CENTENARY EDITION 1893 - 1993

  1893

At a meeting held at the residence of Mr. J. Lionel Stretton at 27 Church Street , Kidderminster on October 19th 1893 - Mr. Samuel Stretton in the chair - it was resolved on the motion of Mr. Lionel J. Stretton seconded by Mr. Walter Moore "That it is desirable to form a Medical Society for Kidderminster and District". Resolution adopted by the Medical Profession in Kidderminster and District at that meeting. "That in consequence of the abuses brought to light by the enquiry into - Medical Aid Associations by the General Medical Council we have decided that we cannot, in any way, countenance these bodies and therefore refuse to recognise  their Medical Officers professionally, in consultation or otherwise, until such abuses are removed".

Signed

Samuel Stretton Kidderminster          J.Lionel Stretton Kidderminster
E.H. Addenbrook Kidderminster         David Corbett Kidderminster
W.Fitch Kidderminster                        W.Hodson Moore Kidderminster
O.C.P. Evans Kidderminster               Frampton Kidderminster
H.Miles Kidderminster                        C.Clifford Batten Kidderminster
J.H.Evans Ombersley                        W.Moore Stourport
E. Stanley Robinson, Stourport          Thos.Pennington Bewdley
Trevor Webster Bewdley                    M.Johnston Bewdley
Dennis Fitch Chaddesley                    E.Greenhill Witley
A.T.Broadlick Kidderminster               F.H.Thompson Cleobury
J.J.Godfrey Cleobury                                     John Woodcock Abberley
Jos.Robinson Kidderminster               William Dudley Kidderminster
Arthur Oldham Kidderminster              W.Beckford Kidderminster
Frank Oliphant Kidderminster             J.G.Baker Kidderminster
Bert Addenbrook Kidderminster         V. W .H.Miles Kidderminster
W.W.Gibson Kidderminster                P.E.Davies Kidderminster
J.P.Holyoake Kinver                           W.Berkley Murray Tenbury
J.Hobbs Clent

At the fol/owing meeting on 19th December 1893 the fol/owing motto was submitted

'OMNES SAPIENTES DECET CONFERRE ET FABULAR"

(It becomes all wise men to gather together and converse)

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EDITORIAL

The Society is 100 years old on the 19thOctober 1993. As you can see from the 'extract' in this edition. the initial reason for forming the Society has long since gone but as a result if its foundation there has been an increased spirit of co-operation between members of the profession, and long may it remain so.

  This centenary edition has been devised with the past in mind and the future in view. Nostalgia is a pleasant sensation and for this occasion seems very appropriate. I have incorporated features by Robert Gibbins, Senior Surgeon at Kidderminster general Hospital (formerly Mill Street and then Bewdley Road Hospital ), John James our first orthopaedic surgeon and Sam Wadsworth a General Practitioner.

  This also seemed to be an opportune time to look to the future, always a difficult task but never more so than now with all the changes taking place around us. We have ideas from John Ball, a G.P. and former member of the G.M.S.C. and Richard Taylor, senior physician at Kidderminster General Hospital .

  This being a very special edition, we have printed the newsletter in a more interesting and flamboyant style and we hope that you enjoy it. The editors also wish to thank members of the society who have produced a superb selection of articles for this special edition and also thanks to those members who have supported the newsletter since its inception 2 years ago. Happy Centenary, and please try to come to one or more of the Centenary events.

Graeme Wilcox,  Barrie Davies

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RECOLLECTIONS OF  MILL STREET HOSPITAL

I came to Kdderminster in 1957 having been appointed as orthopaedic and traumatic surgeon to the Mid Worcestershire group of hospitals. At that time there was very little in the way of facilities at Mill Street Hospital where I was employed for three sessions and I remember arriving at the upper car park and looking at the main theatre above it. This was a small room which doubled up for operating theatre. Sisters office, changing room and sterilising room.  The whole building seemed forbidding. There were never more than two or three cars parked in the car park. A 'blister' was next to the theatre which became sister's office and changing room and it seemed to me that there was much risk of this falling out onto the car park. The laundry was downstairs next to the board room and the nurses used to run downstairs for towels and gowns for our lists.

