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RHB(48)1
is amongst the most important early planning documents in the NHS, issued in
January 1948 - in other words before the NHS began.. It is also probably one
of the rarest. The author has a copy and has scanned and attempted to correct
the errors thrown up by scanning a faded typescript reproduced on poor paper.
Not all of it yet appears here. The
Ministry reproduced it in 1950 with minor revisions, including more
paragraphs, and in normal printed format. Some reflected that time had moved
on, and the RHBs were up and running. The title was changed to The
Development of Consultant Services, and it sold for ninepence. A number of
appendices and maps were added. Reading the guide today, the word
"he" for doctors shows how few women were in the profession. Confidential
R.H.B.(48)l The
Development of Specialist Services |
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1. In earlier memoranda sent to Regional Hospital Boards an outline has
been given of their responsibilities and sugges�tions have been made as to the
steps to be taken in setting up the new administrative framework for the
hospital service and in preparing to undertake the immediate tasks which will
face the Boards and Management Committees from the appointed day. The object of
the present memorandum is different. It has been pre�pared, in fulfilment of
the promise given in paragraph 24. of R.H.B.(47)1) in order to assist the
Boards in facing the long-term problems arising in connection with the planning
and future development of the specialist services.
2. It is
clear that the first care of the Boards must be to ensure the effective
maintenance of the present services. This immediate duty will be more
satisfactorily discharged if it is seen against the background of the long-term
organisation of the service. The attempt has therefore been made in this memo�randum
to examine the scope and content of the different specialist services; to
consider how they might best be organised on a regional basis, bearing in mind
the part to be played by the Teaching Hospital; and to estimate in terms of
hospital facilities and medical staff what are the optimum future requirements
of a developed service. In short, the aim has been to state objectives and to
suggest methods by which over a period of years those objectives may be reached
from the starting point of the existing resources in buildings and personnel.
3. Two
points in particular should be mentioned. The first is that the memorandum is
not put forward in any sense as a series of instructions which Regional Boards
must follow. It seeks merely to suggest tentative answers to questions which
each Board must necessarily face in considering the planning of the services
for their area. The second point is the obvious one that the whole of the
proposals made in the memorandum can�not be made effective on the appointed
day. Arrangements must clearly be made for the continuance of specialist
services from that day, based on the existing hospitals and on the part-time
and whole-time specialists then available. Further suggestions will be made to
Boards in a later memorandum as to the action needed to make these
arrangements.
SPECIALIST
SERVICES
I
INTRODUCTION
1. Historical.
The planning of specialist services on a regional basis has been advocated in
medical circles for many years. It has not hitherto been practicable, however,
except in such limited fields as radiotherapy, and then only in a few-regions,
where progress is of recent date. The distribution of specialists has been
haphazard, determined in large measure by those economic factors upon which
depends the existence of private consulting practice. There have been salaried
part-time or whole-time specialist posts in general hospitals but they have
been relatively few. Furthermore the tuberculosis service and the larger
infectious diseases hospitals have been staffed almost entirely by whole-time
salaried officers. But In the main specialist practice has been a matter of
unpaid hospital responsibilities, coupled with private consultant work which
has provided the whole or greater part of the specialist's income. The
inevitable consequence has been an uneven distribution of specialists who are
too few to meet the needs of the whole population.
2. Increase
and Distribution of Specialist Staff. An immediate result of the
introduction of the National Health Service will be the remuneration of
specialists for all their work within the Service, unless they elect to serve
in an honorary capacity. Thus, for the first time, there will be generally
available the means of providing additional staff where it is most needed.
Regional planning then becomes possible and will be one of the most important
functions of the Board. Distribution can be improved by the creation of new
salaried posts, part or whole-time, beginning first in those areas where the
need is greatest. The deficiency in numbers can be made good only gradually
because the training of specialists is necessarily long. Regional Boards should
ensure, however, that only specialists of a high degree of competence are
appointed to posts of responsibility. The mere possession of a special diploma
is not the moat important qualification far specialist rank; adequate training
and experience are better criteria.
3. Estimation
of Numbers of Specialists. Subsequent sections of this memorandum will deal
with individual special�ties in detail and some attempt is made to forecast
probable requirements in specialist services for a population of a given size.
Such estimates must be largely speculative, as there is not yet sufficient
information on which to base even approximately accurate estimates. But a plan
of development, however tentative, is needed now, and it is the object of this
memorandum to provide material which may be useful to Regional Boards in
formulating their ideas. The realisation of those ideas may not be achieved for
several years, since buildings on the scale required will not exist for some
time yet, and the necessary specialists cannot be mass produced. It is impera�tive
to avoid the mistake of expanding specialist staffs toe rapidly by recruiting
men and women with inadequate training and experience,
4.
Estimates of numbers of specialists given in subse�quent sections are in the
main, in terms of whole or half-time service at one hospital centre, but the
proportion of the individual specialist's time given to the hospital service
which may include domiciliary work) will vary. Some specialists may wish to engage
whole-time in the service; others may engage in private practice for part of
their time. Specialists employed part-time in one hospital centre may give
part-time service in another associated centre.
5. Background
of General Plan. The planning of the specialist services is one of the
primary duties of the Regional Hospital Boards, but it is a task which must
clearly be carried out in close collaboration with the Teaching Hospitals. Each
of the 14 Regional Boards will normally provide a complete range of specialist
medical service within its region. There is no wish to standardise specialist
services throughout the country and each region will be able to plan these
services in the way best suited to the local organisations and local needs;
indeed experiment and variation between regions are essential to future
development. There are, however, general principles which will be applicable in
all regions and it is probable that broadly similar plans will emerge in each.
The present memorandum has been prepared to give Regional Boards a general
background which may be useful in the preparation of local plans. It is not
intended to prescribe a pattern which must be followed or which can immed�iately
be adopted in full, but merely to offer suggestions as to the broad lines along
which development might be guided.
6. Distribution
of Hospital Accommodation. The regions vary considerably in area, in
population and in transport facilities; the smallest has a population of nearly
one and a half millions and the largest one of over four millions. It is
obviously impossible to provide all the hospital services required, for such
large areas and populations in one Regional Centre itself; there must be
Hospital Centres distributed throughout the region, each serving an area though
shape and size of which is determined by density of population and also by
Transport facilities. The region is, therefore, a composite group of hospital
areas, dependent to some extent on a Regional Centre and on one another.
Sometimes a Hospital Centre in one region will make use of specialist staff
from a larger centre in another region or of special services provided at that
centre. Each Hospital Centre should provide most kinds of specialist service
and even the smallest will require a locally resident physician, surgeon,
obstetrician and anaesthetist. The larger centres will naturally have a more
comprehensive range of specialists resident in them and the smaller should be
served by visiting specialists in those branches which provide insufficient
work for a locally resident man.
7. Staffing
of General Hospitals by Specialists. A common feature of the published
reports of the Surveys of Hospital Services, undertaken during the war by the
Minister and the Nuffield Trust, was the recommendation that the clinical
responsibility for hospital patients, other than, those in general practitioner
or cottage hospitals, should rest with specialists. It is necessary, therefore,
to provide not only a sufficient number but a sufficient range of specialists.
It is not enough to provide a general surgeon at a Hospital Centre and expect
him to accept responsibility for all types of surgical cases. Ophthalmic
surgery and the surgery of the ear, nose and throat, to take two obvious
examples, each require the services of a surgeon who practices his specialty
exclusively.
