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Co-ordination and regionalisation of tuberculosis services in England, Wales and Scotland
1941
PUBLIC HEALTH
CO-ORDINATION AND REGIONALISATION OF TUBERCULOSIS SERVICES IN ENGLAND, W A L E S A N D SCOTLAND* By G. LISSANT Cox, M.D., Central Tuberculosis O~cer, Lancashire County Council What is the object of our public health measures dealing with tuberculosis? We must be agreed on this. Is it a twofold object--prevention and treatment? It is very easy to forget or make little of the first, but, I submit, that is wrong. Any scheme dealing with tuberculosis which does not provide full and proper combination of means for prevention as well as for treatment is a bad scheme. It is important to note that measures for the prevention of tuberculosis must be undertaken by county boroughs, non-county boroughs, urban districts and rural districts, whereas arrangements for the treatment of tuberculosis must be made by county councils and county borough councils. Difficulties arise in county areas (but not in county boroughs), where the legal authority for prevention rests with the medical officers of health of the urban and rural districts which make up a county area. The difficulties can, however, be overcome by common sense and good will, but these do not always operate. In England and Scotland, but not in Wales, there is as much variety in the scope and efficiency of measures for the prevention and treatment of tuberculosis as in the soil or landscape of each country. There are two reasons for this: first, the great variety in population, area, wealth, personnel and public health staff of local authorities; and, secondly, the legislation which makes possible and governs all tuberculosis schemes places upon these same widely differing local authorities the duty to make " adequate arrangements" for the "treatment of tuberculosis," and also to take measures of prevention. In this paper it will be convenient to deal with the subject under the following h e a d i n g s : '~'UBERCULOSIS SCHEMES IN ENGLAND.
(A) Legislation governing the prevention and treatment of tuberculosis. (B) The varying schemes of local authorities. (c) Legislation authorising the combination of local authorities for public health and other purposes. (D) Joint schemes in operation in England: (1) Staffordshire, Wolverhampton and Dudley Joint Board for Tuberculosis. (2) Gloucestershire Joint Board for Tuberculosis. (3) Warwickshire and Coventry Joint Committee for Tuberculosis. TUBERCULOSISSCHEMEIN WALESANDMONMOUTHSHIRE,
(A) Legislation governing the prevention and treatment of tuberculosis. (]3) The King Edward VII Welsh National Memorial Association. TUBERCULOSIS SCHEMES IN SCOTLAND.
The Aberdeen Regional Scheme. * Memorandum submitted to the Joint Tuberculosis Council at its meeting on March 1st, 1941.
REGIONAL SCHEMEOF BRITISH HOSPITALSASSOCIATION. EMERGENCY HOSPITAL SCHEME, REGIONALISATION OF THE MINISTRY OF HEALTH,AND COMMENTSTHEREON. SUMMARY AND CONCLUSIONS.
Tuberculosis Schemes in England (A) LEGISLATION GOVERNING THE PREVENTION AND TREATMENT OF TUBERCULOSIS.
Prevention Under the Public Health Act, 1875, and the Public Health Act, 1896, the Minister of Health had power to make regulations governing the prevention of infectious and epidemic diseases, and it was in exercise of this power, that he made the Public Health (Tuberculosis) Regulations of 1912, which were repeated with amendments in 1930. These regulations deal with the duties of medical practitioners, medical officers of health, and local authorities in connection with the notification of cases of tuberculosis, and measures to be taken to prevent the spread of infection. The Minister of Health's power to make regulations is repeated in the Public Health Act, 1936. The statutory power to take steps to prevent the spread of infection is vested in the medical officers of health of county boroughs, non-county boroughs, urban districts, and rural districts. Among such steps, the medical officer of health may utilise the services of the tuberculosis officer or tuberculosis health visitor to visit the homes of infectious cases. Strictly speaking only the medical officer of health, or through him the sanitary inspector, has the right of entry into the homes of notified cases, but in practice the tuberculosis officer and tuberculosis health visitor are rarely challenged when they visit. Prevention is of such importance that it is most desirable that the co-operation between the medical officer of health and the tuberculosis officer should continue. Treatment The responsibility for the treatment of tuberculosis in England devolves upon the county councils and county borough councils. The statutory authority for this duty is contained in the Public Health Act, 1936, Section 171, which reads as follows: Sec. 171.----(1)It shall be the duty of the council of every county and county borough to make adequate arrangements for the treatment of persons in their county or borough who are suffering from tuberculosis, at or in dispensaries, sanatoria and other institutions approved by the Minister. (2) The Minister may under this section approve an institution for such time, and subject to such conditions, as he thinks fit, and may withdraw any such approv~al. (B) T~E VARYING SCrmMES OF LOCAL AUTHORITIES. The county councils and county borough, councils, which are charged with the duty to orgamse tuberculosis schemes, vary in population from under 50,000 to 2,000,000. The following table shows the population groups into which the different counties and county boroughs f a l l : The table also shows the very great differences which exist in population. There are equally great
133
PUBLIC HEALTH
MAY TABLE I.
Population Group Under 50,000
ENGtAND
Counties ...
Rutland
County Boroughs Burton-upon-Trent Canterbury Chester
50,000 to 100,000 ...
Isle of Ely Huntingdonshire Lincolnshire (Holland) Soke of Peterborough Westmorland Isle of Wight
Bamsley Barrow Bath Bootle Burnley Bury Carlisle Darlington Dewsbury Donca~ter *Dudley Eastbourne Exeter *Gloucester Great Yarmouth Grimsby Halifax
Hastings Ipswich Lincoln Northampton Oxford Rochdale Rotherham Smethwick Southport Tynemouth Wakefield Wallasey Warrington West Bromwich West Hartlepool Wigan Worcester
100,000 to 150,000 ...
Cambridgeshire Herefordshire Lincolnshire (Kesteven) Oxfordshire Suffolk West
Birkenhead Blackburn Blackpool Boumemouth Brighton Derby East Ham Gateshead Huddersfield Middlesbrough Norwich
Oldham Preston Reading St. Helens Southend-on-Sea South Shields Stockport Walsall *Wolverhampton York
150,000 to 200,000 ...
Cumberland Yorkshire (E. Riding)
Bolton Southampton Sunderland
20 L000 to 250,000 ...
Berkshire Dorset Shropshire Suffolk East Northamptonshire
2 iO,O00 to 500,000 ...
