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Over to the Lords
493
THE
LANCET
LONDON:SA1’UBDAY, UG’1’. 5, 1946
Over to the Lords by and large, Mr. BEVAN’s handling
of the TAKEN National Health Service Bill in the House of Commons was masterly, and many of those who a few months ago were strongly antagonistic now understand the strength of the Government case. There are grounds therefore for his hope that, though the armies are
arrayed on the battlefield, they are becoming increasingly listless ;and the president of one of the Royal Colleges did well last week to direct attention still
to the peace conferences which must
soon follow. Nevertheless a further chance remains for amending the text of the Bill, during the debate which opens in the House of Lords next Tuesday, and it would be a pity if this discussion were to be a mere formality. Much in the scheme remains highly debatable, and the Government should welcome any attempt to make a good Bill better-to correct weaknesses that might eventually prove its undoing. Uneasiness over several of its provisions is still felt by those most anxious for
its
success.
Despite all the Minister’s explanations, we are still uncertain whether the degree of autonomy granted to hospital management committees is going to be sufficient, in the long run, to induce able men and women to serve them devotedly. The misgivings felt on this score were cogently set out in our columns a few weeks ago1 by a correspondent who rightly pointed out that on the management committee " more than on any other body or person-the Minister included-will depend whether a hospital functions in an efficient and humane manner." Decentralisation of powers, as Mr. BEVAN recognises, is the main safeguard against a uniformly second-rate service, and he has accepted the plea made in our first comment on the Bill2 that hospital management committees should at least have their own pocket-money and be able to accept gifts. He has in fact promised that the regulations will ensure that adequate powers are delegated by the regional boards to the committees. But if that is his intention, is it necessary that the Bill should specifically lay down that the regional boards shall be the bodies to appoint officers, to maintain premises, and " to acquire on behalf of the Minister and to maintain equipment, furniture and other movable property required for the purposes of any such hospital " ? Are the boards really going to appoint subordinate personnel, to paint the building, and to mend broken tables and chairs ? In general Mr. BEVAN has sought to leave himself and his successors a free hand, so that where experience reveals a mistake it will be possible to modify the Bill by regulation, without new legislation. Can he be sure that the statutory assignment of these powers to regional boards-which, especially if there are only 16-20 large regions,33 are capable of becoming pieces of bureaucratic machinery 4-will not need modification ? Some 1. 2.
Lancet, July 20, p. 103. Ibid, 1946, i, 421.
3. Times, July 12, p. 5. 4. Lancet, July 27, p. 137.
hold that in practice it will seriously limit the devolution of responsibility which all desire. If the policy is to delegate to local management committees whatever powers may be found necessary for their functional health, would it not be wise at this stage to omit these particularising subsections ? To some extent the scheme is admittedly experimental, and it might be best to say quite simply that the regional boards and the hospital management committees shall exercise such powers as are respectively delegated to them by theMinister. Though nebulous, this would at any rate not be misleading. Another possible source of future trouble is the wide power of direction given to the Minister in connexion with hospital and specialist services. As we have already remarked,5this power is not restricted to the administrative as distinct from the professional sphere. When Mr. BEVAN was challenged on the point in the standing committee he gave an assurance that he would not be so foolish as to meddle in professional and this assurance, since repeated, matters ; undoubtedly represents his attitude correctly. Yet the profession, with its experience of directions of a semitechnical character that have issued from the Emergency Medical Service, cannot be so easily satisfied. There will be-there ought to be-medical officers in the Ministry of Healthanxious to secure widespread adoption of modern techniques. Will their ideas emanate from Whitehall- with all the authority of directions made in the name ofthe Minister, binding even on the regional boards ? That is the question, and Mr. BEVAN did not really answer it. We hope therefore it is not too late to incorporate in the Bill a formula making it clear how far the Minister’s power of direction legitimately extends. This should not be beyond the wit of legal draftsmen, for the distinction between administrative and professional matters is neither new nor hopelessly subtle : it is commonly respected in the hospital world today. The fact surely is that the simple wording of the Bill as it stands is too simple to meet the complexity of the undertaking. For simplicity’s sake the distinction between the administrative and professional responsibility in respect of the hospital and specialist services has been allowed to slip into the background. It would be a pity indeed if it were to become blurred, for the ultimate consequences could be disastrous to professional
freedom. A related
question, calling for legal debate, is whether practitioners whose conduct the Minister finds harmful to the National Health Service should have a right to -appeal from his decision to a court of law. The procedure as now laid down is that any complaint is made to the local executive council and is examined in the first place by,a purely medical body, the council’s medical subcommittee. A decision on the complaint is then reached by the council, half of whose members are doctors, dentists, and pharmacists. If the defendant practitioner is dissatisfied with the council’s verdict he can appeal to a tribunal of three persons, of whom the chairman is appointed by the Lord Chancellor. If again unsuccessful he can the to Minister himself, who is the person appeal for the finally responsible well-being of the service. But only if one of these authorities appears to have 5.
