- Email: [email protected]
THE ELDERLY SICK: WHO LOOKS AFTER THEM?
539 the West Sussex programme for immunisation control. This would be feasible only if the medical profession as a whole, and general practitioners in particular, were impressed with the importance of providing an adequate preventive service for this section of the community. At present there is little evidence of this, nor is there any statement in the Consultative Document to indicate that the D.H.S.S. intends to take steps to alter this situation. Finally, the fact that there are no proposals for extending occupational health services constitutes another potential danger. In recent years the agespecific male death-rates for ages 45-65 have been unique in that they are the only ones which have increased. Simultaneously there is world-wide concern One about the problems of increasing pollution. aspect of care particularly concerned both with the health of adult males and with preventing industrial pollution is occupational health. As with schoolchildren, general practitioners could, if suitably trained and encouraged, play an important part in personal prevention in this field. However, routine examination of large numbers of apparently healthy individuals merely to prove they are healthy or to discover ailments that are not amenable to treatment rapidly leads to
Reorganisation THE ELDERLY SICK: WHO LOOKS AFTER THEM? GRAHAM J. EVANS* ALEX G. MEZEY H. M. HODKINSON† North Middlesex
Hospital,
London N. 18
The admission-rate of the elderly increases with advancing age and the of majority patients over 75 go to the geriatric department. However, three-quarters of patients in the decade are admitted to non-geriatric beds of 65-74 the hospital service. The clinical picture changes over the age of 75, with a higher prevalence of multiple physical illness and of dementing conditions, and it is in this age-group that most misplacements of patients Geriatrics should be defined as the compreoccur. hensive care of the sick over the age of 75, the service being organised by a geriatrician whose role should Summary
embrace both
hospital
and
community
care.
INTRODUCTION
WE report here on the admission of elderly patients the hospitals serving a defined area of North London. Our purpose was to analyse the distribution of elderly patients between the different parts of the hospital service and to examine critically some basic assumptions in organising medical care for the
to
"
geriatric
"
patient. METHOD
This investigation was carried out in Edmonton and Tottenham, two former boroughs of Greater London. * Present address: Kingseat Hospital, Auckland, New Zealand. † Present address: Northwick Park Hospital, Harrow, Middlesex.
disillusionment. Examination of vulnerable groups, selective examinations on demand, and health education may be more useful; but all these need to be based on an agreed policy supported by research effort to test their efficiency. One common thread linking all these danger areas, and one which could help to change attitudes towards their associated problems, is medical training. Emphasis on hospital treatment of those who have developed
sickness, accompanied by increasing expenditure on specialist services to the detriment of generalist and preventive services, has been allowed to extend to such a point that there seems no way of reversing the tide. The Todd Report, like that of Goodenough before it, lies mouldering on the shelf, and unless a change of emphasis in medical training can be achieved there is little likelihood of bringing about change. It seems that a national approach to the problems discussed here may have
to
be deferred until the next
reorganisation of the Health Service in another twenty-five years. Perhaps by then changes in both undergraduate and postgraduate training policies for doctors will have been implemented and the climate may be ripe for the establishment of a truly unified Health Service. At the 1961 national Census the combined population of these two boroughs was 204,203, of whom 25,376 (12-4%) were above the age of 65; of these, 16,419 (8%) were in the 65-74 decade and 8957 (4-4%) were aged 75 or over. The demographic and the ecological characteristics of the area have been described by Mezey and Evans.1 The investigation was concerned with patients aged 65 and over admitted to hospital for whatever reason. Between May 8, 1965, and May 7, 1966, all psychiatric admissions were included and a 1 in 4 random sample of geriatric admissions were taken. During April, May, and June, 1965, all patients over the age of 65 admitted to’ general departments of the North Middlesex Hospital from that part of Edmonton in which the hospital is situated-the London N.18 postal district which has a population of just over 40,000-were also included (table I). Clinical misplacement was considered to be present when the admitting department was inappropriate to the patient’s main diagnosis.2 FINDINGS
Table 11 shows the age-specific admission-rates calculated from our data. Over two-thirds of patients in the 65-74 age-group went to general departments, and only a fifth to the geriatric department; above the age of 75 the picture was quite different, with the geriatric department taking over half of all hospital admissions of elderly patients. TABLE I-PATIENTS AGED 65 AND OVER ADMITTED TO DEPARTMENTS. OF THE GENERAL HOSPITAL OTHER THAN THE GERIATRIC OR PSYCHIATRIC (IN THREE MONTHS, FROM A POPULATION OF-
