HOSPITALS IN DEMAND
The Test of 1940–1
The development of the emergency hospital service during the first nine months of the war was described in Chapter XI. The story will now be taken up where it was left and pursued through the remaining years of war. By the time of Dunkirk the unwieldy, improvised organisation of September 1939 had become more compact and orderly, and more fitted to receive a flow of casualties. It consisted of fewer and better hospitals and a more settled administration.
When the first wounded and sick soldiers arrived from the Dunkirk beaches in May 1940 the period of inactive war came to an end for the hospital services. But as a hospital problem Dunkirk hardly deserved to be described as a test. Apart from some temporary strain at the Dover receiving end which was quickly relived, the admission of little more than 30,000 Service wounded and sick caused no difficulty and did not reduce the total number of available hospital beds in the country to any real extent. The emergency service had been prepared for much worse.
There were three major tests for the hospital services during the war; the bombing of London, the ports and industrial centres in 1940, the 'Second Front' in 1944, and the flying-bomb attacks on southern England in the same year. The first was the most serious and will be described in broad outline here, the full story being left to the medical historians. The tests of 1944 were to a considerable extent repetitions of earlier experience with the difference that the hospital service was far better prepared and equipped to meet them. Although the service had to provide for casualties from the continent until the Army could establish its own field hospitals in France, it proved capable of dealing with larger numbers than actually arrived. The attacks on the civilian population in 1944, first by piloted aircraft and later by flying-bombs and rockets, reproduced 'blitz' conditions on a smaller scale and over a smaller area. The hospital service found little difficulty in meeting the combined demands of Service and civilian casualties in this concluding stage of the war.
Its real baptism by fire and high explosive took place during the autumn and winter months of 1940–1. This was the test it had earlier expected and for which it had feverishly prepared in 1939. How did
reality compare with the worst fears of the Government? It had been suggested just before the outbreak of war that during the first four weeks of air bombardment there might be need for hospital provision amounting to almost 8,000,000 in-patient days, and that at the end of the four weeks over 400,000 air raid casualties might be in hospitals. It is impossible to imagine what would have happened if the casualties had been on this scale. Reality was indeed different. During the most severe month of continuous bombing (September 1940) air raid casualties in hospital on any one day average only 7,100 and never rose above 7,380. Between September 1940, when heavy night raids started, and May 1941, when they ceased, some 25,000 air raid casualties were admitted to London hospitals and nearly 46,000 to all hospitals in England and Wales.1 In these circumstances, it is not surprising that the national resources of the emergency medical services were never strained to breaking-point. During the decisive six months from October 1940 to March 1941, there were never less than 70,000 to 80,000 empty and available casualty beds in the country, and even in London, at the height of the bombing, a very large reserve of casualty beds was available in the out-country sector hospitals—25,000 beds ready for immediate occupation and 6,000 in reserve—while in inner London the figures were 9,000 and 400 respectively.
However, at the time these casualty figures were being reported they seemed less comforting than in retrospect. It was not easy to make a quick mental jump from estimate to reality. The summer and autumn of 1940 had been a period of great uneasiness and tension. The threat of invasion grew with each succeeding month. The onslaught from the air had started and was increasing in intensity. It was not possible to foresee with any accuracy where future blows would fall. All through the war uncertainty remained; each spring the threat of invasion returned, and even when victory seemed only a matter of months there was still the possibility of desperate attempts at invasion, of gas attacks and of secret weapons still more powerful and destructive. Behind each test successfully passed there lurked the danger of greater ordeals. In retrospect, these fears and the precautions they demanded are easily overlooked. They emergency medical service had to prepare against risks unknown in time, place and quantity, and its policy took shape in an atmosphere of uncertainty and tension.
This tension reached its peak in the autumn days of 1940. Plans for the evacuation of hundreds of thousands of people from areas on the coast were got ready and, as part of these plans, 2,300 patients, some of whom had been transferred from London earlier in the war, were
moved again to other areas.2 In London, thousands of beds were permanently lost while others were put temporarily out of commission as a result of bomb damage. But there still remained a big reserve of hospital accommodation. Although no one knew what further tests lay ahead, it was clear, by November, that the figure of 300,000 beds for air raid casualties—adopted as the aim of the hospital scheme in 1939—could now be reduced. This did not mean, however, that the total of beds earmarked for all emergency needs could be cut down. The needs of the Armed Services, even for ordinary sickness, were growing,3 and in the centres of air attack new dangers of epidemics had arisen. Above all, it was necessary to provide for unknown risks and to maintain adequate reserves in different parts of the country. A considerable amount of wastage was unavoidable if a proper distribution of emergency beds was to be ensured.4 Throughout the war this question of the geographical distribution of beds in relation to needs proved to one of the main problems of the hospital services.
