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MORE BEDS OR BETTER OUTPATIENT DEPARTMENTS ?
757
Letters to the Editor
now often suggested as being essential could be greatly reduced. Before recommending that many additional acute " beds are required, I suggest that committees of manage-
are
"
MORE BEDS OR BETTER OUTPATIENT DEPARTMENTS? SiR,-In these days of reconstruction, when so much thought is being given to an extension of our hospital services, it seems to me that often an undue emphasis is laid on the provision of additional hospital beds, and -not enough attention is paid to measures which may avoid admission to hospital, or may shorten the length of a patient’s stay in hospital. Hospital beds are extremely expensive to equip and maintain, and it looks as if the difficulty of staffing them is likely to be acute for some years to come. In my view, before additional hospital beds are provided in any district, committees of management should first consider the extension of outpatient facilities and X-ray and pathological services, and the establishment of convalescent homes. If all these are on a liberal, or even a lavish scale, not only will patients receive more prompt and efficient service, but the call on hospital beds will be greatly reduced. I have had vivid personal experience of the truth of this statement. Also I have observed that mere provision of hospital beds does not meet the demands of a long waiting-list, and I have seen the financial difficulties which provision of more beds may bring in its train. You, Sir, in the past, have drawn attention to this argument (Lancet, 1943, ii, 545, 619), and I was pleased to see that it is again stressed by the authors of the Hospital Survey for the Sheffield and East Midlands Area recently published for the Ministry of Health. In particular I would wish to draw attention to the comments made in this survey on the need for coördination and extension of the outpatient services provided in that area. The same argument applies to all areas. If, in a town, there are a number of hospitals, each with a small outpatient department, it would be far more satisfactory to consolidate these into one large and well-equipped unit, in which all members of the staffs of the various hospitals who are in charge of beds should hold sessions. The department should be equipped with X-ray and pathological. services to deal with such diseases as diabetes and ansemia, and for the investigation of many of those " cold " cases which now, of necessity, are so often admitted to the general wardsof a hospital. If a hostel and canteen were provided, as the authors of this survey recommend, patients could be detained there in comfort while the investigations were being carried out, or for a night or two after minor operations. The staffing and running of a hostel would be far more economical than that of a general hospital ward. Such a department would be the usual channel for admission of all except acute cases. In it might well be established the consolidated waiting-lists and the admission bureau of all the hospitals in the town, and it is worth consideration whether the notes of patients who have been discharged from these hospitals should also be filed and registered in the department so as to be readily available should the patient again present himself for hospital service. The almoner’s department, representatives of the social and welfare services, and a dietitian should be accommodated, and the department could become a centre for the dissemination of health propaganda in the form of lectures, films, or the distribution of literature. Generally, no doubt, the department should be established in connexion with the largest of the general hospitals which comprise the group. Where it is found necessary to build new or additional hospitals there is a tendency nowadays to advocate their erection outside the towns. If this were done, it would be a matter for local consideration whether it would be more convenient to incorporate the department with the hospital on its new site, or to have a completely separate department near the main traffic terminus of the town, and to have there, in addition, a casualty department where such emergencies as road accidents could be brought for immediate treatment before being sent out to the main hospital. It is my conviction that if these principles were carried out, and if the existing hospitals in a town or area were organised so as to work together as a single unit, the large number of additional hospital beds which
ment would be well advised to analyse the admissions to their hospitals during the next six months, noting the number who might have been efficiently dealt with in an outpatient department of the type indicated, and need not have come into hospital at all. They should also note how many days had been spent by patients merely waiting for investigation or treatment in some special department, and what might have been the saving of days in hospital if, after passing the " acute " phase of an illness or operation, the patient could have been sent to a convalescent home equipped with physiotherapy, occupational therapy, and facilities for outdoor
graded exercises.
Yet further economy could probably be effected by the number of " chronic " beds. The accommodation and staff for such patients need be less elaborate and costly than that of " acute " beds. Also, I suspect that in years to come there will be a growing tendency for the public to demand institutional care for the aged and chronic sick. This tendency is likely to receive an immediate stimulus from the present difficulties in obtaining houses and domestic help. It will be fostered by the establishment of a State medical service, for the public will feel that having paid for a complete service the old folks should get the benefit of it. It is improbable that the tradition, once established in this way, will be reversed when domestic conditions
increasing
h"t’oTYIp ">},<:1"1’,
Plymouth.
