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The Prison Medical Service
967
LEADING ARTICLES
THE LANCET LONDON
2
MAY
1964
Ventilation of Operating-theatres To provide many of their essential services, hospitals are equipped with complex machinery. Its working is generally beyond the understanding of the medical staff, and when it fails they often get unsatisfactory answers to their inquiries about the cause. Ventilation plants in operating-theatres may fail-sometimes even from the moment of installation-to give satisfactory comfort and satisfactory bacteriological controls. Surgeons have rightly demanded to know the reasons. In Glasgow, the Hospital Engineering Research Unit1 has made a detailed study of ventilation performance in four operating-suites and has sought the reasons for the many faults it discovered. The faults were broadly classified as due to inadequate specification, to failure of the installation to meet the specification, and to poor maintenance. Detailed bacteriological studies are not reported, but observations were made on the two main ventilation features whose effects on bacteriological conditions are known-the volume of air delivered, and the direction of air movement between the rooms. The volumes of air supplied to the suites were 97%, 93%, 91%, and 67% of the specified amounts and those for the individual rooms ranged from 100% to 33%. Some electrical and other maintenance faults were found; but it was clear that, even when first installed, the plants had been incapable of delivering the specified volumes of air. Some of the causes were incorrect calculation of system and plant resistance, ducts not conforming to
design specification, a fan running below design speed because the wrong pulley had been fitted, and a poorly constructed duct damper which worked loose and closed stream. These faults should have been discovered when the plant was commissioned; but the hospital authorities had apparently been satisfied by a verbal assurance from the installing engineers that the plant was working properly, and had made no detailed commissioning tests of their own. The airflow tests were done with clean filters in position; dirty filters caused further reductions of ventilation efficiency. Failure to change filters may sometimes be due to procrastination; but one of the hospital engineers, working to a fixed budget, admitted that he delayed the filter changes for as long as he could because the ventilation plant was fitted with 0-5 [.L filters and the annual cost of changing them was 8% of the installation cost of the whole plant. Yet it is already established that sub-micron filters are unnecessary in surgical ventilation units : BLOWERS and CREW2 found that, despite the average bacterial size of only 1 !1-,
against the air
I
I
I
I
1. Hospital Engineering Research Unit. A study of the performance of the air conditioning plants at three operating theatre suites. Sponsored by the Nuffield Provincial Hospitals Trust and the University of Glasgow. 1963. 2. Blowers, R., Crew, B. J. Hyg., Camb. 1960, 58, 427.
outdoor air after 5 [t filtration contained very few organisms of any sort and no pathogens at all. NOBLE et al.3 have shown the reason for this rather surprising fact: pathogenic bacteria are carried in the air not as naked organisms but embedded in particles ranging from 4 to 20 11- and averaging about 13 11-. Relatively simple filters thus remove all organisms that are able to cause wound sepsis. The Glasgow studies showed that airflow between the rooms of the suites was generally as planned (i.e., from " clean " to " dirty " areas) when doors were closed; but reverse flow occurred freely when doors were left open and when there were many openings not fitted with doors. On the matter of comfort, the staff were generally satisfied; but in two theatres conditions ranged from comfortably warm" to too warm "; one of these had an air refrigeration unit and the other had not. Among the faults contributing to overheating were inadequate airflow, due to blocked filters and the other causes already mentioned, and poorly designed and ill-maintained automatic controls, while in one hospital the ventilation air was drawn not from outdoors but from the very warm plant-room. Better design and maintenance would have given greater comfort in all the suites. Perhaps the most important revelation from this study is that the engineering departments of regional hospital boards neither demanded nor themselves applied detailed commissioning tests for ventilation equipment. The required performance has already been stated 4; what is now needed is a standard code of practice for tests to ensure that this is attained. These tests should be performed and a certificate issued by the installing engineers and perhaps repeated by the engineering staff of regional boards before the equipment is accepted. The Ministry of Health should call on an expert body to devise these tests and then recommend them to regional boards. "
"
The Prison Medical Service FOR some years the Prison Medical Service has been seriously undermanned; this has been especially unfortunate at a time of rapid development in both penal and psychiatric treatment of offenders. Insufficient suitably qualified recruits have been attracted to this small service (62 whole-time and 78 part-time doctors), with slow promotion by seniority, liability to posting to distant institutions, and very limited opportunities for specialist study or secondment. The difficulty in recruitment applies especially to psychiatrists. Because of the greatly increased demand for reporting to the courts and for providing treatment they are needed more than in former years. But young psychiatrists, on the threshold of a specialist career, have not felt inclined to join a service where they will spend much of their time in general medical duties, cut off from colleagues and teaching institutions, when they can expect to reach consultant level far more quickly in the National Health Service. Moreover, prison medical officers are hardpressed and have little opportunity to take part in newer 3. Noble, W. C., Lidwell, O. M., Kingston, D. ibid. 4. Medical Research Council. Lancet, 1962, i, 945.
