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Chiropodists in the National Health Service
PUBLIC
HEALTH,
January,
1950
to be available at s u c h institutions a n d be at t h e disposal of t h e local welfare authority, the n u m b e r of sick beds b e i n g in proportion to the n u m b e r of aged in l h e institution. It would be reasonable and economic to provide these sick b a y s in relation to all h o m e s and institutions for t h e a g e d ; only t h e m o s t serious cases should be transferred to hospitals to be u n d e r specialist care. C. There is a n o t h e r field where co-operation between Regional Hospital Boards, Hospital M a n a g e m e n t C o m m i t t e e s a n d local h e a l t h authorities can be improved, viz., in regard to case records. Hospitals should receive all possible clinical i n f o r m a t i o n , b o t h f r o m private doctors a n d from local health a n d education authorities in regard to cases a d m i t t e d to hospitals. In some areas this is already t a k i n g place, for example, full ante-natal reports are u s u a l l y forwarded to m a t e r n i t y h o s p t a l s . Similarly, it is of the u t m o s t importance that i n f o r m a t i o n from the hospitals should be available to the local a u t h o r i t y a n d to the medical officer of health. E x a m p l e s of the kind of "nformation expected of hospital authorities are as iollows : - (I) All information relative to the school child a n d the child under school age. It is generally agreed t h a t the follow-up service by health visitors a n d school nurses h a s done magnificent work in raising the s t a n d a r d of health in our school children. To m a i n t a i n this serv!ce records of all serious illnesses s h o u l d be available to the school h e a l t h a n d child welfare departments, so t h a t the clinics and health visitors shall be m a d e aware of t h e type of illness a n d its treatment at the hospitals. (2) In sickness w h i c h requires h o m e n u r s i n g a n d e q u i p m e n t for the purpose on discharge from hospital, a brief record of t h e illness should be available to t h e Public H e a l t h D e p a r t m e n t . Naturall.y the supervision of all t r e a t m e n t will be u n d e r t h e f a m i l y doctor a n d he will require full clinical notes. It will save t i m e a n d improve the efficiency of t h e h o m e n u r s i n g service if there is direct contact between t h e hospital a n d ~he h o m e nurses. For patients r e q u i r i n g special type of e q u i p m e n t a n d after-care it is particularly i m p o r t a n t that this i n f o r m a t i o n s h o u l d be f o r t h c o m i n g , as u n d e r Section 28 of the N a t i o n a l H e a l t h Service A c t t h e local h e a l t h a u t h o r i t y h a s responsibility in t h e matter. (3) In regard to tuberculosis, it is proposed t h a t t h e dispensary organisation shall continue to operate as before t h e A c t a n d t h e clinical chest p h y s i c i a n will be responsible for some duties to the local h e a l t h authority. Detailed a r r a n g e m e n t s should be organised locally to meet local needs. (4) U n d e r Section 22 of the N a t i o n a l H e a l t h Service Act, local health authorities have responsibility in regard to t h e care of m o t h e r s and y o u n g children a n d s h o u l d receive full i n f o r m a t i o n r e g a r d i n g hospital confinements a n d progress of l h e baby. T h i s is of particular i m p o r t a n c e in regard to a n y complication a n d to t h e prem a t u r e child. In certain areas s c h e m e s have already been prepared. Copies of t h e s c h e m e w h i c h is operated in Bristol will be available at the meeting. (Note.--The Chief Medical Officer, M i n i s t r y of H e a l t h , h a s recently consulted t h e Society on t h e types of i n f o r m a t i o n w h i c h should be t r a n s m i t t e d f r o m the hospitals to medical officers of h e a l t h with a view to a d v i s i n g Senior A d m i n i s t r a t i v e Medical Officers of the Regional Boards and, t h r o u g h t h e m , local m a n a g e m e n t committees.) D. Specialist Services. T h e provision of this service is t h e responsibility of t h e Regional Hospital Board b u t it is now generally agreed t h a t local h e a l t h a n d education authorities have power to employ specialists for their particular services. Owing to the limited n u m b e r available in certain areas there m u s t n a t u r a l l y be co-operation between Regional Hospital Boards a n d local h e a l t h authorities in m a k i n g these a p p o i n t m e n t s . T h e Society of Medical Officers of H e a l t h feel very strongly t h a t t h e services of c o n s u l t a n t s in all b r a n c h e s of m e d i c i n e should be m a d e available to medical officers of h e a l t h in t h e interest of preventive medicine. T h e duties of specialists would necessarily be advisory a n d there s h o u l d be definite allocation of their t i m e to serve local h e a l t h a n d education authorities. E. Ophthalmic Services.--We wish ~o b r i n g t h e special case of t h e ophthalmic service to t h e notice of t h e committee. T h e Society feel that it was a m i s t a k e to remove this work from t h e school health service. T h e correction of visual defects a n d t h e provision of spectacles is so i n t i m a t e l y connected with education t h a t unless the two services are completely a m a l g a m a t e d it will be impossible to take proper care of t h e eyesight of our school population. U s u a l l y it is the teacher who becomes aware of t h e defect. H e or she refers the child to t h e school clinic. T h i s results in the provision of spectacles a n d in t h e school nurse, on h e r next visit, d i s c u s s i n g t h e case with the teacher. T h e school medical officer decides t h e form of education suitable for t h e child. It h a s been said t h a t a weakness in the scheme, w h i c h h a d otherwise operated successfully for so m a n y years, was t h e v a r y i n ~ degree of skill available for the correction of the defect. Thi~ could easily have been r e m e d i e d b y i n s i s t i n g on a h i g h e r s t a n d a r d of training of school doctors or t h e provision of specialists for t h e school o p h t h a l m i c service. T h e Society hopes t h a t in f u t u r e school
