1071

professionals according to a formula that enabled the clinics to meet their operating expenses.7 Federal regulations issued in 1974 defined "critical health manpower shortage areas" and limited N.H.S.C. placements to them. Other regulations stipulated that a memorandum of agreement signed by the community board would constitute the contract between the Government and the N.H.S.C. area. 20 placements were made in 16 communities in January, 1972, followed by 162 more in the summer of 1972. Most of those appointed (138) were physicians, as has been the case throughout the programme. The N.H.S.C. grew slowly, showing that the recruitment of physicians at modest P.H.S. salaries for service in difficult areas would not produce a large field force. Knowing this, Congress established the P.H.S.-N.H.S.C. scholarship programme,8 by which the P.H.S. would pay for professional school tuition and a stipend in return for which the student would incur a year-for-year service obligation. The first scholarships were awarded in February, 1974, and the first scholarship holders to join the N.H.S.C. did so in 1976. The political climate of the programme’s early years was difficult. Social programmes of all sorts were being closely scrutinised by the Nixon administration, but the Act setting up the N.H.S.C. had been signed by President Nixon, and the N.H.S.C. enjoyed continued congressional support. The N.H.S.C. therefore grew despite the prevailing political climate. The Nixon and Ford administrations, however, had a considerable impact on the style and priorities of the early N.H.S.C. Heavy emphasis was placed on the private-practice potential of the programme. Physicians were urged to go into private practice at the end of their tour of duty. Sites were frequently selected and developed with this in mind. Most placements were small (one or two physician) practices, and 95C,;c of them were in rural areas reflecting the difficulty of applying the fee-for-service model to inner city areas. Urban health, the health of ethnic minorities, or that of labouring groups such as migrant workers were addressed only randomly. There was no formal coordination between the N.H.S.C. and other Federal grant programmes or State, county, or municipal health services.

of Radiology, Harvard Medical School, 25 Shattuck Street, Boston, Massachusetts 02115, U.S.A. REFERENCES 1 Mechanic, D. New Engl J. Med. 1978, 298, 249. 2 Derzon, R A Paper read at international conference

Radiological Technology in

San

on

on the Health Care, Research, and

Impact of New Teaching, held

Francisco, in 1978

Rogers, P. G. Paper read at national conference on Referral Criteria for X-Ray Examinations, held in Washington, D.C., in October, 1978. 4. Bell, R S., Loop, J. W. New Engl. J. Med. 1971, 284, 236. 5 Mellins, H. Z., McNeil, B. J., Abrams, H. L., Van Houten, F. X., Murphy, M. A , Korngold, E. Radiology 1979, 130, 293. 6. Abrams, H. L. Paper read at national conference on Referral Criteria for X-Ray Examinations, held m Washington, D. C., in October, 1978. 7 Phillips, L. A. A Study of the Effect of High Yield Criteria for Emergency Room Skull Radiography. H. E. W. publication (FDA) 73-8069, 1978. 8 MacEwan, D. W, Kavanagh, S., Chow, P., Tishler, J. M. Radiology 1978, 126, 39 9 Gerson, D E , Lewicki, A. M., McNeil, B. J., Abrams, H. L., Korngold, E. ibid. 1979, 130, 297. 10. Thornbury, J R., Fryback, D. G., Edwards, W. ibid. 1975, 114, 561. 11. Lusted, L. A Study of the Efficacy of Diagnostic Radiologic Procedures: final report on diagnostic efficacy. American College of Radiology, 1977. 12. Department of Health, Education and Welfare. Population Exposure to X-rays, U S, 1970; table 25, p. 92. D.H.E.W. publication FDA 73-8047. 3.

Primary Care THE NATIONAL HEALTH SERVICE CORPS FITZHUGH MULLAN Director National Health Service

Corps, Public Health

Service, Health Services Administration, Department of Health, Welfare, and Education, Rockville, Maryland 20857, U.S.A.