1963, 61, 385.
968
developments such as group-counselling or staff-training. tunity to gain experience within the prison service. The Accordingly, in 1962, the Home Secretary appointed a recruit would enter at registrar level with a background working party to review the functions and organisation of general psychiatric training, and with every prospect of the service and its relations with the National Health of training, research, and advancement as a specialist in forensic psychiatry, inside and outside the prison. Service; and this working party has now reported.! One of the main issues, already raised in these Ultimately, all reports to courts will be supplied by columns,2is whether the Prison Medical Service should be amalgamated with the National Health Service. Several of the bodies giving evidence to the committee -the Royal College of Physicians, the Royal MedicoPsychological Association, the National Association for Mental Health, and the Institute of Psychiatryfavoured complete integration: the British Medical Association and Institution of Professional Civil Servants did not. On this main issue, the working party recommends continuation of a dual system, at least for some time, with more National Health Service appointments in the prisons, but preservation of a Prison Medical Service of whole-time doctors responsible for organising general medical services in the prisons. The report suggests that this work should appeal to doctors who would prefer " to practise general and social medicine rather than specialise in psychiatry ". Even now there is a wide variety of medical work in prisons-examinations on admission and discharge or for special sentences, daily sick parades, an everincreasing volume of correspondence with outside doctors in order to continue treatment after release, psychiatric reports to courts, and psychological treatment, medical transfers, and arrangements under the Mental Health Act-while different prisons have very different needs. This variety and diversity are likely to increase after the Royal Commission on penal treatment has reported,3 and the working party has given an ambitious and farsighted outline of future servicesthorough psychiatric appraisal of every offender received into custody for the first time, more refined methods of classification, new forms of treatment such as group counselling, in-service training of staff, and arrangements for aftercare. Clearly recruits for these duties will need thorough grounding in general psychiatry and opportunities to maintain clinical contacts and to specialise in forensic psychiatry, inside and outside the prisons, under senior psychiatrists. This system would have the advantages of providing a service for offenders at liberty as well as in prison (and incidentally a larger proportion of reports could be prepared without remand in custody). Some of the most encouraging words in the report are the LORD CHIEF JUSTICE’S statement that he favours the idea that reports should be made by specialists who work part-time in prison and part-time outside, and would thus acquire breadth of outlook and experience. The working party proposes that joint psychiatrist appointments under the Home Office and the N.H.S. should be created. - Similar posts at registrar and senior-registrar level would give young doctors opporOrganisation of the Prison Medical Service: report of the working party. H.M. Stationery Office. 1964. Pp. 15. Is. 3d. 2. See Lancet, 1961, ii, 810. 3. The War against Crime in England and Wales 1959-64. H.M. Stationery Office. 1964. Pp. 20. Is. 3d. 1. The
recruited,
doctors trained in this way. Some of those however, might find that they were more interested in general and social medicine and administration than in psychiatry. These would be candidates for the wholetime Prison Medical Service. But it would still be open to them to be seconded to take the diploma in psychological medicine (a special forensic diploma is not recommended), and later to move back into the National Health Service as consultants if they wished. More senior administrative posts, and supervision of the service on a regional basis, are also recommended. This would leave the medical director free to consider general policy and planning. A small central medical advisory committee, including doctors from outside the Civil Service, should be set up to review progress, especially in the years of transition. The report is remarkable for its clear examination of the issues. But whether the proposed remedies will sufficiently stimulate recruiting may be doubted: indeed, the working party expects considerable delay before enough doctors are trained. It recognises also the possibility of