The   Hospital

The hospital will in many ways always remain the most important feature of a medical service. It is true that very large numbers of minor illnesses are dealt with either by ordinary household remedies or by the general practitioner, but there are few members of the population who escape at least one visit to the hospital during their life. Indeed the greater part of the life-saving as distinct from the alleviation of disease and suffering which is done by the medical profession is in hospitals. The most spectacular life-saving procedures are, of course, urgent surgical operations, but very many people owe their continued existence to the detailed care which is only possible under hospital conditions.

These conditions are worth noting for they emphasize what has already been said about the need for replacing the work and personality of the individual doctor by the combined efforts of a team of medical workers. In the wards of a hospital a patient is not under the care of one member of the staff only but actually is attended to by a team which, if we include those members who are never seen by the patient, is very large indeed. A surgical case which is not absolutely straightforward will require in addition to the porters, stokers, cleaners, storekeepers, cooks and others, the services of the senior surgeon who is in charge of the case, of one or more assistants in the operating room, an anaes­thetist, a radiologist, a pathologist, perhaps a physician in consultation, house surgeons, blood transfusion officer, a ward sister and a number of nurses. Each of these people have definite duties and all of them provide evidence as to the con­dition of the patient or add their quota to the treatment he is having. Occasionally the condition may be one in which a brilliant diagnosis by one of the team, or a particularly rapid treatment by another, can be mentioned as the outstanding feature in the restoration of the patient to health, but in the great majority of cases the health of the patient depends on all members of the team doing their part and on all co-operating with the one aim.

That team work is usually sufficient for those cases that have entered hospital, but if all disease is to be treated efficiently, and if health is to be maintained and disease avoided, the team must be extended in many directions and completed by those who should have seen the patient while in health and with those whose duty it will be to supervise the final return to normal. The hospital must therefore be closely linked with the rest of the medical service, and, as we have indicated, should be related to and probably part of the same building as the health centre, and the staff of the hospital should constitute the corps of specialists who assist the general practitioners.

There is no hospital which functions in this way in Great Britain to-day, although there are hospitals whose staff do provide most kinds of consultant service for a proportion of the population in the area served by the hospital. Hospitals vary in every possible way as to size, as to age, as to architecture, as to plan and as to almost every detail which affects the health of the patients or the comfort of the staffs. There are very few hospitals in Great Britain which have been built in recent years and are of large size. Most of our biggest hospitals consist of buildings to which, over the last forty years, repeated additions have been made. The architecture of some of those that were previously poor law hospitals has to be seen to be believed, while the situation of some of them, particularly in the London area is, almost inconceivable. Many of them are closely surrounded by slum houses, factories and railway lines, and exist in an atmo­sphere which is the very antithesis of everything that might assist a patient in fighting disease. There is therefore need for a complete reconsideration of what should constitute a modern hospital, and the amount of damage which these buildings have sustained from air-raids suggests that the opportunity for that reconsideration will arise at the end of the war. There is in any case a definite shortage of hospital beds throughout the country, and at least twenty-five per cent more than we have to-day will have to be provided. A survey of the position will probably indicate that at least half of our present hospitals would be better to be rebuilt, and with the new beds that are required we can assume that one of the first things that will need to be done in the post-war period is to provide a very large number, certainly not less than one hundred new hospitals. If the opportunity can be linked with the provision of health centres, we shall have a chance of giving the nation a series of new buildings which will epitomize the new attitude towards health and turn the minds of the people more than many years of ordinary propaganda would to the conception of disease prevention and a socialization of medicine.

Perhaps the first problem that requires to be dealt with is that of where to put the hospitals. Those who live in the centre of London and have seen the hospitals there surrounded by a veritable sea of noisy traffic very often advocate that hospitals should be situated in the country and that only casualty clearing stations should be left in the centre. This is an exceedingly attractive idea but it does not bear examination. It is true that with modern transport a very large proportion of even acute hospital cases could be transported outside our large towns and even outside London, but there are other needs which make it imperative that the hospital should be close to the patients it will serve. In the first instance, a hospital and health centre must be placed where the people of the district will be constantly aware of them and able to feel a personal interest and pride in them. In the second place, if the consultants of the hospital are to be available in the homes of the people they cannot be expected to travel long distances. In the third place, if the hospital staff and the domiciliary practitioners are to be in close contact they cannot be separated by a distance of ten miles or, as it would mean in London, twenty-five miles. A fourth point is that if visitors are to be allowed for patients in the hospital they cannot be expected to make long and expensive journeys.

