Confidential.

Labour Party. L.G.97/NOV.1938.

Public Health Advisory Committee.

The science of medicine has been undergoing profound changes during recent years. Diseases that but a few years ago were thought to be incurable are now yielding to treatment. The healing art is no longer mainly dependent on potions and pills, but is roping in to its aid the surgeon, the nurse, the dentist, the physicist, the bacteriologist, the bio-chemist, the masseur, the X-ray and radium expert, and a host of other technicians. It is becoming at once both specialised and mechanised. Two results of necessity follow:- Such is the limitation of the human mind, that for the diagnosis and treatment of all but the simplest illnesses, what is required is not merely a single individual but a large number of persons working together, and each one a master of the special work he undertakes. But however skilled the craftsmen may be, they cannot work without tools, and these are complicated and expensive, and are constantly being altered and improved. An operation is much more likely to be successful when it is performed in a modern up-to-date operating theatre with everything that the surgeon may need ready to hand, and skilled assistants available.

More and more therefore, people are being compelled to take advantage of hospital treatment when they are il1. In a working-class home of two to five rooms, with a family of any size, it is comparatively rarely that a serious illness can be nursed successfully and in those cases in which an operation or some specialised form of treatment is necessary, this is well-nigh impossible.

Unfortunately we have in Great Britain two entirely distinct methods of dealing with our hospital needs, the Voluntary and Municipal. Apart from those for mental disease there are a little more than twice as many municipal Hospital beds in England and Wales as Voluntary, and the figures for Scotland are about the same. The Voluntary Hospitals are of course much more in the public eye. They depend for what they can do on the financial support that they are able to obtain from the public, and the assistance given them without payment by the doctors, and for both of these propaganda and advertising are essential.

Of the two hospital systems the Voluntary is by far the older. Some Voluntary Hospitals have existed for hundreds of years, and it may be said generally that in those staffed by specialists and consultants, and with a medical school attached, the quality of the work is of the best. The exact relationship between the hospital and the medical school is not in all cases appreciated by the public. Patients are apt to regard the enquiring young men and women whom they find around them, as rather a nuisance. But these young people, at the zenith of their mental power, wanting to know the why and the wherefore of everything, and longing to find their teachers in the wrong, have a very salutary and stimulating effect on the whole hospital. Moreover, when these same young people become qualified doctors and go out into practice, whom are they more likely to call in for a second opinion than the consultants and specialists who have taught them all they know? It is this fact and the income that it ensures, that makes the appointment to the staff of a hospital with a medical school so highly prized and enables these hospitals to command the services, without salary, of some of the very best brains in the medical profession.

But although the best possible medical work can usually be expected in the large Voluntary Hospitals with medical schools, staffed by consultants’ and specialists, and with, as a rule, most of the necessary apparatus for efficient examination and treatment the same cannot be said of all the smaller Voluntary or Cottage Hospitals, staffed by the general practitioners of the district. The public are apt to imagine that a hospital is a hospital, and that the best possible work will of necessity be carried out, irrespective of the facilities that can be provided and the character of its medical, nursing, and other staff. They are apt to assume that the general practitioner who performs a given operation, perhaps once in every two or three years, will do it as well as the surgeon specialist who is doing it every day.

The facilities that any given Voluntary Hospital can provide must depend on the amount of money that it can acquire, and when money is scarce, all the services demanded by modern medical science, many of which involve expensive apparatus, cannot be provided, and even those already in existence may have to be cut down. In the same way the Voluntary Hospital with its medical staff which is in almost all cases honorary, can only obtain the services of those doctors who for reasons of interest or cudos, think it worth their while to give their time. Moreover, the hospitals are only able to take advantage of the amount of time, these same doctors feel able to spare from their private practices.

The Voluntary Hospitals were originally founded through charity of the rich to provide help and succour for the sick poor and though most of the people who now use them pay according to their means for the help they receive, they never pay its full commercial value because the services of the doctors are gratuitous. They are, therefore, in all cases recipients of charity and in some Voluntary Hospitals they are made to feel this very clearly. And because they are recipients of charity they find it extremely difficult to obtain redress when they have any grievance against the hospital or its staff.

