The Lancet Jan. 20, 1945

Lecture delivered in London on Oct. 13, 1944, under the Chadwick Trust.

SOMERVILLE   HASTINGS,   MS LOND.,   FRCS Chairman Of  The  London  County Council

Hospital Management in Peace and War

I desire to bring before you some observations on the administration of hospitals in peace and war. I need hardly remind you that I shall be speaking only for myself and not for any organisation with which I happen to be associated. Moreover, I am not proposing that all these suggestions are immediately practicable. They are, I believe, ideals to be aimed at, rather than proposals to be carried out everywhere at once.

THE  GENERAL FRAMEWORK

I want to speak of hospitals as hospitals—that is, living dynamic organisations—and am not proposing to discuss how they should be planned and built, or whether they should be municipal or voluntary.

Nevertheless, the time has long passed when a hospital can be looked upon as an isolated unit, for no single hospital can economically provide for every type of patient who may require treatment. It is generally agreed, I think, that the best medical and surgical work is usually carried out in the wards of a large general hospital. Some would suggest that in association with such a hospital there might be pavilions for infectious disease and tuberculosis, though I do not regard this myself as desirable. Neither do I feel that declared mental disease is best treated in connexion with a general hospital, although at least one of a group of two or three general hospitals should have wards or a separate block for the observation of early acute cases of mental diseases, as well as for the treatment of those not requiring certification, because in both there is often some physical illness that needs attention at the same time. This also has the advantage of readily accessible psychiatric advice for any patient in the general wards who needs it. A good many cases of chronic illness, after thorough investigation in a general hospital, can be usefully transferred to hospitals where they can stay longer. Institutions for younger patients, such as those with chronic heart trouble or requiring rehabilitation treatment, are best situated in the country; but old people, who are not likely to recover, will be much happier in hospitals near their homes.

With the exception therefore of fevers, tuberculosis, declared mental disease, and some chronic cases, most patients needing hospital care are best dealt with within the wards of a large general hospital. For every unit of population of about 100,000 one such hospital of approximately 800 beds will be necessary. There is therefore, in my view, no place in the ideal system for the small cottage hospital, for the patients of such hospitals and their friends are certain to urge upon their doctors the treatment of conditions for which they have neither the experience nor the facilities. The continued education of the general practitioner is much better secured by associating him closely with the work of the large general hospital and by revision courses. Neither is there, in my view, any place for what are generally described as special hospitals; for you cannot cut the body up into little bits and treat each part separately.

It is not suggested, however, that every general hospital should have special departments for the in-patient treatment of every disease. There should be medical, surgical, gynaecological, and perhaps maternity wards in every hospital, but for specialties such as eyes, skins, ear, nose and throat, hospitals should be grouped and wards provided for such cases in one of a group of three or four. For specialties less often in demand, such as neurosurgery, chest surgery, thyroid surgery, plastic surgery, and radiotherapy, a single department for a group of eight or ten hospitals may be sufficient. It is of course assumed that officers in charge of a special department will attend and give advice at any hospital of the group, although for the treatment of ordinary cases beds will be provided in only one hospital.

Children present a peculiar problem, forming as they do a special type of patient, subject however to diseases of every kind and of every part of the body. There should be a paediatrician attached to every maternity department. In addition it may very often be advan­tageous to have children’s wards in one hospital of a group of three or four, when geographical conditions make this possible. Probably, however, the best arrangement of all is a hospital for children only, with its special departments for diseases of different regions, and a hospital school attached to it for long-stay cases in the country.

If the foregoing principles are accepted, even in general terms, it will be agreed that what is necessary is not a number of independent hospitals but a hospital system such as, for instance, that of the joint authority contemplated by the Government’s white paper on the health services. Such a body will have many and important functions. It will have to determine the conditions of service of the staff of all its hospitals, and costing arrangements, as well as the type of case to be admitted to each hospital, and this last may have to be altered at short notice in case of epidemic or emergency.

This then is the general framework into which all hospitals will have to fit. We can now pass to the more detailed examination of each individual hospital.

MANAGEMENT  COMMITTEES

Every hospital should have its own committee of management. In the past this committee has been in complete control in the case of the voluntary hospitals, each of which has usually acted as an isolated unit. If, however, there is to be a hospital system all the really important decisions will have to be made by the central coordinating body. To what extent then is there a place for a committee of management of each individual hospital? Would it not be better to group hospitals for this purpose or abolish local committees entirely? One obvious advantage from the point of view of the hospital staff would be the avoidance of the duplication of authority—there would be one committee only to satisfy instead of two. Nevertheless in my opinion every hospital ought to have its own committee of management, and I would delegate to such a committee all decisions that can safely be left in its hands, remembering that variation is essential for evolutionary progress.

