538

National Health Service

THE CONSULTATIVE DOCUMENT

J. A. D. ANDERSON

Department of Community Medicine, Guy’s Hospital MedicalSchool, London S.E.1

THE Consultative Document on the future of theNational Health Service which was published twomonths ago required comments from " Organisations "to be submitted by July 31. If serious considerationis to be given to comments which have been sub-mitted, then it may be some time before a white-paper-can be produced-unless, that is, the Document wasnot really consultative and definitive policies havealready been decided regardless of possible comment.Because of the limited time available for consultationit may have been difficult to ensure that commentsmade in the name of an organisation represented theviews of the majority. Furthermore, it may have beendifficult to ensure that views put forward by one organi-sation were discussed adequately, if at all, with otherswhich may properly have had an overlapping interest.One declared 2-im in the foreword of the Consulta-

tive Document is common to those of the earlier

green-papers-namely, to bring about improvement inthe National Health Service by breaking down barriersbetween the three existing parts. It seems odd, there-fore, that the Document should suggest that the generalmedical services and also general dental, pharmaceuti-cal, and supplementary ophthalmic services should beadministered by bodies similar to the existing execu-tive councils which will be responsible direct to centralGovernment. The point is made that area boardswill be responsible for setting up these executive

.councils, but without the teeth associated with financialmanagement. Each executive council will have its- own " hot line " to the Department of Health andSocial Security (D.H.S.S.), so that neither the area northe regional boards are likely to have much influencein trying to unify the hospital services with what is leftof the local health authority services on the one hand.and the general medical services on the other.

Pandering in this way to the desire of general prac-titioners to emphasise the independence of their con-tracts may well mean that the health services, whichwere administered under three different branches in

1969, will still be tripartite in 1974. The hospitals,health centres, and all nursing services being adminis-tered by area boards will be responsible to their

regions; the rest of the former local health authorityservices, administered by social services departments,will be responsible to local authorities; while the generalpractitioners, administered by executive councils, willbe responsible direct to the D.H.S.S. Nor is unificationmade any more real by the fact that no firm suggestionshave been made for the future of the school health

service, at present the responsibility of local authoritiesand thence to the Department of Education and Science.In the same way most aspects of occupational health,apart from a small section which is the responsibilityof the Department of Employment and Productivity

through its factory inspectorate, will continue to bematters for the whims of industrial employers.

Separate administration of the services at presentunder Part IV of the National Health Service, and theexclusion of school health and occupational health,would make a mockery of unification. However,scepticism about unification per se and the panaceanresults which might or might not accrue from itsachievement is probably quite healthy. The troubleis that the sacred cow of unification is not the onlything at stake. There are consequences associatedwith the new proposals which could endanger thequality of care received by the public, who are, afterall, paying considerable sums of money (albeit underduress) in the hope of getting the best service.One such danger may spring from demarcation

problems and poor communication between those pro-viding health care on the one hand and those providingsocial care on the other. The benefits of a unifiedsocial service, envisaged by Seebohm, may compensatein the long run for any difficulties or misfortunes inthe early stages of the new order. However, it behovesany one of us concerned with the provision of eitherservice to remember that multiple-entry points to

what could be called community care in the widestsense may lead to increased misery for consumers.Individuals known on the one hand as patients andon the other as clients, who are unfortunate enough tobe chronically sick, aged, or otherwise disabled, areparticularly vulnerable in this respect.A second danger is that general practitioners, at

present emerging fast from the age of the " cottageindustry ", may be forced back into isolation. The

proposals indicate that health centres and communitynurses (home nurses, health visitors, and domiciliarymidwives) will come under managerial control of areaboards which will also have control of the hospitals.The hospitals can be expected to dominate the scenefor no other reason than that they will command some90% of the area boards’ budgets. Under such circum-stances health centres may come to be regarded asannexes of hospitals. Furthermore, community nursescould come to be regarded as the personal perquisitesof hospital specialists, just as the laboratory diagnosticservices and radiological services did in 1948. Such

possibilities cannot be dismissed on the ground thatthe attitudes of 1948 are buried in history since, eventoday, there are many hospitals where direct access tophysiotherapy is denied to general practitioners.The school health service, at present left in limbo,

could be another source of reduced efficiency in theoverall pattern of health care. If the service retainsmedical and nursing staffs employed separately bylocal education authorities, these will be outside themain streams of career structures, with consequentproblems of recruiting.Some general practitioners, eager for a comprehen-

sive role in health care, may claim that the responsi-bility for the health of schoolchildren should be theirs.Routine and/or selective examinations of school-children could be done by general practitioners, per-haps under the supervisory control of a communityphysician working for the local education authority andassisted by a computer program along the lines of

539

the West Sussex programme for immunisation control.This would be feasible only if the medical professionas a whole, and general practitioners in particular, wereimpressed with the importance of providing an ade-quate preventive service for this section of the com-munity. At present there is little evidence of this, noris there any statement in the Consultative Documentto indicate that the D.H.S.S. intends to take steps toalter this situation.