Ibid, 1946, i, 783.
494
legal powers, or to have acted improperly, seek can he help from an outside court. Provided the morale of the profession and the service is high, these arrangements should work well in practice ; and Mr. BEVAN has substance for his contention that the High Court is not the right kind of body to say whether a doctor has been reasonably efficient. Nevertheless under the new regime expulsion from the public service will be an extremely serious penalty, and it seems contrary to the principles of justice that sentence should be passed by the Minister who may be indirectly responsible for the accusation. It was to overcome this objection, of course, that the tribunal was inserted between the local executive council and the Minister ; but two of the three members of this tribunal are to be chosen by the Minister himself. The arrangements nature which Sir are in fact of the " quasi-judicial HENRY SLESSER6 and other eminent lawyers view with alarm, and there is far more in question than administrative convenience. All these are matters that the Lords are well fitted to elucidate. It is their function to take a long view, and we trust that discussion will not be frozen by too ready acquiescence, on either side of the House, in the Bill as it stands.
exceeded its
"
Perforated
Peptic
Ulcer
of the most serious and overwhelming that can befall a human being. Unless catastrophes measures are the hastens disease surgical adopted early, to a fatalending in almost every instance." In the decades since MOYNIHAN spoke these words, early operation for the perforated peptic ulcer has seemed to be as right and natural as the surgeon’s gloves. So it comes as a shock to find HERMON TAYLOR, in the article we published last week, declaring that conservatism has a place-he would even give it pride of placein the treatment of perforation. He puts forward a convincing series of 28 cases treated by conservative methods with 4 deaths ; 3 from conditions unrelated to the treatment, and only 1 in which, as he admits, operation might have made a difference. TAYLOR has turned away from immediate laparotomy, first, because he often found at operation that the perforation was already partially sealed and nature was clearly capable of completing the process. The peritoneal cavity, it appeared, could cope with a considerable quantity of infective fluid, provided that continued gross flooding from the perforation site was controlled by aspirating the stomach. Secondly, he had found that the with mortality operation was high, largely because of chest complications. Thirdly, many of these patients, because of bronchitis, severe hypertension, came in the " poor risk " or myocardial failure, class, where even a minor surgical procedure was hazardous. These results must be studied in conjunction with those of operation. TAYLOR’s cases were mostly early perforations, the delay before admission to hospital exceeding six hours in only 3-a fact that speaks well for the diagnostic alertness of the general practitioners in the district. Is operation really hazardous in such early cases ?1 GiLMOUR and SAINT1 record 51 cases operated on within twelve hours of perforation with " THIS is
6. 1.
one
Times, August 9, p. 5. Gilmour, J., Saint, J. A.
Brit. J.
Surg. 1932, 20, 78.
