9 CkrAef cf' Curative S.:ryices, .F,!SLdstry :)r" Bealth, Serolsalem, Israel

The c;.caFe of actlvl%y a2 ! ~ o s ; ; i ~ i s , wh;ic:pr in mediaeval 'L;lmes wera

UXFJ only exictiw medical insfStutions am3 2s such of m a t imfmstame,

ha? %%nee ex~?ended to embrece co-ky activities of a -?ubllc healkir

mt.ur*, ';cs-?litel z&%inSs.tlrators ape sometims at a loss to c o p wit21

the b~-o&ened scope demrded of then a&- do no%, alicays understand w ~ m t

we M r g i o n of a hos_3i%a3. sneuld be within me fra~ecsido~k of %ire

general tieal%il service, %n actual Tact ,, however, :~ios;:,ttaLs, even If

unaware of It themselves, haye always constituted a p ~ t 09 the

c o r m d t y ;;ublfc heal* organi.,zttiorr arPrP have always :,J..e~yEd their

gzr t in salv2ng We egidem903ogScal ?I-oblems of -tP!e t h e , FOT insta~ca,

as ,won as M e ser~ousnesa of infectious dtseasss was realized, e e

hosa;ltal selivlees ,~ar%i cii,ated In their ix.ea.tnroenC %solation, Tne

e- idcniofogical situation izas zincs c,~an$ad, I~owever, and we a m now

rnore concerned w i t h uhronSc disease t:m wit21 infectious disease,

esjecislly in the mre devekoped cowtries, 32_mr~~f l ,ospitals are

now :-lay$% GisSr ,art by i~a~t ic ipat ing Sn 4k~e treatment; 09 acuk

e ~ ~ c z s ' h . t ~ o n s of c-bofic d i se~se ,

In t-cceilt years, inclleaoed demands zave been made upon huspi%zls

by %iie ;;ub1Sc :ieaLE~ a u ~ i o r ~ l l e s , and. 4he time uas come for a re-em-

lu t~ t ion oi *.e fun0%2cn of the 3:os~ital witciin tize general hes1t;h

::ervice, The first. question bcAich arSses I s : : should c o m t y

rredloal care be hos2ital-opierahte&? 1% would appeal= r'r.eferable for

%Fie hosy;i-kl h be 2n%egrakd into Kiie general flpanaewcrk 02 a l l %he

cornm13t.y ihertlt! cervices, rather for -%hose services to be inte-

grated in to the tos:~ital , To overbaden the hospital with too mrsly

c o ~ ~ x d t y zervices m l d only defeat our allus,

It is s~~ential t o htIffe~'efit3ak~ k%tr'eeri l:cs~lkals i n rural al~d

in ufban arease In rura l areas, co;mmit.y azre would i;erhaiis k most

aifactlve if it were orientated towards the healk? cectre ra%her %L~an

kwamh tha mal hoayitzl. T-;e hea1.f;- centre is an e;lcoellent mecllum

for co~rd5nsting a& pmviding both the curative ard ?revestive aspects

of general aedical care as well as, to some extent, its ,;sor~otive

es.?ects.

T; define: 'bealtii ceatre" was an irffititution daae resdiohl

pzact . i t fo~ and general nurses -provided k:e amplets range of aaedical

servlcelr af -oh they were aapGble, birt rm fom of specialized service,

In the "rural hos~itsl", on t ! other Id, t21ex-e war a oertdn amount

of s-:eeialisat$on, aoooxding to the sy\ecifio disci,-lines. P11t310ySr

that did not %-&s apgly at -sent to all coztntries, ~ i t h develo?ment;

a certain degree of s~eaiali-ation would result even at the level of

r w a l &si~.l;als.

F-ma1 hos9ita3.c usually 1orve E tcx?ll-defiine0 :m::ulatioa. In tke

f l r z t :lase curative mediainre,is an essential feature; it is &LC

nscerzsaqr even in a rural area, to furni& eroer&enoy ~ervSces sad to

5. wlde for remblllta~ion of patients, waich forms a hte- 2er-t

of the duties of m y hospital. In the aghexe of ~mmmtion of health

and srevezttion of dimam, the rural hosp i ta l I s bettar emglayed an

a c ~ ~ ~ t a % % v e level ratiutc then ta mmder semriue dirscrtlg, It car-

have a a e W fnf'lueme on tht 0031PUnity as CL Wt1o1e, but it IS doubtful

whether it o m have anpr reral influence on the individual

0nX.y briet :~8riscts ia the bapital. The xwml lms?ifrl should &ways

e w a u r tro WPk thxwugb tha geasral waatitioner and the m 1 e

bath mse mt;ber tnsn to render a direct semi- to eoaawlity

nit!!% ths of thO- ~ W Y ) > ~ ' o f e ~ ~ i ~ r F d m j 6 m If i f real&,f

necessarg far a imam to attend a hossital in order to rsosltre anterr9tb.Z

aare? In rural amas @spectally, '?osg,itals are generally at scum

&t~ta#e, and It is usually easier for the mother to &o tb t2:e local

health centre or for a mobile team to v i s i t her villa+g!.

