- Email: [email protected]
ORGANISATION IN GENERAL PRACTICE
680
Surgery II ours The final plan was that in the mornings-except on Wednesday and Thursday which were off-duty days for some-two doctors would see patients from 8.30 to 10.30 A.M. and would then give way to two others who would work until 12.30 P.M. These four would see patients by appointment only, and, as it was then thought essential to make provision for casual attenders, without allowing them to destroy the appointment system, a fifth doctor was to be available from 9 to 11 A.M. to see such patients. In actual fact, eventually all doctors saw patients by
Special Articles ORGANISATION IN GENERAL PRACTICE Success of a Shift System
P. M. HIGGINS M.B. Lond., M.R.C.P. GENERAL PRACTITIONER, RUGELEY,
STAFFS
THE cost of building and the restriction of capital make it essential, in planning a group practice or health centre, to study those designs and methods that allow more TABLE I-NEW CALLS, COUNTED EVERY FOUR WEEKS DURING 1955 work to be handled without proportionately increasing -‘ the amount of space required. Improvements in organisation and administration may serve this end so well as to affect considerably the planner’s basic conceptions of what is needed. The traditional routine of general practice has been modified in many places and in various ways ; but in most practices, for a large part of the working dayperhaps six hours or more-the surgery premises are unoccupied. Where the surgery is part of the doctor’s house this may be of little consequence, but in a group centre such a routine is wasteful of accommodation and staff. In 1954 our practice was faced with a sudden and unexpected increase of work. As there was no prospect appointment ; casuals were fitted in as necessary and of enlarging our facilities correspondingly, the only proved much less of a problem than was feared. On Monday evening six doctors were accommodated in solution was to improve organisation so as to make the the three consulting-rooms-three from 4.30 to 6 F.M. best use of the existing premises. and three from 6 to 8 P.M. ; 101/2 surgery hours were thus Our Patients and Our Surgery available and 120 to 130 patients could be seen without strain. On Tuesday evening five doctors worked similar In 1953 the practice consisted of four partners and an shifts. assistant. One of the partners was almost wholly engaged The surgery premises were then in use during the in a small community of about 1800 people, while the in others looked after about 10,500 patients Rugeley following times : Monday Tuesday itself and the surrounding area. In that year a group Surgery 8.30 A.M.-12.30 P.M. surgery- 8.30 A.:B1.-Ì:!.:30 1’.:B1. centre was opened to serve this population. An existing Antenatal 2-4.30 P.M. (’hilclren’s clinic 2-3.30 1’.:B1. P.M. Surgery 4.30-8 P.M. building was adapted to make a waiting-room and office, Surgery 4.30-8 Wednesday Thursday and a lavatory and three consulting-rooms were built on Surgery 9-11.30 A.M. Surgery 9-11.30 A.M. ·
at the
’
rear.
While this work was under way a National Coal Board estate was constructed in the town. Tenants began to move in during 1954, and by the end of 1955 there were 15,132 patients in the practice-an increase of just over 2800. But the increase in work was out of proportion to the numbers : the new patients were 21% of the total practice, but they accounted for an average of 26% of the new calls (table i), and men from the new estate made 42% of the total male attendances (table 11). Though another partner joined us, the practice and its facilities were greatly overburdened. At each surgery the waiting-room was full, the queue often reaching the doors. An hour and a half before the evening surgery started, the waiting-room would begin to fill, and by 5.30 P.M. there there
might were
be 50
or more
people waiting. During
43,253 attendances at the surgery ;
Friday Surgery 8.20 A.M.-12.30
(-Iiiiie} 9-3 ’3U
a
Monday evening 130 or. 140 patients might attend. To deal with this situation separate clinics for children and expectant mothers were held during the afternoons and an appointments system was started. Similar arrangements have been successful in other practices, and they helped us too. But the root of this problem was how to enable more than three doctors to work at each surgery session. The simplest solution-to build one or two extra consulting-rooms-had two disadvantages : (1) the considerable capital cost, and (2) the administrative awkwardness of enlarging, in a linear fashion, the existing building. The alternative solution-to work a shift system -would not have these disadvantages and would, moreover, spread, instead of concentrating, the work-load. As we could not get permission to extend the premises, the first solution was in any case impossible, and we started a shift system on Nov. 1, 1955.
