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Steam-sterdiserWe have found it convenient to provide the bottled sterile

water from the central sterile supply department (C.S.S.D.), asthe same equipment, staff, and delivery system can then beused. Minor modifications of the autoclaves are needed, sothat the steam can be let in slowly, the vacuum period of thecycle cut out, and the timing device set to longer than 60minutes. There is no advantage in sterilising at high tem-peratures. No time is saved, and the risk of explosion is greater.

Sterilising Cycles

The heating-up period must be determined under standardconditions, with the autoclave full (fig. 3) and the thermistor atthe bottom of the tallest bottle (fig. 4). The automatic timer isthen set to this period plus the sterilising period (30 minutes at116°C). We have found this method simpler and safer than tocontrol the cycle from a thermometer in a standard bottle ofwater. It would be easy to forget to change the standard bottleand begin a second run with the standard bottle at a highertemperature than the rest of the autoclave.

Special autoclaves are available, with sprinklers for

rapid cooling. We have found an ordinary autoclave8. Bowley, L. C., Roberts, H. E. ibid. 1961, ii, 206.

rapid enough for our needs. A 15 c. ft. rectangular auto-clave will hold sixty one-litre bottles. The sterilisingcycle is 155 minutes, so that one hundred and eightybottles can be prepared in a working day.The water is stored in the theatre in cold cupboards and

in thermostatically controlled hot cupboards. The cup-boards should not hold more than a day’s supply—i.e.,3 litres per maximal daily number of operations, equallydivided between hot and cold cupboard. To save room,the cupboards should be built into the theatre wall; andthose that can be filled from the back are convenient, asthe c.s.s.D. staff should not enter the theatre.

We have found the following advantages of bottledsterile water over other systems: (1) sterility of the water isassured; (2) space is saved in the theatre sterilising-room;(3) open containers and jugs are avoided; (4) the work ofthe theatre staff is lessened; (5) bottled sterile water is

easier to use for irrigations and cystoscopies; (6) theatres,wards, and other departments are supplied from onecentre.

SUMMARY

The organisation of a central supply of bottled sterilewater is described, and recommended as the safest andmost efficient means of supplying sterile water.

Points of View

OPERATIONAL RESEARCH AND EFFICIENCYIN THE HEALTH SERVICE

MARTIN S. FELDSTEINUNITED STATES PUBLIC HEALTH SERVICE

RESEARCH FELLOW IN HEALTH CARE ECONOMICS,NUFFIELD COLLEGE, OXFORD

* This investigation was supported in part by a grant from the UnitedStates Public Health Service.

THE techniques of operational research were developedduring the late war for such purposes as improving theuse of scarce resources, selecting routes and schedules forshipping, determining the best size for a convoy, choosingamong designs of military equipment, and using bombsmore efficiently. The basic features common to thesestudies were an analytical model of the problem; imple-mentation of the model with statistical evidence; and thesolution of the problem by finding the alternative policywhich maximised or minimised the value of a particularequation in the model.

In retrospect, much of the early research looks crude:criteria were sometimes inappropriate and calculation

techniques unsophisticated. But time and again itenabled vast improvements to be made on " commonsense

" solutions; and, as a result of this wartime experi-ence, operational research now has an important place inmilitary decision-making, in spheres formerly reserved forexperience " and " judgment ".Techniques have improved, and a combination of

operational research and economic analysis is beingapplied in many business firms and in a wide variety ofpublic services.

In the National Health Service, administration andplanning is a process of choosing among alternative usesof limited budgets-among alternative allocations ofresources. Appropriate operational research can makethe process more scientific. Of course, no technique ofmanagement or economics can eliminate the need forexpert opinion and value judgment; but, just as the

thermometer and sphygmomanometer assist in clinicalwork by reducing the number of questions that have to beanswered solely by " judgment ", so operational researchassists in planning and management by reducing thearea of uncertainty. Fuller objective information makesjudgment more effective.Many questions are too broad, and too dependent on

intangible factors, to be answered by these techniques.But there is a wide and important range to which they cansuitably be applied-e.g., choosing between different

community preventive or diagnostic programmes, plan-ning the number of beds for a hospital region, allocatingbeds among various hospital services, and comparingthe value of inpatient and outpatient care for variousconditions.

