Liaison between local authorities and regional hospital boards

PUBLIC HEALTH, August, 1949

229

from tsetse and the human sleeping sickness which ~ a s very serious there had ceased to exist. Moreover, the general conditions of the natives there were much improved and he showed that this experiment in human settlement could be repeated from the public health point of view in other parts of Africa.

(To be continued in our next issue)

CORRESPONDENCE ICE-CREAM : REGISTRATION

To the Editor of PUBLIC HEALTU Sm,--In these enlightened days of preventive medicine it is reasonable to assume that innumerable Public Health Laws, Regulations and Statutory Instruments are more than sufficient to protect the public from the possibility of food-borne invasion of disease. Recent experience in this district indicates that this might not always be so. A person applied for registration of his premises for the sale and storage of ice-cream. There was technical compliance with regulations and no reason existed for refusing registration, except that the applicant was an open tuberculosis case. I advised against .registration but the Senior Health Inspector asserted (and rightly) that the registration attached to prenfises and not to the person and could not be refused on ~these grounds. A letter to the Ministry of Food brought a non-committal reply and referred to abstruse points under the Tuberculosis Regulations and Food and Drugs Act, none of which quite answered my point, which was whether any power existed to prevent an open tuberculous case handling ice-cream. Subsequently the Secretary of the Society of Medical Officers of Health took the matter up with the Ministry of Food and in a letter from the Ministry to the Society (May 19th, 1949)--copy of which was sent to m e - - I was more than interested to learn that " Parliament was quite clear that tuberculosis is so common in this country and the risks of infection are often so obscure that it ~aas limited the powers given to officials to restrict the freedom of patients." I showed my correspondence on this matter to Dr. K. E. Cooper, Director of Laboratories, University of Bristol, and he sent me his observations, extracts of which 1 have his permission to r e p r o d u c e : ~ " . . . It seems to me obvious that droplet infection of icecream from an open case of tuberculosis would so materially increase the danger of transferring infection to persons consuming it, as to be a risk that no person with medical knowledge could take . . . . we are not concerned with isolating tuberculosis patients, but with preventing contamination of food and icecream by bacteriologically positive tuberculous sputum and droplets. Just over half the cervical and abdominal gland infections in humans are not of bovine origin, which suggests to me a considerable incidence of oral and alimentary infection by swallowing food and drink infected bv droplet infection from human open cases. The actual numl~er of deaths so caused must be of the same order as the deaths due to bovine infection-estimated at 1,500 to 2,000 per year. " I t seems to me evident that whatever the present legal position, it would be criminal negligence to allow known open cases to infect food for public consumption. I should therefore take the line that premises in which a known open tuberculous case remains are infected premises, and that until the person leaves them, and they have been disinfected, they are not suitable for registration for the sale of ice-cream. Whether this is practicable from the legal point of view I have no authority to state, but if it is not so, I think it should be made so with the greatest possible speed." I have raised this matter, not in any carping spirit, but as a point of public health importance. The local difficulty has temporarily been resolved by the patient agreeing not to pursue his application, but this is a mere expedient which does not get at the root of the matter. Has any colleague had a similar experience in his district and if so how did he deal with it ? Yours faithfully, J. MENZIES CORMACK, Medical Officer o[ Health. South Gloucestershire (M.O.H.) Joint Committee, Council Offices, Kingswood, Bristol. August 4th, 1949.

SALARIES

OF P U B L I C

HEALTH

MEDICAL

OFFICERS

As we go to press we learn that the following letter dated July 29th has been sent to the Ministry of Health by the Associations of I.ocal Authorities : Representatives of the English and Scottish Associations of Local Authorities met on Tuesday to consider your letter of July 9th and the problem of negotiating machinery for medical practitioners. As a result, I am instructed to say, on behalf of the Association of Municipal Corporations, the Urban District Councils Association, the London County Council, the Association of Education Committees, the Association of C6unty Councils in Scotland, the Counties of Cities Association and the County Councils Association that, whilst a majority of these bodies would prefer the establishment of separate negotiating machinery outside the National Health Service Whitley Councils, all of them, except the Scottish Associations, are nevertheless prepared to participate in the proposed Medical Functional Council provided that its constitution is so drawn and agreed as to provide for the remuneration and conditions of service of medical practitioners employed by or in contract with local authorities being decided finally by a separate committee without need for confirmation by, but subject to report to, the Functional Council. The Scottish representatives were not authorised to commit their Association, but they are recommending participation. It is, of course, assumed that the embargo imposed by the British Medical Association upon advertisements will be removed forthwith. A copy of this letter has been sent to the British Medical Asssociation. The B.M.A. on the same day notified all local authorities that advertisements for vacancies in the public health service will at once be accepted provided that the salaries offered are in accordance with the Modification of the Interim Revision of the Askwith Memorandum and that there is no discrimination between males and females in the matter of bonus. They have requested the Ministry to convene a meeting to arrange the constitution of the Medical Functional Cc,uncil not later than mid-September. LIAISON T h e Scottish