P.M.
Saturday Surgery 8.30 A.M.-12.30
P.M.
Antenatal 2-3.30 1’.:B1. r.vi. Childn’rÙ; 5-7.30 1’.1B1. Surgery
P.M.
No evening surgery.
Thus on most working days the centre was being fully used from 8.30 A.M. to 7.30 P.M. or later. During 1956 TABLE IIŅŅSURGERY ATTENDANCES OVER THE PERIOD DEC.
1955
1955 on
Surgery 5-7.30
Antenatal 2.30-5 I’.M. No evening Hurgery.
seven
(COUNTED
FOR
32
OUT OF A TOTAL OF
5-31,
4O SESSIONS)
doctors, including a trainee assistant, were fitted scheme, using only three consulting-rooms.
into this
Staff Under who had surgery.
old
regime we employed two receptionists, help from the dispenser from the branch Now we have an extra receptionist to work half-time, but this addition has not been made solely because of extra work : the dispenser has been freed
from
our
some
of her duties in the main centre and the hours of the staff have been organised into a more reasonable pattern. The work has of course increased ; in particular the number of telephone calls has gone up. But the work is now better spaced; cards for most patients can be looked out before the surgery begins and the flow of patients is spread over a longer period. The staff are now, however, almost wholly concerned with the reception and organisation of patients and have little time for other duties. some
working
I
’
681 Results
An immediate lightening of the strain and the burden of work was noticed by all the doctors, and it was at first put down to the season. Not until the end of the month were the figures produced, which showed that, in fact, in the first three weeks of November, the attendance-rate had been the highest for the whole year. It is also worth relating the figures to the social classes in the practice population (table i[ii). The main industry in the district is coal-mining, but there are some light industries in the town, mainly employing women. The practice also serves the agricultural area around the town. The occupation groups were derived from the 1951 census; the exact number of working males in the new population is unknown but it must be over 700, falling almost wholly into social classes ill and iv. To assess the success of the appointment system, a count was made of the number of appointments :
(1) By
(2) By
3 P.M. for the the end of the
evening surgery at 4.30 or 5 P.M. evening surgery, for the next morning.
These criteria were fixed in order to rule out any possibility of the numbers containing any casuals turning up early to queue " ; but, needless to say, these are minimum figures. By no means all the patients whose appointments were booked later than these times were "
TABLE III-SOCIAL _
CLASSIFICATION, RUGELEY
AND
STAFFORDSHIRE
mencing Oct. 29 and eight out of ten in the week commencing Nov. 12.) Table iv gives detailed figures for the week with the largest number of surgery attendances (937)-i.e., that commencing Nov. 5. It is interesting to note that the evening surgeries appear to be much more fully booked, and over the four weeks Oct. 22 to Nov. 19 the percentage never fell below 74% and once was as high as 95%. The lower figures (ranging from 40% to 84%) for the morning surgeries may be due in part to the limiting effect of the criteria adopted; the true figure is almost certainly higher than this. These figures show the extent to which patients made use of the system ; we come now to examine its effectiveThe method chosen was to have the ness in practice. number of patients waiting counted every half-hour. Owing to staff changes and pressure of work these figures were collected for only fourteen sessions, between Dec. 5, 1955, and Feb. 24, 1956. The maximum number varied between 6 and 26, with an average of 11 -except for one unusual occasion when it rose to 33 because one partner had fallen ill and another had been delayed half an hour in starting his surgery. When it is recognised that up to 140 patients were seen at one session, it will be seen how effectively the system worked. Moreover, the numbers waiting have to be broken down in three ways :
waiting
casual callers who had to wait their turn. Particularly is this true of the morning surgery, because many more appointments for it would be made over the telephone before the surgery began. That few were casuals is shown by the numbers in the waiting-room at the beginning of each surgery. From July to September there was an average of 62% appointments. Later weekly percentages were:
Week >,
>,
commencing Oct. 22-69% (total attendances 917) Oct. 29-72% ( 855) Nov. 12-73% ( 855) »
"
"
"
(The figures for the last two weeks relating to seven out of ten sessions TABLE V-NUMBERS
not complete, in the week com-
are
WAITING ;
(1) They are waiting to see three doctors. (2) Some are accompanying patients. (3) Some are early for their appointments. The effect of these last two factors became clear one evening when all three doctors were working to schedule, yet the waiting-room contained 12 people. The maximum number waiting was almost always at its greatest at the time when the shifts changed and we are now trying to diminish the effect of this by allowing a gap of 15 minutes at this time. Experience has shown the way to other improvements. The general rule is that 3 patients are booked every quarter of an hour, but allowance is now made for the individual doctor’s rate of work. A profitable study could be made of the consulting-time needed by different groups : for example there is an impression that, on the whole, women patients need more
FOR WEEKS COMMENCING OCT.