It should be the dutg of the obstetrioian to ensure that the

general -titloners in the district are ccmpetent to provide anteratad

care. The caedlatriciao &?ould be an ex-pert not tmly in ourative

nwtters, bat also u CU& questi-.ns as the gr and develogmenit of

ehbldreaj he dlr~uld ac& as an adviser t4 the gempal ?ractitioner

rather tiban as a ilirac* giver 2f ~dvice,

Even at %he w a l Level, htspitals are .yrticfpating fn the fa&&

~.gzinst the syread of c~~amunhcable disease, a d they sh~uld ~~~~~~~~c Ibe able t3 kc~?piltelide mch caseso

In a t P : ~ ~ . c x ~ R@ 3ne p:%~lt of extrerat irag rtarpce arises, namely

n2tfficaticn zf e d c a b l e disea~es, W need far .hi& cannot

be sufficiently etresaed. In maqy ins-es, the hospbtzil is

3irst :)lace in vMch i t is reeli~ed : diseases I s of 8 c:maurbcable

slture knd it i o theref re ,f !~rimary i m p rtcznce that it sh~uld be

tT I.. re ,:P the necessdty f .r speedy n ;%if ic~tisn qf inf zctiaus disease^,

H-:.iever, experience k-s slteo.+n khat such t m t i f i c ~ t i c n is "ne .f the

.eekeaQ servlces encounee~ed in RospZ&Ls, ;LfcC %end t o cverl- .k

fts impwtanre in the. fight egainst c.-macrtnicable diseases.

Another duiry :f the mral Baosplkl is teething, "n a very limited

ccrzle, and espec5ally the t.ea?hing ti' nurses sr nursing &ides to

serve in rural smas, %%e wr:blem 7 . f finr3?Png g i r l s ;f sufficient

adueati. n ti1 ucrk in m-rrsl areas f E a r.: rld-wide c m , and the best

so~ution ?erp%hzas Is ti. be f m d in tecchbng and training girls

1 .cellyo

'i4fa regard to the relat$~nship betveen U e varicus services

:ithim %he mral k o s p i k l , St is necessary t~ think in terms ;f thPe

mrximutn coordinztl*n :.ssAbld k%t;;reen me curative, preventfve, am3

?r-;motive as:jeete, psther ?&an i n terns sf ' ' integrat$~n~'~ ~'da1c.h tvould

ayjear 'ts imply integrati n v.ithiaa -ne bndivichml, 1% is doubtful

:&ether ,.ne nurse can carry out all %@c- dtfferent sspects >f nursing

fiiewiee. ICE, hc.ever, the rnacimum co-rdiraatbzn possllble betmen

&cse rem4er service f r c m tihe bospieLl can be reached, then

much r ~ l l l have ken ~chieved,

In ~ ~ b e n crresc, t-w l~icture 9s entirely different, X n order to

~ c v i d e a regioaal kicz;ikl service, c~+renaely compliw1ted clinical

tac?&eal ~ervioec !?eve t o be .zWntained, tJrbw~ hos:)itdts

r w b "emre a e l l - d e f M ;~;~ulatdm, different deyarbextts wftiin

the ~aem -%s--i%al oftefi s e m d$ffezwnt w:&atiaui. 3-r e m l e e

tne nors mrmuly a:eciali;ed servfces, such as neummwqgsr~r, obviously

:,WVG r: nuah larger .:c:UakLon t m deyarbmnta of M e i c s or

.zleblcirx;-,, l he urtrrii has2Ita1s hage becimue medical cen4ms far

&zgm:.le, constiltation, adlriee, and for giv iw s!m~ial -6 of

%reafasnf, Jn rm instances, hotsever, tmaubnt mi at least be

oonfimed it Ln ti& framewor~ of the camudty I s e a t sa??~$ces - a c-c nh2ah -Mr tr3Ean ;lace over C;e ,revXous 10-p years,

yearc trtc =.rhary fluaction of a ?~sfi.t;al :as ia gi fe / e t m e z ~ . t ; ~

!<:ow it I s rather to srr lve at an accu-mte diagnosis rd;loh, in ismy

'=US, iE *e U W S ~ a a u l t -at.t of medical m0 ;:Ski t??