One of the most valuable assets of the voluntary system has been that through committees of all sorts, and other means, people of a district have been induced to take an interest in their local hospital and feel that it is their own. Even if in the future hospitals should be mainly or entirely supported by public funds, I hope these committees will continue and be extended to all hospitals. It is good for a hospital to be in intimate touch with the public that uses it. It is good for the staff to realise that their labours are known and appreciated. However complete the public provisions may appear to be, there will always be funds to be provided, personal services rendered, and experiments in social service carried out, by voluntary effort. In addition to committees of management, most hospitals will there­fore benefit by Samaritan, aftercare, entertainments, library, and other committees. To the committee of management should be allocated the appointment and discipline of the junior staff, the carrying out of cleansing and minor repairs up to an agreed sum, and other matters. Its main duty will be, however, to make recommenda­tions to the central committee which will have to con­sider these not only as they affect the particular hospital but also the service as a whole.

STAFF  COMMITTEES

To what extent should the staff of a hospital be in a position to influence its administration? I am of opinion that every member of the staff—medical, nursing, and lay—should not only realise the importance of the work he or she is doing, but should also feel assured that any suggestions he may desire to make for the more efficient running of the hospital will receive appropriate consideration. It must be made clear from the very first that if staff committees are formed, they must be advisory and not executive, and deal solely with means of improve­ment of the services provided by the hospital. Discipline, rates of pay, and conditions of service must be entirely outside their terms of reference, being dealt with by national committees, trade-unions, or similar organisations

The medical superintendent, where one exists, and all members of the senior and intermediate medical staff, should be members of the medical staff committee. The junior staff should also appoint representatives. The committee should elect its own chairman. It has been suggested that if there is a medical superintendent he should ipso facto be chairman of the committee. This appears to me undesirable and liable to limit freedom of discussion and recommendation. The terms of reference of the committee should be wide and should include such matters as accommodation, staffing, teaching, research, and equipment. Certain of the recommendations of the medical staff committee will be within the jurisdiction of the hospital superintendent, and if he is in agreement they can be carried out at once. Otherwise they will come before the hospital committee with other matters within the terms of reference of that committee. Other recommendations will go to the central coordinating body either direct or (perhaps better) through a central medical staff advisory committee formed of representatives of the medical staff committees of all the hospitals in the unit.

The nursing staff committee should have a similar constitution. It should consist of representatives elected by student nurses of the first, second, third, and fourth year, of staff nurses, ward, and administrative sisters, and also assistant and male nurses, if employed. Bach of these categories should meet independently to discuss problems and elect representatives. It is probably best that in most hospitals the matron should not be a member of this committee, but recommendations made to the hospital management committee would be seen by the matron and she would no doubt in many cases report to that committee that she had already taken the necessary action. A central nurses’ advisory committee formed of representatives of the local committees to deal with questions of general application and to report direct to the central coordinating body might also be desirable.

In at least one hospital at the commencement of the present war the medical superintendent called together representatives of every grade of staff and asked for suggestions for the running of the hospital during the difficult times ahead, and this committee has been meeting at intervals ever since. Joint production and efficiency committees have proved of value in, industry and ought to be tried out in hospitals. They would have nothing to do with staff matters, but would make it possible for every employee of the hospital to make suggestions for its more efficient running. These staff advisory committees should be formed of representatives of every grade of staff and make recommendations to the hospital committee.

CLINICAL  UNITS

Every general hospital will require at least three departments—medical, surgical, and gynaecological. The medical will usually be the largest, for it will include the chronic sick. Each department, general or special, should be staffed on the “clinical unit” system—that is to say, there should be a physician or surgeon of consultant status, who would be in complete clinical charge, with an assistant, one or two registrars, and a variable number of junior and senior house-officers. In the case of the special departments the clinical unit would be centred in one general hospital, but the doctor in charge or his assistant would attend at other hospitals as required, and also, it is hoped, at health centres and to see patients in their own homes.

THE  SUPERINTENDENT   MEDICAL  OR LAY?