22
AND NOV.
5 1956
682 with advantage, be of the surgery. towards the end given appointments More complete figures for the weeks commencing Oct. 22 and Nov. 5 are given in table v. They relate to a period when, as will be mentioned, a fourth consultingroom was in use ; the figures of patients waiting must therefore be divided by four, and not by three. The main factor in this improvement has been the appointments system. The chief effect of the shift system has been to spread the load. Up to 30 patients are seen before the time when surgeries used to start (at about 9.30 A.M. and 5.30 P.M.), and this has diminished the bulge in the waiting-room. The most significant evidence of improvement has been that we have now been able to reduce the size of our waiting-room so that it now accommodates about 20, instead of 60, patients. Not only does this make it a more attractive place, and lessen the risk of crossinfection, but the space saved has been used to provide a new and more efficiently designed office. The former office has been converted into a double-purpose room which can be used either as a surgery or for dispensing
It lit,4 in fact been used as a and office procedures. fourth consulting-room with an adjustment of our shift
Public Health
directed to this condition or its notification in the past few years locally. I suspect that what is being notified is probably a mild staphylococcal infection. Nearly all the extensive literature on antibiotiu-resiatant staphylococci refers to hospital practice ; and half of these infants were delivered at home. But, in resuming work in an infant-welfare centre after some six years’ absence, I have been extent of minor sepsis in the impressed by the newborn-sticky eye." mastitis (infective, not secretory), paronychia, blisters in the flexures, and discharging navels ; and I get the impression that such sepsis is becoming as important as impetigo was in school-children before the w-ar. In New Zealand staphylococcal infection of the newborn and pemphigus neonatorum are now notifiable diseases,’ presumably because Xew Zealanders are worried as to its prevalence. May this have any relation to the system of paying practitioners according to the number of items of service they provide, which must encourage the use of antibiotics’? The national figures do not, so far, reflect any rise in the notifications of ophthalmia neonatorum. It will be interesting to see whether the Ilford figures are an indication of the shape of things to come.
time than
men
and
might therefore,
" OPHTHALMIA NEONATORUM " AND MINOR NEONATAL INFECTION M.D.
I. GORDON Edin., M.R.C.P., D.P.H.
MEDICAL OFFICER
OF
HEALTH,
ILFORD
IN Ilford, as the accompanying figure shows, notifications of ophthalmia neonatorum were steadilv falling, until there were none in the four years 1952-55. In 1956, however, there were 10 (see figure). The disease notified is not classical opthhalmia neonatorum. When the notification was received, each case was visited by a member of the public-health department, and by that time the condition had practically subsided. No doubt many would have diagnosed the cases as " sticky eye " ; but why did the Ilford practitioners notify these 10 cases in 1956, and none in the previous four years, when undoubtedly they must have seen many cases of sticky eye ? Presumably in 1956 they were stickier than
usual. The-10 cases were notified by six different doctors; 5 of the infants were born at none notified more than 2. home in different parts of the town, and 5 in hospitalfour different hospitals, scattered over Greater London. In 2 of the home confinements there was the same midwife ; in the 3 others different midwives. Hence there is no question of a local epidemic or individual reporting idiosyncrasies. No publicity of any nature had been
system. No claim is made that the above represents an ideal has been done has been done under the pressure of events and in the face of severe limitations. Further developments wait on better days and more spacious surroundings. Until they come, purely administrative changes have enabled this practice to increase its facilities, to deal with all extra 2800 patients, and so to improve its organisation as to serve adequately a population of over 13,000 from a centre occupying approximately 1100 sq. ft.
