Hospitals are a vital part of any medical service. It has often been stated that if at the time Mr. Lloyd George intro­duced the National Health Insurance Act he had provided instead a hospital service by means of insurance payments, he would not only have changed the whole course of develop­ment of the medical services in this country but would have given the working class something it required even more than the guaranteed service of a doctor. The National Health Insurance Act left the hospitals in entirely the same position as they were, and nearly twenty years were to pass before another Parliamentary Act was to change the whole possi­bilities of British hospitals.

We have, as everyone knows, two different hospital systems—the voluntary hospitals and the public hospitals, the voluntary mainly financed by their own schemes and by public charitable support, the others provided almost entirely from taxation. These hospitals have developed during some hundreds of years. The voluntary hospitals are, in the main, the outcome of two methods of establishment. Most of the large voluntary hospitals and particularly those which are associated with the teaching of students, were founded a very long time ago for the treatment of the indigent poor and were often endowed by one person or associated with the good work of some notable Christian. The small voluntary hospitals, on the other hand, and some of the larger ones in modern industrial centres, are usually of a more recent date, and while in some instances the impetus which led to their foundation came from well-intentioned, wealthy individuals, there is a number which has come into being as a result of a local demand among the public— as, for example, those founded as memorials to those who were killed in the Great War —and not infrequently as a result of a movement among general practitioners to establish some kind of hospital service in which they: might have ;a measure of control.

The public hospitals were mainly founded in the last century as a result of the increasing number of people coming under the Poor Law who were in need of medical attention. The development of these was very slow and very uneven, and while in one district a Board of Guardians might have developed its hospitals to a high degree of efficiency, others  remained both architecturally and medically places which could, only be completely condemned.   Until the intro­duction of the Local Government Act in 1929 it: was impossible for even the best Poor Law hospital to compete with a good voluntary, hospital. They were hampered by the legal necessity for every patient admitted to be, technically at least, a recipient of Poor Law relief.   The Local Government Act at last made it possible to remove the Poor Law hospitals from the public assistance system and convert them into municipal hospitals under the :control of and financed by the Public Health Committees of the appropriate local authorities. What this means can best be seen in a study of the work of the Public Health Department of the London County Council, which in the ten years since it took over the Poor-Law hospitals has made the best of them comparable with many voluntary hospitals and has raised the worst of them to a position in which they can do exceedingly valuable work in nursing and healing.   Indeed, one London County Council hospital has been made the centre of the British Post-Graduate Medical. School, probably the highest centre of medical educa­tion in existence.

The voluntary hospitals are the oldest part of our medical service and have succeeded in maintaining their position as completely isolated units right up to the present day, when, as we shall see, they have themselves been compelled to recognise that they can no longer face modern conditions without some form of mutual co-operation.   These hospitals were origin­ally founded by people who believed the Middle Ages’ teaching of the Church that it was the duty of Christians to perform charitable works and to attend to the sick and the poor. Founded therefore on charity, the hospitals :earned the title ” voluntary,” and in earlier times this meant that all the work done in connection with; them was of a voluntary nature and all the money necessary for the maintenance of the sick was obtained by voluntary gifts.

Today the position is very different, and in some hospitals almost the only part of the service which is. voluntary is the work of the honorary medical staff, and only a small pro­portion of the income arises from gifts donated in a purely voluntary fashion. How far removed from the ideals of Christian charity are those hospitals which need a large staff of paid workers to run an Appeals Department and devise schemes for collecting money! The flag day still remains the most popular method, but serves more and more to illus­trate how unreliable charity has become as a means of maintaining the health of the community. Not only are hospital staffs kept busy finding money, and incidentally costing a very considerable portion of the money which they thus collect, but few patients obtain any service from a voluntary hospital without paying in some way. The hospital almoner, who in earlier days answered the dictionary definition and bestowed the charity of the hospital on the poor, has become instead a collector of whatever small sums even the poorest can be persuaded to pay for services received. To such an extent have the users of hospitals resented this re­versal of the voluntary and charitable principles that there has sprung into being, as we have noted, a very largely supported system of insurance by regular contributions against the need for hospital care.

