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so greatly improving methods of treatment that patientswill require less hospital care. But if for the present weare to regard the demand for hospital treatment as

unalterable, we must consider what further economiesin medical man-power can be made. The followingpossibilities suggest themselves :

1. Train non-medical technical staff to carry out preliminaryinvestigations under medical instructions and to arrangefor routine test investigations of new patients-e.g.,electrocardiograms, test meals, barium meals.

2. Erect health centres as quickly as possible. By savingthe time of general practitioners, this may enable themto give some help in hospitals. Alternatively, adoptsome other means of economising in the use of generalpractitioners.

3. Enlarge the medical schools and encourage more studentsto train as doctors.

4. Require doctors to work in hospital for a period longerthan the year prescribed under the Medical Act, 1950,and restrict the entry of doctors to non-clinical postswhich seem to have lesser claims on the medical

profession.5. Encourage students or qualified doctors from abroad to

take up medical work in this country.6. Create more full-time consultant posts to replace some

of the part-time consultant appointments. This wouldenable more work by consultant staffs to be done in thehospitals.

7. Redistribute specialised beds in existing hospitals so asto avoid unnecessary travelling between hospitals in thevarious groups.

When money is to be had for the purpose, the buildingof larger hospital units would result in a saving ofmedical man-power.

If it proves possible to re-educate the public in theuse of the health services, some assistance with hospitalwork should be obtainable from doctors now employedin general practice. Already many hospitals are usingpractitioners as part-time clinical assistants, and this

arrangement might be extended, especially in connectionwith duties in casualty departments where the greatestdifficulty is experienced.Another way of overcoming the staffing difficulties at

a hospital where accident and acute cases are admittedmight beto introduce a senior resident officer (of, say,junior consultant status) who would be appointed forseveral years and would be in line for promotion toconsultant. He should be given facilities for his familyto reside with him at the hospital.

Married women doctors not already engaged in practicemight be encouraged to undertake part-time duties athospitals, and retired doctors might also be prepared todo part-time work.Another possible method of overcoming the shortage

in non-teaching hospitals might be to pay junior medicalstaff at a lower rate in teaching hospitals than in non-teaching hospitals. On the other hand, it might bepossible to arrange for the transfer of junior medicalstaff from the teaching hospitals to the non-teachinghospitals for a period of service.

CONCLUSION

In looking at recruitment to the medical professionattention must be paid to all the medical services con-cerned, not only the hospital service ; and this is amatter which seems to call for discussions at high levelbetween Government representatives, hospital authori-ties, local health authorities, executive councils, univer-sities, the General Medical Council, and the representativemedical organisations. So that these discussions mayachieve a useful result at the earliest possible date wesuggest that the bodies mentioned should appoint repre-sentatives to attend a conference, with the Minister ofHealth in the chair, to discuss what should be done. We

recognise, of course, that before such a conference washeld it would bo necessary to obtain statistics showing 0the number of medical posts in hospital, general practice,and so on, the number of qualified doctors, and the outputof doctors from the universities. It would also be desir.able to have information about the man-power necessaryfor professions other than medicine, for industry, for theArmed Forces, and for other needs, and of the numberof people available to do the work.

1. See Taylor, S. Lancet, 1952, i, 253 (Harlow); Wofinden, R. C.,Parry, R. H. Ibid, p. 1297 (Bristol) ; Ibid, ii, 772 (WoodberryDown); Ibid, p. 931 (Nottingham).

2. The architects were : ROBERT GARDNER-MEDWIN (chief architect);ROBERT MORTON (deputy chief architect for special buildings);JOHN OGILVIE and GEORGE LAWRENCE (senior architects,responsible for development of design and supervision):ERIC HALL (assistant architect) ; and R. J. WALKER, D. A.MACGILLIVRAY, and R. E. A. EADIE (assistants).

