Round the World
1
687 Round the World New Zealand A HOSPITAL WITHOUT WALLS WHEN, during a visit to New Zealand earlier this year as King’s Fund travelling fellow, I was invited by Dr R. F. Moody, superintendent-in-chief of the Auckland Hospital Board, to visit the Extra-Mural Hospital, I expected to be shown a district general hospital involved extramurally with clinical students of the University of Auckland. In fact it turned out to be something quite different and a good deal more interesting. It is an organisation run by the Hospital Board but providing a wide range of clinical and social services with the object of preventing admission, hastening discharge, and supporting the chronic sick and dying at home. There may be some lessons from it for the United Kingdom. The Auckland Extra-Mural Hospital was founded in 1961 in response to a suggestion that hospital boards should be encouraged to adopt a wider role for the hospital by reaching out into the community to provide services that would help the family practitioner to improve and maintain a high standard of health in the population. It was also hoped that by prevent- ing the admission of some patients and shortening the stay in hospital of others economies might be made. It was the unani- mous testimony of those with whom I discussed it that it had achieved the former, though any measurement of the scale of such savings requires a formal. evaluation which has not yet been done. The superintendent of the hospital provides services for a population of about 800 000 spread over an area of approxi- mately 2000 square miles. He has a staff of 180 registered nurses, 10 physiotherapists, 17 occupational, wheelchair, and cerebral-palsy therapists, 2 dietitians, and 26 medical social workers. The hospital also provides domestic support (80 home helps), meals on wheels, linen services, and loan of a wide range of equipment and appliances, including colostomy kits, wheelchairs, and hoists. Chiropody will be provided when there is a definite indication, as will speech therapy. One of the features of the system is the care with which it is coordinated with the work of the family doctor, who retains full clinical control and supervision of the patient. The services are provided by the professional staff on the clear understand- ing that the staff always have medical supervision and support and follow the instructions of the general practitioner. I was told that an important factor in the good relations which have been established between the service and general practitioners in Auckland is the fact that the Extra-Mural Hospital employs no medical personnel other than the superintendent, thus avoiding any misunderstanding that it provides an alternative to the general practitioner. At the time of my visit I was told that in Auckland the ser- vice treats 70 000 patients a year from four district centres for a sum which is less than 2% of the total budget of the Hospital Board. On average each patient is visited 9 times during an episode of care and services are available seven days a week throughout the year. Much of the work is concerned with the severely disabled or dying, but care is also given to patients dis- charged early from hospital and day patients. To me the most enviable features of the scheme, com- pared with the situation of Britain, were: a wider range of pro- fessional and supporting services are under the aegis of a single medically administered organisation (including, be it noted, medically trained social workers and home helps) and the esprit-de-corps and high morale. There is fierce competition for vacancies, notably on the nursing staff. Calls are made on the service equally by hospital staff (to accelerate home-coming and support patients who are to have day-surgery) and by family doctors (to avoid admission). My impression was that in Auckland the extra-mural hospital makes it more likely there than in Britain that planned supporting services will greet the patient arriving home after discharge. I hope that a formal evaluation of the work of the hospital without walls will be undertaken and published and that it will lend sub- stance to the impressions of my brief visit. E. D. ACHESON Professor of clinical epidemiology, University of Southampton United States ADVERTISEMENTS ABOUT MALPRACTICE CLAIMS AWARDS for damages in malpractice and accident suits have reached an all-time high, and many recent settlements have been for several million dollars. Since the damages are decided by juries, the insurance industry has been running advertise- ments in certain papers deploring excessive awards, and asking for restraint from the general public. Many lawyers have pecuniary interest in the size of the award, since they accept cases on a contingency basis and also deduct their costs from the award. William P. Rutledge, a Louisiana lawyer, decided to take on the insurance industry and brought suit against Aetna Insurance Company, Employers Insurance of Wausau, St. Paul Companies, Travellers Insurance, and several other large companies which specialise in accident and malpractice insurance. On behalf of himself and the contingency contin- gent, Rutledge sought to restrain Aetna et al. from running such advertisements. He maintained that the advertisements unduly influenced the jury-in short, they were neither more nor less than jury tampering. The case was heard in a U.S. District Court in Louisiana, and three months ago the judge found for the defendants on all counts. He ruled that "because the advertisement contained statements of matters of public in- terest, there is a heavy presumption against the constitutional validity of any prior restraint on their publication". He went on to say "speech is not stripped of the First Amendment pro- tection, merely because it is in the form of a paid advertise- ment". After this vindication, other companies have taken to using