&ant of ~sdar:; tkemk,eut;-tc8 it '?as -oecoara c:uc:r eetsler to tseat

ce-c ~ , r r o i f 3 e 8ilneat~ and. t:.at In. lles t; .e dnteraace of nsag.

&tfferant a:mcldist services, :n a&c?iti n t3 t.-te basic seat;ioes,

Fn t!& larger *baa hosp2tala e. u%d.t', variety of s y e I a 1 I ~ t clin?-c&l

do?artmmts lurs .i;o be maiataineCs ae elf. as sjxwialS& ssrVioes anr?

equi-?mnt, t.?Ac.~ are oftec~ very delicate and exr~tmsiwe both %x tmy

and to

Zueh a aitustion aaturallp changes our a%tdtm&

f:ncU3nr: o f these b s i t a l a , and oasc c"iz*s to be exeroised mt to

&eat hmulX33.y the atsndsrd of &,~ecAal3c;t servloa *L,WA +,bey are

equl ed to orovicie. T b y have beeom ~1(3ntras for consultation,

boQs for ik.:atients and for out-i;atfen.t;s, arrd ses"vs as a wlnt of referr&l for the mom rliffidt aaseso If, therefam, urbanr-osgitals

are brudened w i t h ;,roblars wr~iah of;lars cas solve, &ray d l 1 tm longer

be able to solus &lose u , i c ~ ~ o-rs cannot, hther of

Leir tasks is, of course, t o provide emergency services,

'.,hat is ti;e role of' urba_rl :los,itizlc uit..in tdie framework of $we-%

ventive mdlcine? One im?or%ant service is that of early ra!iabill-

%aLSon, &Sen lays a most important part when one of tne mln pro-

blems fad* 5 r c!-zonic disease, The urban ~lospitals are also

rsquired to serve in a consultative ca~acity elor such medical services

ae antenatal oare, :sxedlatrics and cni ld guidame, They .too have to

be orepared to atsaept wases of conoaunfeahle diseases and to noaf'y

%hem imnediately ,

Tlre urban i ~ o ~ p i b l ha6 a m c i ~ b d e r role to play in teaching

than har Lte w a P hosp2ta1, It can and should ~ L l c l p a t e in

teaching the medical profession itself, A l t h o u g h not erfl urban

hospitakare university hospitals, the un3versities would be well

advlsed to make use of We rrtch clinical makerial existing in

ul-ban !i3~jitals., Thr~~g' i lack of opporCUntw, students are Somethnes

d&:.vriW of chance of seeing cases wclrtotl tl1ey would often nave to

treat lafer i n their grofessional l i fe , tbilst in a centrali~ed uni-

verslty WspPtal they are l iable to see a more special%: ed fom of

aixrology udeh they w i l l be less likeLy to see as k.?e general practi-

tioners of titie fhture,

Urbarl -~osptta ls should also maintalin scnoals for qualified nurses

snd rkouLd ~ t i c 1 : j a t e in tihe trafniry of laboratory tecrmfcia~ls

radi.ogra.-icers, phisioklserapists, occw-mtional tilerapists, and so on,

:nah.ier of their impor%ant flmctions Is researcn, In recent years

>ractfcal research has assumed such >roportions t ~ a t sometimes it is

5nterfering w L t h the m t n g of tile hbs~itdl and b e treatmen% of t&e

iakilent, A certain balance has %o be reached wuittrrtpby the wbmh hos-

nitxi1 carries out clfnlcal research, In order that tile stambrd of

medical aare wiL1 not d r o ~ , and mtici;~ates in social EIld e p S W o l o g i o a l

i-e~earck, Once again, care si~ould be eiiereised not ta inteepitxi a l l

L-ervioez witilin the howital, but rather to Zntegrate a e hospi.f;al ser-

v i c e s wf thin tre general framekork, 'Rierefore, as far as social and

enXdemlologica1 researc:. 1s concerned, %e general hospitals &ould

usedg htr .~nJy ePt , (~ r carefi-13 51 armfng a ~ d when ill1 ki~e poss3bilitiss

' , 3 JF. "src.7 ecarniaed in e c h z*u:-.

