Now for Health 3 Hospitals

Hospitals are to some people places where seeming miracles have been worked, to others places where death and tragedy take place ; but within the experience of all at some time an essential safeguard against the most dangerous and urgent diseases accidents.    As medicine has advanced hospitals have become more and more important because modern medicine means team-work, doctors of all kinds and other health workers  co-operating to reach the most accurate diagnosis and the best and most rapid treatment.    Hospitals not only provide places of succour for all whose disease or defect is beyond the skill of the general practitioner and beyond the resources of the ordinary home, but they are staffed by those whose special skill and training make them the recognised consultants to the rest of the profession. Hospitals therefore require to provide not only facilities for in-patient treatment, but for the handling of out-patients and above all for the service of special departments, X-ray and laboratory, and for consultant advice.    An ascertainable number of beds is necessary for the area served, and a calculable number of specialists and ancillary workers with a quantity of expensive equipment is essential.

But it has been no one’s business to see that these arrangements are made, and the Coalition Government’s White Paper declared “it is far from true that everyone can get all that is required.” The more recent Domesday Book of the Hospital Services, published by the Nuffield Provincial Hospitals Trust, declared that our hospital service had grown up unplanned and its “three main defects are inadequate accommodation, shortage and mal-distribution of specialists, and lack of co-ordination.” The Labour Party in 1943 declared that “all hospitals, whether public or voluntary, general or special, should be required to come into and conform to a regional plan.”

The National Health Service Bill proposes to end the defects of the hospital system by transferring to the Minister of Health “all existing premises and equipment of voluntary and public hospitals,” and empowers the Minister to acquire, by purchase if necessary, any other hospital or equipment that may be necessary for the new service. (He may exempt a hospital if in fact it is not necessary for the new service.) All general hospitals will then have the one owner, becoming part of a single system along with all mental hospitals, mental deficiency  institutions and infectious fever hospitals.

What should this mean to the ordinary citizen? There is, of course, a great deficiency in hospital beds, but once that is overcome it should mean that every citizen has a guarantee—when he needs it— of a bed in a fully-staffed and equipped hospital; and that his general practitioner can obtain at or from that hospital the advice and assistance of all the specialists he requires without charge to the patient.

Why has the Minister of Health decided to take over completely all the hospitals? His own reply, given in the debate in the House of Commons on April 30th, 1946, was that having seen that every other proposal was subject to unanswerable criticism, he had “decided that the only thing to do was to create an entirely new hospital service, to take over the voluntary hospitals, to take over the local government hospitals, and to organise them as a single hospital service. If we are to carry out our obligation and to provide the people of Great Britain, no matter where they may be, with the same level of service, then the nation itself will have to carry the expenditure and cannot put it upon the shoulders of any other authority.”

The criticisms that have been made on our hospitals and on all schemes which attempt to compromise with the existing arrangements have recently been reinforced by the publication of the Hospital Surveys. These have been carried out by investigators appointed in some areas by the Ministry of Health, in others by the Nuffield Provincial Hospitals Trust. The surveys have gathered information about all our. hospitals and all of them tell the same story of insufficiency and inefficiency in our hospital arrangements. Their views have been summarised in the Domesday Book of the Hospital Services, a document which most convincingly establishes the wisdom of the Government’s decision.

It is worth while recalling the main defects of the present method of providing hospital care. There is first the absolute lack in hospital beds. This has been variously estimated, depending on the figure one takes as the minimum necessary to yield a complete service for all. The Hospital Surveys take what would appear to most observers as a low figure yet calculate that 98,000 new beds are needed for acute general, maternity, tuberculosis, infectious diseases and chronic sick cases.

The distribution of beds “available or about to be available” in England and Wales in 1939, as beds per 1,000 of the population, was given in the Ministry of Health report as :—

General Hospital Beds
Infectious Diseases Beds
Tuberculosis Beds
Maternity Beds

The surveyors who carried out the war-time surveys did not all estimate how many beds should be provided but some did and also estimated the deficiency in each type of bed. Some of the results were :—

Total Acute General Maternity Tuberculosis Infectious Disease Chronic
Berks., Beds, and Oxon. Beds per 1000 9.9 5.0 0.6 1.0 0.8 2.5
deficiency 3857 2265 356 567 156 513
Yorkshire Beds per 1000 8.3 4.0 0.5 1.0 0.8 2.0
deficiency : brackets ( ) indicate surplus. 6028 3623 581 1096 (636) 1364
South Wales Beds per 1000 8.9 5.0 0.5 1.1 0.8 1.5
deficiency 7866 5517 629 695 274 751
London Beds per 1000 8.25 5.0 0.4 0.8 0.8 1.25
deficiency : brackets ( ) indicate surplus. 18648 19832 1143 2430 (4619) (1147)

There are, however, many reasons why we should allow ten beds for 1,000 people—the figure in Labour Party literature on the subject, and at that figure the need is even higher, and in this matter it is better to have too many beds than too few, or we are back where we started.

The second factor is the quality of the hospitals in which the beds are situated ; and here we are on more controversial ground. There are many in the medical profession who consider there is a special virtue in small hospitals run by general practitioners ; but the majority of observers are entirely against them, and the Labour Party in 1944 declared that “cottage hospitals and other very small hospitals should be abolished as soon as possible.”

The same resolution added that so long as they continued to exist they must be regarded as part of a larger hospital rather than as a separate unit. It is this point of view which found favour with Mr. Aneurin Bevan, who told Parliament that “every investigation into this problem has established that the proper hospital unit has to comprise about 1,000 beds—not in the same building but nevertheless the general and specialist services can be provided only in a group of that size.”

