HOSPITALS IN TRANSITION: SEPTEMBER 1939–MAY 1940
Although the emergency medical service did not receive its first test until May 1940, the story of its growth and development had not, up to then, been a smooth or uneventful one. A whole series of problems interrupted progress, some peculiar to the initial stages of creating a new public service, others (like nursing) with deeper roots. The most difficult issue in the autumn of 1939, however, was the situation in which the ordinary sick population was placed. The reason was simple: people did not stop being ill because war had broken out, yet the immediate mobilisation of the hospitals and their staff to look after another set of patients—who did not materialise—prevented the civilian sick in London and other cities from getting care that they needed. A barrier was thus thrown between hospitals and sick people.
On the outbreak of war about 140,000 beds had been emptied of patients, doctors and nurses were posted to different hospitals where they had little to do, equipment was moved away from central hospitals, out-patient departments and clinics closed down, and many consultants found themselves with very few patients to attend. Such a situation could not continue. New measures had to be taken, a new balance had to be struck. This is the main theme of the present chapter.
What came to be the basic wartime hospital problem appeared on the scene not slowly, with time for gradual modification and change, but with an abruptness which startled the Government and the medical profession. In essence, the task was to meet, with much the same pool of hospitals, doctors and nurses, all the normal needs of the sick while, at the same time, so arranging and distributing these resources that a large proportion would, on demand, be immediately available for hundreds of thousands of war injured civilians and sick and wounded service men.
In time of war it has been customary for the civilian to step back and give way to the needs of the fighting services. But the aeroplane, the rocket and the flying-bomb were changing this. In proportion
as the civilian was led further into the arena of risk—whether by bombs or food shortages or in other ways—the war of 1939–45 would make quite new demands on the medical service. Earlier chapters have shown the Government expecting that the outbreak of a war would bring new and heavy demand. The fact that civilian casualties from air raids did not occur at once was hardly a fault of the Government. That they were, eventually, much smaller in number than had been expected was due to a host of reasons—some of which are discussed in Chapter XVI. Nevertheless, during the whole of the war the number of civilians in Britain injured by the enemy was approximately the same as the number of British soldiers wounded in all theatres fighting against Germany, Italy and Japan.1
In September 1939, then, there was added to the priority group of the Armed Forces another large slice of the population—civilians likely to be injured by air attack. The assumption of responsibility by the Government for providing hospital care for this group led, as Chapter V has shown, to the creation of the emergency hospital scheme. With this scheme, the Government undertook to make available—and pay for—first aid and hospital treatment for a large section of the population—but how large nobody knew. As there were no air raid casualties during the early months of the war, hospitals were, therefore, paid for keeping beds empty, and medical and nursing staff were kept standing in readiness.
Progress and Consolidation
In the spring of 1940, when the hospital scheme experienced its first test of the war, it admitted, not civilian air raid victims, but about 32,000 casualties and sick service men evacuated from the Continent with the British Expeditionary Force.2 By May 1940,
however, the organisers of the scheme could face this test—relatively light in contrast to what had been expected in August 1939—with equanimity. For although provision on an immense scale still had to be made for possible air raid victims, the hospital service was in much better shape, better equipped and better organised, than it had been on the outbreak of war.
Fortunately for the peace of mind of the staff, the emergency service had not been entirely idle during the first nine months of the war. Although it was initially organised as a casualty scheme, and therefore had a strong surgical emphasis, paradoxically some 82,000 sick soldiers were admitted to its beds within eight months.3 Its other patients during this period, apart from sick people transferred from inner to outer hospitals to keep beds vacant for air raid victims, were approximately 21,200 Service casualties (most of whom were received in May and June 1940), and only 1,340 civilians (largely evacuated children).4 While, therefore, the cost of the service was borne on a Health Department vote, and it was frequently counted as one of the wartime social services, its most important function was, as events turned out, to provide hospital and medical care for sick and wounded members of the Armed Forces.
On 1st May 1940 there were 1,206 hospitals in England and Wales taking part in the emergency scheme.5 These contained a total of some 406,000 beds of which 263,000 were allotted for casualties.6 About 95,000 were immediately available, while 38,000 were in reserve.7 On paper, the position seemed to be much worse than in September 1939, when another 1,1690 or so hospitals were in the scheme and it was said that 195,000 beds were ready for air raid casualties.8 But in reality, and in terms of the provision of a good standard of medical care, the position was much better than a simple comparison of the figures suggested. This becomes clear when it is understood why over 1,000 hospitals and institutions in England and Wales with about 85,000 beds were cut out of the emergency scheme
within the space of less than eight months.9 Broadly, the explanation of these reductions falls under two heads. The first and most important one was the need to do more for sick civilians; it was essential for reasons which are discussed later in this chapter, to strike a better balance than the original one between this need and the high insurance provided against air bombing. The second cause for the removal of many hospitals from the scheme was that they were qualitatively unfit to make a genuine addition to its strength. This was made clear in Chapter V.10
However, it was not merely by the reshuffling of existing resources that the new balance was struck. Between September 1939 and May 1940 the total of resources had been enlarged and improved by a variety of measures.
The programme of hutted annexes (including a number of new hospitals) to accommodate 40,000 addition beds in England and Wales, launched in March 1939, had got under way. Progress, however, was slower than had been hoped. It had been optimistically estimated that the scheme would be completed within six months;11 but on 1st May 1940 only 10,240 beds were ready for occupation. In the following three months another 12,800 were handed over by the Ministry of Works. This meant that it had taken about eighteen months to complete rather more than half the programme.