In
addition there are types of specialisation which may be developed within
general medicine or general surgery and which are rarely an exclusive interest;
the two examples given, how�ever, and that of dermatology in the province of
medicine do not "belong to this category.
8. The
Distribution of Specialist Services. Throughout this memorandum the term
Hospital Centre is used to describe a group of hospitals which together provide
for a natural aggregation of population, all the normal specialist services.
Whether the hospitals are all in the same town, or one or more of them situated
outside it, they may be regarded as having a functional union and may share in
a common staff. This does not exclude the possibility that there may be more
than one Management Committee in the Hospital Centre. For the treatment of
pulmonary tuberculosis, long-stay orthopaedic cases and mental diseases it may
be necessary to provide in-patient accommodation at some distance from the main
hospital group. General practitioner hospitals included in the group should be
visited regularly by specialists for consultations.
9. The
term Regional Centre is used to describe the Hospital Centre at the
headquarters of the region and includes the Teaching Hospital, although the
latter is outside the administration of the Regional Hospital Board, Here will
be provided both the range of specialist services which must be available in
every Hospital Centre, and in addition those exceptional services which require
the collection of cases from a large population in order to make full use of a
team of experts who have made those subjects their particular interest. The
four principal examples of these are Plastic Surgery, Neurosurgery, Thoracic
Surgery and Radiotherapy.
10. It
may happen in other fields of work, however, that certain types of case will be
referred by specialists to individual colleagues, anywhere in the region, who
have acquired a special skill or who have specialised apparatus. For instance,
there may be some form of operative treatment for a rare disease which may be
developed by one man, working at the Regional Centre or some other hospital
centre, to whom these rare cases will be referred from the region as a whole.
This sort of association grows up voluntarily and requires no special planning.
11. The
Integration of Hospital Services. The main problem of the Regional Board
will be to integrate the specialist services of the Regional Centre and the
Hospital Centres. In theory there are two possible ways of doing this:
(a) In
the first, responsibility for the care of patients in the hospitals throughout
the region would be in the hands of a large staff of senior specialists
resident in or near the Regional Centre, assisted by specialists of lesser
experience working under their direction in the outlying Hospital Centres, None
of the Regions, however, is so small that specialists living at the Regional
Centre could effectively assume responsibility for the care of all patients in
the hospitals of the region. Any attempt to operate such a plan would involve
for the senior specialists an expenditure of time in travelling which could not
be justified. Furthermore to diminish the responsibility of the staffs of
outlying Hospital Centres in this way and to this extent would not be in the
interest either of the staffs themselves or of the public of the area which
they served.
(b) The second
method therefore appears to be the only practical one. According to this plan,
the services of a complete range of specialists (except for the four regional
services already mentioned) "would be available a1 each Hospital Centre
and they would be fully responsible for the hospital treatment of its
population. In the smaller Hospital Centres their services would be shared with
other centres. Under such conditions, linkage between the Regional and Hospital
Centres would "be main�tained by recognising all the specialists
throughout the Region as members of one team. Members of the staffs of Hospital
Centres should, be given, the opportunity to take temporary duty in hospitals
at the Regional Centre, and some grades of specialist in the Regional Centre, should
similarly have opportunities of doing temporary duty in a Hospital Centre.
12. Specialist
Associations. Regular personal contacts between specialists working at the
Regional Centre (including the staff of the teaching Hospital) and those
working at the peripheral Hospital Centres should be encouraged and
facilitated. With this object in view, professional associations in the various
specialties should be fostered on a regional basis so that meetings can be
arranged at regular intervals for discussion or clinical demonstrations,
sometimes at one centre, sometimes at another, probably most commonly at the
Regional Centre. It is desirable that the Heads of Departments of the Teaching
Hospital and other specialists of the highest standing at the Regional Centre
should visit the outlying centres from time to time, to give opportunities for
consultation and exchange of ideas -with the specialists working there. It is
by this free professional association rather than by formal inspection and
supervision that the university centre will both diffuse its own influence and
receive outside stimulus.
13. Association
through Post-graduate Training. Arrangements for post-graduate education
trill provide an additional link between Regional and Hospital Centres. Newly qualified
practitioners will, no doubt, get much of their early experience in resident
posts at those hospitals with which their Teaching Hospital is associated, For
the training of specialists it is anticipated that a series of graded
appointments in the hospitals throughout the region will be organised with the
co�operation of the Department of Postgraduate Studies of the Medical School,
To meet the needs of general practitioners, arrangements for revision courses
and clinical assistantships will be made by the University in Hospital Centres
approved for this purpose.
14. Registrars.
Although this memorandum is not directly concerned with the training of
specialists, practitioners in the later stages of their post-graduate training
are important members of the staffs of hospitals. Various designations such as
registrar, first or second assistant resident medical or surgical officer or
clinical assistant are used for the posts held by such men. In this memorandum
the term "registrar" is used where it is desired to suggest the
employ�ment of officers senior to the house physician or house surgeon grade
and considered to be passing through a probationary period of training in a
specialty. Some practitioners may start on such a course and, after a period of
a year or two turn to training in some other specialist field or to general
practice. Others will continue, acquire post-graduate qualifications and
ultimately, after a full period of training, emerge as specialists suitable for
more senior appointment on hospital staffs. It is not possible to estimate the
numbers in either group and as a result estimates of the numbers of registrars
given in later sections include both these groups.
15. Specialist
Advisers. This memorandum is only a general guide for the assistance of
Boards in the development of their specialist services. It will often prove
difficult, even impossible to apply the general recommendations given here to
particular cases. In these problems as well as in many others the Boards will
need advice from experienced specialists in different branches of medicine and
surgery. The Boards will therefore probably consider it necessary to appoint a
number of part-time consultant advisers from among senior specialists in their
Regions to assist in dealing with the problems of individual specialties. Such
a course was followed by the Ministry of Health in the Emergency Medical
Services and proved a sound policy.
No
reference is made in subsequent sections to medical records and the provision
of a statistical service for hospitals. Regional Boards may find it necessary
to improve the records departments of hospitals, and to increase staff and
accommodation in many of theirs. Certain Universities already have Departments
of Medical Statistics and may be able to assist Regional Boards.
II. TEACHING HOSPITALS
16.
Hospitals designated under the National Health Service Act as Teaching
Hospitals have been given a separate identity and status. Their Boards of
Governors are required in addition to their primary functions of providing for
the sick to provide special facilities for the clinical instruction of
undergraduates and postgraduates, and for research by members of the teaching
staff, in accordance with the educational policy of the university or medical
school concerned. It is highly desirable that there should be the closest
association between the University, the Teaching Hospital and the Regional
Board hospitals, with a view to the encouragement of research and the training
of specialist staff as well as the routine training of students.
17. Undergraduate
Education. No medical school attempts to instruct its undergraduates in the
diagnosis and treatment of the whole range of diseased conditions and their
varieties. The aims of undergraduate instruction in this country have been well
described by the Planning Committee on Medical Education of the Royal College
of Physicians, as follows "The first object in the undergraduate course
should be the teaching of method, method for elucidating the facts concerning
disease, method for welding these facts into an understanding and judgment of
the question at issue, method for testing the validity of this judgment; for
method is a more lasting acquisition than is fact, and without method a man is
lost when he meets an unfamiliar situation, as he is ultimately bound to meet
it, away from his teacher's guidance. The second object should be the teaching
of principle, that is to say the student should be led to understand those
phenomena which recur so frequently in disease that they may be said to be of
fundamental importance. The two objects should be brought before the students
in such a way as to show him that the scientific method can be used in clinical
study - that there is such a thing as clinical science.
