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which will provide for the in-patient treatment of cripples at a properly equipped orthopaedic hospital, and for their care and after-treatment at clinics established in connexion with the hospital and supervised by its medical staff.
Installations for treatment by artificial light have been approved by the Minister at 36 approved residential institutions and at 11 tuberculosis dispensaries. Arrangements have also been approved for this treatment to be given to certain classes of cases of tuberculosis at 30 other institutions, including 23 general hospitals. In London, the County Council, with the approval of the Minister, have extended for a further year the arrangements under which Metropolitan Borough Councils are enabled to send suitable tuberculous cases for light treatment to certain of the London Hospitals. As was stated in last year's Report, the Minister's approval of this form of treatment is at present to be regarded as for experimental purposes, as it is not yet possible for a considered opinion to be pronounced as to the scope and limits of utility of the treatment. The experience so far available indicates that good results can be obtained in certain cases, but it needs to be emphasized that the treatment is not altogether free from danger, and should always be carried out by competent and experienced persons and with close observation of the individual cases.
During the year certain resolutions were adopted by the County Councils Association regarding the principles on which the schemes of Local Authorities for the treatment of tuberculosis should be conducted, and a circular (Circular 771) was issued on the 31st March, 1927, setting forth, for the information and guidance of Local Authorities, the views of the Department on the points raised by the resolutions. This circular, in addition to emphasizing and expanding certain principles which had been laid down in earlier circulars or in Annual Reports of the Department, called the attention of each Local Authority to the desirability of the periodical issue to the public generally, and also to medical men practising in the Authority's area, of information as to the location of each tuberculosis dispensary provided by the Authority, and as to the facilities available at these dispensaries. It was suggested that, by taking suitable steps to spread the knowledge of these facilities, Local Authorities would do much to further the success of their tuberculosis schemes.
Attention was also drawn to the increasing provision, as an additional benefit under the National Health Insurance Acts, of a portion at least of the cost of dental treatment required by insured persons, and to the consequent need of securing that arrangements made by Local Authorities for the dental treatment of persons receiving treatment for tuberculosis should not result in a duplication of services in the case of certain classes of insured persons.
Local Authorities were further informed that, in the view of the Minister and of the Board of Education, "pre-tuberculous" children (i.e. delicate children who on account of their family history or environment might be thought to be predisposed to tuberculosis, but have not been definitely diagnosed as suffering from the disease or suspected to be actually so suffering) should be dealt with by the Local Education Authorities at Open Air Schools certified by the Board of Education under Part V of the Education Act, 1921, and not in sanatoria provided by the Public Health Authorities under their tuberculosis schemes.
Capital grants amounting to £17,725 were paid during 1926-27, making a total of £1,406,369. But of this amount £3,758, representing grants in aid of schemes which have since been abandoned, has been refunded to the Department. Loans amounting to £351,096 were sanctioned during the year for the provision of institutions for the treatment of tuberculosis, making a total, after allowing for sanctions which have been cancelled, of £2,696,112 sanctioned up to the 31st March, 1927, for this purpose. The sum of £351,096 mentioned above includes £143,000 in respect of the provision by the Surrey County Council of a sanatorium at Milford.
During 1926-27 the following payments, apart from capital grants, were made by the Department to Local Authorities in respect of their expenditure on tuberculosis schemes :
(a) £1,531,532, made up of £1,419,738, being the grant on account in respect of 1926-27, and £111,794, being the balance of the grant in respect of previous years. The sum of £1,531,532 includes the payments in respect of the fixed annual grant which has replaced the income formerly accruing to Local Authorities from Insurance Committees in respect of the treatment of insured persons. The amount of the fixed annual grant for a full year is £315,358.
(b) £205,505, being the payment in respect of the residential treatment of ex-Service men for whom the Ministry of Pensions are responsible.
(c) £5,083 in respect of special services rendered by the Tuberculosis Officers of Local Authorities for the Ministry of Pensions during the year ended on the 31st December, 1926. (d) £1,820 in respect of the visiting of tuberculous ex-Service men by the Health Visitors of Local Authorities.