SCOTLAND’S FIRST HEALTH CENTRE

THE first health centre in Scotland, opened by llr.James Stuart, the Secretary of State, on May 15, is anadventure in combined planning and administration;and, as with similar adventures that are alread ’vunder way in England,! its progress will be keenlywatched.

This centre, at Sighthill, a growing new suburb on thesouth-west fringe of Edinburgh, was planned by theDepartment of Health for Scotland with the cooperationof Edinburgh Corporation and the good will of the localmedical committee. It contains suites for six generalpractitioners along with a pharmacy, a laboratory, andspace for an X-ray department ; four dental surgeries;accommodation for infant-welfare and school-health-service clinics ; and a gymnasium and a physiothera.pist’s room. The building is also to be the headquartersof the health visitors and district nurses working in thearea. At present it serves a population of 10,000-12,000.

DESIGN AND FUNCTION

Architects are a frustrated professional group ; forsince 1939 they have had little chance to show theirpaces. The housing programme that has gone forwardsince the end of the war has provided scant opportunityfor initiative ; ; and only occasionally, as in the Festivalof Britain, have the public been enabled to see how theprofession’s views have been shaping during its enforcedquietude. At Sighthill the architects of the Departmentof Health 2 have had the first chance in years of steppingout ; ; it is little wonder that they show themselvesmettlesome. For a building of this sort, the centre isexceptional in that the architectural team has, subjectto the general requirements, had a free rein both in

designing the building and in choosing the furnishings.The mixed array of coachmen can now congratulatethemselves on their forbearance.

Initially the Department had to choose between asmall and relatively inexpensive centre, which mightprove inadequate, and a more elaborate one that mightturn out to be over-large for the demands on it. Thechoice fell on the second of these options : both thenumber and the size of the rooms is large (the floorarea totals some 35,000 square feet) ; and the cost, with I’equipment, is about jEl 60,000.General DescriptionThe building (fig. 1) is in the form of a hollow square

of one storey, except for one side where a second storey

j’houses the dental surgeries and staff rooms. It is builtof concrete brick (clay is scarce in Scotland) with aprefabricated roof of copper on fibre. The wings could be ,

extended ; ; and internal flexibility is assured by a

4 ft. 9 in. module. The partition walls are of foamed-slag Iconcrete blocks ; these have no weight-bearing respon- Isibilities and can thus be pulled down at will. (The idea

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Fig. I-Plan of building :B, Baby-weighing room. C, consulting-room. E, examination-room. L, lavatory. M.T., minor treatment. Q, playroom. S, surgery. St, study or lecture-room.

W, waiting-room. S.W., switch-room.

of putting up rather more temporary partitions wasmooted but abandoned, mainly because of the need fornoiselessness.) The ceilings-of insulation board toppedwith a quilt of glass wool-are reckoned to afford thermaland sound insulation. Heating is provided electricallyfrom conduits embedded in the floors ; the electricityis turned off at peak hours, at which times the roomsdraw warmth from the heat stored in the fabric of the

building.The architects have relied on light, bold use of colour,

and diversity, with a careful choice of furnishings, togive an air of richness and avert the chill institutionalatmosphere. The many colours on the walls rangethrough and sometimes, it seems, beyond the breadth ofthe rainbow ; but the chocolate hue once revered byhospitals and public-houses is nowhere to be found.

Throughout, the colours (except in the corridors, eachof which is painted differently) are

not restful : they are challenging ;and occasionally the challenge mayhave overreached its mark, anyhowfor those facing it every day-onedoctor’s room, for instance, has a

greenish-mustard carpet which drawsthe eyes by its repulsiveness. As to

diversity, the walls of the mainentrance-hall are, in different sections,of stone, of painted plaster, and

rough-cast ; adjacent rooms rarelyhave the same colour motif ; and insome rooms one wall differs from itsthree neighbours.