500,000 to 1,000,000
Bedfordshire Buckinghamshire Cornwall Devon *Gloucestershlre Hertfordshire Leicestershire Lincolnshire (Lindsey) Norfolk Cheshire Derbyshire Durham Hampshire *Staffordshire
*Coventry Croydon Plymouth Salford Northumberland Nottinghamshire Somersetshire Sussex East Sussex West *Warwickshire Wiltshire Worcestershbe Yorkshire (N. Riding)
Bradford Bristol Kingston-upon-Hull Leeds Leicester Newcastle Nottingham Portsmouth Stoke West Ham Liverpool Manchester Sheffield
l 000,000 to 1,500,000 Essex Kent Surrey
Birmingham
1500,000 to 2.000,000 Lancashire Yorkshire (W. Riding) 0 ver 2,000,000
...
Middlesex * Authorities participating in joint schemes for tuberculosis.
134
1941 differences, as regards counties, in geographical area. All these different authorities are supposed to have schemes of similar efficiency and completeness for the prevention and treatment of tuberculosis. It is obvious that this will not take place without combination in whole or part, unless at a much increased cost. But it is also true that in some small counties and county boroughs the efficiency is not low. There are two chief reasons for this: first, an exceptional person who may be working the scheme, and, secondly, peculiar advantages appertaining to certain areas. It follows, owing to the facts mentioned above, that there are some small areas with relatively efficient anti-tuberculosis measures, and some large areas--large in either population or area, or both--which have schemes less efficient than the small areas referred to.
Scheme in a Small Area One may take as an example the county of Westmorland. This is one of the smallest counties in population and in area in England, but it has a fairly good tuberculosis scheme, within certain limits, on both the pulmonary and the non-pulmonary sides of the work. Westmorland is fortunate because many years ago the Meathop Sanatorium was started, and ever since 1912 the staff of the institution have also undertaken the dispensary work throughout this small county. Thus. the doctors in Westmorland have tl/e advantage of consultations with the medical officer of the Meathop Sanatorium or his assistant, and, conversely, the tuberculosis medical team are conversant with both sides of anti-tuberculosis work. There is, however, a serious fault even in this part of the scheme: the sanatorium is situated on the periphery of the county and not in the centre. The sanatorium, of course, admits patients from areas other than Westmorland, because Westmorland could not find anything like the number of cases required to fill 150 beds. Again, a well-known orthopaedic hospital is situated at Windermere. This is for children only. It is clear, therefore, that while Westmorland has a not inadequate scheme which covers pulmonary cases and children but not adults suffering from nonpulmonary tuberculosis, this is due to the accident of two institutions, originally entirely voluntary, having been started within the boundary of this county. Without these institutions the position would be entirely different, and it would appear inevitable that so small a county could not possibly run an efficient complete scheme for the prevention and treatment of tuberculosis, pulmonary and non-pulmonary, on modem lines, but would have to combine in whole or part with one or other of its neighbours, Cumberland or Lancashire. Case [or Combined Areas As shown in the table above, there are a great many county boroughs with populations between 50,000 and 100,000. In regard to the efficiency of the arrangements for the prevention and treatment of pulmonary tuberculosis, they vary as do the county areas. But many of them would have the efficiency of their schemes improved if such towns combined either with each other or with the county area adjoining, as in the
PUBLIC
HEALTH
examples given later of Coventry and Warwickshire and Gloucester and Gloucestershire. It is quite impossible for small authorities to administer and treat pulmonary, and especially non-pulmonary, tuberculosis except as part of a wider area. Combination or regionalisation, for the treatment of non-pulmonary cases and the occasional major surgical case is essential. But, as with some of the smaller counties, some-perhaps most--of the small county boroughs combine parts of the work. In Barnsley, for example, with a population of 70,000, the whole-time tuberculosis officer is also superintendent of the Mount Vernon Sanatorium (52 beds); and he is thereby a real consultant for the doctors in this small borough. The same applies to the relatively small county borough of GrimsSy; and there are other similar illustrations. Unfortunately, however, there are many small areas which by necessity or choice employ tuberculosis officers who devote only a part of their time to tuberculosis work; and it inevitably follows that such officers can never be as efficient consultants for the general practitioners as whole-time officers who also have beds under their own jurisdiction. The number of parttime tuberculosis officers in England in 1932 was 209.* Again, it must be mentioned that many of the authorities enumerated in Table I share or combine in a peculiarly unorganised English way for small portions of tuberculosis work. Two examples may suffice. At the present time patients recommended for artificial pneumothorax treatment in the county borough of Blackpool are treated by one of the Lancashire county staff. Patients in the Isle of Ely county area requiring X-ray examination, with possible artificial pneumothorax treatment, are for the most part dealt with under the highly efficient Cambridge and Cambridgeshire scheme. Finally, there are in England three Iegalised combinations of areas. These and the ample legislation which does at present exist for this purpose, will form the subjects of the next two sections. (C) LEGISLATION AUTHORISING COMBINATION OF LOCAL AUTHORITIES FOR PUBLIC HEALTH AND OTHER PcavosEs. The Astor Committee,~- when considering, in 1912, the action to be taken in regard to the setting up of tuberculosis schemes, " emphasised the desirability, in certain cases, of combination between local authorities in order that schemes should be made on the most economical and efficient basis." Although very little has been done in the way of the combination of authorities for tuberculosis purposes, ample authority has been given by Parliament for any action on these lines which local authorities might desire to take. Legislation has provided three alternative methods by which local authorities can combine for the purpose of making arrangements for the treatment of tuberculosis: (1) Joint Boards.--By the Public Health Act, 1936, power is given to local authorities to combine for any public health purpose under the Act. The combination is made by the Minister of Health, with the consent of . Report on Improvements in the Tuberculosis Service, Joint Tuberculosis Council, 1932. J-The Departmental Committee on Tuberculosis, 1912. 135
PUBLIC HEALTH the local authorities concerned.
The section of the Act containing this provision reads as f o l l o w s : Sec. 8 (1).--For the purpose of facilitating cooperation between councils of counties and county boroughs in the discharge of their functions under this Act, it shall be lawful for the Minister to make by order such provision as appears to him to be expedient for enabling any two or more such councils to discharge through a joint board such of those functions as may be specified in the order : Provided that no such order shall be made except with the consent of all the councils concerned. (2) A joint board constituted under this section shall be a body corporate by such name as may be determined by the order constituting the board, and shall have perpetual succession and a common seal and power to hold land for the purposes of their constitution without licence in mortmain. Thus a joint board may, according to the terms of the order, have the same powers for carrying out its functions as a council have, and may be an independent precepting authority over whose expenditure the constituent authorities have no control. Its powers will depend on the terms of the order, such terms being agreed upon by the constituent authorities. (2) Joint Committees.--Under the following section of the Local Government Act, 1933, local authorities can combine in appointing joint c o m m i t t e e s : Sec. 91 (1).--A local authority may concur with any one or more other local authorities in appointing from amongst their respective members a joint committee of those authorities for any purpose in which they are jointly interested, and may delegate to the committee, with or without restrictions, as they think fit, any functions of the local authority relating to the purpose for which the joint committee is formed, except the power of levying, or issuing a precept for, a rate, or of borrowing money. It will be seen that a joint committee may have the same functions as a joint board, with the exception of the power to raise a rate or to borrow money. (3) Combination by Agreement.--Local authorities, by the provisions of Section 272 of the Public Health Act, 1936, may also make arrangements to combine for purposes where neither a joint board nor a joint committee is n e c e s s a r y : Sec. 272.--Without prejudice to the powers of combination conferred on local authorities by the Local Government Act, 1933, any two or more councils may by agreement combine for the purposes of any of their functions under this Act. It will be noted that in any of the above methods, a combination need not necessarily be between adjoining areas, (D) JOINT SCHEMES IN OPERATION IN ENGLAND.