The government of a Voluntary Hospital is vested in a Committee or Board of Management which appoints itself, and fills up vacancies as they occur. It has absolute and autocratic control of the affairs of the hospital. Usually but by no means invariably, the doctors, who are on the staff of the hospital in an honorary capacity, are represented on the Board of Management, and as far as funds permit their advice is generally taken on medical matters. One of the principal duties of the Board of Management is to think out new methods of augmenting the ever depleted funds of the hospital. Many and varied reasons induce persons to get themselves appointed members of the governing body of a Voluntary Hospital. In most cases it is undoubtedly interest in hospital work and a wish to be of service. But there is no doubt that desire for social distinction or even the hope of “recognition” by means of a title, does play a part with some individuals. In any case however, desire to serve by no means always implies capacity for service.

But perhaps the greatest of all the many disadvantages of the Voluntary system is that each hospital is a law unto itself, and operates as a single isolated unit. With the exception of the few special hospitals, (which have disadvantages of their own, because you cannot cut up the human body into a series of little bits for treatment purposes) each Voluntary Hospital is usually ready to undertake the treatment of any, and every, acute case that applies to it. Indeed, there may almost be said to be an actual scramble for patients since the greater the pressure on beds, the stronger the appeal that can be made for funds.

The small Voluntary Hospital treating every type of case tends, therefore, to become so to speak, a Jack of all trades with the usual inevitable result. It is this same excessive individualism that prevents the voluntary hospitals from uniting together for the provision of ambulance facilities, the purchase of supplies, and other purposes.

The Municipal Hospitals vary greatly in different parts of the country. In some urban districts they are doing much better work than the Voluntary Hospitals of those areas. In a few rural areas,. where a ward or two in the Public Assistance Institution takes the place of a municipa1 Hospital, the quality of the work is deplorable. Before suggesting how these Municipal Hospitals can and should be developed, it may be useful to consider what is the ideal system of hospital provision for a country like our own. This was described in a pamphlet “The People’s Health” published by the Labour Party in 1932 and reads as follows:

“All the experience of recent years seems to point to the conclusion that an increasing amount of sickness will be best treated Under hospital conditions in the future. Therefore, the ideal medical service will need to have associated with it a complete and co-ordinated hospital system. Further, it would appear that with the exception of tuberculosis, infectious fevers, and advanced mental disease, most illnesses suitable for hospital treatment are best dealt with in the wards of a general hospital, where the service of specialists in the various branches of medicine and surgery are readily obtainable and where any necessary pathological examination can be carried out. All the hospitals will be closely linked together to form a single hospital system so that cases of special difficulty can be readily transferred from one to another as required, and for this, and many other purposes an efficient ambulance service is essential. Each County will have its own general hospital or hospitals in the county town and other large centres. The hospitals will be staffed by specialists who will see the cases in the Health Centres. The hospitals wi11 receive patients sent them direct by the Home doctors of the county (who will be encouraged to keep in touch with their patients while in hospital) and in addition cases transferred from the smaller hospitals of the county. The needs of medical education will probably be best met by attaching medical schools to the county hospitals in university and certain other towns. Most of the patients in these hospitals will be drawn from the county in which the hospital is situated and the cost of their treatment will be met by the county. But, in addition it will be possible to transfer to these hospitals cases of special difficulty or interest from any part of the country. The cost of treatment of such patients would be paid for by the county from which they came. In addition to these county and university hospitals, there will be smaller hospitals, especially for accidents and for chronic or less serious cases, dotted about the county. In charge of each of these hospitals will be a capable resident medical officer. Where members of the Home service are living sufficiently near, they will be encouraged to continue the treatment of their patient after their admission to these hospitals. In addition, specialists attached to the county or university hospitals, will be called upon to see patients in consultation in the wards of these hospitals, either when they attend the adjacent Health Centre or when specially sent for. The close association between these local hospitals and the county hospital will make easy the transfer of cases to the latter when required.

There will also be needed one or more large hospitals for infectious disease in each county. It is a great mistake to provide one of these hospitals in every urban district, as treatment is better carried out by doctors with special experience.”

It must be obvious to all, that the hospital needs of the country cannot possibly be met by a Municipal Hospital system that varies greatly in quality in different parts, and nearly a thousand Voluntary Hospitals, each one operating as an isolated unit. In a good many rural districts conditions, so far as hospital facilities arc concerned, are really deplorable. The sick person, unless well-to-do, has to choose between a Municipal Hospital still under the Poor Law and with most inadequate facilities, and a small Voluntary Hospital staffed by local practitioners. Moreover, he can only enter the latter if there happens be a bed vacant and his doctor is willing to recommend him for a mission.