The wards were pleasant though very over crowded. Downstairs were the male wards -Samuel Stretton occupied by general surgical and trauma patients. Towards the present X-ray department down the corridor was the William Adam ward, this later became a day room. Past the X-ray department the corridor carried on to the children's ward, Stanley Baldwin named after the Prime Minister.  Upstairs there were three female wards, Faith, Hope and Charity. The total bed compliment of the hospital was in the region of 75 -80 beds and this included of course medical patients as well, although as far as I remember, most 'medical patients' were treated at home.

 The two surgeons, Mr Gibbins and Mr.Doran, covered Bromsgrove and Redditch like myself and it is difficult to understand how this was done in those days as we could not possibly have been in three different places at once. There was always a first class resident surgical officer at both Bromsgrove General Hospital and at Mill Street , and Mrs Ball who was one of them will undoubtedly remember them all. Of course the work load was very light by today's standards, all three towns were really not very much larger than a very large village and the population growth all round has been quite astounding Similarly, there was very little traffic on the roads at first although we did have a number of motor cycle accdents, especially late at night. Some horrific accidents kept us up at night fairly often until the local young men gave up their motor cycles and took to four wheels.

There was only one portable X-ray machine at Mill Street and no facilities existed for developing and printing X-rays in the operating theatre. This made things difficult for hip pinning. The fracture was reduced and Harold, the theatre porter,  skilfully held the limb in position while the X-rays were taken. The radiographer had to be very fit as she had to dash down the stairs, around four corners to the X-ray department and then back to the theatre. Before I retired we were blessed with smooth anaesthesia, an orthopaedic table to hold the reduced fracture and a large image intensifier for these cases. It was surprising how well the patients did at Mill Street ; perhaps they were made of tougher stuff although life was certainly more peaceful in those days as a whole.

John James

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KIDDERMINSTER MEDICAL SOCIETY ANNUAL DINNER

The Annual Dinner was held on Friday, 14th May 1993 at Spring Grove House. The Guest Speaker was Dr. Michael O'Donnell, G.P., writer, B.B.C. personality and raconteur - also a member of the G.M.S.C. After a highly amusing talk a vote of thanks was proposed by Dr. .John Ball who reminded us that this was a return visit for Dr. O'Donnell as he had been a guest speaker during his presidential year some 20 years ago.

Once again, over 100 members and guests attended and enjoyed an excellent evening. One of Dr. O'Donnell's anecdotes follows; 'A nice day at the orIfIce. There are ear doctors, nose doctors, throat doctors, gynaecologlsts, proctologists. Any place you got a hole, there 's a guy who speciallses In your hole. They make an entIre career out of that hole. And if the ear doctor, nose doctor, gynaecologlst or proctologist can't help you, he sends you to a surgeon.  Why? So he can make a new hole'.

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JOSIAH MASON

The younger members of the society may not appreciate that Kidderminster was the birthplace of the founder of  Birmingham University . Josiah Mason was born in Mill Street in 1795 ( a house still stands on the site of his birthplace).

He followed many trades, including carpet weaving, until in 1817 he became manager of his uncle's imitation jewellery business. In 1825 he purchased for £500 the business of a split ring maker, and commenced to make the rings by machinery. From about 1830 he became a maker of steel pens and in 1844 he joined the brothers Elkington in electroplating. In 1858, Sir Josiah founded almshouses, and an orphanage for girls in Erdington. In the latter part of his life, he founded the Mason Science College at Birmingham , which became the nucleus of Birmingham University . He was Knighted in 1872

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PRE-NATIONAL HEALTH SERVICE
REMEMBRANCE OF TIMES PAST

I came to Kidderminster in August 1946. Rumours about Nye Bevan's intentions for a heath service were rife, and it seemed important to get settled before one was posted to darkest Lancashire . Ken Beatty had just bought a half share in the Church Street Practice and offered me the other half. We had worked together in the Army so knew each other's weaknesses. I borrowed £500 and bought the goodwill and equipment. This precluded any hopes of raising a mortgage and I was lucky to be able to rent 25 Church Street . next to the surgery for £60 per annum. We also rented the surgery at number 24

