THE TUBERCULOSIS SERVICE

823

Special

ment of action taken to reduce the rate of expenditure if necessary. (ii) The board is to examine the statements sent to them

Articles

HOSPITAL EXPENDITURE NEW CHECKS AND CONTROLS

THE Minister of Health has addressed to hospital authorities the following memorandam on their

expenditure : As will be known from statements made in the House of Commons and elsewhere, the Government is deeply concerned at the rapid increase in expenditure Service in relation to the on the National Health national economy as a whole. In 1950-51 the estimated gross expenditure of hospital boards at .8214 million is 45 % above the level of actual expenditure in 1948-49 ; of this total .836-2 million represents expenditure by the boards of governors of teaching hospitals-a rise of 46 % on 1948-49. It is fully realised that the rise in expenditure is due to many factors, some outside the control of boards and committees themselves, and is in no sense a reflection of extravagance or waste on the part of hospital authorities. Essential increases have been made in nursing and other staff salaries ; the level of remuneration of medical and dental staff has been fixed for the first time on a national basis; costs of some consumable goods have risen ; essential improvements have been made in hospital standards and long-standing arrears in maintenance have been met; unstaffed beds have been reopened as the recruitment of nurses and domestics has improved. All these steps have been not only justifiable but unavoidable if a proper service was to be provided. , It is, however, the considered view of the Government that expenditure has now reached a level which must not be exceeded. Consequently, boards and committees must regard their estimates for 195J-51, so far as they are approved by the Minister or the regional board as the case may be, as their final totals of expenditure for the year-which will not be supplemented. Boards and committees should from the outset conduct their administration on the basis that all maintenance costs

during arising staff increases,

the year,

including

all

improvements,

rises in costs of consumable goods, &c., must be met within their approved estimates and that no supplementary estimate will be available ; similarly, all capital expenditure required must be met within the approved capital estimate. This clearly requires that a careful and prudent view should be taken of the possibility of improvements or developments during the year, and that no commitment should be entered into which cannot plainly be met without exceeding the estimate for the sub-heads of expenditure affected. RUNNING CHECK ON EXPENDITURE

It

has

therefore

been

decided

that

the

following procedure should be adopted : Hospital Management Committees (i) A monthly statement is to be prepared by

each manageafter the end of each month, showing under each sub-head used for approval purposes (Regulation 9 of the Hospital Accounts and Financial Provisions Regulations, 1948,-S.I. 1948, no. 1414) : (a) the total of cash payments made and bills incurred but not yet paid during the preceding month, and the cumulative total up to the end of that month, together with comparable figures of the estimates themselves ; (b) a statement of any commitments entered into under each sub-head which may lad to the estimate under that sub-head being exceeded. (ii) This statement is to be sent to the regional hospital board as soon as possible after the end of each month, with any comments the management committee may wish to make, and a copy of the statement simultaneously sent to the ment committee

as soon as

possible

Minister.

Regaonal Hospital Boards (i) A monthly statement covering

appears that there is a danger of exceeding the approved estimate and on the steps taken to prevent this happening.

Boards of Governors A monthly statement is to be prepared by each board on the same lines as that prepared by management committees and sent direct to the Minister ... as soon as possible after the end of each month, together with a report in any case where it appears that there is a danger of exceeding the approved estimate stating the action taken to prevent this ’

happening. On receipt

of the above reports from regional boards and boards of governors (or in any other case where action appears to him necessary) the Minister will, if necessary, arrange for immediate inquiries by his officers to determine whether any further steps should be taken. -

LIAISON

WITH THE DEPARTMENT

It will clearly assist both the Minister and boards and committees in keeping a close watch on expenditure if the Minister is in constant touch with the work of boards and committees as it proceeds. It has therefore been decided that for liaison purposes arrangements should be made for the principal regional officers of the Ministry, or their deputies, to be kept informed of the proceedings of boards and committees by receiving regularly copies of the agenda, papers, and minutes of all meetings of regional boards, boards of governors and, hospital management committees (but not of committees or subcommittees unless they ask for these), and by attending such meetings as appears to them desirable. Accordingly, boards and committees are asked to arrange for the above documents for all their meetings held after the date of this memorandum to be sent to the officers indicated in the appendix.

THE TUBERCULOSIS

SERVICE

Six people recently died of smallpox in Glasgow, and considerable discussion has gone on about it since ; in the same month 100 people in Glasgow died of tuberculosis, and probably about 1000 contracted it in the Dr. HORACE same time-without exciting any remark.

