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Poor law hospitals—Their past and future
J93L
PUBLIC
Poor
Law
HEALTH.
Hospitals Their and F u t u r e .
a43
Past
By It. H. MACWILLIAM,M.B., D.P.H., Medical Officer, Walton Hospital, Liverpool. Such a paper as this by Dr. MacWilliam, read at a meeting of the North-Western Branch, coming from one so well versed in the subject and interesting at any time, at the present moment is not only so but is likely to be found very helpful as well. T 43, Elizabeth 1601, enjoined the A Cappointing of overseers of the poor, amongwhose duties were the raising by taxation of every inhabitant, parson, vicar or other and of every occupier of landes, houses, tithes, impropriate or propriations of tithes colemynes or saleable underwoods in the said parish, in such competent sume and sumes of money as they shall think fytt and convenient----to sett the poor on work, and also competent sumes of money for and towards the necessorie relief of the lame, impotent, olde, blinde, and such others amongst them being poor and not able to worke. In this Act the care of the poor became a definite legal duty of the community. The famous question of Cain was answered in the affirmative, and in spite of much criticism and many protests during the long history of the poor law, the position has been maintairmd, and to-day man is his brother's keeper to a greater extent than ever before. It is probable that the word " impotent " was used to include the sick of all kinds, and this probability is increased when we read Act 39, Elizabeth, which gives power to every person seized of an estate in fee simple----to erect, found and establish one or more hospitals, meason de Dieu, abiding places, or house of correction, at their will and pleasure as well for the finding sustentation and relief of the maymed, poore, needy or ympotent people. In spite of these powers, it is probable that there was very little provided in the way of medical treatment until well on into the nineteenth century. Criticism of the poor taw, chiefly on financial grounds, in the period following the Napoleonic W a r s / l e d to the appointment of the Poor Law Commission in 1832. After two years of very thorough investigation, the report was issued and the recommendations of the Commission were passed, with very little alteration, as t h e Poor Law Amendment Act of 1834. The Commission had set out to find means by which the high cost of poor relief could be reduced, and under the Act the poor law was definitely meant to be deterrent.
It was laid down that " the first essential of all conditions is that the situation of the able-bodied person on relief shall not be really or apparently so eligible as the situations of the independent labourer of the lowest class." The Commission set out to make the poor law unpopular, in the interests of economy, and in this their success was extraordinary. One of the greatest obstacles those endeavouring to improve the service have had, has been the intense unpopularity of everything connected with it. Out-relief was discouraged. Parishes were merged into unions, and workhouses to meet the needs of a number of parishes were built. The applicant for relief was offered an admission order for the house, which he entered with his wife and family: thus arose those huge institutions, the general mixed workhouses, which have so often been the object of criticism. One of the most important features of the Act was the introduction of central control. This was foreign to the habits and ideas of the English people, and opposition to it was very active for a time. The power to make mandatory orders was given the Commission and their successors, the Poor Law Board, Local Government Board, and Ministry of Health. This power was strenuously used. The Commissioners were well supplied with information by a staff of very competent inspectors, who visited the institutions and attended meetings of the guardians at intervals, helping with advice and encouragement, as well as uttering warnings and threats. Detailed rules were made for the work of the guardians and officials. No officer of importance could be appointed or removed, and no building could be erected, without the sanction of the Board. The policy of the Board varied from time to time, but, whatever the policy was, the whole service reflected it, and there can be no doubt that the action of the central authority made for progress and improvement. It is evident that under the I,ocal Government Act of 1929, there will be much less central control. Localities will be left to deal
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PUBLIC HEALTH.
with these problems without the help of Whitehall. The greater freedom may allow some specially progressive localities to advance beyond the average, but, on the other hand, the backward areas will have less inducement to reach a good standard. The stern opposition of the Commission of 1834 to out-relief for the able-bodied was mitigated in the case of the sick, and soon medical practitioners were engaged to attend to the sick paupers. For a time these appointments were made on the same principle, as contracts were let---the doctor who undertook to supply medicine and service at the lowest price got the job. The system was strongly opposed by the profession, and in 1842, the Commissioners issued regulations putting the parish doctor on the footing of a public official as " the district medical officer," with a salary fixed at a fair rate. From the beginning the workhouses contained a certain number of sick. In a population so selected the proportion was sure to be considerable, although it was not intended that the sick or infirm should be brought in if they could be looked after in their own homes on relief. To accommodate these sick, certain wards were set apart as infirmaries, and from these are descended the poor law hospitals of to-day. For a Jong time the conditions of these workhouse infirmaries were very bad. The central authority did not take much interest in the care of the sick. The only medical service was given by the part-time visiting workhouse medical officer. The nursing was by inmates. In 1865, the first Medical Officer to the Poor Law Board was appointed, and from this time progress was fairly rapid. The necessity for this was pressed by outbreaks of various infectious fevers, as in the absence of any other public health authority, the cases had to be cared for by the guardians. The first poor law hospital to have a staff of trained nurses was Brownlow Hill, Liverpool. Their introduction was due to the munificence of William Rathbone. The Metropolitan Poor Law Act, 1867, allowed separate infirmaries, purely for the sick, to be set up in London, and the practice slowly spread to the provinces (Leeds, 1871; West Derby, 1884; Birmingham, 1888). In the Nursing Order, 1897, it was laid down that " no pauper inmate shall be employed to perform the duties of a nurse in the sick or lying-in wards of a workhouse." Originally, of course, the poor law medical
AuGusT,
service was intended purely for the pauper class, but the attitude of the authorities slowly changed. In 1870, C. J. Gochen, President of the Poor Lave" Board, discussed the advisability, from the sanitary and social points of view, of extending gratuitous medical relief beyond the actual pauper class, but little offficial encouragement was given to this and, indeed, local practice tended to extend a little beyond the strict letter of the lave'. The door to progress in this direction was opened when, in giving evidence before the Royal Commission of 1905, Mr. Adrian, Legal Advisor to the Local Government Board, then under the Presidency of Mr. John Burns, gave the following definition of destitution :-" Destitution, when used to describe the conditions of a person as a subject for relief, implies that he is for the time being without material resources (1) directly available, and (2) appropriate for satisfying his physical needs (a) whether actually existing, or (b) likely to arise immediately. By physical needs in this definition are meant such needs as must be satisfied, (i) in order to maintain life, or (2) in order to obviate, mitigate or remove causes endangering life, or likely to endanger life, or impair health or bodily fitness for self support." By skilful application of this formula, it became possible for a much larger class to enjoy the benefits of the poor law hospitals. Criticism of the poor law was greatly stimulated by the Royal Commission of 1905. Two reports were issued by the Commission in 1909. The majority report advocated the substitution of a new ad hoc authority for the guardians, but the minority advocated the complete break-up of the poor law system with the allocation of the able-bodied to a national government department, and the care of the sick, infirm, children and insane to the various committees of t h e c o u n t y or borough authorities. Although Parliament paid no attention to either at the time, the ideas of the minority have gradually permeated the minds of our legislators, and the Local Government Act, 1929, provides an opportunity for the break-up of the poor law. The extent to which this will be carried out depends on the qualities of each local authority. The legal powers of the guardians to provide a medical service for the community were much less than those given to the councils by the Public Health Acts, yet at the time of their ~upersession they had created an organisation
1931.
