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TENURE OF OFFICE OF MEDICALOFFICERS OF HEALTH.

A LARGE and representative deputation was received onThursday afternoon, June 5th, in a private committee room ofthe House of Commons by the Chancellor of the Exchequer(Mr. Lloyd George), the President of the Local GovernmentBoard (Mr. Herbert Samuel), and the President of the Boardof Education (Mr. J. A. Pease). Mr. Montagu, M.P.

(Financial Secretary to the Treasury), Sir Horace Monro

(Permanent Secretary to the Local Government Board), Dr.Arthur Newsholme (Chief Medical Officer to that Board), andSir George Newman. (Principal Medical Officer to the Boardof Education) were also present.- The deputation, whoseobject was to bring before the Government the necessity oflegislation to provide security of tenure for medical officersof health, was joined by a deputation from the SanitaryInspectors’ Association, with a similar object for their con-stituents, and comprised representatives of the BritishMedical Association, the Society of Medical Officers of

Health, the National Housing and Town Planning Council,the Mansion House Council, the Rural Housing and Sanita-tion Association, the Sanitary Inspectors’ Association, andcertain Members of Parliament and private individualsinterested in the question.The deputation of medical ofricers of health, which was

arranged by the British Medical Association, was intro--duced by Sir PHILIP MAGNUS, M.P., who said that last yearhe introduced a Bill in the House of Commons which hadfor its object the remedying of the acknowledged grievancesof medical officers of health. That Bill did not pass itssecond reading, and the then President of the Local Govern-ment Board gave him to understand that it containedclauses with which he was not altogether in agreement.Subsequent to that an important meeting of some of therepresentatives now present was held at the offices of the BritishMedical Association, and it was felt that it might be desirablethat a Departmental Committee should be appointed to inquireinto the whole matter. Before arriving at such a decisionit was suggested that those interested should endeavour tocome before the President of the Local Government Board,the Chancellor of the Exchequer, and the President of theBoard of Education, with a view to ascertaining what wasthe best course to pursue in order to remedy the grievances -to which he had referred. As the objects which the

deputation desired might involve the expenditure ofTreasury money, it was desirable that they should have thesympathy of the Chancellor of the Exchequer, and further,as some medical officers of health, as education medicalofficers, were doing work very similar to that of medicalofficers under the Local Government Board, it was well thatthe President of the Board of Education should be present.The main grievance from which medical officers ofhealth had so long suffered was their want of securityof tenure in the offices they held. This militated verymuch against the performance of the arduous duties-confided to them, and it was a Gilbertian state of

things that medical officers of health should practicallybe under the direction of persons whose defects theyvery often had to point out ; they were prevented to a verygreat extent, unless they were almost more conscientiousthan human beings were generally found to be, from

representing to local authorities the conditions of the slumsin some of the cities as thoroughly as they would like to do.Moreover, a large number of medical officers of health hadnot the advantage of any scheme of superannuation. A,third grievance, for which he hoped some remedy might befound, was that the more work medical officers of healthdid the less they were paid, as at present travelling andother expenses had to be paid out of salary.

Dr. CHRISTOPHER ADDISON, ILP., hoped the Governmentwould take the representations of the deputation into seriousconsideration and give medical officers of health that securityof tenure necessary not only in their own but in the publicinterest.

Mr. E. J. DOMVILLE, Chairman of the Public Health Com--mittee of thie British Medical Association, said that theAssociation had formulated the opinion of its members in

Representative Meeting as follows :-That in the general interests of public health and the medical pro*

fession it is desirable (i.) that medical officers of health should as a rule

(and without prejudice to those at present holding part-time appoint--ments) be required to devote their whole time to official duties; (ii.; .that medical officers of health should be adequately paid, districts .being grouped where necessary to make this practicable; (iii.) that allmedical officers of health should participate in a Government super---annuation scheme ; and (iv.) that all medical officers of health should be -protected in the proper discharge of their duties against capricious-dismissal or reduction of salaries.