The failure to achieve more was due to a variety of causes. As the Ministry of Health was not a hospital owning authority, the bulk of these annexes had to be attached to hospitals belonging to local authorities. They had to be sited in the safer areas where there was a peacetime shortage of civilian hospital accommodation, and where the local authority would take them off the Ministry's hands at the end of the war. These arrangements took time, and more delays were caused by labour difficulties, by the need to substitute other forms of construction for timber which became scarce soon after the outbreak of war, and by the Treasury's insistence, when authority was first obtained, on the 'lowest possible standard'.12 Expensive and time-wasting modifications had later on to be made in the design, fitting and furnishing of these annexes and ad hoc hospitals. Moreover, as
soon as the first ones came to be used many lessons were learnt, with consequential changes in the building plans. Other alterations were caused by surgeons changing their minds as to what they wanted, and by War Office occupation which meant, for example, better kitchen equipment on account of the more generous Service diet.13
In addition to this programme of 40,000 beds, it was decided, in February 1940, to construct a further block of hutted hospitals to accommodate a similar number of beds. The total programme for England and Wales was thus raised to 80,000 beds.14 This decision was taken chiefly on account of increased military needs because (as has been already explained in Chapter V) the Army was relying on the emergency hospital scheme to meet most of its requirements at home. As the size of the Army expanded, soldiers increasingly competed for a larger share of the available pool of hospital and medical resources.
To maintain, as far as possible, the principle of a unified hospital scheme for both civilian and service casualties, it was decided that the Ministry of Health should build, equip and staff these hutted hospitals and allot accommodation to the Army as it was required.15 The siting of the huts and annexes under the second programme of 40,000 beds had, therefore, to be considered in relation to the geographical position of Army commands, as well as to the availability of consultants and the post-war needs of the civilian population.
With three major claimants on hospital space and medical skill—the armed forces, civilian air raid casualties and the ordinary sick—decisions of this kind helped towards a better utilisation of available resources. In the spring of 1940 the total estimated demand under these three heads was higher than ever. The War Office thought it might need before the end of the year 100,000 beds in civil hospitals in Britain,16 an immense number might be required at any moment for air raid and invasion casualties17 and, meanwhile, the needs of the sick population still had to be fully met.
Nevertheless, it was agreed that there could not be another mass ejection of patients from hospitals, sanatoria and convalescent homes.18
As will be explained later in this chapter, most of these institutions had, since September 1939, opened their doors again to the civilian sick. Some other means would now have to be found of temporarily increasing the amount of hospital accommodation until all the new hutted annexes were ready for use. After reviewing the situation in June 1940, the Government decided to create a large additional reserve in the form of converted houses, schools and other buildings for use either as annexes of existing hospitals or as independent convalescent units known as 'auxiliary hospitals'.19 The latter were to be run on behalf of the Ministry of Health by the War Organisation of the British Red Red Cross Society and Order of St. John of Jerusalem as convalescent homes for Service patients and air raid casualties. By the end of 1940, 140 houses had been turned into annexes with 8,850 beds, and 215 auxiliary hospitals with about 5,000 beds had been opened. In addition, plans were made for the taking over of boarding schools and hotels to provide, in an emergency such as invasion, some 60,000–70,000 additional beds for the needs of the civilian population.20 These were known as 'reserve hospitals', each of which was linked for operational and staffing purposes with class I hospitals in the scheme. Those intended to be used first were provided with basic equipment stored ready for use.
The programme of hutted hospitals and the schemes for annexes, auxiliary and reserve hospitals were the main instruments for expanding, either temporarily or permanently, the amount of accommodation for hospital beds. Equally important, however, were the measures taken during the first nine months of the war to improve the quality of a great part of the hospital services incorporated in the emergency scheme. Better facilities for diagnosis and treatment helped towards shortening the time each bed was occupied, a better classification of cases in special hospital centres was also economical, especially in the use of expert medical skill, while extended first aid and out-patient arrangements promised relief from the expected strain on hospital beds.
By the middle of 1940 the hastily improvised first aid scheme of September 1939 had given place to some 2,000 equipped and staffed first aid posts, while about 880 mobile aid units had been organised. The casualty hospitals in all the large cities were, therefore, better protected against a rush of patients needing only first aid treatment.
Free out-patient treatment at hospitals for civilian war casualties was made available by the Government at the outbreak of war. The question of subsequent treatment at the home of the patient by general practitioners was, however, more difficult to settle. This would be needed by people who had been in hospital with a war injury and had reached a stage when they could be discharged, although treatment had not been fully completed; it would also be needed by people who had initially been dealt with at first aid posts or out-patient departments and still required further medical care in their own homes. Some arrangement for home treatment was particularly necessary for injured people living at a distance from hospitals.
The chief obstacle to the provision of a satisfactory scheme was the problem of checking the doctors' claims on the Government for treating war injured patients at their homes. It was therefore decided that as the emergency medical service was based on hospitals, the responsibility for seeing that the patient obtained all necessary treatment had to rest on the hospitals. A scheme for domiciliary treatment was worked out on this principle and announced in January 1940.21 It was laid down that, for those civilian war injured who could not afford to pay doctors for treatment at their homes, the Government would bear the cost and pay a capitation fee to the doctor,22 provided an 'order for treatment after discharge form'23 was first obtained by the patient at the hospital. These forms were not to be handed out at first aid posts, owing to the possibility that local practitioners attending the posts might issue orders for treatment 'which are likely to redound to the financial benefit of themselves or their partners'. People who went to first aid posts and subsequently wanted further treatment at home would, therefore, first have to go to a hospital to obtain a form.24
In practice, these arrangements led to a certain amount of hardship—how much is impossible to tell—especially when hospitals, in employing their pre-war methods and disregarding the patients' means or opportunities of access to hospitals or clinics providing certain special facilities that were needed, discharged patients when they were well enough to get up but before treatment was fully completed.
