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NEGOTIATION
727
40,000 new cases are seen in the outpatient department ; in another hospital only 7% of medical outand about
25%
of
surgical outpatients are require admission. In the staffing of outpatient departments MAITLAND believes that general physicians and general surgeons should be brought to the fore, though they should be able to call on special knowledge or techniques. Science, he reasons,
patients
found to
must be matched with
Annotations
humanism, and humanism shrift where there are many separate, short gets clinics. Again on humanistic grounds, highly specialist he is emphatic about the maximum number of beds in the hospitals ; in their design they should respect the unity of medicine by including a department in each of the major specialties; but lay, medical, and nursing personnel should not be asked to supervise a hospital with more than 500-750 beds, even though a larger number may be administered with equal ease. This is a welcome plea, particularly if it takes psychiatry within its compass. As for the special hospitals, he pointed out that in large centres such as London these were founded at a time when surgeons and physicians in new branches, in peril of being overborne by the main stream, withdrew to evolve their special techniques. The peril is now past; and, rightly contending that continued detachment is harmful, MAITLAND would bring them back into the community of the general hospital. He allows, however, there may be a case for the separation of maternity. With an eye to economy in skill he proposes that those needing active treatment should be separated from others who require only maintenance. This precept is in fact followed in some hospitals caring for the aged sick, notably the West Middlesex ; but his further proposal-that recovery wards should be run in association with wards for the acutely ill-is more novel. Such an arrangement would undoubtedly be economical; but implying, as it would, the transfer of patients from one ward to another, it cannot be said to promote the mental comfort of the patient that he seeks to foster. This consideration is perhaps less important with patients admitted for diagnosis if their stay is likely to be short. We are all familiar with the patient who, simply because a particular investigation demands his presence in hospital, takes up a bed which might otherwise be occupied by an acutely sick man or woman. To avoid this there is a strong case for setting up a special investigation ward in close geographical and administrative proximity to the outpatient department, where patients, until their discharge or admission to the hospital proper, would have dormitory accommodation, with food provided, on a help-yourself plan, in a nearby dayroom. MAITLAND argues against vested interest in hospitals ; despite their emotional appeal, " bigger and better " hospitals should not be the prime objective of the new service. Pride of place, he thinks, should go rather to the public-health branch. Meanwhile hospitals, handicapped by shortages, will pass on a heavy load to the local health authorities which are responsible for the patient after his discharge. Here he attaches great weight to a close nexus between the hospital management committee and the local health authority ; and he casts the hospital almoner for the role of liaison officer. For the operation of the service as a whole he pointed to JOHN STUART MILL’s dictum —" power at the periphery : wisdom at the centre."
NEGOTIATION
As already explained, discussions between the medical profession and the Ministry of Health on the National Health Service Act have so far been conducted by subcommittees of the Negotiating Committee meeting officials of the Ministry. A meeting between the full Negotiating Committee and the Minister himself was arranged for Nov. Iand 12 ; but this has now been postponed, at Mr. Bevan’s request, until Dec. 2 and 3. The postponement will enable him to make a closer study of the document he received from the Negotiating Committee on Nov. 7, in which they present their observations on a number of disputed issues affecting’ general practice. Before members of the profession are asked to reach any decision about participation in the service, they will receive a larger document which will contain the committee’s observations on all the subjects under discussion, and the Minister’s replies to any criticism of his proposals. PATIENTS AS SANATORIUM NURSES
EX-PATIENTS are now fairly often engaged as sanatorium nursing staff ; and on another page Dr. Watt and Miss Sheehan describe a successful scheme of the kind at the King George V Sanatorium, Godalming. Elsewhere Dr. Kissen1 has told of a less satisfactory experience at Bellefield Sanatorium, Lanark, where a process of continuous reablement of selected patients was
