1

STANFORD LIBRA

I. PUBLIC HEALTH.

Infectious Diseases.

TUBERCULOSIS.

Termination of Sanatorium Benefit and Public Health
(Tuberculosis) Act, 1921.

At the beginning of the financial year 1921-22 the termination, in pursuance of the National Health Insurance Act, 1920, of the sanatorium benefit conferred upon insured persons by the National Insurance Act, 1911, was in immediate prospect. The nature of the change involved and the steps taken by the Department in preparation for it were outlined in last year's Report. The termination took place on the 1st May, 1921, and in no instance, so far as is known, was any difficulty experienced at that date in the maintenance of the arrangements in the local administrative areas for the treatment of tuberculous insured persons and ex-service men, for whom responsibility was then transferred from Insurance Committees to the Councils of Counties and County Boroughs.

The Public Health (Tuberculosis) Bill, to which reference was made in last year's Report, became an Act of Parliament on the 12th May, 1921. The terms of the Act are such as to place upon any County or County Borough Council, which had not, prior to the passing of the Act, made arrangements for the treatment of persons suffering from tuberculosis (including insured persons) in accordance with an approved scheme, the duty of making adequate arrangements for the treatment of tuberculosis at or in dispensaries, sanatoria, and other institutions approved by the Minister. The County Council of the North Riding of Yorkshire and the County Borough Council of Great Yarmouth had not, at the termination of sanatorium benefit, undertaken to provide for the institutional treatment of tuberculous insured persons in their respective areas; and it was consequently necessary for the Minister to authorise the Insurance Committees of the North Riding and of Great Yarmouth temporarily to continue their arrangements for providing treatment for insured persons. In each area, however, the Council took over these arrangements after the passing of the Tuberculosis Act, and accepted responsibility for the cost of the arrangements as from the 1st May, 1921.

Other provisions of the Act which may here be referred to are (1) those enabling the Council of a County or County Borough to exercise their powers in relation to the treatment of tuberculosis through a Committee or sub-Committee, and to appoint as members of the Committee or sub-Committee persons (including members of Insurance Committees) who are not members of the Council, so long as not less than two-thirds of the members of the Committee or sub-Committee are members of the Council; and (2) those empowering the Minister by order to constitute an Advisory Committee for the purpose of assisting Councils in making arrangements for the treatment of tuberculous seamen. An Order establishing such a Committee was made by the Minister on the 30th September, 1921.

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B

Schemes of Institutional Treatment.

With the submission during the year by the Great Yarmouth Town Council of a scheme for the institutional treatment of tuberculosis, and the extension of the scheme of the North Riding County Council to insured persons, arrangements have now been made by all the County and County Borough Councils in England for the dispensary and residential treatment of insured and uninsured persons suffering from tuberculosis.

On the 31st March, 1922, the number of dispensaries approved by the Minister of Health, or his predecessors, had increased to 421, being a net increase of 10 during the year. The number of Tuberculosis Officers working under the schemes of Local Authorities on the same date was 339.

The following table shows the various classes of residential institutions which had been approved for the purposes of the schemes by the Minister of Health and his predecessors up to the 31st March, 1922, and the total number of beds of each class, and distinguishes between the institutions provided by Local Authorities and by voluntary bodies:

Including 31 observation beds approved at 9 dispensaries.

These figures indicate an increase during the year of 1,309 beds provided by Local Authorities, and of 183 beds in institutions provided by voluntary bodies, or a total addition to the available accommodation of 1,492 beds.

In London, the schemes of Metropolitan Borough Councils for the provision of dispensary services have during the year been in process of revision as the result of the termination of sanatorium benefit and of the survey by Medical Officers of the Department and of the London County Council to which reference was made in last year's Report. A number of voluntary dispensaries have been taken over by the Borough Councils, including 10 previously conducted by the Central Fund for the Promotion of the Dispensary System for the Prevention of Tuberculosis in London, and 3 others. There are now included in the schemes of Metropolitan Borough Councils 23 municipal dispensaries, 1 voluntary dispensary, and 9 dispensaries established at general or special hospitals.