County councils and county borough councils originally had authority to combine for tuberculosis purposes under the Public Health (Tuberculosis) Act, 1921 (this authority being repeated in the Public Health Act, 1936--see above), but very few councils took advantage of this legislation, and only two joint boards and one joint committee have been set up. They are: (1) Staffordshire, Wolverhampton, and Dudley Joint Board for Tuberculosis; (2) Gloucestershire Joint Board for 136
MAY Tuberculosis; (3) Warwickshire and Coventry Joint Committee for Tuberculosis.
Staffordshire, Wolverhampton, and Dudley Joint Board [or Tuberculosis The Staffordshire, Wolverhampton, and Dudley Joint Board for Tuberculosis administer the scheme for the prevention and treatment of tuberculosis in the county of Staffordshire (population 741,900), and the county boroughs of Wolverhampton (population 144,000) and Dudley (population 61,140). The area covered is 698,684 acres, and the total population is nearly 1,000,000. The county medical officer of health of Staffordshire is the chief administrative officer of the scheme; and there is a "chief tuberculosis officer, three other tuberculosis officers, and one assistant tuberculosis officer. The chief tuberculosis officer acts as medical superintendent of the Groundslow Sanatorium (80 beds). There is also the medical superintendent of the Prestwood Sanatorium (200 beds), who, as well, looks after Edge View Sanatorium for Women (38 beds) and Himley Sanatorium for Children (60 beds). Four chief dispensaries and nine sub-dispensaries are provided, and an X-ray plant is installed at each of the chief dispensaries. The Joint Board maintain institutions with accommodation for 378 patients, and also have 129 beds in other institutions. The tuberculosis officers visit the institutions regularly to discuss their own cases. The scheme has worked smoothly, and no difficulty, so it is said, has arisen between the constituent authorities of the board. This joint board may be taken as an illustration of the advantage to the smaller members of a joint board --e.g., Dudley. The resources in common enable facilities to be provided which the smaller authorities could not otherwise afford. Such a joint board is large enough to have an expert staff, whereas smaller authorities of necessity have to employ their assistant medical officers of health in many other duties besides tuberculosis.
Gloucestershire Joint Board [or Tuberculosis Since 1912-13 a joint tuberculosis scheme has been in operation for Gloucestershire county (population 339,000) and Gloucester county borough (population 56,570). The area covered is 778,621 acres, and the total population is 395,570. The medical staff consists of a chief tuberculosis officer (who is the principal medical officer of the Joint Board), two assistant tubereulosis officers, and a junior medical officer. Six dispensaries are provided, and an X-ray plant is available at two of them, which are held in general hospitals. There are also fifteen other places where patients are grouped for examination at convenient times--namely, out-stations in connection with the Gloucestershire scheme for the extension of medical services. A sanatorium of 250 beds is the main provision for treatment, and the three tuberculosis officers, besides being responsible for all dispensary work, are resident at and (with the junior medical officer) constitute the staff of the sanatorium, the chief tuberculosis officer being the medical superintendent. In regard to preventive measures, there is a close
1941 association between the health departments of Gloucester and Gloucestershire on the one hand, and the Joint Board on the other. Although the Joint Board have only one ad hoc tuberculosis health visitor, a system is in operation whereby the various health visitors are responsible for a particular area and transmit reports on the home conditions of notified cases direct to the chief medical officer of the Board. In the office of the chief medical officer, therefore, there is a record of the housing conditions of every notified case, and continuing reports are also sent in at intervals. The district medical officers of health are, of course, responsible for all sanitary conditions as regards housing, and the chief medical officer of the Joint Board passes on to them the information on which they should act. The chief tuberculosis officer has kindly written me as f o l l o w s : -
"The joint scheme is working very satisfactorily and is certainly to the advantage of the smaller authority, but the main difference of the Gloucestershire scheme from the majority is that ~t is the same medical staff who do all the dispensary work and also the sanatorium work . . . . I am convinced of the advantage of this, because it means that the doctor who sees the patients outside also shares in their treatment at the sanatorium and sees them again after their discharge with full knowledge of what has happened during their institutional treatment. The original case sheet goes to the sanatorium when the patient is admitted, so that there is a continuous record without separate reports from the institution. This saves a large amount of clerical work and is, I think, a very satisfactory arrangement. There are also obvious advantages, such as the avoidance of dlsputes between the tuberculosis officer and the medical superintendent." War~wickshire and Coventry ]oint Committee/or Tuberculosis The Warwickshire County Council (population 390,700) and the Coventry County Borough (population 204,000) have a joint scheme for tuberculosis which has existed since 1914. The area covered is 577,877 acres, and the total population is 594,700. The medical staff consists of a chief tuberculosis officer, who is the principal medical officer of the Joint Committee and does a considerable amount of administrative work; two assistant tuberculosis officers; the medical superintendent and the deputy medical superintendent of the King Edward VII Memorial Sanatorium, near Warwick, containing 225 beds; and two junior medical officers at the sanatorium. The deputy medical superintendent of the sanatorium attends at the various dispensaries--mainly the chief dispensary - - o n at least three dispensary sessions a week. There are seven dispensaries, and in addition a medical officer of the Joint Committee attends a school clinic once a month to make examinations of children suspected of being tuberculous. Two new X-ray plants have been provided---one at the chief dispensary and one at the sanatorium--and a large number of X-ray photographs are taken through the various voluntary orthopaedic clinics in the area, with which the Joint Committee works in close co-operation. Besides the sanatorium
PUBLIC HEALTH of 225 beds for pulmonary cases, 70 beds are provided at various orthopaedic and general hospitals for nonpulmonary tuberculosis. Artificial pneumothorax treatment is available at the sanatorium and in all the dispensaries. The Joint Committee has only one tuberculosis nurse, but it pays 8 per cent. of the salaries of all the county and city health visitors who do the tuberculosis visiting and attend all the sessions of the branch dispensaries - - that is all the dispensaries except Coventry. At Coventry a health visitor attends when the tuberculosis nurse is on holiday or is absent for any other reason. Defects in housing, etc., are reported to the county or city medical officer of health and to the chief tuberculosis officer by'-the health visitors. The medical officer of health of Coventry takes action so far as the city is concerned; and the medical officer of health of the county takes action through the district or local medical officers of health. Voluntary nurses do the actual nursing of the tuberculous sick, and grants are made to various associations in the area. This scheme has had the good fortune to have as its godfathers the late Dr. Bostoek Hill and the late Dr. Snell, and its general excellence is clear from this brief description.