73 children can be given o p h t h a l m i c service in school clinics a n d t h a t all i n f o r m a t i o n available will t h e n be on t h e spot a n d available to the medical a n d n u r s i n g staff, who c a n m a k e use of it freely in the schools in the interest of t h e child. F. T h e Society feels t h a t closer contact between local h e a l t h authorities a n d Regional Hospital Boards c a n also be obtained t h r o u g h different committees. It is n o t e n o u g h for m e d i c a l officers of h e a l t h to be appointed on advisory c o m m i t t e e s of Regional Hospital Boards. T h e y s h o u l d be m e m b e r s of t h e Boards so t h a t they m a y have a word in t h e a d m i n i s t r a t i v e m a c h i n e r y of hospitals in w h i c h already t h e y have h a d so m u c h experience. It is not necessary for m o r e t h a n a representation of medical officers of h e a l t h to be appointed on to each Board. In this way t h e point of view of the h e a l t h d e p a r t m e n t will be b r o u g h t in, with benefit, to b o t h organisations. Medical officers of h e a l t h h a v e already been appointed on to local executive councils in a n u m b e r of areas and m a n y declare that t h ' s is a very useful contact a n d of value to the services. M a n y medical officers of health have been appointed on to t h e m a n a g e m e n t committees of hospitals. It should be stated, however, that the medical officer of h e a l t h of t h e local a u t h o r i t y - - a s distinct from the local h e a l t h a u t h o r i t y - - i s usually, in county areas, extremely interested in the local hospital, a n d as he h a s public h e a l t h responsibilities for the area he should certainly be on the n m n a g e m e n t c o m m i t t e e of t h a t hospital. In t h e case, however, of large cities a n d counties it is placing too great a b u r d e n on the medical officer of h e a l t h to expect h i m to serve personally on three or more committees. In one city at least t h e medical officer of h e a l t h ' s deputy a n d assistants serve on t h e s e committees, t h u s providing a link with the Public H e a l t h D e p a r t m e n t . APPENDIX E. CHIROPODISTS IN THE NATIONAL HEALTH SERVICE
Memorandum o[ Evidence by the Society o[ Medical Officers of Health submitted to the Committee set up by the Minister of Health and Secretary of State for Scotland to consider the Supply. Demand, Qualifications and Training of Chiropodists in the National Health Service and to make recommendations. Supply and Demand T h e question of t h e supply of chiropodists f r o m t h e s t a n d p o i n t of n u m b e r s h a s no doubt already been t h e subject of evidence, a n d
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Health and Tuberculosis Conference London, 1949 ~Verbatim Report of Speeches and Discussions 9¢Illustrated by Photographs 9rList of over 1,000 delegates 9cOver 400 pages. NOW ~rFifteen shillings, post free RF,ADY NATIONAL ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS ~ Tar~stock H o w e North, T a ~ t o c k Square, W . C . 1
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74 it seems u n n e c e s s a r y t h a t we s h o u l d take personal responsibility for s u c h statistics w h i c h can be obtained f r o m more authoritative sources. W e would, however, like to point out t h a t there are two sources of supply : - 1. Y o u n g people on leaving school or soon afterwards. 2. People of more m a t u r e years, say in their twenties, who find themselves in jobs where a d v a n c e m e n t is likety to be s l o w - in other words, waiting for dead m e n ' s s h o e s - - a n d who find their work uninteresting. If y o u n g people are to l)e recruited to chiropody in n u m b e r s more t h a n at present, it m a y be f o u n d necessary to attract t h e m in this way or in t h a t to take up their studies on leaving school. If older people are to be attracted to chiropody it will be necessary to afford t h e m considerable financial help, as otherwise it m e a n s they sacrifice a salary w h i c h for t h e two years' course is in t h e region of £500 or £600. T h i s is a h i g h price to p a y for a qualification which, after all, does not b r i n g in a r e m u n e r a t i o n very m u c h above w h a t they m a y be e a r n i n g at this age. In d i s c u s s i n g w h i c h m a k e t h e better chiropodists, those t h a t come in early or those t h a t come in later, we find t h a t on the whole it is probably those t h a t c o m e in later w h o are preferable. T h e y come to t h e subject with a deeper u n d e r s t a n d i n g of h u m a n nature, and, a l t h o u g h t h e y do not learn t h e theoretical side quite so quickly as the y o u n g e r people, t h e y probably are more influenced by it. W i t h regard to the d e m a n d for chiropodists we can only say t h a t up to this stage, a n d so far as t h e public services are concerned, d e m a n d outstrips supply. T h e effect of setting u p a foot clinic or chiropody clinic is to find in t h e first place a d e m a n d w h i c h is in excess of t h e service provided, a n d at this stage increasing t h e service seems to tap still f u r t h e r larger d e m a n d s . It is therefore difficult to assess what the saturation point would be. A t this stage it would wise to t h i n k in terms of one per 100,000 population in industrial areas, b u t it s h o u l d be fully recognised t h a t this ratio m i g h t have to be increased in t h e light of f u r t h e r experience.