It has been said that the improvement of hospital resources for the diagnosis and treatment of injury and disease was one of the aims of the Ministry of Health. This subject was raised in Chapter V, and a description was there given of the various ways in which the Ministry was undertaking the task of upgrading and bettering a large number of hospitals and ancillary services, such as laboratories, ambulances, blood transfusion arrangements and so forth. Despite the importance attached to financial economy during the first six months of the war,25 which inevitably affected, for instance, the quality of the equipment supplied to hospitals and first aid posts,26considerable progress was made.
In some instances, where a suitable building was taken, extended by the addition of hutted annexes, and used as a large general hospital, the amount of technical and engineering work involved and the range of administrative action required was immense. Moreover, the whole process had to be carried through in a period of time which would have been regarded in the days of peace as quite unprecedented.
By the middle of 1940 the equipment position of the hospitals in the emergency scheme was highly satisfactory compared with all the shortages and defects that had prevailed on the outbreak of war.27 Great quantities of surgical instruments, X-ray and theatre apparatus, ward furniture, drugs and dressings had been distributed, together with over 100,000 new hospital beds. The work of structural precautions, alterations and adaptations had made substantial headway, while the special centres for various types of injury had been, or were in process of being, organised, equipped and staffed. These centres for orthopaedic and fracture surgery, chest and head injuries, plastic surgery and jaw injuries and the treatment of burns, in addition to the neurosis and effort syndrome centres, were all part of the aim of bringing together in the same hospital particular types of injury and sickness and particular categories of medical skill.
To the layman, this probably seemed a sensible policy; but to a large part of the hospital world it was, in some respects at least, an innovation. In place of the tradition all-purpose 'general' hospital the objective was to provide, on a national scale, a pattern of hospitals in which some specialised on one service, some on another. This division of hospital labour had had its supporters long before the war.
They had wished to see the growing medical specialisms reflected in the social organisation of medical practice. Many of the specialities themselves had developed and branched off from the main trunk of clinical medicine. For some, differentiation had proved to be sound; but for others, where unnatural influences had been at work, such as the fencing off of a tract of medicine because it contained enough people to provide a livelihood for specialists, or because the State had to fill a gap by establishing a separate service, it had led to a narrow and stultifying isolation.
Clearly, then, there were dangers in this policy of specialise hospitals, as there are in all forms and varieties of specialisation. It was a policy, too, which involved many difficulties of organisation and which demanded, for its success, some measure of interference with established medical practice. It meant, for instance, arranging a better geographical distribution of consultants and specialists. This was not an easy task. Another problem was to persuade the medical staffs of receiving hospitals to send their patients without delay to these special hospitals to be treated, perhaps, by someone else.
Doctors, like other professional men, take pride in their work and therefore lay great stress on the value of continuity of treatment. Doctors, too, are like their professional brothers in another respect; they live in an age in which they had had to come to term with , and respond to the incentives of business. As one economist has put it, the pressures of the system which surround the doctor are slowly and insidiously 'making something more of a business man out of him, and converting the thing once called "private practice" into a system of individual business competition'.28
The process was a logical one; it was quite understandable so long as the practitioners of medicine were regarded—like everyone else—as sensitive to the moulding forces of the society in which they had to make a living. These influences on the doctors' work were, however, by no means one-sided, but it generally happened that the less creditable manifestations were reported to the Ministry of Health. As in so many sphere of Government, the lapses had to be attended to while the successes went unsung. Moreover, it must also be remembered that in wartime, when the lives of men in the Fighting Services assume great importance, the results of medical treatment are watched and measured to a degree unthought of in peacetime. It was, therefore, one of the tasks of the organisers of the emergency medical service to see that the medical care provided by the State was of a high standard.
About the middle of 1940 complaints began to reach the Ministry of Health of the 'poor quality of treatment' of some patients in
emergency scheme hospitals, of inexperienced doctors carrying out major operations although qualified men were available, and of surgeons holding on to cases to the detriment of the patients' welfare.29 Later, and for the same reasons, the R.A.F. threatened to stop using certain of these hospitals because of the immense importance of conserving aircraft crews and getting them fit again as quickly as possible.
Action was taken to deal with these problems Regional consultants were appointed by the Ministry of Health to inspect and report on the work of the special centres, and regional advisers in general medicine and surgery were asked to tour the emergency hospitals. The areas to be covered by these advisers were later found to be too large, and in December 1940 group advisers were introduced to look after groups of hospitals.30 Their task was to see that patients were transferred to hospitals with special facilities, that consultants were called in, that patients needing special treatment were not unduly detained in the receiving hospitals and that convalescent homes and rehabilitation centres were fully used. The Ministry of Health told these advisers to be ruthless in directing patients to those hospitals where the best treatment was available. There is no doubt that the work of these consultants and advisers was effective.31
The structure of the emergency hospital scheme was steadily strengthened by action of this kind, and by a continuous series of particular achievements in various field—the organisation of a good fracture department in an industrial area hitherto badly served, the establishment in one place of a new laboratory staffed and fitted with modern equipment, the transformation in another place of a public assistance institution into a good hospital. And so on. From a practical point of view, these improvements were worth far more than a merely quantitative achievement of the target. They were worth more than a much larger number of beds distributed around the country in tents or unsuitable buildings with little of the skill and few of the ancillary aids and comforts which twentieth-century medicine can bring. By the standards which the emergency medical service had reached by 1945 its condition, five years earlier, was undeveloped. But it was full of promise. At the time of Dunkirk, achievement had to be measured against the state of the hospitals before the war. By
these standards the emergency service was ready, not indeed for the calamities which had been envisaged, but for the actual casualty lists of 1940 and 1941.
