The Cost of Hospitals
By T. F. W. MACKEOWN* SINCE the start of the National Health Service a constant cause of complaint has been the lack of published statis- tics relating to the staffs and costs of the hospitals in the service. Last week, quite unannounced, both these failures were rectified. Early in the week the Ministry of Health published at a price of £1 a copy a detailed analysis of the staffs in their 2,500 hospitals at the end of 1949. A memoran- dum circulated with the publication stated that within a short time two further publications would bring these staff figures up to the end of 1951. A couple of days later the Ministry published at 10s. a copy a document giving an analysis of costs for the year ended March 31st, 1951. This shows reason- able promptness, and the time-lag and, indeed, the information compare favourably with similar returns for voluntary hospitals only, which were published annually prior to 1948 by the King Edward's Hospital Fund and the British Hospitals Association.
The figures now published are worth the most detailed study, and to anyone with an analytical mind and a knowledge of the country's hospital service they contain a mine of information. There are two main parts-one covering the hospitals con- trolled by Regional Boards and Management Committees and the other teaching hospitals with their separate boards of governors. The costs fall into two main categories-" running charges " which vary directly with the number of patients and "standing charges " which tend to remain unaltered by .normal variations of occupancy. Under the former headings, are in- cluded such items as provisions, drugs and dressings, laundry, crockery, linen, etc., and under the latter the salaries of medical, nursing and other staffs, fuel, light and power, maintenance of buildings, printing and stationery, furniture-replacements, transport, etc.
The unit of comparison is the average cost a week of main- taining a patient. As very few hospitals can supply detailed departmental costs, the Ministry has assumed for the purpose of this return that five out-patient attendances represent the cost" of one in-patient day. The final column in the analysis gives the weekly cost of treating an in-patient after allowing for the vacant-bed factor. The net result is not claimed to be accurate, but the details of the analysis throw much light on the differ- ences in our hospitals today.
One heading which is sure to attract attention is that of provisions; this is misleading because it includes the cost of feeding the staff, and in a well-staffed hospital this is shown in the higher cost per patient under this head. The variations are interesting. In the general hospitals controlled by the Regional Board the weekly cost of feeding a patient and the proportion of the staff tending that patient is £1 13s. 7d., surely a reasonable enough figure; yet the costs per region vary from £1 5s. lid. a week in the Liverpool Region to £2 4s. 5d. a week in the North West. Metropolitan Region. The average weekly cost per in-patient of medical staff salaries is £2 13s. 11d.; in Liverpool it is only £2 Os. 10d. and in Man- chester £2 7s. 8d., whereas in the North West Metropolitan Region it is £3 13s. 5d. On the other hand, for maternity hospi- tals the average cost of medical salaries per in-patient week is £1 Is. 1d., and in Liverpool this cost is £1 6s. 10d., in Man- chester only 13s. 7d. and in the North West Metropolitan Region £1 Os. 2d.
• Administrator and Secretary, University College Hospital, Lonillon.
The value of the report would be increased if it contained a summary of all the regional averages for the various types of hospitals. It is quite obvious, however, that the costs in the North are considerably lower than in the South. The' average net weekly cost for all the regions for a patient in a wholly general hospital is £11 12s. 5d. In the Liverpool Region this figure is £9 18s. I ld., in the Manchester Region it is £10 5s. 4d., in the Newcastle Region it is £10 4s. 5d. and in the North West Metropolitan Region it is £14 1 1 s. 5d. The conclusion to be drawn from this is that there may be considerable pressure from the Northern part of the country to bring its expenditure into line with that of the Southern part. Although the North has many fine hospitals, it would scarcely be disputed that those taken over from the Local Authorities were much better in and near London, particularly the large hospitals of the Middlesex County Council, most of which are now under the North West Metropolitan Regional Board.
For teaching hospitals the variations are greater. The net weekly in-patient cost of the London undergraduate teaching hospitals is £21 7s. 5d.; for the Provinces it is only £15 14s. 3d. It is significant that the two largest London teaching hospitals, University College Hospital and the London Hospital, which are shown here as having 1,023 and 918 beds, have the lowest costs. Size and concentration of buildings affects costs, and indeed some of the hospitals at the top of the list are not only smaller but have a large number of scattered buildings, e.g. nurses' homes. At the other end of the scale is the cost of the mental hospitals. For all the regions the average weekly cost per in-patient is only £3 14s. 2d. This represents variations of from £3 6s. 9d. a week in the Manchester Region to £4 2s. I ld. in the North West Metropolitan Region.. The low cost of the mental-hospital service is accounted for to some extent by the amount of patient-labour used and to a much lesser extent by the shortage of staff.
This document is the most important one to be published since the inception of the National Health Service. If it reveals extravagances, they are contained in such a jungle of figures. that they will be missed or perhaps wrongly interpreted by the inexpert eye. Through some strange whim of the Ministry's, the costing statements do not provide for administra- tive expenditure on central offices maintained by hospital authorities. One is told nothing either of the cost of the head- quarters staff of the Regional Boards themselves. One remains ignorant of the cascade of minutes and agenda, amounting to over eighty foolscap sheets a meeting, that are circulated to certain hospital management committees. A recent book, The Cost of Health, by Dr. Frangcon Roberts, indicated that there was no solution to the problem of cost in a National Health Service. These costing returns emphasise' the nature of the problem, and to one reader at least they have given the startling information that this country contains one isolation hospital where the weekly cost per in-patient is £42 12s. l d.
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