1 death ; SonTHAM 34
of duodenal perforation twenty-four hours with no deaths ; operated MAINGOT3 gives the mortality as 2-6%. Unforit the to is practice group together all tunately the overall and mortality figures for perforations, thus seem treatment high. Even so, surgical 4 in a recent HOUSTON,4 analysis, gives the Newcastle as 184 cases with 8-2% mortality ; for for 1943 figures 1944 as 190 cases with a 6-3% mortality. Surgery has not a great deal to be ashamed of with such on
cases
within
figures. These comparisons in no way detract from the value of the information to be drawn from TAYLOR’S experience. It emphasises the need for emptying the stomach as soon as possible after the perforation has been diagnosed ; the small Ryle tube is not enough, and it is a useful tip to give an amethocaine lozenge to facilitate the passage of a large tube. Morphine should be given as soon as possible and the patient " made comfortable." TAYLOR neither advocates nor condemns the Fowler position, and one may assume that the half-sitting position is the most comfortable one ; it is noteworthy that none of his cases developed a subphrenic abscess. His results have shown that where the diagnosis is in doubt, or where the patient’s poor general condition or the lack of a surgeon prohibits operation, we have a method of treating the early -case with a reasonable chance of success. TAYLOR agrees that when there has been a recent large meal with a likelihood of extensive spilling into the peritoneal cavity, and when the patient comes " too late," surgery is indicated. It must not be forgotten that the perforation is usually an emergency, coming under the care of the house-surgeon or R.S.O., whereas conservative treatment obviously requires an experienced clinical eye ; it might therefore be hazardous to advocate this treatment as the routine, even for the early case. Most surgeons, too, will find operation less nerve-racking than a policy of wait and see. One surgeon with a considerable experience of conservative " I agree conservative treatment has remarked: treatment works, but I have given it up. I have had too much anxiety with the early convalescence of these cases." The conservative method suggests itself as particularly suitable for the aged. TANNER,5 in a series of 16 perforations in people over sixty, had 10 deaths after operation-apparently a formidable mortality. Of 8 cases operated on under twelve hours, however, 6 made a complete recovery, and the 2 deaths were due to bronchopneumonia and cerebral thrombosis ; in TANNER’s view failure to send the patient to the surgeon early was mainly responsible for the high mortality, and in TAYLOR’S 6 cases in men over sixty the only death was in a patient who had perforated twenty-four hours before admission. The operation for perforation is usually simplicity itself. A midline incision seems to be most popular, though a right rectus muscle incision is used by some surgeons because there is an 8 to 1 chance of the perforation being duodenal. In view of the chest complications which commonly follow the perforated ulcer, and the difficulty of attaining adequate relaxaof tion of the abdominal wall, various
methods
2. Southam, A. H. Brit. med. J. 1922, i, 556. 3. Maingot, R. H. Abdominal Operations, London, 1940. 4. Houston, W. Brit. med. J. 1946, ii, 221. 5. Tanner, N. C. Ibid, 1943, i, 563.
THE
LANCET
LONDON:SA1’UBDAY, UG’1’. 5, 1946
Over to the Lords by and large, Mr. BEVAN’s handling
of the TAKEN National Health Service Bill in the House of Commons was masterly, and many of those who a few months ago were strongly antagonistic now understand the strength of the Government case. There are grounds therefore for his hope that, though the armies are
arrayed on the battlefield, they are becoming increasingly listless ;and the president of one of the Royal Colleges did well last week to direct attention still
to the peace conferences which must
soon follow. Nevertheless a further chance remains for amending the text of the Bill, during the debate which opens in the House of Lords next Tuesday, and it would be a pity if this discussion were to be a mere formality. Much in the scheme remains highly debatable, and the Government should welcome any attempt to make a good Bill better-to correct weaknesses that might eventually prove its undoing. Uneasiness over several of its provisions is still felt by those most anxious for
its
success.
Despite all the Minister’s explanations, we are still uncertain whether the degree of autonomy granted to hospital management committees is going to be sufficient, in the long run, to induce able men and women to serve them devotedly. The misgivings felt on this score were cogently set out in our columns a few weeks ago1 by a correspondent who rightly pointed out that on the management committee " more than on any other body or person-the Minister included-will depend whether a hospital functions in an efficient and humane manner." Decentralisation of powers, as Mr. BEVAN recognises, is the main safeguard against a uniformly second-rate service, and he has accepted the plea made in our first comment on the Bill2 that hospital management committees should at least have their own pocket-money and be able to accept gifts. He has in fact promised that the regulations will ensure that adequate powers are delegated by the regional boards to the committees. But if that is his intention, is it necessary that the Bill should specifically lay down that the regional boards shall be the bodies to appoint officers, to maintain premises, and " to acquire on behalf of the Minister and to maintain equipment, furniture and other movable property required for the purposes of any such hospital " ? Are the boards really going to appoint subordinate personnel, to paint the building, and to mend broken tables and chairs ? In general Mr. BEVAN has sought to leave himself and his successors a free hand, so that where experience reveals a mistake it will be possible to modify the Bill by regulation, without new legislation. Can he be sure that the statutory assignment of these powers to regional boards-which, especially if there are only 16-20 large regions,33 are capable of becoming pieces of bureaucratic machinery 4-will not need modification ? Some 1. 2.