The impressive figure of vacant and reserve beds during 1940–1 obscures this problem of distribution. There were certainly shortage and many difficulties, particularly during periods of bombing, but as they were not primarily caused by local of hospital resources but by heavy air attacks or by maldistribution of resources they were always local and temporary. Pressure on central London hospitals was sometimes intense. Serious situations developed in heavily bombed towns, e.g. Coventry and Plymouth, and wherever hospitals were hit or threatened by fire. Among the casualty receiving hospitals in bombed areas two kinds of distribution problems arose. The first concerned the prompt admission of the wounded during the battle, and the second the maintenance of a sufficient number of vacant beds in preparation for the next attack.
Delays in the admission of casualties to hospitals caused, in the early days, by the closing of hospital gates during raids and by an
absence of stretcher-bearers were soon remedied.5 The distribution of casualties among hospitals near the site of an incident presented a more difficult problem. Complaints were made about hospitals with ample bed reserves which declared that they were unable to admit further casualties, about surgical teams of one hospital being worked to exhaustion while those of a neighbouring hospital had nothing to do, and about girl ambulance drivers being sent from hospital to hospital with their cargoes during heavy raids. It took months to find a solution to this apparently simple problem of 'switching' casualties from a overworked to a less busy hospital, and when it was found, the administrative detail varied from place to place. Experience showed that approximately fifty percent of air raid casualties admitted to hospital required operations within six to twelve hours, and that, to avoid delayed operations, admissions needed to be related to the number of operating tables and surgical teams rather than to the number of vacant beds available. The two main practical difficulties were to determine what person was to be made responsible for giving the 'hospital full' sign, and what was the proper ration between operating teams and casualty intake during a given number of hours.6 The next logical step was to relate casualty bed reservations in each hospital to the number of operating teams, but this was an even more difficult problem to solve because it involved the ordinary civilian work and the finances of the voluntary hospitals concerned.7
The principal method of keeping enough beds free for casualties in bombed areas was day-to-day evacuation of patients to out hospitals. For air raid victims this was necessary and desirable, not only for practical, but also for psychological reasons. It had been planned as an integral part of the working of the emergency medical scheme, with fleets of ambulances connecting inner and outer hospitals. As a result, and in the circumstances of low casualty figures, there was never any danger of the pool of emergency beds in the centre being absorbed by accumulating casualties. But in London and the big cities, as elsewhere, hospital accommodation was claimed by the sick as well as the wounded. London, under repeated bombing, provided a striking example of the difficulties that arose from these conflicting
claims; difficulties which, at one time, threatened to overwhelm a part of the hospital service.
The number of beds available for sick civilians in London had fallen to a level greatly insufficient to comply even with a demand reduced by the evacuation of mothers and children and other people. Large numbers of beds were reserved for casualties; many others were out of commission for a variety of reasons such as the transfer of staff to outer hospitals, bomb damage, and the closure of wards on top floors or otherwise dangerously situated. The Ministry of Health did not, however, regard vacant casualty beds as completely out of bounds for sick civilians. The system of reservations was not considered to be rigid and unalterable but an elastic safeguard, and it was taken for granted—perhaps too much for granted—that hospitals would not refuse admission to people urgently needing treatment if unoccupied casualty beds were available. 'Urgent' is a word which allows of many interpretations, and the handling of this problem of the civilian sick in the circumstances of air attack brought to the surface many of the deeper conflicts in the hospital world which the unifying force of the emergency scheme had temporarily covered up. They will be discussed at length in Chapter XXIV, but at this point the main facts of the situation require to be recorded because the needs of the civilian sick were inextricably mixed up with the needs of war victims for whom the emergency medical service had been created.
From the beginning the service had accepted some responsibility for a limited category of sick civilians. They were the 'transferred patients; who had been moved into the country to make room for the reception of casualties in the cities. The Ministry paid for their treatment in out hospitals, but the patients were expected to contribute financially on the same basis as they had done before. Such transfers were limited, however, to patients likely to recover within a short period because the Government feared that otherwise casualty beds in country hospitals might soon be blocked by the chronically sick.8 The process of transferring sick civilians continued throughout the first year of war, but it never reached large proportions because many patients objected to being sent away and for other reasons. When air attacks started, more patients were moved from London hospitals and, at the same time, the method of 'side-door' transfer straight from the out-patient department began to be introduced unofficially. This was at first quietly tolerated by hospital officers and, later, sanctioned by the Ministry because it seemed reasonable for the emergency
service to accept not only persons who were transferred from hospitals but also those who needed beds but could not get them in London.9
After a few weeks' bombing it became clear that the transfer of civilian sick on a limited scale could not prevent waiting lists from growing to dangers lengths in London and other parts of the country, and that the problem of the chronic sick was much too serious to be ignored any longer.10 By December 1940 the situation had become critical, and the Ministry felt compelled to tell hospitals that 'the civilian sick should be admitted freely where waiting lists are accumulating'. This advice was given to all hospitals in the country and, at the same time, the Ministry proposed that patients in bombed areas should be 'transferred to out hospitals at an increased rate'. Simultaneously, hospital officers were instructed to review all casualty bed reservations in the light of air raid experience so as to release beds for the civilian sick wherever possible.11
This crisis was precipitated by the fact that the total load of patients was not only too heavy but also unevenly distributed. The London County Council hospitals were dangerously overcrowded and they were forced to use many of their casualty beds for sick civilians, while voluntary hospitals maintained their great pool of vacant emergency scheme beds by either restricting the admission of new patients or by transferring other patients.12 The public hospitals were unable to follow their example because they were under a statutory obligation to accept all patients whether acutely or chronically sick, who were in need of hospital care, and because the many thousands of their chronic patients were not entitled to be transferred to the country.