Towards a Better Balance
The expectation of frightening casualty lists had provided a part of the stimulus for these improvements. Nevertheless, a price had to be paid for the benefits of this stimulus. It was paid in the currency of distress. Those who suffered in the early months of the war—and at other periods during 1940–5—were not air raid casualties, nor were they men in uniform. They were the sick, the diseased, the old, the young and mothers—all those who were denied hospital room so that there might be space for air raid casualties.32
It is difficult to estimate how many patients were affected by this sudden withdrawal in 1939 of hospital facilities, for no adequate records were kept of the number of beds that were emptied.33 The Government had hoped to find about 100,000 beds for casualties by turning out the sick, but it seems that the hospitals interpreted their instructions so rigorously that about 140,000 sick were, in fact, sent home.34 Many patients, it was said, were prematurely discharged and more beds were made available in voluntary hospitals than the Government had expected.35 Included in the figure of 140,000 were about 7,000–8,000 tubercular patients 'cleared' from local authority sanatoria, representing nearly thirty percent of all those receiving
residential treatment at the time.36 In Wales, approximately sixty percent of tubercular patients were bundled home within twenty-four hours. How many of these were sputum-positive—and consequently a danger to other people—it is impossible to say.
Not only was the hospital population drastically reduced, but it became much more difficult for the civilian sick to get into hospital. Admissions were severely restricted, particularly in London, where, for instance, some two-thirds of maternity beds in all hospitals were reserved for air raid casualties and mothers were being turned away by some voluntary hospitals a week before the outbreak of war. In addition, therefore, to the sick who were sent home, some of whom were 'wholly unfit people'37 and should not have been discharged, there was the problem of existing waiting lists at voluntary hospitals, tuberculosis sanatoria and other institutions.
It was shown in an earlier chapter that, on the basis of the hospital survey reports, there were roughly 100,000 people waiting admission to voluntary hospitals on any given day during 1938–9.38 It may be supposed, because of the restriction in facilities, that the number was somewhat higher at the end of August 1939. By no means all these people were acute cases, nor were they continuously the same people; for waiting lists changed in composition from day to day. Many were probably classified, in the language of the profession, as 'cold' surgical cases who often waited perhaps a month, perhaps six months or longer, for a gynaecological or tonsil operation. Nevertheless, it was a fact, counting the discharged sick, there existed in the early weeks of the war a population of close on 250,000 people who needed, or thought they needed, treatment of some kind in hospital. After six years of war, after the blitz of 1940–1, the later bombings, the flying-bombs and the rockets, the total number of civilian air raid casualties treated in hospitals from beginning to end was roughly forty percent less than the number of sick people turned out of hospitals in about two days in September 1939.
So much for the size of the problem. The figures, intimidating though they are, do not by themselves convey the intensity of the need to strike a new balance in the allocation of hospital resources.
The total represents an appalling aggregate of social stress because it is made up by such numberless individual sufferings and hardships. The hospital almoner probably saw more of these hardships than anyone else. One of them recorded her impressions of September 1939.39 Patients in an early operable stage of cancer were sent home untreated; expectant mothers were refused admission for what were likely to be difficult and dangerous confinements; children in plaster of paris were deprived of the care they needed; bedridden patients—the arthritic, the diabetic and heart cases—were discharged to the care of relations heedless of the fact that these relations might now have evacuated, leaving the house empty; highly contagious tuberculosis patients were sent to crowded homes with young children, perhaps to die, perhaps to infect their families. 'Surely never before', she wrote, 'has a nation inflicted such untold suffering on itself as precaution against potential suffering. And was it all necessary? … War or no war, there could not fail to be civilian sick … Why should it have been considered less disastrous for anyone to die untreated of cancer, appendicitis or pneumonia than as a result of a bomb?
The Government was not wholly accountable for all these hardships. While the directions for discharging patients and admitting new ones were severely worded by the Ministry of Health, selection had, of course, to be left to the staffs of the voluntary and municipal hospitals. This process was, in fact, so rigorously applied by doctors that the number of patients turned out of hospital was about 40,000 higher than the Ministry had expected.
The situation thus created in the autumn of 1939 could not be endured for very long. The Ministry was soon assailed for the lack of hospital facilities for the civilian sick, but what its critics did not know was that it had to urge the voluntary hospitals to throw open more of their beds and resources for the needs of the sick population.
In its attempts to improve matters and to make the emergency scheme a more flexible instrument, the Ministry had to take care not to go too far; otherwise the whole scheme of treatment for air raid and Service casualties would be imperilled. A balance had to be struck between conflicting demands. And this had to be achieved in the face of discordant claims: of hospitals finding it beneficial to be paid for keeping beds empty, and of doctors wanting the advantages offered by a guaranteed salary for whole-time work, yet loath to see their practices dwindling and their patients lost to colleagues who had remained outside the emergency medical service.
So far as hospitals were concerned, the action taken up to May 1940 meant that over 1,000 institutions with about 85,000 beds were released to carry on their ordinary work. These were chiefly small
hospitals, and included many maternity homes, tuberculosis sanatoria, convalescent homes for children and infectious disease and special hospitals, found to be quite unsuitable for the reception of casualties. In addition, between September 1930 and February 1940, a series of measures were adopted to provide more beds for the civilian sick of London and other cities.40 Among the London voluntary hospitals, the number of beds reserved for casualties was reduced by twenty percent in the interests of the sick, and permission was given for those hospitals to use 'frozen' beds so as to bring the total casualty and sick accommodation up to two-thirds of their normal complement.41 Inevitably, it was for the hospitals themselves to decide whether they opened up their beds to the limit allowed. If they did so, the Government stabilised the casualty bed position by transferring more sick people to outer hospitals42 These people then became E.M.S. patients, and the cost of treating them, less the amounts recovered from patients or relatives, was borne by the Government.
