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19
with the necessary home visiting. No institution can be regarded as efficient which carries out its
tuberculosis work under such conditions.
Although in South Kensington and Chelsea under the agreements the home visiting is carried
out by health visitors of the borough council, in actual practice the lady almoner of Brompton Hospital
and a hospital nurse visit and revisit every case until the home conditions become satisfactory. The
work of the lady almoner of this hospital and of St. Thomas's Hospital indicates that a trained social
worker can render most valuable services to dispensary patients. Tuberculosis is a disease usually
associated with defective social conditions, and the assistance of a trained social worker who can deal
effectively with problems which arise from these conditions would be an immense advantage in every
dispensary (as a supplement to the work of the nurses). At present the tendency is for almoners to
work independently of tuberculosis officers, but if social workers are te be employed it should be a sine
qua nan that they should work in intimate co.operation with and under the direction of the tuberculosis
officer.
Generally the dispensary nurse visits all patients attending the dispensary and sometimes also
by arrangement with the Medical Officer of Health, all other notified cases in her district. There appears
to be very little overlapping of home visiting with officers of the Public Health Department, though
this occurs in some cases. Further investigation from the point of view of the Public Health Department
is needed with regard to this matter.
It is impossible to form a sound judgment of the value of the dispensary nursing work without
more detailed investigations, but it would appear that—
(1) The notes of nurses with regard to home visits almost always relate solely to clinical matters.
Even where the report upon the first visit indicates that there is some defect, such as the patient sleeping
in the same bed with another person, it was frequently found that no reference was made to this in
subsequent reports. This suggests that due weight may not always be given to the preventive side of
the work.
(2) In some dispensaries the nurses' reports are not seen by the tuberculosis officer before they
are filed with the case papers. In one dispensary the report form had been changed during the absence
of the tuberculosis officer on military service, and although he had been back on duty for six months
he was not aware of this fact up to the day when the dispensary was visited. This lack of control by
the tuberculosis officer over the work of the nurses must necessarily lead to imperfectly co.ordinated
and ineffective work.
Home Nursing of Patients.—In all boroughs this is carried out, apparently efficiently, by the
local nursing associations. In the case of Chelsea it is supplemented by a borough council scheme for
home nursing provided by the Brompton Hospital staff. Every other tuberculosis officer was definitely
of the opinion that there was no need for a special nursing scheme in his area.
Co.ordination of the work of the Dispensary with that of the Public Health Department,—Voluntary *
institutions usually deal only with a section of the tuberculosis work of their areas; thus, in the case of
Stepney in 1918 the tuberculosis officers dealt with 695 new cases of pulmonary tuberculosis, but had no
relation to and did not even know of the existence of some 850 other cases which were notified for the first
time to the Medical Officer of Health during that year. Tuberculosis officers of these voluntary institutions
regard this as a serious drawback, and think rightly that they should be brought into much more intimate
relationship with the whole of the work relating to tuberculosis in the areas of their dispensaries.
This can only be done by bringing the dispensaries into closer working relationship with the Local
Public Health Departments. Very few, if any, tuberculosis officers are likely to object to such an
arrangement provided the scope of their work is not curtailed in other directions.
Office work of Tuberculosis Officers.—On the average the amount of time devoted by tuberculosis
oncers to office work, mainly reports, is about 10 hours p. r week. There is definite evidence that
this portion of the tuberculosis officer's work has grown considerably recently, due not only to the
demands arising out of War Pension cases but also to the large numbers of progress reports in the cases
of patients who have received institutional treatment either in London County Council or London
Insurance Committee beds, and the greater attention given to the supply of reports, etc., to medical
practitioners.
In some dispensaries the necessary clerical assistance is provided, in others it is still inadequate,
and in still others no provision of any kind is made, with the result that a good deal of the tuberculosis
officer's time is wasted upon work which should be carried out by a clerk.
Efficiency of the Records.—In some dispensaries (Metropolitan and Victoria Park Hospital Dispensaries)
the records of the environmental conditions of patients are kept in the Public Health Departments
of the boroughs served, copies are suppli d to the tuberculosis officers on request, but in practice
copies are asked for only in exceptional cases. In some other dispensaries information concerning
environmental conditions is not filed with the papers of each patient. These arrangements are unsatisfactory,
as they lead to the treatment of the patient without reference to his home conditions and other
circumstances.
The arrangement by which all recommendations made by tuberculosis officers for the treatment
of uninsured persons and all requests by the London County Council for progress reports upon patients, who
have received treatment in resideatial institutions, are made through the Medical Officer of Health of
the borough has led to delay and in some cases considerable delay in the past. It is desirable that these
arrangements should be revised, and that the tuberculosis officers should send all recommendations
for treatment direct to and receive all requests for reports upon the progress of individual patients direct
from the County Council.
55580
R 2