The problem of the aged and chronic sick had been serious enough in peacetime; in war it threatened to become unmanageable. Thousands who had formerly been nursed at home were clamouring for
admission to hospitals when families were split up, when homes were damaged or destroyed, and when the nightly trek to the shelters became a part of normal life for Londoners. Yet everything, except humanitarian considerations—which often take place second place in war—spoke against these poorest and most helpless members of the community. Because they occupied beds for indefinite periods it was wasteful to admit them to specially equipped and staffed emergency scheme beds. To nurse them was not only uninteresting but often unpleasant; the work soon damped the enthusiasm of newly enrolled V.A.D.s who had expected to nurse soldiers and not incontinent and senile old people.13 It was moreover argued in the jargon of the day that the emergency hospital service must give priority to 'potential effectives'.14 Voluntary hospitals, who had refused the chronic sick in peacetime, were even less prepared to admit them in wartime, and tended to define such patients in the widest possible sense. In the circumstances, the traditional burden of public hospitals and institutions became unbearably heavy. At a time when shelter life might well have resulted in widespread epidemics demanding all the resources of fever hospitals, such hospitals were crowded with chronic and aged sick people.15
The term 'chronic' was by no means limited to the aged and the incurable, as was shown by the records of some patients who were regarded as 'chronics' by voluntary hospitals and were promptly transferred to the care of the London County Council. They ranged from babies with broncho-pneumonia and acute bronchitis to young men and women with influenza and pleurisy.16 In short, some of the 'chronics' were ordinary sick people of all ages, suffering from simple, everyday complaints and needing hospital care for varying periods of time. Before the war, voluntary hospitals had treated many of
these patients; they now regarded them as outside their field of service.
It was not surprising that this situation intensified the traditional contradictions between voluntary and public hospitals and forced upon the Ministry the role of mediator and peacemaker.17 It had every reason to act in this capacity because it was partly responsible for the situation and had allowed matters to drift. It was admitted by the Ministry that the emergency medical service had made it financially attractive for hospitals to maintain their full quota of vacant casualty beds at the expense of even the more urgent civilian claims. Beds reserved for emergency scheme purposes were paid for from public funds while the bulk of the cost of treating sick civilians fell upon the hospitals themselves. Voluntary hospital finance had never been secure, and the war had resulted in upheavals which made income from charitable source seem more uncertain.
When bombing reduced the space for beds in voluntary hospitals and casualty beds reservations were maintained at their original level, the hospitals cut down their ordinary civilian work still further.18 These restrictions thrust into prominence certain unsolved financial questions. The Ministry found itself paying an increasing proportion of the questions. The Ministry found itself paying an increasing proportion of the hospitals' running costs and, in addition, it was taking financial responsibility for numbers of sick civilians who, for various reasons, could no longer be admitted to city hospitals and were transferred to emergency scheme hospitals in the country. There was also the fact that the very existence of some voluntary hospitals was at stake as a result of serious damage. Should their identity be preserved by the Ministry or should they be left to their fate? After only a few months of active war the Ministry, when reviewing its financial policy, discovered that it was compelled to face issues of far-reaching importance for the future.19
Problems of Distribution and Voluntary Hospital Finance
There was one common factor in all these problems confronting the hospital services and in all the forces which were shaping policy during and after the attack on London. It centred round the fate of the civilian sick. Swelling waiting lists, evidence of the plight of London County Council hospitals,20 a decreasing share in civilian work by voluntary hospitals, and an increasing number of complaints in the press and in letters to the Ministry—all these symptoms of an approaching crisis could not be ignored. There was no indication however, of any concerted Government plan to meet it; on the contrary, and largely because of the social and political issues involved, each separate symptom as it arose and made itself felt was dealt with in a piecemeal way. In the course of time these problems were tackled from three main angles: by relaxing temporarily the ban on the evacuation from London of chronic sick people, by reducing the number of casualty bed reservations in voluntary hospitals, and by revising the financial arrangements with these hospitals.