Training T h e t r a i n i n g at present takes two years. T h e students work on an average 30 h o u r s per week in a 44-week year, a n d of t h e time devoted to their studies some 1,500 h o u r s are spent in practical work. T r a i n i n g is whole-time a n d a m o n g s t other m e t h o d s of easing the cost to the s t u d e n t t h e possibility of a p a r t - t i m e course e x t e n d i n g over a longer period m a y be entertained. T h e basic t r a i n i n g in chemistry, physics a n d biology takes f r o m seven t o eight h o u r s over one academic year of 44 weeks. W e find it would be of a d v a n t a g e if this basic t r a i n i n g were taken in association with other medical auxiliaries s u c h as physiotherapists, a n d s u g g e s t t h a t the school certificate s h o u l d b e so a r r a n g e d t h a t if these subjects were taken with t h e school certificate t h e s t u d e n t of chiropody could be e x e m p t e d f r o m t h e m . Moreover, if this basic t r a i n i n g were given for a larger n u m b e r of students t h a n chiropodists, it could be held at a large n u m b e r of sub-centres a n d so decrease t h e actual cost to t h e student, who would be saved b o t h travelling a n d in some instances lodging. T r a i n i n g , other t h a n t h e basic t r a i n i n g in these e l e m e n t a r y sciences, should be given preferably a~ hospitals w h i c h are t r a i n i n g schools, n o t of necessity t r a l m n g schools for medical students. If these students were to m i x with b u d d i n g p h y s i o t h e r a p i s t s a n d pathological technicians, etc., it would enable t h e m to learn a great deal apart from their academic lectures, a n d to u n d e r s t a n d t h e i m p o r t a n t part t h e y pla 7 in t h e s c h e m e of medical services as a whole, and, incidentally, the scope of their work. Equally, we find t h a t some, at least a half, of their practical work could be u n d e r t a k e n at public clinics, provided t h a t these clinics were adequately staffed by people capable of giving the necessary t r a i n i n g a n d provided also t h a t t h e n u m b e r of students did not in fact m e a n t h a t t h e y were a c t i n g as dilutees. T h i s would m e a n not only decreased costs by decreasing travel, etc., b u t would also give t h e s t u d e n t a firm introduction to w h a t will be the k i n d of e m p l o y m e n t he is likely to undertake. W e have considered t h e possibility of these s t u d e n t s b e i n g paid for work in public clinics as one m e a n s of m a k i n g t h e cost less costly to the individual, b u t we would deprecate s u c h a procedure a n d believe t h a t financial assistance should be given in s o m e other wav. "Fhe basic t r a i n i n g should be in a c u r r i c u l u m dealing with principles rather t h a n data. T h e later t r a i n i n g should be correlated a n d integrated with other training. In a t e a c h i n g hospital there should be a liaison officer between t h e chiropody section a n d t h e rest of t h e hospital. T h i s m a n could conveniently b e t h e resident officer, h o u s e m a n , or otherwise e n g a g e d in orthopaedics. He should be responsible for seeing t h a t cases of cellulitis septicaemla are in fact d e m o n s t r a t e d to t h e s e s t u d e n t s so t h a t t h e s e names, with
HEALTH,
January,
1950
w h i c h t h e y h a v e to be familiar, are not j u s t n a m e s o u t of a dictionary. If possible, the students s h o u l d actually see cases of gangrene. W e believe t h a t ont 7 in this way can s t u d e n t s be suitably impressed with the need for meticulous care to avoid s u c h u n h a p p y complications.
