1360

was significantly higher for the lower-class patients. Theletters also tended to be shorter when the patient himselfchose the hospital or when the G.P. did not specify whichconsultant he should see.

The falling demand for outpatient services in theLondon teaching hospitals is probably due largely to

depopulation of the surrounding areas and to the improve-ment in consultant facilities of regional-board hospitals.As a result of this trend the services demanded of the

teaching hospitals have become more highly specialised.This situation cannot satisfy their teaching needs, formedical students must have experience of the commonconditions as well as the rare ones. For this and other

reasons, several teaching hospitals in London have nowtaken on district-hospital responsibilities,51 which, coupledwith projects for rebuilding, have enabled plans to bemade for incorporating all aspects of hospital and

specialist services, including geriatrics. A study 52 ofpatient-selection at St. Thomas’s Hospital, London,shows that, in contrast to Guy’s, most of the patientscome from the immediate neighbourhood and there isno distinct pattern of referral from other areas. Even

so, in some specialties the hospital does not yet servethe needs of the area.

The intended role of the outpatient department in ,theNational Health Service was to give the general practi-tioner access to specialist opinion; but the service is notalways used in this way. For some practitioners the out-patient department is merely a means for relinquishingresponsibility. Further research into the referral systemis obviously needed. For example, who advises patientsto attend a particular hospital ? It is presumed to be thegeneral practitioner; but how often does the patienthimself choose ? We know little of the efficacy of out-patient treatment; and how many of the patients continueto receive care in outpatient departments who could in factbe referred back to the general practitioner ? What pro-portion of patients are admitted, and why ? What circum-stances require patients to attend hospitals, and how manymight be diagnosed and treated by the general practitionerif he had better resources at his disposal ? What is thequality of the various outpatient services, and what kind ofpeople use them ? The fatality-rate in teaching and non-teaching hospitals differs for various conditions.53 Does

outpatient care differ in the same way ? Do outpatientattendances have any lasting effect on survival ?

The difficulty with all these inquiries is that we do notknow whether the present distribution of medical care is

doing any good. The traditional indexes of public health(such as mortality and morbidity rates) are useful for

defining patterns of ill health and demographic charac-teristics of patient-populations, but they do not describeactions taken by individual patients and physicians. Littleis known about what makes people decide to seek help.Nor is much known about the medical counsellors them-selves, or why they must sometimes turn elsewhere foradvice. Yet it is the collective impact of these actions thatlargely determines the demand for medical care, and inthis context the patient may be a more relevant unit ofobservation than the disease, the visit, or the admission.The natural history of the patient’s medical care may be amore appropriate concern than the natural history of hisdisease.

51. See Lancet, 1965, ii, 887.52. Bennett, A. E. Unpublished.53. Lipworth, L., Lee, J. A. H., Morris, J. N. Med. Care, 1963, 1, 71.

LOCAL ASTHMAS

MUCH energy has been put into investigating the acuteeffects of air pollution, and some studies-e.g., in theMeuse Valley,l in Donora, Pennsylvania,2 and in London 3-have become famous. In the past few years, however,episodes of " local asthma " have come into prominence.The most famous of these is the so-called Tokyo-Yokohama asthma, which has been noted particularly inUnited States personnel stationed in that area of Japan.4The attack-rate is highest during periods of heavy smogconcentration between October and January. However,the Japanese population is not immune, and it seems

likely that the disease is not asthma but simply acuteexacerbations of chronic bronchitis. The issue is com-

plicated by a difficulty in definition, for the term " chronicbronchitis " has only recently been accepted in theUnited States,

" asthma " and " emphysema "

havingbeen more commonly used in the past.5"Local asthma" has also been reported in New

Orleans 6 where suspicion of a local cause was arousedby an increase in admission to Charity Hospital EmergencyClinic for treatment of so-called asthma. Informationfrom the United States Weather Bureau station suggestedthat the outbreaks were associated with winds of low speedmainly from the south and south-west. At one time blamewas laid on wind-carried smoke from burning waste.

Geographical and other variables have been used to

incriminate air pollution as a cause of disease, but themethods of measuring pollution have in most studies beeninadequate. Kenline,8 investigating the various methodsof assessing levels of atmospheric pollution, showed thatin the evaluation of health effects the high-volume sampleris of limited value. It has to be modified so that samplingis confined to small respirable dust of 5-10 [t maximumsize. That the New Orleans outbreaks are quite differentfrom those seen elsewhere shows clearly that the studyof environmentally caused respiratory disease cannot becontinued successfully without more refined methods ofmeasuring air pollution.

DISPENSING AFTER HOURS

A REPORT in this month’s Which ? recommends thatchemists’ dispensing rotas should be replanned to keepmaximum distances between doctors’ surgeries and a

pharmacy open till 7 P.M. down to less than a mile, and ifpossible less than half a mile. An inquiry conducted inCambridge, Watford, and Islington by the Research Insti-tute for Consumer Affairs showed that the distancebetween a surgery and a late-opening pharmacy was some-times over 2 miles. Moreover, many doctors’ eveningsurgeries did not end until after pharmacists on the rotahad closed at 7 P.M., so Which? suggests that generalpractitioners and pharmacists cooperate to ensure that therota pharmacy is open till half an hour after surgeries end.How easy was it to find out which chemist was open

late ? Most surgeries investigated in Cambridge and1. Batta, G., Firket, J., Leclerc, E. Les problèmes de pollution de

l’atmosphere. Paris, 1933.2. Schrenk, H. H., Heimann, H., Clayton, G. D., Gafafer, W. M., Wexler,

H. Publ. Hlth Serv. Bull., Wash. 1949, no. 306.3. Rep. publ. Hlth med. Subj., Lond. 1954, no. 95.4. Phelps, H. W., Koike, S. Am. Rev. resp. Dis. 1962, 86, 55.5. Meneely, G. R., Paul, O., Dorn, H. F., Harrison, T. R. J. Am. med.

Ass. 1960, 174, 1628.6. Lewis, R., Gilkeson, M. M., McCaldin, R. O. Publ. Hlth Rep., Wash.

1962, 77, 947.7. Newell, G. R., Swafford, L. I. Pediatrics, Springfield, 1963, 31, 134.8. Kenline, P. A. Archs envir. Hlth, 1966, 12, 295.