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CHIEF FINANCIAL OFFICER

The modern hospital with its rapidly growing andcomplicated business problems needs the services of anofficer experienced in finance and accounting, includingstores accounts, cost accounts, business methods, andsystems of internal financial control. The accountingregulations made under the Act provide for such anofficer in the person of the chief financial officer. He is

particularly the servant of the finance committee,to whom he should report direct. This is provided forin the regulations. At the same time he will realise thathis services must necessarily be at the disposal of allcommittees and executive officers of the hospital as

occasion requires them. It is to him that the hospitalauthorities should look for information and guidanceon all financial matters, and he is, or should be, theagency by which they carry out in detail their financialpolicy and system of control.From this, it will be obvious that the appointment is

an important and responsible one. Not only must theofficer be well versed in sound business principles, buthe must understand how to institute and maintain anefficient accounting system based on up-to-date methods;bow to institute a system of internal financial control,not only as affecting cash and its equivalent in servicesand materials, but as affecting each and every transactionwhich will ultimately result in the receipt or paymentof cash ; and how to prepare and operate a budget whichwill act as an instrument of administrative control overall.the finances of the hospital. He must understandendowments and .the investment of funds, and how toprepare intelligent periodical financial and statisticalstatements showing clearly and fully the financial positionof the hospital. He is responsible for the keeping of allbooks of account and financial and statistical records,the examination of accounts, their presentation to thefinance committee, and payment of salaries and wages, and,subject to the direction of the committee, he has solecharge of all finances of the hospital. He is not a book-

keeper-not a mere recording agent : he is a responsibleofficer and he should be clothed, with the requisiteauthority.The chief financial officer should exercise his control

at two distinct places in the system-in the spendingdepartments, and in his own department. The headsof the spending departments should be made responsibleto him for carrying out duties related to the accountingrecords, such as the time-recording of all employees,recording stores received and issued, examination ofinvoices and accounts as to receipt of goods, andexamination of goods for quantity and satisfactoryquality. Control, therefore, begins with the certificationof these records, and it is continued when the records reachthe chief financial officer for entry in the financial andthe costs accounts, and with the preparation and presenta-tion of specified periodical statements to the financecommittee. Thus the term " financial control " reallymeans unity of control as exercised by the chieffinancial officer under the direction of the financecommittee.The various executive officers are principally concerned

with the invention, enactment, and execution of theirhospital, public, and social services, and the chief financialofficer watches these services coldly and critically fromthe point of view of cost. He is a watch-dog, not asleuth-hound ; his financial organisation is not intendedto put a drag on the wheel of progress, but to see that thehospital gets value for its money ; that there is no

extravagance or avoidable waste ; that the mosteconomical methods are used ; and generally, bycriticism and financial vigilance, to serve the same

purpose as the profit and loss account in a commercialconcern.

Disabilities

37. ANXIETY’NEUROSI[S-11 f

I HAVE a bad heredity, which includes alcoholism.Strong emotional disturbances and theatrically violentfamily rows in my childhood made, I am told, classicprovision for later instability. But I was a usefulcitizen doing responsible work, physically and mentallyon top of things, when, at the age of 30, I was knockeddown by a car in the blackout. Without this accidentI think I might have remained stable.

’

I had a head injury and I spent five weeks in

hospital. London was not, perhaps, a good place at thetime for a quiet convalescence. I went on overworking,as everyone did then, and felt more and more exhausted.I had nausea, giddiness, faintness, and tachycardia.Examination showed that the symptoms were functional.I went to a psychologist who prescribed rest and relaxa-tion. I rested, failed to achieve relaxation, felt worse,and went back to work. A year later I was bombed out,and soon after that became unfit to go on with my job,though I was still getting the work done well and fewpeople knew I was as ill as I was.

