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The Fabian Municipal Program Second Series), No. 5.

MUNICIPAL HOSPITALS.

DECEMBER 1900.

THE number of patients using our hospitals has been rapidly increasing during recent years out of all proportion to the increase of population. At the Glasgow Maternity Hospital 2,835 patients were treated in 1894 as against 1,291 in 1874, while at the Glasgow Eye Infirmary during the same period the patients increased nearly 400 per cent. The number of entries of free cases made in the hospitals of Birmingham, was 67,000 in 1867; 107,000 in 1877; 166,000 in 1887; 216,000 in 1898. In 1888 the number was equal to nearly one-third of the population of Birmingham (exclusive of paupers). In 1898 it was equal to nearly one-half of the population. In London, despite an increase in the number of lesser hospitals, dispensaries and medical clubs, the out-patients treated at the great hospitals situated among the crowded populations of East and South London, show remarkable growth. Between 1888 and

1898 the out-patients at the London Hospital increased by 75 per cent., and at St. Thomas's Hospital by 150 per cent. Meanwhile the accommodation for in-patients has been increased enormously by the Metropolitan Asylums Board and the Poor Law Unions. There are 28 Metropolitan Poor Law Infirmaries, with some 15,000 beds more than all the hospitals of London put together. The Asylums Board, in addition to several asylums and homes for children, has 13 fever and smallpox hospitals open, and others planned; a training ship with infirmary and convalescent home; and six ambulance stations, which during 1899 were concerned with the removal of patients on 42,119 occasions. During 1899, 21,063 patients were treated in the Board's hospitals. The total cost of the Board's establishments (including asylums, etc.) for 1899 was £766,783, the whole of which was raised by rates. At the present time, it is safe to say that four out of every five of the population make use of some form or another of medical charity during their lives, and the greater part of serious illness is treated in hospital instead of in the home. In view of these facts it is clearly important for us to know

How our Hospitals are Managed.

Hospitals may be arranged in three classes: (a) charitable institutions, supported by subscriptions and endowments and administered by self-elected and irresponsible boards of these there are 161 important and several hundred smaller ones in the United Kingdom, with an income and expenditure exceeding three millions; (b) private hospitals, homes and asylums for paying patients-commercial establishments, in fact; (c) public institutions, supported by the rates and administered by bodies elected by and responsible to the ratepayers -of these there are already several hundred in existence, costing annually about five millions. The last class may be sub-divided

into (i) Poor Law dispensaries and infirmaries administered by the Boards of Guardians; (ii) lunatic asylums, administered by county councils or county boroughs; and (iii) hospitals for infectious diseases, administered in London by the Metropolitan Asylums Board and in the provinces by municipalities and other sanitary authorities. Among these various governing bodies, differing widely as they do in constitution, responsibility and method of election, there is an absolute lack of co-operation. The words of the 1892 Committee of the House of Lords on Metropolitan Hospitals still apply, not only to metropolitan but to all hospitals. They report: "So far from there being any general system of combination, or any definite division of work among the various institutions, they are on the contrary competing with one another at every point for public support and to a great extent for patients. This . . . is . . . wasteful as regards subscriptions and prejudicial not only to the public who subscribe. . . . and to the sick . . . . but also to the interests of medical science and education."

One result of this lack of a general plan of administration is the

many

Bad Distribution of Hospitals.

The area of London is 120 square miles, but with one or two exceptions all the hospitals of London lie in an area of two square miles. South of the Thames the only large general hospitals are Guy's and St. Thomas's, both close to the river and therefore remote from of the districts they should serve. To the west of Blackfriars Bridge there are fifty-one hospitals, to the east fifteen, leaving some minor hospitals out of account. East of the London Hospital in Whitechapel the hospital accommodation only amounts to between 200 and 300 beds. In some parts of London there is not a general hospital within six miles. An even more scandalous state of things prevails in country districts. Many places have no hospital of any kind within twenty miles, and nothing better than a badly equipped workhouse infirmary within a hundred miles.