This change of policy for the benefit of the civilian sick did not come about without some friction between the various authorities. Much of it was, no doubt, inevitable, partly because there had not as yet been time to weld together the different systems in a scheme based on a diplomatic balancing of two hospital systems. Nor should it be forgotten that the Government lacked complete control over hospitals. They could not be standardised or ordered about. Whether they were voluntary or municipal, their independence had to be respected. They were left, as the Government was careful to point out, to 'manage their own affairs'.43 This mean, in the case of the voluntary hospitals, that it was their business to decide whether they should do as much for the civilian sick as in peacetime. To get them to carry out the Government's policy required a great deal of tact and persuasiveness as well as the application of financial incentives of one kind or another.
In the early months of the war, when the Ministry of Health wanted about twenty percent of the casualty beds in London handed back to the sick, negotiations with the voluntary hospitals were coloured by
the fact that the Government was paying £100,000 a week for beds meant to be kept empty. To press for more beds for the sick meant, in financial terms, the withdrawal of part of this unexpected subsidy.44 The problem was also complicated by the new arrangements made at outer hospitals by the teaching bodies for medical education,45 by the redistribution of staff and equipment, and by the fact at that many doctors and specialists had closed down their practices, accepted whole-time salaries and moved out of London.46 A change in policy involving the reopening of beds in hospitals in the centres of London and other big cities meant completely fresh arrangements at every point, for staff and equipment could not be in two places at the same time. Such a change therefore entailed for the voluntary hospitals more disorganisation and a great burden of administrative work in rearranging their resources. All this cost money, a fact which the hospitals could not lose sight of when many were in debt and were financially in a precarious position. While these issues were being debated the London County Council, who by statute could not turn the sick away, had been forced by Christmas 1939 to encroach on 4,400 of its 7,600 casualty beds.
The voluntary hospitals also found it difficult to understand why the scale of air raid provision required in August 1939 could be reduced a few weeks later although the war had started. The Government believed that the risks were still as great'47 what, of course, had changed the situation was the realisation of the needs of the civilian sick.
The steady growth of public opinion and the pressure of the sick on the municipal hospitals helped to force a decision. It became know, too, that some voluntary hospitals were taking sick civilians above their allotted number and were purporting to put these sick into the so-called 'dead' beds in order to avoid losing pay on the casualty beds, while one or two were filling up their private patients' wards. Nevertheless, there was considerable opposition from the governing bodies and lay administrators of the hospitals to the Ministry of Health's proposals. This was expressed in January 1940 when the Minister met representatives of the London teaching hospitals. It was said that if a large number of new admissions were made and the staff brought back, the sock would be left with no one to look after
them when raids began as many doctors and nurses would have to return to their posts at the peripheral hospitals. Moreover, it was maintained on a number of occasions that the allegations of hardship among the civilian sick were unfounded.48 Waiting lists in London, it was said, had never been so small.49
A gradual improvement in hospital and out-patients facilities at the voluntary institutions in London and other big cities took place during the winter of 1939–40. The influence of public opinion, pressure from the Government, and a desire among doctors to be relieved of their enforced idleness and attend to those who needed them, were all factors which benefited the sick. The concessions made by the Ministry of Health to the British Medical Association in revising the salaries and terms of service of doctors in the emergency medical service also helped to smooth the way.50
There were originally two classes of service, salaried and sessional. Doctors in the latter class were liable for hospital service in their own hospital area according to the needs of the moment. They were paid by the session at the rate appropriate to the kind of work. Salaried doctors, on the other hand, were under an obligation to serve wherever required for the duration of the war and were liable to be temporarily transferred to any part of the country. They were debarred from private practice, and by way of compensation were guaranteed employment for one year.
These terms were not universally popular. At a time when too many doctors were 'twiddling their thumbs and thinking about their salaries',51 the terms meant increased earnings for some doctors and diminished earnings for others. House-officers (junior doctors) liked them, for they were paid £350 a year plus an extra £100 if living out; this was about £350 a year more than most of them had been accustomed to received from voluntary hospitals. Some of the senior doctors and specialists, however, found themselves (to quote the Lancet) with salaries 'that will mean rapid (though not discreditable) bankruptcy'.52
In the middle of September 1939, the Ministry of Health put forward proposals under which salaried doctors were to be paid one-third of their salary in return for a liability to be called upon four days a week if required.53 This offer met with little response. After
further negotiations, the Ministry agreed to accept the recommendations of the profession.54 The chief item in the new scheme was an arrangement where doctors of specialists or higher rank were released from whole-time duty to return to private practice. They were paid a salary of £500 a year for such duty as might be require of them, on the understanding that if in an acute emergency they were called upon for all their time no extra remuneration would become payable.55 These terms, which were later described by the Select Committee on National Expenditure as commercially based and 'neither in the interests of the country nor in accord with the dignity of the profession',56 proved to be acceptable.
This reorganisation, settled during the early, uneventful months of the war, determined on broad outline the terms and conditions of service for doctors for the next five years. The change from whole-time to part-time and sessional terms for medical practitioners in the emergency medical service was an important part of the general reorganisation which the hospital scheme underwent during the first year or so of war.
The other elements in this process of reorganisation were chiefly administrative ones. Most of them were introduced during the summer and autumn of 1940, and as a result of the experience gained during the preceding months when pre-war principles were tested in action.
