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1952 and 1957, of 0-47 per 100,000 for U.S.A., 0-49 forCanada, and 0-85 for England and Wales. This leaves usto decide whether the population of England and Walesis more affiicted by the disease, or whether the diseasehere is more lethal, the incidence being the same. Per-

haps our treatments are less effective, though this hardlyseems likely. A clue may lie in the hospital admission-rate-5-10 per 1000 in the U.S.A.,9 against 0-5-1 per1000 in Great Britain.1O The difference is all the oddersince in a nearer neighbour, Denmark, during 1951-59,the annual mortality of ulcerative colitis was close to thaton the American continent-0°5 per 100,000.11 In anycountry, death was most commonly due to perforation orperitonitis.NEFZGER and ACHESON 12 were also able to trace over

fifteen years the course of 525 men admitted in 1944 toU.S.A. Army hospitals with ulcerative colitis; and tocompare the mortality with 518 controls, matched forage, race, and rank, and discharged to civilian life between1944 and 1947. 10-7% died, compared with 4.8% in thecontrol group, the excess mortality being due either toulcerative colitis (2-9%) or large-bowel cancer (3-2%);there were no deaths from either condition in the control

group. Death from ulcerative colitis occurred chiefly inthe first year after diagnosis or immediately thereafter,while death from cancer came later. Moreover, thegreater the initial extent of the radiologically demon-strable disease in the colon, the worse the outcome. It isnow becoming clear that this is an important point, forEDWARDS and TRUELOVE 13 found a similar correlation ina series of 624 patients admitted to hospitals in Oxfordfrom 1938 to 1962, at the end of which period all caseswere reviewed.

From this Oxford series the natural history of thedisease becomes clearer. Like most studies, it confirmsthat the risk of dying from the disease is greatest duringthe first hospital admission, that the most dangerouscomplication is perforation, and that relapses thereafterare less dangerous. As in duodenal ulceration, one attackvirtually confers lifelong trouble, for after fifteen years’follow-up only 4% had not had a further attack;moreover, the risk of death is throughout greatly in-creased compared with the general population matchedfor age and sex. This risk was appreciably higher inthose recovering from a severe initial attack than after amild attack: it was in fact 15 times greater than normal,compared with 4 times throughout the ten years whichfollowed. This difference has forced EDWARDS andTRUELOVE to the conclusion that colectomy should beconsidered early in severe cases, perhaps even at theoutset, since the mortality-rate in the first attack causingadmission to hospital is still as high as 27% in the corti-sone era (34% before 1952). Elective colectomy carriesa mortality of 3%, but for those cases referred in

emergency it rises to 30%,14 so the immediate gain interms of recovery is small. It must be borne in mind,

9. Bacon, H. E. Ulcerative Colitis. Philadelphia, 1958.10. Melrose, A. G. Gastroenterology, 1955, 29, 1055.11. Mosbech, J. ibid. 1960, 39, 690.12. Nefzger, M. D., Acheson, E. D. Gut, 1963, 4, 183.13. Edwards, F. C., Truelove, S. C. ibid. p. 299.14. Sampson, P. A., Walker, F. C. Brit. med. J. 1961, ii, 1119.

however, that this surgical result is obtained in the mostsevere and late cases which have progressed to boweldisintegration made manifest by dilatation. EDWARDSand TRUELOVE’s severe group included all those with abowel frequency of over 6 motions a day, fever above99-5°F at night or over 100°F on two days out of four,pulse-rate above 90 per minute, and haemoglobin below75%. The problem which has to be faced, therefore, isat what stage before disintegration_in the severe groupcan emergency colectomy be undertaken without raisingthe mortality much above the elective level of 3%.

There are other gaps to be filled in. We still do notknow the incidence of the disease in the population atlarge; for mild cases localised to the rectum, or rectumand sigmoid, do not necessarily find their way to hospital.Indeed, some do not reach their true diagnosis; for thebleeding, in the absence of a loose stool, is quite oftenmistaken for piles. Nor do we know in what proportionof these cases does the disease eventually involve thewhole colon. But, with the numbers submitted to

colectomy since 1948 and readily accessible through theIleostomy Association, it should soon be possible to judgewhether operation restores to those patients who surviveit a normal expectation of life.

The Appropriate CareIN a hospital practising " progressive patient care "

the patients are grouped according to whether they needmuch nursing or little. An experiment in Michigan 1raises the question how far this principle can be appliedin a small hospital. In this country the part of progres-sive patient care that has so far made most appeal is theintensive-care unit, where patients who are seriously illcan have more attention than they might get in ordinarywards. Admittedly, the doctor or nurse accustomed toour traditional wards and firms may not take readilyto the idea that anyone needing special care should bemoved away to a special unit; and DAVIES 2 thinks that,for this reason, intensive-care units will probably beused less here than in the United States. Nevertheless,for the small hospital with difficulty in getting enoughtrained nurses, such a unit may be invaluable.

From the Michigan experience of a smallish hospital,WEEKS 1 suggests that an intensive-care unit is unlikelyto require more than 3% of the beds; and he woulddivide the remaining 97% into (a) continuation or

intermediate beds, and (b) self-care beds. He remarksthat, though the intermediate beds need fewer pro-fessional nurses than the intensive-care unit, theynevertheless need nearly as many hours of nursing perpatient. Many of the people who stay a long time inhospital require more than average bodily care (" moreturning in bed, more linen changes and more observa-tion ") ; but the number for whom a ward sister is

responsible can be larger if none are dangerously ill. Asfor the number of patients capable of

" self-care ",this seems to be somewhere around 20%. But such an1. Weeks, L. E. Hospitals, Sept. 16, 1963.2. Davies, J. O. F. in Problems and Progress in Medical Care; p. 103.