The Hall

The visitor approaching the mainentrance (fig. 2), at the junction ofthe administrative and general-practi-tioner wings, gains a sense of spacious-ness. The surrounding gardens areunfenced ; and to the left of the dooris a large covered verandah with

open fields beyond. Inside the door is a large stone-flagged hall, of which the commanding feature is a"

suspended " staircase, winding up without visiblemeans of support except for a spine of reinforced concrete.

This staircase has a strikingly light and gay air, whichis heightened by the huge window behind it, stretchingfrom floor to roof. To the left of this staircase, besidethe entrance door, is the dispensary ; and on the otherside is the corridor of the administrative wing. To the

right of this, facing the entrance, is an inviting-lookinginquiry bureau with its large window framed in unpaintedWest African hardwood. (West African hardwoodsrecur in variety throughout the building.)The visitor, turning to the right to enter the general-

practitioners’ wing, passes two further large windows.That on the right, or outer, side is double, with a wideinterval between the two layers where plants are growing.

Fig. 2-The main entrance.

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Fig. 3-A consulting-room.

That on the left reveals the inside of the square with two

transplanted silver birches taking root and grass-seedstentatively sprouting. The only furniture in the hallis a couple of cheerfully (and differently) coloured metalgarden chairs.

General-practitioners’ Jr ingThe corridor lined by doors leading into the general-

practitioners’ suites is, like the others, notably silent.This is due partly to the flooring of rubber squares, andpartly to the substance of the walls and ceiling ; and inthe doctors’ rooms double walls make the silence doublvsilent. On the right of the entrance to each suite is a

capacious waiting-room (14 ft. square), in front is anexamination-room (8 ft. by 12 ft.), and to the left is theconsulting-room (14 ft. square, without fittings).The waiting-room has a large central table and, at

present, 20 chairs-though it could take twice thisnumber. These chairs, of which the building contains230, are comfortable, light, convenient, and, as chairsnow go, cheaply come by. They are made of unpainted5-ply wood with a laminated back-support which givesspring ; they are readily stacked ; and they costf:2 9s. 6d. each.The examination-room contains a couch and a

wash-hand basin and board. The consulting-room(fig. 3) has a large desk and a wash-hand basin andboard.

-

Each of these rooms, it may be noted, is differentlyfloored, decorated, and furnished. The doctor’s roomhas a parquet floor of split hardwood, partly concealedby a thick carpet ; and, in keeping with the presentvogue, the decoration of one wall differs impressivelyfrom that of the three others. In this room, too, white-painted venetian blinds of malleable aluminium take theplace of curtains.

Combined-services " lFtM</Continuing anti-clockwise round the square, the next

wing is taken up by " combined services." This wingcontains a steriliaing-room, to serve the whole centre,flanked by two dressing-rooms. It also includes a

laboratory, at present used only as a side-room ; accom-modation (but not at present equipment) for an X-raydepartment ; and a room (still unoccupied) for a

chiropodist. There is, too, an excellent gymnasium, withchanging-rooms attached, intended for use mainly by

with slight physical defects ; and another roomthat will be equipped by the physiotherapist, who haslately been appointed.Child-welfare and School-health OlinicsThe third side of the square-. opposite that occupied

by the general practitioners-is devoted to child-welfareand school-health-service clinics. Here the absence at

present of an antenatal clinic may seem strange; butin Edinburgh such clinics are usually operated by thehospital service. This wing, though connected with theothers, can be approached by a separate entrance with,nearby, a covered perambulator park.Near this entrance is a bright children’s playroom,

with a scaled-down lavatory and wash-room attached.The floor is tiled with rubber in three colours-blue,yellow, and red-in check formation. Most of one sideis occupied by a large window, beyond which is a wired.in verandah. Of the other sides, two are cheerfullypainted (one in grey, the other in scarlet) ; while thelarge wall facing the window is covered with flower.patterned paper-a surprising, and perhaps well-judged,deviation from the Hey-Diddle-Diddle theme thatmight have been thought inevitable. The ceiling isyellow.Another feature of this wing is a kitchen, which can be

used for demonstration or for nourishment.

