1
695 r.3d received his schooling under the State educational system, Ms under obligation to stay and work permanently in Br::ain. But primary and secondary education were available :c all, whereas medical education was not. It was limited in .clume by the number and size of our medical schools, which 0u1J train only about 1 out of every 3 well-qualified candidates nho would like to take up a medical career. He did not want to ’3r that no doctor should emigrate. We had a duty, for example, :0 help medical services in developing countries, and we encouraged young doctors to go overseas for a period to help such countries. He was not thinking of this kind of emigration, but of escape to countries where the doctor/population ratio was even higher than our own and where the financial pickings sounded more attractive. Britain could not afford to train doctors swell the membership of the American Medical Association. One wanted to see a reasonable interchange of doctors across national frontiers, preferably on a temporary basis, and from such interchange our Health Service gained as well as lost. But to accept a fine medical education in Britain with the deli- berate intention of selling it elsewhere where the price might be, or seemed to be, higher, was in his view a cynical and selfish act. We needed in our own Health Service every doctor we trained. Those who advocated emigration might spare a thought not only for their colleagues who would be left to shoulder an inevitably heavier workload, but also for those young men who might have become doctors if they had not been squeezed out of medical school by those who were fortunate to gain places. No-one wanted the sort of crisis we had now for its own sake, but nevertheless at times like these it became possible to con- sider new ideas and solutions which in more normal times might well be regarded as too radical. He intended to make full use of this chance, for he was determined that our great Health Service-and for all its shortcomings it was a great service- should offer worthy opportunities for those who worked in it. A MINISTRY’S REPLY THE Ministry of Health has been reviewing the unfavourable comments on the National Health Service’s hospital building programme which have appeared in these columns and elsewhere, and a memorandum from the Ministry includes the following facts and figures for consideration alongside these criticisms. Data for precise comparisons with the ’30s are lacking, but the annual expenditure on hospital building in England and Wales just before the 1939-45 war is estimated at E10 million, or at present prices E46 million. The current level is E73 mil- lion, which is expected to rise to at least E100 million by 1970. In 1938-39 hospital capital expenditure was 0-19% of the gross national product; in 1965-66 it was 0-23%, and by 1970 is expected to be 0-31%. According to an unpublished W.H.O. document, which gives the latest international figures available, the total capital expenditure on health services (the major part of which will have been on hospitals) expressed as a percentage of the gross domestic capital formation was: Canada 2-31 in 1961, Sweden 212 in 1962, United States 1-76 in 1961-62, United Kingdom 118 in 1961-62, Australia 1-16 in 1960-61, and Czechoslovakia i 10 in 1961. During 1948-65 about E337 million was spent in completed themes for hospital building; about half of this was spent on themes completed in 1961-65. In the earliest years little was an annual average of £9 million—but the mid-’50s saw .: beginning of steady growth to the current annual level of million in those impoverished early years priority was given to existing hospitals rather than building new ones. By only 30 schemes costing £1/4-1 million, and 3 costing over million had been completed. By 1965 these numbers had 98 and 17 respectively. A further 79 and 43 schemes in these cost-categories were in progress, which together comprised more than 80% of the total value of work then under way (E165 million). Small schemes (under E30,000 each) accounted for roughly 58% of the total value of all schemes completed by 1961, but only 30% in the subsequent four years. The proportion continues to fall. 48,684 beds were provided in these seventeen years, and the following departments were newly built or expanded: out- patient 612; accident and emergency 138; operating-theatres 466; radiotherapy and diagnostic X-ray 420; pathology labora- tories 320; physiotherapy and occupational therapy 596; nurse-training schools 313. The Ministry further points out that its building programme is not aimed primarily at increasing the number of beds but at providing the right kind of beds in the right places. Thus the number of beds has changed little since 1948, but the drop in the average length of stay has allowed the number of inpatients to increase by about 3% a year (4,818,000 in 1965, 4,136,000 in 1960, and 2,937,000 in 1949). At constant levels of remuneration and prices, the money for running-costs of the hospital service has increased by about 2% per annum over the last eight years. Boards are now plan- ning two years ahead on an increase of 2-75% a year. Between 1949 and 1965 the number of whole-time nurses (trained and in training) increased by 43%, while that of part- timers nearly trebled. The number of medical staff (whole-time equivalents) increased from 11,735 to 18,904. Included in this increase were: Conferences SARCOIDOSIS THE 4th International Conference on Sarcoidosis was held in Paris on Sept. 12-15, under the presidency of Prof. J. TURIAF (Paris). STRUCTURE Dr. W. JONES WILLIAMS (Cardiff) believed that the sarcoid granuloma was a reaction to displaced or altered lipoproteins and mucoproteins. Histochemical studies revealed similar findings whether the changes were due to sarcoidosis, beryllium disease, Crohn’s syndrome, ulcerative colitis, diverticulitis, cholecystitis, or intestinal carcinoma, or in Kveim nodules. Dr. Z. COHN and others (New York) compared the ultra- structure of skin and lymph-node sarcoid granulomas and of positive Kveim-test sites. Epithelioid cells in all of these lesions showed characteristic interdigitating surface membranes and elongated or oval nuclei with irregular margins and prominent nucleoli. The cytoplasm was abundant and contained well- developed Golgi apparatus, variable amounts of rough endo- plasmic reticulum, many mitochondria, and large vacuoles. Biopsy of one Kveim site six weeks after injection of a mixture of Kveim-test material and carbon particles showed the carbon within large vacuoles of the epithelioid cells, indicating that these vacuolar structures were of phagocytic or pinocytic origin. Dr. J. T. KELEMEN (Debrecen, Hungary) found that the giant cells of tuberculoid granulomas were A.T.p.-ase negative, whereas the giant cells of all other non-specific granulomas were strongly A.T.p.-ase positive. Asteroid bodies were also A.T.p.-ase negative. SILTZBACH-KVEIM TEST Dr. COHN and Dr. L. E. SILTZBACH (New York) fractionated fresh, granulomatous lymph-nodes from patients with sarcoido- sis by disruption in sucrose, and showed that Kveim-antigen activity was chiefly associated with a dense cytoplasmic, non- mitochondrial organelle. Dr. A. T. KARLISH (Reading) noted

