THE FUTURE OF HOSPITALS
By GORDON MALET
HAVING accepted the principle of a universal comprehensive health service, the Government has had to devise a policy to translate the aspiration into reality. _ In the words of the White Paper, " if people are to have a right to look to a public service for all their medical needs, it must be somebody's duty to see that they do not look in vain." The Government's answer is the Joint Health Authority, a planning and executive body, composed of representatives of its constituent local authorities ; this body is to take over the constituent local authorities' hospitals, and, further- more, it is to be responsible for allocating part of the State's grant to the voluntary hospitals—the rest to be provided centrally. Thus planning would be followed through into the sphere of action at a local level—subject always to approval of the plan by the Minister and the satisfaction of the Ministry's hospital inspectorate.
It is not perhaps surprising that the parties concerned do not look with favour on the White Paper proposals. The local authorities see themselves losing direct control of their own hospitals—often the apples of their eyes, sometimes justifiably so. The voluntary hospitals see themselves subordinate to, and dependent for a large part of their income upon, a body on which they are unrepresented ; a body, moreover, with hospitals of its own, which may therefore be expected to look with favour on its own property when the question of extension of services arises. The doctors, as represented by the B.M.A. Council, if less strongly opposed, are at least desirous of direct representation on the authority which will ultimately control the consultant service ; for this service must inevitably be based on the hospitals. Those who are to be excluded from control are agreed in saying that advisory committees provide no substitute ; though, strangely enough, the medical advisory committees of the voluntary hospitals have had little difficulty in persuading lay boards to follow where they would lead.
Before considering the counter-proposals of the B.M.A. Council, the British Hospitals Association and the King Edward's Hospital Fund for London, it is as Well to look carefully at the situation which the White Paper is setting out to remedy. It will then be possible to see how far specific proposals are likely to be effective, and how far they are designed rather to preserve the distribution of hospital control among the parties at present concerned.
Most people—other than hospital users—are more familiar with the great voluntary hospitals than with the municipal hospital service. The picture of a voluntary hospital which springs to mind is of a vast building, prominently placed in a great city, often with a school of medicine attached, and with a fine-tradition of several hundred years' service. Yet such places are in a very small minority. Of the 700 all-purpose voluntary hospitals in England and Wales before the war, only 75 had more than 200 beds ; and of these about one-third were teaching hospitals. . More than 250 of the volun- tary hospitals had less than 3o beds, and another zoo had less than too beds. By and large, then, the voluntary hospitals are small units-; and it is generally accepted that, other things being equal, the service which a small hospital can offer its patients is less efficient in terms of disease cured and lives saved than a large hospital provides. The basic reason for this is simple. Hospital cases require specialist examination and treatment. And specialists must devote their whole time to their speciality if they are to achieve maximum skill. A small hospital cannot keep a full team of specialists fully occupied ; probably at least 500 beds are needed. The only way in which small hospitals can be made to supply an effective service is by grouping them together, with a peripatetic team of specialists. Yet even this cannot be entirely satisfactory, since one specialist may be needed at the same time in three places thirty miles apart.
If we are to have a really efficient and comprehensive hospital service, these facts must be faced ; the small autonomous hospital is an anachronism which we cannot afford. It may well have its part to play as out-station of some major key-hospital ; but this demands some sacrifice of sovereignty. Equally, however, an efficient service demands the preservation of the great voluntary hospitals, whose virtues lie perhaps less in the fact that they are voluntary than that they are fine independent centres of medical practice and learning.
The local authorities' hospitals are by no means so familiar to ,the public, Often they are housed in old and out-of-date Poor Law buildings. Those which have been built or rebuilt in recent' yeari do not occupy high-value sites near city centres. Local authorities have no wish to spend money on site costs, and no need for a central position as a part of hospital appeal policy. Yet local-authority hos- pitals provided, before the war, over 200,000 of the 300,000 hospital beds (of, all sorts) in the country. If the weakness of most of the voluntary hospitals is their small size, the weakness of most of the municipal hospitals has been rather their small, and often inade- quately paid, medical staff. Thus, the service they offered the public was also an imperfect service, though for quite different reasons. Ski it becomes clear that the prime need is for a thorough review of the hospital and specialist service in each area, and a review of the -needs of the area ; for an equation of the one to the other in the form of a comprehensive plan ; and for vigorous action to carry out the plan as quickly as possible. If some sides of the voluntary hospital service badly need co-ordinating, or even in some cases lopping off, no less do most of the municipal hospitals need rebuild:ng, reorganising internally, and restaffing. It cannot give pleasure to either side to contemplate these facts. Yet it was probably from such a dispassionate contemplation that the Government arrived at its White Paper proposals.
The counter-proposals of the B.M.A., the British Hospitals Association, and the King's.Fand are broadly speaking similar. First, they suggest larger areas for hospital-planning than those proposed in the White Paper. They would have some twelve or thirteen regions in place of thirty or forty joint authority areas. The one manifest advantage of a regional organisation is the, possibility of having a University hospital at the hub of each region. But this would not assist in the present serious maldistribution of specialists ; indeed it might operate rather 'to keep them at the University centres than to distribute them more widely. The White Paper areas, with populations of between three-quarters and one and a half millions, are just big enough to provide a basis for an efficient hospital service. Regions could certainly provide such a service, but they are not an imperative necessity.
The proposed regions are, however, to be deprived of the executive functions of the joint authorities. Each would have a Regional Hospital Council, composed of an equal number of voluntary hospital and local authority representatives, together perhaps with some representatives of the consultants. Similarly, at a county or county borough level, there would be Local Hospital Councils. The hospitals would remain under existing managements. But the Regional and Local Councils would prepare the Regional plan and would advise the centre on the allocation of funds. There would be a Central Hospital Board, again with joint representation, along- side the Ministry of Health, and this board would offer the final advice to the Minister on the allocation of direct grants to the voluntary, hospitals and local authorities. The hospital inspectorate which the White Paper proposes would come under the Board rather than the Ministry. And the voluntary hospitals would be assured of equal treatment with the local authorities in respect of grants for capital expenditure.
The-major effect of these proposals is to remove the main burden of execution of planning, which must rest with the distributor of the money, from the local units, the joint authorities, thrusting it upon the Minister at the centre. At the same time, he is deprived of his eyes and ears in the form of his hospital inspectorate. Centralisation admittedly preserves public responsibility for public expenditure. But what of the service which the public is to get? Who is to see that the voluntary and municipal hospitals really co- operate? Who is to see that redundant, or relatively inefficient, hospitals are suppressed, or brought up to standard? Who is to see that patients in need of specialist treatment really do receive it?
The White Paper's answer to all these questions is the financially powerful joint authority, with advisory committees and the Minister's inspectorate to see that the job is done. The voluntary hospitals and the consultants have a legitimate grievance in that the joint authority may tend to favour the municipal hospital. At the same time, it must be remembered that in the matter of accommo- dation the municipal hospitals have the longer way to go. The case might be met by having two representatives of the voluntary hospitals and two representatives of the consultants on each joint authority, even if they had no voting-power. This would guarantee that their cases had a fair hearing ; and since their respective advi- sory, committees would (or should) have the right of appeal to the Minister, it would prevent back-door attempts to black-ball either side.
The basis of an efficient hospital and specialisi service is un- doubtedly the large area. But _both planning and administration should be built on this basis. If the executive side is to rest with as many hospitals and authorities as at present, the chances of large- scale planning bearing fruit are small. The Government is pledged to a comprehensive hospital and specialist service for all. Somebody, as the White Paper says, must see that it is there. The joint autho- rities are the best somebody so far proposed.
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