We agree with Richard Coker1 that the vast majority of non-compliant cases of tuberculosis can be dealt with by a mixture of directly observed therapy (DOT) and inducements. However, when DOT fails in a few cases each year, despite intensive team effort and carrots such as housing or food vouchers, the Public Health Act may have to be invoked. We have had recourse to this measure four times in the past six months but, though providing valuable breathing space, it is extremely costly and proved ineffectual as a solution each time.

Once the patient is admitted there are still potential problems. Treatment cannot be enforced and patients can abscond. There have also been instances of patients assaulting staff, physically and sexually, issuing death threats, breaking hospital property, and terrorising other patients, even interfering with others’ oxygen therapy. Dealing with such patients puts hospital staff and patients under unacceptable pressure and requires extra staffing for security purposes. NHS hospitals were not designed for, nor are they staffed adequately for, custodial purposes.

There is an urgent need to review the Public Health Act and make provisions for small specialist units staffed by nurses with training in and an aptitude for interpersonal skills. Admission to the unit would usually only be required for short periods of time until precipitating circumstances were resolved and alternative arrangements made. The threat of compulsory admission, or a short period thereof, may induce a behavioural change in the patient, allowing DOT to be successful after failing previously. In addition, a centrally based mobile unit of trained staff could be available to help tide teams over emergencies and could reduce the need for the specialist unit, enabling more non-adherent patients to be managed in the community.

We call upon the Department of Health to examine and implement these proposals.