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The Development of the London Hospital System,
1823 - 1982
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The Development of the London Hospital System, 1823 - 1982 |
Developments in the hospital services between the world wars, 1918-1939
‘But are we to compete? And is not that idea of competition the very mistake we are all making?’ Sir Ernest Morris, 1934 (House Governor, The London Hospital) In medical terms the inter-war period was essentially one of consolidation. Methods of clinical investigation and surgical techniques improved, radium and radiotherapy became accepted in the management of cancer, and there were several major advances in therapeutics like the introduction of insulin in 1922, sulphonamides in 1935 and blood transfusion services in 1937. Medical education improved as clinical units of a university nature were introduced into a number of London medical schools, and much thought was devoted to postgraduate education. Hospital organisation and finance became critical issues. The financial crisis of 1920 slowed the campaign to break up the poor law, and was responsible for a drive for ‘value for money’ by coordinating the voluntary and poor law hospital systems which sometimes competed and always overlapped with each other. Ideas which had previously appeared almost revolutionary achieved a degree of respectability, and to overcome rivalries the organisation of all hospitals into a single system was suggested. Money being short, cooperation became the watchword. The creation of the Ministry of Health in 1919, at the end of a hard fought inter-departmental struggle, was in some ways symbolic of new approaches to the provision of health care.1 The Fabians had pointed to the confusion which existed between the health care activities of different government departments, the Local Government Board, the Board of Education, the Privy Council and the Home Office. The new Ministry gathered these functions together, under a Minister who was himself a doctor and a secretary and chief medical officer with deep understanding of medical and political realities. Sir George Newman, the chief medical officer, said that the Ministry reflected an understanding of the need to apply the principles of preventive medicine to the whole population. No longer would individual families receive services from several different organisations, which each worked in water-tight compartments ‘along lines which never met, covering the ground, or part of the ground, that others covered’.2 The Ministry of Health had set an example in collaboration, and there was a political will to achieve cooperation between the hospitals as well. The new Ministry was given a guarded welcome by The Lancet and the British Medical Association, but its formation was seen in some quarters as a first move towards a state hospital service.3,4 The Minister, Dr Christopher Addison, reassured the hospitals that there was no intention of enforcing any particular principle or doctrine. But some senior civil servants, impressed by the organisational opportunities open to local government, saw the possibility of a chain of hospitals, united by motor transport, under local authority control. Taken to the limit, cooperation could eventually lead to the unified county medical service described by the Webbs, encompassing the health functions of local authorities, those provided under the poor law, and the voluntary hospitals great and small. The British Hospitals Association, a successor to the old Hospitals Association, organised a conference at St Thomas’s to consider the relationship of the voluntary hospitals to the new Ministry of Health. The association’s secretary, Mr Buchanan, circulated a paper stating that the hospitals with their special and general departments, and their medical and nursing schools, must be maintained at the highest possible standard. A connecting link with the public hospitals was however necessary. The Association and The Lancet both agreed that the voluntary hospitals must be allowed to continue their great work, which stemmed from the individual freedom of the hospitals to undertake any enterprise which seemed to promise well.5 The experiences of the Great War demonstrated the form the connecting link might take. Men like Sir Robert Jones had developed systems allowing war wounded and soldiers with fractures to be evacuated for treatment, and doctors returning from the Forces had demonstrated their ability to plan and administer large medical organisations, cooperating in the provision of a unified service. Amongst them was Major General Sir Bertrand Dawson, physician to The London Hospital. In his Cavendish Lecture and during debates about the future of the medical profession held at the Royal Society of Medicine in 1918, Dawson maintained that an efficient service could not be self-supporting. Men and equipment must be distributed according to the needs of the community. Local hospitals and clinics should be related to central hospitals in larger towns which would provide specialist services. These in turn might be subordinate to a larger provincial hospital, and all would be maintained by a health authority. Only the teaching hospitals might stand apart, for ‘they served the nation whilst other hospitals served a town or county’.1,6 Dawson pointed to the growing realisation that much disease was preventable and that the best means of preserving health and curing disease should be available to all as a right rather than by favour. He thought that administrative matters should be determined by a board consisting of lay and medical members; professional and technical questions by doctors alone. War service had taught the medical profession many lessons. During the early years of the war Dawson discussed grouping and regionalisation of hospitals, and later when he chaired the Council on Medical and Allied Services the military organisation of the country into ‘commands’ was seen as a possible model for health service organisation.6 (see map below)
At the end of the war the financial position of the voluntary system was weak. Hospital subscriptions from the middle classes had declined and the formation of the Ministry of Health had led some to assume that the needs of the hospitals would soon be met in other ways. The voluntary hospitals no longer received payment for the treatment of war-wounded. Initially the hospitals had been worried about the acceptance of government support, for it breached the voluntary principle to receive state aid. The withdrawal of these funds left the hospitals in difficulty. Inflation during the war had increased hospital costs considerably. The King’s Fund’s distribution committee was particularly concerned with the expenditure of The London Hospital, which was the subject of a special report. Its costs had risen faster than those of the other great London hospitals. In vain did Lord Knutsford protest that his hospital treated more patients per bed than any other, and that the length of stay was the shortest. Many hospitals had deficits despite the contributions made by local authorities as part of schemes for treating tuberculosis and venereal disease. In recognition of the problems the grants made by the King’s Fund in 1918 were increased, and were the largest in the Fund’s history. In spite of the difficulties a number of hospitals were preparing schemes for extension, which seemed to many a good form of war memorial. The annual report of the Fund for 1918 pointed out that the combined effect of many developments, good though they might be individually, would be to add a large number of beds to the total in London. The Fund feared that the revenue available would not increase in parallel, and that the problem of closed beds which it had dealt with successfully at the turn of the century would emerge once more. The new beds might not be provided in the areas needing them most; the Fund therefore asked all hospitals to state what was proposed, for it believed that one of the advantages of a central fund was that it could form a clearing house for ideas of this type. Detailed enquiries were made about the ability of hospitals to support proposed extensions, in an attempt to ensure that beds once provided could be used, and that the new extensions reduced the worst inequalities of provision. By 1920 extensions totalling 3,445 beds were contemplated. Of these only 1,489 were ‘passed’ by the distribution committee, and were therefore eligible for support by the King’s Fund. With perception based upon long experience, Henry Burdett had written in 1893 of the danger a voluntary hospital faced as its work expanded. ‘Many instances might be quoted in the history of the world where a hospital originally supported on the voluntary system with adequate funds provided from the revenues derived from the original endowment, has gradually become hopelessly involved owing to the increase in population resulting in increased demands on its resources. Where this has occurred the government has often-stepped in, first of all with temporary assistance or a special grant, to be followed later by further and larger contributions from State funds with representation in management, and ultimately by the practical taking over of the institution, and the absorption of its revenues by the State.' 7 Burdett repeated this warning in the thirtieth edition of Hospitals and Charities, the last he edited before his death in 1920. He sensed ‘a sinister attempt for what would appear to be political motives to maintain that the voluntary system had failed,’ and to substitute a state system.8 The Labour Party did in fact believe that, solvent or not, the voluntary system could never meet all needs adequately. It believed that local authorities should establish their own hospitals and, as a dual system would create problems, the voluntary hospitals should be absorbed. Hospitals in London and the university towns with a national and even international reputation should be funded and administered directly by the Ministry of Health, but there should also be a system of large central local authority hospitals linked to smaller local and cottage hospitals.9’16 Matters came to a climax in 1920. Notwithstanding an emergency distribution of £250,000 by the King’s Fund and a further £250,000 from surplus funds of the Red Cross and St John’s, it seemed improbable that the voluntary hospitals could continue on their traditional basis unless immediate steps were taken to re-establish the pre-war position. The King’s Fund decided to draw upon its capital resources, but Hospital Sunday did not do so. On 26 January 1921 the King’s Fund considered and ratified its policy for the preservation of the voluntary hospital system.10 The propositions the Fund advanced were that the voluntary system was the most effective and cheapest method of providing the best treatment and advancing medical knowledge and practice; that at least a substantial part of the cost should be met by voluntary contributions; that the current receipts were inadequate to meet the present cost, let alone the debts of the London hospitals, or the need for redevelopment; but that no remedy should be contemplated which reduced voluntary contributions or removed independence of management. It was proposed that payment by patients, insurance schemes, and grants-in-aid by public authorities for specific work should be