VOLUNTARY HOSPITALS
By OUR MEDICAL CORRESPONDENT But they have been primarily and necessarily concerned, for the most part, with more urgent and acute illnesses or those needing the most special investigation ; and for many generations now there have been in existence rate-aided hospitals—at one time most commonly known as infirmaries—whose main function has been the care of poorer or completely indigent patients with chronic or disabling complaints and who could not be properly treated in their own homes. These hospitals have been staffed, as a rule, by whole- time medical men, on a salaried and usually pensionable basis, who have not—as has been the case with the permanent staffs of the voluntary hospitals—been also engaged in private practice. Admir- able as these rate-aided hospitals often were, it would be generally admitted that, in the past, their standards of equipment and pro- fessional skill fell below those of most of the larger voluntary hospitals. But this position has altered very considerably during the last twenty or thirty years.
Largely inspired by the example of the London County Council, many of the greater rate-aided municipal and county council hospitals are now, in the matter of equipment, at least the equals of most of the voluntary hospitals and probably superior to many. Amongst their whole-time professional staffs are to be found individual surgeons and physicians of the highest ability, and many of these hospitals—especially in London—now employ visiting consultants. Cases of a particular kind are often assembled at a particular hospital SO that they can be most conveniently seen and treated by the appropriate leading specialists in association with the whole-time
staffs, who themselves are thereby attaining special experience and skill. The present war, too, has produced a far closer association than ever before between the voluntary and rate-aided hospitals. The " Sector " system in London, for instance, has seen the group- ing together in geographical and administrative units of voluntary and rate-aided hospitals and the staffs of such hospitals as the Middlesex and Bart's working in hospitals—some of them rate-aided —as far afield as Aylesbury and St. Albans. For parts of their course medical students have also been working in rate-aided hospitals, where they have often found teachers of great ability and seen types of cases rarely met with in the wards of voluntary hospitals.
All this has lent considerable force to the arguments of both medical men and others who hold that in future the hospital services of the country should be unified in a State-controlled system financed, as part of the obligations of any well-ordered community to all its citizens, by a national rate or tax. Such a system, it is argued, would bring into a simpler and more efficient scheme the enormous existing variety of large and small general and special hospitals. It would eliminate wasteful and competing appeals for money, put an end to what is held to be the derogatory *spectacle of nurses and students parading the streets asking for contributions, the organisation of fetes and bazaars, the writing of begging letters and the wooing of rich men and women for subscriptions and bequests. Further, it is contended that, given adequate salaries and pensions, surgeons and physicians of the highest promise would be quite content to forgo the financial rewards that have been obtained by some of their predecessors in the past—usually at the price of a long period of struggle and artificially high overhead expenses.
Supporters of the voluntary hospitals are probably in agreement about the increasing problem of their finance and the probability of its becoming even more difficult in the future. But they would claim that, from the point of view of research and experiment and adaptation to changing circumstances, the voluntary hospitals, by virtue of their independence, would always hold the advantage ; human nature being what it is, that competition for places on the permanent staffs, at any rate of the larger voluntary hospitals, would always produce the best, brightest and most self-reliant physicians and surgeons ; and that the " common-room " atmosphere of such hospitals affords opportunities for a frankness of discussion and criticism that would be difficult to create or maintain in a State- controlled hospital, staffed by salaried seniors and juniors on a promotion ladder.
Whatever the pros and cons, however, in the controversy as a whole, there would probably be general assent to the. proposition that the great teaching voluntary hospitals are in a class by themselves, and there are many advocates of a State-controlled hospital service who would be willing to make an exception in their favour. They too, of course, are faced with immense financial problems. Most of them, if they are to survive, will probably require assistance in the shape of such Government grants as are made to certain universities. But this need not imply more control than that at present exercised by the Universities' Grants Committee over the universities. Altogether theirs is a very strong case for political independence. They are the portals of entry into the profession. If it is admitted that, what- ever the future may hold in the way of a State medical service, there must be some body of independent general practitionai and con- sultants to accommodate both doctors and patients who may be dissatisfied with that service—and who could form a body of outside critics necessary for the maintenance of its efficiency—then the schools in which they are nurtured must also be outside. They would continue to provide the common front from which doctors entered either the State service or private practice. They would also, themselves, as great outside hospitals of the highest historic standard, provide a corpus of independent professional and adminis- trative critics, invaluable to the health of any State-controlled hospital service, although at the same time co-operating with it.
It may well be the case that certain voluntary hospitals could with advantage be absorbed into a well and uniformly planned and placed system of State-controlled hospitals. But this could certainly not be said with equal confidence about any of the existing teaching voluntary hospitals, whether in London or the provinces.
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