Qualifications W i t h regard to qualification we beEeve t h a t no s t u d e n t should be allowed to qualify u n d e r the age of 21 years, a n d t h a t a h h o u g h s t u d e n t s c o m i n g into school at an early age m a y in fact have completed the course a n d m a y have sat for all examination, this s h o u l d be looked upon as an intermediate examination. W e believe that these people should be gainfully employed until they are 21, b u t t h a t opportunity should "be afforded t h e m for keeping in touch with t h e scholastic side of their work, a n d t h a t before t h e diploma is awarded at t h e age f 21 .they would have to show t h a t t h e y h a d in fact m a i n t a i n e d their studies. It is impossible to deal with t h e question of chiropody f r o m a public standpoint, with w h i c h we are particularly interested, w i t h o u t h a v i n g a word to say a b o u t r e m u n e r a t i o n . W e find that, as a m a t t e r of fact, a qualified person can set u p in chiropody with a relatively small expenditure of m o n e y (say £100) provided he h a s t h e parttime use of two rooms, w h i c h m a y in his own h o m e , a n d due regard m u s t be h a d to this when assessing t h e salaries of chiropodists. T h i s m a y lead to anomalies when their salaries are compared with those of other m e m b e r s in the public services, b u t this is inevitable so long as some m e m b e r s of the staff have an opport u n i t y of g o i n g into private practice a n d some m e m b e r s of the staff are employed on work w h i c h does not offer a similar opportunity.
Municipal Foot Clinics We should like to take this opportunity of u r g i n g t h a t t h e successful foot clinics w h i c h have been operated hitherto by m u n i c i p a l enterprise in L o n d o n a n d t h e provinces should be allowed to continue in their present form. T h i s service, given usuaUy for a small fee, h a s been very popular with t h e public a n d we believe h a s done m u c h good in increasing comfor~ a n d preventing developm e n t of more serious disabilities. T h e chiropodists who staff these clinics are well aware of t h e necessity of referring foot conditions w h i c h call for medical advice to the hospitals a n d we do not see t h a t t h e r e is a n y necessity for the transfer of s u c h services, where t h e y exist, to the Hospital Service. It is, in our view, a type of service w h i c h can properly be a r r a n g e d at m u n i c i p a l clinics or (in due ,mlrse) at h e a l t h centres.
F O R E I G N OFFICE A D M I N I S T R A T I O N TERRITORIES
OF A F R I C A N
Vacancies exist in t h e Medical D e p a r t m e n t of t h e British A d m i n i s tration in N o r t h a n d East Africa for Public H e a l t h Inspectors, Sanitary A s s i s t a n t s a n d Aedes Control Inspectors. Candidates s h o u l d be m e m b e r s of t h e Royal Sanitary I n s t i t u t e or be A r m y t r a i n e d Sanitary A s s i s t a n t s Grade I. For Public H e a l t h Inspectors a n d Sanitary Assistants, candidates m u s t h a v e knowledge of public h e a l t h procedure a n d be able to p e r f o r m h y g i e n e a n d sanitary inspections of all k i n d s of premises, particularly those used in food trade. For Aedes Control Inspectors, c a n d i d a t e s , m u s t have h a d t r a i n i n g a n d experience in Malarial Control. A p p o i n t m e n t s are t e m p o r a r y a n d are offered subject to medical examination. T h e initial contract is for two years. Salaries: Grade V (a) £400 p . a . x £15 to £475 p.a. G r a d e V (b) £ 3 2 5 x £ 1 5 to £400 p.a. I n addition a Foreign Service Allowance is payable r a n g i n g from £ 1 5 0 - - £ 5 3 0 p.a. (free of U.K. I n c o m e Tax) d e p e n d e n t on w h e t h e r candidates are m a r r i e d or single a n d w h e t h e r or not a c c o m m o d a t i o n is provided. W r i t t e n applications g i v i n g date of birth, full details of education, qualifications a n d experience of posts held, i n c l u d i n g dates, should be addressed to L o n d o n A p p o i n t m e n t s Officer, M i n i s t r y of L a b o u r a n d N a t i o n a l Service, 1-6, Tavistock Square, L o n d o n , W.C.1, q u o t i n g reference n u m b e r F A 668 for Public H e a l t h Inspectors a n d Sanitary Assistants a n d reference n u m b e r F A 718 for Aedes Control Inspectors. In no c i r c u m s t a n c e s should original testimonials be forwarded.
Public Health is t h e Official O r g a n of the Society of Medical Officers of H e a l t h a n d a suitable m e d i u m for t h e advertisement of official a p p o i n t m e n t s vacant in t h e h e a l t h service. Space is also available for a certain n u m b e r of approved commercial advertisements. A p p l y : t h e Executive Secretary of t h e Society, at Tavistock H o u s e South, Tavistock Square, W.C.1. Subscription 31s. 6d. per a n n u m , post free, in advance. Single copies 2s. 6d. post free. Official classified advertisements are c h a r g e d at 2s. 6d. per line or part of a line. M i n i m u m c h a r g e 15s. T e l e p h o n e : Euston 3923.