considered. Block grants were however deprecated, although pro-rata assistance was a possibility. The Lancet agreed that it was the duty of the state to supplement rather than supplant the voluntary hospitals, and to provide the care needed by many who were not ‘an object of charity in the normal sense’. State support should not, however, deprive the hospitals of their independence of control.11 The years 1921-24 were a period of continuing difficulty for the hospitals, and the possibility of the breakdown of the great voluntary hospitals and their medical schools led the government to establish the Cave committee, which first met in January 1921. The committee agreed that there was great merit in the voluntary system, that it was in the public interest to maintain it, and recommended as temporary assistance a state grant of a million pounds with a further grant the following year. The committee proposed the formation of a Voluntary Hospitals Commission to supervise the distribution of the grant, acting on the advice of local hospital committees.12 The King’s Fund agreed to act as the local committee to advise on distributions in the Metropolitan Police District. In its evidence to the Cave committee the Fund had pointed out that its council consisted of people holding representative positions in national, metropolitan and city government, in religious bodies and the medical profession; and that it could be the channel for some form of public assistance.10 Continuing pressure to reduce public expenditure led ti the ‘Geddes axe’. The government decided to provide no more than £500,000, and to give state assistance for a limited period only, simply to allow the voluntary hospitals a breathing space so that they could re-establish their position.13 The voluntary movement would have to meet some of the deficit itself, perhaps on a pound-for-pound basis. The Hospitals Commission recommended by the Cave committee was formed, under the chairmanship of Lord Onslow, and it supervised the distribution of the government’s £500,000 grant. A leader in The Times criticised the Minister for his parsimony and accused his department of seeking a ‘great new experiment in State or municipal hospitalization’. Letters were published from The London Hospital and St Mary’s, drawing attention to the plight of the hospitals.14 His Majesty himself asked the Ministry for reassurance about the position of the London hospitals. In reply the Minister said that the first principle in the government’s mind was that the voluntary system must be maintained in full force and vigour. Had he been so foolish as to wish to destroy the voluntary hospitals no surer way could have been found than unconditional deficiency grants. Voluntary support would then have diminished, state contributions would have risen by leaps and bounds and state control would have followed. The Minister’s letters were difficult to draft. As he pointed out in a personal letter to the editor of The Times, painting the blackest possible picture was a traditional way of stimulating voluntary support. The Minister could say nothing which would reduce the ability of the hospitals to raise money.13 A combined hospitals’ appeal by the King’s Fund which aimed to stabilize the hospitals’ financial position raised £480,000 fairly rapidly.15 The Labour Party used the opportunity of the financial crisis to re-state its hospital policy16 and advanced thirteen propositions which it believed should form the basis of a future hospital service. By 1924 the financial problems were easing and the King’s Fund could report that the deficits of the London hospitals were becoming smaller each year. Hospital savings schemes had been inaugurated, and many hospitals could once more balance their books. In April 1924 a conference was held under the auspices of the Labour Party, attended by a wide variety of organisations including the British Medical Association, the voluntary hospitals and members of professional staff associations. The conference was called to discuss the desirability of further state aid to extend and maintain the hospitals. In sending the conference his good wishes, the Prime Minister, Mr Ramsay MacDonald, said that the problems of the hospital system, if the existing chaos could be so described, was a symptom of inadequate civic organisation. It fell far short of the achievement its friends and supporters desired. He hoped that a common and wise policy might be the outcome of the discussions. Speakers from the left maintained that great though the efforts of the voluntary movement had been, it had failed to provide completely what the nation needed. The only way out of the impasse was for the state to accept the responsibility of providing hospital treatment for all who needed it, transferring the poor law infirmaries to the local authorities, and giving the voluntary hospitals the choice of remaining as they were, or of coming to an arrangement with the local health authority. Lord Knutsford, however, thought that the record of the state in providing health care for the poor and the armed services showed that whilst it might do its bare duty, it would be done without grace. Turning to the Labour Party policy, he spoke scathingly about the statements which had been made. Hospitals were not pauperising agencies, patients were not admitted preferentially if they could pay something towards the cost of their treatment, neither were they afraid of entering hospital because they might be subject to experimental treatment. The voluntary hospitals abided by the Sermon on the Mount, not the cold code of the Charity Organisation Society. Lord Knutsford tartly remarked that the Charity Organisation Society had nothing to do with charity. The best plan would be to strengthen what was admittedly good, and not change to a system of state management which would satisfy nobody.17 Lord Somerleyton, representing the King’s Fund, pointed to the improving financial position of the hospitals as a result of their steady efforts, and the final resolutions, passed by the conference without dissent, called for increased support and public assistance for the voluntary hospitals to preserve the best features of the voluntary system, a closer relationship between public and voluntary hospitals, improved geographic distribution, cooperation between the various institutions, and the ‘removal of all taint of the Poor Law from the infirmaries, throwing them open to all citizens’.17 Similar sentiments were expressed at a conference of the British Hospitals Association, and a conference of Local Voluntary Hospital Committees which had been established to work with the Onslow Commission. It was announced in the House in February 1924 that the Onslow Commission was to seek evidence of the need for additional hospital accommodation, and the best means of providing and maintaining it. Most hospitals, although their financial problems were lessening, were still without the means to extend their facilities. The King’s Fund pointed out the difficulty of trying to determine need for beds from information such as waiting list size, and the replies it received from the London hospitals only permitted an estimate of the number of beds which came into the range of ‘practicable possibilities’. These were beds which would fit into the general pattern of provision, and which could conceivably be funded either at once or in the foreseeable future. The increase amounted to about 2,000 - to something a little over 15,000 in all.18 The Onslow Commission reported that even when the use of available Poor Law beds had been taken into consideration a shortage of beds existed. It favoured state grants towards building costs and a further measure of assistance to help the hospitals to overcome their arrears. However the government would provide no further money and the commission was disbanded in 1928. The financial recommendations of the Cave committee and the inauguration of hospital savings schemes brought about considerable changes in the financing of voluntary hospitals. The needy continued to receive free treatment — the primary function of the hospitals — but it became usual to charge the more affluent. Financial organisation was increasingly based upon payment for services rendered.20’21 The King’s Fund had emerged from the financial crisis more powerful than ever as the spokesman for London’s hospitals. In its evidence to the Onslow Commission it had said that it could fulfil the role of a central administrative body and cooperate with other coordinating bodies on the outskirts of London. It had channelled not only voluntary subscriptions but state grants to the hospitals; and being voluntary itself it respected the independence of the hospitals. Charing Cross Hospital, in its own evidence, suggested that the Fund be given still greater power ‘to smash the hospitals into line as regards expenditure or amalgamation’. Such a dictatorial approach was not the Fund’s way of working. At the zenith of its power, its ‘friendly persuasion’ was seldom ignored. The voluntaries were keenly aware of the need to retain public sympathy if their financial and political interests were to be safeguarded. The King’s Fund established a propaganda committee in 1924 to arrange lectures and produce leaflets and films. Exhibition displays were constructed and a miniature hospital was built to 1/16th scale, complete with a royal statue.22 One parent claimed that his son’s eye had been injured by an ultra-violet lamp in a display of modern hospital equipment. A film was made called ‘A Hundred Years of Progress’, and Ernest Morris, house governor of The London, delivered lectures on the pros and cons of nationalisation of the hospital service. Developments in medical education The recommendations of the Haldane Commission has been overtaken by the Great War. InJune 1918 Sir George Newman, chief medical officer of the Board of Education and later the first chief medical officer of the Ministry of Health, submitted a report on medical education to his Board.23 He expressed some diffidence in writing upon the subject, but in a carefully constructed document he proceeded to review the nature of university education and to identif~r four main deficiencies. They were teaching at a level below university standard; failure of university departments to work with each other; inadequate medical research within the teaching system; and the need for better postgraduate education. The following year grants became available from the Board of Education to assist the establishment of clinical professorial departments where academic staff would work full-time in teaching and research, undertaking no private practice. St Bartholomew’s Hospital had already decided to establish such a unit without waiting for further developments. A unit was also established at St Thomas’s, and University College Hospital received a magnificent gift of £1,205,000 from the Rockefeller Trust for the same purpose. Academic units would not be concentrated into a few university-dominated hospitals as Haldane had envisaged, but would be widely distributed. Some schools, like Guy’s, chose to maintain the traditional pattern and after the first units were established progress was slow. In its evidence to the Goodenough committee in 1942 the University of London listed those professorial units in existence at the outbreak of war in 1939; none existed in half of the London medical schools.