18. In
view of its special functions the Teaching Hospital may not be able to
undertake all varieties of treatment and special investigation. It will
inevitably share obligations under these headings with the hospitals of the
Regional Board. The number of beds for which its Board of Governors assumes
responsibility will be mainly determined by considering the optimum number
which will enable it to perform its teaching and research functions
efficiently.
19. There
will be some selection of the cases admitted to a Teaching Hospital so that
suitable cases may be available for undergraduate and advanced education and
for the needs of research. This selection will be principally effected in the
outpatient clinics, but members of the staff of the teaching Hospital who hold
appointments in other hospitals will be able to assist in this matter and it
will also be served by general collaboration between the staffs of the
hospitals of the region. This collaboration is particularly important in
relation to clinical research; it should extend over the whole hospital system
of the region and may even cross regional boundaries.
20. It is
not possible for the Teaching Hospital alone to provide all the clinical
material required for undergraduate and postgraduate teaching. In particular
arrangements will have to be made by the University or Medical School with the
Regional Board for the use of facilities for instruction in tuberculosis^
infectious disease and mental disease. In addition it will often be necessary
to make similar arrangements for instruction of students in other subjects.
There should be no difficulty in making such arrangements, given the cordial
relations which should exist between the two boards.
21.
Postgraduate Education. The organisation of post�graduate education is
primarily the responsibility of the University with which a Teaching Hospital
is associated. For the effective administration of the policies adopted by the
University there must, however, be the closest co-operation not only between
the University and the Teaching Hospital but between both these and the
Regional Board and Hospital Management Committees.
22.
Postgraduate education may at present be divided into four categories:-
(a)
Graded appointments for the training of specialists.
(b)
Courses of instruction for intending specialists from this country and abroad
(c)
Advanced revision for established specialists.
(d) Regular teaching sessions and
periodic refresher courses for general practitioners
23. The
training of specialists will be effected by the provision of suitably graded
posts in the departments of the University, the Teaching Hospital and hospitals
of the Regional Board.
24.
Facilities for the second and third category of postgraduate education may be
net (a) in special departments in Teaching or Regional Hospitals and (b) by the
designation of postgraduate Teaching Hospitals.
25. The
former method will be that usually followed in the provinces, but in London, in
addition Teaching Hospitals will be established in association with the
Postgraduate Medical Federation and its special Institutes.
26.
Refresher courses for general practitioners should be provided in those
hospitals under the Regional Board which have been approved for this purpose by
the University. Constant contact between general practitioners and hospitals
will, of course, be encouraged.
III. GENERAL MEDICINE
27. Even
the smallest Hospital Centre will need at least one general physician living
locally. This is necessary in order to ensure continuity of supervision and the
economical use of hospital beds, and also to deal with medical emergencies. In
these small Hospital Centres the specialties, other than general medicine,
general surgery and obstetrics and anaesthetics may be covered by visiting
specialists from neighbouring larger centres.
28. To
avoid isolation in his specialty, every specialist working at one of the
smaller centres should also be actively associated with a larger centre. A
member of the hospital staff in the larger centre should be available to take
over his duties during holiday periods or sickness. This principle of relief is
applicable to all specialist services throughout the region so that a
physician's responsibilities are automatically taken over by a colleague of
specialist rank and not delegated to junior medical officers,
29. The
general physician will be expected in future to give an increasing amount of
time to the care of the chronic sick as part of his normal duties. Admission to
wards for the chronic sick should always be by way of the wards or hospitals
for acute cases, and it is to be expected that facilities for the
rehabilitation of the chronic sick will be better and more general than they
now are; the work will be largely supervised by the general physician.
30 It is
difficult to give any accurate estimate of the number of general physicians
required to maintain a satisfactory specialist service. Much will depend on the
extent to which general medicine may become partially sub-divided. General
medicine should not ordinarily embrace paediatrics or dermatology; some general
physicians may elect to give part of their time to paediatrics, but there
should, nevertheless be a paediatrician visiting each Hospital Centre. General
physicians will, however, almost certainly need to undertake some neurological
and cardiological work. The group of muscular and articular disorders included
under the general heading of rheumatism causes a large amount of ill-health and
loss of working time. In some regions active measures are already being token
in the investigation of this group of diseases special diagnostic and research
centres with out-patient facilities and beds at general hospitals in the
Regional Centres and beds for long-stay cases in associated hospitals have been
established. The subject calls for special attention from physicians and
specialists in orthopaedic surgery and physical medicine and it may well become
the special, though rarely the exclusive interest of a physician. Some of the
large spa hospitals may provide useful accommodation for long-stay cases,
provided they are closely linked with the work of general hospitals...
31. For a
population, of 100,000 - 120,000 in an area served by one Hospital Centre, it
is probable that some 250 medical beds mil be required, apart from those for
the chronic sick, tuberculosis and infectious diseases. Estimates of the number
of physicians needed for such a centre can only be approximate. Account mil
have to be taken, inter alia, of the respective amounts of hospital and
domiciliary work to be done, of whether the physicians are employed wholly
within the service or on a part-time basis, and of the various gradations in
seniority among the physicians. Bearing these conditions in mind, it is
suggested tentatively that the medical staff of a centre with a group of 250
medical beds and beds for chronic sick might be -
3 general physicians of senior grade (half-time)
3 general physicians of junior grade (half-time)
Not less than 3 medical registrars (whole-time)
If any of
the physicians devote the whole of their time to duties at this centre the
numbers will necessarily require modification,
32. It is
undesirable that general medicine should be so rigidly sub-divided that all the
cardiological or neurological work becomes concentrated in the hands of
specialists engaged only in these subjects. The general physician should be
kept in contact with men working in these fields and, of course, with
colleagues in general medicine from other centres and, particularly the
university centre. Associations of physicians on a regional basis to include
those working in the specialties should be encouraged. Neurologists,
cardiologists and other specialists of this kind at the Regional Centre (or at
major Hospital Centres which are virtually the equivalent of a Regional
Centre), should be available for consultation by their colleagues at the
periphery.
IV.
GENERAL SURGERY
33. As in
general medicine, so in general surgery, it is essential that every Hospital
Centre should have a locally resident specialist. Since the acute emergency
requiring immediate active intervention is commoner in surgery than in
medicine, it is desirable that there should be at least two surgeons resident
in each centre, although in the smallest centres one or both men may spend part
of their time working elsewhere. As in all the other specialties, it is of the
ut�most importance that a man should be kept in touch with the work of
colleagues; the comments made above about the desirability of professional
associations of physicians apply with equal force to surgery.
34.
General surgery tends more and more to be broken up into special branches. It
should, for instance, no longer embrace gynaecology, even in the smallest
Hospital Centres. There may be occasions when a gynaecological emergency is
dealt with by a general surgeon, as for instance when the initial diagnosis is
uncertain, but apart from this, gynaecology should be regarded as a distinct
specialty. Similarly, orthopaedic and traumatic surgery constitute a specialty
for which separate provision should be made in each Hospital Centre and this
provision should include arrangements for dealing with emergencies.
35 In
some branches of surgery specialism goes further than in others; for instance,
in genito-urinary surgery there is much more marked tendency to separation than
in gastro�enterology. The time is hardly ripe for separating genito�urinary
work entirely, except perhaps at Regional Centers. It seems more likely that,
as in the case of medicine, each hospital Centre will be served by a team of
general surgeons, each of whom may develop a special interest. Thus, the
surgeon who acquires particular skill in the operative treat�ment of diseases
of the stomach may still continue to undertake other abdominal surgery. In the
large centres there may be more than one surgeon specialising in each of the
branches mentioned.
