- Email: [email protected]
PSYCHIATRY AND MEDICAL ADMINISTRATION
1314
drawback; for X-ray therapy, by virtue of the scatter of its beam, attacks not only the main mass of a tumour but also outlying cells. Hence the area for treatment by ultrasonic therapy would have to be very carefully mapped out, and perhaps a lesser dose would have to be directed to the area surrounding the growth. But are cancer cells more sensitive, in fact, to ultrasound than normal cells ? There seems to be no danger to the skin or haemopretic tissues with sound therapy, and less capital outlay is needed. The future of electro-medical engineering is promising. In this marriage of two disciplines, the partners, medicine and electronics, are so well balanced that the question will soon arise as to who should be the direction of new developments. The engineers have undoubtedly stimulated the traditionally conservative doctors, but if human beings are to be looked upon as more than mechanical tools (inefficient ones, perhaps), final control must rest in the hands of the doctors.
a
given
PSYCHIATRY AND MEDICAL ADMINISTRATION *
JOHN T. HUTCHINSON CONSULTANT
M.D. Glasg., D.P.M. PSYCHIATRIST, CANE HILL HOSPITAL, COULSDON,
SURREY
WITH the inception of the National Health Service in 1948, the local-authority general hospitals changed to the voluntary-hospital form of administration, or tripartite administration, in which the hospital was run by a management committee assisted by a medical committee and a matron. In the psychiatric hospitals medical administration was buttressed by a Statutory Instrument (1948) which designated the medical superintendent as chief officer of the hospital. The Mental Health Act, 1959,
abolished the absolute clinical control of the medical superintendent and made it possible for psychiatric hospitals to adopt tripartite administration. This paper sets out the reasons why they ought to consider such an advance now. In 1828 the Metropolitan Commissioners of Lunacy Act stipulated that every madhouse of more than 100 beds in the London area should have a resident medical officer (Dainton 1961). Many hospitals appointed medical superintendents but their powers were not fully defined until the Lunacy Act of 1890. The general hospitals, which started as infirmaries under the Poor Law and became municipal hospitals under the Local Government Act, 1929, were run by medical administrators until 1948. They then adopted the voluntary-hospital system of administration under which the medical staff advised the governors. In the 19th century, because of the influence of Miss Nightingale, the matron was admitted as a third party to the partnership between the governing body and the medical staff, thus giving the concept of tripartite administration. The two chief defects of administration by medical superintendents have been the remoteness of the lay committees and the fact that their powers were delegated to a doctor. One of the functions of the lay committee is the enlightened pursuit of economy-a desirable enough aim -but this is no task for a clinician, whose duty is primarily to his patients. It is best, therefore, that this responsibility should be delegated to a lay person who is not intimately concerned with the treatment of the patient. The physical *
Abridged from the Maudsley bequest lecture delivered to the Royal Medico-Psychological Association on Feb. 11, 1963.
difficulty of the remoteness of lay management committees has now disappeared, but many remain psychologically remote from medical committees. The remedy for this lies in the hands of the clinicians, who often ignore the fact that the hospital service could not run without the unpaid services of the 10,000 people who give their time to its management. Many medical advisory committees complain that medical representation on hospital management committees is inadequate, and forget that they have the power to nominate lay people who share their interest in the welfare of the sick. Management committees and medical committees thrive on mutual interest, and tend to atrophy if they are regarded as rubber stamps for ministerial policy. COMMITTEE PROCEDURE
One of the cornerstones of tripartite administration is an effective medical advisory committee. These committees have existed in the old voluntary hospitals since the 17th century, but they are new corners to the psychiatric hospitals. In 30 psychiatric hospitals Tetlow (1957) found that the staff of only 5 were satisfied with the working of the medical advisory committee. Middlefell (1959) found that in 50 psychiatric hospitals only 25 felt that the liaison between the medical advisory committee and the hospital management committee (H.M.C.) was good. Recently I sent a questionnaire to 102 psychiatric hospitals and 87 replied. TableI shows the normal procedure of medical advisory committees in general hospitals and table 11 summarises the position in these 87 psychiatric hospitals. TABLE I-PROCEDURE OF MEDICAL
ADVISORY COMMITTEES
IN GENERAL
H(1CPTTAT.S
TABLE 11-MEDICAL ADVISORY COMMITTEE PROCEDURE IN
87 PSYCHIATRIC
HOSPITALS
. At 59 hospitals the committee did not consist of senior staff only. The chief danger of this is that the consultants can become a minority group on a committee designed to serve their interests. Junior clinicians are in the hospitals for training in clinical work, and it is wasting their time to send them to committees. It is of interest that barely a quarter of the hospitals invited the group secretary to their meetings. Most committees considered that their deliberations were private and that free discussion would be difficult in the presence of a lay person. These committees seemed to neglect the fact that they are not forums for gossip and that the presence of the group secretary can enhance their status in the eyes of the management committee. This is also true of the attendance of the chairman of the hospital management committee. Since only 51 of the hospitals send monthly