The academic staff were very much in the minority amongst the honorary consultants, and each professorial unit needed at least fifty beds, inevitably at the expense of the other clinicians who continued to teach students, but who no longer had the field to themselves. Slowly the schools began to move closer towards university-based education, and to adopt the pattern of organisation outlined by Sir William Osler in 191124 The University of London came to the conclusion that the minimum number of beds essential to have an efficient medical school was 600, and every medical school came under pressure to increase its laboratories and service departments. Hospitals and schools could not function as they had once done with little more than a number of wards and an operating theatre. Another problem involved medical education for women. The establishment of the London School of Medicine for Women in 1874, in association with the Royal Free Hospital, was followed during the Great War by the admission of women to the majority of medical schools in London. After the war most hospitals reverted to their pre-war tradition, and clinical places were once more difficult to find in London. Poor law reform and the boards of guardians Amongst many other objectives the long campaign to reform the Poor Law aimed to achieve the transfer of infirmaries from boards of guardians to local authorities. Ever since the 1830s there had been increasing dissatisfaction with infirmary management, which varied from the enlightened to the apathetic. Mr Joseph Chamberlain, speaking in 1888 during the second reading of the Local Government Bill, suggested the inclusion of Poor Law administration amongst the duties of the new county councils.25 However boards of guardians remained untouched, as they did ten years later when the London Government Act (1899) abolished the vestries and created twenty eight London boroughs. The Royal Commission on the Poor Laws (1909) had pointed to the overlapping of hospital authorities, and the Majority and Minority Reports had agreed that boards of guardians should be abolished. The Maclean committee, established at the end of the Great War to consider the post-war planning of health services, also supported the transfer of functions.2 The Maclean committee pulled together the points on which the Majority and the Minority Reports had been agreed, and Sir Robert Morant, a senior civil servant with extensive experience of both health and education, added a note to say that he assumed that all the main forms of medical service would be brought together under one Minister, within a Ministry of Health, before such a transfer took place. This happened, the Ministry of Health being formed in 1919, but whilst the transfer of functions became accepted policy, the change was not to the liking of those to be abolished — the boards of guardians and the Metropolitan Asylums Board. Although Burdett had little respect for state or municipal management, he wrote in the introduction to the 1919 edition of Hospitals and Charities that he looked forward to the time when county councils would take over the administration of the entire poor law system. Such a reform would make it possible to classify sick and healthy paupers, and persuade public opinion to insist on the best possible provision being made for pauper patients.8 Burdett also believed that the transfer would make it possible to provide better staff and equipment, to construct outpatient departments, and provide patients in London with the additional accommodation which was needed, particularly away from the centre ‘in the areas where the working classes live’. London infirmary medical superintendents also supported transfer to the London County Council on the grounds of economy, better distribution of patients between institutions, the likelihood that better candidates would be attracted to the medical and nursing services, and the opportunity which would be created to develop specialised services. The superintendents envisaged district hospitals, providing one bed per 300 population, with associated outpatient departments. There would also be special institutions for ophthalmology, ear, nose and throat disease, tuberculosis, orthopaedics, fevers and radiotherapy.26 The Maclean report had suggested that among the functions to be transferred to the London County Council should be those of the Metropolitan Asylums Board. The London County Council agreed, believing that the health functions which were carried out by many different bodies should be united under its control, just as Parliament had united governmental health activities in a single Ministry. The Clerk was asked to report on the health functions of local authorities and other bodies in London, and the report recommended that the council should be the sole and central institutional body for health services in London.27 It was adopted by the London County Council in December 1919, for it was consistent with the general thrust of council policy to extend its sphere of influence and centralise control. The council made cordial reference to the work of the Metropolitan Asylums Board and suggested that its institutions and its highly competent staff should be transferred en bloc. The council also suggested that the voluntary hospitals should establish a central voluntary hospital council with which it might negotiate, and sought a meeting with the new Minister of Health. The representatives of the council were received by the Minister on 23 April 1920. Dr Christopher Addison had previous experience of the council’s ambitions, in the housing field. Nevertheless after the council had presented its case he said it was clear that a good deal of muddle had arisen from the needless multiplication of authorities. While some services were best administered locally, others were not. The more specialised the services, the wider the range of the responsible authority had to be, and it was essential to have an authority to deal with some services over a considerable area. The Minister felt that the council’s main principles were unassailable.28 For the next twenty-five years the Ministry and its officers came to turn, more or less automatically, to local government when an extension of social services was envisaged. Because of the financial crises of the early twenties, and public campaigns for a reduction in government expenditure, there was considerable delay before proposals for Poor Law reform could be considered. They were not circulated to boards of guardians and the Metropolitan Asylums Board until January 1926. It was proposed to abolish boards of guardians and with them the Metropolitan Asylums Board which derived its membership from ‘destitution authorities’. In London the County Council would become the supervising and controlling authority for all health purposes throughout the administrative county, which covered essentially the same area as the Asylums Board. In its reply the Metropolitan Asylums Board stated that it was convinced that the London County Council would find it impracticable to undertake the enormous task of managing all the hospitals and institutions involved, and that an independent body was justified.29, 30 Neville Chamberlain and collaboration In 1919 Sir Bertrand Dawson was commissioned by the new Ministry of Health to chair a council to advise on the systematised provision of health services. (the Dawson report is considered in more detail in the subsequent section) The report proposed, with a good deal of post-war fervour, the linkage of hospitals into a single system. At the time it did not carry much weight. It was common knowledge that there was a substantial body of disagreement amongst the interests represented upon the council, and that the report had been prepared within a tight time limit. The report, admittedly an interim one, ignored costs, the existing system of local government, and the pattern of hospitals, clinics and dispensaries already in existence.21 Nevertheless collaboration became a consistent feature of government policy, for there was the potential for considerable saving if the two systems of hospitals would work together. The King’s Fund had reported a shortage of around two thousand beds in London, and schemes to remedy this had to avoid waste where voluntary hospitals and infirmaries worked beside each other. How waste could be avoided without some form of health authority in each area was difficult to see. Sir George Newman, the chief medical officer at the Ministry, told the Royal Sanitary Institute in July 1925 that division of responsibility between so many authorities led to confusion, waste and inefficiency. What was needed in each area was a single unit of health government which brought together all health functions. In each district there should be a close association of voluntary and state institutions under one authority.31 Mr Neville Chamberlain, the Minister of Health, was equally explicit when he spoke to the Hospital Officers Association in December 1925.32 Neville Chamberlain did not believe that the voluntary hospitals should suffer extinction or come under state control, although he was often accused of wanting to take them over. However he told an audience in Coventry in October 1926 that public heath provision could not be looked at in water-tight compartments. The voluntary hospitals should consider how they might fit into the wider scheme of things. Could cooperation be extended? Might there not be in time some central health