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to the intramural patient. Opportunities for scientificresearch are thus enhanced and the opportunities formedical invention and discovery are increased and mademore effective for longer periods of time. Medicalresearch requires completeness, comprehensiveness, andcontinuity of care for its development and nothing lesscan achieve as much.From the teaching point of view there are far more

lessons to be learnt by the student under such a combinedintramural and extramural programme than in any other

way, and not the least of the advantages is the encourage-ment to the young student to retain and perpetuate,rather than discard, his most precious inheritance fromthe Hippocratic tradition. Under any other plan ofmedical care the young physician finds himself sooneror later influenced adversely by economic necessity,and the result is a compromise with his ideals. Onemust remember here that the practitioner, under thisplan, is forever exposed to hospital medicine from whichhe draws scientific help at strategic times and has atlast the opportunity, which he has coveted for so long,to study each case according to its requirements. Forthe social worker the boon of medical cooperativenessand understanding will in itself be a blessing ; for, asmatters now stand, this worker must seek help for thepatient where the doctor has lost interest.

EXPERIENCE AT THE MONTEFIORE HOSPITAL

The experimental work with this programme wasfirst done in Montefiore Hospital for Chronic Diseases inNew York City, which is the only voluntary generalhospital of its kind, of high scientific grade, in America,and an excellent laboratory for the study of socialmedicine. This demonstration project was indeed so

successful that it was eventually adapted to the group-practice unit which serves an insured section of the

population, and also to the Family Health MaintenanceProject which emphasises (1) prevention for a groupwhich is already insured for curative care, and (2) thefamily, and not alone the individual. The net resultwas a radical change in hospital organisation by whicha new division was added to the existing clinical andlaboratory divisions-namely, a division of socialmedicine. This division is presided over by a full-timephysician whose duties run parallel to those of hiscolleagues on the other divisions of the hospital. Thenew division of social medicine has absorbed the social-service department and now has the primary functionof (a) administering the various projects under its care,(b) cooperating with the clinical and laboratory divisions,(c) teaching the precepts of social medicine, and (d)exploiting the possibilities of research in this field.Many convincing lessons have been learnt.

Over a period of "four and a half years we have beendeeply impressed by the humanity of this new type oforganisation ; but, in addition, it has the great meritof relative inexpensiveness and of utter simplicity ofexecution. We have absolute confidence in its con-

strdetive ’possibilities, and I earnestly hope that theInternational Hospital Federation will exercise its greatinfluence in behalf of a programme which restores to thephysician his natural rights in providing the best possiblecare for his patients.

" Men are imitative. That which contributes to the growthand development of the best men in any profession also is besttherefore for the group as a whole. Some do not believe this.I believe it to be one of the great lessons of life. Much effortof a society frequently is directed at improving minimalstandards. An equal effort directed at the highest level willI feel pay greater dividends-gains and advantages which willaccrue to all engaged in the common venture."-Prof. 0. H.WANGENSTEEN, 1951, introduction to Surgical Foruna of theAmerican College of Surgeons.

Special Articles

THE HEALTH SERVICE IN 1949

review oy me iviinisrry

THIS year, for the first time, the Ministry of Healthhas published separately from the chief medical officer’sreport 1 an account 2 of the working of the NationalHealth Service. Such a survey is of more than historicalinterest ; for it puts in perspective problems preoccupyingworkers in particular branches ; and it also provides ameasure of progress-or stasis. The present reportcovers the year 1949.

GENERAL MEDICAL SERVICE

The report suggests that, apart from a general increasein the number of surgery consultations, the character ofthe average general practice is much the same as it wasbefore the start of the service. The increased demand formedical advice is not necessarily unreasonable.

