General Purposes Committee

PUBLIC HEALTH, July, 1951

199

be just as heavily contaminated as milk with the various pathogenic organisms which may give rise to infectious disease. The Society would like strongly to recommend that all cream should be pasteurised or, if this is not possible, at least cream coming from non-tubercuIin tested herds." 136. Report of the Manufactured Meat Products Working P a r t y . - - I t was reported that a letter dated March 9th had been received from the Ministry of Food referring to the report of the Manufactured Meat Products Working Party. T h e Society's comments were invited on such of the recommendations for amending or additional legislation set out in paragraph 195 of the report as were suitable for incorporating in Regulations to be made under Section 8 of the Food and Drugs Act, 1938. The Standing Sub-Committee for Food Matters had considered this question and it was resolved that the Sub-Committee's recommentation be adopted and the following comments forwarded to the Ministry of Food : -

(b) Nominations were also required for four Public Health Service representatives and four deputies for the annual representatives' meeting at B.M.A. House from June 13th to 16th next. It was resolved that Drs. C. Fraser Brockington, G. F. Buchan, J. A. Stifling and J. A. Struthers be nominated as representatives and that Drs. J. Maddison, R. C. M. Pearson and E. H. R. Smithard be nominated as deputy representatives. 141. Returns of Cases 0f Dysentery.--A letter dated April 12th was received from the Hen. Secretary of the Yorkshire Branch, the apparent differences of opinion between M.O.H.s on the question of Returns of Cases of Dysentery notified. It was resolved that the letter be referred to the Committee set up to co-ordinate and encourage research. 142. Representation oI the S o c i e t y . - - T h e following were appointed to represent the Society : - (a) Sanitary Inspectors' Association.--AnnuaI Conference, Margate, September 10th to 14th. Dr. G. L. Brocklehurst.

Paragraph 195

Greenwood Wilson.

(v) In addition to prohibiting the use of domestic kitchen and sculleries for the manufacture of meat products, conversely, rooms used for manufacture should not be used for domestic washing or other domestic duties. In effect, this means that premises or rooms used for the manufacture or storage of meat products should only be used for activities connected with preparation or storage of food for sale. (xi) Domestic animals should be excluded by regulation, as indicated in sub-paragraph (xi). T h e high salmonella carrierrate of cats and dogs, recently demonstrated, makes this recommendation inevitable. It should receive strong support. (xiv) It is suggested that sub-paragraph (xiv) should follow sub-paragraph (xii) and be renumbered (xiii) because subparagraph (xiv) is ambiguous in that it does not clearly state that the separate sinks are for the two different purposes of cleansing equipment and utensils on the one hand and personal washing on the other. (xxv) T h e use of tobacco (including snuff) and the habit of spitting in rooms used for the preparation or storage of meat products or raw materials should be prohibited. With all the other items in this paragraph, mentioned specifically in Mr. Hopkinson's letter of March 9th, we agree and have no comments to make.

Paragraph 196 We strongly agree with these provisions, and that items (vii) and (viii) should be incorporated in Regulations rather than in a Code of Practice.

Other Suggestions The Society wishes to associate itself with the minority report on pages 42 and 43 of the Working Party's Report, and strongly to support the recommendations therein. t37. Milk Sampling.--It was reported that a letter dated March 20th had been received from the Ministry of Food referring to articles which had appeared from tirae to time in Local Government and other journals, drawing attention to difficulties experienced in connection with milk sampling and the laying of charges for the sale or being in possession of adulterated milk. A small inter-departmental committee had been set up to consider whether any legislative or other changes would be required to overcome such difficulties. A questionnaire for completion by the Society was forwarded with the letter and the Standing Sub-Committee for Food Matters was considering the answers to be given on the questionnaire. 138. B.C.G. Vaccination for District Nurses.--A letter dated March 21st was received from the Queen's Institute of District Nursing asking the Society to consider the question of the desirability of B.C.G. vaccination being arranged for district nurses, particularly in view of the increase in the incidence of ttaberculosis among district nurses. It was resolved that the Queen's Institute be advised to suggest to their members that they should approach their local M.O.H.s on this question and that generally speaking district nurses be strongly advised to arrange for their own B.C.G. vaccination. 139. Royal College of Nurslng.--A letter dated April 9th was received from the Royal College of Nursing asking that the Society should discuss with representatives of the College the question of " Staff Education." It was resolved that the Royal College of Nursing be invited to send representatives to discuss the matter with the G.P. Committee at its next meeting. 140. Public Health Service Representatives, B.M,A.--(a) It was reported that the usual nominations in respect of two P.H.S. representatives to serve on the Council of the Association for 1951-52 had been arranged in respect of Drs. C. Metcalfe Brown and J. M. Gibson.

(b) Public Health Engineering Advisor:v Committee.--Dr. J. (c) Cremation Society.--AnnuaI Cremation Conference, Victoria Hall, London, June 26th to 28th. Dr. C. F. White. (d) Centrat Council for District Nursing in London.--The present representatives, Drs. A. G. G. Thompson and C. F. White. (e) Oxford Conference on Tuberculosis and Diseases of the Chest, Oxford, July 16th to 21st.--Chairman for the morning session on July 19th (on the subject of Rehabilitation and Resettlement) - - t h e President or Chairman of Council.