authority with representatives of the voluntary hospitals upon it, responsible for the general health policy of an area? In return for a certain subordination of their complete and absolute freedom to do what they liked, they might receive financial assistance.13 His speech revived fears of a state take-over and The Times published a leading article criticising his approach. Chamberlain replied that he was concerned with overlapping services and waste of money. Local areas should be examined as a whole, and closer coordination of the institutions in an area by a central body with general powers of guidance was needed. Would not the voluntary hospitals like to play their part? If they did not, such a body would undoubtedly be formed without them, a development he would view with grave anxiety.33 The British Hospitals Association wrote to Chamberlain to ask how the voluntary hospitals might best cooperate with the public health services. Chamberlain considered that discussions might be more productive if there was a series of concrete proposals to be considered, rather than the somewhat abstract topic of ‘cooperation’. He therefore suggested a number of issues which might be considered locally, including the allocation of some categories of illness to one or other type of hospital, the effect of such agreements on future hospital development, the deficiencies which existed and how they could be remedied, the possibility of a clearing house for admissions, so that patients could be admitted rapidly to one or another institution, and what pattern of joint staffing might be desirable.33 Chamberlain was invited to address the association but declined because of the uncertainties surrounding the forthcoming Local Government Bill. The British Hospitals Association consulted its branches and replied to the Minister’s questions without being particularly constructive. Cooperation on building developments did not seem to them to be practicable. The voluntary hospitals already provided a full service, and where they did not they planned to do so, but it would help if their staff could use beds in public hospitals. Dawson, now in the House of Lords, used his influence within the British Medical Association to ensure that its response was more constructive. In 1927 Neville Chamberlain addressed the autumn meeting of the British Medical Association on cooperation between the voluntary system and the municipal hospitals34, and made further attempts to persuade the British Hospitals Association to look seriously at the need for it. In response the Association’s officers told their members that it was imperative that the voluntary hospitals should cooperate with local authorities. The Local Government Bill would soon be law, and if competition developed with the rate-supported hospitals, which had almost unlimited finance behind them, there could be only one outcome. Yet the very thought of cooperation alarmed many of the voluntary hospitals. Eason, the medical superintendent of Guy’s, referred to the elephant who said he was a strong believer in cooperation as he sat on the pheasant’s eggs in a praise-worthy attempt to assist in hatching them out. Some of those who worked for the voluntary hospitals feared that they would be squeezed out of existence by a beneficent public sector. Informal contacts were established between the London voluntary hospitals and the county council’s medical officer of health, Dr F N K Menzies, who began to play an increasing role in hospital affairs. He was described as a big man, mentally and physically, full of vigour and initiative, with a pleasing personality. He had a commanding presence, a persuasive tongue and personal friendships in high places. The Lancet regarded him as a man of affairs with great driving power, a facility for choosing the right assistants and a knack of getting his way in large scale problems of medical administration.36,37 Already an honorary member of the Westminster Hospital’s staff, he met representatives of the voluntary hospitals and assured them that the London County Council was not seeking to take them over. At a meeting with the King’s Fund in 1928 Menzies said that the attitude of the county council was entirely friendly and a tradition of cooperation with voluntary hospitals had been established. However the hospitals should bear in mind that if satisfactory arrangements were not agreed, the Labour group would demand complete municipalisation and would be able to make out a good case. An assumption of arrogance on the part of the voluntary hospitals would only antagonise their friends and throw them into the hands of their enemies. The King’s Fund became convinced that Menzies was a valuable ally, but recognised that if the voluntary hospitals showed an unwillingness to negotiate his patience might become exhausted.10 The British Hospitals Association organised two conferences of London hospitals, for those with and those without medical schools, to discuss the future with Menzies. The teaching hospitals expressed doubt about the ability of the council to manage the vast hospital resources to be transferred to it, and if it tried it might be difficult to avoid antagonism, competition and duplication between the two systems. The voluntaries suggested that the county council could ask them to manage municipal hospitals on its behalf and at its expense. A variety of agency arrangements were possible and existing examples of cooperation were cited. St Mary’s students went to the Paddington Infirmary, and the Infirmary used St Mary’s laboratories. The chairman of the guardians was a member of the St Mary’s board, and the benefits of the association were mutual. Dr Menzies could not agree that the council might consider surrendering its responsibilities, although Herbert Eason, the medical superintendent at Guy’s, repeated the proposal that teaching hospitals could administer the municipal hospitals and deploy their staff in both, at a meeting of the British Medical Association chaired by Menzies in 1927. 35, 39 Two doctors wrote to The Times suggesting an advisory council for hospital services in the metropolitan area, in which the representatives of the voluntary hospitals would be in the majority (because of their long experience) and in which the King’s Fund would play a leading role. There was little support for the idea in any quarter. Meanwhile the King’s Fund established a special committee to consider the steps which should be taken whilst the Local Government Bill was passing through Parliament. The Minister, Neville Chamberlain, saw a deputation from the Fund in November 1928. He was asked if he would make it mandatory for local authorities to co-opt persons with voluntary hospital experience onto their public assistance committees. Chamberlain said that he was all for maintaining the voluntary system, and for coordination, but that he had not met with much response, being suspected of wishing to introduce municipalisation. The danger to the voluntary hospitals did not come from the Bill, but from the progressive improvement of the poor law infirmaries. Co-option would not of itself secure coordination, and would be resented by many local authorities. Furthermore, if it was made reciprocal, with the co-option of local authority representatives onto the boards of the voluntary hospitals, that also might meet with a hostile reception.10, 38,40. A series of informal discussions took place between representatives of the King’s Fund, the London County Council and the voluntary hospitals to explore the problems of working together. In March 1929 the King’s Fund published a carefully drafted memorandum on the Relations between Voluntary and Municipal Hospitals.41 It proposed permanent consultative machinery to consider hospital provision, equipment, staffing and training. It wished representatives of the voluntary hospitals to be appointed to local authority public assistance committees, proposed the coordination of the two hospital systems in nurse training, and the use of the facilities of the municipal hospitals for medical student education. The Local Government Act, as passed in 1929, included a clause placing a duty on local authorities to consult a committee representative of the governing bodies and medical staff of the voluntary hospitals about the accommodation to be provided and the purposes for which it was to be used. ‘It is imperative’, said a Ministry circular, ‘that the Local Authorities establish the most cordial relationships with, and should make full use of, the medic 1 profession in regard to hospitals.’42 In March 1929, shortly the Bill became law, the London County Council wrote to the King’s Fund asking for its views on the manner of cooperation. The Fund had been discussing the matter with the voluntary hospitals and produced a proposal for a group which Dr Menzies felt was too cumbersome to allow any business to be done. Nevertheless the London Voluntary Hospitals Committee was formed along complex lines, representative of the King’s Fund, the Conference of Teaching Hospitals and the London Regional Committee of the British Hospitals Association.40 The Local Government Act (1929) The Act had three main effects on hospital services. It brought poor law infirmaries and fever hospitals into line with other municipal services, opening them to all in need without the stigma of the poor law. It placed them under elected and representative local authorities, instead of ad hoc bodies like boards of guardians. Finally, it