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PUBLIC HEALTH

Hospital Services in ScotlandIN contrast to the position in England and Wales,

where the power of local authorities, including countycouncils, to provide hospital accommodation of anykind is absolute under the Public Health and LocalGovernment Acts, in Scotland it is limited to thecouncils of counties and large towns (over 20,000 inpopulation) and is contingent upon approval bythe Scottish Department of Health of consideredschemes for the reorganisation of the hospital facilitiesof these councils. South of the Border, it is true, acouncil proposing to make new hospital provision mustconsult a body representative of the voluntary hospitalsin the area, but there is nothing to compel it to adoptthe latter’s suggestions. If it intends to borrow forthe purpose, as is usually the case, the Minister’ssanction must be obtained so that, indirectly, theMinistry of Health is able to signify its approvalor disapproval of the scheme. In Scotland, however,the central department’s duty to review the wholeof the institutional provision in an area, whetherunder council or voluntary management, before

signifying approval of a scheme, is obligatory underSection 27 of the Local Government (Scotland) Act,1929. The Scottish department must, therefore,review all the hospital accommodation available forthe people of an area when any proposal for increasingor reorganising it is made, and it must be satisfiedthat the authority has taken reasonable steps to seekand continue to secure full cooperation with everyvoluntary hospital, university, or medical schoolwithin or serving the area.

FIVE REGIONAL CENTRES

It will be seen that this duty really places thedepartment in a position to exercise the initiative inhospital reorganisation and it has set out a very definitepolicy as to how the Act of 1929 should be madeeffective. The great teaching centres of Edinburgh,Glasgow, Aberdeen, and Dundee have all along serveda much wider area than these towns through theirassociated hospitals, and it is proposed that theseshould form regional centres, a fifth region, comprising alarge part of the Highlands, being centred on Inverness.The department has set its face against the multi-plication of small and inefficient units. Its aim isset out thus :—

(1) to raise the standard of institutional treatment ofthe sick poor to the accepted general hospital standard ;

(2) to secure, by cooperation-in any of its numerousforms-between local authorities of adjacent areas themaximum development of a few chosen institutions ratherthan the uncoordinated extension or indefinite continuanceof a large number of small units, more or less duplicatingone another’s services, equipment, and staffs ;

C,

(3) to foster cooperation between the statutory and thevoluntary hospital authorities so that together they maymake a full contribution to the treatment of the sick, tomedical teaching and research, and collaborate in the solutionof those problems of hospital administration (e.g., allocationof patients, scales of charges and payments of staffs) in whichtheir interests are, or must ultimately be, inextricablyintertwined.

Even before the transfer of poor-law functions, ameasure of cooperation between districts had beenattained, some use had been made of poor-law hospitalsfor medical education, and the city and county councilsof Aberdeen had gone far in attaining a commonhospital policy, in collaboration with the voluntary

1 Sixth Annual Report of the Department of Health forScotland, 1934. H.M. Stationery Office. 3s. 6d.

hospitals serving their areas. Obviously it willtake a long time to make the proposed regional systemreally effective. Practitioners in remote parts willincline to send their difficult cases to the teachinghospitals where they were trained, in preference to acentre which, perhaps, they have never seen, and withthe staff of which they have had no contact. At first

sight it would appear that the inclusion of Argyll,parts of which are close to and within easy access ofGlasgow, in a region centred upon Inverness isirrational, but, no doubt, the department is facedwith the need for increasing the population served atthis centre in the interests of efficiency, and it maybe that it expects difficulties of distance and transportto be overcome by the development of the air ambu-lance service already established by Argyll countycouncil and other Highland authorities.