40,000)
540 TABLE II-ADMISSION OF THE ELDERLY TO HOSPITAL: ESTIMATED NUMBERS AND RATES PER 1000 OF HOME POPULATION IN ONE FULL YEAR
TABLE III-MISPLACED
PATIENTS,
BY AGE-GROUP
TABLE IV-PRINCIPAL DIAGNOSIS OF MISPLACED ADMISSIONS IN THE GERIATRIC AND PSYCHIATRIC DEPARTMENTS
Patients aged 75 and over accounted for nearly three-quarters of all admissions to the geriatric department, whereas the corresponding proportions were 40% for general departments, and 52% for the psychiatric department (table n). These differences are highly significant (P<0-001). In the psychiatric department depressive illness was the commonest diagnosis in the 65-74 age-group, with dementia the commonest diagnosis in patients aged 75 and over. All misplaced patients (tables III and iv) were admitted either to the geriatric or to the psychiatric department and the estimated frequency of misplacement was 2 % for the 65-74 age-group and 6 % for the over-75s. DISCUSSION
Our findings show that the majority of the elderly, particularly in the 65-74 decade, are admitted to general departments; it is only beyond the age of 75 that the majority of admissions are to the geriatric and psychiatric departments. It is in the over-75s too, that most patients with mixed physical and psychiatric disability are found and where misplacement is commonest. It seems, therefore, worth examining the role of clinical geriatrics in the care of this steadily increasing section of the population; it is estimated that this proportional increase is going to be relatively
marked, and sustained for longer, in the over-75s.3 One common, if not always explicit, view of geriatrics is that it deals with chronic illness and terminal more
Thus geriatric treatment has been said to it seems probable that the patient will when begin 4 never be restored to a fully independent way of life.4 The attitude by which geriatrics is regarded as the branch of medicine responsible for patients that no other doctor wishes to care for,5 can perhaps be blamed for many present difficulties. Geriatrics has inherited from general medicine not only the chronic wards but often its training and attitudes: some geriatricians, with their own previous training in general medicine, feel unhappy about their role, which they regard as that of a clinical undertaker.6 It is against such a background that Brotherstoncomments: " there is a tendency to call attention to the proportion of elderly patients and the minority who become chronic as somehow we feel swindled of our birthright to deal only with patients forever young and forever acute ". Another view is that geriatrics is the medicine of old age, this being equated with the age of retirement, as is reflected in the official yardstick for geriatric bed provision of 10 beds per 1000 of population over 65. This view reveals an emphasis on the financial burden imposed on the community by the medical care of a group that is no longer economically productive. Indeed, pensioners account for 40% of all bed days in hospital and 38% of all hospital costs, and by the year 2000 the first figure may be 80%.8However, this definition of geriatrics does not accord with clinical practice, as is shown in our finding that three-quarters of patients aged 65-74 were admitted to non-geriatric beds; this is unlikely to be a local anomaly since in 1965 only a third of all in patients aged 65 and over were in geriatric beds.Thus this concept of geriatrics is clearly unrealistic both on practical and on clinical grounds; it is only beyond the age of 75 that multiple physical disease, sensory defect, and intellectual deterioration increase notably. For these reasons we consider that the reintegration of geriatrics into general medicine, as advocated by Brocklehurst et al.,5 is impracticable and undesirable. The nature and extent of the task is unlikely to be handled adequately by general physicians with an interest in geriatrics-an approach which proved unsuccessful in fairly recent years. While training in general medicine is essential for the geriatrician, other clinical disciplines-for example, psychiatry and physical medicine-are no less important. In practice the geriatric department’s main inpatient links are with orthopaedics, physical medicine, and psychiatry, and not with general medicine. Care in hospital is only a small part of the range of medical and social facilities required for the elderly9 where physical and mental impairment are widespread. 10, 11 It would therefore seem more appropriate for the geriatrician to be in charge of the whole range of facilities, including extramural and preventive aspects 12 rather than share admissions with general physicians and keep to a purely hospital role. The problem of misplacement exists largely because we try to fit elderly patients into conventional categories - medical geriatrics for physical illness and psychogeriatrics for mental disorder-instead of providing a service which takes into account the clinical reality that " in old age physical and mental illness are inextricably intertwined ". Psychogeriatric assesscare.