decentralised the financing of these hospitals, consolidating the exchequer grants for the total range of local public services. Speaking to the medical students of the Westminster Hospital, Dr Menzies explained how public opinion had rebelled against the way a sick person had to be regarded as a pauper if he was to be treated by the guardians. Twenty-five years of agitation had at last been successful and the London County Council would soon have 75,000 beds under its control for all types of disease, five times as many as in the voluntary hospitals of London. The principle had been established that sick people in need of treatment should receive it, and if they were unable to provide for it themselves it was the business of the health authority to do so. Menzies recognised the fear of the voluntary hospitals that they would be adversely affected but he saw no reason for anxiety. For twenty years the policy of the London County Council had been cordial cooperation with the voluntary hospitals, and in its new task the council would need the sympathy and support of all who were interested in the care of the sick.43 Sir George Newman, in his annual report at the Ministry, also welcomed the change. ‘For the first time in the history of the public health services the medical officer of health has a direct and ample opportunity for closely and effectually coordinating in his area all the varied medical services of the State.’ ‘Only the best must be good enough for the patients in our Hospitals and in medical treatment expenditure is very often the best form of economy’, wrote Lewis Silkin in a London municipal pamphlet produced by the Labour Party. The London County Council intended that the hospitals to be taken over from the guardians should be used primarily as general hospitals, ‘equivalent to the voluntary general hospitals’. The council would not only possess the majority of beds in London but the biggest hospitals as well: Lambeth, St Giles’ Camber-well and St Mary’s Islington”, The voluntary movement observed the behaviour of the council with apprehension. The council could have continued to administer the infirmaries under the Poor Law Acts but it chose to work under the Public Health Acts instead, which had the advantage for the council that ‘appropriated hospitals’ were removed from the detailed oversight of the Ministry of Health.45 The council’s inheritance Developments in the infirmaries had been patchy although the use of some as military hospitals had led to an improvement of facilities. An increasing number were recognised by the General Nursing Council for nurse training and some had been opened to medical students from nearby teaching hospitals. The Paddington board of guardians had made an agreement with St Mary’s in 1920, and King’s College Hospital and the Camberwell Infirmary were in negotiation. Some infirmaries had developed considerable esprit de corps and opposed transfer to the London County Council as a threat to their individuality. The Lambeth guardians had purchased both radium and deep X-ray equipment, and had sent their senior physician on a tour of Europe to see what was being done in the world of radiotherapy.46 However, few staff of the voluntary hospitals set foot in the infirmaries; some of those who did had had their views confirmed that they provided a second class service with second class staff. The infirmaries were managed by 25 unions. Populations varied from 100,000 to 300,000, with exception of one very large union - Wandsworth. In total, they provided 16,250 beds staffed by 140 doctors. In 1928, Drs Meredith Richards and Manby surveyed the infirmaries for the Ministry of Health.47 Some of the accommodation was found to be excellent, much was indifferent, but most was found to be sufficiently good to serve a purpose. Many infirmaries were on noisy sites, had insufficient isolation accommodation, and did not classify patients according to their needs. Occasionally wards were tightly packed and there might be no margin of beds for emergencies. The surveyors thought that if existing poor law boundaries were disregarded, the facilities could be used to greater advantage. Admission policies also varied. ‘If they did not go out into the Highways and Hedges to compel patients to come in,’ said the surveyors, some guardians ‘were at least ready to welcome all who sought admission.’ Others, acting strictly within their statutory authority, made careful enquiries about the needs and resources of those seeking relief. In some infirmaries the doctors were mainly occupied with surgery and the care of the acutely ill; in others most of the patients were suffering from chronic illnesses. Boards of guardians varied from a progressive attitude to almost complete inertia; these variations could not be justified. In the view of the surveyors, larger areas of organisation were called for. They thought that the administrative County of London was too large a primary unit, just as the borough councils and unions were too small. Meredith Richards and Manby therefore suggested that the infirmaries should be managed in groups based upon borough boundaries, three groups north of the Thames, and two to the south. The special committee on changes in London local government, established by the London County Council, suggested that there should be five non-executive area committees for the purposes of hospital administration, and the council be an to develop the administrative machinery necessary to take conrol.48 Discussions with the guardians made a smooth hand-over possible, and few patients would have noticed the change. The London County Council proved a much less autocratic body than the doctors had feared; consultation with the hospital medical officers was frequent and promotion prospects were better.46 London County Council management The council asked its medical officer and architect to carry out a survey and report on hospital premises. The report on the infirmaries showed that the condition of most left much to be desired. Menzies commented ruefully that all the floors seemed to be breaking up and all needed rewiring. The best were, undoubtedly, Lewisham, Hammersmith, St James’ and St Charles’. The worst were probably St Leonard’s, St Pancras and St Stephen’s.36 The older infirmaries showed little evidence of ordered planning, but those built from 1880 onwards were usually of the H, E, U or V plan, with the administrative block occupying a central position and the wards lying on either side along a main corridor. The London County Council distinguished between hospitals which in essence provided medical treatment and nursing, and institutions for long-term residential care. Menzies told his committee: ‘Many of the deficiencies are attributable to the fact that just as each voluntary hospital is a law unto itself, so hitherto each board of guardians has suffered from a comprehensive legal obligation to provide treatment for all destitute sick persons. Now that the existing poor law boundaries are to be swept away and the area to be considered is the administrative County, a great opportunity is afforded of considering the best way of meeting the needs by rearrangement and regrouping of poor law infirmaries and institutions, so as to utilise them to the maximum degree of efficiency within their limitations.’ Menzies worked on much the same principles as Markham, sixty years before. He suggested the hospitals which might be appropriated by the council under the Public Health Acts, excluding those offering only custodial care. The council approved the list, as did the Ministry, and appropriation took effect on 1 April 1931. Hospitals were divided into six categories:
This classification meant that some residents who were not really ‘sick’ occupied beds in acute hospitals, and it took time to transfer them to appropriate institutions. Indeed, it was not clear to the council whether it was best to separate the acute and chronic sick. The council decided that a hospital standard of care should offered to all, including the chronic sick, the aged and the infirm. The council’s management of its hospital service The nature of the hospitals which had passed to the council varied widely, as did the quality of the staff and their terms of service. The assimilation of 75 hospitals with 40,000 beds and a workforce of 26,000 into a single organisation was a task of the first magnitude which took several years to complete. The achievement was impressive by any standard.49’50 The nature of the services provided by the London County Council differed significantly from those of the voluntary hospitals which seldom retained chronic or long term cases. These were transferred to council hospitals as the local authority had a statutory obligation to provide care which the voluntaries did not bear. The council also faced the increasing problem of care for the elderly; in the thirty years from 1901 to 1931 the proportion of the population over 65 years had increased by 70 per cent, from 4.09 to 7.34 per cent.36 At the same time an attempt was made to cope with the changing pattern of care; the proportion of acute cases admitted was rising, higher social classes took advantage of the service and as the equipment of the ratesupported hospitals was improved more operations were carried out. LCC and voluntary hospitals in London, 1931
