Whither tuberculosis?

Jun.e 1950

137

Correspondence W h i t h e r Tuberculosis ? The l'ditor - 'Tubercle'. S m , - A senior m e m b e r of the Tul)erculosis Service was travelling down?t0 Cardiff. Meeting the Minister of Health lad was invited into the latter's carriage. 'Well, now, tell me, what is the present state of tuberculosis:as the result of m y health act?' ' - - - - a w f u l ' \vas the terse reply. H o w far is this really t.rue? Have we, on balance, better results in prevention and treatment than prevailed under the previous local attthority control and direction? T h e act has broken up the old umwv of prevention and treatment. This is its most serious effect. T h e .best pre-act schemes were founded on preventive lines or at least preyention and treatment were on an equal footing. It was a question of .en~phasis or direction. T h e tu!~erculosis problem should revolve round the chest clinic, not the sanatorium. T h e chest" physician requires beds under his own care for patients from his clinic area (Clare Hall, Middlesex, has one of the best of these arrangements) else he is but a sham consuhant. To acquire experience in general medicine and special training in chest diseases needs a long experiencein a chest clinic where the family is the unit. A training in radiology is also essential. Good chest clinics can provide all this. Adequate experience cannot be acquired by residence only in a sanatorium as medical officer, where there are little or no opportunities for the study of diseases other than tuberculosis, and practically none for the study of the normal. T h e other major change is central governmental finance. T h i s makes a much tighter control from Whitehall, a very big change indeed compared with pre-act days when local authorities like Birmingham, Leeds, Manchester, Lancashire, Middlesex, cut a path through the jungle of inertia and got things done. This centralized finance makes the Ministry, in all its sections, of greater importance than before, because the regional hospital boards are more dependent on guidance by the Ministry, than local authorities before the act. There is urgent need of a reorgajaization of the tuberculosis section of the Ministry. Far too long it has been woefully weak. This nattirally links tip with the recent deplorable recommendation of the Ministry and the Treasury for a lower r a t e o f pay for local authority .work d o n e by the c h e s t physician, work mainly preventive. Who except those who live in the remote and rarified attnosphere of Whitehall, could have suggested one rate of payment to ask a patient how he is, and another

rate of payment to ,~sk how his contact wife or child is? T o trace this to its source, we must go back to the lavish and alluring terms offered and acccptcd I?y 'specialists', a decision made without much, if any, thought of specialists in the pulfiie health services. While the terms pacified a section of the medical profession, no proper attention was paid to the grading of different classes of specialists according to responsibilities, so that we have the serious present anomalies of posts carrying similar work or responsibility paid either at S.H.hI.O. rate or consultant rate. But equally strange, and, I submit wrong, is the de-grading as regards pay and therefore status, of administrative work or direction. It is true m a n y clinicians felt in the past that they had a raw deal relative to the administrators. The boot is indeed now on the other foot! But if administration means encouragement, direction, and ultimate responsi: bility for the journey into the unknown, surely it should rank at least equal (I would put .it higher) to clinical work. The present views seem to come ultimately from the Ministry and Treasury, and indicate a general attempt by the lay civil servant to hold all professional experts - medical, legal, engineering - in subjection to the senior lay civil servai~t who joins very young, fresh with a first-class honours degree. Members of the central civil service consider administration ,as an entity in itself which can be taken on in any branch by a 'clever' m a n whether he has any initial knowledge of the particular service or not. I n other words, the central lay civil service imagine they could pick any ,assistant secretary and nbminate him to do the work of the Chief Medical Officer of the Welsh Memorial Association, or that of the old Central Tuberculosis Officer for L a n c a shire! Medical members of the Ministry should resign rather than bow down to such a false idol. What action 9r remedies are calling out for adoption within the iTamework of an unaltered act? (i) Preventive work must rank ag least equal with treatment, and be paid at the game rate. (2) T h e tuberculosis section of the Ministry of Health must be r e o r g a n i z e d - a n d long ago should have been - and staffed b y those who know from experience every aslSect, epidemiology, prevention, treatment, rehabilitation. (3) The Standing Advisory Committee r~eeds strengthening by the addition from different regions of t w o o r three senior chest physicians with university lectalreships.