( f ) Representatives to meet Planning Sub-Committee of the Occupational Health Committee of the B.M.A. to discuss the Society's memorandum of evidence to the Dale Committee following publication of the Report of that Committee. It was resolved that the President (Dr. J. M. Gibson) appoint such representatives as he thought fit when the meeting was called. T h e meeting was declared closed at ] p.m. APPENDIX A

General Purposes Committee A m e n d m e n t of the N . H . S . Acts A special meeting of the General Purposes Committee was held in the Society's Committee Room, Tavistock House South, Tavistock Square, W.C.1, on Tuesday, February 27th, at 2 p.m., to consider and decide upon the recommendations of the Society to be put forward to the Public Health Committee of the British Medical Association, regarding amendment of the National Health Service Acts, 1946 and 1949, and of the Regulations and O r d e r s made thereunder. Present.--The President (Dr. J. M. Gibson) in the chair, the Chairman of Council (Sir Allen Daley), Drs. C. Fraser Brockington, C. Metcalfe Brown, George Buchan, H. D. Chalke, C. K. Cullen, Miriam Florentin, C. E. Herington, John Maddison, Maurice Mitman, A. A. E. Newth, E. H. R. Smithard, J. A, Stirling, and John Yule. Apologies for absence were received from Drs. ~ . G. Clark, F. Hall, R. H. H. Jolly, Mr. A. Gordon Taylor, L.D.S., and Dr. H. C. Mauriee Williams. Ohairman.--In the absence of the Chairman of the Committee, it was unanimously resolved that the President (Dr. J. M. Gibson) take the chair. Dr. Gibson took the chair accordingly. 117. Mlnutes.--The minutes of the meeting of the Committee held on Friday, January 19th, were confirmed and signed. (PUBLIC HEALTH, March, pages 109-111.) 118. T h e report of the Committee on the Functions of the Medical Officer of Health on the observations forwarded by Branches and Groups was considered and it was finally resolved that the following statement be forwarded to the Public Health Committee of the B.M.A. : T h e Council of the Society was glad to receive the invitation of the Public Health Committee, British Medical Association, to convey the views of the Society on the question of the amendment of the l~resent National Health Service Acts, and of Regulations and Orders made thereunder. The Society is of opinion that a major reorganisation is essential in order to provide unified administration of all Health Services (including Hospitals and General Medical Services) under representative bodies predominantly elected by popular franchise. The Society in its reports of 1942 and 1944 advised : - (l) That there should be established a Central Government Department with health as its sole function and with a Cabinet Minister as its responsible head ; and (2) That in local areas there should be a single authority for health purposes. The Society is gratified that recently the principle expressed in (1) above has been put intc~ operation by the Government,

200 except that the new Minister of Health is not a member of the Cabinet. The principle, however, stated in (2) above has not yet been accepted, and locally the Act is administered throughout England and Wales by some 36 Boards of Governors, 14 Regional Hospital Boards, 374 Hospital Management Committees, t45 Local Executive Councils and 145 Local Health Authorities, or some 694 authorities in all. Other health functions in connection with control of infectious disease and environmental matters are also carried out by 1,489 local sanitary authorities (including the 88 county boroughs already included amongst Local Health Authorities above). T h e School Health Service is conducted by 14,5 Local Education Authorities, the sarae as the Local Health Authorities above, and some 147 excepted districts for education, under the Education Act, 1944. These bodies have all their separate functions and no cleaHy defined methods of co-operation exist in this unwieldy local administration. The Society is of opinion that the earliest possible opportunity should be taken to reduce drastically the number of organisations involved locally in the administration of the Act, having in mind that in each area there should be only one body responsible for all health purposes. In no other way will the Act become an effective instrument for the improvement of the physical and mental health of the people and for the prevention and treatment of illness. The Act has now been in operation for more than two and a half years and its unsatisfactory character is illustrated in connection with the following services. Maternity $erviccs.--The responsibility for these services is divided between Hospital Authorities, Local Health Authorities and General Medical Practitioners under the Local Executive Councils. There is no one authority which can determine the need of the expectant mother as to the appropriate arrangements to be made for her antenatal care, confinement or postnatal care, i.e., as between local authorities' clinics, hospitals, home and convalescence, having regard to the medical and social considerations involved. Infectious DBeases.--These diseases h a v e to be considered as much, if not more, from the preventive as from the curative standpoint. The separation of the L.H.A. from the hospitalisation of such cases is unsatisfactory and does not enable the optimum use to be made of the available beds either for prevention or cure. Tubercul0sis,--Here again as much, if not more, importance is attached to the prevention as to the cure of the disease. The after-care of the tuberculous patient is also a matter of concern both to the patient and the community. As matters stand, the general practitioner, the chest physician and the medical offÉcer of health have each separate functions in regard to a case at different periods of its progress. The need for absolute coordination of these functions under a single administration is imperative if rapid progress towards the elimination of the disease is to be achieved. Child H e a l t h . - - I n respect of the care of children, general practitioners, local health authorities, local education authorities and hospital authorities are all concerned. Many children come under all of these but there is no established linking up and no single complete medical history of every child. At an age when habits are being formed and prevention and cure can be effectively practised complete integration of the health functions of of these authorities is essential in the interests of the child. The Chronic Sick and the l n f l r m . - - I n this field there is divided responsibility with many border-line cases between the two classes and cases which at one period of this progress are hospital cases and at another home cases. The various authorities with responsibilities for these types of cases are the Hospital Authorities, the Local Health and Sanitary Authorities, General Medical Practitioners and the National Assistance Board. There is an urgent need to bring the functions of the first four of these under a single authority so that appropriate provision may be made at the appropriate time for the cases under discussion. Incidentally, a single authority would be able to integrate the best use of nursing resources between home and hospital. The Care of the Mental Defective.--The Regional Hospital Boards are now responsible for providing institutional care of the mental defective (in hospital and hostels); the Local Health Authorities are responsible for the care of the mental defective in the community by occupation centres, home teaching, home visiting, and guardianship. This distinction is quite unreal and the separation if administration makes it difficult, if not impossible, to provide a satisfactory service. Measures might be suggested for better co-ordination of such foregoing divided services but they would only be palliative and still further increase the already complicated machinery for the administration of the Act. In all these circumstances the Society again pleads for a reform of the Act with a view to

