2 OCTOBER 1880, Page 11


THERE are two classes of persons for which such accom- modation is much needed,—those who can afford to pay for the superior accommodation of a hotel, but who are un- welcome guests in sickness, and cannot even for money obtain by hotel arrangements the necessary quiet, nursing, and sanitary conditions to be found in a hospital ; and secondly, those who, equally in want of hospital accommodation, can afford to pay the whole, or a part only, of the actual cost of their maintenance and treatment, without doctors' fees, or any margin of profit to the establishment. Of this latter class, many find their way into the wards of our Metropolitan Hospitals, and pay nothing, there being no requisition for- such payment, nor arrangements for collecting it. A still larger number, deserving of all sympathy, are precluded, by their education, habits, and sense of right, from accepting charity by seeking admission to the free wards of a public hospital ; and yet, when overtaken by serious illness or injury, have no other resource offering a fair chance of recovery. How many men, and women too, of birth and education, but limited' means—poor clergymen, Government and Bank clerks, secre- taries, and others following various avocations, among the middle, professional, and trading classes, besides govern- esses, teachers of music, ladies' companions, and often the daughters, wives, or widows of professional men—have no refuge in cases of sickness, and are exposed to every kind of pri- vation and suffering, because no hospital accommodation in available for persons in their circumstances ! The expense and inconveniences attendant upon illness, or treatment for an operation, in private lodgings can hardly be realised, by those who have never undergone the sad experience. In London a man may even be fairly well off, and yet be compelled to live im anything but a roomy house ; and if he have a. family, it may

be impossible for him to obtain the quiet required for his own recovery, or the isolation in many cases essential for the health of the other inmates. This is an evil from which no- one can hope to be always exempt, however strong or healthy as a rule; and in a family, sickness of some kind must be looked upon as a contingency for every year, with its accompanying troubles and anxieties. In this condition of things, so fraught with preventible sorrow and pain, the public has at last been roused to a sense of the necessity for some adequate effort being made to provide hospital accommodation on payment, for the large floating and resident population of London, who are wholly unprovided for by existing arrangements. Mr. Walter, at the recent opening of the first establishment of the "Home Hospital Association," in Fitzroy Square, said very truly that "there are only two great classes of persons who in sickness or any accident are able to obtain the best medical skill and the hest nursing, namely, the very poor and the very rich." Something has, indeed, been done of late years to fill up the great void in this direction, but very inadequately to meet the want. The Hospital for Women in Soho Square has long had a paying wing, in which accommodation and all hospital advantages are secured at rates varying from 10s. 6d. to three guineas a week. Another in Harley Street, for gentlewomen exclusively, we believe, also partially supplies the want for that class. But how much more is needed in the same direction, and for both sexes, before the urgency of the need can in any perceptible degree be diminished !

We hail with great satisfaction, therefore, the praiseworthy

effort of the Treasurer and Governors of St. Thomas's Hospital to render available one of the blocks or pavilions of that palatial establishment for the reception of rem tin erative paying patients ; and also for the admission into the general wards in a certain proportion of the class of patients of more limited means, who may still be able to pay at the rate of 3s. per diem towards the cost of their maintenance and treatment.

It is sufficiently remarkable that while London is the only capital in Europe or in North America, we believe, where no large provision of this kind has been made, the liberal proposal of the Treasurer of St. Thomas's has been met by a host of objections on the part of the Medical Staff, supported by the Medical journals. It has been found necessary, it seems, to call in the powers of the Charity Commissioners to give the required , authority to the Court of Governors. With such aid, and after many months of discussion and conferences, there seems reason to hope that the difficulties raised by the medical staff are in. a fair way to be removed, with their somewhat tardy con- currence.

The first objection was of a general kind, as to the appro- priation of one of the Pavilions to purposes of profit, though for the benefit of a hospital obliged to keep free beds empty for want of funds,—on the ground that it was required for the treatment and reception of infectious cases. Some question also was raised as to the medical attendance, the staff objecting, naturally enough, to give gratuitous service to such patients, and yet not willing to seem to monopolise a lucrative practice. This has been met by the appointment of a qualified resident medical officer, on a liberal salary, with free option to the patients to call in what further professional advice they might desire in consultation, at their own charge.

As to the admission of unremunerative, but paying patients in the general wards, to a limited number (five in each), many professional objections have been raised. In the Charity Com- missioners' Scheme accepted by the Governors of St. Thomas's, it is provided that these patients should not be admitted, as in ordinary cases, by the resident medical officer, who is re- sponsible for the suitability of the cases, but by the House Committee; or in cases of emergency, the Treasurer, who also determines the duration of the occupancy, and not the physician or surgeon in charge, both admission and discharge being sub- ject to the power of the patient to provide the required funds. A further difficulty arose on the part of the medical officers, who objected to their unpaid services being summarily disposed of for the treatment of paying patients, without their having been consulted on the subject, a proposal imposing upon them a fur- ther sacrifice of time and labour. This is to assume, however, that if these paying patients, to the number of five in each ward, were not received, the beds would remain empty. But this, of course, cannot be taken for granted, as a permanent condition. No doubt, however, the medical staff might fairly claim to have been consulted before the arrangements were made. This, and other points, seem to have been amicably settled in the course of the discussions to which they gave rise, and the opposition is said to have ceased.