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HEALTH,
January,
1950
to be available at s u c h institutions a n d be at t h e disposal of t h e local welfare authority, the n u m b e r of sick beds b e i n g in proportion to the n u m b e r of aged in l h e institution. It would be reasonable and economic to provide these sick b a y s in relation to all h o m e s and institutions for t h e a g e d ; only t h e m o s t serious cases should be transferred to hospitals to be u n d e r specialist care. C. There is a n o t h e r field where co-operation between Regional Hospital Boards, Hospital M a n a g e m e n t C o m m i t t e e s a n d local h e a l t h authorities can be improved, viz., in regard to case records. Hospitals should receive all possible clinical i n f o r m a t i o n , b o t h f r o m private doctors a n d from local health a n d education authorities in regard to cases a d m i t t e d to hospitals. In some areas this is already t a k i n g place, for example, full ante-natal reports are u s u a l l y forwarded to m a t e r n i t y h o s p t a l s . Similarly, it is of the u t m o s t importance that i n f o r m a t i o n from the hospitals should be available to the local a u t h o r i t y a n d to the medical officer of health. E x a m p l e s of the kind of "nformation expected of hospital authorities are as iollows : - (I) All information relative to the school child a n d the child under school age. It is generally agreed t h a t the follow-up service by health visitors a n d school nurses h a s done magnificent work in raising the s t a n d a r d of health in our school children. To m a i n t a i n this serv!ce records of all serious illnesses s h o u l d be available to the school h e a l t h a n d child welfare departments, so t h a t the clinics and health visitors shall be m a d e aware of t h e type of illness a n d its treatment at the hospitals. (2) In sickness w h i c h requires h o m e n u r s i n g a n d e q u i p m e n t for the purpose on discharge from hospital, a brief record of t h e illness should be available to t h e Public H e a l t h D e p a r t m e n t . Naturall.y the supervision of all t r e a t m e n t will be u n d e r t h e f a m i l y doctor a n d he will require full clinical notes. It will save t i m e a n d improve the efficiency of t h e h o m e n u r s i n g service if there is direct contact between t h e hospital a n d ~he h o m e nurses. For patients r e q u i r i n g special type of e q u i p m e n t a n d after-care it is particularly i m p o r t a n t that this i n f o r m a t i o n s h o u l d be f o r t h c o m i n g , as u n d e r Section 28 of the N a t i o n a l H e a l t h Service A c t t h e local h e a l t h a u t h o r i t y h a s responsibility in t h e matter. (3) In regard to tuberculosis, it is proposed t h a t t h e dispensary organisation shall continue to operate as before t h e A c t a n d t h e clinical chest p h y s i c i a n will be responsible for some duties to the local h e a l t h authority. Detailed a r r a n g e m e n t s should be organised locally to meet local needs. (4) U n d e r Section 22 of the N a t i o n a l H e a l t h Service Act, local health authorities have responsibility in regard to t h e care of m o t h e r s and y o u n g children a n d s h o u l d receive full i n f o r m a t i o n r e g a r d i n g hospital confinements a n d progress of l h e baby. T h i s is of particular i m p o r t a n c e in regard to a n y complication a n d to t h e prem a t u r e child. In certain areas s c h e m e s have already been prepared. Copies of t h e s c h e m e w h i c h is operated in Bristol will be available at the meeting. (Note.--The Chief Medical Officer, M i n i s t r y of H e a l t h , h a s recently consulted t h e Society on t h e types of i n f o r m a t i o n w h i c h should be t r a n s m i t t e d f r o m the hospitals to medical officers of h e a l t h with a view to a d v i s i n g Senior A d m i n i s t r a t i v e Medical Officers of the Regional Boards and, t h r o u g h t h e m , local m a n a g e m e n t committees.) D. Specialist Services. T h e provision of this service is t h e responsibility of t h e Regional Hospital Board b u t it is now generally agreed t h a t local h e a l t h a n d education authorities have power to employ specialists for their particular services. Owing to the limited n u m b e r available in certain areas there m u s t n a t u r a l l y be co-operation between Regional Hospital Boards a n d local h e a l t h authorities in m a k i n g these a p p o i n t m e n t s . T h e Society of Medical Officers of H e a l t h feel very strongly t h a t t h e services of c o n s u l t a n t s in all b r a n c h e s of m e d i c i n e should be m a d e available to medical officers of h e a l t h in t h e interest of preventive medicine. T h e duties of specialists would necessarily be advisory a n d there s h o u l d be definite allocation of their t i m e to serve local h e a l t h a n d education authorities. E. Ophthalmic Services.--We wish ~o b r i n g t h e special case of t h e ophthalmic service to t h e notice of t h e committee. T h e Society feel that it was a m i s t a k e to remove this work from t h e school health service. T h e correction of visual defects a n d t h e provision of spectacles is so i n t i m a t e l y connected with education t h a t unless the two services are completely a m a l g a m a t e d it will be impossible to take proper care of t h e eyesight of our school population. U s u a l l y it is the teacher who becomes aware of t h e defect. H e or she refers the child to t h e school clinic. T h i s results in the provision of spectacles a n d in t h e school nurse, on h e r next visit, d i s c u s s i n g t h e case with the teacher. T h e school medical officer decides t h e form of education suitable for t h e child. It h a s been said t h a t a weakness in the scheme, w h i c h h a d otherwise operated successfully for so m a n y years, was t h e v a r y i n ~ degree of skill available for the correction of the defect. Thi~ could easily have been r e m e d i e d b y i n s i s t i n g on a h i g h e r s t a n d a r d of training of school doctors or t h e provision of specialists for t h e school o p h t h a l m i c service. T h e Society hopes t h a t in f u t u r e school