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(4) The N.W. ~Ietropolitan Region, guided by the capable hand of Dr Macaulay, should be followed in its excellent lead, and similar Tuberculosis Advisor)" Committees should be formed at regional level in each region. It compares with the old I~ancashire "l)3berculosis Committee which, being on equal footing with other committees, w ~ able to get things done. (5) There should be a university post of Professor or meantime a Lecturer in Tuberculosis in each region, as had already been done before the act in Birmingham, C a m b r i d g e , Leeds, M a n c h e s t e r a n d Sheffield. Church Slretton, G. LISSANTCOX.

Satop.

Liverpool Region The Editor - ' T n b e r c l e ' . SIR, - Your comments on the Liverpool Regional Hospital Board's plan for the Tuberculosis Service in your March issue have been noted and it is with gratitude that the Advisory Committee in Tuberculosis learns of the interest that is being taken with regard to the attempts to deal with the situation in this Region. T h e report to which you refer was not meant to be a comprehensive survey concerning the whole of the Tuberculosis situation in the Region, but was intended to indicate the steps to be taken to provide additional hospital accommodation, the steps taken to relieve pressure on the existing limited accommodation and also to outline the proposed staffing arrangements for the filture and, therefore, details of deaths and death-rates were not included. As regards Chest Physicians, the Liverpool Regional Hospital Board are only prepared to designate as such Physicians who have a wide background of general medicine, have ;a higher qualification in general medicine and have SFccialized in chest descascs. A Tuberculosis Officer, merely because of transfer on the Appointed Day, has not necessarily been re-designated as a Chest Physician unlcss he conforms with the foregoing definition. In view of the present discussions and negotiations which are now proceeding with regard to the employment of Chest Physicians by Local Authorities it is clearly .inadvisable to comment as to the relationship of the Chest Physician to the I_~cal Authority ahhough strong views in this connexion are held in this Region. It is recognized that the induction of artificial pneumothorax in the patient's home is a contentious one. q here wa_s no mention made

June

1950

in the report to the effect that it was not thought propel'. The opinion of the Committee as stated in the report was against the induction of collapse therapy in the home and this is still the opinion of tile Committee. As regards the questions raised in the ha_st paragraph of your comment, m a y I point out that on Fage 8 of the report to which you refer the name of Dr J. A. Rushworth, the Assistant Senior Medical Officer to the Board for Tuberculosis, is mentioned in connexion with the centralization of the admission of eases to sanatoria. Dr Rushworth is the officer whom you enquire about and whose sole interest is the Tuberculosis and Chest Service. Co-operation with the Medical Officers of Health in the Region is achieved by personal contact between the Assistant Senior Medical Officer for Tuberculosis and the Medical Officer of Health and also with the Chest Physician and Tuberculosis Officers working in the field. A Liaison Committee has been estal)lished which meets regularly and consists of the administrative medical staff of the Board and all Medical Officers of Health to Local Health Authorities in the Region. Matters of mutual interest to Local Authorities and the Regional Hospital Board, including tuberculosis, are discussed. The Deputy Medical Officer of Health of the City of Liverpool is a member of the Tuberculosis Advisory Committee. This Committee has a membership o f fourteen, not counting the Senior Administrative Medical Officer who attends ex-offcio and who tins been present at the greater number of meetings of the Committee. ~Ihe membership includes eight Physicians and of these two are senior members of a Teaching Hospital and of tlie University; the third is a Paediatrician also of a Teaching Hospital and a m e m b e r of the University Teaching Staff; two Medical Superintendents of sanatoria devoted to Pulmonary Tuberculosis; one Medical Superintendent of a sanatorium mainly devoted to Orthopae~lic conditions; and two are Tuberculosi6 Officers. There are two Chest Surgeons and an Orthopaedic Surgeon all with University appointments ml.d a Radiologist who is also attached to a Teachin~ Hospital. T h e members were chosen by the Board's Medical Advisor), Council from medical men working within the service in the Region, the Chairman being appointed by the Advisory Committee itself. In addition to collaborating on the Advisory Committee in the enunciation of the filturc plan for the Tuberculosis Service you will see from page 5 of the report that tim Teaching Hospitals are being consulted in relation to