The council’s approach to the provision of outpatient care also differed from that of the voluntary hospitals. The London County Council relied in the first instance on its district medical officers, believing that there was no point in providing an outpatient department to do work that could be done equally well by its district medical and nursing services. The purpose of the hospital was to fill gaps in the district service, providing medical officers and the follow-up of cases discharged from hospital. None of the council’s hospitals allowed patients direct access to the hospital services, as did the voluntary hospitals. The voluntaries justified the policy of ‘an open door to the sick poor’ by arguments which had little appeal for the council. These included distrust of the general practitioner as a sifting mechanism, the provision of clinical material for students, a facility for poor people who had no doctor or who did not wish to see the council’s district medical officer; and the usefulness of the outpatient department as evidence of the popularity of the voluntaries when appeals for support were made. The council’s management style was centralist, based upon a belief in discipline, system and standardisation. The motive was laudable - a desire to see a rapid improvement in the state of the hospitals, and to enforce economy in the provision of services. However the council’s passion for meticulous supervision soon brought it into conflict with the London boroughs and professional organisations. Local hospital committees had few powers and were run by junior staff from County Hall. Decisions involving money, however little, went to the Central Public Health Committee and its successor the Hospital and Medical Services Committee. Each hospital was seen as only a small part of a very large service and neither the local staff nor the hospital committee had a budget or could take decision on matters of policy. Meat was bought centrally at Smithfield, scalpels and syringes were purchased on a central contract, and the minutes of the County Hall committees reveal a mixture of major issues and a welter of trivia. Two or three times a week the committee would deal with matters of moment like the cost of meals of an individual relief nurse, the length of sick leave granted to a junior doctor, or the admission to the obstetric practice of St Mary Abbots, Kensington, of a couple of medical students. Doctors and nurses were responsible to County Hall through the local medical superintendent. The London County Council said that a proper balance had to be maintained between ‘centralised control and devolution of responsibility to “local” centres’. The council thought it had the balance right but few others agreed. Fully aware of the progress being made in all branches of medical science, the council wished this to be reflected in its hospitals. It believed that a hospital which ‘stood still’ was in fact regressing and that money could be saved and efficiency would rise as a result of investment. From 1933 onwards the council’s annual reports recorded the progress which had been made. Between 1934 and 1939 £4 million was spent on hospital improvements. Hospital construction was examined to determine the best policies to follow in renovating buildings. A study of the relative costs of various types of hospital construction was in favour of semi-permanent buildings which would last up to sixty years, being cheaper and more adaptable to changes in medical practice. The Hospital Standards Committee considered the various types of equipment - artery forceps, waterproof sheeting, sanitary fittings, baths and washbasins - and recommended the type to be used. The way in which the departments of a typical 500 bed hospital might be arranged to facilitate effective working was also studied.51 Even hospital names were standardised. In some cases the names were out of date and the possibility was considered of using the names of saints, kings or persons with local associations instead. The officer concerned felt it ‘desirable to adopt some uniform system of nomenclature’, and as some of the transferred hospitals were already named after saints, he found saints’ names for the others. Because saints were not to be duplicated within the administrative county, he sought associations with local parishes. So Plumstead and District Hospital became St Nicholas’, and St Charles’ and St Alfege’s, among others, were given their names. Nursing was a particular problem. The staff transferred from the guardians exceeded 9,000, employed in no fewer than 78 grades. A matron-in-chief was appointed, responsible to Dr Menzies (now Sir Frederick Menzies). He was of the opinion that the only way to create a permanent and efficient nursing staff with a sense of dignity and pride in its work was to make it responsible to a woman of the same status as the principal medical officers — a development which the officers did not view with unqualified approval. Some hospital matrons began to regard themselves as independent of the medical superintendent, and the senior doctor and nurse in a hospital might not be on speaking terms. The London County Council’s service had its strengths and weaknesses. In the face of its impressive achievement any criticism seemed carping, not least because the qualities of Sir Frederick Menzies were a guarantee that matters would not go badly wrong. In 1934-5 Dr Carnwath, of the Ministry, carried out an exhaustive survey of the public health services provided by the council, describing the problems which the council had faced and the way they were being tackied.36 An abbreviated version of his report appeared in the report of the Ministry of Health for 1934-5. The Minister congratulated the council on its enlightened policy and upon the highly efficient organisation built up by Sir Frederick Menzies for overall planning and control of the hospital and medical services. The council was so pleased that it had the appropriate section of the Ministry’s report reprinted as a separate publication. Voluntary hospital and county council cooperation Under section 13 of the Local Government Act local authorities were instructed to consult a committee representative of the governing bodies and medical staff of voluntary hospitals ‘as to the accommodation to be provided and the purpose for which it was to be used’. This clause, designed to foster cooperation, was an expression of Chamberlain’s views, had the support of the voluntary hospitals, and was moved in the Upper House by Lord Dawson of Penn. The British Hospitals Association meeting at the Westminster Hospital in November 1928, viewed cooperation mainly as a means of allocating beds in the infirmaries to the staff of the voluntary hospitals, to make the transfer of chronic cases easier. Representatives of the teaching hospitals who met the following month at St Thomas’s welcomed the centralisation of the public hospitals under the London County Council. They thought that their senior staff would be too busy to work regularly in municipal hospitals, but that it would be desirable for more junior staff to do so for a stipend, to avoid a permanent division between two systems of consultant staff. The voluntaries could also provide the council with resident house officers, and would wish to take advantage of the teaching facilities that the municipal hospitals could offer.52 Members of the London County Council did not take kindly to the attitude of superiority sometimes adopted by the voluntary hospitals. Both sides became touchy and began to stand on their dignity. The King’s Fund tried to act as peacemaker, and suggested that the representatives of the voluntary hospitals, when speaking in public, should censor their remarks to avoid unnecessary offence. Ten years later, in his reminiscences, Menzies regretted that the interests of the voluntaries were not represented by the King’s Fund, but by the specially formed London Voluntary Hospitals Committee. The King’s Fund was well established, highly respected and backed by large resources. Had the King’s Fund’s council and the London County Council been able to work directly together, Menzies thought that relationships would have been much better. As it was joint discussions were a failure from the start. The London Voluntary Hospitals Committee was chaired by Lord Riddell, president of the Royal Free Hospital, who suggested at the first joint meeting with the London County Council that the best policy for the LCC would be to devote itself to the care of the chronic sick, the aged and the infirm, and to make appropriate financial grants to the voluntary hospitals so that they might deal with the acutely sick. Sir Frederick Menzies did not believe that this was the unanimous view of the London Voluntary Hospitals Committee, but its chairman was not a man inclined to encourage colleagues to speak. Similarly the voluntary hospitals did not wish the London County Council to make significant improvements to its hospitals without prior consultation with the voluntaries.54 To make such propositions to the greatest municipal hospital authority in the world was a little tactless, and the attempt to dictate its hospital policy was greatly resented by some council members. It was made clear that while the council might feel disposed to notify the Voluntary Hospitals Committee of proposals involving a substantial increase in accommodation, it would make its own decisions. Lord Riddell thought this was unsatisfactory, and that the council intended to go its own way and develop its service irrespective of the voluntaries. Nevertheless a two-way exchange of information was maintained. The council