It would appear clear that the development of an efficient and complete hospital service, so urgently needed at the present time, must take place by improvement and extension Of the present Municipal system, for it is inconceivable that the life or death of our fellow citizens should be allowed to depend on the liberality of the response to street collections. It will therefore, be useful to enquire what are the possibilities of improvement of these hospitals under present conditions.

The extraordinary development of a good many of the Municipal General Hospitals in urban areas, has been, perhaps, the most striking feature in the evolution of state medicine during the last quarter of a century. Hospitals have been springing up with good wards and operating theatres, and staffed in not a few cases by consultants. It is interesting to note that this new development was well on the way long before the passing of the Local Government Act (1929), while such hospitals had still to be administered under the Poor Law with all its deterence and restrictions. These Municipal Hospitals had been developed because it became clear to Local Authorities that the Voluntary Hospitals were quite incapable of supplying the hospital needs of the country and its people. Then in 1929, the Local Government Act reached the statute book and made possible the further development of the Municipal Hospitals. It enlarged the area of hospital administration in nearly every case, except that of the County Borough. It may said generally that within limits the larger the area of hospital administration, that is the number of hospitals under the charge of a single authority, the better. Some may consider that the County of London with its 70 hospitals under a single authority too large for efficient administration. But it is certainly true that some Counties and County Boroughs with small populations are too small. It is important to note, however, that under the Act Loca1 Authorities can combine together to any degree that they desire, for hospital purposes, and this should in most cases be encouraged.

Secondly, the Local Government Act (1929) permits, or rather one should say, encourages Local Authorities to clear out the Poor Law; with all that it implies, lock stock and barrel, from the Municipal Hospitals. This can be done by making a declaration, or by appropriation. These are technical terms which come to very much the same thing in the end, the essential being that by one or other of these methods, every Local Authority can and should immediately get rid of the Poor Law from its Municipal Hospitals if it has not already done so.

The Local Government Act (1929) by making possible the enlargement of administrative area and complete removal of the Poor Law from our Municipal Hospitals, opens to local authorities enormous possibilities of development, especially in urban areas where the population is considerable, and the hospitals not too far apart, and these should be taken advantage of to the full, always keeping in mind the final object of administration, i.e. the development of a complete unified municipal hospital service.

In the first place, specialisation becomes possible with all its advantages from the patients’ point of view. Certain wards in one hospital can be set aside for the treatment of Cancer by radium and X-Rays; others in another hospital for eye cases; special facilities can be provided for goitre, plastic surgery, or surgery of the chest, in a third, and so on. At the some time because of the unification that exists, it is an easy matter to transfer patients from one hospital to another, or obtain the services of any type of specialist that the service provides for any given case.

Another equally valuable asset is the elasticity that is provided. A severe epidemic of infectious disease breaks out and the isolation hospitals are filled to overflowing. In such a case a block of wards or even an entire general hospital can be evacuated and used for infectious disease if sufficient alternative accommodation is available. For example, early in 1937 London was suddenly overtaken by an epidemic of influenza. Almost without exception the Voluntary Hospitals refused to admit such cases, and the L.C.C. General Hospitals were, as is usual in midwinter, a1most completely full. At the same time, many of these influenza patients urgently needed hospital treatment. Fortunately at this time the influenza disease hospitals were not especially pressed, and a good many wards were empty. Within a few days, therefore, about 500 influenza patients were admitted to wards especially allocated for such cases in the fever hospitals, and as efficient isolation was maintained, not a single case of cross infection occurred.

Moreover, Municipal Hospitals can be used as clearing houses for observation and sorting out of cases of tuberculosis before transference to sanatoria, and equally well for the operative treatment of tonsils, mastoid disease, etc., among school children.

A Local Authority cannot legally refuse the admission of any patient to hospital if his medical necessities demand immediate hospital treatment. Accordingly in calculating the number of beds required, the highest possible and not the average demand has to be kept in mind. Not infrequently, therefore, especially, in the summer months when illness is less prevalent, a good many beds are vacant, although the cost to the locality for everything except food, medicines and dressings, continues in very much the same way as when the beds are full. It should be possible, therefore, to utilise many of these beds for operations which are in no way urgent, and which in certain affections (e.g. nose and throat cases) are undertaken in the best interest of the patient in the spring and summer months. But if this procedure is contemplated, a consultative out-patient department is essential, for it is most disappointing and unsatisfactory for all concerned for a patient to be admitted to hospital on the recommendation of his doctor, and then sent out again and told to wait.

