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The hospital surveys, 1942–44
NHS AT 50
The hospital surveys, 1942–44
Hospitals are not simply complex buildings, nor are they services, and with that we set off. Hospitals for the merely “sheds for beds”, as they were once described. mentally ill and mentally handicapped were not included. They are the bases for specialised health care which do, There was no attempt to suggest the line the teams of necessity, provide many beds. Many of the half a might take. The similarity between the conclusions million and more beds taken into the NHS in 1948 did reached represented like thinking among ten very diverse include many for long-stay patients with mental or teams. The Sheffield and the London reports were the physical illness or both but most of the nearly 3 million first to be submitted, at the end of 1943, but the others patients who were admitted to hospital in the first year of followed too quickly to have been affected by the early the NHS stayed only a short time for active specialist arrivals. care, mainly nursing and medical. Our region had a population of almost 4 million. There Specialist care needed integrated staff and a measure of were some 300 hospitals ranging in size from half a dozen mutual support within the service’s geographical regions. to 1000 beds in buildings of all shapes and sizes. We saw Before the war the King Edward’s Hospital Fund for London had opened up thinking along these lines. So had local government, notably the Berks, Bucks and Oxon Regional Hospitals Council, sponsored by the Nuffield Foundation. In 1939 Lord Nuffield donated one million of his shares in Morris Motors to set up the Nuffield Provincial Hospitals Trust. By the early 1940s it was generally accepted that there would be some sort of national health service after the war, and that this would require regional integration. In 1942 the Trust joined with the Ministry of Health to sponsor a survey of hospitals in London and the surrounding region, to be carried out by Archibald Gray, a dermatologist, and Andrew Topping, deputy medical officer of health in the London County Council. Later, View of Houses of Parliament from St Thomas’ Hospital, London, 1940 Ernest Rock Carling and T S our challenge as a review of services rather than McIntosh were assigned to survey the north-west, based structures so our visits focused on what people did or on Liverpool and Manchester. were trying to do, in buildings most of which needed Early in 1943 the remaining eight of the regions that modification or replacement. It was obvious that England and Wales had been divided into under the concentrating services on fewer sites would be the wartime Emergency Hospitals Scheme were each ultimate aim. If we thought ourselves fully occupied in assigned to two medical surveyors and a senior that the fourth year of the war, so were the people we administrator from a major hospital. Leonard Parsons, visited; they gave much time to answering our inquiries. professor of children’s diseases in Birmingham, and Naturally, the youngest member of our party kept the S Clayton Fryers who was house-governor (chief notes but subject to strict review by my two colleagues, administrator) for the General Infirmary at Leeds and the final report was very much a three-man effort. covered what was to become the Sheffield hospitals The NHS never has had sufficient capital investment region. The third member of that team was the writer, but we have moved a long way from the incoherent then the Ministry of Health’s regional medical officer for pattern the survey teams found 55 years ago. Then there the wartime North Midlands region. The teams were were voluntary hospitals of substantial size in the four briefed by the two already at work, by the Ministry, and main cities in the region we looked at (Sheffield, by Sir William Beveridge, and we were told that it was Nottingham, Leeds, and Leicester) but elsewhere the intended to establish a national service of which some voluntary hospitals had only 100–200 beds even in large form of regional hospital system would be a part. The towns such as Grimsby or Chesterfield. In most of the medical establishment had already been consulted and main centres the recent growth had been in the municipal broadly agreed. So did the British Hospitals Association, hospitals, derived from former Poor Law institutions. representing non-teaching hospitals run by local However, there were many small “cottage” hospitals and government and charities. We were given a list of the like in smaller towns and even in large villages. Local hospitals, already compiled for the wartime medical
THE LANCET • Vol 352 • July 4, 1998
49
Hulton Getty
George Godber
NHS AT 50