Perhaps it may be useful at this stage to consider the much discussed question of whether the superintendent or director of a hospital should be a doctor or a layman. At Guy’s Hospital there is a medical superintendent and a lay clerk to the governors, each responsible for matters within his own sphere, and the system apparently works well. But in most hospitals it is found to be more convenient to have one person responsible for the general administration of the whole institution, leaving the clinical care of patients to the doctors in charge. Should this superintendent be a doctor or a trained layman? In the case of hospitals for infectious and mental diseases and tuberculosis the decision should be easy.

The cases are all of one type, and, the sphere being limited, it is possible for a single individual to become an expert inall maladies dealt with in that particular hospital. The chief clinical officer will therefore natur­ally become the head of the hospital. In the case of infectious disease, especially, he may well also become the clinical consultant of his district.

In the past, the officer in charge of a municipal hospital has been a doctor, but in a voluntary hospital it is usual to appoint as secretary-superintendent, a layman. It is clear that no single doctor can have sufficient know­ledge and experience to deserve a place as the head of each of the clinical units into which a hospital is divided, and accordingly it has been suggested that one of the heads of the clinical units should act as medical superin­tendent and that the individual selected should be changed every few years. This suggestion has in my opinion nothing to recommend it. A good clinician is but rarely a good administrator; nor would one expect the head of a clinical unit who was really keen on his work to be willing to leave it even for a few hours daily to undertake the administrative control of a large hospital. Nevertheless, there is much to be said for the superintendent of a hospital being a qualified doctor. A man with medical experience is in a much better position, to deal with complaints of patients and their friends, as well as to solve the administrative problems which a committee may present to him. In matters of discipline and the allocation of duties among the medical staff the medical administrator has a distinct advantage. Moreover, it is clear that in the future hospitals will function as a system and not as a series of isolated units. This must imply not only some central control, but also at times rapid change of use of wards or even whole hospitals. A doctor will be in the best position to carry out instructions of this nature.

The work of a medical superintendent is both important and absorbing, but if such an individual is to maintain his keenness and breadth of outlook it is probably desirable that a portion of his time should be devoted to other duties, as for instance the medical care of the resident staff or some branch of medicine or surgery in which he is interested. I have seen the work of medical superintendents who are also pseudo-specialists, and it has not in every case been such as to enhance the respect due to them from those under their administrative charge. A better proposal is as follows. It seems pretty clear that some form of National Health Service is on the way. If, as has been suggested, the country is divided up into units of 100,000 people with wherever possible a large general hospital in each, it might be desirable for the medical superintendent of the hospital to act administratively as supervisor also of the con­sultant services of this unit and also of the health centres or other general-practitioner services.

When a hospital stands as an isolated unit its super­intendent, be he medical or lay, will have to advise the committee of management, which is in complete control, and his responsibility will be great. When, however, a hospital is one of a group or system, all major issues will! be decided by the central coordinating body, and the superintendent will be able to consult the permanent staff of this body in case of doubt. In either case the superintendent should have an intimate knowledge of the law as it affects hospitals, accidents, and employees as well as mental and infectious disease and public health generally. Although there will usually be an engineer to advise on problems of maintenance of buildings, heating, lighting, and so on, and a steward to deal with accountancy and supplies, the superintendent should have considerable knowledge of these also. It seems desirable therefore that all those aspiring to an adminis­trative staff appointment or to become the superintendent of a hospital should be encouraged to take a diploma in hospital administration. It may also be said generally that an officer who has had some experience of central administrative staff work will make a better hospital superintendent.

FULL-TIME   OR PART-TIME   STAFF ?

In my opinion the best results are likely to be obtained if the medical staff of a hospital are full-time officers. I am well aware that the consultant, who visits patients of the well-to-do in their homes, is supposed to derive from this a breadth of outlook unobtainable by any other means. I unhesitatingly agree that for a full under­standing of its natural history, disease must be studied as it occurs in the homes and work-places of the people. But surely the consultant who, as proposed in the white paper, visits, when necessary, any person of whatever class, however lowly, in his home will have a better knowledge of aetiology than one who, as at present, sees no more than a favoured few. By visiting patients in their homes, by outpatient as well as inpatient work, by constant contact with colleagues in every branch of practice and perhaps most of all by research work, the full-time hospital doctor should find no difficulty in maintaining interest and keeping himself up to date. Visits to other clinics in this country and abroad should be encouraged, as well as attendance at national and international conferences.