arrangementwhat
I wish to express my thanks to the staff of the centre for their help in collecting the figures set out in this paper, to Dr. Gerald Ramage, county medical officer of health, for providing the information in table 111, and to Mr. S. Clewes, clerk to the Staffordshire executive council, for figures on the
practice population. The members of the partnership are Dr. B. A. Abbott, Dr. P. M. James, Dr. Stanley Dillon, Dr. P. J. MacMonagle, and myself,
present
Immunisation
against Diphtheria
Observations in Heston and Isleworth have led Andersen 2 to conclude that in immunisation against diphtheria booster doses of antigen provide no significant advantage over primary immunisation only. In a review of children born in 1941, 1944, and 1947, he found that of all who had undergone primary immunisation and had later received a booster dose 91.4% were Schick-nega.tive ; whereas of all who had undergone primary immunisation only 89-9% were Schicknegative. This difference being very small, Anderson concludes that, so long as the incidence ofdiphtheria reinains low, reinforcing inoculations should not be undertaken. Population of England and Wales The Registrar- General3 reports that projections of the population of England and Wales show that, on certain stated assumptions, the total population will increase from 44,821,000 (as at mid-1956) to 45,569,000 in 1961. 47,423,000 in 1976, and 48,545,000 in 1996. In 1956live births registered exceeded deaths by 177,657. The corresponding increase for 1955 was 146,090, and the average increase for the five years 1950-54 was 167,349. 1. Med. Offr, 1957, 97, 16. 2. Anderson, A. Ibid., March 22, 1957, 3. Registrar-General’s quarterly return Office. Pp. 32. 1s. 6d.
p. 161. no. 432, H.M. Stationery
,
Surgery II ours The final plan was that in the mornings-except on Wednesday and Thursday which were off-duty days for some-two doctors would see patients from 8.30 to 10.30 A.M. and would then give way to two others who would work until 12.30 P.M. These four would see patients by appointment only, and, as it was then thought essential to make provision for casual attenders, without allowing them to destroy the appointment system, a fifth doctor was to be available from 9 to 11 A.M. to see such patients. In actual fact, eventually all doctors saw patients by
Special Articles ORGANISATION IN GENERAL PRACTICE Success of a Shift System
P. M. HIGGINS M.B. Lond., M.R.C.P. GENERAL PRACTITIONER, RUGELEY,
STAFFS
THE cost of building and the restriction of capital make it essential, in planning a group practice or health centre, to study those designs and methods that allow more TABLE I-NEW CALLS, COUNTED EVERY FOUR WEEKS DURING 1955 work to be handled without proportionately increasing -‘ the amount of space required. Improvements in organisation and administration may serve this end so well as to affect considerably the planner’s basic conceptions of what is needed. The traditional routine of general practice has been modified in many places and in various ways ; but in most practices, for a large part of the working dayperhaps six hours or more-the surgery premises are unoccupied. Where the surgery is part of the doctor’s house this may be of little consequence, but in a group centre such a routine is wasteful of accommodation and staff. In 1954 our practice was faced with a sudden and unexpected increase of work. As there was no prospect appointment ; casuals were fitted in as necessary and of enlarging our facilities correspondingly, the only proved much less of a problem than was feared. On Monday evening six doctors were accommodated in solution was to improve organisation so as to make the the three consulting-rooms-three from 4.30 to 6 F.M. best use of the existing premises. and three from 6 to 8 P.M. ; 101/2 surgery hours were thus Our Patients and Our Surgery available and 120 to 130 patients could be seen without strain. On Tuesday evening five doctors worked similar In 1953 the practice consisted of four partners and an shifts. assistant. One of the partners was almost wholly engaged The surgery premises were then in use during the in a small community of about 1800 people, while the in others looked after about 10,500 patients Rugeley following times : Monday Tuesday itself and the surrounding area. In that year a group Surgery 8.30 A.M.-12.30 P.M. surgery- 8.30 A.:B1.-Ì:!.:30 1’.:B1. centre was opened to serve this population. An existing Antenatal 2-4.30 P.M. (’hilclren’s clinic 2-3.30 1’.:B1. P.M. Surgery 4.30-8 P.M. building was adapted to make a waiting-room and office, Surgery 4.30-8 Wednesday Thursday and a lavatory and three consulting-rooms were built on Surgery 9-11.30 A.M. Surgery 9-11.30 A.M. ·
at the
’
rear.