A MINISTRY'S REPLY

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695

r.3d received his schooling under the State educational system, Ms under obligation to stay and work permanently inBr::ain. But primary and secondary education were available:c all, whereas medical education was not. It was limited in.clume by the number and size of our medical schools, which0u1J train only about 1 out of every 3 well-qualified candidatesnho would like to take up a medical career. He did not want to

’3r that no doctor should emigrate. We had a duty, for example,:0 help medical services in developing countries, and weencouraged young doctors to go overseas for a period to helpsuch countries. He was not thinking of this kind of emigration,but of escape to countries where the doctor/population ratiowas even higher than our own and where the financial pickingssounded more attractive. Britain could not afford to train doctorsswell the membership of the American Medical Association.One wanted to see a reasonable interchange of doctors acrossnational frontiers, preferably on a temporary basis, and fromsuch interchange our Health Service gained as well as lost.But to accept a fine medical education in Britain with the deli-berate intention of selling it elsewhere where the price mightbe, or seemed to be, higher, was in his view a cynical andselfish act. We needed in our own Health Service every doctorwe trained. Those who advocated emigration might spare athought not only for their colleagues who would be left toshoulder an inevitably heavier workload, but also for thoseyoung men who might have become doctors if they had notbeen squeezed out of medical school by those who werefortunate to gain places.No-one wanted the sort of crisis we had now for its own sake,

but nevertheless at times like these it became possible to con-sider new ideas and solutions which in more normal timesmight well be regarded as too radical. He intended to make fulluse of this chance, for he was determined that our great HealthService-and for all its shortcomings it was a great service-should offer worthy opportunities for those who worked in it.

A MINISTRY’S REPLY

THE Ministry of Health has been reviewing theunfavourable comments on the National Health Service’s

hospital building programme which have appeared inthese columns and elsewhere, and a memorandum fromthe Ministry includes the following facts and figures forconsideration alongside these criticisms.Data for precise comparisons with the ’30s are lacking, but

the annual expenditure on hospital building in England andWales just before the 1939-45 war is estimated at E10 million,or at present prices E46 million. The current level is E73 mil-lion, which is expected to rise to at least E100 million by 1970.In 1938-39 hospital capital expenditure was 0-19% of the grossnational product; in 1965-66 it was 0-23%, and by 1970 isexpected to be 0-31%.According to an unpublished W.H.O. document, which gives

the latest international figures available, the total capitalexpenditure on health services (the major part of which willhave been on hospitals) expressed as a percentage of the grossdomestic capital formation was: Canada 2-31 in 1961, Sweden212 in 1962, United States 1-76 in 1961-62, United Kingdom118 in 1961-62, Australia 1-16 in 1960-61, and Czechoslovakiai 10 in 1961.