COUNCIL OR POOR LAW

As in England and Wales, the council hospitalsexceed the voluntary hospitals in number and accom-modation. There are 243 council hospitals, with18,670 beds, as against 206 voluntary hospitals, with12,575 beds. When, however, special hospitals ofthe kind which serve those purposes which have longbeen the province of statutory public health admini-stration are deducted (e.g., hospitals for fevers,tuberculosis, maternity, and children’s diseases) thereare left, under local authorities, 59 poor-law generalhospitals, with 5570 beds (of which 55, with 3270beds, are mixed institutions, in Scotland calledpoorhouses), and 5 general hospitals, transferred awayfrom the Poor Law, containing 1580 beds. Thetotal number of general hospital beds under localauthorities is therefore 7150, compared with about7000 voluntary beds allocated to general surgicaland medical work. The department draws attentionto the inferior structure and inadequate staffing ofmost of the 55 mixed poorhouses, and the badtradition which hinders their development. Nothingshort of the removal of the sick from these institutionsto proper hospitals will, in its opinion, enable theideals underlying the Act of 1929 to be achieved.It should be one of the first aims of local healthadministration. The retention under the Poor Lawof some of the largest and most up to date of thetransferred hospitals, such as those in Glasgow, isa matter for some surprise, but it must be rememberedthat the Scottish Local Government Act containeda saving clause in Section 12, enabling a council totransfer administration of an institution to anothercommittee than the public assistance committee " forthe purpose of coordinating the services provided bythe council," an action which could not be taken inEngland and Wales without the formality of appro-priation. In effect, therefore, it is possible in Scotlandto substitute the spirit of public health administrationfor that of the Poor Law, while leaving the selectionand admission of patients under the old regime.It is a compromise, however, which should be tempo-rary and is bound to hinder that full cooperation withthe voluntary hospitals and medical schools whichthe department desires.

LOCAL OBSTACLES

While some progress in hospital reorganisationis recorded in 1934, the department is meeting withobstacles of local interest, prejudice, and inertia forwhich, no doubt, they were prepared. An attemptto centralise accommodation for infectious diseasesin Ayrshire has failed because of disagreement as to

888 PANEL AND CONTRACT PRACTICE

methods between the county and Kilmarnock towncouncils. An effort to persuade Dunfermline towncouncil to look far ahead in its planning of new

maternity beds, so that they should ultimately formpart of a hospital centre, was only partially successful.The town council of Stirling seems to be determinedupon the improvement of its own small fever hospitalrather than cooperation with the county council.In spite of more enlightened movements in Invernessand Fife, the department records that progress inhospital reorganisation has been slow and, on thewhole, disappointing.

APPOINTMENT OF A DIETITIAN AT HAMMERSMITHHOSPITAL.-Among the special cases concentratedat Hammersmith Hospital will be many requiringspecial dietetic treatment, and a special dietetic

kitchen is being arranged, to be ready for use, ifpossible, by July 1st. All the L.C.C. hospitalshave food supervisors in charge of the ordinarykitchens, but it is proposed to put a dietician incharge of this kitchen at a salary of jB150-j310-jB200,together with board, lodging, washing, and uniform.

L.C.C. AND LC.A.A.-The London County Councilhaving been informed by the Invalid Children’sAid Association that its provision of convalescenttreatment for children referred to it by hospitals,care committees, and the like, is likely to be curtailedby lack of funds, the Council proposes to use theservices of the Association for the disposal of childrenfor whom the Council is itself unable to provide.Capitation payment will be made at the rate of7s. 6d. a week for eight weeks, and the situation willbe reviewed in six months’ time.