"

Assuming that some of this increase is due to the oppor-tunities presented to those whose faith in the virtue of thebottle of medicine or box of tablets is unbounded, there stillremains the question whether it is in the general interest thatmore people should be taking their trivial ailments to thedoctor with perhaps the risk of developing a disease-consciousframe of mind. If it could be assumed that the increase wasbut a passing phase, then the maximum benefit should beobtained from the Service when a younger generation, imbuedwith ideas of positive health, adopts a more reasonable

approach to minor constitutional disturbances. The paradoxof this question, however, lies in the fact that, ever sincetreatment has been placed on a scientific basis, the cry hasbeen for early diagnosis. The one hope of success in thetreatment of such conditions as tubercular and malignantdiseases lies in early detection... it may well be that the

general practitioner is rendering most service to the com-munity when he is seeing large numbers of people all withseemingly trivial ailments provided he is able to filter fromthem those few whose condition merits further investigation."The complete exclusion of the general practitioner

from the more responsible parts of hospital work hasbeen watched, says the report, with considerable anxietyby those interested in the professional standard of generalpractice. Much thought is being given to the evolutionof hospital departments for such subjects as geriatrics ;" and it is to be hoped that, in staffing such departments,full -advantage will be taken of the experience which canbe obtained only from those who come into contact withpatients in the capacity of family doctor." In the viewof many, the way to improve the practitioner’s standardis by enabling him to become associated with a hospitalin work of the type done by the registrar or clinicalassistant.

" The Service had tended to accentuate the division of the

profession into specialists and general practitioners in the

process of developing the hospitals ; and it would be dangerousif the division were rigidly maintained or the intellectualcontacts of the two branches of the profession were diminished.The good general practitioner will always seek to maintainhis contacts with the new techniques of treatment anddiagnosis as they develop in hospitals. It is to be hoped thatthe specialists will not forget that they also have much tolearn from the general practitioners with their constantconcern with the family group and the first beginnings ofdisease processes in its members, as well as their intimateknowledge of those social factors which play so large a partin the development of ill-health."On the credit side, the antagonisms which have

existed between the local authority and the general1. Report of the Ministry of Health for the Year ended 31st March,

1950. Part II. On the State of the Public Health, being theannual report of the chief medical officer for 1949. Cmd. 8343.H.M. Stationery Office, 1951. See Lancet, Sept. 1, 1951, p. 404.

2. Report of the Ministry of Health for the year ended 31st March.1950. Part I. (1) the National Health Service. (2) Housing,Local Government, Civil Defence, Welfare, Water. Cmd. 8342.H.M. Stationery Office. Pp. 228. 6s. 6d.

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practitioner are disappearing ; the medical officer ofhealth is no longer the competitor who attracts to hisclinics mothers and children who formerly consulted thegeneral practitioner. Furthermore, perhaps one of themost important ways of strengthening and increasingthe influence of the general practitioner is by groupingpractices either in partnerships or by a looser associationwhere doctors arrange among themselves rotas for off-

duty and holiday times ; and there is evidence that sucharrangements are becoming more common.

THE HOSPITALS

The following figures are given for numbers of bedsand patients :The total bed complement at Dec. 31, 1949, was 501,078,

of which 53,021 were temporarily out of service on accountof lack of staff, repairs, redecoration, or other causes. The

corresponding figures for Dec. 31, 1948, were 504,209 and64,695, so that the net number of beds available increased by8543-from 439,514 to 448,057. The number of inpatientswho were discharged from, or died in, hospitals during 1949was 2,936,980, compared with 2,871,978 in 1948. The numberof new outpatients in 1949 was 6,147,825, with total attend-ances of 26,001,184 ; in addition there were 10,108,024attendances in casualty departments. In some respects,however, the figures for the two years were not comparable.At the end of 1949 the number of " hospitals

" in theNational Health Service (i.e., institutions making separatestatistical returns) was 3287, of which 2702 were hospitalsproper-including those at present having no beds but doingoutpatient work alone-and 585 were

" clinics."

Totals of whole-time and part-time medical anddental appointments were as follows :

Consultants 1310 and 12,372 ; senior hospital medical (anddental) officers 686 and 2205 ; senior registrars 1308 and 502 ;registrars 1478 and 244 ; junior registrars 784 and 85, with402 junior hospital medical officers.