The Local Government Board, through its inspectors, had.consistently urged this course upon lccal authorities. Itwas clear that special study and training- in hygiene,including chemistry and bacteriology, did not tend to.

improve the medical man’s opportunities for the generalpractice of ’medicine, and when once a man devoted histime to this branch of work as a speciality he lessened his-chances of success in general work, and he ought to be-freed from the necessity of attempting -to earn his- livingin that direction. It had been constantly found that theefficiency of the medical officer of health had been impairedand his independence of action restrained by the conscious-ness that his future depended upon the extent to which hisaction commended itself to his immediate employers, whose -individual interests were often involved. It was clear that -any officer whose excess of zeal had rendered him unaccept--able to one local authority would have no chance of beingsappointed by any similar body. At the same time provisionshould be made for the removal of officers-whose inefficiencyhad been proved to the Local Government Board, and the--benefits of a scheme of superannuation should be providedfor those who had reached an age limit.

Mr. HERBERT JONES, President-elect of the Society o"Medical Officers of Health, said the object of the deputationwas to put before the Government three disabilities medicalofficers of health were under-the lack of security of tenure ;--the lack of superannuation ; and thirdly (this only-referredto a certain number of medleal officers), in having to payout of salaries uncertain sums for travelling expenses and’office and clerical expenses. Medical officers of health didnot mean by security of tenure that whatever they did and ’however badly they carried on their work they should,remain in their posts. What they did suggest was that theyshould have such security of tenure as would enable them to -carry out their work without any chance of those to whomthey might give offence turning them out of office.

Mr. LLOYD GEORGE : Now you are on that very importantpoint, is it your suggestion that there should be an appeal tothe Local Government Board whenever there is a notice todismiss an officer 7

Mr. HERBERT JONES : Quite so ; we have always heldthat.

Mr. DOMVILLE: We ask that the Local Government Boardshould not sanction appointment for a limited period.

Mr. HERBERT JONES : The next point I want to raise isthat what medical officers of health feel is that they do not’know exactly how far they may go without giving offence to-their authorities.

Mr. LLOYD GEORGE said this was a very important point.He wanted to know what exactly was the position now. It-had not been stated up to the present.

Mr. HERBERT JONES : The position is that a medical’officer of health is elected now and can be dismissed by the -authority that elected him, after three months’ notice, butwithout any appeal.

Mr. LLOYD GEORGE : Without any appeal to the LocalGovernment Board under any conditions ? 7 I understoodthere are a few who have a right of appeal.

Mr. HERBERT JONES: Those are county medical officers ofhealth, also the metropolitan, Scottish, and Irish medicalofficers of health. They have the right, and we ask for thesame treatment for the remainder.

Mr. LLOYD GEORGE : There are only about 100 of these ? 7Mr. HERBERT JONES replied that there were more with-

the metropolitan ofr2cers. Other medical officers wantedsimilar treatment. At present before tbey sent awaytheir annual and other reports- many officers found it

necessary to go through them and blue-pencil anythingwhich they thought might endanger their position. It.was a terrible confession to make from the point of viewof the interests of public health. Medical officers wantedto know exactly how far they might go. At present they-were very much in the position of shepherds-driving sheepnear the edge of a precipice. A fog suddenly came down, .and the shepherd did not’know how near he might go td-the edge without endangering himself. When the fog:-

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lifted the tragic thing was that half the sheep might bekilled. Medical officers of health asked that a fence mightbe put at the edge of the cliff.

Mr. LLOYD GEORGE : Just to give you confidence.Mr. HERBERT JONES added that medical officers wanted

the fence to be a secure one. With regard to superannuation,which was closely bound up with this subject, ministerswould. no doubt be aware that the Royal Sanitary Commis-sion, which first recommended the appointment of medicalofficers of health, made a definite representation that theyshould have superannuation and have the same positionas any other civil servant. One reason the society herepresented was pressing for superannuation was thatthere were some 60 or 70 medical officers of health whohad been very seriously hit by additional legislation putforward and additional Orders of the Local GovernmentBoard. A certain number of them, who were paid a fixedsalary and had to pay travelling expenses, found theywere no longer able to put by what they used to dofor retirement because of the extra expenses chargedagainst their salaries. More work meant for them highertravelling expenses and office charges and a lower netincome. Having accepted office on this basis these menmade no complaint so long as the conditions remained thesame, but that was not the case. Not only had extra workbeen put upon them, but public health was an advancingscience, and to carry out their work as it should be donemedical officers had to add to their expenses. He had obtainedinformation from some of his colleagues which showedthat two or three days in a week were occupied in clericalwok which could be done better and cheaper by a clerkat 30s. or 2 a week, instead of men in receipt of f.600 to.B8CO a year being engaged upon it. Office expenses werealso a charge upon the salary of a medical officer of healthserving under these conditions, and a third expense wastravelling about the district. The area he (Mr. Jones) servedwas 600 square miles in extent, and if-as he could not,though he would like to do-he were to carry out the latestTuberculosis Order he would have to travel from 3000 to5000 miles in a year and bear the cost out of his salary.Medical officers said that was a most unfair state of affairs.His remarks under this head did not apply to every medicalofficer of health, but only to 60 or 70 of them in ruraldistricts and small areas.The Dean of WORCESTER said that for many years he was