PANEL AND CONTRACT PRACTICEA National Laboratory Service

IN the teaching hospitals the medical student iscalled upon to devote a large part of his time to

laboratory work, both practical and theoretical, butso far as the medical man going into panel practice isconcerned, this part of his training is largely nugatory,for the National Health Insurance Acts make no

provision whatsoever for any form of laboratoryservice for patients insured under the Acts. Theinsurance practitioner may prescribe what he likesin the way of drugs, proprietary or otherwise, but heis given no facilities for ascertaining in the firstinstance whether his diagnosis be correct, and in thesecond the response of his patient to the treatmentgiven. Sir Ernest Graham-Little recently asked theMinister of Health if provision could not be made atan early date for such a laboratory service, but theMinister held out no hope of any immediate extensionof the scope of medical benefit in this direction. Amemorandum issued by the Association of Clinical

Pathologists points out that in certain districts, e.g.,Manchester and Wigan, local arrangements have beenmade, rendered possible by loop-holes in the Acts, andfor the reason that unallocated funds happened to beavailable. In other areas, e.g., Chester and Wolver-hampton, laboratory facilities have been offered

by the local voluntary general hospitals at specialcheap rates. The Association holds the view that amatter of this importance should be dealt withotherwise than by taking advantage of loop-holes inActs of Parliament or by the charity of voluntaryhospitals, and for some years past it has been urgingthe inclusion of laboratory examinations as a benefitunder the National Health Insurance Acts. A scheduleof charges has been drawn up at which the investiga-tions essential in general medicine can be performedwithout loss to the laboratories performing them.The Association is of the opinion that clinical pathologycan only be properly carried out by those in closetouch with clinical medicine, that is to say, in thelaboratories attached to general hospitals. Thereexists to-day a network of such laboratories conveni-ently distributed over England and Wales in all themore important towns ; with their aid the pathologicalservices needed by insured patients could readily bemet.

The Practitioners’ Fund for 1934The amount of the fund has been finally determined

by the Ministry of Health at E6,676,573. This amountis subject to economy deductions, 10 per cent. for thefirst half year, and 5 per cent. for the second, theamount available for distribution being f6,175,830.Insurance practitioners therefore contributed from

their remuneration in 1934 over half a million poundstowards placing the country on a sound financial basis.It is to be hoped that the Chancellor of the Exchequer,in view of his Budget surplus, may be able to restorethe capitation fee to its normal value during the,present year.

London’s share of the fund continues to decrease.In 1933 the areal percentage was 12-6666, but for1934 it was 12-5685, producing 776,209. Of thisamount 762,645 10s. had been distributed byway of quarterly advances, so that including a balanceof ;E1 7s. lid. brought forward from 1933 thereremains 13,564 to be distributed, as compared with18,892 last year. The total payment for 1934 willamount to 8s. 7’4932d. per unit of credit, as comparedwith 7s. 11’4652(. for 1933. Some of this increase is,of course, due to the remission as from July 1st of halfthe economy deduction, but the clearance of themedical register which took effect as from Jan. 1st,1934, made a difference of nearly sixpence in the valueof the unit of credit in London.The amount of the fund for 1935 has been provi-

sionally determined, after deduction of 5 per cent., atjoe6,050,000, and, as in previous years, the Ministry statethat it must not be assumed that the final determina-tion of the fund will necessarily enable any additionalpayment to be made to practitioners at a later date.

. What is a Partnership ? P

This question sometimes becomes a conundrum,It was related in this column on Feb. 2nd that Dr. A.and Dr. B., having between them a list of some 5000insured persons, were said to be in partnership.Dr. B. left the practice and Dr. C. joined Dr. A. asa partner, signing the necessary form, in which itwas declared that Dr. C.’s share of the profits wasnot less than one-third of Dr. A.’s. Informationhaving been received about the terms of the agreementbetween Dr. A. and Dr. B., the committee refused torecognise Dr. C. as a partner until the partnershipdeed had been produced for inspection. The com-mittee’s solicitors held that Dr. C. was not in theposition of a principal and that his share of theprofits was obviously less than a third of Dr. A.’sshare. The insurance committee agreed with the

legal opinion, and it was expected that the firm wouldbe surcharged for the 1000 patients or so exceedingthe maximum permitted to principal and assistant.The practitioners having been informed of thisdecision, their solicitors wrote contesting it but

expressing the willingness of Drs. A. and C. to considerany change in the partnership deed which the com-mittee’s legal advisers might suggest as desirable.