Progress in the Dermatological Service in the West of Scotland
Dr Jack O'D Alexander, Emeritus Consultant Dermatologist, Glasgow Royal Infirmary
In this follow-up to my paper of 1971 (Brit J Dermatol 84:470-86) I shall deal with the general situation and its development and then with the individual skin units. My knowledge of this springs from my having been on the staff of the Glasgow Royal Infirmary Skin Department in various grades from 1.4.47 until 1.4.80 apart from 4 months spent as consultant dermatologist at Stobhill Hospital in 1964-65.
The introduction of the NHS on 5.7.48 heralded a new philosophy for health care in the U.K. It was to be free to all for life. Those preferring private care retained this privilege without reduction of their tax-paying contributions to the NHS.
Newly Qualified doctors and aspiring specialists had no difficulty with the new service. Established specialists did face a problem. Accustomed to independence, giving their service voluntarily to local hospitals and earning their living from private consulting practice, they now became salaried employees (called 'consultants'), only allowed private practice if they elected to work part-time (or not at all) in the NHS.
In 1948 before the NHS started there were 6 or 7 consultants in Dermatology in the West of Scotland, three covered the Western Infirmary, the Southern General Hospital and Stobhill Hospital, one (possibly two)at the Royal Infirmary and two at the Victoria Infirmary. I am doubtful of the position of Drs Harvey (Royal) and Carslaw (Victoria) at that time. These seniors were responsible for the Dermatological services for the whole region (population about 2.75 million), for teaching of medical students and any postgraduates there might be. They were helped at O.P. clinics by assistant dermatologists who were for the most part either aspiring specialists or G.P.s. As far as I know none of them were paid for their services but gave it for the experience and their expectations. Each of the five Glasgow teaching hospitals had dermatological beds and the in-patient routine was looked after by a house physician.
New Arrangements under the NHS
The new Western Regional Hospital Board (WRHB),which changed its name from time to time, decided on the consultant staffing to replace the old Voluntary hospital system. The scale of appointments was empirical and largely dependent on advice from the incumbent staff. Not unexpectedly the previous seven senior posts were confirmed with slight adjustments. Dr. Herbert Brown retired from the Victoria Infirmary and was replaced by Dr. RW Carslaw; Dr. AD MacLachlan retired from the Western Infirmary but was not replaced immediately by a consultant. Dr. Ferguson Smith retired from the Royal Infirmary but aappointed to a new post covering Ayrshire.His post was taken by Dr. George Harvey, and Dr. AC Dewar was also appointed to the Royal with sessions in Lanarkshire. This meant that the total number of Consultants for the whole WRHB area remained at seven and did so for the next 12 years.
Junior staff in the five Glasgow teaching hospitals was established on an ad hoc basis. That is to say, there should be enough to cope with the clinical work load plus training time for aspiring consultants and for experience for those intending to be G.P.s. Account had also to be taken for study leave for trainees bearing in mind the necessity of obtaining a higher degree in general medicine to qualify for a consultant post. The number of those wishing to acquire some experience in skin disorders was boosted by returning ex-service dermatologists with considerable knowledge of war-time and tropical dermatology but with no formal training in civilian dermatology and no higher medical degrees. Many of these men had taken up a Government offer of training in 6- monthly periods as 'Class III post-graduates'. In the new scheme they were classed as Senior Registrars (SR) and because of their number there was often more than one SR in an individual unit. A few were classed as Senior Hospital Medical Officers (SHMO), which was an established post below consultant level and presumably the equivalent of an Assistant dermatologist in the pre-NHS days. A teaching unit would thus consist of two consultants, possibly one or two SHMOs, one or more SRs, one or more Registrars, a Senior House officer (SHO) and a house physician, who was resident. In unusual instances there might be a Junior Hospital Medical Officer (JHMO) who would probably be a G.P. This general arrangement continued more or less for 12 years.