Combination by Agreement An example of co-operation for tuberculosis purposes between a small county borough and a county council, without resorting to the formation of a joint board or a joint committee, is provided by the County Borough of Canterbury (population 25,530) and the County Council of Kent (population 1,366,600). Kent County Council do the tuberculosis work for Canterbury, and one of the Kent tuberculosis officers is also tuberculosis officer for Canterbury. The arrangement has been in operation for many years. The combination of areas can be made only with the agreement of all the authorities concerned. As it is unlikely that counties or county boroughs would willingly forego any of their powers under existing Public Health Acts, legislation should be enacted to enforce the combination of those authorities which are considered to be too small to run an efficient anti-tuberculosis scheme. It is interesting to recall that in a report* published in 1932, the Joint Tuberculosis Council made the following recommendation: " Should the formation under the powers of the Local Government Act, 1929, of areas of the size just indicated be unduly delayed, it is suggested that, as appointments fall vacant, the council of a small admirfistratlve area--county or county borough-should be invited by the Ministry of Health to form with an adjacent area a joint committee to administer the tuberculosis scheme as contemplated in the Astor Report and definitely empowered by the Public Health (Tuberculosis) Act of 192t. Alternatively, to avoid the formation of joint committees, a small area could allow its tuberculosis work to be done under an agreement with a larger authority." Report on Improvements in the Tuberculosis Service, Joint Tuberculosis Council, 1932. 137
PUBLIC HEALTH
MAY
In the same report the Council recommended that rural areas of 200,000 population and urban areas of 300,000 could be managed by one whole-time tuberculosis officer with adequate medical and clerical assistance.
teams of doctors. In all the areas there is very close liaison between the dispensary and institution, and in the majority of the areas the team is in charge of both dispensary and institutional work. In addition to the dispensary and institutional facilities provided, there is a central research laboratory in Tubereulos's Schemes in Wales and the charge of a director of research, who is also ProMonmouthshire fessor of Tuberculosis in the Welsh National School of Medicine; and a director of education conducts an (A) LEGISLATIONGOVERNINGPREVENTION AND TREATeducation campaign by means of school and public MENT OF TUBERCULOSIS. lectures. The statutory provisions with regard to the prevenPrevention tion and treatment of tuberculosis are the same for Wales as for England (see above). As in England, local It is in the measures for prevention that the Welsh sanitary authorities in the Principality have certain powers and duties as to the prevention of tuberculosis; National Memorial Association scheme is weak. The medical practioners and medical officers of health have Association does not have a complete staff of ad hoc certain duties as to the notification of the disease; and tuberculosis health visitors to deal with domiciliary it is the duty of county and county borough councils visiting, nursing, or local affairs. Health visitors who to make adequate arrangements for the treatment of deal with tuberculosis only are more successful with regard to prevention of tuberculosis than voluntary tuberculosis. But while in England the treatment of persons suffer- district nurses who deal with all kinds of sickness. ing from tuberculosis is undertaken by county and When the local authorities of a county, as in Lancacounty borough councils, usually acting as independent shire, depute the whole-time tuberculosis nursing staff, units, in Wales and Monmouthshire this duty is under- through the tuberculosis officer, to make reports to the taken on behalf of the several counties and county medical officers of the local sanitary authorities on boroughs by the King Edward VII Welsh National home conditions, this ensures that co-operation between Memorial Association, and is, of course, an example of the tuberculosis service and the sanitary authorities which is so necessary and important for prevention. regionalisation on a big scale. The Committee* which recently inquired into the (B) THE KING EDWARD VII WELSH NATIONAL tuberculosis services in Wales and Monmouthshire MEMORIAL ASSOCIATION. reported as f o l l o w s : The scheme for the "prevention, treatment, and "Unfortunately our inquiry showed that in large abolition of tuberculosis" for Wales and Monmouthareas of Wales the responsibilities of local authorities shire (comprising 13 counties and 4 county boroughs, did not appear to be properly realised, and the duties with a total population of 2,465,800) is operated by under the Regulations were neglected or carried out the King Edward V I I Welsh National Memorial very imperfectly. It is only right to say that in the Association. This Association was founded in 1910 county boroughs in Wales these matters are taken as, and still is, a voluntary organisation. In 1912, it seriously, and, on the whole, the efficiency of the work under the Regulations is comparable to that in secured a Charter of Incorporation and entered into similar areas in England. To a considerable extent agreements with the county and county borough this is true also of a number of the larger urban and councils of Wales and Monmouthshire to provide the populous rural districts and generally in areas treatment services for the whole of the Principality. served by whole-time Medical Officers of Health . . . . Despite changes in legislation from time to time, the As regards areas with part-time Medical Officers of Association has retained its identity and has consoliHealth, however, with a few striking exceptions, the dated its position as the sole authority in Wales conduties of the Medical Officer of Health under the cerned with the treatment of tuberculosis. Regulations were very much neglected, and it would The Association consists of a Board of Governors, appear that the local authorities were either unaware of their responsibilities under these Regulations or which is the supreme governing body of the Associadeliberately ignored them." tion, and a Council, which attends to the management and control of the financial and executive business of It would appear that the very excellence of the the Association. The finance of the Association is Memorial scheme on the diagnosis and treatment side provided by Government grants and by contributions has been an excuse for neglect on the preventive side. from the county councils and county borough councils And this neglect is again an argument for larger local calculated on the basis of population and rateable authorities, for a prime cause of the neglect has been value. the small size and inadequate financial resources of Diagnosis and Treatment these bodies. Wales and Monmouthshire are divided into fourteen dispensary areas, in each of which there are ample radiologieal facilities. A tuberculosis physician, with one or more assistants, is in charge of each area and has his headquarters at a central dispensary. This is an example of the best kind of staffing--namely, by 138
(To be concluded in our next issue.) * Report of the Committee of InquL,T into the AntiTuberculosis Service in Wales and Monmouth~hire, 1939,
PUBLIC HEALTH
CO-ORDINATION AND REGIONALISATION OF TUBERCULOSIS SERVICES IN ENGLAND, W A L E S A N D SCOTLAND* By G. LISSANT Cox, M.D., Central Tuberculosis O~cer, Lancashire County Council What is the object of our public health measures dealing with tuberculosis? We must be agreed on this. Is it a twofold object--prevention and treatment? It is very easy to forget or make little of the first, but, I submit, that is wrong. Any scheme dealing with tuberculosis which does not provide full and proper combination of means for prevention as well as for treatment is a bad scheme. It is important to note that measures for the prevention of tuberculosis must be undertaken by county boroughs, non-county boroughs, urban districts and rural districts, whereas arrangements for the treatment of tuberculosis must be made by county councils and county borough councils. Difficulties arise in county areas (but not in county boroughs), where the legal authority for prevention rests with the medical officers of health of the urban and rural districts which make up a county area. The difficulties can, however, be overcome by common sense and good will, but these do not always operate. In England and Scotland, but not in Wales, there is as much variety in the scope and efficiency of measures for the prevention and treatment of tuberculosis as in the soil or landscape of each country. There are two reasons for this: first, the great variety in population, area, wealth, personnel and public health staff of local authorities; and, secondly, the legislation which makes possible and governs all tuberculosis schemes places upon these same widely differing local authorities the duty to make " adequate arrangements" for the "treatment of tuberculosis," and also to take measures of prevention. In this paper it will be convenient to deal with the subject under the following h e a d i n g s : '~'UBERCULOSIS SCHEMES IN ENGLAND.