Lastly, if the hospital is separated from the health centre it would mean that such special services as the laboratory and X-rays would require to be duplicated at both places.

There is therefore no reason why the hospitals should be placed other than at the centre, or at the most convenient transport point, for the people it will serve. There is, however, every reason why new architectural plans should be made so that the hospitals have a sufficiency of open space around them, and should be so built that those patients for whom peace and quiet is essential should be able to obtain it.

It should be remembered that the ideal hospital should have from eight to twelve hundred beds, and it is, therefore, a building of no mean size. It requires in addition a nurses’ home, which if it is built on the generous scale of accommodation which nurses should be given, but never are to-day, will require to be quite a formidable affair. With all the various extra buildings which are required the hospital should, in an area with a population of one hundred thousand, be usually the most important building in the neighbourhood and it must therefore be treated seriously in an architectural sense. If the country as a whole embarks on the necessary provision of new hospitals, it will be of enormous advantage to standardize most of the equipment, and that standardization will require a fairly standard pattern of ward and most other accommodation in the hospital; but these standardized items need not imply that in a socialized scheme there would be four hundred completely identical hospitals scattered throughout the country, but rather that our architects, in co-operation with the doctors, should give us a series of different buildings that would have something vital and something beautiful to commend them.

There is ample room for the exploitation of new ideas in hospital architecture. Hitherto it has been generally accepted that the ideal hospital is built of two or at the most three-storied pavilions connected by a central corridor along which are arranged the administrative offices, kitchens, laboratories, etc. In this way an attempt is made to give every ward light and air, but a hospital of a thousand beds built on this principle covers a very large area and presents many problems in the way of transport, for example, of patients to the X-ray department, and of food from the kitchens to the wards. There is an urgent need for architects to explore the possibilities of building upwards. Lifts can be used for more rapid transport than the pushing of trolleys through corridors, and there appears no reason why buildings of six or seven storeys on modern lines should not give a better type of hospital in every way than any that is laid out on a horizontal plan.

The medical profession has also to settle many points about hospitals before the architects can do their part completely. Most hospitals, chiefly on the score of economy, consist of large wards with anything from twenty to sixty patients arranged alongside the two opposite walls facing each other. If the necessity for rigorous economy, which has marked the development of the voluntary and the poor law hospitals, no longer applies, is there a better way of arranging our hospital wards? What proportion of single rooms should be provided and what type of accommo­dation should be provided for the semi-convalescent? These and many other problems will have to be settled before new hospitals can be built that will serve the scientific principles of modern medicine.

A plan of hospitals must also be as elastic as possible, or should in the first instance provide accommodation for the absolute maximum number of patients who are ever likely to be admitted at one time. We have had in the past too much in the way of adding beds to existing buildings which were in the first instance only adapted from old buildings, as in the case of many of our cottage hospitals, and not built for their present purpose. In many hospitals the urgent need for expansion to meet a demand for accommodation of one type has resulted in the addition of corridors leading to annex after annex, producing a plan which could not be anything but inefficient.

In preparing plans for hospitals the relation with the health centre will also need to be borne in mind. Together they should form the most important part of the social centre which modern town planners visualize as an essential feature of the towns of the future. There are many social activities which can very usefully be linked with the promotion of health and the prevention of disease, and that linkage can be exemplified by a unity of the buildings that are required. Undoubtedly health propaganda will make considerable use of the cinema and the lecture theatre, and the accommodation provided for this purpose at the health centre will serve many other useful purposes for the community.

So far in this discussion we have assumed that there will be only one hospital system. It is quite clear, in view of the promise of Mr. Ernest Brown (the Minister of Health) that the Government have already determined on the provision of a comprehensive hospital service after the war that the voluntary hospitals cannot much longer remain in their present position of isolated units. There is, however, no reason why the voluntary hospitals should remain at all. In recent correspondence in the British Medical Journal Sir Frederick Menzies, formerly Chief of the London County Council Medical Services, challenged those who supported the voluntary hospitals to state in exact terms what exactly were the advantages and special features which the voluntary hospitals had and which were absent from the municipal hospitals. The replies he received were as amusing as they were irrelevant. In almost every point they cancelled each other out, for men with equally long experience in both types of service put forward diametrically opposite claims. Most of them revealed, without saying it explicitly, that the main support given to the voluntary hospitals has a political significance. Those who fear a change in our social system wish to maintain the idea that hospital treatment is a charity to be given to the working classes out of the bounty of the more wealthy. They therefore endeavour to invest the voluntary hospitals with some mystical qualities which must be preserved at all costs. In spite of the valuable services which the better voluntary hospitals have given in the past, these arguments can have no place during or at the end of the present war.