Out-patient numbers in Dermatology increased steadily with a concomitant increase in ancillary work such as histopathology. Embryo clinics in outlying areas (e.g. in Paisley, Irvine, Vale of Leven, Stirling, Stonehouse etc.) staffed from Glasgow, also increased in size. Much of the resultant work fell on SRs, who were nevertheless glad of the extra experience. However, many of those graded as SR in 1948 (in general medicine and surgery and many other specialities apart from dermatology) were categorised as 'supernumerary SRs' because they were considered to have completed their training. In 1955 as a result of unrest and anxiety about their position, a group of 16 of these individuals, including two dermatologists (I was one of them) all between 35 and 40 years old, married with families, qualified between 11 and 15 years and all with one or more higher qualifications, appealed to the Secretary of State for Scotland, who happened to be my M.P.. They claimed that they had been retained in their supernumerary status because of "their duties there essential for the efficient conduct of clinical and teaching commitments of their respective hospitals"(Extract from the letter to the S.of S; June 1953). They felt that their duties both before and after 5.7.48 were those of consultants. They had accepted their original grading "as there was a definite promise of wide spread expansion of the consultant services." (This had been a reiterated complaint since the onset of the NHS. It was always a case of jam tomorrow but never jam today). The expansion did not materialise. Moreover, often vacancies created by death or retiral were not filled. e.g. when Dr.AD MacLachlan retired from the Western Infirmary in 1948 his post was not filled; instead two SMHO posts were created. This appeal was considered sympathetically by the Secretary of State but was nevertheless rejected after consultation with the WRHB. The latter had also considered the matter and concluded after consultation with the respective heads of departments that the appropriate staging of a medical or surgical and by implication specialist units, was two consultants together with a consultant of slightly junior status (cited in the S. of S. reply to the 16). It should be noted that the senior consultants, whose views were sought, were all part time and retained their pre-NHS bias (and protected their territory). Their view was paramount. It is also noteworthy that the WRHB's idea of two consultants took no cognisance of the number of sessions they worked. In more than one instance this was scarcely more than the equivalent of one whole time consultant--perhaps one or two sessions more. Incidentally all but one of the 16 became consultants later and one was elected President of the Royal College of Physicians and Surgeons of Glasgow. Dermatology staffing remained unchanged.
Early improvements in staffing
In 1958-59 the Royal College commissioned the 'Platt' report on hospital medical staffing. As a Member of the College I felt that I was entitled to give my opinion if I wished. Although I was still a SR at that time I submitted a scheme based on Glasgow and Regional centres outwith Glasgow, envisaging 15 consultants in Dermatology. This scheme was taken up by the 'Wright' committee on the same subject. Their recommendations were published in 1961 and carried out over the next 4 to 5 years. In fact by 1965 fifteen posts in Dermatology were established in the WRHB region. Over the next 30 years this establishment has been slowly increased to 17 by 1970, 18 by 1975 and now in 1998 there are 24 consultant dermatology posts in the Region. (See Table 1.) These posts only came about after persistent pressure firstly from the post-War generation of dermatologists and later by the succeeding generation. Such pressure was necessary to overcome the procrastination, parsimony and especially the shortsightedness of the WRHB authorities. The result, however, is the establishment of a group of enthusiastic consultants with progressive ideas, individual interests and the drive to use their talents for the benefit not only of themselves but also of their juniors and especially of their patients. Because of this they are in a position to offer an enviable dermatological service to the whole of the West of Scotland. The original impetus for this came from John Milne and Alan Lyell. Another factor which greatly helped was that the immediate post-war group suffered from a lack of such support in their training and were determined that their successors should not be so handicapped.