The sums mentioned under heads (b), (c), and (d) are refunded to the Department by the Ministry of Pensions.
Steps were taken, similar to those described in the Report for 1921-22, to fix the maximum liabilities of the Exchequer for grants in aid of the maintenance cost during 1927-28 of the existing schemes of Local Authorities, and the Authorities have been informed of the maximum grants which will be available in respect of that year, apart from the grants payable in respect of any developments which may subsequently be approved by the Minister. The approved maximum net expenditure for 1927-28, exclusive of expenditure on such developments, is approximately £50,000 in excess of the approved maximum net expenditure for 1926-27.
The fourth of the series of annual tables showing the cost per patient per week under various heads at residential institutions for the treatment of tuberculosis was issued during the year. The table shows that in slightly more than one-half of the institutions for which comparative figures were available for the last two years, the average cost per patient per week had increased, but as indicated below, the average cost per patient per week of all cases which received residential treatment during 1925-26 under the schemes of Local Authorities was the lowest since the institution of this system of comparative costing. There is evidence that the table is of great assistance to Authorities in enabling them to decide whether in a given case the various items of expenditure are on the lowest possible level compatible with efficiency.
The gross expenditure of Local Authorities on their tuberculosis schemes during 1925-26 amounted to £2,972,357, this being £122,542 in excess of the gross expenditure during 1924-25. Of the gross expenditure during 1925-26, £566,845, or 19 per cent., related to the dispensary services, and £2,405,512, or 81 per cent., to residential institutions. The net expenditure, after deducting all income except the grants payable by the Department, amounted to £2,614,365, this being £167,023 in excess of the corresponding figure for 1924-25. The income during 1925-26 was less by £44,481 than during 1924-25, £43,247 of this decrease being due to the smaller income received in respect of the residential treatment of war pensioners.
During 1925-26 the average number of occupied beds in institutions provided by Local Authorities was 11,969, and of beds maintained by those Authorities in institutions provided by voluntary bodies was 5,854; the total of 17,823 being 937 in excess of the average number during 1924-25. The average cost per patient per week amounted to 49s. 24d., as compared with 51s. 11d. in 1922-23, 49s. 4d. in 1923-24, and 49s. 11d. in 1924-25.
For various reasons it is not possible to make a detailed analysis of the total expenditure of Local Authorities on the treatment of tuberculosis. For example, a considerable proportion of the expenditure on the residential treatment of tuberculosis is incurred at institutions belonging to voluntary bodies in respect of which inclusive charges at approved rates per patient per week are made. The figures given below relate to the apportionment under the different headings of an expenditure during 1925-26 of £548,052 (out of a total of £566,845) on the dispensary services, and of £1,374,773 (out of a total of £2,405,512) on residential treatment, the latter sum relating to those institutions belonging to Local Authorities which are used wholly for the treatment of tuberculosis.
Percentage of Total Expenditure.
Nurses and Health Visitors
Tuberculous Ex-Service Men.
The number of war pensioners receiving residential treatment for tuberculosis from Local Authorities continues to decline, the number on the 1st April, 1927, being 1,153, as against 1,321 on the 1st April, 1926, and 3,780 on the 1st April, 1920, when the number was at the highest.
Annual Returns in connexion with Local Authorities' Schemes,
and Records at Approved Institutions.
A detailed account was given in last year's Report of the comprehensive Memorandum (37/T) dealing with the above matters which was issued on the 13th September, 1925, to the Local Authorities conducting schemes for the treatment of tuberculosis and to the authorities of approved tuberculosis institutions. As was indicated in that Report, the obligations imposed by the Memorandum had effect from the 1st January, 1926, but a considerable number of Local Authorities, on the invitation of the Minister, furnished voluntarily complete or partial returns for the year 1925 in the form of the tables prescribed in the Memorandum. The examination of these returns revealed that certain difficulties had been experienced in their compilation and in the interpretation of some of the instructions contained in Memorandum 37/T. These difficulties were discussed in correspondence with the Medical Officers concerned; and, in order to facilitate generally the compilation of the obligatory returns for 1926 and future years, it was thought desirable to issue a further explanatory memorandum, setting out some of the sources of error disclosed by the returns for 1925 and showing how these might be avoided for the future. The memorandum (121/T), with a covering circular (Circular 726), was accordingly issued on the 5th October, 1926, and it was particularly recommended for study by the Tuberculosis Officers of those Authorities who had not responded to the Minister's invitation to send in returns for 1925, with a view to the avoidance of difficulties in the compilation of the returns for 1926.