informed the voluntary hospitals of its proposals. The voluntary hospitals commented upon them, supplying in return details of their own plans.55 The London County Council was proud of its achievements in education and housing and intended to make a similar success of its hospital service. Believing that cooperation with the Voluntary Hospitals Committee would be difficult, it worked with individual hospitals, especially those with medical schools. The medical schools were particularly short of obstetric experience, and the facilities of council units were made available. Sir Frederick Menzies also devised a scheme which linked county council infirmaries to the teaching hospitals. After discussions with the London Voluntary Hospitals Committee the London County Council agreed that ‘facilities should be afforded at its special and general hospitals for demonstrations to medical undergraduate and postgraduate students, on the understanding that the council bore no expense and that the work of the hospitals was not impeded’. In January 1933 Sir Frederick Menzies reviewed the arrangements which already existed with KCH, UCH, St Mary’s and the Royal Free, and held discussions with the twelve London deans about the facilities they might require. The scheme he developed was approved by the council, permitting 12-15 students to attend for demonstrations several times a week.56 Sir Frederick’s scheme was based upon geographical relationships, and was illustrated in the report of the Voluntary Hospitals Committee by a sketch map. It is not surprising that the associations which were established in the 1930s persist to this day. The London County Council was worried initially that an arrangement with a teaching hospital might mean that it would have to look to the hospital for consultant staff. The deans thought that this would be desirable but not essential. Nevertheless they were worried about the quality of teaching students would receive, and students were therefore often taught by a visiting consultant rather than by one of the council’s own medical staff. Rules were laid down and the teacher had to select his cases from a list provided by the medical superintendent, and no impression was to be given at the bedside ‘which might convey a wrong impression to the patient as to his diagnosis or treatment’. The arrangements proved satisfactory and all schools save The London (where adequate facilities already existed) took advantage of the scheme. The senate of the University of London ‘expressed their deep appreciation of the action of the Council in making such important additional facilities available’.57
The London County Council and the Voluntary Hospitals Committee agreed that the council should make no general grants of capital or revenue to individual hospitals without first approaching the committee, but the council might make specific arrangements with individual hospitals for services rendered. A joint survey of hospital provision in London was undertaken (see Table 18, page 209). Published in two parts, one for the voluntaries and one for the municipals, the survey’s maps and geographical analysis of patient flows brought the hospital provision for London into focus and enabled the voluntaries to point out that 37% of their patients came from outside the administrative county. National relationships of the hospital systems Local authorities resented the fact that whilst they were obliged to consult the voluntaries under the 1929 Act, there was no reciprocal obligation. In London a mechanism had been created which brought the two sides together, at least in a formal sense. Sir George Newman, chief medical officer of the Ministry of Health, took cooperation as his theme when he addressed the conference of the voluntary hospitals in 1934. Sir George favoured a cooperative hospital system of ‘unity rather than uniformity ... a practical compromise between collectivism and individualism’, rather than placing all hospitals, both voluntary and municipal, on the basis of rates and taxes. Lord Riddell agreed that there must be no jealousy between the two services and admitted that the voluntaries had taken a long time to appreciate the enormous changes brought about by the Local Government Act. Sir Ernest Morris of The London Hospital said that the voluntary hospitals were worried as they had known for a long time that the unsystematic voluntary hospital system could not possibly provide all that was now required of a health service. It would be unable to meet the recommendations either of the Labour Party or Lord Dawson’s consultative council, which said that services ought to be available to everyone. That fear must be mastered - there had been problems enough in the past and they had been overcome.59, 60 Joint survey of medical and surgical services in the administrative county of London, 31 December 1931
The survey excluded services for the mentally ill and handicapped. Source Joint survey of medical and surgical services in the administrative county of London, prepared by the Voluntary Hospitals Committee and the London County Council, two volumes. London, P S King and Son, 1933. The local authorities, however, now had a unified and effective hospital administration, and could confer the power to negotiate upon their representatives. But with whom could they talk? The voluntary hospitals seldom authorised anybody to speak on their behalf, and the Hospitals Year Book of 1932 urged them to strengthen their machinery for consultation so that they could provide a considered and collective view. The days of ‘more or less undisturbed tranquility’ were over and a hospital which made an error in its planning delivered a blow to the voluntary system as a whole.61 Hospitals should now act as members of a system with a common policy. In its financial review of 1935 the Hospitals Year Book pointed out that the income of the voluntary hospitals was relatively inelastic, while the enthusiasm of ‘spenders of other peoples’ money’ was setting a standard in the municipal hospitals which it would be hard to match. The London Voluntary Hospitals Committee It was generally known that the London County Council would have preferred to have dealt with the King’s Fund directly, instead of with the Voluntary Hospitals Committee. The LCC treated the committee rather as it treated deputations, in a manner which lacked the open trust of those working together for a common purpose. Relations improved in 1935 when the committee was reconstituted under a new chairman with new officers, but it was too late. It never became a potent influence or rallying point, devoid as it was of financial resources to persuade or coerce the London hospitals into a common policy. The reconstituted committee was elected by individual hospitals and brought together the London Regional Committee of the British Hospitals Association and the statutory committee with which the London County Council had been dealing, so avoiding the problems of communication between various bodies claiming to represent the London voluntary hospitals. The understandings between the LCC and the committee were codified, and the Ministry of Health accepted the Voluntary Hospitals Committee as the body with which matters of importance to London voluntary hospitals were discussed. In giving evidence to the Sankey Commission, the committee expressed the hope that in the course of time it would formulate the principles of hospital policy in London, and, backed by the King’s Fund, would get the principles translated into action. The secretary of the British Hospitals Association believed that this was sensible, but saw that the only power available was the power of the purse, which the King’s Fund alone possessed. The approved procedure was for the voluntary hospitals to provide early information to the Voluntary Hospitals Committee about substantial schemes, before the press was told. They then had to submit fuller details of proposals which involved substantial capital expenditure, or which produced ‘an important change in the amount, nature, cost or site of the work done’. The committee s object was to ensure that all schemes on which subscribers’ money might be spent were clearly justified by the demand for care, but to avoid detailed enquiries into the need for particular forms of therapy or the precise nature of the accommodation to be provided. It did not wish to trench upon the ‘freedom and initiative that distinguished the voluntary from the municipal hospitals’. The King’s Fund instructed the voluntaries to give it prior knowledge of proposed developments, and to seek the views of Lord Riddell and the Voluntary Hospitals Committee before seeking a grant. Mr Ives, who became secretary to both the Fund and the committee, was circumspect in his dealings with the county council. He said that he ‘was not sure how far it was desirable to submit to the London County Council statements setting out in detail the inadequacies of individual voluntary hospitals’. When the Royal Free Hospital sought permission to expand by a hundred beds because of its long waiting lists and the many acutely ill patients that had to be turned away, these details were not passed on to the council.63 Postgraduate education and the British Postgraduate Medical School The establishment in London between the wars of a postgraduate medical education centre was a unique innovation. Two ideas were brought together, the need for a national and imperial centre for postgraduate education, as Sir George Newman