- Email: [email protected]
Sharing Authority
941
THE LANCET
wards and departments whether they were achieving the right results. These indices were not used in an inquisitorial manner, or wards and departments might well have reached for the whitewash brush. Instead, they were used as the basis for multidisciplinary action meetings which tried to solve the problems revealed by the indices, and which were able to press for strong backing by the board of
management.
Sharing Authority THE external
of health-care systems are undergoing considerable change, with health care being seen as one of a group of social services which need to be coordinated from a base within the community. But subtle internal changes are also taking place. Within some hospitals, doctors and other health professionals are combining in a new kind of management partnership, in the belief that the strength of a group is greater than the sum of its parts. Large hospitals are trying to grapple with their inherent problems of size and complexity by splitting themselves up into smaller units, more manageable and more personal, and by recognising the value of giving enough executive authority to the professional staff to allow them to settle most of the management problems of those units. This general movement towards decentralisation is gathering impetus, and today the wise hospital authority considers not whether, but how, decentralisation ought to happen. In this climate of change, a report1 from Sydney Hospital, Australia, is sharply relevant: it is the record of a total change in management philosophy in favour of professional participation Once the and the decentralisation of authority. had been units would made, departmental change control their own budgets, but would also be accountable for their own results; management decisions would be made as near to the patient as possible; people of different professions would bear these new responsibilities collectively. Underlying all this were three simple but penetrating questions, all demanding self-examination and self-discipline rather than a surrender to authoritarian control: What results are you trying to achieve ? Are you achieving them ? If not, what is stopping you ?
relationships
To
begin this vast process of change, Sydney Hospital decided to give top priority to the patient, aided by a patient-care index, a nurse-utilisation index, and a patient-satisfaction index-three somewhat imprecise tools which would nevertheless tell 1.
Crawford, L. E., Ritchie, 1971, ii, 1291.
F. L.,
Herriott, B. A. Med. J. Aust.
The establishment of patient-care as top priority might seem a concession to convention or sentiment, but people who work in hospital are often aware of the conflict between what the hospital is trying to do and what the patient thinks he ought to be getting. Some valuable pioneer work has been undertaken in the United Kingdom, notably by the King’s Fund, in trying to assess the degree of patientsatisfaction, but Sydney has gone the next step by using the patient-satisfaction index not only as an important element in the attempt to measure the quality of patient care but also as a regular tool of management. Instead of asserting smugly that the patient must come first, they have tried to measure whether this is so, to make sure that he does. Priority was also given to the availability of nurses. Many attempts, theoretical and practical, have been made to relate the allocation of nurses to some index of patient dependency: sometimes the attempts have floundered in over-precise detail; sometimes administrators have flinched from pursuing the data to a logical conclusion. In Sydney, their assessments may have been somewhat approximate, but they were consistently used when making managerial decisions. It would be interesting to learn more of the mechanisms by which the problems of medical
by Sydney Hospital were handled. They certainly have a familiar ring to Cogwheelers-length of stay; drug costs; coordination of preadmission investigations; relationships with the patient-care committee; necropsy and management reported
tissue committees; reviews of clinical work; survey of hospital infection. Once budgets were decentralised at Sydney, patient-care results could then be linked with budgetary targets. Approximate figures were given to wards and departments within three days of the end of the month: not as precise as a computer, but a lot quicker. Professions could now take money into account when making policy decisions about the management of their own units. Today the control of expenditure is no longer a restrictive exercise, but a creative one, a means to an end. What Sydney has done is to decide on a change of management style, to create the machinery which may make this change effective, yet to remain prepared to change any method which may prove ineffective. They have succeeded in achieving all
942
within the mechanics of the established system, even though much of the change was apparently diametrically opposed to the system. Throughout, they have recognised the essential role of management training-not only initial training aimed at getting a change of outlook, but also continued training for all professions, without which reform can easily degenerate into acquiescence. Has this work any relevance for Britain’s Health Service ? No new techniques have been developed. No new management cliches have enriched the jargon. No revolutionary research results have been announced. Perhaps there is enough revolution in the simple claim that costs can be reduced as a byproduct to the improvement of patient care, and that significant results can be achieved by decentralising management responsibilities and by teaching hospital staff how to cope with their own management problems. All this has occasioned a new outlook on the part of staff, and the report suggests that this should be matched by a corresponding change in the outlook of public authorities which control hospitals. With 1974 looming ahead, there is surely a relevance for Britain in this. this
change
Epidemiology of Crohn’s Disease THOUGH
increasing attention is being given to the clinicopathological features of Crohn’s disease, the epidemiological picture is still fragmentary. EVANS and ACHESON1 collected all inpatients admitted with the disease in the Oxford area between 1951 and 1960, but found insufficient cases to allow any detailed analysis: to this have since been added surveys conducted in Norway, Scotland, Sweden, Switzerland, and the Baltimore area of the U.S.A.2-6 In general, the disease has been found to be slightly more common in men than in women, with more new cases in those aged 20-30 than in any other age-group. As with any disease of unknown cause, epidemiological comparisons of geographical, temporal, and other differences in frequency are potentially useful in suggesting environmental influences upon incidence. The overall incidence of Crohn’s disease has been found to vary from 0-81 to 3’14 per 100,000 people each year, with in addition a fourfold fluctuation within one country.2 The jigsaw is far from complete, however-it is uncertain, for instance, whether the apparent rarity of Crohn’s disease within 1. 2.