an active member of a housing committee in one of the mostpopulous districts in the county of Durham, and he hadpersonal experience of the effect of the medical officer beingindependent. Being a county medical officer the position atDurham of the medical officer of health was unassailable,which gave him strength in dealing with the committee andin making reports upon property sometimes owned bymembers of the committee. The medical officer in thosecircumstances never had any reason to fear that any back-handed influence would be brought to bear upon his position,and consequently he could deal with property without fearor favour. He had lived in other parts of the country, wherea different condition of affairs prevailed, where medicalofficers not only went through their reports to consider howfar they might go without offending the authority; he hadactually known of a medical officer of health being requiredto re-write a portion of his report.

Mr. LLOYD GEORGE: By whom?The Dean of WORCESTER: By his council. He had to do

it or he would have been dismissed. Not of course for hisrefusal, but he would have disappeared.

Mr. T. C. HoRSFALL, on behalf of the National Housingand Town Planning Council, said he would speak from the t

point of view created for him by membership of the council,by 40 years’ membership of the Manchester and Salford fHousing Association, and by long connexion with a univer- 1sity settlement in a very poor part of Manchester. The 7powers possessed by urban authorities were now very great. r

They had control of education under the powers given them t

by the Housing and Town Planning Act, especially by their c

power of limiting the number of houses to the acre ; they Ihad greater powers than were possessed by local authorities t

anywhere else. But there was a very marked want in most of our large towns-the want of an influence powerful tenough to create a strong party of reform upon town councils r

and amongst citizens themselves. Unless the zealous members a

of a town council had the support of a large number of the n

citizens they could do very little. The best instrument forreform would assuredly be a perfectly fearless medical man.How were perfectly fearless medical men to be obtained ?At present it was the duty of the medical officer of healthnot to be as fearless in the interests of public health as heought to be, because in many places he knew that, if he tookup a very active policy, a party hostile to him would be formedon the town council and his tenure would be extremely brief.It would always be desirable that a medical officer of healthshould be prudent and tactful, but at present the tendencywas for him to be much too prudent.

Mr. W. G. WILKINS, on behalf of the National Housingand Town Planning Council, said that it was alwaysfelt that in the medical officer housing reform had a strong ’friend, but that the circumstances of his appointment pre-vented him from putting his sympathy into action in manycases.

Miss CONSTANCE COCHRANE supported the objects of thedeputation on behalf of the Rural Housing and SanitationAssociation.Mr. JAMES PARKER, M.P., introduced the representatives

of the Sanitary Inspectors’ Association, saying that sanitaryinspectors found themselves in this matter in practically thesame position as medical officers of health. They came intoquite as close touch with members of the councils andneeded also security of tenure.

Sir JAMES CRICHTON-BROWNE, speaking for this deputa-tion, said that the Sanitary Inspectors’ Association had1600 members, who were carrying on the work of sanita-tion in every part of the country. Their case for security oftenure was an even stronger one than that put so forciblybefore the Ministers by the bodies representing the medicalprofession. The medical officer of health had a certainscientific prestige and social status, and he had the

support of a powerful and determined profession thatwould resent any injustice. But the sanitary inspectorhad no union behind him, and he was liable tobe very summarily dealt with if he gave offence.The medical officer was the advising authority, but the

sanitary inspector’s hand stirred up slumdom, and he wasmost likely to become obnoxious to owners and to tenantswho preferred to go on wallowing in the mire. He mentionedthat the present occasion was the fourth time of asking asfar as sanitary inspectors were concerned, and he causedsome amusement by quoting the expressions of sympathyused by members of the various governments on whom

previous deputations had waited.Mr. H. H. SPEIRS also spoke on behalf of the Sanitary

Inspectors’ Association, pointing out that recent legislationhad greatly increased the work of inspectors, but that therehad been no corresponding rise in the scale of theiremoluments.