PUBLIC HEALTH.
that could be contemplated with a certain degree of pride. There were in England and Wales, 3,500 district medical officers ; 70 separate infirmaries with accommodation for 37,087 sick persons, and 624 institutions with accommodation for 78,842 sick persons. It must be admitted that the quality of this accommodation varied very much. The general voluntary hospitals provided for 48,344 persons; isolation (port sanitary) for 37,351; and tuberculosis sanatoria for 21,409. Reference is frequently made to the beds standing empty in the poor law hospitals, with the suggestion that the hospitals are not being fully used, but empty beds at times can be avoided only by having a waiting list. A poor taw authority must provide accommodation for a peak demand, and cannot have a waiting list. When the pressure is relieved, some beds are empty. Also, to those accustomed to small numbers, 100 empty beds may seem what Lord Moynihan in a recent broadcast called " rows and rows and rows of empty b e d s " ; but in a hospital of 1,200 to 1,400 beds, with an elaborate system of classification, it may represent only a working margin. The s~ck are treated in separate infirmaries or in mixed institutions. The t e r m " institution," by the Local Government Board Order of 1913, displaced " workhouse." The administration of both types of institutions is laid down in detail by the Public Assistance Order of 1930. Separate infirmaries are under complete administrative as well as medical control of a medical superintendent. Mixed institutions are under the administrative control of the Master, usually with the matron as his deputy. The medical oËficer has entire care of medical matters, and no matter how many assistants or consultants he has on his staff, he is ultimately responsible for the care of each individual in the institution. Each chief official has a position of some independence, and he has " security of tenure." The medical officer holds his office until" he resigns, dies, is removed by the Ministry of ttealth, or becomes insane. By the terms of the Public Assistance Order, 1930, a person is admitted to a hospital: (a) By an order signed by the clerk or by the medical officer of health for the council's area, either on a particular direction of the council or on a general direction of the council, in a case in which the person or any person or body on
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his behalf is able and willing to repay the full cost of his maintenance and treatment. This is a new condition, and is obviously important, as it gives authority for the admission of private patients. For some years, private patients have been admitted to many hospitals, but the legality of the procedure was questionable. (b) By an order signed by a relieving officer, accompanied (except in cases of sudden or urgent necessity) by a eertificate of a district medical oËficer or other qualified medical practitioner, or (c) By the medical superintendent-(1) Without an order in case of sudden or urgent necessity, or in pursuance of any statute. (2) When the person is chargeable to the council, and is transferred from another establishment on an order signed by the officer in charge of that establishment, accompanied by a certificate of the medical officer thereof, or (3) In pursuance of an agreement with another council. The conditions of admission to a mixed institution are not quite the same. The responsibility for admission rests with the master, but in cases of illness he will always act on the advice of the medical officer. A patient can take his discharge on giving reasonable notice (usually understood to mean 24 hours), but the medical superintendent or master has no right to discharge a patient if he does not wish to go. The difficulty is got over by transferring him to another institution. Under the guardians there was an obligation to recover, where possible, the whole or part of the cost of relief from the recipient or, the persons liable to maintain him, viz., his children, parents, or grandparents. Actually large numbers pay nothing; some pay the full cost of maintenance, about 30s. a week. There can be little doubt that the demands of the community for hospital accommodation will increase. There is a ,growing inclination among all classes to resort to hospital treatment. With the increasing complexity and cost of medical treatment, the resources of a modern h o u s e h o l d are not sufficient to deal with a serious illness, and the members of the public now know this. Most of this increased hospital aecommodation will have to be provided by the local authorities. The staffs of voluntary hospitals are showing increasing reluctance to undertake the treatment of the destitute. The out-patient departments
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PUBLIC HEALTH.