attempted. Five two-bed side-rooms of a ward (closed owing to lack of were converted into three double bedrooms, a sittingroom, and a dressing-room, for six patient-nurses, each of whom was provided with a rest chair. Meals were taken in the main nurses’ dining-room-Dr. Kissen does not say whether with the rest of the staff or separately. It was intended to transfer each batch of six patients to the nurses’ home as each fresh group of six was recruited. At the start they were engaged for a 24-hour week with a 4-hour day, the duty periods being in the morning, afternoon, and evening of successive days; they were not asked to take night duty. Later it was found possible to increase the hours to 36 a week with a 6-hour day, sometimes broken by a long rest-period. The patients were paid at the rate of student nurses for the hours actually worked, and this very low rate of remuneration -for a 24-hour week they got 118. 8d.-was one of the chief causes of failure ; for most of the girls lived in Glasgow, a half-crown return journey away; and had they chosen to go home for convalescence instead of working they would have received the basic tuberculosis allowance of 258. a week. Nevertheless 11 girls took part in the scheme, including 2 from another sanatorium. Their lesions were inactive, and they were all free from symptoms and had been up all day and on graduated exercise for some time. Most of them spent a week or two at home before beginning work. They were warned thoroughly about the proper use of leisure, but only 4 seemed to take the warning to heart ; most of them spent much time at entertainments in Lanark and Glasgow, and their long off-duty times-put to such improper useroused the resentment of the permanent staff. The patients were evidently not happy in the work, for Dr. Kissen reports many petty squabbles ; and only 1 patient is still on the staff after some ten months’ service. They were advised to stay a year, to enable the medical staff to assess their condition and working capacity, but 6 resigned after less than three months, 3 after less than four months, and 1 after five months. On the whole their physical health had improved, Dr. Kissen considers, despite a slight loss of weight after taking up work. The scheme was abandoned when the closed ward was reopened, and though there have since been requests by other patients to join the scheme, it can hardly have been said to have proved a success.
staff)
One
or
two
reasons
for the
immediately apparent. engaged, and they have to are
1. Kissen, D. M.
greater success at Godalming
Only really be able to do
fit staff are a full day’s
Tubercle, Lond. 1947, 28, 185.
40,000 new cases are seen in the outpatient department ; in another hospital only 7% of medical outand about
25%
of
surgical outpatients are require admission. In the staffing of outpatient departments MAITLAND believes that general physicians and general surgeons should be brought to the fore, though they should be able to call on special knowledge or techniques. Science, he reasons,
patients
found to
must be matched with
Annotations
humanism, and humanism shrift where there are many separate, short gets clinics. Again on humanistic grounds, highly specialist he is emphatic about the maximum number of beds in the hospitals ; in their design they should respect the unity of medicine by including a department in each of the major specialties; but lay, medical, and nursing personnel should not be asked to supervise a hospital with more than 500-750 beds, even though a larger number may be administered with equal ease. This is a welcome plea, particularly if it takes psychiatry within its compass. As for the special hospitals, he pointed out that in large centres such as London these were founded at a time when surgeons and physicians in new branches, in peril of being overborne by the main stream, withdrew to evolve their special techniques. The peril is now past; and, rightly contending that continued detachment is harmful, MAITLAND would bring them back into the community of the general hospital. He allows, however, there may be a case for the separation of maternity. With an eye to economy in skill he proposes that those needing active treatment should be separated from others who require only maintenance. This precept is in fact followed in some hospitals caring for the aged sick, notably the West Middlesex ; but his further proposal-that recovery wards should be run in association with wards for the acutely ill-is more novel. Such an arrangement would undoubtedly be economical; but implying, as it would, the transfer of patients from one ward to another, it cannot be said to promote the mental comfort of the patient that he seeks to foster. This consideration is perhaps less important with patients admitted for diagnosis if their stay is likely to be short. We are all familiar with the patient who, simply because a particular investigation demands his presence in hospital, takes up a bed which might otherwise be occupied by an acutely sick man or woman. To avoid this there is a strong case for setting up a special investigation ward in close geographical and administrative proximity to the outpatient department, where patients, until their discharge or admission to the hospital proper, would have dormitory accommodation, with food provided, on a help-yourself plan, in a nearby dayroom. MAITLAND argues against vested interest in hospitals ; despite their emotional appeal, " bigger and better " hospitals should not be the prime objective of the new service. Pride of place, he thinks, should go rather to the public-health branch. Meanwhile hospitals, handicapped by shortages, will pass on a heavy load to the local health authorities which are responsible for the patient after his discharge. Here he attaches great weight to a close nexus between the hospital management committee and the local health authority ; and he casts the hospital almoner for the role of liaison officer. For the operation of the service as a whole he pointed to JOHN STUART MILL’s dictum —" power at the periphery : wisdom at the centre."
