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COOPERATION BETWEEN HEALTHSERVICE AUTHORITIES

SHEFFIELD SCHEME

THE question of how best to coordinate the threebranches of the National Health Service is still undecided.Meanwhile, however, Sheffield Regional Hospital Boardhas initiated the formation of medical coordinationcommittees in the main hospital areas of the region.These areas comprise : (1) Sheffield and that portionof the West Riding which is within the Sheffield region,(2) Derbyshire, (3) Nottinghamshire, (4) Leicestershireand Rutland, (5) North Lincolnshire, and (6) SouthLincolnshire.The committees are constituted as follows :Each local health authority within the area is represented

by the medical officer of health.Each hospital management committee within the area is

represented by a consultant.Each local medical committee within the area is represented

by two general practitioners.The largest committee is that for Sheffield and the WestRiding, with 21 members ; the smallest, that for NorthLincolnshire, has a membership of 8 only.The committees are purely advisory, and members will

be at liberty to take such steps as they think fit to bringthe committee’s recommendations to the notice of thebodies they represent. At each meeting of a committeea medical officer of the regional hospital board is present.The inaugural meeting of each committee was con-

vened by the regional hospital board and was attendedby the senior administrative medical officer. Thefirst business of each meeting was to elect a chairmanand secretary and to discuss the terms of reference.The senior administrative medical otlicer referred toa number of problems affecting the relationship of thehospital, the general practitioner, and the local authority.The following represent, in outline, the main problemssuggested for future discussion :

Hospital and General PractitionerGeneral :The employment of general practitioners in hospitals.Outpatient appointments ; letters from hospital to

practitioner after discharge of patients from hospital.JIaternity : :The extent to which beds for general practitioners should

be provided in maternity hospitals.Priorities for admission to maternity hospitals.The antenatal supervision of cases booked for admission

to hospital.Chronic Sick :

The care of patients in their own homes in cooperationwith the hospital staff.

Tuberculosis :The division of responsibility between general practi-

tioner and consultant for patients awaiting admissionto sanatoria.

The extent to which the consultant should supervise thedomiciliary use of streptomycin.

Mental Health :Certification by general practitioners.The relation of the general practitioner to the consultant

in regard to domiciliary consultations.Notification to the general practitioner of patients who

are discharged from mental hospitals.Hospital and Local Authority

Maternity : :Routine attendance at local-authority antenatal clinics

of women who have booked at maternity hospitals.The proportion of institutional confinements to beprovided for.

The criteria for admission to hospital and review bymedical officers of health of requests for admissionbecause of adverse social conditions.

The care of premature infants.

Chronic Sick :

The transfer from hospital of persons no longer in need ofmedical care to " part-3

" accommodation in institutions,hospitals, or homes for the elderly.

The establishment of the closest contact with generalpractitioners in regard to facilities for the home careof the elderly sick.

The coordination of hospital and local-authority medico-social services.

Tuberculosis :Assistance in rehousing.Provision of home helps and nurses to assist general

practitioners in domiciliary treatment.Problems of isolation arising from B.C.G. vaccination.

lVlerztul Healtla :

The use of psychiatric social workers and mental-healthvisitors in helping general practitioners with early mentalcases.

The relation of the consultant to the duly authorisedofficer of the local authority.

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1. The Health of the School Child : Report of the Chief MedicalOfficer of the Ministry of Education for the Years 1948 and1949. H.M. Stationery Office. Pp. 92. 3s.

Public Health

The School-child’s Health

THE inception of the National Health Service in

July. 1948, dislocated the school health service in onlyone important respect—namely, the partial collapseof the dental service through the resignation of dentistswho preferred to practise under the N.H.S. In his reportfor the years 1948 and 1949,1 Sir John Charles, chiefmedical officer of the Ministry of Education, remarks thatmost school medical officers seem to have found that thechanges in administration were made smoothly, andthat their work was little disturbed. Liaison with hos-pitals developed satisfactorily, although ’’it is notalways realised by the hospital management committeesthat the school medical officers have the machinery toput into operation after-care, in whatever form it maybe recommended." With free medical care now availableto all under the National Health Service, there is specialneed for close and harmonious understanding betweenthe school medical officer and the family doctor, inorder to avoid duplication ; in some areas thishas been achieved by the school medical officerholding conferences with the general practitioners.