W. A. LISTER.
TUBERCULOSIS IN CHILDHOOD SiR,-Most of those who have read Dr. Alan Moncrieff’s thoughtful and provocative address in your issue of Nov. 17 will agree that childhood tuberculosis in many parts of this country is not being diagnosed where it should be diagnosed, at the tuberculosis dispensaries ; and this is largely due to the failurethere to apply a simple routine investigation to all child contacts of all known cases of tuberculosis. At the Ealing Chest Clinic, such children have a tuberculin patch applied at home by a visiting nurse and attend the clinic three days later. If the patch is negative an intradermal .injection equivalent to 1/100 Old Tuberculin is given. If still negative, the child is patched at three-monthly intervals so long as contact is maintained and again three months after contact is finally broken. A positive reaction, or conversion from negative to positive, indicates immediate radiography of the chest in both postero-anterior and lateral positions, done of course at the clinic, where a machine is available and in constant employment by two radiographers. The results of this policy (Minimum Requirements in the Examination of Tuberculosis Home Contacts ; Thompson, Public Health, July, 1944) have been instructive but without any noticeable effect on the mortality statistics of West Middlesex. Fatal generalised tuberculosis is quite uncommon in our child patients and my experience does not bear out Dr. Moncrieff’s alarming prognosis for childhood infection. Admitting, however, that these clinically interesting lesions ought to be detected, I cannot see how the proposals of the British Psediatric Association can be expected to improve on the organisation outlined above. It is true that many dispensaries are ill-equipped and that some tuberculosis officers are indifferent paediatricians. On the other hand, many paediatricians have an incomplete understanding of tuberculosis, and their outpatient departments have neither the. handy radio-" graphy nor the social-service set-up which it is agreed every modern chest clinic should and must employ. The Association’s project to take over the care of our children, which despite the word " cooperation " is clearly what is intended, cuts at the very root of the improved tuberculosis service at which we aim. Tuberculosis has become a family problem : the whole family looks to the chest clinic for medical as well as the financial care on which they now rely, and any division of this loyalty is to be deprecated. BRIAN THOMPSON, Ealing Chest Clinic, London, W13.
Tuberculosis Officer, Middlesex County Council.
Letters to the Editor
now often suggested as being essential could be greatly reduced. Before recommending that many additional acute " beds are required, I suggest that committees of manage-
are
"
MORE BEDS OR BETTER OUTPATIENT DEPARTMENTS? SiR,-In these days of reconstruction, when so much thought is being given to an extension of our hospital services, it seems to me that often an undue emphasis is laid on the provision of additional hospital beds, and -not enough attention is paid to measures which may avoid admission to hospital, or may shorten the length of a patient’s stay in hospital. Hospital beds are extremely expensive to equip and maintain, and it looks as if the difficulty of staffing them is likely to be acute for some years to come. In my view, before additional hospital beds are provided in any district, committees of management should first consider the extension of outpatient facilities and X-ray and pathological services, and the establishment of convalescent homes. If all these are on a liberal, or even a lavish scale, not only will patients receive more prompt and efficient service, but the call on hospital beds will be greatly reduced. I have had vivid personal experience of the truth of this statement. Also I have observed that mere provision of hospital beds does not meet the demands of a long waiting-list, and I have seen the financial difficulties which provision of more beds may bring in its train. You, Sir, in the past, have drawn attention to this argument (Lancet, 1943, ii, 545, 619), and I was pleased to see that it is again stressed by the authors of the Hospital Survey for the Sheffield and East Midlands Area recently published for the Ministry of Health. In particular I would wish to draw attention to the comments made in this survey on the need for coördination and extension of the outpatient services provided in that area. The same argument applies to all areas. If, in a town, there are a number of hospitals, each with a small outpatient department, it would be far more satisfactory to consolidate these into one large and well-equipped unit, in which all members of the staffs of the various hospitals who are in charge of beds should hold sessions. The department should be equipped with X-ray and pathological. services to deal with such diseases as diabetes and ansemia, and for the investigation of many of those " cold " cases which now, of necessity, are so often admitted to the general wardsof a hospital. If a hostel and canteen were provided, as the authors of this survey recommend, patients could be detained there in comfort while the investigations were being carried out, or for a night or two after minor operations. The staffing and running of a hostel would be far more economical than that of a general hospital ward. Such a department would be the usual channel for admission of all except acute cases. In it might well be established the consolidated waiting-lists and the