USE OF THE CASUALTY DEPARTMENT

821

sphere than others, and that this involvement is highly relevant to the fields of geriatric care, disablement management, psychiatry, and housing and environmental welfare, what is the Would it be measure of the social-work ability of the doctor ? relevant to estimate not only the social-work attitude, as the paper does, but the effectiveness of the doctor

as a

social worker?

such an approach represents in some way a return to the best in 19th and 20th century medical history. If we can find some answers to the general problems (1 to 5 above), and those specific to medicine in general practice (a andb above), we shall have a clearer idea of the socialmedical aspects of the education of future doctors in the implementation of the Todd Report. The

return to

T. A. MADDEN W. C. LETTINGTON.

SiR,-The investigation by Dr. Harwin and his colleagues (Sept. 12, p. 559) focuses on what will probably in the future be one of the most important aspects of general in Britain. The area of influence of the medicohas been enormously increased by the Welfare State; yet, oddly, it has made little progress in the field of general practice, where its potential would seem greatest. Few would question the conclusion of Dr. Harwin and his colleagues that contact between general practitioners and the social services is poor and few are aware of the Seebohm Committee’s recommendations. In considering contact with child-care workers-the most important group for general practitioners-they note that 69% of doctors had had no contacts. This is not adequate grounds for conclusions about the usefulness of such contacts. Professor Townsend’s (Sept. 5, p. 513) closely reasoned criticism of the Seebohm Report, does not take us " Beyond Seebohm ", but spells out many issues in which the family doctor has special interest and for which the " trained social caseworker " suggested by Mrs. Ineson and Dr. Wright (Oct. 3, p. 717), is not essential. In this type of medico-social care one is of course always learning, but the correspondents from the Darbishire House Health Centre seem unduly modest in suggesting that they " are only now beginning to leam ". What is most required is the definition of limited objectives to avoid the better being the enemy of the good. BERNARD BARNETT.

practice social

team

by their own doctors (the records did not reveal why they came directly to hospital). The 1970 questionaries, however, showed that 103 children were brought directly to the hospital casualty department without being seen by a doctor. 17 had tried to contact the doctor: of these, only 5 had been successful in getting through to the doctor’s surgery-in 2 instances the receptionist said that the doctor was out on his rounds and arranged for an ambulance to take the child directly to hospital, and in the other 3 the patients were instructed to go straight to the hospital without any communication from him. 12 patients had been unable to contact the doctor; this may not have been entirely the doctor’s fault-possibly the G.P.O. telephonist did not respond sufficiently quickly with an alternative number. The remaining 86 children had been brought to the hospital without any attempt by their parents to contact the doctor. The following reasons were given: 17 thought their family doctor was off-duty (half-day, weekend). 7 thought they would be unable to obtain an early appointment with their own doctor. 35 gave such reasons as " did not want to trouble own doctor " easier to come to hospital than try and contact own doctor and " knew own doctor would not be on call ".

A further 15 children who came to casualty were probably justified in doing so: 8 were either frequent outpatient attenders or regular inpatients-e.g., asthmatics. In these instances the parents thought it was easier to bring the children direct to hospital, since it was highly likely the family doctor would have requested admission if he had

been called. 2 were anxious parents, who dialled 999 for an ambulance (1 child had had a febrile convulsion, and the other a choking spell). 2 children were visiting relatives, but no attempt was made to contact the relatives’ doctor. 1 child had recently moved to Sunderland and not yet registered with a doctor. From this large group, at least 50% of the parents questioned had in the past had difficulty in contacting their own doctor. This small study suggests that there has been an increase in the proportion of non-accident cases, apart from an increase in routine casualty work. There appears to be a

growing tendency

to use

the

casualty department

as

a

doctor’s surgery which is always open. Many patients are deliberately bypassing their own doctor at certain times of the day because " the doctor doesn’t like being called out at night (or weekend) ". The Hospital Times (Oct. 2) reports from Birmingham that the family-doctor appointments system is throwing burden on the city’s already busy hospital casualty departments. The pattern of medical care is changing as family doctors join rota systems or use the emergency treatment service. The public use of the Health Service

an extra

USE OF THE CASUALTY DEPARTMENT SIR,—I was interested to read Dr. Pinsent’s article on the emergency call service (Sept. 19, p. 604). During the past few years I have been concerned about the increasing use being made of the casualty service at the Children’s Hospital, Sunderland. From the annual returns, the number of children seeking medical attention in this department has undoubtedly increased. Apart from the increase in numbers, however, an increasing number of non-accident cases have been arriving at the hospital for medical advice without being seen, or referred, by their

family doctor (or deputy). I arranged for all non-accident patients (or the accompanying adult) to complete questionaries during an eightweek period from June 18 to Aug. 6, 1970, and compared the findings from these with records for a similar eightweek period in 1966 (when most family doctors in Sunderland were doing their own emergency calls and before the introduction of the emergency call service in the area). During the eight-week period in 1966, only 33 non-accident cases were seen for medical advice without first being seen

has increased, and, as Dr. Pinsent found in his survey, some families use the call service more than others. He was of the opinion that in over 80% of calls the recorded diagnoses did not suggest that medical skills were required urgently. In my series, 70% of children were given advice and/or treatment before being sent home. If the number of non-accident cases arriving at hospital continues to increase, the casualty service will be in jeopardy. One answer may be to ask family doctors to provide a rota, and work with hospital staff in the casualty departmente.g., from 6 P.M. to midnight-in order to deal with nonaccident cases who have not contacted their own doctor. This idea could be extended to include the acceptance of emergency calls for an area by the family doctor on duty in hospital: one doctor could see patients able to travel to hospital for examination and treatment, and a colleague in a radio-car could attend patients in their homes when necessary.

