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HEALTH SERVICE ACCOUNTS

THE system of control and accounting in the NationalHealth Service is examined by the Comptroller andAuditor-General in his report on the civil appropriationaccounts for 1948-49.1

REGIONAL BOARDS

The report draws attention to an important differencebetween the practice of the regional hospital boards inEngland and Wales and in Scotland. Whereas in Englandand Wales management committees submit separateestimates (which may be curtailed by -the boards), inScotland the boards exercise direct and continuouscontrol of current expenditure and incorporate theaccounts of all their management committees in theirown accounts ; and they have their own auditors toconduct a running review of the committees’ expenditure." The direct and early knowledge of local circumstancesavailable to the Regional Boards as a result of thisaudit is expected to enable them to correct promptlyany extravagant practices " ; and it should also assistthem materially in their examination of the managementcommittees’ estimates.The first estimates were founded on expenditure in 1946,

and in the absence of uniform costing data or statisticalinformation, examination of these estimates could notbe based on the comparisons and other checks which arenormally relied on for effective budgetary control.

"Regional boards thus appear to have had little basiseither for critical examination of the estimated main-tenance expenditure or for judging the relative priority ofthe numerous capital schemes proposed by some Com-mittees. These conditions to some extent continued tovitiate comparison for 1949-50."

Regional boards have represented that adequate exami-nation of estimates is further hampered by the shorttime allowed in order to comply with Parliamentaryestimates procedure. Some have also expressed theview that the absence of power for them to regulatemanagement committees’ establishments has led toexcessive staffing and duplication of posts betweencommittees and boards. The treasurers of the boardsin England and Wales, in response to an invitationfrom the Ministry, have made suggestions for strengthen-ing financial control which would bring the system closerto that in Scotland. " The Ministry consider, however,that most of these would be inconsistent with their

policy of delegating responsibility to the Committees."" The Departments adopted the system of approved

budgets as a means of retaining control over total expen-diture while giving a reasonable degree of freedom and

responsibility to their agents.... They see no reason ...to suppose that when the system has had time to settledown it will not be effective or will lead to extravaganceand waste. They consider that, in the long run, dissemi-nation of information of establishments and costs amongthe hospital authorities themselves, coupled with investi-gation of particular cases, is likely to provide a moreeffective check than an attempt to control detailed itemsin advance. To this end- arrangements are being madeto instal appropriate costing schemes."

EXECUTIVE COUNCILS

The report states that examination of the records ofpayments made to general practitioners by executivecouncils in the period from July 5, 1948, to March 31,1949, suggests that net earnings as a whole exceededthe Spens (1939) rates by appreciably more than 20%.

" In particular, the proportions of doctors receiving overE2000 and i2500 (plus betterment) -respectively appeared

to have been considerably higher than those suggested inthe Spens Report. The Departments inform me, however,that they have at present insufficient information as toactual expenses to judge whether the allowance made for

1. Civil Appropriation Accounts (classes 1-9) 1948-49. H.M.Stationery Office. Pp. 480. 9s. 6d.

these in arriving at the net incomes is adequate. For thisreason, and because of the special circumstances prevailingduring the initial period, the results of this period bythemselves are not considered to justify precise conclusions.They propose to obtain more detailed information of

earnings in the year ending 31 March, 1950." .

As to the remuneration of dentists, summaries of

payments authorised by the Dental Estimates Boardsto some 6000 dentists in the period from Oct. 1, 1948,to March 31, 1949, show that about 59% were earningfrom the N.H.S. at a rate above that intended for fullemployment therein. Some 1300 (22%) received fromthe N.H.S. alone gross incomes exceeding E6000 a year.These would be equivalent to over E2880 net if expensescontinued at the estimated rate of 52%, or more if, asis probable, expenses did not increase proportionatelyto fees. Figures recently furnished by the DentalEstimates board for Scotland for the year ended lastOctober suggest that many dentists are still obtainingremuneration much in advance of the Spens scale. Of688 single-handed dentists the gross fees approved for138 (20%) were over 6000, and for 7 (1%) were overjE12,000. These figures do not take into account theinterim cut in earnings over JE400 a month, but theyinclude some work at the reduced fees. -

