Changing patterns of resource allocation in a London teaching district.

The health plans of the Tower Hamlets district management team were studied to determine what effects the report of the Resource Allocation Working Party and the White Paper "Priorities in the Health and Social Services" have had on resource allocation in a teaching district. The study showed that at present acute services are allocated a greater proportion of the district budget than occurs nationally, while geriatrics, mental health, and community services receive proportionately less. In the next three years spending on acute services is expected to decrease, while spending on geriatric facilities and community services will increase. Nevertheless, cuts in acute services will take place mainly through a reduction in the number of beds serving a community function, concentrating all acute services in the teaching hospital. Services to the district might be better maintained by creating a community hospital to meet the needs of patients who would otherwise need to be accommodated in acute beds with unnecessarily expensive support services.     

Prediction of resources needed to achieve the national target for treatment of renal failure.

A model of the treatment of end stage renal failure has been primed with observed survival statistics and used to predict the steady state that will be achieved when the present annual target of at least 40 new patients per million population is in equilibrium with the death rate. The number of patients expected to receive each type of dialysis or a transplant is given per million of population. The personnel and facilities required to care for these patients and the costs of each programme were derived using analyses of workloads and costs in the North Western Regional Health Authority. The study has documented the considerable need for "back up" beds for patients on dialysis who require temporary care as inpatients. The cost effectiveness of transplantation has been demonstrated; at steady state it is calculated that each successful graft saves the service pounds 30,000. Implementation of the minister''s minimum target requires a build up to some three times the resources currently allocated, with parallel increases in numbers of medical, nursing, and other essential staff.     

Integrated dialysis and renal transplantation: small is beautiful.

Many patients in Britain with chronic renal failure suitable for renal replacement treatment die because not enough treatment facilities are available. Moreover, the number of renal transplants performed is insufficient to meet even present needs, so the number of patients on dialysis is rising. The integrated dialysis and transplant unit in Aberdeen, which has a population base much smaller than the average British unit, meets community needs for dialysis and transplantation. The problem of harvesting cadaver kidneys has been solved; the present supply has not only enabled the number of patients on dialysis to remain stable but has resulted in a net export of kidneys. The Aberdeen unit shows how estimated needs for chronic dialysis and renal transplantation may be met.     

Growth of clinical haematology in South Tees Health District 1983-5.

A review of the workload of two newly appointed clinical haematologists in a health district with a population of 307,000 showed that the clinical case load increased rapidly in the first two years. The management of patients with blood disorders, which had previously been dispersed among many departments both within and outside the district, was now concentrated within a single unit with occasional referral as appropriate to regional centres. The development of a clinical haematology service in district general hospitals cannot occur without funding and facilities, including suitably located beds for haematology patients and specifically appointed junior medical staff. Highly trained and experienced nursing staff are essential for the management of patients with bone marrow failure; day care facilities and community nursing are also valuable. Changes and developments in the laboratory as a result of these additional clinical activities are also necessary.     

Options for Optimal Coverage of Free C-Section Services for Poor Mothers in Indian State of Gujarat: Location Allocation Analysis Using GIS

Background

Gujarat, a western state of India, has seen a steep rise in the proportion of institutional deliveries over the last decade. However, there has been a limited access to cesarean section (C-Section) deliveries for complicated obstetric cases especially for poor rural women. C-section is a lifesaving intervention that can prevent both maternal and perinatal mortality. Poor women bear a disproportionate burden of maternal mortality, and lack of access to C-section, especially for these women, is an important contributor for high maternal and perinatal mortality in resource limited settings. To improve access for this underserved population in the context of inadequate public provision of emergency obstetric services, the state government of Gujarat initiated a public private partnership program called “Chiranjeevi Yojana” (CY) in 2005 to increase the number of facilities providing free C-section services. This study aimed to analyze the current availability of these services in three districts of Gujarat and to identify the best locations for additional service centres to optimize access to free C-section services using Geographic Information System technology.

Methodology

Supply and demand for obstetric care were calculated using secondary data from sources such as Census and primary data from cross-sectional facility survey. The study is unique in using primary data from facilities, which was collected in 2012–13. Information on obstetric beds and functionality of facilities to calculate supply was collected using pretested questionnaire by trained researchers after obtaining written consent from the participating facilities. Census data of population and birth rates for the study districts was used for demand calculations. Location-allocation model of ArcGIS 10 was used for analyses.

Results

Currently, about 50 to 84% of populations in all three study districts have access to free C-section facilities within a 20km radius. The model suggests that about 80–96% of the population can be covered for free C-section services with addition of 4–6 centres in critical but underserved regions. It was also suggested that upgrading of public sector facilities with minimal investment can improve the services.