In actual fact, as Mr. Somerville Hastings, Chairman, L.C.C. Medical Services Committee, has stated in a recent pamphlet on the hospital services, “The quality of the services rendered by a voluntary hospital depends mainly upon the character of the equipment available and on the efficiency of the medical and nursing staff. The equipment provided depends again on the money available, and most voluntary hospitals are chronically short of funds. In the villages and all but the largest towns the voluntary hospitals are staffed by the local general practitioners who give to their hospital work what time they have to spare from their private practices; nor can one always be sure that the best practitioners of a district are numbered among the hospital staff, for that position is in many places, to all intents and purposes, bought and sold with one of the local practices.”

One further point may be noted as of some importance if we obtain a co-ordinated hospital system without all of them becom­ing a part of a national medical service. Patients entering either a voluntary or municipal hospital are interviewed by an almoner who assesses and endeavours to obtain what she thinks a patient can pay. Owing to the variation in the quality of hospitals and the type of service that is provided and in the cost of maintenance, the method of assessment and the amounts assessed vary very widely. There is a need, therefore, so long as this system remains for a unified assessment for hospital care. This may be of great importance if the Nuffield’s Provincial Hospitals Trust is success­ful in its attempt to prevent the provision of a unified hospital system by bolstering up the voluntary hospitals with money obtained from local authorities. The position might develop that a voluntary hospital was able to assess its patients very much lower than a local authority hospital nearby because of the amount of money it obtained from the grant which can legally be made from local taxation.

In this chapter we have made another assumption which must be discussed in some detail, namely that all hospitals in a socialized service will be general hospitals taking every type of case. The only exceptions to this rule would be for certain forms of mental disease and for cases of tuberculosis which had been transferred from the general hospital to a sanatorium. Until the incidence of infectious diseases has been reduced it may be necessary, at least in the case of large and crowded communities, to separate infectious diseases, but many doctors advocate that a general hospital should also admit them. With modern know­ledge of the cause of these diseases, of the way in which infection can be avoided, this will probably become the rule as the incidence of such conditions as scarlet fever diminishes with better preventive methods. It necessitates, of course, more cubicles than open wards and a higher standard of nursing, but both of these will be a feature of the next stage of development in hospital care. Perhaps the most important reason for insisting that the hospital must be general is that it is only in this way that chronic cases can be treated without exhausting the interest of the staff. To quote a writer with many years’ experience of such a hospital, “There is a great tendency to exaggerate the degree of infirmity of those who are merely old. Old people who are confined to bed for some transient illness adjust themselves extremely well to bed life. After a time the adjustment is so complete that they will never again of their own initiative get up. With a keen and energetic medical and nursing staff the number of hospitals’ chronic cases will be much less than in a hospital where there is an atmosphere of stagnation.” Such cases also provide very valuable experience for nurses in training. In any case the hospital of a general nature has such a variety of work that every section of the staff will receive greater experience than is possible to-day in most of our voluntary hospitals.

Although the hospital will be a general one the staff will not be expected to be general medical officers as was once the case under the poor law. They will in fact have an opportunity for even greater specialization than is possible to-day when the need for making a living often restricts a man to those parts of surgery or medicine in which he can most quickly build up a practice. Various attempts have been made to indicate how many staff would be required for such a hospital, and the following table is offered tentatively so that some figures may form the basis for wider discussion.

Department	Beds	Chief	Senior	H.S or      H.P.	Total
General Medicine	250	2	2	4	8
Chronic Cases	100	–	–	–	–	‘
General Surgery	210	2	2	4	8
Obstetrics and Gynaecology	150	2	2	4	8
Tuberculosis	80	1	–	1	2
Fevers	70	1	–	1	2
Paediatrics	50	1	1	2	4
Orthopaedics	50	1	1	2	4
Ear, Nose and Throat	20	1	–	1	2
Ophthalmology	10	–	1	1	2
Psychiatry	10	1	1	–	2
Dentistry	—	1	2	1	4
Anaesthetics	—	1	2	–	3
Pathology	—	1	1	2	4
X-rays	–	1	1	–	2
Medical Administration		1	1		2
Total	1000	17	17	23	57