36.
Neurosurgery, Plastic Surgery and Thoracic Surgery are much more sharply
defined as specialties. It may be necessary for the general surgeon
occasionally to deal with a neurosurgical emergency or some very urgent
thoracic condition, but the majority of these cases will be handled, in future,
by surgeons giving all their time to the specialty.
37. In
estimating the number of surgeons required same factors rust be taken into
account in determining the appropriate establishment as were considered in the
case of physicians. Although in surgery- fewer domiciliary consultations my be
necessary, this may be more than. balance the claims of urgent operative work.
38.
Bearing these conditions in mind, it is suggested. tentatively that to serve a
population of 100,000-120,000 ,-% group of 180 surgical beds should be provided
and that these will require the services of:�
3 general surgeons of senior grade (half-time)
3 general surgeons of junior grade (half-time)
Not less than 3 surgical registrars (whole-time)
If any of
the surgeons give the whole of their time to work at this centre, adjustment
will be needed.
39. It
will be appreciated that the chronic sick., though requiring surgical attention
on occasion, do not need the same amount of supervision by surgeons as by
physicians.
V. OBSTETRICS and GYNAECOLOGY
40. These
two allied subjects constitute one specialty, although, rarely, a specialist
may concentrate on one or the other side. As the service develops, gynaecology will
cease to be undertaken by general surgeons.
41
Midwifery alone, on the other hand, is not a service restricted to specialists.
It is contemplated that a domiciliary service will be provided under Parts III
and IV of the National Health Service Act by midwives and general practitioners
with experience in midwifery. In addition Local Health Authorities will
continue to provide ante-natal and post natal clinics. Institutional midwifery
will be the responsibility of the hospital and specialist service, which will
need also to provide specialist aid for domiciliary emergencies, consultative
ante-natal and post-natal clinics (normally at the hospitals), and beds for
abnormal cases.
42 It is
clear from the foregoing that co-ordination of the three branches of the
Suggestions on this matter will be made to Regional Boards in a separate
memorandum.
43 the
number of maternity beds theoretically required for a given population varies
with the birth rate, but for some years to come all the beds which can be made
available and staffed will be necessary. It is probable that, in present
conditions of housing and availability of domestic staff, the great majority of
women would elect to be confined away from home. Certainly the aim should be
institutional provision for at least three quarters of the births. A population
of 100,000 would, therefore, require 60 to 75 lying-in beds, (as the birth rate
ranges between 16 and 20), and about 30 ante-natal beds.
44 The
main maternity units should be at general hospitals rather than in separate
maternity hospitals. A unit of 100 beds is considered the ideal, but a larger
department of perhaps 200 beds forming part of a general hospital be
satisfactory, if suitably divided and adequately staffed. It is probable,
however, that in large urban areas, with a population exceeding a quarter of a
million, conveniently placed separate homes of about 40 beds will be
established for normal cases. Although these separate units may be enough to
have resident medical staffs, they should be under the supervision of the
obstetric staff of the main unit. In small towns-which have no Hospital Centre,
units as small as 20 beds may be provided under the supervision of the general
practitioner obstetrician'� with the obstetric specialists visiting from the
nearest Hospital Centre.
45. It is
estimated that one gynaecological bed is required for a population of 4,000.
The Hospital Centre serving 100,000 population would, therefore, require 25
gynaecological beds but this number would have to be increased to provide for
abortions and about 5 additional beds would be needed for this purpose.
46. The
Hospital Centre with 100,000 population would, therefore, require a total of
some 90 maternity beds, including ante-natal beds, and 30 gynaecological beds
including those for abortions. The staff required for such a group would be 2
half-time or one whole-time obstetrician and gynaecologist and 1 registrar -
whole-time - with other senior and junior resident medical staff.
47. Both
the gynaecological and obstetric work should be closely associated with other
specialist services. The paediatrician should be in charge of the babies in the
nurseries of maternity units. Physicians should supervise the treatment of
certain cases, e.g. patients with heart disease in ante-natal wards.
Pathological and biochemical services, including facilities for endocrine
investigation, must be available. The gynaecological out-patient service should
include the provision of Infertility Clinics.
VI. PAEDIATRICS
48.
Paediatrics is, briefly, medicine applied to the maintenance of health and the
treatment of disease in children. For this purpose children may include persons
up to the age of fourteen.
49. Fully
staffed paediatric departments, distinct from those of general medicine, should
be provided in every Regional Centre, usually associated with a University
Institute of Child Health. A paediatric department should also be established
in every larger Hospital Centre, not as a subsidiary to that of the Regional
Centre, but as an independent special department, responsible for the care of
all children's medical wards in the area. There will also be centres which are
too small to provide sufficient work for a locally resident paediatrician and
in these a service should be provided by a visiting paediatrician, even though
there may be available general physicians with a special interest in paediatric
work.
50. It is
of the utmost importance that hospitals or wards for infectious diseases should
be closely associated with paediatric departments, since so many of the
patients are children and the problems are similar. Equally, the work of
orthopaedic surgeons, cardiologists and tuberculosis specialists must be
co-ordinated with paediatrics. Paediatricians should have the oversight of
nurseries in maternity units.
51. It is
also important that paediatricians working in hospitals should be associated
with the preventive clinic services for children which are maintained by the
Local Education and Health Authorities. This is especially desirable at the
university
52.
In the larger centres separate children's hospitals may continue their separate
existence, or a self-contained children's unit should be provided in a general
hospital gropup. A self-contained unit is much easier to administer from
the point of view of nursing staff and tends to attract the type of nurse
specially interested in children. In the smaller centres the children's
unit should be art of the general hospital. It is particularly important
that the beds in all such units should be in the charge of the visiting
paediatrician.
53 It is desirable, as in other
specialties, to encourage an association of the paediatricians working in out�lying
centres with the university centre. The number of men
engaged in this specialty will be much smaller than in general medicine and
there is, therefore, a greater likelihood of isolation unless care is taken to
ensure that the influence of the Regional Centre extends to the periphery.
54
The number of hospital beds which should be
provided far children has been given as 0.5 beds per 1,000 of popula�tion,
but this is probably insufficient. The number of
whole-tine paediatricians required, according to the British Paediatric
Association, is about six to eight per million of population, but the number
available at the present time falls very far short of this and it will be some
years before there are sufficient fully trained men to meet the needs of the
country. On the basis of these proposals it is
suggested for the standard population of 100,000-420,000, 50 general
children's beds should be provided. As to staffing, the services of one
half-tire paediatrician with a whole-time registrar would be the minimum for
such a populations
55 The surgery of diseases of
children is not a separate specialty in the same any as children's medicine. It
is usual and beneficial for surgery in children to be a special interest
of some general surgeons, but there is not the same distinction between surgery
in the child and in the adult as between paediatrics and general medicine.
Other specialties, such as ophthalmic and orthopaedic surgery, should be in the
hands of the same specialists as for adults.
VII. PATHOLOGY
56. Pathology which includes morbid
anatomy, biochemistry and haematology, must be organised in every Hospital
Centre as a specialist service. This need not embrace the provision of
facilities for Public Health bacteriology, because a separate Public Health
Laboratory Service is being instituted for that purpose, Where there is no
Public Health Laboratory in the vicinity, however, public health bacteriology
may have to be done by the hospital staff in the hospital laboratory, by
arrangement between the Regional Board and the Public Health Laboratory Service,
it is essential that close contact should be maintained. between hospital
laboratories and Public Health laboratories and it may often be convenient and
desirable to house them in the same building.