Mr. LLOYD GEORGE said that part of the demands involveda request for money from the Exchequer, and he had beenlured there rather on that account. He was not quite surewhat answer he could give. After what Sir James Crichton-Browne had said he would not dare to give a sympatheticanswer, and as he could give no other he was rather at aloss. He had never heard a case which was more irresistible,and never, if he might say so, one which was better

presented. His attention had been called to this grievancevery largely through investigations he had conducted,more especially in the last two or three years, andhe had come to feel that these officers were the pivotupon which the whole health administration turned. He

agreed with what fell from Mr. Horsfall, who had had veryconsiderable experience in this matter, that the powersentrusted to local authorities, even at the present moment,were enormous. He would like to see some of themstrengthened, but until greater independence was securedto officers who administered these powers it was idle forParliament to waste any more time carrying new Acts.That was why he felt that some form of security of tenure,that would give independence not merely to the medicalofficer of health but to the inspector, must be an essentialpart, if not an essential preliminary, to any further legisla-tion dealing with the housing question. It was essential forgood local administration that the executive officers shouldbe in a position in which they would feel that they couldreport without fear or favour upon actual conditions in thoseareas. It was put very well by Mr. Herbert Jones in ametaphor that he appreciated very much as he himself came

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from a mountainous area. The medical officer of healthmust be given confidence ; he did not know how to tread.Parliament could not deal with local problems ; they mustbe dealt with locally. Parliament could legislate, but thework must be done in the locality. If the foothold of thelocal officers was a slippery one they could not do theirwork ; it was impossible when a man was liable to be dis-missed at three months’ notice. As Mr. Domville had said,it was not easy for a medical officer of health to begin a newcareer, because his training and experience incapacitatedhim for a class of work to which he might otherwise havedevoted himself-namely, the building-up of a private practice.Therefore, when the community invited men to do work whichwas the most important they could undertake, it was the dutyof the community to stand at their backs and protect them.He was whole-heartedly in sympathy with the demand

put forward. So important did the Government considerthe position of local medical officers of health that whenthe Budget was being framed, and it was a question of dis-tribution of grants, it was felt that there ought to be

specific grants for the payment of a substantial partof salaries of local officers. That put the central

authority in a position to demand better terms from localauthorities, and it was an important feature of the grant.The great majority of local authorities would welcomethe change, although there might be interests which wouldbe opposed, for he was sorry to say that in some areas

people got elected purely to protect certain interests.He understood the President of the Local GovernmentBoard was considering the question of superannuation,but that he was not satisfied with the scheme put forwardas far as medical officers of health were concerned.Meanwhile, it was important that medical officers ofhealth should have a superannuation scheme, because, forone reason, it was the only way of getting rid, withouthardship, of men who were past their work. He was gladto see Members of Parliament on both sides of the Housepresent with the deputation. No Government was all-

powerful in a Parliament. In order to carry throughmeasures of this kind, which were non-contentious, whichdid not arouse partisan zeal, and so did not get behind themthat sort of hydraulic pressure which ensured their passing-in respect of such measures it was necessary to obtain acons iderable amount of support from both sides of the House,and he would invite Members on both sides to negotiatethat kind of support for a measure which would deal withthis problem.Mr. Lloyd George then left to meet a deputation

elsewhere.Mr. HERBERT SAMUEL said that the claims of the

deputation really divided themselves into two parts : First,those relating to the tenure of their offices, and, secondly,those relating to the superannuation of medical officers ofhealth and sanitary inspectors. With respect to the ques-tion of security of tenure, he had held the view for manyyears, and had expressed it on more than one occasion,that the country could not expect really efficient adminis-tration of the health laws unless officers concernedwere protected from the injustice which might now

