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In considering this table the following facts must be borne in mind:—
1. The table represents the proportion of the work of the dispensaries actually carried out during
the years 1917 and 1918 in respect of insured persons, but allowance must be made under item 6 for
patients who were recommended for domiciliary treatment by the Insurance Committee, but who were
actually treated at the dispensaries, and whose attendances are recorded under items G and 7. I estimate
that if these persons had not been treated at the dispensaries the proportion of attendances of insured
persons under item 6 would have been reduced to the extent of 15 per cent, to 18 per cent., and the
proportion of physical examinations to about 25 per cent.
When these allowances have been made, I think it is fairly certain that the services rendered in
respect of insured persons have not amounted to less than 25 per cent, of the total services rendered
by the dispensaries, and that they have not been overpaid for by the Insurance Committee.
2. During the war a limited dispensary service only has been possible. Necessarily only a
moderately complete service was available for insured persons, and a much less complete service for the
non.insured. In the future, when the dispensaries are rendering a complete service for the whole
population, many more patients will pass through the dispensaries yearly, large numbers of them will
be contacts who are mainly uninsured persons, and among them the number of cases of tuberculosis will
be much less than among the patients who passed through the dispensaries in 1917 and 1918. The
proportion of ser.ices rendered to the insured will then be materially reduced under every heading,
and it would therefore be unsafe to use the figures given in this table to determine the future proportion
of services of a completely developed scheme which will relate to insured persons.
3. It must however be remembered that the services rendered to insured persons cannot be
measured accurately either by the proportion of insured persons attending for the first time during any
year or by the proportion of total attendances, for several reasons :—
(а) Definite pulmonary tuberculosis occurs more frequently among the insured than
among the uninsured ;
(b) More work is required with respect to the insured patient than with respect to the
uninsured, e.g., in connection with the domiciliary order, additional written reports, etc.
Having regard to these various considerations, I think that for some time to come something
'ike 25 per cent, of the total work of the dispensary will relate to insured persons and that as the scheme
covers the whole ground more adequately the proportion will gradually be reduced until it approaches
to something like 21 or 22 per cent. This does not mean that the actual cost of the service in respect
of insured persons is ever likely to be reduced, because a complete and adequate scheme implies
additional staff and a correspondingly higher cost to be apportioned.
Assuming then that the cost of the dispensary service for insured persons for the immediate
future should be 25 per cent, of the total cost, and that the total cost of a service such as that contemplated
in 1915 has increased 50 per cent., the contribution of the Insurance Committee for the next
period would need to be increased from £9,362 to £14,043 per annum. Unless the salaries of dispensary
officers and the cost of material, etc., rise to higher levels than contemplated in my estimate, I think
this sum would represent the cost of dealing with insured persons for a considerable time to come. In
other words, that such extensions of the service as are required would relate mainly to the uninsured
and should be met by contributions of the borough councils.
Institutional Accommodation.
The Departmental Committee of 1913, re the provisions for the treatment of tuberculosis suggested
tentatively as a working standard for institutional accommodation one sanatorium bed and one hospital
bed for every five thousand population. This standard is commonly spoken of as the " Astor " standard.
Applied to London with a population of 4£ millions it would give 900 sanatorium beds and 900 hospital
beds. Recent evidence given before the Departmental Committee (1919) shows that this standard
has proved inadequate in cThe number of beds at present available in London for tuberculous persons is difficult to calculate
owing to the great dislocation which has taken place in the normal conditions of institutional provisions
consequent upon the war. This applies particularly to the 28 Poor Law infirmaries where, in 1911
(the last official return available), not less than 2,000 beds were devoted to the treatment of tuberculous
patients at all (except the earliest) stages of the disease. From the best information at our disposal at
present it would appear that the total number of beds available for London patients now is 5,400,
divided up as follows :—
Authorities providing beds.
(1)
Total number of
beds provided.
(2)
Numbers (included in column (2))
of beds provided for—
The Council.
(3)
Insurance Committee.
(4)
Authorities of general and special hospitals and various 1,532 400 685
homes (not exclusively for London cases)
Metropolitan Asylums Board 1,868 350 654
Authorities of London poor.law infirmaries (1911) 2,000 — —
5,400 750 1,339