541
units 4,13 are only a partial answer. We would rather urge the need for a comprehensive geriatric service, aimed principally at the over-75 age-group and headed by a geriatrician whose training and interests include psychiatry and social medicine as well as general and physical medicine. We thank Mr. A. R. Hammond, B.SC., of the Intelligence Unit of the Greater London Council, for most helpful advice on the statistical aspects of this investigation; and Mr. I. A. Syed, M.A., for the statistical analysis. This work was supported by research grants from the Department of Health and Social Security, and from the North East Metropolitan Regional ment
Hospital Board. Requests for reprints should
be addressed
to
A. G. M.
REFERENCES 1. 2.
3. 4. 5.
6. 7. 8. 9. 10. 11. 12.
13.
Mezey, A. G., Evans, E. Br. J. Psychiat. 1970, 117, 187. Mezey, A. G., Hodkinson, H. M., Evans, G. J. Br. med. J. 1968, iii, 16. Registrar General’s Statistical Review of England and Wales for the year 1966: part II, p. 8. H.M. Stationery Office, 1969. Kay, D. W. K., Roth, M., Hall, M. R. P. Br. med. J. 1966, ii, 967. Brocklehurst, J. C., Budd, W. E. R., Clark, A. N. G., Irvine, R. E. Development of Services for the Elderly and Elderly Confused: Report of a Working Party. South East Metropolitan Regional Hospital Board, 1971. Adams, G. F. Lancet, 1964, i, 1055. Brotherston, J. H. F. in Management and the Health Services (edited by A. Gatherer and M. D. Warren). Oxford, 1971. Logan, R. F., Klein, R. E., Ashley, J. S. Br. med. J. 1971, ii, 519. Wigley, G. Lancet, 1968, ii, 963. Kay, D. W. K., Beamish, P., Roth, M. Br. J. Psychiat. 1964, 110, 146. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Smith, A., McGhee, A., Stephenson, E. Lancet, 1964, i, 1117. Anderson, W. F. in Medicine in Old Age (edited by J. N. Agate). London, 1966. Brothwood, J. in Recent Developments in Psychogeriatrics (edited by D. W. K. Kay and A. Walk). Ashford, Kent, 1971.
Points of View NEW DEAL FOR
JUNIOR HOSPITAL
DOCTORS PAUL NOONE* THE conditions of service and
training for the great medical staff are totally majority junior hospital Their sense of vocation is blatantly inadequate. the their skills while and use of organisation exploited, and labour are absurdly inefficient. of
Only six years ago, housemen took home E32 a month The publicity for approximately 420 hours on duty. militant junior doctors managed to obtain since then has compelled significant salary increases, so that a houseman can now expect the same weekly wage for his 102-hour week as a skilled industrial worker gets for 38 hours. As a further bizarre concession, pro-rata overtime payments are made for hours worked in excess of 102 a week (though some doctors have failed to claim overtime pay for fear of upsetting " old-fashioned " consultants who have to countersign any claim). Apart from salary increases little else has changed, despite publicity and widespread public
sympathy. Accommodation is appalling in very many old hospitals, with scarce provision of married quarters, while meals are often not available outside " normal " hours. Duties are ill-defined and allow the doctor to become a " dogsbody ", doing out-of-hours E.c.G.s (even routine E.C.G.S in some hospitals), drug dispensing, emergency pathology work, routine blood-taking, and anything else where there is a shortage of staff. In particular, clerical work-both paperwork and phoning for appointments, results of routine tests, and so on-consumes too much of the houseman’s time and energy. The junior doctor finds *
Chairman, Junior Hospital Doctors Section, M.P.U./A.S.T.M.S
himself frustratingly with less and less time to spend with his patients and their relatives; less time to liaise with G.P.s, social workers, and health visitors; and without time to discuss the clinical and social content of his work with his colleagues in his own or other departments (including those offering diagnostic and therapeutic services). Most contracts for junior hospital doctors at present are simply blank cheques for the hospital authorities to use junior staff as they wish. One of the perennial complaints is doubling up on ward and casualty-department dutiesa dangerous practice which can involve improperly supervised preregistration housemen, as well