admission bureau of all the hospitals in the town, and it is worth consideration whether the notes of patients who have been discharged from these hospitals should also be filed and registered in the department so as to be readily available should the patient again present himself for hospital service. The almoner’s department, representatives of the social and welfare services, and a dietitian should be accommodated, and the department could become a centre for the dissemination of health propaganda in the form of lectures, films, or the distribution of literature. Generally, no doubt, the department should be established in connexion with the largest of the general hospitals which comprise the group. Where it is found necessary to build new or additional hospitals there is a tendency nowadays to advocate their erection outside the towns. If this were done, it would be a matter for local consideration whether it would be more convenient to incorporate the department with the hospital on its new site, or to have a completely separate department near the main traffic terminus of the town, and to have there, in addition, a casualty department where such emergencies as road accidents could be brought for immediate treatment before being sent out to the main hospital. It is my conviction that if these principles were carried out, and if the existing hospitals in a town or area were organised so as to work together as a single unit, the large number of additional hospital beds which
ment would be well advised to analyse the admissions to their hospitals during the next six months, noting the number who might have been efficiently dealt with in an outpatient department of the type indicated, and need not have come into hospital at all. They should also note how many days had been spent by patients merely waiting for investigation or treatment in some special department, and what might have been the saving of days in hospital if, after passing the " acute " phase of an illness or operation, the patient could have been sent to a convalescent home equipped with physiotherapy, occupational therapy, and facilities for outdoor
graded exercises.
Yet further economy could probably be effected by the number of " chronic " beds. The accommodation and staff for such patients need be less elaborate and costly than that of " acute " beds. Also, I suspect that in years to come there will be a growing tendency for the public to demand institutional care for the aged and chronic sick. This tendency is likely to receive an immediate stimulus from the present difficulties in obtaining houses and domestic help. It will be fostered by the establishment of a State medical service, for the public will feel that having paid for a complete service the old folks should get the benefit of it. It is improbable that the tradition, once established in this way, will be reversed when domestic conditions
increasing
h"t’oTYIp ">},<:1"1’,
Plymouth.
W. A. LISTER.
TUBERCULOSIS IN CHILDHOOD SiR,-Most of those who have read Dr. Alan Moncrieff’s thoughtful and provocative address in your issue of Nov. 17 will agree that childhood tuberculosis in many parts of this country is not being diagnosed where it should be diagnosed, at the tuberculosis dispensaries ; and this is largely due to the failurethere to apply a simple routine investigation to all child contacts of all known cases of tuberculosis. At the Ealing Chest Clinic, such children have a tuberculin patch applied at home by a visiting nurse and attend the clinic three days later. If the patch is negative an intradermal .injection equivalent to 1/100 Old Tuberculin is given. If still negative, the child is patched at three-monthly intervals so long as contact is maintained and again three months after contact is finally broken. A positive reaction, or conversion from negative to positive, indicates immediate radiography of the chest in both postero-anterior and lateral positions, done of course at the clinic, where a machine is available and in constant employment by two radiographers. The results of this policy (Minimum Requirements in the Examination of Tuberculosis Home Contacts ; Thompson, Public Health, July, 1944) have been instructive but without any noticeable effect on the mortality statistics of West Middlesex. Fatal generalised tuberculosis is quite uncommon in our child patients and my experience does not bear out Dr. Moncrieff’s alarming prognosis for childhood infection. Admitting, however, that these clinically interesting lesions ought to be detected, I cannot see how the proposals of the British Psediatric Association can be expected to improve on the organisation outlined above. It is true that many dispensaries are ill-equipped and that some tuberculosis officers are indifferent paediatricians. On the other hand, many paediatricians have an incomplete understanding of tuberculosis, and their outpatient departments have neither the. handy radio-" graphy nor the social-service set-up which it is agreed every modern chest clinic should and must employ. The Association’s project to take over the care of our children, which despite the word " cooperation " is clearly what is intended, cuts at the very root of the improved tuberculosis service at which we aim. Tuberculosis has become a family problem : the whole family looks to the chest clinic for medical as well as the financial care on which they now rely, and any division of this loyalty is to be deprecated. BRIAN THOMPSON, Ealing Chest Clinic, London, W13.
Tuberculosis Officer, Middlesex County Council.