JOULES, speaking

on

April 2,

at

a

conference arranged

the Socialist Medical Association, used this example to illustrate our habitual neglect of the tuberculosis problem. The meeting ’was composed largelyof delegates from trade unions and other organisations, and the chair was taken by Mr. SoMERViLLE HASTiNCxs,

by

If expenditure is to be kept within the estimate a -close and continuous watch must be kept on it, and immediate steps taken at the first sign of possible over-

spending.

by management committees each month, make such inquiries give such direction as may be necessary to reduce the rate of expenditure, and within 14 days of the receipt of each statement report to the Minister on any case in which it and

the board’s own expenditure is to be prepared and sent to the Minister ... as soon as possible after the end of each month, together with a state-

F.R.C.S.,

M.P.

Dr. JOULES insisted, as many have done lately, that the general and teaching hospitals are not playing their full part in providing treatment for tuberculous patients. It is a point of honour with such hospitals, he said, to admit every treatable case of cancer within a week ; but they have no beds for patients with early and treatable tuberculosis, whose risk to life may be just as serious and urgent. He believes that these hospitals should set aside 10% of their beds for tuberculous cases, but he is not for compelling them to do so : we should try persuasion first, and we must not be put off, he said, by arguments about the balance of teaching for medical students. There can be no more urgent or important study than tuberculosis for the medical student or the student nurse ; and at present they are Of course, they not taught and inspired about it. must be protected : patients with tuberculosis must be transferred to a special ward, and nursed only by those who have a resistance to the infection ; and nurses and students must be taught proper precautions. These

824 the measures taken in the Central Middlesex Hospital, of which he is medical superintendent ; and he hopes to be able to show that there is no greater incidence of tuberculosis among the nurses in his general wards than among girls in the general population. He warns prospective nurses and their parents that they will be expected to nurse tuberculosis, and has never found this to have a detrimental eff( ct on recruitment. Sanatoria, however, are hard put to it to get nurses. He mentioned a tuberculosis hospital of 760 beds in the Metropolitan area : half the beds are closed, and to staff the remainder the -hospital has only a third the number of trained nurses and a seventh’the number of students, per 100 beds, to be found in any major general hospital. These general hospitals, so lavishly staffed in comparison, should not have the right to second to sanatoria patients whom they will not nurse themselves. Dr. C. H. C. TOUSSAINT, chest physician to the Central Middlesex Hospital, noted that the incidence of tuberculosis among nurses there is far lower than that in any hospital investigated by the Prophit survey. He described three typical cases to show the advantages of combined hospital and domiciliary treatment : all were early cases in young people, all were admitted the day after he first saw them, all were sputum-negative within 2-3 months, and all went home for continued bed rest after a few weeks in hospital. Two are back in full work, less than a year after the onset, and the third-a boy of 15-was admitted with pneumonic tuberculosis last December and sent home sputumnegative and with a rising weight two months later. These case-histories reinforced a remark of Dr. Joules that treatment combined with a short term of treatment has already got scores back to work in 6-9 months. are

provide them, but little has yet been done. Patients in the Metropolitan area are particularly badly off : before the National Health Service began the London authorities could hire beds in sanatoria outside their area, but these beds are now controlled by the regional hospital boards, who naturally think first of their own patients. Mr. J. ROBERTSON suggested that Glasgow is the blackest spot in this black problem, and Dr. S. LEFF gave some figures bearing this out. Three people die of tuberculosis in Glasgow for every one in Aberdeen; and three die in the Gorbals and Govan districts of Glasgow for every one in Cathcart and Langside. He noted how closely the high mortality-rate is associated with the shocking housing conditions in that city, where 30,000 are homeless and another 30,000 living in overcrowded homes. DIFFICULTIES

