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into force, according as opportunity, which largely means money, affords. But in any case, the first
part of the scheme must be that which relates actually to the machinery for dealing with the disease.
I therefore propose to outline first my views with regard to the administrative machinery.
Part I.—Dispensary and general administration.—To begin with the dispensary. Dispensaries
should be established for every borough, but there is no reason why several boroughs should not
make use of the same dispensary whenever possible. It is extremely desirable that the dispensary
should, when possible, be either a hospital or dispensary already in existence. The executive officer
in charge of the dispensary will be charged with the clinical care of the patients, and will be closely
associated with the medical officer of health, who, in addition to this close association with this officer
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will represent the administrative side. Whenever a hospital undertakes the duties of a tuberculosis
dispensary, the public will get the advantage of all the highly-specialised resources, laboratories,
apparatus, etc., and the advice of the whole consultant staff of the hospital, instead of the opinion
of one man only.
Generally speaking, the duties of the clinical officer should be strictly confined to work in the
institution, and the medical officer of health should deal with the home conditions of the patient, the
general practitioner being encouraged in all suitable cases, to retain control of the patient in his own home.
The chief tuberculosis officer for London should be the County Medical Officer of Health. He
should act as the chief administrative executive officer. I propose that, as his clinical experts, he should
have a voluntary advisory committee drawn from tuberculosis experts within the medical profession.
I feel sure that the staff of such specialist institutions as Brompton, Victoria Park and City Road
Hospitals, etc., would gladly co-operate, as would also doubtless, the Royal Colleges of Physicians and
Surgeons. By obtaining the voluntary co-operation of the medical profession, London will gain the
valuable services of the leading medical experts having knowledge of this disease.
The efficient working of the scheme must largely depend on the medical staff of the various
institutions concerned, and at the present moment there is an inadequate supply of highly specialised
officers. I am of opinion that it is essential, in order to improve this supply that appointments to institutions
dealing with tuberculosis, should only be given to those who can produce evidence of having
received adequate training in the methods of dealing with this particular disease.
Where dispensaries, other than hospitals are established, the salaries of the dispensary medical
officers should be standardised. Where the dispensary is a hospital, the hospital authorities will
doubtless arrange the question of payment of its staff, in accordance with such standard. The question
as to whether the payment of the salaries of the dispensary medical officers should be made through
the Council, as are the salaries of the medical officers of health, at present, is one for future determination.
I recommend it, so as to ensure that a proper standard of efficiency is attained by the medical
officers, before joining the dispensary.
In this connection it is desirable to draw attention to the fact that the Local Government Board
evidently intends that cases of tuberculosis should be transferred from the Insurance to the health
authorities. The Insurance Committee, should, through their local committees, have brought to their
notice, such cases of tuberculosis as are locally discovered, as a preliminary to such transfer. With a
proper tuberculosis scheme, insurance will be relegated to its true function, namely one of pure finance.
I might here remark that it appears to me that a ticket system should be instituted for attendance
at dispensaries. Tickets, which should be of two colours, one for insured and one for non-insured
persons, should be readily obtained through medical officers of health and local insurance committees.
They would entitle the holder to a visit and treatment at any dispensary, and would be a voucher for
charges incurred, when presented to the authority responsible for payment.
Such ticket system would very largely obviate book-keeping, and it is desirable to reduce clerical
labour to a minimum.
Part II.—Hospital and sanatorium treatment of patients.—This part of the scheme relates to
adults other than poor law persons, and should be divided into two sections, namely (a) insured, and
(b) uninsured persons.
(a) Insured persons.—The funds provided by the National Insurance Act ought to be adequate
to meet the cost of treating insured persons, and it may be reasonably expected that, if they are not
adequate to-day, they will be made so.
Provision has already been made at Downs Sanatorium (L.C.C.) for 300 male persons, and the
provision is capable of some extension. It is probable, moreover, that in the near future accommodation
for a further 200 patients will be provided. The amount of money available for the treatment
of insured persons is Is. 3d. a head, of which 6d. is earmarked for domiciliary treatment and about
id. for administrative expenses. There is also provided, primarily for research purposes, the sum of
Id. a head, and I think that a portion of this sum should, if possible, incidentally, be utilised for the
training of experts in the treatment of tuberculosis. As I have stated earlier in this memorandum, the
supply of highly specialised officers is very inadequate. Moreover, I am of opinion that it would be
of great advantage if the Insurance Committee, mider the powers conferred upon them by section
60 (1) (b) of the National Insurance Act, would arrange for the education, by means of lectures, of
nurses to be employed in institutions for the treatment of tuberculosis.
It is clearly of importance that at an early stage it should be defined to what extent the various
forms of treatment (sanatorium, domiciliary or dispensary) can be provided as regards insured persons.
Personally, I am of opinion, that sanatorium treatment should only be given in such cases as, being
incipient, show good prospects of recovery, or where a case is so advanced and the conditions of the
home are exceptionally unfavourable as to make the movement of the patient imperative. It must be
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