While this work was under way a National Coal Board estate was constructed in the town. Tenants began to move in during 1954, and by the end of 1955 there were 15,132 patients in the practice-an increase of just over 2800. But the increase in work was out of proportion to the numbers : the new patients were 21% of the total practice, but they accounted for an average of 26% of the new calls (table i), and men from the new estate made 42% of the total male attendances (table 11). Though another partner joined us, the practice and its facilities were greatly overburdened. At each surgery the waiting-room was full, the queue often reaching the doors. An hour and a half before the evening surgery started, the waiting-room would begin to fill, and by 5.30 P.M. there there
might were
be 50
or more
people waiting. During
43,253 attendances at the surgery ;
Friday Surgery 8.20 A.M.-12.30
(-Iiiiie} 9-3 ’3U
a
Monday evening 130 or. 140 patients might attend. To deal with this situation separate clinics for children and expectant mothers were held during the afternoons and an appointments system was started. Similar arrangements have been successful in other practices, and they helped us too. But the root of this problem was how to enable more than three doctors to work at each surgery session. The simplest solution-to build one or two extra consulting-rooms-had two disadvantages : (1) the considerable capital cost, and (2) the administrative awkwardness of enlarging, in a linear fashion, the existing building. The alternative solution-to work a shift system -would not have these disadvantages and would, moreover, spread, instead of concentrating, the work-load. As we could not get permission to extend the premises, the first solution was in any case impossible, and we started a shift system on Nov. 1, 1955.
P.M.
Saturday Surgery 8.30 A.M.-12.30
P.M.
Antenatal 2-3.30 1’.:B1. r.vi. Childn’rÙ; 5-7.30 1’.1B1. Surgery
P.M.
No evening surgery.
Thus on most working days the centre was being fully used from 8.30 A.M. to 7.30 P.M. or later. During 1956 TABLE IIŅŅSURGERY ATTENDANCES OVER THE PERIOD DEC.
1955
1955 on
Surgery 5-7.30
Antenatal 2.30-5 I’.M. No evening Hurgery.
seven
(COUNTED
FOR
32
OUT OF A TOTAL OF
5-31,
4O SESSIONS)
doctors, including a trainee assistant, were fitted scheme, using only three consulting-rooms.
into this
Staff Under who had surgery.
old
regime we employed two receptionists, help from the dispenser from the branch Now we have an extra receptionist to work half-time, but this addition has not been made solely because of extra work : the dispenser has been freed
from
our
some
of her duties in the main centre and the hours of the staff have been organised into a more reasonable pattern. The work has of course increased ; in particular the number of telephone calls has gone up. But the work is now better spaced; cards for most patients can be looked out before the surgery begins and the flow of patients is spread over a longer period. The staff are now, however, almost wholly concerned with the reception and organisation of patients and have little time for other duties. some
working
I
’
681 Results
An immediate lightening of the strain and the burden of work was noticed by all the doctors, and it was at first put down to the season. Not until the end of the month were the figures produced, which showed that, in fact, in the first three weeks of November, the attendance-rate had been the highest for the whole year. It is also worth relating the figures to the social classes in the practice population (table i[ii). The main industry in the district is coal-mining, but there are some light industries in the town, mainly employing women. The practice also serves the agricultural area around the town. The occupation groups were derived from the 1951 census; the exact number of working males in the new population is unknown but it must be over 700, falling almost wholly into social classes ill and iv. To assess the success of the appointment system, a count was made of the number of appointments :
(1) By
(2) By
3 P.M. for the the end of the
evening surgery at 4.30 or 5 P.M. evening surgery, for the next morning.