Articles in the national and medical Press suggest that contact is a matter of great concern to the

patient/doctor

822

general public,

and I feel

we must

try and amend the

assessment allows virtually a of immunisations. 4. In our practice there has been a notable fall in the number of ordinary consultations in this age-group to the other partners in the practice. 5. The examination should not be conducted on the child alone, but on the child in the context of his place in the family structure. The mother’s health and the problems of family interrelationships are also assessed. Finally, I should like to say how intensely satisfying this work is to a primary-care physician, who all too often finds only a curative role to play. G. H. CURTIS JENKINS.

3.

This method of

100%

situation. Children’s Hospital, Sunderland.

A. W. LILLINGTON.

EMERGENCY CALL SERVICE the article by Dr. Pinsent with considerable read SiR,—I interest, and would like to comment on some points that he made. From his investigation he concluded that 81% of the calls were not of an urgent nature, and so he suggests grading of the calls and employment of medical auxiliaries to cope with the non-urgent calls. Whilst this sort of information is easy to obtain in a retrospective study, it would be more informative if a prospective study were done to assess the accuracy of call-grading by auxiliary medical staff working on the switchboard. It is easy to grade a call when you know what the doctor diagnosed at the visit, but we have found that it is nothing like as easy or accurate to grade a call from the information given by a relative or neighbour on the telephone. In our experience, a little knowledge can be a dangerous thing in these circumstances, and we feel that it is much better to accept all calls than take a chance and advise a patient without the sort of background knowledge of health records and home circumstances that the general practitioner might have. As for the availability of police and ambulance shortwave radio for consultation, in the London area, at least, these services are already grossly overworked, and I feel sure that they could not accept the additional load that a consultative service would impose.

developmental

success-rate

MORTALITY IN URINARY SCHISTOSOMIASIS

SIR,-Dr. Forsyth and his colleagues (Aug. 29, p. 472) suggest that radiographically non-functioning kidneys associated with urinary schistosomiasis correlate with high mortality. We should like to add our experience with Egyptian patients in whom one or both kidneys were not visible at intravenous urography. 11 PATIENTS WITH RADIOGRAPHICALLY NONFUNCTIONING KIDNEYS IN URINARY SCHISTOSOMIASIS

DATA FROM

A. G. HOULSON. administrative director, Southern Relief Service Ltd.

AT-RISK REGISTER

Sirshould like to join the discussion arising out of The at-risk your leading article of Sept. 19 (p. 595). register was originally devised as a means by which children who were thought liable to need regular care, because of adverse antenatal and natal factors, could be observed to see whether they did in fact show the effect of those factors. In many parts of the country the at-risk register became quite unwieldy, with different criteria of what constituted an at-risk child, and because of this the system at best worked badly and at worst not at all. I believe that an at-risk register, as at present constituted, is quite unnecessary if, as Dr. Thomas suggests (Sept. 26, p. 672), primary-care physicians take responsibility for the developmental paediatric assessment of all children in their practices. The system we have adopted in our practice is as follows: I see every child on the practice list at regular intervals until it is five years old, and, with the help of health visitors trained to carry out hearing tests and vision tests, and with a sound administrative framework, we find that one doctor (myself) can carry out this work on the children of a practice population of just under 20,000. One doctor can adequately cope, in three two-hour sessions per week, with the entire needs of a practice list of our size. The administration must be foolproof; every child must be seen and any defaulters persuaded to attend. In our own experience we find this a minute problem, since the parents greatly appreciate the care given to their children. From my work the following points arise: 1. It is unwise for a group with less than 500 children on its list to run such a programme, because not enough children are examined to maintain a high index of suspicion. 2. Adequate staff must be employed to run the programme

efficiently.

During the past 8 years, 175 male farmers with urinary schistosomiasis were investigated in hospital; 9 had nonfunction of one kidney and 2 of both. Ages, urographic appearance of kidneys, urine cultures, endogenouscreatinine clearance, and outcome are presented in the accompanying table. Note that 6 of the 11 patients had a urinary-tract infection, 4 of whom had undergone urinarytract instrumentation. 5 of the 11 patients in this series were dead when follow-up was obtained; 4 of these had had urinary-tract infection. Patients 1, 2, 4, and 7 died at home within 6 months of discharge. Patient 3 died at another hospital 3 years after discharge. No necropsies were done, but patients 1 and 7 were urxmic, and patient 4 was found to have squamous-cell carcinoma of the bladder. We agree that radiographic non-function of kidneys appears to correlate with poor prognosis in urinary schistosomiasis. However, we suggest that superimposed bacterial urinary-tract infection is important in the production of renal insufficiency in patients with obstructive schistosomal uropathy (see table). We have shown1 that renal function 1.

Lehman, J. S. Jr., Farid, Z., Bassily, S., Kent, D. C. Am. J. Med. Hyg. 1970, 19, 1001.

trop.