of these hospitals are to provide consuttatio~ services for those armed with a letter of recom mendation from a general practitioner, and those who do not come under the National Health Insurance, and are not sufficiently affluent to pay a private practitioner, are to be referred to the district medical officer. Voluntary hospitals are unable to provide the amount of indoor treatment guaranteed under contributory schemes, such as the " Penny in the £," and it is only by an arrangement, such as that existing in Liverpool with the council that such schemes are prevented from collapsing. The National Health Insurance scheme must some time be brought into relation with hospitals, and the beds needed are not likely to be supplied by voluntary contributions or from National Health Insurance funds. Under section (t3) of the Local Government Act of 1929, each council must consult with a committee representing the local voluntary hospitals, with a view to forming a comprehensive scheme for the hospital service of the area, It is quite possible that schemes will be suggested with elaborate classification of cases by institutions, it may even be suggested that acute cases of various kinds should be treated in the voluntary hospitals, while the chronic cases are treated in the council hospitals. In his report for 1928, the Chief Medical Officer to the Ministry of Health suggested that councils should have some hospitals for acute cases, and others for chronic cases, and the London County Council in their original scheme proposed to follow this plan, but I am glad to see that this idea has now been given up, and each hospital is to have its proportion of acute and chronic cases. I consider that the large general hospital should be the basis of any scheme of hospital service. An area too large for one hospital should be divided up, with a hospital for each part. It should treat all classes of cases--acute cases ; general medicine and surgery in adults and children ; maternity ; gynaecology ; mothers and babies ; venereal diseases ; tuberculosis, pulmonary and surgical ; cancer ; fractures and other injuries; chronic cases of all kinds, and some infectious disease and mental cases. Private patients will be admitted to some hospitals. Sir George Newman, in his report for 1928, discourages the admission of private patients, suggesting that voluntary hospitals are better
AuGus~r,
able to co:oe with the diffculties arising from the entrance of a privileged class in a public institution. Cases will be admitted because they are disabled by illness or because their admission is desirable on public health grounds, not because their cases are interesting or they will provide experience which will train the surgeon or physician. They will be viewed with the eye of the official, who considers the needs of' the community as a whole, and the quality of all parts of the medical service. He will not %el that a very high standard in one or more star hospitals will compensate for a poor general average throughout the service. Tile large general hospital has many advantages. It is economical. Requirements are easily standardised, and purchasing can be on a large scale. Plant and equipment can be used to capacity. Overhead charges are a small item in the cost per head. Dealing with large numbers, it is possible to pay good salaries and obtain high grade officials. Transport charges are reduced to a minimum. The patients can be efficiently treated. No matter what complications may arise, the appropriate specialist can easily be consulted, and the staff will be in the habit of dealing with all sorts of emergencies. A large staff can be organised in an efficient way. It is likely to be active ; the more lethargic members will be stimulated by their more energetic colleagues., The best use may be made of the beds. The maximum demand for one class of case may not occur at the same time as that for another class, and the hospital units may be switched about as required, while with special hospitals, one may be crowded while another is half empty. it makes for smoothness of working. When different classes are allocated to special hospitals transfers are common and every transfer is a potential source of trouble. The patients and their friends do not like it, and disagreement will commonly arise as to the suitability of the case. The administration of the staff is easier than in a small hospital. Holidays and illness average out better, and cause less violent fluctuations in the available staff. The staff can be advantageously distributed; a ward which happens to be busy will have its staff augmented at the expense of one that happens to be slack. The nurses ~an be effciently trained; too much time will not be spent in the nursing
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PUBLIC HEALTH.
of acute cases on the one hand, or of chronic cases on the other. The varied experience which is essential to thorough training will be obtained. It is a great advantage for chronic cases to be treated in a general hospital. They are much less likely to be written off as " dead stock--irretrievably hopeless." A fresh eye will be turned to them from time to time, and whatever is possible in the way of treatment is likely to be done. They may be largely nursed by probationers in training, a form of service that is cheaper and better than that given by assistant nurses. It is an ideal of the nursing profession that all sick in hospital should be nursed by trained nurses or probationers in training. Cases can be treated to a conclusion in one hospital, and by one set of doctors. It is a good thing for a surgeon to see the final results of his treatment, and it is better for a patient than if he is passed on to another surgeon, whose feeling of responsibility will probably be less, or to a doctor w h o - m a y have no interest in surgery. Much labour is saved in the duplicating of records on transfer. A large general hospital will support a large specialist staff. The formation of team will be easy and a healthy system of close co-operation has a chance of developing. I may add that specialised hospitals are very troublesome from the point of view of the man who has to supervise a group. When a particular case cuts across the classifications there will be disagreement as to who shall admit it. tt is probably inevitable, from the spirit of the time, that the whole administration should be in charge of a medical superintendent assisted by a steward, but it is still possible to argue that the business of a doctor is with the care of the sick, and that lay administration should be entrusted to a secretary or lay superintendent. The relation of the medical superintendent to the medical officer of health will no doubt sometimes give rise to disagreement when personalities clash. Speaking for my side, I think the medical officer of health should not concern himsetf with questions of internal administration. His right to general supervision is established, and he has a very large field for his activities in co-ordinating the work of different hospitals and securing harmonious working with other branches of the public health service. It is a bad principle in administration to have two men trying to do the work of one, and a system should not be established if it depends for
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success on the possession of more than average pliability by the officials co.ncerned. In small areas it may be satisfactory i f the medical officer of health is the medical superintendent of the hospital. In addition to the medical superintendent, there should be resident medical officers, senior and junior, and visiting consultants and specialists. The consultants may be compared to the honorary staff at a voluntary hospital, but should be responsible to the medical superintendent, and should give more service than is usually expected from an honorary at the voluntary hospitals. They should be given charge of beds, involving continuous responsibility, and should not be called in merely in consultation on selected cases. A condition of appointment should be that they shall hold not more than, say, one other hospital appointment, for each visiting man should spend so much time in the council hospital that his reputation will be closely associated with it, and the welfare of the hospital will be a measure of his success. It is probably better to have different consultants for each hospital, rather than to have one man attending a whole group. A little mild rivalry and competition may be useful. The junior residents will correspond to house surgeons, and house physicians, with similar duties and responsibilities, and they should be appointed for six to twelve months at a time. The senior resident medical officers should be of an entirely different order, with much more important duties and much greater responsibility. On the clinical side they should be related to the visiting consultants in much the same way as an assistant surgeon or physician is related to his chief, and on the administrative side they should rank as assistants to the medical superintendent. As they advance, some will bear to the clinical side, and become consultant physician or surgeons ; others will bear to the administrative side and become medical superintendents. In this way, an efficient organisation of the profession will be maintained, and a supply of well-trained men for the municipal hospital, as well as for the community in general, will be assured. Among the consultants should be the tuberculosis officer and the venereal diseases officer of the council. They should be given charge of beds with similar responsibility to those of the
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PUBLIC HEALTH.