The Training of would-be Consultant Dermatologists
With the successful struggle over staffing ended in the early 1960s, the log-jam on the training ladder caused by the number of supernumerary SRs was removed. New postgraduate recruits of high quality, including some from overseas, began to apply for registrar posts, of which there might be two or three in any one unit together with one SR. A few of these recruits already had a higher medical qualification but as before most had to obtain one whilst at the same time studying dermatology. The proportion of women applicants steadily increased, although not all necessarily intended to practice dermatology. The latter were not included on the training ladder but might be needed for the necessary clinical requirements of any particular unit. It quickly became apparent that the possession of a higher degree was now mandatory to achieve SR status and in the late 1970s was also deemed necessary for a registrar post on the training ladder. This incidentally fulfilled the view expressed by McCall Anderson some 90 years earlier. The intention was for trainees to concentrate all their efforts on dermatology, the academic standard of which was steadily improving.
In the early 1960s, under the influence of Milne and Lyell and supported by most of the consultants, schemes were evolved for training which would be more or less common throughout the Region. They predated the present national scheme. The various teaching units, apart from tutorial schemes within their own departments, hosted Seminars on various subjects connected with dermatology for all the junior staff in the Region. This made use of specialised knowledge which particular individuals (of whatever status) might have and also occasionally involved inviting the help of specialists in subjects such as Plastic Surgery, Radiotherapy or Immunology. John Milne ran courses in dermatopathology on a regular basis and these augmented by joint sessions in some units between dermatologists and their reporting histopathologists to their mutual benefit. The trainees were also expected to give tutorials to small groups of medical students, which was a valuable exercise for them. They were generally supervised by a consultant.
Thus, a broad education in the clinical aspects of Dermatology was given over a period of two to three years throughout the Region. Trainees were also encouraged to prepare papers on unusual clinical cases or on subjects of their own choosing. It was the custom at the Royal Infirmary that all such papers whether by junior or senior staff were read before a full departmental meeting for criticism prior to its being published or read at a meeting elsewhere. This is an invaluable exercise and educational for all concerned, leading to clear, concise presentations with good quality illustrations and acceptable mode of speaking to an audience.
In 1948 there was no special University department of Dermatology in Glasgow. The consultant staff in the various hospitals were appointed as "honorary clinical lecturers' by the Faculty of Medicine and were paid a token honorarium of between £80 and £150 per annum. In the 1950s James Sommerville suggested that a University Department of Dermatology be established with a base at the Western Infirmary. John Milne was appointed as lecturer in Dermatology with a special interest in dermatopathology. He had trained as a pathologist and had the added advantage of being MRCP. A chair in Dermatology was endowed in 1960 and Milne was appointed the first Professor thus following in the footsteps of GH Percival in Edinburgh. Milne started what was to become a celebrated course in dermatopathology for trainees and consultants, for which there is keen competition to get a place. To complement this he wrote an excellent text-book on the subject. He also started a laboratory for basic research into subjects connected with dermatology, with a lecturer and post-graduate researchers. He was also responsible along with Prof. PJ Hare of Edinburgh for the foundation of the Skin Biology club. This is an association of dermatologists, veterinarians and scientists involved in or interested in any way with work connected with the skin. They meet twice yearly and read papers on subjects so diverse as the wing structure of birds, the growth of vibrissae in mice, photobiology, ectoparasites, bullous diseases, atopic eczema, mutations in sheep, the culture of trout not to mention the very basic research into abstruse genetic and carcinoma research. This has proved an outstanding success and has broadened the outlook of all participating. It has also acted as a forum for the presentation of papers for junior staff to give them experience for larger meetings. Mixing clinicians and research workers is an excellent idea.
After his sad and sudden death in 1978 Milne was succeeded by Rona Mackie. She had been appointed a consultant dermatologist in 1973 having previously worked as a researcher with special interest in malignant melanoma and the immunology of the skin. She trained for these in the pathology and immunology departments of the University at the Western Infirmary. She pioneered a technique for the rapid clinical diagnosis of pigmented skin lesions primarily to identify early malignant melanomas. The latter became her main interest although she pursued investigations into atopic eczema and the immunology of the skin. She is an excellent organiser and skilful procurer of funds for research purposes. This has been so successful that the department under her has expanded greatly. The laboratory now occupies splendid purpose-built premises in the Robertson building of the University with a staff of two Senior Lecturers, 12 post-doctoral and graduate researchers in grant-funded posts, six technical workers and four secretaries. A large number of publications and papers read to learned societies bears witness to the output of the laboratory.