authorities had statutory duties to make hospital provisions apart from their responsibilities for the indigent under the Poor Law legislation. Every district, by itself or cooperating with neighbouring districts, had to provide for the isolation of patients, mainly children, with infectious diseases. The counties and county boroughs were responsible for tuberculosis clinics and sanatorium beds. They also, with some of the larger districts, provided some maternity units though more than half the births at that time took place at home. Those were the days before anti-infective drugs and vaccines arrived to change the pattern of illness needing hospital care. Oddest of all were the smallpox hospitals—all remote, rarely used, and poorly provided with any of the ordinary requirements of a hospital ward. The main focus of the surveys was, naturally, the larger towns where at least the beginnings of a specialist hospital service existed. General practice with nursing help would clearly carry the main burden of care for the whole population but it could only do this if backed by
the close support of secondary care in hospitals—and that in turn needed coordination and the backing of some highly specialised services such as the radiotherapy centres which were about to develop their own regional linkages. The surveys concluded that the hospitals in a district should cease their petty rivalry and move to a functional union with a common staff. That staff could be built up to a coherent team of the specialties needed, and they would be greatly strengthened by the development of diagnostic services such as radiology and pathology. We could not foresee in 1943 the extent to which medical science would advance in the next half-century—nor did anyone else—but we could see that general physicians needed paediatric colleagues and that general surgeons should not be dabbling in gynaecology and orthopaedics. Coordination of the teamwork of neighbouring districts would make possible full coverage in all the ordinary specialties in every part of a region. Collaboration not competition seemed to us the basis for the future.
A consultant’s view
John A Black “Taking all the round of the professions and occupations, you will find that every man is the worse for being poor; and the doctor is a specially dangerous man when poor” (G B Shaw, in paper read to the Medico-Legal Society, Feb 16, 1909)
As a student at University College Hospital, London, in 1940, I picked up a copy of the hospital’s annual report which had been left behind after a meeting. It showed that UCH was almost broke, and it was clear that financial support from government would be required after the war. Later, working in a casualty department in Camden Town, north London, we had to treat as best we could the louse-infested rejects of society from Rowton House, a charity-supported hostel for the homeless. I hoped that the welfare state envisaged by the Beveridge report of 1942 would salvage and support such deprived people. When the NHS began on July 5, 1948, I was in London, half-way through an appointment as housephysician at the Hospital for Sick Children, Great Ormond Street. As a teaching hospital, it was largely insulated from the new NHS, with its own board of governors and direct funding from the Ministry of Health. Consultants who had served in the armed forces had returned to their previous appointments and private practices. 6 years later I became a consultant paediatrician in Glasgow, with overall charge of paediatrics for the County of Renfrew (population 300 000). In Scotland the teaching hospitals were under the direct control of the regional hospital boards. Though this appeared to be a more egalitarian system than the English one, in practice it allowed clinical professors almost complete control over the service in their region. Without 50
designated beds or a junior staff of my own in Renfrewshire, I found it impossible to set up an effective service. By 1963 I was in Sheffield. At that time the NHS was relatively protected from politics, and economic growth allowed adequate funds for new buildings, additional posts, and expansion of services. The first indication of the coming revolution was the Salmon report on nursing (1966), which put the emphasis on management, at the expense of clinical functions, and created a hierarchy of posts removed from nursing care in the ward. This was followed, two years later, by the Seebohm report, which invented the generic social worker. This was a disaster for paediatrics; we lost workers skilled in the management of children’s problems and had to work with staff with little or no training in this area. In 1974 came Sir Keith Joseph’s over-intellectualised reorganisation of the NHS. On the positive side, it created 90 area health authorities which were responsible for a unified service of hospitals, community and domiciliary care, and preventive health services. Below each area were one or more district management teams. The philosophy was “maximum delegation downwards”/“maximum accountability upwards” and decision by consensus, with everyone having a veto. This resulted in near-paralysis and a 30% increase in managerial and clerical staff. After 1974, with the economy slowing down, the emphasis was on cost-cutting and efficiency, with doctors and nurses, partly by default, losing influence on policy. In late 1975 and early 1976 consultants were in conflict over their contracts and the threat of removal of paybeds from the hospitals, but the Sheffield Children’s Hospital was hardly affected by the “work to contract” since most of the consultants were full-time