3. 4. 5. 6.
Evans, J. G., Acheson, E. D. Gut, 1965, 6, 311. Myren, J., Gjone, E., Hertzberg, J. N., Rygvold, O., Semb, L. S., Pretheim, B. Scand. J. Gastroent. 1971, 6, 511. Kyle, J. Gastroenterology, 1971, 61, 826. Norlen, B. J., Krause, U., Bergman, L. Scand. J. Gastroent. 1970, 5, 385. Fahrlander, H., Baerlocher, C. in Regional Enteritis (Crohn’s disease) (edited by A. Engel and T. Larsson). Stockholm, 1971. Monk, M., Mendeloff, A. I., Siegel, C. I., Lilienfeld, A. Gastroenterology, 1967, 53, 198.
reflects the scarcity of medical resources, confusion with infective dysentery, or a truly low incidence. A major problem in such comparisons is the difficulty of standardising criteria of disease diagnosis. Many, and probably most, cases of colonic Crohn’s disease would have been diagnosed in the past as variants of ulcerative colitis, and even now there is a clear need for the application of reliable
tropical
areas
simple yardsticks. The measurement of temporal changes in incidence is particularly likely to be affected by alterations in fashions of diagnostic criteria even when a single group of individuals are responsible for conducting a survey. Thus KYLE, in Scotland,3 believed that much of an apparent increase in the frequency of Crohn’s disease in the Aberdeen area could be accounted for by a rise in the apparent incidence of colonic Crohn’s disease, curiously mainly in women. By contrast, NORLEN and his colleagues, in Sweden,4 found a doubling of incidence of the disease during a twelve-year period from 1956-67. During the same time the incidence of ulcerative colitis showed no tendency to fall, and even rose, suggesting that the change in Crohn’s disease incidence may well have been a real one. A similar change was lately found in Norway, where new cases of Crohn’s disease totalled 2-3 per million per year from 1956-60, rising to 10-5 per million per year in 1964-69, and new cases of ulcerative colitis rose from 23-3 to 32-9 per million
year.2 Though
per
some epidemiological work has suggested that Crohn’s disease may be increasing in incidence, there has been little or no progress in defining factors causing the disease. In the Aberdeen area the disease was found to be infrequent in white-collar workers and in country-dwellers, but opposite trends, with the disease more common in white-collar workers6 and in city-dwellers,4have been found elsewhere. Crohn’s disease has also been shown to be more frequent in Jews than in non-Jewsand to occur in family aggregations.8 It is far from clear, however, whether the familial incidence reflects inborn susceptibility or an increased exposure to environmental predisposing factors. Evidence that a transmissible factor can be passaged through mice suggests that there may well be an infective cause.9 If so, then epidemiological searches for space/time aggregates, as carried out in studies of Burkitt’s lymphomas may be worth trying. The weight of evidence to commend such an approach could be stronger, and immunological 11,12 and electron-microscopical 13 studies, amongst others, have much to commend them. 7. Acheson, E. D. Gut, 1960, 1, 291. 8. Kirsner, J. B., Spencer, J. A. Ann. intern. Med. 1963, 59, 133. 9. Mitchell, D. N., Rees, R. J. W. Lancet, 1970, ii, 168. 10. Pike, M. C., Williams, E. H., Wright, E. B. Br. med. J. 1967, ii, 395. 11. Verrier Jones, J., Housley, J., Ashurst, P., Hawkins, C. Gut, 1969, 10, 52. 12. Parent, K., Barrett, J., Wilson, I. D. Gastroenterology, 1971, 61, 431. 13. Aluwihare, A. P. R. Gut, 1971, 12, 509.