It was not accidental that the first practical measure to be taken concerned those aged and chronic sick people whose misfortunes were particularly obvious to a wide public. At the end of September 1940 the Ministry of Health decided to make a limited number of beds available in reception areas to aged and infirm persons found in public shelters and rest centres, and to accept the full cost of maintenance.21 Some of these old people had not relatives or friends to look after them; some had no homes and spent practically all their time in shelters; their appearance of neglect was a public reproach and a danger to health and morale. Local authorities were asked to find, register and collect such 'shelter derelicts', and the scheme was later extended to include old and infirm persons in private shelters and in their own homes. Persons evacuated from London under this scheme were given the 'status' of air raid casualties and were not regarded as
a responsibility of the public assistance authorities. For the first three months they were not expected to contribute to the cost of their hospital care, and they were allowed to retain whatever income they might have from pensions or other sources
Medical Officers of Health, who were asked to select these people, soon found themselves in difficulties. Some old people were obvious hospital patients and were glad to be taken care of; others objected to evacuation. Many did not wait to be separated from their normal surroundings; married couples wanted to remain together; in some instances, the fear of being treated as a pauper was much more real than the fear of bombs. It became clear that the problem went far beyond the scope and resources of the emergency medical service. Not all the aged and infirm who were unable to stand the strain of shelter life were necessarily in need of hospital care. Many were still active enough to lead useful lives in more normal conditions. To confine them all indiscriminately to bed involved not only were a waste of hospital resources but the risk of making them permanently bed-ridden. What many needed were not hospital beds but hostels.22 But in the absence of hostels, evacuation to hospitals and institutions in the country was the only immediate way of tackling the problem. By early December 1940 about 4,000 old and infirm people had been transferred from London to emergency hospital beds in country areas.
While this scheme was in progress, the situation of the London County Council hospitals was steadily getting worse. At the Ministry, the Director-General of the emergency medical service was strongly in favour of removing all the chronic sick from general hospital beds, even though the number moved from the shelters was expected to exhaust all second-class beds that could be spared in country hospitals. By the beginning of December, action had resulted in the transfer of over 3,500 chronic sick from London hospitals to the country, and at least some of the County Council's casualty beds had been restored to their proper function.
By the end of the year the emergency medical service was facing yet more difficulties. After the attack on Coventry and other industrial centres there were widespread transfers of hospital patients, and the evacuation of injured and sick people was no longer limited to London. In reception areas emergency hospital accommodation was running down and hospital officers were getting worried about the drain on bed reserves. Some of the chronic sick were consequently shifted from one place to another, and much confusion, hardship,
and many complaints resulted from these attempts to move aged patients from beds in good hospitals to which they had been transferred in the first instances. But all these devices could not alter the fact that there was not, in the opinion of those responsible, sufficient accommodation to go round. After having been in force for little more than two months the shelter scheme was suspended, if not abolished, because it was considered that no more beds in reception areas could be spared. It never came to life again.
The Ministry's of Health's attempted, during the first few months of the London attack, to deal with the problem of the aged and chronic sick brought some relief but no solution. In the shelter, conditions were still far from satisfactory as the Minister had occasion to see from himself. The London County council hospitals and institutions were again filling up. The reasons for the suspension of the shelter evacuation scheme were also responsible for the refusal of the emergency medical service to accept further groups of the chronic sick from these hospitals and institutions despite repeated requests. At the same time, the Ministry of Health rejected a suggestion that public school buildings, earmarked as 'shadow units' for the emergency medical service, should be used to accommodate the aged sick. The Government was not prepared to interfere with the work of these public schools unless there was a great increase in the demand for beds for air raid and Service casualties. In the meantime, matters were left more or less as they were, with the bulk of the chronic sick remaining in the bombed areas. No one really wanted to touch this difficult problem and no one really knew how to tackle it. It was much simpler to leave well alone and to say 'first place to the young and war casualties'.; Moreover, the Government continued to stand by the principle of wartime hospital policy that evacuation was not primarily a means of removing patients to safety but the only way of maintaining a sufficient number of casualty beds in the bombed areas.
With the removal of the aged and chronic sick at a standstill, and London County Council hospitals still showing an excess of admissions over discharges, it became increasingly urgent to distribute the load of both casualties and sick more evenly among all the London hospitals. It was an absurd situation that during heavy air raids the surgical staff in some of the Council's hospitals were not fully occupied because they lacked the necessary casualty beds, while over-worked operating teams in voluntary hospitals had more beds at their disposal than they could use. Among nurses it was the other way round: in voluntary hospitals with many fully staffed—but unoccupied—casualty beds they had far less work to do than nurses in the overcrowded L.C.C. institutions. In consequence, the Council found it more and more difficult to attract nurses to its hospitals.
These questions were all mixed up with the fundamental problem of distribution. The most effective way of relieving pressure on L.C.C. beds, and of enabling municipal hospitals in other areas of the country to reserve more beds for casualties, was an extension of civilian work in voluntary hospitals. But over this the Ministry of Health had no control whatever; all it could do to directly influence the policy of these hospitals was to cut down their casualty bed reservations. A first step in this direction was taken in December 1940, when hospital officers were asked to review the figures in their areas and suggest reductions for each hospital.23 It was hoped that in the whole of England and Wales 20–25,000 of the 70–80,000 vacant casualty beds could be released for the benefit of sick civilians.