1315 to the hospital management committee, most of the others probably have little business to consider. At 51 hospitals the medical superintendent gives the views of the medical committee to the hospital management committee. The Bradbeer report thought this undesirable. Many hospitals said that the committee met so seldom because there was a daily meeting of the medical staff. " " This is only a variant of the daily office which superintendents practised before the Mental Health Act, 1959, and it is a cumbersome procedure highly expensive in terms of clinical time. I did not send questionnaires to hospitals for subnormal patients, because their staff is often too small to justify the constitution of a medical committee. Historically they have been managed apart from the psychiatric hospitals and even now many specialists in subnormality will agree that their clinical liaison is not with psychiatry but with other branches of biological research and social
reports
administration. CHAIRMAN’S
DUTIES
At Cane Hill
Hospital, just over a year ago, we had the decide whether or not to adopt tripartite administration. The medical advisory committee asked for this form of administration, which was approved by the hospital management committee and soon afterwards by the regional board. Under this new regime I have been chairman of the medical advisory committee. The hospital is organised on the firm system : each firm is of equal size and headed by a consultant. The consultants meet once a week for only half an hour to discuss policy, and once a fortnight we have a formal meeting of the medical advisory committee which consists of the senior staff plus the group secretary. I am available for day-to-day consultation with the group secretary and the chairman of the hospital management committee, but it is clearly understood that I take no administrative action over the heads of my consultant colleagues, and any views on policy which I express are based on discussions with them. In brief, any administrative strength which I possess is derived from the support of my colleagues and I could not function without such support. I hold office for three years and I do not receive the E250 award. As we are practising tripartite administration, the matron and the chief male nurse have more autonomy; they present their own reports to the hospital management committee. The group secretary is responsible for more administration, and all three seem to value their new independence highly. The three paramount principles for a medical chairman are delegation, communication, and liaison. opportunity
to
ment
committee. It
also the
means
rapid dissemination of any a corollary to the policy
information received, and it is really
of maintaining a good system of communication. One aspect of this is my attendance at the monthly meetings of the hospital management committee, where I report the resolutions of the medical advisory committee, and a fair variety of other matters of medical interest, so that the management committee is fully informed about the medical work of the hospital. One sideeffect of my chairmanship has been membership of more advisory subcommittees of the regional hospital board, but despite all this I have still managed to find time for an adequate amount of clinical work.
Shaw and Samuel (1959) have described an earlier experiment in tripartite administration, at Belmont: but their practice differs from ours in several ways. The medical administrator was appointed, not elected, and Shaw and Samuel regret that he was not regarded as " a representative of the medical staff committee ". This is the crux of the distinction between their pattern of administration and ours. At Belmont the medical administrator holds office for only a limited period and this is the only innovation to the form of medical administration practised in most psychiatric hospitals for many years. Kidd (1961) has described the new role of the superintendent under the Mental Health Act, 1959, but it is difficult to escape the conclusion that he is using a wide variety of adjectives to describe a post that has no real basis in fact, in the same way as we use a variety of treatments for illnesses which we do not understand. A paper by Milner, Kumar, and Bakker (1963) analyses the admission-rate to the firms in a psychiatric hospital and indicates that the patients admitted to the firm headed by the medical superintendent are too few to be of statistical significance. This is the chief handicap to the system of medical administration. Many hospitals now have a firm system, but invariably the clinical division headed by the superintendent (if he heads one at all) is smaller and has fewer admissions than any of the other firms. This state of affairs is a handicap to medical progress and is a bar to the efficient development of the psychiatric services. I am grateful to my consultant colleagues, Dr. A. J. Oldham and Dr. E. Roderic-Evans, without whose support this project would not have been achieved. My thanks are due to the Society of Clinical Psychiatrists whose activities have fostered much of this development, and also to the 87 colleagues who answered my questionnaire. REFERENCES C. (1961) Story of England’s Hospitals. London. Kidd, H. B. (1961) Lancet, ii, 703. Middlefell, R. (1959) Brit. med. J. ii, suppl. p. 4. Milner, G., Kumar, K., Bakker, A. H. (1963) Brit. med. J. i, 389. Shaw, D., Samuel, A. (1959) Lancet, ii, 170. Statutory Instrument (1948) 419. H.M. Stationery Office. Tetlow, C. (1957) Lancet, i, 89.