part-time consultants. Such services as a tonsil and adenoid clinic and refraction clinic may with advantage be associated with the hospital. The visiting obstetrician should conduct an ante-natal clinic at the hospital, and indeed, the whole of the maternity and child welfare of the area may be connected tip to the hospital. Radiologists and pathologists may be on a whole-time or part time basis. A part-time pathologist is likely to give satisfactory service if, for the rest of his time, he is engaged in university teaching rather than exposed to the distractions of private practice. The district medical officer for the area should be associated with the hospital and as far as possible the daily " surgeries " of the district medical officers should be held at the hospital. The district medical officers should have the help of a service of nurses for such cases as they think may be treated in their own homes. Out-patient departments are inevitable for several reasons. Formerly the majority of the patients in poor law hospitals, were in-patients, because they were destitute, and even if their illness or disability was slight, they remained as in-patients of the hospital until so far cured that they could be transferred to the " house " or an institution for the able-bodied. For years a change has been taking place, and this change is likely to go still further under the management of the councils. Many patients of a better class are admitted, and the patient s of the lower classes, owing to unemployment insurance and out-relief, are in many cases in a position to attend as out-patients. It is obviously wasteful to admit these people for trivial diseases, or to keep them as in-patients when they have so far recovered that they are fit to be treated as out-patients. They will come for treatment, such as dressing of wounds and ulcers, massage, ultra-violet light, &c., treatment :of eye and ear conditions. When a poor law institution comes to be recognised in the district as a hospital, it becomes impossible to exclude casualties. Cases who have had operations or courses of medical treatment will frequently be sent up by their own doctors for inspection or advice from the surgeon or physician under whose care they were while in the hospital. An out-patient department must be used as a check on admission: At present on the strength of a certificate from a district medical officer, or a private practitioner, the relieving officer gives an admission order and the patient is
AUGUST,
sent to a ward, although his case may be trivial and there may be a great shortage of beds at the time, or he might have to wait some time for operation, or for X-ray examination, because the time may be booked up for some days ahead. Again, the private practitioner may merely want a consultant's opinion, but in the absence of out-patients department, the only way to obtain this is to have a case admitted. I think, therefore, that for the economical working of municipal hospitals, out-patients departments are inevitable. Municipal hospitals must take a considerable part in medical education. It is obviously wrong that the opportunity given by such concentration of ill people for learning the various branches of medicine, surgery, midwifery and pathology should be denied to undergraduate medical s~udents. Probably one of the greatest needs in the medical curriculum to-day is positions for resident students. It is possible that resident accommodation will be provided in some of the municipal hospitals. The hospitals will benefit enormously from the presence of students. These will provide a critical audience, watching every detail of the hospital work, and stimulating every member of the staff. Criticism is the price of our efficiency. The appointments of house surgeons, house physicians or junior medical officers should be regarded as definitely educational. The appointments should be made at a time of the year that bears a convenient relation to the terms of the medical schools. They should be for a limited period, six months or so. Facilities should be given for study. The senior resident medical officers, as already said, should be regarded as progressing to consultant rank, and study leave to take the courses necessary for obtaining higher qualifications should be granted from time to time. Associated with the general hospitals in any scheme should be convalescent homes and an institution with wards for the infirm, that is where cases such as hemiplegia, cardiac valvular disease with compensation but little reserve, senile infirm, &c., may be housed, but I am strongly opposed to hospitals for chronic cases. It is impossible to train a nursing staff with only one class of case, and the effect on the medical staff is almost inevitably destructive of keen interest in medicine. The term " bedridden, infirm " is often used to include all sorts of chronic cases ; these may not be very interesting to most doctors, but they provide valuable nursing experience, and the proper
1931.
349
PUBLIC HEALTH.
place for them is special wards in the general hospital. Section (5) of the Local Government Act of 1929, states that a council in preparing an administration scheme shall have regard to the desirability of securing that all assistance that can lawfully be provided otherwise than by way of poor relief, shall he so provided, and accordingly in any such scheme may declare that any assistance that can be provided by such acts as the Public Health Act of 1875, shall be provided exclusively by the appropriate Act. This is a point that requires very careful consideration. It might happen that certain hospitals were appropriated by the public health or hospital committee to be administered under various Acts, leaving other hospitals to be administered under the poor law by the public assistance committee. This would be splitting up the hospital service under what would be practically two authorities, although one of the declared objects of the Local Government Act of 1929, was the unification of all health services. It would set up great administrative difficulties and would have the effect of lowering the standard of all hospitals left under the poor law. It would be a melancholy picture if the effect of this great Act was to place the destitute poor under worse conditions than they were before it was passed. So far as I can see, the objection to the poor law is purely sentimental. The various disabilities under which recipients of relief suffered have been removed and, in Liverpool at least, the stigma of pauperism has gone. A patient does not worry because the transferred hospitals are still under the poor law. They are city hospitals and all he cares for is the quality of his treatment, but if two types of general hospital were set up, we should very soon have distinction made between the workhouse hospital and the public health hospital. The poor law at p r e s e n t g i v e s the local authority powers which are ample to provide all the hospital services of a community, and before the poor law is cast aside we should be certain that it is to be replaced by a scheme that will be in every way superior. The future of the poor law hospitals is in our hands. Many experiments will have to be made. Some will succeed, some will fail. Skilfut diplomacy will be necessary, and many wires will have to be pulled/but human nature being what it is, the sense of duty, the passion for excellence, or perhaps merely the personal ambition of the officials, will ensure a position
for state hospitals of the greatest importance in the life of the community.
HIS MAJESTY THE KING has been graciously pleased to appoint, as King's Honorary Physician, Surgeon Vice-Admiral Reginald St. George Smallridge Bond, C.B., M.B., F.R.C.P. (Lond.), F.R.C.S. (Ed.), D.P.H., K.H.P., Barrister-atLaw, who recently received promotion from the rank of Surgeon Rear-Admiral, and was appointed Medical Director-General of the Navy. THE death is recorded, with sincere regret, of Dr. William Knott, one of the senior fellows of the Society of Medical Officers of Health. Born at Wolverhampton in 1857, Dr. Knott was educated in Middlesbrough and afterwards at Edinburgh University, graduating M.B., C.M., and later M.D. He was for many years medical officer of health for the North Ormsby Urban District before that area was absorbed by the Borough of Middlesbrough. THOSE interested in hospital library work are invited to attend the special sessions arranged in connection with the S u m m e r School of Librarianship at Birmingham o.n August 22nd, and with the Annual Conference of the Library Association, to. be held at Cheltenham, o,n August 31st, 1931. Full .details of both meetings may be obtained from the Organising Secretary, British Red Cross Society and Order of St. Jo.hn Hospital Library, 48, Queen ' s Garde n s, Lancaster Gate, Lo.ndo,n, ~V.2. THE Sixtieth Annual Meeting of the American Public Health Association will be held in Montreal from September 14th to 17th, 1931. Some two thousand delegates, representing official and voluntary health services in all parts of North America, are expected to attend. In addition, the Society of Medical Officers of Health will be represented by three members of its Council--Dr. George Buchan, who will submit a contribution entitled A Brief Review of British Public Health Administration " ; Dr. Charles Porter, who will discuss " Education and Training for the English Public Health Service " ; and Dr. James Fenton, who will deal with " Maternity and Child Welfare Schemes and Work in Great Britain." It is greatly to be hoped that Sir Allan Powell, Chief Officer of Public Assistance, London County Council, will also be able to attend the meeting and submit a communication on " The Relation of Public Health to Public Assistance." "
PUBLIC
Poor
Law
HEALTH.