OUTPATIENT SERVICES

The report discusses the arguments for and againstdispersion of outpatient work in separate suites ofrooms, each adjacent to the corresponding wards.Many advantages are claimed for dispersion. A patient

on first arrival goes, not into a large, general, busy, andrather terrifying outpatient department, but into a

small quiet suite of rooms. If he is admitted to a wardhe is still cared for by the same set of people, and heremains under their care if he continues to attend as an

outpatient after discharge from the ward. The medicalstaff have their inpatients and their outpatients all inone place, and it is advantageous both to the medicalstaff and to the patients that each firm should have asingle sister in charge of the nursing work for both

inpatients and outpatients. The work of- the nursingstaff is more interesting if they see the patients throughfrom the beginning to the end of their hospital care

instead of seeing only one stage of it.Those who favour a single general outpatient departmcn;t

point out that only a comparatively small proportionof the hospital’s patients are admitted to the wards,and that it is only to this group that some of the advan-tages claimed apply. Moreover, a ward sister has plentyto do without having outpatients added to her charge.(This could be met by reducing the number of beds in anursing unit, though that should be avoided if possible.An alternative would be to make the sister more of asupervisor, with competent charge-nurses working underher.) In a single department the constant association ofcolleagues is of undoubted value ; consultation isfostered, and patients can be seen by different specialistswithout leaving the department. Furthermore, out-

patients can enter and leave without penetrating into therest of the hospital. A weighty reason for concentrationin one department is that this can be in a separate buildingwhich can be expanded or altered at need.

The case for combining inpatients and outpatients in asingle department may be stronger in the case of some ofthe specialties than in that of general medicine or

surgery-though members of the staff engaged in a

restricted specialty are the very ones who should not besegregated from their colleagues.

MINISTRY OF NATIONAL INSURANCE

IN its second report 1 the Ministry of National Insurancedescribes the 18 months from July, 1949, to December,1950, as a period of consolidation. For the benefit ofthe public as well as in the interests of efficient adminis-tration, work on pensions and family allowances, hithertocarried out in the central offices, was further decentralised,and during the year about 1000 local offices dealt withnearly 25 million callers.

Family Allowances.-At the end of 1950 just over3 million families were receiving family allowances,which cost B61 million in 1950. Nearly 64% of thefamilies had two children under the age-limit andreceived .825 million; 5 % had 5 or more childrenand received .88 million. During the eighteen monthssome 400,000 families qualified for the allowances forthe first time, and nearly 350,000 families who hadalready qualified claimed for further children.

Sickness Benefit.-During the eighteen months 101/4million new claims for sickness benefit were received.The number receiving benefit varied from 790,000 inJuly, 1949, to 1,080,000 in February, 1950. The totalcost in the year ended March 31, 1950, was B65million.

Maternity Benefit.-In 1950, about’ 700,000 womenreceived maternity benefit, About 1 in 7 qualified formaternity allowance of 36s. for thirteen weeks, paid towomen who normally work for gain.

Industrial Injuries Scheme.-Claims for injury benefitwere received at the rate of 15,000-16,000 a week,one-third from the coal-mining industry. The averageperiod of incapacity was over four weeks, but 1 injuredperson in every 70 drew benefit for the full period ofsix months. About 10 % of those who received injurybenefit claimed disablement benefit.

Retirement Pensions.-During the eighteen months,the number of retirement pensioners increased from3,700,000 to 4,000,000, and the number of people stillreceiving contributory old-age pensions from the previousscheme fell from 400,000 to 200,000. The total costwas 2249 million for the year ended March 31, 1950.

RETIREMENT TRENDS

A special chapter discusses the growing importance ofpeople continuing in regular work to a later age, and theeffect of recent changes in the administration of Statepensions. The board’s conclusion which seems to emergefrom the statistical evidence so far available is that

despite the new inducements to postpone retirement,roughly the same proportion of- people are continuingat work. The proportion is fairly high and steady formen, ranging from 58% at sixty-five to 29% at seventy,and slightly increasing for women, ranging from 45% atsixty to 20% at sixtv-five. But changes in habits ofretirement do not only depend on changes in pensionprovisions. The decision to retire is still conditioned

by the conception of fixed retirement ages built up inthe past, and the report adds :

-

" This conception cannot easily or quickly be generallyreplaced in the minds of the elderly by one which relatesthe length of working life to the ability to work rather thanto age.... Not only the elderly themselves, those who mustmake the decision to retire or to continue working, butemployers generally and employed people of younger ageshave alike to adjust themselves to the new scheme andeven more to the change in the length of life."1. Cmd. 8412. London : H.M. Stationery Office. 1951. Pp. 72.

2s. 6d.