The practice was mostly panel patients (working men) and the club (their families). The Club paid 6d. a head per week (£1/6/0d per annum) for free medicine. visits and consultations. This brought in hard cash every week which was extremely welcome! We also had a fair number of private patients. Some of these deserted immediately they found out the practice had changed hands and their goodwill did not usually extend to settling their unpaid bills. I still see one socially who owes me £30. In 1946 this would have paid Tim's school fees at the 'Knoll' for a year.

There were 14 doctors practising in Kidderminster ; 8 were in Church Street , 4 were single handed and the rest 2 - man practices. In spite of competition, all were on good terms with each other socially and professionally, as we were with the consultants and the hospital. We each did 13 surgeries a week. including 3 on Thursday (market day) and 2 on Saturday. In addition, we held a sick parade every day (7.30 to 8.30 am) at the Pay Corps camp at WoIverley and Polish camp at Drakelow, and at a displaced persons (Anglo - lndian) camp up on Birchen Coppice. Astonishingly, I used to do occasional post mortems for the coroners office as well !

The pattern of disease was different - diphtheria, polio, whooping cough and TB were fairly frequent. Coronaries were usually treated at home without the benefits of an E.C.G.  machine. The patients never complained and the thought of being sued was inconceivable. Treatment was minimal, most patients ending up with a bottle from the stock Winchesters in our dispensary. Early diagnosis was the challenge!

Midwifery was badly organised and largely domicilliary. Most of the patients could not afford the £5 we charged for total care, and ante-natal care was at the local authority I clinics run by the MOH. The result was a call to an obstetric emergency to a patient one had never seen. Most midwives were adept at dripping on the chloroform for POPs .

In all, they were the bad old days for the patients but exciting and interesting work for the doctors. Ken Beatty and I changed things fairly rapidly in our practice, but the biggest and best change came with the advent of the NHS.

Sam Wadsworth

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Summer Event at Stone Cottage Garden

On Sunday 8th August, the Summer event of the Society was held at Stone Cottage Garden .

The event was a departure from previous outings in that it involved both young and old. The invitation was for families, and it was taken up enthusiastically by 46 adults and 24 children. There was a superb barbeque and bar in unique surroundings and the weather was very kind. Unfortunately, we were unable to afford the Jazz Band but alternative entertainment was provided. It was an excellent opportunity for members and their families to spend an enjoyable afternoon together.

Olaf da Costa

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NEWS IN BRIEF

Little birds (or perhaps we should say administrative vultures) tell us that the North Worcester Health Authority have succeeded In acquiring the Croft as their offices. G.P. members may recall a promise that the Croft would return to clinical use as soon as was possible - meetings even took place to discuss the possible uses.

This move, achieved by our former Health Authority Chairman Malcolm Cooper (we are not sure which side of the tightrope he has fallen on) has effectively removed assets in the region of £1,000,000 from the virtually bankrupt Kidderminster Health District.

It now seems that the 2 tier Health Service we have heard so much about has arrived in Kidderminster - OFFICIALLY. At a recent meeting between the Trust and Fund holders it was announced that the Health Authority is so short of cash that only patients of fund holders with spare cash will be put on operating lists - patients of fund holders who are overspent and non Fund holders go automatically to the bottom!

There is considerable uncertainty about the future of the A & E Department. Consultant cover is there only for the next six months - there are no official plans (and certainly no cash) as to what will happen when Mr. Laljee retires.

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KIDDERMINSTER GENERAL HOSPITAL
A PERSONAL VIEW OF THE FUTURE

Being within sight of retirement the invitation to write about the future of hospital services in Kidderminster places me in a dilemma. My natural reaction is to look back and say that the best has passed. In the 1970s money was available and the hospital service within the NHS was blossoming. Patients no longer inevitably died from chronic renal failure, endoscopy became available as a routine, cardiac investigation and surgery advanced dramatically and at Kidderminster we became a proper District General Hospital .