These criteria were fixed in order to rule out any possibility of the numbers containing any casuals turning up early to queue " ; but, needless to say, these are minimum figures. By no means all the patients whose appointments were booked later than these times were "
TABLE III-SOCIAL _
CLASSIFICATION, RUGELEY
AND
STAFFORDSHIRE
mencing Oct. 29 and eight out of ten in the week commencing Nov. 12.) Table iv gives detailed figures for the week with the largest number of surgery attendances (937)-i.e., that commencing Nov. 5. It is interesting to note that the evening surgeries appear to be much more fully booked, and over the four weeks Oct. 22 to Nov. 19 the percentage never fell below 74% and once was as high as 95%. The lower figures (ranging from 40% to 84%) for the morning surgeries may be due in part to the limiting effect of the criteria adopted; the true figure is almost certainly higher than this. These figures show the extent to which patients made use of the system ; we come now to examine its effectiveThe method chosen was to have the ness in practice. number of patients waiting counted every half-hour. Owing to staff changes and pressure of work these figures were collected for only fourteen sessions, between Dec. 5, 1955, and Feb. 24, 1956. The maximum number varied between 6 and 26, with an average of 11 -except for one unusual occasion when it rose to 33 because one partner had fallen ill and another had been delayed half an hour in starting his surgery. When it is recognised that up to 140 patients were seen at one session, it will be seen how effectively the system worked. Moreover, the numbers waiting have to be broken down in three ways :
waiting
casual callers who had to wait their turn. Particularly is this true of the morning surgery, because many more appointments for it would be made over the telephone before the surgery began. That few were casuals is shown by the numbers in the waiting-room at the beginning of each surgery. From July to September there was an average of 62% appointments. Later weekly percentages were:
Week >,
>,
commencing Oct. 22-69% (total attendances 917) Oct. 29-72% ( 855) Nov. 12-73% ( 855) »
"
"
"
(The figures for the last two weeks relating to seven out of ten sessions TABLE V-NUMBERS
not complete, in the week com-
are
WAITING ;
(1) They are waiting to see three doctors. (2) Some are accompanying patients. (3) Some are early for their appointments. The effect of these last two factors became clear one evening when all three doctors were working to schedule, yet the waiting-room contained 12 people. The maximum number waiting was almost always at its greatest at the time when the shifts changed and we are now trying to diminish the effect of this by allowing a gap of 15 minutes at this time. Experience has shown the way to other improvements. The general rule is that 3 patients are booked every quarter of an hour, but allowance is now made for the individual doctor’s rate of work. A profitable study could be made of the consulting-time needed by different groups : for example there is an impression that, on the whole, women patients need more
FOR WEEKS COMMENCING OCT.
22
AND NOV.
5 1956
682 with advantage, be of the surgery. towards the end given appointments More complete figures for the weeks commencing Oct. 22 and Nov. 5 are given in table v. They relate to a period when, as will be mentioned, a fourth consultingroom was in use ; the figures of patients waiting must therefore be divided by four, and not by three. The main factor in this improvement has been the appointments system. The chief effect of the shift system has been to spread the load. Up to 30 patients are seen before the time when surgeries used to start (at about 9.30 A.M. and 5.30 P.M.), and this has diminished the bulge in the waiting-room. The most significant evidence of improvement has been that we have now been able to reduce the size of our waiting-room so that it now accommodates about 20, instead of 60, patients. Not only does this make it a more attractive place, and lessen the risk of crossinfection, but the space saved has been used to provide a new and more efficiently designed office. The former office has been converted into a double-purpose room which can be used either as a surgery or for dispensing
It lit,4 in fact been used as a and office procedures. fourth consulting-room with an adjustment of our shift
Public Health
directed to this condition or its notification in the past few years locally. I suspect that what is being notified is probably a mild staphylococcal infection. Nearly all the extensive literature on antibiotiu-resiatant staphylococci refers to hospital practice ; and half of these infants were delivered at home. But, in resuming work in an infant-welfare centre after some six years’ absence, I have been extent of minor sepsis in the impressed by the newborn-sticky eye." mastitis (infective, not secretory), paronychia, blisters in the flexures, and discharging navels ; and I get the impression that such sepsis is becoming as important as impetigo was in school-children before the w-ar. In New Zealand staphylococcal infection of the newborn and pemphigus neonatorum are now notifiable diseases,’ presumably because Xew Zealanders are worried as to its prevalence. May this have any relation to the system of paying practitioners according to the number of items of service they provide, which must encourage the use of antibiotics’? The national figures do not, so far, reflect any rise in the notifications of ophthalmia neonatorum. It will be interesting to see whether the Ilford figures are an indication of the shape of things to come.