BETWEEN LOCAL AUTHORITIES REGIONAL HOSPITAL BOARDS

AND

VCesterrL Regional B o a r d ' s S c h e m e

In the many discussions which have taken place on the questions of co-ordination of the work of Local Health Authorities and Regional Hospital Boards, frequent references have been made to the success of the arrangements made in the Western Region of Scotland, where Sir Alexander Macgregor, formerly M.O.H. Glasgow, is the chairman. It is thought, therefore, that it would be of general interest to give some details of the arrangements in that Region which, although they were introduced on the appointed day of 1948 as an interim measure, have worked so smoothly that they are being continued indefinitely, but subject to modification. On May 5th, 1948, the Scottish Western R.H.B. sent a circular letter to the local authorities in the region in which they said that it was essential to agree at once a scheme for the organisation to be established before July 5th in order that the continuity of services might be assured; the services of special concern were the tuberculosis, maternity and ante-natal, and infectious diseases services. The letter stated that the purpose was to secure (i) liaison between the M.O.H. and the named medical officers who would be transferred to the R.H.B.'s service; (ii) joint or agency arrangements for use by the R.H.B. and medical officers in the service of the local authority; and reciprocal arrangements where desired for the use of the officers of the Board by the local authority; (iii) the joint use of clinic premises where these were physically indivisible into separate L.H.A. and R.H.B. accommodation. The Board's letter continued by suggesting that co-ordinatlon should be effected by continuing admissions to hospital as heretofore; by transferred M.O.s co-ordinatlng specialist services in association with the M.O.H., and so on. The more detailed proposals enclosed with the letter summarised the problem of organisation as fdlcws :-(a) It is vital that a clear and simple .link be established between the medical officers of health of the county and burgh areas, and the boards of management operating within that territory ; (b) To achieve this, the services to be transferred must be equipped with recognised officers who deal with (i) administration, (ii) clinical duties, and (iii) admission responsibilities, or a combination, as existing practice renders expedient for the transition period, of all or part of these duties. These officers, in their respective spheres, will form the liaison points with the medical officers of health.

230 (c) Iu some cases, these officers will be transferable, and they present but little difficulty; in other cases, it will be necessary to enter into agency arrangements with local authorities for a joint use of their officers, until a more permanent basis is established ; (d) In either case, to bring the whole problem under control, it is advisable to identify, on the medical as on the administrative side, those individuals to whom, by virtue of their interim status, there will be delegated--and decentralised~the recognised duty of considering, recommending upon, and ultimately ensuring that all levels of their work can, and do, cover the three main functions mentioned in (b) above. The range of these functions would be determined, area by area, and embodied in specific letters of instructions. (e) The desired arrangements should be proposed at the earliest possible date to the respective local health authorities for their agreement in principle~financial terms to be agreed as a secondary stage. The arrangements so concluded with local health authorities should then be notified to boards of management and to executive councils. These arrangements will embrace the following points : - (i) Liaison between the M.O.H. and named officers of the board in i'egard to specific functions ; (ii) agency arrangements for the use of the services of an officer of the local authority by the board (or vice versa); (iii) the joint use of clinics where these are physically inseparable. The memorandum put forward as immediate considerations: (i) to identify the key man in each function in each area: (ii) to obtain the earliest use of his services on a part-time or interim basis by approach to his employing authority as soon as practicable. The attached schedule suggested the arrangements required in the various counties. Finally the memorandum defined the following terms which had been used in respect of each service in order to arrive at a common pattern in each area : - (a) Tuberculosis : " A r e a supervising tuberculosis physician." Responsible for the supervision of the whole T.B. service in the area, including clinics, for liaison with medical officers of health in accordance with Part 11I Schemes, and for the arrangements for admission to hospitals. (b) Maternity: "Chief obstetrician." Responsible for the hospitals and specialist clinics of the maternity services in the area, in consultation with medical officers of health in accordance with Part III Schemes, and also for arrangements for admission to hospitals. Where no chief obstetrician is available, the senior obstetrician, or obstetrician, in the group will act for his board of management. (c) Infectious Diseases: " A r e a or district medical superintendent." Responsible for the general administration of the I.D. hospitals throughout the area (or district) in collaboration with the local medical superintendents and for ensuring the clinical arrangements at each hospital through resident or visiting medical officers, for concerting arrangements for admission through medical officers of health, and for V.D. clinics. Sr~eoial Arrangement for Glasgow The largest aggregate of population within the West Regional Board's area is, of course, the City of Glasgow, and here it was felt important that the Medical Officer of Health (Dr. Stuart Laidlaw) should continue to co-ordinate admissions to hospitals direct with the medical superintendents of the various fever hospitals and that the Chief Maternity and Child Welfare Officer (Dr. Nora Wattle) should similarly make direct arrangements for maternity admissions with the six or seven maternity units in Glasgow. In the case of these two officers therefore they were given a special title and rank with the Regional Hospital Board of Administrative Co-ordinating Officer. This does not carry any remuneration from the Board but it gives the necessary administrative authority under the direction of Dr. Bowman, the Senior Administrative Officer of the Board. In other parts of the Region obstetric consultants at the main maternity institutions have been nominated as chief obstetricians for maternity cases and with regard to infectious diseases county n~edicaI officers of health have been nominated area medical superintendents, with the district and borough M.O.H.s or the medical superintendents of isolation hospitals nominated as district medical superintendents, sometimes with local medical superintendents also. For instance, in the case of the district in which Hairmyres Hospital is situated, Dr. James Johnstone, the Medical Superintendent, is the nominated District Medical Superintendent and the Local Medical Superintendents are Dr. R. Cordiner (M.O.H., Coatbridge Burgh), Dr. R. J. Lumsden (M.O.H., Airdrie Burgh) and Dr. R. S. Dewar (A.M.O.H., Lanark County).