This is of course a better system than that which was at one time the mainstay of many hospitals, and which still exists to a very large extent— the patronage system by which wealthy subscribers earn the right to nominate so many out­patients and so many in-patients according to the amount of their subscription. The securing of such nomination— the letter, or “line” as it is called in many parts of the country—is essential before the patient can obtain hospital care, but it does not guarantee admission, which is still at the: discretion of the medical staff, nor does it free the patient from the attention of the lady almoner. It may be noted that membership of hospital contributory schemes does not automatically secure admission either, but it should be suffi­cient to cover the patient for all charges coming within the scope of the scheme.

One interesting development that has arisen out of the patronage system is that such organisations as works committees, trade unions, and co-operative societies have been led to make regular contributions to hospitals so that they may have a supply of hospital letters to distribute to members who need them. In some districts the amount obtained by the hospitals from this source reaches a considerable sum. Whether such payments may be considered either volun­tary or charitable is an open question.. For our purposes it is enough to note that the yearly income of all voluntary hospitals shows a steady increase in the proportion obtained as payments from patients, by contributory schemes, and by other similar methods. We must add that local authorities now have the power to pay voluntary hospitals for services rendered and to make considerable contributions from the rates. If all these amounts are added together, it is found that in the provinces of England and Wales only 32 per cent of the income is gained by new charitable contributions. It has been admitted that the voluntary hospitals have to main­tain a constant struggle to discover new methods of raising money, and are constantly revising their system for recovering some part of the cost of maintenance from the patients.

Despite these efforts the voluntary hospitals find them­selves increasingly in danger of bankruptcy. It is no ex­aggeration to say that a very large proportion of the time spent at meetings of hospital boards is taken up with ques­tions which hinge on the state of the hospital’s finances. This may cause difficulties in the medical treatment of patients, for it is a common experience of all staffs of hos­pitals that even when the Medical Committee is unanimously in favour of certain provisions or certain procedures they may find it impossible to obtain the sanction of the Finance Committee. There are those who fear that an organised hospital service may restrict the rights of the medical staff, but at least patients should be ensured that whatever is necessary for their health and well-being can and will be provided. The voluntary hospitals themselves have realised that they are no longer able to give a service wholly in keep­ing with modern ideas. An attempt is therefore being made to “rationalise ” the hospitals, not in the sense in which a scientist would use the term but in that familiar to business men and industrialists who reorganise great industries so that their output and financial profit may be increased. The Nuffield Provincial Hospitals Trust, generously financed by Lord Nuffield, is actively engaged in persuading voluntary hospitals that they can no longer exist as isolated units, and is setting up councils and committees to reorganise the voluntary hospitals so as to concentrate their finances, to cut out over­lapping hospitals, and to provide a service which will still contain certain features of the present voluntary system.

At the moment it looks as though the Nuffield suggestions for regionally organising the hospital services will lead to the disappearance of some of those voluntary hospitals which are of such a size that they are usually termed “cottage hospitals.”   These are usually hospitals so small that they cannot possibly provide a complete hospital service, or can only provide something approaching a complete service by extravagant methods.   We shall see in a moment how the honorary staffs of the larger voluntary hospitals are provided but cottage hospitals usually have no resident medical officer, receive only periodical visits from the consultants of larger hospitals, and are generally staffed by local practitioners. This is of course a complete denial of the whole modern con­ception of the function of a hospital, which is to provide a hospital service in which those special methods of diagnosis and treatment which are beyond the powers and scope of the general practitioner can be provided;  and that the patients admitted should be in the hands of specialists able to give higher opinion than that of the general practitioner who has first seen the case outside.   The patient who for any reason requires hospital care should at the same time obtain a differ­ent opinion from that of the general practitioner who has recognised his own inability to deal with the case in the patient’s home.

Cottage hospitals have served a useful purpose in areas where no other hospital service existed, and they do give the general practitioner a connection with a hospital which may be of considerable professional advantage to him. It is clear, however, that except in remote country districts their useful­ness has vanished, and their function must either change or they must become part of a general hospital service.

