appointment of a Joint Committee consisting of ten members, three appointed by the County Council as tuberculosis authority, one by the County Council as representing the public health authorities, three by the Education Authority and three by the Child Welfare Joint Committee, and for the purpose of bringing the scheme into operation the agreement empowers the Joint Committee to appoint three assistant medical officers and four wholetime nurses (or an equivalent nursing service composed of part-time nurses or of whole-time and part-time nurses) to carry out, under the general supervision of the county medical officer, the duties imposed by statute on the combining authorities or any of their constituent members under or in connection with the treatment of tuberculosis, school medical inspection and treatment, the maternity service and child welfare scheme and the Midwives (Scotland) Act, 1915. The assistant medical officers are also to be appointed by the County Council and its district committees to act as assistant medical officers of health, by the Education Authority to act as assistant medical inspectors, and by the public health authorities to act as assistant inspectors of midwives. The county is divided for the purposes of the scheme into three districts-the Stirling District, the Larbert District and the Western District, but subject to modification as the Joint Committee may think fit, and the assistant medical officers and nurses are allocated to these three districts as occasion may require. Provision is also made in the agreement for the preparation of estimates, the allocation of expenditure and other matters. As will be gathered, the scheme is a well-considered one. It places the medical and nursing services of the combining authorities under the administrative control of the county medical officer, who holds appointments under each of these authorities, and we have no doubt that it will effect considerable improvements in the public health services in the county, and at the same time secure that economy which depends so largely on the cordial co-operation of public authorities dealing with kindred matters. The Highlands and Islands (Medical Service) Fund. It has been shown in previous Reports that as a result of the administration of this Fund the defects which existed in the Highlands and Islands medical service before the passing of the Highlands and Islands (Medical Service) Grant Act in 1913 have been largely remedied. Not only has provision been made for a doctor's attendance when required in the most inaccessible mainland districts and the remotest islands, but the fees payable by patients have been reduced to so low a figure that no person who requires medical advice or treatment, no matter how far removed from a doctor, need hesitate on financial grounds to call the doctor in. Another equally important effect of the Fund is that it is attracting into the Highlands and Islands medical service practitioners of a very satisfactory class, most of them young men equipped with up-to-date medical technique and methods. E ORGANISATION OF AUXILIARY MEDICAL SERVICES. The basic medical service is supplemented by a system of organisations which employ district nurses, most of whom could not be maintained but for the assistance given from the Fund. While it has not been possible so far to extend the nursing service into all parts of the area, the greater portion of the ground is now covered and the most pressing needs met. This nursing service has assisted the medical men and has ministered greatly to the well-being of the people in districts where it is now in operation, and as a knowledge of the benefits of skilled nursing spreads, the localities that are not at present served will no doubt desire to co-operate with us in the establishment of as complete and efficient a service of nurses as the circumstances will allow. We are aware that many of the nurses are working under conditions of great hardship, and it will be our endeavour to assist as funds permit in the improvement of their living accommodation and in any other way that may help to make their work less burdensome and exacting. We consider, for example, that something might be done to lessen the strain which the use of ordinary bicycles imposes on the nurses who are serving in difficult districts, and during the past year as an experiment we have allowed special grants to three nursing associations to assist them to purchase motor cycles for their nurses. When the motor cycles have been in use for long enough to enable us to determine whether this means of conveyance can be used with advantage by nurses on Highland roads and in the weather which they have to face for a great part of the year in the course of their duties, we shall consider whether motor conveyances can be used more generally without placing an undue burden on the localities or on the Fund. The organisation of the nursing service has been the subject of correspondence between ourselves and the District Committees of Lewis, Harris, North Uist, South Uist and Skye; and all these Committees, except that for Skye, where the matter is still being considered, in their capacity as public health authorities have expressed their willingness to accept responsibility under the Highlands and Islands (Hebrides General Nursing Service, etc.) Scheme, 1920, for the local management of the service and for the application of grants paid from the Fund in aid thereof. This advance in organisation will produce improved local supervision, prevent overlapping, and will bring the service under the purview of bodies that are well able to advise on the special needs of their districts. The organisation of nursing and other auxiliary medical services, more particularly in the mainland parts of the Highlands, has also been specially considered by the Highlands and Islands Consultative Council in their capacity as Voluntary Hospitals Committee for the area. The Committee's consideration of the steps which should be taken to secure greater financial assistance from the Highlands for local hospitals and for similar institutions in the South to which persons from the Highlands are sent for treatment, led the Committee to the view that in the special circumstances of the Highlands it was not expedient to set up new bodies to collect funds for hospitals in competition with existing associations or committees that are already collecting subscriptions in the area for the provision of a nursing or ambulance service. On grounds of economy and to avoid overlapping, the Committee decided to press for the establishment, in each county or other suitable area, of a single organisation whose aim it should be ultimately to secure the provision of all necessary auxiliary medical services throughout its area. The services referred to are those specified in our Highlands and Islands (General Nursing Service, etc.) Scheme, 1920, namely, a general nursing service, a hospital service, a scheme or system securing medical consultations, assistance at operations, etc., a dental service, and laboratories and clinics. While we are empowered to afford assistance from the Fund to voluntary organisations providing any of the services mentioned, the Scheme is so framed as to make it possible for local authorities to assume the local management of all the services, and it may ultimately be found that the developments foreshadowed by the Scheme cannot be brought about otherwise. For the time being, however, except in the Hebrides, it