Disabilities

49. FACIAL INJURY

WAR-SCARRED London has many reminders of the years1939-45, but besides its buildings there are many humanbeings who have outward scars, for show. Many peopleare very conscious of these scars, for a disfigured face is.

always noticeable to some extent. -

I was one of those unfortunate people who sufferedfrom the flying bombs, having fragments of plate-glassembedded all over the left side of my face and variousother parts of my body. However I can now take myplace in the world and work for my living like any othernormal being. All this has been due to the skill of theplastic surgeon who has rebuilt my face.

In front of me as I write I have a series of photographs,the first taken four days after I was injured. The trans-formation has been slow (it is now only just a year siriceI had my last operation, and I was a casualty in 1944);so patience is an essential part of the process of reable-ment. I was never one of nature’s beauties, nor did Iever hope to be, but the face is an integral part of thecharacter of any woman. One’s whole attitude to lifecan be changed by one’s appearance.

I never asked for sympathy from anyone ; and itseemed to me that if I was going to enjoy my life I hadto be cheerful. Nothing can be gained by going aboutwith a long face and carrying eternal hatred in one’sheart.

Altogether, I have been in hospital twelve times overa period of 5i/2 years, and each time another stage hasbeen reached. Apart from losing my left eye, I hadsuffered severe damage to the right one, and I was almostblind for about 8 months. I had to rely on friends totake me out of doors for exercise. But I never gave uphope of being able to see more one day, and I had tolearn to be patient, which was not one of my strongpoints.While I was lying in bed during my first spell in

hospital I felt J must do something to occupy the time ;having been, before my accident, an expert knitter,I decided to try knitting again. Dish-cloth cotton andneedles were brought in and I started ! Imagine my joywhen I found that I could knit very well without seeing.From dish-cloths I progressed and soon I was able tomake all sorts of small garments. During my firstconvalescence made baby garments and so earnedpocket-money.

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After a certain amount of repair work had beencompleted I was able to return to my old job-that of apharmacist in a London hospital. I was able to see muchbetter, but I found that a one-eyed person has manydifficulties to overcome-that of focusing and seeingobjects suddenly appear from the blind side being twosuch difficulties.

I was greatly cheered to find that I could still dispenseaccurately, and from that time onwards I was very keento get on with the repairs, as I wanted to find a permanentposition. Having to go back to hospital so often made it’difficult for me to take a job where I was in control.To achieve my present position-that of director of anold-established pharmaceutical business-I had to gothrough many stages. One of the most exciting moments,from my point of view, was when I first had my artificialeye. This may sound trivial, but it meant that I was, onceagain, in appearance at any rate, more like my fellows.Now that my face is complete the quick passer-by noticeslittle if anything amiss. The hospital almoner madearrangements for me to visit cosmetic specialists who givefree advice on make-up for scarred faces. At the Maxfactor Salon I was taught which preparations to use,and my face was made up by them to show me how toapply these products to the best advantage. When theyhad finished no-one would have known I had a singlesear on my face.The Wolfe graft on my forehead is of much lighter

colour than the rest of my face, but my hair always hada natural wave over this side of my forehead and socan be arranged to cover most of the graft.My artificial eye is made of plastic. The main advan-

tage of this material is that the eye is unbreakable,however roughly treated. The colouring has been sowell matched that it is difficult to tell which eye is real :in fact many people have told me how fortunate I wasnot to lose my eye, and needless to say I did not dis-illusion them. The socket requires frequent washing,but the eye itself needs little, if any, care. I usuallyremove it when washing my face, and it is easily rinsedunder the tap. Only one chemical has any effect upon it,and that is chloroform ; so I have to be rather carefulwhen dispensing, as it would be somewhat disconcertingto feel one’s eye gradually dissolving.Wherever I have worked people have been excep-

tionally kind and understanding. Only once have I hadany unkind words said to me : " Wouldn’t you ratherhave died than go about with a scarred face " That