1:caernl -~r)s;it.al s s. auld :~ave 13- - atient services, 3ut-;atie t

sarvices and emer&em;F services. in iut.tri areas tL:2re s .CU d always

be certain basio 01irxLcai de-wtments, for exangle , medicine, surgery,

obetetrics , some gynzzeco ogy and ~~&ec¶iatr2ic9, tciget :eP rlt;; th-e medical

se~vices required t:, maiiltain t ern (radia l o g , laboratory, ;atc.o;agy,

and so onJ The vSo:. :.as of te l been ex~mu!-~ded t st, in ordar to

. .ave cc zsn.,lefie srgsnf ,-ation, t '-re s auld be, i-L adiiit. sn to t A?

deyarknents 3f curative W c i l : e , & ac, mate de: t ~ t r & r _ t of i>reveiltive

medicine, but t n ~ t tiauld only defeat our alms, .qo:iever, O-rbe

service st ould be separate from t - e pk ers, name-g t a sorvios of

-:ubilic heziit, nurses. LCucii a serviae s ou!d a t e frm tile

;:gspital and t. is c&, be ac.,Ieved if t:-e directel- or' trls hos;ital

as e$f?orienoe of --lie health and is competent to o9ordinuta *e

differeat ilulotiws.

Urben nospitals sl~ouLd aontafn vmious s p e c ~ t i u s in n M i t l o n

to t.ie basia oliniml services mentio~~d above, It I s imposs%bLe,

L.wever, to gamr8lLe b u t tap nature of sucn speoia~tLe8, slliicn

vary acoording to tile needs of trie area. Soane of trie more c-nly

required speoialtaes, sw?n as op~t)almology and ear, nose ad tmt

disesses are eveu to be found in a s r h ~ ~ ~ sasaller urban n o q j i t a l ~ ,

In l a r g e r -,ospitcrls, t 1 8 h .ole ga;nut of medical services 1s LA fact

provided, e.g. !:wcEali~ed s u z * p r y , sdcir as cardisc a:.d :-eurosurgery - naurologp sud . ~ ~ ~ ~ d t o l o g g - and tilere is evai. som .ly,.erspeeb+iuation

CU suc.~ as, for h s k r ~ c e , ezloarinolog - &&:en agti., , -dbl ,,. s;-LL,d

;r?vide snecm t 2 m Y m t i a measures, for example b# radiotclerayy,

isotope tbsrasr~~, aad so on*

In-patlent serviaes

Should h e y be organlsed aceordin(; to diaoipline or aooordSag to

rawsing units? If the latter, it is far easier to f i l l trle available

beds, and to solve tile pableat of one specialty havPg vacrw beds,

while in other specialties wards are overcrowded. LucL1 a solution

ce?z1y~o.l, hawever, be ?mctSczlLd- 2;ylied to Ulc 3,stem hmditemanem

Region, 1"m t,~ere SIC mJarity of tne I l osp lWs me orgs-.?~&

wocrding to the "closed staff syatean #nick does not a32w for er

6%:- .ercaf of -atletate l a t o a f f e r e ~ t EUI sing u,d.ts,

T!e q~eztfon of ::ro@-es~ive :s&%cnt care is a very & ~ o r ~ o w ,

,'sl&Wgk c-:eciel ;;mvLoion e!muLd be made %a -~g"ov$de Snbnaivo oare

for thoc.o In need of it, e,g, Lhe uncto~cious or Che exkrerpely ill ,

t -e come ,t of :m=essive :%tSea-L cera is not pr;ac%ojl Lta Km Zasbrn

aterranem EegSon, T .e question was t i~o~ougdly &~au~sed et tile

:intc??utLiona.I - :oe:ii.t;zl CoMerence held Z n IhL1 . i~ in C l T ~f a s yesr,

end, st a result of its dallberatians, even the proponents of auob

cWe :lcre left 1;1th doubts and resoLvd f;o examine the a3tuatZon

afxwrh,

;lltfibol the se%tbni; of Lqe Easbrn ?&ditm~ramm Reg;lon, there fs

tc?erefo~ really no ttl,ternative h% %a allocate pat1en.t;~ by disolp12nee

.",l%hbugh it 3s difficult to Cecide bat a wkient "belongs" to a

given & ~ o i ~ l i a e , mvertrieless trle6.e w e broad df 2201 sixes between,

Tor instance, medical care eLnd. c&re r?et@tia sur@cal intervention,

Oubpatient services

Out;-,mttient services have been sstabl2s:led bg mest hospitals -to

cclunter the accusatioss of being fv0r-v 'bowers, but t..~ pemlulm has

erhap~ c,wung k m far the o i h w ;ny , 1 f general out-pt,ien% servides

are lgkdo unlv~~?&&Lly available im Lie public, they aan destroy a fios~zitel

by overloading the mdioal servicet; #:tiah are its llodt e a s m t 1 4

Peattare, LW care should raf;ler be _rulav$ded w2-thin the aonatnity,

wiP,.? Zialson between the general practitioaer and the epeelalib-t,

and %he outpatlent depar4atent c2blml.d maintain a consulbtive chazact%ro

Aft@?- dl, the hosp2tz;l is used a8 a aentre for diapnosis, because

i% oontains skUled, man-pober and spa3aliaed equipmnt, t,le&e I s

no want in usiw it to solve problems tat oan be solvedat a Ufferent

level, Qub~atltynt se~vices &ou;ld canprim at least tAe same

d l s a i ~ l i n e a as the in-~atient dei~wi;mer)..0.s, eud in some fnsLances it