the Press as a means of informing the public about issues which affect them. Thus, Dresser Industries got Edward Teller, the nuclear physicist, to argue against some of the more extreme views of the antinuclear campaign. TOO SENSITIVE? THERE was despondency in many quarters when the news broke that research workers had identified nitrosamines, pre- sumably carcinogenic, in certain brands of Scotch whisky, though not in others. Considering the methods of manufac- ture, this revelation was not entirely a surprise, and in the present furore over nitrates and nitrites it was only to be expected. The presumption seems to be that where there are nitrates and nitrites then there will be formed those redoubt- able carcinogens, the nitrosamines; and now they have been identified in small amounts in all sorts of substances. The thought that they are there at all worries some, and others worry about the means of their detection. Perhaps our methods of detection, of nitrosamines as well as other purpor- tedly carcinogenic compounds, are becoming too sensitive. For as sensitivity is pushed too far, through the ingenuity of our chemists, such compounds are found almost everywhere. Even certain carefully prepared and tested diets issued commercially and used in dietary cancer research are now suspected of con- tamination by nitrosamines. If nitrosamines are to be avoided then our diets will have to be drastically revised. We shall have to modify our drinking water, particularly when it comes from wells in the countryside. Spinach, lettuce, radishes, carrots, potato, beetroot, celery, aubergines, and various greens must be eliminated, and so bacon, ham, sausage, dry cured meats, cold cuts, all smoked meats and fish-just to avoid nitrates and nitrites.
Transcript of Round the World
687
Round the World
New Zealand
A HOSPITAL WITHOUT WALLS
WHEN, during a visit to New Zealand earlier this year asKing’s Fund travelling fellow, I was invited by Dr R. F.
Moody, superintendent-in-chief of the Auckland HospitalBoard, to visit the Extra-Mural Hospital, I expected to beshown a district general hospital involved extramurally withclinical students of the University of Auckland. In fact itturned out to be something quite different and a good dealmore interesting. It is an organisation run by the HospitalBoard but providing a wide range of clinical and social serviceswith the object of preventing admission, hastening discharge,and supporting the chronic sick and dying at home. There maybe some lessons from it for the United Kingdom.The Auckland Extra-Mural Hospital was founded in 1961
in response to a suggestion that hospital boards should beencouraged to adopt a wider role for the hospital by reachingout into the community to provide services that would help thefamily practitioner to improve and maintain a high standardof health in the population. It was also hoped that by prevent-ing the admission of some patients and shortening the stay inhospital of others economies might be made. It was the unani-mous testimony of those with whom I discussed it that it hadachieved the former, though any measurement of the scale ofsuch savings requires a formal. evaluation which has not yetbeen done.The superintendent of the hospital provides services for a
population of about 800 000 spread over an area of approxi-mately 2000 square miles. He has a staff of 180 registerednurses, 10 physiotherapists, 17 occupational, wheelchair, andcerebral-palsy therapists, 2 dietitians, and 26 medical socialworkers. The hospital also provides domestic support (80 homehelps), meals on wheels, linen services, and loan of a widerange of equipment and appliances, including colostomy kits,wheelchairs, and hoists. Chiropody will be provided whenthere is a definite indication, as will speech therapy.One of the features of the system is the care with which it
is coordinated with the work of the family doctor, who retainsfull clinical control and supervision of the patient. The servicesare provided by the professional staff on the clear understand-ing that the staff always have medical supervision and supportand follow the instructions of the general practitioner. I wastold that an important factor in the good relations which havebeen established between the service and general practitionersin Auckland is the fact that the Extra-Mural Hospital employsno medical personnel other than the superintendent, thusavoiding any misunderstanding that it provides an alternativeto the general practitioner.At the time of my visit I was told that in Auckland the ser-
vice treats 70 000 patients a year from four district centres fora sum which is less than 2% of the total budget of the HospitalBoard. On average each patient is visited 9 times during anepisode of care and services are available seven days a weekthroughout the year. Much of the work is concerned with theseverely disabled or dying, but care is also given to patients dis-charged early from hospital and day patients.To me the most enviable features of the scheme, com-
pared with the situation of Britain, were: a wider range of pro-fessional and supporting services are under the aegis of a singlemedically administered organisation (including, be it noted,medically trained social workers and home helps) and theesprit-de-corps and high morale. There is fierce competition forvacancies, notably on the nursing staff. Calls are made on theservice equally by hospital staff (to accelerate home-comingand support patients who are to have day-surgery) and byfamily doctors (to avoid admission). My impression was that
in Auckland the extra-mural hospital makes it more likelythere than in Britain that planned supporting services willgreet the patient arriving home after discharge. I hope that aformal evaluation of the work of the hospital without wallswill be undertaken and published and that it will lend sub-stance to the impressions of my brief visit.