as S.H.o.s and registrars, who can find themselves having to choose between attending a victim of a road-traffic accident in casualty or a patient whose condition has suddenly deteriorated in the ward. A further source of frustration and dissatisfaction is the present haphazard system of training. Very few schemes allow the young doctor to progress systematically through training posts to a chosen specialty as G.P., hospital consultant, or community physician. Little serious thought has been given (and still less action has been taken) to lay down the length of our training, its direction, purpose, or content. Few of those few who are attempting to train their junior staff have had any training themselves for training or teaching. To become a hospital specialist, one usually needs to jump some Royal College examination hurdle, but even then, in all but a few specialties, much depends on possessing powerful patrons. Long years are spent in the registrar grades by many mature doctors who are nevertheless considered quite competent enough in many cases to deputise regularly for their consultant in his N.H.S. clinics, operating sessions, ward rounds, and so on. The main reasons preventing junior doctors from open revolt are (1) a misplaced sense of " my profession right or wrong " (even though that profession is dominated by pressure groups concerned above all with perpetuating their power, prestige, and private practice), and (2) a deep fear of consultant wrath and the need to have good references to pursue any sort of career. (As a colleague remarked: " They’ve got us by the testimonials.")
It is against this background that the Junior Hospital Doctors Section of the Medical Practitioners Union (M.P.U.) has emerged. M.P.U. has been greatly
strengthened by its recent merger with the Association of Scientific, Technical and Managerial Staffs (A.S.T.M.S.), a union with a remarkable record of organising professional people. With the help of A.S.T.M.S. legal experts, the junior doctors have launched a model contract as the centrepiece of a campaign to mobilise junior hospital medical staff throughout the United Kingdom. Some of the principal demands of this contract are: (1) Duties to be specified and limited-with suitable provisions for dealing with unforeseen emergencies. (2) Accommodation to be adequate (initially D.H.S.S. recommendations should be the minimum standard actually provided), with married quarters available. (3) Arbitration procedure for when there is a disputed
dismissal.
(4) Study leave and study time guaranteed.
to
be
specified
and
(5) Losses of property on hospital premises to be the responsibility of the authorities. (6) A genuine attempt by the employing authorities to secure continuity of employment in a systematic training programme. (7) Hours of duty to be limited to 192 in any 4-week period, with overtime payments or equivalent leave for
Reorganisation THE ELDERLY SICK: WHO LOOKS AFTER THEM? GRAHAM J. EVANS* ALEX G. MEZEY H. M. HODKINSON† North Middlesex
Hospital,
London N. 18
The admission-rate of the elderly increases with advancing age and the of majority patients over 75 go to the geriatric department. However, three-quarters of patients in the decade are admitted to non-geriatric beds of 65-74 the hospital service. The clinical picture changes over the age of 75, with a higher prevalence of multiple physical illness and of dementing conditions, and it is in this age-group that most misplacements of patients Geriatrics should be defined as the compreoccur. hensive care of the sick over the age of 75, the service being organised by a geriatrician whose role should Summary
embrace both
hospital
and
community
care.
INTRODUCTION
WE report here on the admission of elderly patients the hospitals serving a defined area of North London. Our purpose was to analyse the distribution of elderly patients between the different parts of the hospital service and to examine critically some basic assumptions in organising medical care for the
to
"
geriatric
"
patient. METHOD
This investigation was carried out in Edmonton and Tottenham, two former boroughs of Greater London. * Present address: Kingseat Hospital, Auckland, New Zealand. † Present address: Northwick Park Hospital, Harrow, Middlesex.