The hospitals concerned did not welcome this development. In London, although the number of beds involved was only about 600, the hospitals were strongly opposed to any change. It was maintained that the war situation did not justify the reduction, and it was argued that the hardships suffered by sick civilians had been exaggerated. Months went by while negotiations proceeded between the British Hospitals Association and the Ministry. Meanwhile, the air attack on London ceased—though for how long nobody knew—and the case for a cut in the reservation of casualty beds became much stronger.
On 24th July 1941 a meeting of London hospital representatives declared that the release of these beds 'was a desirable step as it would enable the voluntary hospitals to take in more civilian sick and would spread the casualty load as widely as possible'.24 A further six months elapsed without action being taken. In January 1942 agreement was finally reached, and the new reservation figures became valid on 1st March 1942. Compared with the old, arbitrarily fixed, figures they had the advantage of being related in some measure to operating theatre capacity and, therefore, to the number of casualties a hospital could actually handle.25 For some hospitals the agreement meant little or no change; for others substantial adjustments were necessary. Five large teaching hospitals in London, for instance, released a total of 200 beds by a reduction of casualty beds from 160 to 120, and four other hospitals also released forty casualty beds each. But the total gain by the London sick was still in no relation to their needs.
During the fourteen months which had elapsed since a reduction in reservations was first proposed, a fierce dispute had been going on behind the scenes between the London County Council and the
British Hospitals Association, with the Ministry of Health acting as a kind of arbitrator. There was much correspondence and discussion, with facts submitted on both sides. Eventually, the Ministry itself extracted figures from its own records. They covered forty voluntary and twenty-four L.C.C. hospitals and showed that, in February 1941, the ratio of vacant to occupied beds was 1:0·9 for the voluntary and 1:8 for the municipal hospitals. The subsequent reduction in reservations did not remove this wide discrepancy but it did narrow the gap to some extent. Unfortunately, the delay had been a costly one, not only for the Exchequer, but also for London's sick civilians.26
This question of casualty bed reservations was one example of the close relationship which existed between finance and operational policy. It had not been easy for the Ministry of Health to find a method of compensating voluntary hospitals for their contribution to the emergency medical service which was both fair and generally applicable. Costs and types of service varied widely from one hospital to another and, in most instance, it was impracticable to pay fixed rates for vacant and occupied beds.27 It seemed more realistic to apportion running costs between the Ministry and the hospital according to the number of available E.M.S. and non-E.M.S. beds. The difficulty here, though, was that this method compelled the Ministry to accept obligations the size of which it had little or no power to control. If a hospital's internal administration was inefficient and unnecessarily costly, the Ministry's expenditure was unnecessarily high; if a hospital's beds for the civilian sick were reduced in number while its emergency beds remained the same, the Ministry's share in its running costs increased. Yet its only means of bringing its influence to bear was by persuasion and advice which might or might not be accepted.
When this method of payment was tested in practice, it became clear to the Ministry that it discouraged voluntary hospitals from increasing their share of civilian work. Was it surprising that they hesitated to admit sick civilians to their casualty beds when this meant a reduction in Government payments and an increase in their own expenditure? But in the London of 1940 it was not even necessary
to base such action on arguments of self-interest. The battle provided the argument. Victims of air attack and members of the Forces were accorded a position of privilege above everyone else. Their well-being had to be ensured beyond doubt. The troubles of ordinary life, the common illnesses and infirmities, might be much harder to bear under air raid conditions, but they took second place in the matter of hospital accommodation. A sick soldier received immediate care and stayed until he was fit again; a sick civilian had to wait in a queue and was often discharged at the earliest possible moment after treatment. These priorities of war lost much of their former jurisdiction when men and women and children were in the midst of the fighting, but tradition lived on.
When bombing reduced hospital accommodation and dangerous upper wards had to be closed, sick civilians were the first to suffer. Hospitals strove to maintain their quotas of casualty beds even after being bombed, and the financial effects of their so doing were considerable. The Ministry of Health's share of the hospitals' current expenditure rose as the number of civilian beds went down. The Ministry had also to accept financial responsibility for the increased number of sick civilians who had to be transferred to the country. Some voluntary hospitals were damaged to such an extent that their existence was threatened. For the Ministry, all these development added up to a problem with far-reaching consequences.
A review of the financial relationships between the Ministry and the voluntary hospitals could no longer be postponed. It was not simply a matter of saving public funds or arguing about the fairness of a particular method of compensation. Vital issues of hospital policy were at stake. The Ministry could save hospitals or leave them to their fate. It could allow centres of medical teaching and research to disintegrate or help to preserve them. In some instances, buildings, equipment and staff were even more urgently needed by damaged hospitals than financial support.
