers, and international aid organisations can point to the existence of their efforts as a convenient justification for their own failure to act. 58 Victona Park, Cambridge CB4 3EL
BENJAMIN LEE
IMMORTALITY FOR OLD DRUGS
SIR,-Dr Herxheimer (June 30, p 1460) considers the role of drug regulation with reference to the need to reduce the number of old and dangerous drugs. While I largely agree with the sentiments expressed, there are problems with burying old drugs, particularly with the need to ensure that they really are "medically dead". Two examples illustrate the difficulties. All readers of The Lancet will know that marrow suppression can be caused by chloramphenicol, but my impression is that many clinicians tend to overemphasise rather than underemphasise the risk. The incidence of marrow suppression is very low, and chloramphenicol is particularly effective in the management of haemophilus meningitis and epiglottitis and still has an important role in typhoid fever. Many people would also consider it a useful alternative for older patients with severe exacerbations of chronic bronchitis, who have not responded to ampicillin in one of its many *
forms. It is difficult to be certain that any of the alternatives which might be suggested for use in this context are safer than chloramphenicol. The drug which many would choose in this context would be co-trimoxazole and my guess would be that this carries a greater risk in terms both of its effect on the blood and of its many other adverse effects, such as severe skin reactions. A second example is phenylbutazone, again a well-recognised cause of bone marrow problems. No one could justify its widespread use for trivial disorders. Nevertheless, many clinicians believe that phenylbutazone is one of the most effective of the non-steroidal antiinflammatory drugs and will sometimes produce considerable relief when other safer drugs appear ineffective. Its safety profile has to be
SIR,-Mr Chant (June 23, p 1398) argues that clinicians should participate in hospital management because a conflict of interest
not
may arise between the allocation of resources and the needs of their own patients. It is important to recognise this dilemma; failure to do so may compromise the primary duty of a doctor to his patient, or lead to resource allocations which are unfair to individuals whose needs are less acute or who are represented by less persuasive doctors. However, I am not convinced that the solution is to opt out completely: Parliament would be poorer if members had no special interests and experience to declare. Advice from a medical committee involves responsibility, and responsibility without power is as frustrating as power without responsibility is dangerous. Hospital doctors are only too well aware
of the
disorganisation that they witness daily but are powerless to Large hospitals are too complex to be managed by a central
correct.
and uniform administrative system. The time has come to decentralise, and for clinical units to manage their own services; this approach has been a resounding success in at least one The power to organise a service in the interests of the patients is commensurate with the acceptance of financial and administrative responsibility, but this need not compromise the interests of individual patients. Indeed, that is precisely why the decisions should be taken by practising clinicians rather than by professional administrators, medically qualified or not. We do not need medical superintendents but rather surgeons organising surgical services,
hospital.l
medical services, community physicians community so on. Resource allocation is then determined by consultations within the clinical unit, and by discussions between the heads of these units, the district health authority, and in the light of NHS priorities. The delivery of health care within the setting of modern medicine is complex; administrative systems which have failed in the past, whether pre-1948, post-1948, or post-1974, should not be resuscitated but rather we should adopt new ideas, evaluate, refine, and then change them as necessary.
physicians
services, and
Guy’s Hospital Medical School, Department of Paediatrics, London SE1 9RT
people who refuse to go to the clinic but this could be dealt with by telephone system. When patients do not have telephones then wasted journeys will occur with or without computerisation.
upon
CYRIL CHANTLER
1. Heyssel RM, Gaintner JR, Kues IW, Jones AA, Lipstein SH. Decentralized management in a teaching hospital. Ten years at Johns Hopkins. N Engl J Med 1984; 310: 1477-80.