Dainton,
BIRTHDAY HONOURS
important to delegate and share responsibilities as much possible with consultant colleagues, so that they have a corporate responsibility in the care of the patients. This includes such duties as medical care of sick staff, interviewing candidates for medical posts, and representation of the hospital on local committees. Without such delegation it would be
THE list of honours published on June 8 contains the of the following members of the medical profession:
difficult for a medical chairman to carry a full clinical load. Good communications are also important: it is deceptively easy to make rapid administrative decisions and inform colleagues later of any action taken. It is much more difficult to delay administrative action until colleagues are fully
ARTHUR CAPEL HERBERT
It is
as
acquainted with a problem and have discussed it. This may seem cumbersome, and indeed it is difficult and always timeconsuming, but the ultimate results are much better. Policy is formulated fully and no resentment is aroused in medical and lay colleagues. Good liaison amounts to being readily available to medical colleagues, lay administrators, and the chairman of the manage-
Baron
names
(Life Peerage)
HILL, P.C., M.D. Cantab., LL.D., M.P. Formerly Minister of Housing and Local Government.
CHARLES
Knights Bachelor BELL, M.B. Lond., F.R.C.S. President, Royal College of Obstetricians and Gynaecologists. JOHN BRUCE, C.B.E., T.D., M.S. Edin., F.R.C.S.E., F.R.C.S. Regius professor of clinical surgery, University of Edinburgh. IVAN BEDE JOSE, M.C., M.B. Adelaide, F.R.C.S., F.R.C.S.E., F.R.A.C.S. Consulting surgeon, Royal Adelaide Hospital, South Australia. OSWALD ELLIS JOSEPH MURPHY, CH.M. Sydney, F.R.C.P., F.R.A.C.P. Consulting physician, Mater Misericordias Public Hospital, Brisbane.
C.B.
(Military)
Air Commodore RALPH COBURN JACKSON, F.R.C.P.E., R.A.F. Air Vice-Marshal JOHN BROWN WALLACE, O.B.E., Q.H.S., M.D. R.A.F.
Glasg.,
drawback; for X-ray therapy, by virtue of the scatter of its beam, attacks not only the main mass of a tumour but also outlying cells. Hence the area for treatment by ultrasonic therapy would have to be very carefully mapped out, and perhaps a lesser dose would have to be directed to the area surrounding the growth. But are cancer cells more sensitive, in fact, to ultrasound than normal cells ? There seems to be no danger to the skin or haemopretic tissues with sound therapy, and less capital outlay is needed. The future of electro-medical engineering is promising. In this marriage of two disciplines, the partners, medicine and electronics, are so well balanced that the question will soon arise as to who should be the direction of new developments. The engineers have undoubtedly stimulated the traditionally conservative doctors, but if human beings are to be looked upon as more than mechanical tools (inefficient ones, perhaps), final control must rest in the hands of the doctors.
a
given
PSYCHIATRY AND MEDICAL ADMINISTRATION *
JOHN T. HUTCHINSON CONSULTANT
M.D. Glasg., D.P.M. PSYCHIATRIST, CANE HILL HOSPITAL, COULSDON,
SURREY
WITH the inception of the National Health Service in 1948, the local-authority general hospitals changed to the voluntary-hospital form of administration, or tripartite administration, in which the hospital was run by a management committee assisted by a medical committee and a matron. In the psychiatric hospitals medical administration was buttressed by a Statutory Instrument (1948) which designated the medical superintendent as chief officer of the hospital. The Mental Health Act, 1959,
abolished the absolute clinical control of the medical superintendent and made it possible for psychiatric hospitals to adopt tripartite administration. This paper sets out the reasons why they ought to consider such an advance now. In 1828 the Metropolitan Commissioners of Lunacy Act stipulated that every madhouse of more than 100 beds in the London area should have a resident medical officer (Dainton 1961). Many hospitals appointed medical superintendents but their powers were not fully defined until the Lunacy Act of 1890. The general hospitals, which started as infirmaries under the Poor Law and became municipal hospitals under the Local Government Act, 1929, were run by medical administrators until 1948. They then adopted the voluntary-hospital system of administration under which the medical staff advised the governors. In the 19th century, because of the influence of Miss Nightingale, the matron was admitted as a third party to the partnership between the governing body and the medical staff, thus giving the concept of tripartite administration. The two chief defects of administration by medical superintendents have been the remoteness of the lay committees and the fact that their powers were delegated to a doctor. One of the functions of the lay committee is the enlightened pursuit of economy-a desirable enough aim -but this is no task for a clinician, whose duty is primarily to his patients. It is best, therefore, that this responsibility should be delegated to a lay person who is not intimately concerned with the treatment of the patient. The physical *
Abridged from the Maudsley bequest lecture delivered to the Royal Medico-Psychological Association on Feb. 11, 1963.