This situation had not been foreseen and there was no settled policy to deal with it. What hospitals should be assisted and to what extent? Was it in the public interest to save from extinction every small hospital, even if the contribution it could make was not immediately required by the emergency medical service? In November 1940 the Director-General of the service defined the Ministry's two main objects as follows: 'To preserve those institutions that are of national importance for education and medical progress and to have at its disposal as many "well managed" beds as possible'. Its interests, however, went beyond the confines of the emergency hospital scheme; every 'well managed' bed which could be used for sick civilians was important for it would thus help to relieve civilian pressure on casualty accommodation.
In May 1943 the Ministry appointed a committee chiefly to consider what should be regarded as a 'well managed bed'.28 As a result of the committee's work, it was hoped that bombed hospitals would establish country branches or take annexes of existing emergency medical services hospitals under their management; the Ministry was quite prepared to assist hospitals with money to tide them over any initial difficulties. While the help that the Ministry was able to give was of benefit to a number of damaged hospitals, the main source of Government support for the voluntary hospitals during the war was the steady flow of payments made to them under the emergency scheme. Taken as a whole, the country's voluntary hospitals weathered the storms of war and bombing very well. Throughout the war, the Ministry's financial policy was never rigid, and within the framework of general rules it dealt with individual cases on their merits. What it feared more than anything else was to lay itself open to the accusation that its policy might undermine or weaken the voluntary system. Many of its actions and omissions were inspired by this fear. It is a matter for speculation how the voluntary hospitals would have fared without the assistance they received. As it was, their financial position was greatly strengthened, and the Ministry's efforts to maintain the pre-war balance in the hospital world were successful.
In terms of finance, indeed, pre-war deficits became wartime surpluses. The average annual deficit of the voluntary hospitals in England, Wales and Scotland for the years 1937–9 was £24,600, while for the five war years the average annual surplus was £3,176,639.29 If the statistics are examined for only the larger voluntary hospitals (those with more than 100 beds) in the London region, the corresponding annual averages of £376,740 deficit and £793,485 surplus show that the trend was also very pronounced in an areas seriously affected by bombing and evacuation. The increase of receipts over expenditure did not come from voluntary gifts, which tended to fall slightly, nor from increased patients' contributions,
which dropped considerably, but from increased payments from 'Public Services'.30
Although their financial position was greatly strengthened, the voluntary hospitals did less work. The published figures on the number of patients treated, their length of stay in hospital, and the use made of available beds, prove this point. Taken together, the evidence is impressive.31
When an agreement was reached in May 1941 with the British Hospitals Association on various financial issues it did not alter in any fundamental way the method of paying voluntary hospitals.32 One new principle was an arrangement whereby hospitals, who had their total of civilian beds reduced because of bombing or for other reasons, credited the Ministry of Health with a sum equivalent to the cost of the lost beds.33 The purpose of this credit was to compensate the Ministry for the cost it had to bear in accepting as 'transferred patients' those sick civilians who could no longer be admitted to the
hospitals in question.34 The effect of this arrangement was that the Ministry no longer incurred additional expense without additional service whenever a hospital reduced the number of its civilian beds. There was now, according to the Ministry's accountants, no financial advantage to be gained by a hospital in making such reductions. But, as the Ministry itself admitted later on, the core of the problem remained untouched; voluntary hospitals still benefited it they did not place their vacant casualty beds at the service of sick civilians.
The Ministry was not fully satisfied with this arrangement, but it feared the controversies that would undoubtedly have followed any proposal for a drastic change in policy. Its failure to resolve the financial issue was one of the reasons why it felt an added responsibility for the civilian sick and took upon itself wide responsibilities than had been contemplated in 1939. The gradual expansion of its interests and its work beyond the limits of the emergency scheme for casualties is one of the recurring themes in the wartime history of hospital service.
Throughout the war the method of paying voluntary hospitals remained in all essential principles the same. Towards the end of 1944, when the process of demobilising the emergency medical service began, the financial conflict flared up again. The British Hospitals Association stated that a reduction in the number of casualty beds would seriously affect the finances of many hospitals and wanted the matter postponed. But at the time the Government's requirements in terms of beds for war casualties were so much easier to estimate than in 1940–1 that the story of long drawn-out negotiations was not repeated. The Ministry, while ready to discuss the position of any hospital in difficulties, insisted on keeping operational and financial issues strictly apart. It circulated the new casualty reservation figures to the hospitals on the basis of no other consideration than the needs of the emergency medical service.
This account of certain of the wartime problems of London's hospitals has been told as an example—perhaps the most striking one—of the kind of question which the Ministry of Health was compelled to face in organising and administering a special medical service for war casualties. It showed that, as events turned out, the real crisis was one of distribution, caused by the claims of sick civilians upon the hospital accommodation of which the war had deprived them, and aggravated at every point by the inconsistencies and tensions of a hospital world composed of two powers lacking common allegiance to a common policy.
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1Report of the Chief Medical Officer of the Ministry of Health, 1939–45, p. 139.
2 This movement began in June 1940 and was more or less complete by the end of August. In all, 2,352 patients were transferred from hospitals on or near the coast (Report of the Chief Medical Officer of the Ministry of Health, 1939–45, p. 138).
