View report page

17
Treatment at the dispensary.—Formerly many tuberculosis officers wished to treat every tuber
culous patient who came under their notice. At the present time this attitude is not so generally adopted.
This alteration in view appears to be due to two reasons—
(1) Tuberculosis officers realise more fully that it is essential, if maximum efficiency is to
be secured, that the general practitioner should not be excluded from the treatment of this
disease.
(2) They recognise that their treatment of the individual case does'not yield materially
better results than the treatment by general practitioners.
The only considerable class of patient making use of the dispensary who has already a doctor is
the insured person. A small number of tuberculosis officers (Kensington, Bermondsey) refer all patients
in this class to the panel practitioner for treatment, except in cases where dispensary treatment is advised
on special grounds and agreed to by the Insurance Committee. The majority of tuberculosis officers,
however, are prepared to treat patients definitely recommended for domiciliary treatment if this
course meets with the approval of the patient and practitioner. In some areas, however, the tuberculosis
officer is only prepared to treat these cases at the written request of the practitioner ; in other areas the
practitioner is informed by letter or card that the patient will be treated at the dispensary if the practitioner
has no objection. The Insurance Committee cannot, however, be expected to pay the dispensary
for the treatment of cases recommended by them for domiciliary treatment—that would involve the
payment for the treatment of the patient twice, viz., payment to the practitioner and payment to the
dispensary. It is, however, impossible to separate the cost of treatment of this group from the general
cost of the dispensary and even the study of the figures of those dispensaries where treatment of these
cases is refused does not yield for various reasons any adequate data as to the extent of the work. Many
tuberculosis officers would be glad to be relieved of the treatment of these cases and have carried out the
work hitherto mainly to assist the practitioners and to further co.operation. In some dispensaries
patients waiting for admission to sanatorium beds are kept under supervision by the tuberculosis
officer. When the patients' condition is such that they require very skilled supervision, and this is the
case in patients with : ctive disease awaiting sanatorium treatment it is very desirable that they should
remain under the supervision of the tuberculosis officer who will confer with the doctor actually carrying
out treatment should occasion require. The actual treatment, at the dispensary, except in the case
of a few dispensaries where a small number of patients receive tuberculin or other special form of treatment,
should be limited to the giving of certain advice as to hygiene, diet, exercise, etc., supplemented
by the treatment of special symptoms. Unfortunately patients expect bottles of medicine to be given
and tuberculosis officers frequently find it necessary to give medicine for trifling symptoms or even for
no special medical reason in order to secure the regular attendance of the patient. The dispensary drug,
bills as a rule are therefore unnecessarily heavy. In one dispensary the drug bill for one year (1918.19)
reached the excessively large sum of over £900. The extent to which " drugging " obtains is also
illustrated by a hospital dispensary where 4,569 prescriptions were dispensed for a total attendance of
4853. In this case the medicine given included 1,785 bottles of cod liver oil, etc. In another case large
quantities of Virol were used. No doubt the cod liver oil and Virol benefited some of the patients,
but as a matter of sound policy such an extensive distribution of these articles by the dispensaries
without regaid to the spccial needs of each patient is to be deprecated. The fact that patients
expect, and actually receive, medicines, whether they really need them or not, necessarily tends to
make the patient rely more on the medicine and less on advice given in regard to such essential matters
as personal and home hygiene, diet, etc. The wholesale drugging of patients thus tends to impair
the efficiency of dispensary treatment and supervision. The ideal to be aimed at is to keep patients
in attendance at the dispensary by providing an efficient means of " following up " and not by means
of medicines. The majority of cases might without disadvantage be seen at longer intervals, when
it would be possible, on account of the smaller numbers attending to make the necessary enquiries,
examinations, etc., and to impress essential advice and to leave symptomatic treatment as far as
possible to practitioners.
Domiciliary treatment.—In many areas tuberculosis officers state that on the whole domiciliary
treatment is reasonably good. Some practitioners carry out the work excellently and a few carry it out
badly or neglect it almost entirely. Probably some method is required to secure a better general standard
of work and for dealing with cases where inadequate attention is given to patients.
The reports made by practitioners on patients under domiciliary treatment are sent in much more
regularly than formerly, and are on the whole well filled up. This is mainly due to the action of the
Insurance Committee, who now send a reminder to practitioners whose reports they fail to receive
through the dispensaries. Formerly it was the practice to rely upon the tuberculosis officer for the
securing of these reports, but frequently he failed to take the necessary action. There are great advantages
in favour of the present arrangement and it is undesirable that it should be interfered with. Under
this system the tuberculosis officer is relieved from the necessity of pressing practitioners, with whom
it is essential that he should be in friendly relations, for these reports and the work is assumed by
an impersonal committee to whom the practitioner looks for payment.
Dispensary supervision.—When patients are discharged from a residential institution to their
homes the tuberculosis officer is informed, either directly in the case of insured persons or through the
medical officer of health in the case of the uninsured. It is satisfactory to note that a system of
notification of admission and discharge from institutional treatment has now been evolved. In the
case of insured persons many tuberculosis officers state that they would like fuller reports of the con.
55580 r