57 Pathology is a completely defined
specialty which should not be practised in conjunction with general medicine or
with any other clinical branch. A pathologist should he available for
consultation and should supervise the laboratory work in even the smallest
Hospital Centres. In centres serving a population of less than 50,000, there
may not be enough work for a pathologist living locally; in these cases the
routine work should be done by a technician supervised by a pathologist
visiting regularly from a neighbouring centre. Calls on the laboratory service
will certainly increase and eventually even these smaller centres may need at least one pathologist.
In no case should a hospital rely on a postal service or on the services of a
technician not under the supervision of a pathologist.
58. In
the larger Hospital Centres there will be laboratories employing more than one
pathologist. If there are several hospitals in a centre it is generally
desirable that there should be one co-ordinated service of pathology for all of
them. Where there is work for more than one pathologist, it is desirable to
develop some further degree of specialisation, in the branches of pathology.
Smaller centres, by grouping with each other or with neighbouring major
centres, may also develop some degree of specialisation, as each individual
pathologist may have his own particular interest. But such arrangements should
not preclude the reference of specimens for further opinion when necessary, to
the university or other large laboratory.
59. The
laboratory must be brought into the closest possible touch with clinical work.
Both clinician and pathologist have much to gain by consultation in the wards,
the laboratory and post-mortem room. The pathologist should always be
responsible for conducting autopsies.
60. In
pathology, even more than in most other specialties, it is necessary to develop
close links between the 3egional Centre and the other Hospital Centres. The
quality of laboratory work depends very largely on the contacts between. the
individual workers and regular meetings of the pathologist of the Region,
including those in the University Department of the Teaching Hospital, should
be arranged.
61.
Machinery will be needed for providing advice on pathological subjects to the
Regional Board, and this might consist of a committee of pathologists, of whom
one should be Adviser in Pathology to the Regional Board.
VIII. MENTAL HEALTH SERVICE
62. The
suggested framework for the organisation of the Mental Health Services is set
out in greater detail in R.H.B.
47/13. The
following paragraphs indicate generally how those services will dovetail with
the other hospital and specialist services of the Regional Board. Owing to the
special problems of the Mental Health Service, each Regional Board will require
on its central staff a psychiatrist to act as its adviser for Mental Health. He
will be responsible for the co-ordination of the specialist services for mental
health throughout the region and his function will be to co-ordinate - not to
dictate. Although much of his work will be administrative, it is desirable that
he should retain some direct contact with clinical work.
63. The
regional psychiatric service will be based mainly on the mental hospitals,
which will usually serve large groups of population. The number of beds
required in mental hospitals is estimated to be 3.8 to 4. per thousand of
population. The present size and distribution of mental hospitals derives
largely from local government affiliations and will be modified with the
passage of time. The desirable maximum number of beds in a mental hospital is
considered to be 1,000; there will thus be a need for 3 to 4 such hospitals for
a population of 1 million. The number of specialist psychiatrists, exclusive of
junior assistant staffs, required far a nor-teaching hospital of a thousand
beds including its outpatient service and domiciliary work, is of the order of
five.
64. All
psychiatrists at mental hospitals should be associated with the out-patient
work for the area served by the hospital. It is not considered desirable that
psychiatrists should have experience only of in-patient or only of out-patient
work. The out-patient service will be provided as part of the out-patient
activities of the Hospital Centre, and clinics will usually be held in the
out-patient departments of general hospitals. These clinics will be staffed by
psychiatrists from all available sources. There size will vary with the range
of work undertaken, but even at the smaller clinics with limited
scope, which may well be affiliated with the larger centre, there should be at least 2
doctors working part-time and the necessary ancillary staff.
65. Some
beds should be available in the general hospitals where clinics are held. These
beds would be used for patients who do not show marked behaviour disturbances
and who require admission for a limited period for diagnosis or short term
treatment.
66. In
addition it is probable that increased use will be made of Neurosis Centres for
patients suffering from early and milder forms of mental illness not requiring
admission to mental hospitals under the Lunacy and Mental Treatment Acts. Such
centres might be established in association with mental or general hospitals or
alternatively a larger centre could be set up to serve hospital areas.
67. It
can be assumed that at every Regional Centre the University will provide a
teaching psychiatric unit which should be in close liaison with the appropriate
mental hospital and it is desirable that the Professor of Psychiatry at the
Teaching Centre should have access for teaching purposes to mental hospital
beds. It is not anticipated that there will be any difficulty in arranging, by
agreement, for the necessary clinical facilities to be provided. Conversely,
and to everyone's mutual advantage the medical stuff of the mental hospital
should participate in the work of the teaching psychiatric clinic.
68. It is
essential that psychiatrists should be in close contact with specialists in
other fields. They should be available for consultation freely in the general
hospitals and should make use of other specialists for consultation on cases in
mental hospitals. The increased use of neurosurgery in the mental illness
suggests the desirability of selecting certain mental hospitals for the
treatment and rehabilitation of suitable patients. These hospitals should be
near Neurosurgical Centres.
69. The
mental health of children will be the concern partly of the education
authorities and partly of the Regional Board. Local Education Authorities will
setup child guidance centres under the supervision of the school medical
officer or the educational psychologist. The services of a psychiatrist will be
required for diagnosis and advice and to carry out short-term treatment. The
Regional Board will set up clinics for child psychiatry= to deal with cases
which are medical rather than educational and will carry out long-term
treatment.
70. It is
hoped that these two types of clinic wall t closely associated through the
expert staff. Child psychiatric clinics will usually be located where
paediatric cling are provided and it is important that there should be
cooperation between the paediatrician and the child psychiatrist.
In-patient treatment for children will be provided through Regional Board.
.71 Care
of mental defectives. The burden of the care of defectives falls partly on the
local health authorities and partly on the Regional Board. Local Authorities
will responsible for the ascertainment of defectives and the care of defectives
in the community other than those who are on leave or licence from
institutions. Children of school will normally be "ascertained'' only when
they are reported the Local Education Committee for the purposes of the Mental
Deficiency Act, 1913, on the ground that they have been found incapable of
receiving education at school.
72.
Provision of institutional care is made by the Regional Board and it is
probable that the ultimate number beds required will be about 2 per thousand of
the general population. Colonies vary much in size and stage of development.
The smallest complete colony in which satisfactory classification is possible
will have about 800 beds; the maximum size should not exceed 2,000 beds.
73.
Colonies are under the supervision of specialist in mental deficiency and it is
desirable that their special knowledge should be utilised in adult
clinics and in child guidance work.
XI ANAESTHETICS
74 The
practice of anaesthesia has been highly developed in marry of the larger
centres in. this country but has not been widely enough recognised as a
specialty.- The administration of an anaesthetic is a major procedure and for
the most .:art anaesthetics should be given either by specialists, or under the
supervision of specialists, or by medical practitioners with special experience. To avoid anaesthetic complications all
anaesthetics should, as part of their responsibility, co-operate in any
necessary pre-operative treatment and post-operative care. It is of particular
importance that experienced anaesthetists should be available for the
administration of anaesthetics in emergency cases, whether by day or night,
since these are often the worst operative risks and in special need of skilled
attention.
75.
Anaesthetics for obstetric cases in hospital should be given by practitioners
with experience and the same rule should apply to dental and casualty work.