Lancet, July 20, p. 103. Ibid, 1946, i, 421.
3. Times, July 12, p. 5. 4. Lancet, July 27, p. 137.
hold that in practice it will seriously limit the devolution of responsibility which all desire. If the policy is to delegate to local management committees whatever powers may be found necessary for their functional health, would it not be wise at this stage to omit these particularising subsections ? To some extent the scheme is admittedly experimental, and it might be best to say quite simply that the regional boards and the hospital management committees shall exercise such powers as are respectively delegated to them by theMinister. Though nebulous, this would at any rate not be misleading. Another possible source of future trouble is the wide power of direction given to the Minister in connexion with hospital and specialist services. As we have already remarked,5this power is not restricted to the administrative as distinct from the professional sphere. When Mr. BEVAN was challenged on the point in the standing committee he gave an assurance that he would not be so foolish as to meddle in professional and this assurance, since repeated, matters ; undoubtedly represents his attitude correctly. Yet the profession, with its experience of directions of a semitechnical character that have issued from the Emergency Medical Service, cannot be so easily satisfied. There will be-there ought to be-medical officers in the Ministry of Healthanxious to secure widespread adoption of modern techniques. Will their ideas emanate from Whitehall- with all the authority of directions made in the name ofthe Minister, binding even on the regional boards ? That is the question, and Mr. BEVAN did not really answer it. We hope therefore it is not too late to incorporate in the Bill a formula making it clear how far the Minister’s power of direction legitimately extends. This should not be beyond the wit of legal draftsmen, for the distinction between administrative and professional matters is neither new nor hopelessly subtle : it is commonly respected in the hospital world today. The fact surely is that the simple wording of the Bill as it stands is too simple to meet the complexity of the undertaking. For simplicity’s sake the distinction between the administrative and professional responsibility in respect of the hospital and specialist services has been allowed to slip into the background. It would be a pity indeed if it were to become blurred, for the ultimate consequences could be disastrous to professional
freedom. A related
question, calling for legal debate, is whether practitioners whose conduct the Minister finds harmful to the National Health Service should have a right to -appeal from his decision to a court of law. The procedure as now laid down is that any complaint is made to the local executive council and is examined in the first place by,a purely medical body, the council’s medical subcommittee. A decision on the complaint is then reached by the council, half of whose members are doctors, dentists, and pharmacists. If the defendant practitioner is dissatisfied with the council’s verdict he can appeal to a tribunal of three persons, of whom the chairman is appointed by the Lord Chancellor. If again unsuccessful he can the to Minister himself, who is the person appeal for the finally responsible well-being of the service. But only if one of these authorities appears to have 5.
Ibid, 1946, i, 783.
494
legal powers, or to have acted improperly, seek can he help from an outside court. Provided the morale of the profession and the service is high, these arrangements should work well in practice ; and Mr. BEVAN has substance for his contention that the High Court is not the right kind of body to say whether a doctor has been reasonably efficient. Nevertheless under the new regime expulsion from the public service will be an extremely serious penalty, and it seems contrary to the principles of justice that sentence should be passed by the Minister who may be indirectly responsible for the accusation. It was to overcome this objection, of course, that the tribunal was inserted between the local executive council and the Minister ; but two of the three members of this tribunal are to be chosen by the Minister himself. The arrangements nature which Sir are in fact of the " quasi-judicial HENRY SLESSER6 and other eminent lawyers view with alarm, and there is far more in question than administrative convenience. All these are matters that the Lords are well fitted to elucidate. It is their function to take a long view, and we trust that discussion will not be frozen by too ready acquiescence, on either side of the House, in the Bill as it stands.
