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s of Efficiency Studies in the Hospital Servicett help to bring the results of these studies to hospital administrators. The development of management studies in the hospital service can be extremely valuable. Creative operational research can help doctors and health-care officials to choose among different methods of treatment, between in-patient and out-patient care for particular conditions, and to solve other problems of choice in the planning and operation of the Health Service. Analytic and normative studies can both be useful. But there is a danger that much operational research currently being undertaken will be of limited value because the wrong questions are being asked. Instead of merely producing quantitative descriptions of Health Service activities, the analytical research should be finding the underlying relationships that characterise Health Service operations. Instead of searching for elusive 'necessary' or ' adequate ' standards of care, normative studies should be seeking the optimal allocation of resources among competing claims.? Only by providing such information and advice can operational research be useful as a basis for administrative decisions. Unification and Co-ordination The administrative division of the NHS into three functional branches-hospital, local authority, and executive council (general practitioner) services-has * Occasional papers of this type include the Hospital Building Bulletins Hospital Building Notes, Hospital Equipment Notes and Hospital Technical Memoranda all published by HMSO. ** Oxford Regional Hospital Board, Nursing Care in a Modern Hospital, 1962; Oxford Regional Hospital Board, Hospital Out-Patient Services, 1962; Nuffield Provincial Hospitals Trust, Towards a Clearer View: The Organisation of Diagnostic X-Ray Departments, 1962; Gordon Forsyth and Robert Logan, The Demand for Medical Care: A study of the case-load in the Barrow and Furness Group of Hospitals, I960; A. D. Airth and D. J. Newell, The Demand for Hospital Beds: Results of an Inquiry on Tees-side, 1962. For a general survey of recent health services operational research see: J. O. F. Davies, et al., Towards a Measure of Medical Care: Operational Research in the Health Services-A symposiumn, 1962. t Recent reports have included The Filing of Management Papers, I961 and Organisation and Management of Domestic Work in Hospitals, 1960. ft The abstracts are published as a periodical by HMSO. ? For a discussion of this point see: M. S. Feldstein, ' Operational Research and Efficiency in the Health Service', The Lancet, 1963, and 'Economic Analysis, Operational Research, and the National Health Service ', Oxford Economic Papers, I963.

THIS PAPER represents an attempt to develop a conceptual framework that may be useful for comparing the level of physical health of the poverty population, as defined currently, with the health level of the rest of the population of this country. However, according to this framework, the "rest of the population" should not be considered a single homogeneous entity. Rather, it is most meaningfully divided, when the level of physical health is treated as the dependent variable in the relationship, into two large socioeconomic status (SES) strata. A major intent of this paper is to suggest that social-structural factors may affect these two strata of the nonpoverty population very differently, resulting in correspondingly dissimilar levels of health.

Associate Professor of Preventive Medicine, University of California, Los Angeles, California. t Associate Researcher in Health Law, University of California, Los Angeles, California. This paper has been developed by expansion and revision of a position paper entitled "Licensure, Accreditation, and Certification as Assurances of High-quality Health Care," delivered at the 1968 National Health Forum. The original position paper will be published in the proceedings of the 1968 National Health Forum. governmental approval of personnel, educational programs, facilities, and services are generally more than minimal, and strive to promote excellence.2 Specification of standards for certification of specialists and requirements for hospital committees and staff privileges, and required use of consultants in hospitalized cases not progressing satisfactorily, are examples of voluntary control that have far-reaching effects on quality of care. This nongovernmental regulatory process affects the daily operations of practitioners and institutions. Peer group evaluation of physician activities, through utilization review, tissue committee review, and medical audit, can deal with many factors affecting performance, such as ordinary incompetence in the exercise of skills, lack of specialized skills, and diminution of skills as a result of age, debilitation, drug addiction, or alcoholism. Such nongovernmental supervision of practice supplements effectively governmental processes in cases involving alleged violations of licensure laws which entail quasi-criminal penalties. Proof of improper practices in nongovernmental supervision need not be so formal nor so full as in cases involving the governmental process; nor must the alleged violations conform to the rigid stat

This paper discusses the role of the general practitioner in the community Mental Health Service from the point of view of a mental health social worker. The break-through in treatment of many psychiatric disorders has given the medical practitioner a more meaningful role in the field of psychiatric treatment. Prior to the introduction of modern drug therapy most of the treatment was necessarily carried out in the hospitals, where out-patient clinics were few compared to the need for them. The general practitioner had rather limited means of dealing with mentally ill patients, but the Mental Health Act of 1959 has placed a special responsibility on him, for which he is often ill-equipped due to lack of adequate training and, also, disinterest. When the Act was being considered, it was rightly felt that the decisions that were strictly medical should be made by medical practitioners and not by people such as duly authorised officers and magistrates. It was a major step forward in giving psychiatric disorders complete medical recognition, and also in accepting mental illnesses as treatable conditions in which general practitioners had an important role to play. Special grades of medical practitioners, which included a large number of general practitioners, were created to carry out the medicolegal formalities associated with compulsory admission to hospitals. These general practitioners either had special knowledge of psychiatry or were particularly interested in the subject, and they were put on approved lists. Apart from bringing general medicine and psychiatry together, the whole emphasis of the Act is on community care of the mentally ill. This gives the general practitioner an important position in the community set-up. In this paper we shall try to see how far the general practitioner has succeeded in adopting this new and highly responsible role. The degree of success is likely to vary from one general practitioner to another and even from area to area, and this paper is primarily based on the factual knowledge of a social worker in close association with general practitioners who has observed their relationship with the community mental health services.