is not clear that local authorities are willing to accept responsibility for the local management of the services, and accordingly the organisation suggested by the Voluntary Hospitals Committee for the Highlands and Islands should fulfil a useful function in the development of the auxiliary medical services and in strengthening the voluntary agencies which hitherto have borne the responsibility for nursing and other facilities. We are permitted to publish a memorandum issued by the Committee after public discussion at a meeting held in Inverness early in 1923, which reads as follows: Notes on the Formation, Scope and Finance of a Voluntary Health 1. The idea of a Health Association, such as is being proposed for the Highlands and Islands, arises out of a recognition that all the organisations whose concern it is in different ways to care for the sick and to raise the standard of health are engaged in the same social service. An Association would proceed on the assumption that the several organisations and the service itself would benefit from working together, on the basis of this community of service, instead of working in entirely separate compartments. 2. While the field of operations of a Health Association in the Highlands and Islands may ultimately be wide, covering the provision of various auxiliary medical services of the kind indicated in Article 4 of the Highlands and Islands (General Nursing Service, etc.) Scheme, 1920, it is necessary that at first and in present circumstances the scope should be limited to what is immediately practicable without adding materially to existing financial burdens. 3. A Health Association would not be primarily concerned with the provision of the basic medical service or with the discharge by local authorities of their statutory duties and obligations, nor would it interfere in the administration of hospitals and other institutions. 4. The immediate functions of a Health Association in the Highlands would be, briefly, to assist (1) the family practitioner by providing him with adequate nursing assistance and, if possible, the assistance of specialists; (2) the managers of hospitals and other institutions by promoting adequate financial support to enable them to fulfil their objects and, if need be, to extend the range of their operations; (3) the statutory authorities by providing, in return for grants from these authorities, as many as possible of the required auxiliary medical services, which these authorities acting separately would not normally be in a position to provide without throwing an undue burden on the rates. 5. The foregoing brief outline of the immediate scope of a Health Association in the Highlands serves to show that it should not be constituted on any narrow basis, but that it should rather be representative of the interests of the main body of the people, medical practitioners, nursing associations, hospital managers and statutory authorities. A loose federation of existing agencies might have difficulty in applying itself to any purposes other than the mere collecting of funds for these agencies. An Association open to all health agencies and residents in its area, and managed by a committee representative of the residents, existing voluntary agencies and statutory health authorities could be made capable not only of ministering to the needs of existing health services, but also of extending its scope to provide services which are not at present being supplied. On this point also it should be borne in mind that, for the purpose of grants from the Highlands and Islands (Medical Service) Fund, any association should preferably be constituted in such a manner as would enable it, in the normal course of its development, to give effect to all the purposes of the Highlands and Islands Scheme of 1920 referred to above. Note. In certain areas it might be desired that the Health Association should act by delegation from the "local authority concerned" in accordance with the provisions of that Scheme. 6. Given an Association so constituted as to meet present requirements and to provide for future expansion, it could function forthwith (1) as the organisation for the provision of such nurses, midwives, specialists, ambulances, etc. as might be required to supplement the basic general medical service, these additional services to be available for private persons and persons in the care of local authorities; (2) as the recognised agency for collecting, applying and distributing subscriptions and donations towards auxiliary medical services and special institutions, including hospitals in its district and any institutions beyond its boundaries resorted to by the residents in the district; and (3) subject to arrangements to be made with local authorities and with the Scottish Board of Health, as the recognised agency for the local application of grants from the rates for particular purposes, and from the Highlands and Islands (Medical Service) Fund in aid of nursing, specialised services, etc. for the community generally. 7. The area of any Health Association might be a county or any part of a county forming a convenient administrative unit. 8. The methods to be adopted by an Association for raising funds in supplement of grants from local rates and imperial subventions would be determined by the Association according to circumstances. It might be possible, for example, to secure a steady income from membership subscriptions, based on a fixed annual contribution per household, and to raise additional funds for general or particular purposes by special efforts. Whatever system were adopted, the concentration of efforts and the elimination of overlapping which would follow the institution of the new Association should result in increased financial support for the services now referred to. It will be understood that endowment or other funds benefiting particular localities or services would continue to be reserved for those localities or services. 9. The guarantee of permanency of an Association will be founded on breadth of organisation, positive health ideals, and the performance of valuable service that will awaken a health conscience in the people and appeal to the interests and imagination of all classes. We understand that the possibility of voluntary health associations for the Counties of Inverness and Ross and Cromarty is being considered by provisional committees for these Counties. SPECIALIST SERVICES. As a step towards the provision of a specialist surgical service in the districts that are most remote from large hospitals in the south, we have asked the Managers of the Gilbert Bain Memorial Hospital, Lerwick, and the Managers of the Lewis Hospital, Stornoway, to consider whether it would not be possible for them with the aid of grants from the Fund to appoint qualified surgeons who would be available for operations and for consultations throughout the hospital Our preliminary investigations into the desirability of this development show that both the areas served by these hospitals seem to afford sufficient scope to justify the appointment of surgeons for a limited experimental period, and we believe that if the appointments were once made the benefits that would accrue to the residents would call forth such a measure of local support as would enable the appointments to be permanently confirmed. FUTURE MAINTENANCE OF SERVICES. The extent of the assistance granted from the Fund under the approved schemes will be gathered from the financial statements and |
