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Financing of Hospitals
LEADING ARTICLES
THE LANCET LONDON:SATURDAY, SEPT. 1, 1951
Financing of Hospitals HITHERTO the estimates of each hospital management committee for the year beginning in April have had to be sent to the regional hospital board by the preceding Sept. 30. They had to be submitted in great detail, often covering 150 pages or more. The date for
coming so soon after the holiday highly inconvenient both for the com-
their submission, season,
was
mittees and for their officers, and often the various items could not be given the detailed consideration they merited. Moreover the need to prepare these estimates six months in advance of the starting-time made them rather unrealistic. They were constructed without full knowledge of the current financial expenditure, and also with the expectation-indeed the certainty-that they would be arbitrarily cut, if not by the regional board then by the Ministry. (Such detailed budgets can in fact be critically dealt with only by those who know the local conditions, and any cuts made by a central administration must therefore be largely arbitrary.) The precise fate of these detailed extremely hospital estimates on their arrival at the Ministry has called forth some conjecture, for it seems unlikely that the bulky documents, from 374 management committees and 36 boards of governors, were read in full by anybody. However this may be, the management committees did not formally receive final. authority for their revised estimates until well after the beginning of the financial year. This meant that extraordinary items were held up and were then submitted en masse to the committee. Naturally, they were less critically examined than they would have been had they been spaced evenly over several meetings. This considerable delay meant that, by the time some items were ordered, it was too late to get them delivered within the financial year, and they had to be budgeted again. This financial structure imposed on hospitals by regulation s.i.1414 (Accounting and Financial Provisions and Regulations) has been the despair of all critical members of management committees who wanted to infuse a spirit of enlightened economy into their committees but were frustrated at every turn by the procedure laid down. Hence we are thankful to note that new instructions have been received [R.H.B.(51)84 H.M.C.(51)77] which should much improve the financial organisation for the coming year. By Sept. 30, 1951, the management committees will have to forward, not a detailed estimate, but merely a brief forecast, under certain headings, of the amount required for the year 1952-53 to operate the service at the level of development estimated to obtain on March 31, 1952 ; and a month later these will be sent on to the Ministry by the regional boards. By Jan. 15, 1952, after consultations with representatives of the regional boards, the Ministry will notify the boards of the total sums to be allocated to each region for 1952-53, subject to the ultimate approval of the Government and Parliament. By Feb. 29, regional boards will notify their con-
389
stituent management committees of the total sum available for them for the following financial year, beginning on April 1. By March 31, committees should forward their detailed estimates for the year 1952-53. (It is not clear why the regional boards should be allowed six weeks for their relatively simple subdivision, against the four weeks for the detailed estimates by the management committees ; but in practice much of the work of the committees will no doubt have been already performed.) On this basis it will for the first time be possible to produce a detailed estimate related to the actual level of expenditure, and competing claims will have been weighed one against another-a manoeuvre which is vital for a common-sense economy but which has so far been very difficult. The pleasure felt on receiving the new circulars will have been somewhat lessened, however, by the observation that an arbitrary cut has already been fixed for 1952-53 : sums placed under the heading, Maintenance of Buildings, Plant, and Grounds, must not exceed 80% of the corresponding total for 195152. A major cut had previously been made under this heading for the current year, and any further reduction must often mean that preventive maintenance measures will be impossible, which not only is disheartening to those who take a real interest in their hospitals but must also in many instances prove a false economy. With regard to capital expenditure, regional- boards are informed of the amount it is hoped to make available for 1952-53 : the somewhat meagre allocation varies from £240,000 to £800,000, representing a level of expenditure well below that of pre-war days, but it has to be considered in the light of the Defence programme. To give the regional boards time to prepare a realistic programme for their capital expenditure, their estimates will not have to be submitted until Jan. 15, 1952. It is to be hoped that in coming years, the procedure will be still further simplified. There is really no need for the detailed estimates, which hinder, rather than assist, economy at the periphery. Items anticipated in the budget tend to pass the financial channels unchallenged, whereas more urgent and often unpredictable items are held up. Hospital management committees would function at their best if they felt they had the full confidence of the Ministry ; and a very simple estimate of their expenditure, under major headings, is really all that is needed. Later we may perhaps see the introduction of a system of departmental accounting and global budgets of the kind mentioned by a correspondent in his article on p. 395. "
"
Radioactive Isotopes for Localising Brain Tumours IN 1913 GOLDMAN showed experimentally that an intravenous injection of the acid dye, trypan-blue, stamsall tissues but brain. It was later found that acid dyes do not penetrate the blood-brain barrier (B.B.B.), and that the basic dyes which do penetrate it are toxic ; adding sulpho-groups removes toxicity and penetrance together. In disease, however, the barrier is not always maintained ; and SORSBY and his colleagues1 at St. Mary’s Hospital, London, most
1.
Sorsby, A., Wright, 36, 137.