friction in a dual-control system unless all concerned make an effort to work together. Furthermore the report hardly gives due weight to the need in prisons for full-time doctors who are deeply involved in the life of the prison, its climate, and its morale, Unfortunately little is said about the work being done by the present service, and the extraordinary difficulties of meeting the demands of a distressed, exasperated, and commonly abnormal population. The working " party say we cannot see, and none of our witnesses has suggested, how these [administrative] needs could be met satisfactorily within the present frame-work of the National Health Service "; yet in child care, approved schools, and remand homes intensive services are being provided in this way. The report may underestimate the interest of penal work for young psychiatrists, and its attraction once it offers reasonable scope and opportunities for advancement.
Annotations TRAINING FOR GENERAL PRACTICE
SPECIAL training, after registration, is as necessary for family practice as it is for any other branch of medicine. The Porritt and Gillie reports emphasised this, as did the 1961 World Health Organisation report on Training of the Physician for Family Practiced Overseas the importance of such training has been recognised and practical steps are being taken. In the United States it has been suggested that family practice should become a board-accredited specialty requiring five years’ special training. In Aus1. Eleventh report of the Expert Committee on Professional and Technical Education of Medical and Auxiliary personnel. Wld Hlth Org. tech. rep. Ser. no. 257. See Lancet 1963, ii, 231. 2. See Lancet 1963, i, 429, 760.
!
,
B I’ i
,
LEADING ARTICLES
THE LANCET LONDON
2
MAY
1964
Ventilation of Operating-theatres To provide many of their essential services, hospitals are equipped with complex machinery. Its working is generally beyond the understanding of the medical staff, and when it fails they often get unsatisfactory answers to their inquiries about the cause. Ventilation plants in operating-theatres may fail-sometimes even from the moment of installation-to give satisfactory comfort and satisfactory bacteriological controls. Surgeons have rightly demanded to know the reasons. In Glasgow, the Hospital Engineering Research Unit1 has made a detailed study of ventilation performance in four operating-suites and has sought the reasons for the many faults it discovered. The faults were broadly classified as due to inadequate specification, to failure of the installation to meet the specification, and to poor maintenance. Detailed bacteriological studies are not reported, but observations were made on the two main ventilation features whose effects on bacteriological conditions are known-the volume of air delivered, and the direction of air movement between the rooms. The volumes of air supplied to the suites were 97%, 93%, 91%, and 67% of the specified amounts and those for the individual rooms ranged from 100% to 33%. Some electrical and other maintenance faults were found; but it was clear that, even when first installed, the plants had been incapable of delivering the specified volumes of air. Some of the causes were incorrect calculation of system and plant resistance, ducts not conforming to
design specification, a fan running below design speed because the wrong pulley had been fitted, and a poorly constructed duct damper which worked loose and closed stream. These faults should have been discovered when the plant was commissioned; but the hospital authorities had apparently been satisfied by a verbal assurance from the installing engineers that the plant was working properly, and had made no detailed commissioning tests of their own. The airflow tests were done with clean filters in position; dirty filters caused further reductions of ventilation efficiency. Failure to change filters may sometimes be due to procrastination; but one of the hospital engineers, working to a fixed budget, admitted that he delayed the filter changes for as long as he could because the ventilation plant was fitted with 0-5 [.L filters and the annual cost of changing them was 8% of the installation cost of the whole plant. Yet it is already established that sub-micron filters are unnecessary in surgical ventilation units : BLOWERS and CREW2 found that, despite the average bacterial size of only 1 !1-,
against the air
I
I
I
I
1. Hospital Engineering Research Unit. A study of the performance of the air conditioning plants at three operating theatre suites. Sponsored by the Nuffield Provincial Hospitals Trust and the University of Glasgow. 1963. 2. Blowers, R., Crew, B. J. Hyg., Camb. 1960, 58, 427.
