The Case For State Hospitals BY SOMERVILLE ILLSTrIVCS, F.R.C.S.
tin mat week's SPECTATOR Dr. Eric Pearce Gould will write on "-The Case Against State Hospitals.") WHEN people think and speak of hospitals, the picture that usually comes before their minds is that of one of those large institutions generally situated in the centre of a town, to which the sick and injured are taken, and in which nurses and doctors 'are trained —in other words one of the 'large ,Voluntary hospitals with a medical school attached. :In addition to the.
general hospitals just described, however, there are many special hospitals dealing with such conditions as mental and infectious diseases and tuberculosis, which are for the most part provided and controlled by the local authorities. Moreover all general hospitals are not of the type just described. There are the smaller or cottage hospitals usually staffed by general practi- tioners ; and there are also scattered over the country numerous municipal hospitals. Most of these last were till recently Poor Law Infirmaries, but many have now been taken over by the Local Authorities and removed entirely from the Poor Law. In these not only chronic illnesses, but an increasing number of acute conditions and operation cases are dealt with. In London the municipal hospitals are often tucked away in some back street and are little known. to the public, as they do not appeal for funds or advertise in the newspapers, but we must not forget that while there arc fewer than 15,000 beds in the voluntary hospitals of London, there are nearly double this number in the general municipal hospitals of the metropolis. In deciding the desirability or. otherwise of municipal State hospitals, certain important considerations have to be borne in mind: (1) I believe it was Herbert Spencer who pointed out that specialization was essential to pro- gress. If this is so, then medicine must be the most progressive of sciences, for the tendency during the last half century has been to divide up the subject more and more, so that for real efficiency in the treatment of disease, we have to depend to an ever-increasing extent on co-operation and team work: Now the essential feature of the voluntary system of hospital administration is that each hospital is a law unto itself and works alone, with but little, if any, co-ordination with any other hospital. Cottage hospitals are in most cases staffed by general practitioners who not infre- quently carry, out operations and undertake treatment. for which they have had neither, training nor e,xperience. - Patients are apt to assume that because an institution is a charity and not a money-making concern, it must of necessity be efficiently run and do good work, but this is by no means always the case. What is needed in - this country is a system in which the more difficult and complicated cases can be transferred from the smaller to the larger hospitals where special facilities for investi- gation and treatment are provided, and this is impossible without a co-ordinated system of hospitals. It is equally absurd that hospitals should act alone as isolated units and that there should be two 'hospital systems catering for - the same type of disease with practically no co- ordination between them. Public houses are controlled and licensed and nursing .homes have to be registered and.. inspected, but a hospital can be founded anywhere by anyone : without consideration of the needs of the district or the efficiency of' the.- treatment provided.
- (2) Another consideration with which I think all persons of good will must agree is that in the national, interest there should be no bar, financial or otherwise, to prevent those in need of treatment for injury or disease from obtaining what is best calculated to restore them to health. The increasing difficulties. of the voluntary hospitals in obtaining funds have forced them to adopt all sorts of subterniges to obtain what is necessary, e.g., flag days, street collections, draws, lotteries, &c. Some hospitals have raised as much as 75 per cent. of their income by a voluntary levy imposed upon those employed in the district. This levy, though in name voluntary, is in practice almost compulsory. It is open to question whether too much is not already extracted from the meagre wages of a good Many workers. Moreover some who use the hospital do not pay. the _levy, so that a rate or tax which would be met by all in the district according to their ability to pay would -be much fairer. • Almost universally those who, attend voluntary hospitals are expected -to pay- something, though' admittedly in most cases if they complain of poverty they are not pressed. But where the majority pay- it is very uncom- fortable for those who cannot afford to; It is wonderful how reticent the really poor may be about their poverty, and rather than exhibit this; some of them may prefer to avoid the hospital. The ever-increasing struggle of the hospitals. to make both ends meet, does not make for efficiency. A . great -deal of the attention of those in control has to be given up to finding the necessary. funds and in recent times really essential services in connexion with some of our hospitals have had to be seriously .
curtailed.. Writing the Lancet on August. 3rd,- 1929, one of the surgeons of a large London- voluntary hospital Was compelled td admit- " Far from our hospitals being, as .they once were, thO envy of other nations, the great majority- are years behind the times, and lack of funds compels the hospitals of our metropolis to carry on their work in the heart of London with an equipment and in surroundings which would not .be tolerated in a small provincial town in Sweden."
• (3) It may seem- almost superfluous to stress the point that in health as in most other matters prevention is better than- cure. - Iri medical -matters, however, preven- tion and cure are so elosely associated that they must for efficiency be . tackled together. Now- the great objection to. the voluntary hospital system is that it is entirely . unconnected with the prevention. of ._disease., Patients come for treatment .and in most cases the very - best possible is done for them. They return to the same evil _Surroundings of life, get bad again and come back once more to hospital and the cycle. of events is repeated. The municipal hospital system is much more closely associated with the preventive side and it should be increasingly easy in the future to associate the work of these hospitals with that of the medical officer of health and other preventive agencies, since it must be evident to all that when the cost of treatment of disease falls directly on a local authority it will be much. more ready to seek out its causes and try to prevent it. • Nevertheless, in spite of all that has been said, no one can doubt the extraordinary service that the voluntary hospitals have rendered in the past, not only to the relief and cure of disease, but also to the progress of medical science. It may be useful to enquire what has been the cause of this admitted ascendancy of the voluntary hos- pitals, and whether it must of necessity continue. It is not, I think, the fact that these hospitals have been voluntary in character and governed by distinguished laymen. The days of the gifted amateur are rapidly passing, and the important and wise decisions which have been taken in the past by committees controlling the voluntary hospitals have not infrequently resulted from the carefully thought-out advice of full-time paid secre- taries. Nor must it be assumed that because the medical staff of a hospital is unpaid, this of necessity implies that the best type of service is given. Some of the very best work in hospitals is carried out by full-time salaried officials, both medical and lay, and the -nursing in hos- pitals is none the less efficient because the nurses are themselves, perhaps rather inadequately, paid.
In my opinion, the admitted ascendancy of the volun- tary hospitals in the past has depended mainly upon the fact that they have been able to attract to their staff some of the best men in the profession, and they have done this not because of the voluntary principle, but because they have had medical schools attached to them. The . existence of medical students, young men and women in • the prime of their intellectual lives, anxious as all learners are to find their teachers in the wrong, has proved a stimulus to the medical staff and encouraged efficiency in their work. To manv doctors kis a real pleasure to teach students and in addition to this the medical schools have given to a position on the staff of a teaching hospital an economic value. When a student is qualified and goes into practice and meets with a case that calls for a second opinion or a difficult operation, who is he more likely to send for than the man he has learned to trust as his teacher ? The admitted ascendency of the voluntary hospital in my opinion depends upon its medical school, and if medical schools were associated with municipal hospitals many of the leaders of the profession would be only too glad to accept positions on their staffs.
To sum up then, the failure of the Voluntary Hospitals to provide for the increasing medical needs of the public, compelled a Conservative Government to pass the Local Government Act (1929) which encourages local authorities to provide their own Municipal hospitals. A municipal hospital can supply the health needs of the public better in every particular, except perhaps as regards its medical staff. The provision of medical schools in connexion with municipal hospitals would put this right. It is wasteful and uneconomic to have two independent hos- pital systems catering for the same types of case in nearly every locality, and it should be easy to devise a scheme whereby without loss of dignity or efficiency the voluntary ho4:oitals could be absorbed by the municipal.
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