PUBLIC ttEAI.TH, July, 1951 establishing areas suitable for health administration, generally smaller than the areas of Regional Hospital Boards and larger than the areas of Hospital Management Committees, so that there shall be a unified Health Service in each area under a single authority. Pending this reorganisation, which would involve major changes of the N.H.S. and other Acts and of Local Government functions, we commend the following suggestions on which might be based 'amendments designed to get better working of the National Health Service : - (1) N.H.S.A., S. 20.--Lays upon Local Health Authorities the obligation to submit their proposals for carrying out their functions under Part III of the Act to the Minister for prior approval and at the same time to send copies to Regional Hospital Boards, Boards of Governors, Executive Councils and voluntary bodies which may be concerned. The Society recommends that a parallel obligation should be placed on R.H.B.s, B.G.s, and L.E.C.s to inform L.H.A.s and I..S.A. of proposals for developments in their parts of the Service. (2) N.H.S.A., S. 22 and 23--Maternity Services.--The selection of cases for admission to maternity beds in hospitals and institutions, on all but obstetrical grounds, should be made by the L.H.A. in consultation with the G.P.s concerned. (3) N.H.S.A., S. 24 and 28--Tuberculosis.--The Chest Clinic Service and Mass Radiography Units should be with the Local Health Authorities, in order that all domiciliary, preventive and after-care services and contact tracing should be under unified control. T h e M.O.H. should have, through the tuberculous officer or chest physician, power of admission of cases in the interest of spread of infection. T h e chest physician should have for the whole of his work the terms and conditions of services accorded to hospital medical staff. (4) School Ophthabnic Service.--The Council recommends that the Local Education Authority should be appointed agent for the R.H.B. for the purpose of arranging for the R.H.B. for the purpose of arranging the ophthahnic service for school children in its area. (5) Exchange of Information.--The exchange of information between the various branches of the Service should be uniform and laid down by regulation or as an amendment of the Act. APPENDIX B HYGIENE IN HOTEL KITCHENS Interview with A.A. On March 2lst tile Chairman of Council and the Executive Secretary had an interview with Mr. Headley, Assistant Secretary of the Automobile Association, and Mr. Cann-Evans, head of the travel branch of the A.A. and Chairman of the Joint Committee of A.A., R.A.C., and Royal Scottish A.C., dealing with the classification of hotels included in their publications. Sir Allen stated the position regarding the increased incidence of food poisonings and the concern which this was causing amongst those connected with the public health. He further pointed out ,that a high standard of hygiene in hotels was a matter of national concern as it affected tourists from foreign countries, and that the British Tourist and ttolidays Board were in sympathy with any move to effect improvement. The A.A. and other motoring organisations, representing, as they did, more than a million membe÷s, could bring considerable influence to bear on hotels through their system of selection and classification of those applying for inclusion. There was an impression amongst medical officers of health that the A.A.'s surveyors did not pay the same attention to the kitchens and food preparation and storage arrangements as they did to the public rooms when considering applications from hotels for appointment to the A.A. and R.A.C. lists. The A.A. officers, whilst expressing full agreement with the desirability of raising hotel standards, questioned the ability of their organisations to tackle this aspect. They stated that their surveyors were told to visit the kitchens and staff accommodation of hotels in judging the question of inclusion, but that they could only use reasonable discretion and were liable to strong protests from hotels which thought that their applications had been unjustifiably refused. Their starring system was an indication not of quality but only of type of hotel~ Sir Allen urged that the A.A. and R.A.C. had a strong responsibility in including hotels in their lists, as this amounted to a guarantee to their members of their quality. Members could judge for themselves the accuracy of the starring system so far as the public rooms, bedrooms, etc., were concerned, but they could not see behind the scenes, the kitchens, sculleries and store-rooms, and had to rely entirely on the inspection made by