disillusionment. Examination of vulnerable groups, selective examinations on demand, and health education may be more useful; but all these need to be based on an agreed policy supported by research effort to test their efficiency. One common thread linking all these danger areas, and one which could help to change attitudes towards their associated problems, is medical training. Emphasis on hospital treatment of those who have developed
sickness, accompanied by increasing expenditure on specialist services to the detriment of generalist and preventive services, has been allowed to extend to such a point that there seems no way of reversing the tide. The Todd Report, like that of Goodenough before it, lies mouldering on the shelf, and unless a change of emphasis in medical training can be achieved there is little likelihood of bringing about change. It seems that a national approach to the problems discussed here may have
to
be deferred until the next
reorganisation of the Health Service in another twenty-five years. Perhaps by then changes in both undergraduate and postgraduate training policies for doctors will have been implemented and the climate may be ripe for the establishment of a truly unified Health Service. At the 1961 national Census the combined population of these two boroughs was 204,203, of whom 25,376 (12-4%) were above the age of 65; of these, 16,419 (8%) were in the 65-74 decade and 8957 (4-4%) were aged 75 or over. The demographic and the ecological characteristics of the area have been described by Mezey and Evans.1 The investigation was concerned with patients aged 65 and over admitted to hospital for whatever reason. Between May 8, 1965, and May 7, 1966, all psychiatric admissions were included and a 1 in 4 random sample of geriatric admissions were taken. During April, May, and June, 1965, all patients over the age of 65 admitted to’ general departments of the North Middlesex Hospital from that part of Edmonton in which the hospital is situated-the London N.18 postal district which has a population of just over 40,000-were also included (table I). Clinical misplacement was considered to be present when the admitting department was inappropriate to the patient’s main diagnosis.2 FINDINGS
Table 11 shows the age-specific admission-rates calculated from our data. Over two-thirds of patients in the 65-74 age-group went to general departments, and only a fifth to the geriatric department; above the age of 75 the picture was quite different, with the geriatric department taking over half of all hospital admissions of elderly patients. TABLE I-PATIENTS AGED 65 AND OVER ADMITTED TO DEPARTMENTS. OF THE GENERAL HOSPITAL OTHER THAN THE GERIATRIC OR PSYCHIATRIC (IN THREE MONTHS, FROM A POPULATION OF-
40,000)
540 TABLE II-ADMISSION OF THE ELDERLY TO HOSPITAL: ESTIMATED NUMBERS AND RATES PER 1000 OF HOME POPULATION IN ONE FULL YEAR
TABLE III-MISPLACED
PATIENTS,
BY AGE-GROUP
TABLE IV-PRINCIPAL DIAGNOSIS OF MISPLACED ADMISSIONS IN THE GERIATRIC AND PSYCHIATRIC DEPARTMENTS
Patients aged 75 and over accounted for nearly three-quarters of all admissions to the geriatric department, whereas the corresponding proportions were 40% for general departments, and 52% for the psychiatric department (table n). These differences are highly significant (P<0-001). In the psychiatric department depressive illness was the commonest diagnosis in the 65-74 age-group, with dementia the commonest diagnosis in patients aged 75 and over. All misplaced patients (tables III and iv) were admitted either to the geriatric or to the psychiatric department and the estimated frequency of misplacement was 2 % for the 65-74 age-group and 6 % for the over-75s. DISCUSSION
Our findings show that the majority of the elderly, particularly in the 65-74 decade, are admitted to general departments; it is only beyond the age of 75 that the majority of admissions are to the geriatric and psychiatric departments. It is in the over-75s too, that most patients with mixed physical and psychiatric disability are found and where misplacement is commonest. It seems, therefore, worth examining the role of clinical geriatrics in the care of this steadily increasing section of the population; it is estimated that this proportional increase is going to be relatively
marked, and sustained for longer, in the over-75s.3 One common, if not always explicit, view of geriatrics is that it deals with chronic illness and terminal more