3 It was estimated that in the peak sickness period of the winter the Army required 2·5 sick beds for every 100 soldiers without allowing for epidemics. Army statistics for 1943 showed that, on an average, each soldier in the United Kingdom spent nearly eleven days or three percent of his time in hospital and convalescent depot–8·5 days on account of disease and 2·5 days as a result of accidental injuries. (Statistical Report on the Health of the Army 1943–1945, 1948).
4 'It is becoming increasingly plain that the hospital problem is very much a local problem and that taking the country as a whole some wastage is inevitable. That is to say that an adequate insurance must be made both for casualties and sick in every locality, although it is obvious that not every locality would experience all the casualties and sick it will probably be necessary to have at least 250,000 to 300,000 beds in order to ensure that there are enough beds in the right place' (Paper prepared by the Ministry of Health in 1940 for the National Expenditure Sub-Committee on Home Defence Services).
5 A Ministry of Health circular (2153) on 21st September 1940 stressed the importance of hospitals being ready to admit casualties immediately on the arrival of ambulances and of there being sufficient number of stretcher-bearers always available.
6 In June 1941 a Ministry of Health circular stated: '… it has been found that if a hospital has four operating tables and the corresponding staff, it can admit and deal efficiently in from six to twelve hours with about seventy-five air raid casualties of average severity; if it has three tables with about fifty casualties, and if it has two tables with about thirty casualties' (Ministry of Health circular E.M.S.I.297, 6th June 1941).
7 The point is further discussed on p. 453.
8 There were a few exceptions to this rule, e.g the transfer of patients from hospitals in areas on the south and east coasts.
9 The situation was summed up by an official of the Ministry of Health in a note on 14th November 1940: 'It is agreed that in principle we must now accept direct responsibility for providing hospital treatment for those of London's sick who cannot be treated in London owing to the shortage of hospital beds following damage; and that we can no longer limit ourselves to the notion that we accept responsibility only for the sick who are "transferred" to make room for casualties'. This problem of transferred patients is further dealt with in Chapter XXIV.
10 'I have been appalled', wrote an official of the Ministry of Health in November 1940, 'by some of the waiting lists which in some areas are increasing steadily.'
11 Ministry of Health circular E.M.S.I.258, 5th December 1940.
12 At a meeting in May 1941 a high official of the emergency medical service said (to quote from the minutes) that he anticipated 'repeated misunderstandings between the two groups of hospitals so long as the Ministry continued to instruct voluntary hospitals to keep a certain number of beds vacant for casualties while municipal hospitals had a statutory obligation to admit all sick who required hospital treatment. This enables voluntary hospitals to pass cases on to municipal hospitals quite arbitrarily, even when beds are available. While justifiable in teaching hospitals in peacetime this is not helpful in wartime'.
13 Hospitals which had transferred such patients to the country were asked to send nursing and domestic staff with them. The London County Council reported in October 1940 that many nurses resigned on being told of their proposed transfer with these patients.
14 The Minister of Health put this point of view quite unequivocally in a letter of 4th December 1940: 'If we were to move all the chronic sick out of the hospitals in the "target" areas it would literally mean moving some tens of thousands of patients, and no hospital scheme that we could devise could possibly stand the strain. There will be no dispute, I think, that however sympathetic one is with these people, if it is a choice of keeping them in the town hospitals, or keeping civilian or military casualties or acute sick in these hospitals, one must the latter into safety first'.
15 The London County Council's hospital service was seriously strained as early as October 1940. Out of a total of 9.915 beds for general patients and air raid casualties, 6,200 were occupied by the chronic sick, and only 915 were empty and available for casualties.
16 To illustrate this development the London County Council sent the Ministry of Health in February 1941 a list of admissions into St. Stephen's Hospital of twenty patients transferred from voluntary hospitals during a seventeen-day period. Of the twenty, only three were over sixty years of age. Among the remainder, the complaints ranged from influenza and bronchitis to miscarriages, carbuncles and scabies.
17 A high official of the emergency medical service acknowledged this fact in a letter to the London County Council on 21st May 1941: 'We have been exploring the possibility of a better distribution of civilian work and casualty work between the voluntary and L.C.C. hospitals but find that there are many difficulties in the road … My feeling is that there are bound to be misunderstandings between the voluntary and L.C.C. hospitals unless the Ministry take a definite line of responsibility for the distribution of the work'.
18 Exact figures of the amount of civilian work done by London voluntary hospitals are not available but a London County Council memorandum of October 1940 estimated that the figure was as low as ten percent of their pre-war work. This may have been an unduly pessimistic estimate, but it did at least provide some indication of the order of magnitude of the loss of hospital facilities to the sick of London.
19 A departmental minute of 31st October 1940 summed up the situation: 'As a result of the dislocation of hospital services in London, the partial closing of voluntary hospitals, and their damage by air raids, questions are arising that threaten the continuance of certain of these hospitals as independent institutions. action by the Ministry may determine their continued existence as independent units, or make such existence impossible'.