THE LANCET • Vol 352 • July 4, 1998
The hospital surveys, 1942–44
Hospitals are not simply complex buildings, nor are they services, and with that we set off. Hospitals for the merely “sheds for beds”, as they were once described. mentally ill and mentally handicapped were not included. They are the bases for specialised health care which do, There was no attempt to suggest the line the teams of necessity, provide many beds. Many of the half a might take. The similarity between the conclusions million and more beds taken into the NHS in 1948 did reached represented like thinking among ten very diverse include many for long-stay patients with mental or teams. The Sheffield and the London reports were the physical illness or both but most of the nearly 3 million first to be submitted, at the end of 1943, but the others patients who were admitted to hospital in the first year of followed too quickly to have been affected by the early the NHS stayed only a short time for active specialist arrivals. care, mainly nursing and medical. Our region had a population of almost 4 million. There Specialist care needed integrated staff and a measure of were some 300 hospitals ranging in size from half a dozen mutual support within the service’s geographical regions. to 1000 beds in buildings of all shapes and sizes. We saw Before the war the King Edward’s Hospital Fund for London had opened up thinking along these lines. So had local government, notably the Berks, Bucks and Oxon Regional Hospitals Council, sponsored by the Nuffield Foundation. In 1939 Lord Nuffield donated one million of his shares in Morris Motors to set up the Nuffield Provincial Hospitals Trust. By the early 1940s it was generally accepted that there would be some sort of national health service after the war, and that this would require regional integration. In 1942 the Trust joined with the Ministry of Health to sponsor a survey of hospitals in London and the surrounding region, to be carried out by Archibald Gray, a dermatologist, and Andrew Topping, deputy medical officer of health in the London County Council. Later, View of Houses of Parliament from St Thomas’ Hospital, London, 1940 Ernest Rock Carling and T S our challenge as a review of services rather than McIntosh were assigned to survey the north-west, based structures so our visits focused on what people did or on Liverpool and Manchester. were trying to do, in buildings most of which needed Early in 1943 the remaining eight of the regions that modification or replacement. It was obvious that England and Wales had been divided into under the concentrating services on fewer sites would be the wartime Emergency Hospitals Scheme were each ultimate aim. If we thought ourselves fully occupied in assigned to two medical surveyors and a senior that the fourth year of the war, so were the people we administrator from a major hospital. Leonard Parsons, visited; they gave much time to answering our inquiries. professor of children’s diseases in Birmingham, and Naturally, the youngest member of our party kept the S Clayton Fryers who was house-governor (chief notes but subject to strict review by my two colleagues, administrator) for the General Infirmary at Leeds and the final report was very much a three-man effort. covered what was to become the Sheffield hospitals The NHS never has had sufficient capital investment region. The third member of that team was the writer, but we have moved a long way from the incoherent then the Ministry of Health’s regional medical officer for pattern the survey teams found 55 years ago. Then there the wartime North Midlands region. The teams were were voluntary hospitals of substantial size in the four briefed by the two already at work, by the Ministry, and main cities in the region we looked at (Sheffield, by Sir William Beveridge, and we were told that it was Nottingham, Leeds, and Leicester) but elsewhere the intended to establish a national service of which some voluntary hospitals had only 100–200 beds even in large form of regional hospital system would be a part. The towns such as Grimsby or Chesterfield. In most of the medical establishment had already been consulted and main centres the recent growth had been in the municipal broadly agreed. So did the British Hospitals Association, hospitals, derived from former Poor Law institutions. representing non-teaching hospitals run by local However, there were many small “cottage” hospitals and government and charities. We were given a list of the like in smaller towns and even in large villages. Local hospitals, already compiled for the wartime medical
THE LANCET • Vol 352 • July 4, 1998
49
Hulton Getty
George Godber
NHS AT 50