NEGOTIATION
As already explained, discussions between the medical profession and the Ministry of Health on the National Health Service Act have so far been conducted by subcommittees of the Negotiating Committee meeting officials of the Ministry. A meeting between the full Negotiating Committee and the Minister himself was arranged for Nov. Iand 12 ; but this has now been postponed, at Mr. Bevan’s request, until Dec. 2 and 3. The postponement will enable him to make a closer study of the document he received from the Negotiating Committee on Nov. 7, in which they present their observations on a number of disputed issues affecting’ general practice. Before members of the profession are asked to reach any decision about participation in the service, they will receive a larger document which will contain the committee’s observations on all the subjects under discussion, and the Minister’s replies to any criticism of his proposals. PATIENTS AS SANATORIUM NURSES
EX-PATIENTS are now fairly often engaged as sanatorium nursing staff ; and on another page Dr. Watt and Miss Sheehan describe a successful scheme of the kind at the King George V Sanatorium, Godalming. Elsewhere Dr. Kissen1 has told of a less satisfactory experience at Bellefield Sanatorium, Lanark, where a process of continuous reablement of selected patients was
attempted. Five two-bed side-rooms of a ward (closed owing to lack of were converted into three double bedrooms, a sittingroom, and a dressing-room, for six patient-nurses, each of whom was provided with a rest chair. Meals were taken in the main nurses’ dining-room-Dr. Kissen does not say whether with the rest of the staff or separately. It was intended to transfer each batch of six patients to the nurses’ home as each fresh group of six was recruited. At the start they were engaged for a 24-hour week with a 4-hour day, the duty periods being in the morning, afternoon, and evening of successive days; they were not asked to take night duty. Later it was found possible to increase the hours to 36 a week with a 6-hour day, sometimes broken by a long rest-period. The patients were paid at the rate of student nurses for the hours actually worked, and this very low rate of remuneration -for a 24-hour week they got 118. 8d.-was one of the chief causes of failure ; for most of the girls lived in Glasgow, a half-crown return journey away; and had they chosen to go home for convalescence instead of working they would have received the basic tuberculosis allowance of 258. a week. Nevertheless 11 girls took part in the scheme, including 2 from another sanatorium. Their lesions were inactive, and they were all free from symptoms and had been up all day and on graduated exercise for some time. Most of them spent a week or two at home before beginning work. They were warned thoroughly about the proper use of leisure, but only 4 seemed to take the warning to heart ; most of them spent much time at entertainments in Lanark and Glasgow, and their long off-duty times-put to such improper useroused the resentment of the permanent staff. The patients were evidently not happy in the work, for Dr. Kissen reports many petty squabbles ; and only 1 patient is still on the staff after some ten months’ service. They were advised to stay a year, to enable the medical staff to assess their condition and working capacity, but 6 resigned after less than three months, 3 after less than four months, and 1 after five months. On the whole their physical health had improved, Dr. Kissen considers, despite a slight loss of weight after taking up work. The scheme was abandoned when the closed ward was reopened, and though there have since been requests by other patients to join the scheme, it can hardly have been said to have proved a success.
staff)
One
or
two
reasons
for the
immediately apparent. engaged, and they have to are
1. Kissen, D. M.
greater success at Godalming
Only really be able to do
fit staff are a full day’s
Tubercle, Lond. 1947, 28, 185.