This paper undertakes to review the role of the general practitioner in health examinations. The terms preventive medicine and health examination will be defined. The evidences for positive findings, in analyses of studies of large series of personal health examinations and screening examinations will be presented. Findings from studies of general practice, that suggest there may be insufficient attention paid to preventive medicine by some general practitioners, will be presented. Finally, the need for a redefinition of the traditional role of the general practitioner will be discussed.

362 tional compilations of data that tie health inputs to earning or production outputs. This paper is based upon a project now in progress which is designed to measure effects of personal health services, particularly work time saved and resulting earnings. The information was collected from employers and health insurance or prepayment plans in several communities of the northwestern United States. Study groups up to 3,000 persons in size have been drawn from records of both public and private employers of professional and manual workers. From data on each individ

The Regional Office for Europe of the World Health Organisation, with the agreement of the Regional Committee, included in its programme a study of the methods of examining the efficiency of medical care. To advise on the organisation of the study, the Regional Director convened, in December I963, a small group of senior public health specialists interested in different aspects of the problem. In its report the group recommended that, as part of the main study, a separate study should be undertaken dealing with the 'consumption of medical care'. This paper reports the result of this consultant survey and gives a short bibliography of studies published in this field, mainly in Europe. It concentrates on consumption studies directly or fairly closely concerned with evaluation of the services.

Research into hospital utilization has encompassed two major areas. A significant number of descriptive studies have had as their goal the identification of patterns of utilization which might lead to insights as to how the hospital might be used more effectively. Fitzpatrick and Riedel6 cite 25 such descriptive studies in their review of the status of hospital-use research through 1964. During the past two years, many new papers on this topic have been presented, and research of this nature is continuing.' The second type of research has concentrated on techniques for evaluating the appropriateness of individual cases by some method of case review.7 8 Studies in this direction have been considerably fewer than those pertaining to descriptive infor

This paper assumes the necessity for a branch of the medical profession whose duty includes responsibility for the initial management of undifferentiated clinical problems, together with responsibility for maintaining the health of groups of people. It also assumes that the preparation of physicians for such work is at present inadequate and unsatisfactory, and its purpose is to discuss ways of improving this preparation.

THE AIM of the larger study from which this report stems was to identify major social, psychological and physiologic factors that account for variations in patients' compliance with the medical recommendations of their physicians. Fulfillment of this research goal implies two subgoals: investigation of the variations in patient noncompliance, and investigation of factors that may lead to or help explain variations in compliance. The range of factors is almost limitless. Previous reports of this study have focused on the relationship between communication patterns in the doctorpatient relationship and adherence to medical advice.' In this paper the focus is on characteristics of patients. More specifi

lation and mathematical programming. The simulation of the progressive patient care system is based on patient flow through the service zones in an operating hospital, but the program is capable of accommodating any other hospital's structure of facilities or set of patient paths. The mathematical programming approach to the solution of optimal bed allocation raises basic questions on the formulation of objective function and budgeting constraints which are open to further investigation. IN THIS PAPER we describe a model aimed at providing decision-makers in hospital planning and administration with a tool for generating useful information in the design and operation of a progressive patient care facility subject to constraints in the form of investment and operating budgets and goals as measured by subjective evaluations of various kinds of service.

municipal hospitals has grown. These considerations form the background of the research reported in the present paper. This report deals with inpatient utilization and costs of drugs in a group of metropolitan hospitals. It is one of several reports on research in drugs in medical care. It was felt that an exploration of drug utilization and costs in hospitals would provide information which would be useful to

The background of this paper is linked with a question about which much heat has been generated from many quarters. One group, primarily lay, presupposes the answer by the very way it asks the question. That is, 'Why is it so hard to get a doctor to make a house call?' Another group, primarily medical, presupposes another sort of answer when it asks, 'Why is it so hard to get the public to give up the anachronistic and inefficient house call?'

Whoever first evaluates a patient, makes a diagnosis and offers treatment is giving primary medical care. In the developing countries, many medical workers other than doctors give this care. This paper describes the need for the primary medical care worker (PMCW) who has not received his training in the traditional medical school of university standard, and analyzes the problems inherent in such a system.