THE LANCET
wards and departments whether they were achieving the right results. These indices were not used in an inquisitorial manner, or wards and departments might well have reached for the whitewash brush. Instead, they were used as the basis for multidisciplinary action meetings which tried to solve the problems revealed by the indices, and which were able to press for strong backing by the board of
management.
Sharing Authority THE external
of health-care systems are undergoing considerable change, with health care being seen as one of a group of social services which need to be coordinated from a base within the community. But subtle internal changes are also taking place. Within some hospitals, doctors and other health professionals are combining in a new kind of management partnership, in the belief that the strength of a group is greater than the sum of its parts. Large hospitals are trying to grapple with their inherent problems of size and complexity by splitting themselves up into smaller units, more manageable and more personal, and by recognising the value of giving enough executive authority to the professional staff to allow them to settle most of the management problems of those units. This general movement towards decentralisation is gathering impetus, and today the wise hospital authority considers not whether, but how, decentralisation ought to happen. In this climate of change, a report1 from Sydney Hospital, Australia, is sharply relevant: it is the record of a total change in management philosophy in favour of professional participation Once the and the decentralisation of authority. had been units would made, departmental change control their own budgets, but would also be accountable for their own results; management decisions would be made as near to the patient as possible; people of different professions would bear these new responsibilities collectively. Underlying all this were three simple but penetrating questions, all demanding self-examination and self-discipline rather than a surrender to authoritarian control: What results are you trying to achieve ? Are you achieving them ? If not, what is stopping you ?
relationships
To
begin this vast process of change, Sydney Hospital decided to give top priority to the patient, aided by a patient-care index, a nurse-utilisation index, and a patient-satisfaction index-three somewhat imprecise tools which would nevertheless tell 1.
Crawford, L. E., Ritchie, 1971, ii, 1291.
F. L.,
Herriott, B. A. Med. J. Aust.
The establishment of patient-care as top priority might seem a concession to convention or sentiment, but people who work in hospital are often aware of the conflict between what the hospital is trying to do and what the patient thinks he ought to be getting. Some valuable pioneer work has been undertaken in the United Kingdom, notably by the King’s Fund, in trying to assess the degree of patientsatisfaction, but Sydney has gone the next step by using the patient-satisfaction index not only as an important element in the attempt to measure the quality of patient care but also as a regular tool of management. Instead of asserting smugly that the patient must come first, they have tried to measure whether this is so, to make sure that he does. Priority was also given to the availability of nurses. Many attempts, theoretical and practical, have been made to relate the allocation of nurses to some index of patient dependency: sometimes the attempts have floundered in over-precise detail; sometimes administrators have flinched from pursuing the data to a logical conclusion. In Sydney, their assessments may have been somewhat approximate, but they were consistently used when making managerial decisions. It would be interesting to learn more of the mechanisms by which the problems of medical
by Sydney Hospital were handled. They certainly have a familiar ring to Cogwheelers-length of stay; drug costs; coordination of preadmission investigations; relationships with the patient-care committee; necropsy and management reported
tissue committees; reviews of clinical work; survey of hospital infection. Once budgets were decentralised at Sydney, patient-care results could then be linked with budgetary targets. Approximate figures were given to wards and departments within three days of the end of the month: not as precise as a computer, but a lot quicker. Professions could now take money into account when making policy decisions about the management of their own units. Today the control of expenditure is no longer a restrictive exercise, but a creative one, a means to an end. What Sydney has done is to decide on a change of management style, to create the machinery which may make this change effective, yet to remain prepared to change any method which may prove ineffective. They have succeeded in achieving all
942
within the mechanics of the established system, even though much of the change was apparently diametrically opposed to the system. Throughout, they have recognised the essential role of management training-not only initial training aimed at getting a change of outlook, but also continued training for all professions, without which reform can easily degenerate into acquiescence. Has this work any relevance for Britain’s Health Service ? No new techniques have been developed. No new management cliches have enriched the jargon. No revolutionary research results have been announced. Perhaps there is enough revolution in the simple claim that costs can be reduced as a byproduct to the improvement of patient care, and that significant results can be achieved by decentralising management responsibilities and by teaching hospital staff how to cope with their own management problems. All this has occasioned a new outlook on the part of staff, and the report suggests that this should be matched by a corresponding change in the outlook of public authorities which control hospitals. With 1974 looming ahead, there is surely a relevance for Britain in this. this
change
Epidemiology of Crohn’s Disease THOUGH
increasing attention is being given to the clinicopathological features of Crohn’s disease, the epidemiological picture is still fragmentary. EVANS and ACHESON1 collected all inpatients admitted with the disease in the Oxford area between 1951 and 1960, but found insufficient cases to allow any detailed analysis: to this have since been added surveys conducted in Norway, Scotland, Sweden, Switzerland, and the Baltimore area of the U.S.A.2-6 In general, the disease has been found to be slightly more common in men than in women, with more new cases in those aged 20-30 than in any other age-group. As with any disease of unknown cause, epidemiological comparisons of geographical, temporal, and other differences in frequency are potentially useful in suggesting environmental influences upon incidence. The overall incidence of Crohn’s disease has been found to vary from 0-81 to 3’14 per 100,000 people each year, with in addition a fourfold fluctuation within one country.2 The jigsaw is far from complete, however-it is uncertain, for instance, whether the apparent rarity of Crohn’s disease within 1. 2.