Even though full specialists may not undertake all this work, it should not be
lightly left to men whose experience has been limited. The specialised
techniques of Neuro-Surgery, Thoracic Surgery and to a less extent of Plastic
Surgery require correspondingly specialised anaesthetic techniques, and skilled
anaesthetists should be attached to these departments to meet their particular
needs.
76. At
present there are far fewer specialists in anaesthesia than are required, if a
full service is to be provided, a staff of 2 specialist anaesthetists
whole-time, or the appropriate equivalent part-time, with 2 registrars and 3 resident anaesthetists - all whole-time - should be
provided for a Hospital Centre serving a population of 100,000-120,000.
proportionately greater numbers would be needed at centres where special
services such as neurosurgery are available.
X CARDIOLOGY
77.
At each Regional Centre there should be a special unit for the study of all
problems connected with the heart and vascular system. The regional
cardiovascular unit will be recognised as the clinic to which patients can be
sent for a second opinion and for special investigation and treatment. It need
not be a large unit and should not be responsible for the diagnosis and
treatment of all cardiovascular disease throughout the Region.
78. The
routine diagnosis and treatment of cardiovascular disease will be in the hands
of the general physicians is the various hospitals in the region and patients
suitable for reference to the Regional Centre will be selected by those
physicians.
79. It
should be possible for members of the staff of the central unit to visit
regional hospitals from time to tine and in that way maintain the standard of
cardiovascular work throughout the region. In the larger hospitals in more
concentrated areas of population a local physician may develop a special
interest in cardiology and be able to form an associated cardiovascular unit.
80. The
functions of the staff of the central unit might be summarised as follows:
(1) To
act in a consultative capacity in all questions concerning cardiovascular
problems in the region. Cases would be referred to the unit from other
specialist physicians and special departments' e.g. Department of Child Health,
Thoracic Surgery, Neurosurgery and Obstetrics.
(2) To
undertake the treatment of a number of cases of cardiovascular disease, more
especially from the standpoint of research into the methods of diagnosis and
treatment and also to provide clinical material for teaching.
(3) To
undertake research into cardiovascular physiology pathology and therapeutics.
(4) To afford clinical teaching in
cardiovascular subjects, properly integrated with the curriculum in general
medicine, for undergraduates and especially post-graduates in the University of
the region.
81. To
carry out these various functions the regional cardiovascular unit should be
situated in close proximity to those special departments with which
co-operation is desirable. In some regions the Teaching Hospital may not be
able to supply all the necessary accommodation and the requisite number of
beds, and where this is the case a nearby hospital could be utilised. For the
investigation and treatment of in-patients about sixty beds should be available
- thirty for men and thirty for women.
82. The
department, like any special department, would require a waiting room,
examination rooms, rooms for the medical staff, and in addition screening and
electrocardiographic rooms and the necessary accommodation for clerks,
technicians and the keeping of records. Some departments of this character
already exist in London and the provinces, and deal with large numbers of
outpatients. Laboratories for physiological and pathological research should be
readily available.
83.. The
staff required for the running of such a department, including both in-patients
and out-patients, should be under a physician-in-charge, assisted by a deputy.
Either the physician or his deputy should be employed whole time. At least one
whole-time registrar would also be required.
XI DENTISTRY IN HOSPITALS
84. The
value of dental treatment as an adjunct to certain forms of medical
treatment is not sufficiently appreciated and it is only rarely that a hospital
provides adequately for dental care. Those hospitals which do provide dental
:treatment too often limit it to emergency measures.
85. The
hospital service should in future provide a wider range of dental care of
in-patients. Full dental treatment is not practicable for all cases admitted to
a general hospital, especially when the duration of stay is short but it should
be provided in all long stay hospitals. 17here time allows, however' and
particularly when the health. of the patient is directly affected by his dental
condition, it is desirable that a state of dental fitness should be achieved
while he is under treatment. For such patients$ facilities for full
conservative dental treatment and not merely for extractions should be
provided.
86. With
a fully equipped department able to deal with all ordinary forms of dental
care, one whole time dental surgeon should be available for each 500 hospital
beds to ensure adequate dental care for all patients. T=e should be assisted by
one or two dental house-surgeons, one of whom in -the larger hospitals should
be resident.
87. In
addition to this provision for routine dental care, two or three beds should be
provided in every Hospital Centre for patients needing major dental operative
treatment; in a
general hospital of 1.000 beds, three should be set aside for each sex for this
purpose. It is advisable that a dental surgeon specialising in oral surgery
should be available in a large centre or for a group of smaller centres. One
such specialist. working whole-time, would probably meet the needs of a
population of about 300.000; he might supervise generally the work of the
resident dental staff, some of whom might be specialists in training.
88.
Within each region facilities must be provided for dealing with faciomaxillary injuries and diseases and injuries in
which close collaboration between dental surgeon, general surgeon and plastic
surgeon is needed. Further reference to this will be found in the section
dealing with Plastic Surgery.
XII DERMATOLOGY
89. At
the present time fully trained dermatologists are only found in large centres
of population, although in some centres general physicians or general
practitioners with considerable experience in the subject have staffed
dermatological clinics. An efficient dermatological service cannot be
maintained without specialist staff. It may be some years before a sufficient
number of experienced dermatologists will be available to meet the needs of all
Hospital Centres., but it should be the aim to provide such a complete
specialist service as soon as fully trained staff can be provided,
90. The
greater part of the dermatological service is provided in the out-patient
department, &nd clinics should be held at all Hospital Centres. Beds should
be available in association with out-patients clinics, but in the smallest
Hospital Centres the number needed would not justify a separate unit. Ten beds
for each sex should be ample provision in a Hospital Centre serving a
population of 100..000 and no unit should be smaller than this. Separate
hospitals for diseases of the skin are undesirable, except as part of a special
postgraduate training and research unit, as contemplated in London.
91, Four
dermatologists giving at least half their time to hospital work would probably
be needed for every million of population and one dermatologist could undertake
the work at two centres, each serving 100,000-120J.000. Large groupings are
preferable so that there can be adequate provision for reliefs and for contacts
with others working in the same specialty.
92. The
out-patient service should provide facilities for daily treatment of patients.,
on the prescribed lines, by specialty trained nurses and male orderlies.
Provision for radiotherapy and actinotherapy should be concentrated at the
larger Hospital Centres. Radiotherapy should be prescribed by the dermatologist
but the apparatus should be calibrated and supervised by the radiotherapist and
physicist. It is essential that there should be co-operation in this work. There will
be some
radio therapy for skin conditions, e.g. for malignant dermatoses, which is
properly the province of the radiotherapist.
93.
Special provision for the treatment of lupus will be required. Each Regional
Centre might have a unit for the treatment of this disease by special forms of
actinotherapy, but it is probable that residential accommodation need not be
provided in more than two centres in the whole country.
94.
Provision for teaching must be made at the Regional Centre. It will probably be
necessary to have a demonstration unit with say 20 beds in the Teaching
Hospital with the balance in the beds in the hospitals of the Regional Board.
Staffing should be on generous lines to allow for teaching, most of which would
be undertaken in the out-patient department.
XIII. DISEASES OF THE CHEST
95. The
in-patient and out-patient services for tuberculous patients, now provided at
sanatoria and tuberculosis dispensaries, will become part of the Regional
Board's hospital service. The future service should provide in-patient
facilities, partly in special sections of general hospitals and partly in
sanatoria, under the care of specialists in diseases of the chest. The
out-patient service should be related to these in-patient units and should be
established, where possible, in a section of the out-patient department of the
Hospital Centre. In rural areas it will be necessary to keep some outlying
dispensaries for the convenience of patients. The specialist staff will be
available for domiciliary consultations.