The association of bad housing with tuberculosis was and again throughout the meeting. Indeed, Dr. C. K. CULLEN felt that domiciliary treatment is often out of the question for this very reason. How can a housewife rest at home in bed There may be no room which can be given up to her without disorganising the whole home, and it may be impossible to board out the children, or they may write unhappy letters asking to come home. He considers we are wasting money on tuberculosis because we are using half measures : we would save money in the long run by doubling what we spend now. He urged those present to collect statistics in their own areas, to call conferences under the 2egis of trade councils, and to send resolutions to every interested party they could think of, not forgetting the Minister of Health. Miss L. J. GROUT mentioned the difficulty of getting home helps for the tuberculous ; and she described the VARIOUS EXPERIENCE increasing poverty into which the family falls when the earning member is at home with a long illness. In the But the service is uneven. These patients may be contrasted with the wife and a friend of another speaker past, treatment allowances could be officially suppleat the meeting, Mr. L. C. JINKS. His wife, diagnosed mented ; but under the National Health Service the actual sums received are sometimes lower than those as an early case 6 months ago, has been told that she which were available before the Act was passed. The has another 3 months to wait for a sanatorium bed. The result is that after some months the family is apt to friend was referred for major surgical treatment to a be going short of food-just the opposite of what is thoracic unit, and has already been waiting 12 months. needed if they are to resist infection. Other speakers mentioned similar failures. Dr. A. Mr. C. M. HAWKIN, a member of a hospital manageELLIOT described himself as coming from a backward He sent a barmaid with haemoptysis to the chest ment committee, and twenty years a mental nurse, area. clinic, and after she had been obliged to queue for some spoke of the great danger of infection spreading among time in the rain, she was radiographed and later told mental-hospital patients. He wished to see tuberculosis tackled " with the ferocity of D-day." she was not an active case ; 18 months afterwards her Miss ELEANOR BAXHAM, an ex-patient, paid great disease was found to be active, and she was told to go to the sanatoria and nurses, and to those who had tribute home to bed for 9 months. She lived in lodgings, and ensured that she should have extra milk. Tuberculosis, could not go to bed ; and there were children in the house. Moreover, the tuberculosis officer said he did not believe she said, has been neglected by the public, the Governin domiciliary treatment. None of the voluntary ment, and the trade unions-the fault is not in the service itself. Another patient, Mr. C. BENSTED, came bodies approached by Dr. Elliot could help, and finally, " from Papworth, and spoke enthusiastically of the as he said, he kicked up a row with the tuberculosis officer " and she got a bed in a week. Dr. DAVID KERR, importance of reablement, and of training the patient for a proper trade. on the other hand, reported that they have a good tuberculosis clinic in -his area, but that it is used for ACTION maternity and child welfare the day after the clinic is held. He too had stories of people waiting for a Many ways of dealing with this social evil were mooted. Mr. JACOBS was clear that the trade-union bed and deteriorating, perhaps beyond hope. Other speakers mentioned poorly equipped clinics lacking movement must try to get to work on it. " If all the X-ray apparatus. Dr. JOULES said that the Ministry Socialist doctors in the House asked questions about it of Health has a large quantity of X-ray apparatus all the time," he said, " all they would get would be available, which can be had on application. Dr. H. answers." He believes that nearly 90% of those who GRUNWALD urged the value of mobile clinics with refuse examination by mass radiography do so because the finding of a lesion means poverty for their family. X-ray equipment. Mr. J. F. RADLEY wanted to see a trade-union advisory Dr. H. L. TRENCHARD spoke of the difficulty of providfor council on tuberculosis set up, and a nation-wide campaign treatment who have no homes. people ing domiciliary He has been asked to let them stay on in hospital and against the disease. A long resolution was passed, calling on the Government to reorganise general-hospital beds go out to work. Hostels and night sanatoria are needed, so that early cases can be treated in general hospitals; to have authorities local he said ; and the powers

domiciliary hospital

emphasised again

825 to provide night sanatoria and hostels for the infectious ; to modernise hospitals and.chest clinics and to build to increase domestic staff to relieve the new ones ; nurses, and to raise the nurses’ pay and improve their conditions of service ; to ensure full pay to the infected health worker until reablement is complete ; to step up the housing programme ; and to give larger allowances to the patient and his family. Dr. LEFF, in summing up, announced that it had been decided to send a deputation from the association to the Ministry, and that three members of the organisations present were to be invited to join ; and that a standing committee of the association was to be set up on tuberculosis, to which the organisations present were also invited to send representatives.