PUBLIC HEALTH, August, 1949 A COMMITTEE ON HOSPITAL ADMINISTRATION The Central Health Services Council has appointed a committee : (1) to review the organisation of the hospital services under the National Health Service Act, 1946, but not matters concerning the administration of individual hospitals, and to make reconamendations; (2) to frame detailed terms of reference for a committee on the administration of individual hospitals. The members a r e : F. Messer, Esq., C.B.E, j.l'., M.P. (Chairman); Sir Harold Wernher, G.c.v.o., T.D. (Vice-Chairman); E. C. F. Bird, Esq.; Alderman Bradbeer; F. J. Cable, Esq., F.H.A., Sir Allen Daley, :M.D., F.1t.C.P., K.H.P. ; S. C. Fryers, Esq., c.8.E., F.H.^. ; Hon. A. J. P. Howard, c.v.o., M.P.; R. A. Mickelwright, Esq., F.H.A. ; Sir Owen Morshead, 6.c.v.o., D.S.O., M.C., and Dr. W. G. Patterson, ~t.o., M.R.C.P.~ D.P.tI. The joint secretaries are Mr. E. J. S. Clarke and Mr. E. W. Bryant of the Ministry of Health.

B.C.G. VACCINATION The Ministry of Health announced on June 24th that arrangements for introducing B.C.G. vaccination against tuberculosis in this country have been made by the Minister of Health and the Secretary of State for Scotland, and it is hoped to make a start shortly. It has been thought advisable, since B.C.G. has yet to be put to the test of experience under conditions native to this country, to keep the scheme within defined and suitably controlled limits. One part of the scheme will be to offer B.C.G. vaccination to all hospital nursing staffs and medical students as a form of inoculation, among others, to which their professional prudence may dispose them: the other part will be to make the vaccine available to chest physicians or other appropriate specialists, e.g., paediatricians, who may wish to use the vaccine on their individual responsibility in suitable eases such as family contacts of tuberculous persons. The medical advisers of the Ministers consider it necessary, at this stage at least, that this form of vaccination should be the responsibility of physicians with specialised knowledge and experience of tuberculosis. It will consequently not be possible for it to be obtained by anyone going to his own doctor for it, though a doctor who may consider it advisable for a particular person wilt, of course, be able to refer that person to a chest physician. The arrangements for giving B.C.G. to hospital nurses and medical students who voluntarily elect to be vaccinated will be made through the responsible hospital bodies, or the authorities of medi~ cal schools, as the case may be, with whom the Departments will communicate ~bout this part of the scheme. It will be a considerable task to plan and carry out these arrangements throughout the country, and it may take a long time to cover all areas : but within the limits of the medical resources available for the work every effort will be made to press on with it as quickly as possible. Concerning the part of the scheme about individual vaccinations by. chest physicians within their own discretion, these physicians will for the most part be among those engaged in joint service to regional hospital boards and local health authorities (as regards diagnosis and treatment of tuberculosis, on the one hand, and prevention and after-care, on the other). Where a chest physician in this category undertakes B.C.G. vaccination he wilt need to do so in the capacity of his local health authority service and in association with the authority's medical officer of health, since it will come within the scope of the authority's responsibility for the prevention of tuberculosis under Part I I I (Section 28) of the National Health Service Act. A circular will be sent to local health authorities regarding the procedure to be followed to enable B.C.G. vaccinations to be undertaken, within the limitations of this part of the scheme, through chest physicians. Supplies of B.C.G. are to be obtained from the Serum Institute, Copenhagen, from which they will be ordered by the Ministry of Health (or Department of Health for Scotland) and consigned by air weekly. The arrangements for ordering, receiving and distributing the vaccine will be centralised in this way because it must be used with the least possible delay after it leaves the laboratory. Instructions will be made available about the procedure that will need to be dosely observed in applying to the Departments in advance for a specific quantity of the vaccine, as required, for delivery at a stated address for use on a given date. The Departments have had an exposition prepared by experts regarding the principles and technique of B.C.G. vaccination for the assistance of physicians undertaking it. Here it need only be said that it is advisable to vaccinate only such persons who do not react to tuberculin; anti that the strength of the B.C.G. to be obtained from Copenhagen is suitable only for intradermal use. It is proposed to provide standard forms for record purposes regarding B.C.G. vaccinations: and certain arrangements are in view for a long-term investigation to help in assessing the value of B.C.G. under conditions in this country.