96. In
the past, tuberculosis officers have tended to work too much in isolation from
the main body of general medicine. Pulmonary tuberculosis should be regarded as
the field of physicians, trained primarily in diseases of the chest, who have
made a special study of this, one of the commonest forms of disease of the
lungs. The training of the specialist chest physician. should be in line with
that of other
specialist physicians, with the sound background of a training in general
medicine prior to specialisation in the diagnosis and treatment of diseases of
the chest.
97. It is
essential that specialist officers undertaking work at out-patient clinics should
also be in charge of the beds for pulmonary tuberculosis in sanatoria and
general hospitals. This is necessary not only to maintain the quality of the
work of the individual specialist but to give continuity in the supervision of
treatment. It may be that, in larger sanatoria, a resident physician will give
less of his time to outpatient work and more to the supervision of inpatients,
especially where the other physicians have to live in areas where they hold
their out-patient clinics, at some distance from the sanatorium.
98. It is
undesirable that the treatment of tuberculosis should be divorced from the
treatment of other medical conditions of the chest, even if separate
institutions or wards are used. The chest physician undertaking tuberculosis work
must be freely available for consultation in the general hospitals of the
centre to which his sanatorium beds are related. Reference to the surgical
treatment of pulmonary tuberculosis is made in the section on Thoracic Surgery;
it is sufficient here to mention the necessity for regular consultation between
chest physicians and chest surgeons.
99. The
chest physician dealing with tuberculosis must necessarily concern himself with
the epidemiological and social aspects of the disease. He will work in close
cooperation with the paediatrician. and orthopaedic surgeon and rill be
associated in the diagnosis and treatment of nonpulmonary tuberculosis. He
should collaborate with the Medical Officer of Health of the Local Health
Authority on the preventive and social aspects of the disease. The attendance
in the tuberculosis clinics of the Health Visitors of the local health
Authority will help to secure further co-operation. Further guidance on the
collaboration between Regional Hospital Boards and Local Health Authorities
will be provided in due course.
100,
There is much to be said for the view that in all radiological work for
diseases of the chest the specialist radiologist should be associated. This
does not mean that chest physicians would cease to screen their patients. They
would naturally continue to do so, but it would be an essential feature of the
arrangement proposed that the advice of the specialist radiologist would be
available at all times, and that he should see and express an opinion on all radio
graphs of the chest and its contents. The same association is necessary in mass
miniature radiography work and in this the Medical Officer of Health gill also
be closely concerned on the epidemiological aspect.
101. The
Regional Board will need appropriate advisory machinery in this speciality. A
member of their central regional. staff trill be needed to give at least part
of his time to the administrative aspects of the tuberculosis scheme, although
it is important that he should retain an active clinical interest in this
subject.
102. A
population of 100,000-120,,000 will need more than one chest physician. it is
probable that the number required gill be of the order of 15 per million of
population, working whole-thne9 with appropriate staff of registrar
grade, mainly employed in hospitals and sanatoria but also undertaking
outpatient work under supervision.
103.
Sanatorium units should serve a large population and should have a minimum of
200 beds, but the general hospital serving a population of 100,,000-120,000
should have a unit of about 20 beds for the investigation of patients in whom
the diagnosis is doubtful. In addition, small units for advanced cases may be
placed in various hospitals.
XIV. SURGERY OF THE EAR, NOSE AND THROAT
104.
The surgical treatment of diseases of the ear, nose and throat, is properly the
province of a surgeon who restricts his practice to this specialty. Every
Hospital Centre should have an ear, nose and throat department, including
out-patient and in-patient departments. Beds should be provided in separate ward units., not mixed with general surgical beds, so that
nursing staff acquire special experience and skill in the management of these
cases.
105, It
is undesirable to establish special Ear, Nose and Throat Hospitals. A separate
ear, nose and throat unit in a hospital group may be desirable but the usual
arrangement would be the setting aside of a self-contained unit or a floor in a
general hospital. The nature of the acute infections of the ear, nose and
throat is such that it is highly desirable to have a large number of single bed
wards in any unit provided for these conditions. The preponderance of children
treated in this branch of surgery also makes desirable the provision of a
substantial proportion of single-bed wards. In larger Hospital Centres it is
also an advantage to have separate operating theatres.
106.
Although an ear, nose and throat department is necessary in every Hospital
Centre it does not follow that there will be sufficient work for a locally
resident Special ist in the smallest Hospital Centre. Z1herever possible a
locally resident specialist should be provided. Otherwise, a specialist should
visit at regular and frequent intervals from the nearest larger centre. An
experienced senior resident officer should be available and the specialist
should be on call, In extreme emergency one of the locally resident general
surgeons might have to take immediate responsibility for urgent treatment.
107, In
larger Hospital Centres there may be more than one acute general hospital and a
separate infectious disease hospital, children's hospital and sanatorium. An
ear, nose and throat surgeon should be on the staff of each of these hospitals
and, in particular, should be responsible for the treatment of appropriate cases
in isolation hospitals. An attempt should be made to concentrate the bed
provision for ear, nose and throat cases at one or at most two of the
hospitals. Where there is a central hospital with the min out-patient
department and a peripheral hospital with the majority of the beds, it may be
necessary to divide the inpatient accommodation but one in-patient unit should
be provided where possible.
108. In
some large towns there are separate clinics with a few beds where operative
treatment for tonsils and adenoids is undertaken these should be abandoned as
soon as possible and proper facilities and accommodation for an adequate stay
in hospital before and after operation should be provided.
109.
Special provision will be needed for the treatment of deafness. Arrangements
are in hand for the production and supply of a new standard hearing aid and
these should be provided through out-patient departments with appropriate
facilities for examination of patients and for the prescription and adjustment
of the apparatus. A further memorandum on the provision of hearing aids will
follow.
110. A
hospital Centre serving a population of 100,000 - 120,000 will require about 50
beds for ear nose and throat cases. The staff required for such a population
group would be at least one whole-time surgeon or the part-time equivalent and
one registrar whole-mime. This however may be an underestimate and it may prove
that three specialists and two registrars are required for two such Hospital
Centres.
X V. INFECTIOUS DISEASES
111.
Provision for the treatment of notifiable infectious diseases has been the
responsibility of Local Authorities in the past and specialist experience in
the treatment of these diseases has been very largely confined to whole-time
medical officers. It is probable that Regional Boards will wish to re-group the
accommodation for infectious diseases, making use either of special sections of
general hospitals, or in the largest towns, of separate hospitals associated
with general hospitals. The isolation section at a Hospital Centre should be
regarded as accommodation available for the isolation of any suitable type of
case and not solely for the treatment of patients suffering from notifiable
infectious disease. The care of a patient thus isolated because of some
non-specific infection should remain in the hands of the appropriate specialist
e.g., the gynaecologist in puerperal sepsis.