authorities had statutory duties to make hospital provisions apart from their responsibilities for the indigent under the Poor Law legislation. Every district, by itself or cooperating with neighbouring districts, had to provide for the isolation of patients, mainly children, with infectious diseases. The counties and county boroughs were responsible for tuberculosis clinics and sanatorium beds. They also, with some of the larger districts, provided some maternity units though more than half the births at that time took place at home. Those were the days before anti-infective drugs and vaccines arrived to change the pattern of illness needing hospital care. Oddest of all were the smallpox hospitals—all remote, rarely used, and poorly provided with any of the ordinary requirements of a hospital ward. The main focus of the surveys was, naturally, the larger towns where at least the beginnings of a specialist hospital service existed. General practice with nursing help would clearly carry the main burden of care for the whole population but it could only do this if backed by
the close support of secondary care in hospitals—and that in turn needed coordination and the backing of some highly specialised services such as the radiotherapy centres which were about to develop their own regional linkages. The surveys concluded that the hospitals in a district should cease their petty rivalry and move to a functional union with a common staff. That staff could be built up to a coherent team of the specialties needed, and they would be greatly strengthened by the development of diagnostic services such as radiology and pathology. We could not foresee in 1943 the extent to which medical science would advance in the next half-century—nor did anyone else—but we could see that general physicians needed paediatric colleagues and that general surgeons should not be dabbling in gynaecology and orthopaedics. Coordination of the teamwork of neighbouring districts would make possible full coverage in all the ordinary specialties in every part of a region. Collaboration not competition seemed to us the basis for the future.
A consultant’s view
John A Black “Taking all the round of the professions and occupations, you will find that every man is the worse for being poor; and the doctor is a specially dangerous man when poor” (G B Shaw, in paper read to the Medico-Legal Society, Feb 16, 1909)
As a student at University College Hospital, London, in 1940, I picked up a copy of the hospital’s annual report which had been left behind after a meeting. It showed that UCH was almost broke, and it was clear that financial support from government would be required after the war. Later, working in a casualty department in Camden Town, north London, we had to treat as best we could the louse-infested rejects of society from Rowton House, a charity-supported hostel for the homeless. I hoped that the welfare state envisaged by the Beveridge report of 1942 would salvage and support such deprived people. When the NHS began on July 5, 1948, I was in London, half-way through an appointment as housephysician at the Hospital for Sick Children, Great Ormond Street. As a teaching hospital, it was largely insulated from the new NHS, with its own board of governors and direct funding from the Ministry of Health. Consultants who had served in the armed forces had returned to their previous appointments and private practices. 6 years later I became a consultant paediatrician in Glasgow, with overall charge of paediatrics for the County of Renfrew (population 300 000). In Scotland the teaching hospitals were under the direct control of the regional hospital boards. Though this appeared to be a more egalitarian system than the English one, in practice it allowed clinical professors almost complete control over the service in their region. Without 50
designated beds or a junior staff of my own in Renfrewshire, I found it impossible to set up an effective service. By 1963 I was in Sheffield. At that time the NHS was relatively protected from politics, and economic growth allowed adequate funds for new buildings, additional posts, and expansion of services. The first indication of the coming revolution was the Salmon report on nursing (1966), which put the emphasis on management, at the expense of clinical functions, and created a hierarchy of posts removed from nursing care in the ward. This was followed, two years later, by the Seebohm report, which invented the generic social worker. This was a disaster for paediatrics; we lost workers skilled in the management of children’s problems and had to work with staff with little or no training in this area. In 1974 came Sir Keith Joseph’s over-intellectualised reorganisation of the NHS. On the positive side, it created 90 area health authorities which were responsible for a unified service of hospitals, community and domiciliary care, and preventive health services. Below each area were one or more district management teams. The philosophy was “maximum delegation downwards”/“maximum accountability upwards” and decision by consensus, with everyone having a veto. This resulted in near-paralysis and a 30% increase in managerial and clerical staff. After 1974, with the economy slowing down, the emphasis was on cost-cutting and efficiency, with doctors and nurses, partly by default, losing influence on policy. In late 1975 and early 1976 consultants were in conflict over their contracts and the threat of removal of paybeds from the hospitals, but the Sheffield Children’s Hospital was hardly affected by the “work to contract” since most of the consultants were full-time
THE LANCET • Vol 352 • July 4, 1998