Provision of Institutions.

Reference was made in last year's Report to the curtailment of the programme for the provision of additional accommodation for the residential treatment of tuberculosis rendered necessary by the general

financial stringency. Early in the financial year 1921-22 steps were taken to postpone the provision of new institutions, or the extension of existing institutions, except in so far as actual contractual obligations had been entered into, and the number of additional beds which have been or are now being provided under the terms of the circular letter of the 3rd November, 1919, will not exceed 5,000.

During the year capital grants were paid amounting to £295,034, making a total of £1,016,076; and loans were sanctioned, amounting to £273,292, for the provision of institutions for the treatment of tuberculosis, making a total of £1,284,100 sanctioned up to the 31st March, 1922, for this purpose.

Financial Arrangements.

Up to the 31st March, 1921, the grant payable by the Department in aid of the expenditure incurred by Local Authorities on their tuberculosis schemes amounted to 50 per cent. of their approved net expenditure for this purpose, after deducting income from all sources. A grant on account of 40 per cent. of the estimated net expenditure was paid during the year in which the expenditure was incurred, and the balance necessary to make up 50 per cent. of the approved net expenditure was paid after audit of the accounts. As from 1921-22, the grant on account payable during the year in which the expenditure was incurred was increased to 45 per cent. of the estimated net expenditure, and in consequence of the discontinuance of the contributions previously received by the Local Authorities from Insurance Committees in respect of the treatment of insured persons and of ex-service men, certain other alterations in the system of payments to Local Authorities came into force during the year. During 1921-22 the following payments were made by the Department to Local Authorities in respect of their expenditure on tuberculosis schemes :

(a) £1,644,017,* made up of £1,286,014, being the grant on account in respect of 1921-22, and £358,003, being the balance of the grant in respect of previous years. The amount of £1,286,014 includes £259,952 on account in respect of the annual fixed grant which has replaced the income formerly accruing from Insurance Committees in respect of the treatment of insured persons.

(b) £357,450 being a payment on account in respect of the residential treatment of ex-service men for whom the Ministry of Pensions are responsible.

(c) £6,650 in respect .of special services rendered by the Tuberculosis Officers of Local Authorities for the Ministry of Pensions during the eight months ended 31st December, 1921.

(d) £4,122 5s. 10d. in respect of the visiting of tuberculous ex-service men by Health Visitors.

The sums mentioned in (b), (c) and (d) are refunded to the Department by the Ministry of Pensions.

* Exclusive of £1,185 16s. 3d. in respect of an order for payment issued in 1920-21, but not presented till 1921-22.

Restrictions in Expenditure on the Treatment of Tuberculosis.

Pending the receipt of the Report of the Committee on National Expenditure in regard to the public health services which are assisted by grants from the Exchequer, administrative action was taken, both in individual cases and by the issue of a general circular letter, to prevent an extension of the liabilities of the Exchequer in regard to the tuberculosis schemes of Local Authorities. The Department also obtained from each Local Authority an estimate of their expenditure for this purpose during 1922-23, with a view to necessary action being taken on receipt of the Report. After consideration of the recommendations of the Committee, the Government decided to ask Parliament to vote a maximum sum of £1,365,000 for the payment of maintenance grants in aid of tuberculosis schemes during 1922–23, and it accordingly became necessary to inform each Local Authority of the maximum net expenditure during that year towards which the usual Exchequer grants would be payable. The estimate of each Local Authority was reviewed in detail, and the maximum net expenditure approved in the case of each Local Authority should enable at least the same amount of treatment to be provided in 1922–23 as in 1921-22, due regard being paid to falling prices.

As regards capital grants, a sum of £100,080 remained available on the 31st March, 1922, out of the amount set aside for the purpose by the Finance Act, 1911, and the Government decided to ask Parliament to provide a further sum of £175,000 for this purpose in 1922–23. This money will be available during the year for the purpose of paying instalments of the capital grants, as they fall due, in aid of the provision of the additional accommodation referred to in an earlier paragraph of this Report.