Another serious drawback is the lack of a central register of beds. At present a patient can only ascertain whether he can be taken in at any one of the voluntary hospitals by applying at that hospital; and it is by no means uncommon for a patient to apply at several hospitals before finding a vacant bed. At the hospitals of the Metropolitan Asylums Board-a public body—this does not occur, as they are in telephonic communication with the central office where there is a register of beds, and patients are at once assigned to their proper hospital.

A multitude of governing authorities necessarily leads to

enormous

Waste of Money.

Each charitable hospital has its own secretary, who is usually highly paid, and its own clerical staff. But in spite of this expenditure the administration of our voluntary hospitals leaves much to be desired, as is shown by the fact that in the chief London hospitals the difference between the highest and lowest average annual cost per bed is over £70, while in the Metropolitan Asylums Board's

hospitals, which are cheaply and efficiently managed, the difference is not more than £20. The necessity for careful management is, however, apparent when it is realized that a difference of one egg per patient per day at a large hospital means a difference of £300 a year. In this connection many revelations could be made; for instance, a change in a head dispenser at a large London hospital saved 800 in the first half-year. Another hospital is supplied with lemons on contract at three-halfpence each all the year round. The private contract system by which hospitals get their supplies deserves careful study. In 1897 the Metropolitan Asylums Board established a central store and a committee to judge the goods supplied. No less than 50 per cent. were rejected in the first year as inferior. What percentage of inferior goods finds its way into the charitable hospitals is not easy to determine. Sources of serious waste entailed by the competition for subscriptions are to be found in the heavy commissions paid for collection and the cost of advertising-including under this head the promotion of large, fashionable bazaars and entertainments to work the public up to be generous. The public, however, is far from being satisfied with the management of the voluntary hospitals, as is shown by the fact that a hospital fund initiated by the heir to the throne to commemorate the sixtieth year of the Queen's reign has failed to raise one-half of the sum solicited.

Hospitals are, in fact, fast losing their charitable character, and are now used as a right by a very large number of persons who could well afford to pay a doctor, but who prefer the hospital to the-not always competent-general practitioner. This is called "hospital abuse," and is a subject upon which the practitioner not unnaturally waxes eloquent. But it is high time for us to remove the last stigma of charity, and to recognize frankly that it is both just and economically advantageous for the community to provide for those of its members who have become incapacitated for the struggle for existence. We must have, in every district, urban or rural, at least one general hospital under public control, maintained out of the rates, and administered by persons directly responsible to those who find the money. We must, in fact,

Municipalize all our Hospitals.

The existing public institutions supply the nucleus of a municipal hospital system. The Poor Law infirmaries must (1) be entirely dissociated from workhouses and from the Poor Law, (2) have a visiting and resident medical staff appointed, and (3) be made available for the training of nurses and doctors. With them must be combined the administration of the present municipal hospitals, lunatic asylums and inebriate asylums. By section 131 of the 1875 Public Health Act, any sanitary authority may provide a general hospital. It may also subscribe to other hospitals, or take them over. Hitherto these wide powers have been used chiefly to provide for infectious diseases. There are, already, hundreds of municipal hospitals in this country nearly every borough has a fever hospital-Liverpool has five-and many have a smallpox hospital as well. The Metropolitan Asylums Board

into (i) Poor Law dispensaries and infirmaries administered by the Boards of Guardians; (ii) lunatic asylums, administered by county councils or county boroughs; and (iii) hospitals for infectious diseases, administered in London by the Metropolitan Asylums Board and in the provinces by municipalities and other sanitary authorities. Among these various governing bodies, differing widely as they do in constitution, responsibility and method of election, there is an absolute lack of co-operation. The words of the 1892 Committee of the House of Lords on Metropolitan Hospitals still apply, not only to metropolitan but to all hospitals. They report: "So far from there being any general system of combination, or any definite division of work among the various institutions, they are on the contrary competing with one another at every point for public support and to a great extent for patients. This . is . . . wasteful as regards subscriptions and prejudicial not only to the public who subscribe . . . . and to the sick . . . . but also to the interests of medical science and education."

