What Kind Of Service Have We?

Until war became imminent it was only with the greatest difficulty that anyone could be persuaded to regard the chaotic and anachronistic structure of medical practice and hospital services as of any real importance to the nation. Weak­nesses were admitted, but were generally excused as being part of our traditional British method, and anyone who suggested serious changes was considered either to be personally dis­gruntled or politically a revolutionary. The bombing plane and the fact that the Germans had made it quite clear that they were ready to bomb our largest cities as soon as war was declared forced on the Government, the profession and the country as a whole the realization that not only would additional medical services be required but that those in existence would need to be brought into some kind of co-ordinated scheme. As a recent P.E.P. report put it: “In the absence of a unified hospital system the threat of war and all that it was thought to mean in terms of civilian as well as military casualties made it imperative for the Government to take a hand in hospital planning.” Accord­ingly the Ministry of Health formulated, and at the outbreak of war put into operation, the Emergency Hospitals Scheme.

As an improvisation this scheme had undoubtedly many valuable points, but it was prepared only as an improvisation and in many ways disregarded the lessons that could have been learned from the Spanish civil war, and even under air-raid conditions has remained almost as first set out and still fails, in the opinion of most observers, to meet the total warfare of the Nazi Luftwaffe. In some ways its greatest value may be not as a guide to future developments but as a warning as to pitfalls that must be avoided.

The greatest fault of the Emergency Hospitals Scheme is one for which its sponsors cannot, and should not, be blamed. That fault was that it was based on a calculation of air-raid casualties which, even in the very heaviest and very worst raids on London, were much in excess of the actual figures. From the point of view of the organization of medicine in general this error was that it perpetuated the fact that we have two different types of hospitals, and made no attempt to co-ordinate all the medical services in one scheme. There was a considerable correlation of the different hospitals of a district; provision was made for reserving hospital beds for casualties of every type, and the care of these casualties was made a charge on the Government; but the A.R.P. casualty services remained under separate control, and the general practitioners and many specialists remained outside both schemes. Distinctions were drawn between voluntary hospitals and municipal hospitals both as to the proportion of beds that were to be reserved for casualties and as to the method of payment for their treatment.

A further complication was that many hospitals had to be largely removed from our cities into the country, and the scheme therefore included the provision of an ambulance service for moving patients from one place to another. Some of the country hospitals were former institutions, mental and fever hospitals, which the Government provided with X-ray apparatus, labora­tories and operating theatres, and others were newly built hutted hospitals which, by the end of 1941, were expected to provide forty-five thousand beds.

What the E.H.S. does is to co-ordinate all hospitals under the Ministry of Health; the hospitals themselves continue to be administered as in peace time but the emergency medical service division of the Ministry dictates the type of work they will do, and the cost of performing work of that nature is paid by the Ministry in full to the voluntary hospitals but only 60 per cent to the municipal hospitals. The idea is that hospitals in the centre of towns receive the casualties and provide emergency treatment; at the earliest moment patients are removed to base hospitals, sometimes a considerable distance from the town, for further treatment. Hospitals just outside the most likely target areas are used for general surgical cases. The whole country is divided into areas, and those hospitals in an area which come within the scheme have their work co-ordinated by group officers under whom the personnel and equipment are pooled and allocated to the different hospitals as required.

London presented a special problem for her wartime medical services, and there are some special features of the service within that area. The whole of London is divided into nine sectors, each of which is triangular in shape with one of our large teaching hospitals at its apex and stretching out to base hospitals which may be as much as fifty miles away. The number of beds in each sector varies, there being a total of about sixty-eight thousand in the nine sectors; each of the sectors is controlled by a group officer who is a member of the staff of the voluntary teaching hospital at the sector’s apex; each group officer has, of course, a staff and associated with him sector officers who are drawn in equal numbers from the voluntary and municipal hospitals. The appointment of these group officers is one of the funda­mental weaknesses of the Emergency Hospitals Scheme, for they were chosen because they had earned distinction in their own particular branch of the profession at a particular voluntary hospital and not, as should have been the case for a scheme of this magnitude, because of their recognized ability as administrators. Outside the London area the equivalent duties are carried out by a regional hospital officer who is usually a member of the per­manent staff of the Ministry of Health.