Finally, the fact that there are no proposals for

extending occupational health services constitutesanother potential danger. In recent years the age-specific male death-rates for ages 45-65 have been

unique in that they are the only ones which haveincreased. Simultaneously there is world-wide concernabout the problems of increasing pollution. One

aspect of care particularly concerned both with thehealth of adult males and with preventing industrialpollution is occupational health. As with school-

children, general practitioners could, if suitably trainedand encouraged, play an important part in personalprevention in this field. However, routine examinationof large numbers of apparently healthy individualsmerely to prove they are healthy or to discover ailmentsthat are not amenable to treatment rapidly leads to

disillusionment. Examination of vulnerable groups,selective examinations on demand, and health educa-tion may be more useful; but all these need to be basedon an agreed policy supported by research effort totest their efficiency.One common thread linking all these danger areas,

and one which could help to change attitudes towardstheir associated problems, is medical training. Empha-sis on hospital treatment of those who have developedsickness, accompanied by increasing expenditure onspecialist services to the detriment of generalist andpreventive services, has been allowed to extend tosuch a point that there seems no way of reversing thetide. The Todd Report, like that of Goodenoughbefore it, lies mouldering on the shelf, and unless achange of emphasis in medical training can be achievedthere is little likelihood of bringing about change. Itseems that a national approach to the problems dis-cussed here may have to be deferred until the next

reorganisation of the Health Service in another

twenty-five years. Perhaps by then changes in bothundergraduate and postgraduate training policies fordoctors will have been implemented and the climatemay be ripe for the establishment of a truly unifiedHealth Service.

Reorganisation

THE ELDERLY SICK: WHO LOOKS

AFTER THEM?

GRAHAM J. EVANS*H. M. HODKINSON† ALEX G. MEZEY

North Middlesex Hospital, London N. 18

Summary The admission-rate of the elderlyincreases with advancing age and the

majority of patients over 75 go to the geriatric depart-ment. However, three-quarters of patients in the65-74 decade are admitted to non-geriatric beds ofthe hospital service. The clinical picture changesover the age of 75, with a higher prevalence of multiplephysical illness and of dementing conditions, and it isin this age-group that most misplacements of patientsoccur. Geriatrics should be defined as the compre-hensive care of the sick over the age of 75, the servicebeing organised by a geriatrician whose role shouldembrace both hospital and community care.

* Present address: Kingseat Hospital, Auckland, New Zealand.† Present address: Northwick Park Hospital, Harrow, Middlesex.

INTRODUCTION

WE report here on the admission of elderly patientsto the hospitals serving a defined area of NorthLondon. Our purpose was to analyse the distributionof elderly patients between the different parts of thehospital service and to examine critically some basicassumptions in organising medical care for the"

geriatric " patient.

METHOD

This investigation was carried out in Edmonton and

Tottenham, two former boroughs of Greater London.

At the 1961 national Census the combined population ofthese two boroughs was 204,203, of whom 25,376 (12-4%)were above the age of 65; of these, 16,419 (8%) were inthe 65-74 decade and 8957 (4-4%) were aged 75 or over.The demographic and the ecological characteristics of thearea have been described by Mezey and Evans.1The investigation was concerned with patients aged

65 and over admitted to hospital for whatever reason.Between May 8, 1965, and May 7, 1966, all psychiatricadmissions were included and a 1 in 4 random sample ofgeriatric admissions were taken. During April, May, andJune, 1965, all patients over the age of 65 admitted to’

general departments of the North Middlesex Hospitalfrom that part of Edmonton in which the hospital issituated-the London N.18 postal district which has a

population of just over 40,000-were also included (tableI). Clinical misplacement was considered to be presentwhen the admitting department was inappropriate to thepatient’s main diagnosis. 2

FINDINGS

Table 11 shows the age-specific admission-ratescalculated from our data. Over two-thirds of patientsin the 65-74 age-group went to general departments,and only a fifth to the geriatric department; abovethe age of 75 the picture was quite different, with thegeriatric department taking over half of all hospitaladmissions of elderly patients.TABLE I-PATIENTS AGED 65 AND OVER ADMITTED TO DEPARTMENTS.

OF THE GENERAL HOSPITAL OTHER THAN THE GERIATRIC OR

PSYCHIATRIC (IN THREE MONTHS, FROM A POPULATION OF-

40,000)