Towards a Measure of Medical Care: OperationalResearch in the Health Services,! a book produced by theNuffield Foundation last year, should be a furtherstimulus to scientific management. But, besides its manyhelpful and suggestive discussions, the book contains anumber of shortcomings and confusions which are

common in current thinking about the application ofoperational research to health care. By concentratingon these weaknesses, I hope that this article can makeoperational research a more useful tool for health servicemanagement.

"NECESSARY" SERVICES

Administrators must continually decide what servicesand facilities to provide, how to provide them, and howmuch to provide. But to think about these questions interms of " need " or " best possible care " is misleading.In selecting a method of care for a particular patient, or apreventive programme for the community, we cannotalways opt for all that could possibly be useful. There

just are not enough doctors, hospital beds, and otherresources to go round, and a decision to give moredoctor-hours, more nursing, or more bed-days to one1. Toward a Measure of Medical Care: Operational Research in the Health

Services: a symposium. Contributors: J. O. F. Davies, John Brothers-ton, Norman Bailey, Gordon Forsyth, and Robert Logan. Publishedfor Nuffield Provincial Hospitals Trust. London: Oxford UniversityPress. 1962. Pp. 91. 5s.

492

patient or programme is a decision to deny them to otherpatients and programmes. Similarly a national decisionto spend more money on buying drugs and equipment,attracting more nurses, building more hospitals, or

otherwise increasing health-care resources is also a

decision not to spend that money on education, housing,or other desirable purposes. Selecting a particular methodof health care is justified not because it is a " good "

or "

necessary "

use of resources, but because it is a

better use-better than all other uses to which they mightbe put.To find the optimal use of resources we have to weigh

the relative benefits and costs of alternative programmesand methods of treatment. Supposing that resourceswere applied to lengthening the stay of women in hos-pital for childbirth, would the improvement in health be

, greater than if the same resources were used for takingmore of the women into hospital ? If more women weretaken into hospital for delivery, would the improvementin health outweigh the disadvantages of the shorter stay ?Davies 1 is right when he says that " there is a case forstudying which conditions (currently treated on an

inpatient basis) can equally well or better be treated in theoutpatient department ". But this is not enough. Evenif some patients do worse in the outpatient departmentthan as inpatients, it may be proper to treat them there ifthe resources so liberated can be used to better advantageelswhere.Even for health care as a whole there must be an

optimal amount. If money at present spent on other

objects would yield greater benefits when spent on health,then clearly we are spending less than the optimum. Butif a transfer of health expenditure to education, for

example, would yield greater benefits, we are spendingmore than the optimum.

Precise determination of the optimal allocation ofresources within the health service, and between thehealth service and other wants of society, may be

impossible. But to think in terms of optimal allocationinstead of " meeting needs " will produce better decisions.The four articles of the Nuffield study incorrectly

approach health service decisions as though the problemwere to meet specific community

" needs ".

Davies tells us that " one of the main problems with whichthe health service is faced is how to ascertain the needs of thecommunity ". He discussed two types of " needs "-theneeded level of health and the needed facilities and services.

Brotherston says that in the health services " measurementof need and the gap between need and satisfied demand is theultimate test of effectiveness ". He approaches the problem ofmedical planning as one of eliminating the difference betweenthe current health level of the community and some arbitrarylevel of health that the community " need ". But he admitsthat " the area of need moves with medical knowledge andsocial ideology " and he leaves unanswered his own question of"what levels of findings are we to adopt in our definitionof need ? " The reason why his analysis produces no answer isthat it asks an inappropriate question. Instead of seeing howpredetermined indices of the level of health can be achieved,we should ask what alternative things we can produce with ourmedical knowledge and resources, and then select the best ofthem.

Bailey describes a technique used for assessing the " needsof the United Oxford Hospitals " for inpatient beds. He baseshis calculations on doctors’ requests for such beds and theaverage period of the patient’s stay. The simplicity with whichhe then reaches an arithmetic answer may lead his readers toassume that the problem of planning the number of hospitalbeds has been solved. But the question that should be asked

-what is the optimal number of beds for the region, when theresults of hospital care and longer stay are weighed againstalternative uses of these resources-remains unanswered. Incontrast, his calculations try to provide information on thenumber of beds that doctors will request.Not only may this differ considerably from the optimum, but

it reflects the available supply of beds more accurately than itreflects some measure of clinical " need ". In a previousNuffield study,2 Forsyth and Logan found that doctors auto-matically adjust their demand for beds to the available supply:" It appears that the number of beds used is the numberavailable "! Where beds are scarce and waiting-lists long, morepeople are treated as outpatients, and the length of stay isshorter. Application of Bailey’s technique will thereforegenerally show that the current number of beds is the correctnumber for the current period-an unwarranted reassurance!