But I must look forward. On the wider front, cancer, multiple sclerosis and rheumatoid arthritis are still to be conquered not to mention HIV infection. Thus we have to harness medical services (and that simply means money) to care for patients as best we can and to exploit advances in prevention and treatment quickly and efficiently. Government's aim to make money follow the patient is basically sound but as there is no more money available, in real terms, this means that resources have to be redistributed. Now this appears to be all to the disadvantage of the hospital service Indeed, many things must be cheaper done in General Practice and the community than in hospital.

Potential cripplers for the hospitals are capital charges, loss of Crown Indemnity and the financial responsibility for legal claims of all sorts. Reduction in junior hospital doctors' hours has to be accommodated without compromising the service or their training and experience and without further stressing consultants who, contrary to popular belief, do not spend NHS time (or much of their own time) on the golf course or with private patients Thus NHS hospitals will be forced to reduce or amalgamate services that are expensive in medical manpower for relatively small numbers of patients.

We have already lost in-patient ENT services. We have never had in-patient radiotherapy, invasive cardiology, renal dialysis or neurosurgery. Will we be able to keep in-patient ophthalmology and oral surgery for example? The development of our own obstetric service is a tremendous bonus for local people but it is against the trend.  Perhaps the Nurse Practitioner grade will reduce the need for on-call junior doctors in every speciality. The reduction in junior medical staff involvement in out-patient clinics must be accompanied by increased formal training and audit sessions that at the moment are impossible. With more consultants, this may become realistic.

I believe that there will be a Kidderminster General Hospital for the foreseeable future. Geography and the loyalty of our patients and General Practitioners are all on our side. The quality and commitment of our new generation of consultants are paramount The enthusiasm and interest of our newest junior doctors is a constant reassurance to me for the future.

Richard Taylor

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Rex Vs the Medical Profession
(but who. or what is Rex?)

A great deal has been written and spoken recently about the accelerating rise in the number of complaints relating to alleged medical misdemeanors. Naturally. with the increasing complexity of modem medicine, mistakes are bound to happen but the question which is being repeatedly begged is whether the rise in the number of complaints relates to a rise in the number of mistakes made, or rather to a fire which is being repeatedly fuelled and fanned in a totally different professional field. More and more often, cases presented at Medical Service Committee hearings are well prepared, over a deliberately long period of time by the legal profession. Until recently a legal presence at a service committee hearing was not allowed, but changes in the regulations now mean that although barred from actually presenting a case, solicitors are now allowed to be present and to assist the complainant (perhaps the first metaphorical foot in the door). Unfortunately therefore, the rise in the number of complaints is likely to accelerate even more, deliberately fanned by the fiscal hand of the legal profession.

The most unfortunate feature of this disturbing trend is that the legal profession is literally a law unto itself. Rarely, if ever, do legal firms seek independent medical advice as to whether a complaint is viable or indeed even justified. Rather, they tend to drag the accused and the accuser through many months of turmoil while they build a case on what is no more than their personal, and usually ignorantly incorrect interpretation of medical fact - or frequently, fiction.

The fundamental root cause must surely lie in the rapidly diverging work ethics of two ancient professions. Medicine in this country fortunately does not work on the abhorrent item of service attitude which exists in the United States - where the more you do, the more you earn whether it is medically justifiable or not. On the other hand, the legal profession in this country is rapidly following the trans Atlantic trend, and long seems to have forgotten the principles of 'right or wrong' and base their actions and endeavours purely on the demands of their voracious wallets. In the eye of a lawyer, seeking independent medical advice as to whether a complaint is justified or not is more likely to cost money rather than earn it and therefore a course of action to be frowned on rather than encouraged.

No, the law is no longer the ass, as such a statement can only cast criticism upon an innocent animal whose actions have no undertones whatsoever. Rather, the law is fast becoming an amoral and rapidly growing dinosaur whose work ethic is based on greed rather than justice.