THE COST OF BROKEN NHS APPOINTMENTS
SIR,-The assertion in Commentary from Westminster (June 23) that the NHS may be losing as much as 266 million a year because of patients’ failures to attend outpatient clinics is, as with so many other cost assumptions in the NHS, based on the idea that the Service is like any other financial organisation. If a health authority were to receive an income based on work done then every outpatient attendance would add to that income and failures to attend would indeed cause a loss. However, this is not the case and the rate of attendance at the outpatient clinic does not influence the income ofa health authority. What members of Parliament meant was that L266 million worth of medical time was wasted each year, and they envisaged that when the patient does not turn up at the outpatient clinic the doctors and nurses sit back and take a break. Most doctors will realise that this is not the true state of affairs and they know that between 10% and 20% of outpatients do not turn up. Although these non-attendances may be news to MPs they are incorporated into working arrangements at outpatient clinics: most doctors organise their numbers in the expectation of a certain non-attendance rate, and if all patients do turn up the clinics run late. The failure of a patient to arrive at the clinic usually means that he or she has got better, and I make a point of telling people not to bother attending if they have recovered, asking them to telephone the appointments desk to give this information in advance. Were these patients to turn up then it would be a complete waste of their time but would certainly make the outpatient attendance figures look much better, a familiar dodge of boosting figures for the benefit of no-one in particular. The problem simply does not exist. I can understand concern about the waste of ambulance journeys when an ambulance calls
Postgraduate Medical Centre, Royal Infirmary, Blackburn, Lancs BB2 3LR
DAVID S. GRIMES
MEDICAL SERVICE IN THE THIRD WORLD
SIR,-Third World medical work is largely time wasted (Dr Bion; June 30, p 1473) in relation to a resumed hospital career in the National Health Service. What the unemployed (Dr Attanasio; May 19, p 1125), bored, disillusioned, prematurely retired, dedicated, selfless doctor is quite likely to find when he gets out there is not a broadening of experience but the same persistent demand for immediate symptomatic treatment with drugs which practice in Europe has only too well trained him to give. On a recent assignment in southern Somalia, the preponderant conditions I saw, as elsewhere, were malaria, schistosomiasis, infantile diarrhoea, intestinal worms, gonorrhoea, infected scabies, malnutrition, dehydration, and injuries from preventable accidents. None of them conditions in which the overall picture could ever be much altered by "treatment" of relatively few affected individuals. The same issue of The Lancet (June 30) in which Bion replies to Attanasio, spells out the true needs-an end to "the misdirection and ineffectiveness so evident in international programmes" (Dr Silver, p 1459), and the training of a great number of indigenous community health workers (review of Beyond the Dispensary, p 1484). No one wants to denigrate the efforts or intentions of doctors who go to work in the Third World, but the transient help they bring to individuals bears no relation to, and may distract attention from, the large-scale eradication and improvement measures which are necessary. So perhaps UK junior hospital doctors worrying about the cosmic disaster of a hospital career ruined by interruption should meditate instead on the effects of absence of clean water, latrines, dry ventilated shelter, and basic food for millions of the earth’s inhabitants. It may be a blessing in disguise that Western doctors are given so little material incentive, for, while they continue to go, politicians, finance controllers, and international aid organisations can point to the existence of their efforts as a convenient justification for their own failure to act. 58 Victona Park, Cambridge CB4 3EL
BENJAMIN LEE
IMMORTALITY FOR OLD DRUGS
SIR,-Dr Herxheimer (June 30, p 1460) considers the role of drug regulation with reference to the need to reduce the number of old and dangerous drugs. While I largely agree with the sentiments expressed, there are problems with burying old drugs, particularly with the need to ensure that they really are "medically dead". Two examples illustrate the difficulties. All readers of The Lancet will know that marrow suppression can be caused by chloramphenicol, but my impression is that many clinicians tend to overemphasise rather than underemphasise the risk. The incidence of marrow suppression is very low, and chloramphenicol is particularly effective in the management of haemophilus meningitis and epiglottitis and still has an important role in typhoid fever. Many people would also consider it a useful alternative for older patients with severe exacerbations of chronic bronchitis, who have not responded to ampicillin in one of its many *
forms. It is difficult to be certain that any of the alternatives which might be suggested for use in this context are safer than chloramphenicol. The drug which many would choose in this context would be co-trimoxazole and my guess would be that this carries a greater risk in terms both of its effect on the blood and of its many other adverse effects, such as severe skin reactions. A second example is phenylbutazone, again a well-recognised cause of bone marrow problems. No one could justify its widespread use for trivial disorders. Nevertheless, many clinicians believe that phenylbutazone is one of the most effective of the non-steroidal antiinflammatory drugs and will sometimes produce considerable relief when other safer drugs appear ineffective. Its safety profile has to be