After extensive ward visits, Forsyth and Logan foundthat in medical cases 24% of males and 42% of femaleswere not, on clinical grounds alone, in need of inpatientcare. 1 But how useful in planning is the concept of" clinical need " ? Is admission to hospital, or any otherservice, " clinically necessary

"

simply because there is achance of its being beneficial ? Or does

" clinical need "

merely reflect medical fashion ? As Abel-Smith hasremarked, " it is only a matter of time before traditionalmedical care becomes regarded as good medical care".Instead of taking doctors’ requests and length of stay asconstants, we should investigate, for various conditions,the benefits of hospital admission as opposed to out.

patient or domestic care, and of different lengths of stay.Then Bailey’s method could be applied to finding theright number of hospital beds.Need is not the only concept used in this book where

optimum would be better. For example, when Daviesrefers to determining

"

inpatient needs only after we aresatisfied that outpatient departments are adequate instaff and premises ", the word

" adequate " is wanting intwo respects. First, we can almost always find a use formore facilities and staff, and we can always get along withless. Secondly, we cannot separate choices about in-

patient and outpatient services in this way; inpatientservices are not a residual but an alternative.Although calculation of optimal standards of service

could be done neither easily nor rapidly, Britain’s applica-tion of operational research to the health services ought tobegin by asking the proper questions.

EVALUATING EFFECTS

Decisions about the planning of health-care facilitiesand programmes should not be made merely on the

unsystematic appraisal of physicians. As Abel-Smithsays :

" It is no use asking a random sample of physicianswhat they would like to provide for their patients. A

physician who has never known the potentialities of afully developed home care programme or a well runnursing home cannot be expected to have useful opinionsabout which patients would benefit from these types offacility." 3 Choices among alternative preventive,diagnostic, curative, and rehabilitative services shouldbe made on statistically derived estimates of the likelybenefits and the likely costs.

Cost accounting, if properly used, can tell us the cost ofperforming a particular service. The benefits to be

expected from different forms of treatment can beestimated from the results of medical surveys or of specialresearch. We may be able to use data already available; wemay require data specially collected by doctors and health

2. The Demand for Medical Care. London, 1960.3. Abel-Smith, B. Hospitals (J. Amer. hosp. Ass.), May 1, 1962, p. 33.

493

institutions; or we may wish to perform experimentsanalogous to therapeutic trials.Brotherston wisely suggests that it might be well to

stop using the word quality-" a value-loaded wordwhich may hinder rather than help thinking. It might bebetter to think in terms of studies to examine the effective-ness of services and studies to examine performance ".Although he points out that the ideal would be " toassess effectiveness of services measured by their impactupon morbidity or its consequences ", he dismisses this asgenerally too difficult because of the rareness of similarpopulations and the difficulty of excluding the effects ofother variables.

But it would, I think, be a mistake to allow the diffl-culties of multi-variable analysis to frighten us into usingthe alternative " indirect " measures of effectivenesswhich Brotherston puts forward. He first proposes thatthe effectiveness of a service might be measured by thedemand for that service, the number of patient-complaintsor the frequency of change of doctor. But Peterson et al.4found that a general practitioner’s popularity may bequite unrelated to his skill as judged by the expert;and we can have little more faith in the patient’s opinionon the efficacy of methods of treatment or prevention.Brotherston’s second recommendation-that we comparecurrent practice with " standards of comparison (which)may be set out arbitrarily "-begs the question of theoptimal standards for treating a particular condition.But I do not believe that we can dismiss the possibility

of estimating the effects of various methods of care,as Davies does when he says that " the assessment of anyprogramme of medical care by direct examination of thepeople for the effects of changes in morbidity is unlikelyto be successful because of the many other factors thatare likely to have operated. Before and after studies are

rarely possible and two directly comparable populationsrarer still". This, however, ignores the extremely usefulwork already done with the aid of medical statistics,epidemiological methods, and clinical trials. In BradfordHill’s words:

" Far, therefore from arguing that the statistical approachis impossible in the face of human variability, we must realisethat it is because of variability that it is often essential.... Thestatistical method is required in the interpretation of figureswhich are at the mercy of numerous influences, and its objectis to determine whether individual influences can be isolatedand their effects measured." 5

PROPER QUESTIONS

Operational research will improve health-service effici-ency only if proper questions are asked. First, determininghealth policy must be regarded as a search among alterna-tives. Secondly, alternative methods should be judged onappropriate statistical estimates of their effect.