Conclusion

This study highlights utility of Geographic Information System technology for planning service centres to optimize access to vital lifesaving procedure such as C-section. Although the location allocation methodology has been available for decades, it has been used sparsely by public health professionals. This paper makes an important contribution to the literature for use of the method for planning in resource limited settings.     

Community health services.

The Tomlinson report, with its emphasis on primary and community care, offers great scope to community health services, for long the poor relation of the NHS, and particularly poorly resourced in London. The aim is to create services that break down the barriers between primary, secondary, and tertiary health care and concentrate on providing high quality care tailored to individual patients'' needs. Thus a range of flexible options needs to be developed between acute hospital based care and the standard home care arrangements currently provided by district nurses. Examples, include hospital at home schemes, nursing beds, and rehabilitation beds. Together community and primary care services need to consider weekend coverage, to conduct research, and to become a setting for education. The infrastructure for primary and community care must, however, be put in place before acute facilities are shut.     

Management of septic shock.

There have been important advances in the resuscitation of patients in septic shock in recent years. Survival can be improved by earlier recognition and therefore eradication of the sepsis combined with logical supportive measures. As with any acutely ill patient consultation with intensive care unit staff may be useful. Consultation with the intensive care unit does not necessarily imply the need for admission and mechanical ventilation; helpful advice may be forthcoming. Equally, referral to the intensive care unit does not mean an admission of failure but merely a recognition that additional skills and technical facilities are necessary for the patient''s survival.     

Unblocking beds: a geriatric unit's experience with transferred patients.

A study was made of all patients admitted to a geriatric unit over several years. The admission policy included a high degree of priority to requests for transfer from acute beds, which resulted in transferred patients accounting for 25% of admissions. Unblocking acute beds did not lead to prolonged delay in admitting patients from the community to the geriatric unit. Almost 30% of beds allocated to transferred patients were recovered in 30 days.     

"Homeward bound": a minimal care rehabilitation unit.

A 20 bed minimal care rehabilitation unit was set up by Newham District Health Authority in a small hospital originally scheduled for closure when a new district general hospital was opened. During the first year 114 patients were admitted (throughput 5.7), with a median length of stay of 30 days; in the second year 173 patients were admitted (throughput 8.65) with a median length of stay of 28.5 days. The cost per inpatient day was less than that of an inpatient day at the district''s long stay geriatric unit. Before the unit opened 24% of the acute beds had been occupied for more than six weeks, whereas two years later only 6% of the acute beds were occupied for such a period.     

Waiting times for nursing-home placement: the impact of patients' choices.

OBJECTIVE: To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home. DESIGN: Cohort study. PARTICIPANTS: All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990. MAIN OUTCOME MEASURE: Length of time waiting for nursing-home placement and relative rates of placement. RESULTS: The variable found to shorten the waiting time the most was the patient''s choice of a for-profit or nonprofit secular facility; other significant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait. CONCLUSION: The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.     

The Planning and Operation of an Intensive Care Unit

It is desirable that every hospital of 100 beds or more should have an intensive care unit. An attempt is made to outline the more important features to be considered, including the physical aspects, when planning and establishing such a unit. The unit should contain 2-4% of the total number of hospital beds. It should be separate, centrally located and self-contained. Direct observation of all patients must be possible at all times. Efficient and specially trained personnel using modern and special equipment are required. Orientation lectures and demonstrations must be carried out frequently and regularly. The types of patients to be admitted to the unit are discussed, as well as the governing rules and regulations. All doctors should have a right to admit and look after their own patients in the unit; an Intensive Care Unit Committee made up of representatives of the major services is suggested as a means of controlling admissions and discharges and for general administration.     

Patients in acute surgical wards: a survey in Glasgow.

A survey was made of all patients in general surgical, urological, and orthopaedic and accident wards in Glasgow on one day in June 1975. Its purpose was to define features of acute surgical practice of relevance to the future planning of resources, particularly bed numbers. Over 40% of the patients in both surgical and orthopaedic wards were over 65 years. Most patients had serious conditions and could not have been treated other than by admission to an acute surgical ward. But a substantial minority no longer needed such facilities and could have been transferred to second-line beds, although many still required skilled nursing care. Delay in the discharge of elderly patients from acute surgical wards as a consequence of non-surgical (often medical or social) problems results in a proportion of acute surgical beds fulfilling a second-line function. Unless arrangements for the earlier discharge of these patients are made any reduction in acute surgical beds is likely to restrict elective surgery, especially in orthopaedics.     

Demand for patient care.

A study was performed to determine the extent to which patients of all types were receiving inappropriate levels of care. The needs of patients in acute and supporting hospitals, people in residential homes, and patients cared for at home were assessed. A sixth of the hospital inpatients did not need hospital care, while 5% of those in residential homes and 5% of those at home did need hospital services. These findings indicate that a realistic provision of hospital beds would be 4 per 1000 population for all specialties except regional specialties, psychiatry, mental subnormality, obstetrics, and paediatrics. About a third of these beds need to be acute, while the rest may be in supporting or community hospitals. Thus the current provision of acute beds (2-0 to 2-5 per 1000 population) exceeds actual need.     