m y be faund necessary to have only an ou-bpatiert departmeat pro-

viding speoiallat services on a consultative basis, tag, ophthalmology

ancP o ~ r h i n o - l a r ~ ~ ~ l o g y ,

A vaS~ab1c service that can bc performed Qr t:le oubpatient

deigarttwnt is the elfking of patient& sent; for admis-,ion to tl;e

:aos)i&al, It is well b w n that once a person is edmitted to hospital

he does m t get out a2;aSn very qu$ckly, '%his 5s me& in no dis'gara-

g 9 ~ :.sy, for there is a certain legal r.espons;3bSli%y +,o perfom a11

nscesszrg exarminations to eliminate t-e possibility of mthology - but me:? kos~itali;aG90n can be prevented, dtb conceqc,ent saving of

waluabLe bed %,me, if the out-@tien% depax-bmen% 16 used, :Liere

7 s . ~lble, in reaehing the dec3sion hilether Oo nospitali,e or not,

A %y-rn of service which it has been prol~orsed in recent years

a:zould be taken on by out-patient depwbaents is mass screenfng as

arl; of tile :.reve~;Live nealth services, IIOk;eoer, it is doubtM if

=uc.- ‘ark car; really be sers"or& icost effect5valy at hospital level,

me ir&!.vidual ,r,raotitioner, even at tne health c e n h , ultt i~ his amre

erzonaL. knowledge of the gaLient, is perhps bekter plaoed to carrly

2% out, W%tii,out g o i a into t h e ptles.i;iort of the effScacy of mass

ncreen%ng in gemrel, 2t cl=cdld merely be suggested UmL Lie out-

:.=tien% do2artmnt n 1 5 ~ t p e r ~ a p s 1Pa umd for spec3alized screenzlng

after general seleation by the family doctar,

The mrgerzcy services that m t be grovided by all general

hos3itals are extremelty iliipoxtesnt and dmulcl be rm by ni& skilled

:s~..connei, not, ,mshed into a comer and delegated to a Junior as t o o

often ha~~pens. It ic 5w %lose very services that deaths aoour which

aould be _rrevenf;ed given M&er skill, The service silo~ld be available

day might, !Mch makes it s o u e w i ~ t onerous, but it 1s a dlrect

c o m ~ t y .service the hospitals cangot be absolved frm providing,

PGhe ;;roper place s*or we fQ11 r w e of emergletmy services is the

wbtm general hospit;alo kMeh alone ha8 skilled persomel represmting

all the -;or ddscbplines,

Central Eiedf cal Services

Apet lrom Q-ie clinical discFp19nes already ~eferred to, o e r k i n

nsdfcai services ar.e ess%n-i;ial to large general oeyiial, e,g,

chemioal, miarob~ologfcal and haemablogical laboratories, as as

&he radiological depar?aenk, :;ospltal planners in the pest tended

%o tngnk hn terms of mbers of b d e , krt boktle-necks often occurred.

thraugh the elristelace of too mmy beds in reLation f;o the adsting

rad30logical and lelboratory servlceg, -5. -wtl~olo@ department is

also sr?, i m p o ~ h n t 2 ~ 2 % of every hosgPtaL a& is of course indfsaensabbe

for kaching.

Bl-pd Ban;;

A blood bank is no% always essential, esyecia2l.y in urban area&,

where a reg3onal blood bank organization exists, Wt even L a such

cases are hospital should a% least Fave its o m blM-mWning service

4a prtvenk We acciden%s rkioii o1;'%en o c c m d with transfu8ioas,

The ~os'a&ion of tibe dental &epashaent. w$%hin iae hospital varies

frorn counLry to country, A1U1ough for pwposes of cotlwiltt~tioa it.