In fact the small hospitals attempt to give a service which is. far beyond the powers of their staff and equipment, with a few exceptions where both are provided on a scale out of all proportion to the work done. It is quite wrong to think of the small voluntary hospitals as part of a system of the highest quality. As the hospital survey puts it, “there is a tendency to identify the voluntary hospital with the comparatively large teaching hospital and to assume that all reach the same high standards of work—an assumption that is unfortunately not well founded.”

The teaching hospitals number only thirty in all, of which twenty are in England and thirteen in London. “Outside the large centres there is a multiplicity of small hospitals whose divorce from a coherent plan makes them inefficient and uneconomic—and exceedingly difficult to staff.”

Another defect is the lack of co-ordination, which means long waiting lists at one hospital, empty beds at another, serious and complicated cases in hospitals that have neither the staff nor the technical equipment to treat them “whilst a simple case is occupying a bed in a hospital with a high standard in staff and equipment.” It is ideal to have all hospitals large in size, say 600—1,000 beds, each doing its share of general work but each having its special duties in relation to the others, but that ideal may not be reached for some time. We have had some excellent examples of it, however, under the Emergency Hospital Service and the arrangements for treating special types of war injuries.

Other defects may be mentioned without going into detail-Hospital buildings are often placed on sites which at a later stage are too small for expansion; others are hampered for lack of funds necessary for new buildings for which they have the space; pressure on beds means too hurried discharge and lack of full rehabilitation ; while ambulance services often leave much to be desired.

On top of all this and running through the whole system is the haphazard way in which hospital funds are collected. As Mr. Aneurin Bevan put it, “it is repugnant to a civilised community for hospitals to have to rely on private charity—we must leave that system behind entirely.” Many must have shared the Minister’s feelings—” a shudder of repulsion when I have seen nurses and sisters who ought to be at their work, and students who ought to be at their work, going about the streets collecting money for hospitals.” To get rid of that, however, implies a single hospital service and a new administrative machine to plan and control it.

The administrative apparatus proposed is a new and original one. The facts and figures given above lead to the conclusion that hospitals should be regionally organised, for fairly large units are necessary to give the complete service. No existing local government unit can be named as suitable for they vary in size, in financial stability, in the way in which they have tackled health problems before. The Bill therefore proposes to divide the country into 16 to 20 regions, in each of which a Regional Hospital Board will be ” responsible both for the planning and administration …. and it is with this authority that the specialist services are to be associated because …. such services can be made available for such an area and cannot be made available over a small area.”

The Regional Hospital Board will act for the Minister in relation to all hospitals he owns except the recognised teaching hospitals of the area. The latter will, of course, be owned nationally and must play an important part in the regional plan; but they will be controlled by separate Boards of Governors. It is one of the aims of the service to see that ” the effective hospital unit should be associated with the medical school.” This will provide in each area a centre in which active research is being pursued by full-time research workers, where expert opinions can be obtained, and from which new knowledge will radiate easily and rapidly to the general practitioners.

Since many strongly worded statements have been made on the transfer of all hospitals to the Minister of Health, i.e., to the Government and the nation as a whole, it should be made clear that the endowments of all hospitals are fully safeguarded, so far as their primary use for the succour of the sick is concerned, by the terms of this Bill. Endowments of teaching hospitals pass to the new Boards of Governors, “who are to be free to use them as they think best, but are required so far as practicable to see that the purposes for which they were previously usable are still observed.”

The endowments of all the other hospitals are to pass to a new Hospital Endowments Fund, to be used in the first instance to liquidate existing debts and liabilities (which in some cases are high); and then to be apportioned to the Regional Boards which, subject to obviously advisable safeguards, will be free to use their portion — income or capital — for the hospitals within the region.

The Regional Hospital Boards will, of course, receive the full cost of the service from the National Health funds, with a very large measure of freedom from central financial control so that, subject to providing a satisfactory service, as much local initiative and variety of enterprise as possible will be allowed. The Hospital Boards will be appointed by the Minister from people chosen from the local authorities of the area, the universities, the medical profession and other sources with knowledge of and interest in the hospital service.

In addition, however, each hospital unit, that is, a single large hospital or an associated group of small hospitals with equivalent number of beds, will be directly controlled by a Hospital Management Committee, appointed by the Regional Board. On the composition and attitude of these committees will depend the efficiency and spirit of the hospitals. They will appoint certain parts of the hospital staffs, but it is suggested that all senior appointments will be made by the Regional Boards through special Appointments Committees which will contain representatives of the teaching schools in the region.

We cannot leave the subject of hospitals without reference to the related questions of pay-beds and private rooms. Hitherto single rooms in hospitals have been generally those for which extra fees were paid ; and many voluntary hospitals have built private wings or private wards to provide separate accommodation for those prepared to pay for it — and usually for the services of surgeon or physician as well. The Bill permits this practice to continue by making single bedrooms or small wards “available to patients who wish to buy privacy by paying the extra cost.”

It  is,  however,  recognised  that such privacy  is  often  vital to patients who cannot afford to pay extra ; and the pay-beds are there­fore to be available only when all patients who require such accommoda­tion on medical grounds have been dealt with.    The tendency in modern hospital designing is to increase the number of beds in single rooms and rooms with two or four beds and to get rid entirely of long wards   with  very   large  numbers   of beds.    The  provision   of  such separate accommodation for those who  can pay for it,  as distinct from the recognition that such privacy is good medicine, has aroused many fears that two standards of medical care are to continue.    The provision is subject to many restrictions, but it is one of the points on which a close watch will have to be kept for possible abuses.    The general quality of the hospital service should in any case reach such a high level that there will be no possible “frill” which the wealthy can purchase that has anything other than a snob value.