Barrie Davies

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JOHN RUSSELL CUP CRICKET MATCH

The 4th John Russell Cup Cricket match was held at Winterfold House School on Sunday 17th July.  The Consultants, having won the toss, batted first and reached a total of 97 runs all out in 17 overs - having been rather generous with their retirement policy. In reply, the General Practitioners made 100 runs, completing the century with a magnificent boundary from Brendan Jones.

Teams:

Consultants:                             General Practitioners

A.Johnstone (Capt.)                A. Summers (Capt.).
W.Giliison                                D.Malcomson,
D.Cleak                                   D. Herbert.
Rev. P. Brothwell                    P.Batty,
P.Armitstead                           D. Starkie
M. Lewis                                  F. Morgan,
A. Dey                                     G. Parsons,
G. Cox                                     M. Ward.
A. Johnstone Junior                B.Jones
A.Taylor                                  G. McClung,
Runner  Jan Meggy

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FROM MILL STREET TO BEWDLEY ROAD

When I was appointed to Kidderminster General Hospital at Mill Street in 1949, it was in the group of Mid-Worcestershire Hospitals which included redditch, Bromsgrove and Tenbury.

In 1951, Bromsgrove General Hospital was opened and I was then working at Redditch, Bromsgrove and Kidderminster . For the next decade the Group Management Committee directed most of its energy and resources to developing that hospital with the result that Kidderminster got very little attention or finance for its development.

My only surgical colleagues at Mill Street were John Stretton. General Surgeon and Ken Forsyth (1947 - 1975) ophthalmologist. Walter Dunsby (1939 - 1980) was running an excellent pathological service virtually single handed. Sadly, John Stretton died suddenly in 1953. Soon afterwards. F.S. Doran joined me on the staff from Bromsgrove and for the next five years Doran and I looked after the general Surgery including emergencies at the four hospitals. At that time. the RSOs at the two general hospitals were only partially trained surgeons which put a considerable strain on us.

This situation was relieved in 1958 when we appointed Mr. Chitty as consultant surgeon to the group. Unfortunately. he died after two years and after doing a locum for six months Douglas Tooms was appointed in his place. During this lean time, the orthopaedics was in charge of T. S. Donovan from Birmingham and N. Scrase helped out with the trauma. In 1957, John James was appointed as consultant in orthopaedics and trauma for the group.

Pam Ball - our first RSO with the FRCS - was appointed in 1958. and as you can imagine, the tempo at Mill Street increased. She established an ITU in the boards room and John Ball came on as House surgeon. Mr. Laljee followed soon after as RSO in 1961 and stayed with us for two years, returning later as SHO in the Casualty Department. During this time the medical staff were Dr. Malins from Birmingham , Dr. Pat Thorne who served the hospital well from 1954 to 1966 and Dr. Lurring, a GP Physician. In 1961 we started infiltrating the wards at Blakebrook hospital, the old 'poor law' hospital. Two wards were vacated on the old 'A' Block for surgical recovery patients from Mill Street and were looked after by Dr. Pat Campion and later by John Ball. In 1962 an extension was built on to the casualty theatre at Mill street to enable us to use six trolleys for day patient minor surgery. During the 1960s the Regional Hospital Board envisaged a large general hospital at Prestwood. five miles from Kidderminster . This was to cover the districts of Kidderminster, Stourbridge, Dudley and Wordsley. The plan was dropped but by then the plans had already been made to build on the Blakebrook site a subsidiary hospital to Prestwood.

These plans were enlarged, we had numerous meetings with the AHB and finally evolved a three phase building plan. Dr. P. H. Beves who had been appointed consultant anaesthetist in 1966 was largely responsible for the design and equipment of the ITU. We also worked together on the design and layout of the operating theatres. In 1967 a minor operating theatre was constructed in the kitchen block at Blakebrook and we started doing intermediate and minor surgery there using the wards on 'A' block. A year later a new I casualty department had been built on its existing site. In 1969 the new twin theatres were completed along with the nurses tower block, residents accommodation, dining room, kitchens and administration office, so we were now ready to move the surgical work over to Bewdley Road using the two wards on 'A' block (now demolished) and the new theatres and X-ray, the latter under the direction of Dr Macnamara In 1971 the new 'C' block for surgery was opened and the patients transferred from old 'A' block. Their place was taken by the medcaI patients and children from Mill Street .