is nsceesam to provide a dental clinic ratthin any general :hospital,

care should be exercised t o prevent ft f r o m becodng a general dental

serv&ce, #hien should rather be provided witldn the cosanunl* t:lan

within ,rosp%kl,

In former t ines great stress was laid on nauing a hoap3tal $ ~ a ~ m c y

equij~ed ta arepire all the fndiarSdual peparations .t;hsC were prescribed,

ikr.adays, when most preparations w e specific, it is more iriapor~t

Plo emwe t ~ a p-ence of a pharrrraclst r d t h a wide knowledge of all

the rknge o f pmprietary drugs now on %he asarrkst,

n f tnnoz-ta;~b c e i ~ t ~ ~ a ! m r v S c5 In k ~ ~ e nospital. rslore proper

uikillr;;:=fi9x?. m-ses :.<cine ?i-ob'l,.3ia; I s i-:i:e social service, Tiie social

wcr;~er z~ouLd ba 5x1 e_i;i.?r;. ~ 3 9 ?.ik s:%i:Pai w o b l e ~ s Involved in medScal

,-..- . e,c...l, ci:& ",j:-,~t~tj. not , ~ r . , l v i a ~ dji~i~ci . , : : ~ ? E - ~ J ~ c ~ I ; %a ti;.* c ~ . + , Y k t give

;1ri119 c e %;c aorn*~i~< Ly ~ . > c sol-kers oa tile s>$cif ic 2roblems of medical--

: :,cia!. -.;ark.

:.'-vsic+-l:era3y aj:d occu::ia",h w:;A t.-cram services are necessary

f up r e ' , ~ h i l z *.a-c i - c ) )~ ,+oi.'i .,

:i~*.t>t,! ~ a r &r;Seti t..%:-i sc r v . ~ c ,:. i s cc.;i?_tt.;*:! sfcerf la su-c;>ly, a e day -

;;;5~ jri)fle v.Tj%a ; ~ i . > f 5 ~ < ~ ~ r;;.:i! 2 ne tmi~: .10 !,+asi.e their t h e hiling

'j:l-i:: L-. G , ! . , : . .. 31; . i c ; L L : r ; ~ l e l ;:E:.Y.V~(IO~ bit Gie ~~aes-bion zrise,s . . . 3. . , : . , i . . : 9 - e t is of coilrse oft-:.

*.;i' ~i -es i : mebf,-,.--i I.~;lprr*i.s!;ta, b:$& t'-.% LL,PF ? s xio :3e~d Zur t~i& dietxciarz

a<: t;u&~. 1 J t,q ycy:,p -~t-,:;.l i F. p.r.-:, $3 -+: , . ~e ;j_?eLlt?ncs - chis i s a hrt;ier

pxafi .:e of ?.be j.y :+. ;;, o.~er--- s&%erpirsi.t;a t d ~ n & k i l ~ i l can dt-:sta?oy t.he

. ~ q ? a ? ~ of f,ervfc: :.

; y : e d i 6 a l fiecords and S&.trs%icc

in adkiition to the foregoing wdical services. m-n central

technical. services me needed, a&i amng them the tmdicsl w o r d s

and statfs%ics service are very %mLm%nt, Reference has already

been mcde %o m ~ ~ b i d l t y Lurveys in ics;%l;als, and the e x a m t i o n oi

r ~ d f cal records CUI k a useful means of carry ing kern out, fut it

must, be o~ganizec? on a sound basis wi* t.rle rdnimum of afferent forms

and re-6 peraitting an accurate ailysis of the situation.

Phe supply services ahcdd rmder8ta~d the mquirpments of the

different depwtwen-bs and ensure Cxtt they have w h i t they need to get

on with QL?iefr r.ork, inate& of acLiw merely as a pmx!urement agemy

on request, 7n o'(;her words, "supp3Aes should bs supplied", There

C'tbZ1Zd be a r o e l i org&ted c&n.i;ral kitonen able to pmvide ho% food

w ~ i o k ii~ really iiot W - even mare i m 3 r t ; a n t ia tropical countries - food hid: F a d b e n kept really w e l l chilled, 1.hroh cPiarrhoea

occcu-rJng amng pttSen%s addtted for entimly different masuns

miy be due t o irn;~roper facilities in We kitchen,

&intermme

Pro-per dnbnanoe se~vic~s are a t m e form of "preveni;ive

&cinem for. the equlpmnt of a hols~itdi , Too often mintenancia

depzsrtaents kave to undertake expensive repa3rs that oould have been

mideci b mPod2c e);~mLnatlons~

Per some1

It is im~ossible +,o r"bd eta29 reaiiy-rde for al l tiie coaplex

taelrs t o be perfom0 fn a m&rya ~ros.pits1 and anrangemn'%s must, be

mad8 for in-service training, as has Long beeii aacapted bj irdustry,

director, what lsattsre Is not :::zeLer the I;arsozi cofiaemd is a medical

:~raati tloner or not, but ;&ether he ram a trospf -1, i?;ar~ lay-

admlaztratora c a r da so very w e l l , azz if there ic m d e a l director

the ,uxab:err of medlaal. supervision can be overcome by u t i l l d h g the

samriaes of tLl-e cliies" a? m e of the services, ::owaver* conslderirkg

a r\-oc7;bta2 in relation %o the Broadest fbnctions as outlined above,

the oooMmtion of all eervSaes nu& be entrusted to a medical m,

:,hetker lie fs called ~ E . F ~ c ~ z ? or mt, Ano.eher irlfp0rPan.t; person i n