I could barely get myself to the office or stay in ituntil it was time to go. I was always exhausted, alwayscold ; my hands were clammy with sweat ; I cried weaklyand easily. I was afraid to go to sleep ; but I did sleep,to wake with a constricting headache, dizziness, andtachycardia. To these now familiar symptoms were addedwaves of panic fear followed by depression. The panicsalmost overwhelmed me. I felt very much more frightenedwhen I was alone and but a little less frightened withother people. There were only three with whom I felt atall safe and able to relax, though even with them I wasbehind the screen of my fears. At the height of a panicI just wanted to run-anywhere. I usually made towards

‘

one of these reliable friends (two of them were doctors),from wherever I happened,to be. I felt, however, thatI must resist this running away, so I did not allow myselfto reach safety unless I was in extremity. One of mydevices to keep a hold on myself at this time was toavoid using my last chance, for I did not dare to thinkwhat would happen if it failed me. So I would merely gonearer to my bolt-hole and imagine the friendly welcomeI should get. This would often quieten the panic enoughfor me to start out again, or at least not be a nuisanceor use up any good will. Sometimes I was beaten andhad to feel the acute shame and despair of asking forcompany. I felt the shame even when I hadn’t to confessto my need.One of the most distressing symptoms of this period,

which was-and occasionally still is-associated with thepanics, is a sensation of divided personality. There isMe 1 and there is Me 2, though neither of them is reallyme, for " I

" am detached and merely the battleground

for the two of them. Me 1 seems to be my intellect,with a good bedside manner, reassuring and common-sensical. Me 1 chivvies the wretched Me 2 along. Me 2-is the sickly panic-stricken me, who can reduce Me 1to catch phrases, rote repetitions, and cursing. So far,Me 1 has remained on top even in the worst panics,and is helped by occupation. I have never fallen downon a job, and when I discovered that, as long as I felt-reasonably safe, work helped, I kept my brain busy.I could not happily read modern psychological novelsor books with much genuine emotional content. Itwas a bad day when I started Arthur Koestler’s " Arrivaland Departure " (I did not finish it) ; and " Crime andPunishment " was a mistake at the time too. History wasgood, learning some German was better. Tenses anddeclensions were magnificent repetitive stuff to cling toduring panics, and to return to after the climax when

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self-pity and despair threatened to take over. The dayon which Me 1 and Me 2 first briefly coalesced broughta peace which perhaps only those who have beenmentally ill can understand ; though I expect a

painless day to. other Disabilities is an equally joyfulexperience. ",

I went to another psychologist. I was anxious to

cooperate and I think I did. Some relief came simplyfrom knowing that my sickness was not uncommon,that someone could at least understand what a paniccould do, even if he could not altogether appreciatewhat it could be. It isn’t always much help, if one is

physically ill, to know that a lot of people are ill in thesame way ; but I found it most helpful to know thatmy neurosis was not an isolated or isolating thing.This is related, of course, to the fear of insanity ; and theassurance that I was not likely to lose my wits actedlike a supporting plaster, though I could not at oncerely on it and still very occasionally mistrust it. Thiskind of psychotherapy-a sharing of the private burden-helped me to recover enough to know that work wouldrestore some self-esteem. Though my mental capacitywas never affected, my confidence was low and my energylimited. I took a whole-time responsible job, but I hadto fight my symptoms every moment of the day. I wasin despair. The psychologist suggested that I shouldtake on a job in which he was professionally interested,in addition to the one I was doing. Then I knewI was neither dying nor insane. I believed I mightrecover, I almost believed that even disabled- I wasstill a useful person. I took the job. That was oneof the best bits of psychotherapy I have come across.A great fillip followed : a doctor friend told me " thenatural tendency of a neurosis is to recover." This,I thought, sounded like experience and not mereencouragement. I did Coue with this phrase and it almostreplaced German verbs.

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For three years I had been unable to make a train

journey alone. I now felt it was essential to my self-esteem to do so successfully. I arranged the journeycarefully from one place of safety to another, had all

my terrors beforehand, and travelled as if under

light anaesthesia. I cannot say I lost my fears as a

result, but I realised I could do what I had been unableto do.