The work done in the hospitals of the Emergency Hospitals Scheme is wider than that of ordinary civilian air-raid casualties, for it now includes Service casualties and sick, Civil Defence workers, members of the Home Guard, and the Police War Reserve injured on duty, unaccompanied evacuated children, aged and infirm evacuated from shelters, essential war-workers living away from home, fracture cases among Civil Defence workers, and others essential to industry, seamen of the Merchant Navy, evacuated or homeless persons billeted at the Govern­ment’s expense, and a few other special cases. The proportion of the population, therefore, who may under any circumstances be treated under this Scheme is very large, and the potential number of patients under air-raid conditions is very high indeed. In other words the Government has recognized that our present hospital system cannot stand the strain of a modern war, and that there are very large numbers of people for whose medical care the Government must, or in some cases is well advised to, take responsibility. The staffing of the E.M.S. hospitals has been a problem of great difficulty. So far as the London area was concerned the Ministry considered that the only possible way in which the services of the doctors necessary could be obtained was as full-time officers. The absence of air-raids in the first year of war caused a revision of this idea and some hundreds of doctors were removed from the full-time salary list, but retained for a fee of £500 a year to carry out certain part-time duties during the whole of the war and additional duties as the circumstances may require. Other medical men are paid on a sessional basis when called upon to do work for the E.M.S. In yet other cases the hospital continues to pay the salaries of its officers and is’ reimbursed by the payments made by the Ministry of Health.

The Emergency Medical Service includes a number of special treatment centres, of which those concerned with plastic surgery and those dealing with cases of war neurosis are the most important. The Ministry of Health, partly under its own control and partly through the agency of the Medical Research Council, has also set up a laboratory service which consists of two schemes; there are laboratories for routine pathology and there are a group of public health laboratories whose duty is to facilitate and hasten the diagnosis of epidemic disease, and to distribute serological products for the treatment of disease. The service of the latter laboratories is available for these purposes, without payment, to all hospitals and local authorities. In addition the facilities for clinical pathology in each area have been surveyed, and by setting up new laboratories and making use of all those in existence a fairly full clinical pathology service has been provided throughout the country; the work of this service and the method of organization give, to some extent, an example of the type of organization that may develop after the war, and we shall return to it later.

Another important part of the Emergency Hospital Service has been the provision of staff and laboratory facilities for blood transfusion.

The E.M.S. has shown many weaknesses, of which the chief is its divorce from the other medical services, as were the volun­tary hospitals divorced in peace time. It has, however, been of very definite value and, for example, stood up to the reception of casualties from Dunkirk very well indeed, and it has shown that it is possible to pool our medical resources and to link up our doctors and hospitals so that their services can be given where they are most needed. It has also shown that a co-ordinated service can put into operation special schemes for treatment and diagnosis. The medical profession has begun to see that medical planning is not only possible but absolutely necessary. The E.M.S. was formulated for an emergency and its present weaknesses arise from the refusal of the Ministry of Health to recognize that after two years of war the stage of improvisation should be passed, and that if there are years of war still to come a more permanent and better worked out scheme should now be initiated.

There is, however, no tendency in the profession or in the Ministry of Health to make fundamental changes while the war is on. This point of view is probably entirely wrong so far as winning the war is concerned, for the only books which have been written on the subject of medical services suitable for fighting a total war against Fascism, such as those by Jolly and Shirlaw, suggest forms of civilian and military medical services very far removed from those at present in existence, and there is no question in the minds of many people that a great increase in the efficiency of our medical services could be achieved even while the war is proceeding. However, the stress is usually placed upon evolving a medical service as part of post-war reconstruction, and changes in the E.M.S. are therefore likely to consist of further improvisations.