Prof. Mackie was President of the British Association of Dermatologists in 1996.
Apart from the research aspect the University department now has the responsibility for co-ordinating all the junior staff in training posts for the West of Scotland. The new specialist registrar system involves the trainees rotating through the Western and Royal Infirmaries, the Southern General Hospital and Monklands Hospital. This seems a sensible scheme as the number of trainees is now in line with the likely number of consultant vacancies. The great reduction of SRs and registrars of the old scheme, and their final disappearance, is compensated for as regards staffing the hospitals with an adequate personnel to cope with the clinical load by the appointment of career grades below the rank of consultant (Shades of the old SHMO grade!). These are associate specialists and clinical assistants and SHOs (some of the latter may be on the training ladder).
Is the present staffing level adequate? Although there are now 24 consultant dermatologists their functions and distribution vary considerably. For example at Stobhill Hospital there are two consultants but between them they only spend 16 sessions whereas in the 1970s there were 25 sessions. The number of new referrals in the intervening period has gone up by 150%.For this added burden of work there are now 3 SHOs to help. Previously there were registrars and an SR all with dermatological experience whereas SHOs have the minimum of experience. In contrast in the Forth Valley area there are now two consultant dermatologists whose time is entirely taken up with clinical dermatology. They have four GP assistant sessions per week. The service here seems to be a consultant orientated one (in the opinion of one of them the service given to the area is better for this). Would this system of almost entirely consultant service not be very suitable for the more remote areas such as Dumfries and Galloway, Argyllsire and Dunbartonshire? If so, then more consultant posts still will be needed. I can envisage the number ending up about 30.
The Contact Dermatitis Investigation Centre
The CDI unit was the brain child of Dr.Milne and Dr. Lyell. It was started on a shoestring budget at Belvidere Hospital and run and organised from the Royal Infirmary. It supplied a service for the whole Region (although many individual units carried out their own routine testing). There was a whole time nursing staff of three with a secretary and a consultant in charge. It began about 1974 with Dr. SL Husain in charge. He had done a 3-month tour of European centres for information and advice. After his departure for the USA in 1977 his place was taken by Dr. Angela Forsyth, who remains in charge. The unit moved to better premises around this time and in 1990 it transferred to the Royal Infirmary into even better accommodation next to the Dermatology department. It offers an advisory service to industry in the West of Scotland and is much appreciated. It has also proved to be of great assistance in elucidating some difficult cases of eczema/dermatitis for other units in the region apart from the Royal Infirmary.
The Influence of inflation and bed closures
Beds for dermatological purposes were first introduced by McCall Anderson in 1874 when he moved from the Royal Infirmary to the Western Infirmary to become the Professor of Medicine and also Dermatologist to the Infirmary. His out-patients clinic--the Glasgow Skin Dispensary,founded in 1861,remained in its original building in the city centre but transferred to the Western Infirmary after his death in 1908, its funds being used to endow beds already there. These beds are still in use. With the onset of inflation in the mid '70s the reduction of Glasgow's population by one third and the development of independent peripheral units in the Region, a reappraisal of beds for dermatology became inevitable but was hastened by financial priorities.