In 1972, 'S' block was found to be unsafe, it could be shored up but ,after two years would have to be demolished. The medical patients were temporarily  accommodated in 'C' block but the children  were allowed to stay on the ground floor until a 'porta cabin'  type children's ward was established on a different site. This apparent disaster was a blessing in disguise. By an astute move, our then District manager Stuart  Dickens, persuaded the RHB to build us a new medical block in those two years. The  present 'A' block was opened in 1980.  In the meantime, '0' block was under construction as part of a Worcestershire project with Worcester District to provide in-patient and day places for psychiatric patients attached to general Hospitals. Dr Robertson was appointed Consultant in psychiatry. The pathology and physiotherapy departments  were split between Mill Street and Bewdley Road .

With the opening of 'C' block and the new Post Graduate Medical centre, the hospital began to take off.  Dr. Peaston had been appointed consultant physician in 1969 and Drs. Taylor and Murray came in 1972. Walford Gillison was appointed Consultant Surgeon in 1973 and when Dr. Peaston left in 1975 Dr. Stephen Booth was appointed in his place. Dr. Eales returned to Kidderminster as pathologist after some absence at Dudley Road Hospital to join Martin Lewis, the haematologist.

Since I retired in 1979 many changes have taken place with new consuhants and a large increase in junior doctors. The new 'E' block (phase V) is catering for paediatrics, geriatrics and maternity and the newest block (phase VI) will provide the surgical beds, theatre and ITU along with maternity, geriatrics and a complete new outpatient department. Mill Street will then be closed. This will complete the development of one of the best District General Hospitals in the Region.

R.E. (Bob) Gibbins

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Notes of a Case
The Death of a Horse 15^th November 1901

Miranda, a dark brown mare two years old, well bred, highly nervous but in excellent condition suffering from two large suppurating lumps over the elbows. The anaesthetic was commenced at about 3pm in September after she had been hobbled and drawn down In the usual way. She had been prepared by being given a bran mash the night before, and a meal of bran and chaff at 8am that day - that being her last meal.

The chloroform was given in the following manner - a towel was laid on the ground under the animal's head and soaked in chloroform, and this was placed over the nose and mouth. A second towel was folded over this. When more chloroform was required it was poured over the inner towel, enough to soak it once again. It was not for me to question the methods employed, but I must say that it struck me at the time that if I attempted to administer chloroform to a human being in such a manner we should be courting disaster. She inhaled the chloroform quite quietly. There was no struggling, and the respirations were long and deep. I had just removed the first lump, and was preparing to sew up the wound, when the vet informed me that she had stopped breathing. All our efforts – artificial respiration, strong ammonia etc. were unavailing. The time from commencement of inhalation was about ten minutes.

John Lionel Stretton 1901

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THE FUTURE OF PERSONAL CARE IN THE WYRE FOREST

Although the NHS rarely seems to run on an even keel it has, fairly consistently sustained and improved health care in this locality. The relationship seems likely to continue, so to look forward to our future locally we must first read the National Health tea leaves! I believe the future direction of challenge is clear. The rate of change is less so, being driven politically and economically by a heady mixture of aspiration and expedience.

 For the future, affordability will be 'the ticket', finance being the main determinant. Given the economic status of the country and taking into account future probabilities it seems fair to conclude that the major rationale on the future health service will be financial realism. What we see now is an overpowering need to remodel the health care system so that it will in the long term be consistent with our likely resources, economically used. This will require a series of mutations by which the National Health Service will 00 translated from a total health care provision into a much more selective system mainly based on providing core services. Its value and effectiveness will be monitored by a body such as the Audit Commission.