Soon after this I had to learn to drive a car. I hadalways wanted to, but now I lacked confidence. I alsoknew what it was like to be a pedestrian casualty. Myinstructor was sarcastic and gloomy, but I passed thedriving test without difficulty. Driving a car has beenfirst-rate occupational therapy. That sounds irrespon-sible, but in fact the new responsibility widened myconfidence, and fear developed into careful judgment.The vagaries of an old car ensured that the therapywas occupational. Waiting in traffic blocks broughtat first a return of panics-and there was no runningaway.My deepest terrors all this time were my own ; butmy behaviour at home, where I felt safe to take off mycumbersome armour, was distressing, and I know thatonly a saint can play successfully the role of neurotic’scompanion. That someone should play this part, however,is vital to the patient’s comfort. A neurotic is disabledin the very part he must, use to effect his recovery.Sometimes he is as good at it as at lifting himself by hisown bootstraps, and he is lucky indeed if his home isa springboard of unalterable affection, encouragement,and good temper. Mine is ; it remains resilient againstdespair, shame, and fear. I still do not find it easy toaccept my neurosis as being no more my fault than aparalysed leg. Perhaps if I could wear a bandage roundmy head I should feel less ashamed. Perhaps if peopledid not say so freely " You’re all right. You just want topull yourself together" it would be better. It is, unfor-

tunately, still necessary to try to hide one’s neurosisfrom most people.

Growth of insight has helped me greatly. If psycho.logy didn’t cure me it gave me some idea of howthe mind works to avoid, and protect itself against,painful thoughts. I understood this and applied itpersonally as soon as I could. Now, like other Disabilities,I have my methods. The essentials are my few safetydepots-people or places. The safety radius from themgrows longer and longer. I am still claustrophobic;that rules out underground trains for me, but I use.

the District Railway. I find it difficult to meet relationsand childhood friends, and to go to places where Ilived or worked when I was very ill. But I have learnedto make short visits to give me a sense of achievementand to follow them when I am ready for it by a longervisit. Both people and places are shrinking to their normalsize. Depression usually returns about a week beforemenstruation, and I have learned to remind myself thatlife will look different when my period begins. Oftenwhen I am depressed or disturbed I can trace it to a dream.I associate my dream symbols easily now and am relievedto recognise the particular source of anxiety they represent.I have also learned that agitation or irritability abouttrifles usually hides a deeper anxiety which can be broughtinto the open, where it is much less formidable. I am alsolearning not to be a perfectionist-that it is permissibleto admit to anxiety about things I have always sternlytold myself are trifles to be ignored. Many of them,I find, are common fears.

If I am fearful of going anywhere strange to meet myfriends I invite them home instead, or meet them ata familiar restaurant. I am grateful for their forbearance.Strangers, too, can be more helpful than they know,and I have used them deliberately : a cheerful busconductor, a kindly shop-assistant, can help me to calma mounting panic and bring the world into focus again.If I have something difficult to do-to make a journeyalone, to sit trapped under the drier in a hairdresser’s,or to make a public speech-I know I shall be depressedand acutely afraid beforehand. I avoid trying myselftoo high meanwhile. When the time comes I fortifymyself by recalling my past victories, remind myselfthat I can only die once and that it probably won’tbe so bad as this, and accept a slight return of Me 1 and 2.My family take Luminal.’ The actual experience nowis not much worse than severe stage fright, and if someonesees me to the wings I totter on. Surprisingly, no-oneseems to notice. If I am suddenly called on to dowhat I could not do deliberately, I usually manageto do it first and have the fright afterwards, as mostpeople do.

I know that I have reached another stage now. Thewriters of other articles in -this series have impressed mewith their courage and resolution in accepting a frame-work of limitation-even though they ingeniouslyenlarge it. But I dare not accept my sickness-fear-because it never stays arrested. My very safety devicesbecome distorted and grow into symptoms themselves.I must therefore break down as I go along the aidsI build up ; otherwise the habits of response to fear,or avoidance of occasions of fear, can be as inhibitingas the fear itself. Indeed I feel tolerably sure thatmany of my symptoms now are .the result of habit-pattern and that there is less ground than I think formy terror of falling back into the paralysing panic states.So now I hope to go forward from that.

"... Everybody knows that a few imperfect statistics anda little biased observation point ominously to a future inwhich the bulk of the population (apart from the’growingarmy of survivors from happier days) will consist of more andmore highly educated imbeciles of lower and lower grades :but nobody really believes it."-Times Literary Supplement,Aug. 5, 1949, p. 503.