The accompanying Table 2 sets out the skin bed state in the West of Scotland over the years and is self-explanatory. The precipitation of events after 1980 was due to pressure to close hospital beds in general and to an (undeserved) tendency of the WRHB and its successors to regard Dermatology as not requiring beds, whilst dramatic conditions such as cardiac surgery and organ transplant with their relative tiny numbers of patients as having priority over the 95% of the rest of the population. Skin beds therefore became an easy prey to pressure from all sides. The Royal wards, a vital part of a renowned teaching unit were closed in 1990 after a valiant rearguard action for 10 years by Dr. John Thomson. The in-patient needs of the Royal were to be supplied by Stobhill Hospital, which had its original large complement of beds reduced in 1994 to 16 and in 1996 to nil. Thus the admissions for the Royal, for Stobhill, the Argyll peninsula and for Forth valley were to be to the Western Infirmary, which also had to cope with its own inpatients as well as those from Dunbartonshire and North Argyll. To do this, its bed complement was increased from 20 to 22 beds. Sick children's bed state remained at 12 (now reduced to 4) but this had to take the children formerly admitted to Stobhill. The bed state in the periphery was greatly improved as shown in the Table. The most serious loss was in the Royal Infirmary, where Dermatology had started as a specialty in its own right in 1861. This unit had a great tradition in the training of consultants and the likelihood of this continuing was enormously diminished by the closure of the in-patient department. It is a mistake that will be regretted for years to come and the authorities may ultimately be forced to reverse the situation. The merger of the Southern General Hospital and the Victoria Infirmary is also serious as both are teaching hospitals. The Southern General, however, has better facilities and may well compensate for the diminution of the role of the Victoria in the end. There is also the possibility that centres like Lanarkshire and Crosshouse in Ayrshire may be able to train post-graduates in the future (see previous discussion). This is especially applicable to Lanarkshire which has a team of five consultants.
The influence of incomers on Dermatology in the West of Scotland
In 1948 all the senior dermatologists in the Region were Glasgow graduates. There was undoubtedly a parochial atmosphere, well recognised by me since I was a graduate of another centre of medical parochialism -Birmingham. Aspiring dermatologists after 1948 did not all hail from Glasgow. Several European refugees desired to practise here. They included Dr. Tad. Pasieczny an ex-Polish Army Dermatologist, and three women--Dr. Lominska also from Poland, Dr.F.Cohn from Breslau and Dr. Maria Ratzer from Prague. Later Kalman Keczkes from Hungary who escaped in 1956 whilst a medical student. He quickly learnt English, completed his degree at Glasgow and within 16 months had acquired the MRCP. He is now a consultant in Hull. Dr. Pasieczny deserves special mention. A highly decorated colonel in the Polish Army he escaped from the Gestapo in 1939, crossed Europe on foot and skis and ended up in Scotland. There he spent the remainder of the War apart from a distinguished episode as second in command of the Polish expedition to Narvik. Apart from his medical qualifications he had a degree in physical education, was Polish Universities' Fencing and Skiing champion and an International referee for Association Football. He was highly experienced in both Dermatology and Venereology. He was appointed JHMO,the lowest established rank in the NHS at the Royal Infirmary in 1948. Apart from his invaluable whole-time daily work in Dermatology he spent several evenings weekly in the city venereology clinics at the specific request of the WRHB and for nearly 20 years he was the mainstay of the service. It is fair to say that without his authority and experience that service would have been second rate. Yet the WRHB did not pay him a penny for this service and he only got promotion to SHMO after 10 years and ultimately and belatedly in 1965 was made a consultant. He was extremely popular with everyone who worked at the Royal Infirmary, from consultants to clerks, joiners , plumbers etc. to whom he was affectionately known as 'The wee Polish Doctor' .
Apart from these Europeans I was the first and only non-Glaswegian graduate to work as a dermatologist in the West of Scotland for the next 14 years. First impressions were of a closely knit group but there were amazing rivalries, usually concealed. There was almost no communication between the various hospital staffs except at meetings of the North British Dermatological Society (now the SDS) but with many juniors from all areas now attending the atmosphere soon thawed and we began to know not only the seniors in Glasgow but throughout Scotland. The increased friendliness, however, did not extend to an increase in the consultant establishment.