time than
men
and
might therefore,
" OPHTHALMIA NEONATORUM " AND MINOR NEONATAL INFECTION M.D.
I. GORDON Edin., M.R.C.P., D.P.H.
MEDICAL OFFICER
OF
HEALTH,
ILFORD
IN Ilford, as the accompanying figure shows, notifications of ophthalmia neonatorum were steadilv falling, until there were none in the four years 1952-55. In 1956, however, there were 10 (see figure). The disease notified is not classical opthhalmia neonatorum. When the notification was received, each case was visited by a member of the public-health department, and by that time the condition had practically subsided. No doubt many would have diagnosed the cases as " sticky eye " ; but why did the Ilford practitioners notify these 10 cases in 1956, and none in the previous four years, when undoubtedly they must have seen many cases of sticky eye ? Presumably in 1956 they were stickier than
usual. The-10 cases were notified by six different doctors; 5 of the infants were born at none notified more than 2. home in different parts of the town, and 5 in hospitalfour different hospitals, scattered over Greater London. In 2 of the home confinements there was the same midwife ; in the 3 others different midwives. Hence there is no question of a local epidemic or individual reporting idiosyncrasies. No publicity of any nature had been
system. No claim is made that the above represents an ideal has been done has been done under the pressure of events and in the face of severe limitations. Further developments wait on better days and more spacious surroundings. Until they come, purely administrative changes have enabled this practice to increase its facilities, to deal with all extra 2800 patients, and so to improve its organisation as to serve adequately a population of over 13,000 from a centre occupying approximately 1100 sq. ft.
arrangementwhat
I wish to express my thanks to the staff of the centre for their help in collecting the figures set out in this paper, to Dr. Gerald Ramage, county medical officer of health, for providing the information in table 111, and to Mr. S. Clewes, clerk to the Staffordshire executive council, for figures on the
practice population. The members of the partnership are Dr. B. A. Abbott, Dr. P. M. James, Dr. Stanley Dillon, Dr. P. J. MacMonagle, and myself,
present
Immunisation
against Diphtheria
Observations in Heston and Isleworth have led Andersen 2 to conclude that in immunisation against diphtheria booster doses of antigen provide no significant advantage over primary immunisation only. In a review of children born in 1941, 1944, and 1947, he found that of all who had undergone primary immunisation and had later received a booster dose 91.4% were Schick-nega.tive ; whereas of all who had undergone primary immunisation only 89-9% were Schicknegative. This difference being very small, Anderson concludes that, so long as the incidence ofdiphtheria reinains low, reinforcing inoculations should not be undertaken. Population of England and Wales The Registrar- General3 reports that projections of the population of England and Wales show that, on certain stated assumptions, the total population will increase from 44,821,000 (as at mid-1956) to 45,569,000 in 1961. 47,423,000 in 1976, and 48,545,000 in 1996. In 1956live births registered exceeded deaths by 177,657. The corresponding increase for 1955 was 146,090, and the average increase for the five years 1950-54 was 167,349. 1. Med. Offr, 1957, 97, 16. 2. Anderson, A. Ibid., March 22, 1957, 3. Registrar-General’s quarterly return Office. Pp. 32. 1s. 6d.
p. 161. no. 432, H.M. Stationery
,