A. D., Elkeles, A.
Proc. R. Soc. Med. 1943,
THE LANCET LONDON:SATURDAY, SEPT. 1, 1951
Financing of Hospitals HITHERTO the estimates of each hospital management committee for the year beginning in April have had to be sent to the regional hospital board by the preceding Sept. 30. They had to be submitted in great detail, often covering 150 pages or more. The date for
coming so soon after the holiday highly inconvenient both for the com-
their submission, season,
was
mittees and for their officers, and often the various items could not be given the detailed consideration they merited. Moreover the need to prepare these estimates six months in advance of the starting-time made them rather unrealistic. They were constructed without full knowledge of the current financial expenditure, and also with the expectation-indeed the certainty-that they would be arbitrarily cut, if not by the regional board then by the Ministry. (Such detailed budgets can in fact be critically dealt with only by those who know the local conditions, and any cuts made by a central administration must therefore be largely arbitrary.) The precise fate of these detailed extremely hospital estimates on their arrival at the Ministry has called forth some conjecture, for it seems unlikely that the bulky documents, from 374 management committees and 36 boards of governors, were read in full by anybody. However this may be, the management committees did not formally receive final. authority for their revised estimates until well after the beginning of the financial year. This meant that extraordinary items were held up and were then submitted en masse to the committee. Naturally, they were less critically examined than they would have been had they been spaced evenly over several meetings. This considerable delay meant that, by the time some items were ordered, it was too late to get them delivered within the financial year, and they had to be budgeted again. This financial structure imposed on hospitals by regulation s.i.1414 (Accounting and Financial Provisions and Regulations) has been the despair of all critical members of management committees who wanted to infuse a spirit of enlightened economy into their committees but were frustrated at every turn by the procedure laid down. Hence we are thankful to note that new instructions have been received [R.H.B.(51)84 H.M.C.(51)77] which should much improve the financial organisation for the coming year. By Sept. 30, 1951, the management committees will have to forward, not a detailed estimate, but merely a brief forecast, under certain headings, of the amount required for the year 1952-53 to operate the service at the level of development estimated to obtain on March 31, 1952 ; and a month later these will be sent on to the Ministry by the regional boards. By Jan. 15, 1952, after consultations with representatives of the regional boards, the Ministry will notify the boards of the total sums to be allocated to each region for 1952-53, subject to the ultimate approval of the Government and Parliament. By Feb. 29, regional boards will notify their con-
389
stituent management committees of the total sum available for them for the following financial year, beginning on April 1. By March 31, committees should forward their detailed estimates for the year 1952-53. (It is not clear why the regional boards should be allowed six weeks for their relatively simple subdivision, against the four weeks for the detailed estimates by the management committees ; but in practice much of the work of the committees will no doubt have been already performed.) On this basis it will for the first time be possible to produce a detailed estimate related to the actual level of expenditure, and competing claims will have been weighed one against another-a manoeuvre which is vital for a common-sense economy but which has so far been very difficult. The pleasure felt on receiving the new circulars will have been somewhat lessened, however, by the observation that an arbitrary cut has already been fixed for 1952-53 : sums placed under the heading, Maintenance of Buildings, Plant, and Grounds, must not exceed 80% of the corresponding total for 195152. A major cut had previously been made under this heading for the current year, and any further reduction must often mean that preventive maintenance measures will be impossible, which not only is disheartening to those who take a real interest in their hospitals but must also in many instances prove a false economy. With regard to capital expenditure, regional- boards are informed of the amount it is hoped to make available for 1952-53 : the somewhat meagre allocation varies from £240,000 to £800,000, representing a level of expenditure well below that of pre-war days, but it has to be considered in the light of the Defence programme. To give the regional boards time to prepare a realistic programme for their capital expenditure, their estimates will not have to be submitted until Jan. 15, 1952. It is to be hoped that in coming years, the procedure will be still further simplified. There is really no need for the detailed estimates, which hinder, rather than assist, economy at the periphery. Items anticipated in the budget tend to pass the financial channels unchallenged, whereas more urgent and often unpredictable items are held up. Hospital management committees would function at their best if they felt they had the full confidence of the Ministry ; and a very simple estimate of their expenditure, under major headings, is really all that is needed. Later we may perhaps see the introduction of a system of departmental accounting and global budgets of the kind mentioned by a correspondent in his article on p. 395. "
"
Radioactive Isotopes for Localising Brain Tumours IN 1913 GOLDMAN showed experimentally that an intravenous injection of the acid dye, trypan-blue, stamsall tissues but brain. It was later found that acid dyes do not penetrate the blood-brain barrier (B.B.B.), and that the basic dyes which do penetrate it are toxic ; adding sulpho-groups removes toxicity and penetrance together. In disease, however, the barrier is not always maintained ; and SORSBY and his colleagues1 at St. Mary’s Hospital, London, most
1.
Sorsby, A., Wright, 36, 137.
A. D., Elkeles, A.
Proc. R. Soc. Med. 1943,