In some departments the number of staff may appear over-generous but it must not be forgotten that at least the chiefs and seniors in each department will be required to see patients at the health centres and in their homes. Each unit must also provide its own holiday relief and experience might in fact show that a slightly larger number would be required. It is probable also that the number of beds for a speciality such as _ ophthal­mology would be considered too small to provide sufficient work for a man of specialist standing, but the amount of out-patient and other consultative work that such a specialist would have to do in a unit of one hundred thousand people would keep him fully occupied. There is, however, a case to be made out for concentrating all the work of such a speciality at one hospital so that a larger unit could be maintained, and three hospitals might combine for such a purpose. Even larger numbers of hospitals would certainly combine for the rarer specialities such as neuro-surgery and plastic surgery. In conclusion it may again be suggested that a hospital of this size in combination with some thirty to fifty general practitioners would provide a complete service in a way that would be both efficient and economical.

One of the most debated points in a service of this kind is the exact relationship between the general practitioner and the hospital. At the moment there is no uniformity in this matter since hospitals range from small cottage hospitals entirely staffed by general practitioners to large municipal hospitals which are quite cut off from the work of the general practitioner even though he sends to them almost all the cases they receive. It is quite clear that if all the medical men in a health unit are working as one team, and if the consultants of the hospital are constantly seeing patients for the general practitioner at the health centre and in the home, that a much closer relationship between the general practitioner and the staff of the hospital will develop than is always possible at present. In provincial towns where the number of consultants is restricted it does happen that all the doctors of a neighbourhood make use of and have a high regard for the same consultants. In larger areas, of which London is the outstanding example, consultants visit patients over such a wide area and see a few cases for so many general practi­tioners that it is quite exceptional for one specialist in a particular branch to be utilized by all the doctors of a district; on the contrary it is even possible for quite a number of consultants of equal standing but attached to widely separated hospitals to be visiting patients on the one day in a district quite far removed from either Harley Street or their particular hospital. In a health centre unit it may be sufficient to leave the doctors to work out their own relationship, but there are many who feel that the general practitioner must be given a definite position in the hospital. The minimum that one can expect is that the general practitioner should have the right to send into hospital any case he considers requires hospital care without any possibility of veto by a hospital officer. Most people claim, however, that the general practitioner must be given actual duties, such as those of clinical assistant to one of the senior officers in the hospital wards. While this has a certain attraction it would perpetuate the idea that there was some essential difference between the general practitioner and the hospital officer, whereas the correct position is that each should be as highly skilled as possible in his own branch, and in that view there is certainly no need for the general practitioner to act as a junior assistant to his hospital colleagues. Should a general practitioner feel that it would benefit him to have more experience of hospital work that experience should be gained as a part of post-graduate study. It must be emphasized that it is no suggestion of the health centre scheme that once a man has adopted a particular branch of medicine he is tied to it for life. General practitioners showing special ability or a strong desire would be enabled to change over to one of the special branches. There would therefore be in every health unit a certain number of men among the specialists who had worked as general practitioners and who from their under­standing of general practitioners’ work would assist in guarantee­ing a proper relationship between the different departments.

Other contacts between the general practitioner and the hospital staff would undoubtedly develop. It is to be hoped that one feature of the hospitals of the future will be staff meetings both for administrative and technical purposes. One thing which is particularly required is a medical staff council at which, weekly or monthly, the work of the hospital and in particular the record of deaths within the hospital is reviewed by the staff with the greatest possible frankness and exactitude. In this way not only would the medical statistics of the hospital acquire a high degree of accuracy but there would be an opportunity for assessing the quality of the work done by the different officers. This has been attempted in different ways in many hospitals and has been found of particular value in connection with surgery. The operating surgeon who has to explain not only to himself but to all his colleagues, senior and junior, why his death rate from a particular class of operation should be many times higher than the average has to keep his technique up to the highest possible standard. At such hospital conferences the presence of the general practitioner who has first seen the case, and under whose diagnosis it had been sent into hospital, would be an essential feature.

In these and many other ways the conception of a group of doctors working together as one unit would raise even our best hospitals to a higher level than has hitherto been possible. When the active co-operation of all other grades of personnel is is added, and when the conditions of service of nurses and other staff have been brought into line with modern thought, the last vestige of that fear and dislike of hospitals which still remains from pre-Listerian days will vanish,