outdoor air after 5 [t filtration contained very few organisms of any sort and no pathogens at all. NOBLE et al.3 have shown the reason for this rather surprising fact: pathogenic bacteria are carried in the air not as naked organisms but embedded in particles ranging from 4 to 20 11- and averaging about 13 11-. Relatively simple filters thus remove all organisms that are able to cause wound sepsis. The Glasgow studies showed that airflow between the rooms of the suites was generally as planned (i.e., from " clean " to " dirty " areas) when doors were closed; but reverse flow occurred freely when doors were left open and when there were many openings not fitted with doors. On the matter of comfort, the staff were generally satisfied; but in two theatres conditions ranged from comfortably warm" to too warm "; one of these had an air refrigeration unit and the other had not. Among the faults contributing to overheating were inadequate airflow, due to blocked filters and the other causes already mentioned, and poorly designed and ill-maintained automatic controls, while in one hospital the ventilation air was drawn not from outdoors but from the very warm plant-room. Better design and maintenance would have given greater comfort in all the suites. Perhaps the most important revelation from this study is that the engineering departments of regional hospital boards neither demanded nor themselves applied detailed commissioning tests for ventilation equipment. The required performance has already been stated 4; what is now needed is a standard code of practice for tests to ensure that this is attained. These tests should be performed and a certificate issued by the installing engineers and perhaps repeated by the engineering staff of regional boards before the equipment is accepted. The Ministry of Health should call on an expert body to devise these tests and then recommend them to regional boards. "
"
The Prison Medical Service FOR some years the Prison Medical Service has been seriously undermanned; this has been especially unfortunate at a time of rapid development in both penal and psychiatric treatment of offenders. Insufficient suitably qualified recruits have been attracted to this small service (62 whole-time and 78 part-time doctors), with slow promotion by seniority, liability to posting to distant institutions, and very limited opportunities for specialist study or secondment. The difficulty in recruitment applies especially to psychiatrists. Because of the greatly increased demand for reporting to the courts and for providing treatment they are needed more than in former years. But young psychiatrists, on the threshold of a specialist career, have not felt inclined to join a service where they will spend much of their time in general medical duties, cut off from colleagues and teaching institutions, when they can expect to reach consultant level far more quickly in the National Health Service. Moreover, prison medical officers are hardpressed and have little opportunity to take part in newer 3. Noble, W. C., Lidwell, O. M., Kingston, D. ibid. 4. Medical Research Council. Lancet, 1962, i, 945.
1963, 61, 385.