There is one thing upon which all voluntary hospitals have long been agreed, and even if one must say it with regret the medical staffs appear to have accepted the same idea, and that is that they do not wish to take care of the “unprofitable case, the indigent, the unemployed, the mentally  ill, the chronically sick, or the acutely infectious.”   It was the exist­ence of these unprofitable cases which led in some ways to the establishment of Poor Law hospitals, which, up till the change already mentioned, were very largely reserved to the care of the aged and those suffering from chronic diseases. Indeed, it was no uncommon thing for voluntary hospitals— at least in London-—to send on cases from their own wards to the public hospitals, either because after a few days stay they proved to be uninteresting and therefore unprofitable, or because the acute illness which had justified their admission to the voluntary hospital had become chronic.   The public hospitals are legally unable to refuse admission of patients, and so were often used by the resident medical staff of large voluntary hospitals as a means of relieving pressure on beds which they preferred to use for acute cases. The other cases we have mentioned— the infectious and the insane— presented problems which could only be solved by organisations set up by the State or local authorities. Had the voluntary system been in any way a possible method of providing the hospital service which the sick of this country require, it should, of course, have been capable of dealing with every type of illness. As it is, we have now reached the position that out of 450,000 hospital beds, only one-fifth are provided by the voluntary system.

It cannot yet be claimed that all the public hospitals have reached a satisfactory position either in administration, in the  standard of medical service provided,  or in general amenities.   Indeed, there are still over 50,000 hospital beds controlled by the antiquated methods of the Poor Law. Where the public hospitals have been “appropriated “—that is to say, transformed into municipal hospitals—the rate of progress has in many instances been exceedingly rapid, but the Boards of Guardians who built most of these hospitals seventy or eighty years ago built them to last for generations and the mere alteration of buildings to meet modern require­ments has presented many difficulties.   Where these have been overcome, and reasonable comfort ensured, the patients are gradually realising that these hospitals belong to them, and that while the authority controlling them has the legal power and uses it to assess payment for hospital care within the limits of the patient’s income, the staffs have appreciated the true position of the patients regarding ownership of the hospital, and patients have themselves an, opportunity of in­fluencing development of these institutions.    Britain’s Health(Pelican S. 27) says.that there are “many advantages in the method of staffing public hospitals as compared with that employed in a voluntary hospital.   The staff is more closely integrated under the leadership of the medical superintendent. Instead of a number of specialists, one doctor is usually responsible for the patient throughout his illness, although he utilises specialist services.   One of the advantages from the patient’s point of view is said to be that he is less likely to be patronised:   He has also an appeal in the case of a grievance to his own elected representative on the local authority, and may have more freedom in so far as he is treated less as a case and more as a human being.”

This latter point is undoubtedly a reflection on the staffing arrangements of the voluntary hospitals.   Briefly, the system is to have as resident officers a number of newly-qualified doctors who are paid at a very low rate because they are still supposed to be completing their medical education.   If the hospital is sufficiently large there will be one or more resident officers of longer experience, usually men who are studying for a higher degree and taking this type of hospital job because of. the experience it offers.    The remainder of the hospital staff are “Honorary.”    This term refers to the physicians, surgeons, and other specialists who, in return for being made  members of the staff of the hospital, are expected to perform certain duties in the hospital, and have generally a certain number of beds for which they are responsible, but  receive no payment for their services.   For none of these services are they allowed to accept any fee from the patients, although in recent years there has often been a provision of “private” beds to which are admitted on certain terms patients who may pay the honorary staff for their services.

One of the duties which honoraries usually carry out is that of attending in the out-patient departments.   To a very large extent out-patients are still a feature of the voluntary hospitals, which is lacking in the municipal ones.   It is now possible for a municipal hospital to have an out-patient department, but in many of them these are only casualty offices at which emergencies are seen and minor surgical treatment given, while at others not even these facilities have yet been provided.   In the voluntary hospitals the out­patients usually comprise both a casualty department under the care of one of the resident or other junior officers, and a consultative out-patients at which the honorary staff see and give their opinion on cases which have been referred to them by general practitioners. There is in this matter a sharp division of opinion and of practice.   The British Medical , Association has always maintained that only those patients who present a letter from their own doctor should be seen by the honorary staff, unless they are attending by request after they have been in the wards.   This principle has been adopted fully by many hospitals, while some apply it only to Panel patients.   In the latter cases the hospital is saved from having to provide any medicine, which can be obtained through the general practitioner on a N.H.I, prescription, In other hospitals the foundation principle is still maintained and the out-patient department is open to all sick poor.

The great difficulty is, of course, that if all who believe themselves, to be sick are given the right to seek the opinion of a hospital specialist, the amount of work thrown on these doctors becomes so great that they can no longer carry it on as charitable work. At the same time there is the economic fear that if the hospital out-patients is made attractive and advice readily and freely given the general practitioner will suffer further reductions in the number who seek his advice.