The appointment of Alan Lyell to succeed George Harvey as head of the Royal Infirmary Skin department marked a turning point. Trained in London and Cambridge he came via Edinburgh and Aberdeen and was full of new ideas. Moreover, he now had the power to put them into practice. From being an active but hum-drum teaching unit the Royal department soon became a hive of activity and attracted post-graduates to registrar posts in numbers and they were of good quality. During the 18 years (1962-80) when he was in charge no fewer than 12 of these registrars obtained consultant posts either in Scotland or elsewhere and many others continued to practice dermatology at a lesser level. Several of these consultants were from overseas. The influence of Alan Lyell cannot be overstated. The presence of someone with ideas emanating from outside Glasgow was very beneficial to Dermatology in that city and thankfully has been realised, even if subconsciously, because the recent upsurge in the total number of consultant posts in Dermatology in the West of Scotland has included no fewer than eight who qualified elsewhere apart from new Glasgow qualified consultants. Long may this mix continue.
ADDITIONAL NOTE:Day Treatment Centres
Dermatology beds originated because management of skin diseases in general medical wards was regarded by dermatologists as highly unsatisfactory for a variety of reasons. The drastic reduction in such beds has meant the re-introduction of Day treatment Centres (DTC's).This note concerns their activities and whether they are adequate replacement for beds.
DTC's provide a dressing service for Eczema/Dermatitis, Psoriasis and leg ulcers (varying from daily to weekly dressing) and routine PUVA and narrow band UYB treatment,as well as routine patch testing, biopsies, minor dermatologic surgery and laser therapy. They also undertake regular monitoring of patients on methotrexate, immunosuppressive and corticosteroid therapy.
The nursing staff varies from unit to unit dependent on the size and distribution of the local population and the presence of any designated skin beds.In an area of scattered population, such as Dumfriess and Galloway, a DTC is impractical and service is provided by arrangement on an ad hoc basis. Where the population is somewhat more concentrated a DTC is desirable but not always available (e.g. Vale of Leven) All the other areas in the West of Scotland have one or more DTC's. Some (e.g., Ayrshire, Lanarkshire) are highly organised with a full staff (Sister, 2 to 4 staff nurses, plus auxiliaries) and may offer out of hours opening (e.g. 8am to 8pm on weekdays and Saturday opening). This is very popular and overcomes the reluctance of employers to release workers for treatment. Other departments only open during office hours because either management have vetoed the expense of out of hours opening or the Nursing staff are reluctant to undertake the extra duties. In Renfrewshire this has meant out of hours dermatology has to be undertaken by the general physician on call, which is most unsatisfactory. PUVA and UVB treatment is usually carried out by specially trained nurses (sometimes by the dermatologist). The same applies to routine patch testing.
In at least one department there is a set protocol of progression of topical dressings for eczema and psoriasis,which allows the nursing staff considerable freedom of action. However, there is always a dermatologist (consultant or assistant) available to give advice and change treatment where necessary.
The annual attendances at these DTC's is considerable, from 5,000 to 7,000 plus. The duration of treatment on the whole is rather longer than would be the case were more beds available. It is estimated in Lanarkshire that the availability of a DTC can reduce the length of stay in their ward by an average of 4 days.
The general impression given by the consultant dermatologists in the Region is that DTC's work well. Many of the younger dermatologists think that in-patient treatment is seldom necessary but some of the older generation with experience of their own inpatient units regret their departure, whilst acknowledging that new drugs and modern techniques have made them less necessary. One consultant misses the weekly ward round of the whole departmental staff and the subsequent valuable general discussion afterwards.This is an educational opportunity that trainees in the future may be denied.
A further regrettable change in medical education is the proposed removal of dermatology from the students curriculum. This will undoubtedly affect general practice and may indirectly aggravate the loss of dermatology beds.
Whether the economies of bed closure are justified remains to be seen. Can patients be investigated adequately as out-patients?. Will a central token bed complement be sufficient or convenient for this purpose. The present writer's view, although perhaps out of date, is that the authorities who have wrought these changes have gone rather too far and may well have to review their hasty bed reductions for dermatology.