difficulty of the remoteness of lay management committees has now disappeared, but many remain psychologically remote from medical committees. The remedy for this lies in the hands of the clinicians, who often ignore the fact that the hospital service could not run without the unpaid services of the 10,000 people who give their time to its management. Many medical advisory committees complain that medical representation on hospital management committees is inadequate, and forget that they have the power to nominate lay people who share their interest in the welfare of the sick. Management committees and medical committees thrive on mutual interest, and tend to atrophy if they are regarded as rubber stamps for ministerial policy. COMMITTEE PROCEDURE
One of the cornerstones of tripartite administration is an effective medical advisory committee. These committees have existed in the old voluntary hospitals since the 17th century, but they are new corners to the psychiatric hospitals. In 30 psychiatric hospitals Tetlow (1957) found that the staff of only 5 were satisfied with the working of the medical advisory committee. Middlefell (1959) found that in 50 psychiatric hospitals only 25 felt that the liaison between the medical advisory committee and the hospital management committee (H.M.C.) was good. Recently I sent a questionnaire to 102 psychiatric hospitals and 87 replied. TableI shows the normal procedure of medical advisory committees in general hospitals and table 11 summarises the position in these 87 psychiatric hospitals. TABLE I-PROCEDURE OF MEDICAL
ADVISORY COMMITTEES
IN GENERAL
H(1CPTTAT.S
TABLE 11-MEDICAL ADVISORY COMMITTEE PROCEDURE IN
87 PSYCHIATRIC
HOSPITALS
. At 59 hospitals the committee did not consist of senior staff only. The chief danger of this is that the consultants can become a minority group on a committee designed to serve their interests. Junior clinicians are in the hospitals for training in clinical work, and it is wasting their time to send them to committees. It is of interest that barely a quarter of the hospitals invited the group secretary to their meetings. Most committees considered that their deliberations were private and that free discussion would be difficult in the presence of a lay person. These committees seemed to neglect the fact that they are not forums for gossip and that the presence of the group secretary can enhance their status in the eyes of the management committee. This is also true of the attendance of the chairman of the hospital management committee. Since only 51 of the hospitals send monthly
1315 to the hospital management committee, most of the others probably have little business to consider. At 51 hospitals the medical superintendent gives the views of the medical committee to the hospital management committee. The Bradbeer report thought this undesirable. Many hospitals said that the committee met so seldom because there was a daily meeting of the medical staff. " " This is only a variant of the daily office which superintendents practised before the Mental Health Act, 1959, and it is a cumbersome procedure highly expensive in terms of clinical time. I did not send questionnaires to hospitals for subnormal patients, because their staff is often too small to justify the constitution of a medical committee. Historically they have been managed apart from the psychiatric hospitals and even now many specialists in subnormality will agree that their clinical liaison is not with psychiatry but with other branches of biological research and social
reports
administration. CHAIRMAN’S
DUTIES
At Cane Hill
Hospital, just over a year ago, we had the decide whether or not to adopt tripartite administration. The medical advisory committee asked for this form of administration, which was approved by the hospital management committee and soon afterwards by the regional board. Under this new regime I have been chairman of the medical advisory committee. The hospital is organised on the firm system : each firm is of equal size and headed by a consultant. The consultants meet once a week for only half an hour to discuss policy, and once a fortnight we have a formal meeting of the medical advisory committee which consists of the senior staff plus the group secretary. I am available for day-to-day consultation with the group secretary and the chairman of the hospital management committee, but it is clearly understood that I take no administrative action over the heads of my consultant colleagues, and any views on policy which I express are based on discussions with them. In brief, any administrative strength which I possess is derived from the support of my colleagues and I could not function without such support. I hold office for three years and I do not receive the E250 award. As we are practising tripartite administration, the matron and the chief male nurse have more autonomy; they present their own reports to the hospital management committee. The group secretary is responsible for more administration, and all three seem to value their new independence highly. The three paramount principles for a medical chairman are delegation, communication, and liaison. opportunity
to
ment
committee. It
also the
means
rapid dissemination of any a corollary to the policy
information received, and it is really
of maintaining a good system of communication. One aspect of this is my attendance at the monthly meetings of the hospital management committee, where I report the resolutions of the medical advisory committee, and a fair variety of other matters of medical interest, so that the management committee is fully informed about the medical work of the hospital. One sideeffect of my chairmanship has been membership of more advisory subcommittees of the regional hospital board, but despite all this I have still managed to find time for an adequate amount of clinical work.