With considerable difficulty but for! overwhelming economic reasons the I government will have to jettison various parts of the political baggage of the NHS - like a comprehensive service, free at the point of use. What will emerge will be a range of services confined to a national menu of approved clinical options and therapies. This will, in effect be a 'health formulary'. It will consist of practices, procedures and potions which are both affordable and of proven efficacy. Within the next decade, the evaluation of all therapeutic processes will have become a major speciality in its own right, driven by the health purchasers, nationally and commercially.

Because of established trends in recruitment and retirement the majority of doctors will be women in 20 years time, most of them being the generalist service. In terms of total manpower the National Health Service will no longer be the largest employer in Europe (currently 1.25 million employees) but will become a very small and concentrated framework. It will identity key health policies and titrate the range of health service provision in the light of them. Secondly, it will be directing and managing subsidiary modules of relatively independent health care businesses. The latter will include substantial elements of fairly autonomous professionals whose overall pace and direction will be determined by the national financial allocations.

At the point of consumption of health care there will have been equally significant changes. Patients expectations will have continued to rise and the variety of health options will have continued to expand dramatically - the continuing achievement of one medical miracle a month will for example leave no stone unturned ! The combination of rising expectations and ever expanding options will mean that the range of services that are possible will widen and weaken remorselessly. As medical science continues to press forward on the theoretical frontiers of medicine in pursuit of the ultimate there will, in the NHS, inevitably have to be a much more rational use of personal skills and abilities by everyone. So that all health care workers and indeed patients will need to contribute selectively at the upper level of their personal ability but to no lower clinical standard. Not only will super specialisation progress dramatically but the organisation of care, recognising the benefits of concentrating skill and experience, will progressively limit the range of activity of individual clinicians and establishments in the pursuit of effectiveness, safety and as a defence against litigation.

Many distinctions will become blurred. Primary and secondary care will be difficult to distinguish as isolated clinical activities inevitably become a matter of the past. Virtually all care will be aggregated on to single sites providing a co-ordinated delivery on a 'one-stop-shop' basis. The Wyre Forest will have one medical 'Carrefour' for the sake of convenience, efficiency and integrated activity. This will be closely linked with neighbouring hospitals and provider units and each of these can be expected to concentrate on complimentary areas of clinical activity to a much greater degree than at present. The planning and provision of specialist clinical care will be largely based on levels of turnover and clinical experience, the attainment of clinical standards being ranked above issues such as availability and access. What will also be impressive will be the relative absence of in-patient facilities, with the establishment of linked but independent 'hotel-care' accommodation for those patients where some continuity is necessary.

The supermarket analogy will however not stop there. The major provider conglomerates, in terms of their style and modus operandi, will lean more and more on the commercial philosophies rather than follow the old patterns of Whitehall . With the, result that for example a wide range of non NHS services will be promoted on the back of  basic NHS provisions (just as happens in the , practice of eye care today). For example, a visit from the local hospital's gynaecological marketing director will be no more surprising  tomorrow, than' a call from today's pharmaceutical representative.

Organisationally the key health care framework will be a lean one supporting a series of integrated modules responsible for providing a selected range of services. Within the modules the specialist professionals and their staff will largely be self employed in direct contract with the provider units for the basic NHS services and they will provide. within the same framework. private services beyond the range of NHS core items.  'Ah,' you say 'what about the patients?' Well, hopefully the General Practitioner will continue and provide an independent personal care service and the crucial patient advocacy - but then we mustn't be too optimistic must we?

John Ball

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Case Notes  -  28^th May 1897

Punctured wound of abdomen with prolapse of the gut in a girl aged 4 years. A pair of rusty harrows supporting a door without hinges, the sharp points being outwards. The child climbed up pulling the harrow together with the door over on herself. Some of the spikes entered the left of the abdomen causing protrusion of about 8 inches of gut. She was brought 4 miles from the country in a spring cart with the protruded bowel covered with a wet cloth. In order to return the bowel, chloroform was administered and the opening enlarged, the wound was stitched up and a pad and bandage was applied. The child was then driven home in the pouring rain. She had no bad symptoms, but two days later she was sent to the Kidderminster Infirmary under the care of Mr. J. L. Stretton in case any complication might arise. She made an uneventful recovery.

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