For the purpose of assisting Tuberculosis Officers to establish a uniform system of record-keeping, showing the work done and the individual cases seen, a model form of dispensary card register and a model form of dispensary work sheet, together with a statement explaining their use, have been prepared by the Department. This card and work sheet will, it is believed, provide all the information necessary to enable the Tables prescribed in Memorandum 37/T to be accurately completed, and, if they are adopted generally by Tuberculosis Officers, should greatly facilitate the preparation of future annual returns.
Up to the 31st March, 1927, returns in Tables I, II, and III for the year 1926 had been received from 103 Tuberculosis Authorities out of a total of 123. Returns in Table I had also been received from 27 of the Metropolitan Borough Councils. Each return has been carefully scrutinized, and the Department have communicated with the Chief (Administrative) Tuberculosis Officer in all cases in which the returns, through misunderstanding or otherwise, had not been drawn up in accordance with the instructions contained in the explanatory Memoranda. It is hoped that this correspondence, which in certain cases has been somewhat protracted and in others is still proceeding, will result in a substantial general improvement in the returns for the year 1927.
It is satisfactory to record that, up to the 31st March, returns in the optional Table IV had been received from 10 County Councils, 34 County Borough Councils, and 15 Metropolitan Borough Councils. In many other instances returns in this Table for 1926 have been promised as soon as the information can be collected.
As a number of the returns have not yet been received and as many of those received have not yet reached their final revised form, it is not possible to give in this Report summary figures for the whole country, or to present any satisfactory picture of the comparative progress and results of the schemes for different areas. When the complete returns have been received and summarized in their finally accepted form, consideration will be given to the question of publishing separately a tabulated summary in the form best adapted to show the extent of treatment given and the results achieved.
The examination of the returns already furnished indicates that they will be valuable in affording a general view of the tuberculosis work carried out by Local Authorities, and in giving summary figures for such important items of information as the numbers of new cases and "contacts" examined in the course of the year, the number of these in whom tuberculosis was diagnosed, etc.. Information will also be available as to the number of patients receiving treatment in residential institutions during the year, and the immediate results of residential treatment in correlation with the length of treatment provided and the stage of the disease.
New Powers of Local Authorities.
At the date of last year's Report no information was available as to the extent to which use had been made by Local Authorities of the powers conferred on them by section 62 of the Public Health Act, 1925, for securing the compulsory removal to hospital, in certain circumstances, of persons who are suffering from pulmonary tuberculosis and are in an infectious state. As was anticipated on the basis of the experience of those Local Authorities who had previously obtained similar powers in Local Acts, the actual exercise of the powers conferred by the section is called for in a comparatively small number of cases. Generally the fact that these powers exist has made it possible to persuade the infectious patient either voluntarily to enter a suitable institution or to adopt a mode of life more suited to his condition and to the interests of his neighbours. But in one case in which the power of compulsory removal was exercised, it was found necessary to discharge the patient from the institution to which he had been sent because he behaved there in such a manner that he could not, in fairness to the other inmates, be retained as a patient.
Reference was made also in last year's Report to the issue in July, 1925, of regulations designed to prevent persons suffering from tuberculosis of the respiratory tract from entering upon occupations involving the handling of milk, and to enable Local Sanitary Authorities to require persons engaged in such occupations to discontinue them, if found to be suffering from tuberculosis of the respiratory tract and to be in an infectious state. It was stated that the Councils of 18 Counties in England had on application been declared by the Minister to be Authorities for enforcing the regulations, and this number has now been increased to 22. In these cases the County