Hospitals Their and F u t u r e .
a43
Past
By It. H. MACWILLIAM,M.B., D.P.H., Medical Officer, Walton Hospital, Liverpool. Such a paper as this by Dr. MacWilliam, read at a meeting of the North-Western Branch, coming from one so well versed in the subject and interesting at any time, at the present moment is not only so but is likely to be found very helpful as well. T 43, Elizabeth 1601, enjoined the A Cappointing of overseers of the poor, amongwhose duties were the raising by taxation of every inhabitant, parson, vicar or other and of every occupier of landes, houses, tithes, impropriate or propriations of tithes colemynes or saleable underwoods in the said parish, in such competent sume and sumes of money as they shall think fytt and convenient----to sett the poor on work, and also competent sumes of money for and towards the necessorie relief of the lame, impotent, olde, blinde, and such others amongst them being poor and not able to worke. In this Act the care of the poor became a definite legal duty of the community. The famous question of Cain was answered in the affirmative, and in spite of much criticism and many protests during the long history of the poor law, the position has been maintairmd, and to-day man is his brother's keeper to a greater extent than ever before. It is probable that the word " impotent " was used to include the sick of all kinds, and this probability is increased when we read Act 39, Elizabeth, which gives power to every person seized of an estate in fee simple----to erect, found and establish one or more hospitals, meason de Dieu, abiding places, or house of correction, at their will and pleasure as well for the finding sustentation and relief of the maymed, poore, needy or ympotent people. In spite of these powers, it is probable that there was very little provided in the way of medical treatment until well on into the nineteenth century. Criticism of the poor taw, chiefly on financial grounds, in the period following the Napoleonic W a r s / l e d to the appointment of the Poor Law Commission in 1832. After two years of very thorough investigation, the report was issued and the recommendations of the Commission were passed, with very little alteration, as t h e Poor Law Amendment Act of 1834. The Commission had set out to find means by which the high cost of poor relief could be reduced, and under the Act the poor law was definitely meant to be deterrent.
It was laid down that " the first essential of all conditions is that the situation of the able-bodied person on relief shall not be really or apparently so eligible as the situations of the independent labourer of the lowest class." The Commission set out to make the poor law unpopular, in the interests of economy, and in this their success was extraordinary. One of the greatest obstacles those endeavouring to improve the service have had, has been the intense unpopularity of everything connected with it. Out-relief was discouraged. Parishes were merged into unions, and workhouses to meet the needs of a number of parishes were built. The applicant for relief was offered an admission order for the house, which he entered with his wife and family: thus arose those huge institutions, the general mixed workhouses, which have so often been the object of criticism. One of the most important features of the Act was the introduction of central control. This was foreign to the habits and ideas of the English people, and opposition to it was very active for a time. The power to make mandatory orders was given the Commission and their successors, the Poor Law Board, Local Government Board, and Ministry of Health. This power was strenuously used. The Commissioners were well supplied with information by a staff of very competent inspectors, who visited the institutions and attended meetings of the guardians at intervals, helping with advice and encouragement, as well as uttering warnings and threats. Detailed rules were made for the work of the guardians and officials. No officer of importance could be appointed or removed, and no building could be erected, without the sanction of the Board. The policy of the Board varied from time to time, but, whatever the policy was, the whole service reflected it, and there can be no doubt that the action of the central authority made for progress and improvement. It is evident that under the I,ocal Government Act of 1929, there will be much less central control. Localities will be left to deal
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with these problems without the help of Whitehall. The greater freedom may allow some specially progressive localities to advance beyond the average, but, on the other hand, the backward areas will have less inducement to reach a good standard. The stern opposition of the Commission of 1834 to out-relief for the able-bodied was mitigated in the case of the sick, and soon medical practitioners were engaged to attend to the sick paupers. For a time these appointments were made on the same principle, as contracts were let---the doctor who undertook to supply medicine and service at the lowest price got the job. The system was strongly opposed by the profession, and in 1842, the Commissioners issued regulations putting the parish doctor on the footing of a public official as " the district medical officer," with a salary fixed at a fair rate. From the beginning the workhouses contained a certain number of sick. In a population so selected the proportion was sure to be considerable, although it was not intended that the sick or infirm should be brought in if they could be looked after in their own homes on relief. To accommodate these sick, certain wards were set apart as infirmaries, and from these are descended the poor law hospitals of to-day. For a Jong time the conditions of these workhouse infirmaries were very bad. The central authority did not take much interest in the care of the sick. The only medical service was given by the part-time visiting workhouse medical officer. The nursing was by inmates. In 1865, the first Medical Officer to the Poor Law Board was appointed, and from this time progress was fairly rapid. The necessity for this was pressed by outbreaks of various infectious fevers, as in the absence of any other public health authority, the cases had to be cared for by the guardians. The first poor law hospital to have a staff of trained nurses was Brownlow Hill, Liverpool. Their introduction was due to the munificence of William Rathbone. The Metropolitan Poor Law Act, 1867, allowed separate infirmaries, purely for the sick, to be set up in London, and the practice slowly spread to the provinces (Leeds, 1871; West Derby, 1884; Birmingham, 1888). In the Nursing Order, 1897, it was laid down that " no pauper inmate shall be employed to perform the duties of a nurse in the sick or lying-in wards of a workhouse." Originally, of course, the poor law medical
AuGusT,
service was intended purely for the pauper class, but the attitude of the authorities slowly changed. In 1870, C. J. Gochen, President of the Poor Lave" Board, discussed the advisability, from the sanitary and social points of view, of extending gratuitous medical relief beyond the actual pauper class, but little offficial encouragement was given to this and, indeed, local practice tended to extend a little beyond the strict letter of the lave'. The door to progress in this direction was opened when, in giving evidence before the Royal Commission of 1905, Mr. Adrian, Legal Advisor to the Local Government Board, then under the Presidency of Mr. John Burns, gave the following definition of destitution :-" Destitution, when used to describe the conditions of a person as a subject for relief, implies that he is for the time being without material resources (1) directly available, and (2) appropriate for satisfying his physical needs (a) whether actually existing, or (b) likely to arise immediately. By physical needs in this definition are meant such needs as must be satisfied, (i) in order to maintain life, or (2) in order to obviate, mitigate or remove causes endangering life, or likely to endanger life, or impair health or bodily fitness for self support." By skilful application of this formula, it became possible for a much larger class to enjoy the benefits of the poor law hospitals. Criticism of the poor law was greatly stimulated by the Royal Commission of 1905. Two reports were issued by the Commission in 1909. The majority report advocated the substitution of a new ad hoc authority for the guardians, but the minority advocated the complete break-up of the poor law system with the allocation of the able-bodied to a national government department, and the care of the sick, infirm, children and insane to the various committees of t h e c o u n t y or borough authorities. Although Parliament paid no attention to either at the time, the ideas of the minority have gradually permeated the minds of our legislators, and the Local Government Act, 1929, provides an opportunity for the break-up of the poor law. The extent to which this will be carried out depends on the qualities of each local authority. The legal powers of the guardians to provide a medical service for the community were much less than those given to the councils by the Public Health Acts, yet at the time of their ~upersession they had created an organisation
1931.