20 These hospitals were compelled, through shortage of accommodation and pressure of demand, to use the top floors of their often very old buildings. The Ministry of Home Security feared that the London County Council was running 'very serious risks' of disasters in its large unframed hospital buildings. The voluntary hospitals, on the other hand, were able to be more exacting in their interpretation of a dangerous ward, as they were not faced with the same liability for sick civilians.
21 This decision followed the Report of the Horder Committee on Air Raid Shelters, 26th September 1940. Recommendation No. VI of the Report read: 'In order to reduce the strain upon the shelter accommodation, certain classes of persons who inclusion adds to the difficulty of supervision, increases the risk to health, lowers morale and who are a serious encumbrance in the presence of an incident should, as far as possible, be evacuated. These classes include the aged, the infirm and the bedridden.
22 It was clearly impossible to find householders in the reception areas who would billet these old and infirm people under the Government's evacuation scheme. In the early months of 1941 an informal committee was called together to assist the Ministry of Health in finding suitable premises for hostels to accommodate able-bodied old persons and to help in mobilising voluntary action in the reception areas. For details of the number of hostels established see Chapter XIX, p. 374.
23 Ministry of Health circular E.M.S.I.258, 5th December 1940.
24 This meeting was called by the Ministry of Health to consider the organisation of the emergency scheme in London. It was attended by representatives of some voluntary hospitals, the London County Council and the British Hospitals Association.
25 See above, p. 445. The ratio between bed reservations and the 'switching' figure was fixed at 2½ to 1, but there were certain variatations which took into account the special circumstances of each hospital.
26 In at least one instance the reduction in the number of reserved beds did not mean an immediate increase in accommodation for sick civilians. When the emergency medical service cut down the reserve of casualty beds by forty the hospital made a return of its total beds which was lower by forty. The hospital claimed that it was unable to staff the beds set free for the sick. This was difficult to understand, as payment had always been made for the beds by the Ministry of Health on the basis that they were fully staffed and ready to receive war casualties. The Ministry's objections on this score were countered by explanations about staffing rations and special circumstances. Although not entirely convinced, the Ministry eventually decided to let the matter drop.
27 This method was, however, applied to the British Red Cross auxiliary hospitals. See below, p. 461.
28 The committee consisted of Lord Dawson, Sir Ernest Pooley and Sir Allen Daley.
29 Year to year comparisons in the field of voluntary hospital figures cannot be made with any accuracy as a varying number of hospitals provided statistics annually for the Hospitals Year Book The figure do, however, give an indication of general trends:—
1937 (917 hospitals sent in returns) Surplus +£479,467 1938 (847 hospitals) Deficit −£222,654 1939 (835 hospitals) Deficit −£330,615 1940 (794 hospitals Surplus +£1,793,278 1941(713 hospitals) Surplus +£245,921 1942 (806 hospitals) Surplus +£3,543,916 1943 (771 hospitals) Surplus +£4,087,781 1944 (783 hospitals) Surplus +£4,300,096
(Hospitals Year Book 1937–1947, issued by the British Hospitals Association (Incorporated).)
30 In London, for instance, the following upward movement was shown:—
Money from 'Public Services' per available bed 1939 £47.70 1941 £90.39 1940 £95,46 1942 £90.03
(Hospitals Year Book)
31 Voluntary hospitals in England, Wales and Scotland
New In-Patients New Out-Patients Average for the years 1937–9 1,303,101 5,943,206 Average for the years 1940–4 1,265,122 5,749,097 Voluntary hospitals in London
Average for the years 1937–9 297,324 1,910,043 Average for the years 1940–4 197,493 1,431,238
Average length of stay per in-patient days for certain London teaching hospitals
Guys Middlesex St. Thomas's University College St. Bartholomew's Royal Free 1937 17.6 21.2 17.4 21.4 19.6 16.5 1938 19.5 21.0 17.2 20.2 19.4 16.8 1939 17.0 22.1 15.6 17.4 15.8 16.7 1940 11.5 16.3 13.2 13.9 9.8 14.5 1941 11.1 11.7 13.4 13.6 12.6 12.9 1942 15.1 14.0 15.7 14.6 14.3 14.1
Percentage of available beds occupied daily in London voluntary hospitals with 100 or more beds
% 1937 88.81 1841 51.81 1938 87.17 1942 59.18 1939 81.22 1943 63.15 1940 49.96 1944 57.02
The big provincial hospitals showed the same trend ranging from 86.68 percent in 1938 to 64.20 percent in 1940 (Hospitals Year Books).
32 Ministry of Health circular 2380 enclosing W.A.R.184, 22nd May 1941.
33 The somewhat complicated formula attaching to this accounting process was described in Ministry of Health circular 2380, 22nd May 1941.
34 In March 1942 when the number of reserved casualty beds was reduced, the hospital credits to the Ministry were proportionately adjusted.