73 children can be given o p h t h a l m i c service in school clinics a n d t h a t all i n f o r m a t i o n available will t h e n be on t h e spot a n d available to the medical a n d n u r s i n g staff, who c a n m a k e use of it freely in the schools in the interest of t h e child. F. T h e Society feels t h a t closer contact between local h e a l t h authorities a n d Regional Hospital Boards c a n also be obtained t h r o u g h different committees. It is n o t e n o u g h for m e d i c a l officers of h e a l t h to be appointed on advisory c o m m i t t e e s of Regional Hospital Boards. T h e y s h o u l d be m e m b e r s of t h e Boards so t h a t they m a y have a word in t h e a d m i n i s t r a t i v e m a c h i n e r y of hospitals in w h i c h already t h e y have h a d so m u c h experience. It is not necessary for m o r e t h a n a representation of medical officers of h e a l t h to be appointed on to each Board. In this way t h e point of view of the h e a l t h d e p a r t m e n t will be b r o u g h t in, with benefit, to b o t h organisations. Medical officers of h e a l t h h a v e already been appointed on to local executive councils in a n u m b e r of areas and m a n y declare that t h ' s is a very useful contact a n d of value to the services. M a n y medical officers of health have been appointed on to t h e m a n a g e m e n t committees of hospitals. It should be stated, however, that the medical officer of h e a l t h of t h e local a u t h o r i t y - - a s distinct from the local h e a l t h a u t h o r i t y - - i s usually, in county areas, extremely interested in the local hospital, a n d as he h a s public h e a l t h responsibilities for the area he should certainly be on the n m n a g e m e n t c o m m i t t e e of t h a t hospital. In t h e case, however, of large cities a n d counties it is placing too great a b u r d e n on the medical officer of h e a l t h to expect h i m to serve personally on three or more committees. In one city at least t h e medical officer of h e a l t h ' s deputy a n d assistants serve on t h e s e committees, t h u s providing a link with the Public H e a l t h D e p a r t m e n t . APPENDIX E. CHIROPODISTS IN THE NATIONAL HEALTH SERVICE
Memorandum o[ Evidence by the Society o[ Medical Officers of Health submitted to the Committee set up by the Minister of Health and Secretary of State for Scotland to consider the Supply. Demand, Qualifications and Training of Chiropodists in the National Health Service and to make recommendations. Supply and Demand T h e question of t h e supply of chiropodists f r o m t h e s t a n d p o i n t of n u m b e r s h a s no doubt already been t h e subject of evidence, a n d
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Health and Tuberculosis Conference London, 1949 ~Verbatim Report of Speeches and Discussions 9¢Illustrated by Photographs 9rList of over 1,000 delegates 9cOver 400 pages. NOW ~rFifteen shillings, post free RF,ADY NATIONAL ASSOCIATION FOR THE PREVENTION OF TUBERCULOSIS ~ Tar~stock H o w e North, T a ~ t o c k Square, W . C . 1
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74 it seems u n n e c e s s a r y t h a t we s h o u l d take personal responsibility for s u c h statistics w h i c h can be obtained f r o m more authoritative sources. W e would, however, like to point out t h a t there are two sources of supply : - 1. Y o u n g people on leaving school or soon afterwards. 2. People of more m a t u r e years, say in their twenties, who find themselves in jobs where a d v a n c e m e n t is likety to be s l o w - in other words, waiting for dead m e n ' s s h o e s - - a n d who find their work uninteresting. If y o u n g people are to l)e recruited to chiropody in n u m b e r s more t h a n at present, it m a y be f o u n d necessary to attract t h e m in this way or in t h a t to take up their studies on leaving school. If older people are to be attracted to chiropody it will be necessary to afford t h e m considerable financial help, as otherwise it m e a n s they sacrifice a salary w h i c h for t h e two years' course is in t h e region of £500 or £600. T h i s is a h i g h price to p a y for a qualification which, after all, does not b r i n g in a r e m u n e r a t i o n very m u c h above w h a t they m a y be e a r n i n g at this age. In d i s c u s s i n g w h i c h m a k e t h e better chiropodists, those t h a t come in early or those t h a t come in later, we find t h a t on the whole it is probably those t h a t c o m e in later w h o are preferable. T h e y come to t h e subject with a deeper u n d e r s t a n d i n g of h u m a n nature, and, a l t h o u g h t h e y do not learn t h e theoretical side quite so quickly as the y o u n g e r people, t h e y probably are more influenced by it. W i t h regard to the d e m a n d for chiropodists we can only say t h a t up to this stage, a n d so far as t h e public services are concerned, d e m a n d outstrips supply. T h e effect of setting u p a foot clinic or chiropody clinic is to find in t h e first place a d e m a n d w h i c h is in excess of t h e service provided, a n d at this stage increasing t h e service seems to tap still f u r t h e r larger d e m a n d s . It is therefore difficult to assess what the saturation point would be. A t this stage it would wise to t h i n k in terms of one per 100,000 population in industrial areas, b u t it s h o u l d be fully recognised t h a t this ratio m i g h t have to be increased in t h e light of f u r t h e r experience.