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that could be contemplated with a certain degree of pride. There were in England and Wales, 3,500 district medical officers ; 70 separate infirmaries with accommodation for 37,087 sick persons, and 624 institutions with accommodation for 78,842 sick persons. It must be admitted that the quality of this accommodation varied very much. The general voluntary hospitals provided for 48,344 persons; isolation (port sanitary) for 37,351; and tuberculosis sanatoria for 21,409. Reference is frequently made to the beds standing empty in the poor law hospitals, with the suggestion that the hospitals are not being fully used, but empty beds at times can be avoided only by having a waiting list. A poor taw authority must provide accommodation for a peak demand, and cannot have a waiting list. When the pressure is relieved, some beds are empty. Also, to those accustomed to small numbers, 100 empty beds may seem what Lord Moynihan in a recent broadcast called " rows and rows and rows of empty b e d s " ; but in a hospital of 1,200 to 1,400 beds, with an elaborate system of classification, it may represent only a working margin. The s~ck are treated in separate infirmaries or in mixed institutions. The t e r m " institution," by the Local Government Board Order of 1913, displaced " workhouse." The administration of both types of institutions is laid down in detail by the Public Assistance Order of 1930. Separate infirmaries are under complete administrative as well as medical control of a medical superintendent. Mixed institutions are under the administrative control of the Master, usually with the matron as his deputy. The medical oËficer has entire care of medical matters, and no matter how many assistants or consultants he has on his staff, he is ultimately responsible for the care of each individual in the institution. Each chief official has a position of some independence, and he has " security of tenure." The medical officer holds his office until" he resigns, dies, is removed by the Ministry of ttealth, or becomes insane. By the terms of the Public Assistance Order, 1930, a person is admitted to a hospital: (a) By an order signed by the clerk or by the medical officer of health for the council's area, either on a particular direction of the council or on a general direction of the council, in a case in which the person or any person or body on
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his behalf is able and willing to repay the full cost of his maintenance and treatment. This is a new condition, and is obviously important, as it gives authority for the admission of private patients. For some years, private patients have been admitted to many hospitals, but the legality of the procedure was questionable. (b) By an order signed by a relieving officer, accompanied (except in cases of sudden or urgent necessity) by a eertificate of a district medical oËficer or other qualified medical practitioner, or (c) By the medical superintendent-(1) Without an order in case of sudden or urgent necessity, or in pursuance of any statute. (2) When the person is chargeable to the council, and is transferred from another establishment on an order signed by the officer in charge of that establishment, accompanied by a certificate of the medical officer thereof, or (3) In pursuance of an agreement with another council. The conditions of admission to a mixed institution are not quite the same. The responsibility for admission rests with the master, but in cases of illness he will always act on the advice of the medical officer. A patient can take his discharge on giving reasonable notice (usually understood to mean 24 hours), but the medical superintendent or master has no right to discharge a patient if he does not wish to go. The difficulty is got over by transferring him to another institution. Under the guardians there was an obligation to recover, where possible, the whole or part of the cost of relief from the recipient or, the persons liable to maintain him, viz., his children, parents, or grandparents. Actually large numbers pay nothing; some pay the full cost of maintenance, about 30s. a week. There can be little doubt that the demands of the community for hospital accommodation will increase. There is a ,growing inclination among all classes to resort to hospital treatment. With the increasing complexity and cost of medical treatment, the resources of a modern h o u s e h o l d are not sufficient to deal with a serious illness, and the members of the public now know this. Most of this increased hospital aecommodation will have to be provided by the local authorities. The staffs of voluntary hospitals are showing increasing reluctance to undertake the treatment of the destitute. The out-patient departments
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PUBLIC HEALTH.
of these hospitals are to provide consuttatio~ services for those armed with a letter of recom mendation from a general practitioner, and those who do not come under the National Health Insurance, and are not sufficiently affluent to pay a private practitioner, are to be referred to the district medical officer. Voluntary hospitals are unable to provide the amount of indoor treatment guaranteed under contributory schemes, such as the " Penny in the £," and it is only by an arrangement, such as that existing in Liverpool with the council that such schemes are prevented from collapsing. The National Health Insurance scheme must some time be brought into relation with hospitals, and the beds needed are not likely to be supplied by voluntary contributions or from National Health Insurance funds. Under section (t3) of the Local Government Act of 1929, each council must consult with a committee representing the local voluntary hospitals, with a view to forming a comprehensive scheme for the hospital service of the area, It is quite possible that schemes will be suggested with elaborate classification of cases by institutions, it may even be suggested that acute cases of various kinds should be treated in the voluntary hospitals, while the chronic cases are treated in the council hospitals. In his report for 1928, the Chief Medical Officer to the Ministry of Health suggested that councils should have some hospitals for acute cases, and others for chronic cases, and the London County Council in their original scheme proposed to follow this plan, but I am glad to see that this idea has now been given up, and each hospital is to have its proportion of acute and chronic cases. I consider that the large general hospital should be the basis of any scheme of hospital service. An area too large for one hospital should be divided up, with a hospital for each part. It should treat all classes of cases--acute cases ; general medicine and surgery in adults and children ; maternity ; gynaecology ; mothers and babies ; venereal diseases ; tuberculosis, pulmonary and surgical ; cancer ; fractures and other injuries; chronic cases of all kinds, and some infectious disease and mental cases. Private patients will be admitted to some hospitals. Sir George Newman, in his report for 1928, discourages the admission of private patients, suggesting that voluntary hospitals are better
AuGus~r,
able to co:oe with the diffculties arising from the entrance of a privileged class in a public institution. Cases will be admitted because they are disabled by illness or because their admission is desirable on public health grounds, not because their cases are interesting or they will provide experience which will train the surgeon or physician. They will be viewed with the eye of the official, who considers the needs of' the community as a whole, and the quality of all parts of the medical service. He will not %el that a very high standard in one or more star hospitals will compensate for a poor general average throughout the service. Tile large general hospital has many advantages. It is economical. Requirements are easily standardised, and purchasing can be on a large scale. Plant and equipment can be used to capacity. Overhead charges are a small item in the cost per head. Dealing with large numbers, it is possible to pay good salaries and obtain high grade officials. Transport charges are reduced to a minimum. The patients can be efficiently treated. No matter what complications may arise, the appropriate specialist can easily be consulted, and the staff will be in the habit of dealing with all sorts of emergencies. A large staff can be organised in an efficient way. It is likely to be active ; the more lethargic members will be stimulated by their more energetic colleagues., The best use may be made of the beds. The maximum demand for one class of case may not occur at the same time as that for another class, and the hospital units may be switched about as required, while with special hospitals, one may be crowded while another is half empty. it makes for smoothness of working. When different classes are allocated to special hospitals transfers are common and every transfer is a potential source of trouble. The patients and their friends do not like it, and disagreement will commonly arise as to the suitability of the case. The administration of the staff is easier than in a small hospital. Holidays and illness average out better, and cause less violent fluctuations in the available staff. The staff can be advantageously distributed; a ward which happens to be busy will have its staff augmented at the expense of one that happens to be slack. The nurses ~an be effciently trained; too much time will not be spent in the nursing
19al.