(A) Legislation governing the prevention and treatment of tuberculosis. (B) The varying schemes of local authorities. (c) Legislation authorising the combination of local authorities for public health and other purposes. (D) Joint schemes in operation in England: (1) Staffordshire, Wolverhampton and Dudley Joint Board for Tuberculosis. (2) Gloucestershire Joint Board for Tuberculosis. (3) Warwickshire and Coventry Joint Committee for Tuberculosis. TUBERCULOSISSCHEMEIN WALESANDMONMOUTHSHIRE,
(A) Legislation governing the prevention and treatment of tuberculosis. (]3) The King Edward VII Welsh National Memorial Association. TUBERCULOSIS SCHEMES IN SCOTLAND.
The Aberdeen Regional Scheme. * Memorandum submitted to the Joint Tuberculosis Council at its meeting on March 1st, 1941.
REGIONAL SCHEMEOF BRITISH HOSPITALSASSOCIATION. EMERGENCY HOSPITAL SCHEME, REGIONALISATION OF THE MINISTRY OF HEALTH,AND COMMENTSTHEREON. SUMMARY AND CONCLUSIONS.
Tuberculosis Schemes in England (A) LEGISLATION GOVERNING THE PREVENTION AND TREATMENT OF TUBERCULOSIS.
Prevention Under the Public Health Act, 1875, and the Public Health Act, 1896, the Minister of Health had power to make regulations governing the prevention of infectious and epidemic diseases, and it was in exercise of this power, that he made the Public Health (Tuberculosis) Regulations of 1912, which were repeated with amendments in 1930. These regulations deal with the duties of medical practitioners, medical officers of health, and local authorities in connection with the notification of cases of tuberculosis, and measures to be taken to prevent the spread of infection. The Minister of Health's power to make regulations is repeated in the Public Health Act, 1936. The statutory power to take steps to prevent the spread of infection is vested in the medical officers of health of county boroughs, non-county boroughs, urban districts, and rural districts. Among such steps, the medical officer of health may utilise the services of the tuberculosis officer or tuberculosis health visitor to visit the homes of infectious cases. Strictly speaking only the medical officer of health, or through him the sanitary inspector, has the right of entry into the homes of notified cases, but in practice the tuberculosis officer and tuberculosis health visitor are rarely challenged when they visit. Prevention is of such importance that it is most desirable that the co-operation between the medical officer of health and the tuberculosis officer should continue. Treatment The responsibility for the treatment of tuberculosis in England devolves upon the county councils and county borough councils. The statutory authority for this duty is contained in the Public Health Act, 1936, Section 171, which reads as follows: Sec. 171.----(1)It shall be the duty of the council of every county and county borough to make adequate arrangements for the treatment of persons in their county or borough who are suffering from tuberculosis, at or in dispensaries, sanatoria and other institutions approved by the Minister. (2) The Minister may under this section approve an institution for such time, and subject to such conditions, as he thinks fit, and may withdraw any such approv~al. (B) T~E VARYING SCrmMES OF LOCAL AUTHORITIES. The county councils and county borough, councils, which are charged with the duty to orgamse tuberculosis schemes, vary in population from under 50,000 to 2,000,000. The following table shows the population groups into which the different counties and county boroughs f a l l : The table also shows the very great differences which exist in population. There are equally great
133
PUBLIC HEALTH
MAY TABLE I.
Population Group Under 50,000
ENGtAND
Counties ...
Rutland
County Boroughs Burton-upon-Trent Canterbury Chester
50,000 to 100,000 ...
Isle of Ely Huntingdonshire Lincolnshire (Holland) Soke of Peterborough Westmorland Isle of Wight
Bamsley Barrow Bath Bootle Burnley Bury Carlisle Darlington Dewsbury Donca~ter *Dudley Eastbourne Exeter *Gloucester Great Yarmouth Grimsby Halifax
Hastings Ipswich Lincoln Northampton Oxford Rochdale Rotherham Smethwick Southport Tynemouth Wakefield Wallasey Warrington West Bromwich West Hartlepool Wigan Worcester
100,000 to 150,000 ...
Cambridgeshire Herefordshire Lincolnshire (Kesteven) Oxfordshire Suffolk West
Birkenhead Blackburn Blackpool Boumemouth Brighton Derby East Ham Gateshead Huddersfield Middlesbrough Norwich
Oldham Preston Reading St. Helens Southend-on-Sea South Shields Stockport Walsall *Wolverhampton York
150,000 to 200,000 ...
Cumberland Yorkshire (E. Riding)
Bolton Southampton Sunderland
20 L000 to 250,000 ...
Berkshire Dorset Shropshire Suffolk East Northamptonshire
2 iO,O00 to 500,000 ...