Tuberculous Ex-Service Men.

Responsibility for arranging for the provision of residential treatment for tuberculous ex-service men of certain categories, under conditions securing such men a preference over the general population in admission to treatment, passed from the Insurance Committees to the County and County Borough Councils on the 1st May, 1921. The categories of men to whom the arrangements apply are:-(1) men in whose case tuberculosis has been held by the Ministry of Pensions to be attributable to, or aggravated by, service in the Great War; and (2) men invalided from the forces on account of tuberculosis on or before the 30th day after the date of termination of the War. In view of the fixing of the 31st August, 1921, as the official date of termination of the War, men invalided from the forces on account of tuberculosis after the 30th September, 1921, do not come within the scope of the new arrangements, except in cases where tuberculosis is afterwards accepted by the Ministry of Pensions as attributable to or aggravated by service in the Great War.

The approved cost of the residential treatment provided for these classes of ex-service men is borne by the Ministry of Pensions, and the arrangements are generally similar to those previously administered by Insurance Committees, which were described in the Annual Report for 1919-20. The Ministry of Pensions have, however, terminated the arrangement by which, if upon the admission of an ex-service man, not falling within the above-mentioned categories, to residential treatment, the Tuberculosis Officer reported that in his opinion tuberculosis was

attributable to, or aggravated by, war service, the cost of treatment became chargeable against the Ministry of Pensions pending the decision of that Department upon the Tuberculosis Officer's report.

The number of men receiving residential treatment under the special arrangements (in England) on the 1st April, 1922, was 2,789, as against 3,559 on the 1st April, 1921.

The total expenditure of Insurance Committees in England upon the residential treatment of tuberculous ex-service men under the special arrangements administered by the Committees during the period of 28 months from the 1st January, 1919, to the 30th April, 1921, amounted approximately to £960,000.

Vocational Training.

Reference was made in last year's Report to the special Training Sections which were being provided at existing Sanatoria for the vocational training of ex-service men suffering from tuberculosis. The total number of places provided under the scheme has been reduced from 500 to 410. The opening of the Training Sections for vocational training has been deferred pending the settlement with the Treasury and the Ministry of Pensions of the terms and conditions on which the Sections are to be used for this purpose, but it is now anticipated that all the Sections will be brought into use for vocational training by the 1st July, 1922.

After-Care of Tuberculous Persons.

The Public Health (Tuberculosis) Act, 1921, enables County and County Borough Councils to make such arrangements as they may think desirable for the after-care of persons who have suffered from tuberculosis, and up to the 31st March, 1922, the schemes of 38 Local Authorities for the constitution of Tuberculosis Care Committees had been submitted to the Department and approved. In London, interim Care Committees were constituted in each Metropolitan Borough by the London County Council during the War, but a circular has now been issued by the Department, after consultation with the County Council, embodying suggestions for the guidance of the Metropolitan Borough Councils in the organisation of permanent Care Committees to work in co-ordination with the tuberculosis dispensaries serving the several boroughs.

Extra Nourishment.

Prior to the termination of sanatorium benefit on the 1st May, 1921, it was intimated to the County, County Borough and Metropolitan Borough Councils that, in order that there might be no break, on the termination of sanatorium benefit, in the supply of extra nourishment to insured persons suffering from tuberculosis for which Insurance Committees had, in general, previously made some provision, the Department would be prepared to sanction reasonable expenditure by the Councils in temporarily continuing from the 1st May, 1921, the arrangements made by Insurance Committees, and to entertain applications from the Councils for sanction under section 3 of the Public Health (Prevention and Treatment of Disease) Act, 1913, to arrangements for the provision of extra nourishment for tuberculous persons generally in their area (i.e., both uninsured and insured persons), in cases where the Tuberculosis Officer certified that the provision of such extra nourishment was necessary for the proper treatment of the case.