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of acute cases on the one hand, or of chronic cases on the other. The varied experience which is essential to thorough training will be obtained. It is a great advantage for chronic cases to be treated in a general hospital. They are much less likely to be written off as " dead stock--irretrievably hopeless." A fresh eye will be turned to them from time to time, and whatever is possible in the way of treatment is likely to be done. They may be largely nursed by probationers in training, a form of service that is cheaper and better than that given by assistant nurses. It is an ideal of the nursing profession that all sick in hospital should be nursed by trained nurses or probationers in training. Cases can be treated to a conclusion in one hospital, and by one set of doctors. It is a good thing for a surgeon to see the final results of his treatment, and it is better for a patient than if he is passed on to another surgeon, whose feeling of responsibility will probably be less, or to a doctor w h o - m a y have no interest in surgery. Much labour is saved in the duplicating of records on transfer. A large general hospital will support a large specialist staff. The formation of team will be easy and a healthy system of close co-operation has a chance of developing. I may add that specialised hospitals are very troublesome from the point of view of the man who has to supervise a group. When a particular case cuts across the classifications there will be disagreement as to who shall admit it. tt is probably inevitable, from the spirit of the time, that the whole administration should be in charge of a medical superintendent assisted by a steward, but it is still possible to argue that the business of a doctor is with the care of the sick, and that lay administration should be entrusted to a secretary or lay superintendent. The relation of the medical superintendent to the medical officer of health will no doubt sometimes give rise to disagreement when personalities clash. Speaking for my side, I think the medical officer of health should not concern himsetf with questions of internal administration. His right to general supervision is established, and he has a very large field for his activities in co-ordinating the work of different hospitals and securing harmonious working with other branches of the public health service. It is a bad principle in administration to have two men trying to do the work of one, and a system should not be established if it depends for
347
success on the possession of more than average pliability by the officials co.ncerned. In small areas it may be satisfactory i f the medical officer of health is the medical superintendent of the hospital. In addition to the medical superintendent, there should be resident medical officers, senior and junior, and visiting consultants and specialists. The consultants may be compared to the honorary staff at a voluntary hospital, but should be responsible to the medical superintendent, and should give more service than is usually expected from an honorary at the voluntary hospitals. They should be given charge of beds, involving continuous responsibility, and should not be called in merely in consultation on selected cases. A condition of appointment should be that they shall hold not more than, say, one other hospital appointment, for each visiting man should spend so much time in the council hospital that his reputation will be closely associated with it, and the welfare of the hospital will be a measure of his success. It is probably better to have different consultants for each hospital, rather than to have one man attending a whole group. A little mild rivalry and competition may be useful. The junior residents will correspond to house surgeons, and house physicians, with similar duties and responsibilities, and they should be appointed for six to twelve months at a time. The senior resident medical officers should be of an entirely different order, with much more important duties and much greater responsibility. On the clinical side they should be related to the visiting consultants in much the same way as an assistant surgeon or physician is related to his chief, and on the administrative side they should rank as assistants to the medical superintendent. As they advance, some will bear to the clinical side, and become consultant physician or surgeons ; others will bear to the administrative side and become medical superintendents. In this way, an efficient organisation of the profession will be maintained, and a supply of well-trained men for the municipal hospital, as well as for the community in general, will be assured. Among the consultants should be the tuberculosis officer and the venereal diseases officer of the council. They should be given charge of beds with similar responsibility to those of the
348
PUBLIC HEALTH.