The group dental practice discussed in this paper is more than 12 years old. It owns and operates two dental offices, a building (completed in 1965) equipped with 21 dental chairs and two x-ray rooms, and a remodeled structure with eight chairs and an x-ray room. The staff consists of eight full-time and two part-time dentists, two full-time and two part-time hygienists, four laboratory technicians, eleven assistants and ten office workers. The work week is five days (37% hours). Vacations and sick leave add up to a total of four to six weeks per year per person, based on seniority and status. There are nine paid holidays. Comprehensive medical and dental care coverage is provided. The group dental practice was established to fulfill the terms of a contract with the International Longshoremen's and

This paper tests the notion that social class will measure differences in patterns of entry into the medical care process and that entry patterns will be affected by distances. The study was made using a 5 per cent sample of the Kaiser Foundation Health Plan membership of the Portland, Oregon S.M.S.A. in 1967. The population was dichotomized into working class and middle class on the basis of occupation. The working class was made up of machine operators and unskilled employees and the balance of the population comprised the middle class. Distance was determined in miles from residence to the nearest Kaiser facility. The data indicate that social class differentiates patterns of entry into the medical care system, but that when total initial contacts for each social class are examined by distance intervals, further differences emerge. The study, therefore, suggests that distance affects the medical care process differentially by social class and interacts with social class as an explanatory variable. HUMAN ECOLOGISTS have shown that the spatial distribution of maintenance and subsistence activities are related to social or

choice between providing treatment for the mentally ill in general hospitals and community facilities or in state mental hospitals. Periods of disability have been significantly reduced by the new methods of psychiatric care. The acutely ill short-term patient may now be institutionalized and treated far more effectively and efficiently in local community facilities than in the traditional state mental hospital. Decisions to expand community facilities and extend local mental health services do not rest upon therapeutic considerations alone. There are sociological, political and, not least, economic aspects to such social policies. The relative costs of alternative ways of caring for the mentally ill and the economic efficiency of different types of institutional care are highly relevant in determining the feasibility and desirability of increasing the role of locally-oriented mental health services through newly-developed and expanded community facilities. It is the purpose of this paper to consider the development of community facilities and mental health programs within the context of economic criteria. Specifically, the economic efficiency of community activities, represented by treatment in psychiatric wards of general hospitals and in

24. LaBarre, W. (1958) 'The Patient And His Families', Casework Papers. Reprinted (1959) in Child-Family Digest, 9-18. 25. Schulman, S. 'Basic Functional Roles in Nursing: Mother, Surrogate and Heaer', pp. 528-537, in Jaco, op. cit. 26. Coser, Rose L. (I962) Life In the Ward. (Michigan: State Univ. Press). 27. Quoted on p. 14 by Bernard Berelson and Gary A. Steiner (1964) Human Behavior: An Inventory of Scientific Findgs. (New York: Harcourt, Brace). 28. Elinson, J. 'Methods of Sociomedical Research', pp. 449471, in Handbook of Medical Sociology, ed. Freeman, H. E., Levine, S. and Reeder, L. G. (I963). (New Jersey: Prentice-Hall). 29. Simmons, L. W. and Wolff, H. G. (1954) Social Science in Medicine. (New York: Russel Sage Foundation). 30. Lewis, L. S. (I963) 'Knowledge, ger, Certainty, and the Theory of Magic'. Amer. J. Sociol., 6. 31. Lewis, L. S. and Lopreato,J. (I962) 'Arationality, Ignorance, and Perceived Danger in Medical Practices'. Amer. Socio. Rev., 27. 32. Malinowski, B. (1925) 'Magic Science, and Religion', in Science, Religion and Reality, ed. James Needham. (New York: Macmillan Company). 33. Zborowski, M. 'Cultural Components in Responses to Pain', pp. 256-268 in Jaco, op. cit.

The implementation of quality control programs of health care service requires a technology no less complex than that of the quality control program itself. Previous efforts to implement programs where health care practitioners are truly accountable have foundered on: 1. The lack of enthusiasm of major third party payers, 2. The functional inadequacies of Medicare utilization review committees, and 3. The conflict of interests of medical societies. For the Professional Standards Review Organizations (PSRO) to be effective rather than ceremonial, evaluation that is arm's length between evaluator and practitioner is indispensable. The PSRO is the last chance for organized medicine to demonstrate that it can and will control those practitioners who habitually do violence to its ethical and professional norms. The paper lists other options should the presently structured PSRO program fail.

This paper reports the results of a study which set out to determine whether a young dental practitioner who employs the concepts of fourhanded dentistry using one chairside dental assistant could sufficiently increase his productivity by employing an expanded duties dental assistant (EDDA) and one additional chairside assistant to make the resulting increase in overhead economically feasible. Productivity data were collected as 20 senior dental students treated patients in a control setting which consisted of two identical operatories and a staff of one chairside dental assistant, and an experimental situation consisting of two identical operatories equipped the same as the control operatories and a staff of one EDDA and two chairside assistants.