Out-patient departments have their great drawbacks and every inquiry into hospital treatment that has taken place has condemned the arrangements made in these departments. The usual kind of arrangement is that the consultant—let us say the honorary physician—sees his patients at 2 p.m.    All patients are therefore advised that they must attend not later than 1 p.m., for there are certain formalities, such as the writing out of case cards and a visit to the lady almoner, to be got through first.   But if the physician is popular, many of the patients will try to get earlier on his list by coming soon after noon, for cases are of course taken in strict rotation. Most patients do reach the out-patients’ hall by the official time and then comes a long period of waiting in crowded and very often uncomfortable conditions which cannot be of benefit to those who are already ill.   An attempt ma, be made by one of the junior resident staff to see those patients who have not brought a doctor’s letter arid those who have been before and have come only for a fresh supply of the medicine prescribed, so as to diminish the number to be seen by the honorary.   Since he is a purely honorary officer who has of course many other calls on his time, and unless he is particularly conscientious, it is rare for him to reach hospital at the hour at which officially he should be there to see patients.   Between this and the possibility of there turning up among the patients seen at a particular session someone who has a condition requiring prolonged examination, those who are last on the list may, before they leave the hospital, have spent many hours in waiting.   When they require to be seen by other specialists they may have to repeat this same slow and time-consuming procedure on more than one occasion.   Doctors themselves condemn the methods here outlined and a few experiments have shown that an out­patient department can be run in such a way that patients are seen by appointment and need spend only a very little time in waiting.   Another advantage of an appointment system for out-patients is that sufficient time for a full examination can be allocated for each, for at present  treat­ment of some patients is perfunctory, even inconsiderate. This is partly due to the overcrowding, and the difficulty, therefore, of distinguishing the patient who needs really skilled treatment and care. It prevents much attention being paid to the individual convenience of patients. It is aggravated by the not infrequent failure of the honorary to appear and the necessity for one of the juniors to take over, so that those patients who have come from a general practitioner with a view to obtaining a higher opinion than his own may at their first visit fail to see anyone but a relatively recently qualified doctor. This need not be interpreted as a condemnation of the consultants of our voluntary hospitals, as most of them are in fact well qualified for the duties they have undertaken to perform, but when we recall that “Medicine is a service that is purchased by the patient; and sold by the physician,” we may reasonably ask whether anyone has the right to expect that a more efficient service should be given by doctors who have to earn their living by working outside their hospitals than by; those doctors who, as in the case of Municipal hospitals, are paid for the services they render to the patients using that hospital.

When we come to consider the arrangements for dealing with in-patients there is a very marked contrast between the voluntary hospitals and the municipal ones. In the latter it is an almost invariable rule that the staff are resident and full-time salaried officers. A few consultants for highly specialised subjects are usually called in at a fee per visit for special cases. In the voluntary hospitals the resident staff are, as we have already noted, the most junior members of the medical profession, The training of a doctor is a lengthy process, and as the curriculum stands at the present day he completes his studies and becomes registered while still lack­ing sufficient experience to be accepted as fully qualified for practice on his own. A useful method of obtaining further experience is to serve for a period in a hospital, acting as house physician or house surgeon to a member of the honor­ary staff. Unfortunately, while his acceptance of such a position may imply that the student has not yet become a doctor, the existing arrangements rarely allow him to remain a student, for the degree of supervision and instruction which he receives depends on the frequency and length of the visits of the consultant under whom he acts The amount of responsibility thrown on these young resident officers may therefore, be very considerable. In some instances they may have the health of a large number of patients under their care without even a visit from the honorary for quite long periods, yet they are paid exceedingly small amounts £50or £100 a year—-and often find irksome the code of behaviour laid down for them  by the lay committees of the hospitals. In other words they are treated on the one hand as responsible doctors and on the other hand as apprentices still undergoing instruc­tion..Some transition is unquestionably required, but this method of the voluntary hospitals is no longer in keeping with modern thought and will undoubtedly disappear as hospitals and medical services develop.