Section 181 of the Public Health Act 1936 (which does not apply to London) permits the establishment of clinics, dispensaries, and out-patient departments. The specialist outpatient departments should be consultative in nature, and the patient referred back to his own doctor (panel or otherwise) for treatment whenever possible. Further, out-patient treatment should be free as is apparently permitted by the Act just referred to. In such departments it will be convenient to have carried out, where geographical conditions make this possible, the tuberculosis, V.D. and maternity and child welfare work of the Local Authority. Here also School Clinics can be established as well as clinics for Sunlight, Dental, and other treatment, and here as far as circumstances permit, the District Medical Officers under the Poor Law, who should generally be members of the resident staff of the Hospital, can see their patients. In other words the out-patient departments of Municipal Hospitals and their branches can be developed into the Medical Centres of the district. Some Local Authorities have appointed fulltime specialists, who divide their time between the Hospital, the School Clinic, and the Maternity and Child Welfare centre. In much the same way most of the pathological work of a district may be undertaken in the laboratories attached to the Municipal Hospitals.

With a unified Municipal Hospital system, the standardisation of furniture, such as beds, bed-tables, etc., as well as medical and surgical equipment, can be easily effected. Supplies can be purchased in bulk at much cheaper rates. Moreover, by frequent and careful sampling, quality can be ascertained and insisted upon, for no dealer will willingly offend a large and important customer. Other advantages are the pooling of ideas to the advantage of the whole service, and the facilities for research which an extensive and unified service makes possible.

In England Local Authorities are compelled to make a charge according to ability to pay, from the patient or those liable for his maintenance for the inpatient treatment of all conditions excepting infectious disease. Local Authorities can and should make treatment in fever hospitals, and for tuberculosis entirely free. In Scotland Local Authorities arc not required to recover the cost of maintenance in any hospital, although they are permitted to do so.

The first stop then (which can be taken at once) towards the development of a unified hospital system, is the improvement and extension of the Municipal Hospitals. The next must be the inspection und licensing of all Voluntary hospitals of all kinds by the Ministry of Health. This will require legislation, but it is a very necessary reform. As things are at present any benevolently minded person can be found a hospital anywhere, quite irrespective of other existing hospitals, or the needs of the locality, or whether it is likely to do efficient work or not. There is clearly something radically wrong here. Moreover, there should be power to close hospitals that are redundant or inefficient in cases in which repeated suggestion and warning by the Ministry has failed to produce the desired result, in exactly the same way as inefficient nursing homos are compulsorily closed by the Local Authority at the present time.

There should also be free discussion between representatives of the Voluntary and Municipal Hospitals. Section 13 of the Local Government Act (1929) (now re-enacted in the Public Hea1th Act 1936) makes it incumbent on Local Authorities to consult with representatives of the Local Voluntary Hospitals before undertaking any considerable extension of their hospital service, but there is nothing in the Act to compel them to accept any advice tendered. However, as the Act does not suggest the desirability of the Voluntary Hospitals consulting the Municipal under similar circumstances, it will readily be understood that the onesided character of the clause does not make for harmonious working.

There can be no doubt however, that free discussion on equal terms between representatives of the two hospital systems can be of benefit to both. Joint Hospital Advisory Boards are being formed in many places, and are to be encouraged provided that representatives of the two hospital systems only and no extraneous bodies are members of the Board, and it is clearly understood by all that the Board has no executive powers and can only suggest or recommend to its constituent bodies.