DENTAL SERVICE

Whereas at the end of 1947 the number of dentistsin the school service was equivalent to 921 full-timeofficers, at the end of 1949 the corresponding numberwas 732. The report goes on to urge that dentists inthe school service should not preoccupy themselves withfilling deciduous teeth.

" For some time there has been an increasing tendency toadvocate extensive conservation of the temporary teethfor orthodontic .reasons. It is argued by a section of thedental profession that multiple deciduous extractions leadto serious irregularities of’ the permanent teeth in a sub-stantial proportion of cases. This proposition does notcommand universal acceptance but, even if it did, therewould still be a simple question calling for an answer. It isthis-is the conservation of a child’s temporary teeth fora few years at most, together with the avoidance of a con-jectural irregularity of the permanent dentition, more

important than the certain loss of another child’s permanentteeth (or, viewed from another aspect, the same child’spermanent teeth a few years later) ?

"

MEDICAL INSPECTION ’

School medical officers and assistant school medicalofficers in the service of local education authorities inEngland and Wales numbered 1680 in 1948, and 1855in 1949. The total time given by these doctors to theschool health service was equivalent to the full-timeservice of 832 doctors in 1948, and of 861 in 1949 whenthere was a ratio of 1 doctor to every 6421 children.

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During each of these years probably more than half thechildren on the registers were medically inspected.

In 1949 8 % of all children on the school registerswere found to be verminous. Figures for each year since1934, included in the report, show little tendency for theincidence of infestation to decrease. " These figuresare profoundly disappointing.... It is quite true thatmany slight infestations which escaped record fifteenyears ago would not do so to-day, but acceptance of thatas a complete and satisfying explanation of the figureshere given savours of wishful thinking."

TONSILLECTOMY

The number of tonsillectomies carried out on pupilshas fluctuated widely from year to year. In 1948 thetotal of 96,262 was the greatest since the peak year of1931, and has been exceeded on only three occasions-in 1929, 1930, and 1931. " It may safely be assumedthat one reason for the high number was the serious andwidespread epidemic of poliomyelitis in 1947. Thiscaused a postponement of operation, which wouldotherwise have been carried out in 1947."

The report cites a study by Glover which showed thatthe number of tonsillectomies has differed widely betweenone area and another. " Thus in 1948, a child in Birm-ingham was more than four times more likely to betonsillectomised than one in Manchester ; and, whileBristol in 1948 trebled her pre-war rate, Leeds reducedhers to one fifth. 2

OTHER ASPECTS

The report includes essays on the diabetic child, onchild guidance, and on the prevention of tuberculosis.From the first of these we learn that in England and

Wales between 30 and 50 children under the age of15 years still die from diabetes every year. This " isa strong argument in favour of hostels for the minorityof diabetic children whose supervision at home isunsatisfactory."The review of child guidance ends with the following

comment : -

" It is regrettable that psychiatric and psychologicalreports are frequently couched in terms which are quiteunintelligible to a layman, and indeed are sometimes incompre-hensible even to medical colleagues.... If the reports areobscurely phrased, it is suggested that the school medicalofficer should discuss the matter in an informal and friendlyway with his colleague who has written the report. Theremoval in this way of possible misunderstanding will domuch to prevent that disrepute of child guidance whichresults from the use of incomprehensible jargon."With regard to the prevention of tuberculosis, 341,727

school-leavers have been examined by mass radiographysince the first unit was put into operation in October,1943. The findings have been :

Active primary tuberculosis ...... 154Active post-primary tuberculosis.... 318

Tuberculosis-pleural effusion...... 51

Benign intrathoracic neoplasms.... 14

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SCHOOL MEALS

The number of pupils taking school dinners rose from2,500,000 (52.3 %) in February, 1948, to 2,851,000(53-2%) in October, 1949.