penalise them as a result of conscientious work. He pro-posed to take the question in hand straightway andfirst to consider how much could be done under theclauses of the Finance Bill to obtain this security of tenurewithout legislation, because he believed it might be possibleto effect a great deal without waiting for the slow processesof Parliament and the chances of a Bill. One of the diffi-culties placed in the path of medical officers of health wasthe fact that nearly four-fifths of them were engaged inprivate practice and their work might be affected by theprivate interests of patients. Therefore it had long been thetendency of the Local Government Board to urge that when-ever possible whole-time appointments should be created. Theexhortation had not always fallen on willing ears. Localauthorities sometimes, because they liked to keep entire con-trol over the appointments they made, were unwilling to com-bine with their neighbours. Whenever possible medicalfunc-tions were combined, and the Local Government Board and theBoard of Education had made it a practice to encouragethe combination of education medical officership and publichealth appointments, and that policy would continue. Butwhen the question of security of tenure was being considered it had to be taken into account that while the principle

was wholly right for whole-time men, where part-timemen were concerned it might be advisable not to maketheir positions permanent, but to pave the way for theirsupersession by whole-time officers. In general he agreedthat there should be security of tenure also for sanitaryinspectors. With regard to a superannuation and pensionscheme, Mr. Samuel said that in many cases medicalofficers of health retained their posts until they reached75, 80, or more years ; they could not afford to give upthe posts, and the local authorities would not inflictthe hardship of calling upon them to retire. He wasadvised that the Superannuation Bill introduced by SirPhilip Magnus last year was not actuarially sound ; thatthe benefits proposed could not be provided by the con-

tributions which the Bill suggested, and therefore theGovernment could not advise Parliament to assent to it.Furthermore, he found it difficult to distinguish the case ofthe medical officers of health and sanitary inspectors inregard to superannuation from that of other local authorityofficers. As to security of tenure, there was a differencebecause of the fact that other officers were not exposed tothe same difficulties as medical officers of health and sanitaryinspectors. But in regard to superannuation, all that hadbeen said by the deputation might be said with equal truthby representatives of other classes of officials of localauthorities, and he was receiving this month a deputationfrom the National Association of Local Government Officers,who would come to urge the very arguments that the medicalofficers of health and sanitary inspectors had urged. Hethought it would be wise for him to reserve any remarkshe had to make on this subject until he had heard thatdeputation.’ Mr. HERBERT JONES reminded Mr. Samuel that he had

not referred to the subject of travelling expenses.Mr. SAMUEL : That seems to be a matter for you to discuss

with local authorities when making agreements with them.Do you suggest that the Local Government Board, bylegislation or by some other means, should make it obligatoryon the part of local authorities to pay expenses ? Whatmeans do you suggest ? Mr. HERBERT JONES said the payment of travelling

expenses by local authorities should be obligatory.Mr. J. A. PEASE remarked that if there was one branch ofthe Government service which was keenly concerned abouthealth it was the Board of Education. The problem ofeducation was primarily physical, and it was absurd toexamine children medically in the schools and to have themtreated if they returned from healthy schools into slums andunhealthy surroundings.

Dr. ADDISON then thanked the Ministers for receivingthe deputation, and said he believed he oould say, on

behalf of fellow Members of Parliament who were

interested in this question, that they would take theChancellor’s hint as to non-political cooperation and act

upon it.The proceedings then terminated.

ROYAL COLLEGE OF SURGEONS OFENGLAND.

MEETING OF COUNCIL.

AN ordinary meeting of the Council was held on June llth,Sir RICKMAN GoDLEE, the President, being in the chair.A report was read from the Board of Examiners in

Anatomy and Physiology for the Fellowship, stating that atthe recent examination 122 candidates were examined, andof these 40 were approved.A report was read from the Court of Examiners, stating

that at the recent examination for the Fellowship therewere 75 candidates, and of these 40 acquitted themselvessatisfactorily.

In was resolved to issue Diplomas of Fellowship to thesuccessful candidates. It was resolved to issue Diplomas ofthe Licence in Dental Surgery to 7 successful candidates.

In accordance with the recommendations of the Nomina-tion Committee the following examiners were appointed forthe ensuing year -Elementary Biology : George P. Mudgeand Walter G. Ridewood. Anatomy under the ConjointBoard : John Cameron, J. E. S. Frazer, and A. Melville