112. It
is presumed that initially a number of whole-time medical officers from the
larger infectious diseases hospitals will be transferred to the staffs of
Regional Boards. Some of these officers will be of specialist standing and well
able to take their places as members of the specialist staff of the Hospital
Centre
113. In
the smaller hospitals for infectious diseases the supervision of patients
suffering from infectious disease has often been undertaken by part-time
officers who may also be district Medical Officers of Health or general
practitioners. It will probably be necessary to continue arrangements of this
kind for a time., but a primary object of the re-grouping of hospitals should
be to secure that specialists in the treatment of infectious diseases are
available for consultation at the small centres where there are no whole-time
specialists.. The aim should be to secure that the patient suffering from an
infectious disease is under the supervision of a specialist. It will also be
necessary to ensure that resident medical officers are available for all infectious
disease hospitals except perhaps where a small remote isolation hospital must
continue for the time being owing to lack of more central accommodation.
114
The majority of patients in infectious disease hospitals are at present
children; but the changing age incidence of some diseases and the use of
isolation accommodation for other infections may change this. It is difficult
to see to what extent in future the clinical care of patients suffering from
infectious diseases may become merged in the provision for other diseases of
children or of medical conditions generally. It may be that in the distant
future this specialty will be in the hands of paediatricians with a special
interest in the treatment of infectious disease or of general physicians with a
similar bent. In any event the paediatrician should be closely associated with
this work. The otologist should also be called in to treat patients with otitis
or other complications of infectious disease coming within his province.
115. It
is important that specialists in infectious disease employed by the Regional
Board should be available to general practitioners for consultation on the
diagnosis of cases before their admission to hospital. The Medical Officer of
Health has a special statutory responsibility in. relation to the recognition
and control of infectious disease, but the advice of a clinical specialist
should always be- available to him. Equally, of course, to aid him in his
preventive work, the Medical Officer of Health must have free access to all
necessary information about patients in infectious disease hospitals.
116. A
population of 100,000-120,.000 might not require the whole time of one
specialist in this subject. A large centre serving a population of 500,000
might have a hospital unit of 300 or more beds and a staff of three whole-time
specialists who could also supervise the work of senior residents in one or two
associated centres. The extent to which this specialty gradually merges into
general medicine and paediatrics obviously affects the size of the staff
required.
NEUROLOGY AND NEUROSURGERY
117.
These two specialties will always be linked together in a regional service, and
psychiatry will be closely associated with them. The peculiar administrative
problems of psychiatry, however, have caused it to be considered under the
separate heading of the Mental Health Services. Ideally Neurology, Psychiatry
and Neurosurgery should be included together in one department, but even in the
Regional Centres such a comprehensive arrangement is not likely to be feasible
for some years.
118.
Medical Neurology: There are not yet enough neurologists to provide a complete
neurological service and it will be necessary at first to make use of
physicians who do not restrict their practice entirely to this specialty. There
should, however, be neurologists at the Regional Centre who devote the whole of
their time to neurology.
119.
The first essential is to create a neurological department at the Regional
Centre. It is unlikely that all the beds needed for the region can be provided
in one hospital and still less likely that the needs can be met by the teaching
Hospital alone. A demonstration unit could, however, be established in the
Teaching Hospital, with a much larger number of beds in another hospital. In
the larger regions subsidiary units may ultimately be needed at Hospital
Centres. These may be instituted in the first place by specialists from the
Regional Centre holding out-patient clinics and transferring cases for
in-patient treatment to the Regional Centre or, where conditions permit,
providing for their care in beds at the Hospital Centre, in charge of a general
physician with a special interest in neurology. All patients admitted to
hospital with nervous diseases cannot be directly under the care of a
neurologist, but it is necessary to ensure that a neurologist is available for
consultation.
120. It
may be possible for one unit at the Regional Centre to maintain a consultative
service for the whole region, but generally neurologists should be provided at
Hospital Centres serving large concentrations of population.
121. It
has been suggested that from 100 to 150 beds per million of population should
be available for neurological cases, including those which are chronic and stay
in hospital for long periods. The staff required at the Regional Centre will
vary with the size of the region because, in the early years at least, they
will be responsible not only for inpatient and out-patient duties at the
centre, but for consultative clinics at Hospital Centres. Their services will
also be needed in advising on the rehabilitation of certain of the chronic
sick. At least one senior and one assistant neurologist giving at least half of
their time will be needed for every 50 beds; They will be assisted by such
whole-time registrar and junior staff as may be necessary.
122. Neurosurgery:
The requirements for organising a service in this specialty are much the
same as for neurology and the plan should follow the same general lines
123. A
strong team at the Regional Centre is essential and it is preferable to arrange
for all operative work to be done there wherever possible. Because of the
time-consuming nature of neurosurgical operations, relatively generous staffing
is necessary to provide a satisfactory service' including
consultative duties in the region. Many Hospital Centres may urge the
appointment of a neurosurgeon to their staff, but it will be impossible to
satisfy them all without a wasteful use of manpower and, in most cases, because
the full establishment which the work demands cannot be provided. Experience
will show if efficiency can be improved by establishing associated centres in
the larger regions.
124. The
head injury service should be part of the general traumatic service. Some
complicated types of head injury are better treated at the neurosurgical centre
and should be transferred to it, but :host head injuries do not need to be
moved. It is impossible and, what is more, unnecessary that every head injury
should have specialist neurosurgical supervision. It is, however, desirable
that the general surgeon should have opportunities for acquiring such
instruction and experience in the care of head injuries as he may require. Much
more attention should be given to the rehabilitation of cases of head injury
and closer links should also be forged between the department of neurosurgery
and those for rehabilitation and physical medicine.
125. The
optimum size of an active surgical unit is about 40 beds. For a population of a
million, probably from 75 too 100 beds
may be needed for neurosurgeoy and these can be divided between two units.
126. Ancillary
Services: It is most important that the services of a pathologist with a sound knowledge of the special
methods of neuro-pathology should be available. An anaesthetist with special
experience of this work should be attached to every neurosurgical team. The
radiological department should provide special assistance, for neuro-radiology
needs experience and is time consuming, and the closest collaboration is
essential, particularly with neurosurgeoy. Special equipment is also needed. An
electro-encephalograph, operated by trained staff, must be available.
XVI. OPHTHALMOLOGY
127. The
service of ophthalmology provided by Regional Boards will ultimately comprise a
complete eye service including the provision of spectacles for all who require
them This complete service will be impracticable in the early stages in
most areas because of lack of trained staff, and provision is made in Part IV
of the Act for an interim service, the "Supplementary Ophthalmic
Service", which is organised separately from the hospital service. The
hospitals now provide facilities of varying degrees of completeness for
ophthalmic surgery but only a part of the requirements for refraction and the
prescription of spectacles. The problem therefore is twofold: to expand the facilities
within the hospitals as may be necessary for a complete ophthalmic surgical
service, and to develop the refraction service at hospitals and eye clinics as
rapidly as may be to replace the interim service under part IV.
Ophthalmologists, ophthalmic opticians and dispensing opticians all have a
share in this service and the general lines of development are being examined
by a committee of representatives of these groups. A further memorandum will
follow on this subject in due course.
128.
Hospital beds are required for the ophthalmic surgical service in numbers
varying with conditions, particularly with the type of local industry. The number of
beds required may be about 20 in a hospital centre serving 100,000 - 120,000
people. In normal circumstances these beds should be -provided in a general
hospital. In one or two of the largest Regional Centres it may be appropriate
to provide special ophthalmological institutes for postgraduate teaching and
research, but the usual arrangement will be a unit of appropriate size in the
Teaching Hospital with the rest of the beds required for the centre in one or
possibly more hospitals of the Regional Board. The few very small Hospital
Centres with populations of the order of 50,000 will require an out-patient
service, but it is undesirable that operative work should be undertaken there,
because there is insufficient work to permit the specialised training of
nursing and resident medical staff.