The Foucrih (quarterTo look at, the administrative wing, which leads back

to the main entrance, is as fascinating as any otheradministrative department. But it does contain a

lecture-room and two studies, which are likely to proveuseful in connection with the centre’s welfare activitiesand also any teaching of medical undergraduates or

postgraduates.cup the f:3tairs

The four dental surgeries, on the first floor above theadministrative wing, have been constructed after muchstudy, including a

"

mock-up " of one surgery. Facingnorth, each surgery has a bay which is wholly filled by asloping window. Two of the surgeries are given over topriority work under the local authority ; one is for

general dental services ; and the fourth is destined for

major operations. The dentists have their own X-rayroom and a sitting-room.The rest of this floor is taken up by two staff rooms

(one for the medical staff) with a kitchen attached.

DISCUSSION

This centre, like the few that have already been

opened in Britain, is surrounded by question-marks.The building is not palatial-though the architectsdelude the visitor into thinking that it is-but it is largeand has cost a lot of money, and no-one would pretendthat we are likely to see many like it taking shape up anddown the country.

Instead of centres having such a noble start, shouldthey have the sort of start that can be followed up 1But then again, how soon can a start of any sort bedeveloped ? ’z The construction of health centres callsnot only for much money but also for the cooperation of !

several interested parties ; and some such parties arenotably uninterested. And what of the consumer’sreaction t Can we plan for the future on the basis of afew exceptional efforts ? May not these efforts recoilon the heads of their planners by attracting patients fromfar as well as near, thus disturbing a city’s healthservices and dismaying workers in neighbouringareas who are doing their best with less elaborateresources ‘?What of laboratories and X-ray departments are they

wanted ; are they to be run by technicians, and, if so,

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who is to supervise the work ’1 Indeed, is it economic tohave an X-ray department for, say, 20,000 people ?These questions are not new : what is new is the

occasion, by practice, to grope towards some of theanswers. Most of the questions concern the generalpractitioner; and unfortunately to some of them nofinal answer is possible until the role-and the will-ofthe practitioner in this new age is seen more clearly.This, of course, is no reason for not pressing on withhealth centres ; for these may themselves help to deter-mine the practitioner’s role and will. The immediateneed is for experience with centres large and small,elaborately and simply equipped ; and it is to be hopedthat the opportunity at Sighthill will be fully seized byequipping the X-ray department, and by trying differentforms of operation and control both here and in thelaboratory.As to economy, at Sighthill the playroom, the gym-

nasium, and one or more of the staff rooms are perhapsdispensable. Elsewhere in the building-and especiallyin the general-practitioners’ suites-advantage will nodoubt be taken of the flexible design to experiment withsmaller rooms, in order to establish the sizes that aremost economical of space without being inconvenient oroppressive. Perhaps, too, experience may show thatpractitioners and patients will accept less rigidly secludedwaiting-rooms.With regard to construction materials, the copper roof

is a little flourish that will not always be repeatable ; andsimilarly hardwood may be less prominent in latercentres. But, all in all, the designers have made good useof ordinary materials, abjuring the exotic.Meanwhile, plans are well advanced for the second

Scottish centre, which is to be built at Stranraer, near thehospital. It is to be rather smaller than that at Sight-hill; but this will not stop the Health Department’sarchitects from feeling sedately elated at the prospectof once more escaping from the fantasy of the drawing-board into the actuality of bricks and mortar-andcolour.

SENIOR REGISTRARSTHE Minister of Health and the Joint Committee for

Consultants and Specialists have been discussing theposition of those senior registrars in England and Waleswhose appointments will soon be ending in accordancewith the arrangements made in 1951 for reducing thenumber of senior-registrar posts to bring it more intoline with the estimated number of vacancies for con-sultants and senior hospital medical officers in the variousspecialties. The Joint Committee have represented tothe Minister that to avoid undue hardship a longer timeshould be allowed for this adjustment to be broughtabout, so that in suitable cases these senior registrarsand former senior registrars may have longer to seekhigher hospital appointments or other medical postsoutside the hospital service. The Minister has come tothe conclusion that transition to the senior-registrarcomplement envisaged by the plan of 1951 may besmoothed in that way without detriment to the hospitalservice.