In May 1940 the Ministry of Health decided to decentralise a substantial amount of control to the region,s, and to link up the local and regional organisation of the hospital scheme with the department's regional offices and the staffs of the Regional Commissioners.57
Additional appointments were made, including assistant hospital officers whose main tasks were (despite their misleading title) to bring closer together the local casualty services, the hospital services and the regional organisation.58
These changes were made, particularly the decentralisation of work to the regional offices, partly as a result of the recommendations of the Colville-Chatfield commission of inquiry,59 partly because of the war situation which it was thought might lead to the evacuation from London of at least a section of the Ministry of Health. The inquiry found that the hospital officers outside London had been burdened with work which might well be carried by the Ministry's regional officer, that the staffs of these officers were out of touch with the hospital organisation, and that very detailed supervision of financial and other matters by the central department slowed down development and hindered quick and flexible operational control.60 In June 1940 financial control from the centre over the small items of current expenditure was eased, and increased powers of approval were delegated to the regional offices.61
The working of the administration of London region was also criticised by the commission of inquiry and other bodies. It was said that the ten sectors were too inequal in size; that so many sectors, the number having originated from the decision to allot separate sphere of work to as many as possible of the big teaching hospitals, multiplied the problem of cooperation; that there were inequalities between them in matters of staff and beds; and that each sector, instead of working with others on questions of transferring patients and staff and pooling resources, tended to act as an isolated, independent unit.
These points were made more pungently by the Select Committee on National Expenditure which drew attention, in its fourteenth report, to the fact that the aim of flexibility and sharing of work had been discouraged by the original appointment, at the head of each sector, of a distinguished doctor or surgeon already on the staff of a teaching hospital.62 Complaints were also made by the London County Council that medical staff had not been fairly allocated between municipal and voluntary hospitals, and that the former were taking a large number of civilians sick who would, in peacetime, have
been treated by the voluntary hospitals. The latter were, it was said, keeping a much higher proportion of beds vacant for casualties.
Some of these complaints, such as the question of hospital room for the civilian sick, are examined in Chapters XXII–XXIV. As regards the criticisms of the London sector arrangements, the Ministry of Health decided in July 1940 that the time was unsuitable to make any radical changes, even if the complaints were justified. In an attempt, however, to promote more cooperation between the sectors and among the hospitals, a superior directing staff for London and the home counties was appointed, consisting of a director and two assistants representing the interests of the voluntary and municipal hospitals.63 The former hospital officer for London region was then made responsible for supervising first aid, the ambulance services and inter-hospital transport.
This chapter has now sketched the early wartime development of the emergency medical service. It had begun merely as an improvised casualty scheme for treating air raid victims; but by the summer of 1940 it was in process of transition to a national hospital service for a section of the population. This section, comprising (in May 1940) civilians and members of the civil defence organisations injured by enemy action, sick and wounded members of the Fighting Services and certain other groups,64 was not a large one compared with the total of the nation's sick population; but it was steadily added to as the war went on by the inclusion of other groups.65
In some respects the new hospital service was fortunate in not having to carry a heavy burden during its first nine months. For this benefit, however, a price had to be paid by the civilian sick. The Government, in establishing a hospital service to meet the demands of total war, disorganised the existing arrangements for hospital care. It then had to set about repairing the damage that had been done on the outbreak of war. In doing so, and in building up the new service, not as a separate entity but inside and around the structure
of two existing and very dissimilar hospital systems, it encountered many conflicting loyalties and a whole series of previously unresolved problems. Some of these came to the surface during the first year of the war and have already been discussed. They arose against at different times in the next four years and for different reasons. They presented themselves in a serious form when the emergency medical service faced its first real test during the air-raid winter of 1940–1. This is the theme of the next hospital chapter—Chapter XXII.
Contents * Previous Chapter (X) * Next Chapter (XII)
1 Cmd. 6832—Strength and Casualties of the Armed Forces and Auxiliary Service of the United King 1939 to 1945. Tables 5 and 6 of this statement show that up to 14th August 1945 (as reported to 28th February 1946), 239,575 members of the Army and 86.182 civilians were wounded. But the figure for civilians refers only to those seriously injured and detained in hospital. It excludes those who did not go into hospital, and those who were less seriously injured and were treated at first aid posts and elsewhere. So far as is known (and the figures are only rough approximations, the members of a numbered and regulated Service), some 150,000 civilians were slightly injured (a further 50,000 or so received trivial injuries) between 1st September 1940 and 29th March 1945. Broadly, therefore, it may be said that the numbers of injured civilians and wounded soldiers were roughly the same. The numbers killed were 60.595 civilians and 144.079 members of all ranks of the Army. Further details are given Chapter XVI and Appendix 8.
2 Report of the Chief Medical Officer of the Ministry of Health, 1939–45.
3 In addition, many members of the Armed Forces contracting infectious diseases were admitted to infectious disease hospitals run by local authorities, who recovered the cost of treatment from the Service in question.
4 These figures cover the period from 23rd October 1939, when the first complete statistics were received, to 24th June 1940.
5 As stated in Chapter V, this account of the emergency scheme does not deal with the hospital services in Scotland.
6 Report of the Chief Medical Office of the Ministry of Health, 1939–45.
7 In addition, there were about 1010 hospitals run by the three Services and the Ministry of Pensions, containing about 20,000 beds, of which 8,100 were vacant.
8 Estimates of the peak number of beds made available for casualties within the first few days of war vary. The Report of the Chief Medical Office of the Ministry of Health, 1939–45, gives a figure of 187,000, the Summary Report of the Ministry of Health for 1939–41, 190,000, the Minister himself told the Medical Committee of the House of Commons on 18th January 1940 that some 195,000 beds were made available, the Prime Minister announced on 7th September 1939 a figure of over 200,000 beds (H. of C. Deb., Vol. 351, Col. 583), while certain departmental files state the figure as 193,000.
9 After June 1940, and during 1941–3, other hospitals were from time to time suspended from the scheme, withdrawn or downgraded on being found unsuitable. The process of clearing away the 'dead wood', hurriedly accumulated in 1939, took from two to three years to complete.