" The past ten years have seen not only a great increase inthe number of children taking meals at school, but the

development of the service out of all recognition. Between1939 and 1949 the school meals service multiplied roughlyseventeen times. This in itself was an achievement, butequally significant is the change which has taken place in thecharacter of the service during that period. Generally speaking,the feeding centre ’ has given place to the school eanteer4’and even where the change has not as yet become completethere is ground for optimism, because what is considered agood standard for a school meal has been recognised and, intime, the good will oust the bad."

The percentage of children taking school milk was88 in February, 1949, and 86-9 in October, 1949. Bythe end of 1949 over 98 % of all milk distributed underthe scheme was pasteurised or tuberculin-tested.

2. Glover, J. A. Bull. Min. Hlth P.H.L.S. 1950, 9, 62.

Old People Living at Home

Suggestions for improving the welfare arrangements forold people are made in a circular issued by the Depart-ment of Health for Scotland. There are three main

points :(1) To minimise the danger of neglect of old people living

alone, the name and address of the person to whom casesneeding attention can be reported should be published locally.In some areas a register of such cases is kept, and this practiceshould be adopted generally.

(2) A meal service for old people who find difficulty inpreparing sufficient food for their proper nourishment shouldbe available in all districts.

(3) Responsibility for deciding whether a particular oldperson, who cannot be looked after at home, should beadmitted to a hospital or to local-authority accommodationmust be accepted by either the local authority or the hospitalauthority. Doubts about the position in such a case havearisen in the past, probably because of the shortage of bothhospital and residential accommodation.A separate memorandum deals with the meal service,

which, it is suggested, should be provided by voluntaryeffort supported by local authorities. A minimum chargeof 9d. for a normal meal should be made ; the NationalAssistance Board will help an old person whose lack ofmeans otherwise brings him within its scope and whomight be unable to pay this charge. It is emphasisedthat the object of the service is not to augment theresources of the old people, but to ensure that they getenough properly cooked food.

There will always be some old people, says the circular,who wish to be left entirely alone ; and under any systemthere will be danger of such people being found eventuallyin serious distress. But everything possible must be doneto allow them to preserve their independence and yetkeep fit.

Guidance on Design of Houses

Houses, 1952,1 a new supplement to the HousingManual, 1949, contains plans of the type of house whichthe Minister of Housing and Local Government wouldlike local authorities to build this year in order (a) toget more houses from the limited resources, and (b) toreduce capital costs and rents.The main rooms in plans illustrated in this booklet

are as large as those recommended by the DudleyCommittee ; but savings are made in the total superficialarea by careful designing, notably of passage space,storage space, and access from front to back of thehouse. Various ways of achieving essential standardsare described, including " dining-hall " and " largeliving-room " houses. These types are an innovation inhouses of this size in Britain.

The introduction to the booklet says :" To show the present saving by adopting these designs

it has been estimated that a house in Groups I or 11 wouldcost at least £150 less than the average house being builtat the present time, and this would mean a saving in rentof 2s. 5d. per week. The capital saving should be more inthe case of the three-bedroom house and rather less for thetwo-bedroom house ; there would also be price variations inthe different regions. For instance, one council in the Midlandshas already (December, 1951) built a pair of three-bedroomhouses to similar economical designs at a cost of under£1000 each-terrace blocks should show a greater saving.The average cost of three-bedroom council houses com-

pleted in this part of the country was then about£1400. This saving of about £400 means 6s. 6d: a weekless rent." ;

1. H.M. Stationery Office. Is.

" . . . it is to me a sobering thought that almost the twobiggest items of expenditure by the local health authority isin relation to the Home Help Service and to the Hospital CarService ; both desirable, perhaps both necessary, but equallyboth far removed from what one would term the field ofpositive health work."—Dr. HENRY ROGER, medical officerof health for East Suffolk, in his report for 1950.