The hospital doctor, whether a full-time officer or not, should live within a short distance of the hospital in which his patients are warded. The treatment of disease, both medical and surgical, is a continuous process in which the highest skill available may be required at any time. There can of course be no objection to the consultant or specialist travelling some distance from his home to give an opinion, but the surgeon who attends a cottage or other hospital at weekly or fortnightly intervals and undertakes routine operative treatment at these visits is in my opinion asking for trouble.

But while all doctors should live near the hospital in which their patients are housed, comparatively few ought of necessity to live in. In the past, I think, many hospitals, especially municipal, have asked too much of their medical staff. Of course there must always be some doctors on the premises to deal with such sudden emergencies as severe bleeding or suffocation. There must also be highly skilled personnel on call. Fortunately, however, there are very few cases in which serious harm will result from waiting the 10 or 15 minutes that it should take such assistance to reach the hospital. The doctor who, living near the hospital, spends most of his leisure in his home, will usually be of greater value than the resident who spends all his available free time in visiting his wife or friends some distance away.

PROFESSIONAL,  AND  POLITICAL FREEDOM

A great deal has been written regarding the need for complete professional, intellectual, and political freedom for members of the medical profession. If, as seems likely, some 90—100% of the doctors will become engaged in the public service either whole or part time, to grant anything less would be to disenfranchise the profession. And this must apply not only to the doctors but to other health workers as well. All must therefore have the right to speak or write anything they desire. All must also have the right to stand for Parliament. In the past a teacher employed in the State schools has been allowed to become a member either of any local authority or of any but the one that employs him. To apply any such restriction under the set-up envisaged by the white paper with a joint hospital authority covering a large area, would be to exclude doctors and other health workers from sitting as elected representatives of an area in which their local knowledge could be of particular value. Might it not be sufficient if the usual rule were applied, and such representatives asked to withdraw whenever their financial interests were directly or indirectly affected by the matter under consideration?

WORK AND  PROMOTION

A few other points in connexion with medical staffing may be mentioned. It takes many years of training and experience, gained unfortunately by failure as well as success, to make an efficient doctor. Surely everything should be done to make the most effective use of experience gained at so great a cost. To expect therefore such an individual to write letters and keep notes of cases, when this can be done both more quickly and efficiently by a shorthand-typist, is wasteful in the extreme. The provision of such assistance will be found to increase the output of work of many hospital doctors considerably.

One of the weaknesses of the voluntary hospital system is fixity of staff, many of whom, like myself, have remained attached to the same hospital continuously since their student days. It is rarely that a doctor under 40 should remain for more than 5 years at one hospital, and a medical superintendent, whatever his age, ought to change his hospital fairly frequently. Some little experience has convinced me that, with very few exceptions, a medical superintendent has made his greatest contribution to any one hospital within 10 years of his appointment to it.

And now a word about promotion. It is human nature to prefer the known to the unknown, and the committee of management of a municipal no less than of a voluntary hospital generally exhibits a strong tendency to appoint the man or woman on the spot rather than a stronger candidate from outside. The only way to avoid this danger is by having a large unit of hospital administration. Junior or house officers might well be appointed by the committee of management of a hospital in consultation with the medical superintendent and head of the clinical unit concerned. All above this rank should be elected by the central coordinating body or a committee appointed by it. But while it is essential that the final selection should be made by this body, the short­listing, if not indeed the placing of those selected in order of merit, should be carried out by a body of experts. For clinical appointments the short-listing committee should consist of the heads of clinical units in the branch of practice concerned, together with representatives of the central staff: for administrative appointments there should be representatives of the medical superin­tendents and central staff. It is to be hoped that before long all hospitals of any size will take their place in a scheme for undergraduate or postgraduate education. In that case university representatives should be added to the shortlisting committee for all senior appointments which may involve teaching.

STUDENTS

At this point I would like to interpolate a few words about the value of students to a hospital. All who have engaged in clinical teaching will realise how useful to the teacher is the impact of young, vigorous, and critical minds. But that is by no means all. Students bring a breath of fresh air from the outside world which is felt by all — nurses, patients, everyone. Where students are widely distributed, as they must be for efficient clinical instruction, few patients will object to their presence for they realise that fresh facts are often brought to light by the discussion of their cases. The presence of students, either undergraduate or post­graduate, adds to the prestige of a hospital and improves both the status and efficiency of its staff.