10 Chapter V, pp. 66–73. A departmental minute of 16th October 1939 summed up the situation in the following words: 'Had we had more time for the preparation of the scheme, and had we not been perpetually under the necessity of finding an almost impossible number of beds, the hospitals which we now propose to release would never have been included in the first stage of the scheme at all'..
11 See Chapter V, p. 81.
12 The number of beds per hut was very high and possibly dangerous from the viewpoint of cross-infection. Because of the expected shortage of hospital space it was decided, in 1939, to place 42 beds in each hut. In peacetime the standard might have been about 24.
13 See, for instance, Ministry of Health circular E.M.S.I.98, 20th December 1939, recommending more substantial diets for Service than for civilian patients.
14 Including extensions to Ministry of Pensions hospitals—about 2,500 beds.
15 Some expansion of the Army's hospital resources in Britain had already taken place. By 1st May 1940 the number of beds had risen from about 3,000 before the war to 10,944 in 73 hospitals. In addition, there were nearly 3,500 beds in camp hospitals and reception stations.
16 The Navy and Air Force were also, to some extent, claimants, but the accommodation these two Services required was small in relation to the needs of the Army.
17 It was suggested that, at the worst, the Government might have to deal with some 800,000 air raid casualties over a period of six weeks, and that this number might be increased by invasion. The Ministry of Health, in assessing the country's improved hospital resources, was sceptical of this estimate, and decided that it was impossible in the time available, and with the number of doctors and nurses at its disposal, to budget for more than about half this estimate.
18 Ministry of Health circular 2023, 18th May 1940.
19 Following the recommendation of a special commission of inquiry appointed by the Minister of Health. The chairman of this commission was, first, Mr. J. Colville and subsequently, Lord Chatfield. The proposal to set up auxiliary hospitals was made by the War Office, partly because it was considered undesirable that in wartime convalescent soldiers should be sent direct from hospitals to their units, and partly because the War Office wanted to help to free E.M.S. beds for sick patients.
20 Summary Report of the Ministry of Health for 1939–41.
21 Ministry of Health E.M.S.Ge.303, 1st January 1940, and circular 1952, 27th January 1940.
22 A fee of 16s. was paid for each civilian treated (excluding National Health Insurance (patients). The payment covered a period of one year from the date of the first attendance. The cost of drugs and dressings was borne by the Government.
23 Form E.M.S.114.
24 This arrangements was slightly modified in February 1941 after complaints from rural areas, and forms were allowed to be issued from certain first aid posts in areas remote from any E.M.S. hospital (Ministry of Health circular 2263, 18th February 1941).
25 See Chapters IX (pp. 140–1) and X (pp. 154–71) for some illustration of the effects of the economy campaign.
26 For example: only two towels per bed were allowed until July 1940, when the number was increased to four. Similarly, two blankets per stretcher was originally allowed for the inter-change of casualties between hospitals, bus ambulances and casualty trains. Subsequently, after complaints that patients had suffered pain owing to the friction of the metal stretchers, authority was given for five to be provided.
27 Many departmental files contain reports describing 'appalling' shortage of equipment on the outbreak of war.
28 Hamilton, W. H. in Final Report of Committee on the Costs of Medical Care. Chicago. 1932 (p. 193).
29 Confidential letters to the Minister of Health in 1940. The report of an inter-departmental conference on the rehabilitation of persons injured by enemy action drew attention to the 'well-known tendency' of surgeons to hold on to cases which made it difficult to ensure either proper selection or rapid transfer (January 1941). An analysis of bed shortages at hospitals in 1942 provided some illustrations of this. At a particular voluntary hospital in Birmingham, for instance, the private waiting lists of surgeons ranged from nil to 193.
30 Ministry of Health E.M.S.I.257, 2nd December 1940.
31 The Lancet, in summing up at the end of the war the worth of these arrangements said that the consultant service 'under which specialists have regularly visited every hospital in their own group has proved outstandingly valuable' (August 1945, ii, 248).
32 On the outbreak of war, all hospitals and institutions in the emergency scheme were instructed to restrict new admissions among the civilian sick to acute cases, to transfer patients from certain hospitals in vulnerable areas to base hospitals, and to send other patients home, 'not on a peacetime standard of fitness for discharge, but on the assumption that only those should be retained for when institutional treatment is essential' (Ministry of Health E.M.S./Gen./231, 24th July 1939).
33 A departmental minute of October 1940 reported: 'no statistics are available showing the number of such beds which were emptied'.
34 With the introduction of new beds and the emptying of old ones a total of between 187,000–195,000 were made available for the reception of air raid casualties (See p. 185). Of this number, one report stated that some 150,000 beds were obtained by ejecting the sick and moving other patients to institutions not equipped to deal with casualties, while another estimate provided a figure of 163,500. How many patients were moved and how many discharged? In one report it was said that 'nearly 10,000' were moved, while others gave more specific figures of 5,500 moved from London and 18,000 from provincial hospitals, making a total of 23,500. From a careful scrutiny of these estimates it would seem that the higher ones are likely to be closest to the truth, and it therefore follows that about 140,000 patients were discharged from hospitals, sanatoria, children's homes, convalescent homes and mental institutions at the beginning of September 1939.
35 Letter from Ministry of Health to British Hospitals Association, 14th March 1940.
36 Precise figures of the number of tubercular patients discharged are lacking, apart from a figure of 1,003 for the institutions maintained by the Welsh National Memorial Association. Of about 28,000 beds in England and Wales provided for this disease before the war, roughly 21,000 were still available in September 1939. While 26,456 patients were receiving residential treatment on 1st July 1939, the number had dropped to 19,150 on 30th November 1939. By the latter date, some of those who had been discharged had re-entered a sanatorium. From these figures it would therefore seem reasonable to say that between 7,000–8,000 tubercular patients were sent home on the outbreak of war.