Finally, the proper scope for operational research mustbe understood. Many matters of policy and organisationare too broad to be formulated in the quantitative termsnecessary for successful operational research. But itwould be equally unwise to adopt too limited a view.Operational research must be recognised as much morethan work-study, organisation-and-method techniques,and other measures to reduce costs.

Creative use of operational research and competentstatistical analysis can help us to choose among alternative4. Peterson, O. L., Andrews, L. P., Spain, R. S., Greenberg, B. G. J. med.

Educ. 1956, 31, no. 12.,5. Hill, A. B. Principles of Medical Statistics. London and New York,

1956.

programmes of prevention and diagnosis, to choosebetween inpatient and outpatient care for particularconditions, and to solve other problems of choice in theplanning and operation of the health services.Although no decision about health care can be made

without common sense and value judgments, appro-priate quantitative estimates can greatly improve thesedecisions.

Symposium

SOCIETY OF MEDICAL OFFICERS

OF HEALTH

THE society’s second annual symposium was held inLondon on Feb. 22.

The Adult Psychiatric Patient in the CommunityDr. EDWARD HUGHES said we should think carefully before

committing ourselves to community care of the mentally ill,and we should not do so under the impression that it was

cheaper than hospital care, which it probably was not.Dr. J. K. WING observed that, in the 1930s, nearly two-

thirds of schizophrenic patients admitted to hospital couldexpect to stay for at least two years and probably for the restof their lives. Now the proportion was only 10%, but thefigure of two-thirds still applied to the proportion who, fiveyears later, were in hospital or day hospital, unemployed, orshowing severe symptoms of their illnesses. Schizophreniawas still a chronic disease. Referring to his published data onthe post-discharge disorders of the majority of chronic schizo-phrenics, Dr. Wing noted that, though the social atmosphereof the family was often strained, the relatives usually seemedprepared to put up with this and to make considerable adjust-ments in their own lives. They seemed to share the publicreaction against " institutions " and displayed astonishing goodwill. The burden of caring for those with schizophrenia wasshifting from hospital to community and the numbers wouldincrease. Dr. Wing listed as necessary measures close super-vision of drug administration, regular contact with the patientat home and/or in the clinic, treatment of the early relapsebefore it deteriorated into a social crisis, provision of shelteredworkplaces, counselling for relatives, and the use of dayhospitals for patients unwilling to accept ordinary ones.A paper read for Dr. IAN SKOTTOWE outlined the six main

categories of mental-hospital admission. The acute short-staypatient of good prognosis called for little social help, but thelong-stay patient called for much more social work; from 1955to 1959 about 10,000 patients, mostly schizophrenics, weredischarged after being in hospital for over five years. A thirdto a half were likely to return within a year, and readmissionstended to become more frequent and longer. The large groupof patients who recovered quickly in hospital and as quicklyrelapsed on discharge also made big demands on the socialservices. The fourth main group-neuroses and personalitydisorders-came into hospital much more often than formerly,but even so admissions were the very small visible part of an

iceberg probably ten times the size. Voluntary bodies workingunder supervision could be helpful in supporting many of theseinadequate people. Then there were the alcoholics, also under-represented in hospitals; a crucial part of their treatment wasrelated to readjustment after discharge. Finally, regarding theelderly, a sentimental wish to keep them from institutions wasmisplaced if their frequent and treatable depression, para-phrenia, or confusion was misdiagnosed as senility and wasneglected.

Dr. Skottowe laid special emphasis on the need to fostercommunication, and he urged that case assessments be madejointly on clinical and social grounds by psychiatrist andsocial worker. Local-authority workers should receive trainingin psychiatric outpatient clinics for at least one two-hour