There is one big change which would normally improve the service from the point of view of the patient without requiring any change in the form of the service. The E.M.S. was set up for the purpose of dealing with those cases that were injured during air-raids, or while on service. The Government, as already noted, has gradually been compelled to add other categories of sick and injured to those who may be treated in E.M.S. hospitals, but has still left many curious anomalies. Perhaps the outstanding example is that of the discrimination between children living in the neighbourhood of an E.M.S. hospital, for local children cannot be admitted to such a hospital, while unaccompanied evacuated children can. It has occurred that children living in the same house have required the same medical treatment, but only the billeted child could receive this at the local hospital while the native child had to go to another institu­tion at a considerable distance. Medical men working in these hospitals have invented their own method of surmounting this difficulty by arranging for a patient to be put on the waiting list of a hospital in the centre of London and then arranging for him to be transferred to the E.M.S. hospital at his own door. There is now no reason whatsoever why all classes of the population should not be admitted to any E.M.S. hospital and treated by the staff of that hospital.

This would have important repercussions on the question of medical personnel, for the division between the civilian and military medical services, between E.M.S. hospitals and those outside the scheme, between voluntary and municipal hospitals all give rise to a waste of medical man power. It should be possible for doctors to attend patients whatever their wartime duty may be, for army doctors who are not fully occupied to see civilians, and for civilian doctors in blitzed areas where their practice has diminished to attend to service cases. In other words, while it is still necessary to reserve a certain number of beds for air-raid casualties the number of those need not be so high as was once thought, and all our sick and injured should be treated in hospitals which have been pooled for the use of the whole population.

Since we are concerned in this chapter with the type of medical service existing at present we need not go further into the administrative changes that would appear to be advisable in the E.M.S. We should, however, note one further dividing up of the medical services which appears unnecessary; the splitting of the A.R.P. services from the general practitioner on the one hand and the hospitals on the other. Just as the reservation of hospital beds for air-raid casualties exceeded enormously the actual number of casualties because it was based on misconceptions of the nature of air-warfare, so the casualty service with its insistence on large numbers of full-time first-aid personnel neglects all the lessons that were to be learned from the experience of other countries before 1939 and of this country since then. The casualty services are normally under the control of local medical officers who have neither rights nor duties in relation to the voluntary or municipal hospitals in the area. That fact has only to be stated to indicate all the possi­bilities of overlapping and of deficiencies in our air-raid casualty services; that they have functioned so well is due to the quality of those serving in them and to their disregard, when necessary, of all official rules and regulations; but, fundamentally, the method of dealing with casualties by stretcher parties, first-aid posts, advanced hospitals and base hospitals neglects all the advantages of a system such as that advocated by Shirlaw of classification and resuscitation posts with rapid transport to hospitals outside the target area.

There remains one point to which attention must be drawn. Owing to the individualistic arrangements of medical practice there has been no real guidance given and no effective control of the work of general practitioners either in those areas which have lost their population by bombing and voluntary evacuation, or of those whose population has been enormously increased by the arrival of people from the bombed areas. It is common knowledge that in the bombed areas there are doctors who now have very little to do but who cannot give up what does remain of their practice because to do so would be to lose all that they have invested in that practice, while in some of the reception areas doctors are tired and over-worked from the number of new people for whom they must cater.

We may sum up the type of service that we have in the midst of war by saying that it remains as individualistic both as regards general practitioners and hospitals as before the war, but that there has been added the Emergency Hospital Service which has provided a lesson in the pooling of hospital services for a particular purpose; that purpose has also led to a certain improvement among some of our worst hospitals and institutions, which had to be improved to deal with air-raid casualties at all. The difficulties that have arisen in trying to administer this new form of service without superseding the old has, however, led a constantly increasing number of doctors to ask themselves whether a better and simpler form of medical service cannot be devised.