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Tuberculosis. Provision was made for dealing with the problem in two main divisions,
viz., (a) a dispensary service for each metropolitan Borough, around which was
linked, on the one hand the public health service of the borough and on the other
all the various voluntary agencies in the area for helping sufferers, co-ordinated by a
representative care committee system; and (b) provision of residential accommodation.
The scheme provided for incorporating existing voluntary accommodation
including general and special hospitals in London and sanatoria, and for avoiding
overlapping with work already done both by voluntary agencies and public authorities
(e.g., Poor Law), both in respect of out-patient and residential treatment, and it was
emphasised that the purpose of the Council was to supplement and not to supersede
existing agencies and accommodation for dealing with the problem.
As the duty of providing for the domiciliary treatment of insured persons under
the National Insurance Act was made the function of the Insurance Committee,
the arrangements for utilising the dispensary service in London in that connection
were left to the London Insurance Committee, upon whom also devolved the
responsibility until the passing of the National Insurance Act, 1920, of providing
residential treatment for insured tuberculous persons, but optional powers were
conferred upon county councils enabling them to supplement insurance funds in the
event of the money available under the National Insurance Acts being insufficient
for the requirements.
The original tuberculosis scheme for London, in its main principles continues in
operation, but in October, 1922, it was revised principally in the direction of meeting
the changes which were necessary, owing to the withdrawal of " sanatorium benefit "
from the benefits of insured persons under the National Insurance Acts, and modifications
in machinery and method which experience had indicated to be desirable.
The eleven voluntary dispensaries established by the Central Fund, and the
dispensaries started by voluntary local committees in Poplar and St. Pancras,
were all ultimately embodied in the schemes of the borough councils in whose areas
they were situated, and, in addition, 8 dispensaries were specially established within
hospitals. Borough dispensaries had also been provided in seven boroughs. From
time to time fresh schemes were submitted for the Council's approval until in 1919
all the borough councils had approved schemes. The total number of dispensaries
is 33 and there are branch dispensaries in 2 boroughs. Although every borough then
had its approved scheme, the development had proceeded almost entirely under
abnormal conditions due to the war. An investigation into the work of the dispensaries
which was conducted in 1919 revealed serious defects. It was found that
the dispensaries were cognisant of a relatively small proportion of the total cases of
tuberculosis in their area and that insufficient time and attention were devoted to the
examination of contacts and to home visiting. Thus the first essential condition
of efficient work, viz., that the tuberculosis officer should have knowledge of all the
tuberculous patients, suspects and contacts in his district, remained unfulfilled.
The small proportion of tuberculous patients known by the tuberculosis officers
was accounted for to a considerable extent by the lack of co-operation in some areas
between the tuberculosis dispensary and the department of the medical officer of
health. Some medical officers of health interpreted the Public Health (Tuberculosis)
Regulation, 1912 (Article XI.), in the sense that it precluded them from making
use of the services of the tuberculosis dispensary in matters concerning notified
cases (not dispensary patients) or from notifying the dispensary of such cases. The
tuberculosis officer's ignorance of the " notified " cases extended automatically
to the contacts. Further difficulty, which operated even in districts where the
tuberculosis officer was in touch with the medical officer of health, arose from the
fact that many cases of tuberculosis were not notified immediately the disease became
definite, many cases even remaining unnotified until the patient's death. Another
serious weakness in the dispensary system was the apparent failure to realise the