Training T h e t r a i n i n g at present takes two years. T h e students work on an average 30 h o u r s per week in a 44-week year, a n d of t h e time devoted to their studies some 1,500 h o u r s are spent in practical work. T r a i n i n g is whole-time a n d a m o n g s t other m e t h o d s of easing the cost to the s t u d e n t t h e possibility of a p a r t - t i m e course e x t e n d i n g over a longer period m a y be entertained. T h e basic t r a i n i n g in chemistry, physics a n d biology takes f r o m seven t o eight h o u r s over one academic year of 44 weeks. W e find it would be of a d v a n t a g e if this basic t r a i n i n g were taken in association with other medical auxiliaries s u c h as physiotherapists, a n d s u g g e s t t h a t the school certificate s h o u l d b e so a r r a n g e d t h a t if these subjects were taken with t h e school certificate t h e s t u d e n t of chiropody could be e x e m p t e d f r o m t h e m . Moreover, if this basic t r a i n i n g were given for a larger n u m b e r of students t h a n chiropodists, it could be held at a large n u m b e r of sub-centres a n d so decrease t h e actual cost to t h e student, who would be saved b o t h travelling a n d in some instances lodging. T r a i n i n g , other t h a n t h e basic t r a i n i n g in these e l e m e n t a r y sciences, should be given preferably a~ hospitals w h i c h are t r a i n i n g schools, n o t of necessity t r a l m n g schools for medical students. If these students were to m i x with b u d d i n g p h y s i o t h e r a p i s t s a n d pathological technicians, etc., it would enable t h e m to learn a great deal apart from their academic lectures, a n d to u n d e r s t a n d t h e i m p o r t a n t part t h e y pla 7 in t h e s c h e m e of medical services as a whole, and, incidentally, the scope of their work. Equally, we find t h a t some, at least a half, of their practical work could be u n d e r t a k e n at public clinics, provided t h a t these clinics were adequately staffed by people capable of giving the necessary t r a i n i n g a n d provided also t h a t t h e n u m b e r of students did not in fact m e a n t h a t t h e y were a c t i n g as dilutees. T h i s would m e a n not only decreased costs by decreasing travel, etc., b u t would also give t h e s t u d e n t a firm introduction to w h a t will be the k i n d of e m p l o y m e n t he is likely to undertake. W e have considered t h e possibility of these s t u d e n t s b e i n g paid for work in public clinics as one m e a n s of m a k i n g t h e cost less costly to the individual, b u t we would deprecate s u c h a procedure a n d believe t h a t financial assistance should be given in s o m e other wav. "Fhe basic t r a i n i n g should be in a c u r r i c u l u m dealing with principles rather t h a n data. T h e later t r a i n i n g should be correlated a n d integrated with other training. In a t e a c h i n g hospital there should be a liaison officer between t h e chiropody section a n d t h e rest of t h e hospital. T h i s m a n could conveniently b e t h e resident officer, h o u s e m a n , or otherwise e n g a g e d in orthopaedics. He should be responsible for seeing t h a t cases of cellulitis septicaemla are in fact d e m o n s t r a t e d to t h e s e s t u d e n t s so t h a t t h e s e names, with
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w h i c h t h e y h a v e to be familiar, are not j u s t n a m e s o u t of a dictionary. If possible, the students s h o u l d actually see cases of gangrene. W e believe t h a t ont 7 in this way can s t u d e n t s be suitably impressed with the need for meticulous care to avoid s u c h u n h a p p y complications.