NURSES

I shall not’ venture more than a few general observations on the administration and conditions of service of the hospital nursing staff. The student nurse must be regarded much more as a student and much less as a source of cheap labour than at present. With this in view she must be given a chance to gain experience in the nursing of as many different types of patient as may be required, even if this necessitates a change of hospital. She should work a 48-hour week or less, and these hours should include not only all lectures and classes but also an hour a day spent compulsorily in library or classroom for study or the writing up of lecture notes. The only satisfactory way to study a clinical profession is to read up details of the work on which one is actually engaged, and every student nurse must have ample opportunity for doing this.

Unless the student nurse’s home is reasonably near the hospital she should reside within its curtilage during her student days. She should be housed in a hostel presided over by a warden, who should be responsible to the medical superintendent for the order of the hostel and well-being of the nurses. As much freedom should be granted as is consistent with the important duties that the student nurse has to perform, and while the matron of the hospital should maintain strict discipline as long as the nurse is on duty or in the classroom, her jurisdiction should abruptly cease directly the nurse leaves the hospital.

There is a good deal to be said for making the residence in hospital of all State-registered nurses and sisters optional. Given a comfortable bed-sitting-room and facilities for entertaining visitors there are many nurses who prefer to live in a hostel with friends and colleagues; and especially is this the case during difficult times like the present. On the other hand there are some who feel that the complete freedom that they desire is impossible under these conditions. There is no doubt that the right thing is to leave the matter to be determined by the individual nurse or sister, but this uncertainty of demand gives rise to serious difficulties on the part of those responsible for the provision of hostel accommodation. The nurse who marries and sets up a home will of course live out. She should be required to give up nursing only temporarily before and after childbirth.

PRIVACY FOR PATIENTS

People vary greatly as regards their reactions to their fellow beings. Some, perhaps because they have lived under more or less overcrowded conditions all their lives, cannot bear to be left alone even in sickness. Others, when ill, desire solitude beyond all else. It would not be very expensive to change all hospital wards into curtained cubicles, and I am hopeful that this may be achieved within a few years of the end of the war. The provision of curtains, together with the occasional change of the position of patients in the wards, should go far to satisfy the wishes of most. But in addition, for those who are acutely ill or noisy or in any way likely to disturb others, a supply of single-bedded side wards is essential. Surgical cases are especially liable to be restless during the first night after operation. It is useful therefore to have a section of a surgical ward partitioned off by a glass screen. To this section new cases are admitted, and in it they remain until the day after operation, when they should be transferred to the other part of the ward.

Should wards or rooms for paying patients be provided in hospitals and should payment be for privacy and extra amenities only? Or should there be in addition fees to the doctors for services rendered? I would answer both questions in the negative. However hospitals may be paid for in the future, I feel that there must be no demand for any immediate financial contribution which could act as a deterrent and tend to prevent anyone from taking advantage of the hospital services that he needs. But if hospital treatment is free to all, no-one will be willing to pay for it unless he expects to receive superior amenities or greater care in treatment, as in practice he certainly will. This must necessarily imply that the services provided for those who do not pay this extra sum are not of the best. It is infinitely better, I think, to try to raise the standard for all than to provide an improved service for a favoured few, selected solely because of their relative affluence. Small wards, cur­tained cubicles, and a sufficiency of side wards should be capable of giving privacy to all who desire or need it.

There is one relatively small matter in which both voluntary and municipal hospitals are too often sadly lacking. It is in provision for the comfort of those visiting seriously ill relatives. A room, that can be warmed, with comfortable easy chairs and couches, should be provided and provision made for a simple  meal at night if necessary. It is not  likely that such amenities would be often abused.

WAR

Comparing the present with the last great war, there have been two definite improvements. First, the Emergency Medical Scheme, through which all hospitals of any size, both municipal and voluntary, have had to obey the instructions of the Ministry of Health, has brought some order into our chaotic hospital system. Secondly, Service cases have been admitted to the same hospital as civilians and treated by the civilian doctors in them to a much greater extent than in the last war. This classification of patients according to the nature of their affections rather than the type of clothing that they wear is certainly a step in the right direction. But it must go further and be extended to the wards of hospitals, for every type of disease requires its own special type of nursing and treatment. It is manifestly absurd to have in the same hospital different wards for civilians, sailors, soldiers, and airmen with a few cases’ of the several types of disease in each. It should be easy to so assimilate the regulations governing the feeding and behaviour of each of these classes that neither becomes adversely affected by the presence of the other. All cases of allied affection could then be treated in the same wards with consequent benefit to all concerned.

In conclusion, I wish to express my thanks to Sir Allen Daley, MOH for the County of London, for much helpful advice, both in the preparation of this lecture, and also during the 10 years of administrative experience that made it possible.

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