Thus geriatric treatment has been said to it seems probable that the patient will when begin 4 never be restored to a fully independent way of life.4 The attitude by which geriatrics is regarded as the branch of medicine responsible for patients that no other doctor wishes to care for,5 can perhaps be blamed for many present difficulties. Geriatrics has inherited from general medicine not only the chronic wards but often its training and attitudes: some geriatricians, with their own previous training in general medicine, feel unhappy about their role, which they regard as that of a clinical undertaker.6 It is against such a background that Brotherstoncomments: " there is a tendency to call attention to the proportion of elderly patients and the minority who become chronic as somehow we feel swindled of our birthright to deal only with patients forever young and forever acute ". Another view is that geriatrics is the medicine of old age, this being equated with the age of retirement, as is reflected in the official yardstick for geriatric bed provision of 10 beds per 1000 of population over 65. This view reveals an emphasis on the financial burden imposed on the community by the medical care of a group that is no longer economically productive. Indeed, pensioners account for 40% of all bed days in hospital and 38% of all hospital costs, and by the year 2000 the first figure may be 80%.8However, this definition of geriatrics does not accord with clinical practice, as is shown in our finding that three-quarters of patients aged 65-74 were admitted to non-geriatric beds; this is unlikely to be a local anomaly since in 1965 only a third of all in patients aged 65 and over were in geriatric beds.Thus this concept of geriatrics is clearly unrealistic both on practical and on clinical grounds; it is only beyond the age of 75 that multiple physical disease, sensory defect, and intellectual deterioration increase notably. For these reasons we consider that the reintegration of geriatrics into general medicine, as advocated by Brocklehurst et al.,5 is impracticable and undesirable. The nature and extent of the task is unlikely to be handled adequately by general physicians with an interest in geriatrics-an approach which proved unsuccessful in fairly recent years. While training in general medicine is essential for the geriatrician, other clinical disciplines-for example, psychiatry and physical medicine-are no less important. In practice the geriatric department’s main inpatient links are with orthopaedics, physical medicine, and psychiatry, and not with general medicine. Care in hospital is only a small part of the range of medical and social facilities required for the elderly9 where physical and mental impairment are widespread. 10, 11 It would therefore seem more appropriate for the geriatrician to be in charge of the whole range of facilities, including extramural and preventive aspects 12 rather than share admissions with general physicians and keep to a purely hospital role. The problem of misplacement exists largely because we try to fit elderly patients into conventional categories - medical geriatrics for physical illness and psychogeriatrics for mental disorder-instead of providing a service which takes into account the clinical reality that " in old age physical and mental illness are inextricably intertwined ". Psychogeriatric assesscare.
541
units 4,13 are only a partial answer. We would rather urge the need for a comprehensive geriatric service, aimed principally at the over-75 age-group and headed by a geriatrician whose training and interests include psychiatry and social medicine as well as general and physical medicine. We thank Mr. A. R. Hammond, B.SC., of the Intelligence Unit of the Greater London Council, for most helpful advice on the statistical aspects of this investigation; and Mr. I. A. Syed, M.A., for the statistical analysis. This work was supported by research grants from the Department of Health and Social Security, and from the North East Metropolitan Regional ment
Hospital Board. Requests for reprints should
be addressed
to
A. G. M.
REFERENCES 1. 2.
3. 4. 5.
6. 7. 8. 9. 10. 11. 12.
13.
Mezey, A. G., Evans, E. Br. J. Psychiat. 1970, 117, 187. Mezey, A. G., Hodkinson, H. M., Evans, G. J. Br. med. J. 1968, iii, 16. Registrar General’s Statistical Review of England and Wales for the year 1966: part II, p. 8. H.M. Stationery Office, 1969. Kay, D. W. K., Roth, M., Hall, M. R. P. Br. med. J. 1966, ii, 967. Brocklehurst, J. C., Budd, W. E. R., Clark, A. N. G., Irvine, R. E. Development of Services for the Elderly and Elderly Confused: Report of a Working Party. South East Metropolitan Regional Hospital Board, 1971. Adams, G. F. Lancet, 1964, i, 1055. Brotherston, J. H. F. in Management and the Health Services (edited by A. Gatherer and M. D. Warren). Oxford, 1971. Logan, R. F., Klein, R. E., Ashley, J. S. Br. med. J. 1971, ii, 519. Wigley, G. Lancet, 1968, ii, 963. Kay, D. W. K., Beamish, P., Roth, M. Br. J. Psychiat. 1964, 110, 146. Williamson, J., Stokoe, I. H., Gray, S., Fisher, M., Smith, A., McGhee, A., Stephenson, E. Lancet, 1964, i, 1117. Anderson, W. F. in Medicine in Old Age (edited by J. N. Agate). London, 1966. Brothwood, J. in Recent Developments in Psychogeriatrics (edited by D. W. K. Kay and A. Walk). Ashford, Kent, 1971.