E. D. ACHESONProfessor of clinical epidemiology, University of Southampton
United States
ADVERTISEMENTS ABOUT MALPRACTICE CLAIMS
AWARDS for damages in malpractice and accident suits havereached an all-time high, and many recent settlements havebeen for several million dollars. Since the damages are decidedby juries, the insurance industry has been running advertise-ments in certain papers deploring excessive awards, and askingfor restraint from the general public. Many lawyers havepecuniary interest in the size of the award, since they acceptcases on a contingency basis and also deduct their costs fromthe award. William P. Rutledge, a Louisiana lawyer, decidedto take on the insurance industry and brought suit againstAetna Insurance Company, Employers Insurance of Wausau,St. Paul Companies, Travellers Insurance, and several otherlarge companies which specialise in accident and malpracticeinsurance. On behalf of himself and the contingency contin-gent, Rutledge sought to restrain Aetna et al. from runningsuch advertisements. He maintained that the advertisementsunduly influenced the jury-in short, they were neither morenor less than jury tampering. The case was heard in a U.S.District Court in Louisiana, and three months ago the judgefound for the defendants on all counts. He ruled that "becausethe advertisement contained statements of matters of public in-terest, there is a heavy presumption against the constitutionalvalidity of any prior restraint on their publication". He wenton to say "speech is not stripped of the First Amendment pro-tection, merely because it is in the form of a paid advertise-ment".
After this vindication, other companies have taken to usingthe Press as a means of informing the public about issueswhich affect them. Thus, Dresser Industries got EdwardTeller, the nuclear physicist, to argue against some of the moreextreme views of the antinuclear campaign.
. TOO SENSITIVE?THERE was despondency in many quarters when the news
broke that research workers had identified nitrosamines, pre-sumably carcinogenic, in certain brands of Scotch whisky,though not in others. Considering the methods of manufac-ture, this revelation was not entirely a surprise, and in thepresent furore over nitrates and nitrites it was only to beexpected. The presumption seems to be that where there arenitrates and nitrites then there will be formed those redoubt-able carcinogens, the nitrosamines; and now they have beenidentified in small amounts in all sorts of substances. The
thought that they are there at all worries some, and othersworry about the means of their detection. Perhaps ourmethods of detection, of nitrosamines as well as other purpor-tedly carcinogenic compounds, are becoming too sensitive. Foras sensitivity is pushed too far, through the ingenuity of ourchemists, such compounds are found almost everywhere. Evencertain carefully prepared and tested diets issued commerciallyand used in dietary cancer research are now suspected of con-tamination by nitrosamines. If nitrosamines are to be avoidedthen our diets will have to be drastically revised. We shall haveto modify our drinking water, particularly when it comes fromwells in the countryside. Spinach, lettuce, radishes, carrots,potato, beetroot, celery, aubergines, and various greens mustbe eliminated, and so bacon, ham, sausage, dry cured meats,cold cuts, all smoked meats and fish-just to avoid nitratesand nitrites.