A well-known medical writer recently  remarked on this situation that the municipal hospital system “does, not pro­vide for the continued stream of young men holding short-time resident appointments, an admirable training for the best students after qualification’. If this criticism is valid, the most obvious change to make would be to rearrange the staffing of municipal hospitals so that there would be a very large increase in the number of junior residents’ positions ; moreover, if this is the best training for the young general practitioner, arrangements should be made that will enable every new graduate to have this additional education. It is in fact open to considerable argument that the work of a resident medical, officer whose primary duty is to do the donkey work for a senior surgeon is in no way comparable with the work which a general practitioner does in the homes of the people.

A hospital system must be devised in which, by relating it both to the domiciliary service and the work done in surgeries arid clinics, experience could be given to every newly qualified doctor in both general: practice and the routine of hospitals, and not only fit him for his future work but give him some experience on which to make his choice as to which branch he would prefer to adopt. At the moment many of the municipal hospitals do have a number of junior resident positions, but in general they are staffed by assistant medical officers who take the first :appointment for a period of three or four years but tend to become permanent hospital officers, When these hospitals were under the Poor Law they did undoubtedly have on their staffs a large number of medical officers who did not find sufficient stimulus in the work to reach a high professional standard. The position is now very different, and local; authorities like the London County Council, who have spent money on improving the hospitals themselves and have offered higher salaries in return for demanding a higher standard of qualification and experience, now attract medical men of all ages who can compete technically with the average honorary at a voluntary hospital Indeed it is no exaggeration to say that the amount of surgical experience, for example, which senior resident surgeons at municipal hospitals get is in excess of that obtained by most surgeons at voluntary hospitals.   There are already examples of surgeons working in municipal hospitals who have earned an international reputation.

Yet, however the hospitals are staffed and whatever the facilities for admitting cases to the beds, we have still to find an answer to our question— What help does the general practitioner get in diagnosis, and what assistance is there for the patient in treatment?   The difficulty remains that the general practitioner is cut off entirely from the hospital ex­cept in the case of those cottage hospitals which are staffed by the local doctors themselves and offer little additional assistance to them beyond that of having a convenient place to which they can send cases they are unable to deal with single-handed in the patient’s home.   There are three major difficulties in the separation of the general practitioner from the hospitals.   The first is that the, patient passes out of his hands and he has no opportunity to follow the course of the , illness, which would be so instructive in many instances: nor if a case is one in which he has a particular interest can he influence the treatment;   and in cases which recover he is not in a position to carry on post-operative care, or the treatment of diseases which last for a long time, unless he has full information from the hospital officer concerned.   The second difficulty is that the general practitioner does: not have that “mutual impact with senior experienced men which has been the source of the chief advances of Medicine.”   We must assume that whatever the hospital system the main body of doctors working there will be the best brains of the pro­fession, and it follows that only by meeting these men and .discussing with them cases which they know ultimately can the average practitioner absorb the knowledge and inspiration they can give.

We must remember, however, “that if the patient is in need of institutional and, therefore, probably specialist treatment, he should be able to get the very best.” In relating the general practitioner to the hospital, therefore, he cannot be given duties or powers which would place him in a position superior to that of the specialists inside the hospital.

The third difficulty is that even when a hospital has empty beds there may still be difficulties in admitting every case ,or particular types of cases. In pre-war London doctors often had great difficulty in finding a hospital prepared to take a case directly from the hands of the general practitioner and after much discussion and complaint an Emergency Beds’ Service was inaugurated, on application to which a doctor could always find a bed somewhere for his cases. Even if this system worked efficiently from the points of view of the doctors and of the hospital concerned it might often be un­satisfactory to the patient. That indicates how little control the patient has over his medical service once he has passed a stage at which he can be treated at home. The relation between the general practitioner and his hospital must be such that he is aware of the policy being pursued at any particular moment, that he knows what reserve of empty beds there is, and that he should be in a position to ensure the admission of those cases which his experience tells him are genuinely in need of hospital care.

It must be confessed that while the patient who lives within an easy distance of a large voluntary hospital and who is ill enough to go into that hospital will get every type of diagnostic and curative aid that is known, these resources of medical specialisation are not available in many parts of the country, are rarely obtainable in the homes of the people; and never procurable for those illnesses which are of a minor medical nature yet may be of vital importance to the patient arid to his future. In these matters he as in the hands of the specialists, and our next consideration must, therefore be the reason for the existence of this important section of themedical profession.

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