500,000 to 1,000,000
Bedfordshire Buckinghamshire Cornwall Devon *Gloucestershlre Hertfordshire Leicestershire Lincolnshire (Lindsey) Norfolk Cheshire Derbyshire Durham Hampshire *Staffordshire
*Coventry Croydon Plymouth Salford Northumberland Nottinghamshire Somersetshire Sussex East Sussex West *Warwickshire Wiltshire Worcestershbe Yorkshire (N. Riding)
Bradford Bristol Kingston-upon-Hull Leeds Leicester Newcastle Nottingham Portsmouth Stoke West Ham Liverpool Manchester Sheffield
l 000,000 to 1,500,000 Essex Kent Surrey
Birmingham
1500,000 to 2.000,000 Lancashire Yorkshire (W. Riding) 0 ver 2,000,000
...
Middlesex * Authorities participating in joint schemes for tuberculosis.
134
1941 differences, as regards counties, in geographical area. All these different authorities are supposed to have schemes of similar efficiency and completeness for the prevention and treatment of tuberculosis. It is obvious that this will not take place without combination in whole or part, unless at a much increased cost. But it is also true that in some small counties and county boroughs the efficiency is not low. There are two chief reasons for this: first, an exceptional person who may be working the scheme, and, secondly, peculiar advantages appertaining to certain areas. It follows, owing to the facts mentioned above, that there are some small areas with relatively efficient anti-tuberculosis measures, and some large areas--large in either population or area, or both--which have schemes less efficient than the small areas referred to.
Scheme in a Small Area One may take as an example the county of Westmorland. This is one of the smallest counties in population and in area in England, but it has a fairly good tuberculosis scheme, within certain limits, on both the pulmonary and the non-pulmonary sides of the work. Westmorland is fortunate because many years ago the Meathop Sanatorium was started, and ever since 1912 the staff of the institution have also undertaken the dispensary work throughout this small county. Thus. the doctors in Westmorland have tl/e advantage of consultations with the medical officer of the Meathop Sanatorium or his assistant, and, conversely, the tuberculosis medical team are conversant with both sides of anti-tuberculosis work. There is, however, a serious fault even in this part of the scheme: the sanatorium is situated on the periphery of the county and not in the centre. The sanatorium, of course, admits patients from areas other than Westmorland, because Westmorland could not find anything like the number of cases required to fill 150 beds. Again, a well-known orthopaedic hospital is situated at Windermere. This is for children only. It is clear, therefore, that while Westmorland has a not inadequate scheme which covers pulmonary cases and children but not adults suffering from nonpulmonary tuberculosis, this is due to the accident of two institutions, originally entirely voluntary, having been started within the boundary of this county. Without these institutions the position would be entirely different, and it would appear inevitable that so small a county could not possibly run an efficient complete scheme for the prevention and treatment of tuberculosis, pulmonary and non-pulmonary, on modem lines, but would have to combine in whole or part with one or other of its neighbours, Cumberland or Lancashire. Case [or Combined Areas As shown in the table above, there are a great many county boroughs with populations between 50,000 and 100,000. In regard to the efficiency of the arrangements for the prevention and treatment of pulmonary tuberculosis, they vary as do the county areas. But many of them would have the efficiency of their schemes improved if such towns combined either with each other or with the county area adjoining, as in the
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HEALTH
examples given later of Coventry and Warwickshire and Gloucester and Gloucestershire. It is quite impossible for small authorities to administer and treat pulmonary, and especially non-pulmonary, tuberculosis except as part of a wider area. Combination or regionalisation, for the treatment of non-pulmonary cases and the occasional major surgical case is essential. But, as with some of the smaller counties, some-perhaps most--of the small county boroughs combine parts of the work. In Barnsley, for example, with a population of 70,000, the whole-time tuberculosis officer is also superintendent of the Mount Vernon Sanatorium (52 beds); and he is thereby a real consultant for the doctors in this small borough. The same applies to the relatively small county borough of GrimsSy; and there are other similar illustrations. Unfortunately, however, there are many small areas which by necessity or choice employ tuberculosis officers who devote only a part of their time to tuberculosis work; and it inevitably follows that such officers can never be as efficient consultants for the general practitioners as whole-time officers who also have beds under their own jurisdiction. The number of parttime tuberculosis officers in England in 1932 was 209.* Again, it must be mentioned that many of the authorities enumerated in Table I share or combine in a peculiarly unorganised English way for small portions of tuberculosis work. Two examples may suffice. At the present time patients recommended for artificial pneumothorax treatment in the county borough of Blackpool are treated by one of the Lancashire county staff. Patients in the Isle of Ely county area requiring X-ray examination, with possible artificial pneumothorax treatment, are for the most part dealt with under the highly efficient Cambridge and Cambridgeshire scheme. Finally, there are in England three Iegalised combinations of areas. These and the ample legislation which does at present exist for this purpose, will form the subjects of the next two sections. (C) LEGISLATION AUTHORISING COMBINATION OF LOCAL AUTHORITIES FOR PUBLIC HEALTH AND OTHER PcavosEs. The Astor Committee,~- when considering, in 1912, the action to be taken in regard to the setting up of tuberculosis schemes, " emphasised the desirability, in certain cases, of combination between local authorities in order that schemes should be made on the most economical and efficient basis." Although very little has been done in the way of the combination of authorities for tuberculosis purposes, ample authority has been given by Parliament for any action on these lines which local authorities might desire to take. Legislation has provided three alternative methods by which local authorities can combine for the purpose of making arrangements for the treatment of tuberculosis: (1) Joint Boards.--By the Public Health Act, 1936, power is given to local authorities to combine for any public health purpose under the Act. The combination is made by the Minister of Health, with the consent of . Report on Improvements in the Tuberculosis Service, Joint Tuberculosis Council, 1932. J-The Departmental Committee on Tuberculosis, 1912. 135
PUBLIC HEALTH the local authorities concerned.
The section of the Act containing this provision reads as f o l l o w s : Sec. 8 (1).--For the purpose of facilitating cooperation between councils of counties and county boroughs in the discharge of their functions under this Act, it shall be lawful for the Minister to make by order such provision as appears to him to be expedient for enabling any two or more such councils to discharge through a joint board such of those functions as may be specified in the order : Provided that no such order shall be made except with the consent of all the councils concerned. (2) A joint board constituted under this section shall be a body corporate by such name as may be determined by the order constituting the board, and shall have perpetual succession and a common seal and power to hold land for the purposes of their constitution without licence in mortmain. Thus a joint board may, according to the terms of the order, have the same powers for carrying out its functions as a council have, and may be an independent precepting authority over whose expenditure the constituent authorities have no control. Its powers will depend on the terms of the order, such terms being agreed upon by the constituent authorities. (2) Joint Committees.--Under the following section of the Local Government Act, 1933, local authorities can combine in appointing joint c o m m i t t e e s : Sec. 91 (1).--A local authority may concur with any one or more other local authorities in appointing from amongst their respective members a joint committee of those authorities for any purpose in which they are jointly interested, and may delegate to the committee, with or without restrictions, as they think fit, any functions of the local authority relating to the purpose for which the joint committee is formed, except the power of levying, or issuing a precept for, a rate, or of borrowing money. It will be seen that a joint committee may have the same functions as a joint board, with the exception of the power to raise a rate or to borrow money. (3) Combination by Agreement.--Local authorities, by the provisions of Section 272 of the Public Health Act, 1936, may also make arrangements to combine for purposes where neither a joint board nor a joint committee is n e c e s s a r y : Sec. 272.--Without prejudice to the powers of combination conferred on local authorities by the Local Government Act, 1933, any two or more councils may by agreement combine for the purposes of any of their functions under this Act. It will be noted that in any of the above methods, a combination need not necessarily be between adjoining areas, (D) JOINT SCHEMES IN OPERATION IN ENGLAND.