Qualifications W i t h regard to qualification we beEeve t h a t no s t u d e n t should be allowed to qualify u n d e r the age of 21 years, a n d t h a t a h h o u g h s t u d e n t s c o m i n g into school at an early age m a y in fact have completed the course a n d m a y have sat for all examination, this s h o u l d be looked upon as an intermediate examination. W e believe that these people should be gainfully employed until they are 21, b u t t h a t opportunity should "be afforded t h e m for keeping in touch with t h e scholastic side of their work, a n d t h a t before t h e diploma is awarded at t h e age f 21 .they would have to show t h a t t h e y h a d in fact m a i n t a i n e d their studies. It is impossible to deal with t h e question of chiropody f r o m a public standpoint, with w h i c h we are particularly interested, w i t h o u t h a v i n g a word to say a b o u t r e m u n e r a t i o n . W e find that, as a m a t t e r of fact, a qualified person can set u p in chiropody with a relatively small expenditure of m o n e y (say £100) provided he h a s t h e parttime use of two rooms, w h i c h m a y in his own h o m e , a n d due regard m u s t be h a d to this when assessing t h e salaries of chiropodists. T h i s m a y lead to anomalies when their salaries are compared with those of other m e m b e r s in the public services, b u t this is inevitable so long as some m e m b e r s of the staff have an opport u n i t y of g o i n g into private practice a n d some m e m b e r s of the staff are employed on work w h i c h does not offer a similar opportunity.
Municipal Foot Clinics We should like to take this opportunity of u r g i n g t h a t t h e successful foot clinics w h i c h have been operated hitherto by m u n i c i p a l enterprise in L o n d o n a n d t h e provinces should be allowed to continue in their present form. T h i s service, given usuaUy for a small fee, h a s been very popular with t h e public a n d we believe h a s done m u c h good in increasing comfor~ a n d preventing developm e n t of more serious disabilities. T h e chiropodists who staff these clinics are well aware of t h e necessity of referring foot conditions w h i c h call for medical advice to the hospitals a n d we do not see t h a t t h e r e is a n y necessity for the transfer of s u c h services, where t h e y exist, to the Hospital Service. It is, in our view, a type of service w h i c h can properly be a r r a n g e d at m u n i c i p a l clinics or (in due ,mlrse) at h e a l t h centres.
F O R E I G N OFFICE A D M I N I S T R A T I O N TERRITORIES
OF A F R I C A N
Vacancies exist in t h e Medical D e p a r t m e n t of t h e British A d m i n i s tration in N o r t h a n d East Africa for Public H e a l t h Inspectors, Sanitary A s s i s t a n t s a n d Aedes Control Inspectors. Candidates s h o u l d be m e m b e r s of t h e Royal Sanitary I n s t i t u t e or be A r m y t r a i n e d Sanitary A s s i s t a n t s Grade I. For Public H e a l t h Inspectors a n d Sanitary Assistants, candidates m u s t h a v e knowledge of public h e a l t h procedure a n d be able to p e r f o r m h y g i e n e a n d sanitary inspections of all k i n d s of premises, particularly those used in food trade. For Aedes Control Inspectors, c a n d i d a t e s , m u s t have h a d t r a i n i n g a n d experience in Malarial Control. A p p o i n t m e n t s are t e m p o r a r y a n d are offered subject to medical examination. T h e initial contract is for two years. Salaries: Grade V (a) £400 p . a . x £15 to £475 p.a. G r a d e V (b) £ 3 2 5 x £ 1 5 to £400 p.a. I n addition a Foreign Service Allowance is payable r a n g i n g from £ 1 5 0 - - £ 5 3 0 p.a. (free of U.K. I n c o m e Tax) d e p e n d e n t on w h e t h e r candidates are m a r r i e d or single a n d w h e t h e r or not a c c o m m o d a t i o n is provided. W r i t t e n applications g i v i n g date of birth, full details of education, qualifications a n d experience of posts held, i n c l u d i n g dates, should be addressed to L o n d o n A p p o i n t m e n t s Officer, M i n i s t r y of L a b o u r a n d N a t i o n a l Service, 1-6, Tavistock Square, L o n d o n , W.C.1, q u o t i n g reference n u m b e r F A 668 for Public H e a l t h Inspectors a n d Sanitary Assistants a n d reference n u m b e r F A 718 for Aedes Control Inspectors. In no c i r c u m s t a n c e s should original testimonials be forwarded.
Public Health is t h e Official O r g a n of the Society of Medical Officers of H e a l t h a n d a suitable m e d i u m for t h e advertisement of official a p p o i n t m e n t s vacant in t h e h e a l t h service. Space is also available for a certain n u m b e r of approved commercial advertisements. A p p l y : t h e Executive Secretary of t h e Society, at Tavistock H o u s e South, Tavistock Square, W.C.1. Subscription 31s. 6d. per a n n u m , post free, in advance. Single copies 2s. 6d. post free. Official classified advertisements are c h a r g e d at 2s. 6d. per line or part of a line. M i n i m u m c h a r g e 15s. T e l e p h o n e : Euston 3923.
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