715 Letters to the Editor THE N.H.S. IS BIG BUSINESS SIR,-Dr. Seale’s article of Aug. 26 is like the first glow of dawn on a murky sea. Let us gi...

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the Editor


SIR,-Dr. Seale’s article of Aug. 26 is like the first glow of dawn on a murky sea. Let us give thanks that such sound sense comes from somebody of authority and wisdom within the Health Service. Let us give even greater thanks that the memorandum on which his article is based was submitted by request to the Minister’s Advisory Council, whence it must surely reach the Minister himself, who is wise enough and big enough to take notice. But I must at once declare interest. I am a management consultant, responsible for over fifty hospital work-study surveys in three different regions. But just as my organisation was getting absorbed in hospital problems and I was convinced that my survey teams could make some impact we were virtually banished by a circular, issued by the Minister’s predecessor, forbidding hospital authorities to engage and pay outside consultants from Exchequer funds. This same circular encouraged regional hospital boards to appoint one work-study officer each, whole time. Remembering that a team of four work-study consultants took some five months to cover the domestic assistants, orderlies, and porters in two hospitals, I wondered how long it would take one man to survey all departments of a hundred or more hospitals. The numbers of work-study officers have since been allowed to grow, so that the time needed to cover the hospital service can now be reckoned in decades instead of generations. But management is scarcely touched at all. Dr. Seale gives a fillip to my conceit by confirming some of the gospel I have been preaching for years, such as that the N.H. S. is big business and must be run as such, that it lacks the equivalent of managing directors, and that there is a lamentable resistance to delegation, particularly financial delegation. But his recommendations go further than my terms of reference have ever taken mine and show how the central planning, administration, and finance should be overhauled. Until this is done the hospitals and groups will have no authority to look to their own internal efficiency, which some group secretaries have long been anxious to do. Economy, Dr. Seale rightly says, is not an end in itself. Money saved should be used to increase efficiency. One of the reasons why the results of work study have tended to be measured in terms of financial savings is that efficiency cannot be measured by any recognised yardstick. But a way found to do things more economically is nearly always a way to do them more efficiently. A rough calculation, based on the financial results of my teams’ surveys, shows that the hospital service could save E10 million a year on ancillary staff alone and be made the more efficient for it. A useful sum to apply to the purchase of quality. S. J. NOEL-BROWN. London, S.W.I. NURSING CURRICULUM twenty years I have lectured to nurses in medicine and marked State examination papers. I continued to do them because it gave me ideas how students in other hospitals answered questions and I am often surprised at the amount of knowledge they have. Now we are to have changes which neither the medical profession nor the sister tutors have had an opportunity to discuss. In future medical, surgical, gynaecological,



and other subjects are going to be mixed up in two general papers. For this reason I replied to the General Nursing Council saying that if this was so I must resign because I am incapable of marking gynxcological or orthopxdic questions and probably also surgical questions. I can see endless disputes between the medically qualified examiners and the nursing examiners if this is allowed to happen. Even at this late hour can we not have " one general medical and one general surgical paper " instead of two general papers set by an examining board of two nursing tutors, one physician, and one surgeon ? I feel sure this would help recruitment of examiners, although even so I can see trouble in the joint marking by a physician or surgeon and a nurse. Miss Louden (Sept. 2) raises other points. She says lectures " are given at an arbitrary " period in a nurse’s training. " Arbitrary " according to the Concise Oxford Dictionary means " Derived from mere opinion, capricious, unrestrained, despotic: (Law) discretionary". Presumably she is using the word in the legal sense; if not I can assure her that sister tutors choose the time for lectures very carefully. I for one would find it difficult to give as she suggests an elementary course early in a nurse’s training followed by a specialised course later. It would certainly mean more lectures. For some time I have advocated without success that staff nurses should be given postgraduate lectures and indeed that they should have the opportunity of getting a certificate equivalent to that issued by the midwife’s board; and this should be in a specialty of their choosing.

I therefore summarise criticisms:

by making



(1) For the sake of the nurse and the teacher, we should maintain a division between medicine and surgery. (2) Give the State-registered nurse a better opportunity for postgraduate education in a specialty of her own choosing. R. E. SMITH.



SIR,-Your report of the death of a young policeman in Manchester from heatstroke in the operating-theatre (July 15, p. 164) is a further reminder that the microclimate of the unconscious patient, unacclimatised to operating-theatre conditions, and lying in still, saturated air under the towels or waterproof sheets, may be more severe than that imposed by the ambient air on the conscious occupants of an overheated theatre. He is not in a position to do anything if the mechanisms which regulate his body temperature are inadequate to cope with the heat load. Harris and Hutton1 also reported, from Guy’s Hospital, three similar deaths-of a child, a young man, and another patient whose age was not given-in July and on days which were warm but not excessively hot. One recalls a query from a surgeon in Singapore as to whether atropinisation of two patients before thyroidectomy might have contributed to their demise at operation. Unexpected deaths in such circumstances, particularly when there is a sudden change in climate, are perhaps more common than the hospital authorities suspect. Paradoxically, it may be more important for those who live in temperate regions to be aware of the dangers of climatic excess than for those who have lived with a hot climate all their lives, who are fully acclimatised to its

vagaries. The

patient’s condition is only part of the provoked by a lively correspondence

years ago, 1.

Harris, T.


story. A few in the British

B., Hutton, A. M. Lancet, 1956, ii, 1024.