exceeded its
"
Perforated
Peptic
Ulcer
of the most serious and overwhelming that can befall a human being. Unless catastrophes measures are the hastens disease surgical adopted early, to a fatalending in almost every instance." In the decades since MOYNIHAN spoke these words, early operation for the perforated peptic ulcer has seemed to be as right and natural as the surgeon’s gloves. So it comes as a shock to find HERMON TAYLOR, in the article we published last week, declaring that conservatism has a place-he would even give it pride of placein the treatment of perforation. He puts forward a convincing series of 28 cases treated by conservative methods with 4 deaths ; 3 from conditions unrelated to the treatment, and only 1 in which, as he admits, operation might have made a difference. TAYLOR has turned away from immediate laparotomy, first, because he often found at operation that the perforation was already partially sealed and nature was clearly capable of completing the process. The peritoneal cavity, it appeared, could cope with a considerable quantity of infective fluid, provided that continued gross flooding from the perforation site was controlled by aspirating the stomach. Secondly, he had found that the with mortality operation was high, largely because of chest complications. Thirdly, many of these patients, because of bronchitis, severe hypertension, came in the " poor risk " or myocardial failure, class, where even a minor surgical procedure was hazardous. These results must be studied in conjunction with those of operation. TAYLOR’s cases were mostly early perforations, the delay before admission to hospital exceeding six hours in only 3-a fact that speaks well for the diagnostic alertness of the general practitioners in the district. Is operation really hazardous in such early cases ?1 GiLMOUR and SAINT1 record 51 cases operated on within twelve hours of perforation with " THIS is
6. 1.
one
Times, August 9, p. 5. Gilmour, J., Saint, J. A.
Brit. J.
Surg. 1932, 20, 78.
1 death ; SonTHAM 34
of duodenal perforation twenty-four hours with no deaths ; operated MAINGOT3 gives the mortality as 2-6%. Unforit the to is practice group together all tunately the overall and mortality figures for perforations, thus seem treatment high. Even so, surgical 4 in a recent HOUSTON,4 analysis, gives the Newcastle as 184 cases with 8-2% mortality ; for for 1943 figures 1944 as 190 cases with a 6-3% mortality. Surgery has not a great deal to be ashamed of with such on
cases
within
figures. These comparisons in no way detract from the value of the information to be drawn from TAYLOR’S experience. It emphasises the need for emptying the stomach as soon as possible after the perforation has been diagnosed ; the small Ryle tube is not enough, and it is a useful tip to give an amethocaine lozenge to facilitate the passage of a large tube. Morphine should be given as soon as possible and the patient " made comfortable." TAYLOR neither advocates nor condemns the Fowler position, and one may assume that the half-sitting position is the most comfortable one ; it is noteworthy that none of his cases developed a subphrenic abscess. His results have shown that where the diagnosis is in doubt, or where the patient’s poor general condition or the lack of a surgeon prohibits operation, we have a method of treating the early -case with a reasonable chance of success. TAYLOR agrees that when there has been a recent large meal with a likelihood of extensive spilling into the peritoneal cavity, and when the patient comes " too late," surgery is indicated. It must not be forgotten that the perforation is usually an emergency, coming under the care of the house-surgeon or R.S.O., whereas conservative treatment obviously requires an experienced clinical eye ; it might therefore be hazardous to advocate this treatment as the routine, even for the early case. Most surgeons, too, will find operation less nerve-racking than a policy of wait and see. One surgeon with a considerable experience of conservative " I agree conservative treatment has remarked: treatment works, but I have given it up. I have had too much anxiety with the early convalescence of these cases." The conservative method suggests itself as particularly suitable for the aged. TANNER,5 in a series of 16 perforations in people over sixty, had 10 deaths after operation-apparently a formidable mortality. Of 8 cases operated on under twelve hours, however, 6 made a complete recovery, and the 2 deaths were due to bronchopneumonia and cerebral thrombosis ; in TANNER’s view failure to send the patient to the surgeon early was mainly responsible for the high mortality, and in TAYLOR’S 6 cases in men over sixty the only death was in a patient who had perforated twenty-four hours before admission. The operation for perforation is usually simplicity itself. A midline incision seems to be most popular, though a right rectus muscle incision is used by some surgeons because there is an 8 to 1 chance of the perforation being duodenal. In view of the chest complications which commonly follow the perforated ulcer, and the difficulty of attaining adequate relaxaof tion of the abdominal wall, various
methods
2. Southam, A. H. Brit. med. J. 1922, i, 556. 3. Maingot, R. H. Abdominal Operations, London, 1940. 4. Houston, W. Brit. med. J. 1946, ii, 221. 5. Tanner, N. C. Ibid, 1943, i, 563.