THE National Health Service Corps (N.H.S.C.) was established by the Emergency Health Personnel Act of 1970, by which the United States Public Health Service (P.H.S.) could meet the health-care needs of underserved civilian populations. Although the P.H.S. has had a long record of health-service delivery to statutorily designated populations (American Indians, the Merchant Marine, Federal prisoners), this was the first time that federally employed physicians were to provide complete medical services to the general population. ’

HISTORY

1970 evidence had accumulated that the United States had too few physicians and that they were unevenly distributed. 1-3 Not only health planners and politicians but also many medical students and young physicians were aware that many areas had an inadequate medical service.4,5 The Emergency Health Personnel Act, passed on Dec. 31, 1970,6 called for the P.H.S. to recruit physicians and other health professionals for areas that were short of physicians. The programme was a joint community and government project. The P.H.S. would supply the health professionals while the community would provide office space, other personnel, and the necessary overheads. Patients had to pay for services at a rate fixed by the community board, but no one was to be denied service because they were unable to pay. This resulted in slidmg fee schedules and lenient billing policies. The community clinics, in turn, were obliged to reimburse the Federal Treasury for part of the cost of the N.H.S.C.

CURRENT STATUS

By

.

Since 1977, a number of important changes have taken place. The Health Professions Educational Assistance Act,9 passed on Oct. 12, 1976, re-established and augmented the scholarship programme, which became simply the N.H.S.C. Scholarship Program. The new law also broadened the methodology for defining health manpower shortage areas, so that there are now almost 1200 counties, census tracts, trade areas, and neighbourhoods eligible for N.H.S.C. assistance.’° Some 25 000 000 Americans live in these areas. The law redefined a number of aspects of the scholarship programme and, most importantly, increased the authorisation for the programme such that its potential for growth was considerable. Finally, the law mentions facilities such as State mental hospitals and State prisons as appropriate placements for members of the N.H.S.C., suggesting formallv for the first time that the N.H.S.C. become involved in institutional work.

1072 The second major change has been the emphasis by the Carter administration on the development of inte-

systems for providing services to traditionally underserved people. The result has been increased cooperation between Federal grant programmes (the Community Health Center Program, the Urban and Rural Health Initiative Programs, the Migrant Program, and the Maternal and Child Health Program) and the N.H.S.C. This has meant that in 1978 68% of the new health professionals were placed by the N.H.S.C. in communities receiving Federal grants. This cooperation between the N.H.S.C. and the other sections of the P.H.S. has increased the effectiveness of P.H.S. work in the poorest and most isolated segments of the population. Moreover, the Carter administration is committed to improving urban health. At present, 22% of the N.H.S.C. placements are at urban sites, compared with 5‘ 2 years ago; the aim is approximately 40% by the early 1980s. Finally, the scholarship programme is reaching maturity. In 1978, the N.H.S.C. placed 458 graduates of that programme in health manpower shortage areas. In 1979, that number will rise to 640 and in 1980 to 1040. 283 other physicians, who have no scholarship obligation, were recruited in 1978. The current (March 1, 1979) field strength of 1504 is double that of autumn, 1977; the aim is 2820 N.H.S.C. professionals by the fall of 1980, a threefold growth in 3 years. N.H.S.C. professionals are placed in 751 N.H.S.C. sites ranging from fishing villages in Maine to farmworker clinics in the Rio Grande Valley of Texas, from hospital-based practices in Baltimore to Alaskan native dispensaries on the Bering Sea. N.H.S.C. staff is made

grated

First, there will be a continued shortage of physicians in many American communities. Current Department of Health, Education, and Welfare estimates suggest that. although more physicians are being trained, there will be a shortage of 16 000 primary-care physicians in health manpower shortage areas in the mid-1980s

(unpublished document by Health Services Administration/Health Resources Administration, Department of Health, Education, and Welfare). Since all the national health insurance plans currently under discussion deal primarily with the financing of health services and not with guaranteed access to health-care services, the passage of a national health insurance plan in the next few years would have very little short-term impact on underserved areas.