968
developments such as group-counselling or staff-training. tunity to gain experience within the prison service. The Accordingly, in 1962, the Home Secretary appointed a recruit would enter at registrar level with a background working party to review the functions and organisation of general psychiatric training, and with every prospect of the service and its relations with the National Health of training, research, and advancement as a specialist in forensic psychiatry, inside and outside the prison. Service; and this working party has now reported.! One of the main issues, already raised in these Ultimately, all reports to courts will be supplied by columns,2is whether the Prison Medical Service should be amalgamated with the National Health Service. Several of the bodies giving evidence to the committee -the Royal College of Physicians, the Royal MedicoPsychological Association, the National Association for Mental Health, and the Institute of Psychiatryfavoured complete integration: the British Medical Association and Institution of Professional Civil Servants did not. On this main issue, the working party recommends continuation of a dual system, at least for some time, with more National Health Service appointments in the prisons, but preservation of a Prison Medical Service of whole-time doctors responsible for organising general medical services in the prisons. The report suggests that this work should appeal to doctors who would prefer " to practise general and social medicine rather than specialise in psychiatry ". Even now there is a wide variety of medical work in prisons-examinations on admission and discharge or for special sentences, daily sick parades, an everincreasing volume of correspondence with outside doctors in order to continue treatment after release, psychiatric reports to courts, and psychological treatment, medical transfers, and arrangements under the Mental Health Act-while different prisons have very different needs. This variety and diversity are likely to increase after the Royal Commission on penal treatment has reported,3 and the working party has given an ambitious and farsighted outline of future servicesthorough psychiatric appraisal of every offender received into custody for the first time, more refined methods of classification, new forms of treatment such as group counselling, in-service training of staff, and arrangements for aftercare. Clearly recruits for these duties will need thorough grounding in general psychiatry and opportunities to maintain clinical contacts and to specialise in forensic psychiatry, inside and outside the prisons, under senior psychiatrists. This system would have the advantages of providing a service for offenders at liberty as well as in prison (and incidentally a larger proportion of reports could be prepared without remand in custody). Some of the most encouraging words in the report are the LORD CHIEF JUSTICE’S statement that he favours the idea that reports should be made by specialists who work part-time in prison and part-time outside, and would thus acquire breadth of outlook and experience. The working party proposes that joint psychiatrist appointments under the Home Office and the N.H.S. should be created. - Similar posts at registrar and senior-registrar level would give young doctors opporOrganisation of the Prison Medical Service: report of the working party. H.M. Stationery Office. 1964. Pp. 15. Is. 3d. 2. See Lancet, 1961, ii, 810. 3. The War against Crime in England and Wales 1959-64. H.M. Stationery Office. 1964. Pp. 20. Is. 3d. 1. The
recruited,
doctors trained in this way. Some of those however, might find that they were more interested in general and social medicine and administration than in psychiatry. These would be candidates for the wholetime Prison Medical Service. But it would still be open to them to be seconded to take the diploma in psychological medicine (a special forensic diploma is not recommended), and later to move back into the National Health Service as consultants if they wished. More senior administrative posts, and supervision of the service on a regional basis, are also recommended. This would leave the medical director free to consider general policy and planning. A small central medical advisory committee, including doctors from outside the Civil Service, should be set up to review progress, especially in the years of transition. The report is remarkable for its clear examination of the issues. But whether the proposed remedies will sufficiently stimulate recruiting may be doubted: indeed, the working party expects considerable delay before enough doctors are trained. It recognises also the possibility of friction in a dual-control system unless all concerned make an effort to work together. Furthermore the report hardly gives due weight to the need in prisons for full-time doctors who are deeply involved in the life of the prison, its climate, and its morale, Unfortunately little is said about the work being done by the present service, and the extraordinary difficulties of meeting the demands of a distressed, exasperated, and commonly abnormal population. The working " party say we cannot see, and none of our witnesses has suggested, how these [administrative] needs could be met satisfactorily within the present frame-work of the National Health Service "; yet in child care, approved schools, and remand homes intensive services are being provided in this way. The report may underestimate the interest of penal work for young psychiatrists, and its attraction once it offers reasonable scope and opportunities for advancement.
Annotations TRAINING FOR GENERAL PRACTICE
SPECIAL training, after registration, is as necessary for family practice as it is for any other branch of medicine. The Porritt and Gillie reports emphasised this, as did the 1961 World Health Organisation report on Training of the Physician for Family Practiced Overseas the importance of such training has been recognised and practical steps are being taken. In the United States it has been suggested that family practice should become a board-accredited specialty requiring five years’ special training. In Aus1. Eleventh report of the Expert Committee on Professional and Technical Education of Medical and Auxiliary personnel. Wld Hlth Org. tech. rep. Ser. no. 257. See Lancet 1963, ii, 231. 2. See Lancet 1963, i, 429, 760.
!
,
B I’ i
,