It may be a question whether the patients able to pay a guinea a week for hospital accommodation and treatment will, without any compulsion, prefer to be classed as "paying," instead of "free "patients. And we have no law in London, as there is in Paris, to tax a patient seeking admission to a public hospital according to his or her means. Without this, and some very effective machinery for houte-to-hoase inquiry, it would not be possible to ascertain with any degree of certainty or accuracy what were the means of patients claiming free admission. This may prove to be one of the most serious obstacles to any general and successful application of the system of requiring payment where it can be afforded. Even if all the Metropolitan Hospitals, as has been suggested, could agree on adopting some rule to that effect, a very doubtful matter in itself, the rejection of applicants for treatment and admission to hospitals which are supported by voluntary subscriptions or endowments for charity, on the ground that they were, from their circumstances, not fit objects of such charity, would present great, if not insuperable difficulties. Both governors and patients might be disposed to contest the right so to deal with charitable endowments. And if it be left perfectly voluntary, at the option of the patient, to pay or not to pay, it may be considered doubtful what degree of success would attend the innovation. Abuse of charity there may be, both with patients seeking admission to the wards of our Metropolitan Hospitals, and with those applying for treatment in the out-patient department, who could well afford to contribute the whole or a part of the cost of their treat- ment (and no doubt there is much), but it cannot be easily dealt with under existing conditions. What, clearly, can be done, is on a purely voluntary system to admit a class of patients into the wards of our public hospitals where it is now impossible to receive them, on payment. No persons then desiring to preserve their self-respect and sense of independence would be at a loss, as at present, to reconcile these with the desire to secure all the advantages of the best skill, best nursing, and all the dietary and sanitary conditions of a well-organised public hos- pital, by paying for the same, at a tariff within their means. '['hi mould be a great step in advance, and in the right direc- tion. Whether under such altered conditions the Medical Staff, now giving their services gratis and as a matter of charity, should not receive some proportionate consideration for the benefits they would confer on the paying patients, is worthy of grave consideration. We think in fairness they would be entitled to, and without derogation might receive, some honorarium. As regards remunerative paying patients to be treated in separate wards in Block 2 of the St. Thomas's Hospital, to be named "The St. Thomas's Home," any objec- tion on the part of the staff has been, as already stated, fully met.

As to the profession generally, and more especially the general practitioner, it does not appear that their inter- ests would suffer, as has been feared, by removing from their field of practice those who would otherwise call them in and pay them for their attendance. In the first place, the paying patients admitted into the general wards would be situated exactly as the free patients as to location, treatment, and diet. They would have no special inducement, therefore, to prefer the hospital, unless the nature of their case rendered the higher skill and other advantages of hospital treatment essential to their recovery. In this case, the general practitioner would himself be the first to recommend such a step, in the in- terest of his patients and his own reputation. Moreover, for those who form the poorer class of a general practitioner's paying patients, the remuneration is often very doubtful, and a large de- duction has to be made for bad debts. The gain to the patients would be great, but the loss to the practitioner very little, if any. By such extension of the scheme of the Charity Commissioners to other Hospitals for the reception of non-remunerative paying patients, so as to include those with smaller means, a sense of self-respect would be greatly encouraged, and the panperising element of charity eliminated. With the same object, we would gladly see some well-considered scheme to enable out-door patients to contribute to the expense of their medicines at least. As to any injury either course is calcu- lated to inflict on the general practitioner, although it is not unnatural that some alarm should have been expressed on this head, we do not believe it is really to be feared, if due care be taken in framing the rules to be adopted.

On this subject of paying hospitals and paying wards—one of deep and general interest, as we have endeavoured to show, to a very large class of persons in this metropolis—a work has lately appeared, by Mr. Burdett, the honorary secretary of the Home Hospital Association, already alluded to as having opened a home hospital under the auspices of the Duke of Northumberland, and an energetic Committee, for the pur- pose of providing the required accommodation. In this work* will be found collected in small space a great amount of valuable information as to the steps taken in other coun- tries, and in our own colonies, to supply the need of such assistance.

It is worthy of remark that our American cousins have long been in advance of ourselves in this matter. The system of pay-wards, Mr. Burdett shows, is so widely popular there, that even the large Pauper Hospitals—for example, the Belle Vue, in New York—occasionally admit this class of patients, and also possess what they term a pay list. He tells us that the pay system is popular with the medical profession, with the majority of the public, and the people themselves. "Experience has shown that in the United States the tendency is more and more to increase the accommodation provided for pay patients, because it is felt that it will prevent many classes from becoming paupers, and will at the same time produce amongst all classes a wholesome regard for the preservation of their health. It cannot be doubted that the system of pay-wards, as practised in America, by accustoming the bulk of the people to readily avail themselves, when ill, of the hospital accommodation at their disposal, is calculated to preserve the public health, and to pre- vent the spread of epidemic disease." In this country, no doubt, ti-ere is a great amount of popular prejudice to be over- come, before recourse to the public hospitals will become general amongst the class of persons who can afford to pay 3s. a day for their accommodation. But the more people can begot to realise when they are attacked by serious illness the advantage of hos- pital treatment, and that it is more economical and better for themselves, their relations, and families, that they should thus be eared for at the price of a moderate payment, the more com- pletely will the public benefit, through the facility for isolating infected persons, and so protecting the population from the spread of infections or contagions diseases.

• Pay Ilaspilals and Paying Wards throughout the World. By Henry C. Burdett, London: J. and A. Churchill.