Second, there are many people in the N.H.S.C. health-manpower "pipeline" who will become available for placement throughout the mid-1980s. There are 4648 recipients of N.H.S.C. scholarship awards in medtcal and related schools and another 2441 in residency deferment (deferred from service to complete residency training). In 1979, approximately 1500 new scholarships will be granted. If awards continue to be given at this rate, 10-15% of the medical students in the country will graduate with an N.H.S.C. obligation, and the field strength of the programme will grow to approximately 8000 by 1985.

.

upof:

and osteopaths (17-9% board certified, board 35.2% eligible, and 46.9% not board eligible) belonged to the following specialties:

Physicians

THE FUTURE

Since the N.H.S.C. is gramme, its development

publicly supported prodepends on a mix of health planning, politics, and funding. Two factors are clear. a

DISCUSSION

The N.H.S.C. is an exciting experiment. It is a major effort on the part of the United States Government to guarantee all its citizens access to organised primarycare. At the same time, it is an attempt to tie training in the health professions to a service commitment. Both of these undertakings are new in North America. How the programme will fare in its adolescence will be seen in the next few years. If it is to become an important and permanent part of medical care in America, a number of developments will have to occur. To date the N.H.S.C. practices developed have been primarily community based and family oriented. However, fully to address the problems of medical underservice in America, the N.H.S.C. needs to be able to offer its services to institutions such as municipal hospitals, State mental hospitals and prisons, county health departments, and homes for the retarded and elderh. This is a difficult challenge since it involves the staffing of programmes that are often deeply entrenched in their own systems, poorly managed, and underfinanced. Using its offer to provide manpower as an incentive for change, the N.H.S.C. stands to help staff these institutions and to improve the quality and responsiveness of the services rendered. The medical schools of the United States must come part of the way to meet the challenge of the N.H.S,C. Since the N.H.S.C. scholarship programme is underwriting a significant part of the cost of medical education in the United States, not only do the students haBee 311 obligation to practise in underserved areas, but also the schools themselves must have curricula that address :he challenges and problems of working in these areas Every college of medicine and osteopathy in this country,

1073 N.H.S.C. scholarship recipients. Currently, 46 institutions have more than 50 N.H.S.C. students enrolled. Schools need to develop primary-care tracks in their curricula which focus on the specific issues of health care for the poor, the isolated, the institutionalised, and the disenfranchised. The quality of the N.H.S.C. programme and the attitude of all concerned, practitioners and patients alike, will suffer considerably if the N.H.S.C. attempts to place a cadre of frustrated ophthalmologists and neurosurgeons in small Appalachian practices, in state hospitals, and in inner-city clinics. The N.H.S.C. needs medical schools to take the problem of training practitioners for underserved areas seriously and creatively. Finally, both the executive and legislative branches of the Federal Government must firmly support the programme. Retooling the medical assembly line as well as restructuring parts of medical practice in the nation will not come without a price tag." A principal goal of the Public Health Service is the establishment of equity

has

some

Point of View "HAVE YOU EATEN LABURNUM?" R. M. FORRESTER

Mary Sheridan Centre, Leigh Infirmary, Leigh

Summary

In

WN7 1HS

three thousand children are admitted to hospital in England and Wales because of laburnum poisoning. It is suggested that laburnum is not as dangerous as has been thought and that many of these admissions are unnecesan

average

summer over

sary.