One result of this lack of a general plan of administration is the Bad Distribution of Hospitals.

The area of London is 120 square miles, but with one or two excep tions all the hospitals of London lie in an area of two square miles. South of the Thames the only large general hospitals are Guy's and St. Thomas's, both close to the river and therefore remote from many of the districts they should serve. To the west of Blackfriars Bridge there are fifty-one hospitals, to the east fifteen, leaving some minor hospitals out of account. East of the London Hospital in Whitechapel the hospital accommodation only amounts to between 200 and 300 beds. In some parts of London there is not a general hospital within six miles. An even more scandalous state of things prevails in country districts. Many places have no hospital of any kind within twenty miles, and nothing better than a badly equipped workhouse infirmary within a hundred miles.

Another serious drawback is the lack of a central register of beds. At present a patient can only ascertain whether he can be taken in at any one of the voluntary hospitals by applying at that hospital; and it is by no means uncommon for a patient to apply at several hospitals before finding a vacant bed. At the hospitals of the Metropolitan Asylums Board-a public body-this does not occur, as they are in telephonic communication with the central office where there is a register of beds, and patients are at once assigned to their proper hospital.

A multitude of governing authorities necessarily leads to

enormous

Waste of Money.

Each charitable hospital has its own secretary, who is usually highly paid, and its own clerical staff. But in spite of this expenditure the administration of our voluntary hospitals leaves much to be desired, as is shown by the fact that in the chief London hospitals the difference between the highest and lowest average annual cost per bed is over £70, while in the Metropolitan Asylums Board's

hospitals, which are cheaply and efficiently managed, the difference is not more than £20. The necessity for careful management is, however, apparent when it is realized that a difference of one egg per patient per day at a large hospital means a difference of £300 a year. In this connection many revelations could be made; for instance, a change in a head dispenser at a large London hospital saved 800 in the first half-year. Another hospital is supplied with lemons on contract at three-halfpence each all the year round. The private contract system by which hospitals get their supplies deserves careful study. In 1897 the Metropolitan Asylums Board established a central store and a committee to judge the goods supplied. No less than 50 per cent. were rejected in the first year as inferior. What percentage of inferior goods finds its way into the charitable hospitals is not easy to determine. Sources of serious waste entailed by the competition for subscriptions are to be found in the heavy commissions paid for collection and the cost of advertising-includ ing under this head the promotion of large, fashionable bazaars and entertainments to work the public up to be generous. The public, however, is far from being satisfied with the management of the voluntary hospitals, as is shown by the fact that a hospital fund initiated by the heir to the throne to commemorate the sixtieth year of the Queen's reign has failed to raise one-half of the sum solicited.

Hospitals are, in fact, fast losing their charitable character, and are now used as a right by a very large number of persons who could well afford to pay a doctor, but who prefer the hospital to the-not always competent-general practitioner. This is called "hospital abuse," and is a subject upon which the practitioner not unnaturally waxes eloquent. But it is high time for us to remove the last stigma of charity, and to recognize frankly that it is both just and economically advantageous for the community to provide for those of its members who have become incapacitated for the struggle for existence. We must have, in every district, urban or rural, at least one general hospital under public control, maintained. out of the rates, and administered by persons directly responsible to those who find the money. We must, in fact,

Municipalize all our Hospitals.

The existing public institutions supply the nucleus of a municipal hospital system. The Poor Law infirmaries must (1) be entirely dissociated from workhouses and from the Poor Law, (2) have a visiting and resident medical staff appointed, and (3) be made available for the training of nurses and doctors. With them must be combined the administration of the present municipal hospitals, lunatic asylums and inebriate asylums. By section 131 of the 1875 Public Health Act, any sanitary authority may provide a general hospital. It may also subscribe to other hospitals, or take them over. Hitherto these wide powers have been used chiefly to provide for infectious diseases. There are, already, hundreds of municipal hospitals in this country: nearly every borough has a fever hospital-Liverpool has five-and many have a smallpox hospital as well. The Metropolitan Asylums Board

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