Accordingly the Minister has authorised hospitalboards to retain senior-registrar posts in excess of thosecovered by the plan of 1951, for a period not extendingbeyond the end of 1955 at the latest, where this willavoid extra staff having to be employed in other gradesand fully suitable candidates are forthcoming for theretained posts.As the engagements of the present holders come to an

end the posts which are to be retained will be advertised.Applications will be entertained from the present holders,from other senior registrars whose appointments willend in the near future, and, in certain circumstances,

from former senior registrars. The term of these postswill be one year, but boards will be free to allow a secondyear where other employment has not been obtainedby the end of the first year.Though the holders of these posts will continue to be

free to compete for higher hospital appointments, theywill do so in competition with other candidates, andtheir retention as senior registrars will not give themany special claim or constitute any guarantee that theywill be successful in the competition.

In addition, there will still, of course, be nothing toprevent a retiring senior registrar from applying for,and being appointed to, a post within the trainingestablishment. If, however, he is reappointed to thesame post, the term of his reappointment will be limitedto two years. "-

The Joint Committee have expressed their agreementwith these arrangements.

MINISTRY’S OBSERVATIONS

The Ministry of Health, in a letter to hospital boards,states :

" Where it is decided to retain a post it should be advertisedat the appropriate time as a post for one year, with a possibleextension to two years (but not beyond 31st December, 1955)if the holder has not obtained other employment in the mean-time. The present holder will be free to compete for itand applications should also be entertained from any otherpersons in their fourth or subsequent years as senior registrarsin the specialty and those who though not now holding postsas senior registrars have occupied such posts for three or moreyears and have vacated them since memorandum RH]3(50)106/BG(50)96 was issued on 6th November, 1950. The applica-tions should go to the Appointments Committee for considera-tion and recommendations. It is most important thatthere should be a genuine competition which gives equalopportunity to the present holder of the post and to otherssimilarly situated.

" Where a transitional post becomes vacant before 1st

January, 1955, it may be advertised again but transitionalposts becoming vacant on or after that date should beabolished and other arrangements made for the work hithertoperformed by the holders.

" In some regions where the reduced establishment ofsenior registrars has already been reached, it may be that inthe case of a few of the posts which have been abolisheddifficulties have been caused in the staffing of the hospitalsand to the men in posts similar to those which this scheme isdesigned to relieve. In such circumstances the Ministerwould see no objection to the revival of a post temporarilyas a transitional post, but this should be exceptional....

" In their own interests it should be made clear to successful

applicants that their selection for transitional posts mustnot be taken as conferring on them any special claim to higherhospital posts or constituting any guarantee of their

being successful in due course in the competition for theseposts....

" It is essential that this transitional arrangement whouldnot interfere with the four years training plan and that thenumber of posts within this plan should not be reduced onaccount of the retention of the transitional posts. TheMinister regards it as of the greatest importance that theopportunities of younger men who wish to start trainingin the senior registrar grade should not be prejudiced by thenew arrangements.

" There can, of course, be no objection to a senior registrarwho has completed training in one specialty transferringto another specialty and completing a further four yearsin this second post ; such interchange may be of great benefitto the specialty. There is also nothing to prevent a fourthyear senior registrar from applying for the same or anotherpost in the same specialty which falls within the trainingplan, but it is essential that his greater experience shouldnot determine his appointment rather than that of a potentiallybetter future consultant and in any case no senior registrarshould be reappointed to the same post for more than anadditional two years. The criterion for selection should

always be that the applicant likely to make the best consultantat the end of his four years training should be chosen."