Shaw and Samuel (1959) have described an earlier experiment in tripartite administration, at Belmont: but their practice differs from ours in several ways. The medical administrator was appointed, not elected, and Shaw and Samuel regret that he was not regarded as " a representative of the medical staff committee ". This is the crux of the distinction between their pattern of administration and ours. At Belmont the medical administrator holds office for only a limited period and this is the only innovation to the form of medical administration practised in most psychiatric hospitals for many years. Kidd (1961) has described the new role of the superintendent under the Mental Health Act, 1959, but it is difficult to escape the conclusion that he is using a wide variety of adjectives to describe a post that has no real basis in fact, in the same way as we use a variety of treatments for illnesses which we do not understand. A paper by Milner, Kumar, and Bakker (1963) analyses the admission-rate to the firms in a psychiatric hospital and indicates that the patients admitted to the firm headed by the medical superintendent are too few to be of statistical significance. This is the chief handicap to the system of medical administration. Many hospitals now have a firm system, but invariably the clinical division headed by the superintendent (if he heads one at all) is smaller and has fewer admissions than any of the other firms. This state of affairs is a handicap to medical progress and is a bar to the efficient development of the psychiatric services. I am grateful to my consultant colleagues, Dr. A. J. Oldham and Dr. E. Roderic-Evans, without whose support this project would not have been achieved. My thanks are due to the Society of Clinical Psychiatrists whose activities have fostered much of this development, and also to the 87 colleagues who answered my questionnaire. REFERENCES C. (1961) Story of England’s Hospitals. London. Kidd, H. B. (1961) Lancet, ii, 703. Middlefell, R. (1959) Brit. med. J. ii, suppl. p. 4. Milner, G., Kumar, K., Bakker, A. H. (1963) Brit. med. J. i, 389. Shaw, D., Samuel, A. (1959) Lancet, ii, 170. Statutory Instrument (1948) 419. H.M. Stationery Office. Tetlow, C. (1957) Lancet, i, 89.
Dainton,
BIRTHDAY HONOURS
important to delegate and share responsibilities as much possible with consultant colleagues, so that they have a corporate responsibility in the care of the patients. This includes such duties as medical care of sick staff, interviewing candidates for medical posts, and representation of the hospital on local committees. Without such delegation it would be
THE list of honours published on June 8 contains the of the following members of the medical profession:
difficult for a medical chairman to carry a full clinical load. Good communications are also important: it is deceptively easy to make rapid administrative decisions and inform colleagues later of any action taken. It is much more difficult to delay administrative action until colleagues are fully
ARTHUR CAPEL HERBERT
It is
as
acquainted with a problem and have discussed it. This may seem cumbersome, and indeed it is difficult and always timeconsuming, but the ultimate results are much better. Policy is formulated fully and no resentment is aroused in medical and lay colleagues. Good liaison amounts to being readily available to medical colleagues, lay administrators, and the chairman of the manage-
Baron
names
(Life Peerage)
HILL, P.C., M.D. Cantab., LL.D., M.P. Formerly Minister of Housing and Local Government.
CHARLES
Knights Bachelor BELL, M.B. Lond., F.R.C.S. President, Royal College of Obstetricians and Gynaecologists. JOHN BRUCE, C.B.E., T.D., M.S. Edin., F.R.C.S.E., F.R.C.S. Regius professor of clinical surgery, University of Edinburgh. IVAN BEDE JOSE, M.C., M.B. Adelaide, F.R.C.S., F.R.C.S.E., F.R.A.C.S. Consulting surgeon, Royal Adelaide Hospital, South Australia. OSWALD ELLIS JOSEPH MURPHY, CH.M. Sydney, F.R.C.P., F.R.A.C.P. Consulting physician, Mater Misericordias Public Hospital, Brisbane.
C.B.
(Military)
Air Commodore RALPH COBURN JACKSON, F.R.C.P.E., R.A.F. Air Vice-Marshal JOHN BROWN WALLACE, O.B.E., Q.H.S., M.D. R.A.F.
Glasg.,