County councils and county borough councils originally had authority to combine for tuberculosis purposes under the Public Health (Tuberculosis) Act, 1921 (this authority being repeated in the Public Health Act, 1936--see above), but very few councils took advantage of this legislation, and only two joint boards and one joint committee have been set up. They are: (1) Staffordshire, Wolverhampton, and Dudley Joint Board for Tuberculosis; (2) Gloucestershire Joint Board for 136
MAY Tuberculosis; (3) Warwickshire and Coventry Joint Committee for Tuberculosis.
Staffordshire, Wolverhampton, and Dudley Joint Board [or Tuberculosis The Staffordshire, Wolverhampton, and Dudley Joint Board for Tuberculosis administer the scheme for the prevention and treatment of tuberculosis in the county of Staffordshire (population 741,900), and the county boroughs of Wolverhampton (population 144,000) and Dudley (population 61,140). The area covered is 698,684 acres, and the total population is nearly 1,000,000. The county medical officer of health of Staffordshire is the chief administrative officer of the scheme; and there is a "chief tuberculosis officer, three other tuberculosis officers, and one assistant tuberculosis officer. The chief tuberculosis officer acts as medical superintendent of the Groundslow Sanatorium (80 beds). There is also the medical superintendent of the Prestwood Sanatorium (200 beds), who, as well, looks after Edge View Sanatorium for Women (38 beds) and Himley Sanatorium for Children (60 beds). Four chief dispensaries and nine sub-dispensaries are provided, and an X-ray plant is installed at each of the chief dispensaries. The Joint Board maintain institutions with accommodation for 378 patients, and also have 129 beds in other institutions. The tuberculosis officers visit the institutions regularly to discuss their own cases. The scheme has worked smoothly, and no difficulty, so it is said, has arisen between the constituent authorities of the board. This joint board may be taken as an illustration of the advantage to the smaller members of a joint board --e.g., Dudley. The resources in common enable facilities to be provided which the smaller authorities could not otherwise afford. Such a joint board is large enough to have an expert staff, whereas smaller authorities of necessity have to employ their assistant medical officers of health in many other duties besides tuberculosis.
Gloucestershire Joint Board [or Tuberculosis Since 1912-13 a joint tuberculosis scheme has been in operation for Gloucestershire county (population 339,000) and Gloucester county borough (population 56,570). The area covered is 778,621 acres, and the total population is 395,570. The medical staff consists of a chief tuberculosis officer (who is the principal medical officer of the Joint Board), two assistant tubereulosis officers, and a junior medical officer. Six dispensaries are provided, and an X-ray plant is available at two of them, which are held in general hospitals. There are also fifteen other places where patients are grouped for examination at convenient times--namely, out-stations in connection with the Gloucestershire scheme for the extension of medical services. A sanatorium of 250 beds is the main provision for treatment, and the three tuberculosis officers, besides being responsible for all dispensary work, are resident at and (with the junior medical officer) constitute the staff of the sanatorium, the chief tuberculosis officer being the medical superintendent. In regard to preventive measures, there is a close
1941 association between the health departments of Gloucester and Gloucestershire on the one hand, and the Joint Board on the other. Although the Joint Board have only one ad hoc tuberculosis health visitor, a system is in operation whereby the various health visitors are responsible for a particular area and transmit reports on the home conditions of notified cases direct to the chief medical officer of the Board. In the office of the chief medical officer, therefore, there is a record of the housing conditions of every notified case, and continuing reports are also sent in at intervals. The district medical officers of health are, of course, responsible for all sanitary conditions as regards housing, and the chief medical officer of the Joint Board passes on to them the information on which they should act. The chief tuberculosis officer has kindly written me as f o l l o w s : -
"The joint scheme is working very satisfactorily and is certainly to the advantage of the smaller authority, but the main difference of the Gloucestershire scheme from the majority is that ~t is the same medical staff who do all the dispensary work and also the sanatorium work . . . . I am convinced of the advantage of this, because it means that the doctor who sees the patients outside also shares in their treatment at the sanatorium and sees them again after their discharge with full knowledge of what has happened during their institutional treatment. The original case sheet goes to the sanatorium when the patient is admitted, so that there is a continuous record without separate reports from the institution. This saves a large amount of clerical work and is, I think, a very satisfactory arrangement. There are also obvious advantages, such as the avoidance of dlsputes between the tuberculosis officer and the medical superintendent." War~wickshire and Coventry ]oint Committee/or Tuberculosis The Warwickshire County Council (population 390,700) and the Coventry County Borough (population 204,000) have a joint scheme for tuberculosis which has existed since 1914. The area covered is 577,877 acres, and the total population is 594,700. The medical staff consists of a chief tuberculosis officer, who is the principal medical officer of the Joint Committee and does a considerable amount of administrative work; two assistant tuberculosis officers; the medical superintendent and the deputy medical superintendent of the King Edward VII Memorial Sanatorium, near Warwick, containing 225 beds; and two junior medical officers at the sanatorium. The deputy medical superintendent of the sanatorium attends at the various dispensaries--mainly the chief dispensary - - o n at least three dispensary sessions a week. There are seven dispensaries, and in addition a medical officer of the Joint Committee attends a school clinic once a month to make examinations of children suspected of being tuberculous. Two new X-ray plants have been provided---one at the chief dispensary and one at the sanatorium--and a large number of X-ray photographs are taken through the various voluntary orthopaedic clinics in the area, with which the Joint Committee works in close co-operation. Besides the sanatorium
PUBLIC HEALTH of 225 beds for pulmonary cases, 70 beds are provided at various orthopaedic and general hospitals for nonpulmonary tuberculosis. Artificial pneumothorax treatment is available at the sanatorium and in all the dispensaries. The Joint Committee has only one tuberculosis nurse, but it pays 8 per cent. of the salaries of all the county and city health visitors who do the tuberculosis visiting and attend all the sessions of the branch dispensaries - - that is all the dispensaries except Coventry. At Coventry a health visitor attends when the tuberculosis nurse is on holiday or is absent for any other reason. Defects in housing, etc., are reported to the county or city medical officer of health and to the chief tuberculosis officer by'-the health visitors. The medical officer of health of Coventry takes action so far as the city is concerned; and the medical officer of health of the county takes action through the district or local medical officers of health. Voluntary nurses do the actual nursing of the tuberculous sick, and grants are made to various associations in the area. This scheme has had the good fortune to have as its godfathers the late Dr. Bostoek Hill and the late Dr. Snell, and its general excellence is clear from this brief description.