Published for the Nuffield Provincial Hospitals Trust by OxfordUniversity Press. London, 1964.

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estimate is derived from the kind of hospitals we havetoday; and, when we provide outpatient departmentswith operating-theatres and day beds, the proportion ofself-care patients in the ordinary wards in this countrymay well be no more than 7%-10%. This British

development of outpatient treatment and investigationis something that has no real counterpart in the UnitedStates or on the Continent.

In our own country, when the provision of beds isdiscussed, a subject too often forgotten is the need tomeet the winter load of respiratory infections. TakingBirmingham as an example,3 the number of emergencyadmissions to " acute " hospitals rose by 32% between1955 and 1963, and the winter load of emergency admis-sions of 1955 has become the summer load of today.The additional burden on hospitals in the winter monthsis becoming heavier-partly because patients with acutebronchial conditions, who would formerly have died,now recover to be admitted again later. We shall

3. Porter, K. R. D. Postgrad. med. J. 1963, 39, 599.

have to consider very seriously how to cope with thisseasonal demand; for acute medical beds could easilybe silted up, and whatever number of geriatric beds isprovided may prove too small at the winter peak.4As DAVIES 2 says, in the future more and more investi-

gation and treatment are likely to be undertaken withoutadmission to the wards. Moreover, the corollaryof progressive care in hospital is continued care after thepatient goes home. Hence unquestionably we shallhave to develop the kind of help that is often given bestby practitioner and local authority working together.One example that should be widely followed is that ofStafford,5 where a doctor on the staff of the countymedical officer of health, working from the generalhospital, tries to coordinate the resources of hospital,local authority, and general practitioners, so that thepatient gets full benefit from any or all. In the outpatientdepartments of our new hospitals, rooms for local-

authority staff might promote this kind of integration.4. Adams, G. F. Ulster med. J. 1963, 32, 44.5. McFarland, W. D. H., Ramage, G. Lancet, 1963, ii, 1267.

Annotations

STAFFING SCOTTISH HOSPITALS

IN place of the separate regional staffing reviews whichhave taken place in England and Wales, Scotland decidedto follow the report of the Joint Working Party on theMedical Staffing Structure in the Hospital Service (thePlatt report) by a national survey embracing the fiveScottish regions, conducted by a small group under thechairmanship of Dr. J. H. Wright. Their report,2 pub-lished last week, was prepared after wide consultationand the digestion of much statistical evidence. Thecommittee first set themselves the task of devising,specialty by specialty, formulx which would relate

staffing needs to an index of work load appropriate tothe specialty. They then applied these yardsticks to theparticular circumstances of individual units as a " pointof reference rather than a rigid rule ". Though somewill complain that these yardsticks are rather more orrather less than 36 inches long, regions in England andWales might do well to measure against them some oftheir own recommendations (which, it is believed, showsome remarkable variations).The committee started from the premise contained in

the Platt report that hospital staffing must be based uponconsultants as the only doctors working in hospitals(apart from general-practitioner hospitals) who shouldtake full clinical responsibility for the treatment of

patients. They then built up, unit by unit and henceregion by region, the numbers, including university staff,required in each specialty. Over Scotland, the committeerecommend an increase in consultant posts of abouta third above the 1961 figures. They recognise, how-ever, that because of either shortage of money or lackof trained staff it may take some time to fulfil therecommendations. This will be particularly true oftheir suggested large increases for the mental-healthservice.

They have wiselv considered the " junior " grades1. Medical Staffing Structure in the Hospital Service. H.M. Stationery

Office, 1961.2. Medical Staffing Structure in Scottish Hospitals. H.M. Stationery

Office, 1964. Pp. 79. 5s.

together-medical assistants, registrars, senior house-officers, house-officers, and general practitioners employedunder paragraph 10(b) of the Terms and Conditions ofService-and record figures of " supporting staff " foreach unit. Here the recommendation amounts to an in-crease of about a fifth on 1961 figures. In due course it willbe interesting to compare the recommendations made forEngland and Wales, bearing in mind the higher ratio ofmedical students and hence teaching beds to populationin Scotland which establishments might be expected toreflect. The report repeatedly draws attention to the

important teaching and research role of Scottish hospitals;and, while rightly advocating that consultants should

spend most of their time in one hospital, it recommendsthat when working in non-teaching units they should havesmall commitments in teaching units.While noting the controversy about the proposals for

the grade of medical assistant, the Scottish committeeare satisfied that there is a clear need for this grade andfound little evidence of a desire to reject it in principle.They see the advantage of a grade which provides forcontinuity of staffing at junior levels and recognise thatthere are doctors suited by temperament and interest towork in a specialty without taking full responsibility.They conclude :

" Provided there is adequate consultantcover-and we have allowed for this in our recommenda-tions-we see no reason why this grade should not beavailable for use in all specialties and all hospitals if localcircumstances make this desirable." We hope this con-clusion will be accepted so that negotiations on the salaryand conditions of the grade can proceed without moreado.On the employment of general practitioners in the

hospital service, the committee commend the sugges-tion in the Platt report that young graduates should beencouraged to spend longer in junior posts before enter-ing general practice, in order to equip themselves for

part-time work in the hospitals later. Indeed, they seethis as essential if adequate supporting staff are to beobtainable by the hospital service. It seems, however.that this could come only at the expense of the alreadyhard-pressed general-practitioner services until the totalnumber of available doctors can be increased; and even