part-time consultants. Such services as a tonsil and adenoid clinic and refraction clinic may with advantage be associated with the hospital. The visiting obstetrician should conduct an ante-natal clinic at the hospital, and indeed, the whole of the maternity and child welfare of the area may be connected tip to the hospital. Radiologists and pathologists may be on a whole-time or part time basis. A part-time pathologist is likely to give satisfactory service if, for the rest of his time, he is engaged in university teaching rather than exposed to the distractions of private practice. The district medical officer for the area should be associated with the hospital and as far as possible the daily " surgeries " of the district medical officers should be held at the hospital. The district medical officers should have the help of a service of nurses for such cases as they think may be treated in their own homes. Out-patient departments are inevitable for several reasons. Formerly the majority of the patients in poor law hospitals, were in-patients, because they were destitute, and even if their illness or disability was slight, they remained as in-patients of the hospital until so far cured that they could be transferred to the " house " or an institution for the able-bodied. For years a change has been taking place, and this change is likely to go still further under the management of the councils. Many patients of a better class are admitted, and the patient s of the lower classes, owing to unemployment insurance and out-relief, are in many cases in a position to attend as out-patients. It is obviously wasteful to admit these people for trivial diseases, or to keep them as in-patients when they have so far recovered that they are fit to be treated as out-patients. They will come for treatment, such as dressing of wounds and ulcers, massage, ultra-violet light, &c., treatment :of eye and ear conditions. When a poor law institution comes to be recognised in the district as a hospital, it becomes impossible to exclude casualties. Cases who have had operations or courses of medical treatment will frequently be sent up by their own doctors for inspection or advice from the surgeon or physician under whose care they were while in the hospital. An out-patient department must be used as a check on admission: At present on the strength of a certificate from a district medical officer, or a private practitioner, the relieving officer gives an admission order and the patient is
AUGUST,
sent to a ward, although his case may be trivial and there may be a great shortage of beds at the time, or he might have to wait some time for operation, or for X-ray examination, because the time may be booked up for some days ahead. Again, the private practitioner may merely want a consultant's opinion, but in the absence of out-patients department, the only way to obtain this is to have a case admitted. I think, therefore, that for the economical working of municipal hospitals, out-patients departments are inevitable. Municipal hospitals must take a considerable part in medical education. It is obviously wrong that the opportunity given by such concentration of ill people for learning the various branches of medicine, surgery, midwifery and pathology should be denied to undergraduate medical s~udents. Probably one of the greatest needs in the medical curriculum to-day is positions for resident students. It is possible that resident accommodation will be provided in some of the municipal hospitals. The hospitals will benefit enormously from the presence of students. These will provide a critical audience, watching every detail of the hospital work, and stimulating every member of the staff. Criticism is the price of our efficiency. The appointments of house surgeons, house physicians or junior medical officers should be regarded as definitely educational. The appointments should be made at a time of the year that bears a convenient relation to the terms of the medical schools. They should be for a limited period, six months or so. Facilities should be given for study. The senior resident medical officers, as already said, should be regarded as progressing to consultant rank, and study leave to take the courses necessary for obtaining higher qualifications should be granted from time to time. Associated with the general hospitals in any scheme should be convalescent homes and an institution with wards for the infirm, that is where cases such as hemiplegia, cardiac valvular disease with compensation but little reserve, senile infirm, &c., may be housed, but I am strongly opposed to hospitals for chronic cases. It is impossible to train a nursing staff with only one class of case, and the effect on the medical staff is almost inevitably destructive of keen interest in medicine. The term " bedridden, infirm " is often used to include all sorts of chronic cases ; these may not be very interesting to most doctors, but they provide valuable nursing experience, and the proper
1931.
349
PUBLIC HEALTH.
place for them is special wards in the general hospital. Section (5) of the Local Government Act of 1929, states that a council in preparing an administration scheme shall have regard to the desirability of securing that all assistance that can lawfully be provided otherwise than by way of poor relief, shall he so provided, and accordingly in any such scheme may declare that any assistance that can be provided by such acts as the Public Health Act of 1875, shall be provided exclusively by the appropriate Act. This is a point that requires very careful consideration. It might happen that certain hospitals were appropriated by the public health or hospital committee to be administered under various Acts, leaving other hospitals to be administered under the poor law by the public assistance committee. This would be splitting up the hospital service under what would be practically two authorities, although one of the declared objects of the Local Government Act of 1929, was the unification of all health services. It would set up great administrative difficulties and would have the effect of lowering the standard of all hospitals left under the poor law. It would be a melancholy picture if the effect of this great Act was to place the destitute poor under worse conditions than they were before it was passed. So far as I can see, the objection to the poor law is purely sentimental. The various disabilities under which recipients of relief suffered have been removed and, in Liverpool at least, the stigma of pauperism has gone. A patient does not worry because the transferred hospitals are still under the poor law. They are city hospitals and all he cares for is the quality of his treatment, but if two types of general hospital were set up, we should very soon have distinction made between the workhouse hospital and the public health hospital. The poor law at p r e s e n t g i v e s the local authority powers which are ample to provide all the hospital services of a community, and before the poor law is cast aside we should be certain that it is to be replaced by a scheme that will be in every way superior. The future of the poor law hospitals is in our hands. Many experiments will have to be made. Some will succeed, some will fail. Skilfut diplomacy will be necessary, and many wires will have to be pulled/but human nature being what it is, the sense of duty, the passion for excellence, or perhaps merely the personal ambition of the officials, will ensure a position
for state hospitals of the greatest importance in the life of the community.
HIS MAJESTY THE KING has been graciously pleased to appoint, as King's Honorary Physician, Surgeon Vice-Admiral Reginald St. George Smallridge Bond, C.B., M.B., F.R.C.P. (Lond.), F.R.C.S. (Ed.), D.P.H., K.H.P., Barrister-atLaw, who recently received promotion from the rank of Surgeon Rear-Admiral, and was appointed Medical Director-General of the Navy. THE death is recorded, with sincere regret, of Dr. William Knott, one of the senior fellows of the Society of Medical Officers of Health. Born at Wolverhampton in 1857, Dr. Knott was educated in Middlesbrough and afterwards at Edinburgh University, graduating M.B., C.M., and later M.D. He was for many years medical officer of health for the North Ormsby Urban District before that area was absorbed by the Borough of Middlesbrough. THOSE interested in hospital library work are invited to attend the special sessions arranged in connection with the S u m m e r School of Librarianship at Birmingham o.n August 22nd, and with the Annual Conference of the Library Association, to. be held at Cheltenham, o,n August 31st, 1931. Full .details of both meetings may be obtained from the Organising Secretary, British Red Cross Society and Order of St. Jo.hn Hospital Library, 48, Queen ' s Garde n s, Lancaster Gate, Lo.ndo,n, ~V.2. THE Sixtieth Annual Meeting of the American Public Health Association will be held in Montreal from September 14th to 17th, 1931. Some two thousand delegates, representing official and voluntary health services in all parts of North America, are expected to attend. In addition, the Society of Medical Officers of Health will be represented by three members of its Council--Dr. George Buchan, who will submit a contribution entitled A Brief Review of British Public Health Administration " ; Dr. Charles Porter, who will discuss " Education and Training for the English Public Health Service " ; and Dr. James Fenton, who will deal with " Maternity and Child Welfare Schemes and Work in Great Britain." It is greatly to be hoped that Sir Allan Powell, Chief Officer of Public Assistance, London County Council, will also be able to attend the meeting and submit a communication on " The Relation of Public Health to Public Assistance." "