To what extent should there be co-operation between the Municipal Hospitals and the Voluntary? Some reactionary Local Authorities are content to refer nearly all the acute and difficult cases that come under their charge, to the local Voluntary Hospital – a most undesirable practice. In the first place this assumes that there is something inferior and second-rate about the Municipal Hospital, which it is presumed is only capable of tackling minor or chronic affections. The result is that, since we all tend to respond to what is expected of us, if not already second-rate the Municipal Hospital very soon becomes so. There is however, an even stronger reason against this practice. A Local Authority has a statutory duty to provide for the medical needs of the people of, its area. It is clearly its duty, therefore, to see that the provision is adequate. How can an authority be sure of the adequacy of a service that depends for its efficiency or otherwise on the amount of money collected by flag days and street collections, and the amount of time its medical staff can spare from their private practices. On the other hand, in a relatively small area it cannot be economical for both Municipal and Voluntary authorities to provide treatment for those affections which are less commonly met with, and require complicated and expensive types of apparatus and a staff to use them with special experience. Where for instance the local Voluntary Hospital possesses a sufficient amount of radium and an officer who knows how to use it (a happy but unusual combination except in a few large towns) a Local Authority may be justified in referring cases that require this treatment, and paying for it, not by a regular grant, but by direct payment for work done. In those cases in which direct payment is made for work done, the Local Authorities, by constant inspection and otherwise, should take steps to see that treatment is efficiently carried out, and should at once cancel the agreement if there is any doubt of this. In most cases, however, it will be much better to arrange with some adjacent Municipal Authority that has provided facilities for such specialised treatment. In this way some of the local Authorities around London have arranged with the London County Council for the treatment of any small-pox cases that may arise in their areas and pay the L.C.C. a retaining fee plus a weekly sum for every case treated. Plastic surgery Cases from other areas are also taken into hospital by the L.C.C. as far as accommodation permits, but in this case no retaining fee is charged.

Where the Local Authority has provided a complete and efficient hospital service, it is found that people of all classes are only too willing to take advantage of it1 as they have every right to do. This should be encouraged because the presence of persons who are used to comfort and efficiency and will put up with nothing less, is calculated to maintain the standard to the advantage of everyone concerned. Where the Municipal Hospitals are providing a really efficient service, they are preferred by many people to the Voluntary. People feel that the hospitals are their own because they are paying for them through the rates, and have a direct control in their management through their elected representatives to whom they can apply if they are not completely satisfied with the way they have been treated while in hospital.

In many areas Hospital Contributory Schemes exist. Persons with incomes below a certain limit pay 2d or 3d weekly in return for accommodation in certain Voluntary Hospitals as far as beds permit. In many districts arrangements have been made for a fixed weekly sum to be paid on behalf of member of these schemes who are patients in Municipal Hospitals and in return the local Authorities agree to accept this sum without enquiry or assessment. There can be no objection to such an arrangement at the present time, although it would be much better of course, if all treatment in all Municipal Hospitals were entirely free.

Owing to the rapid improvement of the service rendered by the Municipal Hospitals, many Voluntary Hospitals are finding it difficult to keep their beds full and wards have not infrequently to be closed. Generous hearted persons are discovering that they are already paying towards the support of the hospitals through the rates and are asking why they should pay twice. The Voluntary Hospitals are also finding that while wealthy people are still willing to rebuild or extend a hospital in memory of themselves or some relation, they are much less inclined to help with the ordinary maintenance costs. The Voluntary Hospitals are, therefore, in difficulties and are in many cases asking for help from the Local Authorities. What is to be done?

As has already been shown, the work in some of the smaller Voluntary Hospitals is anything but first-class and the sooner they cease to be the better. On the other hand the treatment given to in-patients in most of the larger Voluntary Hospitals with medical schools attached is good. Moreover at the present time there is neither accommodation not facilities available in municipal Hospitals to deal with all the patients now accommodated in Voluntary Hospitals. Clearly, therefore, it would not be in the public interest for all the Voluntary Hospitals suddenly to close their doors.

Where a Voluntary Hospital, because of lack of patients or funds; finds it necessary to close blocks of wards, there can be no objection to a Local Authority coming to terms with the Voluntary Hospital for use of these wards provided that the Municipal Authority appoints the staff and accepts full responsibility for the treatment given in the wards that they are using. It is even more satisfactory, when under similar conditions, a Voluntary Hospital applies to the Local Authority with a request that the hospital should be taken over. A few years ago the L.C.C. had the offer of an excellent modern hospital which cost a quarter of a million pounds to build soon after the great war. The gift was accepted and the hospital, now enlarged, is doing excellent service for London children.

People are appreciating more and more the futility of two competing hospital systems and it is clear that there will be an increasing tendency in the future for Voluntary Hospitals to be taken over by Municipal Authorities.

What do you think?

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