3. 4. 5. 6.
Evans, J. G., Acheson, E. D. Gut, 1965, 6, 311. Myren, J., Gjone, E., Hertzberg, J. N., Rygvold, O., Semb, L. S., Pretheim, B. Scand. J. Gastroent. 1971, 6, 511. Kyle, J. Gastroenterology, 1971, 61, 826. Norlen, B. J., Krause, U., Bergman, L. Scand. J. Gastroent. 1970, 5, 385. Fahrlander, H., Baerlocher, C. in Regional Enteritis (Crohn’s disease) (edited by A. Engel and T. Larsson). Stockholm, 1971. Monk, M., Mendeloff, A. I., Siegel, C. I., Lilienfeld, A. Gastroenterology, 1967, 53, 198.
reflects the scarcity of medical resources, confusion with infective dysentery, or a truly low incidence. A major problem in such comparisons is the difficulty of standardising criteria of disease diagnosis. Many, and probably most, cases of colonic Crohn’s disease would have been diagnosed in the past as variants of ulcerative colitis, and even now there is a clear need for the application of reliable
tropical
areas
simple yardsticks. The measurement of temporal changes in incidence is particularly likely to be affected by alterations in fashions of diagnostic criteria even when a single group of individuals are responsible for conducting a survey. Thus KYLE, in Scotland,3 believed that much of an apparent increase in the frequency of Crohn’s disease in the Aberdeen area could be accounted for by a rise in the apparent incidence of colonic Crohn’s disease, curiously mainly in women. By contrast, NORLEN and his colleagues, in Sweden,4 found a doubling of incidence of the disease during a twelve-year period from 1956-67. During the same time the incidence of ulcerative colitis showed no tendency to fall, and even rose, suggesting that the change in Crohn’s disease incidence may well have been a real one. A similar change was lately found in Norway, where new cases of Crohn’s disease totalled 2-3 per million per year from 1956-60, rising to 10-5 per million per year in 1964-69, and new cases of ulcerative colitis rose from 23-3 to 32-9 per million
year.2 Though
per
some epidemiological work has suggested that Crohn’s disease may be increasing in incidence, there has been little or no progress in defining factors causing the disease. In the Aberdeen area the disease was found to be infrequent in white-collar workers and in country-dwellers, but opposite trends, with the disease more common in white-collar workers6 and in city-dwellers,4have been found elsewhere. Crohn’s disease has also been shown to be more frequent in Jews than in non-Jewsand to occur in family aggregations.8 It is far from clear, however, whether the familial incidence reflects inborn susceptibility or an increased exposure to environmental predisposing factors. Evidence that a transmissible factor can be passaged through mice suggests that there may well be an infective cause.9 If so, then epidemiological searches for space/time aggregates, as carried out in studies of Burkitt’s lymphomas may be worth trying. The weight of evidence to commend such an approach could be stronger, and immunological 11,12 and electron-microscopical 13 studies, amongst others, have much to commend them. 7. Acheson, E. D. Gut, 1960, 1, 291. 8. Kirsner, J. B., Spencer, J. A. Ann. intern. Med. 1963, 59, 133. 9. Mitchell, D. N., Rees, R. J. W. Lancet, 1970, ii, 168. 10. Pike, M. C., Williams, E. H., Wright, E. B. Br. med. J. 1967, ii, 395. 11. Verrier Jones, J., Housley, J., Ashurst, P., Hawkins, C. Gut, 1969, 10, 52. 12. Parent, K., Barrett, J., Wilson, I. D. Gastroenterology, 1971, 61, 431. 13. Aluwihare, A. P. R. Gut, 1971, 12, 509.