THE laburnum flowers in late spring and early sumIts seeds are attractive and hang on the tree in their pods for months. They look like peas and they do not taste bad. The tree grows well in towns and appears to be more in evidence in heavily populated areas than in the country. In other words, you find laburnum where you find children. Throughout the summer months casualty departments receive a steady flow of children who have eaten the seeds or the pods-or, very occasionally, the flowers. Some are sent home with a caution, some after an emetic or gastric lavage; but many are admitted to hospital for overnight observation. In the summer of 1976 seventeen children were admitted to Wigan Infirmary for this reason. Each child stayed overnight, and each went home the next day, none the worse for his adventure. Admissions recorded for the same reason in the whole of the north-west region of England totalled 309 in 1976. Assuming that laburnums grow equally well throughout the country, and that children behave alike, we can guess that in England and Wales in 1976 about 3800 children were admitted to hospital overnight for this reason. Were all these admissions really necessary? Laburnum has a bad reputation. Its alkaloid, cystisine, is present in the seeds and the pods of all the various varieties that are grown. It is known, in very special circumstances, to have killed people’ and animals.2 Mitmer.

in health care. With consistent governmental support the N.H.S.C. can achieve that goal. REFERENCES 1. President’s Commission on the Health Needs of the Nation. Building America’s Health, Vol 2, p 117. U.S Government Printing Office, Washington, 1952 2. National Commission on Community Health Services. Health is a Com-

munity Affair, p. 91 Cambridge, 1966. Commission on Higher Education. Higher Education and the Nation’s Health Policies for Medical and Dental Education; p. 18. New York, 1970. 4 Mollan, Fitzhugh. White Coat, Clenched Fist: The Political Education of an American Physician, p 41 New York, 1976. 5 U.S Senate, Committee on Labor and Public Welfare. Report, Health Professions, Educational Assistance Act of 1974, p. 69. U.S. Government

3. Carnegie

Printing Office, Washington. 6 Eric Redman. I he Dance of Legislation. New York, 1973. 7 U. S Congress, Public Law 91-623, Emergency Health Personnel Act of 1970. 8 U.S Congress, Public Law 92-585, Emergency Health Personnel Act Amendments of 1972. 9. U.S Congress, Public Law 94-484, Health Professions Educational Assistance

Act of 1976.

10 U. S Government Federal

Register, Vol. 43, no. 189. Shortage Areas, Sept. 28, 1978. Richmond, Julius B. The Blue Sheet. 1977, 20, p. S-4.

List of Health Man-

power

11.

chelP discussed human laburnum poisoning in detail in 1951and found no mention of it in the Index Medicus during the previous twenty-five years. Another twentyfive years have passed and still nothing of significance has been published on the subject. None of Mitchell’s cases came to any serious harm, but the two that he described in detail seem to have been quite ill for a brief

period. The Hospital Activity Analysis national computer for the period 1963/ 74 showed only five deaths coded under the International Classification of 998. As this code includes all food poisoning (including fungi, shellfish, and fifty-seven varieties of plants), it seems likely that the "laburnum" element over this period was very low. The common symptoms of laburnum poisoning are vomiting and restlessness. The more rare and violent symptoms are reported to be abdominal pain, dizziness, and convulsions. All these symptoms appear within a short time of ingestion and they are reported to subside completely within twelve hours. One of the commonest causes of attendance of children at casualty departments is head injury. Most of these children are allowed to go home with "head injury instructions" which are intended to alert parents to important symptoms and to ask them to bring the child back if they are worried. In this way, many admissions avoided. It would seem easy to adopt a similar course in laburnum poisoning and to give simple instructions to parents, including the promise to review the child and admit him if necessary. It might be wise always to suggest an emetic in the casualty department but some might think this even more traumatic than laburnum are

itself. If this approach is tried, its effect on the admissionrate for code 998 should be easy to monitor at hospital level.

REFERENCES 1 Richards, H G H, Stephens, A Med. Sci Law. 1970, 10,260 2 Forsyth, A A , British Poisonous Plants, p. 34 H.M Stationery Office. 3. Mitchell, R. G Lancet, 1951, ii, 57

The National Health Service Corps.

1071 professionals according to a formula that enabled the clinics to meet their operating expenses.7 Federal regulations issued in 1974 defined "cri...
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