Combination by Agreement An example of co-operation for tuberculosis purposes between a small county borough and a county council, without resorting to the formation of a joint board or a joint committee, is provided by the County Borough of Canterbury (population 25,530) and the County Council of Kent (population 1,366,600). Kent County Council do the tuberculosis work for Canterbury, and one of the Kent tuberculosis officers is also tuberculosis officer for Canterbury. The arrangement has been in operation for many years. The combination of areas can be made only with the agreement of all the authorities concerned. As it is unlikely that counties or county boroughs would willingly forego any of their powers under existing Public Health Acts, legislation should be enacted to enforce the combination of those authorities which are considered to be too small to run an efficient anti-tuberculosis scheme. It is interesting to recall that in a report* published in 1932, the Joint Tuberculosis Council made the following recommendation: " Should the formation under the powers of the Local Government Act, 1929, of areas of the size just indicated be unduly delayed, it is suggested that, as appointments fall vacant, the council of a small admirfistratlve area--county or county borough-should be invited by the Ministry of Health to form with an adjacent area a joint committee to administer the tuberculosis scheme as contemplated in the Astor Report and definitely empowered by the Public Health (Tuberculosis) Act of 192t. Alternatively, to avoid the formation of joint committees, a small area could allow its tuberculosis work to be done under an agreement with a larger authority." Report on Improvements in the Tuberculosis Service, Joint Tuberculosis Council, 1932. 137
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MAY
In the same report the Council recommended that rural areas of 200,000 population and urban areas of 300,000 could be managed by one whole-time tuberculosis officer with adequate medical and clerical assistance.
teams of doctors. In all the areas there is very close liaison between the dispensary and institution, and in the majority of the areas the team is in charge of both dispensary and institutional work. In addition to the dispensary and institutional facilities provided, there is a central research laboratory in Tubereulos's Schemes in Wales and the charge of a director of research, who is also ProMonmouthshire fessor of Tuberculosis in the Welsh National School of Medicine; and a director of education conducts an (A) LEGISLATIONGOVERNINGPREVENTION AND TREATeducation campaign by means of school and public MENT OF TUBERCULOSIS. lectures. The statutory provisions with regard to the prevenPrevention tion and treatment of tuberculosis are the same for Wales as for England (see above). As in England, local It is in the measures for prevention that the Welsh sanitary authorities in the Principality have certain powers and duties as to the prevention of tuberculosis; National Memorial Association scheme is weak. The medical practioners and medical officers of health have Association does not have a complete staff of ad hoc certain duties as to the notification of the disease; and tuberculosis health visitors to deal with domiciliary it is the duty of county and county borough councils visiting, nursing, or local affairs. Health visitors who to make adequate arrangements for the treatment of deal with tuberculosis only are more successful with regard to prevention of tuberculosis than voluntary tuberculosis. But while in England the treatment of persons suffer- district nurses who deal with all kinds of sickness. ing from tuberculosis is undertaken by county and When the local authorities of a county, as in Lancacounty borough councils, usually acting as independent shire, depute the whole-time tuberculosis nursing staff, units, in Wales and Monmouthshire this duty is under- through the tuberculosis officer, to make reports to the taken on behalf of the several counties and county medical officers of the local sanitary authorities on boroughs by the King Edward VII Welsh National home conditions, this ensures that co-operation between Memorial Association, and is, of course, an example of the tuberculosis service and the sanitary authorities which is so necessary and important for prevention. regionalisation on a big scale. The Committee* which recently inquired into the (B) THE KING EDWARD VII WELSH NATIONAL tuberculosis services in Wales and Monmouthshire MEMORIAL ASSOCIATION. reported as f o l l o w s : The scheme for the "prevention, treatment, and "Unfortunately our inquiry showed that in large abolition of tuberculosis" for Wales and Monmouthareas of Wales the responsibilities of local authorities shire (comprising 13 counties and 4 county boroughs, did not appear to be properly realised, and the duties with a total population of 2,465,800) is operated by under the Regulations were neglected or carried out the King Edward V I I Welsh National Memorial very imperfectly. It is only right to say that in the Association. This Association was founded in 1910 county boroughs in Wales these matters are taken as, and still is, a voluntary organisation. In 1912, it seriously, and, on the whole, the efficiency of the work under the Regulations is comparable to that in secured a Charter of Incorporation and entered into similar areas in England. To a considerable extent agreements with the county and county borough this is true also of a number of the larger urban and councils of Wales and Monmouthshire to provide the populous rural districts and generally in areas treatment services for the whole of the Principality. served by whole-time Medical Officers of Health . . . . Despite changes in legislation from time to time, the As regards areas with part-time Medical Officers of Association has retained its identity and has consoliHealth, however, with a few striking exceptions, the dated its position as the sole authority in Wales conduties of the Medical Officer of Health under the cerned with the treatment of tuberculosis. Regulations were very much neglected, and it would The Association consists of a Board of Governors, appear that the local authorities were either unaware of their responsibilities under these Regulations or which is the supreme governing body of the Associadeliberately ignored them." tion, and a Council, which attends to the management and control of the financial and executive business of It would appear that the very excellence of the the Association. The finance of the Association is Memorial scheme on the diagnosis and treatment side provided by Government grants and by contributions has been an excuse for neglect on the preventive side. from the county councils and county borough councils And this neglect is again an argument for larger local calculated on the basis of population and rateable authorities, for a prime cause of the neglect has been value. the small size and inadequate financial resources of Diagnosis and Treatment these bodies. Wales and Monmouthshire are divided into fourteen dispensary areas, in each of which there are ample radiologieal facilities. A tuberculosis physician, with one or more assistants, is in charge of each area and has his headquarters at a central dispensary. This is an example of the best kind of staffing--namely, by 138
(To be concluded in our next issue.) * Report of the Committee of InquL,T into the AntiTuberculosis Service in Wales and Monmouth~hire, 1939,