37 Minute by the Director-General of the E.M.S., 4th February 1940.
38 See Chapter V, p. 73. Hospital waiting lists are recognised to be very inadequate indices of demand but, in the absence of more reliable evidence, they must be accepted as a very rough guide. This problem of waiting lists during the war is further examined in Chapter XXIV.
39 Morris, C., Social Work, January 1940.
40 Out-patient facilities which, in London, were mainly confined to the voluntary hospitals, were either closed down or seriously curtailed at the beginning of the war. The Ministry of Health had not stipulated that this service, which in 1938 registered over 2,000,000 attendances at voluntary hospitals in London, should be withdrawn. Suspension was partly caused by the transfer of staff to outer hospitals. On 22nd November 1939, King Edward's Hospital Fund announced that the maternity of out-patient clinics were functioning again at the more important London hospitals.
41 Ministry of Health, E.M.S. Gen. 300, issued to London voluntary hospitals on 21st December 1939. Hospitals in the provinces were allowed to admit civilian sick up to a higher proportion of normal capacity.
42 The policy of transferring sick people from inner to outer hospitals had been in operation from the beginning of the war. The effects of this policy are discussed in Chapter XXII.
43 Statement relating to the Emergency Hospital Organisation, Cmd. 6061, July 1939.
44 This point was made in a departmental minute of 17th October 1939. A proposal to reduce casualty reservations was dropped on this occasion because of the 'storm of criticism' that it would arouse among the London voluntary hospitals.
45 The subject of medical education during the war is the concern of the Medical History.
46 There were also, as the Lancet said, 'A large number of eminent consultants (who) have accepted service under the scheme, sacrificing incomes much greater than those they now receive while still bearing the cost of expensive consulting rooms, townflats or houses, and often enormous life insurance premium'. (Leader, 28th October 1939, ii, 947.)
47 See Chapter IX, p. 138.
48 At meetings with representatives of the voluntary hospitals on 9th October 1939, 9th November 1939 and 1st December 1939. See also letter from the chairman of the British Hospitals Association to The Times, 9th December 1939.
49 Statement to the Ministry of Health by the secretaries of the teaching hospitals, November 1939.
50 On 5th February 1940 the Director-General of the E.M.S. minuted that a serious staffing situation would arise if 'further concessions' were made to the British Medical Association.
51 The Lancet, 'From our Peripatetic Correspondent', 23rd September 1939, ii, 719.
52 Leader, 23rd September 1939, ii, 699.
53 Ministry of Health E.M.S.I.53, 18th September 1939, and E.M.S./Gen./279, 5th October 1939.
54 See letter from chairman of Council, British Medial Association, in the Lancet, 2nd December 1939, and Ministry of Health E.M.S.P.19, 29th November 1939.
55 Instead of a whole-time salary of £800–£950. Revised arrangements were also made for the following: (1) the individual employment of house-officers at £350 a year was replaced by compounding payment to the employing hospital at £200 per head for the number of house-officers required for the purposes of the scheme; and (2) the employment of part-time officers on a sessional basis was confined to voluntary hospitals where whole-time E.M.S. clinical staff were employed and to local authority institutions; elsewhere, capitation payments were made to voluntary hospitals for E.M.S. cases treated, the find so constituted being at the disposal of the medical board to divide among the honorary staff in any way it liked. Capitation payments were fixed at 1s. 6d. per night per in-patient and 6d. per out-patient attendance. These terms wee somewhat modified later in the war. E.M.S. staff supplied to voluntary hospitals were allowed to treat civilian sick—or non-E.M.S. patients—in these hospitals. In return, non-E.M.S. staff were expected to help with casualties in an emergency. (Ministry of Health circulars E.M.S.Gen.293, 27th November 1939; 1942, 30th November 1939; and 2176, 18th October 1940.)
56 Eighth Report from the Select Committee on National Expenditure, 1940.
57 Ministry of Health notes on decentralisation were issued between 28th May 1940 and 27th June 1940. Operational control of the hospital scheme was not delegated to the Regional Commissioners as was the case with the casualty services in May 1940. The chief reason why authority was not delegated was the need to pool hospital resources on a national basis, and to override regional boundaries .
58 Ministry of Health E.M.S.Gen. 319, 12th April 1940 and E.M.S.I.144, 8th May 1940.
59 This commissioned was appointed by the Minister of Health to inquire into certain aspects of the working of the emergency hospital scheme.
60 The policy of close financial control by headquarters, which the Colville-Chatfield commission thought harmful, was laid down in a circular issued by the Ministry of Health on 22nd January 1940 as a result of the Treasury's call for economy in spending (circular 1954).
61 Ministry of Health circular 2064, 22nd June 1940.
62 Fourteenth Report from the Select Committee on National Expenditure 1940–1, 13th May 1941.
63 Certain other minor changes were made at the same time affecting the administrative control of the sector hospitals in London and surrounding counties. Also, in September 1940 ,the supervision and control of all hospitals in London region in respect of their part in the emergency scheme were transferred from the office of the hospital officer of London region to Whitehall.
64 Members of the police forces and of the mercantile marine injured by enemy action' injured and sick members of Dominion, Colonial and Allied Forces; injured and sick prisoners of war and interned persons, and sick unaccompanied evacuated children. All these groups were entitled to free hospital treatment under the E.M.S. Sick civilians, transferred from one hospital to another to keep beds empty for air raid casualties, who were also entitled to treatment, were required to contribute to the cost according to means. The position of this group is further discussed in Chapter XXII.
65 See Chapters XXII and XXIII.