the WdnisWtion 02 a nospital ic. the chief of the nurshg serviae,

and e trAuavirate of ley-addnibtrator, medical dfrectar arrd roiSef

m s e cttl bo considered an i&&L dlr%ct;ing bodyo

:a3t FdapiP;als in tile &stern ~ ~ L e r ~ ~ ?iee;ton w e under tile

oont~ol of ths government or d c i ~ ~ t 2 i t y , so the question az*ises

whetlher it is really nedessary to have (L Wm?d of govemuors. Jven

in a state-owned hosyiteL1, however, it is valuable to have hie public

ililvolved in I ' ts woWems, Th%s aan be achieved by sopre kind of

b a r d aansicting of lay people p ~ o d m n k in-publlc lifs - for emmple,

etie looal w a r s or trade union 1eeder.s. The mediaail off%aer- of nealci

s:i,auld be an ac&ive masher 03 6"3s board in order to ensure a liaison

bekreer; the general healC~ services a& W.e hosp1ta1,

CotlppSt%ess &ad Unes of Authority

SneciaJ. comitteee t;o deal. asitxi oar3ous a&inis'&atlve mattars

do not usually grove succsssf'ul, 1% is betkr %hat the &rectors

a t the different departments 8 b d d have cle-cut authority, Perhaps

cr l le f t cf deal demmenks r!~ould r arm or be represoneed on a

senera& nwxkkcal a o d t t s e , b% the mdical &rectos?, if tmre is one,

:Aou.ld be i t c c ~ ~ .

AnoLher question related to aanageuenk is how lines of authori.t;y

should run. Lhaulr! tthe chief nurse of a dew%pe~i% take ordsrs f r o m

3ne !:eat3 of the nursing service, or s~ou ld she be under tile orders

of t e nedicd2 ohief of the &partPrent? E b t i i l ines of authorfty must

e-xi-t: G e chief nusse of s d e p ~ ~ b m e n l m a t accey:t *;rcl2essfoml

zii.tliorit,y frwd Lhe chief of Cce mrsTng service ae well aE &i&.stra-i;i;.e

~ u ~ o r i t y fkm the m d i c a i c-Wef o"l'L:se de:xwtmxnt.

Y EECLAL £3CW3?S

'turclng is of course a service tvhich cuts acmsc a l l the other

yervfczs in a h o s ~ f t a l , Tn vPerj of the s i : ~ i e of staff, it is

obviour that a31 nurses carno% be Belly qualified, and also tylat so=

mst & accepted oii a :st-tiat? Isasis, 1.t is also very important to

1m'k.e yrovltsbon for in-serv5ce %raining, It is g;elrera.lly accepted

t ;~et e newly qualifieci pkqrsfciw. in cgike of mly years of s%u& is

still not a rPulLy 2-gendenk 3 r o Z e s c l w i l k ing, a d the same applles

%o nurzes.

f~ few yews ago it was t!lou&t *-at %lie grovislon of' 3sjct-iiatric

semScea by t i e general l.ros,:lial. :;a€ an ideal salution to the problem

3f :>&yc'ilie%ry in %he ~~mt~u l l . t y , but it f s nors; xealf :ex3 that on3y

ce~ta in case? c m be treated on that, basis. Low far psychiatric

servdoe~ in L?e ge~eral -aosy+Lal ?lave a preventrve efgeo'i; 2n r e w d

tc s ; ~ n i c syo~:osis $in com:n,~.?~Tt~ re~ainss to bc Ce'ieralned, ant3

tl:atil Cxtn it LE dif f f cillt to ea;f wr,zbier evsrjl genera?, Lospltai

FA-ould -have o. psychPatr3lc depwtwnt or sot, In general the best

3 l a n seems t o be to pmvide f o p an oubpatlent psycilZabric department,

can do no ham, is no% vtry expensive to run uld does 115%

in;olve too deep a coizsitrnent,

Cira9ra3 hosy9txQ.s w e soae%tms accused of not p r o v l b suffiotent

rehabilitation services, 1here %s, ;loidever, a tendelmy to exa2;e;erate

the iE;lpoa-..tanco of re~~abilSta%.ioa as a separate entiky : If is a way

of &inking raUler kimn a separate d&soipl ine , There ciiould be a

aoneultaLnt fn renabilitation, bQ, he rrorhs best by i&lwncing his

colleagues to become rehabl2Ltation-minded rather than by miming a

te:mate service. mere ape also certain limitations 'to W.e pocsi-

bSlft iec of rebbilitatforz w i t h k n the framework oP' We i iospital:

the ?&t%ent o m t usuall;y be kept in nosyl.i;al w&il the exxi of tile

ve!1abili%at9an yi-ocees, including t i r e ? vocat9onz%l and social aspects,

,12 general IiosplLaLs should take dn caset, of conmaualcable asease.

1% I s :.asQefuL to establish special comamioabLe disease i?ospftals.

t'e1.y fes diaeazer cz3.1 for complete isolation; what is usually

requl~ed is ratner barrier nursing,

one-care Programes

3 . t i~ oiten claimed t.1a-t; ger~eral ZrospitsLs ought t o provide ilome-

care 3rogrwmes, k t i ; ~ e mtter calls for rs-examination, The best

>:o~e-care service for t;~e acutely ill o m bo grovided by the genera3

-wacU tionerc a*d We nurse. t.r:e.ther the hosspf tal & i d provf de

direat ~erv iaes for cl-a-onio aseases ria the camunity is another

w s t i o n , brt there 403 the problems car, bst be taken care of by

&he generel :jractitionei and the public -2ealLh nurse, w i k h tl?e

:.os.?itab available as a centre for special consultation. The pro-

~ % s i o n ad doailel liary occupatio=l -i;i'~emrty and physiotherapy a a r r f ed

out bj the Hospital as _oart of its home-care servlce seem a very

r.lastefuJ. aad expensive a2vangemerr.k. 1% is more effbof e a t b provide

transport far bhg5ng patients in group3 daTLy t o the hospihl for

"SAC5 treatment,

In )lann3ryg hosgital services impor%aat quesf;ions are how to

debsmine the m'oer of beds peq~iseh, k.ie disciplines to be represen%&,

etc. There 1s no universal solution, buk generally epeaking there

exist two basic rrteC~ods cf assessing nee&, %he yrospective and t r~e

retrospective, The prospective metirod i s long and difficult to apply

because of the ntrupr imponderable factors Involved - ~ o g r a p h i c ,

e c o ~ m i o , sooio-cultural, finally arriving at an aswsmtent of'morbb

dity patternc, The retmspeotive method, which conslsts of analysing

the exteint of satisfaction of de&s - occupancy rates, average duration

of stay, bgd turnover :$siting 1Psts, bottle-necks, etc, - is simpler

to apply, altbbugh the question of whether? beds are being used to

the best advantqp is of course more difficult. The ideal is

ierhaps to aktecqt a synthesis of &be two approaches, making both a

general rro~pective ana3yais end a detailed re%rospotive ~ s i s ,

2nd attsm9ting to correlate the two.

Once a decisionhas been taken on the scope of the services reguirf?dl,

the question of mgi~nall~atian arises. The t h e m of ~egionali~ation

16 strai~3tfor~iard enougll: a system oE keaith cerrtrec, small hospitals,

lager hosbitals, central hos?it;als, eta, dith a sort of a t a e

service bets;een ti~em. In ;;ractlce, i~or.ever, .tile matter Is ccmplicated

by suck .,roblem as hospitals being placed under different autimritieo

and dm, n o e s , increasing public soph.1stication. hwn regionall-

;ation ::a first envfsaged, the 3ublio b d Z 3 . S mcti less Interested in

tho organ%=atien of rnedloal services than it is fadsy and it may have

been easier to shuttle the M v i d u a l patient f m m one .t;y-e of service

to another as seemed to be indicated. Regioraali,;ation is an ideal

t o be aiaed at, hat -re as a mean8 of ooordSrratlon thnn as a system

ror wwiw ,wrtients Cra cm hospital to dlz0tk.i as sbsmsd to be

el;sorat5&%11 avquireb.

lb siting of an ind2uldud general hospital is o f b n for$u.tt~ousz

ctw3 l-&?pens %o be offered, cerwin services anvt awaiLable in tkLd

urei&burhaod, etc. Sow general principles o w 1 .to be observed,

Sirst* tne hs;~ i t ed should be cejnkrally placed - not necessarily

geogrspinlodlly but in relation to t.ranspo& possibilities, !be

m i g h b a u r ~ &mild be f ree of nuisaces such as susells, smoke andi