Parliament The Medical Bill IN the House of Lords on April 18 Viscount ADDISON, Lord Privy Seal, moved the second reading of this Medical Bill. It was, he said, an entirely non-party measure and its introduction was welcomed by the General Medical Council. Its main purposes were to improve the standards of medical education, to secure better provision for instruction in the care of patients before a doctor was admitted to full registration, and to deal with the powers and status of the General Medical Council and others in questions affecting discipline. In all professions, he continued, people really began to learn after they had nominally qualified, and this was abundantly true of those who had the care of human beings in real or imaginary sickness. It was therefore proposed that after qualification a doctor should be required to have not less than a year’s practical experience of the care of patients under supervision in a hospital or other approved institution. He was assured that there were more vacancies in house-appointments in England and Wales than there were people qualifying each year. It would be for the General Medical Council to consider what was meant by the term " an approved institution." As it might not be practicable to bring this provision into force everywhere at any one time the G.M.C. would fix the date when it should come into operation. The Bill also provided that the G.M.C. should be able to visit and inspect medical schools and examine their standards of training. Lord Addison felt, however, that there ought not to be too many bodies with power to inspect. Quite properly the universities and the University Grants Committee had the power, and the aim would be that this new power of inspection should be coordinated with the exercise of the same powers by these other bodies. It had been represented for many years past that the constitution of the G.M.C. might be improved, and under this Bill the number of members of the council would be increased from 39 to 45. There would be a specially appointed disciplinary committee which, apart from the chairman, would have only 19 members, of whom substantially a third would be medical men who had been elected by their fellows. A medical man struck off the register would in future have an opportunity to appeal to the Judicial Committee of the Privy Council. The fee for interim provisional registration would remain at 5 guineas as at present, but when the final interim period was finished and a man or woman was added to the register, the fee would be increased to 11 guineas. The statutory description of the body, instead of being the General Council of Medical Education and Registration of the United Kingdom, would in future be simply the General Medical Council-the title under which it had been generally known for many years

past. Lord HoRDBB admitted that he had been a severe unrepentant critic of the Government during the last two or three years, but he supported this Bill. He believed that the first five clauses, if properly administered, would add considerably to the efficiency of and

doctoring and general practice in Britain. The Bill did improve the conditions of doctoring, but it gave the doctor the best chance of being efficient. Immediately after qualification, and synchronously with registration, the young doctor went out into practice ill fitted in the sense of responsibility and judgment (which was born only of experience) and the ability to declare the inherent principle which was in him. If properly administered the present Bill could do much to remedy this. But several points called for careful consideration. Was it clear that this additional year was to be added to the present 5-6 years of the ordinary curriculum ? The position should be safeguarded, so that the present curriculum was not modified to make this desirable twelve months part of the 5-year or 6-year period. Again, what was to be the status of the qualified but only provisionally registered doctor ? Lord Horder suggested that the provisional registration should entitle the newly qualified doctor to full responsibility and privileges within the terms of his appointment, such as were accorded to registered medical practitioners in general. For example, would he be legally entitled to prescribe dangerojs drugs ? Might he sign death certificates or certify as to insanity ? Should his remuneration be the same as the present rates for not

Lord Horder did not feel certain that there were enough suitable hospital appointments available for these provisionally registered docto s. He thought that any approved hospital should be able to provide a minimum of 20 beds or an equivalent number If there were not sufficient of these of outpatients. institutional posts he suggested that some of these people should be accredited to recognised approved groups of practitioners. This might be an incentive to get on with the health centres so as to provide some The venue in which these young people could work. idolatry of the hospital had gone rather far. These young men and women were ultimately going to be The object was to faced with domiciliary practice. make them more efficient doctors, not to feed their already avid desire to leave the ranks of general practice and become specialists. In the wording of the Bill, Lord Horder further thought the medical and surgical spheres could be so expanded as to include specialties, such as diseases of children, diseases of the eye, diseases of the skin, and obstetric practice. Special hospitals where these important subjects were taught would be an admirable field in which to place a number of the provisionally registered men and women. Turning to the second part of the Bill, Lord Horder pleaded for fuller direct representation. If you wanted to keep order in a house you should give some power to the master of the house. If the penal cases committee, which was a sifting committee, was to continue he hoped it would have a different personnel from the disciplinary committee who had the final say in matters brought before them. He understood that, though not bound to do so under the Medical Act of 1858, the G.M.C did arrange for " due inquiry " when a doctor had been convicted of felony or misdemeanour. As he read the present Bill it would be possible for the council to erase a doctor’s name e in these circumstances without a formal inquiry. He was informed by the defence bodies of the medical profession, who handled 90 % of the cases on the doctors’ behalf, that they considered it would be undesirable that there should be no formal inquiry, or that the habit of making an inquiry should be dropped. They strongly contended that section 20 should be amended to provide for due inquiry to take place in all cases. Lord AMULREE believed that if medical students were encouraged to spend part of the year with an approved panel of general practitioners it would make many of them more willing to go into general practice. Such a scheme would also improve the status of the general

house-appointments ?

practitioner. Lord WESS-JoHrrsorr regretted that the first two clauses of the Bill had been drawn so rigidly. A period of 12 months might prove not to be practicable. If the G.M.C. were not so rigidly bound the reforms which they all heartily desired could be introduced at an earlier date. In the case of a practitioner or qualified man in the Commonwealth or from a foreign country, the G.M.C. were empowered to accept that he had " otherwise acquired such experience." The same provision