thought had never entered my head, for there are somany things in life to do.To me there seems to be a choice for those with facial

injuries : either you fight on and face the world or elseyou go behind doors and lead the life of a recluse. Thesecond choice was never, at any stage, mine-even inthe beginning, when I was a mass of bandages-and Iwould encourage all who have similar injuries to realisehow much there is to be gained by leading a normallife.At first one can never be sure of other people’s reaction

to a disfigured face, and it hurts one’s feelings to see anyone shrink. But in time one learns to watch others withdetachment. When they realise that one’s face is scarredthey are apt to become somewhat embarrassed and towonder whether they should look or not. What does itmatter ? I have been told by many people who knowme that after a time they don’t notice any disfigurementat all. In time people will get used to seeing these scarredfaces, and there are quite a number about in the worldtoday.Many times I have thought how lucky I have been

compared with some of my fellow citizens ; for I havegood health, two good arms and legs, and one reasonablyefficient eye ; and, above all, I have been able to carryon with my career.

Public Health

STATE OF THE PUBLIC HEALTH

RETROSPECT OF 1948

THE ninth year of austerity, 1948, was memorable inmany ways, writes Sir Wilson Jameson, chief medicalofficer to the Ministry of Health ; for" it was -one of struggle against economic adversity in theshadow of international gloom intensified in June by theblockade of Berlin, continual anxiety as to the air-lift to thatbeleaguered city and growing tension in the Near and FarEast. But all these and many other depressing circumstances,the British people took with their usual good-temperedgrumbling and that cheerful confidence in ultimate successwhich has never yet deserted them."

It was a memorable year in other ways as well. On

July 5 the National Health Service began its colossaltask.

START OF THE HEALTH SERVICE

The start of the service is reviewed in the Ministry’sreport by Dr. G. E. Godber. The immediate advancewas not that all things were at once available, but thatthere was now a way to secure them in the future.

Fortunately, such confusion as arose at the change-overwas for the most part in offices rather than in hospitalwards, doctors’ surgeries, or any of the other placeswhere the patient is served.

’

In the preparatory phase the greatest pressure fellon the hospital service ; and soon after the service started,new factors began to appear. Outpatient attendancesbegan immediately to rise ; and the increase was

particularly noticeable in gynaecology, radiology, patho-logy, and ophthalmology. This was not unexpectedand " indeed -marked only an accentuation of a changealready apparent before the appointed day-a changewhich is steadily increasing the emphasis on hospitalsas centres for diagnosis rather than mainly institutionsproviding beds for the treatment of the sick." Therewas also an increase in the demand for pathological andradiological investigation for general practitioners.An appendix shows that between July 5 and Dec. 31, 1948,

the 4756 specialists undertaking domiciliary work visited

29,246 patients. -

Another early effect was an increased demand forbeds for the elderly chronic sick. This was more

apparent in London and the South than in the industrialNorth, and again it was an acceleration of a trend already ,’existing before 1948. During the winter the position,especially in London from January to March, 1949,became extremely difficult, and many old people couldnot be admitted despite acute illness. The rapiddevelopment of home-help services and the extensiveuse of home nursing did much to relieve hardship, " butthere is no doubt that many households and particularlyelderly couples living alone need greater relief than suchservices can give." <

With regard to health centres, the only scheme

approved for the construction of a new centre was thatof the London County Council at Woodberry Down, onwhich work is now proceeding. No authority has yetput forward a comprehensive programme in a schemefor centres, " and it would be undesirable to confirmsuch a programme, if one were submitted, in view of ourpresent inexperience in this field."

In some areas the attendances at antenatal clinicsfell away as a result of expectant mothers seeking ante-natal advice from practitioners booked under the mater-nity medical service. " It is to be hoped that thevaluable work of these clinics will not be lost; since they1. Report of the Ministry of Health for the Year ended 31st March,

1949, including the report of the chief medical officer on thestate of the public health for the year ended Dec. 31, 1948.Cmd. 7910. H.M. Stationery Office. Pp. 373. 7s. 6d.