had advocated23 and the desirability of providing a firm scientific basis for medical development. In December 1919 Sir Bertrand Dawson, at the request of his Consultative Council, impressed upon Dr Addison, Minister of Health, the need for improved facilities for postgraduate education. In October 1920 the chairman of the University Grants Committee (UGC) asked the Minister to form a small committee on postgraduate education in London. There was pressure on the UGC to fund postgraduate education and a number of schemes were under discussion.64 The Minister agreed and appointed a committee chaired by the Earl of Athlone, the chairman of the Middlesex Hospital. The committee was asked to ‘investigate the needs of medical practitioners and other graduates for further education in medicine in London and to submit proposals for a practicable scheme for meeting them’. The Athlone Committee worked fast and considered a wide range of evidence. It held 26 meetings and reported in May 1921 that a school attached to a hospital of at least 300 beds, centrally situated in London, should be devoted solely to postgraduate education. The ‘great special hospitals’ should be closely associated with the school, but it was held that undergraduate and postgraduate education could not easily coexist in the same institution. Little more was done at the time because of the financial problems of the early twenties, but in 1925 the Minister of Health, Mr Neville Chamberlain, appointed a committee of medical men to devise a practicable scheme. Chamberlain chaired the committee himself, and it included his chief medical officer, Sir George Newman, the Presidents of the Royal Colleges of Physicians and Surgeons, Lord Dawson, and Herbert Eason of Guy’s.66 This committee established a sub-group to visit a number of London hospitals. It rapidly eliminated the Westminster and Charing Cross, because of the limitations of their buildings, and the Royal Northern as it was too far from the centre of town. St George’s would have nothing to do with the idea. The Middlesex and St Mary’s appeared more suitable, but the committee decided that all the other teaching hospitals should be asked whether they wished to be considered. Sir George Newman thought it safe to say that there were more undergraduate schools in London than would be required to meet future needs; that the tendency would be to concentrate education into a smaller number of schools; and that there would be no difficulty in sparing one for postgraduate education. On 17 June 1926 letters went to all the teaching hospitals. Within a few weeks, and sometimes within a few days, the proposal had been turned down by University College Hospital, King’s College Hospital, The London, Guy’s and St Bartholomew’s. St Thomas’s and the Middlesex took a little longer to refuse. In almost all cases the idea was rejected because the future postgraduate hospital would be required to give up undergraduate education. St Mary’s was the only hospital willing to consider the proposition, but asked for further details. In the meanwhile, however, the West London Hospital volunteered and an inspection showed it to be a possibility. After consideration, the Minister’s committee concluded that the West London was the only hospital appropriate for conversion and expansion into a postgraduate centre. Further discussions with its board, however, showed that it had little idea of the scope of the scheme and considerable misgivings about its ability to raise the money to support the beds which would be required. The hospital looked to the Ministry to solve these problems. ‘This is not a Board’ commented Sir George Newman, ‘with whom we can go out tiger hunting’. Sir Berkeley Moynihan, the President of the Royal College of Surgeons, shared his concern and suggested that the passing of the Local Government Bill should be awaited. Then, the best poor law hospital in London should be selected and the college built nearby. This would demonstrate that a first class medical school could be attached to a municipal hospital and that the association of a medical school with a state hospital was constructive and advantageous, rather than restrictive and bureaucratic. There would be no need to beg for voluntary subscriptions. Nevertheless talks continued with the West London, the enthusiasm of its board increasing from cool to lukewarm. Although work on the Local Government Bill was taking up a great deal of time, Neville Chamberlain reassembled his committee in November 1928 to consider the next steps. The imminent municipalisation of the infirmaries led the doctors on the committee to repeat the proposal that an infirmary should be used instead of the West London. Sir Berkeley Moynihan saw Neville Chamberlain in private the day before a meeting of the postgraduate committee on 20 February 1929. During the meeting the President of the Royal College of Physicians, Sir Humphrey Rolleston, said that the objection to the West London scheme was that the committee would not be aiming at the best within its reach. The West London was not central, the problem of its existing staff (and its quality) had not been solved, and the scheme might cost as much as an entirely new institution. Sir Berkeley Moynihan said that the West London was not large enough to accommodate all the special departments required, that the medical staff was not of such standing as to be easily assimilated into the new centre, and that alternatives should be explored. Mr Chamberlain read out a letter from Lord Dawson which asked for exploratory talks with the London County Council. The committee discussed the possible use of the infirmaries at Camberwell, Lambeth, Lewisham and Wandsworth and none of the members opposed the idea. Mr Chamberlain agreed at the committee’s request to approach suitable members of the London County Council. In the meanwhile, he would see the chairman of the West London Hospital to inform him of the reservations of the committee about proceeding further.67 The London County Council proved to be willing. A report proposing the association of the new school with the Hammersmith Hospital went to the Cabinet and was presented to Parliament in April 1930. The postgraduate school was to be established at the Hammersmith with the assistance of a government grant.68, 69 Although the idea of using a municipal hospital had been generally supported by the eminent doctors who were members of the postgraduate education committee, it was not to the liking of the London Voluntary Hospitals Committee. While unable to suggest any alternative, it pointed out that the voluntary hospitals were the traditional basis for medical education and argued that expansion into postgraduate teaching would be better conducted in a voluntary than in a municipal hospital. It maintained that doctors with large private practices had the widest clinical experience and best knew the needs of general practitioners. The stimulus of postgraduate education, and the Treasury grant which went with it, should be kept within the voluntary system. If a London County Council hospital became the new centre, its whole-time staff would become university teachers, suggesting that the centre of gravity of even undergraduate teaching might gradually shift to the municipal hospitals, an occurrence which would greatly undermine the voluntary system as the teaching of medicine was one of its main sources of strength and vitality. A further objection was that to place the centre of postgraduate education on the outskirts of London was a fundamental mistake.70 During subsequent discussions with the LCC it was agreed that while the Hammersmith should be well equipped as a hospital, unrealistic standards of provision were not necessary. The quality of the teaching would depend on the quality of the teachers. The economic problems of 1932 led to a reduction in the government grant from £250,000 to £100,000. The scheme came to a halt and the appointment of the dean was delayed. For a time it was feared that the whole project would have to be cancelled, but in November 1932 the chancellor agreed that it could go ahead and the London County Council was informed.71 The council facilitated the conversion of the Hammersmith Hospital into a centre for postgraduate education, matching the government’s grant by one of its own. The British Postgraduate Medical School, as it was called, agreed to meet a proportion of the extra cost which arose from its establishment in relation to the hospital, the LCC and the school sharing the cost of equipment for joint use. The school was opened in 1935, Professor Francis Fraser moving from St Bartholomew’s Hospital to become its first professor of medicine. Some of the intentions of the founders were expressed by King George V at the opening. The school was to be ‘rooted in the ward and the laboratory’ and was to ‘renew knowledge and disseminate it for the benefit of mankind’. Stress was laid upon the contribution to be made to the Commonwealth, and the overseas relationship was underlined by the composition of the governing body. Professor Fraser was later to play a key role in the hospital service of London during the years of war, and in the emergence of the pattern of the National Health Service in the capital. He was able to establish new traditions at the Hammersmith and to ensure that from the beginning the hospital and school were staffed at consultant level mainly by whole-time academics. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