Points of View NEW DEAL FOR
JUNIOR HOSPITAL
DOCTORS PAUL NOONE* THE conditions of service and
training for the great medical staff are totally majority junior hospital Their sense of vocation is blatantly inadequate. the their skills while and use of organisation exploited, and labour are absurdly inefficient. of
Only six years ago, housemen took home E32 a month The publicity for approximately 420 hours on duty. militant junior doctors managed to obtain since then has compelled significant salary increases, so that a houseman can now expect the same weekly wage for his 102-hour week as a skilled industrial worker gets for 38 hours. As a further bizarre concession, pro-rata overtime payments are made for hours worked in excess of 102 a week (though some doctors have failed to claim overtime pay for fear of upsetting " old-fashioned " consultants who have to countersign any claim). Apart from salary increases little else has changed, despite publicity and widespread public
sympathy. Accommodation is appalling in very many old hospitals, with scarce provision of married quarters, while meals are often not available outside " normal " hours. Duties are ill-defined and allow the doctor to become a " dogsbody ", doing out-of-hours E.c.G.s (even routine E.C.G.S in some hospitals), drug dispensing, emergency pathology work, routine blood-taking, and anything else where there is a shortage of staff. In particular, clerical work-both paperwork and phoning for appointments, results of routine tests, and so on-consumes too much of the houseman’s time and energy. The junior doctor finds *
Chairman, Junior Hospital Doctors Section, M.P.U./A.S.T.M.S
himself frustratingly with less and less time to spend with his patients and their relatives; less time to liaise with G.P.s, social workers, and health visitors; and without time to discuss the clinical and social content of his work with his colleagues in his own or other departments (including those offering diagnostic and therapeutic services). Most contracts for junior hospital doctors at present are simply blank cheques for the hospital authorities to use junior staff as they wish. One of the perennial complaints is doubling up on ward and casualty-department dutiesa dangerous practice which can involve improperly supervised preregistration housemen, as well as S.H.o.s and registrars, who can find themselves having to choose between attending a victim of a road-traffic accident in casualty or a patient whose condition has suddenly deteriorated in the ward. A further source of frustration and dissatisfaction is the present haphazard system of training. Very few schemes allow the young doctor to progress systematically through training posts to a chosen specialty as G.P., hospital consultant, or community physician. Little serious thought has been given (and still less action has been taken) to lay down the length of our training, its direction, purpose, or content. Few of those few who are attempting to train their junior staff have had any training themselves for training or teaching. To become a hospital specialist, one usually needs to jump some Royal College examination hurdle, but even then, in all but a few specialties, much depends on possessing powerful patrons. Long years are spent in the registrar grades by many mature doctors who are nevertheless considered quite competent enough in many cases to deputise regularly for their consultant in his N.H.S. clinics, operating sessions, ward rounds, and so on. The main reasons preventing junior doctors from open revolt are (1) a misplaced sense of " my profession right or wrong " (even though that profession is dominated by pressure groups concerned above all with perpetuating their power, prestige, and private practice), and (2) a deep fear of consultant wrath and the need to have good references to pursue any sort of career. (As a colleague remarked: " They’ve got us by the testimonials.")
It is against this background that the Junior Hospital Doctors Section of the Medical Practitioners Union (M.P.U.) has emerged. M.P.U. has been greatly
strengthened by its recent merger with the Association of Scientific, Technical and Managerial Staffs (A.S.T.M.S.), a union with a remarkable record of organising professional people. With the help of A.S.T.M.S. legal experts, the junior doctors have launched a model contract as the centrepiece of a campaign to mobilise junior hospital medical staff throughout the United Kingdom. Some of the principal demands of this contract are: (1) Duties to be specified and limited-with suitable provisions for dealing with unforeseen emergencies. (2) Accommodation to be adequate (initially D.H.S.S. recommendations should be the minimum standard actually provided), with married quarters available. (3) Arbitration procedure for when there is a disputed
dismissal.
(4) Study leave and study time guaranteed.
to
be
specified
and
(5) Losses of property on hospital premises to be the responsibility of the authorities. (6) A genuine attempt by the employing authorities to secure continuity of employment in a systematic training programme. (7) Hours of duty to be limited to 192 in any 4-week period, with overtime payments or equivalent leave for