Mobile Unit for Screening for Cervical and Breast Cancer

In 12 months'' use of a mobile unit for cervical and breast cancer screening in Gloucestershire 3,211 women attended at an average of five sessions a week. Clinic sessions were organized and the running costs of the service met by a voluntary organization. The keeping of records, provision of laboratory facilities, and the follow-up of patients were carried out in close cooperation with the county health department.     

Psychogeriatric Ward for Mentally Disturbed Elderly Patients

The operation is described of a special psychogeriatric ward of 23 beds set up in 1967 to provide treatment for mentally disturbed elderly patients who could not be kept in a general ward or at home. The unit is in a predominantly geriatric hospital which serves a population of 340,000 and in the four and a half years reviewed 600 patients were admitted. Half of the admissions were emergencies. A consultant geriatrician was in charge and the nursing staff were general trained. The number of beds was found to be adequate for the demand. Few patients had to be transferred to a psychiatric hospital, but, since the mental disturbance was often associated with severe illness and the patients were old, the death rate was high. The nursing staff have found the work interesting and stimulating.     

Statistical Approach to Planning an Integrated Haemodialysis/Transplantation Programme

A mathematical model has been constructed to assist in planning the future requirements of a combined haemodialysis and transplantation centre. It has been used to predict the number of patients in the dialysis unit, the general wards, and at home on dialysis, as well as providing further information on transplantation rates and overall costs. The model can be adapted for units with different facilities from our own.It can be primed with data from an individual unit or with pooled data from the whole country. The purpose of this paper is to demonstrate the methodology of a particular statistical approach.     

Multiple resource limitation: nonequilibrium coexistence of species in a competition model using a synthesizing unit

During the last two decades, the simple view of resource limitation by a single resource has been changed due to the realization that co-limitation by multiple resources is often an important determinant of species growth. Hence, the multiple resource limitation hypothesis needs to be taken into account, when communities of species competing for resources are considered. We present a multiple species–multiple resource competition model which is based on the concept of synthesizing unit to formulate the growth rates of species competing for interactive essential resources. Using this model, we demonstrate that a more mechanistic explanation of interactive effects of co-limitation may lead to the known complex dynamics including nonequilibrium states as oscillations and chaos. We compare our findings with earlier investigations on biological mechanisms that can predict the outcome of multispecies competition. Moreover, we show that this model yields a periodic state where more species than limiting complementary resources can coexist (supersaturation) in a homogeneous environment. We identify two novel mechanisms, how such a state can emerge: a transcritical bifurcation of a limit cycle and a transition from a heteroclinic cycle. Furthermore, we demonstrate the robustness of the phenomenon of supersaturation when the environmental conditions are varied.     

The physician,the parent and the retarded child

The problem of the retarded child and his parents is one confronting practicing physicians more and more frequently. Current estimates indicate that state hospital facilities for retarded persons in California are short nearly 6,000 beds. There are long waiting lists for available facilities. Many families are in desperate need of help. To advise a family to send their child to a State hospital is not a real solution nor one possible in the great majority of instances. The responsibility of the physician goes beyond this. Parents' groups have developed in the last few years and are making a real contribution to a resolution of the problem. Local community resources have increased and will further increase. A more accurate clinical understanding of the retarded child has been formed and his treatment needs more clearly defined. Physicians, parents, community and State agencies must work together to effect a coordinated program.     

El anciano en la unidad de geriatría de agudos

Although the implementation of acute geriatric units (AGUs) in general hospitals has a grade A of evidency, in Spain, only 12% of them have this resource. The estimation of geriatric especializad beds for the care of acute frail elderly people is of 2.6/1000 inhabitants older than 75 years. AGUs have demonstrated to reduce the functional loss associated with the hospitalization and to increase the percentage of older people that can return home, without increases in mortality nor costs. In this review we present the characteristics of patients who benefit from AGUs, the services offered, the structure and functioning of the unit, the role of the professionals that work in it and the quality indicators that must be acomplished.     

A DATA MANAGER for the health information system Berlin.

The needs for permanently changing the logical and physical structure of a medical datebase during the development of a health information system have initiated the project of implementing a DATA MANAGER. The concept of the DATA MANAGER covers facilities for the development of the logical data structure model including documentation of the model and programming support for application programs accessing the health information system (HIS) database. The outstanding facilities of the INTERLISP system have been found to be appropriate for writing the DATA MANAGER. A first data structure model, on which the DATA MANAGER will operate, is roughly outlined.