During 1948-65 about E337 million was spent in completedthemes for hospital building; about half of this was spent onthemes completed in 1961-65. In the earliest years little wasan annual average of £9 million—but the mid-’50s saw.: beginning of steady growth to the current annual level ofmillion

in those impoverished early years priority was given to

existing hospitals rather than building new ones. Byonly 30 schemes costing £1/4-1 million, and 3 costing over

million had been completed. By 1965 these numbers had98 and 17 respectively. A further 79 and 43 schemes in

these cost-categories were in progress, which together comprisedmore than 80% of the total value of work then under way(E165 million).

Small schemes (under E30,000 each) accounted for roughly58% of the total value of all schemes completed by 1961, butonly 30% in the subsequent four years. The proportioncontinues to fall.

48,684 beds were provided in these seventeen years, and thefollowing departments were newly built or expanded: out-patient 612; accident and emergency 138; operating-theatres466; radiotherapy and diagnostic X-ray 420; pathology labora-tories 320; physiotherapy and occupational therapy 596;nurse-training schools 313.The Ministry further points out that its building programme

is not aimed primarily at increasing the number of beds but atproviding the right kind of beds in the right places. Thus thenumber of beds has changed little since 1948, but the drop inthe average length of stay has allowed the number of inpatientsto increase by about 3% a year (4,818,000 in 1965, 4,136,000 in1960, and 2,937,000 in 1949).At constant levels of remuneration and prices, the money for

running-costs of the hospital service has increased by about2% per annum over the last eight years. Boards are now plan-ning two years ahead on an increase of 2-75% a year.Between 1949 and 1965 the number of whole-time nurses

(trained and in training) increased by 43%, while that of part-timers nearly trebled. The number of medical staff (whole-timeequivalents) increased from 11,735 to 18,904. Included in thisincrease were:

Conferences

SARCOIDOSIS

THE 4th International Conference on Sarcoidosis washeld in Paris on Sept. 12-15, under the presidency ofProf. J. TURIAF (Paris).

STRUCTURE

Dr. W. JONES WILLIAMS (Cardiff) believed that the sarcoidgranuloma was a reaction to displaced or altered lipoproteinsand mucoproteins. Histochemical studies revealed similarfindings whether the changes were due to sarcoidosis, berylliumdisease, Crohn’s syndrome, ulcerative colitis, diverticulitis,cholecystitis, or intestinal carcinoma, or in Kveim nodules.

Dr. Z. COHN and others (New York) compared the ultra-structure of skin and lymph-node sarcoid granulomas and ofpositive Kveim-test sites. Epithelioid cells in all of these lesionsshowed characteristic interdigitating surface membranes andelongated or oval nuclei with irregular margins and prominentnucleoli. The cytoplasm was abundant and contained well-developed Golgi apparatus, variable amounts of rough endo-plasmic reticulum, many mitochondria, and large vacuoles.Biopsy of one Kveim site six weeks after injection of a mixtureof Kveim-test material and carbon particles showed the carbonwithin large vacuoles of the epithelioid cells, indicating thatthese vacuolar structures were of phagocytic or pinocytic origin.

Dr. J. T. KELEMEN (Debrecen, Hungary) found that the giantcells of tuberculoid granulomas were A.T.p.-ase negative,whereas the giant cells of all other non-specific granulomas werestrongly A.T.p.-ase positive. Asteroid bodies were also A.T.p.-asenegative.

SILTZBACH-KVEIM TEST

Dr. COHN and Dr. L. E. SILTZBACH (New York) fractionatedfresh, granulomatous lymph-nodes from patients with sarcoido-sis by disruption in sucrose, and showed that Kveim-antigenactivity was chiefly associated with a dense cytoplasmic, non-mitochondrial organelle. Dr. A. T. KARLISH (Reading) noted